Health for the Millions, Vol. 8, No. 1 - 5, Feb. - Oct. 1982.pdf
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/ol. VII!
No. 1
A
Bimonthly
of
the
Voluntary
Health
Association
of
India
FEBRUARY
1982
HEALTH FOR THE MILLIONS
Vol. VIII No. 1
February 1982 ; Editorial
CONTENTS
Are you responsible for designing and implementing child health
. programmes ? Are you interested in nutrition and child care pro
grammes ? Or are you concerned in any way about child health as a
i parent, family member or citizen ?
1. Measuring How They Grow
12. The Road to Health —
A Few repairs
20. Does the Garment fit Your
Child ?
21. Low Cost Drugs Pago
22. Opportunities
23. News from the States
25. News
28. Wanted
Editor : S. Srinivasan
Executive Editor : Augustine J.
Veliath
Production : P. P. Khanna
Assistance : P. George and
John Agacy
If your answer is yes, to any of the above questions, the lead
article in this issue on nutritional assessment will interest you. Discussed
I in this article are different methods and techniques for assesssing nutri: tional status of the infant/child. The article introduces and discusses a
relatively new tool : the "thinness” chart or the weight-for-height chart.
This chart, when perfected, could be useful when children's ages are
difficult to obtain. Or where time and resources are limited. With the
help of the chart one can distinguish quickly between wasted and stunted
children. Children who are extremely thin for their height are wasted.
They need immediate medical attention. Stunted children are short.
This could be because of previous or chronic malnutrition. But when
weighed, they may have normal weight for their height. The thinness
chart tells you that stunted children need watching rather than imme
diate attention. If you had used a weight-for-age chart only, these
stunted children might be classified as wasted. Thus stunted children
may receive emergency care when not needed.
The thinness chart is a wall chart 140 cm by 100 cm (58 ' 39
inches). It has long, vertical columns. Each column is marked with a
different weight; starting al 5 kg and increasing to 25 kg in 0.5 kg gaps.
There are bands: of colour at the top of the columns : normal weight in
; green, subnormal weight in yellow and seriously subnormal in red. We
, discuss further instructions on how to use this chart inside this issue.
Circulation : L. K. Murthy
The chart was developed as an aid to staff in an MCH clinic in
East Nepal, under the leadership of David Nabarro. The chart is being
currently field tested in India and at elsewhere. Readers are requested
first and third covers : David Werner
to send their comments to David Nabarro, C/o Editor, Health for the
■ Millions. Nabarro is with the London School of Hygiene and Tropical
Owned and published by the
Voluntary Health Association of ;I Medicine.
India, C-14, Community Centre, i
We also invite readers' replies to the letter of Sathya and Nalini
Safdarjung Development
Area, |
New Delhi-110016, and printed ■ of VHAI. They have asked for comments on modifications to the Road
at Printsman, Mew Delhi.
I to Health Card, a weight-age chart.
DAVID NABARRO
Measuring How They Grow
(This article presents different methods and techniques
for assessing nutrition. It attempts to do this from a
practical perspective. It is written for those who are
responsible for designing and implementing child
health, nutrition and social welfare programmes in
particularly the Indian sub-continent. The kind of
information provided by different nutritional indices
is reviewed in some detail. New techniques for
making assessments are discussed.
The article is in two parts: Infants and children in the
first part and pregnant women in the second.
The first two sections in the first part consider methods
and techniques for the anthropometric assessment of
children (anthropometry means the measurement of
the human body). Methods for regular assessment
are discussed in Section 1. for intermittent assess
ment in Section 2. The choice of standards for
comparison and selection of cut-off points for identi
fication of malnourished children are considered in
Si
< -' • .,
Sections. Techniques that simplify the assessment
of nutrition and the classification of nutritional
status, particularly suitable for porkers who have had .
little formal education, are descrioed^in^ Section, 4, ■
Methods for coding and reporting riutrltionaITfn,forma
tion are suggested in Section 5. Usefu'FclinjspJ. - signs
that are used in nutritional assessment are summarised
in Section 6, and Section 7 concludes the first part.
The short length of the second part of the paper
underlines the difficulties we have when trying to
assess the nutrition of pregnant women.
The subject of this article is a field in which new
developments are occurmg rapidly. It is also a subject
that is extremely broad. The author has been selec
tive in deciding what to include. For both these
reasons, the reader is encouraged to read further into
the subject, and a short bibliography is appended to
identify a few useful texts and sources of reference
material).
Assessing Infants and Children
1: Regular Assessment
The weight of a child who receives an adequate
diet and does not suffer from severe illness, will
increase steadily during infancy and childhood.
Weight gain will be greatest in the first year of life,
and then level out at between 2 and 2.5 kg. per year.
In Mother and Child Health programmes, regular
child weighing provides a useful guide to the health
of the child. Failure to gain weight, sometimes
referred to as faltering of weight gain, suggests that
either the child's diet is inadequate or that he is ill
or both; weight loss suggests that the child's health
may be in danger as a result of these influences.
Ideally, children are seen and weighed regularly, if
possible at monthly intervals. Hanging spring balan
ces, with easily readable markings, are now widely
available and particularly useful for this purpose
(figure 1). The balance should be accurate. The pre
cision required is that weight should be correct to
nearest 0.5 kg. The child's weights are plotted on a
weight record (sometimes called a 'Road-to-Health
Fig. 1 A Child being weighed on a spring balance
health for the millions/february
1982
1
Card' or Growth Chart—see figure 2). Health workers
can, from the shape of the weight curve, easily decide
whether or not the child needs special attention from
medical staff. The technique is described in detail by
Morley and Woodland (1979). If they are to use
weight records routinely in Mother and Child Health
work, field staff need to know the child's age. This is
easy if regular weighing is commenced in infancy—
for example, when the ANM sees the mother for her
post-natal checkup. The staff also need to be taught
how to fill in the record, and how to interpret the
weight curve so that it helps them to make correct
decisions.
People who are responsible for planning child
health programmes have recognised the value of
regular weighing of children. Hence they recommend
weighing machines as are supplied to MCH centres.
However, costs are high. The number of weighing
machines of good quality that are available is small.
Therefore, balances are not found still in the majority
of the MCH clinicsand primary health centres. This
holds true for rural as well as urban areas. Until
Fig. 2 A child weight record. The child's birth month is February
weighing machines become widely available, other
methods for continuous nutritional assessment have to
be considered. A rough guide as to what is happening
Tri-coloured arm tape for maternal nutrition
Kusum P. Shah and P.M. Shah
It is fairly well established that the incidence of
low birth weight is higher in poorly-nourished
women. However, it is often not feasible to carry out
accurate body weight measurements in rural areas,
and a simple field technique to assess the nutritional
status of a woman is non-existent. A significant corre
lation has been observed between arm circumference
and weight of women of child-bearing age, sugges
ting that arm circumference can be used as an indi
cator of body weight and have potentiality for use
during pregnancy to identify at-risk pregnancy, culmi
nating in the delivery of a low birth weight baby,
Since the average weight gain during pregnancy in
developing countries does not leave much margin for
increase in adipose tissues after allowing for the
weight of a full-term foetus, expansion of blood
volume, placenta and liquor amnion, it would be
reasonable to expect that the arm circumference may
not be influenced much by pregnancy, especially in
poorly-nourished women.
18,5 cm 20.8 cm
22.7 cm
pale
orange
yellow
Fig. i. Tri-coloured arm tape.
2
red
The observation on body weight and arm circum
ference in women are incorporated on a plastic tape.
It was observed that those women who had an arm
circumference of 20.8 cm or less weighed less than
37.5 kg, and were, therefore, considered severely
malnourished. Those who had an arm circumference
between 20.9-22.8 cm and weighed between 37.5 to
45.0 kg were grouped as moderately malnourished,
and those above 22.8 cm, weighing 45.0 kg or more,
as mildly malnourished or normal. The critical cut-off
points in grading of nutritional status is based on the
previous studies demonstrating the interrelationship
between maternal weight and low birth weight in the
newborn. Tri-coloured arm tapes (see figure) with
bands of pale yellow at 18.5 cm to 20.8 cm from the
end, orange from 20.8 to 22.7 cm, and bright red for
for over 22,7 cm were designed indicating severe
malnutrition, moderate malnutrition and mild malnutri
tion or normal nutrition respectively. The villagers in
India relate red with blood, i.e. good health, and,
hence, a red-coloured band represents, good nutrition.
This simple tri-coloured tape can be used by primary
health workers to detect malnourished, at-risk preg
nant women for nutritional supplements whose arm
circumference falls within the pale yellow band.
Source : Appropriate Technology for Health (WHO)
HEALTH FOR THE MILLIONS/FEBRUARY
1982
can be gained from regular measurements of a child's
Mid Upper Arm Circumference (Shakir, 1975). Studies
have been made in industrialised countries. They
suggest that in a well-nourished child, this should
increase rapidly during the first year of life (from
10 cm at birth to 15 cm at age 1); slowly during the
second year (to 16.5 cm, see figure 3)—and then stay
constant during the third, fourth and fifth years. In the
majority of developing countries even the children
who appear to be well nourished do not attain Arm
Circumferences of 10 cm at birth, 15 cm at year 1 and
AN ARM-CIRCUMFERENCE-FQR-AGE GRAPH
Fig. 3 Using a tape to measure mid upper arm circumference.
(Tapes available from VHAI)
16.5 cm at year 2. However, there should be a regular
increase in Arm Circumference as the years go by.
Even though the measurement is hard to make with
precision, a fall in Arm Circumference of one centi
metre or so can easily be detected and serves as a
warning that all is not well.
Intermittent Assessment
Often it is just not possible for health workers to
see children regularly. Assessments of their health
and nutrition have to be made on the basis of obser
vations and measurements made on a single visit. The
measurements that are most frequently used for this
purpose are body weight, height, or length and mid
upper arm circumference. To provide the worker with
useful information, the measurements obtained need to
be compared with values that would be expected if
the child is well nourished. When the comparison is
made, a "nutritional index" is obtained. The degree of
deficit—i.e. the difference between the observed and
expected value, which is usually expressed as a
percentage of expected—is used to grade the child's
nutritional status. Ideally, a child will be defined as
being malnourished if the deficit observed is asso
ciated with a high probability of the child's health
being impaired. In its extreme, the child will become
ill or die. In practice, however, not all of these
relationshipshave been fully worked outandnutritional status tends to be graded according to inter
national conventions. We consider below the nutri
tional indices that are commonly used, the infor
mation they provide and their usefulness as indicators
of dangers faced by the child.
The actual measurements that are used for indivi
dual nutritional status assessment depend, primarily,
on the circumstances under which the assessment is
made.
Measurements of Arm Circumference should be
undertaken using a tape marked at one centimetre
intervals. The results can be plotted on an 'arm
circumference recording card' (figures 4 and 5).
Useful information can be obtained when this
measurement technique is used even if the child's
age is not known accurately.
Equipment for mid-upper arm circumference
measurement is inexpensive and the technique is
easily performed. However, unless workers who make
the measurements are carefully trained and use a stan
dard technique, substantial errors will be made. This
may lead to children being given inappropriate
treatment.
HEALTH FOR THE MILLIONS/feBRUARY
1982
Fig. 4 Using a tape (made from non-expanding plastic) io
measure Mid Upper Arm Circumference
3
Fig. 5 Mid Upper arm circumference record card
Birthweight and Weight-for-Age
For children under the age of one year, age will
usually be known. And the index weight-for-age is
usually employed. Birthweight reflects the state of
the child's nutrition in utero. This will depend both
on the mother's nutrient intake and on her state of
health. It is a useful indicator of the dangers that the
child will face in the neonatal period and infancy,
especially if it can be related to the gestational age of
the child. In this way, premature and small-for-dates
babies can be distinguished. In general, low birth
weight infants have been shown to have a higher
likelihood of subsequent illness (Mata, 1978). Prema
(1978) found that neonatal death was infrequent with
children whose birthweight was above 2.5 kg : there
was a four-fold increase in likelihood of neonatal
asphyxia as mean birthweight fell from 2.25 to 2.0 kg.
In the first year weight less than the expected weight
for age remains a useful indicator of the dangers that
children face. Studies in the Punjab (Kielmann and
McCord, 1978) showed that children aged less than
one year whose weights were less than 60% of the
expected weight for age were 11 times more likely to
die in the year following assessment than those
whose weights were more than 80% of expected
(Harvard Standards). The relative risks for children in
the 60-69% weight and 70-79% weight for age
groups were 5.6 and 3.8 respectively. This relation
4
ship was less pronounced for children aged more than
one year, unless they were in the 'under 60% group'.
The relative risks were 12.3 and 1 respectively.
Weight-for-Height and Height-for-Age
Weight for age, on its own, does not distinguish
between children who are underweight because of
longstanding nutrition and those weight deficit is due
to recent weight loss. This distinction may be impor
tant from as early as the age of one year, especially
when decisions are being made about the type of
therapy children should receive.
Long term, or chronic, undernutrition—which again
may be due to a combination of both dietary inade
quacy and illness—is reflected in slowed skeletal
growth. The deficit will be made up relatively slowly
following any improvements that may occur. There
fore, the chronically malnourished child is under
weight because he or she is shorter than expected for
his age. A child whose height or length is less than
90 /0 of the expected height for age is defined as
STUNTED. If it is less than 85% of expected, the
stunting is severe. In children under five, this stunting
is largely a result of adaptation to adverse environ
mental and nutritional factors in the home. This capa
city to adapt by slowed growth would appear to be
the child s advantage. There is no evidence that the
potential rate of height gain under five varies in diffe
health for the milltons/february
1982
rent ethnic groups. Inherited factors may, however,
exert a strong influence on the maximum height which
adults can reach. These individual differences appear
between age five and adulthood.
Acute malnutrition will lead to loss of weight; if
this weight Io£s is severe, the child will be thin. One
method for assessing thinness is through deriving the
nutritional index 'weight-for-height.' The child's
weight is compared with the expected weight for a
child of the same height. If the weight is less than
80% of expected, the child is defined as being
WASTED. If it is less than 70% the wasting is severe.
This index can be assessed without reference to the
child's age. In children aged over one year it may
give misleading results when children are thin but
have oedema or ascites : they may be classed as not
wasted. Oedematous children should be categorised
separately. Figure 6 shows two underweight children:
A is wasted, B is stunted.
tainty as to whether stunted—and even severely
stunted—children faced increasing dangers. In many
countries in south east Asia, while only 8% or so of
children under five might be wasted, over 60% would
be likely to be stunted. However, stunting prevalence
is usually low under the age of three.
Detailed studies of the short term mortality risks
faced by wasted children have not yet been reported.
Morbidity risks have been studied by Tomkins (1980),
working in Nigeria. Children aged between six and
thirty months, who were wasted, experienced 1.47
times as many episodes of diarrhoea during the three
months after the assessment (the rainy season) compa
red with those who were not. The duration of diarrhoea
was 1.79 times as long in the wasted group. Such
differences were less when children who were stunted
were compared with those who were not.
Longer term mortality of children has been studied
in detail by Chen and co-workers in Bangladesh
(Chen et al, 1980). 2000 children, aged between 13
100
and 24 months were assessed using weight, height,
90
arm circumference. They were followed up prospec
tively for 24 months to identify children who died.
80
The two year mortality experience for children in
different nutritional status grades was then calculated.
70
23.1% of the children were severely stunted
when
initially assessed. 41.5% were not stunted. The
60
Height
death rate in the group who were severely stunted
in Ctn.
50
was three times as great as the rate in the non-stunted
group. 3.7% of the children were severely wasted
40 when initially assessed. 68% were not wasted. The
death rate in the severely wasted group was 2.8
30
times greater than the rate in the non-wasted group.
1.7% of the children were both severely stunted
20
and severely wasted. 28.6% were neither wasted nor
10
stunted. The death rate in the first group was 6.8
times as great as in the second.
In this study, children who were severely wasted
or severely stunted faced greater dangers during the
Fig. 6 Boy A and boy B are the same age and each weighs 10 kg. two year follow-up period than those who were not.
The expected weight for their age is 14 kg. Boy A is
The increase in risk was similar in each group. The
underweight because he is wasted. Boy B is under
small group of children who were both severely
weight because he is stunted.
A two-way classification of nutritional status that wasted and severely stunted, however' had a still
takes both wasting and stunting into account was higher risk of death.
The dangers associated with being severely
suggested by Waterlow in 1972. On the basis of
stunted
during the age 12-23 months are not neces
accumulated clinical experience, he suggested that
sarily
a
direct consequence of the stunting itself.
children who were both wasted and stunted are in the
greatest immediate danger. Not only are they acutely They may also remain even if the stunted child is
malnourished, but they have also experienced long given nutritional help—for example, supplementary
standing under-nutrition too. Wasted children were feeding. It is likely that a series of factors in the
also thought to be in danger as an immediate result home environment of a deprived child-such as in
of their acute malnutrition. There was some uncer creased exposure to infection, or little time available
HEALTH FOR THE MILLIONs/fEBRUARY
1982
5
for child care—both lead to stunting and also endanger
the child's health. We do not yet know the long term
risks of different degrees of stunting in children aged
four or five. It is likely, though, that those who are
extremely stunted (e.g. less than 80% height-for
age) at this age will be in considerable danger.
Many of the stunted children in the Bangladesh
study will have experienced weight loss in the weeks
immediately preceding death. Perhaps some lives
could have been saved, at least in the short term, if a
Mother and Child Health programme, in which
childrens' weights were monitored and a range of
medical and nutritional services provided, had been
operating in the area where the surveys were under
taken.
Arm Circumference for Height
Acute malnutrition can also be assessed from the
arm circumference to height ratio, which is easily
assessed with the QUAC stick. Sommer and Lowens
tein (1975), again working in Bangladesh, showed
that at the time of the 1970 famine, when over 8,000
children were assessed using this technique, low arm
circumference-for-height identified children were likely
to die in the months immediately after assess
ment. The method identified 56% of the children who
died within one month, 38% of deaths within 3
months and 20% of deaths within 18 months of
assessment. The results suggested that at a time of
severe food shortage, arm circumference for height is
a sensitive indicator of children in immediate risk of
death.
Some Conclusions
Present evidence suggests that
(1) Birthweight can be used to identify children
facing increased dangers in the neonatal
period,
(2) In the first year of life, weight-for-age effi
ciently identifies some of the children who are
at risk,
(3) From the age of 12 months, weight-for-height
and mid-upper arm circumference for height
may identify many of the children who are at
risk of death in the immediate future. This is
particularly the case in situations of extreme
food shortage,
(4) Height-for-age, especially in children aged
less than two years, identifies a group of
children with increased risks in the longer term,
and
(5) Children who are both severely stunted and
severely wasted face greatly increased dangers
6
compared with those who are neither. How
ever, they will represent only a very small
percentage of the population at any point in
time. We need to see whether death rates
among severely stunted children can be re
duced through the provision of MCH services
with regular weight monitoring.
Limitations
These nutritional indices, derived from measures of
body dimensions obtained on a single occasion, give
us indicators which can be used to identify children
who are at greater risk of dying. However, they are
not direct MEASURES of the body's state of nutrition.
A number of body functions—activity, growth, tissue
repair and many physiological and biochemical
mechanisms—depend directly on the supply of nutri
ents in the body. These functions are not easily
measured, so we depend on external signs—or indi
cators—of how the body's internal nutritional system
is operating. Anthropometry—with its measures of
body shape and size—gives us easily obtainable
indicators. In Section two we have compared anthro
pometric indices with a direct measure of body func
tion (though an extreme one)—death.
Except in situations of extreme food shortage,
none of the 'single occasion' indices have so far been
shown to be very efficient at identifying all children
in a community at risk of death and differentiating
them from those who are not. Even if a group at high
risk is identified by setting cut-off points at a low level
(e.g. the severely wasted and severely stunted group),
many other children who die will be missed. If the
cut-off points are set at a higher level (e.g. detecting
the group who are stunted and wasted as well), a
higher proportion of children likely to die will be
detected. But so, too, will many children who are not
at risk of death. In the first case the indicator used is
insensitive. In the second case it is non-specific.
Hence, the discriminant efficiency of these 'single
occasion' indices is low, and it is not surprising that
we instinctively prefer to have information obtained
from regular assessments of a child's or pregnant
mother's weight—or even arm circumference—when
trying to make decisions about treatment. We suspect,
from clinical experience, that weight loss or reduction
in mid upper arm size is both a sensitive and a
specific indication that a child faces disability or
death in the near future. Prolonged periods without
weight gain are likely to indicate that the child
faces long term risks to his/her health. To help us
decide how best to organise and make use of conti
HEALTH FOR THE MILLIONS/FEBRUARY
1982
nuous assessment routines however, we need to study
these relationships epidemiologically, too.
3 : Choice of Standards and cut off
points
Whenever nutritional state is assessed using
anthropometric measures, problems may be encoun
tered with the choice of comparison standards and
cut-off points for identifying the malnourished. We
often consider the average values for nutritional para
meters in populations (e.g. weight) as standards for
individuals to compare themselves with. We feel
reassured if someone's weight is close to the average;
worried if it is far higher or lower. It is no surprise,
therefore, that malnutrition has often been defined in
terms of the degree to which someone's height or
weight differs from the average.
A cut off point is set as a particular percentage of
this average (or a fixed number of standard deviation
units from the average) and any observation below
this point defines a malnourished individual. For
example, two standard deviation units below the
mean weight-for age (i.e. under the third percentile)
is often used as a cut off point. We may then ques
tion what standards we are using. Most workers
make use of the International Standards (Harvard
Standards, published in the WHO Monograph by
Jelliffe, 1966, or the new NAS/WHO standards,
(published by WHO in 1979) or standards derived
from privileged groups in developing countries. The
figures are very similar. But we may wonder whether
they really are appropriate for assessing the nutri
tional status of children in poor communities. On the
WHOSE PURPOSE
DOES OUR
BABY-WEIGHING
PROGRAM SERVE?
There are, however, problems with using popula
tion averages as nutritional standards. In any commu
nity, the average nutritional status will depend on
many factors including household socio-economic
conditions and health status. There is no reason why
the average nutritional state of children in a poor
country should represent adequate nutrition. By the
same token, the average nutritional state of children
in a wealthy country may represent over nutrition.
This suggests that it is particularly important that
whatever standard is used—be it local or international
—it is calibrated in terms of the actual health risks
faced by children whose measurements are above or
below the standard figure.
This is why Section 2 concentrated in such
detail on the risks associated with undernutrition
assessed by different indices. The risks vary with:
(1)
type of nutritional index used (weight/height,
height/age, etc.).
(2)
characteristics of the environment in which
assessment is made (importance of different
disease and economic influences, availability
of food, etc.).
(3)
the type of 'malfunction', or danger, being stu
died (e.g. physical weakness, mental impair
ment, disability, illness or death) and
(4)
the time interval after assessment in which
the outcome is sought (1 month, 3 months,
1 year, 2 years etc.).
For the time being, until more risk-related informa
tion is available, it may be easiest if we use one of the
well-known International Standard populations (e.g.
Harvard or NAS), or National Standards (e.g. as sup
plied by Indian Council of Medical Research and the
Indian Academy of Paediatrics). We should also use
internationally agreed cut-offs, but differentiate bet
ween different grades of undernutrition (see Sec
tion 5). We should express our results separately for
different age groups. Then, assuming that the environ
What is the real reason that
most health workers weigh babies?
*
What effect, if any, does this
have on the children’s health?
How could the program be improved?
By whom’
David Werner
HEALTH FOR THE MILLIONS/FEBRUARY
one hand, they do represent what could be achieved
by the children in the community if they are getting
adequate diet and are healthy. But, on the. other hand,
not all the children whose weight are two standard
deviations below the mean weight for age from Inter
national Standard populations will be clinically mal
nourished. We may therefore request that a local
standard be developed so that a more meaningful cut
off can be identified.
1982
7
mental characteristics of the area in which the
reported risk studies have been undertaken are broadly
similar to those in which we are working, we can use
their results to help us interpret the severity of health
and nutritional problems faced by the children we
assess.
4 : Techniques that Simplify
Weight-for-Height Chart
The nutritional index weight-for-height is not easy
to assess under field conditions. Recently a weightfor-height wall chart was developed as an aid to staff
in an MCH clinic in East Nepal. After being weighed
the child is placed standing in front of the chart
against a vertical column marked with his weight
(figure 7). The upper end of the column as three
coloured zones. If the child's weight is less than 80%
of the expected weight for height, the child's head will
reach up as far as the red zone in
the column. If the child has a
weight that is greater than 90% of
expected, the head only reaches
■into the green zone. A yellow,
zone, in between the green and
the red, identifies children who are
between 80% and 90% of
expected weight for height (Nabarro
and McNab, 1980).
The red zone is divided into two help sections to
workers differentiate between wasting and severe-was
ting. A weight-for-length chart has been developed
for identification of marking in children who cannot
stand. It is particularly designed for children less than
2 years.
The chart can also be used to identify a target
weight to be achieved when wasted children are re
habilitated. A weight-for-height record card has been
developed for use in nutritional emergencies, (figure 8)
Height-for-age Chart
A similar chart has been developed to identify
children whose height are less than expected heightfor-age. First the age of the child is ascertained, then
the child is placed in front of a column marked with
his age. Again, the upper zones of the column are
Fig. 7 Weight for height wall chart.
Put the chart near scales. The chart
goes on the wall. The wall must be
even. The bottom of the chart must
touch the ground.
Note the weight.
8
Find the weight on the
chart with your finger.
Weigh the child
Have the mother help the
child to stand directly under
your finger,
health for the millions/february
1982
Check that the middle
of the child's head is
under his weight on the chart
Now put your hand flat
on the child's head. Which
colour does your finger touch ?
If the child is in the
lower red, he is very thin
and needs more food
at once.
HEALTH FOR THE MILLIONS/FEBRUARY
Check to see that the child’s
shoulders and feet are
against the chart.
Is the child in the upper
red, lower red, yellow,
or green ?
If the child is in the
yellow, he is thin and may
need more food. Check him
regularly.
1982
Make sure that the child's
feet are against his weights
shown at the bottom of the chart.
If the child is in the upper red,
he is dangerously thin and needs
more food urgently.
If the child is in the green,
he is well nourished. Three
cheers 1
commump, health cell
v Main, / Block
Korarrungala
/
bangalore-560034 * /
9
Fig. 8 Shows the weight for height record card of a child seen in a child health clinic.
marked with Red. Yellow and Green, though the
order is reversed compared with the weight-for-height
chart. The head of the chart child who is severely
stunted reaches only into the red zone on his column.
A child with a normal height-for-age reaches as far as
the green zone. Children who are stunted, but not
severely stunted, will reach up to the middle zone
coloured yellow. Charts for length-for-age have also
been developed.
Mid Upper Arm Circumference
In practice, however, weighing scales are rarely
available in rural areas and weight-for-age and heightfor-age wallcharts are not portable. When nutritional
status of children is being assessed in the community
intermittently, the mid-upper arm circumference on
its own can provide a very rough estimate of the
dangers faced by a child. A tape, again coloured red,
yellow and green, has been developed (Shakir, 1975)
for use with children age 12-60 months. It can be
locally made—using, for example, banana skin or Xray strip. The assessment method is easily under
stood by workers who are barely literate—including
school children and mothers.
Advantage is taken of the fact that in well-nouri
shed communities, children's arm circumference in
creases relatively little between age 1 and 5. Children
whose arms have circumference of less than 12.5 cms
are identified with a red colour; those between 12.5
and 13.5 with a yellow and those over 13.5—green.
It is easy to obtain an inaccurate result with this
technique. So great care must be taken when
measurements are made, especially if several different
measurers examine a group of children. The colours
used on all these devices can be adjusted to make
them locally appropriate.
Morley and Woodland (1979) have suggested a
further modification of the Arm Circumference assess
ment procedure. They suggest that health workers
should be encouraged to feel the sizes of childrens'
arms for themselves and not to rely solely on tapes
to make the measurement. Using the thumb and index
finger, the worker makes a circle around the child's
upper arm at its mid-point. With experience, he will
be able to identify a difference in the circumference of
two arms of 1 cm—and perhaps, even | cm. Health
workers in training can participate in an exercise
(figure 9) in which they can try to see who is best at
accurately detecting the malnourished out of a bag of
'arms'. These would be represented by wooden cylin
ders with different circumferences. Health workers
could use 'arm circling'
as a way of greeting
young children. They
would be able to use
this activity as an
entry point for talking
to mothers about their
childrens' nutritional
state. However, all
such new ideas need
to be carefully exam
ined in the context
Fig. 9 Teaching arm circling,
10
HEALTH FOR THE MILLIONS/FEBRUARY
1982
in which they are to be used before being intro
duced into either a field health programme or an
educational campaign.
5: Coding and Reporting
Anthropometric assessments based on single
occasion measurements can be classified. The Gomez
(1956) classification grades children with weights
that are different percentages of expected weight for
age, and has been modified for use in India by the
Indian Academy of Paediatrics. Weight-for-height and
height-for-age are graded using the Waterlow classi
fication—paying particular attention to combinations
of stunting and wasting.
In practice, the weight chart, described in Section
1, can be used to help classify weight-for-age. Weightfor-height can be classified in terms of the 5 colour
gradings on the Weight-for-height wallchart. Similarly,
mid-upper arm circumference can be classified in
terms of the red, yellow and green markings on the
tape, or using 7 one centimetre sections identified on
the arm circumference tape between 9.5 and 16.5
cms.
The individual record cards that have been design
ed for use with each of these indices can also be
used to record the results of community surveys.
Figure 10 shows the use of the weight-for height
record to keep a note of month-to-month changes in
weight-for-height status of a community's children.
It is easier to interpret nutritional information that
is reported if children in different age groups are
differentiated. Children under the age of 36 months
are likely to be particularly dependent on their mothers
for their nutrition (either for breast milk or weaning
foods). Children aged more than 36 months are likely
to be independent eaters. Results for children aged
under five should be broken down into at least two
groups (0-35, and 36-39 months). If possible, distinc
tion should be made between those in the 0-11
month and 12-35 month groups as well. This applies
whatever the nutritional index used.
Changes in the nutrition of children when asses
sed longitudinally can also be classified. The method
used needs to be carefully designed.
One suggestion is as follows :
Changes in the weights of a group of children are being
classified. A specific month is identified (the classifica
tion month). In order that a value for weight change
can be obtained, a child should have been weighed
during this month (the reference weight). The child
should also have been weighed at least once during a
specified interval beforehand (e.g. between three months
and two weeks before the reference weight). The most
{Continued on page 17)
Fig. 10
LONGITUDINAL COMMUNITY NUTRITIONAL STATUS RECORD
The Weight-for-Height Record Card can be used to record the number of children with different Wt[Ht percentage values
attending in MCH clinic or feeding centre. If all the children in a village are assessed regularly, the information may also prove
useful as part of nutritional surveillance system: the card can be used to record the information and convey it to centres where it
is analysed and assessed.
Individual cases can be recorded in groups of five {figure 10a) or totals can be written into the relevant boxes {figure 10b). Separate
cards may be used to record the weight-for-height percentages of childrenin different age groups.
If the cardis too small, a larger card, with similar design {not necessarily coloured) can easily be prepared by hand.
Fig. 10 a
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HEALTH FOR THE MILLIONS/fEBRUARY
1982
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11
The Road to Health
—a few repairs
Dear friend,
We have been printing the Road to Health Card
for under fives in 14 languages and have been en
couraging the use of this card among our member
institutions and other health centres.
In the course of our visits to various health centres
we found that this card was not being used as effec
tively as it should be. Part of the problem was with
the layout and markings on the card. We are therefore
in the process of modifying this card. We would
greatly appreciate your going through it and sending
us your comments. We are printing on the following
pages our revised version. Please compare this with
the older version you probably have.
or a red danger area or a red line. Such charts
confuse many health workers with limited educa
tion."
We also feel that if a child has been grossly under
nourished but is regaining weight under special
care the growth curve of this child will follow the
direction of the centiles but the child's weight
may never fall within the two centiles (5th & 3rd).
The following revisions have been made in the
new card :
* We had previously marked the weights on the
card both in kilograms and pounds. The markings
were only on the extreme right and extreme left
side of the card. While the left side gave kilograms,
the right side gave pounds. The health workers
found it difficult to mark weights especially in the
middle of the card. For easier reference we have
now marked the weights at the beginning of each
year and kept them uniformly in kilograms.
Alterations
Additions
Front side (0-3 years)
Front side (0-3 years)
* instead of being from 0-4 years the front side of
the card has 0-3 years. This enables us to have
larger squares for the first three years and makes
the card look less congested.
* In order to stress the fact that the direction of the
curve is most important, we have included mes
sages regarding this (bottom, right hand side).
♦ We have deleted the lines representing the first
and second degree malnutrition. We found that
the health workers were paying more attention to
the position of the weight and the degree of
malnutrition it represented rather than paying
attention to the direction of the growth curve.
David Morley and Margaret Woodland in their
book See How They Grow (page 33) mention :
"Our hope is that the children we care for have
growth curves that move parallel to these centile
lines, without being concerned whether they are
above or below them. We do not accept the use of
cards marked with different levels of malnutrition,
12
* Many health workers mark the child's weight at the
first attendance in the first column on the extreme
left of the card. They forget that this column is
meant for the weight at birth. To reduce this con
fusion we have written "At Birth" just next to the
first column to serve as a reminder.
* A number of people want to know on what basis
the percentile curves have been drawn. We have
mentioned the reference for it.
Back side (4 & 5 years)
* We have included some important points that the
health worker should remember while using this
card in a box just below the immunization chart.
HEALTH FOR THE MILLIONS/fEBRUARY
1982
fr
fw>
Write date given
1
4
3
2
5
Vlantou K
test
ROAD TO HEALTH CHART
O- 5 YEARS
BCG against T B
Result
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Polio
Clinic
Child's Number
(’*’■‘**
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Triple (D P T)
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Vitamin A
TH ?WT Child's Name
?T
*T
Other
Boy/Girl
Hf 37T jfTTT
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Occupation
Mother’s Name
Father's Name
SfTC Tfesr REMEMBER
®
Occupation
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• ?g?q g^
f^Tf^r Date of Birth
HRT Month
g-^yg ggy grfgg
ejsrt
Weigh the child every month
4T 373W
Caste or Community
A healthy child's weight will increase every month
Year
g§ ftrri wr <trt wgr grf|g
This card must be kept with the mother
HT
[
TT °FT Lfc(l Home Address
:
18
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Birth
order
4
Names of Brothers
& Sisters
Age
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State of Health
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HR-1 HINDI/ENGLISH
HEALTH FOR THE MfLLIONS/FEBRUARY
1982
13
PLANNING
SITR sffrU
Reasons for Special Care
1
14
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CD
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UPPER LINE 50th CENTILE BOYS
LOWER LINE : 3rd CENTILE GIRLS
EE
£
Growth Chart for International use, WHO Geneva 1978
1 a 2 WM
1-2 YEARS
ft^TH
^? ftn? ^7
the child's growth
z
sfe eztth sTW I Watch the direction of the line showing
•
If
GOOD
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BIRTH - 1 YEAR
eST faiTTH
DANGER SIGN
zrrf^r ft?
is growing well
m qfaf 5 I Su"esu feedin9
the child atleast 5 times each day
HEALTH FOR THE MILLIONS/FEBRUARY
1982
3 & 4
4^5
3 - 1 YEARS
4 - 5 YEARS
spSRTCT VERY DANGEROUS
4hrRV
| | Means the child
14
fen
H^T^TT
| I
special care
May be ill, needs
health for the millions/february
1982
Voluntary Health Association of India
C-14, Community Centre, S. D. A.,
New Delhi-110016.
15
* In another box below the above we have given
important messages on supplementary feeding.
These have been given in bolder point in the
regional language so that any literate person can
read and explain this to the mother.
Deletions
Front side (0-3 years)
* The previous Road to Health Card had four sepa
rate messages on supplementary feeding : two
pictorial and two written ones. This made the card
very congested. Also we found that the pictures
could not be understood without the writing
below.
For an illiterate person the pictures therefore con
veyed little or nothing. A literate person could
read them but the print was too small. As we
consider this information important we have dele
ted the pictures and given the message on supple
mentary feeding in bolder print on the reverse
side.
Back side (4 & 5 years)
* On the top right hand side, in the immunization
chart, we have deleted the column for small post
as it is no longer given. Instead, we have added
one on vitamin-A as there is a high incidence of
vit-A deficiency in many parts of our country.
* Below the immunization chart there was a chart
for entering problems and treatment given to
children. We have deleted this chart because the
space is too little for any useful entry to be made.
Hardly any health workers use this space. How
ever, we think this information should be recorded
on a separate OPD card for the child.
We hope you will find time to go through this
card carefully and give your valuable suggesions re
garding the content, print size, lay out etc. Please re
member that the cards will have to be bilingual with
the regional language getting more prominence.
Thanking you and looking forward to hearing from
you.
Yours sincerely.
Dr C. Satyamala & Ms Nalini Bhanot
P.S. Please reply at ourVHAI address.
Dosage based on weight and height
Certan drugs have to be administered propor
tionally to the weight of the patient, particularly
when children are concerned, but many peripheral
health centres do not have scales or staff able to use
them correctly.
There is a constant and rather reliable correlation,
at least within a country or an ethnic group, between
weight and height until adult life. Besides, it is
easier to measure height rather that to weigh an
individual, particularly one confined to bed.
Practical carrying out of the approach
This approach has been applied in the mortality
control during epidemics of meningococcal meningitis
where early treatment is an essential factor in the
chances of survival.
The treatment put at the disposal of each village
deprived of nursing staff consisted of sulfa-mides at
the dosage of 1 tablet per 5 kgs of weight.
16
A linear relationship studied and elaborated bet
ween the height and the weight was reproduced on a
wooden ruler.
According to the height of the patient, and parti
cularly of a child, it was easy to determine whether 1
(I), 2 (II) .............. 6 (llllll) tablets were required with
out risking under or over-dosage.
Staff responsible for the health of a village/community were provided with a stock of tablets and a
measuring stick as in the figure above, thus allowing
for a simple and precocious treatment, extremely
effective in the case of meningitis.
Inventive minds could exert their ingenuity in
establishing similar relationships to define the dosage
relating to other kinds of diseases and communicate
to us the results of their research.
Source : Appropriate Technology for Health (WHO)
G. Causse, Chief Medical Officer, Becterial and Venereal
Infections, Division of Communicable Diseases, WHO,
Geneva.
HEALTH FOR THE MILLIONS/FEBRUARY
1982
{Continuedfrom page 77)
recent weight reading during this interval (at the previous
weight) is subtracted from the reference weight. The
result then can go into one of seven categories viz—
More than 1.5 kg gain
Group 1
1.0 to 1.4 kg gain
Group 2
0 5 to 0.9 kg gain
Group 3
No change (0.4 kg loss to 0.4 kg gain)
Group 4
0.5 to 0.9 kg loss
Group 5
1.0 to 1.4 kg loss
Group 6
1.5 kg loss or more
Group 7
These can easily be condensed to 5 groups :
More than 1.5 gain
Group 1
0.5 to 1.4 kg gain
Group 2
No change
Group 3
0.5 to 1.4 kg loss
Group 4
1.5 kg or more loss
Group 5
A similar kind of classification can be used for arm
circumference using the same kind of criteria for inclu
sion of the measurements for a particular child :
More than 2 cms increase
Group 1
1 cm to 2 cm increase
Group 2
No change (less than 1 cm increase or
decrease)
Group 3
1 cm to 2 cm decrease
Group 4
More than 2 cm decrease
Group 5
These kinds of categorisation become important
whenever information is being reported about changes
in childrens' weight or arm circumference—e.g. in a
nutritional surveillance system based on continuous
monitoring undertaken in an MCH programme. Again,
children in different age groups should be distingui
shed.
6 : Useful Clinical Signs of Nutritional
Status
Many other clinical and anthropometric signs find
their way into texts on nutritional assessment. Only
those anthropometric measurements which provide
important information and can easily be made have
been described so far. By the same token, only a
selected group of physical signs will be described. The
other signs, while providing interesting data for the
clinician or researcher, are, in general not very useful
for helping to decide which individuals and groups
have a priority need for nutritional assistance. They
are either rather non-specific signs of nutritional
problems or they appear when the condition is so
advanced that little can be done about it.
Oedema is a sign of severe protein energy malnutri
tion and its presence may have important implications
for the way in which the child should be treated.
No simple techniques exist for the diagnosis of
early vitamin A deficiency. Initial optimism about vital
dye staining techniques (using Rose Bengal or Lissamine Green) has not been maintained. There seems
lhealth for the millions/february
1982
to be no substitute for the careful clinical examination
of the eye. Conjunctival Xerosis is hard to diagnose
unless the Bitot's spot is present as well. The later
signs of the deficiency (corneal xerosis and ulcera
tion) are easy to detect, but the challenge is to
identify children who might be in danger before they
reach this stage. Colour coded charts and slide sets
are available (VHAI and TALC) for teaching health
workers to detect conjunctival xerosis and Bitot's
spots.
Recent work in Indonesia has suggested that
mothers themselves can often say whether or not their
children are night-blind especially if a local term for
this condition is widely known (i.e. "chicken eyes").
Current opinion is that the presence of night blind
ness is both a sensitive and a specific symptom of
early vitamin A deficiency in the child.
Anaemia, too, has to be detected clinically unless
laboratory facilities are available. Fortunately, with a
little experience, most health workers can inspect the
mucous membranes of the eyelids and mouth easily
and detect severe anaemia. Again, colour-coded charts
are available to help them make the diagnosis. It is
rarely possible to assess the blood haemoglobin level
of children in rural areas.
In many nutritional surveys and clinical exami
nations a lot of emphasis is placed on the relatively
non-specific signs of deficiency of the B Vitamin
Group—particularly angular stomatitis, cheilosis,
tongue changes and so on.
Anaemiometer
Based on the study of haemoglobin level and
colour of conjunctiva, a simplified small scale with
three bands of red colour shades has been worked
out as a tool to help the primary health care worker
Colour bands representing:
HE «—mild anaemia
*—moderate anaemi.
♦—severe anaemia
C
Anaemiometer.
in diagnosing mild, moderate and severe anaemia by
comparing different shades of colours with the colour
of conjunctiva. The accuracy of these bands in the
range of ± 1.0 g of haemoglobin and colour of con
junctiva was 83.4, 78.0 and 71.9 per cent in severe,
moderate and mild anaemia, respectively. This field
technique avoids the routine method of pricking and :
collecting the blood.
Source : WHO (ATH) !
17
In general, if severe vitamin B deficiency is present,
it is likely to be accompanied by other nutritional
deficiency diseases as well. Isolated B vitamin defi
ciency is rare except among people eating very un
balanced diets. It has been reported sporadically in
communities undergoing a transition from eating, as
their staple, rice dehusked manually or by foot, to rice
dehusked in the mill.
In some areas—particularly amongst the moun
tainous regions of the Indian sub-continent iodine
deficiency is a problem. This can be detected through
clinical examinations to look for goitre and cretinism
in a community. Goitre is graded depending on
whether it is palpable, just visible or very large. More
useful information can be obtained from urine exami
nations for iodine or, better still, levels of thyroid
hormones in the blood. These are, however, both
expensive and difficult to undertake.
7 : Conclusions
Nutritional assessment is not an easy subject
to discuss outside the context of the particular situa
tion in which it is undertaken. The requirements of
programmes where individual children are being
monitored regularly or where population surveys are
being undertaken are different. The choice of measures
and indicators selected and the cut-off points to be
used to identify the malnourished, whether conti
nuous or intermittent monitoring is undertaken, will be
dictated by the kinds of attention (medical care, nutri
tional therapy, etc.) available and the amount of re
sources set aside to tackle the problem.
An understanding of the information provided by
different indicators can help programme planners to
select those which are most useful for their pro
grammes. In general, dynamic measures—change in
weight, arm circumference and even height—are the
most useful for assisting field workers to make deci
sions about individual children. This requires that
programmes are designed to maximise the likelihood
that children who are likely to face nutritional and
health problems are seen and assessed regularly.
Assessing Pregnant
Mothers
Unfortunately, no universally accepted methods
exist for the assessment of the general nutritional
status of pregnant women on a single occasion. A
number of investigators are studying the usefulness
of the mid-upper arm circumference tape and modi
fied calipers for assessing skinfold thickness in field
18
situations. Results are not yet available. Equipment
for measuring adult weight is rarely available outside
hospitals, though this measure can give a useful indi
cation of the likely birthweight.
Weight gain during pregnancy is also use
ful: Prema (1978) found that mothers from ‘ the
upper income bracket had a higher initial weight,
gained an average of 11 kg during pregnancy and had
children whose average birth-weight was 3.13 kg.
Lower income mothers started with lower weights,
gained an average of 6 kg in pregnancy and had
children whose average weight was 2.7 kg at birth.
It would seem possible that the rate of weight gain
during the second trimester of pregnancy may prove
to be a useful indicator of the need for nutritional
supplementation during the last three months. This
could be studied in areas where antenatal programmes
are being initiated.
