Radical Journal of Health 1986 Vol. 1, No. 1, June Health care in Post-Revolutionary Societies.pdf
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COMiW-'ITY HEALTH C ELL
47/1, (First Hear) St. Marks Read.
Bandore - 560 001,
Health Policy Under State Socialism
Epidemiology of Aggression : Hicaragua
Population Policy in China
Health Care in Mozambique
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HEALTH CARE IN
POST-REVOLUTIONARY SOCIETIES
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Number 1
1
Editorial Perspective
ISSUES IN 'POST REVOLUTIONARY’ HEALTH
CARE
Dhruv Mankad
Working Editors :
Amar Jesani, Manisha Gupte,
Padma Prakash, Ravi Duggal
Editorial Collective :
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)
3
HEALTH IN NICARAGUA
Amar Jesani
11
MEDICAL CARE AND HEALTH POLICY UNDER
STATE SOCIALISM
Bob Deacon
22
POPULATION POLICY AND SITUATION IN CHINA
Malini Karkal
Editorial Correspondence :
25
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HEALTH CARE IN MOZAMBIQUE
Padma Prakash
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39
A BIRD'S EYE VIEW OF PSYCHOLOGY
Pornima Rao
Discussion
CONTRADICTIONS WHERE THERE ARE NONE
Thomas George
Up date - News & Notes : 29
The views expressed in the signed articles do
not necessarily reflect the views of the editors.
Edito rial Perspecti ve
Issues in ‘Post-Revolutionary’ Health Care
HEALTH care system and the health status of the people, of modernisation in PR societies. Still, in the process, these
like all the other aspects of social life, have undergone societies were indeed able to meet the basic requirements of
tremendous changes in those societies where the rule of food, clothing, shelter and medical care of all the people,
capital has been challenged in a revolutionary fashion by the irrespective of their incomes and thus therefore, resulted in
toiling masses. The class nature of the forces that led the a healthier population.
revolution or of those which rule these societies at present, Better Access to Medical Services: Medical services being by
may be controversial, the direction taken by these societies and large free and extensive, are easily accessible to most
after the revolution may be criticised, but the fact that there people. One’s economic position does not prevent one from
have been dramatic improvements in the health status of the availing oneself of the best medical care available. This has
people of these societies following the revolution canot be indeed affected morbidity and mortality patterns in the PR
denied. Conventional health indicators have shown amaz societies.
ingly rapid improvement (as compared to capitalist societies
But whether the health care structure that has emerged
of comparable size, population and levels of development) is really democratic and ‘socialistic’, operated by the working
in the USSR, China, Vietnam, Nicaragua, Mozambique and class possessing the necessary skills and knowledge is a
the East European countries. These societies arc being debatable issue. There are indications to show that it is not.
categorised here as post-revolutionary (PR) societies. (We use There are strong tendencies towards professionalism and
the term ‘Post-revolutionary’ rather simplistically in place technocratic control. One also needs to assess whether or not
of the more controversial ‘socialist’, though we arc aware that a sexist bias against women exists in the field of health care
the use of this term too, is not free of problems.)
and medicine. Therefore, it is not adequate to apply only the
Several features distinguish the health care systems of the conventional health criteria to assess the nature of the health
PR societies from those of the capitalist societies. They care system and the health status in societies generally K
include, public ownership of health care institutions and recognised to be different from capitalist societies. More
allied industries like the pharmaceutical industry, (he near sensitive indicators like comparisons of differences brought
absence of privatised medical care, free or heavily subsidised about in health and disease patterns in USA and USSR (dr
health care, rationalisation of health care delivery, strong India and China), wage differentials among medical and
emphasis on the promotivc and preventive aspects, disease health personnel, the proportion of women occupying high
control by mass action rather than by biomedical interven positions, the extent of homogenisation (narrowing down of
tions alone, decentralised control, integration of traditional sex, race, class, occupational and regional differences of
systems and their practitioners into the existing delivery health and disease indices) and so on need to be applied.
system and so on. Not that all of these could be found in Only such characteristics can differentiate a developed
any one or all of these societies. For instance, emphasis on ‘socialist’ pattern of health care from that of a developed
decentralised control and self-reliance at the local level capitalist society. Whether the health care systems in PR
prevailing in China may not be found elsewhere (Sidel and societies has indeed reached such a stage is an issue requiring
Sidcl, 1982). But one or more of these are generally to be much analysis and discussion.
found in the health care systems in all the PR societies.
While noting the positive aspects of health and health care
Rapid changes in conventional health indicators in the PR societies, one cannot fail to take note'of several
characterised by steep falls in infant mortality rates; reduc features which raise vital issues regarding the nature of health
tion in morbidity due to infections like tuberculosis, malaria, care in these societies, having wider implications outside the
schistosomiasis and Sexually Transmitted Diseases (Sigerist, field of health and medicine.
J947; Alderguia and Alderguia, 1983; Quinn, F973) and
It is noticed that indicators like life expectancy at birth,
reduction in population growth rates cummulatively point IMR and others have reached a plateau and are even.
to the improvements in the health status of the people. They regressing.
have been brought about no doubt, as a result of better nutri
Also, a tendency towards overmortality of males over
tion, sanitation and hygiene, easy availability of sale drink females is noticed {International Journal of Health Services,
ing water, improvements in housing, improved facilities for 1983; Gidadhubli, 1983) due to steep increase in cardiovascular
women (as compared to those in the capitalist countries), diseases, cancer and accidental deaths. A similar
better medical care as well as better work environment phenomenon is noticed in the advanced capitalist societies
indicated by more stringent environmental and industrial also (see Doyal with Pennel, 1983). These diseases have been
safety standards (Derr et al, 1982). The two most important associated with over consumption, stress and other en
factors responsible for these improvements, can be identified. vironmental factors. Whether high incidences of such
Rapid Modernisation and Abolition of Absolute Poverty: diseases signify a life-style and an environment resembling’
Though not a uniform phenomenon in all the PR societies, those in the advanced capitalist societies or not is a ques
this has been the most important factor in improving the tion that needs to be resolved.
health of the people. This was made possible as a result of
In the USSR, an increasing concern is being felt about the
the defeat of the old bougeoisie and their allies in these rise in alcoholism. Various legal and administrative measures
societies. Now, whether the ensuing nfode/’o^tion was have been initiated to curb this problem (Lindgren, 1985)
‘socialist modernisation’ as envisaed by Marx or not is a Alcoholism is associated with psychosocial stresses. Under
moot point. Similar quantitative improvements have also capitalism, besides other factors, a lack of creative pleasure <
been seen in the advanced capitalist societies dilrihg the 19th in work, leads an individual to avenues of superficial
and early 20th centuries and therefore, they by themselves pleasures. Alcohol is one of (hem. Is a similar process still
cannot be said to be the characteristics of ‘socialist’ nature at work on an increasing scale in PR society like USSR? This
June 1986
A
rather uncomfortable question needs id be faced squarely crucial question of the relationship of a social formation and
in order to comprehend the real nature of the processes substructures thereof. Though developments in health and
affecting the psychosocial health of the people in these health care systems come under the influence of socio
societies. Another related indicator reflecting the sociop- economic factors in movement—that is of history—this rela
sychological disharmony is the incidence of mental disorders tionship is not one -to-one and deterministic. It is a highly
complex relationship of mutually dependant dialectical
and suicides.
Though quantitative indicators of health do give an idea interactions. And therefore, each problem has to be
about the health status of a society, but it does not give the understood within its specific historical and social context.
Thus, while studying health and health care in any social
total picture. It can be shown that'early development of
capitalism also produced improvements in the quantitative formation, one important point needs to be kept in mind.
indicators of health care. What it did not improve was the A ‘socialist’ health care system develops in the historical con
quality of health care: doctor-patient-relationship has become text of the process of ‘revolution’ and thus carries with it
depersonalised, the aged are marginalised; the mentally sick the stam^ of the specific processes of the society with all
are heavily drugged and dehumanised. What is the situation their contradictions. Neglecting this aspect may lead one to
in the PR societies? How and how much different is the an incorrect understanding of these societies as well as their
quality of care to the sick, the aged, the minorities, the health situations (Segall, 1983). One may be led to a narrow
women and the mentally sick from those in the capitalist empiricist position; a position which adopts a static view of
societies? What one finds would point to what could well social structures and considers the health care system existing
be an important differentiating feature of a ‘socialist’ health in a society as directly reflecting its socio-economic processes.
Taking an isolated view of the events that went into making
care system.
In a capitalist society, medicine reflects and reinforces the up the health care system in a PR ‘Socialist’ country, this
bourgeois ideology. Thus, a disease is reduced to a biological position labels whatever exists there as being ‘Socialistic’ in
phenomenon, ignoring the rolc-often a determining one-of nature. On the other hand, it may also lead one to take an
social, economic and cultural factors in its causation. Such idealist view constructing an abstract ‘Socialist’ model of
a view justifies the use of biomedical interventions causing health care devoid of any socio-historial context. Various
a growth in the demand for industries producing the required characteristics are ascribed to such a model. Out of these,
technological inputs. On the other hand, the hierarchical rela which constitute the necessary and the sufficient conditions
tionships in the medical field amongst the medical personnel, for a ‘Socialist’ health care system are unspecified. Therefore,
between doctors and patients-reflects the bourgeois ideology mere absence of a few characteristics of this idealised model,
of class, race and sex dominance. Now in the PR societies, in an imperfect concrete health care system, full of contradic
how do health planners, doctors as well as people view health tory tendencies of a PR society, leads one to label it ‘nonand disease. How are the relationships amongst various socialistic’. Worse still, it denies the possibility of waging
health personnel? These are questions of vital iriiportance struggles to incorporate some of these feature into the health
that should be resolved while assessing the health care care systems of capitalist societies.
It would not be entirely out of place here to mention a
systems of PR societies.
There have been disturbing reports of dissidents in PR related problematic of the role of struggles in a capitalist
societies being labelled as ‘behavioural deviants’ and of use* society to imparting to. the health care system, some of the
of psychotropic drugs to bring about behavioural conformity. ‘Socialist’ characters. Whether a movement for greater social
This is a blatant example of the use of ideology in medicine control over health care services and allied industries is a
to serve the political needs of a.class or a group by converting movement towadrs a ‘revolutionary’ health care system or
an essentially political issue into a medical problem. What not is a crucial question for those fighting for fundmenial
are the compulsions that such practices persist in PR societies social changes. One exteme view, might see such a struggle
is also an issue related to the question of ideology in medicine itself as a revolutionary movement thereby overlooking the
in PR societies.
overall persepctive of such a system. On the other hand, an
In some countries like Poland for instance, chronic shor equally extreme view may call such a movement as ‘refortages of drugs, equipments and staff are reported. {Interna 3mist’ as it does not touch the root-cause, thereby overlooking
tional Joyrnal of Health Services, 1983) Now whether this the vital importance of stages in the movement for ‘revolu
shortage is real, that is as related to the needs of the people tionary’ health care. Several other factors like the leadership.
or false that is as related to the needs of the socially more mass mobilisation, methods used for raising people’s ’
powerful medical profession remains to be seen. A false shor awareness, modes of organisation and struggles also need
tage could be felt if there is a tendency towards to be assessed before making any judgment. A thorough
overmedicalisation of life; by replacing community level analysis of the inter relationship of a health care system and
health care personnels and paramedics by doctors; by the a social formation would go a long way to resolve a cons
demands of doctors for more technological inputs of tant dilemma faced by those involved in such struggles.
doubtful value and so op. If the shortages are indeed real,/
a study of the underlying socio-economic processes could
reveal much about not only the. health care scene of the In this issue: Amar Jesani writes about the problems and process affec
health in Nicaragua; Malini Karkal discusses the population policy
society but also about the problems of ‘socialist’ reconstruc ting
in China and Padma Prakash draws attention to the changes brought
tion during the PR period.
about in the health care system in Mozambique after 1975. Bob Deacon’s
reprinted article raises relevant issues regarding health and health care
• in the three post-revolutionary societies. Soviet Union, Hungary and
oland. And we introduce ‘Update’ a section for reports, notes and
Now, the causes of these problems and the underlying pro comments.
Towards a Dialectical Understanding
cesses can only be understood in the context of the prevail
ing social and economic conditions of the existing social for
mation. An analysis of these problems bjings us to the very
2- •
-
—dhruv niankad
(References: see p 39)
Radical Journal of Health
Health in Nicaragua
Epidemiology of Aggression
amar jesani
Though the Nicaraguan revolution is still fighting for survival against escalating US aggression, it. has ushered
in far-reaching changes in the field of health and health care. These changes are examined in this paper. The
author refers to the role health workers played in the Nicaraguan revolution and discusses the post-revolutionary
reforms introduced in the health care system and the consequences of US imperialism's continuing war against
Nicaragua for the people's health. Health professionals, the author argues, will have to understand (he epidemiology
of war better since the world is likely to witness more revolutionary upheavals and crises as well as imperialist
aggressions.
A QUARTER of a century ago, the victory of the.'socialist
revolution in Cuba, till then the so-called backyard of the
US imperialism, generated a new wave of revolutionary
movements, not only in the Carribcan basin, Central
America and Latin America, but all over the world. The
revolutions in Grenada (March 1979) and Nicaragua (July
1979) widened the breach opened in the imperialist empire
by the Cuban and Indochinese revolutions. The revolution
in Grenada was, however, crushed by US imperialism before
the whole process could completely unfold and get fully con
solidated. The revolution in Grenada nevertheless in
augurated changes in the health and health care system of
that country, though it is beyond the scope of this article
to deal with them. Also, the information available to us is
very fragmentary to allow us to discuss the changes in detail.
On the other hand, although the Nicaraguan revolution is
still fighting for its survival against escalating US aggres
sion, it has unleashed far more profound changes in all
aspects of people’s social life, including in the field of health
and health care, enabling us to examine them in considerable
detail
There are few regions which have been so much the ob
ject of the foreign policy of an imperialist,power as Central
America.and the Carribean. It has been the theatre for per
manent US intervention for 85 years. The US has always
claimed the right tQ lay down the law there. It considers this
whole region to be an integral part of its ‘defence system’
and has 40 to 50 military bases there and is building many
new ones. In 1982-83, 20 per cent of entire US military budget
was earmarked for this region. Behind this military involve
ment is the US economic interest in the area which is a ma
jor communications and trade route as well as a great,raw
material reserve and source of cheap labour power in the in
ternational division of labour (Fourth International, 1985,
p 89). This is the reason why the countries in this region are
kept strictly subordinated to imperialism to such an extent
that the political regimes there are ‘created’ by the US.
The super-exploitation of people there by imperialism
has led to deterioration of living standards to abysmal levels,
extreme poverty, unemployment, and so on. The resistance
to this exploitation has also grown so much so that people
are in a state of permanent war with the military state
machines. The health consequences of this continuous war
are far-reaching, to the extent that the health professionals
are suddenly required to scientifically understand the health
June 1986
consequences of war or the epidemiology of war and
agression.
Nicaraguan Revolution: Historical Background
The Subjugation'. Nicaragua, like other parts of Cen
tral America, was conquered in 1523 by the Spaniards and
they subjugated the Ghorotec Indians of t-he Aztec family.
It become a centre for slave trade for more then three cen
turies under Spanish rule. It attained “independence” in 1821
and slavery was abolished in 1824 (Weber, 1981, pp 1-5). Ever
since its “discovery” Nicaragua has always been of interest
to the great powers. The US has militarily intervened in
Nicaragua at least three times.
The first US armed intervention took place in the mid
nineteenth century at the time of California gold rush. This
intervention, though short-lived, opened a way for US finan
cial and political interests which, in the course of half a cen
tury, converted Nicragua into a coffee exporting country with
a plantation economy. Coffee constituted 50 per cent of the'
value of Nicaraguan exports till the cotton boom of the
1950s. All, exports were chiefly to the US. The second US
intervention took place in 1909 and US forces continued to
occupy the country from 1909 to 1925. When the' US
withdrew its forces in 1925 it thought that the regime backed
by it would survive,'but the rebellion against the puppet
regime led to the third US intervention within months after
the withdrawal. This, time the US continued lb occupy
Nicaragua till 1933.
During this third intervention, the US helped create a
military force, called the National Guard, inJ927. The
National Guard was.at the beginning commanded, equip
ped, trained and financed by the US. The chief of the Na
tional Guard, Anastaslo Somoza Gracia, seized power in
1936 and established a US backed family dictatorship lasting
for almost fifty years (Weissberg, 1981). Under Somoza,
Nicaragua acted like a true puppet of the US and, through
the National Guard, provided counter-revolutionary military
forces during the 1954 attack on the progressive Arbenz
regime in Guatemala (which incidentally, profoundly
politicised a doctor, Ernesto ‘Che’ Guevara, who sub
sequently led the Cuban revolution with Fidel Castro) and
during the 1965 offensive in the Dominican Repubic. It was
from Nicaragua, moreover, that the CIA mercenaries left for
the. 1961 Bay of Pigs landing in Cuba, the most concerted
(albeit unsuccessful) US attempt to destory the Cuban revolu
tion (Weber, 1981, p 30).
3
The Revolution: The third US intervention in 1925-26
inspired a nationalist uprising led by general Augusto Cesar
Sandino.'The war of resistance, fought on the lines of guerilla
warfare, lasted till the murder of Sandino on 21st February,
1934. But it helped in radicalising many individuals who had
been also influenced by the October Revolution. The 1959
Cuban revolution gave the struggle in Nicaragua further
impetus and in 1962 the Frente Sandinista de Liberation Na
tional (Sandinista National Liberation Front, FSLN) was
formed. The FSLN combined guerilla military warfare and
rural and urban mass organisation and mobilisation for 18
years to lead the revolutionary insurrection on 19th July, 1979
that overthrew the Somoza regime, destroyed the erstwhile
state power and created a completely new statue apparatus
under the leaderhip of the FSLN. It is under the leadership
of the FSLN that the reconstruction’of the Nicaraguan
society is under way.
Before we take up discussion of the changes in the
Nicaraguan health services after the revolution, it would be
useful to know what role the health functionaries played in
the revolution, although this aspect of the revolutionary
movement is not very well documented. While the health care
services have long been deficient in the Central American
region, doctors, medical students and other health func
tionaries have participated in and even led struggles for social
reform. Some examples can be given easily. Che Guevara in
Guatemala, Calderon in Costa Rica, Romero and Castillo
in El-Salvador, Bolanos and Rosales in Nicaragua and
Morales and Alvarado in Honduras led political movements
and governmental efforts toward the establishment of social
security systems, workmen’s compensation, the legalisation
of unions, and agricultural reform (Garfield and Rodrigues,
1985). In Nicaragua, besides the above-mentioned doctors,
reference can be made to a hunger strike by the health
workers in the capital, Managua, in January 1979, in pro
test against the killing of dozens of people participating in
a gigantic demonstration to mark the first anniversary of
the assassination of Pedro Joaquin Chamarro, an antiSomoza editor of the bourgeois paper La Prensa (Weber, 1981
P 4).
Post Revolutionary Health Services Reforms
'Further, it should be kept in mind that these principles
and new health care planning were inaugurated in the con
text of the thorough-going revolutionary reforms started in
the entire social structure. The way the FSLN has introduced
agrarian reforms, which undoubtedly have helped in improv
ing the health status of the people will illustrate this point.
In July 1981, the first agrarian law was enacted which
made it possible to confiscate land left lying fallow by owners
holding 350 hectares or more of land on the Pacific Coast
and 750 hectares or more on the Atlantic Coast. Another
law enacted in early 1986 removed these limits of 350 and
750 hectares and has made it possible to confiscate land of
all big landowners who do not plan for efficient production
(Udry, 1986). The cffects.of these reforms can be seen in the
fact that in 1978. 36.1 per cent of land was owned by those
with more than 350 hectares, whereas they now (in 1984) own
less than 11.3 per cent. The owners of more than 150 hectares
of worked land, who possessed more than 50 per cent of the
land in 1978, now have no more than 23.8 per cent. The land
distribution has been carried through briskly. In the first
fourteen months of the agrarian reform, the average rate of
granting property titles was 647 per month, and the area of
land involved was on average 15 hectares per family. In
addition to the distribution of land for private cultivation,
38 per cent of land is under state ownership (APP 19.3 per
cent) and co-operatives (10 per cent in Service Co-operatives.
CCS and 8.7 per cent in Sandinista Agricultural Co
operatives. CAS) (Devillicrs, 1984).
The contribution of these reforms to the improvement
of the health status of the people cannot be underestimated,
especially in a country which has a predominantly agri
cultural economy. Otherwise mere changes and improve
ments in health care delivery cannot achieve in seven years
only, the tremendous improvement in the health status of
the people. In short, what we are arguing for is not only that
a revolutionary regime should seriously undertake thorough- •
going redistribution of wealth, but also that in order to make
health a fundamental right of the people, people must be
given the basic right over the means of production and the
result of their productive labor power.
People’s Participation
Another basic principle of the health services in
Nicaragua is people’s participation “in health policy deter
Nineteen days after the victory of the Nicaraguan revolu mination at all levels”. This term, ‘Peoples Participation’ is
tion the new government issued a declaration outlining the so much abused, particularly in the field of community
basic principles of the new health care system. These prin health, that it must be put in a proper perspective in the con
ciples are:
text of Nicaragua. Fundamental to our understanding of peo
1 Health shall be a right of everyone;
ple’s participation is people’s power—political and economic
2 Health services will be a responsibility of government; power in the hands of the working people, mediated through
3 The public will participate in health policy determination their own mass organisation and having decisive say in
at all levels and
decision-making. Only if such people’s power is existing can
4 All health services will be planned on a regionalised, it get permeated in genuine participation of people in health
systematic basis, (Braveman and Roemer, 1985).
care. Therefore, wc must examine in brief whether these
Special emphasis within the new system was put on necessary pre-conditions for the genuine participation of the
maternal and child health, occupational health, and primary people, as envisaged in the basic principles, exist in
health care for everyone. 1/5 overcome the deficiency in the Nicaragua.
availability of health personnel, high priority was also given
The revolution in one stroke destroyed the essential part
to educing them in njiich greater number and in a new of the bourgeois state apparatus—its repressive forces—and
mould.
created a new revolutionary army, called the Sandinista
Basic Principles
4
Radical Journal of Health
People’s Army (EPS), whose origin, composition, leadership
structure and training was.a direct result of the revolutionary
struggle. The original police force was smashed and the
Sandinista police was set up from working class fighters,
thrown into unemployment because of war damage to the
economy. In February 1980, the Sandinista People’s Militia
(MPS) was formed by arming tens of thousands of workers
and poor peasants. The Sandinista Defence Committees
(CDS) are another organised structure of the armed work
ing people for their self-defence. While the EPS and the San
dinista police are part of the organised state structure, the
MPS and the CDS are made of working people. The point
to be noted is that the defence of the nation and exercise of
power are not the functions of the state apparatus alone, but
also of the armed volunteers from the urban and rural pro
letariat and the peasants. While discharging their duty as
workers and peasants, the working people wield arms to fight
against any attempt to take back the gains of the revolution.
Therefore, even though the ruling classes arc not completely
expropriated—they continue to hold substantial econdmic
power under the mixed economy—their political power is
completely expropriated and any refusal by them to go along
with the decisions taken by the revolutionary government is
met with further expropriation, thereby deepening the revolu
tion and consolidating the dictatorship of the proletariat.
Now let us see how these armed workers and peasants
and even those who are not armed but come from the same
classes have set up their mass and class organisations. We
will mention five of them here: (1) the Sandinista Workers.
Confederation (CST) and (2) the Associaton of Rural
Workers (ATC). The CST and the ATC arc trade union
organisations representing about 75 per cent of urban and
rural wage workers. They provide an organic link by their
constant cooperation and thus materialising the workers and
peasants alliance. (3) The National Union of Farmers and
Rajichcrs/Stock Rearers (UNAG) (4) The Luisa Amanda
Espinoza Associationof Nicaraguan Women (AMLAE) (5)
The 19th July Sandinista Youth (JS 19) (Udry, 1985).
The Sandinista democracy rests in the first instance on
these mass organisations. Their power is not subordinated
to any other abstract concepts. Further, although the FSLN
commands political hegemony on the working people, it has
not brought the Nicaraguan society under one party strait
jacket. Instead, at the larger level it has opted for political
pluralism and has legally allowed all political parties, both
bourgeois and working class to operate, however, within the
framework of new realities. In November 1984 elections, the
opposition got 30 per cent of votes. This shows that
Nicaragua has opted for a different type of political struc
ture by allowing all political ideas io contend for hegemony
within the dictatorship of proletariat and has thus chosen
to face up to a series of problem that are relatively new in
the history of the transition to socialism.
This is why a worker and a farmer in Nicaragua is not
only a worker or a farmer, but also an armed defender of
•revolution, a soldier, and some of them even health workers
and/or leaders of their mass and class organisations. Thus,
the people’s participation in health care is an integral part
of people’s participation and contrdl over all the socio
economic processes in the Nicaraguan society.
June 1986
Health Care under Somoza
Nicaragua is one of the poorest countries in the region
with a population of thirty lakhs. In addition to poverty, il
literacy and ill-health, it faces a severe problem of structural
unemployment. Th'is is illustrated by the fact .that the entire
work force in Nicaragua grew only 6 per cent from 1961 to
1971. While the population aged 15 to 64 years grew by 40
per cent in the same period. This led to massive urbanisa
tion with a large proportion of the population living in
shantytowns (slums) on the edge of major cities. Roughly
one-third (ten lakhs) of the country’s total population is con
centrated in its capital, Managua. This is one of the reasons
why Nicaragua has 55 per cent of urban population despite
the central role played by agriculture in its economy (Garfield
and Rodriguez, 1985); 35 per cent of urban and 95 per cent
of rural population lacked access to potable water (Halperin
and Garfield, 1982).
As in any underdeveloped capitalist country, the official
health statistics of pre-1979 Nicaragua arc highly unreliable.
