Swasth hind, Vol. 31, No.12, December 1987.pdf

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swasth hind

In this Issue

Page
Population management
—Search for new strategy

December 1987

Agrahayana-Pausa

289

J. R. D. Tata

Vol. XXXI, No. 12

Saka 1909

Neo-natal care—role of health education
Paras Nath Garg

293

Readers Write

Pregnancy wastage—magnitude, causes and
prevention

297

The article, *77te Other Side of Smack— Addiction'
(May-1987) was a very educative one for tackling the
most dread disease spreading amongst the youngsters.
Swasth Hind deals with various medico-social problems
not only of the youth but also of the grown-ups in an
easy-to-understand non-medical language.

Dr G, V. S. Murthy, Dr V. P. Reddaiah
and Dr S. K. Kapoor

—J. R. Laroiya
President
Federation of All NOIDA Residents
Welfare Associations
A-475, Sector-19
Noida Complex
Distt. Ohaziabad-

Field trial on village level—surveillance of
epidemic-prone diseases and its evaluation

Dr R- S. Sharma, Dr K. K. Datta and
Dr Mahendra Dutta
Oral Health in India—current status and
strategy for health education

Single Copy.

.

.50 Paise
Rs. 6.00

Annual

A—Z Dental Care

307

• Dr Daya Sanghal

309

Dr A. K. Mukherjee

How drugs affect our nutritional status

313

Kamal G. Nath

School for treating spinal cord disease

(Postage Free)

304

Dr S'. Venkatesh

Prevention of childhood accidents

SUBSCRIPTION RATES

301

315

K. R. Swadeshi

Workshop on Health Writing

Editorial and Business Offices
Central Health Education Bureau
(Directorate General of Health Services)

Kotla Marg, New Delhi-110 002

316

T. K Parthasarthy

Articles on health topics are invited for publication in this
Journal.
State Health Directorates are requested to send in reports of
their activities for publication.

EDITOR

N. G. Srivastava

Sr. SUB-EDITOR

M. L. Mehta

COVER DESIGN

B. S. Nagi

The contents of this Journal are freely reproducible.
acknowledgement is requested.

Due

The opinions expressed by the Contributors are not neces­
sarily those of the Government of India.
SWASTH HIND reserves the right to edit the article* sent
for publication.

POPULATION MANAGEMENT
—Search for New Strategy
J. R. D. Tata

A reduction in the birth rate is an essential pre-condition for our achieving the ulti­
mate objective of health and welfare for all and freeing the country from the crippling
economic pressures of an ever-rising population.

Those who like myself have for
for so long been so deeply conscious
of our population problem cannot
but lament the fact that even after
the passage of forty years of Inde­
pendence and although our country
was the first in the world to adopt
family planning as a state policy,
so little progress has been made in
reducing our population growth rate
while so much of our energies and
time has been, and is still being,
spent
on secondary or minor
issues........... I pay tribute to those
Members of Parliament who, by
forming the Indian
Association
of Parliamentarians on Popula­
tion and Development led by
Shri Sat Paul Mitai, have shown
that they .......
have realised
With our birth rate still hovering
the gravity of the problem and
around 33 per thousand and our
intend to play an active and sustain­
death rate at 12, should we be
ed role in its ultimate solution.
surprised that all demographic pre­
dictions show that, without a dra­
To begin with, it is worth noting
matic reduction in our birth rate, that, contrary to the belief of many
we shall not reach the kind of sta­ people in our country that our popu­
ble population achieved by the rich lation problem is an age-old one,
countries of the world until to­ and consequently not amenable to
wards the end of the next century, modem scientific solutions except
and our people will continue, for over'many centuries, it actually is a
most of it, to be amongst the poorest very recent one. For it dates back
only to the past fifty or sixty years
in the world?
few weeks ago, the world's
population passed the five bil­
lion mark and is still growing at the
terrifying rate of-about a billion
every twelve years, or over 80 mil­
lion a year. It took us only thirtyfour years after Independence to
double our population from about
350 million to 700 million. At 780
million today, it is still growing at
the rate of about 15 million a year,
and will probably reach a billion by
the turn of the century. As a re­
sult, we have had, during the past
forty years, to divert nearly twothirds of our annual GNP growth
to the needs of the 440 -million
people we have added to our num­
bers.

A

Decembbr’1987

in the course of which the discovery
and application of new drugs and
forms of treatment and health cere
brought a dramatic decline in the
death rate, while the birth rate re­
mained more or less constant. If
the same population problem trend
did not occur in the West it was
because the birth rate was already
relatively low, education was univer­
sal and the economic benefits of
small families helped by rapid eco­
nomic growth and the unrestricted
availability of contraceptive pills and
other devices were already well ap­
preciated.

Unfortunately, in India, because
of poverty, ignorance and illiteracy,
combined with deeply ingrained
social customs, the realisation of the
benefits of smaller families has only
recently begun to dawn on the mass­
es of our people, andi the birth rate
has remained- high.

Speed of population explosion
The suddenness and speed of the
population explosion took the coun­
try by surprise, including the Cen­
tral and State Governments which
not only lacked experience to deal
with the grave socio-economic pro-

289

WHO gives Intra-uterine Devices Clean Bill of Health
Intra-uterine devices (IUDs), now used by more than 60 million women
around the world, are “probably the most effective and reliable reversible
method of fertility regulation available to women”, according'to the World
Health Organisation (WHO).
The experts emphasized that they were referring to the currently avaiexperts from both developing and developed countries who were convened
to look into the mechanisms of action, safety - and efficacy of the devices.
The group’s report has just been published—WHO Technical Report No.
753.

The experts emphasized that they were referring to the currently avai­
lable copper- and hormdne-releasing IUDs, when properly used. They noted
the particular situation in the United States, where two manufacturers dis­
continued making and marketing IUDs in response to. increasing legal costs
arising from lawsuits in which pelvic infection and subsequent infertility
were claimed to result from IUD use. As a result, governments, family
planning agencies, the media and individuals expressed concern about the
safety of IUDs in general. It was in response to this concern that the scien­
tific group of experts was convened.
In their report, the experts stated that the decisions to withdraw the
Lippes Loop, Copper-7 and TCu-200 IUDs from the American market
“were based on commercial and financial considerations rather than on
questions of safety”.
They considered the IUD to be “an important method of fertility regu­
lation with high continuation rates and significant advantages in conveni­
ence of use”. They added: “The newer copper-releasing devices are compa­
rable to oral contraception in terms of safety and efficacy, and the use of
IUDs in both developed and developing countries should continue to be
supported as a reliable and safe method of reversible fertility regulation”.

But they reiterated the importance of the careful screening of women
who were considering using IUDs to ensure that nd contra-indications were
overlooked, such as genital cancers, vaginal bleeding of unknown cause,
suspected pregnancy or active pelvic infections.
Commenting on the way in which IUDs exert their contraceptive effect,
the group of experts concluded, from the evidence presented to them, that
the presence of an IUD alters the uterine and tubal environment in such a
way as to interfere with the normal function of both sperm and ova. It
thus impedes. fertilization, rather than preventing implantation of already.
fertilized ova in the uterus, as was previously thought. This statement
may go a long way towards answering certain philosophical or religious
concerns as to the mode of action of this method of contraception.
O

blems it caused, but aggravated them
by giving them such a low priority
as to devote, year after year, only
one per cent of Plan outlays to deal­
ing with them.

290

Thus it is that, as we celebrate
the first forty years of our Indepen­
dence many of us ponder anxiously
on what the next hundred years will
hold for the billion and a half or

so of our people who will be alive
by then.

With well over a third of our con­
tinuously growing population still
below the poverty line, with our
agricultural resource base merciless­
ly eroded by deforestation, soil ero­
sion and pollution; with availability
of new land for c-ops steadily dimi­
nishing and existing land holdings
relentlessly fragmented, our villages
are no longer havens of peace and
relative prosperity, and the. young
increasingly tend to flee from them
m order to migrate to overcrowded
cities in search of a better life, instead
of which they find they have to
endure the degradation of slum life,
brittle social relations and frequent
turmoil. As a result, more than half
of the people of Bombay, India’s
richest city, live in disgraceful hut­
ment colonies and some of them
literally on the. city payments! The
position in • Calcutta is no better
except for the fact that the city has
more space in which to expand.
Shortages of drinking water and
power, traffic congestion, overcrowd­
ing in hospitals and schools are such
that the authorities of our capital
cities feel. that they are fighting a
losing battle.
While there is, thus, much to
bemoan, there is no cause for des­
pair. Forty years ago, we. did not
expect our population to explode in
our face, and did not understand or
visualise the seriousness cf its eco­
nomic and social consequences, and
therefore how to deal with them
when they hit us. We do now. We
have learnt from our failures and
shortcomings as well as from- our
few successes. We have today the
knowledge, the skills and the tools
to tackle the obstacles in the way.
We have acquired invaluable ex­
perience in planning and adminis­
tering huge welfare programmes of

SWASTH HIND

great complexity and have made
substantial progress towards our
objectives. 45 million couples in
their reproductive age or 35 per cent
of the total have been effectively
protected against unwanted births.
76 million births are estimated to
have been averted so far and 8
million are being averted every
year.
*

gin with, as a crucial determi­
nant of fertility amongst women in
India. All the statistics prove it.
We all know, . for instance, that
Kerala, with the highest female lite­
racy rate in the country, enjoys also
the lowest birth rate, while Rajas­
than’s appallingly low female lite­
racy rate is accompanied by the
highest birth rate in the country, a
statistical relationship which is re­
flected in most of the other States.
We have a clear demographic
This should surely suffice to con­
goal, namely, the achievement of a
vince the Central and State Govern­
net reproduction rate of one, involv­
ments that concentrating on literacy
ing a reduced birth rate of 21 per
programmes, particularly amongst
thousand. How soon can we rea­
girls and young women, would be
listically expect to reach that goal?
a most effective instrument in re­
The Planning Commission having,
Age of Marriage
ducing the birth rate, quite apart
more than once, extended its ear­
There can be no doubt that a re­ from its immensely beneficial contri­
lier estimates have now projected
the year 2010 or thereabouts as the duction in the number of years of bution to the task of eradicating the
married life in a woman’s reproduc­ ignorance, discrimination, injustice
earliest possible target date.
tive cycle, would be dramtically re­ and other evils which continue to
flected in the number of children plague our long-suffering women.
We have already succeeded in
she is likely to bear. This measure
winning a considerable degree of ac­
was indeed adopted in 1978 when
ceptability of smaller family norms
Literacy and primary education
the legal age of marriage was raised
amongst women; contraceptive pro­
programmes
are primarily the res­
from 15 to 18, but this law has been,
tection methods are estimated to be
Governments,
z
from the start, perhaps the most ponsibility of State
adopted by about 25 per cent of
flouted one in our country, and a and the levels of achievement in
women of childbearing age; we
large proportion of girls are married each State depend largely on the
have marshalled a variety of contra­
degree of interest and determination
well before the legal age ..........
ceptive technologies and built up
on the part of the respective
the beginnings of a vast network
Governments
and on the prio­
This is, admittedly, a difficult pro­
of medical and para-medical man­
blem but one which must be faced. rity given to education in their
power.
Would it
Apart from the specific objective of allocation of funds.
be
unfair
to
suggest
that
it is the
any law, the continued toleration of
With better management and sup­ its violation by Government and Government, as much as the people
port, the organisation built up over public opinion encourages the disre­ of the States lagging behind in the
the years of 12,000 primary health gard and violation of other laws rate of literacy amongst their women
centres and 90,000 sub-centres man­ and undermines the very concept who need to be educated and mo­
ned by over 40,000 doctors, 185,000 and framework of a society based tivated, and that whatever be the
multi-purpose health workers and on the rule of law. I see no alter­ reasons given, or the justification
390,000 village health guides could native, therefore, to our urging Gov­ claimed for their low literacy rate,
dramatically transform the grim si­ ernment to ensure a more vigorous in glaring contrast with that of other
tuation still facing us.
States, they can no longer be accept­
enforcement of this law.
ed or tolerated. Except for emer­
While there is, therefore, no rear- Literacy
gency demands that may be made on
son for pessimism, clearly much
My second point concerns the them in times of floods, drought
more must be Jone, and done more critical
importance of female or other calamities, literacy pro­
effectively than in the past if our education, and literacy to be­ grammes must be given in every

December 1987

advance towards our goal is to be
accelerated. A task of this magni­
tude and complexity necessarily co­
vers a vast number of different ele­
ments and measures to be co-ordi­
nated . into a coherent whole. I have
neither the knowledge nor the ex­
perience, and certainly not the time
today, to cover the whole field and
shall therefore limit the remainder
of my remarks to touching upon
four specific measures which, if ac­
corded the necessary emphasis and
priority, would, in my view, give a
great momentum to our whole pro­
gramme.

291

State the kind of priority which has
produced such splendid results in
some of them. If a shortage of funds
proves to be the main impediment,
means must be found, with the inter­
vention of the Central Government,
if necessary, to supplement them.

In this context, 1 would like to

80,000 today. An expenditure

on

congratulate those, including Door-

incentives and rewards of up to Rs.

but telling

message conveyed to viewers after

5,000 per birth saved by sterilisation
or otherwise would, I believed, pro­

die televised

Hindi, news almost

duce spectacular results and prove

every night which, directly or in­

to be a highly viable investment for
the nation.

darshan, for the brief

directly, brings home the need

of

family planning as a means of en­

Such monetary incentives

could

Communication

suring the family's, and more espe­

take other forms, such as for in­

A major cause of our .failure to
achieve fuller and quicker results
in our family planning and health
programmes has lain in a failure
of communication, which is at the
very heart of any programme aimed
at convincing people of the need
to change longstanding beliefs and
habits. The fact that large sections
of our rural population have up to
now been largely inaccessible except
to their immediate neighbours be­
cause of their remote location and
lack of communications except radio
has been a major impediment to
greater progress towards our goal.

cially the child’s, health and happi­

stance presenting

ness.

newly married woman a bond which
would provide her,'at the end of

Incentives

The fourth point I would

twenty years, a sum of, say

urge

to be considered and discussed today
is die potentially powerful role

292

of

monetary incentives and, to a lesser

extent, disincentives, as a means of
inducing people to adopt small

Rs.

50,000, provided she had not given
birth to more than two children.

Other incentives could take the form
of preferential allocations of
and housing to the parents.

jobs

If my remarks have, up to now,

family norms and contraceptive pro­

been aimed exclusively at means of

tection throughout a woman’s years

achieving a reduction of our birth

of fertility. It is an unfortunate, but

rate, it is not that I am unaware of

a

the many other facets of the popula­

country such as ours in which most

tion problem. It is because 1 believe

of the people are not only poor but

that a reduction in the birth

perhaps inevitable, fact that, in
The advent of television and the
Central Government’s wise and
imaginative plan rapidly to expand
its network to cover most of the
country’s population will, if effec­
tively used, provide an invaluable
means of direct and, literally, visible
communication with people in the
rural areas, provided, of course, that
television sets are installed and their
maintenance assured in virtually
every large village in the country.
This is a superb means of inform­
ing, advising, helping, teaching and
entertaining people who have in the
past been kept isolated, ignorant
and largely helpless. To be effective,
however, the programmes beamed
to them will have to. be carefully
planned, innovative, credible and in
tune with the realities of village life.
This programme should be given a.
high degree of priority.

to every ycung

rate

largely uneducated even small mone­

is an essential precondition of our

tary or. equivalent incentives can be

achieving the ultimate objective of

potent means of motivating people.

health and welfare for all and free­

A pitifully small reward of Rs. 200

ing the country from the crippling

per sterilisation has been fairly wi­

economic pressures of an ever ris­

dely adopted in India for some years

ing population.

and, say to say, has had some effect

As we stand on the threshold of
the twenty-first century, the basic
mit to contraceptive surgery.
issue is whether, as a free and richly
endowed people, we achieve bare
In 1981 the capital cost to the survival or the vigorous growth
nation of providing the basic re­ which alone can assure to our peo­
quirements of every additional citi­ ple the happiness and prosperity
zen throughout his or her life and for which they have yearned for so
long.—prom Keynote Address deli­
of that of their progeny over two
vered at the National Seminar on
generations, was of the order of Rs. Population Management: Search for
42,000 in the then current rupees, New Strategy on 29 August, 1987,
a figure which would be nearer Rs. New Delhi.

in inducing men and women to sub­

SWASTH HIND

NEO NATAL CARE
—Role of Health Education
Paras nath Garg

There is much evidence to indicate that mortality and morbidity for mothers and children
could be reduced, if existing knowledge were applied in a more diligent and vertical
manner and if medical and midwifery personnel were more efficiently trained, oriented
and motivated.

