Socialist Health Review 1985 Vol. 2, No. 2, Sep. People in Health Care.pdf
Media
- extracted text
-
COMMUNITY HEALTH CELL
47/1. (First Ficor) St. Marks Road,
Bangalore - 550 001.
CLASS LOCATION OF DOCTORS
UPSIDE DOWA RESEARCH : AAAEffllA STUDIES
CHWs IO SHAHDOL
communiTv health projects
AT THE CROSSROADS ?
CRITIQUE OF ILLICH
o
Yol II
Number 2
PEOPLE IN HEALTH CARE
53
Editorial Perspective
PEOPLE IN HEALTH CARE
C. Sathyamala
57
DOCTORS IN HEALTH CARE
Sujit K. Das
Working Editors :
67
Amar Jesani, Manisha Gupte,
Padma Prakash, Ravi Duggal
UPSIDEDOWN MEDICAL RESEARCH
Rajkumari Narang
Editorial Collective :
74
Ramana Dhara, Vimal Balasubrahmanyan (A P),
Imrana
Quadeer, Sathyamala C (Delhi),
Dhruv Mankad (Karnataka), Binayak Sen,
Mira
Sadgopal
(M P),
Anant
Phadke,
Anjum Rajabali, Bharat Patankar, Jean D'Cunha,
Srilatha Batliwala (Maharashtra) Amar Singh
Azad (Punjab), Smarajit Jana and Sujit Das
(West Bengal)
Socialist Health Review,
19 June Blossom Society,
60 A, Pali Road, Bandra (West)
Bombay - 400 050 India
Printed at:
Omega Printers, 316, Dr. S.P. Mukherjee Road,
Belgaum 590001 Karnataka
Rates
:
Rs. 20/- for individuals
Rs 30/- for institutions
US §20 for the US, Europe and Japan
US$15 for other countries
We have special
countries.
84
COMMUNITY HEALTH PROJECTS: AT THE
CROSSROADS ?
Sumathi Nair
92
Editorial Correspondence :
Annual Contribution
SOCIAL DYNAMICS OF HEALTH CARE
Imrana Quadeer
rates for developing
(Contributions to be made out in favour of
Socialist Health Review.)
REVOLUTIONARY IN FORM,
REACTIONARY IN CONTENT
B. Ekbal
95
DUST HAZARDS IN COAL MINES
Amalendu Das
REGULAR FEATURES
Dialogue : 89
We had to hold back the excerpted article
"Sexual Division of Labour : The case of Nursing"
by Eva Gamarnikov due to lack of space.
The views expressed in the signed articles do
not necessarily reflect the views of the editors.
Editorial Perspective
PEOPLE IN HEALTH CARE
other profession enjoys the amount of adu
lation or gets its share of brick bats as does
the medical profession. The problems of ill-health
being what they are in our country, every discussion
and debate on such issues revolves around the
question of availability of doctors This factor has
assumed such a major importance that the doctorpopulaiion ratio has come to be accepted as a
standard measurement
of health services and
indirectly of the health of a population. In this
process ihe important contribution made by the
other categories of health workers remains invisible
only to come up when they strike work.
The central role doctors play in diagnosing and
treating diseases is not merely confined to the
provision of such services but extends to the entire
field of health care including the right to define
what constitutes disease and the right to treat it.
The medical profession argues that if high quality
services are to be made available and if 'purity' of
medical practice is to be maintained it is essential
that the profession retains complete control through
registration and legislation. Further, the medical
profession argues that diagnosing and prescribing
are superior to all other skills and only those who
possess such skills have the necessary authority to
direct the course of health itself. That all such
arguments merely form a facade for maintaining
monopoly over a valuable commodity can be seen
by looking at the way medical practice evolved into
its present professional status.
The Beginnings of Medicine as a Profession
The emergence of the medical profession can
be traced to 14th-15th century Europe which witn
essed a class alliance between the upper middle
class male 'regular' doctors and the feudal church
leading to the ruthless extermination of other
healers, mostly women, through well organised
witch-hunts Similarly, two centuries later in America
the 'regulars'tried to gain monopoly over medical
practice by attempting to pass state legislation in
collusion with the emerging industrial and comm
ercial bourgeoisie. Initially such attempts met with
mass protests which culminated into a popular
health movement. Unfortunately, the effort against
legislation could not be sustained and the move
ment degenerated into a number of medical sects.
September 1985
The 'regulars' attempt at cornering the market
for their expertise was based on two factors.
Firstly, the 'regulars' need to eliminate competition
now arose as, for the first time, the practice of
medicine was being viewed a full time economic
activity. Secondly, if this activity was to bring in a
substantial income, it was necessary to improve
the image of the activity by giving it a professional
status. As a mark of distinction the regulars adopted
the Hippocratic oath and code of ethics as their
standard. It is important to note that all this took
place before medicine had attained any scientific
aura or had developed any rational medical inter
ventions. In fact, the regulars of that time
practised what was known as heroic therapy which
included blood-letting,
purging and applying
leeches among other such horriffic remedies.
With the support of the industrial and commer
cial bourgeoisie, it was just a matter of time before
specific and effective interventions in the disease
process developed which further consolidated the
power the medical profession had gained through
legislation and the physical extermination, of other
healers. It was this monopoly that shaped the form
and content of medical care to its present form.
The predominant hospital structure and the emer
gence of other categories of workers such as the
nurses, laboratory, x-ray technicians, pharmacists
and others has evolved and revolved around the
functions that a doctor performed.
It was also not a mere accident that nursing
emerged as a suitable profession for women or
that it was subordinated to doctoring. By the time
medical practice had become established as the
domain of male regular doctors, women had been
eliminated from health care for all practical purposes.
The authority that doctors had in defining norma
lity allowed them the power to advance pseudo
scientific theories and sexist arguments regarding
the intellectual capabilities of women to prevent
them from entering medical colleges. Women from
the upper classes were increasingly being told to
conserve their energies for the supreme function of
being a woman, that is procreation, and were
therefore forced to lead a sedentary life. For the
women from this class who did not or could not
marry, life had little option. Apart from teaching
there was hardly any respectable 'genteel', non
53
industrial occupation which would be socially acce
ptable and at the same time provide a certain
level of economic independence. The goal of Flor
ence Nightingale, the 19th century reformer was to
create a paid job in health care for women. To
make it acceptable to doctors Nightingale demo
nstrated in the battle field of the Crimean war that
nursing would remain subordinate to doctoring and
her attempt to make the occupation acceptable to
women was to draw analogies between nursing
and housework. The doctor nurse relationship was
projected as a husband-wife interaction and nursing
was stated to be 'natural' to women, as it coincided
with what was considered to be her natural biolgical
function. Since Nightingale’s effort was to create a
job for the women in health care she made it quite
clear that it would in no way question the suprema
cy of doctors or the subordinate position of nursing.
Feminist historians however question the acceptance
of nursing as a natural sexual division of labour. By
taking patriarchy as an analytical category they have
tried to argue that what is generally considered a
natural sexual division of labour is in reality a social
division of labour which designates men to be
superior to women in all social interactions, con
cerning men and women.
The heritage handed down to the nursing
occupation by Nightingale and other reformers has
left its indelible mark on the issues identified by the
nursing profession in the later years. Nurses have
taken up issues related to registration, professional
status and for a certain degree of organisational
autonomy. But at no time has the nursing pro
fession questioned its subordinate position. In fact
one of the barriers for expanding the nurses role
to a nurse-practitioner came from the nurses associ
ation in the US, who were reluctant to accept the
responsibility for diagnosing and treating.
In India one could say that the health care
system expanded only after independence. Although
on the whole its evolution was similar to the develop
ment that took place in the West, there were
certain dissimilarities. For instance, even as far
back as 1883 several universities in India began
to accept women as medical students. The Bhore
committee in its recommendations at 1946 stated that
at least 20-30 percent of seats in medical colleges
should be reserved for women students. The change
in attitude of the profession towards women stu
dents was perhaps related to the constraints placed
by the purdah system on women in general which
prevented the male medical profession's entry into
areas such as maternal and child health. The post
54
independent years have seen atlrrepts to provide
medical services through an alternative health care
structure by establishing primary health centres and
subcentres to cover rural populations. But through
out all these developments adequate care was taken
to ensure that the monopoly exercised by doctors
would be maintained and remain unquestioned
The Bhore
committee stated categorically
that only the physicians trained in allopathy,
should
be called doctors and the doctor was
to be the unquestioned leader of the medical
team whether it was in the operating room or in the
primary health centre. It emphasised the training
of one level of doctors and recommended the aboli
tion of the Licenciate course. Without analysing
the class background of the doctors or their class
interests the members of the committee hoped
that training sufficient number of doctors would
ensure that they would opt for the villages That
the committee was not sufficiently interested in
the other categories of health personnel can be
seen by the number of pages devoted in their
report on the training of doctors and all other
categories of workers. Later committees too have
emphasised the role of doctors at the cost of
neglecting all other health personnel. The need to
train a 'lower' category of practitioner is discussed
time and again but is always rejected on the plea
that it would lead to quackery. At the same time
when the suggestions that a 'lower' level of nurse
be trained was made by the nursing council it
was greeted as the most feasible solution given
the low resources available in the country. Similarly
when the Shrivastav committee made its recommen
dation in 1975 for training village level workers,
it also allayed the fears of the medical profession
by stating that since the role of these function
aries was educational, their curative skills would
be limited to just a few remedies for simple day
to day illnesses.
The end result of all such actions has been
to create a structure which is rigidly hierarchi
cal reflecting the class structure in the broader
society. Just the way the economic status or caste
of a person largely influences his/her future position
in any socio-economic activity, in medical practice
too these factors very often determined which level
of hierarchy s/he will
occupy in the health
structure. This streamlining into 'suitable rung in the
hierarchy is generally mediated through the person s
performance in and access to education. For ins
tance, the three categories of nursing personnel we
have in India that is the B.Sc. nurse, the Registere
Socialist Health Review
Nurse Registered Midwife (RNRM) and the Auxi
liary Nurse Midwife (ANM) required different levels
of educational qualifications to enter into their res
pective training schools. This determines the class
that will be predominant in each of these categories
which is further consolidated by the differential
salary structure and status afforded to these three
categories in the nursing profession.
Since medical care is a valuable commodity and
the right to provide it has been appropriated by
doctors, all other categories of health workers
and the functions they perform remain subordinate
to that of doctors. This monopoly is often carried
to ridiculous lengths, such as the prohibition on
nurses to start an intravenous drip or give an intra"
venous injection.
Reports discussing the problems of health
personnel have also mostly focused on the problems
faced by doctors. One hears repeatedly that
doctors have to face innumerable problems such as
lack of educational facilities for their children, lack
of 'entertainment' in the village and less opportuni
ties for professional growth; and that unless these
facilities are provided it would be unrealistic to
expect doctors to work in the villages. But these
'problems' really pale in significance if one considers
the difficulties an ANM faces during the course of
her work.
Nurses : Problems They Face
The problem nurses face needs to be dealt with
separately. Their contribution has been mostly
towards the care of patients, although they perform
important technical tasks too.
The rural health
services rest largely on the functioning of female
health workers and their non-performance could
very well paralyse the entire rural health network.
Yet their status within the structure of health
services has remained one
of subordination.
Attempts in the past to improve the status and
image of nursing has very often been limited to
increasing the content of the curricula or the tech
nical content of their work. But this only ends up
in reemphasising the fact that 'caring' as a function
cannot be held on par with that of diagnosing and
prescribing.
As women, nurses have an added problem of
sexual harassment which they have to continuously
face both within and outside their work situation.
One reads of newspaper reports of nurses who are
molested, who commit suicide because of sexual
abuse or are murdered for their unwillingness to be
September 1985
casual sexual partner. One could hazard a guess
that the women health workers in rural areas are
probably exposed to such problems to a greater
extent. This is not because the rural males are
different from their urban counterparts but rather
the situation that the nurses are in makes them
more vulnerable. Isolated as they are in remote
villages, with little support from other health
workers these women health workers suffer in
silence out of sheer economic necessity to retain
their jobs. This could also be the reason why such
incidents are under-reported.
Although this problem has been recognised as
a major constraint there has been no systematic
effort to document these incidents or evolve support
systems to tackle such problems. Addition of self
defense into all nursing curricula as a skill to be
developed by nursing students could perhaps be
one such way. But a more realistic solution would
only emerge if nurses' unions take up this issue
seriously to launch a struggle to make their work
place safe. Indeed for such struggles to succeed
they will have to become part of much larger
struggle of all women. The top two categories of
nursing personnel are generally better placed to
form unions as they work in hospitals and are phy
sically proximate. The ANMs on the other hand who
work mostly in the PHCs and subcentres have little
opportunity to come together to raise their collec
tive demand.
The work force employed in the hospital
industry is similar yet distinct from that employed
in other industries. The distinction lies firstly in
the fact that these functionaries work on raw
materials (patients) to produce a non-quantifiable
product 'health'. Secondly, the physicians and
sometimes the nurses who occupy the higher level
of hierarchy view
themselves as professionals
rather than as workers. This often contrasts with
the attitude of non-medical hospital workers who
view their activity merely as a job. But the situa
tion is changing now. Doctors, nurses and other
'professional' health workers are getting unionised
and demanding more and more job benefits, fixed
duty hours and overtime pay, in the process assum
ing the form of wage earners. But even when such
issues are taken up they try to use their'professional'
status to push their point. For instance, in the
recent strike by the interns from medical colleges in
Delhi, a placard was used with the legend 'Doctors
lathi charged! What next!'
Although the demands of the 'professional’
categories are similar to that of non-medical hospital
55
concept of self-help can ever become a viable
alternative to the present system as it exists today.
workers there is little attempt to identify these
issues as common issues and to unionising on the
basis of their identity as workers.
C Sathyamala
C - 152 MIG Flats
SAKET
NEW DELHI 110017
One of the limitations of this perspective as well
as the whole issue on 'People in Health Care' is
that we have concentrated on health workers
functioning as part of the allopathic system of
medicine. We really know very little about health
workers belonging to other systems of medicine in
India, in terms of their role and status. Further even
among the workers in the allopathic system very
little information is available about non-physician
health workers.
In this issue :
Sujit K. Das explores the much debated subject of
the class location of doctors and queries the stereo
typical definition of medical care as a commodity.
Rajkumari Narang looks at various studies in ana
emia to illustrate her contention that the choice
and treatment of problems in medical research is
rarely governed by factors such as people's needs.
Imrana Quadeer examines the impact of the rural
social and economic realities on the Community
Health Worker's Scheme. Sumathi Nair takes a
closer look at four Commumity Health Projects
and asks what their relevance is today. The issue
also carries two articles outside the theme of People
in Health Care. Ekbal reviews the marxist critiques
of the llichian School and Amalendu Das throws
light on dust hazards faced by coal miners
Finally, a word about the people on whom the
'people in health care' work upon. As patients they
are the most powerless in the interaction that
takes place in a health care set up. They are
neither in a position to direct the course of
their treatment nor can they demand a social
accountability from health personnel. The self-help
movement in the west has been a reaction to such
powerlessness. It remains to be seen whether the
SUBSCRIPTION RENEWALS
Is this your last subscribed issue?
A prompt renewal from you will ensure that your
copy of Vol. II No. 3 on 'Systems of Medicine' is mailed directly from the Press. Book
your copies by renewing your subscription now I
Our subscription rates remain :
For individuals — — Rs. 20/- (four issues)
For institutions------- Rs. 30/- (four issues)
Foreign subscriptions :
US §20 for US. Europe and Japan
US S'! 5 for all other countries
(special rates for developing countries)
Single copy :
Rs. 6/-
DDs, cheques to be made out to SOCIALIST HEALTH REVIEW, BOMBAY.
Please write your full name and correct address legibly. And please don't forget to add
Rs. 5/- on outstation cheques /
igz
lot
SHR BACK NUMBERS
We have in stock the following issues :
Vol I : No. 2 - - Women and Health (Reprinted edition)
No. 3 - - Work and Health (Limited stock)
No. 4 - - Politics of Population Control
Vol II No. I - - Imperialism and Health (limited stock)
Vol I No. 1 is out of print. We are planning to reprint it, if we get more than 200
orders - - at a cost of Rs. .10 each. We can get the entire issue photocopied at Rs. 25/If you wish to obtain individual copies of any of the other issues, please send
us for Vol I Rs. 5/- per copy plus postage of one rupee (ordinary post), for Vol II No. 1
send Rs. 6/- plus postage.
56
Socialist Health Review
DOCTORS IN HEALTH CARE
Their Role and Class Location
sujit k das
Doctors have played a central role in health care services. In India medicine has enjoyed both
state and popular support since the independence. State health services expanded rapidly as did the
number of doctors. Many of these doctors went into private practice or migrated to other countries and
others into the state health services. This article explores the much debated subject of the class location of the
medical professi >n. Is the genera! practitioner a productive labourer or a capitalist ? Does the doctor in service
belong to the working dess ? The author draws attention to the effect of the state sector on the medical profe
ssion and traces the growing agitational movements and organisation of state doctors in the country,
with special emphasis on West Bengal. Agair-st this backdrop he queries the stereotypical definition
of medical care as a commodity.
J^jjoctors are the most important people in health
care. Even the official expert group on health,
after unrestrained criticism of the doctor-dependence
of our health system concedes "Moreover, the
doctor as the leader of the team can play an
important role and influence the values and the
quality of caring among the whole staff if he shows
these concerns himself" (HFA, 1981).
Radical
critiques on health care call for reversal of the
doctor-dependence of the health system but never
theless wish for a change towards socialisation and
social
orientation of
the medical profession.
Popularly, doctors |are looked upon as next to
gods since they deal with life and death and no
wonder doctors are often beaten up when a
patient dies or there is allegation of negligence on
the part of the doctor. The popular view offers the
medical profession the key position in health care;
expects it to protect the health of the people;
regards it as the greatest depository of knowledge
and wisdom regarding health; believes that the
weakness of the health care service is due to lack
of adequate
number
of doctors.
From the
Presidents of India down to the Taluk functionaries
they have all been exhorting the medical profess
ion to be patriotic enough to go to the remote
villages and stay there to serve the under-privi
leged rural people
Surprisingly few attempts have been made to
investigate, analyse and understand the medical
profession in the perspective of concrete reality.
Despite its crucial role, the medical profession is
commonly assessed on the basis of subjectivism.
Just as the modern medicine had been borrowed
from the west, the Indian critiques of the Indian
medical profession appear, more often than not, to
have been borrowed from the western radicals. The
September 1985
profession had hardly been looked into as what it
is, but often analysed on the basis of what it
should be.
Development of the Profession
In India the art and practice of healing devolved
on to a group of socially engaged men, and several
systems of medicine developed and have survived
till to-day. Each system was somewhat welldeveloped corpus of knowledge and its practice
had traditionally been taken up by successive
generations. Following the changes in the relations
of production and exchange, independent practi
tioners
emerged.
Later, systems
of modern
scientific medicine (allopathy) and Homeopathy
came from the west and took roots.
In the 19th century, modern medicine had little
to offer. The 20th century, heralded the appearance
and development of a scientific basis and since the
thirties, appearance of chemotherapy and improved
surgical techniques created a surge of interest in,
and attraction towards, modern medicine owing to
its dramatic life-saving achievements. Popular att
raction received a further acceleration around and
after the second world war as a result of the inven
tion of newer wonder drugs and technology. The
practice of modern medicine, likewise, earned a
heightened respectability and soon rapidly emerged
as a profitable livelihood.
Demands for the expansion of the hospital
services have been raised from all corners. The
situation is a parallel of what prevailed during the
expansion of hospital services in the National
Health Service (NHS) of UK. "For the politician, it
might be assumed, there could be no better adverti
sement than a shining new hospital: a visible symbol
of his or her commitment to improving the peoples'
57
health. For the doctors, new hospitals meant the
opportunity to practise what is considered to be
higher quality medicine. For the consumer, in turn.
new hospitals surely meant better services with
higher standards of treatment (Klien, 1984). No
wonder therefore, in a market economy, almost all
aspiring doctors moved towards the practice of
curative medicine with its life-saving and relief
producing implements. Iliffe has put it succinctly,
“Just as abortion would be a sacrament if men
became pregnant, so health professionals would
stampede into preventive work if prevention could
be made into a marketable commodity” (Iliffe, 1983).
Introduction of welfare activity by the state saw
the expansion of state health care service and the
number of health personnel increased rapidly
(Table I). Later, indigenous systems and homoeopa
thy, for reasons not discussed here, also received
state patronage.
Table I
Year
No. of Med.
Colleges
Students admitted
50-51
60-61
70-71
80-81
28
60
95
106
2675
5874
12029
10934
Qualified
1557
3387
10407
12170
Figures are incomplete as: a few centres failed to report.
Source : Health Statistics of India ( 1982) : C.B.H.I.,
Ministry of Health & F.W., Govt, of India.
Table II Year I98I.
Total No. Went Returned Regd. in No. admi- Total No.
registered abroad from
Employ tted in P.G. Regd.
abroad
ment
Courses
Doctors
in other
systems
268,712
4766
2381
16406
8241
382,686
Source : Health Statistics of India (1982) and
University of Calcutta.
These doctors opted for private practice or
other employment or post-graduate education for
specialisation, or migration to foreign countries. For
the last few years more than 2000 doctors have
been settling abroad annually. There is no available
data to indicate the number of doctors engaged in
each category but the distribution follows the mar
ket situation and economic compulsion. Old pattern
of general practice recruits less and less. Number of
women doctors has been steadily increasing since
1976-1977 and they generally settle towards certain
culturally chosen occupations e.g. gynaecology and
obstetrics, pediatrics, pathology, plastic surgery,
anaesthesiology, non-clinical disciplines in medical
58
colleges and also dental surgery. Most of the
women opt for employment and independent wom
en private practitioners prefer G & O and Pedia
trics. Unemployment is a late development (Table II).
Class and the Medical Profession
Private
Practice and General Practice
In West Bengal, approximately 70 percent
doctors are engaged in private practice. They in
clude independent practitioners. Insurance Medical
Practitioners
of ESI (M.B.) Scheme, part time
practitioners of the state and private sector emp
loyees. The General practice has been changing
with changing social relations, scientific developme
nts and cultural attitudes. In earlier times, the general
practitioners (GP) could not demand any consultati
on fee and had to distribute drugs to his clients. He
then used to incorporate what he considered to
be his due consultation fee, within the price of the
drug. As a result, the consumption of non-essential
drugs and compounded drugs was high Also the
actual price of a compounded drug is difficult to
check and verify.
Later, consultation fee has
gradually been introduced and has received public
acceptance, resulting in the development of a
class of GPs who are only prescribers.
Indian society has a long tradition of voluntary
efforts for charitable medical care to the community.
In fact, a good number of clinics and hospitals
had been established through philanthropic end
eavours. In order to earn and maintain 'nobility',
the price doctors had to pay was to attend to
emergency patients, give free 'service' to a few
indigent patients and offer honorary service in the
voluntary institutions. Besides respect, speedy reco
gnition and fame, this attachment to charitable
institutions used to bring other material returns.
