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AUGUST
AiraHanes
1980
Rental] Meallth Care
R. Srinivasa Murthy and N, N. Wig
Department of Psychiatry,
P. G. I. M. E. R.
• In the developing countries, trained mental health
professionals are very scarce indeed-often they
number less than one per million of the population.
Clearly, if basic health care is to be brought within
reach of the mass of the population, this will have
to be done by non-specialised health workers-at all
levels, from the primary health worker to the nurse or
doctor-working in collaboration with, and supported
by more specialised personnel. This will require
changes in the roles and training of both general
health workers and mental health professionals ’ (1)
During the last two decades, there has been a
major shift in emphasis for the provision of medical
care. This refers to the increasing importance of
paraprofessionals in all types of health activities.
This has been the outcome of a desire to provide
f some care for everybody rather than everything for
some. ’ The chief implications of this change have
been, (i) deprofessionalisation of the many health
functions, ( ii ) decentralisation of services and
(iii) the emphasis on ‘ priority conditions ’ and
• priority problems ' for action The last aspect is of
great relevance as overloading the peripherally placed
health worker would be counterproductive. The
present paper deals with the need and scope for the
provision of basic mental health care to the rural
population through the existing health staff.
Traditionally the care of the mentally ill persons
has been thought to be a luxury and only the need
of the affluent populations. Besides it has been con
sidered complex and expensive ! If this were to be too
true, the inclusion of mental health skills and princi
ples for the multipurpose workers ( MPW ) will not
be appropriate. However, the presently available in
formation about the prevalence of mental disorders
and the disability caused by them call for a reapprai
sal of the above stand. In any community, it can be
expected that 2-3 % of the population is suffering
from severe neuropsychiatric problems (psychosis,
epilepsy and mental retardation) and comprise about
a third of those disabled due to various reasons.
Besides, recent advances in the field of psychopharma
cology have provided specific treatments for many
of the serious disorders within reach of everyone.
There is convincing evidence that appropriate drug
thetapy provides one of the most powerful means
available for the treatment and control of a number of
neuropsychiatric disorders of public health importance
such as schizophrenia, the affective disorders and
epilepsy (2) In terms of prevalence, severity, ( disability
to the individual and the family and community ) and
the amenability to therapy, severe mental disorders
qualify to be one of the important public health
problems.
ROLE OF AUXILIARIES
The MPWs and other health staff become very
important in the provision of mental health care to
the rural population for more than one reason. Firstly,
most psychiatric services are situated in urban areas
and out of reach of those in the villages. The MPW,
who is often the only source of help is closest to the
community and available at all times. In addition, he
’t. Marks
- 560 001
Chandigarh
(2)
is already carrying out specific treatments of conditi
ons like malaria. Secondly, the presently available
number of psychiatrists (about one per million), and
other mental health professionals like psychologists
and social workers is grossly insufficient. They are
very inadequate to provide the services and the
numbers will be un'ikely to be sufficient even in the
next fifty years, with the present facilities fortraining.
In this situation, ihe MPW and the other health staff
in the field have to become intermediaries between
the specialist and the community. Thirdly, the presen
tly existing beliefs about mental disorders ( mostly
related to religious and supernatural explanations )
prevent the utilization of even the existing services. In
this paradoxical situation of limited facilities and poor
utilisation, the
auxiliary placed close to the
community is best suited to alter their beliefs and
practices. Fourthly, treatment of conditions like
epilepsy call for continued use of drugs on long-term
basis. Patients discontinue the treatment due to pro
blems of transport and finances. This can be overcome
to a significant extent by the auxiliary becoming the
source of drugs and supervision. This type of care
has been shown to be successful in the domiciilary
treatment programme of tuberculosis. From the above
brief considerations, it can be visualised how it is not
only important to include the mental health skills in
the routine functions of the health staff, but also
advantageous in terms of the benefits to the indivi
dual and the community.
TASKS FOR THE AUXILIARIES
The tasks are shared in a step-wise manner with
inereasing differentiation and complexity for the more
trained personnel. For example, the simplest task of
recognising someone as having ‘ altered behaviour ’
will be easy for the most peripherally placed person
who can guide them to the available treatment agen
cies, or provide immediate help with one of the drugs.
The approach, as is clear, is to utilise the present
health staff to provide basic mental health servicesThe specific disease entities that will form the
* priority conditions ’ will be acute psychoses (excit.
ements and retardation), chronic psychoses, epilepsy,
mental retardation and depression. The. MPW can be
envisaged to care for the epileptics and acute psycho
tic conditions, as also those with other psychoses.
For exampie, in about 8000 population, there will be
about 50 persons suffering from epilepsy and 30-50
will have psychosis. These two groups can be treated
effectively with two drugs-namely phenobarbitone
and chlorpromazine Thete will be need for one other
drug, Imipramine hydrochloride for the treatment of
depression. Thus with three simple drugs, a large
majority of those with severe neuropsychiatric diso
rders can be provided the needed help.
Following the decision about the priority conditi
ons, the tasks to be performed can be formulated.
Training has to be carried out both in the recognition
of the mental disorders and the use of the drugs. It
has to be in the form of initial lectures, demonstrat
ions, followed by support and guidance in the field in
their day to day work. As the skills taught will be
put to use in the routine work (there will be sufficient
number of ill persons at any one time ) it can be
envisaged that what is taught is not forgotten Ano
ther important aspect of the training of MPWs for
mental health care will be the need for exposure and
strengthening of the knowledge of the other health
staff, like doctors, who will form the day to day
support to the health workers. Thus it will be seen
that the effort would be to build up a step-wise task
distribution with in-built referral system.
The practicability of the suggested plan namely, the
integration of the mental health care with general
health services needs be demonstrated in practice.
However, it is to be noted that the Chinese bare-foot
doctors are routinely using the drugs suggested in the
plan in their day to day work-Chlorpromazine tab
lets and ampoules, phenobarbitone and diazepam.
(3) In Zambia, a category of medical workers called
medical assistants have been providing a nationwide
network of mental health services. (4)
CONCLUSIONS :
The planning of all health setvices from the grass
roots is a very novel approach with many challenges
and frustrations. It calls for the cooperation and
coordination of a wide variety ot professionals so
that meaningful programmes emerge to provide ser
vices for those living in rural communities In this
brief communication, we have highlighted the sccpe
for the organization of basic mental health services at
the level of multipurpose workers and the other exis
ting health staff.
REFERENCES :
1.
World Health Organization (1975) Organization
of Mental Health services in Developing coun
tries. Sixteenth Report of the WHO Expert
Committee on Mental Health. Technical Report
Service 564. Geneva. Switzerland.
2.
Harding, T. W. and Chrusciel, T.L ( 1975 )
Bull. WHO 52:359.
3.
Sidel, V. W. (1972) Medicine and public health
in the People’s Republic of China. Ed. Quinn.
J R 1977. DHEW Publication No ( NIH )
72-67.
4. Kapusa. ( 1972 ) Personal communication.
(3)
the attitude of society and the psychiatrist towards madness
Most people seem to take a mad person for
granted.
Accompanied by a joke or two about his crazy
behaviour, the general impression is that he has a
screw loose ' somewhere. Few people realise that
no individual behaves in such a way without a reason.
Fewer still understand that ‘ going mad ’ is not instan
taneous but the result of a process which has been
going on for a long time. It is only when the person
is unable to live with this process anymore that he
breaks down and gives himself up to the fantasies of
his mind.
For a person confronted with emotional break
down, what are the alternatives that present them
selves ? Rather, what is likely to be done with him
by the people he lives with ? This largely depends on
the economic status and cultural practices followed in
the community. In our communities the tendency is
either to diagnose the crazy person as being possessed
by a devil ( and various religious and supernatural
methods are employed to extract this devil ) or a
person who is ' plain mad, * is left to his own devices
which invariably means emotional and economic
deterioration.
It is only in the urban areas that the alternative of
the mental hospital presents.
This article deals with how psychiatry looks at the
phenomenon of madness and tries to show that
instead of being liberating for the individual, it is
actually an agent of suppression. One look at any
mental hospital will reveal the bizzare and inhuman
results that modern medicine has effected upon people.
Patients stare at you blankly, each one with his own
stormy history. There is little personal association
between the staff and patients, only a cold, neutral,
suspicious wall. In fact there is a lurking fear in
many doctors and nurses that too close an associat
ion with patients may result in they themselves going
mad and funnily enough this is a standard joke about
Psychiatrists.
How does a psychiatrist elicit a history, diagnose
and treat someone with abnormal behaviour? Largely
from the symptoms. Taking a common example,
when a person exhibits disturbed behaviour, it is
usually a member of the family who brings the person
to the psychiatrist stating that she/he is behaving
oddly. After a brief interview which consists more of
asking about what the patient has been doing rather
than how and why he is doing so, the psychiatrist
arrives at one or other of the following conclusions :
either a psychosis (where the person is out of touch
with reality ) or a neurosis ( in touch with reality ).
Little emphasis is placed on the existential situa
tion in which the person breaks down. At best it is
mentioned as a precipitating cause of his illness. No
attempt is made to go into the details of his family
back-ground, of the relationships of the various
family members with one another and the family unit
as a whole. No enquiry is made whether the person's
moods of sadness, anger, frustrations, despair are a
product of his interaction with the family. No attempt
is made to increase the understanding and awareness
of the patient and certainly no encouragement is given
to him to act on his genuine feelings and desires and
thereby attempt a solution to his problems. In short,
instead of trying to view the patient’s problems,
the patient himself is considered a problem.
That personal change is very necessary for the patient
is over-looked by the psychiatrist, who through his
technical understanding of the disturbed behaviour,
views the patient as ‘ one in whom madness resides. ’
The commonest diagnosis arrived at is schizophrenia,
or ‘ split personality.’ Could we not view this condition
as the adoption of false roles by people whose true
roles have not been allowed to develop or have been
consistently rejected by the people around them ? If
we view it in this manner, we begin to perceive the
relationship between the individual’s madness and
society. If an individual’s sense of reality and experi
ence (consciousness) is negated by the people around
him (usually the family which unconsciously mirrors
social values) then his consciousness becomes ‘unreal’
in contrast to the ‘ real ' consciousness of the others.
The latter have been powerful enough to impose their
consciousness upon the former. Disturbed behaviour
exhibited by the individual is a response re-action to
his isolation and alienation. Drug addiction is another
manifestation of his isolation, where the drug is used
as an escape mechanism. In the power equation bet
ween the two sides ‘ reality and unreality, ’ the
psychiatrist invariably acts on the side of ' reality. ’
(4)
The central theme running through academic psy
chiatry is that there is something inherently wrong
with the person that causes him to feel and behave in
an abnormal way. In other words, a person is either
born or destined (genetically, bio-chemically etc. )to
become mad at some stage of his life. This is some
what analogous to the Hindu theory of Karma. Tran
slating Karma into psychiatry ! * it is impossible to
escape from the cycle of one's own genes and amino
acids since they have been pre-determined. ’ This sort
of pre-judgement of human behaviour makes it easier
for the psychiatrist to rationalise his suppressive
therapy on the person who has broken down, and
also later explains away the relapses which occur.
What evidence exists to prove that schizophrenia is
determined genetically or biochemically ? As yet
there is no conclusive evidence. Every few years a
‘ revolutionary ’ break-through is announced that
some chemical or other is responsible for the abnor
mal states experienced. Such discoveries usually end
up being disproved. For example, when a chemical
cousin of LSD was discoverd in the brain it was
hypothesized that its fluctuation was responsible for
hallucinatory mental states. This theory was popular
until it was shown that this fluctuation occured in
normal people too.
That disturbed behaviour does seem to run in
certain families is true and this is probably responsi
ble for generating the notion that schizophrenia is
hereditary. Recent work on genetic transmission of
schizophrenia has thrown doubt on this notion. On
the other hand, it is increasingly being recognised
that certain patterns of family interaction can be
disturbing and thus generate disturbed behaviour. It
is important to take note of this since it can afford a
key to this much mystified (disease. By placing the
disturbed behaviour of the individual in the context
of his family, it is possible to study the emotional
dynamics and situations which produce such bizzarre
behaviour, which when seen alone seems utterly
{□comprehensive.
A mad person is oppressed by his situation and
his madness is a result of and reaction to his being
unable to live any more with this oppression. In a
bid to free himseif from this oppression he perpetrates
an exploding violence upon others or an imploding
(Cont, on page 7)
EDITORIAL
Many people think that psychosis is a problem of
the West-that the stress of living in a competative,
industrialised society, with its materialistic outlook,
brings about various tensions and emotional problems.
Some people go to the extent of saying that our rural
people do not have such stress in their life and there
fore are less prone to disorders like hypertension and
emotional disturbances ! This was the line of thinking
of clinicians and even psychiatrists at a seminar on
" Stress " held in Varanasi in 1977. Some even feel
that Indians are very spiritual and philosophical and
know how to maintain the mental equilibrum 1 Such
thinking, apart from various other considerations, has
not allowed psychiatry to be given its due place in
our medical and health set up.
Oppression,— physical, mental, economical, social
and political is a strong cause for psycholgical distur
bances. Women being the more oppressed, they are
subject to more of these disorders. In our set-up,
where even minor physical disorders do not get proper
attention, psychiatric patients have no access to proper
care and cure. To some extent, temples and godmen
replace the psychiatrist. Then there are the exorcists.
To top it all is the oppurtunity to pretend, or even
truly believe, that some spirit or god has taken possess
ion of the person. This gives the person an occassion to
completely let loose his/her inhibitions-itisthe Couch.
In this issue we present two view points in this
field. Srinivasa Murthy tries to argue that the CHW
can be trained to recognise and treat at least some
common neurospsychiatric problems. Dhara is concer
ned with the neglect of the patient, the poor quality
of care and most important, the wrong approach to
treatment. He discusses the causes of the problem in
our society. The third article (to be published in the
next issue) is about psychiatry in the United States.
A feminist group challenges the attitude of psjchiatrists towards female mental patients and tries to show
how psychiatrists and mental institutions oppress the
patient further rather than help relieve the primary
oppression.
There is a great need to improve psychiatric care
in our country. But, we should not blindly pattern
it on Western lines. Let us first try to understand the
cause and not just treat symptoms. We are neither
yogis nor saints A large majority of the people are
oppressed economically, politically and socially.
Every psychiatrist, would be psychiatrist and clinician
must be awave of this to understand his/her patients
and their problems.
Kamala Jayarao
(5)
IN SEARCH OF APPROPRIATE MEDICINE-1
COUGH MIXTURES
Cough sedatives and expectorant mixtures are
probably the most commonly prescribed preparations
along with tonics, and the sale of these forms the
butter on the bread of quite a few pharmaceutical
firms This study was prompted by our need for a
cheap and effective anti-tussive.
Indications for cough suppressants
Cough is a protective reflex which helps to expel
irritant matter from the respiratory tract. Indiscrimi
nate arrest of cough is not desirable. If the cough is
due to the centre being too hypersensitive to reflex
irritation from the upper respi-ratory tract ( larynx
and above ) and where cough is of unproductive
nature central depressants like opiates are indicated.
In children sedation at night is more effective.
sting to find that a pure cough expectorant is not
cheaper than a pure cough sedative or cough sedative
expectorant mixture. It is also interesting to find that
the cough mixtures available in bulk ( 5 litre Jar )
are only cough expectorants and these are the pre
parations dispensed by a private practitioner as a
cough remedy in all cases of cough irrespective of
their site of irritation ( even if the site is above
glottis )
2)
The average daily cost of taking a cough
remedy is :
Cough sedative-expectorant - 1.50 to 2.25 Rs./day
(40 ml syrup)
Pure cough sedative
- about 1.10 Rs./day
Pure cough expectorant
- 1.25 to 2.25 Rs./day
(40 ml. syrup)
Utility of cough expectorants
Expectorants are used in the treatment of cough
due to irritation of the respiratory mucosa below the
epiglottis and respiratory conditions in which the
secretion is thick and viscid needing liquifaction.
Commonly used expectorants ( Ammonium chloride,
iodide, Ipecacunha, are supposed to stimulate out
put of respiratory tract fluid reflexly through irrita
tion of gastric mucosa. For this, simple steam inhal
ation is a much better, effective and reliable therapy.
It must be remembered that except for dextrome
thorphan and codeine ( centrally-acting cough
suppressants ) experimental proof of effectivity of
other drugs used in cough mixtures is totally lacking
and the rationale for their use can be debated.
With these facts in mind, we evaluated most of
the cough mixtures available in the market today and
found out some interesting facts.
1)
Most of the proprietary preparations available
as cough remedies generally contain a central cough
suppressant, an expectorant, an antihistaminic and a
brochodilator in pleasantly flavoured syrupy base.
Combining the therapeutically incompatible cough
suppressants and expectorants cannot be justified
except for the fact that it enables the pharmacy to
sale their product with a good margin of profit
(cough sedative is costly due to condeine content),
when sold in market as a cough remedy. It is intere
Note:- The cost of cough mixtures with same in
- gredients varies as much as 50%.
3) Many available commercial preparations con
tain drugs in either quite inadequate or excessive
doses and some of them contain drugs which are out
dated and no longer recommended.
These observations prompted us to evolve a sedative
mixture and an expectorant mixture containing only
the required drugs in adequate dose in a palatable
base and which would be reasonably priced. As we
have no access to the required drugs in their powder
form which are available only in bulk, we arrived at
approximate cost by using tablets available in the
market, so that cost computed by us is necessarily
higher than it would be for the drug companies who
buy the drugs in bulk in their poder form. Still a
difference can be made out between the market price
of commercial preparations and the cost of the
mixtures as prepared by us using tablets bought in
retail.
How to prepare cough mixture t
1) Cough sedative
i)
Crush and make'into powder
a) 10 tablets of codeine phosphate
(100 ml.)
+
(10 mg.-6 paise each)
b) 5 tablets of ephedrine
HC1
(30 mg.-1.5 paise each)
+
c) 5 tablets of chlorpheneramine
maleate (4 mg- 2 paise each)
ii)
Dissolve the powder in warm water and filter
iii)
Dissolve 6
heaped teaspoonsful of sugar
( 66 gms. 20 paise )
in J cup of boiling water and add 1 drop of
pineapple flavour.
iv)
Add 0.5 gm (flat teaspoonful) of Na benzoate
as preservative to the filtrate and mix well with
sugar solution to make it 100 cc. total.
( 1 teaspoonful flat = 2.2 gms.)
Dose : 10 ml/6 hrly for adult
these drugs act by their silogogue action. Their easy
availability, low cost and effectivity are distinct
advantages to advocate them in place of lozenges.
There must be other drugs of similar kind in others ’
experience which need to be brought up and scientifically analysed. May I request our colleagues who are
more wise than me in this field of indigenous drugs
to come forward and add to our knowledge ?
Sanjiv Chugh
Sevagram
( Those who are interested in a detailed article
may write to Dr. U. N. Jajoo, Deptt. of Medicine,
Medical College, Sevagram, Wardha, Maharashtra)
5 ml/ 6 hrly for children
Cost
2)
55 paise per day.
DEAR FRIEND—
Cough Expectorant (100ml. )
i ) Crush and make into powder.
a) 5 tablets of chlorpheniramine
(4 mg.-2 paise each )
maleate
b)
5 tablets of ephedrine HC1
1.5 paise each )
( 30 mg-
c)
less than one flat teaspoonful of ammonium
chloride ( 3 gms-3 paise)
( 1 TSF flat=4 gms )
ii ) Dissolve in hot water and filter.
iii) Dissolve 6 heaped teaspoonful of sugar
(60 gms-20 paise) in | cup of boiling water to
which 2 drops of pineapple flavour are to be
added.
iv ) Add 500 mg ( J teaspoonful flat ) of Na
benzoate as preservative to the filtrate and
mix it with sugar solution to make 100 cc
Dose ; 10 ml/6 hrly/day adult
Cost : 16 paise per day.
Remember Na benzoate is added to avoid fungus
overgrowth. Those who wish to utilse the drug within
48 hours, need not add the preservative. Pleare preserve in clean container to avoid fungus overgrowth.
What can you contribute
We all know our grand mothers asking us to keep
HARADA ( Sour taste ) and Jesthamadh ( Sweet
taste ) beneath tongue for suppressing irritative use
less cough. We all have seen it working well. Probably
I was happy to read “ Ban on Tetracycline Liquid
Form ” (May-June 1980). Few more points can be
stressed about abuse of drugs.
It is observed that several drugs are used without
any rationale concerning their dose and mode of
administration. Some of these, apart from tetra
cyclines, are—Vitamins, Steroids and improper
combinations of drugs.
Vitamins, especially the Forta preparations are
used indiscriminately. Every one knows it as an econo
mic waste but still even consultants and specialists(?)
prescribe it mechanically.
Steroids are very commonly used, though they
should not be. Nowadays they are even used as
antipyretics I
Many drug companies combine al) drugs used for a
specific disease, eg., arthritis, amoebiasis etc., in
subclinical doses. Practitioners should avoid such
combinations, preparations.
A doctor should have consideration for the patient
but it is well known that majority practice for
money. The patient suffers not only economically but
also physically.
It needs man power and interested people to
provide public education in this matter. If the
Government and medical associations take proper
steps, this can be done.
Can MFC take an
enthusiastic part in such a movement ?
SUBHASH SURANA
Jeur (Sholapur)
(7)
( Cont, from page 4 )
violence upon himself. In the former case, he will be
branded by psychiatrists as a homicidal maniac and
in the latter a suicidal depressive, we also begin to
see why women are doubly oppressed. Society,
operating through the family, places many more res
trictions and constraints upon women than men, thus
oppressing them both socially and sexually.
Standard froms of psychiatric therapy are directed
towards suppression of symptoms and feelings. In the
main they consist of electro-shocks, tranquillizers
and surgical resection of part of the brain. Who has
the time to sit and talk to a guy who is ' nuts ’ ? A
good cure is one where the patient is ' quiet and
polite. ' Davidson’s renowned Textbook of Medicine
re-inforces this view saying that schizophrenics should
be ‘ allowed to participate inconspicuously on the
fringe of group actvities.'
Even though these suppressive measures have been
proved to cause irreversible brain damage by
destroying brain cells, therapists have not heeded these
unfortunate side effects saying that the treatment
is in the best interests of the patients. These modes of
treatment are de-humanising, de- personalising and rob
the individual of the capacity to feel and act. They
are largely carried out in mental institutions and
asylums. Consequently it is in these asylums that
we see people suffering from the most serious said
effects, vegetating away in their meanigless existence.
It is not surprising that so dehumanising a form of
scientific therapy should exist in the society in which
we live. The economic framework of society which
generates unemployment, poverty, competition turns
life into a never ending rat-race for survival. This
social insecurity reflects upon the individul through
the family, the family being the representative unit of
society. The social problem becomes an emotional
problem for the indiuidual, as he begins to view his
existence as an unwanted and rejected one by his
family and therefore by society.
Take the following situationsA child who is the victim of emotional tensions
existing between his parents who have been
forced to marry, live together and reproduce
because it is socially correct to do so. He
develops psychological problems due to the
anxieties of his formative years
A girl entrapped by the rigidities and orthodoxy
of a joint family finds that she has no control
over what to do with her life and ultimately the
only control she does have is to decide whether
to live
A man unable to find employment and feed his
family seeks refuge in the dullening effects of
alcohol and drugs in a bid to forget about the
problems he faces
An old man unable to work any more becomes
economically un-productive and a burden on the
family drifts off into senile psychosis
The competition to survive alienates man from
man and ultimately man from himself.
In this apparently hopeless situation what are the
alternatives available for people who have become
alienated to find themselves again ? It must be
emphasised that alternatives are present and must be
actively sought for by the alienated. Basically it lies
in becoming aware of the oppressive situation one is
entrapped in and acting to change the situation both
at an individual and social level. “ We must change
the world in order to change ourselves ” writes
Christopher Caudwell in his critique on psycho-ana
lysis. Groups like the Radical Therapists ( MFC
Bulletin No. 5; May-1976 ) seem to advocate and
implement this ideology in therapy which consists of
groups of patients engaging themselves in various
activities directed towards revolutionary social change
concurrent with discussion and reflection and action
upon their individual problems. R.D. Laing, the
anti-psychiatrist believes that the schizophrenic
experience is a 1 voyage ' which has to occur without
hinderance and through which the person has to be
helped and guided. This voyage comes to its natural
termination over a variable period of time and acts
as a self-healing process if allowed to occur freely.
To sum up a quotation from Laing’s ‘‘ Politics of
the Family ” :
“ Marx said : ‘ under all circumstances a Negro
has a black skin, but only under certain socio-econo
mic conditions is he a slave'. Under all circumstances
a man may get stuck, loose himself and have to turn
round and go back a long way to find himself again,
Only under certain socioeconomic circumstances will
he suffer from schizophrenia. "
Ramana Dhara
Hyderbad.
—
mfc bulletin : August 1980
RN. 27565/76
MENTAL
HEALTH
EDUCATION
INFORMATION ABOUT MENTAL RETARDATION
Persons with retardation or slowness in their
mental growth and capacities are called mentally
handicapped or mentally retarded. They are also
referred to as ' slow developers
‘ less inteligent ’
or ■ innocent. ' The following are some facts about
this condition.
LOOK AT YOUR HAND
All the fingers are not of the same size and shape.
Similarly look around you- all the persons are not
of the same height, shape or colour. We accept these
differences as part of the differences between persons.
Similar to the above physical (external) differences
there are differences in our mental abilities-that is, in
the capacity to think, learn and understand new things
and to solve probiems. This capacity is also called
' Intelligence The differences in this capacity ( or
amount of intelligence) is the basis of classifying
some persons as being mentally retarded.
It is only those persons whose ability to learn and
understand things is significantly less than others from
the same social background, who are called retarded.
A child/person who is mentally retarded has slow
motivation, poor learning capacity and experiences,
difficulties in social adjustment.
HOW COMMON IS IT ?
In every 100 population, about 3 persons belong
to this category. Of these one person will not be able
to care for himself and thus dependent on others
fully, while others will be only partially handicapped.
DEGREES OF MENTAL RETARDATION
Broadly there are three groups-mild, moderate and
severe. A person with mild retardation will be gener
ally a few years behind in learning and development
compared to those of his age but will be able to take
Editorial Committee :
anil patel,
anant phadke
abhay bang
luis barreto,
narendra mehrotra
rbhikesh maru
kamala jayarao, EDITOR
FOR
Regd, No. PNC-328
AUXILIARIES
care of himself and learn some simple trades. Mod
erately retarded persons will have only the ability to
take care of their basic needs and not engage in any
trade, though they may be able to do simple things like
cleaning, washing or packing things. Severely retar
ded persons need help for their day to day basic
needs like feeding, clothing and washing.
CAUSES OF MENTAL RETARDATION
The most frequent causes in the Indian situation
are the followingnutritional deficiencies during pregnancy,
malnutrition during the first 2 years of life,
delayed or difficult labour,
infectionsof brain and severe illness in childhood,
head injury by falling or accident,
untreated epileptic fits.
In addition, sometimes they are due to other causes
of unknown origin.
MANAGEMENT
It is most important to remember that mental
retardation is not an ' illness ’ but a disorder with
‘ limited mental capacity. ' The main emphasis of
management will be in assessing the degree of retar
dation and planning of suitable activities. to utilize
maximally the capacities present. There is no ' cure ’
in the form of drugs, shock therapy or diet to make
them normal.
The major effort will be to repeatedly and patiently
train the person to learn various things from eating,
taking care of his personal hygiene to talking and
carrying out simple tasks and trades An approach of
realistic optimism is what is necessary in the total,,
management.
R. Srinivasa Murthy
Views & opinons expressed in the bulletin are those of the authors and
not necessarily of the organisation
Annual subscription- Inland Rs. 10/- For Foreign countries by Sea
Mail 3 US $/ By Air Mail for Asia-4 US 8 Europe, Africa-7 US $, USA
Canada-9 US S.
Edited by-Kamala Jayarao, National Institute of Nutrition P.O. Jamai
Osmania, Hyderabad. 500007. Printed by- Anant Phadke at Balbodh
Mudranalaya, Pune 30. Published by- Anant Phadke for Medico Friend
Circle, 50, LIC Quarters, Pune 411016, India.
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bulletin
MAY
1981
Mow Safe 8s The Pill ?
The introduction of steroidal oral contraceptives in
1960’s for family planning has marked the beginning
of one of the biggest experiments in human history
where the experimental target is the woman rather than
a laboratory animal. Today more than 20 million
women, all over the world, use the oral pill. It is often
said that the risk of smoKing is greater than that of
using the oral contraceptives (OC) While a - lot of
scare generated by professional and lay press may be
unnecessary, such complaisance is also not justified.
A person who smokes does so out of choice for physi
cal pleasure, whereas unsuspecting women having
confidence in the judgement of the medical profession,
use OC.
Combination versus “ Progestogen only ” pill.
Hormonal contraceptives currently being used are of
three types, a) The combination type oral pills which
contain combinations of synthetic oestrogens and progestogens b) the low dose progestogen pills ( mini
pills) and c) the injectable long-acting progestogens.
The combination pill was the earliest to be introduced
and continues to be the most popular method in the
developed countries and in China. In developing coun
tries like India, daily pill taking may be problematic
and hence many physicians prefer long-acting injectables, which can be administered once a month or once
in three months. The advantages of the oral pills are,
they can be dispensed by paramedical workers and if
found to be unsuitable can be immediately discontinued.
The paper pill developed in China, is an interesting
technological innovation aimed at improving the ease
of packing and reducing the cost.
The association of some of the side effects of the
pill with oestrogen has prompted a search for “ pro-
gestogen only ” formulations. The major problem with
these is the irregular menstrual cycles. The progestogenonly formulations have not been studied as extensively
as the oral combination pills, but they do appear to be
free of some of the metabolic and clinical side effects
of combined pills. Thus the alterations in metabolism
of carbohydrate, protein, lipid, minerals and vitamins
often seen in women using OC are not observed in
those using the mini pills or the injectables-depoprovera and norethisterone enanthate. Depoprovera
however has been banned in many countries because
of its tumorogenic effects, found in dogs. According to
a recent evaluation by WHO such a ban may be un
justified since only very high doses of hormones which
are never used for contraception lead to the develop
ment of such tumours. Besides, the Beagle dog is
highly prone to develop tumours and hence is not a
good animal model.
In the combination pills the oestrogen-progestogen
combinations are given for 21 days in the cycle with a
gap of 7 days. The sequential pills in which the estro
gens were given for 15 days followed by the combinaticn of oestrogen and progestogen for 7 days have
been withdrawn due to a suspicion of endometrial
hyperplasia. (a suspected precancerous change). The
earliest OC contained 100 ug or more of synthetic
oestrogens, ethinyl estradiol or mestranol. The dose
has since been reduced without sacrificing the contra
ceptive efficacy. Now, most formulations contain 50 ug
or less of these oestrogens. Numerous synthetic pro-
Mabtab S. Batnji
National Institute of Nutrition,
Hydrabad - 7.
(2)
gestogens are used in OC. The nature and the severity
of side-effects due to the oestrogen are believed to be
modified by the type and the dose of progestogen in
the pill.
The hazards - what are the facts ?
The alleged clinical side effects of OC that have
provoked maximum reaction in medical and lay press
are: a) changes in glucose tolerance ( so called
diabetogenic effect — a misnomer ), b) cardiovascular
effects (hypertension, thromboembolism, myocardial
infarction) c) teratogenesis (chromosomal abnormali
ties and congenital malformations ), d) neoplasia
particularly liver tumours), e, impaired liver function,
f ) hypovitaminosis. A dispassionate examination of
the literature shows that except for the cardiovascular
changes and perhaps benign liver tumours (hepatomas),
the risk associated with the others is negligible.
Diabetes ■ There is only a mild deterioration in the
glucose tolerance of some women, which at the most
May be undesirable in diabetics or potential diabetics.
Many experts are of the view that OC can be used
even by diabetics provided their blood sugar can be
controlled by giving insulin or other drugs. However,
at present, use of OC by diabetics is contraindicated,
unless there is close medical supervision.
Teratogenesis t In 1967, Carr observed chromo
somal abnormalities in six of the eight abortuses
collected from women who became pregnant after
tak:ng OC and in 1974, Janerich and Piper reported a
slightly raised incidence of congenital defects in infants
born to OC users who had conceived soon after
discontinuation of OC or who continued to use OC
for some time during pregnancy. Though there are
reports to the contrary too, more studies may be
desirable particularly in India, where pregnancies in
irregular pill users can be expected to be a common
occurrence.
Cardiovascular diseases Estimates of women who
develop hypertension while using OC have ranged
from 0-25 %. The condition is reversible on disconti
nuation of OC. Though only some women may develop
frank hypertension, many more may show a slight
increase in blood pressure. There is an increased risk
of thromboembolism and myocardial infarction which
is particularly marked in women who smoke and in
elderly women. In India the incidence of smoking
among women is negligible. Also the incidence of
cardiovascular diseases among young women is lower
in Asia. If care is taken not to prescribe OC for
elderly women, the cardiovascular disease risk factor
can be avoided to a large extent. The increase in
serum lipids often observed in Western women using
OC is not seen in malnourished Indian women, parti
cularly with low dose oestrogen formulations. Recent
studies in U.K., and Sweden suggest that the incidence
of venous thromboembolism and heart disease has
been reduced significantly after the introduction of low
dose oestrogen OC.
Liver function : Though obstructive jaundice was
reported earlies, subsequent studies have failed to find
impairment in liver function.
Liver tumours : A cause and effect type of relation
ship between long term OC use and hepatocellular
adenoma has been observed. The risk increases with
age, duration of use ( more than 2 years ), potency,
family history, and in women who may have been
operated for liver/tumours earlier. For the developing
countries it is essential to find out if malnutrition and
infections increase the risk.
As of today there is no evidence to suggest an
association between combination type oral contra
ceptives and malianancy of any form.
Interaction with malnutrition, drugs and diseases :
The question of interaction of OC with malnutrition,
infections and drugs used in the treatment of infections
and diseases peculiar to developing countries is curren
tly being studied. Two types of effects can be expected.
a) Hormones may aggravate the existing state of
deficiencies and diseases, and modify the drug effect,
b ) diseases and drug use may diminish the effectiveness
of OC.
Use of OC raises the requirement for several vita
mins such as B-complex vitamins, vitamin C and per
haps even vitamin A. However, recent studies show
that where dietary deficiencies are marked, OC does
not worsen the situation. Even if it does, administra
tion of vitamins either daily, or for the 7 non—hormone
days in the cycle can prevent the deterioration and
help to improve the existing nutrition status. Con
sidering the cost of OC the additional cost for vita
mins may not be very much. The only vitamin which
has to be supplemented in unusually high amounts,
5-10 times the tecommended allowance, is vitamin B6.
( contd on page-7 )
(3)
REDIRECTING
CONTRACEPTIVE RESEARCH
By Judy Norsigian
Research Priorities
First, as you may know, contraceptive research at
present focuses heavily on hormones, drugs and inva
sive devices, such as hormone-releasing IUDs, prosta
glandins, injectable progestogens, silastic hormonal
skin implants and antipregnancy vaccines. At the same
time, there is relatively little research on safer and
cheaper mechanical and barrier methods, on contra
ceptives which act locally rather than systemically, or on
methods which require no mechanical intervention
whatsoever. Examples of such safer methods include the
cervical cap, diaphragm, contraceptive sponge, ovula
tion method and thermal sperm- control.
The safer contraceptive methods also tend not to
require physician’s intervention, thus providing low cost,
easily accessible birth control for more people. Parti
cularly good examples are the contraceptive sponge,
FROM THE EDITORS DESK. There is.no question that world population is; grow
ing at a rate not commensurate with availability of
material resources. The population growth rate in devel
oping countries is generally higher than in the developed
case. There is therefore ameed to evolve-methods to
control this growth. The policies for and the methods
of population control, however, need to be critically
and continuously evaluated. In two of the early issues
of the Bulletin (Nos. 9 and 10), the population con
trol policy vis a vis the socio-economic conditions
were discussed.
In this issue, we present a more technical aspect,
namely, contraceptive research and the hazards of the
“pill.” Mahtab Bamji, in her article, discusses the
associated risks of steroidal coontraceptives and
concludes that the benefits outweigh the risks. The
other viewpoint is from the Boston Women's Group.
Much contraceptive research is directed towards
women. The woman ultimately has to bear the burden
of either pregnancy or contraception. The Group
feels that since all contraceptive research is dominated
by men, the drug compaines are controlled by men and
the policy makers are men, there is no proper under
standing of women’s problems. MFC is not directly
involved with feminist mavements. The question
which I, however, wish to raise is—when scientific
research is also dominated by men, to what extent are
women scintists and doctors influenced and perhaps,
“ brain-washed ” by male thinking ?
Kamala Jnyarao
which requires no fitting,and the ovulation method,
which requires no mechanical intervention.
Those of us active in the women’s health movement
are concerned that present funding is too heavily
weighted toward drug and device research. Too often
such research has exposed human subjects, mostly
women, to serious adverse consequences. In cases where
insufficient research has resulted in premature approval
of contraceptive methods, much larger female popula
tions have been exposed unnecessarily to dangers. The
sequential Pill and Daikon Shield are two well
publicized examples of this, although all Pills and IUDs
might well be classified as unjustifiably, hazardous, in
light of the extensive and increasing documentation of
Pill and IUD risks. lu addition, adverse consequences
of contraceptive drugs and devices account for a sur
prisingly large number of hospital admissions, which
are both expensive and traumatic for the women
involved.
It is alarming to note that in 1976 out ofS70 million
spent worldwide on contraceptive research outside of the
drug industry, only 50,000 dollars was spent on barrier
method research. Safe birth control methods do not
receive priority by those who control the research dol
lars, while potentially dangerous methods do attract the
majority of funds. We urge a major reordering of priori
ties, so that research on the safer birth control methods
mentioned above receive the greatest emphasis. New
priorities would also include research on better ways to
communicate information about birth control methods.
Male Researchers and policy makers :
It is interesting to note that most contraceptive
investigators are male and hence have little direct
understanding of the practical impact of their research
on women. According to the inventory of population
research projects in the U.S. over SO % of federally
funded investigators in the areas of contraceptive
development and contraceptive evaluation during 1976
were males. It is of no small significance that these
male investigators will never have to use the methods
that they develop. Moreover, we believe that their
focus on the biological model and their fascination and
involvement in the research process sometimes over
(4)
shadows their concern for the well-being of research
subjects.
In our opinion, there needs to be more research
conducted by Community-based women’s health centers
which have worked directly with those who are intended
to benefit from this research. Furthermore, subjects
should play a major role in designing and/or approving
the research design. We believe that such an approach
would result in stricter adherence to research protocol.
Our third area of concern is policy-making. Private
organizations like the Population Council, Ford
Foundation, the Rockefeller Foundation, Planned
Parenthood, and drug companies, as well as the federal
government, sponsor practically all current contracep
tive research, setting priorities for this research as well.
Policy-makers for these organizations are also primarily
males, who make decisions with little or no input by the
many users of contraceptives, who supposedly benefit
from the research.
An example of policy recommendations that almost
totally ignore the areas of safer research we are ad
vocating may be found on page 40 of the Inventory
and Analysis of Federal Population Research.
1.
Development of male contraceptive methods and
techniques, including studies of combinations of
known drugs and new delivery systems.
2.
Synthesis of new chemical agents for the regula
tion of female and male fertility.
3.
Expanded screening capabilities as well as ac
celerated assessment of new' and old chemical entities.
4.
Critical biological assessment of biodegradable
drug delivery systems.
5.
Investigation of new methods for reversible and
permanent sterilization of both males and females.
6.
Development of a long
ceptive method.
7.
acting female contra
Increased research on intrauterine devices.
8.
Support of clinical studies required by FDA to
to expedite the availability of new methods.
9.
Assessment of the mode of action of post
ovulatory contraceptives.
10.
Development of technology for the detection of
ovulation and utilization of such technology for
family-planning purposes.
These recommendations were submitted by the
ICPR Committee., composed of 17 men and one woman
We doubt if a committee composed primarily of women
-consumers as well as researchers and government administrators-would have presented a similar list of
recommendations.
It is our position that women should be creating
policy on behalf of women, at the very least, and that all
users of contraceptives should have a significant voice
in determining what kind of research is funded. To the
extent that birth control is still primarily the responsibil
ity of women, and that women are the ones who bear the
major consequences childbirth, as well as the risks
and serious complications of birth control, women
should have a major voice in determining which contra
ceptive research priorities will best meet their needs.
Currently, the National Women’s Health Network
(NWHN) is conducting a nation-wide survey of over
100 women’s health centers and women’s health educa
tion groups to establish what women’s health organiza
tions see as their contraceptive research priorities. When
complete, this study will be a first-of-its-kind, revealing
what kind of research women want and expect the
government to fund.
The Network is particularly concerned that the
whole issue of contraceptive research be viewed in the
context of the rising incidence of sterilization abuse. The
widespread absence of safe and effective birth-control
methods and the promotion of newer, more hazardous
contraceptives, coupled with the withdrawal of abortion
services, especially for poorer women, has forced more
and more people, both men and women, to submit to
sterilization as the solution to fertility control. At this
time, we urge a moratorium on all funding for new ex
periments with new sterilization methods and recom
mend further investigation into the consequences of cur
rent methods of sterilization.
The medical establishment, including government
and private organizations, universities, and industrial
supply corporations, presently promote research which
emphasizes patents, profits and the development of new
technologies. The NWHN recommends a shifting of
priorities so that safer contraceptives, for both men and
women, can be developed and marketed in a timely
manner.
Extracted from Science Fot The People.
•
(5)
TOWARDS A NEW IMMUNIZATION STRATEGY
[In the seventh Annual Meet of the MFC at
RUHSA, we spent 1J days in discussing critical issues
in the care of under-fives- nutrition, inmunization,
diarrhea - as faced at the level of community work.
We had planned to publish the proceedings of this
discussion on all these three topics in the Bulletin.
But wc have now decided to publish only the report
on immunization strategy - a discussion in which
Dr. Jacob John of the Christian Medical College,
Vellore, presented his path-breaking idea of a really
scientific strategy for mass-immunization of the underfives Editor.]
THE PROBLEM
Should immunization be performed on a mass scale
at a community level ? What strategy should be
adopted to get 100% coverage? What vaccines should
be used ? How to improve compliance of people with
an immunisation programme ? How to simplify the
procedure ? Should immunisation be voluntary or
compulsory ? These questions were raised in the minds
of many.
To immunise or not to immunise on a mass scale
was the basic question. Various views were expressed.
The extremists on one side adopted a nihilistic view :
the entire immunisation programme is futile. Their
reasons :
1.
Within the present social structure and with the
available Government health structure, no signi
ficant immunisation coverage is possible. Immu
nisation is therfore no longer an epidemiological
tool to reduce disease, but a means of personal
prophyhaxis for those with access to the health
system.
2.
3.
4,
The necessity for and efficacy under field condi
tions of available vaccines, have never been
tested on the basis of hard epidemiological data
in India.
Especially with vaccines which cause some reac
tion e. g. DPT-people’s compliance in completing
the course of vaccination is poor.
Lack of a proper “ cold chain ” i. e. a system to
keep vaccines which are sensitive to heat in a
cold environment from the point of production
to the point of delivery.
The result is that existing immunisation programmes
have little impact on the morbidity and mortality rates
in a community. They are a collosal waste of human
and material resources which can be diverted to basic
purposes.
The moderates wanted to stick to the present stra
tegy but improve coverage through a massive health
education programme and motivation of the people
for immunisation - a typical moderate remedy for all
ills relating to the social, political or health care
systems.
DECIDING PRIORITIES
SCIENTIFICALLY
Dr. Jacob John, a virologist at the Christian Medi
cal College, Vellore, provided what was perhaps a
happy mean. According to him, cne of the main pro
blems with the present Immunisation schedule and
system was that it was unscientific. Western schedules
had been taken over and tacked on to the Indian health
care delivery system. If properly followed, according
to the present schedule, an Indian child by the age of
five years, was expected to have 28 separate injections
all to be provided by the ANM at the doorstep.
According to Dr. John, in order to overcome these
difficulties, it is necessary to I.
Select vaccines according to need, efficacy and
safety.
2,
Simplify immunisation schedules.
3.
Concentrate on mothers for improving compli
ance.
A vaccine can be assigned approximate “ notional ”
scores according to its need, efficacy and safety. Need
is determined by the prevalence of the disease; morbi
dity and mortality due to that disease in the commu
nity. Efficacy is decided by the degree of protection
obtained after immunisation. Safety depends on the
incidence and severity of adverse reactions due to the
vaccines.
Even though accurate data regarding prevalence,
morbidity etc. are unavailable, rough scores can be
assigned on the basis of available data and common
experience. We went through this exercise at our
session. The scores we assigned, through consensus,
were as follows : (The scores were assigned on a scale
of 0-4’)
(6)
Vaccine
Against
leed
Efficacy
Diphtheria
Whooping cough
Tetanus
Polio
1
3
3
4
T.B.
Small Pox
Measles
Typhoid
Cholera
4
0
4
2
1
4
2
4
2 or 4
' depending on
‘ cold chain ’)
1 or 2
4
4
2
1
Safety
Product of
the three
4
2
4
4
16
12
48
64 or 32
3
2
4
3
3
24 or 12
0
64
12
3
is that the cluster schedule uses available manpower
more efficiently, in order to acnieve wider coverage as
well as greater epidemiological impact. By this means
logistic problems (e.g. “ cold chain ” for oral polio
vaccine) are also minimised.
Dr. Jacob John and his colleagues have tried this
new strategy in a village near Vellore.
To avoid adverse reaction of the vaccines and high
dropout rate at present, the strategy was modified to
give two safe vaccines like measles and polio.
Following rules were followed to achieve 100 %
coverage :
1.
Keep immunisation centre separate from primary
health centre because sick children are brought
to primary health centre and their mothers equate
coming to P.H.C. to sickness.
2.
3-4 days before the immunisation day, ANM
should go; from house to house distributing
immunisation cards and hand bills giving infor
mation about disease and benefit of its prevention
by immunisation. Idea, being, though mothers
may not be able to read the information it can
be transmitted to them by some literate person
in the surroundings. ANM should talk to mother
and motivate her for immunisation. In . this
strategy ANM has to go from honse to. house
only once.
The idea is to reorder the immunisation schedule
and programme completely.*
1 Instead of AN Ms immu
nising individual children in their homes right through
the year, health teams immunise all the children in a
community together, according to a simplified schedule
based on the ranked priorities, at a time and place
fixed beforehand. The visit of the health team is
preceded by one week “ propaganda blitz ” which
aims at providing information about immunization, as
well as about the specific time and place as planned.
The proppganda is directed mainly at the mothers of
the target children.
3.
Give exact time at which mother should bring
her child to the immunisation centre.
4.
Give all children below one year three doses of
oral polio vaccine at an interval of 4 weeks and
give single dose of measles vaccine to the children
above one year.
5.
Collect immunisation cards that were given to
the mothers by ANM so that it becomes easier
to keep a record of the number of people who
attended the centre.
, The epidemiologic basis of the “ cluster ” schedule
is that if a large proportion of the vulnerable popula
tion (children under five) are protected together, the
transmission of infection becomes much more diffi
cult,. so that even unprotected children have less
chance of getting the disease. (Similar strategy was used
to to eradicate small-pox 1. The programmatic basis
1.
Schedule is simpler
2.
It is necessary to go to particular village on three
days at an interval of one month in a year.
Because of this storage and transport problems
are minimised. Vaccine can be stored at district
place throughout the year and can be brought to
the village only thrice.
Dr. John’s experience was that the ranking of the
the vaccines, on the basis of the product scores, tended
to agree, no matter who went through the scoring
exercise. According to this ranking system, the priority
vaccines were against1) Measles,
5) Diphtheria,
2) Polio, 3) Tetanus,
6) Whooping Cough.
4)
TB
THE “ CLUSTER - APPROACH ”
The most important innovation described by
Dr. Jacob John was his concept of “ cluster ” immu
nisation.
We hope soon to carry an article by
Dr. John describing the epidemiological basis and
practical details. So this is only a short account.
Advantages of this strategy are :
(7)
3-
Since the mother is told in advance the exact
time and place at which the immunisation will
take place. She knows exactly what she is
expected to do.
4-
Number of children immunised is counted from
the numbering of immunisation cards that are
collected after immunisation.
Since D. P. T. is not added in the system adverse
reactions are minimal and compliance is better.
Once community is immunised for polio and measles
people will realise the benefits of immunisation and
slowly D.P.T. can be added to this strategy.
5.
The following are other important deviations from
conventional thinking, embodied in Dr. John’s recom
mendations :
1.
Mlid viral infection or diarrhoea should not be
a contraindication to oral polio vaccine at a
community level. Sero conversion is still possible
even in the presence of minor ailment.
2.
Breast feeding can be allowed to follow OPV
after one hour.
3.
All three doses of DPT should be given. One do
se does not give any immunity. Two doses give
30% immunity in India as against 60 % in the
West.
Measles vaccine should be made available all
over India.
Dr. Jacob John reported that the “cluster” strategy
had been used in some vilages in the North Arcot
District for measles vaccination,yielding 100% coverage.
4.
Many sceptics expressed doubts about Dr. John’s
recommendations. Some of these were1.
Scores given to the vaccines do not take into
account practicality and availablity; e.g. measles
vaccine is not available throught most of India.
The cost of the vaccine is prohibitive.
2.
Logistic problems in reaching villages at prefixed
times, and “ cold chain ” problems, may prove to
be very difficult to overcome.
3.
The “ cluster ” approach has only worked under
very special circumstances whether it would
succeed elsewhere is difficult to predict.
4.
The addition of D.P.T. to the immunization sche
dule may reduce the compliance of village com
munities.
Dr. Jacob John argued that the cost of the measles
vaccine can be reduced considerably if we produce i
in India.
Whatever the doubts raised, the moral of the entire
exercise was seen to be relevant by all-Do not stick to
the immunisation strategy desised by Westerners, try
to evolve your own strategy on scientific grounds for
your own area with different social and cultural back
ground. The rules of the game arc not sacred but can
be broken and moulded to suit our needs. This was
the point Dr. John wanted to stress upon. Finally, the
question that remained unanswered was : would a
revolutionised immunisation strategy bring about a
better health standard in the absence of social change ?
[ Nilin Nadkarni ]
□
( contd, from page 2 )
Malnourished women excrete the steroid hormones
faster than well-nourished women; whether this is one
of the reasons for the higher incidence of mothod
failure in India needs to be investigated.
That the use of OC does have a small element of
additional health risk has to be accepted. But .is this
risk greater than the risk of repeated pregnancies ?
All the side effects of OC are also seen in pregnancy.
Among the methods of contraception currently avai
lable, use of OC does seem to be the most effective
( if properly used ), easily reversible and easily dispen
sable method. It can be the method of choice for
spacing pregnancies, but not a permanent method for
contraception over long periods of time. A large
segment of the population can benefit from this method
of contraception.
Future research should be aimed at developing
formulations with lesser side effects, and at reducing
the cost. The low dose formulations have achieved
this goal to a considerable extent. In India more
educational inputs to improve the acceptability of OC
will also pay good dividends. The present emphasis
on permanent methods such as tubectomy and
vasectomy should continue for couples having more
than 2-3 children.
□
RN. 27565/76
Regd, No. P N C W-96
mfc bulletin May; 1981
UPJOHN, DEPO-PROVERA AND THE THIRD WORLD
The National Women’s Health Network, representing
both women’s health groups and i ndividual consum
ers and providers from across the country, has been pro
testing efforts of the Upjohn Company to seek FDA
approval of Dcpo-Provera as a contraceptive. Use of
this injectable contraceptive, a known carcinogen asso
ciated with serious risks and harmful side effects, repre
sents a major threat to the health and well-being of
women, and possibly to their offspring as well.
Many serious side effects of the drug Depo-Provera
are well-known including the fact that Depo-Provera
has in the past.
1) Been shown to cause malignant breast tumors in
beagle dog studies.
2) Shown evidence of increasing the risk of cervical
cancer in women who use it.
3) Been shown to increase the incidence of irregular
bleeding disturbances, necessitating the administration
of estrogen to control the bleeding.
4) Been associated with a risk of congenital
malformations in humans exposed to the drug during
pregnancy.
5) Been shown to cause long-term infertility and pos
sible permanent sterility in many women after they have
ceased taking the drug and
6) Been linked to numerous other undesirable ef
fects such as weight gain, acne, hair loss, severe mental
depression, etc. as shown in over 125 affidavits from
women who have received the drug for contraception in
the Los Angeles area.
To date, the long-term safety of Depo-Provera has
not been established, and yet, it is estimated that “ 3 to
5
million women presently use this drug as a contracep
tive worldwide. ” This represents another massive
experiment like those of the Pill and DES. which
Editorial Committee :
anant phadke
christa manjrekar
mohan gupte
ravi narayan
kamala jayarao, EDITOR
have caused
severe and
unnecessary
damage to
thousands of women.
Furthermore, in some countries, lactating mothers
have been urged to use Depo-Provera despite the fact
that infants may suffer from the ingestion of DepoProvera in breast milk. Promotional material for this
drug distributed by Upjohn in parts of Africa is parti
cularly irresponsible in this respect: One brochure
recently sent to the Networh depicts a mother breast
feeding her child, along with the caption : “ Now, when
she most desires dependable contraception. ”
As the following remarks of the chairperson of the
National Council of Women of Kenya indicate, women
in Africa are concerned about the widespread and indis
criminate use of depo-Provera :
We are told that few women in developed nations
are on the injection - ( Depo-Provera ), yet we have
evidence that this method is now being used almost
indiscriminately in our country. Claims of strict con
trol by the Ministry of Health appear very questionable.
What control does the Ministry have over Private
Doctors who advise large numbers of women ?
We need urgently and sincerely to ask ourselves
whether we would jeopardise the health of our nation
in our effort to control the population explosion. It
is crucial that we. establish our own research and even
encourage direct and independent research into the
whole area of Family Planning, as to long-term effects
of modern Family Planning methods. We must never
become the dumping ground for any half-baked
methodologies and drugs which the originators ( for
reasons well known to themselves ) arc unwilling to
administer to their own people.
(—Kenya Woman. V. I. No. 6. 1978 )
Views & opinions expressed in the bulletin are those of the authors and
not necessarily of the organisation.
Annual subscription-Inland Rs. 10/-For Foreign countries- By Sea
Mail US $ 3/R.V Air Mail for Asia US 8 4; Europe, Africa— US 87 USA
Canada- US 89.
Edited by- Kamala Jayarao, National Institute of Nutrition, P. O. Jamai
Osmania, Hyderabad. 500007. Printed by- Anant Phadke at Balbodh
Mudranalaya, Pune 30. Published by-Anant Phadke for Medico Friend
Circle, 50, LIC Quarters, University Road, Pune 411016, India.
,
1)
medico friend
circle
bulletin
MAY
1982
Will you call this misuse ?
Antibiotics account for 20% of drug sale in India
( 1976 figures ). Many times it is difficult to prove that
drugs are being misused or irrationally used, because
in majority of prescriptions, the doctor hardly ever
writes the diagnosis Even from the hospital records
it is difficult to conclude correctly because written
documents do not mention all that is in the mind of
a treating doctor (It speaks of our recording quality. ),
say for example :
i ) A critically ill patient of meningo-encephalitis
where diagnosis is uncertain, use of Inj Chloromycetin,
Inj. Chloroquin, Inj. S/M, INH together can be
justified to cover up enteric encephalopathy, cerebral
malaria, tubercular encephalitis and pyogenic menin
gitis. It is a shot gun thrapy, but is justified if one
takes into consideration the seriousness of the illness
and non-availability of investigational support.
ii ) A child wiih upper respiratory infection may
have conducted throat sounds in chest which are
wrongly interpreted as crepitations and thus patient is
thought to have bronchopneumonia. Use of antibiotics
now is perfectly justified. It may be a serious mistake
on the part of the treating doctor that he did not
examine after the child is made to cough, but is a part
of the game which has to be conceded.
iii ) A child with severe diarrhoea is treated with a
combination of anti-protozoal ( Metronidazole ) and
antibiotics to cover up wide range of diarrhoeal
diseases in a setting where examination facility is not
available. This may also be justified if one keeps in
mind that the doctor will not like to delay the treat
ment and risk the child’s life.
iv ) It patient with fever of more than 7 days
duration who cannot afford to get his blood investiga
tions ( Widal, blood culture, peripheral smear for
parasites) done for a perfect diagnosis, is put on
Trimethoprim + sulpha combination to cover up
resistant malaria, resistant'typhoid fever, and gram
negative septicaemia, this may be justified.
It all means, that the prescriptions may vary
considerably in the same patient in different settings The
budget of the patient, availability of investigative pro
cedures, human error on the part of the doctor al1
have their say. Therefore it is difficult to rationally
analyse some-one else’s prescription without knowing
the situation in detail.
But there are indiect means to judge that doctors
do overshoot. Indian literature in this regards is scarce.
However there are studies available where the
prescriber is informed in advance that his / her
prescription will be screened for appropriateness of the
drug prescribed or he / she is asked to fill up a form
justifying the use of antibiotics These trials have
shown decreasing trends in antibiotic use up to 25%
( 1-5 ). In other studies where physicians have been
made to write the diagnosis over the prescription, it
was found that antibiotics were prescribed without any
evidence of infection in as many as 62% - 90%
UIhas N. Jajoo
Bajaj wadi, Wardha, 442114
CELL
A medical practitioner with time slowly realises
that there are really few diseases where allopathy can
offer a cure. Infective illnesses is one such area.
‘ Antibiotic ’ is the greatest tool that modern medicine
offers today against bacterial infections. However it is
a double edged sword, if not utilised properly it not
only harms the patient but also has wide ranging
social implications, evidence of which is ample in the
medical literature.
COMMUPJIT'/ HEALTH r e .i
Hisose of Antibiotics, Antimicrobials
(2)
prescriptions0. Thus there is no doubt that antibiotics
are improperly used.
How are antibiotics improperly used?
A)
Used when not indicated, e. g.
i
) For common cold and all upper respiratory
illnesses which arc in majority self limiting viral
infections. It is estimated that as many as 12%
prescriptions of antibiotics are given for common
cold.8
ii
) For acute diarrhoea in children without any
evidence of dysentry, severe malnutrition, septicaemia.
iii) For viral infections without any evidence of
bacterial superinfection.
B)
Used when contraindicated, e.g.
i
) A patient of chronic renal failure gets sulpha
drugs, tetracycline, aminoglycosides ( Nephrotoxic ).
ii
) A new born infant gets Chloromycetin ( grey baby syndrome ).
iii
) A diabetic patient gets sulpha drug like
trimethoprim 4- sulpha
combination
(Papillitis
Necroticans ).
iv
) Inj. streptomycin in a patient of ear-disease
(ototoxicity).
C)
Irrational combinations, e. g.
i ) Penicilin with tetracycline or Chloromycetin
( See appendix).
ii ) Gentamycin + Kanamycin ( two drugs of the
same group ).
D ) Improper selection of drug, e. g.
i)
Use of Ampicillin because organisms are thought
to be resitant to penicillin ( Ampicillin does not act
against penicillase producing organisms ).
ii ) Demeclocyclin is used when other tetracyclines
which have less toxicity and equal effectivity are avai
lable.
iii) Erythromycin Estcolate ( hepatotoxic ) is used
when one other salt of erythromycin (erythromycin
ethylsuccinate) which is less toxic and equally effective
is available.
iv ) Use of penicillin G when more acid stable
preparation (Penicillin V) is available.
v
) Routine use of Inj. streptopenicillin for bacterial
infection. Tuberculosis being so rampant and strepto
mycin being one of the cheap primary line of drugs,
routine use of this combination is not justified if one
keeps in mind the drug resistant tuberculous infection.
vi
) Use of Rifampin + Pyrazinamide + INH in a
case of defaulter of tuberculous treatment who has
turned up for the first time to the hospital. Majority
of these patients still respond to primary drugs9, and
in our setting shift to costly drugs of secondary line is
not justified.
vii
) Use of Chloromycetin ear drops which contain
propylene glycol as preservative which irritates the ear.
viii
) Using Chloromycetin + streptomycetin combi
nation orally for cases of acute diarrhoea (streptomycin
need not be given in short lasting bacterial diarrhoea.
The common organisms are not sensitive to this drug.)
E) Defective route of administration :
i ) Use of Injection Chloromycetin when patient can
be given oral drug. ( Injectable drug has erratic
absorption ).
F) Inadequate doses :
The possibilities are i ) Doctor prescribes dose for
inadequte duration ii ) The patient does not have
enough money to buy the total course of antibiotics,
thus either reduces the dose or the duration. The
notorious drug misused by doctors is injection terramycin which is available in the concentration of
50mg/ml. For adequate dose, 5 cc of this oily prepara
tion has to be given in an adult which is so painful
that probably patient will not come back. The most
convenient way is to reduce the dose. ( 125 mg / ml.
concentration is not generally available. ) It serves two
purposes; one it reduces cost to the doctor and second
it continues to give satisfaction to a patient of getting
a coloured injection.
What are the harmful effects ?
i ) Adverse reactions
ii)
High cost of the prescription (See appendix)
iii) Resistant bacterial infection.
Mutation in genes destroys affinity of target site for
the antibiotics or modifies permeability of the cell so
that antibiotics cannot enter the cell and find its
target site. This is the mechanism for development of
resistance in a given patient. However, problem of
drug resistance does not remain limited to
the
patient. Diug resistance in an infectious organism can
be transmitted to other sensitive organisms of the
same or different
species
through
so-called
“ Resistant Factor ’. This drug resistance is due to
ability of the bacteria to modify the antibiotics with
the help of certain enzymes that they can produce. The
modified antibiotics cannot recognise their cellular
target and therefore have no inhibitory effect o n the
cell.
( 3)
To make things worse, this transmissible resistance
is against series of drugs ( multiple drug resistance).
The fact that R factors can be transferred to every
genus of enterobacteriasae through non-pathogenic
bacteria like E coli ( normal inhabitants of intestine)
has become a major poblic health problem. If a person
harbours E. coli with R-factor in the intestinal tract,
they can turn sensitive pathogenic organisms like
shigella, salmonella, V. Cholera to resistant ones. If
this continues further, we may reach a situation when
the future of chemotherapy can appear bleak.
Evidences for this type of resistance in the Indian
situaion are many.(’) Studies done on healthy subjects
who had not consumed any antibiotics for atleast one
month showed 28% of them harboured multiple drug
resistant strains of E. coli and much lowei\6%)incidence
of multiple drug resistant strains among individuals of
nearby village The resistance was predominanly for
drugs like Sulfonamide, Streptomycin, chloramphenicol,
ampicillin, kanamycin, and tetracycline which are most
commonly used antibiotics. Resistance to newer
drugs like gentamycin and trimethoprim has also
emerged.
W/»y antibiotics are misused ?
The possible reasons could be ;i ) Poverty of knowledge of the prescriber
ii) Shot gun therapy
iii i Antibiotics are prescribed also by the doctors
from other disciplines of medicine such as
Ayurveda, Homeopathy, Unani etc. i.e those
who are supposed not to be qualified allopathic
practitioners.
iv) Persuasive
sales
promotion
by
drug
pharmaceuticals which are often the only source
of knowledge for a busy practitioner.
v ) Easy availability of these drugs over the counter
to the public who quite often practice selfmedication.
vi) Absence of cross-checks on the prescribing
habits of the doctors.
vii) Consumer is unaware of the harm that mis-use
of antibiotics can inflict.
Is there a solution to the problem ?
- Refresher course for the doctors on indication
of antibiotics in infective disorders ?
- Availability of antibiotics only by the prescrip
tion from the qualified allopathic doctors ?
- A mandatory justification by a doctor for the
prescription of antibiotics ?
- Abolition of different brand names and
insistance on generic name ?
- Mass education of the “ Consumsrs ” about
the indications of antibiotics use in common
infective illnesses ?
I personally feel that the last option will be most
effective, if one keeps in mind that antibiotic misuse
involves vested interests of both doctors and drug
industry.
Appendix—1.
Cost of Commonly used antibiotics
Sr.
No.
Drug
Dose
..
per tab./cap/ Total
Rs. cost
inj. cost
I. Sulphadiazine 2 tabs 3 times
(M&B)
x 5 days
2. Penicillin-V
I30mg 6 hrly.x
(M & B) 5 days
3. Tetracyc line
500 mg 6 hrly.
(Paran)
x 5 days.
4. Chloramphenicol 500 mg 6 hrly.
X 5 days
5. Septran
2 tabs, twice
1 Bruxwell)
a day x 5 days
6. Inj. Gentamycin 40 mg 8 hrly
( Lyka l -80 mg. x 5 days
7. Kanamycin-lgm 1.5 gm total
x 5 days
8. Amoxycillin
1 tab. 3 times
a day x 5 days
9. Doxycyclin
2stat; 1O.D.
(US Vit )-100mg x 4 doys
0.30
9.00
0.48
9.60
0.34
13.60
0.31
12.40
1.00
20.00
10.20
76.50
15.75
133.00
1.70
25.50
1.80
10.80
References ;
1 ) JAMA 2585 : 242, 1979
2 ) JAMA 242 : 1981, 1979 237 : 2819,
1977;
227 : 1023, 1974, 227 : 1048, 1974
3 ) Annals of Int. Med. 76 : 537, 1972; 79 : 55,
1973
4 ) Med. Assoc. J. 116 : 253, 1977
5 ) Lancet : 2 : 407, 1981; 2,461 : 1981; 2 : 349,
1981
6 ) JAMA. 213 : 264, 1970
7 ) Science Today : Sept, 1981 page. 26
8 ) Insult or Injury 1979, published by social Audit
Charles Medawar p. 123.
9 ) WHO Expert Committee on tuberculosis-9th
Reper. No. 552, p. 21.
10) Ann. of Int. Med. 128 : 623, 1971
11) The pharmacological basis of therapeutics, 5th
edition, by Goodman and Gilman.
[This article is based on the discussion paper that
Ulhas Jajoo had prepared for the VIIIth Annual
MFC meet. ]
(4)
HEALTH ACTION INTERNATIONAL—
This is an “ international antibody ” formed in
May-1981 “to resist the ill-treatment of consumers by
multinational drug-companies.’’ Its a network of
about 50 groups including consumer developmental
and other groups interested in health and pharmaceuti
cal issues.
Member groups of Health Action International
wil] address such issues as :
An end to the commercial anarchy of prescription
drug competition ” ( for instance in India, there are
some 15,000 branded drugs on sale-compared with
just 225 ‘‘ essential drugs ” identified by the WHO )
“ An end to patent protection for essential drugs.
The “ essential drugs ” indentified by WHO “ are too
important to be left in a monopoly domain. ’’
The progressive replacement of properietory brands
with generic drugs-which usually cost many times less
The “ decommercialisation of essential drugs ”
assuring that people who need drugs get them.
Regional or national production and bulk-buying
arrangements to reduce to an absolute minimum the
cost of essential drugs.
Immediate action plans for the new coalition,
Health Action International include :
Setting up an international clearing house for
information on commerciogenic disease; pharma
ceutical industry structure, ownership and marketing
practices; and for the coordination of consumer action
campaigns.
The launching of an international Hazardous Pro
duct Warning Network- “ the Consumer Interpol. ”
The withdrawal or restriction on the use of any drug in
any one of five reference countries will trigger immediate
communication to each of over 110 different organiza
tions in some 50 countries. The aim is to encourage
local groups to pressure government and industry to
effect simulataneous restrictions - and to avoid the
commonly-found double standaids between developed
developing countries.
Direct actions will be aimed at the worst offenders
in the drug industry : publication of counter informa
tion, such as the leaflet on Lomotil released at the
IOCU-BUKO conference by the British research
action group, Social Audit; confrontation at companies
annual general meetings; and the possibility of inter
national consumer boycotts and legal actions against
“ the truly intransigent. ’’
Achievements :
HAI has forced Searle to revise labelling of Lomotil.
It is active in the boycott against Ciba Geigy for the
sale of clioquinol drugs in many parts of the world.
A news bulletin [ HAI, News ] is being published from
October-81 every two months. It will serve as a
channel for communicating news on the activities of
HAI participating members, ideas, new information
and resource material in health and Pharmaceuticals.
The International Organization of Consumers,
Unions ( IOUC ) links the activities of consumer
organizations in some 50 countries. An independent,
non-profit and non-political foundation, IOCU
promotes world-wide co-operation in consumer ptotection, information and education. The Headquarters of
IOCU are at 9 Emmastraat, The Hague, Netherlands.
The Regional Office for Asia and Pacific is at P. O.
Box 1045, Penang Malaysia. For further information
contact Editor, HAI-News on this address.
[Based on IOCU newsletter]
Boycott against Nestle pays off
Nestle, the giant multinational company has been
selling its breast-milk-substitute powder all over the
world. It had refused to accept the WHO code of
marketing of breast-milk substitutes Infant Formula
Action Coalition, [ INFACT ] consisting of over 50
organizations has organized an international consumer
boycott against all Nestle products. Feeling the crunch
of the boycott, Nestle has now agreed to comply with
the WHO code. The boycott is to continue “ until the
Nestle actions match their rhetoric ... abiding by both
the letter and spirit of the WHO code, country by
country around the world. ’’ For further information
contact- INFACT 1701 University Ave. S. E. Mpls.
MN 55414, U.S.A.
0
(5)
Attention Please!
Campaign against irrational use of drugs
The mass-educational campaign against hormonal
pregnancy-test was an encouraging experience Articles
on this issue were published in most of the leading
dailies and some periodicals all over India. Now
Voluntary Health Association of India, MFC, Arogya
Dakhata Mandal and other similar organizations have
sent letters to the Drug Controller of India asking him
to take specific steps that we have outlined to curb
the misuse of hormonal preparations in pregnecy.
Various women’s organizations arc also sending simi
lar letters to the Drug Controller.
The manner in which different organizations
co-operated with each other has raised expectations
about the next campaign. MFC Voluntary Health
Association of India, Arogya Dakhata Mandal and
like-minded people are starting a mass-educational
campaign on diarrhea, oral rehydration and uselessness
of most of the commercial antidiarrheal preparations.
Let us make this campaign a better organized one and
on a larger scale than the one against hormonal
pregnancy-test. A scientific background paper on this
topic would be ready by 15th May. It is expected that
Bulletin readers would make use of this paper to write
articles, give talks, make posters etc. for the people.
The paper will be sent to those who ask for it. Please
send Rs. 5/- ( or more 1 ) if you can, to cover
the cost of cyclostyling.
The Voluntary Health Association of India (VHAI)
requires a young, energetic and enthusiastic medical
doctor (MBBSj,to work with the Community Health
Team. The candidate should be prepared to travel
extensively and be able to organize and conduct
workshops / seminars in Community Health and
Development mostly in rural areas. Experience prefera
ble. Salary will be commensurate with qualifications
and experience. Apply within two weeks with bio
data to :
Voluntary Health Association of India
C-14, Community Centre, S.D.A.,
New Delhi 110 016.
Manan Ganguli writes : Their centre can supply
oral rchydration packets prepared according to WHO
formulation. Price Rs. 0.75 per packet plus postal
charges, write to
Lok Kendra, Titamo Jabhaguri Panchayat,
Madhupur 815353, (Santhal Parganas) Bihar.
Dear friend
At the VUIth Annual Meet of MFC at Tara, there
was a discussion about banning of liquid tetracycline
preparations. There was a consensus that some times
there is a choice between a child receiving a cheap
antibiotic like tetracycline •. which is less hazardous
than chloramphenicol ) or no antibiotic at all.
In rural situations a patient may not afford to come
to the clinic from his village daily for a five day course
of Procaine Penicillin. It was therefore argued that
unless we know the incidence of tetracycline-sideeffects, at what dose they are more likely to occur etc,
we should not ask for a ban on these liquid prepara
tions. Dr. Anand is continuing the debate in his
letter below —
“ I support the ban on tetracycline liquid prparations for the following reasons.
1. Side effects due to tetracyclines like staining of
teeth, depression of bone growth and increased
intracranial pressure in children are very well docu
mented ( Goodman and Gilman's pharmacological
Basis of Therapeutics, 6th Edition ). Samples used
after the date of expiry have been found to cause
renal damege due to degraded products of this parti
cular antibiotic.
Since returning from the MFC meet held on 23rd
and 24th Jan. 82, I have seen four cases of ugly look
ing stainning of teeth due to tetracyclines. It can be
argued that it was a coincedence and that this observa
tion need not reflect the true incidence of the disease
But is it also possible that sometimes we do not
notice certain things unless we make a conscious effort
to look for the same ? For instance, how many of us
carefully examine the teeth so as not to miss an apical
tooth abscess as a cause of unexplained fever ?
2. Many of us who have been treating children of
poor parents from slums and from the rural areas
have not used tetracyclines for bronchopneumonia and
other infections for many years. We have never felt
handicapped for this reason.
3.
I have seen prescriptions of tetracycline liquid
preparations for new-born babies. If these were
not available, the doctors who have been prescrib
ing the same are less likely to use the capsules of
tetracyclines. ”
Raj Anand,
Bombay.
(6)
PRIMARY HEALTH CARE : THE REAL PICTURE
There is much written, and published on alternative
health strategies by health planners, highlighting the
various options available to ensure that at least basic
health services are available to the masses. The most
recent to climb the ambitious ladder being the “ Health
lor ail by 2000 A.D. ’’
THE EXPECTATIONS
Starting with the Bhore committee that set out
recommendations as early as 1946, a series of
committees have made voluminous recommendations
on the new approaches, new breed of health workers
and changes in medical education, training unipurpose
and multipurpose workers and the like. This apart,
there are atlcast more than half a dozen schemes
sponsored both by the centre and the state, operating
through the state machinery of the Primary Health
care services, like malaria control, leprosy control,
tuberculosis control, Family Planning besides the
programme of mother and child care which covers a
gamut of basic services.
1 he promises of primary health care hinge heavily
on the Primary health infrastructure covering a popu
lation of 1,00,000. The primary health centre is
generally staffed by two medical officers, one of them
being a lady medical officer and other staff. The final
unit of 1000 population is manned by one male and
one female worker. The ‘ premise ’ is that these front
line workers will deliver services to meet the primary
health needs of the masses. In Karnataka these front
line workers are the ANM and the Multipurpose
worker. Some of the specific Primary health care
functions of the front line workers are-maintenance of
ante-natal care, eligible couple and child registers,
referring mothers with gynaecological and medical
problems follow up of these referral cases, conducting
deliveries immunization of underfives, distribution of
iron tablets and contraceptives and refering cases for
medical termination of pregnancy and sterilization.
This note attempts to high light a few obvious, loop
holes at the final stage of health care delivery. To
begin with, how far in reality have the front line
workers and the medical officer internalized the concept
of preventive service and health education? What is
the expectation of people to whom the services are
delivered ?
THE REALITY AT PERIPHERY
A simple example based on the observations made
in the field in a backward area in Karanataka is taken
for elaboration. It was found that the focus of the
PHC service was predominantly curative. The available
curative services are again used only by the people
living within a certain radius, further helped by
communication facilities. Immedieate needs were for
pencillin injections, paracetamol, treatment of minor
wounds and accidents, ‘ B ’ complex injections as
placebos and other therapies needed for diarrhoea and
viral infections. However it was not uncommon to
observe a mother carrying a prescription for
‘ protinules ’ recommended by the doctor for a two
year old bordering on second degree malnutrition; a
mother rushing in a child with diarrhoea and fever
of unknown cause, being treated with two doses of
analgesic and two doses of ‘ antibiotic ’, as revealed
by the doctor himself. If this be the practice of quali
fied doctors then nothing much be said on the practice
by the male workers. How is one going to stop such
practices ?
Most of the front line workers are busy building
the health data base. Much of the preventive services
on paper never reach the huts. There is hardly any
direct supervision of their field work, the responsibility
rests heavily on their honesty and trustworthiness.
The medical officer with a meager vehicle allowance
of Rs. 300/- month can hardly hope to move out of
his head quarters. There is a constant shortage of
essential drugs, bl aching agents and DDT so much
so they can hardly cover the target area leave alone
the frequency with which they have to be used. The
undue emphasis given to family planning services has
come under much criricism especially after the
Emergency. The pressure was for meeting a target.
A critical look at the resource allocation for family
planning shows a continued increase of t.ie Family
Planning budget as a proportion of the total health
and Family welfare budget (Table 1). At the same
time, in successive plans investment in health
has occupied a smaller and smaller share of the total
plan investments.
(7)
On the weak shoulders of the ANM who has taken
on an unenviable role rests the success of the primary
health care services. Sandwiched between the govern
ment and the rural people she becomes a weak line
in the chain.
Demedicalisation of the people’s health beliefs and
expectation of health services appear to be some of
the crucial issues in the battle to be won. People no
longer feel ‘ Health as a personal responsibility ’. The
dependency on the allopathic system of medical care
has penetrated to the practitioners of indigenous
medicine even in interior villages. The indigenous
system of medicine is dying a fast death. The practi
tioners have resorted to antibiotics and injections to
raise the hopes of the people for a fast cure. The
relationship is one of customers receiving service and
officials delivering the service. Sometimes a poor
image of the health worker leads to non-acceptance
of the preventive services.
Table 1. Family Welfare and Health Budgets by Plans
FW
budget
Rs.
Million
Health
Ministry
Rs.
Million
1st Plan
(1951—‘56) 1.45
2nd Plan
‘ 56-' 61) 21.56
3rd Plan
(‘61-66) 248.60
Annual Plans
‘66-’67
‘68-69. 704.64
4th Plan
<69-<74
2,844.33
5th Plan
‘ 74-‘78
4,507.00
1939
Year
FW as 70 Health
of
Plan as
Health
%°f
budget
Total
investment
0 06
3.3
3697
0.58
3.0
7,128
3.49
2.6
7238
9.74
2.1
21,372
13.31
2.1
12.72
1.8
i
35,434
* includes medical, FP, sanitation and water supply
** provisional figures
Source : Department of family welfare, Year Books
• 77-' 78 and ‘ 78- ‘79; Pocket Book of Health
statistics, Govt, of India.
A PIPE-DREAM ?
It is heartening to read the policy recommendations
made by the recent committee set up jointly by ICSSR
and ICMR. One of the recommendations reads-“...
to replace the existing model of health care services
by an alternative new model which will be firmly
rooted in the community and aiming at involving the
people in the provision of the services they need and
increasing their capacity to solve their own problem .
The report has also outlined the conditions essential
for success. ' The alternative model which is
decentralised and participatory will require a different
set of attitudes The bureaucrats and the professio
nals will have to cultivaie respect for the people and
a faith in their ability to identify and find solutions
for their problems. " This is easily said than done.
The well meaning expert committee has stressed on
simi’ar hopeful conditions. They add . ‘ the success
of the alternative model will depend largely on the
quality of health services. This will of course include
the usual problems as proper selection, training, crea
tion of proper conditions of work and service, adequate
supervision and guidance and good administration
which will ensure justice and fair play and relate
rewards visible to quality and punishment to failure
We cannot afford to forget that for the very same
reasons not only the programme of primary health care
but several other well planned schemes have met with
incredible failures. In the present, complex socio
political environment how is one to assure these
conditions? Whois to fulfill these responsibilities'?
As is clearly seen, most of the plans and recommenda
tions on paper beautifully fit into the objectives to be
achieved, but at the point of delivery the link hardly
withstands the socio-political pressures and the prob
lems of personnel. If the PHC were to be used as the
point of delivery, it is that phase of implementation
that should receive maximum attention. On the other
hand, the entire ideology gets watered down at that
stage.
Finally to conclude, the fast changing socio-political
and cultural conditions do not let the accepted modes
of basic services to percolate deep down to the really
needy people. The blocks are far too many not only
in the health services but also in many of the rural
development services. Unless there is commitment to
clear these blocks on a war footing, the promises of
primary health care will continue to be a pipe dream.
Vanaja Ramprasad.
RN. 27565/76
mfc bulletin ; MAY 1982
Regd No. PNC W-96
FROM THE EDITOR’S DESK
The Poor Man's Poison is Nobody's Concern
The above statement is from one of the four arti
cles by Prabhash Joshi on lathyrism, published by
Indian Express consecutively starting April 9, 1982.
Two MFC sympathisers-Beena Naik of Navsari and
R. Chandrasekhar of Madras, have written to say that
MFC should do something about it.
I may remind our readers that in December 1977
I wrote all about this problem ( Kissa Khesari Ka Bull. No. 24 i. I traced the historical development,
the climcal picture, the first ICMR survey, the sugge
sted solutions and the total indifference of the govern
ment, the ‘ impractical ’ solutions released from the
research laboratories, etc. I used it as a model to
show the socioeconomic structure of our public health
problems. Abhay Bang was much excited and
enthusiastic over the issue ( Bulletin No. 26 ). As a
result, the MFC organised a 3—day survey of rural
Rcwa. As a strict, “ scientific ” epidemiological
survey, it had drawbacks. But, for each one of us
who participated in it, it was a rich, never - to-be —
forgotten experience. “ Walking 15-20 km. every day
in the hot sunny summer of central India, sleeping
under trees, starving for the whole day, tolerating
insults, threats from the police, all these formed the
memories . . ” ( Luis Barreto, Report of the Camp,
Bull. No 30, 1978 l. Yes, the landlords resented our
searching questions our meeting the landless and
bonded labour, our interest in lathyrism, and sent the
police after us. 1 They knew what will be revealed,
like the statement of a bold labourer, “ we are being
slow — poisoned by the landlords so that we should
always remain weak and be dominated ” ( Barseto,
loc. cit ). Compare Joshi's reference to the landlord's
“ confession " that they do not give wheat and rice as
wages, lest the labour become strong and disobedient.
Twenty years after the ICMR survey, Dr C.
Gopalan, the eminent nutritionist revisited Rewa He
was told that the labour was not anymore getting
khesari dal as wages ( NF( Bull. April 1982). This is
Editorial Committee :
anant phadke
christa manjrekar
ravi narayan
ulhas jajoo
kamala jayarao, EDITOR
not true. We saw with our own eyes, as did Joshi
now, that they continued to receive birri ( a mixture
of wheat, barley, Bengal gram and khesari ).
Dr. Gopalan believes that the decline in the practice
is due to the fact that khesari is being “ exported ” to
other states for adulteration of arhar and Channa dal.
This we too learnt in 1978, both from the landlords
and the labourers. Perhaps, its all for the good.
Arhar and bengal gram today are only in the reach of
the upper classes. Let us realise we are being slow poisoned by our own “ class. ” Maybe the powers that
be, will sit up and notice.
Dr. Gopalan says, “ Nutrition scientists in their
idealism often plead for a nutritional orientation ........
.... the reality seems to be that commercial
considerations and the play of market forces will
determine . . agricultural development ” (NF1 Bull.
April 19821. Did I not say that solutions offered by
scientists failed to take socioeconomic realities into
consideration (MFC Bull. 24)? I am glad Dr. Gopalan
too now sees this. But, why has he left the play
of the power structure ? That which keeps the poor
not only poor, but weak and oppressed ? True,
khesari is being exported. But the distribution of birri
continues, as before. In this land of plenty, none shall
be denied.
Let me not be accused of evading Beena's and
Chandrasekhar’s question. What will the MFC do
about it ? MFC is a small organisation Its voice is
weak - the cumulation of whispers from different
corners of India. We need a broad and large base, we
need money and people, particularly people If each
Bulletin reader can enrole more subscribers, if each
member can bring in one more member — then in the
future may be we can link hands with like — minded
groups all over the country - so that the whisper
becomes a roar. Till then, our strongest voice is only
the Bulletin. Please see that its vocal cords do not
get paralysed
Kamala Jnya Rao
Views & opinions expressed in the bulletin are those of the authors and
not necessarily of the organisation.
Annual subscription- New rates from July 1981-lnland Rs. 15/- For
Foreign Countries- By Sea Mail US S tyBy Air Mail for Asia US$6;
Europe, Africa- US 89, USA Canada-US $11.
Edited by- Kamala Jayarao, A-9, staff Quarters, National Institute of
Nutrition P. O. Jamai Osmania, Hyderabad. 500007. Printed by- Anant
Phadke at Balbodh Mudranalaya, Pune 30. Published by-Anant Phadke for
Medico Friend Circle, 50, LIC Quarters, University Road, Pune 411016, India.
medico friend
circle
bulletin
JUNE
1982
Treatment of Acyte Doarrhoea m Children
Diarrhoea is the excessive loss of fluid and electro
lytes in stool and its treatment can be conceived as
two fold :
1 ) replacement of lost fluids and electrolytes---rehydration and
2 ) reduction of further losses of stool---- antidiarrhoeal therapy.
The first goal of rehydration with oral rehydration
solutions (ORS) and parenteral fluids has been discus
sed previously (MFC Bull. 47 — 48.)
Antimicrobials-very limited role.
This discussion is concerned with the many antidiarrhoeal preparations available in this country,
usually advertised as infallible, suitable for all
diarrhoeas and of low toxicity. Since most acute
diarrhoeal diseases are both self - limited and short lived, well designed double-blind and placebo contro
lled studies in which stool output or duration of
diarrhoea are measured and compared are required to
prove the efficacy of therapy. Tables 1 and II summarize
selected therapeutic trials A plus sign in the efficacy
column indicates that stool outputs were clinically and
statistically significently reduced.
