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Political Context of the Work of International Agencies /
A FUNDAMENTAL SHIFT IN THE APPROACH TO
INTERNATIONAL HEALTH BY WHO, UNICEF, AND THE
WORLD BANK: INSTANCES OF THE PRACTICE OF
“INTELLECTUAL FASCISM ” AND TOTALITARIANISM
IN SOME ASIAN COUNTRIES
Debabar Banciji

Navarro has used die term “intellectual fascism” to depict the intellectual
situation m the McCarthy era. Intellectual fascism is now more malignant in
e poor countries of the world. The Indian Subcontinent, China, and some
other Asian countries provide the context. The struggles of the working class
culminated m the Alma-Ata Declaration of self-reliance in health by the
peoples of the world. To protect their commercial and political interests,
retribution from the rich countries was sharp and swift, they “invented”
Selective Primary Health Care and used WHO, UNICEF, the World Bank,
and other agencies to let loose on poor countries a barrage of “international
initiatives as global program on immunization, AIDS, and tuberculosis.
These programs were astonishingly defective in concept, design, and imple­
mentation. The agencies refused to take note of such criticisms when they
were published by od1Crs. They have been fascistic, ahistorical, grossly
unscientific, and Goebbelsian propagandists. The conscience keepers of
public health have mostly kept quiet.
OVERVIEW
Gmng a personal account of studies on class, health, and quality of life during
1965-1977 in the United States, Vicente Navarro (1) has brought back chilling
memones of the dreaded McCarthyism which overshadowed almost every facet
o intellectual life in that country. He has, very appropriately, used the term,
intellectual fascism” to describe this phenomenon. The intellectual fascism that
is being practiced by the rich countries of the world on the health services of
the poor, dependent countries is of an even more malignant variety. There is
an unholy nexus between the ruling classes of the rich and the poor countries in
International Journal of Health Services, Volume 29. Number 2. Pages 227-259, 1999
© 1999, Baywood Publishing Co., Inc.

227

i~>3 h

228 / Baneiji
imposing health programs on the poor, because it serves their commercial and
political interests. Even the most cogent, well-documented, and well-argued
observations questioning the scientific validity of these programs are ignored
u”? 'J5' °f 016 markc,-8enerated information revolution, the rich have brain­
washed the helpless masses of the poor to sell their programs. They have also
ignored the fact that health policy formulation is
L a highly W
.„H,
complex
process,
requiring optimization of very complex systems. The task- becomes
-------__j even more
complicated when it has Ito ’be performed
‘
J ...
in the context of poor, non-Western
countries. These considerations have------------1
received scant attenhon from the health
policy experts hired by rich countries.
Asia is a huge continent, with extreme variations in geography, population,
ethnic composition, and political commitments. In this report, only the countries
all in the median” positions will be taken into account. Among them, again,
rcfcrcnccs wil1 56 madc t0
cascs of health service developments on
the Indian subcontinent and in China to provide a setting for discussion. Together
they account for more than two-fifths of the entire population of the world, and
a much higher proportion of die world’s poor.
The long expenence of India in developing its health services has escaped
the attention of scholars from the rich countries, of both the hired and die
progressive” varieties. It has been a most virulent form of intellectual fascism.
These scholars were actively aliistorical, apolitical, and atheoretical. After Inde­
pendence. India’s ruling class, which had led the freedom struggle against the
colonial rulers, was impelled by the working class to fulfill the promises it had
made while mobilizing them for the struggle. This was the compelling motive
orce for its ushering in very ambitious healdi programs to cover the needs of
the unserved and the undeserved during the first two decades of independence,
even though the country faced massive problems.
The situation in China is entirely different from that in India. Significantly the
two major ideas in public health that emanated from China—the barefoot doctor
and the use of the traditional Chinese systems of medicine in their health serwCCSy^CrtflC outconlcs of toe revolutionary movement, particularly the Lonn
Ma.rch- Vinf°rtuna,el>r’China nls° adopted the now well-discredited Soviet model
which failed to work. Deng Xiaoping’s move to promote “market socialism" dealt
an almost deadly blow to the village commune system, which sustained the
barefoot doctors.
Other Asian countries such as Sri Lanka, Pakistan, Bangladesh, Malaysia
Indonesia Thailand, and the Philippines have also made "progress" in developing
f
n* SkerVICCS 71,6 f°Ur lasl-named countries were among those specially
/ a W°c Capi,al fOr stimulal'ng rapid economic growth during the
past two decades. Even at the peak of theirgrowth phase, serious flaws have been
observed m the health services in the form of rapid privatization leading to gross
of firoh30? Pr7aLe h°SP,talS and alrn°St Criminal ncglect of toe poor because
of further decay of the already inadequate health services for the poor people

Intellectual Fascism and Health / 229
One can well imagine the health and health service consequences of the severe
financial crises that have overtaken these ‘Tiger” countries since 1997.
The ferment in the development of health services in Asia and elsewhere
unng ^e 1960s and 1970s triggered major changes in World Health Organiza­
tion (WHO) policies. The Alma-Ata Declaration on Primary Health Care was the
culmination of the chain reaction. Apparently for tactical reasons, all the rich
countries of the world signed the Declaration. But their retribution for such a
daredevil declaration by the poor was swift and sharp. As it from nowhere, they
mvented ’ the concept of Selective Primary Health Care (SPHC). A large number
of concerned scholars categorically questioned the scientific validity of the con­
cept, but all failed to make any impression on the exponents of SPHC.
Two mam issues stand out from the awesome manifestation of power by the
nch countries in imposing their will on the poor. First, although they lay claim to
being the inheritors of the European Enlightenment, which involves a deep commitment to the scientific method, they have shown contemptuous disregard for
these principles whenever, scientific data stood in the way of their commercial
and pohtical interests. Second, the bulk of public health scholars, who proclaim
eir a egiance to the scientific method and commitment to social justice, found
it worthwhile to remain silent while such active desecration took place.
As a follow-up, the ruling classes of the countries of the world exercised their
coHtrol over international organizations such as UNICEF, WHO. and the World
Bank WB) to get them started with formulating some selected programs as
global initiatives. ” These were bristling with inconsistencies, contradictions and
patent scientific infirmities. Even the main planks for the formulation of these
^datives were profoundly flawed. First, how can one have a “prefabricated”
g obal initiative given the extreme variations among and often within poor
countnes. Second, selection of health problems for action conformed more to
special interests of the rich countries than the poor. Third, a tcchnocentric
approach to problem-solving was adopted. Fourth, there is an obvious contra­
diction m the scientific bases of the claim that the suggested globe-embracing
programs are cost-effective given the profound variations among and within
countnes. Fifth, by their veiy nature, international initiatives cannot promote
community self-reliance. Sixth, there is the key question of dependence and
sustainability; donors” have used their tremendous influence on the pliable
ruhng classes of the poor countries to ensure that the ill-conceived, ill-designed
and ill-managed global initiatives are given priority over the ongoing work of the
ea t organizations. Finally, and above all, these programs arc the very anti­
theses of the Alma-Ata Declaration.
It is grimly ironic that soon after die leadership given by WHO and UNICEF in
writing one of the brightest chapters in the history of public health practice in
lhCi^ °uf aCCeptancc of lhc Alma-Ata Declaration by all countries of the world
in 1978. the ruling classes should have started the international initiatives that
opened one of the darkest chapters. By the early 1980s. UNICEF let loose a

230 / Bancrji
barrage of global initiatives on the poor countries of the world. WHO and the
World Bank lent the full weight of their considerable prestige and influence in
strengthening this menacing trend in public health thinking and action.
The outbreak of the AIDS epidemic in 1982, which later took the form of a
pandemic, legitimately thrust on WHO die onerous responsibility for action on a
global scale. Il developed the Global Programme for AIDS. Despite the bewilder­
ing variations in the epidemiological behavior of the disease—including its com­
plex social and cultural dimensions, which required a very flexible approach to
program formulation—the program conformed to a set pattern which was prin­
cipally shaped in the United States.
WHO’s declaration of the tuberculosis problem as a “Global Emergency” was a
totally surprising move. The database to justify such a sweeping declaration was
virtually nonexistent. Ironically, allocation of overriding priority to the interna­
tional initiatives, all down the line, led to the neglect of other services provided at
the peripheral or grassroots level. This included tuberculosis work. WHO had
also launched two other global programs with considerable fanfare. One was the
Diarrheal Disease control programme and the other was meant to deal with acute
respiratory infections in infants and children. Mercifully, these programs failed
right at the take-off stage. The World Bank had joined WHO to launch yet another
international initiative called the Safe Motherhood Initiative. This loo has a
very long way to go.
Some high-profile research administrators got together to set up a global Com­
mission on Health Research and Development in 1987. Practice of Essential
National Health Research was the centerpiece of die report Even the very scanty
materials produced to document progress in its implementation leaves little
doubt that the initiatives taken could have little impact on the strengthening of
health services in the countries of the world.
It should come as no surprise that virtually every global initiative taken by
WHO, UNICEF, and the World Bank since the promotion of SPHC by the rich
countries suffered from serious infirmities. Remarkably, even when these
infirmities were pointed out to the organizations, diey failed even to enter into
discussion on the issues raised or take any corrective measures. It is not necessary
here to make a comprehensive critique of all die programs. Only three of the
major ones—on immunization, AIDS, and tuberculosis—will be taken up here,
and these only very briefly.
Even a very broad analysis of the process of policy and program formulation
and implementation of the immunization program (EPI/UPI) reveals that the
apical organizations of international public health have shown scant regard for
some of the fundamental principles of public health practice. They have dared
to launch a global/universal immunization program without caring to have a
reasonably reliable epidemiological baseline. They have tended to “homogenize”
the situation, even the 100 or so poor countries have widely varying parameters.
When there is no epidemiological baseline, how is it possible to assess the

Intellectual Fascism and Health / 231
epidemiological impact of the program? Without paying any attention to these
vital infirmities, the WHO/UNICEF/WB establishment has not hesitated to repeat
in 1998 the wild claim that: “Today 80 percent of the world’s children receive
this form of protection against childhood diseases their first year of life.”
WHO and UNICEF had joined the Government of India to get the Indian
program systematically evaluated in 1989. The results were published in the form
of a book, which was widely circulated. The findings seriously questioned the
claims by WHO/UNICEF/WB. Another all-India study conducted in 1992-1993
revealed that at the national level as few as 35.4 percent of eligible children were
fully protected, with the coverage hovering around 9 to 22 percent among many
of the highly populated states with die poorest records of infant mortality. If
the situation is so bad in India, die conditions prevailing in the world’s least
developed countries, and many more, will certainly not be any better.
The same trend was followed when WHO, along with a large number of U.N.
agencies, set out to design the Global Programme for AIDS (GPA), which was
principally directed toward the poor countries. Despite the efforts by WHO/WB
officials and their Indian camp followers to control information and extensively
spread unsubstantiated information, it was possible, as early as in 1992, to bring
out a monograph that called into quesdon a number of critical assumptions in the
formulation of the GPA in India. This too was disregarded.
The justification given by WHO/WB for launching the Global Programme for
Tuberculosis (GPT) is even more fantastic and incredibly contradictory. Out of
the blue, as it were, in the early 1990s, WHO/WB sounded a maximum-alert
alarm bell to proclaim that tuberculosis had become a “Global Emergency” and
the GPT was the way of tackling it. Once again, despite putting on a cloak of
secrecy while selling the program in India, a comprehensive document was
prepared pointing out major epidemiological, sociological, economic, and organi­
zational and management flaws in the GPT. But this did not deter the authorities
from pushing on with their doomed venture.
A very large area is covered in this report to demonstrate how the imposition
of an enonnous, high-priority, prefabricated health service agenda of the rich
countries on the poor ones has virtually decimated the somewhat promising
growth of people-oriented health services in a country such as India. The over­
riding priority assigned to a Malthusian family planning program for over four
decades by the ruling classes, both national and international, has also had a
devastating impact on the growth and development of the health services in India.
As described later, Nicholas Demerath, Sr., has given a well-documented account
of the various ways in which India’s family planning program has been influ­
enced by the U.S. government (U.S. AID) and other U.S. agencies.
In conclusion, let me list just a few of the major areas of distortion. First, the
public health practiced by exponents of the international initiatives is starkly
ahistorical. Second, tire scientific term “epidemiology,” which forms the foun­
dation of public health practice, has been grossly misused by the new breed of

232 / Bancrji
experts. Third, suppression of information, use of doctored information, spread of
misinformation and disinformation, and lack of effective evaluation/surveillance
are expected outcomes. Fourth, directors-general of two top public health insti­
tutions in India extended their support to the GET, even though serious flaws
in the program were repeatedly brought to their attention. After they endorsed
the WHO/WB program, they found highly lucrative positions in WHO. This
and many other such instances mark the rock-bottom of the moral and ethical
standards of the parties concerned. Finally, those who are expected to be the
conscience keepers of ethics and morality in public health practice are perhaps
the worst offenders in inflicting such a humiliation on the poor peoples of
the world.
The line of action for those few who still attach high value to intellectual and
moral integrity, and are prepared to pay the sort of price mentioned by Navarro,
emerges from the analysis presented in this report.
INTELLECTUAL FASCISM
Giving a personal account of studies on class, health, and quality of life during
1965-1997 in the United States, Vicente Navarro notes that “terms such as class,
working class (not to mention class struggle), and just plain capitalism were
dismissed as ideological. No serious scholar, aware of the penalty it would carry,
would dare to use these terms” (1, p. 391). He has, to my mind very appropriately,
used the term “intellectual fascism,” whose “destructive powers could be even
worse than the fascism I had experienced in Spain" (1, p. 392), to describe this
phenomenon.
The intellectual fascism that is being practiced by the rich countries of the
world against the poor, dependent countries is of an even more malignant variety.
In the field of health, to subserve their commercial and political interests,
the ruling classes of the rich and the poor countries have formed an unholy
nexus which enables them to impose prefabricated, technocentric, dependence­
producing health programs on the poor. These interests are so powerful that
even most cogent, well-documented, and well-argued observations calling into
question the scientific validity of these programs are simply ignored. When it
comes to protecting their interests, the special brand of intellectuals/scholars
who are hired by the ruling classes are ruthless, unscrupulous, and nonchalant (2).
The Bhopal tragedy of 1984 (3-10), in which the Union Carbide Corporation
got away so lightly with the consequences of its criminal neglect—which led to
the spraying of the deadly chemical methyl isocyanate on hundreds of thousands
of people, leading to the death of thousands and severe health damage to scores
of thousands—provides an awe-inspiring case study demonstrating the power of
the nexus of the ruling classes.
The ruling classes of the rich countries have also mobilized a number
of international agencies and myriad bilateral and “voluntary” agencies or

Intellectual Fascism and Health / 233
nongovernmental organizations to implement their agenda for action. Suppres­
sion of information, doctoring of information, misinformation, and disinforma­
tion have been freely used as means to push their agenda. Making use of the
market-generated information revolution, they have employed the approach of
social marketing (11, 12) to brainwash the helpless masses of the poor so as to sell
their programs. The way in which the "experts” employed by the World Bank
have twisted and distorted the meaning of health policy formulation almost
beyond recognition, by bringing it down to the level of health financing (13),
provides a startling instance of this new brand of scholarship from the rich
countries.
Lest they "forget” the essence of health policy formulation by hiding them­
selves in the jungle of the massive, programmed information onslaught, it is
worthwhile to ‘‘remind” the hired experts about some of its basic concepts.
(“Man’s struggle against oppression is a struggle between memory and forgetful­
ness”—Milan Kundera.) Health policy formulation is a highly complex process,
requiring optimization of very complex systems. For this purpose, epidemio­
logical, medical and public health, and organizational and management issues are
visualized in tlieir social, cultural, and economic contexts so as to crystallize them
in the form of policies based on constitutional and other types of political com­
mitments (14). The task becomes even more complicated when it has to be
performed in the context of poor, non-Westem countries. Western medicine is,
after all, Western in origin. Furthermore, it has been grafted onto countries that
already had ways of coping with their health problems. The grafting was done
usually against the background of colonial conquest, as in the case of India, or in
blatant imperialistic settings, as in the case of China. Differences in the ecology
of diseases, availability of resources, cultural meanings of health problems and
health practices, formulation of appropriate technologies and economic produc­
tion practices are some other important determining factors. These considera­
tions have received scant attention from the health policy experts hired by rich
countries (15).
EARLY EFFORTS TO DEVELOP HEALTH SERVICES
IN SOME ASIAN COUNTRIES
Countries ofAsia
Asia is a huge continent, with wide variations in geography, population, ethnic
composition, and political commitments. For instance, there are Japan and South
Korea at one extreme, and Nepal, Bhutan, and Afghanistan at the other. Here I
will discuss the role of foreign and international agencies and other organizations
in health policy formulation in terms of those Asian countries occupying median
positions. A very brief reference will be made to the cases of health service
developments on the Indian subcontinent and in China to provide a setting for

234 / Banerji

appens that information available on development of health service systems in
these other As.an countnes is very scanty and often of rather unreliable quality.
Health Service Development on the Indian Subcontinent
The long experience of India in developing its health services has escaped the
anenbon of scholars from the rich countries, of both the hired and the ‘•progres­
sive vaneties. Indeed, the former category has actively ostracized the ind.genous
‘ h°larSh'P' aPP^n‘ly >0 create-space" for justifying the agenda handed down
o them by their paymasters; it has been a most virulent form of intellectual
fasdsm. As pointed out by Navarro (1. 16). and earlier noted by John McKmlay
(17 tn a slightly different context, these scholars were actively ahistoncal
apolmcal, and atheoretical. Such an approach subserves the class interests of
the rulers. Obviously, thts normally would require considerable elaboration
(e.g, 18). but in the present context I will present only a bare outline of India’s
experience.
The British inducted Western medicine in India in the wake of their colonial
thC.,atler half of the 18th ccnlury. primarily to strengthen their
exnfoTr
exploitative machinery—the army, the civil service, the European business class
and a wafer thin, uppermost crust of native collaborators (18). Reciprocally
this further weakened the native working class, which constituted more thim
V8 percent of the population. They were further pauperized due to colonial
exploitation, thus further increasing the disease load, and were made to lose
wnmriwUS)5 COPlnS meChaniSmS th3t thcy had ‘fcwloped over the course of
,aunchcd M an‘i-c°lonial freedom
'LSPOnSC' the Pe°Ple °f
struggle, which became a mass movement, leading to the overthrow of the
"I'm’947 (‘9)' 1110 rcP<>rtS °f ‘hC National Health Sub-committee
of tf? N
on
National Congress in 1940
f
lann'ng Commilte= °f th=
(20) and the famous Shore Committee (21) (which, incidentally, was spearheaded
the 2rei8? T7 SUCh 3S ■'Ohn Gran' and Hcnty SiSerist> in 1946 provided
0" °f 3 bIUeprin‘ for buildinS an ^^an health
servi« fo f'
service ror tree India.
■ Af*'r ’"dependence, the ruling class, which had led the freedom struggle was
Z
Of ,he WOrking ClaSS 10
thc promises it had made while
mobilizing them for the struggle. This was the motive force for ushering in very
ambntous health programs to cover the needs of the unserved and the unden
served, even though the country faced massive problems—accentuated severalold in the wake of Partition. A nationwide network of Primary Health Centres

Intellectual Fascism and Health / 235
(22) for the rural population was established from 1952 to provide integrated
health services to entire populations, as part of a still more ambitious Community
Development Programme (23). Ihe Primary Health Centres formed the sheet
anchor for developing the other important facets of the health service system
for example, people-oriented manpower development (24-27), research (28 29)
regionalization of the health services (30), inclusion of the indigenous systems’
of medicine (31), and so on. Very well-designed public health research on tuber­
culosis conducted in India had a far-reaching influence on tuberculosis programs
all over the world, including in the rich countries. This research showed that
home treatment is as good as sanatorium treatment (32); that the BCG vaccine
has little protective value, at least for adults (33, 34); that a substantial propor­
tion of tuberculosis patients in a population were already seeking assistance at
Primary Health Centres and other health institutions; and that sputum smear
examination is the most reliable diagnostic tool (35-37).
The major political upheaval that followed imposition of the National Emer­
gency in 1975-1977 was instrumental in adoption of the program of entrusting
people s health in people’s hands" (38); using community health workers chosen
by the people themselves has been another landmark. These movements
culminated in enunciation of the National Health Policy in 1982 (39), which
proclaimed that:
The prevailing policy in regard to education and training of medical and
health personnel, at various levels, has resulted in tlie development of a
cultural gap between the people and the personnel providing care. The
various health programmes have, by and large, failed to involve individuals
and families in establishing a self-reliant community ... the ultimate goal of
achieving a satisfactory health status for all our people cannot be secured
without involving the community in the identification of their health needs
and priorities as well as in the implementation and management of various
health and related programmes.
As discussed later, the approach adopted by die special brand of experts hired
by the rich countries and their camp followers is diametrically opposed to that
envisaged in the National Health Policy. Incidentally, as also pointed out by
Navarro (1), the emphasis on democratization of community health services is
also conspicuously missing in the approach adopted by the erstwhile "socialist
countries (including China) and those European countries that have set up
national health services.
Health Service Development in China
The situation in China is entirely different from that in India. China had the
most blatant form of imperialistic exploitation, as symbolized by the Opium

236 / Banerji

Medical Colle8e

was China’s fU5t raedical

..
contrast India had three government-funded medical
iZl In a41’’ S*Snifi“^y. the two major ideas in public health that
svsten^of^ 0
.barefOOt dOCtOr a"d 1156 °f the Phonal Chinese
systems of med.cine m the health services (42)-are the outcome of the revolutionary movement, particularly the Long March. Unfortunately, China also
adopted the now well-discredited Soviet model, which failed to work. In sheer
frustration, Mao had exclaimed, as late as in 1965 (43):
Ten Ae Ministry of Public Health that it works only for fifteen percent
o the population of the country and this fifteen percent is mainly composed
of gentlemen wh.le the broad masses of peasants do not get medical treat' Tt L"01 Chan8e ■“ [MiniStry °f Public Heal[h’sJ narne into the
m'
imstry of Urban Health, the Ministry of Gentlemen’s Health or even the
Ministry of Urban Gentlemen’s Health?
promote “markCl socialism” d“h an almost deadly
Sow m the n m°Ve
blow to the village commune system, which sustained the barefoot doctors
Even Jough enueal of the Soviet model of health services. Navarro (U h^s
to a di«s7
“r UliSt mOdcI ad0pted by Pos,‘Soviet Russia has led
to a disastrous collapse of the health service system of that country. Almost
grudgingly he also concedes that “the same process is now underway in China ”
sLmhstPs°v™em
C°1,apSe of thc earIicr
b™" 6 b™^' ab<’U,
socialist system, China is now asking for help from WHO’s Division for
soN^,Droh?OOPCraUhn 17th C0Untries and PeoP'“ i" Greatest Need "to
solve problems in health financing in connection with re-establishment of
Coopcrat-= Medical System” (44). China also created a

Xh A

“ °r °ther C°Untri“ Whcn il acccP,ed

World

BankAVHO-supported tuberculosis program with alacrity, turning a blind eye
to the myriad scientific design flaws repeatedly pointed out by scholars from
of T C°7 (4r'47)' Tha‘ Ch*na Sh0U'd n0W ad0p! an °Pen|y ^rave policy

X a S oCf’thWhile

b b^ deSCribCd

dangCrS °f P0^'^"

,
thC caP,talls' system, is yet another indication of grave
Lwc
,
flaws ,n its population policies and planning. Incidentally, no political llader

S,xr ” “of ■

Intellectual Fascism and Health / 237
77ie "Tiger" and Other Asian Countries
The state of Kerala in India (population 30 million) (48, 49) an Sri Lanka (50)
(population 16 million) stand out sharply among all the low-income countries in
having remarkably good health and mortality statistics. Other Asian countries
such as Pakistan. Bangladesh. Malaysis, Indonesia, Thailand, and the Philippines
have also made “progress" in developing their health services.
The four last-named countries were among those specially favored by the
world capital for stimulating rapid economic growth during the past two decades.
Even at the peak of their growth phase, serious flaws have been observed in their
health services in the form of rapid privatization leading to gross overcapacity in
private hospitals and almost criminal neglect of the poor because of further decay
of the already inadequate health services for the poor (51). In a recent article
arrac ough (51) has described how the conglomerate corporations of Malaysis
wh.ch often own plantations, also run Die leading private hospitals, using the
latest technology. He points out the paradox that the workers on the rubber and
pa m estates are the poorest in the country. Conforming to laws originating in the
colonial penod. the services now being provided to them are “woefully inade­
quate and offer little more than treatment of minor ailments and first-aid." Given
such a situation in 1994 in one particularly "successful" "Tiger" country, one can
we imagine the health and health service consequences of the severe financial
crises that have overtaken these “Tiger" countries since 1997. Although some of
these consequences are already visible in the form of a sharp deterioration in
health and mortality statistics and an acute scarcity and sharp rise in price of
drugs, the full impact of the crises on the health service systems has yet to be
systematically assessed.
]
THE ROAD TO ALMA-ATA AND THE
RESPONSE OF THE RICH
The Alma-Ata Declaration: A Watershed in Public Health Practice
This very broad account of the evolution of health service systems in the two
Asian giants, and a mere mention of the state of affairs in many other Asian
countries, set the stage for understanding and analyzing the practice of intel­
lectual fascism by a syndicate of the world’s ruling classes, with those that are
rich and powerful setting the agenda for action. The ferment in the develop­
ment of health services in Asia and elsewhere in the world during the 1960s
and 1970s triggered major changes in WHO policies. The Alma-Ata Declaration
on Primary Health Care (52) was the culmination of the chain reaction Health
as a fundamental human right, community self-reliance, intersectoral action for
health, social control over health services, use of appropriate technology
encouragement of traditional systems of medicine, essential drugs—these are

