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A SOCIALIST.'HEALTH REVIEW TRUST PUBLICATION
New Series VOLUME III
VIOLENCE AND HEALTH CARE
PROFESSION: TOWARDS A CAMPAIGN
FOR MEDICAL NEUTRALITY
NURSES AND HUMAN RIGHTS:
PROTECTING PROVIDERS OF CARE
HUMANITARIAN ACTION AND FIELD
WORKERS; SOME CONTROVERSIAL ISSUES
INDIGENOUS HEALTH CARE SYSTEM IN
KARNATAKA: AN EXPLORATORY STUDY
Rs 25
Consulting Editors:
Amar Jesani,
CEHAT, Mumbai
Binayak Sen, Raipur, MP
Dhruv Mankad,
VACHAN, Nasik
K Ekbal,
Medical College, Kottayam
Francois Sironi, Paris
Imrana Quadeer,
JNU, New Delhi
Leena'Sevak,
London School of Hygiene and
Tropical Medicine, London
Manisha Gupte.
CEHAT, Pune
The Radical Journal of Health is an
interdisciplinary social sciences
quarterly on medicine, health and
related areas published by the Socialist
Health Review Trust. Il features
research contributions in the fields of
sociology, anthropology, economics,
history, philosophy,psychology,
management, technology and other
emerging disciplines. Wcll-rescarchcd
analysis of current developments in
health care and medicine, critical
comments on topical events, debates
and policy issues will also be
published. RJH began publication as
Socialist Health Review in June 1984
and continued to be brought out until
1988. This new series of RJH begins
with the first issue of 1995.
Editor. Padma Prakash
V R Muraleedharan,
Editorial Group: Aditi Iyer, Asha
Indian Institute of
Technology, Madras
Vadair, Ravi Duggal, Sandeep
Khanvilkar, Sushma Jhaveri,
Sunil Nandraj, Usha Sethuraman.
Padmini Swaminathan,
Madras Institute of
Development Studies, Madras
Sandhya Srinivasan,
Harvard, USA
C Sathyamala, New Delhi
Thelma Narayan,
Community Health Cell,
Bangalore
Veena Shatrugna, Hyderabad
Irudaya Rajan, CDS,
Trivandrum
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Publisher: Sunil Nandraj for
Socialist Health Review Trust.
All communications and
subscriptions may be sent to :
Radical Journal of Health,
19, June Blossom Society,
60-A Pali Road, Bandra,
Mumbai 400 050.
EMail: rjh@nrp.ilbom.ernet.in
Typsetting and page layout at the Economic and Political Weekly.
Printed at Konam Printers, Tardeo, Mumbai 400 034.
Volume III New Series Number 3 July-September 1998
Editorial: A Paradigm of Violence
Health Care as Human Right
Padma Prakash
Ravi Duggal
139
141
Violence and Health Care Profession:
Towards a Campaign for Medical Neutrality
Amar Jesani
143
Nurses and Human Rights:
Report of Amnesty International
157
Humanitarian Action and Field Workers:
Consequences and Ambiguities
Francoise Sironi
179
Communications
Indigenous Health Care System in Karnataka:
An Exploratory Study
R Mutharayappa
187
Letter to Editor
An Appeal
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which threatens to destroy the very' fabric of multinational, multicultural
and multireligious culture and polity of India, the victory of secular and
democratic forces is a necessary condition for India entering into the 21 st
century as a modem democratic state ensuring communal harmony,
progress and psosperity.
Coalition Against Communalism. Berkley, CA, USA
Punjabi People’s Cultural Association, Concord, CA,USA
Coalition for Egalitarian and Secular India, Los Angeles, CA, Gadaritc
Cell, Bakersfield, CA
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ton, MA,
New York Ekta,
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A Paradigm of Violence
By regarding violence as an inevitable consequence of the currently
dominant development model of capitalism, of the process of change,
were refusing to address the severe and serious consequences of
violence on people's health and well being.
IF the last years of the closing century arc to be seen retrospect, a
particular characteristic would be not the technological advances, nor the
strides in communication, but the emergence and spread of what is often
called a culture of violence. It isn’t just wars and social strife, but the
permeation of violence as a behavioural norm. At one level it speaks of
a societal response which is intolerant of injustice; but more often than not
it is an articulation of the injustice of inequality. And this violence has
consequences for health and well-being. Given this, it is surprising that
the health system is only now recognising the fact that certain features of
the health picture in the last decade or so may well have their roots in this
culture of violence.
Il isn’t that violence has not been subjected to study: there have been
biological explanations which submit that human beings are naturally
aggressive; there is the ‘culture of poverty’ approach which sees violence
as being a feature essentially of families with certain characteristics, one
of which is poverty, but also race, and in India, caste, etc. As Barbara
Chasin points out in her recently published reader, Inequality and Vio
lence in the United States: Casualties of Capitalism (Humanities Press
International, USA), although interpersonal violence and crime in the
street have been remarkably well reported, it isn’t as if crime rates have
risen sharply. In fact, workplace-related deaths outnumber deaths classi
fied under ’crime'. In the Indian context, violence as a consequence of
communal and caste tensions and the consequent deaths would probably
form a substantial proportion of all violent deaths. And yet the latter are
not seen to be contributing to the current culture of violence.
Neither of these explanations acknowledge the structural approach to
violence which stresses such factors as distribution of wealth, social
resources and power to explain both structural violence and interpersonal
violence or rather the ‘culture’ of violence. There is another variant
explanation which secs violence as the inevitable consequence of the
development model that has been currently adopted as dominant. For
example, not only does an economic model which is motivated by
competition, inevitably makes for inequality, it also rests on the existence
of a large enough proportion of the deprived, or those who will aspire to
be the other and so enter competition.
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139
At another level, if the growth of the economy dependes on say the
harnessing of natural resources, this objective overrides all other
concerns, including that of those who do not benefit and are in fact
endangered by this act. Thus the inflicting of violence on the power
less becomes a pattern of the very dynamic of the development model.
While such an explanation makes a great deal of sense and contributes
to the construction of a political perspective on violence, it prompts
certain questions.
It would leads to the obvious conclusion that violence would
disappear, or would be mitigated under a more humanitarian model of
social and economic development. Thus the only solution is to struggle
for a different social order. This in fact, rather simplistically pul, has
for a long lime been the accepted understanding of violence in the
progressive movement - as a characteristic feature of the superstruc
ture which need not be, in fact cannot be dealt with until the economic
base has been changed. Thus violence by the stale, directly, indirectly,
seen and unseen, must be countered by political movements for
revolutionalry change. Such a perspective also makes a fine distinc
tion, not always spell out between, violence of say, an angry mass
movemment of people demanding their rights, or even at one extreme
the deliberate planned violent destruction of the capitalist/industrialist/landlord /bania, etc, and that of the state and its organs. Undoubt
edly, there is a distinction and that hardly needs to be elaborated upon
here. On the other hand, it is this fine distinction which has blinded us
to the recognition of the consequences of violence. Today there is
sufficient material to show that it is not only the victims of violence
but those who take pari in social and political movmements which
often inevitably take recourse to violent means who suffer from its
consequence. This approach to violence is reflected also in progres
sive health movements which have so far left the subject unlouchcd.
While there is burgeoning literature on say analyses of the state’s
distorted approach to health care, or even of the medical system’s
biased and blinkered outlook on women’s health, the subject of how
to deal with the survivors of violence, whether it is rape, interpersonal
violence in the family, or its agonising outcomes among political and
social activists, has received little attention.
And yet, in the coming years the response to systemic violence will
come through the greater participation of people and perhaps also a
resurgence of movements which are now at a low ebb. As global
initiatives like the structural adjustment programmes sharpen in
equalities and exacerbate the social and political divide in third world
countries, violence is not likely to abate. It may well lead to a
coalescing of progressive social forces inimical to the established
order and the dominant development models, to the posing of a
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people’s challenge and to the emergence of alternatives. Such a
passage will doubtless produce drastic changes in the health picture.
Also, it would be utopian to imagine that the resulting society will be
free from violence, either in terms of actions and events or in terms of
the stresses and strains. We need to devote considerable thought and
time to such issues as how to rehabilitate and aid the survivors of
violence, and also, to cope with it, in such a manner that it contributes
to the emergence of a political perspective where the victim/survivor
emerges empowered.
-Padma Prakash
Health Care as Human Right
If all people, irrespective of their economic or social status are
to have access to health care, then the state has to play a more
decisive role in ensuring access to such care. This is possible only
if health care is regarded as a right.
HEALTH care as a right is considered desirable universally. Yet all over
the world the private sector dominates the provision of care. Today
health care is fully commodified and people are left to the mercy of the
market. What is worrisome about the health care market is that it works
as a supply-induced demand market. This means that the providers of
care dictate the terms of the market. This is disastrous for the poor, and
especially in a country like India where 75 per cent of the population
lives at or below subsistence, such terms are often debilitating or even
fatal.
In the developed countries, while health care may not be stated as a
fundamental right, access has been made more or less universal either by
legislation and /or insurance or some special provisions for those who do
not have the purchasing power. Thus fiscal mechanisms have been
created in these countries, with an overwhelming proportion of contribu
tions from the state, to assure basic access although the providers may be
from the private sector. Similar is the situation of provision of education,
though here the state institutions are more active in running the institu
tions themselves.
In underdeveloped countries there arc not many examples of such near
universal access, except perhaps some of the erstwhile socialist countries
and a very few other developing economics like South Korea and Chile.
In a country like India where three-fourths of the population still lives in
the villages, providing universal access, whether for health care or
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141
education, becomes even more difficult. While public health facilities are
reasonably well-developed in urban areas the infrastructure in the rural
areas is grossly inadequate. This puls a lot of pressure on the urban
facilities thus impeding their efficiency.
In conditions of widespread poverty where family earnings arc barely
adequate to meet two square meals, seeking health care from the market
becomes a luxury. Yet that is where the poor are often pushed to seek
health care because public facilities are ill equipped to serve their needs.
Often this has led to severe indebtedness wiping out the few assets a
family may own. The National Sample Survey data shows that after loans
for agriculture, the second largest cause of indebtedness is for health care.
This is a serious matter and needs urgent attention. It is here then that the
question of rights becomes important.
While stale health care services are just too inadequate to meet peoples
demands, the private health sector is huge and fairly well spread out. But
the quality of private health care in India is abysmal. More than half the
private practitioners are unqualified. Of those qualified two-thirds do not
practice their own system (homeopathy or ayurveda) but allopathy for
which they have not received training. There arc statutory authorities (the
various medical councils and the local governments) to oversee that only
qualified people practice the profession they have been trained in but they
have not shown any concern in this regard and hence the private health
sector has grown wild and uncontrolled. A number of small studies and
a few national ones have clearly indicated that for ambulatory carc over
three-fourths of those seeking care use private providers. Given the
questionable quality of private health care such a large usage of the
private health sector is fraught with danger. Thus there is an urgent need
for a political will to lake up health care as a mailer of human rights.
In a country like India where poverty is the core concern of the political
economy establishing health care as a human right becomes even more
important. The new economic policies under SAP have had a negative
impact on the health sector with declining stale investments in health carc,
rapidly increasing prices of medicines and further consolidation of the
private health sector with the corporate sector entering the fray in a big
way. With the state under pressure to reduce its participation directly in
the economy it is important that the social sectors like, health care,
education, social security, rural development programmes, etc do not get
diluted but strengthened. The stale must take the lead in reorganising the
health care system as a public-private mix where a planned and organised
system of financing and provision.and not the market determines how
people access health care. This will only be possible if health carc
becomes a human right.
—Ravi Duggal
142
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1998
Violence and Health Care Profession
Towards a Campaign for Medical Neutrality
Amar Jesani
All types of violence produce traumatic effects on the survivors.
More often than not, it is the health professional — the doctor,
the nurse or paramedic - who is a primary contact for the survivor.
This may be either as a confidant, a care-giver, and unfortunately
enough also often as a collaborator of those who deal out violence.
This article reviews the present situation under three heads: violence
against women; communal and caste violence, and violence by state
agencies. Also examined are roles of health care personnel in caring
for survivors as well as in preventing violence. The paper argues
for a campaign for medical neutrality in India.
UN THE medical discourse in India, the concern for violence has been
(conspicuous by its absence. In much of medical research, and literature,
tithe mention of the victims and survivors of violence, their special medical
meeds and rehabilitation, is rare. This is despite the fact that violence
iinvariably inflicts physical or psychological trauma. In any form of
• violence, the victims and many survivors come in contact with health care
workers. Survivors themselves approach or are taken to health care
services for the treatment of their physical injuries and psychosocial
trauma. After the death of the victim, the doctor conducts an autopsy. In
fact, the medical record of violence on the survivors and victims consti
tutes an important evidence for police investigation and the legal process
for punishing the offenders and compensating victims and survivors. The
apathy of the medical profession could result in delayed or denied justice
to many victims of violence.
The figures quoted by the media and social science researchers from
various sources on the incidence of all types of violence and the estimated
numbers of victims are indeed shocking. Interestingly there is hardly any
mention in our scientific journals and health policy documents about the
implications of such a phenomenon for the health care services. While
one does not want to sensationalise and exaggerate the phenomenon of
increasing violence in our society, one also cannot desist from saying that
for the health care services it is a big, but ignored, epidemic of the present
time.
Although the intensity of this epidemic needs to be assessed, sadly,
there is little work done on the subject. The data on burden of disease
presented in the World Bank Report (1993) suggest that morbidity due to
RJH
(New Series)
Vol III: 3
1998
’
143
education, becomes even more difficult. While public health facilities are
reasonably well-developed in urban areas the infrastructure in the rural
areas is grossly inadequate. This puts a lol of pressure on the urban
facilities thus impeding their efficiency.
In conditions of widespread poverty where family earnings are barely
adequate to meet two square meals, seeking health care from the market
becomes a luxury. Yet that is where the poor are often pushed to seek
health care because public facilities are ill equipped to serve their needs.
Often this has led to severe indebtedness wiping out the few assets a
family may own. The National Sample Survey data shows that after loans
for agriculture, the second largest cause of indebtedness is for health care.
This is a serious matter and needs urgent attention. Il is here then that the
question of rights becomes important.
While stale health care services are just loo inadequate to meet peoples
demands, the private health sector is huge and fairly well spread out. But
the quality of private health care in India is abysmal. More than half the
private practitioners are unqualified. Of those qualified two-thirds do not
practice their own system (homeopathy or ayurveda) but allopathy for
which they have not received training. There are statutory authorities (the
various medical councils and the local governments) to oversee that only
qualified people practice the profession they have been trained in but they
have not shown any concern in this regard and hence the private health
sector has grown wild and uncontrolled. A number of small studies and
a few national ones have clearly indicated that for ambulatory care over
three-fourths of those seeking care use private providers. Given the
questionable quality of private health care such a large usage of the
private health sector is fraught with danger. Thus there is an urgent need
for a political will to lake up health care as a mailer of human rights.
In acountry like India where poverty is the core concern of the political
economy establishing health care as a human right becomes even more
important. The new economic policies under SAP have had a negative
impact on the health sector with declining state investments in healthcare,
rapidly increasing prices of medicines and further consolidation of the
private health sector with the corporate sector entering the fray in a big
way. With the slate under pressure to reduce its participation directly in
the economy it is important that the social sectors like, health care,
education, social security, rural development programmes, etc do not get
diluted but strengthened. The stale must lake the lead in reorganising the
health care system as a public-private mix where a planned and organised
system of financing and provision.and not the market determines how
people access health care. This will only be possible if health care
becomes a human right.
—Ravi Duggal
142
RJH
(New Series)
Vol Hl: 3
1998
Violence and Health Care Profession
Towards a Campaign for Medical Neutrality
Amar Jesani
All types of violence produce traumatic effects on the survivors.
More often than not, it is the health professional — the doctor,
the nurse or paramedic - who is a primary contact for the survivor.
This may be either as a confidant, a care-giver, and unfortunately
enough also often as a collaborator of those who deal out violence.
This article reviews the present situation under three heads: violence
against women; communal and caste violence, and violence by state
agencies. Also examined are roles of health care personnel in caring
for survivors as well as in preventing violence. The paper argues
for a campaign for medical neutrality’ in India.
IN THE medical discourse in India, (he concern for violence has been
conspicuous by its absence. In much of medical research, and literature,
the mention of the victims and survivors of violence, their special medical
needs and rehabilitation, is rare. This is despite the fact that violence
invariably inflicts physical or psychological trauma. In any form of
violence, the victims and many survivors come in contact with health care
workers. Survivors themselves approach or are taken to health care
services for the treatment of their physical injuries and psychosocial
trauma. After the death of the victim, the doctor conducts an autopsy. In
fact, the medical record of violence on the survivors and victims consti
tutes an important evidence for police investigation and the legal process
for punishing the offenders and compensating victims and survivors. The
apathy of the medical profession could result in delayed or denied justice
to many victims of violence.
The figures quoted by the media and social science researchers from
various sources on the incidence of all types of violence and the estimated
numbers of victims are indeed shocking. Interestingly there is hardly any
mention in our scientific journals and health policy documents about the
implications of such a phenomenon for the health care services. While
one does not want to sensationalise and exaggerate the phenomenon of
increasing violence in our society, one also cannot desist from saying that
for the health care services it is a big, but ignored, epidemic of the present
time.
Although the intensity of this epidemic needs to be assessed, sadly,
there is little work done on the subject. The data on burden of disease
presented in the World Bank Report (1993) suggest that morbidity due to
RJH
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Vol Hl: 3
1998
'/■
143
violence and accidents accounts for 8.1 percent of all morbidity (DALYs
lost) among women and 10.2 per cent among men in India.
The science of medicine incorporates a sociological and epidemiologi
cal understanding. Medicine, and for that matter, any science not geared
to the real social and epidemiological issues often loses its humanitarian
perspective. Violence does not leave health professionals completely
unaffected. After all, doctors also come from a social milieu which has
varied and conflicting standpoints on the violence. To what extent is the
attitude of doctors to violence shaped by their social positions and
ideological orientation in our country? There has been little empirical
research or documentation on health care providers’ altitude on the subject
and the extent to which individual biases get reflected in medical practice.
The number of health care professionals in our country is staggering.
We have 1.2 million properly qualified doctors (one doctor for less than
900 persons) who are legally registered with three medical councils. In
addition, we have about 0.3-0.5 million non-qualified and non-registered
doctors practising in the country. We have nearly 0.6 million nurses of
various categories and also have a large cadre of paramedical workers.
Inal 1, we have over two million professional and para-professional health
workers who need to be educated to take cognisance of violence as a
public health issue and undertake advocacy to ensure that they play a
positive, constructive and ethical role in caring for the survivors of
violence.
In this review, we have summarised the present situation under three
sections: violence against women; communal and caste violence and
violence by state agencies. We have reviewed selective literature to
highlight lacunae in the role of health services and profession in prevent
ing violence and caring for survivors. Indeed, there are also many positive
features, too. However, there is very little written documentation avail
able and is often only considered as pan of individual doctor or hospital’s
philanthropic zeal. In any case, it is still not much of a concern for the
profession and the system at large. While the Indian Medical Association
has begun some educational campaign among its members, this leaves out
60 per cent of doctors in our country who are non-allopalhic doctors and
it is restricted to torture. Besides, it has not shown real commitment to the
cause by taking action or campaigning for action against those doctors
who have been named as collaborators in human rights violations.