December 1987

29

weight and premature babies can
during and for the first month survive with warm, clean environ­
after birth, occupies less than year ment and proper feeding. A large
of an average life-span but is so number of stillbirth can also be
regular antenatal
hazardous as to account for more prevented with
deaths than the next thirty years, check-up.
and survival with crippling sequelae
may determine the whole future of
Most of the deliveries continue to
the individual. Thus increasing at­ take place at home under the super­
tention is focused on the need to vision of relatives and Untrained
reduce the very high rates of mor­ TBAs who are ignorant of asccptic
tality and morbidity that occur technique.
Umbilical dressing is
around the time of birth and in the applied under unhygienic conditions
early weeks following it.
by untrained attendants.
he life of an individual before,

T

There is a much evidence to indi­
cate that mortality and morbidity A Challenge
rates for mothers and children
Antenatal attendances are good
could be reduced, if existing know­
but
the number of deliveries in. the
ledge were applied in a more dili­ health
units is strikingly lower than
gent and critical manner and if the antenatal figures seen in the
medical and midwifery personnel clinics. What happens to the others,
were more efficiently trained, ori­ where do they deliver and who con­
ented and motivated.
ducts the deliveries? Most of these
cases
are termed self delivery or
Neonatal care starts before concep­
delivery
assisted by a relative or a
tion
neighbour, because delivery was
Neonatal care starts even before imminent, while a few are said to
conception or pre-marital age, be “conducted by a TBA”. Why
through postponement of first then do the women attend the ante­
pregnancy until the mother herself natal clinic only to delivery at
has reached full physical maturity home? Why do they call an untrain­
and through spacing of birth.
It ed TBA and not a trained TBA or
continues from conception, through Midwife? Do. we as health workers
suitable care during pregnancy, frighten the mothers away?
child birth and childhood^
Magnitude

= 69.3 per 1000 live births Neonatal
Mortality Rate 1980.
= 60-80% deliveries conducted
by Traditional Birth Attendants
(TBA).
= 10-15% deliveries conducted by
only TRAINED TBAs.

= 24.73% Female literacy in India
1981.
= A number of socio-cultural fac­
tors are associated from pre­
marital age to neonatal care.

The important mortality causes
include neonatal tetanus, birth
trauma, birth asphyxia, prematurity
and respiratory problems. Neonatal
tetanus is totally preventable by
immunizing the mother in pregnan­
cy. Birth trauma and birth asphy­
xia can be prevented by proper ob­
stetric care and simple resuscitative
measures like suction and bag and
mask ventilation. Many low birth

294

We have found that some women
feel reluctant or ashamed to be de­
livered in overcrowded rooms or
places, houses which may not be
very clean. They feel that a midwife
who in most cases lives in a better
hpuse would not understand their si­
tuation. They would rather'be deli­
vered by one who lives among them
and understands what their pro­
blems are. This is. a Challenge.

individually and collectively
to
maintain health, and SEEK help
when needed.

Health education is the concern
of all the health providers irrespec­
tive of their position in the health
care system. This is a team work
arid aims at bringing people toge­
ther from various levels for esta­
blishing better co-operation and co­
ordination for the common cause.
Health workers should remem­
ber : —
Health edu- — By whom = Every one
cation
To whom = Every one
Where = Everywhere

Health education breaks down
the barriers of ignorance, prejudi­
ces, misconceptions and dangerous
traditional practices among the
community and target group about
the
maternal and child health
(MCH) care and provides learning
experience which favourably in­
fluence the knowledge, attitude and
practices. It acts as a strong ce­
menting force for the acceptance 'of
MCH services through active invol­
vement.
Health education needs.
* Community participation
* Media support
* Technical expertise and desire
for action.
Community participation is the
key to the success of health pro­
gramme. In neonatal care pro­
gramme, the active participation of
the following sector is essential:

WHY — T—
W = Women
H = Traditional
Health
Prac­
titioners
Health Education for Neonatal care
Y = Younger generation
It is realized today that science
and technology can contribute to the T = Traditional Birth Attendantsimprovement of health standards . Women are predominantly nononly, if the people themselves be­ formal health care providers, in
come full partners of the health their capacity as mothers, grand­
care providers in safeguarding and mothers, wives, daughters and
promoting health.
members of .Mahila association in
the community. A much cited pro­
Health education in primary verb still holds true:—
health care aims to foster activities
“Teach a mother to be healthy
that encourage people to:—WANT
She will teach the rest of man­
to be healthy+KNOW—how to
kind”.
stay healthy, Do what they can do

SWASTH HIND

The role of grandmothers in pre­
paration of daughters to be a suc­
cessful wife and mother for com­
plete “Motherhood" cannot be
overemphasized. This part is now
decreasing and is a challenge to
health care providers.
Traditional
Health Practitioners
(THP)
Organized health services in India
provide only 10% of the medical
care, another 10% is provided by
qualified physician and the balance
is split between home medical care
and indigenous 'practitioners.
The folk health system, includes
a veriety of health roles in rural
setup, it must be involved and en­
couraged.
This system has deep
roots in the local culture. The folk
practitioners know their clients and
feheir problems personally. They
understand why people do what
they do. The formal health system
is, however, completely alienated
from the local culture. It must
be remembered that “mere identifi­
cation and involvement of traditional
health practitioners (Folk Health sys­
tem) in health education on M.C.H.
care is not enough. More important
problem is to orient them, and sus­
tain their interest in the assigned
responsibilities”.

Today’s young people are the
healthiest age group and are better
educated than ever before. The po­
tential of youth, if it is to be pro­
perly tapped, requires understanding
and support. Youth is very special
time with special challenges. Young
people’s participation in community
activities—particuarly in P.H.C. is a
KEY—pre-requisite for H.F.A. by
the year 2000 AD.
Traditional birth attendants
“Four Indians out of five come in­
to the world between the hands of
the Traditional Birth Attendants".

The TBA’s role is a good example
of community participation in MCH
care and backbone of the pro­
gramme. TBAs are continue to de­
liver 60-80 per cent of newborn,
specially in rural areas. TBAs play
a maximum educational role in neo­
natal care.that starts even before
conception to childbirth. Proper
selection of TBAs, acceptable to the
community, their time to time ori­
entation. training and active invol­
vement in MCH care is essential.

December 1987

Many low birth-weight and premature babies can survive with
warm, clean environment and proper feeding

Media support
Media plays an extremely useful
role in bringing home to the people
the fundamental ingredients of
health education. The selection of
media, according to the target group
(i.e. socio-cultural background) is
most essential. The mass media
channels of communication, such
as radio, T.V., films, slides and
print media like pamphlets, folders
etc. should be used in a coordinated
way for producing the necessary
impact. Overdependence on mass
media should however be avoided.
Mass media can bring to the people
basic information. For maximum
result information must be picked
up by the network of personalized

health communication channels by
can the health workers themselves.
This can be done by visits to
homes and communities, on the
one hand and by meeting people in
clinics, dispensaries, hospital, indi­
vidually and collectively and deve­
lop new ways of thinking, acting
and behaviour on the other hand.

The most important of all require­
ments is the desire of action, techni­
cal expertise towards the health care
providers.
Health care providers should ap­
preciate the power they wield
through health education. Health
education is a very potent approach
that can influence people to the ex­

295

tent that unfelt needs, become felt
needs and felt needs become de­
mands with political, social and
cultural undertones. In their new
roles, health care providers should
ensure that there is a constant flow
of information from the people to
the decision makers.
Contents of health education in
neonatal care.
The contents of health education
can be devided into Three, major
heads.
(A) Complete
preparation * for
Motherhood as global condition.
* Pre-marital, antenatal, natal,
and postnatal period.
* Psycho-prophylactic , prepara­
tion for child birth.
♦ Role of grandmothers or elderly
in preparation of daughters for
their role as wife and mother.
. ♦ Social encouragement among
community.
(B) Neonatal Care
* Resuscitation
* Cord care
♦ Breast feeding
* Prevention of infection
* Maintenance of body tempera­
ture.
♦ Early detection of congenital
disorders.
Dangerous traditional practices
* Delaying the first feeding 2/3
days after delivery.
* Fasting after delivery.
* Stopping of feeding to the child
during illness.
* Late introduction of supplements,
(at the age of 9-10 months).

♦ Kissing of new-born baby by re­
latives.
* Deliveries in dark, ill-ventilated
and cleaned by using cow or buf­
falo dung.
. .
* Using ash, oil in cord in place of
suitable powder.
Health Education Target Group

The following target groups are
basically concerned with the educa­
tional and motivational responsibili­
ties. Orientation and reorientation of
these groups in neonatal care is the
basic role of health #care providers.
* Parents, grandmothers.

* Special health camps in the com­
munity level such as diagnostic
and treatment camps, eye camp,
family planning orientation camp.
* Balwadi and Anganwadi centres
during health checkup of mo­
thers and children and distribu­
tion of medicine and nutritional
packets in I.C.D.S. project areas.
• .Adult education centres.

Principal of Health
Neonatal Care

Education in

* General principles of health edu­
cation, i.e., felt health needs, com­
munity participation and motiva­
tion etc.
* TBA, THP, Health guides and * Communication principles i.e. se­
Multi-purpose Workers.
lection and preparation of media
and messages according to socio­
* Balwadi and Anganwadi workers.
cultural and economic level of
* Mahila and youth club members.
target group.
* Community leaders including vil­ * Learning is a reciprocal process.
lage health committee members
* Parents be regarded as partners.
and opinion leaders.
* Parents must feel that new ideas
come from them.
Health Education Opportunities
* Parents should not be blamed for
Health care providers have ample
the child condition.
opportunities of health education in * Parents need moral support.
the following areas. Message is the
heart of the communication. Hence, * Parents have several expectations
message must be prepared and me­ * Last but not least—learning by
doing.
dia or channel of communication
used which are appropriate for the
specific target groups according to Recommendations
their sociocultural level.
* Orientation of doctors, MPW’s,
CHG’s, TBA’s, THP’s, Trained
* Marriage counselling.
Dais, Balwadi workers.
* Hospital clinics such as antenatal, •* Motivation of doctors towards
postnatal, neonatal, under five
health education.
years and hospital wards..
* Integration of health education in
* Home environment during regular
educational curriculum at every
A nnaprasan-Ceremony
home visits.
level, including adult education.
* Cutting of umblical cord through * Day care centres and creches and • Payments of delivery incentive to
women working fields, f.e., agri­
unhygienic and unsterilized instru­
Dais after neonatal care.
culture and industry.
ment by TBA and relatives.
*-Neonatal and infant care work­
shop should also be organized at
Community involvement
PHC level, where MPW’s. Tradi­
tional health practitioners, CHGs
Primary health care requires and promotes maximum
and Dais- be involved.
community and individual self-reliance and participation
* Hospital health education should
in the planning, organization, operation and control of
be strengthened.
* Possession of vaccination certifi­
primary health care, making fullest use of local, national
cate—a pre-requisite for school
and other available resources; and to this end develops
admission.
through appropriate education the ability of communities
* Discharge hospital ticket must
to participate.
have clear and specific contents of
health ' education to be followed
—Declaration of Alma-Ata: Article VII. item 5
at'home level.
Q

296

SWASTH HIND

PREGNANCY WASTAGE
—Magnitude, Causes and Prevention
Dr G. V. S. Murthy, Dr V. P. Reddaiah, Dr S. K. Kapoor

Pregnancy wastage is now emerging as a major cause of maternal illness, as compared to
a few decades ago. .. Its importance stems from the fact that planned parenthood
necessitates assurance of the safety and survival of a wanted and planned pregnancy.

December 1987

297

iiE attainment of optimum and to when the foetus becomes viable
ideal standards of maternal is still, controversial. W.H.O. has
health is a major objective of the decided on 20 weeks (5 months
health services of all countries in pregnancy) as the cut-off point. For
the world. As the world slowly in­ international comparisons, the con­
ches towards 2000 A.D., the com­ ventional cut-off point of 28 weeks
mon causes of maternal ill health (7 months pregnancy), is still fol­
like anaemia, postpartum haemm- lowed.
orhage (bleeding), . infection, and
birth injuries, are slowly diminish­ Spontaneous, abortions
ing in frequency, due to the rapidly
Loss of the foetus before 28 weeks
improving care during pregnancy, at of pregnancy is conventionally ac­
childbirth, and during the post natal cepted as a spontaneous abortion
period. In contrast,
pregnancy (An abortion which occurs by it­
wastage is now emerging as a major self, without any action being sought
cause of .maternal illness, as com­ to ‘end’ the pregnancy). However,
pared to a few decades ago.
in recent times, the cut-off point has

r

Magnitude of pregnancy wastage

The presently available data sug­
gests that an overall ratio of 15-20
spontaneous abortions per 100 preg­
nancies may be a reasonable esti­
mate3. This, however, represents
clinically recognised pregnancies
which in India usually occurs late
in the first, trimester. But some
women may conceive and abort so
early in pregnancy, that the preg­
nancy and its subsequent abortion
may not be perceived by the woman.
Such early embryonic loss is thought
to be seen in more than 60% of
the conceptions*.

been taken as 20 weeks. This has
been done due to the fact that in
many countries a 20 week pregnancy
has been found to be* viable. Loss
of the foetus before 20 weeks is
called an early abortion, while loss
occurring between 20 to 28 weeks,
is termed a late abortion®.

Regarding induced abortions, sta­
tistics are not very reliable, as even
today, many of them are performed
illegally. Estimates range from 30
million to 55 millipn a year, the
world over, or about 40-70 per 1000
women of’ reproductive age group’1.

means, to detach from its .proper
A child born dead after 28 weeks
site1. Abortion is generally under-. of pregnancy is termed as a still­
stood as the termination of a preg­ birth2. It is also defined as the
nancy before the foetus has attained complete expulsion or extraction
‘viability'. Viability refers to the from its mother, of a product of
stage at which the foetus can survive conception, after 28 weeks of preg­
outside the womb. However, the nancy, which after such separation
interpretation of the exact period as- does not show any evidence of life.

and emotional factors in addition to
certain conditions like maternal and
foetal hemoglobinopathies, etc.

What is pregnancy wastage?

