Swasth hind, Vol. 39, No. 10 - 12, Oct. - Dec. 1995.pdf

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swasth hind
Oct.-Dec. 1995

Asvina-Pausa

Saka 1917

Vol. XXXIX, No. 10-12

Page

Meeting Children’s Needs
Child health and rights of the child

149
151

—Dr Devi Saran Sharma
—Dr K. D. Gautam
—Dr S. C. Gupta
Education for nutrition promotion

153

—Dr Sarala Gopalan
Vitamin A deficiency and child survival

155

—Dr Ruchika Kuba

OBJECTIVES

Breastfeeding : Its importance and our concern

Swasth Hind (Healthy India) is a monthly Journal
published by the Central Health Education Bureau,
Directorate General of Health Services, Ministry -of
Health and Family Welfare, Government of India,
New Delhi. Some of its important objectives and
aims are to :
REPORT and interpret the policies, plans, pro­
grammes and achievements of
the Union
Ministry of Health and Family Welfare.

—Dr (Miss) V. Patil
—Dr (Mrs) Y. R. Kadam
—Dr (Miss) S. N. Shinde

157

and

Exclusive breastfeeding —the need for promotion

159

—A. M. Mehendale
161

Diet for pre-school children

—Dr (Mrs) Inderjit Singh
Food service sanitation :
health concern

A growing public
166

—R. K. Bans al

ACT as a medium of exchange of information
on health activities of the Central and State
Health Organisations.

Reaching out to rural children :
Meal scheme
Feeding the world

FOCUS Attention on the major public health
problems in India and to report on the latest
trends in public health.

Social aspects of milk

KEEP in touch with health and welfare workers
and agencies in India and abroad.

—Inaugural speech by Dr Shanker Dayal Sharma
President of India

REPORT on important seminars,
discussions, etc. on health topics.

Dispel fears and raise inceptions about HIV/AIDS 176
HIV/AIDS pandemic : the Indian context
179

Edited by

conferences,

M. L. Mehta
M. S. Dhillon

Assisted by

G. B. L. Srivastava
K. S. Shemar

Cover Design

Harbhajan Singh

Cover Photo

O. P. Kataria

Editorial and Business Offices
Central Health Education Bureau
(Directorate General of Health Services)
Kotla Marg, New Delhi-110 002

Mid-day-

168
169

—Daya Krishna
171

—Brig. (Dr) N. L. Sachdeva
International Conference on AIDS —Law
and Humanity

174

—Dr Shiv Lal
—Dr D. Sengupta
Prevention of HIV transmission in health care 183
setting—Universal Precautions
Book Review
Back inside cover
Articles on health topics are invited for publication in this
Journal.
State Heilth Directorates arc requested to send in reports
of their activities for publication.
The contents of this Journal are freely reproducible. Due
acknowledgement is requested.
The opinions expressed by the contributors are not necess­
arily those of the Government of India.
SWASTH HIND reserves the right to edit the articles sent
in for publication.

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Child Health.

MEETING CHILDREN’S NEEDS
—Excerpts from the State of the World's
Children Report (1995)
“Unless the investment in children is made, all of humanity’s
most fundamental long-term problems will remain fundamental
long-term problems.”
CC K jf eeting children’s needs de-

JLVJl pends not just on social ser­
vices but on their parents haying jobs
and incomes. The cost of a major
effort to bring about land reforms,
invest in small producers, and
create large numbers of jobs wouldbe very much more than USS 30
billion a year. Double it; it is still
less than the world spends on wine.
Triple it; it is still far less than the
world spends on cigarettes.
“Even if the resources were to be
made available, money alone is not
sufficient. Sustained political com­
mitment and competent management
are just as important. But to say
that the world cannot at this stage
afford the financial cost of meeting
its children’s needs and ending some
of the very worst aspects of poverty,
malnutrition,
preventable disease,
and illiteracy, is plainly absurd.
And there is a need to kindle a new
sense of this absurdity among a
worldwide public. Of course the
normal growth and development of
children can be protected.
Of
course absolute poverty can be
overcome.
Of course population
growth can be slowed. Of course
environmental deterioration can be
arrested, For decades now, this
has not been a question of possibili­
ties but of priorities. And the truth
of the matter is that these problems
could and should have been largely
defeated in the 1970s and 1980s;
if one tenth of the resources that
have been devoted to building mili­