We have also reviewed here some information on the need for
education and training of doctors in order to make them aware of the
problem, take measures to prevent it and, above all, to change their
attitude towards violence and the victims. The last issue is very important.
For in all the three types of violence, there is some evidence to suggest that
a section of doctors themselves believe in the use of violence against
victims/survivors in “certain circumstances”. Or that, they arc less than
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sympathetic if the victim has certain negative attributes or when the
victim is ‘stereotyped’ by society as deserving of the violence.
I
Violence Against Women
The great surge of the women’s movement in the 1980s brought the
issue of violence against women on the political agenda of the country.
Yet, a survey of violence against women in the less developed countries
has shown that it is a grossly neglected public health issue [Heise, Raike
ct el 1994]. Violence against women and children is the most common
form of family violence and it has social, cultural and religious sanction.
Studies by Flavia Agnes in the 1980s in Mumbai and other studies have
shown that it cuts across class. These social variables only change the
form of violence, not its high prevalence. In a study of 120 families at
NIMHANS, Bangalore, Bhatti (undated) found that some form of vio
lence against women was prevalent in all families. The physical and
verbal violence was the highest (88 percent) in the low-income families
while in the middle income (43 per cent) and high-income (35 per cent)
families those forms were less prevalent. However in the latter groups,
there was a higher prevalence of social and emotional violence. In a large
study of230 women from urban middle and upper classes, Sathyanarayan
Rao and his colleagues (1994) from the department of psychiatry in the
Mysore Medical College investigated the pattern and causes of psycho
logical violence against women in the family. They came to the conclu
sion that psychological and emotional torture is very prevalent in middle
class families. In a study by Mahajan and Madhurima (1995) of 115
women in lower caste households in a village on the outskirts of Chandigarh*
in Punjab as many as 87 (75.7 percent) women reported physical violence
against them by their husbands. Further, of these 87 women, 58 (66.7 per
cent) said that they were beaten regularly. Similarly, dowry deaths and
their increasing number, despite changes in law, point to the pernicious
prevalence of family violence.
While the women’s movement has brought family violence out of the
closet and made it a social and political issue, violence against children
within the family and outside has still not been properly recognised,
except in the campaigns against child labour and the problems faced by
street children. Studies on child abuse in India are difficult to find
although our experiences suggest that violence against girl children,
iincluding sexual violence, is as highly prevalent as wife beating.
The role of health care professionals is ambiguous in cases of family
wiolencc. In an investigation [YUVA, MFC et cl 1990] of a gang rape in
{Bombay it was found that despite the visible signs of injuries in regions
which would make any medical person suspicious of rape, the male doctor
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turned away lhe woman after giving routine treatment of injuries. This
was done, according to lhe doctor, simply because lhe woman did not tell
him that she was raped. In this particular case, the woman had reported
rape to lhe nurse on duly but could not communicate lhe same to the male
doctor. In a recent case of lhe rape of a hearing impaired girl in a
government-run Observation Home for Juveniles in Mumbai, the same
pattern was observed in the doctor’s behaviour. An investigation team
found that the officials of lhe Observation Home did not report the crime
to the police for 20 days. However, they did gel the victim examined by
their in-house doctor, who also failed to follow proper procedures.
Indeed, the doctor also failed to do the medical examination of and collect
forensic evidence from the offender who was also present all lhe time in
the premises of the institution [FACSE 1998].
Failure to collect relevant forensic evidence and counsel the survivors
due to ignorance and indifference are not the only problems the profession
needs to address. There are also instances of doctor’s direct collusion in
falsification of evidence and protecting lhe offenders. For instance, in a
case of custodial gang rape and torture of a tribal woman by lhe police in
Gujarat [Al 1988]. lhe commission of inquiry constituted by the Supreme
Court had found two doctors al the government hospital guilty of
shielding the policemen. They had also issued a false certificate.
Shally Prasad's (1996) study in Delhi found aconspiracy of silence on
the part of physicians. The private as well as stale-employed physicians
seldom acknowledged the cause and totality of woman’s injuries. They
also did not make referrals to counselling services or women’s
organisations. Physicians generally avoid involvement in gender-based
abuse because of lhe social stigma. Physicians’ general altitude of denial
is manifested through delayed and often inappropriate medical examina
tions. denial of the crime and health impact on women and limited health
care assistance beyond immediate trauma. Often physicians deliberately
do not ask questions regarding lhe cause of injuries because they do not
want to be involved in a legal case. Her interviews with over 30 survivors
of abuse and health care providers showed that long-term care, STD
screening, counselling and preventive care were not generally included in
the examination. On lhe other hand, lhe case studies of rape survivors
showed that physicians often did not conduct thorough and lime-sensitive
medical examinations, which resulted in the loss of valuable medical
evidence. She recommends that associations of medical professionals
should be motivated to upgrade rape protocol, implement comprehensive
treatment and long term care for survivors, implement similar training
and refresher training for medical students and doctors, etc. She also
makes a plea for the establishment of a central bureau of forensic
specialists in public hospitals to co-ordinate lhe collection of medical
evidence. Il is in this context that the initiative of CEHAT, Mumbai in
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developing a manual and kit for medical and forensic examination of
sexual assault victims is going to be very useful [D’Souza 1998J.
Despite the partial success achieved by women’s groups in getting
rape laws amended, most survivors do not come forward to report
violence against them and most of those who reported the crime, have not
got justice. The lack of a system within the health care system for
reporting cases of violence seen and inadequate or incorrect medical
evidence in rape cases, etc are some of the many important reasons for
such failure. Moreover, the profession and health system do not have any
mechanism to make accountable and punish those doctors who are
negligent and guilty ofcollusion with offenders. In fact, medical audit and
strict accountability systems are must in order to prevent violence and
help survivors get justice.
Similarly, in cases of wife beating, although such battered women do
approach doctors for treatment when severely beaten up, their medical
record would invariably show the injuries as accidental. While it is true
that often women do not report the true cause of injury due to fear, even
in those cases where such reporting is done, women have found the
doctors uncooperative. Indeed, examination of medical records by us has
invariably shown that in all ‘medico-legal’ cases the doctors are tutored
not to write detailed history of assault. The hospital managers and
forensic experts have taken stand that writing history of assault is the job
of police, and not doctors. Besides, it is argued, by not writing the history
of assault, the doctor would be able to protect him/herself better in the
court of law. Not only that, the forensic experts have also taken position
that in medico-legal cases the doctor’s role is only to collect forensic
evidences and in such examination, no doctor-patient relation is estab
lished. Thus, according to them there is no ethical obligation on doctor to
care for the survivor. It is obvious that such a position has devastating
consequences, particularly in rape cases
There have been some efforts to study sexism in medical textbooks and
medical practice. But there has been no efforts made to look al the
violence within the families of health professionals. In some of our work
with the auxiliary nurse midwives [lyerand Jesani 1995], we came across
many instances of violence against women health professionals. In order
to sensitise health workers to problems of survivors of violence it is
necessary make them think and talk about their own lives and problems.
<
11
Communal and Caste Violence
Most of the sociological studies have shown that the doctors hail from
upper caste and class strata of the society [Ommen 1978; Vcnkatratnam
1979], With the phenomenal increase in the number of private medical
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colleges, the dominance of these strata in the profession is on the increase.
This social background of doctors provides a fertile ground for social
forces using caste (casleism) and religion (communalism) for political
mobilisation and the capture of power. It is, therefore, not surprising that
in communal and caste mobilisations, significant support has come from
the professional classes, which include doctors. Our personal experiences
with doctors at a professional level and in our interaction with them in
several health service studies in urban and rural Maharashtra, we have
found health professionals’ views highly coloured by caste and commu
nal ideologies. Very few studies and personal experiences of doctors are
available on this subject. However, the available material does make one
concerned about their role and attitude.
Negative Role: Indifference and Approval
While a big section of doctors worked tirelessly in providing medical
relief to victims during communal riots in Mumbai in 1984 and in 1992-3,
some doctors in personal conversations confessed that some of them were
as much involved in believing and spreading wild rumours as the general
public. During the 1984 riots, some social workers who took survivors to
the city hospitals had complained apathy and indifference, particularly by
the Class IV support staff, towards survivors from a particular commu
nity. An eyewitness testimony by a doctor [Sharma 1991: 9] on the
behaviour of doctors at the M G M Medical College and the M Y Hospital,
Indore, during communal violence in October 1989 (the ‘rathyatra’
violence) is revealing. He and his colleagues from the Socially Active
Medicos found that, the “doctors themselves harbour anti-minority sen
timents and contribute to the harassment both by spreading rumours and
by blatant discrimination in health care provision”. According to this
eyewitness account, the doctors contributed to communal tension by
‘inflating’ death figures for the majority caste, thus making it appear that
they were the ones victimised. He also describes an observation by his
colleague on the medical care provided to minorities: ‘‘Far from slopping
at manipulation of death figures,... doctors were also seen to deny proper
medical care ... Dr - , a member of Socially Active Medicos, while
working in casualty ward witnessed blatant discrimination of patients
according to caste; at times, he even saw a proper line of treatment
suddenly changed when it became apparent that a patient was circum
cised”. On the positive side, Sharma also describes the case of Ariwala,
who during those violent days continued work at the hospital for long
hours, thus leaving his house unprotected. The rioters indeed looted his
house while he was caring for survivors at the hospital.
While this negative role played by some doctors in events of violence
must worry the health care professionals, they should also recognise that
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indifference to and approval of communalism and castism in the society
could only divide them. In the worst cases, such a division could also fuel
caste and communal conflicts. For instance, in the early 1980s, when the
middle classes of our country raised the issue of abolishing reservations
in higher education for lower castes (the schedules castes and scheduled
tribes), the doctors were very much part of the campaign. Indeed, in
Gujarat in mid-1980s, the medical students supported by doctors and
organisations of their parents played a very prominent role in the anti
reservation agitation. Medical professionals publicly castigated the res
ervation policy and asserted that the ill-equipped and less-intelligent
tribal doctors and those from lower castes were primarily responsible for
the declining medical standards, and so on. It is also significant to note
that, the anti-reservation campaign and the social atmosphere created by
such powerful forces was used, at that time, in Gujarat by vested interests
to inflict violence on lower caste individuals and groups.
Similarly, communal riots are accompanied by rumours against the
minority, and such rumours could also include vicious hate-propaganda
against doctors from the minority. This situation does not allow minority
victims to reach hospitals (because of the tense environment outside the
hospital) and also make out the majority community to be victims in the
hands of minority-doctors. Such an atmosphere communalises the issue
of providing immediate medical care to survivors of violence. For
instance, in mid-December 1990, Aligarh, a town in Uttar Pradesh was
rocked by communal violence. A local Hindi daily newspaper made
allegations that “patients and their relatives had been deliberately killed
on communal lines by the doctors on duty at the Jawaharlal Nehru
Medical College, Aligarh Muslim University’’, implying that the Muslim
doctors at this hospital systematically killed the Hindu patients. It was
also alleged that one of the reasons for the communal violence in Aligarh
was such killing in the hospital. Indeed, these reports alleged that the
neutrality of medicine was seriously compromised in the hospital.
While there was no investigation of the allegations of violence of
medical neutrality in Lucknow hospital described above by Sharma, a
medical group in New Delhi, called Delhi Medicos’ Front sent a team of
doctors to investigate the allegations in Aligarh. The team interviewed all
individuals who were supposed to be eye-witness to the massacre of
Hindu patients. Both Hindu and Muslim doctors were interviewed. The
team ultimately came to the conclusion that: (1) No incident look place
between December 7-10, 1991 inside the hospital building as alleged by
the Hindi newspapers of the Uttar Pradesh. (2) There was no discrimina
tion against patients on communal lines. (3) There were three stabbing
incidents outside the casualty on the 8th and 9th December 1991 by some
masked men. (4) Press reports in the Hindi newspapers of UP are totally
false and baseless [Sofat, Saxena, Siddiqi 1991].
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Psychosocial Trauma
Communal violence produces serious psychosocial trauma among
survivors, the victimised community and among the witnesses. Follow
ing riots in Mumbai, there were numerous reports in the media describing
the kind of psycho-social trauma suffered by survivors. Departments of
psychiatry in various public hospitals provided information on the kind
of symptoms suffered by survivors, particularly children, [see various
press reports documented in Jesani, D’Sa; Alphonse 1993: pp 74-120].
Harish Shetly and Anjali Chhabria (1997) have documented
psychosocial problems suffered by people due to riots. Some of the
findings of various studies documented by them are as follows:
A study conducted by the Department of Psychological medicine al the
R N Cooper Hospital, Mumbai, among 400 survivors between JanuaryApril, 1993. showed that: (1) Survivors refused to visit the hospital to talk
to the staff, but they willingly waited near their homes for the team to
arrive, (2) intrusive thoughts, flashbacks, avoidance behaviour, numb
ness of emotions, hyperarousal, ‘existential dilemma’ and ghetto mental
ity were evident in some areas, (3) Avoidance behaviour is more common
among the middle aged and middle and upper middle class socio
economic groups, (4) Somatic symptoms are noticed in adults, (5)
Hyperarousal, intrusive thinking and hostility increased after a month of
the event and decreased with passage of time, (6) Depression increased
with the passage of time, (7) A persistent feeling of uncertainty was the
commonest negative emotion.
A study conducted by the department of psychiatry, B Y L Nair
Hospital, of 192 hospitalised patients revealed that: (1) 33 per cent
expressed anger and were in a state of shock, fear and helplessness, (2) 2
per cent of them had attempted suicide — all females who had seen the
mangled bodies of their husbands. (3) 36 per cent had suicidal thoughts.
(4) 21 per cent suffered from severe anxiety, (5) 41 per cent had paranoid
thinking and obsessional symptoms. (6) all had loss of libido, (7) PTSD
feature scored very high and a few were emotionally anaesthetised.
Another study conducted by the department of psychiatry, B Y L Nair
Hospital, among 500 children from two Municipal Schools revealed that:
(1) psychiatric morbidity was very high, (2) victims were affected more
than non-victims, (3) children staying in hutment were affected more than
those staying in chawls. (4) A follow up study after six months revealed
that 11 per cent of the children were suffering from distress. According
to the educational department of the municipal corporation, 30,000
children dropped out of the schools after the riots.
While day-to-day discrimination against women and the lower castes
in the provision of health care is prevalent (and unethical), the role of
health professionals during the large-scale caste and communal violence
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has remained unexplored. During the communal violence in Bombay in
1992-3 we came across some doctors in public and private hospitals who
justified the violence against minorities. At the same time, we also came
across many doctors who were opposed to communal violence and
showed their commitment by taking care of survivors at great personal
risk. To what extent do caste and communal biases amongst doctors gel
manifested into overt discrimination in the treatment? This subject needs
more exploration and research.
Ill
Violence by State Agencies
Autopsy
The abysmal condition autopsy rooms across the country, conduct of
autopsies, quality of their reports and access to these reports etc. have
been a matter of concern for long. There have been reports in the press
about the pressure exerted by the police on doctors to give favourable
findings. The famous case of police custody death of Dayal Singh made
the Resident Doctors’ Association of the AIIMS (New Delhi) protest
against such pressure is mentioned in the Amnesty International [Al
1992] report titled Torture, Rape and Deaths in Police Custody. Simi
larly, the autopsy reports of two nuns murdered in a Bombay suburb and
the doctors’ role in unscientific interpretation of its findings created a
great furore [Solidarity for Justice 1991]. In addition to the autopsy
reports of these nuns, we also had an opportunity to go through a sizeable
number of autopsy reports of custody deaths and so called ‘encounter
deaths’ in the last few years. In general we found that they usually have
incomplete and often unscientific documentation. Il is significant to note
lhai the Supreme Court had to pass an order in 1989 that all post-mortem
examinations held at the AIIMS be standardised.
Torture
Some of the retired and senior police officers, “reared in the old school
of correct policing’’, have publicly criticised the “new methods of polic
ing”. These new methods arc “supposed to be firm, unorthodox, effective
and harsh, and they condone the use of torture, illegal detention and
tempering with records, and in worst cases even condone execution by
police officers of hard core criminals” [Rustamji 1992], The 1992 report
of the Amnesty International cites 13 cases of custody death due to torture
in the period 1985-89 in Maharashtra. However, a Mumbai newspaper
The Independent, reported a study by the prestigious Karve Institute of
Social Work, Pune giving the loll ofcustody deaths in Maharashtra as 155
in 1980-89 period. It was found that of these 155 deaths, 102 (20 per
annum) had taken place in the five year period of 1985-89 for which the
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Al had reported only 13. On analysing the causes of the 155 custody
deaths, it was found that only 9.7 percent were admitted as due to police
action. However, of them, 44.5 per cent were attributed to suicide or
acts of the accused. 7 per cent to acts of the public, 22.6 per cent to
disease and illness, 13.6 per cent were termed natural deathsand in 2.6 per
cent the cause was not known or record not available [Jesani 1995].
Indeed, this record reflects more poorly on the indifferent and incompe
tent way autopsies have been conducted than on the actual causes of
deaths.
In one investigations [CPDR 1990] of a police custody death in
Mumbai it was found that the young victim was brought to a public
hospital in a serious health condition. The doctor took the case history and
gave routine medical care in the presence of a police officer who had
accompanied the victim. As a consequence, the victim did not inform the
doctor about the torture. He was taken back to the custody where he was
further tortured. He eventually died.
These examples represent only the tip of the iceberg. Il is not that the
doctors who often come into contact with the survivors and victims arc
always conscious accomplices in covering-up cases. A section of doctors
involved are plainly ignorant about this aspect of medical work. Another
section is indifferent to the plight of sufferer due to their own social biases
against survivors and victims. Such indifference is also produced by
social pressure to conform to the dominant belief. Besides, the psychosocial
trauma inflicted by the torture is completely ignored, often because there
is no training imparted to them for managing such trauma and also due to
the low economic value of such medical work. A third section simply
believes that being in the employment of the government, the police
department or the prison, they are bound by the orders of their superiors
and the code of their service does not allow them to ‘blow the whistle’.
Another reason for doctors’ apathy to these issues is that they consider
themselves as mere technicians. Some doctors have often remarked, “we
are doctors, we treat illness, we are not interested in torture or rape”. They,
therefore, do not make the necessary efforts to explore the causes and
history. This is both inadequate science as also insufficient understanding
of medical ethics.
Recently, in a survey done amongst its members (743 doctors, 61.5 per
cent of them General Practitioners, and 17.2 per cent of them in Govern
ment service), the Indian Medical Association (1995) found that 71.1 per
cent (or 533 out of 743) of doctors in India have come across a case of
torture in their medical practice. Interestingly, of those who have seen a
case of torture, only 23.8 per cent said that such case was brought to them
by the police, thus indicating that the survivors of torture do directly
approach the medical professionals. Further, 15.7 per cent of them said
that they were witness to the infliction of torture, 18.2 per cent said that
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there are doctors in India who have knowingly participated in torture, but
only 18.2 per cent knew where to report suspected cases of torture.