The doctor used to test the emerging therapeutic
techniques on poor patients without informed con
sent and without risk and later employ the technique
thus perfected, in cases of
paying clientele
in the private practice. Actually, the situtation
is so advantageous that there is serious competition
among the contending doctors to secure honorary
employment in the charitable medical establishments.
A sort of corrupt practice was also rampant where
the patients had to pay the honorary doctor in order
to avail of the free hospital service. This mal
practice has now been almost eliminated in West
Bengal due to higher level of consciousness of the
people, but is still in vogue in many other states.
The GP therefore, acts as a retailer of drugs;
sells his skilled labour designated as 'service to
Socialist Health Review
individual buyers; and it may further be argued that
he employs his knowledge and skill as capital and
sells the product of his own labour in the market
as commodity. Is he a productive labourer or
capitalist? Karl Marx, in his inquiry into the social
status of independent handicraftsmen and peasants
as well as that of producers of non-material produc
tion e.g
artists,
actors,
teachers physicians,
etc., said ''It is possible that these producers,
working with their own means of production, not
only reproduce their labour power but create surplus
value, while their position enables them to appro
priate for themselves their own surplus-labour........
And here we come up against a peculiarity that is
characteristic of a society in which one definite mode
of production predominates, even though not all
productive relations have been subordinated to it. ...
The means of production become capital only in
so far as they have become seperated from labourer
and confront labour as an independent power. But
in the case referred to the producer - the labourer is
the possessor, the owner, of his means of produc
tion. They are therefore not capital, any more than
in relation to them he is a wage-labourer*' ( Marx ).
The GP is actually engaged in a precapitalist mode
of production, but nevertheless produces commo
dity of use value and sells it for exchange value. Our
much maligned GP is not altogether a demon or
blood sucker. He is just a small commodity pro
ducer who still renders essential service which the
state is unable to provide for. A close study of
the GP will reveal how the western medicine took
roots here, changed the health culture and in the
process changed its own.
Speed of expansion of the market of private
practice has lately been thwarted and is gradually
being squeezed for several reasons. Increase in
the purchasing capacity of the people cannot keep
pace with the increase in the number of doctors
thrown into the market. Secondly, expansion of the
state sector in medical care has been impressive
and concentrated in the urban areas and these are
totally free or heavily subsidised. Socially dominant
classes who can afford to purchase medical care,
have been able to capture the largest share of
the free/subsidised state service. As a result, private
sector medicare did not develop to the expected
level. Thirdly, private practice has a latent period
to reach profitability. Lately, increasing numbers
from the lower income groups have been recru
ited in the medical profession, who cannot afford to
sustain this latent period. All these have resulted in
increasing trend towards employment and migration
abroad, unemployment and underemployment.
Doctor-in-Service
Expansion of organised medical care service
through state, public undertakings, ESI, big private
industry and voluntary organisations has resulted
in a marked increase in the number of doctors in
employment. Though private medical practitioners
still constitute about 3/4th of the medical profe
ssion, the doctors-in-service attract the major, if
not entire, attention in any debate on health care
owing to the fact that the organised sector is the
trend-setter and almost always features in planning
and debate In this context, the present discussion
dwells largely on the doctors-in-service among the
practitioners of modern medicine. However, no
discussion on the medical profession or for that
matter, medical care is compreshensive unless it
also includes private practitioners of modern medi
cine and of the other systems.
The non-practising employed doctor is actually
a wage earner destined to identify himself with the
aspirations of similar wage-workers of the so-called
white-collar category. Though the 'noble profession'
ideology provides an excellent instrument for the
private practitioners to maximise profit in their
trade, it has ironically proved to be a constraint
in the way of fulfilling his aspirations. Because
ot the stigma of 'noble profession', he cannot claim
fixed duty hours; cannot claim 'overtime' i.e. extra
remuneration for extra work; cannot employ 'redtapism' in his daily work-load; cannot even utilise
his earned leave to escape from the drudgery of fre
quent emergency duties. He is further handicapped
in regard to democratic rights so much so that
unionisation of doctors is frowned upon by the
society; agitative action is taboo; call for strike
in hospitals is taken to be sheer blasphemy. On
top of it, the doctor has little hold in the administra
tion of medical care and in the matters of policymaking, programming and power hierarchy, the
doctor is placed in a lower position subordinate
to the generalist administrator But more about this
later.
Do they, then, belong to the working class? The
question has never been raised or debated. On this
issue, the dogmatic marxists adhere to Reductio
nist ideology. ' Reductionism involves a version of
historical materialism which presents all social
phenomena as 'reducible' to, or explicable in terms
of, the 'economic base'. Thus political struggles
or social ideologies are explained as manifesta
tions or
'reflections'
of economic forces. In
this presentation marxism is reduced to asset of
4
September 1985
59
relatively simple and universal 'laws'.......... Such a
position is guilty of 'essemialism', that is of seeing
the economy as embodying the essence of all
social phenomena which are then simply expressed
or made manifest in the social world” (Hunt, 19/8).
This methodology necessarily attempts to define
classes at the economic level and attaches little
importance to the forces operating at the political
and ideological level Working class is differentiated
by the difference between productive and unprodu
ctive labour. Mera wage-earning or labour-selling do
not provide entitlement for entry into the working
class. ''The working class in the capitalist mode of
production is that which performs the productive
labour in that mode of production......... Although
every worker is a wage-earner, every wage-earner is
certainly not a worker, for not every wage earner is
engagedin productive labour ' (Poulantzas, 1 975).
While in cases of white-collar wage-workers of
the industry, transport and mercantile enterprises,
Marx concludes that they are productive labourers,
the physicians-actors-teachers etc. are also produc
tive labourers. He observes, when they sell their
labour power (manual or mental) in a capitalist
establishment which appropriates their surplus labo
ur and makes a profit by selling the products
as commodities. But he adds, "All these manifes
tations of capitalist production in this sphere are
so insignificant compared with the totality of
production that they can be left entirely out of
account” (Marx, 1978).
Technology, capitalist organisation of produ
ction and productive forces are much more devel
oped now than at Marx's time, though the develop
ment of medical care service as a sector of capitalist
industry is still rudimentary in India. The new
’ working class of advanced capitalism — the
technicians, engineers, scientists etc. — is held, by
Serge Mallet, not only to be revolutionary but the
'avant-garde' of the revolutionary socialist move
ment (Mallet, 1975). Services have long been deve
loped into profit making industry in the developed
countries.
Here in India, doctors as wage-earners are
now commonplace. To what class do they belong?
The established left still subscribes to the liberal
concept of health care and therefore, has yet to
face this question. The progressive view, however,
is confusing, to say the least. "The capitalist can
organise the production of surplus value through
the provision of health care and can realise higher
profits in this service industry. It is immaterial
60
whether the surplus value is realised directly
through the productive activities in the clinics and
hospitals owned by the Capitalist or indirectly,
through the provision of health care by the State to
maintain or increase the productive capacity of the
labour” (Jesani and Prakash. 1984). Such an
assertion is based on dubious premises that medical
service has developed into an industry; that the
State also acts as a productive enterprise; and that
State Health Care Service is an organised invest
ment by the capitalist class on the
industrial
productive labour.
What then is the status of the producers of
'health care' ? The above assertion automatically
places the employed doctors into the category of
the working class. But alas, the entire medical
profession carries, in the radical viewpoint, the
same class background as the bourgeoisie and
performs its predestined social task of legitimisingstrengthening and maintaining the bourgeois medici
ne. Why this confusion? ''The mere quantum of
the so-called marxist analysis of health, done in the
West has so impressed us that we have literally lifted
their formulations and transplanted them on the
Indian scene, without even thinking whether they
are applicable. Further, in our hurry to fill in the
gaps in our knowledge, we have concentrated on
theory of health and medicine. That theory, however
has been sought by filling the accepted theoretical
constructs with Indian data and developments rather
than beginning with health and health services itself
to test the assumptions as well as the theoretical
constructs” ( Quadeer, 1984 ). In other words, in
order to understand and analyse its status, role,
trend and potential in health care, we have to make
an actual study of the medical profession in its con
crete reality.
Professionalism
"Professionalism within health care is based on
the idea of 'service' and on the practice of trade.
It is a market concept expressed in the relationship
between a customer (the patient), a tradesman (the
professional) and assorted suppliers (the drug
industry, other superior professionals). Trade secrets
are necessary for the maintenance of the market
relationship, and permit professionals to define
themselves as special, and beyond the control of
those ignorant of these 'trade secrets'. The auto
nomy of health professionals — particularly doctors
rest on the range of their trade secrets” (lliffe 1983).
With this conception it follows that professionalism
could be curbed or even abolished with the
Socialist Health Review
abolition of market economy i. e. private trade or
commodity market in health care. This appears to
be another instance of radical presumption. Profe
ssionalism is not a creed peculiar to the medical
profession nor to the bourgeois ideology. Professio
nalism not only regins in private medical trade but
also exists among the employed non-practising
professionals, among the medical teachers of nonclinical disciplines and among the doctors engaged
in public health work.
Professionalism exists in pre capitalist economy
and continues in the post-revolutionary societies
where the ownership of the means of production
has undergone a change and private trade almost
abolished. In a round table discussion on private
medical practice organised by WHO, it has been
revealed that private practice, in certain forms
exists and is developing in the socialist countries
(Roemer, 1984) Medical co-operatives are spring
ing up where state-employed doctors are allowed
to spend upto two hours a day and are entitled to
a 50 percent share of the payment received from the
patients in cash for the services rendered. Even in
China, barefoot doctors who are essentially parame
dics, are allowed part-time private practice. A common
practice developing in these countries is that of
giving gifts to doctors in hospitals and often the gifts
are relatively large amounts of money. All this is
done to ensure better quality of service (which is by
no means certain). How is the quality of service to
be determined ? How are measures and gradations
to be made ? There is as yet no acceptable indicator
or scale. Hence, quality will be determined diffe
rently by different social ideologies and health
cultures, and the latter are manipulated by profe
ssionalism. Specialisation and mystification are
only other facets or instruments of professionalism
utilised to maximise the price of medical service in
private practice.
Specialisation, however, is not an exclusive
exploitative imposition. It is also an integral part of
social division of labour, not only unavoidable but
necessary in any social formation including the one
based on non-exploitative mode of productionWhat is relevant is not to confuse social division
of labour with capitals' division of labour. In an
analysis of modern chemical industry in UK Nichols
and Beynon have shown that though technical divi
sion of labour is a must in any industry in any mode
of production, in the capitalist mode the technical
imperatives are subordinated to political imperatives
and technology exists to serve and augment capital.
September 1985
"Certainly in any mode of production, given the exi
stence of specialised training, some men will be
more technically competent to solve certain problems
than others This is so obvious as to hardly require
stating. But something else which should also be
obvious is often ignored. For concern with the tech
nical structure of complexes like Riverside (the fact
ory site) can also tco easily obscure the fact that
they are not even designed to make chemicals, but
to make chemicals for profit The reality is that their
division of labour is capital's division of labour.....
(Nichols and Benyon, 1977) Professionalism, also,
could make its contributions in the struggle against
the ruling class and the state. The history of the
development of health care service in Great Britain
has shown that the professionalism of the doctors
thwarted, at different stages, the attempts of the
state to reduce or withdraw the medical benefits
demanded by the people Here in India also, profe
ssionalism often reinforces the demands of the peo
ple for the egalitarian distribution of medical services
against the discriminatory practice of the state.
What do we expect from the doctors? Here, the
bourgeois, left, radical and popular views converge
and appear as if grossly influenced by the ideology
of professionalism. A doctor should render utmost
efforts irrespective of the socio-economic status of
the patient; should always ungrudgingly serve emer
gency patients without consideration to his own
convenience; should always be guided by the code
of ethics formulated by the profession; should act
as a friend-philosopher-guide to the patient; should
exude hope and confidence in his conduct etc. etc.
Concomitantly, the community accorded certain
privileges to the profession. The doctor knows best;
he should not be questioned; he has the unchallen
geable right to handle and manipulate the patient's
body; his good faith is taken for granted even in
cases of the patient's death and disability.
What do the doctors think about their own role
expectation? In a large study in two medical college
hospitals in Tamilnadu, Venkatratnam revealed that
the doctors' understanding of their role expectation
is a composite of their own individual perception,
occupational
compulsions
and
organisational
( professional
and
institutional )
principles
(Venkatraman, 1979). Role expectation comprises of
professional, academic, research, managerial and
social. Many interesting facts and controversial
issues regarding doctors' responsibility towards
patients,
role towards other health workers,
requirements of teaching-training-research, level of
61
communication with patients, social responsibility
and so on have been revealed in the above study
and these should be analysed before rushing to
issuing sermons on doctors'
role expectation.
Peculiarly, the 1CMR-ICSSR report, while casti
gating the profession for its negative attitude
towards preventive and promotive health care
recommends for their'alternative model’ of health
care service that "the doctors will still continue to
play an important role in the new health care
system. But this will not be over-dominating and
will be confined more and more to the curative
aspects of the referral and specialized services for
which they are trained” (HFA 1981).
Universally, the understanding of role expec
tation of the doctors suffers from an idealistic
approach. All expect the doctor to be humane,
shorn of commercial urge, dedicated to patient's
welfare, imbibed with principles of social justice
etc etc. No one asks why the doctor should follow
such a model or what objective conditions may
compel him to do so? Or for that matter, what objec
tive conditions persuade the doctor to do as he does?
Perception of role performance differs between
the professionals and the consumers for obvious
reasons. Confusing and paradoxical situations pre
vail. While the State hospitals and the doctors are
almost always on the dock by the consumers and
mass media for the severe shortcomings in role per
formance, the very same hospitals and the professi
onals are very much in demand for their high
quality and indispensible medical service. True, the
service is attractive because it is free. But even
amongst affluent consumers the notion prevails
that the hospital doctors are more skillful, know
ledgeable and equipped. Generally, the doctors'
notion on role performance is that they do their best
under the given circumstances and they could do
more if they have a free hand in the administration
which is responsible for the constraints. The factors
underlying these confusions and paradoxes are
being unravelled by the growing momentum of the
organised movement of the doctors.
Doctor's Organisations and Agitations :
West Bengal
Medical practitioners got themselves organised
under Indian Medical Association in the thirties.
Later, practitioners of each speciality discipline built
up separate associations. The basis of these ass
ociations is professionalism, academic and pseudoacademic. It should be mentioned that non-clinical
and even public health disciplines organised their
62
own associations. But the associations could not
cope with the task of tackling the emerging aspi
rations of the employed doctors.
In fact, a
contradiction developed between them. Ironically,
the bone of contention was economic as well as
ideological. The ideology of professionalism appe
ared to be a drawback for the service-doctors.
The pay packet of service was unattractive not
only in comparison with the income in private
practice but also compared unfavourably with that
of the similar category of government officers,
for instance the civil service, or the engineering
service.
This situation had been a hangover
from the British days when doctor's pay packet
was deliberately kept low with the understanding
that they would make it up with the earning from
private practice, a privilege then enjoyed by all
service-doctors. Later, with the expansion of the
state sector, more and more doctors had been
employed on non-practising basis but this principle
of wage policy did not change.
In matters of job requirement, job perquisites
and job satisfaction, there was nothing glamour
ous to look forward to. Duty hours was virtually
feudal - a doctor was 'on call' for 24 hours a day for
emergency need and seven days a week; almost all
health centres in the rural areas were manned by one
doctor in each; there was no ceiling on the number
of patients one had to attend daily; a rural medical
officer, in addition to his clinical duties, was entrusted
with the tasks of family planning, MCH, School Hea
lth, Immunisation, Epidemic Control Administration
and what not. System of recognition and appreciation
of good and dedicated service was absent. Avenues
for higher education, promotion, research, or even a
transfer to a better post after a scheduled period of
service, were severely limited. Because of longer
period of training to acquire qualification, a doctor*
usually enters service at a later period compared to
others andconsequently is entitled to a lower pension
and lesser amount in the retirement benefits.
The state hospitals were always understaffed
and underequipped and hence, the scope of prac
ticing what the doctor was trained for, was thereby
Limited. On top of these, the health administration
was run by the generalist administrators. These
people had no career attachment to the health
department; were not answerable for failure or
mismanagement; had no inclination to learn the
problems of the health care service as well as of the
employees. The doctor had no voice in health plann
ing, hospital service development and technical deve
lopment. The autonomy enjoyed by the profession
Socialist Health Review
in regard to clinical practice in the NHS of UK was
not even partly granted to the doctors here. On
the other hand, the political authorities found it
convenient to put the blame on doctors and other
health workers for all their failures, misdeeds and
incompetence in the health sector. Consequently,
doctors and the health workers, as they were the
ones, at the counter, had to suffer the burden of
public wrath in the form of physical assault, humi
liation, abuse and so on.
What did the doctors do to overcome these
adversities? It is worth while to note that the
state service was last in the list of priorities of a
new medical graduate. The order being private
practice, specialisation, migration abroad and if
all fail — then he opts for service. Lately, because
of competition, the options have shrank greatly and
large numbers are now competing among them
selves for limited state service; doctors from Orissa,
Assam, Bihar, Bangladesh are now applicants to
the West Bengal State Service.
In this situation how have the service-doctors
reacted ? Quality has been the first victim and
expectedly so. No matter whether 50 or 500 attend
the outpatients clinic the experienced doctor mana
ges to tackle them within 3 hours or so. In a
100-bed hospitcl, 200 patients stay indoor regularly
but the same number of doctors and health workers
treat them without spending any additional timeinthe
hospital. The next escape route is private practice —
both authorised and unauthorised. In west Bengal
except in the case of clinical teachers of the majoritv
of medical colleges and doctors in the district and
subdivisional hospitals, private practice is not allow
ed. In fact, 7/8th of the State doctors are non
practising. The States of Orissa, Andhra, Maharasht»a, Punjab, Hariana and others have either
entirely or partly non-practising state service. Some
other states have indicated that they will too follow
suit. The entire Union government and the public
undertakings sector is non-practising. Expectedly,
most doctors aspire for the limited practising
privilege of the service and in the non-practising
sector, unauthorised private practice is growing
wherever there is scope and opportunity.
The question of the alleged reluctance of the
doctors to serve in the rural institutions should be
understood and analysed with this background in
mind. Concerned people have swallowed the
government propaganda
that because of such
reluctance on the part of the doctors, the govern
ment despite earnest efforts and liberal financial
September 1985
allocation, fails to provide medical care to the
rural
people. By absorbing
this propaganda
uncritically, the health activists on the one hand,
unwittingly agree with the
government that
medical care is synonymous with the presence of a
doctor, fall in another trap that provides for offer
ing barefoot doctors Homoeopaths-Ayurveds and
simple home remedies for the villagers in the
garb of tradition, indigenous culture and community
medicine. The fact is otherwise. It is deliberate
government policy to keep the service conditions
of the rural medical officers unfavourable with a
view to discourage the doctors from taking up
rural postings; and in this attempt, one must admit,
the government has been successful to the exent
that even the occasional few socially conscious
people-oriented young doctors, after a stint of
rural service, try their utmost to move to the urban
area or quit. ‘ The Siddhartha Roy Congress govern
ment's regulation of 1974 stipulated that physicians
with specialist degrees would enjoy a higher pay, a
special allowance and would be exempt from rural
postings. It was only natural that young doctors
went in for specialisation just for the sake of
avoiding rural posting, if not for higher emolu
ments. The Left Front government has not felt it
necessary
to
change
the
regulation'' (The
Statesman, 1985). This policy in fact, induced even
those doctors, who had already settled in the
rural areas, to move for any type of specialisation
and settle in urban areas. Does it show reluctance
on the part of the doctors or that of the government ?
Lately, the Marxist Left Front government in West
Bengal introduced against the protest of the
medical profession, a short term three year medical
course to train up doctors who would fill up the
rural vacancies. Next year, the junior doctors in the
State launched agitation for jobs in the State
service and demanded that all rural posts be immed
iately filled up by currently eligible 3000 unemployed
young medical graduates. Under public pressure,
the Left Front publicly declared that there were no
such vacancies and they were unable to provide
jobs, not even in the rural areas. The short-term
medical course had to be wound up in any case,
the discrimination against the rural medical officers
persists. No one, of course, raises the question why
doctors, of all people, must go and serve the
villagers who are ignored in respect of all other
consumer goods. It must be understood that the
recent organised demand of the junior doctors for
rural appointment is not due to any sudden surge
of patriotism but simply due to pressure of
unemployment.
63
In course of time, however, the consoling
compensation through private practice turned out
to be insufficient. Service-doctors and junior doctors
ventured to organise their own bodies on trade
union basis to voice their grievances which did not
find deserving place in the earlier professional
bodies like IMA which was dominated by private
practitioners. In 1973, junior doctors launched a
movement in West Bengal demanding better pay
and service conditions, and better provisions in the
State hospitals They had to go on strike and come
out partially successful by obtaining pay hikes.
In 1974, the State doctors 'in alliance with the
State engineers) resorted to strike for 41 days but
maintaining the emergency services. Their demands
were not only economic but encroached on the
political and ideological level. They demanded
exclusive executive power for
the scientists,
technologists and professionals in the scientific and
technical departments of the State administration
which were the preserve of the generalists, and
parity in pay scale with the Indian Administrative
Service (IAS). This agitation generated intense
debate throughout the country and the issue has not
yet been settled The West Bengal government
ultimately made a few concessions but unfortunate
ly, with the subsequent imposition of Emergency in
the country, the terms of the agreement were
not implimented, leaders were sacked and doctors
terrorised. The fall out of this agitation was visible
elsewhere; the pay scale of the doctors in the Union
government and public undertakings were soon
revised upwards to bring it on par with that of the
IAS at the lower level.
This agitation made a breakthrough on several
grounds.
People
saw to their surprise that
renowned professors and principals of the medical
colleges, eminent specialists and senior engineers
holding high ranks in the state service, walking in
processions, squatting on the pavements and
holding street-corner meetings. It then struck them
as a novelty that the 'noble' doctors could resort
to agitative ways that befit only common workers.
Doctors, it was stressed, had no right to jeopordise
the well being of the patients by striking. This
agitation, perhaps for the first time, focussed
people's attention on the affairs of the medical
service, particularly into the government assertion
that the doctors and health workers were respo
nsible for all the ills in the system. This agitation
was followed by a series of agitative movements
all over the country, mostly by the junior doctors
but also by the state doctors in Delhi, UP, Orissa,
64
Assam, Maharastra
Andhra, Bihar - though with
different demands as was expected owing to diff
erent levels of development. Everywhere, organisati
ons of service-doctors sprang up independent of the
IMA. The agitation in West Bengal also brought
changes in the orientation of Bengal IMA, which
despite its long history of co operation with the
government had to come out actively in support
of the service-doctors and junior doctors.