October—December, 1995

tary capacity over those decades Becoming Involved
had been devoted to achieving basic
“Where there have been thou­
development goals, then we would
sands of organizations, there
now be living a world with little or
must be tens of thousands,
no malnutrition, with far less disease
where there have been tens of
and disability, with far higher levels
thousands of people, there must
of literacy and education, with
be millions.”
higher incomes and lower birth
rates, with fewer social and environ­
“A people-led change in the cli­
mental problems, with fewer civil
conflicts and refugees, and with mate of ideas, in what is consider­
ed acceptable or unacceptable in the
fewer and less destructive wars.
relationships between people and
nations, is the best hope that the
“This comparison between military great changes to come will be chan­
The common
expenditures and human needs may ges for the better.
be the most often repeated cliche in focus of that effort must be to give
the development dictionary. But we the protection of the normal physi­
must never tire of making it, never cal, mental, and emotional deve­
allow this state of affairs to be coun­ lopment of children a first call on
And
tenanced as in any way civilized or our concerns and capacities.
justifiable, never allow the most a first step towards that aim is to
blatant imbalance of our times to achieve the basic goals for the
subside into the tacitly accepted. world’s children that have already
Even in the postcold war era, the been established and behind which
world annual expenditure on mili­ considerable momentum has already
tary capacity, on missiles, tanks, been built.
aircraft, fighter plans, remains, at
a level that is four times the com­
“But if the race against time is to
bined annual incomes of the poorest be won, then where have been
quarter of the developing world’s thousands of organisations there
people—the 1 billion absolute poor. must be tens of thousands^ where
those who are without the basics of there have been tens of thousands
life, those without education and of people, there must be many mil­
jobs, those without clean water or lions.
basic health care, those whose child­
ren die and become disabled in such
“And by becoming involved in
numbers, those who are forced to this struggle, in whatever way and
ruin their own environments and on whatever front, it may be that
futures for the sake of staying alive an answer will also be found to the
today.
problems which today beset so

149'

many of those, in all nations of the
world, who arc the principal bene­
ficiaries of the progress that has
been achieved in this century. For
it may be that the being involved in
a cause larger than oneself is a deep
human need from which we have
been diverted by the particular direc­
tion that progress has taken in
recent times.
If so, it is a need

of which George Bernard Shaw has
left us a powerful reminder:
“This the true joy in life, the
being used for a purpose recog­
nized by yourself as a mighty
one,
1 am of the opinion
that my life belongs to the
whole community and as long
as I live, it is my privilege to
do for it whatever I can. Life
is no brief candle to me. It

is a sort of splendid torch
which I have got hold for the
moment, and I want to make
it binn as brightly as possible
before handing it on to future
generations.”

—James P. Grant

(UNICEF Executive Director. 19801995) ®

JAMES P. GRANT-UNICEF Executive Director, 1980—1995
BIOGRAPHICAL INFORMATION
Mr James P. Grant, who stepped down as Executive Director of UNICEF on 26 January, 1995, died of cancer in New York on
28 January. He was 72.
James P. Grant assumed office as the Executive Director of the United Nations Children’s Fund (UNICEF) and Under SecretaryGeneral of the United Nations on 1 January 1980, succeeding Henry R. Labouisse. In 1989, he began his third 5-year term at the
helm of UNICEF.

His 15-year term of forceful personal advocacy led the organisation to unprecedented activism in pursuit of its mandate for
the child, and moved the U.N. system and world leadership to historic and legal commitments to child survival and development.
Born in Beijing, China on 12 May 1922 Mr Grant had a long and distinguished career in the field of development which began
with service in China in 1946 and '1947 for the United Nations Relief and Rehabilitation Administration. His development assign­
ments had also taken him to Turkey, Sri Lanka and India.
An American national, Mr Grant was UNICEF’s third Executive Director. Mr Grant came to UNICEF from the Overseas
Development Council, which he helped found in 1969, serving, as its President and Chief Executive Officer. He had previously served
with the United Stites Agency for International Development (USAID) as an Assistant Administrator (1967—1969) and as
Director of the USAID programme in Turkey with the rank of Minister (1964 -1967).
He was Deputy Assistant Secretary of
State for Near East and South Asian Affairs (1962—1964) and a Deputy Director of the International Cooperation
Administration (USAID’s predecessor) with responsibility for world-wide programming and planning (1959—1962). His overseas
assignments included service as Director of the United States aid mission in Sri Lanka (1956—1958), and Regional Legal
Counsel resident in New Delhi for United States aid programmes for South Asia (1954—1956).

Mr Grant had served as director of a number of organisations involved with development issues, including the Commission
of Participation in Development of World Council of Churches, the International Voluntary Services, the Pan American Develop­
ment Foundation, the Institute of Current World Affairs, Save the Children and the Foreign Policy Association. He served as
President of the Society for International Development from 1979 to 1983. He was a trustee of the Rockefeller Foundation and John
Hopkins University, and a member of the Trustee Visiting Committee, School of Nutrition, Tufis University.

Mr Grant received a B.A. from Berkeley University in 1943, and a Doctorate in Jurisprudence from Harvard University in
1951. He received honorary degrees from the University of Notre Dame and Hacettepe University in 1980, Maryville College in
1981, from Tufts and Denison Universities in 1983 and University of Maryland in 1986. He was also awarded an Honorary Professor­
ship in 1983 from the Capital Medical College of China. He had received a number of awards, including Distinguished Public Service,
USAID (1961), Rockefeller Public Service (1980), Gold Mercury International, 1984 by ICC—International Organization for Co­
operation, Rome and Lome, and the Presidential Citation of the American Public Health Association in 1985. He is the author of
a large number of publications dealing with development matters.