238 / Banerji
DeC,arati°n- 11 3150 COntaincd a

definition of

The Invention of Selective Primary Health Care
Apparently for tactical reasons, all the rich countries of the world signed the
Alma-Ata Declaration even though it shook the very foundations of the con­
ventional thinking on international public health as hitherto practiced by these
countries. The Declaration marked a watershed. It was also clear to the rich
countries that such a declaration of self-reliance by the poor peoples of the world
was against them class interests. They saw its “subversive" character. Navarro (1)
as described how the use of such radical terminology as "class interests" has
long been seen m the United States as “too ideological," with the enjoinment that
such things have to be "value free"—forgetting that this is itself a most value­
laden term. The retribution for such a daredevil act as the Alma-Ata Declaration
was swift and sharp.
As if from "nowhere," the rich nations "invented" the concept of Selective
PHmaO' Health Care (53). The justification was that Primary Health Care was
good, but was too ambitious; one therefore should be selective in choosing areas
that are cost-effective. To legitimize such a fragile stand, they got hold of a very
poorly designed, and even more poorly conducted and analyzed, study in Haiti
fhe pnncipal author was then an “assistant clinical professor of medicine” at
Harvard. Such a paper would have been rejected out of hand by even the poorest
academic journal in a developing country. Hat it found ready acceptance for
publication in the prestigious New England Medical Journal speaks volumes
about the intensity of intellectual fascism that still prevails in the United States
More than 80 scholars from schools of tropical medicine and other public
health institutions m Europe and from the United States, Africa, and Asia
gathered at Antwerp to discuss SPHC. In the Antwerp Declaration (54, 55) they
categorically questioned the scientific validity of die concept. Social Science and
Medicine (56) brought out a special issue with a detailed account of the dclibera‘llOnLat rtntWurP There WerC artiCleS °n ,he SUbjeC'in the Gnomic and Political
Weekly (Bombay) (57) and the International Journal of Health Services (58) The
Journal of the Indian Medical Association (2) carried a leading article on the
subjec,. AII
d
0(hen. (e g _
(o
impressjon on
attended h6".
S
0" t0 Or8ani“ 3 high-Pr°fi>e meeting
'
attended by top executives of WHO, UNICEF, the World Bank, and many other
XT”’ ’pT" 35 I1,ke-rninded Pcrsons wh° called themselves public health
scholars, at Bellagio, Italy (63), thus getting a resounding endorsement for SPHC
rlaheJ R°
my OrEan,ZCd 3 Similar mceting at Cartagena in Columbia (64)
(called Bellagio-II) to get a similar endorsement.
TWO main issues stand out from the awesome manifestation of power by the
nch countries m imposing their will on the poor. First, although they lay claim to

Intellectual Fascism and Health / 239
being the inheritors of the European Enlightenment, which involves a deep com­
mitment to the scientific method, they have shown contemptuous disregard for
these principles whenever scientific data stood in the way of their commercial
and political interests. Second, despite the brave scholars who stood up to the
bullies at Antwerp and at other forums, the bulk of public health scholars, who
proclaim an allegiance to the scientific method and commitment to social justice,
including the Alma-Ata Declaration, found it worthwhile to exercise discretion—
the better part of valor. They remained silent on the most blatant desecration of
scientific principles and methods, presumably to avoid the anger of the most
powerful country and its camp followers. This brand of “intellectuals,” who
belong to the middle class and attained their positions of importance by putting
on a mask of progressivism, can also be said to harbor at least some traits of
intellectual fascism, which they try to hide deep within them. They too need be
exposed. Where were they when China started its pogrom of enforcing the norm
of a single-child family, or when Indira Gandhi imposed a National Emergency
and let loose a reign of terror, and used force to sterilize millions of people
against their will (65)? The Vietnam “war hero” and then President of the World
Bank, Robert McNamara visited India at that time and is on record praising India
for its achievement in fighting the menace of population explosion (66).
LETTING LOOSE A BARRAGE OF
INTERNATIONAL INITIATIVES
UNICEF’s Primacy in Imposing International Initiatives
As a follow-up to acceptance of Selective Primary Health Care, the ruling
classes exercised their control over international organizations such as UNICEF,
WHO, and the World Bank to get them started with formulating some selected
programs as global initiatives” for implementation in the poor countries. The
brief accounts of the evolution of health services in India and China and mention
of some other Asian countries will provide the context for understanding how
different has been the conceptualization, formulation, and implementation
aspects of these initiatives undertaken by the triad (WHO, UNICEF, and the
World Bank). On the basis of this description it is possible to list some major
aspects of their actions.
1. Even the main planks for formulation of these initiatives were profoundly
flawed. How can one have a “prefabricated” global initiative when one takes
into account the extreme variations among and often within the poor countries?
This very obvious determining factor escaped attention, or, more likely, was
deliberately overlooked, when the initiatives were formulated. The situation bears
an uncanny resemblance to the economic “rescue packages" of the International
Monetary Fund (IMF).

J

240 / Banerji
2. Selection of health problems for action conformed more to the special
interests of the rich countries than to the specific epidemiological situations in the
various poor countries.
3. A technocentric approach to problem-solving was adopted, not because it
provided the “optimal solution” (67, 68), but because this was “friendly” to the
economic interests of the rich countries. The biotechnology, refrigeration, and
drug industries, particularly in the private sector, are some examples. There was,
besides, the opportunity for the creation of high-salaried employment in rich
countries, for hirelings who could then exercise the enormous power bestowed on
them to perform the jobs assigned by their paymasters.
4. There is an obvious contradiction in the specific bases of claims that the
suggested globe-embracing programs are cost-effective, given the profound vari­
ations among and within countries. Presumably because of this, no serious efforts
were made to assess cost-effectiveness at the time of program formulation. The
claim of cost-effectiveness by once highly respected organizations such as WHO
and UNICEF is an example of the blatant spread of almost manifest disinforma­
tion. The latest instance of this almost deliberate effort to avoid subjecting their
assumptions to objective evaluation comes from the failure of WHO/WB to set up
reliable baseline data on “Annual Rate of Infection” (69) for monitoring the progress
of the huge Global Programme of Tuberculosis which they had launched.
5. By their very nature, international initiatives cannot promote community
self-reliance.
6. Because countries receive a considerable proportion of the funds from out­
side, there is the key question of dependence and sustainability—apart from the
real danger of vulnerability to political exploitation by the “donors.”
7. The “donors” have used their tremendous influence on the pliable ruling
classes of the poor countries to get overriding priority assigned to the illconceived, ill-designed, and ill-managed global initiatives at the expense of the
ongoing work of the health organizations. In India, for example, the primacy
given to the programs pushed by the WHO/UNICEF/WB triad, along with an
almost frenzied preoccupation with the family planning program, has had a
devastating impact on almost every facet of organization, management, and
growth of the health services infrastructure. In the case of China, as (under) stated
by Navarro (I), it was more an overt political decision by the oligarchic ruling
class to shift investment away from the people-based health services; privatiza­
tion was the slogan for socialist market orientation.
8. Above all, these programs are the very antitheses of the Alma-Ata Declara­
tion and, in the case of India, of its National Health policy (39), which envisaged
“involving the community in the identification of its health needs and priorities as
well as in the implementation and management of the various health and related
programmes.”
It is grimly ironic that soon after the leadership given by WHO and UNICEF in
writing one of the brightest chapters in public health practice—acceptance of the

Intellectual Fascism and Health / 241
Alma-Ata Declaration in 1978—by all countries of the world the ruling classes
should have started the international initiatives that opened one of its darkest

ment to their oppressors before their tormentors are again forced to admit their
mistakes and to abandon their ill-conceived misadventures, so that the oppressed
can then resume their long, grinding struggle toward access to people-oriented
services for their populations (57). Using the hindsight of 1998, it is appalling to
find so few who have had the courage of their convictions to call the bluff of
the tormentors of the oppressed.
By the early 1980s, the triad of WHO, UNICEF, and the World Bank had
started to give a global form to the grossly inadequate but politically and
economically important concept of Selective Primary Health Care. UNICEF
opened up a barrage of global initiatives on the poor countries of the world. WHO
and the World Bank lent the full weight of their considerable prestige and
influence m strengthening this menacing trend in public health thinking and
action. At first, UNICEF came up with four areas for “special” attention in
child health: Growth Monitoring, Oral Rehydration, Breast Feeding Promotion,
and Immunization (GOB) (70, 71). It was soon impelled to add to the list:
Fertility Promotion, Feeding Programme, Female Development, thus making
it GOBI-FFF (72). Again, it had to backtrack and focus its anention only on
immunization. This project was named the Universal Programme of Immuniza­
tion (UPI) (73, 74), or simply the strengthening of WHO’s pre-existing Extended
Programme of Immunization (EPl) (75). It is not difficult to visualize die impact
of such a fickle-minded approach on the world’s utterly dependent, poorest of the
poor countries. At a later stage, there was yet another turnaround, when one of
the six diseases—poliomyelitis—was singled out for eradication from the globe
(76, 77). Thus, the disturbing signals were already there on the quality of care
and on the considerations that had gone into the triad’s drawing up policies and
plans for acting globally to fulfill the responsibility assigned to the three agencies
in their respective constitutions.
In the world of the poor, with virtually no system even to record births and
deaths, not to mention a dependable health information and evaluation system,
experts ’ hired by UNICEF, WHO, and many affluent countries of the world
made the pronouncement that six immunizable diseases—tetanus, pertussis
diphtheria, tuberculosis, poliomyelitis, and measles account for most deaths
among infants. It was assumed that a massive program of vaccination against
these six diseases would create a strong enough “herd immunity” to eliminate
them as public health problems, if not total eradicating them within five years
presumably as in the case of smallpox (74).
To cope with the mind-boggling task of immunizing hundreds of millions of
infants, particularly those living under the most primitive conditions in extremely
remote areas of the very large number of the world’s poorest countries (where,
incidentally, a much higher incidence of the six diseases would be expected),’

242 / Baneiji
experts from UNICEF/WHO suggested an intensive program of mass com
mumcalton, using the new technological advances. The globally telecast poo
travaganza organized by the Irish pop star, Bob Geldof at London’s Wembkv
Stadium m the form of “Band Aid,” and later, a still bigger show at the same nlaee

"e •ci’' -^' “WOr,<1 Ai<1” (12)>

aEainst t^?x d’lnStlnC“ ’

tW° °U[5tandin*

S“

t0 C°ntribUte t0 UNICEFs ^ade

r
10 SaVC
'iV“ °f
P0™ " Ihc
hypocrisy of the
over affl
vuka
’
Jng away hUndrcdS Of biIIiOnS Of dollars ,0 sustJdn their
vulgar entenamment industry,” could not have been more blatant There were
■^‘dentally, few protests from the concerned people of the world at this patently
mdece" lnsu]t ,o
poor by
m Jy
hund d ’r C„° y d'ffercnce ^'"8 that their number has swollen to the
so called info™ •°nS' b7',WaShcd by thc Potent w“Pons provided by the
so called information revolution. UNJCEF also hired experts from the marketing
Scnisad
'’
"t3™ "SOCial nlarkctjng" 'o these techniques used to “fight”

•ojhe
As I will briefly mention later, the propaganda blitz let loose on the poor
countnes of the world to promote EPI/UPI has apparently been “forgotten" wWrin
few years, because it has served the purpose for which it was generatJ Se
cou ™^•
Zd

m°V,n8 faSt in tbC infonnali°n highways in the rich
u "CW PaS‘UrCS fOr he'piug to launch new international

bZZfZ
f0rg0tten about the data that had seriously questioned the very
the program (54-62). They, too. seem to have moved on to new pastures
UNlX0" neW CnlSad“' PUb'iC heakh eXpCrtS at WH0 ak0 fulIy cndorse^e
UMCEF mttiattve on EPI/UPI. and WHO undertook to use its falflungTrgani
undeZkentfZtask dfffCrent countnes 10 Push this program (74-76). It has also
by 2W (77)
running the global program for eradicating poliomyelitis

The WHO Global Programme for AIDS (GPA)
nJd,' 0Utb.reak. Of thc AIDS epidemic in 1982, which later took the form of a
eloh |m'C’i ef‘^mately thrust on WH0

onerous responsibility for action on a

States (78). As pointed out later, this proved to be its Achilles’ heel. At

Intellectual Fascism and Health / 243
a later stage, implementation of the GPA was entrusted to an inter-agency U.N.
organization called UNAIDS.
The WHO/WB Global Programme for Tuberculosis (GPT)
..rPf W°rid Hcalth Organization ’s declaration of the tuberculosis problem as a
Global Emergency” was a totally surprising move. The database to justify such a
sweeping declarauon was virtually nonexistent. It has been accepted (eg 35-37
79) worldwide for more than four decades that public health programs’against
tuberculosis are based on general health services, which are expected to take on
the task of diagnosing and treating the bulk of tuberculosis cases in the poor
countries. Ironically, allocation of overriding priority to the international initia­
tives all down the line, led to the neglect of other services provided at the
peripheral or grassroots level. This included tuberculosis work.
What made the very perpetrators of the decline in tuberculosis care work up
such an intense concern for the disease as a public health problem is an interest­
ing case study for scholars interested in a more detailed study of the political
economy of health services. One plausible explanation might be the sudden
1
10 the PrOblern in the United Slatcs and olher rich countries when their
DS epidemics activated the dormant primary foci in many persons with AIDS
and this led to spread of tuberculosis to others. This triggered alarm bells for the
ruling class, which, m the course of its exponential polarization from the poor has
create a sterile/sanitized world for itself. An irrational and therefore very malig­
nant fear of microbes struck terror in tire hearts of the rich. One consequence of
tps mass hysteria against germs, which received support from the once sober and
highly respected International Union Against Tuberculosis and Lung Disease
(e.g., 45-47, 80), was that these unfounded fears (as will be elaborated later) took
the entire world back a century to the days of the long-discarded single-etiology
theory of diseases. What is worse, this observation on tuberculosis in the rich
countries was extrapolated to the entire world. Already, as the AIDS epidemic
seemed attain a plateau in the rich countries, poor countries were singled out as
e nch breeding grounds for a devastating spread of the AIDS pandemic. As
almost a majonty of the adult populations in these countries had acquired primary
tubercle foci, a fear complex was actively generated to claim that this would lead
to widespread outbreaks of tuberculosis, hence the declaration of the Global
Emergency. Incidentally, subsequent experience has shown that both fears proved
to be unfounded. Black Africa is very much there, in spite of the rapid phase of
spread of AIDS: there is no tuberculosis epidemic even in this region. The
*nC‘de"ce/Prev^enc= of AIDS and tuberculosis is a tiny fraction of what was
predicted by the WHO/WB experts in North Africa, in Central, West, South
Southeast, and East Asia, and in South America (81, 82). All these facts speak
volumes about the technical competence of those who rule over the destiny of the
world s health services, particularly in the poor regions.

244 / Baneiji
Sticking tenaciously to the single-etiology theory, despite overwhelming
evidence to the contrary, and the (virtual?) “reality” of the Global Emergency, a
strategy was developed for the GPT. It consisted of making a massive effort to
identify tuberculosis cases in entire populations, then subjecting them to Directly
Observed Treatment with Shortcourse chemotherapy (DOTS) (83). Starting with
China (45, 46), which did not find anything amiss in the DOTS approach, WHO
and the World Bank have come together and managed to successfully “push
through” this approach to the poor countries of the world.

WHO s Other Efforts to Launch Global Initiatives
The World Health Organization had also launched two other global programs
with considerable fanfare. One was the Diarrheal Disease Control Programme
(84), with Oral Rehydration Treatment as its centerpiece. The other program
was meant to deal with acute respiratory infections in infants and children (85);
it envisaged timely administration of antibacterial drugs to affected children,
using paramedical staff in rural and urban areas. Despite the usual promotional
efforts of WHO/UNICEF/WB, mercifully, these programs failed right at the
take-off stage.
The World Bank had joined WHO to launch yet another international
initiative: the Safe Motherhood Initiative (86). Child survival programs
were later dovetailed with this initiative. Apart from the question of cost­
effectiveness, the success of this initiative, like all the preceding ones, depended
on the capacity of the health service systems to undertake the task envisaged
in the program.

Global Initiative in Launching
Essential National Health Research ”
Some high-profile research administrators, who had earlier headed many key
research organizations/committees, both nationally and internationally, in 1987
got together to set up a global Commission on Health Research and Development
(87). The report of the Commission, and an account of the subsequent follow-up
action and its impact, provide an interesting administrative case study on the
intellectual make-up of the key decision-makers who have dominated the field
worldwide for the past three or more decades. While the Commission had a
self-imposed deadline for its automatic “liquidation" within one year, it could not
present the report until 1991. Practice of Essential National Health Research
(ENHR) was the centerpiece of the report. The Commission took some more time
to hold well-publicized seminars in different parts of the world to promote the
report. It received warm endorsement from government leaders and most of
academia throughout the world, including the prestigious Nobel Symposium (88)
The Swedish Agency for Research Cooperation with Developing Countries

Intellectual Fascism and Health / 245
(SAREC) (89) and the International Development Research Council of Canada
(IDRC) (90) were among the foremost institutions to promote ENHR and the
other recommendations. The then Executive Director of UNICEF proclaimed that
“in future at least five per cent of UNICEF’s budget will be devoted to research.*’
This promise, incidentally, was never kept SAREC and IDRC also agreed to
provide funds for yet another proposal of the Commission to set up a two-year
task force, with its office located in Geneva, to encourage developing countries to
implement ENHR (88). The materials produced to document progress in the
implementation of ENHR (88) leave little doubt that the initiatives could make
little impact on the strengthening of health services in the countries of the world.
The ENHR movement has not achieved anything more substantial than what was
already done by WHO’s Advisory Committees on Medical/Health Research at
the global and regional levels.
SERIOUS INFIRMITIES IN THE GLOBAL
INITIATIVES
It should come as no surprise that virtually every global initiative taken by
WHO, UNICEF, and the World Bank since the promotion of Selective Primary
Health Care by the rich countries suffered from serious infirmities. Remarkably,
even when these infirmities were pointed out to the organizations, they failed
even to enter into discussion on the issues raised, not to mention taken any
corrective measures. That the infirmities were indeed serious is borne out by the
fact that the programs consistently failed to yield the results expected of them. It
is not necessary here to present a comprehensive critique of all the programs.
Only three of the major ones—the EPI/UPI, GPA, and GPT—will be taken up,
and only very briefly.
Even a very broad analysis of the process of policy and program formulation
and implementation of EPI/UPI reveals that the apical organizations of inter­
national public health have shown scant regard for some of the fundamental
principles of public health practice.
1. They have dared to launch a global/universal immunization program
without caring to have reasonably reliable, global baseline epidemiological data
(91). The specialty of epidemiology should have been the very soul of EPI/UPI.
Its absence has made it “soul-less.”
2. While using their patently unsubstantiated “estimates,” they have tended
to “homogenize” the situation even in the 100 or so poor countries, with their
widely varying parameters affecting the incidence and prevalence of the six
target diseases.
3. With no epidemiological baseline, how is it possible to assess the epidemio­
logical impact of the program? It could well be argued, “from the other side,”
that the impact, if any, may have been due to the natural histories of the diseases
over time.

246 / Bancrj;
4. No data have been produced to demonstrate the degree of effectiveness of
the vaccines under the ecological/epidemiological conditions prevailing in the
different countries.
5. No evidence has been produced to justify why the level of "herd immunity”
has been fixed at 85 percent.
6. It is incredible that the program managers claimed that the programs could
have been implemented “satisfactorily” in countries such as Chad and Niger,
not to speak of Sudan, Somalia, and Sierra Leone, or Colombia, Ecuador or
Guatemala. In Asia, Afghanistan, Nepal, Myanmar, Cambodia, and Laos provide
the challenging examples. It requires stupendous logistical capabilities to ensure
that an epidemiologically adequate proportion of infants receive potent doses of
the vaccines in all die countries of die world.
Two academics, specializing in epidemiology, Vance Dietz from the Centers
for Disease Control and Prevention and Felicity Cults from the London School of
Hygiene and Tropical Medicine, have recently produced an article in this Journal
(76) on evaluation of mass immunization campaigns on the basis of a literature
review. The fact that not one of the epidemiological issues raised in the foregoing
discussion—which, incidentally, have been published in the Journal on more than
one occasion—received any mention in their review gives a chilling picture of the
depth to which the practice of public health principles has fallen during the past
three decades. The authors explicidy mentioned that they “did not address the
broader issue of comparing different approaches to the delivery of a strategy
within the context of primary versus selective health care." Why? They did not
even take up the broader epidemiological, sociological, and organizational and
management issues raised, even when these issues fell within the severely limited
range of the review. In their Scheme of things, of course, issues concerning
political economy and the less than academically acceptable role of international
and other foreign agencies, including their own institutions, were considered
politically improper." Either they have become conditioned to follow the line
laid down for them by the dominant intellectual group, or they did not dare
deviate from this for fear of inviting retribution from them.
John Bland an John Clements (74) of the WHO/UNICEF/WB establishment,
have not hesitated to repeat the wild claim, as recently as 1998 in the World
Health Forum, that "Today 80% of the world’s children receive this form of
protection against childhood diseases during their first year of life," even though
overwhelming data have clearly pointed to the contrary.
It is remarkable, and to a considerable extent frustrating, that neither academics
such as Dietz and Cutts nor program managers and experts such as Bland and
Clements cared to take cognizance of the well-designed and well-conducted
evaluation studies carried out in some of the poor countries by “local" scholars.
Dietz and Cutts claimed that these findings did not come within the parameters
they had (arbitrarily) set for their literature search. Bland and Clements “blindly”
accepted die government data, widiout caring to question their validity and

Intellectual Fascism and Health / 247
reliability. Indeed, Dietz and Cults should have noticed that one of the "local"
studies has more than once been discussed in some detail in the references cited
by them. These two studies are briefly referred to below.
The EPI/UPI program of India, meant to last five years from 1985 was the
largest in the world. WHO and UNICEF joined the Government of India to get
the program systematically evaluated in 1989. The results were published in the
form of a book, which was widely circulated (92). It showed that the immunization coverage was less than a fifth in the two-thirds of the population that account
for most of the poor, as well as for most of the infant mortality in the countrythe surveillance system was almost nonexistent. A similar situation existed for
potency tests of the vaccines at the time of inoculation. The book described how
reports of immunization coverage had been exaggerated by 100 percent or more
to please the national and international officers responsible for administering the
program. It also reported at least 56 recorded deaths due to the vaccination
process itself. There was virtually no outcry, nationally or internationally against
this outrageous consequence of the program. Had even one such dea± taken
place in a nch country, the entire program would have been halted An in-depth
study of the program in the State of West Bengal (93) has reinforced the findings
of the national study.
All these startling findings made no impression; there was little follow-up
action or correction of the records and reports. Another all-India study the
National Family Health Survey (94), was conducted with the involvement of
the U.S. Agency for International Development (U.S. AID) and the East-West
Centre al Honolulu in 1992-1993 (dial is, well after “completion" of the time
limit for the EPI/UPI). This study revealed that at the national level as few as
35.4 percent of eligible children were fully protected, with the coverage hovering
around 9 to 22 percent among many of the highly populated states with the
poorest records of infant mortality. In this survey, there was no study of the
surveillance system, nor was there any check on the potency of the vaccines at the
time of inoculation. Apparently, even these admittedly bare data which called
into question the effectiveness of EPI/UPI, did not receive the attention of Bland
and Clements (74).
If the situation is so bad in the case of India, which has a fairly extensive
network of health services at the grassroots level, the situation in Chad, Niger,
and many countries mentioned earlier—as indeed, in all the world’s least
developed countries (44) and many more—will certainly not be any better. What
then was the basis of the claims made by Bland and Clements?
That EPI/UPI was not a temporary aberration becomes clear when one subjects
the other global initiatives to academic scrutiny. The “malady” seems to have
pervaded the entire academic world of the ruling classes—as. for instance, was
encountered by Navarro (1) when he ventured to study class issues in public
ealth policy studies in the 1960s. The same trend was followed when WHO,
along with a large number of U.N. agencies, set out to design the Global

248 / Baneiji
Piogramme for AIDS, which was principally directed toward the poor countries
Incidentally, the first Union Budget (1992-1993) (13, 95, 96) after India sub­
mitted to the IMF conditionalities included a 20 percent slashing of the alloca­
tion to health services (including the tuberculosis program), without accounung
for inflation. However, the World Bank and WHO “assisted" India in setting up
the National AIDS Control Programme (NACP), which accounted for almost a
fourth of the total allocation in the same financial year. Following the now
familiar line, NACP was formulated under a veil of secrecy and no modificauon
was permitted unless it got clearance from the World Bank Headquarters in
Washington, D.C.
Despite the efforts by WHO/WB officials and their Indian camp followers to
control information and extensively spread unsubstantiated information, it was
possible as early as in 1992 to bring out the monograph Combating AIDS as a
Public Health Problem in India, which questioned a number of critical assump­
tions in the formulation of GPA/NACP. Besides addressing matters of inter­
disciplinary methodology, the monograph raised issues of comparative epidemi­
ology by taking up the history of syphilis. Interestingly, Steve Wing (97) has
raised important issues in his article “Whose Epidemiology, Whose Health?”
There is an interesting reference to a comparative analysis of the epidemiological
behavior of AIDS and syphilis. Among the important issues raised were the
profound implications of AIDS changing from a principally homosexualassociated disease in the rich countries to a heterosexual one in the poor coun­
tries; the key question of the natural history of the disease, as manifested in the
differential incidence in different parts of me world, including among the
countries of Sub-Saharan Africa; cultural, social, and economic parameters of
the “nsk groups” which determine the epidemiology of the disease; and the need
for formulation of suitable strategies for different countries, based on these con­
siderations (98-102). From the WHO/WB experts and program managers there
was a stony silence on the issues raised in the monograph. Quite predictably, the
objectives set before NACP in 1990 remain unfulfilled (103, 104), and very likely
AIDS is set on a course broadly similar to that followed by syphilis as a public
health problem in India over a period of time. A special category of sickness of
mind appears to be afflicting the key decision-makers, who consciously hire an
army of properly sanitized and brainwashed personnel to translate their “sick”
ideas into action. For the oppressed classes and for all those who are prepared to
take up their cause, it appears to be a re-enactment of a form of colonialism, with
as described by Navarro (1), fascistic overtones.
Justification given by WHO/WB for launching the Global Program for Tuber­
culosis is even more fantastic and incredibly contradictory. It is simply bizarre
Out of the blue, as it were, in the early 1990s, WHO/WB sounded the maximum­
alert bell to proclaim that tuberculosis had become a “Global Emergency” and the
OPT was the way to tackle that emergency (105, 106). How did a Global Emer­
gency occur? What was WHO/WB doing when this emergency, was building up?

