Swasth hind, Vol. 24, No. 10, 1980.pdf

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extracted text
In this issue
261

Peptic Ulcer and nutrition
Sint Inderjit Singh

264 Health hazards in nightsoil disposal practices in
urban community ■
Brig. S. L. Chadha

268 Institutes—6—National
Bangalore
Dr A. Banerji

Tuberculosis

Institute

270 The inequality of death, assessing socio-economic
influences on mortality
278 Study : Implementation of multipurpose worker’s
scheme in Ambala district—an Evaluation
Y. P. Gupta, A. B. Hiraniani, K. S. Sinha,
N. N. Biswas

Readers Write
I have liked very much the December 1979
issue of Swasth Hind. It gives too much infor­
mation on child health and maternal health.

280 Health education in leprosy control
Dr C. S. Gangadhar Sharma

Dr A. G. Qureshi
P. O. Zirapur
Distt. Rajgarh
M. P. 465 691

282 India—world’s largest donor of doctors
Peter Ozorio

i

286

On Nutrition: Nutritional anaemia

288 Workshop on health
Services at JIPMER
Dr S. lP. Mehta

hospital

289 Professional preparation of health education
specialists
292 Community health volunteers’ page—Measles

Swasth Hind is very fine for health care. Its
price is also very cheap. The topic on Hook­
worm published In January 1980 issue is, indeed,
very necessary for the health of human beings.
Rameswaran

Tanakarapa Mansion
Soonambo, G. B. Nagar
Aska-761110
Ganjam—Orissa

education in

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Asstt. Editor

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Cover Photo

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Cover Design

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Editorial and Business Offices
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Kotla Marg, New Delhi-110 002.
October 1980

Asvina-Kartika

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PEPTIC ULCER AND NUTRITION
Smt Tnderjit Singh

Peptic ulcer—a common abdominal disease—is a product of modern civilization. Under
the present-day living conditions constant tensions or conflicts at home or the office keep
the mucous membrane congested with blood which persists e^h during sleep as the sub­
conscious mind does not relax. This congested mucous membrane is easily injured to
produce ulcer. However, with proper diet and timely treatment peptic ulcer can be cured.

eptic ulcer is a composite term denoting a
superficial or deep erosion of the inner lining of
the stomach or its continuation known as duodenum.
When the erosion is in the stomach, it is called gastric
ulcer and, it is called duodenal ulcer when it affects
the first part of the duodenum.

P

Peptic ulcer, however, is not responsible for a high
rate of mortality, but once it occurs and develops un­
checked, the ulcer is likely to last a life-time, disabl­
ing the normal life of a person and causing painful
complications.
Following are the general symptoms which indi­
cate the presence of a peptic ulcer in a person:

@ Burning pain in the stomach.
Discomfort or
pain above the navel region which tends to come
on directly after a meal, might suggest a stomach
(gastric) ulcer. In case the pain comes two to
three hours after a meal it might indicate duo­
denal ulcer.

• Nausea, blood vomiting, frequent eructations, gas
formation and indigestion.
• Black tarry stools called, melena. Stools at first
are black, then maroon and finally red that is
only slightly darker than the blood.
Causes

Peptic ulcer is one of the commonest abdominal
diseases. In fact, it is a product of modem civiliza­
tion. Under the present-day living conditions, constant

October 1980

tensions or conflicts at home or at the office, keep the
mucous membrane congested with blood which per­
sists even during sleep as the sub-conscious mind does
not relax. This congested mucous membrane is easily
injured to produce ulcer. The injury may be due to
increased secretion of hydrochloric acid or due to
drugs like aspirin or painkilling drugs for arthritis
which damage the mucous membrane of the stomach
and duodenum.
Hydrochloric acid is normally secreted by the
stomach so that foods like meat and fish are easily
digested. During periods of stress or anxieties, how­
ever, its secretion increases. Thus an ulcer once pro­
duced in the stomach or duodenum is perpetuated by
heavy secretion of the hydrochloric acid. Acid secre­
tion also increases with decrease in blood sugar that
occurs during fasting of more than three hours dura­
tion. Smoking and consumption of alcohols and ex­
cessive coffee or tea not only damage the mucous
membrane of the stomach but also increase hydrochlo­
ric acid secretion. Severe bums, too, are capable of
causing peptic ulcer. These are in brief the various
causes of this ailment, the main culprit of course,
being the excessive secretion of hydrochloric acid.
On suspecting the presence of any of the symptoms,
it is advisable to consult a doctor for necessary ad­
vice and treatment. He will make out the diagnosis
from the patient’s symptoms and a few laboratory
tests like gastric analysis and X-rays. Surgery may

261

depend on the stage of the ailment. However, side
by side with the prescribed treatment, regulation of
diet is also most important. In fact, it is an essential
part of the treatment.
Dietary treatment

The dietary treatment for ulcer patient includes:
0

Reducing the acid level of the stomach and
giving it sufficient rest by minimizing the move­
ment of the stomach muscle.

should specially avoid is to gobble up food in a
tense atmosphere.

G Generally, almost all the foods have a neutraliz­
ing effect on the acid gastric juices. However,
protein foods are more effective buffers and thus
there is less free acid to irritate the ulcer when
such foods are consumed.
Accordingly, it is
desirable to have some protein in the shape of
milk, dais (decuticled split legumes), soft cheese
or chicken eggs in every meal.

• Providing the nutrients essential for rapid heal­
ing of the ulcers—especially protein and vitamin
C. Antacid and antispasmodic drugs are generally
prescribed by the doctor along with the dietary
modifications.

® Avoid taking strong coffee, tea and alcoholic drinks
since they stimulate the flow of acids in the stom­
ach.

• In order that the dietary treatment along with the
drugs, work effectively, it is most essential that
worry, anxiety and tensions which tend to in­
crease the production of hydrochloric acid, are
avoided as far as possible.

© The intake of acid foods like tamarind and sour
butter-milk should be avoided since they add to
the acidity of the stomach secretion. However,
lemons or oranges can be taken since they are
mildly acidic. They are also important sources
of vitamin C.

Points to patients

It is important that the following general rules of
diet are observed by the patient to secure an early
relief and recovery.

• Hydrochloric acid secretion is a continuous pro­
cess and food in the stomach neutralizes the acid.
In the absence of food, the acid further damages
the mucous membrane and produces discomfort
or pain, usually two or three hours after the meal.
Therefore, a patient should never allow the stom­
ach to be without food for a long time. It is
advisable to have a couple of biscuts, along with
milk, in between the main meals. Three main
meals a day, along with snacks, will be an ideal
routine.
• Large meals should be avoided since over-eating
leads to distension and discomfort. Also keep
away from very hot or very cold foods and too
many liquid foods as they tend to increase the
motility of the stomach. It is advisable to be
moderate in eating, avoiding extremes.

• Be particular about the meal timings and do not
neglect meal, howsoever important the work
may be.
Take time to eat.

262

One thing the ulcer patient

® Reduce the use of foods high in roughage, such
as, radishes, cucumbers, celery and cabbage. This
principle holds true for any fresh fruits or vege­
tables containing fibres, skins or seeds. These
foods increase the motility of the stomach and
cause greater irritation.

like chillies, mustard, pepper, cloves and
highly seasoned foods should be avoided since
they are irritating to the mucous lining and cause
increased secretion of the hydrochloric acid.

0 Spices

0

Fried foods should be avoided completely.

0

Have a glass of milk before going to bed to
reduce injury to mucous membrane of the stom­
ach which is likely to be empty of food during
the night.

Although many don’ts have been mentioned re­
garding the diet of the ulcer patient, it is felt that
food tolerance is a highly individual matter. Psy­
chological and emotional factors often play a vital
part in the acceptance or rejection of a particular
food. Therefore, the patient should avoid the foods
which do not suit him and make a moderate selection
from the agreeable foods after trials for sometime.

Swasth Hind

Given below is a typical dietary pattern which may
be modified to suit the individual patient.
Daily Menu for Peptic Ulcer Patient
Morning—6 a .in.

Milk, 2 cups (with 2 teaspoonfuls of sugar)

New WHO Regional Director
For South-East Asia

Breakfast—8 a.m.

Bread—2 slices

Butter—2 teaspoonfuls
Cheese—2 slices or Boiled egg—one

Milk—1 cup.
10 a.m.

Milk—2 cups (with sugar)

Dr U Ko Ko was nominated Regional Director of
WHO’s South-East Asia Region by the WHO Re­
gional Committee at its 33rd session at Mal6, Republic
of Maldives, which commenced on September 1, 1980.
After confirmation by the WHO Executive Board at
its forthcoming session, the newly nominated Regional
Director will assume office. He will succeed Dr
V. T. H. Gunaratne, who has held the post since
1968.

Lunch—12 noon

Cooked rice or bread—1 serving

Mashed dhal—1 cup

Cheese—2 slices or Cooked minced meat—1 serving
Boiled potato—2

Born in Burma in 1929, Dr Ko Ko obtained his
medical degree from the University of Rangoon in
1953. He obtained diplomas in Public Health from
the University of Edinburgh in 1956 and in Tropical
Medicine and Hygiene from the London School of
Hygiene and Tropical Medicine in 1957.

Milk pudding—1 cup
2 p.m.

Milk—1 cup
4 p.m.

Biscuits—2

Milk (with sugar)—1 cup
6 p.m.

Milk (with sugar)—2 cups

Dr Ko Ko began his career in the health services
of Burma with the Ministry of Health as an Assistant

District Health Officer in 1954 and later served as a
District Health Officer cum Team Leader of Aung
San Health Centre, Insein. He became Asistant Direc­
tor of Health Services in 1961. Three years later,
he was promoted as Deputy Director. From 1966 to
1969, he also worked as Professor of Preventive and
Social Medicine at the Institute of Medicine II in
Rangoon.

Dinner—8 p.m.

same as for Lunch
10 p.m.

Milk—1 cup.

October 1980

Dr Ko Ko joined WHO in 1969 as Regional Ad­
viser in Community Health Services in the WHO Re­
gional Office for South-East Asia in New Delhi and
became Assistant Director of Health Services three
years later. In 1978, he was appointed as Director
of Health Services, redesignated later as Director,
Programme Management.

263

HEALTH HAZARDS
IN NIGHTSOIL DISPOSAL PRACTICES
IN URBAN COMMUNITY
Brig. S. L. Chadha

Today, the whole environment is being polluted by the accum­
ulation of liquid and solid wastes, especially nightsoil because
of increasing population and rapid urbanization.
An effective
solution to the problem of collection, transportation and final
disposal of nightsoil in urban community is complex involving
technical, administrative, financial and legal problems. Failure
to do this constitutes a threat to the public health problem.
transportation and disposal of
nightsoil is one of the pressing problems of city­
life, particularly in a developing country like India.
This has assumed, along with disposal of other wastes,
a great importance. The Ministry of Agriculture had
estimated that the city communities which form onefifth of the population were generating over 12 mil­
lion tonnes of wastes every year in the form of refuse,
nightsoil and slaughter house wastes. These wastes,
if properly treated, could immensely help in agricul­
tural production.

the public cleansing services have been inadequate.
At present, there are 32 municipal corporations and
about 1,500 municipalities in various States and Union
Territories. For smaller towns, there are notified area
committees which look after civic functions to a
limited extent. There are also Cantonment Boards for
civil areas of Cantonments set up under a Central
law for performing civic functions under their juris­
diction.

Urbanization in our country has certain unique fea­
tures. While the rural population is spread over vast
areas located in more than half-a-million villages, the
urban dwellers are concentrated in 2,921 (1971 Census)
places of different sizes and varying areas individually.
It is also significant that more than 57 million of city
people, eg,, 52.41 per cent live in 142 cities classified
as Class I places, each having a population of 1,00,000
and over. Among these Class I cities there are nine
metropolitan cities, each containing over one million
population, more than onefourth of the entire urban
population. The Class II towns with population bet­
ween 50,000 and 1,00,000 number 198 and have just
12-15 per cent of the urban population.

The public cleansing work, including disposal of
nightsoil in urban areas, is attended to by the local
authorities with the powers under Municipal laws.
The work is done by a health officer assisted by
deputy/zonal health officers and sanitary inspectors.
In some Metropolitan cities, viz, Bombay and Delhi,
there is the Department of Conservany and Sanita­
tion Engineering which functions independently or
as a part of Engineering Department. This depart­
ment is responsible for collection and disposal of refuse
and nightsoil and other urban wastes including sewer­
age system.

he collection,

T

The local bodies like coiporations and municipa­
lities in the urban community are responsible for en­
vironmental sanitation, including collection and dis­
posal of wastes. In most of the towns and cities,

264

Nightsoil disposal

Nightsoil disposal is an important hazard in most
of the towns and cities. Out of about 2,921 urban
places hardly 200 are provided with sewerage system
and sewage treatment plants. In fact no city or town
has yet been fully sewered. Only 15 per cent of the
urban population of the country is served with sewer-

Swasth Hind

Need to realize a clean living environment,
says Smt, Gandhi
The Prime Minister of India, Smt. Indira Gandhi, writing in the
August-September issue of World Health, says:

“Today, mankind as a whole has the knowledge and the
means to ensure basic sanitation all over the world”. Welcoming
the plans of WHO to observe the UN International Drinking Water
Supply and Sanitation Decade, 1981—1990, she calls on all
countries of world to collaborate fully with the Organization
“so that World Health Assembly’s resolve to provide clean
Water for all the people of the world by 1990 can be a reality”.

Smt. Gandhi concludes: “May the United Nations Water Decade
prove to be an example of international cooperation in helping
people everywhere to realize one of their basic needs—a clean
living envi ronment. ”
age system. A small percentage is served with septic
tanks. A majority of urban population, over 80
million, therefore, depends on dry conservancy system.
The nightsoil collected from this population is about
22,000 tonnes per day. The system of collection, trans­
port and disposal is, however, yet to be mechanized
fully. Our cities and towns therefore still continue to
be in an unsatisfactory state of cleanliness.
Poverty and low standards of living in slum areas
in cities also affect sanitary conditions. There is lack
of interest in the public besides shortage of public
funds. Average investment on solid wastes manage­
ment in Indian cities is as low as Rs. 500 per head
per annum. Social and religions also contribute to
the insanitary conditions. Lack of professional public
health engineers, sanitarians and middle level manage­
ment personnel and trained labour have also been a
great constraint in this activity. Fragmentation of
administrative responsibility in this respect further
frustrates the progress.