However, it is particularly important that all preg
nant women are examined regularly for signs of
anaemia. A low haemoglobin in pregnancy is asso
ciated with increased risks to both mother and child
during delivery, and, again, a low birthweight.
Anaemia may have been brought on not only as a
result of dietary lack, but also because of co-existing
parasite infestation; a check may need to be made for
the presence of hookworms.
In conclusion, there is widespread interest in
searching for new methods of monitoring the nutri
tional status of pregnant women that are suitable for
use in rural antenatal clinics. They are urgently needed.
REFERENCES
Chen L C et al (1980). Anthropometric assessment
of energy protein malnutrition and subsequent risk
of mortality among pre-school children.
Am J ClinNutar, 33, 1836-1845
Gomez F, Ramos-Gaivan R, Frenk S, Cravioto J M,
Chevez R and Vasquez J (1956). Mortality in
second and third degree malnutrition.
Journal of Tropical Paediatrics 2, 77-83
Jelliffe D B (1966). The assessment of the Nutritional
Status of the Community WHO Monograph Series
No. 53, WHO, Geneva.
Kielmann A A and McCord C (1978). Weight for age
as an index of risk of death in children.
Lancet i 1247-1250
Mata L (1978). The Children of Santa Maria Caque :
International Nutrition Policy Series No. 2, MIT
Press, Cambridge, Mass.
HEALTH FOR THE MILLIONS/FEBRUARY
1982
Morley D M and Woodland M (1979). See How They
Grow Macmillan Press, London.
World Health Organisation /u,979). The Asses srHtept\.
of Nutritional Impact, WI-(O^Geneva.
*
Nabarro D and McNab S (1980). A simple new techni
que for identifying thin children. (The weight-forheight wallchart).
For a fuller discussion df . ( ganGALO?a. i ★ 1
Journal of Tropical Medicine and Hygiene 83
p 21-33.
Prema K (1978). Pregnancy and Lactation,
Nutritional Aspects.
Some
Indian Journal of Medical Research, 68 (Supple
ment) October 1978 p1-16.
Shakir A (1978). The Surveillance of Protein Calorie
Malnutrition by simple and economical means.
J Trop Paed Env Child health, 21 69-85.
Sommer A and Lowenstein MS (1975). Nutritional
status and mortality : a prospective validation of
the QUAC stick.
American
287-292
Journal of
Clinical
Nutrition,
28
Tomkins A M (1981). Nutritional Status and severity
of Diarrhoea among pre-school children in rural
Nigeria. Lancet (in Press)
Waterlow J C (1972). Classification and definition of
protein calorie malnutrition.
British Medical Journal ii 566-569
(1) The material in Section^, see :
Dowler, Payne, Ok Seo, Thomson and Wjje'efer/
Nutritional Status Indicators : Theirlnt^rpretation and Place in Policy Planning. Available
from Nutrition Policy Unit, London School of
Hygiene and Tropical Medicine.
(2) Xerophthalmia, See :
Sommer A (1979). Field Guide to the Detec
tion and Treatment of Xerophthalmia, World
Health Organisation, Geneva.
The materials described in this paper, including
the guides for detecting Xerophthalmia, are availa
ble from :
Voluntary Health Association of India, C 14,
Community Centre, S.D.A. New Delhi 110016,
India.
Teaching Aids at Low Cost, Institute of Child
Health, 30 Guilford Street, London WCIN
IEH England.
Correspondence should be addressed to David
Nabarro at the Department of Human Nutrition,
London School of Hygiene and Tropical Medicine,
Keppel Street, (Gower Street), London WC I 7HT,
U.K. and/or the Editor, Health for the Millions.
Recognised !
The Indian Nursing Council has recognised the
Nurse Anaesthesia Course prepared by VHAI. An
extract of the Minutes of the Indian Nursing Council
meeting held on 25th November 1980 reads:
"The Council considered the minutes of the
sub-committee meeting held on 24th September
1980, regarding Anaesthesia Course for nurses
prepared by the Voluntary Health Association of
•HEALTH FOR THE MILLIONS/fEBRUARY
1982
India, New Delhi. It was resolved that item 2 and
3 of the Minutes may be deleted as approved by
the Executive Committee and to recognise the
course in Nurse anaesthesia prepared by Volun
tary Health Association of India, New Delhi"
Health for the Millions heartily congratulates the
administrators and pioneers of this course. Miss
Mary McNabb and Sr. Joan Thazhathel.
19
APPROPRIATE TECHNOLOGY
Does the garment tfit your child ?
The MGDM Hospital, Kangazha, Kerala has helped
develop many new ideas relevant to child care.
The casette record audiometer to pick up early
cases of deafness in school children; and the portable
dental unit to diagnose dental problems (in early
Garment for mass
stages) of children of school going ages are two such
nutrition screeming
examples (see "Right Technology, Right Place", in
HFM, August 1978; and "Health by the Pupil" in
HFM, February 1979).
More recently the health workers at MGDM have
modified the Intradermal Jet Injector (I J I). This modi
fication has led to a negligible breakdown rate. Those
of you who have put your IJ Is in cold storage can put
them back in use with this modification. For details
write to Health for the Millions or Dr M V Joseph at
Garment on a
MGDM
Hospital, Kangazha,
Kanjirapara, P O
malnourished child
Kottayam, Kerala 686515.
Another simple technology from MGDM which
needs to be more well known is the garment for
assessing malnutrition of children. The garment is'
illustrated below. It encompasses various other
factors like mid-arm and chest circumferences, and trial and error method. (When combined with the
shoulder girth. The garment was designed by a bangle test 90 out of 100 cases of malnutrition could
be detected). In malnourished children, the garment
fits and it can be buttoned. Not so with normal
children.
The garment test was applied on a nutritionally
wide group of children. Among grade one mal
nutrition children, 83 per cent could be identified.
When the garment test was combined with the bangle
test, nearly 90 per cent of the malnourished children
could be detected. False positives were only 5.4 per
cent. It could be reduced to 2.8 per cent when com
bined with the bangle. The false positives were
mostly below two years of age. The accuracy rate
when the two tests were combined was nearly
100 per cent (99.1).
In many areas the underfives do not oblige by
coming to the underfive clinics. It then becomes the
responsibility of the health worker to monitor their
growth by visiting them. The garment and the bangle
tests (and mid-arm tape/band) are useful devices in
such cases which also give high accuracy. They can
be used as part of Child-to-child programme very
easily. They are relevant especially where weighing
machines are not the most appropriate, and where
health workers find it difficult to go around trudging
with weighing machines.
—MIRA
20
HEALTH FOR THE MJLLIONS/FEBRUARY
1982
Low Cost Drugs Page
Child Health—The Homoeopathic Way
(An eight page booklet is available from the
Department of Family Welfare, Government of India,
entitled Homoeopathic Treatment for Common Ail
ments of Infants and Children. It suggests treatments
for colic, diarrhoea, vomiting, cold and cough, sore
throat and tonsilitis, constipation, disturbed sleep,
indigestion, troubles during the dentition, pain in the
chest, loss of appetite, toothache, worms trouble,
boils and abscesses, and injuries. The treatment is to
be used, says the booklet, only as a first aid and in
case the child does not feel better after a day or two
he should be referred to the doctor. For copies of the
booklet, write to : MCH Unit, Publications Section,
Nirman Bhavan, Ministry of Health and Family Wel
fare, New Delhi 110 011. We reproduce below some
extracts.—Ed- H FM)
Homoeopathic medicine is the safest medicine and
is based on the law that medicine in very small doses
can cure a disease provided that medicine is known
to cause similar symptoms in an apparently healthy
human being. The homoeopathic medicine helps the
patient by raising his own defences against the invad
ing organisms. The patient is helped in mobilising
inherent powers of curative reactions in the body.
Because of its ease of administration and sweet taste,
the homoeopathic medicine is most welcome by the
children. It is a common experience that these medi
cines bring about very speedy relief to children suffer
ing from diseases.
Dispensing and Storage
The medicine can be dispensed either in small
globules made up of cane sugar or in powders of
milk sugar (Lactose). This can also be dispensed in
plain drinking water. It is better to store these medi
cines in globules away from strong smelling subs
tances like camphor, menthol, etc., and they should
be stored in cool places away from exposure to the
sun. Medicines stored like this can retain efficacy for
many years. The bottle should be tightly corked.
‘HEALTH FOR THE MILLIONS/FEBRUARY
1982
Doses
For infants 1 or 2 globules of No. 20 size is enough
for a dose. For older children up to 8, they can be
given about 4 globules a dose. In the case of adults,
6 globules will be enough. In case of combination of
tablets, dissolve 4 tablets in half a cup of lukewarm
drinking water and give one teaspoon full of this to
the infants as recommended. The paper used for dis
pensing should be clean and white.
Common Ailments
Colic Baby
Colic is one of the commonest ailments to which
a new-born child is subject to. Such colic usually
continues till the age of 3 months and colic is usually
worse towards the evening and is very annoying both
to the mother as well as to the other members of the
family.
Treatment : Give Colocynth 30, every half an hour,
till the relief is obtained.
As a preventive measure, this medicine could be
given three times a day and if there is no colic for a
week, it could bestopped. If no relief is obtained,
give the following combination alternately every one
hour and if it is better, every two hours : Mag, Phos.
12x, Ferrum Phos 12x, Nat. Mur. 12x. Silincea 12x,
Kali Phos 12x.
Vomiting
Vomiting in little children is a fairly common symp
tom. In case a child vomits soon after taking milk,
and goes to sleep after vomiting, give Aethusa 30,
every 3 hours. In case of vomiting accompanied with
diarrhoea, fever or colic, give Ipecac 30, alternately
with Arsenic—Album 30, every one hour and if better
every two hours.
Troubles During Dentition
Diarrhoea, crying, sleeplessness, irritability, etc.,
are the common conditions which are associated with
the teething in children. Give Chamomilla 30, alter
nate to Calcium Phos 6x for 7 days every two hourly.
21
If the stool is offensive followed by normal stool in
the evening give Podophyllum 30, every two hourly
for two days.
2.
Give Chamomila 30, every two hours, to
*
children having diarrhoea during detention,
especially when the child is cranky irritable.
If the stools are :
Worms Trouble
This is one of the commonest complaints in young
children which very frequently invite medical atten
tion. The complaints are bedwetting, grinding of
teeth and occasional abdominal pain with a great
craving for sweet. Give China 30, thrice daily for
seven day.
Diarrhoea
This is another common condition which very often
invites medical attention in children. This may be
accompanied with other ailments
1. Give China 6, and Cynodon Dactyton 6x,
alternately two hourly.
..
(i)
watery, profuse.
painless, offensive;
(ii)
mixed with blood
and mucus;
(iii)
accompanied by
nausea, or vomiting;
..
(iv)
of undigested milk
..
Podophyllum 30,
and Combination
No. IV. alternately
every two hours
Merc. Sol. 30, and
Combination
No.
IV.
Arsenic—Album 30,
alternately
with
Ipecac
every
2
hours.
Mag.
Carb.
30,
| hourly,
Counselling for Family Life Education
: April 12th-16th, 1982
: Ashirvad 30 St. Mark's Road Cross,
Bangalore-560 001
Organisers : CREST—Centre for Research Education
Service and Training for Family Life
Promotion, 14, High Street,
Bangalore-560 005
Date
Venue
PARTICIPANTS: Lecturers, Teachers, Social Workert
& Youth Leaders
For details write to above address
Training for Doctors
Resource Persons
VHAI is currently preparing a register of qualified
resource persons who would be available to assist
health care programmes in activity related to health
and development. At present concentration is on the
U.P. and Delhi Area. It is intended gradually to extend
this coverage if the response is good.
Any person in these or other areas of India
interested in being listed in our register may fill out
one of the information sheets being sent out or con
tact Dr. Tunnie Martin at the VHAI office for more
information.
♦
22
♦
*
Applications are invited from inservice Doctorspreferably from voluntary organisations for 6 weeks
intensive training in leprosy. They should be below
45 years of age and should have at least 2 years of
experience in leprosy. Four doctors will be selected
for the award every year. Besides actual first class
train fare to and fro or Rs. 500/- which ever is less,
each candidate will be paid Rs. 30/- per day as
allowance during tbe training period. Training will
be in one of the six centres selected by the Technical
Committee. They should give an undertaking to
continue working in the field of leprosy after training
at least for another 3 years. Application forms can be
had from the Hind Kusht Nivaran Sangh, 1-Red Cross
Road, New Delhi—110 001, and the last date for
receipt of completed application forms is April 15,
1982.
health for the millions/february
1982-
neuje
Andhra Pradesh
VHA ANNUAL MEETING
A hundred and thirty delegates welcomed the
Honourable Minister, Sri A. Madan Mohan, Health
Minister, Government of Andhra Pradesh. He was
manifestly pleased with the gathering. In his talk he
praised the VHA movement for sponsoring close co
operation among all religious communities, and
working helpfully with the Government. He said that
the Government welcomed the movement, and was
happy to extend co-operation. The meeting was two
days, Feb. 5-6, 1982.
Sister Martin, J,M.J., as President and Chair
person, welcomed the members and guests. She is
now Assistant to their Mother General in Holland,
However, she will spend about half of her time in
India and Indonesia.
At election time the members were unwilling to
hear of any other nomination, and instead that she
remain President, with their urging sheagreed.
Prominent among the resource persons was Mr.
S. Prasada Rao, Assistant Commissioner of Labour,
Government of Andhra Pradesh. He announced that
the A.P. Government would very soon develop a
statement of minimum wages to be paid to various
categories of employees in private hospitals and
nursing homes. The process would begin by a com
mittee of persons visiting hospitals in various areas of
of the State, to determine the actual situation regard
ing salaries, and to assess comparative costs of living.
Mr Rao invited the A.P. VHA to appoint a person to
represent them, and to become a member of the
Government Committee that would go around making
a study leading to recommendations.
The A.P. VHA now has 147 members. During the
past year they have had an impressive number of
seminars and workshops. Popular among them have
been some District meetings of members. The Guntur
District members wish to meet as often as three times
a year.
•health for the millions/february 1982
Among the seminars organized
on a State basis have been a
Holistic Health Seminar, Advan
ced
Transactional
Analysis,
Evaluation of Nutritional Pro
grammes.
Health
Education
Materials, and Hospital Accounting. There were five community health workshops
of two days each.
Similar programmes will be held in the current
year. Among them will be school health programmes,
and a State convention of village health workers,
Executfve Secretary, Mr D Rayanna, and Commu
nity Health Secretary, Miss Zina Kidd, deserve high
praise for bringing the A P VHA to a high level of
development.
AND NOW DISTRICTS
The AP government has issued a notification
expressing the intention of the government to bring
employees in non-government hospitals, nursing
homes and clinics under the relevant schedules and
provisions of the Minimum Wages Act, 1948. The
government is interested in ensuring that at least
minimum rates of wages are paid to different catego
ries of workers in non-government institutions. In
some states like Gujarat and Kerala, minimum wages
have been fixed by the respective state governments
for non-government health institutions,
XXX
A workshop on evaluattion of nutritional program
mes was organised by APVHA in collaboration with
the National Institute of Nutrition, Hyderabad, from
November 1 6, 1981. The 4-day programme included
field visits to a PHC, block development office and
demonstration and application of various tools rele
vant to evaluation of nutritional programmes.
xxx
APVHA has pioneered the organisation of district
level meetings of its members. The purpose of these
meetings has been greater exchange of resources
and experiences among the voluntary health members
within the respective districts. These meetings also
help to bring District Medical and Health Offciers,
government employees and the members of the
voluntary health institutions under one forum. District
meetings were held by APVHA during OctoberDecember 1981. These meetings were in Krishna, West
Godavari and Guntur districts
23
West Bengal
FOLLOW-UP AND DRUGS
The West Bengal VHA had a two-day follow-up
meeting of the trainees of the community health and
development workshop conducted in 1980. About
50% of the original participants attended the follow
up meeting. The follow-up evaluation was encourag
ing and several ideas for redesigning the future pro
grammes emerged.
XXX
A one-month residential training on community
health and development at Howrah is being planned
by WBVHA from February 15 to March 17 1982. In
the second week of April a workshop on community
health and development at Darjeeling for senior
management people is scheduled.
XXX
There has been a good response to the circular
sent out by WBVHA to member institutions requesting
information and cooperation for a central drugs pur
chase unit. The purpose of the unit would be to
supply medicines in time and at low cost. Eventually
the central drug purchase unit could evolve into a
cooperative of the member institutions.
Bihar
DOWN TO EARTHING
The Bihar VHA organised a one-week Physical
Assessment Workshop at Patna, The resource per
sons for this workshop were Dr. Mira Shiva of VHAI
and Dr. Ulhas Jajoo of the Medico Friends Circle.
The object of the workshop was to help in upgrading
of diagnostic and therapeutic skills of nurses working
in isolated health centres. The emphasis was on, as far
as possible, making an accurate diagnosis with good
history taking and physical examination with simple
and easily available diagnostic aids. Rational use of
low cost drugs formed the second most important
component. This included the use of simple oint
ments, which could be easily prepared in the
peripheral centres. The workshop is a part of an on
going process of information
dissemination and
spreading of diagnostic skills to especially the centres
which are at the peripheral levels.
x
x
x
More news is now available about the Village
Health Worker's Convention organised by BVHA at
Chandwa, Palamau District—October 2-3. 1981. The
theme of the convention was: How to Improve
24
Village Health. The report of the VHWs in the Palamau
area focussed on their achievements, areas where they
have tailed and their future plans. It was reported
that due to the work of the VHWs the incidence of
malaria has been significantly cut down in Ranchi
district. As a part of the convention there were pre
sentations on leprosy prevention and treatment of
leprosy by Dr. Margaret Owen ; maintenance of good
health with the help of natural resources and various
issues on working with people in the area of health.
The evaluation of the Convention by the participants
was encouraging.
XXX
The St. Barnabas Hospital, Ranchi, has announced
its intention of starting a school for general nursing,
affiliated to the Mid-lndia Board of Education, Indore,
MP. The first training session wiil commence from
July 1982.
Kerala
SO LONG
The KVHS news letter made its appearance after
a very long time. The latest dated December 1981
reports on KVHS' proposed activities for 1982-83,
and activities carried on in 1981. Among the proposed
activities are:
VHWs' Training Programme in Mananthawady
and health promoters course in the same place;
Regional Administrative Training Programmes; a
multi-purpose HWs' course; Human Relations and
Personal Growth Workshops; Holistic Health Work
shops and a seminar on hospital labour.
xxx
KVHS bid farewell to its elected secretary, Mr.
Vijaya Singh Yesudian. He was a very active, selfless
and dedicated member. Mr. Yesudian has taken up a
job in the Salem Steel Project as Hospital Adminis
trative Officer. The new secretary is Sr. Ancey, SD.
Mr. Philip Koshy is the joint secretary.
♦
*
*
The Kerala Voluntary Health Services has proposed
the following activities for 1982-83.
1.
2.
3.
4,
Village Health Workers Training Program in
Mananthavady.
Health Promoters Course in Mananthavady.
Regional Administrative Training Program in
Trivandrum.
Multipurpose Health WorkersCourseat I.H.M.,
Bharananganam and Pushpagiri, Thiruvalla.
This is a Govt recognised Diploma course.
health for the millions/february
1982
5.
Three Human Relations and Personal Growth
Seminars.
6.
7.
Holistic Health workshop.
Seminar on Hospital Labour.
A second follow-up meeting on the Zankhvav
course on Community Health and Development is
being planned by GVHA for January 1982.
XXX
Gujarat
CHILD CARE
The GVHA held its annual convention and general
body meeting on November 21-22, 1981 at Bharuch.
A major part of the 2-day programme was spent in
discussing the organisation of child care programmes
and experiences with under five programmes. To faci
litate discussion, a position paper under fives was
prepared by the Centre for Promotion of Community
Health, Mongrel. As a follow-up on the discussion
during the annual general meeting, an evaluation
based on the trends of the position paper is being
planned under the coordination of Ashwin Patel.
XXX
GVHA's proposals for 1982 include a convention
for VHWs in various parts of Gujarat; translation of
David Werner's IV/jere There Is No Doctor into
Gujarati; a seminar on curative diagnosis and treat
ment for people working in community health; and
publication of a short brochure on GVHA on its com
pletion of a decade since its inception.
XX
X
Kirit Shah, has taken over the new organising
secretary of the Gujarat Voluntary Health Association.
He is a post-graduate in social work. HFM wishes
the new secretary good luck and good ideas.
News
Visitors from Overseas
Dr. Henry Heimlich, Head of the Clinical Services
Division, St. Xavier's University, Cincinnati, Ohio is
known all over the world for his life saving techniques.
The Heimlich manoever to save victims from choking
to death on food and drowning; the Heilmlich valve
for thoracic surgery, the portable oxygen cylinder. He
was in India to institute a research programme that
holds promise for the treatment of cancer. Heimlich
addressed VHAI Staff and others on Computers for
World Peace.
David Werner, author of "Where There is No
Doctor"
Werner made a slide presentation at the Al I MS on
January 28 on the evolution of 'Project Piaxtla', the
health net work run by the farm people covering
several thousand square miles of mountain terrain,
serving more than 10,000 persons in 100 villages in
Mexico. He was given a standing ovation by the
packed audience at the end of his presentation. His
next presentation was at the Viswa Yuwak Kendra,
New Delhi on Thursday, February 4. On that occasion
he screened 100 slides on the contribution of school
children to the Mexican health project.
HEALTH FOR THE MILLIONS/FEBRUARY
1982
David Werner
He paid a day's visit to Dr. Sethi's limb rehabilita
tion centre at Jaipur.
Werner was the key resource person at the UNICEF
session on "Childhood disability" on February 5.
National Award for Daleep Mukarji
In recognition of his service in the field of socio
medical relief, Dr Daleep S. Mukarji, Director, RUHSA,
has been honoured by the Dr B. C. Roy National
Award Fund with a cash award of Rs. 5,000/-.
25
Welcome Averthanus !
;
Dear friends.
We are happy to announce that on March 1st,
1982 Mr. Averthanus D'Souza becomes the new
Executive Director of VHAI. He has had three years
of education in Oxford, England, and in India and has
had many years of administrative experience. He is
acknowledged to be dedicated to social justice and
to the uplift of the weaker sections of society. In the
recent past, he has been Administrator of a hospital
in Bombay.
For the success of this gaze over the horizon into
the future, I request all of you to give him warm a re
ception, genuine support, and the generosity of your
prayers.
To help with the transition, I shall remain in the
VHAI office as his Assistant till the end of this year.
It has been characteristic of VHAI to engage in
innovative, continuing adult education. Our latest
major thrust in this direction has been Holistic Health.
This is a view that embraces the whole person and
the whole of society. With individuals, importance
is given to developing a sense of responsibility for
one's own health, Other areas of emphasis are nutri
tion, physical exercise, psychological balance and
spiritual wholeness, open to welcome the fulness of
God.
It responds to the spiritual thirst that is leading
all of us and the whole world to the greatest crisis
decision of history, to live together in yvorld commu
nity, or to indulge our passions leading to nuclear
destruction.
VHAI is the first organization in India to take up
this concept, and give it educational forms. This new
vision of health stirs up astonishing enthusiasm. We
are now enlarging this service. We believe that within
three years, this movement will be vibrant all over
India. This new wisdom and opportunity for growth
is open to all, We invite all dedicated persons, reli
gious and social organizations and institutions, like
dioceses, religious congregations, seminaries, novi
tiates, development associations and civic communi
ties along with our professional health people to join
with us and grow along with us.
It is a high honour for Averthanus to enter the
planning service of VHAI on the rising crest of this
new wave.
Averthanus, I welcome you with an open heart. I
shall do my best to help you, Staff, Board and all of
us to ease gently, alertly and creatively into the
future. It is not necessary to know everything or to
have every competence . It is helpful to accept the
human race as suitable people to live with.
Devotedly,
Dr. James S. Tong
26
Look After Your Vaccines !
Health workers carrying out immunization pro
grammes often work in temperatures of 40°C or more.
Since vaccines quickly lose their potency if stored or
transported under such conditions, it is essential to
maintain an uninterrupted "cold chain" from manu
facturer to user. WHO's Expanded Programmes on
Immunization has produced a series of information
sheets on all aspects of the vaccine "cold chain". The
following sheets are now available, free of charge,
from Appropriate Health Resources and Technologies
Action Group (AHRTAG), 85 Marylebone High
Street, London W1.
—Product Information Sheets (in English, French
and Spanish). (SUPDIR 55 AMT. 3).
—Testing Voltage Refrigerators for Vaccine Refri
gerators and Freezers (EPI/CCIS/81.3).
—Vaccine Hand Carrier and Cold Box Testing
(EPI/CCIS/81.3).
—Vaccine Refrigerators and Freezers—Summary
of recent tests (EPI/CCIS/81.6).
—An annotated Bibliography of all WHO material
(EPI/CCIS/81.9).
—Vaccine Cold Chain Monitor (how to check if
vaccines have been kept at the correct tempera
tures). (EPI/CCIS/81.8 and EPI/CCIS/81.10)
—Organising and Running a Course on Com
pression Refrigerators for Repair Technicians
(EPI/CCIS/81.12).
♦
♦
♦
The Great Health Robbery
The theme for the academic part of VHAI's next
General Body meeting will be : "The Great Health
Robbery".
This is a colourful way of calling attention to
numerous aspects of exploitation and social injustice
encountered among purveyors of health and develop
ment services. All participants are invited to send us
instances known to them which would be of value to
share with pothers. Also suggest suitable responsesHEALTH FOR THE MILLIONS/FEBRUARY
1982
■and courses of action. Readers are requested to send
an outline of intended presentation,
Ideas also for posters, sayings, slogans, cartoons,
etc., related to theme may be sent to VHAI imme
diately.
There will be a meeting of the VHAI Executive
Board at the same venue, on April 26. It will be an
all-day meeting.
♦
*
*
education
of
— Rational dreg therapy
—Role of medical auxiliaries in making health care
low cost
—Simple pharmacy management for health insti
tutions and programmes
—Role of non-drug therapies and other systems of
medicine
Anne Cummins Biography
Sr. Anne Cummins played a pivotal role in the
shaping of VHAI and its training programmes.
All those who have known, loved and worked
with Anne Cummins are invited to make a contribu
tion to the compilation on her life being prepared by
VHAI. This contribution may be in the form of a
complete memoir, recounting incidents revealing her
personality, her strength, her weaknesses, her influ
ences over people.
The assistance of all who came to know and work
with her will make our biography a truly rich offering.
Therefore, send your contribution in freehand or typed
script at the earliest possible, at VHAI's address.
*
*
*
ED and ANNE Scholarship Fund
The VHAI Board Meeting in October 1981 passed
a resolution to open a scholarship fund in honour of
Ed Nabert and Anne Cummins who were close
friends. The grants would be used for people who
work in line with VHAI philosophy.
Appeals were despatched in the New Year to their
close friends and relatives, catholic institutions, our
HFM/CONTACT mailing lists and our sister organiza
tions.
Generous contributions and letters appreciating
the idea of this Fund are being received at VHAI from
all over the country, and abroad.
*
*
♦
Drugs Issue-Feasible Alternatives
A workshop—''Drugs Issue-seeking feasible alter
natives" was held in Pune from January 8-10.
Selected individuals deeply concerned and involved
with the issues were invited. The 27 participants
included journalists, consumer activists, teachers of
pharmacology and community health coordinators,
and health personnel from the field.
The objective of the workshop was to draw up
concrete action plans, undertake specific responsi
bilities and mobilize all available resources.
The major areas covered were:
Drug situation in India
‘HEALTH FOR THE MILLIONS/FEBRUARY
—Drug information and ongoing
health personnel
1982
Some papers, and handouts were circulated.
The workshop not only helped in getting a core
group concerned with the drugs issue together—but
it helped in focussing on very concrete action plans—
which VHAI and other participants will be involved in.
It was organised by Dr Mira Shiva with the help of
Srinivasan, Chandra, Augustine, Dr Sathyamala and
much support from VHAI secretarial staff.
*
*
*
Correspondence Course in Health Care
Administration (CoCo)
1981 closed with two CoCo seminars. At the
November seminar twelve participants attended out of
whom ten were promoted.
A notable feature of this batch of CoCo is that the
assignment of students to different VHAI staff has
worked very well. The batch student has been
getting individual, concentrated attention and the
result in terms of growth and change are gratifying.
At the closing seminar from December 11-16, six
students graduated. In addition to this a hospital
administration resident also received his certificate. Of
the six students, five were coordinated by George
Ninan of VHAI.
Evaluation report
Copies of the correspondence course Evaluation
Report may be obtained by writing to Renu
Khanna CoCo Coordinator, at VHAI.
*
*
*
Community Health Team Training
The first regional meeting of the Community Health
Team Training Course was held in Ambapada, South
Rajasthan from January 19-21. This was the first time
the participants of the CHTT met together after their
course to review what they had accomplished till
now and to gain new inputs.
The meeting was a heart warming experience in
many ways:
27
—the participants had opened up considerably to
each other and to resource persons.
A Letter from RAHA
—sharing experiences generated ideas for others.
(We reproduce below a letter received at VHA! office. from a friend—Ed,HFM)
—many people had gained confidence after meeting
various government officials.
—some had been able to interest their team mem
bers in the training as a result of which we had
five team members present for the regional
meeting. These five persons expressed their
desire to attend the rest of the regional meetings
also.
The inputs during the regional meeting were on
conducting a baseline survey. Time was also spent on
learning how to prepare and use audio visual aids
using locally available material.
Resource persons individually spent time with
each team to review in detail their past activities and
guided them in making plans for the future.
Wanted
Health Coordinatar,
C/o Bishp'is House, Ambikapur,
November 25, 1981
Dear Mira and Ruth
*
Greetings to both of you. I am glad to send the
short report of school health programme in Surguja
district. With the help of our health centre nurses we
could do something.
Three schools are taken care of by the RAHA
(Raigharh—Ambikapur Health Association), one by
Holy Cross Hospital staff and two by the government
PHC. The PHC is busy with many government
schools. The Children in these schools are mostly
tribals, coming from poor families, except from the
town area, where there are well off families. It's en
couraging that health centre nurses are regularly help
ing in school health programme. I found the school
teachers interested in the programme, although cons
tant motivation is required from our part.
The following figures will tell you the general
health of the students.
Total number of students in three schools seen by
RAHA : 2000
Cases
(1)
General Duty Medical Officer-cum-Anaesthetist, Age No. Weak- Worm Goitre Eye Ear Tooth Skin Gland Fever
MBBS, DA for a group of tea estate in Upper Group
ness
abd.
pain
Assam
(2)
A Nurse with Training in Anaesthesia
(3)
General Duty Medical Officer, MBBS, Dip. Card.
For further infoimation contact: Group Chief Medical
Officer, Margherita Tea Estate, P. O. Margherita,
Dist. Dibrugarh, Assam-786181
♦
*
*
Multipurpose Female HW
Hospital Community Health Project requires female
multipurpose health worker. Must be able to keep
simple records in English. Salary scale up to Rs.
300-10-341-EB-15-430-EB-30-630 or according to
experience and qualifications. Apply to Administrator,
Herbertpur Christian Hospital, Herbertpur P.O., District
Dehra Dun, U.P. 248 142,
28
5-10 1100 18%
4 8%
3% .4%
1.6%
1.7%
.2%
.3%
11-12 100 1%
13-18 800 1.3%
1.9% .2% 1.3% .3%
2.5% 1.5% 1.5% 1.9%
.1%
.1%
.8%
.1%
.4%
.7%
Our problem is now to get vaccination from PHC.
When I visit I am assured to get from PHC, but we
find it difficult to get it. Now I plan to buy from the
companies for our school children and for the health
centre.
We are keeping fine. There was a nurses' refresher
course in Kunkuri from Nov. 16 to No. 21. Altogether
25 nurses took part in it. Sr. Marie Therese, myself, Sr.
Angela and Dr. Susma of Holy Cross Hospital helped
each other to make it successful. One more group
has to be given the same course. The team is helping
in the Balwadi programme. With this information let
me stop here.
Love and regards,
Sr. Pratiti
*VHAI staff
HEALTH FO THE MILLIONS/FEBRUARY
1982
WHAT ADVICE
WOULD YOU
GIVE THE
MOTHER OF
THIS CHILD?
X_______________ >
/QCT what if
•SME IS TOO
POOP. TO BUY
HER BABY
GOOD FOOD?,
It) TELL HER
NEEDS TO EAT
MORE AMD BETTet
WHAT HSR
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'COULD FtcD HOA
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'sheprobably
STARTED BOTTLE
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WARN HER AGAIU3T
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(1’0 TELL HER HER
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HER ADVICE
ASO5T HOW TO
\
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IS MORE
LAND AMD
BETTER PAY ]
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HAS TO WORK
that
AMD LEAVES TV.E
EABY WITH HER
OTHER CHILDREN,
WHAT ADVICE
WOULD YOU
GIVE THE
OF
THIS CHILD ?
< CLEARLY 3ME NEEDS
’
MORE THAN A£ViCE,
BA.3Y HAS S&SM LOSING
WEIGHT FOR b\OMTH3_,
AMD SORELY SHE HAS
ALREADY BEEN GWEN
ADYIC-E, SHE NEEDS
PERSONAL HELP-.
THINK YOU ARE BC5TH MISTAKEN
CHART SHOWS THAT THE SA3Y IS
•BELOW AVERAGE WEIGHT BUT US
GAINING WtE.GWT STEADILY AND
NORMALLY MONTH SY MONTH. PgR-
l WOULD 4TKAM1HE THE BAK/ CA2EAND IF ME SEEbLS HEALTHY
CONGRATULATE Ml3 MOTHER FOR J
AKIMG SUCH XCDDCARE OF HIM,
AND TELL HER NOT TO YfORRY IF
^OBVIOUSLY TOE CHILD HAS BEEN UNDER’WEI^HT
FDP A LONG TIME. THERE MUST BE SOCIAL
VROBLETtAS INVOLVED. PERHAPS THE FATHER’S
GONE AMD GHE F'AS TO WORK . OR PERHAPS
she’s backwards OR HAS special
SMALLER
THAHeTHeRS.
_±_
THIS ANSWER IS RIGHT.
SE SURE HEALTH WORKERS
KNOW IT - O» THEY MAY
cause the mother
NSOLESS WORRY ABOUT rT.
li
is the presentiment that imagination is more real.
And reality less real than it looks.
It is the hunch.
That the overwhelming brutalit y of facts that oppress and
repress is not the last word.
Il is the suspicion.
That reality is more complex than realism wants us to believe:
That the frontiers of the possible arc not determined by the
limits of the actual.
And that in a miraculous and unexpected way, life is preparing
the creative events >
Which will open the way to freedom and resurrection.
.
For Private Circulation Only
RubmAIv
rwHErassssssr
WO
zooo
OMMUNITY HEALTH
26, V Main, I Block
Koramangala
Bangalore-560034 -
2103-0
WHITHER
NATURE
WHITHER
HEALTH
WHITHER
NATURE
WHITHER
HEALTH
WHITHER
NATURE
WHITHER HEALTH WHITHER NATURE WHITHER HEALTH
HEALTH FOR THE MILLIONS
No. 2
Vol. VIII
April 1982
Editorial
CONTENTS
HEALTH AND THE ENVIRONMENT
1. Fishing in Troubled Waters
In this issue we discuss some aspects of health that are not thought
to be strictly relevant to health by health workers. However, it is now
well established that health inputs alone do not improve the health of
any community. Economic well-being and education are a’so relevant.
5. Forestand III Health
I
9. The Slumming of Rural Life
It is in this context we discuss the travails of fishermen in Kerala.
Similar experiences have been felt by people in other coastal areas of
India. A some what well-intentioned technological change—mechanised
trawlers—has become a source of oppression than of improved wellness.
Our country's history of the last 35 years has several other such exam
ples to offer. In a slightly different vein, modern, allopathic drugs have
become a source of dependency and oppression than one of help and
healing alone. Traditional herbs and medicines, and traditional healing
systems are being edged out.
12. Unsafe and Unclean
17. Toxic Chemicals and Human
Health
19. Poison : What is in Name
20. Drugs Column
21. Cattle Immunisation
One of the offshoots of "progress" has been greed for natural
i resources, as evidenced by cutting down of trees without thought.
I Cutting of trees has threatened the lives of the poor who are totally
22. Industrial Masks
i dependent on it. Incidentally; they make collection of certain, useful
medicinal herbs even more difficult. Obviously the desirable policy has
: to be not no-cutttng of trees but intelligent planting, cultivation and
I cutting of trees.
23. News from the States
24. We Weed You
24. Opportunity
Production : P. P. Khanna
Assistance P. George and
John Agacy
Trees are a big source of energy for a majority of people in India.
Another source of energy is nuclear power. In fact at one time we were
, even told that nuclear power is the answer to humanity’s energy prob[ lems and other problems. That this is an illusion, and a dangerous one
; at that, is the point of another one of the articles in this issue.
I
We also outline yet another danger to the health of the environi ment: pollution through pesticides and toxic chemicals. Readers' expej riences of and reactions to these issues are requested.
Circulation : L. K. Murthy
I
Editor: S. Srinivasan
Executive Editor : Augustine J.
Vefiath
Owned and
published by the
Voluntary Health Association of
India, C-14, Community Centre,
Safdarjung Development
Area,
New Delhi-110016, and printed i
|
at Printsman, New Delhi.
PLEASE RENEW YOUR SUBSCRIPTION TO HEALTH FOR THE
MILLIONS. IT IS STILL Rs. 12/- PER YEAR.
GEORGE NINAN
RENU KHANNA
Fishing in Troubled Waters
Af.C. Escher
"Raghavan and Justin were at a Joss. For two days
they had been unable to catch any fish. AH the fish
had gone into the paddy fields and the landlords
would not let them fish there. Because of the bunds
built by the government, breeding rates had come
down. The effluents from paper and steel factories
polluted the waters and reduced the number of fish
even more. The landlords were using small nets and
catching even the smaller fish from the paddy fields.
Raghavan sighed as he thought of his ailing mother
and small child. Justin grew red with anger as he
thought of the relatively better-off fishermen in their
mechanised boats fishing in the in-shore areas during
the breeding season. He thought of the poor crop of
fish when he and his mates go out in their country—
boats once the rains are over.
"The fire of rebellion stirred: Raghavan and Justin
decided to go to the paddy field for fishing. After all.
that was government water, and they were licensed
fishermen who had paid the Professional Tax. They
went to fish. At dawn, came the news that Justin and the traditional fishermen (see box for details of the
Raghavan had been severely beaten by the land traditional fishermen and the fish economy) have their
owner's goondas. Not only that, they had also been effects on their health and well being and that of their
arrested by the police for theft."
families. The men are out at sea, all night. During the
day they mend their nets and boats. Their women go
Politics of Health
as far as 20 to 30 Kms selling the fish. The eldest
David Warner, in his book Helping Health Workers child is the caretaker for the younger ones—the child
Learn writes of his early experiences as a health ren grow up without sufficient parental love and care.
worker in a village in Western Mexico. Initially, he Is this situation conducive to health ?
thought that the causes of ill health were restricted
to the villager's physical conditions and surroundings
—poor nutrition, lack of sanitation, clean drinking
water, and the long distance to even closest health
centres. Gradually, he became aware that ill health did
not only have immediate physical causes, but also
underlying social causes. He writes. "Time and again,
I have experienced occasions where death and suffer
ing of children and other persons I have come to love
have been the direct or indirect result of human
greed." Looking at the fishermen's situation we cannot
help but agree with Werner. The social problems of
HEALTH FOR THE MILLIONS/aPRIL 1982
The problems of subtle exploitation—the mechani
sed trawlers fishing in-shore and destroying the hope
of the traditional fishermen in their country boats:
middle-men who do not pay the full value for the
catch, who charge high rates of interest on loans;
the government bunds which severely cut down fish
breeding in inland waters; land reclamation which
has reduced the area of water; the industries which
pollute the water and destroy the harvest; the multi
national corporations and big business houses which
export marine products—lead to further depression of
the small fishermen. The resources are plenty.
1
Traditional, Modern and Ultramodern
The Indian fishing economy consists of three
sectors : traditional, modern and ultramodern. The
traditional sector forms the base of the economy and
accounts for about 70% of total marine fish catch
in the country. The traditional fishermen use non
mechanised craft. They have evolved their gear and
fishing techniques to best suit the local conditions ;
they fish in the shallower waters nearer the coast
which abound in large quantities of the smaller
species of fish. Their techniques are labour inten
sive ; their productivity is low. Because of low
productivity, rapid depletion of resources does not
occur. And, even at very low levels of productivity,
there are large surpluses available for disposal and
trade. The traditional fishermen generally dispose
their catch either through their wives or through a
host of middle-men. Their final consumers are predominently rural clientele.
The modern sector emerged as the market for the
produce began expending. Preservation techniques
(like salting and drying), use of ice for storage and
during transportation made possible the disposal of
the catch to inland urban centres. As the middle
men availed of these opportunities they grew
bigger. Some began to perform the role of financers 'helping' the traditional fishermen to modernise
and mechanise his craft. The attempt of the
modernisation was to increase production and pro
ductivity. These did increase—but along with the
production and productivity increased the depen
dence of this new class of traditional fishermen on
the middleman.
The fishermen faced with a buyer's market, receiver/
no significant returns for increased productivity, the
consumers in a sellers' market had to bargain hard
over the soaring final prices inspite of persistent
poor quality of fish, decaying for want of sufficient
ice and transportation. The modern sector consists
of about 65 to 70 thousand traditional fishermen
operating around 11 to 12 thousand small mecha
nised boats which contribute a little over a quarter
of the total marine fish catch.
India has over half a million traditional fishermen
in about 1800 fishing villages, They account for 70%
of the total marine catch in the country. Only around
20% of the potential yield of 14.39 million tonnes of
2
The ultra-modern sector emerged with the involvment of big business houses and multinational
corporations.
The emphasis was on modernisation, research and
development. International collaboration and advice
from such international organisations as FAO was
sought. One such case of international collabora
tion was Norway. The Norwegians attemped to
transplant the technology prevalent in Norway at
that time (early fifties) to a quiet fishing village
accustomed to its traditional and deeply rooted
system of operations. They injected some foreign
mechanised boats instead of trying to mechanise
the traditional catamarans. They set up an elaborate
sales organization which made the fish too expen
sive for consumers around the area. Chaos
resulted.
Fortunately for the Norwegians, they discovered the
unexploited potential of India's marine resources.
Prawns, which did not have much of an internal
market were an excellent product for export to the
USA where the demand for them was picking up.
Thus in the early sixties, fisheries suddently became
a sector with enormous export potential in a situa
tion when foreign exchange was a crucial need.
All and sundry who ventured to take the risks of
entrepreneurship were encouraged.
The big business houses entered the marine export
trade to fulfill their export obligation as export
houses.
The basic features of the ultramodern sector were
the very high degree of technological sophistication
and great dependence on commercial energy. The
circuit of economic activity was high investment,
high cost, high productivity, high depletion, and
high pollution. This made it inevitable that the end
commodities had to be of high unit value to ensure
reasonably high payoffs to the interests involved.
the Indian Ocean is being exploited at the moment.
However, the small fisherman remains poor—and
often becomes poorer.
HEALTH FOR THE MILLIONS/aPRIL
1982
'
i
i
I
I
Protein Siphoning
The traditional fishermen with their labour, inten
sive techniques were able to supply rich sources of
protein to rural consumers at low costs. The increasing
mechanisation of the fishing economy is increasing
the cost to the rural consumer. He cannot afford the
fish. Therefore, an increasing proportion of the pro
duce is finding way to the urban elite. The increasing
sophistication of preserving, deep-freeze vans, etc.
takes the protein sources away from the section of
population which need it the most. The paradox does
not stop here. Protein sources are siphoned off into
other countries. Our annual foreign exchange earnings
from marine products are over Rs. 200 crores and we
rank sixth among the fish producing countries of the
world. Resources that can nourish India's under-nouri
shed majority go to satisfy the palates of well-fed in
USA and Japan, or to fatten their hogs and the
chicken through fish-meal.
Liberating Efforts
Several activist groups have been involved with
the fishermen in their struggle for social justice. The
All-Kerala Fishermen's Federation (KFF) is one such
group. This took up the cause of Raghavan and
Justin—this group confronted the police with the
question of what they had stolen. The police were at a
loss for an answer. The KFF is one of the largest uni
ons in Kerala. It is the only one to succeed in getting
a government Act passed to ban mechanised trawlers
from fishing within the inshore zone. This took years
of struggle and many hunger strikes 1 However,
following the pressure and lobbying of the mechanised
boat owners and marine products exporters, the
Fisheries Minister in Kerala lifted the ban within two
weeks. The mechanised trawlers were allowed to fish
near the shore during breeding seasons. The KFF
plans to intensify their protest action as the breeding
season is fast approaching. Says Fr Jose Kaleekal
(Regional President of the KFF), "We have had suc
cess— limited as it may be. But the greatest of all our
achievement is that we have been able to bring the
fishermen out of social and political wilderness,
and alienation. They realise that they have power
also."