Pregnancy wastage is synonymous
with the terms ‘foetal wastage’ or
‘foetal death’. The World Health
Organization (W.H.O.) has recom­
mended the term ‘foetal death’ to
describe any outcome of pregnancy,
other than live births. Thus, preg­
Stillbirths have been reported to
nancy wastage includes spontaneous Induced abortions
range from 1-2 per cent of all preg­
abortion, induced abortion, and still­
The use of abortion to regulate nancies in various studies2,6,7.
births.
human fertility, has been in existence
Thus ‘ it can be seen that preg­
since
the dawn of human history.
The importance of pregnancy
nancy
wastage is of collosal magni­
wastage stems from the fact that An induced abortion is termed as
tude
and
needs priority attention of
planned parenthood necessitates as­ the deliberate termination of a preg­
surance of the safety and survival nancy, before the 28th week though the health personnel.
of a wanted and planned pregnancy. under law in India pregnancies can Causes of Spontaneous abortions
Thus high- levels of pregnancy only be terminated up to 20 weeks. and stillbirths
wastage* would have a deleterious •Prior to the advent of liberal views
The ultimate cause of spontaneous
effect on the national family welfare on the termination of pregnancy, in­
abortions
and the precise mecha­
duced
abortion
was
mostly
resorted
programmes.
to, for the termination of illegitimate nisms leading to it are still un­
Abortions
known. Suspected determinants of
pregnancies.
The word, abortion, is derived
the same include genetic, infectious,
from the Latin word ‘Aboriri’ which Stillbirths
physical chemical, immunological

298

1. Genetic factors.—Chromosomal
abnormalities due to . faulty sper­
matogenesis or faulty maternal
gametogenesis have been commonly
SWASTH HIND

incriminated as causes. Other sug­
gested possible causes include de­
layed ovulation, viruses, radiation
and ‘ageing’ effects of sperm or
ova. Developmental defects of the
female genital tract could also be
responsible. The major types of
' chromosomal aberrations include
autosomal trisomy polyploidy, and
monosomy Xs.
However it is
thought that early spontaneous abor­
tions is a means of eliminating unfit
genotypes, thus ridding the popula­
tion of bff-spring who may develop
abnormally*.

with type ‘O’ blood group. This
factor may be of more importance
in recurrent abortions.

years, minimal at 20-35 years and
increases progressively, thereafter,
beyond 35 years of age11.

5. Maternal and foetal hemoglo­
. There is a significant tendency for
binopathies.—These are known to
foetal wastage to increase with birth
influence the rate of prenatal, losses.
order (Order of live births)11. The
There is conclusive evidence that a
risk of stillbirths is relatively high
sickle cell crisis, occurring before
for first births, decreases at second
the 28th week of pregnancy, may
and third births, increases slightly.
precipitate an abortion3.
for fourth births and then increases
6. Placental anomalies—Velam- very sharply for later birth orders,
entous. insertion of the cord, a tracing a J-shaped
curve2. How­
single umbilical artery, placenta ever, an inverse J-shaped curve is
wastage and
praevia or hydropic changes in villi found when foetal
are seen more frequently in spon­ parity (the number of live births)
2. Infectious factors.—Infections
taneous abortions3. A causal rela­ are considered. This means that the
may also cause spontaneous abor­
tionship between placental mem­ more the live births, a woman has,
tions either through foetal infection
brane infections and stillbirths has the less the chance of foetal wast­
and death or by initiating uterine
age3.
been reported10.
contractions. Viral infections known
7. Psychosomatic
factors.—The
to cause spontaneous abortions, in­
it has also been found that the
importance
of
emotional
factors in
clude German measles, cytomegalo­
rate of abortions, decreases consis­
virus, smallpox, viral hepatitis, re­ spontaneous abortions has still not tently, with increasing age at
spiratory viruses, and gastro-enteri- been adequately outlined3. Physio­ menarche.
tis. Malaria, toxoplasma, listeria logical stress and emotional stress
and urinary tract infections are also causing overripe ova through de­
A pregnancy occurring too soon
incriminated3. Syphilis, brucellosis layed fertilisation or delayed ovula­ or a very long time after the pre­
tion leading to early spontaneous
and systemic infections are incrimi­
vious pregnancy, is more likely to
abortions, has been postulated3.
nated in stillbirths3.
result in foetal, wastage, it has
8. Malnutrtion and vitamin defi­
3. Physical and chemical fac­
also been thought that women who
tors.—Radiation during pregnancy ciencies.—-These two factors have not smoke more than 10 cigarettes per
has been strongly incriminated as as yet been conclusively proved to day, tend to have more foetal wast­
a cause of pregnancy wastage3. result in spontaneous abortions and age.
Drugs like Thalidomide,, goitrogens stillbirths, though low serum d-tocoand folic acid antagonists may also pherol levels, deficiency of Vitamin Induced abortions
E, and low serum folic acid levels
lead to abortions in some cases3.
Most induced abortions are per­
In human beings no drug can be have been postulated to lead to
spontaneous abortion and stillbirths. formed because the woman does not
considered completely safe during
the early pregnancy. Trauma can
9. Male determinants.—Male My­ wish to carry her pregnancy to
rar’ely be proved to be the direct coplasma urethritis leading to ’ in­ term. Only in a small minority it
cause of a spontaneous abortion3.
fection of the female cervix, poor is a threat to a woman’s life or
health or fear of ’the child being
4. Immunological factors.—There sperm quality and lethal factors
born deformed or defective, the
is a growing body of evidence to carried by the spermatazoa, have
cause for seeking an induced abor­
suggest that incompatibility between also been incriminated as causes of
tion3. The indications for seeking
mother and foetus is an important foetal wastage3.
an induced abortion may be medi­
factor in human foetal loss8. As
Certain correlates of spontaneous cal, eugenic, humanitarian or. social
early as in 1961, it was concluded
in nature3. A number of countries
that isoimmunization by foetal anti­ abortions and stillbirths
gens is a major factor in the out­
Foetal wastage has been found to have liberalised their legislation and
come of
pregnancies in mothers be higher at maternal ages below 20 permit
abortion on request for

December 1987

299

nancy, when the foetus is in the References
formative stages. Similarly care
1. Rao, K. N. Abortion and fa­
about woman’s age at pregnancy mily planning. J. Indian Med Asso,
(too less or too old), child spacing, 59(8), 1972.
and habits like smoking should be
2. Family formation patterns and
A multi-centric study carried out taken. . Induced abortion should not
health
—An international collabora­
by the Indian Council of Medical be resorted to as a method of fer­
tive
study
in India, Iran, Lebanon,
Research, found that the overall in­ tility control, except in exceptional
W.H.O.,
cidence of complications (both im­ circumstances when tested contra­ Phillipines and Turkey.
Geneva,
1976.
mediate and delayed) following in­ ceptives can be utilised at an earlier
duced ’ abortions is low. 'Haemor­ stage.
3. Spontaneous and Induced abor­
rhage, cervical and- uterine injury
tion. Report of a WHO Scientific
2. Governmental
action.—The
were the commonest immediate com­
Group,
WHO Chronicle, 25(3),
training
of
female
.
health
workers
plications while pelvic infections,
1971:104—111.
urinary tract infections and wound in regular recording of menstrual
4. Keith, E. D. Early embryonic
infections were the important delay­ histories as well as provision of
mortality
in women. Fertil Steril,
proper antenatal care services even
ed complications’7.
in the remote areas are essential 38(4) 1982:44-7-53.
However, it should be remember­ parts of Governmental action. Re­
5. Abortion available to most
ed, that induced abortions should gular recording of menstrual his­ women. People, 3(2), 1976:30-31.
never be promoted as a major means tories of married women would help
6. Omran, A. K. Editor, Fur­
of fertility control, as it can have to understand the magnitude of the ther studies on family formation
catastrophic effects on the demo­ problem and also in preventing or patterns and Health: An interna­
graphic situation in the country as detecting early wastage which may tional collaborative study in Colom­
occur. Emphasis on spacing of bia, Egypt, Pakistan and the Syrian
well as on the woman’s health.
pregnancies, maternal nutrition dur­ Arab Republic. WHO, Geneva,
Preventive and control strategies
ing pregnancy and strict enforce­ 1981.
These strategies need to be dis­ ment of the law regarding the age
7. Warburton D. Spontaneous
cussed at two levels—individual at marriage are other important
abortion
risks in man: data from
effort and organised sector activities. measures. Special attention paid to
reproductive
histories collected in a
young primiparas and elderly grand
1. Individual action.—Infectious multiparas would also help in dec­ medical genetics unit. Ain J Hum
factors leading to foetal wastage reasing pregnancy wastage. Efforts Gene, 16, 1964:1-25.
could be minimised if prompt medi­ should also be directed towards edu­
8. Theide H. A. Cytogenetics and
cal attention is sought for treating cating women with a history of still­ abortions.
Med Clin North Am,
these conditions. Similarly unneces­ birth for registering their subsequent 53(4); 1969:773—94.
sary exposure to radiation, if avoid­ pregnancy for institutional delivery
9. Bishop M. W. H. Paternal
ed, can also be beneficial. The most as they tend to be at a higher risk
contribution
of embryonic death. J
important preventive measure at in­ of losing the subsequent pregnancy.
Report
Fertil,
7, 1964:383—96.
dividual level is avoiding unneces­
The provision of VDRL testing
sary and needless medication in
10. Altshuler G. The role of the
facilities
at the primary health cen­
early pregnancy. Self medication
placenta in foetal and perinatal
should be curtailed and the woman tres, would also help in detection pathology. Am J Obstet Gynecol,
should make it a point to inform and treatment of syphilis, which is 113(5), 1972:616—26.
the doctor of her menstrual history, an important factor for foetal wast­
11. Potter R. G. Foetal wastage
whenever need for consultation and age.
in
11 Punjab villages. Hum Biol,
medication arises. Drugs like oral
Though the causation of preg­
anti-diabetic drugs, trimethoprim sul­ nancy wastage is far from clear, 37, 1965:267.
fonamides, metronidazole, meclizine, these strategies would definitely help
. 12. Collaborative study on short
estrogen-progesterone combinations in reducing the problem to manage­ term sequelae of Induced abortions,
ICMR, New Delhi, 1981.
should be avoided in early prag- able proportions.

broadly interpreted social indica­
tions5. The majority of women
undergoing induced abortions are
aged 20-29 years.

300

SWASTH HIND

Field Trial on Village Level
Surveillance of Epidemic-prone Disease
and its Evaluation
. Dr R. S. Sharma Dr K. K. Datta Dr Mahendra Dutta
A pilot project was undertaken on studies for strengthening of epidemiological surveillance
of five important epidemic-prone diseases, viz., diarrhoeal diseases, measles and polio­
myelitis among children under five years, viral hepatitis and Japanese B. Encephalitis
among all the age-groups. The strengthening of surveillance by the optimal use of the
health infrastructure consisted of “lay-reporting system” through well-trained multi­
purpose workers. The correction factors were determined. These were: 21*96 for diarr­
hoeal diseases, 1 * 8 for measles and 17 * 5 for viral hepatitis.
he National Institute of

Com­

The assessment of the suiveillance. me was within the existing health

municable
Diseases (NICD, programme was made by conducting infrastructure and without disturbing
T
Delhi) had undertaken studies on cross-sectional sample-survey of the other programmes being imple­

strengthening of epidemiolgical sur­ these diseases during August-Sep­ mented through the multipurpose
veillance of five important epidemic- tember, 1984. The survey provided workers, other paramedicals and
prone diseases, namely, diarrhoeal valuable information regarding the primary health centres. The Bran­
diseases, measles and poliomyelities problem and magnitude of the epi­ ches of NICD provided the techni­
among 0-4 years children; viral hepa­ demic-prone diseases in Alwar dis­ cal guidance, training and feed-back
titis and Japanese B. encephalitis trict. The various ‘Correction fac­ by publishing quarterly bulletin.
among all the age groups.
The tors’ applicable to the surveillance
2. The evaluation survey was
Project was operative for varying data were also detected. The find­
carried
out by cluster sampling tech­
period during 1983-86 in the districts ings of the assessment survey are
nique (1, 2, 3) in Alwar district. 30
of Alwar (Rajasthan), Mysore (Kar­ presented in this paper.
clusters were located randomly from
nataka), East Godawari (Andhra
a sampling frame of 1574972 popu­
Pradesh).
The model envisaged Material and methods
weekly flow of information from the
I. Taking into consideration the lation in 1892 villages, in 14 Primary
rural community through the Multi­ frequency of epidemics in the coun­ Health Centres in the district. 1981
purpose Health Workers within the try, with special reference to these census, population was taken into
existing health infrastructure and diseases without an effective surveil­ consideration. Cumulative popula­
services-system. This channel of lance programme, the five epidemic- tion frequency was calculated against
surveillance from villages /sub-cen­ prone diseases selected for the study each village arranged in order as in
tres, Primary Health Centre, and were diarrhoeal diseases, poliomyeli­ .1981 census list. Sampling interval
the district would- lead to early tis, measles, viral hepatitis and was obtained by dividing the cumu­
detection of outbreak and an effec­ Japanese B.^encephalitis. The lay-re- lative population by 30. The first
tive containment. The surveillance porting system through well-trained village was located on the basis of
is also important for the assessment multipurpose worker was introduced random number equal to or less
of disease control programme.
at the village level. The program­ than the sampling interval.
This

December 1987

301

was followed by the location of litis, viral hepatitis were 2.4 episo­
second cluster by adding the samp­ des per child per annum (4), 2/1000
ling interval to the cumulative popu­ children/ <2 years per year, 17.8/0.1
lation of cluster/village number one. million 0-4 years per annum (5) and
The remaining 28 clusters were loca­ 1/0.1 million per annum.
ted by adding the sampling interval
3. Sample size per cluster was cal­
successively in the above arranged
culated
by dividing the total disease­
village list.
specific sample size by 30.
Total
The disease-specific
age-groups and per cluster sample sizes are
selected for the survey and the refe­ given for each of the diseases in
Villages adjoining the
rence periods for interview/history table II.
are given in Table-IL
nuclear village were taken for survey
till requisite sample size was obtain­
The disease-specific sample size ed.
was worked out to give the preci­
4. The definition of patient, to be
sion estimates of +10 per cent at
used by the para-medical, for the
90 per cent probability level as given
initial detection of case was as
below:
follows : diarrhoea—child
having
Z8 x p x (t—2)
(1.65)«p (i-p) three or more loose motions in a
n=» ------------------------ «= -------------------- day and for infants mothers’ judge­
L8
(10% of p)8
ment was taken as reliable guide,
The assumed P values for diarr­ measles—child having fever with
hoeal diseases, measles, poliomye- rash, poliomyelitis lameness—child

Table I—Average monthly incidence of epidemic-prone diseases by lay-reporting
surveillance in study areas
Average monthly incidence rates

Diseases

Mysore

East Godawari

Alwar

Children under 5 years
Diarrhoea (per 1000) •

9-7

7 •

2-9

•

124-8

33-3

8-1

18-6

7-2

46.