Common methods employed for disposal of nightsoil in cities and towns are: —
* Disposal along with refuse by sanitary landfilling
and composting.
♦ Trenching.
♦ Burial.
* Incineration.

October 1980

♦ Septic Tanks.
* Chute system. The nightsoil is collected in drums
which'are transported and emptied into a sewer
at fixed points.
* Sewerage system.
Health hazards

Public health hazards arising from nightsoil disposal
are due to unhygienic conditions caused by:—

(1) Obnoxious practice of manual handling and car­
riage of nightsoil by sweepers to public refuse dumps
and nightsoil receptacles. Sometimes domestic nightsoil is carried by sweepers in unstandardized recept­
acles as head-loads. Numerous forums have con­
demned their practice as degrading of human dignity.
(2) Transportation of nightsoil receptacles and cmtying their contents into municipal carts/vehicles for
final disposal by trenching or composting. If trench­
ing or composting is not done properly it results in
prolific flybreeding. The lids of receptacles and tanks
mounted on municipal carts/vehicles are at times illfitted and this gives ample chance to flies to breed
on nightsoil.

(3) Uncontrolled and haphazard dumping into lowlying areas of refuse mixed with nightsoil often attract
ragpickers. Files spread the material all around.
thereby creating insanitary conditions that breed rats
and flies—a danger to public health.

265

(4) Disposal of nightsoil by incineration is likely to
contribute to air pollution.

(5) The disposal of nightsoil into a sewer under
“chute” system is fraught with danger as it involves
manual handling which may lead to soiling of hands,
arms and feet of the workers.

Nature of health hazards

1. Faecal-borne communicable diseases:—Morbidity
and mortality rates from faecal-bome diseases are
high. Transmission of diseases whether by direct
method, vector transfer or indirect, is due to environ­
mental contamination by nightsoil. The disease agent
is transmitted through various channels, e.g. water,
fingers, flies, soil and food.

The various types of faecal-bome diseases are:

(6) Discharge of untreated sewage into fields or
into nearby water courses. This is done due to weak
financial position of most of our municipalities which
are unable to set up proper sewage treatment plants.
Such practice of raw sewage disposal can be danger­
ous from public health point of view as it contami­
nates vegetables and pollutes water.

Safe method of disposal of nightsoil is by septic
tanks or proper sewerage system. Sewerage has not
been able to keep pace with rapidly expanding cities.
Hence there is not even one fully sewered city or
town.

(a) Bacterial diseases—bacillary dysentery, typhoid
fever, diarrhoea, enteritis and cholera.

(b) Protozoan diseases—amoebic dysentery, balan­
tidial and flagellate diarrhoea.
(c) Helminth diseases—ascariasis, hookworm dise­
ase, trichuriasis, oxyuriasis and paragonomiasis.

(d) Viral diseases—viral hepatitis and and polimyelities.
2.

Joint,, muscle and tender diseases—Such diseases
are common amongst nightsoil and refuse collec­
tors.

GLOBAL COOPERATION CRUCIAL FOR HARM-FREE
ENVIRONMENTAL DEVELOPMENT
In his message on World Environment Day (5 June),
the Secretary-General,
Dr Kurt Waldheim,
said
“eight years ago on 5 June, people from all parts of
the world gathered at Stockholm to participate in a
unique event. They had come together to set in mo­
tion a programme never before undertaken in the
world—to protect and enhance the global environ­
ment”.

present and future generations of man, the United
Nations Environment Programme (UNEP) is current­
ly focussing attention, inter alia, on the dangers of
an increase in carbon dioxide content in the atmos­
phere, the impact of military activity on the environ­
ment, and the condition of the world’s children; who
are the most vulnerable sector of society to pollutants
and environmental stresses, he added.

Since then, he said, there has been nothing short
of a revolution in people’s thinking about the natural
surroundings of human life, the earth’s resources and
the risks in upsetting the balance whose preservation
is necessary for civilization, or indeed survival.

Global crisis

New thinking

The Secretay-General added
“this new thinking
comes after three decades of the most far-reaching
improvements in the standards of living, during which
yesterday’s luxuries became today’s necessities. Yet
the world is increasingly aware of the undesirable
side-effects of this surge of consumption.”

In keeping with its guiding principle of safeguard­
ing and enhancing the environment for the benefit of

266

There is no doubt, Dr Waldheim said, the crisis of
human environment is of a global nature requiring
collective policies and joint solutions. The transfor­
mation that has already taken place during the pre­
sent decade in our thinking about environment needs
to be matched by our preparedness to accept changes
in living standards. There is a need to bring about
alternative lifestyles that do not waste precious natural
resources.
Dr Waldheim emphasized that global co-operation
is crucial to facilitate the kind of development that
will not injure the environment.—V.N. Weekly Newsletter, 13 June 1980. cs

Swasth Hind

3.

Mechanical and physical hazards—Risks of phy­
sical injury are common in all types of sewerage
system resulting from:—(a) dangerous atmosph­
eres due to oxygen deficiency (b) toxic gases,
vapours and inflammable and explosive gases,
and (c) flooding of sewers.

4.

Air-borne diseases—Air is contaminated by (a)
aerosols due to sewage treatment plants, (b) dis­
posal of nightsoil by incineration, and (c) dust
generated by handling sludge. Contaminated air
may cause lung and skin diseases.

5. Direct handling of nightsoil in its disposal by
composting, trenching and “chute” system may cause
intestinal or skin diseases amongst workers with poor
personal hygiene.

Today, the whole environment is being polluted by
the accumulation of liquid and solid wastes, especially
nightsoil because of increasing population and rapid
urbanization. An effective solution to the problem of
collection, transportation and final disposal of nightsoil in urban community involves not only complex
and challenging technical questions but also difficul­
ties of financial, legal and administrative dimensions.
Failure to deal with the ever-increasing quantum of
human excreta effectively and in time constitutes an
alarming threat to public health and human well being.
A proper system will have to be developed whereby
its collection transportation and disposal are attended
to in a sanitary manner keeping in view cleanliness
of cities, prevention of environmental pollution and
eradication of degrading practice of manual handling
of nightsoiL □

PROTECTING OUR ENVIRONMENT
Of late, the educated sections among our people
become somewhat conscious of the environmental
problems. But this knowledge has not yet seeped
down to the masses, nor are effective steps being
taken for preventing and counter-acting pollution of
various kinds.

Untreated sewerage and industrial effluents with
toxic elements are polluting the water resources in our
urban areas. While a majority of our villages do not
have easy access to portable water, even those who
have this facility pollute it through their unhygienic
practices. Many diseases, some of them on epidomic
scale, are directly and indirectly caused by the pollu­
ted water. Careless spraying of insecticides and pesti­
cides poison the water, soil and air in our countryside,
affecting the health of men as well as cattle.
The
devastating floods, droughts and landslides, which
have increased in recent years, have brought home to
the people the dangers of indiscriminate felling of trees.
The deforestation in the various parts of the world is
increasing the quantum or carbon dioxide in the at­
mosphere and threatens to cause major climate
changes. In our metropolitan cities and other indus­
trial centres the factories are incessantly belching out
smoke containing carbon, harmful chemicals and toxic
metallic particles which affect the lungs and eyes of
the people residing in those areas.

October 1980

In order to protect our environment the mass media
should carry out a sustained and systematic publicity
campaign. The government and local bodies should
take immediate steps for treating the sewerage and
for compelling the industries to purify their affluents
before they are discharged into the public waterways.
Government should also increase the pace of provid­
ing protected water supply to the villages. These pro­
grammes will, of course, cost an enormous amount of
money but human life and health are more precious
than money. For preventing the indiscriminate felling
of trees there should be a nation-wide movement on
the mode of CHIPCO of Uttarakhand (UP) which
should also add to its activities the planting of trees
on a large scale. Despite the annual Vanmahotsav
Official action in afforestation has so far been very
inadequate, and the country can be made green
within a short time only if the youth take up this work
with a missionary zeal. Meanwhile the statutory
Boards which have already been set up at the Centre
and in the States to control water pollution should
work more actively and enforce the Water Act of
1974 with more vigour by prosecuting the factories,
etc., which cause pollution. Last but not the least.
we, as a developing nation, should not repeat the
mistake of the developed nations in over-exploiting
our national resources in the name of economic deve­
lopment.—Courtesy: Yojana, 1 July, 1980.

267

Institutes—6

NATIONAL TUBERCULOSIS INSTITUTE
BANGALORE
Dr A. Banerji

The progress of health programmes is very much dependent on the facilities available in
the country for training and research. This feature, Institutes of India, introduces such
institutes as they play a vital role in the preparation of personnel to man health and
medical services. This is the sixth in the series of the feature.
he problem of tuberculosis is mainly rural-based
because 80 per cent of the population live in vil­
lages in India. This was the finding of the Indian
Council of Medical Research (ICMR) through the Na­
tional Tuberculosis Survey conducted in 1955-58. This
is contrary to the age-old conception that tuberculosis is
predominant in towns and cities. For this reason,
facilities for diagnosis and treatment of tuberculosis
were concentrated mostly in urban areas. In a subse­
quent study, it was found that domiciliary treatment
with the chemotherapeutic agents is as effective as
institutional treatment. It is also much cheaper in
cost and. easily available to the patients who were
otherwise denied proper treatment because of shortage
of beds.

T

The above two studies changed the whole concept
of tuberculosis control in the country. Backed with
this new knowledge, the National Tuberculosis Ins­
titute (NTI) was born in 1959 at Bangalore with the
assistance of WHO and UNICEF. It was inaugurat­
ed by the late Prime Minister Jawaharlal Nehru in
1960. This Institute is the only one of its type in
the entire South-East Asia Region.
Objectives

The main objectives of the Institute are:
a. To formulate a nationally applicable tubercu­
losis control programme.
b. To train the required key personnel for orga­
nizing such a programme all lover the country.
c. To plan and conduct further epidemiological,
sociological, bacteriological and operational
research studies.

268

Achievements
Formulation of Tuberculosis Control Programme
On the basis of several operational and sociological
investigations carried out by the Institute between
1959 and 1961, a programme was formulated and
tried in the field conditions in the Ananthpur
district of Andhra Pradesh. It was later accepted
by the Government of India for its imple­
mentation throughout the country, as a National
Programme. This has been a major breakthrough in
the methodology of tuberculosis control.
The programme envisages free diagnotic and treat­
ment facilities through all health institutions in the
country to the patients reporting with symptoms
of pulmonary tuberculosis.
Thus, these facilities are
provided as near to the patients’ homes as possi­
ble. This will facilitate better acceptance and co-ope­
ration from the patients since treatment of tuberculo­
sis is a prolonged one, extending to a period of more
than one year.
Training
To organize such a programme all over the coun­
try, it became necessary to train a large number of
workers both medical and paramedical; hence the
tuberculosis training programme. The main feature
of the training programme is to impart “inservice
team training”. Each team consists of a medical offi­
cer as the team leader, a treatment organizer, a labo­
ratory technician, a statistical assistant and a BCG
team leader. Till date, the Institute has conducted
41 training courses, each lasting for 13 weeks dura­
tion and has so far trained 670 medical officers, 800
treatment organizers, 522 X-ray technicians, 609 la­
boratory technicians, 537 statistical assistants and

Swasth Hind

354 BCG team leaders. The Institute has thus trained
a total of 3,492 workers who arc expected to organize
the programme in 400 districts of the country. Be­
sides these, the Institute has also trained several WHO/
UNICEF participants sponsored by the developing
countries in the South-East Asia region.

The Institute has undertaken operational studies
for simplifying, standardizing procedure for diagnosis,
treatment and for developing the programme in con­
sonance with the changes in
the infrastructure
of the health service. The diagnostic procedure had
to be simple and cheap enough to be carried
out by the available staff of the existing Gene­
ral Health Services on a permanent basis.
Re­
search undertaken at NTT has shown that diagnosis
can be easily made by simple examination of sputum
for those reporting to health institutions with cough
of more than two weeks’ duration. X-ray is not a
‘must’ in the diagnosis of the infectious cases of pul­
monary tuberculosis. Rather, mass case-finding by
X-ray examination—a very costly procedure that our
country cannot afford—does not yield any better result
compared to the simple, cheap and easily applicable
method of scutum examination of the out-patients in
hospitals and dispensaries in general. With the intro­
duction of “multi-purpose workers” scheme, the fea­
sibility of their involvement in finding out cases has
been studied by the Institute and the results are pro­
mising.
The main problem in combating tuberculosis is
that the patients do not complete their prescribed

treatment. Studies undertaken to study the sociolo­
gical behaviour of patients and the different methods
of motivating them to complete their treatment have
shown that one of the main reasons for discontinua­
tion is the prolonged duration of treatment of more
than one year. A study in collaboration with the
TCMR is in progress to explore the possibility of
shortening the treatment period to five to six months.

There is yet another important factor which influences
the planning process of TB programme. The NTT
research work has revealed that tuberculosis disease
problem in the country is to be viewed as a long-term
one like the problem of nutrition and leprosy. And
no crash programme for tuberculosis control on the
lines of smallpox eradication can succeed.
The Institute has recently been given the responsi­
bility of mointoring the programme in the country.
Of the 400 districts in the country, the programme is
functioning in 317 districts. Based on these reports,
about one million TB patients are on treatment in
the entire country.
The greatest contribution of the NTT has been to
work out the modalities of a down-to-earth programme
which is integrated with the general health services:
tuberculosis being a widespread disease and a long­
term proposition.

These modalities have been utilized by the pro­
gramme planners in India and other develooins
countries to formulate and set the trend of tuberculosis
control activities.

TUBERCULOSIS IN INDIA—A few Facts
O Tuberculosis is infectious. In India, about 38 per cent
of the population are infected. This does not mean that
they have tuberculosis.
Sixty lakh people get infected
every year.
O There are about 120 lakh tuberculosis patients. Of these
about 25 lakhs are excreting bacilli and infecting others;
they are known as ‘cases’ and are infectious. Examination
of their sputum throuch microscope or culture can dia­
gnose whether they suffer from tuberculosis or not. The
remaining 95 lakhs are not infectious and thus pose no
risk to the community. Thev can be diagnosed by X-rav
and other investigations.
Every year, six lakh patients
become infectious.
O The challenge today is how to diagnose and treat these
patients who are spread over about 6,00.000 villages and
4.000 towns and cities. To meet this challenge Disjrjct
Tuberculosis Programme of the NTI provides facilities
for diagnosis and treatment through the existing, health
services such as PHCs, rural and urban dispensaries, etc.
Todav. after the launching of the District Tuberculosis
Programme ten times cases are diagnosed and treated.
■OSnutum examination under microscope is a sure method
of diagnosis than X-ray. X-ray reading needs long-term

October 1980

socialized training. Whereas with minimal training any-j
body can examine sputum.