©

150

Swasth Hind

CHILD HEALTH AND
RIGHTS OF THE CHILD
DR Devi Saran Sharma
DR K. D. Gautam and
DR S. C. Gupta

A study in an urban slum has revealed that the health and living standard of
children there is very low and socio-economic and educational profile is taking a
very unfavourable trend. The Morbidity and mortality among children are
of high order. This shows that the introduction of various schemes and projects
in the area was poor and delivery of health and welfare services as well as their
utilisation highly inadequate.

N the United Nations Conven­
tion on ‘The Rights of the
Child’, States accepted the obliga­
tion to make provisions for social,
mental, physical and spiritual well­
being of the Children by taking
measures in the areas of infant and
child
mortality,
comprehensive
health care, environmental sanita­
tion, nutrition, maternal and other
care, family planning, education,
recreation, security, survival, exploi­
tation and abuse.

J

But a recent study of children
in an urban slum shows a complete
betrayal of the society and state
towards aforesaid rights of the
child.
This study, to assess the
health and welfare status and rights
of the children below the age of 15
years, was conducted in a well

October—December, 1995

Data on different aspects of child
known slum area of Agra City
during the month of August 1993. health were collected by the authors
The community taken for this study personally on a predesigned sche­
is attached to the Urban Health dule. All the 101 families of the
Training Centre of Social and Pre­ community, randomly selected out
ventive Medicine Department of of a group of four communities at­
S. N. Medical College, Agra, for tached to the Urban Health Centre,
the purpose of imparting field train­ were contacted by house to house
The observation technique
ing to medical students as well as to visits.
provide comprehensive health care and refering to records of Urban
to the community. The same com­ Health Centre were also used as
munity had also been covered by and when required.
the Institute of Social Sciences,
Agra University Agra for Method Findings of the Study
Oriented/Developmental
Field Population'. The total
popula­
Work of M.S.W. students batch of tion of 101 families interviewed was
1990-91. Simultaneously a U.G.C. 774.
The average size of family
sponsored project entitled “Experi­ was found 7.7 persons.
It is not
ments in Developmental Field Work” out of place to mention here that
was also introduced by the Social the average family size of the coun­
Work Department of the Institute try is 5.6 and of the State of Uttar
Pradesh is 5.87.
of Social Sciences, Agra.

151

This shows that the personal
Occupation*. The main occupa­
tion of most of the families is shoe hygiene of the children in the com­
making and they belong to lower munity is very poor predisposing
socio-economic group.
them to various Gastro Intestinal
Tract (G.I.T.) and skin diseases.
Break-up according to Age!Sex*.
The total number of children below Infant Mortality:
During
the
the age of 15 covered was 364. period of last 5 years, 31 infants ex­
Thus the average number of child­ pired in 26 families.
The main
ren per family is 3.6. Among 364 causes of death were Marasmas,
children, 48% were male and 52% Tetanus, Pneumonia, Polio and
female.
The break-up by age Diarrhoea..
shows that 9% were infants, 23%
were in the age group of 2-4, Morbidity: Out of 364 children
33.25% were in 5-9 age group and 194 (53%) had at least one symp­
34.75 were in the age group of tom suggestive to a disease and a
good number of children reported
10-14.
to have multiple symptoms. Majo­
Education: Out of total children rity of the children had. G.I.T.
246 (68%) were of school going age. diseases, respiratory disorders, skin
Out of 246 eligibles only 95 (38%) diseases, diarrhoea, worm infesta­
were going to school.
It means tion, etc.
62% are not going to any school.
The correlation between age and the Disability: 13 (3.6%) children out
class revealed that even boys upto of 364 were found physically handi­
the age of 11 years were studying capped. Out of these 13, 10 have
in standard-I. Among 246 children polio, 2 some injury and one defor­
22 (8%) have dropped out from mity since birth.
schooling.
This shows lack of in­
terest in the child education in this Immunization Status: The situa­
community which needs further tion of immunization status of
children is very much unpleasant.
research.
None of the children was reported
Child Labour: Out of 246 child­ to have completed the immunization
ren aged 5 years and above 30 schedule.
The data on morbidity
(12%) are working.
They are all shows a prevalence of various pre­
working in the shoe industries with ventable illnesses among children.
their father or brothers, thus, sup­
Health Care: Although the study
plementing family income.
population is covered by the Urban
Personal Hygiene: Observation to Health Centre of SPM Department
personal hygiene of children reveal­ yet they usually go to private prac­
ed that dresses of children were titioners to meet their health needs.
dirty in 74 (73%) families. Nails
CONCLUSION
of children were not trimmed in 76
(75%) of the families.
The child­
The study revealed that the
ren in 70% families were found to health and living standard of the
be taking bath irregularly.
The study population was very low.
teeth of the children of 85% fami­ <The socio-economic and educatio­
lies uere found dirty.
nal profile is taking a very unfavou­

152

rable trend.
The morbidity and
mortality among children are of
{high order. This shows that the
introduction of various schemes and
projects in the area is poor. The
delivery of health and Welfare
Services as well as their utilization
is highly inadequate.