The Trivandrum Social Service Society (TSSS)
is another group. The TSSS began helping the fisher
men of Trivadrum district by making boats and nets
available through cooperatives. Through self-ques
tioning and analysis the TSSS have continued to
evolve in their role and functioning. The TSSS team
helped the fishermen from the only cooperative that
is completely controlled by real fishermen to sell their
fish. Earlier, the fishermen were at the mercy of the
merchants. They discovered their collective strength
through struggle and hardship when they did not go
out to sea for three weeks. They realised that their
catch meant money. So they began to collectively
bergain for a good price. That began to end the ex
ploitation at the hands of the merchants. The fisher
men also began to perceive the larger structure of the
fish economy.
Unexploited Potential Yield of India's
Exclusive Economic Zone (in '000 tonnes)
Total (Species)
Species Group
0-50 mt
50-200 mt
Exportable Species
Penaeid Prawns
Other Crustaceans
Cephelopods
Tuna and
Allied Fishes
High-Priced Species
Low-Priced Species
88
30
12
46
380
25
10
135
—
212
631
220
380
950
Total
931
1710
200 mt
**
500
* *Unexploited potential of Andamans included
Source : P C George, B T Antony Raja & K C George,
Fishery Resource of the Indian Economic Zone,
Souvenir, issued on the occasion of the Silver Jubilee
Celebrations of the Integrated Fisheries Project,
Cochin, October, 1977.
HEALTH FOR THE MILLIONS/aPRIL
1982
3
Any liberation efforts seems to imply organisation
of those who are oppressed. Collective bargaining is
a source of tremendous power. The role of a good
leader seems to be one which encourages questioning
and analysis of the existing problems, one which
helps the exploited to experience their power.
From Here, Where ?
The fishing area can be divided into depth zones
—the 'in-shore zone' is from the coastline to a depth
of 50 metres and this contains about 51 % of the total
potential catch. The 'deep sea zone' is at a depth of
50 to 200 metres and this contains 38% of the poten
tial catch. The result (11%) is in the depth beyond
200 metres. India does not have any deep sea fishing
operations of significance. Thus most of the fishing is
restricted to the inshore areas and the deep sea zone
lies unexploited to a large extent.
Modernisation and mechanisation do seem to be
the answers when one considers the 2.21 million
tonnes of untapped marine products in the deep sea
zone, (See table). But the interests of the traditional
small fishermen have to be protected. There has to be
healthy and complementary growth and development
of all sectors of the fish economy. If the zone rights
are adhered to, the chance of direct competition bet
ween fishermen using non-mechanised craft or small
mechanised boats and the larger deep-sea vessels
does not arise at all. Catches made in the deep sea do
not affect the level of catches made in the inshore
waters. The question that needs to be asked is
whether or not these vessels will restrict their opera
tions to the deep sea. Experience has shown that they
have not.
References
1.
Fishermen’s Cooperative in Mariand, Kerala, by John Kurien 3. Entry of Big Business into Fishing and its impact on the Fish
in Readings on Politics, Poverty and Development Kamala
Economy, John Kurien, Economic & Political Weekly Vol.
Bhasin, Vimala R (Ed.) FAO, New Delhi
XIII, No. 36 (1978)
4. Helping Health Workers Learn, David Werner and Bill
Bower. Hesperian Foundation, 1982.
2. Marine Food Resources : Present Status and Problems,
Dr VVR Varadachari, Dr TSS Rao, and ZA Ansari NFI 5. Fr Jose Kalleckal, KFF, Personal Conversation with George
Ninan.
Bulletin, Jan. 1982.
State of Environment
The Centre for Science and Environment, in co
operation with voluntary organizations and individuals
fighting to preserve their environmental heritage, will
publish an annual State of the Environment
Report.
The State of the Environment Report will review
what is happening to India's rivers, forests, dams, air,
land, cities, villages, flora and fauna, etc. If will also
present critical case studies of groups/movements
engaged in environmental struggles, analyze govern
ment initiatives and actions, and highlight statistical
information with the help of maps, charts and
graphs.
The report will focus on changes in our natural
4
surroundings and how these affect our lives—who
benefits, who loses.
Some of the issues dealt with in the State of the
Environment Report-1982 are forests, rivers, dams,
land, air, animals, marine life, urban environment, rural
habitat, agriculture, energy, human health, climate,
government initiatives, and action by local bodies.
In addition, the report will contain an up-to-date
bibliography and resources section. It will be of
interest to every one concerned with the state of
India's environment.
Those who want copies please write to : Centre for
Science and Environment, 807 Vishal Bhawan,
95 Nehru Place, New Delhi 110019.
HEALTH FOR THE MILLIONS/APRIL
1982
MIRA AND CHINU
FOREST AND ILL HEALTH
prevention
water retaining and soil protective ability of the land.
With the thinning of forests to 40 to 50 per cent cove
rage, even this protective ability is lost. A 33 per cent
coverage on average is required for India, taking all
areas into account. Our forest coverage as shown by
satellite pictures is less than 10 per cent I
Tribal Anger
trees PkEVSm - soi L EROSI
rCcoDs, laxnDSudgs, drought, Pca/£Rty
Forests are the wealth of a nation, they say, more
than that, they are the health of a nation, especially
of its poor people. Forests have been traditionally an un
ending source of materials used in industry and homes
of people. They are directly connected to the climate,
the soil, the environment and the quality of life of
people. (Seethe box: Natural Forests Vs Commercial
Plantations). Most importantly, they are the only
source of life and livelihood to the population that
inhabit them. Forests also are a source of fuel,
fodder for animals and food for the people. Once this
delicately connected chain is upset, major catas
trophes can occur for all concerned: soil erosion,
floods, drought, landslides, and low rainfall and depri
vation of livelihood for many, especially the poor.
At the rate at which forests are being depleted
in India, all these calamities will occur in greater
magnitudes, There is growing evidence to indicate
that this is already happening in India. In India
three million hectares of forest areas have vanis
hed
out of existence since 1952. A minimum
of 60 per cent protective forest
coverage is
required in ecologically crucial areas to maintain the
HEALTH FOR THE MILLIONS/aPRIL
1982
Most of the people who inhabit the forests are
tribals. In India, about half of the 40 million tribals are
dependent on forests. However, non-tribals also in
habit forests in large numbers, for instance, in the
Garhwal region of Uttar Pradesh. AH of them have a
similar relationship with the forests; forests give them
food, shelter, recreation, employment and security.
And all of them face similar problems: land alienation
money lending, contractor system, loss of traditional
forest rights, and increasingly intense commercial ex
ploitation benefiting mostly middlemen and outside
businessmen. Also government legislatons—both
during the British days and after—have been a further
source of oppression, confusion and corruption.
Naturally, such conditions have given rise to many
social movements against successive governments and
other powers-that-be. The Chhota Nagpur insurrection,
the revolt of the Nagas in the Northeast, the Santhals
in Bengal, Mundas in Bihar, Koyas in Andhra, Maria
Gonds in Bastar, Kurchias in Kerala, Kond Maliahs in
Orissa and the Babejhari revolt in Adilabad are some
of the major forest based revolts during the pre-in
dependence era. Even after independence the trend
has continued in various parts of the country: Naga
and Mizo tribal movements, Jharkand movement in
Bihar, Worli tribal movements in Maharashtra, Savara
and Jatapur tribal armed revolt in the Parvathipuram
agency area of Srikakulam district of AP etc.
At present, there are atleast six notable tribal or
forest based movements in ladia. They are of differ
ent intensity. They are in: the Northeast (Nagas and
Mizos), Adilabad (Gonds), Chipko (Garhwal), Jungle
Bachao Andolan (Thane district, Maharashtra), Jhar
khand and Singhbhum (Bihar)). The burning issue
behind all these is the same: the rights of those
dependent on forests for centuries for their needs of
food, fuel, fibre, fodder, etc. cannot be simply snatched
5
L
For every child a tree
On World Environment Day 1982
Four designs contributed by Richard Zemnickis of Canada
for UNEP's "For Every Child a Tree" project.
6
HEALTH FOR THE MILLlONs/APRIL 1982
away and/or handed over to those whose interest
is short-term commercial exploitation.
Chipko
gradient; ban on felling of fodder species like horn
beam; ban on excessive resin tapping from chir pines
without giving adequate time for wound-healing
(which results in uprooting of thousands of such trees
per year) and priority in reforestation, with trees that
meet the local needs and demands of the 5Fs—
food, fodder, firewood, fertiliser and fibre. At present,
one set of Chipko activists led by Sunderlal Bahuguna
are making a footmarch from Kashmir to Kohima to
promote awareness about the need for tree preserva
tion. In Chamoli area, another group of villagers and
activists with the guidance of Chandi Prasad Bhatt
are involved in planting seedlings as part of a refore
station program. Eco development programs in sur
rounding villages for students and youth are also
being held.
New Forest Bill
Even as these movements were taking place, the
axe has fallen in terms of an apparently good intentioned Forest Bill.
I
1
—-
Among these the Chipko movement of Garhwal in
the Himalayan regions of U P has become more well
known. In April 1973, the UP government allotted
ash trees in the forest area of the Garhwals to a sporte
goods company in Allahabad. Earlier the very same
trees had been refused to the local villagers for mak
ing yokes for the bullocks. The light durable ash
wood used for making yokes for centuries is also used
for making cricket bats. The government's decision
angered the villagers. So when the contractors came
to fell the trees, the villagers gathered around and
hugged the trees ('Chipko' is Hindi for 'to stick'). The
Chipko movement was thus born and spread to the
entire region. The women specially are the most
affected. In April 1980, women of Budha Kedar drove
away axeman of a shuttle factory owner, who had
come to cut the horn beam trees (used as fodder tree
in the scarcity season).
The demands of the Chipko movement are worth
noting: ban on commercial green fellings about
1000 meter altitudes and slopes above 30 degrees
HBALTH FOR THE MILLIONS/APRIL 1982
—
•
SENTZNCZ : 3 Months
CRIME. iMatkCma on,
cMglss.
Mzer the torest bill
The Central Board of Forestry has prepared a draft
of a new forest act to replace the Indian Forest Act,
1927. The new forest bill which is under considera
tion will, if passed, give extraordinary powers to the
government to control plantation, production, collec7
Natural Forests vs. Commercial Plantations
In many parts of the country, the forest depart
ment is replacing natural forests with plantations
of commercially valuable species of trees. This
change has far reaching consequences.
A natural forest has a vide variety of plants and
trees in it. There are the tall sunlight-seeking trees,
the medium-sized plants and shrubs, and the
grasses that spread out on the forest floor. These
plants derive their nutrition and water from the
soil and carbon dioxide and oxygen from the
atmosphere for their growth. In turn they enrich
the soil back through their leave droppings that
dry up and mix with the soil. The roots of the
legumenous plants have nodules of bacteria which
help in transforming the atmospheric nitrogen
into soil nutrients.
The forest cover also checks the force of falling
rain thus preventing soil erosion. The thick vege
tation on the forest floor also facilitates gradual
percolation to
ground water preventing it
from flooding away. The replenished ground
water is the water source for the wells; streams
and rivers in the plains during dry season. The
roots of the plant keep the soil bound together
preventing erosion and landslides.
The plants replenish the atmosphere with fresh
oxygen. The green cover of the forests maintains
the humidity over the region thus controlling the
climate and favouring rainfall. Apart from this,
natural forests also abound in insects, birds and
animals who live by feeding on the plants or some
other animal. They in turn also play a crucial role
in the growth of plants through pollination dis
persal of seeds and enriching the soil by their
droppings. Above all, there are also the human
dwellers in and around the forests, utilising the
tion, trade and transport of all produce that directly or
indirectly originate from forests. The Bill itself though
it proposes to remove middlemen (which it will not be
able to do so), gives the government to lease forests
to any private party it likes. It legitimises all the illegal
and corrupt practices of forest, officials by giving
them various powers. The main thrust of the proposed
Act, as pointed out by a recent critique (Undeclared
Civil War, A Critique of the Forest Policy: PUDR,
April 1982, Rupees 2/- per copy. Copies available
from VHAI), is against the tribals and other forest
inhabitants. '"With a single stroke of the pen, the
8
plant and animal resources and the physical
environment of the fotests, and in turn enriching
it through their practices of planting and protecting
trees.
Thus a natural forest is a complete system,
called an ’ecosystem', of plants, animals and the
physical environment maintained in a mutual
balance. Any process that upsets this balance
will lead to destruction.
In commercial plantation of select species only,
this system balance is destroyed. The non-com
mercialplants and the insects, birdsand the ani
mals dependent on them are the first casuality.
As a consequence, the soil looses its source of
nutrients, the roots that bind it and protection from
rain water flow. Soil erosion, floods and land
slides are immediate consequences. The replenish
ments of atmospheric oxygen and humidity is cut
down. This in turn further affects plant growth.
And an inevitable cycle of degeneration sets in.
There is ample experience to show this. In
the pine plantations of Uttarakhand, the tree fern
lengda used for food, and ringal, a wild grass used
for making baskets, have become extinct. In these
plantations the acidity of the soil is increasing
rendering it infertile. Soil erosion from these
plantation slopes is of the same order as that on a
barren slope. In the Nilgiris, the steady expansion
of wattle and eucalyptus plantation has led to a
decline in water flows of perennial streams.
Development of commercial forests ignoring basic
natural laws can only lead to disaster.
Source ’ A note prepared by Kalpavriksh, a Delhi
environmental action group.
government is abolishing all their traditional, com
mercial and democratic rights. With this Act, any
chance of earning a decent livelihood for them will be
destroyed. They will be reduced to a state of total
dependence on forest officials who now assume
powers to become in turn a revenue official, a civil
court, a collector, a police official, a magistrate, a pro
secutor, a judge and a jury."
No forests, no people, no health.
*
*
♦
♦
HEALTH FOR THE MILLIONS/APRIL 1982
CLAUDE ALVARES
The Slumming of Rural Life
The Kabini Paper Mill in Nanjangud taluk is, to all
external appearances, an innocuous small size factory
producing about seven tons of paper a day from a
variety of raw materials including waste cartons.
When a group of us visited it a few Sundays ago,
there was no factory official within the premises, but
on seeing the invasion (we had about twenty people,
including a few ecologists): a staff member came
out to ask us what we wanted. We explained to him
that we were studying the environmental effects of
industries located in rural areas.
For the sake of regulation, the factory authorities
had constructed three lagoons connected by meander
ing canals where the effluent was ostensibly being
treated. Perhaps they did treat the wastes when the
health inspector arrived, or whoever, after which they
probably treated him well. For the rest of the time,
they must have used about a bottle of acid per
lagoon: capitalists are parsimonious when it comes to
"wasting" their money on muck that can be dumped
in someone else's backyard,
Waste in Water
We were certainly in for a most pleasant surprise,
for, as he described it to us outside the gates, the
KPM was a model paper factory making unit, and
there was no pollution associated with the factory
at all. In fact, said he, no effluent was released
outside the factory premises. Whatever little effluent
was produced (and it was hardly anything as the
factory used waste paper as feedstock) was aerated
and digested in tanks. There was really nothing
worth worrying about.
ween twelve at night and four in the morning:
catch any government authority visiting at that
hour. The chairman of the village was behind paid
Undoing
Rs. 800 a month to keep his trap shut, his authority
That was his undoing. His pretty little introduc
tion, uninvited, indicated he was either lying or that
the factory was for long shutdown, which it clearly
was not that particular afternoon : the purr of the
small monster could be heard outside the gates. Now
more than ever we were keen to examine the inside
of a paper mill that did not produce a polluting
effluent : a miracle of sorts, which we must confirm,
before we announced it to all the world. At this
stage, the man said we couldn't go in, since we must
first get permission from the secretary who was not
in, but whom he would try to raise on the telephone.
outside the window, to accept the ruin of everybody's
health including his own: he was making up, they
said, the money he had invested in the last elections
which he had lost.
That was when the villagers sighted us and
curious, asked us what we were about. On knowing,
they became visibly upset and agitated and insisted
we go to the village and see the ruin that the paper mill
was visiting in their lives. Surprised again, we walked
down to the village and to the fields. What we saw
there made some of our team members so livid with
rage that they refused to go back to meet factory
higher ups who tipped off that we had arrived,
appeared on the double, sacrificing a peaceful after
noon dozing at home.
HEALTH FOR THE MILLIONS/APRIL 1982
What I suspect is that the wastes were let, un
treated, directly into the drinking water supply of the
villages (the first lagoon seemed to have been dry
for a considerable length of time). The villagers
informed us that the letting out was done bet
Between the factory limits and the water canal of
the village the effluent usually overflowed the channel
and scorched the ground over large tracts of land.
During the day, the water level in the canal died
down, since there was no discharge but the died
effluent on grass stalks along the canal indicated in a
crude memory form the level actually reached at night
when the chemical brew entered the area.
Swollen Bellies
The three villages of Kailehalli, Kathadipura and
Chamalapur had no alternative source
of drinking
water besides the canal: so they continued to drink the
stinking, contaminated water. Children and women
had red eyes and swollen bellies, and almost everyone
complained of stomach'pains and skin rashes. Large
9
Feedstock
The other point is about feedstock: the factory was
supposed to use the elephant grass from wastelands,
but for some reason, it had begun to use paddy straw
instead. Since cattle have no purses, the factory won
over the supply. Within the factory grounds were
stacks of paddy straw mammoth enough for a herd of
elephants to frolic in. This misuse of a precious cattle
feed resource-should never have been permitted under
any circumstances. (On the one hand, the Karnataka
Animal Husbandry people try to increase milk pro
duction, and on the other, the Industries Department
ruins the fodder situation). It will have its impact soon
on milk production and draught power. Agriculture is
bound to suffer, that much is certain. Already the
mental health of farmers owning cattle is seriously
strained in the dry months when huge hunts are
organised for straw and long lines of fine animals
*
for lack of food, are being given over to the butcher.
numbers of livestock had perished : in Kaiiehalli alone,
156 sheep had died, and in Chamalapura, between
150 to 200. Across the canal, the fields were gra
dually attempting to digest the poisonous slurry and
failing: in one field, a large spongy mass had arisen
like a mound and the ground around it had bouncy
The KPM, we found, was not alone in its irres
ponsible attitude towards public health; the Rasoli
Paper Mills dumped its effluents and so did the
Caseem Kareem Waste Silk Factory. The Sujata Tex
tile Works let its effluents into the river upstream,
about 300 yards from where the Nanjangud town
took in its water for drinking. No doubt these factories
do provide some employment to the people of these
villages and towns. But there is serious injustice
involved all the same. It may be possible to argue
(though I am’not for it) that our present technology
quality to it. Paddy yields per acre had dropped from
20 to 15 quintals. The KPM had furnished a solitary
tap for drinking water in the scheduled caste area
of the village which carried water from the factory,
as if this was sufficient for the population of
three villages, for cattle and sheep, for irrigating fields;
but this was the KPM's concept of what constitutes
compensatory justice.
Two other points about the factory need mention:
the authorities running the mill told us that it was too
small for installing a recovery plant: the cost would
be prohibitive. In other words, small may not be
beautiful in such circumstances. And it is precisely
these small-scale plants that are being hung round the
necks of the rural population.
10
health for the millions/april 1982
will always pollute, we have no choice, and there
fore, if you want jobs be'prepared to drink bad water.
But for the sake of a few jobs, why are entire villagers
and towns being penalised? If 3,000 people from
Nanjangud town are employed by Sujata Textiles,
why should the remaining 27,000 people be forced to
drink muck?
Such is our blind allegiance to the spirit of our
age: depravities such as this are passed off as the
inevitable price of progress, as entrepreneurship, as
rational economics activity. The economics is based on
a technology whose impact can only be worked out
in tmmiserising the already deteriorating environment
of defenceless villagers, and of the poor generally,
who have been at the receiving end of the garbage of
civilisations for centuries. Should I drop a bottle of
poison into a public drinking water source, I can be
arrested as a criminal. But if I do it through a factory,
I may even end up being praised. Certainly, no one is
going to question my profits.
(This is an extract from a two-part article that
appeared in The Deccan Herald. Reprinted here cour
tesy The Deccan Herald—Ed. H FM)
Dear Editor
Neyveli
23-4-1982
Dear Editor,
I congratulate you to have introduced Homoeopathy in your esteemed journal Health for the
Millions through Low Cost Drugs page in February '82 issue (page 21).
For my reference, I am writing to MCH Unit, Ministry of Health and Family Welfare, New Delhi
for a copy. Pending receipt of this, I want to offer the following comments.
(1)
I think, the drug indicated on page 22—para 1 .Worm Trouble—should be CINA 30 and not
China 30.
(2)
Under diarrhoea—para 2(i) & (ii), the combination No IV has not been specified. I presume it
should be Biochemic Combination only.
(3)
Page 21 Common Ailments—Colic Baby Treatment. It is presumed the’combination Mag. Phos.
12x etc, etc reports to Biochemic Tablets.
After receiving a copy, I have called for, of the original, I shall again write on the subject, if need be.
Yours sincerely,
T S Thiruvengadam
E 7 Rajendra Road
Block 17, Neyveli 607 801
HEALTH FOR THE MILLIONS/aPRIL
1982
11
CHINU SRINIVASAN
Unsafe and Unclean
Nuclear power as an energy of alternative has made
many promises but has largely remained unfulfilled.
Nuclear reactors are not only health hazards but are
becoming dangerous for even routine human survival.
This article explores why.
Nuclear power and nuclear reactors are remote,
sophisticated things for most of us. At best they inspire
quiet confidence in our scientists and in our technolo
gical progress. We have our nuclear reactors, our own
communications satellites and our steel plants.
On a closer look however, nuclear (or "atomic")
power and nuclear reactors need not be remote,
sophisticated things. Indeed they are not so. They
affect our lives closely. For the fact of the matter is
that nuclear power and nuclear reactors do not do all
that is claimed for in favour of them.
Briefly, the experts and policy-makers (and there
is not much difference between them in the First
World and the Third World) say nuclear power is safe
and clean. Nuclear power is a source of cheap and
abundant power assuming of course everybody, every
where needs more and more power (or energy) as a
sign of progress. Nuclear power because it is cheap
and abundant, is the kind of thing that will accele
rate the development of India.
One wishes these arguments could be right. But
everyone of them has been shown to be faulty in
their logic, at the cost of being even dangerous to
entire communities surrounding existing and proposed
nuclear plants.
Energy Logics
Much of how the average Indian uses energy is
not exactly known. This is because many of these
forms of energy (apart from the food one eats) are not
sold or bought in the market. However, sufficient data
exists to show the energy demand picture: Out of
every 100 units of energy consumed by Indians, coal
contributes 14 units, oil 25 units (excluding non
energy oil demand), electricity 13 units of which
about half is hydro-based, firewood 31 units, dung 7
unitsand agricultural wastes 10 units.
Electrical generation is mostly through coal or
hydropower. Nuclear energy accounts for less than
two percent of electrical generation.
12
However, to say that the so-called energy crisis
in India is due to oil prices and electricity is not strictly
true. If one considers the numbers of people affected,
and the severity on the affected population, the oil
electricity crisis seems to be insignificant compared
to the crisis in the firewood, fodder and agriwaste.
Forests are being felled or monopolized by political
elites and their friends. Traditional energies like fire
wood, fodder for drought animals, agri waste, etc. have
become less and less easy to obtain. Often to get
firewood, fodder, etc it takes upto 8-10 man hours
per day in a poor, rural family.
Considering these problems, it is difficult to find
justification in the vast amounts spent in nuclear
energy in India. Nuclear energy produces electricity,
and electricity is something that the existing non
nuclear power plants are producing far below
capacity !
As a physicist said, "It's like using a forest fire to
fry an egg".
[Anyway, why do we need increasing amounts of
electricity, when cheaper and sater alternatives are
being made feasible and practical ?]
Nuclear Economics
We are repeatedly told by the nuclear powers-that
-be in India that nuclear power would be cheaper than
coalbased power. However even that is not true.
D K Bose in his article 'Accounting of Nuclear
Power' (Economic and Political Weekly August 8,
1981J sets the ratio of capital cost for nuclear to coal
based power at 1.33 Comparative American figures
for light water reactors range from 1.07 to 1.53.
Nuclear power plant costs for the Canadian CANDU
heavy water reactors adopted by India are even higher,
and they seem to be going still higher. The Narora
(UP) and Kalpakkam (Madras) are now reported to
be costing Rs 327.40 crores and Rs 210.89 crores
respectively. Whereas the older estimates were
Rs 209.89 and Rs 132.41 crores respectively. And
they are yet to be finished and far behind schedule.
Both the units of the Rajasthan Atomic Power Plant
(RAPP) at Kota were repeatedly closed down in the
HEALTH FOR THE MILLIONS/APRIL
1982
last two years. The performance of RAPP I has been
consistently poor. It has not worked consistently even
for three months in the last nine years. There have
been 251 breakdowns in nine years which comes to
an average of one shut-down for every 13 days.
RAPP II, commissioned two years ago, has broken
down on an average of one every 19 days.
The first unit of RAPP was shut down in the first
week of March 1982 as engineers could not plug a
five month old suspected leakage in metal tubes in
the reactor despite spending Rs 2 crores on it. The
second unit RAPP that functioned fairly well last year
has been shut down since January 20,1982, due to
turbine vibrations (turbines manufactured by BHEL).
New blades are being ordered from England (for the
rotor). Restart depends on availability of new blades
from England.
The capacity factor—the ratio of actual hours of
power generation by a plant to the hours expected
from its rated capacity—has generally been estimated
theoretically at 80 per cent. However in practice, and
the RAPP I is a good example, the experience here
and in the US with nuclear power plants suggests
average capacities as low as 57-61 per cent. The cost
of capital per unit kilowatt hour is obviously affected
by the capacity factor.
Studies have also shown that the total cost per
kilowatt hour for coal based plants is between 14.91
to 18.34 paise. For nuclear plants it is 17.52 to
22.08 paise. To this even if one adds transportation
and fuel cycle costs, coal based power still turns out
to be cheaper. Even if one considers price rise in
fuels: Non-coking coal in India went up b/100 per
cent during 1973-78, and during the same period
uranium went up by 500 per cent I
In 1966, 34.2 per cent of the total cost of nuclear
power was accounted for by fuel costs, 49.9 percenl
by capital and the rest by maintenance and operations.
In 1975, capital costs had risen to 77 percent and the
fuel costs had declined to 18.2 percent. Construction
costs in the same period went up by 24.4 percent I
To these costs one has to add the cost due to
bureaucracy and plain mismanagement in the nuclear
power sector in India. Faced with such evidence
(leaving out environmental damage factors), one fails
to understand why so much money and time is wasted
on propagating nuclear power. Nuclear power plants
—like steel plants are even promised to the States as
incentives for good behaviour. The central government
has said Gujarat will have its own nuclear power plant
at Kakrapar.
Nuclear Power Ecology
The most crippling burden nuclear power systems
impose is not the merely financial costs. The environ
mental and social costs are even more practical
reasons for wondering whether our priorities are
sensible.
Until the early 1970s the dangers of nuclear power
were mostly unknown or not studied adequately.
However since then, there is an increasing amount of
real-life evidence to indicate that nuclear power plants
are not safe. A nuclear reactor must be cooled cons
tantly to keep it from melting. A cooling system
failure could cause a catastrophic accident. One such
accident, according to nuclear promoters could cause
3,300 deaths, 45,000 illnesses, 140 billion rupees
worth of property damage and contaminate 3,200
square miles. Critics put the estimates much higher.
SANGUINE
COMPASSIONS
NUCLEAR PROMOTERS LIKE TO DESCRIBE
WHAT A SMALL RADIATION DOSE NU
CLEAR POWER PLANTS EXPOSE US TO
COMPARED WITH OTHER SOURCES OF
RADIATION. ONE PROBLEM WITH SUCH
COMPARISIONS IS THAT THEY DON’T TELL
US HOW MUCH DAMAGE IS BEING CAUSED
BY THE OTHER RADIATION SOURCES. A
RECENT STUDY ESTIMATES THAT ONE
MILLION AMERICANS
LIVING TODAY WILL
GET CANCER FROM MAN-MADE SOURCES
OF RADIATION. ANOTHER PROBLEM
WITH SUCH COMPARlSlONS IS THAT THEY
GREATLY UNDERESTIMATE THE RADIATION
DOSE WHICH WE RECEIVE FROAA NUCLEAR
PLANTS- THEIR FIGURES ARE BASED ON
HOW MUCH RADIATION THE PLANTS ARE
DESIGNED TO RELEASE
INSTEAD OF ON
HOW MUCH EXTRA RADIATION PEOPLE
ARE ACTUALLY GETTING.
ILLUSTRATED BY LEONARD R|FAS
health for the millions/april 1982
13
Some of the major nuclear accidents in the world
are catalogued in the illustration Countdown to Melt
down. These kind of accidents only make suspect of
the probability calculations of nuclear safety made by
many studies which advocate that nuclear power
plants are safe. Almost all such analyses ignores the
so-called human error factor. How do we, as one
social scientist put it ensure the reliability of complex
systems made up of hundreds of thousands of compo
nents, all supplied by the lowest bidder? Even if one
assumes the probability values for the various chain of
events are correct as in one of the more well known
studies on nuclear safety—the Rasmussen study—the
probability of major accidents till 2000 AD is one
every six years I
Furthermore, nuclear power has two major out
puts : nuclear radiation and radioactive wastes. The
former causes cancer. The Three-Mile accident of
1979 in USA condemned to death anywhere from 1 to
2500 people according to various estimates. Leaks
and malfunctioning in reactors are common. Our own
Tarapore Plant in Bombay has a constant radioactivity
problem.
Moreover, reprocessing of spent fuel (as we
are attempting at Tarapore) is a very tricky business
and has been given up in the US. A reprocessing
accident can be atleast as dangerous as a reactor acci
dent. Yet the reprocessing plant lacks most of the
reactor safeguards and procedures.
The problem of radioactive wastes is 'even more
worrisome. Even after recycling of fuel, one is stuck
FR.O<b
with radioactive wastes. It has been calculated by
Robert Pohl that the health effects of a nuclear plant's
uranium supply tailings (a radioactive waste) are
greater than all the effects from an equivalent coalfired plant including pollution and mine accidents.
The problem here is where does one dump these
radioactive wastes ? How does one physically isolate
tons of material from all life for centuries and centuries
to come ? The problem has not been solved. Several
interesting solutions have been found to be unwork
able in one way or the other.
Even the non-radioactive waste (so it is claimed)
dump policies of the Nuclear Fuel Complex (NFC)
Hyderabad have been irresponsible; leading to injuries
(and may be deaths) to people around NFC.
Even marine life could be in danger. Kalpakkam
reactor will require for cooling as much water as the
city of Madras uses. The heavy cooling requirements
are the reason why most power plants are near the
sea or large water bodies. This water will be returned
to the sea at a higher temperature. Even slight changes
in temperatures are known to be fatal to acquatic life.
It has been estimated nuclear power plants have
an operating life of 40 years. After this time the
reactor vessel and its surrounding structures are radio
active and too dangerous to approach. So far no
large reactor has been decommissioned. It may cost
more than Rs 1000 crores per reactor. A 1976 nuclear
industry study said that the best way to decommission
plants would be to "mothball" them under guard for
100 years while the worst radioactivity decays and.
UEGfi»
THE AMSTERDAM NUCLEAR RESEARCH
INSTITUTE DUMPED NUCLEAR. WASTE
IN A DITCH. PR. DICK HILLENIUS, A
BIOLOGIST, SUBSEQUENTLY FOUND
FROGS WITH EXTRA LEGS AND
OTHER MUTATIONS BEHIND HIS
HOME. RADI AT ION IS KNOWN TO
CAUSE MUTATIONS IN ANIMALS AND
GENETIC DAMAGE IN HUMANS.
ILLUSTRATED BY LEONARD R1FAS
14
HEALTH FOR THE MILLIONS/aPRJL
1982
CnUNTOUHIN TO KIELTDEIttJN
-.
■
A frightening catalogue of nuclear reactor disasters and near disasters
»
_____ ;_____________ ■______________________________________________ .
HQ
DEC. 1952
CHALK RIVER experimental
reactor. Ontario. Canada. Human error
and jammed safety device brought partial
meltdown. Release of millions of gallons
of radioactive water inside reactor.
Decontamination took 6 months.
OCT 1957.
WINDSCALE No 1
plutonium reactor, near Irish Sea.
England. Technical mistake brought
ignition of 12 tons of uranium Fire out of
control 24 hours. Worries of explosion
Escape of radioactive iodine, more than 2
million litres of milk laced with iodine
confiscated and dumped
1959
SOUTHERN URALS. USSR.
Radioactive waste leakage suspected
cause of contamination and evacuation of
hundreds of square miles Presence of
Strontium 90 means area under
quarantine for centuries. Soviets have not
disclosed numbers of dead and ill.
IHHB
S'
JAN 1961
IDAHO FALLS. USA SL1
tost reactor. After a love-triangle murder
attempt backfired, three service workers
killed by steam explosion and radioactive
flash. Bodies so radioactive they had to
be buried in leadlined coffins placed in
leadlined vaults.
OCT 1966
ENRICO FERMI plant
south of DETROIT. USA. Reactor had
partial meltdown in starting-up operation.
Flow of coolant to reactor core blocked.
Alert went out to evacuate Detroit, but
China syndrome avoided. Commented one
engineer, 'we almost lost Detroit
JAN 1969
LUCENS reactor.
Switzerland. Fortunately built in deep
cave Explosion of radioactivity and loss of
coolant over uranium core Cave sealed to
avoid leaks Decontamination took 21
months.
M
U.S CONGRESS
"AN ACCIDENT LIKE
MARCH. 1975 BROWNS FERRY.
Alabama. USA nuclear plant Electrician
using candle to check for airleaks started
fire which destroyed many safety devices.
including emergency core-cooling system.
Plant close to meltdown. Damage cost
SI 50 million. 1981,station fined $50,000
(or failure to meet basic fire safety
requirements.
16
■HEALTH FOR THE MILLIONS/APRIL
1982
MARCH 1979
THREE MILE ISLAND.
Pennsylvania. USA. ’Woist accident in
US nuclear history’. Combination of
human error and faulty safety
mechanisms. First stage of meltdown
occurred as cooling water leaked to
expose core. Radioactive gas leaks.
Warning of possible evacuation to
millions. Dumping of radioactive water
into river from which drinking supplies
taken.
326. V Main, 1 Block
Koramcngala
®an9a,ore-560034
India
THIS (THREE MILE ISLAND
NOT ONLY ODULb HAPPEN
; AGAIN &DT IS LIKELY
\
To AT ANYTIME/7 /
15
then tear them down and bury the parts as radio
active waste. It is not clear who would undertake this
task, nor who would pay for it. Possibly nuclear
power plants are condemned to become waste
baskets for ever.
Other arguments like risk of theft and threat by a
few mad persons, the nuclear arms race and the
inability of the nuclear power industry to generate jobs
(except for a few) and promote development are fairly
well-known.
There is not a dearth of safe, renewable energy
alternatives to nuclear power. As an energy source,
nuclear power has been found to be inappropriate
from the point of costs, the real energy needs of the
people and ecology. Unfortunately, nuclear power
promoters, in this country as elsewhere, are a small
powerful elite; and to that extent probably do not
empathise with the firewood and fodder energy needs
of the majority. Nevertheless, our priorities seem to
be inappropriate, wasteful and self-defeating. A new
set of priorities and values, would place rapid refore
station above nuclear power in India.
/Motes : The illustration "Countdown to Meltdown" is
reprinted kind courtesy the New Internationalist
magazine. The other illustrations are excerpted
from ALL-ATOMIC COMICS, available from
Edu-comics, Box 40246, San Fransico, Cali
fornia, 94140, USA $ 1.25 for a single copy.
For further reading and references
1.
"Accounting of Nuclear Power", DK Bose,
Economic and Political Weekly, August 8, 1981.
2.
"Does Nuciear Power Provide Reliable Electri
city", URJA, January 1981.
3.
"Rasmussen on Reactor Safety", IEEE Spectrum,.
August 1975.
4.
"Environmental Impact of Nuclear Power
Industry—Kalpakkam Project", M.R. Srinivasan
and T. Subbaratnam, Seminar on Environmental
Pollution in Madras Metropolitan Area, MMD,
Madras.
5.
Content of Science and Technology : The care of
Nuclear Energy, Rathindranath Roy, Centre for
Study of Developing Societies, New Delhi.
6.
The Case Against Nuclear Energy : Special
cartoon issue. New Internationalist, August
1981.
7.
All-Atomic Comics, (quoted above).
8.
Nuclear Power, Walter C. Patterson, Pelican
1976 (reprinted 1980).
9.
The Menace of Atomic Energy, John Abbots
and Ralph Nader, 1977.
10.
No Nukes—Everyone's Guide to Nuclear Power,
Anna Gyorgy and friends. South End Press,
Montreal 1979.
11.
Nuclear India—A Technological Assessment,
G.G. Mirchandani and P K S Namboodiri, Vision
Books, New Delhi.
RENEWABLE V6. NON RENEWABLE
ONE REASON SOMETIMES GIVEN
FOR USING NUCLEAR POWER IS
THAT WE ARE USING UP EARTH'S
COAL AND OIL. RESERVES. COAL
AND OIL ARE NON RENEWABLE
RESOURCES . THIS MEANS THAT
THERE IS ONLY A CERTAIN AMOUNT
OF THEM AND THE MORE WE BURN,
THE LESS WE WILL HAVE LEFT.
RENEWABLE ENERGY SOURCES ARE
SOURCES OF ENERGY WHICH CAN
REPLENISH THEMSELVES NATURALLY.
SOME RENEWABLE ENERGY SOURCES
ARE WOOD ,TIDES,WIND, FAL LI NG
WATER,AND SUNLIGHT. HOW MUCH
USE WE MAKE OF THESE SOURCES
NOW DOES NOT LIMIT HOW MUCH
OF THEM THERE WILL BE IN THE
FUTURE. NUCLEAR POWER PLANTS
BURN URANIUM FUEL. URANIUM
IS A SCARCE NONRENEWABLE.
RESOURCE.
ILLUSTRATED BY DELORES THOM
16
HEALTH FOR MILLIONS/APRIL
1982
Toxic Chemicals and Human Health
Japan has suffered two major epidemics of
methyl-mercury poisoning from the industrial release
of mercury compounds into Minamata Bay and the
Agano River, followed by accumulation of the mer
cury by edible fish. At Minamata, the dead bodies of
Japanese fishermen contained from fO to 30,000
times more methylmercury than normal.
Some newborn infants at Minimata was found to
have 20 to 30 per cent more mercury in their blood
corpuscles than their mothers. A foetus has at least
four times the sensitivity of an adult to methylmer
cury. The results: an usually high proportion of
children were born with rare deformities.
Epidemic jaundice with a high mortality rate broke
out in more than 150 villages in north-west India in
1974. Nearly 100 people died among the 994 who
fell ill. The outbreak followed the consumption of
badly stored maize. Aflatoxins, producing liver
damage, have been detected in groundnuts, maize
and tree nuts. The jaundice victims in north-east
India could have been exposed to heavy doses of
aflatoxins for several weeks. The origin of such
toxins: bacteria and moulds which grow in or on food.
Pesticide residues in crops, pollutants taken up
by fish and other aquatic organisms from the water,
and substances produced by the growth of bacteria
or moulds are just three ways toxic chemicals can
enter the human food chain, the 1981 State of the
Environment Report notes.
*.
Wowic* An A
Resource £u<Xe
Toxrc chemicals in the form of pesticides have
been a boon in controlling diseases carried b/ in
sects and microbes. By reducing sickness and in
creasing agricultural production, they have made life
better for millions of people. But toxic chemicals in
food have also been responsible for several devastat
ing epidemics:
Over 6,000 people in Iraq were admitted to hos
pital with food poisoning in an outbreak in 19711972. More than 500 of them died. The cause: con
taminated bread which had been prepared from
cereals treated with alkyl-mercury fungicides. The
pesticide designed to protect a crop had turned into
a man-killer.
‘HEALTH FOR THE MILLIONS/aPRIL
1982
In the latest annual Report of the Executive Direc
tor of the United Nations Environment Programme
(UNEP), Dr. Mostafa K. Tolba, calls for measures to
reduce the levels of toxic chemicals in foods. At the
same time, the Report presses for more research into
how contaminants accumulate and move through the
food chain and for research into their effects on human
health.
Food Contamination
In a special chapter focussing on the toxic chemi
cals and human food chains, the report says moni
toring programmes have so far produced only limited
information about the concentrations of substances
such as long-lived radio isotopes, persistent organochlorine pesticides, polychlorinated biphenyls (PCBs)
and metals in human tisssues, selected foodstuffs
and wildlife.
17
"These inadequacies result partly from differences
in analytical techniques and the lack of good methods
for measuring some contaminants and partly from
statistical sampling problems," UNEP reports. As a
result, general statements about the scale of the
food contamination problem are bound to contain
various inaccuracies. At the same time, as more evi
dence of contamination of food with toxic chemicals
has been obtained, it has increasingly been realized
that knowledge about the hazard to human health
posed by many chemicals present in food is inade
quate.
There is a dearth of reliable information about
the long-term risks involved in exposure to most
substances. The general public is understandably
concerned by the fact that toxicologists are at present
unable to give reliable estimates of the risk.
UNEP's Global Environmental Monitoring System
(GEMS), in cooperation with the Food Agriculture
Organization (FAO) and the World Health Organiza
tion (WHO), prepared guidelines in 1979 for estab
lishing or strengthening national programmes to
monitor food contamination.
and hydrocarbons in their tissues as a result of con
tamination of rivers, lakes and coastal waters.
Under a joint programme of the FAO, UNEP and
WHO, 20 institututes in different countries are carry
ing out studies to monitor the contamination of animal
feed. The GEMS Food Contamination Monitoring
Programme—in which 21 countries are taking part—
is trying to provide better information on food con
tamination through its system of international coope
ration.
poisoning can cause disturbances of the respiratory
system, hypersecretion in the eyes, alter pigmentation
and result in skin eruptions. It has also been found
But the causes and effects are not always so easy
to measure. Fish can accumulate PCBs, for example.
Feeding cows and poultry fishmeal contaminated
by PCBs can transfer the toxin to milk and eggs, PCB
to produce liver cancer in rats and mice.
Antibiotics
Some pathways for toxic chemicals into the human
food chain—and their dangerous effects—are well
known. Chemicals present in the soil may be taken
up by the roots of plants used as food for man
or animals. "The epidemic of chronic cadmium
poisoning (itai-itai disease) in Japan in the 1940s
was caused by the consumption of rice and other
foods which were heavily contaminated with cadmium
taken up from irrigation water polluted with effluent
from a zinc mine," the UNEP study reports.
"There is some evidence that in Sweden the
level of cadmium in autumn wheat has increased
during the last 50 years, probably due to contamina
tion of the soil with cadmium by deposition from the
atmosphere or from phosphate fertilizers," it adds.
Cadmium and lead are concentrated within matter
taken up by the edible molluse (mussels and oysters).
Fish and other aquatic organisms have shown a
marked increase in the level of DDT, PCBs, toxaphene
18
Residues of antibiotics, hormones and other drugs
used to treat or prevent animal diseases or to promote
growth may be present in meat, milk or eggs. The
residue levels are usually very low and probably pose
little risk to human health, the report agrees. But it
adds, "There is concern about the risk of develop
ment of pools of ant imicrobial-resistant bacteria
pathogenic to man or domestic animals."
Preservative agents and anti-oxidants offer bene
fit to health because they prevent food from spoiling.
But some additives, such as nitrites and sulphur
dioxide, can react with other food components^
UNEP warns. Certain kinds of food colouring and
preservatives produce allergic rashes and asthma in
a small fraction of the population according to a WHO
report.
—UNEP & Ecoforum
HEALTH FOR THB MlLLlONs/APRIL 1982
NIKKI MEITH
Poison : What is in a name ?
Not long ago Jan Huismans received a letter of
thanks from an official in Guyana who had just
managed to stop the import into his country of a large
shipment of weedkiller harmful to the health of human
beings.
The US company which manufactured the herbi
cide had been persuaded by the US Environmental
Protection Agency to withdraw it from the market.
The Guyanan had stopped his country's order for the
chemical after reading of the case in the "Bulletin”
of the International Register of Potentially Toxic
Chemicals (IRPTC) of the United Nations Environment
Programme.
"Information exists somewhere on every one of
the approximately 60,000 chemicals in common use,”
noted Huismans, the Dutch director of IRPTC. "But
it is buried in manufacturers' files, in national govern
ment reports, in background documentation for
national and international legislation regulating trade
in chemicals, in data banks of research institutions,
and in scientific and technical journals in dozens of
languages.
"What was desperately needed was a centralised
link-up of these sources, which would be independent
of commercial interests as well as scientifically objec
tive and available to everyone without bias,” he
added.
IRPTC has just produced its first data profiles,
covering 330 chemicals. These were selected from
40,000 compounds on which the IRPTC has informa
tion on the basis either of potential threat to human
health or the environment, or because national or inter
national agencies had expressed concern about their
potential hazards. About half of them are pesticides.