Halperin and Garfield (1982) point out that “the Somoza
regime paid so little attention to health matters that even such
basic data as birth and death certificates were collected for
only about 25 per cent of the population”. The official
estimate of the Infant Mortality Rate (IMR) was given as
35 per 1000 live births ano was reported so in one of the
WHO documents of 1980. A survey conducted in a part of
rural Nicaragua in 1977, however, showed that the IMR in
the sample population corresponded to an IMR of the order
of 150 per 1000 live births (Heiby, 1981). Life expectancy at
brith was 52.9 years. Indeed, Nicaragua had the lowest life
expectancy at birth and one of the highest levels of the IMR
in the region.
Malaria was a major public health hazard. Upto 60 per
cent of the Nicaragua population had malaria during the
1930s. From 1934 to 1948, 22.4 per cent of all registered
deaths were due to malaria. Upto 70 per cent of hospital beds
were occupied by malaria patients during epidemics (Garfield
and Vermund, 1983). The national malaria control pro
gramme was started in 1947 and was converted into an
eradication programme, keeping with the change effected in
ternationally at the behest of international agencies. Accor
ding to Halperin and Garfield (1982), one-third of the people
contracted malaria at least once in their lives. One of the
important reasons for this high incidence of malaria was the
indiscriminate use of insecticides in cotton and rice farm
ing, leading to the Anopheles mosquito vector exhibiting
resistance to all insecticides in common use, including DDT
(dicophane), diedrin, malathion, propoxur and chlorofoxin.
As a result in 1978 approximately 4.4 persons per 1,000 con
tracted this disease. The revolutionary civil war paralysed the
health services and the incidence of malaria rose to 7.3 per
1,000 in 1979 and 9.4 per 1,000 in 1980 (Halperin and
Garfield, 1982). This forced the Nicaraguan government to
opt for, as an emergency measure, mass anti-malarial drug
administration in 1981..
. Besides malaria, tuberculosis and parasitism were endemic.
Among the top ten killers of children were diarrhoea, tetanus,
measles, whooping cough and malaria. Some of the major
causes of death in 1973. are shown in Table 1:
5
indigenous medical practices and what the revolutionary
government is doing about it.
Table 1
Causes of Death
1.
2.
3.
4.
5.
6.
Infectious -and parasitic diseases
Diarrhoeal diseases
Pneumonia and influenza
Avitaminosis and other nutritional
diseases
Homicide and war
Poorly defined causes
Source'. Garfield and Rodriguez, 1985.)
Death Rate
per 100,000
population
(1973)
141.8
97.0
190.5
2.1
24.0
151.8
An official community health experiment was carried
out in Nicaragua from 1976 to 1978. In this programme,.768
parteras (traditional birth attendants) were trained in six-day ’
courses, to carry out in theircommunity improved obstetrical
care, treatment of diarrhoea in children using packets of oral
rehydration salts, provision of contraceptives, provision of •
aspirin for fever and pain
so on. A trained partera was
given a free he?’**' l';*
..as required threafter to purchase
supplies through me local government clinics. At the end of
the experiment in 1978, about 40 per cent of the Parteras
had already dropped out (Heiby, 1981). The government was
so disinterested in the programme that it did not make any
serious effort to keep it going nor did it carry out any follow
up work.
•
Thus, what the revolution inherited was poverty illhealth, unemployment and rickety health services. In addi
tion, it also had to (1) care for the families of the 50,000 dead
in the civil war and the 100,000 wounded people and their ■
families, and cope with (2) considerable destruction ol
industry (Somoza bombed his own industries to thwart
revolution), disorganisation of two agricultural cycles.with
repercussions on food supplies and exports (GDP per capita
had declined to levels of. 17 years before), a massive foreign
debt, a near-total lack of foreign currencies and high infla
tion, (3) a poorly developed economy (much less developed
than Cuba in 19’59), (4) dependence on agro-exports for
earning foreign exchange, and (5) the ever-present threat of
economic sanctions and even of a blockade (Fourth Inter
national, 1985).
Some studies in malnutrition have estimated that bet
ween 46 and S3 per cent of Nicaraguan children were
malnourished. The same studies have indicated that a high
proportion of these children (25 to 45 per cent) had the more
severe secondary and tertiary types of malnutrition (Halperin
and Garfield, 1982).
Health Services: A decade before the revolution four
separate agencies and independent health ministry offices
in each province ran in Nicaraguan health,system. All four
agencies.and provincial officies of the health ministry func
tioned independently without any coordination. The ministry
of health had the main responsibility for rural health care.
For the salaried population, the Nicaraguan Social
Security Institute (1NSS) was established in 1957. Twenty
years later it Served only 16 per cent of the economically
active population and only 8.4 per cent of the country’s total
population. (Garfield and Taboada, 1984). Several churches
ran highly respected hospitals, but for the most part they Post-revolutionary Reforms
Many persons mistakenly think that immediately after
treated only those who could pay cash. The National Guard
had relatively good medical services, including most the proletarian revolution, the revolutionary regime brings
specialities, through a system of hospitals and clinics of its under state ownership all the means of production and
own.
services. Actually, while the state takes upon itself the respon
. Health Expenditure: Of all the expenditure in the health sibility of providing adequate health care, it docs not do so’
sector, jhe INSS commanded 50 per cent, the ministry of by any such overnight take-over of the services. The seizure
health only 16 per cent and other local agencies, charitable of state power andjhe nationalisation of the core of the
and private insurance groups the remaining 34 per cent economy can be timed by the day of the insurrection, but
(Garfield and Taboda, 1984). This way, a great divide was the actual consolidation of the revolution takes place in
created between a tiny minority of insured salaried workers course of time,- by a process in which the continuing class
(mainly white collar government employees) and the over struggle within the country and internationally plays a pro
whelming majority of non-insured. Preventive care was minent role. Even decades after the revolution in these coun
neglected, save for some disorganised attempts in respect of tries, small-scale private producers (artisans, private medical
malaria. All of the INSS and much of the rtiinistry’s budget practitioners, small capitalists, etc) are not completely
was devoted to curative care. Of the approximately 13 dollars expropriated. They survive as a marginalised sector and
per capita spent in Nicaragua in 1972 by the health sector, under restrictions. Therefore, an attempt to characterise a
only about 3.15 dollars went for preventive care (Garfield revolution in its initial years only on'.the basis of the pro
and Taboada, 1984)..
portion of (he state-dwned economy and services-could lead
Health Personnel’. The Somoza dictatorship considered to wrong conclusions. ’What is decisive is the ideology anc
students, especially in the health professions, a potentially class nature of-the revolution’s leading organisation, the
subversive group and tried to limit their number. Thus., actual role played by the new state in the ongoing class
Nicaragua had only one medical school with 73 students in struggle does the state side with workers and farmers? Does
a class. The total number of doctors was 1,300 and there were it expropriate those propertied classes who go against the
only 43 professional nurses per 100 doctors. Not surprisingly, people’s interest?—and the development and extension of the
80 per cent of rural health manpower consisted of folk workers’ and farmers’ power and control over all aspects of
healers. We do not have any information about their • the new social structure.'
Radical Journal of Health
The continuing presence of private sector in the been carried out since 1979. The new six-ycar- course con- ’
economy thus does not disprove the proletarian character sists of clinical service, leaching, administration and research.
ol the revolution, although such a sector docs have subver For imparting such integrated medical training, ‘work-study
sive potential. This makes it more imperative for the revolu programmes’ arc instituted wherein the student is required
tionary stale to deepen the class struggle. The stale of reform to assist from the outset in supervised public education pro
of the health care system in Nicaragua is also at this stage jects, in community surveys to asses health needs, door-toonly. Although the state has undertaken full responsibility door programmes to give immunisations, serve as an ad
tor providing health care (sec basic principles cited above), ministrative assistant in local public health offices, etc. The
and it has achieved astounding success in improving health student is also placed in work settings to learn about occupa
•care, this has not been done by sweeping abolition of the tional health and in outpatient settings to learn about preven
private sector and private practice. The trend, however, is tive maternal and child health services. On the other hand,
clear. The state is for people’s health care. Those health the clinical rotations are almost always hospital-based, thus
personnel who want to continue in the old way of looting creating a discrepancy between the primary care, goal and
people, will not be allowed to do so. First restriction and (hen, hospital based training practices. This discrepancy is increas
if necessary, expropriation.
ingly being questioned by the teachers and students
Health Structure; Immediately after the revolution, the (Braveman and Roemer, 1985).
previously separate health agencies were integrated within
Nicaragua has six nursing schools with five times the
the Ministry of Health (MINSA) and a United National prc-1979 enrolment. The educational qualification required
Health System was started.
for enrolment has been drastically lowered. For Auxiliary
Doctors’ Response: Nicaragua had one medical school Nurses the person should only be literate and ten months’
in Leon and a second one was opened in Managua in 1981. training is given. Technical Nurses require primary school
By 1983, 2,240 medical students were undergoing training education and are given two years’ training. While profes
in these schools, an increase by four times over the 1978 level sional Nurses require secondary school graduation and arc
(Braveman and Roemer, 1985). Unlike in the case of Cuba, given three years’ training (Braveman and Roemer, 1985). At
only about 300 of the total 1,300 doctors left the country this rate it is certain that Nicaragua will correct the present.
due to the revolution. This was largely because private prac adverse nurse-doctor ratio very rapidly.
tice was allowed. Before the revolution, about 65 per cent
One of the earliest programmes stdrted by the MINSA
of the doctors were paid for some public service, but for most was training paramedical health aides, catted-brigadistas, who
of them this constituted only a few hours a day and the rest were selected from the youth organisations. They received
of the time they were engaged in private practice. After several.months’ training and were sent to isolated rural areas.
revolution they were pressurised to fulfill their contracted They were to serve tor at least two years after which they
time and increase their scheduled public practice to at least would be eligible for professional training. In fact many of
six hours a day. Their salaries were standardised (Garfield them went on to become health educators and medical
and Taboada, 1984).
students. The doctors forcefully opposed this programme and
After revolution, the doctors’ official organisation so it was revised. The.revised programme look up mobilisa
Federacion de Sociedades Medicas de Nicaragua tion of a large number of people in the immunisation, •
(FESOMENIC), which is a leader of the Federation of malaria prophylaxis and sanitation campaigns which were
Professional Organisations (CONAPRO) and has the back launched in 1981. The campaign included a short-term train
ing of the propertied strata, increased its political activities. ing course and public health education. It is estimated that
In 1980 when the government started discussing a law to upto 10 per cent of the country’s population was mobilised
regulate professional activities, it opposed it looth-and-nail. as health volunteers in these campaigns. The class and mass
It organised a one-day walk-out and even threatened mass •organisations listed earlier in this article actively participated
emigration to Miami. The government retreated by making and provided volunteers. They also promoted the formation
the law less specific. Nevertheless, the government passed the of local, regional and national community, health councils
law and for the first time made the doctors and other pro which are now active throughout the country (Garfield and
fessionals accept the government’s right to regulate their pro Taboada, 1984).
• ..
fessions. This tussle at the same time divided the profes
But a campaign means a programme that ends at one
sionals into the progressive and the conservative camps and point of time. This is not allowed to' happen by converting
in July 1981 a formal split look place The progressives could the activity into permanent-work by providing extensivemaintain official recognition and this ultimately forced the training to a section of the volunteers. There are now 25,000
conscrtativcs to rejoin the organisation (Garfield and of these permanent but volunteer brigadistas comprising
Taboada, 1984).
about 1 per cent of the total population (Garfield and
Personnel and Training: International assistance has Taboada, 1984). This supports our earlier contention that
greatly helped Nicaragua to fill up deficiencies in the number many of the workers and peasants are armed defenders of
of personnel. There arc about 800 foreign health workers in the revolution and also health workers. People’s participa
Nicaragua, coming mainly from Cuba, Latin America and tion is not a cosmetic exercise, but is elevated to self-activity
Western Europe. Cuba and the Pan American Health by the people to decide the condition of their lives.
Organisation have also greatly assisted in leaching
Achievements of (he Campaigns: As mentioned earlier,
programmes. .
during and after the civil war, the incidence of malaria in
A complete overhauling of the medical curriculum has creased so much that there was no alternative but to take
June 1986
7
up mass campaigns to bring it under control. The govern
ment opted for Mass Drug Administration (MDA) in 1981.
Three ambitious goals were set: (1) to prevent new cases, (2)
to cure subclinical cases, and (3) to reduce the transmission.
For this purpose, *70,000 voluntary workers, brigadistas, were
trained. These volunteers recruited many helpers. A malaria
census was carried out in which 87 per cent were covered.
The drugs were given to an estimated 19,00,000 people. More
than 80 lakh does of chlorbque and primaquine were
distributed in October 1981.
As a result, the total number of malaria cases fell con
siderably from November 1981 to February 1982. However,
the incidence of P.Vivax cases returned to endemic level by
March 1982, while that of P.falciparum stayed below endemic
level for three more months. The net result was that if we
take the average of the previous two years’ incidence rates
as the baseline, there were 9,200 fewer cases of malaria than
expected during the four months of reduction in general in
cidence. It is clear from this that the objectives of preven
tion and cure of malaria infection were better realised than
that bf reducing transmission, as the MDA could not reduce
transmission to a ‘break point’ below which malaria eradica
tion could occur (Garfield ancLVermund, 1983). This shows
that even such a massive exercise could not realise the
theoretically possible decisive break in the chain of infection.
Compared to this moderate success o.f the MDA cam
paign, the immunisation campaign was a resounding suc
cess. BCG vaccinationis given at birth, and the three-fold
increase in coverage since 1980 reflects .a huge expansion in
maternal care. Diptheria-pertusis tetanus (DPT) immunisa
tion is given at health centres and health posts as part of
routine child growth and development services. The DPT
coverage is increasing at an average rate of 30 per cent per
year. However, this increase is not so spectacular. Measles
vaccination reches 60 per cent of children in the first year
of life and.85 per cent before their sixth birthday (Williams,
1985).
.
The key to this success in immunisation is a mass cam
paign through holding regular ‘health days’ all over the coun
try. For health days, 20,000 volunteer brigadistas have been
trained in vaccination, health education, etc. On health days
vaccinations are done between 7 am to 6 pm with schools,
community buildings and health facilities as assembly points
finishing with a house-to-house' sweep through the
neighbourhood. The results are announced through mass
media (Wiltjams, 1985). Table 2 shows tfeie immunisation
coverage.
Table 2: Estimated Immunisation Coverage of
Children unT>er 12 Months
Immunisation
BCG
DPT
Poliomyelitis
Measles
Percentage Coverage in
1980
1984
33
. 15.
20
15
97
33
76.
60
Source'. Ministry bf Health and UNICEF Office, Managua
(as givenin Williams, 1985).
Health Financing’and Facilities: Government funds
directly related to the provision of health care jumped from
">00 million cordobas in 1981 and reached an estimated 1.-593
million cordobas in 1983. In 1981, the government budget
for health was 12 per cent of all public spending (Garfield
and Taboada, 1984).
In the last months of the revolutionary war, Somoza’s
National Guard destroyed four hospitals, seriously damag
ed five others and looted four more. Post-revolutionary
reconstruction has nr- nrovided 18 hospital beds per 10,000
population 'ru
• v 4,829 hospital beds in Nicaragua, but
greater awareness and accessibility has increased their use.
Five hospitals with 1,078 beds are under construction (Gar
field and Halperin, 1983). To tackle problem of diarrhoea;
especially in infants, the government initially planned 170
rehydration centres, but popular demand and people’s ac
tion have brought 226 such centres into existence (Halperin
and Garfield, 1982). The availability of health services has
increased tremendously. Il is estimated that more than 80
per cent of the population now has some regular access to
medical care (Garfield and Taboada, 1984).
Health Condition. Finally, about some overall
achievements. The IMR has got reduced to 80 per 1,000 live
births. No case of polio has been reported since 1982 despite
an epidemic in neighbouring Honduras in 1984. Only 3 cases
of diptheria were reported in 1983. Neonatal tefanus.
however, still remains a significant problem (Williams, b985).
In short, the reforms in health care in Nicaragua show
people’s determination to collectively change society. The
future of the revolution is, however, not fully secure and is
threatened by internal and external dangers. This has hap
pened to all such revolutions. The Soviet. Union was invad
ed by several countries to destroy the Bolshevik Revolution:
Cuba had its Bay of Pigs invasion; Vietnam had to fight for*
decades for survival; Grenada was overpowered; Nicaragua
has been assaulted by the GIA sponsored contras and a par
tial blocade since 1981. The very fact that it has achieved
so much under conditions of a threat to its very survival and .
conlinous war since 1981 shows the revolution’s lasting power.
the new state’s mass-base and the preparedness of the-work
ing masses to sacrifice to preserve the gains of th'c revolu
tion, including the gains in health and health care. Never
theless, the war has its impact, and such protracted aggres
sion has consequences ior people's health. Epidemiology ol
war is an emerging subject and the war on Nicaragua has
made it much more relevant. Health professionals will have
to understand it more and more for the world is likely witness
more revolutionary upheavals, revolutionary crises, and im
perialist aggressions.
Health Consequences of War in Nicaragua
The Central American countries are under the grip ot
vio ence, more so since 1980. Violent death is the most com
mon cause of death in El Salvador, Guatemala and
Nicaragua since 1980. At least 40,00 people have been killed
i ”i
lta^ an^ dealh squads in El Salvador (population 47
lakhs) and many more have been killed in bombing .and other
41 takhc? 1S eStin2alcd lhat 20»000 Gautemalans (population
hv thp
most o them indigenous tribes, have been killed
by the army In the last three years. The war takes a toll mainly
Radical\journal of Health
of young men. This is illustrated by the fad that although terms of availability of health facilities, as the Nicaraguan
life expectancy at birth among Salvadoran women has risen Health Workers Union (FETSALUD) reported to visiting
steadily, reaching 67.7 years in 1980, it fell remarkably for American physicians, the increase the in the number of
Salvadorar men from 58.4 years in 1978 to 52 years in 1980. civilians and soldiers wounded in the war has strained existing
More than 1,20,000 Central Americans have died from war- health facilities, leaving less resources for normal civilian
related causes since 1978. This amounts to a 10 per cent rise needs (Siegel, 1985).
Further increase in the health budget has been suspend- .
in mortality above expected levels during this period. It is
estimated that more’than a million Centra] American live cd due to increase in military spending, the budget for which
as refugees within the region and a million have fled to increased from 18 per cent in 1982 to 25 per cent in 1984.
America (Garfield and Rodriguez, 1985). This is how im Not only that, 20-25 per cent of Managua’s health workers
perialism is trying to crush the hopes and rebellion of peo are-at the war front, actually fighting with arms and many
ple in Central America, who have been inspired by the of them arc getting killed. This has necessitated training of
Nicaragua revolution. The effects of imperialist aggression new health personnel.
The economic embargo on Nicaragua by the US has
on Nicaragua are no less tragic.
More than 100,000 persons were wounded in the revolu devastating consequences for health care. Immediately after
tionary war in Nicaragua and 50,000 lost their lives. After the revolution, there was a crisis in the availability of phar
the revolution, the CIA-backed contra attacks have, between maceuticals. The foreign drug companies wanted the debt
January 19S0 and January 1986, killed 3,999 persons, wound incurred by the Somoza government to be settled before sen
ed 4.542 persons and 3.791 persons have been kidnapped. ding any more drugs. The Sandinista government had to
In 1985 alone, 1,852 persons’ were wounded. 1,463 were killed accept responsibility for the debts in exchange for favourable
and 1,455 kidnapped, indicating the counter-revolutionaries terms of repayment (Halperin and Garfield, 1982). Another
who have been killed in the armed conflicts—they are also major problem is the lack of spare parts for medical equip
victims of US aggression—the number of casualties totals ment. Much of the machinery is made in the US, but shor
23,822 persons including 13,930 dead (Ortega, 1986). The tage of US dollars as a-result of the war makes acquisition
president of Nicaragua, Daniel Ortega, in his recent speech of replacement parts difficult (Siegel, et al, 1985). Thus, when
to the National Assembly said that the total number of peo equipment breaks, it may remain out of commission or one
ple killed as a result of the US policy of terrorism against piece of equipment must be cannibalised to fix another
Nicaragua would be equivalent, as a proportion of the (Hclperin and Garfield, 1982).
In 1983, agricultural losses directly related to the war
population, to some 1,03,000 dead for the US (Ortega, 1986).
totalled 10 million dollars. Since 1981, total destruction
Ortega also gave information about other losses:
1. In 1985, aggression increased Nicaragua’s balance of pay related to health has been valued at over 70 million dollars
ment deficit by 108 million US dollars, the trade deficit rose (Siegel, et al, 1985).
by S 89 million and the capital deficit by S 19 million.
Effects on Diseases
2. A total of 120,324 people have been displaced from their
The term ‘epidemiology of aggression’ was first used
lands by the war, of these, 33,000 have been relocated to 55
by a group of doctors connected with Regional Leishmaniasis
urban and rural settlements.
3. Health services to 250,000 people have been impaired due Group in Nicaragua, to analyse health data ascribablc to the
to the damages caused to 55 health units, including one US aggression in 1982. Before 1979 leishmaniasis was known
to exist in Nicaragua but was not reported to the WHO. After
hospital and four health centres.
4. 48 schools have been destroyed and 502 other education the revolution reported cases increased and came to ocupy
centres can no longer operate because they arc located in war the fifth rank among all notified infectious diseases. When
zones; as a result, a total of 60,240 elementary and 30,120 the Leishmaniasis Group started a study of this disease in
adult education students arc no longer,able to attend classes. 1982 in one region, the study was violently interrupted after
5. In the area of social services, the mercenaries have 24 hours by a contra attack in which several people were kill
destroyed four rural child care centres, three nutrition cen ed, including Dr. Pierre Grosjean, one of the two European
tres for children and two offices of the Nicaraguan Social volunteer physicians (Morelli, et al, 1985).
Security Institute. This has directly affected services to 2,222
One aspect of the epidemiology of war is the impossibility
children and elderly people.
of obtaining basic data. Cases registered in this region pro
The strength of the Nicaraguan revolution lies in peo gressively increased from 1980 (143 cases) to 1982 (2,107
ple’s power and in its accomplishments in the fields of health, cases); since 1982, with the intensified war activities, the
education (the revolution’s strategy of imparting education number of notified cases fell to 1.054 in 1983 and 806 in 1984.
to all has been most successful), nutrition, employment, etc. This is not due to actual decrease in number of cases but
The counter-revolutionary contra mercenaries know this. due to destruction of facilities, less access to services and
Hence health and educational centres and health func migration. Another aspect of this epidemiology is related to
tionaries arc made special'targets of attacks. At least 22 troop movements. Non-immune people have the clinical
health workers (including two European volunter physicians), manifestations when they enter, in troop movements, the
medical students, nurses, malaria control workers, health natural environment of leishmaniasis. This Can be seen from
educators and vaccination campaign workers have been killed age-sex distribution: the significantly high incidence usually
while delivering health care (Siegel et al, 1985). Garfield seen in under 5s has shifted to appear in males aged 15-30
(1985) puts the number of health workers killed at 31. In years. The third aspect is related to migration. People living
June 1986
in endemic areas often resettle, because of the war, in non
endemic areas, resulting in the first appearance of the disease
in those zones. Thus, as the Leishmaniaris Group puts it,
in the war-affected northern regions of the country, aggres
sion and leishmaniaris, indeed, coincide.‘cpidcmiologically’
(Morelli, 1985).
Before we conlude, a mention should be made of the
psychological effects of war. The Americans, for instance
still suffer from (he psychological effects of (he Vietnam war
and a numbr of studies are still being carried out to assess
the increased number of vehicular accidents and suicides
amongst Americans who were drafted to fight for US im
perialism in Vietnam. As reported by Dr. Felipe Sarti, the
chief psychologist at a psychiatric day centre in a pool suburb
of Managua, approximately 25 per cent of all patients show
depressive illnesses connected with the war.. This depression
is particularly prevalent among parents and siblings of
soldiers who' have been killed or sent to the front (Scigcl,
et al, 1985).
The US sponsored aggression is still continuing and no
end to it seems likely in the near future. Such a situation can
jeopardise (he revolution in the long-term. This annihilation
of revolution must stop. The US administration knows that
if it opts for direct intervention, it won’t be any cakewalk.
The working masses arc armed and they will fight till (he
last person. And hence this new strategy of protracted
aggression combined with economic harassment and inter
nal sabotage through the still-unexpropriated big strata of
the former ruling classes. The danger is real. If a massive
counter revolutionary attack is mounted by all of them it
will have a chilling effect on the revolutionary movement all
over the world. Even if such an attack fails, there are bound
to be major distortions in the revolution. Its democratic
fermer. may get lost. A massive bureaucratic state apparatus
may emerge and with the best class-conscious workers and
peasants dead in the war, such an apparatus can get con
solidated. International solidarity is a need of the hour.
Many health professionals have reacted with revolu
tionary zeal to this need. Today, over 900 internationalist
health workers are helping the revolution. They are from
Cuba, Latin America, Mexico and Europe. Many more can
and should join. If we allow imperialism to roll back this
revolution, as it did in Grenada, history will not forgive us.
No matter how- strong the justification for localist thinking
and local-based activity, this international defeat will affect
all of us sooner or later. We must say, “Imperialism—hands
off Nicaragua”.
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Onega. Daniel, (February 21, 1986 Speech to the National Assembly)
Barricade International, Managua, February 27, 1986. Excerpts
Reported in Intrcontinental Press, New York, 1986, (April 7): 217.
Siegel, David. “The Epidemiology of Aggression: The Effects of War
on Health Care”, Nicaragua Perspectives, 1985 (Spring—Summer):
21-24.
• .
Siegel, David, Baron Robert, Epstein Paul, “The Epidemiology of Ag
gression: Health Consequences of War in Nicaragua” Lancet, 1985,
8444 (June 29): 1492-1493.
Udry, CharlesrAndre, “The Sandinista Revolution and Mass Democracy"
International Viewpoint, 1985 76 (May 20): 9-16.
Udry, Charles Andre, “A major step forward for the Revolution” Inter
national Viewpoint, 1986 (April 21): 13-14.