Suggestions
1. A comprehensive community
health
care
programme
should be provided to meet
the health needs of the child­
ren.

2. The integrated child deve­
lopment services and facili­
ties
should be augmented
and implemented properly.

3. Health education in the com­
munity must be highly em­
phasized.
The family and
community should be made
aware of the child rights and
health.
4. The monitoring and evalua­
tion of health and welfare
services is necessary.

5. Surveillance study should be
carried out at community
level.
6. Lastly, multi-sectoral ap­
proach should be taken to
child’s rights and problems.

REFERENCES
1.

Park IE : Text Book of Preventive
and Social Medicine,
Banarsidas
Bhanot, Jabalpur, 1983.

2.

Sharma Devi Saran : Health Hos­
pital and Community. Agra Publi­
cation, 1-988.
0

Swasth Hind

Food and Nutrition

EDUCATION FOR
NUTRITION PROMOTION
DR Sarala Gopalan
Secretary* Department of Women and Child Development
Ministry of Human Resource Development

Government of India

NATIONAL NUTRITION WEEK
—1-7 September, 1995

has always played an ex­ tional awareness forms its bed rock. women of child bearing age and
traordinarily vital role in the The nutritional status is, thus, an young children. Iron deficiency
rise or the fall of a nation. Fortuna­ outcome of complex and inter­ affects the learning ability in children
and productivity in adults besides
tely for India, famines are a part related set of factors.
contributing to maternal mortality
of history. Food security in terms
of adequate domestic production has
Il is heartening to note that India in the country. Iodine deficiency
been achieved. Despite spectacular has succeeded in overcoming famines is widely prevalent throughout the
increase in the food grain production and eliminating classical nutritional country and results in lowering of
Q. in children, reproductive losses
in recent years the problem of chro­ deficiency syndromes like beri-beri, I.
nic malnutrition continues to exist pellagra, scurvy etc. There has been and varying degrees of mental re­
Deficiencies of other
extensively, especially among chil­ a striking decline in clinical forms tardation.
such as folate and
dren and women, because they are of severe and moderate malnutrition micronutrients
other B-complex vitamins, vitamin
caught in the relentless sequence of among children. The infant Morta­ ‘C’, zinc and calcium also exist.
ignorance,
poverty,
inadequate lity Rate has also declined. How­
food intake and disease. This has ever, there are still some unfinished
The prevalence of diet related
led to an increasing awareness among tasks of the first phase. In addition chronic non-communicable diseases
planners about the importance of to {problems of protein energy like obesity, hypertension, cardio­
good nutrition. Today, ‘Malnutri­ malnutrition in children and chronic vascular diseases and diabetes mellition’ is no longer considered an out­ energy deficiency in adults, several tus is closely linked to inappro­
come of food deficiency or a health micronutrient (vitamins and mine­ priate diets often characterised by
problem but as a multi-dimensional rals) deficiencies persist amongst excessive intake of energy and fat,
problem interfacing all efforts of both the children and adults in particularly the saturated fats, and
developing human resources. The India. The deficiencies of vita­ low fibre intake. The changing food
nutritional status of a nation is min ‘A’, iron and iodine are speci­ consumption patterns and more
closely related to food adequacy and ally important because of their sedentary lifestyles are leading to
its distribution, levels of poverty, serious health consequences and this situation. It has also been
women’s education, rate of popu­ wide geographic distribution. Vita­ noted that while the major nutri­
lation growth and access of its po­ min ‘A’ deficiency in its most tional problem afflicting the vast
pulation to health, education, safe severe form results in irreversible majority of the Indian population
drinking water, environmental sani­ blindness in children. Iron deficiency is related to hunger and under nutri­
tation, hygiene and other social affects all age groups and both tion, the diet related noncommuni­
services, while the extent of nutri­ sexes, the incidence being higher in cable diseases emerge as disturbing
ood

F

October—December, 1995

153

trends related to over-nutrition even continuation of breast feeding well
among the less affluent communities. into the 2nd year.
The need for increasing community
awareness about nutrition and
healthy life-styles,
therefore, can The awareness about the relation­
ship between nutrition and health,
not be overemphasised.
nutritive value of locally available
foods, nutritional needs of different
The foundations of the. country’s age groups, common nutritional defi­
most important nutritional problem ciency diseases, their identification,
i.e. growth retardation in infants and management and
prevention, the
young children are laid down before importance of safe drinking water,
the completion of the first year of personal hygiene, food hygiene and
life. In order to have any signi­ environmental sanitation to ward off
ficant impact, key behaviours and infection with a view to derive maxi­
skills have to be learnt and practised mum benefit from a given intake of
during the period spanning pre­ food,
conservation of nutrients
gnancy, the first year of lactation during food preparation and existing
and sustained throughout early child­ nutrition health and welfare sendees
hood. These include nutritional needs to be created at different levels
care of pregnant women right from utilising all available channels of
the first trimester, ante-natal check communication.
Nutrition and
ups, tetanus-toxoide vaccination, pre­ health education concepts need to
paration for breast feeding, initiation be integrated effectively into all
of lactation at birth, feeding of colo­ formal and non-formal educational
strum, exclusive breast feeding for systems as well as into all nutri­
4-6 months, appropriate and timely tion programmes. Let us launch
complementary feeding with the use a crash programme on “Education
of local foods, immunization of in­ for Nutrition Promotion” for cre­
fants, oral rehydration therapy, ating mass awareness about nutri­
growth promotion, child spacing and tion at all levels, right from the

public at large to the planners and
policy makers, agricultural and
other scientists, food industrialists
NGOs and others since education
of the people for nutrition pro­
motion is one of the most impor­
tant tools for achieving the optimal
state of nutrition for the people.