Table I presents one classification of antidiarrhoeal
preparations, lists examples, describes efficacy as
demonstrated in therapeutic trials and lists side
effects. (2-4) The secretion-reducing drugs are poten
tially useful in the secretory diarrhoeas caused by
V. cholera: or toxogenic E. coli., and are all currently
experimental.
Note that oniy ORS has unquestioned efficacy with
low toxicity. ORS is the mainstay as it actually meets
both goals of diarrheoa treatment.
Antimicrobial therapy may also be considered anti
diarrhoeal, but since each organism must be treated
specifically, efficacy data is presented by organism in
Table II. Viruses probably are the most important
cause of diarrhoea in children; the organisms listed
account for a minority of cases in most locales.
Antimicrobial therapy may also reduce the excretion
and spread of organisms and this is detailed as “effect
on duration of positive culture. ” The antimicrobials
selected here are those to which the listed organisms
are usually sensitive in vitro. These antimicrobial
sensitivities vary, and local patterns os bacterial resi
stance should be monitored to select effective drugs.
Note that only diarrhoea associated with Shigella,1)
V. cholerae, (12, 13 ) giardiasis I1'1) and amoebiasis (15) are unequivocally benefitted by antimicrobial
therapy. It is important to note that six well designed
trials of antimicrobials for uncomplicated Salmonella
gastroenterilis all showed no effect of antimicrobial
therapy (5-10). Some of the more recently discovered
organisms have not yet been subjected to controlled
therapeutic trials.
In general a child with diarrhoea should receive
ORS. Current antidiarrhoeal preparations, despite
their long history of usage are ineffective or too toxic.
Although most diarrhoea in children is infectious, the
use of antimicrobials is currently justified only in those
children who have severe cholera or shigellosis.
Fortunately, bacillary dysentery and cholera are rela
tively easy to recognize clinically. Amoebiasis and
giardiasis can be identified with simple microscopy and
also respond to antimicrobials.
Nonspecific or
unidentified diarrhoeal disease is unlikely to improve
with antibiotic therapy.
M. C. Steinhoff,
Department of Child Health
CMC Hospital
Vellore-632 004.
(2)
In summary, current understanding of the pathoge
nesis of diarrhoea and recent careful studies of therapy
indicate the following :
1 ) ORS is safe for all children with diarrhoea.
2 ) Most antidiarrhoeal preparations are ineffective,
some, such as Lomotil, are too toxic for
children.
3 ) Only cholera, shigellosis, giardiasis and amoebiasis should be treated with antimicrobials.
The clinician’s problem is that he/she cannot know
the etiology of every case of diarrhoea, making
therapeutic choices difficult. I think this difficulty can
be eased somewhat by realizing that only a minority
( Continued on page 7 )
Table I
Antidiarrheai Therapy
Efficacy
Type
Example
Adsorbents (2)
Kaolin, pectin,
attapulgite, bismuth salts.
Atropine, hyoscyamine
0
Codeine, tincture of opium,
+
Anticholinergics
Opiates (3)
0
Lomotil, Immodium
Lactobacillus (4)
Absorption-increasing
Secretion-
Curd
oral glucose-electrolyte fluids
Aspirin,
decreasing
(experimental)
chlorpromazine
0
-4-
Side Effects
adsorption of antibiotics
and other drugs.
Salivary, ocular, and
cardiac parasy
mpatholytic effects
respiratory depression,
coma, prolongation of
shigellosis
none
Hypernatremia possible
salicylate toxicity,
hypotension,
dyskinesia.
Table II
Antimicrobial
Therapy
Decreased duration,
volume of diarrhoea
Organism (reference)
Selected Antimicrobials.
Escherichia coli
enteropathogenic
ampicillin, T/S
+
+
tetracycline, T/S
? 4-
? 4-
0
0
enterotoxigenic
Salmonella spp
(5-10)
Shigella spp (11)
V. cholerae (12, 13)
giardiasis (14)
amebiasis (15)
chloramphenicol,
ampicillin
neomycin, amoxycillin
T/S, nalidixic acid
++
tetracycline, T/S
.++
metronidazole
metronidazole
++
? = controlled studies have not been done in children
T/S = trimethoprim-sulfamethoxazole
Decreased duration of
positive culture.
++
++
++
(3)
RICE POWDER AS AN ALTERNATIVE OF SUCROSE IN ORAL
REWDRATION SOLUTION
Oral rehydration solution (ORS) has been used
successfully in the management of diarrhoea. It
has been found that glucose and sodium are coupled
in the small intestine and glucose accelerates the
absorption of solute and water. Sucrose replacing
comparatively expensive glucose in the ORS for all
practical purposes has been found to equally
satisfactory.
Recently Dr A Majid Molla of ICDDR, carried
out a study to examine the efficacy of ORS using a
cereal such as rice powder, in place of sugar.
The WHO recommended formula for ORS was
used, sodium 90 mMol, chloride 80 mMol, potassium
20 mMol, bicarbonate 30 mMol per litre. Sucrose
( 40g) was replaced by 30g of rice powder. Invitro
hydrolysis converts 80-86% of the rice powder into
glucose giving the WHO recommended amount of 20g
of glucose to be liberated in the intestinal lumen.
Rice powder was dissolved in water and cooked for a
few minutes to make a smooth liquid Electrolytes and
enough water were added to make one litre of solution.
The stool output of the sucrose group was in gene
ral higher than the rice powder group. The success
rate in the rice powder group was almost same as the
sucrose group.
Most of the failures were in cases where the intake
could not match the output due to excessive purging
and/or vomiting They were transferred to intravenous
therapy. The degree of dehydration and the purging
rate were directly related to failure of the ORS to
correct dehydration This was also true for standard
ORS ( ORS with sugar ).
The advantages of using rice powder for the ORS
are many. Starch is rapidly hydrolyzed in the intestinal
lumen by (salivary and pancreatic) amylase to glucose,
maltose, maltitriose and branched dextrine1. These
carbohydrates are further hydrolyzed to glucose by the
maltases of the brush border of the enterocytes2. Even
one-month old infants can digest and absorb a large
amount of starch3 as most of the active disaccharidases
are fully developed at birth4. Intraluminal digestion
of rice powder used in the ORS liberates monosaccha
ride glucose slowly, it causes no osmotic diarrhoea, as
seen when succrosc of glucose exceeds the recommen
ded amount in ORS. The possibility of increasing fluid
loss through osmotic diarrhoea also limits the amount
of sugar used in the ORS with rice powder releases the
glucose gradually and slowly in the intestine, it negates
the possibility of causing an osmotic drag of fluid from
the vascular space to gut lumen. This finding opens up
the possibility of using a higher concentration of
carbohydrate in the ORS, which in addition to provi
ding glucose as the vehicle for the transportation in
the absorption of the electrolytes would also provide
some energy’.
Rice is an unique starch containing the mixture of
two different polyglucoses, amylose and amylopectin.
It has 7-10% protein and very little electrolyte. As
mentioned earlier, acid hydrolysis converts 80-86% of
the rice powder into glucose. There are important
amino acids in the protein content of rice: glycine
30-36 mg; lysine 30-34 mg; leucine isoleucine 30-40
mg per lOOgm of rice3. Glycine has been known to
promote transportation of sodium from the intestinal
lumen c. ( Despite the protein content of rice, rice is
not a rich source of protein in the diet and the amount
of glycine may not be sufficient to promote the absorp
tion of sodium ).
The efficiency of the specific intestinal enzymes to
hydrolyze rice powder remains at a satisfactory level
during diarrhoea due to V. cholerae and E. coli-post
hydrolysis sugar content in stools passed in 24 hours
remained similar. Studies on assimilation of nutrients
have demonstrated that carbohydrate absorption from
a rice meal is least affected during diarrhoea caused
by cholera and enterotoxigenic E. coli; even in case
of invasive organisms like rotavirus or shigella,
this remains excellent.
Rice is the staple food of 60 %of the world’s popu
lation. In all the countries of Asia, where 50% of the
world’s population live, rice is grown and eaten. In
addition, r'ce is also the staple food to millions of
people in Africa and Latin America. Most of the
developing countries, where diarrhoea is a big problem
are located in these areas.
In Bangladesh one of the traditional treatments of
diarrhoea is to feed the patient soaked flattened rice
(China) to which salt and sugar has been added.
Rice is readily available even in the poorest homes.
It is also a traditionally familiar component of treat
ment of diarrhoea, hence would pose no cultural barrier
in its acceptance. Since there is no adverse effect like
osmotic drag in the intestine, it is desirable to place
more than 30 grams of rice powder per litre into the
ORS. The patient should drink enough fluid to match
the output. The higher starch content poses no hazard
and actually has a potential benefit of added caloric
density.
[ to be continued ]
(4)
Dear Friend,
I read with great interest Dr. C. Gopalan's comme
nts on my article ' Food requirements as a basis
for minimum wages. ’ I am very encouraged to note
that —
1)
The issue has interested an eminent nutritionist
like Dr. Gopalan.
2)
The final figure of minimum wage arrived at by
DR. Gopalan’s calculations is almost same as that
of mine.
3)
The balanced way in which he has reacted is quite
a lesson for us in MFC who often react in a very
aggressive and emotional fashion which creates more
heat than light.
Even if the final figure is same, I dare to differ on
some points with Dr. Gopalan.
11 Energy Requirements Dr. Gopalan assu
mes that the average body weight of male labourers
is 44 to 46 kg. instead of 55 kg. as assumed by ICMR
as reference body wight for Indian man. He has taken
this figure from 2 studies. The sample size in these
studies is 6 adult males in one and 30 in another.
These studies were primarily designed to measure the
calorie expenditure of male labourers by doing
metabolic studies. For such tedious studies obviously
sample cannot be too large. Hence these studies are
useful for knowing the calorie expenditure of
labourers of the given body weight, DR. Gopalan is
not justified in using the average weight of the small
sample from this study as the average weight of crores
of Indian males.
I do not know why ICMR has taken 55 kg. as
reference weight for Indian males. I am also not aware
of any study which gives average body weight of Indian
labourer, taking wide sample on National level. Hence
I am not in a position to comment what is average
weight of Indian labourers but obviously above two
studies can not be used for this purpose.
The second question which crops up is, are we
going to provide food for the existing low body
wieght and thus seal the fate of Indian labourer at the
present low body weight ? As the studies at NIN have
shown, Indian, by heredity or constitution are not
destined for a low body weight as was previously
thought and if provided with adequate food and other
care, an Indian child matches the Western standard of
growth & development. Hence it is chronic undernutrtion which has resulted in our present underweight
' pigmy ’ population. Unless this class is provided with
more food, the underw eight will persist So one should
provide the food required for person of optimum body
weight(55 or 65 kg) to break the the present bottle neck
and allow the labourer’s children to grow to
their fullest physical potentials. When treating a child
with marasmus, do we ever say that he should be
given calorks according to his present body weight ?
On the contrary he is given nutrition according to the
expected hody wieght for his age so that he can grow
to that optimum level.
Whiie calculating the calorie requirements for the
unemployed period of the labourers, DR. Gopalan
has assumed that their calorie requirements are those
of sedentary persons. The off duty w'ork and house
hold work that labourers, specially females, have to do is
much more strenuous than a sedentary class person has
to do The ASTRA study of rural energy patterns has
shown that rural women do on an average 8 hours of
domestic labour (collection of fire wood.fetching water,
cooking, carrying husban'ds food. Ivestock grazing )
expending 1010 calories per day on this work alone.
Obviously, even on unemployed days, the labourers
need more Calories than a sedentary person. Batliwala
has recently (EPW, Feb. 27) proposed an interesting
approach to bridge the energy deficiency by cutting
down domestic labour by poviding amenities like
electricity, water supply, easy fuel to the rural people
so that this huge energy expenditure on domestic work
is saved
DR. Gopalan has also not made any calorie
allowance for the periods of pregnancy and lactation.
As Kamala Jayarao has shown in her article, “ Who is
malnourished; Mother or the woman ? ” an average
woman spends about half of her reproductive life
(15 to 45 years) either in prenancy or lactation.
Thus it appears that Dr. Gopalan has underestima
ted the calorie needs of the labourers. This under
estimation is further aggravated severely by the small
family size of 4 as assumed by him.
(5)
2 ) Family Size :
3)
Dr. Gopalansuppports his calculating food allowances
only for a small family by saying that it is consistent
with National policy. Who decided this National
policy ? How is this figure of two children decided ?
Has any thought been given to why do poor need
and produce more children ? When 25 to 30% the
children die before the age of 5 years-and this average
figure will be still higher for the poor class-how can
we enforce that poor should stop at 2 only ? It is now
fairly accepted that poverty is the main reason, for
higher birth rate. Hence the slogans like ‘ Develop
ment is the best pill '.
Dr. Gopalan has aimed at providing a balanced
diet to the labourers. It is most welcome. As I was
operating within the framework of Page committee,
I couldn’t venture to ask for a balanced nutrition and
argued only for cereals and pulses. But let me point
out that the cost of balanced diet taken into
calculation by DR. Gopalan is one prevailing in 1979.
By'82, the costs have scaled up by at least 40%. For
calculations of minimum wages today, prices of 1982
have to be used.
4) Less wages for women.
The difference in wages for males and females
proposed by DR. Gopalan is not justified on the basis
of difference in work output because men and women
do different types of work. Men do physically strenuous
work while women do more skillful and tedious types
of operations. The output of two different categories
cannot be compared. But women usually put less
hours of labour (they go late on fields due to their
domestic duties) and on this ground unequal division
may be considered.
If food allowances are made only for 2 children
because such is the National policy now, what will the
poor do with their already existing extra children ?
starve and kill them ? Incidently many of these
‘ surplus ' children were bom when the National
policy was of 3 children or when there was no
National policy.
By making allowances for a smaller family of 4when the reality is that the poor have a family size of
5.6, the allowance for 4 will be distributed in the family
over 5.6 persons, obviously frustrating DR. Gopalan’s
efforts to provide minimum standard of life to the
poor and perpetuation of poverty will frustate all the
efforts to achieve the ‘ National goal ’ of family size of
four. It is a self defeating proposition.
Balanced diet
DR. Gopalan has touched the heart of the whole
problem when he stated “ The prescription of mini
mum wages will have only academic value if there is
no machinary for strict enforcement. ” In our are
we are facing difficulties in trying to enforce even the
existing minimum wage act of 4.5 Rs. per day. How
the minimum wage of 12 Rs. can be actualised ? But
then this is the next inescapable logical step of all this
exercise. May be other people can take over this
responsibility than we the medicos.
While one should agree with DR. Gopalan that
small family norms should be achieved, the methods
have to be different. Even though I am not proposing
an indefinitely large family, let me just point out that
for the purpose of land ceiling or urban wealth taxes,
there is no limit on the family size. The rich have the
facility to have more children to save their wealth In
the organised sector, the wages are calculated for a
family of five. In such context, restricting the minimum
wages of the poor so that they can maintain only a
family of four does not seem justified.
l) The average body weights of rural adults are
46-50 kg (males and 40-44 kg, (females) : National
Nutr. Monitoring Bureau, 1980). The figure 55 kg.
was fixed oy 1CMR arbitrarily when data on Indian
adults were not available. Now ICMR has attempted
to make suitable alterations.
While Dr Gopalan states at one place that “ many
of the assumptions in the above calculations are based
on a appreciation of the hard current realities and not
on “ idealistic ” consecration,” one fails to understand
why doesn't he accept the hard fact about the existing
family size of poor.
2 ) The comparison of energy provision for adults
and for a marasmic child is not correct. Since children
possess the growth potential, their requirements are
calculated on “ ideal weight. ” For adults, Since maxi
mum growth has stoped, calculations are made for
“ actual weight ”
—Editor
Abhay Bang
(6)
IIU£OGH£
During the last five years there has been a lot of
discussion on the new concept of treating diarrhoea.
The WHO produced a nice little booklet on this sub
ject in 1976. One quarterly newsletter ' Diarrhoea
Dialogue ’ is being produced by a WHO collaborating
centre. In its turn MFC has published an article * Oral
Rehydration ’ in Nov-Dec. issue, 1979. We are familiar
with the name of ‘ ORT’, ‘ ORS ' etc. - we, doctors,
even have memorised how many mEq of Sodium or
Potassium are there in one litre of WHO recommen
ded oral fluid.
So what ? Pharmaceutical companies are still pro
ducing ‘ rubbishy ’ anti-diarrhoeal preparations;
doctors are prescribing ‘ Chlorostrep ’, ' Pectokab
‘ Streptomagma ’, sometimes with ' Electral Saline
drips are immediately put in a bit more severely
dehydrated cases; ‘ quacks ’ are putting up a saline
drip for any case of diarrhoea and charging poor
villagers Rs. 10/- or more.
With this background, I want to fit in Somra some
where - I find it difficult. Somra wants himself to be
fitted in the more remote villages, on the distant village
markets on his old noisy bi-cycle with a tin-box and
pictures. He explains to the villagers gathered around
him, sometimes in tribal language, sometimes in Hindi‘ Take one litre of water, boil it, let it cool; then add
the whole content of the packet, stir it and start drinking
so long as diarrhoea continues. In case of vomiting...'
Tora can fill this gap correctly, he knows what to do in
case of vomiting. Once he brought his son 12 yrs old,
with severe diarrhoea and frequent vomiting. At first
Tora went to Somra and started giving oral fluid—but
the vomiting was a nuisance. In the evening we again
prepared another litre of rehydration fluid and started
feeding Tora’s son with a tea-spoon exactly at one
minute interval. After five such feeds we stopped
exactly for five minutes and started again. Soon Tora
had adopted the time intervals and continued in the
same manner throughout the night. In the morning
the boy walked back home, one mile away, with his
father. Let us go back to Somra. He explains ' In case
of vomiting give the fluid slow’ly with a spoon just
like in this picture, but never stop fluid in diarrhoea
and vomiting.’
Somra is a village health worker and it would not
be an exaggeration to say that he has saved many
lives with his rehydration packets. He knows this and
so is concerned to make them as widely available as
possible in remote village homes and in village shops
and markets. His work seems far removed from those
places where intellectual discussion take place about
ORT, where, for example, the merits of oral rehydra
tion as a ‘ home remedy ' are expounded and it is
explained that we mnst not make villagers dependent
on packets, we must use local ingredients.
But,
Somra says, in many homes even sugar is not available,
do we then use salt and water ? ’ Does that mean that
a serious case has to be transported to the centre for a
drip to be put up and antibiotics given ? Somra knows
that he can treat even serious cases with his rehydrat
ion packets and without antibiotics .. And more
importantly, he is promoting a tool with which the
villagers can fight against the doctors and quacks who
exploit them.
Even now, diarrhoea is a killer in many villages in
many parts of India. In the villages it does not kill
only the patient, but his/her family too. The exhorbi
tant charge ( often between Rs. 200/— to Rs. 300/- )
made by the doctor or a quack ( no difference ) for a
saline drip and few injections of ‘ vitamin B comp, ,
1 Baralgan ’, results in losing land, property, animals.
What causes diarrhoea ?
There is no doubt that we ‘ 11 have to find out the
causes (‘ aetiopathology ’ 1 before going to its treat
ment. The answer is - insecurity and exploitation in
earning, lack of proper housing, ignorance, superadded
by infection of enterovirus, shigella, E. coli and what
not.
Now treatment. We speak of anti-diarrhoeal
preparations, we say ‘ Ban Lomotil ’, at the best we
try to adopt ‘ scientific and appropriate ’ oral rehydra
tion therapy. In fact, all our discussions are centred
around the secondary-infection; we forget the primary
cause.
1 know that I am going into some other discussions.
Some may object : ‘ Now you are talking about some
thing which is not the job of the great ( ! ) medical
profession. Some may say : ‘ This is a political
discussion’, Some will simply agree — I would call it
intellectual nodding. So again to Somra. I talked to
him on this point. Somra knows the primary cause
very well - the question is how to treat it. Let all
Somras meet and discuss it.
Manan Ganguli,
Jagadishpur, Bihar
In his enthusiasm about ORT and CHW, perhaps
Manan is exaggerating a bit. Antibiotics and doctors
too have their place. Somra alone cannot decide
whether ORT alone is enough or whether and which
antibiotics are needed. Home made Jaggery - salt sodabicarb - water solution has some advantages and
some drawbacks compared to the ready-made packets
which Manan is campaigning for. A more objective
view point is needed.
Editor
n
(7)
( contd from page 2 )
of cases will be benefited by antibiotics. Therefore, the
clinician should use antibiotics only in those severe
cases which have a high probability of being caused
by one of the four organisms mentioned above. Thus
no mild case should receive antibiotics. Cases of very
frequent watery stools with vomiting which may be
cholera should be presumptively treated. Incidence of
cholera varies across this country and local patterns
will help a decision about cholera. (We at Vellore get
it in sporadic outbreaks). Severe bloody dysentery
with tenesmus and fever is probably shigellosis, and
should also be treated. (Local patterns vary for dysen
tery also, amoeba are rare in Vellore ). Chronic
diarrhoea may be giardiasis or amoebiasis and should
also be treated. These rules lead to the presumptive
treatment of only a minority of diarrhoea cases.
REFERENCES
1. WHO: A manual for the treatment of acute
diarrhoea. World Health organization ( WHO/
CDD/Ser/80.2) Geneva, 1980.
2. Portnoy BL, Du Pont HL, Pruitt D, et al : Antidiarrhoeal agents in the treatment of acute
diarrhoea in children.
J. Am. Med. Ass. 236 : 844-846, 1976
3. Du Pont HL, Hornick R : Adverrse effects of
Lomotil therapy in Shigellosis. J Am. Med. Ass.
226: 1525-1528, 1973
4. Pearce JL, Hamilton JR : Controlled trial of
orally administered lactobacilli in acute infantile
diarrhoea. J. Pediat. 84 : 261-262, 1974
5. Mac Donald WB, Friday, F, McEacharn M :
The effect of chloramphenical in salmonella
enteritis of infancy. Arch. Dis. Child
29 : 238-241, 1954
6. Petterson T, Klemola E Wager O : Treatment
of acute cases of Salmonella infection with
ampicillin and neomycin. Acta. Med. Scand.
175 : 185-190, 1964.
7. Effect of neomycin in non-invasive Salmonella
infection of the GI tract. Lancet 2: 1159-1161,
1970.
8. Kazemi M, Gumpert TG, Mark Ml: A controlled
trial of Salfatrimethoprim, ampicillin and no
therapy for salmonella gastroenteritis. J. Pediatr.
83 : 646-650, 1973.
9. Olarte DG, Trujillo SF1, Agendelo ON, et al :
Treatment of diarrhoea in malnourished infants
and children. Am J. Dis child. 127 : 379-388,
1974
10. Nelson JD, Kusmiesz H, Jackson LH, et al
Treatment of Salmonella :gastroenteritis thiw
ampicillin, amoxicillin, or placebo, Pediarics.
65 : 1125-1130, 1980.
11.
12.
13.
14.
15.
Nelson JD, Kusmiesz H, Jackson LH, et al:
Comparison of trimethoprim- sulfamethoxazole
and ampicillin therapy for shigellosis
in
ambulatory patients. J. Pediatr. 89: 491-493,
1976.
Lindenbaum J, Greenough WB. Islam MR :
Antibiotic therapy of cholera in children. Bull
WHO 37 : 529-538, 1967.
De S, Chauduri A, Duta D, et al : Doxycyline in
the treatment of cholera. Bull WHO 54 : 177179. 1976
Levi GC, de Avila CA, Neto VA : Efficacy of
various drugs for treatment of giardiasis. Am. J.
Trop. Med. Hyg. 26 : 564-565, 1977.
Rubidge CJ, Scragg JN, Powell SJ : Treatment of
children with acute amoebic dysentery. Arch Dis
Child 45 : 196-197, 1970.
Only 13 out of 51
Commercial Antidiarrhoeals found useful.
Nitin Sane a MFC-subsriber in Pune has studied
51 commonly used commercial preparations sold as
antidiarrhoeals to find that only 13 of these contained
ingredients (in adequate doses) whose efficacy has been
scientifically proved. The rest 38 preparations were
found to be useless on account of various reasons.
Their breakdown is as followsPreparations which are useless because they contain
a ) drugs in insufficient amount-20 products.
b ) irrelevent drugs for example chlorpheniramine ..
9 products maleate )
c ) drugs of doubtful value.
(for example-pectin, kaolin) ...25 products
d ) drugs not indicated in diarrhoea
(for example-streptomycin ........ 21 products.
e ) drugs which should not be used on account of
their toxicity
(for example-diodoquin)........ Il products.
f ) drugs in wrong combination
(for example combination of chloramphenical
with streptomycin) ...... 14 products.
Many preparations contained more than one of the
undesirable features centioned above.
Preparations containing Metronidazol, furazolidone
were considered as useful even if these were acco
mpanied by ingredients like pectin, kaolin which are
of doubtful value.
The preparations given in the November 1981 issue
of Monthly Index of Medical Specialities [ MIMS ]
under the heading “ antidiarrhoeals " were taken for
this study. MIMS has not included single-ingredient
brands of Ampicillin, trmethoprim-sulfamethoxazole
etc. in this list. The above analysis is based on the
latest editions of Textbooks of Pharmacology by
Goodman-Gillmon, Martindale etc.
RN. 27565/76
mfc bulletin : June 1982
FROM THE EDITOR’S DESK
Given below is a statement regarding imports of
bulk drugs into the country. This was published in
“ Drugs and Pharmaceuticals ” I expect the informa
tion is genuine.
You will notice that money spent on some is almost
unchanged, some increased, some decreased. The last
category bothers me. I, however, do not know
whether the reduction in import indicates an increase
in indigenous manafacture ( a heartening news ) or
whether it is a true reduction ( highly disconcerting ).
There is no reason to suspect that the prices of these
drugs in the international market have come down.
On the other hand, in view of the world wide inflation,
the apparent reduction in import should be less than
the real reduction.
The drugs whose import shows a fall include anthelmenthics, antileprotics, antituberculars, antiepileptics,
(excluding barbiturates), vitamins and vaccines. The
ones whose import has substantially increased include
anticancers, antihypertensives, cardiac glycosides. It is
necessary that we know the true meaning of it. Can
anyone give us details of indigenously manufactured
bulk drugs, in the same time periods as given here ?
That may set our hearts to rest or give us points to
ponder and issues to be set right depending on the
available facts. Can I expect some interested member
of MFC or reader of the Bulletin, to help us ?
Drug imports during 1980-81
According to the Directorate General of the Health
Services, in 1980-81 the value of imports of bulk
drug intermediates was Rs. 56.93 crore, a fall of 13.0%
on the previous year’s total of 65.4 crore. The table
below gives the breakdown category wise of the bulk
drug imports for 1979-80 and 1980-81.
Editorial Committee :
anant phadke
christa manjrekar
ravi narayan
ulhas jajoo
kamala jayarao, EDITOR
Regd, No. PNC-328
1979-80.
(Rs. )akhs)
1980-81
(Rs lakhs)
324.5
Anaesthetics/Analgesics
81.3
Anthelmintics
49.7
Anti-amoebics
2288.7
Antibiotics
240.0
Sulpha drugs
58.2
Antidiabetics
140.0
Antihistaminics
30.8
Antileprotics
Anticancers
39.0
Antituberculars
366.7
149.0
Antimalarials
Antidepressants
16.1
Anti-epileptics
18.0
Antihypertensives
51.7
Anticholinergics
19.6
Antitussives and Expectorants
18.8
Blood preparations
28.2
Diuretics (mercurial)
14.9
Diuretics (non-mercurial)
170.1
243.4
Endocrines
Sympathomimetics
108 0
Vitamins
664.3
Hormones (& intermediates)
176.9
Minerals
79.3
Haematinics
01.6
Coronary vasodilators
35.1
Digitalis/cardiac glycosides
05.9
102.3
Tranquillisers
X-ray diagnostics
48.7
00.7
Immunologicals
Vaccines
57.0
Barbiturates
17.3
Miscellaneous New drugs
243.4
Drug intermediates
66EO
385.9
30.7
51.2
2473.5
356.6
NA
53.9
13.3
51.2
171.2
190.6
14.0
06.0
103.3
05.1
05.1
10.3
05.3
106.7
248.5
99.2
360.3
198.5
138.6
NA
47.4
10.6
72.3
37.7
NA
41.2
15.8
297.6
91.3
6545.5
5692.8
~
T
,
Drug Imported
Total
Kamala Jayarao
Views & opinions expressed in the bulletin are those of the authors and
not necessarily of the organisation.
Annual subscription- New rates from July 1981-lnland Rs. 15/- For
Foreign Countries- By Sea Mail US 8 4/By Air Mail tor Asia US 8 6;
Europe, Africa- US 89, USA Canada-US 811.
Edited by- Kamala Jayarao, A-9, staff Quarters, National Institute of
Nutrition P. O. Jamai Osmania, Hyderabad. 500007. Printed by- Anant
Phadke at Balbodh Mudranalaya, Pune 30. Published by-Anant Phadke for
Medico Friend Circle, 50, L1C Quarters, University Road, Pune 411016, India.
80
medico friend
circle
bulletin
AUGUST
1982
High Cost Medicine
A mother entered the out patient department
of a hospital situated deep in a tribal area of
Chandrapur
district,
carrying
her 3 year
old child. The chid was burnt around knee
joint, the previous night. To save themselves
from severe cold, mother and child slept near the
fire and the child accidentally put its legover the
Ere. Mother had to walk 10 miles to reach this
hospital. The doctor talked sympathetically and
applied a bulky dressing around the joint so that
it should not slip. An hour later, mother was back
with another child. The first child walked in with
her. The dressing was missing. The doctor could
see that all his efforts were in vain and started
scolding the mother for her neglect. Doctor attri
buted this behaviour of the mother to the free servi
ces offered to them. According to him the patient
and the mother did not deserve the compasionate
behaviour bestowed on them. He refused to exa
mine the other child. He asked the mother what
she did with the big bandage. Mother went out, andwas back within a minute with two LANGOTIES
(underwears for the child) made out of the same
cloth. Doctor could not help than to distressfully
look at the naked child standing before him.
I was an observer of the whole drama. There
was a real challenge—the naked poverty and the
real priority needs of the people. If one wishes to
take medicine to ‘THE PEOPLE’ one must consi
der whether it is within their limits to bear. A
socially conscious doctor thus will start thinking of
1 low cost medicine ’ - effective, cheap and appro
*
priatc in the existing socio-economic situation. A
series of questions start as to why allopathic medi
cine is so costly today. We will try to go through
litem.
.•
-
{A
Profit motivation of the drug indnstry :
i)
Do you know what is the difference between
the production cost and the .market cost of Tetra
cycline capsule ? (6 to 8,times).
ii)
Can you guess the extent of overpricing a
multinational drug company can force on the local
company to import its raw materials ? ( See
appendix- 1 ).
iii)
Why the same drugs under different brand
names have marked difference in Consumer price ?
iv)
What is the motivation behind the gifts
offered to medical practitioners ?.
v)
What do you feel is the reason for lavish
samples that the drug representatives offer ?
(Hathi Committee Report 1975 “The scale of
sampling has been lavish and has a particular signi
ficance in India since majority of general practiti
oners dispense the drugs they prescribed and may
therefore charge their patients for drugs they have
been acquired free. ”).
vii)
What is the drug representative / doctor
ratio in our country as compared to western coun
tries ? Why ?
Ulhas N. Jajoo
Bajaj wadi, Wardha, 442114
Drug Representative
Underdeveloped
1 :
country (India)
Developed countries 1 ;
Doctor ratio
4
30
vii) Why drugs banned in Western world are
still being sold in our country ? c.g.
Pkenacetin, Amidopyrine, Analgin, Lomotil,
Depo-provera, Proluton Depot, etc.
viii)
Why substandard and outdated drugs reach
under-developed countries for marketing ?
ix)
Do you leel thar all the drug combinations
in the market have a rationale? Experts have
listed 100 drugs as essential. There arc
30.000 drug preparations in Indian market.
Sub-committee of the drugs consultative
committee has recommended a list of fixed
dose combinations to be weeded out from
the market.
x)
Do you feel all drugs available in the market
today have proven efficacy and safety ?
xi)
How many genuine new drugs come in the
market every year ? Arc these imitations
with slight modifications of the existing
drugs ?
(“Drugs & Third World” 1974 quotedOutof 1500 drug patents introduced in the
year, 3% were genuine new drugs, 10%
were major modifications and 87% were
purely imitative drugs).
xii)
Have you studied the fluctuations in the
market price of Gentamycin over last 10
years ? Why so ?
(1969 - 35 Rs. per 80 mg vial
(1980 - 5.80 Rs. per 80 my vial)
xiii)
Why docs drug industry generously support
medical seminars and conferences ?
Without their financial help do you feel these
conferences can be held with same vigour ?
a)
Having to wake up a child more than once
in the morning
b)
Child unwilling to go to school or leaves
pencils behind.
c)
Child complaining about other children at
school.
The drug companies want consumers to believe
that with one vitamin-forte every day, he will stay
active and alert all the day; tiredness, irritability,
lack of concentration arc all symptoms of vitamin
starvation, which if neglected can get worse.)
- (Vitamin C lessens smoking hazards ! )
- (Gripewater helps infants suffering from con
vulsions ! )
xv)
Have you noted double standards in
instructions ?
Migril -
Country
U.S.A.
U.K.
Africa/Asia
Maximum weekly dose
10 mg
12 mg
24 mg
Ancoloxin (Meclazine HCI 50 mg )
U.S.A. - Not to prescribe during pregnancy
in view of the teratogenic effects of
the drug in rats.
U.K. - Undesirable during first trime
ster of pregnancy, the administration
of Ancoloxin may be warranted if
vomiting is severe.
Africa & Third world - Primarily indicated in
the treatment of nausea, vomiting of pregnancy.
xvi)
Do you know that the brand names are
usually written in bold letters ? Caution and toxi
city in small letters which arc read five times less
than the headline ?
xvii)
How do you feel about the following sales
promotion methods ?
xiv)
Have you noted the ways in which drugs
arc advertised ?
- A prize of 10,000/- Rs. to a practitioner who
prescribes certain number of prescriptions in
fixed number of months or prescribes only one
company product.
A Vitamin forte advertisement lists symptoms
that arc associated with Vitamin starvation like -
- For every 100 boxes of a drug ordered, 20 boxes
are given free of charge (Botins with purchase).
3
Given a ‘cut’ for every 100 prescriptions of a
certain brand.
xviii) How about these cultural activities ?
- Chocolate Companies show films on Cocoa grow
ing in schools & run essay competitions.
- radio cpiiz or sponsoring athclctic events.
- ‘Beautiful baby contest’ to promote sale of infant
formula. Entry' to these competitions is typically'
restricted only' by numbr of bottle tops or wra
ppers. Draws arc often televised or broadcasted
and reported in press.
xix)
How much y'ou can think the packaging
cost can be ?
( Packged food
- Ingredient
- Packing
- Labour
56%
33%
11 % )
xx)
How do you find this statement from a
Marketing Manager- “Advertising does more than
merely sell products, it informs, educates, changes
attitudes and builds images ? What do we sell ?
“ Never a product, always an idea.”
The function of advertising agencies is to seekto influence human behaviour in ways favourable to
the interests of their clients or to “ indoctrinate ”
them?.
xxi)
Have you heard of “Drug black-mail ?”
With 85-90% of drug patents in developing
countries, multinational firms can virtually' hold
third world countries with inadequately' developed
resources, to ransom. Thus alpha-methyl-dopa
can vanish from market. Scarcity' can develop or
essential drugs like anti-tubercular and anti-leprosy
drugs. Who has heard of scarcity of tonics,
Vitamins and cough - cold remedies ?
Too many investigations :
Open up any book of Modern Medicine, you
will find a big list of investigations. Try' to calcu
late the cost of these investigations. I am sure, in
majority you will find costs exceeding the cost of
treatment. Arc all these investigations absolutely
necessary ? In our context don’t you feel simple
blood sugar estimation, X-ray, an ECG, is
also a costly commodity' ? What are the criteria to
guide us, before a patient is subjected for costly
investigations ? Will you like to ask the following
questions before sending the patient for such inve
stigations ?
a)
b)
Will it alter the management?
Will it help in proper and definitive diag
nosis ?
c ) Can paticnt/socicty' afford it ?
d)
What is the risk involved ? Do benefits overweigh the risks ?
Will you justify' a battery' of investigations, (i)
Without a thorough bed-side examination ? (ii)
Without considering senitivity or specificity of the
diagnostic tool ? (iii) For research purpose which
is totally irrelevant to our health priority ?
I am quoting a few examples, which a student
of medicine can scan through the literature and
reach his own conclusionsDO YOU FEEL THAT
a)
each young hypertensive must be investigated
thoroughly with IVP; aortography; Urine plus
serum renin levels, scanning; V. M. A. estimation
etc. ?
b) each case of viral hepatitis should
subjected to all the liver function tests ?
be
c ) every' case admitted in medicine with cough
need to undergo routine X-ray chest ?
d) each case of head - injury' should undergo
computerised tomography for the diagnosis of sub
dural haematoma ?
e) blood-gas analysis is necessary in the diagnosis
of chronic obstructive airway disease ?
f)
ultra-sonography is much more useful than oral
cholecystography in diagnosing cholelithiasis ?
g) each case of massive upper G. 1. T. bleeding
must undergo emergency' fibre-optic gastroscopy' ?
Overshoot by the doctors :
- Do you feel acute diarrhoea in adult always
requires antibiotics ?
( 4)
- Do you feel upper respiratory infections need to
be covered with antibiotics ?
( In India an estimated 12% of all prescriptions
for antibiotics are for common cold).
— Don't yon feel corticosteroids are generally over
used and misused ?
— Do you feel thal some-times surgery is underta
ken intentionlly when not indicated e. g. Tonsils, Uterus, Appendix........
( According to W. H. O. there are 75 ways
doctors misuse drugs. Commonest is over use of
drugs.
- Too large quantites
- For too long duration.
- Entirely unnecessary drug.
- Too many drugs at the same time.
Medical Corruption :
- Have you heard of surgeons asking for money
after putting the patient on operation table ?
- Have you heard of bribe being routinely given
for admission in a T. B. Hospital ?
- Have you heard of links between the “ Drug
Shop Owners’’ and the doctors?
- Have you heard of “Rings” that the doctors
have in big cities ?
— Do you feel the results of drug trials published
in the medical journals or quoted by drug sales
representatives are unbiased ?
(Clinical trials of new compounds conducted by
physicians doing clinical trials in 1973 whose
work was spot checked by the food and drug adm
inistration were guilty of a range of unethical
practices, including giving wrong doses and falsi
fying records. I n 1 /3rd of all reports submitted,
the trial was never done at all, in another 1 /3rd it
did not follow the manufacturer’s protocol and
only' in final third were there rcults of any' scientific
value. )
Costly Hospitalisation :
This includes- Doctor’s salary, salary of nursing
staff; hospital management and maintenance.
Few facts to note- Bed occupancy of private hospitals in India on
average is 40-50%.
- An extensive peripheral health infrastructure
cuts down total expenditure on health.
— Much of the doctor’s responsibilities can be
handed over to less skilled but trained stall.
(To be concluded in the September issue.)
Apptndix - I
Product
Multinational
import price
to Colombia
(US dollars)
Chlordiazepoxidc 1250
Diazepam
2500
Metronidazole
390
Hydrochlorthiazide 90
Tetracycline base 250
Promethazine
140
Indomethacin
640
Quotation Percentage
of over
to more
developed pricing
countries
18.90-20
6,155
30-45.55
6,478
11-15
3,398
1,530.7
5.2
948
23.5
654.3
19.7
611
72.5
ATTENTION PLEASE
The campaign on diarrnoea
Please send me cuttings of articles published in
the lay-press through your efforts on importance
of oral rehydration, proper diet in diarrhoea and
misuse of drugs in diarrhoea. Please inform us
about the response of the people to this mass-edu
cational campaign that we have launched. This
information is necessary' to plan the future action
on this issue at the coming midannual Executive
Committee meet of MFC at the end of this month.
This meet will be followed immediately by' the
drug-issue-meet a VHAI-MFC collaboration.
SAHEL1, a Women’s Resource Centre in Delhi
and Voluntary Health Association of India have
jointly prepared a poster warning women not to
take any tablets or injections to confirm the suspic
ion of being pregnant. The text points out that
these drugs may' cause congenital defects in your
baby, that this drug-test is unreliable, that these
drugs can not induce abortion. The text it in Hindi
and figures of a pregnant woman, a deformed baby
and tablets, injections renders the poster useful to
semiliterate population. Printed copies are avai
lable at Saheli. 10, Nijamuddin (East), New Delhi
-14, and at VHAI, C -14, Community' Centre, S.
D. A. New Delhi-16 at Rs. 1/— per piece. Bulk
orders will get a concession.
□
(5)
KEEPING TRACK-1
Dear Friends,
lhe year 1982 has been a year of travel for us,
giving us an opportunity to meet friends and share
experiences and perspectives- Meeting many who
ate responding creatively to the problems and
issues of Health care in the field has been a rich
experience. At a meeting with Anant in Pune, in
April this year, we discussed the need for most of
out members to keep in touch with the growing
medical literature on the issues relevant to the mfc
quest. Though the bulletin has tried to keep the
members in touch with ideas in the field, many
would like to get to original sources. I have agreed
to start a column entitled ‘KEEPING TRACK’ to
enable mfc members to do just that- keep track of
thought- provoking and interesting books and
reports, easily available for one to read. The column
will present notes and extracts from these books
not with a purpose of reviewing it, within the
context of any well defined Mfc perspective (which
is still being gelled!) but as an indication to readers
of the scope and message of the book. Readers are
invited to read and react to the generalisations of
the authors by virtue of their own field experience.
It was proposed that a few copies of some of these
should be available to MFC members as a sort of
circulating library. While this can possibly be
considered in our future meetings, we start off this
column with two books on the Indian Health
Scene.
An Alternative System Of Health Care Service In India :
J. P. NAIK : Alternatives in Development Scri
es, Indian Council of Social Science Research,
Allied Publishers, New Delhi, 1977 : Rs. 10.-00
litis booklet presents three articles by J. P. Naik,
D. Bancrji and Jacob Chandy-threc pioneers who
seriously question the philosophical framework and
organisation of health care service in India and
raise issues and alternatives. It also presents impo
rtant extracts from the Rcpart of the Group on
Medical Education and Support Manpower (Srivastava Report-see Bullatin No. 21 ) These articles
place in perspective the growing national debate
on alternatives ro the existing sysrem which Dr.
Ramalingaswamy (Director General, ICMR) has
d'esenbed as “ over centralised, over-expensive,
over professionalised over-urbanised and over-my
stified ”
J. P. Naik raises issues regarding target groups,
emphasis on Preventive and Protective aspects choice
of technology, agents of health care, infrastructure,
drugs, involvement of the people and educational
aspects in his oration on the alternative systemProfessor Bancjec categorically emphasises that
formation of an alternative is essentially a political
question and makes a plea for greater democrat!'
zation of the political system. This will “ subord
inate medical technology to the interests of the
community; it will be demystified, deprofessiona
lised, deburcaucratised and decommercialised. ”
Professor Chandy makes a plea to consider Health
Science as distinctly different from medical science
and introduce it as a compulsory part of the school
curriculum so that there is ‘‘ a scientific, awareness
created through formal education for the attain
ment and maintenance of health. ”
Alternative Approaches To Health Care :
ICMR ( 1978 ) ( available on request gratis
from ICMR, Ansari Nagar, New Delhi 110029).
A Report of an ICMR Seminar held in Hyder
abad in November 1976 and includes fourteen long
case studies and a few short case studies on health
projects in India, mostly in the voluntary, non
governmental sector. Also it includes a review of
the issues raised by these projects and delineation
of areas of further research.
An important report since it is the first one in
thirty years where the Indian Council of Medical
Research accepts Health Care Delivery as an
important area of research.
Important for MFC readers to sec these case
studies, not as alternative approaches in themselves
as portrayed by the project-wallahs but as raising
issues which could be part of an alternative strategy
in an alternative socio-political milieu !
Ravi Narayan
(6)
Calcutta National Welfare Organisation
The Calcutta National Welfare Organisation
(CNWO), has been in existence for approximately
two years now. On 13 th March 1982, the orga
nisation hosted a seminar on “ Rural Health Prob
lems and the Role of Doctors”. In the course of
the seminar, and in conversation with the organi
sers and some members of the organisation, the
following impressions were gained of their aims,
objectives and methods.
The organisation arose out of a need felt by
students in N. R. Sarkar Medical college and R.
G. Kar medical college to identify the flaws in the
medical system in the country. Some of them felt
that most members of the medical profession knew
that our health care delivery system fell far short
of deliverying the goods, but the exact reason for
this failure was not apparent. They therefore reso
lved to set up a forum for study and action in this
direction. The result was CNWO. With the
opinion that action would be an educative experi
ence and also -would point towards solutions to
problems that appeared, two medical centres were
set up in peripheral areas of Calcutta. Drugs,
manpower and other requirements for these centres
were obtained by the students, own efforts.- These
centres differed from the Lions and Rotary club
affairs, in this aspect- the students who went there
went with the understanding that the medical
centre served a double purpose; for the medical
personnel, it highlighted the problems in delivery
of medical care and demonstrated how closely
health care was linked with social, cultural, econ
omic and political factors; for the people it was a
needed service. Because of the dedication of the
members, their willingness to work in all weathers
and in the most adverse circumstances, they were
ableto attret many members.
A conscious effort was made by the members to
involve all levels of medical personnel in their
activity, so that every one from students to profess
ors could participate in the learning experi
ence, and contribute to the solution of problems
identified. Efforts arc also being maed to unite all
streams of medicine existing in the country on a
scientific basis so that a verified and effective hea
lth care dclivcy system can be evolved, and the
existing mistrust and hostility' between different
systems of medicine might be removed.
CNWO hosted a seminar referred to above on
13 th March 1982. The seminar served at least
two purposes. Firstly it served to focus the health
problems existing in the rural areas, and some of
the difficulties that arose when trying to solve them
through governmental agencies and, secondly it
enabled the organisers to meet people with similar
ideas from other parts of India. The organisation
also launched a magazine called ‘People’s Health’
to coordinate the activities of similar organisations
already existing in other parts of India, to keep in
touch with such organisations and also to serve as
a forum to debate tbc problems in health care
delivery. The address of the organisation is;
Dr. D. Dutta, Sec CNWO 8, Raja Gurudas
Street, Calcutta 700 006.
Thomas George
(Madras Medical College)
It is sad that we were not aware of CNWO.
This reflects the deficient communication amongst
unorthodox groups. We hope that MFC and
CNWO would come together on activities of mu
tual interest.
— Editor
People’s Institute Ibr Development and Training
is in need of an interested lady-doctor to run a
health-programme and health training in Shahdol
district of Madhya Pradesh where one of thenspear-head teams in working. The health pro
gramme has definite social, economic and orga
nizational overtones. Those interested should write
to Prof. Subhachari Das Gupta, P I D T, 2 Kaushalya Park, Hau/. Khas, New Delhi-16.
★
(7)
dear friend
Manan in his letter ( see MFC Bulletin 76 )
makes the following points while commenting on
Ml C. in general and the bulletin and the Meet in
particular
s'-) MFC is not unique in its existence and struc
ture.
b)
Bulletin docs not fulfil its role completely.
c) i) Meet also does not fulfil its purpose because
people discuss some topic “ independent of its
social demand. ”
ii)
Meet does not end in a positive action
programme.
I would like to respond to these one by one.
a)
MFC is unique in its existence and structure
beesuse it is the only organisation of its kind
comprising of medicos and paramedicos who arc
socially conscious, anti-establishment and who arc
seeking alternatives to this dehumanised and irra
tional system of health care. (Compare this with
several other medical associations.) It is unique as
the only voice heard from within the medical
profession in favour of an egalitarian, community
based and rational health care system amidst the
cacophony of anti CHWs, pro-multinational and
other elitist pronounements by other medical orga
nisations. Fd just like to point out here that it
was Abhay Bang of MFC who pointed out the
unscientific bias in Page Committee’s report on
Minimum wages and not any association of nutri
tionists; it was MFC-VHAI who campaigned
against misuse of EP forte; not the IMA.
It is in this context one can and should be
optimistic about MFC’s development and progress
( I think Manan contradicts himself here, by poin
ting out on the one hand “the potential of MFC to
serve a purposeful role” and asking in the same
breath what there is to be optimistic about?) If he
means the real potential, one which exists in reality
and not the ideal one-which should bc-thcn, that
exactly is what should be optimistic about, for
what else is the source of this potential if not the
progress sq far ?
b ) MFC being an organisation of socially
committed medicos, the bulletin thereof as Anant
rightly points out has to act as a propagator of its
commitments to alternate health strategies, rational
therapeutics and socially relevant views on health,
besides acting as a medium of discussion amongst
its members. Only a polemical organ of a political
organisation can have the sole purpose of being
only a medium of debate which the MFC is certa
inly not, its ‘political’ role being limited to providing
on the basis of scientific evidence, issues in the field
of medical care for political action.
c) (i) This comment of Manan’s on the themes
of the MFC Meet is totally baseless. In every
Meet, the subject to be discussed was chosen for
the precise reason of it being socially relevant (e.g.
misuse of drugs, role of CHW cte.) Manan should
have, before coming to any conclusion on this point,
examined the themes of all the meets and pointed
out which ones were really “ independent of social
demand”.
(ii) Considering the fact that MFC’s primary
role is not that of an activist organisation and also
that most of its members do not have MFC as
their No. 1 priority, the action programme decided
at Tara (Campaign against misuse of drugs in
diarrhoea ), was in my opinion, adequate. Whether
the actions are carried out is to be seen.
This does not mean thet I do not concede any
shortcomings in MFC’s functioning or lethargy in
the members. We do need to take another look at
the way in which wc function, the way in which
we conduct our discussions and also the priority
wc attach to MFC. Wc still need to be more disc
iplined in the matters of discussing topics, deciding
on a programme, and most important on implem
enting it. Except a few members, wc still do not
attach significance to contributing to the Bulletui.
Actions decided upon at the Meet arc not followed
up properly. All these need to be rectified before
MFC’s potential is truly realised. Wc also need to
form a common perspective on certain fundame
ntal issues like the scope of Community Health
projeots in improving the quality of peoples, lives,
or criteria by which a Community Health care
system is to be evaluated. In this respect, I agree
with Mananthat the Meet will be of little value
“ unless one finds a comman ground leading to
action ”• The potential exists and the time has
come to concretise it,-
Diiruv ,1/ank </, Nipani .
RN. 27565/76
mfc bulletin : AUGUST 1982
Regd No. P. N. C.W-16
FROM THE EDITOR’S DESK
Banning Hormonal Pregnancy drugs-only a partial
victor.
The Tinies of India of 1st July carried a heart
ening news for us.- “ The Government has decided
to put a total ban on the manufacture and market
ing of all the pregnancy testing medicines in the
country.... The decision to ban the fixed dose com
binations of oestrogen and progesterone, prescribed
only for the indication of secondary amenorrhoca
and similar gynaecological disorders has been taken
in consultation with medical experts in view of
reports of large-scale misuse of these preparations
for the termination of pregnancy. ”
Though the Govt, may not admit it, the camp
aign against the misuse of these drugs by Voluntary
Health Association of India, MFC, Arogya Dakshata Mandal, Peoples Science Movement and
some journalists can proudly claim that their
efforts, initiative built up a pressure on the Govt.
to take this decision. But as usual, even the first
annucemcnt was marred by a clause—“ The stipu
lated cut-oil' date for the manufacture of these
drugs has been fixed as December 1982 and cut-off
date for sale in the market - June 30, 1983.” Why
this delay, time lag of almost a year before these
potentially dangerous drugs stop reaching the con
sumers ? 1 he official news release has accepted the
dangerous character of these drugs by saying “The
use of these drugs in pregnancy could lead to the
birth of babies having congenital abnormalities,
experts say. ” But even then the ban docs not
come into immt diate effect. This is perhaps in
deference to the concern of the drug manufacturers
that they will sustain losses. Docs the concern for
their losses over-ride that for the newborn babies
who may be born without limbs or with congenital
heart defect ?
Within a fortnight of this first announcement,
the deputy minister of Health, Miss. Kumud Joshi
has announced that “ there is no ban on the use of
Editorial Committee:
anant phadke
christa manjrckar
ravi narayan
|(
ulhas jajoo
kamala jayaraojEDITOR
drugs for pregnancy tests........ at present hormonal
products were indicated only for secondary amen
orrhoca not due to pregnancy ............. The firms
marketing these hormonal products had also been
directed in March 1982, to include the warning
reading as “ not to be used for pregnancy test and
in suspected cases of pregnancy ” on the cartons. ”
[Times, 16-7-82] This announcement does not
directly say that the earlier decision is invalid and
that the Govt, has abandoned the idea of banning
these preparations. It only says that at present
there is no ban. But this appears to be the thin edge
of a wedge. The ban will not come at all unless
all of us continue to build a presssure on all sides in
favour of AN IMMEDIATE' BAN. Please note
that the news docs not make clear whether the
warning would be in bold letters or not.
Recent editions of text books of Gynaecology'
do not recommend preparations containing high
dose combination of ocstrogcn-progestcronc for any
case of amenorrhoca. A patient with secondary
amenorrhoca of more than equivalent of 3 cycles,
(or six months) is given high doses of progesterone
after confirming that she is not pregnant. If this
“ progesterone challenge ” as it is called, fails to
elicit a response, ( start menstruation ) a course of
oestrogen is given, followed by progesterone after
this “ oestrogen-priming. ” Thus there is no indi
cation for the use of these high dose combinations
and the patient will not lose anything if these pre
parations are banned.
We appeal to all those concerned about prevening avoidable congentital malformations due to
these drugs to rouse public opinion in various
ways and to write to the Drug Controller of India
[Ministry of Health, Nirman Bhawan, N. Delhi-16]
requesting him not to go back from the earlier
decision but to go ahead with an immediate ban on
these preparations.
Anant Phadke
Views & opinions expressed in the bulletin arc those of the authors and
not necessarily of the organisation.
Annual Sllbscription-Ncw rates from July 1981-Inland Rs. 15/-. For
Foreign Countries- By Sea Mail US J 4/. By Air Mail - Asia US $ 6;
Europe, Africa- US $9; USA, Canada-US $ 11.
Edited by-Karnala Jayarao, A-9, Stall’ Quarters, National Institute of
Nutrition P. O. Jamai Osmania, Hyderabad. 500007. Printed by-Anant
Phadke at Nanda Printers, Pune 30. Published by- Anant Phadke for
Medico Friend Circle,50, LI C Quarters, University Road, Pune 16, India
medico friend
circle
bulletin
81
47/1, (
SEPTEMER 1982
Low-Cost Drag Therapy
(This article is the continuation of the discussion
initiated by the author in his article in the Augustissue-Editor.)
In the preceding piece I had put forward some
points about high cost medicine. In this piece we
will grope towards low cost drug therapy.
Will the Govt dare to do it ?
In India, the Hathi Committe report had sugge
sted abolishing brand names of 13 essential drug
formulitions in an attempt to begin breaking vice
like monopoly. Those formulations included certain
commonly used pain killers, anti-anaemics, anti
biotics, antihypertensive and anti-parasitic drugs.
In 1979 the government was reported to have
decided to abolish brand names of just five drugsanalgin, aspirin, ferrous sulphate, chlorpromazine
and piperazine salts-brands which arc manufactured
by multinationals. It came as no surprise that the
move was stoutly opposed. Not so strangely. Indian
Pharmaceuticals firms also resisted it and it was
quickly abandoned at least for the time being.
Sometime ago, the authorities had decided to
force some semblance of sanity in the marketing
of vitamins in India by permitting the sale of only
two categories of formulations termed ‘therapeutic’
and ‘ prophylactic. ’ Accordingly multi- vitamin
manufacturers in India are reported to have subm
itted their new price lists for the two categories to
the Ministry of Petroleum and chemicals. The
ministry was supposed to grant price approvals by
Dec.. 1978. For reasons best known to itself, the
deadline was progressively postponed from then to
July 1979, then to Sept., 1979 and finally to Dec,
1979.
Since then, however, the Ministry has maintain
ed a mysterious silence over the whole subject,
prompting doubts that the whole matter has been
indefinitely shelved. A study of the Economic Tinies
a while ago revealed that there were 68 companies
that would be affected by new legislation, of which
as many as 24 were multinationals. The 571 multi
vitamin formulations that have flooded Indian
market, almost all would have to be reformulated,
at a cost of Rs. 1. 5 crores to the manufacturers.
Enough reason, surely, to delay things as far as
possible !
Why docs this happen ?
Dependance on multinationals for essential
minimum drugs.
Pattern of drug production is irrational and
irrelevant to our health, needs c.g. for Anti T. B.
& leprosy drugs even half the requirement is not
met. D. D. S. remains non available for 6 months.
For many drugs installed capacity is far less than
licenced capacity ( 50% for insulin). Production
of non-essential items like tonics exceed licenced
capacity. Primaquin and trimethoprim (for malaria)
arc not produced locally at all and imports of
chloroquin exceeds the production. Vaccine against
influenza, mumps, measles and polio arc not prod
uced in India at all. What does it mean ? We lack
political will.
Will the voluntary sector take the lead ?
Can the voluntary institutionsadopt a policy of prescribing by generic names
only ?
build up a policy for dealing with persuasive
pressure tactics of sales representives ?
Ulhas Jajoo
Bajaj wadi, wardha
limit its formulary to the essential minimum
drugs in accordance with Hathi Committee list
giving priority to generic drugs ?
adopt a policy of preparing some drug prepara
tion c. g. Ointments, Syrups, drops, IV fluids,
tablets ?
develop a social audit system, analysing say
prescribing practices, treatment cost analysis, hospi
tal stay etc. ?
lay down local standards for prescribing and
investigating common illnesses ?
develop extensive peripheral
health care
netwok, draining the central hospital ?
Does a conscientised health personnel have any scope ?
Will a medical prctitioncropenly denounce the drug industry’s selfish
motives ?
keep away from persuasive practices of drug
industry,
gifts, research finance to scholars
money for medical seminars, etc.
have an open mind towards other forms of
treatment— seek information, be willing to incor
porate them.
think and believe that he is a consumer first
and then prescribe ?
seek out the consumer movement in his/her
areas and join hands with them in their fight for
justice ?
I believe that a conscientious physician can
reduce the cost of drug th-rapy considerably by
observing certain rules for oneself When and if he
is convinced about the need to give drugs, the
following points should be kept in mind The considerations which should guide the sele
ction of appropriate drugs or the drug preparations
arc
i) Cost of the drug : Allopathic medicines, due
to the selling game of the drug industry, arc beyond
the capacity of the needy. Choice of the cheapest
brand; selection of generically available drug as
much as possible; and preparation of some comm
only used drug preparations in one’s own dispe
nsary; arc the only ways which a conscientised
medical practitioner can follow in the existing
structure.
ft' Quality of drug : Drug market is teeming
with corruption. A nongcnuinc drug selection
must be avoided Practical solution for a lone
medical practitoner is to study the cost of a drug
available in different brand names and then select
one for use which is cheapest and also qualit
atively expected to be good. Drug industry’s propa
ganda about the bioavailability of the product need
not be accepted blindly until there is a scientific
proof to support the claim.
iii)
The form in which drug is given : The drug
available in form of an injection or available in
syrupy form is much more costly than the same
amount of drug available as tablet or capsules. For
example,
a)
a child if it can swallow the powdered drug,
syrupy base can be avoided. A tablet or a capsule
can be broken, and the powder can be mixed with
honey or sugar juice to mask the bitter taste.
Please avoid giving uncrushed tablets/capsules to a
child lest it acts as a foreign body.
b)
Avoid injections if the tablet/capsule can
be swallowed or can be put through Ryle s tube
in the hospital.
c)
Eye applicaps are much cheaper than the
ointments available in tube. Fach eye applicap (c.g.
Chloromycetin) can be used for total 6 applications
if it is opened up from the tail end of the tip.
iv)
Use of simple drugs (home remedies) : Some
Home remedies arc accessible, cheap and provide
a symptomatic relief. These remedies should be
encouraged for the symptomatic treatment.
e. g- ‘Harda’ or ‘ Jcsthamad’ as silogogues to
suppress irritative upper respiratory cough.
'Tulsi kada’ or ‘Haldi’ for fomentation of a red
throat.
v)
Integration with other pathics. One must
realise the limitations of allopathic science today.
Allopathic drugs have offered a use for infective
diseases, but for the vast majority of other probl
ems it still remains a palliative help. Homeopathy
science particularly claims better results for allergic
conditions. A controlled study of such remedies
from other pathics is worth undertaking.
Preparation of some common drugs
A. Skin ointments : The skin ointments can be
prepared in small amounts daily by using butter,
Dalda, cream, paraffin or coconut oil as a base.
The locally available base is particularly preferred
because it is much cheaper and is not required to
be purchased in the bulk (sec table appended
on P. 7).
(3)
KEEPING
(This column has been started from last month to
enable readers to keep track of important thoughts
currents, ideas in the field of analysis of health caresystems- Editor )
Limits to Medicine- Medical Nemesis. The
Expropriation of Health.
Ivan Illicit, Penguin Books (Pelican 1977.)
The foremost critic of trends in modern Medical
Practice, Illicit presents thought-provoking evide
nce that “ the medical establishment has become a
major threat to health and the disabling impact of
professional control over medicine has reached the
proportions of an epidemic ”, Discussing Iatroge
nesis in great detail, Illicit makes one of the most
forthright pleas for 'demystification of medical
matters’ and exhorts lay people to reclaim greater
autonomy over health decision making. He writes
that “ A professional and physician-based health
care system that has grown beyond critical bounds
is sickening for three reasons. It must produce
clinical damage that outweighs its potential bene
fits, it cannot but enhance even as it obscures the
political conditions that render society unhealthy;
and it tends to mystify and expropriate the power
of the individual to heal himself and to shape his
or her own environment. The medical and para
medical monopoly over hygienic methodology and
technology is a glaring example of the political
misuse of scientific achievement to strengthen ind
ustrial rather than personal growth”. The book
is divided imto four parts and deals with Clinical
Iatrogenesis in Part I, Social Iatrogenesis (medicalisation of life ) in Part 11, Cultural Iatrogenesis
(disabling impact of medical ideology on personal
stamina) in Part III and The Politics of Health
in Part IV. Interestingly Illicit warns that ‘‘if
contemporary medicine aims at making it unnece
ssary for people to feel or to heal, eco-medicine
promises to meet their alienated desire for a plastic
womb”. He also warns that gullible patients
should not be relieved of the blame for their thera
peutic greed by making physicians scapegoats.
Health must be seen as a virtue, as a right and
people must be involved in “ political action rein
forcing an ethical awakening-that will limit medi
cal therapies because they (the people) want to
conserve their opportunities and powers to heal ”,
A thought provoking book to be read by all mfc
members,
TRACK- II
Medical Hubris-a Reply To Ivan Illicit
David Horrobin, Churchill Livingstone, 1978.
This book should be read after the cat Her one
since it is the first serious critique of Illicit’s book.
Horrobin dots not dispute the facts presented by
Illicit, but disputes his interpretation. In spite p
all the inaccuracies and exaggerations in Illicit’s
books that he attempts to point out, he concedes
that Illicit’s first sentence “ The medical establish
ment has become a major threat to health is right
and that this book could prove to be one of the
key medical documents of the second half of the
twentieth century ”.
In a very open and level headed assessment of
the criticisms of Modern Medical Practice, the
author gives his own tentative suggestions to bring
about a change in this situation. He makes a
plea fora) More “Science” in medicine to eliminate the
errors encouraged by warm emotion that ‘ to do
something must always be better than to do
nothing ’;
b)
Less use of technology by subjecting them to
stricter control to determine whether they really
benefit the patient;
(Continued on pagc-6)
Low-Cost Medicine (contd.)
B. Eye-Ear Drops : Can be prepared with lesser
cost if the sterilised salt of the drug (available in
the market in sterilised form as injections) is diss
olved in appropriate amount of distilled water for
fresh use ( Sec table appended on page no 7. )
These solutions, ointments should be prepared in
small quantities so that they are not required to be
stored for a long time.
References :
“ Insult or Injury.” Charles Medawar. Social
Audit.
2.
Drug Dis-information: Charles Medawar,
Social Audit.
3.
Health for the millions: April —June 1981
Issue.
4.
Science today: Sept., 1981.
5.
Therapeutic Guide lines. African Medical &
Research Foundation
6, Drugging the Indian: Shivanand Karkal in
“DEBONAIR July 1980”.
1.
Why PHCs have failed
Reflections of an intern
through periodic visits. 1 he working staff of the
P. H. C. have been traditonally arranged in the
form of a pyramid, the doctors coming at the top.
Doctors arc extremely reluctant to be posted at
P. II. C.s for it is literally a professional dead end.
There is a fear of sophisticate skills becoming
rusty. Also, a fear of an academic fade out due
to abscence of the type of stimulating atmosphere
that one feels one obtains in city hospitals and
urban practice. Another sorepoint for the P. H. C.
doctors is the unsatisfactory working conditions,
There is an unhealthy preoccupation among
lack of adequate stall’ and equipment, primitive
health administrators and politicians to evaluate
living quarters and a salary that hardly compen
the success of a programme in terms of the money
sates for the troubles that have to be suffered.
and resources expended rather than the results
Very few among the staff may report for duty
achieved. This attitude has led to a classic example
regularly. Even those staff who do report for duty
of overexpectation and under achicvmcnt.
do so at their convenience. All this goes on with
the full connivance of an indifferent medical
If an objective analysis is to be made in terms
officer who is rarely exemplary as far as perform
of standards of community health-Neonatal/infantance of his own duties are concerned.
child mortality, morbidity indices, effectiveness of
USELESS EUIPMENTS AND DRUGS
public health measures in the control of epidemics
All this is not helped by the fact that equipment
etc. then the only conclussion can be-that the sett
and drugs available at the average P. H. C. arc of
ing up of P. H. C.s and their functioning have
spartan nature. Refrigerators do not work (these
been a miserable failure, at no time reaching the
arc often gifts made by W. H. O., UNICEF etc.),
targeted goals. The only fields where a respectable
sterilisers do not exist, syringes and needles are of
degree of success has been achieved are those of
such poor quality that most of the injectable spills
mass immunization programmes, maternal health
out, bandages & dressings arc dirty & obviously
and family planning. Even here especially as far
unsterile, catheters arc inheard of ( I haven’t seen
as immunization programmes arc concerned, the
one in the setting of a P. H. C.), microscopes are
success is in most part due to the large scale parti
used solely for the purpose of the malaria progra
cipation of voluntary and international agencies.
mme & arc not available for TC/DC, urine exam.
As for family planning the programme can be
stool exam etc. (this list of absent or malfunctioning
called a success only as far as meeting of targets is
equipment can be extended endlessly). As for the
concerned. The enormous expenditure of men and
drugs stock-it is laughably inadequate. The only
materials is such that the cost effectiveness of the
drugs availrable with any degree of abundance and
whole programme would be questionable.
consistency are the therapeutically insignificant
What arc the factors that have inhibited the
ones- sulfadimidine tabs, multivitamins, A. P. C.
functioning of P. H. C.s in the expected manner ?
•( God only knows why this combination is still
This I can say with the limited experience I
allowed), antidiarrhoeals (either—Diphenoxylate or
gained during a couple of months of rural
phthaly sulfa thiazole), inj Tetracycline, inj B 12,
internship.
antituberculous drugs is usually the entire inventory
UNMOTIVATED STAFF
ol dings available. With this much of drugs &
P. H. C.’s are isolated units of health care.
equipment the examination & treatment of patients
Interaction with each other is nonexistent while
even by the most idealistic doctor rapidly degener
their only connection with the nearest hospitals is
ates into a hypocritical farce. A long & disorderly
Primary Health Centre is a post-independence
phenomenon consistent with the stated objectives
ol successive governments namely-assuring the
rural masses of a minimum health facilities. While
the working of these P. H. C.s is subject to frequent
audit and inquiry by govt, bodies, no independent
survey has been conducted to analyse the human
aspects of the issue - aspects which can be glossed
over by cleverly displayed statistics, making deaths
and disease seem like distant facts.
(5 )
queue of patients aw ait attention as an overworked
& impatient doctor performs a cursory & indiffe
rent examination dishing out prescriptions empiri
cally (a permutation and combinations of'the
limited ciioice available). The notion of the pati
ent that capsule is better than a tablet and an
injection is a cureall is encouraged by the doctor
who cateis to these notions by hastening to prescr
ibe .m injection (in such a manner litres & litres
ol cyanocobalamin arc poured into patients ). At
best the P. H. C.s can be described as pill dispen
sing machines, tonnes and tonnes ofMVT, SDT &
APC being unloaded on a public that cannot afford
a leasonable alternative. Thus it would be nothing
but foolishness to imagine that these P. If. C.s
are serving the health needs of the rural population.
Like the drugs they dispense they arc merely plac
ebos for the politician who have to show’ ‘results’.
The ‘ results ’ being buildings, staff, & equipment
not the health of the community.
IS THERE AN ALTERNATIVE ?
Based on our experience with P.H.C.s we
must conclude that the whole concept in the pres
ent form of implementation has been an utter fail
ure. P. H. C. s have been conceived as outposts
of medical care- an attempt being made to take
them to the very doorsteps of the people. To this
end they have been burdened with a complete list
of programmes, targets & quotas which they are
not suited to carry out due to the lack of matching
infrastructure ( in the form of drugs, equipment &
maintenance). As compared to P. H. C.s, small
hospitals may serve the needs in a better fashion.
With the present limitations, the only alternative
to P.H.C.s in my opinion, would be to open
small fully equipped hospitals in rural areas with
adequate complement of speciality staff (surgery,
medicine, Dental, ENT, opth., obstetrics .& gyna
ecology, pediatrics). One such ‘Rural Mini Hosp
ital can be opened to serve the 7-8 lakh popul
ation previously catered to by 10 P.H.C.s. This con
centration may lead to better standards, attraction
of better medical talent to rural centres, ieduction
of wastage & inefficiency (that are inevitable in a
larger operation) and better utilization of available
infrastructure. P.H.C.s can be replaced by prim
ary health workers. The primary health care sho
uld be the responsibility of P.H. W.s; for, afterall
the standard of medical care presently available
in P. H. C.s can be adequately & more efficiently
delivered by w'cll trained P.H. W.s. Health care
in the country is at cross roads. Any meaningful
solution can result only from a fuller understanding
of the issues involved by the concerned authorities.
Enlightened opinion from the medical community
can change the deplorable state of affairs. Such
involvement and participation has been strangely
lacking. Until then the present farcical set up
will continue unchanged by health administrators
seeking shortcuts & make do’s.
5.
Swaminathan
Stanley Hospital, Madras 6.
Educational Campaign Against Diarrhoea
In Pune all the leading dailies have published
articles on diarrhoea written by members of the
Lok-Vidnyan-Sanghatana. I have prepared a small
12 page pamphlet in Marathi for LVS on dia
rrhoea and its management. 1000 copies have been
rapidly sold out. The. LVS has made a pictorial
exhibition on diarrhoea and oral rehydration which
is being show'll in various bastis. The pamphlet
has been translated into Gujarathi by Rashmi
Kapadia and his friends. A small cyclostyled note
on how to give oral rehydration has been sent to
all the district news-papers in Maharashtra by
Arogya Dakshata Mandal in Pune. It was publish
ed by many news-papers. This Mandal is also pre
paring a in Marathi pamphlet on diarrhoea and its
management.
Dhruv Mankad and his collegues in Nipani
distributed a one page instruction sheet during a
recent out break in Nipani on how to give oral
rehydration. Dhruv has also prepared a “ Dear
doctor / chemist ” letter on diarrhoea like the one
on Oestrogen-progcsteronc forte. Vimal Balsubramanyam has written an article on diarrhoea in
the Daily - Telegraph of Calcutta. Articles written
by other friends have as yet not been published.
Those who want a copy of the back-ground paper
prepared by Dilip Joshi can still write to me along
with a money-order of Rs. 5/The next issue will contain a report on the
decisions made at the Jaipur meet and at the MPG
Executive Committee meet at Tilonia.
— Anam Phadke
(6)
DEAR FRIEND
I do not wish to disagree with the editorial
comments (July 82) about prevention or control of
tuberculosis. But your readers may be interested
to know' the experience of our health project at
Chirner in Uran Taluka (Raigad District) during
the last eight years.
Apart from other health interventions T. B.
diagnostic programme has been an important part
of our efforts in the area. The first major diagn
ostic camp was in May 1976 and several others
were conducted in the following five years, last
one in 1980. Our method was house to house
survey by village volunteers and later CHVs and
screening by Maharashtra State Anti-T. B. Associ
ation. About 120 cases have been diagnosed during
this time. As patients have tended to come from
variable distances it is not easy to give incidence
figures, although an attempt was made by noting
down the patients’ addresses.
I w’ill comment only on the situation in Chirner
(Population 3,800) about which our knowledge is
most complete and not comment on the surroun
ding population which has also benefited to some
extent from our efforts. We were able to detect 10
paticnts/1000 population in Chirner. With the help
of the local Sarpanch and other leaders in the
village as well as the Community Health Volunt
eers appointed by the Government in 1978 wc
have tried to ensure that every diagnosed person
takes the treatment and I can say that we have
succeeded in a significant way in improving com
pliance.
Wc visit Chirner only in a fortnight. Our
impressions arc based on the patients that
come to us (apart from the several house to house
surveys- last in 1980). But the number of patients
• with tuberculosis that have come to our notice has
come down dramatically. While a fresh case was
seen in 1975 and 1976 at least once a month, in
.the last two years 1980 and 1981 (same is true
of 1982 ) there have been only one or two
cases arising among the local population in the
whole year. Only new cases were among those
who had gone to live in Thana, Panvel or Bombay
for a job and had come back to Chirner for rest
after they were diagnosed. During these eight
years the economic condition has improved, but
only marginally. In 1977 an economic survey
conducted by Mrs. C. K. Dalaya of Economics'
Department of Ruia College, Bombay indicated
that per capita GNP of Chirner was about l/3rd'
of the GNP of India at the time. Wc do not yet
have a proper road nor a resident qualified doctor;
But prevalence of tuberculosis in the village seems
to have reduced.
Although it is conventional wisdom to say that
tuberculosis is a socio-economic disease, if you can
reduce the number of patients who go round infe
cting others, there is no doubt at all that prevale
nce of the disease will reduce substantially. Ibis
is quite easy to achieve in small communities if
you can win the co-operation of all the people.
In larger cities it is a Flerculcan task.
We can say with reasonable confidence that the
new' born babies in Chirmer arc not exposed to the
tubercular germ in the air, although they come in
contact with several hundred people every day.
Although they continue to live in small huts and
houses, with insufficient ventilation they seem to
escape tuberculosis. From this experience I have
come to believe that it is not impossible for us to
get rid of tuberculosis even before wc are rid of
poverty.
V. C. Tai walker
Bombay-8
Keeping Track-II continued from page -3
c) Attempts to be made to keep medical institu
tions as small as possible and only for those who
strictly need them;
d) Assess professional training and prescribe
levels of training actually required to enable people
to do jobs effectively and cut out unjustifiable part
of courses;
c)
Challenge the discrepancy between the high
ideals which doctors often profess and their perso
nal life styles and ensure that the profession should
be more humane and less a ' certain road to
wealth and security’ so that the rightly motivated
people arc attracted to it.
These changes should be made at four main
levels ; o( the individual doctor, ol the organisation
ol the piofession, of the relationship betwen govern
ment and medicine and medicine related indus
tries, and of the medical school.
A book which puts Illich’s criticism in proper
perspective.
_
A. Ointments
1. Corticosteroid
2. Antibiotic
Drug ol
choice
Market
Preparation
Cost in
Rupees
How to prepare
Cost in
Rupees
Betamethasone 0.125%
or Dexamethasone
0-125%
a) Neomycin 1%
Betnovate
(Glaxo)
4.10/5gm.
1.4440.10
1.54/5gi
Neomycin
sulphate 0.5%
(archcm Aristo)
Terramycin 3%
(Pfizer)
1.35/10gm.
0.3040.20
0.50/
10 gm.
Bctnovet-N
(Glaxo)
4.24/5gm.
12 tabs, of Betamethasone
powdered (Paran) 41 TSF of base
1/3 cap. of neomycin
(Unichem 350 mg)
2 TSF of base
1 /5 cap. tetracycline
(Paran) +
1 TSF base
12 tabs Betamethasone
powdered (Paran) 41 /6 cap of neomycin
(Unichem 350 gm) -f1 TSF base
2 tabs of enterovioform
(250 mg CIBA) +
4 TSF base
12 Tabs Betamethasone
(Paran) 41/2 Tab Enterovioform -f1 TSF of base
3gm salicylic acid -}6 TSF of base
3 gm Sulphur 46 TSF of base
b) Terramyc.ini %
3. Corticosteroid +
Antibiotic
Betamethasone 1.25%
+
Ncomycine 1%
4. Hydroxyquinoline
Vioform cream
Quninidochlor 3%
or
(CIBA)
Di-iodohydroxyquinoline3%
Betamethasone 1.25%
Betnovct-C
(Glaxo)
+
Quinidochlor 3%
5. Corticosteroid +
Hydroxyqinoline
1.76/5gm.
1.97/20gm.
4.24/5gm.
Salicylic acid
10%
Sulphur 10%
Mycozol
(Parke & Davis)
Eskamcl
i) Corticosteroid
Dexamethasone
1%
Betnesol eye
drop
(Glaxo)
4.10/3 ml.
ii) Antibiotic
eye drops
Chloromycetin
1%
Vanmycetin4%
(Fairdeal)
2.29/5 ml.
ii) Corticoteroid-fAntibiotics
Dexamethasone 1%
Chloromycetin 1%
Pyrimone
(Fairdeal)
5.43/5 ml.
6. Keratolytics
7. Sulphur
2.19/28gm.
4.00/28gm.
0.8 -f0.18/
0.10______ 5gm.
1.44-t0.1540.10
1-69/
5gm.
0.2040.40
0.60/
20gm.
1.4440.05
1.10
2.59/
5gm.
0.3040.60
0.30-p
0.60
0.90/
30gm.
0.90/
30gm.
4 00
0.35
4.35/
8 ml.
0.304-
0.50/
0.20
5 ml.
B Topical Eye Drugs
e
Dexamethasone vial
(Biochcm) 4Add distilled water to
make 8 millilitres
Inj. Chloromycetin in
powder form (Biochcm)
0.5 gm 45 cc. distilled water
Corticosteroid eye drop
+
80 mg. Chloromycetin
powder dissolved in water
I
water ^,make 8 cc
4.00
0.50
4.85/
8. ml.
0.35
mfc bulletin : SEPTEMBER 1982
Regd No. P. N. C.W-96
FROM THE EDITOR’S DESK
Ainbftg the various engagements the Prime
Minister was to fulfil during her recent visit to the
U. S . one was to meet the Indian Scientists wor
king there. This, according to the newspaper
reports, was to find and evolve ways to bring back
the scientists to work in India. Whoever advises
the Prime Minister on such matters, seem to har
bour the misconception that what primarily ails
our Science and Technology, is the loss of talentquantitative and qualitative. Be that as it may,
the newspaper report started a different chain of
thoughts in my mind.
Docs the term scientists include the medical
doctors ? Arc any altempts made to bring back the
doctors too ? When the issue of brain drain is
discussed, somethings remain unsaid. But they arc
there, in between the lines, if one wishes to read
them. It seems to be implied that our research
laboratories arc so equipped and maintained that
they can utilise the advanced training acquired
abroad ; our hospitals arc too ill-equipped to do so.
This is true. Many of our research laboratories
have good funds, suffer less red-tapisom and beauracratic pressures. The workers in the research
Institutes have greater freedom. This is not true
of our hospitals.
Concerned, or ever perhaps obsessed with the
urban-rural disparctics, MFC has more or less
neglected the urban health care system. In reality,
our urban and teaching hospitals arc nothing to
be proud of In a comparative analysis of funds,
personnel and equipment available in research
institutes and urban hospitals, the latter fare very
poorly.
Although the term ‘ Scientists ’ includes people
in variours fields and research institutes deal with
Editorial Committee:
anant phadke
christa manjrekar
ravi narayan
ulhas jajoo
kamala jayarao EDITOR
equally varied fields, as individuals concerned with
health care we may look only into the medical
field. The analysis may hold good for other fieldstoo. Research institutes arc set up and exist at
public expense. They arc not there to help indi
vidual scientists to further their own interests.
They are supposed to find solutions for the countrv’s problems, and thus aid progress of the nation.
The solutions worked out have to be implemented
in the field. In this case, the term field also in
cludes hospitals. If, therefore, the hospitals have
no facilities, arc ill-equipped and ill-staffed, howwill the efforts of the research workers bear
true fruit ?
Secondly, while on the one hand we wish our
scientists and technologists to return home, what
arc we doing with the doctors ? We arc actively
encouraging the brain-drain to the Middle-East
and Africa-all in name of helping the developing,
less developed, least developed, undeveloped coun
tries. What happens to development in the health
and medical fields in our own country ? Those
going to such countries and working in their
district and rural hospitals, mind you, arc not just
fresh graduates Our professors and senior lecturcers
are to be found there.
The MFC has been exercised about setting up
of super-speciality units in teaching hospitals. But
let us remember, that such hospitals arc very few.
The majority of the urban hospitals are also in a
deplorable state. Let us not forget or ignore this.
frying to attract workers back to our research
laboratories but actively draining out the medical
specialists seems, to me, another glaring instance
of wrong planning.
Kamala Jaya Rao
©
ts
Views & opinions expressed in the bulletin are those of the authors and
not necessarily of the organisation.
Annual Subscription-New rates from July 1981-InIand Rs. 15/-. For
Foreign Countries- By Sea Mail US S 4/. By Air Mail - Asia US $ G;
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Edited by- Kamala Jayarao, A-9, Staff Quarters, National Institute of
Nutrition P. O. Jamai Osmania, Hyderabad. 500007. Printed by-Anant
Phadke at Nanda Printers, Pune 30. Published by- Anant Phadke for
Medico Friend Circle,50, LIC Quarters, University Road, Pune 16 India
medico friend
circle
bulletin
AUGUST, 1983
STATISTICAL MALPRACTICE IN DRUG PROMOTION :
A CASE-STUDY FROM BRAZIL
Cesar G. Victora
INTRODUCTION
Drug corporations have been accused of
providing Latin American physicians with mis
leading information about their products by
exaggerating their indications and minimising
their hazards [1]. Such practices have also
been reported for several other developed and
peripheral countries [2-6].
The purpose of the present paper is to show
how faulty, misleading statistics have also been
employed in order to influence the prescribing
habits of Brazilian doctors. During a 6-month
period in 1979, all advertisements delivered to
Q Internal Medicine specialists in a private
group practice in the city of Pelotas, Brazil
were examined. These totalled over 350
materials ranging from full reports of clinical
trials (always accompanied by a promotional
leaflet) to a unsubstantiated claims on the
properties of particular products with any
references. The very diverse nature of these
promotional materials makes it possible to
establish specific figures on the prevelances of
the different types of fallacies, since the
majority of advertisements avoided details of
sampling, diagnostic criteria, measurements of
outcome or statistical analysis of the evidence
being employed. The examples below, however,
include only those fallacies which occurred
3 or more times in the materials surveyed.
COMMON TYPES OF FALLACIES
Biased sampling
The antibiotic phosphomycin is advertised
as being -100° effective in chronic urinary
tract infections". The small print of the paper
supplied with the advertisement, however,
informs that this assertion was based on
a sample of eight patients with chronic
U.T.I. obtained after excluding "those whose
urine
contained phosphomycin-resistant
bacteria". The 100° figure, after all, is not so
impressive.
Inexistence of control groups
This was the commonest fallacy in the
survey. For example, diphenidol (an anti
emetic) is quoted to be 96° effective in
the control of vomiting in children. As then.
is no information on the length of observation
of each child, nor on the existence of a
control group, the figure being quoted is
meaningless.
Small experimental groups
The advertisement for a cold remedy
reproduces the results of a trial in which 100°
of the patients receiving the preparation
showed improvement of symptoms. The small
print reveals that the treatment group included
only five patients. It is understandable that
clinical trial involving rare diseases would not
be able to include many patients, but it is im
possible to accept such results when the dis
order being studied is the common cold.
Non-significant differences
A sulfamethoxazole-trimethoprim combina
tion is advertised as being superior to the
tetracyclines for the treatment of acute
exacerbations of chronic bronchitis. The
statement, however, is not supported by the
evidence supplied by the manufacturer, since
the differences (Table I) do not reach statis
tical significance.
Fallacious comparisons
Comparisons of efficacy.
Mefenamic acid
is compared to acetaminophen and codeine
in the treatment of "osteoarthritis, rheumatoid
arthritis, intervertebral disk herniation and non
specific rheumatism". These comparisons,
however, make little sense, as the problems
involved are relieved by the anti-inflammatory,
as well as by the analgesic properties of
mefenamic acid, whereas the two other drugs
possess only the latter effects [7], The adver
tised drug should have been compared to
others with both properties. Such as aspirin,
ibrupofen, oxyphenbutazone, etc.
Comparisons of adverse reactions.