Weber. Henri, "Nicaragua: The Sandinista Revolution”, Verso, London.
1981.
Weissberg, Arnold., “Nicaragua: An Introduction to the Sandinista
Revolution", Pathfinder Press, New York, 1981.
Williams. Glen, "Immunisation in Nicaragua", Lancet. 1985, 8458
(October 5): 780.
Amar Jcsani
2/72 ONGC Flats t
Reclamation’
Bombay 400 050
RADICAL JOURNAL OF HEALTH
Forthcoming Issues
September 1986: Vol I no 2.- Primary Health Care
December 1986; Vol I no 3; State Sector in
Health Care
March 1987: Vol I no 4
June 1987: Vol II no 1
September 1987: VoHlno2:
Medical Technology
A
Agrarian Develop
ment and Health
Health Issue in
People’s Movement
10
Radical Journal of Health
Medical Care and Health under State Socialism
bob deacon
1 he transformation of the social relationships of welfare is central to socialist and communist social policy and
may be thought through in •relation to six key aspects of social policy: (1) the priority afforded social policy,
(2) the form of control over welfare provision, (3) the agency of welfare provision, (4) the nature of the relation
ship between welfare provider and user, (5) the rationing system adopted by (he welfare institutions concerned,
ana (6) the assumption embodied in the policy regarding the sexual division of labour. This article reviews medical
-are and health policy in three countries, (he Soviet Union, Hungary and Poland from the standpoint of a perspective
of ideal socialist and communist medical care and health policy derived from an analysis of Marxist and allied
critiques of capitalist medical care policy and theoretical work on socialist social policy. The author concludes
that medical care policy in all three countries exhibits very few characteristics of socialist medical care. It also
examines the possibility (for the moment suppressed) provided by the Solidarity movement in Pyland of a new
development toward a more genuine socialist medical care and health policy.
The article has been slightly abridged from (he International Journal of Health Services Volume 14, number
3, 1984 and excludes the detailed review of medical policy in Hungary.
Socialist Medical Care Policy
The aim of this article is both to explicate a socialist con
ception of ideal medical care policy and to review medical
care policies in the Soviet Union, Hungary and Poland to
sec whether they provide concrete examples of socialist
medical care.
It is clear from George and Manning’s (1) review of the
few specific statements on socialism and health made by
Marx, Engels, and Lenin that their emphasis is on those
causes of ill-health located in the nature of capitalist socie
ty. As an example take Lenin’s view that “thousands and tens
of thousands of men and women, who toil all their lives to
create wealth for others, perish from starvation and constant
malnutrition, die prematurely from disease caused by horri
ble working conditions by wretched housing and overwork”
(2). A socialist health policy would therefore be concerned
primarily to prevent avoidable disease. There is far less in
their writings on the particular form ofcurativc health ser
vice that should be provided to cope with unprcvcntablc
disease.
Few subsequent Marxist theorists, addressing the nature
of socialism have had anything specific to say about medical
care. Bahro (3) is an exception here. His discussion'of the
need to alter the division of labour radically under socialism
is illustrated by the example of the organisation of work in
’a hospital: “We can just as well imagine the everyday situa
tion in a hospital, to take an example from a different sphere,
one still more strongly burdened with the prejudices of the
traditional division of labour, in which the entire staff con
sisted of people with full medical training, or other pertinent
qualification, who also took part in all nursing and ancillary
work and in social and economic functions as well” This twin
concern with both preventive medicine—the fact that it will
become a high priority under socialism—and the altered
forn) of curative medical care will recur as (he Conception
of socialist medical care emerges in this article.
t'
Lesley Doyal’s (4) excellent analysis of the causes .of, and
ways of curing, ill-health under capitalism is structured
around these twin concerns. Her brief postscript to The
Political Economy of Health, where she considers the im
plications of this analysis for the struggle for a healthier
society, discusses both aspects. On the question of preven
tion of ill-health under socialism, she is sensibly cautious:
June 1986
Naturally we would not argue that a transformation of the mode
of production would abolish illness—people will always become
sick and die. But what we'can show are the ways in which poten
tially avoidable illness has become prevalent under capitalism ...
[It follows that] the demand for health is in itself a revolutionary
demand.
This concern with preventing avoidable ill-health is a
touchstone of socialist policy. It would reach into every
corner of working and domestic life. Not only would each
work process be evaluated from the standpoint of whether
it made workers ill or not, but also such diverse aspects of
life as food, housing, transportation, and personal relation
ships would be affected far more than under capitalism by
considerations of their health-enhancing potential. Changes
in life-style in relation to all of these things would be a mat
ter of general public concern and action. Necessary economic
and social’changes that would enable.pcoplc to live, eat, and
relate differently would be a matter of medical policy.
On the form of curative medical care under socialism,
Doyal (4) writes:
'The struggle must therefore go beyond the immediate demand
for more state-organised medicine, towards a critical re-evalnation
of the more qualitative aspects of the current organisationof
medicine and a redefinition of our health needs; This is not. of
course, to suggest that in a socialist society all existing medical
knowledge and skills would simply be abandoned in favour of
something called “proletarian medicine” . .. [But] no technology
would be used uncritically and without some assessment of its
value according to criteria which had been democratically decid
ed t pon ... Hence a socialist health service would not only have
to provide equal access to medical care but would also have to
address itself seriously to such problems as how to demystify
medical knowledge and how to break down barriers of authority
and status both among health workers’' themselves and also.
between workers and consumers.
The (heme of the necessity of changing the social relation
ships embodied in medical practice under socialism is taken
up by other Marxist critics of the National Health Service
(NHS) in Britain. After criticising existing left orthodoxy,
which sees within the existing structures of the NHS a moreor-less socialist form- of medical care requiring only an in
jection of formal democracy, Mick Carpenter (5) argues:'
A socialist health service .. . will be one where all barriers of
hierarchy and mystification, bctween.health workers and between
them and the sick people they work with are torn down. It will
be a health care provided neither because of the material necessity
11
that responded to the feminist critique would abolish the
sexist content of medical practice. Thus, women’s ailments
and conditions (e g, menstruation, menopause, pelvic igamVicente Navarro (6) has pursued this theme of changing matory disease) would be given proper attention. Gender
the social relations of medical practice, insisting that “Com stereotyping of women through the use of such labels as
munist medicine is not bourgeois medicine better distributed “hysterical” would be challenged. Women would take con-'
but, rather, a qualitatively new form of medicine created by
trol over their bodies in matters of sexuality (abortion on
new relations of collaboration and cooperation in the pro demand) and childbirth (natural childbirth). The form of ser
cess of the production and reproduction of health’’
vice would be altered so that women did not just perform
The forms of medical technology and science themselves
the caring functions such as nursing while men pei formed
are therefore likely to be transformed under communism.
a separate curing function. Nor would women be left to carry
This is not to argue that all capitalist medical science and
the burden of caring for the family. A socialist epidemiology
technology is false or wrong, merely that capitalist social rela
would
also incorporate a feminist epidemiology. Central to
tions of production are reflected in the present choice of
this would be the recognition that the disabling double
research areas and in the forms of technology used. Different
social relations, those of reciprocal cooperation' would be burden of paid work and domestic work should be alleviated.
The conclusion so far that socialist medical care would
reflected in the technology of communist medicine. An
attempt to specify the way medical technologies under embody a transformation in the social relations of medical
capitalism reflect the social relations of capitalist^ has been practice reflects the general conclusions I have drawn
made by the Radical Science Journal collective (7). For in elsewhere (14) that the transformation of the social relation
stance, Shelly Day (8) suggests that obstetric technology ships of welfare is central to socialist and communist social
reflects both capitalist and male interests in the \yay it rein policy. I have argued that the conception of a transforma
forces the passive role of women juSt at the point where tion of social welfare relationships needed to be thought in
(ideally) their active control of birth process is required. relation to six key aspects of social policy: I) the priority af
Postnatal depression, Day argues, may result from this highly forded social policy, 2) the form of control over welfare pro
vision, 3) the agency of welfare provision, 4) the nature of
contradictory experience.
Recently a number of authors and organisations have the relationship between welfare provider and user, 5) the
attempted to construct in a more concrete way the expecta rationing systems adopted by the welfare institutions con
tions we should have of a genuinely socialist medical care cerned, and 6) the assumptions embodied in the policy regar
policy. Colin Thunhurst (9) has argued that the scope of ding the sexual division of labour. 1 also argued that a distinc
health services should be increased to embrace an occupa tion should be drawn between socialist and communist social
tional health service controlled by workers. Alex Scott- policy. The summary of our expectations of both socialist
Samuel (10) has suggested the need for a socialist epidemio and communist medical care policy indicated in Table 1 is
logy in which a community diagnosis focus would be cen based on those general considerations relating to social policy
tral, where questions would be asked by those who live in as a whole and the specific considerations reviewed so far
a locality about who is ill and why and what could be done in this article relating to medical care in particular.
to create more healthy living and working conditions..-!! has
A few comments on Table 1 are necessary. First, it has been
also been argued (11) that the service should allow for alter argued so far that a policy for health under socialism (and
native modes of treatment, and for the involvement of peo communism) would not just be a policy of providing a
ple in the provision of services in the way that is now transformed medical care service. Issues of medical care
prefigured by some Well Women clinics. There should be a would be redefined into issues of health, which in turn would
“different relationship between health team and patient ... become issues of working conditions, housing, and economic
[providing] the patient with the opportunity to participate and social life in general. It has been argued (15) that a
in a fully informed decision concerning the course of treat socialist conception of health can only be developed once
ment.”
medical care itself, is removed from the centerpiece of
The Politics of Health Group (11) has argued that we need analysis. The view taken here is that in assessing progress
to challenge the medical dominance and “hierarchy” in the in any socialist society, we need to consider both the form
health service; to give patients more say in their own health that socialist medical care provision will take (to cure and
care; to capture more control over our health; to give “com care for those suffering from unavoidable disease) and the
munity care” real, meaning; to achieve more and better extent to which a socialist health strategy has been developed
routine health care for non-life threatening complaints; and that places equal emphasis on changing social conditions to
to fight the causes of ill-health. •
prevent avoidable ill-health. The table attempts to show both
One organisation that has tried in its practice to prefigure how the form of medical care would be different and how
these conceptions of a genuinely socialist medical care policy a socialist health strategy would be developed (though
in the here and now is the Community Health Council in
per aps concentrating more on medical care policy than on
Brent, North London. Its publication It’s My Life Doctor health strategy). Measures of whether a socialist health
(12) designed for use by the local community, sets out seven
strategy is eing developed are provided by the criteria deal
common medical problems, how they might be prevented, ing wit 11 te priorities ol medical care as between .cure and
how the National Health Service fails in relation to them,
prevention, an by the assessment of the outcome of medical
and what kind of preventive and curative health policy would
th? P°hCy. *" lCnns of morbidity and mortality.
be more appropriate to the needs of people suffering such
nnnnt c* ’1i* Pnor,ly given to medical care under socialism
problems.
The feminist critique of medical care practice under the h hPakiinP y C ™casurcd ’n terms of the resources put into
nerson nn SeCl°r ° l!le cconomy, whether in terms of money,
NHS is also vyell advanced (13). A socialist health service
person power, or facilities. While we would expect health exof wage workers nor out of an imposed set of obligations which
fall upon certain people, mainly daughters and wives.
12
Radical Journal of Health
pcnditurc to become a higher priority in the initial stages
of socialist development, the infusion of resources is clearly
no measure ol socialist progress in medical care in societies
already at the threshold ot communism. As we have argued,
greater bene!it in terms of the health of the population is
more likely to come from transformed working and living
conditions that prevent avoidable ill-health. A measure of
the output of the health service in terms of morbidity and
mortality rate is a better indication of the priority afforded
to a society’s health than a measure of money spent on the
health sector. A lower level of morbidity and mortality is also
likely to reflect the importance attributed by a society to the
preventive aspects of medicine, which are otherwise so dif
ficult to quantify.
What people suffer and die from is another important
measure of socialist progress. This applies both to under
developed and developed socialist societies. In the former,
the eradication of the preventable infections and com
municable diseases will be a crucial indicator; in the latter,
a reduction in the incidence of the new illnesses of developed
societies will be a measure. Socialist and feminist epidemio
logy has already made progress in identifying the social
causation rooted in the capitalist mode of production of such
conditons as cancer and cardiovascular diseases. A genuinely
socialist health strategy would therefore be expected to have
acted upon the conclusions of this new epidemiology and
effected changes in the relevant social conditions which will
show up in terms of reduced morbidity and mortality from
these new “capitalist” diseases.
Third is the rationing of medical care. Elsewhere (14) we
have concluded that services did not necessarily have to be
free at the point of use to be allocated along socialist lines.
As long as incomes were more-or-less equalised, and as long
as the commercialism of the private market was no longerpresent, the attaching of a price to a service provided by the
state (e g, housing) could permit the users of a service to
ration their own use of the service (a smaller or bigger
house?) according to their own set of priorities. Now there
is the argument that charges for health services, even if
incomes were equalised, should not be made because an in
dividual use of the service has indirect impact on the health
and welfare of others, and everyone’s use must therefore be
encouraged even if an individual would order her or his own
priorities differently. Indeed, there is even the argument for
Table 1
Expectations of socialist and communist medical care policy
Aspect of social policy Aspect of medical care policy
Priority
Control over welfare
provision
1. Outcomes in terms of
health
2. Resources in terms of
money
3. Resources in terms of
pcrson-power/facilities
4. Priorities in terms of
cure, care, prevention
5. Central control
6. Local control
7. 'Control of medical
technology industry
Socialism
Communism
Less and more equal morbidity and
infant mortality than capitalism;
greater and more equal life expectancy
Higher expenditure than capitalism
Less and equal morbidity and infant
mortality; greater and equal life
expectancy
Need for higher expenditure may
no longer exist
Need for higher level of resources
may no longer exist
Prevention and care central
Higher level of resources than
capitalism
Prevention and care prioritised
Central direction with political
cadre influences
Democratic worker and user
involvement.
Nationalised and progress toward
socialised relationships
Agency
8. Agency of provision
Relationships between
provider and users
9. Status of doctors
Slate, workplace, family and market
giving way to community provision
Lower than under capitalism
10. Division of labour in
medicine
Reduction of vertical and
horizontal divisions
11. Nature of medical
technology
12. Status of patients
Progress toward new forms
Rationing systems .
Sexual divisions
"13. Region and class access,
usage, and outcome
14. Rationing procedures
between individual
patients
15. Sexual division in
medical care employment
16. Sexist content of medical
practice
June 1986
Higher, accompanying deprofessionalisation of doctors
Progress toward equality
Free usage with access rationed by
work and need according to
democratically determined formulae
Progress toward no division
Progress toward no sexist content
Centre provides democratically
resolved planning guidelines only
Mass participation in policy
resolution and implementation
Socialised working relationships
within industry and between it and
the health service
Community provision
Equal status with all workers
Abolition of vertical divisions;
movement between horizontal
divisions
New forms of medical technology
reflecting communist social relations
Equal status with providers
Equal access, usage and outcome
Free usage with access according to
self-perceived need
No sexual division of medical
labour
No sexist content of medical
practice
13
a practice of financial inducements to use a particular ser
vice for the beneficial impact that an individual’s use of it
might have on the health of others. This assumption of nil
direct cost to the individual consumer of the service is built
into the table as a measure of socialist progress (even though
this may not be such a crucial aspect of a socialist health
service as is usually assumed). It can be taken as one measure
of a nation’s collective commitment to the health of all its
members.
for a healthier population than populations in equivalent
capitalist societies?
The Soviet Union spends a far smaller proportion of ns
gross domestic product on health care than the Common
Market countries. Michael Kaser (18) estimated that 2.5 per
cent of GDP was sppnt on health care m the USSR m 1968,
compared with 5.1 per cent of GNP for the United Kingdom,
8.0 per cent for Italy, and 5.0 percent for Ireland. A more
recent estimate (24) based on 1974 figures suggests this has
dropped to 2.5 per cent. However, in terms of the number
There are a number of other problems associated with the of doctors and hospital beds per head of population, the
criteria used to determine socialist and communist progress Soviet Union is far ahead of these same countries. There
in medical care, including those of putting into operation were, in 1977, 34.6 physicians per 10,000 people in Russia
the general measures indicated in the table. How exactly is compared with 2^ Z m the EEC as a whole. There were 121
the “lower” status of the medical profession to be determin hospital beds tor the same population in 1977 compared with
ed? How is progress toward deprofessionalisation to be 95 for the EEC (24). These details arc summarised in Table 2.
measured? What arc the indicators of the abolition of the The apparent paradox between low expenditure levels and
sexist content in medical practice? These problems of opera high-level provision is resolved once it is understood that first,
tionalisation are often compounded in practice by the non there has been far less capital expenditure on Soviet medical
availability of data. Despite these difficulties, however, 1 care compared with the EEC. In 1970, 5 per cent of health
believe it is possible to draw some general conclusions about service outlays was devoted to capital expenditure in the
the socialist status of the medical care policies of rhe coun USSR compared with 10 per cent in Britian in 1971-1972 (18).
tries studied.
This explains the often reported poor quality and over
crowding of medical care institutions and the lack of surgical
Soviet Medical Care Policy
and pharmaceutical equipment that occurs from time to time.
There are-many accounts of the Soviet health service by
As to the priorities within health service expenditures, it
writers of various shades of socialist opinion. These vary is clear that, despite the early creation of a preventive arm
from the openly enthusiastic (16) to the fundamentally critical of the health service, the hospital sector of medicine
(17). The summary survey provided here is distilled from dominates all the other sectors and consumes the largest pro
these and a number of other secondary sources (18-20). For portion of resources. The Bolshevik government in the very
the discussion of the extent to which there are sexist aspects early days established the important departments of sanita
to the organisation and content of medical care, more general tion and epidemiology, with responsibility for flying pro
works on the position of women in Russia have been con paganda squadrons combating social sources of disease. This
sulted (21-23). Detailed references are not generally provided was seen in 1928 by one sympathetic commentator (25) as
to these frequently, used sources.
“offering a good example of the new attitude and principles
of
Soviet medicine.” Even in 1925, however, expenditure on
George and Manning (1) stale that, at the outset, Bolshevik
medical care policy'goals included: comprehensive qualified sanitary and hygienic education and on campaigns against
medical care; availability to everyone in the population; a contagious disease consumed only 2.6 per cent of the health
single,~unified service provided by the state; a free service; 'service budget (25). The Council on Medical Education in
extensive preventive care, with the aim of creating a healthy 1925 aimed to produce doctors with not only a thorough
population; and full worker’s participation in the health ser scientific understanding of the connection between biological
vice. While many of these goals continued to guide policy
Table 2
and many were achieved, the development of medical care
policy also came to be shaped by other historical exigencies, Medical Care Expenditures, Resources, and Outcomes in the Soviet
especially in the periods of socialist retrenchment during the
Union, Eastern Europe, and Comparable Capitalist Countries3
New Economic Policy (1921-1929) and of intense industriali
Soviet
sation and forced collectivisation of the 1930s. The way these Indicator
Hungary Poland Nonsocialist
factors influenced medical care policy and the final outcomes ___________ Union
comparison
of policy will now be considered in detail, under the following Percentage of GDP 2.5b
3.3b
3.9b
5.1-6.7'
headings: the priorities of medical care; the control of
spent on medical care
(EEC states)11
medical care; the agency of provision of services; the rela Population/physician ■ 28pe
435*
606*
455* (West
tionships embodied in medical care; the agency of provision
Europe)
of services; the relationships embodied in medical care; the Popularion/hospital 82u'
114*
113*
105* (West
bed
rationing procedures adopted; and lastly, .the extent of sex
Europe)
Infant mortality/
27.8f
24.3
22.4*
11.4-17.6*1
ist organisation and content of medicine.
1000 live births
Priorities of Medical Care
Does Soviet medical care live up to the expectation we
would have of it if it were socialist in terms of 1) providing
more health care resources than comparable capitalist
societies, 2) distributing health bare resources and activities
disproportionately in favour of prevention, and* 3) providing
14
Life expectancy:
Male
Female.
(EEC excl.
Portugal)
66.5f
74.3f
66. lr
72.8f
66.5*
74.9r
70.2* ’
76.3*
(Britain)
GNpTl^Mm 8’ 20’"4- b ,974-1' ,971-72' d P-cn.aSeof
Radical Journal of Health
processes and disease, bin also with: 1) sufficient social
science background to enable them to understand current
s^Lia‘ . an^ world events: 2) the materialist point of view,
which is essential to a correct understanding of the mutual
relationship between an organism and its milieu, 3) the social
service point of view, which takes into account the working
conditions and home life of the patient; and 4) the knowledge
and ability not only to treat diseases, but to prevent them.
However, an analysis of the curriculum of the Medical School
of Moscow University of 1925-1926 suggests that even if we
aie to include such topics as “Historical Materialism and the
History of Revolutionary Movement,” only about 5 per cent
of the content was directly related to these four points. The
socialist idea of creating a new medical knowledge and prac
tice derived from new social relations of production reflected
in a new division of labour between doctor and patient, does
not seem to be borne out by the existence of this diseaseand clinically-oriented curriculum.
Turning to the present day, the proportion of doctors work
ing in hospital care compared with ambulatory care is in
creasing. There is more rapid increase in the number of
doctors specialising in tertiary medicine (e g, surgeons,
neurologists, psychiatrists) (17). One estimate (19) of the pro
portion of health care resources devoted to “environmental
health and physical education” is 4.8 per cent. There is
evidence, though, that the quality of primary care is better
than that of hospital care.
The outcomes of the Soviet health service, measured in
• terms of morbidity and mortality rates, cast considerable
doubt on whether sustained socialist progress in health has
been achieved. During the early years of the Revolution, pro
gress was made in decreasing mortality and morbidity. By
1925, even though industrial output and grain harvest were
below‘1913 levels, infant mortality had fallen to half of the
prc-Revoluiionary level (20). This progress, when compared
with that of the’West, has now been lost, as can be seen from
Table 2. Today, mortality rates for infants and adults com
pare very unfavourably. There were 27.8 infant deaths per
1000 live births in the whole of the USSR in 1975 and 19.2
pcr-1000 in the Ukraine Republic, compared.wth 15.7 in
Britian in 1978. Infant mortality actually rose from 1971.
when it was 22.9 per 1000, to 27.9 per 1000 in 1974 (20). Life
expectancy was 66.5 years for males and 74.3 years for
females for 1970-1975, compared with 70.2 and 76.3 for
Britain in 1977. There is evidence that life expectancy for
adult males began to decline in the mid 1960s. Age-adjusted
death rates for adults rose from 861 per 100,000 in 1965-1966
to 955 per'100,000 in 1972-1973. The largest increase in mor
tality has been in the 40-59-year category (20). The absence
of morbidity and mortality data analysed by social class docs
not permit any assessment as to whether there has been
greater equalisation in longevity and mortality.
An analysis of the diseases Russians now suffer and die
from also provides a disturbing commentary: “As the death
rates from infectious disease have fallen in the Soviet Union,
mortality from cardiovascular diseases and cancer has risen,
both relatively and absolutely. The force of these modern
epidemics has been sufficient to raise [the] age adjusted death
rate by 18 per cent over (he last decade” (20). Cooper and
Schatzkin (20) comment that “social environment... typical
of capitalist society.. . can be shown to be responsible for
these mass diseases.” The first Commissar of Health in the
June 198u
USSR said: “There is no interest in concealing the social
character of these diseases.. . the social causes of diseases
among working people are found out in order to remove
them." But Cooper and Schatzkin (20) conclude: “The
opposite [now] appears to be the case: disease is promoted,
its social character is obscured and avoidable hazards are not
removed T
Control of Medical Care
The early days of the socialist experience in Russia
(1917-1921) provide perhaps some of the most potent ex
amples of the possibilities of socialist medical care policy
in terms of formal control over medical care policy and in
stitutions. The direct confrontation in the 1920s between (he
medical profession’s Pirogov Society.and (he Bolsheviks.
which was won by the Bolsheviks with the aid of (he health
workers’ union, should be noted. This struggle curtailed (he
special privileges of the profession and the control ii had
over medical carc institutions al that lime. This early period
of Russian history provides us with (he best practical ex
amples of how the important issue of control of health ser
vice and other welfare institutions will be raised under
socialism. The debate, which is also recalled by Navarro (17),
between (hose who favoured control by the workers in health
service institutions and those who favoured control by soviets
or delegates of workers in a locality, is one which poses for
us now the question’ of what form democratic control should
take in any future socialist society. In this example, the form
of administration chosen was one in which doctors, as statesalaried employees, had no special professional access to
power, with the day-to-day management of health service in
stitutions invested in a nominee of the local.soviet, who
would be advised by an elected committee of health service
workers. Those who favoured control of each institution by
a democratically elected committee of workers of that in
stitution were criticised for not understanding the needs of
overall' planning and were defeated.
With the eventual erosion of any active life in the local
soviets and as soviets became empty conduits for the rule
of an increasingly centrally controlled and Stalinist Com
munist Parly that determined even local policies through the
national budget, any vestiges of active worker participation
in—let alone control, of—health service institutions disap
peared. At the same lime, the initial decline in the power of
the medical profession was reversed. The Ministry of Health
has relied heavily in more recent years on the advice of the
increasingly institutionalised medical profession, and it has
become the practice for all directors of health service institu
tions to be qualified doctors. The ratio of income between
doctors and nurses is now as large as 10:1 (17). Indeed,
George and Manning (1) conclude that, nowdays, “Soviet
health carc [is] centrally controlled to meet the requirements
of industrialisation and (he academic interests of medical
scientists.” However, despite this heavy reliance today on
medical personnel to run the health service centrally and
locally, a large proportion of these administrators are Com
munist Party cadres and are, of course, in the last analysis,responsible to the Central Committee of the Party (17). The
socialist notion of political control of policy through the
active involvement of party cadres at all levels of administra
tion is theoretically maintained; however, from the point of
view of an ideal socialist medical care policy, the ideas and
15
practice of these cadres leave much to be desired. They no
longer appear to favour—if they ever did—the genuine mass
involvement in health matters which should be the hallmark
of communist medicine.