Intellectual Fascism and Health / 249
It is reflected in the Epidemiological Intelligence Reports these agencies are
constitutionally bound to present? Then why did they cut back the staff of the
Tuberculosis Unit at the Headquarters in the 1980s to barely one (45)? Why
didn’t they raise an alarm when the national tuberculosis program in the poor
countries were being pushed onto the back burner to create “space” for highpriority program such as EPI/UPI or NACP, with the already crippled health
services reeling under the impact of brutal cuts imposed by orders of the IMF?
This would be a comical drama had it not been to tragic, costing the lives of
hundreds of thousands of the poor, whose voices were stifled by the ruling
classes.
A streak of steely determination on the part of WHO/WB in imposing the
prefabricated, DOTS-driven agenda of the GPT is reflected in the leading presen­
tation of a World Health Forum Round Table, which gives the pre-eminent
position to DOI'S (83). That even the conversion rates claimed for the new
spectrum of drugs used in DOTS are nothing startling is exposed by comments
made by the veteran tuberculosis worker of the old school, John Crofton, who
was a participant in this Round Table Discussion (79, 83): He states’ "We
demonstrated in Edinburgh in the 1950s that 100% cure of pulmonary tuber­
culosis, with no relapse, could be a reasonable aim (even with the drugs then
available: streptomycin, isoniazid and para-amino salicylic acid).”
The GPT was particularly painful for tuberculosis workers in India, who have
been instrumental in making such a mark in tuberculosis research and action
worldwide over the past four decades. A meeting of key tuberculosis workers
called by the Tuberculosis Association of India and the Government of India in
1992 to discuss the poor state of the country’s National Tuberculosis Programme
came out with well-argued and eminently implementable lines of action (107).
Once again, a comprehensive document was prepared pointing out major
epidemiological, sociological, economic, and administrative flaws in the GPT
(108). To initiate dialogues, this too was extensively circulated to various
agencies by the Voluntary Health Association of India, specifically including the
chief executives of WHO, UNICEF, and the World Bank and aid missions of
some of the major “donors.” However, as in the previous cases, they remained
unmoved; they refused to enter into discussion on scientific aspects of the pro­
gram. A detailed account of the efforts made to bring them round to scientific
discussions is also included in this document (107).
The cloak of secrecy shrouding the "selling” of the program to India has been a
particularly unpleasant feature (108). The WHO/WB experts actively avoided
entering into discussion with their counterparts at the National Tuberculosis
Institute. Bangalore, and others actively involved in the conceptualization,
formulation, and implementation of India’s National Tuberculosis Programme.
Instead, they interacted extensively with the then director-general of the Indian
Council of Medical Research, who had been a tuberculosis microbiologist, and
the then director-general of health services of the Government of India, who was

250 / Baneiji
a specialist in orthopedics. Both these functionaries were later offered positions in
the South-East Asian Regional Office of WHO.
CONCLUSIONS: A FRIGHTENING SPECTACLE OF DISTORTION OF
THE PRINCIPLES AND PRACTICE OF INTERNATIONAL PUBLIC
HEALTH BY WHO, UNICEF, AND THE WORLD BANK
A very large area has been covered in this report to demonstrate how imposi­
tion of an enormous, high-priority, prefabricated health service agenda by the rich
countries on the poor ones has virtually decimated the somewhat promising
growth of people-oriented health services in a country such as India. Poor people
will have to struggle for their right to access to services that are specifically
designed to conform to their epidemiological, sociological, cultural and
economic requirements. For this purpose, they will not only have to fight the
nusconceived and motivated interventions in the form of international initiatives;
their struggle will also include restructuring of the entire health/health service
system to be in tune with their requirements. This will be a long grinding
struggle.
5
It may also be mentioned in passing that the overriding priority assigned
w I to a
Malthusian family planning program ffor over four Jdecades by the ruling classes,
both
has
had a devastating impact on
also —J
, national and international (109-116),
>
--------the growth and development of health services in India (114). In his book Binh
Control and Foreign Policy (117), Nicholas Demerath. Sr., has given a welldocumented account of the various ways in which India’s family planning pro­
gram has been influenced by the U.S. Government (U.S.AID) and other U S
agencies, such as the Population Council, the Ford Foundation, the Population
Crisis Committee, the Council of Foreign Relations, and programs sponsored by
numerous universities, church organizations, the International Planned Parent­
hood Federation, and other voluntary associations. So powerful has been the
population lobby in the United States that it forced the publishers. Harper and
Row, to hastily withdraw Demerath's book from bookstore shelves all over the
world. It has now become a collector’s item.
From the standpoint of sociology of knowledge, it is interesting to note that no
other scientific specialty, not even the cousins of public health such as clinical
medicme/surgery, microbiology, and health statistics, has undergone such a farreaching distortion. What a macabre situation, reflecting the nature of intematronal and national power plays of our time. This is indeed the darkest chapter
in the history of public health. In conclusion, five major areas of such distortion
are summarized.
L The ‘'public health" practiced by exponents of the international initiatives
is starkly ahistoncal (16, 17). They seem to consider themselves the inventors of
the wheel. So carried away were they with the “...
“new” thinking injected into their
heads by the ruling class that they seemed to have
- 2 no use for the pioneering work

Intellectual Fascism and Health / 251
in public health done in earlier years by many profound and dedicated scholars.
C.E.A. Winslow s classic definition of public health way back in 1920 (118)'
Henry Sigerist s emphasis on the history of medicine (119-121) to develop a
perspective for building health services, as in the report of India’a Shore Com­
mittee (21); John Grant's efforts to promote regionalization of health services and
take public health research and practice to rural field stations (40 122)- the
pioneering works of Rene Sand (123), John Ryle (124). and Iago Galdston (125)

.

in giving content to the important specialty of social medicine; John Gordon's
pathbreaking field research at Khanna in India on the epidemiology of child
mortahty and morbidity (126); Hugh Leavell's insightful ideas on the develop­
ment of strategies for intervention in the epidemiological behavior of a health
°n ana'ySiS °f itS natUral histOr* of disease in
individual
(127-129); Edward McGavran's exposd on an epidemiological approach to
solvmg a public health problem (130); Milton Roemer's contributions to health
manpower development (131); George Foster's pioneering work on medical
anthropology (132); P. V. Benjamin and Halfdan Mahler's dedicated efforts to
establish the National Tuberculosis Programme in India (35) and the latter's role
in getting the Alma-Ata Declaration on Primary Health Care all over the world—
these are but a few of the works of just some of the pioneers. The public health
experts hired by WHO/WB/UNICEF have been selectively bred and properly
programmed to be unaware, or at least to pretend to their paymasters that they are
unaware, of (he work of such pioneers.
2 The scientific term "epidemiology", which forms the foundation of public
health practice, has been grossly misused by the new breed of experts. On the
asis of the unrepresentative nature of the data used and their highly questionable
reliability and validity, and the very limited data on causative relationship,
validity and reliability of impact measurement, and the time trends, we can reject
out of hand the scientific bases of almost all the international initiatives taken by
the triad. Epidemiology, besides, includes the crucial areas of natural histories of
,d,‘S-,T" °VCr tnne (133~139) and in the individual, as emphasized by Leave!)
(128). The experts have chosen simply to ignore other important areas, such as
the social meaning of epidemiological data, the politics and political economy
of health, and concepts of health administration elaborately developed in poor
countries like India for over six decades (18, 129). In their zeal to sell their wares
they have also grossly distorted the concept of health economics, by confusing it'
wrtl, health financing (13). This amounts to practice of public health quackery
A Similar fate was meted out to a well-established research tool-operational
research (67, 68, 140-146). Developed in the course of World War D, it has very
specific connotations and has enormous application to public health practice
as rt seeks to optimize complex systems. These specifications too were simply
ignored, and operational research has been grossly vulgarized (e g., 69)
3. Suppression of information, use of doctored information, spread of
misinformation and disinformation, and lack of effective evaluation/surveillance

r

252 / Banerji
arc expected outcomes when
programs are meant to serve power managers,
required by their paymasters to satiate the
ever increasing hunger of the
marketplace.
4. Directors-general of two top public health institutions in India extended
their support to the OPT. even though serious Haws in the program were
repeatedly brought to them notice. After they endorsed the WHO/WB program
they found highly lucrative positionsJnpositions jn WHO. It is not necessary to speculate
stJ'd d ft" lnStanC“' This marks the rock-bottom of the moral and ethical
standards of the practices of the parties concerned
in tb?c0ShX°
0,6 conscience
of ^ics and morality
'°
h Phh w h
h pract,ce~teachers public health schools/institutes. key public
health administrators in national and international institutions, nongovernmental
organizauons, and political leaders/activists responsible for safeguarding and
suThum6! f
‘b' peOplc~arc perhaps thc w°rst offenders in inflicting
such humiliation on dte peoples of the world. Apparently attracted by the finan­
cial rewards, many of these professionals actively associated themselves with the
not so ethical and moral ventures. Many others looked the other way fearing
retribution for exclaiming that the emperor had no clothes. And there must hav!
been a very substantial number of this "intelligentsia” who could not move
themselves to find out what was happening. The situation certainly did not
compare m depth with that in Hitler’s Germany or even Franco’s Spain but the
resemblance is uncanny. It shows how cheaply the leaders of the profession
be brought, to lend them support for patently unscientific, unethical and
immora^programs which have cost literally
hundreds of
of thousands
thousands of
of lives
lives of
of
literally hundreds
The line of action for those few who still attach a high value to intellectual and
moral mtegnty, and are prepared to pay the sort of price mentioned by Navarro
(1), emerges from the analysts made in this report. Tire Indian subcontinent and
China must take the responsibility for rediscovering their lost heritage, to set
the tone for a tentative, people-oriented health services for the long-exploited
^piuuco,
depnvcd peoples of the world.

REFERENCES
1.

LAoh'l'°riCal reV,iCW (1965-'977> Df studi«
class, health, and quality
ofhfe. A personal account. Int. J. Health Serv. 28(3): 389-406 1998
?
J^'
in
UnivCrSal Child Immunization Programme
£,™mme.
J. Indian Med. Assoc. 84(8): 229-232, 1986.
,MCd'Cal R“carch- P^nsonon of 1CMR Supported Research
1

Delhri985

Bh°Pa‘

Co"abora'inS

New

4. Medico FriendI Circle. The Bhopa! Disaster Aftenttath: An Epidemiological and
Socio-medical Survey. New Delhi. 1985.
Qna

Intellectual Fascism and Health / 253
5. Morehouse, W.. and Subramanian, M. The Bhopal Tragedy. CGPA. New York 1987
6. Sadgopal.
Sadgopal, A. Comments on ICMR’S Epidemiological Report of the Gas-Exposed
Localities of Bhopal. Submitted to the Supreme Court Committee. New Delhi. June
28, 1986.
7. Indian Council of Medical Research. Scientific studies on Bhopal gas victims:
Part-A. Indian J. Med. Res. 86(Suppl), 1987.
8. Narayana, T. The Health Impact of the Bhopal Disaster: An Epidemioloeical
Perspective. LSHIM, London, 1987.
.
9. Baneiji, D. Bhopal tragedy and Sarkari scientists. Econ. Polit. Wldy. 20(32): 1330
1985.
10. Banerji. D. An epidemiological and sociological study of the Bhopal tragedy: A
preliminary communication. Medico Friend Circle Bull. 114. June 1985.
11. Manhoff. R. K. Social marketing and nutrition education: A pilot project in Indonesia
Assignment Children 65/68: 95-113, 1984.
12. Grant. J. P. Marketing child survival. Assignment Children 65/68: 3-9, 1984.
13. World Bank. Health Sector Financing: Coping with Adjustment Opportunities for
Reforms. Population and Human Resources Division. Washington. D.C., 199">
14. Baneiji. D. A Socio-cultural, Political and Administrative Analysis of Health Policies
and Programmes in India in the Eighties: A Critical Appraisal, p. 9. Lok Paksh New
Delhi, 1990.
D ^oc’a* and cultural foundations of health service systems of India. Inquiry

16. I^Vs170’ V C0minCnt: WJ1OSC globalisation? Am. J. Public Health 88(5): 742-743,
17

I984,n,ay’ J B Issue5 in ,lie Political Economy of Health Care. Tavistock, London,

18. Baneiji, D. Landmarks in the Development of Health Services in the Countries of
ASia' PP’ 29-53’ Nuclcus for Health Policies and Programmes, New Delhi,
19 1990° H and RuthcnnOnd’ D‘ A Hisfory

PP 236-316. Routledge, London,

20. National Planning Committee, Sub-committee on National Health (Sokhey Com­
mittee). Report, edited by K. T. Shah. Vora, Bombay. 1948.
21. Government of India. Health Survey and Development (Bhore) Committee. Report
(Bhore Committee). Vol. IV. Manager of Publications. Delhi. 1946.
22. Dutt, P. R. Rural Health Services in India: Primary Health Centres, Ed.
2. Central
Health Education Bureau, New Delhi. 1965.
23. Bhattacharya, S. N. Community Development:: An Analysis of the Programme in
India. Academic Publishers, Calcutta, 1970.
24. Taylor, C. E., et al. Doctors for the Villages:: Study of Rural Internship in Seven
Medical Colleges. Asia Publishing House, Bombay. 1978.
25. Banerji, D. Social orientation of medical education in India
Econ. Polit. Wldy. 8:
485^188, 1973.
26. Government of India, Group on I'
” ‘ Education
‘
Medical
and Support Manpower. Health
Services and Medical Education: A Programme for Immediate Action. Ministry of
Health and Family Planning, New Delhi, 1975.

254 / Banerji
27. Government of India. Central Health Council and Central Family Welfare Council

aSKsa;

*** ',im *1 mw ”’ "

28. Pandit. C. G. Fifty Years of Progress: Indian Research Fund Association and ICMR
Indian Council of Medical Research, New Delhi. 1961.
29 ^^DeDu^m
PreV€ntive Medicine -Indian Council of Medical Research,
30. Government of India, Health Survey and Planning (Mudaliar) Committee. Report
M.nistry of Health, New Delhi, 1962.
31. Government of India, Central Council of Health. I J.
Indian System of Medicine and
Homeopathy, Agenda Item No. 6. Ministry of Health
and Family Planning, New
Delhi, 1974.
32. Tuberculosis Centre. Madras. A concurrent comparison of home and sana-

^^treatment of pulmonary tuberculosis in India. Bull. World Health Organ. 29:
33. Baily, G V. J. Trial of BCG vaccines in South
India for tuberculosis prevention.
Indian J. Med. Res. 72 (Suppl.) July 1980.
34. World Health Organization. BCG Vaccination i
Policies: Report ,of a WHO Study
Group. WHO Technical Report Series Number 652. Geneva, 7980.
35. Banerji, D. A social science approach to strengthening India's National Tuberculosis
Programme. Indian J. Tuberculosis 40: 61-82, 1993.
36. Nagpaul. D. R. District Tuberculosis Programme in concept and outline. Indian
J. Tuberculosis 14(4): 186-198, 1967.
37 9 *25 9^1 TubCrCU,°SiS 35 3 Prob,crn of social planning in India. NIHAE Bull. 4(4):
38. Government of India. Annual Report 1977-78. Ministry of Health and Family
Welfare, New Delhi, 1978.
7
39. Government of India. Statement of National Health Policy. Ministry of Health and
Family Welfare, New Delhi, 1982.
40. Siepp, C. (ed.). Health Care for the Community: Selected papers of Dr. John B.
Grant. Johns Hopkins University Press, Baltimore, Md., 1963.
41. Ramasubban, R. Public Health and Medical Research in India: Their Impact During
the Bnttsh Colonial Policy. SAREC Report No. 4. SAREC, Stockholm, 1982.
'
V‘ W” 311(1 Sidc1, R- 7110 hca,th carc dcl'very System in the People’s Republic
?975h,na 10 Hfallh by ,he PeoPle‘ edited by K. N. Newell, pp. 1-13. WHO, Geneva,
43. Lampton. D. N. The Politics of Medicine in China: The Policy Process 1949-1977
Dowson, Folkstone, England, 1977.
44. Jancloes. M. The poorest first: WHO's activities to help the people in greatest need
World Health Forum 19(2): 182-187, 1998.
45. World Health Organization Tuberculosis Unit. First Prog,
ramme Report (1989-90)
and Future Plan (1991-1995). Geneva,’1991.
46. World Health Organization. Tuberculosis Programme: Report of the Second Meeting
of^he Coordination, Advisory and Review Group. WHOaVS/CARG/91.4. Geneva,
47. World Health Organization. WHO Repi
'on on Tuberculosis Epidemics, 1995. WHO
TB/95/183. Geneva, 1995.

Intelleclual Fascism and Health / 255
48. Mari Bhat, P. N„ and Irudayarajan, S. Demographic transition in Kerala Econ Polit
Wkly. 28(23), 1992.
49. Jagadeesan, C. K. Exploring an enduring myth: The ‘Kerala Phenomenon.’ Health for
the Millions 23(2): 13-15, 1997.
50. World Health Organization. Intersectoral^nkage and Health Development, edited
by G. Gunatillake. WHO Offset Publication No. 83. Geneva. 1984.
51. Barraclough. S. Growth of corporate private hospitals in Malayasia: Policy contra­
dictions in health system pluralism. Int. J. Health Serv. 27(4): 643-660
643-660, 1997.
52. World Health Organization. Primary Health Care: Report on the International Con­
ference on Primary Health Care, Alma-Ata, USSR, September 6-12, 1978. Geneva,
1978.
53. Walsh, J. A., and Warren, K. S. Selective primary health care: An interim strategy for
disease control for developing countries. H. Engl. J. Med. 301: 967-974, 1979.
54. Institute of Tropical Medicine, Antwerp. Proceedings of the Meeting on Selective
Primary Health Care, November 29-30, 1985. Antwerp. 1985.
55. Institute of Tropical Medicine. Antwerp, Manifesto. Antwerp. 1985.
56. Editorial. The debate on selective or comprehensive primary health care Soc Sci
Med. 26(9): 877-878,1988.
57. Banerji, D. Technocentric approach to health: Western response to Alma Ata Econ
Polit. Wkly. 21(28): 1233-1234. 1986.
58. Banerji, D. Crash of the Immunization Programme: Consequences of a totalitarian
approach. Int. J. Health Serv. 20(3): 501-510, 1990.
59. Grodos, D., and de Bethune, X. Les interventions sanitairs sdectives: Un pifcge pour
les politiques des santd du tiersmonde. Soc. Sci. Med. 20: 879. 1988.
60. Newell, K. N. Selective primary health care: The counterrevolution. Soc. Sci Med
26(9): 903-906, 1988.
61. Wisner, B. GOBI versus PHC? Some dangers of selective primary health care Soc
Sci. Med. 26(9): 693-699, 1988.
62. Banerji, D. Primary health care: Selective or comprehensive. World Health Forum
5:312-315, 1984.
63. Rockefeller Foundation. Protecting the World’s Children: Vaccines and Immuni1984^ WZ/r^,n
Health Care, Conference Proceedings, Bulletin I. New York,
64. Rockefeller Foundation. The Task Force for Child Survival: Protecting World’s
Children, Bellagio II. New York, 1986.
65. Banerji, D. Will forcible sterilisation be effective9
Econ. Polit. Wldy. 11(18):
665-668, 1976.
66. Government of India. Centre Calling, X
67. Churchman, C. W., et al. Introduction to Operation Research. John Wiley, New
York, 1957.
68. Andersen, S. Operations research in public health. Public Health Rep. 79(4), 1964.
69. Government of India, Tuberculosis Division, Directorate Genera! of Health Services.
Hational Tuberculosis Control Programme: Current and Revised Strategy: A Brief.
Ministry of Health and Family Welfare, New Delhi, 1995.
70. Grant, J. P. Child survival and development revolution. Assignment Children
61/62(1): 21-31, 1983.

256 / Baneiji
71. Mandi, P. E. Achieving nation-wide programme coverage: Innovative strategies
and methods. Assignment Children 65/68, 1984.
72. Vittachi, V. T. CSDR: Dialectics of development Assignment Children.
69/72:
19-31. 1985.
73. Grant, J. P. Universal child irritnunization by 1990. Assignment Children 69/72- 3-11
1985.
74. Bland, J., and Clements, J. Protecting the world’s children: The story of WHO’s
immunization programme. World Health Forum 19(2): 162-173, 1998.
75. World Health Organization. 41st World Health Assembly. World Health
Forum
3:470-480, 1980.
76. Dietz, V.. and Cutts, F. Use of mass campaigns in the Extended Programme of
Immunization: A review of reported advantages and disadvantages. Int J Health
Serv. 27(4): 767-790, 1997.
77. Mann, J. Global AIDS: Epidemiology, impact, projections, global strategy. In AIDS:
Prevention and Control: World Summit of Ministers of Health on Programmes for
AIDS Prevention, Jointly Organized by WHO and the United Kingdom, 26-28
January, 1988, pp. 3-13. WHO, Geneva, 1988.
78. Crofton, J. Don’t let us wait another 40 years: Discussion on the Round Table on
Tuberculosis control: Is DOTS the breakthrough of the 1990s?’ World Health Forum
18(3-4): 233-234. 1997.
79. World Health Organization. Expert Committee on Tuberculosis: Eighth Report.
Geneva, 1964.
80. Fox. W. Tuberculosis in India: Past, present and future. Indian J. Tuberculosis
37: 175-213, 1990.
81. Banavalikar, J. N., el. al. HIV seropositivity in hospitalized pulmonary tuberculosis
patients in Delhi. Indian J. Tuberculosis 44(1): 17-20, 1997.
82. Baneiji, D. Combating AIDS as a Public Health Problem in India. Voluntary Health
Association of India and Nucleus for Health Policies and Programmes. New Delhi,
1992.
83. Kochi, A. Round Table: Tuberculosis control—is DOTS the breakthrough of the
1990s? World Health Forum 18(3-4): 225-232, 1997.
84. World Health Organization and UNICEF. The Management of Diarrhoea and Use
of Oral Rehydration Therapy, Ed. 2, pp. 1-15. A Joint WHO/UNICEF Statement
Geneva, 1985.
85. World Health Organization. Programme for Control of Acute Respiratory Infections
Programme Report WHO/RI 89(3). Geneva. 1989.
86. World Health Organization. Maternal Care for Reduction of Perinatal and Neonatal
Mortality. A Joint WHO/UNICEF Statement. Geneva, 1986.
87. Commission on Health Research and Development. Health Research: Essential
Link to Equity and Development. Oxford University Press, New York, 1990.
88. Council for Health Research for Development. COHERD/ENHR Evaluation in
Progress. Newsletter COHERD 6: 2. July-September 1996.
89. Swedish Agency for Research Cooperation with Developing Countries. Annual
Report 1988-89. Stockholm, 1989.
90. International Development Research Centre, Canada. Twenty Years of Development
Through Research. Ottawa, 1990.

Intellectual Fascism and Health / 257
91. Government of India, Universal Immunization Programme by 1990: Report of a
Task Force. Ministry of Health and Family Welfare. New Delhi. 19^4
J
92. Gupta. J. P., and Murali. I. National Review of the Immunization Programme in India.
National Institute of Health and Family Welfare. New Delhi. 19^f)
93. Banciji. D. National Review of Immunization: The Case of West Bengal Centre of
Mcd>cine and Community Health, Jawaharlal Nehru University, New Delhi.

ec-s-p.