Measles (per 1 lakh)

Poliomyelitis (per million)

•

with lameness on either of the legs,
viral, hepatitis—persons with yellow
colouration of eye, Japanese ence­
phalitis—individual with high fever
and stupor. In addition local names
for the disease and symptoms were
used.
5. All the paramedical field wor­
kers, supervisors and medical officers
were trained thoroughly for the sur­
vey. The field, household and other
relevant information were recorded
in protested proformae. Random
cross-checking was done by the epi­
demiological team.
All the cases
detected by para-medical in the sur­
vey were verified within a week by
the medical officers to find out the
‘Correction factor’ for lay reporting.
6. The recently introduced pro­
gramme of surveillance promotion
in the district was evaluated by com­
paring the routine surveillance data
with the results of the sample-sur­
vey. Correction factors were deter­
mined for application to the on­
going surveillance data, after adjust­
ments for lay-reporting efficiency
and the degree/extent of reporting
regularity.
Annual estimates of
magnitude of these diseases in the
district were made.
Study Area

Alwar district is situated in north­
eastern part of Rajasthan State.
Jaundice (per million rural)
214
8-7
19
Afravali Hills ranges pass through
the middle of the district from north
to south.
The eastern part of the
Table-n—Survey of five epidemic-prone diseases In Alwar district
district is green and well irrigated,
Disease
while the western part is dry and
Age Group
Reference
Sample size
period
--------------------- ——sandy.
Total population of the district
Total For Cluster
as per 1981 census was 1.75 million
Diarrhoeal Diseases •
• <5 years
90 (rural 1574972,
2700
Two weeks
urban
181277).
Rural population of the.district as
200
Measles •
•
■ <2 years
6000
Six months
on 1st June, 1984 has been estimated
8700’
290
Lameness due to Poliomyelitis * * 5-9 years
Prevalence
to be 16,68,711, which is inhabited in
10000
Viral Hepatitis
•
•
- All ages
300000
Six months
1892 villages. The population den­
10000
J. Encephalitis
•
•
• All ages
300000
Six months
sity for the district is 211 per sq.km.
All cases

302

SWASTH HIND

past fortnight. Out of 2708 child­
ren surveyed 186 cases of diarrhoea
were detected by the field workers,
out of these 186 cases, 157 were
clinically confirmed by medical offi­
cer. Therefore, the incidence rate per
10,000 children of under 5 years per
fortnight was 68.7 by lay-reporting
and 58 by clinical confirmation. The
Lay-reporter ‘Correction factor’ was
thus 0.84. Male and female ratio
Results and discussion
of cases was 5.8 :4.2. 52 per cent
of the cases were below 2 years.
Survey: Table-I shows the ave­
Diarrhoeal Diseases
Dysentery was diagnosed in 58 per
rage monthly incidence rates as
Table III shows the details of cent of cases and the remaining 42
detected by ‘lay reporting’ in three
project districts. The weekly data households, children below live years per cent were that of diarrhoea.
and other analytical details have surveyed • and cases of diarrhoea The number of’diarrhoea cases for
been presented separately.
The detected by paramedicals during the the district were estimated to be
19305 ± 1505 (2 S.D.), for two
weeks of August 1984. The annual
Table III—Lay-reporting Correction Factors for the diseases studied
estimates for the district was 501956
cases (vide table IV).
The num­
Lay
Coverage in Survey
ber of cases reported by multipur­
No. of cases
reporting
No.
of
Disease
No. cf
Detected ConfirmedI Correction pose workers of the district ' were
Villages Households Population
by para­ Clinically Factor
880, for the same period. The data
medicals
were adjusted for nqn-reporting/
partially reporting units/areas of
Diarrhoeal diseases
32
2040 13725 (2708
157
0-84
186
multipurpose worker. Out of 19305
<5 years)
Measles
76
9703 73921 (6005
0-70 estimated cases for the district for
96
137
<2 years)
two weeks 880 cases were detected
Lameness due to
97
12114 83505 (10505
137
0-73 by the surveillance through para­
187
Poliomyelitis
5-9 years)
medicals, giving the ‘correction fac­
Viral Hepatitis •
•
150
47778 311373
0-82 tor’ of 21.9297
229

Average maximum temperature
range is 30-32.5°C and average mini­
temperature varies from
mum
12.5°C to 15°C.
The average
annual rainfall is 68.6 cms.
The
district has 14 primary health cen­
tres, 126 sub-centres, 30 rural dis­
pensaries and 26 aid posts. There
are six hospitals located in three
urban areas.

J. Encephalitis

150

47778

case yield was very high by the com­
munity level lay-reporting as com­
pared to routine Institutional data.
Total population surveyed to eva­
luate the lay-reporting system, in all
the 30 cluster was 311375, constitu­
ting 18.5 per cent of estimated rural
population as on 1st June, 1984.
The surveyed population constitu­
ted 47778 households in 150 villa­
ges.
The average household size
was 6.6 persons.

311373

0

0

Table IV Incidence and prevalence rates of epidemic-prone diseases and estimated
number of episodes in Alwar district

Disease

Incidence/prevalence rate

Projected episodes
for the district
during reference
period +2 SD

Annual
estimates
(*)

Diarrhoeal diseases 58 per 1000 (< 5 yrs.)
biweekly

19305 + 1505

501956

Measles

16 per 1000 (<2 yrs.)
half-yearly.

3732+293

7464

Poliomyelitis

13 per 1000 (5-9 yrs.)
prevalence

2792+235

2792

73-5 per 0-1 million
half-yearly.

1242 + 82

2484

Viral Hepatitis

•

♦Unadjusted.

December 1987

The survey revealed that the
number of episodes of diarrhoea
per child of 0-4 years were 1.5;
Recent survey of diarrhoeal diseases
in eleven centres of India showed
that the number of episodes in rural
area vary from 1.1 in Hyderabad to
8.5 in rural Manpur (6).

Measles

The reference period for measles
was six months.
As shown in
table III out of 6005 children of
under 2 years surveyed 137 (2.3%)
cases of measles were paramedically
detected and 96 (16 per 1000) clini(Continued on Page 319)

303

ORAL HEALTH IN INDIA
— Current Status and Strategy for
Health Education
Dr S. Venkatesh

Oral health and general health are inseparable. Because oral diseases—dental caries, perio­
dontal disease, oral cancer—may be a ma ifestation of or an aggravating factor in some
more widespread systemic disorder. Thus, action taken for improving oral health proves
very important for safeguarding general health.

ral health it concerned with the func­ Objectives for 2000
1. Dental, caries, 2. Periodontal
tional efficiency of not only the teeth
Global objectives for' oral health have diseases and 3. Oral Cancer.
and supporting structures but also of the been established in the context of Health
surrounding parts of the oral cavity and of for All by the year 2000, after careful I. Dental Caries : Dental
caries
the various structures related to mastica­ review of available information and con­ or decay destroys the hard tissues
tion
and the
maxillo-facial complex sidering the time available and the reali­
(W.H.O., 1970).20 Oral health and general ties of achieving changes in the oral health of the teeth and may cause pain, in­
fection, disfigurement and other pro­
health are inseparable as oral disease may status of populations.22
be a manifestation of or an aggravating,
In 1979, WHO adopted the target for blems. It results from interaction
factor in some more widespread systemic
2000 AD of no more than 3 Decayed, between three factors:
bacteria,
disorder. Thus, action taken for improv­
Missing or Filled Teeth at 12 years of
diet
and
host
susceptibility.
32
For­
ing oral health proves very, important for
age. In collaboration with a special Work­
safeguarding general health.
ing Group of International Dental Federa­ mation of dental plaques is followed
■There are numerous problems in deve­ tion (F.D.I.) four other targets were added by production of acid by the -plaque
loping a concept of positive oral health19 in 1981.-26 The targets thus identified are: bacteria by fermentation of ingested
Early symptoms of oral’disease often are
Age {in years).
Target
carbohydrates, especially sugars.
unnoticed or considered to be of little sig­
5_6
50%
should
be
free
of
denta
This, in turn, leads to localised demi­
nificance. The chronic, recurrent irreversi­
caries
ble, cumulative and prevalent nature of
neralisation of the enamel surface
oral diseases have contributed to be wrong ■ 12
3 or fewer decayed, missing o
and if unchecked, results in progres­
belief but oral problems are inevitable
filled teeth
sive
destruction of the tooth. The
and are not preventable. To many persons,
18
85% should retain all their
teeth arc of very low importance so that
damage done to the tooth structure
teeth
few attempts are made to preserve or pro­
is
permanent and irreversible and
35—44
50% reduction in 1981 levels
tect! them. The relative efficiency and com­
of
edentulousness
treatment
by doctor/dentist is requi­
fort provided
by artificial replacements

O

such as dentures also add to the difficul­
ties. Other compounding problems include
the undramatic nature of most oral dise­
ases, the association of dental treatment
with pain and discomfort and the reluct­
ance to observe simple oral practices re­
lated to prevention of oral disorders.

304

65-|-

25% reduction in 1981 levels red.
of cdentulousness

Problems
The three most important oral
diseases prevalent in India are:

Magnitude of problem: The pro­
blem of dental caries in India has
been on the increase during the last
four decades both in terms of pre­
valence and severity (table I). The

Swasth Hind

prevalence was as low as 37% in the is above 80% with 5 decayed teeth
1940s with. 1.5 permanent decayed per child on an average at the age
teeth per child on an average. Pre­ of 16 years.
sently, the prevalence of dental caries

3.

Mouth rinsing with dilute solutions o
fluoride after midday meal for schoo
children — can reduce incidence of caries
by about 35%.

4.

Where drinking water has a very high
fluoride content, defluoridation should
be carried using Nalgonda technique.

5.

Sweets and candies should not be allowed
to be sold near school.

6.

Use of fluoridated toothpastes except
by children living in areas of endemic
fluorisis.

7.

Promotion of oral hygiene practices.'

8.

Periodic dental
screening for early
detection and treatment.

Table I—Magnitude of dental caries

Authors

Place

Age group
studied (in
3(rs)

Prevalence
of caries
•

Shourie (1941)3

Madras City

7—20

.39-8%

Shourie (1941)8

Delhi City

5—17

60-3%

Shourie and Soni (1950)*

Bombay City

3—20 •

71-8%

Kokila Jai (1951)*

Gujarat

3—15

Vacher (1952)’

Amritsar

8—13

51-5%

Shourie (1953)*

Bhopal City

5—17

40-3%

Thaper (1953)*

Moga

6—20

591%

II. Periodontal Diseases : Perio­

Chawla & Chaudhry (1957)“ Lucknow

18—22

55-95%

dontal disease is the greatest single

Dutta (1965)1*

Calcutta

6—12

48-2%

cause of tooth loss in India.28 This

Miglani et al (1970)“

Madras

17—32

43-98%

term refers to any disease peculiar to

Ramachandran, Rajan
and Shanmugam (1970)“

Tamil Nadu

1—51 Urban
Rural

66-2%
47-8%

the periodontium or parts

Tewari and Chawla (1972)“

Chandigarh

6—16

72-35%

affecting gums and supporting jaw­

Mishra and Shee (1979)“

Urban Orissa

5—16

60-41%

bones. The most common categories

Tewari and Chawla (1979)“

Chandigarh

6—61

72%

seen are. chronic marginal gingivitis

Vora and Mirchandani (1980)’°Bombay •

5—15

79-62%

Vijayakar and Nayak (1981)** Bombay

15—56

97

Khera (1984)’1

6—16

83-6%

Gauba et al (1986)’*

Rural Punjab
Rural Ludhiana

7—17

.

.

•

68-7%

82

thereof

and covers advanced gum disease

and

periodontitis.82

gingival lesion and its

The

initial

progression

are related to the bacterial plaque

present at or under the gum margin.
Influencing factors
The most important factor in cau­
sation of caries is sucrose28. Sweets
are the children’s favourites. Sweets
are also considered auspicious and
exchanged on celebrations or festive
occasions. Shikanjvi drink (made
with fresh lemon, sugar and water)
is widely drunk in summer as it is
considered a health drink.

caries. A fluoride level of 0.7 to Gingivitis precedes periodontitis
1.2 ppm is required in drinking which may further go on to pocket
water for prevention of dental caries. formation and destruction of alveo­
Higher concentrations on the other lar bone. Unlike dental caries, gum
hand lead to development of dental
inflammation can .usually be control­
and skeletal fluorosis.
led by improvements in oral hygiene
Mehta and Arya (1981)25 made
practices.
the interesting observation that while
a cup of tea contains 0.25 mg of Magnitude of problem
fluoride, the calcium from the milk
Various surveys in different parts
binds the fluoride and hence makes
of India show that the periodontal
it unavailable for the body.
diseases have a high prevalence
Preventive Measures 20, 32, 33
(Table II). Every second person

Cough lozenges also have a dele­
terious effect on the teeth. A dec­
rease in salivary secretions due to
increased intake of tablets, like pro1. Flouridation of public water supplies in
pranalol and diazepam increases the
concentrations between 0-7 to 1-2 ppm above 35 years of age has pus oozing
hazard of caries.
fluoride reduces dehtal caries by 50—65%. gum pockets. 82
The disease starts
Very low levels of fluoride in
drinking water can result in dental

December 1987.

2. Use of fluoridated salt and milk and fluo­ very early in life with bleeding from
ride tablets have been tried in some
gums.
couatries.
'

305

Table n."^^>rcva^cncc °f periodontal diseases

Influencing factors:

Author and year

Place

Prevalence of
periodontal
Disease

Marshall Day (1940)1

N. India

60%

Mehta (1953)8

Bombay

.100%

Gupta (1962)’=

Trivandrum

90-3%

Chawla (1963)™

Lucknow

100%

Miglani (1965)lfi

Madras

95%

Mangi (1966)w

M.P.

98-9%

Vacher (I967)17

. Amritsar

86*6%

Vijaykar (1979)24

Bombay

92 7%

Studies by Marshall Day (1944)/
Mehta et al (1953)8 and Mehta et al
(1956)10 show that socio-economic
status does influence prevalence of
periodontal diseases.

No significant difference has b6en
observed on comparing the urban
and rural distribution as indicated
by Mangi (1966)16, Vacher and Gupta
(1967)lT and Vijaykar and Nayak
(1981)?*

The single most important factor
associated with periodontal diseases
is ‘Oral cleanliness'-25 Already for­
med dental calculus further reduces
the effect of oral hygiene measures.
Habits such as smoking and betel
leaf chewing are found to be related
to higher prevalence and severity of
periodontal disease.

People with systemic diseases and
malnutrition may be more prone for
periodontal disease.23
Preventive Measures

1.

Rinsing of mouth with plain water
after each meal and regular brushing
of teeth particularly before going to
sleep at night and after rising in
the morning.

2.

Use
of paste in preference to
powder with tooth brush.
These,
who cannot afford tooth brush, can
use ‘dalun’ (chew-stick).

3.

Finger massage of gums and teeth-

4.

Calculus when found should be re­
moved by dental hygienist,

III. Oral Cancer : Cancer of the
tongue, mouth and pharynx is an
important oral health problem in
India.- This may be related to chro­
nic irritation from decayed teeth or
poorly fitting artificial restorations
or continuous exposure to toxic sub­
stances such as from smoking, re­
verse smoking, betel chewing etc.
A case of advanced dental caries. This could have been
avoided with simple oral hygiene practices.

306

Oral Cancer account for 38% of
all body cancers in India.33
SWASTH HIND

Preventive Measures
1. Smoking should .be avoided.