Sporadic movements on various issues such as
reduction of job burden, physical security at the
work-site, better provisions for emergency care,
improvement of rural medicare and more scope for
higher education have taken place culminating
in the 1983 statewide movement.The junior doctors
demanded, besides bettrer pay, service conditions
and provisions for emergency care and a health
policy with priority to preventive care. The Left
Front Government took recourse to unprecedented
repressive measures using party cadres and the poli
ce. Brutal police violence on the junior doctors
brought state doctors onto the scene, also in an
unprecedented manner. Perhaps for the first time in
the world, state doctors in their strike action with
drew from the emergency services. This was an
organised retaliation of the doctors against organised
terrorism of the Left Front government who reiterated
the earlier declaration of the Congress regime that
the doctors had no right to strike The government
had also earlier started denying the doctors the
right to any agitative activity
This was strange
and definitely unacceptable to doctors who had
to earn democratic rights through hard struggle in
1974 when the conduct rules for the government
servant had been revised. The doctors received,
unprecedented public support even though they
committed such so-called anti-humanitarian acts as
deserting the emergency counters. The government
finally had to withdraw the victimisation and
punitive measures
and concede the immediate
demands of the strikers.
There are now indications that service doctors
are now beginning to realise that the aspirations of
their occupation are directly related with the nature,
object, standard and extent of the state health care
services. They have now raised the demand for
clear declaration of the aims and objects of the
state health policy and a controlling role in impl
ementation, a plea to share responsibility with power.
The service-doctors in West Bengal demanded that
free state medicare be exclusively reserved for the
indigent population only, which produced indignant
protests not only from the privileged middle class
Socialist Health Review
but a few political parties with 'Left' labels. Diff
erent mass organisations are now holding meetings
and seminars on the health policy and state health
acare administrlion There has also been a renewed
spurt in the agitative movement of the junior doctors
and service-doctors in other states for instance Bihar,
UP, Orissa, Maharastra and Delhi.
These organised movements of the service
doctors brought many undiscussed issues into
public attention. Should the doctors be treated as
a special occupational group with limited democra
tic rights and additional responsibilities to society?
And if so, why? What are then the limits of the
forms of agitation for the doctors, if they have
grievances to agitate for ? Are the doctors also
entitled to fixed duty hours just like others? Why
should doctors alone have a moral or social obli
gation to serve the villagers who are deprived of,
and are discriminated against in respect of all other
commodities and services? Should the generalists
enjoy the power and the doctors bear the respon
sibility of state health care service? And finally, who
doctors are primarily responsible to, the employer
or to the patients or to their professional ethics?
The foregoing development and issues per
suade us to take a new approach — the marxist
approach — to determine the role expectation and
analyse the role performance of the medical pro
fession. In a market economy, the medical professi
on cannot but be governed by its rules and to
expect them to swim against the current is an
utterly idealistic proposition. The service-doctors
tend to behave as other wage-workers do. They
try to extract as much wage with as little labour
as possible, in contrastwith the employer's tendency
to extract as much labour with as little wage. It is
all very well and easy to define 'medical care' as
a commodity in the capitalist mode of production
but it needs explaining how the universally free
state medicare remains a commodity and behaves
as a commodity. Or what here is the relation of pro
duction between the owners of the means of pro
duction and the sellers of labour power? It needs
study to understand why the primary need of food
clothing-shelter is denied to a dying citizen but free
medicare service is demanded and created and, the
nature of the class struggle that brings about this
state response. All these studies in the concrete
reality of the Indian situation will bring us back to
the question of class identification.
Conclusion
"The separate individuals form a class in so far
as they have to carry on a common battle against
September 1985
another class; in other respects they are on
hostile terms with each other as competitors. On
the other hand, the class in its turn assumes an
independent existence as against the individuals,
so that the latter find their conditions of life
predetermined, and have their position in life and
hence their personal development assigned to them
by their class, thus becoming subsumed under it"
(Marx and Engels 1976’. The individual s role in the
production process, his location in the social
relations of production, the productive or unprod
uctive nature of his labour - all these form the
basis of inquiry. But as regards the identification of
class, the common interest, common behaviour and
common action, which are often independent of
individual wills, — or the common outlook towards
social events, political and.ideological orientations —
are also important and often act as positive forces.
To this Engels has drawn attention : "The econo
mic situation is the basis, but the various elements
of the superstructure-political forms of the class
struggle and its results, to wit.
Constitutions
established by the victorious class after a successful
battle etc., juridical forms, and even the reflexes of
all these actual struggles in the brains of the
participants, political, juristic, philosophical theories,
religious views and their further development into
systems of dogmas - also exercise their influence
upon the course of the historical struggles and in
many cases preponderate in determining their form"
(Marx and Engels 1965) In order to understand the
social role of a group of similarly placed wage
earners, their historical development in relation to
the changes in the mode and relations of production
as well as their political and ideological expressions
vis-a-vis the dominant political and ideological
current in the given society, are to be studied.
Class is actually, a historically developed, ideo
logically
shaped and economically determined
dynamic relationship expressed
through
class
struggle. Thompson's notion of class reveals this
aspect. 'By class I understand a historical pheno
menon. unifying a number of disparate and seem
ingly unconnected events, both in the raw material
of experience and in consciousness. I emphasize
that it is a historical phenomenon. I do not see
class as 'structure' nor even as 'category', but as
something which in fact happens (and can be
shown to have happened) in human relationships ...
Like any other relationship, it is a fluency which
evades analysis if we attempt to stop it dead at any
given moment and anatomize its structure... The
relationship
must always be embodied in real
people and in a real context" (Thompson 1982).
65
The social role of the employed section of the
medical profession is therefore, determined by their
role in the dominant mode of production and
by their interaction classes in the social events.
Sellers of labour
power primarily sell
their
labour power to earn a living not to produce
commodities. By the complexity of social division of
labour, some have greater interest in their products
while others have greater interest in the production
process. Each of the occupations has an ideologi
cally determined skill, status and price. All have
common despair in unemployment and all undergo
the similar feeling of inferiority, helplessness,
subordination and subjugation in relation to their
employers. Vic Allen, thus describing the wage
earners,
concludes that bourgeois sociological
stratification of different hierarchical classes and
the reductionist categorisation of productive and
unproductive labourer without empirical substantation, will not be helpful in an attempt to differentiate
between wage earners (Allen 1978). In the case of
health professionals, the study should go much
deeper and wider. Health and medicine are not
mere sterile figures or say, mortality and morbidity
statistics. Illness involves pain, fear and desperation
in real life and these saturate the milieu wherein
medical
care operates. Cultural instincts and
ideological creeds strongly influence and occasion
ally determine medicine and medicare. Medicine in
its practice and institutional forms is not merely
commercial
exploitation or oppressive
power
relations imposed by the dominant class — as
radicalism may have us believe — but is a resultant
of class struggle, of antagonistic and non-antagonistic contradictions between classes; of interactions
at the economic, political and ideological levels
The question of the role and behaviour of the
medical profession is relevant to the building up of
a Peoples Health Movement (PHM). PHM is not
merely imparting health education to the individual
or
community. PHM does not end with the
exposure of the inadequacy and exploitative nature
of capitalist medicine. PHM needs to acquire
expertise, to develop sound scientific basis of
egalitarian health system, to search for the mechaanics of building up of a socialist health culture
and to strive for subordination of medical science
to social needs and aspirations. It is a stupendous
task and the role of the health professionals is
crucial. This necessitates objective study of the pro
fession before theorising study of the developing
contradiction in the profession and the nature of
the contradiction; the dialectics of the medicine; the
66
development of the elements of socialist medicine
during bourgeois dominance; the dialectics of
cultural change and development. In the ensuing
struggle the weapons of the bourgeois science and
technology ought to be counterpoised by the wea
pons of peoples' science and technology. Involve
ment of the medical personnel will not be determined
by humanist exhortation or so called deprofessionalisation but by class contradiction and class struggle.
The medical profession or a section of it - be it cate
gorised as the 'new petty bourgeois' (Poulantzas,
1975) or the 'new working class' (Mallet, 1 975) wilhave its own determinant role to play and the PHM
activists must need to analyse and understand this
role in order to formulate the strategy and tactics in
the emerging social events of the health sector.
Sujit K. Das
S 3/5 Sector III,
Salt Lake, CALCUTTA 64
Reference
Allen, Vic : The differentiation of the Working Class in Class and
Class Structure, edited Alan Hunt, Lawrence Wishart,
p 7, London 1978.
Health For AH - An Alternative Strategy : ICMR - ICSSR Report :
Indian Institute of Education, Pune, p 209, 91, 1981.
Hunt, Alan Class and Class Structure (Ed. A>an Hunt', Lawrence
and Wishart, London, p 7, 1978.
Iliffe, Steve : The NHS : A Picture of Health?
Wishart, London, p 150, 147 1983.
Lawrence and
Jesani, Amar and Prakash, Padma: Political Economy of Health
Care in India, Socialist Health Review. (I: 1 ) 30, June 1984.
Klein, Rudolf : The Politics of The National Health Service, Long
man, London, p 75-76, 1984.
Mallet, Serge The New Working Class. Spokesman Books, Notting
ham, 1975, p 25-32.
Marx, Karl Theories of Surplus Value. Part I, Foreign Languages
Publishing House, Moscow, p 395-6, 399
Marx, Karl Capital, Vol. Ill, Progress Publishers, Moscow, p 293
1978.
Marx, K and Engels, F : The German Ideology, Progress Publishers,
Moscow p 85, 1976.
Marx, K and Engels, : F Selected Correspondence, Progress Publi
shers, Moscow, p 417, 1965.
Nichols, T and Beynon, H : Living with Capitalism : Class relations
and the Modern Factory. Routledge and Kegan Paul, London,
p 69, 1977.
Poulantzas, Nicos : Classes in Contemporary Capitalism, New
Left Books, London, p 20, 1975.
Quadeer, Imrana : Dialogue, Socialist Health Review, (1.3) 133,
1984.
Roemer, MJ. World Health Forum. WHO., 5:3 195 1984.
The Statesman General Practitioners ■ a disappearing breed,
16th
May, 1985.
Tnompson, E P : The Making of the English Working Class, Preface,
Penguin Books, England, 1982.
Venkatratnam, R : Medical Sociology :
in an Indian
Setting.
Macmillan, Madras, 1979.
Socialist Health Review
UPSIDE DOWN MEDICAL RESEARCH
The Case of Anaemia
rajkumari narang
What conditions and influences the development of medical research ? What motivates a researcher to
choose a particular pioblem area ? Under colonial rule research was a // onopoly of a small group of scientists,
mostly British some Indian. Curiosity and the need for experimentation and perhaps some concern for the suff
ering generated a number of interesting and relevant studies. After the ‘50s the orientation and the ethos of
medical research have changed — the problem areas are not those which benefit the majority but those which
are most likely to bring recognition to the researcher. Even when occasionally, an area of relevance such as
anaemia is chosen, it is looked upon as a purely medical problem, deemphasising the social and epidemiologi
cal aspects. This results in a medical[technological solution which can at best, provide temporary relief. The
author critically reviews the studies on anaemia over the years to illustrate her contention that the choice and
treatment of problems in medical research is rarely governed by factors such as people's needs
^^octors and scientists from the very early part of
this century belonged to a privileged class trai
ned and employed by the British and lacking in
involvement with the needs of the native popula
tion. We find however that there is a certain amount
of eagerness to learn, experiment, and change thin
gs inspite of the primitive technology and little basic
knowledge in the field of physiology. Although the
knowledge of science was incidental and the doct
ors were guided by the prevailing assumptions and
biases of their class, the mood of liberalism sweep
ing the country encouraged them to be open in
their pursuits.
The science of medicine was still young and
technology not so well developed. The lack of sophi
sticated laboratories and equipment was compen
sated, it appears, by more sincere attempts to learn
about the lives of the poor and to look at the wret
chedness of their condition that resulted in killer
diseases. Curiosity and the need to experiment were
also important considerations of that time. Scientists
were new to the discipline and had not yet mastered
it, to start the manipulations so obvious in the
seventies, and eighties. This could have been the
result of moral concern or a more humanistic
approach.
The independence movement, world war and
the general political atmosphere could have diverted
the efforts of the scientists towhat were seen as the
needs of the country, but there was a persistence and
demermination to eradicate anaemia. The callousness
of the later research is absent, though anaemia must
have been uninteresting and unexciting to the whites
(as a condition rarely encountered in the West)
and the Indians bred in their tradition. In contrast
September 1985
after Independence when anaemia still tops the list
of killers during childbirth, scientists are bored with
the problem unless it lends itself to molecular
manipulation and sophisticated technology use.
There is no patience or concern with the lives of
the poor, or with the neglect of women, and the
environment of infection and infestation. The age
of cold hard objective reasoning demanded ruth
lessness with the poor. The human angle was side
tracked and with that out went methodical epidemeological research. If anaemia has not disappeared
with the iron pills — the country cannot stop its
march to the 21st century with the electron micros
cope, ELISA, molecular biology, monoclonal anti
bodies and so on. "Socio-economic problems are not
the concern of the scientists", as one award
winning consultantscientist to international agencies
remarked. Even technology has not been used for
the poor. We have sensitive tests developed to
detect diabetes (less than 5 percent have it) inborn
errors of metabolism (prevalent in 1 in ten thousand
or 1 lakh population), but the method of anaemia
detection is the same as that we had in the thirties I
Research today has stepped out of the homes
of the poor, by passing the dirty lanes, open drains,
concrete monstrosities and smoke emitting factories,
straight into the air-conditioned labs and test tubes.
Problems that are rooted in an exploitative socio
economic system are sought to be solved from the
rarefied atmosphere of the laboratories. Solutions
to hunger and anaemia are sought through statistical
manipulations of mean and standard deviation. It
seems as if scientists are now fighting by proxy
the battles of the ruling classes regarding food
needs, minimum wages and hunger; their scientific
vision can accept strips of data fed into the com-
67
puier, but not the living, half dead tired women
who flock to the hospitals everyday. This myopia
seems characteristic of our research today. This
mechanical tiansfer of data reflecting the lives of
the poor had occurred in the west almost 25 years
ago. India seems to be one of the few developing
countries trying to catch up in this field. The price
we pay for the use of these advanced techniques
is that we loose sight of the human being at the
other end. Increasingly we isolate ourselves and our
research from the human reality out there. The study
of the historical research on anaemia serves as a
paradigm.
Anaemia : A Case in Point
In 1915 Dr. A.L. M udaliar in the Annual Clinical
Report of the Raja Sir Ramaswamy Iyengar lying-in
Hospital vividly described the clinical picture which
cannot be improved any further. ''The anaemia of
pregnancy is a malignant type of anaemia thatseems
to be much more frequent than is supposed — it is
not only a fairly common complication during preg
nancy but is one of the most fatal complications In
1914 the disease was responsible for 35 percent of
the mortality — more frequent in multipara than in
primipara, and has a very insidious onset; patients
hardly realised the gravity of this condition till the
whole body is swollen up and they get an attack
of dyspnoea when they seek admission. Breathless
ness on slight exertion and extreme weakness are
prominent symptoms. An analysis of the blood shows
reduction in the RBC ------- ' (Mudaliar, 1 91 5). In
1927 Margaret Balfour from the Haffkine Institute.
Bombay published her findings on Anaemia (Balfour,
1927). This is an important study by a white woman.
Her meticulous observations betray her colonial
background, but her concern for the enormity of
the problem is real. As a woman she is also concer
ned about the maternal mortality due to anaemia
much more than the other researchers of that time.
The study is well documented with her starting
observations, "In view of the frequency with which
the disease occurs in India, it is surprising how
little attention it has attracted", a fact which is
true to this day. She adds, "This is no doubt partly
owing to the fact that little obstetric practice
is in
the hands of
medical
practitioners".
(Balfour, 1927). It was a period when the medi
cal profession seriously believed that only they
could understand problems and change the whole
face of society. They feel that the key to the health
of the community lay in their hands. Even Balfour
identifies her hurdles typically "It is notoriously
difficult to get a correct history from hospital patients
68
in India" is her starting shot. The formal training
of the doctor was obviously not different then.
The framework in which they functioned had no
thing to do with the real lives of the people. Any
patient who deviated from the textbook pattern
of disease was non-compliant or difficult. The
woman's real experience of pain and illhealth did
not fit into the classical patterns of disease. Doctors
expected direct, well-defined, specific answers to
their curt questions whereas the woman's under
standing of pain was different. This socio-cultural
void has only increased with time because today
doctors donot even demand answers to questions
any longer. They already know it all and have no
time to ask the questions.
Nevertheless Balfour’s research is exhaustive
because she finds that anaemia is not just anaemia
but is associated with a host of other problems
such as fever 83 3 percent, diarrhoea 38 percent,
Albuminurea 30 percent liver enlargement 8 percent,
spleen enlargement 18 percent, oedema 100 percent,
vomiting 40 percent, sore tongue 3 I percent, Epistaxis
7 cases and weakness — always (It is heartening to
note that an important symptom now dismissed as
"subjective'' and ''imaginary", was actually elicited
and documented). Her startling findings of 42 per
cent maternal mortality and 53 percent stillbirths
led to the recognition of the fact that Anaemia had
to be tackled somehow.
Her treatment consisted of rest, diet, iron, blood
injections g.m).,. She also visited the homes of
the poor anaemics and attempted to link up the
problem with the lives of the women (a rare quality
compared with the clinical detachment of the present
day doctors). Since the incidence of anaemia was
higher among the Muslims in her study she states
"------- The main cause of this is probably the purdah
condition under which Mohammedian women live.
The poorer classes are confined in a single room
where they lead a very inactive life. Hindu women,
though under the same general conditions as regards
poverty, overcrowding and epidemics, do not observe
purdah in Bombay and so have a freer life '. She
continues, contradicting herself
The Hindu
woman does not go out much because customs
and habits did not encourage it. - - The work of the
home does not require a great deal of activity,
especially if it is shared by several women. Modern
conveniences also tend to reduce domestic duties
^sounds familiar) while modern principles regarding
physical exercises and games for women have not
yet taken root in India except in a few cases. A
generation ago the women of the family ground
Socialist Health Review
the corn daily and fetched water from the well.
Now in Bombay atleast they buy the corn ready
ground in the bazar and the pipes bring the water
to the poor".
These observations betray the prevailing assu
mptions about women. Instead of recognising that
these were much needed conveniences and looking
for causes elsewhere she feels that the women had
no right to look sick, flabby and unhealthy with
anaemia and confuses inactiveness which is a sym
ptom of severe anaemia with the cause.
The major flaw in the study was, however,
the fact that only women with haemoglobin (Hb)
levels less than 50 percent were considered anaemic.
Now the norma! Hb level in the West was 14
gms. whereas the normal detected in the Indian
poor was between 9.5 to 10 gms. Hence 50 percent
(4 5 — 5gms ) of the normal in India was obviously a
very precariously low cut-off point. (The cut-off
point for anaemia in pregnancy today is Hb less
than 11 gms). Obviously the actual incidence of
anaemia in Balfour's study was much higher. She
had no problems accepting lower standards for
Indians This is true of the other researchers too.
They may not have had the expertise then, but
they did have the information of higher standards
being applied in Britain. They did not find it necess
ary to question the norms, nor did this upset them.
It is not surprising that science rejected and gave
credence to the Britisher's view of the quality of the
Natives life. In fact scientists strengthened these myths.
To th's day Science has fought shy on the challenges
of racism, facism, sexism, or social inequalities. It has
conveniently toed the line of the dominant ideology and
under the garb of scientific truth has disallowed debates
and questions. In fact scientists employed by the
government are true, lawful servants ! In spite of
Balfour's incidence of 10 to 20 percent (the pre
vailing figures are 60-70 percent) the high maternal
mortality rate led her to postulate a toxic condition
associated with pregnancy. She could not demon
strate cure with medicinal iron etc., because we
know that treatment for anaemia is very long
drawn out.
In the same year McSwiney recorded 43 cases
of anaemia (McSwiney, 1927). Unfortunately the
hospital stay of the women and treatment was for a
few days only, because women came only when
they were critical and did not stay long enough to
get treated after delivery. She was convinced that
follow-up of the patients was not possible as “They
were all poor and ignorant folk who became
September 1985
restless after some weeks of improvement and
bitterly resented the innumerable injections and
demanded their discharge at the earliest moment".
McSwiney like today's doctors was unaware that
women's labour was needed to run the home and
care for the children and that she could not allow
herself the luxury of treatment in the hospital I
McSwiney however talks of preventive treatment
early in pregnancy to be followed up to term to see
whether anaemia could be prevented.
The search for a "cause" of anaemia continued
and in the meanwhile experiments on animals were
carried out with two diets "a Hindu Diet" and a
"Muslim Diet" (Wills and Mehta 1 930). But it was too
early to ' detect" iron deficiency anaemia by mani
pulating diets because contributing factors were
many including Malaria; Kalazar, Syphilis, and host
of other infections
In 1932 A L. Mudaliar and K. Narsimha Rao
from the Government Hospital for women and
Children, Madras reported their detailed study of
anaemia (Mudaliar and Rao, 1932). Their criteira for
Anaemia continued to be (4.5-5.0 gms). But they
had made attempts to focus on the multiple factors
such as gastric acidity diet infections and others.
and postulated the following theories to explain
the cause of this killer disease: 1) Infective theory
2) Vitamin deficiency 3) Toxemia 4) Deficiency of
Anti-anaemia factor.
A Landmark in Anaemia Studies : 1940s
Upto this point the studies were not organised,
but by 1942 L.E. Napier and Neal Edwards published
their report financed by the Indian Research Fund
Association (IRFA) which was a major document and has, I think, come nearest to defining the
problem (Napier and Edwards. 1942). It dealt with
most of the questions including Haematological
techniques and included a guide for research and
extension work. It is a landmark in the field of
anaemia.
Part I deals with a short history of anaemia
research in India and it was documented that Dr.
V.R. Khanolkar
was investigating into the Hb
standards in health and disease. The findings of lhe
earlier Anaemia Sub-Committee appointed by the
Scientific Advisory Board of IRFA, in 1939 by Ml Neal
Edwards, V R. Khanolkar and S S. Sokhey was also
reviewed, where the major conclusions were that the
cause of anaemia is ' common to a large percentage
of the population though the dominant cause will be
different" and recommended a study of "normal Hb"
69
and incidence of Anaemia including the effect of
treatment. They had also recommended the study of
clinical data and diet intakes in pregnant and non
pregnant women during and after pregnancy
(Napier and Edwards 1942).
The report also accepted that "In the past
anaemia has attracted less attention than it deserved,
partly on account of the general attitude of com
placency that is adopted towards a disease state
not commonly associated with a high mortality and
partly on account of a physiological misconception
namely that the normal Hb in the blood of persons
living in tropical countries is lower than that of the
residents of the temperate climate. The misconcep
tion regarding the Hb level in the tropics has now
been fully exposed — Anaemia is a very important
factor in causing death in infections and other
diseases in which, had the patient started with full
complements of blood — they would have recovered
..." (Napier and Edwards 1942). At last there was
some light at the end of the tunnel.
The report also reviews the work done on
pregnancy anaemia. Significant reviews are those
of Margarget Balfour where she reported that
anaemia was responsible for 61.9 percent of all
maternal deaths in Bombay and 35.6 percent in
India (Balfour, 1 927). Neal Edwards, with data from
the Women Hospital gave an incidence of anaemia
49.5 per thousand pregnant women in 1936 (taking
Hb less than 50 percent) and Napierand Dasgupta's
figures of 1b8/1000 pregnant coolie women in
Assam (Napierand Dasgupta, 1937).