An
advertising campaign for acetaminophen inclu
ded the distribution of two leaflets entitled
"The stomach and aspirin" and "Why risk?" The
first makes no reference to the product
being promoted, but includes citations from
27 articles on the adverse gastric effects of
aspirin, headed by the assertion that "its risks
often outweigh its benefits". The second adver
tisement, which contains information on
acetaminophen, shows an endoscopic photograph
of the stomach of "a 24-year-old woman who
erythromycin in a table listing the plasma
concentrations of each antibiotic necessary for
killing different species of bacteria. Such a
comparison is not valid, however, since the two
drugs arc pharmacologically distinct, and the
fact that a lesser quantity of erythromycin
is not per se an indication of any superiority.
A better indicator of a drug's usefulness
is the therapeutic ratio, that is, the balance
between its efficacy and undesirable effects [9].
Table 1
Tig-I Efficacy of miconazole and two other drugs in topical
fungal infections.
Comparison of the efficacies of sulfamethoxazole-lrimelhoprim (SMX-TMP) and tetracyclines in the treatment of
'acute exacerbations of chronic bronchitis', as it appeared
in a promotional leaflet (significance levels not quoted
in the original)
Trial
SMX-TMP x tetracycline
SMX-TMP x dimethylchiortetracycline
?o
Cures
No. patients
in group
76
60
81
67
98
96
27
24
Misleading graphs
This was the second commonest fallacy
identified in the materials surveyed. An
advertisement for miconazole, for example,
compares the efficacy of this agent with
that of two competing drugs - clotrimazole
and haloprogin - by depicting these as three
circles (Fig. 1). The first drug, clotrimazole,
quoted to be effective in 59-70% of topical
fungal infections, is represented by a circle
with an area of about 14 cm2. The second,
haloprogin, which is 68-92% effective, is
shown as a 41 cm2 circle, whereas the adver
tised drug miconazole, being 75-100% effec
tive, is depicted as a 133 cm2 circle. By
looking at the areas of the circles, it appears
that the efficacy of the product being adver
tised is 10 times larger than that of the
first, and over 3 times larger than that
of the second, whereas the actual ratios
should be approximately 1.4 and 1.1 respec
tively.
*
P
0.30
0.37
* By the X test with one degree of freedom in each trial.
had ingested nine grams of aspirin in a 12-hour
period, after intake of alcoholic beverages".
Since the dosage is considerably larger than the
maximum recommended, and alcohol is also
a gastric irritant, it should be expected that
inflammation of the gastric mucosa would be
observed. Both advertisements omit the fact
that although it does not seem to cause
significant gastric side-effects, acetaminophen
is on the whole considered to have more
serious and irreversible toxic effects than
aspirin, and that it should be reserved to those
patients who cannot tolerate the former [8.9]
.
*
Comparisons of potency. The publicity for
a brand of amoxycillin compares this drug to
DISCUSSION
The examples described above are not
intended to represent, or to quantitate,’ the
whole spectrum of faulty medical advertising
in the country. They should rather be seen
as instances in which faulty methodology
has been applied with commercial purposes.
It is hoped that the documentation of these
errors will lead physicians to analyze with
greater caution the information which is
supplied to them by drug corporations. This
* The lesser toxicity of aspirin relative to that of
paracetemol has been recently questioned. The present
paper, however, refers to promotional materials distributed
in 1979, when the prevailing opinion among pharmacological
authors was than aspirin was a safer drug [7-9].
2
medical schools in the country was incorpora
ted into the teaching of the specialities during
the seventies. In many places, the overall
result, rather than being better integrated
teaching was that the. subject lost the impor
tance it once had. This is strongly felt by
medical students, who have given a high
priority to the re-establishment of therapeutics
as a separate discipline in st veral lists of
demands of their unions.
is particularly relevant for Third World
countries, where the actions of these companies
seem to suffer less governmental restrictions
than in the developed world.
It might be argued that such methodo
logical fallacies are the result of incompetence,
rather than ill intent. Actually, as Huff
has noted, "as long as the errors remain one
sided, it is not easy to attribute them to
bungling or accident" [10]. In the promotional
materials surveyed, not a single example
was found of a fallacy which would make the
advertised product seem worse.
(c) Continuing education of physicians.
Continuing education must overcome many
difficulties, especially in a large country such
as Brazil to be effective. There are some
simple measures, however, which may have
a beneficial effect. One of such is the distri
bution of independent, non-profit publications
such as the Medical Letter on Drugs and
Therapeutics, or the Drug and Therapeutics
Bulletin. These publications besides reviewing
specific products, may help to create a healthy
skepticism among doctors regarding the
claims of manufacturers.
It should also be stressed that many
of the advertisements provided information
which was apparently of good scientific quality.
The proportion of 'sound' advertisements, again,
is hard to quantify since so many of the
pieces examined did not include enough detail
for a judgement to be reached. The mere
existence of the errors described, however,
should be sufficient to arise concern about
the subject of medical advertising.
The establishment of ethical codes to be
followed by the industry in their advertise
ments to the medical profession is a contro
versial subject, of very difficult enforcement.
This matter certainly deserves detailed exa
mination by medical associations and unions
and by the Ethics Committees of the Regional
Medical Councils. With very few exceptions,
these do not seem to have dedicated enough
attention to the subject up to the present.
Perhaps one of the first measures to be
taken in this field would be a critical triage
of the advertisements carried out in the
medical associations' own journals which not
infrequently employ the faulty techniques
described above.
Unfortunately, many doctors seem to rely
on the drug industry as their main source
of information on new products. This is partly
due to inadequate teaching of medical statistics
and therapeutics in medical schools as well
as to the lack of continuing education, but the
structure of health care is also to bear part
of the blame. Most physicians hold several
jobs with limited time being left for studying,
competition is often fierce and the promotion
of medicines is intense and sophisticated.
The possible solutions for these problems
are therefore not simple and certainly involve
many aspects of the organization of the
medical sector in the country. Some useful
measures, however, could be taken without
delay. These include :
The overall priorities of the drug industry
in the Third World also deserve critical
examination by professionals and layman alike
and the educational measures cited above
constitute only a partial solution.
They
represent, however, steps which could be
taken on the short run. And, considering the
situation described above, there is an urgent
need for action. As long as some manufacturers
continue to employ biased advertising practices
in order to increase their sales, the lives
and well-being of patients must have been
at some risk.
(a) Better teaching of medical statistics
at the schools of medicine. This discipline is
usually taught in the pre-clinical years, and
the study of clinical trials is often left out.
Scheduling this subject in part to one of the
later years of the medical course may make it
more relevant to the main use most future
physicians will make of it - which is, rather
than getting involved in doing research them
selves, evaluating the work of other researchers
with a view to applying it to the care of
their own patients.
REFERENCES
1.
(b) Better teaching of therapeutics at the
schools of medicine. This subject which was
taught by itself some 10 years ago in most
2.
3
Silverman M. The Drugging of the Americas Univ, of
California Press, Berkeley, 1976.
Muller C. The overmedicated society: forces in the
marketplace for medical care. Science 176, 998, 1972.
3.
4.
5.
6.
Waldron I. Increased Prescription of Valium and
Librium: an example of the influence of economic
and social factors in the practice Gf Medicine Int.
J. Hlth Sert. 7, 37, 1977.
Dunne M., Herxheimer A., Newman M. and Ridley H.
Indications and warnings about chlorampnenicol.
Lancet ii. 781, 1973.
Yudkin J. S. Provision of medicines in a developing
country. Lancet i. 810, 1978.
Ledogar J. R. Hungry for Profits. IDCC/North America.
7.
New York, 1975.
Goodman L. S. and Gilman A. (eds.) The Pharmacolo
gical Basis of Therapeutics. MacMillan. New York.
1980.
8.
Acetaminophen. Med. Lett. 18, 73, 1976.
9.
Modell W. (Ed.) Drugs of Choice 1978-1979. Mosby.
St. Louis. 1978.
10. Huff D. How to Lie with Statistics. Penguin. Mlddlesex. 1973.______________________________________ _
Source : Social Science & Medicine 16:707, 1982.
ANTIBIOTIC THERAPY
best are (1) S. typhi and other salr, onellosis
(except S. getis which should not be treated
with antimicrobials) (2) CNS infections because
of excellent blood-brain barrier penetration
and good activity against many common CNS
pathogens.
[Recently the Medical clinics of North America
published a symposium on Antibiotics. Since
many of the infectious conditions seen in our
Country are rare in the U.S. and vice versa,
we have taken some aspects which may be
useful to us and presenting them here, as a
single write-up]
Aplastic anaemia has been observed
even in patients who used chloramphenicol
ophthalmic ointment or eye drops, so that
other antibiotics are generally preferred for
superficial eye infections.
The cornerstone of rational management of
the patient with an infection remains the
isolation and identification of the infecting
microbial pathogen and determination of
its susceptibility to antimicrobial agents.
However, because of the lag time between
recognition or suspicion of infection and the
availability of susceptibility data, initial
therapy must often be based upon presumptive
evidence derived from the initial evaluation
of the patient. In chosing the most appropriate
antibiotic for a particular infection, one of
the first decisions that must be made is
whether a bacteriostatic agent will suffice
or whether bactericidal therapy is required
for most uncomplicated infections, a bacterio
static agent will be adequate.
The combination of Trimethoprimsulpnamethoxazole (TMP-SMX) is effective against a
large spectrum of micro-organisms. It is
marketed in a ratio of 1:5. Both are folate
metabolism inhibitors. Each drug is bacterio
static when used alone but the combination
has bactericidal action. Even when organisms
are resistant to SMX, they may still be sensi
tive to the combination.
Indications for combination antimicrobial
therapy continue to evolve as newer, broader
spectrum antibiotics are developed for clinical
use. Situations where the combination of two
or more agents has been shown to the bene
ficial are (1) mixed baterial infections where
organisms are not susceptible to a common
agent (2) to overcome bacterial tolerance,
(3) to prevent drug resistance, and (4) to reduce
drug toxicity.
Chloramphenicol
This has been the subject of severe abuse,
resulting in numerous unnecessary cases of
aplastic anaemia as well as escalating rates
of resistance. In view of the potential toxicity
and restricted spectrum, it is generally recom
mended for serious infections in which location
of infection or susceptibility of pathogen
indicate limited antimicrobial option. The
infections which satisfy these criteria the
4
1.
It is currentlythe preferred therapy for
shigellosis. In many parts of the world,
shigella have become resistant to tetra
cycline and ampicillin, but are still sensi
tive to TMP-SMX.
2.
It is an excellent back-up drug in Salmo
nellosis. Currently chloramphenicol is
the drug of choice for serious typhoid
fevers whereas ampicillin can be used
against less serious species. TMP-SMX is
an excellent alternative to both these.
3.
It is ideal for chronic and recurrent upper
respiratory tract infections. FDA (USA)
does not recommend its use in initial
acute upper respiratory tract infections,
because less expensive single agents
are equally effective.
4.
It is extremely effective in acute otitis
media due to H. influenzae.
Urinary Infections
After treating urinary infections with
appropriate antibiotic, the frequency of
recurrent symptomatic infections can be
reduced only by long term prophylaxis (months
to years). Infections recur soon after prophy
laxis is stopped.
antibiotics act in a "static" fashion when
present in low concentrations. Furthermore,
bactericidal agents have never been shown
to be superior to bacteriostatic agents in the
therapy of infectious disease processes. Except
where granulocyte count is less than 500 cmm.
and in bacterial endocarditis, whether an
antibiotic is bacteriostatic or bactericidal
should not be a factor in antibiotic selection.
Bacterial resistance to tetracyclines is usually
mediated by R-factor. Clinically, resistance
has been a problem primarily with conventional
tetracyclines and much less with doxy and
minocyclines. All tetracyclines should be
avoided in children less than 8 years of age.
They may cause temporary inhibition of
bone growth.
Nitrofurantoin appears to be a versatile
antiseptic because it is effective against upper
urinary tract infections, recurrent bacteriuria
and as a long term suppressive agent in
children and pregnant patients.
Methanamine is also effective in females
with uncomplicated recurrent bacteria including
those with multiple resistant pathogens as
well as a prophylactic agent in males with
recurrent infections. Methanamine per se is not
bactericidal. Its mode of killing micro
organisms is the result of its hydrolysis to
ammonia and formaldehyde. Formaldehyde
is only liberated at acidic pH and once genera
ted, is bactericidal at any pH. Fortunately
normal urine is sufficiently acidic, to generate
free formaldehyde from methanamine. It
was hoped that weak acids such as mandelic
acid, hippuric acid or ascorbic acid would
further lower pH. However, there is little
evidence that methanamine combined with
these acids (mandelamine) confer any thera
peutic or pharmacologic advantage over
methanamine base alone. These urinary anti
septics offer increasing financial advantages
over TMP-SMX.
Erythromycin
This has a broad spectrum of antimicrobial
activity and is one of the safest antimicrobial
agents in clinical use. Resistance among
pathogens that were previously highly suscep
tible is being reported. It is a drug of choice
for a number of infections and is an alternative
to penicillin in streptococcal infections,
syphilis and in rheumatic fever prophylaxis.
A 10-day course of erythromycin is
recommended by the American Academy
of Pediatrics as the treatment of choice
for pertusis. It clears the pathogens from
the nasopharynx effectively.
Erythromycin is used extensively for
treatment of diphtheria and diptheria carriers.
In acute infections, however, antitoxin remains
the primary therapeutic modality. Erythromycin
is highly effective in eradicating ( C.diphtheria
from the nasopharynx within ^8 to 72 hours.
A 10-day course is recommended because of
a high relapse rate after a briefer course.
Tetracyclines :
These have an usually broad spectrum
of antibiotic activity. They are generally well
tolerated, have few serious side-effects
and are one of the most commonly prescribed
antibiotics in the world.
Oxytetracycline and
clilortetracycline are short-acting. Doxycycline
and minocycline are long-acting.
Acute otitis media caused by streptococci
may be treated effectively by oral erythro
mycin.
Combinations
of
erythromycin
with sulphonamides have been shown to
be
comparable to ampicillin, in treating
infections, regardless of causative organism.
Erythromycin should not be used alone
in serious staphylococcal infections.
All tetracyclines are bacteriostatic. There
has been much discussion whether bactericidals
are superior to bacteriostatic antibiotics.
This distinction is an in vitro rather than an
in vivo difference. Bacteriostatic antibiotics
act in a "cidal" fashion when present in high
concentrations and conversely, bactericidal
SINGLE DOSE THERAPY FOR ACUTE INFECTIONS
Abhay Bang
At the M.F.C. annual meet at Tara, a
discussion had cropped up on the possibility
of a single large dose of antibiotic for treating
acute respiratory infections. The discussion
remained inconclusive
definite information.
in
the
absence
of
I recently came across a small review on
5
'single dose therapy in the management of
urinary tract infection' (I. N. Slotki, 'The
Medical Annual' 1980-81 eds. Sir R. B. Scott
and Sir James Fraser) I am quoting it here
to advance this discussion in M.F.C. further.
I need not reemphasise the advantages of
single dose therapy in the treatment of acute
infections specially while working in the
rural areas.
In conclusion, single-dose therapy of lower
UTI in the absence of radiological abnormali
ties is highly effective. Moreover, it is less
expensive, easy to administer, non-toxic and
has not been shown to be associated with
more frequent relapses or re-infections than
conventional longer courses of antibiotics
(Kallenius ans Winberg, 1979).
REFERENCES
The review says 1.
In the earliest report on single dose
therapy of acute UTI Gruneberg and Brumfitt,
(1967) found that a single 2 g. dose of the
long-acting sulphonamide; sulphomethoxine,
was as effective as a 7-days course of ampi
cillin 500 mg 8 hourly in 50 non-pregnant
women. Williams and Smit (1970) achieved a
cure rate of 77 per cent using a single dose
combination 1 g of streptomycin and 2 g of
sulphametapyrozone in pregnancy bacteriuria,
sulphametapyrozone was shown to be as
effective as a 7 day course of ampicillin
50 mg. t.d.s. (Slade and Crowther, 1972).
2.
3.
4.
5.
Sterilization of urine by an antibiotic to
which the organism is sensitive can be achieved
within 24 hours (Fairley et al., 1978). The
same study also showed that, where organisms
persisted at 24 hours, they were present in
all daily urine collections over the next
week. It would seem likely, therefore, that
even a single dose of an antimicrobial agent
could eradicate uncomplicated UTI.
6.
7.
8.
In the last 4 years the efficacy of single
dose therapy of UTI has been established
in both children (Kallenius and Winberg, 1979)
and adults’ (Bailey and Abbott, 1977, 1978).
Legalization studies of UTI using the 'bladder
washout' procedure (Ronald et al., 1976) and
the 'antibody-coated bacteria' assay (Fang
et al., 1978; Leading Article, 1979) have shown
that kanamycin sulphate (500 mg i.m.) amoxy
cillin (3g) and co-trimoxazole orally each in
single does eradicated lower tract infections
in almost all cases. A high proportion of
upper tract infections as indicated by these
techniques either persistor rapidly relapse.
Bailey and Abbott (1977, 1978) found that
single doses of either co-trimoxazole or
amoxycillin 3 g were curative in 85-90 per
cent of patients with normal intravenous
urograms but in 50 per cent or less of those
with abnormal radiology. Fairley et al. (1978)
confirmed the different responses between
patients with and without radiological abnorma
lities, of the urinary tract and proposed that
failure of single-dose therapy to eradicate
UTI is an indication for further investigation.
9.
10.
Bailey R. R. and Abbott G. (1977). Treatment of
urinary tract infection with a single dsse of amoxycillin. Nephron 18, 316
*
Bailey R. R. and Abbott G. (1978). Tnatment of
urinary tract infection with a single dose of trimethoprim-sulfamelhoxazole. Can.Med. Assoc. J. 118, 551
Fairley K. F., Whitworth J. A., Klncald-Sn llh P.
et al. (1978). Single dose therapy of urinary tract
infection. Med. J. Aust. 2, 75.
Fang L.S.T., Tolkoff-Rubin N. E. and Rubin R. H.
(1978). Efficacy of single-dose and conventional
amoxycillin therapy In urinary tract infection localizeo
by the antibody-coated bacteria technique N. Engl.
J. Med. 198, 413.
Gruneberg R. N. and Brumfitt W. (1967). Single
dose treatment of acute urinary tract infection :
a controlled trial Br. Med. J. 3, 649.
Kallenlum G. and Winberg J. (1979). Urinary tract
infection treated with single-dose of short-acting
sulphonamide. Br. Med. J. 1, 1175.
Leading Article (1979) Single-dose treatment of
urinary tract infection J. Am. Med. Assoc. 241, 1226.
Ronald A. R., Boutros P. and Mourtada H. (1976).
Bacteriuria localization and response to single-dose
therapy in women J. Am. Med. Assoc. 235, 1854.
Slade N. and Crowther S. T. (1972). Multicentre
survey of urinary tract infections in general practice:
Clinical trial of single-dose treatment with sulfametopyrazine. Br. U. Urol. 44, 105.
Williams J. D. and Smith E. K. (1970). Single-dose
therapy with streptomycin and sulfametopyrazlne
for bacteriuria during pregnancy. Br.' Med. J. 4, 651.
WORLD HEALTH AUTHORITIES
CONDEMN INDUSTRY PRACTICES
May 1983 marked the second anniversary
of the adoption by the World Health Assembly
(WHA) of the International Code of Marketing
of Breastmilk Substitutes. As the Assembly
met again in Geneva last month, they reviewed
progress made in implementing the Cot^e
at the national level and also commented on
current practices of the infant milk industry.
Although no changes were made in the
text or legal status of the International Code
at this WHA, many delegates were out-spoken
contd. on page 7 ......
6
in their condemnation of recent practices
of the industry and called for more vigilance
on the part of WHO and governments. A
few examples follow :
LETTER TO EDITOR,
Dear Friend,
I have gone through the article "Rational
therapeutics, selection of appropriate drug"
by U.N. Jajoo in the June 1983 issue of M.F.C.
Bulletin. It has been mentioned in the article
that Aspirin remains the drug of choice as an
analgesic and anti-inf lammatery agent in
pregnant women. This doesn't appear rational
since Aspirin is contraindicated in pregnancy
because of its (?) teratogenic effect and
toxic effects. Paracetamol (Acetaminophen)
is safer in pregnancy. 1 wish to quote following
sentences from well known authors in this
respect.
I)
2.
3.
"A more dangerous development which we
are witnessing today is the attraction of
mothers, even in the rural areas, to artificial
feeding, not only because it is seen to be
convenient, but because it has become a
sort of status symbol. These dangerous trends
must be counteracted. The activities of
promoters of artificial infant feeding must
be curtailed and closely watched. It is with
considerable regret that we have received
information that
some major industrial
establishments are beginning to develop cold
feet and may not after all be that keen
now (to implement the Code.)"
Professor U. Shehu, National WHO Pro
gramme Coordinator, Nigeria
"Aspirin and other salicylates, when
given in pregnancy are associated with
occurence
of
achondroplasia,
hydro
cephalus,
congenital heart disease,
congenital dislocation of the hip
and
talipes"
(FORFAR - Prescriber's Journal (1973)
13, 130).
"It is distressing that both local and
foreign manufacturers of infant milk still
engage in marketing practices which take
advantage of the loopholes of the International
Code.. We hope that WHO will continue
to review progress regarding national efforts
to implement the Code, and in particular,
regarding industry compliance with the spirit
and letter of the Code. Violations of the
Code cannot be tolerated when it is infant
health that suffers as a result".
Dr. S. S. Sidhu, Secretary, Ministry of
Health and Family Welfare, India.
"There is no evidence that therapeutic
doses of salicylates cause fetal damage in
human beings, although babies born to
women who ingest salicylates chronically
may have significantly reduced weights
at birth. In addition there is a definite
increase in perinatal mortality, anaemia,
ante partem and post partem haemorrhage,
prolonged gestation and complicated
delivaries".
(GOODMAN GILMAN'S - The Pharmacolo
gical basis of therapeutics, 6th Edition
(1980).
"Some companies involved in the manu
facturing of breastmilk substitutes have
produced parallel codes which they claim are
in support of the International Code.. It is
important that WHO should be vigilant, for
such action in future might end up by under
mining the Code."
Dr. Z. M. Diamini, Director of Health
Services, Swaziland
"Salicylates are used in a free and un
controlled manner throughout pregnancy.
Impairment of platelet functions and
haemostatic functions can occur in the
new born foetues born to these women.
It has been experimentally proved that
Aspirin can produce congenital defects.
There is no report to indicate teratogenic
effect of acetaminophen. Acetaminophen
appears to be a safer drug in pregnancy".
(ALFRED SCOTT (1981): Archives of
Internal Medicine Vol. 141, No.3, 358).
"It was hoped that manufacturers would
...cooperate in implementation of the Code
by, as much as possible, trying to modify
their practices, sales promoticn, labels and
so on... There is really strong evidence that
the practices have not changed - the same
sales promotion, tins are labelled exactly
the same - and just recently we have also
seen the distribulion of child growth charts
by one of the manufacturing firms to be
used- in the health services."
Dr. J. T. Kakitahi, Director of Nutrition
Services, Makerere Medical School, Uganda
[From IBFAN News, June 1983]
You will agree with me if I say that
congenital malformations due to drugs should
be prevented at any cost. Please think twice
before prescribing Aspirin in pregnancy.
Dr. P. S. Patki
Pune
7
RN.27565/76
mfc bulletin : AUGUST 1985
Regd. No.P.N.C. VI-96
CENTENARY OF TUBERCULOSIS BACILLUS
Tuberculosis once a killer disease is
completely curable today. The credit goes
to Robert Cock, who hundred years back
discovered mycobacterium.
Last year all
over the world the centenary of the TB vaccine
was celebrated. Included in this celebration
was pipariya, a small town of Hoshangabad
District Madhya Pradesh. A TB Camp was
being organised by the local unit of Indian
Medical Association in collaboration with
Pipariya Government Hospital. The Seven
day camp has raised many questions concerning
clinical and social context of this disease
that is rampant amongst people in this country.
The organisers of the camp consisted
of six practising medicos from the town and
some social workers. Finances for the camp
came through donations in terms of cash
and kind both; the latter included X-ray
plates, medicines and injections. In all 028
persons from the low income group were
identified and invited to the camp for syste
matic diagnosis, through pathological tests
and X-ray, resulting in detection of TB in
108 persons. Of these 108 persons, 52 turned
out to be new cases, the rest 96 had some
history of treatment. In all 35 cases were
detected who didn't have TB at all but were
being treated for TB. A shocking revealation
indeed! Many of them have received permanent
damage through intake of large dosage of
streptomycin, resulting in 60 percent loss
of hearing power. The irony is that these
people were being treated by no quacks
but by qualified (MBBS) doctors. These 35
patients were actually found to be suffering
from bronchial asthma or other lung and
heart diseases. The doctors were strongly
of the opinion that bronchial asthma or other
lung infections can easily be differentiated
from TB through simple clinical tests. This
raised a serious question on the quality of
our trained medical personnel in general
and their professional ethics in particular.
A continuous treatment for nearly 18
months ensures complete cure of this disease.
And it is for this reason alone that TB is
popularly known as King of all diseases.
TB is also fairly well known to have a high
incidence rate among the weaker sections
of the population. For the poor people TB
simply amounts to an additional cause of
indebtedness; and for the medical practitioner
it i.s merely a boon (in disguise if you wish).
A long, course of expensive treatment leads
to total pauperisation and ultimately to death.
Since TB is infectious and germs easily multiply
in unhygenic, dark and suffocated dwelling
places, it easily embraces the whole family.
This eventually strengthens the old belief
that TB is a killer disease and is hereditary
as well.
This is a major reason for the failure of
National TB eradication programme. A poor
patient has the financial limitation to dis
continue teatment the moment he feels
slightly better after a few days of treatment,
only to come back to the doctor after several
months with added complications. A dis
continuity in treatment for a week means
extension of the 18 month period by 3 weeks.
Doctors have preferred to keep quiet since
this laxity ultimately benefits them. A full
course of treatment ensures 98 percent cure,
whereas in our country this rate, on in
average, is merely forty percent. Not only
this, in this camp some persons were identified
who have had treatment running to more
than 15 years.
TB is a major concerned so far as peoples
health is concerned. Governments program
is in a sordid state, limited only to identifica
tion drive with minimal concern for curability.
Medical education in the country has failed
to give cognisance to this national priority
in their curriculum or specialisation. Even
the Govt. Health structure had laid more
weightage on Ear, nose and throat diseases
than on TB that is believed to plague the
larger section of the toiling masses. This
TB camp has been a tiny oasis in a large
desert. Unless government itself shows concern
for this and acts rationally nothing significant
can be expected of these voluntary charitable
efforts in an ocean of misplanning and fixing
up of wrong priorities on the part of the
Government; incompetence and narrow self
interests on the part of the trained medical
personnel of the country; and lack of education,
indebtedness and peculiar social psychology
that is a characteristic feature of the toiling
masses of this country.
Rajendra Hardenia & Goulam Bhallachorya, Disl. Hoshangabad.
Editorial Committee:
Anant Phadke
Padma Prakash
Ravi Narayan
Shirish Dalar
Ulhas Jajoo
Kamala Jayarao-EDITOR
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual Subscription - New rates from July 1981 - Inland Rs.15/-. For Foreign Countries By Sea Mail US $ 4; by Air Mail - Asia US $ 6; Europe, Africa - US $ 9; U. S. A.;
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Edited by Kamala Jayarao; A-9; Staff Quarters; National Institute of Nutrition, P.O. Jamai
Osmania; Uydeir»oad-500 007. Printed by Shirish Dalar al Abhyankar's S. & T. Inst., Bombay-4.
Published by Anant Phadke for Medico friend Circle; 50 LIC Quarters; University Road,
Pune - 16; INDIA.
medico friend
circle
bulletin
SEPTEMBER, 1983
HEALTH "CARE" VS. THE STRUGGLE FOR LIFE
Mira Sadgopal’
(January 198 3)
Part - I
India's
people, and the world's people,
are faced with a gigantic health "care"
establishment. It is lar from being a vacuum,
a situation of "neglect" as most politicians
and planners would have us believe, or some
time themselves beheve. Like a huge and
ungainly bureaucracy, it is both organised and
unorganised. Its various parts are linked
with each other in both gross and subtle ways;
equally, the parts function in contradiction
with each other. Some of the parts of the
establishment succeed in holding away in
certain spheres by vii tue of historical advan
tage and the forces that back them at the
moment.
Any group claiming to explore
"alternatives" must understand human health,
and likewise any other sphere of human welfare
(like education, economic development, legal
justice, etc.) in this perspective. The individual
man, woman or child is powerless and thus
always prone to being sucked, duped or dragged
into the establishment system.
India provides a magnificent panorama of
such a health care establishment.
Most
obviously, we have in this country a giant
multi-tiered Government-operated public
health infrastructure, the bottom levels
of which are organised into something called
the "primary health care" system. It is topped
by a spread of state hospitals and national
medical institutes as well as various large
central public health agencies. Ultimately,
this government system is empowered through
finance by international organisations and
agencies like the WHO, UNICEF, DAN1DA,
etc.
Second in consequence is the vast body
of "quafified" Private Practitioners which,
although it is less organised and partially
thrives on Us own disorganisation, also exhibits
a hierarchy of influence and power largely
corresponding to the proximity of its parts
to the cities and the drug industries. It includes
graduates of "allopathic" medicine as well
as graduates of the ayurvedic colleges,
although most ol the latter depend on the
use of modern allopathic medicines. The
minimum requirement for organisation to
promote and protect the interests of their
members as a class is fulfilled by the Indian
Medical Association.
Taking third place in visibility, although
it exerts the most pervasive and devastating
influence, is the huge drug industry complex.
Theie is a polarisation within this group
between competing indigenous and multi
national companies which is unequal, so
that indigenous industry either succumbs or
adopts policies in tune with the multinationals.
The multinational drug industry profoundly
controls policy and practice within the
Government health system as well as the
behaviour of Private Practitioners by plying
central government committees and deploying
a large army of medical representatives.
Fourth is a large group on the fringe
of the health establishment power structure,
loudly names "Quacks" by the Private Practi
tioners. It is a very interesting group without
any real political power or legal sanction
which thrives on the contradictions of the
• Klshore Bharall Group, P.O. Bankhedl, Dist. Hoshangebad, M.P. - 461 990
establishment, the extreme powerlessness of
the masses and the total culture of mystifica
tion which maintains this. This group finds its
niche in the rural areas and the lacunae of the
towns.
they seek quick help from private practitioners,
knowing it will cost, but anxious to get
well and back to work. They hope to get by
with a strength-giving injection, a few pills
may be, and a bottle of life-giving tonic
which the doctor will prescribe. So a couple
of chickens and some grain is sold to raise
money.
A fifth group exists in the twilight beyond
the fringe, often indistinguishable from the
masses but merging into the category known
as "quacks". They cannot really be called part
of the establishment, but they are quite
often the first, last, and sometimes the only
recourse of the poor. These are the village
dais, the bonesetters, the guinas, ojhas and
bhagats (faith healers and magicians). They
are traditional, indivisable from the belief
system of the masses. The larger health care
establishment has an ambivalent attitude
towards this section - it is largely ignored
or ridiculed. Recognising their hold over
the people, some members, such as the dais,
are sought to be co-opted by government
training into the primary health system.
The doctor well recognises the story
and the appearance. He suspects it is tuber
culosis. He knows the capacity of the poorthey will pay for the belief that they will
get well, and as long as that belief can be
sustained, they will keep on paying the same
doctor. He also knows that this disease,
if properly managed, has a good chance
of continuing without cure for several years
before the patient dies. Furthermore, the
widespread attitude that TB is incurable,
supported by the vast majority of cases
which eventually end in death, and the doctor's
own observation that patients cannot sustain
regular treatment does not lead him to nurture
any professional interest in obtaining a cure.
Therefore, neither is he interested in proving
the diagnosis. A private practitioner will
avoid telling that he is treating a man for
TB as long as possible. Otherwise he is sure
to lose his patient to another doctor. Likewise,
sending him for sputum test or X-ray, which
may be available through the nearest govern
ment hospital, would be giving him away, or
privately done would use up available funds.
He is not interested in prognosis either it will be sufficient to see that the man gets
temporary relief and is kept fluctuating within
a safe margin between cure and death, with
an occasional dramatic rescue from death's
clutches, for as long as possible.
Also according to establishment values,
organised health services are operated to
a greater or lesser extent by large public
and private industries and by the central
government for its employees. These are
all subject to the same pressures of the
health care culture which bear on society
in general and are only partially modified
by local or specific political conditions.
For practical purposes, we may add to this
category the attempts of a number of voluntary
agencies to provide proper and uniform health
services in project areas.
Seeing the larger interconnecting structure
of the health establishment in this way gives
us an intellectual idea of its magnitude,
but what does it mean for the common man
and woman in India?
What does the doctor's treatment consist
of, aside from its psychological content?
First on the list is Streptomycin injections,
one daily if possible, which is more likely
impossible if the patient lives far away.
(He may be given tablets of Isoniazid in
various proprietary preparations in place
of streptomycin, in which case he is certain
to be sent off with a couple of impressive
on-the-spot injections, such as liver extract
and red-coloured vitamin Bl 2.) Next, he
will be prescribed ethambutol tablets (under
one of the marketed brand. names), a secondline drug for TB which is comparatively
expensive but which is being promoted by
multinational companies through their medical
representatives as a first-line drug. Third,
a corticosteroid hormone like betamethazone
(again, under numerous brand names) will
For a start, we can listen to the stories
of hundreds upon thousands of men and women
suffering from tuberculosis in our cities,towns and villages. Over and over again
we can see a plot thus exposed in stark
nakedness, as each tells of the struggle to
get treated and cured by any possible means.
For instance, a villager who gins cotton
has noticed a gradual loss of weight and
energy and may be a cough for several months.
But so many of the poor are already exhausted
and emaciated by life - they find the line
between relative health and disease is imperceptively crossed - and they think it is only
"weakness". When work becomes impossible
2
be routinely given or prescribed by most
private practitioners at the start of antiTB treatment, as it is expected to bring about
rapid relief from symptoms and a specific
false sense of physical well-being which
may be the major factor in hooking the patient.
Fourth will be a large bottle of mineral
and vitamin tonic which also ironically contains
something to stimulate the appetite of the
person who is basically dying of hunger anyway.
Fifth, a syrup will be added to suppress
the cough.
to follow up. After a varying number of
visits to the doctor, and especially after a
marked improvement, he stops going - he may
go back to work. He also meanwhile consults
a gunia of his community about wording off
the risks of getting TB, and after certain
divination the gunia advises I im to carry
out certain rituals and sacrifice, which are
usually done.
After some time, he again loses weight,
and his cough worsens. He thinks abcut return
ing to the doctor. The doctor's mention
of TB has scared him, and he is ambivalent.
He may do one of three things: he may go
to another private doctor or a quack, he
may go to the government doctor, or he may
return to the same doctor after all. If he goes
to another doctor, he goes with a blank
slate - he doesn't mention that he has seen
another doctor, or flatly denies previous
treatment. Hence, a second version of his
first experience is likely to unfold.
The expense of the first week of such
treatment works out as follows (approximately):
1.
Inj. SM (cl Rs. 3.00/day x 7
21.00
2.
Tab. Ethambutol I twice/day
@ Rs. 2.50/day x 7
17.50
3.
Tab. Betamethazone 1 thrice/
day x 7
21 tablets
8.00
4.
Vita-mineral tonic - single
large bottle
20.00
5.
Cough syrup - single bottle
8.00
A streak of realism may hit him. He
may realise that the chance he has TB is
high now, and decide to see the government
doctor. At least he may get a clear answer
even if he doesn't have faith in the government
treatment.
74.50
The doctor's initial fee will vary, but he
will also take a daily fee for injecting strepto
mycin. If he is a good dramatist and psycho
logist, and the family is obviously prepared
to pay, he may set up an intravenous drip
and charge heavily.
The government doctor is a strange kind
of super human. He is invested with the
power to treat when he pleases at the Govern
ment's expense. (He also carries out a respec
table private practice in his home at the
Government's expense.) A patient approaches
him in fear and trembling. Diagnosis for
purposes of initiating government treatment
is obtained through sputum exam or X-ray,
whichever is feasible. Anti TB treatment is
started on the doctor's orders. He tells the
patient he has TB, or he says, "There is a
chance of it turning into TB!" depending
on the role he wishes to play in the drama
with the Patient - Government Doctor or
Private Practitioner. Sometimes he adopts
a dual role, issuing government drugs from
the Primary Health Centre for seeing him
privately at home, too.
Quite often, the person does not have
enough cash to buy some of the medicines.
Typically, the tonics and non-TB medicines
will be bought and the anti-TB medicines
will be partially or totally dropped from
the list. (A survey done by Veena Shatrughna
has shown that many doctors write the tonics
and less necessary medicines first, perhaps
to oblige the drug companies, and the specific
curative medicine last.).
How long is this to go on? We have found
that a doctor tells the patient initially that
his treatment may take a varying period
between two weeks to three months. He may
decide to further prepare a mental frame by
stating that the man is lucky that the doctor
has caught the "disease" at this stage because,
although he doesn't have TB yet, "There is
a chance of it turning into TB!"
Government rules for the treatment of
new cases of TB are clear and rational,
the full treatment of eighteen months provided
for under the National Tuberculosis Control
Programme. After positive sputum examination,
treatment is started. Streptomycin injections
are to be given daily for one month, then
on alternate days for two months more.
(An abbreviated schedule which is medically
Even if a man has collected enough funds
for the initial treatment, he may not be able
3
d)
e)
f)
acceptable is 'daily x 15 days, then alternate
days x 2 weeks, then twice weekly x 2 months,
again totalling 3 months.) Daily Isoniazid (INH)
tablets are also given.
3.
After three months, sputum examination
is to be repeated (if the patient is still cough
ing up sputum). There should be no more
tuberculosis bacilli detectable in the sputum.
Then, if not before, an X-ray screening is
called for if feasible from the nearest TB
X-ray facility. The reduction in the extent
of lung damage is thus monitored every
six months until six months have passed
since disappearance from the X-ray of the
signs of damage, when treatment may be
officially discontinued.
Problems of Drug supply and Regular Issue.
a)
b)
c)
d)
e)
4.
If progress is satisfactory, Streptomycin
injections are to be replaced after three
months by another drug, usually Thiacetazone
(THZ) but it might be Para-Amino Salicylic
Acid (PAS). The PHCs dispense Isoniazid
and Thiacetazone in combined INH/THZ
tablets to be consumed daily for the total
remaining period of treatment. To ensure
that a patient keeps up regular treatment,
he is supposed to be called every month on
a particular date three days before the drugs
with him are due to finish. In case he does
not turn up within a few days, a printed
postcard reminder is to be sent to him.
If he does not respond to three such reminders
(and he has not died), he is known as a
"defaulter".
b)
c)
b)
c)
There are innumerable obstacles in the
way that ensure failure of treatment or
"default". We can list these, as follows :
6.
1.
Problems of Diagnosis
a)
b)
2.
sputum exam: technician not available,
or refuses
x-ray/screening facility distant,
expensive, out of order, or x-ray
plates not available.
b)
c)
a)
b)
c)
7.
8.
4
unavailability of doctor/health worker
to inject
fee for injection daily
PHC may refuse to issue injections
to patient to take home
Problems of Transport
a)
b)
c)
intention, or lack of intention of
doctor to inform
patient's fear
contradictions in the belief system
in society about disease
brainwashing of doctors by medical
representatives
overproduction beyond licenced capa
city of tonics, etc., by large and
multinational drug companies
mystification among the masses about
tonics and the desperation for quick
life-giving cures
Problems of Local Arrangement to Inject
Streptomycin
a)
Failure of Communication to Patient by
Doctor
high/rising prices of essential firstline drugs, especially Streptomycin
injections
shortage of all first-line drugs in the
market due to gross under-production.
increase in market supply of expensive
second-line anti-TB drugs like ethambutol, rifampicin
Unnecessary Medicine Cost on Vitamin and
Mineral Injections and Tonics, and costly
Cough Mixtures
a)
But what really happens to the ordinary
patient, or to our villager friend who gins
cotton ?
genuine short supply to PHC from
District HQ
siphoning off of TB drugs into the
market
siphoning off of TB drugs into private
practice
incomplete issue of drugs
doctor's failure to indent (maladminis
tration)
Problems of Medicine Cost from the
Market when unavailable through govern
ment supply
a)
5.
doctor's impatience
mystification of doctor's role
poor relations/faulty communication
between PHC staff
distance
cost in time, energy, fare
irregular public transport
services
The Social Milieu at Home
a) poverty - poor shelter, starvation
b)
c)
d)
9.
c)
d)
e)
f)
Conditions of workplace and Occupation
a)
b)
c)
d)
10.
b)
demoralisation
sex-bias in case of women, especially
when childless or without living male
offspring
belief in magic and lack of scientific
concept of disease
economic exploitation
noxious physical conditions, like
inhalation of cotton fibre and poor
ventilation, etc.
lack of safety standards
lack of alternatives
Now, it is sufficient to say that the
average poor man of India who gets TB
today is likely to face every single one of
these obstacles, except 8(c) as he is not a
woman. Inevitably, he becomes a defaulter,
or he dies, or more likely both. Are there
really any alternatives ?
Specific Malpractices by PHC Staff and
Doctor
a)
misinformation or non-information of
patient
failure to record (incomplete) issue
of drugs
neglect of monitoring schedule
failure to maintain treatment card
failure to contact defaulters by
postcard.
(to be continued)
Private practice
ANTIBIOTICS IN DEVELOPING COUNTRIES
1977, the WHO provided a list of
210 essential drugs, to help developing
countries choose a limited number of drugs
that are inexpensive but of high quality.
Though such lists have been in use in
Scandinavian countries, the drug industry was
highly critical of the WHO list. A survey
studied marketing of antibiotics in Central
America and
was
published in Lancet
(3an 3, 1981).
A second type of combination is antibiotics
with enzymes, claimed to improve uptake by
inflammed tissues. Some preparations for
gastrointestinal infections contain Kaolin and/
or pectin. A third combination is antibiotic
with a mucolytic and/or cough suppressant.
'Bisolvon Eritromicina' with bromhexine is said
to increase immunoglobulin A. Antibiotics
are claimed to be effective against influenza
and viruses. A preparation meant for infants
contained streptomycin, tetracycline with
enzymes.
In
In Mexico, 930 brands cf antibiotics were
marketed, of which 180 were combinations. In
comparison, Sweden has 90 brands with only
2 combinations.
The Survey shows that in each country of
Central America, not less than 200 brands of
antibiotics are marketed. The investigators
say "how can doctors in these circumstances
become familiar with the essential properties
of important drugs. A reduction in the number
of drugs might improve antibiotic use in
clinical practice".
The stated reasons for use of combinations
are that they have a broader spectrum of
action and that antibiotics reinforce each
other or that they will be effective even if
resistance against one occurs.
[Do Bulletin readers have any such information for India? - ED]
NATUROPATHS IN THE USA
(Extract from Pediatrics 68:907, 1981)
"holistic medicine". Today's naturopathic
colleges require 3 or 9 years of undergraduate
study for admission with a basic prernedicine
background. The graduate is expected to be
skilled at performing minor surgery, and
assisting in all phases of obstetrical care
for natural child birth and home deliveries.
Despite the availability of a highly develop
ed, formal-medical care system, many Ameri
cans place substantial reliance on folk medicines
and unorthodox practitioners. We often encoun
tered families who indicated that a naturopath
was a major source of their health care.
Schools of naturopathy reached a peak
around 1950 and declined by 1960. The fortunes
of naturopathy took a dramatic upturn in
the 1970s, along with the increasing popularity
of natural foods, organic gardening, and
Fasting-from days to weeks-is recommen
ded for many ailments, including arthritis
and sinusitis. The symptomatic treatment of
fever is thought to interfere with natural
5
subservient to the authority. Injections are
only available on a prescription basis. When
we teach people to live well, to eat properly
that doesn't require a pinnacle-type structure.
curative processes. The efforts of naturopaths
are therefore directed toward strengthening
the individual's resistance to disease. Through
optimal nutrition and hygienic practices,
the need for vaccinations could be totally
obviated. Several practitioners also expressed
the belief that injecting antigens was an
abnormal form of exposure, an invasion of
the patient's defenses, and therefore poten
tially harmful. True exposure to some of
the infectious diseases was often considered
the preferred method of obtaining long term
immunity. "The inoculations are not known
to give life-time protection, whereas actually
contracting the disease does. In the old days,
they used to have a 'measles party' in order
to deliberately expose children. 1 would like
to see the Public Health Department make
this kind of exposure available".
Homeopathic remedies are an important
component of many of the naturopaths' inter
ventions. While defending homeopathy as
efficacious, many naturopaths acknowledged
the placebo effect of these remedies.
The emphasis by naturopaths on patient
teaching, individualized care, and 'natural'
remedies, and their aversion to scientific
medicine have become increasingly valued by
medical care consumers. Because many ail
ments are minor and self-limited, and many
naturopathic remedies are without obvious
harm, encounters with naturopathic practi
tioners are often benign, if not clearly bene
ficial. In the case of childhood infectious
diseases, however, immunizations can be life
saving. Specifically, immunization programs are
preventative, and their efficay involves stimu
lating the body's natural defense mechanisms.
Such approaches were also defended
on egalitarian grounds. "The vaccine route
was chosen because of the medical orientation,
essentially a pinnacle type hierarchical system
with a very clear authority figure and people
LETTER TO EDITOR
Dear Friend,
How are we going to establish the divine image
we had once upon a time ?
Medical Ethics and Practice
We have come to a stage where thorough
re-evaluation and redefining of ethical values,
to suit the present day problems of our system,
has become absolutely essential.
Medical Ethica has become the talk
of the day both inside and outside the medical
community. A large section of people are
frustrated with the treatment they get from
hospitals, medically and otherwise. Private
treatment is expensive and even the mjddle
class is neither able to afford the specialist
nor his prescription. The common man is
becoming more and more sceptical about
the professional integrity of medical men.
On the other hand, medical men of eminence
and professional integrity are also very much
puzzled as to why such a curse has fallen
upon such a noble profession. People in power
also lose no opportunity to accuse us of
erosion of values, perhaps to shirk their
own responsibilities. .
Medical ethics involves seeing that patients
get proper and adequate treatment. Looking
back, we find that the emphasis of traditional
ethical codes was on the responsibility of
doctor towards his patient. But with the
progress of ■ science, particularly medical
science and society, the effectiveness of
health services is primarily decided by how
best the medical system is organised, though
responsibilities of the doctor towards the
patient continue to remain fundamental. In
modern days, when medical science is capable
of eliminating certain diseases altogether and
can prevent the occurrence of many others
it is not only the individual doctor's compe
tence, but mainly the effectiveness of the
medical policy and its implementation over
a social plane that ensures the health of
the society. Hence, maintenance of medical
ethics has become more of Governmental
responsibility.
While confronting different adverse condi
tions in our profession, doctors are also
thrown into an ethical dilemma. Circumstances
force doctors to compromise with medical
ethics every now and then.
Why at all such an ethical crisis today?
What has gone wrong with our system? What
are the real factors behind all these maladies?
Moreover, institutionalisation of medicine,
6
specialisation, team (or) group practice
etc., are the outcome of progress of medical
science and practice. Hence under conditions
of institutionalised medical care, ethical
responsibilities also rests on the institution
and is shared by other medical personnel,
like nurses, assistants, technicians, etc.
These develop nents have opened up new
ethical questions which cannot be solved
by traditional codes of medical ethics.
conditions and scientific advance? What is
going to be our attitude towards these grave
problems facing our community? Is it going
to be one of coming to over-sirnplified conclu
sions, superficial judgement and ill-motivated,
escapist accusations of people in power?
Or are we going to analyse the problems in
the overall context of the medical system
and strive to evolve proper medical policies
and their effective implementation, thereby
evolving a new code of medical ethics, that
will suit present day conditions ?
Is the erosion of medical ethics, accidental
and isolated or is it a reflection of the poli
tical, economic, social and cultural crisis
that has engulfed our country? Is our ethical
dilemma due to our own individual vacilla
tions or is it due to the contradiction between
personal and social interests, between backward
We invite you to
suggestions and opinions.
give
y^ur
valuable
Medical Action Forj"i
Madras
WHY SOYA BEAN ?
K. T. Acharya
During the current year, nearly 8 to 9
lakh hectares appear to be under soya bean
cultivation mainly in Madhya Pradesh, with a
yield expectation of perhaps 6 lakh tonnes
of soya beans. These figures are expected
to double in the next three years (M.P.
Mansingka, Chairman, Soyabean Processors
Association of India; quoted in The Hindu,
September 29, 1982).
from earning foreign exchange to the tune of
some Rs. 80 to 100 crores, there are such
attractions to individual producers as export
entitlements.
But there is another side to this success
story. For long it was convenient to argue
that soya beans were being additionally grown
on land that would otherwise lie fallow during
the Kharif season, thus ensuring sufficient
soil moisture for the following rabi wheat
crop. Growing soya, a leguminous crop, on such
land was said to fertilise the land, while
shedding of its leaves helped to conserve
needed moisture. Today, however it would
appear that two-thirds of the land under soya
in Madhya Pradesh was what once used to
raise jowar, millets, several lentils, and
groundnut (India Today September 30, 1982,
p.127). All these are foods that can be directly
cooked and consumed by common people,
which is not true of the soya bean.
What has led to these rapid and remarkable
developments in what is after all an unfamiliar
crop? One is the support price offered by
the government to the soya bean, which
ensures a profitable return to the farmer.
There is no such attraction for the groundnut,
our major oilseed crop, which continues to
languish. It • is stated that the profit per
hectare of soya considerably exceeds that
derived from the groundnut (India Today,
September 30, 1982 p. 127). Industrialists are
well content too. Processing soya yields about
16 to 18 percent oil, and any edible oil today
fetches an excellent return because of des
perate shortages and high oil prices. The oil
cake which results is an excellent protein-rich
cattlefeed with a well-established international
demand. The high lysine level of 6.2 percent
is 'exceptional among oilcakes, though it is
well to remember that many common dhals
(bengal, gram, masoor, tuvar and mung) have
even higher levels. There is no worrisome
problem' of aflatoxin contamination. All of it
is exported, earlier largely to Southeast Asia
and to the Gulf countries, and more recently
to European countries as well (Dattu Hegde,
Economic Times, August 19, 1981). Apart
Undoubtedly soya oilcake is edible. It is
now exported, but even were it to be used for
humans in India, this would necessarily be in
processed foods that will not reach everyone
as will jowar, millets or pulses. The value of
processed foods in India is just two percent
that of total foodstuffs. The oil yield of the
soyabean is small, just 16 to 18 percent,
against 40 to 45 percent for all groundnut.
So unless the yields of the soyabean are 2.5
to 3 times that of the groundnut, there is
little advantage to the oil economy (A.C.
Chhatrapati, Economic and Political Weekly,
1980, 15 No. 37, Sept. 13, 155.7). In practice,
7
rnfc bulletin : SEPTEMBER 1985
RN.275S5/76
FROM THE EDITOR'S DESK
Mi.;, Sddgopal had recently raised the ques
tion of popularising natural methods of family
planning (Bull.No.89). Whatever the disadvan
tages and even the--health risks of chemical
contraceptives,' they caqnot be replaced by the
natural methods, in this 'Country. The women
need to be educated about the physiology of
fertility; the methods for testing for ovulation
need to be really simple, inexpensive and
accurate. Most important, as Mira too has poin
ted out, it need total cooperation and commit
ment from the man, which in present day
Indian Society is well-nigh improbable. Even if
every other criterion is fulfilled, the protection
rate may not be as high as with other methods.
This can cause much tension among the couple.
This is not to deny that simpler methods for
detecting ovulation need to be discovered. But,
this is to emphasise that continuing research is
needed on other forms of female contraception
and more commitment towards work on male
contraception.
As we have discussed and pointed out more
than once, there is an urgent need to focus
attention on barrier methods. It is a matter
of real concern that no research groups, either
in the public or private sector, is concentrating
on improving the technology in this area. Some
(continued from page 7)
the average output of soyabeans per hectare
is 800 kg. no different from that of ground
nuts under ordinary rainfed conditions, and far
below that when its is given even two irriga
tions (A.C. Chhatrapati, Economic and Political
Weekly, 1980, 15.No. 37, Sept. 13, 1557).
Can the escalation in the raising of the
soya be justified from the point of view of
food needs? As it is, over 50 percent of our
land area is cultivated. This is an excessively
high figure, and the areas devoted to forests
(22 percent) and pasture (^.4 percent) are both
alarmingly low. The possibilities of more culti
vable land are therefore all but exhausted, and
further increase in food production must come
from higher productivity per hectare. For the
vast majority of our people, what matters for
reasons of cost are foodstuffs that can be
consumed without processing.
Are there such overwhelming reasons
for the extensive lobbying and deliberate
market support in respect of this commodity
when there are desperate shortages of such
Editorial Comraittoe:
Anant phadke
Padma Prakash
Ravi Narayan
Shrish Dalar
Ulhas Jajoo
Editor
Kamala Jayarao
Regd. No. P.N.C. W-96
argue that this is perhaps due to the fact that
turn-over of barrier contraceptives ' is less
compared to,pills and may not be profitable to
the drug industry. Not so, really. Effective
barriers will be more popular and ensure a
wider .market.
Even if the argument of a low consumption
is true, why are the research groups in the
public sector too, equally inattentive? Perhaps,
they are not prestigious areas of R&D? We
hear so much these days about relevant
science and relevant technology? Is this
area not relevant, considering the 2 percent
or more growth rates?
What does relevancy in research denote?
Relevant for the research workers or relevant
for the country as a whole? Working on steroi
dal contraceptives brings international recogni
tion. Even the parent country may ignore
research in barrier contraceptives. And of
course, funds for research-if they are received
from a foreign or international agency, that
includes an annual holiday abroad for the.
scientists, or, is it simply this-that all con
cerned have forgotten that there existed
at one time barrier contraceptives for women,
too and that the available technology needs
only to be improved upon. Women's groups and
doctors alike should ask for free availability of
effective barrier contraceptives.
everyday foods as pulses, oilseeds, and prices
of these are skyrocketing? The soya bean
is an acknowledged source of protein for
animals, and marginally of processed foods
for man. Neither of these can be considered
priority matters in India.
Nor ■ must we disregard the inherent
risk of competing in international soyameal
export markets with giants like the USA
and Brazil who will largely dictate prices
and policies. At one, 'vegetable', cooking
type soya bean varieties like Verde, Disoy,
Bansai and Kim were reportedly being deve
loped. As foods with a natural high protein
and medium oil content, these would deserve
a fair trial as potential items in the everyday
food basket, but little is heard about them now..
To encourage the use of scarce agricultural
land in India in ways that contribute only
marginally to supplies of everyday foods that
are in increasingly short supply is a policy that
is fraught with danger. Serious reconsidera
tion is called for.
[Reprinted from NFI Bulletin, Jan. 1983]
Views and opinions expressed in the bulletin are those of the authors and not necessarily of the
organisation.
Annual Subscription-New rates from July 1981-Inland Rs.15/-. For Foreign Countries-By Sea Mail
US $ 4; by Air Mail-Asia US $ 6; Europe, Africa-US $ 9; U.S.A.; Canada-US $ 11.
Edited by Kamala Jayarao; A-9; Staff Quarters; National Institute of Nutrition, P.O. Jamal Osmanla;
Hyderabad 500 007. Xerox-Offset by Shrish Qatar at Abhyanltar’s S.&T.
Bombay 4. Published
by Anand Phadke for Medico Friend Circle; 50 LIC Quarters; University Road, Pune-16; INDIA.
medico friend
circle
Mtetm
NOVEMBER 1983
HEALTH PROBLEMS OF TOBACCO PROCESSING WORKERS
Some Impressions
Dhruv Mankad
by constant sprinkling of the tobacco zarda
The tobacco processing industry of Nipani
with water is a problem added to the risk of
(Karnataka) employs around 6,000 workers,
constant skin contact.
most of them being women. Given the apalling
conditions under which they work and live - Initially, my colleagues and I had formed
the latter not being very much different
tentative ideas about the work-related diseases
from that of other workers of the unorgani ed
(I hesitate to call them occupational diseases
sector — it would be unscientific not to
for want of any evidence of correlation
suspect the presence of a variety of workbetween the work and the disease) we were
related diseases amongst them.
likely to come across. We expected that
the workers would be suffering from the
When 1 started working for a dispensary run
following :
by an institution in close association with
their Union
Chikodi Taluka Kamagar Maha(1) Respiratory diseases : Chronic bronchitis,
sangh, I began to look for correlations between
emphysema, bronchial asthma etc. due to
the symptoms presented by the workers
and the nature of their work. After working
constant inhalation of tobacco dust.
for around two years what I observed is
- Malignancies of the respiratory tract.
a distinct pattern in the diseases and health
- Laryngitis, Laryngeal tubercle etc.
- Increased proneness to tuberculosis.
problems that afflict these workers. . Although
I have not done any systematic study as
(2)Skin diseases like contact dermatitis and
yet, I have been able to form some impressions
allergic disorders.
which I wish to share.
The process of converting raw tobacco into
processed zarda or beedi zarda consists of
a number of part-manual, part-mechanical
operations of winnowing, sieving and pounding.
At times all these are done with the help of
machines. Finally, various grades and kinds
of tobacco are blended into a mixture as
required for a particular brand of beedi. The
whole process, particularly winnowing and
blending, causes a lot of fine tobacco dust to
fly up into the air of the closed rooms that
pass-off as factories. For a newcomer it
is impossible to stand there even for half
a minute without retching or getting a bout
of coughing and sneezing. New recruits often
feel giddy and vomit while working. The
whole process also entails direct contact
of the skin with tobacco. During the blending
which is done with legs, the heat generated
Although based on my subjective experience,
I can say with some confidence, and relief
too, that some of the conjectures were pro
bably wrong :
a)
Respiratory disorders like chronic bronchitis,
emphysema etc. are not as widespread as
we had expected, though probably more
common than encountered elsewhere.
b)
We have not come across any patient with
malignancies of the respiratory tract, which
is somewhat perplexing as constant contact
with tobacco in other forms have been
associated with malignancy. We had three
patients with oral cancer but they had a
history of tobacco chewing.
c)
Bronchial asthma too, does not seem to be
any more common than elsewhere. But
in at least two out of eight patients taking
regular treatment from our dispensary, the
onset could be correlated directly with the
work.
d)
massaging the affected part with or without
a counterirritant. Liniment turpentine is
perhaps the most frequently used drug in
the dispensary. Of course, low nutritional
status, housework and frequent child birth
cannot be ruled out as other possible
causative factors without a thorough study.
Tuberculosis too, does not seem to be any
more widely prevalent than in other areas.
In fact, 11 of the 13 T.B. patients under
our treatment so far, have been beedi
rolling workers or their family members.
Only one woman patient was working
in a tobacco factory and the other was
her daughter. This is a very perplexing
epidemiological
fact requiring further
investigation. Many occupations involving
inhalation of various kinds of dusts make
the workers vulnerable to T.B. e.g., slate
pencil industry, stone breaking etc. It
is also a well known fact that beedi workers
are more prone to T.B. No causative factors
have been identified as yet, though.
i)
This problem seems to be more acute
in beedi-rolling workers. They complain of
pain and stiffness of neck, too. They sit
in even more awkward position - with
straight back and legs stretched out in
front of them and stooping over the tray
containing tobacco and beedi leaves kept
over the legs.
c)
Laryngitis is quite common especially
after the mixing operation which as
mentioned above causes a lot of tobacco
dust to rise. In may women and men
voices have changed and some even
lost them altogether.
The experience so far raises certain ques
tions which we are trying to solve by a syste
matic study of some of these problems :
1) What are the relative incidences of the
diseases noted above in the workers and
control subjects - sexwise and age group
wise. If the results confirm the subjective
experience so far then,
ii) Skin problems like dermatitis, urticarial
rashes etc. are quite common. Many
women complain of fissures in the soles
of their feet, causing great discomfort.
Many problems not considered earlier have
been encountered :
a)
b)
Chronic dacryocystitis seems to be more
common than encountered elsewhere.
It may be because of chronic inflammation
as a result of tobacco induced irritation,
blocking the nasolachrymal duct, or as a
result of physical blockage of the duct by
tobacco dust.
The incidence of dyspeptic symptoms,
hyperacidity and we suspect even peptic
ulcer may be quite high. Almost all the
tobacco workers who have attended the
dispensary have one time or the other
suffered from these symptoms. One factor
which we have not considered is the habit
of tobacco chewing which is quite prevalent.
2)
Why is the incidence of both pulmonary
tuberculosis and malignancy of the respira
tion tract so low? Has it anything to
do with the fact that most of the workers
are women?
3)
Are the muscular problems related to
posture during the work or are they due to
other causative factors noted above ?
It is a matter of regret that there is
not a single study on the health problems
of the workers of an industry involving mate
rial whose hazards are well documented. The
National Institute of Occupational Health
could help me with only a single reference
to a study on hazards to agricultural workers
involved in tobacco farming. Dr. Gupta of
Department of Occupational Health, Central
Labour Institute, Bombay did promise to
initiate a study on an official request from
the Medical Inspector of Factories. In turn
the Medical Inspector of Factories has passed
over the responsibility of producing a "prima
facie evidence" on to us.
The commonest complaint that the workers
have is low backache and pain between
the shoulder blades. This problem seems
almost universal amongst the tobacco
workers. To this, one can add the problem
of painful and stiff knee joints. Many
operations like pounding and sieving require
the worker to squat on her legs for hours
together. This awkward posture must take
its toll. That most of these problems
are caused by muscular strain is borne out
by the fact that relief is obtained by
(continued on page fl)
2
SEX DETERMINATION TESTS : A TECHNOLOGY WHICH WILL ELIMINATE WOMEN
Amrita Chhachhi & C. Sathyamala
40 years as they have a higher chance of
producing a mongoloid child (Down's Syndrome)
and (2) women who are known carriers of
sex-lined disorders like hemophilia, Duchenne
muscular dystrophy etc., which only affects
males. In these cases, a sex determination
test is performed through amniocentesis
and if the foetus is a male then doctors
predict that there is a 50% chance that
the child will be affected.
'A world of men where the few women
who do exist are kept in purdah, no longer
able to move freely, or work or travel, a
world where women as rare commodities
are given as rewards to 'outstanding males'.
Polyandry and prostitution is introduced
and women are treated like Queen ants...'
a futurist nightmare or echoes of Huxley's
Brave New World? The scenario traced above
is not science fiction or a vague future possi
bility. Today modern developments in medicine
have made it possible for parents to choose
the sex of the unborn child and thus determine
the sex ratio of a country. The use of these
modern techniques have serious implications
especially in India where 'choice' is restricted
and determined by one's sex, caste, class and
by the degree of control exercized by the
state. An advertisement by two doctors expli
citly advocating the use of sex determination
tests through aminocentesis as a way by
which parents could 'choose' a male child
by aborting unwanted female foetuses, created
an uproar in the Capital. Women's organizations
have called for a ban and the district medical
authorities have ordered the clinic to stop
these tests. The doctors have taken the stand
that they have not violated any law and
are only providing a facility for sex determina
tion, within a period in which abortion is
legally permissible.
Like all medical techniques, amniocentesis
also carries a certain amount of risk to the
health of the mother and the unborn foetus.
It is hard to estimate the degree of risk
because it depends on a number of factors
such as stage in pregnancy when the procedure
is performed, the proportion and amount
of fluid removed, the actual techniques used
and the skill and experience of the obstetrician.
Between the 13th and 18th week of pregnancy
the risk of having a miscarriage is less than
1% though in the West, amniocentesis is not
normally done unless the woman has at least
provisionally decided to have an abortion
if the tests proved positive. Parents have to
fill in a form at the Department of Human
Genetics, Edinburgh University which goes
like this - 'We understand that the birth of
a normal child cannot be guaranteed from
the results of studies on amniotic fluid and
its contained cells.'
Amniocentesis from the Greek amnion
(membrane) and Kentesis (pricking) was deve
loped to detect genetic abnormalities by
examining the cells of the unborn child a few
months after conception. It is performed
by inserting a long needle through the mother's
abdomen and drawing off a small sample
of the amniotic fluid - the liquid in which the
foetus floats. The cells from the foetus are
separated from the fluid and either examined
directly under a microscope or placed in
a nutrient bath where they continue to grow
and divide. By analysing these cells chemically
doctors can identify nearly 70 genetic diseases,
most of which are serious. Certain genetic
disorders can be detected directly by examining
the chromosomes present in the foetal cells.
However, certain other diseases cannot be
detected in this way. In these cases the
doctor can only predict the probability of
genetic disorders by finding out if the foetus
is male or female i’.e. by a sex determination
test. Amniocentesis is done for detecting
foetal abnormalities in (1) women above
Amniocentesis for genetic studies done
at 16 weeks of pregnancy often requires
multiple needle punctures. A report in the
American Journal of Obstetrics and Gynaeco
logy shows that 22.2% of cases required
more than 2 needle insertions to get the
adequate amount of fluid. Needle insertions,
even done by skilled doctors and after identify
ing the position of the placenta and the
foetus through ultrasound photographs, can still
puncture the placenta or a blood vessel.
Fluid obtained through such bloody taps
cannot be used for examination and another
insertion is required. Too many insertions
and excessive extraction of fluid with the
accompanying danger of leakage from the
uterus means that the foetus can be deprived
of the fluid's protective action.
While the chances of a spontaneous abortion
are not estimated to be more than 1%, a
study of the outcome of 242 pregnancies
after amniocentesis shows the following pattern:
3
Therapeutic abortion
Spontaneous abortion
Premature delivery
Stillbirths at term
: 6
: 3 (1.5%)
: 8 (4 %)
: ’ 3 (1.5%)
version of Malthusianism. Its message is
the same - overpopulation is the prime cause
of poverty, though it is more optimistic
in seeing a successful family planning as
curing humanity's ills.
The liberalisation
of the abor'ion law in 1971 is being seen
as a form in which the population problem
can be solved. Government-sponsored program
mes and private clinics like Marie Stopes'
have explicitly advocated abortions as the
new method in family planning. After the
violent reactions to the sterilization campaign
directed towards men, there is today a return
to women as the 'target group' for family
planning. While it is true that women do
wish to control their fertility (for example,
the long queues formed by women to get
laparascopic sterilisation in Bombay, 1980),
unless the risks to a woman's health of indis
criminate use of these techniques are also
disseminated and back-up services and safe
facilities offered, these methods will ultimately
work against the interests of women.
While stillbirths were all due to obstetric
causes, spontaneous abortions and premature
delivery formed a significant 5%. Needle
puncture marks on the baby, dislocation of
the hips and respiratory complications are also
some of the known complications. In spite of
the use of ultrasonography (photograph of the
baby using sound waves) in the West, chances
of complications remain. Doctors however,
feel that in cases where family history of
the mother's age leads them to suspect genetic
defects, the benefits of amniocentesis more
than justify the dangers.
In the West, the discussions on the ethics
of doing amniocentesis is still raging between
the pro and anti-abortion lobbies. The anti
abortion lobby sees this technique as yet
another violation of divine law. In India,
the issue has taken a different turn. Questions
are being raised not about the diagnostic
value of the technique itself but on its parti
cular social use against one sex. Five years
ago the AllMS initiated experiments on sex
determination through amniocentesis. They
were flooded with requests for abortion as
soon as the parents were told the foetus was
a girl. The issue of abortion of female foetuses
"may not be acceptable to persons in the
West but in our patients this plan was followed
in 7 out of 8 persons who had the test carried
out primarily for determining the sex of
the foetus. The parents elected for abortion
without any undue anxiety". (Indian Pediatrics,
May, 1975).
There is the danger that the population
control argument can easily be made to
fit-in with the stand that women's organisa
tions take regarding the right of women
to gain control over their bodies and choose
whether or not they wish to have children.
Women will have to constantly distinguish
their demands by stressing women's control
over her own fertility, the separation of
sexuality from procreation and that demands
for better and safer abortion facilities are one
step within a general programme of funda
mental change. The focus would thus be
different from feminists in the West who are
still struggling for a more liberal abortion
law. It is all too easy for a population control
advocate to heartily endorse women's rights
at the same time diverting attention from
the real causes of the population problem.
Lack of food, economic security, clean drink
ing water and safe clinical facilities have
led to a situation where a woman has to
have 6.2 children to have at least one surviving
male child. These are the roots of the popula
tion problem, not merely the 'desire to have
a male child'.
The issue was raised in Parliament and
the tests were subsequently banned in the
AllMS through an order of the Indian Council
of Medical Research. However, these tests
for the specific purpose of aborting female
foetuses are still being performed by govern
ment and private hospitals as well as private
clinics in Bombay, Kanpur, Meerut and other
cities. Private practitioners have of course,
found a flourishing market by playing on
social attitudes which see the birth of a
girl as a disaster. The most disturbing thing
about the use of amniocentesis for sex deter
mination is its resultant sanction to abortion
as a form of population control and the impli
cations its widespread use would have on
the sex ratio in India.
Population
control
is
the
20th
Sex determination tests do not guarantee
the birth
of
a
male- • ' child.
Multiple
abortions would be one of the results
of such tests. This will lead to increased
blood
loss (more than
70% of Indian
women . are
already
anaemic),
infection
and injury r to the uterus and the possibi
lity of secondary sterility.
century
4
Sex determination
femicide
tests
will
be
lead
to
patriarchal attitudes (fuelled by consumerism)
which are behind the advocation of sex deter
mination for choosing male children by aborting
unwanted female foetuses. Hie link between
the value placed on preserving women's
lives and health and their role in production
is demonstrated by the fact that the only
states in India which deviate from the norm
of the declining sex ratios i.e. Andhra Pradesh,
Tamil Nadu, Karnataka, Madhya Pradesh,
Kerala and Orissat
*)
are also known for
the active participation of women in agri
culture and other forms of economic activity.
It is these issues along with a broad and
sustained programme for organizing women
that women's organizations can help to reassert
the value of women in society. While a ban
on sex determination tests can to a certain
extent limit the blatant elimination of women
from the population, the problem has to
be tackled also at a deeper level.
A variant of the 'quality' of the population
argument
which has its antecedents in a
thinly disguised racism and the brutal forms
of eugenic control which saw its apothesis
in Nazi Germany, is the use of sex determina
tion for the mass elimination of female
foetuses. The use of a technology is determined
by the particular social context in which it
is placed. In the Indian context where female
infanticide still continues in a subtle form
in spite of being banned overtly, such tests
would result in femicide.
Unlike in the West where women outnumber
men, in India not only are there fewer women
but each year more women die than men.
The sex ratio has been decreasing yearly
from 972 women per 1000 men in 1921 to 930
per 1000 in 1971. Only recently has there
been a slight improvement to 935 per 1000
men. Three times as many girls as boys
suffer from Kwashiorkar (protein deficiency),
while more boys than girls receive hospitalisa
tion and medical care. Female infant mortality
rates were higher by 60% initially up to five
years of. age, are now found upto the age
of eight or nine, indicating the prolongation
in the period of neglect of girls. The next
critical stage to take its toll of women is
frequent, closely - spaced pregnancies and
child births. The maternal mortality rate
is shockingly high: 573 deaths for every
1,00,000 live births. This is far in excess of
even countries like Sri Lanka where the
figure is 300 /100000 live births. If we add
to this the fact that 6.6 lakh women die due
to illegal abortions each year, the implications
of a further reduction in the female popula
tion through 'choice' provided by sex deter
mination tests becomes horrific.
The stand taken by the two doctors from
Amritsar reflect the deeper malady slowly
afflicting the medical profession as a whole
and private practice in particular. In our
country there is absolutely no check on private
practitioners with the result that the art of
healing has become commercialised. Indiscri
minate use of medicines, unnecessary diagnos
tic tests, unnecessary surgeries, lack of
safety precautions and facilities are just
some examples of what commercialisation
can lead to. In the greed for more and more
profits if a few principles of medical ethics
are sacrificed - so what! Incidentally the
Amritsar clinic does not have ultrasonography
facilities which are necessary before perform
ing amniocentesis and it even offers free
repeat tests without warning of the compli
cations these would result in. The Indian
Medical Association's role in setting standards
and conformity to medical ethics has certainly
not been up to the mark.
One reaction to these tests has been that
why should be we bring women into this
world if the world doesn't want them. Perhaps
with fewer women in society their status
might rise and their value increase. Since
the 20's there have been less women in India
and the number is decreasing but there has
been no large scale change in social attitudes newspaper reports of dowry deaths, rape
and murder are a daily testimony to this.
The burden of dowry is only begging the
question of why women are viewed as value
less, unproductive and dispensable as human
beings. The increase in the practice of dowr^_
and the cases of bride burning now brought
to public notice are reflections of the same
At a meeting of women's organizations,
a resolution was passed calling for a ban
on sex determination tests after making
a distinction between the medical use of
amniocentesis and the social abuse of sex
determination. However, sex determination
is itself used for. the diagnosis of certain
genetic diseases and a total ban will either
withdraw this facility for parents who have
high chances of producing a deformed child
or will push the availability of these tests
into the already thriving underground world
of illegal practice (where abortion was, before
*
5
This Is not entirely true. Kerala is the only exception.
See Health Care - which way to go p.68 - Ed.
(continued on page 8)
BATTLE OF THE BODY : Antibiotics versus Supergerms
In
1928 Alexander Fleming discovered
penicillin. It was first used to cure bacterial
infection in 1940, giving birth to the era of
antibiotics. The world gave a sigh of relief:
a wonder drug against the deadly menace
of bacteria had been found. Are we now
facing the end of the golden age of antibiotics?
Experts from all over the world warn that we
may. Continued misuse and overuse of anti
biotics are causing these drugs to lose their
power over bacterial infections. Consumer
*
Interpol
echoes the dramatic appeal of some
150 scientists from more than 25 nations, who
in August 1981 urgently called for worldwide
standards and controls for the advertising,
prescription and distribution of these wonder
drugs before all the wonder is gone!
The Stronger Germs Survive
Today increasing numbers of people no
longer respond to antibiotics they had pre
viously used. The second or third choices
usually are more and more expensive and
mean a greater strain for the already weakened
body. The use of antibiotics for minor illnesses,
where the body's own defence system could
easily cope with the infection or for infections
where antibiotics are ineffective, should
be discouraged for it only creates favourable
conditions for the growth of resistant bacteria.
Hospitals are the hotbed for the develop
ment of "supergerms", bacteria that are
resistant to several antibiotics. There we have
a situation where different strains of bacteria
already resistant to one or more antibiotics
are multiplying together, transferring their
resistance to one another. Horror stories
about supergerms are becoming more frequent
in the news. Several common bacterial infec
tions have already outclassed the antibiotics
designed to cure them.
The first antibiotics used in medical treat
ment were obtained from bacteria which
produced them naturally as a weapon against
other types of bacteria. Later, as a result of
advances in biochemical research synthetic
derivatives became possible. Different anti
biotics are poisonous to different bacte-ua.
The first known one, penicillin, for instance,
interferes with the cell wall construction of
sensitive' bacteria while others inhibit the
production of bacterial protein. Whatever
the mode of antibiotic action is, it stops
the bacteria from multiplying and sometimes
kills them. Some bacteria, however, are resis
tant because they can inactivate the antibiotic.
The genetic information for this ability is
called the Resistance Factor or R-Factor.
In the 1940s, penicillin was 100% effective
against the common type of bacteria, Staphy
lococcus aureus. In 1981 it was found only
10% effective. The consequences can be
disastrous. In 1972 the outbreak of a typhoid
epidemic resistant to chloramphenicol, the
relatively inexpensive antibiotic of choice
for typhoid, claimed more than 10,000 victims
in
Mexico.
About
the
same time in
Kerala in India some 3,000 people were
affected. And in Guatemala, 13,000 people
died of typhoid because of the bacteria's
resistance to two standard antibiotics. Reports
of such resistance also came from North
Africa, Europe, Vietnam and Thailand.
What is most annoying is the fact that
the R-Factor can be transmitted to bacteria
not yet resistant. This means that not only
the descendents of a resistant cell will inherit
resistance but also the bacteria that come in
close contact with such cells may acquire
their resistance. The result: an enormously
speedy spreading of resistance which is most
desirable for the bacteria fighting for the
survival of their species but not for human
beings fighting against the disease caused by
them. In fact the presence of a certain anti
biotic enhances breeding of resistant strains
because the sensitive ones will eventually
die leaving more space and breeding ground
for the resistant ones. This is called selection
ad vantage.________________________________ ,
*
.
More and More Expensive Antibiotics
Such developments have positive aspects
for the pharmaceutical industry. The early,
so-called 'first generation' antibiotics, whose
patent control have long lapsed, are relatively
cheap drugs with a low profit margin for
the manufacturers. The higher priced second,
third, fourth generation drugs promise much
better profits. And so it is in the interests
of the producers to promote saturation use of
their products when they have a new, more
profitable derivative in store. Last year, The
Wall Street Journal carried the message
of new super drugs - structural grandchildren
of penicillin. Fast, powerful and seemingly
safe but the treatment cost up to US$90 a day,
Consumer Interpol Is o programme of the Internationa!
Organisation of Consumers Unions (10CU), an Indepen- dent, non-profit body promoting cooperation In
consumer protection, education and Information.
6
two or three times more than with earlier
antibiotics. Even rich countries with elaborate
health insurance systems are becoming worried
in the face of such price hikes.
national Plasmid Conference held in Boston in
August 1981, emphasised, "Let no one suppose
that widespread use of antibiotics is in any way
a substitute for good sanitation and personal
hygiene. Efforts in improving these mainstays
of infectious disease prevention and control
must be encouraged and strengthened".
For a number of reasons the threat of
widespread antibiotics resistance is graver in
Third World countries where because of
common poor sanitation and malnutrition
infectious diseases are rife. Third World over
use and misuse are fostered when :
At the same time, a careful plan for the
use of antibiotics is needed. The WHO Scientific
Working Group on Antimicrobial Resistance has
made some useful recommendations on this :
* manufacturers and their agents tout their
antibiotics as the omnipotent cure-all for
every sickness;
Surveillance of antibiotic resistance
National action to control antibiotic use
Control of antibiotic use in hospitals
Improving the quality of antibiotic
prescribing
5.
Hospital hygiene
What can consumer groups do to reduce
the overuse and misuse of antibiotics? Helping
consumers understand more about antibiotics,
what they can do and what they cannot, is
one area. Antibiotics do not affect viruses.
So taking them for flu, for example, is futile.
If consumers know how to distinguish which
of the common illnesses are caused by bacteria
and which are caused by viruses it would
help them prevent misuse, such as when
their doctors misprescribe antibiotics.
1.
2.
3.
4.
* combination antibiotics are commonly
marketed, a totally irresponsible practice in
view of the risk of multiple resistance;
* lack of restrictions or effectively enforced
restrictions on the availability of the drugs,
means that people can buy them casually
over the counter;
* Insufficient knowledge and poverty (they
often buy as much as they can afford, which
is rarely sufficient to finish a course of
treatment) aggravate the risk of resistance ;
* doctors habitually prescribe broad-spectrum
antibiotics as a quick answer to their
patients’ complaints, not only for minor
infections b' t also for viral ones. Antibiotics
do not work against viruses. These doctors
claim that the antibiotics are given in case
secondary (bacterial) infection develops.
In addition, consumers should know that:
Self-medication with antibiotics in unwise.
Never buy antibiotics without a doctor's
advice or prescription.
The antibiotic resistance problem in the
Third World is even more serious when one
considers that the resistance is generally
against the relatively cheaper drugs such as
ampicillin, tetracycline, chloramphenicol and
sulfonamide. As the Mexican and Guatemalan
experience have shown, the large-scale import
of expensive new antibiotics for an epidemic
caused by resistant germs can be crippling to
the health care budget of poor country.
Instructions for taking the drug should
be followed faithfully. It is essential to finish
a course of antibiotic treatment, even if they
feel better after a couple of days. Not finish
ing the course of drugs only enhances the
development of resistant germs.
Antibiotics are better not taken for minor
complaints, and never taken for prophylaxis,
that is, in case one gets a bacterial infection.
Nobel prize winner Walter Gilbert's dim
future prospective is valid for the whole world:
"If we continue to use antibiotics totally free,
we can look forward to a period in which 80 to
90 per cent of the infectious strains that arise
are resistant". And what then?
The other prong of the attack on the anti
biotic problem is to put some restraints on the
companies who use every trick in the book to
promote their products to people who cannot
afford them, and who are actually harmed by
some of them. We cannot afford drugs
that don't work and which create more
serious health' problems when appropriately
used.
. It is not too late to begin working on
how we can keep the lid on resistant germs.
With bacterial infections prevention is better
than cure. Infectious diseases in the Third
World thrive because of malnutrition, poor sani
tation, lack of clean water and deplorable hous
ing conditions and so these must be tackled
first. The scientists who met at the Inter
(Condensed from
April 1983, No.4)
7
Consumer
Interpol
Focus,
mfc bulletin : NOVEMBER 1983
RN. 27565/76
Regd. No.P.N.C. W-96
FROM THE EDITOR'S DESK
TOBACCO SICKNESS
We present in this "issue an article by
Dhruv Mankad on health problems of tobacco
processing workers. Dhruv Mankad needs
to be congratulated for the systematic work
he has undertaken. The article is based on
his personal experience. Although he is careful
to say this is not a systematic study, his
results compare very well in those reported
by the National Institute of Occupational
Health, Ahmedabad (NIOH).
The symptoms described such as nausea,
vomiting, dizziness, headache etc. belong to
a syndrome known as green tobacco sickness.
This was first reported by Gehlback from the
U.S. (JAMA 229, 1880, 1974). This was descri
bed in those who work on tobacco fields in
North Carolina state and hence the name
green tobacco sickness. The authors stated that
though the symptoms were known to the
workers for many years, they were never
described till then in medical literature. This
was considered to be of a recurrent, self
limiting nature. Symptoms occured a few hours,
after starting work and was described as a
combined dermal-respiratory exposure. Gehl
back also found that smoking protected against
the symptoms, perhaps due to an increased
tolerance to nicotine.
In our country, tobacco is mainly cultivated
in Andhra Pradesh and Gujarat. There were
said to be 1.2 lakh workers in the organised
tobacco industry as of 1974. Studies by NIOH
on
those
harvesting
tobacco
as
well
as handling cured leaves confirmed the findings
of Gehlback. They also described difficulty in
breathing, breathlessness, dry cough etc.
(continued from page 2)
Is this callousness on the part of the authori
ties due to the fact that these workers
belonged till recently to the so-called un(continu.ed from page 4)
it was legalised). A suggestion made at the
meeting to ban these tests for private practi
tioners and restrict their availability to only
2 or 3 recognised government hospitals could
provide a certain degree of control over the
abuse. Women's organizations and consumer
associations would have to keep a constant
vigil to see that these tests are not being
used to eliminate female foetuses
Between using a pill or another contraceptive
and between abortion of female foetuses
through sex determination lies not only a comI Editorial Committee:
I Anant Phadke
j Padma Prakash
I Ravi Narayan
| Shirish Datar
■ Ulhas Jajoo
Editor
I Kamala Jayarao __
In 1980 NIOH did a study on tobacco processing
workers in Nadiad, Gujarat. The work included
pulverising dry leaves, sizing and fillingup in the bags. Symptoms were found in
70 per cent of the workers but most commonly
only after heavy dust exposure or during
hot summer months. Symptoms persisted
only for a few hours and were considered
by the investigators to be mild in nature.
The NIOH study also found a slight increase
in the incidence of tuberculosis and also
hypertension. Dhruv Mankad has raised the
question as to why the incidence of tuber
culosis and cancer were not high in those
studied by him. As far as tuberculosis is
concerned, unless the incidence in the general
population is known, it is difficult to state
why there is no increased incidence in the
beedi workers. After all tuberculosis is an
infectious disease and other factors described
by Dhruv can only be precipitating factors.
As far as cancer is concerned, it is not so easy
to find a correlation between occupation
and the disease. A large number of workers
have to be studied, their ages known and
also the length of exposure to tobacco should
also be known. Therefore, by a small study
like this one cannot categorically say whether
the incidence of the two diseases is high
or not in these workers.
1 am glad that Dhruv has given us these find
ings on an industry regarding the health
problems of which, as he rightly says, we do
not have much information. I also hope this
will enthuse other members to share their own
experiences, although the studies may not
always compare with those taken up by
established research workers and centres._____ _
organised sector or is it because most of
them are women ? I do not think any syste
matic study is required to answer this particular question.____ _________________________
parison of the developments of science and the
increasing choices available to the indivi
dual but a whole series of issues concerning
social relationships between men and women in
the family and society, the control of and
access to technology, the kind of technology
being developed and how much choice a
socially discriminated group like women
can exercise in such a situation. Today
we have dowry demands as a condition
for a girl's marriage, tomorrow another
condition
for
marriage
could
well
be
an undertaking that she will only produce
sons!
Views and opinions expressed In the bulletin are those of the authors and not necessarily of the
organisation.
Annual Subscription - New rates from July 1981 - Inland Rs. 15/-. For Foreign Countries - By Sea
Mail US $ 4, by Air Mail - Asia US $ 6, Europe, Africa - US $ 9, U.S.A., Canada - US $ 11.
Edited by Kamala Jayarao, A-9, Staff Quarters, National Institute of Nutrition, P.O. Jamal Osmania,
Hyderabad 500 007. Xerox-Offset by Padma Prakash at Abhyankar’s S & T Inst., Bombay 400 004.
Published by Anant Phadke for Medico Friend Circle? 50 LIC Quarters, University Road,
Pune - 16, INDIA.