2. Betel leaf and nuts should not be
used.

A—Z DENTAL CARE
Dr Daya Sanghal

3. Tobacco chewing in the form of
quid should be stopped.

Aching tooth troubling you?
Consult, a Dental Surgeon, he will help you.
4. Physical irritation from sharp teeth, Brush your teeth with tooth brush and paste.
broken teeth, ill-fitting dentures etc.
Take your own time, don’t make any haste.
should be brought to the notice of
the dentist.
Clean your teeth twice a day.
To save the teeth it is easiest way.
5. Periodical screening shoud be done
for early detection of oral cancer. Deposit in bank? improve it.
Deposit on tooth? gel reinoved it.
Oral Health Care
Enamel of tooth is outer most layer.
Oral Health Care has two components”
It protects the inner tissues, preserve it with care.
1. that which influences the ways of Fluoride in diet is necessary.
life of the individual and commu­
To keep the teeth carious free.
nity so that oral health is promoted’
or maintained and* oral diseases is Gum bleeding happens due to tartar or dental plaque,
prevented.
The deposit may lead to pyorrhoea and/or tooth decay.
2. that which provides adequate treat­ Healthy teeth help in maintaining general health,
ment to those
with oral diseases
I am sure, you know “Health is Wealth”.
facilitating arrest of disease at an
early
stage and prevention
of Instruct the children to avoid sweets & candies from diet.
• loss of function.
And remind them for brushing in the night.
Jack fell down and broke his tooth crown,
Primary oral health care37 would
Jill called dentist to make it again.
thus consist of effective ways of
Knowledge about beauty remains incomplete,
teaching and promoting self-care of
Till it covers the care of the teeth.
involving communities in oral care
Lemon, raw vegetables and fruits in diet,
decisions and of developing educa­
Help in keeping the gums healthy and teeth bright.
tion and instruction packages for
Massage is necessary for the gums.
To keep them health, pink and firm.
different groups in the community.
Never use your teeth to open a bottle or crack a nut,
Your tooth may be loose, lost or hurt.
Role of Health Education
Orthodontist deals with dental irregularity,
Health education has been defined
He removes the ugliness and creates beauty.
as any’ combination of learning
Prosthodontist believes in construction.
He also preserves whatever is left after destruction.
opportunities and teaching activities
Question your dentist about dental care.
designed to facilitate voluntary adap­
He is a person to help you for tooth welfare.
tations of behaviour that are con­
Replacement
of missing tooth is necessary,
ducive to head th (Green 191923)
To
approach
a Prosthodontist make hurry.
Individuals, groups or communities
Stained
teeth
are
no. more a problem.
may require modification / adaptation
As
to
remove
the
stains bleeching can be done.
of their behaviour.
Teething in children may be much painless,
If due care is taken for cleanliness.
Five general principles have been
Use
of charcoal tooth powder is not fair.
identified by WHO (1984)” for health
It makes the teeth sensitive to hot, cold, sweets & air.
education in community oral health
Visit your dentist regularly,
programmes.
And follow his instructions properly.
These are:—White, pearly, shining bright are the few words.
Which should be used to describe your teeth onwards.
1. Every
available preventive oral
health procedure
includes educa­
X-Ray can tell you the hidden decay,
tional components.
Impacted teeth also can be detected this way.
2. Education of a variety of different
target groups, e.g.,- health person­ Yellowish teeth are natural with fail' complexion.
While milky white, are common in dark one.
nel, parents, school teachers, stu­
dents, food ’
manufacturers
etc. Zestful life with broad smile, ’
should be an integral part of any
Wish you good dental health •throughout your life.
regular effort, legislation or pre­
ventive service-programme.

December 1987

307

Educational
materials should beStrategy for oral health education pro­
REFERENCES
designed to gain or focus attention gramme
to' provide new knowledge, to faci­ The different phases in the strategy20 1. Marshal Dey CD & Tandon G.C. Brit.
litate inter-personal and group dis-., would be:— .
Dent. J. 69 : 381, 1940
cussion and to reinforce or clarify
2. Marshal Dey CD & Shourie K.L. Indian
prior knowledge and behaviour. Ma­ 1. Collection of information for plan­
J. Med. Res. 32 :47,1944
terials such, as leaflets, news releases, ning:—
Shourie KL Indian J. Med. Res. 29 : 701,
posters, films and slides are appro­
(a) magnitude of oral health problem. 3. 1941
priate educational aids.
(b) oral health
services and facilities
4. Shourie K.L. & Soni NN J. All India Dent
available.
4. Oral health education should
be
Asso. 22 : 185, 1950
(c) information about the community—
built into general health education
their level of understanding, cultural 5. Kokila Jai J. All India Dent. Asso. 23 :
programmes.
beliefs, practices etc.
3, 1951
5. In all community and school based (d) identification of available channels
6.
Shourie KL J. All India Dent. Asso.
settings,
oral
health instructions
of communication.
25, 1953
should be consistent and compatible
with scientific knowledge as well as 2. Establishment of objectives for oral 7. Vacher BR J. AU India Dent. Asso. 24:
1, 1952
with
local
culture,
educational health education: —
(a) listing of actions desired of indivi­ 8. Mehta FS et al J. All India Dent. Asso.
system and social goals.
duals, familities and community.
26 :4,1953
Methods for community oral health
(b) specific information for communica­
education
tion to target groups and specific be­ 9. Thaper SL J. All India Dent. Asso. 26 :
I, 1953
liefs requiring change.
These include:—
10'
Mehta FS, Sanjana MK &.Shra(T BC
3- Assessment of barriers to oral health
1. One-to-one communication.
Intern. Dent. J. 6 : 31, 1956
education and ways of overcoming these.
2. Group meetings and discussions.
Chawla TN & Chaudhry K. J. All India
4. Appraisal of apparent and potential 11. Dent.
Asso. 29 : 165, 1957
3. Organisation of the community. by resources such as Governmental depart­
forming committees, working with ments and agencies, voluntary organisa­ 12. Gupta OP J. AU India Dent. Asso. 35 :
local leaders and holding meeting tions, professional associations, commu­ ' 45, 1962
with professionals.
13. Chawla TN, Nanda RS & Mathur MN
nity level organisations etc.
J. AU India Dent. Asso. 35 : 151, 1963
4- Use of mass media such as Door- 5. Development and implementation of
14. Dutta A J. AU India Dent. Asso. 37 :367,
darshan, AIR, Press, Cinema slides detailed plan of action.
1965
etc.
• identification of individuals and groups
15.
Miglani efa/ICD Newsletter Nov. 1965
to be involved in planning.
The effectiveness of an oral health edu­
16.
Mangi J. Indian Acad. Dent. 7 : 55, 1966
cation programme depends on:—
identification of target group/audience.
17. Vacher BR & Gupta RK J. AU India
(i) level of understanding of the target • specific information resources, methods
Dent. Asso. 39 : 5, 1967
audience.
and educational
aids required for 18. Ramachandran K,
Rajan B. P. and
communication (Fig. 1).
Shanmugham S J. All India.Dent. Asso.
(ii) their acceptability of suggested oral
42 : 65, 1970
health measures.
6. Evaluation.
19. Miglani DC, Sujeer VN, Chandra Ross
(iii) the economic feasibility of putting
Such systematic oral health educa­
& Raghupathy E, J. Indian Dent. Asso.
these measures into practice.
42 : 219, 1970
tion strategy is of crucial importance
(iv) availability of oral health services in the prevention and control of oral 20. W.H.O. Tech. Rep. Ser. No. 449, 1970
and of advice generating confidence
21. Tewari A & Chawla TN J. Indian Dent.
diseases.
in the community.
Asso. 49 : 231, 1972
22. Mishra & Shec J. Indian Dent. Asso.
Fig. I
51, 1979
Scheme for Development & Testing of oral Health Educational Material
23. Green LW International J. Health Edn.
22 :161,1979
DATA-BASE
24. Vijaykar HN & Nayak R Dental Dia­
_________________ I________ ____
logue 8 : 31,1981
25.
Mehta F & Arya R J. Indian Dent. Asso.
TARGET ORAL
TARGET GROUPS
51, 1979
DISEASES
TARGET ORAL HEALTH
TARGET DELIVERY SYSTEMS 26. Federation Dentairc Internationale JIndian Dent. Asso. 54 : 227, 1982.
MEASURES
[
27. Talim S.T. J. Indian Dent. Asso. 55 :
MATERIALS** 395, 1983
28. Mistry K.M. J. Indian Dent.' Asso. 55 :
TARGETED CONTENT
387, 1983
29. Talim S.J. J. Indian Dent. Asso. 55 : 401,
DESIGN**--------------------- Attractive
1983
Clear
simple
30. Vora & Mirchardani N. Cited in J.
unifying theme
Indian Dent. Asso. 55 : 395, 1983
PRODUCTION
31. Khera N. Tewari A. & Chawla H.S.
I
, Indian Soc. Ped. Prev. Dent. 2:19, 1984
DISTRIBUTION
32.
W.H.O. Tech. Rep. Ser. No. 713, 1984
I
EVALUATION
33. Sidhu S.S. J. Indian Dent. Asso. 57:
I
373, 1985
REVISION
34.
Anon.
J. Indian Dent. Asso. 57 : 377,
♦♦Requires consultation among
1985
# dental experts
35. Gauba K. Tewari A. & Chawla H.S.
media professionals
J. Indian Dent. Asso. 58 : 505, 1986
® members of target groups
36. W.H.O. Tech. Rep. Ser. No. 750, 1987

3.

308

Swasth Hind

PREVENTION OF CHILDHOOD ACCIDENTS
Dr A. K. Mukherjee

AH childhood injuries are not preventable. In fact, the minor injury that accompanies child­
hood experimentation with the environment provides an experimental factor in child develop­
ment. Therefore, in setting goals for prevention programmes, it is important to define the
severity level and the causes of injuries to be targeted for intervention.

13% of the world’s popu­
lation is disabled, 15% of these
being due to injury (WHO, 1976).
India’s share would be roughly 12
million disabled due to injury. A
community based survey carried out
by Sahasrabudhe and Sancheti (1979)
indicated that 0.7% of the population
had Orthopedic deformities. Assum­
ing that 20% of these were due to
injuries, this would give an all-India
figure of one million. As disability
can occur due to deformity and as
injuries can also cause other disabi­
lities like deafness, blindness and
mental defects, it is presumed that
the figure of 12 million disabilities
due to' injuries in India would not
be out of order. The incidence every
year would be around a million and
childhood injuries form a very im­
portant cause.
bout

A

For nearly half a century, injuries
have been recognised as a leading
cause of childhood morbidity and
mortality. In United States, it is esti­
mated that every year some 30,000
children and youth die of injuries—
more than 4 times the number dying
of other diseases. Injury has also
been recognised as the leading cause
of * loss’of potential years of producPlaying with bow and arrows can result in
serious eye injuries.

309

December 1987

tive life. The total impact of child­
hood injuries in terms of serious dis­
ability, mental retardation, medical
costs, etc., is enormous.
Similar statistics are hard to ob­
tain in India because of the very
small proportion reporting to hospi­
tals/health centres. While in U.S., an
accidental death is defined as one
which occurs within one year after
the accident, no such definition has
yet been used in India. Such figures
as are* available are of those deaths
reported to the police. If an injured
child dies at home owing to second­
ary complications many families do
not report the death to the police. A
large number of accidental deaths
and injuries also go unreported in
rural areas possibly because the
police stations are far away/the
rural people do not want to get in­
volved with police.

Guli danda is also a common cause of childhood injuries.

10 to 20 lakhs being disabled seri­ wall & Gupta, 1974;
ously injured.
Chaudhuri, 1962).

Children and young adults form
a sizeable group in the domestic and
Accidents and injuries form a
traffic accidents. Falls, burns and
major cause-group of deaths in rural
poisoning are the major causes of
India accounting for 5.5% of all
injuries of children at home as shown
deaths in 1983 (as compared to 4.2%
by several studies in India (Chandra,
in 1971). 2.6% of these accidents
1976; Gandhi, 1963; Sharma & Sax­
and injuries have occurred in infants,
ena, 1974; Ghose et. al, 1962; Agar­
6.2% in the 1-4 year age group and
15.5% in those children aged 5—14
years.. Thus, we see that almost a
quarter (24.3%) of the deaths due to
the accidents and injuries in rural
India are in these under 15 years of
age.

Chaudhuri &

The term ‘accident’ has proven a
barrier to progress in its prevention.
It implies a misfortune or an ‘act of
God’, an occurrence not understan­
dable in terms of the normal cause
of the disease. People often attri­
bute avoiding accidents to sheer luck,
a.miracle or a good fortune. It is.

' An estimate made of accidental
injuries in India shows that annually
(i) Traffic accidents may be res­
ponsible for 40,000 deaths with ano­
ther 4 to 8 lakhs being disabled ser­
iously injured;

* domestic accidents may acc­
(ii)
ount for 2 lakh deaths with 20 to 40
lakhs being disabled/seriously in­
jured;
(iii) occupational accidents would
account for one lakh deaths with

310

Playground and play equipment also present hazards to children

SWASTH HIND

advisable to use terms such as ‘IN­
JURY’ and
‘injury control’
instead as they support the view that
accidents have a context, and can
be avoided. Thus, this would repre­
sent a major shift in our concept of
the idea of accidents as random.
chance, uncontrollable events to the
recognition of injuries as describable
epidemiologic conditions that can be
controlled or prevented. A systema­
tic approach can then be used for
prevention strategies.

Multi-disciplinary approach
There is need for new data sour­
ces, new classification system and
new conceptual frameworks for ap­
proaching the problem of childhood
injuries and their prevention. This
field needs a multi-disciplinary ap­
proach. Practising paediatricians,
neurologists, surgeons, Orthoped i.cians and other doctors—encounter
children with injuries of various
levels of severity. Research needs to
be focussed on the mechanism of in­
jury, treatment and rehabilitation.
Epidemiologic studies need to be
carried out on the different types of
childhood injuries.

The Childhood injuries can be
analysed in terms of the epidemiolo­
gical triad. Here, the agent is the
object that is the direct cause of in­
jury, the host is the affected child
A positive approach needs to be inculcated among children
and the environment includes not
by motivation for adopting safe play habits.
only the physical situation but also
or burns respectively)—a develop­ ment viewpoint as those involving
the psycho-social one. .
mental approach that emphasizes (1) Self/home management, (2) Cas­
The crawling nine-month-old in­ that children have different cogni­ ualty treatment & discharge, (3) hos­
fant who explores the world with tive, perceptual, motor and language pitalization, and (4) death. No doubt
his mouth may, with equal likeli­ competencies.
all childhood injuries are not pre­
hood, poison himself by swallowing
ventable. In fact, the minor injury
The clinical manifestations ol that accompanies childhood experi­
misplaced pills, choke on a ‘goli’ or
receive a serious burn, from the stove. childhood injury ranges from minor mentation with the environment pro­
Thus, there is need to focus on deve­ cuts and bruises io. severe multiple vides an important experimental fac­
lopmental commonalities of the be­ trauma and death. For convenience tor in child development. Therefore,
haviour (instead of a discipline speci­ in our understanding, we normally in setting goals for prevention
fic approach to poisoning, choking group them into four from the treat­ programmes, it is important to define

December 1987

311-

the severity level as well as the
causes of injuries to be targeted for
intervention.

Children should be taught safe play
habits by motivating them through
a positive approach.