Agency of Provision of Services
The main agency of provision of health care in Russia is
the state. Hospitals polyclinics, feldsher outposts, and so
forth arc all run on behalf of the state by local councils, but
there is scant evidence of mass participation in, or democratic
election to, the local bodies which run these institutions. The
workplace features quite significantly in the system of pro
vision. Under the Stalinist industrialisation policy, a large
number of health centres were established in industrial enter
prises. There ranged from 100-bed hospitals to the provision
of a nurse. They were organisationally separate from the
Soviet-run health services and were part of a policy of giving
priority to preventing loss of industrial production. The
demands of industrialisation and the needs of workers
coincide to some extent here, but it is not easy to determine
how far these services gi\e priority to the latter over the
former when it comes to a direct conflict between them. The
scarcity of Russian data on disease and death analysed by
social group, and the nonpublication of accident data, is
perhaps indicative of which priority is uppermost. There is
further evidence of the priority given to workers in Russia
by the development of separate health service institutions run
by and for railway workers and the wide provision of rest
cure and convalescent homes and holiday villas by trade
unions for their members.
The private market is an important provider of medical
care services in the Soviet Union, although there is some legal
and some illegal private practice. Abortion constitutes on
example. Additionally there are autonomously financed
medical institutions, or “paying polyclinics’’ (plutnaya
poliklinika), in Moscow and other big cities where patients
pay a small sum for prearranged appointments with
specialists. Like the nonpaying polyclinics, these are run by
the local authority and are not really examples of the opera
tion of a competitive market in medicine. They provide,
however, a commentary on medical care rationing procedures
used. If you can pay, you get better treatment. Although it
is discouraged, payment for treatment is also made on a
regular basis to doctors and nurses in ordinary state hospitals.
In the 1960s the table of customary payments ranged from
5-25 roubles for attention in hospital to 500 roubles for a
course of treatment for venereal disease by a senior specialist
(18). Women in the family still provide a large amount of
medical care in terms of nursing the sick and elderly. This
is institutionalised in the provision made for women (not
men) to receive state grants for time off work to look after
sick children.
Relationships Involved in Medical Care
Turning now to the various aspects of the relationships
involved in medical care, wc must remember that the status
of the medical profession in the Soviet Union is lower than
in the West. The division of medical labour is similar,
however. The only exception is the feldsher system of partly
trained nurses-midwives-practitioners who practise in rural
areas. This is a socialist innovation, but one inherited from
pre-Revolutionary days. Indeed, early Bolshevik policy, later
.
< ,-ui nf these “second-class doctors.”
a“or not Bolshevik policy initially understood that
socialist medicine must redefine the pract.ce of medtetne, tn
such a way that a change in the division of labour takes place
in both the vertical and horizontal senses, there is no evidence
that this policy was pursued in latet years. Indeed, the
absence of a family doctor system brings specialisation and
mechanistic medicine even into the diagnostic stage of the
polyclinics. George and Manning (1) write.
For example, the Ministry of Health recently stated that “it is
impossible to conceive tb
-ly a single doctor with a broad
background co- ” ” ”
-^antec highly qualified care for patients
suffering from a variety of illnesses which arc frequently com
plicated to diagnose and treat.” Such a view in contrast to the
major incidence of relatively simple and sclf-Iiimting illnesses
brought to primary-level physicans, clearly indicates rhe inteiest
and perception of medicine oriented towards academic specialisa
tion rather than patient needs.
. • ,
ri
There is also the practice of tipping doctors, which reflects
the esteem in which doctors are held by patients. There are
no adequate independent complaint procedures against doc
tors. There is no free choice of doctors by the patient. These
points contribute to the conclusion that there has been no
sustained challenge to the relationships involved in the
capitalist practice of medicine in the Soviet Union. Navarro
(17) is convinced that.the Soviet system of health care is
dominated, as in the West, by what he terms technologicalisation, depoliticisation, hospitalisation, and urbanisation.
Rationing Procedures
Docs Russian medical care embody socialist aspirations
in its system of distribution and rationing? There is evidence
(1) of a sustained attempt to provide for a reasonable degree
of territorial justice between different regions of the USSR
in terms of doctors and hospitals, although the quality of
service probably varies geographically more than the quan
tity. The emphasis on central planning has enabled this
achievement to be registered. Within each region of the coun
try, however, resources arc concentrated in the urban
areas.For example, Moscow in 1972 had 76 physicians per
10,000 inhabitants compared with 28.3 for the country as
a whole (17). There does not appear to be a larger number
of feldshers to compensate for this in the underprovided-for
rural areas.
It is more difficult to be precise about the allocation-of
services between social classes and groups. The urban con
centration of resources, taken together with the development
of workplace-based health services, reflects a concentration
of provision in favour ot the urban working class as oppos
ed to the peasantry. There is, however, no hard evidence about
health service usage by social class, or even, as wc saw earlier
health outcomes by social class. Nor is the impact of any
differential usage on health known.
The fact that polyclinics arc, for example, open on Sun
days for all services is a reflection of an overt policy to make
services available in a way that fits the needs of working peo
ple. Against this, however, has to be set the existence of
closed-access clinics and hospitals such as the colloquially
termed Krc/nlouka for senior state and party officials. There
is also a special polyclinic for scientists with a doctorate Fur
thermore, the people who have privileged access to'these
facilities arc the ones who are likely to be able to purchase
pharmaceutical preparations, not otherwise readily available,
in closed-access shops (/.akrytie rasprediteti) (18).
Radical Journal of Health
The medical care services arc for the most part free, with
the exception of the paying polyclinics described earlier. Price
is generally as a rationing device only in relation to drugs,
denture, spectacles, and surgical appliances, and there are
the exemptions for the young and the disabled. About 30
per cent of the cost of drugs in 1970 was recoverable by
charges, which compared with 50 per cent in Britian (18).
How services that are free are actually rationed informally
between competing consumers is again not known. Waiting
lists and queues clearly Operate, but there is no discussiondi the impact of these informal ad hoc rationing devices on
usage by class, age, or sex in the literature reviewed.
health care as it affects female consumers is far more pat
chy. The right to abortion -has sometimes existed in Russia
and other times, especially from 1936 until the 1960s, has
been expressly removed (26-28). The demographic needs of
the country have, in later years, played the most important
part in influencing this policy. Childbirth nearly always lakes
place in hospitals. In so far as medical care and allied child
care facilities have been developed with the extra express
“needs” of women in mind (c g, their right to paid time off
to nurse a sick child in hospital), it has been argued that they
have been predicated oh the twin requirements of women
as workers and as mothers. The emphasis on the. role of
women in Russia as mothers, despite their role as workers,
Sexual Divisions
is well-known and, some would argue (29), was even present
There are two aspects to the impact of the Russian health in the work of Alexandra Kollontai in the 1920s. Indeed, it
service on women: first, the extent of and nature of female would appear that there is resistance among some Russian
involvement in health service employment; and second, the women to the demands of this double burden, so that genetic
’ degree to which the practice of medicine is sexist in its con- and psychological counselling is now a service being provided
. tent. There is no doubt that women have been recruited to in Moscow' to encourage childbirth and happy marriage (21).
all ranks of the medical and nursing professions and to an Lapidus (23) concludes:
cillary employment in the health services in far larger pro
Soviet sociological analyses show no sensitivity to the distinction
between reproduction—a biological fact—and child rearing or
portions than in equivalent Western health services. Ninety
housekeeping—socially learned roles whose relationship to biology
per cent of primary care physicians, 70 per cent of nonprofes
is not given but requires explanation. The equation of. femininity,
sional workers, and 50 per cent of managers and administ
maternity and domesticity is virtually universal, and the recogni
rators are women. Eight-five per cent of the total health
tion that roles might be socially assigned rr'hcr (han endowed
labour force is female (17). (It must be remembered that the
by nature is largely, absent.
status of even senior professional health service employees Although Lapidus does point later to emerging Russian ex
is lower in Russia than in the West.) Women moreover occupy amples of critical literature that attempt to challenge this idea
a small proportion of the more senior posts. Only 20 per (literature that goes so far as. to present.the case for reduced
cent of medical professors are women. There is also some working hours for nien to overcome the sexual division of
evidence that, as the status of doctors increases, the employ labour), it is more than likely that mpdical care texts, educa
ment of women in this sphere is declining. Only 54 per cent tion, and practice in this area are predicated on conservative
oRthose now embarking on medical training are women, and and antifeminist assumptions. A feminist analysis of Russian
men are admitted into medical studies with lower grades than medical textbooks and medical practice is awaited.
women (21).
It is possible now to go some way toward determining
Evidence to allow any firm conclusions to be drawn about whether any or all of the 16 expectations of socialist or cotnTable 3
Extent to which Socialist and Communist Medical Care Expectations have been Realised in Existing Socialist Societies
'Aspect of medical care policy3
1. Outcomes in terms of health
2. Resources in terms of money
3. Resources in terms of person-power/facilities
4. Priorities in terms of cure, care, prevention
5. Central control
6. Local control
7. Control of medical technology industry
8. Agency of provision
9. Status of doctors
10. Division of labour in medicine
11. Nature of medical technology
12. Status of patients
13. Region and class access
14. Rationing procedures
15. Sexual division in employment
16. Sexist content of medical practice
Number of socialist expectations realised
Number of communist expectations realised
Soviet Union
Nob
No
Socb
NoSoc
No
’/z Soc
Soc
Soc
• No
No
No
No
*/: Soc
Soc
N.A.
6
0
Russia, 1917-21
No .
No
Soc
Soc
Soc
Soc
/i Soc •
Soc
Soc
No
No
No
No
'/: Soc
Soc
N.A.
8
0
Hungary
Poland ‘
(Solidarity’s
proposals)
No
No
’/: Soc
No
Soc '
No
V> Soc
. Soc
Soc
No No
No
No/i Soc
_Soc
N.A.
5'/:
0
No
No
No
.No
Soc
No
'/: SOC
Soc
Soc
No
No
No
No
No
. Soc
N.A.
4'/:
0
(Soc)
(Soc)
(Soc) .
(Soc/Com)b
(Soc/Com)
(Soc/Com)
(Soc/Com)
(Soc/Com)
(N.A.)b
(N.A.)
(N.A.)
(Soc)
(Soc)
(Soc)
(Soc)
(N.A.)
(12) .
(5)
Notes', a See Table 1 for an explanation of criteria used in this table.
•
b Abbreviations- N A., inadequate information available to enable judgement to the made; No, the socialist or communist expectation
has not been realised’Soc, the socialist expectation has been realised; Soc/Com, the aspect of the service could be attributed to the
realisation of cither socialist or communist expcctaion; Vi Sqc, in some respects but hot all, socialist expectation has been realised.
June 1986
munist medical cate delineated in Table 1 have been realised
in (he Soviet Union. The results are tabulated,'along with
those for the other countries to be reviewed in this article.
in Table 2. For only five of these indicators is it felt ap
propriate to claim unqualified socialist achievement in con
temporary Russia, with some indication of this in a further
two. The five relate to the level of service provided (more
doctors and beds), the nature of the central control of the
health services (political), the agency of provision of medical
care (state and workplace), the status of physicians (lower),
and the position of women as employees of the service (large
percentage). Even some of these-have to be qualified, how
ever, and, importantly, there is evidence of recent'reversal.
The slatqs of doctors appears to be rising, the position'.of
women in the profession declining, and the influence of
medical expertise on -central policy increasing.
It is, of course, possible to interpret even these five in
dicators of socialist medical care policy in a different light.
It could be argued that these aspects of the service are com
patible with, and necessary to, the needs of an exploitative
state capitalist or state bureaucratic ruling class. Their
apparently socialist character may conceal other reasons for
their existence. A society in which the accumulation needs
of the ruling group took precedence over the consumption
needs of the working class would quite likely adopt tight cen
tral control over health planning, develop a workplace-based
system of health care to ensure productivity, limit the in
dependent influence of doctors (and be more successful at
this than a capitalist ruling class operating in conditions of
parliamentary democracy), and pull all women into the
labour force. Indeed, such a state capitalist or state bureau
cratic class, while adopting these measures, would equally
not adopt many of those measures which we have associated
with socialist medical care but which Russia does not exhibit.
Such a class would not spend much on health, would not
allow a democratic form of control over its institutions,
would not encourage preventive measures which clashed with
accumulation needs, and so on.
There is certainly no evidence of communist achievement
in Russian medicine. Paradoxically, however, in the early days
of Revolution there was some such evidence in, for example,
the democratisation of the service at- a local level. This
development has long since been reversed. There was also
an important stress earlier, at least in official pronounce
ments, on preventive medicine. Russian medical care, then
provides us with very few concrete examples of our concep
tion of ideal socialist medical care, and none of communist
medical care.
One final cautionary note. It was stated earlier that in one
particular way the table of expectations of socialist and com
munist medical care (Table 1) underemphasised the fun
damental break with capitalist medicine that communist
medicine entails. Communist medicine would involve itself
with all aspects of social and productive life (working con
ditions, living conditions, eating habits, relationships) in so
far as they affect health. This review of Soviet medical care
has only noted such wider aspects in small ways, and then
negatively, c g, in relation .to the pattern of disease, which
is similar to a capitalist one. It is most unlikely that all aspects
of social life in the Soviet Union are evaluated in terms of
their impact on health. The conclusions drawn therefore pro
bably overemphasise the socialist nature of Soviet medical
care policy.
18
Hungarian Medical Care Policy
I do not intend to provide as exhaustive a review of
medical care services in Hungary or Poland. Both countries
occupy similar positions as members of Comecon and arc,
as we shall see, Modelled in many ways on the Soviet ex
perience, with the important difference that they had this
experience imposed on them after the Second World War.
There is a limited secondary literature available on the
Hungarian health service. The main sources used here are
Kaser (18), Ferge (30), and World Health Organisation
(WHO) publications (31), which are supplemented by per
sonal observation and by discussions with the small group
of social analysts working within the Institute of Sociology
in Budapest.
Health care is universally available in Hungary and largely
free at the point of consumption; however, this university
was finally achieved only in 1975. The insurance basis of the
scheme excluded about 15 per cent of country dwellers, in
1960, but this was reduced to about I per cent by 1972 as
a result of the collectivisation of agriculture that took place
between 1958 and 1962. Those excluded were helped on a
means-tested basis with medical fees by the social aid com
mittees of local councils. Before the Communist Party came
to power after the war, a large proportion of the population
was excluded from coverage—except for the 133 days of
Hungarian Soviet Republic of Bela Kun in J 919, a genuinely
Hungarian-born revolutionary workers’ council type of
government, under which medical care was in principle pro
vided free to all. (This regime was crushed and replaced by
an authoritarian right-wing regime.) The system of health
care in Hungary is remarkably similar to that in Soviet Union
in a large number of aspects, although there is less factory
medicine, more private medicine, and no use of feldshers.
The overall conclusions about Hungarian medical care are
summarised in Table 3. They arc remarkably similar to those
for the Soviet Union, except that whereas the socialist nature
of aspects of Soviet health care was in some doubt because
of non-availability of data, the availability of such data for
Hungary defines these aspects more clearly as nonsocialist.
This is particularly the cause in the matter of inequality of
morbidity and mortality by social class. Hungary differs from'
the Soviet Union only in not ever having experienced the brief
democratisation of the health services that Russia did-in the
early years-of the Revolution.
Polish Medical Care Policy
The purpose of including Poland in the survey is to ex
amine whether the working-class uprising led by Solidarity
in 1980 and 1981. might have made medical care policy more
genuinely socialist had it not been.suppressed^ In the discus
sion of Soviet and Hungarian medical.care polices, little men
tion was.made of the existence of any social forces struggling
against the current form of provision./ This was mainly
because there are none at present having much impact.
Poland, by contrast, provides us with a modern laboratory
in which to test out the theory that working-class struggle
agaihst the existing form of socialism contains within it the
seeds-of a struggle for a mote genuine, type of democratic
socialism. Clearly Solidarity drew into its wake all manner
of ideas, themes, and groupings whose aims may not have
been the better development of "socialism; however,-these
counter-revolutionary tendencies were insignificant (32).
Radical Journal of Health
More interesting is whether the end result of the struggle for
socialism by Solidarity might have led to a pluralistic con
ception of socialism in which self-managed enterprises
became increasingly subject to market forces to the possible
detriment of the overall socialist objective For our purposes
here, we focus on the demands and the forms of struggle
that arose in the cour.se of the life of Solidarity as far as
medical Care is concerned.
In almost all respects, Polish medical care policy is like
that of the Soviet Union and Hungary. Data on health ex
penditure and medical care outcomes are included in Thble 2.
The number of doctors and hospital beds per head of popula
tion is small compared with both the other Eastern Euro
pean countries studied and Western Europe. A full account
of medical care policy in Poland can be found in Millard
(33, 34) and Kaser (18). Millard (34) summarises his findings
as follows:
The health service has remained in a state of crisis, currently
i worsening as a result of mounting economic dislocation and
political tension. Inadequate access to treatment, lack of continui
ty of care, poor quality of care, profound shortages of drugs and
supplies, and the absence of preventive medicine are some of the
manifestations of this crisis. Its main causes lie in the political
weakness of the Ministry of Health, with consequent underfunding and the non-fulfilment of its plans. This situation is ex
acerbated by continuing organisational fragmentation, the neglect
of primary care, existence of conflicting aims in health policy,
and the dominance of an ideology of clinical specialism.
Rather than reviewing the Polish health service systemati
cally in terms of the six questions and 16 criteria applied to.
the Soviet Union and Hungary, I shall concentrate on three
aspects of policy which, taken together, indicate just how.
far the Polish health service had reached a state of crisis even
worse than in other Eastern European countries surveyed.
As we shall see later, it was precisely to these aspects of
medical care policy that Solidarity paid most attention in
its proposals for fundamental change in Polish society. The
three aspects are the failure of the central planning system,
the inequalities of access and corruption involved in access
to decent health. services, and the neglect of preventive,
medicine.'The summary Table 3 does, however, evaluate the
Polish medical care service in terms of all the criteria
established earlier.
Crisis of Planning
Central planning of medical care and the implementation
of the plan at the local level are in the hands of people placed
in position through the system of nomenklatura. This party
control of key positions extends as far as directors of im
portant medical establishments (32). It was described in the
critical report prepared by members of the Experience and
Future Discussion Group (DiP) (35) in Warsaw in 1980 as
“the personal merry-go-round’’ which enables a person listed
to be appointed to a post conferring equivalent or even higher'
status after having bungled a previous job. The tendency in
this situation is for particular aspects of plan fulfilment to
be nominally achieved even by cheating or misrepresenting
data, and for plans to be politically constructed to accom
modate the interests of those engaged in their nominal fulfil
ment. Those whose jobs rest on paper fulfilments have no
interest (unless pushed from below) in real fulfilment of
plans, especially if, as we shall see later,-their particular
material interests are separately catered to. Only the
democratic association of actual producers has a genuine in
1
June 1986
terest in real plan fulfilment. These tendencies found expres
sion in the Polish health services in terms of, for example,
extending the stay of certain patients in hospital who no
longer needed treatment to bring down the average cost of
treatment of patients registered in that hospital to the norm
in terms of cost per patient per day. Another example is that
certain units did not provide access to diagnostic equipment
for other units since they did not want to bear the cost. A
further example is where construction enterprises concen
trated on fulfilling easier compdnents of their building pro
gramme than those represented by hospital construction. In
so far as problems arising from these practices were iden
tified by the Polish government, the solution was always seen
in terms of improved administration rather than a political
challenge to the structural aspects of the system that led to I
these practices (34).
Inequality of Access
The other side of this coin of bad management is that the
managers can afford to be protected from its worst aspects
by virtue of their privileged access to special clinics, or their
ability to bribe their way past the access barriers of the state
service. The following account drawn up by the Experience
and Future Discussion Group (35) portrays this graphically:
The state of the municipal and general hospitals is catastrophic:
hospital wards are overcrowded, and cases of death among patients
left in hospital corridors are not uncommon. Conditions created
by chronic under-investment in health services fully warrant the
assertion that access to treatment, hospitals, good doctors and
medical equipment has become very difficult to obtain for the
majority of the public. At the same time, the privileged few have
special enclaves of luxury closed to people who do not belong
to that group. A glaring example is the Ministry of Health clinic
at Anin. .
Free health care for the vast majority of the population was once
considered an achievement of People’s Poland. But unfortunately,
today the situation is completely different. Irregularities and defi
ciencies in health care havC meant that medical treatment now
requires money, quite a bit of money, as well as connections and
pull. They have led to a distressing situation—if one does not
bribe the nursing staff, one does not get decent attention, and
if one does not bribe the doctor his care will be marginal. One
now pays to get a bedjn a hospital or an operation, to say nothing
of medicine. Gradually the public Is being divided into two
categories: those who can afford proper medical care and those
who cannot.. If the situation docs not improve substantially, the
latter group will get even larger. If we are to compare incomes
to the real costs of obtaining treatment by a specialist, we would
probably find-that at least half the public could not. afford it to
day. This situation is alarming in the extreme.
It has been estimated (36) that the money allocated recently
to create 120 places for the privileged elite at the Anin Clinic
could have added 1,100 places for ordinary patients. This
privileged access to special hospitals is riot restricted to the
managerial and bureaucratic elite, but is available also to paid
officials of the TYade Union Central Committee. The TUCC .
has its own polytechnic “which has the advantage.of refer
ral for inpatient treatment to the Hospital qf the Ministry
of Internal Affairs” (18). No doubt this was one of the
reasons for the rapid desertion from the official trade-union
movement to Solidarity once it was formed.
Neglect of Preventive Medical Care
The lack of'attention to preventive medicine in Poland in
volves the continuation of dangerous working processes, the
19
pollution of the atmosphere and rivers, and the production
of carcinogenic foods. On the first point, a Solidarity
spokesman (32) stated:
Health and safety has been one of our greatest problems for many
years. The health and safety representatives of the old unions were
too close to management. The health and safety councils were
worthless. Production had to be kept up at all costs.
Something of the consequences of this situation can be
judged by an analysis of work days lost in Poland. In 1974,
accidents, poisoning, occupational, and nonoccupational in
juries were reported to be the cause of 20 per cent of all days
lost from work (18). On the question of atmospheric pollu
tion, the Experience and Future Discussion Group (35)
commented: ‘
Industrial enterprises emitted 3,439 million tons of gases [in 1977]
into the atmosphere but trapped only 667,000 tons. If one adds
to this that the majority of stack filters are almost always shut
down because of the energy shortage, it must be concluded that
Poland is one of the few countries in the world in which emis
sion of industrial gases and particles into the air is not subject
to control.
On the question of harmful foods, the same report (35)
asserts that “25 per cent of the food products on sale have
characteristics that are to some degree harmful to health, to
say nothing of the many food products that are commonly
adulterated by producers!’ Added to this must be the chronic
alcoholism in Poland. .
Table 3 summarises the pQsition as far as the socialist
status of its health services is concerned. Even allowing for
the corrupt system of party nomenklatura to be classed as
socialist cadre control, Poland scores still worse than its
socialist neighbours. The second column indicates the ex
tent to which the demands of and forms of struggle adopted
by the Solidarity movement during its brief life, if imple
mented or adopted permanently, would have led to the health
service becoming more genuinely socialist or even
communist.
Solidarity and Medical Care Policy
Clearly a number of different political currents were pre
sent within the Solidarity movement. Those who propounded
an explicit commitment to a Marxist analysis were probably
in a minority, and argued with others who held a perspec
tive of a pluralist socialism in which decentralised self
management enterprises operated to meet needs in the con
text of market demand. Nonetheless, it was impossible to
perceive a fairly consistent line emerging from Solidarity on
the question of health policy. This policy can be deduced
from the reports of thesExperience and Future Discussion
Group (35), the text of the charter of Workers’ Rights
published in September 1979 (32), from the Gdansk agree
ment itself in August 1980 (37), and from ad hoc reports that
emerged from Poland before the imposition of martial law
in December 1981. These reports indicated that more
resources should be found for health care and greater priority
should be given to preventive medicine. This was usually ex
pressed in the more limited terms of occupational safety, but
a general concern for “the pillage and devastation of the
natural environment” was present. In common with all other
parts of the economy, the centralised planning system should
be replaced by a system of workers’, self-management.
'Medicine should be free (at least, and this reflects a certain
sectionalism in the union’s demands; to health service
workers). Privileged access to medical care should be abolish
20
ed and a fairer democratic rationing procedure for aiiocation to, for example, holiday homes, should be worked out.
Early retirement (age 50 for women and 55 for men or f er
30 and 35 years’ work, respectively) was a further healthrelated demand. Missing from the analysis of issues and list
of demands was any real confrontation with the existing
horizontal technical division of labour m medicme or with
the form of technology and curative procedures used,
although, in general transformed social relationships were
at the heart of the methods and goals of Solidarity. The
statements on the status of the medical profession were
equivocal on this point. Also absent was any concern for the
sexist content of medical practice. Indeed, spokespeople in
volved with 0*•* --f m movement often expressed quite con
servative views on the issues of central concern to Western
socialist feminists. The Experience and Future Discussion
Group (35), for example, concluded: “Family policy oughtto be as solicitious of the material well being of the family
as of its moral status, which requires better preparation for
family life, safeguarding the stability of the family, and the
efforts to control the mass spread of abortion!’ The October
1981 Solidarity conference resolved, in a section dealing with
family policy, to urge the creation of decent living conditions
for unmarried mothers in order to discourage abortions.'
However, by November -1*981, one month before the demise
of Solidarity, the Guardian (38) could report the existence
of a Women’s Forum in Warsaw which listed among its areas
of concern the need to dispel stereotyped images and harm
ful myths about women in society, to ensure teaching about
and improvement of birth control techniques, and to over
come the situation where arguments about abortion are
“distinctly naive.”