96
medico friend
circle
bulletin
4
DECEMBER 1983
MDSOSE ©F CORTICOSTEROIDS
Ulhas Jaju
Sewagram
In a majority of illnesses beyond cure, the
best that the allopaths can do is to suppress the
severity of the disease manifestation and to pro
vide relief from agonising symptoms to make life
more comfortable. The bulk of the share is credited
to the corticosteriod group of drugs. They are
the most powerful, anti-inflammatory and immuno
suppressor drugs — a boon for non-curable inflam
matory and immune disorders.
Though very potent and life saving drugs,
steroids can cost life — if not properly utilised.
Over-use and misuse of steroids has posed life
threatening complications like reactivation of dor
mant infection notorious being tuberculosis; bleed
ing peptic ulcer, bone rarifaction and fractures;
precipitation of coma in diabetes etc.
Although it is a drug of last resort in most of
the illnesses, somehow it is used very frequently by
the doctors. The reason for the popularity is the
dramatic relief that these drugs offer which helps
the doctor to earn credibility. Steroids bring
down temperature, relieve joint swelling and pain,
relieve asthma, suppress allergic reactions etc. —
just to mention a few effects. Quite often and
wrongly, steroids are prescribed as the drug of
their choice.
There are different ways in which steroids
are misused/overused.
(i) Prescribing steroids where the drug has no
value : The common examples are viral hepatitis,
viral infection (except rare examples where anti
inflammatory property is utilised), fungal skin
lesions and parasitic infections (with exception
where it is used to suppress allergic manifesta
tions).
The usual practice of adding steroids to blood
to suppress transfusion reactions needs to be de
nounced. It is always better to know the blood
transfusion reactions early, than to suppress them.
Disorders like acute rheumatic carditis, shock,
myeloblastic leukemia, and alcoholic hepatitis are
situations where the role of these drugs is still
debated.
(ii) Overshoot by doctors for early relief of
symptoms : Steroids are never the first line drugs
in diseases like bronchial asthma and rheumatoid
arthritis. In bronchial asthma, topical therapy or
inhalation should be the preferred route of admi
nistration. Decision for systematic therapy must
be taken with great care since the majority of
patients once put on corticosteroids remain indefi
nitely on such maintenance therapy. Its use to
suppress fever of unknown cause is unscientific.
Fever is a useful body response against the offend
ing agent.
(iii) Wrong route of administration : Systemic
therapy has more complications than local use.
Hence, in disorders like bronchial asthma (Inhala
tion, skin application) and ulcerative colitis
(enema), systemic therapy is better postponed as
long as possible. Topical steroid application or
subconjunctival injection of steroids builds up ade
quate levels of the drug in the anterior segment of
the eye. Systemic therapy thus, is unwarranted.
(iv) Selection of wrong drug : Among corticos
teroids, some are immediate acting (hydrocorti
sone) while others take hours (dexamethasone).
Injection of a drug like dexamethasone, in an
urgent situation like anaphylactic shock is merely
to satisfy oneself that immediate action has been
taken. The drug of choice should be intravenous
hydrocortisone.
(v) Prolonged use of drug even after remission
is achieved : In diseases like nephrotic syndrome,
multiple sclerosis, ulcerative colitis, the drug has
no role in maintaining remission. The side effects
of prolonged use overweigh the utility.
Combinations containing
antihistaminics
and
steroids lead to the hazard of steroid dependence.
(vi) Guns fired by the drug industry : Many fixeddose combinations of steroids exist in market.
Fixed drug combinations do not allow alteration of
any of their components, nor allow for varying the
dosage schedule of individual medication. For any
disease, in any patient, the appropriate dose of
corticosteroids to achieve a specific therapeutic
effect must be determined by trial and error and
must be re-evaluated from time to time as the
stage and the activity of the disease alter. One of
the fixed-dose combinations recommended by the
subcommittee of the Drug Consultative Committee
for being weeded out, are steroid combinations.
Reasons for misuse :
Ignorance of the prescriber, over-reliance on
the claims of drug companies and their representa
tives, anxiety to earn a good reputation by provid
ing early relief of symptoms (directly proportional
to the income), absence of cross-checks on irratio
nal prescribing habits, aggressive marketing stra
tegy of the pharmaceutical firms, failure of govern
ment to restrict irrational drug combinations in the
market and above all, lack of consumer education,
are the reasons for these unethical practices.
The following facts need to be kept in mind
while studying the accompanying table showing
some available fixed-dose combinations.
Remedy :
Education of the uneducated (doctors) may
pay minor dividends. The drug can be made avail
a) Pain-killers should not contain steroids.
able only for specific indications when signed by
b) Drug combinations containing corticoste a qualified doctor. A people-oriented government
roids and anabolic steroids have no scientific basis. can ban fixed-dose combinations. The last but not
c) Steroids are useful in treatment of filarial the least, consumer education and their voice
infection only when immediate sensitivity reactions against irrational prescriptions alone can, in the
are observed on administration of di ethylcarba- long run, help in curbing such bad practices.
mazine citrate. Routine advocation of steroid +
DEC combination unnecessarily exposes the
patient to the toxicity of steroids. Steroids do not Bibliography :
have anti-microfilarial action.
1. Med. Clin. N.A. Sept. 1973.
2. Ann. Int. Med. 81 : 505, 1974.
d) For allergic disorders of chronic nature,
3. J. App. Med. 7 : 1007, 1981.
steroids are used only as a desperate remedy.
4. MIMS India Vol. I, No. 12, 1981.
DRUGS CONTAINING CORTICOSTEROIDS
Ingredients
Brand Name
Pharmaceutical
firm
PAIN KILLERS
Deltaflamar (Tab.)
INDOCO
Ingapred (Tab.)
INGA
Rumatin (Tab.)
NOEL
Rumatisone (Tab.)
SIRIS
Thilazone-P (Tab.)
UNIQUE
—Phenylbutazone 125 mg
—Dexamethasone 0.37 mg
—Mg. trisilicate 150 mg
PHARMED
—Dexamethasone 0.25 mg
—Phenylbutazone 100 mg
—Mag. Trisilicate 150 mg
Triactin-D (Tab.)
j'
—Dexamethasone 0.25 mg
—Oxyphenbutazone 75 mg
—Dried aluminium hydroxide 150 mg
—Mg. trisilicate 100 mg
—Phenylbutazone 50 mg
—Prednisolone 1 .25 mg
—Dexamethasone 0.25 mg
—Paracetamol 150 mg
—Phenylbutazone 100 mg
—Diazepam 2 mg
—Dried alum-hydroxide gel 60 mg.
—Prednisolone 2.5 mg
—Phenylbutazone 100 mg
—Atropine methonitrate 0.15 mg
2
Ingredients
Brand Name
Pharmaceutical
firm
Betaflam (Tab.)
VILCO
—Betamethasone 0.25 mg
—Oxyphenlbutazone 100 mg
—Analgin 250 mg
—Diazepam 2.5 mg
STEROID ANABOLIC DRUG
Dexabolin (Tab.)
ORGANON
—Dexamethasone 0.5 mg
—Ethylo-estrenol 0.5 mg
ASTHMA PREPARATIONS
Asmaplon with
prednisolone (Tab.)
KHANDELWAL
Betasma (Tab.)
VILCO
Cortasyml (Tab.)
ROUSSEL
—Theophylline 100 mg
— phedrine HCI 16 mg
—Phenobarbitone 16 mg
—Papaverine HCI 8 mg
—Prednisolone 2.5 mg
—Betamethasone 0.25 mg
—Chlorpheneramine malleate 2 mg
—Ephedrine HCI 15 mg
—Theophylline 120 mg
—Prednisone 1.5 mg
—Ephedrine HCI 10 mg
-—Theophylline 80 mg
—Phenobarbitone 10 mg
ANTIFILARIALS
Neusonil Forte (Tab.)
PCI
Unicarbazan Forte (Tab.)
UNICHEM
STEROIDS 4- ANTIHISTAMINIC
M S D
Perideca (Tab.)
—Dexamethasone 0.33 mg
■—Diethylcarbamazine citrate 100 mg
Thophylline 90 mg
—Dried Al. hydroxide 60 mg
—Prednisolone 3.75 mg
•—Chlorpheniramine malleate 5 mg
—Dexamethasone 0.25 mg
—Cyproheptidine HCI 4 mg.
Ref.: MIMS India, Vol. 1 No. 12, 1981.
IS ANTITUBERCULAR TREATMENT REALLY VERY EXPENSIVE ?
Dr. Nagendranath Nagar
*
injections). Thus having completed a total of 90
injections, the patient has to take onlv INI I 300 or
he may take INH 4- Thiacetazone tablet, costing
paisa 10 and 20 respectively, per day, for another
one year.
Inj. S M = 1 per day X 30 =
..............
1 month
4- INH 300
Inj. S M = 1 Alt. day X 30 =
..............
2
months 4- INH 300
Inj. S M = 1 twice weekly X 30 ..............
34 months 4- INH 300
Then
only INH 300 or INH 300 4Th 150 per day for 12 months.
But, this regimen is useful in places where free
injection facilities (like Govt. PHC) arc available,
Generally, it is said that treatment of tuber
culosis is quite long and very expensive and hence
patients stop treatment as soon as they feel better.
I
submit 'that though treatment is quite long,
it is not as costly as is generally thought, by doctors
and social workers.
Injection Streptomycin (SM) 4- Isoncx
(INH) = Rs. 3.00 + 0. 10 = Rs. 3.10 per day.
(Injection charges not included)
If SM + INH regimen is followed, it will cost
Rs. 3.10 per day, flint too only for the firs' month.
In the second month the patien. has to take the
injections on alternate days thereby reducing the
to average of Rs. 1.60 per day. After another 30
injections, i.e. by 4th month 'the expense is further
reduced, as the patient has to (take the injections
only twice a week for another 4} months (30
* Anjuman Hospital, Dahod.
3
or where a compounder or nurse is available, who
will charge minimum for injection (Rs. 1 or paisa
50 only.).
In my opinion, anoithcr, cheaper regimen
would be
Ethambutol (800 — 1200) + INH 300 or
INH + Th per day =
(Rs. 1.30 - 1.90) 4- 0.10 or 0.20
= Rl>. 1.40 - 1.50 to
Rs. 2.00 — 2.10 per day.
In this regimen, the patient not only saves the
injection charges but also saves his time and ener
gy, which he has to spend in going to the place
of injection. A lot of inconvenience can thus be
avoided.
Though many people doubt the efficacy of
Ethambutol, in my opinion, this is the ideal com
bination for our rural population. The medicines
are to be continued for at least 1 year, to be
followed by IN,H or INH 4 Th for another 6
months. Thus it is evident that for an uncompli
cated case treatment does not cost more than Rs.
4 per day. It is another matter that there are many
people, who can not afford even this. If the treat
ing doctor is really interested in the patient, he
can well utilise his intelligence in tailoring the
treatment plan, according to the financial condi
tion of his patients.
Truly speaking treatment is made costly by
vested interests and ignorant doctors. How ?
1. By addition of (uscle.4>) malt and other tonic
preparations to the prescription. The clever
pharmaceutical people, so strongly hammer
down the importance of various malts and
'
ferrols, that lhe moment the young doctors
see a case of T.B. they would first write the
fcrrol and then SM or INH.
2. Many doctors think that giving injectable
calcium to TB patients helps to 'calcify the
lesions early . Many doctors use various cal
cium preparation to dissolve the SM powder
for injection. This practice definitely help);
the doctor and the pharmaceutical companies
but the patient the least. It increases the cos:
by another Rs. 3 or 4 per injection.
3.
Addition of various other calcium, iron,
multivitamin, protein and anabolic prepara
tions to the prescription.
Thus a treatment which should originally cost
Rs. 3 or 4 is unnecessarily being made expensive,
costing Rs. 8 to 10 per day. 1 would ask had a
person been able to afford Rs. 8-10 per day on his
drug bills, why should he have tuberculosis ?
I would like to avail this opportunity to re
quest my sensible colleagues to ponder over their
own prescription; and modify their habits for rhe
benefit of poor patients. It has been proved be
yond doubt that mositl of the TB patients would
improve gradually, if they take anti-TB drugs re
gularly, without help of iron, calcium or multi
vitamin preparations.
The addition of Thiacetazone to INTI is quite
beneficial. It affects the cost factor only by 10
paisa per day.
The shorter regimens using Rifampicin and
pyrazinamide are no doubt very effedtive and pro
mising but these drugs are still beyond the reach of
our poor masses.
Most of the private pradtioners do not dis
close the diagnosis of tuberculosis to the patient
because of the false fear of losing the patient. I
would suggest that the patien: should be well in
formed about the disease and he must be well
convinced to continue the treatment for 1| years.
He should also be taken into confidence about the
cost of the treatment. All these measures will ,
definitely reduce the number of defaulters and
would improve compliance. It would not be out
of place to mention that ambulatory treatment is
preferred these days and sanatorium regimen is
reserved only for complicated or gravely ill patients.
In my opinon M.M.R. is the best- method of
detection of Pulmonary TB, though the equipment
is very costly (around Rs. 7,00000/-, 50% of which
is custom and excise duties and other taxes). But
one chest X-ray would cost only Rs. 1.00, as against
a full size X-ray costing Rs.30 ,o Rs. 60.
A large net work of Tuberculosis associations
and clubs should be spread throughout the country,
where
i) the drugs should be sold at subsidised
prices.
ii) the injections can be administered to the
patients, free.
These centres need not have a doctor in attendence but one or two experienced paramedical
staff who can administer injection and keep records.
1 he voluntary health organisations must press
the Government to exempt excise duty and other
taxes on antitubercular drugs, and M.M.R.
apparatus.
A
4
FANCY, FALLACY AND FACTS ABOUT FIXED-DOSE
FORMULATIONS
— S. K. Kulkami
*
ith the changing trend in prescription writing
polypharmacy of prescribing more than one drug for
a particular ailment has become verv common in
medical practice. Whether the physician prescribes
multiple drugs because fixed combination dosage
form s are available or vice-versa i.e. pharmaceutical
manufacturers make these dosage forms as physician
prescribes more than one drug at a time is a highly
debatable issue. But in either way the patient is
exploited.
Do Fixed-Dosage Combinations have any
Advantage :
1.
Improved compliance ; In situations such
as hypertension, mixed bacterial infection, where
more than one therapeutic compound is indicated
fixed combination has better patient compliance.
2.
Synergism : The widely accepted synergistic
combination is Co-trimoxazolc (Sulphamethoxazole
and Trimethoprim). This combination is official
in certain pharmacopoeas. By sequential blockade
this combination shows enhanced therapeutic action.
But recent evidence tends to question such efficacy'
at least in the treatment of urinary tract infection.
Trimethoprim alone has been demonstrated to be
more effective, with low incidence of. resistance and
side effects. In the light of this the future role of
Co-trimcKazole remains to be determined. It is
unwise to use this combination in minor infections.
More than one third of all the new drug procts introduced world-wide during 1978 were fixed
combiuaition preparations. The trend varied from
country to country'. In Japan only 10% of the new
products were fixed-ratio combinations whereas in
European counties it was up to 56% as in Spain.
However, such statistical data are lacking for the
developing countries although the trend is for the
.production and prescription of fixed combinaion
drugs. The WHO TRS 641 (1979) while listing
nearly 650 “essential drugs” included only 7 such
drug combinations.
The other classical example of synergism is the
use of thiazide diuretics with other antihypertensive
agents in the management of essential hyperten
sion. During 1979 in Germany alone more than 16
million prescriptions were written for such combi
nations.
There are many preparations of fixed dose
combinations available for the treatment of various
ailments ranging from nutritional deficiency to cardio-vascular diseases. It is interesting to note that
highest number of such preparations included vita
mins (HO), cough suppressants (71), antidiarrhocals
(64), iron preparations (66), antacids (.0), analge
sics (67), and tonics (65). The enormous differences
in the cost of these preparations is worth studying.
In none of the above categories, however, reallybis
any need for multiple drug treatment. The availabilitv of such a high number of combination
products clearly shows (i) public ignorance (ii) lack
of pharmacological knowledge of doctors and
(jii) exploitation by the industry The protago
nists and antagonists of fixed dose combinations mayhave their own arguments but the drug regulatory
authorities should look into the therapeutic rationale
of these combination products strictly on their merits
and help in the prevention of public explcitation.
It is essential that public awareness towards un
necessary medication through fixed combination
should be increased through media.
3.
Enhanced efficacy : The discovery of peri
pheral dccardoxvlase inhibitors has not only enhanc
ed the therapeutic efficacy of levodopa in Parkin
sonism but has reduced the dose of levodopa and
hence its side effects. Similar example of estrogen
and piogestogen combination in oral contraceptives
may be given. Treatment of tuberculosis calls for
more than one drug at a time. This not only
enhance!; the efficacy of combined treatment but
also reduces the risks of bacterial resistance. How
ever, fixed-dose combinations of Rifampicin and
Isoniazid pose problems as Rifampicin dose is
calculated on the basis of body weight. Added risks
of ■ inflexibility in dosage regimen of Rifampicin is
over weighed as agains: the beneficial action. The
Government has recently decided to stop the pro
duction of this combination.
* of P.G.I., Chandigarh
5
sulphonamide content.
In such individuals
(sulpha-ccnsitivc) Trimethoprim alone can be used
instead of depriving its use by prescribing Cotrimoxazole. Such problems may be more when
3
or more drugs are present in one preparation. It
is always desired that increased benefit expected from
a combination must out-weigh additional risks of
adverse reactions.
4.
Reduced side effec'.s : Some argument is
given for the co-administration of a second drug
along with the primary drug to overcome the side
effects of the primary drug. This is particularly
in case of antibiotic treatment. For example ad
ministration of Pyridoxine along with Isoniazid to
prevent peripheral neuropathy seen with Isoniazid.
Such fixed-dose combinations tend Lo offer better
compliance but any combination genuinely shown
to reduce the side effects (increased safety) while
maintaining the cfficaci must be judiciously consi
dered as the treatment of choice. Unfortunately,
many of such fixed-dose combinations have not
been subjected to appropriate tests of therapeutic
efficacy and safety, and, therefore, it connot be as
sumed that all combinations are therapeutically
rational and safe.
4.
Physician's ignorance of the contents ; In
majority of the instances when the physician pres
cribes a fixed-dose combination he is less likely to
know’ the exact ingredients of the combination.
This is particularly so when the,combination con
tains more than 3 drugs.: If doctors are unaware
of the ingredients of multiple drug combinations,
there is hardly any justification in prescribing such
preparations, say which contain 3 or more drugs.
There is also a tendency of using multiple drug com
binations where the diagnosis is doubtful or soppy.
What are the Disadvantages of Fixed-Dose
Combinations ?
1.
Fixed-dose ratio : While prescribing a
fixed-dose preparation the physician loses flexibility
in dosage. The effective dose of a drug varies
among patients and in disease states. In certain
disease); such as insulin-dependent diabetes, mental
depression, hepatic and renal failure the dose has to
be tailor-made. Drugs like Rifampicin have to be
administered on the basis of body weight. Though
fixed-dose preparations are convenient dosage forms,
they definitely encourage bad prescribing by doc
tors. The inflexibility of the ratio of combination
of drugs is a definite disadvantage in mos' cites.
There are situations where fixed-dose combina
tion may have clear cut advantage such as in
hypertension. Similarly, some sound combinations
may be available, as we .have in Co-trimoxazole.
But even in these situations if the prescriber is not
aware of the ingredients it may lead to unwanted
reactions. For example, prescribing a beta-blocker
combination to a hypertensive patient who is asth
ma.ic may precipitate asthma. Similarly Co-trimo
xazole though scientifically sound and widely used,
opinions seem to be moving in favour of using
Trimethoprim alone. A scries of adverse reactions
to Co-trimoxazole arc appearing in literature.
Therefore, it is important to weigh the therapeutic
advantages over potential toxicity of a preparation.
In the developed countries the trend is already
away from the fixed-dose combinations. Some
European drug regulatory agencies are thinking of
restricting the number of available combinations.
The recent decision of our Government to ban the
manufacture of some fixed-dose formulations is a
welcome step in this direction.
Encouraging
generic names against brand names may be another
step towards discouraging branded combination
preparations. But the most effective way would be
through intelligent and selective prescribing. If
doctors prescribed fewer drugs patients arc less in
clined to buy them. If doctors are selective and
discriminating in their use of combination products
the manufacturers might be more restrained.
2.
Irrational combination : Some combinatiions are simply irrational. For example, barbitu
rates or benzodiazepines plus analgesics, anti
inflammatory steroids. Some such combinations
contained vS amins also. The British Committee
on the Review’ of Medicines (1979) felt that almost
all barbiturate combinations, even the ones with
coronary dilators, should be withdrawn on the
grounds of doubtful efficacy and hazards of depen
dence. WHO TRS 641 (1979) on ‘Essential
Drugs’ hiR deleted multivitamin combination from
its list suggesting that fixed-dose vitamin combina
tions should not be used indiscriminately. Vitamin
needs (should be worked out of a par icular problem.
3.
Increased toxicity : The use of two drugs will
always increase the risks of idiosyncratic reactions.
This can be avoided if individual drugs are used.
For example some patients show hypersensitive
reactions to Co-trimoxazole which could be due to
♦ ♦
(Source : Drugs Bulletin, April 1983)
6
X M. F. C. ANNUAL MEET
As announced in .he October issue, the X
M.h.C. Annual Meet will take place in January
end 1984, 27th to 29th January, 1984. Dr. Samir
Choudhary, Director of Child In Need Institute
(CINI) near Calcutta has kindly agreed to the con
vening of this meet at CINI.
The first two days of the Annual Meet would
be devoted to the discussion on the theme “Why
alternative medical education is necessary?” and the
third day ‘will be reserved for the Annual General
Body Meeting of MFC.
Why discuss medical education ? : There has
been a istrong feeling among the members of Medico
Friend Circle and like minded people that the esis ing medical education is inappropriate. In fact one
of the founding inspirations of MFC has been .he
realization of the irrclevencc of the medical educa
tion to the needs of the rural poor. But it is only last
year at Anand that we sa't down together to syste
matically discusss the issue of medical education.
In the mid-Annual Executive Committee Meeting
at Kishore-Bharati in mid-July. 1983, it was decided
that we should take up the above mentioned theme
for discussion at the coming Annual Meet. In a
sense, it would be a continuation of the discussion
at Anand. But the emphasis would be quite diffe
rent. The discussion at Anand focussed on “Alter
native Medical Education”. That discussion was
mainly (though not exclusively) aimed at the con
ference in Dhaka on alternative medical education
for which some MFC members were invited. This
time the aim would be 'to build a strong ease as to
how the existing medical education is not appropri
ate. Though a criticism of the existing medical
education presupposes some general notion of the
alternative, those who were not present at the
Anand-discussion would in no way feel handicapped
at the coming CINI Meet.
What shall we discuss ? : During our prior
discussion at Anand at Kishore-Bharati, we identi
fied about 10 broad sub-topics which more or less
cover medical education. These were- (1) Selec
tion of students, (2) their social background,
(3) Social background in which the student will
work: (4) The basic role of the doctor; (5) Nature
of training set-up; (6) Orientation of teachers;
(7) Structure and content of course; (8) Metho
dology of training; (9) Method of cvalution;
(10) Method of continuing education. All these
points cannot be properly diseased in a matter of
two days during the coming Annual Meet. At
Anand and at Kishore-Bharati, we could discuss
first five points in some detail and could come to a
broad consensus. (On other points, we could get
time only to broadly delineate further sub-topics &
issues). Based on this consensus, an article will be
circulated well in advance, arguing how the existing
system of medical — education is at fault on these
first five aspects of medical education. It is hoped
that all the participants would broadly agree with
this article. If there arc any fundamental objec
tions, these will be discussed at the beginning of
the discussion at CINI. Otherwise we would direc
tly go for the discussion on the remaining issues.
The first five issues constitute the fundamental pre
condition of medical education. Thus if the medi
cal education is to become relevant and useful for
the cause of the people of India, the policy about
these preconditions of medical education has to
change fundamentally. In absence of this, mere
changes in content of the curriculum will hardly
be of of any use. But it is not sufficient to discuss
only the pre-conditions. Methodology of training,
structure and content of cirriculum is equally im
portant. We have therefore decided to focus the
discussion on 'these issues which have so far not
been discussed in MFC in a systematic manner.
How shall we discuss ? : We will divide our
selves into three groups — The first group will
discuss about what is wrong with the structure and
content of the prcclinical, clinical and paraclinical
subjects as taught in today’s medical education.
The Second group will discuss about what is
wrong with the structure and content of community
medicine as taught in today’s medical education in
India. This would involve discussion on (a) Pre
ventive medicine (b) Sociology of Medicine.
The Third group will discuss about what is
wrong with the methodology of training in today’s
medical education.
After these group discussion, there will be a
plenary session wherein the discussion in each
group will be reported and discussed upon one
after another.
Background Material :
These discussions cannot be done properly un
less we do some systematic home-work before the
meeting. The following background material will
be circulated before the meeting
A special joint January-February issue of MFC
Bulletni would be published in the first week of
January', 1984. It would contain : (i) An article
reviewing the attempts made in different countries
RN. 27565/76
mic bulletin : DECEMBER 1983
to develop an alternative curriculum, (ii) An article'
reviewing the development of medical curriculum in
India during last 150 rears, (in) A note showing
the divergence between the health-needs of the
people of India and the structure of the health
delivery system in India. It would then broadly
online the type of doctors we need given the health
needs of our people.
These articles would create a general background
for the discussions. Besides these articles in the
Bulletin, following cyclostyled article will be sent to
all partipants :—
a)
A Position Paper arguing how the existing
medical education is alt fault as regards the funda
mental prerequisites mentioned above.
The
discussion would proceed assuming this critique un
less there are any fundamental objections from
participants;
b) A Position Paper on each of the three topics
mentioned above for group discussions. These
position papers will not be taken up for discussion
as such but will be at the back of our mind when we
start the discussion;
c)
A Discussion Paper on each of these three
topics for group discussion, ft will be in the form
of onlv a series of questions drawn up to delineate
various subissues that need to be discussed during
the group-discussion . These questions will be taken
up for discussion one by one.
All these cyclostyled papers will be sent to
Repel. No. P.N.C, W-96
participants one month in advance so that
participants can do some more home-work on their
own. Those who want to send any written com
ments are welcome to do so. We will try our best
to circulate such comments in advance to all
participants. But there will be no “reading" of
any papers during the Meet.
Travel Arrangements and Registration :
As usual, participants will have to pay for their
own travel. For return reservations, the hosts will
have to be informed at the earliest. Those of you
who want to come to the Meet are requested to
write to me immediately, if you have net done so
earlier. Late-informers may not get Return-reser
vations. CINI is at the other end of Calcutta
City, about 15 Kms. from the station. Return
reservations will be made through an agency. Those
who have not informed me so far may now directly
write to the Dircc or, CINI, (and inform me also)
Village Daulatpur, P.O. Amgachi, Via Joka, 24
Parganas, West Bengal alongwith all details of train
number, date., .etc. and the fare and Rs. 15/- for
the commission of the agency. I will send all the
participants a detailed note about arrangements at
CINI. As reported earlier, food will be subsidized;
but the participants will have to pay something to
wards food-charges. For details write to me.
Anant Phadke,
Convenor, MFG.
CAMPAIGN AGAINST THE IRRATIONAL PRODUCTION AND MARKETING OF DRUGS
This month marks the launching of a nation
wide campaign against the irrational patterns of drug
production in the country and unethical marketing
strategics used by them to promote non-essential
drugs, and again1,): drug misinformation. Several
consumer groups, voluntary' organisations, people’s
’science movement groups and pharmaceutical trade
unions are participating in the camapign. The cam
paign has taken the form of a network of intensive
action programme at the local level which educate
people and involve them in demanding a change in
Editorial Committee:
Anant Phadke
Padma Prakash
Ravi Narayan
Shirish Datar
Ulhas Jajoo
Editor
Kam ala Jayarao
tire drug picture of the country. The Lok Vidnyan
Maharashtra has published an appeal to the doctors
in the October issue of the Pune Journal of Conti
nuing Health Education.
The letter lists nine
common misuses of drugs because of misprcscription
on the part of the doctors. Quoting from standard
tex-.books it explains why these practices are irra
tional and appeals to the doctors to refrain from
such practices.
Dr. Zafrullah’s Chowdhury’s current visit to
India gives the campaign an added fillip.
Views and opinions expressed in the Bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15/-. For Foreign Countries — By Sea Mail US $4,
by Air Mail — Asia US $6. Europe. Africa — US $ 9, U.S.A.. Canada — US $ 11.
Edited by Kamala Jayarao, A-9, Staff Quarters, National Institute of Nutrition, P.O.
Jamal Osmania, Hyderabad-500 007. Printed by Padma Prakash at New Age Printing
Press, 85, Sayani Road, Bombay-400 025. Published by Anant Phadke for Medico Friend
Circle; 50 LIC Quarters, University Road, Pune-411 015, INDIA.
SUBJECTWISE INDEX ®F MFC BULLETINS
Subject Categories :
1) Health Services — General
2) Health Services in Other Countries
3) Health Schemes, Projects and Groups
4) Medical Education
5) Problems of Doctors
6) The Nursing Profession
7) Science and People
8) Indigenous Medicine
9) Community Health Worker
10) Sexist Bias in Health
11) Maternal Health
12) Contraception and Abortion
13) Population Growth and Control
14) Children and Health
15) Nutrition and Hunger
16) Lathyrism
17) Environmental + Occupational Health
I.
Health Services—General
Banerji D, History of health services in India, 1-2:
jan-feb 1976, p1
Jaya Rao K, Nanavati K, Katgade V, Report B: dis
cussion on 'our present day health problems
and needs', 1-2: jan-feb 1976, p7 (proceed
ings of II ann. mfc meet)
Patel A, Report D: discussion on 'health for the
people : finding a practical way', 1-2: jan-feb
1976, p9 (proceedings of II ann. mfc meet)
Banerji D, Evolution of the existing health services
systems of India, 3: 1976, p1
Qadeer I, A rush for alternatives, 3: mar 1976, p7
(review of 3 recent WHO/UN publications)
Elliott C, Is primary health care the new priority?
Yes, but
(part I), 4: apr 1976, p5
Elliott C, Is primary health care the new priority?
Yes, but
(part II), 5: may 1976, p3
— , Health or 'health services'?, 5: may 1976,
p5 (review of Care of Health in Communities
and Medical Nemesis)
Qadeer I, Dear friend : much ado about
. 6:
jun 1976, p7 (about King M, Medical Care in
Developing Countries)
Bang A, Much ado about
8: aug 1976, p4
Qadeer I, Dear friend : much ado about
, 10:
oct 1976, p8
Parmer S, Health care in the context of self-reliant
development, 12: dec 1976, p4
Phadke A, Report B: discussion on 'health services:
an analysis', 13: jan 1977, p6 (proceedings
of III ann. mfc meet)
Jain T, New national health policy, 20: aug 1977,
p1
Phadke A, A programme for immediate action, 21:
sep 1977, p1
18)
19)
20)
21)
22)
23)
24)
25)
26)
27)
28)
29)
30)
31)
32)
33)
Health during Mass Calamity
Water Supply and Sanitation
Diarrhea and Oral Rehydration
Drug Industry Malpractices
Drug Misuse
Rational Drug Therapy + Action
Drug Policy Alternatives
Tuberculosis
Malaria
Leprosy
Mental Health
Miscellaneous: Technical and Medical
Misc. : Non-Technical or Non-Medical
Role of MFC and Members
MFC Bulletin
MFC Meet Reports (Organisational)
Compiled by Mira Sadgopal
Qadeer I, People's participation in health services,
23: nov 1977, p1
Shah D, Dear friend: new national health policy,
23: nov 1977, p8
Jaya Rao K, Why an alternative health policy?, 25:
jan 1978, p7
Bang R, Health services in India: report of discus
sion on paper, 26: feb 1978, p7 (proceedings
of IV ann. mfc meet)
Destanne G, Two ways for health economics
(part I), 27: mar 1978, p1
Destanne G, Two ways
(part II), 28: apr 1978,
p5
Gideon H, Making the community diagnosis, 30:
jun 1978, p1
Banerji D, Political dimensions of health and health
services, 31: 1978, p1 ★
— , News clippings: the need, the words, and
the deeds
33: sep 1978, p4
MFC, The rural health care scheme — mfc view,
34: oct 1978, p2
— , Rural orientation of policy makers, 34: oct
1978, p8
Ganguli M, Health & Society, 51: mar 1980, p7
(journal notice)
Maru R, Murthy N, Rao T, and Satia J, Professional
management in health bureaucracy, 53-54:
may-jun 1980, p1
Barreto L, Primary health care, 55: jul 1982, p1
Jaya Rao K, Kerala : a health yardstick for India,
58: oct 1980, p1
**
Deshpande M. Dear friend: people's participation,
59: nov 1980, p6 (response to A Bang's
account of Savar project in 58)
Bang A, People's participation and economic selfreliance in community health: 64; apr
1981, p1>
*
COMMUNITY HEALTH CELL
JANUARY 1976—MARCH 1984
47/1, (F irst F loor)St. Marks Road
BANGALORE - 560 001
ISSUES 1-99
Ladiwala U, Dear friend: I would like to visit Nag
pur, 32: aug 1978, p4
Kapadia R, MFC news: MFC group in Bombay, 33:
sep 1979, p5
— , MFC news: Sevagram (report of two dis
cussion — 1. drug industry 2. nurses) 34: oct
1978,
p4
Soni M, MFC news : Ahmedabad (report of a meet
ing of members), 34: oct 1978, p4
Parikh I, Dialogue : health project — a means of
social change, 39, mar 1979, p7
— , MFC news : (MFC ground at Sevagram),
40: apr 1979, p6
— , MFC news : (Meeting of MFC group at
Calicut, Kerala), 41: may 1979, p8
— , 'India is Kundungal' (Calicut group experi
ence), 42: jun 1979, p7
— , When the search began (field experience
of MFC group, Sevagram), 47-48: nov-dec,
1979, p5
Desikan K, Dear friend (response to Sevagram
group's article in 47-48) 50: feb 1980, p5
Arole R, Comprehensive rural health project,
Jamkhed, 49: jan 1980, p1
Tharyan T and Joseph A, The Veppampet story,
53-54: may-jun 198, p6
2. Health Services in other countries — , The paramedics of Savar : an experiment in
health in Bangladesh, 57: sep 1980, p1
**
Prem R, Few points to ponder over......... 17: may
Bang A, Learning from the Savar project (part I),
1977, p7 (European health services)
58: oct 1980, p5
Rajan V, Community health in China, 22: oct 1977 Bang A, Learning from the Savar project (part II),
p1
59: nov 1980, p1
44 3T,
^tflR22: oct 1977, p (obser Bang A, 'ACHAN' — a new Asian organisation,
vations in southeast Asian countries — part-l)
59 : nov 1980, p6
— , CINI — Child In Need Institute, 60: dec
— 4^
R 23: nov 1977, p5 (part-fl)
1980, p1
Conover S, Donovan S and Susser E, Reflections — , Some more activities of CINi, 6y: jan 1981,
on health care in Cuba, 68: aug 1981, p1
p4
3. Health Schemes, Project and Groups Phadke A, RUHSA (Rural Unit for Health and
Social Affairs), 63: mar 1981, p5
Khanra L, Report F: report on projects description,
1-2: jan-feb 1976, p11 (proceedings of II ann- — , Some more activities of CINI, 61: jan 1981,
P4
mfc meet)
U, Community participation in primary health
— , News (reports received from Vadodara and Jajoocare,
66: jun 1981, *
-rp4
Surat groups in Gujarat), 4: apr 1976, p3
— , Health Action International, 77: may 1982,
Nanavati K, Community health care centre, Thaltej,
p4 (HAI is affiliated with the international
4: apr 1976, p4
organisation of consumers unions — IQCU)
Chandran N, Report: regional mfc camp, Kerala, 9: George T, Calcutta National Welfare Organisation,
sep 1976, p7
88: aug 1982, p6 (report after CNWO
Katgade V, Health care delivery through ESIC, 15:
seminar)
mar 1977, p1
— , Socially conscious epidemiological ap
proach, 82: oct 1982, p6 (report of Mangrol
Sadgopal M and Gupta V, Doctors' camp at Kishore
group's work, from mid-ann. meet)
Bharati: a probe into the cycle of poverty and
disease, 15: mar 1977, p5
— , Health work in a working class movement,
Jaya Rao K, Dear friend: health care delivery
82: oct 1982, p6 (report of Binayak Sen's
through ESIC, 18: jun 1977, p7 (response to
work with Chattisgarh Mukti Morcha, from
mid-ann. meet presentation)
V Katgade's article in No. 15)
Katgade V, The scope of health projects: report of
4. Medical Education
discussion on paper, 26: feb 1978, p7
— , Mao Tsetung's June 26th directive (slightly
Bang R, One 'Sir' every two minutes 30: jun 1978,
amended)
of 1965, 9: sep 1976, p8
p5
Schumacher E,_ The two ways, 10: oct 1976, p7
Kapadia N, Pujai: an experience with mud and Anon., Dear friend : needed — new managers for
rain, 32: aug 1978, p3 (a student recollection)
medical colleges, 14: feb 1977, p5
Clark A, What development workers expect from
health planners, 67: jul 1981, p1 TrTr
Ramprasad V, Primary health care: The real pic
ture, 77: may 1982, p6
Subramanian A, Health for all: an alternative stra
tegy (a note on the current tasks), 79: jul
1982, p1
Narayan R, Keeping track — 1, 80: aug 1982, p5
(review of two documents on alternative
health care by ICSSR/ICMR)
Narayan R, Keeping track — II, 81: sep 1982, p3
(review of lllich I, Medical Nemesis and
Horobin D, Medical Hubris)
Swaminathan S, Why PHCs have failed: reflec
tions of an intern, 81: sep 1982, p4
Dandare M and Karandikar V, Integrated health
programmes: some questions, 84: dec 1982,
p5
Nabarro D, Health for all by the year 2000 : a
great polemic dissolves into platitudes?
(part I) 90: jun 1983, p1
Nabarro D, Health for.all........ ? (part II), 91: jul
1983, p1
Jesani, and Prakash P, Health for all?, 94: oct
1983, p8 ,reply to D Nabarro's article)
2
Dey S, Dear friend: needed — new managers
...... (I), 15: mar 1977, p4
Jindal T, Dear friend: needed — new managers
........ II) 15: mar 1977, p4
Kothari Ml and Mehta L, Knowledge is confusion I
17: may 1977, p5
Nene D. Dear friend : needed — new managers
for medical colleges, 17: may 1977, p8.
Zala M. Dear friend : Knowledge is confusion, 18,
jun 1977, p7
— , Dear friend : increase in the seats for medi
cal college students in Maharashtra, 22: oct
1977 p
Patel B, Dear friend : Up against new medical
colleges 23, nov 1977, p8
— . Medical studies in Malayalam, 32: aug
1978, p4
Kashlikar SJ, medical education : physiology and
frogs, 33: sep 1978, p4
Dhaddha S, Dear friends : on 'medical education
in Malayalam', 33: sep 1978, p5
Singh T, Dear friend : medical education and
investigation dependance, 35: nov 1978, p7
— , Product of medical education, 37: jan 1979
p4 (cartoon)
Agarwal D. Threat to PSM, 42: jun 1979, p8
(G.O.I.), National medical education policy (draft
plan), 46, oct 1979, p2
Sonwalkar A, Dialogue : concerning three years
medical college, 46: oct 1979, p4
Mfeqftsf
*«f),
445
4tl 4141474 H4
tr47 amifa^RT46: oct 1979, p5
§> Dialogue:
4UT 45T
aftx
47-48
nov-dec p7
44 ar, Dialogue : 4413 gfgspfa 44 f, 47-48:
nov-dec 1979, p8 (reply to Jajoo S)
—
News clippings : triumph of reaction, 47-48:
nov-dec 1979, p11
Patel A, Dialogue : Three year medical diploma (I),
49: jan 1980, p11
g, Dialogue : Three year medical diploma
(II), 49 : jan 1980, p11
44 ar Dialogue : Three year medical diploma
(III), 49: jan 1980, p11
Cook G, Another view-point : training of doctors
and delivery of health care in developing
countries, 55: jul 1980, p5
Jain T, View-point: medical education and training
of interns, 62: feb 1981, p5
Phadke A, The caste war by medicos, 63: mar
1981, p1
**
__ , Substandard doctor?, 63, mar 1981, p8
Phadke A, Important facts about the medicos' agi
tation in Gujarat,'64: apr 1981, p3
__ , Basic (k) medical education, 37: jul 1981,
p6
Tharyan T, A reorientation of medical education,
68: aug 1981, p2
Mankad D, People and health : a brief report on
the Dhaka conference, 89: may 1983, p1
Sathyamala C, Innovative programme in medical
education: three case studies; 87-98: jan-feb
1984, p10
Jaya Rao K, From the editor's desk, 97-98: jan-feb
1984, pl6
Mankad D, Group A: structure and content of preclinical, clinical and para-clinical subjects,
99’ mar 1984, p1 (ann. meet report)
Jesani A, Group B: content and structure of com
munity medicine, 99: mar 1984, p4 (ann.
report)
Satnyamala, Khanra L and Kapoor I, Group C:
changing the methodology of training in medi
cal schools, 99: mar 1984, p7 (ann. meet
report)
5.
Problems of Doctors
Patel A, Hyde park : doctor-patient relationship :
an acute crisis, 31 : jul 1978, p4
— , And the doctors get what they want, 31:
jul 1978, p4
Gole S, Dear friend: medical council elections, 35:
nov 1978, p7 '
snsj.g %et, t®t! f^sr qtfizn h feo 751
36: dec 1978, p6
, Chloroform (review notice of book in
Marathi by Limaye A), 36: dec 1978, p7
Sen B and Barreto L, Unemployment among doc
tors, 3 7- jan 1979, p3
Dharmadhikari, D, The challenge of history to
medicos, 38: feb 1979 p1
Punse D, Dear friend: unemployed doctors and
unsold cloth, 38: feb 1979, p3
Patel A, Unemployment among doctors X 50 heads
(ann. meet report of discussion at Varanasi
meet). 38' feb 1979, p5
— , Operation medicine: on the path of agita
tion, 40: apr 1979, p6
yai 4, Dialogue: tsrff : 4 47 44 4 4JS 44,
40: apr 1979, p7
Chandra S, Dialogue: the rural internship: The facts
and the factors, 44: aug 1979, p4
Huang C. City doctors go to the countryside, 44:
aug 1979, p6
Jagannatha Rao P, Morel T and Madhavan P,
View-point: why doctors too agitate, 55: jul
1980, p3
Jaya Rao K, Editor's note, 55: jul 1980, p7 (doc
tors' strikes)
Punwani D, .Dear friend (unethical medical prac
tices), 58' oct 1980, p8
— , From the editor's desk: the ban on private
practice, 91: jul 1983, p8
Medical Action Forum. Medical ethics and practice,
93: sep 1983, p6
—
6.
The Nursing Profession
Bang R, Nurses: the cursed nightingales, 33: sep
1978, p5-Ar
— , News clippings : Nursing profession not for
men?, 34: oct 1978, p4
•—- , News clippings: 4><lftt - Qi4>
4>ft,
eft
4ft Mt 50: feb 1980, p6
3
Bang R. Nurse: the woman in the medical system
(part-1), 71: nov 1981, p1
Bang R, Nurse: the woman........ (part-ll), 72: dec
181, p8
7.
. All India convention of people's movement,
88: apr 1983, p4
Umapathy P, Rural nutrition education : a futile
effort?, 94: out 1983, p1
—
Science and People
8.
— , go to the people........ 1-2: jan-feb y976, p3
Kothari M and Mehta L, Points of view: medicine
2000 AD, 18: jun 1977, p1
Conklin E, The effects of the professional agnosti
cism of scientists, 18: jun 1877, p3
Guevara C, The principle upon which the fight
aoainst disease should be based........ 18: jun
1977, p7
Kabuga C, Why andragogy , 29: may 1978, p1
— , Current concepts in parasitology, 29: may
1978, p8
—
The debt, 34: oct 1878, p1 (quote from
Bhore Committee Report)
Abu, 'On weekends, I always became rural orient
ed', 34: oct 1978, p8 (cartoon)
Gandhi M, To the scientists of India, 35: nov 1978,
PBhagwat A, Bhagwat's seven laws, 31: nov 1978,
P1
Roy D and Qadeer I, Is a stethoscope appropriate
technology? 36: dec 1978, p4
Knaus W, God that is failing, 40: apr 1979, p1
Bearden J, A research fable: the needle in the
haystack, 37: jan 1979, p5
Huxley J, Genes and the Society, 41: may 1979,
p1
— , Low cost slide projector by NID, 42 : jun
1979 p8
Choudhury B, Polygamy and positive eugenics, 42:
jun 1979, p7 (response to article by Huxley J)
Patel A, Dear friend: eugenics is anti-evolutionary,
anti-democratic, 42: jun 1979, p7
Mehrotra N, Management of Indian science, 49:
jun 1980, p10 (symposium notice)
— , Teaching aids at low cost, 52: apr 1980, p3
— , Concern of young scientists: Indian science,
53-54' may-jun 1980, p7
Phadke A, Vigyan jatra in Maharashtra, 53-54:
may-jun 1980, p4
Brecht B, A worker's speech to a doctor, 60: dec
1980, p8
Chowdhury Z, Research : a method of colonization,
62, feb 1981. p1 *
★
■—■ , Whither Indian scientists? 67: jul 1981, p4
Panth M, Scientists in villages, 68: aug 1981, p8
(poem)
— , Aids — posters for disabled by AHARTAG,
71: nov 1981, p3
— , The best foot forward, 72: dev 1981, p7
(approp. tech, in artificial limb rehabilitation,
Jaipur)
Bang A and Bang R, Other side of health educa
tion some experiences of health education in
a rural community, 76: apr 1982 p1
4r
*
Jaya Rao K, From the editor's desk, 81: sep 1982,
p8 (urban health care system and public
research establishments)
4
Indigenous Medicine
Khanra L, Report C: discussion on 'alternative
approach: various pathies' 1-2: jan-feb 1976,
p9 (ann. mfc meet)
Vaidya B, Dear friend, 3: mar 1976, p6 (history
of ayurveda — response to article by Banerji
D in 1-2
Patel A, Dear friend, 3: mar 1976, p6
Aron, Dear friend, The limits of fasting, 9: sep
1976, p6
Vaidya B, Ayurveda and allopathy, 10: oct 1976, p6
Jaya Rao K, Dear friend: ayurveda and allopathy
(I), 11: nov 1976, p8
Singh T, Dear friend: ayurveda and allopathy (II),
11 ■ nov 1976, p8
Phadke A, Dear friend: ayurveda and allopathy,
12: dec 1976, p7
Soni M and Surahiyala K, Role of various 'pathies'
in community health, 14: feb 1977, p8
(report of MFC seminar at Ahmedabad)
Kapur S, Dear friend: a topic for study groups,
19: jul 1977, p6 (study of simple remedies)
fer; h antler qfl
ftrai,
31 jul 1978, p5
Vaidya A, Modern medicine and ayurveda: a syn
thesis for people’s medicine, 33: sep 1978,
p1 ★
Bang A, Editorial, 33: sep 1978, p3 (synthesis of
modern and indigenous medicine)
Kanchana Mala NP, Clinical trials with some
ayurvedic preparations 33: sep 1978, p8
311
qft argq?
%,
34:
oct 1978, p7
CCRUM, ‘jJRITt fcRT H 6NR0I
sft jjfta?!’
55' jul 1980, p8
Vad B, Herbal remedies and medical relief, 64:
apr 198y, p4
Multani P, Ayurvedic drug industry, 67: jul 1981,
p4
Jaya Rao K, 'Allo-ayurvedopathy', a non-scientific
hybridization, 73-74: jan-feb 1982, p5-A*
— , Attention please! (notice of first Asian Con
ference on Traditional Medicine), 85-86: janfeb 1933, p11
— , Naturopaths in the USA, 93: sep 1983, p5
9.
Community Health Worker
Shah P, Junnarkar A, Dhole V, Village health assis
tants, 12: dec 1976, p1
Raju U, Relevance of ICMR research project: tea
cher's training as barefoot doctor, 20- aug
1977, p5
Werner D, The VHW — lackey or liberator?, 25:
jan 1973, p1
*
— , A para-medical worker paid Rs. 6 per month,
31: jul 1978, p4
-
1974
Ujjain
1975
Sevagram
1976
Vadadara
Rasulia
1977
Calicut
Ahmedabad
1978
1979
Vadordara
Rewa
Varanasi
1980
Jamkhad
1981
Kavanur
New Delhi
Vadodara
1982
Bombay
Tara
MFC MILESTONES
Relevance of Present
Health Service (M)
Present Health Problems
(M)
First Bulletin published
Nutrition Problem in
India (M)
Community Health
Approach and Role of
Doctor in Society (M)
'Other Pathies' —
Workshop
First Anthology printed
Kissa Kesari Ka Camp
Unemployment among
doctors (M)
Community Health
Worker (M)
Community Paediatrics
(M)
Drug Industry and the
Indian People (N)
Campaign against
medicos-agitation on
reservations
Women and Health (N)
Misuse of Drugs by
Doctors (M)
Campaign against
EP-forte
New Delhi
Sewagram
1983
Dhaka
Trivandrum
Hosangabad
1984
Calcutta
Bombay
M = Annual Meet; N = National level meet with
other organisations; Regional camps and EC
meets have also been held at various places.
Werner D, Liberation of VHW, 49: jan 1980, p6
Werner D, Comparison of doctor and village health
worker, 49: jan 1980, p7
Maru R, Community health worker: some aspects
of the experience at national level, 51: mar
1980, p1
*
Sadgopal M, VI all-lndia meet of mfc at Jamkhed,
52: apr 1980, (topic: the community health
worker plus field study of CRHP Jamkhed)
Vaidya A, Dear friend, CHW, National experience,
52: apr 1980, p10
Jajoo U, Role of the village health worker — a
glorified image, 62: feb 1981, p4*--fc
Vaughan JP, Barefoot or professional: Community
health workers in the third world, 70: oct
1981, p1
Jaya Rao K, From the editor's desk, 70: oct 1981,
p8 (community health worker — overview)
10.
Jaipur
Anand
Second Anthology printed
Campaign against
irrational diarrhoea
management
Meeting with David
Werner
Drug Workshop (N)
Prejudice against women
in Health (M)
People and Health
Conference (N)
People Science Move
ments Convention (N)
Alternative Medical
education — EC Meeting
— Campaign against
irrational production
and marketing of
drugs
— Coordination of
Dr. Zafarullah
Chowdhury's visit
Why an alterative medical
curriculum (M)
Drug Action Network
Meeting (N)
100th bulletin published
Agarwal A (figures from Bangladesh on hospital
admissions and deaths in women), 76: apr
1982, p7
Ehrenreich, B and English D, Witches, healers and
gentlemen doctors, 85-86: jan-feb 1983, p1
Ruzek SB, The women's health movement, 85-86:
jan-feb 1983, p5 (book review)
Ehrenreich B and English D, Oppressive 'scientific'
procedures, 85-86: jan-feb 1983, p6
Grossman M and Bart P, Taking the men out of
menopause, 85-86: jan-feb 1983, p7
Phadke A. From the editor's desk: not so glorious,
85-86: jan-feb 1783, p12
Gupte M, Chatterji M and Patel V, Prejudice
against women in medical care, 87: mar 1983.
(proceedings of IX ann. mfc meet)
Phadke A, Session V: evaluation of the discussion,
87, mar 1983, p8 (proceedings of IX ann.
mfc meet)
Chhachhi A and Sathyamala C, Sex determination.
tests: a technology which will eliminate
women, 95: nov y983, p3
Sexist Bias in Health
Sanford W, Dialogue: woman as consumers of
medical care, 51: mar 1980, p6
CSIV, The Worecesterward: violence against
women, 57: sep 1980, p3 (feminist group
opposes abuse of psychiatry)
Jaya Rao K, Women and health: report of a work
shop, 67: jul 1981, p8
Bang R, Third international conference on women
and health, 69: sep 1981, p6
II.
Maternal Health
Sadgopal M, Training of dais, 24: dec 1977, *
Gole S, Dear friend: increased percentage of
caesarean deliveries in private hospitals, 28:
apr 1978, p4
5
Jajoo U, Dear friend: increased percentage of
caesarean deliveries in private hospitals, 29:
may 1978, p7 (response to Sanjeevani Gole's
letter in 28: apr 1978)
Gupta S, Training of dais, 42: jun 1979, p5
Jaya Rao K, Who is malnourished: mother or the
woman? 50: feb 1980, p1
*
Patki, PS, Letter to editor, 92: aug 1983, p7 (com
parative safety of aspirin and paracetamol in
pregnancy)
AVAILABLE
A reference file on Gonoshasthya Kendra, G. K.
Pharmaceuticals and the Bangladesh Drug Policy.
Prepared for Dr. Zafarullah Chowdhury's
visit in December 1983 by mfc/ISI/OXFAM at
Rupees Five (Rs. 5.00 only) from mfc Bangalore
office. Please send money order.
12. Contraception and Abortion
Dingwaney M, Dear friend: can doctors sympathise
with abortion? 21: sep 1977, p7
Jaya Rao K, From editor's desk, 65: may 1981, p3
(influence of male thinking in contraceptive
research)
Bamji M, How safe is the pill? 65: may 1981, p1
Bamji M, Male contraception, 71: nov 1981, p'ii
— , Abortion: the woman's plight and right, 50:
feb 1980, p7
Norsigian J, Redirecting contraceptive research,
65: may 1981, p3
— , Abortion in India, 71: nov 1981, p5
— , Complications of abortion in developing
countries, 71: nov 1981, p6
—- , Abortion and contraception, 71: nov 1981,
p7
Sadgopal M, Letter to editor, 89: may 1983, p7
(natural family planning methods)
— , From the editor's desk, 93: sep 1983, p8
(barrier methods of contraception)
I3. Population Growth and Control
th t,
tew
faTSPai.
9 sep 1976, p4
Qadeer I, Population problems: a view point, 10:
oct 1976, p1
Shah D, Dear friend: population control and cul
tural values, 10: oct 1976, p8
Jaya Rao K, Dear friend: Population problem: a
viewpoint, 12: dec 1976, p8
Jaya Rao K, Dear friend: family planning .............
when ,16: apr 1977, p7
Maheshwari S, Population control vis-a-vis family
welfare, 23: nov 1977, p3
Panat S, Dear friend: doctors and family planning,
32’ aug 1978, p5
. Rewards beyond motherhood, 51: mar 1980,
p7 (review of Newland K, Women and Popu
lation growth)
Phadke A, Dialogue: family planning and the pro
blem of resources, 67: jul 1981, p3
**
—
I4.
Phadke A, Population explosion: myth and reality,
9- sep 1976, p1
ANNOUNCEMENT
HEALTH CARE IN INDIA
The Centre for Social Action has just publish
ed an interesting, thought-provoking and rather
comprehensive booklet of 144 pages on "Health
Care in India". This booklet first presents the
historical background of our health system, inclu
sive of a chapter on "Health for AH" and the new
"National Health Policy". It then reviews the pre
sent situation and analyses the root causes of our
failures. After its chapter on the "meaningful
experiences" of China, Cuba and Vietnam, and the
State of Kerala, the booklet finally describes the
"possibilities of relevant action" in the fields of
"Community Health Care" and "Conscientisation,
Political Action and Health".
This well done booklet is available for
Rs. 4-00 only (postage included; discount of 20%
for 5 copies or more; payable by money order)
from Centre for Social Action, 64 Pemme Gowda
Road, Bangalore 560 006.
6
Children and Health
Warerkai U, A simplistic approach, 14: feb 1977,
p7 (review of Morley D, Paediatric Priorities
in the Developing World)
Gibran K, Living arrows, 40: apr 1979, p5
Nene D, The child in the health centre, 18: jun
1977,
p8 (review of a manual of health cen
tre paediatrics)
Jaya Rao K, Dear friend: to which school shall we
send our children?, 20: aug 1977, p8
Bang A, Editorial: 1979, 36: dec 1978, p3 (inter
national year of child)
Utkal Gandhi Smarak Nidhi, Need for a parents'
movement, 36: dec 1978, p2
Rani P, Peep in the child's mind, 40: apr 1979, p4
'4)t h
Tpfl 4=^,
49: jan 1980, p10
Nair S, Gowri and the international year of the
child, 49: jan 1980, p9
Gopalan C, The child in India (part-l) 59- nov
y980, p1
Gopalan C, The child in India (part-ll) 60- dec
1980, p'6
Nadkarni N, Towards a new immunization strategy
65: may 1981, p5
Singh T, Accident-prone children, 70: oct 1971, p5
(UNICEF), The disabled child, 72: dec 1981,” p6
, From the editor's desk, 88: apr 1983^ p8
(mass immunisation of children)
IX'aVVchilHhar"^S^arada' L' APProPriate Strategy for
on.ldhood immunisation in India, 88: apr
laws, pi
— . Life in the vaccine, 88: apr 1983, p5 (test
ndicator for viability of vaccines)
.Journal of rural paediatrics, 94: oct 1983,
P5 (notice)
IS.
Nutrition andHunger
Jaya Rao K, The myth of the protein gap, 4: apr
1976,
P1
Patel A, Dear friend: who is the culprit?, 5 may
1976, p7
Shah D, Dear friend: the protein gap, 5: may 1976,
p7
Jaya Rao K, Dear friend: who is the culprit?, 7:
jul 1976, p7
Jaya Rao K, Vitamin A deficiency, 8: aug 1976, p1
Singh N, Dairy research for whom? 8: aug 1976,
p5
Jaya Rao K, Dear friend: dairy research for whom?
9: sep 1976, p6
Muller M, The baby killer, 11: nov 1976, p6
Jaya Rao K, Report C: discussion on 'socio-econo
mic aspects of the nutrition problem in India'.
■ 13: jan 1977, p8 (proceedings of ann. mfc
meet)
Qadeer I, How relevant are feeding programmes?
14: feb 1977, p1
— . The green revolution for whom , 14: feb
1977,
p8
Jaya Rao K, How important is birth weight in
infant health?, 16: apr 1977, p1
Jawlekar K, Dear friend: the green revolution for
whom?, 16: apr 1977, p6 (response to arti
cle in 14)
Shatruahna V, Milk for the baby!, 16: apr 1977,
p8
Warerkar U, Dear friend: how important is birth
weight........ ?, 18: jun 1977, p6
Shatrughna V, Dear friend: how important is birth
weight in infant health?, 19: jul 1977, p6
Jaya Rao K, Dear friend: how important is 'size
at birth'? 21: sep 1977, p7
Singh N, Nutritional problem in India, 19: jul 1977,
p1
Nene D, Dear friend: food for heart?, 20: aug 1977,
P7
Singh N. How not to try solving nutritional prob
lems, 27: mar 1978, p5
Mathew, I was hungry and......... 33: sep 1978, p3
Rendra W, Prayer of the hungry, 35: nov 1978, p8
Kshudha, No child shall drink it's mother’s tears
as milk, 36: dec 1978
__
T0 restrict bottle feeding, 36: dec 1978, p3
(legislation in Papua, New Guinea)
__ , News clipping: Too much iron in milk foods,
39: mar 1979, p3
L°|e R, Nutrition in India: medical problem —
political solution, 42: jun 1979, p1
Sukhatme P, Who are the real hungry? 43: jul
1979,
p1
7
Jaya Rac K, Dear friend: nutrition: medical prob
lem, political solution (I), 43: jul 1979, p6
Patel A, Dtar friend: nutrition: medical problem,
political solution (II), 43: jul 1979, p6
Bang A, Pood requirements as a basis for minimum
wages, 72: dec 1981, p1 **
Gopalan C, Nutritional basis of minimum waqes,
76: apr 1982, p4
Jaya Rao K, From the editor's desk, 76: apr 1982,
p8 (food supplements — commercial inte
**
rests)
— , Boycott against Nestle pays off, 77: may
1982, p4
Bang A, Dear friend, 78: jun 1982, p4 (response
to comments by Gopalan on Bang's article)
’Food requirements. ..')
**
Gupta M, (letter to editor), 82: oct 1982, p11
(body weights of Indian labourers)
— , From the editor's desk: malnutrition and
intelligence, 83: nov 1982, p8
**
— , International Code of Marketing of breast
milk substitutes, 84: dec 1982. p1
Lucey J, Does a vote of 118 to 1 mean the USA
was wrong , 84: dec 1982, p2
May C, The 'infant formula controversy': a noto
rious threat of reason in matters of health,
84: dec 1982, p3
Surjono D et al. Breast vs. bottle — scientific
evidence, 84: dec 1982, p6
— , It's worthwhile to restrict infant formulas,
84: dec 1982, p8
— , What the companies say, 84: dec 1982, p8
— . The Nestle boycott, 84: dec 1982, p8
Jaya Rao K, From the editor's desk: the business
of infant feeding, 84: dec 1982, p10
— , Weaning food and diarrhea, 90': jun 1983,
p8
Jaya Rao K, How successful are supplementary
feeding programmes? 91: jul 1983, p3 (also
see cover article in 14)
Acharya K, Why soya bean? 93: sep 1983. p7
— , World Health authorities condemn industry
practices, 92: aug 1983, p6 (milk food)
16.
Lathyrism
Jaya Rao K, Kissa Khesari ka, 24. dec 1977, p1
*
Bang A, Dear friend: kissa khesari ka. 26: feb
1978, p8
Barreto L. Kissa khesari camp ka, 30: jun 1978, p4
(report of the regional camp on lathyrism)
*
Chand H. Dear friend: Lathyrus and homoeopathy,
31: jul 1978, p4
Jaya Rao K, From the editor's desk: The poor
man's poison is nobody's concern. 77: may
1982, p8
I7.
—
—
Environmental and Occupational
Health
, Smoking burns up memory, 32: aug 1978,
P4
, Smoke of 100,000 million dollars. 32: aug
1978, p4
, News clippings: less infections if docs have
short hair, 34: oct 1978, p4
— , News clippings: chemicals pose hazards to
human sperm, 34: oct 1978, p4
— , Alcohol: the problems increase, 42: jun
1979, p4
— , News clippings: pollution — the time to act,
44: aug 1979, p7
Bhat R, Pesticides: a necessary evil, 61: jan 1981,
p1
Jaya Rao K, From the editor's desk, 61: jan 1981,
p4 (food contamination by pesticides)
— , How pure is our food?, 61: jan 1981, p8
Krishnamurthy C, Environmental cancer in India,
82- oct 1982, p10
Mankad D, Health problems of tobacco, process
ing workers, 95: nov 1983, p1
Jaya Rao K, From the editor's desk: Tobacco sick
ness, 95: nov 1983, p8
—■
I8 Health during Mass Calamity
Patel A, Approach to health problems in famine,
44- aug 1979, p1
Foege W, Guidelines for disease control in times
of famine, 44: aug 1979, p8
Patel A, Morbi disaster: health problems (a case
against mass cholera vaccination), 45: sep
1979, p1
*
Shah R, Dear friend: natural calamity — an oppor
tunity, 47-48: nov-dec 1979, p10
— , Emergency care in natural disasters: views
of an international seminar, 66: jun 1981, p1
Jaya Rao K, From the editor's desk, 66: jun 1981,
p4 (preparation of health personnel for natu
ral disasters)
— , Education and training of medical students
for mass casualties situations, 66: jun 1981,
p8 (Israel)
— , Cholera vaccine: Inappropriate aid? 94:
oct 1983, p2
19.
Water Supply
, Adequate, clean, available, 19: jul 1977, p7
(review of The Poverty of Power by B Com
moner)
Barreto L, The national water scene, 37: jan 1979,
p1
Gupta V and Takiar S, Drinking water: newer
appropriate techniques vis-a-vis experiences
in the village, 31: jul 1978, p6
Patel A, Water supply in tropical countries: quan
tity vs. quality, 52: apr 1980, p1
*
Shinde D, Dear friends (water supply) 55: jul
p7
—
20.
Diarrhea and Oral Rehydration
Damodaran M, Oral rehydration: the principles,
practice and the possibilities, 47-48: nov-dec
1979, p1
*
Patel A, On diarrhea and rehydration: what, why
and how?, 47-48: nov-dec 1979, p3
*
— , Guidelines for the treatment and prevention
of dehydration, 47-48: nov-dec 1979, p4
*
. ORT: The Turkish experience, 47-48: novdec 1979, p4>Jaya Rao K, Oral rehvdration therapy: do you
believe in it? 60: dec 1980, p3
Hirschhorn N, Issues in oral rehydration, 60: dec
1980, p4
Datar S. Dear friend, 61: jan 1981, p6 (prepara
tion and use of ORS)
Parekh B, Communication (on treatment of diarr
hea), 64: apr 1981, p5
Feachem R, Oral rehydration with dirty water?,
68: aug 1981, p7
Ganguli M, (supply of ORS packets according to
WHO formulation), 77: may 1982, p5
Steinhoff M, Treatment of acute diarrhea in child
ren, 78: jun 1982, p1
**
— , Rice powder as an alternative of success in
oral rehydration solution, 78: jun 1982, p3
(to be continued in 79)
Ganguli M, Dialogue, 78: jun 1982, p6 (use of
ORS packets by CHW)
Feachem R, Priorities for diarrheal disease con
trol, 79: jul 1982, p5
— , Rice powder instead of sucrose, 79: jul
1982, p7 (remaining part of article in 78)
— , Attention please: the campaign on diarrhea,
80: aug 1982, p4
Phadke A. Educational campaign against diarrhea,
81: sep 1982, p5
— , From the editor's desk, 90: jun 1983, p8
(rice starch solution as ORT)
—
21.
Drug Industry Malpractices
Phadke A, Brand names: a ruse for higher prices,
6' jun 1976, p5
Agarwal A, Dear friend: brand names (I), 7: jul
1976, p7
Kashlikar S, Dear friend: brand names (II), 7: jul
1976, p7
Bang A, Dear friend, brand names (III), 7: jul
1976, p3
Phadke A, The drug industry: an analysis, 7: jul
— , How drug companies operate, 19: jul 1977,
p5
— , Doctors in the drug industry's pocket, 28:
apr 1978, p1
— , The joke of the year, 33: sep 1978, p8
(drug price propaganda of OPPI)
— , Do you know this (about the world blood
trade), 55: jul 1980, p8
Ganguli M, Have you read this?, 59: nov 1980,
p7 (notice)
— , The high cost of Metakelfin, 68: auq 1981,
PS
Surana S, Dear friend, 70: oct 1971, p6 (compa
rative costs of drug brands)
Phadke A, Multinationals in Indian drug industry:
no positive role to play, 73-74: jan-feb, 1982,
**
p1
Agarwal A, Vietnam: herbs and war 73-74- ianfeb 1982, p6
Agarwal A, Sri Lanka’s experience with bulk pur
chasing, 73-74: jan-feb 1982, p7
8-
Jaya Rao K, From the editor's desk, 73-74: janfeb 1982, p1O (multinational in drug industry)
, If there are no side effects, this must be
Argentina, 73-74: jan-feb 1982, p12
Vaidya A, Dear friend, 76: apr 1982, p5 (response
to Phadke A in 73-74)
Jaya Rao K, From the editor's desk, 78: jun 1982,
p8 (imports of bulk drugs)
Jajoo U High cost medicine, 80: aug 1982, p1
, Bitter pills: Medicines and the third world
poor, 87: mar 1983, p8A
Victora, C, Statistical malpractice in drug promo
tion: a case study from Brazil, 92: aug 1983,
p1
— , Reporting of adverse drug reactions in Bri
tain, 94: oct 1983, p2
— , Campaign against the irrational production
and marketing of drugs, 96: dec 1983, p8
22.
Patki U, Global amnesia with clioquinol 83 nov
1982, p5
Sun M, The controversy around Depo-Provera, 97:
mar 1983, p1
— , From the editor's desk: wrong choice,
wrong solution, 87: mar 1983, p10 (indiscri
minate use of injectable steroid contracep
tives)
— , Antibiotics in developing countries, 93- sep
1983, p5
— , Battle of the body: antibiotics vs. super
germs, 95 nov" 1983, p6
23.
Drug Misuse
Jaya Rao K, Tonics: how much an economic waste,
11: nov 1976, p1
Singh T and Kaur C, Dear friend: brand names and
tonics, 12: dec 1976, p8
— , ’I did take the tonic. Sir........ ', 33: sep
1978,
p8 (cartoon)
Shatrughna V, Drug prescription: Service to whom?
31 • nov 1978, p4
*
— , Ban on tetracycline liquid form, 13-14: mayjun 1980, p5
Gopalan C, 'The body has limited ability to store
water soluble vitamins........ ', 55: jul 1980, p8
— , Vitamin therapy, 55: jul 1980, p8
— , Do you know this (about Lomotil), 60: dec
1980,
p3
— , Upjohn, Depo-Provera and the third world,
65: may 1981, p3
Mankad D, Report of the VIII annual mfc meet, 75:
mar 1982, p4 (misuse of drugs)
Phadke A, Campaign against hormonal 'pregnancy
test", 75: 1982, p7
Phadke A From the editor’s desk, 75: mar 1982,
p8
Mathur V, Hazards of hormonal pregnancy test, 75:
mar 1982, p9
__ , From the horse's mouth........ : progesterone/
estrogens, 75: 1982, p10 (warnings from
PDR, 1981)
__ , Health education campaign........ . 76: apr
1982, p7 (hormonal pregnancy test)
Jajoo U, Misuse of antibiotics, antimicrobials, 77:
may 1982, p1
**
Anand R, Dear friend, 77: may 1982, p5 (ban on
liquid tetracycline)
__ , Attention please! campaign irrational use of
drugs, 77: may 1982, p7
__ , (Saheli/VHAI poster), 80: aug 1982, p4
(poster against hormonal pregnancy test)
Phadke A, From the editor's desk: banning hormo
nal pregnancy drugs — only a partial victory,
80: aug 1982, p8
Balasubramanyam V, Dear friend, 82: oct 1982,
p11 (misuse of anabolic steroids)
kf-
Rational Drug Therapy + Action
Patel A, A story of r factor, 26: feb 1978, p1 (anti
biotic resistance)
Gambhir A, In search of appropriate medicine, 36:
dec 1978, p7 (antibiotics)
Bharatiya Grahak Panchayat and Arogya Dakshata
Mandal, Operation medicine : an appeal for
vigilant action, 37: jan 1979, p7
Sonwalkar A, Dear friend: 'Operation medicine',
38: feb 1979, p3
Chugh S, In search of appropriate medicine — I
cough mixtures 56: aug 1980, p5
**
Jajoo U, Low-cost drug therapy, 81: sep 1982, p1
Phadke A, Drug workshop at Jaipur 83: nov 1982,
p4
Desai D, An Indian low cost drugs project, 83: nov
1982, p5
Jajoo, U, Rational therapeutics: selection of appro
priate drug, 90: jun 1983, p4 (analgesics)
— , Antibiotic therapy, 92 aug 1983, p4
Bang A, Single dose therapy for acute infection,
92: aug 1983, p5
Nagar N, More on aspirin, 94: oct 1983, p8 (also
see letter by Patki in 92)
Kulkarni S, Fancy, fallacy and facts about fixed
dose formulations, 96: dec 1983, p5
Phadke A, Drug action network meet, 99, mar
1984, p11
24.
Drug Policy Alternatives
— , A new strategy for drugs, 60: 1980, p8
Phadke A, The committee for rational drug policy,
73-74: jan-feb 1982, p13
Agarwal A, Towards a relevant drug policy, 75
mar 1982, p1
— , MFC resolution on events in Bangladesh,
82 oct 1982, p11 (national drug policy
against multinational)
**
— , Conclusions reached by the drug sub-group
at the natioal health policy seminar, 91:
jul 1983, p6
25.
Tuberculosis
Patel A, Tuberculosis: a health problem, 6: jun
1976, p1
Junnerkar A and Ketkar Y, Community participa
tion in TB control, 18: jun 1977, p4
Jajoo U, In search of appropriate medicine-ll:
critical evaluation of utility of chest radiology,
57: sep 1980, p6
9
Aitken J, Point of view: to inject or not to inject,
61: jan 1981, p7
**
Jaya Rao K, From the editor's desk, 79: jul 1982,
p8 (Koch centenary)
**
Talwalkar V, Dear friend, 81: sep 1982, p6 (TB
control programme)
Jaya Rao K, Is BCG vaccination useful , 89: may
1983, p7
— , Centenary of tuberculosis bacillus, 92: aug
1933, p8
Sadgopal M, Health 'care' vs. the struggle for life
(part-l) 93: sep 1983, p1
Sadgopal M. Health 'care' vs......... (part-ll), 94:
oct 1983, p2
Nagar N, Is antitubercular treatment really very
expensive? 96: dec 1983, p3
26.
Malaria
Soni M and Thakkar J, MFC regional camp, Pindval
(malaria survey), 6: jun 1976, p3
Patel A, Malaria eradication programme: its
genesis, 13: jan 1977, p1
Patel A, Malaria eradication vs. malaria control: a
case of confusion of terms, 14: feb 1977, p4
Patel A, Malaria control programme: an integral
part of community health and development,
16: apr 1977, p4
Sen B, Malaria in post-independence India, 17:
may 1977, p1
Agarwal A, Pesticide resistance, 61: jan 1981, p8
Linear M, FAO: the pesticide connection, 67: jul
1981, p5
Farid M. Malaria and global politics. 82: oct 1982,
P1
Chapin G and Wasserstrom R, Agriculture and
malaria, 82: oct 1982, p3
Jaya Rao K, From the editor's desk: under the
mosquito net........ 82: oct 1982, p12
27.
Leprosy
fMtSI, W
39: mar 1979, p1
Gupte M, Leprosy control: problems and possibili
ties, 39: mar 1979, p1
Pandya S, Can India eradicate leprosy?, 39: mar
1979, p4
Gupte M, Leprosy control: problems and possibili
ties, 39: mar 1979, p1
Pandya S, Can India eradicate leprosy? 39: mar
1979, p4
— . New developments in leprosy, 39: mar
1979, p6 (XI International Leprosy Congress,
1978)
Bang A, Editorial, 39: mar 1979, p3
Sharma R, Leprosy control in India: review and
suggestions for future, 40: apr 1979, p3
4K3
Dear friend:
? 41: may 1979,
p6
28.
Mental Health
Steiner C, Radical psychiatry: principles, 5: may
1976, p1
617 »T, Dear friend: 4>ftR 4141 : MfRRf 41 914 4)^4isfl,
10
43: jul 1979, p7
Srinivasa Murthy R and Wig N, Auxiliaries and
mental health care, 56: aug 1980, p1
Dhara R, The attitude of society and the psychia
trist towards madness, 56: aug 1980, p3
Jaya Rao K, Editorial 56: aug 1980, p4
**
Srinivasa Murthy R, Mental health education for
auxiliaries, v6: aug 1980, p8
Chandrashekhar C, Serving the unserved: PHCs for
psychiatric care, 69: sep 1981, p5
29.
Miscellaneous — Technical and
Medical
Chugh K, Acute renal failure in north India, 43:
jul 1979, p5
i
Suryanarayana V, Cataract surgery by tumbling
method. 83: nov 1982. p6
— , Medical laboratory manual for developing
countries (volume 1), 85-86: jan-feb 1983, p5
30.
Miscellaneous : Non-technical or
Non-Medical
— , Low energy economics, 8: aug 1976, p7
Jaya Rao K, Dear friend: are we truly independent?,
21: sep 1977, p6
— , Our typewriter works quite well except for
one key.............. 26: feb 1978, p8
fast q, R 8RR4 g, 31 jul 1978, p6
Gandhi, The talisman, 32: aug 1978, p1 (poem)
9,
Mr-af q 4>?1... 32: aug 1978, p8
Sidgwick H, Free thinking, 33: sep 1978, p1
RR?ft 4,
441 44R4r | 5«0<1....?
33: sep 1978, p3
firsj q, ajltftq, JJS5I4 <K 4)61 446
4 3114,
34: oct 1978, p1
Frost R, a semi-revolution, 37: jan 1979, p7
Williams 0, a total revolution (an answer to Robt.
Frost), 37: jan 1979, p7
Marx K, Man: the alienated individual, 38: feb
1979, p1
— , Work experience gives vision, 39: mar 1979,
p8 (a student's experience of adult literacy
work)
— , Modern medicare, 40, apr 1979, p8 (cartoon)
Chopra P, the plan plants a time bomb, 41: may
1979, p7 (land redistribution)
SFJR
aft iff
: 42: jun 1979, p6 (poem)
3144, 46414T 43: jul 1979, p8 (poem)
(444R, fPTal ! 4R1 44141 3tqq...”......... 46: oct
1979, p1
611144 Sf, ttfcFT 144.^61311 6 xri t, 46: oct 1979, p1
— , Rural medicare hospital: trying to appear
'rural'!, 47^48: nov-dec 1979, p12
Aptekar N, Death: reflections, 59: nov 1980, p5
Laxman R, "You are going to ask for a second
opinion? well...'', 67: jul 1981, p6 (cartoon)
Bang R, Small-pox reappears?, 69: sep 1981, p7
Wind J, LDC — WHO cares?, 76: apr 1982, p3
31. Role cf MFC and Merrbers
Sen B, Revitalisation of MFC: hard introspection,
crucial decisions, 45: sep 1979, p3 (mid
.Medico Friend Circle; objectives, organisa
annual MFC meet report)
tion and programmes, 1-2: jan-feb 1976 p10
(as approved at l| ann. MFC meet)
— , Changing emphasis of MFC, 45: sep 1979,
p6
Sadgopal M, where do we fit in?, 7: jul 1976, p3
Phadke A. Dear friend: from the horse's mouth...., 44 ST,
: 44T >i<, 441
4J5 ? 46: oct 1979,
8: aug 1976, p3
46: oct 1979, p3
Phadke A, Dear friend' limitations and role of Gurubani S, Dear friend: kudos to MFC, 47-47:
MFC, 16: apr 1977, p5
nov-dec. 1979. p10
Patel A, Dear friend: limitations and role of MFC, Mankad D, Communication: a search for alterna
18- jun 1977, p6
tives, 63: mar 1981, p7
Singh T, Dear friend: encourage us, 19: jul 1977, Wagh H, Dear friend, 66: June 1981, p6 (res
p6
ponse to article by Bang A in 64)
Phadke A, MFC — which way to go?, 28: apr Werner D, Health care and politics: a personal
1978, p5
statement. 69. sep 1981, pl
*
Qadeer I, Dear friend: MFC — which way to go? Rao M, Communication (medical ethics and poli
,
(I)
29: may 1978, p5
*
tics), 67: jul 1981, p7
Phadke A, Dear friend: MFC — which way to go? Ganguli M. Dear friend
, 76: mar 1982, p6
,
(II)
29: may 1978, p5
(criticism of MFC)
Bang A, Dear friend: MFC — which way to go? Mankad D, Dear friend, 80: aug 1982, p7 (res
(Ill), 29: may 1978, p6>E
ponse to M Ganguli)
Bang A, Editorial: From awareness to action, 32: Phadke A. Role of health work done by MFC
aug 1978, p3
members, 82: oct 1982, p7 (mid-ann. meet
Gaitonde R, Dear friend: role of non-medicos,
32: aug 1978, p4
32. MFC Bulletin
Banerii D, Health work as a lever for social and
Patel A, Editorial, 1-2: jan-feb 1976, p3 (MFC
economic change, 32: aug 1978, p1
and bulletin)
Roy D, Hyde Park: MFC — which way to go? (I), — role
, About the bulletin, 1-2: jan-feb 1976, p3
32: aug 1978, p5
Phadke
A,
Dear friend, 4: apr 1976, p4 (bulletin,
Qadeer I, Hyde Park: MFC — which way to go?
role of MFC)
(II), 32: aug 1978, p7
Phadke A, Dialogue: MFC, which way to go?, 34: Qadeer I, Dear friend: is this a readers' bulletin?,
5: may 1976, p7
oct 1978, p5
— , An appeal
6: jun 1976, p4
Jaya Rac K, Dialogue: Settle the question once and
Katgade
V, Dear friend: from the horse's mouth...,
for all, 34: oct 1978, p6
7: jul 1976, p5 (criticism of MFC bulletin)
Qadeer I, Dialogue: dilemma of individual medico,
Roy D, Dear friend: why readers do not respond ,
34: oct 1978, p7
7: jul 1976, p7
aWJ
35: nov 1978, p3
— , To the readers, 8: aug 1976, p4
Patel A, Dialogue: economic change is not the — , To the leaders, 7: sep 1976, p3 (bulletin
panacea-health work can become the key,
questionnaire)
35: nov 1978, p5
Shah S, Dear friend: had enough about myths, 9:
Wagh H, Dear friend: decision is essential, 35:
sep 1976, p5 (appeal for more field experi
nov 1978, p7
ences)
Rindani A, Dear friend: MFC friend in USA, 36: Patel A, Editorial, 13: jan 1977, p3 (progress and
problems of MFC bulletin)
dec 1978, p8
Gokani A, Dear friend: great grandson of Mahatma — , Reminder, 14: feb 1977, p1 (bulletin subs
cription and membership fees)
Gandhi writes, 39: mar 1979, p5
Parikh I, Dialogue: health project — a means of Singh T and Kaur C, Dear friend: be practical, 18:
jun 1977, p7
social change, 39: mar 1979, p7
Punpani D, Dialogue: in search of utilization, 39: Junnarkar A, Dear friend: an appropriate title, 18:
jun
1977, p7
mar 1979, p7
Sen B. Dialogue: to a soul 'in search of utiliza Kapur S, Dear friend: points of view — medicine
2000
AD, 19: jul 1977, p6 (response to arti
tion' (I), 40: apr 1979, p7
cle in 18)
Bang R, Dialogue: to a soul 'in search of utiliza
— , Subject index of back issues of MFC bulle
tion' (II), 40: apr 1979, p7
tin from the first issue, 24: dec 1977, p
Kashalikar S, Dear friend: what can be done? 41: Patel A, Editorial, 26: feb 1978, p3 (problems of
may 1979, p6
the mfc bulletin)
44 si,
: arfflln 1 gwr 45 44<r....,
Tejinder Singh, Dear friend: which way the bulle
tin to go? 29: may 1978, p7
44: aug 1979, p3
Bhagwat A, Dialogue: why retired doctors for the Bang A, Editorial, 30: jun 1978, p3 (mfc bulletin
standards and perspectives)
villages?, 44: aug 1979, p5
11
Bang A, Editorial, 31: jul 1978, p3 (problems of
the mfc bulletin)
Sadgcpal M, Dear friend: about the bulletin, 31:
jul 1978, p3
— , Please
31: jul 1978, p4 (bulletin
article instructions)
Kathiria V, Dear friend: why hyde park?, 32: aug
1978, p4
Bang A, editorial: Where is the space?, 34: oct
1978, p8
Panchai P, Dear friend: simplify still more, 35:
nov 1978, p7
Bang A, Editorial (review of the mfc bulletin for
1978), 38: feb 1979, p3
— , Internship and you, 40: apr 1979, p8
(appeal for written experiences)
Manudhane S, About the bulletin: a view from
USA, 42: jun 1979, p8
Sarmandal D, Dear friend: I am surprised to
know
43: jul 1979, p7
— , You be ouh hands, 43: jul 1979, p8
Bang A, Dear reader, 45: sep 1979, p8
— , In case you have not
47-48: nov-dec
1979, p11
— , To catch the next month's train, 47-48:
nov-dec 1979, p12
Patel A and Bhargava A, The readers speak about
mfc bulletin 52: apr 1980. p4
— , Please note (change of bulletin editor), 52:
apr 1980, p12
Phadke A. (Explanation for not bringing out may
issue), 53-54: may-june 1980, p5
Jaya Rao K, Editor's note (on taking over editor
ship), 53-54: may-jun 1980, p8
— , Will you help us? (sample subscription
scheme) 60: dec 1980, p2
— , Important: (increase in subscription rate)
62: aug 1981, p3
— , Attention please!, 76: apr 1982, p7 (MFC
life subscription)
Sadgopal M, Proceedings of the fourth all India
meet of MFC — Report A, 26: feb 1978, p4
Barreto L, Proceedings of V annual of mfc, 38:
feb 1979, p4
Jaya Rao K, proceedings of MFC general body
meeting, 52: apr 1980, p9 (VI ann. mfc
meet)
Phadke A, MFC VII annual meet, 63: mar 1981, p5
Phadke A, The biannual executive committee meet
at Hyderabad, 68: aug 1981, p3
( ,, ) , Attention please (MFC is now a regis
tered association and trust), 75: mar 1982,
p9 (VIII ann. meet report)
( ,,
, Attention please (decisions taken at VIII
ann. meet), 76: apr 1982, p7
( „ ) , Attention please (decisions taken at VIII
ann. meet), 76: apr 1982, p7
( ,, ) , Mid-annual executive committee meet
ing, 82: oct 1982, p5
( ,, ) , MFC organisational decisions, 87: mar
1983, p8A (IX ann. MFC meet report)
( ,, ) , Report of the X general body meeting,
99: mar 1984, p9
included in the second anthology;
★★ Included in the third anthology
Note
a. New address of MFC is:
326. V Main, I Block,
Koramangala,
Bangalore 560034
(Phone: 565484).
b. Limited copies of issues No. 41, 42, 45, 46,
56, 57, 65, 66, 70, 71, 78-81, 85-86, 92-95
and 99 are available at Rs. 2-00 each (50 US
cents or equivalent).
c. All other issues in xerox from are available
with the MFC office in Bangalore at Rs. 5.00
a copy (US $2/- or equivalent).