The earlier studies had found that the causes
of maternal mortality was in the following order :
(1) Sepsis, (2) Anaemia and (3) Eclampsia, and
report that among the cases of sepsis which heads
the list, there are many cases in which if the patients
had not been severely anaemic as well, they would
have recovered. (It was also known that in Britain
and Wales, anaemia was the cause of only 0.05
percent maternal deaths).
The review of the epidemeological data shows
that the associated problems such as fevers, syphi
lis and other infections were very important and
reported that "the discrepencies in the findings of
the different observers may well be explained on
the grounds that there are multiple causes and that
these are not equally represnted in the various series
of different observers".
Reviewing the haemoglobin level from various
parts of India they seem to miss the important
70
finding related to the socio-economic gradient ref
lected in the following figures :
West
Indian
Men
14.5 — 16.0
Men
(Coolies)
12.63
Women
(Students)
13.73
Women
(Middle Class)
12.63
Women
(Coolies)
10.5
Women
(Coolies)
(Pregnant)
9.22
14.5 — 16.0
Hb levels in gms/100 ml.
According to the table the poor and specially
women were at a disadvantage at the start of
pregnancy. This "normal" low Hb levels resulted
in anaemia at the onset of pregnancy when the
needs are more, and by the end of pregnancy, the
condition was so critical (Hb less than 5 gms) that
their symptoms were of heart failure.
They were also surprised that the coolie popu
lation of both Assam nd Shivrajpur in Maharashtra
had the same Hb. levels, but less than the Western
levels. They at last postulated economic and dietary
factors, because in 1936 Napier and Dasgupta had
given iron to coolies and raised their Hb to 1 2 gms
and had suggested that there was another limiting
factor too (obviously food) (Napier and Dasgupta,
1936). In another experiment by the same authors
they found that coolies who were well fed for four
weeks before iron therapy showed better responses
than those who were not given food (Napier and
Dasgupta, 1937 b). The haemoglobin of the well
fed group had come up to the levels of healthy
men.
Another finding by Napier and Dasgupta was
that when the obviously anaemic women had been
excluded, the mean Hb was much the same as
amongst non-pregnant normal women (Napier and
Dasgupta, 1937 a).
Given the limitations of 1942 the scientists
were very close to the truth by virtue of their
keenness and determination to get to the truth. They
were not looking for easy solutions yet. The major
findings can be summed up :
Socialist Health Review
(1) that the food intake was low in anaemics;
(2) there was a massive hookworm infection;
(3) there was inadequate iron intake; (4) Associated
infections and other infestations. (Mitra, 1 939,. They
had no knowledge of the following yet because
science had yet to unveil some of the mysteries of
the cell.
(1) The mechanics of the cell cycle, and haemo
globin synthesis: (2) Need for folic acid and other
nutrients; (3) Results of experiments with radio
active substances. Inspite of the limitations of that
time they humbly accepted the fact that "the
essential difference between the study and the
treatment of a case in a sanitary advanced countryon the one hand and a sanitary backward country
such as India on the other is that in the latter one
has always to make one's study against a back
ground of widespread infections such as malaria
and hookworms, and of malnutrition both general
and special
Each infection and each food defi
ciency must be considered as possible contributory
factors ... ".
Part III of the report is optimistic because the
authors are convinced that anaemia can be preven
ted and perhaps special anaemia clinics would
help understand the "social, environmental and
dietary factors ... ". It would also help treatment
and research. They felt that the "hit and miss
procedures" were wasteful and expensive, and the
severe cases were being admitted to purdah
hospitals where the facilities were absent and the
pathologist who saw the slide never saw the patient.
Hence "the background, environmental and personal
diet and family customs must be given the same
consideration as is applied to the blood slide and
clinical findings".
There is a chapter on the details for conducting
an anaemia enquiry and research. It is very well
thought out with the women as the centre, and not
the scientists ego, pet hypothesis or personal ambi
tions. They suggest that "questions should be
intelligently considered and not mechanically noted.
For example in a meat eating family the mother who
may be the subject of investigations may herself
take practically no meat if she eats what remains
after the other members of the family have eaten.
Similarly lack of sunlight entering a particular room
where the woman spends 24 hours a day may be
in fact of more importance than the degree of venti
lation of the room".
The approach is sympathetic and explores qua
litative details beyond the narrow confines of
September 1985
"science" as will be obvious in the more recent
work on anaemia, lhere is another interesting
human observation differentiating the moderate
anaemia from severe. The authors are surprised and
find it worthwhile to document that in "Moderate
anaemia" the patient usually makes no complaints
and is found on routine enquiry. On enquiry she
may admit to feeling tired, but many women expect
this in pregnancy and think nothing of it. (Today
we have lost even this sensitivity that the medical
profession had in 1942! It is seen as a subjective
symptom and therefore not to be relied on). In
severe anaemia there may or may not be presenting
symptoms. The degree of anaemia which may
develop without symptoms is a testimony to the low
standard of well-being with which many women
seem satisfied. Questioning will reveal increasing
lassitude, shortness of breath, palpitation and
swelling of the feet and lace ... ".
The recommendations and the propaganda leaf
lets are again documents with well thought out
solutions to tackle the teaching of anaemia and
even "A method of haemoglobin estimation should
be taught to every midwife ... " has been suggested.
They cry out for early detection, and regular exami
nation of the pregnant women.
The piopaganda leaflets could be used even
today because they deal with the questions of a
good diet, special foods, medicinal iron, care and
so on and also notes the responsibility of men " ... It
is in the hands of the fathers and husbands to take
steps to prevent the mother's suffering and ensure
their health and safety during pregnancy and
childbirth".
This optimism was understandable, because
science had opened up new frontiers and the combi
nation of scientific knowledge with the resolve to
apply it for the good of womankind made every
thing seem possible. The whole attempt appears like
a dream today and anaemia still tops the list of killers
during child birth followed by sepsis and eclampsia.
Abortive Search for Quick Cures
Independence saw the report of Dr. S. Pandit
published in 1948 entitled Causes of maternal mortality
(Pandit 1948) —positive report still in the same
optimistic mood. But major research bodies like
ICMR were not touched by the strong winds of
change sweeping the country. There was no sense
of urgency, only clinical detachment for the next
10-1 5 years. Normal levels of Hb were worked out
and the role of folic acid and iron confirmed.
Instead of getting on with eradication, scientists
COMMUNITY HEALTH CELL
47/1, (First Floor) St. Marks Road,
Bangalore - 560 GOT.
71
betrayed their contempt for the poor people with
studies like Role of rice diet contributing to increased
fertility (Annual Report NRL, 1956). They had jumped
on to the band wagon of population control even
before they were invited. From this time onwards
one finds them bending over backwards to please
the powers that be and "science was placed at the
service of the ruling classes” even when the rest of
the country and ihe bourgeoisie was talking of
plans, people, democracy rights etc. The scientists
were not impressed. They had internalised the
ruling class contempt for people's lives and food
needs and a lot of time was spent looking into
Ducks egg protein and its virtues and the role of
mothers milk in causing malnutrition. The studies on
anaemia were secondary. An important finding in
1956-57 was allowed to pass by because it was
notexciting or sophisticated enough (Annual Report,
NRL, 1957). It was down to earth and pedestrian.
The study showed that iron cooking vessels helped
in increasing the iron content of foods cooked in
them. Such a study obviously would not lead to
international and national recognition and awards,
and one could not "claim” anything for this hence the disinterest. By now research had turned
into an industry which could churn out huge spin
offs for scientists in terms of patients, trips abroad,
publications and awards! The new breed of scientists
were not going to settle for simple iron cooking
vessels.
A search for a miracle and a quick cure was
launched to put an end to the nagging problem and
to claim credit for having wiped out anaemia. The
environment, foods, infections, poverty had to be
bypassed, "All that takes time” as one of them
exclaims. In the sixties sketchy details of iron needs
were worked out by simple additions of the need
during pregnancy, lactation, menstruation and by
1969 Dr. C. Gopalan announced the findings that
iron and folic acid would be distributed all over the
country as a National programme (Gopalan, 1969).
He said ''Till such time as we are able to
bring about a significant improvement and diver
sifications in the dietaries of the poor sections of
our population, the practical (emphasis mine) an
swer to this problem must lie in the systematic
distribution of iron to our poor pregnant women
through MCH centres and PHCs”. (Note the signi
ficant patronising tone!) Even this is recommended
in the latter half of pregnancy because "A significant
proportion of the poor pregnant women can be
reached only in the latter half of pregnancy”. The
researcher's pragmatism must be appreciated along
72
with his candid confession! This reflects how the
researcher has stopped identifying with the subjects
of research and has instead objectified them. By
1 970 Dr. Gopalan even announced the well worked
out doses of iron to wish away the problem of
anaemia from all segments of the population (Gopa
lan 1970). Dr. Gopalan was of course oblivious
of the problems of long distance storage, distri
bution, lack of commitment of the staff, the felt
need of the women, the massive problem due to
inadequate food, overwork, infection and anaemia
was reduced to a farce, by the pill. It was not
the fault of the women that it did not work. Any
wonder it has not even been evaluated!
In the meantime the WHO in 1968 had reco
mmended fortification of food with iron, one of
the exciting new suggestions that would increase
iron in food, and do away with pills (WHO, 1 968)
Hence work was started at the National Institute
of Nutrition to identify the chemical composition
of an iron compound that would mix well with
common salt ^which is consumed by all). The rese
arch was time consuming because the hurdles are
numerous. The drug (tonic) industry Watched this
progress with apprehension but they need not
have feared because since iodine fortification of salt
in the goitre area had been a failure - it was a
foregone conclusion that this research would remain
a curiosity until such time as the system became
really concerned with the poor.
Upside Down Research : 1970s
In the seventies it was forgotten that anaemia
was still a killer, it again became an "exciting
problem” and gained fresh recognition. Anaemia
means less blood, less oxygen and (?) alteration
in utilisation of food for energy for work, with many
other associated changes. Hence while the resear
chers now marked time waiting for anaemia to
disappear, their curiosity was raised with questions
of anaemia and immune response, anaemia and work
output (we had studies on the same plantation
coolies in the Nilgiris by Dr. Rahamatullah, who
made anaemic women (Mean Hb. 6.2 gms.) work
and calculated the increase in work after they were
given iron (Rahamatullah, 1983). There were also
studies of a’teration in the immune response in
anaemics, and other molecular level changes such
as changes in enzymes functions.
In the meantime by the late seventies when
anaemia could not be wished away nor used for
"exciting" research we have a breed of scientists
Socialist Health Review
who were willing to flog a deadhorse—the pay
offs would be recognition, awards etc. It was
obvious that anaemia had to be presented differ
ently. Hence statistical jugglery was resorted to in
thousands of anaemics showing that anaemia had a
role in prematurity, stillbirths, abortion, IUCD, Pill
use maternal and child morbidity, toxaemia, body
weights, arms circumference, skinfold thickness,
sore tongue etc. Research had now been turned
upsidedown (Ann. Reps. NIN 1979-83) The causes
of anaemia were no longer important — the correlations
with absurd parameters started, and by a process of
elimination the researchers arrived at the "Risk Care
Approach" a bastard of ibe eighties—an attempt at
planning for the 21st century by efficient and
smooth salesmanship based on statistical manipul
ations (ICMR, 1985). It states that indices of MCH
caie like low birth weight and prematurity rates —
have not shown the decrease commensurate with
expansion of health services — an attempt to cover
the entire vulnerable population (pregnant and
lactating women, infants and children) with the
available limited health man power — might have
prevented effective functioning and resulted in lack
of perceptible impact ... and ''Dealing with problems
of large magnitude with available limited resource?/
adapting a risk care approach might pay higher
dividends —"
The health care system was now using the
language of the stock exchange. The philosophy
being that since only a small section of women are
really in the "risk group" — contributing to mortality,
the others may be in the border line — and never
mind about them — they should be identified and
treated. There is no concern for the quality of life,
the nagging tiredness and the inability to work.
Further it is felt that in the rural communities it
is not possible for the doctor to visit far flung areas
and hence one must find out the minimum number
of antenatal visits needed. (Ann Rep NIN, 1982).
By process of statistical elimination the follow
ing women are placed in the "Risk Group". Hb less than 8 gms Wt - less than 40 kg; Ht - less than
140 cm. Any other problems during the earlier
pregnancies.
Other
scientists impatient with the slow
progress of the tablets devised ingenous methods
of injecting the whole dose of iron into women
(who had Hb less than 8 gm.). Exploiting the
popularity of injections in our country, scientists
recommend large scale injections of iron to over
come the non-compliance of the patients and
September 1985
cover up thus our lack of will and perseverance in
tackling the problem of anaemia. (Note the simi
larity to the use of Net-en in F.P Programmes).
Considering the huge government funding that
goes into research today, the question that faces
us is one of ethics What is the researchers' respon
sibly to society? What are the attitudes and
assumptions that should inform his/her research?
Is s/he justified in sacrificing even scientific
rigour to expediency. Should not a sense of humility
underline every piece of research undertaken and
attempts be made to make it relevant to the needs
of the people? Today the role of science in solving
the problems of the people is being increasingly
questioned. If the scientists do not recognise how
enormously privileged they are at the cost of the
country and attempt to fulfil even the limited tasks
before them they are in danger of rapidly becoming
redundant.
Rajkumari Narang
through Socialist Health Review
Bombay
References
Balfour, Margaret I. Maternal Mortality in childbirth in India. Indian
Medical Gazette. 62 : 646, 1927.
Gopalan C. Review of some recent studies Golden Jubilee Souvenir.
Nutrition Research Laboratory, Hyderabad, 1969.
Gopalan, C. Some recent studies in the Nutrition Research
Laboratories American Journal of Clinical Nutrition. 23:35
1970.
ICMR. Risk care approach to antenatal and intrapartum care,
ICMR Bulletin 16:1, 1985.
McSwiney, S.A. The anaemia of pregnancy — A study of 47
cases. Indian Medical Gazette, 62:487, 1927.
Mudaliar, A.L. Annual Clinical Report of Raja Sir Ramaswamy
lying-in Hospital, 1915.
Mudaliar, A.L. and Rao A N. Interim Report of Pernicious
Anaemia of Pregnancy Indian Medical Journal of Research
20 : 435, 1932.
Napier, IE. and Edwards, M.I.N. Memorandum on Anaemia in
Pregnancy in India Indian Research Fund Association, Thacker
Spink and Company, Calcutta, 1942.
NIN. Annual Reports of the National Institute of Nutrition, 19791983.
Nutrition Research Laboratories, Conoor. Annual Report 1955-56
p. 19.
Pandit, S. Summary of the findings of investigations into the causes
of maternal mortality in India. Indian Research Fund Associ
ation Special Report. No. 17, 1948.
Rahmathullah, V. Anaemia and productivity among tea plantation
workers in South India Proceedings of Nutrition Society of
India, no. 28. p. 16, 1983.
Wills, L and Mehta, M.M : Studies in Pernicious anaemia of
pregnancy, part IV Indian Journal of Medical Research. 18 :
663.1930.
73
SOCIAL DYNAMICS OF HEALTH CARE
The Community Health Workers Scheme in Shahdol District
imrana quadeer
7he Community Health Workers Scheme was introduced ostensibly to promote people's participation in the
delivery of health care. The scheme did not however envisage other changes in the health infrastructure or
incorporate new developmental strategies. The article examines the impact of the rural social and economic
realities on the scheme in Shahdol district of Madhya Pradesh where it was introduced in 1977. It shows that
the prevailing network of linkages which serve only to increase and strengthen the hold of the elite, have
fully absorbed and distorted the scheme. The poor who were the supposed beneficiaries, had no say in either
the decision making or the running of the scheme. The author concludes that in the absence of efforts to
either change the social matrix or at least control some of the key components, schemes such as this one are
bound to fail.
* | 1 he Community Health Workers (CHW) Scheme
was introduced to the Indian health services
panorama with many promises. It was to promote
people's participation, provide health care to the
poor and deprived rural population, and be the
vanguard of Primary Health Care in the Indian
setting. A constant refrain in the planning process
was the need to revive self-sufficiency in Primary
Health Care and make it a part of the broad deve
lopmental process.
The scheme however, was introduced without
any significant changes in the health service infra
structure which was to support it. It simply took
over the responsibility of implementing the existing
health programmes without any review of priorities
and the technologies used. The general develop
mental strategies remained as stagnant as ever and
above all - despite all the laudable objectives - the
rural population was treated as one homogenous
mass without taking into account the reality of
social classes and their dynamics. The implications
for the working of the scheme were quite serious.
This paper examines the impact of the rural social
and economic realities on the working of the
scheme. It is based on a part of data collected for a
study of the CHW Scheme in the pilot blocks of
district Shahdol in Madhya Pradesh. The research
team consisted of three research investigators.
Methodology
Our hypothesis was that the Scheme's actual
performance would be determined by the nature of
social dynamics in the area and the official efforts
made to overcome the constraints imposed by these
dynamics. The aspects that we focussed upon were :
(a) Social and economic stratification of the rural
population; (b) the links of CHWs with the village
74
strata; (c) the links between strata which indirectly
influenced the behaviour ot its members; and (d) the
links with the personnel of the health services.
These were the areas which we explored
through observations, interviews and group discu
ssions with people of different strata, the CHWs
and the PHC staff.
The study population consisted of the first pilot
Block selected for the implementation ot the CHW
scheme. This Block had a population of 39,642
with 109 villages in all.
General surveys were conducted in 34 villages
from where CHWs were selected and in 4 villages
which did not have CHWs. These surveys were
used to understand (a) the socio-economic back
ground of the villages, (b) to explore the views of
village residents regarding the scheme and their
CHWs, (c; to collect information about the CHW,
and (d) to assess the status of other developmental
programmes.
For the purpose of this survey, two strata were
identified : the "elite" who were defined as the
surplus producing farmers,1 regular government
employees, and those who held official positions of
Sarpanch or Upsarpanch; and the "poor" who were
the marginal or subsistence farmers and the landless
labourers. From both the strata, a 60 percent
purposive sample of households was interviewed
singly or in groups. The total number of households
in the villages covered was 3,743 and their popula
tion was 20,534. Out of this the sample covered
19”? elite and 2194 poor households. The malaria
worker's house list was used for the purpose of
identification and 1 to 2 days were spent in each
village by the three investigators.
Socialist Health Review
In six selected villages where the 'best'2 CHWs
resided an intensive survey was carried out. About
one-two months were spent in each village. For
this in depth study three strata of households were
identified based on landholdings and employment.
These only roughly coincided with what we consi
dered well-off households, subsistence farmers,
marginal farmers and landless labourers but they
sufficiently reflected the economic stratification of
the village population." The categories were of
households owing 0 to 5 acres of land, more than 5
to 10 acres of land and more than 10 acres of land
along with those having permanent employment in
the government services (Table-1).
The intensive study provided qualitative data on
socio-economic aspect of village life, health and
health care services, developmental programmes,
CHW's work and popularity, and his interactions
with PHC personnel as well as the people. For qua
ntification of some of these, an interview schedule
was administered to a 30 per cent stratified random
sample of households.
In addition to these surveys the PHC personnel
were observed and interviewed in detail regarding
their views and support to the scheme. This was
cross-checked with the CHWs as well.
The Pilot Block and the Socio-economic
Back ground of it's People
Covering an area of 5125 sq.km., this Block
retained parts of the forest which covered the entire
district 30 years back.
It had 19 panchayats
(all Reserved) and 109 villages. Except for one
railway line and two metal roads which cut across
the Block, its transport was mostly through mud
roads. It had a coal mine, and a thermal power station
was being proposed within its boundaries. The Block
had a higer secondary School, 72 primary schools
and 10 junior high schools. Its tribal population was
25,704 and scheduled caste population was 1830.
Size and Social Composition of
Villages Surveyed
All the villages were predominantly tribal. They
could be grouped into 12 villages which had a
few Scheduled Caste households (group I), 15
villages with 1-2 households of the Hindu upper
castes (group II) 7 which had 10 percent or more
households belonging to the upper castes (group
III) and 4 where the muslim population was signi
ficant (group IV).
Although these villages were commonly refe
rred to as tribal villages, they could be called
September 1985
tribal only to the extent that the majority of their
residents belonged to one tribe or the other. The
organisation of these villages, their economic relati
ons and their social rules had little which could
be called exclusively tribal. The small minority of
non-tribals in the village maintained a posture of
superiority and freely referred to the adivasis
(tribals) as "Stupid' and ''lazy ", and blamed their
character for their impoverished living conditions.
A slightly deeper look into the dynamics of these
villages, however, brought out the real mechanics
of these characterisations.
Economic Stratification
Estimation of households owning 0 to 5 acres of
land (poor) and those owning more than 10 acres
of land or employed (well-off) gave an idea of
the economic stratification in these villages (Table 2).
The stratification, seen against the social back
ground of the villages, brought out some interesting
features of socio-economic patterns. Six out of the
seven villages of group III had the largest numbers
of well-off farmers. Most of these villages were
also the larger villages of the Block which were
well-connected and provided employment to a sign
ificant percentage of theirown population. Secondly,
employment in the colliery was a significant reason
for the observed percentages of well-off house
holds in all villages, especially Group I and Group
II villages. Villages of Group IV alone had no such
households. Most of their Muslim and tribal inhabi
tants worked as rickshaw-pullers or as wage-labour
in the nearby town.
Another striking characteristic of the pattern
was that percentage of households owning not
more than five acres of land increased from Group
IV to Group I. It was also evident that the nontribals generally constituted the bulk of the well-off
farmers or the employed residents of the village
whereas the adivasis were the poor, landless, or
marginal farmers. Though all non adivasis were not
always well-off, invariably the Brahmins, Thakurs
and Jaiswals, if they did not have sufficient land
holdings, had the few available government jobs
and had captured whatever other employment opp
ortunities existed in the area.
Yet another feature that emerged was the large
number of poor and ill-fed people in spite of a
significant number having land. Only in 19 villages
the percentage of landless was 30 percent or above.
Thus, having land was not necessarily a guarantee
against poverty. It was not uncommon to find
75
households who owned land but had no means to
use it. Often the land was too difficult and un
productive to labour upon. So they preferred to
do wage labour rather than toil on an unpredi
ctable piece of land.
The Web of Life
The pressures of production processes knit the
people to gather into a web of social relations the
terms of which were determined by the nature of pro
duction, the intensity of needs, and by the paucity
of economic alternatives in and around the area.
Agriculture was the major activity binding people
together. The marginal and poor farmers owned 1 5
acres of land and were able to produce grain
which sufficed for 2—6 months. Together with the
landless the/ constituted 31 80 percent of the
surveyed population. These farmers depended upon
their labour to earn for the rest of the year. The
subsistence farmers were those who owned land
and could produce enough for the year with family
labour alone. The rest we called middle farmers
or the well-off farmers who employed labour and
also managed to produce some surplus. They con
stituted 0—45 percent of the households.