The most disturbing finding of this study is that 57.5 per cent believed
that coercive techniques may be justified to elicit information from
uncooperative suspects. 58.3 per cent thought that manhandling during
interrogation was unavoidable. 36.7 per cent said that solitary confine
ment was not torture. 49.3 per cent justified forcible feeding of hunger
strikers and 49.7 per cent found nothing wrong or unethical in doctors
remaining present during the process of execution by hanging. The IMA
survey data generally confirm what we have said earlier. They also
emphasise that there is a great need to educate doctors in India to change
their attitude in cases of human rights violation.
IV
What Needs to be Done?
All types of violence produce a traumatic effect on survivors. The
trauma could be on the body or on the mind. In a well-documented case
of mass torture of villagers by the security forces in Manipur, although
there were official denials, a team of doctors including psychiatrists
visited and examined 104 survivors in that area 22 months after the
incident. They found that a high number of them were suffering from
post-torture traumatic stress. They found that 36.6 percent were suffering
from recurrent dreams of torture, 66.3 percent of disturbed sleep, 54.4 per
cent were not able to enjoy village festivals, food, sex and even friendship,
37.6 per cent showed loss of self confidence, developed a sense of
foreshortened future, etc. [Biswas, Das et el 1990].
There is extensive work done by doctors on the treatment and rehabili
tation of survivors of violence in many countries, but in India health
professionals have not done much organised work. The survivors of
violence are special types of patients, and they would be missed, and
continue to suffer if not treated. Medical documentation and record
generated in the process of treatment could be formidable evidence to get
justice for them. Thus, an independent, conscious and trained health
professional while treating cases of violence can also become a deterrent
and a means prevention of violence.
For prevention of violence and rehabilitation of survivors, doctors
need to work with other professionals, activists and officials. While
doctors in India have gradually become used to working with hospital
social workers (particularly in big hospitals), they still have not learnt to
network with human rights lawyers, human rights organisations, anticommunal groups, women’s organisations etc. to assist survivors in
getting justice and for their rehabilitation. Rehabilitation of survivors of
violence in our own society has many socio-political, cultural and
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economic dimensions. Often survivors need shelter homes, jobs and other
support to start a new life or protection from offenders to go back to their
homes in the locality where the violence had occurred. While doctors
themselves are not in a position to undertake such social responsibilities,
the success of treatment and rehabilitation normally depends upon getting
such support for survivors. Such a medical goal can be achieved only in
collaboration with other professionals and activists. Besides, despite
democratic spaces available in our country, it is not uncommon for
doctors actively trying to help victims to have to face threats and violence
themselves, thus needing protection. This could be achieved only by
having the support of strong and active professional organisations, as well
as by having the support of human rights lawyers and activists.
The educational and training intervention among health professionals
(doctors, nurses and other paramedical) is at present a pressing need in
India. Such an intervention must have three components: (a) Effecting
attitudinal changes and promoting professional ethics;
(b) education and training for providing ethical and rational treatment
to survivors and for developing skills in investigation of human rights
violation, and (c) creating an environment and building an institutional
support system for health professionals, including legal protection, to
make it possible for them to play a positive and constructive role in both
caring for survivors and preventing violence.
Il must also be kept in mind that doctors and other health professionals
are ultimately a part of society, and the code of ethics cannot completely
insulate them from the societal influences in their ideology and practice.
When a society condones violence against certain groups of people and
when a section of it tends to participate in inflicting such violence from
time to time, it cannot provide a correct and conducive environment for
health professionals to be ethical in the event of violence. Thus, it is
equally, if not more, important to back up such intervention among
health professionals with strong public advocacy and education on the
subject.
The long-term goal of all health activists is to make doctors real social
reformers. They have often used the term social doctor to contrast the
technician doctor. In the situation of violence, the first step for making the
doctor socially oriented is to make him or her respect medical neutrality.
Medical neutrality emphasises that in the situation of violence doctor’s
ethical obligation is to care for survivors and victims, never to side with
offender and aid the pursuit of justice. At societal level the medical
neutrality emphasises protection for doctors to discharge their ethical
duties, protection for doctors who are ‘whistle blowers’ (who make
known the violation of human rights and unethical medical actions). To
build such a campaign is the responsibility of health profession as well as
the society al large.
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Will (he health profession in India be able to build such a campaign?
Given (he rising curve of violence in India, the health profession is going
to come under the greater medical, social and international scrutiny for its
role in coming times. There is a need to make such a beginning. However,
given the history and numerous reports of doctors’ collusion in human
rights violence in India, at the beginning of such campaign the profes
sional associations and their councils will have to first take a firm stand
against medical collusion. They will have to make those who are guilty
accountable and weed them out from their ranks. A casual admission that
there are a few black sheep within the profession would not have much
credibility. Il needs to be backed by concrete decisive actions. Such
actions would greatly aid in building genuine campaign for medical
neutrality in India.
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Biswas Bipasa, Das Sujil Kumar et el (1990): Post Torture State of Mental
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1993’, Solidarity for Justice, Mumbai, p 180.
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Back Volumes of Radical Journal of Health and Socialist Health
Review are available al Rs 150 per volume
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Nurses and Human Rights
Report of Amnesty International
Nursing shares with other health professions a commitment to
the well-being of the patient and to a professional practice based
on codes ofethics. Over the past two decades, national and international
nurses associations have refined theirprinciples to reflect an increasing
commitment to human rights and the protection ofthe patient. However.
because of their frontline work in areas of conflict and tension
there are persistent risks of nurses being victimised as a result
oftheir witnessing abuses or treating individuals seen by the authorities
as opponents or subversives. On the other hand they may risk being
pressured to collaborate in, or remain silent about, abuses occurring
in their presence or with their knowledge. Even in daily routine
work, ethical and human rights problems arise.' This paper reviews
some of the risks of human rights violation faced by nurses, their
role in the defence and promotion ofhuman rights, including provision
of care to refugees and asylum seekers, and argues for a continuing
and stronger role by the nursing profession in the defence ofpatients
under threat, and the protection of vulnerable nurses and nursing
associations. It further argues for a constant monitoring by pro
fessional associations and human rights groups of pressures on
nurses to engage in unethical behaviour.
AMNESTY INTERNATIONAL (Al) is an international human rights
organisation with more than one million members in more that 180
countries or territories. It works for an end to torture, ‘disappearances”.
judicial and extrajudicial executions; it opposes the detention of prisoners
of conscience and campaigns for prompt and fair trials in political cases.
Al believes that health professionals have an important role in the
protection of human rights and the exposure of abuses2 and that some of
its own goals are coincident with principles of ethics as articulate^ by
health professional and humanitarian organisations. A number of State
ments adopted by the International Council of Nurses3 (ICN) are relevant
to Al’s work and goals.
The Nurse’s Role in Safeguarding Human Rights, a statement adopted
by the ICN in 1983, notes that “nurses have individual responsibility but
they can often be more effective if they approach human rights issues as
a group”. The statement goes on to outline the rights of those in need of
care and the rights and duties of nurses.1 The Nurse’s Role in the Care off
Detainees and Prisoners, first adopted in 1975, reaffirms ICN support for
the Geneva Conventions, endorses the Universal Declaration of Human
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Rights and “condemns the use of all [interrogation] procedures harmful
to the mental and physical health of prisoners and detainees” The
statement goes on to say that “nurses having knowledge of physical or
mental ill-treatment of detainees and prisoners must take appropriate
action including reporting the matter to appropriate national and/or
international bodies”. It also rejects demands for nurses to play the role
of security’ personnel by. for example, carrying out body searches for
security’ reasons.
The Nurses and Torture statement, adopted in 1989, notes that nurses
may be called on to carry out a number of functions which assist torturers.
It commits the nurse to giving care to people seeking it, prohibits the nurse
from assisting in any way in torture and urges national nurses associations
to provide a mechanism to support nurses m difficult situations.
The Nurses and the Death Penalty statement, adopted in 1989, con
cludes that “participation by nurses... in the immediate preparation for
and the carrying out of slate authorized executions [is a violation of
nursing’s ethical code. ICN thus calls on national nurses associations to
work for the abolishment of the death penalty...”
In addition to these ICN statements, the United Nations Principles of
Medical Ethics, adopted in 1982 enjoin health professionals to act
ethically and specif: that participation in, or tolerance O( torture is
unethical (principle 2) and that the only ethical role for a health profes
sional working with prisoners or detainees is to “evaluate, protect or
improve their physical or mental health”.5
Some national nurses associations have also taken initiatives to en
shrine human rights principles in their codes of ethics. For example, the
Canadian Nurses Association adopted a position statement on human
rights in 1991. Il endorses the Universal Declaration of Human Rights
and states that “nurses have an individual and universal responsibility’
to protect [human rightsj”.6 The Association created a volunteer
human rights Officer post to bridge the potential gap between principle
and action. Among the duties of the officer is urgent action letter
writing. One Canadian nurse has suggested an amendment to the ICN
policy to permit their action on behalf of nurses who have been abused for
a wider scope of reasons such as their race, religion, politics, orelhnicity.7
In 1 983 the American Nurses Association staled their view that partici
pation in an execution was in breach of nursing ethics/ and in 1991,
adopted a position statement on ethics and human rights which
notes, inter alia, that "the principle ofjuslice is one point at “.hich issues
of ethics and human rights rntersect”.9 The British Royal College of
Nursing (the professional body of nurses in the United Kingdom)
published in 1994 a paper on female genital munlalion “to raise nurses’
awareness of the issue and give them a greater understanding of the issues
involved”.10
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Nurses as Victims of Human Rights Violations
The risks faced by some nurses in their professional, social or political
activities are illustrated in the following cases.
In Turkey, torture, ill-treatment, death threats and political killings are
widespread and continuing problems. Health professionals are not im
mune from the routine detention and torture which occurs. Mediha
Curabaz, a nurse working in the southern city of Adana, was arrested,
tortured and raped with an electric truncheon during her detention at
Adana Police Headquarters in August 1991. She subsequently made a
formal complaint supported by a medical report. Her case against the
police was blocked bv a decision of the Adana Provincial Governor’s
office. Mediha Curabaz’s objection to the Appeal Court was rejected.
However, she also filed a civil suit for the injury she sustained in police
custody. She won this case and was awarded a small sum in compensa
tion.
Another nurse, Nazli Top, then aged 23 vears. was arrested in April
1992 in an Istanbul street. She was three months pregnant at the time but
was nevertheless subjected to torture including sexual abuse.11 After 10
days she was released without charge by the Istanbul State Security’
Court. She was examined the day after her release at the Istanbul office
of the Human Rights Foundation where medical findings consistent with
her allegations were documented. She brought a formal complaint of
torture against the police but this was rejected by the prosecutor’s office
and an appeal to a local criminal court was also rejected. Her babv was
subsequently bom. apparently healthy.12
In November 1993. Al issued an urgent appeal on behalf of Olcay
Kanlibas, a 23-year-old nurse from Divarbakir who was feared to be at
risk of torture and disappearance.13 She was detained a week earlier at the
State Hospital in DiVarbakir where she worked. On that night, an entry in
the hospilaWs register noted that she had been admitted to the casualty’
ward but no information was given regarding her problems or the
treatment she needed. The police denied that she was in custod’.. No
reason was acknowledged for her detention though she was known to be
a member of the Turkish Health Workers Union. Al later learned that she
had been released after interrogation and torture.
In I 996 Al included the cases of three female nurses in a report on the
violations of human rights of women in Mexico.14 The nurses were
participating in a vaccination program in Chiapas and were travelling in
an official brigada sanitaria with four other women and three men. Their
vehicle was stopped on the evening of4 October 1995 by 25 masked men
carrying weapons. A group of armed men attacked the nurses when their
vehicle was forced to stop to remove stones on the road. Two of the
women had to be hospitalized.
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In response to AIs expression of concern about the case, the Mexican
government replied that the office of the attorney general of the stale of
Chiapas initiated an investigation which was referred to the Office of the
Attorney General of the Republic of Mexico. According to the government
“the only person who has had contact with the victims, the Head of No 2
Health district San Cristobal de las Casas (Chiapas) declared that they [the
victimsj were unwilling to be interviewed or undergo any form of medical
examination”.
In 1 995 Amnesty International learned of a wave of intimidation against
the familv of trade union leader Luis Lara secretary general of the Public
Health Workers Union.15 and also a member of the Executive Committee of
the umbrella trade union confederation, the United Trade Union and Popular
Action.16 This had apparently been intended to force him to cease his trade
union activities. In April 1995 he began receiving telephone calls during
which the unidentified caller warned him to cease his trade union activities
or his familv would suffer. On July 14. 1995 an attempt was made to kidnap
his 14-year-old daughter. Corina, but the attempt failed when neighbours
intervened. On September 7. another of his daughters a nurse 22-year-old
Olimpia Azucena Lara, who worked in the San Juan de Dios Hospital in
Guatemala City, was waiting for a bus in the Zone 12 area of Guatemala City,
when she was approached by an unknown man who threatened her with a
pistol. The man look her to a nearby field where he brutally beat her and left
her unconscious. She was found by neighbours with her face swollen and
unable to speak.17 No one was prosecuted for this attack.
Susan Wangui a nurse and the wife of Mirugi Kariuki, a human rights
lawyer and former prisoner of conscience was arrested on September 18,
1993, She and several others were arrested with prominent political
activist Koigi wa Wamwere while travelling to the town of Burnt Forest
in the Rift Valley Province. With five others they were held incommuni
cado in Nakuru police station where some of the men were tortured. After
six days in custody they were taken to court and charged with possession
of weapons (which they denied) and ‘seditious publications’. The publi
cations in question were leaflets produced by the National Democratic and
Human Rights Organisation and similar pamphlets. They were also
charged with violating security regulations enforced in areas of ‘tribal
clashes’. The security' regulations were published on September 20 and
back-dated to September 17,1993. The detainees were all released on bail.
Susan Wangui. a nurse at a government hospital, was suspended without
pay after her arrest This was the second time she had been arrested in
connection with her husband’s political acli viliy.IX
Imprisonment of Nurses
Vo Van Pham is a nurse who is serving a sentence of 12 years’ imprison
ment and who has been adopted as a prisoner of conscience by Amnesty
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International. He was arrested on July 6, 1991 in central Viet Nam and
sentenced as someone ‘‘who organises, incites, or actively participates in the
establishment” of an ‘‘organisation aimed at overthrowing the people’s
government” and ‘‘causes grave consequences”. It appears from the official
indictment that his crime had been to make comments in favour of multi
party’ democracy in Viet Nam and allegedly planning the organisation of a
political grouping to participate in a democratic political system. In addition
to his 12-year sentence of imprisonment, he was also sentenced to a further
two years’ probation to take effect from the end of his prison term. Vo Van
Pham is currently held in Z30D/K1 ‘re-education’ camp at Ham Tan, Binh
Thuan province. Amnesty International believes it likelv that he was not
afforded a fair trial and also that he may not have had proper access to a legal
representative of his choice.
Vo Van Pham is aged 49 and is married with six children. He was born
in 1947 and was resident in Quang Ngai city at the lime of his arrest in
1991. He studied at Danang Nursing School from 1968-1969 and subse
quently worked as a nurse in Quang Ngai General Hospital. At the end of
1969 he joined (or was conscripted into) the local armed forces. After the
communist victory, he was detained for ‘re-education’ without charge or
trial until February 1976, as were hundreds of thousands of other people
know or suspected to be associated with the defeated South Vietnamese
regime. He is believed to have resumed his career as a nurse prior to his
re-arrest in 1991. Amnesty International has called upon the Vietnamese
authorities in the past to release Vo Van Pham and recently renewed its
appeals for his immediate and unconditional release on the grounds that
he is a prisoner ofconscience.19
(
The Cuban nurse, Reynaldo Soto Hernande, (born November 2,1966),
who is also apoet and human rights activist - he is a memberof the Comite
Cubano Pro-Derechos Humanos, Cuban Committee for Human Rightswas arrested on September 7, 1994. On September 14. 1994 he was
brought to trial al the People’s Municipal Tribunal (Tribunal popular
municipal) in Moron. Ciego de Avila, where he was sentenced to three
years’ imprisonment for dangcrousness tpcligrosidad). under Article 72
of the Cuban Penal Code. He was reportedly sentenced on the same day
that he was told of the charges. He was thus not given enough time to find
himself a lawyer and was assigned a state lawyer.
He is serving his sentence al the Prision Provincial de Ciego de Avila,
nicknamed ‘Canalela’. During his first month in prison his books, pencils
and paper were reportedly confiscated because he was accused of produc
ing a clandestine magazine called Transicion. He was not allowed any
reading material and family visits were suspended until January 1996. He
was also threatened with being transferred to another prison far from the
province of Ciego de Avila, if he did not slop publicly criticising prison
conditions.
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His slate of health has apparently deteriorated: he has lost some
30 kilos and has chronic ear-ache and a skin disease caused by the lack
of hygiene in the prison. The authorities reportedly refuse to provide
him with the necessary, medical treatment. In August 1996 he was kept
for two months in a punishment cell after going on a five-day hunger
strike.
Reynaldo Soto Hernaridez had previously been arrested on May 3.
1990 and sentenced to three years' imprisonment, charged with disre
spect (desacato), under Article 144 of the Cuban Penal code, for having
written a letter to a newspaper, opposing the execution by shooting of
General Arnaldo Ochoa and three mililar,’ officials in 1989.20 In addition
to the three years’ sentence he served an additional three months’
imprisonment for arguing with a prison officer. Following his release he
was briellv detained a number of times.
Reynaldo Solo Hernande, has written several poetry books, published
outside Cuba, such as The Sick God (El Dios Enfenno), written while in
prison in 1992. He has won several literary competitionsand was awarded
the provincial poetry prize in Ciego de Avila in 1994 for his book Rooms
(Hahitaciones). He wrote the book Eango in 1994 when he was detained.
He also had his poems published in national Cuban magazines such as We
are young (Somos jovenes).
Gregono da Cunha Saldanha aged 31 and a nurse al lhe Bidau General
Hospital in Fast Timor's capital Dili, was arrested on November 12, 1991
during a peaceful demonstration at the Santa Cruz cemetery in Dili. Al lhe
demonslration. East Timorese unfurled banners and shouted slogans
calling for East Timor's independence from Indonesian rule. Indonesian
soldiers opened fire on the crowd of some unarmed 2,000 East Timorese,
many of whom were students and other young people. An estimated 270
people were killed during and after lhe massacre and a further 200 people
may have ‘disappeared’. Despite Indonesian government claims to have
investigated lhe massacre. The fale and whereabouts of lhe dead and
missing have yel io be properly clarified.
Gregono da Cunha Saldanha was arrested al the Santa Cruz cemetery
after being shot and wounded by Indonesian soldiers. Al lhe end of
December 1991 lhe police chief in East Timor told the press that Gregorio
da Cunha Saldanha had been seen “holding a microphone and giving
instructions to the demonsirators”.21 According to the authorities, his
main ‘crimes were his organisation of lhe demonstration which ended
with the Santa Cruz massacre, and his membership of a group know as the
Comite Ejecutivo (CE), which had assigned to him lhe task of leading the
Santa Cruz demonstration. The prosecution argued that the actions of
Gregono da Cunha Saldanha and other members of the CE had them
selves caused lhe deaths of lhe 50 people killed on November 12, because
they had encouraged East Timorese to demonstrate against Indonesian
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government rule in East Timor.22 For the first week of his detention he was
held at the Military’ Hospital. Wirahusada.