Cheaper
arrangements still being negotiable.
d. Limited copies of Anthology — Health Care
Which Way to Go—, covering issues 26-52,
are available with the MFC office and with the
Voluntary Health Association of India (VHAI),
C-14, Community Centre, Safdarjung Develop
ment Area, New Delhi 110016.
33. MFC Meet Reports (Organisational)
Sadgopal M, Report A: the meet, 1-2: jan-feb
1976, p5 (proceedings of II all India meet
of mfc)
Bhatt N, Report A: the meet, 13: jan 1977, p4
(proceedings of III all India mfc meet)
OBJECTIVES OF BULLETIN
—
—
—
—
—
To gather together lone fighters seeking
for an identity and friendship.
To cover lacunae in our knowledge of
the health system and health planning
in India and new field experiments.
To motivate and involve the readers
sitting on the fence through dialogue
and debate.
To evolve a style and level of content
within the reach of the common man.
To encourage medical students to share
new, raw and enthusiastic ideas.
12
—
To feature materials from other walks
of life — education, psychology, socio
logy, economics and agriculture —
which have a bearing on health.
—
To become a medium of expression,
dialogue and communication as well as
a source of conceptual and informative
inputs for all those who are trying to
think differently and fall out of the
routine and established pattern of
medicine.
POLICY
KATl]©mAL
A Drug Action Network Memorandum
WE. the health personnel and citizens of India
recognize health as a fundamental
right of the
people in this, our welfare state. We recognize and
strongly believe that the health status of our people
is more dependent on their access to adequate food,
safe and adequate water, proper sanitation and clean
environment.
and life saving drugs on a priority basis at
the national level. ,
Drug production by multinationals and
private manufacturers in India should also
be aligned with national health priorities.
Bulk procurement of essential and needed
drugs should be through world-wide com
petitive tenders and rationalization of drug
purchases should govern both the public
sector as well as private health sector.
Imports and production of non essential,
specially hazardous drugs, should be strictly
curtailed.
WHILE we support the overall perspective and
approach of the new National Health Policy State
ment and demand its proper implementation, we
believe that, a Rational Drug Policy is an integral
part of a good National Health Policy.
WE. therefore, demand the following:
1.
2.
3.
4.
5.
We have a right to safe, essential, quality
drugs which are in keeping with the health
needs of the people, at costs which the
majority can afford.
We urge our government to accept and
implement the Hathi Committee Recom
mendations which are also in keeping with
the WHO Guidelines for a Rational Drug
Policy.
Further the national drug formulary should
be revised and compiled by an expert multi
disciplinary committee keeping the follow
ing criteria in mind:
Essentiality
Efficacy
Safety
Cost
Ease of administration
Availability
Potential for misuse
Such evaluation of the drugs in the market
and revision of the lists should be done
periodically.
The Essential Drugs Policy should be adop
ted for all health services, government and
private, and priority in production, distri
bution and dispensing should be given to
these essential drugs.
The public sector should produce essential
10.
Drugs which have been banned from sale
after being marketed for some time in one
country may not be submitted for clinical
trial or marketing in India. The onus of
proving why a non-essential drug should be
introduced or allowed to continue on the
market should be with the manufacturer
and such introduction should be proceeded
by adequate trials and evaluation by Drug
Control Authorities.
Comprehensive drug legislation which covers
areas such as price control at different
levels, patents, and marketing practices
should be incorporated to serve the objec
tives of the national drug policy and there
INSIDE
Medical care — a critique and beyond
3
Dear Friend
6
Keeping Track
6
V/Drug Alert
7
Vocal Figures
7
Editorial
8
should, be levies, sales tax or excise duty
on any pharmaceutical
product in the
essential drugs list by the Central or State
governments.
11.
No technology transfer agreement shall be
legal and binding which contains restrictive
practices, disproportionate and unneces
sary use of imported intermediaries or
obsolete technologies or unfair arrange
ments with respect to prices, payments or
repatriation of profits.
12.
The National Drug Policy, should state
clearly the steps towards a complete aboli
tion of brand names and as a first step use
of generic names should be made compul
sory in medical education, prescribing and
labelling of drugs. Generic names should
. appear more prominently on all packagings.
13.
It shall be the primary responsibility of the
manufacturer to ensure the quality of drug
products. However, it shall be the statu
tory responsibility of the Drug Control
Authorities to monitor the standards and
ensure a minimum uniform level of govern
ment control. Consequently, the govern
ment shall take all necessary measures to
enable the Drug Control Authorities to
function in an effective manner and dis
charge the statutory duties thrust upon
them.
14.
15.
specially when their performance in health
care delivery is known to be effective.
16.
In all review committees, statutory bodies
and other such bodies, there should be ade
quate representation of consumer groups
and the voluntary health sector.
17..
Drug companies should follow ethical
marketing practices, and this should be
ensured by their own organizations like
Organization of Pharmaceutical Producers
of India (OPP1), Indian Drug Manufac
turers Association (IDMA), International
Federation of Pharmaceutical Manufac
turers Association (IFPMA). We deplore
the tendency of these companies and asso
ciations to get round every progressive mea
sure of the government through recourse
to technicalities of the law and through
the courts.
18.
The marketing code drawn up by Health
Action International (HAI) should form
the basis for a National Code for Marketing
Practices. This should be accepted by our
government and should be suitably imple
mented through legislation.
19.
The government of India should take a lead
and endeavour to influence the WHO and
the WHA to adopt the Code in the interests
of the other developing countries and their
people —
It shall be the statutory duty of the drug
control authorities to inform health person
nel and consumers, of the essential drugs
lists, policies, categories or brands of
drugs banned for manufacture or sale,
through publication in the national news
papers; magazines, and medical journals
with adequate explanations and details.
— Voluntary Health Assocation of India
— Centre for Science and Environment
— Centre of Social Medicine and Com
munity Health, Jawaharlal Nehru
University
— Kerala Sastra Sahitya Parishad
Availability of drugs required in the Gov
ernment’s National Programmes should be
ensured on a priority basis to the govern
ment as well as voluntary and private health
institutions. Quotas for anti tuberculosis-,
anti leprosy, anti malarial drugs, iodized
salt etc., should be made easily available
with regularity of supply to the voluntary
health institutions where ever possible,
— medico friend circle
— Arogya Dakshata Mandalt
— Lok Vigyan Sanghatana
— Consumer Guidance Health Services
■— Consumer Education Research Centre
— Federation of Medical Representatives
Association of India.
bandhu Training Centre, R. K. Pct, 631 303
(Tamil Naduj.
ANNOUNCEMENTS
1.
Leadership Development Course in Commu
nity Health and Development 9 September
to 23 October 1984.
A Course for non-doctors in existing commu
nity based programmes—designed to provide
knowledge and skills to promote building of
communities. For details write to Dcena-
2.
Continuing Education for General Practitioners
A self-paced correspondence course for MBBS
doctors/General Practitioners to up/date
knowledge and skills for better patient care.
For details, write to the Coordinator, Conti
nuing Medical Education, Christian Medical
College, Vellore 632 002 (Tamil Nadu).
MED0CAL CARE — A CRITIQUE AND BEYOND
Satchidanandan, Cahcut
A WORKER SPEAKS TO A DOCTOR
We know what is it that makes us sick.
They say you are to treat us when we are ill.
They say you have learnt medicine for ten years in
excellent institutions built on the sweat of the
people
And you have spent large sums to learn your art.
Then you should be able to cure us, but can you?
When we visit you, you take off our rags and probe
our naked little bodies
What is it that you are looking for?
— the cause of our illness?
you would know better by looking at our rags.
It is the same disease that consumes
our bodies and our clothes.
You say our shoulders ache because of moisture,
the same has stained the walls of our huts.
Now tell us, where does this moisture come from?
A little food and a lot of work
make us pale and weak.
Your prescription says: put on more weight.
It would be better to tell a blade of grass
not to get wet in the rain.
How much time will you give us?
We see that a single carpet in your mansion
costs the fees you get from five thousand patients.
You will plead innocence, sure.
The stain on the walls of our hut
has the same tale to tell, too.
— Bertolt Brecht
The worker in this poem is pointing to a serious
disease that has come to afflict the physicians in our
country too: their absolute alienation from the com
mon people whose toil have made them what they
are. Careerism, callousness, corruption and greed are
fast turning many of our doctors into a class of dubi
ous integrity. But I refuse to consider the situation
absolutely irredeemable. 1 do not mean to suggest
that every doctor should transform himself into a
Che Guevara or a Norman Bethune, but there is no
reason why young idealists, that many of you cer
tainly are, cannot switch on a programme of house
cleaning, a revolution of the scalpel and the
stethescope.
What will be the nature of this medical revolu
tion that I wish you would set your minds to? What
are its theoretical premises and its understanding of
itself? What realistic goals and practical programmes
can such a movement for socialist medicine have? I
am presenting before you a very sketchy outline for a
total critique of modern medical practice from a
socialist perspective and the programmatic promotion
of a counter-medical culture.
I
We shall begin with an examination of the basic
tenets of the political-economic critique of modern
medical and health care projects. The politicaleconomic critics do not dispute the benefits of modern
medicine; only they want the weaker sections of the
society to have easier access to its unalloyed blessings.
Poor or unequal geographic distribution of doctors
and hospitals, lack of proper service in the rural areas,
low technical quality of service, discriminating treat
ment based on race, caste or sex, insufficient alloca
tion of funds for medical care in government budgets,
non-availability of necessary medicine, the genera]
urban orientation of medical services, the exploitation
of underdeveloped countries, especially of the third
world by transnational corporations, chemical and
technical experiments performed on colonial people
by imperial masters, the unethical use of medicine in
war and in the promotion of imperial interests —
these are the recurring issues raised by these critics.
The solutions to these problems are also politicaleconomic: creation of an organised health care system,
government sponsored mechanisms to promote a
more equitable distribution of and better quality in
health care, greater centralization and careful bureau
cratization . The more radical of these critics also find
fault with all kinds of private ownership and control
of medical and paramedical institutions. They
demand complete control or even the pros
cription of the profit oriented private clinics
and medical supply companies — in short a sociali
sation of medicine on the models of Soviet Union or
the countries of Eastern Europe.
The political-economic critique, we should admit,
is still not entirely irrelevant in the semi-colonial and
underdeveloped situation obtaining in India. The
enviable prestige that doctors enjoy in a generally
illiterate country, their high status and money making
capacity are enough temptation for any parent to
wish to secure an admission for his child in a medical
college even at the cost of honesty. The primitive power
of a patriarchal society continue to drive even the dis
inclined to the profession resulting in technical incom.
pctence. The unwholesome alliance between pharma
ceutical distributors and physicians and the callous
export of useless or even harmful drugs by their
global producers and corruption rampant at all levels
of health services make the situation still worse.
There is also a disproportionate emphasis placed on
hospital oriented curative medicine compared to pre
ventive medicine and environmental hygiene.
It is wise to remember that the majority of the
diseases that attack and kill our people are of an
infectious nature like tuberculosis, diarrhoea, dysen
tery, typhoid, leprosy and cholera or are' mental dis
orders resulting in psychosomatic dysfunctions that
spring from the tensions natural to our social milieu.
But we have modelled our medical development on
means of social control. The unlimited growth of
medical care also threatens to destroy the environ
mental and cultural conditions needed by people to
live a life of autonomous healing. Medical technology
has been helping industrial growth rather than per
sonal growth. He admits that chemotherapy has
played a significant role in the control of pneumo
nia, yaws, malaria, tetanus, diphtheria, scarlet fever
and sexually transmitted disease but it has contri
buted little, he argues to the decline of mortality or
morbidity from these diseases. Even further the pain,
dysfunction, disability and anguish resulting from
technical medical intervention have contributed to
the increasing morbidity of modern life. The un
wanted side-effects of medicines have also increased
with their power. Many drugs are addictive, mutila
ting or mutagenic; antibiotics can at times alter the
normal bacterial flora and induce a superinfection;
other drugs help breed drug-resistant strains of bac
teria. The overuse of dangerous diagnostic proce
dures, the administration of synthetic hormones,
chemical stimulation of labour, ultrasonic fetal moni
toring, the routine use of anaesthesia for delivery,
overdose of powerful drugs like chloramphenicol, using
drugs in dangerous combinations, medical treatment
of non-existent diseases and unnecessary surgery have
a disabling effect on their victims. Professional call
ousness and negligence are increasingly being attri
buted to a break down or absence of equipment;
thus moral faults come to be justified as technical
errors. This aspect of the problem Illich calls ‘clini
cal iatrogenesis’. Medical practice also sponsors
sickness by encouraging people to consume curative,
preventive, industrial or even environmental medi
cine. Defectives are prevented from work and prom
ptly removed from the scene of political struggle to
reshape the society that has made them sick. This
invalidating process is what Illich calls 'social iatro
genesis’. Health professions also destroy people’s
capacity to deal with their human weakness in a
personal and autonomous way. Birth and death are
equally controlled and culturally mediated by medi
cine. Death is turned into a profitable commodity
with endless potential. Health management is desig
ned on the engineering model. This has been termed
‘cultural iatrogenesis’.
1 would like to add two more modes of iatro
genesis; one is philosophical. Modern western medi
cine suffers from an overdose of scientism, an extreme
form of mechanical materialism. First, it follows the
doctrine of specific etiology, where the existence of
a cause is mechanically connected to the disease.
Second it conceives the human body as a machine
the functioning of whose parts is considered inde
pendent of the mind of the organism. It does not
take into account the interactions of body, mind and
physical and social environment. Thus’ there’ is a
disassociation of mind and body in this medical tech
no ogism. Both these can be traced to the capita
listic formal logic that governs medical science Only
a dialectical approach can make medicine a genuine
science. The medical technology itself is capitalistic;
western lines concentrating on non infections diseases
like diabetes, cancer, hypertension and cardiovascular
diseases, more prevalent in the developed countries.
Most of the communicable diseases are bred and
nourished in India by conditions of underdevelop
ment and can be considerably controlled by improve
ments in the living standards of the poor. Better
food, facilities for better housing and clothing, regular
supply of disinfected water, more leisure and facili
ties for recreational activities, cleaner surroundings
and a peaceful environment alone will put an end
to the contagion that make our hospitals overcrowded
helL. The struggle for the prevention of diseases has
thus become an increasingly political question related
to the removal of exploitation and the establishment
of a genuinely socialist society. Modem statistical
studies by Rene Dubos. Thomas McKeown, John
Prowles and A. L. Cochrane have proved beyond any
doubt that the fall in the death rates and the decline
in contagious diseases recently observed in the deve
loped countries have little to do with curative medi
cine. They are products first of better nutrition and
housing facilities, second of improvements in control
of the environment and only third of personal medi
cal attention. 1 know that this has been formally
recognised by our national health programmes and
that social and preventive medicine has been formally
included in our medical syllabi. But the question is
how' far does this awareness inform the real activities
of our doctors and health forums. What is their
cumulative contribution to the study and dissemina
tion of epidemiology, medical sociology and environ
mental education? I think this is precisely a field
where informal and non-bureaucratic medical move
ments can make great strides.
Il
The socio-cultural critique of medical practice
is a more recent development. Ivan Illich, the Vien
nese thinker who has developed a series of institu
tional alternatives for technological societies was
perhaps the first to develop a consistent and radical
cultural evaluation of western medical care. Besides
Illich, feminists like Linda Gordon and Pauline Bart,
black radicals like Frantz Panon and medical socio
logists like Irving Zola and John Ehrenreich have
helped to create a profounder understanding of this
cultural crisis. Illich opens his book, ‘Limits to Medi
cine’ with the words “The medical establishment has
become a major threat to health. The disabling
impact of professional control over medicine has
reached the proportions of an epidemic”. He calls
this epidemic, ‘Iatrogenesis’ meaning a disease born
of physicians. Illich holds that it is the layman and
not the physician who has the potential perspective
and effective power to stop this epidemic (though 1
see no reason why earnest and intelligent physicians
cannot join hands with the layman in an attempt to
demystify medicine). The increasing ‘medicalization of
life’, Illich argues, is a form of the colonisation of
the body. By holding the exclusive right to deter
mine what constitutes health and sickness and what
shall be done to them, medicine has become a major
4
that is why a mere socialisation of medicine cannot
make it socialist. The other mode is moral iatroge
nesis. Professionalism in medicine has unfortunately
come to mean a defence of occupational and class
privilege rather than high standards. The profession
thus has created an elite fatally cut off from the
public, speaking a highly specialised language meant
io mystify the layman. The cruellest examples of
moral iatrogenesis may be found in psychiatry which
openly practices the social control of deviant beha
viour. It is concerned not with clinically measurable
somatic dysfunctions but with what is socially defined
as abnormal or unacceptable behaviour. R.D. Laing’s
classic example may prove' my point. A man gibber
ing away on his knees, talking to some one who is
not there should normally be considered mad; but
society has come to define this activity as ‘prayer’ so
that we consider it perfectly sane. Psychiatrists have
the power to label several states ranging from rare
creativity to revolutionary activity as forms of
insanity. They help the preservation of the statusquo by silencing its opponents as in the Soviet Union.
Our hope here lies in' the development of anti
psychiatric movements trying to discover the social
roots of abnormal states and discouarging monstrous
methods of treatment such as ECT, replacing them
with love, understanding and patient persuasion.
campaign should enable the people to ask questions
to the doctors on,terms of equality and judge the kind
of care and treatment offered to them. Secondly
the new movement can see to the enforcement of the
oft-broken medical code of conduct. This should be
realised as far as possible, by persuasion, moral
authority and honest example rather than direct
coercion. Thirdly, the forum can conduct or guide
revealing studies in the geography, history, sociology
and politics of medical care in India, particularly in
the States. These studies can expose the various
forums of institutionalized corruption and expose the
sexist, casteist and class prejudices now inhibiting
medical study and practice and the effects of colonia
lism on our attitudes to illness and cure, thus evolving
a total critique of medical practice in the country.
Fourthly it can propose alternatives to the present
medical syllabi so that they may place greater empha
sis on a realistic study of our environment and study
of the doctor-patient relationship. Healing relation
ships are as much social as they are physiological; so
chemistry, biology and physics alone cannot form an
adequate basis for scientific medicine. It should find
place for subjectivity and consciousness in the study
of man so that it becomes a dialectical science. Tradi
tional medical systems like tribal cures, indigenous
and holistic systems like Ayurveda and non-allopathic
systems like nature cure, homeopathy, Unani medi
cine and acupuncture should form a part of the
syllabi. The forum can also encourage researches in
mixed medicine that integrates the various approa
ches. Fifthly it can assist the deprofessionalisation of
medicine, by teaching the patients to conduct their
own laboratory testsvand offering compressed courses
in environmental hygiene and preventive medicione to
volunteering youth as is done in the case of the ‘bare
foot’ doctors in China. (Books like ‘Where there is
no doctor by David Werner can be of use in such
courses). It should simultaneously ‘reprofessionalise'
medical care by invoking the idea of health care as
a calling and a selfless mission. Sixthly and lastly,
it can also build up a parallel system of clinics and
nursing homes where the foundation is laid for a new
type of doctor-patient relationship and a novel
approach to the problems of medicine including
psychiatry.
Ill
The political-economic critique and the socio
cultural critique of modern medicine are not as con
tradictory as they may appear to be. If we can un
leash the imagination of the people and lay the fourrdations of a popular movement it must be possible
to bring about a synthesis of the perspectives of
‘more’ and ‘different’. What is required in. the
Indian situation of scarcity and corruption is an
equal emphasis on the need for more services
and the need for a different approach to health
altogether. The seed of such an ambivalent popular
movement for socialist medical care can be sown now,
in the form of a forum of radical medical
students, teachers, practising doctors, psychiatrists,
non-professional health workers and active sympa
thisers. The primary task of this forum will be cons
tituted by campaigns of demystification and conscientization. The aim of these campaigns will be the
demedicalization of society by spreading the concepts
of self-help. But we should take care to see that it
does not promote superficial fads. Some medical
technology
is useful but
inappropriate
for
use by utrained people.
Rejecting this would
be a self-destructive form of ‘autonomy’. What
is required is more a reorientation of dependency,
rather than a complete abandonment of dependency.
Conscientization can be done through the publication
of books, pamphlets and periodicals and by camps
and classes meant for weaker sections based on the
dialogical and problem-posing
modes of socialist
pedagogy as outlined by Paulo Freire. The whole
Courtesy: Calicut Medical College Magazine 1982-83
Health for all-depends on three things: Reduc
ing poverty and inequality and spreading education;
organising the poor and underprivileged to fight for their
basic rights; replacing counterproductive consumerist
western model of health care by alternative model based
in the community.
— ICMR/ICSSR
5
DEAR FRIEND...
Tuberculosis — Annual Meet theme: 1985
What is the purpose of this exercise?
— Is the purpose to do a critical analysis
alone and leave it at that?
Or
— Discuss the various dimensions of the
TB problem for our own understanding
and for education of others in mfc.
Or
— Discuss the TB issue from the point
of view of the workers in the field of
health with the purpose of ensuring
some improvement ie., action plans
being an important aspect of our work
— this would obviously be based on
the above two but would mean our
going beyond that.
In CINI this issue had come up, as to the chang
ing role of mfc and I strongly feel, unless we are to
some extent involved in coordinated action over selec
ted priority issues, we will stay this big and have very
marginal impact.
I feel extremely strongly about the TB issue and
I’d hate to sec the whole thing limited to an intellec
tual exercise, no matteFhow fantastic.
Mira Shiva
VHAI,,New Delhi
KEEPING TRACK
1.
(1)
Actual discussions should focus on the follow
ing issues:
a) Where does TB fall in our priorities?
b) What priority in exact terms has been
accorded to it in our national, state
level, hospital level and day to day
practice as well as in medical education?
c) assessment, remarks, criticism in the
current direction of approach to the
problem of TB.
d) What could be the rational approach
at each of the above mentioned levels?
We should avoid discussing details of chemo
therapy etc., if we are to encourage participation of
non-medical people in mfc.
Current concepts and WHO recommendations
about diagnosis and chemotherapy and the evolution
of the care of TB at our national level may be cir
culated through background papers and the bulletin.
Kartik Nanavati
Ahmedabad
Available from Centre for Socal Action, Gundappa Block 64, Pemme Gowda Road, Ban
galore-560 006.
2.
(3) The main article in June’s issue “Towards an
Appropriate Strategy’ was very interesting for us as
this is the sort of work we are starting to try to do.
I wish it had been more detailed, in fact.
Please keep up the immensely good work that
mfc does. It is one bright patch in an otherwise very
gloomy picture.
Keith & Caroline Walker
Gangavarpatti, T.N.
Rational Drug Therapy — a small book on
recent advances in the treatment of common
diseases, rational approaches to treatment,
side effects of various drugs and clinical diag
nosis of common diseases by various experts
in the field.
To be published by Arogya Dakshata Mandal.
Register orders with Dr Patwardhan of Pune
Journal of Continuing Health Education.
■1913, Sadashiv Peth, Pune 411030.
3.
Socialist Health Review (quarterly) A new
collective' effort which aims to provide a forum
for exchange of ideas and for generating a
debate on practical and theoretical issues in
health from a radical or marxist perspective.
For further information and subscription
(Rs. 20-00 for individuals and Rs. 30-00 for
institutions) write to Socialist Health Review,
19 June Blossom Society, 60-A, Pali Road,
Bandra (West) Bombay 400 050.
4.
Diarrhoea Dialogue — a quarterly newsletter
published by AHRTAG (Appropriate Health
Resources and Technologies Action Group
Ltd), London. It shares practical information,
experiences and field studies on child health
with special reference to diarrhoea.
(2)
Self-sufficency in health care
Rakku’s story: Structures of 111 Health and
the source of Change. Sheila Zurbrigg.
An analysis of the Indian health care system
and of the basic source of change. 250 pages.
Rs. 10-00 (US $5).
(Wc have received a letter from Dr William
Cutting, one of the editors, offering to put
readers of mfc bulletin on the free" mailing
list. Those who are interested, please send us
your names with postal address (in caoitals)
by 31st July 1984).
pdxdWll NT
*
A'WiHbLe
A community health project in-charge, pre
ferably a lady with minimum 2 to 3’years
experience in community health nursina and
rural development activities is required imme
diately by ANKURAN, a self-reliant health
project in Gudn Mahalla, Chatra Dist
Hazaribagh, Bihar 825 401. Send applications
with complete bio-data, copies of certificates
and a passport size photograph to Sri Anand
Kumar, its Secretary.
DRUG ALERT!
DRUGS FOR ARTHRITIS IN THE DOCK
On 17th May 1984, local newspapers announced
that two popular drugs used for arthritis (Tanderil
and Tendacot) — both oxyphenbutazone derivatives
■— were ordered to be immediately withdrawn, from
the market in UK by a government order1. The action
was taken on the recommendations o'f the Committee
on Safety of Medicines (CSM) . Though the manu
facturer Ciba Geigy had exercised its right of appeal
under the Medicines Act to stall the government’s
decision, which actually had been 1 taken sometime
ago, the Medicines commission had upheld the deci
sion to revoke the licence.
400 deaths are reported to have taken place in
Britain in the last two years due to these drugs2.
The committee found them twice as dangerous as three
other drugs belonging to the phenylbutazone group
(Butazone, Butacodine and Butacote) which were
withdrawn in March this year. The CSM had conti
nued to receive reports of adverse reactions including
fatal ones due to blood disorders, gastro-intestinal
intolerance and bleeding3.
Sidney Wolfe, Director of the Health Research
group (sponsored by Ralph Nader) has estimated that
world wide probably more than 10,000 patients had
died as a result of taking these drugs. In his letter to
the Department of Health and Human Services, he
gave anaemia, agranulocytosis, leukemia, gastro
intestinal bleeding and peptic ulcerations as the lead
ing causes of drug induced deaths. Other deaths were
also attributed to hepatitis, thrombocytopenia and
renal failure4.
Interestingly in the last two years, three other
non-steroidal anti-inflammatory drugs benoxaprofen,
indoprofen and zomepirac and a formulation of indo
methacin (osmosin) were also withdrawn. A review
of a current CIMS5 shows 20 formulations of oxy
VOCAL FIGURES
Our current state-wise break up of readers are
— Maharashtra (212); Gujarat (63); Karnataka
(36); Delhi (28); Bengal (27); Kerala (26); Bihar
(19)’ Andhra Pradesh (17); Tamil Nadu (17);
Madhya Pradesh (13); Punjab (9); Uttar Pradesh
(8)- Orissa (5); Goa (2); Assam, Himachal Pradesh,
Meghalaya and’Haryana have one each, mfc has yet
to make an entry into Arunachal, Kashmir, Mizoram,
Nagaland, Tripura, Manipur, Pondicherry, Andaman
and Nicobar. How national are we?
Can members/subscribers/readers help us to
reach out to more people by sending us names and
phenbutazone (Algesin-0, Aristopyrin cream, Butacortindon, Butadex, Butaproxyvon, Disiflam, FlamarP., Ganrilon, Inflavan, Kilpane, Maxigesic, Oxalgin,
Oxyrin, Oxytriactin, Reducin-A, Reparil, Rumatin,
Suganril, Tendon, Tromagesic) and 8 formulations
of phenylbutazone (Actimol, Algesin, Aristopyrin,
Butapred, Ebeflam, Parazolandin, Zolandm, ZolandinAlka) recommended for use by doctors in India.
How many patients must die before something is
done about this in India as well?
An mfc annual meet background paper in 1982
concluded that the ideal anti-inflammatory drug was
yet to be discovered and Aspirin remained the agent
of choice when cost-factor and benefit to risk consi
deration were taken into account0. Have events in
UK endorsed this?
With such a large number of anti-inflammatory
drugs in the docks, will homeopathy7, ayurveda and
non-drug therapies have a role to play in the treat
ment of arthritis?
— Community Health Cell, Bangalore
References
1.
Hindu, 17th May 1984.
2.
Pune Journal of Continuing Health Education, Issue 69,
May 1984.
3.
Lancet: January 2, 1984 (Non steroidal anti inflammatory
drugs — have we been spoilt for choice)
4.
Lancet, March 31, 1984 (phenylbutazone and oxyphenbut
azone: FDA considers petition for ban in USA).
5.
CIMS — Current Index of Medical Specialities, May 1984.
6.
Meena Kelkar, Anti-inflammatory Agents' Pune Journal of
continuing Health Education.
7.
World Health Forum, Vo! 4, 1983: Homeopathy today —
round table.
addresses of people who may be potential subscribers
and share our perspectives?
Two bulletins will be sent free to them as a
trial subscription!
mfc office, Bangalore
WARDHA MEETING
The mid-annual EC/Core group meeting of mfc
will be held at Wardha from 27-29th July 1984 at
Gauri Bhavan, Sevagram Ashram, Sevagram (Maha
rashtra) . At this meeting discussions will be held on
organizational issues and plans for the annual meet
on 'TB problem and control’.
RN. 27565/76
mic bulletin: JULY 198-4
Editorial
THE 1CMR/ICSSR report on ‘Health for All’
has warned that “eternal vigilance is required to
ensure that the health care system does not get medicalised, that the doctor-drug producer axis does not
exploit the people and that the abundance of drugs
does not become a vested interest in ill-health1”. The
Drug Action Network which has come together in the
last two years is symbolic of this vigilance, which is
growing in India. The memorandum drawn up by
the participating organisations, which is featured in
this issue highlights the diverse aspects of drug policy
towards which this vigilance has to be directed.
THE banning of a wide range of commonly used
drugs for arthritis in U.K., in recent weeks (article
on Drugs alert) raises questions about the complexi
ties of this vigilance. In countries like U. K. and
U.S.A, in spite of drug safety committees, compre
hensive drug laws, efficient drug control authorities,
active consumer groups and socially sensitive elements
in the profession — drugs continue to slip through and
get used for years before their dangers get known and
bans are instituted.2 How much more difficult will it
be in our country where all these elements of ‘vigi
lance’ are still only in the process of evolving?
William Osier’s exhortation that one of the
first duties of the physician is to educate the
masses not to take medicine3 is particulaly
relevant in today’s drug situation.
The role
of doctors in acting as watchdogs is primary
Subscribers are informed that due to an RMS
go slow in Bangalore, clearance of the mfc bulletins
in June was delayed. The bulletins must have reached
in the third/fourth week. We apologise for the un
avoidable delay!
In future bulletins will be despatched on the
10th of every month. Please let us know if you do
not receive them by the 17th of the month (this
applies to Indian subscribers only).
mfc office, Bangalore
editor:
ravi narayan
UNLESS there is a growing realisation among
medical students, young doctors, teachers, health
workers, professional associations, consumer educa
tion groups and science movements that this problem
needs to be tackled in the form of an organized
movement very little change can be expected in the
present situation. Satchidanandan’s critique presents
an analytical framework and background against
which such a movement would have to evolve. His
suggestions for a multi-dimensional campaign of
demystification, conscientization, study, curriculum
change and deprofessionalization could well be initia
ted taking drug issues as the focal point. It would,
however, be important to keep in mind that over
seventy five percent of the people in India have little
or no access to health care. Hence an action pro
gramme only on drug matters would be cut off from
the needs and aspirations of the majority3. However,
if this became part of a wider people’s movement for
socio-political change, the drugs problem would be
tackled at its very roots.
Keireiresiiees
Please note
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
Regd. No. L/NP/KRNU/202
— laws, controls and authorities notwithstanding.
Are doctors prepared adequately for this role in India?
Medical education stresses the minutiae in pharma
cology and medicine without stressing the factors of
cost, safety and social relevance. It also does not
consciously immunize the doctors against the half
truths of persuasive medical advertising''. Irf the
absence of programmes of continuing education in
the country, practicing doctors continue to be infor
med only by the profit oriented pharmaceutical indus
try, thus worsening the situation.
1.
HEALTH FOR ALL — AN ALTERNATIVE STRATEGY:
ICMR REPORT, 1981.
2.
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS:
Lancet Editorial, 21st January, 1984.
3.
FEED BACK ONgPRESCRlBING: Lancet Editorial, 11th
February 1984.
4.
WHAT IS RATIONAL DRUG THERAPY?: Health for
the Millions, April-June 1981.
5.
CONSUMER ALERT—CONSUMER ACTION : Bulletin
of Sciences, Vol. 1, No. 2, December 1983.
Views and&opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US S 4 for all countries
Air Mail : Asia — US S 6; Africa & Europe — US S 9; Canada & USA — US S 11
Edited by RavilNarayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560 034
Printed by Thelma Narayan at Prulinc Printing Press, 44. Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
105
medico friend
circle
bulletin
SEPTEMBER
1984
NATIONAL TUBERCULOSIS PROGRAMME
: some problems and issues : *
Binayak Sen
**
“Why is it that even though the felt-need oriented National Tuberculosis Programme is in operation in the
country for over two decades, more than 80 percent of infectious tuberculosis patients are still being turned
back at various health institutions with nothing more than a bottle of cough mixture?”
— D. Banerji, EPW, 22 Jan. 1983
1.
Conceptual Problems
In their seminal 1962 paper on symptom aware
ness in tuberculosis, Banerjee and Anderson, re
emphasized the problem of tuberculosis as a problem
of human suffering, and outlined a strategy for tuber
culosis control based on this concept. This strategy,
abjured a policy of active case finding. Instead, it
concentrated its attention on greater diagnostic
sensitivity towards and adequate treatment for those
people suffering from symptoms suggestive of tuber
culosis who presented themselves at the existing
hospitals and clinics. Together with the Madras
Chemotherapy Centre study on domiciliary treatment,
it forms the theoretical basis of our present day
tuberculosis programmes.
The credibility of this system rests on the ade
quacy with which the entire range of presenting
symptoms is handled. The logical corrolary of the
adoption of this approach would, therefore, be the
development of an integrated and well-defined system
for tackling the entire range of tuberculosis sympto
matology .
Instead, the National Tuberculosis Programme has
set its sights on a Mirage — the interruption of bac
terial transmission. To this end, it defines a ‘case’ of
tuberculosis as a person excreting tubercle bacilli in
his. sputum. This approach is unscientific because it
is only at a much later stage along the exponential
curve of falling prevalence that the interruption of
transmission becomes even a remote possibility. It
also ignores the fact that never in the history of human
tuberculosis has a reduction in transmission been
brought about by a specifically medical intervention.
• A note prepared for the mfc core group meeting (July ’84)
at Wardha
•* CMSS, Dalli Rajhara, M P—491228
As a result of my four years experience of work
ing in voluntary institutions participating in district
tuberculosis control programmes — in Hoshangabad
and in Durg — I am familiar with the way in which
this approach works in practice. A person who pre
sents himself at a Public Health Institution with symp
toms suggestive of tuberculosis is not regarded as a
person suffering from disability and consequently in
need of help, but simply as an entity to be categorised,
i.e., TB or not TB. After a cursory physical examina
tion he is sent for a sputum test. If he obliges by
producing a positive sputum, that is the end of the
matter. He can then be placed on a standard treat
ment regime (generally INH and Thiacetazone daily)
and forgotten about. Once in a way his sputum may
be checked but the treatment regime is not affected
thereby. I have documented evidence of patients,
sputum positive after a year’s treatment with INH
and thiacetazone, being continued on the same drug.
When challenged, the government doctor has explained,
“that is the only regime available”. In point of fact, in
practice this is “often true.
But, we will come to problems of chemotherapy
later. The point I am trying to make is, that from
INSIDE
National Tuberculosis programme
— some problems & issues
2
Sevagram meeting
4
Dear Friend
5
■All India Drug Action Network
7
Editors Note
8
apparent primary tuberculosis can safely be treated by
a short course of INH alone. This is a notion that
goes against all bacteriological logic. One only crea
tes a population of INH resistant bacteria, strategi
cally situated to subsequently produce reactivation
disease.
the point of view of a desperately sick man, frightened
by a dreaded diagnosis, it is cold comfort to be given
30 tablets and told to come back again after a month’s
treatment, and assured that he will get well in 18
months time. This is particularly so since there are doc
tors at every street corner assuring patients (with con
siderable honesty) that they will get well with some
private treatment in six months or less.
b.
Let us now come to the case of those who were
sputum negative. The cost of a 'free MMR X-ray
from Durg to a person in Rajhara, is well over Rs.
50.00. The cost of a local private X-rav is Rs. 35.00.
Which should the patient choose?
It should be noted that I have been talking all
along of the ideal case. We have not taken any account
of the government doctor nudging the patient towards
his private clinic; the laboratory technician asking
for his ‘fee’; the X-ray technician’s rudeness, or the
irregularity in drug supply.
3.
In a Government District Hospital, despite all
the other problems, one can atleast meet doctors who
are interested in their work in the medical, surgical,
gynaecological and other specialist departments. Not
so in tuberculosis. The department which should, by
all epidemiological logic, claim the most brilliant and
dedicated of our technical manpower, is invariably
academically dead. In Hoshangabad, the District
Tuberculosis Officer was simply absent for a long
period of time.
The para-medical staff, on the other hand, are
often exceptionally dedicated and able. They often
run the programme practically independently. How
ever, they have to pay the price for their competence.
In Durg, the statistical assistant — a key person.
and in this case extremely competent and dedicated
— has been on full time deputation to the Civil
Surgeon’s office, helping to administer the hospital.
Primary TB and Extra-pulmonary TB
Treating the problem of tuberculosis as a pro
blem of suffering people, rather than as a problem
of successfully eliminated parasitic myco-bacteria,
brings us to two sets of illnesses often neglected in
the current programmes, viz.
a.
Staff Problems
Cases of ignorance among people working in
the field of tuberculosis are not rare. This is because
almost the entire field level medical staff of the
tuberculosis programme are ‘dead-beats’ — people
who have been promoted to an administrative posi
tion because their seniority has become an adminis
trative embrassment.
The patient of tuberculosis is basically a suttering person. It is the least of his concern that he is
excreting M tuberculosis in his sputum. What he is
much more worried about is the fact that he has
cough, chest pain, fever, body ache and nausea. He
cannot work. He feels weak. He loses his sexual
potency. His children starve and often fall ill in
their tum. A physically distant and emotionally re
mote health centre can offer him nothing. It is well
to remember that the Madras Chemotherapy Centre
study on domiciliary treatment had weekly home
visits as part of their protocol. It is a great pity that
this investigation has formed the basis for a programme
that thinks it sufficient to throw some tablets once a
month at a desperately sick man.
2.
Extra Pulmonary Tuberculosis
The chapter on Epidemiology in the Text Book
of Tuberculosis (by the Tuberculosis Association of
India) has nothing to say about extra pulmonary
disease. In my experience this forms a significant
proportion of cases of tuberculosis. In particular,
‘scrofula’ (burnt out tuberculous cervical lympha
denitis) is still a common finding in backward areas
of the country.
Primary Tuberculosis
Between 10 & 20 percent of Indian children are
tuberculin sensitive by the 'time' they are five years
old, though some surveys (Raj Narayan) yield a lower
estimate. The popular (medical) conception of pri
mary tuberculosis is of a mild intercurfent illness that
is only incidentally detected in a chest X-ray and
attains clinical significance only in the ‘progressive’
form. This is not true In malnourished children not
only is infection itself accompanied by significant mor
bidity, but it is the‘interaction’ between infection and
nutrition — that is the factor that needs to be con
sidered. When we consider that, according to ICMR,
65 % of Indian children are malnourished, the dimen
sion of the problem becomes a little more plain.
4.
Chemotherapy
a.
Existing patterns
In theory, the National Tuberculosis programme
provides a wide choice among several alternative
regimes. These include, daily INH and thiacetazone
with or without an initial period of intensive treatment
with daily streptomycin and/or PAS. The bi-weekly
supervised regimes consisting of INH/SM and INH/
PAS, have been designed specially to ensure patient
compliance.
Even according to the treatment manual supplied
to the district Tuberculosis Officers, only sputum
positive patients are eligible for all these regimes
X-ray positive, sputum negative patients often just
It is a common misconception (even, as I have
discovered, among TB ‘Specialists’), that clinically
(Continued
2
on page 8)
as sick as their ‘positive’ brethren and about 5 times
an numerous, are eligible only for the daily, self
administered INH/TH regime. Presumably compli
ance is not a consideration where they are concerned.
In actual practice, the only regime available
with any regularity is daily INH/TH. (Incidentally,
pyridoxine tablets necessary to counteract INH indu
ced pyridoxin deficiency are practically unheard of.
Patients are told to eat lots of peanuts!) PAS I have
not seen in the past one year. Streptomycin is cons
tantly in short supply, so that patients are often
randomly shunted back and forth between regimes
containing SM and those without. The effect of such
regime changes in ‘midstream’, on treatment effectivity, bacteria sensitivity, and patient compliance
remains, as they say, a subject for research.
(3)
Coming to the INH/TH regime, TH is by no
means an uncontroversial drug. Its use is banned in
some countries-but let that pass. The incidence of
‘major’ toxicity in a study in Madras showed the
following incidence of side effects:
phase regimes are used, with an initial
intensive phase using three drugs. However
in my experience, such regimes are available
only to a very small proportion of patients
even in the district centres, and to practi
cally none in the peripheral centres. Most
patients go on a standard two drug regime
(generally INH-TH).
When a patient fails to respond clinically to
a particular regime, there are no facilities
for drug sensitivity testing even in these
selected cases. Theoretically, in the exis
ting model, they can be referred to Tuber
culosis Sanatoria for treatment with 2nd line
drugs. In practice, however, (a) practically
none of these patients do get referred to
Sanatoria; and (b) even among those who
are started on second line drugs at such
centres, there are no facilities to continue
drugs after the patient is discharged.
The Ione patient I managed to get referred to a
Sanatorium in Bhopal emerged after two months
looking much better and clutching a prescription for
rifampicin and ethambutol.
Cutaneous hypersensitivity reactions — 7%:
Jaundice — 3%;
Intractable vomiting — 3%
c.
Apart from these, there are minor side effects
such as anorexia, nausea, vomiting and head ache.
Weight gain and rise in haemoglobin level are less in
patients on TH as compared with those on PAS. The
effect of such minor side effects on patient compliance,
especially in the absence of adequate medical super
vision and reassurance, can only be imagined.
Possible Alternatives
It is well known that there now exists a wide
variety of alternative drug regimes for the treatment
of tuberculosis, many of which result in cure of a
higher proportion of patients in a much shorter period
of time than existing standard regimes. The conven
tional wisdom is that these alternative regimes com
prise a ‘second line’ of treatment for patients resis
tant to the standard regimes.
We will consider possible alternative regimes in
the next section. For the moment let us stick to
the first line/second line chemotherapy model. We
have already noted, some of the problems with the
bi-weekly INH/SM reiiime not available for sputum
negative patients, and limited and irregular supply of
SM. In addition, there is a rule that SM injections
can only be given at the PHC level. In other words,
this regime is effectively available only to those who
live within about 5 kms of a PHC.
The fact that the government itself does not take
this argument seriously is shown by the free availa
bility of the so called ‘second line’ drugs in the open
market. Of course, the price is far beyond the reach
of the ordinary tuberculosis patient. As a result, we
have in India the ironic situation, where the District
Tuberculosis Officer and the PHC Medical. Officers
are the only medical
practitioners who (in their
official capacity) have no access to the newer drugs
for the treatment of tuberculosis.
Drug resistance
Coming now to the problem of resistant tuber
culosis, there are a number of problems in the. exis
ting framework.
(1)
Drug resistance in tuberculosis is not a rare
phenomenon. Existing studies show that the
prevalence of primary drug resistance to
both INH and SM in India are (individually)
of the order of 5 to 10 percent. The pre
valence of acquired drug resistance is not
known to me. But the success rate of the
standard first Ime treatment regime is of the
order of 80 to 85 percent, under ideal
conditions.
(2) There is evidence to show that pre-treatment drug sensitivity tests do not affect the
outcome of treatment, provided standard two
b.
In effect there are today, in tuberculosis, as in
every other field of medical and indeed of public
life, two sets of policies in operation ■— one for the
poor and one set for those who can (even if only with
difficulty) pay.
The argument against the newer regimes can now
be seen plainly for what it is — a question of cost.
It is worth going into this question in some details.
5.
The question of cost
a. How much ?
The cost of a complete course of treatment with
the newer drugs at current market prices is of the
3
TEHE SEVAGKAM MEETING
The core group of our friends circle spent five
days together at the end of July, at the Sevagram
Ashram in Wardha. The agenda included discussions
on the 1985 annual meet in Tuberculosis, the role of
mfc in the Drug Action Network and various other
organisational issues. The meeting was an informal
interaction in the ‘mfc style’ greatly facilitated by the
simple and ‘mat-level’ life style of the Ashram. We
present here a few of the important issues discussed
and the decisions taken for the information of our
members and bulletin subscribers.
Session
I — Our Concerns
A salient feature of such meetings is the oppor
tunity to get to know what various participant mem
bers are doing in the field and to discover the wider
issues with which health and medicine are so intri
cately enmeshed. Responding to the question of
“what have been your chief concerns since the Cal
cutta meet?” participants shared their involvement
and action in the last few months. We heard about
the problems of tribals vis a vis dams and eviction
from forest lands in Gujarat; the inadequate response
of authorities in Gujarat and West Bengal to the
hepatitis and dysentery epidemics; the difficulties of
attempting scabies control in tribal belts; taking steps
against stepwells perpetuating guinea worm infesta
tions in Rajasthan; the effects of proposed mechani
zation on workers especially women in the tobacco
processing industry in Karnataka; the travails and
hopes of programmes for identification and release of
bonded labour in Rajasthan; the irresponsibility with
which safety and waste disposal issues are tackled in
a Nuclear fuel complex in Andhra; the successes of a
small town library and cultural centre attempting to
popularize science and social issues through discus
sions and street theatre in Madhya Pradesh; the expe
rience of improving the economic status of women
with ambarcharkha in Maharashtra; the process of
rationalising health care, and increasing communitv
orientation among voluntary agencies in Gujarat:
the complex cultural and social factors involved in
countering the problems of witch-hunting in Maha
rashtra; the preoccupations of a small town general
practitioner in West Bengal; the experience of a low
cost drug distribution and quality testing project in
Gujarat; a programme of cancer detection in urban
Hyderabad; and the dilemma’s on the issue of post
graduation of a young doctor from Tamilnadu.
newsletter; and the various articles for the lay press
and existing bulletins which members had contri
buted .
Session II — Organisational Issues
1.
Funds
The budget was finalised and it was decided
that the estimated deficit would be covered by a con
certed bulletin subscription and membership drive
including life subscribers for the bulletin (Rs. 250).
Funding agencies would be approached only if the
third anthology estimates went above the total pro
ceeds from 2nd anthology sales.
2.
Anthology
a)
The third anthology was finalised with addi
tion of a few more articles than those decided at
Calcutta/Hoshangabad meetings. VHAI’s offer to print
it was accepted. The anthology was named — Under
the Lens-Health and Medicine.
b)
It was decided to request VHAI to reprint
the second (Health Care-which way to go) and first
(Insearch of a diagnosis) anthologies
c)
A pre-publication offer and a post-publication
package deal for the three anthologies is also being
planned
d)
An anthology on Medical education issues is
being planned based on bulletin articles and back
ground papers of Calcutta, Anand and Dacca meetings.
3.
Bulletin
a)
Trial subscription process will be activised
b)
Editorial guidelines were finalised
c)
A reminder process for lapsing subscriptions
was streamlined. Rubber stamps “your subscription
ends ------------ ” and ‘please renew your subscription’
will appear on the last two months of the subscrip
tion as well as for two months after the lapse. No
money order form will be sent in future. Only two
months lapse will be allowed before discontinuing.
d)
The Back issues distribution system of Centre
for Education and Documentation, Bombay was accep
ted. Mfc office will cater to only small orders.
Copies of Index of 100 issues is available with the
office at Rs. 2.50 each.
Being mainly a ‘thought current’ mfc perspec
tives need to be shared to wider and wider audiences
through articles for the lay press, lectures in public
forums and the organisation of meetings around
relevant issues. We heard about the meetings on
Drugs organized by Andhra and West Bengal VHA’s
resulting in the formation of two drug action forums;
the meetings organized by Lok Vidnyan Sanghatana
on drug issues in Maharashtra; the birth of the
Socialist Health Review and the Drug-Action Network
.. C)
itheracs to be featured in the bulletin in
h lThs are 0 Child Healtfl
view
°f y?
day theme f°r 1984) ii) Worker's
health, in) Urban health-slums and urbanization, ivj
The return of epidemics, v) Health in the people's
science movement vi) Alternative systems of mediTuhe AP7ort' frOm tnCSe th6re "d11 be SPecial issues on
Tuberculosis as well as Drug issues.
4
■ Contributions in the form of articles, book
reviews, dear friend lettersand entries for keeping
track column
are
welcome from
all our’
members and subscribers. Send them in as soon as
possible so that these thematic issues can be planned
well in advance.
Session HI — Discussion on Tuberculosis
The theme for the 1985 annual meet is “Tuber
culosis and its control in India”. The theme was selec
ted because Tuberculosis as a problem is very closely
linked with the unhealthy structure of society and the
national control programme is one of the oldest ones
of its kind in the country. Two members Binayak
Sen and Mira Sadagopal had written background
papers for discussion. The former is featured in this
bulletin. The latter entitled “TB and Society” is avai
lable on request from the author C/o. Kishore Bharati, P.O. Bankheri, Dist. Hoshangabad, Madhya
Pradesh-461990. A special reference file of papers
on various aspects of the Tuberculosis programme had
been prepared by Ramakrishna, one of the associates
of the Bangalore office. All these were very much
appreciated.
The discussion raised many important questions
about the problem and existing situation of the dise
ase and the control programme in the country. How
ever it was obvious that there was need to collate
available information on various aspects of Tubercu
losis from studies and field projects to enable the
group to arrive at a realistic, rational and alternative
approach to tackling the TB problem. The planning
for the annual meet which ensued came to the
following important decisions.
i)
Dates/venue 27-29th January 1985 Bangalore
is first preference for venue because of the proximity
of National Tuberculosis Institute. Madras is second
preference (To be finalised soon).
ii)
Background papers The following twelve
background papers will be prepared by members in
groups or singly, a) Evolution of. TB control in
India ■—historical reasons and conceptual premises.
b)
Problem of TB in special situations like socialist
tountries, states in India like Kerala and Gujarat am
reasons for differences, c) Epidemiological reality at
District level d) Case detection-diagnosis, misdiagno
sis and over-diagnosis, e) Extrapulmonary and child
hood Tuberculosis, f) Rational TB therapy and drug
related issues like economics, availability and rationale
of alternative regimens, g) BCG immunization — the
present status, h) Treatment of TB in other systems
of Medicine, i) TB on the 20-pomt programme —
implications, j) Case holding and patient compliance
and motivation, k) Role of private practitioners and
non-governmental voluntary organisations m TB
control 1) Education and awareness building in TB
control.
iii) Surveys A practical survey on the existing
situation of TB and the control programme will be
carried out through the bulletin to get a much larger
participation from members/subscribers. Short-term
enquiries on aspects such as the status of TB in
medical education; the costs to the patients with
alternative regimens; how is TB managed in hospitals,
private practice and PHCs in the light of the recom
mendations on alternative regimes; drug availability
problems at different levels, etc will be undertaken
with the help of interested members especially student
groups associated with mfc.
iv) Pre-planning for Meet September issue of
bulletin will introduce theme and give tentative
details of the meet. Background papers will be ready
for circulation by 1st November. Bangalore group
will identify questions for discussion and produce
short working papers and plan out a programme for
the meet — small group discussions and plenary
sessions. Background/working papers will be ready
for despatch to all interested members/subscribers
from 10th of December on which date a special issue
of the bulletin on TB containing relevant material as
well as an article by Anant on the role of mfc like
organisations in tackling the TB problem will be
posted.
(Note: If any member/subscriber is keen
to participate in any of the above mentioned preli
minary exercises for the annual meet kindly write to
us immediately giving areas of interest and ways and
means of suggested involvement.) Group work will
help us in gaining a much wider perspective!
Session IV — Mfc role in DAN
There was a detailed discussion on three papers
written by Anant on the future perspectives and
organisational character of Drug-Action-Network
(DAN) and also of mfc’s role in it. Anant, who will
be coordinating this activity on behalf of the mfc,
has reported on this matter as well as the two-day
DAN meeting (3O-31st July 1984) elsewhere in this
bulletin.
'Dear
DDiend...
Rational Drug Policy
Received the July 84 issue of mfc bulletin and
found the memorandum on Rational Drug Policy very
comprehensive, complete and interesting. This is
one field which needs regular and persistent pressure.
I am sure with the example of a country'like Bangla
desh practising strict drug policy we can look forward
to success.
Was suprised to learn about the statewise break
up of mfc readers. I shall be sending soon a list of
friends at various medical, colleges who may be poten
tial subscribers. Also will motivate friends at Vara
nasi to get involved.
I came to know of mfc during my internship at
rural health training centre, Chiraigaon. I will feel
happy to extend any sort of help at any time.
Naresh Kumar
23rd July 1984
BHU, Varanasi.
ALL INDIA DRUG ACTION NETWORK
consciously choose where to begin and concentrate.
We have to prioritize activities which must be taken
up immediately, for example: the Government’s ban
order in July ’83 on twentytwo hazardous inessential
drugs and the sequelae to this ban-order. Secondly
we have to concentrate on those drugs which are
most commonly used and those around which a mass
movement can be launched. It was therefore decided
to concentrate on the following:
A meeting of those groups who have been in
contact with each other for the last two-three years
in connection with “Drug-Action’ was convened at
Wardha on 30th and 31st July i.e. immediately after
M.F.C’s mid-annual core-group meet. Representatives
of the following organizations participated:
* Arogya Dakshata Manda!, Pune
* Consumer Guidance Society of India,
• Delhi Science Forum.
* Federation of Medical Representatives’
Association of India (F.M.R.A.I.),
• Foundation for Research in Community Health, Bombay
• Kerala Shastra Sahitya Parishad (K.S.S P.)
• Lok Vidnyan Sanghatana. Maharashtra,
■ LOCOST Project, Baroda,
• Medico-Friend Circle,
• Voluntary Health Association of India (VHAI)
• V.H.A.I , West Bengal.
1)
The Government’s ban-order
The Ministry of Health and Family Welfare
had issued a Gazette notification on 23rd July ’83
“to prohibit the manufacture and sale” of 22 cate
gories of drugs and drug-combinations. There are a
number of loopholes and problems in this ban-order.
The matter has now gone to the Supreme Court. In
the meantime attempts were made to prepare a list
of brands containing these 22 categories of drugs,
since the Government has not published such a list.
There are some problems in this work because the
Government Order is vague on some points and be
cause some manufacturers have deleted ingredients
listed in this Government Order without changing
the brand-name of their formulation. For example
amidopyrine has been removed from “Spasmindon. ”
The lists made by Mira Shiva and Dr. Rane would be
compiled together and Mira Shiva will send a copy to
those who want if. It would also be published in the
MFC-Bulletin. This list would enable people to know
which brands to boycott till their manufacture itself
is stopped or till these ingredients are removed from
these brands.
As a preparation to this meeting of the Drug
Action Network, there was a discussion in the MFCcore group meeting about MFC’s involvement in this
activity. It was decided that M.F.C. would of
course continue to be a part of this activity. M.F.C.
can help by contributing to the spread of this move
ment in different parts of the country. MFC can
also contribute by providing socially conscious medi
cal expertise; this would be MFC’s specific contribu
tion . It was also decided to form a drug-cell in MFC
of those members who want to participate in this
movement. Anant Phadke would co-ordinate this
drug-cell and would act as MFC’s representative.
Anant had prepared two notes — “Essentials of a
Rational Drug Policy” and “Towards a Rational Drug
policy in India.” These notes were discussed and
modifications were suggested. They were later pre
sented in the Drug Action Network meeting.
2)
Supreme Court Case:
As was reported in the March ’84-issue of MFC
Bulletin, Vincent Panikulangara has filed a Writ
Petition in the Supreme Court to amend and add to
his original petition about banning of the 22 cate
gories of drugs. The drug-companies have filed coun
ter-affidavits and the Drug Action Network should
make available medical-technical expertise to Vincent
to answer the medical-technical issues raised in these
counter-affidavits. It was decided that DAN should
assure Vincent of such expertise.
30th July: Discussion on the perspective
The first day of the meeting was devoted to the
discussion on what in our view is the outline of a
Rational Drug Policy in India. Sujit Das (Drug Action
Forum, West Bengal), Anant Phadke (MFC) and
Amitab Guha (FMRAI) had prepared notes on
Rational Drug Policy. These notes were discussed.
3)
Ban on Oestrogcn-Progesterone
tions:
A consolidated draft of a Rational Drug Policy
(a sort of manifesto of the group) was prepared by
a small group at the end of the meeting at a late
night session. It will be cyclostyled and circulated
for further comments, modifications, concretization
etc. and would be finalized for printing in the next
meeting of the Coordination Committee to be held
in a couple of months.
forte prepara
f
'S
nOt e®ective. The representative
DR? L nlC‘enCA ^orum'Dinesh Abrol, informed that
2,
^2?
P p?red to move the Supreme Court about
know The \
°n
combination and wanted to
Sed thatP1thT °f °thers« was unanimously
decided that this combination has no scientific iustiof thTnS°MVer
m.View of the serious natae
d UP a water tJ mvolved ^th the use of this
drug, a water-tight case can be made
With this
sanction’ from DAN Delhi
4?
,j
go ahead with its plan’s in tMs regard
”
31st July — Action Programme and Co-ordination:
Since there are so many irrational drug-combi
nations and so many irrational practices, we have to
6
4)
Ban on Analgin, Chloramphenicol-Streptomycin
combination, fixed dose combination of
Cortico-steroids :
As in the case of Estrogen-Progesterone forte
these drugs need to be immediately banned. Medical
aspects of these drugs had already been discussed hi
earlier Drug-Workshops and it was unanimously
decided to take the question of the ban on these
hazardous combinations in the coming campaign.
5)
Drugs alert
Alert on indiscriminate use of oxyphenbutazone
group of drugs, Lomotil and anabolic steroids in
children and of clioquinol — There was no unani
mity about a complete ban on these drugs but it was
agreed that these potentially hazardous drugs are
being widely misused. Since many doctors are not
well informed about these drugs, it is necessary to
alert all doctors about these high-level drugs.
6) Irrational drug-combinations
common diseases:
used
to
9)
There are atleast 15,000 brands of drugs sold in
India. Majority of them are irrational. But this has
to be concretely demonstrated, item by item. If we
can not scrutinize all the 15,000 formulations in the
immediate future, we need to scientifically scrutinize
atleast the top-selling brands to show the irrationa
lities in these formulations. (Can MFC members take
up this task? One person or a group can not take
up the task of scrutinizing all categories of drugs.
One person/group can take up responsibility of one
or two categories of drugs.)
treat
For example-antidiarrhoeal combinations, anal
gesic combinations, haematinics. The technical
material on these three groups of drugs is almost
ready and hence it is possible to say something very
concrete about these groups of drugs sold under
different brand-names. Different persons have taken
specific responsibilities and the technical material
would be sent to Mira Shiva by August-end; and she
will then duplicate it and send this collected material
to those who want it.
7)
10)
Over-the-counter drugs:
Popular Slogans.:
It was felt that we need to form some popular
slogans to be used by all groups. The following slo
gans were agreed upon:
“i) Make available adequate quantity of life
saving and priority drugs to the needy.
ii)
drugs.
iii)
panies .
iv)
Co-ordination Committee :
It is obvious that a lot of co-ordination would
be required to launch an All-India movement. It was
however felt that we should not form a separate
organization. A Co-ordination Committee would be
sufficient. Those groups who have been active, in
contact with each other for the last two years and
hence present for this meeting would constitute the
Coordination Committee. Those groups/organizations
who agree with the “MANIFESTO” prepared during
this meet, and who would show some consistency in
the sharing of responsibilities can be coopted into
this Co-ordination Committee of DAN. The network
was renamed as ‘All India Drug Action Network.’
Mira Shiva has been the de facto convener of DAN.
She was requested to become the Convener of the
Coordination Committee. She had to agree. It was
decided that the Coordination Committee would be
concerned only with the Coordination of National
level work. The work at local levels is the respon
sibility of local groups/organizations. Expenses in
curred for Coordination work would be shared equally
by all members of the Coodination Committee.
Non-medical groups like Science groups or con
sumer groups would not be able to involve them
selves much in issues which are highly technical.
Hence technically simpler issues like over-the-counter
drugs would be more appropriate for such groups.
Lok Vidnyan Sanghatana has prepared certain
demands about over-the-counter drugs — for exam
ple, withdrawal of irrational combinations, pre-censorship of advertisements, ban on advertisements of
tonics in the lay media. These demands would now
be made a part of the ‘All-India Campaign.’
8)
Further study.:
The concept of Essential Drugs (a better term
would be priority drugs) is a vital aspect of a rational
drug policy. Such a prioritized list of drugs based on
the disease-pattern in India is not available today
and this concept is also not accepted by the Gov
ernment authorities. We must, therefore, argue out
the necessity of such a list and prepare such a list.
Mira Shiva has done most of the necessary ground
work and has summarized it in her two notes circu
lated at the workshop. We need to study and finalize
the list prepared in her note — “Graded Essential
Drug List. ”
Since the Drug Action Forum of West Bengal
is to launch a big movement in West Bengal on the
drugs issue from last week of November, if was deci
ded that all groups in different parts of India would
start their campaign from 23rd November 1984.
Some groups will start earlier but would have a special
booster programme from 23rd November so that an
All-India impact is made.
Implement the ban-order: ban all hazardous
Nationalize the Multi-national Drug Com
In spite of the hectic schedule, we managed
some time for a slide-show by Dr. Ekbal of KSSP
on their work in the “Save the Forests" campaign
Prepare Scientific Drug Policy.”
7
RN. 27565/76
and on the Drugs-issue. The work done on both these
issues tells us how KSSP.is a real mass-movement and
hence very inspiring.
The simple yet comfortable arrangements at the
Sevagram Ashram was quite a welcome change for
city-dwellers; except for the smokers since smoking
was strictly prohibited in the Ashram premises!
Anant Phadke
Attentcon Rease ’
Those MFC members who want to help out in
the Drug-campaign are requested to write to Anant
Phadke, 50, LIC Quarters, University Road, Pune-16.
In your letter please indicate how you would like to
help
a)
Regd. No. I./NP/KRNU/202
mfc bulletin: SEPTEMBER 1984
By writing articles, giving talks on the issues
taken up in the campaign? If yes, what
kind of back-ground-material would you
need? Will you please pay for the material?
Will you please send some amount on an
ad hoc basis as your contribution? — Say:
Rs. 10/- to Rs. 25/-.
b)
By offering to scrutinize one or two cate
gories of drugs? (Say cough-mixtures or
tonics.) Those who have access to medical
libraries are earnestly requested to take up
this work.
c)
By offering to collaborate with other orga
nizations in your local area?
d)
By trying new ideas to make the campaign
stronger?
(Continued from page 3)
order of Rs. 500.00 to Rs. 1000.00. Regimes con
taining Streptomycin are liable to cost more, because
of the administrative cost of giving the injection.
We are not talking of enormous sums of money.
The cost of bi-weekly INH/SM with an initial inten
sive phase is not much less. Neither is the cost of
INH/PAS regimes. The logic of the exclusive depen
dence on INH/TH now becomes clear.
Put another way, the cost of treating a case of
tuberculosis with the newer drugs and the cost of
treating a case of intestinal obstruction or pyogenic
meningitis is about the same. The cost of treating a
case of ischaemic heart disease or lung cancer or
brain tumor or diabetes mellitus or chronic renal
failure is several times higher. The comparison becomes
ridiculous when one carries the contrast to fields
outside medicine — say, to defence or CHOGM.
b. Cost to whom ?
The second aspect of the cost equation — what
is the ‘cost’ of a twenty percent relapse rate which is
the best result obtainable with the standard 'first line’
regime? What is the ‘cost’ of a case of thiacetazone
induced agranulocytosis or Stevens-Johnson Syndome?
What is the ‘cost’ of travelling up and down from
village to PHC, village to District centre, village to
wherever, for 18 months as against the six months
with newer regimes? What is the ‘cost’ in bus fare?
What is the ‘cost’ in lost income? What is the ‘cost
in the suffering of a poor man? This is a question which
the policy makers of tuberculosis must answer.
Placement Available
Editor’s Note
In this issue the Sevagram meeting is highlighted.
The organisational issues on which decisions were
taken are featured as well as a report on the DrugAction-Network meeting and mfc’s role in it. A
background paper prepared by Binayak Sen is intro
duced to initiate hopefully a growing dialogue on the
TB question which will climax at the annual meet
in January 1985. The planning process leading up
to the meet is also presented. Members and subscribers
are requested to respond to all these reports with
constructive criticism, ideas, suggestions and action.
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
editor:
ravi narayan
Wanted a trained health worker or nurse or a
doctor, interested to live and work in a rural set-up
— a community health project in 12 tribal villages
of Srikakulam District (A.P.) This project is run
by a voluntary organisation working for rural deve
lopment. Our work includes Adult education, com
munity organisation community health, agricultural
extension and income generating activities. Salary
will be Rs. 600/- to 1000/- per month. Lady candi
date is preferred. Those interested please contact
V. A. Mary, Director, Samajika Vikasa Kendram,
Saravakota-532 426.
Srikakulam Dt. (A.P.)
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US $ 6; Africa & Europe — US $ 9; Canada & USA — US $ 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
107
medico friend
circle
bulletin
NOVEMBER
1984
EDITORIAL
Dmgs_ Awareness a&w] Aetooui)
“One of the most distressing aspects of the pre
sent health situation in India is the habit of doctors
to over prescribe or to prescribe glamourous and costly
drugs with limited medical potential. It is also un
fortunate that the drug producers always try to push
doctors into using their products by all means — fair
or foul.......... If the medical profession could be made
to be more discriminating in its prescribing habits.
there would be no market for irrational and unneces
sary medicines."
— ICMR/ICSSR, Health for All Report
Among the many challenges that face the All
India Drug'Action Network in its campaigns in the
future, one of the key issues will be to make the doc
tors in India more ‘discriminating’ in their prescription
practices. Any pressure on policy makers to evolve a
rational drug policy will fail if the medical profession
does not support it and accept self-imposed controls.
This is possible only through relevant professional
education, continuous dialogue and discussion in our
professional meetings and associations and a meaning
ful continuing education. Who will initiate this?
The All India Drug Action Network at its Wardha meeting decided to take a dozen drugs
in their initial campaign against ‘irrational and un
necessary medicines’. These broadly divide into two
groups:
The first is up for banning. These include Analgin
(singly or in combination); EP Forte drugs, Chloromy
cetin and Streptomycin combinations; Lomotil in
children and fixed dose combinations of steroids.
Enough is known about them and only action is
awaited.
The second group is up for a concerted consumer
doctor alert. These include Anabolic steroids, Antidiarrhoeals, Analgesic combinations, Clioquinols, Oxy
phenbutazone and phenylbutazone, Haematinics,
Tonics and Streptomycin-Penicillin combinations.
Here the dangers and irrationality are known but
there is lack of awareness in the professional and lay
public. Awareness must precede action.
In this special issue one of our members presents
his recent study of antidiarrhoeals. We also
feature a summary of the study done by the Interna
tional Organization of Consumer Unions on Anabolic
Steroids. The joint study on drug utilization pattern
by NIN/CERC highlight the problem of self-prescri
bing. The letters from the People’s Science Movement
in Maharashtra and the mfc Rational Drug Policy
Cell, are symbolic of what we can do to'initiate
a ‘discriminating prescribing practice’.
The challenge is a four-fold attack on the pre
sent situation — Rational Drug Policy, Public inte
rest legislation, Consumer awareness and Rational
therapeutics. Strange as it may seem, the need
for regulating the prescribing practices of doctors
is not new. Centuries ago the Koutilya Arthashastra
•had this to say —
“The physician who sets about to treat a disease
without knowing anything about it is to be
punished even if he is a qualified physician; if he
does not give proper treatment, he is to be
punished more severely; and if by his treatment
the vital functions of the patient are impaired,
he must be punished most severely.”
Is the medical profession in India today waiting
for such corrective action?
INSIDE
Antidiarrhoeals — how many are rational
Letter to the Drug controller
2
3
Over the counter drugs—a people’s science
movement’s concern
4
Anabolic Steroids — promoting whose growth
6
Drug utilization survey report
8
Kerala High Court Judgement
8
Annual Meet 1985 (Supplement)
Anti—Diarrhoeals: How many are Rational?
— Shishir Modak, Pune
Press Release
In a recent rigorous scientific scrutiny by Dr.
Shishir Modak of mfc, a paediatrician from Pune,
of 47 proprietary drug preparations sold as
anti-diarrhoeals, it was found that only 7 of these 47
commercial preparations were justified from the scien
tific view point. The preparations given in the issue of
Current Index of Medical Specialities (CIMS), May
1984 (used by thousands of doctors for ready reference
to commercial preparations) under the heading: “antidiarrhoeals” were taken for this study.
Recent research has questioned the usefulness of
many antibiotics and other drugs in the treatment of
diarrhoea. Based on this latest authentic expert
medical opinion in this field, it was found that most of
the ‘antidiarrhoeal’ preparations available in the
market were scientifically unjustified on one of the
following grounds:
Extracts.from study
The problem
Diarrhoea is frequent passage of loose stools.
Diarrhoeas are extremely common and endemic in our
country. Almost every child upto the age of 5 years
gets 1-2 episodes of acute diarrhoea in a year. It is a
number one killer in infants and small children. There
fore, every doctor is actively involved and should be
thoroughly trained regarding proper management of
acute diarrhoeas.
A large number of formulations are sold in the
market as antidiarrhoeal agents. They are usually broad
spectrum and claimed to be effective in diarrhoeas due
to different aetiological factors ranging from bacterial,
protozoal, non-specific etc. However, doubts are
always raised about rationality of all these prepara
tions. The purpose of this study is to assess the
rationality and effectivity of multiple antidiarrhoeal
preparations available in the market.
Material and methods
The 47 different formulations listed under the
heading: ‘Antidiarrhoeals’ in the CIMS, May 1984
issue were studied. Each ingredient of every formula
tion was evaluated separately on its own merit. The
comments are based on the available scientific litera
ture on this topic, published in recent standard text
books and periodicals. Finally, each product was
graded according to the resultant rationality of its
ingredients.
Antimicrobials as single ingredients (eg. Ampi
cillin, Tetracycline etc.) were not included in this
assessment.
RESULTS
1. Only SEVEN formulations had products
whose use was justified.
Furoxone suspension, Lactisyn, Laviest
insufficient dose or wrong proportion
;
of dose
for example: Neomycin in many preparations; wrong
proportion between furazolidone and metronidazole.
i.
ii.
irrational inclusion of some drugs
;
for example: Chlorophenirmine maleate; or inorganic
salts of sodium, potassium etc., or chloroquin
iii.
inclusion of drugs not indicated in diarrhoea
:
for example: streptomycin in the famous ‘Chlorostrep’
and some other preparations of the same formula.
iv.
inclusion of a drug which is too toxic for its :
• use in fixed-dose combinations of anti-diarrhoeals
for example: inclusion of antiperistaltic drugs and of
4-aminoquinolines (diodoquin, quinidochlor etc.) in
many anti-diarrhoeal preparations.
Salazopyrin, Sofrakay, Sporlac, Wallamycin
SIX formulations had electrolytes or other
ingredients which should be deleted.
Furamide compound, Furamide suspension
with Neomycin, Linopec, Neldar, Pectokab,
Prepared attapulgite.
3. NINE formulations had ingredients in the
wrong or insufficient proportions.
Aristogyl F, Diarmycin-N, Diarrest, Entero
mac, Furamide compound, Furamide suspen
sion, Metroquin F suspension, Neldar, Pectokab-MF.
4. EIGHT formulations had drugs which should
be avoided and/or should be available strictly
under prescription.
Dysenchlor Tab, Enterovioform, Lomotil,
Lopamide, Pelopem, Ridol, Streptomagma
suspension.
5. TWENTY formulations should be officially
banned, because they contain ingredients
which may cause serious damage and hence
should not be used in any fixed drug
combination.
Chlorambin suspension, Chlorostrep, Combactin, Darzin with Neomycin, Dependal,
Ematid, Enterosan, Enterostrep, Kaltin with
Neomycin, Lomofen, Mebinol, Mexaform,
Neo-Combactin, Pesulin-O, Protoquit, Rerokab suspension, Salvacol, Saril, Streptoparaxin, Streptophenicol.
2.
CONCLUSIONS
1. Antibacterial drugs should be used very
judiciously and only if absolutely necessary
in management of diarrhoea;
2. All formulations containing combination of
chloramphenicol and streptomycin should
be banned as antidiarrhoeal agents;
A Setter to the Drug controller
Sir,
1.
Banning of the irrational, unscientific prepa
rations sold as antidiarrhoeal agents. To
start with, banning of preparations contain
ing a combination of Chloramphenicol and
Streptomycin, since this unscientific combi
nation is the most frequently used ‘antidiarrhoeal’ agent.
2.
Making it mandatory for all producers of
antimicrobials used in diarrhoea to print in
a prominent way the following statutory
recommendation on the covering package:
"Medicine, even when useful, is not enough
in treating diarrhoea. Drinking oral rehydra
tion solution is atleast equally important in
all diarrhoeas.”
We would like to draw your attention to certain
measures which you can take up to curb misuse of
drugs in diarrhoea and foster oral rehydration in
diarrhoea.
As you may be aware, it is estimated that between
1 to 4 million children die every year in India due to
diarrhoea. Recent research has created possibilities
of saving these lives since it has definitively establi
shed that:
in majority of cases of diarrhoea, use of anti
biotics plays no positive role;
most of the deaths due to diarrhoea are not
due to toxaemia but due to dehydration;
(c)
most of the cases of dehydration can be very
well treated with oral rehydration;
(d)
out of a plethora of antibiotics available, in
vigorous scientific studies, only six have been
proved to be definitively useful and safe.
(a)
(b)
'Te't
Dr. Shirish Datar of the medico friend circle has
in a earlier paper summarized the scientific evidence
about treatment in diarrhoea and has also shown that
' out of 48 antidiarrhoeal preparations listed in the
January 1983 issue of the MIMS, only four are fully
scientifically justified.
On our part, we have launched an educational
campaign on diarrhoea, misuse of drugs in diarrhoea
and the importance of oral rehydration in diarrhoea.
If your office takes up initiative and takes definitive
steps as suggested above, such steps would go a long
way in promoting a rational approach to the manage
ment of diarrhoea; save millions of rupees of the poor
people now being spent on unnecessary drugs and
save lakhs of poor children who would otherwise die
due to dehydration in diarrhoea. We hope you would
give due consideration to our appeal.
We feel that the production, promotion and
marketing of anti-diarrhoeal agents should be brought
in line with these recent developments. We suggest
that your office can take the following steps to help
to achieve this aim:
(Continued from page 2)
3.
4.
5.
6.
and to print and insert inside the package a
detailed pictorial instruction sheet explain
ing how to prepare and consume oral rehydration solution at home by using ordinary
sugar, salt and baking soda. The printing
should be done in Hindi and English and a
regional language as is done in the case of
preparations like Licel, Diazone, Fleet etc.
All formulations containing streptomycin or
chloramphenicol (alone) should be avoided;
All other antibacterial agents if combined
in antidiarrhoeal formulations, should be
provided in adequate dosage: eg: Neomycin,
Colistin, Furazolidone, Cotrimoxazole etc
Hydroxyquinoline derivatives should not
be added in any of the fixed dose combina
tions. As far as possible, these agents should
be avoided and should be available strictly
against prescription;
Antiperistaltic drugs (Lomotil, Loperamide,
Opium) should not be used in children below
2 years and when used in children, should
be used very cautiously in proper dosage and
for very short period of time. They should
not be added in any fixed dose formulations.
Antispasmodic drugs like dicyclomine should
be carefully used in children and should never
be added in fixed dose combinations.
Thanking you,
Yours faithfully,
A. R. PHADKE
Convenor
Oct. 1983
National Executive Committee, mfc
P.S.: This letter was sent almost a year back, but the
Drug Controller’s office did not bother to res
pond to it as yet.
(The latest position about antidiarrhoeals is
highlighted in the same issue. Refer lead article-Ed)
Placemen! Available
Vacancy for trained laboratory technician to
work in health centre and associated development
work, including training of village health workers and
help in mobile health team and specialising in mother
and child health and TB control. Contact Robin
Sleigh, Project Leader BACRDP, C. S. I. Nava Jeevana Kendra, Kavtftalam 518344, Adoni Taluk. Kurnool District, A.P. (Language—Kannada or Telugu)
For copy of the report which include detailed tables,
merits and demerits of ..preparations and references,
write to: The Medico Friend Circle, Rational Drug
Policy Cell, 50 LIC Quarters, University Road,
Pune 411016.
3
Over the Counter Drugs
A People's Science Movement's Concern
*
responsibility to see that plain aspirin is available to
its tax payers.
We demand that advertisement of OTC analge
sics should be precensored to ensure that consumers
are not misled (as happens today) by the advertise
ments. A representative from the People’s Science
Movement and from consumer movements should be
invited to join the committee precensoring the adver
tisements. Any claim which has not been proved
scientifically, should not be allowed to be published in
the advertisements.
code on how to treat the fish, it's time for
the fishes to get together and decide how
they want to be treated
(From ICDA News, June 1981)
Dear Sir,
Lok Vidnyan Sanghatana has been actively work
ing in the field of propagation of Science amongst the
people in order to foster a scientific attitude amongst
them. Health is one of our concerns also.
Since last year, we have been studying the pro
motion of medicines for common ailments. We were
quite surprised to find that the formulation, adverti
sing and labelling of over-the-counter (OTC) drugs is
at great variance with the science of medicine. We
are approaching you with an appeal to immediately
put a stop to the irrationality of the drug companies
in the formulation and marketing of over-the counter
drugs. Some examples will illustrate our view point.
ANALGESICS
I. May we draw your attention to the study made
by Consumer Education and Research Centre1 and
earlier by Dr. A. R . Phadke2 on OTC analgesic com
binations? They have shown the unscientific character
of most of the OTC combination analgesics. Both the
studies are based on irrefutable authentic scientific
literature and we urge you to take early action in the
light of the analysis made in these two studies. For
example, we request you to ban all OTC combination
analgesics. Only single ingredient preparations con
taining either Aspirin or Paracetamol may be made
available as OTC analgesic/antipyretic drugs under
generic name. Brand names unnecessarily increase
prices. Since simple aspirin probably does not fetch
‘enough’ profit, drug companies may curtail its pro
duction if they are not allowed to mix other ingredi
ents with aspirin. We believe that it is government’s
fr?™ Lf°K V'dnyan Sanghatana, Maharastra to the
November Im" °fHea th and Dru8 Controller dated 26th
May we draw your attention to the recently pub
lished study by Mr Jain (M. Pharm.) and Mr Pramod Kulkarni (Management graduate) for CERC3?
The study analyses in detail the labelling done on
OTC analgesics and shows that the labelling is
grossly deficient. We request you to take an adequate
note of this study. We support their contention that
to protect the consumer from potential hazards of
OTC analgesics, rule 96 of the Drugs and Cosmetic
Rule 1945 be amended so that it becomes mandatory
for the manufacturers of these drugs to provide ade
quate information on indications, contra-indications,
side-effects, warnings, dosages and storage.
COLD REMEDIES
If. The study by Dr. A. R. Phadke mentioned
above also analyses the following OTC medical pro
ducts ■—■ cough and cold remedies, (Vicks, Glycodin
etc.), OTC tonics, breast-milk substitutes, other food
substitutes like Boumvita, Complan, GIucon-D etc.
All these products are widely advertised in the laymedia-newspapers and periodicals, radio, TV etc. In
the light of the analysis given by Dr. Phadke in this
paper, we request you to allow the production of only
those tonics and OTC cough and cold remedies that
are strictly in accordance with the Science of Pharma
cology. Producers of irrational formulations should
be asked to stop production of these drugs till they
reformulate their products on a scientific basis. For
example — Rubex and Vicks ointment contain six
ingredients each, out of which menthol alone has any
scientific value in the treatment of common cold. The
production of these ointments should not be conti
nued unless they are reformulated on a scientific'basis.
Dr. Phadke has shown how the advertisements
of these products are misleading. It is, therefore
necessary to pre-censor the advertisement of all these
OTC drugs on the lines suggested above
TONICS
III. As for tonics, most of the tonics advertised in
the lay press need reformulation. Totally useless ore
parations like Waterbury’s Compound ’(Red Lab D
and Gripe-water should be banned.
1
b ° }
s —itoi“ -S-i
muni-vitamin preparations __ rn ;In senous
•
ancjj
f
prolonged illness, when the patient’s metabolism con
tinues but there is grossly deficient intake of food and
hence vitamins (for example, in typhoid or chronic
malabsorption); (ii) During convalescence from such
illnesses — for the same reasons as above; (iii) when
specific deficiency disease is present —■ for example,
xerophthalmia, rickets etc.; (iv) as placebo, in a very
limited number of cases, and used with judicious dis
cretion. In all such situations, a doctor’s advice be
comes indispensible. Hence unlike in case of drugs
like aspirin, there is no genuine indication for selfmedication of multivitamin preparations.
It is estimated that out of a total Rs. 1200 crores
worth of drugs sold in India only about Rs. 350
crores are essential. The rest are fashionable, useless
preparations. We are alarmed at this unscientific
strategy in the drug industry and appeal to you to set
up a Committee to scrutinize scientifically all the drug
preparations available in the market. This committee
should have representatives from the consumer’s
movement and science movements.
We hope that you will give-due consideration to
the demands made above and take an early and effec
tive action .
We, therefore, demand that advertisements of
vitamin preparations should be allowed only in medical
literature and not in the lay media.
Expecting a positive response and thanking you,
Yours faithfully,
General Secretary & Member, Health Action Commitee
Many OTC drugs claimed to be Ayurvedic, are
available in the market. It is doubtful whether they
are really based on Ayurveda. Even to those, who
have not studied Ayurveda, it becomes obvious that
for these preparations, the claims made are too great
to be achieved. We demand a scientific scrutiny of
all these preparations and their marketing.
Lok Vidnyan Sanghatana
cc. The Drug Controller of India, New Delhi.
References :
FOOD SUBSTITUTES
1.
IV. Bournvita, Boost, Complan, Glucon-D ....
etc., are mere food substitutes and have no additional
medical advantage as compared to ordinary foods.
But their advertisements convey a wrong impression
that they are extra energy-givers.
These advertisements need to be precensored.
2.
3.
Advertisements of breast-milk substitutes and
weaning foods also carry a misleading impression.
Producers of breast-milk substitutes in India do not
as yet completely follow the International Code of
Marketing of Breast milk substitutes as approved by
the WHO.
4.
Pramod Kulkarni et al. Analgesic Combinations, a study
made for CERC, August 1983. Thakorebhai Desai Smarak
Bhavan, Near Law College, Ellisbridge, Ahmedabad 380006
AR Phadke. Scientific Scrutiny of some over-the-counter
drugs. Paper presented at the All India Seminar on‘-The
Drug Industry and the Indian People” held on 7-8 Nov
1981 at New Delhi.
Inadequecy of label information on OTC analgesics. Kishore Jain and Pramod Kulkarni, released by CERC. Nov.
1983.
Kamala Jaya Rao: Tonics—how much an economic waste,
mfc bulletin II, November 1976, p I.
Further Reading on
Drugs selected for All India Campaign
1. ‘The Clioquinol Controversy’;
2. Some painful facts about a painkiller;
3. Using Tetracyclines for children and pregnant
women;
4. Why not to prescribe anabolic steroids;
5. The case against EP Forte;
6. -Consumer alert on oxyphenbutazone and
phenylbutazone;
7. Hazardous, banned, bannable and dumped
drugs;
8. Scientific scrutiny of some over the counter
drugs;
9. Banned Brand List.
10. Why amidopyrines must go
Background papers available from:
Low Cost Drugs and Rational Therapeutics
Cell VHA1, C-14 Community Centre, SDA,
New Delhi 110016
Also mfc bulletins 11, 55, 60, 75, 77, 78, 81, 82
92 & 103. These are available with the Centre
for Education and Documentation, 3 Suleman
Chambers, 4 Battery Street, Bombay 400039.
The example of these OTC drugs/food substitutes
suggests that the production and marketing of drugs
in India contains a number of irrationalities. We,
therefore, feel that the overall drug policy of India
should be reformulated on a Scientific basis. Bangla
desh has shown us that this can be done. The Indian
drug industry is much stronger and mature. The AH
India Seminar held at New Delhi on “The Drug
Industry and the Indian People” therefore, after two
days of intense deliberations on 7th and 8th Novem
ber 1981, come to the conclusion that the Multina
tional drug companies can very well be nationalized
without causing any shortage of essential drugs. If
Bangladesh can implement a rational drug policy,
why can’t India do it?
The misuse of drugs cannot be curtailed, let
alone stopped, without an educated consumer. Wc
on our part have been trying to educate the consu
mers about this issue. We also have joined the
nation-wide campaign against the irrational production
and marketing strategy of drugs in India. As a science
organization, we are naturally concerned about unsci
entific drug preparations. But our strength is limited
and the misuse can be stopped only when the govern
ment takes appropriate steps.