While a number of such general goals of medical care policy
were emerging during the life of Solidarity, sectional demands
were also being put forward of interest only, for example, to
the workers in the health service- The demand that salaries of
all health service workers be increased, and that additional pay
ments be made for handling patients with infectious diseases,
are two of these The latter embodies the idea of hazard pay,
which could be criticised from a socialist perspective
Solidarity, in the form that gave rise to these"demands,
is now repressed. This, itself, is a commentary upon the
nature of Polish socialism. However, even in* its short life,
and before it had time to work out a strategy for the suc
cessful implementation of workers’ democracy in Poland, it
accomplished some achievements in the health, field. These
included: the change of use of administrative buildings to
health use, the sacking of certain incompetent and corrupt
health officials, the closure of an aluminium plant in Silesia
because of the effect it was having on the local environment.
and the direct control by workers of the distribution of
medical equipment in short supply.
Thus, while Millard (33), writing even before the demise
of Solidarity,- was partly correct in his interpretation that
“there is no cause for optimism as the Poles struggle with
the problems of years of under-funding, a cumbersome and
inadequate planning system, a weak ministry, and a hierarchy
of organisation and status which favour, clinical specialism
to the detriment of a.widely conceived primary care sector
unifying curative and preventive medicine”, he was also partly
wrong in not seeing the potential, albeit not realised, for the
sodahst transformation of the health service that was surely
there m the ideas and programme of Solidarity
Radical Journal of Health
Conclusions
This survey of medical care policy hi existing socialist
societies has led to one inescapable conclusion. In the
economically advanced socialist societies of the Soviet Union
and Eastern Europe there is very little evidence of socialist,
let alone communist, forms of medical care policy. Mortality
data from these countries, which are a measure of health
policy as distinct from medical care policy, also compare
unfavourably with data from equivalent capitalist countries.
Il has been argued that the few characteristics of Eastern
European medical care policy that have’been described as
socialist (e g, the state’s role as major provider, the lower
status of doctors, the employment of women in the health
sector) may be attributed, for example, to the fact that these
societies are dominated by a state bureaucratic or a state
capitalist ruling class. Such a class is able to exercise more
effective control over employment policies and levels of pay
unhindered by the independent health trade unions and pro
fessions that are a factor in the West.
The accounts have not revealed a static picture of policy.
There was evidence in the early days of the Russian Revolu
tion of radical experiments in medical care policy. These seem
to have given way over the years to a more orthodox capita
list-like view of what constitutes good medical care. Hungary
and Poland never experienced such radical experiments. The
possibility, once again for the moment repressed, of a new
leap forward toward a more genuine socialist and even com
munist medical care and health policy in Poland has been
described.
Acknowledgment—1 am indebted to Julia Szalai of the
Institute of Sociology, Budapest, for her detailed comments
on a first dr-aft- of the section on Hungary.
USSR International Journal of Health Services 12(3), 1982.
21 Buckley, M Women in the Soviet Union. Feminist Review 8. 1981.
22 Heitlingcr, A Women and State Socialism. MacMillan, London, 1979.
23 Lapidus, G Women in Soviet Society. University of California Press,.
Berkeley, 1978.
24 Pluto/Maspero.’World View 1982. Pluto, London, 1982.
25 Haines, A J Health Work ih Soviet Russia. Vanguard Press, New
York, 1928.
26 Scott, H Does Socialism Liberate Women? Beacon Press, London,
1978.
27 David, H Family Planning and Abortion in the Socialist Countries
of Central and Eastern Europe. Population Council of New York,
1979.
28 Connexions 5, 1982.
29 Heinen, J Kollontai and the history of women’s oppression.’A'fir
Left Review 110, 1978.
30 Ferge, Z A Society in the Making. Penguin, London, 1979.
31 World Health Organisation Regional Office for Europe. The Plan
ning of Health Services. WHO, 1980.
32 McShane, D Solidarity, Spokesman, London, 1981.
33 Millard, L FThe health of the Polish health service. Critique 15, 1981.
34 Millard-, L F Health care in Poland: from- crisis to crisis. Interna
tional Journal of Health Services 12(3), 1982.
35 Vale, M Poland: The'State of the Republic. Pluto, London, 1981.
36 K O R The state of the hospital system. Critique 15, 1981.
37 Programme of the Solidarity Conference of October 1981. Labour
Focus on Eastern Europe 5(1-2), 1982.
38 The Quardian. November 5, 1981.
Deacon
Department of Social and Political Studies
•Plymouth Polytechnic
Drake Circus
Plymouth, Devon, PL4 8AA, England
Obstetrician on Trial
AFTER a 10-month suspension from all clinical and lectur
ing duties, obstetrician Wendy Savage is in the midst of a
month-long inquiry into the management of five women dur
References
ing childbirth at the London Hospital. She is accused of pro
1 George, V, and-Manning, N Social Welfare and the Soviet Union. fessional incompetence, a charge usually reserved for
Routledge & Kegap Paul, London, 1980.
alcoholic, drug dependent or similarly incompetent doctors.
2 Lenin, V Quoted in reference, p 105.
The barrister representing the local health authority
1 Bahro, R The Alternative-irf Eastern Europe. New Left Books,
which'brought the charges said the case was being presented
London, 1977.
4 Doybl, L The Political Economy of Health. Pluto, London, 1979. as if it were a Contest between the-male establishment and
5 Carpenter, M Left wing orthodoxy and the politics of health. Capital the women’s movement, and between the impersonal.imposiand Class II, 1980.
tion of technology and a woman’s freedom to decide how
6 Navarro, V Radicalism, Marxism and medicine. International Journal
she gives brith. While he does not see the case in this light,
of Health Services 12(3), 1982.
the women’s health movement in Britain is convinced it is
7 Radical Science Journal 9 & 11, 1981.
8 Day, S Is obstetric technology depressing? Radical Science Journal precisely that.
Wendy Savage is the only obstetrician at the hospital .
12, 1982.
9 Thunhurst, C It Makes You Sick. The Politics of the NHS. Pluto, who does home visiting for ante-natal care, and she involves
women fully in decisions as to how they give birth. She is
. London, 1982.
10 Scott-Samuel, A Towards a socialist epidemiology. Critical Social at odds with other doctors in the hospital over the politics •
Policy Conference. Sheffield, 1982.
of obstetric practice, and has fought to keep the abortion
11 Politics of Health Groups. Cuts and the NHS. Pohg, London, no date.
unit open when others would like to close it. There has been
12 Brent Community Health Council. It’s My Life Doctor. London, .
evidence during the inquiry that the head of obstetrics in
1981.
13 Doyal, L Women, health and the sexual division.of labour. Critical tended to try and oust' her from the time he took over his
job. The previous head of the department, who had set the
Social Policy 3(1),' 1983.
14 Deacon, B Social Policy and Socialism. London, 1983.
principles and standards which Ms Savage also follows, also
15 Stark, E Doctors in spite of themselves. The limits of radical health faced a great deal of hostility until he left.
criticism. International Journal of'Health Services 12(3), 1982.
What the local health authority probably did not ex
16 Hyde, G The Soviet Health Service. Lawrence & Wishart, London,
pect was for the case to get such wide public attention. The
1974.
17 Navarro. V Social Security and Medicine in the USSR. Lexington inquiry has been held in public at Ms Savage’s request, ac
companied
by constant
media coverage and public discus
Books, Lexington, MA, 1977.
,
.
Kaser, M Health Care ih the Soviet Union and Eastern Europe. Croom • sjOn. Whatever the outcome, the practice of obstetrics is
Helm, London, 1976.
bound to be affected, as so many women have heard the
19 Ryan, M The Organisation of Soviet Medical Care. Blackwell/Martm- arguments for women’s choice in childbirth.
Robertson, London, 1978.
..
20 Cooper. R, and Schatzkin, A. The pattern of mass disease in the
June 1986
—Women Global Network on Reproductive Right*
comm^itv health a--,
t.’i.r"1 fioori s,-ws ro.,<
Population Policy and Situation in China
A Note
malini karkal
Chinese population policy has had two major programmes to control births.' the
launched in the early 1970s and the one-child family campaign introduced tn 1979. The
results of these campaigns have been undoubtedly impressive, surpassing the ac tevemen s
?
Even so. it is unlikely that the goal of limiting the country’s population to 1.2 billion tn the year 2000 set by
the Chinese govrnment will be achieved. Opposition to the one-child family programme as een wi esprea ,
especially since the introduction of the ‘responsibility system’ changing the unit of economic management from
the production team to th.e family. The one-childfamily norm has also been found to clash wit i tra itiona
inese
social and cultural beliefs and practices.
•
The author concludes by asking whether, by seeking to drastically restrict child-bearing, the Chinese govern
ment may hot be undermining its ability to foster the kind of development that it now believes to be crucia for
achieving the four modernisations.
THE Chinese population was estimated .to be 410 million munist Party of China and the State Council stipulated the
in 1840. By 1949, when the People’s Republic of China was Instructions on Conscientious Advocacy of Family Plann
founded, the population had grown to 540 million, show ing. These advocated controlling of births. Family planning
ing an annual net increase of 1.19’million, or an average an projects were undertake in cities. Production and distribu
nual growth rate of only 0.25 per cent. High birth rate tion of contraceptives was systematically planned. The ufban
accompanied by high death rate accounted for the low growth brith rate showed a definite decline as a result. However,
preoccupation with the Cultural Revolution in 1966 halted
rate of population during this pre-liberation period.
After the establishment of the People’s Republic, the coun all other work, including that of family planning, thus
try’ population situation showed a dramatic change.. The resulting in the earlier mentioned rapid growth in popula
death rate which was well above 20 per thousand (28 per tion during 1966-71.
thousand in 1936) dropped to 10-18 per thousand in the 1950s
In the early 1970s a vigorous family planning movement
and then came down further to a little over 7 per thousand ws launched which had the motto “later, longer and fewer”.
by 1970. This change was brought about by improvement The programme advocated later marriage, longer spacing
in sanitation, public health, medical care and consequent between births and fewer children. The age at marriage was
elimination of several infectious diseases.
meant to be 25 for men and 23 for women in rural areas and
An even more marked change was noticed in infant mor 26 for men and 24 for women in urban areas—a five-year
tality. The infant mortality rate (IMR), which was well over postponme’nt from the 20 for men and 18 for women
200 per 1,000 births during the pre-liberation period, came stipulated under the Marriage Law of the early 1950s.-A
down to 70.9 by 1957. In 1970 the urban IMR was 11 to 13 spacing of at least four years between births was expected.
and in the rural areas it was around 30.
And finally the expected number of children per couple was
The birth rate continued to be high and till 1970 it was two.
above 33 per thousand. This high birth rate coupled' with
In 1978 family planning work in China entered a new stage
the low death rate resulted in rapidly growing- population. and in 1979 the “one couple, one child” policy was put forth.
In the six years between 1966 and 1971, the population of The new Constitution stipulated “the control of population
China increased by 120 million, a figure close to that of the quantity, the improvement of population quality, and the
growth during 1840 to 1949, a period of 109 years. *
mutual adaptation of population and socio-economic
During the early years of the People’s Republic from 1949 - development”- In keeping with this objective it was officially
to 1952, a period considered to be one of economic restora announced that “the State promotes family planning so that
tion, the rise in the natural growth of popultion was regarded popultion growth may adapt to the plans for economic and
as an indication of prosperity and improvement in the stan social development . .. Both husband and wife are obliged
dard of life of the people under socialism. During this period to practice family planning ... Late marriage, and late
neither abortion nor sterilisation was permitted.
childbirth-should be encouraged”. Simultaneously, close kin
Unchecked population growth and its effects on planned . and persons with congenital and genetic diseases were pro
economic development attracted the attention of leaders and hibited from marriage.
scholars and that influenced the change in Chinese popula
China now has a goal of keeping the average rate of
tion policy. In August 1953 the Government Administration populaton growth to 1.2 million per annum till 2000 AD.
Council approved “regulation of contraception and induced It has a policy that advocates one child per couple, strict con
abortion”. However, at this time neither was any definite trol of second births and resolute prevention of third births.
family planning programme formulated, nor was there any Strict action is expected against families not following this
education of the people for planning and limitation of births. policy.
. •
Family Planning Policy
Impressive Results
A specific family planning policy was formulated in the
Demographers point otft that the achievements of the
early 1960s. ‘In 1962 the Central Committee of the Com- .family planning programme of China are incomparable.
.22
Radical Journal of Health
° th70 Chl^esc women bore an average six children; by
1980 this number had dropped to 2.2. In 1981 and 1982 woman was 2.3-and not 1. This difference was'in part an
Chinese fertility showed a minor increase,- but in 1984 the effect of a change in the timing of first births that resulted
number of births per. woman was 2. It is expected that from the enactment-of the new-Marriage Law of 1980.
Chinese fertility will show a further decline in the future. Though the law had raised the legal age of marriage asTDfed
by the Marriage Law of the early 1950s, from 18 to 20 for
The previous world record holder in fertility decline, Japan,
girls and from 20 to 22 for boys, in effect’the new legal age
had shown a reduction of ‘only’ 56 per cent during a com
of marriage was lower than that stipulated under the latcrparable period and the number of births per woman in Japan
longer-fewer campaign. Thus the passing of the law has
had come down from 4.5 in 1947 to.2 in 1957.
lowered the age of marriage-in reality.
From the discussion so far it is seen that the Chinese
Another problem in implementation of the policy of the
population policy has had two large-scale programmes to one-child family has been the decentralisation of the
control births, the later-longer-fewer campaign introduced administrative responsibility for enforcing it. Individual
in the early 1970s and the one-child campaign introduced localities are responsible for propagating and, implementing
in 1979. Obstacles to the implementation of the one-child the regulations. Top-ddwn pressures for stricter enforcement
family programme include the agricultural responsibility combined with bottom-up demands for more children have
system which strengthened the motivation for large families resulted in several lacunae in the implementation of the
by shifting responsibility for production from the collective policy. Another problem in the implementation of the policy
to the household. Chinese culture also advocated “more sons, is related to the economic incentives, such as wage sup
more blessings” and the Marriage Law of 1980- in effect plements and priority in housing, schooling, medical care,
lowered the age at marriage. Facing public resistance, in early etc. These costs are expected to be borne by the local
1984 the. Party Central Committee reviewed its stand on fer authorities. Where the local authorities are rich, many
tility control and on 13th April issued a Central Document. couples sign up and as a result eat into the local funds.
The Central Document reaffirmed the critical importance
Another difficulty has been that local cadres have many
of family planning and re-emphasised the need to promote incentives to manipulate figures to match the officially
the one-child family in order to achieve the four modernisa prescribed quota whereas the higher level cadres have few
tions, quadruple industrial and agricultural output, raise per incentives to-uncover these errors. As a result, the data defi
capita income to S 800, and hold the population at 1.2 billion ciencies created at the bottom of the administrative hierarchy
by end of the century.
are passed upwards, multiplying as they go up.
The immediate demographic results of the later-longerAlso, official policies pronounced over rime have had con
fewer and the one-child campaigns are most readily measured flicting effects. The responsibility system introduced in
by the recent rapid reduction in fertility. Bongaarts and 1980-82 shifted the unit of management and accounting from
Greenhalgh have analysed the effects of the two policies on the production team (a unit of 20 to 30 households) to the
the Chinese population. They state that as a result of the. family. This system also reduced the common funds of teams
socio-economic development during the post-revolution and increased the private wealth of families. The economic
period, the fertility of the Chinese population would have value of children has been increased and there is a strong
undoubtedly declined, though at a much lower rate than the motivation for larger families. Encouragement to small-scale
observed one. These authors observed that replacement fer enterprises and sideline activities has also motivated larger
tility (family size of two children) would have been achieved families. In the light of improved prosperity, the incentives
at the beginning qf 21st century, instead, of in the early 1980s for the one-child family have become ineffective.
as actually observed because of government efforts to reduce
In the light of the experience so far, UN estimates suggest
that on an average the Chinese family is more likely to have
fertility.
Bongaarts and Greenhalgh estimated that, without the. 1.9 children by 1990-95 instead'of the officially prescribed
later-longer-fewer campaign of the 1970s, the Chinese 1. The Chinese population, according to UN projections, is
population would have growth frpm 0.818 billion in. 1970 to therefore estimated to be 1.23 billion by 2000 and 1.43 billidn
1.58 billion-in 2000 and 2.41 billion in 2050. In contrast, the by 2025. These figures arc higher than the target of 1.2 billion
later-longer-fewer policy, by itself, would bring about a for 2000. Further, the Chinese population is expected to con
popultion size of 1.28 billion in 2000 and 1.81 billion in the tinue to grow after 2025, against the government’s goal of
a decline to 917 milion by 2050.
year 2050.
Thus the implementation of the later-longer-fewer policy
Social and Cultural Consequences
still leaves an eventual population size well in excess of 1.2
billion in.the year 2000—the goal stipulated by the Chinese
Sociologists predict many detrimental effects of the oneleadership. The one-child campaign is expected to solve this child policy in terms of its effects on intra-familial relations,
problem. A completely successful implementation of this gender inequality and the psychological characteristics of
policy" would virtually stop growth of population. The only children. They also opine that by fundamentally alter
population would reach 1.04 billion in 2000, 1.06 billion in ing the basic social and economic unit, the onc-child policy
2025, and then fall to 917 million in 2050.
may tear the fabric of Chinese society in a way that uproots
people’s sense of their place in the world and the family’s
Opposition to One-Child Family Norin •
ability to take care of the old. These problems have already
Experielice fof the five-year period from. 1980 to 1984, the begun to emerge and are likely to grow more severe if the
period after punching of the one-child family policy, shows one-child policy is successfully implemented.
In the accepted system the unit of family is concerned with
that in reality the. population size is higher than expected.
short-term
tasks of production and consumption and the line
It was observed that the average number of children per
23
June 1986
is concerned with long-term matters of inheritance, succes
sion and inier-gcneraiional countinuity. An individual’s place
in the descent line gives him a sense of immortality and
meaning to his existence. Among the basic duties of an
individual to his family is to produce a son for the conti
nuance of the family line. Since the sex-ratio at birth is
around 105 boys to 100 girls, the one-child family policy will
leave almost half the couples without a son and prevent the
men from performing their duties to their ancestores, thereby
uprooting their sense of the continuity and purpose of life.
The resistance of the Chinese population to the one-child
family is noticeable everywhere. Cases of famalc infanticide
and physical abuse of mothers who give birth to daughters
have also been widely reported.
The Chinese Constitution makes its obligatory for
daughters to support their parents. Acceptance of this change
at the cultural level is obviously not easy. Even in families
with sons, the benefits for only-children are provided by the
State or the collective work unit, rather than the parents.
Thus the work units supplant parents as providers and the
earlier prevalent system of the mutual obligations of genera
tions is disturbed. This change is bound to affect the oldage support which, under the traditional system, is provided
by the family.
Since late 1978 China has moved to expand the role of the
private sector, not only in agriculture but also in commerce,
services and industry. Since the family has proved to be the
most effective production unit in such a set-up, the one-chile
family policy will work against the success of the role of the
private sector. A family with one son is too small-to be effi
cient and that with one daughter will face restrictions on ver
tical extension.In short, by drastically restricting child-bearing, China may
be limiting its productive capacity and undermining its ability
to foster the kind of development that it now believes is
crucial for achieving the four modernisations.
References
John Bongaarts and Susan Grcenhalgh, ‘An Alternative to One-Child
Policy in China’, Population and Development Review, Vol 11, No 4,
December 1985.
Jain Song, Chi-Hsien Tuan and Jing-Yuan Yu, Population Control in
China: Theory and Application, Pracger, Praeger Special Studies,
New York, 1985.
Judith Banister, ‘Analysis of Recent Data on the Population of China’,
Population and Development Review, Vol 10, No 2, June 1984.
Liu Zheng, Song Jain and others, China’s Population: Problems and
Prospects, China Studies Series, New World Press, Beijing, 1981.
Leo A Orleans (cd), Chinese Approaches to Family- Planning, The
Macmillan Press Ltd, 1979.
Malini Karkal ■
International Institute for Population Studies
Deonar, Bombay 400'080..
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24
Radical Journal of Health
Health Care in Mozambique
padma prakash
Independent Mozambique, despite constant threats to
its very existence and three severe droughts m ten years
has succeeded in evolving a framework for providing /
‘ational health care. This article examines developments
m health care within rhe revolutionary context of the gov
'ernment’s avowed programme for constructing a socialist
society.
MOZAMBIQUE is a country of five million on the south
eastern coast of Africa. It became independent in 1975 after
a prolonged ten-year armed struggle against the five centuries
old colonial rule of Portugal. Spearheading the liberation
movement was the Frente de Libertacao de Mocambique
(FRELIMO), the vanguard party of the alliance between the
workers and peasants. The armed struggle can be said to have
begun in September 1964 with 48 guerilla fighters in four
provinces of northern Mozambique. Portuguese troops
numbered 70,000, half of them European. In the 10-year war,
over 2,000 FRELIMO guerillas were killed.
The constitution ol the Republic of Mozambique and
the government programme envisage the construction of a
socialist society. Within this revolutionary context and as a
part of the programme of reconstruction, Mozambique has
made radical changes in its health care structure which has
meant a reprioritisation of health care, the introduction of
new types of health personnel; more appropriate mothods
of education; and a fundamental restructuring of the phar
maceuticals sector. It is the last, Mozambique's drug policy
which was elicited much interest and attention by its suc
cess in bringing down the prices of drugs and making them
available to the largest numbers. However, none of these have
been isolated programmes—they have been proposed and im
plemented as an integral part of a comprehensive programme
of nation-building derived from a larger political perspec
tive of a socialist society. Also, it seems obvious that these
programmes, especially relating to health care, have evolved
out of the years of struggles and that experience of
FRELIMO in the liberated zones has informed social policy
after independence.
Before examining the health care programme in indepen
dent Mozambique, it is useful to take brief note of the
political and economic developments in the country and the
external pressures and internal constraints which have in
fluenced the course of development.
In September 1975, the first FRELIMO-controlled parlia
ment, albeit appointed by the Portuguese, was installed as
the transitional government. However, even as it began to
find its feet, in December it had to focus its energies on put
ting down an attempt by a section of the army to bring down
the government. In the aftermath, President Samora Machel
warned against the tendency of confusing “popular victory
with permission to satisfy egotistical desires and consider
ing luxury and depravity as a right by dint of.. .participa
tion in the struggle.”
In July 1976, the Mozambique Council of Ministers met
for the first time and outlined the country’s development
policy and its main priorities. These were directed not at
“reforming the country’s old structures but at replacing them
with a “new society for the benefit of the masses . The state
ment said: “... radical change (was envisaged) to place the
state at the service of the masses of workers and peasants.
Priority was to be given to rural areas—and national defence
June 1986
was to be closely linked io nation-building and resources were
to be mobilised for setting up “communal villages”. As
regards religion, the masses would be protected against any
pressure to practise religion. “The Catholic church is a reac
tionary organisation giving rise to counter revolutionary ac
tivities in people’s democracies.” Efforts were instituted to
transform the FRELIMO forces into a regular army and to
reorganise the police force.
One of the major features of the development policy was
a scries of nationalisation measures—the takeover of private
schools and colleges, hospitals, clinics and all private doc
tors’ and lawyers’ practices. The export of cashew nuts—
45 per cent of world output—was placed under govern
ment control. All buildings and land were taken oveiTCertain individuals” were to work for three years without pay
ment. Everyone had to pay one day’s salary each month in
to a “solidarity bank” to be used to help “oppressed people
of the world”, particularly Nambia, Rhodesia and South
Africa. With the announcement of nationalisation measures
however, relations with Portugal deteriorated and agreements
of co-operation between the two countries remained
suspended.
While 60,000 Mozambique refugees who had fled to
Tanzania were invited to return, new citizenship legislation
denied residence to any foreigner who had satyed outside the
country for more than 90 days. Thousands of Portugese who
had fled the country after racial clashes in 1974 lost the right
to return.
The liberation of Mozambique “radically altered the
balance of forces in favour of African nationalists” There
was an intensification of guerilla warfare against the White
minority regime in Rhodesia by African nationals based in
Mozambique. The border between the two countries was
closed and Mozambique, following UN imposed sanctions
including the confiscation of Rhodesian property in Mozam-,
bique. This resulted in a closure of Rhodesia’s rail links with
the ports Beira and Maputo. It also cut Rhodesia’s food sup
plies to Mozambique. Mozambique appealed to the UN
Security Council for an aid of S 1,000,000 a year to meet
the financial consequences of the decision to apply sanctioris
against Rhodesia. Sweden increased its aid to Mozambique
by 40 per $ent. UK supported the decision; Uganda and
Zambia saw Mozambique’s decision as an “act of courage
and commitment to the cause of peace and justice tor all
mankind” and urged support for Mozambique until victory
was won by Zimbabwe. Mozambique’s losses in customs and
port dues were estimated at £ 17,000,000 a year and about
86,000 Mozambians, it was feared, might be prevented from
repatriating their earnings from Rhodesia.
By 1983 Mozambique was reeling under the worst ever
drought in 50 years. Moreover, the tactics of the Mozambique
National Resistance supported and funded by South Africa.
of attacking crucial economic targets, of kidnapping foreign
technicians and attacking health centres were aimed at under-
25
cities. Private health care was available only to a privileged
mining Mozambique’s effort at creating badly-needed
urban bourgeoisie. Even within the public health care system
development facilities. Harvests were disrupted and in one
district all the seven communal villages, three agricultural lees were charged for services as 'he b-sis of race. Social
co-operatives and state farms were destroyed. Black discrimination was practised in all hospitals and services were
marketing in food and other consumer essential were ram separate to Blacks and Whites. With (he emphasis on
pant and there was a rise in crime rates. Death penalty which lucrative private practice, curative medicine developed to the
had been abolished in 1979 was reinstated as was public Hog detriment of promotivc and pievcntivc health care. Majoi
ging for robbers, rapists and black marketers, whereas the public health programmes were,taken up only sporadically
previous emphasis was on clemency. In early 1983. chloera or under pressure from the international community.
Typically, as elsewhere, the country was purposely kept
killed 250 people and afflicted 7,000 in drought affected
underdeveloped—people had little access to educational or
regions.