OThe earlier belief that tuberculosis patients need sanato- ;
num admission, nutritious diet, bed rest and regular ex­
ercise for their cure is not true. The discovery of potent
anti-TB drucs have made it possible to treat the patients
at home, with the normal diet that they take.
OTuberculosis is curable.
Potent drugs are available to
cure if. Drugs can be supplied to patients even in the
remotest rural areas through the existing network of
health services. But, the duration of treatment is at least
12 months, preferably 18 months. Uninterrupted treat­
ment with adequate doses is an important factor for
tuberculosis cure.
OBCG vaccination is still useful for children of nre-school
age up to five years, preventing a bacillary tuberculosis.

Olt is necessary to utilize the existing health staff like mul­
tipurpose workers, auxiliary nurse-midwives, basic health
workers in umvidina vaccination to the children. They
must be trained,... And a network of supplies and super­
vision bias to be developed.
a

269

THE INEQUALITY OF DEATH
Assessing Socio-economic Influences on
Mortality
Death operates at different levels in different places and
among different groups. Mortality levels are influenced by socio
*
economic factors that are differentially distributed by soda! class.
Ulis inequality of death is part of the gross inequality in health
status between countries and within countries, and is equally
unacceptable.
The following article, excerpted from WHO
Chronicle of January 1980. describes efforts to study the diffe­
rentials in mortality associated with socio-economic status, and
some of the difficulties and pit-falls encountered in such statistical
studies.

are two main reasons for studying diffe­
rentials in mortality by socioeconomic groups.
One is related to the identification of determinants of
mortality. All societies are to some extent differentiat­
ed into social groups distinguished by occupation, edu­
cation, income, region, ethnicity and other characteris­
tics. These distinctions are associated with variations
in individual endowments, personal behaviour, and
relations between the individual and the State. To
a large extent, social divisions structure all human
relations and form the background against which the
biological processes that lead to illness and death ope­
rate. Socioeconomic differences are thus mortality
determinants of a different type from such factors as
birthweight, nutritional intake, cigarette smoking or
water quality. Virtually all these socioeconomic factors
here

T

that are more proximate to the event of death are
differentially distributed by social class, and the social
class differences in the incidence of these factors pro­
vide a means of identifying their effect on mortality
and hence of influencing mortality levels.
What is more, the distribution of social classes is
itself a determinant of mortality levels in so far as a
different distribution would typically be associated with
a different level of mortality in a population. This
gives rise to the concept of “socioeconomic epidemio­
logy” according to which changes in health and mor­
tality levels can be effected not only through specific
health and medical action but also through changes in
the class structure, and in particular by bettering living
conditions among the poorest and most disadvantaged
groups.

•Based on the report of the Meeting on Socio-economic Determinants and Consequences of Mortality in Mexico City in
June 1979, which was sponsored and funded among others by WHO, the United Nations, the Committee for International Co­
ordination of National Research and Demography (CICRED), El Colegio de Mexico, ILO, Institute de Investigacioncs Sociales
(Mexico), International Review Group of Social Science Research on Population and Development, International Union for the
Scientific Study of Population (IUSSP), Organization for Economic Cooperation and Development (OECD) the United Nations

fund for Population Activities (UNFPA), and the World Bank.

270

Swasth Hind

Class or cultural differences in mortality cannot be
studied simply in terms of the various advantages and
disadvantages of a section of society. Significant ele­
ments in cultural differences are differences in the
attitudes adopted and the priorities given to risk-taking,
the different values attached to the incidence of mor­
bidity and mortality in the various sex and age divi­
sions of the family and society, and the relative des­
erts of such divisions in terms of food and treatment.
Unless these attitudes, priorities, and values and their
rates of change are understood, there can be no correct
assessment of levels of mortality, of the success or
failure of technical innovation, or of the speed of
change in mortality.

A second major reason for attention to socio-econo­
mic differentials in mortality is what they reveal about
social inequalities. Just as governments and econo­
mists arc concerned with income distribution as well
as average income levels, they must be concerned with
inequalities in the distribution of life itself. Even if
social class mortality differentials were unable to pro­
vide information that helped to reduce the general
level of mortality, they would still be of considerable
interest as pointers to inequality. Concern with social
justice leads to active attempts to reduce differentials
in mortality. Measures of these differentials therefore
become important indicators of the success of equalitarian programmes, as well as indicators of the distance
still to be travelled.
The present situation

There is no doubt that mortality levels have been
declining throughout the world, though at an uneven
pace. This can be inferred from the increasing rates of
population growth in the mid-1950s in many developing
regions of the world, including the lower income coun­
tries. In the majority of the developed countries, mor­
tality further decreased during that period and life
expectation improved at almost all ages. Some evidence
exists that socioeconomic differentials in mortality
have not been reduced as a result of the general decline
in mortality, and may have even widened. In this con­
nexion, it has been pointed out that in at least some
cases the absolute size and proportion of total popu­
lation at the extreme ends of the social groupings may
have been reduced, and thus the very high and very
low mortality groups are relatively small proportions
of the population (in the United Kingdom 5% and 7%
respectively).

In some less developed countries, mortality decline
has been found that is independent of economic level

October 1980

and development. In these countries, measurement of
trends in differential mortality has so far been a rather
neglected area, largely because of the scarcity of data.
Although generalization from the limited evidence at
hand is subject to great caution, it would appear that,
here also, the decline of mortality levels has not dimi­
nished the socioeconomic differentials in mortality
within a given country, and that even the opposite has
occurred in several instances. It seems that, in the same
way as economic development has sometimes widened
the socio-economic disparities in a society, it has also
led to a widening of disparities in chances of survival.
In theory all may have equal access to health services,
but in practice this may not be so because of differing
educational levels and attitudes towards health priori­
ties. Health care programmes, even if intended for all,
may give greater advantages to the privileged classes
that are better prepared to make use of them than to
the illiterate and the underprivileged.
One result of the uneven decline in mortality seems
to be that the differences between populations in vari­
ous parts of the world are wider than ever before.
This is supported by observations based on data for
Africa, southern Asia and Latin America.

Within low-mortality developed countries, major
regional and sex differences in levels of mortality are
found to persist. The comparison of European coun­
tries, during the period from 1950 to the early 1970s,
revealed a regional difference of 11 years in life ex­
pectation at birth for males as well as females (from
73.6 to 62.6 years for males and from 79.2 to 68.5
years for females). The causes of these differences are
still inadequately explored; however, it appears that
male mortality is often relatively higher in the regions
that are most highly urbanized and where mining
and heavy industry or dockyards are concentrated. In
contrast, the populations of predominantly agricultural
regions appear to enjoy a higher life expectation. In
less developed countries, however, rural mortality is
apparently universally higher than urban mortality.
Apart from the regional differentials and their pos­
sible association with the social and economic profile
of the region, differences in mortality persist within
countries by social class, subculture, ethnicity, edu­
cation, housing conditions, income, etc. Most of these
characteristics are interrelated and it is difficult to
point to any one of them as being the major determin­
ant. Whatever classification of population stratification
is adopted, the same pattern eventually emerges: the

271

underprivileged, poverty-stricken, disadvantaged groups
persistently appear as groups of higher-than-average
mortality, even in the low-mortality countries.
Io some extent (yet unknown), social diseases ap­
pear to determine the occupation of individuals and
their social class. It undoubtedly takes some considera­
ble time to die of tuberculosis or of the effects of
alcoholism. It is likely that the existence of the disease
transfers the person to a lower social class—thus even­
tually affecting higher-than-average mortality in the
lower social class. A similar process of selection may
undoubtedly transfer ill people from higher to lower
income occupations or induce early retirement. Thus,
social class differentials in mortality are to some extent
the result of the dynamic processes through which
selection operates.
The view has been expressed that elimination of the
socioeconomic differentials in the low-mortality coun­
tries, despite the general mortality decline, is a possi­
bility that is unsupported either by theoretical consi­
derations or by empirical evidence. The prevailing
differences in life expectation at birth in those coun­
tries are relatively small, and even if the causes were
better known than they are at present, the total elimi­
nation of mortality differentials may not be a practical
possibility. Against this is the widely held opinion
that, at least in less developed countries
*
a marked
further decline in mortality may be obtained if efforts
arc focused on those aspects of social welfare, health
care and economic development that can be shown to
be most closely related to lower mortality levels.
The situation in less developed countries

The situation in the countries with moderate to
high levels of mortality differs in many respects from
that in the developed countries. First, only very limit­
ed hard data exist to assess the extent of mortality
differentials, but in the relatively few societies that
have them they reveal considerably wider differentials
by social class and other characteristics than are nor­
mally found in developed countries. In most instances,
mortality has to be estimated by indirect methods
that are usually able to throw only limited light on
the mortality of infants and young children. Secondly,
very few countries have adequate vital registration
systems that would enable the age and sex specific pat­
terns of mortality to be established by social, economic,
cultural and other indicators. Hence, very little is known
about socio-economic differentials in the mortality of
adults. Women of childbearing age appear to have

272

excessive mortality in some high-fertility, high-mortality, less developed countries. Thirdly, in many cases
the only data available on which to base the analysis
of mortality differentials are global socioeconomic in­
dicators which are not very useful, such as per capita
national product, proportion of illiterates, proportion of
urban dwellers, or proportion in the industrial work
force, whereas it would be more appropriate and
useful to base such analyses on household and com­
munity variables such as access to health services,
schooling, water supply, and regularity and seasonality
of food supplies.

Several studies have shown that one of the differen­
tiating variables consistently linked with child morta­
lity is education, and particularly the mother’s educa­
tion. How education affects mortality is, however, still
an unresolved problem calling for intensive research.
Reliable information on causes of death in less deve­
loped countries is virtually non-existent. In many cases,
only deaths that occur in hospitals, a small fraction of
the total, are certified as to their cause, and these
present an unrepresentative sample, particularly with
respect to residence and social class. Yet even the frag­
mentary evidence available clearly points to the possi­
bility of preventing many deaths, especially among
children and women of childbearing age. There is a
growing body of opinion that reorientation of health
programmes from hospital-based curative systems to­
wards community-based preventive systems and envi­
ronmental sanitation would not only achieve a speedier
reduction in mortality levels but would also help to
reduce the wide gap between social and economic
groups within a society.

Although much more data and further research are
needed before the operation of the various factors of
differential mortality can be understood, present know­
ledge is sufficient to encourage action against poverty,
malnutrition, ignorance and! superstition, as well as in
support of efforts to provide preventive health care and
meet the basic health: needs of the population in
order to reduce the gap in mortality between socio­
economic groups.

Problems of data collection
A research worker investigating mortality differen­
tials by socioeconomic groups has usually, at the mac­
rolevel of analysis, to make the best use he can of tabu­

Swasth Hind

lated data such as population censuses, economic sur­
veys, national budgets and expenditure, and informa­
tion on production, health personnel and health facili­
ties. Much of this is in the form of national or sub­
national averages, and characteristics such as distribu­
tion of income or access to health care facilities are
rarely, if ever, available. Data from demographic
surveys are also unsatisfactory. The variables that
describe the social and economic, position of indivi­
duals, families and households are often inadequate or
unreliable since such surveys have limited objectives
and are not specifically designed to explore social,
economic, cultural and other differentials in mortality.

The variables that are most often available at the
microlevel of analysis are: occupation of the head of
the household, occupational status of the wife, edu­
cation (years of schooling, but often only whether
literate or not); household assets (selected items);
housing conditions (number of rooms; material of roof
and walls); water supply and sewage disposal; income
of the household; and land tenure.
When conducting an analysis of differential morta­
lity in the less developed countries, it is highly desira­
ble to collect, in addition to individual data, informa­
tion on family, household and community characteris­
tics. Some family characteristics, such as how decisions
are taken in the case of illness, by whom, and on what
grounds, may be difficult to obtain but could throw
light on the causes of differential mortality. Others con­
cerning the availability of food and distribution of
food within the family might explain to some extent
differential levels of undemutrition and malnutrition.
Anthropological procedures might usefully be intro­
duced to obtain information on family attitudes to risk­
taking, to the dangers of sickness and death, to the
cost of treatment, and to the risks involved in deferring
treatment.

The reason for introducing community variables in
the analysis of differential mortality is that the environ­
ment in which individuals and families live and work
determines, presumably to a large extent, the risks to
which they are exposed and the available ways of
remedying the adverse effects. These community varia­
bles include such things as the structure and opera­
tion of the health services, the prevalence of diseases
such as malaria, the quality of community sanitation.
and climatic characteristics. A microlevel study that
omits them risks missing important influences on mor­
tality levels, and also risks attributing an undue in­
fluence to the variables that are included.

October 1980

A problem constantly encountered in studies of
differential mortality by socioeconomic status is that
of the time reference or time lag. The data found in
censuses, surveys and vital statistics tables usually per­
tain to the date of reporting or to the time of death,
and no background information is given on socioecono­
mic variables such as income, occupation or place of
residence, which may have been quite different at the
time of first occurrence of the deterioration in health
that led to death perhaps many years later. Strictly
speaking, only accidental deaths and those due to an
acute illness are likely to be unaffected by the time
lag and the consequent distortion of the social and
economic indicators.
Composite indices—advantages and disadvantages

Social status is a multidimensional concept. The
terms “upper class” and “lower class” call to mind
a whole series of images related to education, occupa­
tion, style of life, housing conditions and so on. In
view of the multiplicity of dimensions of class, many
sociologists have recommended using social status or
class indices based on combinations of specific varia­
bles. There are several good reasons for doing this—
e.g., the sample size may not be large enough to allow
analysis by single characteristics, and secondly, the
reliability of individual characteristics may be doubt­
ful and it is hoped that the composite index will over­
come the defects.

Against these advantages must be weighed some
serious disadvantages. One is that the combination of
variables into a single index makes it virtually im­
possible to distinguish which of the underlying varia­
bles may be more important in determining mortality
levels. If composite indices alone had been used in
certain studies, for example, it would not have been
possible to discover the critical role of maternal edu­
cation in the child mortality of many populations.
There are good grounds for retaining the mother’s edu­
cation (years of schooling) as a separate variable, at
least in the analysis of infant and child mortality. A
second and related disadvantage is that the use of a
composite index prevents the identification of parti­
cular target groups for social and health programmes.