The profiles give the basic chemical properties of
the compound; its toxicity; how it is absorbed into the
body; how to dispose of its container; reported effects
on human health, the environment and laboratory
organisms; what legislation controls its use and how
to apply it safely and effectively.
Huismans hopes to add about 100 chemicals
yearly, but this depends on the support he gets from
his sources: primarily the national and international
organizations active in chemical research and control,
HEALTH FOR THE MILLIONS/APR!L
which Huismans calls his "network partners”. The
network partners supply the scientific data, but IRPTC
reaches governments mainly through its national cor
respondents, who now represent 90 countries.
"The national correspondents are the main conduit
by which IRPTC data reach the people who need it,
such as the authorities who must decide whether to
import a particular chemical, how to label it and where
it should be used,” said Huismans. They also provide
IRPTC with information on their countries' laws on
hazardous chemicals and accidents which have led to
official inquiries.
An index of available data profiles is published
twice a year, as is the Bulletin, which Huismans
described as "a way for national authorities to com
municate with one another all the news about hazar
dous chemicals that cannot be found in the scientific
literature.”
IRPTC cannot recommend laws to control chemi
cal trade or initiate legal action on behalf of its
users. "In a way, our limitations work to our advan
tage,” Huismans said. "Since we are not in a position
to confront industry, we do not mind antagonising
one of our best sources of data.
"Industry has in its files an enormous store of un
disclosed information of great value to us. Some of
it is secret because it involves new product research—
and some of it may very well reflect unfavourably on
chemical safety,” he added. But much of it is unpubli
shed because the chemicals have no adverse effects
and this does not interest science journals. But such
"negative results” on safe compounds do interest the
IRPTC.
What is the relationship between IRPTC and
the chemicals industry? "Extremely variable,” said
Huismans. 'We must deal with manufacturers on a
company-by-company basis, because their attitudes
differ. We work strictly on the understanding that we
will not compromise on acceptability of data, or
accept any interference concerning what information
goes into our data base.
This does not mean we expect them to give us
highly commercially sensitive information, such as the
manufacturing process. But if we accept their data
1982
19
for our files, we expect it to include everything that
relates to health and environmental safety, he said.
But obviously it is impossible for IRPTC always to be
certain that the companies are complying with Huis
mans' criteria. And what do the cooperating com
panies get in return ?
"They get what everyone gets from IRPTC—an
objective presentation of their product. Many com
panies admit that a fair and balanced view of their
products is in their best interest," said Huismans.
adding that two chemical "giants" he approached
recently agreed that their health and safety data
should not be held confidential, and expressed a
willingness to communicate it to IRPTC.
Huismans said his major frustration was the
slowness of many governments to establish the
national mechanisms through which IRPTC must
operate if it is to be effective. He noted that the 11 3
nations at the 1972 UN Stockholm Conference on the
Human Environment had recommended that such a
system be established.
"The register was created at their request," said
Huismans, adding that its effectiveness depended on
their response. "As governments become more aware
of the health and environmental tragedies they could
face from many of the chemicals they manufacture
and import, their interest will no doubt grow," Huis
mans said.
—Earthscan &■ Ecoforum.
DRUGS COLUMN
BAN ON PHENACETIN
The Drugs Controller of India has indicated that the
ban on the manufacture of phenacetin and its combi
nations will be effective from May 1, 1982.
Cough cures questioned
Certain drugs taken to cure coughs and colds are
being seriously questioned. The drugs, available with
out prescription, may cause severe injury or death
even after only one capsule has been taken, accor
ding to an editorial in the Lancet. In these certain pro
ducts, the drug phenylpropanolamine is formulated
with other drugs which may, apparently, increase side
effects. The brand names Dimonate, Exyphen, Pholcofox, Runurel, Tixylix and Triotussic are recommended
for treating coughs, colds or flu; Dimotapp, Trigesic,
Triominic, Totolin and Eskornade are recommended for
catarrh, runny nose, sinusitis and congestion. There
is no evidence that Phenylpropanolamine is effective
in preventing complications of infections, sa^s the
Lancet, and the drug can damage the heart muscle
permanently, cause a rise in blood pressure, irregular
heart rhythms, induce brain haemorrhage or stroke.
(HAI News)
20
Bad week for Valium
The week of March 14 was a bad one for Valium
(diazepam) in the US. First Washington Post publish
ed an article based on an interview with the Drug
Enforcement Administration's director of compliance,
Gene Haislip. He was quoted as saying that large
quantities of diazepam are being disguised as metha
done (Quaalude) for street sales—"the fastest grow
ing illegal drug business in the country". Then the
Public Citizen Health Research Group launched its
new 108-page book, Stopping Valium, which vigor
ously criticises the promotion of all benzodiazepines.
The book warns consumers that frequently-prescribed
therapeutic levels of the drugs can be addictive. Fin
ally within that week the movie, I'm Dancing as Fast
As 7 can, about a housewife addicted to Valium,
opened its second week in theatres nationwide. The
book Stopping Valium is available from Public Citizen
Health Research Group, 2,000 P Street, NW 708,
Washington DC 20036, USA.
(HAI News).
HEALTH FOR THE MILLIONS/aPRIL 1982
RENU
Cattle Immunisation
Clara Swain Hospital, Bareilly, has a community
'health programme. It was started in January 1980 as
"the Rural Health and Community Development Project,
The project covers six villages. It is administered from
the Rural Health Centre, a branch of the same hospital
at Faridpur.
The objectives of this project are not very different
from the objectives spelt out by many similar projects
in India. What is different is the way some of thefee
objectives are being realised.
The project personnel are working actively and
closely with a number of government agencies. Apart
from the Community Development Blocks, the U P
State Electricity Board, and the State Bank of India,
close collaboration exists with the Veterinary Hospital.
The veterinary doctor holds regular weekly clinics in
the six villages. The villagers eagerly ayvait his arrival
with their cattle. There is 100 percent immunisation of
the cattle—not so of the children ! The commendable
feature of this project is that it has truly moved to ful
fill the needs of the people. The villagers feel that it
is more important for their animals to remain healthy
and productive. The project people do not demur—
they liaise with the vet and arrange the weekly clinics.
Gradually, through this example, they establish the
value for immunisation of children.
Greater emphasis is placed on socio-economic
development than health activities per se. Gram Vikas
samities have been set up. Fishery ponds have been
dug in three villages in collaboration with the Com
munity Development Blocks. In the last two years
twenty-eight persons have been trained in tailoring.
Their self-employment opportunities are worked out
with Khadi Gram Udyog and the SBI.
The Khadi Gram Udyog agreed to set up a scheme
for spinning, weaving and marketing of the finished
garments. The native skills and strengths of the
■women are encouraged—they make beautiful baskets,
boxes and vases with dried wild grass. These are
marketed in an organised way.
HEALTH FOR THE MILLIONS./aPRIL 1982
Ah exciting moment at the volley ball
tournament
These are some routine ongoing activities. How
ever, a memorable event took place on October 17,
1981. The six project villages and the project person
nel organised a community development and health
fair. The aim of the fair was to bring about greater
coordination with the government departments in
socio-economic growth activities. Combined with the
fair was an exhibition to attract the villagers. Some of
the events in the programme were : wrestling matches,
baby show, cattle show and a volley ball tournament
(this became a very popular sport in the villages). The
sport also helped in diverting the attention of the
youth towards healthy physical activities and mental
well being. It has brought about a gradual unification
and breaking of caste barriers.
The fair was a raging success. Over 10,000 people
came from far and near villages—it helped in cement
ing the relationship between the villages. The villagers
felt an involvement and satisfaction
through their
participation in the fair. As a stimulant towards in
creasing self-confidence and inter-dependence, this
was helpful.
21
TECHNOLOGY
industrial Masks
Pneumokoniosis is the term used for a group of
diseases which occur in a significant proportion of
workers and labourers employed in various types of
mines and industries such as sugar mills, textile
mills, flour mills, cement factories and other similar
industrial units where a lot of dust is raised in the
atmosphere. These diseases are caused by the in
halation of various types of industrial dusts which
initiate the process of chronic lung damage. Initially,
the worker starts having a mild cough which pro
gressively becomes more and more severe. Later on,
the workers starts having difficulty in breathing which
ultimately may completely incapacitate him because
he becomes breathless even on slight physical
exertion.
vides complete protection even if the worker breathsthrough the mouth. The elastic bands lock behind
the neck and hold the filter in place.
Cloth masks: The cloth masks also cover the nose
and the mouth and have elastic straps which lock
behind the neck. These masks are made from a special
thickness cloth. The cloth masks remove the parti
culate matter as well as vapours from the air and can
be washed with ordinary soap and water.
Nasal masks: Workers who do not wish to cover
their mouth with the mask, can use the nasal maskswhich are like the cloth masks, but cover only the
nose.
Cloth mask
The only,way to avoid such diseases is to prevent
them, because once the disease has developed,
almost nothing can be done. The simplest .way to
prevent these diseases is to prevent the entry of
these mineral and industrial dusts from entering the
lungs. The best way of doing so, is to wear a mask
on the face while at work. The industrial masks
(External Filters) developed at the All India Institute
of Medical Sciences, New Delhi, have been designed
for this purpose (contact • Dr J S Pasricha)
The following models are available:
Industrial filter: It is made of soft plastic material
which covers the nose and the mouth and thus pro22
Nasal mask
Utility
The industrial masks should be used by all theworkers who are exposed to any kind of industrial
dusts. They can be useful to even those workers who
have already started having symptoms of pneumoko
niosis. Their use will protect the workers from damage
due to further inhilation of dusts. These can also
be used by individuals having an allergic disease
such as asthma allergic rhinitis atopic dermatitis
or urticaria due to air-borne allergens. (In such cases
however, the nasal filters are cosmetically superior).
The masks can also be used by any individual who
wants to protect himself from air-borne environmental
pollution.
HEALTH FOR THE MILLIONS/APRIL 1982
nenefe
Tamil Nadu
HEALTH THROUGH SIDHA
Among the new activities planned by TN VHA
for 1982 are workshops on alternative medicare,
physical assessment, health care planning for plan
ters, laboratory techniques for rural areas, Sidha medi
cine, transactional analysis and holistic health, This
was announced at the TN VHA annual meeting on
February 19-20, at Madras.
Experiences shared at this meeting were including
those on : women and health, experiences with sca
vengers, role of animators in rural areas, and a perso
nal village experience among Harijans of Kotagiri.
Gujarat
ZANKHVAV WITH LOVE
The second series of followup meetings of the
Zankhvav training programme was held at two sepa
rate places, Ahmedabad and Zankhvav, for North
and South Gujarat in January. The attendance was
high, and now even extra centres have joined the
original group. The next series of follow-up meetings
is scheduled for June.
XXX
Among other happenings in Gujarat have been : a
week long camp by the Man'grol group, MFC and
Sangharsh Vahini as a preparation for working in four
new villages; a young team of students help Fr Jerry
put up 6 shows in a big slum in Ahmedabad on
scabies; build up of low cost educational materials
in the form of puppets, slides, plays, etc, and conti
nuation of the evaluation of under-five programmes
by GVHA so that become more effective.
Bihar
HERBAL EFFICACY
The BVHA held its annual general meeting on
February 18-19, 1982 at Patna. There was a panel
HEALTH FOR THE MILLIONS/APRIL
1982
of three speakers on
* the theme:
Health for All by 2000 AD
through people's participation.
One of the speakers, Mr Jean
Louis Bato, shared about the
findings of the
comparative
study he had conducted on
herbal and allopathic systems of medicines in Mozam
bique. The study showed that more than 80 per cent
of the diseases in Mozambique can be cured effecti
vely by locally available herbal medicines.
X-RAY COURSE
Members of the BVHA unanimously approved at
the annual meeting that the BVHA sponsor the oneyear X-Ray technician's course to be conducted by
Kurji Holy Family Hospital, Patna. The course, to
start from September 1982, will require a minimum
qualification of high school preferably with science.
Kerala
A meeting of hospital administrators, directors
and heads of religious groups took place on January
2-4, 1982 at Mananthavady. The meeting, a culmi
nation of various awareness building seminars, was
held under the auspices of CHAI and KVHS. Later, a
follow up meeting was held on February 18, at
Muvattupuzha.
Andhra Pradesh
WHAT'S NEW
Among the new future programmes of APVHA
announced recently are one on Wholistic Health for the
whole family and a long term training programme for
Agency Assistants.
New Delhi
OD Times Again
The sixth seminar on organisational development
(OD) and renewal for healh care organisation was
held in Pune, March 26-31, 1982. The seminar was
organised by VHAI. There were many presentations
by the participants on their personal experiences of
OD. The concept of OD seems to be undergoing a
change with every annual seminar. OD is something
which is wellness sustaining as much as it is
a trouble-shooting exercise in an organisation. The
need for new technology interventions too in the
form of non drug and herbal therapies was empha
sised.
23
We need you
Doctors
Dedicated Christian doctors and nurses, preferably
Christian, to work in a rural hospital and community
health centre at Anantnag, Pahalgam. For particulars
contact the medical superintendent, John Bishop
Memorial Hospital, Anantnag 192101, Kashmir.
Youth and Energy Wanted
The Voluntary Health Association of India requires
a young, energetic and enthusiastic medical doctor
(MBBS) and a non-medical person with MSW/Post
graduation in any discipline, to work with the com
munity health team. The candidates should be pre
pared to travel extensively and be able to organise
and conduct workshops in community health and
development, mostly in rural areas.
Experience
preferable. Salary will be commensurate with quali
fications and experience. Apply within two weeks
with bio-data to Voluntary Health Association of India,
C-14, Community Centre, SDA, New Delhi-110016.
Wanted for a rural 160-bed Hospital, Nursing
Superintendent B.Sc Nursing with 2 years experience
or R.N.R.M. with advanced Administration Certificate
with minimum 5 years general experience. Salary
negotiable. Age 35 to 45 years. Write to the Medical
Superintendent, St. Luke's Hospital, Hiranpur, S.P.,
Bihar 816 104 for application form before 30th June
1982.
Opportunity
Rural Development
A six months' certificate course Integrated Rural
Development is being offered by RUHSA. Graduates
or non-graduates with at least three years experience
as grass-root level community workers in rural
development programmes can apply.
Ability to
communicate effectively in English and knowledge of
reading and writing one Indian language are essential.
Session commencing July 1982. For application and
other details write to : Programme Director, RUHSA
Post, KV Kuppam-632201, N.A . Tamil Nadu.
New Book From VHAI !
Management Process in Health Care
How ?
If you are concerned with
* planning health care programmes
♦ administration of health programmes
* management of hospitats and health centres
* training of personnel in health care management
or
♦ even simply curious about how management
principles can be applied to health care in
India
,, , , _
then the Management Process in Health Care
is a book that is sure to interest you.
This book is an outcome of VHAI's experience
in management education for persons in hospitals
and health centres. Over the past ten years,
Carol Huss, MHA, PhD, of VHAI, has been
working with a team of professional managers
in training such persons. It brings to you through
cases and illustrations, live experience of these
years.
Write to VHAI for further details.
24
HEALTH FOR THE MILLIONS/APRIL
1982
Correspondence Course
in
Health Care & Wellness Management—Batch VII
1982-1984
After a break of one year, we are ready to take the seventh batch of students for
the two year correspondence course.
To date five batches of students have graduated—the sixth batch is in the process
of completing the two years, programme. With 50 health care administrators
successfully completing the course, a formal detailed evaluation was conducted
in 1981. On the basis of the data generated through this evaluation, the Corres
pondence Course has been considerably modified. To the basic core of 'manage
ment' has been added the 'Wellness Management' dimension. This seeks to ex
plore all kinds of alternatives to make health care low-cost, appropriate and rele
vant. The aim of the Correspondence Course in Health Care and Wellness
Management is to expose administrators of health care organisations to these
alternatives.
The new prospectus and application form is available on payment of Rs. 5/-only
(Crossed Indian Postal Order drawn in favour of VOLUNTARY HEALTH ASSO
CIATION OF INDIA).
You can write to :
Renu Khanna
Correspondence Course Coordinator
Voluntary Health Association of India
C-14 Community Centre, SDA
New Delhi-110 01 6
Last date for receipt of applications : September 10, 1982
Opening Seminar :
November 1 -6, 1 982
M
An Indian Chief's Message
Chief Seath of the Duwanish Tribe wrote these words in a letter sent to
President Franklin Pierce of the United States in 1855 :
The Great Chief in Washington sends words that he wishes to buy our land.
How can you buy or sell the sky—the warmth of the land? This idea is
strange to us. Yet we do not own the freshness of the air or the sparkle of
the water. How can you buy them from us ? Every part of this earth is sacred
to my people. Every shiny pine needle, every sandy shore, every mist in the
dark woods, every clearing, and humming insect is holy in the memory and
experience of my people.
x
X
X
X
X
We know that the white man does not understand our ways. One portion of
the land is the same to him as the next, for he is a stranger who comes in
the night and takes from the land what he needs- The earth is not his brother
but hi s enemy, and when he has conquered it he moves on. He leaves his
father’sgraves, and his children's biith right is forgotten.
X
There is no quiet place in the white man's cities. No place to hear the leaves
of spring or the rustle of insect wings. But perhaps because I am savage—
and do not understand--the clatter only seems to insult the ears. And what is
there to life if a man cannot hear the lovely cry of the whipporwill or the
arguments of the frog around the pond at night.
X
'A
X
x
The whites too, shall pass—perhaps sooner than other tribes. Continue to
contaminate your bed and you will one night suffocate in your waste. When
the buffalo are al! slaughtered, the wild horses all tamed, the secret corners
of the forest heavy with the scent of many men, and the view' of the ripe
hills blotted by talking wires. Where is the thicket ? Gone. Where is the
eagle ? Gone. And what is to say goodbye to the swift and the hunt, the end
of living and the beginning of survival.
X
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For Private Circulation Only
HEALTH FOR THE MILLIONS
Vol. Vlll
No. 3
Juno 1982
The People and Me
CONTENTS
1.
People's Participation in
Health
5.
Give us this Day Our Health
8.
Where there is no Surgeon
10.
Incident in Garo
11
A Letter on School Health
12.
Book News
13.
Drug Nows
14.
Nows
16.
News from the States
Go to the people ?
Sure 1 go to the people !
(1 wonder why he is pushing me.)
Be open with the people ?
Ofcourse, I'm being open with them 1
(I'm as open as 1 can be
but 1 don't want to hurt them.)
People's participation ?
You know 1 let them participate.
(But each according to his ability.)
Live with the people ?
Naturally 1 live with them.
(This is one earth after all.)
Love the people ?
1 always love them -just like they love me I
(And when they learn to love me more,
1 might love them more).
Self-reliance and self sufficiency ?
You know 1 always believed in the theory of self-reliance.
(Oh yes I It's c good theory, but not self-sufficient)
Editor : S. Srinivasan
Executive Editor : Augustine J.
Veliath
Production : P. P. Khanna
Assistance : P. George and
What's your problem ?
’ No probs 1
What problem could there be
Between me and the people
When 1 go with them,
Live with them and
Make them participate.
John Agacy
— With due apologies from China to
whoever wrote something similar.
Circulation ; L. K. Murthy
Owned and
published by the
Voluntary Health Association of
India, C-14, Community Centre,
■Safdarjung Development
Area, '
j lew Delhi-110016,
and printed I
at Printsman, New Delhi.
PLEASE RENEW YOUR SUBSCRIPTION TO HEALTH FOR THE
MILLIONS.
IT IS STILL Rs. 12/
PER YEAR.
:
AB HAY BANG
People's Participation in Health
Some Myths
Some decades ago, development of undeveloped
communities meant doling out food, clothes, medicines
and money to the poor who were just passive reci
pients. Gradually a realisation came that this was a
bottomless pit which would never fill. So came the
concept that 'people' should work fortheir own im
provement. However it was soon realised that people
could not be made to work unless they were involved
in the process of development. Thus came the idea of
people's participation.
There are three questions I want to ask.
1.
2.
3.
What do we mean by people's participation ?
Who are the 'people' ?
Is people's participation possible in com
munity health ?
Different people have different meanings for
people's participation. Some project workers say that
there is overwhelming people's participation in their
projects; thereby meaning that the people are taking
benefits from their programme. Does merely taking
benefits of the programme or participating as bene
ficiaries mean people's participation ?
Some call it people's participation when the people
are receiving benefits not as charity but are paying or
rather are forced to pay for the benefits. Does such
payment for services mean people are participating?
Then people are very actively participating in the whole
of the commercial system today where everybody
pays for whatever he or she gets. Then can compul
sory payment for the benefits, which is glorified as
'economic contribution of the people to the pro
gramme' be a hallmark of people's participation ?
A very successful community health project claims
that "the villagers collectively constructed a road from
our hospital to the village so that our health team
would reach the village", and foreigners are much im
pressed by this 'people's participation.' One however
finds that the road was constructed by the labourers
of the village in 'food for the work' programme and
the villagers were mainly paid labourers.
HEALTH FOR THE MILLIONS/JUNB
1982
The same community health project says, "Our
village health workers have been selected by the
people of the village and our project has a people's
committee as advisory board. ‘'Though this is meant
to be participation by the people in decision making,
on closer enquiry, one finds that almost every V.H.W.
was selected by the head of the village and two or
three influential persons and the project staff. The
people's committee consists of established leaders and
the rich people of that area. Does the decision making
power given to the few rich and established leaders
of the village and mutely followed by the rest of the
villagers mean people's participation ? By this defini
tion the whole political system today has very wide
people's participation.
Obviously all these are not examples of people's
participation.
The last point takes us to the next question, 'who
are the people' ? This is quite a tricky and political
question. A big power invades a small nation and puts
its 'yes man' in power and says 'people of this nation
have invited us to liberate them.' Do mere heads of
government mean people ? A rich man who also heads
the Gram Panchayat takes a decision as to who
should be the VHW from that village. Is he the
people ?
The male head of the family says "the tradition of
our family requires women to remain in purdah and
all people approve of this tradition". Is he the whole
family or are the males alone, the people ?
No I In all these instances decision making does
not represent the desire of all the people, definitely
not of those who have no voice and freedom to speak
but who very badly need an opportunity to take part
in the decision making to ensure that it is in their
interest and not to oppress them.
Thus I have tried to show what is not people's
participation and who are not 'the people' : If this is
not people's participation then what is it ? Who are
the people ?
Probably everybody born as a human being has a
right to be included in the 'people', be it the oppressed
or the oppressor.
1
But for operational purposes, we will have to say
that the oppressed, the exploited and the needy should
have priority in the comprehensive definition of the
people.'
When these people understand the situation and
issues by critical consciousness and take part in deci
sion making, implementation and evaluation of pro
grammes and take the responsibility of the work as
well as share in the benefits...it becomes people's
participation.
There cannot be genuine people's participation
without a proper political atmosphere and educational
process. Even then true people's participation may be
a distant goal.
Prerequisites of people's participation
Today's political and socio-economic system is
directly opposed to real people's participation. How
can there be a true people's participation when women
have no equality, the poor have no strength to assert
and the oppressed have no opportunity to participate
in the decision making of the political system ? When
we, the enlightened elite citizens of the society have
no scope to participate in the affairs of the nation
except to vote for the best of the available bad choices
once in 5 years or to write a letter to the Editor once
in a while, how can those who are weak, poor, op
pressed and ignorant, really participate ?
It is obvious that the real people's participation is
a distant dream to be achieved by a process of econo
mic, political and cultural liberation.
When one views the objectives and the claims of
people's participation in community health projects
one cannot help but laugh. The present system is
anti-participatory. Moreover there are more vital fields
in which people would prefer to participate first. Health
is a low priority issue.
The expectation that people will participate in a
real sense in a mere community health programme is
unrealistic. This conclusion is also supported by the
experience of numerous workers in community health
who have learnt it the hard way that people cannot
be mobilised and organised through and for health
work. It does not mean that there should be no efforts
towards people's participation in health programmes,
All efforts to involve the people, especially the needy
and the oppressed in making decisions and their
implementation should be made. This will marginally
help a participatory culture to be created. But it must
be realised that people's participation is essentially an
2
objective of political and educational process, and
health work has only weak political implication. If
community health work is a part of political activity,
it will get it's backing and advantage. But without a
proper political context, not much of genuine people's
participation can be achieved in community health
work alone. Hence people's participation per se
cannot be a primary objective of community health
programmes.
If people's participation is real and genuine, one
should not talk of people's participation in the pro
ject’s health programme but of the project's participa
tion in the people's health programme. But realistically
this cannot happen through the health process alone.
Some workers use another misguiding term, 'com
munity participation' in conmmunity health progra
mmes. There are two obvious fallacies. One, there is
no organised entity as 'community' in the villages
today. There are individuals, families, castes, classes,
political groups and one cannot create communities
out of such individuals and groups for the purpose of
and through mere community health work (though
community health work might marginally help this
process). Secondly, though claims are made of having
achieved community participation, in reality only the
existing social organisations (Panchayats, etc.) and
established leadership are involved in decision-making.
We have already seen that such leaders alone are not
the people and hence they cannot replace the
community,
Economic self-reliance: why ?
Another popular fashion-word is 'economic self
reliance', commonly used as a criterion of evaluation
and boasting feature by many agencies and projects
in community health. How did this come to be given
such an importance that it has almost become an
important objective of community health programmes?
The workers keep on desperately running after this
objective, forgetting that economic self-reliance is not
the purpose of their work and they cannot afford to
sacrifice their original purpose i.e. to improve the
health of the vulnerable people.
With growing realisation in the developed (ex
ploiter) world that mere doling out of food and clothes
cannot permanently, improve the life of the poor in
the undeveloped (exploited) countries, a concept was
born that people should be given such economic pro
grammes which can generate income for themselves
and hence they don't have to depend, on outside help
eternally.
HEALTH FOR THE MlLLIONS/jUNE
1982
dent on the rich class for its income and survival
rather than otherwise. This brings gradual changes
Fine I Good policy! But then this has to be an in the priorities, strategies, methods, behaviour, and
objective of economic programmes to be achieved relationships of the community health project and it
through economic activities. This has been implicitly ends in serving primarily the needs and priorities of
accepted in the field of community health also. This the rich.
has caused, tremendous diversion and confusion and
An analysis of the clientele of most of the mission
a time has come to challenge this assumption. There hospitals, who in an attempt to become economically
are many reasons. When a community health project self reliant started charging the cost of the treatment
tries to become economically self reliant, it adopts two to patients, shows that ultimately they ended with two
methods.
maladies. They were underutilized, and were utilized
predominantly by the rich class.
Sathyamala from VHAI has described (Health For
The Millions, February 1 980) how she saw at many
places voluntary hospitals half empty, beds occupied
by the rich, who only could pay the charges; and the
next door Government hospitals and dispensariesinefficient, low quality, corrupt but still overburdened,
full of poor patients. What an irony ! Then why
should dedicated missionaries run such hospitals ?
Even the private commercial health care system (eg.
Jaslok Hospital) can do and does the same role. Then
where is the difference ?
(b) To raise income, the second strategy adopted
is to charge the poor more and more in an attempt to
make them pay at least the cost of the treatment. We
have already seen how it results in elimination of the
poor from the curative health care, 60% of admissi
ons in a hospital of a famous community health
project which claims to be economically self reliant
(a) It starts charging the rich to gain more income, are from the rich coming from the area outside the
(the so called 'Robinhood' method). Ultimately this project. Remaining include rich and poor from the
results in the community health project becoming project area but again in what proportion ? The
dependent on rich clientele for it's economic self- hospital is mainly utilized by the rich.
An argument forwarded is that the poor are given
reliance. To satisfy this clientele comes the sophistica
primary health care through VHWs financed by
tion, X-rays, E.C.G., more indoors, more specialization,
and more and more workers and time to cope up with the income generated from the rich in the hospital. It
all this. Also come in the unscientific, unethical pracmeans the VHWs give elementary care in the village
ices like giving unnecessary injections, tonics, mysti to the poor and rich also but doctors and hospitals
fying the symptomatic relief etc. to draw and retain are mainly for the rich. Such discriminatory strategy
becomes inevitable when community health project
the paying patients.
The rich class is much more shrewd than commu accepts the objective of economic self reliance and
nity health projects. It is almost never dependent on tries to raise the income through health programmes.
this community health project alone for its own health
It is true that the poor also should be charged a
care (though occasionally individuals may need and little for health care so that they do not become
seek such curative services, such examples don't objects of charity and pity. Also, if they are charged
prove that the whole class is dependent on community they feel that they have paid for health care and so
health projects). They almost always get their health the care must be of some quality, earned by them. It
needs fulfilled through the commercial private health is common experience that the poor also value such
system. Only in very remote places, persons from such treatment and advice for which they have paid. But
class might depend on communrty health projects. this logic is then taken to its extreme that the poor
Thus the community health project becomes depen should pay the whole cost of treatment, which is
Self-reliance Logic
health for the million/june
1982
3
pretty high in the present system. The poor, already
exploited by the present economic system has very
little resource, on which community health project
further puts its claim.
An argument is often put forward that the poor
also have the capacity to pay for curative services.
They manage to mobilise the resources when you
make it compulsory for them to pay.' This is the
philosophy of the private doctors. Once, when I put
this argument before a poor man, he said 'Took
Doctor Sahebl. If I am ill and dying and if you press
me for charges I shall sell my house, my family shall
starve and then only I will be able to pay your money.
But if I do it does it mean I had the capacity to pay
you?"
When this objective of economic self reliance is
almost thrust on the community health projects in the
voluntary sector by funding agencies let us ask a few
questions.
Who is self-reliant today ?
Is the government self-reliant in the sense it gene
rates all its necessary income by productive activity ?
No I It depends on squeezing the people by taxes,
direct and indirect. None of the welfare programmes
of the government are selfsufficient.
Are the funding agencies-self reliant ? In spite of
decades of working, all of them continually depend
on donations from people in the developed countries.
They do not generate their own income by an econo
mic programme run by themsel.es, even though their
main field of work is fund raising.
Funding agencies can raise
money through
Western capitalism. However this capitalistic system
depends, at least partly on the developing countries
for its market, and remember, the market is the source
of income for capitalism.
It is unrealistic to expect in such a situation that
community health projects should be able to generate
enough income to become economically self sufficient.
Health and education are the responsibilities of
the state and society, as is law and order. Voluntary
agencies enter in it because the government cannot
do it adequately for the people. The government gives
free health care to all, specially to the poor, Then
why should the voluntary community health projects
charge poor patients to whose rescue they claim to
have come ?
Many community health projects tacitly accept this
objective of economic self reliance under increased
pressure by funding agencies tfrid they are forced to
either deviateTrbm their primary objectives or to do
various manipulations dhd show that they are econo
mically self-reliant. This includes artificially swelling
the health income, (some times by selling the donated
drugs or by including the farm income) or by hiding
certain expenditures of health programme. Some pro
jects reduce the expenditure by underpaying their
staff. All these compulsions come because of the
acceptance of the criterion of economic self-reliance.
Having observed closely many community health
projects in India and abroad, and following our own
experience. I wish to say that no community health
project which is predominantly preventive and educa
tive in nature and which serves mainly the poor can
become economically self-reliant. All such claims need
to be reexamined because they create illusions.
Projects should try to generate income either
through economic programmes or from committed
supporters who have money to donate for the cause.
Such income generation will make it less dependent
on outside aid. This cannot however be the primary
objective of community health work.
False Limitations
Another aspect which community health projects
should not uncritically accept is trying to see that the
per capita health expenses in their community health
programme is equal to that of the government. Govern
ment spends a lot of money on wrong priorities and
allocates meagre resources for health due to
which the poor mainly suffer. Voluntary health pro
jects need not take it as their responsibility to show
ways to fulfil health objectives within the false
limits set by the government. It usually means de
privation of the poor. What voluntary agencies could
be doing is to decide the minimum health care every
person should get and try to show the ways of doing
it at the low cost level whatever that cost should be
compared to the government’s per capita health
expenditure. This is the way by which one can press a
system to mend its ways. Voluntary health projects
should not try to fit into the system's false limitations.
While deciding the minimum health care, the nation's
economic standard (GNP or per capita average income)
should be taken into consideration but not the per
capita health expenses by the government. Otherwise
we land up with the solutions and ways of commu
nity health care which are less than minimum to the
real needy.
{This is a slightly abridged version of an article
that first appeared in MFC Bulletin, April 1981.
Reproduced here courtesy MFC—Ed.HFM. MFC is
to publish this and other important articles in a book
form. For.details contact MFC or us).
HEALTH FOR THE MILLIONs/jUNB
4
1982
MADHU SARIN
Give Us this Day Our Health
The case of a landless family in Harijan Nada
Sondhi Ram's family has only four members—him
self, his wife Premi, a teenaged son Kaka and another
son about six years old. Being completely landless,
the family subsisted on Sondhi Ram's earnings as an
unskilled daily wage labourer. In addition, as common
in villages along the Shiwalik hills, the family used
to keep a few goats which cost little to raise in money
terms. Free grazing in the adjoining hills made goat
keeping an attractive means of supplementing house
hold income and diet. For the impoverished landless
families, this was almost an essential component of
their otherwise highly vulnerable life support system.
Sickness due to malnutrition tends to plague the
poorest, the most. During such times, due to the in
ability to work for a daily wage, it is almost essential
to have some saleable asset in hand to tide over the
crisis. As a goat or a kid can easily be sold for
Rs 200/- or more, and as goats multiply rapidly, goat
keeping performs this function well. The milk invari
ably supplements poor diets.
But the goats are among the worst enemies of the
hills. Today, the Shiwaliks have attained the unenviable
status of being the most denuded hills in the world.
Indiscriminate grazing, particularly by the more
agile goats, has played a major role in this process.
For years now, the Haryana Forest Department has
been trying to discourage goat keeping by inflicting
heavy fines for goats caught grazing.
In June 1980, regular work with the villagers as
a part of the project was begun. At that time, Sondhi
Ram's family was in dire straits. He himself was
terribly sick and unable to work. Something was
terribly wrong with his stomach and most of the food
he consumed was rejected by his body. While he tried
to cure himself with medicines obtained from hakims,
the family was living on the money obtained by selling
off all their goats. The trouble was that once this ran
out, there was not going to be any more coming in as
there were no more goats or their kids to sell.
Sondhi Ram was not impressed. He sent the visiting
team away with the remark that they could not help
him as destiny was against him.
Rope Hope
His outlook on life had become truly bleak as he
saw no hope for himself or his family. The strains of
poverty and illness had led to a quarrel with his wife
who had gone off to her parents' home. Around
that time, attempts were made to persuade Sondhi
Ram to adopt converting bhabbar grass into rope as
a vocation. He was told that by so doing, he could
increase his daily income by two to three times.
HEALTH FOR THE MILLIONS/JUNB
1982
Nada Sahib village was brought within the ambit
of a unique operational research project on soil conser
vation and denudation control in early 1980. (See
'Water in Dry Hills', HFM, August 1981). A centra!
concern of the project is the upliftment of the villagers
by tying up their economic interests with soil conser
vation measures. However, before other benefits had
started coming in, the campaign against the goats
was intensified. Many families sold off their goats and
Sondhi Ram was amongst them.
During the next four months, Krishna in the hamlet
demonstrated to the others that rope production
could indeed be an attractive source of supplementary
income. There was demand for five new rope
machines. Sondhi Ram had enlisted himself as one of
the new candidates. Once the machine arrived, how
ever, it was his teenaged son Kaka who started using
it. Sondhi Ram expressed the hope that at least his
son might acquire a better means of supporting him
self.
Classic Case
During the same month, November 1980, a doctor
friend was persuaded to visit the hamlet. On seeing
Sondhi Ram's caved-in and white nails, he said that
he represented a classic text book case of chronic
anaemia. His bad stomach was possibly due to worms
5
Kaka, extremely frail and in torn clothes, learning to use the rope
machine in October.
or an ulcer. On examining Kaka he found that the boy
suffered from rheumatic heart disease. On his advice,
both father and son (and many others in the hamlet)
were given iron tablets to be taken daily. There was
marginal improvement over the next month.
The cold and wet spell during December 1980
brought new problems. Frequently, Kaka was unable
to use the machine as his joints became swollen and
extremely painful. His average daily output of rope
dropped from 8 kgs. a day to barely 1 or 2 kgs. a day. It
was also learnt then that Kaka had been told by his
teacher to leave school to get himself treated because
of similar joint pains earlier. As a consequence, even
his schooling had come to an end. Sondhi Ram had
also become sick again and (was unable to work.
Despite having a machine to use, the family was
unable to earn much from it due to the poor health of
both its potentially productive members. Everyday,
the family was getting deeper into debt and becoming
further demoralised.
Kaka Earns
Seeing the hopelessness of the situation, consi
derable effort was put into getting Kaka properly
examined at the P.G.I. in Chandigarh. This took four full
days. The excellent examining doctor, who understood
the realities of rural poverty, prescribed just one
penicillin based injection per month for the boy's
rheumatic heart disease. In addition, he recommen
ded that Kaka should simply try and eat more of
roti.
Kaka's taking the monthly injection (the cost is
only Rs 4/- equal to less than half the daily wage) has
been religiously ensured since then. The results have
been rewarding, to say the least. The boy started
6
looking healthier within a couple of months and his
rope production increased. At the end of March 1981,
a social forestry project aimed at raising fuel, fodder
and bhabbar grass (the raw material for the rope) for
the villagers was started in the adjoining hill area.
Members of landless families are given absolute
priority in working on the project. Kaka switched to
working there on a regular daily wage basis soon
after the project began. For several months subse
quently, Kaka became the main economic support of
the family. In purely economic terms, from literally
zero earning capacity, the boy has earned Rs 3,395/in 18 months (Rs 350/- from rope and Rs 3,045/from daily wage work in 12 months). The cost of his
monthly injection for 15 months has been a bare
Rs 60/-.
The returns in human terms are virtually incalcul
able. With an improvement in family circumstances,
Kaka's mother returned sometime in the middle of
1981. While this led to better care of the younger
son, it also resulted in fewer quarrels and everyone
eating better.
A few months later, Kaka working on the Social Forestry Project
on daily wages.
Sondhi Ram's ailment
After Kaka started working on daily wages, Sondhi
Ram started producing rope himself. Premi, his wife,
helped by preparing the grass for the rope. His
output, however, remained low, an average of 2 or
3 kgs a day. His health seldom permitted him to work
a consistently for any length of time.
In November 1981, he came out with a worrying
revelation. He said that he was beginning to lose
sensation in the lower parts of his legs. Even on
hitting his feet or ankles, he could not feel anything.
HEALTH FOR THE MILLIONS/JUNE
1 982
remarkably better. His legs are back to near normal
and in early February, he was able to produce 31 kgs.
of rope in 4 days—a remarkable improvement over the
2 to 3 kgs. per/day in the past. And since February, he
has been able to work regularly on daily wages. Kaka
and Sondhi Ram's combined monthly income now
adds up to Rs 555/-.
Premi Too Roped
And now Premi has started to use the rope
machine. As she also has to take care of the little
boy and do all the cooking, her average daily output
is only about 2 to 3 kgs. But the Rs 100/- or so that
this fetches is a welcome addition to the Rs 555/being earned by the men, particularly as now the
family is making a ' determined effort to pay off the
debts it accumulated during the difficult days. Kaka
is now wearing new clothes and chappals with the
dignity and self confidence that his becoming a major
earner in the family has brought. The rotten and
leaking thatch roof of the verandah has been finally
replaced and now one doesn't hear of any quarrels
in the family.
So really, from a situation one and a half years
ago, when the family seemed to be on the verge of
total economic collapse, now there are three earners
in the family—and only critical inputs in the field of
health enabled it to benefit from the larger develop
ment project in their village.
*
*
*
NEW ORGANISATIONS
Sondhi Ram in better health and in better days.
Advice of the director of a team evaluating the nutri
tional impact of the larger project was sought. He
said it could be diabetes, cancer, or something equally
serious. He arranged Sondhi Ram's being admitted to
the PGI for 10 to 12 days for a comprehensive check
up. Fortunately, the results were reassuring. He had
neither diabetes, nor cancer, nor anything else equally
drastic. It seems that possibly due to the long years
of malnutrition, his body was being unable to absorb
vitamins adequately. He was discharged with a
prescription of vitamin B 12 injections and asked to
take two Berin tablets (Vit. B1) daily for 2 to 3 months
besides being more carefulwith his diet—not in terms
of expensive items but simply to eat more roti, dj!
and green vegetables.
Today, only three months after a proper diagnosis
and treatment, Sondhi Ram is looking and feeling
HEALTH FOR THE MILLIONs/jUNE
1982
Kalpavriksh
Kalpavriksh is a Delhi based student environmental
action group. "At present we have 70 members. For
the past two years Kalpavriksh has been working in a
small way for a better environment for Delhi's citizens,
also through audio visuals, workshopsand discussions
trying to create awareness. We had been fighting for
the preservation of the ridge, and remaining green
areas as well as the problems of water availability and
pollution in Delhi. We were especially horrified to note
that out of a population of 57 lakhs, 40 lakhs don't
have access to a source of clean water. In the last six
months, Kalpavriksh has specifically taken up two
projects—opposition to the havoc caused by the Asiad
to the city and people of India and secondly an active
campaign against the proposed forest bill."
7
RITA MUKHOPADHYAY
Where There is no Surgeon
Villages lack surgical care even for common in
juries. Emergencies associated with child-birth
often result m death. The World Health Organi
sation is developing a new strategy to bring neces
sary facilities for surgical care to villages.
The World Health Organisation (WHO) is setting
up a programme that will help developing countries
to provide surgical aid in their villages for common
diseases and injuries.
WHO is encouraging governments all over the
world to draw up plans to establish adequate health
services for all their people by the year 2000. Surgical
facilities are almost non-existent in rural areas even
though surgical cases probably account for 15 to 20
per cent of all attendance at clinics and hospitals.
Emergencies like severe burns, animal bites, strangu
lated hernia, fractured limbs and several women's
problems like obstructed deliveries, which require
operations, occur frequently in villages.
A new department of essential surgical care has
been set up by WHO at its headquarters in Geneva
under the famous Indian surgeon Dr. B.G. Sankaran,
who was until recently director general of the health
services of the government of India.
"The distribution of surgical resources in countries
and throughout the world must come under scrutiny
in the same way as any other intellectual, scientific,
technical, social or economic commodity", WHO's
director-general, Halfdan Mahler told an international
conference of surgeons. "The era of only the best
for the few and nothing for the many is drawing to
a close". He lamented that "the vast majority of the
world's population has no access whatsoever to
skilled surgical care and little is being done to find a
solution".
The essential surgery programme of WHO that is
now being drawn up will identify what types of skills
and instruments are needed to deal with the majority
of patients who need surgical attention. Many ex
perts believe that simple skills and equipment are
sufficient to take care of most such patients. WHO
will promote the idea of training doctorsand other
health cadres working in rural centres to undertake
this type of essential surgical treatment.
8
The WHO programme is being developed in colla
boration with regional medical centres which will
identify specific needs of different countries. Medical
centres in China, Sri Lanka, Bangladesh, Italy, Mexico
and United States have already started work on
essential surgical care. India is also planning to
establish two centres, one at the Banaras Hindu
University and the other Jamkhed, Maharashtra,
where a pioneering rural health care project has been
established by a dedicated voluntary team led by Drs.
Mabelle and Rajnikant Arole.
The manner in which Vietnam developed its nation
wide surgical service during its war with USA consti
tutes the most dramatic success story in village
surgery that has yet emerged from anywhere in the
world. The havoc created by the incessant bombing
forced the Vietnamese to develop an unprecedented,
decentralised medical infrastructure that could under
take operations at any place and time within the
country. This medical achievement was probably a
major factor in the ultimate victory of Vietnam, and
remains unmatched even in countries which have
enjoyed peace.
The Vietnamese decentralised surgical skill by
teaching surgery to all their medical personnel includ
ing specialists in childcare, epidemiology and tuber
culosis. Almost every doctor was, thus, turned into
a practitioner of general surgery. These doctors could
operate inside a trench with planes flying overhead and
a man pedalling away on a bicycle to generate electri
city for the makeshift operating theatre. With a few
weeks of training, Vietnamese village health workers
also learnt to perform operations to cure entropion,
a frequent complication of an eye disease called
trachoma.
Many operations can be carried out by village-level
'barefoot surgeons' after suitable training. Dr. Zafarullah Chowdhury, who directs a rural health care pro
ject near Dacca, Bangladesh, has taught village
women to perform tubectomies—operations to sterilise
women. The success rate of these women has
Consistently proved to be as good as that of postgra
duate doctors.
Surgical costs can also be cut dramatically by using
simple equipment and techniques wherever possible.
HEALTH FOR THE MILLIONS/JUNE 1982
.According to Dr. Peter Bewas, a British surgeon work
ing in the Birmingham Accident Hospital, an operation
table of antique design which has an overhead
shadowless lamp with a household bulb and a foot
sucker made of motor-car type pump, has been used
for years in several hospitals even in U.K.