In /\pril 1983 the Fourth Congress of the FRELIMO other facilities. Mozambicans were a source of cheap labour,
party set out some immediate goals which ..necessitated a especially in mines in other countries. Police and military
change in priorities in certain areas. The Congress recognised authorities were used to repress progressive ideas and
that combating hunger was the immediate priority. It out movements.
lined agrarian reforms-—small family farms, which had thus
Medical 'Training
far received little help were to be supported. The develop
The first medical school was set up in 1963 and the first
ment of large farms, and of agriculture co-operatives was
seen as a medium-term objective. Slate farms were to be doctors graduated in 1969 --the students being drawn mostly
reorganised and consolidated instead of expanded in the from the elite. Of 122 graduates before independence only
following five years. Existing machinery was to be put to bel two ever joined public service. The (raining which was tor
ter use. Resources were to be diverted from large projects in seven years was archaic and outmoded even by existing
industry and agriculture to small projects which would yield European standards with “excessive theorisation” and lack
immediate returns. In the party polilburo the emphasis of practical training. What little there was of “practical"
shifted from military personnel to peasants and those who training comprised thoerotical demonstrations in the presence
had been active in the liberation struggle. President Machel of patients. Basic laboratory methods were not taught, but
acknowledged that Mozambique had “erroneously developed diagnosis according to the trainers, depended upon sophisti
a hostile attitude to private enterprise”. A new investment cated laboratory methods.
code was drawn up in 1984 permitting transfer of profits and
tax exemptions, etc, in certain sectors, but not in sectors such Pharmaceutical Industry
as petroleum. No private unit has been allowed to be set up
Mozambique had no pharmaceutical industry of its
in the pharmaceutical sector either.
By 1984 over 5,000,000 people had been affected by own—all drugs were imported. The six supplying countries
drought. Agricultural production was cut by 80 per cent in were Portugal, Switzerland, West Germany. South Africa.
the country’s 10 provinces. Lakhs of tonnes of cereals and France and UK. Over-invoicing, monopolies for supply of
cassava, a staple food, were lost. According to an FAO report, certain drugs, etc, were typically rampant. Most TNC sub
100,000 died of starvation. Mozambique signed an agreement sidiaries showed large deficits. The government drug budget
with South Africa—in return for South Africa withdrawing was S US 1 milion in 1974 for a population of 9 million—
support to the guerilla forces of the Mozambique National average of US S 0.11 per capita. Any drug regulation was
Resistance, Mozambique would expel ANC activists. How virtually non-existent. .Almost the only drug ever banned
ever. MNR continues to receive aid and clandestine support from being imported was thalidomide. Most drugs were
from wealthy Portugese in South Africa who number over available over.the counter irrespective of their potential
600.000. The MNR is now said to be operating in all the hazard.
country’s provinces. Only the northern most province, the
Health Care in the ‘Liberated Zones’.
cradle and stronghold of FRELIMO is free from such ac
tivity. The RNM is said to have 8,000 to 17,000 men.
Even at the outset when the armed struggle for libcraFood aid has come in from East European countries as lion began in 1964, the health of the fighting people was a
well as from USSR, Zimbabwe etc. However, Mozambique major concern. First aid assistants and rural medical aides
has never been self-sufficient in food. The country’s annual were trained and supported by one doctor and a few nurses.
cereal requirement is around 515,000 tonnes; local produc As (he struggle developed into a ‘popular democratic revolu
tion is only 180,000 tonnes. It is against a background of tionary’ movement the colonial administration collapsed in
these developments of the last ten years that we must view many places. Invariably, the destruction of health services
accompanied the withdrawing of colonial authority.
changes in health status and health c<*re.
In these ‘liberated zones’ FRELIMO took over the
State of Health Carr in Mozambique before
responsibility of administration and building new structures
to govern the areas. One of the first such services the
Independence
FRELIMO was compelled to set up were health care facilities.
Health service before independence had the In the beginning the liberated zones were divided into smaller
characteristic features of health care under colonialism. There administrative units. In each geographical administrative unit
was economic, racial and geographic discrimination. Health were built health centres and-hospitals using locally available
facilities were predominantly urban and in White settler materials. A hierarchical network of health units was created.
areas—over -Ards of the doctors in 1974 were in Maputo. These health facilities became particular targets of attack.
Auxiliary diagnostic facilities were available only in three These units had to be built in the forests and even there they
26
Radical Journal of Health
vsere constantly under threat of air attacks which included
citizenship.
napalm bombing. Education and health facilities became
In 1977 a new National Health Service (NHS) was set up
priority areas of concern. Ambulators services were also pro.
and a new health, policy defined and evolved certain
vided in remote villages and also so as to protect the health
priorities:
structures from being delected by the colonial armv—which
Preventive medicine and environmental sanitation and
would have been likely if obviously ill people had had to move primary health care:
over distances io come to hospitals.
Extending health coverage, the top priority being given
However, the lack of adequate personnel for providing to “communal villages” which were being constructed incor
health care led to innovations and the training ol local people. porating agricultural co-operatives, medical care, family plan
Political and military training of course preceded health ning, occupational health and school health programmes..
training. Neither the militants nor any other category of
Strategies for controlling major epidemics—TB. leprosy.
worker received salaries at this stage.
schistosomiasis, sleeping sickness, blindness', intestinal
Attached to these larger health units was a farm where parasitosis with (he diagnostic and prophylactic measures.
land was worked and food produced collectively by everyone. defined.
These hospital (arms played a very important role in defining
Evolving a health team approach with new categories
a more realistic concept of health—health was associated not of personnel
just with the curative process but with production and pioAnd mov importantly, ensuring and encouraging com
per distribution of the right kinds of food.
munity participation.
Once the liberation movement gained strength and the
In 1977, to provide a basis for changes in the health
colonial structures began to break down rapidly; constraints structure and the redefining of personnel a pedagogical
regarding resources and personnel became more acute. It was seminar was held with doctors who had been exposed to
at this point that it was acknowledged that the preventive health problems in the liberated zones. It was decided that
measures would considerably ease the pressure on curative the doctors of the future were to be able to organise, lead
facilities which was becoming acute due to lack of resources. and train a health team and act as a •health agents’ to
Military personnel began to be trained as ‘sanitary agents’ transmit health concepts to people A new curricula was
and health educators. Over a million people—almost the designed .to suit the purpose. A community orientation in
entire population of the liberated zones—arc claimed to have even those subjects which had hitherto had a clinical ap
been immunised against small pox and cholera in this period. proach was attempted. However, the leader of the health
team, it was proposed, would be a ‘graduate in health ser
Post Independence Development
vices’ and not a ‘doctor’. Specialisation would be after 2-5
The experience gained during these years was attemp years in primary health care work a: the community level
ted to be generalised even during the phase of the transitional under supervision. He/she would then be called ‘doctor in
government. In the health sphere this was a period of con health sciences’. This concept of the ‘doctor’ as rhe leader
frontation in many ways between the health workers trained of the health team has undergone some change. Bv 19SI
in the liberated zones and the university trained medical per attempts were being made to ‘democratise’ the decision a\
sonnel. The concentration of sophisticated equipment and to who should lead the team. Also, there was provision now
the razzled dazzle of medical technology often undermined for horizontal mobility. But these changes aimed at diluting
the confidence of the ‘new’ health personnel. The attitude the rigidity of the hierarchies in the health system were being
of the university trained doctors was both openly challeng opposed vigorously by doctors.
ing and subversive. This group, both nationals and foreigners
There were other problems in bringing about such
with its technical expertise and its class background played radical changes in the concepts of medical education. There
a significantly detrimental role.
was only one training school for doctors and this could not
The decision to nationalise health services was therefore be closed. Secondly, any change in the medical education
an urgent necessity, especially if access to health services were curriculum had to be such that the final qualifications would
to be open to all without class and race distinction. Secondly, be recognised by the world medical community, as well as
these measures were necessary to slop “mislortune and sceptical elements within the country.
diseases” from being “motives for exploitation”. And thirdly, Drugs for All
ii was only with this decision that it became possible to “en
By 1978 a new pharmaceutical policy had also been
sure the reprioritisation within health care” and ensure that
adopted
which has been resoundingly successful. Il was
the curative .component of health did not mask the relevance
of the socio-economic roots of ill-health ol disease. Most directed at reinforcing national economic independence: a
importantly, the role played by doctors and the medical new pharmaceutical regulatory system was established to
establishment was becoming a threat to the liberation move check the flow of drugs into, the country: the NHS was to
ment. In nationalising the services, president Machel aptly develop adequate structures for the management ol drugs.
A new Pharmaceutical Service was created in 1975 under
described doctors as “social parasites” and “traitors” who
the ministry of health. A Theraputics Expert Committee
dispensed medicines “like beer from a bar’.
An immediate consequence of this nationalisation was (CTTE) was established as well as a central agency for
an exodus of doctors from Mozambique. Only 60 doctors medicines and medical supplies. A new law was passed com
remained in the country by October 1975 together with about pelling drug agencies to re-register their products, and firms
a 100 medical students and teams from North Korea. China were told that the government wished to sec as few products
and Bulgaria. Two years before there had been 300 doctors, as possible in the market. However, their compliance was
almost all White. Of the teaching staff of 96 in 1973 only entirely voluntary. In the months that followed the ‘request’,
14 remained—of these only five opted for Mozambican the numberof products in the market fell from 13,000 to
June 1986
27
ivn only
2,6(X). It ;/so eart.cd ’.he government 0-> * 70/XX) <htou;d>
registration fees.
By December 1976 the CI IE had produced a jk*w
national formulary 10 months after the WHO’*. first rcpon
on Essential Drugs. It listed 640 items comprising 4W
therapeutic substances, 20 diagnostic agents and 14 dressingsA second revision of the formulary was published in 1980
which contains only 502 items.
Prescription rules were also established, one of these
being that all prescriptions were to use generic names. In 1981
a study of 4,OCX) prescriptions showed that 33 per cent were
in accordance with the National Formulary rule.4. Com
pliance was lowest in the casually department of the reputed
Central Hospital in Maputo where there arc health person
nel from various countries who are not familiar with generic
names.
A state corporation MEDIMOC has also been establish
ed for drug procurement by the merging of five private
import companies which had been abandoned by their
foreign owners. By 1981 60 per cent of the drug procurement
for NHS was being handled by MEDIMOC. The new' drug
tender system had also accounted for a 41 per cent savings
on drug purchases. In 1977 a state corporation for the retail
sales of drug was also formed to ensure availability of quality
drugs.
The creation of a national pharmaceutical industry is
one of the objectives decided upon at the Third congress of
FRELIMO in 1977. Preparatory studies arc under way and
a small ORS plant has been set up. The government phar
maceutical budget has gone up from US S one million in
1974 to S 12.5 million in 1982 accounting for 20.1 per cent
of health budget from 8.1 per cent in 1974.
Conclusion
Given the fundamental conviction that everyone has a
right to health, the actual realisation of the political nature
of the skewed distribution of health facilities came about
through FRELIMO's experience in liberated zones. Not only
were health facilities the targets of the colonial army, the
medical establishment’s support to the government acted to
strengthen anti-people measures. The denial of health care
to people on the basis of class, race or sex was not a matter
of chance but a deliberate measure by the colonial rulers to
suppress and undermine the development of the revolu
tionary potential of the masses. Nationalisation of health
services was an important act not only because it would en
sure that health care would-be more accessible to people but
because the measure effectively nullified the subversive nature
of a discriminatory health system and deflated the poten
tial influence the medical establishment could wield over the
masses.
However, implementing changes that strike at the social
status of doctors has not been easy. Although there does not
appear to be any reporting on this aspect, there is reason
to believe that dissatisfaction among doctors regarding their
remuneration and social status has been rising. The idea that
a doctor may be just one of a health team and not its leader
will take a long time to be accepted. Another feature of the
health system which is not much discussed appears to be the
notion of community participation. While the ‘health agent’
is selected by the ‘community’, it is not clear as to what is
the extent of their participation. Mozambique’s 12 million
people speak 12 languages and 21 dialects and also belong
28
a no: :on.
.< - e made
■t; mor; dill?/;
emphasis on
roes between
it and more sop'msuca
:e of heart
be under some strain. I
diseases which often l
surgical measures, may be rather hign. In 2 nealth census
of six villages the incidence of hypertension
n per cent
in the coastal villages and 25 per cent inland. 1 he 1,800-bed
hospital in Maputo has highly sophisticated cardiac service
with one of the three theatres being reserved exclusively-for
it. Whether this is a genuine response to health needs or a
mailer of ‘prestige’, especially considering the close associa
tion of some of these surgeons with the famous South
African heart surgeons is not clear.
Another area about which little is said is the status and
use of local/tribal health practices. Although some of the
local doctors have been retrained as health agents, this does
not mean that local practices, if they have survived at all,
have been integrated. In fact, this is very unlikely. The em
phasis has been on using modern preventive and promotive
measures—immunisation, nutritional inputs (which has
hardly got off the ground) popularising the use of latrines,
use of ‘clean’ water, etc.
It is Mozambique’s drug policy which is an unqualified
success. Prices of drugs have fallen since 1977; they are being
made available to an increasing proportion of the popula
tion and there has been a drastic curtailment of unnecessary
and toxic drugs. The policy is under periodic review and revi
sion. But the development of an indigenous pharmaceutical
industry will bring other problems—of imports of machinery,
raw materials, of wages and ultimately, of cost of drugs.
These arc, howevbr, not insurmountable problems.
Even ten years after independence Mozambique has to
cope with constant threats to its very existence as a state
necessitating heavy military expenditure it can ill afford. It
is dependent on imports of grain to feed its drought-struck
population. Despite all this, it has so far succeeded in
establishing a framework tor the provision of rational health
care to its population.
[AcKnowledi’emeni: Some of the information (and insights) is from in
terviews with Dr Carlos Marzgao in 1983.]
Bibliography
Martins. Holder, Gameiro, Victor and Cabral. Jorge “Health for AH:
Another .Approach based on the experience of the liberated zone
during the people's war in Mozambique” Paper presented at the
seminar organised by the Dag Hammarskjold Foundation. Uppsala
1977.
Marzgao. Carkw and Martins. Holder, “Alternative Medical Education:
The Mozambican Experience” Paper presented at the seminar on
‘People and Health' at Dacca, 1983.
Marzgao. Carlos and Marlins. Holder: “A Theoretical Model for the
Training of community-oriented people-dedicated graduates in health
sciences”: paper presented at the Dacca seminar, 1983.
Martins, Holder: ‘‘Pharmaceutical Policy in Independent Mozambique:
The first years . Bullcim, 14(9), Institute of Development Studies
Sussex, 1983.
Padma Prakash*
19. June Blossom Socy
60-A. Pali Road
Bombay 400050
UPDATE
news and notes
Health in Seventh Plan: Boost
to Private Sector
IF recommendations of the Bhore Committee (1946)
are to be considered as some kind of a bench mark ratio proportion of allocation between FP and Health
tor health planning, then one has to admit that ail the Sector has increased from 0.002 to an astounding 0.96
plans for the health sector, including the latest one per cent between the First and Seventh Plans. A cor
have failed to live upto it. For instance, the Bhore relation between the percentage allocations to health
Committee has suggested that for a population bet and FP over the Seventh Plan periods shows a high
negative correlation (Pearson’s r) of - 0.88. Along
ween 10,000 and 20,000 there should be a 75 bedded
with the narrowing ratio gap between health and FP,
Primary Health Centre (PHC) which would provide
this rvalue is a clear indication that the growth of* the
coordinated preventive and curative services through public health sector has been sacrificed" in favour of
doctors, public health nurses and health assistants. family planning activities.
However, 40 years later even the 6th Five Year Plan
Reviewing the performance of health programmes
(1980-85) target of one PHC with only seven or eight
beds for a 30,000 population is far from realisation. the Seventh Plan document states that, “Most of the
implementation of health sector plans have never concerned (disease) control programmes suffer from
poor management and monitoring. .. Health manage
been taken seriously because:
a. The health sector is not considered a priority area ment support and supervision is an area that needs
of development by the government. Since the power considerable strengthening’’
Further, the Seventh Plan emphasises the need to
base resides with the kulaks upon whom the vast rural
landless and marginal and small farmers arc depen provide greater support to the voluntary sector in both
dent for their livelihood state resources are mainly used health and family planning. This is in keeping with the
to strengthen the surplus appropriation capabilities of promise given in the National Health Policy of 1982,
‘The policy envisages a very constructive and suppor
the kulaks and the bourgeosie.
b. The private health sector and the system of private tive relationship between the public and the private sec
practice of medicine has prevented the government tors in the area of health by providing a corrective to
from appropriating the medical and health functions re-establish the position of the private sector’ (India,
by providing sops such as ‘charitable hospitals’ and 1985).
That the focus of the health sector will continue to
‘voluntary hospitals’ that provide ‘concessional’ care.
be
family planning activities is made clear by the
c. Government planning and programming has never
taken into account what the actual requirements of the following statement in the Seventh Plan document in
people are—people have always been ‘given’ what the tersectoral co-ordination and co-operation and the in
government thinks the people want, and even that does volvement of voluntary agencies in the programme (of
the government) will be necessary in this (FP) pro
not reach the people; and
gramme to an even greater extent than in health. Add
d. The Government’s obsession, under the influence
to this the large allocation to the family planning sec
of imperialist agencies, in planning and implementing
tor of Rs-3,256.26 crore which as a proportion to the
health programmes, has always been with family
health sector allocation of Rs 3392.89 crore is the
planning.
highest ever (proportion = 0.96).
The Seventh Five Year Plan (1985-90) in the above
Another important feature of the health sector in
sense is no different from the earlier plans. It provides
the Seventh Plan is its recognition of non-communicable
an even more vigorous support to the private and
diseases as an important area for development;
‘voluntary’ sectors and the entirejbeus is on improving
“Development of specialities and superspecialitics will
the management of the various programmes under the
need to be pursued, with proper attention to regional
health sector. And the historical trend of a reduced pro
distribution.” Whereas with regard to the highly
portional allocation to the health sector is continued.
prevalent communicable diseases, they mainly affect
In the 'first five year plan the health sector con the deprived masses, the Seventh Plan document stops
stituted 3.82 per cent of the total plan outlay but began at saying that the programmes have failed in achiev
to decline in each subsequent plans—3.01 per cent, 2.63 ing their targets and therefore only better managementper cent, 2.12 per cent, 1.92 per cent, 1.86 per cent and is the answer.
Related to the focus of diseases of the priviledged
1.88 per cent. That this decline in health sector alloca
tion is due to greater investment in population con few the plan recommends a special priority to new.
trol activities is obvious from the fact that allocations medical technology, especially biotechnology and elec
to the family planning (FP) sector have increased from tronics. The special attention that AIDS, cancer and
0.005 per cent of total plan outlay in the first plan to coronary heart diseases are receiving and the current
1.80 per cent in the Seventh Five Year Plan. Even the boom of the diagnostic industry is a clear indication
June 1986
29
where the health sector priorities he.
Hnalh. it i>. interesting io note that (he health sen
ior plan does not comment on the drug industry on
which the national disease control programmes are
grcaieiy dependent Drugs and pharmaceuticals arc left
to the Industries sector where no mention oi essentia!
drugs is made. liven with the major communicable
diseases being national programmes, (lepross. tuber
culosis, malaria, blindness, filariasis, goilic and guinea
worm infestation) there is no concern in the plan docu
ment about shortages of these essential drugs which
are imported in bulk inspite of a sophisticated phar
maceutical industry in India.
K;i\i Ihmeal
Local Health Traditions and
Primary Health Care
LOCAL health traditions arc primarily based in the
use of local flora, fauna and minerals A very signifi
cant aspect of the local health traditions and its prac
titioners is their seif-rclimti nature. These traditions are
of an entirely autonomous character rooted in a com
munity’s social traditions of knowledge and supported
from within the community. No government or any
other agency has ever been required to offer any direct
support to these traditions of health-care. \ seven-day
meeting was held in November 19X5 at Karjat.
1
Maharashtra, to discuss ways for strengthening local
!
health traditions related to primary health care People
•
■ from 30 rural organisations interested and active in the
j
community health field from Kerala, Tamilnadu,
Andhra, Karnataka, UP, Bihar, MP and Maharashtra
attended the meeting.
Most of the groups previously carried the prejudiced
impression that local health cultures were based on
blind belief or purely an empirical experience because
this is the false propaganda that western science had
spread about indigenous knowledge. In fact, to date
not a single serious evaluation exists of the strengths
and weaknesses of any local health culture in any part
of India, despite the fact (hat millions of Indians still
subscribe to traditional health practices. There is evi
dence to establish that Ayurveda is the scientific main
stream behind all the local folk and tribal health tradi
tions in India. There appears to be a symbiotic 'rela
tionship between the two. The mainstream drawing
strength from the particular experiences of numerous
local-streams and the local streams in turn being
enriched through interaction with the mainstream.
*
1
■ The meeting observed that a sort of cultural
genocide (which began about 200 years ago) on the
local’health culture of thousands of village com
munities is yet taking place in independent India. This
is inspired by the’Western ethno centric outlook of the
Indian scientific establishment. Ironically although
local health traditions are in fact more comprehensive
< x in scope and cover all and more than the usual elements
that are expected from the ‘primary health care’ pro
grammes of the government, these local traditions are
being totally ignored and suppressed.
When one talks about the scientific temper in India,
we urnallv impose an essentially European ‘mainstream’
c>,h....q tradition (Europe also had non-mainstrcam
scientific traditions, eg.. based on writings of Goethe)
on the Indian people. There is in fact also an in
digenous scientific temper that still persists amongst
millions of our rural folks and amongst the tribals.
This mdieenous scientific temper is indeed very dif
ferent in content and form from the European one and
it is only cultural arrogance and intolerance that may
make us blind to its value.
Strengths and Weakness of Local
Health Traditions
In the Karjat tribal block over the last 5 years a
detailed documentation ol the local health tradition
is being undertaken. Similar work is'being conducted
in other parts of Maharashtra (Nanded district,
Gadchiroli and Poona district), as also in Warangal in
AP, Ranchi in Bihar and Coimbatore district in Tamil
Nadu.
Although the local traditions are comprehensive in
their ‘scope-they undoubtedly reveal several weaknesses
in treatment proceduresand diagnosis when subjected
to critical evaluation by the science of Ayurveda.
Although with regard to the use of local herbs the local
tradition has an amazing knowledge of local flora its
ecology, identification. types, etc, knowledge about
properties of plants is incomplete. There arc perhaps
several reasons which may explain how and why these
weaknesses have set in—in the first place the local
traditions arc ‘oral’ traditions of knowledge and in the
natural course of things oral traditions the world over
have been found to decay over ‘time’.. They need to be
revitalised from time to time in order to regain ‘vigour’.
An external reason for the current decay of local tradi
tions is the derision, neglect and oppression they have
suffered due to the intolerant attitude of the western
scientific tradition towards these practices. A third
reason is the break of active links during the last few
centuries with mainstream science of ayurveda. This
has. resulted in mutual losses. Tncse weaknesses
however do not detract from the comprehensiveness
of the local traditions, nor' reduce their potential for
making the community self-reliant in its primary health
care needs.
Workshop Report
Documentation of Local Flora: On the first day '■
participants accompanied by the botanists, from
‘Maharashtra Association for Cultivation of Science’
and AVR Educational Trust, Coimbatore, visited the
local forest and collected 25 illustrative specimens of
locally used medicinal plants. There were detailed
.discussions on the basic botanical notes that should
1 be taken about each plant and what parts of a plant
are essential to collect for purposes of identification
and how plants can be pressed and dried and put into
herbariuni sheets.
On the same day, in the evening there was an in
troductory talk on Dravya-Guna Shastra which is.
1
i
Radical Journal of Health
about the theory and methode hv
•a \
establishes the properties of plants' attd prcdictTtheh
effects on the human body.
The next two days of the workshop were spent in
observing and participating in the preparation of
medicines by processing plants in various ways. Nine
different basic techniques of processing of plants were
demonstrated viz, kadha, swaras, tel, ark, ghanwati
shar, satv, malam and choorna.
Documenting Local Health Care Practices: Two days
were spent on understanding some of the strengths and
weaknesses of the local traditions regarding (1) mother
and child care (2) home remedies and (3)*ihe treatment
of common ailments and first aid. The ADS presented
participants with a copy of the type of questionnaire
they had used to study the local traditions which could
be used as general model for similar studies
elsewhere-~but the detailed format may vary from
region to region.
Food and Nutrition: The sixth day was spent in
discussion on two subjects, viz. the basic natural prin
ciples of ayurveda and the ayurvedic theory of nutri
tion. As a result of this western ethnocentric view,
today under the banner of spreading science to villages,
very many sound nutritional practices of villagers are
being destroyed and undermined because of lack of
understanding of the Indian nutritional science.
On the seventh day there was discussion around the
historical analysis of the colonisation of the Indian
mind by the mainstream west—a process which began
200 years ago and continues even today under a
political leadership which wants India to ‘catch up with
the wrest’ in the 21st century. A view was put forward
that perhaps it was at a historical moment of weakness
that the Indian civilisation accepted the cultural and
inellectual traditions of their colonisers and that this
acceptance was not based on any critical process of
evaluation of the western traditions.
It was unanimously resolved to form an informal
national committee, the Lok S.wasthya Parampara
Samvardhan Samiti for strengthening local health
cultures. The AVR ayurvedic trust, Coimbatore, agreed
to act as the secretary of the committee.
For further information please contact Dr. G.G.
Gangadharan, Lok Swasthya Parampara Samvardhan
Samiti, Pathanjalipuri P.O., Thadagam, Coimbatore
641 108.
Drug Multinationals and WHO
THE unofficial, information links between multina
tional corporations and some UN agencies have long
been debated. The ICP (Industry Co-operative Pro
gramme) within the FAO was a prime example, and had
to be dismantled once the links were discovered by
action groups. On the other hand, the WHO prescrip
tion for a rational drug policy is well known, has been
recommended for all countries, developed and
underdeveloped and is often adduced as proof of the
WHO’s neutrality. Ils prime principal contribution has
June 19b6
been the selection of a list of essential drugs numbering
250, and which the WHO has suggested is more than
adequate for a population’s basic health programmes.
a list, of course, that has not enamoured the WHO to
the drug multinationals.