Methods and approaches

Methods of analysing mortality data to study asso­
ciations between mortality patterns and socioeconomic
variables depend largely on the type of data available.

273

If census (stock data) and vital registration (flow data)
are available, the traditional approach has been to use
the former as denominator (population at risk) and the
latter as numerator (events). Groupings on both sides
by sex and age are necessary. Unfortunately, the only
possibility of analysis offered by this approach is to
effect further disaggregations by characteristics such as
urban/rural residence and occupational categories.

The linking of census and death records has been a
decisive step forward in the methodology of mortality
analysis by socioeconomic status in more developed
countries. Three approaches can be discerned from
work in progress:

added a sample of persons bom subsequently and a
sample of immigrants arriving since the 1971 census.
The events at which information about the sample
members is recorded include censuses, birth of children, deaths of infants, death of spouses, cancer regis­
tration, and death.

Population registers that exist in a few countries at
the present time are another valuable source of data
on socioeconomic conditions, and have been used in
certain Scandinavian countries in analyses of differen­
tial mortality.
The use of indirect techniques

— the follow-back studies at present being conducted
in the United States of America;
— prospective studies, such as those undertaken in
France and the Scandinavian countries;

— the longitudinal studies recently started in the Uni­
ted Kingdom.
A feature of the studies undertaken in the USA is
that a sample of death certificates was drawn within a
period of three to four months shortly after the 1960
census. Linkage was made with the 1960 census re­
turns as regards criteria such as education, income and
occupation. The short period between census and death
ensures that the background information from the cen­
sus is not obsolete and thus largely avoids the time­
lag difficulty. A recent refinement of this approach is
the retrospective collection of details about the de­
ceased person from his or her relatives.

Two examples of prospective studies may be men­
tioned from France. In one, birth certificates have been
linked with death certificates for a sample of births.
This makes it possible to obtain very accurate infant
mortality rates per generation for each socio-occupational category. The other is a cohort study in which a
sample of individuals between 30 and 64 years of age
drawn from the 1954 census was classified once and
for all into socioeconomic categories and matched
with their death certificates; the sample is being fol­
lowed up at all ages until all the subjects concerned die.
Great interest centres on the longitudinal study un­
dertaken by the Office of Population Census and Sur­
veys in London which is designed to cover continuously
approximately 1% of the population of England and
Wales. To a sample drawn from the 1971 census are

274

All the above approaches require an elaborate sys­
tem of record-keeping, updating and retrieval which
are available in only a few countries. In the less deve­
loped countries the only usable sources of information
at present and for some time to come are sample sur­
veys, census data, and sample registration schemes.
The reporting of events such as births and deaths has
frequently been retrospective, with all the shortcomings
of such reporting, although sample registration sche­
mes and multiround surveys have come into use recent­
ly as a means of limiting them. A further difficulty is
that any underreporting that may occur may introduce
differential biases with respect to sex of the deceased
person, the educational status of the respondent, or
his or her age, and thus lead to spurious findings.

In view of these difficulties in using direct techniques
for the estimation of differential death rates in the less
developed countries, research workers usually also ob­
tain estimates by one or more indirect approaches.
Indirect techniques frequently use only one source of
information, which may be either a census or a survey,
to obtain information on the number of children ever
bom and children surviving, by age of mother, orphans
by age, etc. As the census or survey also contains in­
formation on specific socioeconomic characteristics of
the parents of the children and of the household, some
tabulations can be made for the differential analysis of
mortality.
Unfortunately, the indirect techniques most com­
monly employed are valid only for estimations of child
mortality between birth and the ages of two, three or
five years, as the case may be. Although the social
and economic circumstances of the family as measured,
for instance, by mother’s education, father’s occupa­
tion, and housing conditions have been shown to have

Swasth Hind

a pronounced bearing on the level, and sometimes on
the sex differentials, of early child mortality, they do
not allow more than an uneasy inference to be drawn
about differentials of mortality at other ages.
Apart from the ubiquitous drawback of the time
lag, indirect techniques are beset by certain difficulties:
different population groups may report to interviewers
with different degrees of accuracy and may be sub­
ject to different age patterns of mortality. Thus as­
sumptions may be made about particular conditions of
the population that are not necessarily valid for each
group, especially in the case of groups exposed to in­
ternal migration. Another problematic point is the com­
position of the group when mothers
*
education is con­
sidered. In many less developed countries, women’s
access to education is a relatively recent phenomenon,
and the older women in a group are likely to have
a much lower level of education than the younger.
International cooperation

The resurgence of interest in mortality research car­
ries a challenge to WHO and the United Nations in
their role of coordinators of health and population sta­
tistical activities. The following are some of the direc­
tions that international cooperation activities might
take:
Collection of data.—International assistance may be
required in organizing single or multiround surveys that
could provide the information on mortality needed by
governments and planning agencies. Such surveys
might be a first step to introducing or enhancing the
development of efficient national registration systems
for vital events.

Linking of existing data,—A largely untapped source
of information to which attention should be drawn is
the linking of existing data, as mentioned above. For
instance, linking housing and population censuses
could provide information on family housing condi­
tions; linking agricultural censuses with population
censuses would provide data on land holding and
utilization.

Education and training.—To heighten the aware­
ness of health administrators and medical and pub­
lic health students about the existence of socioeco­
nomic mortality differentials, materials should be
prepared for use in schools.
Short-term training
courses should be organized, especially in the less
developed countries, for health statisticians and other
government statisticians. In addition to mortality data
collection, processing and analysis, the curriculum of
such courses should include estimation procedures
based on indirect methods, and their limitations.

October 1980

Other subjects on which research needs to be pro­
moted are: the underlying causes of sex differentials
in mortality; the ways in which female education is
related to differential mortality, especially in less de­
veloped countries; and the biological ageing process
and differentials in the rate of ageing, by socioeco­
nomic groups.
Encouragement is needed for re­
search on the direct and indirect effects of work con­
ditions, including those of the housewife, in order to
improve understanding of socioeconomic differen­
tials in the adult years of life.
Future trends

The paths that research into mortality differentials
are likely to take in the future will be determined large­
ly by the stage of development reached by societies
and by national statistical systems. The countries of
the world do not really fall into the tidy grouping of
more developed and less developed but are situated
at different points along a continuum. It is however
convenient, in trying to estimate future prospects, to
separate countries into two groups since their needs
differ quite clearly, especially at the two extremities of
the continuum.
The less developed countries

The principal problem in the less developed coun­
tries is a lack of data. This relates both to quantity
and quality. Vital registration systems in these areas
are either deficient or non-existent. Consequently the
necessary foci of future activity will have to be on
the development of the vital registration systems and
of national survey capabilities. The former is the ulti­
mate goal, but realistically speaking will take at least
a generation or more to come up to acceptable stan­
dards of coverage and reliability. In the meantime,
countries will have to rely primarily upon surveys as
the source of good data for analytical and planning
purposes. Past surveys have paid little attention to
mortality and failed to produce useful data either for
estimating general mortality levels or for evaluating
differentials. A greatly expanded survey programme,
preferably coordinated and directed by WHO and the
United Nations is thus one logical direction for future
research activity. It is also clear that, if both levels
and trends are to be analysed and differential analysis
is to be undertaken, sample sizes will have to be sub­
stantially enlarged, special techniques developed, and
surveys not only multiplied but also extended over
longer periods than in the past. All this will be neces­
sary if patterns of mortality at all ages are to be fixed
with reasonable certainty, which is a prerequisite for
effective planning.

275

On a more specific level, a contribution to the study
of differential mortality could be made by WHO by
reinitiating or anticipating the expansion of the sur­
veys of infant, early childhood and maternal mortality.
There are several reasons for doing so. First, the large
core of experience that exists and could be drawn upon
for additional surveys of that kind, and secondly the
fact that morbidity and mortality in those age groups
commonly provide the most sensitive indicators of
levels, trends and differentials in mortality. The same
surveys can also be utilized to collect data of deaths
at other ages, and through enlarged samples provide
important information on the age and sex patterns
of mortality over the entire life span. Finally, im­
portant questions about morbidity and causes of death
might be incorporated in these surveys.
Finally, an essential concern in mortality studies in­
cluding research activities must be the training of na­
tional personnel and the development of national
household survey capabilities. The United Nations Sta­
tistical Commission, the Economic and Social Council
of the United Nations, the United Nations General
Assembly and the World Health Assembly have all
given the highest priority to the achievement of these
goals.

The more developed countries
The direction of research in the more developed
countries will tend primarily towards the refinement
of research techniques that are already known and are
being used in at least a few places. In "research on diffe­
rential mortality, more attention will have to be given
to finding explanations of the causes and consequences
of the sometimes subtle age and sex differentials.
This does not imply that levels and trends in mor­
tality in different population subgroups are well known
in the more developed countries. In many the basic
measurements have not been made, or else the data
collected have not been ordered in a way that enables
differentials to be established. Thus research in the
more developed countries will be directed less to the
collection of new data than to the more effective utili­
zation of existing data and data that are routinely col­
lected. Among techniques currently being tested, the
linkage of data from different sources would seem par­
ticularly promising for future development.

In sum, it may be said that future research in the
more developed countries will concentrate on questions
of how and why, and in the less developed countries,
at least initially, on questions of what, where and how
much, o

SOCIAL AND PUBLIC HEALTH PROBLEMS ASSOCIATED
WITH DRUG ABUSE
It is possible to identify certain specific social pro­
blems associated with drug abuse. Among them are the
following: —

(1) Drug abuse may result in economic losses that
have an impact on the user’s immediate social circle
(family or other dependents) and ultimately on society
as a whole.

(2) There may be a deterioration in family relations
resulting from (1) or from the user’s incapacity to func­
tion as a partner or parent.
(3) Drug users might be involved in various forms
of criminal behaviour beyond the illicit possession of
drugs for their own consumption. Such behaviour could
include crimes committed in order to acquire drugs,
offences in vehicular traffic or at work, trafficking in
drugs in order to ensure the users’ own supplies, and
crimes of violence committed under the influence of
certain drugs.

276

(4) Drug abuse leads to demands on social services
and medical resources, the cost of which is borne not
only by drug users but by the general public.
(5) Drug users are potential agents in the spread of
drug abuse both in their immediate social milieu and,
when they travel, in other national or international
settings . ..
Among the public health problems that have been
associated with drugs of abuse are: serum hepatitis,
infections, and septicaemia from the use of nonsterile
injection methods; physical disabilities resulting from
vehicular and other accidents; death due to overdose
and mixing of psychotropic drugs with other substan­
ces; nonspecific health disorders resulting from neglect
of personal hygiene and inadequate nutrition; men­
tal disorders and toxic psychoses precipitated by cer­
tain psychotropic drugs; damage to tissue, the central
nervous system, and the fetus.
From WHO Technical Report Series No. 618, 1978 (WHO
Expert Committee on Drug Dependence: twenty first report) PP26-27.

Swasth Hind

Health Minister’s Message
National Family Welfare Fortnight
The National Family Welfare Fortnight was observed
throughout the country from 16 to 30 September, 1980.
We publish below the messages from the Prime Minister
of India, Smt. Indira Gandhi, and the Union Minister
of Education, Health and Social Welfare, Shri
B. Shankaranand. (The Fortnight has since been
observed as a Month.)

PRIME MINISTER’S MESSAGE

As you all know
*
the Family Planning Programme
in our country is designed to strengthen the concept
of planning in family life. We know that it is not
correct to produce more children than we can take
care of properly. If we do so, it will be unfair to
our children. It will also undermine the health of
their mothers. Further, it will jeopardize our efforts to
lead happy lives.
“Over the years, the family planning programme has
acquired a much larger base. Today it provides essen­
tial maternal and child health care services to mothers
and children. At the same time, it contiues to offer
advice and facilities relating to family planning to
married couples. The basic aim behind the programme
is to help us all to lead better lives. This it seeks to
achieve in conjunction with other programmes of
development.

Smt. Indira Gandhi

“ A NATION’S wealth are its people. As we launch
zxthe Sixth Five Year Plan we are more than ever
before keenly aware of the importance of harnessing
human talents in the service of the nation. If each
man, each woman and each child is to become a better
citizen, a better worker and a better contributor as well
as beneficiary in the process of development, our em­
phasis must be on two programmes: education in its
widest sense and family planning.
Smaller families ensure more efficient management
of income for the maximum welfare of every member
of the family. Family planning is essentially a means
of improving the health of women and children, and
to make the nation as a whole to become stronger and
more dynamic.

It has always been our view, and I reiterate it that
this programme will be wholly voluntary. People should
be persuaded to have smaller families. If properly ap­
proached it is not difficult to convince them.”
New Delhi,
September 9, 1980.

October 1980

Indira Gandhi

Shri B.Shankaranand

We are trying to expand and strengthen services
both in relation to maternal and child health care and
family planning. We are also trying to disseminate
information about these services and to educate the
people on whose willing cooperation depends the suc­
cess of family planning. In this effort, we are taking the
support of all organizations that are interested in the
welfare of the people.
My appeal to the married people today is—take
advantage of these facilities, plan the birth of your
children according to your circumstances and lead a
better life. - To those who are already practising family
planning, my appeal is that they may talk about its
advantages to their neighbours and to others who may
come in contact with them.
It is recognized that whatever may be our means,
we can lead better lives if we plan our families. Let
us do so—in our own interest, in the interest of our
children and in the interest of our nation.”
B. SHANKARANAND

277

STUDY

Implementation of
Multipurpose Workers’ Scheme
in Ambala District
—An Evaluation
Y. P. Gupta, A. B. Hiramani, K. S. Sinha and N. N. Biswas

he Multipurpose Health Workers’ (MPW) Scheme
was introduced in the State of Haryana in the
year 1975. Initially, two districts, viz., Ambala and
Mahendragarh were selected for the purpose of imple­
mentation of MPW scheme. The Central Health Edu­
cation Bureau undertook an evaluation study of the
implementation of MPW scheme in the State of Har­
yana. The following were the objectives of the
Study:

T

Objectives

1. To study the structure and functions of MPW
scheme.
2. To find out the criteria laid down to determine
the feasibility of the MPW scheme in the
selected districts.

3. To study the different steps worked out for the
successful implementation of the MPW scheme
and the extent to which these were adhered to
in actual practice.
4. To ascertain the training status of workers, with
particular reference to the role of HFPTC and
Primary Health Centres (PHCs) in providing
training to the workers under the MPW scheme.