^^4

94. International Institute ofPopulation Studies. National Family Health Survey in IndiaAn Introductory Report. Bombay, 1994.
95. Tuasidhar, V. B. Expenditure compression and health sector analysis Econ Pnlit
Wkly. 27(45), 1993.
‘
96. Duggal, R. Public health budgets: Recent trends. Radical Health 1(3): 177-182
1995.
*
97 19988’ S Wh°SC Cpidemi0,0gy’ whosc hca,th? lnt- J- Health Se'rv. 28(2): 241-252,
98. Mann. J. (Quoted inj Women and AIDS: The unprotected sex. Womens Health J

April-June 1990.

99. Mann. J. Global AIDS: Critical issues in the prevention in the 1990s lnt J Health
Serv. 21(3): 553-559, 1991.
100. Moss, A. R., and Baccheti, _. Natural history of HIV infection. AIDS 3: 55-61, 1989.
101. Peterman, T. A., et al. Epidemiology of AIDS Epidemiol. Rev. 7: 1-21, 1985. ’
102. World Health Organization. Global Programme on AIDS: Current and Future
Dimensions of the HIV/A1DS Pandemic. A Capsule Summary. WHP/GPA/RES/
SFI/92.1. Geneva, 1992.
103. Editorial. Health for the Millions 22(6): I, 1996.
104 ^996^*’ D AIDS thrCat tO Ind’a: A rcsPonsc- Health for the Millions 22(6): 23-27,
105. Anil, P. TB: A global emergency? In A National Consultation c
on Tuberculosis,
pp. 22-23. Voluntary Health Association of India, New Delhi, 1994.
106. Jhunjhunwala. B. C. Efficacy of the Revised National Tuberculosis Programme.
In Z/anono/ Consultation on Tuberculosis, pp. 12-21. Voluntary Health Association
of India, New Delhi, 1994.
107. Nagpaul. D. R. Editorial: Surajkund deliberations. Indian J. Tuberculosis 39- 1-2
1992.
108. Banerji, D. Serious Implications of the Proposed Revised National Tuberculosis
Programme for India. Voluntary Health Association of India and Nucleus for Health
Policies and Programmes, New Delhi, 1997.
109. Banerji, D. Population planning in India: National and foreign priorities lnt J Health
Serv. 3(4), 1973.
110. Banerji, D. Will forcible sterilization be effective? Econ. Polit Wkly HHRy
665-668,1976.
111. Community response to the intensified family planning
programme. Econ. Polit.
Wkly. 12(6-8): 261-266. 1977.
112. Banerji, D. Family planning in the nineties. Econ. Polit. Wkly. 27: 883-887, 1992.
1 13. Minkler. M. Thinking the unthinkable: The prospects of compulsory sterilization in
India. Int. J. Health Serv. 7(2): 237-248. 1977.

<^=-

s^5'7 . ..

f.rst

258 / Banerji
114. Banerji, D. Health services and population policies. Econ. Polit. Wkly. 11(31-33):
1247-1252. 1976.
115. Banerji, D. India’s forgotten people and the sickness of the public health service
system: A prescription for the malady—A summary in three parts. Health For The
Millions 23(3-5), 1998.
116. Bergstrom, S. Welfare as a need in Indian population policy. Tropical Doctor. Pt. 1:
182-184, October 1982.
117. Demerath, N. J. Birth Control and Foreign Policy. Harper and Row, New York, 1976.
118. Winslow, C. E. A. The untilled fields of public health. Science 51(8): 23-33, 1920.
119. Marti-Ibanez, F. Henry Sigerist on the History of Medicine. MD Publications,
New York, 1960.
120. Sigerist, H. E. Civilization and Disease. Cornell University Press, Ithaca, N.Y., 1943.
121. Sigerist, H. E. History of Medicine. Oxford University Press, New York, 196 /
122. Grand, J. B. International planning of organizations of medical care. In Health Care
for the Community: Selected Papers of Dr. John B. Grant, edited by C. Siepp. Johns
Hopkins University Press, Baltimore, Md.. 1963.
123. Sand, R. The Advance of Social Medicine. Staples Press. New York, 1980.
124. Ryle, J. A. Changing Disciplines. Oxford University Press, London, 1948.
125. Galdston, I. The Meaning of Social Medicine. Harvard University Press, Cambridge
Mass., 1954.
126. Wyon, J. B., and Gordon, J. The Khanna Study: Population Problem in Rural Punjab.
Harvard University Press. Cambridge, Mass., 1971.
127. Leavell, H. R. Levels of application of prevention medicine. In Preventive Medicine
for the Doctor in his Community: An Epidemiological Approach, edited by H. R.
Leavell and E. G. Clerk, pp. 14-38. McGraw-Hill, New York, 1965.
128. Leavell, H. R. Basic unity of private practice and public health. Am. J. Public Health
43: 1501-1506, 1953.
129. Leavell, H. R. Health administrator in the making. NIHAE BulL 1: 15-19, 1968.
130. McGavran, E. G. What is public health? Can. J. Public Health 441—451, 1953.
131. Fulop, T., and Roemer M. I. International Development of Health Manpower Policy.
WHO, Geneva, 1982.
132. Foster, G. M. Medical Anthropology. John Wiley, New York, 1978.
133. Dubos, R., and Dubos, J. The White Plague. Little Brown, Boston, 1952.
134. Dubos, R. Mirage of Health, Utopias, Progress and Biological Change. Anchor
Books, New York, 1959.
135. McDermott, W. Demography, culture and economics and the evolutionary stages
of medicine. In Human Ecology and Public Health, Ed. 4, edited by E. D. Kilbome
and W. G. Smille, pp. 7-28. Macmillan, London, 1969.
136. Mckeown, T. Role Medicine: Dream, Mirage or Nemesis? Nuffield Provincial
Hospitals Trust, London, 1976.
137. Grzybowski, S. Epidemiology of tuberculosis with particular reference to India.
Indian J. Tuberculosis 42: 195-200, 1995.
138. Chakraborty, A. K. Tuberculosis situation in India: Measuring it through time. Indian
J. Tuberculosis 40: 215-226, 1993.
139. Grigg, E. R. N. Arcana of pulmonary tuberculosis. Am. Rev. Tuberculosis Pulmonary
Dis. 78: 151-172; 426-453; 583-603, 1958.

‘l

Intellectual Fascism and Health / 259
140. Mishra. B. D. Organization for Change: A Systems Analysis of Family Planning in
Rural India. Radicnt Publishers, New Delhi. 1982.
141. World Health Organization. South-East Asian Regional Office. The Concept of
Health Services Research. New Delhi. 1983.
142. World Health Organization. South-East Asian Regional Office. The Concept of
Health Services Research. New Delhi, 1985.
143 HTn’G M ’ Cl aI Pal,entS' H°sPitals arui Operational Research. Tavistock. London.
144. Banerji, D. Administration of family planning programme: A plea for an operational
research approach. Management in Government 1(2): 46, 1969.
N5 Banerji. D
145.
D. OpCratiOnaI
Operational rcsearch
research in 1,10
the r,cld
field of public
publi< health. Opsearch 9: 13-16,
146. Banerji, D. Research in Delivery of Health Care in Countries of SEARO
WHO/SEARO, New Delhi, 1976.

Direct reprint requests to:
Dcbabar Banciji
Nucleus for Health Policies and Programmes
B-43 Panchsheel Enclave
New Delhi 110017
India

k * > tfv* •

F‘

/8c c ca v e d

The Information Age
Challenges : Role of NGOs

Chandra Kannapiran is Senior
Programme Officer in the
Information and Documentation
section of V1IA1. She has been in
VHAI for more than 18 years.

Chandra Kannapiran

In today’s world the most powerful
resource used by people in
government, business or any other
system in life is Information. People
have always relied on information
for rational behaviour, be it
physiological, environmental or that
of more abstract higher realms of
thinking and decision making. It is
information on which is based the
adaptive changes that one normally
makes throughout one’s life.
The Setting

Information is also used as a
weapon today either to build or
break a system. Be it a political
campaign, news reporting (a la BBC!)
or advertising a new product in the
ever competitive commercial
market, a scientific break though in
biotechnology, it is information,
which is moulded according to the
interest of the provider that reaches
the masses.
The new developments in
electronics and telecommunications
has enhanced this process. Every
country tries to strengthen its
knowledge base to have a firm hold
on its resources and technology. At
the same time, by using satellites
and remote sensing facility they try
to extract as much information as
possible from other countries for
their own benefit. As a result, each
country tries to compete with one
another to acquire the latest
information technology and partake
in the information age race. Speed
and variety is the order of the day in
this age.
We are witnessing a historic process
of humankind, which will inevitably
change man’s psyche. Our inner

images of reality, responding to the
acccderation of change outside
ourselves, are becoming shortlived
and temporary. We are creating and
using up ideas and images at a faster
speed than ever before. As a result,
family life, market place and others
are breaking into varied mini­
markets. They demand continuously
expanding range of options, models,
hypes, types and colours. Bell
telephones which once hoped to
put the same black telephone in
every home, now manufactured
thousands of combinations of
telephone equipments in all the
colours, shapes, styles etc. Now
Cellular’s have hit the market. The
situation is the same with food,
fashion designing and architecture.
It is not what knowledge the country
holds but the speed with which it is
continually renewed, by passing on
the know-how to those who need it
and acquiring new techniques
swiftly from all over the world. It is
not the "stocks” but the "flows” that
matter. The key infrastructure of
the present and the 21st century is
the electronic networks. For the
national economic development
building up this 'information
highway’ across the continents has
become the vital part of life.

"Info-rich” and "Info-poor” deepens
further. As a result, there is growing
unrest which bursts out in the form
of violence. Dissatisfaction and
terrorism have become part and
parcel of our social life. It is said
that ‘Tomorrow’s terrorist may be
able to do more damage with a key
board than a bomb’. This is a good
example to show that new
technology could also be misused.
It may be the ‘suppressed
information’ or ‘tailored information’
by the authorities, which may be
the cause of unrest or terrorism.
Through violence they try to
demonstrate that they are deprived
of economic development or
political mileage. A country which
builds up massive super technology
in the name of development, may
ignore the basic needs and
aspirations of the majority
population. Due to this ‘haphazard
development’ we see contrasts in
every sphere of life. A country might
have a sophisticated technology
equivalent to the first world
countries, while on the other hand,
there might be incidences in dayto- day life, which would remind us
of the medieval period. For the
people,
our
multitude
of
‘development’ is a distant dream !

'rhe Deprived Millions

The Striking Contrasts

While the world is coming closer
together at one level to form the
‘global village’, its is also breaking
into fragments at another level.
Development does not reach a
massive portion of the population.
While the information age benefits

At this juncture of history, each one
of us has a role to play to bridge the
gap between the ‘Information-rich ’
(Info-overfed) and ‘information-poor ’
(Info-starved) people. Working in
the NGO sector, we are constantly
in the process of empowering people
with information to change their
present situation to a better
tomorrow. Paulo Friere said.

are few and its fruits are enjoyed by

the power holders, the cleavage
between the "well informed” or

Health for the Millions • Souvenir • Oct. 1995 • 68

"Conscientizing people will facilitate
people perceiving their needs". We
use several methods to emphasise
his statement through our awareness
programmes,
training,
skill
development campaigns and socio­
economic
initiatives
and
interventions. All these little acts go
a long way to strengthen the
individual and in turn, the whole
society. Charles Jepson, Director of
Office Marketing Hewlett Packard
Co. says “Information is catalyst for
effecting change at every level.
That’s what makes its power so
awesome”
Gone are the days where oral culture
was the only way to transmit
information or communicate
knowledge. At that time myths,
legends, history and others were
passed on from generation to
generation through speech, songs,
folklores, charts etc. All this
knowledge was stored in the mind
of the individual. The information
was personalised and individualised.
The next civilization moves this
memory outside the individual. It
smashed the memory barriers and
spread mass literacy, build libraries
and museums and learnt to store
information outside the person.
Today, we are about to take a
quantum jump into a whole new
world where information is the
ultimate and infinite power. The
mapping of earth by satellites,
monitoring of patients by electronic
(cyber)
computer
sensors,
communications, etc. reaching the
nooks and corners of the world, is a
virtual reality. This civilization will
have more finely organised
information about itself than ever
before,. Even more astonishing is
the conversation between human
and the intelligent environment
around us.
It is this vast amount of information
which explains that we are in the
age of ‘Information Explosion ’.
Though many more vistas netjd to
be explored, further arming the
information arsenal.

The Super Technology
Satellites have revolutionised the
daily lives of people when it entered
the drawing rooms of houses in
cities, as well as in villages. Different
types of information are bombarded
into the minds of people from all
over the world. As a result there is
utter chaos in the minds of people.
More questions. What is the truth ?
How is this product better than the
other one ? How to select from the
hundreds of varieties ? Whom to
believe ? What actually happened?
So on and so forth. This gives rise to
all kinds and shades of people :
Sure shots, converts, sceptics,
solipsists, sophists... leave apart, the
info-starved.
At this information age, we should
use the same technology to provide
the correct information and to
strengthen the deprived millions.
There was a time when the sword
was a powerful weapon, but when
the sophisticated automatic weapon

and reach the right information to
people to empower themselves.
Alvin Toffler, the great futurist of
our times, rightly said " the arrival
of the computer is not only likely to
bring in revolutionary changes in
various walks of human endeavour.
Even lifestyles will change. In such
a highly complex
society,
information would be the most
essential and highly valued property.
Knowledge would be power in the
real sense of the phrase”.
The computer creates an historically
unprecedented situation. It processes
the data it stores and makes social
memory extensive and active. The
computer can be asked by us to
think the unthinkable and the
previously unthought. It make
possible a Hood of new theories,
ideas, artistic insights,technical
advances, economic and political
innovations. In this way it can
accelerate social change and thrust
towards social diversity.

■v

''v

IBB-

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'^13

came into the picture, war strategies
changed. Oil lamps are replaced by
electric bulbs in villages. Tractors
are used in agriculture.

In the same way, info-war has to be
fought with (titlermil strategics. By
using tin! same h t hnolugy, vve could
militantly criticise misinformation

Francis Bacon predicted that
“knowledge itself is power ”. Our
generation is witnessing this fact in
all the realms of contemporary life.
Knowledge turns out to be not only
the source of the highest quality
power, but also the most important
ingredient of force and wealth. This
explains why the battle for control

Health for the Millions • Souvenir • Oct. 1995 • 69

of knowledge is heating up all over
the world. 7/je poivar, muney and
knowledge form a single interactive
system. Information cun be used to
increase money or to multiply the
force at your command. Unlike
bullets or budgets knowledge does
not get used up. This is the reason
for its supermacy in the latest power
game - the “Info-Wars”.
The Role of NGOs in the
Information Age

The NGOs face an extremely difficult
task in this information era. How to
give a ‘Democratic Development
Plan’ to the different strata of the
society ? How to have a 'balanced
strategy’ to improve the social sector
in line with the other important
sectors like defence, economy ? I low
to include the peojilcs basic needs
i
he various policies ? How to
appropriately use the super
technology for the people ? These
are some of the questions NGOs
face in this information age.
Sam Pitroda correctly said that
"information is a major tool for social
transformation in India". Social
justice and freedom both now
increasingly depend on how each
society deals with three issues :
Education, Information technology
(including media), and Freedom of
expression. To achieve this status,
there is a need for the speedy
universalisation of access to
computers, information technology
and advanced media. This requires
a ■ 'pulation as familiar with this
ii. mational infrastructure as it is
with roads, trains, vehicles and other
existing infrastructure.

on wide range of development, social
justice, environment, health and
other issues. All the innovations,
findings and success stories could
be shared with others working in
similar acreas around the globe. At
the same time many new ideas,
techniques, skills and strategies
could be learnt from other parts of
the world. Computer networks, EOn-line
Mail,
Databases,
conferencing etc, go a long way in
bridging the gaps between the
‘information-rich’ and ‘information­
starving’ societies. A good example
is the recently held international
conferences. NGOs played a strong
and well publicised role at the Earth
Summit, ICPD, Social Development
and the World Conference on
Women held at Beijing. These are
excellent examples to show the
acceptance of NGOs as key partners
in developing and implementing
development policies.

Computer communications and
networking can help build national
and regional information resources
that can be disseminated in Local
Languages. At the same time
international sources can also be
tapped and thus bridge the
geographical distances. NGOs could
pass on our innovations to the first
world and turn the flow from south
to north. Dy this process, the
monopoly over information in the
hands of a few countries could be
challenged.
They could also regulate the two
way flow of information. This would
be a major contribution of NGOs in
this information age. This way, we
could monitor and streamline several
projects and natural resources and
avoid problems of patenting etc.

Development strategies make no
sense, unless they take full account
of the new role of knowledge in
wealth creation. Information is a
major component for the success of
a firm. It is imperative that the NGOs
understand the need for managing
information effectively, as it would
ultimately lead to their successful
performance.

The information highway welcomes
the NGOs to share their innovations
and experiences in exchange for the
ideas and techniques from the rest
of the world. The benefits are
manifold:

NGO activities include field level
action plans, research and analysis

♦ NGOs would have the ability to
collect and send information,

Health for the Millions • Souvenir • Oct. 1995 • 70

ideas from and to the remote
corners of the world
♦ To access information in different
forms, written material audio,
visual (graphics) multi-media and
many more

♦ Increased speed and accuracy in
its retrieval and conununication
across national boundaries
4 Quick
reproduction
information

of

♦ Low cost link to exchange and
share large volumes of data
♦ Saves time and resources
❖ Exchange into at any time and at
any place
❖ Development of a global network
of people with a common
interest like health activists .
❖ Opportunities for professional
development
❖ To help fnlfil the needs of people
using the latest technology
Our country is famous for its natural
resources and time tested indigenous
knowledge of herbal medicine. Since
it is not ‘scientifically’ proved by us
with regard to its efficacy, some of
the technologically affluent countries
are patenting our herbs which we
used for generations, as their
invention ! Time has come for us to
strengthen our hold, ascertain our
position, save our resources, and
also get the credit internationally as
the pioneering country in various
fields, by using new strategies to
face the technological threats.
NGOs have earned their name for
their innovations, appropriateness
and people centred initiatives. India
is one of the leading countries in the
Information race, both in hardware
and software production. We have
all the infrastructure available to be
at par with any first world country.
Here, the role of NGOs is unique.
They should find ways and means
of making this technology people
oriented. It should be moulded

according to the local needs and
make it appropriate to solve their
day-to-day problems.

As NGOs, we should see whether
the new information technology
could answer the following
questions:
Could we avert another Bhopal
Gas tragedy ? Can we avoid
Earthquakes like Latur ? Can we
prevent Dhanbad mine disaster ?
Could we control Malaria and TB
deaths ? These are some of the
challenges before NGOs in this
information age.

PIT

I

massive international sources and
pass it on to the regional or local
centres and also transmit the
innovations of the field level
initiatives al the national and
international levels. NGOs could
thus focilitate the two-way
flow of information between north
and south.
VILAPs Share in llie Information
Age
For the past one and a half decades
VHAI pioneered
in Health
started
Documentation and
term
short
conducting
training
documentation and

Welcome the Information Highway
It is said that tomorrow ’s
‘Development’ strategies will com
not from Washington or Paris 01
Geneva but from Africa, Asia and
Latin America. They will be
indigenious, matched to actual local
needs. They will not over emphasise
economics at the expense of culture,
ecology, religion or family structure
and psychological dimensions of
existence. They will not initiate any
outside model. They will rather
create new ones. The information
age provides the world’s poorest as
well as the richest nations with
wholly new opportunities.

'
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■

A •g
>■ IRarrw) ■

-yrtlkir

7

■

NGOs should enter the information
highway and act as a bridge between
the international and local
information resources. They would
be the perfect judges to collect the
relevant information from the

etc. VHAI entered the Information
age through Computerisation
including
Computer
Communications, E-mail and
tapping International Databases like
Medlars, Popline etc. for the use of
its various activities, state VHAs and
affiliate groups. At present VHAI is
preparing itself to be a platform for
exchange of information between
International, National, State,
District and Village Information
Centres. We are aware that we have
a long way to go, Selecting and
Repackaging information from the
grass-root level initiatives for the
international plane. This is a
herculian task. But we are confident
and determined to achieve this feat.

programmes for the NGOs. VIIAl
also helped many NGOs to start
their own documentation centre in
varied fields like tribal development,
medicine,
slum
traditional
information centres, environment

Let us join hands and reach out
and humanise the distant tomorrows.
As NGOs, we have a destiny to
create in
this challenging
information age.

Message to VHAI
Your strenuous efforts for pretty long period has brought a very nice set up in the country. It will be
an asset in the long run for poor and needy patients in the country.

Go ahead and have brilliant success.
Gautam C. Mazumdar
Hony. Secretary
Indian Red Cross Society
C.S. Samariya Red Cross International Eye Bank
1, Atulya Bhavan, Near Consumer Centre, Sarkhej-Gandhinagar Highway, Thaltej, Ahmedabad-54.

Health for the Millions • Souvenir • Oct. 19^5 • 71

PRIMARY HEALTH CARE - A CHRISTIAN MANDATE
February 26,1996
BISHOP D C GORAI

President of CMAI, distinguished participants, members of
the medical fraternity, our respected guests and partners
from overseas churches and agencies - I greet and welcome
you to a meaningful consultation on PRIMARY HEALTH CARE - A
CHRISTIAN
MANDATE organised by
the Christian Medical
Association of India.
We are all co-workers in the work of our Lord Jesus Christ.
God has called us to initiate new ventures of love for
restoring health and healing among all people in the various
communities of our motherland India. Plurality of situation
is a social reality and therefore diversity of approach is
very essential in our deliberations and plans of action. At
various grassroot levels different models have to be evolved
to reach the poorest of the poor on a priority basis.
Jesus calls us to
1 . To spread the good news to the poor.
2. To restore sight to the blind.
3. To clearly demonstrate that the Lord is ever
anxious to save everyone especially the poor
(Gospel of Luke 4:18 - 19)
Our Lord hears the anguished cry of the poor
|
and the
dispossessed children of God who also have the right to
wholeness. Therefore, let us obey the call of the greatest
healer, our Lord Jesus Christ and stand beside the poor. It
is i--necessary for us to identify ourselves as one of them and
then jointly promote the healing process to restore health
for all. All of us have our equal right on the wealth of the
country so that a steady process of human enrichment may
lead towards the holistic development of people everywhere.
< well
“
'' formulated
health strategy which aims
This calls for a
at creating health consciousness
a healthy community. We
— for
.
believe that all people are important therefore sick and
malnourished people need greater attention and care to be
made whole.
Healing is a Social Process with the following components:
1. Education & Training for health consciousness.
2. Care and Treatment: Preventive, curative, promotive and
rehabilitative.
3. Balanced food and pure drinking water.
4. Ecological / environmental / cleanliness
5. Physical fitness - games /' exercises and clean habits.
6. Value - based living standards.