However, different strategies will be needed for
different types of surgical problems. Problems like
laceration, superficial burns, abscesses, ulcers and
some uncomplicated problems like hernia, a com
mon ailment in many parts of the developing world, a
three-tiered approach may be necessary in which each
level of the health service—village, health centre, and
district hospital—has a clear role to play. Hernias
cannot be treated in a village but village-level health
workers can certainly diagnose them especially
amongst children, and recognise dangerous hernias
before they strangulate.
In normal circumstances, hernia cases will have to
be referred to district hospitals for treatment or opera
tion. But in case of an advanced strangulated hernia,
medical auxiliaries at the front line health centre
should be able to stabilise the patient by injecting
intravenous fluids before a surgeon from the district
hospital can arrive or the patient can be carried there.
On a rainy day, when no transport is possible, a
medical auxiliary should even know how to operate
in an emergency with a reasonable chance of success.
Otherwise the patient will simply die.
In the existing situation, even simple and basic
facilites for immunisation are not available in most
villages. Organising surgical services for villages is,
therefore, inevitably going to be a long-term objective.
There could even be opposition to such efforts from
the surgical profession itself. "We are aware that
professionals tend to oppose any move which tries to
demystify their profession", says Dr. Sankaran. But
many surgeons who support the concept of essential
surgery hope this will not be so. Essential surgery
should do the medical profession only good in the
long-run. If surgical services were to become available
at primary health centres, this would only increase
the people's respect for the medical services as a
whole.
*
*
♦
Ban on Pregnancy Test Drugs
Dear Friend,
The news item in TAe Hindustan Times of 30th June, 1982, reads : "The Government has decided to
put a total ban on manufacture and marketing of all the pregnancy testing medicines in the country. The
decision to ban the fixed dose combinations of oestrogen and progesterone, prescribed only for the
indication of secondary amenorrhoea and similar gynaecological disorders, has been taken in consulta
tions with medical experts in view of reports of large-scale misuse of these preparations for termination
of pregnancy. The use of these diugs in pregnancy could lead to birth of babies having congenital
abnormalities the experts said.
The Ministry of Health and Family Welfare has directed all the manufacturers of the fixed dose combi
nations of oestrogen and progesterone (other than those used as oral contraceptives in low doses) to
ban these preparations. The stipulated cut off date for the manufacture of these drugs has been fixed
as Dec. 31, 1982, and cut off date for sale in the market as June 30, 1983... They (medical experts)
have pointed out that now there are substitutes available in the country for the management of
secondary amenorrhoea and similar gynaecological disorders, the communication said."
Seems like our campaign has had some effect. However, the ban comes to an effect only from June
1983. The fact that the Government has decided to ban these drugs means that it has recognised
their harmful effects. Despite this, the ban is deferred by a year. Obviously the losses that the drug
companies would suffer in the event of an immediate ban weighs heavier with the Government
than the possible harm that will be done during this year to children yet unborn.
So, we request all of you who have taken an active part in this campaign to write letters to the editors
of the newspapers; and the Drugs Controller asking for an immediate ban. We also take this oppor
tunity on behalf of the Pune Drug Workshop participants to thank all of you for your active participa
tion in this campaign.
Sincerely,
Dr. C. Sathyamala
IHEALTH FOR THE MILLIONs/jUNE 1982
9
NIRMALA AND SATHYA
Incident in Garo
During our recent trip to the GarojHills (Meghalaya)
we chanced upon something interesting. We were
taking an evening walk around the village of
Mendal when we saw a tree bearing a wooden
board on which something was written in Roman
Script. (The Garo language is written in the Roman
Script). The translation of this notice was "Village
Mendal: Reserved forest 1982. Nobody should cut
bamboo or collect leaves of the sal tree. Anyone
found doing this will be fined Rs. 50/. Order of the
Headman, Mendal".
Since we had no camera, we sketched the tree.
After this we sought out the headman of Mendal to
find out the background to this notice. We share
below some excerpts from our interview with the
headman. This is yet more evidence against the
widely-held notion that villagers are ignorant and are
responsible for deforestation. On the contrary, vill
agers have a sense of responsibility about conserving
forest resources. Their economy depends upon the
forests, and they are not short-sighted about this.
CL. Does anybody disobey the rule of reservation ?
A. People do not normally break the rule because
they are scared of the rest of the village. If at all
they do, they are fined Rs. 50.
Q. Who is responsible for deforestation?
A. Both the villagers and the contractors take wood’
from the forests. But the villagers take only a little,
for their own needs. The contractors take large
quantities.
Q. Who gives the contractors permission to‘[take
wood?
A. The Nokmah (the hereditary leader of a group of
villages) has the right to give such permission.
Now-a-days the contractors give him a lot of
money, and he gives the permission.
Q. When did you put up the notice ?
A. This particular notice was put up this year, and is
valid for the next three years. We have been doing
this since 1953 (since the village of Mendal
was set up). At a time we reserve only one part
of the forests allotted to the village.
Q. Did the government take the decision to put up
this notice or did the village ?
A. The people of the village had been feeling that
this should be done. At a meeting of the whole
village (i.e. forty families) the decision was
taken. After this a copy was sent to the Govern
ment.
Q. What made you all feel
done ?
A.
that this should be
We could all see that the bamboos were becom
ing less.
Q. What other effects do you think deforestation
has ?
A. The soil gets spoilt, and no bamboo will be left.
There is less rain, less water, and less fish in
the streams. The river near Mendal is smaller
now than it used to be.
io
HEALTH FOR THE MILLIONS/JUNE
1982
A Letter on School Health
The school health training programme was from
May 10 to 15. It went off successfully. There was
an inaugural function which was appreciated by all
the participants and others. There was the solemn
act of lamp lighting, each one lighting one wick
of jhe lamp respectively while a prayer was being
recited.
Twenty-one teachers from eight schools partici
pated in the course. The course was mainly centered
on imparting practical skills and experience to the
teachers, in early detection and treatment of minor
ailments in children, as well as prevention of com
municable and deficiency diseases, and first aid
skills.
It also dealt with certain topics like personal and
general hygiene, abnormalities in growth develop
ment of children, nutrition and methods of health
education to pupils. There was an evaluation of the
programme on the last day. The evaluation showed
that the participants were extremely happy to have
undergone this course as it enriched their knowledge
on health. Some expressed that the course programme
was above their expectations and one said, the
interest taken in this course motivates them to do
something positively for the health of their students.
Then on May 28 we met the headmistress and the
teachers to discuss on the cost of health records, the
method and time of filling them, how to raise the
finance for the programme, etc. Suitable decisions
were taken. The fund will be raised by the school
itself. The dates for the physical checkup are fixed
from June 15. We have supplied health records
already on payment.
We will be giving them the medicine kit and first
aid kit when we go for the initial physical checkup,
on payment ofcourse. Being the first time they have
taken a small number of children under this pro
gramme. Later on they will increase. We have given
them all cyclostyled notes of all the lectures. So, I
had to do a lot of work. For two weeks I could not
take class for our student nurses. Now I am busy with
preparing medicines and first aid kit. Till the end of
June the physical check up will go on. Next month
we will have new students for nursing.
Sr. M. Edmund, Fr. Muller's School of Nursing,
Mangalore
(Sr. Edmund is a student of VHAI's Correspondence
Course in health care administration. The school
health project is part of her term paper.—Ed. HEM)
CORRESPONDENCE COURSE IN
Health Care & Wellness Management—Batch VII 1S82-1984
After a break of one year, we are ready to take the seventh batch of students for the two year corres
pondence course.
To date five batches of students have graduated—the sixth batch is in the process of completing the
two years programme. With 50 health care administrators successfully completing the course, a formal
detailed evaluation was conducted in 1981. On the basis of the data generated through this evaluation,
the Correspondence Course has been considerably modified. To the basic core of 'management' has
been added the 'Wellness Management' dimension. This seeks to explore all kinds of alternatives to
■ make health care low-cost, appropriate and relevant. The aim of the Correspondence Course in Health
Care and Wellness Management is to expose administrators of health care organisations to these
alternatives.
The new prospectus and application form is available on payment of Rs. 5/- only (Crossed^lndian Postal
Order drawn in favour of VOLUNTARY HEALTH ASSOCIATION OF INDIA).
You can write to :
Renu Khanna, Correspondence Course Coordinator, Voluntary Health Association
of India, C-14 Community Centre, SDA, New Delhi-110016
Last date for receipt of applications : September 10, 1982
Opening Seminar:November 1-6, 1982________________________________________
HEALTH FOR THE MILLIONS/jUNB
1982
each, airmail incl.
surface incl. P&P.
*
BOOK NEWS
Learning from the Rural Poor by Henry Volken,
Ajoy Kumar and Sara Kaithathara. The mobile
orientation and training team (mott) and its first book
Moving Closer to the Rural Poor are not strangers to
the readers of this magazine.
Shared experiences of the team is now available
in this compact volume of five chapters. The third
chapter "Community Health Education : Faith in
the Rural Poor' and its Appendix 'Syllabus for
Community Health Workers' should be compulsory
reading for all those who support and oppose training
of community health workers. The MOTT teams
involvement in agriculture and adult education are
reflected in other chapters.
Pages 119
Price Rs 15/-
1982
*
*
*
Education and Income Generation for Women by
Dr Jessie Tellis-Nayak, Director, Programme for
Women's Development, Indian Social Institute, high
lights the need of education and the ability of women
to earn in cash or kind. Different strategies for nonformal education and various phases like planning,
implementation and evaluation are spelt out. This very
practical book enumerates the principles one must
follow in undertaking income generating activities.
Pages 85
Price 20/-
1982
Copies of both books available from VHAI as well
as the Indian Social Institute, Lodi Road, New
Delhi 110003.
*
*
♦
More Aids for Disabled
Designs for making a range of different aids for
disabled children are now available in a new book
published by AHRTAG. The aids have been deve
loped by Don Caston who designed AHRTAG's "pop
up' pictures of aids for disabled children.
There are 53 pages of drawings in the book show
ing a wide range of aids from walkers and climbing
frames to chairs and beds. The text has been kept to
a minimum and is all printed on the cover.
VHAI will soon be placing an order with AHRTAG.
Please order your copies. Price .' £ 3.00 ($ US 7.00)
12
P&P,
£ 2.00
(8 US 5.00)
*
each,-
*
OXFAM and the British Leprosy Relief Association
(LEPRA) have brought out a package of teaching
and training materials with 24 documents. It is an
attempt to bring together and distribute all the availa
ble learning materials in leprosy. The materials are
entirely in English and much of it is of UK origin. The
package has been prepared for medical students,
medical officers, (with or without experience in
leprosy) leprosy control officers, tutors and other
potential teachers. The subsidised package costs £ 15.
It is intended for carefully selected staff who are
working in leprosy including those who intend to use
it in a teaching programme. The set includes 11 books
and booklets, two sets of colour transparencies, four
journals and seven other miscellaneous items in
durable bag. Those interested write direct to OXFAM
Medical Unit, 274 Banbury Road, Oxford 0X2 7DZ,.
England or to VHAI's Publications Officer.
*
*
*
Science and Technology for
Women
This is a status report on the S & T for women pre
pared by Centre of Science for Villages on behalf of
the committee appointed on 'Science and Technology
for Women' by the Department of Science and Tech
nology as per recommendation of the Planning Com
mission. This compendium is divided into five sections
under which available technologies from various insti
tutions have been classified. The source of information
has been indicated in abbreviated form and a list of
the institutions which they represent is given in the
appendix. The account of each technique is vpry
short, but would give enough information to form an
idea of the process. For further information, concerned
institutions may be contacted. Each technology has
been marked with three, two or one star(s) respec
tively indicating : (i) the technologies available and
accepted in the field, (ii) lab-tested technologies ready
for transfer in the field and (iii) technologies with
potential, but requiring optimization.
The technologies given are under five heads :
1. Employment generating technologies, 2. Drudgery
reducing technologies, 3. Technologies for safe
drinking water and sanitary facilities; 4. Nutrition and
health improvement technologies; and 5. Hazards and.
accidents protection technologies.
Compendium available from DST. Technology Bhavan,
New Delhi.
HEALTH FOR THE MJLLIONS/jUNE
1982
DRUG MEVVS
DRUG FIRMS TO PAY DAMAGES
Pharmaceutical manufacturers Ciba-Geigy and
Draco have in an out of court settlement agreed to
pay 1.8 million Swedish Kroner as damages to 38
persons who had suffered serious side effects by
taking Enterovioform, reports PTI.
The plaintiffs, according to a local daily, claimed
11 million kroner and the companies offered 20,000
kroner.
CibaGeigy's Enterovioform, which first attracted
world wide attention when the company was sued in
Tokyo in the early seventies, is banned in this country
since 1975.
Dr Olle Hansson of Gothenburg, who figured as
an expert witness at the Tokyo trials and later in
England and in this country, has been carrying on an
unrelenting crusade against Ciba's 'shocking cyni
cism' in continuing to sell Enterovioform in the deve
loping countries.
A boycott of Ciba's replaceable drugs Dr Hansson
called for, resulted in the company losing a quarter of
its sales in Sweden, according to 'the Swedish drug
market', a confidential trade report which found its
way into the local press sometime ago.
♦
♦
*
ALLIANCE FOR PRUDENT USE OF
ANTIBIOTICS (APUA)
Antibiotics have been developed to treat diseases
caused by micro-organisms in humans, animals, and
cultivated plants. However, these antimicrobial agents
are losing their effectiveness because of the spread
and persistence of drug-resistant organisms. More
over, unless steps are taken to curtail the present
situation we may find a time when such agents are
no longer useful to combat disease.
We are faced with a worldwide public health prob
lem. It is due in large part to the indiscriminate use of
antibiotics, especially in the following practices: (a)
dispensing antibiotics without prescription; (b) using
clinicallyuse-ful antibiotics as growth promoters in
animal feeds and on agricultural crops; (c) prescribing
antibiotics for ailments for which they are ineffective;
(d) misleading consumers by advertising antibiotics
as "wonder drugs", especially in areas where dispen
sing is not regulated; (e) using different labelling and
advertising to sell the same product in different parts
of the world.
Let no one suppose that widespread use of anti
biotics is in any way a substitute for good sanitation
HEALTH FOR THE MILLIONS/JUNE
1982
and personal hygiene. Efforts in improving these main
stays of infectious disease prevention and control must
be encouraged and strengthened. At the same time,
it is imperative to increase awareness of the dangerous
consequences of antibiotic misuse at all levels of
usage: consumers, prescribers, dispensers; manufac
turers, and government regulatory agencies. Only then
can we begin to institute measures to curb the un
necessary use and flagrant misuse of these drugs.
The above statement evolved from presentations
and discussions during the conference on Molecular
Biology, Pathogenicity and Ecology of Bacteria! Plas
mids, held in Santo Domingo, Dominican Republic,
January, 1981.
146 scientists from 24 countries have drafted this
statement to instigate action towards halting this
ever-increasing worldwide problem. They would like
this communication to serve as the impetus from orga
nizing national and international committees from
which directives for prudent antibiotic use can be esta
blished. As a first step, then, urge that a uniform
practice in the prescription and distribution of antibio
tics be implemented and enforced in those areas
where adequate medical expertise is already availa
ble. Furthermore, they urge that proper standards of
advertising and dispensing of these drugs be agreed
upon and adhered to in all nations of the world.
For more information on APUA (Alliance for the Pru
dent Use of Antibiotics), write to its president:
Prof. Stuart B Levy, Department of Molecular
Biology and Microbiology, School of Medicine
Tufts University 136 Harrison Avenue, Boston,
Massachusetts, 02111, USA.
Healthy Medicine
WHAT MEANS 'HEALTHY' ?—A set of guidelines
from the World Health Organization is intended to
help WHO member states to decide which indicators
to use, particularly at the national level but also at the
regional and global levels for monitoring progress
towards health for all by the year 2000. Four cate
gories of indicators are suggested. They are health
policy indicators; social and economic indicators; indi
cators of the provision of health care; and indicators
of health status, including quality of life. In the past
there has been a tendency to concentrate almost
entirely on health status indicators but other indicators
must be included because the concept of Health for
all means a level of health that permits all people to
live a socially and economically productive life.
13
NEWS
Alliance is Born
Representatives of health, consumer and develop
ment action groups have formed the National Alliance
for the Nutrition of Infants (NANI). NANI's imme
diate programme calls for co-ordinated action for the
promotion and protection of breastfeeding.
A preparatory committee is establishing goals and
an action programme. It includes health groups and
professional associations like the Voluntary Health
Association of India (VHAI) and Medico Friends
Circle; consumer organizations like the Indian Federa
tion of Consumer Organisations (IFCO) and the Con
sumer Guidance Society of India (CGSI) as well as
development action groups like Action India. Each
member will involve new organisations and individual
participants in its own sector.
All readers of Health for the Millions are invited to
join NANI. There is no membership fee, only a re
quest to share your commitment, ideas and time for
this cause.
have gone out to capture the hearts and minds of the
health professionals, and they have succeeded. Vigo
rous action now can prevent breastfeeding in India
from deteriorating to the disastrous situation prevail
ing in countries like the Philippines where aggressive
promotion is rampant.
The first regional meeting of NANI held in Bombay
on May 3 was attended by 30 representatives of
various women, health and consumer groups in and
around Bombay. They expressed their anguish at the
scant respect with which the various baby food
manufacturers have treated the code so overwhel
mingly endorsed by the World Health Assembly in
Geneva in 1981. A vocal supporter of the code at
the Assembly, the meeting recalled, was Mrs Indira
Gandhi, the Indian Prime Minister.
At the first regional meeting
which coincided with the "Nutrition
Week", NANI asked all baby food
manufacturers to abide by the
letter (and the spirit of the code.
NANI's plan of action includes :
They should stop all advertisements
(1) Co-ordination of action to assure implemen
of fbaby foods and refrain from
tation of the strongest possible code of marketing for
using the pictures of healthy
infant foods. The government's working group pro
babies on baby food packages and
posed a code modelled on the code adopted by the
labels. AMUL being the largest
World Health Assembly last May. NANI requests the manufacturer of baby foods, and a unique co
government to bring forth this code and imple
operative should set the example.
ment it with all deliberate speed.
(2) Monitoring of sales and promotional activities
AMUL's commitment, a NANI spokesman hoped^
of infant food companies in hospitals, clinics and is not as diluted as the much advertised "AMUL code
health centres. What good is a code unless one can of ethics."
be sure it will be scrupulously respected ? Compa
The Consumer Guidance Society of India which
nies need scrutiny and constant vigilance as world
hosted
the meeting appealed to all consumers to be
wide investigations reveal continuing malpractices
on
the
alert
and to be prepared for appropriate action
that accelerate the demise of breastfeeding.
if the companies fail to respect the code.
(3) Documentation of the penetration of commer
cial baby foods in rural area. Participants in the
The Voluntary Health Association of India, New
Alliance will answer questionnaires and provide Delhi, urged all health professionals particularly obste
photographic evidence.
tricians and paediatricians to do all they can to promote
(4) Education aimed at the general public to breastfeeding. Quoting recommendations of the Inter
counteract the propoganda distributed by the infant national Federation of Gynaecology and Obstetrics
food companies. NANI participants will design and that the mother be allowed and encouraged to initiate
distribute posters, leaflets and booklets aimed at pro breastfeeding as soon as possible, preferably within
the first hour of delivery and rooming in with on
viding sound information on breastfeeding.
(5) Immunization of the health workers and insti demand feeding be encouraged, the VHAI spokes
tutions against potentially harmful effects of commer man alleged that most hospitals in India do not follow
cial baby food promotion. The infant food companies these sane principles.
14
HEALTH FOR THE MILLIONS/jUNE
1982-
NEWS
Bottles on Prescription
Earthen Pot for Drinking Water
Investigations carried out at the N I N, Hyderabad,
Recent information from Port Moresby General
Hospital indicates that the policy of having feeding show that from the health point of view, the earthen
bottles available since 1977 only on prescription is pot is a better vessel for storing drinking water than
having a significant impact. The number of shops sell the more durable stainless steel and aluminium con
ing feeding bottles has greatly reduced, breastfeeding tainers. It has been found that the clay in the earthen
has increased; and general awareness of the dangers pots has the property of absorbing bacteria in stored
of bottlefeeding without adequate safeguards has water and keeping the water cool. (National Inst, of
grown. All these factors have played an important Nutrition, Indian Council for Medical Research,
role in reducing the number of gastroenteritis admis Hyderabad—700007)
sions to the hospital and associated deaths in infants,
less than six months of age. (From Diarrhoea Dialo
Grain Cleaning Device
gue (UK), 7.11.81).
1983 : World Communications Year
After four years of discussion within the United
Nations system, the UN General Assembly has finally
decided that 1983 will be World Communications
Year. The purpose of the year is the "development of
communications infrastructures." particularly "to in
crease the scope and effectiveness of communica
tions as a force for economic and social development."
The year's activities will focus on national communi
cations policies and activities. The expressed aim is
"to seek ways to use the tremendous achievements
in communications technology to promote the har
monious development—economic, social, cultural—
of mankind as a whole."
The declaration of World Communications Year
has long been sought by several organizations, but
there were problems over which UN agency should
take the lead : the ITU or Unesco ? This question
was linked to the matter of financing. The coordi
nation of an international year, let alone national
activities, requires fairly substantial sums. Who should
pay ?
The General Assembly decision confirms that the
ITU is to be the lead agency, and that the year is to
be financed by voluntary contributions. The search
for funds will be enormously helped by the timing of
the fourth World Telecommunications Exhibition
(Telcom 83) to be held in October/November 1983 in
Geneva.
The ITU hopes that national coordination com
mittees will be set up in many countries. For more
information, write the WCY 83 Secretariat, Places des
Nationals, CH-1211 Geneve, Switzerland.
•health for the millions/june 1982
The C F T R I, Mysore has developed a machine
which not only removes stones of various sizes and
shapes from the grain, but also denser impurities such
as glass pieces and iron filings. The machine called
"destoner" lets dry granular material to flow over an
inclined vibration screen. Air from a pressure fan,
located below the screen in the body of the machine
is forced through the openings in the vibrating screen.
The steady grain flow holds the grain in a partially
fluidized state. Stones and other denser materials
which are not fluidized remain in contact with the
screen and get conveyed upwards and flow out at the
end of the machine. The lighter material grain, free
from stones, slides down and gets discharged. The
"destoner" can handle a wide range of grains since
the quality and velocity of air, the inclination of vibra
ting screen and the opening for the discharge of
stones can all be varied. (Contact : Central Food Tech
nology Research Instt., Food Technology, P.O.,
Mysore-570013)
Low Cost Overhead Projector
Appropriate Technology Development
Centre,
Coimbatore, has developed an overhead projector
which can project on a wall or a screen (size
1.5 metre X 1.5 metre) any transparency (size 50 mm
X 50 mm). Anything drawn on a transparent plastic
(polythene or acetate sheet) or a thin tracing paper by
means of Indian ink, glass marking pencil or pastels
can be projected. It makes use of a Philips comptalux
bulb 230 V., 60 or 75 watts, placed in a sturdy, easyto-dismantle steel base. The cost, including focussing
arrangements is Rs. 300/-.
15
neu b !
rom
Bihar
REGIONAL MEET
The Regional meeting of Santhal Parganas was held
at Mohulpahari Christian Hospital on June 18-19,
1982, on the theme'Low Cost Care'. The resource
persons were Br. Francis S.J. and Dr. B.E.L.
Thompson. Br. Francis gave a very enriching talk on
Naturopathy and indigenous system of medicine. Dr.
Thompson shared about how to bring down the cost.
The group decided to engage themselves in more pro
motive and preventive care than curative care. Partici
pants felt that use of naturopathy and indigenous
medicines will surely help to cut down the cost. It
was proposed that BVHA should organise an exhibi
tion during Hinjla Mela in Santhal Parganas. This
will be useful to educate the people about drug
hazards and baby food misuse.
Madhya Pradesh
VHA MEETS
The first MP VHA conference for Village Health
Workers is expected to be held in the last week of
September or first week of October. MP VHA is
inviting a nurse or another person, who has been
teaching the VHAs in each program, to attend the
meeting with them.
AP VHA will organise a VHWs conference in the
first week of October 1982. On this occasion a Telugu
booklet based on the experiences in community health
projects in AP will be brought out.
WE NEED YOU~
"
A rural health project under 'Operation Flood'
requires a doctor, MBBS. Age and sex no bar. Has to
visit two villages atleast daily, travel daily 60 Kms and
be based at Bhatinda town. Salary Rs. 1,700/- per
month plus accomodation. Contact : Ms. Anita Paul,
care Managing Director, Guru Coop. Milk Producers'
Union, Milk Plant, Bhatinda, Punjab—151 001.
♦
♦
1. An M.D. Doctor, general physician or paedia
trician. He will be the R.M.O. Salary initially
Rs. 2500/- (negotiable). Well furnished quarters
provided.
2. An MBBS with 4 years experience. Salary
Rs. 1500/- (negotiable). Free quarters.
Write to : Director, Immaculate Mission Hospital,
____________ MUKTSAR, Punjab 152 026.
16
——
10-week courses are available in Community
Health and Development for nurses and paramedical
workers involved in community health and interested
in training village health workers. Courses begin :
January 17th 1983 (Applications due November 30th).
Contact Programme Director, INSA/INDIA, Rural
Health and Development Trainers Programme, 2
Benson Road, Benson Town, Bangalore 560046.
Health Equipment Maintenance
Andhra Pradesh
•
Community Health Programme
* Five trainees of VHAI's Health Equipment Mainte
nance Programe (HEMAT) will be graduating in
July 1982. They are available for service in rural
and semi-rural health care institutions, from
August 1982.
* The third batch of HEMAT will start their course
from August 1982. Sponsored candidates will be
given preference. Maximum number of trainees
in this batch will be ten. Prospectus and other
details available from VHAl on payment of Rs. 5/postal or M.O. (payable to Voluntary HealthAssociation of India).
Write for further details to : Program Coordinator,
HEMAT, Voluntary Health Association of India,
C-14, Community Centre, Safdarjung Development
Area, New Delhi—110 016
health for the millions/june 1982
One Month Holistic Health Workshop
From September 15 to October 15, 1982 at Dehradun.
The objective of the workshop is to help individual participants learn about alter
native methods of health care. This workshop is geared not only to fulfil the
personal needs of individuals, but also for incorporating some of these techniques
in their work as health personnel in hospitals, health centres, community health
programmes, as social workers, counsellors, teachers, or development workers.
The workshop will be in four sections. For those who have not attended any pre
vious Holistic Health Workshop, attending the basic Holistic Health course from
15th to 1 7th September is required.
The design is planned as follows :
September 15—1 /
:
*Basic concepts, aims & objectives of Holistic Health
•Its relevance in the Indian context
•Towards appropriate use of Medical Systems
September 18
24
:
‘Non-Drug Therapies
■Commonly used home remedies & Herbal medicines
September 26
October 1
* Nutrition
•Organic farming
♦Bee Keeping
‘ Nature cure
October 3—8
•Stress Management
October 10—15
Assertiveness training
We will be limiting the group to 20 for the experience to be more meaningful. Last
date for admission is August 25, 1982. For further details and application forms
write to : Dr. Mira Shiva, M.D., Course Coordinator, Voluntary Health .Association
of India, C-14 Community Centre, SDA, New Delhi 110 016
z
Drinks odd Bond©
Village Bondo is about 15 km. south of Mandar, in Ranchi district, with 32
families owning approximately 2.5 acres of land. A community health and
development programme was started in March 1979, with emphasis on
mother and child health care, a daily feeding programme, and a monthly
check-up of under-fives. After a few months we conducted an achievement
motivation training programme for thirty members selected by ,the villagers.
This training makes use of people's experience and different games, to bring
awareness among the people.
During the sessions the group was convinced, unless they cooperate and help
each other, development cannot take place in the village. At the end of the
training programme, they came to the conclusion that they will have regular
meetings with villagers, and be more united to solve their problems. Through
these meetings, cooperative action took place; and they started to work
together to help each other. In the course of time, we trained two village
health workers, who helped the villagers towards more healthy living.
After sometime, they felt the need for another training programme for those
who had missed the previous course. Therefore, the team conducted th0
course for another 30 participants in the village. Interested parents also
attended the course. Through this participation the activities improved. The
members now became more aware of their strengths and weaknesses. The
main point brought up in the village meeting was, the "curse" of alcoholism.
The following points came up in the related discussion: the misery in the
homes, the bad example for the children, the wastage of hard earned money,
the scandal to the neighbourhood, the disturbances at night and the court
cases. They realized the evil of alcoholism, and made great efforts to give
up the "curse" of their misery. More specifically they decided to stop pro
cessing and drinking alcohol. And they are happier now.
Another point they have realized was that they have spent so much extra time
and money to get their daily needs fror; *he general market. Now they have
decided to have their own common shop in the village, and supply all re
quirements to the villagers at reasonable prices. Committee members to
manage this shop were selected from their own leader.. This educational
process has helped them to realize, how they could help themselves.
—-Jonas Lakra, Holy Family Hospital, Mandar
For Private Circulation Only
HEALTH FOR THE MILLIONS
women on women
Vol. VIII No. 4
Attitudes towards women in India are related
to the general perception of women as child
bearers. Our health services also reflect this
perception. A woman's health problems come into
focus when they are related to her child-bearing
role. But problems that get magnified during
pregnancy have their roots in her social and eco
nomic status in the society.
This is largely
ignored.
Aug. 1982
CONTENTS
Shutting Out or Shying
Away
3 Double Trouble and Toil
6 Health Hazards of Wo
men Workers
9 A Nurse by Any Other
Name
12 Where Have All the Wo
men gone?
13 Thought to Action
14 Organizing Peasant Wo
men
16 United they Marched
17 Myths About Women
18 Still A Mystery—Why?
20 Home Remedies
22 Drugs in Pregnancy
25 Mother Care by Dais
26 Hospital Care for
Mothers
27 Mother’s Card
31 Book Review
33 News
1
Editor: S. Srinivasan
Executive Editor: Augustine
J. Veliath
Production: P.P. Khanna
Assistance: P. George
Circulation: L.K. Murthy
Owned and published by the
Voluntary Health Association
of India. C-14, Community
Centre, Safdarjung Develop
ment Area. New Delhi-110016,
and printed by Filmahal En
terprise at Sanjay Compo
sers
&
Printers,
Uphaar
Cinema Building, Green Park,
New Delhi-110016.
We attempt in this issue to highlight these oftforgotten aspects that are linked to the question
of women’s health. Health workers can no longer
afford to look at the clinical manifestations of illhealth in isolation. We hope that the contents
of this issue respond to those who ask us, ’’But
why stress on women and health?
In preparing this issue we were surprised at
the scarcity of data regarding women in India.
We see this as yet another aspect of the neglect
of women’s problems in our society. We hope
that the issues raised in the pages following, will
contribute to further discussion, research and
action. We look forward to what you have to
say, about what we had to say.
Nalini, Nirmala, Radha and Sathya
WOMEN'S HEALTH
shutting out or shying away
Poverty is the single largest cause of ill health
in our country. Social injustice is probably the
main reason that poverty continues to exist. Both
these factors affect the health of the population
at large, be they men, women or children. Because
of this it is commonly thought that women have
no special health problems other than those
related to childbearing.
/
This point of view however, does not consider
the possibility that a woman’s position in society
itself may have a detrimental effect on her
health. We consider below some of the factors
peculiar in a woman’s life.
undernourished
The average calorie intake of rural women is
estimated to be 1,400 while that of men is 1,700.
These figures are meaningless in themselves un
less compared to the actual amount of work and
hence energy spent by them respectively. In an
interesting study conducted by ASTRA,
*
for
the first time an attempt was made to cal
culate the time spent by men, women and
children on various domestic and productive
work. On the basis of this, the energy cost
of doing each of these tasks was calculated.
The study concluded with the observation "if we
disaggregate human energy, the contribution of
men, women and children is 31 per cent, 53 per
cent and 16 per cent respectively (as percentages
of total human hours per household per day).
This data incidentally substantiates what was
hitherto only speculation that in many (if not
most) rural areas women work harder than
men.’’J
•Application of Science and Technology to Rural
Areas, a Programme of the Indian Institute of Science.
Bangalore.
t Quoted from ‘Rural energy Scarcity and Nutrition’
by Shrilatha Batliwala in EPW, February 27. 1982.
HEALTH FOR THE MILLIONS/AUGUST 1982
According to the same study, the daily calorie
expenditure for women was 2,505 and for men
2,473. Looking at the figures for calorie intake
(men 1,700, women 1,400) in this context, it
becomes clear that while both men and women
get less calories than they need, the gap is
greater for women. (We must remember that
this does not include‘the greater calorie require
ment of a woman during pregnancy and child
birth, during which time she continues with her
daily activities.)
The full significance of this level of under
nutrition on a woman’s health is still not realised.
Undernutrition makes a person more prone to
infection and increases the severity of an illness.
As the level of undernutrition is greater in
women, one would expect that the incidence of
disease would also be higher in them.
Undernutrition causes stunting in growth in
both men and women. But the repercussion of
stunting is more significant in women as it affects
the shape and size of their pelvis. Women who
have good nutrition during infancy and child
hood are more likely to have a normal pelvis
than those from the deprived sections of society.
Calcium deficiency in adult life gives rise
to softening and distortion of the pelvic bones.
These directly affect a woman during childbirth.
Anaemia, a common enough sign in women,
is mainly due to undernutrition. The effects of
this one condition on a woman's health can vary
from such ’’vague” symptoms as weakness, fati
gue, breathlessness, tingling and numbness of the
limbs and loss of appetite, to more serious con
ditions like cardiac failure.
Yet anaemia in
women only assumes importance when it in
creases maternal mortality during childbirth.
1
ing. The difference is that while the physically
harmful effects of drinking and smoking are
well-researched and established, the effects of
high levels of stress on a woman’s health, remain
largely uninvestigated. What’s more, smoking
and drinking are acknowledged as health pro
blems. Stress on the other hand is not even con
sidered as a health problem in women.
physical violence
A health problem assumes national significance
when the incidence is high and it increases mor
bidity and mortality.
no stress on stress
The relation between stress and ill health has
come to be well recognised. Most investigations
so far have concentrated upon the stress induced
by competitive, high pressured life styles in
urban areas. That women face high levels of
stress is largely ignored.
Physical violence against women (wife beating,
burning to death, rape, etc.) is common enough.
It causes injuries and death. However, the medi
cal implications of physical abuse on a woman’s
puerperal sepsis
Apart from the stress of survival, faced by
men and women, there are stresses that are
peculiar to a woman’s life—sexual harassment,
In 60 per cent of the cases, this infection
is caused by bacteria particularly anerobea,
which normally inhabit the vagina. They
only become pathogenic when reduced mater
nal resistance or damaged vaginal tissue
permit the anaerobe to grow.
maternal mortality study
In a study done in Malaysia, maternal
mortality amongst anaemic women was five
times that of non-anaemic women. The effect
on the foetus was even greater, the still
birth rate being six times as high as in nonanaemic women.
fear of pregnancy, adjusting to a new household
upon marriage, bearing the resentment of in
laws, to name a few. The gravity of these pro
blems gets to be noticed only when something
dramatic like a rape or suicide is publicised in
the press. Even then, it is seen as a rare, isolat
ed incident.
Undoubtedly, these are social problems. So
are the problems like drinking alcohol and smok-
body are still not documented. What is the ex
tent of bodily harm caused to women in terms
of broken bones,, lesions, etc.? What are the men
tal effects of such ill-treatment? (If nothing else,
such investigations could provide the much need
ed data which have come to be essential pre
requisites for taking action at any level.) The
relation between women and health must be seen
in the broader context of women’s condition and
status in society. Their health problems have so
far been minimised because data are generally
not available to highlight the issue. It is equally
true that the data are not available because the
problem has not been acknowledged. Perhaps
this is where the first step lies.
ISIS
2
HEALTH FOR THE MILLIONS/AUGUST 1982
HER WORK
double trouble and toil
In India, a woman marks for more than 16 hours a day. Yet many
misconceptions exist regarding this important aspect of her life. In the
following article we have tried to clarify some of these misconceptions
because they affect a woman's condition and status in society, and there
fore affect her health.
It is popularly believed that within the family
there is a division of labour between man, the
bread winner, and woman, the homemaker. Thus,
it is the man who does the 'work’, the economi
cally productive activity.
impossible maths
As woman is pereceived primarily a mother,
the tasks she does are seen as natural extensions
of that role and not really as 'work’. Food pro
duction, processing and storage, water and fuel
carrying, home production and marketing of
products—all this is merely part of being a
woman and housewife. Thirty
five million
women are unpaid workers on family farms or
non-farm enterprises, according to official fig
ures, which are doubtless an underestimate.
Apart from these there are those who are 'just
housewives’, whose plight Habitat News has
dramatised by a simple calculation: Upon tran
slating the work done by women into women
hours and totalling these up to women days it is
found that in a family of six, 3| woman days
of work are done each day. Mathematically, this
means that 3| women work the whole day.
The work is in fact done by a single woman with
the aid of her female children, or a woman with
the aid of her daughter or daughter-in-law. Even
then, it seems to be a mathematical impossibility.
But it is stark reality: ”... in a family of six
in rural India, one woman day is spent in gather
ing and sorting fuel, one woman day in fetching
and transporting water, one woman day in caring
for the well-being of the family, half a woman
day in craft, kitchen garden, cleaning and other
activities, every day. These mathematical im
possibilities of spending more hours than there
are in a day or performing more tasks than
physically feasible, sum up the plight of the
HEALTH FOR THE MILLIONS/AUGUST 1982
AfA'/-fcMA TKAA
IMffiZSHblUTY II
rural woman”. And all this is glossed over
'household activity’.
as
women breadwinners
The distinction between breadwinner and
homemaker and the consequent distinction bet
ween men’s work and women’s work do not
break down even when a woman joins the paid
labour force. Here too women are assigned par
COMMUNITY HEALTH CELL
326, V Main, 1 Block
KprStfnanfla'a
Bangalore-560034
3
ticular kinds of work, on two assumptions.
Firstly, the woman continues to be thought of as
homemaker, earning being a secondary exten
sion of that role (she might need some money for
the home). She is therefore less committed and
less competent in her work. On the other hand
'working’ (to earn) is a man’s primary activity
and it is thought to come easily to him. Women
are not usually trained for skilled jobs—they
remain in the low-skill, low-income range.
The second assumption behind women being
assigned only particular kinds of work is that
they are physically weaker. The work that they
do is supposed to be "light work”. There is a
circular reasoning here: that women do light
work, therefore they are weak, therefore the
work they do is light work, and so on.
The only way to answer these assumptions is
to confront them with facts. The first assump
tion is really an opinion—that women are not
breadwinners, committed to their work, and
are a doubtful investment. The fact is that in
many families, women are the only persons with
a reliable income. To refuse to describe them
as breadwinners is to blind onself to reality.
more work, less pay
The second assumption—that women are physi
cally weaker—has been disproved by a pioneer
ing study undertaken by the Indian Institute of
Science, Bangalore. By computing the calorie
expenditure of men and women in their daily
tasks throughout one year, the study concludes
that women work harder than men. Further
more the specific tasks in agriculture that have
been thought of as "light” because women do
them have been found to be more energy con
suming, over the year, than those done by men.
For example, weeding and transplantation (two
typically female tasks) involve an average daily
expenditure of 85 calories each, while ploughing
and irrigation (two typically male tasks) involve
an expenditure of 50 calories each.
Women’s
work is not easier, but more tedious.
Despite this, women’s work continues to be
paid less and women are paid less even when
they do same work as men. Thus in 1975-76 a
4
woman employed for sowing and transplanting
got Rs. 3.10 as daily wage, while a man was paid
Rs. 4.69.
male bias
The failure to perceive woman’s role in the
economy extends, regrettably, to development
programmes and government plans. An ICRISAT
study notes that technological innovations in
agriculture have been concentrated on the men’s
tasks. Public work programmes like the Employ
ment Guarantee Scheme have been designed for
men’s slack seasons in agriculture, though these
differ from women’s, as women are busy at diffe
rent times of the year from men. As far as
women are concerned the programmes come up
with embroidery, cookery, and food preserva
tion—all in keeping with the general notion of
what a woman does.
Even where technology is introduced for what
have traditionally been women’s tasks in agri
culture, it is introduced to the men. It has been
pointed out that the curriculum of agricul
tural universities includes no reference to the
role of women in agriculture. Nor do agricul
tural extension services have women specialists
in any field and for the men specialists it is
difficult to communicate with the women. A
study of a village in Kumaon shows how the
HEALTH FOR THE MILLIONS/AUGUST 1982
role of women in agriculture was not taken into
account by the extension services, and new
methods of fertiliser application and transplan
ting were taught to the men. The attempt at
innovation failed because it upset the traditional
division of labour. Thus the non-perception of
women’s work has implications not only for the
women, but for the economy.;
double trouble
Sometimes the introduction of new technology
can result in more tedious work for the woman.
An FAO report tells us that where pesticides
were introduced, spraying the crop became men’s
work—as always with the use of new equip
ment. But most pesticides are mixed with water,
and fetching water is women’s work. This meant
more trips to fetch water and thus more fatigue
for the women.
It is naively thought by some that the mecha
nisation of many tasks that used to be done in
the household should reduce the burden of
women. Oil presses and rice mills, for example,
should relieve some of woman’s drudgery. But
the fact is that this kind of equipment is owned
by somebody who had the money to buy it, and
is used by him to make profits. Most women do
not have the cash required for making use of
such technology. Nor is their drudgery relieved,
because going to the mill or the oil press would
be a long and difficult trudge, carrying a load
of material. There are no cheap labour saving
devices for housework.
i
All this is expressed by the term "double
burden”. There is no slack season either, for
woman. Life is a single long stretch of unremit
ting toil. To add to it all, there is sexual ex
ploitation at the work place. Thus, while middle
class women tend to look for employment as a
liberating force, the working classes are more
realistic, and see it as an added burden. It will
continue to be a burden, as long as woman’s
work is not recognized, and paid accordingly
and given the benefit of new techniques to re
lieve drudgery.
drugging, the answer ?
|
I
Feels like a new woman :
symptoms of mental depression gone
QUIETAL
(Amitriptyline)
* Lifts depression and calms anxiety
* Restores normal sleep, and boosts appetite
* Brightens up the mood and promotes interest
(Extract from an advertisement for Quietal)
Women in any occupation can successfully cope
with the stress and strain of everyday life if their
general metabolism is at its functional peak.
PHOSPHOMIN IRON
The elixir for energy
(Extract from an advertisement for Phosphomin
Iron)
There is an alarming trend towards the increasing use of tranquilizers
for relief of anxiety and depression. The prescription can spread to the
rural areas. In these areas, overwork and the fight for survival are the
main causes of such symptoms. Prescribing tranquilizers in such a case
is not much of an answer.
HEALTH FOR THE MILLIONS/AUGUST 1982
health hazards of women
workers
The fact that certain jobs affect the health of
the workers, men or women, is known for years.
Why then are we particularly concerned with
the occupational health hazards of women?
Firstly, the majority of women workers are
employed in the unorganised sector and little
thought has been given to the health hazards
inherent in their work. Most of the efforts at
health, legislative or otherwise, have remained
restricted to the organised industrial sector. This
is because of the rising bargaining power of the
workers in the industrial sector which has en
abled them to demand that the work place be
made safe. This, however, has not been the case
in the unorganised sector in which the great
majority of women workers are employed.
Not much data is available on the working
conditions and health hazards related to women’s
occupations. Much more work needs to be done
regarding this issue. Here, we have put together
information available on a few of these occupa
tions. We have not considered in detail the
health problems caused by housework because
these are well known.
Secondly, women have traditionally been em
ployed in certain types of work that are consi
dered suitable for them. Jobs requiring caring,
patience, dexterity, submissiveness and light
labour are chiefly female occupations. Examples
of such occupations include bidi rolling, watch
making, office work (typing, stenography) and
nursing. Women have also been employed in
certain other jobs like unskilled construction
labour not because those are female occupations
but because women can be paid lower wages.
The health hazards in all these jobs which are
’’women’s work” can therefore be considered as
health hazards specific to women.
Thirdly, women have an additional problem
in that during pregnancy the environmental
factor could affect the baby in the womb. Cer
tain substances in the work place can enter the
bloodstream, cross the placenta and possibly
cause harm to the foetus. Birth defects, spon
taneous abortions and still births can be caused
this way.
6
agricultural work
Women are chiefly employed in work like
transplanting, weeding, harvesting, threshing, etc.
This work requires a lot of bending, and chronic
backache is a common problem.
In areas where pesticides and fungicides are
used extensively, women’s health can be affected
in many ways. After the pesticide has been
HEALTH FOR THE MILLIONS/AUGUST 1982
sprayed some amount of it remains in the field.
While women are working in the field they
inhale, ingest and come in contact with the
pesticides in the field. This is known to cause
cancer, miscarriage, birth defects and genetic
mutations. Skin and eye lesions can also develop.
The risks involved are greater because very
often the pesticides are sprayed by untrained
workers, leading to overspraying.
bidi making
Most of the bidis are produced in Gujarat and
Andhra Pradesh. The industry employs predo
minantly women workers in bidi rolling and in
tobacco harvesting.