5. To study the actual functioning of the workers
under the MPW scheme vis-a-vis their prescrib­
ed roles, and the training they received.
6. To study the procedure of supervision and tech­
nical guidance.

278

7. To elicit the reaction of the villagers and non­
officials at village and PHC levels regarding
the working of the MPW scheme.
8. To study the system of documentation at all
levels concerned.

9. To identify the problems encountered in the
implementation of the MPW scheme at sub­
centre, PHC and district levels, and to elicit
suggestions to overcome these.
Method of the study

District Mahendragarh was dropped from the purview
of the study because of mass transfers of health staff
in the district As such only Ambala district was
selected. The study was conducted on sample basis
and a multistage sampling plan was used.
Out of eight PHCs in Ambala district, one PHC,
Raipur Rani which was a model PHC was excluded.
From among the seven PHCs, three PHCs were ran­
domly selected. Further, two sub-centres from the
selected centres were randomly selected. And from
each sub-centre, two villages—one the sub-centre head­
quarter village and one from the remaining villages
were selected, the latter village was selected randomly.
Thereafter, five villagers (three males and two females)
and three leaders—one each formal and informal male.
and one formal female leader were interviewed. The
five villagers were selected by following systematic
random sampling procedure.

Swasth Hind

A total of 122 persons—30 health personnel and 92
villagers—were interviewed with the help of semi­
structured schedule. In all four such schedules were
used. Besides, three record-proformae one each for
district, PHC and the sub-centre levels—were filled
in for selected units. The study was conducted in 1977.

field staff increased. The health supervisors carried
out concurrent and consecutive checks. Progress of
the scheme was reviewed through sector meeting, in
addition, checking of daily diaries and other records
was also resorted to for reviewing the progress of the
work.

Findings

The community’s experience with regard to the ser­
vices rendered by the health centre was confined to
malaria, family planning,
smallpox, maternal and
child health services, and treatment of minor ailments.
The workers had reported that they had good contacts
with the cummunity; but the community could not
recall whether one or more persons visited the villages
for providing health services.

The implementation of the scheme was well-planned
at various levels. The training of the staff was ade­
quately taken care of. The training was provided at
the Health and Family Welfare Training Centre,
Rohtak, as also at the PHCs in the Ambala district
to different categories of personnel concerned with
the implementation of MPW scheme. The training
was reported to be adequate but the facilities for con­
ducting it were reported to be insufficient. One-fourth
of the health supervisors, (male and female) and the
health workers (male and female) did not receive
training. This was largely due to the transfer of the
trained staff.
The MPW scheme was implemented in two phases
in the district. The chief medical officer had divided
the district into three sections putting each section
under the charge of a district level officer. At the
PHC, the medical officer and the lady medical officer
had not divided the area between themselves. Usually,
the latter had chosen areas which were near the PHC,
while the medical officer-incharge visited their areas
4-9 times a month, the lady medical officer visited
fewer number of times.

The health supervisors and the health workers were
found, by and large, to be carrying out their duties
as per schedule, with more emphasis on malaria.
This was so because the district was in the grip of
malaria.
The medicine kit which was to be provided to the
health workers for treatment of minor ailments was
not supplied (1977). The treatment of minor ailments
was the sheet-achor of the MPW scheme which was
grossly neglected. It was only carried out to some
extent by the lady health visitor/auxiliary nurse­
midwife.
It was a feeling of the workers that their performance
was more effective under MPW scheme than earlier.
As envisaged, the supervision of the work of the

October 1980

The system of documentation at the PHC level was
not followed as recommended by the Government of
India. It was a combination of the old and the new
patterns. Maintenance of an ‘atlas’ by both the health
supervisors and health workers was a new feature
under the scheme. But this was not found to be up
to the mark.
The scheme did face some problems. The district
level officers did not receive specific guidelines for
the implementation of the scheme, particularly in terms
of data to be maintained and returns to be submitted.
The existing staffing pattern at the district level indi­
cated that the officers were found still working for
specific programmes. For example, the district family
planning officer was concerned only with family plan­
ning work and likewise, the district malaria officer
with malaria. This created confusion among the
MPWs in deciding priority.

The district level officers also pointed out that there
were enough malaria cases in the district and as
such, the workers’ efforts were directed chiefly towards
the control of malaria. This resulted in neglect of
other aspects of the MPW scheme. The medical
officer-incharge, PHCs was also aware that the district
level officers on their supervisory visits laid more em­
phasis on their individual programmes. Non-availability
of medicine-kit and inadequacy of stationery were the
foremost problems of the workers at the sub-centre
level. The supervisors were also reported to be not
clear about their supervisory role—Detailed report can
be had from the Research Division of the Central
Health Education Bureau, New Delhi.
O

279

Health Education in Leprosy Control
Dr C. S. Gangadhar Sharma

Leprosy is highly endemic in Tamil Nadu.
Ignorance, illiteracy, general apathy
and lack of timely and proper treatment are responsible for the spread of leprosy.
The answer is health education of the people.
amil Nadu is one of the States in India where
leprosy is highly endemic. The disease has been
mentioned in the ancient literature. Though the dis­
ease was known yet a little or no organized effort was
made either for treatment or to ameliorate patients’
plight And the society was mutely witnessing the
suffering of the victims.
Some social workers say that leprosy patients are
ostracized by the society. I request them to go to
the villages and find for themselves that no such in­
human practice is in vogue. Such an attitude is not
prevalent among the socially and economically back­
ward communities. The patients are maintained as
long as they continue to add to the family income by
sharing work without demanding any special privilege.
They are given the same diet that the others eat, and
they live together within the family-fold without being
isolated. These patients visit their friends and rela­
tives and attend to religious or social functions in the
community. The patients do not experience any diffi­
culty in getting their children married.
But the condition is undergoing a sea-change in the
urban areas, especially among the affluent and literate
society. With increasing value attached to economic
standard in the social and community life, a change
is taking place in the behavioural pattern. The people
in such a society, now-a-days, try to dissociate them­
selves with their relatives afflicted with leprosy if they
are not of the same economic status. But even among
these groups, one can find that patients with advanced
leprosy, with high degree of positivity and deformity,
receive special attention when they attend to religious
or social functions, if their economic standard is above
the status of others.

T

Ignorance

Even now, many people, including the literates, do
not recognize early signs of leprosy. They always
associate deformity with leprosy. Unless an individual
has a deformity, he is not identified as a leprosy
patient.
They are not aware of early conditions of leprosy
as it is an asymptomatic disease causing no distress

280

like pain or itching sensation. When people have a
fixed idea that leprosy patient must have deformity,
they fail to accept the fact that early leprosy condi­
tion can be present in any normal looking individual.
When told that a member of their family is having
the early evidence of the disease, they become aggres­
sive, refuse to accept it; hence do not take any treat­
ment. The change of attitude in them is witnessed
only when the disease progresses and causes defor­
mity.
All the early lesions of leprosy however, do not
progress and cause deformity. The progress of the
disease depends upon the development of tissue im­
munity or organization of tissue defence. With strong
tissue defence one can clear the bacilli, and the early
patch disappears. Persons with varied degree of tissue
defence continue to fight with the organism. And the
result depends upon the virulity of the organism and
the strength of tissue resistance. If no tissue defence
is organized, the disease causing organism multiplies
and spreads without any impediment. It has been
scientifically found out that defence mechanism is
built up by cellular components. But the exact factor
which has failed to stimulate it to the same degree of
defence in all has not yet been identified.
A few among the affluent society have a strong
belief that they will not develop leprosy. They think
that it is the poor and starving people living in the
rural areas and slums alone can get it. Because of
this deep-rooted belief they do not accept the fact
when told that their children are detected as patients
of leprosy during school medical checkup. Instead
of taking steps to treat them they consult with their
family doctors who very often fail to tell the facts
about the disease. The patients realize their folly
only when the disease progresses.

When an adult is told about evidence of the disease
in him develops an inferiority complex and breaks
down psychologically. He fears that the disease is not
curable and he will end up as a crippled and would
be disowned by his own fellowbeings. He is mortally
afraid when anybody sees him during his visit to the

Swasth Hind

leprosy clinic or a specialist. He feels that he might
be identified as a patient of leprosy and he would
lose his social status. He would prefer to get his
treatment secretively from a quack rather than from a
qualified specialist. Sometimes, he consults half-adozen persons and get many ideas about what he
should do.

Leprosy is a disease caused by Mycobacterium laprae
even though it does not satisfy the Koch’s postulate
to confirm that organism as the causative agent for the
disease.
Mode of spread

The exact mode of the spread of leprosy is not defi­
nitely confirmed though various theories are being
expounded. There are chances of organism entering
through the nose from the contaminated air (droplet
infection), through the mouth from the edibles handled
by the patient, through the skin with close and inti­
mate contact with the patient or garments contaminated
by him. It is impossible to avoid being ‘infected’
in modem time because people are found crowded in
transports, meetings, bazars and places of recreation
like cinemahalls. Wherever there is a crowd, there
are always a few unknown patients from whom trans­
mission of the bacilli can take place.
Some have a firm belief that it can occur only in
certain families. They and their siblings will not
develop the disease because their parents or grand­
parents did not suffer from it. They do not realize

that today everybody is exposed to the risk of infec­
tion and anybody can get it. Further, one cannot be
definite whether their parents had the infection or
not; for, nobody has been maintaining any health
records. Leprosy has been associated with deformity.

Chances of contracting leprosy by sexual contact
has not been scientifically proved. However, short
stories are written and films produced for public show
giving currency to such notions. Such stories make
people believe that individuals with good character
cannot get the disease. People who have not indulged
in any extra-marital relations refuse to accept that
they are showing the manifestation of the disease.
The answer is health education of the people. Health
education should therefore lay emphasis on the follow­
ing points:—

* Anybody can acquire leprosy infection.
* All infected people do not develop the disease.
* The disease does not progress in all the persons.
Progress of the disease depends upon the deve­
lopment of tissue defence.
♦ It is not necessary that there should be a patient
in the home to spread leprosy to others in the
family.
♦ Leading a pious life, possessing wealth or literary
status of an individual will not prevent develop­
ment of the disease in him.
♦ Leprosy is curable like any other disease and
requires regular treatment. a

One CHV in each village by 1982-83,
CH Vs for slums also
The Community Health Volunteers (CHV) Scheme was launched on 2 October, 1977 with the aim
of placing “People’s health in people’s hands’*.
It completes three years.
Evaluation studies made by the National Institute of Health and Family Welfare along with six other
leading institutes of the country, have indicated that the CHVs scheme has been highly successful, accepted
by a majority of the people and has contributed significantly to the malaria control and the success of family
welfare programmes.

Every village in the country is to have its own CHV by 1982-83. The CHV scheme is also to be
extended to the slums to help slum-dwellers to participate in programmes designed to promote their health,
says a PIB release of 24 August, 1980.

By the end of June 1980, a total of 1,45,139 CHVs have been trained. The CHV scheme has been
extended in its third phase in 723 Primary Health Centres PHCs. The scheme in its first and second
phases, had already covered 1698 PHCs.

Every village or community selects one person per every 1000 population. The selected persons
undergo three months
*
training in promotive, preventive, and elementary health care. After the training,
the volunteer is provided with a basic kit, medicines and a manual. The CHV is paid a stipend of Rs. 200
during the three months
*
training and Rs. 50 per month as honorarium. He is also provided with medicines
worth Rs. 50 per month for free distribution.
CHVs also give to the villagers simple remedies for common diseases and act as a bridge between
them and the nearby PHCs. Another notable task of CHVs is the propagation of the small family norm.

October 1980

281

WHO STUDY

INDIA-WORLD’S LARGEST DONOR OF
DOCTORS
Peter Ozorio

multi-national
study by the
World Health Organization has
found that in the early 1970s, an
estimated 140,000 physicians—about
six per cent of the earth’s reported
total—were working outside their
countries of origin or training.

A

Of that number, some 120,000
or 85 per cent, practised in just five
countries. There were about 77,000
migrant physicians in the United
States; 21,000 in the United King­
dom; 11,000 in Canada; 6,000 in the
Federal Republic of Germany; and
4,000 in Australia.

Some 2,000 also migrated to Swi­
tzerland, making it the sixth highest
among countries where physicians
sought employment.
The study charts the migration of
physicians and nurses, its directions
and dimensions, analyzing as well
the “push” and “pull” factors that
determine it—that is, the forces that
compel or attract migration.

About five per cent of all the
world’s nurses are estimated to be
outside their countries of origin, the
study also shows. Each year some
15,000 migrate with about 90 per
cent going to eight countries.

I A commonly held view places a heavier
burden of blame for the “brain drain”
on the affluent countries.
However, a multi-national stuuy, “Phy­
sician and Nurse Migration: Analysis
and Policy Implications’*7 recently pub­
lished by the World Health Organi­
zation (WHO) says that the respon­
sibility rests equally upon • both the
richer “recipient” and poorer “donor”
countries.
The WHO study also shows that the
“drain” on a country is not so much
in the loss of “brains” — ano'her
commonly held view—but in mon^y
spent on the education of a physician,
or nurse who—unable to find employ­
ment at home—seeks it elsewhere.

This is a reference to tighter im­
migration laws and to tougher stan­
dards of licensing.

The study urges all countries
affected by migratory trends to work
together—now not the case—so that
a “mutually beneficial approach to
regulating health manpower may be
found”.

While world-wide in scope, the
data upon which conclusions are
based is drawn from 40 countries
most affected by migration. Also,
the study gives details of the expe­
rience of 13 countries, and through
a list of “do’s and dont’s”, it recom­
The ‘Brain Drain9
mends ways of managing migratory
Though a commonly held view flows.
places a heavier burden of blame on
the rich for the migration of physi­
Titled “Physician and Nurse Mi­
cians, nurses and other skilled per­ gration: Analysis and Policy Impli­
sons—the so-called brain drain— cations”, its WHO authors are Dr
the study contends that the responsi­ Alfonso Mejia, Chief, Manpower
bility rests equally upon the “reci­ Systems; Mrs Helena Pizurki and
pients”, the richer, and the “donors” Mrs Erica Royston.
the poorer, countries,

Thus, on the one hand, the study
warns developing nations that: “It
is not enough for donor countries
merely to lament the migration, wash
From the mid-60s to the mid-70s, their hands of the affair by laying
the United States attracted some the blame entirely on recipient
5,200 nurse migrants yearly, again countries.”
topping the list. The United King­
And, on the other hand, it says to
dom was next, with 3,300,
and
Canada third with 2,900. In addi­ developed nations: “It is not suffici­
tion, 850 migrated to New Zealand ent that the major recipient countries
and 590 to Switzerland.
individually and unilaterally take

282

measures—as they are now doing—
to curb the inflow of physicians.”