.AU children should grow up in a
safe environment. Towards this end,
anticipatory guidance for injury pre­
Falls form another important vention should be an integral part
There is also need to evolve a cause of childhood injuries. Varia­ of primary child care provided for
simplified standardised instrument bles such as age, sex, socio-economic all infants and small children. Par­
for scoring the severity of injuries. class, place of residence, time of day . ents need to be counselled on ageseasons are associated with the
Those already in use in western and
frequency of injuries due to falls. appropriate, season-appropriate and
countries Such as the Abbreviated The number of falls needs to be limi­ locality-appropriate preventive mea­
Injury Scale, Injury Severity Score, ted by suitable environmental modi­ sures which reduce common serious
etc., arc complicated, trauma-orien­ fication, by use of appropriate devi-» injuries.
ces and by parental counselling.
ted and are for evaluating emergency
A co-ordinated political, medical,
Traffic-related injuries among chil­
treatment and subsequent care rather
dren are another area of concern. individual and community effort is .
than for prevention.
Having created a world in which required for prevention of childhood
injuries. This effort must be organi­
It is important to develop a- pro­ children are exposed to the hazards sed as a planned programme where­
of the road, we have the obligation
file of the family, and the child at to protect them from these hazards. in the epidemiological factors are
risk and to identify the agents of There is need to address ourselves analysed, a target injury is identified
injuries as this would contribute to to answer questions e.g. pedestrian and an effective'intervention strategy
selected. A systems approach (with
injuries to children such as—
preventing childhood injuries.
phases such -as Analysis, Design,
(i) .What are the main detri­ Development, Implementation and
Selection of toys
ments of unsafe behaviour Evaluation) should be adopted.
and accidents?
Play and playthings arc important
Mass media have an important
(ii) What our educators do. gives
in the process of growing up for
role to play in frequent reinforce­
the
mental
make
up
of
the
children providing them not only
ment of targetted messages and to
child at various ages?
bring about behaviour changes. Note­
an outlet for their energy but also
worthy in this context is the effort
(iii)
What
can
be
done
to
reach
an opportunity for discovering for
the objectives of traffic edu­ made over Doordarshan prior to
themselves.
But, the joy of play
Holi for the prevention of eye in­
cation?
juries and prior to Diwali last year
sometimes ends in tragic disability
or death. Parents need to be edu­ Another aspect is the prevention of and again now with reference to the
injuries to children travelling in management of burns.’ While tele­
cated to avoid toy hazards such as vehicles as passengers or sometimes vision and radio are suitable for
aspiration and ingestion dangers, as driversshort messages, newspapers can re­
inforce the messages or print feature
bums and shock, catch injuries, ex­
Burns injuries among children, articles on target-injuries. Prominent
plosions and poisonings, lacerations, which vary in severity and frequency and creditable community leaders
noise, piercing injuries, projectile in­ include flame, scald, contact, elec­ can be quoted and community efforts
juries and even strangulation on long trical and chemical burns and smoke lauded. Involvement of mass-media
representatives in our childhood in­
ropes or loops. Advice needs to be inhalation injuries. There is a mark­ jury
prevention programmes provi­
given to parents on the purchase of ed variation in the patterns of risk des the necessary expertise on the
• toys appropriate for child’s age, sex, of boys and girls. Prevention of effective use of the media.
development and
temperament. burn injuries, inculcation of emer­
A well organised programme for
These toys should have the least gency behaviour to reduce burns the prevention of childhood injuries
potential for misuse. Under-five chil­ severity and rehabilitation of a child should also include monitoring and
dren should have their play super­ victim with burns who has function­ evaluation. Changes, not only in
morbidity and mortality due to in­
vised and taught by good example. al disability and disfigurements needs juries should be measured, but also,
our concerted efforts.
Toys should be properly stored to
in the reduction of risk hazards in
prevent falls.
Childhood poisoning, a tragically order to,erisure that the programme
common event, is often due to the is effective and for making necessary
changes. —From the Inaugural Ad­
Positive approach
negligence of parents in following
dress of the author during the Semi­
Playground and playground equip­ simple precautionary measures.
nar on Prevention of Childhood1
ment also present hazards to child­
Other common causes of child­ Accidents organized by the National
ren, e.g.» swings, slides and see-saws hood injuries in India, include "ani­ Institute of Public Co-operation and
Child Development on 14 October,
result in a large number of injuries. mal bites and drowning.
1987 in New Delhi.
A

312

SWASTH HIND

HOW DRUGS AFFECT
OUR NUTRITIONAL STATUS
Kamal G. Nath

All drugs are toxic, if used in excess, and will almost always cause undesirable side effects—
Nutritional deficiency being one of them.

he drugs we use include over the

counter (OTC) and prescription
T
medications, alcohol and hard drugs.

Even nutrients themselves, vitamins
in particular, are sometimes used in
large amounts as drugs instead of
nutrients.

’While drugs are used by all agegroups, the health conscious elderly
are the most likely to be overusing
OTC drugs such as laxatives and
vitamin supplements in addition to
the prescription drugs they use to
treat their many ailments. Teenagers
and young adults are in age group
that most frequently abuse hard
drugs.

is used, the more likely it is
to cause damage.
(3) Use large amounts ‘ of one
drug. Drug effects are exag­
gerated when excessive doses
are taken.

(4) Use several drugs at once.
In that case, one drug may
multiply the effect of another.

Drugs can cause nutritional defi­
ciencies in several ways. A very
obvious effect is reduction of food
intake because drugs either suppress
the appetite, perhaps by interfering
with taste, smell or saliva production,
or cause nausea, vomiting and
diarrhoea. The most severe food re­
All drugs are toxic, if used in duction response to drugs is seen
excess, and will almost always cause in cancer patients undergoing che­
undesirable side-effects, one of motherapy.
which may be nutritional deficiency.
Persons most at nutritional
risk Diet and Drugs
from drug use are those who:
Drugs may reduce absorption of
(1) Lack reserve nutritional stores nutrients: —Laxatives for example,
and are more vulnerable to speed up the emptying of the stomach
nutritional assault. They are and intestine so that nutrients have
already undernourished, are less time to be absorbed.
Some
chronically ill, or are in a drugs such as antacids, change the
period of rapid growth.
acidity level in the gastrointestinal
(2) Use drugs over a long period tract and affect the solubility of the
of time. The longer a drug nutrients such as minerals. Some

December 1987

drugs, such as diuretics increase the
excretion of nutrients in urine by the
kidneys. Sodium and potassium are
depleted in this way.

Some drugs interfere with meta­
bolism of nutrients: —Drugs may
damage the liver so it cannot meta­
bolize vitamins, store nutrients or
synthesize protein. Or, they may
damage the pancreas so it cannot
make digestive enzymes; sometimes
drugs are used for the deli berate, pur­
pose of interfering with
nutrient
metabolism.
For example—anti­
coagulants act by reducing vitamin
K, the vitamin needed for blood
clotting. Anticonvulsant drugs used
by epileptics may alter the meta­
bolism of Vitamins D, K and folic
acid and they can also cause appetite
loss.
Nutrient synthesis by bacteria in
the intestine also may be adversely
affected by certain drugs. Anti-biotics in particular tend to kill ‘friend­
ly’ bacteria in the intestines at the
same time that they are destroying
disease causing bacteriaOral Contraceptives are hormones
that affect numerous metabolic pro­
cesses:—They are known to reduce

313

blood levels of thiamine, riboflavin,
Vitamin B6, Bn, C and folic acid and
also to affect metabolism of protein,
fat and carbohydrates.

Obviously, it’s very important
that people be given explicit direc­
tions for each drug: when it should
be taken before, after, or during
meals—and what foods, if any, need
to be avoided when the drug is used.

First, alcohol acts as an appetite.
depressant and an alcoholic may eat
very little, thereby getting too few
nutrients except calories. But al­
cohol requires nutrients for its meta­
bolism and the liver preferentially
metabolizes alcohol. This depletes
the nutrient supply needed for meta­
bolism of other nutrients.

How Food affects drugs absorption
and action: —While
drugs affect Nutrition and alcoholism
nutrition, food eaten during drug use
Alcohol is both a food and a drug.
can affect the drug action—some­ It is considered a food because it
At one time it .was thought that
times decreasing it, sometimes in­ does supply energy, 7 calories per the liver disease resulting from al­
gram, and some alcoholic beverages
creasing it.
coholism was totally due to the poor
such as beer and wine, also have
diet and state of malnutrition of the
How food affects drugs in the other nutrients, including carbohy­ alcoholic. It is now known, how­
drates, protein, minerals and vita­
body—Delay and/or reduces absorp­
ever, that alcohol is toxic to the
mins. i However, these nutrients are
liver and other organs even in the
tion: improves absorption; prevents present
in minute quantities, and al­
nausea or vomiting and
causes coholic beverages are high calorie’, presence of a good diet. Alcohol
causes changes in the liver similar
low nutrient—density foods.
toxic food drug interaction.
to those found in protein malnutri­
Alcoholism, or too much alcohol tion.
Often when a drug is taken at the
consumed regularly over an exten­
same time as food, or shortly after
Because of alcohol’s toxic effect
ded period of time, can lead to
eating, the food in the stomach will
on the liver, stomach,
pancreas
serious nutritional deficiencies as
delay the absorption of the drug,
and intestines, they act less efficien­
well as to physical ailments, such as
and it also may reduce the amount
tly in digesting metabolizing and
obesity, gout, alcoholic hepatitis,
absorbed.
absorbing nutrients.
Alcoholics
cirrhosis of the liver and many neu­
are found to have symptoms of
rological disorders, including a form
Some drugs are absorbed more
deficiency of B-vitamins, especially
of psychosis. Alcohol also appears
readily when taken with food. Fat,
thiamine, which may result in beri­
to play a role in the development of
for example, may promote absorption
beri, anaemia caused by lack of folic
coronary heart disease, cancer and
of certain compounds. Moreover,
acid, night blindness from lack of
diabetes. Alcohol seems to work
drugs are taken with food to prevent
vitamin A, loss of taste sensitivity
synergistically with cigarette smoking
reactions such as. nausea and vomit­
and appetite from lack of zinc, tre­
to enhance a person’s chances of
ing. Some drugs are metabolised
mors from lack of magnesium and
developing cancer of the oral cavity.
faster when the diet is high in pro­
shortages of protein, vitamin C and
The effect of alcohol and tobacco
tein and low in carbohydrate.
potassium.
combined is greater than the sum of
Drastic changes in diet, for example,
In the presence of alcohol, the
their individual effects.
an increase in fibre, may affect
liver increases its synthesis of trigly­
the intestinal bacteria and change the
Nutritional disorders
resulting cerides and these fats are secreted
rate or level of absorption of some from the over use of alcohol come in the blood leading to Hyperlidrugs.
about in several ways.
pedemia and possibly atherosclero­
sis,' high blood pressure and coro­
Effect of alcohol, on nutritional status:
nary heart disease.
The liver
stores
the
fats
too
and
becomes
a
Depresses
Malnutrition
Nutrient
Too few
appetite
— deficiencies.
— nutrients
fatty liver.
A damaged liver is
unable to store fat soluble vitamins.
Increases
Malnutrition
Too many
appetite
Fat not absorbed may take up
— calories
— Overweight/Obesity
calcium and result in kidney stone
Toxic effects on liver,
Malnutrition
Reduced efficiency
Impairment of glu­
stomach* Pancreas, intes­
of digestion absorption
Nutrient deficiencies, increas- development.
tines and other organs
— & metabolism
— ed triglyceride production.
cose and glycogen stores in the

314

SWASTH HIND

other nutrients such as Vitamin C need to take supplements.
The
and E, the belief
has been that groups most likely to need supple­
they are relatively harmless, even ments are:
when used in large amounts. How­
— Pregnant
and
lactating
ever, evidence is accumulating that
Treatment of alcoholics includes
suggests, caution is needed when us­
women.
nutritional rehabilitation with nut­
ing these apparently harmless nutri­
rient supplements, to rebuild the
— Children or teenagers who
ents in amounts well above the Re­
body’s nutrient stores. As with all
eat poorly balanced meals.
commended
daily
Allowances
other aspects of nutrition and diet,
(RDA).
moderation is the most
healthful
— Elderly persons with limi­
Often the
rationale used by
mode.
ted diets.
people who take, extra large dose of
More research is needed on this vitamins is that if a small amount
— People who eat out most of
subject, in view of some of the con­ is good, for them, then a large
the time.
flicting information. Scientists say amount must be even better. But
it is too early to endorse moderate it should be recognised that while
— People convalescing from
use of alcohol as a heart attack increasing the dosage of a the­
surgery, burns, injuries, etc.
preventive, especially because of rapeutic compound leads to maxi­
mum. effectiveness, a further increase
— People with malfunctioning
its known medical risk.
leads to the production of toxic
digestive systems or aller­
Nutrients as drugs
affects.
gies.
liver lead to hypoglycemia, an in­
crease of lactic acid level and a
rise in blood uric acid, and this
makes an alcoholic prone to gout.

Sometimes nutrients, usually vita­
mins, are prescribed in large or
mega doses for treatment or preven­
tion of an ailment. When used in
large amounts, nutrients go beyond
functioning as nutrients and instead
act as drugs.

Vitamins work in
partnership
with each other and with other
In cases where nutrient supple­
nutrients in performing their func­ ments do appear to be needed, pro­
tions in the body. The best way
ducts supplying moderate amounts
for us to get them in proper balance
i.e., similar to RDA are generally
is to eat a wide variety of foods.
Money spent on high nutrient the safest choice.
One of the major reasons why density foods from the Basic Five
Some vitamins lose potency over
many health professionals object to can provide us with better nutrition
time. Air, light, heat all can des­
the use of megadoses of nutrients than money spent on expensive
vitamin
supplements.
troy them. So, supplements should
is their potential toxic affect on the
be stored in a cool dark place and
body. For some nutrients, such as Nutrient supplements.
the fat soluble vitamin A and
Vitamin and mineral deficiencies should not be kept for a long period
D, toxicity is well documented. For do exist, and some people may of time.
O

Please don’t forget to intimate the change of address.
your Subscription Number.

To ensure prompt supply of the journal, please quote

For all enquiries please write to :

The Director
Central Health Education Bureau
Kotla Marg
New Delhi-110002

December 1987

315

WORKSHOP ON HEALTH WRITING
T. K. Parthasarathy
Press Institute of Indian
(PII) organised a three-day
workshop on Health Writing from
July 8 to 10, 1987, at the Institu­
tion of Engineers, Bangalore, in col­
laboration with the Asian Mass
Communication Research and In­
formation Centre (AMIC), Singa­
pore, the Press Trust of India and
Deccan Herald, Bangalore. This
was the second one on Health Writ­
ing organised by the Institute in
the past eight months. The Banga­
lore Workshop was confined only to
the southern States as the Institute
plans to hold two more workshops—
one each in the Eastern and Western
. Regions later.
he

T

Objectives

The workshop set itself the follow­
ing objectives:

4 To provide information on na­
tional and regional health problems
to help journalists understand, iden­
tify the sources of information and
utilize different formats for handl­
ing the information;

Programme; Diarrhoeal diseases national newspapers and magazines
and oral rehydration; Communica­ in the past few years.
ble diseases control: Kysanur forest
He said it was not enough to
disease.
know that 35 people died of gastro­
The
five-lecture-sessions were enteritis in Kanpur or there were
handled by resource persons who 40 starvation deaths in Kalahandi.
were senior health administrators What was more necessary was that
and experts in their own right on what these figures meant to the
the subjects they covered.
common man and what action, if
The sixth session was a sort of any, was being taken to deal with
round-up. providing, answers to ques­ the problems. Before a crisis situa­
tions unanswered or not fully clari­ tion was reached, media men should
fied.
How can newspapers help highlight the problems and warn the
people to participate in health pro­ readers.
grammes? was one question. Another
“Media cannot solve many pro­
point was about the term “afford­
blems or carry on campaigns on all
able by the community”, mentioned
of them. Media, if properly em­
in the definition on primary health
ployed,, do reach large numbers of
care. When the services are pro­
people. If the people could be
vided free of cost to the people, how
reached and involved in the pro­
does ‘affordable’ fit in?
gramme to take action to improve
WHO, UNICEF and the Cen­ their lives, journalists to that extent
tral Health Education Bureau of would have done a fine job. But to
the Ministry of Health and- Family do this journalists should first equip
Welfare, New Delhi, provided ma­ themselves with information and se­
terial for the use of the journalists. condly acquire skills for better pre­
A video film on health provided by sentation and greater communica­
UNICEF was also screened.
tion”, he added.

* To explain the need for news and
feature reporting on the subject to
help spread the health message.