Contact with tobacco is known to be injurious
to health. In this work tobacco enters the body
through both inhalation and absorption from
the skin. The symptoms are similar in both
cases and include nausea, vomiting, dizziness,
prostration and weakness. Some workers may
develop breathlessness and asthma. Tuberculosis
is common among workers (exact incidence not
known) though it is not directly related to the
tobacco dust. It is caused by the poor working
conditions (overcrowded, ill-ventilated rooms,
long hours of work and low wages).
The ill effects of tobacco smoking on the
foetus are well known. Probably the same effects
could occur when the tobacco dust is directly
inhaled or absorbed. Work needs to be done in
this area to document the likely side effects on
the foetus of a woman rolling bidis.
electronic and watch making industry
This industry employs women because of their
manual dexterity and infinite patience. The
women often have to assemble components and
handle substances such as arsenic, asbestos,
beryllium, lead and mercury. Apart from caus
ing skin irritation and dermatitis many of these
substances are toxic when inhaled or absorbed
through the skin. In addition many such as lead
and mercury are capable of penetrating the
placental barrier and harming the foetus. The
eye sight is also affected.
construction work and quarry work
office workers
This work is done by both men and women and
has the same side effects for both, except that
it could again have more ill effects on a pregnant
woman.
Health hazards include silicosis (lung disease
due to inhalation of excessive dust particles),
accidents, deformity of bone structure, back
ache, slipped disc, etc.
HEALTH FOR THE MILLIONS/AUGUST 1982
With the cost of living going up, women in
large numbers are taking up this work. These
workers are exposed to many untested chemicals
in photocopies, and stencil fluids. Trichlor ethy
lene is used as a base for solvents in correcting
fluids, inks, adhesives and cleaning agents. It
causes head-aches, fatigue, dermatitis and at
high levels causes nausea, vomiting and con-
i
Nursing staff come in contact with chemicals,
gases and radiation in the course of their work.
Exposure to anaesthetic gases is thought to in
crease the risk of spontaneous abortion and con
genital abnormality in future offspring and is
also linked with the development of cancer, liver
and kidney diseases. A working party of the
Association of Anaesthetists reported recently
that "...it is generally accepted that under nor
mal circumstances the spontaneous abortion
rate lies between 9 and 15 per hundred live
births. Various surveys indicate that the rate
for women employed in operation theatres lies
between 17 and 27 per hundred live births’’. (At
the same time the researchers stress that there
is no direct clinical evidence to relate this obser
vation to the inhalation of anesthetic gases.)
what then
fusion. Several bottles of correcting fluid open
at the same time in a typing pool could result in
an unsafe level of TCE in the air. It can also
be addictive. Office workers also suffer the
hazards of noise, bad lighting and seating.
nursing
A common occupational hazard of nurses is
prolapsed disc lesion, caused by the constant lift
ing of patients, often without the aid of lifting
devices .Because the physical effects of the job
are cumulative, nurses have found it difficult to
claim industrial injury compensation. Other as
pects of nursing are the exposure to contagious
diseases (eg. T.B.) and the long hours and shift
work. Varicose veins is a common problem.
How are these problems to be handled?
Experiences in other countries show that pro
tective legislation for health and safety of
women tends to eliminate women from the work
force. But making pregnant or fertile women a
special category of "workers at risk” is not the
answer to the use of dangerous substances and
practices. The only solution is to clean up the
work place so that it is safe for all.
Occupational health hazards are not any one
individual’s problems. They affect all workers to
some degree be they men or women. Therefore
the demand to make the work place safe should
be backed by an organised effort by all workers.
this is the law
Certain categories of workers are entitled
to compensation for injuries or illness arising
out of the nature of their work (Workmen’s
Compensation Act).
Employers are supposed to provide for
fencing and safeguards for machinery and to
8
instal exhaust fans or whatever else may be
needed to keep the work place environment
safe
(Factories Act). *
Women are entitled to paid leave for six
weeks before as well as after delivery and
nursing breaks till the child is fifteen months
old
(Maternity Benefits Act).
HEALTH FOR THE MILLIONS/AUGUST 1982
RUTH HARNAR
a nurse by any other name
Shakespeare’s Juliet spoke of names saying
’’What’s in a name? That which we call a rose
by any other name would smell as sweet!”
At a national professional nurses’ conference,
an official said that all the trouble of nurses, in
cluding low status and disrespect were because
of the name ’’Nurse”, and it should be changed.
His suggestion? -’’Petty Doctor’*. Members of
the profession were insulted by the insinuation
that nurses are persons ’’having secondary im
portance, little or no significance—marked by
narrow interests and sympathy” (the dictionary
definition of—petty). We have inherited the
name NURSE from a long history of service
offering loving concern and skilled, intelligent
care of the sick and the well throughout their
lives.
Like the sweet scent of Juliet’s rose, there
would be no change in a nurse’s life or burden
simply by a change of name. She would still
have to suffer the risks of ill health, insults,
injury (both physical and psychological) and a
future of poverty which most nurses face. The
reasons for this are—the nature of the work,
the traditions of Indian society, the discouraging
and oppressive attitudes of those whom she
works with—or ’’under” most closely, and the
fact that 95% are women.
Documentation and statistics are available (or
each statement I am making, but I’m not going to
cite them here. This is a "cry from the heart”—a
situation that has concerned me for a long time
I speak from observation and from personal con
tact with nurses who have suffered indignities.
'ANM’s/ health workers (F)
A few days ago I was delighted to meet a
Sister Tutor who had been a student of mine,
with ten of her students, "Health Workers
(Female)”. But as they waved me goodbye from
the place where they left the bus in a remote
rural area, I was struck with a feeling of pity
as I looked down into the sweet faces. What
would happen to them in another year or two?
They were very young, most of them, single
HEALTH FOR THE MILLIONS/AUGUST 1982
girls, from poor families. Like the Auxiliary
Nurse Midwives (ANMs) (why has the name
been changed—to leave out the word "nurse”
so the profession would disown responsibility
for them?) they will be assigned to remote sub
centres, where they are likely to have to live
alone. Most often the centre is far from her home
or may be in another state. She may not know
the local language, the customs of the people;
she is a stranger there. The people of the village
do not accept her as one of themselves—and, un
less she is very fortunate, no one there cares what
happens to her. The social traditions in most areas
do not accept the idea of a young unmarried girl
living without her family in a village.
impossible job description
The ANM has a job description which it is
not possible for her to accomplish. She must
deliver 50% of the midwifery cases in her 5 to
10 villages—going at any time, day or night with
the men who come to call her. This is in addition
to walking 8 to 12 kms a day to visit her villages
every week—on poor paths, in all weather; she
spends almost half of her time in travel—almost
always on foot. Every month she takes her
report to the Primary Health Centre where the
clerk threatens to withhold her pay because she
has not yet completed the eligible couples survey
in one of her villages, or, demands a monthly
bribe, accusing her of giving a false report, be
cause she couldn’t possibly have done all that
work. She must keep the clinic open part of
each day—with very inadequate medicines for
treatment. One clinic I saw had shelves of empty
bottles. Diarrhoea was a common complaint. For
adults she had an antibiotic. The dose was 2
capsules 3 times a day for 5 days (30 capsules).
Her entire stock for the month was 25 capsules.
Student ANMs have been sent to villages with
an allowance and instructions to find their own
room, hire a lady to cook for them or do their
own cooking. ANMs have worked many hours
each day during their training. Yet the hours of
teaching have been as little as an average of
one a week.
9
scapegoats and doormats
Nurses are the scapegoats for everything that
goes wrong with patient care. A pharmacist puts
a wrong label on a bottle. When the nurse gives
the medication she is arrested for the patients’
death. When the case is brought to court, the
label has been carefully corrected.
A doctor denies ever having ordered a medi
cine which had bad results—because the order
was given on the telephone in an emergency—
which he didn’t bother to come for.
general nurses
In hospitals where most of the General Nurses
are trained and work, the nurses’ problems are
somewhat different. Living conditions may be
very crowded. One example was a nurses’ home
where 6 bath rooms were available for 120
students, 80 staff and another 60 staff nurses
who came by local train from their homes. Food
is often poorly cooked in insanitary conditions.
On the wards, nurses must care for all kinds of
patients for 8-12 hours a day in conditions where
half the patients may be on the floor. On one
inspection visit I saw a very neat ward with a
patient in each bed and another under each bed
with her head a foot or two out from under the
end of the bed. The nurse-patient ratio is extre
mely inadequate, partly because of the shortage
of nurses, partly because the number of patients
may be twice the number of beds and the old
nurse-bed ratio remains unchanged.
Supplies, equipment, medicines needed for
giving adequate care to patients are just not
available.
The matron or nursing superintendent may
be making every effort to provide these, but she
has all the responsibility for nursing care of
patients and the ward situation but none of the
authority required. She may be nominally on
an administrative committee but is afraid to
speak up or make any complaints. She has little
to say in the selection of nursing personnel and
no say in discipline or termination of nurses’
services.
10
When the nurses report finding a private room
patient who has committed suicide, carefully
keeping the fact from the other patients who
would be upset, the doctor who is called forces
the door open, and shouts: ”My God, he’s dead Cut him down”. Luckily, the nurses were able
to delay obeying this order until after the police
arrived—or they would have been blamed.
A doctor leaves his watch in the bath room.
When he finds it gone he blames the ward nurse
and calls the police. She is taken to the police
station and kept there all day—until the matron
is informed about it in the evening.
A nurse’s family may have difficulty in ar
ranging for her marriage because of the kind of
work she must do in caring for patients. Some
of it is termed ’’dirty”. She must touch dead
bodies; she must clean up a dying beggar
woman brought from the streets into the hospi
tal, she has to make sure the patient’s bodily
functions are taken care of—but most of all she
must care for men when they are sick.
All of these duties are looked down on by the
same people who desperately need someone to
care for them when they are ill and in need. It
would be only fair to show some appreciation of
the nurse who does this work; instead, she may
be treated as a servant and complaints are made
to the authorities if she does not obey.
the nurse—as a woman
All the above problems are aggravated by the
fact that the profession is largely one of women.
HEALTH FOR THE MILLIONS/AUGUST 1982
the team tried to get in her bed in the village
house where they were staying overnight.
The reports of suicides, murders and even
madness among nurses who have been sexually
exploited by doctors, medical students, goondas
in a village—even by supposedly respectable
men of the upper classes and leaders—read like
horror stories.
the ’’noble” profession of nursing
I have come to dread listening to inaugural
speeches at conferences and meetings. I find my
self listening with painful attention for the
speaker—usually a responsible officer—to use the
phrase "your noble profession”. They insist that
women should take up nursing rather than men
because nurses need to be gentle, tender and
loving, like mothers caring for children.
Because she is a woman the matron is not
given the authority she needs to carry out her
responsibilities.
Girls and women in Indian society are looked
down on if they undertake the ’’dirty” tasks of
nursing—because the traditions and culture have
tended to keep women at home.
But most difficult of all are the sexual insinua
tions, insulting demands and sexual violence
nurses and ANMs have suffered—because they
are women.
A doctor in charge of a health centre tells the
newly appointed ANM that she can have the
assigned room if he can keep the second key and
use her whenever he wishes.
A missionary doctor, against abortions as a
general rule, told me that she had performed 4
abortions within a short 4 or 5 months for ANMs
who had been raped—or used by their officers or
visiting politicians.
The father went to stay with his daughter
after her room was invaded and all her belong
ings stolen by robbers who held her at knife
point. But he couldn’t go on tour with her—and
she finally quit her job when the technician of
HEALTH FOR THE MILLIONS/AUGUST 1982
But what they are really saying when they
use the word ’’noble” is that—"because you are
women, you must always be kind and self sacri
ficing where your patients are concerned. You
must be obedient to men of the medical profes
sion who are your superiors. You must never
never ask anything for yourself—better working
and living conditions, limited hours of work,
holidays or a fair salary—because this would
be betraying your ideal of service to the suffer
ing.”
So nurses go on, trying to do their work under
impossible circumstances, trying to use their
intelligence, knowledge, and skill for the wel
fare of others, trying to support themselves and
their families; trying to keep healthy and sane
under all of these pressures;
How long —Oh how long must this continue?
sexism
Nursing, our predominate role in the health
system, is simply a workplace extension of our
roles as wife and mother. The nurse is socialized
to believe that rebellion violates not only her
"professionalism”, but her very feminity . . . Take
away sexism and you take away one of the
mainstays of the health hierarchy.
Barbara Ehrenreich and Dierdre English
in IVttc/ies, Midwives. and Xurses.
11
where have all the women gone ?
Why do women seldom use the organised health
services?
The major reason is of course, that women,
especially a poor woman, cannot afford the loss
of time, the cost of treatment and the cost of
travel that a visit to the health centre involves.
She has to make arrangements to have someone
look after the children, cook and do a hundred
and one things that must be done at home. When
she falls sick she keeps postponing her visit to
the health centre in the hope that she will get
well on her own; but this delay often results in
a greater damage to her health. If she falls sick
during the busy agricultural season, she had
rather drop dead than visit the health centre as
the income is crucial for the survival of her
whole family.
Another reason is the status she has as a
woman in the family. The illness of a woman
as compared to a man is taken less seriously both
by herself and the rest of the family. If her
husband falls ill, she herself is the first one to
make him go to the health centre. In her eyes
his life is more valuable than her own. For, the
implications of becoming a widow are frighten
ing. But for herself there is the image of woman
as being tolerant, able to bear an immense amount
of pain and suffering. And in keeping with this
is the age old value that "a woman should not
complain”. So she bears her pain and suffering
patiently till symptoms become so obvious that
she needs urgent medical care.
doctored attitudes
Even if she manages to drag herself to the
health centre, the impersonal attitude and mysti
fication of the medical process by health person
nel often scare her away.
Radha is 26 years old and belongs to a poor
Harijan family in a village 60 kms from Madras.
Life for her is a misery at this young age due to
a strange ailment she calls a "curse” on her. She
has been suffering from loss of bladder control
ever since her first delivery eight years ago. It
was a "forceps” case. The doctor told her that
12
something had gone wrong and asked her to come
back after three months. She realised very soon
that what had gone wrong was that she had lost
bladder control. This is a known complication of
forceps deliveries. However, the doctor did not
explain this to her, when he asked her to come
back for another operation. After this operation
(to restore bladder control) things seemed allright
for a while, but the problem came back. She
has had three more children since then but all
these were delivered at home for fear that the
hospital may mess up things further. At no
stage the cause of the problem, or what was being
done about it was ever explained to her. A
second operation might help, but who is to re
assure her against her fear of doctors and ope
rations?
reluctance and shame
There are many others who do not go to the
hospital with their gynaecological problems for
fear of being sterilised. Mariamma, a mother of
three and pregnant again says, "I know they do
abortions but they will do it only if you are w‘T
ing to get sterilised.” For such women the only
way, given their social constraints, is to go to a
local woman—the ’villi’ woman, in Mariamma’s
case. The villi would thrust a thorny stick
through the vagina and this would start a pro
fuse bleeding. Eventually the foetus would come
out (sometimes it wouldn’t, the woman would
bleed to death. More than 6.6 lakh women die
in this way every year).
HEALTH FOR THE MILLIONS/AUGUST 1982
Most PHCs are staffed by male doctors and for
many women it is extremely embarrassing to be
examined by them. This is particularly true of
gynaecological problems, when a woman has to
expose her most intimate parts for inspection.
reaching them
What is the solution then?
Building more
health centres and training more personnel? If
not, then how do we reach women? How do we
get a woman to realise that she is also a person,
that she is often ill and needs care? How can
we help demystify medicine so that women will
no longer feel afraid? How do we give rele
vant and appropriate care to women?
These are some of the questions that we as
health workers must address ourselves to. The
work done by some women’s groups in the coun
try gives reality to the hope that women need
not always suffer alone and that they can be
reached.
The above case studies were sent to us by Ms T. K.
Sundari. Rural Development Society, Chingleput, Tamil
Nadu.
thought to action
aurat ka chamatkar—a report from saheli
Aurat Ka Ek Chamatkar was first presented at
the Mehrauli mela in 1980, near New Delhi. The
theme of the exhibition focussed on women and
reproduction.
In early September 1981, some of us in Sahe
conceived of working on a package of educational
materials on women and health. To start with,
we used ’'Aurat Ka Ek Chamatkar” as the base
and expanded on it. We had a series of discus
sions with Dr. Meera Sadgopal on menstruation,
from menarche to menopause, and contraception.
We felt we wanted to extend the focus beyond
the woman’s reproductory functions, interlink
the biological and social factors that determine
the role and status of women in our society. And
so the name underwent the concomitant change
to—"Aurat Ka Chamatkar”—encompassing every
stage of a woman’s life and drawing in many
other facets.
Our programme
on
Women
and
Health
is
evolving through a process of interaction with a
wide section of women and being built and
changed according to the feedback. Our aim is
to create an awareness among women of our
body and how it functions so that we gain greater
control over our bodies and our lives.
So far, we have organised an Orientation Pro
gramme for the Abner non-formal adult educa
tion teachers and are visiting their centres once
a week, with a different topic.
We have taken the exhibition to IIT and dis
played it at a workshop on technology for rural
women in February 1982.
Some Action India volunteers took it 1°
Madhupur for a 4-day camp of 60 women acti
vists organised by Oxfam.
It is now on its way to Kanpur to be shown to
the wives of industrial wrorkers.
The exhibition will be available to any women’s
organisation to use in colleges, bustees or rural
areas on payment of Rs. 10 per day and trans
port charges.
('Saheli’ is a voluntary organization in Delhi.
whose main aim is to provide services and support
to women. For details, write to 10. Nizamuddin
East. New Delhi.)
Dispelling Myths
Shramik Sangathana, a group in Dhulia
District have also developed a health exhibi
tion in Marathi. They have found it useful
in generating discussion among men and
about myths related to women’s body.
(For more about Shramik Sangathana’s
work with women, see page 14).
13
SUJATA GOTHOSKAR KANHERE
organizing peasant women
The experiences we would like to narrate here
are not exhaustive in any sense. Yet they could
indicate a definite direction. After all, there is
nothing like an experience in itself. What
follows would not be more experiences, but a
reflection on these experiences. It would include
accounts of reflections by working class women
who have experienced oppression and struggled
against it.
shahada and taloda
Shahada and Taloda in Dhulia district of
Maharashtra are extremely rich and fertile.
Seventy-five per cent of the land is in the hands
of fifteen percent of population, mainly non-tribal
people outsiders, and twenty five percent of the
land is in the hands of twenty five percent of the
population, mostly tribal people. These are small
plots of one to three acres, insufficient for survival.
Hence the owners have to work as agricultural
labourers. Forty percent of the population, main
ly tribal people have no land of their own, and
work only as agricultural labourers .The women
from both these last classes have to work in the
fields for a wage as well as work in the home
without any help.
toilers organise
In Shahada and Taloda Talukas, a local organi
sation called the Shramik Sanghatana (Toilers’
Organisation) took up the issue of the lost lands
of the tribal people. A systematic agitation be
gan. Hardly any women attended the public
meetings. Later, the issue of harassment of
labourers, especially women was taken up. Propoganda against the rape of tribal women by
the rich peasants, goondas (hooligans) and police
as well as agitation against these began. Women
sporadically came out to agitate and protest, but
no systematic organisation of women evolved.
In 1972, the labourers took up a struggle for
higher wages. Women were being paid only 75
paise for a whole day’s work. At places like Pariwardha, women were drawn into the struggle
14
against the strike breakers. At Mod village they
participated in morchas for wage demands. Later
the women said: "We did not believe that we
women could shout slogans about our demands,
our wages, our oppression. We never thought
we could do it. We were told that our place was
at home”. At Pariwardha, women were in the
forefront in stopping the strike breakers. But
they were looked upon as mere appendages. At
the time of negotiations, the men said: "We will
negotiate about the wages of women. They need
not come”. This was resented by the women.
Women argued: "We will negotiate about our
wages. We have participated in the struggle and
militantly too”. However, the participation of
women remained sporadic and isolated in a few
pockets.
During the 1973 drought, women began to
become more active and interested in the strug
gle. At about the same time a women’s shivir
(camp) was organised by the Shramik Sangha
tana, after discussions with the women active in
the struggles. The men’s resistance to the
women’s camp was overcome after a protracted
discussion with them in the midst of the women.
violence against women
In the shivir, women narrated their own in
timate experiences. Here in a non-oppressive
atmosphere, they could discuss their real pro
blems. They narrated experiences of how the
rich peasants and others treated them as sex
objects. They resented it. They decided to fight
against it, individually and collectively. Then
they discussed the question of liquor drinking
and the wife beating which ensued from this.
This too had to be struggled against collectively—
however private it might appear—they decided.
Women who had already participated in strug
gles whether over atrocities or over wages, ha1
experienced their own energy, their capacity
and their power. They could not reconcile their
resistance to the rich, their struggle against
HEALTH FOR THE MILLIONS/AUGUST 1982
rapes, with their docile acceptance of being
beaten by drunkard husbands. Karankheda
women asked the other women in the shivir to
help them begin their struggle against liquor
drinking and wife beating. The whole shivir
went to Karankheda. They broke all the liquor
pots. They threatened husbands with grave con
sequences if they beat up their wives. With this
began a spate of struggles against all forms of
oppression of women. Bands of women and the
youth would move from village to village threa
tening drunkard husbands, the goonda elements
etc, and convincing other women to join them.
"Now we are afraid no more of the police patil”,
they sang. Now there was a greater dimension
to their struggle against casteism, corruption,
unemployment, low wages, etc.
women’s movement
The process of development of the women’s
movement in Shahada in rural Maharashtra, as
well as among Bombay slum women, seems to
be taking a similar course. A minority of women
participated in the general class struggle over
class demands of either working conditions or
living conditions-. The mass of women remained
outside these struggles or were only marginally
involved. This minority which was active in
these struggles, however, faced an increasing
contradiction between their newly realized
power in the struggle for their conditions of
work and living on the one hand, and their sub
ordinate position at home and in society. This
together with the struggles that developed over
the questions of wife-beating, rape etc., i.e.,
over overtly women’s questions, drew a majority
of women into the struggle against their oppres
sion as women. Their involvement in the class
movement also had a totally new dimension and
perspective now.
man-woman relationships
What was the pattern of man-woman relation
ships during and after these struggles? Had they
changed during the process? In the beginning,
women and their participation in any struggle
were looked upon as a mere appendage to the
struggle which was mainly the concern of men.
Wife-beating, sexual excesses, expressions of
the woman’s secondary, subordinate position visa-vis the man were considered to be natural.
normal oi' at most a private affair.
ISIS International Bulletin
Spring 1979
But the struggles by the women challenged
these dominant ideas among the men as well
as among the women. Consultation with the
women during struggles and negotiations, helping
women activists with their domestic work were
early symptoms of a changing attitude towards
women. The idea that women are no better than
cooks and child-bearers is here in the process of
being overthrown. Women are also considered as
not only leaders of women but are accepted as
leaders of all the labourers in the village. The
women’s struggle did and does challenge the
ideas dominant until then. It helps to create a
new and higher sort of relationship between the
sexes. This, however, must be by its very
nature—as indicated by these experiences—an
on-going struggle that challenges not only parti
cular manifestations and expressions of women’s
subordination and oppression, but shakes the
very roots of the oppression of women.
HEALTH FOR THE MILLIONS/AUGUST 1982
15
Source:
united they marched
The Community Health Development Pro
gramme (CHDP) of Kottar Social Service Society
covers 107 villages of Kanyakumari district,
Tamil Nadu. It offers health services, but with a
difference!
Initially, the programme concentrated on pro
viding MCH services along with food distribu
tion. After a period of questioning, they decided
that their priority should change to educating
women on economic and social issues. Instead of
providing services, the women should be or
ganized to demand these services from the Gov
ernment.
Working in this direction led to the women
"flooding the government PHCs to get their
children vaccinanted”. The much surprised health
authorities then decided to collaborate with the
staff of CHDP to provide the health services in
these villages. This experience gave the women
confidence in their power as an organized group.
The women went further, to take up other issues
which affected them.
j One such issue was that of drinking water.
fl’In one village there were no proper facilities
I for drinking water. The committee of the
16
women’s club went several times to the Panchayat union office but this effort proved to be
a waste of time and money. So they decided co
go in large numbers to get their demands for
drinking water, this time carrying their earthen
ware water pots. But as always the Panchayat
office did not look concerned. So the women
oroke their pots in the office and returned home.
This dramatic gesture had its effect. Within two
weeks the Panchayat Officers came to the village
to discuss the problem and before the end of
the month, a drinking water pump was installed
in the villages. The men of the village could
not believe their eyes because they had long
given up the issue as impossible and unrealiz
able!
One of the latest issues taken up is that of
providing adequate food grains at fair prices.
For this, the women’s group linked up with
others in the district and organized a procession,
several kilometers in length.
This is the beginning of a women’s movement
•in the area.
From the report sent by the staff of CHDP, Kottar
Social Service Society
HEALTH FOR THE MILLIONS/AUGUST 1982
myths about women
Women are often treated cruelly because of
myths related to their body. Below we try to
dispel some of these false notions.
menstrual blood is unclean. In fact, there is no
difference between menstrual blood and blood in
any other part of the body.
is a woman responsible if she does not
bear a child?
is a woman capable of transmitting evil?
It does not take long for a woman to be label
led ’’sterile” if she does not bear a child soon after
marriage. She is then considered unlucky—cap
able of having an ill effect on the cattle, crops
and weather. At social functions her presence is
deemed inauspicious. Convinced that she is illfated, her family and husband can desert her
too.
In most rural areas, the real causes of inferti
lity are not known. Studies have shown that in
25 per cent cases infertility is caused by factors
affecting the woman, in 25 per cent by factors
affecting the man and in the remaining 50 per
cent cases by factors affecting both the man and
the woman.
is a women responsible if she does not
bear a male child?
The truth is that a woman’s body has nothing
to do in determining the sex of the child she
bears. The sperm cells of the male are the one
that differentiate into male and female cells
(X and Y chromosomes) thus determining the sex
of the child.
is a woman impure when she is
menstruating?
Menstruation is a normal physiological fact of
life. If only people would believe it! A men
struating woman is often isolated from the
others in the house, not allowed to cook food,
not allowed to touch pickle and other preserved
food and not allowed to do any productive work.
This belief usually stems from the notion that
HEALTH FOR THE MILLIONS/AUGUST 1982
In Punjab it is believed that a child gets
marasmus when the spirit of another marasmic
child (dead or alive) enters its body through a
medium. A study done by Dr. D.N. Kakar of
P..G.I. Chandigarh shows that most often the
medium is believed to be a woman.
Witch-hunting is another gruesome aspect of
this myth that women are evil. According to a
newspaper report, scores of women are tortured
and mercilessly killed every year in Madhya
Pradesh because they are held responsible for
all types of calamities, ailments, deaths, epide
mics, loss of cattle, property and other troubles.
This is rarely reported to the police, because
witch hunting has social sanction.
In fact marasmus has nothing to do with an
evil spirit. It is a form of malnutrition. Health
and other problems for which women are held
responsible as 'witches’ have their roots in social
and economic factors. Women become the suf
ferers because people do not have a clear under
standing of their own situation and are driven
by helpless rage to look for scapegoats.
is a woman abnormal if she enjoys sex?
Fiction and reality is full of the notion that
»only ’fallen’, ’low’ women enjoy sex. A good
woman is not supposed to know anything about
sex, or have normal bodily reactions to it. There
are cases where women who had vaginal secre
tion during intercourse were sent for medical
examination, as they were thought abnormal!
The fact is that it is normal and healthy that a
woman should enjoy sex.
still a mystery : why ?
A woman’s womb is still a mystery in many
ways. Numerous theories exist, yet no definite
reasons have been found for some common gyn
aecological complaints. Take the case of dysmenorrhoea (painful menses) a common enough
complaint in women. A1 critic says:
’’Hardly a day, or a medical journal goes by
which does not offer a new near-panacea
whose rationale conflicts with many others
....It reflects more essentially the psychoso
matic ineffectiveness of the prescribing phy
sician, and in general the results are not
superior to our sage advices at the beginning
of the century”, (emphasis is ours)1.
The picture is as blurred when it comes to
other menstrual disorders. A book on gynaeco
logy has this to say on various menstrual prob
lems:2
Premenstrual syndrome:
(These are symptoms a woman experiences before
she gets her menses)
’’The aetiology (reasons) is obscure and none of
the many hypotheses has been substantiated”.
The irritable bowel syndrome:
(during menses)
’’The name is a compromise indicating the lack
of understanding of the disorder”.
Idiopathic oedema:
(Swelling of unknown origin during menses)
"The cause is unknown but stress, either domes
tic or occupational appears to precipitate the
attack”.
A woman is likely to suffer from these com
plaints for about 30 years of her life. In addi
tion she could also have problems like leucorrhoea (white discharge) and prurites vulvae (itch
ing of the vulva), both of which are very com
18
mon complaints in women. (At least one in ten
women who attends a gynaecologist complains
among other things of itchiness of the vulva.)
For a woman the discomfort of these com
plaints is real. Moreover, she has to live wit
them day in and day out; Often she does not seek
medical help for such complaints. In this context
we feel concerned about the attitude of health
personnel.
A widely used book for general practitioners'3
has this to say on leucorrhoea:
’’Majority of the women in our country are
housewives. In most of the other countries,
the women do as much office work as men
and in addition do the duties of housewives.
HEALTH FOR THE MILLIONS/AUGUST 1982
Thus Indian women have more "spare” time.
Since majority of them have no other acti
vities or hobbies and do not do any reading
(being uneducated), they spend most of their
spare time concentrating
on
their
vaginal
discharges.” (emphasis ours).
The underlying attitude that will be encou
raged in general practitioners is self evident. It
is also significant that leucorrhoea (white dis
charge) is the only common gynaecological prob
lem discussed in the book.
more sage advice
Another book4 (on MCH), recommended for
medical officers in the PHC, has devoted only six
pages out of its 473 pages for gynaecological
problems. In these six pages, twelve gynaecolo
gical complaints have been dealt with An exam
ple of the advice suggested for these problems is
as under:
primary dysmenorrhoea
(painful menses)
Mild: Often no treatment is required. Reassu
rance and normal active life is enough.
Severe: For relief of pain give analgesics. Re
assure patient and recommend normal
life. If a woman is married, D & C will
help. Vaginal delivery of an infant
usually gives great relief.
menorrhagia (abnormally profuse menses)
and dysfunctional uterine bleeding
If no organic cause is found, after medical and
gynaecological examination, it is termed dysfunc
tional bleeding. It is common in puberty. But in
most women the normal cycle flow becomes esta
blished within a few months. No treatment is
indicated in these cases except give iron orally to
avoid anaemia .Reassure the parents that it will
cease and encourage the girl to lead a normal
life. If bleeding persists more than a few months,
refer. If such a bleeding occurs in a married
woman do a D & C and send scraping for histo
pathological examination to rule out any endormetriosis. Often D & C gives relief temporarily.
leucorrhcea (white discharge)
Frequent symptom often associated with others
like backache, general weakness etc. When asso
ciated with local itching, infection is usually the
cause (the treatment for trichomonas, moniliasis
and gonococal infection is given).
Here too, the woman’s problem seems to be
minimized to taking rest, leading a normal life,
or come worse D & C. In the absence of a clear
understanding of these gynaecological complaints,
health personnel really cannot alleviate the prob
lem. However sweeping such complaints under
the carpet is of no help to a woman. The prob
lem is still very real for her.
References:
1.
2.
3.
Derek Llewellyn Jones: Ch. 28, Vol. Two, Funda
mentals of Obstetrics and Gynecology, ELBS and
Faber & Faber Ltd., 3 Queen Square. London WCI.
Derek Llewellyn Jones, op. cit., Ch. 6.
OP Kapoor: Part II Kapoor's Guide for General
4.
Practitioners, 1976, S. S. Publishers, 16 Rajat. Mount
Pleasant Road, Bombay 400066.
Dr J F W Miller (ed.) Handbook for the Delivery
of Care to Mothers and Children in a Community
Development Block.
women wonder why the causes of the following are still unknown
'
Ectopic gestation (tubal pregnancy)
Placenta praevia (placenta implanted in the
lower segment of uterus)
Abruptio placentae (separation of a normal
ly implanted placenta)
Pre eclampsia and eclampsia (convulsions
during pregnancy)
Prolonged pregnancy (pregnancy prolonged
beyond the 294th day)
45% causes of premature labour
HEALTH FOR THE MILLIONS/AUGUST 1982
— incidence 1 in 150 pregnancies
— incidence 1 in 100 pregnancies
— incidence 2 in 100 pregnancies
— incidence 5-10 in 100 pregnancies
— incidence 10 in 100 pregnancies
— incidence 10 in 100 pregancies.
19
WOMEN’S HEALTH PROBLEMS
home remedies
Women in the rural areas have often turned
to home remedies for their common gynaecolo
gical problems. In the absence of medical know
ledge any treatment will remain incomplete.
Both allopathic treatment and home remedies
can at best offer symptomatic relief. Home reme
dies have the added advantage of being low-cost,
easily available and probably less toxic. Clinical
trials need to be undertaken to prove the effi
cacy of these home remedies. We list below some
of the commonly used ones.
proved effective in a large number of cases
of stubborn trichomonas or non-specific vagi
nal infection. Peel a clove of garlic and
crush it. Wrap in a thin gauze piece. Insert
it into the vagina leaving a tail of gauze out
side for easy removal. Burning may occur.
leucorrhoea (white discharge)
1.
Dry the leaves of Bel (Hindi—Bel; TamilVilvum) and powder them. One teaspoonful
of powdered leaves to be taken in one cup
of milk, morning and evening.
2.
Powder the root bark of Side (Hindi-Kharenti; Tamil-Arvalmanaippunder Botanical
name—Side Cordigolia).
Add milk and sugar.
3:
Take juice of 35 gm of Adenema—hissopifolium (Tamil-Vellarugu kudineer). Add 200
ml of water and prepare a drink per day.
4.
For white curdy discharge: Apply on a pad
some cottage cheese (Hindi—Paneer) and
curd and place it at the vaginal opening.
This will stop the itching and draw out the
infection. Use until symptoms do not recur
within 12 hours.
5.
6.
Yeast and other organisms do not thrive in
an acidic environment. Therefore douching
with lemon juice, vinegar can help. Use
juice of half lemon or vinegar and a table
spoon of crushed vitamin C powder in a litre
of water and douche. It may sting a little.
1.
Botanical
name—Ferula foetida (Hindi—
Hing; Tamil—Perungayam; English—Asafoetida)-.
Method of preparation: Take a very small
piece of asafoetida, roast, powder and take
orally.
2.
Black cummin seeds—6 gm.; Cinnamon
bark—6 gm; Dried ginger—6 gm; Lead-wort
root bark—6 gm; Fennel seeds—6 gm.
Preparation: Take the above. Add 200 ml of
water and prepare decoction reducing to |th.
Dose 20-30 ml twice daily.
3.
Grind a few leaves of bitter gourd (HindiKarela; Tamil-Paharkai) with some pepper
and garlic. Take this once a day for 3 days.-
For trichomonas *infection: Garlic supposi
tories. Garlic contains lots of sulfur and has
♦Trichomonas infection is characterised by a thin and
foamy, greenish-yellow or whitish, bad smelling vaginal
discharge, with itching. It burns to urinate. The geni
tals may hurt or be swollen.
20
dysmenorrhoea (painful menses)
HEALTH FOR THE MILLIONS/AUGUST 1982
USA
menorrhagia (profuse menses)
1.
Take 50 gm of Jambu bark (Hindi—Jamun;
Tamil—Naval). Crush it well, add 200 ml of
water and prepare a decoction reducing to
quarter. Dose: 30-50 ml twice daily.
2.
Take 50 gm of touch-me-not plant, add 200
ml of water, prepare decoction reducing to
quarter. Dose: 30.50 ml twice daily.
3.
Extract the juice of the leaves of pergularia
(Hindi—Utran; Tamil—Uttamani; Botanical
name—Pergularia daemia) and take with
honey.
4.
Take skin of Pimpal Babool (Hindi—Pimpal;
Botanical name—Feens religeosa) and bark
of Tamarind tree and rub them on a stone.
Grind and take it along with honey twice a
day.
swelling of feet in pregnancy
1.
Boil some palm sugar and fennel (Hindisaunf) together. Strain and drink three times
a day till swelling disappears.
2.
Boil leaves of prickly chaff (Hindi—Chirchira; Tamil—Nayurvi) and take it in the
morning.
References
—
Herbal remedies for Vaginitis
by Feminist Health Works, 487A Hudson Street,
New York, NY 110014
—
Where There Is No Doctor by David Werner
—
Common Remedies in Siddha System of Medicine
(Central Council for Research in Indian Medicine
and Homoeopathy)
—
ICCW News Bulletin. Vol. XXIV, No. 6.
CARING FOR LIFE
Throughout the world it is women who look
after the old. In industrialised countries wives
and daughters provide over 70% of all health
care for older people. In the United Kingdom
300,000 women remain unmarried so they
can look after their parents.
Graphics— David Eaton
HEALTH FOR THE MILLIONS/AUGUST 1982
21
drugs in pregnancy
In the 1960s more than 6000 children were
'maimed in West Germany alone. The reason—
pregnant mothers were prescribed an ’’apparen
tly innocent sedative” thalidomide. The children
born to these women had severe limb defects.
This tragedy brought to light the important
fact that many drugs taken during pregnancy
affect the foetus and can cause foetal abnormali
ties (birth defects).
During pregnancy, the foetus is frequently
exposed to a variety of drugs or chemicals
which have been prescribed to the mother for
therapeutic purposes. Drugs taken by the mother
during the first three months of pregnancy can
lead to a variety of structural and functional
abnormalities in the foetus. On the other hand
drugs given to the mother during labour tend
to produce immediate and generally short term
effects in the foetus. Sometimes these effects may
persist into neonatal life.
The expected malformation of the foetus
depends on when the drug is given to the
mother during her pregnancy. In the first week
after fertilization (preimplantive period) the
embryo is relatively resistant to adverse effects
from its environment. In a few days, organs start
forming. This is when drugs can have dangerous
effects. Drugs taken during the first 15-25 days
of foetal development, affect the nervous system,
those taken during 20-40 days affect the heart
and those taken during 24-46 days affect the
limbs. As you will notice many organs are deve
loping at the same time. This means the drugs
taken during this period can cause a combina
tion of different abnormalities. By the first three
months of pregnancy most of the organs are
already formed. After this period the foetus will
have the same kind of adverse reactions to drugs
as that in an adult.
During the crucial period of foetal develop
ment (the first three months) several drugs can
induce the same type of malformations and one
agent can induce more than one type. Let us
look at some of the drugs commonly given to
mothers during pregnancy.
22
analgesics
Analgesics such as salicylates (like Aspirin)
are used in a free and uncontrolled manner
during pregnancy. These are prescribed for
headaches, superficial pain, fever etc. If these
drugs are taken during the first three months
of pregnancy they may cause congenital defects.
When taken during the later part of pregnancy
they may lead to bleeding tendency and jaundice
in the newborn. This is due to the impairment
of platelet and haemostatic function in the baby.
So far paracetamol appears to be a safe drug
in pregnancy.
Opiates and their synthetic derivatives (like
morphine) commonly used during labour can
lead to respiratory depression in the newborn.
Spontaneous breathing becomes difficult in such
babies. If these drugs are given to the mother
during pregnancy, the foetus can become addic
ted to them while still in the uterus.
anti hypertensive drugs
Thiazide diuretics (like Chorthiazide) used in
the last trimester to reduce oedema and hyper
tension may cause internal bleeding disorder
(thrombocytopaentic purpura) in the baby.
Reserpine also causes high morbidity (10%)
in infants born to mothers receiving this drug.
These infants may have severe nasal discharge,
lethargy, loss of appetite and respiratory depres
sion.
Clonidine has shown to have adverse effects
on the foetus in animals.
Propranold can produce growth retardation in
the foetus.
Menexidil can produce foetal hypertrichiosis.
Alpha methyldopa (aldomet) and mydrallazine
appear to be safer antihypertensive drugs in
pregnancy.
psyopharmocological agents
Phenothiazines (like Sequill) are frequently pre
scribed during early pregnancy for vomiting.
HEALTH FOR THE MILILONS/ AUGUST 1982
These drugs can reduce the blood flow in the
uterus and placenta. Continuous treatment with
these drugs in pregnancy may produce eye
defects in the baby.
antibiotics
These are often used for treating bacterial
infections during pregnancy. Most of these drugs
can pass the placental barrier.
Sulpha drugs if taken in the last few days of
pregnancy can cause haemobysis (breakdown of
red blood cells) and jaundice in the newborn.
These drugs also combine with haemoglobin and
cause methaemoglobinaemia thereby reducing
the oxygen carrying capacity in the newborn.
Sulpha drugs should not be used in pregnant
women nearing term. Streptomycin if taken
during pregnancy, may lead to permanent dam
age to the eighth nerve of the infant causing
deafness (1%). It can also cause weakness of the
muscles in the newborn.
Tetracycline when taken from the fifth month
of pregnancy can stain the teeth of the baby and
also make them brittle (enamel hypoplasia). It
can also affect the growth of bones leading to
stunting of the baby.
Chloramphenicol can cause death of the baby
due to circulatory collapse if taken during the
last few weeks of pregnancy.
Penicillin appears to be the safest antibiotic for
pregnant women.
progesterone acetate, hydrogestone or depot progestogens.
Severe cases of threatened abortion may re
ceive depot estradiol valenate or estradiol ben
zoate in addition to depot progestogens. Limited
use has also been made of diethystilbestrol.
The efficacy of supportive hormone therapy is
not proven either for high risk pregnancies or
for normal pregnancies. Furthermore there is
evidence that there is an increased risk of con
genital malformations especially of' the heart,
among children exposed to supportive therapy.
WHO recommends that:
diethylsibesterol should not be given to
women known or suspected of being pregnant
(one side effect was that many female children
developed vaginal cancer).
The benefits of progestogen and estrogen the
rapies have not been proven conclusively. In the
absence of proof and with the possibility of
these drugs being harmful to the baby it is wise
not to use these drugs.
as hormonal pregnancy tests
These drugs are usually a combination of
estrogen and progesterone. They are used to
find out if a women is pregnant or not. Some
doctors and chemists also prescribe them for
inducing abortion. Some common brand names
are EP Forte, Secrodyl, Cumovit, etc.
female sex hormones
These need special mention as they are used
for a variety of purposes.
(a)
as a supportive therapy in pregnancy i.e.
for threatened abortion, habitual abortion,
premature or delayed abortion.
(b)
to test pregnancy and induce abortion
(c)
as contraceptives
We will look now at the drugs used for each
of these purposes separately.
as supportive therapy during pregnancy
The most widely used products have been oral
allylestranol, norethisterone acetate, medroxy
HEALTH FOR THE MILLIONS/AUGUST 1982
23
These drugs should not be used because they
are not safe.
probably higher in India). Such pregnancies are
called break-through pregnancy.
They cause foetal abnormalities (neural heart
and limb defects).
/
They are not reliable for diagnosing preg
nancy (one in five women are pregnant when
the test says they are not).
Such pregnancies are associated with spon
taneous abortions. Evidence also shows an in
creased risk of congenital malformation. There
is a possibility of multiple births and chromo
somal abnormalities.
They do not induce abortion.
WHO recommends that these drugs should
no longer be used for diagnosing pregnancy.
as oral contraceptives
Women do not ovulate while taking oral con
traceptives (the pill). However from time to
time women forget to take their pill regularly.
If the pill is taken irregularly the chances of
pregnancy are high (1% in developed countries,
To conclude, we have mentioned only some of
the commonly used drugs in pregnancy. There
are many others which are also harmful for the
foetus. The medical profession clearly has a
grave duty to refrain from all inessential pre
scribing of drugs for all women of child bearing
age. It is not sufficient to merely ask a woman
if she is pregnant or not. It is also necessary to
consider the possibility that a woman may become
pregnant while taking the drug.
For further information on the effect of drugs
in pregnancy, write to VHAI.
Acknowledgement : "Drugs and pregnancy”
By Dr P. S. Patki and Mr Moholkar
B. J. Medical College, Pune.
WORDS
to a health worker
to a pregnant mother
While prescribing any drug to a pregnant
woman ask yourself: Is it essential? Does it
have any harmful effect on the new horn
child?
—
Avoid taking drugs during pregnancy.
.—
If you are prescribed a drug, ask if it is
essential.
Get accurate information on the drugs you
usually prescribe to pregnant women.
—
Does it have any harmful effect on you or
your child?
Since most of the drugs sold in the market
are under brand names and often contain a
combination of three or more drugs, read the
contents carefully before prescribing.
—
Ask for and read the accompanying litera
ture at the chemist before buying the drug.
Do not have blind faith in drug representa
tives.
For further information on the effect of drugs in pregnancy, write to VHAI.
24
HEALTH FOR THE MILLIONS/AUGUST 1982
mother care by dais
Beneficial
1.