Migratory trends

The first migratory wave took
place in the late 1950s and early
1960s, the study says, with “an
exodus from war-ravaged Europe to
the New World.” About the end
of the 1970s however, the donors
began to change, from developed to
developing—and particularly Asian
—nations. So did the recipients.
Now they are the industrialized,
plus the oil-producing nations, and

Swasth Hind

in particular Saudi Arabia. Some in­
dustrialized countries however are
both donors and recipients.
Highlights of the study show the
following migratory patterns:

How to Manage
Migration of Health Personnel!

—In general, 95 per cent of mi­
grant physicians from Latin America
go to North America and five per
cent to Europe.

The brain drain, according to the WHO multi-national study,
“like most migrations is basically a symptom of deeper problems.
The desire or need to migrate is bound to lessen as these pro­
blems are resolved”.

About 40 per cent from Africa go
to Europe, another 40 per cent to
Canada and the United States, and
over 15 per cent to Asian and other
African countries.

The following advice may be useful for health authorities to
help manage the migratory flows:
— Do produce as many physicians as the country can afford,
or alternatively, do increase the demand for their services.
— Do plan for numbers and categories of health personnel.
— Do match education and training programmes to a coun­
try’s priorities.
— Do develop management capacity, beginning with a na­
tional corps of teachers.
. — Do rely on yourself, for “no country can really rely on
another country to solve its problems”.
— Do create a national network of local institutions to
facilitate technical cooperation.
— Do implement policies and plans realistically. But,
— Do not withhold passports “unless you want to create
greater discontent and encourage illegal migration”.
.— Do not ban foreign qualifying examinations “since phy­
sicians bent on migrating will travel to neighbouring countries to
sit such examinations”.
— Do not try to make salaries competitive with salaries in
rich countries, for then the services of physicians will be “out of
the reach of even larger segments of the population”.
— Do not coerce professional health personnel to work for
a specified time in hardship areas unless this applies equally to
other professions.
— Do not-attempt to solve health problems by wanting to
have ‘enough’ physicians.
“In affluent countries, the notion of ‘enough’ has no limits”.
the study says, “while in many poor countries, more than ‘enough
*
seems already to have been produced.”

About 65 per cent from Asia go
to North America, 30 per cent to
Europe, and five per cent to deve­
loping countries.

—In the United States, migrants
accounted for 10 per cent of all phy­
sicians in 1963, and for 20 per cent
—or one in five—in 1974, when mi­
gratory trends peaked. Tn terms of
absolute numbers, totals increased
from 6,000 in 1965 to 8,000 in 1973,
by over 30 per cent.

In addition, one of every three re­
sidents and interns in the United
States is a foreign medical graduate.
and, the study shows, there are twice
as many mierant women MDs than
there are U.S.-born.
Much like their U.S. colleagues.
the migrant physicians care for
patients, though more work in hos­
pitals. The migrant inclines more
towards research than towards ad­
ministration.
—Tn the United Kingdom, the
study shows, about 25 per cent of
all physicians are foreign medical
graduates, or one in four.

“Tn 1973. they accounted for 16.5
per cent of all physicians in general
practice, and 34 per cent of those
in the hosoital service”, the study
states, “where they are greatly overrepresented in the junior grades and

October 1980

In the United States, for instance,
the average age of the migrant phy­
sician from India was 33. and from
—In the two countries, the study the Philippines 36, as compared to
shows, the foreign medical gradua­ the United States 43.
tes tend to be younger than their
national counterparts. Those from —In Canada, over 30 per cent—
Asia are youngest of all.
or one in three—of all physicians

under-represented
grades.”

in

the

higher

283

are foreign medical graduates. Ac­
cording to the study, there were
9,400 migrants in 1971. and 11,200
in 1973—an increase of 12 per cent
in two years.

—In the Federal Republic of Ger­
many, there were 5,600 migrant
physicians in 1971, including 1,800
Europeans and 2,200 Iranians.
—Tn Haiti and Ireland, there are
fewer physicians in the countries
than there are abroad.
Major donors

Kingdom, with an estimated 2.000 physician-to-population ratio of 2.2
migrating yearly, followed by Aus­ physicians per 100,000.
tralia with 1,500.
That is low, the study says, but
it is still “much higher than the
The ‘Sustainable Level’
country’s sustainable level”. With a
What is the primary determinant per capita income of about U.S.
of migration? According to the $120, and a growth rate of 1.5 per
study, developing countries turn out cent per annum, India “really could
far more MDs than they can afford afford only 35.000 physicians”.
to employ.
As “the vast majority of the
The situation is just the reverse population cannot possibly pay for
in developed countries. Mainly as private care”, India, in effect, then
a result of “restrictive practices of
had a “surplus” of between 80.000
the medical profession”, these coun­
to 100.000 physicians.
tries turn out an insufficient numb­
er of MDs, thereby providing open­
India estimates it costs U.S.
ings for the migrant physicians.
59,600 to train a physician. Thus.

The No. 1 donor country today
of physicians is India, with an esti­
mated 15,000 MDs abroad. “There
Neither the developed nor the de­
is scarcely a recipient country in the
veloping nations attain what the
world where there are no Indian
study refers to as their “sustainable
physicians”, the study asserts. The level”. The former, needing more
figure represents 13 per cent of the physicians, train too few. and the
country’s total.

the “15,000 physicians at present
outside India represents a lost in­
vestment to India of U.S. SI 44 mil­
lion”. But the loss is not in the
services they could have rendered
had they remained at home.

latter, needing less, train too many.
“They would, most probably, not
Migration then becomes inevitable,
for at its root is supply and demand. have found suitable employment,
and might even have been a charge
Because many U.S. students fail on the economy”, the study pointed­
to gain admittance to medical ly states, while explaining:
schools at home, they go abroad
The loss is “in the fact that the
for training. Mexico is “chief host”
money
spent on the education of
to them, the study says. As a result,
these emigrant physicians would
about
a
tenth
of
all
graduates
of
The money spent on the training
have been better spent on other
of migrant Filipino doctors “cons- foreign medical schools practising in forms of health personnel and heal­
titues a lost investment of some US the United States are U.S. citizens. th care”.
SI00 million”, the study says, “over
Thus far. there has been little
The “drain” on a country is there­
twice the annual health budget of
or no attempt to relate graduates to fore not so much in the loss of
the Philippines”.
the numbers a countrv can afford “brains”—another commonly held
Twenty-five countries are listed in to employ. Tn the light of known view—but in the monev put into the
the study as donors of physicians. estimates showing that “eight medi­ education of a nhvsician who. un­
among them: the United Kingdom cal auxiliaries could be trained for able to find suitable employment
with 8.300 abroad, the Federal Re­ the cost of one physician”, the study at home, seeks it elsewhere.
public of Germany with 4.600 and says “one may ask why countries
High income abroad, a “pull”
produce physicians apparently with­
Ireland with 4,300.
factor,
coupled with a lack of gain­
out regard for the demand of their
ful
empoymenf
at home, a “push”
The No. 1 donor country of nur­ services.
factor,
are
among
maior influences.
ses is the Philippines. Figures show
When
the
factors
combine
the sfudv
13.500 Filipino nurses abroad, or India’s example
savs.
“
then
the
propensity
to mig­
88 per cent of all nurses in the
The sfudv notes that India is the rate becomes strong”.
countrv. It is estimated that 2.400
‘‘world’s largest donor of medical
migrate yearly.
Fa
ting migration
manpower”. Estimates put India’s
Second among 20 countries listed total number of physicians at 135.000
What makes migration so rela­
as donors of nurses is the United in 1972, which gives the country a tively easy? First and foremost, it

The Philippines is the second lar­
gest donor. Figures for the early
1970s show 9.500 MDs abroad, equ­
ivalent to 68 per cent of the coun­
try’s total, and to “at least eight
years’ production of its medical
schools”.

284

Swasfh Hind

is the increase in the number of
schools over the last 20 years, many
established, partly, because a medi­
cal career is regarded as an impor­
tant vehicle for social mobility” in
the developing world.

Of some 30 Arab states, Syria
In the United Kingdom, for ins­
tance, of the 21,000 migrant physi­ had the lowest number of migrant
cians practising in the 1970s, most physicians—30 or just 1.8 per cent
were from countries with English- of the total of all MDs in the coun­
language or Commonwealth ties. try.
These are factors that not only make
Saudi Arabia and the United
migration easier but also determine
States
are the only two countries
the
direction
it
takes.
By 1970, there were already 17
that are essentially recipients, the
more schools in the
developing
Among migrant physicians were study says. Most others are both
world, with a total of 489, than in
the developed world, with 472. Even some 9,200 from India, Pakistan, recipients and donors of physicians
so, five years later, the margin of and Sri Lanka, whose numbers in­ and nurses, among them the United
difference widened to 92, with 608 creased by 52 per cent over five Kingdom, Canada, the Federal Re­
years; 3,100 from Ireland; 1,100 public of Germany and Australia.
and 516 respectively then.
from Australia; 900 from South
The United Kingdom, for instance,
Over those years, Brazil establi­ Africa; 360 from New Zealand; and “lost some 8,000 physicians chiefly
shed 53 schools to achieve a growth 260 from Nigeria.
to Australia, Canada, and the Unit­
rate of 230 per cent; Mexico 34 for
ed States, but gained 21,000 chiefly
a rate of 188 per cent; India 62 for
from Commonwealth countries”.
141 per cent; and Colombia 7 for Oil-exporting states
Many of those leaving were origi­
100 per cent.
Yet another trend pointed up by nally migrants to the United King­
the study is the migration of physi­ dom.
By way of comparison, Spain cians and nurses to oil-exporting
established 11 schools for a 110 per Arab countries, notably Saudi Ara­
Along with a handful of other
cent growth rate; Japan 23 for 50 bia, Algeria and the Libyan Arab nations, the United Kingdom and
per cent; the United States 38 for Jamahiriya.
Canada are often “way stations”—
45 per cent; and the Soviet Union
for political, cultural, economic,
18 for 26 per cent.
educational,
or professional reasons
For instance, there were 1,140
migrant physicians at work for the —rather than final destinations for
However, of the 119 schools set Saudi Arabian government in 1974, migrations. This is another trend
up in the developing world between representing about 90 per cent of all brought out by the study.
1970 and 1975, 31 were established MDs in government employ. More­
In 1972, some 650 physicians,
in countries without a single school over, nearly all came from Muslim
originally
from Asia, who had set­
before.
nations, including 590 from Egypt
tled
in
those
two countries, moved
and 420 from Pakistan, and none
on
to
the
United
States. In much
Migration is facilitated also by from developed countries. In addi­
the
same
way,
Spain
was a stepping
medical curricula still largely based tion, there were between 2,000 and
stone
for
30
Cuban
migrants.
on standards of the western world, 3,000' migrant physicians in private
the study says.
practice.
Therefore, “for many physicians,
According to Dr David TejadaThere were also 2,400 migrant
de-Rivero, WHO Assistant Direc­ nurses employed by the government.
tor-General: ‘Health leaders in de­
veloping countries frequently share
Figures for that year also show
the values and interests of then- Algeria with 1,200 migrant physi­
counterparts in affluent societies.”
cians, about 70 per cent of the
country’s total; Libyan Arab Jam­
They essentially train students “up ahiriya, with 780, or 94 per cent of
to international standards’1 conferr­ its total; the United Arab Emirates
ing “a degree that is tantamount to with 200 or 95 per cent; Oman with
an international passport”, all of 160 or 90 per cent; and Bahrain
which facilitates migration.
with 80 or 77 per cent.

October 1980

migration is not a once-and-for-all
move, from one country to another”,
the study shows.
Whatever the migratory trends,
however, the world situation is this:
Only one fourth of the world’s phy­
sicians are in the developing world
where two-thirds—the majority—of
the earth’s population lives, while
three-fourths are in the developed
world, where a third
*
of the popula­
tion lives. c=3

285

On Nutrition'
NUTRITIONAL ANAEMIA
This is the sixteenth in the series of the feature. Nutritional anaemia is the end result of a
severe nutrient deficiency. From the public health and socio-economic points of view,
anaemia is important because it interferes with the sense of the well-being of the individual
and reduces productivity and work capacity besides contributing to the overall mortality
and posing threat to the life of the mother. This can be prevented as well as treated.
The World Health Organization has defined nutri­
tional anaemia as a condition in which the hemoglobin
content of the blood is lower than normal as a result
of a deficiency of one or more essential nutrients,
regardless of the cause of such deficiency. Malaria,
schistosomiasis, and various other diseases can con­
tribute to iron deficiency anemia and several causes
of anaemia can coexist in an individual.

Nutritional anaemia is the end result of a severe
nutrient deficiency, usually iron, less frequently folate,
and rarely vitamin B12. Hemoglobin concentration,
by which anaemia is diagnosed, is a relatively in­
sensitive index, thus a person who is
* found to be
manifests itself clinically in pallor, anorexia, lassitude,
anaemic is already suffering from quite a market
degree of nutrient deficiency. Very severe anaemia
dizziness, breathlessness, and edema and soreness of
the tongue and mouth.

From the public health and socio-economic points
of view, anaemia is important because it interferes
with the sense of wellbeing of the individual, and re­
duces productivity and work capacity, it aggravates
many other disorders; it contributes to the overall
mortality associated with malnutrition, and, in the
case of anaemia in pregnancy, it poses a threat to the
life and health of the mother at the time of delivery
and contributes to low birth-weight and thus poor
viability of the infant
Some individuals can seemingly function normally
with severe degrees of anaemia, but most cannot.
Even mild anemia impairs wellbeing. For example,
studies of sugarcane cutters in Guatemala, latex tap­
pers and weeders in Indonesia, and tea-pickers in Sri
Lanka have shown a direct relationship
between
hemoglobin concentration and work output.
Causes of nutritional anaemia
Nutritional anaemia may be caused by insufficient

intake, poor absorption, or an increased requirement
of one or several blood-forming nutrients.