There were lively discussions on
Without the technical input of the
all days of the Workshop.
■health sector the media, could not
fulfil their obligations to serve the
The workshop comprised lecture Acquire skill of presentation
interests of the public. What the
sessions, field visits, case studies and
Shri S. Prakasa Rao, Director, media persons
should remember
discussions.
PII, set the tone to the Workshop was that the mode of presentation of
Ten participants- from newspapers when in his inaugural address • he their reports, the style and language,
and news agencies attended the said it was heartening that the pro­ sometimes even the choice of words
Workshop. The workshop discussed cess of realization of the importance would have to vary according to the
five subjects: Health for all by 2000 of health writing had begun, thanks educational and social levels of the
AD and Nutrition; Immunization to the interest shown .by many respective target populations.

316

SWASTH HIND

Shri. T. K. Parthasarathy, Editor,
SEARB Bulletin of the Internatio­
nal Union for Health Education and
former Editor, Swasth, Hind was the
Course Director. He said that the
Press should highlight the positive
aspects of health programmes. The
Press should also mention those as­
pects where the community
had
failed to adopt preventive measures.

people relating to the
prevailing
health problems with an emphasis
on their prevention and control.

The mother should be taught
the signs and symptoms of dehy­
dration. Health education of the
people was very essential for pre­
This difference should be reduced vention of diarrhoea and for giving
and the area of interaction between prompt attention to the victims.
the providers
and
the receivers Personal hygiene,
environmental
(community) should increase and sanitation and proper storage and
given
this would lead to the higher accep­ use of water should be
importance.
tance of the health programmes.

Immunization Programme
Dr. C. Achuthan,* former Joint
On the
second
day.
Dr.
Director of Health Services, Karna­
T.
M.
Ramesh,
Additional
Director
taka, who took the first session, ex­
plained the concept of Health for (F.W. and MCH) spoke on the Im­
All by 2000 AD (HFA). He said munization programme. The uni­
immunization programme
HF A did not mean complete absence versal
of diseases from the face of earth. which started in 1985 was import­
It only meant that everyone had the ant and this was being monitored by
Em­
right to health care and had access the Prime Ministers’ office.
to the health care system (preven­ phasis was placed on child survival
tion, treatment, diagnosis and reha­ which meant reduction of infant
bilitation). This began from the mortality and child mortality and
simplest care which was available improvement of. health standards.
in the home and in the community
up to the highest level hospital care. Diarrhoeal Diseases
It was based on the nature of health
Dr. D. G. Benakappa, Professor
problem and on the resources of the and Head, Paediatrics Department,
community.
Vani Vilas Hospital, Bangalore pre­

Communicable Diseases
Dr. J. L. Javere Gowda, Director,
Health Education & Training, Direc­
torate of Health Services, Karnataka
spoke on communicable diseases and
their control/eradication on the last
day of the Workshop. This was
followed by a presentation on the
Kysanur forest disease (KFD), pecu­
liar to Karnataka State, by Dr. D.P.
Narasimha Murthy, a retired Dy.
Director of Communicable Diseases
and Professor of P.S.M. Department
at.the Kempa Gowda Institute of
Medical Sciences, Bangalore. Dr.
Murthy was closely associated with
the KFD programme while in ser­
vice.

Dr. Gowda traced the history of
faced his lecture with the statement
malaria control programme from
that the child was the most neglect­
1953 and said the incidence of the
ed. Twenty per .cent of children
disease was brought down drammamalnourished.
Diarrhoea claimed
tically by 1966 when the disease was
1.5 million children every year in
nearly eradicated. But there was re­
India. Lack of
protected, water
currence later and the programme
supply, fly nuisance, material mal­
was revised, and the modified pro­
Primary health care approach nutrition were some of the import­ gramme was to prevent deaths due
gave equal emphasis and place to ant causes for heavy child morbi­ to malaria. He mentioned the steps
indigenous
systems
of medicine dity and mortality.
taken by the National Malaria Era­
which were popular in the countryDr. Benakappa said that in the dication Programme (NMEP) to
side.
Vani Vilas
Hospital, Bangalore, achieve the goal. Health workers
Dr. Achuthan said that people drugs were not used but oral rehy­ were maintaining surveillance—look­
should be involved in the health dration solution was given to the ing for fever cases, getting blood
programmes from the planning stage patients. Thus a saving of Rs. 3 samples for examination, giving pre­
treatment, and radical
so that they could be convinced lakhs on drugs was made by the sumptive
blood tests revealed
that the programme was their own Hospital. While intravenus admi­ treatment
malaria.
Laboratory
. services
nistration
of
glucose
needed
a
and should participate in the activi­
were
provided
at
the pri­
not need any
ties connected with its implementa­ doctor, ORT did
tion. Primary health care had given medical help. The ORS could be mary health centre level for quick
examination of blood slides. The
first position.to educating of the made at home.

Dr. Achuthan described the basic
principles, of. primary health care
which took the health services to the
doorsteps of the home, workplace
and the community and the most ad­
vanced hospital.

December 1987

317

DDT spray was used in areas where
the annual parasitic index was 2 or
more.

mitted by a particular type of hard
tick. The disease was named so as
the etiological agent was first isolat­
ed from visceral specimens of a fre­
shly dead monkey procured from
Kyasanur forest near Barige village
in Shimoga district. Subsequently,
further isolation of the virus was
made from human cases of illness
resembling typhoid in the adjoining
villages, ticks collected in forest floor
and on monkeys.

lihood of KFD spreading to Kerala,
Goa and Maharashtra and that the
three States should take necessary
precautionary steps in advance.

Drug distribution centres and fever
treatment depots were set up in re­
People’s participation
mote and needy areas utilising the
community support. Dr. Gowda
At the last session, Dr. V. Rama­
said that nomads and migrant lab­
krishna, Regional Director, South
East Asia Regional Bureau of Inter­
our of projects were spreading the
national Union for Health Educa­
infection by not taking radical treat­
tion, addressed the participants on
ment where needed. There were
People’s participation. He said peo­
pockets of resistance to get the hou­
ple should be closely associated with
ses sprayed with DDT or other in­
The treatment of KFD was essen­ the welfare programme from the
secticides needed in the situation. tially'symptomatic. Analgesics and planning stage. Primary health care
The coverage at times was as low as anti-fever drugs were given. Rehyd­ meant total involvement of the peo­
ple. They should be involved in the
32 per cent.
ration was done with I.V. fluids in community survey for health pro­
certain cases. Coagulants were used grammes, and should be deemed as
Dr. Gowda referred to the Japa­
if there was a bleeding tendency and equal partners in the development of
nese B encephalitis which was im­
antibiotics given to prevent secon­ health programmes. Such participa­
tion was a continuous, process.
ported into India in 1979. The dis­
dary infection.
ease was characterised by high mor­
Ms Nazreem Bhura and Mr.
tality and disability. More than
KFD was restricted to a few ta­ Raghunathan raised questions about
one-third cases died, and another luks in Malnad forest areas of Shi­ ways to secure information from the
one-third disabled. There was no moga district for nearly 15 years health authorities. It was stated that
specific medicine, and treatment was from 1957, affecting mainly four ta­ when items based on information
symptomatic. Vaccines available in luks limited to an area of about 250 collected from their own sources
were published, the health authori­
foreign countries were very costly. sq. miles. During 1974-76 the sp­ ties put out denials. What was the
read was noticed southwards involv­ remedy?
Children were mostly affected by ing new areas.
Dr. Ramakrishna said that keep­
the disease. He referred to the pecu­
ing
away information was bad. Offi­
liar situation in Madhi (Karnataka) Control Measures
cials tended to do this for fear that
where sugarcane crushing industry
Control measures included main­ they might be exposed to criticism
was the main stay. The piggeries
from their superiors. This was partly
tenance
of constant surveillance of also due to the Press publishing
were set up to feed on the waste
products of sugarcane crushing. The infected areas and their borders for negative aspects or blowing out of
mosquitoes picked up the infection monkey deaths and human cases proportion certain incidents. How­
ever, the Press should do a sort of
from the pigs and spread the dis­ and spraying of insecticide in areas investigative
reporting. Agencies
where
monkeys
had
died
recently
to
ease.
such as the Press Institute should
kill the infected ticks. People should collect information and supply to
One of the measures advocated avoid visiting the forest areas espe­ correspondentswas to isolate the pigs for a period cially in the epidemic seasons (post­
Dr. Ramakrishna spoke of a co­
of 24 days or remove the pigs aro­ monsoon) as also areas specially
operative at Malur where people put
und 2-3 km away from the residen­ where monkeys had died recently.
by a small sum everyday and later
tial areas. The vector mosquitoinvested
it in a development pro­
People should report unnatural
culex vishuni—could not travel the
gramme. The cooperative was today
distance under normal conditions. monkey deaths promptly to facilitate running a primary health centre
People’s participation on these pre­ autopsy for confirmation of the pre­ meeting all the drug requirements.
sence of infection. Suspected human
ventive aspects were needed.
In Chinnalapatti village in Tamil
cases resembling KFD should be re­
Nadu,
people had constructed com­
ported for treatment. Patients should
Kyasanur Forest Disease
munity latrines with their own re­
be given blood for diagnostic pur­ sources. Village people paid a small
Dr. Narasimha Murthy said that poses.
sum and used the facility which bro­
the Kyasanur forest disease (KFD)
ught good revenue. These, he said,
was peculiar to Karnataka. It was
Dr. Murthy said that there was were good examples of people’s par­
an arthropod-borne disease trans­ enough evidence to suggest the like­ ticipation. O

318

SWASTH HIND

Field Trial : Surveillance of Epidemic-prone Diseases and Its Evaluation—Continued from page 303
cally confirmed, giving the lay re­
porting ‘Correction factor’ of 0.7.
The projection for the district was
3732 + 293 (2 S.D.) cases for six*
months period (yide table IV). As
shown in table V ongoing surveil­
lance programme in the district
detected
2016 cases, giving the
‘Correction factor’ of 1.8.
The
same for clinically confirmed data
was 2.6.
Lower correction factor
for measles than for diarrhoea was
due to Che fact that measles can be
easily detected by .the paramedical
worker than the diarrhoea cases in
the community. This may be strong
point for measles elimination pro­
gramme.

prevalence rate per 1000 children of
5—9 years will be 13x1.25=16.29.
The annual incidence rate per 1000
children 'of 0—5 years would be
16.29 =
5=3.26. since the child­
ren examined cover a five year
period.
About one-fourth of the
cases including death and complete
recovery, are not detected in the
clinical surveys for residual polio­
paralysis.
Therefore, the rate was
further multiplied by 1.33 correction
factor (9) to take into account such
cases, viz. 3.26x 1.33=4.3, which is
corrected annual incidence, calling
for priority of oral polio vaccination
programme in the district.

tor of 17.5. The same for clinically
confirmed data was 23.9 (table V).

No case of Japanese encephalitis
was detected in the district, because
this area is not endemic for the
disease.

REFERENCES

1.

Henderson,
R-H.:
Sanderson, S.
(1982): Cluster sampling to assess
immunization coverage—a review of
experience
with sampling method.
Bulletin of World Health Organi­
sation 60.253.

2.

Rothenberg, R.B.; Labajior, -A.:
Singh, K.B. and Stroh Jr.G. (1985):

Viral Hepatitis
Poliomyelitis
Table-TIT shows that out of 10.505
children of 5—9 years surveyed 187
(18 per 1000) cases of polio lame?
ness were para-medically detected,
among these 137 (13 per 1000) were
clinically confirmed, giving the layreporting correction factor of 0.73.
The district estimates were 2792 ±
235 (2 S.D.).
Polio-lameness pre­
valence was adjusted by multiplying
a factor. 1.25,. taking into considera­
tion the paralysis in body parts other
than lower limbs which are affected
in 75-80 per cent of cases (9). There­
fore, the corrected polio-lameness

The reference period for viral
hepatitis was six months.
Table
III shows that out of 311373 per­
sons surveyed 297 (95.4 per 0.1 mil­
lion) cases of Jaundice were para.medically detected out of which 229
(73.5 per 0.1 million) were clinically
confirmed as viral hepatitis, giving
lay-reporting ‘correction factor’ of
0.82. The projection for the district
was 1242 ± 82 (2 S.D.) cases for
six months (table IV).
As shown
in table V the recently introduced
ongoing surveillance programme in
the district detected 71 cases of viral
hepatitis, giving the correction fac­

Observation on application of EPI
cluster survey method for estima­

ting disease incidence.
Bulletin of
World Health Organization 63.93.
3.

Cochran. W.G. (1945): Sampling
Techniques. John Wiley and Sons,
New York.

4.

Manual for the planning and evalu­
ation of National Diarrhoeal Disea­
ses Control
Programme (1981):
World Health Organization WHO/

• COD/SER/81.5.23.
5.

Expansion of Polio Vaccination Pro­
gramme (1982): EPI Bulletin 2.23.28.
Ed.
Dr. R.N.
Basu, Directorate
General of Health Services, Ministry
of Health and Family Welfare, Govt.
of India, New Delhi.

6.

National Diarrhoeal Diseases, Survey
in India,
First round (Feb.-May

Table V—Correction factors for ongoing Community Surveillance data (the pilot project)
Abvar district, Rajasthan

Episodes in the district during the
reference periods
Disease

Detected by Expected
clinical
on-going
surveillance* cases**

Correction factors

Diarrhoeal Diseases

880

730

19305

2t-9

26-1

Measles

2016

1431

3732 .

1-9

2-6

71

52

1242

17-5

23-9

Viral Hepatitis

♦Adusted for non-reporting/partially reporting units.
♦♦Adjusted for lay-reporting-efficiency.

December 1987

1985):
Directorate
General
of
Health Services,
Govt, of India,
Ministry
of Health and
Family
Welfare, New Delhi.

Clinical cases On-going
Clinically
extrapolated surveillance confirmed
rby sample
data (Col.
data (Col.
survey
3/2)
3/D
7.

Basu, R.N. (1984): Manual on epi­
demiological surveillance procedure
for selected diseases, 58-70. National
Institute of Communicable Diseases,
Govt, of India, Ministry of Health
and Family Welfare, New Delhi.

319

SCHOOL FOR TREATING SPINAL CORD DISEASE
K. R. SWEDESHI

There is a special boarding school . One of the most essential proce­
in Moscow where children not only dures is electrostimulation of the
study, but are also treated from var­ back muscles and abdomen. These
ious spinal cord diseases. The school muscles must be strong enough to
has its own specialists who treat chil­ form a natural corset, which can les­
dren both with conventional as well
as modern methods and in some
specific cases take the help of surgery.

sen overloads on the spine cord.
Additional weight on legs during

also taught to the students in order
to improve their posture.

are as dangerous as
underloads. At the same time, over­
strain may exhaust resources of or­
ganism. Svetlana and Irina devote
Overloads

exercises also helps as much time for physical training
After carrying out prophylactic ex­ this. Medical therapy includes ru- as recommended by the physicians.
aminations on mass scale, physicians malon and vitrious body injections. Both go for swimming, but Svetlana
of the school selected conventional Medicines arc replaced by acupunc­ has been advised butterfly stroke and
Irina back-stroke because of her
methods used for centuries and en­ ture whenever possible.
stooping. Svetlana wears an ortho­
riched them with by applying
Specialists immediately diagnose pedic corset and Irina recliner—sim­
modern medical scientific techniques.
children on their arrival at the school plified
scmicorset—which
draws
Thousands of children have al­ and find out the particular disease back scapulae.
ready been treated here. Those who they are suffering from. Thus, when
physiotherapy

Corsets are changed frequently
could not be treated completely have Svetlana and Irina came here, speci­
alists
found
out
that
the
former
was
with
the growth of children. Their
also improved their health and the
from
second-degree desks and special plaster-beds' also
progress of their maladies has been suffering
checked—90 per cent development scoliosis and the latter from kypho­ differ quite apart. Students suffering
of various spinal cord diseases— sis—the two forms of a widespread from scoliosis read in a lying pos­
from further growth. During their •serious disease of vertebral column ture as it helps them avoid load on
class periods, students are advised

which affects 30 per 10.000 children.

to lie down or sit in special postures

on specially designed furniture in
order to lessen the loads on their
spinal columns.