The new drug policy has reversed many of the
offensive features of the drug scene available it;
most third world countries including India, where the
production of a large number of inessential and harm
ful drugs has led to a decline in the production of basic
and essential drugs. Despite what critics of the
Bangladesh drug policy, instigated by drug MNCs have
claimed, the new policy has led to an increase in the
production of essential drugs, r ■ educed prices and
improved drug investment by the very same companies
who have tried to’criticise the policy in the past.
Concerned about these positive developments and
their possible impact on other third world countries.
the drug MNC have now recruited a Sri Lankan lawyer
to write a book attacking the policy. The book is
entitled, The Public Health and Economic Dimensions
of the New Drug Policy of Bangladesh, is written by
D C Jayasuriya, and sponsored by the apex organisa
tion of drug multinationals worldwide: The Interna
tional Federation of Pharmaceutical Manufacturer’s
Association.
Jayasuriya uses his former WHO consultancy; status
to give his ‘evaluation’ of the Bangladesh drug policy
some measure of legitimacy, which it, being a spon
sored study, readily lacks. The document is being
passed about as a ‘WHO document on the BangladeshDrug Policy’.
More interesting is the fact that the document has
been sent to the personal addresses of Drug Con
trollers, Health Ministers and other influential ad
ministrators in all Third World countries. This has not
however been done in Bangladesh, where a whisper
campaign instead has been let loose to say that the
“WHO has published a document against the drug
policy!’ The WHO is obviously aware of. these
developments and has yet not distanced itself officially
from the Jayasuriya ‘evaluation’.
The requisition of a Third World individual to attack
a socially useful policy from another Third World
country, at the obvious behest of drug MNCs. is deeplydisturbing. No action has been taken against
Jayasuriya despite ’the fact that these developments
have been brought to the attention of the Director
General of the WHO, Dr Halfdan Mahler himself.
We believe that part of t-he reasons for the incapacity .
or unwillingness of the WHO to act firmly is rooted
in the financial indebtedness of the WHO to countries
like the USA. For example, it took a full two years
before Dr Halfdan Mahler himself publicly approved
the Bangladesh drug policy. There is need for more
unambiguous approach. If necessary, the WHO should
seriously consider alternative sources of funds to act
more forcefully in the interests of all drug consumers.
’ . Even now it is ironic that the WHO is unwilling- tcact when it sees an attack on a drug policy that is baser.
on the recommendations of the organisation itself.
Third World Network
31
Homoeopathy
b k sinha
Homeopathy, the author contends, goes well with the
necessary medicines available to all.
holistic health movement and holds the promise of making
HOMOEOPATHY is today’s medicine because it offers a another ruling class whiclr enables the society to develop
way out from the situation the people in need ot medicine further: If, again because of the level of development of the
face. One of these problems is the cost. Treatment has society, such a class has not emerged which could withstand
become terribly costly, forcing an overwhelming majority of persecution, it leads to various kinds of distortions in the
people to suffer helplessly or succumb to diseases. existing body of knowledge of the society and to an ever
Homoeopathic treatment is much cheaper. The manufacture increasing difficulty in procuring the means of life from
of these drugs does not involve the kind of technology which Surroundings, to maintain its existence and that of the rul
would lead to monopoly and consequently to cost escalation. ing class. If the natural surrounding of such a society is boun
Besides, the action of homoeopathic drugs does not depend tiful, it manages to keep itself alive despite its stagnation and
on the quantity of drugs administered but on potency and consequent distortions in its consciousness; if not, such
higher the potency, the less there is of the medicinal matter societies must perish leaving the marks of their existence on
in it. ?\nd one of its basic principles is to keep the dose of history.
the medicine to the minimum.
An individual’s response to the problems faced has
Homoeopaths prescribe drugs on totality of symptoms. elements of both universality and particularity. Universality,
This saves the ordeal of going through surgical operations because the basic problem sought to be solved and the tools
in most cases. Its principles for treating a group of symptoms of enquiry at a specific stage of development arc universal.
have been tried and tested in the last 175 years and its struc Particularly, because the answers to these problems are in
ture is such that new information can continually be incor terms of what is available either from nature or from what
porated into the existing body of knowledge. And the logic is inherited from previous generations. Hence the clement
behind these principles is such that it avoids logical contradic of particularity is to a minimum level in primitive societies.
tions of other systems of treatment by elevating the concepts It is for this reason that different societies existing at dif
of health, disease and cure to a level where these contradic ferent points of time and space and drawing the necessary
tions do not operate.
means of life in a similar method and ways tend to enquire
In all societies and in all ages, human beings face con into the problems they face in similar ways and arrive at
crete problems and is oppressed by them. Consequently, they similar answers. At a certain point of time and space, if there
endeavour to solve them and .to understand them. The is a change in a society’s methods and ways of procuring the
understanding of the problem is crucially dependant on the necessary means of life, its ideas about the problem it faces,
tools that they possess including the power of abstraction. its tools of enquiry and the answers it advances for its solu
Both these tools and power of abstraction crucially depend tion too change, in the main. But societies where this change
on the state of development of the society. Within this limita has not taken place continue to live in the old ways with their
tion,- there is yet another limitation: that of the class nature old ideas
of the problems.and following from it the class nature o'
Health and freedom from illness is one of the. most basic
the solution advanced. If the problem of study stems from
human
needs. Primitive response to this need is universally
the class needs of the ruling class and the solution to it does
not question the beliefs and ideas justifying the existence and magical. It could not but be so. For it was a long time before
the privileges of the ruling class, the individual studying these human societies could even pose the problem properly and
problems and.advancing solutions get support, recognition did not possess even the elementary tools to enquire into the
and glory from the ruling class. If these bases arc questioned, problem. Later, as experience accumulated abstractions of
such individuals incur the wrath of the ruling classes and experience as beliefs and theories were put forward. Hence
arc dealt with accordingly. If the questions studied and .the we see the sprouting of different systems of treatment in dif
answers advanced arc such as do not interest the ruling ferent societies. Some of these systems have survived to this
classes, howsoever beneficial they may be to the advancement day although they could not remain unaffected by the
of fire society as a whole, those are simply ignored till a class 'development of science and logic either in their own society
comes to recognise their usefulness, either as the ruling class or in other societies they came in contact with.
of the day or as a class in struggle against the ruling class
Besides, the human endeavour to fulfill health needs and
for supremacy and power. It goes without saying that discover cures for illness directs enquiries into various aspects
societies whose ruling class in certain periods of lime either of the problem including the human body, cause of disease.
suppresses such studies and solutions of the problems or effects of drugs, hygiene, etc. The answers to all these ques
ignores them is condemned to stagnate and degenerate. tions must be limited by the tools available and must at the
Historically, we see two types of development that take place same tirqe reflect current beliefs including taboos. Besides,
in societies condemned in this way, depending upon the level the less developed (he tools, the greater the grip of beliefs '
of development of the society in question. If because of the and taboos. On the other hand, the greater the stakes behind
development, such a class has emerged in the society which these beliefs and taboos, the greater the force with which (hey
could withstand persecution, the task of developing society are defended. Hence any ot the system^ of treatment needs
drives many individuals to take up such study notwithstan to be evaluated for its objectivity, not on the basis of its own
ding the persecutions. The ruling class is then replaced by
theories and beliefs, not on particulars, but on the basis
32
Radical Journal of Health
I HF
of science. on the basis of what is abstracted from the
medicines and the way medicines act and advanced several
• particulars, the universal.
. H. WC>l0^k 'nl° thc steins of treatment practised in hypotheses which were later substantiated by different
branches of science.
ancient civilisations like the one in India (Ayurveda); China
In Hahnemann’s days therapeutic practice was appaling.
and Greece we find that each identifies the cause of disease
Stuart Close says:
differently. While Ayurveda identifies vayu, pitta, and kapha
Ideas which now scorn absurd were then matters of thc most
as three doshas, a disordered state of which afflicts the body
serious moment, and in their practical working out often became
with diseases of various kinds, the Chinese system identifies
tragical. Blood letting, the outgrowth of one of these false theories
the. balance two opposing principles—the yang and the
affords a good example. Thc celebrated Bouvard, physician to
Louis XIII, ordered his royal patient forty seven bleedings, two
ying—and an imbalance, therefore, meant diseases. Similarly
hundred and fifteen empties or purgatives and three hundred and
the Greeks believed that when the four humours—blood,
twelve clysters during the period of one year ... the death of
phlegm, yellow bile and black bile—were in balance, there
our own George- Washington was undoubtedly caused by the
was a state of health; when not, diseases resulted. Rome, after
repeated blood-letting to which he was subjected. He was almost
completely exsanguinated (Close, 1979, pp 28-29),
conquering Greece, based its system on Greek system but
Roman physicians developed the system immensely.
Nature of Scientific Enquiry
Even a cursory glance at their history reveals that the inner
Science
studies
nature in general and within this univer
vitality of these systems which propelled them to acquire new
sality,
the
different
aspects of nature, thc particularities. All
. experience and propound theories is subsequently plagued.
scientific enquiry reflects nature more deeply, truly and com
The loss of vitality of these systems reflects the loss of vitality
pletely. But what exists in nature is matter in motion. Hence
of the civilisation and societies which gave rise to these
what science studies is different forms of matter in motion,
systems. A period of stagnation followed. The reason is
scientific judgements and concepts relate to it and therefore
simple: the then ruling class in all these societies had become
are needed to be placed at different levels.
parasitical in course of time and therefore its relation with
To illustrate the point: The simplest form of motion is
scientific enquiry had became antagonistic. Consequently, change of place—mechanical motion. But there is no such
scientific enquiry was discouraged and scientists were thing as motion Of a single body although motion towards
persecuted. This is brilliantly underlined by D. P. a centre common to many bodies can be treated as such. But
Chauopadhyaya in his works (Chattopadhyaya, 1976, 1977). as soon as a single body moves irp a direction other than
European historiography describes the period 600-1400 towards the centre, the laws of falling to which it was sub
A.D. as the Dark Ages of medicine. Dissection of the human ject, undergo modifications:• body was prohibited. “The history of Europe in those days
a. As laws of trajectories and lead to reciprocal motion.
is the-history of typhus and plague, of rats, lice and men. .
of several bodies, plenetary motion, equilibrium in motion
The lack of scientific knowledge promoted superstition in itself. But the real result of this kind of motion is ultimately
medicine. Sainis were invoked for the curing of disease—St. thc contact of moving bodies—they fall into one another.
Clare for sore eyes, St. Sebastian for plague, St. Appolonia
b. As laws of bodies iir contact—ordinary mechanics,
for toothache, etc (Nelson,’1927).
livers, inclined plane, etc. But the effect of the contact is not
Science having been tabooed elsewhere, Arabia came exhausted by these. Contact is manifested directly in two
’forward to take science and medicine to new heights. They forms: friction and impact. Both have the property that at
preserved Grecp-Romari wisdom, further developed it and certain degree of intensity and under certain conditions, they
enriched it with new drugs. Their contribution in the field produce new effects like heat, sound, electricity... no longer
of pharmacology is great. Th^system of medicine they gave mechanical effects. •
'
rise to-is known popularly as Unani system. But later, their
c. As science of these forms of motion—physics. Itcivilisation and along with it their medicine fell into a period establishes the fact that under certain conditions, they pass
• of stagnation much as in other societies and for mostly the- into one another and at certain degree of intensity which
•same reasons.
varies according to the different bodies set in motion pro- •
Thanks to thc maturing of merchant and manufacturing duce effects which transcend physics, changing thc internal
capital in some societies, not only the persecution of scien structure of the bodies—chemical effects.
tists came to an end but they began to receive state encourage
d. As science of chemical nature and internal structure of
ment. Individuals came forward in many fields of activities bodies. Its .task Becomes to prepare these substances artificial
including science, logic, medicine and so on, who could be ly and it subsequently prepares the ground tor dialectical
compared with Columbus in their fields. Beginning with transition to the organic sciences... (Marx and Engels, 1953,
FrdCtorius and Paracelsus, a galaxy of physicians shed new pp 342-43).
We thus see that all these branches of science study the
light on various aspects of the human body and diseases.
Newton and Bacon widened thc horizon of human thought particularity of contradiction and are differentiated on this
to an unprecedented level. Further development of knowledge very basis. These contradictions are rooted in the objective
came to depend crucially on the development of a logic and world and are independent of human will. And human
based on it the classification of the existing knowledge. In thinking is a subjective relfection of the objective world. But
the field of zoology, it was taken up by Cuvier and in thc human thought may or may not reflect the objective world
field of pathology by his contemporary, Hahnemann, the correctly. The contradiction between a correct and an incor
founder of homoeopathic system of treatment. But rect reflection of the same thing in nature gives rise to another
Hahnemann did much more than attempt to classify type of contradiction—logical contradiction. Appearance of
diseases—he developed a logic which put forward different a logical contradiction in human thinking means that the
concepts in relation to diseases, cause of the diseases, thought is not correct and development of thinking depends -
June 1986
33
upon its solution. But for this, it must be separated from of the effect” (Chattopadhyaya, 1976, p 477). But this prin
dialectical contradictions—the contradictions existing ciple in itself could not have taken Hahnemann beyond Hip
independently in nature. But given the nature of human pocrates. As it constituted a part of the complex whole he
knowledge and the way it has advanced, logical contradic was reasoning, it propelled him to go further and devise'
tions too are mistakenly treated as dialectical contradictions suitable means for its application.
and pose difficulties for separating the two. Besides, it can
Allopaths and other systems of medicine believe that the
be separated only on the basis of practice. But the word prac cause ol the disease must be diagnosed before to determine
tice has to be understood clearly—it is different from what proper treatment. But knowledge of the cause of the disease
can be termed as ‘naive practicality’. For practice to be depends on the level of theory and the available tools of
correct, it has to be guided by theory and the latter must investigation. A further deepening of knowledge must
correspond to the level at which the contradiction pperates. therefore invalidate old therapeutic practice which is-only
Consider an example. Euclidean geometry grew out of logical and sound. But the cause of the disease is too com
practical activities spanning centuries. Ils axioms and plex. Disease, like health, is influenced by a number of fac
theorems are still found correct and serve our needs. It served tors in complex combinations. This constitutes a logical con
Newton’s needs as well when he was formulating his laws tradiction and leads to unsound therapeutic practice.'James
of gravitation. Newton’s laws of gravitation arc’one of the Krauss says:
greatest triumphs of science. But he could only describe
It is impossible to know all the antecedents causative of disease
consequents. .
How [hen shall we remove’or palliate these
gravitation, he could not explain it; limited as he. was by. the
effects by medical substances? Here, Hahnemann steps in to say.
level of science of his day. Explaining it would require on
‘remove the effects and you remove the disease'. We must apply
the one hand, such fundamental advances as the develop
medicinal substances on the basis of knowledge of (heir actual
ment of the concept of fields, the creation of electrodynamics
effects which wc have ascertained and know. Disease effects are
and the theory of relativity. It would also require, on (he other
removeiby the application of medicines having corresponding
hand, a deeper approach to natural science, its methods and
medicinal effects. Scientific comparison of disease effects and
medicinal effects for application leads to the diagnostic inferences
problems. But when one begins to explain gravitation, one
of scientific medicine, makes scientific medicine possible (Krauss.
simultaneously begins to see the contradiction inherent in
1979, p 9).
both Euclidean geometry and Newtonian mechanics. This
Besides, Hahnemann had observed the oppositeaction’of
of course, does not mean that Euclidean geometry or
Newtonian mechanics are wrong; they arc very much cor large and small doses of medicine. Ipecac in large doses.
rect within their own limits. The confusion arises only when caused nausea and vomiting and in small doses, under cer
tain condition, cured it. This held good for a number of drugs'
their limits are violated.
then in use. This observation led him on the one hand to
anticipate what was later discovered and formulated by the
Hahnemann's Contributions
Arndt-Schulz law, an allopathic rule formulated towards the
Hahnemann lived in an age in which he could ask ques end of the nineteenth century. On the other hand it led him
tions and provide answers only in the hypothetical form; he to propound the theory of potentisation or dynamisation.
could not back up his hypothesis with exact experiments, nor
Potentisation is a process of dilution and vigorou> suc
could he express himself in the exact language and terms of cession at each stage of dilution. If the original medicinal
science. The problem was compounded for him as he substance is soluble in ethyl alcohol, the starting point is a
enquired into complex subjects like health, disease, cure, ac concentrated solution called mother tincture (OL If it is not.
tion of drugs, etc. He could bank only on his power of obser then it is titurated with 99 parts (in centisimal and decimal
vation and abstraction and could draw but little from his scales of dilution respectively) of milk sugar. After (his initial
predecessors. The competence with which he founded his (ituration; one part of this is again titurated with 99 or 9
therapy is amazing. And in so doing, he gave a new inter pans of milk sugar depending upon the scale. After third
pretation of these concepts, applied some of the known prin tituration, he observed, the medicinal substance becomes
ciples in a different way and developed his system of cure. soluble in alcohol. [Tit u rat ions therefore anticipate the
It was Hahnemann who gave the name allopathy to the development of colloid chemistry.] It is then treated like solu
system which was practised in his lime. In his time, quite like ble substances and further diluted to reach higher potencies.
the present, treatment generally proceeded on the principle
Dalton’s atomic theory and Avagadro’s hypothesis were
that a disease or a symptom of disease is cured by using a known in Hahnemann’s days. The atqm'was not considered
medicine thatopposes the symptom, either by direct sup to be divisible by the former and according to tire latter, one
pression or by inducing a reaction leading to its suppression. gram molecular weight of any compound or element con
Even the descriptive terms for drugs with prefix “anti” in tained approximately 6 x 1023 molecules. Therefore, if one
dicate the principle on which they are prescribed. He opposed gram qiolecular weight of any substance, say for example
this principle and called his system homoeopathy. The basic 48.46 gram, of sodium chloride (natrum muriatievfin) is
principle of homoeopathy is stated in a phrase: “Similia dissolved in 99 parts' of water then the solution will contain
similibus curentur” or “Like shall be treated by like”.
6 x IO23 molecules. If one part of this solution is diluted in
Hahnemann was not the first to propound this idea. It 99 parts of water then the solution would.contain 6 \ IO21
had been expressed by thinkers and scientists from ancient . molecules assuming that the solution is thoroughly mixed.
times. He acknowledged his debt to Hippocrates, in whose Second dilution1 will leave 6 x IO19 molecules. If we go on
writing the principle of “like cures like” appears. In ancient then.a stage will be reached when the number of molecules
Indian philosophy we find a similar reasoning advanced by present in the solution will be 6 x IO1.- At this point if we'
Uddalak Aruni in Chandogya Upanishad, “The essential take a hundredth-part of the solution then the number of
nature of the cause is to be inferred by the essential nature molecules will be 6 x LO’1 or 0.6. It means that beyond 12th.
Radical Journal of Health
centesimal or 24th decimal potentisation, not even a single
♦molecule of the original substance is there in the medicine.
But the more commonly used medicines are 30lh and beyond.
Hahnemann was aware of this paradox. He advanced the
reasoning that the process of dilution and succession released
a spirit like power Stuart Close adds, “..: homoeopathic
potentiation (potentisation) is nothing more or less than a
physical process at which the dynamic energy, latent in crude
substances, is liberated, developed and modified for use as
medicines” (Close, 1979, p 219).
Hahnemann by arguing that removal of symptoms itself
meant cure from the disease and by treating the question of
health, disease, and power of medicine to cure at a dynamic
plane, elevates them to a plane where the contradiction
inherent in other systems of treatment does not operate. This
in itself is a great advance in science and the applied science
of medicine.
of the original substance present in a highly diluted solu
tion, the energy associated with this subatomic activity
should be present in the solvent (Hubbard, 1977, pp 433-36).
The above two tentative approaches to the explanation of
the activity of high potencies have some implications that
can be tested in the laboratory. lira series experiments in
the 1950s, A Gay and J Boiron demonstrated measurable dif
ferences between the capacitances (dielectric constants) of
distilled waler and of sodium chloride dissolved in distilled
water and carried through stages of dilution upto 10
Also, in 193’1, Paterson and Boyd showed that-lhe Schick test,
conventionally used to determine the presence or absence of
immunity to diphtheria, can be altered through the
administration of high potencies of either alum precipitated.
toxoid—used by the allopaths in material doses to induce
immunity—or of Diphtherinum, a nosode prepared from a
diphtheritic membrane. There are many more studies of
experiments to prove the effect of high potency drugs. Weiner
Homoeopath) and Its Detractors
and Goss cite a few examples in their book (Weiner and Goss,
Homoeopaths and homoeopathic treatment are more 1982, pp 129-30).
Another group of detractors allege that since homoeopathy •
widespread than is normally estimated. England is an
is
solely concerned with symptoms, it ignores even such
important centre for homoeopathic leaching and practice and
homoeopathic doctors arc part of the National Health cause(s) of the disease that modern science so powerfully
Service. According to an official estimate in 1972, there were establishes, like bacteria. Some go further and argue that even
more than 72,000 registered homoeopaths in India. Other after the symptoms are removed as a result of homoeopathic
commonwealth countries like Australia, New Zealand and treatment, the cause remains and therefore the symptoms
Canada have quite a significant number of homoeopaths. again reappear. Yet another criticisms is that since it treats
It is also taught and practised in the USA, France, Germany, individual patients and prescribes different drugs to different
Switzerland and Holland. This in itself should be sufficient persons suffering from similar symptoms, it is not suitable
to silence those who ridicule the homoeopathic system of in epidemic conditions. A surprising thing about such
treatment by saying that there is no medicinal substance in criticism is that they are levelled not by uninformed persons
but by highly informed ones, by ‘experts'.
the drugs.
Such criticisms spring from a profound ignorance of
They can convince themselves by the reasoning advancedby Bernard and Stephenson. In an article written in 1967 they Hahnemann’s teachings and subsequent developments in
proposed that through the process of dilution and succes other fields of knowledge and science. In section 31 of
sion, the active substance acts as a template, communicating Organon, Hahnemann says: “The inimical forces, partly
a field to the solvent through the formation of polymer psychial, partly physical iq which our terresirialexisience is
chains (gaint molecular aggregates) in the solvent. The three exposed, which are termed morbific noxious agents, do not
dimensional structure of such polymers would be specific possess the power of morbidly deranging the health of man
to each individual solute. Once the structural informational unconditionally, but we are made ill by them only when our
content of the solute has been transmitted to the solvent organism is sufficiently deposed and susceptible to the attack
through the formation of the polymer chains, the solute need of the morbific cause...”
We thus sec that Hahnemann not only identifies “morno-longer be present for the solvent to communicate that
information to the human organism (Bernard and Stephenson, bific noxious agents” but also explains the reason because
of which not every one succumbs to bacteria though all may
1967, pp 277-86).
be equally exposed to them. Il would be interesting to note
Mathew Hubbard pointed^out in an article in 1977 that
that he recognised the presence of bacteria and attributed
when Avagadro formulated his law, matter was not believed
to these animal forms, too minute for the eyes to see, many
to be visible beyond the level of the atom. Now, of course,
forms of epidemic and acute illnesses. He announced his
we have identified subatomic particles, and one contem
deductions in 1818, more than 60 years before Koch isolated
porary model defines atoms as ordered waves of energy. Thus
the tubercle bacillus (Roberts, 1979, pp 180-81).
when we study the phenomena associated with apparently
Stuart Close says:
material substances, we are no longer restricted to the realm
The real cause (of the disease) is the whole of these antecedents.
of matter; matter and energy are interchangeable and are con
and we have no right, philosophically speaking, to give the name
stantly being transformed from one form to the other
of the cause to one of them, exclusively of the others.
(according to the first law of thermodynamics, as electrons Also,
Brilliant and successful as liave been (he attainments of
jump from one orbit to another around the nucleus of the
bacteriologists in creating a new science of sanitary engineering,
atom, radiation is released, which can be measured on a
they have failed and must continue to fail, to establish bacteriology
spectroscope). Each chemical element has its own spec
- as the basis of a therapeutics.
troscopic “fingerprint”, which is produced by this Further,
characteristic pattern of radiation. He proposed that the
In cholera, for example, admitting the existence and presence
energy released from such molecules of matter must permeate
of the bacilli as one causative factor, we still have to reckon with
sanitary, atmospheric and telluric conditions; with economic and
an entire solution; thus, even if there is not a single atom
June 1986
35
of doctors or drug manufacturers: nor it can allow us to live
passively unmindful of the questions that shape our existence
and unstirred by the need to better our social life. Il will have
to identify the social, economic and political aspects ol the
whole termed as health problem; propose concrete ways of
solving them and mobilise people to solve these problems.
Hence those who are oppressed in such a system ol treat
We thus see that homoeopathy is closer to the modern con ment and health care will have to struggle for developing
cept of health care and preventive medicine than other tomorrow’s system of treatment and health care. And in this
systems of treatment including allopathy.
struggle, homoeopathy can became a tool, as it frees us from
Homoeopathic treatment has been successful in epidemics our dependence on those who are the targets of this struggle.
even during the lifetime of Hahnemann. Weiner and Goss
But before homoeopathy becomes a tool in this great
give a detailed report of a survey conducted in England to struggle, it must rid itself of all that is unscientific in it, and
determine the effectiveness of a homoeopathic nosode, must not shy away doing so. The most important among
Influenzinum. This holds good for the diseases caused by them is its secretarianism that the believers and practitioners
the virus also. Weiner and Goss add a speculative note:
of homoeopathy so strongly display. One of the reasons for
There is a widespread concern about the dangers of the research its secretarianism is due to attacks on it and its inability to
In bacteriological warfare; scientists and the lay people alike meet these attacks on the grounds of science. This has been
portray the possible disastrous consequences of the escape of so right from the days of Hahnemann. So vicious has been
virulent organisms that have been specifically bred to resist
this attack that even a man of his nature had to limit himself
chemotherapy. Mysterious illnesses, such as ‘legionnaire’s disease’
have also aroused public interest. The allopathic response to to: “The physician’s high and only mission is to restore the
legionnaire’s disease was to search for an etiologic agent in order sick to health, to cure, as it is termed” (Hahnemann, 1977,
to determine the proper medicine to eradicate the hypothesised p 92). He also added a footnote to’it saying, “his mission
‘bacteria’ responsible. In theory, homoeopathic treatment could is not, however, to construct so called systems by interweav
yield impressive result in such instances for two reasons; (1) both ing empty speculations and hypotheses concerning the in
situations have the characteristics of epidemics, hence a single
ternal essential nature of the vital processes and the mode
remedy or a group of remedies could be determined for each par
ticular epidemic as the proper, treatment inthc majority of cases; in which diseases originate in the invisible interior of the
and (2) since homoeopathy selects the remedy on the basis of organism (whereon so many physicians have hitherto am
symptom alone, identification of the organism involved would bitiously wasted their talents and their time). ” But now
not be necessary, nor it would be necessary to develop a the times have changed, homoeopathy can meet this attack
chemotherapeutic agent that had the specific effect of eradicating fully. Besides, history has put a different task before socie
• that organism.