Insufficient intake
Insufficient intake of iron is chiefly observed in
young children consuming dairy products or other
foods of low iron content at a time when their require­
ments are relatively high for the rapid build up of
blood and tissues.
It is also found among young
women who voluntarily restrict their dietary energy
intake for aesthetic reasons, because iron and energy
intake are roughly proportional. There are other in­
stances of insufficient iron intake, but these are rather
exceptional and are usually combined with other defi­
ciencies such as occur in famines.
The intake of folate and vitamin Bn is usually
sufficient in most diets, only becoming insufficient in
the presence of special culinary or dietary practices.
Overcooking of foods, especially vegetables,
can
cause folate deficiency, and complete avoidance of all
animal products in the diet, as practised by some
vegetarians, may lead to vitamin B]3 deficiency.
Poor absorption
The rate of absorption of iron is influenced by the
dietary pattern and the level of iron stores in the
body.
It is increased by the presence of animal
products in the diet, or of some other constituents
such as vitamin C and some amino-acids. The iron
in vegetarian diets is usually poorly absorbed, and
unless there are other factors present that enhance
the absorption, iron deficiency anemia will develop.
This is probably why widespread and severe anaemia
is so frequently observed in some developing coun­
tries, such as those in Asia.
Increased requirements
The body’s increased requirement for iron may be
physiological or pathological. Normally, a certain
percentage of women lose large quantities of blood
during menstruation and, therefore, require higher
amounts of iron.
During pregnancy, folate and iron

requirements arc increased, becoming six times grea­
ter for a woman in the last three months of pregnancy
than for a non-pregnant woman. As a consequence,
women of reproductive age are especially vulnerable
to iron and folate deficiencies.
It is interesting to
note that hormonal contraceptives tend to reduce the
menstrual blood flew and thus the loss of iron; how­
ever, intra-uterinc contraceptive devices have the.
opposite effect, in certain pathological conditions, such
as hookworm infestation, there may also be increased
loss of blood and, therefore, of iron.
This is, in
fact, a major cause of anemia in most developing
tropical and sub-tropical countries.

Prevalence
There are now about one billion women in their
reproductive years; over two-thirds of them live in
developing countries, and bear on average over twice
as many children as do women in the developed
countries.
At any given time roughly every sixth
woman, 15 to 49 years of age, living in developing
countries is pregnant, compared with about one in 17
in developed countries. From the information avai­
lable, it appears that at least half of the non-pregnant
women and nearly two-thirds of pregnant women
have hemoglobin levels below those established by
WHO as indicative of anemia. This makes a total
of some 260 million anemic women in the develop­
ing world alone. The overall proportion of anaemic
women is highest in Asia and Oceania, followed in
the descending order by Africa and Latin America.
In developed countries, the prevalence of anaemia
ranges from 20 per cent in non-pregnant women and
up to 35 per cent in pregnant women. The total
female population between 15 and 49 years old in
these countries is estimated at 275 million, of whom
16 million are pregnant at any given time.
Assum­
ing conservatively that 10 per cent of non-pregnant
and 30 per cent of pregnant women are anaemic, this
would make an additional 31 million, bringing the
world total (outside China) of anemic women bet­
ween 15 and 49 years of age to 291 million.
Accurate information concerning the prevalence of
anaemia in children under school age is not available,
but figures of 20 to 50 per cent have frequently been
mentioned. Therefore, the total figure of anaemic
individuals may be around 500 million, and perhaps
more.
Treatment
Treatment consists of administering iron compounds
orally.
Rarely is the anemia so severe that it re­
quires emergency treatment, such as blood trans­
fusion.
Giving iron tablets is, as a rule, sufficient;
but they must be taken two or three times a day for

October 1980

several weeks before the hemoglobin concentration is
restored to normal levels.
The length of adminis­
tration is a major drawback to the treatment; be­
cause motivation to continue medication is usually
lacking in anemic individuals. Iron compounds for
treatment of anemia should have high bioavailability,
acceptability, and low cost.
Reduced iron and fer­
rous sulfate meet these criteria. Iron is best absorbed
when the stomach is empty; however, it is also then
that it most frequently causes side-effects that consti­
tute another drawback to the treatment.
Most iron
preparations currently used are accompanied by a
high proportion of side-effects such as epigastric pain,
heartbum, vomiting, constipation, or diarrhoea. There
is an urgent need to develop more acceptable iron pre­
parations that cause fewer or no detectable side­
effects.

Prevention
The obvious approach is to increase the amount of
iron and folate absorbed and to reduce blood losses.
A change in dietary patterns, together with program­
mes to control parasitic diseases, are needed to
achieve the objective.
The increased consumption
of iron absorption enhancers, such as foods of ani­
mal origin, would help, but may not be immediately
practical in some areas for cultural or economic
reasons.
In the short-term, and in emergencies, the distri­
bution of iron suplements should be considered. The
approach may be especially effective when it is direc­
ted toward well identified, easily reachable, vulnera­
ble groups such as mothers during the second-half of
pregnancy. Side-effects and duration of administra­
tion are against drawbacks.
Another measure designed to improve the iron sta­
tus of the total population is to fortify food with iron.
The selection of the food vehicle and of the iron com­
pound is critical. The food vehicle must reach the
population at risk, and its flavour, colour, and tex­
ture must not be changed by the fortification process.
Several have so far been identified for iron fortifica­
tion; salt, wheat flour, milk powder, sugar, mono­
sodium gultamate, and fish sauce. The iron com­
pound must have a high bioavailability, be stable,
and inexpensive. It has been difficult so far to meet
all these criteria, and only a few fortification pro­
grammes have proved successful. Most have not been
evaluated, and it is not certain that they are effective;
this is especially true of some national programmes
of fortification of wheat flour. More developmental
research is urgently needed in this field. —Courtesy t
U.N. Administrative Committee on Coordination-SubCommittee on Nutrition.
n

287

WORKSHOP

HEALTH EDUCATION IN HOSPITAL
SERVICES AT JIPMER
Dr S. P. Mehta

A

workshop on Health Education in Hospital Ser­

vices organized by the P.S.M. Department of the
Jawaharlal Institute of Postgraduate Medical Educa­
tion and Research (JIPMER) Hospital, Pondicherry
in collaboration with the Central Health Education
Bureau (CHEB), New Delhi was held at Pondicherry
from 9 to 11 April, 1980. This is the seventh in the
series of such workshops held in different parts of the
country.

The objectives of this workshop included a review
of the existing conditions and resources available for
health education in JIPMER and other hospitals in
Pondicherry, and identifying the scope for integra­
tion of health education with the routine activities of
the hospital.
The workshop also sought to develop
a plan of action for educational activities at all pos­
sible areas in a hospital setting, and select appropriate
methods and media for this workshop. It also aimed
at identifying the roles of different categories of medi­
cal and para-medical staff in hospital health education.
Twenty-two senior medical officers from JIPMER
hospital and other hospitals in Pondicherry participa­
ted. Dr B. C. Ghosal, Director, CHEB, New Delhi in
his keynote address stressed the importance of impart­
ing health education in the normal routine activities
of hospital.
Dr (Miss) S. Pandit, Dy. Assistant
Director-General, CHEB, presented a scientific paper
on concept, philosophy and principles of health edu­
cation. Dr V. Sambasivam, Director of Health and
Family Welfare Services, Pondicherry, inaugurated the
workshop.

The participants were divided into two groups. The
first group discussed about the ‘‘analysis of existing
conditions and identification of situation and scope for
health education in hospitals”. The group observed
that there was no well-defined health education pro­
gramme in JIPMER hospital; but some efforts were
made to educate the patients in some of the depart­
ments.
In their view health education was mainly
given by personal communication and no audio-visual
aids were being used.
The group agreed that there

288

was a great scope for health education in out-patients
department with the help of audio-visual aids. The
staff of the hospital should undertake the educational
activities.
It suggested that the charts carrying slo­
gans should be displayed at all strategic locations in
the hospital.

The second group discussed the “plan of action for
health education activities in all possible areas in hos­
pital setting.” The group listed the points for planning
any programme on health education. The group also
discussed a specific plan of action. Many problems
were considered like leprosy, tuberculosis, malnutrition
and family planning.
It decided to draw a plan of
health education on scabies in the OPD and wards.
Recommendations
The recommendations of the workshop included:

♦The group consensus was in favour of integration
of health education in the hospital services. For
its effective implementation, each and every indivi­
dual working in or for the hospital irrespective of
the part he plays, should undertake educational
activities as part of his daily routine.
♦The preventive & social medicine department
should be a central guiding force for all technical
matters including planning, execution and evalua­
tion of the educational activities and in the pre­
paration of educational media required for such
activities.
♦There should be an apex body in the form of
health education committee consisting of medical
superintendent, health educator and the represen­
tatives of all other departments including nurses.
This committee should do planning, implementa­
tion, building up of financial resources and
arrangements for training of various personnel in
health education.

♦Formation of an educational cell headed by health
educator for the daily implementation of educa­
tional activities. This cell should include repre­
sentatives from residents, nurses, medical students
and social workers, a

Swasth Hind

WORKSHOP

HEALTH EDUCATION IN HOSPITAL
SERVICES AT JIPMER
Dr S. P. Mehta

A

workshop on Health Education in Hospital Ser­

vices organized by the P.S.M. Department of the
Jawaharlal Institute of Postgraduate Medical Educa­
tion and Research (JIPMER) Hospital, Pondicherry
in collaboration with the Central Health Education
Bureau (CHEB), New Delhi was held at Pondicherry
from 9 to 11 April, 1980. This is the seventh in the
series of such workshops held in different parts of the
country.

The objectives of this workshop included a review
of the existing conditions and resources available for
health education in JIPMER and other hospitals in
Pondicherry, and identifying the scope for integra­
tion of health education with the routine activities of
the hospital.
The workshop also sought to develop
a plan of action for educational activities at all pos­
sible areas in a hospital setting, and select appropriate
methods and media for this workshop. It also aimed
at identifying the roles of different categories of medi­
cal and para-medical staff in hospital health education.

Twenty-two senior medical officers from JIPMER
hospital and other hospitals in Pondicherry participa­
ted. Dr B. C. Ghosal, Director, CHEB, New Delhi in
his keynote address stressed the importance of impart­
ing health education in the normal routine activities
of hospital.
Dr (Miss) S. Pandit, Dy. Assistant
Director-General, CHEB, presented a scientific paper
on concept, philosophy and principles of health edu­
cation. Dr V. Sambasivam, Director of Health and
Family Welfare Services, Pondicherry, inaugurated the
workshop.
The participants were divided into two groups. The
first group discussed about the “analysis of existing
conditions and identification of situation and scope for
health education in hospitals”. The group observed
that there was no well-defined health education pro­
gramme in JIPMER hospital; but some efforts were
made to educate the patients in some of the depart­
ments.
In their view health education was mainly
given by personal communication and no audio-visual
aids were being used.
The group agreed that there

288

was a great scope for health education in out-patients
department with the help of audio-visual aids. The
staff of the hospital should undertake the educational
activities.
It suggested that the charts carrying slo­
gans should be displayed at all strategic locations in
the hospital.
The second group discussed the “plan of action for
health education activities in all possible areas in hos­
pital setting.” The group listed the points for planning
any programme on health education. The group also
discussed a specific plan of action. Many problems
were considered like leprosy, tuberculosis, malnutrition
and family planning.
It decided to draw a plan of
health education on scabies in the OPD and wards.
Recommendations

The recommendations of the workshop included:
*The group consensus was in favour of integration
of health education in the hospital services. For
its effective implementation, each and every indivi­
dual working in or for the hospital irrespective of
the part he plays, should undertake educational
activities as part of his daily routine.

♦The preventive & social medicine department
should be a central guiding force for all technical
matters including planning, execution and evalua­
tion of the educational activities and in the pre­
paration of educational media required for such
activities.
♦There should be an apex body in the form of
health education committee consisting of medical
superintendent, health educator and the represen­
tatives of all other departments including nurses.
This committee should do planning, implementa­
tion, building up of financial resources and
arrangements for training of various personnel in
health education.

♦Formation of an educational cell headed by health
educator for the daily implementation of educa­
tional activities. This cell should include repre­
sentatives from residents, nurses, medical students
and social workers. t=i

Swasth Hind

Professional Preparation of Health Education Specialists
National Meeting of the Work­
Smt. Serla Grewal, Additional of health education specialists in
ing Group on the Professional Secretary & Commissioner (Family the delivery of primary health care
Preparation of Health Education Welfare and MCH)
inaugurated and relate to various tasks being
Specialists was organized by the the meeting. She observed that performed by him to fulfil these
Central Health Education Bureau, health education was a very impor­ functions”. The reports of the three
Directorate General of Health Ser­ tant aspect of health care program­ groups were presented and discussed
vices, in New Delhi from 21 to 25 mes. India had committed herself and these resulted in consensus re­
July 1980.
This Inter-Country to the W.H.O. and to her people commendation on the subjects. The
Workshop on Professional Prepara­ about reaching primary health care participants were then again divid­
tion of Health Education Specialists for all by the year 2000 AD. In this ed into two groups to deliberate on
in support of programme of Health context there was a need for a re­ two subjects, namely, (i) “To review
for All by the Year 2000 A.D. orga­ view of the curriculum of the DHE the curriculae of the three institutes
nized by World Health Organiza­ courses being conducted by the three imparting DHE with special refe­
tion, SEARO, New Delhi from 4 institutes and to modify it for pre­ rence to their roles and functions in
paring appropriate health education support of programmes for health
to 11 August, 1980.
specialists. These in turn could im­ for all by the year 2000 and to mo­
An important agenda item for the
part necessary knowledge and skills dify the curriculae relevant to this
national working group meeting was
to the health functionaries at all need”, and (ii) “Strategy for effec­
the oppurtunity for exchange of in­
levels.
tive utilization of health education
formation on latest developments,
specialists in States and Centre—
trends, accomplishments and prob­
Dr B.C. Ghosal, Director, C.H.- modification or re-organization nee­
lems in each of the three institutes
E.B.,
in his address of welcome said ded for the same”.
in India offering Diploma in Health
that
health
education was required
The reports of the working groups
Education
(DHE), viz. Central
Health Education Bureau (CHEB), to play a much more expanded and were presented on the concluding
New Delhi; All-India Institute of critical role in primary health care session of the meeting. The groups
identified the various positions at
Hygiene and Public Health, Calcutta; in India.
different levels of the health set-up
and Gandhigram Institute of- Rural
The W.H.O. Programme Coordi­ where health education specialists
Health and Family Planning Gan­
dhigram, Madurai, with a view to nator, Dr D.A.W. Nugent, informed could find their role. They also de­
make recommendations to re- that similar meetings were being veloped the functions of the health
view/modify/upgrade such prepara­ held in other countries of the South- education specialists at various le­
tion so that it may more effectively East Asia Region in preparation of vels. In relation to the DHE course
contribute to the goal of primary the WHO meeting. He dispelled curriculum, the groups, among other
the scepticism of some that ‘Health things, called for incorporation of
health care.
for All by 2000 AD’ was a slogan essential contents related to primary
There were 17 participants to the saying: ‘‘This is a slogan no doubt, health care. They also recommend­
meeting. They included the Direc­ but many battles have been won on ed that at least five per cent of the
tors of All-India Institute of Hygiene slogans”.
budget of every health programme
and Public Health and the CHEB,
should be specifically earmarked
representatives from the Gandhi­
for health education component.
Three Groups
gram Institute, Directors of Medical
The participants elected Dr N.S. Valedictory session
and Family Welfare Services from
The valedictory session of the
Haryana and Uttar Pradesh, and Deodhar, Director, All-India Insti­
W.H.O. Consultants Dr J. Gross­ tute of Hygiene and Public Health meeting was chaired by Dr (Smt)
man and Dr. H.S. Hassan besides as a Chief Rapporteur. The par- S. Chawla, Director-Principal of
Lady
Hardinge
Medical
distinguished specialists in the field • ticipants were divided into three the
groups to deliberate on ‘functions College and Associated Hospitals.
of health education.