Al his trial, which began in March 1992. Gregono da Cunha Saldanha
was accused of being the principal organiser of the Santa Cruzdemonstration. He was charged and convicted under Indonesia’s sweeping Anti
Subversion Law and sentenced to life imprisonment. Like all political
(rials in Indonesia and East Timor, his trial was highly unfair and it
appears that al least some of the evidence against him was extracted under
duress. Throughout the trial Gregono da Cunha Saldanha denied charges
of subversion. He acknowledged that he had engaged in peaceful and
open activities for East Timor’s independence from Indonesian rule. He
has been adopted by Amnesty International as a prisoner of conscience.25
More than 100 East Timorese were arrested in the immediate after
math of the unrest.24 A further two were detained by the military
intelligence unit of the Sub-Regional Military Command for East Timor
in Dili: Hcndrique Belmiro da Costa and Malheus Gouiviea Duarte, a
nurse and civil servant with the health department. Amnesty International
expressed concern that the two may have been subjected to torture,
including electric shocks, while in military detention. Hendrique Belmiro
da Costa was reported to have had stitches to his head as a result of wounds
sustained through torture. Both men were both charged under Article 108
of Indonesia’s Criminal Code which punishes armed rebellion against the
government with between 15 and 20 years’ imprisonment.25 In the event,
Hendrique Belmiro da Costa was sentenced to six years and two months’
detention, and Malheus Gouiviea Duarte to four years.
Yu Nguk Ding aged 72, a former nurse and Jehovah’s Witness for
more than 40 years, began a one-week prison sentence on July 2, 1996
after refusing on conscientious grounds to pay a fine of 700 Singapore
dollars for her conviction under Singapore’s Undesirable Publications
Act. She had faced a maximum sentence of two years in prison in
connection with possession of religious publications. This was the second
time Yu Nguk Ding had served time in prison for her religious conviction.
She had reportedly been imprisoned for five day’s in April 1996 after
being convicted on a similar charge of possession of illegal literature.
Since November 1995 more than 60 Jehovah’s Witnesses have been
convicted of membership of an illegal society or possession of banned
literature. All Were sentenced to fines but most were then imprisoned for
up to four weeks after refusing to pay the fines on conscientious grounds.26
Human Rights of Nurses in Conflict
Among the thousands of cases of political killing in Peru which remain
unresolved (and will in all likelihood remain so in the light of the amnesty
law introduced in 1996) is that of Marta Crisostomo Garcia, a 22-year-old
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nurse who was killed on September 8. 1989 by eight hooded men in army
uniform when they broke into her home in the neighbourhood of San Juan
Bautista, district of Huamanga Ayacucho department. Marla Crisostomo
had witnessed a massacre by members of the security forces in which al
least 30 peasants from the town of Cayara, in the province of Victor
Fajardo, Ayacucho department, were killed on May 14, 1988. Marla
Crisostomo had given extensive testimony to the public prosecutor in
charge of the case about the events on that day. She had also helped
identify the body of her aunt. Jovita Garcia Suarez, one of the victims of
the massacre. Before Marta Crisostomo was killed she had appealed to the
public ministry for protection in the light of the ‘disappearance’ and
killing of other witnesses to the massacre. Her appeals were unsuccessful
and she was tracked down by armed men and shot dead.
The Peruvian authorities have never carried out impartial or thorough
investigations into the deaths of Marta Crisostomo or any other witnesses
to the Cayara massacre. In March 1990 Amnesty International joined
Americas Watch (now known as Human Rights Watch Americas), an
international human rights monitoring organisation, as co-complainants
on the Cayara case before the Inter-American Commission on Human
Rights, and requested for the case to be submitted to the Inter-American
Court of Human Rights. In its report, the Commission concluded inter
alia that agents of the Peruvian state killed Marla Crisostomo Garcia, and
that they did so with the aim of avoiding her testifying in the future
regarding the Cayara massacre. In February 1993 the Inter-American
Court of Human Rights accepted procedural objections raised bv the
Peruvian government and ruled that the case be shelved on the grounds
that the Commission had failed to adhere to certain procedural regula
tions. Nine years after the massacre those responsible for Marla Crisostomo
Garcia’s death, the death of her aunt and the other 30 victims of the Cayara
massacre are still at large.
A number of health professionals became victims of a law introduced
by the Peruvian authorities in 1996 to encourage alleged members of the
armed opposition (particularly the Parlido Comunista del Peru - Sendero
Luminoso (PCP)) to identify further members in return for lesser penal
ties. In 1996 Al appealed for two doctors who had been sentenced to 22
years imprisonment after being falsely accused by PCP members seeking
to lower their sentence through provisions of the Repentance Law.
Nelly Baldeon, another victim of those seeking to benefit from the
Repentance Law was a nurse who was studying at San Marcos National
University in Lima. She was detained on September 21,1993 by members
of the anti-terrorist police branch. DINCOTE, after an alleged member of
the PCP had accused her of having supported Socorro Popular, a PCP
welfare organisation. Nelly’ Baldeon and three other women on her
course had presented a project on ‘Subversion and Terrorism in Peru’.
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During police investigations Nelly Baldeon was shown this project and
acknowledged it was hers. As a result, she was charged with ‘crimes of
terrorism’ and sentenced to 20 years’ imprisonment by a lower court.
Nelly Baldeon was released on July 26, 1995 after an appeal was filed on
her behalf to the Supreme Court of Justice.27
In October 1993. in El Bosque, in the municipality of Riofrio, Valle de
Cauca department, six women were among members of two families
dragged from their homes, tortured and killed by army and paramilitary
personnel. According to witnesses, men in combat fatigues, some wear
ing police or army uniforms and some with their faces covered, arrived in
the community early in the morning. Seven members of the Ladino family
and a man slaying in their house at the time were tortured and killed by
the armed men later that morning, together with five members of the
Molina family.
Military commanders immediately claimed that the 13 victims were
members of the ELN, who had died in a confrontation with armed forces
from the Palace battalion. However, this version was contradicted by eye
witnesses, who claim the dead were peasant farmers who were unarmed
when shot. The women victims were: Carmen Emilia Ladino (aged 33),
a Gregorian nun who taught at the local school and acted as community
nurse; Luz Edelsi Tusarma (aged 16), who was four months pregnant
when she was murdered (her boyfriend was a member of the Molina
family). Maria Zenaida Ladino (aged 35); Lucclly Colorada de Ladino
(aged 35); Dora Eslcla Gaviria Ladino (aged 16) and RitaEdiliaSuazade
Motina (50). Five of the women were raped before being shot. Both
families had settled in El Bosque some 40 vears earlier after fleeing
violence in other parts of the department. Following this massacre, the
government announced that the commander of the Palace Battalion,
Lieutenant-Colonel Luis Felipe Becerra, had been honourably discharged
from the army Subsequent investigations led to arrest warrants being
issued against him and several other members of the armed lorces.2* In
March 1997. Lieutenant-Colonel Becerra was one of 34 soldiers acquit
ted of the killings.
Another nurse killed in Colombia was Hildegard Maria Feldmann, a
Catholic lay missionary who was shot with Jose’ Ramon Rojas Erazo and
Hernando Garcia, two peasant fanners from El Sande, in Guachaves
municipality. Nariilo department, by soldiers from the Caballeria
Mecanizada No 3 Cabal, attached to the army’s III brigade. Hildegard
Feldmann was a member of the Community of Lay Missionaries of
Fribourg, Switzerland, and had worked as a nurse and midwife in rural
Colombia since 1983. On September 9. 1990, she was tending a sick
woman in the home of Jose Ramon Rojas Erazo when troops opened fire
on the house without warning. Hildegard Feldmann and Jose Rarnon
Rojas Erazo died instantly. Hernando Garcia, who had sought refuge with
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his wife and other villagers behind Ramon Rojas’ house, was wounded in
the leg by the soldiers and tried to hide under some rocks near a river. Soon
afterwards, a group of soldiers found and killed him.
Guerrillas of the Revolutionary' Armed Forces of Colombia (FARC)
had been active in El Sande at that time. A group of them were reportedly
bathing in a nearby river when the soldiers attacked the area, and an
unidentified guerrilla was killed. Military' authorities immediately issued
a communique’ claiming to have killed four guerrillas, including Hildegard
Feldmann, in combat. Later, the army changed its version of events,
claiming that Hildegard Feldmann had been killed while working as a
nurse in a house where an armed group had been found, and that she bad
been killed in the crossfire between the army and FARC guerrillas. This
version of events was refuted by eye-witnesses who testified that no one
in the house had fired at the military. Official investigations into the
incident initially exonerated the army of responsibility for the killings but
in April 1995 the Procurator Delegate for the Armed Forces brought
disciplinary charges against two members of the III brigade.29 Where
members of the Colombian military, are implicated in killings they are
rarely prosecuted or charges brought against them are dismissed.
A Zairian refugee30 who crossed into Tanzania in late 1996 testified to
an attack made by members of the Alliance des forces democratiques
pour la liberation du Congo-Zaire (AFDL), the Alliance of Democratic
Forces for the Liberation of Congo-Zaire.
The attack began at about five in (he morning. We fled, but the patients who
had just been operated on could not move from their beds. When we went back
the next day, we found them, killed in their beds by a bullet through the mouth.
Lemera Hospital, about 85 km north of Uvira, is the largest in SouthKivu, with about 230 beds. In early October 1996, about 300 patients were
being tended there. Some were Zairian soldiers wounded in the armed
confrontations that were taking place with increasing frequency in the
area. Many others were from Burundi. The hospital management had
asked for increased protection from the military in exchange for tending
the soldiers. Military reinforcements from Kinshasa were sent to Kidoti,
two or three kilometres away.
In the early hours of October 6, members of the Tutsi-led armed group
attacked Kidoti. There were fatalities both among the Zairian soldiers and
the rebels. There were also civilian casualties, at least two of whom
appeared to have been targeted and killed deliberately.
Two priests were killed. One of them. Koko, was killed on the spot, the other,
1’abbe’ Ndogole, was taken hostage first and was found dead later in the
mountains.
Then the armed group went on to attack Lemera Hospital.
Those who could not flee in time were killed. The attackers entered the
hospital, looted the medicines and lulled the patients. Two nurses. Kadaguza
and Simbi, and an assistant nurse, Maganya, were killed.
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When those who had fled returned to the hospital, at about four in the
afternoon, they found a scene of carnage. According to eye-witnesses,
around 30 patients had been killed in their beds, either with bullets or
bayonets. Most were members of Burundian armed opposition groups
who had been wounded in fighting in Burundi. Nurses had been killed in
their quarters. A Burundian doctor whose house riddled with bullets
escaped moments before the attack. The killings of the wounded soldiers
in their hospital beds and of civilian nurses in their quarters at the Lemera
hospital were clear breaches of international humanitarian law.31
Guinean army officers, immigration officials and local authorities
belonging to the Mandingo ethnic group are reported to have participated
in the forcible return (in violation of international law) of Liberian
refugees fleeing the forces of the (United Liberation Movement of Liberia
for Democracy (ULIMO), one of the armed groups contesting power in .
Liberia in the 1990s.
This reportedly happened to a Liberian nurse at Zorzor Hospital. Lofa
County who said that he had to flee when ULIMO attacked the hospital
on February 13,1993. When he attempted to cross the border into Guinea,
a Guinean Mandingo soldier took all his money and then forced him at
gunpoint to cross back into the fighting in Liberia. As he was walking
away the Guinean soldier shot him in the back. The bullet went through
his body narrowlv missing his heart and left lung. He survived in the bush
for a week before he was able to cross into Guinea and obtain medical
treatment.32
In April 1992 a delegation from the Turkish Medical Association
(TMA) visited the southeast of Turkey to examine conditions and
problems for health personnel there resulting from the emergency legis
lation in force in the area. A state of emergency applies in 10 provinces
in the southeast where the security forces have been engaged in counter
insurgency operations against Kurdish secessionist guerrillas of the
Kurdish Workers Party (PKK). The security forces are alleged to be
responsible for frequent human rights violations in the area where there
are also reports of abuses committed by guerrillas. The TMA’s report
indicated that security forces often occupied hospitals and other medical
facilities. At the time of their visit Nusavbin State Hospital was frequently
used as a base and shelter security forces during periods of armed conflict.
Where doctors in southeast Turkev fail to report that they have treated
gunshot wounds they put themselves at risk of interrogation and possible
prosecution under Article 169 of the Turkish Penal Code which forbids
sheltering, guiding or assisting members of armed organisations with a
maximum possible sentence of 7 years under the terms of the Anti-Terror
Law. As the TMA delegation’s report noted:
...if they don’t report these they may face three years in prison; if they do, they
arc afraid for their security... [Moreover] the workload is very heavy due to the
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shortage of doctors, nurses and other medical personnel, in addition to the large
number of patients. A lot of self-sacrifice is required, particularly during
incidents [of shootings].”
Under international humanitarian law, as embodied in the Geneva Con
ventions of August 1949 and the two Protocols of 1977. medical staff working
for the 1CRC and others working under the protection of the red cross symbol.
should be accorded respect as non-combatant and not made targets of m 11 i tary
aggression. Nevertheless there are abuses regularly reported. In August 1993,
an ICRC convoy was ambushed near the town of Gorahun in Sierra Leone.
In the attack two nurses - Susanne Buser from Switzerland and Sarah Leomy,
from Sierra Leone-were killed. A third. Swiss nurse was injured. The ICRC
condemned the killings and the disregard for the protective red cross symbol
which was clearly visible on convoy.54
In the early morning of December 17, 1996, six delegates of the
International Commilt of the Red Cross were shot dead while sleeping in
their quarters al the Red Cross hospital Novye Atagi in Chechnya. Five
of the six delegates were nurses: Fernanda Calado, Spanish member of the
ICRC. Ingeborg Foss and Gunnhild Myklebust from the Norwegian Red
Cross, Sheryl Thayer from the New Zealand Red Cross and Nancy
Molloy, a nurse manager from the Canadian Red Cross.’5 In his address
to the memorial service in Geneva for the victims, the ICRC president
Cornelio Sommaruga called for
reflection above all on the best manner to guarantee protection and assistance
to victims of these conflicts without rules, where even the fundamental
principle at the base of the Red Cross movement - respect for medical
personnel, respect for the protective [red cross] emblem, respect for hospitals,
humanitarian sanctuaries - is deliberately violated.
Nurses and the Infliction of Punishments
Nurses are sometimes called on to assist the state carry out punish
ments. When lethal injection was introduced in the United States as a
method of execution in the late 1970s it gave rise to much debate and
ethical reflection in health circles.’6 Among those who adopt a position on
this subject was the American Nurses Association which adopted a
statement that “[rjregardless of the personal opinion of professional
nurses regarding the morality of capital punishment, it is a breach of the
nursing code of ethical conduct to participate either directly or indirectly
in a legally authorised execution”.37 With physicians taking an increas
ingly strong line against medical participation in executions,5X the pres
sure on nurses and paramedical workers to play this role is likely to
increase. Currently in the US, doctors appear to be directly involved in
executions in a few states, with their anonymity protected in at least one
state; 7 in others, a variety of paramedical staff assist in establishing
intravenous lines to enable execution to proceed.
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In Afghanistan, the increasing use of cruel corporal punishment has
serious implications for both the victims and those who may see them as
patients. According to Al’s information, convictions and punishment
under the Taleban can be arbitrary and brutal. In Kandahar, for example,
former prisoners reported that the nioulavi (religious official) presiding
over the court had only a vague knowledge of shari'a and imposed
sentences completely arbitrarily Local people quoted him as saying that
he favoured executions and amputations over detention. Most Taleban
appear to believe in the deterrence value of these punishments.
Reflecting a belief in the deterrent effect of this punishment, amputa
tions are carried out in public. In some instances reported to Amnesty
International, ordinary Taleban guards have believed themselves entitled
to act as both judges and executioners. On April 6, 1996, Taleban arrested
Abduallah and Abdul Mahmood, two men from Uruzgan, on charges of
theft. Reports suggest that they were first severely beaten. Then the
Taleban guards cut off their left hands and right feet. The guards whose
mood was described as ‘jubilant’, then pressed red-hot iron plates against
the wounds to stop the bleeding.40 It is not known what nursing care was
available to the victims but lheir treatment suggests that proper care was
not a priority.
Some nursing staff working in hospitals in Kabul were reported to
have been harassed for infringing strict dress codes imposed by the
Taleban. Two nurses had been told by Taleban officials that they should
continue working at the one of the capital’s hospitals while others had
been sent home. On October 30, 1996, the Taleban official in charge of
the security of the area - reportedly a 17-year-old youth - came to the
hospital. The nurses were not wearing burqas (traditional dress) as-they
considered it was not practical clothing for a nurse in a hospital^b’ut they
were fully covered with scarves and long coats. The young man became
very angry and grabbed the women by their hands, dragging them to a
nearby tree and hitting them with a broken branch. One of the women tried
to run away. The young man forced her onto the floor and held her
between his feet while beating her with the stick.41
Nurses Working in Inadequate Conditions
Amnesty’ International has concerns about the conditions in many
prisons around the world. One of the problems which Al has documented
is the inadequate provision for medical care. In Zambia, for example,
conditions in Lusaka prison are extremely poor and insanitary, medical
care is minimal and there is a high incidence of deaths in the prison.
Lusaka Prison was opened in 1930 with a capacity for 260 inmates. At
present, there is an estimated prison population of between 1,200 and.
1,400. One recently-released detainee stated that prisoners have to sleep
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in a sitting position with their knees raised as there is insufficient space
for them to stretch (heir legs.
In November 1995. a delegation from the Human Rights Committee
of the Law Association of Zambia visited the prison and fbund the
overcrowding shocking. In the report of their visit, they noted that there
was a lack of waler in the prison which meant that inmates were unable
to wash regularly, while basic necessities such as blankets, clothing and
medical supplies were limited or non-existent.
Sanitation in the prison is extremely poor. There arc open pit latrines
outside the cells, in a commnnal holding area about half the size of a
football pitch. Prisoners complain that the latrines become choked despite
attempts to sluice them with water. The severe overcrowding, poor
sanitation, inadequate medical facilities, meagre food supplies, and lack
of potable water result in a high incidence of disease and illness.
Dy’sentery and tuberculosis are particularly intransigent problems and
prison officials told the Human Rights Committee that, between January
1 995 and the lime of their visit in November that year, 75 prisoners had
died of tuberculosis and related illness. One ex-prisoner estimated that
more than 40 people had died in the prison during the period of his
confinement from early June to 10 September 1996. Prison conditions
have not improved since the visit of the Human Rights Committee’s
delegation, and a similarly high death roll can be expected to continue
until improvements are made.
A government-appointed Human Rights Commission which investi
gated prison conditions between 1993 and 1995 also found that prisoners
were without basic necessities such as soap and clothing, that food was
unfit for consumption and that prisoners were denied medical treatment.