The National Nutrition Week
instituted by the Food and Nutri­
tion Board in 1982 is celebrated in
the country from 1-7 September
every year in collaboration with
the concerned Departments, of the
State Governments, national insti­
tutes, home science colleges etc.,
with a view to create awareness
among the people about various
aspects of nutrition. The celebra­
tions include
organisation
of
exhibitions, cooking demonstrations,
film and slide shows, recipe com­
petitions, baby shows, group dis­
cussions, seminars,
essay/slogan
quiz/ debate competitions and
other programmes in rural and
urban areas of the country. The
L1th National Nutrition Week was
celebrated from 1 -7 September,
1995.

GENERAL MESSAGES RELATED TO NUTRITION
1. Start breast feeding within one
hour of delivery. Colostrum
(mother’s first milk-light yel­
lowish thick fluid) is rich in
proteins, vitamin ‘A’ and antiinfective properties. It is the
infant’s first immunization.

2. Feed exclusively
mother’s
milk for first four to six
months of life. No need for
any supplement to fluids or
milk or any foods during this
period.

7.

Include a variety of foodstuffs
in daily diet, as a mixed diet
is more nutritious.

8.

Get your child
timely.

9. Do not allow
foods.

15. Mixture of cereals and pulses
in the ratio of 3:1 in the form
of chapattis, kitchidis, dosa,
idli etc. is more nutritious.

immunised

flies to touch

10. Keep your surroundings clean.

11. Maintain personal hygiene.

16. Take daily some raw vege­
tables in your diet like rad­
dish, leafy vegetables, chut­
ney, onion, carrot, tomatoes,
cucumber, lemon, etc.

17. Use whole wheat flour (un­
sieved) for preparing chapat­
tis, puris, etc.

3. Start feeding semi-solids, pre­
ferably home-made after 4-5
months not later than six
months
continuing
breast
feeding.

12. When your child has diarr­
hoea or vomitting, give him
extra water in the form of
O.R.S., cooked pulse water,
thick soup etc.