The forms of labour exchange varied from
fixed period contracts "Harvahi", daily payments in
barter system "bani mazdoori", to free use of the
plough for two days in exchange of five days of
labour "Podika”, and loaning of bullocks for a
season in exchange of grains. The wages were
either two kilos of paddy or Kodu a course grain
daily or 240 kilos of paddy orKodu for four months
of Harvahi. Sometimes, instead of this, the Harvahi
was given 12 kilos of grain to sow on a piece of
land. The produce was his except for the land rent
that was deducted. Yet another form of exchange
was working free of cost for each other at the time
of sowing and harvesting, a practice most common
among poor and marginal farmers. Wage labour
was uncommon and money as payment was offered
only by farmers who were essentially colliery
employees. Very often even these terms were not
available to people who then depended upon
collection of forest produce and fire wood.
The subsistence farmers using family labour
just about managed to eke out a living. Their sole
concern was to remain operational and they con
sequently tended to keep aloof, being always on
the look- out for odd jobs to supplement their income.
The artisans were few (Basorth, Agaria, Chamar,
Lohar and Kumhar castes). Their trade was dwindl
76
ing in the face of competition put up by the crow
ing industries. Many did wage labour and farming
as well or had completely shifted over to these.
The non agricultural labour was yet another
cog in the wheel, exploited both by the contractors
and government agencies Paid around Rupees
three a day in spite of the existing minimum wages,
the labourers had to seek employment with these
very exploitative agencies because, firstly, the
contractors and private businessmen were hand in
glove with each other and secondly, there were no
other alternatives.
Through these working relations, the poor
found themselves entangled in an exploitative
network but knew of no ways to get out of it.
Even though the well-off farmers were unable to
provide work to all who needed it, they wielded
power through their ability to provide odd loans
(of seed,
grains and money) and "sifarish",
(influence).
The well-off were thus left alone to make
their own profits, not just through land but through
most of the administrative agencies which existed
in the area and which were supposed to deliver
help and relief to the poor. One example of this
was the Panchayats, which worked as tools to soak
up public resources for private purposes. The Block
Development Officer worked through them and
through the village elite and so managed to reach
only a small section. The elite used their sources
and their contacts to exercise their own power and
to consolidate the conditions of their own family
members. As a matter of fact, the word elite' in the
context of these 38 villages is a misnomer. What
we really had was a handful of not-so-affluent
families who, either because of their caste Hindu
background and past power, or because of their
land holdings, had acquired respectable positions.
'Respectable' because they were the ones who
entertained, hosted, and informed visiting officials,
police personnel, and, at times, politicians, and
they were the chosen few for delivering to the
people whatever the Block administration, had to
offer. The intensive study showed that only a few
in category III performed this role.
It was not uncommon to find that in these
villages the lowly paid but most’ sought out posi
tions of CHWs, Adult education tutors, and Raha-
tkar relief work mates had been captured by the
same persons belonging to these families or the
family of the Sarpanch or different members of his
Socialist Health Review
c'an. It was here, then, that caste and family
loyalties began to influence the economic relations.
The opportunities were few and unemployment
vast. With the majority of adivasis being unacqua
inted with laws, rules, and functioning of the
administrative system, it was not difficult to usurp
(with the help of higher officials) what was meant
for them. Still better was the practice of including
one or two of them, giving them a few crumbs, and
getting their thumb, impressions on the official
papeis. The divisions within the adivasis and the
influence of Hinduism, which had brought in with
it the concepts of superior and inferior tribes,
helped to ward off any dissent. The Raj Gonds,
who considered themselves Khsatriyas (Thakurs)
through their social superiority as well as land
ownership, were the closest to the bureaucracy.
The landless and poor lived in fear of the
local administrative machinery. In the event of an
encounter they would rather let the 'Bare log'
(big people, the rich) of the village play the inter
mediary than face them on their own. It was a
common practice to pay the Sarpanch to get one's
work done rather than do it oneself. The officials,
however, perferred a system of direct payment.
The police and the Patwari were the two most
feared officials. Every village had people complain
ing of land disputes where, simply because they
could not pay them, either their land was transferred
to others or they were threatened with 'benami5.
The experience at the Tehsil office was no different,
where every clerk wanted his pound of flesh. If
any one tried to bypass this system he either never
got his work done or he was so entangled with the
"rules" and "laws" and all the loopholes that go
with them that he was left utterly bewildered. It
was basically to avoid this unfamiliar world of
''Kanoon" (law) that the people were forced to part
with their hard earned money. It was no wonder
that they were mortally afraid of the "Sahibs".
The petty traders who brought off the produce
of the farmer or their forest collections were another
link in the chain of exploitation. Since people
needed oil, salt, clothes, and other necessities they
had to exchange some of their produce for money.
This exchange occurred at harvest time when grain
prices were lowest and the poor farmer invariably
lost in this exchange. He in fact lost twice because,
soon after his own stocks finished he had to go
back to the same traders who now sold him his
grain at double the price. Similarly, the forest
produce collected by the villagers were bought at
September 1985
throwaway prices and the same were sold at 200
percent profit in the market.
Introduction of the CHW Scheme
It was within such, conditions that the CHW
Scheme was introduced in the Block from 2nd
October 1977. The implementation was done in a
hurry
The PHC staff had only a week to inform
panchayats, do the propaganda in .the villages,
complete the formalities of selection and make
logistic arrangements for the training programme.
The staff had severe reservations about the princi
ples of the scheme (that health care through non
professionals is possible) and the abilities of the
local population. Also, they were reluctant to take
any additional work responsibility so they followed
the dotted lines of the slate circulars and did not
bother to take initiatives in preventing the selections
from being distorted by the existing power balance.
Selection Procedure
The result was that the selections were left to
the discretion of the panchayat and therefore, effec
tively, to the whims of the Sarpanch or the
Upsarpanch. In the majority of the panchayats,
neither were all panchayat members contacted, nor
all villagers were informed. Only those applicants
were encouraged whom Sarpanches favoured. Very
often the PHC in fact strengthened the hands of the
Sarpanch in selecting undesirable candidates due
to caste, class, and religious links and justified
themselves by saying, "if others are doing it why
shouldn't I". For 40 positions only 54 applications
were forwarded, of which from 30 villages single
applications were received. In ten villages the tie
was either between members of the elite (mostly
non-tnbals) or among the many relatives of the
sarpanch. In two cases rejected candidates were
finally accomodated by creating new village clusters
for them. This showed that not only the supervising
staff but also the doctors and the Block Develop
ment Officer participated in the manipulations.
According to some of the PHC staff members,
"most of the Thakur and Brahmin candidates were
no good compared to some adivasi candidates. But
the lower educational level of the latter were used
as an excuse to reject them". They felt, "relations
and connections were more important than qualities"
and said "the discretionary powers of the selection
board always favoured the elite".
Of the 36 CHWs interviewed, 22 said they were
informed by the Sarpanch about the scheme, 12
.said .thp. PHC staff told them, and only 2 had heard
77
of it from their friends. Invariably, those called by
the Sarpanch were asked to apply for the training.
None was told to inform others.
The general survey as well as the intensive
study revealed that the majority of the people had
no information regarding the scheme in general or
the selections in their villages. This was particul
arly so for category I where 88.2 percent expressed
no knowledge of selections (Table 3) Among those
who expressed knowledge of the selection process,
none thought it was their responsibility also. People
considered Sarpanch or the hospital to be respon
sible for selection of CHWs in 45-50 percent of
the households
Background of CHW
Sixty percent population of the block was of
scheduled tribes or castes. Despite this, of the 37
CHWs selected, only 20 were from adivasi house
holds and none from the scheduled castes. The
reasons for such distortions began to unfold when
we looked at the socio economic backgrounds of
these CHWs.
Social Background : The majority of the CHWs
were Brahmins and Thakurs among the non-tribals.
Even the lower caste Hindus had a very marginal
representation (Table 4). It was revealing that the
tribal CHWs came largely from those villages where
the entire population was either tribal or some lower
caste Hindus lived there. In those villages where
10 percent population or more was caste Hindus or
muslims, invariably all CHWs were non-tribals.
Even in those villages where only 1-2 caste Hindu
families resided 53 percent CHWs were non-tribal.
Our data further shows that except for seven
CHWs who were not related to the Panchayat
members, all others either had links with past or
present panchayats or were themselves Sarpanches
or Upsarpanches (Table 5). These links were
common to adivasi and non-adivasi CHWs and
indicated close-knit elite groupings whose members
kept interchanging their positions in the power
capture game. Yet another link of the CHWs was
with influential families of their villages (Table 5c).
If we take this into account then even out of the
seven CHWs we are left with only four who could
claim no links with the power elite I
Land Holdings and Occupation The land-holding
pattern of the CHWs was very different from that of
the general population. It reflected their links with
78
the landed sections (Table 6). It also brought out
the differences between the tribal and the non-tribal
elite quite clearly.
Not only the tribals owned
comparatively less land, their families alone depen
ded upon wage labour. Only three out of 20 tribal
families had an employed member while among the
non-tribals six out of 16 had employed members.
The CHWs themselves had varied occupations
in addition to their health work. Eight did farming
also, four were big contractors, and four had
become professional practitioners of sorts. Eight had
managed to get the supervisor's jobs in relief
projects while two had become tutors in the adult
education scheme. Another three had managed »o
get both these jobs at the same time while the
remaining seven did odd jobs like taking contracts
for bidi leaves, shopkeeping and so on. The relevant
fact is that the 17 who owned over 1 5 acres also
held the most paying occupations like contract
work, professions of sorts, and large farms I Also
it was significant that, despite a scarcity of jobs,
this small group had managed to acquire multiple
employment.
Education and Age Twenty percent and 30
percent of the adivasi CHWs were high school and
middle pass respectively as against 41 percent and
47 percent of nonadivasis with similar achievements.
The low achievements of adivasis only underlined
the irrelevance of making middle school a criteria for
selection.
The desirable age of a CHW was to be over
25 years of age. In this Block however, twenty
three (64 percent) were under 25 years of age.
Performance The general survey data helped to
group CHWs into four groups based on people's
responses. Of the 34 villages, in 15 the elite as
well as the poor talked well of their CHWs, in 4
the elite talked well but the poor wer divided, in
another 12 the poor as a whole were dissatisfied,
and in three both categories of households were
dissatisfied.
The elite, despite their satisfaction, said that the
CHWs were useful only for minor illness. They were
neither aware of the scope of principles of the sche
me nor of the duties of CHWs. He was considered a
paid PHC employee. The non-tribal elite were often
patronising towards their tribal CHWs. For example,
they commented, "He is the only educated one
among them and education has put some sense in
him"; "The poor fellow can treat only according
Socialist Health Review
to his intelligence, how can he go beyond"; or,
"The boy is sincere, he always comes to ask if
any thing is required''. For the non-tribal CHWs
however, the tone changed to "He is very intelli
gent and we hope that he would be considered
for more than just a Swasth Rakshak". ''He does
so much more than the health worker and is still
so poorly paid"; or "The non-tribals have done
well in all spheres and CHW is no exception".
The well-off tribals, on the other hand, were pro
tective about their own tribal CHWs and even
tried to cover up their faults, but if they had a
non-tribal CHW, they were cautious and respectful
and talked in appreciative but subservient tones of
the 'Bhaiyyaji' or 'Babu' (big brother).
In villages where the poor were divided in
their opinions the population was generally mixed.
Here the social group to which the CHW belon
ged invariably favoured him, like in villages Medki,
Dhawrai and Khickkiri. In Badwahi the Brahmin CHW
was unpopular among all the tribal poor except
for the Baigas who expressed satisfaction Baigas
also happened to be a landless majority who
worked for the Brahmins and were almost bonded
to them as labourers.
According to the poor the CHWs charged for
giving them drugs and often even for chlorinating
wells They said that instead of visting the houses
of the poor the CHWs preferred to go to the nearby
villages where they could practise easily. The Harijans complained that theirhouses were never visited,
''He is for the 'bare log' and not us", "We dare not
ask for help, if he gives something it is our good
fortune but there is none with such a fortune*'.
Despite their views this section of the villagers was
keen not to get into trouble for talking, "We don't
want any more trouble''.
In villages where the CHW did not reside,
people were familiar with his curative functions
but had not seen their CHW for months togetherWhen people's views of their CHWs are seen against
the data on the CHWs' socio-economic backgrounds,
some of the trends that emerge are revealing. All
CHWs who were given satisfactory rating by the
poor as well as the rich were tribals except for 1
out of 1 5 in this group. On the other hand, those
who were not liked by the poor but liked by the
elite were non-tribals mostly, 9 out of 1 2 CHWs in
the group. The distribution of tribal : non tribal in
the other two groups was 2:2 and 1:2. Given the
distribution of villages, it naturally follows that the
popularity of CHWs among the elite as well as
September 1985
the poor was higher in purely tribal villages
(58.3 percent) where CHWs were also mostly
tribals, whereas their unpopularity among the poor
alone was higher among the mixed villages — 8 out
of 12, i.e. 84 percent villages, where most CHWs
were non-tribals.
In addition to the findings of the general survey
the intensive study of six villages brought out the
following significant findings.
Nature of Services Provided by the best CHWs
These CHWs were considered helpful by the
people. However, their performance over the year
had declined remarkably. Thus in the villages where
they did not live they had stopped paying their
usual visits or they went only once or twice a
month. In the residential villages also, people felt
that the CHWs initial enthusiasm had died down.
Even then they agreed that the CHWs did help in
illness. Their utility in minor illness was acknow
ledged but there was a significant difference in the
response of the three categories.
Allopathic treatment was used alone or in
combination with other forms of treatment by 55.0
percent, 76.8 percent and 92.2 percent of the house
holds in category I, II, and III respectively. The
reasons for this difference were more economic
rather than a matter of preference. An important
tact was that the CHWs were the source of allo
pathic treatment (alone or with other sources) in
39.0 percent households of category I and 26 per
cent in category II and III Apart from this higher
dependence of the poor on CHWs, it was also
important that the poor combined CHWs with
traditional healers and the well -off with hospitals I
(Table 7.)
For major illness the use of allopathy was
markedly higher in all categories (80 percent or
more) but the use of CHWs was much less. Even
then, out of all households using allopathy, the
highest use of CHWs was by category I (40 percent),
the lowest by category III (14.8 percent). This was
an interesting finding which indicated that the poor
now had health care facilities which they did not have
before. The information on the CHWs* preventive
activities, their free accessibility and their practice
patterns however, reveals the nature of this success.
CHW's preventive activities in the area of
chlorination of wells, maternal and child health,
education and environmental sanitation were almost
negligible. Only 31.7 percent category I house
holds (as against 0.9-2 percent of the first two
79
categories) said CHWs chlorinated wells in their
houses and even they were not aware of their other
activities (Table 8).
In the beginning the CHWs used to visit differ
ent areas of their lesidential village and the
villages alloted to them but this had now become a
raritv. People now had to request them to see a
patient Though these CHWs helped according to
most people. 29 percent households in category I
said that the CHWs refused to come and see a
patient Also, 28 percent of the poor said that he
charged for injections - indulged in private practice as against 16.7 percent and 3.9 percent in category
II and III (Table - 8). In addition, in case of major
illness, even category I households paid in 84 per
cent of illness a.though they used CHWs to the
maximum 40 percent This indicated that though
the CHWs were mainly used by category I, the
trend
showed replacement of the ' traditional
Gunia" a by a ‘'modern Gunia" rather than emer
gence of self help and self sufficiency.
Supervision : The scheme envisaged supervision
by the community in administrative matters and the
PHC in technical matters. However, high percenta
ges of households in the first two categories said
they knew nothing about supervision (Table - 3).
Even those who mentioned panchayats separated
themselves from the responsibility since there was
no identification with the panchayat at all. The
Sarpanches themselves were least inclined to be
active in this aspect. In fact since they were a party
to the selections and mostly related to CHWs, even
in cases where people were unhappy they found no
reason to act against the CHW's interests. Of the 19
panchayats, none had taken any action against any
CHW at any point of time nor made efforts to
stream-line the CHW's activities.
Five CHWs were themselves Sarpanches
and
Upsarpanches and they said that their panchayats
had no directives about the panchayat's supervisory
responsibilities. Even among the CHWs, only 3.5
percent had heard of the panchayat's supervisory
role
The technical supervision by the PHC staff was
more a bone of contention rather than an asset. The
Health Workers attempted to pass on their work to
CHWs, boss over them and treat them as subordi
nates. The CHWs resented this once they realised
that the PHC workers were more interested in
private practice. Some were also able to retaliate
given their social status and acquaintance in the
village. The extent to which this conflict developed
80
was largely determined by the socio-economic back
grounds of the CHWs
The non-tribal CHWs were
assertive, dominating and socially powerful. They
either cared little for the paramedical workers or
were treated well by them out of sheer desperation.
Among the tribals, the resourceful CHWs (Sarpan
ches or well off) managed better since their local
status was important but the others fared poorly
They were not only not given any help by the
various PHC workers but also treated with much
contempt.
The role of the senior staff at the PHC and
district levels was not much different. All the
doctors and most of administrative staff came from
non-tribal caste Hindu backgrounds and had their
own views of the social reality. In their busy
schedules of working for Family Planning progra
mme, Rahatkars, office administration, and looking
after the 'VIP' visitors, the District Health Officers'
only contact with the people of the area was
through their private practice For them the 'locals'
were a mass of backward and unintelligent humanity
with whom it was difficult to communicate. Conde
scendingly, the DHOs let the PHC medical officers
handle the scheme. They themselves were hardly
familiar with it. According to the two consecutive
DHOs, 'What can these untrained locals do; let
them atleast help our health workers". For them
even the village Mukaddams and the Sarpanches
were "unintelligent people".
Given the choice,
they were for closing the scheme any day.
At the PHC, except for one medical officer
(out of four) all the rest were either indifferent or
vocally against the scheme even though they agreed
that the CHWs were giving some help to people
where their own workers had failed. Interestingly
enough, all these medical officers used the CHWs
nfluence to get referred cases for their private
practice. This link was strong and in return some
CHWs were patronised by the medical officers.
Their usual answer for letting things pass was,
"we have no control over the CHWs and the
Panchayat doesn't act. Even if we report something
there is too much political interference and we know
that except for getting unpopular we won't gain
much".
Discussion
Our data projects a pattern of social reality
wherein a handful of the non-tribal elite in collabora
tion with the well off tribals controlled the majority
of the poor — individually through terms of work
and collectively through social institutions like
Socialist Health Review
panchayats. Both tribal and non-tribal poor had
little access to the Block's developmental agencies.
The areas general backwardness precluded alter
natives to the existing pattern of living. Further,
there was a general lack of information and educa
tion and the interaction of the majority of the poor
with the outside world was extremely restricted.
This meant that their dependence on the elite and
the dole provided by the state was total. As a result,
the two in collaboration got away with many acts
of ommission about which the people may know
but coula do nothing.
In such a setting, the exercise of giving
"people's health in people's hand" through their
'elected representatives' may sound good on paper
but is bound to get mutated by the social matrix
within which it is placed. This is what happened
to the CHW Scheme in Shahdol. Though officially it
was a voluntary scheme, a scheme of the people, it
continued to run — despite reminders from the state
— as yet another of the government's unsuccessful
schemes.
The relevant aspect of the problem is that
though the scheme did not work according to plans,
the CHWs did cater to certain needs of the village
population. It is thus apparent that while the expli
cit design of the CHW Scheme had not worked,
there was an implicit design to its functioning. This
design can only be recognised when we look at the
linkages of the CHWs with the other categories, as
suggested by the hypothesis of our study.
Links between social classes
The influences of the existing socio-economic
configurations on the working of the scheme are
clearly visible through our data. The supremacy
of a small group of landed elite who controlled the
local resources and also the channeling of govern
ment funds, created a situation wherein the
appropriation of resource and labour had become
a part of life. The CHW Scheme provided emplo
yment and therefore could not escape the general
trend. Appropriation of opportunities provided by
it not only brought economic assets for the local
elites and their families but also an opportunity to
strengthen their social positions by favouring
some who mattered. The undemocratic functioning
of the panchayats only made the task easier.
Following the initial grabbing of positions however,
the enthusiasm reflected by the panchayats dwindled
into apathy and disinterest when it came to
supervision and control. In other words, after
September 1985
providing patronage to their favourites the pancha
yats resumed their usual slumber.
It is also important to realise that the Pan
chayats could get away with this usurpation of
the scheme only because people were in no position
to protest against those who controlled the impleme
nting institutions, given their social and economic
as well as political dependence.
Given the domination of a small section of the
population, there was no social pressure on fhe
selected CHWs. Those who did work had their own
motives. They were either interested in building
their social images or were politically motivated
(as the CHWs of Gijri and Varamtola) or had
monetary interests. They some times augmented
their 'salaries' (honorarium) through indulging in
private practice and nobody objected to it. Even
those CHWs who were considered good by all
showed preferential treatment towards category III
households. They charged them less frequently,
were readily available to them, and also provided
some preventive services however meagre those
may be. But the CHWs relationship with the welloff was contradictory. While they served them well,
they were used less frequently by this section and
only for minor illness. In return for their services
though, the well-off protected and praised them
and thus ensured the high cost of medical services
for the poor.
The CHW in general knew that if they could
humour the well-off they would be free to handle
the rest the way they wanted. This trend of ignoring
the poor was so dominant that even those few
CHWs who came from the poorer families often
tended to ignore their own kind and over a year,
had learnt to reproduce the behaviour patterns of
their better-placed colleagues. Thus, they were
either practising in their own villages or going to
areas where no CHWs were posted and the people
knew nothing about the scheme so that they could
sell the medicines with ease.
Despite their ambiguous beliefs the majority
of the poor opted for allopathic treatment if they
could afford it and had also realised the import
ance of chlorination of wells and vaccinations. In
procurring these services however, the people had
learnt that money, connections and 'sifarish' were
the tools that worked. Voluntarism on the part
of the provider and organised demand on the
part of the recipients had not been a part of their
experiential base as was clear from their experience
81
of the political processes
administration of the area.
which
moulded
the
Links of CHWs with Social Class
Yet another crucial link was between the CHWs
and the existing social classes. This was responsible
for the quality of selections as well as work of the
CHWs. As we have seen, only 4 out of the 36 CHWs
could be said to represent the average villager. The
rest had their connections with the present or previous
office bearers in the Panchayat or came from the
better-off families possessing large acreages of land
or other business. Since this section of the village
population appropriated all resources coming for
rural development the CHW scheme was also
appropriated. This explains the atypical background
of the majority of CHWs as also their ability to
acquire other employment. Consequently, not only
were there a large number of non-tribal CHWs but
the quality of their work in general was affected in
several ways.
Firstly, since the CHWs were given the protec
tion of the elite they could do almost what they
wished without being answerable or accountable to
anybody. In turn the panchayats, the statutory body
responsible for their supervision, took no action
against them.
Secondly, since the CHWs joined the scheme
as a means to augment their income or status they
concentrated almost entirely on curative work.
Whatever little preventive measures they implemen
ted in the beginning was also given up over time or
else they would even charge for chlorinating wells.