A

October 1980

289

Dr B. Sankaran, Director General
of Health Services, delivered the
valedictory address. Dr B. C. Ghosal, Director, CHEB in his address
of welcome said that the meeting
had proved extremely useful in
chalking out the educational respon­
sibilities and training needs of health
education personnel at various le­
vels. Health education should be
given due place in planning imple­
mentation and evaluation of pri­
mary health care activities.
Dr Sankaran, in his valedictory
address, said that health education
could be successful if it were rela­
ted to the needs of the target group.
The discipline was extremely impor­

tant in the context of primary health
care and it could contribute
a great deal to bridge the gap
in acceptance level of services, pro­
vided education was suited to the
requirements.
Dr Sankaran said that it was not
correct to plead that community had
not been utilizing the services. “If
goods arc set properly and display­
ed well, they would be utilized, he
added.
Dr Sankaran advised the health
education specialists to keep them­
selves abreast of the latest know­
ledge and information in the health
field, so that the same could be
transmitted to the people. He was

glad the meeting had gone in depth
into the training strategy and place­
ment of heath education specilists
at various levels starting from the
periphery.
Dr (Smt) S. Chawla stressed the
need of incorporating health educa­
tion as a subject in the under-gra­
duate and post-graduate curriculae
in the field of medical education pro­
grammes.
Dr N. N. Biswas, Deputy Direc­
tor (Trg.), CHEB while proposing
a vote of thanks expresed his grate­
fulness to the WHO for providing
finances for this national meeting
and all those in making this work­
shop a success.—D.L.N.

Hope for Asthma Sufferers
Hopes of a cure for asthma have been raised by the success of scientists in isolating
what may be the chemical that causes breathing difficulties. Another team has discovered that
natural painkilling substances produced by the body may act as the trigger for asthmatic
attacks.
A team of six doctors and students from the Institute of Basic Medical Sciences and
Imperial College in London have spent the past three years trying to identify the mysterious
chemical present in the lungs which causes the breathing problems in asthmatics.
Scientists in Europe and the United States have known of the chemical’s existence for
many years, but only now has the London research team been able to isolate the chemical,
which is known as SRSA—Slow-reacting substance of anaphylaxis. Dr Priscilla Piper, spokes­
woman for the Institute, said: “We have isolated it, purified it and completely characterized
it. It has a molecular structure of a sort which was not known before. It may prove to be
very important in the whole field of detoxification.”

SRSA is one of several molecules released from cells involved in allergic responses.
The name derives from the fact that these substances cause smooth muscle to contract slowly,
and it is now believed that SRSA in particular is involved in asthma and allergies.
The London team’s discovery may be an important step towards the development of
new anti-asthma drugs. At least one British chemical firm is currently testing a drug that
suppresses SRSA.

Doctors at King's College Hospital, London, however, believe they may have acciden­
tally found the substances that trigger off asthmatic attacks, during research into diabetes.
They discovered that sometimes when a certain test is applied to diabetics it produces wheezing
like an asthma attack.
This is believed to be due to a substance called enkephalin, which is
one of the recently discovered chemicals in the brain which act like a natural morphine.
New hope for asthma sufferers springs from the fact that the effect of enkephalin can
be blocked with an injection of a substance called naloxone: —
—B.1S. <=□

290

Swasth Hind

A view of the procession on the observance of the World Health Day—7 April 1980 in Hyderabad.

World Health Day—1980 Observed in Hyderabad
colourful procession with anti-smoking slogans
and exhibition explaining the hazards of smoking
and a public meeting were the highlights of the World
Health Day celebrations in Hyderabad on April 7,
1980.

A

The nursing students, staff nurses, sanitary inspec­
tor trainees, medical students and house
surgeons
and doctors formed a van guard of the procession
which started from the Gandhi Medical
College,
Bashirabagh. Dr D. Bhaskara Reddy, Director of
Medical Education and Dr M. Venkata Rao, Direc­
tor of Health and Family Welfare received the pro­
cessionists at the Health Museum, Hyderabad.

The processionists carried 60 placards with anti­
smoking slogans in English, Telugu and Urdu and
made loudspeaker announcement explaining the health
hazards of smoking.
Shri A. Sambasiva Rao, retired Chief Justice of
Andhra Pradesh High Court inaugurated the Exhibi­
tion which will be open for the public for the next 12
months.
Films-shows were also organized at the
venue of the Exhibition.

Later at the public meeting Shri Sambasiva Rao
emphasised the need for intensive campaign by the

October 1980

Government and the voluntary agencies against smok­
ing.’
He said that this education should be a conti­
nuous process and accent should be placed on the
young especially the teenagers.

Dr Harish Chandra a former consultant of WHO,
in his presidential address said that smoking should
be banned in all the public places. He felt that he
' could not understand the logic behind bringing vast
areas of land under tobacco cultivation when mal­
nutrition was widespread in the country. Dr Nara-simha Rao, retired State TB Officer, said that the
babies of the pregnant women who smoke were prone
to low birth weight and congenital disorders.
Dr Hyder Khan, Superintendent, Gandhi Hospital,
Secunderabad, said that it was proved beyond doubt
that smoking can cause cancer of the lung, bladder,
skin and heart diseases.
Mere legislation and en­
forcement he said would not solve the problem. A
systematic and sustained education about the dan­
gers of smoking would yield desired results.
Dr Venkata Rao released the Souvenir brought out
by the Peoples Information Centre. Dr T. John
Phillip, Assistant Director of Medical and Health Ser­
vices Health Education received the first copy of the
Souvenir.
1=3

291

MEASLES
This is the twenty-eighth in the series of the feature. The Community Health Volunteers,
among other things, are to educate the community on preventive, promotive, curative and
rehabilitative aspects of health. Measles—a contagious disease— is the most common of all
eruptive fevers in childhood. All persons, who have not had the disease earlier, are highly
susceptible to measles. With proper care, and timely vaccination, wherever available,
measles can be prevented.
easles is a highly contagious hind the ears and on the chin. The
Every effort must be made to pre­
disease caused by a specific rash gradually spreads downwards vent complications. The child must
virus. It is the most common of all and covers the whole body. The be kept clean by bathing him daily.
eruptive fevers in childhood.
rash always remains thickest on the The eyes should be protected from
face.
The rash lasts for about five glare and washed frequently with
Who is susceptible to measles?
days
and
gradually disappears. The clean water. The child should be
All persons, who have not had
dried
scabs
then begins to peal off kept in a well ventilated room. Over­
the disease previously are highly
in
fine
flakes.
During all this pe­ clothing should be avoided. The
susceptible to measles. As the dis­
riod
running
nose,
watery eyes, child should be given plenty of
ease is widespread in India, the
sneezing,
coughing,
diarrhoea
and fluids at frequent intervals. He
children contract it early in life,
fever
continue.
With
the
disap
­ should be given his normal diet.
usually before two years of age.
The immunity (protection) that a pearance of the rash, the other In addition, milk, curds, khichri,
rice, porridge, fruits, etc., can be
person develops after suffering from symptoms also subside.
this disease is long-lasting. People What are the chief complication of given. It must be remembered that
a child with fever needs more food,
usually get measles only once in measles?
their life-span.
Most children recover from meas­ not less. Reducing the quantity
les without any ill-effects. Compli­ and quality of food, during and af­
How is measles transmitted?
cations may however be very severe ter measles can lead to severe mal­
The measles virus is transmitted in malnourished and very young nutrition in children specially in
through the air and therefore di­ children. The common complica­ those with already poor nutritional
rect contact with the infected per­ tions are secondary bacterial infec­ status.
son is responsible for its spread. tions of the throat and lungs. The
In case cough and fever do not
Infected persons are most contagi­ ears are frequently affected in the
subside
after the disappearance of
ous before fever and rash appear. form of purulent discharge. The
rash
and
the child shows other sym­
Transmission is more frequent in­ eyes and brain may also sometimes
ptoms
of
acute illness of the doctor
side a room and when children be involved. Eye damage due to
should
be
consulted at once for pos­
come together. About two weeks ulceration and opacity of cornea
sible
complications
of measles.
usually elapse between exposure may lead to impairment of vision.
to infection and development of Acute dehydration is one of the most How can measles be controlled?
the illness.
Measles can be prevented by giv­
frequent and dangerous complica­
ing one dose of measles vaccine
tions
of
measles
in
countries
as
me
­
What are the symptoms of measles?
asles is often accompanied by diarr­ wherever it is available. The vacci­
The early symptoms of measles hoea and vomiting. Measles can nation can be given to a child bet­
are similar to those of common also aggravate malnutrition.
ween nine to twelve months of age.
cold namely running nose, red eyes,
When the vaccination has been given
a dry cough and slight fever. On Care of the patient
correctly
the protection afforded is
Isolation of the child is difficult
the second or third day of the dis­
quick-acting,
reliable and long-last­
in small houses and its usefulness is
ease, white or bluish-white specks,
ing.
It
is
thought
that a single in­
the size of the grain of sand, may doubtful. By the time the diagnosis jection is enough to protect a person
is made, other children have already
be seen on the inside of the cheeks.
been exposed to it. However, if for lifetime.
The rashes usually appear on the possible the patient may be isola­
GET YOUR CHILD IMMUNIZED
fourth day after the onset of the ted for seven days after the appea­
AGAINST MEASLES, WHEREVER
symptoms, beginning on the face, on rance of rash, specially from child­ AVAILABLE, BETWEEN 9 and 12
MONTHS OF AGE.
the forehead, at the hair-line, be­ ren under three years of age.

M

292

Swasth Hind

Mental ^Health Exhibition
An exhibition on mental health
was organized in the Raipur Rani
Block of Ambala District. Punjab
on 30 and 31 March 1980. The
Mental Health Association (MHA)
along with the Department of Psy­
chiatry, Post-graduate Institute of
Medical Education and Research,
Chandigarh and Haryana Health
Service, Haryana were the organi­
zers. The MHA is a voluntary non­
profit organization of village lead­
ers specifically aimed at enhancing
the effectiveness of the programme
to care for the mentally ill in the
Block.,
On these two days, a big annual
fair was held in the Block, near the
village of Raipur Rani. Thousands
of villagers from nearby villages

thronged the fair site on foot and
bullock-carts to pay their respects
to the goddess Durga Devi. This
‘Mela’ forms the most important
religious and social event of the
area.
Against this backdrop, the MHA
organized an exhibition for creat­
ing an awareness among the villa­
gers on severe mental disorders.
Information about the available
modem medical services were also
provided. In this venture the staff
of the PHC, Raipur Rani and PGI
were actively involved.
On display in the ‘PANDAL’ was
a set of ’attractive posters with co­
loured photographs and simple

Hindi messages. These provided in­
formation about the misconcep-j
tions prevalent in the community
about mental disorders, the recog-j
nition of severe mental disorders
like psychosis, depression, mental
retardation and epilepsy. The im­
portance and the cost of treatment;
the duration and outcome with
treatment, were also outlined. A
pamphlet in Hindi on mental health
was distributed free among the vi­
sitors to the ‘pandal
*.
A special
feature of the exhibition was the
intelligence tests for children. This
proved very popular and attracted
people to know their ‘intelligence’.
About 5,000 people visited the ex­
hibition.
—R. Srinivasamurthy.

Centre for Education and Health
Manipal, a small village in South Rs. 3,600/- have been identified. riage guidance clinic and a dental
Kanara district, is fast becoming a Poor families are being offered me­ clinic.
good centre of education and health dical facilities free of charge. The
The organisers of this new move-:
Centre1 for Health protection for
services. This has become possi­
planned Families has an outpatient ment say that the work of family
ble by the guidance of late Dr
clinic at Udipi, 5 kms West of Ma­ planning gets intensified if the accep­
’ T.M.A. Pai who excelled in pub- nipal. It provides people of the tors are assured of protection
• lie service. In Manipal, families area family planning services and against diseases.
—J. N Dhar
with annual income of less than runs a child health clinic, a marOUR CONTRIBUTORS
Smt. Indcrjit Singh
Associate Professor
Department of Food & Nutrition
College of Home Science
Punjab Agricultural University
Ludhiana.
Brig. S. L. Chadha
Former Municipal Health Officer
Municipal Corporation of Delhi,
Delhi.
Dr A. B. Bancrji
Di rector-Incharge
National Tuberculosis Institute
8, Bellary Road
Bangalore-570 003
Karnataka.

Dr C. S. Gangadhar Sharma

Dr N. N. Biswas,
Deputy Director (Training.)

Deputy Director of Medicial Services
and Family Welfare (Leprosy)
Madras-600 006.
Tamil Nadu.

Dr A. B. Hiramani
Deputy Director (Research)
Dr K. S. Sinha
Deputy Assistant Director
(Media & Training)
and

General

Shri Y. P. Gupta
Research Officer
Central Health Education Bureau
Kotla Road,
New Delhi.

Dr. S. P. Mehta
Professor & Head of the Department
Preventive and, Social Medicine
Jawaharlal Institute of Postgraduate
Medical Education and Research

Pondicherry-505 006.

Regd. No. D(Q-359
Regd. No. R.N. 4504/57

Position: 2509 (3 views)