18. Wash rice once or twice with
minimum1 quantity of water
before cooking.

4. Continue breast
long as possible.

5. Give food 5 to 6 times a day
to young children.

13. Women must take extra food
to meet the additional require­
ment during pregnancy and
lactation.

19. Cook rice in just sufficient
water to avoid discarding of
cooked rice water which dra­
ins out nutrients.

6. Give more of pulses, milk and
milk products in the daily
diet of children.

14. Consume green leafy vege­
tables daily in one or the other
form.

20. Do not wash vegetables after
cutting and also do not re­
move thick peels.
O

154

feeding as

Swasth Hind

VITAMIN A DEFICIENCY
AND
CHILD SURVIVAL
Dr Ruchika Kuba
itamin A is widely distributed
in animal foods (as preformed
Vitamin A is known to enhance the immunity of a
Vitamin Aretinol) and plant foods
person. Its relative deficiency results in breakdown
(as provitamins-carotenes). It parti­
cipates in a number of body func­
or weakening of the immune system and hence an
tions like normal vision, integrity and
increase
in infective ailments. Studies have shown
normal function of glandular and
epithelial tissue which lines intesti­
that Vitamin A supplementation reduces the morta­
nal, respiratory and urinary tracts,
lity
and morbidity due to a number of infectious
and is anti-infective, etc. The signs
diseases especially those related to the gastrointes­
of the deficiency of vitamin A are
predominantly ocular ranging from
tinal tract. Hence, Vitamin A supplementation, in
night blindness to keratomalacia.
addition to preventing the nutritional blindness, may
However, extra ocular manifesta­
tions like follicular hyperkeratosis,
be a very effective proposition for boosting child sur­
anorexia and growth retardation are
vival.
also recognised. Vitamin A defici­
ency occurs commonly among
children of developing countries es­
pecially those who are undernou­
rished and have a diet poor in Vita­ tus.2,6 Thus deficiency of Vitamin 0.00001) 55% reduction in measles
A has been linked to child survi­ deaths (13% to 77% two tailed
min A foods.
o=0.017) and from other causes of
val.7
death (excluding diarrhoeal & res­
Vitamin A and Mortality
Vitamin A Supplement & Morta­ piratory cases and measles) by 34%
Many recent studies seem to indi­ lity
(15% to 48% two tailed p=0.001).
cate that even mild vitamin A defi­
A slight increase in respiratory
ciency causes an increase in mor­ A meta analysis of the effects of death was found though this was
bidity and mortality due to respi­ Vitamin A supplementation on mor­ significantly different from an odd
ratory and intestinal infections1. bidity and mortality from infectious ratio of l.8 Two double blind ran­
Follow up of surviving children re­ diseases was done by Glaziou & domised, placebo controlled trials
vealed that respiratory and diarr­ Mackerras.8 Of the twenty con­ of Vitamin A supplementation in
hoeal diseases were 204 times more trolled trials identified by them, adjacent population in northern
likely to have developed in those 12 were included in their ana­ Ghana13 was carried out. They also
who had been xerophthalmic than lysis. The included studies fell found that although mortality rate
in non-xerophthalmic peer, group3. into three distinct groups—six due to acute Gastroenteritis (GE)
Mortality rates have been reported community based trials, three trials was lower in Vitamin A supple­
to be higher in malnourished child­ of children hospitalised with meas­ mented group, those due to acute
ren in hospitals with xerophthalmia les, and three trials in very low respiratory tract infection were not
than in those with normal eyes1,5 birth weight infants. Five out of so.
However, in a longitudinal study of the six community studies 9,10,11,12,13
4000 pre-school aged Japanese showed that the overall mortality
The three studies of children hos­
children it was found that children reduction was highly significant pitalised with measles (ll, “,16) show­
with mild xerophthalmia (night both statistically and clinically. The ed a somewhat greater mortality
blindness, bitot spots or the two combined results for community benefit than community studies; an
conditions together) died at four studies suggested a reduction of odds ratio of 34 (.15 to .77) i.e., a
times the rate as compared to their 30% (95% confidence interval 21- risk reduction of 66%. The three
non-xerophthalmia peers: the excess 38%’ 2 tailed p<. 00001) in all cause studies combined showed a 70% re­
mortality was related to the seve­ mortality. Analysis of cause speci­ duction in deaths from respiratory
rity of the xerophthalmia and this fic mortality showed a reduction in causes (15%—9% two tailed p=.O2)
‘dose related’ risk was independent death from diarrhoeal disease by and a reduction in deaths from diar­
of the child’s general nutritional sta- 39% (24% to 50% two tailed <Jp rhoea consistent with the commu­

V

October—December, 1995

155

Daulairc N M P, Starbuck E S,
Houston R M, Church M S, Stukcl
T A, Pandey M R. Childhood morta­
lity after a high dose of vitamin A in
high risk population BMJ 1992; 304:
207-210.
10. Vijayaraghavan K, Radhalah G, Prakasam B S, Sharma K V R, Reddy V.
Effect of massive dose Vit. A on
morbidity and mortality in Indian
Children. Lancet 1990; 336: 13421345.
11. Rahmathullah L. Underwood B A,
Thulasiraj R D, Milton R C. Diarr­
hoea, respiratory infections and growth
are not affected by a weekly low-dose
vit A supplement: a masked controvert
trial in children in southern India. Am
J Clin Nutr. 1991; 54: 568-577.

9.

nity trials but with very wide con­
fidence intervals?

available and affordable
systems.

Four Community studies 12,IS,1C,17»
two studies on children hospitalised
with measules 18,14 and one study
on very low birth weight infants1’
have extensively studied the morbi­
dity. Almost all studies of vitamin
A supplementation on morbidity
have shown no difference in preva­
lence of diarrhoea and respiratory
infections.80 However, morbidity
for those hospitalised with measles
is clearly reduced. The trial on very
low birth weight infants1’ showed a
reduction in lower respiratory tract
infection from 55% in control
group to 21% in vitmin A group
(p <0.029). Reduction in the
deaths due to measles in an equally
important factor, if not greater, than
vitamin A supplementation to reduce
this morbidity and mortality. Also
we know that vitamin A deficiency
can precipitate measles, hence the
two are interdependent.

Also it has been shown10 that
periodic supplementation is effec­
tive and if necessary supplementa­
tion can be provided even on an
emergency campaign basis. Periodic
dosing should not preclude or com­
pete with efforts to improve the local
food supply and dietary vitamin A
intake by venerable groups (e.g.,
by means of dietary counselling and
fortification). However there may
be a compelling reason in terms of
child survival to control vitamin A
deficiency quickly through periodic
Ghana Vast Study Team; Vit A supple­
supplementation while longer term 12. mentation
in north Ghana: effects on
solutions are persued.
clinic attendances, hospital admissions

delivery

Vitamin A Supplementation
Cost Effectiveness

and

and child mortality.
Lancet 1993;
342: 7-12.
13. Hussey G D, Klein M. A randomised
controlled trial of vit A in children
with severe measles. N Eng J Med.
1990; 323: 160-164.
14. Barclay A J G, Foster A, Sommer A,
Vit. A supplement and mortality related
to measles : A randomised clinical
trial. BMJ 1987; 294: 294-206.