Former detainees have told Amnesty International that prison officials do
not take prisoners to hospital until they’ reach a critical stageof illness and
that they fcarescape attempts. However, the prison infirmary-staffed by
a nurse and by a doctor who visits once a week - has no facilities for
dealing with serious illness and medicines are said to be limited to
analgesics.42
It is not only in developing countries that nurses may find themselves
working in unacceptable conditions, facing cither inadequate facilities or
abusive treatment of prisoners. In 1995. Amnesty International wrote to
the Texas authorities to express its concern al information it had received
from three prisoners at Ramsey I Unit (Rosharon County) alleging that
prisoners there had died because of lack of. or delay in. medical care. The
prisoners further alleged (hat it was normal practice at the Unit to deny
prisoners medical treatment and that five nurses including the director of
nurses and the charge nurse had resigned because oi general conditions
regarding medical treatment at the Unit. Particular concern was expressed
about two inmates, Bobby Felder, who died during the night of March 17/
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18, 1994. and Walter Newsome, who died on August 29. It was alleged
that Bobby Felder submitted a number of written requests about pain in
his abdomen over several months prior to his death, but that medical care
had been refused or delayed, and that Walter Newsome had complained
to medical and custodv staff about “unbearable pain in the abdomen” for
two years prior to his death.
Other allegations from the three prisoners about conditions at the Unit
include lack of psychiatric care, and delay’s in receiving life sustaining
medicines in cases of AIDS sufferers; that prisoners are hand-cuffed and
shackled for long periods causing pain and suffering: that handicapped
prisoners are made to do hard labour or work beyond their capacity; that
prison officials deliberately place incompatible prisoners together; and
that rapes, sexual assaults and physical assaults occur among inmates
without intervention from prison officials. It is also alleged that on or
about April 15, 1994. while the entire unit was placed on ‘lock-down’
(confinement to cells). 1,100 prisoners were taken to the gym and stripped
naked by female guards, while male guards and supervisors stood by,
laughing.43
A reply from the director of health services of the quality control
division of the Texas department of criminal justice stated that the deaths
(referred to above) had been investigated extensively and appropriate
corrective action taken where necessary. Although Amnesty Interna
tional sought details of the specific action which was taken, no further
information was received.
The failure to provide proper care, adequate medication and security’
against violence by staff and fellow prisoners constitutes a pattern known
to prevail in prison infirmaries and hospitals in many countries around the
world. Nurses regularly have to deal with this reality and to face the
evident gulf between the ethical principles underlying practice and the
practical situation applying in prisons and detention centres world wide.
Forensic Nurses
Forensic sciences are those sciences applied within a legal or judicial
framework, usually in support of the investigation and prosecution of
crimes and the management of victims and those accused or convicted of
crime. Forensic nursing has been defined as “the application of the
forensic aspects of health care to the scientific investigation of trauma”.
Likewise, clinical forensic nursing was defined as “the application of
clinical nursing practice to trauma survivors or to those whose death is
pronounced in the clinical environs.44 One area in which the work of
forensic nurses could have a significant impact is in the investigation of
rape.45 However, the nurse can play other roles, including as a protective
force within the justice system, and the potential importance of this
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protective role was recognized in the report of a protracted inquiry’ into
the death of a young Australian man in a police lock-up in 1988.
Stephen Wardle died, aged 18 at the East Perth Police Station, Western
Australia, within hours of his arrival thereon the night of February 1,
1988. According to the police, he was “arrested [...] for his own safely”
on suspicion of drunkenness at the Entertainment Centre in Perth al about
9.30pm. Following formal registration at the police station at 9.40pm he
was detained in a police cell some time after 10.40pm. When he was
processed for reception in the cell block, police recorded ‘No Visible
Injuries' upon him. Fears for his health, for example when he could not
be roused, were repeatedly expressed by several people in the police station
during the night, yet no action was taken. Al 5.O5am the next morning.
Stephen Wardle's dead body was discovered in a cell with rigor mortis
well established, and bruises, bumps and abrasions clearly visible.
After various enquiries into his death - none of which were found to
be satisfactory by the family of the deceased - the matter was referred 10
the slate Ombudsman. After completion of the inquiry, the Ombudsman
invited Stephen Wardle’s family to his office to advise them about his
findings and to tell them that he did not recommend any action to be taken
against any of the police officers on duly at the East Perth Police lock-up.
In his view, allegations made by the family about the unanswered
questions relating to their son's death were ‘without substance’ and
“resulted from an exacerbation and transference of the Complainant’s
natural grief beyond the actual cause of death”.
However, “[notwithstanding this, [the Ombudsman held the view that
the death of Stephen Wardle was an unnecessary death in custodv. It
might well have been avoided if there had been in place in the Lock-up
a full-time nurse, a better system of inspections of detainees and increased
awareness of the part of the officers.”
According to a letter sent by the Western Australian minister for police
to an Amnesty International member in May 1993. “a nursing post has
been established in the Fast Penh Lock-up [which] operates from 8pm until
4am on Thursday. Friday and Saturday nights.” To Amnesty Interna
tional’s knowledge, this nursing post did nolconlinuetobe fully functional
for more than a few weeks after its establishment46 though the authorities
deny this. In any event, the short operation hours of the nursing post on endof-week nights only-were highlighted in an inquest report of March 19,
1997 which found them unsatisfactory and recommended extending the
hours to the benefit of both prisoners and police. Western Australia was the
first stale in Australia to consider introducing a nursing post in a police
station when deaths from lack of adequate medical care became an issue
during the Royal Commission into Aboriginal deaths in custody.
Forensic nursing is a new field and nurses without training may be
called on to take part in a forensic investigation. An example of the failure
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of such an invesligalion involving a nurse is illustrated in the follow
ing account. In the village of Democracia in Amazonas State. Brazil,
three escaped prisoners were killed on September 6, 1992 in circum
stances suggesting extrajudicial execution. The three men, Mario
Ce'sar Bastos. Deusmar Demo and Roselei Fernandes Rosa, escaped
from a jail in the village of Maricore on September 5, 1992. They headed
by fool to the village of Democracia, where they were recaptured by a
military police patrol without a struggle. Instead of being taken back to
Manicore they were taken along minor roads into the bush. Witnesses
subsequently heard firing and the bodies later showed several bullet
wounds in the head and shoulders. Rosalei Fernandes Rosa had his mouth
gagged with a piece of cloth and the other two men had had their thumbs
cut off.
Later the same day, a six-member investigating parly, which included
a local doctor and a nurse, arrived to investigate the killings. Il is believed
that neither the doctor nor the nurse had forensic expertise and certainly
the conduct of the examination was inadequate. Al the scene of the
killings the investigators allegedly made only a cursory examination of
the bodies. The doctor reportedly told the nurse that the each man had
received a single shot and said that the cloth over Roselei Fernandes
Rosa’s mouth was a ‘robber’s mask’. No bullets were removed, no
photographs were taken and no villagers interviewed. The bodies were
buried immediately and the commission was reported to have stayed on
site for around one hour.
Six days after the killings a second invesligalion look place. Photo
graphs of the location were taken and local witnesses were interviewed.
though a line-up for the identification of military officers involved failed
to include two of the three men thought responsible for the killings. No
exhumations were performed, however, and thus there was only scant
medical documentation for future criminal proceedings against military
police later charged with the killings.
A number of authors have written on the subject of the nursing needs
of asylum-seekers and refugees, particularly those who have been torlurcd47. A paper from the Dutch Refugee Health Care Centre (now re
organized and re-named as the Pharos Foundation and located in Utrecht)
sets out the range of tasks a nurse may have in working in the field of
refugee reception. These include taking a history of the refugee, making
an preliminary evaluation of the presence of different types of trauma
sequelae, ensuring proper medical examination of the refugee, giving
information on the national health care system, advising on general
hygiene, vaccination for children, and the prevention of disease including
sexually transmitted diseases and liaising with local health authorities.
Women and children are given special attention including provision of
relevant information on family and child care.4*
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Nurses who have no specialisation in the Held of refugee health or
trauma may nevertheless encounter victims of human rights violations
during their work in hospitals and community, clinics and for this reason
a wider awareness of the effects of torture and trauma is desirable.
Each State Party shall ensure that education and information regarding the
prohibition against torture arc fully included in the training of law enforcement
personnel, civil or military, medical personnel, public officials and other
persons who may be involved in the custody, interrogation or treatment of any
individual subjected to any form of arrest, detention or imprisonment Article
IO. Convention Against Torture
Aspects of human rights education are not just an optional extra for
medical or nursing schools but. as article 10 of the Convention against
Torture suggests, an obligation on the part of states parlies to the
Convention. To date, no comprehensive data exists on the extent to which
states are meeting their obligations under article 10. However, there are
serious questions as to the extent to which health professional education
adequately addresses professional ethics and human rights. A pilot study
in the field of medical education in the UK suggested that students
perceived human rights education as inadequate.49 In an attempt to
contribute to increasing awareness of these themes, nurses who are
members of Amnesty International have been active in promoting the
teaching of human rights to nursing students. For example, nurses in the
German section of Al have produced an educational pack which discusses
human rights standards, nursing ethics and care for victims of human
rights violations. In Denmark, the Al nurses group has compiled a 50 page
human rights guide for nursing students. It has been sent to all schools in
Denmark. The dossier includes: the history of human rights, the role of the
UN, nursing ethics, human rights conventions, discussion of nursing and
human rights a game to provoke discussion, a guide to further information
on human rights and a literature list. The material has been accepted at all
schools of nursing in Denmark. In Canada, nurse-members of Al corre
sponded with a number of levels of the Canadian government and the
Canadian nursing sector in order to promote more effective implementa
tion of article 10 of the UN Torture Convention in their country. Nurses
in Britain, Switzerland, Canada and other countries have also been
actively involved in promoting human rights education among their
colleagues.
Conclusions
Nurses have historically played a positive role in the provision of
health care and the defence of humane values. These values are embodied
in the existing codes of ethics and statements of principle of nursing
associations. Al believes that nurses should ensure that national and
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international codes adequately address human rights issues and needs as
they develop. The existing international codes make an excellent starting
point but should be reviewed to ensure that they adequately address the
kinds of abuses and needs documented in this report.
Some nurses have been persecuted for their clinical activities in areas
where human rights violations are widespread. Others have been victimised
for their legitimate political or social activity. The defence of nurses and
other health professionals at risk is a major challenge facing the nursing
profession and society at large. Nursing professional associations could
investigate what further measures they might take to translate theirK
position statements into concrete active support for nurses at risk of
human rights violations. Associations could also investigate what further
mechanisms are available to influence government policies which fail to
adequately protect nurses.
It is not only individual nurses who are al risk. In some countries
officers from the nursing association have been subjected to written or
telephone threats or being followed and harassed by those who see the
association as ‘subversive’ or opposed to government policy. Nursing
organisations could investigate strengthening already existing mecha
nisms to support associations under threat. These include rapid response
by other associations which have the freedom to focus international
attention on those under threat. Where nurses collude in the practice of
human rights violations or assist in their cover up, there should be resolute
action by professional associations to ensure that such behaviour is
exposed and stopped.
Flowing from nursing ethics, the nurse’s role as a protector of and
advocate for, patients’ rights needs clarification and defending. Nursing
associations could investigate the possibility of establishing a human
rights and ethics officer if such a post does not currently exist. Amnesty
International believes that human rights education can strengthen the
ethical awareness of the nurse and her or his more effective role in defence
of the patient. To this end nursing associations should ensure that
education in relation to government-sponsored torture the death penally,
breaches of international humanitarian law and other areas of human
rights and professional ethics are given more prominent emphasis during
the training of nurses. Nursing associations might examine ways in which
they could more effectively cooperate with other health professional
associations to protect health services, human rights and the integrity of
their members when they come under threat.
Notes
1
Driscoll J ‘In Defence of Patient/Person Human Rights within National
Health Care Provision: Implications for British Nursing’ Nursing Ethics,
1997; 4:66-77.
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Amnesty International. Prescription for Change: Health Professionals and
the Exposure ofHuman Rights Violations. M Index: ACT 75/01/96. May
1996.
3 The International Council of Nurses is the international representative body
for nurses. It was founded in London in 1899 and is the oldest international
health professional organisation. Currently based in Geneva, it represents 1.4
million nurses from more (han 110 national associations.
4 This and the other ICN declarations cited are available from the 1CN and
national nursing associations. They are also contained in: Ethical (Codes and
Declarations Relevant to the Health Professions. Revised Third Bdition.
London: Amnesty International Publications, 1994.
5 See: ibid.
6 Canadian Nurses Association (50The Driveway. Onawa K2P 1E2). Position
Statement: Human Rights, November 1991.
7 Agar-Newman K. ‘Comments on the ICN position statements regarding
human rights.’ Nursing Ethics 1994. 1: 242-243.
8 American Nurses Association (600 Maryland Ave, SW. Washington DC
20024). Statement by ANA Committee on Ethics, November 1983.
9 American Nurses Association. Position Statement on Ft hies and Human
Rights, September 1991.
10 Royal College of Nursing (20 Cavendish Sq, London WIM OAB). Female
Genital Mutilation- The Unspoken Issue. March 1994.
11 Amnesty International. Alleged Torture and Rape of Nurse: Nazli lop,
Turkey. Al Index: FUR 44/53/92. 18 June 1992.
12 Amnesty International Turkey: Human Rights and the Health Professions. Al
Index: EUR 44/159/96. December 1996
13 Amnesty International. Turkey: Olcav Kanlibas (female) nurse Aged 23, Al
Index: EUR 44/l()t)/93. 3 November'1993.
14 Amnesty International. Mexico: Human Right. Violations Against Women. Al
Index: 41/09/96, March 1996
15 Asamblea de Trabajdores de Salud Publica.
16 Accion de (Vnidad Sindicaly Popular (UASP).
17 Amnesty International. Guatemala: Maquila Workers Among Trade Union
ists Targeted. Al Index: AMR 34/28/95. November 1995.
18 Amnesty International. Women in Kenya: Repression and Resistance. Al
Index: AFR 32/06/95. 1995.
19 Amnesty International. Imprisoned Nurse: Vo Van Pham alias Vo Thanh
Long, Viet Nam. Al Index: ASA4I/05/97 February, 1997.
20 General Arnaldo Ochoa and other senior military officials were tried in 1989
on charges of drug trafficking and smuggling. Ochoa and three others were
subsequently executed.
21 Jakarta Post. December 30, 1991.
22 Despite considerable evidence pointing to (he killing of an estimated 270
people by Indonesian troops during and afier the Santa Cruz massacre, the
Indonesian government has claimed that ‘about 50" people were killed.
23 Amnesty International. Indonesia and East timor. 50 Years in Power - 30
Prisoners. Al Index: ASA 21/01/95. January 1995.
24 See Amnesty International. Indonesia and East Timor: The November 12.
2
176
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Protests, (ASA 21/53/94), November 15, 1994, and Indonesia and East
Timor. Update on the November 12, Protests. (ASA 21/56/94). November 23,
1994.
25 Amnesty International. East Timor: Twenty Years of Violations, Statement
before the United Nations Special Committee on Decolonization - ll Jidx
J995. Al Index: ASA 21/33/95, 1995.
26 Amnesty International. Singapore: Amnesty International Condemns Impris
onment of 72-year-old Woman for Possession of Banned Religious Litera
ture. Al Index: ASA 36/5/96. July 2, 1996
27 Amnesty’ International. Women in Peru. Al Index: AMR 46/19/95, 1995.
28 Amnesty International. Women in Colombia: Breaking the Silence Al Index:
AMR 23/41/95, 1995.
29 Ibid.
30 On May 17, 1997, forces of the Alliance des forces democratiques pour la
liberation du Congo-Zaire (AFDL) entered Kinshasa, the capital of Zaire and
declared victory after a seven-month armed campaign against the Zairian
army. The AFDL leader, Laurent Desire Kabila, has declared himself presi
dent. suspended the Zairian constitution, changed the name of the country to
Democratic Republic of Congo and installed a new government.
31 Amnesty International Hidden from Scrutiny: Human Rights Abuses in
Eastern Zaire Al Index: AFR 62/29/96, 20 December 1996.
32 Amnesty International. Liberia: A New Peace Agreement - An Opportunity to
Introduce Human Rights Protection. Al Index: AFR 34/01/95 September 20,
1995.
33 See: Amnesty International. Turkey: Human Rights and the Health Profes
sions. Al Index: EUR 44/159/96. December 1996.
34 Sierra Leone: two ICRC nurses killed in ambush. International Review of the
Red Cross. 296:446, September-October 1993.
35 ‘Homage to assassinated delegates pronounced by ICRC President’ Cornelio
Sommaruga. ICRC News, December 20, 1996. http://www icrc.ch/icrcncws/
45fe.htm. The sixth victim was Hans Elberbout. a Dutch construction man
ager. from the Netherlands Red Cross who had joined the ICRC in Chechnya.
36 Amnesty International. The Death Penalty in the USA: An Issue For Health
Professionals. AMR 51/40/86, 1987.
37 Amnesty International, The Death Penalty in the USA: An Issue for Health
Professionals, AMR 51/40/86, 1987. See also: Health Professionals and the
Deallh Penalty, Al Index: ACT 51/03/89, 1989.
38 Physicians for Human Rights, Breach of Trust, Boston: PHR, 1994.
39 Amnesty International, Medical Concent: Death Penalty Legislation in
lllionis, USA, Al Index: AMR 51/67/95, May 1995.
40 Amnesty International, Afghanistan: Grave Abuses in the Name of Religion:
Al Index: ASA 11/12/96, November 1996; Urgent Action 112/97: Fear of
Further Amputations, Al Index: ASA 1 1/03/97 April 24, 1997.
41 Amnesty International. Afghanistan: Grave Abuses in the Name of Religion:
Al Index: ASA 1 1/12/96, November 1996.
42 Amnesty International. Medical Concern: Inyambo Yeta, Zambia, Al index:
AFR 63/07/96, October 1, 1996.
43 Amnesty International. Allegations of lll-trealment in Five Prisons in Texas.
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Ai Index : AMR 51/48/95, March 1995.
Lynch VA ‘Clinical Forensic Nursing: a New Perspective in the Management
of Crime Victims from Trauma to Trial’. Critical Care Nursing Clinics of
North America, 1995, 7:489-507.
45 Voelker R ‘Experts hope team approach will improve the quality of rape
exams'. Journal of the American Medical Association, 1996, 275: 973-4.
46 Amnesty International. Australia: Too Many Open Questions - Stephen
Wardle's Death in Police Custody AI Index: ASA 12/13/96, 17 October 1996.
47 See, for example, Cowgill G Doupe G ‘Recognising and Helping Victims of
Torture’. Canadian Nurse, 1985: 81:19-22; Jacobsen L. Vesti P, Torture
Survivors. Copenhagen: IRCT. 1992; Thomsen KS, ‘Torture Survivors: a
Challenge to Nursing Practice'. Nursing Ethics, 1994; 1:233-36.
48 Initial Medical Reception of Asylum Seekers and the Role of the Nurse.
Rijswijk: Centrum Gezondheidszorg Vluchtelingen 1990. 5 pp.
49 Vincent A, Forrest D Ferguson S. “Human Rights and Medical Education’,
Lancet, 1994; 343:1435.
44
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178
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Humanitarian Action and Field Workers
Consequences and Ambiguities
Francoise Sironi
Field workers engaged in humanitarian work have often to confront
not only stressful but openly violent situations in the countries they
are assigned to. It is only recently that the traumatic stress they
experience and how best to resolve it and rehabilitate these socially
committed individuals are being discussed.