Underlying the specific precepts of homoeopathy there is ty, especially in poor and exploited countries. If more and
a vitalistic principle that is clearly spelt out in Organon (sec more persons are embracing ’homoeopathy and arc even
tions 9 to 14). Section 15 visualises the “affection of the mor struggling for its transformation, then it only underlines the
bidly deranged spirit-like dynamis (vital force)” and "the historical task. And given the social need and the historical
totality of the outwardly cognizable symptoms produced by task, necessary forces will come forward to help in this great
transformation.
it in the organism and representing the existing malady, con
stitute a whole.” This vitalistic principle at the heart of the
References
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Bernard, G.P. and Stephenson, J.H. ’-.Microdose Paradox, A New
tion distinguishes it from allopathy and other systems of
Biophysical Concept’ , Journal of the American Institute of
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Homoeopathy, September-October 1967, pp 277-86.
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dian Philosophy, Delhi. 1976.
form of miasms— subtle, imperceptible substances as “im
Chattopadhyaya, Debiprasad, Science and Society in Ancient India
perceptible as the vital force itself”. He divided all diseases
Research India Publications, Calcutta,'1977.
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Delhi,
First Indian Edition, 1979.
These are'rapid in development and have a definite course
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consisting of three phases: (a) a prodromal period of onset;
Publishers, New Delhi, 1977.
’
(b) a period of progress and (c) a period of decline. The vital Hubbard, Mathew, ‘‘A 20th Century Critique of Avagadro’s Law and
Its Implications , Journal 'of the American Institute of
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Homoeopathy, September 1977.
'
■
the attack on the organism is not so violent as to cause death.
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(2) Chronic diseases or chronic miasm: There is again a pro
Edition of Hahnemann's Organon". Organon of Medicine bv
dromal period and a period of progress of the disease but
Samuel Hahnemann, B. Jain Publishers, Reprint, 1979.
Nelson,
Sir Arthur, Health Problems in Organised Society P S Kinc
there is no period of decline. The vital force is not able of
and Sons Ltd, London, 1927. quoted by Park, J.E, Textbook of
curing itself. Under certain circumstances the chronic disease
Edition'll!
Med‘Cine' Banar$'das Bahnot, Jabalpur. Third
may quieten down and may become virtually devoid of symp
toms, but each time it is aroused by adverse conditions and Marx, Karl and Engels, Friedrich, Selected Correspondence Foreign
Languages Publishing House’ 1953
’
K
becomes worse than it was during the previous exacerbation.
Roberts, Herbert A, The Principle and Ari of Care by Homoeopathy
Chronic miasms are further classified into three categories:
B. Jain Publishers, New Delhi, Reprint 1979
1
psora, syphillis and sycosis to facilitate better choice of Weiner, Michael and Goss. Kathlcan. The Complete Book of
Homoeopathy, Bantam Books, USA, 1982.
remedies.
social conditions and habits of life, with means and inodes of
transportation and intercommunication between individuals and
communities; with individual physical, mental and emotional
states, etc., all of which are essential factors, in some combina
tion. in determining and modifying the susceptibility of in
dividuals to the bacilli; for without some combination of these
factors, the bacilli is impotent and the disease would never occur
(Close, 1979, pp 268-69).
What would tomorrow’s system of treatment and health
care be like? It can never allow humans to suffer for the profit
36
B K Sinha .
Homeopathic Clinic
Tiwasa. Dist Amravati 444 903
Book Reviews
Exploding Myths
anant phadke
When the Search Began by Ulhas Jajoo, M G Institute of Medical Sciences, Sevagrain, Wardha. 442 102;
November 1984, pp 50, Rs 5.
MANY health projects especiallyin the non-government or collections had its own problems. The people with larger
so-called ‘voluntary’ sector tend to report exaggerated success holding had to contribute more without getting any
stories about what they have achieved, when in reality, things privileges. They were, therefore, not enthusiastic and half of
are quite different. Such reports or claims-create myths about them dropped out of the scheme after the first year. The
what health projects can and have achieved. There arc a very drop-out rate was less among other groups. Among landless
few exceptions to this myth-making. “When the Search labourers, the participation increased over years. It is not
Began” is one such notable exception. It is an unusually frank clear from their account as to why the response to this scheme
and critical reporting of the healthwork done in the villages was better than to the earlier one. No economic or political
near Wardha by Dr Ulhas Jajoo, his collegues and students activity has been reported. Perhaps the support of the
from the Mahatma Gandhi Institute of Medical Science, medical college including the doctor’s monthly visit made
Sevgram, near Wardha, Maharashtra. Instead of continuing the difference.
the usual arm-chair discussions, this group went into the
Honest Reporting
field, analysed their experiences in a critical and open-minded
fashion. They found that many of their initial assumptions,
Over a period, the group’s activity acquired a certain struc
widely prevalent ideas related to healthwork, were wrong.
ture and some credibility. In the course of the work they
The “search” has been for a socially, economically, politically encountered many dilemmas, learnt some lessons and these
appropriate strategy for rational healthwork. This story of have been honestly reported. For example only acute cases
their search is very useful to any newcomer who honestly could be provided free or subsidised treatment, whereas
wants to do any worthwhile work. It is, however, questionable people expected free treatment for all types of illness once
whether the structure of delivery of healthservices they have they gave their contribution at harvest time. If a fee is charged
formed is radically different from the usual prescriptions for service the poorest, who arc the ones most in need, would
(with their blindspots). Secondly healthwork has been not get these services. The contributions from villagers could
equated in effect with delivery of healthserviccs, with no pay only for the payment of the VHWs and their drug-kits,
mention of socio-political aspects of healthwork. Let us the ANM and the diesel for the vehicle used to transport
understand their work, and their perspective as given in this them to and from Wardha. The author correctly points out
short report.
that it is a myth to believe that such healthwork can finan
cially become self-sufficient. But the group has insisted right
from the beginning that some contribution must come from
The group decided to go into field-work and describes how, the villagers. About 35 per cent of the collection from the
during the rains, their first visit to Punjai, a way-off village, villagers was kept aside for the payment of VHWs. This was
turned out to be so difficult. It frankly admits that they chose to ensure that VHWs are responsible to the community and
a nearer village—Nagapur, because they realised after the not acting merely as an agents of the health-authorities.
first visit to Pujai, that regular work there would be too
The bewildering experiences about their health-educational
difficult. In Nagapur, they' started with a weekly clinic and efforts has been sincerely reported. For example, textbooks
a drug-bank witlrcontribution of Rs 4 per family. The drug had taught them the importance of latrines in controlling
bank soon went bankrupt and they realised that this con diseases. But* the villagers had their own problems and hence
tribution was too meagre to run a drug bank. The initial did not accept the idea of building latrines. They did not
enthusiasm of the villagers soon waned. The group came to have extra money to build even a cheap latrine for each
the conclusion that because people were so engrossed in their household. Community latrines would be nobody’s baby and
attempts to somehow get two meals a day, health was not hence would be left uncared for. The use of sanitary latrines
at all a priority, that health-education, immunisation, etc, meant fetching additional quantities of water, which was
did not elicit much response since it was not their felt-need. extra burden, mainly borne by the women. The villagers had
When they touched the villagers’ felt-need (e g, getting bank their own logic for using the road-side (of the approach road
Ioans) the response was quite different. The report however, to the village) for open-air defacation. It was, they pointed
does not elaborate how and to what extent the group con out, the cleanest place during the rains, and was much safer
tinued this economic activity. It shifts to a new idea—of at night due to the street lights! About the small family-norm,
collecting grain at the time of harvesting, in proportion to the medical team had no counter-argument to the villager's
land-holdings. This grain is to act as a kind of collective argument that they need two sons so that at least one of them
insurance for free treatment for all acute illnesses for all would survive to support them in old age. The medical team
members of the scheme and also free treatment for acute and realised that unless infant mortality is brought down, oldemergency cases at Wardha in the Sevagram medical college age security provided, family planning propaganda would
hospital. The medical college thus supported, subsidised this not take roots. It is worthwhile to quote their forthright con
new insurance scheme in a substantial way. The grain clusions drawn from their initial experience.
Novel Health Insurance
June 1986
37
immunised. This is a notable achievement. This “cluster ap
(I) Our medical education .in the hospital is inad,eqate to equip
us with the skills required in the rural setting. (2) Socio-economic proach” is-demanding in terms of mobilisation of the people
factors (poverty) and political frame-work of the existing society and very few healthprojects have adopted it. Using the same
are major obstacles in the development of appropriate medical approach, for polio vaccination, in six visits, 81 per cent of
care, a field about which we are kept ignorant during our medical the'children received three doses and 55 per cent received
education. (3) Medical problems are not the priority need of the
five doses—this also is by no means a small achievement.
people. (4) The awkward-looking behaviour of most of the people
Rational selection and use of drugs, preparation of cheaper
is the natural reaction in their environment. Inability to under
stand their environment is chiefly responsible for the big com ..formulations like a cough-mixture and a few ointments have
munication gap between them and we, the educated. (5) In a poor been reported. But for the rest, a familiar picture emerges—
socio-economic setting, idea of self-reliance in health care activities Village Health Workers working for a paltry “honorarium”
is a myth. The poor community has to depend on someone from of fifty rupees per month, a full-time trained Assistant Nurse
outside, may be a voluntary agency or the state. (6) Community
Midwife supported by a hospital facility nearby. There are
participation in health care is more preached than practised. Those
who claim it, cither do not understand what community participa many problems in this approach; some of which have been
tion means or are telling a blatant lie mostly, for collecting funds' mentioned by this report. The ability of the VHW to
on which they so heavily depend. Collecting people to dole out diagnose and treat is very limited; much more limited is the
a gift, which they have never dreamt of, cannot be called com likelihood of people having sufficient faith in them about
munity participation (pp 8-9).
these functions. A monthly visit by doctors is too insufficient;
emergencies cannot be dealt with at all; health-education is
never taken seriously unless imaginative and special efforts
Their medical insurance scheme however, was a kind of are attempted. A paltry drug kit of a very limited amount
a success. The data that has been quoted (p 14) about two • (a mere Rs 30 in this case) with the VHW is too inadequate
out of the twelve villages in which the work spread,, shows , to m6ct even a fraction of the drug-needs for minor illnesses;
that “percentage of coverage for health-insurance” increased unecessary domination of doctors is hardly challenged.
from 46.5 per cent in the first year to 71.5 per cent in the
To assess the “morbidity load” (amount and type of
3rd year. (This however does not tally with the earlier claim illnesses) in the community, aqd to determine on the basis,
of collecting contribution from 90 per cent of the .villagers the type of health-activities to be conducted, the type and
in the first year (p 7)). The corresponding figures for amount of human-power anddrugs required, (and not any
labourers and marginal farmers went up from 36 per cent arbitrary amount) to organise these services through a
to 78 per cent. In the section “Evaluation and Cost-analysis” democratically working team, etc, etc are tasks which have
they have arrived at a figure of Rs 2 per head per year as •not been satisfactorily resolved. The content and form of
the cost of the healthservices (excluding the cost of hospital health-education which is appropriate and which really
admission) provided by. them. The government of India’s per makes sense is also something which needs a lot more work
capita public health expenditure of Rs 28 (1981-82) has been ... there are so many problems and blindspots.-This report
quoted to provide a camparison and it has been claimed (hat does not even attempt to throw any light on any of these.
“much improved health-seryices, which have the benefit of Their work has created a learning process. This itself is an
involving villagers as contributory participants, can be pro important achievement and hence one hopes that this work
vided within existing resources, if a new medical strategy is would not become stagnant, with whatever has been achieved
planned and implemented” (p 15). One cannot justifiably so far, but would take up some of the challenging aspects
draw any such conclusions whatsoever from the cost-analysis in the field of delivery of health-care to the people. With
of their work. One has to compare the health-facilities pro all their efforts, the search has only begun and there is a long
vided and the costs incurred and find out whether the costs way to go. .
are less or more. Such a cost-analysis of their work and of
The challenge in. healthwork is not only of organising a,
the government’s work and then comparing them would tell
cost
effective, appropriate, rational, democratic mode of
us as to the extent to which the government’s work is costly.
No such analysis has even been attempted and hence no such health-intervention from the point of view of community
medicine. It is at least equally important to expose in practice
conslusions can be drawn from their cost-analysis.
Jhe socio-political dimension of the established medicalpractice, to conscientise people dbout the exploitative,
Conventional Barrier
oppressive, mystifying misuse of medical science and to forge
Are there any positive achievements of this work apart an alternative in^ractice. Such health-cohscientisation has
from the lessons that the medical team learnt? A collective to be a part of broader socio-political, work. People may not ’
health insurance scheme (with all its limitations) in rural area, be interested in vaccines to begin with, or in unrealistic health
running for five years with increasing participation by the advice. But they do get interested in knowing how the existing
poorer sections of the community is definitely an achieve medical system exploits them and how to get out of its
ment. Anybody conversant with the field would realise how clutches. If aspects of non-exploitative, liberating healthwork
difficult it is to achieve what appears on paper as small are forged in practice, such healthwork can contribute a lot.
objectives. One may point out that the support from the Most health projects have no such perspective of health con- .
Kasturba Hospital was quite crucial in the evolution and scientisation; they are aimed solely at delivering health ser
viability of this scheme.
vices. This does nof.challenge the existing system in a direct
The achievements in the health field are however, quite manner, Similarly most health projects have no link have
limited. Using “cluster approach” (collecting, immunising
worPk.rSPe
6
gm8 3 Hnk WUh br°ader socio-political .
all the eligible children in a cluster, in one day) 95 per cent
of eligible children in a few “villages around Sevagram” were
It is not clear from .“When the Search . .’’.as to.how this-
Cost Analysis
38
Radical Journal of Health
work is different from other so-called successful projects in
(his respect. Most health projects unless they arc willing to
take large funds from donor agencies, or be supported by
big institutions, cannot do any worthwhile work in the, field
of delivery of health services. (Chattisgarh Mines Shramik
Sangh s health work in Rajhara is an exception which
hopefully, would duplicate elsewhere) Health educaiion/conscientisatio.n as a part of broader political work is a low
cost but challenging and important work which has so far
not been attempted. This is in contrast to the numerous
funded projects in the field of delivery of health care. It must
be pointed out that the report under review does not cross
this conventional barrier.
Ana nt Pliadke
50 LIC Quarters
University Road
Pune 411 016
A Bird 's Eye View of Psychology
are apt to our conditions do ijoi figure, c g, Bhatia’s tests
and child development tests.
Psychology has made quantum jumps in the 60s and 70s
but what has not been done is to dispel the wrong notion
(hat psychology means something to do with abnormal
people—being the layman’s understanding. All the reserach
done is commendable, but what has this resulted in terms
of follow-up. actions and policies? The author himself puts
the impact of psychology in these words, “Psychology in
India has made significant contributions to the individual
and unlimited spheres of our life like in industry, educational
and clinical fields because they share many characterstics of
similar institutions in western societies where this discipline
has developed. But on a macro level and on larger social
issues such poverty, inequality, social justice and social
change, psychology has yet to make a significant impact!’
The author’s message to practising psychologists and scholars
to be ‘indigenous’ and ‘Indian’ in their pursuits is very apt
for psychology to enlarge its role in our national life.
The book would have added to its stature if the author,
with his vast knowledge and experience, had given more em
phasis to the future trends and direction’s that Indian
psychology should take—to make it more meaningful and
relevant to our society and solving its problems.
Tlic overall merit of tht book lies in its broad canvas giv
ing a bird’s eye-view of the psychology scene in India. It could
be a good reference source for scholars and educationists
alike to be aware of what is happening around the country.
Its bibliography is in itself a mine of valuable information.
Altogether, the book is a commendable effort.
Psychology In A Third World Country—The Indian Ex
perience by Durganand Sinha, 1986, Sage‘Publications.
THE term ‘psychology’ is a concept borrowed from the West.
Thus initial studies were fiaturally based on Western concepts.
This of course does not mean that psychology has not evolv
ed any roots of its own in India. But it is undeniable that
Western psychologists and ideas have permeated every aspect
of our life and behaviour. Sinha repeatedly brings out this
truism in this book covering the psychology scene in India.
The purpose of this monograph, done at the instance of
Purnima Rao
UNESCO, was broadly to examine the impact and role of
psychology in a Third World country like India.
It is but natural that psychologists in India are very much
influenced by the West in the kind of reserach work done. (Continued. from p 2F
The offspring is bound to imitate its parent till such time
that it can form its own ideas and opinions and-finally enter
References
its own creative phase. Psychology today in India could be
said to have arrived. We are not only able to evolve our own
Alderguia,- Jorge Valdez-Brito and Aldcrguia, Jorge Henrique: "Health
theories and concepts but are also in a position to influence
Status of the Cuban Population", International Journal of Health
the' world at large.
Services, Vol F3, No 3, 1983. pp 479-485.
Sinha traces the growth of ‘psychology’ in India in four •Derr, Patrick; Goble, Robert: Kaspersoh, Roger E; and Kates, Robert
W: “The Double Standard in Worker Safety", Science Today, April
phases pre-Independence, post-independence phase of ex
1982, Vol 16. No 4, pp 86-145.
pansion, phase of problem-oriented research and finally the
Doyal,
Leslie with Pcnijel. Imogen: The Political Economy of Health,
phase of indigenisation. This can be looked at another way
Pluto Press. London.’ 1983.
in developmental terms. The infant stage of being shackled Gidadhubli, R G: “Soviet Economy towards the Year 2000—American
to the West; the childhood period where aping went on; the
View”, Economic and Political Weekly, Vol XVIII, No 42, October 15,
adolescent phase when Indian psychologists tried to break
’1983, pp 1803-10.
away from the bonds of the West, attempted to coin their • International Journal of Health Services, “Health and Health Protection
of the Polish Population", Vol 13, No 3, 1983, pp 487-513.
own terms and asked questions of their parents and their
motives, changed and"adapted values and attitudes to suit Lindgren^Stepan.fTr): “Alcoholism in USSR”, Frontier, Vol 17, No 41,
June 1, 1985.
their environment; and the adult phase where indigenous Segall, Malcolm: “On the Concept of a Socialist Health System",
research is being done and a certain amount of influence be
International Journal of Health Services, Vol 13. No 2. I983v
ing wielded on others, especially in the Third World
pp 221-225.
Sidel, Ruth and Sidcl, Victor W: The Health of China, Beacon Press,
countries.
Boston, 1982.
The author seems to have taken an unduly critical attitude
Sigcrist, Henry' E: Medicine and Health in Soviet Union, Jaico Publishing
particularly in his reivew of the post-independence period
House, Bombay, 1947.
like a harsh parent! Fortunately, as the review proceeds a Quinn, Joseph R: "Medicine and Public Health”, in Medicine and Health
Care: People's Republic of China, US Department of Health. Educa
more objective account is seen.
tion and Welfare, 1973.
The bulk of the presentation is in terms of enumerating
the research work done in India covering different areas and
Dhruv Mankac!
1877 Joshi Galli
branches of psychology. But in the area of testing, there do
Nipani 591 237
seem to be some gaps. Several tests have been adapted and
39
June 1986
Dialogue
Contradictions Where There Are None
Thomas George
ANANT PHADKE’S article “Organising- Doctors: Towards
What End?” is full of ambiguities and sweeping generalisa
tions. At the very outset Phadke says that doctors belong
to a social layer called “the new middle class—a peculiar pro
duct of developed capitalist society”. One can question the
understanding that Indian society is a developed capitalist
society; he has given no indication as to how he arrived at
this concept. To mechanically transfer concepts developed
for Western societies is neither scientific nor helpful.
Phadke has gone on to enumerate four contradictions that
doctors in government services face due to what he sees as
their ‘contradictory class location’ betwen the capitalist class
and the working class. The first of these is that they are wage
earners as well as officers. He feels that since they are officers
they will stand apart from their subordinates in wage strug
gles. It is difficult to understand how this constitutes a con
tradiction. Is Phadke implying that doctors will seek to crush
the wage-demands of the subordinate staff? If so, this is an
unreasonable understanding. Wage demands of subordinate
staff in no way hurt the doctors, even if they belong to
Phadke’s “new middle class”, since it is not they who pay
the wages. So the mere fact that at this stage of social evolu
tion in India the doctors may not actively support the wage
struggles of their subordinate staff in no Way constitutes a
contradiction.
The second contradiction that Phadke sees is the one bet
ween the need of the government-employed doctor to amass
wealth and his limitations as a wage-earner expected to follow
the ethics of a noble profession. Here again Phadke seems
to have fallen into a widespread misconception. Just because
doctors have a relatively secure economic position, one can
not call it wealth. It is true that the government forces doctors
to do private practice by deliberately paying low wages. It
is also true that very often this private practice is unscientific.
But this constitutes a point on which to organise doctors.
Most doctors would like to do scientific practice. They would
also like to earn a good living. If it can be demonstrated to
them that these two things arc not fundamentally in
compatible, but only appear to be so because of the existing
organisation of society, surely they would work to change
this organisation. We must understand that the present rulers
of India will only provide a level of health care sufficient
to keep the people quiet. The quality of health care is not
determined by the doctor, it is determined by the government.
The government is not interested in spending the amount
necessary to provide adequate scientific health care. It will
spend only enough to prevent uncontrollable unrest and no
more. It will pay the doctors as little as it can thereby forc
ing them to supplement their income by private practice. The
fundamental conflict therefore is not between doctors and
the people but between the doctors and the government.
According to Phadke the third contradiction is between
the “technocratic scienticism” of doctors (that is, their way
of looking at health and disease as primarily a question of
interplay of gfcrms and chemicals amenable to drug therapy)
and the real need for community medicine. I think that this
40
is vanity oure and simple. Many activists feel that they have
discovered the Keys of the Kingdom, the root cause of India’s
poor health status, and that this is the lack of a “community
approach” by doctors. The fact is that every doctor is well
aware of the social aspects of disease though he may not have
a clear analysis of the Indian social structure, or what to do
about it. But is the solution to this problem the “community
orientation” of doctors? The government certainly thinks so
and the doctors’ “lack of community orientation” is favourite
excuse for poor health services! But neither the government
no.r Phadke has cared to explain how doctors are to put into
practice this fabled “community orientation” in the existing
scheme of organisation of society and health care.
Phadke’s fourth contradiction escapes me entirely. I don’t
understand how the fact that “medicine transcends narrow
barriers and exposes medicos to universal concepts” and the
fact that (according to Phadke) the majority of doctors are
from an upper-caste urban .background, constitutes a
contradiction.
The sad part is that Phadke’s analysis leads him to a funda
mentally elitist position. He wants to organise only “a small
section” for a comprehensive revolutionary change in the
medical system because he feels that only a small section will
respond to his analysis. History tells us that revolutions are
not brought about by small sections of society. So when an
analysis leads one to such conclusions, it is a clear indica
tion that one should analyse again and look for and correct
the errors in understanding. Only such a scientific process
can clarify the debate.
Thomas George
P G Student in Orthopaedics
Medical College
Trivandrum - II
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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 highlights one theme, but it also publishes (i) Discussions
on articles published in earlier issues (ii) Commentaries, reports, shorter contributions
outside the main theme.
Our forthcoming issues will focus on : Primary Health Care, Medical Technology,
Agricultural Development and Health, Health in People's Movements.
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
Primary Health Care 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 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. This
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.
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RTH IS A SATELLITE OF THE MOON
The apollo 2 cost more than
the apollo 1 cost, enough.
the apollo 1
The apollo 3 cost more than the apollo 2
the apollo 2 cost more than the apollo 1
the apollo 1 cost enough.
The apollo 4 cost more than the apollo 3
the apollo 3 cost more than the apollo 2
the apollo 2 cost more than the apollo 1
the apollo 1 cost enough.
The apollo 8 cost a whole lot but you didn't feel it
because the astronauts were protestants
they read the bible from the moon.
bringing glad tidings to all Christians
and Pope Paul VI blessed them when they returned.
The apollo.9 cost more than all the rest together
including the apollo 1 which cost enough.
The great-grandparents of the people of Acahualinca
were less hungry than the grandparents.
The great-grandparents died of hunger.
The grandparents of the people of Acahualinca were
less hungry than the parents.
The grandparents died of hunger.
The parents of the people of Acahualinca were less
hungry than the people who live there now.
The parents died of hunger.
The people of Acahualinca are less hungry than
their children
The children of the people of Acahualinca are
born dead from hunger,
and they're hungry at birth, to die of hunger.
The people of Acahualinca die of hunger.
Blessed be the poor, for they shall inherit the moon.
LEONEL RUGAMA
(NICARAGUA)
Leonel Rugama was a member of the Sandino National Lib
eration Front. He and another comrade were trapped in a
house in the city of Managua in January, 1970. The house
was surrounded by troops and war materiel. The two men
put up a courageous f'ght which lasted several hours. When
their ammunition ran out, the army finished them off. Rugama
was 20 years old.
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