5
Anabolic Steroids
Promoting whose Growth?
b. In April 1982, Ciba Geigy announced the
discontinuation of production and sale of Dianabol,
their anabolic steroid product. In 1983, a year after
the announcement, Dianabol was still available for
purchase in India, since there was no recall of stocks
from the distributors.
c. India has the largest number of brands of
anabolic steroids available — 30. In UK and USA
it is 6 and 4 respectively.
Anabolic steroids are synthetic derivatives of the
male sex hormone, testosterone. Testosterone has
both an androgenic effect ie., it is responsible for the
expression of the male characteristic in human beings
and an anabolic effect ie., it stimulates the overall
building up of body tissues such as muscles, bones and
blood. Synthetic derivatives with pronounced anabo
lic properties but relatively weak androgenic proper
ties have been developed in the belief that they could
induce body tissue building. However, the body build
ing effect of the drug can only occur when sufficient
nutrition is available at the same time. The most com
mon synthetic derivatives of testosterone are ethyloestrenol, methandienone, nandrolone, oxymethalone and
stanozolol. The anabolic steroid preparations in the
market are either single products or those combined
with vitamins and minerals.
Indications:
The indications provided by package inserts for
various brands include:
i.
Aplastic anaemia or other severe anaemias;
ii.
Osteoporosis (mainly senile and postmeno
pausal)
iii.
Pituitary dwarfism;
iv. Lack of/or reduced appetite (anorexia)
v.
Malnutrition, weight loss or poor weight gain
in children;
vi.
(chronic) wasting diseases (eg., malignancies,
kidney, liver disease and debility)
vii.
Convalescence (after surgery, infections, burns,
fractures);
viii.
Cytotoxic treatment, radio-therapy;
ix. (prolonged) corticoid therapy;
x.
Diabetes retinopathy (disease of retina due to
diabetes)
USE:
The indications are mainly treatment of senile
and post menopausal bone disorders and aplastic
anaemia. It is also used in children for certain growth
disorders but this can result in serious disturbances
on their growth and sexual development.
Some authorities doubt even the above uses.
AMA Drug evaluations: "objective evidence of im
provement in patients with senile or corticosteroidinduced osteoporosis has not been demonstrdbed”.
US-F.D.A.: “The anabolic steroid, nandrolone is effec
tive only for the management of anemia associated
with renal insufficiency, and all other indications lack
evidence of effectiveness."
Expert opinion:
Dr. A. Herxheimer, Clinical Pharamacologist,
the Editor of Drugs and Therapeutics Bulle,tin and
the Chairman of IOCU’s Health Work group has said
on anabolic steroids for malnutrition —
Adverse side effects:
The side effects are rather serious. Some of the
worst are:
(i) in women: irreversible symptoms of masculinisation such as deepening of the voice;
hirsutism and male pattern baldness.
(ii) in men: atrophy of the testicles, inhibition of
sperm development; and impotence.
(iii) in children: stunted growth due to the pre
mature closing of the epiphyses, the joints
between the growing ends of the bones;
subsequent infertility; in young girls, enlarge
ment of the clitoris; and in prepubertal boys,
precocious sexual development such as enlar
gement of the penis and increased frequency
of erection.
(iv) other side effects include: tumours of the
liver; jaundice; fluid retention; acne and
nausea.
“The special foolishness of using such a drug in
malnourished children is that these children need food
to grow. They don’t need hormones. They have their
own hormones and even if malnutrition means that
they don't have enough, then the way to get them well
is to feed them properly".
on the drug as an appetite stimulant —
“to stimulate appetite is irrelevant because the
cause of the decreased appetite has to be treated."
on the drug being marketed for increased growth —
‘Giving anabolic steroids will increase their
growth initially, but it will lead to premature cessation
of growth in the long bones of the limb so that the
size of the limbs will be smaller in the end, than it
would if the child grew more slowly and naturally."
Availability:
Case Studies:
a. In India anabolic steroids are officially to
be sold as prescription drugs but they are available
over the counter ie., without prescription.
(a)
6
Organon’s brands in India carry indications
for lack of appetite, poor weight gain and poor
growth, even listlessness and lack of energy-
Organon says that its Fertabolin ‘helps to gain
normal weight and height’ as well as ‘stimuates physiological appetite.’ Its promotional
literature pictures a happy looking well nou
rished boy.
(c) Not only are the drugs indicated for poor
appetite and malnutrition in children, they
are presented jn easy-to-take (drops, syrups)
palatable (fruit-flavoured) formulations.
(b)
—
aplastic anaemia and pure red-cell aplasia.’
Some Conclusions:
There is'no evidence that the lack of informa
tion or the misinformation has been due to
ignorance or oversight of the manufacturers.
The study indicates that it is a deliberate
practice of the manufacturers to distort and
suppress the information on their products in
the markets in the Third World.
(b) This incomplete or inaccurate information
seriously hampers the ‘benefit versus risk assess
ment’ that is required before the drug is used.
(c) Even though the promotional material direc
ted towards doctors and not medically ignorant
laymen, false claims abound and dangers are
suppressed. Marketing departments of multi
national drug manufacturers know that the
doctor is either too busy or not motivated
enough to check against independent authori
tative sources and that his first and main source
of information is usually the ‘medical repre
sentative’!
(d) The responsibility of providing accurate,
balanced, objective and complete information
on drugs is on the manufacturer of the pro
ducts. The governments are in the end res
ponsible for ensuring that the manufacturers
provide the necessary information and that it
is presented in a way that is intelligible to the
prescribers (for prescription drugs) or to con
sumers (for over the counter drugs).
(e) Anabolic steroids have no rational place in the
range of drugs necessary for use for the health
needs of third world couittries. They have un
certain therapeutic value and can cause serious
harm.
(NOTE: Anabolic steroids have been taken up in the
All India Drug campaign as one of those
requiring Consumer Doctor alert)
Source: Extracts from ‘Anabolic Steroids’, an inter
national survey on availability and marketing
by International Organization of Consumers
Unions, Region! Office for Asia and the
Pacific PO Box 1045, Penang, Malaysia.
(a)
Contra-indications and precautions:
These are — Pregnancy; Lactation; Cancer of
the prostate; Cancer of the breast in males; Cancer of
the breast in females; Kidney or liver disease (either
contraindicated or precautions to take); Caution in
children, skeletal maturation to be checked (x-ray)
periodically; Caution with clinical tests, Eg. glucose
tolerance test, liver function tests, etc., Caution in
combination with anti-coagulant therapy.
Many of these are not listed in the products in
India. In neighbouring countries, eg., package inserts
of Orabolin in Bangladesh states “explicitly no indi
cation in children” and Fertabolin in Phillipines
assures “in case the young ones take more than neces
sary, don’t worry — Fertabolin is completely safe”.
(It is small mercy that we in India are saved from
such blatant misinformation!).
Some package inserts made no reference to any
side effects, eg., in India, Adroyd (Parke Davis).
“The incidence of disease cannot be manipulated
and so increased sales volume must depend at least in
part on the use of drugs unrelated to their utility or
need or in other words, improperly prescribed. Human
frailty can be manipulated and exploited and this is
fertile ground for anyone who wishes to increase
profits”.
— Kefauver Committee Hearings on Drugs, USA.
Double Standards:
An examination of Ciba-Geigy’s Dianabol pac
kage inserts from India and from the USA tells the
same tale of double standards. The American Diana
bol package insert gives only one indication — quali
fied as ‘probably’ effective — for senile or postmeno
pausal osteoporosis. The Indian Dianabol package
insert, lists the following indications:
Available with: Low Cost Drugs & Rational
Therapeutics Cell, Voluntary Health Association of
India, C-14, Community Centre, SDA New Delhi110016.
‘As adjunctive therapy in the following condi
tions:
diseases with negative nitrogen balance
severe protein malnutrition (marasmus)
protracted convalescence following severe
infections, surgery (contributes to the normali
sation of tissue healing processes), and burns
chronic wasting diseases, cachexia
Await
Towards a People-Oriented Drug Policy —
Special Issue, (Oct-Nov 1984) of MEDICAL SER
VICE, the monthly journal of the Catholic Hospital
Association of India.
We are glad to inform you that the CHAI has
agreed to send all our subscribers this special issue. It
includes an A to Z of problem drugs, an A to Z of drug
policy issues and widening horizons — a reading list
among other articles.
teatmenT'svith cytotoxic agents and radio
therapy (to diminish their catabolic effects)
specific growth retardation in children (under
endocrinological supervision)
7
RN. 27565/76
mfc bulletin: NOVEMBER 1984
Regd. No. L/NP/KRNU/202
Drug Utilisation Survey Report
This survey was conducted by the National Ins
titute of Nutrition (NLN) in cooperation with the
Directorate of Drug Control Administration and AP
Chemists and Druggists Association, Hyderabad in
the twin cities of Hyderabad and Secunderabad cover
ing 10% of the 330 retail pharmaceutical shops.
Some of the findings of the survey are as follows:
self medication rate was an alarming 46%.
27% of the doctors’ prescriptions were for 3
to 4 drugs. Only 4.3% of prescriptions were
for more than 4 drugs.
— the maximum number of prescriptions were
for Nutritional Products (tonics, enzymatic
preparations and vitamins), then antiinfectives
(antibiotics and sulfas) and then analgesics.
— 58% of the self medicated drugs were schedule
‘L’ and ‘H’ drugs which cannot be sold with
out prescription , nor should be consumed
without medical supervision, because of the
associated major side effects and toxicity.
— amongst self administered drugs analgesics,
nutritional products and antibiotics topped
the list.
—
—
Analgesics, antipyretics and anti-inflammatory drugs
—
30.2% of the self prescribed analgesics, anti
pyretics and anti-inflammatory agents were
scheduled drugs. These were mainly analgin,
phenylbutazone (with or without corticoste
roids) and ibuprofen.
—-
an earlier survey by the CERC (Consumer
Education and Research Centre, Ahmedabad)
had shown that of 13 over-the-counter brands
of these drugs, 11 did not provide any infor
mation. The 44 doctors interviewed reported
seeing on an average 8 to- 10 cases of drug
poisoning per month.
Vitamins and Tonics:
—
only 31% persons surveyed had a correct
concept regarding nutritional supplements.
The majority held the erroneous view that
daily consumption of tonics was essential for
health. The credit for this false belief goes to
advertising pressure as well as doctors’ pres
cription practices.
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
editor :
ravi narayan
16% of the doctors had prescribed simulta
neously more than one vitamin preparation
having the same ingredients in various dosage
forms.
— iron deficiency anemia, B12 deficiency, were
the commonest deficiencies in the population
but sales of B Complex (Bl, B2, B6, B12)
combinations and other vitamins topped the
list of sales figures.
Antibiotics:
— over 30% of the doctors’ prescriptions con
tained antibiotics.
— approximately 12.8% of self-prescribed drugs
were antibiotics.
— most antibiotic prescriptions were for sulfa
and trimethoprim combinations, tetracyclines
and penicillin were the most popular self
prescribed drugs.
— 30% of the antibiotics purchased for self medi
cation were for less than a day. Only 18%
were purchased for a full course of five days.
Only 40% of prescriptions for antibiotics were
bought for five days.
The findings of the N1N and CERC surveys
indicate the urgent need for public education where
disease and drugs are concerned.
Source: The Drug Action network: Newsletter —
Jan. 1984
"
__
Kerala High Court Judgement on Ban of
Harmful drugs
“As between the lives of the citizens of this
country on the one hand and the loss that may result
to the manufacturers and traders by the immediate
ban on the manufacture and sale on the other, the
Government has chosen to view the latter as of more.
concern . . . While it is necessary that the manufac
turer and the trader must not lose in his industry or
business, the insurance against the loss should not be
at the cost of human life or human health ... It,
therefore, appears to us that the provision of a cut off
date for manufacture as well as sales is an irrational,
highly unjust, unfair and amoral approach adopted as
a result of distorted appreciation of values . . . .”
(Copies of the full text of the judgemertt) are available
from KSSP, Parishad Bhavan, Trivandrum, Kerala)
V16WS and opinions expressed in the bulletin are (hose of the authors and not necessarily
ot the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US S 6; Africa & Europe — US S 9; Canada & USA — US $ II
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560 034
Printed by Thelma Narayan at Pauline Printing Press, 44. Ulsoor Road. Bangalore-560042
Published by Thelma Narayanjfbr medico friend circle, 326, Vth Main 1st Block
Koramangala, Bangalore-560034
0\
medico friend
circle
bulletin
MAY
INJECTABLE
1985
COMTCACEPTiVES
Injectable contraceptives (ICs) have been on
the pharmaceutical map of the world since the ear
ly ‘sixties. Ever since then they have been at the
storm centre of a controversy that may well be the
longest ever on a medical issue. Two countries,
USA and UK have appointed public enquiry com
mittees on the matter.
In India, the ICs controversy was of largely
academic debate until about six months ago when
the government issued a directive permitting the
import of NET-EN, one of the ICs. Around the
same time it was also decided to introduce the IC
as one of the cafeteria methods offered in the govern
ment Family Planning Clinics.
The ICs controversy has raised some fundamen
tal issues — the manner in which decisions which
affect thousands of people are taken; the ethics of
medical research and control and the more funda
mental problem of appropriate animal models for
the testing of drugs. It also brings into focus once
again, the role of the multinational drug companies
in pushing potentially harmful drugs in the third
world with the active participation of the con
cerned governments.
ICs are hormonal contraceptives which may be
administered in the form of once in 60 or 84 day
injections. They are synthetic progestogens. The
two currently available ICs are Depot medroxyprogestogen acetate (brand name Depol Provera)
and Norethisterone enanthate or NET-EN (brand)
name Norigest) While they are both synthetic pro
gestogens they belong to
different
groups
of
steriods.
These synthetic progestagens
inhibit the production of gonadotropin which
in turn prevents ovulation. The endometrium
and the fallopian tubes are also perhaps affected
contributing to a reduction in fertility.
Depo Provera has currently been approved for
use in 84 countries whilst NET-EN is ‘registered’
for use in 25 countries but approved for use in 40.
It is neither registered nor used in UK or the US
(War on Want, 1984).
The Depo Provera Board of Inquiry in the US
has strongly recommended to the FDA that the
drug sould not be licensed as a contraceptive. In
UK however, the Board of Inquiry has cautiously
permitted the use of ICs in cases where other
methods are unsuitable. In India Depo Provera is
not allowed to be imported. However, it is not
banned dither.
Since Depo Provera has been in use much
longer, much more research material is available
on this than on NET-EN. Although they are diff
erent steriods, it is possible to examine some of
these findings with reference to
NET-EN.
Toxicological
studies
have
been
carried
out in accordance
with the requirements of
the US FDA. These results have been monitored by
the WHO Toxicological Review Panel periodically.
The drugs have been tested on rodents, beagle
dogs and rhesus monkeys. The Depo Provera ani
mal studies have come in for a lot of criticism. Ste
phen Minkin ia former Nutrition Chiief of the UNI
CEF project in Bangladesh
first
revealed
that Upjohn, Depo Provera’s manufacturer had not
in fact reported all t!he findings of their trial on
beagle dogs. The 7-year studies on beagle dogs had
INSIDE
Bhopal-Citizen’s responses
4
Dear Friend
5
Ganibi Hatao
6
</frrational Painkillers
6
Book Review
7
Keeping Track
7
=\zJ3rugs Alert
8
Depo Provera has been tried out in India, by
the ICMR, but reports have never been available.
There are two major NET-EN studies — both coordi
nated by the WHO. The first was a two-year multi
national comparative trial of three regimens of DP
given at 90 days interval, NET-EN at 60 d'a.y inter
vals, and 84 days interval. Over 3000 women parti
cipated in the trials which began with recruitments
in 1977 and the final follow-up in 1982 (WHO,
1983). The other multicentre trial was conducted
in India by the ICMR in 16 Human Reproduction
Research Centres. This study compared two regi
mens of NET-EN of one 200 mg injection at 60
days and 90 days. Over 2000 women, participated in
this study which ended its first phase in October
1983. (ICMR, undated).
shown that mammary gland nodules developed m
ad tnose animals which survived beyond the first
few year’s and some of these were malignant.
Another finding was acromegaly
or an abnormal
orowth process. Ten-year monkey studies have a so
been conducted using DP. Again mammary nodules
developed in the low-dose groups.
Endometrial
carcinoma was also observed in some of the mon
keys (WHO, 1982). Minkin further reports that
curvature of the spine was also, found in experi
mental animals, which is a possible indicator that
Depo Provera inhibits growth hormones.
The NET-EN studies have not however shown
the same results. The beagle dog studies have
shown that the drug may be inhibiting or affecting
carbohydrate metabolism. One case of endometrial
cancer was reported in the monkey studies. The
WHO Toxicology Review Panel, after a thorough ex
amination of the results came to the following
conclusions — (i) that beagle dogs were considered
an unsuitable toxicological model for the study of
progestogens; (ii) that the tumours in DP admini
stered monkeys arose from a cell type not found in
women and so could not be considered to indicate
increased risk for cancer. (WHO, 1982).
A common feature of both the studies is the
very high drop out rates, most of which were due to
menstrual irregulaities. In the 1977 WHO trial the
drop out rate per 100 women ranges from 59 to 89
and in the Indian study about 50 per 100. Menstrual
irregularities included amenorrhoea, excessive bleed
ing, and spotting. In the WHO study 40 percent of
the women suffered from! amenorrhoea of more than
90 days.
Late last year the USFDA’s Board of Inquiry
has categorically countered both these contentions
of the WHO Panel. It has stated that “Data from
the studies on the rhesus monkey and beagle dogs
cannot be dismissed as irrelevant to the humbn with
out conclusive evidence to the contrary. Such evi
dence is not available at this time. Therefore, the
fact that malignant neoplasias developed in two
species in target organs of sex steriods must be con
sidered as an indication of the potential of proges
togens, including DMPA, to promote the develop
ment of malignancies in target organs.” (Report of
Public Board of Inquiry, (1984) .
The 1982 WHO document has specifically
noted that menstrual irregularities are not likely
to- be a major health problem’. There is really no
scientific evidence to back this up! Very little is
known about the mechanism of bleeding disturbance
especially those related to steroid contraceptives
(WHO 1982). This being so, it is rather curious
(that the Indian decision to introduce the IC into
the family planning programme should have come
after the study results were known. One apparently
facetious argument that is being used is that since
Indian women are in any case anaemic, amfenorrhoea would in fact help them in the long run. A
similar argument is forwarded for another of the
side effects, weight gain. In the light of how
little is known about menstrual irregularities, such
If one were, to accept the WHO conclusions on
the unsuitability of beagle dogs as toxicological
models for progestogens, then obviously the animal
studies data becomes invalid. If this is so, on what
basis are human trials, which can only follow upon
animal trials, being conducted?.
mfc Anthologies
Human Trials
There
are
volumes of
literature
on
the Depo Provera human trials. One of the ‘pio
neers’ in the use of Depo Provera was E. MacDaniel
who tried out the drug on thousands of Thai women.
These studies have come in for a lot of criticism.
The US Board of Inquiry has stated that the data
on humans is insufficient and inadequate to either
confirm or refute the animal study results (Report
of Board of Inquiry. 1984.) It has pointed out that
in a.majority of the studies there were no controls,
nor is there sufficient background inforrrJation on
which one may decide on the possible carcinogenic
risk. Moreover the Thai trials have also been critici
sed on ethical '-rounds—‘informed consent’ was no
where practiced'.
We are sorry to inform our readers about
the unavoidable delay in the Printing of the
Hird anthology and the reprinting of the I
and II anthology.
Those who have sent us
pre-publication payment are requested to bear
with us. The pre-publication offer of Rs. 35/for the set of three anothologes is also being
extended till 30th of May 1985.
2
arguments coming from ‘experts’ in the field must
be roundly condemned as being thoroughly unscienti-
IC’s become part of the ‘cafeteria’ approach, in
formation will be at a greater premium because then
there will be no need to ‘persuade’ the subject so
'as to get a adequate sample for research. The
manner in which ICs have been introduced smacks
of indecent haste. For one thing, although the TCMR study was completed by October ‘83, no report
was forthcoming until recently. In fact the first
published article seems to have appeared not in an
ICMR publication but as an article in a specialised
journal to which few non-rcsearch oriented institu
tions have access—Contraception. It may of course
be argued that since there has never been a tradi
tion of debate on .scientific and medical issues in
the country, why should ICMR have acted any
differently. And that is in fact the major issue
here. — that people have a right to decide whether
or not they would like to take the risks, that are
today being thrust upon them.
It is also rather disturbing to note that a 24month study should be deemed sufficient to prove
the drug s safety when it is known to be a possible
carcinogen. Another area which has been ignored is
the possible teratogenic effects of ICs. The child
may be exposed to the drug if the mother’s pregn
ancy is undiagnosed when the contraceptive is ad
ministered .
Experts have stated that there is a positive
and significant association between progestins and
birth defects (War on Want, 1984). There have
been hardly any well-designed follow-up
of
children wiho might have been exposed to the drug.
Contraception failure may also lead to exposure of
the foetus to.progestogens. In the two studies cit
ed contraception failure occured in 0.4 to 1.4 wo
men per 100 women (WHO, 1983). While this
seems like a small proportion, the total numbers are
likely to be large when ICs are being given through
the family planning clinics. Another- factor to be
considered here is the effect of progestogen’s on
breast fed infants. According to the WHO report
a breast fed infant of a mother on NET-EN would
receive about 0.05 per cent of the maternal dose
over a two-m'onth interval. (WHO, 1982). It has
been reported that even this small amount may
prove harmful because (i) the brain is not fully
developed and is sensitive to hormones and (ii) the
immature liver and the consequent slower elimina
tion may lead to a high accumulation of the hor
mone in the blood. (War on Want, 1984). When
so 'little is known in this area, is it ethical to
introduce this contraceptive in the national family
planning programme.
Padma Prakash, Bombay.
REFERENCES:
The ICMR has outlined a set of guidelines for
family planning clinics regarding the use of ICs
(GOI, undated). These are very .similar to the WHO
guidelines and include criteria for selection, pre
examinations to exclude cancer of the breasts and
genital cancers, undiagnosed abnormal uterine bleed
ing and so on. Given the overcrowded understaffed
family planning clinics how much time would the
doctor be able to devote to the potential IC user.?
As reported earlier the government has now
allowed the import of NET-EN by private practi
tioners, nursing homes etc. And yet there is no
mechandsmi to ensure that the guidelines are follo
wed . Moreover, ICs have a great potential for
misuse. For .instance, in UK, women in some hos
pitals were refused rubella vaccine unless they ac
cepted DP (Campait'n against Depo Provera).
Closer home in Bhopal, women are not being allow
ed to have MTPs unless they accept copper T’s.
This perhaps is the most frightening aspect of the
whole situation. Women will loose whatever
little control they had over contraception. There
is plenty of evidence that even during the trial
phase, ‘informed consent’ was only a myth. When
1.
War on Want, Norethisterone enanthate, Dec.
1984. UK.
2.
WHO, Multinational comparative clinical Tri
als on Long-Acting Injectable Contraceptives:
NET-EN given in two dosage regimens and
Depot MedroXy Prorpsterone Acetate. Final
Report Contraception, July 1983.
3.
WHO, Facts about Injectable Contraceptives,
Memorandum from' a WHO meeting, Bulletin
of the WHO 60 (2) : 199-210 (1982).
4.
GOI, Guidelines for use of NET-EN, an Inje
ctable contraceptive for its use in Govt and nonGovt FP. Clinics, Undated 1984.
5.
Report of the Public Board of Enquiry on Depo
Provera, Weisz Chairperson, Ross GT and
Stolley PD. 1984 Oct.
6.
ICMR, Comparative Evaluation of contracep
tive efficacy of NET-EN (200 mg) injectable
contraceptive given every two or three months.
Mimeo, undated.
7.
Campaign against Depo Provera UK, 1984.
Placement
Available
We are looking for 'a Hindi speaking doctor to
help run a small rural health .project in Santhal
Parganas; Salary negotiable. Applicant please write
with details of qualification and experience to: M.
Ganeiili, PO Jagdishpur, Via Madhupur; Dist Depghar; Bihar 815353.
3
EohopaS => Citizens Responses
(a) A National Convention on ‘Lessons from Bhopal:
Environment, Science and Democratic Rights
in the context of the Role of Foreign Capital and
the Indian State” Was held on Feb 17-18 at Gandhi
Bhiavan, Bhopal. It was attended by more than 150
delegates belonging to about 65 organisations from
13 different states of the country and also by dele
gates from Afpanistan and Nepal. Copies of the
declaration made by the Convention are available
from: Rashtriya Abhiyan Samiti, Zahreeli Gas
K'and Sangharsh Morcha C/o Vibhuti Jha, Advocate
49 Shyamala Road, Bhopal 462002.
The mfc Bhopal intervention
(a)
(b) A National Campaign Committee (Rasht
riya Abhiyan Samiti) was formed at the above con
vention and had its first meeting on April 6-7, 1985
iat Bhopal. It decided to organize a mass rally
(hold a public meeting and present a memorandum
to the Prime Minister with signatures—target be
ing ten lakhs) at Delhi on June 5, 1985 which is
observed as world Environment Day. For a copy of
the memorandum, and further details of the national
committees, plan and suggestions for action, write
to the above address, (a)
(c)
(b)
Communication
strategy on Health Issues
A note on the need to evolve a communication
strategy on health issues following the Bhopal gas
tragedy hta been prepared and circulated to volun
tary agencies and citizens groups working in Bhopal
and the MP Government health authorities. This
note is available on request from the mfc office.
Bangalore. Thelma Narayan of mfc will be based
m Bhopal from 12 to 28 May 1985 to help evolve
such Lt communication strategy. Please send com
ments on the note, ideas suggestions to her C/o
Gandhi Bhavan, Shyamala Hills Near Polytechnic;
Bhopal 462002.
Bharat Vignan Kala Morcha
The Kerala Sastra Sahitya Parishad has organi
zed an All India Science through Art campaign,
covering 8000 kilometres in the month of May thro
ugh 100 places spread over Karnataka, Andhra
Pradesh, Madhya Pradesh, Maharashtra; Rajasthan
Uttar Pradesh and Delhi. This morcha is dedicated
to the memory of the brothers and sisters who lost
their life in the Bhopal genocide with a promise
to avenge their death. The route/dates in May 1985
of the Yatra are as follows: Bangalore (1-3), Harihar
;
(4)
Hubli (5-6); Sholapur (7); Pune (8-10); Secundertabad (11-14). Bhopal (14-18); Indore (18-19).
Ajmer (20-21); Jaipur (21-22); Delhi (22-29).
(c)
Study on Pregnancy outcome
A tentative plan for a study on ‘Pregnancy
Outcome’ to be undertaken in Bhopal in the second
week of June has been drawn up and preprations
ure on the anvil. Volunteers interested in participa
ting and readers/members interested in supporting
this study with ideas, suggestions and technical
information, please write to: S’atyamala, C-152MIG Flats, Saket, New Delhi- 110017.
(d) Eklavya has brought out a Bhopal—The
State of the Environment report on the 100th dav
of the gas tragedy (March 12, 1985), in English and
Bhopal Gas Tragedy'—Jan Vigyan Ka Saval — a
brochure in Hindi on their exhibition held in the
bastis. For further details/copies write to:
Eklavya, El/208, Arera Colony; Bhopal 462016
(e)
the mfc study report :
The report of the study undertaken by the
mfc team from 17-26 March 1985 has just been
consolidated at Baroda on 27-28 April and will be
ready for circulation by the end of May. The report
which probably will be among the first community
based epidemiological and socio-rr.edical surveys to
be released to the scientific community, press and
public will highlight the grave findings of the state
of health of the Bhopal gas victims three months
after the disaster. It will also contain a report on
peoples perception of health services, case studies
and biblio-Yaphy. For further information, write
to mfc office, Bangalore.
The JNU Study
An epidemiological 'and sociological study of
the Bhopal tragedy focussing on the size, distribu
tion and causes of the various health conditions
produced by the tragedy, and social and economic
profile of the victims was undertaken by the Centre
for Social Medicine and Community Health of JNU
in December- January 1984-85 and has been reported
in JNU News in April 1985
“No More Bhopals”—an exhibition
The Centre for Education and Documentation,
Bombay, along with a few friends has put together
a large exhibition to highlight the world’s worst
’industrial (accident in Bhopal. Two sets of 35
posters mounted on flat hard board are available:
one in Hindi and one in English. These two sets
are now circulating in India. All groups interested
in showing it may contact: CED 3 Suleman Ciiamber,
4 Battery Street, Behind Regal Cinema Bombay
400039 (telephone 2020019).
For further details and copies of the report,
write to:
D Banerji, Professor of the above
Centre, JNU New Delhi 110067.
4
y)
^Dear friend. . .
Drug Action Focus
4.
Annual Meet 1985 — Some reflections
This was the first mfc meet I attended. I am
very happy to have come. I am impressed and
encouraged to meet such a variety of people
who are committed to people especially the op
pressed and who are concerned about a change
in values — ,a change of society.
The meet was interesting, but a little too
packed; there was not enough time to meet
people individually (But in only 2 days it is
almost impossible)
Hilda Sina, Vagamon, Kerala.
2.
First let us say that the qualities, backgrounds,
achievements, activities, and aspirations of the
group in general were varied and exciting. It
is good that such different people can come to
gether with some hopes and interests in com
mon, and share and develop their ideas. Tire
•old’ group did not dominate the ‘new’ nor did
they show impatience nor intolerance with
the ‘new’. Even the long term mfc members
did not criticise each other in harsh terms
and showed mutual respect even in disagree
ment. This is amazing and highly commend
able.
Everyone seemed welcome to attend and parti
cipate. The attitude seemed to be that we
could all learn from each other.
Small group discussion followed by plenary
sessions were very good. A little more time
for informal meetings would have been nice.
It would have been nice to have all the back
ground papers before the meet because read
ing time was short once we arrived..
The meet served its main purpose for us in
meeting like minded medicos and non-medicos
alike from various parts of India.
Penny Dawson, Jamie Uhrig,
Mitraniketan, Kerala.
3.
I got to know quite a number of people with
whom I would never have come in contact otherwise.
It was quite informative except where people were
getting into unavoidable technicalities, which of
course were difficult to follow.
The time limitation was an inhibiting factor.
We had to skip quite a lot of things.
I was in the group discussing how to raise pub
lic awareness about TB. The ways that were dis
cussed were the ones that we had already discussed
in our SPACE meetings. Participants were trying
to express with their experiences why they oamc to
such conclusions. They were not allowed to tell their
experiences but what they had inferred from it—
of course due to lack of time.
Then some participants had a set of opinions
formed and they refused to come out their circle.
This led to heated arguments now and then.
On the whole it was nice.
—Malarvizhi, Madras.
1.
Instead of choosing new topics each time can
we h'ave a meet where we reanalyse some Past
issues and topics. There is a general feeling
amongst people that after discussions we do
not follow up on the topics anymore. Drugs
topic for example.
I think although the Drug Ac'ion Network is
working full time some of us in mfc feci side
lined now and find little or nothing to con
tribute Raising the issue in an annual meet
may turn out newer aspects of the problem.
I think that DAN is directing its efforts in the
wrong direction. Instead of pressing the drug
controller of India for action all of us should
conscientize undergraduates and upcoming do
ctors. Our fight should be at a lower level
rather than at the level of government policy.
This is my disillusionment with the DAN and
1 hope we can correct its course by ano her
discussion on the topic of drugs.
Vineet Nayar, Vellore.
Whither Company Doctor?
5.
The purpose of this letter is to motivate a
social scientist or a researcher to conduct a
study on the interaction between a worker and
the so called “company Doctor" I am sure that
the findings of such a study will be revealing.
Both public and private sector Industries em
ploy doctors on parttime or full time basis to
man their first aid centres, 'ambulance rooms,
dispensaries and hospitals, and these doctors
'are called “company Doctors”.
An observation made by me (over a period of
three decades) is that the workers look at the
company doctor with askance. He is consider
ed as a “management Agent” having no sym
pathy for the workers. The workers attribute
the following characteristics to the company
doctor.
1) He lacks human touch. He thinks that
workers FEIGN sickness.
2) His medical opinion and diagnosis are de
pendant on the instruction of the com
pany/management .
c) At the behest of the management, he goes
to the extent of certifying as “medically
unfit” even physically fit persons.
4) He asserts that working environment and
sanitation are the best available any
where.
In most cases where his opinion is contested
and referred to outside doctors and specialists,
he is proved wrong. In
* most of the court
cases, he is disbelieved and held to be biased.
I wish that there is a healthy debate and any
company doctor comes forward to assuage these
feelings of workers. It is observed that public
sector employees have better opinion about
their company doctors.
Yours
U.S. Venkatraman,
Bangalore
GAR9BI
Rational Drug Policy cell mfc
HATAO S
PRESS RELEASE
A move is on in India’s Planning Commis
sion to determine anew the parameters for defin
ing poverty.
The action was undertaken, reportedly,
after Prime Minister Indira Gandhi observed that
'she found a lot of bright faces in rural India,
which Was not reflected in current official statistics
showing that poverty in India is actually increas
ing.
The controversy actually started last year
after a cross-country walk-athon by Janata
Party President Chandra Shekhar, who said that
he was appalled to find the dehumanizing poverty
in which India’s masses were living 36 years after
independence.
UrrationaS Pain-Killers
Only 14 out of 59 analgesic preparations found
scientifically justified 1
Dr Jamie Uhrig and Dr. Penny Dawson of
Medico Friend Circle have analysed 59 preparations
listed as analgesics and antipyretics in the July5 84
issue of MIMS, India and found 45 of these 50 pre
parations to be irrational on some ground or the
other.
Basing themselves on the latest authentic
text-books, Dr. Uhrig and Dr. Dawson rigorously
studied each of these preparations and graded
them into the following categories :
A: Use of the product is justified-14 preparations
for example: Plain paracetamol, Aspirin etc..
B: The combination is not proven to be superior
to single ingredient preparation and hence
not recommended . . ........... 17 preparations.
For example — Equagesic, Malidens, Micro
pyrin, Optalindon .... etc
C: The combination has been proven to be in
ferior to single ingredient preparation and
should be withdrawn . .
11 preparations.
For example—Apidin, Carbutyl, Dolopar
Plus, Norgesic, Parvon—N, Parvon—P, Proxivon, Spasmo—proxivon, Sudhinol—N C....
etc.
D: The preparation contains analgin and should
be banned ........................... 17 preparations.
For example------ Codosic, Dolopar, Novalgin,
Ultragin, Sedyn—A forte, Spasmizol. . etc.
Drinking Water Data
Half of the country’s 576,000 villages still did
not have any drinking water facilities, Shekar said
after his 2,500-mile trek that took him through six
of India’s 22 states in six months.
According to official statistics, 339 million
of the total population of about 700 million were
below the poverty line defined as la daily 'mini
mum calorie intake of 2,400 per person in the ru
ral areas and 2,100 in the urban areas, or a $6.50
per capita' income a month in the rural areas and
$7.50 per capita income a month in the urban
areas
This means that 45 percent of the people still live
on a less than subsistence level. Of them, 272 mil
lion were in the rural areas and 67 million in the
unban .'areas, showing that large-scale poverty con
tinued in the villages.
We conratulate Dr. Uhrig/Dr. Dawson for
their spontaneous initiative in conducting this
study. This study is 'available with the Rational
Drug Policy Cell of M.F.C. at a cost-price of
Rs. 3/. Please write to:—Anant Phadke, 50, LIC
Quarters, University Road, PUNE—411 016.
Also available with tmfc office, Bangalore.
Officials Are Upset
These statistics and comments by Shekar
were not appreciated by the powers that be. They
felt, and some economists backed them that the
extent of poverty in the country was being exag
gerated and that undue publicity might hamper
foreign investment.
So a group in the Planning Commission ad
vocated a lowering of the cut-off point, thereby lift
ing a large segment of the people above the poverty
line.
According to views
expressed by some
members of this group, the actual calorie intake
for
Survival
was
actually
much
lower
One of them, Prof. P.V Sukhatme, contended that
the present cutoff point was the average. require
ment of a healthy 'and active .population and not
the minimum below which a person should be con
sidered undernourished. He suggested that a defined
lower end of the range of the energy intake of a
healthy individual be used as the cutoff point for
determining undemutrition and the poverty line.
from 339 million to 215 million and the midterm
appraisal contends that that the number has already
been cut to 282 million in the first two years of
the plan.
If these claims are indicative, all 339 million
can be expected to be lifted above the poverty line
by 1990 some economists said. And if the line itself
was amended, poverty itself could be expected to
be eradicated in India very soon.
Prof. C. Gopalan Director General, of the
Council of Medical Research, has disputed Prof.
Sukhatme’s claim and said that mean cialorie
intake of a community should continue to be the
dividing line of poverty. He hoped that the com
mission would not undertake such a deceptive short
cut to national prosperity considering the magni
tude of the problems of poverty.
Source:
INDIA ABROAD.
April 6, 1984.
Targets of Sixth Plan
The Sixth five year development plan (198085) target is to reduce those below the poverty line
6
Book
Xteping
BEHIND POVERTY, Djurfeldt and Lindberg,
Oxford & IBH Publishing Co., 1976 — Books 22 &
23 in Scandinavian Institute of Asian Studies Mono
graph Series.
Health Care in India seems to have few hard
cut opinions: this makes it easier to digest (but
far more boring) than Rakku’s Story. The latter
is a hard hitting (ie., unpleasant) view of the medi
cal system. It rejects the alternative approaches
usually suggested and so rejects their creators
(after all it is these people who might have pro
fited from reading Rakku’s Story).
(mfc Sources)
1.
When the Searh Began — Ulhas Jajoo
The story of a team of friends and their ex
periences in organising a Novel Health Insurance
Scheme among villagers in Maharashtra — the
lessons le'amt, the failures’, the perspectives
gained.
Mahatma Gandhi Institute of Medical Sciences
Sevagram — 442 102, Maharashtra (Rs. 5|—) .
2.
Futher, Rakku’s Story is too local in place as
well ‘as in time; it does not explore the broader
Tamil Nadu or Indian situation at all; no effort is
made to refer to the history of the area.
I agree that the people represented in the
book do not know 'history or a geography — politi
cal, economic or social. But changing the world
begins at this point, at this question: How, do we
in this historical and geographical situation relate
to other situations? For this is the beginning of the
next question: How can we change the present
situation?
Urach
Health Education Posters on Malnutrition
— Ulhas Jajoo
A set of xeroxed posters developed from the
experiences gained in the above project (1)
Mahatma Gandhi Institute of Medical Sciences
Sevagram — 442 102, Maharashtra (Rs35|- for
a set)
Minimum Wages — need for fair reward to labour
in Agriculture and Employment Guarantee
Scheme — Abhay Bang.
— An examination of the cost of production
of labour and new recomendation of what should
be appropriate minimum wages based on Calorie
and Protein requirements.
■—AcadarrJy of Gandhian Studies, 2-2-11334/5,
New
Nqllakunta,
Hyderabad — 500 004
(Rs. 2|-)
3.
Here one points to Djurfeldt & Lindberg’s
book Behind Poverty. The first section of this
study is devoted to filling in such background
material and, it is both specific to the area dis
cussed (Chingleput in 1969-70) and also related
to relevant parts of the broader situation unlike
Health Care in India which has a vague “wide”
background or Rakku’s Story, which has a super
“narrow” outlook.
Diarrhoea and ORT — Lalit Khanra
A discussion of the issues involved in the manage
ment of diarrhoea
and the rationale
of
oral-rehydration therapy for pro-fessional and
and community education (in Bengali)
Chandabrati, Tamluk Dist, Midnapore; West
Bengal — (Rs. 1|-)
4.
Studies like Behind Poverty (the social for
mation of a Tamil village) might be done for
other areas — North Arcot, Larkana, anywhere.
This study is useful to its immediate neighbours
and as a model for other areas to imitate. But
ready made analysis of tall India (without speci
fying how different various areas are) like Health
Care in India are prone to become “Bibles’
5. Diseases of Children (in Marathi)
— Bipin K. Parekh
A book for educating para-medical staff and
for child health education with 64 pages of line dra
wings from a total of 175 pages.
Mamata, Maniledar Malegaon — 423203 Dist
Nasik. (Rs.20/-)
Why don’t more people read their State Ga
zettes, State Histories and study local languages
as a background to NGO work in communities?
ANNOUNCEMENT
If you are prepared to launch a public ser
vice or development project, working full time and
develop this into a self sustaining, independent
innovative effort — contact Kishore Saint, Exe
cutive Director, The Ashoka Foundation 11—A,
Old Fatehpura, Udaipur. — 313 001 with introdu
ctory note, plans and brief biodata. The founda
tion wishes to support young enterprising persons
with strong social commitment in efforts express
ing creativity and initiative so thalt new solutions
to the myriad problems in our society may
emerge..
Pills Against Poverty — companion volume to
Behind Poverty — is a book by two Scandinavian
University Sociologists on the introduction of
Western Medicine in a Tamil village.
The name gives away the authors' views but
one hopes doctors will read Behind Poverty first,
however tempting the medical topic is.
Prabir, CMC, Vellore
7
mfc bulletin: MAY 1985
RN.27565/76
Regd. No. L/NP/KRNU/202
Drugs in Diarrhoea—A Question of Life & Death
Clioquinol & Antimotility Drugs—are they safe?
CLIOQUINOL
Medicines like Enteroquinol, Mexaform and
Enterovioform contain Clioquinol — the drug that
has resulted in thousands of cases of paralysis 'and
blindness due to Subacute Myelo Optic Neuropathy
(SMON).
SOME FACTS
1. In the thirties, when Ciba-Geigy intro
duced Clioquinol, the animal experiments had
shown the occurance of the same disorder of the
nervous system as was found later on in human
beings The company, in fact had warned the ve
terinarians not to use the drug in animals. But
this information was not passed to others
2.. . Even cases of SMON studied by doctors
on behalf of Ciba-Giegy have shown that the disease
is found all over the world and was not confined to
Japan Seven cases were reported from Bombay.
3. Clioquinol can also produce Optic atro
phy. The Indian' Opthalmogists do see cases of
Optic atrophy for which they fail to assign any
cause. When asked, if they took the history of
prolonged or repeated courses of Clioquinol taken
by these subjects, the answer was in negative.
4.
Now that Clioquinol is shown to be harm
ful to animals as well as human beings, why should
this drug be used when we have comparatively sa
fer alternatives like Metronidazole? Dr. Andrew
Herxheimer, editor of the reputed ‘Drug and The
rapeutics Bulletin’ told me that considering all the
factors like efficacy, safety and price; Metroni
dazole was definitely to be preferred and with the
present available evidence, Clioquinol should not
be marketed. (Incidentally he is aware of the sus
pected carcinogi'necity of
Metronidazole
in
mice)
5. After all the scientific evidence was pre
sented in the Japanese Courts, Ciba-Geigy render
ed an unqualified apology for the suffering that
Clioquinol caused and then decided to withdraw the
drug world-wide.
6
When Clioquinol is readily available,
even cases of watery diorrhoeas (which are mostly
due
to viruses) 'are treated by Clioquinol group
Editorial Committee :
kamala jayarao
anant phadee
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
of drugs. So it is 'better not to have such a drug
for which a safer alternative was available.
7.
Myself, a pediatric CdHea.ue and two very
busy general practitioners of Bombay have not used
Clioquinol for years and we are all quite happy
about it.
With my most sincere regards,
Yours sincerely,
Sd/—
Chairman, Medical Committee,
Consumer Guidance Society of India,
Ciba — Geigy Withdraws Tanderil
The multinational pharmaceutical firm CibaGeigy Pharma has announced the withdrlawal of the
drug Tanderil world-wide and restricted use of the
drug Butazolidin, the Voluntary Health Associa
tion of India said here today.
Tanderil was commonly prescribed for joint
pains While its sales will be discontinued by the
firm, it has announced that Butazolidin will be
restricted to the treatment of only four classical
forms of rheumatic diseases: 'active ankylosing spon
dylitis, acute gouty arthritis, active
rheumatoid
arthritis and (acute attacks of osteo arthritis. It is
to be recommended only for cases where other 'the
rapeutic measures have been tried and found un
satisfactory .
Dr. Mira Shiva, Coordinator, Low cost drugs
and Rational Therapeutics attached to the VolunHealth Association, snid the demand for sceeening
all the drugs in the market, with immediate with
drawal of the hazardous drugs cannot be emphasis
ed more. The basic expectations from the national
Drug Policy in' the offing were: (A) The withdra
wal of hazardous and irrational drugs: (B) Adequate
production, distribution, and availablity of essen
tial and life-saving drugs; (C) Availability of un
biased drug 'information for health personnel and
public and (D) Effective quality control and drug
control.
DECCAN HERALD
13th April 1985
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign; Sea Mail — US$4 for all countries
Air Mail : Asia — US$6; Africa & Europe — US $ 9; Canada & USA__USS 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block
Koramangala, Bangalore-560 034
medico friend
circle
bulletin
JUNE
47/1-
1985
EDITORIAL
THE
CHALLENGE
OF
BHOPAL
"The growing multinational culture must be destroyed because it leads to economic chaos, increased
social disparities, mass poverty and filthy affluence in coexistence, environmental degradation, and ultimately
civil strife and war.
To get a balanced, rational development and to preserve the environment, a new development process is
needed. The biggest intellectual and political challenge of our times is to articulate and demonstrate this
new kind of development."
— A statement of shared concern
Citizens report on state of India’s Environment, 1982.
Its six months since the worst industrial and
environmental disaster in recorded history. Bhopal
has not only been a nightmare for those who were
there on the night of 2/3 December, 1984. It is
also a portent of events to come.
World Environment Day (5th June) has
come and gone. There have been the usual meetings.
seminars and lectures, the usual lip-service to eco
logical sensitivity, the usual narrations of the
health and social hazards of environmental pollu
tion and the usual pious recommendations of what
c'an and should be done.
How many more Bhopals will we need in this
country before we are shaken from our apathy?
—from our callousness to our disadvantaged
:and exploited fellow human beings who are
always the worst hit in such disasters.
>—from our insensitivity to nature, our forests,
our rivers and our land.
—from our insensate rush for chemicalising and
technologising our lifestyles.
—from our race for profits even 'at the cost of
the health of our workers, our people.
The medical community in India will be
increasingly called upon to respond to the medical
aind health problems caused by more ecological
disasters. What will our response be?
Will we see every disaster as a chance to
refine our clinical skills, satisfy our charity and
■welfare urges, exploit the research potential for
career development and use the opportunity to ask
for more and more sophisticated gadgetry for our
institutions?
Or will we be challenged by these disasters
to riaise our voice collectively to oppose the unheal
thy trends in our society to use our knowledge
and social potential to support the growing aware
ness for a healthier and more egalitarian social
system; to use our research skills to strengthen and
concientise our fellow human beings to an increas
ing health 'and ecological awareness.
The dilemma of a man who enters a room
to find a tap running and a wash basin overflowing,
faces us today. Will we choose 'to be floor moppets
or tap turners off?
Overpowered, compromised and hypnotised
by ‘the products and high pressure sales tactics of
the multinational pharmaceutical industry, our sen
sitivities have been so dullened that we are quite
content to be merely - ‘floor moppens?. Can we ever
be tap-turners off? The International movement of
physicians for prevention of Nuclear war is a thou-
(Continued on
page 8)
INSIDE
Bhopal
The mfc study
2
The JNU study
3
The ‘Nagrik’ study
5
Mental Health?
5
Also
Nuclear reactor-an alert
x/Tood in the hands of Big business
6
7
The mfc study
The Bhopal disaster aftermath
— an epidemiological and medicosocial investigation.
Medical Monitoring of affected people
Community he'alth orientation of medical
relief centres.
vii)
Family based records.
— only this will meet the peoples needs and expec
tations.
v)
vi)
The medico friend circle survey team
which undertook an epidemiological and medico
social survey in Bhopal, of a randomly selected
community based sample of 60 families each of
J.P. N'agar (severely affected) and Anna Nagar
(minimally affected) trom 19th to 25th March 1985
has found that more than 100 days after the disa
ster the people affected by the toxic gas exposure
which included MIC suffer from a multisystemic
manifestations of physical
and
mental ill
health further compounded by psycho-social and
socio-economic family and community crisis.
2. A communication strategy which will include
a) A continuing education strategy for all he'alth
personnel working in gas-affected areas in go
vernment or voluntary agency clinics.
b) A creative non-formal health education of the
affected people in which available knowledge
of the disaster and its effects on health must
be translated into supportive interventions in
lives of the people.
Salient Findings
* A multidimensional1 symptomatology reflec
tive of pulmonary, gastrointestinal, neuro mus
cular and visual dysfunction
* Disturbances in vision particularly distant/near
vision problems
* Disturbance in menstrual function in women with
an increase in certain types of gynaecological
problems, as well as a disturbance in sexual
functions in male.
* An established effect on Lactation in nursing
mothers.
* A highly probable risk to> the child in i/bero.
* A large magnitude of psychic impairment
This str'ategy must be dynamic, responding
to new developments in the peoples health status as
well as to research findings as they become known.
3.
An integrated, community based, epidemiologically
sound, research endeavour.
This must shift focus from hospital or dis
pensary based samples to population based samples.
Epidemiological profiles of ill health and disabi
lity need to be built up using sodium thiosulphate and
other treatment not only as therapy but also
potent epidemiological tools through well designed
community based trials.
All 'the above ill health is within the
social context of a highly disadvantaged, low income
croup of b'as'ti-dwellers, whose earning capacity
has been further compromised due to loss of
wages; physical disability and mental stress affec
ting work performance; and who h'ave escalated
into an acute socio-economic crisis due to inadequate
compensation and greater indebtedness due to in
creased lo'an taking to avoid penury. Unless the
health of Bhopal victims is seen in this totality, one
cannot even begin to appreciate the true magnitude
of the human problem.
Urgent issues needing focus are risk to the
unborn foetus and risk to the reproductive system
of affected individuals. There is also urgent need
for informed consent 'as a minimum medical ethic.
Government — voluntary agency
collaboration
Closer coordination and encouragement
of active collaboration by government, ICMR and
local decision m'akers with voluntary agencies, citi
zens committes, action groups and socially sensi
tive sedtions of the medical and scientific commu
nity.
This coordination must be dynamic, open to
dialogue and debate, mutu'ally supportive and free
of suspicion.
4.
Recommendations
The relief and rehabilitation of the affected
population must therefore be through an integrated
community health and development plan which is
evolved by multidisciplinary interaction 'and close
collaboration between the government and non
government voluntary agencies and citizens groups
fully involving the affected community in planning,
decision m'aking, organising and maintenance of the
services.
The welfare and rehabilitation of the disaster
victims must be our primary concern.
(NOTE:—- The above is 'a synopsis of our
conclusions and recommendations which will be
'available as a printed report of the mfc study by
the middle of the month (cost Rs. 5/-). The report
■includes the detailed findings of the team; includ
ing tables; review of available literature on MIC
and details of ICMR and other studies in Bhop'al,
some observations on the psycho-social dimensions
of health; a review of the medical relief and reha-
We recomend,
I, A community oriented relief and rehabilitation strat
egy which must include
(i) Occupation/economic rehabilitation
(ii) Basic supplies till (i) is over
(iii) Psychosocial support
iv) Medical relief including detoxification
(Continued on page 3)
2
The JNU study
An Epidemiological and Sociological
Stody of the Bhopal Tragedy
— A Preliminary Communication, (Feb 1985) Debabar Benerji
Study of the immediate sequence of events
which culminated in the Bhopal Tragedy should
cover a very wide range of scientific investigation.
It becomes still more extensive when the immedi
ate causes are analysed against the background of
the wider issues of concern for protecion of people
against industrial hazards in India.
Non-availability of certain critical informa
tion concerning the poisoning and several other
hurdles created further problems. Quantity and the
rate of discharge of the “gas”, its chemical compo
sition, direction, and velocity of the wind and the
influence of physical behaviour of the discharged
“gas” on incidence, spread and virulence, are ex
amples of such critical information.
Clamping of virtual embargo on information
on these activities, mass exodus of the victims
before “Operation Faith”, invasion by lawyers and
touts and (an understandable) deep distrust of
the victims, have been other hurdles which came in
the way of conducting the study.
Demarcation of the affected population, their
stratification into most intensely affected (hi h
mortality), moderately affected (low mortality)
and others (no mortality) and their sub-stratifi
cation interms of mohallas w'as the first phase of
the study design. Each mohalla was taken as a
unit for applying the field work (observation) tech
nique to obtain data on the sequence of events.
With the observational data forming the back-drop,
quantitative data were obtained by administering a
semi-structured interview schedule to a random
sample of 6.66% (1 in 15) households in each
mohalla of the most intensely and the moderately
affected population. A study population of 68,000,
covering 29 mohalls (yeilding 700 households for
administering the schedule), was taken up.
Data from field work made it possible to
reconstruct the social, psychological 'atmosphere
among the population which had to take the brunt
of the poison gas. They were mostly very poor peo
ple steeping huddled together in their ramshackle
shanties in the winter night of December 2-3, 1984.
They were not told of the potential danger from the
Union Carbide Plant. They all insisted that they
were never told of the preventive measures to be
taken against any possible gas leakage. They did
not hear any alarm sinnal.
The immediate task before scientists in
India was to have an integrated approach to collec
tion of data. At the Centre of Social Medicine and
Community Health of Jawaharlal Nehru University
(CSMCH), we were particularly anxious to syn
chronise our own actions with other units within
wider organisations under the leadership of the
CS'IR. CSMCH had immediately got in touch with
ICMR to develop a joint approach to study the
problem. However, as time passed it was felt at
CSMCH that there were still considerable uncertain
ties about obtaining the vitally needed epidemiologi
cal and social science date through a joint study
with ICMR. As it was feared that valuable informat
will be lost if there was any further delay,
CSMCH took upon itself the task of collecting at
least some basic data. These included: (1) size and
distribution of the cases: (a) who were cured? (b)
who continue to suffer? (c) who have developed
complications? and, (d) who have died because of
the poisoning?
(2)
social-economic
background
of
the
victims;
(3)
ecological setting of the affected areas;
(4)
community organisation and power struc
ture;
(5)
pre-existing community perception and
knowledge about the hazards; and (6) com
munity response to the disaster
It was quite a challenging task to design and
conduct in a short time such a complex study.
(Continued on page 2)
bilition services being organised; and a study on
the peoples perception of these; the scientific con
troversy about the cyanogen pool and thiosulphate
treatment and our recommendations for relief, reha
bilitation, communication, research and Govt-NGO
collaboration. The report also features a reference
list of over 80 articles relevant to the Bhopal disa
ster. We release this report with the sincere hope
that it will support the affected people in their
demand for justice and meaningful relief and rehabi
litation.
Copies will be available on request from
mfc office in Bangalore & Pune; CEDS—Bombay-.
K.S.S.P. Trivandrum; VHAI, New Delhi; Gandhi
Bhavan, ZGKS Morcha office; Eklavya in Bhopal;
and S.H.R. Office, Bombay after 25th of June.
They were woken up with a sense of increa
singly intense feeling of irritation of the eyes and ac
companied with a most horrifying sense of suffo
cation The suddenness of the onslaught affecting
every person in the middle of the nkht, violent
cough and vomiting and purging and the atony of
suffocation and the psychological and physical im
pact of sudden blindness generated an atmosphere
of extreme panic. Even at a time when the very
survival of an individual was at stake, there were
numerous instances of efforts to come to the help
of the near and dear ones. But in the depth
that winter night, when a virtual panicky stampede
had already started in the neighbourhood, individ
uals were struck with a dreadful feeling of help
3
with large holes, proportion of kuccha houses.was
higher; proportions having a tap or an electrica
'connection was significantly lower While the
proportion of muslims among the dead was simi
lar to that in the overall population, the propor
tion of those belonging to the lower and backward
castes was significantly higher.
In all, 82 dead people and 5 lost cases, pre
sumed dead, were identified in the course of data
collection through the schedule. This amounts to
1305 dead in the population of 68,000. Amongst
87 dead or lost cases, males predaminate, accounting
for 52 (60 per cent) of them.
A very significant findin "■ in the analysis
was that this male predominance was almost ex
clusively accounted for by those falling within the
age ranee of 2 to 20. Why is it that in all the
age groups within 2-20 years, the males predominate
to such an extent? This needs very careful study.
In 49 households there was only one death per
household. There were two deaths in 11 house
holds, three deaths took place in four households
and only one household had four deaths
Even at the time of collection of the date
(January 6-15, 1985), 57 per cent of the victims
still complained of being il1.
21 per cent had decided not to run out. of
their houses and the percentage of the dead who
did not run is 25.42% 73 per cent cams out 'and ran
on foot; 6.3 per cent used some vehicle in trying
to get away. None of those who used a vehicle had
died, while 75 per cent of the dead were among
those who ran on foot.
40.2 per cent of the affected population
have been treated in hospitals,2.5 per cent in dis
pensaries, 25 per cent by reneral practitioners; 2\ 5
per cent by registered medical practioners (RMPs);
46 per cent in camps and 9.1 per cent in institu
tions outside Bhopal.
NOTE: The quantitative date presented above are
only tentative, based on hand tabulation of some
data. Furthur analysis is awaited.
lessness when they were themselves unable to see
anythin;?, coughing and vomiting violently and,
above all, gasping just to keep alive.
At a macro level it has been possible to
reconstruct the terror inspiring spectacle of the
Union Carbide Plant talcing the form of a real life
Frankensteinian Monster in the middle of the night
and literally fumigating tens of thousands of in
nocent human beings like rats and pests. It is a
devastating indictment of those who blindly wor
ship technology and industry and consider them
selves as liberators of mankind.
Following the now well established pattern
of tyranny of industry on the toiling masses, even
among the shanty dwellers, the weakest sections
suffered more because many were already handi
capped with pulmonary insufficiency (due to various
conditions) and poor oxygen capacity (due to anae
mia) . They had also to pay a heavier price because
the patched up planks, pieces of tin, elastic sheets
and thatch which formed the walls and roofs of
their pathetic hutments, left gaping holes for the
deadly gas to come within the grossly overcrowded
single “room”. When they found themselves getting
increasingly suffocated within their hutments, they
tried to run away in the open, often in the direction
of the wind carrying the gas. Men, women, children
ran till they fell down unconscious. Many were
trampled on in the stampede. There were no rescue
efforts till the day break.
As in any other city in the country, a large
number of homeless people lived in and around
the Bhopal Railway Station — transit passengers,
vagrants, destitutes 'and beggars. As they were
more exposed, the impact of the poison on them
was much greater — the deaths must have been
proportionately larger in their case. But there is no
record or estimates, of this.
As expected, the few rich, who came within
the central sweep of the fumigation, did not suffer
as much damage. They had the protection of their
well-built houses and healthier bodies and many
of them could escape the gas by using bicycles,
scooters, cars, jeeps, tempos or trucks.
More than half of the affected population
belong to a category which did not get two full
Imeals everyday all around the year. Only 10 per
cent of them could be considered well-off in the
sense that they do not have any problem in getting
two-full meals and have an income of, say. Rs 150
per head per month or more. Half of the houses
had holes in them which allowed in air from out
side in the winter. 70 per cent of the houses were
kuccha houses. Only 38 per cent had a tap and 60
per cent had an
electrical connection, 30 per
cent of them were muslims, 20 per cent belonred
to lower castes and 18 per cent to the backward
castes.
A remarkable feature of the socio-econo
profile. of the dead is that in terms of every crite
ria, tins group was even more disadvantaged than
the affected population. There were more poor
among the dead, 56 per cent of them lived in houses
MID-ANNUAL MEETING
The mid-annual EC/Core group meeting of
mfc will be held at Sainik Rest House, Patiala from
26th to 29th July 1985. At this meeting we will be
discussing the following:
1)
The role of mfc — Discussions will be based on
articles of Ashvin Patel and Anant Phadke fea
tured in mfc bulletin 100-1 in April — May 1984.
2)
The me intervention in Bhopal — an assess
ment and future strategy.
3)
Some case, studies will also be presented to
try and identify the focus of 'he next annual meet
on the theme. Occupational and ’ Environment
health.
. Detailed information and further background
is being sent to all invitess separately. In lieu of
the uncertainties of Punjab, alternative venues are
'also being explored. Delhi is a likely alternative.
4
The Bhopal Disaster:
Tho 'hLagrik' Stady
Effects on Mental Health
(Highlights of the survey conducted by the
Citizens Committee for Relief and Rehabilitation,
Bhopal, the Voluntary Health Association of India;
New Delhi and the Bhopal Relief Trust, Bombay).
‘Things can be so bad that to be sane is insane’
Nietzsche
The Bhopal disaSer Has once again brought
to the fore the phenomenons! psycho-social collec
tive stress that people can be subjected to by manimade or natural interventions in history. “The
psychologic’al phenomena of disasters are the con
sequences of the combined individual stress reac
tions and of reactions to changes in the social
milieu1. Hence the psychic distress and behavioural
disturbances of ’an indivdual cannot be fully under
stood or managed unless they are analysed as
—‘elements in the disruption of the equilibrium, of
a social system”. (1) The fourth Advisory meeting
on Mental Health (ICMR) December 121-14, 1984,
viewed the mental health needs of the affected popu
lation as follows: (3)
The acute needs are the understanding and
provision of care for confusional states, re'-ctive
psychoses, anxiety-depression reactions and grief
reactions.
Longterm needs arise from the following
areas, namely (1) Psychological reactions to acute
and chronic disabilities, (H) Psychological prob
lems of the exposed subjects (currently not affected)
to unoertainities of the future, (HI) effects of
the broken social units on children and adults, and
(iv) Psychologic's! problems related to rehabilita
tion”.
A mental health team from Lucknow com
prising psychiatrists', psychologists and psychiatric
social workers have been conducting regular out
patient services at a Government Polyclinic in
Bhopal and visiting 10 Government dispensaries in
rotation. The mental disorders seen are neurotic
depression, anxiety neurosis and hysteria. Psychotic
disorders are rare. There are plans to survey the
affected population for detecting and providing
Salient Findings
People living as far as 8 Km away from the
carbide factory have been affected by the MIC
gas.
* Of the 741 patients examined by the Survey
team, (104 to 109 days after disaster) it was
found that injury persisted in almost all the cases
in spite of the treatment that the victims had
received so far.
*
*
*
’
4
*
*
*
*
There was a high level of thiocyanate in the
sub-soil lakes and filtered water of Bhopal, even
more than 100 days after gas disaster
The blood of 'affected population showed that
their average thiocyanate level was three times
that of the average found in Bombay.
An unusually high number of women had abor
ted and were also complaining of unexpected
white discharge.
Clinical examination of expectant mother re
vealed that the development of the foetus has
been adversely affected
The vision of a large percentage of children had
been affected by MIC and a sizable num
ber of the affected people m'ay develop cataract
irrespective of their age. A large number of
people have refractive errors.
A good number of patients were found to be
having stomach and abdominal complaints.
The affected population mainfestcd neuro muscuweakness of an unknown nature.
The tragedy has also created excessive psycho
logical stress
Important Recommendations
(Continued on
Systematic follow up and monitoring of all affepeople for a minimum of three years.
* Every person in affected area to be X-rayed at
six monthly intervals for three yelars. to ensure
that further complications did not arise.
* All women who were pregnant at the time of,
the gas disaster and those who conceived sub
sequently should be carefully monitored. Modern
monitoring techniques like Ultra-Sonography
and aminocentesis should be used for the pur
pose. The parents must be 'advised about the
possibilities of abnormal babies, and should
be suitably conselled for continuation or termi
nation of pregnancy.
* Ophthalmic damps should be set up immediately
in the city for testing of vision and providing
spectacles.
* Affected people should be made to undergo
investigations like the electromyography (EMG)
*
page 8)
before and after exercise for both limb and
eye muscles.
* All babies born since December ‘84 have to be
monitured carefully for the growth and latent
abnormalities.
* Rehabilitation programmes will h!ave to be.
worked out after assessing the damage for
helping the victims to take up new jobs and
occupations in conformity with their disability.
* Potable water in Bhopal needs to be made
safe and there is urgent need to decontaminate
the water if the level of thiocy'anate was found
persisting.
Source:
Report of “Medical Survey on Bhopal Gas
Victims” released on May 2, 1985. Copies
available with Nagrik Rahat Aur Punarvas
Committee, 34 Ashiana Complex, Kohejiza,
Bhopal-462 001.
5
MojcOeaiir Reactors
An) A0®rt
environs of the present NFC site, since daily one
drum of waste is produced and the quantity is
likely to double. This hazard is particularly dange
rous since it gets carried through generations.
Nuclear reactors and fuel complexes are
increasingly becoming status symbols of moderni
sation. As an energy resource the government is
fast promoting their development all over the
country. In many countries their continued use
is beginning to be questioned in lieu of the potential
environmental hazards. We present here a letter to
the Prime Minister which was sent by- the Joint
Forum for Protection of the Environment, Hydera
bad in May 1982. This forum consists of the Hydera
bad branches of the Indian Women Scientists Asso
ciation, Forum for Science, Technology and Society
and the Society of Biolo ical chemists of India.
The letter brings out in graphic detail a real-life
case study of the potential hazard of such com
plexes.
“This letter is to share with you our serious
concern about what we have read, heard and seen
regarding the safety measures and methods of
disposing wastes at the Nuclear Fuel Complex
(NFC) in Hyderabad. The information contained in
this letter is based on a) recent visits by the mem
bers of our Forum to NFC, and the discussions held
with some senior officials of NFC regarding waste
disposal facilities, -and (b) feed-back from some
of the past and present employees of NFC, re arding in-house safety measures. We are convinced
that the situation as it stands -is alarming, and
likely to become disastrous if NFC goes ahead with
its plans to double the production under the exist
ing conditions. NFC is a high technology enterprise,
which handles vast amounts of toxic, mutagenic,
inflammable and radioactive materials. Thus it has
to be especially responsible in its material handl
ing and disposal, and in educating the workers re
garding the hazards involved and the care needed.
As a public sector enterprise, it should be a trend
setter in such matters.
Some of our findings of particular concern
are as follows:
3)
Disposal of non-radioactive wastes: Despite
the NFC’s claim that only non-pyretic materials
like magnesium chloride are dumped out, the
presence of inflammable materials like magnesium
and zirconium in these dumps appears to be true:
and the recent deaths due to burns in the area that
have been repored in the national press need no
reiteration here. In view of the ignorance and
poverty of the masses in India, extra precautions
and security -in disposal of such wastes is
essential. The disposal of extremely toxic metals
like arsenic and selenium produced in the special
materials-plant of the NFC is also not safely done.
4) Effluent treatment facilities: The sedimenta
tion tanks and evaporation ponds are poorly cons
tructed and lead to contamination due to spillage,
particularly in the monsoon season. The effluent
treatment facilities at the NFC appear to us
to be primitive and inefficient, considering the fact
that the NFC is a high-technology enterprise.
5) Hazards to school children in the area: Besides
the hazards mentioned above, we are also informed
that three children of rhe DAE Central School have
died in recent years of malignacies. It is impera
tive that routine screening and health, checking of
children be done by an independent body such as
the school health board doctors.
6) Workers’ safety: Apart from the environmental
hazards listed above, there seem to be inadequacies
in the safety measures in the in-house working of
the NFC, -posing health hazards to the workers
there. A few examples are: chlorine leakage in the
zirconium sponge plant; bursting of boiler pipes
(such as what happened on 26/3/82); exposure to
high temperatures near the chlorinating plant
(which might lead to conditions of “sub-fertility”
in men as suggested by the high rate of abort-ion
among their wives); high levels of alkali dust and
sulphur dioxide in the atmosphere around the zir
conium oxidation plant causing allergy and bron
chial problems; respiratory problems due to fumes
of oxides of nitrogen in the uranium oxide plant
where exhaust facilities are poor; provision of
poorly designed masks to workers in the rrinding,
blending and ammonium diuran’ate cake oven areas';
no masks in the wet areas where there are fumes of
nitrogen oxides. Rubber gloves are provided twice
a year only, and as a result the workers often have
to handle dangerous material with- tom gloves or
even bare hands. An instance was reported to us
where an officer allegedly handled uranium powder
with bare hands as an act of bravado, presumably
to convince the workers that the material they were
handling was not all that hazardous. This report, if
1)
Contamination of drinking water wells in the
area with nitrates and radioactive materials: This
is a problem that the NFC is aware of> the trend
already is alarming, and is bound to reach serious
proportions in the near future if no corrective mea
sures are taken. Also, the firm that buys the nit
rate-rich effluents from NFC, M/s. Deccan Nit
rates, does not handle them with the required care,
resulting in ground water pollution.
Burial of radioactive waste — Uranium: The
present containers used for the packing and burial
of the waste uranium are dangerous, since they
cannot withstand the environmental wear and tear.
There is every chance of the waste seeping into
the ground and entering the food chain. Though, al
pha rays are poor penetrators, they are extretnely
dangerous when ingested.
There also appears to be the eventual danger
of spreading this hazard to areas other than the
2)
(Continued on page 8)
6
Food in the Hands of Big Industry
ment which claims to improve the health and nutri
tion of millions of children through a nation-wide
network of 1CDS Programmes.
I do not know whether the Tatas are using
the national iodisation plants or whether their salt
production is in addition to that produced by the
public sector or whether those plants are now let to
lie idle. The point is, that a health programme, not
dependent on ‘drugs’, has passed into the private
sector.
That, however is not the end of my story.
Of the total common salt, or sodium chloride manu
factured, only a small amount goes for -human
consumption. Much of it is used for industrial
purposes. The Tata chemicals were perhaps already
-manufacturing common salt, and production of
iodised salt will be a very small -part of this ven
ture. However, for producing edible salt for iodisa
tion, they apparantly produce more salt than
needed for fortification. The Tatas are therefore
now marketing table, salt, at least in the cities
where table salt (powdered common salt) is mostly
used.
Hitherto, table salt was marketed by small
entrepreneurs. It Was
mostly pulverised crude.
salt. Tatas salt may be more refined. However, the
small industries will never be able to compete with
a big industrial house. By taking the lead from the
Tatas, if other chemical manufacturers also market
table salt, the small or cottage industries will have
to close their business. A year or two ago, Brooke
Bond, the famous Tea and Coffee House Started
marketing powdered spices like chilli, turmeric,
dhania etc. Once again, entry of a big industrial
house into the domain of cottage industries. Very
recently, in the South, another big company has
started marketing vadams (badis) and papads, in
fancy shapes and under very fancy- names
This then is a slow but steady entry of big
industry into that part of the processed food market,
which uptil now was entirely under cottage indus
tries. Although such cottage industries were in the
hands of middle classes, driving them out of busi-
Iodine — deficiency goitre is one of the
nutritional prolems that can be very easily con
trolled and prevented. This Was been -successfully
done in many European countries. In India, the
entire Sub-Himalayan belt comprising of Jammu
& Kashmir, Punjab, Haryana, H P; northern parts
of UP. Bihar and Bengal, the far-eastern States
and isolated pockets in Maharashtra and M P. are
endemic for goitre. In 1959, the government with
UNICEF aid set tip 12 iodisation plants to produce
iodised
salt
(Potassium
iodate
added
to
common
salt).
The salt
produced
was to
meet about 50% of the estimated needs and also
some of the needs of Nepal. However, and not sur
prisingly, even this simple programme of manufa
cture and distribution of the salt, suffered from
various defects. These were reviewed by Dr. Gopalan
under the title ‘The National i-oi-re Control Pro
gramme — A sad story’ (NFI Bull. July 1981).
About four years ago, at a seminar at the
N1N, we were informed that the government was
contemplating handing over the iodisation pro
gramme to the Tatas. In this matter, obviously the
govt, did not drag its feet and on my recent visit
to Delhi, I saw iodised salt in the market. Whether
handing over the production to the Tatas will solve
the goitre problem, is an entirely different matter.
I do not know whether Tatas will also handle the
distribution One of the reasons for the failure of
the National Programme was nonavailability of the
required number of railway wagons for the trans
portation of salt, and that the railways did not
provide covered wagons during the rains. How
will the Tatas solve this problem, and if distribu
tion is still in the hands of the government, then
what matters who produces the salt?
The Control Programme involved manufa
cture and distribution of the iodised -salt. Plants
for iodisation were set up with UNICEF aid and
we had all the technical know-how. Since it was
fortified common salt, the -house wife would use it
in cooking and there was not much nutrition educa
tion involved. The salt was to be sold in place of
ordinary cooking salt, therefore sale of ordinary
salt was to be banned. The extra cost of iodisation
was not to be borne by ths people but by the govt.
There the salt was to be sold at subsidised
cost. Perhaps, Tatas are now receiving th.? subsidy.
Whether administrative inefficiency alone was
responsible for handing over the production to the
Tatas or whether other factors weighed equally or
more, one will never know.
As Dr. Gopalan said
“administrative incompetence, lack of co-ordina
tion between various agencies involved, and Com
mercial and vested interests (emphasis mine) have
apparently combined to wreck the Programme.”
Although termed a National Programme it was natu
rally restricted to certain contiguous geographical
areas. Of couse, in a country of India’s dimensions.
even this area is sufficiently large. Nevertheless,
the Programme was a comparatively simple one.
But it failed and that too, in the hands of a govern
continued on page 8)
mfc needs you in Bhopal
Your support,
donations,
involvement;
volunteered presence and participation continue to
be required in Bhopal.
Ths tasks ahead.
— Organisation of Detoxification
clines and
trials through voluntary agencies.
— Pregnancy outcome study
—■ Developing content for Health education and
awareness building postsrs, pamphlets etc.,
•— and many other areas of action.
For further details write to mfc, Gandhi Bhavan,
(ne'ar -polytechnic), Shyamala Hills, Bhopal —
462 002 or to mfc, Bangalore office.
7
mfc bulletin: JUNE 1985
RN.27565/76
Effects on Mental Health
(Continued from page 5)
-supportive follow up for mental health problems in
adults, adolescents and children (2).
A team of psychiatrists from NIMHANS,
Bangalore 'Wave conducted training programmes in
mental health for the medical officers of the state
health services, posted in the gas affected areas.
Tht training provides the necessary skill to diag
nose and manage the common mental problems seen
in the victims of the gas exposure (2).
A mental health care manual has also been
prepared by the Bangalore team (3).
The mental helalth dimension is a much
neglected dimension of health inspite of the much
publicised WHO definition of health. Doctors in
Bhopal wera disregarding or misinterpreting the
symptoms of
stress
and
passing
it off
as malin ering or compensation, neurosis. This
mis-diagnosis was sadly reflective of our medical
training which plays only lip service to mental
he'alth inspite of its grave importance in health'
care and the doctor patient relation-ship.
We salute our community oriented Psychia
tric colleagues for bringing to the fore this much
neglected dimension through practical interventions
in supportive care, communication and training in
Bhopal and not exploiting the situation only for
its research potential.
1.
2.
3.
4.
Kinston, W and Rosser, R. (1974)
Disaster: Effects on Mental and Physical state, Journal of
Psychosom. Research 18. 437
Directorate of Information and Publicity, M.P. Govt (1985)
Review meeting of ICMR Projects at Bhopal, Khabar,
Sth May 1985.
Mental Health Care Manual for Medical Officers.
by R. Srinivas Murthy et al., National Institute of Mental
Health and Neuro Sciences, P.O. Box. 2900, Bangalore 560 029. (For copies of the manual write to Dr. R. Srinivas
Murthj at the above address)
Also available with mfc office a list of references on mental
health aspects of disasters.
The Challenge of Bhopal
(Continued from page 1)
ght provoking example showing that if we want ’
to, we can.
Bhopal too is a challenge? So are many- other
more insidous developments in our country. The
growing Investment in nuclear >— energy now dis
credited as an energy resource in the West, or the
gradual take over of the cottage industry in food
by big business, — bach of
this
though
different from the other has a growing similarity
representing either a subservience to the profit
motive or an insensitivity to health hazards or
Editorial Committee :
kamala jayarao
anant phadxe
padma prakash
ulhas jaju
dhniv mankad
abhay bang
editor:
ravi narayan
Regd. No. L/NP/KRNU/202
both. We feature some of these aspects in this
bulletin. We also feature investigations in Bhopal
which raise some of these issues’for our readership.
Minimata, Seveso, Long island were toodistant to make any impact. Amlai, Chembur, Handigodu, Harihar, Zuari, Nagda, Mavoor, Silent vally,
Thai vaishet hare not stimulated us either. Will
Bhopal do so?
Nuclear Hazards
(Continued from page 6)
true, is truly shocking.
7)
Functioning of the health physics unit: The
health physics unit that monitors radioactivity and
oher environmental pollution in the NFC should be
under an independent agency not answerable to NFC
or the BARC. The alleged victimisation of a scien
tist of the health physics unit who did try to raise
his voice about some of the environmental issues.
(if correct) is a matter of deep concern.
In conclusion we. suggest that an independent
panel of experts and concerned ctizens be invited
to make an indepth, impartial inquiry, and review
ths situation in its totality (rather than isola
ted accidents) and suggest immediate remedial
measures. In this regard our Forum will be willing
to offer Whatever help it can.”
(Some action towards improvement has taken
place in response to this letter. For instance the
Nuclear Fuel Complex has been brought under the
Pollution
Control
Board
and they
have
to
obtain
consent
from
the
Pollution
Control Board before discharge of the efflu
ents. They have built a compound wall to
improve security. Their sedimentation ponds have
been lined with some kind of plastic material to
prevent seepage. Several shortcomings still need to
be reexamined.)
Will citizen’s groups keep up the pressure
please! This is particularly urgent since a recent
government decision will promote their installation
all over the country in our attempt to prepare our
selves for the ‘quantum
*
jump
into the
21s Century. The movement against the prevention
of Nuclear War is not enough!!
(see mfeb 102)
(Continued from page 7)
ness in this manner, will not help the poor but only
expand the ranks of the poor. I am not an econo
mist. I do not understand the full implications
and the reasons for big industry entering into the
small-chain food market, but to me the consequen
ces appear alarming.
— K. S. Jayarao, Hyderabad
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
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Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560 034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
116-7
medico friend
circle
bulletin
AUGUST—SEPTEMBER
PUBLIC HEALTH,
1985
POVERTY, AMD EMPOWERMENT
— A CHALLENGE **•
David Werner •*
In today’s world the biggest obstacles to ‘health
for all,’ are nor technical; but rather social and politi
cal. Widespread hunger and poor health do not
result from total scarcity of resources, or from over
population, as was once thought. Rather, they re
sult from unfair distribution, of land, resources,
knowledge, and power—too much in the hands of
too few. Or, as Mahatma Gandhi put it: There is
enough for everyone’s need but not for everyones’
gre,ed.
It is often argued that the major obstacles to
health are economic. And true, for most of the
world’s people, the underlying cause of poor health
is poverty—poverty and their powerlessness to do
anything about it. Yet, the economic resources to
do anything about it do exist. Unfortunately con
trol over those resources is in the hands of local,
national and world leaders whose first priority, too
often, is not the well-being of all the people, but
rather the quest to stay in power
We are all aware of the, health related inequi
ties that result in millions of premature deaths
every year. 1 in 2 of the world’s people never in
their lives see a trained health worker. 1 in 3 are
without clean water to drink. 1 in 4 of the world’s
children are malnourished Etc.
It has been estimated that to provide adequate
primary health care for all the world’s people
would cost an extra $50 billion a year—an amount
equal to world military spending every three weeks.
So we can see that the underlying obstacles to
primary health care are not really economic, but
rather political.
•
Convocation address, Johns Hopkins School of Public
Health, 1985
*• The Hesperian Foundation, PO Box 1692, Palo Alto,
CA 94302
The politics of health and health care are
fraught with contradictions. Just as an example,
look at smoking. The governments of overdeveloped
countries now warn their people that “Cigarette
smoking is dangerous to your health.” Yet these
same governments, while cutting back on health bene
fits to the poor, continue to subsidize the tobacco
industry with millions of dollars. And since fewer
people in the rich countries now smoke, the big
tobacco companies have bolstered their sales cam
paigns in the Third World, where the growing epide
mic of smoking now contributes to more deaths
than do most tropical diseases1The subsidizing of the tobacco industry is
but one of many, many ways in which attempts at
public health are dissipated by governments that
try to stay in power by catering to the interests of
the powerful. The United States of America, as one
of the world’s wealthiest and strongest nations,
has consistently made international decisions which
favour the rich and powerful at the expense of the
health and well being of the poor majority. Its
opposition to the United Nations mandate opposing
the unethical promotion, of infant milk products
is a good example. It is interesting to note that in
the long run, the grassroots, popular boycott
of Nestle's and other multinationals, did more to
bring the milk companies into line than did all
the mandates from the United Nations.
An equally blatant example of how US foreign,
policy is prepared to obstruct a poor nation’s health
INSIDE
Dear Friend
4
Reporting from Patiala
5
Developing Standard Treatments
7
Editorial
8
tions have recently taken place or are in process.
New governments with wide popular support have
«onei about redistributing resources and extending
primary health services fairly to all the people.
However, the powerful nations of the world, for
Ithe same reasons they oppose the UN decree on
infant milk products, or the Bangladeshi govern
ment’s new drug policy, consistently violate inter
national and humanitarian codes in order to try to
destory the revolutionary governments that have
dared to side with the people.
in order'to protect powerful economic interests is
seen by its reaction to the Bangladesh Health Mini
stry’s new drug policy. As we all know, overuse
and misuse of medications in the world today has
reached epidemic proportions. In. poor countries,
upto 50% of the health budgets are spent on impor
ted drugs. Of the 25,000 different medications now
being .promoted, only about 250 are. ranked as ess
ential by the World Health Organization. Yet the
' drug companies promote their products in the poor
countries with a vengence. The information they
publish about their products in these countries is
'often dangerously falsified. In many poor coun
tries, the drug companies spend more on brainwash
ing and misleading the doctors than the medical
schools spend on educating them. The companies
repeatedly and illegally pay Ministers of Health
under the table to keep on utilizing pharmaceuticals
that have been banned in developed countries and
dumped on the Third World. All in all, the. abuses
and false promotion of needless, costly, and irratio
nally combined medications have’ reached alarming
and health threatening proportions, particularly in
the Third World. When the Bangladeshi government,
recognizing serious shortages in 150 essential drugs,
passed a decree that banned the import of 1,700
non-essential preparations, the multinational drug
companies did everything in their power to make
the Bangladesh government annul the
decree1.
After all, if a poor country like Bangladesh can
take a stand against the multi-nationals in favor
of its people’s health, might not other nations follow
the example? So the multi-nationals began to make
threats Factories would be closed. Foreign com
panies would pull out. Workers would be fired.
Acute shortages of essential drugs would result.
The future of foreign investment in Bangladesh
would be in jeopardy. Representatives from the
US government not only refused to support Bangla
desh's new drug policy, they threatened to reduce
or discontinue foreign aid if it were upheld
Yet the peoples of the world, little by little.
are beginning to awaken, to join together to prot
est the exploits of the powerful, and the injustice
which damages their health.
We ar,e on the edge of a worldwide movement,
led by the poor and oppressed, in defense of their
rights to a fair share of what the world provides.
Health for all can only be achieved through a struggle
for social equity—a struggle led, not by those on
top. but by those on the botton, by the people
themselves.
Given the fundamentally political nature of
hpalth, what are you going to do in public health?
If what you are looking for is simply a well
paid respectable job, you should have no problem.
But if you honestly want to help those in greatest
need gain the strength and ability to improve their
health, and their lives in a lasting way, then your
future is less certain, and—depending on which
country you go to — perhaps unsafe.
You may try to stay out of politics, to work
within the realm of public health in the narrower,
more conventional sense. Baby weighing, latrines,
dark green leafy vegetables. MCH; CRT; GOBI
and all that.
As has been demonstrated in China, Cuba,
Nicaragua, Kerala State of 'India, and elsewhere,
the health of a nation’s people has more to do with
fair distribution of resources than with total wealth.
Fair distribution, in turn, depends upon egalitarian
government. What it comes down to is that the
health of the poor in the world today is abysmal
because too many governments are in the hands
of powerful, elite groups, or military juntas? that
do not fairly represent their people. Clearly, what
is needed is radical change, of governments and
social structures. Those who rule the world today
will not bring about the changes that are needed
for the well-being of the people. They have too
much self-interest in maintaining the status quo.
The changes can only come about through organi
zed action of the people themselves. In most coun
tries' today, primary health care implies a very
fundamental; social evolution)—if not revolution.
In several countries today,
But be careful even with, the best intentions,
you can easily end up doing more harm than good.
Health work is never apolitical. Either it is done in
ways that try to keep people under control, organi
zationally disabled, overly dependant on centraliz
ed,
institutionalized
overprof-essionalized vet
inadequate services.
Thus, health care can be either people em
powering in the sense that it gives people greater
control over the factors that influence their healtli
and their lives; as well as greater leverage over pub
lic institutions and leaders. Or it can be people
disempowering, in so far as it is used by the authori
ties as an instrument of social control. People em
powering health care utilizes health education, not
> to change people’s attitudes and behaviour, but
rather to help people to change their situation.
Or, as Pablo Friere would say it, to change their
world.
.popular revolu
2
1 would like to look with' you at just one Issue
in .public health, which will perhaps make you reflect
on the political implications even in areas that at
first glance seem non-political.
Or it can also be made building on local customs,
by using rice water, soups, or mild herbal teas..