TODAY, almost at the end of this century there are few places in the world
which have not yet been explored; there is no country in the world which
western modernity has not influenced. The new conquistadors have
different weapons. Two of them are humanitarian action and western
medicine. Behind the ideology of benevolence lies in fact a powerful
system of deculturation.
Humanitarian action involves important ambiguities. Those ambigu
ities emerge not only through a theoretical analysis, but also and mostly
through the psychological problems that occur among humanitarian
workers. Whether those persons are traumatised after a difficult mission
where traumatic events occured or whether they suffer from psychologi
cal problems due to the progress of the operation or due to the difficulties
linked with the return, in all cases we could observe the following: Those
persons are in fact real ‘captors of ambiguity’. They are the embodiment
of the ambiguities of the humanitarian organisation to which they belong.
My demonstration will be based on the one hand on testimonies from
foreign collegues (doctors, psychologists) who have themselves experi
enced the perverse effect of humanitarian actions. On the other, my
demonstration will be based on clinical cases, examples from my
psychotherapeutic practice with humanitarian workers. This
psychotherapeutic follow-up is done in Paris, at the treatment centre
called Primo Levi. Primo Levi Centre1 is first of all a treatment center for
victims of torture and political violence. Besides other activities of the
Association, Primo Levi (training and transmission of our experience in
treating traumatised patients, missions in Russia for example), we also do
debriefing or more exactly psychotherapeutical support with expatriate
workers from humanitarian organisations who request our help, after they
come back from mission.
The persons we treat present unexpected (for them) psychological pain
during or after difficult and afflicting humanitarian missions (like war
situations, catastrophics, genocide). They have recurrent nightmares, feel
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uncasx. anxious, dcpivsscd. without knowing why. Very often, this
psychological pain lakes the shape ot an 'existential crisis’. What they
often expivss than, is an actual experience of breaking (of rupture),
puzzling doubts about then previous investments and about their identity.
They feel undecided, sometimes confused, they don’t know anymore
what is good for them and what is bad. Nevertheless, it would be a mistake
to analyse this existential crisis as an individual problem, in terms of
“difficulties linked to the return*, or misadaptation of expatriates to
previous life in their home country. This type of analysis actually hides
the fact that something totally different is occuring: this existential crisis
cannot be perfectly understood by focusing only on the individual, private
psychological realm, it is directly correlated to the essence of humani
tarian action itself. This existential crisis shows that the humanitarian
missions have really changed or modified the expatriates who present the
crisis. They personify the ambiguities that underly humanitarian work.
they express through individual suffering, the paradoxes contained in the
humanitarian action.
Another common mistake is the following: it happens quite often that
a traumatic event precedes the existential crisis. Wrongly, the existential
crisis is covered up, with a traumatic reaction to a traumatic event. But in
fact, the traumatic event actually acts as a releasing factor of the existential
crisis. It facilitates or quickens its outbreak. They quickly earn then that
when the passion for ‘good* or ‘benevolent’ action pretends to become
universal, treating in the same manner different operations and people all
over the world, they are behaving in fact according to the logic of war.
Gina
1 don’t know what happens to me, I cry all day long since I came back to France.
I am scared at night. 1 see him in front of me, 1 see his bulging bloodshot eyes.
I can feel his breath on my face. He was slinking alcohol.
Gina is a beautiful young woman. The impression I got from the very
first moment we met is that she is living under a cover, she is leaving in
slow motion, ever since she came back from her last humanitarian
mission. She insisted telling me how she used to be before “I was
dynamic, super, alive; always ready to conquer the entire world with my
will, my heart and my brain". Yes, so she was. But life decided differently
for her, and gave her some unforgettable scraws.
When she graduated in medicine, Gina did not exactly know what she
had to do, what she wanted to do in her life. Private practice? She was too
young. Working in a dispensary or a hospital? No. definitely not. it was
too boring, too anonymous. Before ‘joining the system* (as she said), she
wanted to ‘breathe a little hit*. Humanitarian work seemed to be for her
the ideal area where she could practice medicine, bring something to the
others, discover oilier countries and al the same time leel 'useful*. She did
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a first mission that lasted three months in an African country and it was
super. Everything was OK. She wanted to go on, try it a second time. The
drama broke out in Eritriea. She was in charge of closing a mission that
came to the end of its development: installing a dispensary with vaccina
tion and primary health care for the local people. She was not satisfied
there. This mission ended up in a big misunderstanding. The local staff
had not been chosen according to the recommendation of the customary
authorities, but according to the technical know-how and abilities of those
local nurses trained by the humanitarian team. In fact, another person was
supposed to take on the responsibility of the dispensary and run it
according to the local way?
It was the end of the afternoon, when a man burst into the dispensary.
He was very angry. He threatened the working team and the patients,
fixing the barrel of on Gina’s temple. This threatening man haunted her
nihtmares since then. Many months after her retun, Gina experience
contradictory feelings, and she is perfectly aware of this phenomenon. A
part of her totally identified with the humanitarian values and culture.
“You see, I was exasperated by the attitude of the native. I had authentic
racist feelings, and at the same time, I was totally puzzled, to experience
those feelings.” Another part of her rejected what she was doing in this
country. She was confused and had the feeling of being nothing but a
pawn on the humanitarian chessboard, whose slakes exceeded, according
to her, help, generosity and transmission of experience. In order to
comment the situation of Gina, let us examine now some of the ambigu
ities linked to humanitarian action that emerged during debriefine ses
sions with humanitarian workers.
Perverse Effect of Victimisation
Very often, the persons whom the humanitarian workers treats or helps
to, slowly loose their status of human beings. More exactly, they enter into
a precise category the one of the victim. This reduction of the complexity
of an identity justifies their action towards the person they help to. Il helps
lhem to reinforce their own image of saviours, or teachers. Surprisingly
during the debriefing sessions, they didn’t talk very much about the
natives to whom they brought assistance. I got very often the representa
tion that they were living in a cognitive bubble (blister). They had their
aim and objectives of the mission and stuck to it. “I sometimes got the
feeling of uselessness” they often say. “It seemed to me” said one person
“that what was important to those responsible in the humanitarian
organisation was to pul a flag in this country”.
The victimisation is reinforced, sometimes, by a curious attitude: The
humanitarian workers, on the field, act as if they know better than the
natives the needs of the population. And that is how they create a new
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artificial representation of the person, that doesn't correspond to what she
is. The human being is than reduced to a victim, in order to make the
reality less complex.
One of my collegues in Paris (in Georges Devereux Center) told me
about his personal experience with humanitarian organisations. He is an
Armenian. Since he was young he has seen numerous humanitarian
organisations in his village. The local authorities saw the financial
interest and accepted their presence. The population was forced to be
vaccinated. After vaccination, my colleguc was told to attend to educa
tional programmes. The population inner hostile - they could not under
stand what those foreigners wanted. What were their intentions? “I was
very young” he said, “but nevertheless I had the strong feeling that they
were all trying to take something away from me, something that I had
inside and that they could not get”.
According to the project, the humanitarian organisations choose the
natives they decide to educate or work with. The criteria of selection
correspond very often to empathy with the western values, or profcssionnal
correspondance, without trying to find out first, how the health system for
example works from the inside.
I do not want to name the humanitarian organisation where the
following happenned. because it would stigmatise it’whereas this kind
of thing happens in many humanitarian organisations.
A mission was organised in an eastern country that is still in war. This
mission consisted in training health professionals in treating patients who
had been psychologically traumatised. No one from this country had
made this request. An exploratory mission had been orgaanised according
to what the members of this humanitarian organisation thought those
people would need. The participants (western psychologists and psychia
trists) had to identify the right partners to be trained. They were upset
when they found out that there was only one psychiatrist and one
psychologist in this important town. The French psychologist who
participated to the exploratory mission and with whom I spoke did not
wonder whether it was adapted or not to train those professionals in
psychotherapy. He also told me, puzzled, that nobody goes to the
psychiatrist there. Most of people go to traditional healers. He had the
deep conviction that he and his collogues would succeed in implementing
psychoanalytical theories and treatment in this town where most of the
natives know nothing of the western way of thinking on disease, mourn
ing and sorrow.
Generally, the humanitarian organisations act as ifculture did not exist.
They reduce a human being to its universal part. So, one can say that they
reduce a man to a monk without distinction, without cultural specificity.
Whether they are in Burundi, in Colombia or in India, their methods arc the
same. This occidental arrogance leads sometimes to a clash with local
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collaborators. It is after such events that humanitarian workers develop
what I call these existential crises. This is what happened to Gina.
I propose for discussion, two arguments, explanations which are
central in this process: on the one hand humanitarian work considered as
a process of initiation which can lead to traumatophilic addiction and on
the other, humanitarian work as a process of deculluration.
A common representation underlies both the leaders of humanitarian
organisations and the volunteers who want to work with them. It is the
idea of an initiatory process. When they accept to work for humanitarian
organisations, the volunteers are all at a changing point in their life.
Consequently, they consider humanitarian organisations as a place where
they can shift from their former life to a new life. Humanitarian
organisations act then like a provisory group of affiliation. Joining
humanitarian organisations has the effect of a brcakinil point, with
initiatialory properties, yet in a controlled risk taking procedure. Con
fronted with difficulties inherent to theircommilment (loss of idealisation
through confrontations with the natives or with the team), the volunteers
re-examine their motivations and feeling of belonging to the humanitar
ian organisation. The issue is the following: they develop an existential
crisis, or they stick, much stronger than before, to the ideology of the
humanitarian organisation they are working with. In that case, they enter
into a process of traumatophilic addiction.
Betty
Betty was working in Rwanda last year for a French humanitarian
organisation. She described this mission as being problematic for her.
Nevertheless she wanted continue to be a volunteer two months more
after the end of her contract. She came back to France, and after two
months, she was sent to another country for some months. She was
satisfied with what she did there. When she came back, she attended a
training course in Pans, organised by the same humanitarian organisation,
in order to become ‘project coordinator’. Il is at the end of this course, that
she felt uneasy, depressed, empty and all the questions she had in Rwanda
came back, I saw her at that time.
A lot of questions arc haunting me day and night: Am I able to work again in
the humanitarian field? Because I remember how I was rejected by the
humanitarian team in Rwanda. The people were really hard with me. The
logistician was completely obsscssed with his organisational work, the nurses
and the doctor were cold, and closed up. They never told me where I could find
what 1 needed in order to do my job.
Paola
Paola worked for many years in a humanitarian organisation. She
carried on one mission after another, going to the most difficult places in
the world, shere wars and genocide took place. “I needed that. I have very
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good memories of those limes. I could not stop it. I was good al work”.
But one day. in Somalia, as she was walking alone on the beach, a day
before her departure for Paris, she was attacked by a native. Who wanted
her money and her jewels. When she came back to Paris, she settled down.
had important management responsibilities in Paris, with the same
humanitarian organisation. She was piloting projects, dealing with
personnal and team problems, and used to meet the expatriates when
they returned from lheir missions. After a few months, she felt deeply
depressed. Actually, she entered in this existential crisis process. She
was ill, didn’t work for a few months, until she came out of it, like a
new-born person. During all these months, she had undertaken psycho
therapy, linked to what happened to her in this job. Now she is working
again and plans to work as a trainer and manage the problems of the
return.
Among the young persons sent to places in the world where something
happens, nobody has previous experience of war, nobody has previous
experience of death. The misfortune of others (the native victims who arc
rescued) become an initiatory experience. Here again, there is another
ambiguity of humanitarian actions - the way they are organised in these
days. Humanitarian workers are confronted with fatigue, stress, danger
and horror. This modifies their personality. After that, they can feel
invulnerable. This is what Betty was confronted with among the staff
during her first experience in Rwanda.This feeling can be detected in
hyper-control and hyper-counsciousness. Although I reject any attempt al
medicalising existential, contextual problems, we could call those reac
tions of traumatophilic addiction, the ‘Rambo syndrome’. What is the
difference then between them and the soldicrs?The difference is that with
soldiers who belong to the army of a country, those kind of traumatic
initial experiences are part of the process. They make sense. Despite them
one can think about army and military affiliations. The paradox with
humanitarian action is that those kind of volunteers behave like soldiers
defending and spreading the ideology of benevolence and so-called
‘good’ and ‘peace’. This so called neo-affiliation is so real that a neo
culture emerges in those groups: they have their own languages or
technical words. Places of actions are identified like battle places. After
‘Sarajevo’, one can meet the others in Kigali or Grozny.
Humanitarian Work and Deculturation
The visibility of humanitarian action working as a deculturation
process in traditional societies is quiet clear. Betty told me that al that lime
she was already aware of the ambiguities linked to humanitarian action,
yet she continued to work, because she liked her job. In one country where
she worked the humanitarian mission had a precise objective: To open
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1998
and lead to autonomy four medical dispensaries. In two years they (rained
local doctors and nurses. Meanwhile the salaries of the natives was very
high, due to the fact that they were paid by the humanitarian organisation.
Their salaries were as high as that of some ministers in the government of
the country. Betty explained to me:
At the end of the mission, I was confronted with a great difficulty. When the
dispensaries became autonomous, the salary of the native collaborators be
came normal again...that is to say, 10 times less than what they got before. They
didn’t agree to this. 1 had to explain to them that it was their duly as doctors and
nurses to treat people and consequently accept those difficulties because their
job is not linked to money-making.
The ideology that underlies humanitarian action is the ideology of
exportability. What is exported or implemented when medicine and pills
are distributed in a tribe? Humanitarian medical action for example has
a very perverse effect. Il is fragmenting natural groups, and rcoarganises
them around the categories of western medicine and western beliefs and
values. Like Christianity, they use a technic of infiltration. When they go
away, nothing can be like anything before anymore. Deculluration can be
illustrated with another example.
A humanitarian organisation is conducting a project among an Indian
community in a country in South America for many years now. At first,
the project consisted of a vaccination campaign and in establishing a
dispensary of primary medicine by training local people. The local
westerners responsible of the project thought that it would be necessary
for the Indians to know how to calculate, and manage finances so that they
would notbe taken advantage of other communities in the neighborhood
or by foreigners. But this request never emerged from the Indians. Again,
another ambiguity of humanitarian actions: The medicalisalion of politi
cal probolems, the medicalisalion of history.
Rony Brauman. the former president of the French humanitarian
organisation Mcdccins sans Frontiers (from 1982 till 1994) writes:
The problem with humanitarian action is not the idea of benevolence and
compassion in itself, but their social misuse, their political meaning. The
humanitarian rhetoric separates individual misfortune from the causes of the
evil. When a genocide turns into a ‘humanitarian crisis’ as they call it
nowadays, this event becomes a tragic event among many others. All the
questions about the reasons of its occurence, the complicities, the responsabililies
are replaced by the concept of ‘emergency aid’. The genocide is in the shadow
whereas at the frontdoor (with T V, news) we attend to an edification of our
kind feelings of benevolence.
“Each road has its turning” sings Billie Holliday. Il is always dangerous
when human groups act blindly, without thinking first of the conse
quences of their actions. We must, once and for all sit down and honestly
analyse what underlies humanitarian actions.
RJH
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Vol III: 3
1998
185
good memories of those limes. I could not slop it. I was good al work”.
But one day. in Somalia, as she was walking alone on the beach, a day
before her departure for Paris, she was attacked by a native. Who wanted
her money and herjcwels. When she came back to Paris, she settled down,
had important management responsibilities in Paris, with the same
humanitarian organisation. She was piloting projects, dealing with
personnal and team problems, and used to meet the expatriates when
they returned from their missions. After a few months, she felt deeply
depressed. Actually, she entered in this existential crisis process. She
was ill, didn't work for a few months, until she came out of it. like a
new-born person. During all these months, she had undertaken psycho
therapy, linked to what happened to her in this job. Now she is working
again and plans to work as a trainer and manage the problems of the
return.
Among the young persons sent to places in the world where something
happens, nobody has previous experience of war. nobody has previous
experience of death. The misfortune of others (the native victims who are
rescued) become an initiatory experience. Here again, there is another
ambiguity of humanitarian actions - the way they are organised in these
days. Humanitarian workers are confronted with fatigue, stress, danger
and horror. This modifies their personality. After that, they can feel
invulnerable. This is what Belly was confronted with among the staff
during her first experience in Rwanda.This feeling can be detected in
hyper-control and hyper-counsciousness. Although I reject any attempt al
medicalising existential, contextual problems, we could call those reac
tions of traumalophilic addiction, the ‘Rambo syndrome’. What is the
difference then between them and the soldiers?The difference is that with
soldiers who belong to the army of a country, those kind of traumatic
initial experiences are part of the process. They make sense. Despite them
one can think about army and military affiliations. The paradox with
humanitarian action is that those kind of volunteers behave like soldiers
defending and spreading the ideology of benevolence and so-called
‘good’ and *peace - This so called neo-affiliation is so real that a neocullure emerges in those groups: they have their own languages or
technical words. Places of actions are identified like battle places. After
‘Sarajevo’, one can meet the others in Kigali or Grozny.
Humanitarian Work and Deculturation
The visibility of humanitarian action working as a deculturation
process in traditional societies is quiet clear. Betty told me that al that time
she was already aware of the ambiguities linked to humanitarian action,
yet she continued to work, because she 1 iked her job. In one country where
she worked the humanitarian mission had a precise objective: To open
184
RJH
(New Series)
Vol 111:3
1998
and lead to autonomy four medical dispensaries. In two years they trained
local doctors and nurses. Meanwhile the salaries of the natives was very
high, due to the fact that they were paid by the humanitarian organisation.
Their salaries were as high as that of some ministers in the government of
the country. Belly explained to me:
At (he end of the mission, I was confronted with a great difficulty. When the
dispensaries became autonomous, the salary of the native collaborators be
came normal again .that is to say, 10 limes less lhan whai they goi before. They
didn’t agree to this 1 had to explain to them that it was theirduty as doctors and
nurses to treat people and consequently accept those difficulties because their
job is not linked to money-making.
The ideology that underlies humanitarian action is the ideology of
exporlabilily. What is exported or implemented when medicine and pills
are distributed in a tribe? Humanitarian medical action for example has
a very perverse effect. It is fragmenting natural groups, and rcoarganises
them around the categories of western medicine and western beliefs and
values. Like Christianity, they use a technic of infiltration..When they go
away, nothing can be like anything before anymore. Deculluration can be
illustrated with another example.
A humanitarian organisation is conducting a project among an Indian
community in a country in South America for many years now. At first,
the project consisted of a vaccination campaign and in establishing a
dispensary of primary medicine by training local people. The local
westerners responsible of the project thought that it would be necessary
for the Indians to know how to calculate, and manage finances so that they
would nolbe taken advantage of other communities in the neighborhood
or by foreigners. But this request never emerged from the Indians. Again,
another ambiguity of humanitarian actions: The medicalisalion of politi
cal probolems, the medicalisalion of history.