1

7. Unity in the diversity of health-care alternatives in
relation to the reality of Indian society.
8. Health and Healing as a process for empowering people to
overcome social, mental and physical disabilities.
9. Control of population explosion, pollution and HIV/AIDS.
In India, ill-health is largely a consequence of poverty,
ignorance, superstition and lack of education. On the matter
of education for health the rich and the poor, the educated
and the not-so educated people alike display great ignorance
and therefore endanger their lives and the lives of others.
All of them need proper health education so that each may
play his/her role as health keepers for others.
Disease and ill-health have a close socio-economic nexus,
Therefore it is not the exclusive prerogative of the health
I
professionals. Society as a whole, must adopt a holistic
approach in promoting healthy minds and heal thy' bodies
through practical demonstration of sound 1iving habits.
Medical treatment is not merely curing the i1Iness bu t i t
must aim at determining the causative factors of disease and
eradicating them. This will strengthen the healing process
for everyone in the community especially the marginalised
people in our society. This work has to be continued in the
socio-economic, medical, ecological, political, moral and
spiritual dimensions which cover preventive, curative and
rehabilitative thrusts. Primary health care is a long term
commitment of a nation that wishes to be whole.
The Government of India is trying its best to foster the all
round growth and development of its people. In this context
let us remember that healthy people create a healthy
in
turn produces a
community which,
healthy nation.
Therefore, appropriate Primary Health Care programmes are
the prerequisites for strengthening our national aspiration
to move forward into the 21st century.
The call of the World Health Organisation ’Health For All by
2000 ’ is a prophetic challenge for everyone in the World
and especially for India, where 40% of the people live below
the poverty line. Health for All is a beautiful vision but
perhaps for us in India
in the present context, the
attainable goal is 'Health Care For All Within A Decade.’
The Christian Medical Association of India has to provide
dynamic leadership in challenging the NGOs and government
agencies for a more speedy and human approach to result
oriented programmes for the people in the interior of rural
India. They must enable the hospitals and health care units
to resolve some of the disturbing
health problems through
systematic training, by enforcing discipline and by sound
managerial skills. Poor management, a "status quo"

2

mentality, adhocism, absence of collective participatory
leadership and a ?lack of social audit have greatly weakened
the organisational capacity of the health care ministry. It
is time that our institutions. are sensitive to the new
dimensions of human suffering and express by action the
concern of the Church. The Church has to be a pioneer in
empowering the victims of ill-health to have a new dream for
a bright future.
Fortunately, most of our Christian Hospitals and health
centres are in rural areas. This provides us wonderful
opportunities to serve the rural poor with quality care. But
let
us not labour under the misconception that only the
poor people need primary health care.
Low cost treatment must continue to be a high priority for
medical/health
th
institutions
which
are
Christian
medical/heal
care
the Church
primarily not-for-profit service wings
of
established in the name of Jesus Christ. It is imperative
for us to undergo a process of re-or intation for a more
prophetic health care agenda. for tomorrow.
The multidimensional health problems of our society have to
be tackled with modern skills and competence. The poor who
have very little money to pay for treatment, have to be
welcomed to the Christian Hospitals and Health Care Centres,
primarily because the doors of (other
'
private hospitals and
nursing homes are closed to them due
-.^3 1to prohibitive charges.
Christians Mission Hospitals must become
---- a 'Mission of Hope’
to all and especially to the hopeless and helpless; people of
our land. This urgency imposes a divine imperative for a
thorough overhauling of our health delivery facilities and
systems.
a)
By improving existing facilities, This would include
diagnostic facilities which are generally lacking in the
rural areas.
b) By starting new types of Ihealth care centres, especially
in the woefully backward areas of our country.
c) By inducting more committed and skilled health workers
and by bringing renewal and revival among the existing staff
members
and
workers
who
are
depressed,
often
very
disheartened and demoralised due to various rreasons, factors
and forces, It is time to give due attention.» to restoring a
work-culture and medical ethics in our own institutions and
in all institutions all over India. The
CHAT has to play
the role of a catalyst, in these circumstances.
d) By applying contemporary understand!ngs of the socio­
economic problems of the country where our people have been
struggling for survival, it is time that efforts be made to

3

change the attitudes of health professionals so that all may
dedicate themselves as catalysts of health for others.
But this will require:
Spiritual,
i)
moral
and ethical
re-orientation of
all
workers to inculcate in them a rsense of vocation for service
and sacrifice. This is indeed the universal quintessence
-------------- of
all Cnristian endeavors.
ii) The dilapidated infrastrueture of the health centres and
hospitals have to be infused with new life to meet the
growing and varying needs of the community. The hospital
authorities must be challenged to see things in their true
perspective to ensure that the poor are not exploited by
commercialization of medical care by the health industry.
in)
in
Facilities for appropriate care and
treatment
ygienic conditions have to be provided, so that the health
professionals may effectively deal
with various health
problems and related complexities. This does not necessarily
mean super-specializations for each hospital/centre . But it
does require minimum basic modernisation of the hospitals
and primary health centres so that patient care can be
conducted smoothly and competently at a time when 'CONSUMERS
PROTECTION ACT ’
has come
as a corrective and deterrent
come as
process for the public interest.
iv) If the health-care strategies for the
poor are to be
ef feefive and sustainable they must reflect a systematic
understanding or
the perceptions of
the poor who are
normally not included in the corridors of power.
Their
of power.
voices are inva r iab1y absen t from debate on policy reforms
directed at
<
improving their 1ives. The aspirations of the
poor havei to be articulated i n
all health care policies
which are meant for them.

v) We are experiencing so
many problems in maintaining and
supporting our health workers. There is a great need
for
offering a suitable wage for a
living for all
respectable
heal th care professionals in primary health
--- 1 care centres.

demands
situation
justice
The
in
strengthening
the
qualitative service to the poor and the helpless,
The
question of a sustainable health care programme by
NGOs
needs special consideration in the context of free supply of
some medicines by the govt, Tor
for certain illness such a
tuberculosis, leprosy, malaria etc., Every organisation has
to mobilize resources with the participation of the target
group and business houses. where possible.
h
tl<Jnr's are conscious about, the skills, competence
and ethics of cordiality of the hospital and primary health
care programme workers. We reaffirm that poor people deserve

4

the best care and health education, Let us remember that
cost effective considerations are very necessary but must
not become the clinching factor in the mission strategy for
primary health care delivery.
It is time that the NGOS/Chu rches reaffirm that primary
health care programmes are a must in the context of
privatazation and commerci1 alisation of medical care and
increasing poverty. Rut primary health
heal th care does not mean
merely
dysentery,
night-blindness,
treating
diarrhoea,
scabies, etc,. The nature and scope of preventive treatment
has assumed a new magnitude in the context of various fatal
diseases of the modern day globalisation scenario which
causes great suffering to the poor and the middle-income
group. Primary health care is essentially caring for people
so that they learn to survive and serve fellow human beings.
The charitable aspect of the compassionate ministry of
but also
Jesus must find a place not only in our hearts
in our health care practice and this should be duly enforced
ky a Christian code of conduct. Without compassion,
a
nation cannot progress, nor can it achieve unity of all its
peoples. This is especially relevant in India which has so
great diversity and plurality of situations, which along
with acute poverty creates a situation where the rich get
richer and the poor poorer. The gap between them gets bigger
and worsens at an alarming rate. It is high time that this
deterioration is checked through social transformation.
While the Indian Church is poor, we are conscious of our
with
the
and
universal.
heritage
partnership
Church
Therefore we are not alone in our missionary journey.
As a caring community, we must promote a feeling of
solidarity with those people who are deprived and suffering,
enabling them to enjoy the fullness of life which Christ has
offered. (John 10:10) This will demonstrate a new model for
service and sacrifice, both of which are prerequisites for
the development and prosperity of our country and indeed the
world _
Recently, hundreds of people died of plague, malaria and
gastroenteritis. Similarly, hundreds of people are dying of
AIDS, Hundreds die of hunger, yet the world continues
obiivious, on its selfishi path, blind to the plight of
others. 11 is high time that every educational, social,
religious
and
institution
medical
awareness
promotes
programmes for the prevention of HIV/AIDS not only in our
country, bu t also the
who
1 e world. Therefore our primary
whole
hea1 th-care programmes have to include these in their
agendas.

5

The CHAI has provided leadership in popularising community
health / primary health care concern all over India. It has
become a facilitator, trainer and trend-setter and has
displayed a great concern for the poor. It must continue to
encourage health-activities to uphold the cause of the poor.
I appeal to all our overseas partners, churches and various
Christian agencies to strengthen the Healing Ministry
undertaken by churches/social action groups in new areas.
'poor people’ Tn India to have access to
This will enable
health care facilities in order to sustain national growth
and development. Jesus said ” when you do it to the least,
you do it to me." Let us hope and pray that the CMAT emerges
to reckon with. May it continue fulfilling the
as a force
Christian mandate- of celebrating life with its fullness for
all . This must include those who have money and others who
lack it. Let us give health a chance so that as Indians, we
may become a healthy people, in the global village of
tomorrow. A healthy India will make a better world. If
health is wealth then we have a tremendous treasure trove
just around the corner, Together, holding hands and with
pooled resources, let us move towards these new riches by
exploring new horizons in Christian Ministry as co-workers
in His Healing Ministry.

*}:****

6

PRIMARY HEALTH CARE: BEYOND MATERNAL & CHILD HEALTH
Dr R.S.Arolo

Dr. Chcrian Thomas, esteemed colleagues and friends. Thank you for giving me this
opportunity to address you this morning to share some of my views and experiences on Primary
Health Care. The theme for discussion is Primary Health Care: beyond Maternal and Child Health
Services.
Primary health care is an approach to health. It is a radical approach to health that goes
beyond medicine. Its central theme is equity that leads to the goal health for all. It is about
processes and concrete outcomes, be it medical, social, or political. It is a radical shift from a
individual disease-based model that is dictated by the medical profession to one that views health
from a broad perspective and where programmes and priorities are defined and articulated by the
community. In the medical model the causes of ill-health are often looked at from a purely
technical aspect with little or no attention being paid to the underlying or basic causes which may
be deeply rooted in socio - political and economic structures. Primary health care in the ultimate
analysis is directed towards equity and social justice which ultimately leads to a movement of
empowering individuals and communities to be in control of their lives.
Many ideas on PHC were brought together at Alma Ata in 1978. It was in Alma Ata that
governments from 134 Member States and representatives of 67 United Nations organizations,
specialized agencies, and NGOs came together and agreed upon Health for All by the year 2000
The definition that was formed and is used is:
Primary health care is essential health care based on practical, scientifically

sound, and socially acceptable methods and technology, made universally
accessible to individuals and families in the communities through their full
participation and at a cost the community and the country can afford to maintain
at every stage of their development in the spirit of self-reliance and self

determination.
In the Christian perspective it is bringing the Good News to the poor. Christ’s clear
proclamation that He came to establish the Kingdom of God on earth as He declared at Nazareth:
The Spirit if the Lord is upon me, because he hath anointed me to preach the
Gospel to the poor; he hath sent me to heal the broken hearted, to preach
deliverance to the captive, and recovering of sight to the blind, to set at liberty
them that are bruised, to preach the acceptable year of the Lord.
M

fl'V

>(c 243C

d CLa .^ cco—

1

How was Primary Health Care envisaged at Alma Ata? It was based on a few successful
experiences around the world in the early seventies. Jamkhed was one of them. These projects in
turn drew upon the rich experiences of pioneers and stalwarts such as James Yen in China and
who, later influenced the formation of community development blocks in India. Carl Taylor,
David Morley and Maurice King, Sidney Kark, Kenneth Newell to name but a few, also led the
way and influenced greatly the Alma Ata Declaration. Many of the projects studied were
developed by dedicated Christian groups.

Drawing from the experiences of these projects, certain strategies were identified. Let me
begin by recapitulating the main strategies of PHC. These include: commitment to equity”
community participation (essentially empowerment); integration of promotive, preventive, curative,

and rehabilitative services; intersectoral collaboration; and appropriate technology' and services All
these strategies are very much interrelated. These main strategies point to a much wider range of
activities than Maternal and Child Health. However it was not by accident that in most instances
PHC became sy nonymous with MCH services.

Primary Health Care (PHC) came into existence as a challenge to the medical paradigm of
viewing health as only physical and owned by the providers. For the first time we were really
putting people front and centre. But it was also about a devolution of power. Devolution of
power of the medical profession and of all the so-called experts to the ordinary people. Hardly had
the ink dried on the document at Alma Ata, that those in power, the medical profession started
finding excuses. The donors and international agencies took the teclmological excuse route. They
decided to change the terms and call it selective primary health care. The selection was done by
them. Their reasons included that the PHC or the community based comprehensive approach was
too idealistic - in short the message was that health, for all was not possible. They said the
comprehensive package which addressed the real problems of inequity was too expensive. They
also wanted measurable goals and quick solutions. The goal became more important than the
process - essentially health statistics became more important than the people. The very essence of
PHC namely people being in charge was prevented.
It was not easy to promote a shift in paradigm from doctor centered to people centered
approaches. In our mission hospital setting where we are already struggling for financial resources,
PHC meant a devolution of power and sharing of knowledge. It meant that those who had given
their lives to hospital work, seeing their life work being superseded, it was difficult to let go.
Therefore, this selective PHC became a welcome strategy - of staying in our ivory hospital towers

and from time to time going into ’adopted’ villages, (a very derogatoiy term), and providing
immunization services and MCH services.

Community participation was reduced to people

availing themselves of these services. Perhaps providing a room to hold the clinic and a worker
from the village to act as a promoter for the health services that we provide. Maternal and Child
Health services to a large extent became synonymous with Primary Health Care.
The route taken was an easy' one.

A few common diseases with technologically known

solutions were identified and packaged into maternal and child health services. In many' instances a
worker from the community was identified to work with the health professionals. However, the
PHC movement was not dead. It was revived again at Riga when member states of WHO again
reiterated and committed themselves to Primary Health Care . In the past few years the

2

importance of primary' health care is being realized and has been hailed as the most relevant way to
address health issues. Europe and other affluent countries have also recognized the need for
primary health care in their own countries and in fact one of the best known PHC programmes

exists in Scotland today. Conununity based comprehensive Primaiy Health Care is not second

class medicine. It is not an interim or stop gap approach. It is based on sound scientific and moral
principles.
As Christians are we not called upon to bring ‘health and healing to the nations’? We are
called upon to bring justice and equity among people. Because our God is about justice and
equity. Are we true to what we believe in? If so, it is imperative that we go beyond matemal
child health and address the basic causes leading to poor health. Going beyond matemal and child
health is no more a political nicety, it is a necessity. In the words of Dr. Hafdcn Mahler “it is a
moral issue. Wliat can be done?
Drawing from experience at Jamkhed, I would like to discuss some of the basic principles of PHC
and share how we can move beyond matemal and child health services. The overarching and the
most important principle is equity.
Equity is about fairness of distribution. It is not the same as equality' which is not always
fair. In PHC we speak about health for all. In fact that was the main goal of the PHC movement.
This does not denote that every person will have the same services, or, for that matter the same
level of health. What it means is distribution of health services according to health needs. Needs
not entirely detennined by the health professionals but by the people. It is about addressing those
in most need. If resources do not permit all being served, those most in need must have priority
and what is done must be relevant to their situation. An equitable outcome and process is a central
aspect of PHC. It is central because equity is about values such as respecting and caring and
restoring dignity. It is essentially working towards an equitable, just, and peaceful society. Mary
in her song to her cousin Elizabeth expressed equity in simple terms.
He hath shewed strength with his arm; He hath scattered the proud in the
imagination of their hearts; He hath put down the mighty from their seats, and
exalted them of low degree. He hath filled the hungry with good things and the
rich He hath sent empty away,. Luke :1; 51-53.
Equity in health care implies more than providing health services to the poor. It implies getting to
the root of the problem - which is the socio-economic political and religious base of our society. It
is only when these unjust structures are addressed that we can hope to achieve true equity.
In practical terms equity in health care implies meeting health needs according to people’s
basic needs. It does not merely denote ensuring provision of health services regardless of caste,
class, and geographical location. Since communities have different health needs it is important to
detennine their respective needs rather than having a package of activities determined by us wliich
we expect people to follow whether it is a priority to them or not. For example, it has always been
felt that the matemal child health services are the most important components of a Primary Health
Care programme because over sixty percent of the population are women and children. This is
what we presumed when we first went to Jamkhed. We had already planned our programme as
providing MCH services. From the medical point of view they are important services. We asked

3

the community leaders. They agreed with us. However, on sitting down and listening to the people,
it became quite evident that poor people were more interested in food and water. They had no time
for the luxary of health services or for that matter immunization. They were right. We were
wrong. A deeper analysis of the situation revealed that over fifty percent of the health problems of
women and children were related to lack of food and safe water. The impact of adequate and
proper feeding practices and safe drinking W’ater was far greater than immunisation services. This
is already proven in the developed countries where measles is not necessarily a killer disease as it is
here. This to a great extent can be explained by the higher nutritional status of the child. In
Jamkhed too, the interventions addressed to nutrition and water brought down infant mortality
long before we could afford to add measles immunization. Introduction of immunization, ante
natal care and a few other services was not enough. It would have had a relatively7 small impact
in the face of starvation and lack of clean safe water. With meager resources, we realized that
reducing malnutrition and providing safe water was far more important than MCH service
delivery.

In addition to determining their needs, another important aspect is that this process lets
people themselves define their own needs and priorities in their own terms. PHC is not only
providing services but enabling communities to be part of the decision making processes.
Participation in the decision making process at the point of defining their own needs is a good
beginning in the theory to practice process. This can be done using various epidemiological tools.
Beginning with the simple step of having informal discussions with individuals to detennine the
workings of the village. This helps to understand who is who in the village: who are the decision
makers, who would like to be the decision maker’s, what are the factions and their alignment or
misalignment. This has a direct bearing on equity; Because, if' equity is about fairness, then it is
important to know and understand all facets of a community. If the commonality and differences
are not fully understood one can make the mistake of aligning with or introducing programmes that
are beneficial to one group at the expense of another. Also, one runs the risk of non-cooperation
resulting in lack of ownership of programmes. To expand on this I again share my experience in
Jamkhed.
After having understood the village structure, we arranged village meetings.

It was

important to ensure that all groups were represented and the place and time was accessible. Such

meetings helped to broadly identify the areas of needs, concerns, and wishes. It was an
opportunity for us to explain what PHC was about (though at that time it was not known as PHC)
and listen to their reactions.
This was just the beginning of community participation, the next strategy of PHC.
Community participation is a process where people are the key actors. Individuals and
communities take active part in the decision making process which may change their lives. Since
health is dependent on the village community as a whole, it involves interconnected aspects of life
which the individual can only affect when there is cooperation among the members of the
community for the benefit of all. Health is then a fundamental reason for community involvement
and also provides a reason for community involvement and cooperation which eveiyone can easily
see as valid.

4

One of the challenges in community participation is participation by those in need, i.e., the
poor, and especially the poor women. The existing power structures in villages leaves little room
to enter villages other than through them. As we moved about and gained the confidence of the
poor people it became more and more evident that the needs of the leaders were not the same as
those of the poor and marginalised. While the leaders were interested in having a hospital,
diagnostic and surgical facilities, the majority of the people were preoccupied with basic survival.
They sought medical help only for life threatening illnesses and injuries. They were not interested
in having a hospital or fancy diagnostic machines. They knew better. They knew about survival.
They identified water and food as their first need. This is the basics for prevention, a core goal of
PHC. It became clear to us that preventive and curative services needed to be integrated with
other development strategies. We also realized that while we wanted community participation, no
such concept of community was inherent in the village. The lines drawn by caste, economics and
the need for power have kept such a community from forming. We had to find ways to help
people to step across the lines and begin to dissolve those lines before true participation can be

achieved.
At Jamkhed we encouraged the men from the poorer sections of village to form Farmer’s
Clubs. Later women were also organized to form Mahila Mandals and along with the X illage
Health workers they form a team to address all issues. Their active involvement is critical to the
success of the community-based PHC programme. This where we have a major role to play.
Community based PHC programmes depend on people’s action.

Values of caring, sharing,

respect for each other and the concept of equity has to be imparted. Undergirding all community
processes are the values which lead to equity and justice. These ethical issues are important and
need to be formulated and discussed. The objective is to form sharing and caring communities
who will be empowered to take decisions in an empowered way.
Since community participation is going to be elaborated on in another session, I move onto
the next strategy of PHC - the integration of curative, preventive, rehabilitative, and promotive
services. Each of these areas are important in their own right. If the objectives of PHC is to meet
the health needs of the poorest of the poor in the most effective and efficient manner, then it is
only logical that all the services be integrated. People cannot be divided based on what type of
services they need, their health needs must be treated in an holistic manner. The integration is also
critical given that almost 80% of all diseases can be prevented. We cannot deny the need for
curative and rehabilitative services, although emphasis on the prevention end would be more
effective in the long run. Integration of curative, preventive aspects of health is important. I have
seen many a health worker not being effective because of this compartmentalization. Once, I went
with a public health nurse on her rounds in the village. She had her tool kit of health educational
materials. She patiently went from house to house talking to mothers about preventive health care.
We often came across children with acute illness and mothers would ask tor treatment. The nurse
would say that her job was to talk about prevention and that a another person would come later for
treating the child. All the hard work of the public health nurse was lost because of lack of
sensitivity to the needs of the people. We must be prepared to respond within reasonable limits in
a holistic manner.

5

At the primary level, the integration of all services is not only possible, it is essential. The
diseases in the village are simple, repetitive and for most guidelines have been developed to treat
diseases that are common. For example the mother can be taught home remedies and oral
dehydration based on home-based fluids. Mothers need to be taught all about acute respiratory
diseases. A well-integrated referral system to health facilities will greatly enhance the acceptance
of PHC by the people. This is more so in areas such as antenatal care. Unless there is facility for
referral and emergency obstetric services, antenatal care is of little use as credibility will be lost if
there is no place for referral for obstetric emergencies.
Our experience at Jamkhed has shown that it is possible to integrate the so-called vertical
programmes into primary health care. For example leprosy control programme was integrated
It was found that when we stalled treating leprosy in the context of
from the very beginning.
PHC, most of the problems were quickly solved. Once village people understood that leprosy’ was
not as contagious as they thought it to be and that deformities could be prevented, people
themselves made eradication of leprosy one of their objectives. The detection of leprosy is
included in the general health surveys. The village health worker is also trained in leprosy follow
up. It is she who ensures that the treatment is complied with. Since the village health worker is

concerned with many other activities, her visit to a leprosy patient’s house is not specifically
pointed out as having leprosy.

Leprosy patients can lead a normal life fully accepted by the

community. Once the village people understood the cause of deformities they helped to encourage
the patient to act responsibly and encouraged him to wear shoes. Village people also helped in the
rehabilitation process and ensured that the families were also taken care of. This integration has
dispelled the stigma attached to leprosy in Jamkhed villages. Often, it is fear that prevents leprosy
patients from seeking treatment early. Over the years over 4000 leprosy patients have been treated
in the villages. Through the village communities these leprosy patients have been well rehabilitated
and are leading normal lives, fully supported by the village communities.
This approach has also
been financially cost effective as far as leprosy is concerned. Leprosy paramedical workers are
multipurpose workers having multiple skills.
Similarly the PHC approach has effectively reduced the prevalence of tuberculosis in the

villages. Village people see this as a priority and ensure both compliance and also rehabilitation of
the family. Community support is important specially when women get tuberculosis. She has the

fear that she will be kicked out by the husband. Community support ensures her well being.
As part of the integration of services there is a need for intersectoral collaboration, because
health is more than medical care. Primary health care seeks to get at the root of the problem and
most of the medical problems in this part of the world are linked to socio-cultural, economic,
environmental, and political issues. Thus, intersectoral collaboration is necessary to improve the
health of the population. Over 50% of the low birth weight babies are bom in India today despite
the large infrastmeture of health services and emphasis on antenatal care. Maternal services, in the
form of antenatal care alone cannot solve the problem. The problem is rooted in the social
structure of the society which relegates women to a secondary status. Low birth weight with its
consequences is inevitable, as women are denied the ven' basics of adequate food and rest so
essential during pregnancy. It is not only poverty that has to be addressed, the deep-rooted social
evils of women as objects and not subjects and caste barriers have to be rooted out. It is only

6

people themselves who can change these social structures. This means going far beyond the
domain of the health system. Collaboration with other sectors of development is essential for the
achievement of PHC.
Another important aspect of the PHC approach is demystification of knowledge. Health
knowledge has to be shared in such a way that people are empowered to act. It is not just giving
them a few messages on what to do. This concept is based on the fact that people can understand
complex facts if they' are simplified and shared in a way that they can understand. In health it
means understanding not only the cause of desiease or its prevention, but also learning to assess
the situation in one’s own village and working out what is the basic cause which may be embedded
in the social structure, beliefs, attitudes and then working out how solve the problem. This type of
learning enhances the skills and encourages people to become more self reliant.
Recognition of intersectoral collaboration by health workers is very important if primary7
health care is to go beyond maternal and child care. They need to be aware that the root causes of
many diseases is more socio-cultural, economic, and political in nature, in order to be more
effective in ensuring health for all. Working in collaboration with other sectors is obviously an
essential strategy. This also includes a knowledge of other development programmes and agencies.
Though w© did not directly employ any agriculturist, veterinary doctor or other experts, we were
able to bring about intersectoral collaboration by' acting as catalysts and working in partnership
with government.
As people were organized into viable community groups, they expressed their needs.
Landless people were more interested in having fann animals such as goats, chickens and cows.
They were interested in having village veterinary workers rather than human health workers. We
were able to get the local veterinary doctor and extension workers to provide the necessary’ training
and follow-up. Intersectoral collaboration is not inherent in the government hierarchy. However
this PHC approach which' has strengthened the community organizations has helped to bring the
various departments together for seminars held for village people. Departments of agriculture, soil
conservation, minor irrigation, animal husbandry, social forestry, block development officer and
banks and cooperatives come together for the seminar. Each explains his or her development
programme and how the people can avail themselves of the services. Poverty’, improvement in
food production, income generation are all aspects which ultimately affect health. We can play an
important catalytic role in converging services at the block level.
These seminars are popular because people get knowledge and awareness on many
development issues. Legal problems are discussed with government officials. Particularly status of
women. Women have been able to get property rights and many women liave become joint
owners of property with their husbands.
Another strategy of PHC is ensuring appropriate technology and services. To be true to
the spirit of PHC, of its commitment to equity, the introduction and use of certain technologies
and services must maintain the respect and dignity of individuals. Women have multiple health
needs, yet the services to meet their health needs, focuses only on their reproductive role. It would
appear that women are only cared for by the health system only when they are pregnant. For