The relative advantages and disadvantages of
packets versus home-mix have been much debated.
Studies show that their safety and effectiveness is
roughly the) same—-provided that the packets are
available when needed, which often they are not.
The area I refer to is ORT, Oral Rehydration
Therapy. (Personally, I prerer to call it RLL or
Return-of-Diquid-Lost. This is because most of
the world’s people have limited schooling and may
not understand words like ‘oral’, or rehydration, or
therapy. I think the first step towards putting
health into people’s hands is to simplify our langu
age. Besides, RLL—“The Return of Liquid Lost”
sounds friendlier and more poetic.)
Politically, however, the two
methods are
diametrically opposite. The use of packets keeps
the control of diarrhoea medicalized, institutiona
lised; mystified;, and dependency — creating. In
order to rehydrate a baby with diarrhoea; the family
has to depend on a magical, often imported, ‘medi
cine’ that involves a whole chain of commercial
international, governmental; bureaucratic;, profes
sional, and distributional links. If any link of the
chain fails, the supply of packets stops. Or if peo
ple in the countryside begin to stand up for their
rights, the supply of packets stops. Thus; control
ol the most common, most fatal, most easily c i co.
health problem is taken out of the people’s hands.
Poor families are made to look to government for
help, and be grateful for small, lifesaving handouts.
I am sure that, in your public health program,
you have studied the various alternative approaches
to oral rehydration in depth, weighing their com
parative advantages and disadvantages. I wonder,
however, how much you have looked at the political
implications of the, different alternatives which
are
people
empowering,
and
which
are
are dependency-creating. For surely the ‘empower
ment factor’ should always be a key consideration
when evaluating the long-term implications of any
health care alternatives.
The use of the home-mix has just the opposite
effect of the packet. It is a de-mystified and de-my
stifying approach that is independent of outside re
sources, except for an initial educational component.
It helps people realize that with a little know
ledge and no magic medicine whatever, they can
save their children from a powerful enemy, without
being beholden to anyone . Thus the home-mix helps
to liberate people from unnecessary dependency
and to build people’s self-confidence in their own
ability to solve the problems that limit their
well-being.
As we all know, when a'child has diarrhoea,
the Return-of-Liquid-Lost can be lifesaving. In so
far as diarrhoea is the number one cause of death
in children in the world today, oral rehydration is
one of the most important health, measures that
mothers, fathers, children; school teachers; and
health professionals can learn. Its potential impact
on people's health—and on people’s confidence to
cope for themselves with one of the world’s biggest
killers—is tremendous. It is safe to say that if
school children could learn how to prepare and
give! the “special drink” to their younger brothers
and sisters with diarrhoea, then the world’s children
could have a bigger impact on lowering child morta
lity than do all the doctors and nurses on earth.
It is no surprise then, that around the world
small community-directed programs committed to
basic rights consistently choose the home-mix.
Nor is it a surprise that WHO, most health ministrids, and other large national and international
agencies are “packeteers. ”
As you are well aware, there are two main ap
proaches to oral-rehydration therapy: “packets”
and “home mix”.
Oral rehydration is but one of many hotly
debated health issues, which will concern you in
the practice of public health. When you are faced
with making decisions or giving advice as to alter
native approaches, always remember to look at the
political implications. Approaches which are people
empowering, even if they seem to take longer or;.
to involve a greater element of risk or uncertainty,
in the long run may do more towards bringing about
a Healthier, more equitable society, than other
methods which appear to be safer, more predictable,
more measurable, or more easily administered.
Packets—or “sachets” as they w.ere called by
the experts until somebody discovered that not
even college graduates understood that word—are
prepackaged envelopes or sugar and salts for mixing
with a liter of water. Packets are mostly produced
in millions by multi-national companies under
contract to organizations like WHO, UNICEF, and
USAID. They are usually distributed through regi
onal offices to health ministries, clinics, ORT cen
tres, and — finally — to mothers when their chil
dren get diarrhoea.
The home mix, on the other hand, is prepared
completely in the home, using local ingredients
and traditional measuring methods in order to mix
water with the indicated amounts of sugar and salt.
One thing I think is clear: That health for all
will only come about through a restructuring of
Continued on page 6
3
Dear Jriend
Injectable contraceptires
I went through the leading article published
in the May Issue (NO. 113, May 1985) with deep
interest. Padma Prakash has done an excellent re
view and it needs to be appreciated. In this regard,
I would like to add the following.
As far as the results Of animal experiments
are concerned it is unequivocally accepted that they
are poor substitute for the pathophysiological
mechanisms operative in human beings and, there
fore, the results obtained should be applied to hu
man beings with caution. Therefore, now the situa
tion is that animal models for studying efficiency
and/or toxicity of a given drug is not considered
to be an absolute finding unless other evidences
point to their authenticity. In case of testing of
medroxyprogesterone acetate (Depo provera) the
incidences' of increased breast cancers in Beagle
dog model has been rejected by majority of the
experts working in the field of contraception.
The only progestagen contraceptives (Depo
'Provera and NET-EN) are new drugs and at pre
sent data are not sufficient to point out any specific
contraindications to these drugs. The majority of
side effects listed are those extrapolated from those
observed after using combination contraceptives
which have doses of ingredients far exceeding those
required for the contraception and therefore, fihose
data are not quite acceptable in this context.
In case of depo provera the human experimenta
tion were undertaken only after realisation that
this and similar other contraceptives lacked any
other serious side effects and therefore merit a
human trial. In addition long before depo provera
was tried as contraceptive, it was in use to treat
endometrial cancer and precocious puberty in fe
males at a very high dose without causing any ad
verse effect—Muiticentric trial of this drug over a
period of few years since then has substantiated
the above view. The only side effects — causing
concern were high incidence of amenorrhoea which
was reversible on stopping rhe treatment’.
Recently a study of depo provera carried out
in Chile from 1974 to 1977 directed towards the
adverse effects on children brought out the follow
ing interesting points:
(1) Depo provera treated mothers lactated
longer in comparison to those not using
any
contraceptives or using mechanical devices.
2)
There was no difference in the develop
mental aspects of children born of mothers using
depo-provera and those born of motehrs not using
any contraceptives.
(3) The morbidity findings, health status and
results of physical examinations of the children
born of two groups of mothers were comparable
over this period. Therefore it appears that inject
able contraceptives do not exert any adverse effect,
atleast during early years of development.
The ICMR has also published its results of
long trials and they are similar to the above men
tioned results. Apart from menstrual irregularities
they did not detect any ether abnormalities attribu
table to the drug use.
Though the new generation of oral countracep- •
fives due "to very low hormonal content have shown
a drastic reduction in adverse effects listed in text
books, this can not be considered as an ideal as
the risks still exists. However, only progestogen
contraceptives have been devoid of such side effects
and are certainly preferable over combination con
traceptives.
Recently a study of intrauterine device use has
found that incidences of salpingitis' and secondary
infertility is 2-3 times greater in those using them
in comparison to those not using any device.
Therefore from above evidence it appears
that injectable contraceptives are comparable to
those methods of contraception currently in use
and there is not sufficient evidence to discourage
their use when contraception is necessary to con
trol. population explosion. On the above basis
W.H.O. has listed. Depo proyera as one of the
essential drugs.
I am of opinion that apart from the moral ob
jections and objections over its misuse, depo pro
vera and NET — EN remain the best of all contr
aceptives in present use.
i—A. M. Jha, Bombay.
References: 1) Jimenez J, Ochoa M, Soler M.P.
and Forties P. (1984) Contraception Vol. 30, No.6
P.323.
2) Dalinc J. R. etal. (1985) N. Eng. J. Med.
Vol. 3121 (No. 15). P. 937.
3) Cancer D W etal (1985) ibid p 941.
From the mfc Bangalore office :
1.
2.
3.
Anthology I (In Search of Diagnosis) and Antho
logy II (Health Care Which Way to Go) are
reprinted and ready for despatch. The price
is Rs. 12.00 and Rs. 15.00 respectively.
Copies also available with the VHAI Publica
tion Section, C-14 Community Centre, SDA;
New Delhi 110016.
Anthology III (Under the Lens—Health and
Medicine) is on its last lap in the press. It
will be ready for despatch in
September.
Rs. 15.00.'
We apologise for the delay in printing the
Bhopal Study report. It is now in. press in
Banr.alore and will be released in a few weeks.
A summarised version in English and a lay
version in, Hindi are also on the anvil.
The core group of medico friend circle met in
Patiala from 25th to 28th July 1985 to discuss the
role of mfc in general, our intervention in Bhopal
in particular and take other organizational deci
sions on the agenda. Our hosts were Amar and his
friends of the People's Health Group
tion and Bhopal an overall consensus has been emer
ging; (vii) The articles in the bulletin, are mainly indi
vidual views and readers/members are welcomed
to make their own decisions;
(viii) There are no full timers in the organisa
tion and contact making with potential members/
subscribers is adhoc and mostly through the bulletin.
Alternatives/Possibilities : Role of mfc
e
A wide range of roles were considered during
the discussion, (i) Critical evaluation and analysis
of national health programmes and health care ap
proaches; (ii) Evolving/evaluating
alternative
health care strategies at field level; (iii) Acting
as a forum for raising health issues and organising
campaigns; (iv) monitoring
heSlth policies
and playing a watch-dog role; (v) Influencing health
policies by lobbying and legal action; (vi) Medical
activism which would include organising people
around health issues; (viii) Investigative research
with a critical social perspective; (viii) Documen
tation, collection, review and dissemination; (ix)
Partic'ipating/linking with other groups in a health
action network: (x) Consultancy/support work
for community health projects; (xi) Organising field
orientation for medicos and others to sensitise them
to broader social issues in health (xii) Building stron
ger links With members through sharing of experi
ences and evolving common perspectives.
From ‘thought current’ to action
The issues of Drug Misuse and the Bhopal
disaster are two critical areas where mfc as a group
has moved beyond discussion. When a
thought
current needs to mobilise its members and other
socially sensitive people for action how does it go
about it? This is one of our real dilemmas at pre
sent. Individual members have always taken action
locally on issues along the mfc perspectives but
how can the; collective dimension, be reinforced?
With the demands of the present and the
future
this is a question which each of us has to ask
ourselves seriously.
One of the ways we could go about it is to
have small cells—groups of members who review
creatively roles and needs around well defined
areas, eg: critical analysis and monitoring of health
policies and programmes; alternative approaches
in community health care; communications and
lobbying for health action; investigative research—
priorities, issues and relevant methodologies; This
group work may help to enrich the circle and move
it aIon,T the new dimensions of the future. From
amateurishness to scientific rigour; from personal
involvement to collective action; from adhoc'ism
to planned development
A sense of realism
During the discussion a large number of fea
tures of the circle as it had evolved over the years
was identified which affected our capability to play
the above roles. These factors were both strengths
and weaknesses
The discussions about role of mfc at Patiala
were a beginning of a process of ' reflection and
debate which must go on till the ‘light is seen'.
(i) The circle has been basically a forum for
discussion, dialogue and experience sharing of
(individuals involved in socially relevant health
action
(ii) Members are widely dispersed all
India.
Oo the Bhopal Front
over
Review of our action
(ii'i) All members are involved full time with
other organisations which may or may not share
the perspectives with mfc and most do not have
adequate time for collective effort;
A post mortem of mfe’s intervention in Bhopal
—fact finding report, epidemiological study and
communication strategy identified the growing
needs for consensus in action, the imperatives
in dealing with the media, and the difficulties of
networking among voluntary agencies and action
groups in general
' (iv) The members are from divei-s.e back
grounds and even though we share an increasingly
common perspective, the differences of opinion at
action level do exist and are respected by all;
The June incident
(v) mfc has conciously tried not to organise
or 'institutionalise but remain a friends circle and
an informal network;
(vi) mfc has resisted taking organisational
stands as such but individual members take commit
ted stands which are shared by other members.
However, on many issues like drugs, medical educa
mfc got some undue credit in the press cover
age during the public and media uproar about
the MP government’s action of arrests of the doc
tors and volunteers of the Jana Swasthaya Kendra
While mfc sent protests and appeals to the high
ups in the Centre and State we also had to clarify
our role which was primarily technical support to
5
the Kendra. This catalyst role was part of
the overall support to all health groups in Bhopal
—voluntary, government or otherwise (Details of
the clinic in focus were given in mfcb 115—July
1985)
Post Script
Meeting with ICMR
The mfc core group met Prof V. Ramalingaswami, the Director General of ICMR and some of
his senior colleagues on 29 July at the ICMR head
quarters to discuss the mfc Bhopal study findings
and the research projects of ICMR. Critical com
ments were shared on both these1 matters. The
ICMR welcomed mfc’ls involvement and assured
us of support. They also agreed to invite mfc re
searchers to their meetings, on Bhopal as well as
take the initiative to convene a meeting of all vol
untary agencies involved in health action at Bhopal.
The mfc study report
Three versions of tire study report were
planned. (i) a complete, detailed, scientific version
in English; (ii) a summarised version for deci
sion makers and for lobbying in English; (iii) an
abridged ‘la/ version with illustrations in Hindi
especially for the disaster victims.
Pregnancy outcome study
Continued from page 3
The study on the effect of toxic gases on preg
nant women, scheduled for July was postponed to
September (22-29). The objectives of the study
will be to assess the increase in spontaneous abor
tions, still birth rates and congenital malforma
tions in the affected population. The study is
being undertaken in coordination with many other
or anisations with Sathyamala of mfc as coordi
nator. (For further information, contact Sathya
mala, C-152, MIG flats; Saket. New Delhi 110017).
our social order so that there is a fairer distribu
tion of wealth, resources, and power — a society
where people can lehrn to live together in peace,
where professionals' and laborers and farmworkers
can embrace each other as equals, share the same
standard of living, the same wages, and watch out
that no one takes more than his share at someone
else’s expense.
But as I have already mentioned, such a res
tructuring for a healthier social order is not likely
to come about from those at /the top. It can only
come /through the organized, united action of those
at the bottom..
Future role
While reiterating its technical, research and
'communication support to all health groups work
ing in Bhopal, both voluntary and. governmental,
a local review was thought necessary. Anant Phadke
will base himself in Bhopal for a tew weeks in Augu
st-September to identify the future and continued
role. It is hoped that a broad network of voluntary
agencies and health action groups will coalesce
so that meaningful health efforts can be continued.
A health communication effort with the basti dwell
ers will also be explored.
As health professionals, we are among the fat
and fortunate few, the elite of society, the one
percent of the world’s population with university
degrees. Whether we like it or not, we are in some
ways part of the problem—part of the inner circle
of a social order that perpetrates poor health. Our
'challenge, then, is not to try to change the people;
or to try to make them more healthy according to
our mandates. Lt is rather to allow the people to
change us, to make us less greedy, more humble;
more able to serve the people .on their terms.
Our challenge is to help those on the bottom create
a new economic and social order in which every
one can afford to be healthy.
Organizational
Medical Education Anthology
The anthology committee reviewed all the re
source papers on medical education prepared for
the Anand, Dacca and Calcutta meetings. If inter
mediate deadlines are kept the anthology should
be released in January to coincide with the confer
ence on ‘Reforms in Medical Education’, organi
sed at Bombay by the Indian Association for the
Advancement of Medical Education.
P I L Wins Again
A public interest litigation petition filed by Dr.
Nishit Vora and others on behalf of the Jana Swasthaya Kendra came up for hearing in the Supreme
Court. Chief Justice PN Bhagvati, Justice RS Pathak
and Justice A Varadarajan directed the Madhya
Pradesh Government to put forward a scheme for
distribution of sodium thiosulphate for the treat
ment of 2.5 lakh MIC gas victims in Bhopal posi
tively by the 25th of August. The court also direc
ted the MP police and the CBI to return within
four days two resisters of the clinic seized on June
25/26.
(Source: INDIAN EXPRESS, 15.8.85)
Annual Meet — 1986
The theme of the annual meet in January
1986 would be “Issues in Environmental Health -—
a case study of Pesticides”. The meeting will be
held in Pune or Bombay. A variety of issues for
background papers were identified.
6
Developing Standard Treatments
Recent Publications
1.
The State
(1985).
Standard treatments are management plans
worked out by experts on the basis of the best
evidence available. The treatments chosen should
be the cheapest and safest that will be effective,
and the doses, duration of therapy and indications
.for treatment should be stated clearly and simply.
Each country should develop Standard Treatments
for the common causes of death, the common causes
of admission and the common causes of outpatient
attendance Different regimens may be needed for
different age groups and different health workers.
but every effort should be made to keep the plans
as simple as possible.
Of India’s
Environment
Report
Just released end of August. For further infor
mation write to. Centre for Science and Envi
ronment, 807 Vishal Bhavan, 95 Nehru Place;
New Delhi 110019.
Many doctors, trained to rely on their own
clinical judgement, find if difficult to accept the
idea of standardized treatment plans. However,
recognition of the importance of developing stand
ard treatment plans is growing among health care
practitioners in both hospital-based and rural cli
nic settings.
2.
No Place to Run. A joint report on Bhopal by
PRIA (India) and Highlander Centre (USA).
Write for a copy to: Society for Participa
tory Research in Asia, Sainik Farm, Khanpur;
New Delhi.
3.
The Lessons of Bhopal. A community Action
Resource Manual on hazardous technologies.
For further information, write to: Interna
tional Organization of Consumer Unions,
Region office for Asia and Pacific, PO Box
1045, Penang, Malaysia.
Focus on Diarrhoea
Developing of ‘Internal’ Stanch.rds
Increasing numbers of doctors, anxious to.
improve the level of clinical care available for
their patients, find that a consensus amongst colle
agues often allows the development of more ap
propriate standard treatment plans than those pro
duced by a doctor working alone. This group appro
ach to standard setting, carefully considering all
the relevant factors, can be a useful educational
process in it self for all concerned. Furthermore, it
is more likely that relevant treatment standards
will be developed if they are prepared by those who
will use them rather than by external experts.
‘Internal’ standards prepared in this way are also
more likely to be accepted, understood and used.
They are particularly valuable in ensuring that
commonly occuring problems like ARI receive a
uniformly high quality of care.
This package is aimed at professional health
workers who are responsible for the organization
of health services in a community, district or region.
The package contains two tape-slide sets
(Diarrhoea-a major public health problem and
Diarrhoea-approaches to control), an illustrated
hand-book (Focus on Diarrhoea) and an information
chart (Coping with -— Diarrhoea). A package con
taining a video cassette instead of the two-tape-slide
sets is also available.
It provides information to help health workers
understand the problem of diarrhoea in their area
and start planning control activities. It does not
provide guidelines for the implementation of these
activities, but suggests sources where this informa
tion can be obtained.
Primary Health Care aad ‘External’ Standards
It is available for sale with:
Given the wide range of knowledge andexperience within the primary health care team, it
is likely that those with the least medical training—
the village health workers in developing countries
—will find externally developed standard treatments
more useful and easy to accept as part of their
programme of supervised training. Nevertheless
participation by all health workers in the process
of standard setting should always be encouraged.
Susanne O’Driscoll
Department of Tropical Hygiene
London School of Hygiene and
Tropical Medicine
Kejppel Street,
London WCIE 7HT.
use the use of appropriate standard management
plans is an essential element in the strategy to
reduce overall morbidity and mortality from acute
respiratory infections in developing countries.
This will not only contribute to their train
ing but also help to win their co-operation and en
sure that the role planned for them is a realistic
one. Trainers need to introduce standard treat
ments to health workers with sensitivity and imagi
nation. Their success in doing' this is critical beca-
—-John Webb. (From ARI News).
7
RN.27565/76
mfc bulletin: AUGUST—SEPTEMBER 1985
tudes and behaviours—various forms of social con
trol of health evolved as a result.
EDITORIAL :
In the, last few decades the social and partici
patory dimension of health care has received greater
attention. The term public health when it was first
coined stressed the development Of various services
and programmes which were important to maintain
and promote the health of the public. The emph
asis was on the responsibility of the government,
the municipal authorities and statutory authorities
as providers and organisers of services. The public
’.ere basically recipients. This was the era
of laws and regulations, control
authorities
and public health programmes. Since public health
proponents saw the need to change people’s atti-
SCIENCEAND TECHNOLOGY
COMMUNICATION
— An all India Directory
The Department of Science and Technology
(DST) has decided to compile a comprehensive
data base, fully coded for computerised classifi
cation and retrieval of voluntary organisations enga
ged in S & T communication. This ‘Directory' would
be quite different from others both in content and
potential usage. It seeks to cover all major dimensioss of the organisations activities and would thus
serve as a comprehensive reference base and data
bank for S & T communication activities through
out the country. Any reader who fepls that your
project/work should feature in this directory should
contact: Centre for Technology and Development,
B-l, Second Floor, L.S.C.; J. Block; Saketi> New
Delhi 1100017. Send Mr. D. Rahunandan, Secre
tary, brochure! and materials highlighting your
organisations aims and objectives;, literature detail
ing your activities; names and addresses of other
organisations engaged in similar/ related activities.
S & T communication is a very wide category
and covers such aspects as agricultural exten
sion and rural development; health, nutrition and
family welfare; artisanal and intermediate techno
logies; popularisation of science! and non-formal
education and environmental protection.
Editorial Committee :
kamala jayarao
anant phadKe
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor:
ravi narayan
Regd. No. L/NP/KRNU/202
The health care approaches in recent years
have tended to see partnership with people as more
important than services for people. The need to
support people in their efforts to change their life
situations making it more healthy rather than impo
sing controls has been felt. This empowering nature
of community health effort has often been missed in
all the rhetoric and slogan mongering of the ‘pri
mary health care; and ‘health for all by 2000 AD'
enthusiasts both within and without government.
That a process of creating a healthy society and
thereby a healthy public must include a restruct
uring of our social order towards a greater equity
'of resources and opportunities and on initiating of
a more participatory, decentralised, ^emysti'fiefd
commusity building process are conveniently for
gotten. Cannot these become the goals of our health
projects and programmes? Health; professionals
submerged in the technical challenges of their work
also miss this critical dimension—this beng an
additional reflection of
the biased ethos of
their own formation institutions. David Werner's
convocation address to public health graduates
of the John’s Hopkins Public Health School tackles
this dimension in hi's usual thought provoking
style and highlights once again, the challenges ahead.
Placement Available
A Medical Officer for leprosy control project
which is in the process of diversifying into commu
nity health and health education fields. Salary’ Rs.
1600 or more on negotiation if the applicant has ex
perience in leprosy work. Free accomodation would
be provided. Apply to The Secretary at Arogya
Agam, Aundipatty 626512 Madurai
District;
Tamilnadu.
APOLOGIES
Due to unforeseen problems in the press we
were not able to bring out the 16-page double
issue we had announced in 115.
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US S 6; Africa & Europe — US $ 9; Canada & USA — USS 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560034
SUBSCRIPTION END.:
•SE RENEW IT
medico friend
circle
bulletin
NOVEMBER
I98S
Health of the Environment
— a Statement of Concern
In the last three years —- environmental
awareness has grown dramatically in India. Its
most noteworthy aspect, however, is that it has be
come increasingly humanised. The crowing under
standing of the importance of the natural environ
ment and its complex linkages with culture, the
economy and society, has helped to put the human
being, particularly the last human being that
Gandhiji always talked about, at the centre of the
environmental concern. And this has brought the
environmental concern itself right to centre of older
concerns like poverty, unemployment, inequality
and oppression.
Yet, little of practical note has happened in
these years that can give us the confidence to say
that the trend towards environmental destruction
has been arrested. On the contrary environmental
degradation continues unabated.
The Bhopal disaster has stunned those res
ponsible for pollution control, and put fear in the
hearts of millions of industrial workers and people
living near factories. But Bhopal is not the1 only
disaster. Subtle and invisible processes continue to
undermine human and natural resourc.: base. Thou
sands of workers in factories and fields all across
the country are maimed and killed every year.
Satellite data has confirmed that India is indeed
losing more than a million hectares of forests every
year, something that forest departments have consi
stently and perversely sought to deny. All our hill
and mountain ecosystems, the cradles of our life
giving rivers, are deteriorating rapidly. Even in
heavy rainfall areas where forests should be in full
bloom, the land is becoming a barren desert. Every
day thousands of hectares of India’s once rich bios
phere slide into a vast wasteland; the only differ
ence in three years is that to day the word ‘waste
land’ has become a part of official vocabulary.
These wastelands cover no less than one third to
one half of India’s land mass. Meanwhile, the
quality of life in towns and cities is degenerating
rapidly Environmental degradation threatens every
Indian today.
The creation of wastelands has hit every
rural and urban household. Even necessities for
survival like fuel, fodder and water are now so
difficult to obtain that women and children have
to spend extraordinary amounts of time scrounging
for them. When life becomes impossible within the
rural ecosystem, because of growing floods, drou
ghts, deforestation, soil erosion or because of de
clining soil productivity, people simply give up and
join the stream of urban migrants, leading to what
urban planners call “unplanned urban growth’.
The process of transforming India into a
wasteland, which began under the British rule, has
continued under the post-independence govern
ments. The most brutal assault has been on the
country’s common property resources, on its graz
ing lands, forests, rivers” ponds, lakes, coastal
zones and increasingly on the atmosphere. The use
of these common property resources has been orga
nised and encouraged by the state in a manner that
has led to their relentless degradation and destruc
tion. And sanction for this destructive exploitation
INSIDE
Pesticides: Health and Environmental
Hazards
Editorial
4
5
A letter from tire Chief Justice
6
Dear Friend
7
Pesticide & Health: case studies
9
News from Bhopal
9
Beating the Pesticide mafia
10
The Dirty dozen campaign
11
mfc news
11
KGAT Card
Keeping Track
12
12
land and water will have to be increased substanti
ally But sustainable increases will be possible only
under a system of participatory management and
control. Every planner and politician must remem
ber that the environment is not a fixed asset. In
fact. India’s resource-illiterate planners have stea
dily turned it into a wasting asset with their deve
lopment programmes and with each passing day,
its population supporting capacity decreases instead
of increasing. India can beat the problem of poverty,
unemployment, drudgjery and oppression only if
the country learns to manage its natural resource
base in an equitable and ecologically sound way.
But equally, if poverty, unemployment and inequa
lity are not removed, it will be impossible to save
the environment.
has been obtained by the state in the name of ‘eco
nomic advancement’ and ‘scientific management’.
Nature can never be managed well unless
the people closest to it are involved in its manage
ment and a’ healthy relationship is established bet
ween nature, society and culture. Common natural
resources were earlier regulated through diverse,
decentralised, community control systems. But the
state’s policy, of converting common property re
sources into government property resources has
put them under the control of centralised bureaucra
cies, who in turn have put them at the service of
the more powerful. Today, with no participation of
the common people in the mana ement of local re
sources, even the poor have become so marginalis
ed and alienated from their environment that they
are ready to discount their future and sell away
the remaining natural resources for a pittance.
All this poses serious questions for our
leadership, and opportunities, too. No other acti
vity can simultaneously provide more employment
today and attack the problems of poverty, drudgery
and landlessness, than programmes to regenerate
the country’s ecological infrastructure. But emphasi
sing and implementing these programmes will re
quire a vision that is sadly lacking in our leaders.
And yet facing up to the environmental challenge
—the challenge of equitable and sustainable deve
lopment—could unite the entire country at this
time of strife and violence.
Indian villages have traditionally been inte
grated agrosylvo—pastoral entities, with grazing
lands, agricultural fields; forests and i roves; and
water sources like ponds, wells and tanks. The
state’s development programmes have torn asunder
this intergrated character of the villages. The state
has rarely implemented plans to manage and en
rich entire village ecosystems.
The crying need, is to redefine the role of
the state. Instead of trying to play the role of the
producer. Forest bureaucracies, for instance, are
entrenched in their belief that they can grow trees.
Just imagine what would have happened if the
agriculture department, which today largely plays
tine role of the enabler through its research and
exteinsion, was also to assume the responsibility
for growing crops! Famine would probably stalk
the country every year.
There is no doubt that international techno
logical pressures will test our leadership severely.
A major and extremely rapid technological trans
formation is taking place in the advanced industrial
countries, with simultaneous developments in micro
electronics, biotechnologies, ocean engineering
technologies,
communications
technologies,
renewable energy systems
and
various
technological
changes
other
areas.
These
will not only bring
about profound changes
in the entirei technostructure of the industrially
advanced countries before the end of this century,
but they will also have deep ramifications for the
rest of the world. In the developing world, where
development has seldom meant more than a mad
race to catch up with the West, these technological
chan es will pose serious problems. If catching up
with the West needed a major commitment in the
1960s and 1970s, it will require the total commit
ment of all our national resources in the 1980s
and 1990s.
The process of state control over natural
resources that stalled wlh the period of colonialism
must be rolled back. The earlier community control
systems that regulated the use of common natural
resources were often unjust and need'ed restructur
ing. Given the changed socio-economic circumstan
ces and greater pressure on natural resources, new
community control systems 'have to be established
that are more highly integrated, scientifically sophi
sticated, equitable and sustainable. This is the
biggest challenge before India’s political system—
not just the politicians and their parties, but also
citizens and social activists. In the last decade or so,
voluntary agencies and people’s movements—like
the Chipko Andolan in Garhwal, the Bhoomi Sena
in Maharashtra or the Chattisgarh Mines Shramik
Sangh in Madhya Pradesh, to name some—have
consistenly shown that despite all odds, this kind
of social restructuring is possible.
This will raise serious questions of choice
Do we develop our science to stay in the technologi
cal race, to enter the 21st century on the terms of
the world technological powers? Or do we develop
our own science focussing on our land and water
resources, on our forests and grazing lands and
on removing the growing environmental imbalan
ces that threaten the very survival of millions of
our countryfolk
There is no reason to believe, that India’s
population has outstripped the capacity of the coun
try's environment to yield its biomass needs. True,
the productivity of our basic natural resource like
The question clearly is; what sort of develooment do we want? World geopolitics may demand
2
that we follow the ‘technological imperative’.
Justice demands that we follow the ‘national im
perative’. India’s leadership has little choice. And
this choice will have to be made consciously by
the country’s political system—and not be left to
scientists and other experts.
fodder, soil enrichment, building materials, agri
cultural implements and atrisans’ raw materials.
Planning for rural development must, therefore, be
redefined to mean planning for integrated rural
ecosystems.
The creation of integrated rural ecosystems
will call for an extremely sensitive use of science
and technology. It will call for the development of
a people’s’ science that harmonises the principles
of traditional knowledge with modern science to
serve the complex human needs in a sustainable
manner. Most of today’s scientists have little to
offer towards these goals. Their experience is limit
ed to simple monocultures, whether in farming,
in forestry, in fishers or in animal husbandry. And
their science has proved too rudimentary and sim
plistic for managing complex ecosystems.
Ironically, the most dramatic failure is in
an area where ‘modern’ science and technology
have been applied the most, the urban system.
Even though India will largely remain a rural
country, it will posess the world’s largest urban
population by the turn of the century. Managing
these large urban systems will pose colossal pro
blems. Already the political system is buckling
under the size of the urban system and the speed
with which it is growing. India’s premier city, Cal
cutta became unmanageable during the 1960s and
1970s. Bombay is rapidly becoming so in the 1980s.
And before the end of the century, it will be the
turn of Madras and Delhi. Many lesser cities like
Kanpur "died a long time ago. And almost nobody
pays any attention to the hundreds of small and
medium towns that dot the country. The quality of
urban life is declining everywhere and in every
area: slums are growing, housing problems are
increasing, transport problems are becoming un
manageable, water is scare and undrinkable, insani
tary conditions are proliferating, and the air is be
coming u nbrbath able.
This scenario definitely does not mean that
India ought to turn its back to global technologi
cal advancement. But its imagination and its
ingenuity will lie in making appropriate choices
We don’t have to be swept off our feet by the gla
mour of modern artefacts; we have to use our intel
ligence to choose and to match our technological
capabilities to real needs.
It is possible to use the principles of
materials science and structural engineering to
construct sturdy comfortable and aesthetic mud
homes. Of all the building materials available in
India, mud can make the maximum contribution to
wards providing decent housing for all. Again,
India’s planners do not have to design cities for
motorised private vehicles which pollute the air,
contribute to urban sprawl, make us more depend
ent on fossil fuels and make the transport system
loss accessible to the urban poor. It is possible to
plan for an urban transport system combin
ing private bicycles—still the most accessible and
non-polluting form of transport—with a highly effi
cient, modern and sophisticated public transport
system. The list of feasible and equitable innovations
is elndless.
Planners and politians often like to use the
phrase ‘unplanned urban growth’. But this is a mis
representation of facts. Urban led development has
always been a basic feature of planning in India.
The- rural development strategy has not been to
develop rural areas per se, to meet the bas'c needs
of the rural poor in particular. But the strata y has
mainly been to ‘develop’ the rural areas by putting
their resources at the dictates of the urban markets
and by transforming the rural environment itself
into mass monocultures of marketable commodi
ties. In this sense, much of rural development has
simply been an extension of urban development.
And within the urban system we have completely
and blindly followed the extremely high cost and
resource-intensive Western model. The result is
on one hand, an exploding urban system, which des
pite disproportionate investments, is bursting at
its seams, and, on the other, a badly mauled and
ravaged rural system, whose p.oductivity is declin
ing every day, and which keeps pushing more and
more people into an increasing ly chaotic urban
system.
All this requires a clear vision, an imagina
tive and honest political system, in which elections
are fought without black money, contractors and
land speculators are put under control, the indus
trialist who pollutes is prosecuted, and so on. This
country never had a greater challenge before it
and never a more urgent need to restore ethical
values in its social and political life. The land can
be greened and the environment improved, but
only if the people who control the socio
political system can learn to control their greed.
If this growing rot has to be stemmed, an
alternative pattern of development has to be found
urgently both for our towns and villages. Urban
and rural development have to occur in a symbiotic
manner. Such a process will require planning for
more self sustaining urban areas and the enrich
ment of the rural environment to meet the rural
population’s diverse biomass needs for food, fuel.
Source:
3
The State of India’s Environment 1984-85
The Second Citizens’ Report, Centre for
Science and Environment, New Delhi.
Common Pesticides : The Health and
Environmental Hazards
PESTICIDE
ASSOCIATED HAZARDS
Carcinogenicity;
environ
mentally.. persistent
Highly toxic if swallowed or
inhaled; toxic to fish birds
and bees
Oncogenicity
BHC
Oncogenicity, mutagenicity,
CARBARYL
teratogenicity; hightly toxic
to honeybees; toxicity incre
ases for human with a lowprotein diet
Acute inhalation and high
CARBOFURAN
oral toxicity,;
extremely
toxic to birds, fish, shrimp,
crab and other wildlife; fa
tal if swallowed
Oncogenicity: reduction of
CHLORDANE
non-target species e.g. fish,
bees etc. Environmentally
persistent; fatal if swallowed
Environmentally persistent;
DDT
virtually
nonde-gradable;
suspected
carcinogentcity;
hazardous to avian (bird)
life
Fetotoxicity,
mutagenicity,
DDVP
neurotoxicity, oncongenicity,
highly toxic to birds and
others wildlife
Contact poison, fata] to shr
DIAZINON
imp and crab
Oncogenicity, mutagenicity,
DIMETHOATE
fetotoxicity; highly toxic to
bees and birds
Extremely toxic to birds,
ENDOSULFAN
bees, fish and other wild
life, persistent in the envirronment
ENDRIN
Highly toxic by inhalation
and skin absorption; onco
genicity, teratogenicity and
reduction of non-target spe
cies
MONOGROTOPHOS Acute dermal toxicity; toxic
to birds, aquatic fauna, bees
and other wildlife
PARATHION
Extremely high & acute in
halation and dermal toxicity;
residue effects on birds,
mammals and aquatic spec
ies, large accident history
ALDRIN/
DIELDRIN
“What I want to known Sam, is whether it is true
we’re getting ‘humanicide’ as a by-product, and
its chances of marketability”.
(Source :
EcoForum, Vol. 8, No. 3. 1983)
PHOSPHAMIDON
TOXAPHENE
Acute dermal toxicity, resi
due effects on birds and
mammals
Tumour induction, hazard to
to wildlife, reduction of nontarget species, environmen.
tally persistent
Pesticides used in India and
Banned or Restricted Abroad
Pesticide
Some countries in which it
is banned or restricted
Aldrin
USA,
UK, W. Germany,
Sweden;
Canada,
Italy,
USSR, New Zealand
USA, Japan, USSR, Den
mark, Sweden, France,
W. Germany
Argentina USA, UK, Tur
key; Sweden; Denmark, Bul
garia, Italy
Australia, Colombia, Greece,
UK; USSR, Poland, Switzer
land, USA
Argentina, UK, USA, Japan;
Mexico, W. Germany, Fin
land
BHC
Chlordane
DDT
Endrin
Parathion
Toxaphene
Italy, Japan, Spain
Argentina, Finland,
W. German, Italy
Source: Pesticides or Biocides (refer keeping Track)
4
EdatoriaE
*
The theme of the next annual meet in
January 1986 is “Issues in Environmental Health
a case study of Pesticides”. Why are we discuss
ing this theme?
In the factories where they are produced,
unsafe and hazardous processes are a risk
to workers’ health.
*
In the fields, where primarily the finished
products are used in unsafe and uniformed
ways, they are gradually becoming a threat
to the health of the agricultural workers.
*
The uniformed and unsuspecting consum
er using it in and around the homes, is ex
posed to a potential hazard.
4
The massive use in the national disease
eradication programmes have their own
story to tell.
*
Agricultural use also contaminates water
and soil leading to pesticides entering the
food chain. Contaminated food results in
accumulation of pesticide residues in the
human body increasing the risk of chronic,
cumulative pesticide poisoning.
"
Accidental and suicidal poisonings are now
common place in hospital emergencies, the
former often occurring in epidemic propor
tions.
”
Endemic familial
arthritis of Malnad
(Handigodu syndrome) is an example of
insidious and mystery' diseases that are
said to be linked to pesticide use.
Why Environmental Health?
Over the last decade and particularly in re
cent years more and more data is accumulating
from research studies and field experiences of deve
lopmental activists that India is not lagging behind
the rest of the world in polluting and destroying
its environment through a series of man made eff
orts to mobilise the country’s natural resources
for the ‘development’ process. The first citizens
report on the Environment (1982) succinctly re
corded this as “a resource use pattern initiated by
the current development process, attacking and
destroying not just the environment — the wild
life, forests and fisheries for instance—but also the
vast majority of human beings, especially the poor
and their cultures”.
The second citizen’s report on the environ
ment 1984-85 warns that “Bhopal is not the only disa
ster. Subtle and invisible processes continue to
undermine human and natural resource bases.
Thousands of workers in factories and fields all
across the country are maimed and killed every
year”.
The statement of shared concern from the
same report featured in this bulletin brings out not
only the dilemmas of the developmental process
but exhorts us to search for more people oriented,
ecologically sensitive and ethical approaches to
development.
Pesticides also lend themselves to a deeper
understanding of the agricultural and industrial
imperatives of the Indian model of development-;
the role of multinationals; the role of legislation
and health and safety controls; the state of consumer
awareness and public health education; the siting
of hazardous industries; the choice of technology
and a host of other issues arising out of this multi
dimensional problem.
Those of us involved in health and health
care issues cannot fail to recognise the gravity of
this situation or do we? since this ecological insen
sitiveness is at the cost of human health. We must
not forget that Amlai, Chembur, Handigodu, Harihar, Zuari, Mavoor, Silent valley Thal-Vaishet
and now Bhopal are primarily a threat to human
health.
The Focus of the Meet
A two day meeting of a hundred odd people
involved in health care and interested in environ
mental health and pesticides cannot cover all dimen
sions of the problem. In fact an attempt to do so
would be futile. What we could do is to initiate a
study-reflection process which will continue beyond
the meet and help many in the months to come, to
identify, recognise, understand and respond to en
vironmental health problems.
Why Pesticides?
Environmental Health is too vast and vague
to be discussed in abstract and hence the need for
selecting one problem as an illustrative example was
felt.
In our meeting at Patiala was decided to
choose Pesticides as a case study for our discus
sions not because of the unexpected focus they have
received due to the Bhopal disaster but because as
a group of chemicals they lend themselves very well,
to a total understanding of the issues involved in an
Environmental Health problem. The range of pesti
cide related health problems for instance are:
The focus would, therefore, be on how to
study an environmental health problem using pesti
cides as an example.
* We could marshall all the available facts
and studies about the situation of the pesticide pro(Continued on page 6)
5
implemented by the administration without resort
to any judicial action.
May I therefore, request for your cooperation
in this matter. If you find that—
i. any social or economic legislation enacted
for the benefit of the poor and the oppressed
is not being implemented by the administra
tion at the lower levels.; or
ii. if there is any exploitation or injustice
meted out to the weaker sections of th?
community; or
iii. if the people are not getting their social
and economic entitlement on account of
indifference or inaction on the part of the
official machinery; or
iv. if you encounter any problems or difficulties
with the administration.
A Letter from the Chief
Justice of hdsa
(This letter was sent to me recently. I am sharing it
with all of you for information — Convenor)
From: Mr. Justice P. N. Bhagwati, Chai; man,
Committee for implementing, Legal Aid Schemes,
3 Janpath Road, New Delhi - 110001.
Committee for Support of Social Action Groups
You will be glad to know that in my capacity
as the Chairman, Committee for implementing
Legal Aid Schemes set up by the Goveriment of
India for implementing legal aid programme in the
country, I have constituted a small sub-Committee
consisting of myself as Chairman and a few officers
in the higher echelons of service drawn from vari
ous Ministries of the Government of India as mem
bers, for the purpose of attending to the problems
and difficulties which may be encountered by vari
ous non-political social action groups operating in
the rural areas at the grass root level. The object of
forming this Sub-Committee is that whenever any
problems or difficulties with' the administration
are encountered by socal action groups or social
activists, the attention of this Sub-Committee can
be invited to those problems and difficulties so
that this' Sub-Committee can take up the matter
with the administration and try to see that these
problems and difficulties are resolved satisfactorily
without the social action groups or the affected
parties having to go to a court of law for judicial
redress. There are a number of matters where the
administration can. be persuaded to intervene with
a view to helping the poor and underprivileged
segments of society to realise their social and eco
nomic entitlements and the function of this Sub
Committee will be to ensure that the consider
able amount of Social and economic legislation has
been enacted by the Central and State Governments
for the benefit of the poor and the down-trodden is
I would like you to immediately draw the attentiol of this Sub-Committee so that, to the extent
possible, this Sub-Committee may be able to help
you with the administration. There are quite a
large number of matters which can be sorted out
with the administration without resort to judicial
action and our first effort must be to get our pro
blems and difficulties resolved by the administra
tion and it is only if the administration fails to do
so that we should resort to public interest litigation.
1 shall, therefore', very much appreciate if you
would be good enough to extend your cooperation
to us in this matter. You may address your com
munication directly to the Committee at the
following address.
Committee for Implementing Legal Aid Schemes,
Committee Social Action Groups,
Block No. 11, Gali No. 12, Jamnagar Hutments.
Shahjahan Road, NEW DELHI - 110 011.
Yours sincerely,
Sd/
P. N. Bhagwati
With warm regards,
Editorial (Continued from page 5)
of individuals, groups and networks committed to
creating a greater awareness of the problem and a
search for alternatives in action.
If by the end of the two day discussions we
have understood the various dimensions of an envi
ronmental hoalth problem and evolved a holistic
approach and methodology of studying it in our
own local areas, the meet would have served its pur
pose.
The last bulletin started of the process of
preparation. In this bulletin further stimulus is
provided. Apart from the thought provoking state
ment of concerned citizens, various extracts from
books, environmental bulletins and other resource
materials and keeping track column are an invita
tion to further reading. The dear friend column
and a recent letter received from the Chief Justice
puts future action in perspective
blem and locate it in the total context of environ
mental health in India.
* We could critically review the available data
'on the pesticide related health hazards to the indus
trial and agricultural workers in India, identifying
lacunae and further directions for study.
* We could consider the data available on
pesticide residues in food, water, soil and in the
consumer public itself and assess the magnitude of
the problem.
* We could look at existing science, en
vironmental and development policy as well as legi
slation and related controls and understand their
contribution to the situation.
* We could become more aware of the actions
6
is not possible to come to a consensus in our under
standing of how to proceed in action — atleast
not
always.
The direction
is similar but
mode
of action
will
differ
according
to our perspectives. We have now to choose bet
ween two options:—
i) Do we insist on common action and in the
process either split up (each group may claim to be
■mfc) or let the group wither away in what appears
to be a natural aging process. OR
ii) We regard each other as important and
necessary and express concern towards each other,
try to understand how the other- person is thinking
and acting, try to spell out the direction in which
wc should progress and leave the action at an indi
vidual level.
Dear Jriend
mfc role
mfc has been trying to define it’s role (refer
minutes of Patiala meeting mfcb 116-7). The expec
tation of individual members are so varying that it
has been difficult to come to a common conclusion
In the process the decision is being kept open.
Most of us wish to see mfc in action, be it
drug action forum or Bhopal disaster. In their bub
bling enthusiasm (I am all for it), the individual
members sometimes try to project their action
(action which they feel correct) as mfc’s action.
All the members might not support the way in which
action is taken. In the process, I see some members
withdrawing from mfc—a sign that mfc will wither
away if the same process continues.
What I mean is that we be non-possessive
for a ^roup-action and be more committed to mak
ing friends and understanding each other.
I am trying to limit the role of mfc to a body
of friends with a common concern and regard for
each other, interested in trying to spell out a com
mon direction. The action is left to the members
individually. Which means, there will be nothing
like mfc activity but activity
performed by the
members of mfc. In the process if a group of mfc
members find a common action, they can go ahead
with it in a group capacity and not in mfc’s
capacity.
We are so possessed by the obsession that
mfc should plunge into collective action, that we
have started neglecting the group’s linking thread
i.e. the friendship. There was a time when we used
to come together to share our field experience and
our dilemmas in day to day life. We tried to overcome
our loneliness by coming to mfc where we found
some thing to fall back upon.
Look at the mfc meetirgs in the recent past!
We are so ’‘action oriented” that we come together
only for a specific business. The agenda is packed
and exhausting. The poor convenor is hard pressed
in trying to sort out all the matters in a specific
time. In the process there is hardly any time
to
strengthen the bonds of friendship. Infact they often
get burnt during heated aggressive discussions—a
characteristic of mfc. After all we are all conscientised individuals! We see the need for intellectual,
partnership, the tender linkages between hearts in
a common search is forgotten. The vociferous few
dominate the group meetings and succeed in gett
ing mute consensus. The mute members, do not
dare oppose the vociferous few, and in the process
prefer to keep away from action and sadly from the
medico-friends circle itself.
The task ahead is tremendous. Our numbers
at present are quite inadequate. In the process of
our individual searches our egos are also nurtured
making us feel that our way is the only. way. Let
this 'ego’ not clash-I see it happening. In turn let
us nurture friendship, a friendship that can appre
ciate another’s views however different from ours.
For a group like mfc, to grow in a spirit of dialogue
and evolve, however slowly, a common perspective.
this attitude must remain primary.
Ulhas Jajoo
MGIMS
Sevagram, Wardba.
AIDAN role
Saw Vineet’s note in the mfc bulletin of May
1985 (No. 113) I was quite amazed at his assess
ment of Drug Action Network’s (DAN) direction
of efforts.
I am not against action. A committed indi
vidual is always involved in action at his own level
The real issue is whether mfc as a group is coher
ent enough to take-up common action-
If there is anything we all feel good about the
Network, it’s the total liberty of members to choose
the level of action and mode of action related to
drug issues — as long as they are in keeping with
the major objectives.
We come from various backgrounds. Wc
have a common goal... We have commitment. The
'road that will take us to the desired goal differs
considerably depending on which shade of ideology
we owe our motivation. Though we do no'.
doubt the bonafides of each other’s commitment
towards the goal, we agree to disagree on the stra
tegy of action. The means adopted to reach the goat
‘is important to most of us.
The Drug Controller of India happens to be
merely one person in a massive bureaucracy dealing
with Drug Policy issues. With the National Drug
Policy in the offing, pressure has to be applied at
various levels on various individuals involved in
the making of the drug policy from the members
of Parliamentary Drue Consultative Committee
What I am trying to drive at is that due to
the heterogenous nature of membership in mfc, it
7
countries;
which
are
struggling
to
get
out of the clutches
of
the
'pharmaceutical
giants. If a handful of health activists have to
intervene, it can only be at the most strategic
points. I am afraid, for effectively motivating thou
sands of undergraduates coming out of the 106
medical colleges, we will have to depend upon the
socially conscious members of mfc. DAN has never
made any promises of changin the world over
night. It is an emerging force no doubt, depend
ing on long term commitment and contribution of
a host of persons like you and me to the drug and
health scene of the country. Most of the organiza
tions involved,in AIDAN are extremely clear about
their choice of their working strategy and details
of their action plans. Fighting for a Rational Drug
Policy is the priority of the Network, as decided
by the Coordinating Committee; it being the need
of the hour.
to the Department of Chemicals and Fertilizers,
Ministry of Health to Social Action groups, faculty
members of medical colleges, consumers etc.
The DAN expects pooling in off efforts, so
while some networkers contribute by protest mar
ches, signature campaigns, public and consumer edu
cation others contribute by alerting key social
action groups and monitoring policy changes. Our
contribution depends upon our initiative, our
understanding or the problem and our area of fun
ctioning. For those based in medical colleges, the
expectation is that they contribute In screening
medical literature, reaching out to medical gradua
tes and providing back up support.
The entire DAN cannot and should not put
its efforts in medical colleges. Why don’t we en
quire from others in mfc what their experience has
been in terms of impact with such efforts? These
efforts were not related to the issue of drugs but
dealt with the much more fundamental concept of
‘health’
>—mira shiva
Coordinator , (AIDAN);
New Delhi
(We request reactions to both these letters so
that the dialogue can be continued — Editor.)
You must be aware that the National Drug Policy
is coming up in the parliament in the monsoon ses
sion and if you have been following up the trends,
you would be as distressed as many of us are. The
discussion on these matters should not be merely
at the consumer and medical graduate level, but
also at the level of faculty and top brass of teach
ing institutions.
Announcement
Dear Doctor....
You may not be aware that when we were try
ing to muster support for the courageous Bangladesh
Drug Policy, when pressure from vested interests
was mounting, the support came much more from
IITs
(Indian
Institute of Technology) than
medical colleges.
Of the drugs that are being marketed in our
country, approximately 60% are either unscientific,
harmful, substandard or banned. Doctors have to
depend mainly on the drug companies for informa
tion about drugs. Tall claims (often false) are made
by drug companies about these drugs while all the
harmful effects and contraindications are not
placed before the doctors.
What can those who want to work primarily
with medical students do? Here are some suggetions:
1. Review medical literature regarding fixed
dose combinations of steroids and other to prove
their irrationality;
2. Review whatever sources we can about the
various drug utilization studies in India and
identify areas of interest for conducting special
studies on drug utilization patterns, eg' TB care or
diarrhoea care.
Drugs Action Forum, West Bengal is going to
publish a quarterly journal on Drugs and Rational
Therapy which will also contain information on
harmful, banned and unscientific drugs. The journal
will function under the guidance of an advisory body
comprising of some members of the All India Drug
Action Network (AIDAN) and other noted doctors
of the country. Doctors and health personnel are
likely to be benefited.
3. Prepare guidelines of what young doctors
ought to know about Rational Drug Policy.
Annual Subscription Rs. 12.00 (Four issues).
4. Follow up Pharmaceutical policy issues in
Economic Times, Eastern Pharmacist, Financial
Express; Business Week etc., to follow the trends
and communicate these to the doctors and under
graduates.
Bank drafts in favour of Drug Action Forum,
West Bengal or Money orders for subscription may
kindly be sent to the undermentioned address.
(Please do not forget to mention your name and
address in M.O. coupon).
The Bangladesh Policy itself may not be able
to survive, if India formulates the kind of drug
policy it seems to be formulating. This would put
an end not merely to our own efforts towards a
Rational drug policy, but also of other third world
Dr. P. K. Sarkar, Editor
Journal of Drug Action Forum, W.B
254. Block-B,
Lake Town, Calcutta,700 089
8
Pesticides
and
Health
— some case studies
Occupational Health :
over 200 people were affected in 40 villages. For
the victims it began with intermittent pain in the
hip and knee joints which later became continuous
until some could hardly stand up. This crippling de
formity, later given the rather long-winded name
of ‘Endemic Familial Arthritis of Malnad’ (EFAM).
appears to be linked to pesticide use.
"A survey ol farm workers engaged in spray
ing in Gujarat showed that they were not provided
with face masks, only 50% covered their nose and
mouth with a cloth, 20% failed to wash after spray
ing. Mr. S. Selliah, Asian representative of the
International Federation of Agricultural and Allied
Workers, said:
The people affected by EFAM were all poor
people of low caste. At certain,times of year, especi
ally when food is short, the poorer villagers eat
crabs which are found in the rice fields. At the time
the disease appeared there had been two important
changes in the area. Firstly, the landowners
stopped serving food to the labourers as part of
their wages and secondly the green Revolution had
brought high-yielding seed varieties and pesticides
to the area. So, not only were the poor thrown
into greater reliance on the paddy-field crabs for
food but also those same paddy-fields were increa
singly contaminated with pesticides, including parathion and endrin. Due to inbreeding and special
genetic characteristics, the people of Malnad were
particularly susceptible to the apparent effects of
pesticides residues in the environment, consumed
via the paddy-field crabs.”
Source: A Growing Problem (refer keeping Track)
‘A number of people get affected by occupati
onal pesticide poisoning but people don’t usually
report to the hospital until it’s too late. Also, the
sufferer is usually also suffering from other health
problems which contribute to death. This means
that one of other causes will usually be recorded as
the cause of death....
Pesticides are often mixed by hand and some
times pesticide powders are just sprinkled by hand
onto the crops.’
Even for organised plantation workers it is
a struggle to obtain even the simplest protective clo
thing. Mr. R.M.R. Singham of the General Emplo
yees Union, representing 10.000 workers in the
Indian State of Karnataka says:
“In Karnataka Plantations the workers who
are using the pesticides do not get any protective
clothing. This Union has raised a demand with
Karnataka Planters Association for gloves and face
masks.”
News from Bhopal
The Jana Swasthya Kendra has started fun
ctioning in its new premises from 21 Oct 85 at
Karachi Chola, one of the severely affected bastis.
The activities of the Kendra now include administ
ration of sodium thiosulphate injections, paediatric
care and dissemination of health information. The
Kendra is now supported by ZGKS Morelia and
concerned citizens of Bhopal.
*
*
*
The Hindi translation of the mfc report and
the Health Education pamphlet for the gas victims
is well underway as a joint mfc — Eklavya collabo
ration. (In the news item mfeb 118, October 1985
Eklavya was inadvertently mentioned as publisher
only.) Dhruv Mankad and Narendra Gupta will be
in Bhopal in the first half of November in this
connection.
Pesticides mentioned by Singham include
disulfoton, phosphamidon and endosulfan, all of
which are covered by Health and Safety regulations
in Britain requiring the use of protective clothing.
In 1980 a team from the National Institute of Occu
pational Health had recently spent two months in
vestigating conditions in South India. They found
that there is an unnecessary risk to workers’ health
from pesticides. On one plantation 40 differem
chemicals were used. Although pesticide applicators
were given some protective clothing, their assistants
were unprotected even though they mixed the
pesticides the most hazardous part of the operation.
The study is not yet complete but workers in
a sample had reduced levels of cholinesterase (an
effect of certain pesticides) and workers complained
of headaches and insomnia.”
*
*
*
The National Campaign Committee on Bho
pal will organize special meetings from 27 Nov to
3 Dec during Bhopal week through its member
.constituents. On Dec 3, there will be a special progromme/nteeting in Bhopal. On 3 Jan 1986, a rally
will be held in Delhi to present a memorandum to
the Prime Minister. On 4 Jan 1986, a National
Seminar on Issues of Environment, Science and
Technology will be organised. For further informa
tion, write to RAS office.
Environmental Health :
“In 1975 health authorities in the Malnad
area of Karnataka in South India began to report a
mysterious new disease. It emerged that the first
cases had begun to appear in 1969/70 and by 1977
9
* Discourage the use of crop varieties that are
susceptible to pest attack and which require the
use of large doses of harmful pesticides.
Beating the pesticide mafia
— need for consumer action
* Encourage scientists
varieties of these.
The Bhopal accident has been a terrible
tragedy but it would be a greater disaster if we limit
our action only to helping its victims and to preven
tin/ further events of a similar sort. We should, ra
ther, work to control the root cause of the trouble,
study
traditional
* Clear up stagnant water in your neighbour
hood instead of calling on the municipality to spray
for mosquito control.
the use of dangerous pesticides and other chemicals.
* Develop a monitoring and reporting network
to check pesticide use and inform other action
groups of what is happening.
.As consumers we should ask ourselves
whether we wish to continue allowing ourselves to
he poisoned. If we do not, we should act now to
stop the sale of dangerous pesticides; to ensure that
permitted pesticides are used correctly, to continu
ously monitor the level of pollution in what we con
sume and in the environment
and encourage
the use of alternatives to synthetic pest'ibides.
* Stop looking to thfe West for all solutions to
our problems and try to think independently for
more appropriate ones.
* Join consumer groups that fight against pesti
cide misuse such as the pesticide Action Network.
Some of the suggestions given by various
organisations and individuals are listed below.
We should remember that if we don’t act
now, the situation will only get much worse, as big
industry tries to sell more and more dangerous pes
ticides and other chemicals to make larger profits.
If environmental damage continues to increase, the
position may well become irreversible, if it is not
already so now.
* Ensure that government enacts stricter regu
lations concerning the manufacture, import, sale
and use of dangerous pesticides and fully enforces
those that alreadj exist
* Ensure that industries, particularly MNCs,
obey pollution control laws and do not sell banned
or unnecessary products, that their advertisements
slate the correct effects of their products and their
■container labels have adequate warnings of all the
dangers involved in using them.
The power of the pesticide mafia will be
broken when farmers start using simple biological
controls and natural pesticides, such as neem, which
they can extract for themselves. The neem pesticide.
is made by boiling neem leaves for 30 minutes.
That is all the ‘technology’ required to produce a
pesticide that has proved to be more effective aga
inst the paddy stemborer than anything MNCs have
to offer. This is a clear example of how appropriate
technology can control the oppressive powers of
industry and MNCs in particular.
* Investigate the legal aspects of irresponsible
sale, incorrect labelling and misleading advice to
farmers, and the infringement of fundamental rights
by the government permitting dangerous pesticides
to be used freely here.
Finally, pesticides are only one of the means
that MNCs use to control and oppress the
Third World. Other agribusiness methods include
the sale of crop varieties whose seed have to be
bought from MNCs, large scale mechanisation of
farming from tractors to expensive sprinkler and
trickle irrigation systems, and now genetic engineer
ing by which they can control what we grow while
robbing us of our gene heritage. MNCs also oppress
us through other high technology industries, parti
cularly the pharmaceutical business, which may
even be causing us more harm than the pesticide
one.
* Boycott all products of industries that conti
nue manufacturing and selling harmful items.
* Check pesticide use in your area, make sure
that users take proper precautions and know the
dangers involved in using them.
* Get your local colleges or other institutions
to monitor pollution of all sorts.
*
to
Stop using synthetic pesticides yourself.
* Ask farmers (and grandmothers!) what tradi
tional methods of pest control were used before syn
thetics were forced on them. Spread this knowledge.
Like cancer caused by their pesticides, MNCs
■have been compared to malignant tumours that in
vade healthy bodies and soon appropriate and ex
tract all the available nutrition, leaving a sick and
dying entity behind
* Encourage the use of natural pesticidtes and
traditional methods which any farmer can use with
out dependence on big business. Many farmers al
ready possess the necessary knowledge but thtey are
led to believe that foreign, synthetic pesticide tech
nology is superior and so neglect their own.
Source: The Pesticide Malignancy
track).
10
(refer keeping
THE DIRTY DOZEN CAMPAIGN
Pesticides are used widely throughout the
world, and their use helped increase crop yields,
avert food losses to pests, and control diseases, to
name but some of the benefits. But the unchecked
proliferation of these chemicals has also had deva
stating consequences. Millions of people have been
poisoned and hundreds of thousands killed by
modern synthetic pesticides since the mid 1940’s
when they were first developed.
The “Dirty Dozen” Campaign singles out
twelve extremely hazardous pesticides that should
be banned, phased out, or carefully controlled, every
where in the. world. Each of thelse 14 pesticides
have been banned or restricted in most industrialis
ed countries as public health and environmental
safety measures. Yet all 12 are widely available in
developing countries, where regulatory controls
are fewer, and where the toll they take is dispropor
tionate.
This international dirty dozen campaign is
being launched by PAN on 5th of June — the
World Environment Day — as an attempt to deal
with the double standard in international market
ing of pesticides. The selection of twelve most haza
rdous pesticides have been made to carry out an
/international public education, media and lobby
campaign to pressure governments and manufactur
ing industries to act more responsibly by passing
better control laws and instituting better marketing
practices.
The campaign willcompile data on the following twelve pestici
des: BHC, Lindane, Campheclor, Chlordane;
Chlordimefrom, DBCP, DDT; the Dris; EDB;
Pesticide, Parathion, 2; 4; 5-T,
* Prepare and distribute media packets,
* Produce educational material to be used by
PAN members in educational efforts,
* Monitor poisonings, legislation and market
ing practices pertaining to the 12 pesticides.
and update the list annually.
*
Now what is PAN? Growing concern in the
NGO community about the increasing overuse of
pesticide and its deterimental impact upon human
health and the environment led to a meeting in
Malaysia during 1982 of a broad spectrum of NG'O’s
from developing and developed countries. The main
concern of the meeting was to find a way for NGO’s
to effectively control the global proliferation of
■pesticides. The meeting resulted in the creation of
the Pesticides Action Network (PAN) which has
now grown to encompass over 300’ consumer, deve
lopment, environment, trade union and religious
groups in 49 countries. The goals of PAN are:
*
*
*
*
the promotion of vector control, and
the promotion of ecologically and socially
sound agriculture.
PAN attempts to attain these goals by ex
changing information between members and provi
ding international support to local initiative, besides
representing NGO views at relevant national and
international policy forums and increase joint eff
orts between the groups from developed and deve
loping countries.
Source: Eco Forum, news alert, May 1985.
For Furthur in formation on PAN write to:
Dorothy Myers. Oxfam, 274, Banbury Road; Oxford
UK,
David Built) ELC, P. Box 72461, Nairobi, Kenya.
mfc
News
The Bhopal report (long delayed) was finally
out of the press end of October and has been des
patched to all those who asked for it. Abridged and
unabridged copies are available for Rs. 2.00 and
Rs 8.00 each. Bulk orders of the report will also
be sent out on request.
The report is also available for sale from
the Indian Social Institute (Bangalore), KSSP Office
(Trivandrum), Centre for Education and Documen
tation. and Foundation for Research in Community
Health (Bombay), Centre for Science and Environ
ment, Society for Participatory Ressarch in Asia
and Centre for Social Medicine and Community
Health, JNU (New Delhi).
* The mfc office will move from Bangalore to
Nipani on 1 Jan 1986, when Dhruv Mankad will
take over as convenor from the New Year.
Furthur details will be announced in the next
bulletin.
* The mfc annual meet 1986 will be held at
Khandala (Maharashtra) from 27-29 January 1985.
The theme for the meet is “Issues in Environmen
tal Health—a case study of Pesticides”. For fur
ther details write to Padma Prakash, 19 June Blossom
Society, 60-A Pali Road, Bandra- Bombay 400050.
* mfe’s Third Anthology ‘Health and Medi
cine: Under the Lens” (Rs. 15.00) and reprints of
First Anthology—In search of Diagnosis (Rs. 12/-)
and second Anthology—Health Care: which way go
to (Rs. 15.00) are now available from the Voluntary
Health Association of India (C-14 Community
Centre, SDA, Opp. IIT Main Gate; New Delhi
110016) -and the mfc Bangalore office.
We apologise to all those who had made pre
publication payments for the inordinate delay caused
unavoidably by the press. The orders are being des
patched now.
the end of misuse and abuse of pesticides,
th0 promotion of safe use of necessary pesti
cides in the home.
11
RN.27565/76
mfc bulletin: NOVEMBER 1985
Appropriate Technology :
KGAT Card for Detection of
Malnutrition
During recent years growth monitoring per
se has been regarded as a strate y of preventing
severe malnutrition and death in children. Tools
for measuring growth are simple and easy to use
(weighing scale, measuring tape etc.) and are avail
able in a community/family. However, no tool is
available at present which may be simple, small,
portable and easy to use for interpretation of anthro
pometric measurements collected at peripheral
level. The K.G.A.T. card has been developed to
fulfil this need.
K.G.A.T. card is very easy to operate.
Just adjust the age of your child (up to 60 months)
on the respective window of the card, you will get
instantly the minimum expected weight (in kg).
hei ht (in cm) and mid upper arm circumference
MUAC) it warns that your child is suffering from
the critical values (which are also shown simultane
ously against each parameter ii.e. weight, height
MUAC, it warns that your child is suffering from
severe malnutrition. Alternatively, by adjusting the
height (in cm) of your child on the" KGAT card,
you get the instant minimum expected weight for
this height along with the critical value which indi
cates severe malnutrition. If your childs nutrition
status is between normal and severe category of
rhitrittCIn, it means he is suffering from mild to
moderate degree of malnutrition.
Different critdria used to interpret anthro
pometric measurements in terms of malnutrition have
been shown in the card. The reference values used
for various parameters in KGAT card have been
taken 'from W.H.O. Monograph Series No. 53
(D.B. Jelliffe, Assessment of Nutritional Status
of the Community 1966) which except in case of
MUAC, have been derived from the Harvard Stardards (Stuart and Stevenson, 1959 Table).
The pilot field testing of this tool was done
in a group of 20 educated mothers in an urban clinic
of Delhi and it was found to be 100 per cent accept
able. The decree of agreement between qualified
MBBS doctor vs educated mother was 95-100 per
cent. The detailed field testing of this card is being
tested at three centres.
It is felt that this simple card would be an
extremely useful guide for helping millions of lite
Editorial Committee :
kamala jayarao
anant phadxe
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor:
ravi narayan
Regd. No. L/NP/KKNU/20z
rate nutrition-conscious mothers, peripheral health
and Nutrition Workers and supervisors to monitor
the health
and
nutrition
status of
child
ren in the community.
The card is available from the Institute of
Health & Nutrition, E-85 Ansari Nagar, New Delhi
_ 110 029.
Umesh Kapil & M. C. Gupta
KEEPING TRACK
Pesticides and Health
* A GROWING PROBLEM — Pesticides and
the third World Poor, David Bull, Oxfam.
This book examines the problems which
arise from the use of pesticides for the purpose for
which they were designed — the improvement
of agricultural production and the control of dis
ease. It highlights the problems of pesticide poison
ing and the fact that it is essentially preventable
and that the pesticide exporting countries have a
potentially significant role to play in its prevention.
It warns of the consequences to the health and
food supply of millions of poor if the problems
of resistance, long-term impact of pesticides and
the pesticide treadmill are not heeded.
Available from VHAI, New Delhi and Oxfam
offices.
* PESTICIDES OR BIOCIDES — The Pesticide
problem in India.
Kalpavriksh Pesticides working group, Delhi
a paper dealing with various aspects of the
pesticide problem including pesticides in health
programmes, pesticides in Agriculture; Environmen
tal and health hazards; pesticide residues, role of
agribusiness and the alternatives.
For copy write to Amita Baviskar, 9 D;
Maurice Nagar, Delhi —- 110007.
* THE PESTICIDE MALIGNANCY
A paper dealing with the manufacture of
dangerous pesticides in India by MNCs, the role of
foreign governments, roles of their Indian partners,
the use of dangerous pesticides, the pusher of
pesticides, the effects on humans and the environ
ment, synthetic 'pesticides, alternative methods of
pest control and suggestions for consumer action.
Compiled by Maharashtra Prabodhan Seva
Mandal, 79 Carter Road, Bandra, Bombay 400050
(write to above for a copy).
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US 5 6; Africa & Europe — US $ 9; Canada & USA — US $ 11
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44. Ulsoor Road, Bangalore-5b0042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
A DRUG CAMPAIGN NEWSLETTER
mfc Rational Drug Policy Cell
DECEMBER
Dear Friends,
This is to keep you informed about recent even
ts, various issues and current developments about
Drug Action and campaigns with which we have
been associated. To make our interventions more
meaningful, we need your active interest, time and
commitment. Please write to Anant Phadke at our
rational drug policy cell, 50 LIC quarters, Universi
ty Road; Pune 411016 if you would like to partici
pate in and support the campaigns. A lot could be
done in the New Year if you are willing to join
the ongoing efforts.
Eternal vigilance is required to ensure that
the health care system does not get medicali-
sed, that the doctor-drug producer axis does
not exploit the people and that the ‘abundance’
of drugs does not become a vested interest in
ill health.
— ICMR/ICSSR Health for All Report, 1981
INSIDE
A letter from the AIDAN Coordinator
3
An AIDAN press release
4
Imported Drugs: poor quality
5
A Buko-pharma campaign
6
Vitality and Energy through Hoechst
7
A live saving directory
8
,
Keeping .Track
9
Action Alerts
9
Health Care in India—book review
10
Annual Meet - 1986
11
Drug Campaign News
11
Double Standards
12
1985
Fighting for A People's
Drug Policy
— The KSSP Experience
Dr. B. Ekbal *
The Kerala Sastra Sahitya Parishad, the People’s
Science Movement in Kerala intervenes in areas
like Health, Education, Ecology and Problems of
War and Peace. In the field of health, KSSP is very
strongly questioning the relevance of the present
day health delivery system which is curative orient
ed, individualisedi institutionalised and highly cost
ly and catering to the needs of only a wealthy mino
rity. KSSP feels that a People’s Health Movement
alone can change the health delivery system in fav
our of the rural poor. KSSP has been striving for
the last few years by various means to initiate such
a movement in our country. With this purpose KSSP
is at present organising health camps, health educa
tion classes, people’s theatre forms and audiovisual
campaigns and field studies on an extensive scale
Although granting that drugs and hospitals have
only a minimal role to play in achieving a healthy
living for the poor, we felt that exposing and fighting
the anti-people and exploitative tactics of the drug
companies should play a major role in the campaign
for a People’s Health Policy for our country. The
aim is twofold, on the one hand we should demystify
pnarmaceutical products as far as the people at large
are concerned and on the other hand this can be
used as an entry point into the medical profession
so as to conscientise the doctors and medical stu
dents on the wider health issues.
KSSP started its campaign for a Peoples Drug
Policy from the World Health Day, April 7th, 1984.
With W2 years intense campaign we could make
the drug issue a subject of public debate, make peo
ple aware of the unethical marketing practices of
drug companies and also could identify and organise
a number of doctors and medical students who are
socially conscious and are ready to wage a fight for
a People’s Drug Policy.
We started the campaign with a few major de
mands. These are demands for the production and
distribution of essential drugs, banning of non ess
ential, irrational and dangerous drugs, better qua
lity control of drugs and implementation of the
Hath! Committee Recommendations like, nationali
sation of the drug industry, strengthening of the
public sector, introduction of generic names and
updating of the national formulary. Through the
campaign these demands are explained in detail to
ceutical sector could be focussed during the Bhopal
campaign.
the people with the help of documented facts, figures
and authentic governmental and non govern
mental resource materials.
We are at present organising an All India
Seminar on ‘Drug Industry: A decade after Hathi
Committee’ to mark the occasion of the 10th Anni
versary of the publication of Hathi Committee Re
commendations. Since we have a public sector
pharmaceutical company in Kerala (Kerala State
Drugs and Pharmaceutical Industry) supplying
about 45% drugs to the Kerala Health Service a
call to strengthen KSDP is already made so as to
make it capable of producing all the essential drugs
for the Health Services. With this end in view a
seminar on ‘A Drug Policy for Kerala’ will be orga
nised in January 1986.
The campaign started by conducting seminars
simultaneously in all the 14 districts of Kerala on
tire World Health Day. The theme paper was pre
sented by a KSSP activist doctor. Representatives
of doctors organisations, medical representatives and
pharmacist organisations and eminent personalities
took part in the discussion. Later 45 zonal conferen
ces were organised taking the campaign still further
forwards. By the end of the year, most of the 600
units of KSSP evenly distributed throughout Kerala
organised seminars attended by hundreds of doctors
and thousands of people.
What are the concrete results of the KSSP campaign so far?
Apart from lectures and seminars a number of
articles on the various aspects of the drug issue
were published both in KSSP journals and in other
popular magazines. Two books were published and
the studies done by Medico Friends Circle on Anal
gesics and Antidiarrhoeals were reprinted and popu
larised among doctors. We are at present summari
sing the Hathi Committee Report which will be
published by the end of December 1985. Through
the Rural Science Forums of KSSP, about 2000,
wall news papers explaining the various aspects
of the drug issue were displayed in the rural areas.
Thus the message was communicated to the rural
people.
I . . The drug issue has been already developed into
a subject of public debate.
The Science Cultural Programme organised by
KSSP is a powerful medium for the popularisation
of ideas on various issues. Every year Science Cult
ural March will be organised from one end of Kerala
to the other end taking the message of science to the
people in a big way. A few items on health
issues including drugs were included in the last two
jathas which attracted the attention of tihe people.
KSSP units are at present functioning in the
Medical Colleges also. With the help of these units
seminars and discussions are regularly conducted in
the medical colleges. A number of articles have al
ready appeared on the drug issue in the medical
college magazines. Recently the Trivandrum Medi
cal College students opened Dr. Olle Hanson cor
ner to sell books on drug issues at the All India
Paediatric Conference conducted, in the Medical
College campus. KSSP activist doctors who are
also members of professional bodies like Indian
Medical Association and Kerala Government Medi
cal College Teachers Association and Kerala Gov
ernment Medical Officers Association and Medical
Students Organisation have made the drug issue a
live subject of discussion in these bodies and could
make their professional bodies take a positive stand
on this issue on many occasions.
2.
People from all walks of life are now aware of
the various issues involved, like essential ver
sus irrational and dangerous dru'S, exploitative
tactics of the MNCs and the indifference on the
part of the Government in implementing the
Hathi Committee recommendations.
3.
A number of doctors and medical students sym
pathetic with our views are identified and
organised.
4.
The prescription habits
but definitely changing.
5.
The sale of irrational and dangerous drugs
coming down.
of doctors are slowly
' President, Kerala Sastra Sahitya Parishad
Please Note
mfc organisational changes
From 1st January 1986
Convenor: Dhruv Mank
*»d
mfc office address: 1877 Joshi Galli
For Future
Nipani 591237
Correspondence
Belgaum dist.
Karnataka
We coupled our campaign on the Bhopal Geno
cide with the Drug campaign effectively. Bhopal as
the inevitable out-come of the multinational exploi
tation of the MNCs including that in the pharma
2
is
| ;
A letter from the AIDAN coordinator
you all are involved in — if you could drop a letter
concerning your views about a people oriented
drug policy to
Needed Intervention in the
National Drug Policy
—Mr. R.K. Jaichandra Singh
Minister of State for Chemicals &
Petrochemicals,
Shastri Bhavan
•New Delhi — 110011
•—Mrs. Mohsinha Kidwai
Minister
Ministry of Health & Family Welfare
Nirman Bhavan
New Delhi — 110011
—Dr. D. B. Bisht
Director General of Health Services
Ministry of Health
Nirman Bhavan
New Delhi — 110011
-—Dr. Vaidyanathan Ayyar
Development Commissioner (Drugs)
Ministry of Chemicals & Fertilizers.
Shastri Bhavan
New Delhi — 110011.
Dear Friends.
Most of you are already aware of the exploi
tative functioning of the pharmaceutical companies
in third world countries.
You are also aware that the National Drug
Policy is under formulation. The outcome will be
mainly decided by the pressure and influence of the
drug industry’s foreign sector and the national
sector.
The National Drug & Pharmaceutical Develop
ment Council (NDPDC) which was formulated in
1983 to look into the drugs issue — has looked into
the mere pricing and production aspects of the
drug problem and that too from the point of view
of the drug industry.
There is a strong possibility that the National
Drug policy will be like the Textile policy.
with a copy to me, your contribution would be
derply appreciated and would
make a great
difference.
It is crucial that the peoples interest is safe
guarded . The drugs are supposed to be produced in
their interest after all.
Since the National Drug Policy is in the parlia
ment — it would be a pity if inspite of all of us
knowing about it, we let an anti-people drug policy
be passed unchallenged.
Our demands are very rational and fundamental.
-— Availability of essential and life saving drugs
(i.e. adequate production and streamlined dis
tribution) to the peripheral areas.
— Withdrawal of hazardous and irrational drugs.
— Availability of unbiased drug information to
health personnel and consumers.
(This would include updating of our National
Drug Formulary which has not been done since
1977 and provision of therapeutic guidelines
as in British National Formulary. Provision of
Consumer Caution in regional languages—
for problem drugs).
—- Adequate Quality Control and Drug Control
(so that every 5th drug in the market is not
substandard as it is at present according to
Government’s own figures, and an improve
ment in the existing drug control mechanism
has to be ensured).
— Drug legislation reform needed to prevent
drug companies from misusing legalistic loop
holes against the people.
In no other country are matters related to
drugs dealt by the Industry Ministry and not Health
Ministry — the priorities
and influences are
obvious.
Warped growth pattern of the pharmaceuticals,
flooding of the market with irrational and hazardous
drugs, total confusion about essential and non- ess
ential drugs is not in the interest of our people.
The Banned and Bannable Drug list with infor
mation about these drugs being produced by VHAI
is in the press. It is another attempt at focussing
attention of the people on what is going on in the
name of health oare, and why they must speak up
and safeguard their own interest.
The issue related to withdrawal of hazardous
drugs, availability of drug information, ensuring
drug distribution has been totally and conveniently
omitted from the Drug Policy recommendations by
the NDPDC — inspite of these being the chief pro
blem areas from the peoples point of view and even
according to WHO criteria of a Rational Drug
Policy.
If you can spare sometime and concern (not be
cause you lack it, but because you are already in
volved with other things) please alert your friends,
your organisations network and request them to take
whatever action they can take—from writing protest
letters to the policy makers involved, to editors, and
holding meetings. Since medicines deal with health
and lives of people and no matter what area of work
With the involvement in Bhopal issue, the drug
policy issue has received a very low priority from
many of the groups involved in Drug Action itself.
(Continued on page 12)
3
All India Drug Action Network
A Press release
22, August 1985
given in the appendix of this report is grossly inade
quate and meant only to reduce "the basket of
price — controlled drugs”.
Mr. Veerendra Patil, the Minister of Chemicals
and Fertilizers told the delegation of th' All India
Drug Action Network which met him yesterday to
submit a memorandum about the new drug
policy and AIDAN’S alternative Rational Drug
Policy. AIDAN is a body coordinating the drug re
lated work of different organizations working in
the field of health, science policy, consumer and
people’s science movement from different parts of
the country.
The Minister was unable to respond to all
these questions related to the selection of drugs and
suggested that a joint meeting with the Health Mini
stry is required to sort out these issues
AIDAN has, after indepth analysis and many
intense discussions formulated an outline of a Rat'onal Drug Policy which was submitted to this Mini
stry in November 1984. The Rational Drug Policy
Statement which sums up this outline was submitted
to the Minister today. Apart from thia central ques
tion of essential drugs and irrational drugs, this
statement emphasizes the need for proper, continu
ing education of doctors, other medical personnel
and consumers, stoppage of misleading promotional
literature of drug companies, the necessity to adopt
“The International Code for Ethical Marketing of
Pharmaceuticals” as detailed by the Health Action
Internationals proper drug distribution to the poor
and the needy, through Governmental channels,
abolition of taxes on priority drugs, plugging the
specific loopholes identified by AIDAN in the im
port of drug technology and in the licensing policy
to ensure self reliance, adoption of the 1975 Helisinki (Mark II) Declaration on
ethical
drug
trial on human subjects.... etc.
It
points
out that
all these
measur es
cannot
be planned unless the Government is
keen
on a Rational Drug Policy and not a drug pricing
policy and unless profit making ceases to be the pri
mary criterion for the drug industry.
In its Rational Drug Policy Statement, AIDAN
has drawn attention to the fact that unless un
scientific, useless drug combinations which consti
tute the majority of drugs available in the market
are withdrawn, enough resources would not be
available for
the
production of
lifesaving
and other
essential drugs.
The
delega
tion pointed out that some of these irrational drugs
are even harmful and the Government is doing
hardly anything about it. Out of a number of bann
able drugs, Government had banned 22 categories
of drugs in an order on 23rd July, 1983. This ban
order is not properly implemented. The Ministe.
replied that this implementation is beyond the pur
view of his Ministry. To many of the demands re
lated to the Rational Drug Policy, his response
was that these concerned the Health Ministry. It
thus appears that there is no proper coordination
between different ministries and the existing drug
policy is only concerned with licensing and price
regulations.
In its memorandum, AIDAN has pointed out
that the very approach of the report of the Steering
Committee of the National Drug and Pharmaceuti
cal Development Council (NDPDC) is mistaken
from the point of view of the needs of thia people.
It is not based on the disease pattern in our country
but is meant, to put in its own words, “to decide on
the selectivity of price regulation,” Instead of pro
gressing beyond the Hathi Committee report, the
Steering Committee report
is re ressive
in character
This is because of
the very
method of the constitution
of the NDPDC
(with no representative from the people), its terms
of reference and method of functioning. The report
contains no reference whatsoever to the question
tof essential drugs as recommended by the WHO,
no reference to the question, of irrational,
and
hazardous drugs. It deals only with different de
mands about profit—margins, price regulations
coming from different sections of the industry, and
hence is irrelevant to the needs of the people
Ithe Minister was told. The list of essential drugs
Correspondence, meeting various officials and
aven the minister has failed to bring about any
change in their concerns. AIDAN has therefore
decided to take th'ase issues to the people and also
show by way of demonstration, how things can be
•done. Member organizations of AIDAN are pub
lishing lists of brands of banned and bannable haz
ardous drugs. Two pilot studies to assess how
many drugs in different categories (antidiarrhoeals, analgesics) are irrational have been complet
ed. Prioritized essential drug list is being finalized
and studies are b,eing launched to calculate the
drug needs of certain essential drugs based on the
actual incidence of diseases. A critical analysis of
the drug industry in India is already being circula
ted in regional languages and likewise aspects of
alternative strategy would also be circulated Mem
ber organizations of AIDAN have recently launched
such a mass movement and have received a good
response from the people as well as many doctors
4
*
' '
♦I
Imported Drugs:
Poor Quality
The African Experience
Dr. P. S. Patki *
Most of the countries in the tropics may be re
ferred
to
as developing
countries
and
they do -have certain features in common. These
countries lack sufficient skilled man power, and
orthodox scientific medicine is relatively young.
Medical technology is under developed and hence
they import most of their drugs from the advanced
countries. Dr. K. K. Adjepon—Yamoah, a pharma
cologist from University of Ghana Medical School.
has undertaken an extensive study to evaluate the
quality of the drugs which are being imported in
his country. The findings of his studies are quite
astonishing.
The result indicated that a large number of sub
standard drugs were circulating in the hospitals.
(Seo Table I.)
Table-I
Drugs analysed during a quality control programme
Drug
Total No. of Samples found
samples
unacepptable%
Antibiotics
1) Penicillins
2) Streptomycin
3) Tetracyclines
4) Chloramphenicol
Analgesic — Antipyretics
Antimalarials
In Ghana 90% of the drugs used in clinical
practice are imported from Western countries.
Secondly drugs may be imported as semi-finished
raw materials and then formulated into various
dosage forms. In 1978 there were 328 official drug
importers in Ghana and each importing firm had
its own favourite exporting country and company!
The number of different proprietary drugs is large
and there are many brand names containing the
same pharmacological agent. For example the mar
ket survey revealed 15 different brands of ampicil
lin from different sources.
24
68
26
11
17
25
50
11
34
18
41
12
Penicillin content of some of the preparations
was as low as 22% and streptomycin content in one
sample was as low as 5%.
Clhe should remember that the comments on
imported drugs apply to the locally manufactured
drugs also.
Apart from the accelerated physical and chemi
cal degradation of drugs, poor storage facility cau
ses some of the drugs to get contaminated. Thus
it was found that 30% of 50 random samples of
stock solutions of drugs for oral and topical appli
cations contained over 100,000 or.anisms/ml- E.coli
Pseudomonas and Salmonella were among the orga
nisms identified. Such contaminations are thera
peutically undesirable and dangerous. In another
study it was found that a low degree of contamina
tion was present in eye drops, nasal and ear drops
and a high degree of bacterial contamination was
found in mouth washes, dusting powders, and
creams.
Undoubtedly many of the drugs imported have
been, of great
therapeutic value. There have
been many instances of failure of therapy in the
tropics. While the same may be due to drug resis
tance, many are attributable to poor quality of
drugs. Treatment of a case of infection with a
‘counterfeit’ drug or degraded drug is dangerous
and causes therapeutic disasters. Another factor is
the rate at which drug combinations of an undesi
rable nature are found in the tropical countries.
Examples are that of Amidopyrine + Phenylbuta
zone, Phenylbutazone + Aminophenazone. Drugs
like phenylbutazone are being pushed into tropical
countries in large amounts. Wlhy is it so?