Vitamin supplementation is among
the most cost effective interventions
in developing countries. Further­
more since Hussey et al showed
that
hospitalisation period was de­
Mode of Vitamin A Supplementa­
creased by an average of 4.7 days, 15. Bloem M W, Wedel M, Egger R J,
tion
supplementing children hospitalised
Speek A J, Schrijver J, Saowakontha
Regular low dose of vitamin A with measles is likely to be not only
S, et al. Mild vit A def. and risk of
supplementation 8l,88 and periodic effective but also cost effective.14
respiratory tract disease and diarrhoea
on preschool children in north-east
(4-6 monthly) high dose supplemen­
Thailand. Am J Epidemiol 1990; 338:
tation 23,° have both been found
67-71.
to reduce mortality in childhood.
REFERENCES
16. Abdeljaber M H, Monto A S, Tilden
More frequent supplementation of
R L, Schork A, Tarwotio I. The
children with vitamin A have a l.fDcmarya E M (1986) Children in
impact of vit A supplementation on
Tropics.
No.
165.
morbidity; a randomised community
greater effect on child survival than
intervention trial. Am J Public Health.
less frequent dosing—supply of 2. Sommer A, Kartz J, Torwotjo I :
1991; 81: 1654-1656.
about half of a preschool child’s
Increased risk of respiratory diseases
and diarrhoea in children with pre­ 17. Coutsoudis A, Broughton M, Coovadaily requirement by way of fortifi­
dia M. Vit -A supplementation reduces
existing mild untreated xerophthalmia.
cation reduced mortality by 45% in
measles morbidity in young African
Tans Am Ophthalmol Soc 1983;
Indonesia31 and weekly vitamin A
children; a randomised placebo-con­
81:825-53,
trolled, double-blind trial. Am J clin
doses of 25000 retinol equivalents
Nutr 1991; 54: 890-895.
3. Mclean D
S, Shirajian E,
reduced mortality by 54% in South
Tchalian M, Khoury G. Xero­ 18. Shenai J P, Kennedy K A, Chytil F,
India23. This is probably because
phthalmia in Jordan, Am J Clin
Stahlman M. Clinical trial of vit A
the more frequent supplementation
Nutr 1965; 17:117:30,
supplementation in infants susceptible
maintains retinol levels better than
to broncho-pulmonary dysplasia.
J
4. Pereira SM, Begum A, Dumm ME.
Pediatr 1987; 111: 269-277.
infrequent high doses. The effect of
Vitamin A Deficiency in Kwash­
low dose supplementation indicates
Letter to editor. Michael C Latham.
iorkor Am J clin Nutr 1966:19: 19. Division
of Nutritional sciences, Cor­
the potential impact of including
182-86,
nell University Savage Hall Ithaca
more foods rich in vitamin A in the
New York USA. 21) Muhilal, Permei5. Sommer A. Molality associated
diet but fundamental behaviour
sih D, Idjradinata Y R, Muherdeywith
mild
untreated
xerophthalmia.
change at the household level can
antiningsch, Karyadi D. Vit A forti­
Trans Am Opthalmol Soc 1983:81 :
fied monosodium glutamate and health,
be accomph’shed only over several
825-53.
growth and survival of children of
years during which time children’
children,^, controlled field study. Am J
6. Hussaini G, et al (1983) Lancet 2 :
could continue to die needlessly10.
Clin Nutr. 1988; 48: 1271-1276.
585.

Although periodic large dose de­
livery may lead to a more modest
reduction in child mortality than
more frequent, smaller doses. This
approach is a feasible strategy for
most developing countries seeking
to reduce child mortality with vita­
min A by means of immediately

156

20.

Rahmathullah L, Underwood BA,
Thulasiraj R D, et al. Reduced
mortality among children in southern
Indi a receiving small weekly dose of
vit A. N Eng J Med 199; 323: 929-935.

7.

Glasziou P P, Mackerras DEM.
Vitamin A Supplementation in infec­
tious disease—a meta analysis. BM J,
1993; 306; 366-376.

8.

West K P, Pokhrol J R P, Katz J, 21. Patel M S. Eliminating social distance
between north and south; cost effective
et al. Efficacy of vitamin A in reducing
goals for the 1990s Gcvena Unicef
preschool child mortality in Nepal.
1990. (Staff working paper no. 5). Q
Lancet 1991; 338:67-71.

S wasth Hind

BREASTFEEDING :
Its Importance and Our Concern
Dr (Miss) V. Patil
Dr (Mrs) Y. R. Kadam
and

Dr (Miss) S. N. Shinde

C6If ever I get a chance, I should love to be reborn—just to
have the ecstacy of being refed by the kindly mother.”
—Oscar Wilde

JT’here is no
doubt that the
J breastfeeding
ranks supreme
among all leading factors perpe­
tuating and promoting an eternal
bond of love and affection between
a child and his/her mother. More­
over, besides strengthening the emo­
tional and psychological bonds bet­
ween the two, the breast milk fully
meets the nutritional requirements
of the new entrant into this world
upto the age of 4 to 5 months. How­
ever, beyond this age, the breast
milk alone, is not able to meet the
increasing demand of “energy and
other nutrients due to rapid growth
and development of the baby, call­
ing for supplementary feeding in
addition to breastfeeding—a pro­
cess popularly known as weaning.
The breast milk has been regarded
as the fundamental food for growth
and development of the baby during
the period of infancy (upto 1 year
of age). In many communities/cul­
tures, mothers continue to breast­

October—December, 1995

feed their babies up to the age of
18—24 months.