7

example 85% of women are anemic; however this problem is not addressed until the woman is
pregnant. Womens health is more than maternal care and family planning. Yet, we continue
through our health services to take a narrow and inequitable view of women's health. It is
necessary to emphasize women’s health at all ages in her life.
One of the aspects of PHC is that technology should be accessible, affordable, and
culturally sensitive. It means the use of technology which is based on scientifically sound
principles. It ranges from low cost, simple techniques such as the use of home-based fluids for
diarrhea to high technology which may be quite expensive initially. For example the use of twoway radio for continuing education of health care of grassroots worker is technology that is useful
and relevant where their a limited mechanisms for communication and where geographic access
makes it difficult. For the efficient use of scarce professional human resources a vehicle (jeep) is
important as time should not be spent in long and exhausting hours of travel. The use of women
from the village as village health workers can be considered as appropriate as expensive
professionals are not only scarce, but are as effective as a person from the village. The examples of
appropriate technology are numerous and I will not elaborate on it accept to list a few such as the
growth monitoring chart, delivery pack
PHC also includes appropriat j rehabilitation of those who are handicapped in any form.
Often rehabilitation is thought to be expensive and beyond the scope of PHC. However with the
main thus being equity, rehabilitation plays an important role. When all those needing
rehabilitation are aggregated at the le 'el of a state or country, the sheer number of people to be
rehabilitated makes one feel it is an impossible task. However if we reduce the problem to the
lowest level, that of the community or village, it is only a few that have to be rehabilitated.
In Jamkhed, village artisans such as carpenters and blacksmiths, have been trained to make
tlie Jaipur foot which is an artificial limb designed specifically for the local culture of sitting on the
ground, squatting, and working on the farm. The development of the Jaipur foot required taking
local resources and with some guidance they were able to create something that is appropriate to
the needs of the people. Essentially, we took a technology and got the community involved to
address a need in their own community. It was appropriate because, the technology' was tested.
Going beyond Maternal and child heal'h is not only because of the more comprehensive approach
to health, it also occurs as health of mothers and children undergo change.
Primary Health Care is a dynamic process and if successful the communities’ priorities
change in due course of time. Over the years the priorities in Jamkhed have also changed. In the
beginnrng in the 1970s the health priorities were mainly malnutrition. Children had not been
immunized and tetanus was frequently seen in the hospital. As people become more aware and
knowledgeable, health priorities started changing. Immunizing children became a social norm. A
small family social norm occurred as more and more women started deciding on small families. In
the early seventies close to fifty percent of the outpatient clinic was children under five being
brought with common childhood diseases. By 1980 the hardly two percent of the our patient
attendance was children. Instead of health workers going out and uiging mothers to immunize
their children, people started demanding immunization. Wasting, stunting and low birth weight

8

were the predominant problems in the early seventies. Through the community based programmes
these problems were addressed. The disease pattern slowly changed.
At Jamkhed the healtli education and dialing knowledge with village health worker and
people has been a dynamic one. The continuous training every fortnight has helped to enhance the
health
workers knowledge and skills. Therefore, within antnatal care for instance, the detail of antenatal
care continues to increase. In the beginning no mention is made of problems such as Rh
incomparability. However with each round of training more and more knowledge is imparted and
so community knowledge is eventually built up. This enables people to demand more and more
services.
People’s priorities changed. They demanded more on women’s health. There was a
demand for regular screening for hypertension, diabetes, cancer, Responding to the people’s
demand Village Health Workers were trained to monitor blood pressure, test urine for sugar and
take cervical smears and do pelvic examination. New programmes have been instituted
concentrating on adolescent girls, a hitherto neglected age group. Anemia is a major problem and
supplementary iron during this period would help combat anemia. Attention is also being paid to
her nutrition.
In the context of PHC, the whole question of HIV/AIDS is being addressed. The Mahila

Mandate have discussed the issue of AIDS and how it is transmitted. Through the health worker
they receive regular up dates. A an organized group they have identified the high risk women.
Such women include the wives of men who have to stay outside such as truck drivers, bus
conductors and drivers and those working in the cities. The Mahila Mandal supports her as she
tries to protect herself by insisting that her husband uses condom. This is a relatively new
programme and will be monitored to see its effects. Some villages have decided to do routine
screening for STD and if it is high also test for HIV/AIDS.
In addition to change in priorities in health, as the development process proceeds take on more
activities relating to environment. Through the PHC programme environmental issues such as
social forestry with large scale planting of trees are carried out. In villages there is acute shortage
of fuel. Hence women are interested in tree plantations. Environmental sanitation and
construction of drainage pits for waste water and building toilets are also areas where people show
interest.
The evolution of community based primary health care is that it moves from first

addressing common childhood illness and maternal health to looking at health as a whole. Once
the common infectious diseases are taken care of, the next priority is addressing more chronic
diseases associated with the aging process and affluence. They are mainly diseases of life style.
This includes high blood pressure and diabetes and cancer. And eventually the programme
programmes attempt to address more complex problems such as HIV/AIDS and environmental
issues. I especially mention AIDS as the epidemic is assuming large proportions and soon the
devastating effects will become evident. Addressing HIV/AIDS in the context of community
based initiatives will be important and this is the challenge we as Christians will have in the years to
come.

9

Today as never before we as Christians are being challenged. The market forces are
closing in on the poor. The social sector programmes are rapidly being replaced by private
enterprise. And during this period of transition both in terms of economy and interms of
epidemiological transition, it is the poor that will suffer. We are called to respond to the needs of
the poor. Christ has given us His Peace- Shaloa Freely we have received freely we must share
what wc have received. :”My peace I leave with you “ Peace; Shaloam in Hebrew means more
than peace. It means health in all its wholeness. It denotes harmony within oneself, harmony with
other human beings, harmony with all God’s creation and harmony with the Creator. It is this
Shaloam that we must strive to bring about in the areas where we work. May God give us Grace
to respond to the needs of our people. Shaloam.

10

THE RISE AND FALL OF PRIMARY HEALTH CARE
Prem ancTHari John
In the Beginning:
Alma Ata visualised PHC as an approach aimed at not merely eliminating disease but as “a
complex of strategies that determined people’s livelihood and Quality of Life”(i). Social,
political and economic equity, fulfilment of the basic needs of the majority and above all,
people’s participation in decision making became the key words of this approach. Sociological
and qualitative solutions were placed above technological and quantitative gains. This approach
did not arise in a vacuum. It was historically rooted in the concept of the barefoot doctors of
China deployed in large numbers during the Cultural Revolution of 1968(2; as well as experiences
gleaned by its various mutants in Guatemala 1970 (Beherhorstf India 1973 (Arole, John) and
Indonesia 1976 (Gunawan). It was also rooted in the failure of the so-called public health
services to touch and heal the vast majority of people, i.e. the disadvantaged of the Third World.
Also, by then, more in hindsight than by systematic analysis, it was recognised that lack of
people’s participation was a major bottleneck to successful change at the community levels).
Community participation was therefore identified as the ‘‘key" to PHC. It was also recognised
that the reasons for poor health are due in large part, to the unequal distribution of existing
resources and that a more equitable situation can be brought about only by structural changes^).
As Mahler says “Health is politics on a social scale ” and therefore the ‘PHC approach’ started
addressing health improvements in the political context. The expectation was that community
participation in health programs will act as a catalyst for social change by empowering local
populations to become involved in the political process^). Having affixed their seals and
signatures to the declaration on PHC, most of the rulers of the world found that this approach
was intensely political, if carried out in the spirit in which it was conceived and that it would
alter power equations, first locally and eventually on a wider scale (as was demonstrated in
Peru<6) and Indonesian ) in favour of the powerless . Against this background began the
deliberate efforts of WHO to water down PHC through the promotion of the concept of
vertical interventions and Selective Primary Health Carew, Properly understood and
implemented the key to the comprehensive PHC approach was the processes that the
community went through whereas verticalisation focused on the program of intervention^
Also in spite of declared intentions, governments never really put any pressure on the class in
power, the paradox of political democracy imposed on an undemocratic social structure io).
Therefore, there was a deliberate shift - from wide coverage to intensive care, from societal
goals to achievable, technological goals, from qualitative objectives to quantitative ones. The
interests of the powerful, then as now, continue to direct the development of the rest of the
globe. The result is , less than four years before the magical mark of 2000 A.D., Primary Health
Care as a paradigm has been lost on the way and “Health for All” remains a distant mirage.
The Problem:
Much has been written about the “health” of India (or rather the lack of it), the health status of
its people, its systems and structures, almost all of it documented by the Ministry of Health itself,
(and published in the Pocket Book of Health Statistics). Briefly it can be stated that:
1

I.
ii.

iii.

at Independence, a completely inappropriate system based on western models, was
chosen.
this system, not by oversight but by design, ( as a result of urban, upper class, upper caste
decision making for the largely rural, lower caste, lower class population), failed to
address the needs of the majority i.e. the rural poor, the Dalits, the indigenous people and
among them, women.
successive five- year plans allocated less and less (in terms of percentage of total
budget) and out of that, allocation to rural health continued to show a marked decline.

Table-1:

Five
Year
Plans

I

II

Annual
Plans

IV

V

Annual
Plans

VI

%of
health
budget
to total
budget

3.30

3.00

2.60

2.10

1.90

1.82

1.86

Table-2:
Five Year
Plan

I

II

III

IV

V

VI

Outlay on
Primary
Health
Centres &
Rural
Health as
% of total
health
budget

17.8

10.2

18.05

6.6

5.4

8.54

iv.

meanwhile disease patterns were showing a significant divergence - i.e. the diseases of
the urban and rural rich on the Euro-American pattern and on the other hand, diseases
ofpoverty, a distinctly different pattern affecting only the disadvanaged.

v.

Systems and structures were built up mainly to service the better off (Cancer Hospitals,
Institutes of Post Graduate Education, Medical Schools, CAT Scans etc.) And when the
poor were taken into consideration at all, investment was made on hardware (PHC
buildings, vehicles, again medical schools to produce doctors for the PHCs etc.).
2

vi.

More medical schools were opened not nursing schools. Valium, Zocor and Nifetipidine
catering to the richer classes were easily available, but drugs for the treatment of
Tuberculosis or Leprosy were not.

vii.

There is an ever widening gap between the advantaged and the disadvantaged.

In summary, the end result was quite predictable and reflected a state in which the planners were
comfortable with (and confirmed by data provided by the government itself) as seen below.
The Great Divide:
Two distinct types of health status have been in evidence. Consider IMR alone, which, rather
erroneously, is considered as an index of development:

Table 3.
Year

Rural

Urban

Combined

1971

138

82

110

1981

119

72

905

1986

115

62

885

1996

120

48

79(12)

The above shows the rural-urban divide. There is also the rich-poor divide, the educated uneducated divide, the upper caste - lower caste divide and so on. The point is that the majority
of people, especially the disadvantaged, had and continue to have, no meaningful access to the
health care delivery system be it government, private or even “Christian”(i3). (For an in-depth
look at the PHC system, refer Banerji. The result is a morbidity pattern for the poor which is
not very different from what prevailed in 1947.
The same disparity is exhibited in the economic sphere also:
Table 4:( 14)
Country

Per Capita GNP in US $.
For total population (1990)

Estimated GNP in US $. for
poorest 20% of population

Bangladesh

210

69

India

360

90

Nepal

180

28

Pakistan

400

138 '

Sri Lanka

470

139

3

Class divisions are nowhere as well seen as here. After five decades of Indepence, the per
capita income of the lowest 20% of the population of India has not increased more than one
dollapis).

In sum, India failed to achieve a mode of life in which a statistically significant majority of its
citizens have been able to fulfill their material and spiritual human needs(i6). The unbridgeable
gap that exists between the North and the South, also exists between the advantaged (in terms
of class, caste, ethnicity, gender, urbanised) and the disadvantaged in India and nowhere is this
more explicitly seen than in the field of health.
What Now:
Into this already bleak scenario, new, and vicious, players have stepped in. These are the
international financial institutions, specifically the World Bank and IMF. Their domination of
the lives of the Third World has been insidious, inevitable and now, total. Their Structural
Adjustment Programs (SAP) which impoverished and bankrupted several Latin American and
African nations have now subjugated the economies of South Asia. Parliaments can no longer
pass laws based solely on the needs of their citizens. In more ways then one, India is not a
sovereign nation any more. The economic, social and therefore, the political agenda of the
nation is set in Washington. Even the health goals are no longer the concern of the WHO, let
alone the Ministry of Health in New Delhi. They are now set by the World Bank, just as in the
early eighties when it was the World Bank that opted for selective PHC with achievable and
quantifiable goals as opposed to comprehensive PHQi?) and forced WHO to accept it as a
policy.
Structural Adjustment Programs:
The 20th century is drawing to a close but unfortunately the World Bank and the International
Monetary Fund are imposing a set of policies on developing countries which are, directly
contradictory to their own policy position stated by Robert McNamara in 1976. WB/IMF have
proposed certain structural adjustment programs (SAP) as a precondition for loans. Developing
countries need these loans urgently to maintain their fragile economic, service outstanding debts
and to import essential items such as food, fuel and pharmaceuticals. These countries are
caught in a vice and seem to have no other alternative. The main policies demanded by WB/IMF
under the SAP include the following:
*

reduce or remove government subsidies on food, education and health.

*

devalue currency - (prices of imported basic items such as food and pharmaceuticals will .
be increased.)

*

remove trade and exchange controls and liberalise trade - (limited foreign exchange will
be used by the rich to import luxury items; low priced generic drugs may disappear from
the market.)

*

privatise public sector enterprises - health care services is one sector targeted - (health
4

costs will escalate)
*

charge user fees for public sector health care services - (the poor will drop out of the
safety net provided by free health services.) (i«)

The absolutely negative impact of SAP as a long term solution to poverty has been well
documented (i9). A noticeable increase in maternal mortality in Latin America, infant mortality
in sub-Saharan Africa and incidence of malnutrition in rural Orissa in India among other places
has been extensively documented po). (For a fuller discussion on this see Balasubramaniam,
C.R. Bijoy and Martin Khor on this topic in LINK Vol. 13.No.2 Sept. 1995).
The inescapable fact emerges that the powers that be have deliberately abandoned the poor to
their own devices, including a paring down of the public health services, often the only “safety
net” that the poor have, inefficient as they have so far been.
What of Us?
It is well to pause and ask ourselves, while all this has been happening what has been the
response of the NGO sector? Specifically what has been the response of the so-called Christian
Health System? The Christian Medical Establishment? I submit that our response has been
negligible, in fact non-existent mainly because the shakers and movers in the establiushment are
ignorant or choose to be ignorant of this rising challenge. We have been on a “business-asusual” approach, going on as if nothing has changed. Nor is the track record of the NGO sector
likely to give hope to the disadvantaged. The point that they raise in their defence is that “what
can we do against global forces? What can we do against the World Bank?” The problem seems
too big and therefore unsolvable. It is well, therefore to pause again and take stock of ourselves:
*

Are we able to visualise the problem clearly? (Including the historical roots of the
problem, of which wittingly or unwittingly we have been a part, the current scenario and
the likely situation in the future, say in 2050 A.D.).

*

Are our programs and activities, our systems and structures adequate in handling the
problem now? (Not to speak of 2050 A.D.)

*

Are our resources - our organisational base, our resource base and our human
potential base sensitive and “informed”? Are they adequate in working towards solving
the problem?(Not to speak of 2050 A.D.)

We better recognise what a dispassionate analysis will tell us: That (i) we are utterly incapable
of participating in the transfonnatory processes of the people given our present decision making
procedures, our systems and structures and that (ii) whatever we can achieve can only be done
in partnership with the people with whom we have in the past had an unequal and often uneasy
partnership
A People’s Movement?
The title given to me for this presentation is “PHC - A People’s Movement” - the underlying
5

premise being twofold: One is that people \ health should be in people's hands (it has not been
so till now, it has been in the hands of the professionals and that is why things have not worked)
and secondly, people power should be harnessed, potentiated and maximised. Movement is
defined as “consciously propagated, organised action on a mass scale focused around a central
issue”. We should recognise that any movement, be it political (like the Jharkhand Movement),
or ecological (like the Narmada Movement) or social (like the Dalit Movement or the women’s
movement) needs three operative factors: (i) a clear and “just” issue, (ii) an informed,
sensistive and dynamic leadership capable of visualising the future, nurturing and facilitating
the movement and finally (iii) methods that would raise people’s enthusiasm, build people’s
power, and channel people’s resources in a sustained manner in achieving the objectives of the
movement.
The political capacity to reform the social order and to achieve social goals can either come
from above i.e. through a people - responsive government, that would have:
I)

a coherent and stable national, political leadership that allows for the clarification of
goals, their prioritisation and then sustained pressure from above for goal completion.

ii)

a clear pro-lower-class ideology that gives the government legitimate authority to pursue
goals beneficial to the rural poor. (The failure to translate “socialist” ideological
commitments into a strong left-of-ccnter regime capable of redistributive intervention
is India’s greatest political failure).

iii)

an organisational ability to go to the people and penetrate the countryside without being
captured by propertied groups(22).

Unfortunately we are well aware that successive governments since independence, have opted
for clear, upper class and often upper caste goals (always with pro-poor rhetoric), what Myrdal
calls as the soft-state nature of governance and the conflict between the promises made and the
actions undertaken by the states. The less said about the present political climate, modes of
governance and the capacity of the ruling classes to respond to the legitimate needs of the
disadvantaged, the better.
In a situation such as this, we, the voluntary sector, can play several roles: (i) we should stop
playing the usual silent majority role and play a more active “political" role individually and
organisationally and (ii) recognizing that the present problem is class-based and the existing
problem solving by the ruling classes is also ^class-based^, we go to the people direct and start
building people-power. It is not as difficult, hopeless or as far fetched it may appear - the
recent history of the World is replete with instances of people-power over-throwing structures
thought to be invincible. The precedents therefore are there and are hope-giving ones.
Whichever movement has been successful, the bedrock on which they were built, have been
“people^ and their inherent capacity to break off their shackles. In a process such as this, the
role of NGOs is only facilitatory but nevertheless a crucial role. The only way in which we
can even halfway fulfill this role is by setting our own house in order. This requires, on the one
hand enormous humility on our part to accept that we have been less than adequate so far and
on the other, the capacity to refashion our systems and structures in a manner that would
potentiate people power. Specifically, organisational strategic planning that would result in:
6

i) appropriate organisational development and ii) motivating, enthusing, training, developing
and nurturing human potantial, specifically “informed”, young people, with the knowledge,
skills and capacity to facilitate people’s trans form atory processes. As we move into the Third
millennium, if we do not take up this challenge we will stand indicted by posterity as
accomplices in creating and maintaining sick societies.
Note: In order to understand this presentation in its entirety it is necessary to read the enclosed
background papers fully. 7 hese are:

1.
2.
3.
4.

5.

Privatisation ofHealth. Its Impact in South Asia - K. Balasuhramaniam.
Mismanaging Health - Privatisation and Politics of Economy - (\R. Bijoy.
Shift in Global Health Strategy - Martin Khor.
q (All from LINK, Madras, Vol. 13. No.2. Sept. 1995)
Towards the Third Millennium, Community Development in India, Health and HealingHari & Prem John.
The Christian Health Care Systems and the poor ofAsia - Hari John.

References:
1.
2.

4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

14.
15.
17.

kL9:
20.
21.

22.
23.

WHO, Primary Health Care, Geneva 1978
Sidcl R. et al. The Health of China, Boston 1982.
Rao. V.K.RV. New Approaches to Indian Planning, Delhi 1985
Rifkin S. Acta Tropica - Dec. 1995
ibid
Muller F. National School of Public Health, Medellin, 1980
Morley, D. Practicing Health Lor All Oxford 1983
Walsh ct.al Selective PHC, NFJM, Vol.20.1974
Rifkin. S. in Social Science A Medicine Vol.26. No.6. 1986
Qadeer.I. in Social Scientist, Vol.22 1994
John. P.O. et.al. Towards the New Century , 1CSSR, Delhi 1989
Asiaweek, I long Kong, 23.2.96
Banerji D. Health and Eamily Planning Services in India, Lok Paksh, Delhi 1985
Human Development Report, UNDP, Oxford 1993
Abraham M.F. Studies in Third World Development, Delhi 1992
John, Hari et.al. Towards The Third Millennium , Tubingen, 1995
Walsh, op.cit.
Balasuhramaniam K. Privatisation ojHealth d: Its Impact in South Asia, LINK Vol. 13,
No.2. Madras, Sept. 1995
Comia G.A. et.al. Adjustment with Human Eace, Oxford, 1988
LINK, op.cit.
John, I lari. The ('hristian Health ( are System d- The Poor oj Asia, Moshi, 1 anzania,
June 1995.
John, Hari, “Towards. ” op.cit.
Myrdal, Asian Drama, New York 1968.

Pcj gf 23296
c:\cmai. w pd

7

THE STRATGEY FOR HEALTH & HEALING

Dr. A.KTharien
Christian Fellowship Hospital
Oddanchatram

1. INTRODUCTION:
We are going through a crisis in civilization. Old concepts and ideas are submerging
and newer insights are surfacing before us. There may be many under pinning issues such as ,
nuclear economic, ecological, food, human aggression or new morality and ethics. At the core
of most of these are also health issues. The nuxiern medicine seems to be evolving,
from the whole to the part
from the person to the product
from belonging together to a state of isolation
from total approach to fragmented approach

IL HEALTH:
Let us have a look at the very concept of health. WHO defined health as a state of
complete physical and mental well being. They have recently added another dimension - the
dimension of spirituality. To expand further, health is a state of vital and harmonious well
being, which reflects all these qualities - a state of dynamic wholness. Wholenss need not be
confined to physical perfection as many of the physically disabled also could be truly healthy.
Concept of harmony should extend beyond the person to include relationship to his
environment, his neighbour and his creator. So health is a function, a quality of life, unfolding
a personhood which is dynamic, comprehensive, coporate and forward looking. It has moral
and ethical values aiming for a purposeful living.
III. HEALING:
Apart from curing any illness healing is concerned with any aspect of a person ’s life
which falls short of wholeness. It is also restoring a person to harmonious relationship to fulfill
the purpose for which he is created. It is a reconciling and a renewing process. It may be
concerned with remedies that are physical, psychological, spiritual, socio-economic or
environmental to restore a broken body, broken mind, broken life or broken society. Healing is
the gospel which Jesus Christ preached and practised.

IV. THE HEALING SCENARIO IN INDIA:
In spite of the great strides made recently in science and technology, India still remains
as one of the backward countries of the world. Our longivity is 58.6 years. Following is the
morbidity in India:-

Malaria
Leprosy
Gastroenteritis
Goiter
Tuberculosis

2.1 million
2.8 million
9.2 million
8.8 million
12.7 million

i

1

51

Filariasis
Waterborne diseases

18 million
50 million

A good many of these are preventable. Infant mortality is said to be an index of the
health of a nation. India’s 1MR is 80 per 1000. Following is the comparative figures for IMR
for 1992-93:Bangladesh
Pakistan
India
Philippines
China
U.S.A
U.K
Sweeden
Japan

119
108

80
45
35
9.1
9
5
5

V. RELATED FACTORS IN 11EALTI I:
Several developmental factors, even within the western health care system have led to a
broader comprehension and integreated appraisal of the determinants of health and causes of
illness. Health disorders are multifactorial and interactive. It is increasingly recognised now
that the life styles and environment plays a large role.

In his recent key note address at Medical Anthropology Conference in Suraj Kund near
Delhi Dr. Reddy, Chief Cardiologist of AIMS, New Delhi said nearly half of the cardiac
problems that he secs could be avoided if physical exercises, proper diet and proper life style
were followed. The recent epidemic of plague in Gujarat is an illustration showing
environmental factor play a key role in epidemics. Let us look at some of the major factors in
the Indian context.
a) Poverty

About 40% of our people live below the poverty line. India ’s GNP is Rs.5,529/-. We
are about sixth from the bottom. Poverty is described as the starting point of the vicious circle
of mal-nutrition, illhealth, population explosion, unemployment, backwardness etc. Health is
the prerequisite for increased production.
b) Malnutrition
One of the basic needs of a person is food. A third of our people go to their bed with
a hungry stomach. Staple food should be made available at subsidised rates like Rs.2/- per
kilo for rice as in Andhra Pradesh. Appropriate food habits, high protein and vitamin rich food
such as raggie, green leaves should be encouraged. Breast feeding instead of costly baby food
should be implemented.
c) Water

Safe drinking water is a major factor influeftcihg hvalttj. ^HO reports ilUt 25 to 30%
of hospital beds are occupied by patients whose illh^S fe nsUtCd to polluted water. 0nly less
than third of the villages have water supply Scheme.