Care and attention given to
the woman’s physical and
mental state of health, right
from the time of confirmation
of pregnancy till 40 days
after the child birth. (This in
cludes building up her phy
sical strength, self confidence
and will power.)
2.
Advice regarding avoidance
of sexual intercourse in the
third trimester of pregnancy.
3.
Advice regarding avoidance
of certain "wind-producing,
indigestible foods” during
pregnancy and lactation.
Harmless
Harmful
1.
Wearing of amulets and
charms to ward off evil spi
rits.
1.
Advice regarding deliberate
undereating in the third tri
mester of pregnancy.
2.
Advice regarding avoidance
of contacts with strangers
during the period of delivery
and seclusion.
2.
Advice regarding avoidance
of consuming certain locally
available nutritious foods.
3.
3.
Advice regarding disposal of
placenta in a culturally pres
cribed manner to avoid any
chance of harm to the new
born through black magic.
Massaging vigorously the wo
man’s abdomen during the
second and third months of
pregnancy.
4.
Lack of asepsis in procedures
adopted for delivery.
5.
Advice regarding excessive
intake of "desi ghee” to the
woman for lubricating the
birth canal.
6.
Referring
seriously
sick
children to indigenous medi
cine practitioners.
4.
Advice regarding perform
ance of inexpensive ritual
ceremonies, such as purifi
cation bath.
4. Washing of mother’s dirty
clothes and disposing of ban
dages after the child birth.
5.
6.
Advice regarding prolonged
breastfeeding.
5
Treating mother’s minor ill
ness with certain harmless
indigenous medicines.
6. Treating child’s minor ill
ness through home remedies.
Providing services in an at
mosphere of cordiality, mu
tual trust and inter-depen
dence (in contrast to the
strange, impersonal atmos
phere of the hospital).
Source: Folk and Modern Medicine
by D.N. Kakar.
If you think of other points, regarding
mother care by dais, share with us at VHAI.
I
promote breastfeeding
BUT DON’T LET IT MISFIRE
Breastfeeding is good for the baby and mother.
According to the law (The Maternity Benefits
Act) every woman delivered of a child should be
allowed two nursing breaks a day till the child
is 15 months of age. No campaign for breastfeed
HEALTH FOR THE MILLIONS/AUGUST 1982
ing is complete unless it lobbies for the enforce
ment of this law and for the provision of creches.
Without this, the breastfeeding campaign may
well backfire on working mothers, most of whom
work out of sheer necessity.
hospital care for mothers
Beneficial
1.
2.
3.
4.
5.
6.
Harmless
Early detection of complica
tions in pregnancy and their
treatment.
Surgical intervention where
necessary to save both mo
ther and child.
Possibility of saving the
newborn child’s life (prema
ture birth, respiratory dep
ression etc.)
Immunization against teta
nus.
Aseptic technique to reduce
infection.
Psychological assurance that
the mother is in good hands.
3.
Impractical advice about nu
trition, rest-.
2. Unnecessary procedures like
shaving of the pubic hair,
enema etc. at the onset of
labor.
3. Position of the mother (litho
tomy) more to suit the con
venience of the medical per
sonnel.
1.
Harmful
4.
5.
6.
1. Treating all child birth as
medical events (creating doc
tor and drug dependency).
2. Impersonal and unsympathe
tic attitude.
7.
Over medication and harmful
medication (routine sedation
in labor that can cause res
piratory depression in baby).
Unnecessary surgical inter
vention (all primigravidas
*
to
be given routine episio
**
tomy;
too many forceps ap
plication, caesarean sections).
Unnecessary
induction
of
labour (not giving the wo
man enough time to go into
normal labor).
Separation of mother and
child for a period of time
after delivery (ranging from
a few hours to a day). Inter
feres with breast milk re
flex.
Not available at all times to
the mother.
‘Women giving birth
time.
for the
first
‘•surgical incision of a woman’s peri
neum. See below.
damaging child birth operation
A routine ’’genital mutilation” is being carried
out on most pregnant women, often without
their consent, according to the author of a Na
tional Childbirth Trust report.
The controversial, but common, practice of
episiotomy (the surgical incision of a woman’s
perineum during childbirth to ease delivery) is
being done far more than is essential and is caus
ing women unnecessary pain and postnatal diffi
culties.
That view is expressed by Mrs. Sheila Kitzin
ger, a social anthropologist and a counsellor and
teacher for the NCT, in Some Women’s Expe
riences of Episiotomy which is the result of a
two-year survey and study of the subject.
Episiotomy, the only surgical intervention
which takes place on the body of a healthy wo
man without her consent and often without her
knowledge, has become a normal and almost
.26
inevitable consequence of childbirth for all wo
men having first babies and most of those having
second and subsequent babies, she argues.
"It is a genital mutilation, the most common
form of genital mutilation we have in the West”,
Mrs. Kitzinger mother of five, said at the launch
ing of her report.
’’Episiotomies are done much too casually and
women are far too often teaching material for
students”, she said.
Mrs. Kitzinger’s survey of 1,800 women attend
ing NCT antenatal classes in England and Wales
who had babies between March 1979 and March
1980, revealed that women who had had episio
tomies (more than two-thirds of the sample)
were twice as likely to experience severe pain
in the first week after delivery—from The
Times, London.
Courtesy : Saheli Documentation Centre.
HEALTH FOR THE MILLIONS/AUGUST 1982
mother’s card
As the majority of the population in deve
loping countries are not fully served by present
systems of health care delivery, alternative ap
proaches involving primary health care (PHC)
are being carried out in many places. Primary
health workers have various tasks to perform (e.g.,'
diagnosis and management of community and
family health problems), but owing to their
frequently limited educational backgrounds,
simplified aids and other appropriate technology
are indispensable to help them to do their work.
The successful experience in India and Somalia
(among rural and urban communities) of using
"mothers’ cards”, which record the obstetric
history of women of reproductive age over a
continuing period at the primary level, encoura
ges us to present below a description of this card
which could be adapted for use in other places.
Printed in the local languages on thick paper,
the mother’s card provides information on
whether she is using family planning measures
and on her menstrual status, pregnancy period,
whether at risk during the pregnancy, immuniza
tion status against tetanus, expected date of con
finement and on breastfeeding. Details of four
pregnancies can be recorded on each card. A
duplicate card, printed on thin paper, is retained
by the primary health worker, while the main
card (protected in a plastic bag) is kept by the
mother herself.
Each card can be folded in the spaces between
the three columns on either face of the card
(see figures on opposite page). On the front of the
folded card, the health worker writes the name
of the village or health centre, the date, the
women’s name, address, present age and ages at
menarche and at marriage. The latter may have
to be based on indirect evidence, e.g., the age of
her eldest child. Other data that are entered
include the women’s weight (as measured in a
portable spring balance scale), height, and pre
vious obstetric history (in summary form). On the
back of the folded card is entered information on
the women’s menstrual history (space is provi
ded for recording this every month from the
HEALTH FOR THE MILLIONS/AUGUST 1982
age of 14 to 45 years and the type of contracep
tion practised. At the bottom of this column are
given various symbols (representing regular or
missed periods, abortion, breastfeeding, etc.),
which must be used when filling in this part of
the card.
If two consecutive periods are missed, indica
ting that the woman is pregnant, then the ap
propriate section on the inside of the folded card
is filled in. The health worker records the woman’s
parity, expected date of confinement, weight,
presence of oedema (swelling of legs), whether
immunized against tetanus, etc. This part of the
card is filled in every month during the first
seven months of pregnancy, and every fortnight
during the last two months Two weight curves
are de.picted on the card; if the woman’s weight
is nearer the lower curve or below it, she is at
risk of producing a baby of low birth weight.
Women whose weight line is near the upper
curve are likely to deliver babies of 3.1kg and
above. (It should be noted that these limiting
curves will vary from one ethnic group to
another and they must be determined on the
same or a closely related community by special
research.)
Indicators of risk, which should be noted by
the health worker, are: (1) weight of 38 kg (or
less) before pregnancy or less than 42 kg at the
24th week of pregnancy (2) height of less than
145 cm; (3) severely pale; (4) very small child
(less than 2 kg) from a previous pregnancy; (5)
age under 18 or over 30 years and primiparous;
(6) age over 35 years during the pregnancy; (7)
past history of abortion, stillbirth, or loss of
child within one month of birth; and (8) carry
ing her fifth (or later) child. All such pregnant
mothers should be shown to the nurse or medical
officer for remedial action and follow-up.
The urine of pregnant women with swollen
leg is examined for albumin, either by the health
workers or by her nurse supervisor. The latter
palpates the abdomen, estimates the haemoglo
bin, and sees that tetanus toxoid is given. The
1 OBSERVATIONS IN PREGNANCY PERIOD
KA1A MOOEL INTEGRATED
MOTHER-CHILD HEALTH NUTRITION
(MCHN) PROJECT
Cmv. Kim. TMuM Mam. Dat. THANA
Fig. j.
28
The two sides of the Mother's Card, used in the project in India.
HEALTH FOR THE MILLIONS/AUGUST 1982
blood presssure is checked by a nurse or medical
officer. All these are recorded on the card and
its duplicate.
These cards have been used in India since
1976 and were introduced into Somalia early in
1980. In the Kasa Model Integrated MotherChild Health and Nutrition Project in Maha
rashtra, India, 27 part-time social workers with
limited education (4-10 years of schooling) were
able—after training—to fill in over five thousand
cards every month relating to about 88% of the
eligible women in sixty villages covered by the
project. The average age of these workers was
22.3 years and a little over half of them were
males. Information on menstrual history was
for further reading
Catalogue of Agencies reaching poorest women in
India : Institute of Social Studies, M-l, Kanchenjunga, 18 Barakhamba Road, New Delhi. Lists the
agencies, with addresses, and assesses the work
done.
ISIS International Bulletin : ISIS, Case Postale
301, CH-1227 Carouge/Geneva. Subscription : US
Dollars 20 air mail, Individual copies; US Dollars
1.5 per copy.
Management of Obstetric Emergencies in a
Health Centre
by B. Essex : A WHO Publicacation. Available from World Health Organisa
tion, Indraprastha Estate, Ring Road, New Delhi.
This book is .meant to be used by nurses who
have to handle obstetric emergencies in a health
centre. Practical midwifery training and a know
ledge of basic theory is a pre-requisite for using
this book. Flow charts provide clear guidelines
for selecting the best course of action in each
situation. A valuable practical guide for all in a
rural health centre.
Manushi:
110 024.
C-l/202, Lajpat Nagar, New Delhi
This is a bimonthly produced both in Hindi and
English by a feminist collective in Delhi. It takes
a refreshing new look at women’s problems and
provides a medium for women to speak out.
HEALTH FOR THE MILLIONS/AUGUST 1982
obtained by these male workers with the help
of traditional birth attendants or their own
female relatives. On average, two pregnancies
out of every seven or eight were found to be
at risk at any given time in villages with over
l900 population. The use of these cards also
^strengthened the family planning programmes
in the area.
The cost of each card, its duplicate and the
plastic bag, which could serve for ten years or
longer, was $0.15. (about Rs. 1.50) The growth
cards of young children in the family could also
be kept in the same plastic bag.
Source : WHO (AT) Newsletter
Our Bodies, Ourselves
by Boston Women’s
Health Collective : Simon and Schuster, Simon
and Schuster Building, Rockefeller Centre, 1230
Avenue of the Americas, New York, New York
1002.
Available in India from Manushi,
Lajpat Nagar, New Delhi 110 024.
Price : 25/-
C-l/202,
This is a book by and for women. It painstak
ingly explores women’s body, sexuality, and the
feelings associated with them, through the shar
ing of intimate experiences. A must for every
woman.
Witches, Midwives and Nurses by Barbara
Ehrenrcich and Dcirdre English (1973). The Fe
minist Press, SUNY/College al Old Westbury, Box
334, Old Westbury. N.Y. 115686.
This booklet is a history of women healers. It
has aroused tremendous response from a wide
spectrum of the reading public. The interest gene
rated by this booklet inspired the authors to work
on 'For Her Own Good’ (The book reviewed in
.this issue of Health for the Millions).
Standards and Policy Statements of General
Interest to Women Workers: ILO, Geneva, Avail
able from ILO, Delhi.
International Women and Health Resource
Guide: Joint Project of ISIS and Boston Women’s
29
Health Book Collective. Available from ISIS or
Boston Women’s Health Book Collective.
Nurse: The woman in the medical system—
MFC Bulletin 71-72 by Dr. Rani Bang.
Contains useful information on resources
women and health all over the world.
The author has put together a number of rele
vant statistics related to the nursing profession.
The article explores the economic and social sta
tus of the nurscs and their sexual exploitation by
the medical profession. The future potential of
the nurscs in health care and in social change is
discussed in detail.
for
Slree Arogya (Marathi): Published by Lok
Vidhyan Sanghatana, 125, 9/2 JangaJi Maharaj
Road, Pune 410 004. Price: Rs. 3/-
A good book on women’s health.
Women and Health Care : A comparison of
Theories by Elizabeth Fee, in International Jour
nal of Health Services, Vol. 5, No. 3, 1975. (This
journal should be available in any medical library).
This article analyses the perspectives and the
alternatives suggested to the present health care
system, by feminist groups who are liberal, radi
cal and socialist.
Profiles of Poverty by Leela Gulati. Hindustan
Publishing Corporation, Delhi. Price: Rs. 55/-.
A study of five poor working women in Kerala.
It questions the middle class notion that going
out of the house to work always improves a wo
man’s status. A realistic appraisal.
The Maternity Benefits Act, 1961. (With state
amendments and short notes): Law Publishers
and Booksellers, 34, Lalbagh, Lucknow 226001.
Rs. 1.50 (1977).
The Medical Termination of Pregnancy
1971. Government of India (1978) Re. 0.55.
Act
Rape—Proposed Changes in the Law: Lawyers’
Collective, 8th Floor, Stock Exchange Towers,
Bombay 400 023.
This booklet examines the proposed changes in
the law regarding rape. The problem of rape con
cerns every woman, so we should all be aware of
the issues involved.
Who is Malnourished—Mother or the Woman?
by Kamala Jaya Rao, MFC Bulletin No. 50, Feb
ruary 1980.
In this article the author argues that the nutri
tional problems of women are an offshoot of the
inferior status and expendable nature of the
female in society. Mere welfare programmes are
not sufficient to tackle the root cause. The argu
ment is well substantiated with facts and figures.
30
Status of Women in India: 1CSSR, New Delhi.
A report by the committee on the status of
women. It is a comprehensive, well-documented
work.
Women and Health Bookshelf by Jane B. Spra
gue (PhD), American Journal of Public Health
1975 Vol. 65.
The books, articles and other resources listed
here represent an extensive view of the topical
boundaries of women and health. Most of the
listings deal with women and health in the United
Stales.
resource centres
1. Asian Women’s Institute: C/o Lucknow Pub
lishing House, 37, Cantonment Road, Luck
now.
2. ISIS, Case Poslale 301, 1227, Carouge, Swit
zerland.
3. Women’s International Network: 187, Grant
Street Lexington, MA 02173, USA.
4. BWHBC, Box 192, West Somerville MA 02144,
USA.
5. Women’s Occupational Health Resource Cen
tre, American Health Foundation, 320, East
43rd Street, New York, NY 10017.
6. ASTHA, C/o Anjali Monteiro, Xavier Institute
of Communications, Mahapalika Marg, Bom
bay 400 001.
7. Centre for Women’s Development Studies:
B-43, Panchsheel Enclave, New Delhi 110 017.
8. 'Saheli’, 10, Nizamuddin East, New Delhi
(Documentation).
9. Jigyasa, 5, Deen Dayal Upadhyaya Marg, New
Delhi 110 002. Reading cum Documentaton
10.
Centre.
Manushi, C-l/202, Lajpat Nagar, New Delhi
110 024.
HEALTH FOR THE MILLIONS/AUGUST 1982
BOOK REVIEW
for her good ?
FOR HER OWN GOOD: 150 Years of the Experts’
Advice to Women, by Barbara Ehenreich and
Deirdre English. Published by PLUTO PRESS,
Pages 325,
Price: Paperback £ 3.60
Hardcover £ 8.50
The authors tell us that the idea of this book
began with a course on 'Women and Health’ that
they were teaching in a college: "Preparation
^pfor the course led us along a surprising trail...
' We had the feeling that we were uncovering a
long suppressed story, one which had the power
to explain many things about our own present
day experience as women.” The result of their
explorations is For Her Own Good. It is a book
that illumines in lightning flashes the dark
landscape of pre-modern medicine, and shows its
continuities with modern medicine. It places in
historical context so much of our own experience
and thus makes it comprehensible. And b^st of
all, the narrative is all along lucid and extremely
readable.
We begin with a glimpse of the pre-industrial
economy, which was centred on the home. The
woman’s
contribution was
essential
here.
Clothes, soap, buttons, bread—all were made at
home, by a woman whose skills gave her dignity.
gfr Healing too was part of a woman’s arts, and she
drew upon empirical knowledge that had accu
mulated over generations. Healing was a natural
part of being a woman and a mother-tenderness
and nurturance was inseparable from the skill.
She also knew well the curative powers of
various herbs, and if one was exceptionally
skilled in this she became known in the com
munity as a "wise woman”.
How then did women lose their healing func
tion and even the knowledge of their own bodies
to the medical profession? For Her Own Good
documents this process against the background
of the great upheaval of the Industrial Revolu
tion. We will see that women could be deprived
HEALTH FOR THE MILLIONS/AUGUST 1982
The Feminist Press
of their healing function only as part of a gene
ral process of losing their place in society.
The Industrial Revolution was itself a cor
relate of the coming of the market. Economic
activity had earlier been carried on to satisfy
human needs. But now protit became the main
aim. Production came to be caried on a large
scale, in factories outside the home, with equip
ment only the rich factory owner could afford.
The home was stripped of its economic functions.
Men went out of it to work. The women who
stayed behind became something of an anomaly.
31
Thus arose the Woman Question: What should
woman do? Should she follow her traditional
skills into the factory that had usurped them?
In that case, should there be an abolition of the
family, with the community taking over the care
of children? But this was horrifying to those
who contemplated the Woman Question. As men
became part of a calculating profit-oriented
world, women remained as the keepers of the
humaneness of. humanity. They were all that
the Market forbade men to be - loving, "giving,
nurturing. Men were loth to lose the refuge
of warmth that their homes, presided t over by
women, provided them.
The male answer to the Woman Question was
that women should stay at home. And the justi
fication was supplied by medical science on the
basis of female biology. Being a woman was
seen from the male view point, as a pathological
condition, as proved by the recurring crisis (!)
of menstruation. Taking care of her health was
a full-time task for a woman (upper class: some
how the low classes did not come into these
considerations). Furthermore, a woman’s body
was seen as a battleground between uterus and
brain. These two organs competed for the limi
ted quantity of energy available in the body. If
a woman therefore cultivated her mental facul
ties it could only be at the expense of the repro
ductive. Brain work was therefore selfish and
morally wrong for a woman. Her duty to pos
terity, as laid down by science, was to stay at
home and give her all to the uterus.
■ Medicine began to form as a profession in
medieval Europe and its male practitioners had
prestige by the fact of being male in a patriar
chal society. The church cast its weight behind
them, and the witch-hunts of the fifteenth and
sixteenth centuries, in which thousands of women
lost their lives, included female healers among
their quarry. For those who think of the use of
the medical profession as a triumph of science
over superstition and "old wives tales” the
authors of For Her Own Good give examples of the
state of knowledge of the two groups involved.
The knowledge of the "witches” was empirical,
the wisdom garnered from centuries of healing.
Belladona, used even today as an anti-spasmodic,
was commonly used by the female healers td
inhibit uterine contractions when miscarriage
32
threatened. Digitalis still an important drug in
the treatment of heart ailments, is said to have
been discovered by an English witch. The SwissGerman alchemist Paracelsus, who is today
hailed as the father of modem medicine, con
fessed that he "had learned from the Sorceress
all he knew.”
But how has the medical profession usurped
the function of healing and come now to make
pronouncements on the very women it disposessed?
On the other hand, the medical profession
based its practice on theories about "humours”
and "complexions”. It was the study of theology
and Latin and Greek texts that was considered
essential for a doctor, he did not come into con
tact with the human body at all. Having no
empirical knowledge, the doctors knew nothing
of anatomy or physiology. In illustration of the
absurdities of male medical practice at a time
when female healers were being hounded as
witches, the authors tell us that "the Physician
of Edward II, who held a bachelor’s degree in
theology and a doctorate in medicine from Ox
ford, prescribed for toothache writing on the
jaws of the patient 'In the name of the Father,
the Son, and the Holy Ghost, Amen or touching
a needle to a caterpillar and then to the tooth.’
absurd 'experts’
Witch-hunts were a drastic way of eliminat
ing competition. But the process continued, in
less dramatic ways, down the centuries. The crux
of the matter was that healing had become a way
for some people to make money, and they wanted
to have exclusive control over this function. The
profession consolidated itself with the support
of the authorities behind it. Laws were passed
restricting medical practice to those who were
"trained”. This at a time when the usual medical
procedures were bloodletting, purges, and arse
nic tonic!
Healing now having become a commodity to
be paid for, it had to be visible and measurable.
To this end doctors vied with the disease to pro
duce outrageous symptoms to show that they
were doing something. This was called "heroic”
medicine. The authors say, with the delightful
HEALTH FOR THE MILLIONS/AUGUST 1982
turn of phrase that is characteristic of their style;
The story related in For Her Own Good is thus
of relevance to us all, whether as women, or as
■"Unfortunately for the health of the young re
public, the heroic approach contained an inherent consumers and practitioners in a health care sys
drift towards homicide. Since the point was to tem. We have imported this system in its totality
prove that the treatment was more powerful than from the West, as part of an economic structure
the disease, it followed that the more dangerous geared towards profit making. It is only in this
a drug or procedure, the more powerful it was kind of structure that caring could become a
presumed by most doctors to be. For example, commodity, and human values be relegated to
blisters (induced by mustard plaster, etc) were second place along with the women who are their
a common treatment for many diseases. In an keepers.
1847 paper a physician observed that etxensive
blistering frequently had a disastrous effect on who’s own good?
children, sometimes causing convulsions, gang
We need, then to take a good hard look at the
rene, or even death. He concluded from this that medical system that we have adopted and so far
blisters ought to hold a high rank in the treat accepted without questioning its basic premises.
ment of disease of childhood!”
Can healing really be done by a stranger, for
This was the kind of "expertise” that elimina payment? Can such a stranger even diagnose the
ted the lay healer. Women’s net works of infor cause of the illness? Should we dismiss all home
mation sharing gradually ceased to function. This cures as 'old wives’ tales’? These are some of
was partly because they were discredited in so the questions we need to ask ourselves.
ciety, and partly because the new industrial so
ciety isolated each woman in her home and des
troyed the concept of community. For, families
were constantly on the move from one neigh
bourhood to a better one, from one town to an
other in pursuit of more money, better jobs. This
transience made any net work of neighbourhood
women impossible.
halo and dazzle
In the meantime the practice of medicine was
becoming more scientific, in a modern sense.
There was an insistence on laboratories and
costly equipment, to impress the science-dazzled
layman and preserve the halo of the medical
profession. This also made medical education ex
pensive, and thus possible only for a few. The
medical schools of rebel sects like the 'Popular
Health’ and 'Hygiene’ movements were forced to
close down for lack of funding. Medicine became
what it is today, an elite preserve. But even in
its "scientific” form, modern medicine retains the
old bias against women and the old fondness for
prescribing desirable social roles for them. A
successful career woman is looked upon with
suspicion by the gynaecologist as one who is "re
jecting her feminity”. If she happens to have
any ailment of the reproductive system, scarcely
an attempt is made to look for an organic cause.
Speculation about the workings of her psyche are
deemed to be sufficient diagnosis.
HEALTH FOR THE MILLIONS/AUGUST 1982
In India the situation may be a little different
from that described in the book, which docu
ments the Western experience. We had in India
two highly developed and systematised systems
of medicine—Ayurvedic and Unani—before we
adopted the Western "scientific” system. The
nature of the home cures practised by house
wives suggests that they were based on either of
these systems and that only serious cases were
taken up by the 'vaid’ or ’hakim’. The coming of
Western medicine cast the indigenous systems
into shade. The main conflict here was between
traditional and modern rather than between male
and female. The female healer had already been
vanquished on other battle fields. The resultant
systems had only to be transported over.
Today the practitioners of the indigenous sys
tems of medicine too have gone commercial. It
would be interesting now to study their attitude
towards 'home cures’ and informal information
sharing in this light. It seems likely that their
commercial nature would move then to conform
increasingly to the elitist paradigm of modern
medicine.
The extent to which modern medicine has in
fact replaced the traditional systems is not
known. The process has been poorly documented.
Studies on the nature of the indigenous systems
of medicine and the extent of their influence
would be enlightening.
33
NEWS
‘the great health robbery’
Dr Harbans Dhillon has been unanimously
chosen the President of the Executive Board of
Voluntary Health Association of India at the
three day VHAI Board and General Body Meet
ing which concluded in Ahmedabad on April 29.
She succeeds Dr Rajnikant Arole who con
tinues to be a member of the Board.
Other office bearers are:
Secretary
: Dr Daleep S Mukarji
(Tamil Nadu)
Vice President : Mr G D Kunders (Karnataka)
Joint Secretary : Mr Tom Kalliath (Bihar)
Treasurer
: Mr A T D’Souza (Delhi)
Members of the Board besides Dr Arole (Maharashtra) are
Miss Pauline Brown
(Madhya Pradesh)
Dr J S Mahashabde
(Madhya Pradesh)
Sister Eymard
(Kerala)
Dr Ashwin Patel
(Gujarat)
Mr D. Rayanna
(Andhra Pradesh)
The theme of the convention, "The Great
Health Robbery” called attention to commercial
exploitation of five identified vulnerable groups:
Infants from whose mouths mother’s love and
milk are being snatched away by ruthless infant
formula companies, and feeding bottle manufac
turers.
Consumers who are persuaded to take drugs
they do not need, and in greater quantities than
needed.
People to whom essential medicines such as for
malaria, leprosy, polio, tuberculosis are not avail
able due to less profit in these.
Women, who as a group have been neglected
and exploited.
Workers, especially with regard to dangerous
occupational hazards.
The theme was highlighted by a poster exhibi
tion. Averthanus D’Souza, Executive Director of
34
the Voluntary Health Association of India, in a
statement characterized the deliberate promo
tion of harmful drugs as a gross violation of
human rights. He called upon people to inform
themselves about the indiscriminate use of drugs.
He alleged that drug companies used their eco
nomic strength to subvert national interests and
corrupt medical practitioners. He called on ah
alert people to give force and focus their efforts
to prevent the Great Health Robbery. There were
also presentations by special invitees to the con
vention.
Ms Ela Bhatt of the Self Employed Women’s
Association (SEWA) described how the unorgani
zed section of women workers, small traders,
those engaged in low skill services, street side
vendors and hand craft producers, have come
together. Many of these need a small capital. To
save them from exploiting money lenders, the
Association has started a women’s bank. This is
a unique institution. All the depositors and bor
rowers are women, and all the employees in the
bank are women. There has been a struggle
through the Association for the women to get the
stipulated minimum wage.
Ms Amina Amin of the Ahmedabad Women’s
Action Group (AWAG) in her paper gave nume
rous examples of exaggerated claims in adver
tising that' result in health robbery of women
and children.
HEALTH FOR THE MILLIONS/AUGUST 1982
Mr. N. D. Zaveri spoke of low wages and
health hazards suffered by tobacco workers, es
pecially women who roll bidis.
village law service
Father Mathew Kalathil spoke on a village law
service, with which he is connected, and which
has its headquarters at the Rajpipla Social Ser
vice Society, in Bharuch District. The law group
is primarily concerned with cases of exploita
tion. especially of land aggression. As a part of
the service, selected young men from the villages
are trained to do simple things like searching
for all the facts, making petitions, being liaison
between the Society and the village people. The
society has a senior advocate to present their
cases in court, and to pursue them as far as
necessary, even all the way to the Supreme
Court.
consumer education research
Ms Rani Advani represented the Consumer Edu
cation Research Centre. They expose false and
misleading advertising, adulteration and sub
standard quality articles on the market. If ne
cessary, they make a lawsuit against the mala
fide perpetrators of such social injustices.
Dr. Ashwin Patel spoke on drug excesses,
the excesses in pricing and in prescribing an
undue amount of drugs. Dr S. Joseph’s paper
humorously referred to the unholy marriage
between the drug industry and the medical pro
fession.
discussion group
In the evening, five groups were formed for
discussions and their reports were given next
morning.
visit to national dairy board
On April 29, thirty participants went on a tour
to Anand. They first visited the National Dairy
Board. The nearby factory of the Amul Dairy
was visited next. Railway tracks come right into
the factory compound. Huge goods train tank
wagons carry surplus Amul milk to Bombay,
Calcutta and to Delhi.
HEALTH FOR THE MILLIONS/AUGUST 1982
The factory is spotlessly clean and sanitary.
More than 3000 people work in it. Those who
are close to the milk in any form wear white
clothing, including a white cap to cover their
hair. The products in addition to milk are cheese,
powder milk, condensed milk and chocolate bars.
AMUL is Anand Milk Union Limited. It is a
central co-operative, federating some 800 village
milk co-operatives situated throughout Kaira
District.
chichodra eye hospital
Lunch was served at Chichodra hospital,
with Dr R .R. Doshi, the President of GVHA
as host. Dr. Doshi has been a founder member
of Gujarat VHA, and has been a VHAI Board
member for several years. In addition to the eye
hospital near Anand, he organizes village eye
surgery camps all over Gujarat. He has some
.twenty camps a year. Famous surgeons volunteer
the time for a camp once a year.
tribhuvandas foundation
The last visit was to headquarters of the Kaira
District Mothers and Infants Health programme.
There were reasons to be happy to see this grow
ing health service beginning to serve the whole
area of the Amul Dairy. A few years ago, Sister
Anne Cummins, with Fr. Tong, had a formal
meeting with the managers of Amul Dairy. It
was recommended that they start a health ser
vice for their people, similar to the one they had
for their buffaloes. It was discovered that all
the buffaloes in the whole district had a balanced
diet, were immunized against communicable
diseases, and had a battery of 42 veterinary doc
tors for promotive and curative health among
the cattle. There was no similar service for the
people.
The Tribhuvandas Foundation was set up to
start a low-cost promotive and maintenance
health service, especially for women and child
ren. There is a mobile nurse team, supported by
doctors for visiting the villages. They are train
ing in each participating village, a Village Health
Worker and a Village Infant Worker. People’s
participation is insisted on. There is also a young
farmers’ centre for providing scientific training
to young farmers.
—Purabi
35
chai and community health
Community health services in the rural areas
of India have been stepped up by the Catholic
Hospital Association of India. A Central Com
munity Health team working from their Delhi
office, supervises the work Fr. John Vattamattom,executive director of CHAI, was speaking to
Purabi Pandey of VHAI.
)
In the large regions, there is a regional team.
This team conducts fortnightly orientation cour
ses for regional animators with experience in
nursing or social work. This is followed by an
other fortnight’s field training and a recall alter
6 months for follow up. Topics covered include:
integrated approach in community development,
community health and social change, role of wo
men in community development, health educa
tion, control of communicable diseases, responsi
ble parenthood, drug policy and indigenous me
dicine, health survey, mother and child health,
nutrition, school health, people’s participation in
community development.
The central health team at present coordinates
seven such units. Fr. John Vattamattom, head of
the team, plans to add 5 more regional units to
cover a total of 109 dioceses. Presently 30 dioceses
have some trained community health personnel.
Explaining the movement,
Fr.
Vattamattom
says each diocese takes up a model village. A
committee appointed by the Bishop under a dio
cese coordinator executes the plans. The ideal is
to have one village health worker for 500 persons
and receive support from the community. How
ever, in some areas they are paid. The co-ordi
nators are not necessarily religious sisters. Per
sons outside church affiliations are also appoint
ed.
On a question as to whether there would be
overlapping in projects of VHAs and CHA re
gional units, Fr. Vattamattom said great care
would be taken to avoid taking up working in
the areas where VHAs were active.
The general coordinator is Sr. Marina with a
background of nursing and community health.
She is assisted by Miss P.C. Rita, who is a gene
ral nurse and has a diploma in community health
and development.
Fr. Vattamattom who has been travelling ex
tensively expressed satisfaction at the enthusiasm
for their latest thrust in community health ser
vices. With this expansion he saw the need for
VHAI developing manuals and teaching aids to
cope up with the increasing demands in the
future.
Mother’s Instinct
Elizabeth Cady Stanton tells in her autobio
graphy, for example, how an early encounter
with male medicine reinforced her feminist con
sciousness. Her four-day-old infant (one of seven
children) was found to have a bent collarborne.
The phsician, wishing to get a pressure on the shoul
der, braced the bandage round the wrist, “leave that,”
he said, “ten days, and then it will be all right.” Soon
after he left I noticed that the child’s hand was blue,
showing that the circulation was impeded.
Stanton removed the bandage and tried a
second doctor, who bandaged the infant in a
slightly different way. Soon after he left, she
noticed that the baby’s fingers had turned purple,
so she tore off his bandages and sat down to devise
36
her own method of bandaging the bent collar
bone.
At the end of ten days the two sons of Aesculapius
appeared and made the examination, and said all was
right, whereupon I told them how badly their bandages
worked, and what I had done myself. They smiled at
each other, and one said, “Well, after all, a mother’s
instinct is better than a man’s reason.” “Thank you
gentlemen, there was no instinct about it. I did some
hard thinking before I saw how I could get pressure on
the shoulder without impeding the circulation as you
did.” ... I trusted neither men nor books absolutely
after this, either in regard to the heavens above or the
earth beneath, but continued to use my “mother’s in
stinct”, if “reason” is too dignified a term to apply to
a woman’s thought...
—For Her Own Good
HEALTH FOR THE MILLIONS/AUGUST 1982
NOW IN HINDI
Dear Friend,
It will please you to know that the HINDI version of WHERE
THERE IS NO DOCTOR is due for release shortly. It will be a complete
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Sincerely,
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July 1, 1982
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official seal
“thus god judged the women”
Once upon a time very long ago, God needed some one to help him
with something he wanted to have done. He turned to the women, who
already had their hands full even-.jin those days. Just then they were
sitting making milk jugs and water basins and mats to cover the huts.
God summoned them, "Come here! I shall send you to an important
mission.” The women replied, "Yes:<we are coming, but wait a moment,
we shall just finish our work hereT After a while, God summoned them
again. "Wait a moment, we are nearly done. Let us just finish our mats
and jugs,” said the women.
The men did not have to milk, build houses, fetch wood and water as
the women did; their only duty was to put up a fence and protect the
livestock So since at the moment they had nothing else to do, they came
running at God’s call and they said, "Send us instead, Father”. Then God
turned to the women and said, "Hereafter, women, your chores will
never be done. When one is completed then next will be waiting for you.
Hence, the men may rest since they came at once when I called but you
women will have to work and toil with neither pause nor rest till the
day you die”.
And so it has been ever since.
(Garri folk tale. North Kenya'}
For Private Circulation
Vol. VIII
No.
5
A
Bimonthly
of
the
The richness of years
Voluntary
Health
of
India
OCTOBER 1982
of experience, love and pain
are locked inside every old person.
And as more people survive to old age,
so the world grows richer.
To touch the old,
Association
COMMUNITY HEALTH CELL
326, V Main, I Block
Koramongala
/
Bangalore-560034
India
HEALTH FOR THE MILLIONS
I
----------------------------------------------------- —
Vol. VIII
No. 5
October 1982
___
CONTENTS
1
Five myths on aging
3
Some health problems
7
Ten nursing ideals
9
Ten policy guidelines
10
One and the many
12
One among the many
14
An anti-malarial drug
15
Ban on 18 harmful drugs
16
Sixteen Bangladesh Criteria
18
Bice water for diarrhoea
19
Industrial disputes act
21
Eight ways to live longer
Of Good Vintage
The UN Assembly which held its session in July 1982
at Vienna, has drawn the attention of everyone to the prob
lem of aging and has appealed for a worldwide efforts to
improve the lots of the aged.
Mr William Kerrigan, the Secretary General of the
Assembly on aging, characterised the aging of nations as a
triumph and a sign that hunger and disease are in retreat.
But we must ensure that the triumph of humanity is not a
tragedy for the aged.
The first article in this issue discusses the five myths
about old age. Then we have a look at the health problems
of the aged, seeking solutions for each one of them. An
other article seis out ten basic principles as a proposed
framework for formulating policies and programme on
aging.
One of the common needs of people in old age is
CARE. Nursing is the most caring profession of the world.
Editor : S. Srinivasan
Muriel Skeet outlines the ten key principles of nursing the
Executive Editor : Augustine J.
aged. Prevention is better than cure. We haven't forgotten
Veliath
that. Eight ways to live longer appears as suggestions a
friend can g?ve. Prescribe it for yourself. Prescribe it to
News & Events : Purabi Pandey
others too.
Production : P. P. Khanna
Ruth Harner of VHAI surveys the Indian scene to
Assistance : P. George and
look at the one and the many Indian approaches to the
John Agacy
care of the elderly. 'One among many' is the 85 year old
i
Mr Samarthlal J Vaidya. We reprint his confessions,
Circulation : L. K. Murthy
courtesy Helpage India.
I
1 '
'' '
— Augustine J. Veliath
Owned and
published by the
Voluntary Health Association of
India, C-14, Community Centre,
Safdarjung Development
Area,
New Delhi-110016, and printed
at Printsman, New Delhi,
PLEASE RENEW YOUR SUBSCRIPTION TO HEALTH
FOE MILLIONS. IT IS STILL Rs. 1 2- PER YEAR.
Five Myths on Aging
Many of the so-called 'ravages' of time are not inevitable. By dinging to the myths
of aging, we are cheated of the opportunity to ensure a good old age for ourselves.
Myth 1
Myth 3 .
Old Bodies are Sick Bodies
Too Old to Work
Aging is not a disease. It is a disease that disables
and not old age. While this means that the old in
poor countries are often crippled by a host of un
treated diseases, in industrialised countries only five
per cent of the old are bedridden..
Old people fall ill no more often than any other age
group. But they take twice as long to recover and
partly because of half hearted attempts at rehabilita
tion. So the old tend to get either inappropriate treat
ment or no treatment at all.
Myth 2
Wringled Face, Shrivelled Brain
If a young man forgets where he left his umbrella,
someone will help him to find it. If an old man
forgets, people tend to assume that he is going
senile.
But the evidence is that the young are just as
'senile' as the old. Experiments comparing 300 old
people—average age 12—with University students
found that on measures of senility like confusion,
forgetfulness, and self-neglect, students were more
senile than the old.
A World Health Organization study found that old
people are no more liable to mental disorder than the
young. And less than six per cent ot mental disorders
in the old, are due to brain astrophy.
Learning and memory remain unimpaired until
■ eighties. In fact the amount of information stored can
actually increase with age along with our skill at
taking in new information. Seventy year old Aus
tralians have learnt German just as fast as 15 year old
school children, while a class aged between 54 and
’ 75, learned Russian nearly twise as fast as college
students.
If you are clever now, you may be even cleverer
when you grow old.
HEALTH FOR THE MILLIONS;OCTOBER
1982
Most people can work until they die. In many
countries they have to. With experience and skill to
compensate for any decline in agility and strength,
there is nothing to stop old people in most occu
pations working as long as they choose—nothing, that
is, except compulsory retirement and discrimination in
the work place.
The International Labour Office reports that the old
can be just as productive as the young, make fewer
mistakes and stay away from work less often. If they
have more accidents—and the evidence is inconclu
sive—it is because they are working in bad conditions
with machines dangerous to people of all ages. It is
jobs that are unfit for people and not people who are
unfit for jobs.
Forced out of employment while still fit to work,
then obliged to subsist on pensions paid from the
salaries of younger workers, old people are made
dependent.
Myth 4
Sex at Sixty ? You must be Joking
It may take longer, but what's the hurry ? At least
47 per cent of couples in their eighties still enjoy
regular and frequent sex.
Old people feel love, hate, pain and desire, just as
strongly as anyone else. The difference is that they
are no longer permitted to show it.
Bereavement is the greatest trauma anyone is
likely to suffer. And the loss is sexual as well as
emotional. But aging men and women are often
frowned on when they want to marry and forgotten
to' consort' in many old-age institutions. Virility at
25 becomes lechery at 65. Yet one study that threequarters of elderly remarriages were successful. And
the bride and groom lived happily ever after.
I
t
Myth 5
George Elliot married men years younger than them
selves, they caused a public outcry.
Fun Stops at Fifty
If old people are miserable, it is because we make
them miserable. By exhorting them to 'act their age'
we force our stereotypes on them.
Such people will remain exceptions as long as the
majority of the old continue to believe that they are
unfit for work and unfit to play; that they grow more
stupid each day and that their illnesses are incurable.
Gandhiji was not 'acting his age' when at 60 he
led a 200-mile protest march against the British.
Marian Hart was not 'acting her age' when she flew
the Atlantic solo at 84. And when Edith Plaf and
If you don't like the stereotypes, if you want to
keep on living and loving till you die, then it's time to
change the myths before they take control of your
life.
Longer lives
Meanwhile improvements in
health and nutrition mean that
people are living longer.
Average life expectancy at
birth was only 47 in 1960. By
2025 life expectancy is
expected to be 70 years.
INDUSTRIALISED
COUNTRIES
Okay, Leave Me Alone
/ don't like sitting in a park
feeding pigeons,
DEVELOPS
COUWPJES
talking to burning old men
suffering and coughing,
taking predigested pap
for
lunch,
Going on alone
In the industrialised world women
in their 60s outnumber men by 10 to
7. By the time they reach their 80s
women outnumber men by
2 to 1.
being constantly told not to
smoke, not to drink; it's bad
for my health;
Okay, leave me alone.
I am the same man, only older.
2
J..
health for the millions/october
1982
Some Health Problems
Aging is not a disease. It is disease that disables and not old age. Here a medical doctor suggests appro
priate treatment for some diseases which people generally associate with old age.
Treatment
Symptoms
It can be treated by eye drops. A
very simple operation will cure the
problem.
Eye—Glaucoma
One type occurs normally in women
in the age group of 50-60 years.
There is at first
• some blurring of vision
• appearance of halos around
lights and
The eyes remain white (only one
eye is affected at a time)
• occasional headache.
This may lead to an acute conges
tive stage in which there is
• The person is prostrated.
• The pulse is irregular and
weak.
• intense pain in the eye.
The pain is also felt on the
affected eye's side of the
face.
• There is rapid decrease in
the ability to see. Within a
few hours of this attack, the
person's vision may decrease
so much that he/she may be
able to make out only hand
movements.
• there may be vomiting.
This is an acute emergency
Immediate referral to a doctor is
necessary. If not treated, eye sight
might be fully lost.
O Both eyes are affected.
O Eyes become red and con
gested; the eye-lids become
swollen.
Simple Glaucoma
In the second type of glaucoma,
both men and women are affected,
The problem occurs usually after
the age of 70 years.
There is a gradual loss of peripheral
vision (the central vision is not
affected till a long time).
This type of glaucoma is almost
symptomless and is often not
noticed till eye sight is practically
lost.
Therefore all persons above the age
of 50 years should have a regular
eye check up by a doctor and spe
cially when a change of glasses is
required.
The person usually does not notice
any problems with the eyes. There
is :
• mild headache
• eye ache
HEALTH FOR THE MILLIONS/OCTOBER
1982
3
Symptoms
Signs
Treatment
• loss of
near vision (is
unable to read and do close
work. Noticed by the need
to continuously change the
power of reading glasses).
This type of glaucoma may also
lead suddenly to the acute conges
tive stage of glaucoma.
TEST FOR GLAUCOMA
Have the person cover one
eye, and with the other look at
an object straight ahead of him.
Note when he can first see
moving fingers coming from
behind on each side of the head.
Normally fingers are first seen
In glaucoma, finger
movement is first seen more
toward the front.
Cataract
Cataract in old people is due to
degeneration of the lens fibres lea
ding to opacity of the lens. Dia
betics are more affected.
The lens look opeque (whitish).
When the cataract is immature, the
iris throws a shadow on the lens
when light is thrown in the eye;
when the cataract is mature, there
is no shadow.
No medicine can cure this condition.
If a person has diabetes, it must
be treated. When the cataract be
comes mature, it can be removed
by a simple operation.
• It is found in persons above
the age of 50 years (almost
universal in persons above
70 years), it is common in
both men and women. Both
eyes are affected but often
develops earlier in one eye
then the other. There is a
gradual loss of eye sight.
Heart trouble
More common in older people
especially those who are fat, smoke
or have high blood pressure.
• there is anxiety and difficulty
in breathing after exercise.
• It starts with breathlessness
on walking, climbing stairs. It
slowly progresses to a stage
where the person has breath4
• Different heart diseases may
require different
specific
medicines which must be
used with great care. If you
think a person has heart
trouble, seek medical help.
It is important that he has
the right medicine when he
needs it.