Vertebral diseases are also treated
with thermal therapy, which impro­
ves nutrition of osseous and muscu­
lar tissues. Thermal therapeutics in­
clude both conventional—massage
and wool wrapping—and modern—
silver eletrophoresis, paraffin appli­
cations, ultrasound, Bernard currents
and quartz-lamp ultraviolet irradia­
tion treatment.

320

Curative methods of both the cases
have many common features. But
the methods differ as these diseases
progress differently. The main ob­
jective in these cases is .to reduce
loads on the backbone and pressure
on intervertebral discs on their con­
cave side, which creates favourable
conditions for normal
vertebral
growth. Special physical training
helps therapeutic methods.
In
addition to physical training, les­
sons and therapeutic exercises,
each other lesson includes a PT in­
terval for relief exercises. Archery is

the backbone whereas those suffer­

ing from kyphosis are provided with
desks of conventional make.
Children suffering from scoliosis

and kyphosis are given special diet—
rich in protein, phosphorus and cal­

cium. They are given five meals a

day, mostly consisting of meat and
curds dishes, as well as fruits. The
free upkeep and treatment of each
student cost the

State

more than

1,200 roubles per annum.—Informa­

tion Department of the USSR Embassy in India, New Delhi.

SWASTH HIND

BOOKS
C*

—

)

Measurement in health promotion the possibility of measurement in
and protection
any given field; Finally, it should
interest scientists concerned with
Copenhagen, WHO Regional the development of measurements
Office for Europe, 1987.
in epidemiology, health services or
(WHO Regional Publications, social policy, and help them identify
areas where further work and new
European Series, No. 22)
methods are needed.
658 pages, ISBN 92 890 1113 O
Price: Sw.fr. 80.-.
Traditionally, epidemiologists have
measured people's health by concenra ting on how sick they are and at
what rate they die. A joint publica­
tion by WHO and the International
Epidemiological Association publi­
shed in 1979 looked instead at how
healthy people were. While this can
give a picture of the state of health
of any group of people at any one
time, it does not help explain why
they are healthy. The present book
now takes a step further and shows
how to measure the changes in peo­
ple’s health, which can be used to
assess the effectiveness of public he­
alth policies and programmes.

AUTHORS OF THE MONTH

J.R.D. Tata
Industrialist
Fata Group of Industries
Bombay
Paras Nath Garg
Lecturer in Health Education
S.S. Medical College
Rewa
Madhya Pradesh
Dr G.V.S- Murthy
Senior Resident,
Dr V.P. Reddaiah
Assistant Professor
and
Dr S.K. Kapoor
Associate Professor
Centre for Community Medicine
Institute of Medical Sciences
AIDS diagnosis and control: cur­ All-India
Ansari Nagar
rent situation. Copenhagen, WHO New Delhi-110029
Regional Office for Europe, 1987. Dr R.S. Sharma
ISBN 92 890 1051 7, 36 pp., price Assistant Director
Sw. fr. 5.-.
Epidemiology Division
National
Institute
of
Communicable
Dieseases
People are scared of AIDS, but 22 Sham Nath Marg
now is the time to replace fear with Delhi-110054

facts and action. The help of people Dr K.K. Datta
from all sectors of society is an ess­ Assistant Director General of Health Ser­
vices (AIDS)
ential ingredient of a successful cam­
Bhawan,
paign to control the disease. Only Nirman
New Delhi-110011
cooperative action, based on accu­
Part I clarifies the concepts of he­ rate information, can help end this Dr Mahendra Dutta
Director
General
of
Health Services
alth and health promotion, discusses threat to health for all.
(Planning)
the main ways of improving health,
Nirman Bhawan
and identifies the areas of health
This book, a report on a WHO New Delhi-110011
promotion and protection that can meeting held this year, contains a Dr S. Venkatesh
be measured. Part II works more clear analysis of the current situa­ Specialist (Public Health)
Health Education Bureau
like a textbook: it discusses how to tion of AIDS in Europe, of three Central
Kotla Road,
measure health, health promotion models for predicting the future of New Delhi-110002
and health protection, and summa­ the epidemic and of needs for fur­
Dr (Mrs) Daya Sanghal
rizes the measurement options avail­ ther research. Perhaps even more Head
of the Dental Department
able. Part III gives some specific valuable, however, it provides sug­ Lady Hardinge Medical College
examples of the measurement of im­ gestions for action to prevent and New Delhi
provements in health, both successes control the spread of the disease. Kamal G. Nath
and failures.
Current practice is evaluated and re­ Assistant Professor
commendations are made: on scre­ Home Economics Department
University of Agricultural Sciences
This book will help health plan­ ening for antibodies to the human Hcbbal, Bangalore-560024
ners and professionals to appreciate immunodeficiency virus (HIV); on Karnataka
the nature and size of the health counselling and care for people with K.R. Swadeshi
problems and the programmes need­ HIV infection, AIDS or related con­ Information Department
ed to overcome them. It is aimed ditions, particularly pregnant women USSR Embassy in India
primarily at people in health depart­ and their babies; on public health New Delhi-110001
ments who are responsible for health measures and legislation; and on Dr A.K. Mukeriee
Director
General of Health
management, policy development prevention through information and Additional
Services
and, ‘in particular, health promo­ health education.
Nirman Bhawan,
tion, which is an increasingly im­
New Delhi-110011
This book is interesting and use­ T.K. Parthasarthy
portant part of the movement for
health for all. This book clarifies ful reading for decision-makers, he­ Hon. Editor
the central concepts of health pro­ alth authorities, professionals in he­ SEARB Bulletin and
Director
motion and encourages all concerned alth and other sectors, and the pub­ Course
PH Workshop
lic.
It
can
help
people
to
take
ac
­
to put them into action. In addition,
B 92 Pandara Road
it should enable readers to assess tion against AIDS. O
New Delhi-110003

Regd. No. R.N. 4504/57

Read

swasth hind

AROGYA SANDESH

(A Hindi illustrated monthly)

SPECIAL NUMBERS-1987
January
Anti-Leprosy Day Number
March-April Immunization : A Chance for For
Every Child
♦Healthful living
June
Environmental and Health 1987:
Year of the Homeless
♦Information on health programmes
August-Sept. 40 years of Independence and
Health
*New developments in the field of health
November
Nehru on Health
Children’s Day Number
♦Health news from India and abroad
Each issue is a herald of health

SWASTH HIND
Gives you a perspective On
India’s Plans and Programmes
in the field of Public Health

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Index for
Volume XXXI

VOLUME XXXI

SI.
No.

1.
January
2.
February • •
3—4. March-April
5.
May ...
6.
June
7.
July •.
8—9. August-September
10.
October
11.
November
12.
December

January to December

1987

Pages

Month

•'
•
•
■
•
•
•
•

1—32
33—60
61—100
101—128
129—160
161—188
189—224
225—256
257^288
289 -320

SWASTH HIND
INDEX
VOLUME XXXI

January to December 1987
he following is the index for all reading material published in SWASTH HIND during

1987.

This is the title index. The authors’ name are given in italics
t Pages

Pages

A.I.D.S—an international perspective
—Fakhry Assaad Jonathan M. Mann

58

Dispelling doubts and fears about immunization role of health education through mass
media
—Dr (Sint) V. K. Bhasin

Adverse health effects of environmental
pollutants.
—Dr Dinesh Chandra & Dr Mangesh Shukla

136

Diet and immunization programmes
—Dr P. Bhaskaram & Dr B. S. Narasinga Rao

Acute respiratory infection

241

—Dr Shanti Ghosh
A—Z dental care
—Dr Daya Sanghal

307

A

91

E

B

Backgrounder to a programme against vaccine— preventable child diseases

74

80

—M.S. Dhillon

Expanded programmes on immunization
—present position and future plan
—Dr P. C. Roy

62

Epilepsy education and its evaluation
—Prakashi Rajaram & Dr R. Parthasarathy

]p

Ecology and health
—Dr B. N. Ghosh

170

. Education and actue respiratory infection
—Dr Bhakt Prakash Mathur & Dr P. Sdlil

|

73-

Childhood diarrhoea — the deadly killer
:—Dr Umesh Kapil

94

Commonsense can aviod accidents
—Dr Madhuban Gopal

114

Environmental radioactivity and health
—Dr M. P. Jain & Dr (Maj. Gen.) N. Lakshmipathi
Environmental Sanitation — a study in a Village of Andhra Pradesh
—Dr H. Audinarayana

Cough and Cough
—Dr J. N. Pande

119

Elements of a new ethic for children
—David P. Haxton ’

0
^5

Eye banks in India

Combat misbeliefs to achieve Health for all
by 2000 A.D.
—P Manohar Reddy

176

281

Challenges in health education
—Dr B. S. Sehgal

197

Changing perspectives on rural health care —
an overview
—S. Srinivasan

201

C

F
Food allergies and sensitivities
—Smt. Vijayalakshmi

45

Field trial on village level — surveillance of
epiaemic—prone dieases and its evaluation
—Dr R. S. Sharma,
Dr K. K. Datta,
Dr Mahendra Dutta

301

G

D
Dabboo turns a new leaf
—Dr R. L, Biilani

24g

47

Gastroenteritis can be prevented—everyone
has a role
—Dr S. R. Naik

^43

Pages

Pages

M

H
Health services for rural childien
—Dr (Sint) V. K. Bhasin

29

Health education in malaria control '
—M. L. Metha
Healthy productive life — an industry based
occupational health education programme
—A Kumaresan.

39

Medico-social problems of today's youth
—Lt. Col. A. C. Urmil & Col. P. K. Dutta

101

N
161

Health for all must become a movement (40th
World Health Assembly)
—Shri P. V. Narasimha Rao

169

Health habits of school-going children-?- A
Study
—A. C. Moudgil, S. K. Verma, Parmjit Kaur,
Amita Ummat and Raman Metha

174

Health in 1986-87
—Emphasis on community participation
—S. S. Dhanoa

206

Health for all by the year 2000
—Retrospect and prospect
—Dr (Smt.) V. K. Bhasin

210

How arugs affect our nutritional status
—Kamal G. Nath

313

1

Need for people’s participation—Involvement
of voluntary organizations in leprosy Era­
dication
—Dr C. K. Rao

21

Nutrition education at school level
—Dr A. C. Moudgil, Dr S.K. Verma,
Dr Parmjit Kaur, Ms. Amita Ummat &
Ms. Raman Mehta

107

Nutrition and mental development
—Dr R. D. Sharma

110

National AIDS control strategy
—Dr K. K. Datta

182

New hope for early breast cancer detection

187

National Health and Family Welfare
Programmes—Achievements during 1986-87

217

National Sexually Transmitted Diseases
Control programme
—Dr N. C. Bhargava

245

National Workshop on Training in community
Eye Health Education—report
—Dr S. Venkatesh

250

' •

India sets ambitious family planning targets
—Suneet Vir Singh
Immunization—a way to child development
—Dr Mahendra Dutta

49
65

Nenru accorded first priority to child health
—Smt. Vidyaben Shah

257

Immmunization—need for a coverage
break-through
—Dr Sanjiv Kumar & Prof. L.M. Nath

72

Nutiitional blindness
—Dr Vinodini Reddy

261

Integrated child development services and
immunization programme
—Dr V. L. Vasudeva

87

Neo-natal care—role of health education
—Paras Nath Garg

293

Immunization programme—changing strategies in a rural field area
—Dr Bir Singh, Dr S.K. Kapoor & Dr J. Lope

97

Iatrogenic corneal Ulcers
—Dr Swatantra Sharma, Dr Prakash Gupta &
Pradeep Kumar Gautam

121

O
Occupational hazards—present risk to
future generations

L

Leprosy—understanding to replace fear
—Ashutosh Sinha

27

Leprosy—Progress in sight

57

Love and prayers only won’t do
—Late D. Lakshiminarayan

100

-

165

Oral Cancer— a man-made disease
—Dr P. K. Ray and— B. S. Khangarot

234

Oral health in India —• current strategy
for health eductaion
—Dr S. Venkatesh

304

P

Primary Health Care Under National Leprosy
Eradication programme
—Dr N. S. Dharamshaktu

4

Pages

Posters sell tne idea of small family
—G. Venk a tarman

32

Psychiatric nurse — an active agent of mental
health education
—K. Reddamma — T. P. Prema
Popularising breast feeding as a method of
contraception— a study of Yamadi
tribal women in Andhra Pradesh
—Dr G. Gurumurthy
Plastic surgery has special role in India, says,
Shri Rajiv Gandhi
Planning for a sound housing
—Dinesh Chand
Population Management—Search for new
2 strategy
—J. R. D. Tata
Pregnancy wastage—magnitude, causes and
prevention
—Dr G. V. S. Murthy, Dr V. P. Reddaiah &
Dr S. K. Kapoor
Prevention of childhood accident* .
—Dr A. K. Mukherjee

33

122

127

] 52
289
297

309

Pages
Spreading of family planning message through
the medium of Rangali
—G. Venkatarman
Six childhood communicable diseases—causes,
symptoms and prevention
-—Dr P. N. Sehgal and Dr J. P. Narain
Social aspects of immunization
—Dr A. B. Hiramaniand— Dr (Kunz.) Neelam
Sharma
Savita’s sad story
—Dr R. L. Bijldni
Sound and fury
Shelter programmes to be broad-based
Status of health services in India—a comparison
—Dr Mahendra Singh
Strategy adopted by India to achieve health
for all evaluation
—Col. K. K. Vadhera (Retd.)
Strategies for child welfare in India
—Ratna Sdhu
School for treating spinal cord disease
—K. R. Swadeshi

R

52
67
78
125
133
172
190

215
278

315

T

Reconstructive surgery in leprosy
—Dr K. V. Desikan
Rehabilitation in leprosy
—Dr Earnset P. Fritsch i
Recent scientific advances in leprosy control
— a review
'—Dr V. N. Bhatia and Dr S. Balakrishnan
Raju becomes a volunteer
—M. L. Mehta - ,
'
Rural enviromental intervention and filariasis — a study
—Susila Nayai, A. M. M. P. Dwivedi and
A M. Mehendale

Rights of children
—Nigel Cantwell

9
14
18

180
230

141
148

Understanding health problems of leprosy
.—K. Balan

53

W

S

Spondylosis and backache
—Prof. P. K. Dave

104

U

269

Status of National Leprosy Eradication Programme in India — 1986
—Dr C. K. Rao
Social dimensions of leprosy problem
—S. P. Tare

. The other side of smack—addiction
—Dr M. S. Bhatia and Dr N. K. Dhar
The man-made environment, health ano behaviour
—Dr R. D. Sharma
Tribal women and their health proolems
—Dr (Smt.) Parahha Ramalingaswami

1

6
36

Women, Water and sanitation
—Dr (Ms) T. V. Luong
Water supply for villages
—M. L. Kapur
World Health Day— 1987
Vaccines production being geared
—M. L. Metha
Water related diseases
—Dr (Smt.) Niharika A. Nath
Workshop on health writing
—7T K. Parthasarathy

‘

*

142
146
156

226
316

SPECIAL NUMBERS—1987
January

Anti-Leprosy Day Number

August-Sept.

40 years of Independence and Health

November

Nehru on Health
Children’s Day Number

March-April Immunization : A chance for Every Cm Id

June

Environmental and Health 1987: year
of the Homeless

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