2

i

d) Population Explosion
Today we are 900 million in India - we will cross a billion at the turn of the century.
Our population doubles in every 27 to 30 years. Rapid population growth curbs our capacity
even to perpetuate the present inadequate facilities and services as we have to stretch thin our
fragile economy to cover our ever growing population. Population control should become a
peoples movement. China has demonstrated that by improving the quality of life of people
population can be controlled.
c) Social Factors
Housing, literacy, emancipation of women, employement (3.7 crores unemployed)
and such other social factors play a vital role in health. Shelter is an essential requirement in
human life. A recent survey in the city of madras and Bombay revealed that 25 to 30% of the
city population dwell in slums and pavements. 46.6 million need housing. A new technology
of low cost building with locally available materials is the only solution. Our literacy rate
though gradually rising up but is still low. A study in Hyderabad showed the infant mortality
of literate mothers is far less than that of illerate mothers.

f) Environmental Hazards
Environment plays a crucial role in prevention of illness. There is a complex
interdependence of geological factors, flora and fona. Toxic wastes are accumulating, breaking
the protective ozone layer. Rapid deforestation is affecting rainfall and weather conditions.
Pollution is caused by excessive use of pesticides. The Coimbatore study revealed that 70% of
mothers milk contained pesticides.
VI. ALTERNATE STRATEGY FOR BE'ITER HEALTH:
a) Primary Health Care: 80% ot health care need is primary. Social awareness and self
reliance arc key factors in human development. So also is health. Individualls and
communities should resume responsibilities for their own health and strive for self reliance.
The prevailing health care system is largely allopathic western model. This is highly
centralised, capital intensive, hospital based and in-accessible to the masses. It is dualistic,
reductionist and mechanistic with over technologisation and consequent impersonalisation in
both diagnosis and therapy, especially in rural areas. 75% of the nations health budget is for
the benefit of 25% of people in urban areas mostly spent for the upkeep of sophisticated high
tech medical institutions. Modern technology and treatment has a place in managing acute
and complicated illness but the benefit goes to less than 5% people.
b) Traditional System of Healing: A few days ago I was participating in an international
conference at Suraj Kund near Delhi. Participants from various Asia Pacific and European
countries demonstrated how effective are some of the traditional healing methods - Ayurveda,
Unany, Yoga, Accupuncture of China, Pranic healing of Philippines, Sora of Japan etc. These
are less expensive least toxic or non-toxic as some healing methods are non invassive.
c) Health Personnel & Training Programme: Present pattern of training in health is the
western. With the commercialisation of medical training there seems to be an over production
of doctors through the mushrooming of substandard private medical colleges producing about
13,000 doctors a year. The present curriculam and system of training needs to be restructured
to meet the needs and demands of the community, inculcating, ethical and moral values for a
wholistic healing. What we really need is an adequate number of health workers who will
spread themselves into the community to meet the primary health needs of people in dealing
with preventive and promotive health and health teaching programme.
3

i

d) Networking: The Government should identify all the existing healing services, private,
mission, corporate etc and also all the system of healing. These should be coordinated in the
larger frame work of service. There should be a net working of all healing services from
primary health care to secondary, tertiary and very specialised care which will be accessible to
all. There should be a gradual referral system developed from primary to tertiary care.
c) Role of Drugs in Health Care: The recent Wineberg study in USA reveal the following
factors in healing: -

20% of healing is by drugs and modern techniques
30% by OBECALP (ie, placebo effect)
25% by HAVITHORN effect (let off steam technique)
25% by FACTOR X. said to be spiritual and related factors
This unknown X factor is now recognised as the pnemo neuro psycho immunology
phenomenon. Eminent medical people give testimony of spiritual healing seen in their
practice.
0 Holistic Healing: The scientific method is based on the knowledge of biological process as
verifiable, quantifiable and reproducible entities. The Indian system of traditional medicine
emphasises life styles, morality, hygiene, nutrition, positve emotions and spiritual values as
important enablers in fastering health. These two approaches can come together in holistic
healing. Holistic means attention not only to the biological factors in an illness but also to
psychological, social, emotional and spiritual factors which may contribute to the illness or
wellness. Every ailment is a complex disorder of the whole person in all its different
dimensions. A wholistic and enabling approach to healing not dominated by the biomedical
paradigm, is an essential premise of whole person medicine. We have to grapple with this
evolving redical change in our understanding of medicine from its mechanistic orthodoxy to a
more crative metamorphosis.
g) Rational Drug Policy: 80% of todays health expenses are for drugs. WHO recommends
only about 160 drugs as essential drugs. But there are about 50,000 to 100,000 formulation in
the market. Some of them are spurious (Glycerol tragedy in Bombay, I.V. Fluids and sura
deaths in Delhi are examples).

We need to appoint a drug authority to list the essential drugs with its generic names,
and control the prices. Essential drugs should be supplied at subsidised rates and accessible to
all. All products should be tested and standardised. All spurious and substandard preparation
should be banned. Unethical marketing practices should be discouraged, and an ethical
marketing code on the model of the WI IO should be followed.
VII. TRAINING OF HEALTH WORKERS:
What is needed today urgently is not training of doctors but health workers, specially
village level health workers to deal with 75 to 80% of common illness at the primary level. Just
as China had succedcd in achieving health through bare foot doctors India also should try to
produce village level health workers. This experiment has been successfully tried in Tamilnadu
and other places. These village level health workers are able to identify common ailments like
malaria, tuberculosis, diarrhoea, filariasis, Ibprosy etc. and deal with it or refer them to
appropriate centres for treatment. Vo|pntary organisation like CMA1 should encourage such
training programes.

4

I

VIII. CONCLUSION:

As we look forward to stepping into the new century inspite of several handicaps and
negative factors, I visualise a bright future for India. We have the third biggest scientific
manpower in the world. We have plenty of talented and motivated personnel. We have an
abundance of raw materials, natural resources, energy potentials and a rich cultural heritage.
Let us mobilise all our resource potential and work hard with a firm determination upholding
the ethical and moral values to make our mother land, a leading nation of the world, to brigh
prosperity, health, harmony and peace.

*

*

♦

♦

♦

Resources: Health Information India ‘93,
II& F Welfare ‘94, UNICEF ‘95
World Children ‘95

5

♦

*

* * * *

CHAI CONSULTATION ON
“ PRIMARY HEALTH CARE - A CHRISTIAN MANDATE”
New Delhi - 26th - 28th February 1996
Bible Study :
I. Primary Health Care and Healing Ministry of the Church today

John 2: 13-22 (see also Mathew 21 : 12-14,
Lk 19:45-46

Mk 11:15 - 17 &

Introduction ; Cleansing of the temple is reported in all the gospels. But
John’s word has some special marks.
1 • Timing : To John this is the beginning of the Mission of Christ: as if Jesus
is demonstrating in action what the whole of His mission is all about. To
others it is the final action that disturbed his enemies and led them to act
to arrest him and to kill him. Did he do it twice - both at the beginning
and at the end ?

2. Significance : John alone relates this event to the inauguration of his
mission of the kingdom “ Destroy
I will rebuild ” Corruption and
power-politics eating away the very heart of faith is destroying the
structures from inside. His rebuilding is what Jesus gives in answer to
the demand for a sign to prove his credentials as Messaiah.
3. Message : True to the nature of this 4th gospel, there is a rearrangement
of the source material so as the reveal is a subtle way the deeper and
inner meaning of the word in action. The essential message is that Faith and Healing - cannot be institutionalised. It is a dynamic movement. Not
lake but a stream.

The text:
1. Use of violence : Jesus never a pious lotus eating Buddha, He was a man
of action. But he was a scourge on systems, inhuman institutions and
economic power-never on human beings as such.

2. lather’s house and Den of thieves : distance in effect is not very far at
any time in history - There is a very good rational in secularizing,
commercialising and institutionalising worship and Faith and mistaking
means for end.
3. The zeal of thy house : Fs 69:9. The prophetic fervor that brought
about changes begins with zeal eating us up: what 'eats us up’ today ?
4. Sign : Jesus rightly related this action to the Messianic Mission and asked
for a corroborating proof- Mission has to be proved in action.

5. Destroy : Charge against Jesus that he was destroying - but systems itself
leads to destruction.
6. Rebuild : A new start, not white-washing the old-renewal both personal
and collective in the work of the risen Lord even today.
7. From Institutions to Movement : that is what the Healing ministry of Jesus
always is .

1

Conclusion :

I. Institutionalism, commercialisation and secularism is destroying the
ministry of Healing.
2. need a new zeal that should eat the whole of us.
3. luet the Lord rebuild.

Bible Study II
Lk~ IO: 1-10 and 16-24
2. Mandate and Motivation

Introduction:

1. Healing the side was the central part of the Ministry of Jesus. He sends his
descipies with authority. Here the 30 are sent. See also ch - 9:1
2. He sends them two by two : The life together is essential for the power of
healing to be released for the service of others.

3. They report back to Jesus - like others of sucess, of failure, of statistics but
Jesus puls his finger on something else.
Text:

I. Satan falling from heaven : striking as the heart of the evil power of the
world, of power by, of poverty, sickness and superstitions is what
restoring people for the purpose for which God created them means.
2. Names written in heaven : Made workers together with God. Participation
is the kingdom making process in the real motive.
‘
O see beyond the particular to the universal, from
3. Revelation : ability
Io
part to the whole, from curing to making whole is the revelation :

4. Eyes that see there things
c. : The opportunities that are open to us ~
Discoveries in Medical Sciences, the <Communications explosions,, the
infrastructures that share the resources God has given are subjects for Joy.
Message :

I. BIIC is not an end in itself but a necessary condition for people to enjoying
the fullness of life that the Ix>rd offers.
2. The mandate is both to heal and to bring the message of the kingdom.
This is a single mandate - separating the two will only make us ffail to obey
the call.
'y we look for evaluations not on the success of failures of the
3. Ultimately
health standards but on the extent Io which we are in obedience to His
call. It is this mandate that gives meaning and significance to our life and
mission - not merely the agenda that the world sets .

Rev A C Oom men.
2

i

CONCLUSIONS OF THE CONSULTATION ON
'PRIMARY HEALTH CARE - A CHRISTIAN MANDATE’
CMAI, NEW DELHI, FEBRUARY 1996

The Church has a mandate to work towards a just and healthy society. We
believe that Primary Health Care in it’s widest sense would be instrumental
in this work. We are conscious that as of now, the poor remain marginalised
have a clear bias or preferential
and exploited, and that we as a Church
option for them. We realise that with the change of direction in India’s
globalisation, structural reforms and
economic development policies with
marketisation of society, the poor are being sidelined and jeopardised even
more. We are
committed to increasing the understanding of the contextual
realities of the country, within the Church,
it’s institutions, amongst
health professionals and the public at large, and of the urgent roles we need
to take on, especially on the side of the poor.
In this scenario, we feel that there is an urgent need to
congregations, and it’s institutions to the
a) Sensitise the Church it’s
it’s
that Jesus calls us to, and
wider understanding of the Healing Ministry
the emerging health scenario to which it needs to respond.
b) Study and analyse the existing health context with it’s social, economic
and political ramifications, especially with relation to it’s implications
on the health and life of the poorest of the poor; and to respond by taking
sides with these persons through advocacy and through solidarity in the
pursuit of justice.
c) Promote the concept of Primary Health Care in it’s widest sense, through
all the channels available, in ways that will empower people and make
health a people’s movement. The Church with it’s congregations, Christian
Health Professionals and Training Institutions need to be geared for this
movement.
Many suggestions on what specifically needs to be done have been raised.
will need to be looked at in detail and taken up subsequently.
These
Overall, however, some sort of an action plan has emerged, with the
following possible outcomes.
1. We recommend to the CMAI to foster regional/local, issue-based networks
of people and organisations interested in Primary Health Care. These should
ideally use minimum resources, linking up in solidarity and fellowship with
congregations, organisations and people’s movements. The reality of the
concentration of need in the BIMAROU states would call likewise for a

1

concentration of
This effort would hope to
response in such areas.
sensitise the Church to wake up to it’s great role in working towards a
healthy society.
We recommend to the CMAI that it set up the mechanism for follow-up of
this dream, maybe through a small core-group. They would need to study
the existing situation, other responses and networks currently in place,
and help develop this forum, making local, national and international
linkages as needed.
2. There has been a strong expression of the need to invest on Human Resource
Development, and
the need to develop mechanisms for nurture of and
expressing solidarity with persons stepping out in roles in Primary Health
Care. Many specific suggestions have come up, and we recommend that CMAI
respond to them as appropriate.
3. There is a dire need for a pooling of information on the health of the
country, from the various institutions and organisations in the network.
This would create an alternative source of health information at a national
scale; this is greatly needed to make up for the deficiencies and gaps in
the governmental health information system. We recommend to CMAI that it
set up the mechanism for this, linking up with other organisations as
needed.
Three levels of follow-up

were suggested :

1. Individual:

We as individuals, commit ourselves to the philosophy and
practice of Primary Health Care, through our own individual and
institutional linkages.

2. Organisations: We recommend that CMAI work with other
and people to effect follow-up of these ideas.

interested groups

3. Information Sharing : We request the CMAI to keep us informed of the
follow-up and progress in this work. We would also continue to share our
experiences and responses with the rest of the network.

Compiled by
Dr Thelma Narayan
Dr John Oommen

28.2.96

2

26T}[-28T}{

1996

PROGRAMME
Monday 26tfi ‘Fedruary 1996
02.00 pm. - 04.00 pm

Registration - YMCA CCL Conference Centre

04.00 pm. - 05.00 pm

Tea

05.00 pm

Inaugural Function

07.00 pm

Opening Prayer :

The Rt. Rev. Bishop S.R Thomas

Welcome:

Dr. P.S.S Sunclar Rao, President, CMAI

Introduction:

Dr. Cherian Thomas, General Secretary, CMAI

Remarks:

The Rt. Rev. Bishop Lawrence Mar Ephraem

Inaugural Address:

The Rt. Rev. Bishop D.C Gorai

07.30 pm. ~ 09.30 pm.

Welcome Dinner - YWCA Blue Triangle, Ashoka Road

Tuesday 27th ‘February 1996
07.30 am. - 08.30 am.

Breakfast

09.00 am. - 09.30 am.

Devotions - Rev A C Oom men

09.30 am.

10.30 am.

Keynote Address ~ Dr R S Arole
PIIC - Beyond MCI I’
Chairperson: Dr. C.M Francis

10.30 am.

11.30 am.

Keynote Address - Dr Abraham Joseph
PIIC - A priority for Hospitals'
Chairperson: Dr. Thelma Narayan

11.30 am.

11.45 am.

Tea

11.45 am. - 12.45 pm.

Keynote Address ~ Dr Prem C John
PIIC - A people’s movement’
Chairperson: Fr. John Vattamattom

01.00 pm. - 02.00 pm.

Lunch

02.00 pm. - 3.00pm.

Keynote Address - Dr (Mrs) M Arole
PIIC - A need for Empowerment’
Chairperson: Dr A K Tharien

I

03.00 pm. - 04.30 pm.

Group Discussions

04.30 pm. - 05.00 pm.

Tea

05.00 pm. - 06.00 pm.

Presentations by groups & Plenary discussions

07.30 pm. - 09.30 pm.

fellowship dinner

‘Wednesday 28tH Tebmary 1996
07.30 am.

7

08.30 am.

Breakfast

09.00 am. - 09.30 am.

Devotions - Rev A C Oommen

09.30 am.

10.30 am.

Keynote Address - Dr Cherian Thomas
PHC - A need for networking'
Chairperson: Dr. V. Benjamin

10.30 am.

11.30 am.

Presentations by Overseas Partners

11.30 am.

11.45 am.

Tea

-t-

11.45 am. - 12.30 pm.

Presentations by Overseas Partners (continued)

12.30 pm. - 01.30 pm.

Discussion

01.30 pm. - 02.30 pm.

Lunch

02.30 pm. - 04.00 pm.

Plenary and Recommendations

04.00 pm.

Closing function

I2'3

Nanes and Addresses of confirmed participants
P H C - A CHRISTIAN MANDAfE

INDIA
1.

Fr. Jose Melettukochiyil
Assistant Director
CHAI
PB 2126 Gunrock Enclave
Secunderabad 500 003
Andhra Pradesh

2.

Dr. C.M Francis
CHAI
157/6 Staff Road
PB No:2126
Secunderabad -500003
Andhra Pradesh

3.

Dr K M Shyamprasad
Dept, of Cardio Thoracic Surgery
Rainy Hospital
G A Road, Royapuram
Madras 600 021

4.

Dr. Abel Rajaratnam
R U H S A
RUHSA P.O
North Arcot DT
Tamilnadu - 632009

5.

Rt. Rev. Bishop D.C Gorai
Bishop’s House
Chowringhee Road
Calcutta
700 071
West Bengal

6.

Dr. George Joseph
Executive Director
CSI Council for Healing Ministry
Chathedral Road
Madras - 600086
TamiInadu

7.

Dr. R.C Biswas
Di rector/Secretary
Cathedral Relief Services
St. Paul’s Cathedral
Cathedral Road
Calcutta - 700071
West Bengal

8.

Dr. A.K Tharien
Christian Fellowship Hospital
Oddanchatram 624619
Tamilnadu

9.

Dr. P. Zachariah
Co-ordinator
Faith & Healing Cell
First Street
Periyar Nagar
Vellore - 632002

10.

Dr. Samuel Kishan
Secretary, SBHS
CNI Bhawan
Pandit Pant Marg
New Delhi -110001

11.

Dr. Iris Paul
Reaching Hands Society
Malkangiri Dist.
Orissa 764 045

12.

Dr. V. Benjamin
Cline Road
Cook Town
Bangalore - 560 005
KARNATAKA

13.

Dr. Prema Zachariah
Christian Medical College
Brown Road
Ludhiana
Punjab - 141006

14.

Sr. Dr. Agnesita
Sancta Maria Health Centre
Palliagaram
Chengalpattu -603 107
Tamilnadu

15.

Sr. Dr. Hermina
Administrator
St Pius X Dispensary
Perungudi
Madras-600 096
Tamilnadu

16.

Dr. Brigeetha V V
Di rector
St. Mary Poliy-clinic
Gourabagh,PO Guramba
Lucknow - 226007

Fr. Thomas Kunnunkal sj
l7- Regional
Superior
St. Xavier’s
Raj Niwas Marg
Delhi - 110054

18.

Mr. Bennett Benjamin
Consultant Coordinator
Post Bag No. 11
TIRUPATTUR 635 601
Tamilnadu

19.

Dr Raj Arole
Society for Comprehensive Rural Health Project
Jamkhed P 0
Ahmednagar Dt
Maharashtra 413 201

20.

Dr Prem John
EXECUTIVE DIRECTOR
A C H A N
702 B, Shavalya Buidling
16, Commander-in-charge road
Madras - 600 105
TAMILNADU

21.

Dr Abraham Joseph
CHAD Department
CMC
Vellore
632 004
Tamilnadu

22.

Mr. William Stanley
W I D A
NH - 43 Semiliguda
Koraput Dt
Orissa - 764 036

23.

Dr P S S Sundar Rao
President CMAI
SLRTC
Karigiri 632 106
Tamil Nadu

24.

Rev. A.C Oommen
Christian Fellowship Hospital
Oddanchatram -624619
Tamilnadu

25.

Dr. Johnny Oommen
Christian Hospital
Bissamcu ttack
Koraput Dt
Orissa -765019

v

26.

Dr N Devadasan
Gudalur Adivasi Hosp.
P 0 Box 20, Gudalur
Nilgiris 643 212
TAMILNADU

27.

Bishop Lawrence Mar Ephraem
Auxiliary Bishop of Trivandrum
Christu Raja Puram
Marthandam P0 629 165
Kanyakumari Dt
Tamilnadu

28.

Fr. Joseph Chittoor
St. Thomas Church
Sangameshwarpet
Chikmangalur Dt
Karnataka-577 136

29.

Dr. Alfred Mascarenhas
14 High Street
560 005
Bangalore
Karnataka

30.

Dr Jacob Cherian
Christian Fellowship Community Health
Santhipu ram
Ambilikkai
Madurai Dist
Tamil Nadu 624 612

31.

Dr Sara Bhattacharjee
CHAD Department
CMC
Vellore
632 004
Tamilnadu

32.

Dr Mathew K Philip
Medical Director
Seventh Day Adventist Hospital
Ottapalam 679 104
Kerala

33.

Dr Ravi Narayan
Community Health Cell *
No. 367 “Srinivasa Nilaya"
Jakkasandra, 1st Main
1st Block, Koramangala
Bangalore 560 034

34 .

Dr Thelma Narayan
Community Health Cell
No. 367 "Srinivasa Nilaya"
Jakkasandra, 1st Main
1st R1ock, Koramanga1 a
Bangalore 560 034

35.

Mr Luke Sampson
SHARAN
42, Gautam Nagar
New Delhi 110 049

36.

Mr Nevinlle Selhore
SAHARA
E - 453
Greater Kailash II
New Delhi 110 048

37.

Dr A G Thomas
Principal Medical College
Christian Medical College
Ludhiana - 141 008
Punjab

38.

Dr Beverly Booth
14, Birbal Road
Jangpura Extension
New Delhi - 110 014

39.

Fr John Vattamattorn
C/o CHAI

PB 2126 Gunrock Enclave
Secunderabad 500 003
Andhra Pradesh
40.

Dr J Jacob
Di rector
St. Stephen’s Hospital
Tis Hazari
Delhi 110 054

41 .

Bishop (Dr) S R I horn, v;
Bishop House
22, YMCA Road
Byculla
8
Bombay

42.

Dr David W Thomas
Executive Secretary of
Methodist Medical Council
C/o The Methodist Hospital
Jai Sing Pura
Mathu ra
Uttar Pradesh

43.

Dr B P Ravikumar
Superintendent
Philadelphia Leprosy Hospital
Salur 535 591
Vizianagararn Dist
Andhra Pradesh

44.

Dr Pramod Kalsekar
Dept of Community Health
Wanless Hospital
Miraj Medical Centre
Mira j
Sangli Dist
Maharashtra 416 410

45.

Dr J M Das
Medical Superintendent
St. Catherine’s Hospital
Mall Road
Kanpur 208 001
Uttar Pradesh

46.

Ms Reiden Refadal
Di rector
Methodist Rural Public Health Centre
Mursan 204 213
Dist Aligarh
Uttar Pradesh

47.

Dr Ashok Chacko
Community Health Coordinator
Champa Christian Hospital
Champa
Bilaspur dist
M P 495 671

48.

Ms Pauline Biown
Jorbat Christian Hospital
Jorbat
Jhabua Dt
MADHYA PRADESH- 457 990

4

k

OVERSEAS
49.

UNICEF - Dr(Mrs) Mabel Arole
Kathmandu
Nepal

50.

United Mission to Nepal
Kathmandu
Nepal

51.

DIFAM - Dr Rainward Bastian
Germany

52.

E Z E
Germany

53.
54.

I C C 0

55.

Lutheran World Relief ~ Rev Eugene Thiemann
USA

56.

World Council of Churches Geneva

57.

Bread For the World - Ms Ingrid Ostermann
Germany

58.

Dr Jan Vorisek
CEBEMO
The Netherlands

Dr Bill Gould

Erika Marke.

Ms Maria Verhoevan
Ms Christina de Vries
The Netherlands

Dr Daleep S

I

Mukarji

I. » Ol

1t'l

FIKS I SESSION

< I' <

s SO Io 4:WW pm

Yellow .(
What
an d

is happening today in t he rm I or i a 1
c:.,- eno
i n 11 -< e C l-f r• i s t i a n F. e a 11 h network
regarding
Primary Health Care ?
Y e11ow 11
What can concerned ian d sen s i t. i ve? I: h r i t ,i r i
hea 1 I h
p i'" c» f e b s i on a 1 s. / wo r k e r
o regarding Pr im.^r y
_o
. s d
He a I th CS’-rr-

Pink

I

What are 1.1 re i m p 1 i c a t. i on s o I L i re
f| i I |(.|
t:j
iI ,
political and e c o r> o u i i c d e v e 1 c:• f :< m e n t s i
n Indi a
f or Primary Health Care ?

Pink

II

W11 a t c a n , a n d h (u s t „ c
on g r eg a t i on ,
p<; - r- i1O'— ,
congregations.
fellowship groups do about Primar y Ho,-J i-p
r

Green

-■■■< rid

(.■;</

I

What can
can,5 and must, Christian/mj sc:i on ho<
P » I««1 s
r e g a r d i n g p r i m a r y H e a 11 h C a r e ?
What is t hr? t r
(. h r i s t. i a n r • e s p o n s-#.- b i 1 i t y ?
C?reen
L

do

II

What.
is the responsibil ity/rnandato
Churchi
for Primary Health Care ?

n1

( Qi u'!■ I .< i >f t f"

I Hn

-s »- n

I I

(

‘ r I •

' f }

I-1*

SL

Ye? 11 ow

3I SS.K Ibh

•'•I : U/i

Ic hrti/i »||

I

Spell out a strategy for reorientat ing the direction
the cOur11ry ' s 11ea 1111 c:are towar ds I ■'r i.mar y 11ea Illi C .■ <r o.
of
What
can he Cl'MI's role
in
ro I e i
r -i this rearientatiui • '?

Ye.I low

11

Spel 1
attr
egui }jp i i »q
out a ^tral.^qy
strategy for
at.tr ac
at: ting
t j rig 5,
arid
sus taining Chr vst.i an hea .1 th prof ess.iona .1 s/wor I ers in the
r 1 r?
you
havr ■
identi fied
for them in Primc<i'y Ilea lib I ,n > ■
How
can
t h e C M Pi I f a c i 1.11 a t e 111 i s ?

Fink

I

c <u t
t.
S pr> 1 1
a
f". 11* a t r ?g y M
for
r o< -r i on I j ng
I hr
C h r i s t i a n / m i s; > i o n 11 o s j;j j. t a 1 s (ospecia11y
11 ifj
I r < |er
ones)
to ward $•>
1.1 iei r 1 eg i t i ma te ro 1 e
in
I? r i m a r y
Health Care, What cani C.' MPi I d o t. o r e o r i e r 11 it ':' mi-0her
insti tutions tn this way
i
'?