• People with heart trouble
should not work so hard that
HEALTH FOR THE MILLIONS/oCTOBER
1982
Symptoms
Signs
lessness when he/she lies
down. (This is characterised
by asthma-Hke attacks.)
• The person suddenly wakes
up in the middle of the night
gasping for breath.
© Swelling of the feet becomes
worse in the afternoons.
© Pain in the chest on exertion
is felt, it is relieved by resting.
This pain may radiate to the
eyes, shoulder, arm etc.
® In the acute stage, (heart
attack) the person has severe
pain in the chest (a heavy
weight crushing the chest).
Pain is not relieved by restaccompanied by a profuse
sweating. There is a sense
of impending death.
they get chest pain or have
trouble in breathing. However,
regular exercise helps to pre
vent a heart attack.
© Persons with heart problems
should not eat greasy food
and should lose weight if
they are overweight.
0 If an older person begins
having attacks of difficult
breathing or swelling on the
feet, he should not use salt
or eat food that contains
salt. For the rest of his life, he
should eat little or no salt.
© If a person has angina—
pectoris or a heart attack, he
should rest very quietly in a
cool place until the pain
goes away.
Stroke
(Cerebre Vascular accident) It com
monly results from a blood dot or
bleeding inside the brain.
O In case of blood clot, the
symptoms are comparatively
gradual. The person is often
dazed. There may be recur
rent attacks of weakness of
the limbs, may also be
paralysis. There may be
dizziness, sudden loss of con
sciousness and double vision.
In case of bleeding inside the brain,
the symptoms are often sudden.
There may be headache, vomiting,
loss of consciousness, weakness
and paralysis of limbs. The person
and might have a past history of
high blood pleasure.
O If the stroke is due to high
blood pressure, it is impor
tant to reduce further bleed
ing in the brain by reducing
the blood pressure. If the
person is unconscious, he
needs special care.
© maintain a clear air way
for breath.
O Protect the skin.
0 Maintain
urination
and
excretion.
O Do not give him anything by
mouth.
O When he/she recovers con
sciousness, give regular ex
ercise for limbs and special
exercises for skill move
ments.
Enlarged prostate gland
0 If the person cannot urinate.
he should sit in a tub of
warm water. If he still does
not pass urine, then a
catheter might be needed to
remove the urine.
This is common in older men. It is
caused by a swelling in the prostate
gland which obstructs the passage
of urine.
The person has difficulty in passing
urine. The urine comes in drops
and may even completely stop.
Sometimes the man is not able to
pass urine. The person passes
urine more often especially at night
(4-5 times at night). He may have
pain in the lower abdomen. The
man may also develop fever, puffi
ness of face.
HEALTH FOR THE MILLIONS/oCTOBER
Treatment
O Serious and long standing
cases need an operation.
1982
5
Symptoms
Signs
Cirrhosis
Treatment
At the first sign of cirrhosis, do the
following:
Weakness, loss of appetite, upset
stomach, and pain on the person's
right side near his liver.
• Never drink alcohol again.
• Eat as well as possible foods
high in protein and vitamins.
Sharp pain in the stomach at the
edge of the right rib cage. This
pain sometimes reaches upto the
right side of the upper back.
• Do not use any salt in food.
Insomnia
• Get plenty of exercise during
the day.
• • Do not drink coffee or black
tea, especially in the afternoon
or evening.
• Drink a glass of warm milk
or milk with honey before going
to bed.
• Take a warm bath before going
to bed.
• If you still cannot sleep, try
taking an antihistamine like
promethazine (Phenergan) or
dimenhydrinate
(Dramamine)
half an hour before going to
bed. These are less habit-form
ing than stronger drugs.
Gallbladder disease
The pain may come an hour or
more after eating rich or fatty
foods. Severe pain may causevomiting. The pain comes in
waves.
Sometimes there is fever.
If the person has a fever, she
should take tetracycline or ampi
cillin.
Do not eat greasy food. Over
weight (fat) people should eat
small meals and lose weight.
Take belladonna or another anti
spasmodic to calm the pain.
Strong pain killers are often needed.
(Aspirin will probably not help).
In severe or chronic cases, seek
medical help. Surgery is needed
only if a person had 2 or 3 such
attacks.
This article has been adopted by Dr. C. Sathymala from the Indian version of where there is No
Doctor. Reprints of the Chapter on Health and Sickness of Old People are available from VHAI.
Where there is No Doctor is also available in English, Hindi, Telugu and Bengali (Vo! 1.) from VHAI.
HEALTH FOR THE MILLIONS/OCTOBER
1982
Ten Nursing Ideals
1. Care is the Key Word
One of the most common needs of people in old
age is care. Not just being 'taken care of', but it is
being 'cared for' and being 'cared about'. It is the care
which provides comfort and support in times of anxi
ety, lonliness and helplessness. This includes listing
and then intervening appropriately and effectively.
This care is the primary component of nursing in
every country of the world.
2. Continuous and Sensitive Watching
Identified at an early stage, many potential health
and social problems of old age can be controlled or
avoided. This implies continuous surveillance of the
elderly at the primary health care level but with sensi
tive awareness of every person's right to privacy.
5. Mobilize Local Resources
3. Right to Independence
Nursing care includes teaching the elderly person
and his family how to maintain independence. Elderly
people, like everyone else, have the right to take
risks, but they also have the right, like everyone else,
to a health service which supports their efforts to main
tain health. Help may take many forms from advising
on food and medicines to dental care, or supplying a
piece of equipment or devising strategies that can
reduce feelings of worthlessness at crisis such as
retirement or bereavement.
Self-care should not be elevated to the level of
an ideology, nor should it be seen as an alternative
to, or a substitute for, informed care provided by an
other. Often, in the lives of aged people, there is a thin
borderline between self-care and self-neglect. This
line must be watched for and recognized promptly if
the quality of an old person's life is to be maintained.
4. Realistic Involvement of the Family
To be realistic about the amount of time and sup
port families can give to their elderly members,
even in developing countries, where extended families
still exist, it should be noted that all are not able to
provide the necessary care and company. And family
health for the millions/october
patterns are changing. In many parts of the world, there
is a decided shift of younger generations away from
villages to urban areas. Women, the traditional provi
ders of care, are assuming new responsibilities outside
the family, while aging of whole populations means
that inevitably, children of the very old are themselves
likely to be elderly. Nevertheless, evidence from all over
the world demonstrates that the most prompt and
continuous support of old people comes from their rela
tives. A major objective of the formal nursing services
should be to support, and not supplant this conti
nuing care. Family members should know that they
may expect to receive immediate help, relief and
advice when and wherever they need it. Nursing
personnel can help the public to understand the
phychological processes of aging so that they are
accepted as a normal part of the life-cycle.
1982
Because their contact with the community is
usually extensive and intimate, nursing personnel have
its confidence and are in a strategic position to mobi
lize local resources, to encourage development of
appropriate aids and to put scientific information into
simple, everyday language which will be easily under
stood, accepted and acted upon.
6. Refer When needed
A new network of nursing personnel working at
the primary health level can perceive, recognize and
act when an elderly person shows the first sign of
impairment or difficulty. Appropriate nursing interven
tion may be all that is required, but if assessment
reveals the need for referral, immediate sign-posting”
to the appropriate health service, or organization may
prevent disability or dysfunction. Where nurses have
knowledge and experience of both hospital and com
munity settings, and enjoy good working relationships
with members of related disciplines and professions,
they are able to synthesize the needs of old people
and synchronize health and social services to ensure a
continum of care. In some of the more industrialized
countries, this may include day hospitals, mutual help
groups, hot meals and club or transport facilities pro
vided by either formal agencies or volunteers.
7
7, Special Care for Special people
10. The Parting Gift
If an old person does develop a chronic physical
or mental condition, nursing can help the patient and
his or her family to help themselves for the rest of
elderly individual's life. The basic life pattern will
remain, but the nurse will guide and support to a way
of life which accommodates illness. She will place
emphasis on adequacies and abilities rather than
upon deficiencies and limitations to help the patient
remain in command of life in a new situation. The
nurse discovers the patient's interpretation of "a good
quality of life" and sets nursing goals to help
attain it.
Total nursing services are likely to be needed by
the aged person's family and friends during and after
dying. For the dying person, nursing should provide
constant human care which can make the last weeks
of life a valuable experience instead of a period of
humiliation, deprivation and suffering. While physical
symptoms of distress may be effectively alleviated by
nursing, the response to the emotional state of dying
person is more difficult. The nurse needs to be aware
of local customs and of the social and religious as
pects of dying. Nursing includes care of the dying
person's family and friends in the form of practical
services and psychological support. Especially for an
aged bereaved spouse, the nurse can provide appro
priate facilities, care and comfort during the period of
stress and grief.
8. Seek Help
Reliance upon the family must be selective and, if
the aged person is alone or removed from any living
relative or friends, the nurse should make arrange
ments for more intensive services from professional or
voluntary agencies.
9. Institutions as Last Resort
Notwithstanding, for a minority of aged people
with impairments, transfer to a hospital or another care
institution will be unavoidable. The nurse can make
sure that the elderly person and his/her family or
friends are familar with all the options. By appre
ciating the effect of institutionalization upon aged
individuals displaced from a normal environment, the
nurse enables them to remain in control of personal
activities wherever possible. The nurse will try, by
planning with the patient, to ensure that a normal
pattern of daily living is continued.
The efficient and effective use now, by all coun
tries of the nursing networks for their aged people,
could bring far-reaching benefits. Nursing personnel
are in a strategic position to help people, from an early
stage, to avoid lifestyle practices that are likely to lead
to disease or disability in later life, and to develop
practices which can contribute to a healthy old age.
In industrialized areas, nurses should be aware of
employer's and employee's responsibilities in achieving
optimal performance at any age and also to prepare
for retirement, thereby reducing the effects of transi
tion from being ''employed" to being "retired".
Foresight in planning for future old people, and the
development of a fine sense of timing in relation to
today's old people, should be two priorities in nursing
services everywhere, if the world is to achieve lifewith-quality in old age.
Adapted from an article by Muriel Skeet
Caring for Life
Throughout the world, it is women who look after the old. In industrialized countries, wives and daughters
provide over 70% of all health care for older people.
In the united kingdom, 300,000 women remain unmarried so they can look after their parents.
8
HEALTH FOR THE MILLIONS/OCTOBER
1982
Ten Policy Guidelines
Sharing the Benefits of
Societal Development
1.
Beyond material needs, aging people requirethe same interaction,
emotional support and care as the rest of society. Therefore re
sources must be allocated preferentially to the most economically
deprived people, whatever be their age.
Individuality
2.
Like younger people, aging persons differ one from another.
Nondependence
3.
An explicit objective of health policies should be to help aging
persons maintain the maximum degree of independent life in the
face of increasing difficulty in performing daily activities.
Choice
4.
Aging people themselves usually know best what is needed and
how it should be carried out.
Home Care
5.
Care is the best for disabled persons of advanced age within
their own homes. Home care is not only the best economic alter
native, but also the provider of more emotional satisfaction. A
considerable proportion of mental disorders in old age are either
treatable, partly preventable or modifiable by means that neither
require elaborate technology nor the placement of patients in
institutions.
Accessibilty
6.
Public services should be accessible to all generations. This
applies not only to health services but also to recreational, leisure
and educational facilities.
Engaging the Aging
7.
Aging people might help young or disabled people, as in the
surrogate grandparent projects of some countries. A consequence
of housing policies aimed at re-uniting the generations would be
the creation of better balanced communities which blend different
age and social groups.
Mobility
8.
Assist aging citizens to achieve the maximum degree of mobility to
enable them to attend village markets, shopping areas, community
centres, religious services and when needed, primary health care
facilities.
Productivity
9.
Public and private employers, trade unions, educational bodies,
voluntary agencies and aging self-help groups should organize
programmes to provide stimulus, motivation and purposeful life
after retirement.
Self health and
Family Care
10.
Public authorities should recognise and support relatives who are
caring for frail aging people at home, since this often imposes
heavy, physical emotional and financial demands.
health for the millions/October.
1982
9
Ruth Harnar
One and the Many
The Indian Constitution in its Directive Principles
of State Policy includes public assistance to the aged
'to the extent resources permit'. A committee on
wages, income and prices has drawn attention to the
necessity of providing social security for the destitute
aged. The Third and Fourth Five Year Plans recom
mended that such a scheme be evolved by the
Government and the Fourth Plan even made a pro
vision for funds for this purpose. But financial cons
traints prevented it from being carried out. Others
have in recent years stressed this need but very little
has been done.
A scheme for old age pension does exist giving
the extremely inadequate assistance of Rs 20 to 60 a
month. It is to a very few destitute aged who can go
through the complicated procedures to prove eligibi
lity.
Few other recommendations for the welfare of the
aged are found among them. They are :
• provide old age pensions from State funds supple
mented by Central Government grant.
• Revise these payments depending on cost of living
index, including allowance for food, clothing, rent
and medical care.
• No queues for the elderly in outpatient department
in hospitals.
• Free and separate wards with geriaric specialists.
• Home for the destitute aged (Mother Theresa's
homes can be cited as examples).
• Day care centres for organized care and recreation.
• Free or concessional travel in public transport
systems.
• Separate compartments in suburban trains.
• Joint residences with the younger generation.
• Periodic visits to the homes of the elderly by both
voluntary and professional workers.
It has been stressed that while special homes may
be necessary for the destitute, the emphasis should
be on social and community activities and not on
10
custodial care. It is also necessary to stress on good
health and prevention in order to prevent poor health
in old age—an objective of the Primary Health Care
Approach.
Involvement of Welfare Organizations
Many groups are becoming concerned about the
situation of the elderly members in the socity. Many
welfare organizations, societies for the blind, charit
able trusts and missions are undertaking specific
projects.
Age-Care-lndia is an example of concerned
people working together to take action. This is
a group of doctors and nurses (more are being
recruited) who give their time to answer calls for
home visits to elderly who are unable to care for
themselves. Retired nurses are also being employed
to help the old persons to take care of themselves in
their homes—or to provide the help needed. Age
care plans to open a day-care centre where old
people can come for recreation, craft-work, meeting
friends, for a meal and check-up, and for other health
care needs.
Helpage India is a Registered
Charity under Societies Registra
tion Act, 1860 with its Head
office at Massey Hall, 1, Jai
Singh Road, New Delhi-110001
(Telephone No. 32 04 91).
It is a new enterprise in the
field of Age care in our country.
IIImIO
Its objective is to promote the welfare of the
aged people, irrespective of caste or creed, and in particular to raise funds in India for the support of
specific projects and schemes designed to assist the
elderly in need.
This charity is also dedicated to creating public
awareness about the problems faced by the increasing
number of elderly people in our country. Helpage
India has been promoted and floated by the British
HEALTH FOR THE MILLIONS/OCTOBER
1982
Charity "Help the Aged" and its international wing
"Helpage International",
sations to undertake more than 100 projects designed
to meet the needs of elderly all over the country.
The constitution of Helpage India recognises
people who are above 50 years as "Aged".
Future plans
Why Helpage India
The average person's life span is lengthening.
More people are living to a riper age—thanks to the
advanced medical sciences. At the same time, the
social customs, especially in the industrialised areas,
are changing. The traditional joint-family system
which was very effective in the yester years in our
country is weakening, whereby the elderly are neglec
ted, left alone to look after themselves and face a
number of physical and emotional problems.
The society, we feel very strongly, has a responsi
bility to look after these elderly who have contributed
to the society in every way and make their life com
fortable in their last days. Helpage India strongly
feels that the primary responsibility for the care of
the agedrzwst still be with the family, especially the
poorest may live a useful and dignified life receiving
proper care whenever it is needed; otherwise, we
shall be faced with a grave social problem in the
years ahead.
Several secular and religious based organizations
have for some time run 'Homes for the Aged' but
much more needs to be done. In our view, the
'Homes' are not the only solution for this problem,
but a variety of service schemes such as non-institutional care like Day Care Centres, Medical Services,
Counselling and Re-employment services, and fulfil
ment of emotional and psychological needs of the
elderly need to be organised. In order to promote and
bring in such a new element in the care of the aged,
Helpage India is trying to provide practical advices
through its projects staff and also provide funds
which are raised through the efforts of its full time
fund raising staff.
Achievements
Helpage India does not operate welfare schemes
of its own. However, it has supported various organi
HEALTH FOR THE MILLIONs/OCTOBER
1982
Helpage India would like to assist programmes
which would encourage the old people to be active
and help themselves. It is particularly anxious to enco
urage those who want to organise non-institutional
care for the elderly. Within this framework, some of the
programmes which could be taken up are: Self-Help
Projects or occupational workshop facilities. Day Care
Centre, Rural based programme to meet the specific
needs of rural aged, Domicilliary services. Counselling
Services, regular medical care including Cataract
Operation camps. Geriatric Clinics care including
Cataract Operation camps, Geriatric Clinics care and
rehabilitation of physically handicapped aged people,
aged blind, aged and infirm leprosy patients, aged
and terminal cancer patients, etc.
Finance
Helpage India raises funds from the public
through 'Sponsored Walks' in School, and donation
from individuals and groups. Donations to Helpage
India are eligible for Tax Relief under Section 8OG
of the Income Tax Act, 1 961,
Public Education
Besides educating the present younger generation
through our 'Sponsored Walks' Helpage India also
organised 4 regional Seminars on 'The Problems of
the Aged and some solutions'. Helpage India has
also supported and are willing to support any study
programme related with aged people which might
develop into a project shape later as its follow-up
measures.
International Participation
Helpage India had been invited to participate in
the Asian Regional Conference on Active Aging,
by the Opera Pia International for Active Aging, Uni
versity of Santa Thomas. It was held in January
1982 at Manila, Phillipines.
11
One Among th e Many
Samarthlal J. Vaidya—eighty-five years old himself—runs an old people's organi
zation in Ahmedabad. Here he tells his story in a nutshell.
From 1924 till 1942, I took an active part in the
Congress Party. Then when many of my colleagues
were in jail, and because of the burdens of financing
my children through college education, I gave up my
political aspirations despite the protestations of my
old classmate Morarji Desai, and I took paying guests
into our ten roomed bungalow.
At that time I thought that I should devote the rest
of my life to be some service to others. I did not
need the Congress Party to help me. If I found a man
on the road who had collapsed from the summer heat,
I would get a rikshaw and take him to hospital. Why
did I need the Congress Party to help me do that ? I
asked myself.
12
When I was young, I had started the Congress
Youth League. Now as I was myself getting old, I
thought about an old men's league, and I found that
many old people were in need of services. So I took
up the cause of the old and on the 7th December,
1956, I started 'Vanprastha Seva Samaj'.
There was another reason—a personal matter. For
some years, I had stayed with my grandfather-in-law.
But because I found his life was stained by politics, I
left him and moved away. He was heartbroken. For a
long time, he never wrote to me.
Then one day, I got a letter asking me to come
and see him at his village, and he sent Rs 200 for the
HEALTH FOR THE MILLIONS/OCTOBER
I 982
I first class fare for myself and my wife. So we decided
We have about 80 old people plus another 15 who
to go. But just before boarding the Gujarat Mail, I got help to look after them. The youngest is 70. Another
a telegram to say that he had expired. He must have recently expired at the age of 105. They say to me:
c lied many times before he died in the hope of seeing 'Samarthlal you are yourself 85 and how is it you don't
us again. So we decided that since we had failed one get tired of doing this work ?'To which Isay: I don't
old man, we must help 100 others.
look on it as 'work'. I enjoy it. I have created my own
I started the Samaj with Re 1 donation and one Heaven. Even in my own house, I have well-to-do
inmate. Then I was given the Ramkrishna Mission as old people staying with me. They pay me something
a building. I surprised everybody by collecting because they can afford to. But most of my 'family'
Rs 3,000 in one month. But the Ramkrishna Mission can pay nothing. It costs me Rs 125 per month per
would only permit us to have men and we wanted to head to look after them.
look after old women as well, for women in our
country have a more miserable life. So in 1961 we built
our own place for Rs 64,000 with helps from Govern
ment and some business people. Now with Helpage
India's assistance, we are building an upper story.
OPPORTUNITIES
STOREKEEPING IN THE HEALTH CENTRE
Appropriate Health Resources and Technologies
Action Group Ltd are preparing an illustrated guide to
storekeeping in health centres and rural hospitals in
developing countries. Practical ideas on storage, stock
control and dispensing of drugs and other medical
supplies would be welcome. AHRTAG wants to hear
about your day to day problems in relation to storage
and supplies. Please contact :
AHRTAG, 85 Marylebone High Street
London, W1, UK.
NURSE ANESTHESIA COURSE
Applications are invited for the VHAI Nurse Anes
thesia Course (North batch). South batch course
began in September 1982 at the I.H.M. Hospital,
Bharananganam, Kerala.
North batch begins in
January 1983 at Frances Newton Hospital, Ferozepur,
Punjab. Write to Sr. Joan Thazhathiel, c/o VHAI.
I tell them all : Laugh, laugh, laugh and the world
will laugh with you. Cry, cry, cry and you will cry in
the corner alone. That is my motto—to keep a smile
on my face.
years experience or Diploma in Hospital Administration
with five years experience. Salary will be Rs. 1200/per month but it is negotiable,
For further information, contact : The Director,
Methodist Hospital, Jaisingh Pura, Mathura-281003,
U.P. India.
DOCTORS
Nagaland Gandhi Ashram needs for health care
two M.B.B.S. doctors. Simple accommodation and
Rs. 1,000 p.m. are offered. Apply immediately to :
Natwar Thakkar, Secretary, Gandhi Ashram, P.O.
Chuchu Yimlang, Dist. Mokokcoung, Nagaland798614.
A LABORATORY SUPERVISOR
A Laboratory Supervisor to head the Laboratory
Department. Salary commensurate with qualification
and experience. Apply immediately to Administrator,
Nazareth Hospital, Mokama-803302, Patna Dist.
YOU NEED ME ?
WE NEED YOU
ADMINISTRATORS
Methodist Hospital at Mathura needs a Business
Manager. Qualification of the person should be
M.H.A (Hospital Administration) or M.B.A with three
HEALTH FOR THE MILLIONS/OCTOBER
1982
An ex-leprosy patient seeks a position—anything
at all—in a Leprosy after care and observation colony.
He is a homoepathic practitioner. His Address :
Dr. Suniti Charan Nandan, P. O. & Village Mejia,
District Bankura, West Bengal.
13
An Anti-Malarial Drug
(Ayush-64, An Ayurvedic Preparation)
Malaria was widely prevalent all over the world
and claimed millions of lives. However, by using
modern antimalarial drugs like quinine, chloroquine
and also insecticides to kill mosquitoes, the disease
was temporarily controlled. Nevertheless, it has been
found that mosquitoes have developed immunity to
the insecticides and their breeding continues un
abated. It has also been realised that the modern allo
pathic antimalarial drugs are highly toxic and their
repeated use causes numerous side-effects resulting
in ocular disturbances etc.
In order to provide safe, inexpensive and effective
remedy for malaria, an anti-malarial drug has been
developed under the name AYUSH-64 based on Ayur
vedic formulations.
that of the modern drug was 600 mg. of chloroquine
and 30 mg. of Primaquine on first day and 15 mg. of
Primaquine for the following days. Both the drugs
were powdered and encapsuled balancing the weight
to 500 mg. with starch, coded and randomly allocated.
Absence of malarial parasites in the blood smear 2
days after the period of treatment was taken as the
criterion for assessing the efficacy of the drug. On the
basis of blood smear examination before and after
treatment, the efficacy of the Ayurvedic drug was
found to be as good as that of the allopathic drugs
like chloroquine and primaquine. Successful treatment
of one severe case of malaria was observed where the
patient responded fully to the treatment with Ayush-64
by the daily dosage of 1500 mg. for 4 days without
any side effect.
The drug has been produced for the last several
years in a pilot plant. Field trials have also been con
ducted by distributing tablets through some institu
tions and centres spread all over India.
The main raw materials are four herbs which are
abundantly available in India. Besides, a few additives
like starch, gum accasia, gelatin, sugar, sodium ben
zoate are required
A clinical study on malaria patients drawn from
malaria clinics of the Corporation of Madras (India)
was conducted. Of the 58 cases, 30 received Ayur
vedic treatment (Ayush-64) and 28 standard modern
allopathic drug. The duration of treatment was 4 days.
The dosage of Ayurvedic formulation was 1500 mg.
on the first day and 750 mg, on subsequent days and
For further information please contact: The Manag
ing Director, National Research Development Corpora
tion of India, 61. Mahatma Gandhi Marg, Lajpat
Nagar-lll, New Delhi-110 024, or, Director, Central
Council for Research in Ayurveda and Siddha,
Dharma Bhavan, S-10, Green Park Extension Market,
New Delhi-110016.
CIBA-GEIGY WITHDRAWS DIANABOL
Dianabol, a branded product of anabolic steroid,
methandienone is being withdrawn by its manufac
turer Ciba-Giegy from all the world markets. This
product was introduced, according to company state
ment, about twenty years ago to enhance tissue build
ing properties and reduced sexual stimulating effects.
It used to be indicated in cases having negative nitro
gen balance, like in cases of post-operative weight
14
loss and children with retarded growth etc. However,
its undesirable effects were more, compared to
efficacy. The statement further says that now with
the availability of other safer treatments, the company
sales were affected making the whole operation un
economical. Thus dianabol product range has been
discontinued worldwide.
HEALTH FOR THE MILLIONs/oCTOBER.
1982
Drug News
Ban on 18 Harmful Drugs
The Drugs Controller of India banned 18 drug
combinations on March 8, 1982 (see box). About
350 drugs are banned. These are the branded pro
ducts of the above 18 combinations of selected firms.
Many more is to follow. The firms have been asked
to stop production by the end of September 1982.
The chemists and stockists would need to stop mar
keting from March 1983.
In paediatric preparations, tetracycline drops have
been banned from May 1, 1982.
The government is considering of imposing a total
ban on dimethisterone (a female hormone drug, e.g.,
Secrodyl tablets).
The drugs controller sent letters on March 26,
1982 to all firms producing female hormone drugs
informing them to print the contra indications on each
pack 'Not to be used for Pregnancy Tests and in
Suspected Cases of Pregnancy'. The firm replied and
also sent samples of packs with the required warning.
The drugs controller took up the matter again with
ICMR and the Federation of Obstetrics and Gynaeco
logy Bombay, to find alternatives for hormone pre
parations. The government has requested the above
organizations and the Indian Medical Association to
send circulars to doctors informing them not to use
these drugs for pregnancy testing.
This seems to be one of the outcomes of the
nationwide campaign against hormonal drugs. VHAI
and some other concerned groups were involved in
the same. (For more information on the dangers of
hormonal drugs, write to VHAI).
Categories of Fixed Dose Combinations Recommended to be Weeded
out by the Drugs Technical Advisory Board
1.
Fixed dose combinations of Amidopyrine.
11.
2.
Fixed dose combinations of Vitamins with antiinflamatory agents and tranquilisers.
12.
3.
Fixed dose combinations of Atropine in Anal
gesics and Antipyretics.
13.
Fixed dose combinations of Tetracycline with
Vitamin C.
4.
Fixed dose combinations of Strychnine and
Caffeine in tonics.
14.
5.
Fixed dose combinations of Yohimbine and
Strychnine with Testosterone and Vitamins.
Fixed dose combinations of Hydroxyquinoline
group of drugs except preparations which are
used for the treatment of diarrhoea and dysentry.
15.
6.
Fixed dose combinations of Iron with Strych
nine, Arsenic and Yohimbine.
Fixed dose combinations of Steroids for internal
use except combination of steroids with other
drugs for the treatment of Asthma.
7.
Fixed dose combinations of Sodium Bromide/
Chloral hydrate with other drugs.
16.
Fixed dose combinations of Chloramphenicol
except preparation of Chloramphenicol and
Streptomycin.
8.
Fixed dose combinations of Ayurvedic, Unani
Drugs with modern drugs.
17.
Fixed dose combinations of Ergot except combi
nation of its alkaloid ergotamine with Caffeine.
9.
Fixed dose combinations of Phenacetin.
18.
10.
Fixed dose combinations of Anti-histaminics
with Anti-diarrhoeals.
Fixed dose combinations of Prophylactic Vita
mins with anti-T.B. drugs except combination
of I.N.H. with Vitamin BG
HEALTH FOR THE MILLIONS/oCTOBER
1982
Fixed dose combinations of
Sulphonamides.
Fixed dose combinations of
Analgesics.
Penicillin with
Vitamins with
15
Sixteen Bangladesh Criteria
The Chief Martial Law Administrator of Bangla
desh promulgated the Drugs (Control) Ordinance
1982 to control the manufacture, import, distribution
and sale of harmful, ineffective and unnecessary
drugs in the country, reports a Bangladeshi news
paper of June 13, 1982.
The ordinance will come into force with imme
diate effect. Under this ordinance, manufacture, im
port, distribution and sale of 1707 drugs have been
prohibited. However, time will be allowed ranging
from three months to nine months for their manufac
ture and sale in order to enable the importers, pro
ducers and sellers to utilise or dispose of their stock
of drugs and raw materials.
An expert committee of the Bangladesh Govern
ment which recommended the withdrawal of the
1707 drugs, used the following criteria in evaluating
all the registered/licensed pharmaceutical products
manufactured and/or imported in Bangladesh :
I. The combination of an antibiotic with another
antibiotic or antibiotics with corticorsterioids or other
active substances will be prohibited, Antibiotics harm
ful to children (e.g., Tetracycline) will not be allowed
to be manufactured in liquid form.
II. The combination of analgesics in any form is
not allowed as there is no therapeutic advantage and
it only increases toxicity, especially in the case of
kidney damage. The combinaton of analgesics with
iron, vitamins or alcohol is also not allowed.
III. The use of codeine in any combination form
is not allowed as it causes addiction.
IV. In general, no combination drugswill be used
unless there is absolutely no alternative single drug
available for treatment or if no alternative single drug
is cost effective for the purpose.
Certain exceptions will be made in
cases of
eye, skin, respiratory and haemmordial preparations,
co-trimaxazole, oral rehydration salts, anti-malarial,
iron-folic, etc, as well as certain vitamin preparations,
allowing combinations of more than one (1) active
ingredient in a product.
16
V.
Vitamins should be prepared as single ingre
dient products with the exception of B complex.
Member vitamins of B complex with the exception of
B12 produced as a single ingredient product (e.g.
B1,B2, B6.). Vitamins will not be allowed to be
combined with any other ingredient such as minerals,
glycerophosphate, etc. It will be allowed to produce
vitamins in tablets, capsules and injectable form
only.
No liquid forms will be permitted because of
wastage of financial resources and the tremendous
misuse involved. However, paediatric liquid multi
vitamin (with No. B12, E.M. and/or minerals) will be
allowed to be manufactured in bottles of up to 15 ml,
size with droppers. Paediatric liquid preparations of
single ingredient vitamins will also be allowed to
be manufactured in bottles of up to 15 ml. with
droppers.
VI, No cough mixtures, throat lozenges, gripe
water, alkalis, etc. will be allowed to be manufactured
or imported as these are of little therapeutic value and
amount to great wastage of our meagre resources.
VII. The sale of tonics, enzymes, mixtures/preparations and so-called restorative products flourish
on consumer ignorance. Most are habit-forming and
with the exception of pancreation and lactase, these
are of no therapeutic value. Henceforth, local manu
facture or importation of such products will be dis
continued. However, pancreation and lactase will be
allowed to be manufactured and/or imported as single
ingredient products.
VIII. Some drugs are being manufactured with
only a slight difference in composition from another
product but having similar action. This only confuses
both patients and doctors. This will not be allowed.
IX. Products of doubtful, little or no therapeutic
value and rather, sometimes harmful, and are subject
to misuse will be banned.
X.
All prescription chemicals and galenical pre
parations not included in the latest edition of British
Pharmacopeia or British Pharmaceutical Codex, will
be prohibited.
health for the millions/october
1982
XI.
Certain drugs, in spite of known serious side national companies. Multinationals will, however, be
effects and possibility of misuse, having favourable allowed to produce injectable vitamins in single in
risk-benefit ratio may be allowed to be produced in gredient products.
limited quantity for restricted use. These will be pres
XV. No foreign brands will be allowed to be
cribed by specialists only.
manufactured under licence in any factory in
XII. The same or close substitute of a drug which Bangladesh if the same or similar products are availis being produced in the country will not be allowed able/manufactured in Bangladesh as this leads to un
to be imported as a measure of protection for the necessary high prices and payments should be
local industry. However, if local production is far reviewed.
short of needs, this condition may be relaxed in some
XVI. No multinational company without their own
individual cases.
factory in Bangladesh will be allowed to market their
XIII. A basic pharmaceutical raw material which
products after manufacturing them in another factory
is locally manufactured will be given protection by in Bangladesh on toll basis.
disallowing itself or its substitution to be imported
After approval of these recommendations by
unless sufficient quantity is not available in the
Government, the
licensing authority for drugs
country.
(Director, Drug Administration) will have to issue
XIV. The role of multinationals in prvoiding medi necessary orders withdrawing/cancelling the licensing'
cines for this country is acknowledged with apprecia registration of the products, with the provision of a
maximum period of six (6) months'grace for using up
tion. In view of the calibre of machinery and technical
know-how which lies in their hands for producing the present stock or corresponding raw materials.
important and innovative drugs for the country, the Henceforth no raw materials should be allowed to be
task of producing antacids and vitamins will lie solely imported for the manufacture of these products. All
with the national companies, leaving the multi future licensing/registration should be given after
nationals free to concentrate their efforts and resources evaluation of the products on the basis of the above
on those items not so easily produced by smaller criteria.
A Correction
I wish to draw your attention to the Health for the
Millions, April 1982. Under 'News from States' you
have published the information that Kurji Holy Family
Hospital is starting a one year X-ray course from
September, 1982. Probably you took this informa
tion from the minutes of the General Body meeting
1982. We would like to inform you that the X-ray
course is only at a proposal stage pending approval
of higher authorities of Kurji Holy Family Hospital.
M. Zaman
Executive Secretary, BVHA
Missed out
The conversation reported on page 10 of Health
for the Millions (June '82) was with the kind help of
Mrs. Myrtle Fernandes, Principal, Government Aided
High School, Mendall in interpretation.
Editor, hfm
HEALTH for THE M1LL1ONS/OCTOBER
1982
Management Process
in
Health Care
To be realeased in November
The book discusses the application of management
principles in hospitals and rural health projects.
Pre-Publication Price Rs. 50/Regular Price Rs. 58/-
pp. 650
To order (add Rs. 8/- postage), write io :
Management Process in Health Care
Voluntary Health Association of India
C-14, Community Centre, SDA
New Delhi-110 016
17
Mira
Rice Water for Diarrhoea
The D and V Blues
Babies who have D and v
Shrivel up and fail to pee.
Fill thCrr* up W'th LOTS OF WAT
Maxing Spc.cle.1 Drink’s a cinch--
Sugar *. 1 Teaspoon. Stlt
1 Pinch.
Water-. 1 Glass--or big fat cup.
Give breast »nilk too--for BREAST IS BEST.'
The debate between the propagators of pre-packed
ORS (Oral Rehydration Salt) or diarrhoea mixture, and
those who believe in mothers making their own
mixtures continues. Those who strongly believe in
self-sufficiency and self-reliance would recommend
the latter. Studies have shown that though addition
of too much extr asalt may cause hypernatiemia, and
too much sugar causes osmotic diarrhoea, in actual
practice the incidence of bungling with the amount of
salt and sugar is not so high as to warrant centralized
distribution of packets when mothers can easily pre
pare their own.
Probably the best thing that has happened regar
ding ORS is the acceptance of the findings of Prof.
Wong Hock Boon, a paediatrician from Singapore, who
has been advocating the use of rice water (kanji) for
rehydration of babies.
The stopping of diarrhoea could be because that
the starch-sugar in the rice water draws out less fluid
into the gut lumen as compared to glucose. The other
reason could be that the starch in rice water is more
easily digested by babies than simple sugars. A little
salt may be added to take care of sodium losses.
18
Studies done by ICDDR, B (International Centre
for Diarrhoeal Diseases, Research, Bangladesh) have
also indicated the therapeutic value of rice water for
effective rehydration of diarrhoeal cases.
For rice eating communities, this would be a real
boon, specially with the ever increasing price of sugar
and difficulty in obtaining cleanly prepared, un
adulterated jaggary (some have access to one or both,
of course).
A point to be noted is that for ages, illiterate
mothers in many areas have been giving rice water to
their children with diarrhoea and even otherwise.
According to David Werner (Author of Where there is
no Doctor), women in Mexico have been giving rice
water to children with diarrhoea. This is even when
rice is neither the staple diet of mexicans nor one of
the cereals commonly used.
Advantages of Rice Water
Even one month old infants can digest and absorb a
large amount of starch. It causes no osmotic diarrhoea
as glucose following digestion of rice powder is libera
HEALTH FOR THE MILLIONS/OCTObER
1982
ted slowly). Higher concentration of carbohydrate in
form of rice water compared to glucose can be used.
This provides extra energy as well as provides glucose
in transportation and abscriptjon of the electrolytes
(because it is free from dangers of osmotic diarrhoea).
Carbohydrate absorption from a rice meal is least
affected during diarrhoea caused by cholera entero
toxigenic E Coli and invasive organisms, rota virus or
shigella. Rice is the staple food of 60% of world's
population, hence availability and acceptance problem
is easily overcome. Since rice is cooked at least twice
a day, the rice water obtained from it costs no addi
tional money to buy ORT constituents. Since it is
already boiled, no extra effort or fuel is required.
Since it is boiled for a length of time it is safe from
contamination.
If you would like to have more information about the
use of rice water for rehydration, write to : Professor
Wong Hock Boon, National University of Singapore,
University Department of Paediatrics, Singapore
General Hospital, Outram Road, Singapore. For infor
mation on ICDDR, B's work on locally available star
ches, write to : Library and Publication Unit, Inter
national Centre forDiarrhoel Disease Research, Bangla
desh, GPO Box 128, Dacca—2, Bangladesh.
Method of Preparation
Sodium Chloride (table salt) 3.5. grams
Sodium bicarbonate (baking soda) 2.5 grams
Potassium Chloride 1.5 grams
Glucose 20.0 grams
Dissolve in one litre of boiled water.
The above is the WHO recommendation for the oral
rehydration mixture; now replace glucose (20 grams)
by dissolving 30 grams of rice powder dissolved in
water and cooked for a few minutes. This replace
ment is suggested by Dr Majid Molla of ICDDR, B in
the report of his study published in 'Glimpse' (Vol. 3,
No. 11, November 1981) in the article "Rice Powder as
an Alternative of Sucrose in Oral Rehydration therapy."
Industrial Disputes Act (Amendments) Bill, 1982
The I.D. Act (Amendment) Bill, 1982 was adopted
by both houses of Parliament in the August Session.
It redefines 'industry' and excludes hospitals, educa
tional institutes etc from the purview of this term.
But the workmen employed in these establish
ments also need protection. A machinery for the
resolution of their individual and collective industrial
disputes has been provided for.
An employer must constitute within a specified
period a Grievance Settlement Committee for resolv
ing industrial disputes; a Consultative Council and a
local Consultative Council for the resolution of dis
putes of a collective nature. It also provides for the
arbitration of disputes not resolved by the Grievance
Settlement Committee or the Consultative Councils.
The bill also provides for the recognition of those
trade unions of workmen which are registered under
the Trade Unions Act and each of its office bearers is
a workman in such establishment or in any other esta
blished, as defined in the bill.
Where any matter is referred for arbitration under
health for the millions/october
1982
the provisions of the Bill, the arbitration award will
have to be given within a specified period. The em
ployers as well as the workmen would have the right
to choose arbitrators either from the panels maintained
by the appropriate Government or from outside.
Matters which would constitute individual disputes
include termination of employment of any workman,
whether by way of discharge, dismissal or retrench
ment or otherwise, suspension and computation of
money due from the employer to a workman. Matters
which would be industrial disputes of a collective
nature include wages and allowances, hours of work,
leave with wages and holidays, medical benefits and
super annuation benefits.
Appropriate penal provisions are also provided in
the Bill for ensuring strict compliance of the law.
Hospitals and other Institutions which have been
excluded from this act are covered under Hospitals
and other Institutions (settlament of disputes) Bill
1982. This Bill is expected to come for discussion
during the fourth coming session.
19
nausfc.
Madhya Pradesh
MP VHA will hold a VHW conference this year.
At its annual general body meeting, MP VHA de
cided to hold its next annual meeting in Indore on
Feb. 11-12, 1983 on the two possible themes :
Water: Killer or Life Giver.
Drugs : Use and abuse.
Plans for the next few months include a commu
nity health workshop in Bastar, consultation on cur
riculum for VHWs in Sidhi district.
MP VHA Organising Secretary's report says that
VHA movement continues to grow. Rajgarh Social
Service Centre, Lakhnedon and Chhapra health centre
have growing programmes. In Bastar district regional
meetings, school health and leprosy programme
are taking place. Eye camps combined with nutri
tion are planned by VHA members in co-operation
with others.
West Bengal
Training programmes of West Bengal VHA for the
future include:
• a training workshop on community health and
development at E.S.I.I. Durgapur from Novem
ber 1-30;
• a condensed course on homeopathy for rural
health workers leading to a certificate, from
December 1—January 15, 1983 at Dhyan Ashram,
24 Parganas;
• a weekly non-residential training programme from
3-5 P.M. leading to a certificate on Population
Education for VHWs.
The new address of West Bengal VHA is: 8 Sarojini
Naidu Sarani, Calcutta-700017
Bihar
6 4-1 Again
Bihar VHA will be again starting a 64-1 series of
training programmes for hospitals and health centres.
The first programme is scheduled for December first
weak. For details contact:
Mr. Zaman, Executive Secretary, Bihar VHA.
Kurji Holy Family Hospital, Patna—800010
Andhra Pradesh
Gujarat
AP VHA will hold a village health workers con
ference in the first week of October 1982. Ideas for
discussions are invited. A Telugu booklet on com
munity health project experiences in Andhra is to be
published. A human relations and communications
seminar (basic T A) was conducted by Sr. Carol
Huss and her team from July 26-30 at Jeewan Jyoti
retreat house, Hyderabad. District meeting had been
held at Khammam and Guntur in August 1982;
School health programmes are stepped up in con
sultation with the district health centres and schools
in their area.
20
Sewa Rural
Drs. Anil Desai, Lata Desai, Haresh Shah and
Pankaj Shah have put Jhagadia on the map regarding
Community Health. Following a very methodical step
by step plan, they have launched a programe in 11
villages.
With the help of 7 students of the Surat Medical
College and 15 students from the NSS, Baroda,
SEWA RURAL has completed a baseline survey (i.e.,
infant mortality, birth rates, pregnant mothers, underfives and available medical facilities) to serve as an
indicator for their Project Planning and future
evaluation.
health for the milljons/october
1982
8 ways to live longer
Sweden's life expectancy is nearly twice that in
Ethiopia. So if you want to live longer first choose a rich country. But then look at your
lifestyle - wealth can be fatal too.
EXERCISE YOUR MIND
Like your muscles, your bram atrophies with
disuse. Senility is six times greater m old folk who
withdraw from people and from life.
WATCH YOUR EYES
Old age usually affects eyesight and hearing.
But in poor countries curable eye and ear infections
can cause much greater disability'.
The answer is a health system offering effective
diagnosis and referral.
EAT PROPERLY
Malnutrition causes half a billion
deaths annually. But obesity helps
kill 50% of people in industrial
countries by putting pressure on
heart and joints, causing heart
disease, strokes and arthritis.
There are very few fat 80-year olds.
STAY HAPPY
Stress increases blood pressure.
Depression makes you apathetic.
Both contribute to heart disease.
Lonely old people have a 50% higher
death rate than married couples.
STOP SMOKING
Every' cigarette you smoke shortens
your life by 5’/? minutes.
LIVE WELL
The surest way to live longer is to be born in a rich
country. A clean, warm home, safe water and a full
stomach all reduce vulnerability to
infectious diseases
KEEP MOVING
Too much rest can kill you — by making your
circulation sluggish and your muscles weak.
Just one year of exercise can make a 70-year old as
fit as a person’of 40.
GET INVOLVED
If your needs and abilities are not respected or
taken seriously— complain The best person to fight
for better housing, employment and
health care is you
lihnlrafiu/i by licr<?k Matin.
H arid J \ tern/''
IW
SILENCE
...And the hospital surgeons, the knives,
There is the silence of a spiritual crisis,
And the long days in bed.
Through which your soul, exquisitely tortured,
But if he could describe it all
■
Comes with visions not to be uttered
He would be an artist.
Into a realm, of higher life,
But if he were an artist
There would be deeper wounds
And the silence of the gods
Who under§tan/l^c/I^bt7^x without speech...
Which he could not describe.
...And there is the silence of age,
There is the silence of a great hatred,
Too full of wisdom for the tongue to utter it
And the silence of a great love,
In words intelligible to those who have not lived
The great range of life.
And the silence of a deep peace of mind,
And the silence of an embittered friendship
For Private Circulation Only
)
— Lines from an American Poem
Position: 52 (17 views)