Thirdly, since income generation was possible
only through charging for their services and further
more, since they could not very well charge those
elite families through whose benevolence they had
become CHWs, the brunt of paying for their practice
was borne by the poor. Additionally, it should be
remembered that the poor had no one else to go to
while the well-off preferred to go to alternative
health facilities like doctors and hospitals — parti
cularly so in case of major illness. This explains the
paradoxical situation of the poor using the CHW
more and paying more too.
Fourthly, most of the CHWs were appointed
through the agency of the Sarpanch or Upsarpanch
but once they themselves became familiar with the
bureaucracy and the government officials they
began to develop their own alternative income
sources. Thus, the post of Sarpanch would become
82
far more lucrative as would the positions of Rahatkar mate or petty contractor. As a consequence,
these alternatively more profitable occupations
would demand more of their time and energy and
the quality of work in community health would
decline Even the house visits being done initially
would stop
Fifthly, even those few tribal CHWs who
came from poorer families were drawn into the
search for better incomes and thus began to ignore
their own social strata. It would be unrealistic in
such a context to expect them to remain devoted to
the cause of the poor
Links with the Health Bureaucracy
The notion of their own social and technical
supremacy generated a feeling of contempt for the
CHWs among health workers at various levels of
the health services hierarchy. The result was indiffe
rence. condescending tolerance, and disinterest
among the senior officials, and jealousies and resetment between paramedical workers and CHWs who
had captured the clients of the field workers and
had now replaced them as doctors!
The health and welfare bureaucracy did nothing
to reverse these trends. Given their own needs and
links with the local elite they only used these
patterns for making profits. They in fact, often
protected the defaulting CHWs and never made
efforts to streamline their work by either putting
pressure on the panchayats or their own organisa
tion. In the process they only reinforced the existing
patterns rather than improve them.
Conclusions
Given the indifference, inefficiency and ineffecti
veness of the health bureaucracy, the powerful hold
of the elite, and the collaboration of the well-off
tribals as well as the administrative bureaucracy of
the district, the prevailing network of linkages had
fully absorbed and distorted the CHW Scheme. The
poor, in whose name the scheme was launched,
were made to pay heavily for receiving some medical
care while they had neither a say in decision-making
nor a hand in the running of the scheme. It is a
paradox that the well-off, who used the CHWs the
least, were also the ones who were bestowed with
the CHWs' attention and the poor, who used them
the most, had to beg, plead, and wait. This 'success'
that the scheme boasts of is certainly not an achieve
ment but a reflection of the dire need of the toiling
people.
Socialist Health Review
Our study concludes that people's participation
in a health care scheme cannot be an isolated event.
The degree of participation (or non-participation) is
determined by the overall socio-economic relation
ships which bind a population and within which
all schemes have to function. It is these links with
the larger system that decide the success or failure
of a scheme. Though confined to a Block, our
study identifies the social linkages which influence
the scheme and underlines the fact that it is the
nature of these linkages which is crucial for the
scheme wherever it is introduced.
The experience of Shahdol teaches us that in
the absence of efforts to either change the social
matrix, or at least control the key components
influencing the scheme, or offering people a taste
of free preventive and curative health care services,
to expect that people wiil hail the CHW Scheme as
their own and that they will also have the strength
to control a truant CHW, is far from being realistic.
This, in fact, amounts to protecting the holy cow of
people's "participation", irrespective of its social
context.
Imrana Quadeer
Centre for Social Medicine and Community Health
Jawaharlal Nehru University
New Meharauli Road
New Delhi 110067
Notes
1.
Those farmers who could sell their produce for profit or
could save it for the coming year.
(These villages were mostly so poor that indentification of
such households was never a problem and every one knew
which households could save or sell after consuming two
meals.)
2.
Judged on the basis of opinions of villagers, PHC doctors
and paramedicals.
3.
This stratification was used firstly, because it sufficed for the
purpose of the larger study, and secondly because the
information required was easily available. For a more
rigorous class analysis however, land holding alone is not
sufficient.
Table - 1
Categorisation using Land Holding and Employment Status in the Intensive Study Villages
Village
Category III
Category II
Category - 1
0-5
°/of
up to
Zo
5-1 0 a
No.
5 acres
No.
Over 10
acres
oz
Zo
No.
Gijri
Barbaspur
Maliagoda
Kumurdu
Badwahi
Varam Tola
Employed
Total
acres
%
No.
°Z
Zo
43
62
26
47
143
21
48.2
52.5
29.1
43.0
69.0
52.5
10
3
39
35
44
5
11.2
2.8
43.8
39.3
21.2
12.5
0
3
17
18
10
3
2.8
19.1
16.5
4.8
3.3
36
33
7
9
10
11
40.4
31.7
7.8
8.2
4.8
27.5
89
104
89
109
107
40
345
54.0
136
21.3
51
7.9
106
16.6
638
Table 2
Distribution of surveyed villages according to the percentage of 0-5 acre land owning and well off households in
the four Groups of villages.
Group I
Group II
Group III
Group IV
Group I & H
land owning
households
Villages
oz
Zo
Villages
Villages
together
°/
Zo
%
Villages
0/
Zo
upto 50
51-75
76-90
4 (33)
6 (50)
2 (17)
4 (27)
8 (53)
3 (20)
1 (14)
4 (57)
2 (29)
0
2-(50)
2 (50)
8 (30)
14 (52)
5 (18)
9 (75)
1 (8.3)
1 (8.3)
1(8.3)
8 (53.3)
3 (20)
2 (13.3)
2 (13.3)
1 (14.2)
4 (57.1)
1 (14.2)
1 (142)
4 (100)
0
0
0
%
of 0-5 acre
%
o/ of well-off
Zo
households
6-5
5-1’0 10-15
15
1
See PP. 97 to 100 for tables 3 to 8.
September 1985
83
COMMUNITY HEALTH PROJECTS: AT THE CROSSROADS ?
sumathi nair
Any number of alternative experiments in community health have come up in the last decade. This article takes
a doser look at four such projects which have today become models for others. The article is not an attempt
to run down any one or other project or its founder. Rather, it raises relevant questions about the contribution
of these projects to health and development, their overall perspective, and the manner in which they are
organised and administered.
* he early 70's was a period for a general spurt in
development activities of different kinds. This
was the time when some of the major community
health projects were started. It is over a decade
now since they have been established and their
effectiveness in achieving the goals initially set up
is now under review.
A careful study of these projects would reveal
various conflicting aspects which deserve deeper
study. All these projects have, over the years,
come to revolve around the founders, while
the people centred thrust they had set out to achieve
has not been realised. Yet their contribution to the
field of community health cannot be denied.
The focus of this article is to try and analyse
what led to the present situation — the limitations
inherent in such projects and the other contributory
factors. I must add that this article is not an attempt
to run down any one or other project or its founder.
Admittedly it is far easier to be analytical in
retrospect, than it must have been to have visua
lised the pitfalls before the event.
For the purpose of this exercise, I will take
four well-known health/development projects —
Gonoshasthya Kendra (GK) Bangladesh, the Jamkhed
Project, Maharashtra, the Deenabandu
Project.
Tamil Nadu, and the Comprehensive Rural Oper
ations Service Society (CROSS) project, Bhongir,
Nalgonda District, AP. My comments are based
on personal experience, literature and personal
communications.
Gonoshasthya Kendra (G K): In 1971 during the
Bangladesh war of liberation, a few doctors, of
whom Dr. Choudhary was one, set up a hospital
for the care of the wounded, which moved into a
rural area after the war and started a community
health project in Savar, near Dhaka. This Peoples,
Health Project is now funded by foreign donors.
Today they have 65 trained paramedics (mostly
women), nine of whom are village based. They
undertake health work, run a school, pharmaceutical
factory, a women's centre and have formed
84
agricultural cooperatives. They are today sought
after by the government and international bodies.
for the health
training they provide GK has
"arrived" — they have further plans for expansion.
Jamkhed : The comprehensive Rural Health Project
was founded by Drs. Rajnikant and Mabel Arole in
1971 in Jamkhed, Ahmednagar Dist., Maharashtra
in 30 villages (covers 60 villages now). They set up
a project to deliver health care in rural areas, imple
menting the village health worker scheme involv
ing community participation. They also gradually
included training in agriculture, provision of safe
drinking water, employment schemes, nonformal
education etc.
They
have
been
receiving
some support from donors abroad. The Drs. Arole
were given the Magsaysay award for their work in
this field.
The Deenabandu Project : Drs. Prem and Hari
John started their work in
Deenabandhupuram
some miles from Vellore in Tamil Nadu in 1972-73.
They gradually shifted their focus from "help to all"
— to helping the needy. A community health progr
amme was started and village health workers were
trained. They are supported largely by the organisa
tion called World Neighbours. Here too, the doctors
realised that ill-health had to be tackled in a broad
and integrated manner taking all factors leading to
poverty into account. They have, for this, started
several programmes — economic loans, agriculture
and animal husbandry, literacy classes etc.
CROSS: Founded by M. Kurien in 1975 with the
intention of "empowering the poor", they undertook
the work of organising the poor to fight for their
rights. Starting with less than a 100 villages with
funds from donor agencies abroad, the organisation
has expanded today, to reportedly. 500 villages in
and around Bhongir, in Nalagonda District of Andhra
Pradesh. The programmes include providing econo
mic loans, training in agriculture and animal
husbandry, health and adult literacy, to the poorer
sections of the villages. Their major achievement
has been the formation of sangams for men and
Socialist Health Review
women, in each village, where the problems they
face and the programmes offered, are discussed.
CROSS is today supposedly one of the leading
development groups in the country.
The founders of these projects are all doctors
(except for Kurien) who had been trained within
the established medical system and yet had the
vision to conceive of an alternative approach to
health, one for which few models were available at
that time. Besides, all these groups, spoke in terms
of "community participation". It was perhaps the
spread of leftist ideas at that time that influenced
these non-political groups with the ideals of
democracy and people's rule. Kurien and Choudhary,
in particular, had connections with the communist
parties of their countries. One therefore assumes
that their notions of people's participation was
based on a relatively better understanding of the
rural situation and the power structures that operated
within it.
The Drs. Arole and Drs. John, on the other
hand, were more influenced by the Christian missi
onary spirit and were thus keen on doing "service
to the need" (John & John, 1984). To them people's
participation had a different meaning. "We started
his as a total community programme for the rich and
the poor alike, for we believed we had a duty to
all "(John 8-John, 1984). Similarily Dr. Arole, talking
about their selection of Jamkhed says, "At Jamkhed
the leaders made arrangements to provide accomo
dation for the staff of approximately 20 people..........
...... The leaders also tried to understand the basic
concepts of the project". (Arole 1980). When the
leaders of a village are given such importance it is
not likely that there could have been much partici
pation by all sections in the village Drs. John admit
that they gradually realised that their understanding
was not right (John & John 1984).
Despite their differences in background and
approach to start with, all of the project holders
realised gradually that health was not a matter of
merely delivering medical services, it was closely
bound to the poverty of the people, their lack of
food. Gradually the programmes expanded to impro
ving agriculture and economic backwardness thro
ugh the granting of loans, setting up of night schools
and women's groups. They made attempts to tackle
the problems which, as they saw it, lead to ill
health.
With the loans provided — at GK it was 100
taka per person at first with a 4 percent interest to
improve his agricultural production — some of the
September 1985
village folk did manage to improve their living
conditions. All the villages that were adopted by
CROSS in its initial years have at least one well
today, for general use. Training in improved agricul
tural methods, on all projects have helped some of
the poor to make the best use of the little they had.
The non-formal educational classes, on all projects,
taught some of the village people to read and know
where to put their signature and so on. Basic arith
metic taught to the women at GK have helped them
as they said, to run their small vegetable vending
business more efficiently.
It is in two particular areas however — that of
health (except atCROSSIand women's development
that there has been a great advancement. This can be
seen in the lives of the women, who have been
involved in the project, particularly in Savar, but
also in the other project areas. Many women who
have only known oppression have now come to
look on their lives with greater hope and confidence.
The excitement this knowledge has generated was
seen in the literacy classes at GK in the fact that a
woman health worker found the courage to stand
for panchayat elections at Jamkhed and in the
militancy of the women at Bhongir (CROSS).
In the area of health all the areas mentioned
have in the last decade registered a fall in the IMR,
immunisation coverage of mother and child is high,
the family planning acceptance rate is also far higher
than the national average and the maternal mortality
rate has fallen. The number of 'at risk' cases are
provided with regular care and in case of emergen
cies immediate care is provided by the referal sys
tem, where operations too are conducted.
The improvement in the health status and the
status of women in these areas, are more or less,
directly as a result of the programmes undertaken.
This has been achieved through consistent hard
work over the years, the training provided to the
paramedics is quite thorough and they are very
conscious of the great responsibility placed on them.
Today if there was to be a test of skills in dea
ling with rural health problems at the village level,
between these paramedics and city trained doctors,
the paramedics would come out in flying colours.
Inspite of the benefits these development pro
grammes have conferred on the people of the area
anyone with some understanding of developmental
issues, who visits any of the four projects menti
oned comes away with a feeling of disappointment
and disquiet. Before visiting GK, it was, for me, from
all I had read, a model project in community health
85
with the people directly involved in the programme.
I looked forward with great anticipation to seeing
the project, only to be disappointed from the first
few hours itself. The project has a 100 acre campus
with two large multiple-storied structures on it. As
I entered the campus, I was made to wait at the
gate before being taken to one of the senior para
medics I knew, just so that my reference could be
cross checked. The women gate-keepers were in
uniform and were there to see that all and sundry
do not enter the place. This by itself was shocking—
such a clearly hierarchical structure and such control
did not, in my mind jell with a democratic set-up.
The rest of my stay only led to confirm this
impression.
Centralisation of Authority
Perhaps the other projects do not have such
structures but certainly from all reports, these
other projects too have a tacitly functioning hier
archy, which is fairly rigid with the sole decision
maker/arbitrator on practically all issues, being those
at the top, be it a Choudhary, Kurien, John or
Arole. No doubt it is these few who have had
both the vision and the longest exposure to the
work undertaken and hence have a right to a certain
amount of decision-making. But what of the others
who also worked along with them over the years?
There appears to be very little of sharing in the
process of decision-making. This almost total autho
rity that they wield was once defended by one
project director who said, ' After all I get the funds,
so its for me to decide what I do with it'7. Perhaps
the others would not put it quite so blatantly, but
in essence this approach operates in their projects
too. Another director is known to have sent in a
proposal for a new scheme without consulting his
senior colleagues, who came to know of it only
when a member of the donor agency mentioned it a
year later!
The major danger in such autocratictrends is that
of the centralisation of power. Every major and
often minor decision needs an okay from the people
at the top. This becomes particularly difficult as the
project expands and the work increases, as has
happened in all four cases. Not only do the indi
viduals at the top have to work harder— which any
one familiar with these projects is witness to, many
of the decisions get delayed and several are not
followed up. Often field level coordinators do not
feel confident enough to take on a responsibility
they will later have to answer for. At times issues
instead of being settled at the village/cluster level,
are brought by an individual directly to the chief
86
so as to gain support for his point of view, before
presenting it to the village sangam. In CROSS, for
instance, the scope for such lobbying with the
boss is immense. The "games of power", that
eventually set in are in contradiction to the earlier
vision of ''community participation".
The trend described here is perhaps due to the
lack of accountability the project heads enjoy.
Maybe in the earlier phases of their growth they
were accountable to their funders, or there might
have been the danger of their funds being stopped.
But as their fame and "success'' increased they
have now got a ' carte blanche" on funding. Often
no major uncomfortable questions are asked of the
project holders nor are any but the barest stipula
tions made of them.
The project holder is theoretically not answer
able to the people whom he has set out to serve.
The people are not told very much about programme
budgets, policies, apart from what is necessary for
their day to day functioning. Yet the project
directors, particularly in the early years of their
work, have shown a sense of responsibility to the
rural poor, perhaps because of their basic ideali
stic motivation. Nevertheless there is very little the
people can do about changing policies, today. They
are not taken into account.
As for the lay public, they could not care less
about what goes on at these projects. The Gove
rnment of India, had an uneasy relationship with
such organisations earlier but now seems keen on
formalising it. Toward this effort recently it was
announced that henceforth all foreign funds to such
projects would require central government clear
ance. Even if this is implemented strictly, the way
this money is spent would be entirely decided by
the project directors. Thus these directors have the
field to themselves. A method of operation which
does not have an inbuilt system of checks and
balances is very likely to lead to absolute control
by those in charge. This is not very healthy for
those around them or for themselves.
The same authoritarianism also makes the pro
ject directors hypersensitive to criticism. They have
received such accolades from the press, both nati
onal and international and are proud of their
achievements, so much so, that they will put up
with little criticism. A group of doctors wanting to
do a critical evaluation of the Jamkhed project in
1980 were very specifically told that their report
would have to be okayed by Dr. Arole before it
went to the press. Such behaviour is but a symptom
Socialist Health Review
of the malady but this too proves harmful to the
project in the long run.
Cosmetic Changes, Not Structural : Why?
It is true that in all these projects, it is clearly
recognised that the prevailing ill health is due to
the socio-economic backwarndness of the area. As
a result the project directors have become concerned
about the general betterment in the living condi
tions of the people apart from providing health
care. Yet these efforts in the form of economic
loans, agricultural inputs etc. described earlier are
only superficial, cosmetic changes which do not bring
about structural change. At the most they tempor
arily lull some people into believing that ''something
is being done''. In the long run as we shall see.
they do more harm than good. The dependency of
the target population on the project increases
Worse still, those among the poor who do get
benefits from the projects, are envied by those
who do not — this is as true of every one of the
four projects described as of other such projects.
In fact, this sometimes leads to village feuds. While
at GK I was told of a case where non-beneficiaries
implicated a beneficiary in a police case. The conflicts
in the fragmented, caste ridden village situation
thus get further aggravated by these efforts.
Such a superficial approach to the solving of
deeprooted rural problems is particularly difficult
to understand from people like Choudhary or Kurien
who, considering their background, ought to have a
clearer perception of the interplay of socio-political
forces in society. One is naturally led to speculate
on what could be the influences which result in
this deviation from their original goal. Four possible
reasons could be :
(1) Constraints placed by donor agencies — despite
their easy relationship with donor agencies today,
these directors must have had certain conditions
laid down for them in the early days of their
effort. Perhaps it was tacitly made clear, that any
attempt at fundamental change would not be supp
orted. For example, in the earlier phase CROSS did
try to organise the rural labourers. Gradually this
activity stopped or was sporadic, over a small
area, with the director being careful not to be
present on such occasions. The donor agencies
could perhaps have had a direct influence on the
petering off of the radical approach.
(2) The reason for sticking to cosmetic change could
also be that the radical approach is too demanding,
too risky to be sustained over a long period. Most
September 1985
workers within such organisations join for ' emplo
yment" and a "living wage'' and not because of
their 'commitment to a cause". They are, therefore,
not too willing to risk their lives for the villagers
they are supposed to represent. This is not to say
that it has never happened. One paramedic at
GK was, in 1976, murdered by the local people
who were opposed to the change he was trying to
bring about. Possibly there are other minor instan
ces of acts of courage in other projects too, but, as
the years go by, one gets to hear of few incidents
of actual struggles with the local powers. As menti
oned earlier the risk to one's life and sustainance
of the project, is too great.
(3) Thus we come to the next factor in this tie-up —
that of the groups gradually taking care not to
antagonise the forces in power. There even appears
to be an understanding among the local power
groups the police and these organisations that each
will leave other alone. The status-quo remains and
basic change fails to occur. There is the example
of a coordinator at CROSS who, with the blessings
of the director, employs unpaid bonded labour on
his farmlands, while he gets a salary from the
organisation, for the "upliftment of the poor''.
(4) These experiences have not in any way led
to any deeper analysis of the problems which these
projects both face and create. Or if such an ana
lysis has been made none of the projects have
acted upon it. Just as the different departments
within the government have come to function inde
pendently of each other, inspite of knowing the
need for inter-departmental coordination, so too on
these projects the directors have had to narrow
down their efforts to chiefly providing health care
and superficial changes or things would become
too difficult for them. All efforts at radically chan
ging the health situation, has to remain at the
verbal level. One would find that since it is so, once
these directors withdraw from the area, the health
situation in 5-10 years time would most probably
revert to what it used to be before the doctors
took over.
Models Which Are Not Replicable
The next major issue, is that of the replicability
of these projects. It is not possible to replicate
any of them unless one is an Arole, John or
Choudhary. Sheila Zurbrigg points out that the
success of the Jamkhed project led the Govern
ment to implement the Community Health Worker
(CHW) scheme at the Primary Health Centre level
in 1978 (Zurbrigg, 1983). And this was, as is
87
established today, a failure — for one thing the
"essential ingredient of the 'model' project— a rela
tionship between village level health worker and his/
her community based on trust, committment and
accountability to the poor village families'* — was
missing. This led her to ask, ' If the essential
relationship of a CHW approach is therefore doomed
when placed within the caste-class structure of
society, what possibility is there for effective broad
replication of the locally successful 'model pro
ject? '(Zurbrigg, 1983). Similarly the present medical
education does not generate, in doctors, any sense
of commitment to the poor or their health problems.
The medical system too, on the whole does not
cater to the needs of the rural areas, much less
the rural poor. Thus any question of the replica
bility of such projects is moot.
Related to this is the growing dependence of
the people in a project area. When a project like any
of these gets established its continued effectiveness
over a period of time becomes heavily dependent
on the presence of the individuals who started them.
None of the projects functions in a manner which
will enable it to carry on as before if the 'leader'
were not there. The people in the project areas
become dependent on them and their sustainance
depends on the project. Even the health workers
are rarely allowed to work independently (though
some senior paramedics do so, to a certain extent,
at Savar). As Prem and Hari John admit, "Of
course, two independent control mechanisms do
exist in the programme, more to see the effecti
veness of the VHW than to ''supervise" " (Zurbrigg,
1983). This inability to give up control becomes a
decisive factor in determining the eventual nature
of the project. This is the tragedy, that inspite
of setting out to establish a people's project, even
after a decade of work, the people cannot, or are
not seen as being capable of running their own
project.
Together with this is the notion of self-sufficien
cy. There has been a time in all the projects where
there was some talk of making the project selfsufficient. Initially, at CROSS the idea was that
the economic loans given to the poor would be
returned in full and with this pool of money thus
generated, fresh loans, without outside help, could
be made. This could be done in several areas and
gradually the economic loans programme could
become self-sufficient. But this idea was not seen
through and gradually the talk of self-sufficiency
died down. With so much foreign funds available so
easily where was the need to learn to be independent?
88
Here
it must
be said
that perhaps a health
project is difficult to sustain without funds — as some
others have learned to their cost. But it is not
impossible (Werner 1978). Even assuming that a
certain minimum of funding is necessary, surely
some attempt to generate it locally could be made?
It is interesting to note that this notion of selfsufficiency does bother Drs. Prem and Hari John.
Thev however manage to side-step it, though not
very convincingly, by saying "We had this problem
until we realised that "Self-sufficiency'' referred to
the project, while what we were aiming to build
at the community level was self reliance". We were
working towards building community capability in
health care and hence self-reliance" (John-John).
How can a people dependent on a project that is
not self-sufficient, be taught to be self-reliant?