Pink

II

Spel 1
out.
a
strategy,
or
1 i Be
<::• f
ac t. ,i c«n
for
getting
Chr is t.i an
congr < (|.< t .i or e- „
p. H i ’ h'
and
fel 1owship
gr oups
involve!.
in
» hr
I i hI 1
c-1
role
you
have
i den t.i. Tied
f (.:• r
thein
i 11
I 'r i mar y
I leal hif
What
Care.
can
be CHPiI's role i i i lli.i S < ni igr <-'( I a I i < 4 I a j
involvement ?
Green

I

Spell out a strategy
strategy of
of line of action
ar tion for gettinci
I I io
t
1
s
s
C h r i s t i a n / m i s s i o ni
h
p
i
a
(e
o
s
p e c i a 11 y 111 e
hospita1
more numerous
in idd J e
ones)
level
actively invoked in the
kind of Pr .i ma r y
He;-1 th
have
identified for tle/n.
that
you
Wha t c an t he
hllAl
drI
r eo r i en t j. t s m em b e r institution^ in this
?

/

Green

II

out.
Spe.l 1
’IL
a
J ’
strategy or line
of /ft|1i(.n
< I» I I i j, f |
I or
if,/.
Church
to ac c e fj t an d bec <::«me c omm i 11I
to the. r r. I . ’ you
h.’/i
id er it i find
h 'r
LI ii'
I 'hurt h
in
hi i Hi< ir
Ik - M h
i
What
should
do
regai d.
CHPiI
in
this
l.hc
I
hi
l)
' Ii a r m i r • the healing ministry?

Extracts from

Health For All : An Alternative Strategy
I ssu es &, Conc 1 usions

O
X

Z

•A

r’
ci.

s• .O'

y

■’

»

k.

b O

V* 9

i

I£i
82

We are optimistic about the possibilities of bringing
better health to the people of India.
A new partnership between
the health system and the people can release their tremendous r
The remarkable scientific
capacity to solve their own problems.
advances of recent years can be adapted specifically to meet the
needs of the poor and deprived rather than being focussed mainly
on sophisticated care for the elite.
Abundant demonstrations have
shown what needs to be done,to produced ramatic changes in the
health and w elfare of those in greatest need, especially women and
children.
We are, therefore, convinced that the goal of health for
The plan we have pre­
all by 2000 AD is realistic and practicable.
sented here is expected to help the country to achieve this goal
Its principal message is
through vigorous and sustained action.
that this goal cannot be achieved by a linear expansion of the
existing system and even by tinkering with it through minor re­
Nothing short of a radical change is called for;
and
forms.
for this’it is necessary to develop a comprehensive national
policy on helath and to create an alternative model of health
•caro services.

i

4 '

7

The basic challenges presented in this plan, are to initiate an integrated plan of health, development and family plan­
ning, bas’ed bn a hopeful vision of what can be achieved by the
year'2000.
It necessarily implies the adoption of several al­
ternative policies which have been broadly outlined in this
Report.
No twenty year perspective should try to provide detailed
That is essentially a. task for
prescriptions for implementation.
the five year and annual plans; and in a vast and plural country
like India, .for each State Government and district authority to
decide -in the .light of the national policies laid down by the
Government of India.
What this plan provides - and that is all
what a plan of this type can ever hope to provide - is a frank
analysis of the existing health situation, highlighting the gap
between even minimal aspirations and the actuality, .a comprehen­
sive conceptualisation of where the country might be at the end
of this century if this challenge is taken seriously, critical
analysis of constraints and major policy options, a discussion
of interlinkages and priorities, and an indication of the best
strategy available to realise, our objectives, with some idea of
These are preits administrative and financial implications.
. sented here in a format designed to be used by all those who
will be most concerned with these issues, including leaders of
public opinion.
The various Chapters of this Report present t-he
rationale and justification for the new directions proposed in
the different health sectors and a fairly detailed indication

Report of a study Group set up jointly by The Indian Council
of
of Social Science Research and the Indian Council
Medical Research, New Delhi, I960.

e

(2)

of the changes needed in
programmes and strategies.
In this
ing Chapter, we shall I
concludbring together
our
major
and
conclusions
commendations to facilitate
the consideration of this document reto expedite action thereon.
and
Health for AH by 2000 A.D.

What does this
goal of health for
all by 2000 AD
else terms?
We have F
suggested that this should mean the mean in pre-r
good and adequate health
provision of
---.i care for all citizens the poor and under p
and e specially for
Pr^rlaged ?ro
Ip
r
In our <
a tremendous reducti
on in imorbrdity
1 ‘
„
----imply
and mort
mortality
ality resulting in a
of the total death
rate from 15 to
- f9 and in the birth rate,9 Jrom
This will
to 21.
also imply that the
one’ that !nf
(which is
now 1.67) will be :
Rate (which
reduced to r
reduced from 120
mortality
be
would
to 6 0, that the a”
- average family si2e
to 2.3 children,
4.3; children
and that the total
- - “1
- of India
Population
at about 1200 mUliDn by gbout
may
stabilize
205Q., This would indeed
break-through, not l .,1
break-through,
be a great
only in health, but also in
We consider
planning.
development and f
f amily
--r these targets as realistic
and practicable.
If this goal is to be realised,
health care services if
Health is a function,
Of the overall integrated development’of
developmentin of
i1™1’ 8fiai-d political,
:
political.
?„d 9„d .oclrti„ go to‘
go;
together.
bei? of ssupportive services - nutrition
Imn

medicaI Care> but
economic
-

“e

— u«, boo /

f dePe"ds on a num-

m e n t an d ed ucation ;
end thZ inf^nc^ofXrriljH
e"Vir°"- ’
status is far
—' ^ater than that of medical CareThe "ma-00 health
which will improve
’ health are thus cutside
programmes
proper.
These were comparatively n.gleoted in the^L^ 30^'
-•i care
years and
-J 'such
not be repeated; and
error should
during the next two decades the
of (1) integrated overall development
fol ■
threeJ Programmes
’
h
environment iand’ ‘health education, and’(3)
^drovement in nutrition,
health care services for all and esXiallv fDrf°h1S10n °f ad^Uate
privileged, will have
large investment^ in^he^t^8

*• b.

— — under-

Integrated Development

‘h*

T’"™’

«’ i —
both cb.,p a„d .xpe„dabJB.U’ of
"J its

Br„t.st iilne,s of

""d U'Hdr.n i. 1P„; th

Health infor
tarian goal and it cannot be achieved
a
essentiaHy agalif
achieved
in a society of this type.
ntegrated programme of development th
The
to be6 pursued
f'Ursued c----over the next 20 years
should therefore be basically aimed
spreading education, and improving the r.
Poverty and inequality
e^Cln9 poverty
reducing
-11 as of the poor and deZZ s'cciaiTUS
and ^ildTen Z
°f
st at us of*
This will Indude the
following:
social groups.

1) Rapid economic growth with the

national income

object of doubling the
per capita (at constant prices) by

2000 AD.

reasonable wages to

n9 a guarantee of work
on
every adult who offers
3 to work for 8 hflours a
day.

(3)
Creation of adequate opportunities of gainful employment to women,
with an emphasis on equity of remuneration and reservations to make
up for past neglect, so that women become ’visible’ assets to their
families.
3) Improvement in the status of women with a determination
and to make it rise substantially
to check the adverse sex-ratio
upwards, say to 972, the level it was in 1901.
4) Adult education with emphasis on health education and
vocational skills, the targets being to cover the entire illiterate
population in the a gc-group 15-35 by 1991 and liquidation of illiteracy by 2000 AD.
5.) Universal elementary education for all children (age
group 6-14) to be provided by 1991,
6) Weelfare of Scheduled Castes and Scheduled Tribes.
7) Development of an
family planning.

intensive and .integrated

8) .Creation of a■democratic,
form of government.

decentralised

programme of

and participating

9) Rural electrification; and
10) Improvement in housing, with emphasi s on the provision of
houses for the landless and slum clearance.
We have recommended that the details of these programmes should
be worked out and that they be implemented fully over the next 20 years.
Fa mily Plan ninq
Family planning should become a people’s movement.
This process would be facilitated by the efforts at integrated development and
the education and organization of the poor and underprivileged groups.
11 is desirable that there should be
National Population Commission
’set up by
on Act of Par'll ament \to -Toirmulate and implement an overall
population policy.
The objective should be to reduce the net re­
production rate from 1.67 to 1.00
nd the birth rate from 33 to 21.
This will imply effective protection of 60% of eligible couples
(against 22% at present).
While the emphasis on terminal methods
should continue, there should be far greater use of other methods as
The accent should be on education and motivation, especially
well.
through inter-personal communication and group action.
Incentives,
There
especially those of a compensatory character, should be used.
should be concentrated effort to work with women as well as men.
While the health care services have a role to play in motivation
also, their main responsibility is to supply the needed services,
and to undertake follow-up care,
The alternative model of health
care services has been designed toi meet these challenges fully and
squarely.

&. . .

(4)
bLut^rition
Among ether supportive programmes, nutrition deserves prioritv
ec use it is a major foundation cf health.
For this purpose, it is
neccss.-ry to grow adequate food, to reduce post-harvest losses, to
create an adequate system of storage and distribution, and to increase
the purchasing power of the people by creating employment for men,
It will nIso be necessary to give special
and especially for women.
attention to improving the nutritional status of women and children
Breast feeding should be encouraged and women trained and assisted
to take better care of children through weaning at the right time
and threugh a more efficient management of the child's diet in the
immediate post-weaning period. Pregnant and lactating mothers
Special Programmes
a1V£’? thu special Paction they need.
should be developed for specific nutritional disorders like iron-deficimcy anemia, or vitamin - A and iodine deficiencies.
In addition
supplementary fending programme may have to be organized for careful­
ly identified target groups at risk.
Impjr□y^ernEnt cf the Environment
The second supportive service is improvement of the environ—
merit.
It will reduce infection and make programmes of nutrition ithave tjo be developed
self more effective. Several programmes will
----- ------Safe drinking water supply should
from this point of view.
1 be proviurban_ and rural areas nt an average annual estimated cost
d®d 1:0
of Hs.7,SOO million.
In urban areas, the sewage disposal system
will have to be.improved by eliminating the basket service system in
ten years, providing water seal latrines to all households who have
po facilities at present, during the same period, and ultimately,
installing good sewage disposal systems with essential purification
works in all urban areas by 2000 AD. The estimated costs cf this
programme will work out to Rs.1,125 million per year.
A massive
programme of proper collection and disposal of solid Wastes and
their conversion into compost will have to be developed in all areas
the estimated cost being Rs.4, 000 million a year on an average. ' In ’
rural areas, an intensive programme of improving sanitation, with
special emphasis cn proper dis. os3l cf night soil, will have to be
developed at an estimated cost of Rs.5,000 million a year.
Greater
attention will have to be paid tc town and village planning (with
special emphasis on removing the segregation of the Scheduled Castes),
and large-scale programmes of housing for the rural poor and clear­
ance of urban slums will have to be undertaken, with emphasis on the
development (fif low-cost building technology. Urgent steps have to
be taken to prevent water and air pollution, to control the illindustrializati
effects of industrialization
and to provide better work-place.
H e-'lth Ed ucati on

Th e third supportive service is health education.
Il
It gives
information, teaches skills and cultivates attitudes and Values
which help an individual to be healthy,
Health education is not
also a one-shot affair:
c
an
individual will need it throughout his
life.
The best way to universalize-health
- education
--------- -.1 and therefore
is to make it an integral
:*
part of general education which, in its
turn, will have to be life-long. In early childhood (0-5 years),

(5)
l\l utrition
Among other supportive programmes, nutrition deserved
priority because it is a major foundation of health*
For this pur­
pose, it is necessary to grow adequate food, to reduce post-harvest
losses, to create an adequate system of storage and distribution,
and to increase the purchasing power of the people by cileating
employment for men, and especially for women. It will also be
necessary to give special attention to improving the nutritional
status of women and children. Breast feeding should be encouraged
and women trained and assisted to take better care of children
through weaning at the right'time and through a more efficient
management of the child’s diet in the immediate post-weaning period.
Pregnant and lactating mothers should be given the special protec­
tion they need. Special programmes should be dev/eloped for specific
nutritional disorders like iron-deficiency anemia, or vitamin-A and
iodine deficiencies. In addition, supplementary feeding programme
may have to be organized for carefully identified target groups at
risk.
I mprovement of the Environment
The second supportive servjca in- improvement of the povirooment . It will reduce infection and make programmes
no’trltion
itself moreeffective.
Several programmes will have to be developed
from this point of view.
Safe drinking wat&r supply should be
provided to all urban and rural areas at an average annual estimated
cost of Rs.7,500 million.
In urban areas, the sewage disposal
system will have to be improved by eliminating the basket1 service
system in ten years, providing water segl latrines to all households
who have no facilities at present, during the same period, and ulti­
mately, installing good sewage disposal systems with essential purl- c
fication works in all urban areas by 2000 AD.
The estimated costs of
A massive
this programme will work out to Rs.1,125 million per year.
programme of proper collection and disposal of solid wastes and their
conversion into compost will have to be developed in all areas, the
estimated cost being Rs.4,000 million a year on an average. In rural
areas, an intensive programme of improving sanitation, with special
emphasis on proper disposal of- night soil, will have to be developed
at an estimated cost of Rs.5,000 million a year.
Greater attention
will have to be paid to town and village planning (with special empha­
sis on removing the segregation of the Scheduled Castes), and large-scale
programmes of housing for the rural poor and clearance of urban slums
will have to be undertaken, with emphasis oh the development of a
low-cost building technology. Urgent steps have to be taken to pre­
vent water and air pollution, to control the ill-effects of indus­
trialization and to provide better work-place environment.
Health Education

It gives
The third supportive service is health education.
information, teaches skills and cultivates attitudes and values
which help an individual to be healthy. Health education is not
also a one-shot affair:
an individual will need it throughout his
life. The best Way to unversalize health education therefore is
to make it an integral part of general education, which, in its

(6)

turn, will have to be life-long.
In early childhood (0-5 years), it
is primarily the responsibility of the mother to give to to her
child and she must be trained to d o so.
For older children (6-14
years), health education should be an integral part of general ele­
mentary education which should be universal.
Health education suited
to adolescEints and youths should be an integral part of secondary and
university

education alsoi

tion should be
The

What is

an integral part

health

extremely important,

health

educa­

of adult education.

personnel have three

major responsibilities for

health education.
They should assist the general education system
to provide health education by devising suitable programmes, training
of teachers, production of materials and conduct of experiments.
They have also an educational role with regard to e^jery patient be­

cause all proper medical treatment often includes an element of
Finally, they have a very important role in which
health education.
they try to give health education to the
groups who need it

most.

poor and

under privileged

The Central and State Health Bureau should

be reorganized and strengthened to help the health personnel to dis­
charge

these responsibilities.
The mass media should be harnessed
purposes of health education.

fully for

The AlternativL Mod cl of Health Services
This brings us finally to the central problem of the action
required within the health field itself to reach the goal bf health

for all by 2000 AD.
As stated earlier-, no meaningful results can be
obtained by a linear expansion of the existing health services or by
tinkering with them through minor reforms.
We have, therefore,
proposed that this model should be totally abandoned and a new al­
ternative model should be created

in its place.

c

This new model differs from the existing model in several
important respects.
It abandon_s the top-down and elite oriented
approach of the existing services and is based or rooted in the
community (which means a population of 1,00,ODD which will have a
Community Health Centre, a sub-centre for every 5,000 population and
a villager-neighbourhood centre
rises to specialised referral
levels.

It

for

every 1, 000 population) and then

services at

the district and regional
gives up the ovrr-emphasis which the present system places

on large, urban hospitals and creates a small community hospital of
about 30 beds in each community to meet the vast bulk of its referral
needs.
It moves away from the predominantly curative orientation of
the existing services and integrates promotivu, preventive and cura­
tive aspects at all levels.
It redefines the role of drugs and
doctors so that they remain the best agents of health care and do
not develop a vested interest in ill-health.
It gives, up the_.centralized and bureaucratic character of the present system and adopts a
and participatory approach which will in­
volve the community intimately in planning, providing and maintain­
It strives to integrate the valua­
ing the health services it needs.
ble elements in our culture and tradition (e.g. the ashrama concept
of stages.in lifey none onsumeiist attitudes, sense of individual and
decentralized, democratic

( 7)
community responsibility, yoga and simplicity and self-discipline
as the core of a life-style). It also strives to create a national
system of medicine by giving support to and synthesizing the indiFinally, it.abandons the over-expensive model of
gen°us system.
the health care systems in the developed countries and creates an
It
economic model which will
ill be within the reach of the ccountry.
is our considered view that health should
should have
have the
the same
same priority
priority
•a education and that both should receive,
:
about 6% of the national
income by 2000 AD.
This would provide all .the
----- ----- ) funds needed to
implement this model and to develop its essential
support services.
It is our recommendation that this model should be
fully created,
in a phased and planned manner, by 2000 AD.
MCH Services
In this new model,

rr

special efforts will have

— 1 services which
an attempt to cover all

to be mode to

Those services will be
With strong referral support from the MPWs.
largely domiciliary.
A detailed programs should be drawn up of the
different services that will be provided at the village, sub-centre
and community levels, end priorities in MCH activities should be
cJ-e«ly laid down.
The MCH staff nt each level should be adequate and
sh
Id *eCelVe Job sPcclflc training.
Health education of the mothers
should be an important component of MCG services and care should be
a on to see that these services retain their essential character as
slices for women and children even while laying adequate emphasis
on family planning.

T he

Communicab le Di scases

, . ...
Tbe 9ommunicable diseases still form the largest cause of mor­
bidity and mortality and the fight against them will have to be con-

rn«

Wlth.St:11 rL'/t£r Vi9OUr in the yesrs

The existing pro-

tuberculosis, leprosy, filariasis, pnlio
mvelitis 9adnT
myelitis and Japanese Encephalitis will have to be strengthened, broadly
Diarrhoeal diseases, especially those of
tbe lines indicated.
proper linTs
,Sp!:Clr11 ^phasis.
To ddvelop these programmes on
nH “
is necessary to develop a gODd surveillance system
, ’
stration
pn%nnnCln°rt
a11 rese«ch institutes and the admini•, By 2000
t
CUI obJect should be to eradicate (or at least
□ hlbi
dlarrhoeal diseases, tetanus, diptheria, hydroand leorosJ1 rnS’
’ tubcrculosis’ guine.n-worm, malaria, filariasis
a I I Li

±c piuSy •

Rehabilitation Services
estimacted 60
physically handicapped in
the enun^v"
h h
million more are added.
Despite this
fVGry year’
the rehabilitation services are poor and inadequate.
Rehabilitation
RSehabi!LSIa " be,inte^ted with other community health servLeJ
Rehabilitation workers should also be drawn from the community and
New technohealth education will include rehabilitation education.

.n°’

b‘

““"S

( 8)
Personnel and Training
Under the new alternative model, the organization of the
health services will be radically different from that in the exist­
ing system.
A new personnel and training policy will, therefore,
have to be adopted on the broad lines

indicated.

personnel, the CHVs, will be introduced
between the community and the services.

A new category of

and will be the’ main bridge
The middle level personnel

This will include health assist­
ants, MPWs, nursing personnel whose numbers will be much larger and
whose status will need considerable improvement, and paramedicals.
Very important questions about doctors will hove to be sorted out;

will increase■very substantially.

these relate to their numbers, training,

conditions,

value

system and

remuneration

proper devclopm nt

and

social

of post-graduate

course.
The training and utilization of sp ciolists and super­
specialists will have to be reorganized from the point of view of
Facilities for training in public health
effective utilization.
should be

increased.

There should be

adequate

arrangements for the

continuous in-service education of all categories of health person­

nel.
The Government of India should establish, under an Act of
Parliament, a Medical and Health Education Commission, with compre­
hensive terms
training and

of reference.

A continuing study

taking effective action thereon

of personnel and
should be a major res­

ponsibility of this Commission.
Drugs and

Pharmaccutic a Is

There is need for a c lear-cut drug policy and a National
Drug Agency to implement it properly,
The pattern of drug production
in the country should be modified to suit the disease pattern.
The
drugs required by the poor people should
------ b
je produced in adequate
quantities and mad., available at the cheapest price
This
s possible.
applies specially to the few simple drugs
required at the community

is also necessary compile a list of other essential drugs,
of all essentia 1 d rugs should be calculated and
steps taken to see that they arc produced,
The production of high price
level.

It

The quantities needed

and useless drugs needs to be controlled,
sion to over-prescribe should be curbed,

the tendency of the profes-

The production of basic drugs
has to be made more selfsufficient and in this, the small scale sector
needs to be encouraged subject to strict quality control.
The dominance
of the foreign sector should be reduced still furth
ler.
------Price c ontrol
should be more effective; the cost on packaginj: a nd overheads should
be reduced; the introduction of new drugs should b
e strictly controlled
and proliferation of drugs by minor variations should not be allowed;
to the
the prices, of essential drugs should
should be
be kept
kept to
minimum, a higher
the minimum,
mark-up being allowed, if necessary,
in other
other drugs;
and all
all essen­
drugs; and
essnry, in
tial drugs should be sold only under generic names.
There should be
adequate arrangements for quality control of all drugs, including
indigenous medicines and R and 0 in drugs needs to be greatly
encouraged.
There is considerable imbalanc. in the consumption of
drugs in urban and rural sectors of the health system which needs
to be corrected and it' may be desirable to move towards a system .
tahen the patient pays for the cost of drugs.

Research

The.main problems in research are selection of
of priority
priority
areas, quality and utilization of research, improvement in research
capability, and attainment of indigenous self-reliance. The
prioThe priority areas obviously are: primary health care, epidemiology,
communicable diseases (with spec.al emphasis on diarrhoeas), en­
vironmental research, and research on drugs end problems of rural
wa er supply and sanitation. It is also necessary to promote re­
search on social aspects of medicine jointly under the ICMR and
ICoSR, especially on the economics (f health and financing of health
services. Other important areas are indigenous medicine, health
implications of industrial development, and family planning. Con­
siderable attention has to be given to the development of appro­
priate technology. Side by side, there should be an emphasis on
the development of clinical and basic research, particularly in the
field of biology, and a determined bid to build up high level indigenous research capability with a view to attaining self-reliance?
Administration, Finance and Implementation

The introduction of the alternative model has large admini­
From the administMative point
strative and financial implications.
ot view, it is necessery to redefine the roles of the Central and
tate Governments in view of the large powers delegated to the local
bodies at the district level and below.
Volun ary agencies will
have to function within the overall policylaid down by the State.
But they should receive enc ouragement an d aid, especially when fight­
ing at the frontiers and dcing pioneer work. There will be consider­
able tensions within the new health care services and need for reThis is the responsibility
definition.of roles and mutual adjustment.
of the administration to secure through good leadership and proper
training. The referral services should be strengthened and stream­
lined; a new and efficient national information system should be
created; and adequate arrangements made fnr more effective coordinaticn at all levels.
On the financial front, the total investment in health services will have to be substantially stepped up and the health expendi­
ture wi11 have to rise by about 7 to 9% per year (at constant prices).
The existing priorities will have to be radically altered and the
bulk of the additional resources will have to go int o; pr omoti v e and
preventive activities, in rural areas, in the development of supportive
services like nutrition, sanitation, water supply and education, and
underprivileged groups.
This will need taking of both positive and
There should be adequate grants to local bodies
negative decisions.
and communities to enable them to discharge their responsibilities •
and while the basic responsibility of financing health will continue
to rest with the.Centre and States,' an effort should be made to tap
local taxes and individual payments to cover drug costs.

(10)

The alternative model proposed here is a large step in
the creation of a national health service, but it does not create
it. In our opinion, the time is not ripe for the purpose and the
issue may be examined in due course, say, ten years from now.
There is, however, need to control private practice and it should
not be allowed to employees in the public health care system.
Conditions Esscnti : 1

or Success

This, in brief, is the plan we have proposed, for realising the goal of health for all by 2000 AD.
There con be no two
opinions about its desirability, and what we have outlined is enough
to show that the goal is realistic and feasible.
As we said at the opening of our Report, the country dedi­
cated itself, when it adopted the Constitution in 1950, to create
a new social order based on equality, freedom, justice and dignity
of the individual and to eliminate poverty, ignorance and ill-health.
This ’mid-term’ review after three decades shows that, in so far as
health is concerned, the country is still far short of its objective
inspite of major advances.in several areas. It also shows that an
attempt to eradicate ill-health will not succeed in isolation and
that it can be pursued side by side with the other two interdependent
and mutually supportive objectives of eliminating poverty, inequality
and ignorance, and against the backdrop of a socio-economic trans­
formation which will give effective political power to the poor and
deprived social groups. It is, therefore, necessary that the
country rededicates itself to this task and strives to achieve its
goals by 2000 AD. Succeeding generations will never forgive us
if we fail to do so.
The attainment of this goal depends, above all, on three
things: (1) the extent to which it is possible to reduce poverty
and inequality and to spread education; (2) the extent to which it
will be possible to organize the poor and underprivileged groups
so that they are able to fight for their basic rights; and (3) the
extent to which we are able to move away from the counter-productive,
consumerist Western model of health care and to replace it by the
alternative model based in the community which is proposed here.
These are our tasks and it needs millions of young men and women,
both within and without the health sector, to work for them. If a
mass movement for this purpose can be‘organized and the people
rededicate themselves to the realisation of their national goals,
the country will be able to keep its trust with destiny at least*
by 2000 AD, if not earlier.

Position: 1294 (4 views)