Rony Brauman. the former president of the French humanitarian
organisation Medccins sans Frontiers (from 1982 till 1994) writes:
The problem with humanitarian action is not the idea of benevolence and
compassion in itself, but their social misuse, their political meaning. The
humanitarian rhetoric separates individual misfortune from the causes of the
evil. When a genocide turns into a ‘humanitarian crisis’ as they call it
nowadays, this event becomes a tragic event among many others. All the
questions about the reasons of its occurence, the complicities, the responsabilities
arc replaced by the concept of ‘emergency aid’. The genocide is in the shadow
whereas al the frontdoor (with T V, news) we attend to an edification of our
kind feelings of benevolence.
“Each road has its turning” sings Billie Holliday. It is always dangerous
when human groups act blindly, without thinking first of the conse
quences of their actions. We must, once and for all sit down and honestly
analyse what underlies humanitarian actions.
RJH
(New Series)
Vol III: 3
1998
185
Note
[This paper is based on a presentation made at the Second World Conference of
the international Society for Traumatic Stress Studies.)
1 The Primo Levi Center is managed by an inter-associative network. Five non
governmental organisations compose Primo Levi Association: Amnesty Inter
national, Association des Chretiens pour i’Abolition de la Torture (ACAT).
Juristes sans Fronlieres (JSF), Medecins du Monde (MDM), Treve.
References
Brauman R (1994): Devant le mal: Rwanda, tin Genocide en Direct, Arlea.
- (1995): 'Le Sacre de L'urgence', Le Debat, No 84.
Guillebaud, J C (1994): 'Entre Progres et Regression', Le Debat, No 84.
Guisnel, J (1995): 'Blessures Humanitaires’, Liberation, 24/10/1995.
Lelouche, P (1995): 'Les Sanglots de L’impiiissance’, Le Debat, No 84.
Resten P (1994): ‘L'hunianitaire, Jusqu’ou’, Passages, Decembre 1994.
Rufin J C (1995): 'D’une Peura L’autre’, Le Debat, No 84.
REVIEW OF WOMEN STUDIES
April 25, 1998
Whatever Happened to the Dreams of Modernity?
The Nehruvian Era and Woman’s Position
Nirmala Banerjee
Periyar, Women and an Ethic of Citizenship
V Geetha
State Welfare Policy and Women, 1950-1975
Nirmala Buch
Dalit Women’s Writing in Telugu
Challapalli Swaroopa Rani
‘Doosri Azadi’: SEWA's Perspectives
on Early Years of Independence
Ela R Bhatt
Testimonies of Struggle
For copies write to:
Circulation Manager
Economic and Political Weekly
Hitkari House, 284,
Shahid Bhagatsingh Road, Mumbai 400 001
186
RJH
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1998
Communications
Indigenous Health Care System
in Karnataka
An Exploratory Study
Despite the expansion of modern medicine, people continue to
use the sendees of indigenous practitioners. This study in Magadi
taluk near Bangalore attempts to understand why they do so, what
are the health problems most often dealt with by indigenous practioners
and what training do they have for practising medicine.
SINCE independence, there have been several efforts to revive traditional
system of medicine for providing primary health care, particularly, in
rural areas of the country. Because, it is observed that people in rural areas
are familiar with the use of plants and herbs for the treatment of diseases
as well as for birth control. However, the pattern of traditional treatment
of diseases varies among social groups and also across regions. If any
meaningful health policy meant for the rural poor is to be formulated, it
is important to lake note of the extent of traditional practices and their
implications to modern health care.
Health care systems practised in India may be categorised as: (a) the
modern medical system which includes allopathy and homeopathy, and
(b) the traditional medical system, which comprises Ayurveda, Siddha.
Unani and folk medicine. In addition, many people are following yoga
and naturopathy for treating their ailments. All these systems are popular
among the people. The indigenous system of medicine is practised mainly
because it is cheaper, easily available with no side effects. A large number
of hereditary medical practitioners practise this system. They include
herbalists, bone-setters, traditional birth attendants, traditional psychia
trists, spiritual healers and other specialists. These practitioners are
recognised by the village community as providers of health care who use
immediately available local resources like flora, fauna and mineral
substances. Women have been the custodians of these practices and
knowledge.
The indigenous health care system is practised primarily for two
reasons: first, it is cheaper and easily available; secondly, the traditional
health practitioners have established close rapport with their clients. In
view of this, the role of indigenous practitioners among rural communi
ties needs special attention.
RJH
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AH
\
Vi 187
S
Studies of indigenous health care system emphasise mainly the super
natural beliefs related to disease and treatment. Hardly any study exists
with respect to; (a) people’s perception about traditional health care
system, (b) characteristics of indigenous health practitioners and their
clients; and (c) interaction of indigenous and modern system of medicines
at various levels, and reason for the popularity of indigenous system. The
present study therefore, is an attempt in this direction.
The main objective of the present study is: To understand why people
use traditional medicines for their health care needs even though modern
health facilities are available; what type of disease/ailmcnts do people
seek the services of indigenous practitioners; and To study the
characteristics of practitioners and their clients.
The area selected for the present study is Veeregowdanadoddi primary
health center of Magadi taluk coming under Bangalore rural district. V G
Doddi is selected for the study mainly because the traditional system of
medicine still holds sway in the area. Veeregowdanadoddi PHC has one
medical doctor, nine para-medical workers and 42 trained birth attendants.
In addition, there are eight private medical doctors practising in this area.
From V G Doddi, Magadi town is just seven km where there is a general
hospital and another general hospital is situated al Ramanagaram town
which is 20 km away from V G Doddi. The distance from this place to
Bangalore city is just 60 km towards east. Even though all these modern
health facilities are available people use indigenous medicines for their
health care needs in the area.
There are 67 villages coming under V G Doddi primary health centre
area. Out of these 67 villages, we identified 26 indigenous medical
practitioners with the help of PHC health workers, indigenous practitioners
and the users of indigenous medicines. Out of these 26 indigenous
practitioners, 16 practitioners are experts in treating different diseases
and they devote much of their time in the collection of herbs, and ad
ministering medicines to the patients. For the purpose of sample selec
tion, on the basis of the numberof patients they treat in a day, we classified
them into two categories: (i) full-time practitioners and (ii) part-time
practitioners. Full-time practitioners are those who treat a minimum of
four to five patients a day. Keeping this in view and the number of patients
they treat in a day, the type of disease they treat, we selected 10 indigenous
health practitioners in different villages for in-depth interview. After
contacting and discussing with the traditional health practitioners, 10
clients from each of the practitioners have been selected on the basis of
the list °iven them. These clients were interviewed mainly to cross check
whether the indigenous medicines are really effective in curing the
disease, and why they prefer indigenous medicine instead of modern
medicine. For the purpose of this study, we covered only (he full-time
practitioners.
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A separate interview schedule was used to collect information both
from the health practitioners and theirclients. Besides using the interview
schedule, observation method has also been employed for collecting
qualitative data. The data gathered from the indigenous health practitio
ners are: the type of training they have undergone, how they diagnose the
disease, knowledge about medicines and method of treatment, type of
disease they treat and their perception of indigenous and modern medicines.
The information obtained from the patients are; knowledge about
practitioners, type and duration of disease and treatment and, why they
prefer indigenous medicine to modern medicine.
Before commencing the actual interview, a good rapport was established
with the indigenous health practitioners. Necessary care was taken in
building up rapport with the respondents. After obtaining information
from the practitioners, their clients were interviewed to get accurate and
reliable information. During subsequent home visits, data relating to
delicate matters like abortion, contraception, use of herbal medicines for
delaying births etc. were obtained. At times, the services of neighbors and
local health workers were utilised for eliciting more reliable information.
Data collection was carried out during January-March 1995.
Though the modern health facilities are available the indigenous
health practitioners still make a significant contribution to the medical
care of the people in the study area. There are many factors which have
influenced people to rely on traditional medicines. They are: the indigenous
medicines are cheaper, easily available, confident about curing disease
and no side-effects. For instance, in our sample,many people went to
allopathic practitioners for treatment of diseases like Balagraha,
Leucoderma etc, but got no relief. However, these diseases were cured
under the traditional method.
In the study area, whenever people are attacked by diseases they have
to travel long distances to reach a modern medical clinic or pharmacy.
This results in loss of wages. Sometimes the cost of transport itself often
exceedes the cost of medicine. Most of the respondents report that when
there is health problem one has to walk on an average 5-6 km to get
modern health facilities from their villages. On the other hand, they get
traditional medicines within their village or within 1 km of their settle
ments. The traditional healer is ready to visit the patients at his residence
and give confidence to the patient and his people that he would cure the
disease. Always the patients feel free to ask questions with the traditional
healer regarding how to obtain more herbs and remedies. These charac
teristics are absent or less pronounced in the case of modern medical
practitioners.
Another interesting aspect of traditional health care system is that it is
popular mainly because of its treatment strategies. The treatment strategies
used in the traditional system include; immediately available local
RJH
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189
resources like flora, fauna and minerals, mind or body approaches such
as meditation, physical exercises and massage programmes. Sometimes
their therapies arc associated with rituals and beliefs. These are low- cost
and locally available treatments. Generally, traditional healers do not
collect any fee cither in kind or in cash from the patients. There is an
affinity and social bond existing between the traditional practitioner’s
and their clients. Whereas in modern medical system we found inva
sive practices such as blood transfusion, surgery, injections etc. The
modem medical system is not only expensive but also has a risk of side
effects.
Cultural factors play a significant role among people in relying on
traditional medicines. The traditional medical knowledge is primarily
household practices. These practices arc home remedies, food habits,
rituals, etc. The treatment is frequently a family based process, and the
advice of family members or other important members of a community
has major influence on health behavior. The traditional healers and their
therapy are quite integrated with indigenous culture and the ways of life
of the people. It is relatively cheaper and its practitioners are usually more
accessible to the patients. Most of them arc ordinary folks, coming from
similar socio-economic background like their clients. The relationship
between traditional health practitioners and their patients are reciprocal.
The traditional healers are respected and are in high esteem in their
villages. Since the traditional practitioner lives and carries his profession
according to his status, he will be confident of his abilities in diagnosing
and treating the disease. Whereas the modern medical man does not name
the disease, keeps his diagnosis to himself and keeps the patient and his
kin who attends on him in dark. On the other hand, since the traditional
healer speaks the local language, he will be close to the patient and his
group, and creates a sense of security in them.
In essence. ’radmonal medicines arc low cost, easily available and the
healths art local people If local person is treating the disease the response
is better evoked. for instance, in the study area, a veterinary practitioner
who uses allopathic medicines and treats human ailments. All serious
cases. difficult •
and incurable ones are taken to him with full hope
bccair.e he is a local person. He believes in traditional medicines,
prach*1 • h1 fhxl iff dir im s and also treats the patients w ith modem drugs.
'fins has' f
d a r< \p< /1lnl attitude among villagers towards him. He
earn* more than any other practilioncis in terms of money fame and
alter
and rs alv/ays willing to help the needy.
I h< * ornmori an*l lr< /picnlly ocvuiring diseases in the study area are:
Mtah lul' din ,illli/lions, diabetes. asthma, jaundice, ‘balagraha’,
‘aielmlu H oU'havn hi I riiaildu* (Oedema), ‘noothi*. *bennapani\
spirit po. ' <sion, • n lie indigenous practitioners give treatment from
minor ailrre nl. to > /> n < liioiin disease*. While some practitioners treat
190
Kill
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V<>/ 111: 3
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only two or three diseases like snake-bite or skin diseases, others are
experts in giving treatment for asthma, cancer, diabetes, rheumatism and
contraception. In addition, there are some practitioners who are specialised
in diseases of children and in driving spirits.
Most of the practitioners indicate that they treat more than one disease
and prescribe only indigenous medicines. Their indigenous medicines arc
mostly hereditary formulae prepared from herbs, powders, minerals and
products of animal origin. Many of their methods and medicines arc
closely guarded secrets. No written records or files arc maintained by most
of the practitioners. However, a few practitioners did maintain some
records of medicinal formulae having inherited them from their ancestors
and were reluctant to produce them before us during the fieldwork. There
seems to be little interaction among the individual practitioners and there
is a sort of informal referral system especially among a few specialists i e,
those who are known to have particular expertise in treating some specific
diseases.
In the study area, for some diseases there is no allopathic treatment is
available. For instance, bavu or kettaddu, arshithi, noothi, bennapani etc.
The symptoms of the bavu disease is swelling under the skin particularly
in certain parts of the body like cheek, shoulder, sides of the chest, neck
etc. It resembles mumps when it appears on the cheek. The popular
belief is that there is no treatment for this disease in the allopathic system.
In our sample, there were 19 patients who had this condition and got cured
under the traditional method. Many of them initially went to allopathic
practitioners but got no relief. When we enquired with the allopathic
doctor he admitted that there was no treatment for this type of disease in
the allopathic system and that it might be difficult to diagnose such
diseases. In the indigenous system the treatment consists of chanting of
mantras and also administering of herbal medicines. All the 10 indigenous
health practitioners interviewed for the present study reported that they
gave medicines for ‘Bavu’ bennapani. noothi diseases. However, herbal
medicines prescribed for this disease varies from one practitioner to
another.
There is a persistent belief both among the traditional practitioners and
people that the indigenous medicines have effective cure for certain
complex diseases such as arthritis, asthma, diabetics, skin afflictions,
snake bites, sexual malfunctions etc. There is also a belief among
indigenous practitioners and people that for certain diseases like balagraha
and nomedicine ortreatment is available both in indigenousand allopathic
systems. The only remedy is magical and propitiation of the evil spirits.
Whenever children suffer from this disease, the indigenous physician is
approached who, in turn, gives them magical treatment. The indigenous
physician after performing the pooja and rituals to the deity, blows some
ashes on the child and ties a yantra (amulet) around the neck. In our
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191
sample, there were 10 children who suffered from balagraha disease got
cured from the magical treatment.
The non-availability of proper medicines for specific diseases in the
primary health center is another reason for the people to use indigenous
medicines. Forexample, according to them, when people bitten by snakes
go to PHCs, the doctor usually send them away on the plea that the PHC
is not provided with anti- venom drug. Therefore, people resort to the
traditional medicines which are available easily.
As has been noticed in the study area, there are some mental ailments
which are caused by evil spirits and ghosts of dead persons cured by the
traditional healers. It is believed that malevolent male devils choose
young women and live in them as spirits. So, as long as they live in the
young woman, the woman will never conceive and bring forth children.
It is also believed that spontaneous abortions are caused by ill effects.
Whenever such diseases occur people approach the traditional healercum-magician todrive away the evil spirit from the women. The magician
recites certain mantras and performs rituals to ward off the evil. In our
sample, there were five cases where an exorcist who drove out the evil
spirit that lived in married women.
The practice of abortion whether spontaneous or induced are repor
ted to be widespread in the study area. According to the traditional
healers the rale of abortions are more among young girls who have had
pre-marital sexual relations and widowhood pregnancies. Our enquiry
during the fieldwork revealed that the unmarried girls and widows
who terminate pregnancy prefer indigenous medicines eventhough
facilities for termination of pregnancy through modern method are
available. This is mainly because women as a group would like to keep
the event of abortion a secret among themselves. One of the lady
practitioners claims that she knows the method of induced abortions
by using indigenous medicines, delaying births and permanent method
of contraception. She also indicated that she has treated cases like
abscesses, milk vitiated, breast dry up and excess and irregular menstrua
tion etc. In our sample, there were four cases who terminated their
pregnancy through indigenous method and five clients who were using
traditional medicines for birth control. These clients belonged to weaker
sections.
Characteristics of Indigenous Health Practitioners
The socio-economic characteristics of indigenous health practitioners
are provided in Table 1. By and large, most of the traditional practitioners
are living either in joint families or extended families. Living in joint
families would help the practitioners to procure plants, herbs, leaves from
the forest.
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The practitioners whom we interviewed are local people belong to
different caste groups. Among them two are vokkaligas, two kurubas, two
nayakas, two gollas, one marati and one brahmin. Most of these practitio
ners are males though there is only one female practitioner specialising
mainly in gynecology and obstetrics. All the practitioners are between 50
and 80 years of age and all of them are married. Over half of them entered
the profession because of the tradition within their family and others
because their relatives arc practising the system. The indigenous health
practitioners are not registered practitioners of indian medicine and no
one has received formal education in ayurvedic medicine or indigenous
medicine. The educational level of
Table 1 :Socio-econo.mic
the practitioners is less than higher
Characteristics of Practitioners
secondary which means that they
Number of
have seven to nine years of school Characteristics
Practitioners
ing. They acquired skills and knowl
edge of indigenous medicine only
9
Sex: Male
Female
after several years of apprenticeship
1
Age Groups
with their ancestors or relatives.
5
51-60 Years
The main occupation of the tradi
4
61-70
Years
tional healer is agriculture. Most of
1
71-80 Years
them’ own between 15 to 40 acres of
Marital Status
land. While six have irrigated land
8
Currently Married
others have only dryland. Since they
2
Widow/Widower
are landowners it is easy for them to
Education
grow some of the rare medicinal
4
7th Standard
plants in their farm. During the field
4
8th Standard
2
9th Standard
work we came across both full-time
practitioners and part-time practitio Type of Family
Extended Family
2
ners. Usually, the full-time practitio
8
Joint Family
ners are aged and cannot work in the
Caste Groups
field. They run their clinics or dis
Brahmin
1
pensaries at home. Nearly half of the
2
Vokkaliga
indigenous health practitioners are
2
Kuruba
engaged in full time practice. The
2
Nayaka
part-time practitioners are those who
2
Golla
combine their indigenous medical
1
Marati
profession with agriculture. Their Land Ownership
15-20 Acres
2
main occupation is agriculture.
2
21-30 Acres
Whenever patients seek their ser
31 -40 Acres
6
vices they treat them. The part-time
Annual
Household
Income
(In
Rs)
practitioners arc mostly snake-bite
15,000-20,000
2
curers and skin disease experts.
20,001-25,000
2
A majority of the practitioners
25,001-30,000
6
reported that they treat nearly four to
RJH
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193
eight patients a day and give the medicines on all days in a year. However,
on full moon and new moon days they do not prescribe medicine. The
practitioners get medicinal herbs from the savandurga forest. According
to them savandurga forest is rich in medicinal plants since from their
ancestors. The traditional health practitioners do not collect any fee either
in kind or in cash from the patients. For certain diseases the medicines arc
prepared in combination with herbs collected and roots purchased from
the Gandhige Shops. In such cases, the practitioners give a list of herbs/
roots to be purchased from the shop. Alternatively, they collect actual cost
of the materials if they buy it from the Gandhige shops.
Out of the 10 indigenous practitioners interviewed, six got training
from their parents; two indicated that they picked it up from a relative
whose children did not want to inherit the profession. Two of the
respondents entered the profession of their own interest. Sometimes, the
healers themselves chose persons other than their family members as
successors. All these traditional practitioners never had a formal training.
The kind of training that is pursued by the traditional healers to pass on
their powers is informal i e, by word of mouth.
Different types of practitioners arc tr/Med in different ways. Those
who practice only yantra/mantra for curing the disease got training during
eclipse night either from their fathers or from their teachers. On the other
hand, practitioners who combine herbal medicine along with yantra/
mantra practice mantra on eclipse night and also do sacred chanting
before the herbal plant forone yearduring new moon day. The practitioners
who use only herbal medicine in their profession work as apprentices
with their teacher and observe collection of herbal plants and preparation
of medicines. The period of training varies from one day to one year
depending on the type of disease they want to treat.