Another trend manifest in these circles today is
the development of jargon and "management"
techniques. Thus CROSS hasa management consul
tant on call to tell them about "systems analysis" and
"strategy planning" and so on, to help alleiviate
rural poverty — the old methods having tailed
perhaps the new will succeed. Terms like 'inter
sectoral integration",
"integrated
community"
approach and so on are bandied about. They do
this more, it would seem, to please the elite they
interact with and ihe donor agencies, than to help
solve any rural problem, for it is hard to believe that
these founders still do not acknowledge that the
essential question is one of sharing of power and
its fruits by all.
What now ?
These projects have come a long way in the
last 10 years — there were several points along the
way where things could have changed for the better.
But this was not to be. Now after having a positive
impact on the health status of the people, their
continued presence in the area is only likely to create
fresh problems, as we have seen. It is time now
that they either decided to gradually withdraw or
radically change their strategy. The passing years
have proved thatthese miniscule efforts do not really
make any impact on the total health situation. They
would be far more effective today if they undertake
organising work among the rural poor and see that
they demand that the existing government health
facilities be made available to them.
Sumathi Nair
H N. 1-1-298/4 Ashok Nagar,
HYDERABAD 500 020.
References
Arole, Raj. Medico Friend Circle Bulletin no. 45, January 1980.
John, Prem and John, Hari. The Evolution of a Community-based
programme in Deenabandu Contact, no 82 p. 4,1,6,8.
December 1984.
Zurbrigg, Sheila. Rakku's Story - Structures of ill-health and the
sources of change. Sidma Offset Press, Madras.
.
Werner, David. The VHW — Lackey or Liberator ? Medico Friend
Circle Bulletin no. 25, January 1978.
Socialist Health Review
DIALOGUE
Work and Health : An Alternative Perspective
Bharat Patankar and Jogen Sengupta
The "work and health" question (SHR 1:3) is a
historically specific one. Its meaning has changed
with changes in the social structure. There are
societies which do not face this problem at all. All
these aspects of the problem have to be considered
in formulating strategy and action in today's context.
There were societies which did not face the
question of "work and health". These were societies
which "work" is not defined in state, class,
patriarchal, race or caste terms. Their vestiges exs't
today. Not only that but in them "work" is not
regarded as "struggle" with nature or an attempt
to master nature. When male and female human
beings think of themselves as part of nature and live
and act accordingly, they cannnot separate "work"
from play or pleasure. Appropriating from nature
external to rhem does not become a thing separate
from lively and creative intercourse with it. So the
risks, hazards and dangers could not be considered
as "work and health" issues, but as part of the
total life of human beings along with nature.
Work and life got decisively separated from and
turned against each other only after patriarchal,
statist and class domination emerged. Casteist and
later racist domination became part of these. It is
only from this point that human existence and the
enrichment of it becomes seen as a struggle with
external nature, an attempt to achieve mastery over
nature. It is only in such societies that the problems
of health becomes seen as one of ''work and health".
In these societies the life of the majority is
decided not by themselves but by the stale, males,
dominating classes, castes and races. Once 'work"
got separated from other life it became the first health
problem, giving rise to unhappiness and a sense of
subjugation. This alienation was the first and
greatest problem of "work and health", causing
basic ill-health whether work contains other risks,
hazards and dangers or not. People working under
such conditions could not feel that part, the
work
part, of their lives as their own. Or
they internalised this ill-health and became dehu
manised apart from the attempts of struggle they
gave against these conditions. This major aspect of
ill-health because of work will remain in our lives
until the end of various hierarchical subjugations
September 1985
and alienations from remaining nature, no matter
what changes take place in the technology. The
nature of this ill-health has taken various forms
depending on changes in the social structures.
Technoloy is not separable from the process of
subjugation of the people who work with it. It is
not free from the type of relations of humans with
nature. Its structure internalises these relations. The
particular kind of technology we are experiencing
today which is destroying the ecological balance and
creating disastrous health problems for people
working with it shows these internalised social
relations. The fight against ill-health and the
hazards of "modern technology" cannot simply
mean dislodging the ruling class which controls it
but a fight against all the practices and social
relations which structure it.
Patriarchy and the sexual division of labour
create distinct health problems for women and
children. This happens not only in the fields and
factories but also in home work (which is not
considered work at all in the male chauvinist
culture). This problem of work is related not only
to surplus value creation and technology but also
to specifically sexual and patriarchal relations. With
out a study of this aspect of "work and health"
one cannot deal with the ill-health of a majority of
the population.
Casteist social division and division of labour
have been creating problems of health related to
work for more than thousands of years in India.
Apart from class divisions, these forced the majority
(in some cases a minority) of the people to do work
which obviously creates health hazards and traumas
of all kinds. Today, even wrapped in capitalist rel
ations of production on a wide scale, casteism and
racism are creating specific problems related to work.
Class and state domination is both a part of
this picture and a major factor in themselves creating
ill health related to work. While it is true that these
dominations are very much concerned about extra
cting surplus or surplus value, it is not the sole
concern they have. Whether capitalists or the state
will spend resources for reducing health problems at
work also depends on their concern to maintain
their continuing existence as dominating sections.
At certain conjunctures they might even bear losses
89
or
invest in "non-profit-creating" measures to
maintain health in the long term interest of appropri
ating surplus or surplus value. Such actions might
be deceptive for anyone who sees the picture only
as one of "continuous greediness to increase
surplus value no matter what happens with the
workers’ health."
Today the new movements of ecology, health
and safety groups in the unions, workers' control
and grass-roots democracy, various kinds of peoples'
science movements, women's health groups and
so on are bringing forward studies and practice
helpful to this question Many left groups are
becoming conscious of this aspect and trying to act
accordingly. These are important advances and close
coordination of all the movements, unions, organ sations of the rural poor community organisations,
cultural organisations will deepen and extend this
movement. It will be a movement that may start
with efforts to reduce ill health in fields, factories
and homes, but it has to fight to abolish class, state,
caste, and patriarchal domination along with abol
ishing the technological monstrosities specific to
these dominations. This only can establish harmony
with nature and abolish ' work" itself, the first and
basic cause of ill health.
Bharat Patankar
At Kasegaon
Dt SANGLI
Maharashtra.
Need for Population Control Cannot Be Ignored
Vrijendra
The editorial perspective (SHR, 1: 4) by Manisha
Gupte does an excellent job of summarising the
marxist critique of Malthusian view on the 'problem
of population'. However, the perspective gives
rather an incomplete picture of the situation. It is
true that the ideology of population control, as
preached and practised in the poorer countries of
the world, is primarily used to divert attention from
the real issues and factors behind poverty and other
related aspects of life for a vast majority of people.
The perspective fails to adequately emphasise
the well established fact that in the experiences of
today's developed market economies, the changes
in the family size and population structure since
Industrial Revolution followed a rise in living
standards of population. It was also significantly
affected by a host of legal and institutional
measures adopted by the goverment of the day as
the needs and priorities of
the
ruling classes
changed. This, of course, only enforces the view
that population control is a consequence of the
development process and cannot be a substitute
for necessary strutural changes in a system where a
tiny minority is the prime beneficiary of the process
of development.
Another important aspect that should have
been reflected in the perspective is related to the
changes in the pattern of population growth in the
centrally planned economies of Eastern Eurpe,
USSR and China in the last few decades. One does
not have to agree with the details of alternative
systems there to recognise the effectiveness of
90
medical system in these countries and its impact on
their population growth.
The idelogical misuse of the family planning
and population control by the ruling classes in
various countries of the world should not detract
anyone from the possible disturbing effects of
continuing high rates of population increase in
large parts of the world. Again, one does not have
to be a neoMalthusian to say that, unlike the
historic experiences of the developed market econmies which could afford the 'natural' adjustments
in their population growth and structure spread
over a long period, the world as a global entity
has to take cognizance of the natural resources
and their potential growth as well as limits to
growth as the global population continues to in
crease. Family planning and population control
must constitue an explicit objective of any meaning
ful strategy of development. Population control
cannot be a substitute for development; develop
ment without measures to check population growth
is not likely to be very meaningful either.
I am quite surprised to see the benefits of birth
control and contraceptives only briefly discussed
under the sub-title of'the feminist perspective', as
if there were no socialist perspective of birth control!
I am sure the author views the feminist perspective
as integral to the socialist perspective, but she fails
to clarify that benefits of birth-control and contrace
ptives have much wider implications for the society
as a whole and must be recognised as such, apart
from their effect on sexual mores of the society.
Socialist Health Review
Women, for obviovs reasons, are the direct (actual
and potential) beneficiaries of the various methods
of birth-control.
They also are, as a result
more
prone to various,
at times dubious,
experiments in the field. But, quite surprisingly,
again, the author has not even mentioned the
the politics of number in relation to birth-control
for men.
Another issue that deserves mention : I am
greatly disappointed that a magazine like SHR does
not have any leading feature on the health issues
and the peoples' right to know potential and actual
hazards to their health, associated with industries in
which they either work or which are in the vici
nity of their homes, except for a note-like article
by Anurag Mehra. I am sure that despite your prior
commitments, Bhopal tragedy deserves more impor
tance than has been hitherto accorded. I hope your
next issue on 'Health and Imperialism' will more
than compensate for this omission and will also
focus on the implications of this tragedy for the
peoples' right to health and safety in addition to
its other aspects rooted in the political economy
of industrialisation in the poor countries of the
world. And finally, hearty congratulations for timely
production of SHR.
17 March. 1985.
Vrijendra
A2/26, SEEPZ Staff Quarters.
Andheri (east). Bombay-400 093.
Criticism of Tubectomies Unscientific
Anant Phadke
A frontal attack by Sucha Singh Gill in his
Politics of Birth Control Programme in India (SHR I : 4)
though not comprehensive enough, was very much
n eeded. But he goes too far at the end of his article,
and makes some very sweeping statements which
can not stand a little deeper probing. The way he
attacks and rejects tubectomies as a method of
sterilisation is unscientific. It is superficial to criticise
tubectomies by just saying that after tubectomies
"back-ache, pelvic pain and other problems make
the women chronically ill. In a survey conducted in
Punjab, more than 80 percent of women complained
of one or more problems after operation " There is a
lot of literature on complications, complaints after
tubectomies and it is widely known that many
women wrongly attribute many of their health
problems, particularly back-ache to tubectomies. A
survey merely reporting what women felt after
tubectomies is too insufficient a basis for a swee
ping criticism of tubectomies. A correct argument
would bo to point out that though incidence of
complications due to tubectomies is not high in
absolute terms, tubectomies should not be pushed
when far more simpler and safer method of sterilisa
tion is available for the male. Since the government
and the medical system does not want to attack
the patiiarchy in the society, <they themselves help
perpetuate it) it is pushing tubectomies, when in
reality it should be used only in exceptional
circumstances.
Gill's reasoning that birth control programme
is "a serious attempt by the rulers to reduce the
number of their enemies in order to reduce the
risk to their oppressive regime" is quite off the mark.
Increase in the number of pauperised population
does not increase the chances of social revolution
or even a revolt. It is the contradiction between
developed capacities, aspirations of the people (as
a result of capitalist development) on the one hand
and their actual suppression (especially in periods
of crisis) due to capitalist social relations that create
possibilities of revolution.
Gill does not take into account the role of
patriarchy in deciding the size of the family. The
necessity of having male children; non-cooperation
of husbands in family planning (both consequences
of patriarchy) contribute to a larger size of the
family even when women do not want more
cnildren. (In India every year, about half a million
women undergo medical termination of pregnancy
and about four to six million undergo abortion
through unsafe methods which kill thousands of
women every year. This shows that they many
times do not want pregnancy.) It is true that unlike
in middle and upper class families children in toiling
classes do contribute to family's income. But they
probably consume more than what they produce
since upto the age of atleast three years they
consume on an average, about a quarter (in terms
of calories) of what adults consume without being
able to contribute in production. Slightly older
children look after younger children and spare adults
tor outside work. But the point is—was there a nece
ssity of having this younger child in the first place?
High infant mortality and lack of old age
security are the real justification of having a some
what larger family The rest is due to patriarchy
and ignorance about family planning. Let us not glo
ss over this and indirectly justify any unnecessary
burden on women due to patriarchy ignorance...
Anant Phadke
50 LIC Quarters
University Road
Pune 411016
•if
September 1985
91
REVOLUTIONARY IN FORM, REACTIONARY IN CONTENT
A Critique of Ivan Illicit
b ekbal
Ivan lllich's contribution to the analysis of health care and the HHchian school of thought which it has
generated have contributed enormously to the strengthening of the basic tenets of bourgeois individualism.
The school's very political basis together with its regressive solution to the problem make it reactionary in
content. It serves the purposes of monopoly capita! by promoting a victim blaming ideology, an anti-tecbnoloqical mode of medicine in commodity form and advocating a tightening of the medicare belt. The article presents
a marxist critique of the basic theoretical and political postulates of UHch. It is largely based on two articles,
f Vicente Navarro's "The Industrialisation of Fetishism'' in 'Medicine Under Capitalism' (Prodist) New York, 1976,
and Howard S. Berliner's 'Emerging Ideologies in Medicine in 'The Review of Radical Political Economics'
(9:1, 1977) J.
Jn the last decade a number of books have appeared
attacking clinical medicine in fundamental ways.
Of these Ivan lllich's Medical Nemesis (Pantheon
1976) has received wide critical coverage in the
popular as well as the academic media. Although
lllich offers a highly informative and important
critique of scientific medicine, in the final analysis
he tries to suggest a reform of medicine along
bourgeois ideological lines. This leads him to con
clude that health is a function of our individual
consumption pattern, that less medical care is
better, so that working class would be better-off
(healthier) in the long run by tightening their medical
care belts.
The net impact of lllich is to serve the purposes
of monopoly capital by : (1) Diverting attention
from the economic sources of disease and collec
tively based response and advocating a victim
blaming ideology; (2) Undermining the petit bourgeois
mode of medical care delivery leading to life style
politics; and (3) Legitimising a cut-back of all
forms of medical care services.
The Roots of the Crisis
There is no doubt that modern medicine is
passing through a period of deep crisis in the
developed countries outside the socialist block.
The crisis of modern medicine reflects and is a part of
the crisis of modern capitalism. Briefly, the cause of
the crisis lies in the falling rate of profit due primarily
to increasing variable capital costs (mainly wagesand
fringe benefits) not matched by increased produ
ctivity. Resumed accumulation requires the destruc
tion of unproductive capitals and the diversion of
variable capital (including social wages) towards
new, relatively productive constant capital. Lowering
92
variable capital costs involves both the diversion
of labour and money away from the reproductive
sector (health, education, labour, welfare) and the
reorganisation of the reproductive sectors to place
them more firmly in the control of capital. The
health system has thus come under the scrutiny of
capital to reduce those costs and help expediate
the recovery process. An ideology which promotes
anti technological (hence cheap) modes of medicine
in commodity form is advantageous to capitalist's
efforts to lower the costs of labour.
During periods of economic expansion and
explicit class struggle, capital has been forced to
provide greater medical care and preventive services
for workers (raising its variable capital costs). As
accumulation slackens the need to reduce those
costs of reproducing labour heightens. As the costs
of capital rise through expanding medical techno
logy and through inflationary medical care reimbur
sement systems, without concomitant gains in terms
of productivity, capital seeks to lower the level
of health care provided. This struggle takes an
added significance in a period of severe economic
crisis.
Victim Blaming Ideology
As capitalism progresses and leaves increas
ingly dire health hazards in its wake, the technolo
gically-oriented system of medicine tends to mask
the origin of that morbidity by treating illness as
an individual disorder through the use and pur
chase of commodities. Increases in disease morbidity
and mortality and the increasing recognition that
they are directly attributed to the capitalist
mode of production cause concerns for capital on
two distinct levels. It brings the legitimacy of
capital into question at the point of production
Socialist Health Review
as workers become more concerned about the effects
of the production process on health, and it greatly
increases the costs of providing medical care as
workers spend more time off the job going through
elaborate radiological, chemical and surgical thera
pies. The economic crisis exacerbates this struggle
and thus capital tries to shift the responsibility
for disease back to the worker —in this case through
the promotion of victim blaming ideology—and of
individual solution for the worker defusing the class
aspect of the morbidity.
Victim-blaming is not a new ideological response by
capital It has been used in education, welfare and even
in health before, //hat is especially significant about this
new wave is that, there is a chance that victim-blaming
strategies may become the basis for public policy. In the
west the popular media have been devoting a
growing amount of space to life style changes and
their positive contributions towards health. It is clear
that this victim blaming epidemiology is getting
wide circulation and acceptance.
Ideology of Industrialism
lllich is an articulate theoretician of the most
prevalent and influential ideology used to explain
our societies; i. e. the ideology of industrialism. The
primary characteristic of that ideology is that
the production requirements
of
the
techno
logical process and Pari Passu (at the same
rate) of industrial organisations are the most
important determinants of the nature and form of
our western developed industrialised societies. In a
fatalistic and almost deterministic way the former, the
technological process, leads inevitably to the latter,
the industrialisation of society. Moreover, according
to the theorists of industrialism industrialisation has
transcended and made irrelavant and passe the
categories of property, ownership and social class.
Indeed ownership loses its meaning as legitimisation
of power. And control, now assumed to be divorced
from ownership has passed from the owners of
capital - capitalists - to the managers of that capital,
and from there to the technocrats.
A final characteristic of industrialism is that it
claims to be a universal process. In other words all
societies regardless of their political structure, will
evolve, according to the dictates of industrialisation.
Indeed, according to a key component of that ideo
logy, the theory of convergence, all societies will
progress towards the urban industrial model of the
future. Thus, socialism and capitalism are usually
seen as two convergent roads to the same destin
September 1985
ation - the industrial model. Viewed in this way, the
social problems of capitalist societies become not
the problems of capitalism (an altogether passe cate
gory) but the problems of industrialisation.
lllich believes that industrialism is the main force
shaping our societies and that unavoidable and
irreparable damage accompanies industrial expans
ion in all sections, including medicine, education
and so on. The industrialisation of medicine leads to
the creation of a corpse of engineers — the medical
profession — comparable to the technocrats of the
main social formation of industrialised societies, the
bureaucracy. Thus, the industrialisation of medicine
means its professionalisation and bureaucratisation.
And lllich believes that capitalism and socialism
are
indeed
outmoded
concepts
since they
are basically converging towards the same path of
industrialisation that overwhelms and directs their
social formations. In this interpretation, then, the
class conflict has been replaced by the conflict
between those at the top, the managers of the bure
aucracies indispensable to the running of an indu
strialised society and those at the bottom, the
consumers of the products — goods and services
administered by those bureaucracies. As applied
specifically to medicine, that conflict is the one
between the medical bureaucracy, primarily the
medical profession and
medical care system;
and the consumers, the patients. This antagonistic
conflict appears as iatrogenesis (damage done
by the provider) it is clinical when pain, sick
ness and death result from the provision of medical
care; it is social when health policies reinforce an
industrial organisation which generates dependency
and ill-health, and it is structural, when medically sponsored behaviour and delusion restrict the vital
autonomy of people by undermining their compet
ence in growing-up, caring for each other and agingHow can we avoid and correct this iatroge
nesis, the extensive damage done by the industrial
isation of medicine? Before stating his own solution
lllich briefly considers several other alternatives
presently debated in political circles. In discussing
solutions for clinical and social iatrogenesis, he
especially rejects the socialisation alternative that
he attributes to the equalising rhetoric of what are
misleadingly termed the progressive forces among
which he includes liberals and marxists. According
to his normative conclusion, the redistribution of
medical care implied in the socialisation alternative
would make matters even worse since it would tend
to further medicalise our population and create
further dependencies on medical care. According to
93
Illich ''less access to the present health system
would, contrary to political rhetoric, benefit the
poor”. In that respect Illich finds the creation of the
National Health Services in Britain as a regressive not a
progressive step.
Instead of socialisation and its implied redistri
bution Illich recommends the following solutions for
clinical and social iatrogenesis. The mode of pro
duction in medicine should be changed via its
deprofessionalisation and debureaucratisation. He
suggests that licensing and regulation of healers
should disapoear and concerns of where, when,
how and from whom to receive care should be
left to the choice of the individual. Collective
responsibility for the health care should be reduced
and individual responsibility should be maximised.
Self-discipline, self interest, and self care should
be the guiding principles for the individual in
maintaining his health. In summary, each one should
be made responsible for his own health.
As for the structural iatrogenesis, he again
dismisses the alternative of socialisation and public
control of the process of industrialisation, reco
mmending instead the reversal of that process ie.
breaking down the centralisation of industry and
returning to the market mode. The essence of his
strategy for correcting structural iatrogenesis, then
is an anti-trust approach with strong doses not of
Marx or even Keynes but of Friedman.
A major weakness of his evaluation is that he
takes as an indicator of the effectiveness of medical
care, indicators of cure. Indeed, he seems to confuse
care, with cure. And in evaluating the effecti
veness of medical care he does what most clini
cians do; he analyses the degree to which medical
intervention has reduced mortality and morbidity.
In other words the effectiveness of health care
intervention is analysed in terms of curing disease
and avoiding mortality. But the limited evidence
available indicates that medical care may reduce
disability and discomfort in peoples' lives. For that
taking care to occur, our medical care system would
have to change very profoundly to better enable
the system to provide that care. Still Illich does
not seem to accept the possibility of creating another
system in which the priorities would be opposite
to those of the present ones, with emphasis given
to care as opposed to cure service. Actually, Illich
would not even welcome such a care-oriented system
since it would increase the dependency of the
individual on the physician and on the system
of medical care, preventing the much needed
self-reliance and autonomy.
Illich considers social iatrogenesis, the addictive
behaviour of the population to medical care, to be
94
the result of manipulation by the medical bureau
cracy. He postulates that the consumer behaviour
of our citizenry is primarily determined by its mani
pulation by the bureaucracies created as a result of
industrialisation. The manipulation of addiction co
nsumption and by bureaucracies (including medical
care bureaucracy) is not the cause, as he postul
ates, but the symptom of the basic needs of the
economic and social institutions of what he calls
industrialised societies, the industrialised capitalist
societies. Those bureaucracies, are the mere sociali
sation instruments of those needs ie. they reinforce
and capitalise on what is already there—the need for
consumption, consumption that reflects a dependency
of individual on something that can be bought, either
a pill, drug, a prescription or a car.
Actually those dependen cies are mere symptoms of a
more profound dependency that has been created in our
citizenry not by industrialisation but by the capitalist mode
of production and consumption - a mode of production
that results in the majority of men and women in
our societies having no control over the product
of their work, and a mode of consumption in
which the citizenry is directed and manipulated in
their consumption of the products of their work.
This dependency on consumption—this commodity
fetishism—is intrinsically necesssary for the survival
of a system that is based on commodity produc
tion. In the medical caresystem in capitalist system
we find that (a) the alienation of the individual in
his world of production leads him to the sphere
of consumption of health services and that (b)
the medical care bureaucracy is just administering
those disturbances created by the nature of work
and the alienating nature of the capitalist mode
of production.