Now the major question to be answered in relatfen to drugs are (a) Quality (b) Efficacy (c) Safety
and (d) Quantities to satisfy national needs.
Quality :
The great diversity of the sources and types
of proprietary drugs available in many tropical
countries necessarily means that there are likely to
be wide differences in the chemical and biological
properties of imported drugs belonging to the same
pharmacological class.
A disturbing feature which has been noticed
on a number of occasions is that inert substances
are packed into capsules and sold as specific drugs.
These could be termed ‘counterfeit’ drugs. In 1972.
a random sample of procaine penicillin in a govern
ment hospital was found to contain no antibacterial
activity. A large consignment of calamine powder
was shipped to Ghana in 1976 and chemical analy
sis later revealed no calamine in the powder. In
another study a sample of imported fortified pro
caine penicillin was found to contain one part of
procaine penicillin and five parts
of peni
cillin iG, the official requirement is the reverse
ratio. A systematic analysis was conducted m the
Ghana Government Regional Medical Stores bet
ween July and December 1972. Penicillin, Strep
tomycin, Tetracyclines, Chloramphenicol; antimaterials and analgesic antipyretics were studied.
There are a large number of proprietary pre
parations in the tropical countries sold in the name
of ‘tonic’, blood ‘tonics’, drugs for ‘vitality’, neuro-
• Reader in Pharmacology, B. J. Medical College, Pune.
5
10PTo sun-up, the developed world have a major obli
tropic drugs etc. Most of them are of doubtful or
unproven therapeutic value. Phenacetin is now
a restricted drug in advanced countries but in the
tropics it is available freely. Arsenic is hardly
used in the developed world as a drug but in Ghana
arsenic pessaries in the name of stovarsol is tjvailalable in plenty.
gation to thedeveloping countries in the transfer o
technolo y and good drugs. Most important is that
he developed countries should pass laws which
will prohibit the export of drugs which have not met
their local registration requirements.
Financial considerations
1
References
Ghana spends around 10% of her budget
on healt'h. Between 30-50% of the health funds are
spent on drugs. Inspite of this there is shortage of
essential drugs such as vaccines, chloramphenicol,
antihelmenthics, and antimalarials. In the face of
these shortages market places are full of an array
of fast moving drugs such as tonics, vitality drugs,
aphrodisiacs and so on. There appears to be very
little- relationship between the drugs that are
available and the real health needs of the deve-
A
9
3.
Drug alert
Binka J. Y (1973) Quality evaluation of some
drugs in Ghana market.
Ghana. Pharm. J. 1,77-81
Boakye — Yiadam K and Buaducy (1974).
Evaluation of microbial contamination of phar
maceuticals in Govt, hospitals in Ghana.
Ghana. Pharm. J. 2, 12-13.
K. K. Adjepon—Yamoach (1982): Drugs for
developing countries, in Clinical pharmacology
and therapeutics Ed: P. Turner, MacMillan
Publishers, pp 536-541.
campaign!
about these problem drugs and ask for action: to
make information meetings, to write letters of pro
test to Hoechst, to inform the public, and to lobby
politicians.
To make this campaign a success, we need
strong international support. Hoechst drugs are
sold nearly everywhere. Hoechst has agencies or
subsidiaries in most countries of the world. So
everybody is affected by Hoechst. And everybody
can support the campaign:
Research: Advertisements, package leaflets,
reports on bad marketing are needed primarily from
developing countries, but are useful from industria
lized countries too.
Action: To maximize the pressure on Hoechst
it is important that groups and doctors from as many
places in the world as possible protest against the
Hoechst marketing malpractice. We will supp
ly you every month with background information on
a Hoechst problem drug and ideas for action.
We ask you to:
* Write letters of protest to your local Hoechst
subsidiary and/or Hoechst AG, D- 6230 Frank
furt, West Germany
ask doctors and pharmacists to write similiar
letters
* inform the public wherever possible
ask experts for support
start a Hoechst campaign in your own country
It is very important for us, that you report us
your activities and the response you get from Hoe
chst. Your support is important for a successful
campai n against Hoechst and for better heakh'
oincerely yours
eann.
Dear Friend,
Essential drugs could be an import
ant part of a rational health policy. Although the
concept of essential drugs and primary health care
is accepted as the right solution, very little happens
in reality. Most' countries are flooded with hazar
dous, irrational and expensive brand drugs. This
is especially true for developing countries which are
a growing and very little controlled market for
pharmaceuticals.
The Pharma-Campaign of BUKO, a network
of more than 200 Development Action Groups in
West Germany, is fighting since five years against
the harm and waste produced by the irrational mar
keting of drugs by multinational companies. BUKO
is the co-founder of 'Health Action International’
(HAI), a network of some 50 groups in more than
30 countries worldwide.
The. most powerful drug companies ar: based
in a few industrialized countries. Development Act
ion and Consumer Groups in these countries think
it is their duty to campaign against the global mal
practice in drug marketing in the ‘home countries'
of the drug multinationals. The world’s biggest
pharmaceutical manufacturer Hoechst is based in
the Federal Republic of Germany. As ‘the bi gest’
sets a lot of the bad standards all companies prac
tice, BUKO and HAI decided to start a campaign
against dangerous and irrational Hoechst drugs.
The campaign was launched in West Germany
in September with the public announcement of an
“Examination of Hoechst drugs by Development
Action Groups”. We promised to present every
month a Hoechst problem drug till the shareholders
meeting mid-1986. We be an with the multivitamin
preparations RECRESAL, VITAHEXT and FESTAVITAL (see article that follows). We inform our
member groups, interested doctors and the press
Jorg Schaaber and Rudiger K ttler
August- BebH-Str-62
D—4800 Bielefeld 1, Fed Rep. Ge. many
6
o
VITALITY AND ENERGY THROUGH HOECHST?
Its an easy job for pharmaceutical companies
to sell multivitamins in developing countries. Many
people tear to get not enough vitamins in their food,
and pay' a lot of money for vitamins and tonics brew
ed in the laboratories of the chemical industry of
tne Norin. Nevertheless a sufficient and complete
diet would b. the right and cheaper solution. The
pharmaceutical industry knows that people give
their last money for drugs — even when the pills
nont work. The worlds biggest pharmaceutical
company Hoechst is involved in this business with
the poor. In Germany no multivitamins and tonics
are sold under the name “Hoechst" In the developin countries the same company sells several “cure
alls”.
performance” (4) to “eliminate despondency, pre
mature fatigue, lack of concentration, apathy and
lack of appetite quickly.” (5).
Irrational, expensive, dangerous
The B- Vitamins included in RECRESAL/VIT
AHEXT are in a sufficient quantity in an ordinary
meal. But even in the case of vitamin deficiency
the patient does better in spendinc. his money for
food.
In India for example the consumer of VITAHEXT pays up to 7 US$ a month if he adheres to
the dosage given on the package. A big amount of
money compared to the income of many Indians.
RECRESAL/VITAHEXT can even do harm
to the consumer. Hoechst has added vitamin Bl2 in
the form of cyanocobalamin instead of the today
normally used hydroxycobalamin. This antiquated
form of vitamin B12 can mask the degeneration of
the spinal cord and can damage the optic nerve.
(6, 7) The long-term use of Phosphates may lead
to extraskeletal calcification and to disorders in
the mineral metabolism. (8).
Vitamins — A Healthy Business
A big part of pharmaceutical sales in the Third
World is made with absolutely irrelevant or irratio
nal products. One example are the heavily pro
moted multivitamins and tonics. In Brazil, Vene
zuela and Pakistan vitamins are the second-most
sold products. (1) Most of the vitamin prepara
tions, are multi-ingredient products.
The German multinational company E. Merck
earned most of its money in Bangladesh by selling
multivitamins. They dominated the market for the
irrational vitamin B combinations with a share of
68%. To sell even more of those products the
Merck manager decided to promote their vitamins
to “fresh graduates and quack doctors in rural mar
kets” . (2) The managers were aware of the vitamin
and tonic image of Merck and asked the parent
company: “To remove this ‘vitamin’ image from the
mind of the doctors and chemists; Merck should
forcefully introduce essential products like antibio
tics etc. immediately.” (2) This sort of business
is no longer possible in Bangladesh due to the
strict new drug policy, but still exists in most deve
loping countries.
Festavital A curious mixture
Hoechst’s marketing of FESTAVITAL is abso
lutely irresponsible. FESTAVITAL is an unbeliev
able mixture of digestive enzymes, dried ox bile,
the vitamins Bl, B2, B6, some other vitamins of
the B- group, vitamin C and E, methionine, hesperidin and some trace elements. Hoechst’s indications
for FESTAVITAL in Third World countries are
“Overstrain, pregnancy- lactation”. (9)
There is no medical justification for such an
irrational mixture. Hoechst even takes the risk to
harm consumers with this product, The folic acid
component (a B—vitamin) in FESTAVITAL can
promote damage of the nerves, as no vitamin B12
is added. The Martindale warns: “The inclusion of
folic acid in multivitamin preparations may be dan
gerous.” (10) The long-term use of vitamin A can
lead to a vitamin A poisoning with many health
problems. (7, 11) No responsible acting company
should therefore add vitamin A in (the any way
irrational) multivitamin mixtures.
Hoechst and Vitamins
The worlds biggest pharmaceutical producer
Hoechst takes its share of the vitamin and tonic
market. The company based in Frankfurt, West Ger
many manufactures the preparation ylTAHEXT (in
Africa sold as RECRESAL) and FE^TAXITAL.
Experts call such mixtures ‘expensive
place
bos” (3) .
West Germany: A developing country?
FESTAVITAL is available in Germany under
the name VITAFESTAL and sold by the Hoechst
subsidiary Casella med. The indications are absolu
tely different to those in the developing countries.
In Germany VITAFESTAL should help against
“digestive disorders”. (12)
RECRESAL has been available in West Ger
many till 1983. Both products are registered under
the old drugs law which did not ask for .proven effi
cacy and safety.
Recresal and Vitahext
RECRESAL/VITAHEXT is a mixture of the
vitamins Bl, B2, B6, B12, caffein; phosphates.
sugar and alcohol (5% to 20%) . Indications for
this irrational combination are: physical and mental
fatigue, lack of appetite, disorders of nutrition and
metabolism. (4) Hoechst promises that the com
bined action of all ingredients stimulates the appe
tite: activates the metabolism and strengthens the
formation of blood; the nervous and cardiovascular
system. (5) The “pleasantly flavoured syrup
(4) is claimed to “enhance physical and
mental
Buko asks for withdrawal
RECRESAL/VITAHEXT and FESTAVITAL
are unnecessary products; there is no justification
to sell them any Ion; er. These products speculate
(Fontinued on page 8)
7
A LIFE-SAVING DIRECTORY
Turning the tide on trade in Hazardous Products
ference on hazardous products. NGOs are presently
using this resource to draw attention to the double
standard’ that exists between developed and develop
ing countries in the area of hazardous pesticides and
unsafe pharmaceuticals. NGOs see the directory
as a powerful tool to make governments and con
sumers more aware of the problems caused by the
increasing international trade in toxic substances.
WHAT IS THE "CONSOLIDATED LIST’ ?
A new directory published by the United
Nations and known as “The Consolidated List of
Products whose Consumption and/or Sale Have
Been Banned, Withdrawn, Severely Restricted or
Not Approved by Governments” is a first step in
the direction of resolving some of the life-threaten
ing problems caused by the largely unregulated trade
in banned and restricted products.
The “Consolidated List”' contains critical infor
mation on regulatory decisions, restrictions and
bans taken by national governments on harmful
pesticides, dangerous pharmaceuticals, hazardous
consumer products and toxic industrial chemi
cals. Sixty countries contributed data on more than
500 products for the first edition.
For government officials, the directory serves
as a useful handbook to identify potentially hazar
dous products in the international marketplace.
Use of the handbook can lead to regulatory action
to control damages that could be caused by those
products.
0
Order a copy for your organization to use.
You can get one free by writing to:
Mr. Luis Gomez
Assistant Secretary General
United Nations DIESA-PPCO
DC 2 18th Floor New York
N. Y 10017 USA
Ask for a copy of the “Consolidated List”
The Hazards—some examples
DDT, DBCP, PARATHION These and other
pesticides poison at least 575,000 people every year.
Most of this poisoning occurs in the Third World;
where, day after day, farmers and their families are
exposed to toxic chemicals banned in the industria
lized world years ago.
CHLOROFORM Many countries have now
reco nized chloroform to be a cancer-causing agent
and have prohibited its use in medicines. Neverthe
less, a women’s group in Bombay, India: reports
that a popular cough syrup containing the dangerous
chemical is still available Over-thc -counter. The
label reads, “Keep bottle tightly closed to avoid
loss of chloroform”.
Source:
A flyer on the consolidated
UN. —recently received by us.
list
from
(Continued from page 7)
with the fear of poor people to get not enough essen
tial vitamins, although better nutrition is the right
solution. The marketing of these multivitamins is
unethical, we asked Hoechst to withdraw RECRE
SAL and FESTA VITAL worldwide.
First reactions
In a first reaction Hoechst admitted that our
critique on the indications and warnings for FESTAVITAL are right. Hoechst won’t withdraw this
product and has only promised to standardize the
information. (13) Hoechst did not respond to our
critique on RECRESAL VITAHEXT. H.S./ JS.*
DALKON SHIELD The manufacturer with
drew this dangerous intrauterine device (IUD) from
the U.S. market in 1974. In 1983, U.S. govern
ment officials warned that the device should be
removed from all women still using it. But the
manufacturer admits that the Daikon Shield was
inserted in women in some 79 countries. Many of
those women have not been warned of the hazards
of serious infection. They are still walking around
with a time bomb in their bodies. Because of a lack
of information, women are becomin- sterile, som:
are even dying.
1)
HOW DID rr COME ABOUT?
The directory is the outcome of years of con
cern within the United Nations about unrestrained
trade in products that are, for health and safety rea
sons, strictly regulated or even prohibited in some
countries. In 1982, the United Nations General
Assembly adopted a resolution calling for the prepar
ation of a directory listing the hazardous products
and describing regulatory actions that had been
taken on them.
2)
3)
4)
M. Tiefenbacher, Lanbarence genugt niegt mehr. Pharma
-Dialog 63 (BPI) Frankfurt 1980
Merck Marketing Plan Bangladesh 1980—1982
G. Kuschinsky, Taschenbuch der modernen Arzneimittelhehandlung, Stuttgart 1980, p. 378
%g. '"J!1® Package leaflets in Ruanda and Kenia 5) PLM
gS^^^^chZd^
“i^^tE
children are in danger
WHO CAN USE THE DIRECTORY?
Non-governmental organizations (NGOs) have
found the U.N. directory to be an invaluable re
8
8) Martinda?pUn rie^’ esPeclaHy
0?
keeping
Action
Jrack
I)
Locost Handouts
following handouts have been prepared by
Locost during the year.
H F
y
i) Analgesics (Painkillers) by Dr Bal ii) Antidiarrhoeal drugs—symptomatic measures by Dr.
i . K. Amdekar, iii) Haematinics — Part 1 —
pharmacological aspects by Drs Sagun Desai and
Rajul Desai iv) Haematinics- Part II—Some clini
cal aspects by Dr Anita Srivastava v) Haematinicspart III— Preparation of commonly used haemati
nics vi) Haematinics- Part IV- A survey of formu
lations available in India vii) Product information
sheets on Ampicillin, Atropine, Paracetamol and
Mebendazole.
If you are interested in copies please write to
LOCQST (Low cost standard therapeutics), G P O
Box - 134, Vadodara-390001
(1)
*
Alerts
The Hatch bill
Senator Orrin Hatch introduced a bill No.
S. 2878 in the U.S. Senate last year. The passing
of this bill would allow export of U.S. FDA unap
proved drugs to other countries. It should be noted
that the existing American Law embodied in section
801 of the 1938, Food, Drug and Cosmetics Act; pro
hibits the export of drugs which have not been ap
proved for use in U.S.
When the bill was introduced last year, protest
came from all over the world against the retrograde
amendment — from Thailand, Srilanka, India, HAI
associated groups and public interest groups in the
US. After all the public outcry, the bill was not
voted upon. The bill has been recently reintroduced
with some modifications. Basically it will allow for
export of pharmaceuticals not approved for use in
U S A to countries with regulatory and drug enforce
ment procedures considered adequate by F.D.A.
The problem for the Third World Countries will be that
the re-export of these products from the above mention
ed countries cannot be regulated. We need to protest
about this.
(2)
Antidiarrhoeals- A rationality Study: by Dr.
Shishir J. Modak for Rational Drug Policy Cell,
mfc. Now reprinted by Kerala Sastra Sahitya Parishad. Price Rs. 2/-. Available with mfc, AIDAN
and KSSP offices.
(3)
Analgesics and Antipyretics—-a Rationality
Study
by Drs Jamie Uhrig and Penny Dawson
for Rational Drug Policy Cell of mfc.
Now reprinted by Kerala Sastra Sahitya Parished. Price: Rs. 2/— Available with mfc. AIDAN
and KSSP offices.
2)
Watering down of UN consolidated List—of hazar
dous drugs and chemicals
There is a move to exclude the brand name and
the manufacturing data and also to exclude drugs
that were recommended for being weeded out be
cause of their therapeutic usefulness. For countries
with poor drug controls and gross lack of availability
of unbiased drug information any such dilution of
information related to hazardous chemicals and
pharmaceuticals is unacceptable. These changes
are being contemplated because of pressure from
certain sources.
(4)
AIDAN Handouts:
The All India Drug Act
ion Network has circulated the following handouts
this year.
i) Graded Essential Drug list, ii) Priority Drug
list of NDPDC, iii) the Hatch Bill iv) AIDAN press
release v) New Drug Policy and AIDAN Steering
Committee Recommendations vi) Banned brands
list (inprint)
Those interested in copies please write to Mira
Shiva, AIDAN Coordinator, C-14 Community cen
tre;. SDA, New Delhi-110016.
All such instances of double standards pertain
ing to health, industrial and safety matters need to
be opposed.
*For
further details
and
action
plans
write to Mira Shiva, AIDAN coordinator, C-14
Community centre SDA New Delhi - 110016.
(5) Ramakka’s story and the Drug Policy of India
an audio-visual set (120 slides and casette)
price Rs. 450/- Produced by Centre for Non For
mal and Continuing Education Ashirvad 30 St.
Mark’s Road, Bangalore-560001 .
(7)
Pills, Policies and Profits
by Francis Rolt. Published by War on Want.
Price £2.95-|-postage.
The book examines commercial, political and
professional reactions to Bangladesh’s Drug policy,
both within the country and internationally. It ex
plains the way in which the policy has been obstruct
ed and the difficulties of trying to improve the
health of the majority in a poor, Third World
country.
(Available from Third World Publications,
151 Stratford Road, Birmingham, Bll; IRD; U.K.)
Towards a people oriented Health Po icy
A reference file on Gonoshasthya. Kendra,
G. K. Pharmaceuticals and the Bangladesh rug
(6)
Policy.
,.
,
Prepared by mfc, Indian.Social Inst.tue and
Science Circle Bangalore. (19 )
(price Rs. 5.00) . A few copies still available with
mfc office, Bangalore.
9
Book Review
ught out well by the authors. They go on to shO'Y
on the basis of the expenditure outlays for rural
health and water supply during the V and VI tn
that during the latter, there has been a significant
change in favour of rural health. But given e
general direction of the book’s contentions, one is
almost surprised at the conclusion the authors reach
retarding the impact of this apparent shift in prio
rity during the VI plan. The authors claim that “thislimited but significant shift of policy and expendi
ture has also produced some results”. Then they
enumerate the increased number of Primary Health
Centres opened, sub centres upgraded and Com
munity Health Volunteers trained, in support.
Was this the result that the planners had promised?
Or the authors had expected? One is certain
that it was not so. One had expected to see signifi
cant changes in the people’s health status. Has
that happened? Unfortunately, the authors have
been unable to cite a single parameter to show
sudh an improvement.
HEALTH CARE IN INDIA: George Joseph, John
Desrochers, Mariamma Kalathil, Centre for Social
Action, Bangalore, pp 148; Rs. 4.CO.
Doctors, health planners and other profes
sionals working in the field of health, often feel
frustrated by the slow pace of change in the healtn
situation of the Indian people. This leads one to
become cynical about the utility of trying out alter'natives in health care, on tlie one hand. On the
other hand, it leads one to become smugly satisfied
about the small achievements within one’s area
of work, not bothering about the general situation
at all. There is a third alternative: to integrate tihe
work at a microlevel with a correct perspective of
the macro-situation, thereby simultaneously contri
buting, in however small way, towards change in
the health situation of the country.
HEALTH CARE IN INDIA is written for those
“action oriented persons and groups who work at
the local level. . . and are-searching for an ov all
perspective”. The book makes a commendable
attempt at an overall analysis of health care in
India looking at its socio-economic and political
aspects.
Next, the authors analyse the National Health
Policy (NHP) of 1983 in light of the ICMR/ICSSR
report on Health for All. They emphasise the
character of the ICMR/ICSSR
report. They
allege that some of the important issues raised
by the ICMR/ICSSR report have been totally neg
lected by the NHP statement. The report lays down
alleviation of poverty, removal of social economic
inequality, and spread of education as essential
pre-requisites to achievement of Health for all by
2000 A. D. But the NHP conveniently overlooks
these aspects, and talks only of minor reforms in
health care services. The authors pinpoint the
flaws in the policy, quite effectively. What they
fail to note, however, is that the ICMR/ICSSR re
port itself is a diluted version of the reality. The re
port has failed to analyse the real socio-economic
cause behind the poverty, inequality and lack of edu
cation of Indian people and therefore the solution
it has offered remains at best, mere wishful thinking.
The authors begin by tracing the history of
the development of health services in 'India. After
devoting a few lines on the traditional systems of
medicine, this chapter focuses mainly on the model
of health care based on ‘modern’ medicine develop
ed from the British period till the Health for All
document (ICMR/ICSSR report). They correlctly
state that the model that, the British developed,
showed their concern for their “own political and
.economic gains”. But the preceding analysis fails
to clearly bring this out. In fact, the conclusion the
authors reach after describing the public health
measures taken by the British between 1864 and
1946 is incorrect and contradicts the earlier state
ment quoted above. The British enacted these laws
not, as the authors conclude, because they “increas
ingly recognised the State’s responsibility for pub
lic health” but because the British were aware of the
disastrous consequences of the spread of epidemics
as a result of bad sanitary conditions, bn the British
Army and bureaucracy (1) That is precisely why,
the British did not usher in a Sanitary Revolution
which they did in their own country during the
19 th Century.
One would like to add one more shortcoming
of the National Health Policy which the author’s
have overlooked. With the over flooding of the
drug market with irrational drug formulations on
the one hand and shortages of priority drugs on
the other hand, there is an overwhelming need for
a National Drug Policy. NHP is totally silent about
this extremely grave problem.
Using a wealth of statistics and information
based upon the reports of various committees ap
pointed by the Indian Government as well as the
Five Year Plans (FYPs), the authors have been
able to show the yawning gap between the prono
uncements of the planners, policy makers and poli
ticians and the actual achievements. The glaring
failures in establishing a model of egalitarian, rural
biased and preventive health care have been bro
.. ThC^°°k brings out V€ry lucidly the deteriora
ting health situation of the Indian people with the
li Ps °kP°PUlati10n mOrtality and nionbkiiW^stati
stics. The population growth rate runs hint, Luk
slowing down the Infant MortaUty Rate stili X
of the highest amongst the deLoni J
°M
though cholera epidemics are rare its ino’J1^101^’
still high, TB and leprosy are Xant iTV
tion in children and anemia in women have Cached
10
an alarming proportion. All the indicators reflect
a dismal state of affairs.
sures and the spread of the education have contribu
ted to the higher health status of the people of
Kerala.
In an excellent analysis of these failures, the
authors correctly conclude that, "a health care sys
tem functions within the broader socio-and politi
cal and cultural-or ideological system.... Though
enjoying a limited autonomy and freedom of operation, the health care system basically corresponds
to and reflects what happens in the society. It is
therefore normal that the health policies of
the. Inchan Government betray the same class bias
as its economic policies. . . ”. For those who may
be doubtful or resentful of this ‘ideologisation’ of
health pioblems, the authors elaborate further on
the social forces, and vested interests who shape the
health policy and its implementation. They include
piivate enterprise in health, health professionals
and drug companies. Here, one would havte expect
ed a more thorough analysis of these forces-the
political economy of health care in India. But tho
ugh the vested interests within the health sector are
adequately discussed, the role played by the 'poli
tics and economics’ of the interests outside the
health sector-of classes and class struggles is not
discussed.
Based on these experiences, the authors enu
merate various possibilities of ‘relevant health
action’. The spectrum ranges from setting up a
curative network to conscientization and political
action. The report then focuses
upon the
debate on the relative importance of community
health oare, community development and conscienti
zation/ political action alternatives.
The critical review of this debate and the
authors’ position would form a theme of a seperate
article. Therefore, we peed not go into it. One
would like to state however, that all the three ap
proaches become irrelevant and status quoist if the
‘ultimate’ aim-the emancipation of the people
from the oppressive reality is overlooked.
In conclusion, one would like to observe in
agreement with the authors that “the possibilities
of meaningful involvement are clear enough to all
to come out of their indifference, lethargy and dis
couragement and to rediscover a new sense of dilu
tion and purpose.”
In all, the book deserves the critical attention
of all those involved or interested in health issues
with a broad perspective of a total social change.
In the end, the authors strike a hopeful note.
There are forces within the present system which
are trying out alternatives. In a very informative
chapter, these various alternatives are discussed;
The authors cite from the experiences of the
developed capitalist countries to show the role
played by improved nutrition, living conditions as
well as wide public health measures in improving
the health standard of the people. Further they cite
the example of Vietnam, China and Cuba to show
how, removal of poverty and inequality alcng with
establishment of an egalitarian, and prevention
oriented health care system can bring about rapid
land dramatic changes in the health status of the
people. The authors also show hew
giving .mportance to preventive and promotive health mea-
References :
Radhika Ramasubban, The colonial legacy and public
health system in India—Socialist Health Review vol. I.
No. 2 pp 6—12
1
— Dhruv Mankad, Nipani
Drug Campaign News - 1985
Recent events
1.
ANNOUNCEMENT
2.
mfc annual meet 1986
Venue ; Khandala (Maharashtra)
Dates : 27-29 January 1986
Theme: Issues in Environmental Health
a case study of pesticides
For further information, registration details,
travel information and background papers,
write to:
Annie George, mfc
Foundation for Research in
Community Health
84-A, R.G. Thadani Marg
Worli, Bombay 400018,
3.
4.
5,
11
Protecting -the child consumer:—a workshop
on irrational medication and infant foods orga
nised jointly by the Consumer Guidance Society
of India and the Indian Academy of Paediatrics
at Gorakhpur (U.P) in September.
A Drug Action Forum was launched in Orissa
in October.
Towards a people oriented Drug Policy:— a
workshop organised by Catholic Hospital As
sociation of India at its 42nd National Conven
tion in Lucknow (U.P) in November.
A Decade after Hathi Committee:— an all
India seminar on the Drug Industry organised
by the Kerala Sastra Sahitya Parishad at Tri
vandrum in November. The seminar was cos
ponsored by the Department of Science
and Technology and the Indian Council of So
cial Science Research.
The Drugging of Asia—Pharmaceuticals and
the Poor:- A seminar organised by the Interna
tional Organisation of Consumer Unions, the
Voluntary Health Association of India and
Asian Community Health Action Network in
Madras in December.
DOUBLE
STANDARDS
The examples given below. show how inappro
priate medicines are promoted and marketed in
Third World countries-very often with inadequate
information. These examples only hint at the ex
tent of the problem, which involves drug prescri
bers, users and regulators as well as the companies
that produce them. What it amounts to is the whole
sale importation of a system of medicine incapable
of addressing the real health needs of the developing
world:—
Expensive broad spectrum antibiotic drugs
like CLAFORAN (Hoechst/Roussell, FRG/France),
BAYPEN (Bayer, FRG) and AUGMENTIN (Bee
cham, UK) must be used very carefully. Indiscrimi
nate use encourages the growth of antibiotic resis
tant bacteria, and furthermore these drugs are ex
tremely expensive. CLAFORAN costs about SUS
10 per gram, and a daily dose is between 2 and
6 grams. Ideally, broadspectrum1 antibiotics should
be used only when safer, cheaper, narrow spectrum
antibiotics have failed. In East Africa, however,
these drugs are being promoted among general doc
tors, who are given the impression that by prescrib
ing these expensive drugs they are giving their pati
ents the “best”.
In Kenya and elsewhere glossy posters of ex
pensively dressed men and women promote TONOVAN, a testosterone-based potency drug from Sche
ring (FRG). This drug and E. Merck’s PASUMA
STRONG and Organon’s ANDRIOL are just some
of the products sold by European companies in East
Africa to treat impotence. Male anxiety about sex
ual performance creates a ready market for seemin
gly scientific potency drugs. Most can be purchased
over the counter, without a prescription. Clinically,
however, hormone-based drugs can treat only 2%
of all impotence. In effect these drugs are an ex
pensive and dangerous placebo for the great majo
rity of the men who take them. Testosterone can
cause liver damage and many of the drugs are
irrational combinations of other ingredients. TONOVAN and PASUMA STRONG, for example, con
tain yohimbine (an aphrodisiac), strychnine, and
vitamin E as well as testosterone. Yohimbine and
stryhnine, in particular, have potentially serious
side-effects.
Merck, Sharp and Dohmes’s PERIACTIN is
advertised in Pakistan and other developing coun
tries for “natural weight gain" for the growing child;
for the adolescent who is underweight, and for the
convalescent who needs good appetite”'. This US
based company with extensive European holdings
promotes PERIACTIN as a tonic in countries where
child malnutrition is rife. But appetite stimulants
do no good, since malnutrition can only be effecti
vely treated by food, and other causes of weight
loss is a symptom — not a disease in itself. Drugs
like this are an expensive distraction from children’s
real health needs; one course of treatment with
Sandoz’s appetite stimulant MOSEGOR costs aro
und US $ 10.00. And a double standard is involv
ed as well In the developed world Sandoz markets
a chemically identical drug for migraine treatment.
Product literature, for this drug notes that a slight
increase in body weight is observed in some pati
ents” PERIACTIN has not been promoted as an
appetite stimulant for children in the US
since
1971, because the US Food and Drug Administra
tion considers the evidence for the indication to he
inadequate.
ENCEPHABOL (E. Merck, FRG) and ARCALION 200 (Servier, fr.) are just two of the irra
tional “brain tonics” marketed by European com
panies in Africa and Latin America ARCALION
200 —■ a vitamin Bl derivative — is promoted for
“mild depression and anxiety, psychogenic impotence
of recent onset, impairment of memory and concen
tration and reactive asthenia”. Adults, and child
ren are supposed to benefit from it if they suffer
from “tics, stammering, enuresis; difficulties at
school” There is little or no clinical evidence
to support these claims. In Africa, glossy promoti
onal brochures advertise ENCEPHABOL as treat
ment for male “mid life crises” while in Latin
America school children take it to improve brain
performance, concentration and sociability.
Source: Promoting the essentials Virginia Beardshaw Special Report: Drugs and Agrichemicals
HAI, PAN, ICDA, BEUC March, 1985.
(Continued from page 3)
Following my meeting with Mr. Jaichandra
Singh, Chemicals Minister on 4.11.1985 it is clear
that contribution from the Health Ministry by way
of drawing up a clearly defined essential drug list
for the nation for guidance of both public and pri
vate sector has not come.
These should include — drawing up an up
dated national formulary with therapeutic guidelines.
•and—a list of drugs that are hazardous and irra
tional .
Failure in monitoring exact mode of drug use
misuse and drug shortages will prevent identifica
tion of problem areas and formulation of functional
strategies that are required.
In view of the urgency and in view of the seri
ousness of the nature of the Drug Policy your
intervention is needed.
’ ?
With sincere regards,
Yours sincerely,
(DR. MIRA SHTVA)
Coordinator
Low Cost Drugs & Rational Therapeutics
and Convenor
All India Drug Action Network
12
123
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DECEMBER 1986
Dipyrone, Hoechst And the Boston Study
Wilbert Bannenberg MD
Dipyrone (synonyms: metamizole, noramidopy
rine, novaminsulphone. avaminsulphone; brand names-novalgin, baralgan) is a controversial drug since
1934. It was developed by Hoechst as an analgesic,
and belongs to the pyrazolones—group, of which we
know since 1934 that they may cause a severe side
effect: agranulocytosis. Between I960 and 1977 the
drug has been taken off the market (for safety reasons)
in the USA, Canada. UK., Ireland, Australia, New
Zealand and the Scandanavian countries. On the
10th Oct. 1986, the Journal of the American Medical
Association will probably publish (it has since been published-ed.) a paper by Shapiro and Levy—the‘Boston
Study' on the risk of agranulocytosis with dipyrone.
Hoechst and some 100 other companies who manu
facture dipyrone (the WHO list of diypyrone brand
names is very long 1) will use this study to prove that
dipyrone is (more) safe than was thought. Hoechst had
already started a mass media campaign stating that the
risk of agranulocytosis from dipyrone was “only I in
a 1,000,000".
Some critical observers disagree. They maintain
that the study does not bring any new information on
the risk of agranulocytosis, and that the Boston Study
presents the data in a way which makes it look better.
It must be noted that the risk of 1 in 1,000,000 is valid
for anyone who takes one or more tablet of dipyrone
during one week only. If dipyrone is used for longer
periods, the risks will be greater (tnis was actually
confirmed by Shapiro during a press conference in
Stockholm, and it was the only sentence which was
missing in Hoechst verbatim records of the same
meeting.). For example, if one uses it every week,
the risk is 1:20,000 per year. With other calculations,
one can estimate a risk of 1:70,000 packages of dipy
rone. Obviously, this is a more appropriate way of
quoting risk figures. It must be admitted however,
that data from the 1950’s (1:300 or so) are clearly
invalid, and that agranulocytosis in general is a rare
disease: in most countries 6 to 10 cases per million
inhabitants are diagnosed every year. The ‘share’
caused by dipyrone differs, but ranges between 13 to
35% in the current Boston study. The problem with
dipyrone is that it is so widely used. Its world use is
quoted by Hoechst at 10,000,000 kilograms per year.
This means that even with a low risks of 1:1,000,000
some 7000 cases of agranulocytosis can be expected every
year. Most of the dipyrone is used in communist and
developing countries where standards of drug control or
medical care are lower. This means many avoidable
deaths and it is HAI's (and other such organizations')
task to take up this issue.
To help you in dealing with this issue, 1 present
here a summary of the problems with dipyrone and the
‘Boston Study". It is recommended to read the
BUKO ‘Pharma Brief’ for other view points. Please
note that the Boston Study was limited to the study of
agranulocytosis and aplastic anaemia (which is not
related to dipyrone). Other severe side-effects of
dipyrone such as shock, hypotension, Lyell syndrome,
and Moscowitz syndrome were not studied.
Dipyrone VS Aspirin and Paracetamol
The benefits of dipyrone is not greater than simple
aspirin or paracetamol. Hoechst claims that dipy
rone has spasmolytic and anti-inflammatory proper
ties besides the analgestic and anti-pyretic properties
but that is not correct at least in the normal dosages.
Dipyrone is neither belter nor worse than aspirin or
paracetamol. To assess its place in the market, one
should compare risks and benefits. Hoechst claims
that the agranulocytosis side-effect of dipyrone
causes fewer deaths than aspirin (gastric bleeding) or
paracetamol (liver toxicity in high doses). This can be
countered by the fact that these are avoidable risks
because the aspirin risk group can be identified and
packages of paracetamol can be made small enough
(e.g. 10 tablets only) so that it cannot kill while agra
nulocytosis due dipyrone cannot be prevented as it
happens unexpectedly, sometimes even after years of
'safe’ use.
Other arguments against dipyrone arc:
—even after 100 years of use, the mode of action is
still unknown.
—unknown is
also which metabolite causes
agranulocytosis or other side-effects (and how). It
is known, for example, that the drug aminophcnazone, banned worldwide because of severe side
effects, has some similar metabolites as dipyrone:
does this mean that dipyrone metabolites cause the
same side-effects?
—basic pharmacology data (e.g. use in renal, liver,
or elderly patients) carcinogenicity, teratogenicity
are not yet known, as it was developed before the
‘thalidomide scandal’ and could therefore get easier
registration.
agranulocytosis with the use of dipyrone in ‘normal
controls. If the agranulocytosis cases used more
dipyrone than the controls did, this is an argument
for a link between dipyrone and agranulocytosis. The
higher the difference is the more likely a connection
between the disease and the drug. Such case control
studies are difficult to implement, and strict control is
needed on its proper conduction, as it is easy to intro
duce bias. The most important criterion is that the
‘controls’ must be representative for the general popu
lation and have similar risk factors for agranulocyto
sis as the ‘cases’. The Boston study aimed to detect all
cases of agranulocytosis in defined areas in West
Germany, Spain, Italy, Sweden, fsrael, Bulgaria,
Hungary, Brazil, and Indonesia. Later, Brazil and
Indonesia were excluded, because it was not possible
to get trustworthy data. In Sweden dipyrone had
been banned. Italy and Bulgaria were included later,
but did not have enough cases for statistical analysis.
So only the data of 5 study areas could be used: West
Germany, (Berlin and Ulm), Spain (Barcelona), Israel
and Hungary (Budapest).
1984: Letter to the Lancet
Shapiro published the intermediate results in the
Lancet of 25th Feb 1984 (pages 451-2). It is interest
ing to compare this letter with the final paper. Some
strange things happened:
—the frequency of pyrazolone use in the control
group is quoted as 0.4% to 5%. However, the
—there are 2 Japanese reports that link dipyrone to a
control group in the final paper quotes 1.27%
significant increase in hepatoma toxicity studies
to 20.63%.
It means Shapiro has taken
with mice. Hoechst has never challenged these
new or other controls who apparently used more
reports.
pyrazolones than the first group. It is statistically
highly unlikely that both control groups are re
—interactions with other drugs such as anti-diabetics
presentative for the same population, and this
have never been investigated.
means that the results are questionable. The three
fold
increased use in controls means also a three fold
All this information is enough to refuse its regis
lower relative risk, which is beneficial to Hoechst.
tration under new drug safety criteria. So why
should we allow a ‘comeback’ of dipyrones?
—Shapiro quoted a case fatality rate of 5%. In the
final report this figure doubles to 9%.
The Boston Study
Hoechst did not agree with the Swedish studies on —Shapiro said he needed 400 cases of agranulocytosis
to assess the risk properly. However, due to large
the incidence of agranulocytosis in connection with
percentage of exclusions, only 221 cases are analyzed
dipyrone, and commissioned a new study in 1978 to
in the final study. Yet, he calculates risks without
the Boston Drug Epidemiology Unit (Dr Shapiro) to
problems.............
find out the real incidence of agranulocytosis. This
study looked only at agranulocytosis (and aplastic
anaemia) and did not look into all other side-effects of Results as in Final Paper
dipyrone.
One of the strangest results is the wide regional
The study is a ‘case-control’ study which basically variability in the ‘relative risk’ for agranulocytosis
compares the use of dipyrone in all found cases of due to dipyrone:
Ulm
12.2
Israel
1.8
Berlin
20.9
Budapest
0.9
Barcelona
30.5
Incidence rates of agranulocytosis vary not only
between countries, but also between community and
hospital cases in the same country. This is illustrated
with the following table.
region
This means that in West Germany and Spain
dipyrone is strongly associated with agranulocytosis,
but there appears to be little or no risk at all in Israel
and Hungary. This result could not be explained by
Shapiro or Levy. Of course it is possible that there is a
real difference in the risk, but I think it is more likely
to bea result of faulty methodology. Let us analyze
the percentage of agranulocytosis cases who admitted
the use of dipyrone:
Ulm
21%
Israel
20%
Berlin
35%
Budapest
13%
Barcelona
30%
Controls
who used
di pyrone
Pyrazolone
use (IMS)
DDD's per
1000/day
relative
index
1.7
W. Germany
23%
13.3
Spain
1-2%
12.0
1.0
Italy
2.2%
10.6
2.0
Israel
11.0%
3.3
33.3
hosp rate.
hosp/
comm
index
ULm
3.5
10.8
3.1
Berlin
2.3
9.4
4.1
Barcelona
4.2
5.6
1.3
Israel
5.6
3.1
0.6
Budapest
7.2
5.0
0.7
(all rates in agranulocytosis cases per million person
years) Why is the hospital rate in Germany so high?
Are German patients given more dipyrone or other
agranulocytosis causing drugs than in other countries?
Or is it that the community rale is relatively low?
Could this be an indication that the community cases
were undetected ? The mortality due to agranulocyto
sis in developed countries was estimated in literature
to be 15 to 25%. Shapiro now finds a Case Fatality
Rate of 9%. From the data it can be concluded that
the CFR in community cases (10%) was higher than
the hospital cases (6%). This is probably the effect
of less effective or delayed medical care and it supports
the expected higher CFR in developing countries where
medical care is less likely to be available. For deve
loping countries it is safe to expect a CFR of 25 to
50%. (as it was in Europe 30 years ago). Most cases
will never be diagnosed., because they die of ‘normal’
pneumonia, and because they often obtained dipyrone
without prescription or medical supervision. (The
study should have given regional CFRs).
There appears to be not a 20-fold difference, so
the lower relative risk should be explained by some
thing else. I suggest that it is caused by biased selec
tion of controls. Let us analyze the percentage of
controls who admitted the use of dipyrone, and com
pare it with the IMS sales data of pyrazolones in that
country (IMS sales quoted by Laporte):
Country
Comm.rate
Criticism of Methodology
It appears that the controls in Israel used 5 times
more dipyrone than the controls in other countries.
How can be this related to the IMS sales data, which
suggest that Israel actually uses 3 to 4 times less
dipyrone? IMS data from Israel are known to be less
reliable but would they be responsible for a 20 fold
difference? The conclusion must be that the con
trols used in this study were not representative for the
population or that the results were falsified. It
must be realized that a ‘higher’ use in controls produces
an equal ‘lower’ relative risk, which is beneficial for
Hoechst.
Due to a veiy strict criteria a high percentage of
the agranulocytosis cases were actually cxclud.d from
the study: 31 % of the community cases (94 of 299), and
all (130) hospital cases. Although this is scientifically
correct, it increases the likelihood of increased bias.
Shapiro does mention this himself in the study. But
he fails to explain why they couldn’t find proper
matching controls for the hosp.tal cases, whereas they
did find enough controls (1751) for the community
cases. The absolute incidence of all agranulocytosis
might be underestimated due to missing patients (not
admitted to hospital in study region, not diagnosed or
died before diagnosis was made).
The controls also used a lot of analgesics: 27%
of them mentioned the use of any analgesic drug in
the week before. I do not have any figures to compare
with, but this is definitely a drugged world I
Many people died: an unknown number before
diagnosis (agranulocytosis patients may die of ‘nor
3
the civic authorities on the KEM (MARD) doctors’
strike. By threatening the doctors with disciplinary
action the BMC and the representatives of political
parties in the Standing Committee have shown utter
disregard for all the norms of democratic functioning
and the law. We wish to point out that: (1) The
KEM doctors agitation was not for demands for
personal gain-they were not demanding wage increase,
tenure etc or even better conditions for themselves.
(2) The doctors have repeatedly stated that the objec
tive was only to draw public attention to the atrocious
conditions of the public hospitals, (3) The doctors did
not abstain from duties even when they were on hunger
strike.
mal’ opportunistic infections e.g. pneumonia, and
might not be recognized by general practitioners. As
the incidence of agranulocytosis rises with age, one
expects elderly people to be more affected. They
might get less intensive treatment and might be
‘allowed’ to die because of other factors (other severe
diseases or euthanasia). A further 7% of undiagnos
ed agranulocytosis cases died before interview could be
done, and 9% died after the interview. The inter
views were different in structure in different countries
because the number of dipyrone-containing drugs
differed enormously, ca. 350 in West Germany, 173
in Spain, and only 3 in Hungary. As each drug name
had to be read out to each patient and control the list
was far longer in Germany than in other countries.
This might have lowered the attention of the intervie
wer or the memory recall of the patient, and might
have resulted in different reliability of interview
techniques. Shaipiro mentions this problem too and
he ‘solved’ it by reading only those drug names which
belonged to the 90% most sold drugs. As the study
came up with enormous regional variability it must
be excluded that some of the non-mentioned drugs
carry a different risk (e.g. due to colorants, excipients,
or method of use).
The authorities have generally accepted these
points-but have denied the lack of facilities, bad main
tenance, lack of drug etc without producing even a
single fact to support the denial. Not only that, the KEM
doctors’ point was aptly vindicated when the autho
rities were forced to close down an operating theatre
following press disclosures of unhygenic conditions
there.
What has in fact angered the civic authorities and
the political parties in the standing committee is the
unusual boldness and the high level of consciousness
and social responsiblity displayed by these doctors in
this agitation. What has frightened them is that the
KEM doctors have broken away from the power
structure (in our society doctors are an integral part
of the power structure) and have tried to directly
appeal or educate the people about their rights- i.e.,
in the words of the authorities, ‘violated the rules’
of democratic game. The BMC authorities are not
unware that such actions by doctors can well act as
catalysts in bringing together doctors and patients
(people) who can demand accountability from civic
institutions. This is precisely what has unnerved the
civic authorities-only they call it ‘inciting the patients’.
Shapiro stated in his article, that confounding
remains possible, and that methodological problems
must be considered to explain the strange regional
variability.
Conclusion
The ‘Boston Study’ does not necessitate a new
policy regarding dipyrone. The study design is
difficult to interpret and there is unexpected and un
explained regional variability in risks. The study
authors even state that the results cannot be interpo
lated towards other countries. Even when the risk is as
low as Hoechst says, the drug is used so massively
that every year 7000 cases of agranulocytosis can be
expected in our world. The drug is not better than
aspirin or paracetamol, but has some very serious side
effects. Therefore it should be
The KEM doctors have shown remarkably high
standards of social responsibility. Any action aga
inst them by the civic authorities will be a gross viola
tion of the most primary democratic rights of the
Indian citizen. The doctors have committed no
illegal act; they have used only non-violent and
constitutional means of agiation; their only ‘offense’
is that they have chosen not to hide the conditions
in the public institutions in which they work_ condi
tions which directly affect thousands of people. In
attempting to conceal these conditions the BMC is in
fact, comitting a grossly illegal act.
—severely restricted (prescription only) in countries
where adequate medical facilities are available.
—banned in developing countries or any other country
where its (mis) use cannot be controlled or where
adequate medical care is absent.
(Courtesy Health Action International)
In Support of MARD’s Strike.
Amar Jessani
Padma Prakash
We the Bombay Group of the Medico Friend
Circle are disturbed and agitated at the stand taken by
4
Dipyrone Hearing in Germany
On 19. October 1986 the German Federal Health
Office held a hearing on dipyrone in Berlin to re
evaluate the risk/benefit ratio of this old but in certain
countries still much used painkiller.
The Health Office presented figures of the adverse
reaction monitoring system. Although the data is
rather incomplete due to underreporting there were
94 lethal cases after the intake of dipyrone in the
FRG from July 81 to July 86 in the files. The
Health Office evaluated only three of these cases as
unrelated to dipyrone.
thing from making all forms of dipyrone prescription
only and a ban of combination products, a further limi
tation of indications to a total ban is possible.
Source:
Pharma Brief, W. Germany
Campaign Newsletter No. 6.
CAP-Report: A fact-sheet on Analgin.
—Book Review.
The Consumer Association of Penang (CAP),
Malaysia is an example of how a determined group in
a Third World Country can rouse public opinion by
publishing
a series of study-reports on a number of
Haematological reactions (agranulocytosis) were
the cause of death in 46 cases, allergic reactions important consumer-issues. The small book under
(shock, skin) in 39 cases. This makes clear that other review, 8th in the series of study-reports by CAP,
risks of dipyrone than agranulocytosis must be taken has been published at an opportune time. The ques
into account.
tion of Analgin is being hotly discussed after the
publication of the so-called Boston-study on the
The controversial discussion of the Hoechst- incidence of agranulocytosis due to Analgin and a few
sponsored Boston study on analgesics, agranulocytosis other antiinflammatory agents. In such a context,
and aplastic anemia took a large amount of time in this ‘CAP-Report’ on the details of the use, misuse and
the hearing. The coordinator of the study, Dr. adverse effects of Aminophenazone and Dipyrone
Samuel Shapiro had some difficulties to explain how (Analgin) in Malasia should be of valuable help for
they came to their final “excess risk estimate” of agranu the activist groups not only in Malasia but to some
locytosis of 1.1 per million for any intake of dipyrone extent in other third-world countries also since it
during a week’s period. Many of the invited scientists gives valuable information in consolidated form on
did not think that this was a very useful figure be the adverse effects of Aminophenazone and Analgin.
cause it does not allow to quantify the risk on a user/ Though aminophenazone has been banned in India,
Analgin continues to be extensively used and misused
year basis.
and hence the small chapter on Dipyrone, which gives
Calculating with other figures in the study and a valuable information on adverse effects of dipyrone
consumption estimate it was thought in the end that as reported from different countries would be of
the risk is more likely to be in the range of 1 in 30,000 great interest to Indian-readers. Chapter No. 4 on
1 in 70.000 per user and year. The speaker of the “regulations concerning aminophenazone and dipy
FRG’s Pharmacists Association concluded at the end rone in other countries” is also of general interest.
of the hearing that it took him a long time to under It shows that dipyrone has been withdrawn or banned
stand that the risk of agranulocytosis is as high as it in a full dozen countries and is under prescription
was already estimated in the 1981 hearing of the
control in five countries.
Health Office on dipyrone.
The chapter on "International marketing’ exposes
The Deputy Health Senator of Bremen, Prof. the double standards practised by multinational drug
companies.
Thus for example, though Dipyrone has
Schonhofer pointed out, that only a ban of dipyrone
can reduce the risks, as less dangerous alternatives are been withdrawn from the U.S. from 1977, subsidiaries
available. He also mentioned that dipyrone is a of American multinationals like Dupont, Foremostsevere problem for the Third World, as much of it is Mckesson, Richardson-Merrel, Searle, Upjohn., etc.
used there and the possibilities to survive the adverse continue to market Dipyrone in Latin America. The
reactions is much lower than in industrialized count indications for use also differed. For example, in
ries. He made an appeal to the responsibility of the 1974, Wintrop, another multinational, advocated”
“menstrual pain” as one of the indications for dipy
biggest dipyrone-producing country to act.
rone whereas “in the U.S., F.D.A.—required drug
In two month the Federal Health Office will labelling had warned women who were menstruating
announce its decisions on dipyrone. As the president against using Dipyrone because of the possibility of
of the Office pointed out in his final statement every severe haemorrhage.”
5
as to the name of the patient, doctor or date, dis
pensary, place... .etc.. . .etc.
In rhe remaining chapters, there is some systematic
recording of the different brands available, misleading
claims made, wrong information provided by drug
companies to queries; overprescription by doctors in
Malasia. Anybody wanting to do a similar study
report in India would find this CAP-report as a good
example of concrete documentation of nasty market
ing practices of the drug companies. Four case
reports of adverse drug-reaction due to Aminopyrine.
Aminophenazone and Dipyrone have been given.
These give an idea about the human agony involved
in these lethal adverse drug-reactions. The Malasian
cases, however, do not give the identification details
A couple of references have been repeated. Other
wise this is a well-written, quite readable report.
We. in India, should aim at preparing similar report on
some of the most hazardous drugs being sold in India.
Anant R.S.
(CAP-Report, No. 8, Drugs and the Third World:
Aminophenazonc and Dipyrone-hazards and market
ing Practices, published by Consumer Association of
Penang, 1986: 87, Cantonment Road, Penang, Mala
sia, pp. 132. Price : not given.)
SC flays continuance of banned drugs
The Supreme Court today (Nov 13) flayed the
Union Government that it is ‘’murder'’ to permit,
under the stay orders of the High Courts the conti
nuance of drugs banned by it in 1983. While hearing
the cases on oestrogen-progesterone pregnancy drugs,
the judge declared that they were surprised that the
High Courts should have granted stay orders in such
matters. There was no answer on behalf of the Union
Government to the persistent query of both the judges
as to why it had not sought transfer to the Supreme
Court, of the cases pending in the various High
Courts against the July 23. 1983 notification banning
the 18 drug formulations as dangerous to public
health and which according to the Union Govern
ment had been stayed by the High Courts of Bombay,
Calcutta, Andhra Pradesh and Gujarat. Some of the
18 banned fixed dose combinations are of steroids.
amidopyrine, chloramphenicol, atropine in analgesic
anitpyretics, analgin, tetracycline and analgin with
vitmin C, phenacetin, chloramphenicol with strptomycin, penicillin with strptomycin and anti-histaminics
in antidiarrhoeals. In its reply to the Supreme Court
petitions filed by the drug companies, the Union
Government has stated “it is only a few companies,
particularly the multinationals with vested interests
who are opposing the Government's action.”
The Drugs Controller of India has been directed
to decide whether oestrogen-progesterone pregnancy
tests should be banned because they are a danger to
public health. This decision must be given within a
maximum period of six months concerning Menstrogen injections and tablets, Menstrogen forte in
jections and Organutin tablets manufactured by Infar
(India) Ltd. as also E.P. Forte manufactured by Unichem. The Judges directed the Drugs Controller of
India to give notice of the inquiry to the two com
panies before them as also the Petitioner. The notice
must also be published in two national papers of the
Hindi and English languages plus one regional lan
guage newspaper. The Judges stated that these
directions were being given because in matters con
cerning public health, the people likely to be affected
should be given an opportunity of participating in the
inquiry. The Drugs Controller of India has been
directed to allow any consumer group or party who
wishes to participate in the inquiry and they may be
given such hearing as the Drugs Controller thinks fit.
The two companies and the Petitioner will be entitled
to be heard and present their evidence in the inquiry
with both parties exchanging the evidence presented.
The evidence will also be made available to the con
sumer groups participating in the inquiry. It will be
open to the Drugs Controller to hold an inquiry,
where necessary at places other than Delhi to suit
the convenience of consumer groups and other persons
participating in it.
The Supreme Court in its order came down heavily
on the Union Ministry of Health, the Medical Council
of India, and the Indian Medical Association for
‘betraying- the cause of Public Health by non-action
on the implementation of the notifications ofJuly23,
1983 banning the manufacture, sale and import of
these 18 drugs.
Source:
6
Hindustan Times 14-11-86
Letter to WHO & UNICEF
Dear Dr. Mahler/Mr Grant
At a special WHO/UNICEF meeting in Geneva,
from 17-18 December 1985, a group of experts con
cluded that transnational baby milk companies should
stop donating milk supplies for newborn infants in
maternities and other maternity situations.
is so small that donations by companies cannot be
justified, particularly given the dangerous promotional
potential of such supplies donations. For the few
babies that need them, hospitals can afford to pur
chase infant milk supplies, just as they buy supplies
of other food, equipment and medicines.
The experts recognized possible social and eco
This WHO/UNICEF meeting was the result of a
nomic situations in which infants may need breast
request by delegates at the World Health Assembly in
milk substitutes. They noted that infants in institu
May 1985, who wanted clarification of the provisions tions such as orphanages and refugee camps may
of the WHO/UNICEF International Code on the justifiably need free infant milk, through those in
Marketing of Breastmilk Substitutes. At this meeting stitutions. In such cases, the donations should be
member delegates had reported that transnational provided for as long as the infants concerned are in
baby milk companies had violated the Code by pro need.
viding excessive quantities of artificial milks to hospi
tals in order to create demand for the products.
However for the majority of newborns where
breastmilk has been proven to be the best source of
Nine experts from eight countries together with infant nutrition, free or subsidized supplies of breast
WHO and UNICEF staff participated in the December milk substitutes in maternity wards or hospitals would
1985 meeting to provide clarification and guidelines lead mothers to be dependent on these sources of
to the Code's provisions on free breastmilk substitute nutrition for their newborn once they leave the care of
supplies, to member states of the WHO. This meeting the hospital.
produced a report of its proceedings and recommenda
tions, and also revised a background paper on physio
In most of the Third World where mothers are poor
logical factors influencing breastfeeding.
and illiterate, and clean water supply is often non
existent, the incidence of diarrhoea among infants
This report was submitted to the 39th World being fed with contaminated water is very high. Poor
Health Assembly in May 1986. However we read families who cannot afford expensive infant milk for
with great concern the news report published in the mulas will stretch their meagre supplies of the latter.
International herald Tribune (IHT) Saturday-Sunday, This will mean diluting the milk formula which will
May 10-11, 1986, that one of the recommendations in lead to malnutrition of infants. Diarrhoea and
the report had been omitted.
malnutrition can lead to fatalities and impairment of
healthy growth among children.
The recommendation was that ‘maternity wards
and hospitals should not be recipients offree or subsidi
It is for this reason that the WHO/UNICEF expert
zed supplies of breastmilk substitutes.
group had recommended that hospitals should not
The IHT reported that the above recommendation receive free or subsidized infant formula and other
was omitted from the WHO/UNICEF guidelines breastmilk substitutes. We regret that this crucial
because of pressure from the United States and the recommendation was omitted in the final WHO/
baby food manufacturers. We were upset to read UNICEF guidelines. We are all the more concerned
this report because if it is true it would mean that the by the news report that this omission was caused by
WHO and UNICEF have unfortunately been sub ‘pressure from the United States and the baby food
jected to and succumbed to outside pressure in the manufacturers’. If this report is correct, then it
indicates that powerful vested interests have been
performance of their duties.
able to exert undue influence on the WHO and UNI
We feel this is a serious matter because the re CEF in a crucial matter related to the health of in
commendation that was omitted had been the result fants of the Third World. Such a development,
of careful deliberation. The experts at the WHO/ you will agree, is most disturbing and will be objected
UNICEF meeting in December 1985 after carefully to by everyone who has the interests of children at
examining the medical grounds for providing breast heart. Moreover, such manipulation of United
milk substitutes to newborns determined that the Nations agencies by business companies and govern
percentage of infants who need breastmilk substitutes ments protecting such interests is deplorable.
7
77565/76
We therefore would like to seek your clarification
whether the report on the omission of the recommen
dation is accurate.
We also strongly appeal to your goodself as Direc
tor-General of WHO and Executive Director of UNI
CEF to use your offices to reinstate the original guide
lines for the sake of infants and children in the Third
World.
We seriously hope that you will consider our re
quest as it comes from the peoples of the Third World.
We would also appreciate a response from you at your
earliest convenience. Best Wishes.
Sincerely,
S M Mohd Idris
Coordinator
Third World Network. 87, Cantonment Road,
Penang, Malaysia.
Bill to Restrict Ads on Breast Milk Substitutes
A bill to restrict the trade as well as production.
supply and distribution of breast milk substitutes and
feeding bottles is to be introduced in 'he Winter
Session of Parliament. It seeks to:
* ban all forms of advertisement suggesting that milk
powder and milk related equipment are equivelant to
mother’s milk.
* make it mandatory to print a notice on every con
tainer that “breast milk is best for your baby" and
insert a warning that breast milk substitute is not
the sole source of nourishment for an infant.
Labels on the container should indicate the hazards
likely to occur if the milk is prepared inappropriately.
Advertisements should not have words such as
‘humanized’ or maternalized; nor should they carry
photographs of ‘fat’ babies as part of the promotional
gambit. The bill seeks to forbid all forms of incenti
ves for the sale of breast milk substitutes. Inspectors
will be empowered to enter and search buildings where
clandestine trade of breast milk substitutes is being
carried out. Under the proposed enactment the
punishment for contravening various clauses includes
imprisonment upto three years and a fine of Rs 5000/Source:
Times of India, 3-11-1986.
XIII ANNUAL MEET OF THE MFC
Medico Friend Circle will hold its XIII Annual Meet at Seva Mandir Training Centre, Kaya
(near Udaipur), Rajasthan, on the 26th and the 27th of January 1987. The theme chosen for discussion
this time is “Family Planning in India : Theoretical Assumptions, Implementation and Alternatives”.
We invite you to attend the Meet and share your views and experiences. The participants are as
usual expected to pay for their own travel. Simple boarding and lodging facilities will be available at the
venue, on a payment of Rs. 20/- per day per person. We charge a small registration fee to cover the cost
of the cyclostyled background papers. Return reservation facilities are also avialable. If you wish to attend.
please write to us at : Medico Friend Circle, 1877, Joshi Galli, Nipani - 591 237. We will then send you the
venue details and background papers.
Convenor, MFC
Editorial Committee:
Anil Patel
Abhay Bang
Dhruv Mankad
Padma Prakash
Vimal Balasubramanyam
Sathyamala, Editor
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organization.
Annual Subscription— Inland Rs. 15.00
Foreign: Sea Mail — US $ 4 for all countries
Air Mail: Asia — US S 6; Africa & Europe — US § 9; Canada & USA — US § 11
Edited by Sathyamala B-7/88/1, Safdarjung Enclave, New Delhi 110029
Published by Sathyamala for Medico Friend Circle Bulletin Trust, 50 LIC quarter
University Road, Pune, 41106.
Printed by Sathyamala at Kalpana Printing House, L-4, Green Park Extn., N. Delhi 16
Correspondence and subscriptions to be sent to—The editor, F-20 (GF), Jungpura
Extn., New Delhi-110014.
medico friend
139
circle
bulletin
APRIL 1988
Medical Research on Trial
Sharon Kingman'5
Medicine is a double-edged sword. It can
work wonders, but it can also cause immense
harm. Such extreme effects are, of course, ex
ceptional, and doctors may well recognise them
without carrying out formal studies. More com
monly, there may be no material difference bet
ween alternative treatments, or only a mode
rate difference, which doctors cannot reliably
assess without large, formal studies. So doctors
need to know not only whether a treatment is
moderately effective, but also whether it has any
moderately harmful or unwanted side effects.
As a result, much medical research involves carry
ing out trials—studying groups of patients who
are taking different treatments and comparing
their progress.
A glance at the many medical journals pub
lished in Britain alone shows just how numerous
such trials are. Yet, ironically, the medical pro
fession does not exploit such an established me
thod of evaluation to the full. The public, in its
turn, frequently attacks this method of research,
on two fronts. When clinicians try to evaluate
treatments that people already believe will do
them good, they are accused of withholding
therapies unnecessarily. Yet when an establish
ed treatment turns out to have little effect, or
research shows that a new one has unwanted
side effects, doctors have to counter claims that
they are using patients as "human guinea pigs".
The medical profession must shoulder some
of the blame for this state of affairs. It is often
* Reprinted from New Scientist, 18 Sep. 1986, p. 48-52.
slow to evaluate the effectiveness of traditional
treatments/ yet sometimes quick to adopt new
therapies and techniques before finding out what
their risks and benefits really are. Frequently,
doctors deny the need to assess their actions
for fear of revealing their uncertainty about the
treatments they prescribe. Some clinicians stick
to their old habits even when research suggests
that patients would benefit from a different ap
proach. Given the reluctance of many doctors
to accept the need for strict evaluation, it is not
surprising that patients often do not expect treat
ments to be systematically tested and that many
of them remain unaware of the value of scientific
evaluation of medical and surgical therapies.
Yet the lessons for both doctors and patients
ought to have been learnt a long time ago.
Many treatments that appeared at first sight to
be beneficial had serious and unexpected con
sequences. Doctors often detected the side effects
only by carrying out careful studies—randomised
controlled trials to assess the risks and benefits
of a treatment.
A good example was the attempt to prevent
rickets in the late 1940s by adding vitamin D,
which increase the absorption of calcium from
the gut, to baby foods. Unfortunately, babies
that were hypersensitive to vitamin D became ill
and died from high levels of calcium in their
blood. Another salutory tale is the epidemic of
blindness in infants that began in the 1940s and
continued for 12 years. The problem, which was
identified with confidence only by a randomised
clinical trial after about 10000 children had been
affected, was the practice of giving too much
oxygen to premature babies to aid their survival.
Equally tragic was the development of vagi
nal cancer in girls born to mothers who had
taken a drug called diethylstilbestrol (DES)
during pregnancy, with the aim of preventing
miscarriage and between 4 and 6 million mothers
and their offspring were exposed to DES dur
ing the mother's pregnancy. Doctors carried out
13 studies between 1946’and 1955 to test the
effectiveness of DES in preventing miscarriage
and other problems in pregnancy. Of these
studies, seven—none of which had adequate
controls—found that the treatment was useful.
The other six, which were adequately controlled,
found no evidence for a beneficial effect. Des
pite this evidence, doctors continued to pres
cribe the "treatment" for an estimated 100,000
pregnant women per year for 15 years. The full
dimensions of this medical disaster have yet to
be established.
Clinical trials to settle controversial issues can
still meet with resistance from many quarters.
When trials began, in the 1950s, to investigate
the risks and benefits of giving extra oxygen to
premature babies, some nurses believed so fer
vently that extra oxygen helped these infants to
survive that at night they covertly gave more
oxygen to the infants in the control groups.
This practice not only prejudiced the trial's chan
ces of establishing whether extra oxygen did
help these children to survive, but also, as it
turned out, exposed babies in the control groups
to the risk of blindness.
among women's organisations that one group
in the trial will receive pills which are in fact
placebos."
This attitude ignores the existence of the
double-edged sword, so amply demonstrated by
the examples above. Critics of the MRCs trial
take the view that it is unethical to withhold
extra vitamins at the time of conception because,
they claim, we already know that vitamins are
beneficial. Yet Nicholas Wald. Professor of En
vironmental and Preventive Medicine at St.
Bartholomew's Hospital Medical School, and
Paul Polani, Professor of the Paediatric Research
Unit at Guy's Hospital Medical School, dispute
this conclusion. Writing in the British Journal
of Obstetrics and Gynaecology, they argue that
"the issues affecting whether a particular study
is ethical are complex, but a crucial condition
is that no individual subject should be known to
be at a disadvantage through entering the trial..
Although there is at present no evidence that
any of the extra vitamins used in the neural tube
defect intervention studies will cause harm, there
is also no evidence that they are acceptably
safe". Wald and Polani believe that the two
previous studies into this topic were flawed—one
did not have satisfactory control group, the other
was too small. The only way to find the answer,
they say, is to carry out a large, randomised clini
cal trial. There are plenty of examples where
failure to randomise can suggest striking "the
rapeutic" results which turn out to be spurious.
The uncontrolled trials of DES provide one.
lain Chalmers, director of the National Peri
natal Epidemiology Unit at the Radcliffe Infir
mary, Oxford, also argues that critics are wrong
to call such trials unethical. Writing in Birth,
he says: "The ethical basis for randomised
controlled trials is that both the anticipated be
nefits and the unexpected risks of inadequately
evaluated interventions are distributed by chance.
Equality of opportunity thus applied to both
positive and negative effects. In placebo con
trolled trails, those individuals receiving placebos
will escape the unexpected risks of active treat
ments. No doubt, he adds, those women who
received placebos in the randomised trials of
DES for example, would wish to emphasise
the rights of controls to this form of protection.
In 1983, Britain's Medical Research Council
(MRC) set up a trial to test whether mothers
who took extra vitamins at around the time of
conception had fewer children with neural tube
defects such as spina bifida. Earlier research,
using potentially less reliable methods, had
suggested that a combination of vitamins might
reduce the number of affected children, but many
doctors remained in doubt. Some doctors criti
cised the trial, and following their lead, rep
resentatives of several pressure groups wrote in
the national press that "there is ample medical
evidence, and no controversy, about the fact
that a good diet, which includes the vitamins
used in these trials, maximises the chance of not
having a handicapped baby, especially if start
ed well before conception. .there is concern
Public acceptance can be an obstacle
It is much more difficult to evaluate an inter
vention once it has been accepted than it is to
2
test one that is entirely new. Amniocentesis is
a case in point. This procedure has become a
routine part of antenatal care for many preg
nant women. It involves removing some of the
fluid that surrounds fetus, and analysing it in
order to diagnose conditions such as spina bifida
or Down's syndrome. If the fetus is affected the
parents can choose to have the pregnancy ter
minated.
Chalmers, "of over 5000 women whose preg
nancies have been investigated with chorion
villus biopsy in the US, a total of only four wo
men seeking prenatal diagnosis have partici
pated in the randomised trials. Although expe
rience has already suggested that chorion villus
biopsy may sometimes be followed by severe
maternal septicaemic shock (comparable to that
which led to the withdrawal of the Daikon
shield), as well as less serious problems, Ameri
can women appear to be eager to buy this un
evaluated service from the growing number of
clinicians prepared to sell it to them.” One rea
son for this low figure must be that patients are
reluctant to enter a trial if it means that they
may not receive an investigation that they want
to have.
Amniocentesis has been in common use for
over 15 years; over 20,000 are performed each
year in England. Yet the results of the first pro
perly controlled evaluation of amniocentesis
were published only earlier this year. These re
sults suggest that, although this is not a common
problem following delivery, there may be an in
creased risk of respiratory difficulties, such as
respiratory distress syndrome and pneumonia
in newborn babies whose mothers had amnio
centesis during pregnancy. Chalmers says; “So
far, no evidence is available with which to as
sess whether or not lung function will be com
promised in the long term in the vast numbers of
children who have been (and continue to be)
born following amniocentesis. Had amniocen
tesis been introduced within the context of a
controlled experiment from the outset, however,
this information would now be available."
Such difficulties in evaluating new techniques
come about because, as Chalmers says, "New
surgical procedures, unlike new drugs, can be
introduced into medical practice without any
requirement from public authorities that theyhave
been shown in adequately controlled studies
to be efficacious and reasonably safe," Surgi
cal interventions have as much potential as
pharmaceutical products for causing inadvertent
harm. Despite this, Chalmers expects conside
rable resistance to any moves to strengthen the
controls on introducing new surgical techniques.
The public's tolerance of "this poorly controlled
form of experimentation by health professionals'
results, he believes, from the degree of trust that
most people have in their doctors. People expect
doctors to know what is best. What is more,
doctors can find it difficult to admit that they are
uncertain about the treatment they prescribe,
something that they must do if they are to eva
luate their practices in a scientific manner.
Doctors in several countries, including Britain
are determined to avoid the same problem with
another newly developed technique, chorion
villus biopsy. This procedure could largely rep
lace amniocentesis, as it allows diagnosis of fetal
abnormalities such as Down's syndrome earlier
in pregnancy. It involves taking a sample of the
developing placenta for analysis. This is done
by passing a small instrument through the cer
vix, the neck of the uterus. By the end of 1 983,
doctors had used this technique to investigate
240 pregnancies. Only two years later, this
figure had risen to 10,000. Soon, there may be
hundres of thousands of children whose mothers
underwent chorion villus biopsy during preg
nancy, so that even if the proportion affected
by complications-chronic infection, for example
is quite small, the actual numbers could be very
large. Doctors in Canada, Denmark, Finland
and Britain have decided not to use chorion
villus biopsy except in properly controlled trials.
Such voluntary self-regulation is by no means
universal, however. In the US, the National
Institutes of Health tried to persuade clinicians
to collaborate in a randomised trial. But, says
Such confusion can lead to double standards,
with one set of rules for systematic research and
another for routine clinical practice. One doctor
has epitomised the current situation nicely: "I
need permission to give a new drug to half my
patients, but not to give it to them all."
What we need now, says Chalmers, is more
open acknowledgement to the public of the
insecure nature of the evidence on which many
doctors base their opinions and practice, follow
ed by a discussion of how those doctors honest
enough to admit their uncertainties should go
about protecting the interests of their patients.
3
Treatment by chance
Should they pursue controlled experimentation,
or the kind of uncontrolled experimentation that
characterises much health care at the moment?
Part of the problem, Chalmers believes, is that
some people find it difficult to accept that
"common or garden misery matters" that do not
kill people—for example, whether one type of
suturing material causes more or less discomfort
to women who have to have stitches following
the birth of their child—deserve scientific evalua
tion.
Why do such large discrepencies persist in
medical practice? Individual doctors are not
really to blame. Frequently, there are many diffe
rent treatments-often a wide choice of drugs,
perhaps in varying combinations, for an illness.
If a new treatment for a condition is outstandingly
better than all the others, then its benefit will
usually quickly become evident to the doctor
who prescribes it. But one combination of treat
ments may be only about 20 per cent more effec
tive than another. In this
case,
*
it will be difficult,
if not impossible, for doctors to pick up this
degree of improvement in their patients by simple
observation. And a clinical trial involving just a
few hundred patients will usually fail to yield a
statistically significant result if the improvement
in outcome (in the death rate, for example)
is only of the order of 20 per cent. Doctors may
consider such a moderate effect worthwhile,
provided that they can demonstrate it reliably.
But without reliable evidence, apparently con
flicting results from clinical trials of inadequate
size may have the effect of paralysing further
attempts at serious evaluation, as individuals in
both camps—for and against the treatment
point to results that support their view. The end
result is the current situation where the treat
ment that patients receive frequently depends on
which hospital and which doctor they happened
to attend, rather than on a scientific evaluation
of which treatment is more effective.
Even medical practices that could save lives
are only thinly evaluated. The commonest cause
of death in Britain is heart disease. Yet a review
of how doctors in different countries treat pa
tients recovering from a myocardial infarction
(heart attack) shows how uncertain we are about
the "best treatment" for these people. Take the
data collected in a clinical trial conducted in
different countries during 1981 to 1984. In
Italy, 33 per cent of patients who had just had
myocardial infarction received intravenous nit
rates (drugs that dilate the blood vesels reducing
the workload on the heart) while they were in
hospital. Yet in Sweden, less than 1 per cent
had this treatment.
Research has clearly shown that if patients
take betablockers (drugs that slow the heart
and lower blood pressure) in the months or
years following a heart attack, this treatment
reduces their risk both of dying and of suffer
ing a further heart attack by about a quarter.
Despite this evidence, only 5 per cent of Danish
patients had betra-blockers on discharge from
hospital, compared with 24 per cent in Britain
and over 40 per cent in Sweden. Confusion
even exists over the usefulness of a drug that
has been around for over 200 years-digitalis
which improves the efficiency of the heart.
Only 3 per cent of British patients received digi
talis on discharge from hospital following myo
cardial infarction, compared with more than 30
per cent in Finland.
The results of a clinical trial carry clout only
if they are statistically significant. If the therapy
is capable of reducing the death rate or the in
cidence of some other serious but relatively
rare outcome by only about 20 per cent—as is
true of many current treatments—then making
sure that the results will be statistically signi
ficant means making the trial much larger than
is, at present, standard. Salim Yusuf, of the Na
tional Heart, Lung and Blood Institute, Mary
land, and Rory Collins, British Heart Founda
tion Senior Research Fellow, and Richard Peto
Imperial Cancer Research Fund Reader in Canecr Studies, both at the Radcliffe Infirmary, Ox
ford, say that many doctors do not appreciate
sufficiently just how large clinical trials need to
be in order to detect moderate differences in
mortality reliably. Writing in Statistics in Medi
cine, they point out that even if doctors were to
Similar variations occur, to a greater or lesser
extent, between different' hospitals around Bri
tain. Yet all doctors have access to the same in
formation. They cannot all be prescribing the
best treatment for their patients. Some of them
must be wrong, to some degree.
{Contd. on p. S')
4
,
1
I
Pricing the Medical Care in Government Hospitals :
Problem and Alternative Solution
Abhay Bang and Rani Bang
meet the goal of 'Health care for all." Mahara
shtra was nearing this commendable goal when
this decision suddenly came from the blue and
deprived the State of the honour. The public
feeling can be judged from the fact that on our
appeal 1500 persons from 70 villages of this
tribal district came to sign a memorandum and
two MLAs agreed to take this to the state govern
ment.
The government of Maharashtra has intro
duced fee for medical care in all district hospi
tals and medical colleges hospitals from Feb
ruary '88. The patients have to pay Rs. 2 for
outdoor card, Rs. 10 for urine, blood or sputum
examination, Rs. 20 for X'ray, Rs. 30 for ECG,
Rs. 5 per day as the bed charges for indoor
admission and Rs. 150 for a major operation.
This is not simple 'fee rise' as stated by the go
vernment because earlier there were no charges
to most of the patients for any service in these
institutions except 10 paise for OPD card. Hence
all other charges are a new category of tax and
the outdoor card fee is raised by 2000 percent.
What is the effect ?
The Prime Minister is repeatedly expressing
his expectation that the public sector units
should generate profit. Everybody thought that
this applied to the public sector companies in
volved in production or economic endeavours.
But the state government seems to be apply
ing this to the public services like health care
as well. Is it necessary?
As we see from the small district town of
Gadchiroli, the patient attendance in the dis
trict hospital has suddenly decreased. The mid
dle class is turning to private practitioners while
the poor patients are avoiding to go to the hos
pital or are refusing to get admitted or treated
even when they are found to be suffering from
serious diseases. "We can't pay for the treat
ment" is their plea. Government has announced
that 40% of the patients shall be treated free,
but this is left to the discretion of hospital autho
rities. Can a Civil Surgeon every day decide who
should be treated free from the daily crowd of
300 to 500 patients? The experience of anti
poverty programmes suggests that the benefits
selectively meant to be for the poor usually don't
reach them. So most of the poor are not likely
to receive the benefit of free service.
The two arguments often put forward in
justifying the introduction of this fee structure
are:
— These hospitals are meant to be referral
hospitals, but they are unnecessarily crow
ded by patients with minor problems who
come mainly to get injections.
— The cost of medical care is increasing very
fast so the government must try to meet
the two ends.
While there is some truth in both these points,
the solution of charging a fee creates a still
bigger problem. By charging the patients, the
government has succeeded in reducing the num
ber of patients, but not the 'unnecessary' ones.
The poor anyway don't attend the hospital for
minor problems because they can't afford to
lose the wages. The new criterion of elimina
tion is not the seriousness of need for medical
help but ability to pay. This means that now the
government medical care is selectively for those
who can pay and not for those who are in
need. This is essentially same as the private sec
tor medical care. To crown the similarity, the
proportion of 40% free service offered by the
government is the same as one proposed by the
Director of Apollo hospital in his proposal for
new commercial hospital in New Delhi.
This decision of the government of Maha
rashtra in principle means that the State is no
longer willing to shoulder the responsibility
of free medical care to the needy as public
service. If this sets up a trend, people especially
the poor, may increasingly lose the benefits
of free medical care, education or even police
protection as their rights. Our country is com
mitted to 'Health for All by the year 2000.' This
is something beyond the ability of the govern
ment to deliver because health depends on food,
income, education, housing, water supply and
health care—basic amenities which the govern
ment can not provide to the poor people in the
near future. But the government can at least
5
Book Review
Drugs" appears to be towards this direction and
is a necessary addition to the reading list of those
who want to prescribe rationally.
"Problem Drugs", by Andrew Chetly and David
Gilbert, Health Action International, 1986. Copies
available from: Emmastraat 9,2595 E G, The
Hague, Netherlands, (not priced).
The information pack covers the following
areas : Antidiarrhoeals, antibiotics, analgesics,
cough and cold remedies, drugs in pregnancy,
growth stimulants, combination drugs, and con
traceptives.
Medical personnel frequently come across the
so called drug information leaflets being pro
fusely distributed by the pharmaceutical industry.
But the publication "Problem Drugs" aims at
educating the practising doctors and other medi
cal people as to how one should look at any drug
or any 'me-too-drug".
In the field of antidiarrhoeals, a lot has been
already discussed in other platforms as well.
Although ORT has been established as the effec
tive treatment in diarrhoea, it is common know
ledge that patients are prescribed drugs which
have never been proved to be effective. Specific
drugs are neither available nor required. The au
thors have done an extensive review of literature
and have quoted standard references which prove
that antibiotics (streptomycin, chloramphenicol)
adsorbents (kaolin and pectin) Bismuth, charcoal,
quinolines and other anti-motility drugs are use
less. Comparing the effectiveness of the anti
diarrhoeals in the various market preparations,
the authors drive the point home that most of
them have ineffective agents. Regarding lopera
mide they quote a clinical study conducted in
Libya and UK which showed that loperamide did
not diminish duration of diarrhoea or hospital
stay or enhance weight gain. The leaflet published
on hydroxyquinolines is excellent. Neurotoxicity
of these compound is well known. But still in
many countries including India, products contai
ning clioquinoles are available. Then what exactly
has the government and social organizations done
in this regard?
Every drug has its adverse effects along with
its benefits. One should clearly recognize that no
drug exists (or even may exist in future) which
does not bring out some inherent adverse effects
along with it. On comparative basis, one may be
more 'adverse' or dangerous than the other. But
it is we, the medical people who should know
how to use a drug and be aware of the safety
factors. Medicine has become a business and will
stay so for a very long time. The pharmaceutical
industry is structured and operated to gain a good
hold in the market and naturally it has to use all
the possible gimmicks to sustain and thrive.
Hence the role of an educated medical person
is more important because s/he always must de
mand a drug which is of high quality, which meet
the health needs, is effective and that the patient
can afford. Present drug market is flooded with
innumerable drugs. The authors have quoted a
reference which claims that 70% of the drug in
the market is inessential and or undesirable pro
ducts. Can the products of the pharmaceutical
Coming to the chapter on antibiotics, the authors
industry help to improve the health of the people? reach the conclusion that these drugs are pres
The answer is definitely an yes. But this would cribed even in those conditions where they are
apply to only some of the products. We know not required. Fixed dose combination of anti
now that the WHO has recommended a list of biotics (other than cotrimoxazole) have no speci
200 essential drugs, but what about the rest of fic indications. USA and Sweden have withdrawn
the drugs and their combinations? In the present many of these antibiotic combination whereas
day of competition the drug industry with the we all know the state of affairs in India. Anti
best marketing strategy often succeeds—no mat biotics such as chloramphenicol should be re
ter how bad or good the drug is. Medical person served for the treatment of enteric fever and
nel are influenced to such an extent that they tend should not be allowed in the use of other infec
to remember only the brand names and hardly tions. In the recommendations, the authors have
know the pharmacological agent that they are advocated that combinations of antibiotics should
prescribing. Hence a continuing education prog be restricted and a warning on resistance should
ramme aiming at providing the correct informa be printed in the drug literature.
tion is very much needed especially in a develop
ing country like India. One of the main aims of
In the chapter on analgesics, the authors have
the authors of the information pack "Problem mentioned these are the most commonly pres
7
R.N. 27565/76
cribed and over-the-counter drugs. The WHO
has recommended only 5 agents viz., aspirin,
paracetamol, ibuprofen, indomethacin and allo
purinol. The combination of analgesics has never
been proved to be superior to a single agent. Al
though I agree with this in general, the combi
nation of aspirin and codeine has been shown
clinically to be superior to any single agent.
The case of phenacetin has been narrated very
well. Dipyrone has been banned or severely res
tricted in many countries and the authors advo
cate that this should be banned every where. The
same case holds good for phenylbutazone.
The chapter on cough and cold remedies is
also exhaustive. It is a well known fact that there
is no such thing as a cold cure and the most
effective treatment is symptomatic relief. The
market survey will show a large number of expen
sive preparations with least effectiveness.
Coming to the chapter on drugs in pregnancy,
the authors have given a good review of litera
ture on this topic and have recommended that a
clear and universally recognized graphic symbol
should appear on every drug (except haematinics and calcium) saying that these drugs are
not safe in pregnancy. Information regarding this
matter should appear in the lay press also. The
role of EP drugs and DES in clinical practice is
highly questioned by the authors. These drugs
present more risks than benefits. The story of
these agents is a sordid and sorry tale. Every
doctor should go through this leaflet.
The chapter on growth stimulants again makes
an interesting reading. The need to wipe out
anabolic steroids, appetite stimulants, vitamins
the so-called brain tonics, has been beautifully
brought out by the authors. The authors highlight
that "probably no single class of drugs has been
the target of quackery as the vitamins". Govern
Editorial Committee:
Anil Patel
Abhay Bang
Dhruv Mankad
Kamala S. Jayarao
Padma Prakash
Vimal Balasubrahmanyan
Sathyamala. Editor
ment should induce strict control over the claims
made by the vitamin preparations. In contracep
tives, the authors have described the origin and
up to the present status of injectables and imp
lants and recommend that till the controversy
of their utility is over they should be removed
from the regular market.
On the whole, all the chapters have been well
written and the package appears attractive. The
language is easy to understand and the details
are helpful. Further improvements would be if
the authors could include their experiences in
other countries. In conclusion I feel that a copy
of this information packet should be made avail
able in every medical college, major hospital and
libraries catering to medical personnel.
Prahlad Patki,
Reader in Pharmacology, BJ Medical college, Pune.
(Contd. from p. 4)
test a certain treatment in a randomised trial of
2000 patients by giving half the patients a cer
tain drug, and find that only 80 patients in this
group died, compared with 100 of the controls
(exactly a 20 per cent reduction in death rates),
this difference would still not be statistically
significant. They add: "In real life, of course,
the situation is even worse than this as the ave
rage trial size is probably nearer to 200 than to
2000 patients!" In general, they say, there may
need to be between 1000 and 2000 deaths in
such a trial before there would be a good chance
of demonstrating a statistically significant differ
ence.
Source : New Scientist, 1 8 Sep. 1 986, p. 48-52.
(To be concluded in the next issue.)
Views and opinions expressed in the bulletin are those of the authors
and not necessarily of the organization.
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Edited by Sathyamala, B-7/88/1, Safdarjimg Enclave, New Delhi 110029
Published by Sathyamala for Medico Friend Circle Bulletin Trust,
50 LIC quarter University Road, Pune 411016
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