A majority of the practitioners start learning the profession at an early
age. While five respondents started their profession when they were 20
years old. others were initiated when they were between 20-30 years of
age. There are some pidclilioners who were trained initially for treating
only one or two diseases by their Gurus/relatives but, later they started
treating olherdiseases because of their individual practical experience. A
number of herbal medicines and medicinal plants have been identified
and used for different diseases by these practitioners.
Most of the practitioners indicate that they diagnose the disease before
recommending any medicine or treating the patients. The diagnosis
depend upon the type of disease. Generally, the indigenous health
practitioners use physical examination such as viewing the patient’s
body, touching, symptoms of the disease and eliciting information by
questioning. There arc simple techniques and procedures that are identi
fied by the practitioners to diagnose the disease. For example, whenever
a patient is brought in with a suspected snake-bite, one of the tests that the
194
RJH
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1998
practitioner gives is lo ask the patient to chew ‘chillies’. Based on whether
the patient identifies the hot taste correctly or not a preliminary diagnosis
is made that the patient has been bitten by poisonous or non-poisonous
snake or that he is not bitten by a snake at all and is merely suffering from
a fright. This test is based on the logic of how poisons affect various
physical senses including the sense of taste. Similarly, the pregnancy can
be detected by a simple method. For example, a sample of the patient’s
urine is collected in a coconut shell and the leaves of Turuchula (Tragin
involucrata) plant are left to soak in it overnight. If the woman is pregnant
the leaves appear spotted. Similarly, there are ways and means of
diagnosing jaundice and other diseases.
The number of patients interviewed for the study is shown in Table 2.
According to the clients the common and frequently occurring diseases
in the study area is Balagraha, Arshithi, respiratory problem, Bavu or
Kettaddu, Noothi, Bcnnapani and spirit possession. The diseases such as
Arshithi (Allergy). Noothi. Kettaddu. and Spirit possession, are common
among females while Snake bite, Jaundice and Leucoderma diseases are
more among males. One of the practitioners reports that the malevolent
male devils chose young women and live in them as spirits. So, as long
as they live in the young woman, the woman will never conceive and
bring forth children.
The socio-economic characteristics of clients are provided in Table 2.
In our sample, there are 58 males and 42 females. Most of the clients are
living with nuclear families and
only about 42 per cent of patients
Table 2 : Number of Patients in the
Sample by Disease
are living with extended families.
Over 35 per cent of clients both
Disease Number of
among males and females are in
Patients
the age group of less than ten
Balagraha
10
years. These patients were af
Bavu or Kettaddu
19
fected with Balagraha. Bavu, and
Diabetics
5
respiratory diseases.
Asthma
4
The educational level of the
Snake Bile
8
respondents indicates that over Arshithi (Allergy)
5
one-third of the clients are illiter Noothi (Type of Wound)
8
ates and another one- third of the
Bone Setting
2
patients have studied upto higher Scorpion Bite
2
Abortion
4
primary ic., upto 7th standard.
5
The people with college educa Contraception
5
tion who had taken medicines Jaundice
Leucoderma
4
from traditional practitioners for
5
their ailments is about 10 percent. Spirit Possession
Bcnnapani (Wound in the Back) 5
The clients belong lo different
Other discascs(minor ailments) 10
caste groups and majority of them
RJH
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1998
195
REVIEW OF LABOUR
May 30, 1998
Public Action, Social Security and
Unorganised Sector
Ramesh C Datta
Social Security for Unorganised Sector
Renana Jhabvala
Industrial Restructuring: Workers in Plastic
Processing Industry
Nandita Shah
Nandita Gandhi
Who Is Responsible for Maternity Benefit:
State, Capital or Husband?
Bombay Assembly Debates
on Maternity Benefit Bill, 1929
Impact of Liberalisation on Labour Market
in India: What Do Facts from NSSO’s
50th Round Show?
Economic Reforms and Labour
Amrita Chhachhi
Sudha Deshpande
Lalit Deshpande
Shubhashis Gangopadhyay
Wilima Wadhwa
For copies write to
Circulation Manager
Economic and Political Weekly
Hitkari House, 284,
Shahid Bhagatsingh Road,
Mumbai 400 001
196
RJH
(New Series)
Vol 111:3
1998
are from weaker sections. Most of the respondents are casual agricul
tural labourers. They own very meager land and are in lower income
brackets. We are not sure, whether people belonging to only weaker
sections lake treatment for their ailments from traditional practitioners
because of their lower income or whether such diseases arc common
only among weaker sections. As we observed during the fieldwork
many of the clients, irrespective of caste groups initially went to allopa
thic practitioners for treatment of their ailments. When they did not
get relief from allopathic doctors they shifted to the indigenous practi
tioners.
An attempt has been made to gather information regarding the distance
from clients’ villages to primary health center where modern health
facilities are available. Most of the respondents report that when there is
health problem one has to walk on an average 5-6 kms to get modern
health facilities from their villages. On the other hand, they get traditional
medicines within their village or within 1 km. of their settlements.
Another interesting aspect here is the non-availability of doctor and also
proper medicines for specific diseases in the primary health centers. For
example, according to them,when people bitten by snakes go to PHCs,the
doctor usually send them away on the plea that the PHC is not provided
with anti-venom drug. Therefore, people resort to the traditional medi
cines which are available easily.
A majority of the clients expressed that they go to indigenous practi
tioners mainly because the practitioners are native men, medicines are
cheaper, easily available and the treatment strategies are much better than
the modern method. The traditional therapy is always family based
process like food habits, home remedies, rituals etc. Where as in allopathic
systems these things are absent. Most of the clients believed that diseases
like balagraha, bavu and spirit possession cannot be cured by the modem
method. The only remedy is performing rituals.
In recent years, the herbal therapy has emerged as an alternative
system of medicine in the country, particularly in the rural areas. It is
observed that nearly 80 percent of people in rural areas rely on traditional
medicines for their health care needs [Akerele 1993]. Taylor (1976)
has estimated that the organised health services in india provide only
about 10 percent of the medical care and the remaining is split between
home remedies and indigenous practitioners. Similarly, Bannerman
(1982) points out that traditional medicine still remains the only source
of care for majority of people in villages. This is because, traditional
medicines are easily available and practitioners are more accessible
to patients. For instance, when a snake-bitten person goes to PHC
for treatment, generally, the doctor may not be on duty all the time
and the anti-venom drug will not be available at the PHC. Thus, in
the absence of medical doctor and the non-availability of required
RJH
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medicines for specific diseases in PHCs one has to opt for indigenous
medicines which are available on time.
Various reasons have been at
Table 3: Socio-Economic
tributed for the people to use in
Characteristics of Clients
digenous medicines such as
Characteristics Number of
nearness, familiarity, accessibi
Patients
lity of medicines, belief and the
Sex: Male
58
healers are local people. If the
Female
42
local person treating the disease
Type of Family
the response is evoked better.
Nuclear Family
66
People in general, had a feeling
Extended Family
34
of affection and respect towards
Age Groups (in completed years)
the practitioners because those
<5 Years
18
healers had always tried to help
5-10 Years
16
them. And for similar reasons,
11-20 Years
12
even if a failure is encountered
21-30 Years
15
31-40 Years
26
by a practitioner, the pool of his
41+ Years
13
patients, nevertheless, remains
Education
unaltered.
Illiterates
36
The non-existence of modern
Primary (1-4 Standard)
18
medicine for certain type of dis
Middle (5-7 Standard)
19
eases is another reason for the
Higher Secondary
people to use indigenous medi
(8-10 Standard)
16
cines.
For example, there is no
PUC
8
allopathic treatment is available
College
3
for bavu, bennapani, and
Caste Groups
Lingayat
6
balagraha disease and it may also
Brahmin
4
be difficult for the allopathic prac
Vokkaliga
7
titioners todiagnose such diseases.
Kuruba
9
In the absence of modern medi
Banjara
10
cines whenever such diseases are
Golla
8
attacked people approach indig
Holcya
16
enous
practitioners who in turn
Madiga
22
perform rituals and prescribe some
Bovi
18
herbal medicines.
Annual Household
According to Bannerman
Income (In Rs)
(1982), the disease and treatment,
<3,000
26
3,001-5.000
28
particularly in the rural areas, can
5.001-10,000
37
not be understood in isolation.
10,000+
9
Health and treatment are very
Distance
much connected with the envi
5.4 Km
Average Distance to PHC.
ronment. The traditional health
Average Distance to
care system and treatment are
Traditional Practitioners
0.8 Km
based on their deep observation
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and understanding of nature and environment. The knowledge of many
medicinal plants has often been derived by observing their use by other
animals. Further, he points out that traditional medicine still remains
the only source of care for many people in the villages, and for them
primary health care is synonymous with traditional medicine. Zhang
(1994) reports that over two-thirds of births in the world arc delivered
by local or traditional midwives or birth attendants. In rural areas tradi
tional birth attendants are the only source of assistance and care, and
deliver over 90 percent of the births. Further, he slates that “the work
force represented by tradilional/practitioners and traditional birth atten
dants is a potentially important resource for the delivery of primary
health care. In many developing countries, medical doctors are few
compared to traditional practitioners. In Ghana, for example, the medical
doctor/lolal population ratio is 1:20000 compared to the traditional
practitioners/loial population ratio of 1:200, in Swizlerland it is 1:10000
compared to the traditional praclitioners/total population ratio of 1:100”
[Zhang 1994]. Medicinal plants and herbs arc of great importance to the
individuals and communities and are widely used in various traditional
remedies.
Il is interesting to note that when both traditional and modern health
facilities are available people often prefers traditional medicines. This
is because, people believed that indigenous medicines have greater
effectiveness in curing certain diseases such as jaundice, skin afflictions,
bone setting, asthma, arthritis, diabetics etc. The treatment given for
these diseases by the traditional healers generally do not cost much as
they make use of locally available herbs. Whereas in allopathic system
the medicines arc not only expensive but also causes side effects.
Interestingly, a study conducted in north India tends to support this
view. For instance, in treating eczema and other chronic skin diseases
herbal therapy has produced quite encouraging results than allopathic
medicines [Chavundaka 1986]. Similarly, in the present study, there
were 3 diabetic patients taking allopathic medicines for fasting blood
sugar for two years. When they did not gel relief from the allopathic
medicines, started using indigenous medicine for treatment of their
ailment. After taking traditional medicines their fasting blood sugar
came down and they became normal after 11 weeks of continuous
treatment.
Most of the users of indigenous medicines are landless labourers, rural
artisans, casual agricultural labourers and weaker sections. Some own
very meager land and are in lower income brackets. Majority of the users
lake treatment from traditional practitioners for snake-bile, skin diseases,
mental ailments and children diseases. The women folk go to traditional
practitioners for their gynecological problems as they would like to keep
the event a secret among themselves.
RJH
(New Series)
Vol III: 3
1998
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Conclusion
Despite the expansion of modern health care, there is no indication that
traditional systems are losing their influence. According to WHO estimates
there are about five lakh practitioners of traditional medicine in India and their
qualifications range from university degrees to skill and knowledge acquired
after several years of apprenticeship with established practitioners. The
indigenous system of medicine is practised by a large number of hereditary
practitioners. The techniques of the indigenous system vary according to the
style and practice of the healer and may include meditation and relaxation. For
instance, yoga practice is said to be helpful in counteracting tension and
stresses of modem life and in treating mental disorders and nervous system.
The practitioner claims that yoga exercises and other practices prevent the
occurrence of disease or relieve the body of symptoms.
The traditional practitioners have never had formal training. The kind
of training that is pursued by the traditional healers to pass on their powers
is informal ie. by word of mouth. The diagnosis of the disease is based on
the physical examination and symptoms of the disease, practitioners treat
more than one disease and prescribe only indigenous medicines. Their
indigenous medicines are mostly hereditary formulae prepared from
herbs, powders, minerals and products of animal origin. The users of the
indigenous medicines are mostly weaker sections.
Indigenous medicines had made a significant contribution to the
medical care of the people. Because, the traditional therapy is always
family based process like food habits, home remedies, rituals etc. When
both traditional and modern health facilities are available villagers often
accept traditional medicine. The reason behind this is the dependence on
and confidence in traditional medicinemen which are often responsible for
the non-acceptance of modern medicine. The traditional approach estab
lishes faith and assurance in the patients,while modern medicine lacks this.
Further, the traditional practitioners share the common cultural beliefs and
practices of the patients, so that naturally they have more faith in them.
R Muthurayappa
Population Research Centre
Institute for Social and Economic Change
Nagarbhavi, Bangalore 560 072
Note to Contributors
We invite contributions to the RJH. Original research articles, perspectives.
field experiences, critiques of policies and programmes in health care, medi
cine and allied areas are welcome. Please send manuscripts, preferably typed
in doublespace, if the material is on a word processor, please send us a hard
copy along with the matter on a diskette preferably in WS4. Address all
communications to the editor at the address on the inside front cover.
RJH
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201
Appendix: Indigenous Health Care System in Karnataka
Name of the
Disease
Local Name of the
Plants/Leavcs/Roots
To confirm
Turuchula gida
Treatment
Collect patient’s urine in a pregnancy
cocunut shell, pul Tragia involuerta
leaves, and soak it overnight. If the
woman is pregnant the leaves appear
spotted.
To find out if foetus
Apply cow’s butter to the abdomen of
in the womb is alive
the woman in question. If the child is
alive the butter will melt. Otherwise
child is presumed to have died.
To deliver the dead Shivani gida
Take bark of white teak (Gurelina
foetus
arborea), grind and mix it with hot
water. To be taken internally as a single
dose.
All kinds of head
Gajjuga Kayi
Dried ginger.peppcr, inner pulp
aches
Yakkada gida
of Indian Felbcrt (Cacsslpinia
bonducella) grind and mixed with the
milk of giant swallow wort (Calatropis
gigantca) apply and inhale the smoke.
For Vomiting and
Engu
Asafoctida and mixed with lemon
nausea fruits make it juice and suck the
juice every morning for 3 days.
All kinds of fever
Tulasi
Leaves of Sacred basil (Ocinun
Bele Tumbe
Sanctum) lenchus cepholotes Howers,
grind them and mixed with garlic and
pepper powder - lake every morning
for 3 days.
Dog bile
Khachi gida
Juice of black night shade (Solanum
nigrum) leaves (well grown plant) take
internally twice a day for 3 days.
Asthma
1) The smell of a mangoose supposed to
cure Asthma.
Thonde Balli
2) Ivy gourd (Coccina Cordi- folia)
garlic and pepper powder mixed and
grind it. boil with the breast milk, lake
internally for one month.
Moorele Honne 3) Desmodium adscenden, CymboMajjigc hullupogon Cilratus - Grind
them and boiled together. Take
internally as and when required.
Muthugada Beeja Inner pulp of the seeds of Flame of the
For Worms in the
forest (Butemonospcrma) rubbed with
Stomach
lemon juice on the stomach and also
take internally.
202
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Appendix
Name of the
Disease
Diabetics
Snake Bile
Abortion
Leucodcrma
Jaundice
Bavu or Kettaddu
RJH
Local Name of the
Plants/Leaves/Roots
Treatment
Cymbopogon citratus - ten leaves boiled
with water, take internally one tea cup
full for 3 months.
1) Aristolochia Indica, Adathoda
Eswari bccru
Adumuttada
Vasica - Grind and make it juice give
internally. Snake poison will come out.
Soppu
Lakkigida
2) Vitex Nigundo, Clitoria tematea.
Shankada Oovu grind make it paste and take internally
as a single dose (For Cobra snake).
3) Indian Madder (Rubia Cordiboria)
Siragatti gida
grind and make it paste, lake internally
for five days (all other poisonous snakes).
Bitter gourds, Croton polyandrum.
Japalada gida
Piper longum treacle, garden radish.
Pippili gida
Euphorpia neiifolia - Grind them and
Ycle Kalli
make it paste. This paste made into sticks.
The stick if inserted into vaginal canal,
induce the menstrual flow. Coniraception
Thungeshasi The milkofgianl swallow
Wort Yakkadagida (Calolropix gigantia)
menthis leaves, roots of white yam
(dioscorea alata) mixed together with
turmeric powder and made into a paste.
After deli very lake internally for 90 days.
The dried leaves of white giant
Yakkada yele
swallow wort (Calolropix gigantia)
grind with curd and made into a paste.
The paste should apply on the affected
parts of lhe skin.
1) Phyllanihus cmbilica. sacred basil.
Kircnclc
leaves of Kcmpuganike (
)Krishna Tulasi
Grind and made into paste. The paste
Kcmpuganike
should take internally for five days
(For Yellow Jaundice).
2) Circuma longa, Phyllanihus
Arishina,
emblica, Chebulic Myrobalans,
Kirinele Soppu
Terminalia Belcrica - Grind and made
Checbce gida
into a paste. The paste should lake
Bhahira gida
internally for five days. (For Oodu
Kamale and Ona Kamale).
Aristolochia Indica, Withania
Eswari beru
Eremaddina Beru Somnifera. Kcmpuganike leaves,
Kcmpukanike
Haridala - Grind them with cow
Soppu
butter and made into paste. Apply this
Haridala
paste on swollen part for seven days.
Majjigc hullu
(New Series)
Vol 111: 3
1998
203
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RJH
(New Series)
Vol 111:3
1998
Issues in
MEDICAL ETHICS
A quarterly journal owned and published by the Forum for Medical
Ethics Soceity, a non-profit organisation, a collective promoting
ethical values in health care.
Provides a platform for discussion on all aspects of our system
for ensuring health and treating illness or disease, with special
reference to ethical principles.
Features original essays reflecting different points of view, suggested
guidelines, boook reviews, reports of meetings, ethical cods adopted
by different cultures and organisations.
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Issues in Medical Ethics
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To believe that one particular conception of
the world, and of life generally, in itself
possesses a superior predictive capacity is a
crudely fatous and superficial error.
Certainly a conception of the world is
implicit in every prediction, and therefore
whether the latter is a random series of
arbitrary notions or a rigorous and coherent
vision is not without its importance; but it
precisely acquires that importance in the
living brain of the individual who makes the
prediction, and who by the strength of his
will makes it come true... When a particular
programme has to be realised, it is only the
existence of somebody to ‘predict’ it which
will ensure that it deals with what is
essential — with those elements which,
being ‘organisable' and susceptible of being
directed or deflected, are in reality alone
predictable.
Antonio Gramsci
Selections from the Prison Notebooks
Orient Longman
To believe that one particular conception of
the world, and of life generally, in itself
possesses a superior predictive capacity is a
crudely fatous and superficial error.
Certainly a conception of the world is
implicit in every prediction, and therefore
whether the latter is a random series of
arbitrary notions or a rigorous and coherent
vision is not without its importance; but it
precisely acquires that importance in the
living brain of the individual who makes the
prediction, and who by the strength of his
will makes it come true... When a particular
programme has to be realised, it is only the
existence of somebody to ‘predict’ it which
will ensure that it deals with what is
essential — with those elements which,
being ‘organisable' and susceptible of being
directed or deflected, are in reality alone
predictable.
Antonio Gramsci
Selections from the Prison Notebooks
Orient Longman
Position: 2628 (2 views)