Illich finds structural iatrogenesis to be due to
the culture of industrialisation. His solution for that
iatrogenesis includes breaking down the industrial
bureaucracies, and returning to self-reliance and
enlightened self-interest. But by focussing on the
medical bureaucracy as the 'enemy', Illich misses the
point because those bureaucracies are the servant
of a higher category of power - the dominant class.
In the health sector power is primarily one of class,
not of professional control. Indeed, the medical
bureaucracy administers but does not control the
health sector. We find then that the main conflict
in the health sector replicates the conflict in the
overall social system. And that conflict is primarily
not between the providers and consumer, but
between those that have a dominant influence in
the health system (the corporate class and the upper
middle class) who represent less than 20 percent of
(Contd. on page 100)
Socialist Health Review
DUST HAZARDS IN COAL MINES
A Brief Overview
amalendu das
The global energy crisis of the last decade has provided an impetus to the development of coal resources
which has, in turn, meant large scale indiscriminate mechanisation programmes. These have had disastrous
consequences for the health of miners. The article highlights some of these health hazards which are being
largely ignored by both the mining industry and the trade unions.
r
Of late the management of our nationalised coal
industry has laid considerable stress on promot
ing the production of coal. And to achieve this end
large scale mechanisation with borrowed foreign
technology has been adopted. Critics from the Trade
Union front have correctly identified the drawbacks
of such a plan of reckless mechanisation. Lack of
employment generation, high overhead cost that
erodes the benefit of the economy of scale, depen
dence on foreign countries for spare parts of the
machines are the important aspects of their criticism.
But one important consequence (perhaps the most
vital one) of reckless mechanisation seems to have
escaped the attention of all concerned. This is the
problem of health hazard which is increasing at an
alarming rate.
It is unpalatably true that hazard has been
synonymous with the term coal mining in India. The
risk of fatal disasters to which the coal miners are
exposed to is as great today as it has been during
the days when coal mines were owned privately —
Chasnala (1975), Jitpur (1978), Hariladih (1983)
disaster. The introduction of sophisticated machines
has in no way reduced the chances of such accid
ents. But that is a different story altogether. Here the
attention is intended to be drawn towards that
kind of hazards which silently, slowly and steadily
shorten the life span of the miners, or make them
physically disabled even when there is no massive
disaster in the mines.
Coal mines are inherently unhealthy places to
work. Not only in underground mines, but also in
open cast quarries where giant earth movers are
used, the workers inhale large amounts of dust,
fumes and gases which cause many killer diseases mainly respiratory in nature. They include influenza,
asthma, emphysema, stomach and lung cancer,
hypertension, Pneumoconiosis and bronchitis. The
most fatal of all respiratory diseases is Pneumocon
iosis commonly known as black lung disease which
is incurable. (See SHR : I : 3, December 1984).
September 1985
It is caused by the inhalation and retention
of respirable coal mine dust m the lower lungs.
A noticeable dose-response relationship usually
appears when exposure continues for a decade or
so. Coal worker's pneumoconiosis is classified into
levels of ascending severity from simple to compli
cated by X-ray diagnosis. Continuous dust exposure
can accelerate a case of simple pneumoconiosis to
more advanced stages. Miners with progressive
massive fibrosis are usually totally disabled. If the
dust concentration is still higher, emergence of pne
umoconiosis is earlier. Some miners seem to be more
vulnerable than others and this vulnerability is yet
to be explained. Habit of smoking appears to have
no significant role in causing pneumoconiosis among
the miners. It certainly contributes to lung impair
ment to a miner as it does to any non-miner. It
has been established with a fair amount of certainty
that it is dust, be it coal or otherwise, which can
cause pneumoconiosis among the miners. So dust
is identified as the greatest hazard.
Dust may be looked upon as suspended solid
contaminent in a state of minute subdivison present
in the air. It is produced during various indust
rial activities like blasting, grinding, drilling and
crushing or whenever any material used in industry
undergoes disintegration. Such operations enhan
cing the occurance of dust are too common in
coal mining industry. As the material undergoes
progressive disintegration it acquires certain proper
ties which has killer significance with regard to
health of those exposed to its action. The very
minute size (0.2-10.2 microns) itself confers it
high reactivity both chemically and biologically
and it becomes more toxic than its parent lump
from which it has been disintegrated. These tiny
particles once air borne can neither be swept off
nor trapped by existing technical means. It is
estimated that one cubic meter of a coal lump,
after progressive disintegration may form 10l-parti
cles and eventually spreads through 283 million
cubic centimeter of the working environment.
95
Because of its small size these dust particles do not
settle down and remain suspended in the air for
quite long time.
It is quite natural, therefore that the various
operations at the mechanised coal mines not only
generate more dust but they reduce the size of the
dust particles to a minimum. And these tiniest parti
cles are more dangerous. Scientists have estimated
that particles which are retained in the alveoli, the
gas exchanging sacs of the lung
weigh 5 micro
grams or below. These particle are termed as respi
rable dusts.
Generally the larger particles (nonrespirable
dust) do not penetrate the alveoli and are not
thought
to
cause
pneumoconiosis.
While
the
distinction between
respirable and non
respirable dust is scientifically valid, it is clear that
both sizes can impair lung functions when inhaled
in quantity over time. The larger particles are prob
ably linked to bronchitis among the miners. Althou
gh these particles are generally not retained in the
lung, continuous exposure to them during normal
work year produce more or less constant irritation of
the upper respiratory tract. Breathlessness has also
been found to be significant among miners who do
not show X-ray evidence of pneumoconiosis. Rese
archers believe the breathlessness is related to chro
nic non specific obstructive pulmonary disease.
Some investigators have found, in addition to pneu
moconiosis and broncho-pulmonary disease, a third
as yet unidentified disease process that reduces the
ability of the lungs to exchange gases.
Black lung disease has come to represent a
broad definition of occupational respiratory dis
abilities in miners of which coal miners' pneumo
coniosis (henceforth referred as CWP) is one major
component. Respirable dust which is invisible to
the unaided eye accounts for less than one percent
of the dust in a mine. It is not clear how much non
respirable dust is retained in the lungs when the
standards for respirable dust (if they exist at all)
are being met.
Along with CWP, coal miners will continue to
experience other lung diseases— bronchitis, severe
dyspnoea (shortnesses of breath) and airways
obstruction. Many of these illness are work-related.
Coal mine dusts contain a wide range of non-coal
constituents
including
silica and naphtalenes.
Researchers have found as many as 13 Polynuclear
Aromatic Hydrocarbons (PAH) in the respirable
mine dusts they had studied. (Shultz, Fridel and
Sharkey, 1972). PAHs are tested carcinogens.
Besides trace elements that are mentioned above
there are a host of other elements listed as'hazardous
elements
which are liberated as dust or gas
96
in the place where coal is cut from the working
face. These hazardous elements are identified as
Arsenic, Beryllium, Cadmium, Fluronine, Lead and
Mercury. It is worthwhile to mention here that a
mine producing one million tons of coal generates
one ton of each element annually. These elements
may have a role in producing black lung disability
either alone or synergestically. They may also play
a role in the excess lung and stomach cancer found
among the coal miners
Diesel powered equipments are commonly found
in all the mechanised coal mines throughout this
country. Diesel engines produce emissions that are
known to be hazardous, unburnt hydrocarbons,
oxides of nitrogen, particulates, PAH, phenols,
aldehydes, oxides of sulpher, trace metals, Nitrogen
compounds, smoke and light hydrocarbons many
of which cause adverse respiratory effects.
Noise is a proven hazard to the miners working
in a mechanised mine. Noise may cause temporary or
permanent loss of hearing sensibility, physical and
psychological disorder, interference with speech
communication or the reception of other wanted
sounds and disruption of job performance. Excess
ive noise may also cause changes in cardiovascular,
endocrine, neurolgic and other psychological functi
ons. Studies on the subject indicate that coal miners
have miserably worse hearing than the average.
CWP and other work related disease in coal
mines have been recognised as the subjects of largescale investigations in countries like USA and UK
and this recognition came through relentless stru
ggle of the workers themselves. A physician Dr.
Lorin Kerr who is also the representative of the coal
miners of America voiced his alarm against CWP
"At work, you (coal miners) are covered with dust.
It is in your hair, your clothes and your skin. The
rims of your eyes are coated with it. It gets between
your teeth and you swallow it. You suck so much
of it in your lungs that until you die you never stop
spitting up coal dust. Some of you cough so hard
that you wonder if you have a lung left. Slowly you
notice you are getting short of breath, when you
walk up a hill. On the job you stop more often to
catch your breath. Finally just walking across the
room at home is an affort because it makes you
so short of breath. (Kess, 1968.)
We do not have any Dr Kerr to lament for
our miners. Our miners are not even aware of
such a fatal disease. As the detection of CWP is
difficult in the initial stage without powerful X-ray
examination (the facilities for which is non-existent
in our colliery hospitals) the miners who suffer from
shortness of breath or exhaustion are often wrongly
treated.
Socialist Health Review
The author has encountered several such cases
in the Jharia coalfield. Kripal Chamar of Damoda
Colliery has been treated as a TB patient because
he has been suffering from shortness of breath.
Kripal was told that TB is a curable disease but he
wonders why in his case the medicine does not
work. Another miner Chanari Beldar of Kenduadih
Colliery died of TB(?) two years ago. When this trou
ble of breathlessness began Chanari used to abstain
from his work once or twice a week. He received
charge sheets and warning letters for negligence of
duty. No one bothered to enquire about the real
causes of his illness and consequent abstenteeism.
We do not know the exact number of miners who
suffer from breathlessness or other similar symptoms
of CWP among Indian coalminers. But certainly
the number is not small. Even in technologically
advanced countries where more effective dust
control methods are used and where people are
more aware of such diseases, the number of miners
affected by CWP is quite large. It was estimated
that in USA between January 1970 and December
1977,4,20.000 coal workers were awarded Federal
Black Lung compensation because of total disable
ment due to CWP. In UK, National Coal Board had
conducted a survey during 1974-77 and found that
seven percent of the British coal miners were suff
ering from CWP. In India a small scale study con
done by Dr Viswanathan in 1964 showed the in
cidence of CWP varied between 6.0 to 16.8 percent.
The situation here in India is certainly alarming.
Last decade witnessed a global energy crisis
caused by price-hike of petroleum resources cou
pled with impending depletion of the same and
this resulted in reemergence of coal as vital alter
native. Eventually its scale of production was raised,
mines were mechanised with borrowed technology
associated with heavy over-head cost in terms of
foreign exchange but a thing which was conveni
ently forgotten is the probable environmental impact.
Legislations, covering mines safety fail to add
ress the problem related to miners' health and
welfare. It appears that miners' health and welfare
as an entity distinct from mines safety is yet to
be recognised. It is equally distressing to note
that established trade unions with commendable
fighting spirit while realising economic demand are
yet to recognise this invisible monster—the fugitive
dust which slowly but steadily, surreptiously advances
forward to collect its toll among the miners Now
the question is who will cry a halt?
Amalendu Das, Central Fuel Research Institute, DHANBAD
References
Kerr, Lorin Speech to United Mine Workers of America, UMWA
Convention Congressional Record, September 25, 1968 p. 1446.
MSHA Mines Safety and Health Administration USA. The public
law 91-173 83 Sec (202) Act is basically a compensation
legislation was passed in February after a month-long wild
cat strike that idled 42,000 miners in West Virginia, USA.
Shultz, J L, Fridel, R.A and Sharkey, A.G. Detection of organic
compounds in respiratory coal dust by high resolution mass
spectroscopy Bureau of Mines, Technical Progress Report 61 ,
Pittsburg, p. 14,1972
ducted in 1960-66 by the Chief Advisor of factories
revealed that 178 (18 percent) of 2754 coal miners
who were radiologically examined were suffering
from CWP. Another random representative survey
From Pg. 83
Table - 3 :
People's knowledge of agencies for CHW selection and supervision
Category III
Category II
Category I
1
12
3
2
2
1
3
3
♦ SELECTION
No. of house holds
°/
Zo
5
90
7
13
23
6
13
26
12
4.9
88.2
6.8
30.9
54.7
14.2
25.4
50.9
23.5
18
84
9
33
25
26
17.6
82.3
21.4
78.5
49.0
50.0
** SUPERVISION
No. of house
holds
°Z
Zo
*Code for Selection
1. By Sarpanch with or without other members.
2. Don't know
3. By hospital with or
without Sarpanches.
* *Code for Supervision
1. Supervised by Hosp/PHC
2. Don't know
September 1985
Tribe caste
Table - 4 : Social IBackground of CHWs
No of HWCs
%of Total CHWs
Gonds
Baiga
Koi
Panika/Kangikar
Brahmin/Thakur
Gupta/Srivastav
Muslim
15
4
1
2
11
2
2
40.0
10.8
2.7
5.4
29.7
5.4
5 4
97
Table - 5
Relationship of CHWs with Scrpanch and other Elite in Pali Villages
(a)
Relations with present Panchayat :
Himself a Sarpanch or
Upsarpanch
Sarpanch or Upsarpanch
a cousin/uncle/inlaw/
father
1.
2.
3.
4.
5.
Kannavahra
Paharia
Dhawrai (J)
Medhi
Kathai
6.
Varmathola
1.
2.
3.
4.
5.
6
7
8.
9.
10.
11.
12.
13
Jamrhi
Bhautra
Vardhar
Makra
Khichkiri
Sarwahi
Bannoda
Karkati
Audhera
Malchua
Chaka
Gijri
Shahpur
(b)
None
Panchayat members/
Mukhias as uncle/aunt/
cousin
1
2.
3.
4.
5.
Badwahi
Odri
Sans
Maliagoda
Barhai
Not related to
Panchayat Members
1. Kanchodar
2. Jamuhai
3. Amiliha
4. Khalaund
5. Dhawrai (P)
6. Malaudu
7. Madaria
8. Manthar
9. Sunder Dadar
10. Sundri
11. Ghunghuti
12. Vadhvachhot
Relations of above with previous Panchayat :
4.
Uncle was
Sarpanch
5.
4.
Father was
panchayat member
2.
Brother was
Sarpanch
Father was
Sarpanch
3.
Uncle was
Sarpanch
8.
Uncle was Mukhia
7.
9.
Aunt was member
of Pali Zila
Parishad
Father was
Sarpanch
9.
Father was
Sarpanch
1 2.
Father was
Sarpanch
4.
Brothers as
school teachers,
railway clerks,
railway khalasi
father-railway
gangman
5.
Brothers Patwari
and rationshop
owner
12. Uncle was
Sarpanch
1 3. Father was
Sarpanch
(c)
CHWs who had relatives in other influential positions:
1.
Father was a welloff Thekedar of the
area. Brothers
Revenue Inspector
and Gram Sahayak
6.
6.
Brother school
teacher
13. Father
Thekedar
Father Patwari
Father Ranger;
brothers in army.
+ Change of Address
Radical Community Medicine, 14, Spring Crescent
Southampton SO2 IGA U.K.
98
Socialist Health Review
Table - 6 :
Land Holdings of the CHW's family and occupation of male members (fathers & brothers)
Relatives
2—5
Occupation
6
0
0
7
0
0
1
0
2
0
3
0
9
7
8
9
15.0
—
45
43.7
40
56
3 (8.3)
♦Out of 17 CHWs,
(1)
Adivasi
(2)
Non-Adivasi
17* (47.1)
16 (44.4)
11 (30.5)% owned more than 20 acres of land
Preferred action in Minor Illnesses in the intensive study villages
CHW
alone
CHW
with
traditional
medicine
CHW
with
hospital
CHW
with
private
practitioner
Hospital
only
Hospital
with
traditional
medicine
0
0
1
1.9
29
28.4
2
4.7
3
5.8
9
8.8
9
21.4
8
15.6
2
1.9
0
1
1.9
2
1.9
0
10
19.6
8
7.8
11
26.1
14
27.4
Table - 8 :
Peoples awarness of Preventive activities of CHWs in intensive study villages and his Private Practice
Total
°Z
II Total
I
%
III Total
0/
Zu
Activity
Private
practitioner
alone
Gunia
Home
treatment
10
9.8
2
4.7
2
3.9
36
35.2
12
28.5
2
3.9
6
5.8
6
14.2
6
11.7
Category II
Category I
house holds
TOTALS
102
—
42
—
51
—
Category III
1
2
3
4
1
2
3
4
1
2
3
4
1
0.9
5
4.9
24
23.5
21
49.9
1
2.3
2
4.6
18
42.8
27
56.8
7
13.7
6
11.7
9
17.6
—
Chlorination
Total
%
72
70.5
MCH
Services
Total
°/
Zo
97
0
95.0 —
5
4.9
42
100
0
—
0
—
—
—
49
100
1
—
1
—
—
—
67
5
30
—
32
0
10
—
22
2
27
_
65.5
4.9
29.4
—
76.1
—
23.8
—
43.1
3.9
52.9
—
43
42.2
29
28.4
30
29.4
—
30
47.6
7
16.7
15
35.7
—
—
37
72.5
2
3.9
_
—
12
23.5
Source of
Total
information
regarding
%
prevention
Private
practice
IV
3
0
0
Table - 7
III
5
3
2
No. of CHWs
II
4
3
Farming
.'O
I
(2)
(2)
(1)
15 acres
(1)
Farming with
employment
Wage labour
■q
over
acres
(2)
Total households
Category
5-15
acres
(1)
Codes :
Total
%
I
II
III
—
IV
1.
Don't know/He does not chlorinate wells.
1.
No
d) Neighbours, friends
and their own observation
(D
Give free medicine
2.
3.
4.
He chlorinates wells.
Ws use Jhiria/river
Chlorinates occassionally
2.
3.
Yes
Don't know
(2) = CHW
(3) — Paramedical worker
with or without others.
(2)
(3)
Charges for injections
Don't know.
September 1985
99
(Contd. from page 94)
of the population and control most of the health
institutions, and the majority of the population
(lower-middle class and
working class)
who
represent 80 per cent of the population and who
have no control whatsoever over either the produc
tion or the consumption of those health services.
To focus then as lllich and majority of social critics
do, on the conflict between consumers and medical
providers as the most important conflict in the
health sector, is to focus on a very limited and
small part of the actual class conflict.
One of the functions of the services bureau
cracies - including the medical bureaucracy - is to
legitimise and protect the system and its power
relation. One aspect of that protection is social
control — the channelling of dissatisfaction which
lllich introduces as structural iatrogenesis. But to
believe that social control is due to the culture of
medicine and the pervasiveness of industrialisation
is to ignore the basic question of who regulates
and most benefits from that control. An analysis of
our societies shows that the service bureauracies —
including the medical care ones - although willing
accomplices in that control, are not the major
benefactor. The ultimate benefactor of any social
control intervention in any system is the dominant
class in that system.
In short the major suggestion of lllich for
solving our problems is self-reliance, self-care and
autonomy of the individual - what can be described
as ’ifestyle politics. This philosophy strengthens
the basic ethical tenets of bourgeois individualism.
Moreover, the lifestyle approach to politics serves
to channel
out of existence any
conflicting
tendencies against those structures that may arise in
our society. The strategy of self-care assumes that
the basic cause of an individual's sickness or
unhealth is the individual citizen himself, and not
the system and therefore the solution has to be
primarily his and not the structural change of the
economic and social system and its health sectorContrary to what lllich and others postulate, the
greatest potential for improving the health of our
citizens is not primarily through changes in the
behaviour of individuals, but primarily through
changes in the patterns of control, structures and
behaviour of the econmic and political system. The
latter could lead to the former. But the [reverse is
not possible. Actually, it is precisely because of
the impossibility of the reverse, and thus the lack of
conflict between lllich's message and the basic
tenets of the capitalistic economic system that his
message, the lifestyle politics is and increasingly
will be presented by the organs ofthe media as the
resolution of our crisis and problem.
B. Ekbal, Dept of Neurosurgery
Medical College TRIVANDRUM
MERIND
MERIND LIMITED
New India Centre, 17, Cooperage Road,
BOMBAY-400 039.
100
Socialist Health Review
Why don't you write for us ?
This periodical is a collective effort of many individuals active or interested in the
field of health or interested in health issues. The chief aim of the journal is to provide a
forum for exchange of ideas and for generating a debate on practical and theoretical
issues in health from a radical or marxist perspective. We believe that only through
such interaction can a coherent radical and marxist critique of health and health care
be evolved.
Each issue of the journal will focus on one theme, but it will also carry (i) Discus
sions on articles published in earlier issues 0i) Commentaries, reports, shorter contri
butions outside the main theme.
Our forthcoming issues will focus on ; Systems of Medicine, Mental Health and
Health Care in Post-Revolutionary Societies.
If you wish to write on any of these issues do let us know immediately. We have
to work three Months ahead of the date of publication which means that the issue on
Systems of medicine is already being worked on. A full length article should not
exceed 6,000 words and the number of references in the article should not exceed
50. Unless otherwise stated author's names in the case of joint authorship will be
printed in alphabetical order. You will appreciate that we have a broad editorial policy
on the basis of which articles will be accepted.
We have an author's style-sheet and will send it to you on request. Please note that
the spellings and referencing style of reprint articles are as in the original and are NOT
as per our style.
We would also like to receive shorter articles, commentaries, views or reports. These
need not be on the themes we have mentioned. These articles should not exceed 2,000
words. Please do write and tell us what you think of this issue.
All articles should be sent in duplicate. They should be neatly typed in double
spacing, on one side of the sheet. This is necessary because we do not have office
facilities here and the press requires all material to be typed. But if it is impossible for
you to get the material typed, do not let it stop you from sending us your contributions
in a neat handwriting on one side of the paper. Send us two copies of the article
written in a legible handwriting with words and sentences liberally spaced.
The best way to crystallise and clarify ideas is to put them down in writing. Here's
your opportunity to interact through your writing and forge links with others who are
working on issues of interest to you.
WORKING EDITORS
Please send me Socialist Health Review for one year (four issues). I am
sending Rs.
as subscription and/or donation by Demand
Draft/Cheque. (D D. and cheque in favour of Socialist Health Review
and for cheque, add Rs. 5, if outside Bombay).
Name
Address
_____________________________________________
.___________________________
PIN
The People
(Excerpts
Pablo NeruS
That man I remember well, and at least two
centuries have passed since I saw him :
he travelled neither on horseback nor in a
carriage — purely on foot
he undid
the distances.
carrying neither sword nor weapon
but nets on his shoulder,
axe or hammer or spade;
he never fought'with another of his kind his struggle was with water or with earth,
with the wheat, for it to become bread,
with the towering tree, for it to yield wood,
with the walls, to open doors in them,
with the sand, constructing walls
and with the sea, to make it bear fruit.
I knew him and still he is there in me
Where he lived everything
a man touched would grow :
the hostile stones,
hewn
by his hands
took shape and form
and one by one took on
the sharp clarity of buildings
he made bread with his hands
set the trains running.
I think that those \p/ho made so many things
ought to be masters of everything.
And those who make bread ought to eat I
And those in the mine should have light*!
Enough by now of grey man in chains I
Enough by now of the pale lost ones !
Not another man will go past except as a ruler
Not a single woman without her diadem
Someone is listening to me and although they
do not know it,
those I sing of, those who know
go on being born and will fill up the world.
Position: 499 (8 views)