Composition of Breast Milk and its
importance
The composition of breast milk
has been rightly described as “tai­
lor-made”, since it ideally suits to
meet the nutritional requirement of
a baby during early half of its in­
fancy. 100 ml of breast milk pro­
vides 66 calories, 1.2 g proteins,
3.8 g fats, 7.0 g lactose, 0.1 nig iron,
2 to 6 mg Vitamin C, 170 to 670
International Units (IU) of Vitamin
A, 4 to 6 IU of Vitamin D, 0.18
IU of Vitamin E and 88% water.
Besides these, the breast milk also
provides several biochemical/nutri­
tional constituents, anti-infective
and anti-allergic factors which play
a significant role in body physio­
logy. For example among bioche­
mical/nutritional constituents, poly­

unsaturated fatty acids help in in­
creased absorption of calcium (ess­
ential for development of bones and
teeth). Cystine helps in brain deve­
lopment; nucleotides play a key
role in protein synthesis; polyamines
are needed for development of en­
zymes, and high proportion of water
(88%) helps in maintaining the so­
lute load on kidneys at low level
and thus protects the kidneys. The
anti-infective agents include lyso­
zymes which are anti-bacterial; bifidus factor which inhabits the
growth of bacteria; lectoferrin
which is bacteriostatic in its action,
and secretory IgA which helps in
elimination of enteroviruses and E.
Coti organisms. Secretory IgA also
comes in the category of anti-aller­
gic factor since it blocks the absorp­
tion of foreign macro-molecules,
protein and helps in preventing
the allergic reactions caused by
them.

157

Other Advantages of Breast milk
Besides, there are several other
points also which go in favour of
breast milk, as compared to milk
from other sources, for feeding the
infants, for example, no prepara­
tion is required. It is always fresh,
free from risk of any external con­
tamination and ready for instant
use whenever the baby cries for it.
It is adequately warm due to body
heat and always available at a tem­
perature suitable to the baby. Al­
though during recent years, some
concern has been raised regarding
the contamination of mother’s milk
through certain drugs, pesticides
and certain lifestyles such as smo­
king and drinking, eft., which they
follow, yet in most cases such con­
tamination has been found within
tolerable limits. However, this still
remains an issue on which more
studies and research are required.
Meantime every mother/prospec­
tive mother needs health education
on this aspect.

Colostrum
Colostrum is the term used for
breast milk which is secreted during
first few days after delivery. It is
exceedingly rich in proteins, sodium,
potassium, chloride, fat soluble vi­
tamins and protective antibodies
(mostly immunoglobulins mainlyconsisting of IgA). These antibodies
offer a significant protection against
bacterial and viral infections occur­
ring in the lumen of the intestine.
According to UNICEF—“Colos­
trum is just what the newborn needs
after its birth”. The need of the
hour is, therefore, to apprise all
mothers about the importance of
colostrum through various ongoing
programmes on Maternal and Child
Health (MCH) care, that it should
not be discarded; the infant should
be put to breast preferably within
first three hours after birth and fre­
quent sucking by the baby should
not be prevented but promoted since

158

it is by far the most reliable galactogogue.
Breast Feeding : Mothers Role :
Action desired
During ante-natal period itself
every expectant mother should be
thoroughly educated on the “art and
science” of breast feeding.
Such
health education must include her
own nutrition, proper care of bre­
asts through regular examination.
She should be specifically told not
to stop breast feeding when the
baby suffers from diarrhoea and
properly explained the adverse effe­
cts of stopping breast feeding such
as dehydration. It is worthwhile
to recollect that all diarrhoeal dis­
eases lead to malnutrition among
children. The latter is again a pre­
disposing factor towards various in­
fections associated with diarrhoea.
Thus, there is always a vicious cir­
cle between malnutrition and infec­
tion. The WHO has advocated four
key strategies to break this vicious
cycle, namely Growth Monitoring,
Oral Rehydration Therapy, Breast
Feeding and Immunisation popu­
larly known as GOBI strategy. Every
mother/expectant mother must be
apprised with the aims, execution
and advantages of this strategy and
importance of her active participa­
tion. She should also be educated
on the importance of weaning, the
time when it should start and de­
tailed information in respect of vari­
ous supplementary foods. However,
she must continue the breast feed­
ing for as long a time as possible,
e.g., in our own Indian context it
may extend even up to one and half
to two years. Mothers must be ap­
prised about the importance of
breast feeding in helping in birth
spacing also, since “small family
norm” is the only way to curtail
the onslaught of population explo­
sion. Many sfudies/surveys carried
out in our country reveal that mo­
thers/expectant mothers still do not

possess adequate and correct know­
ledge regarding breast feeding. The
need of the hour is, therefore, to
more extensively use all available
media and greater involvement of
governmental and non-governmen­
tal agencies working in this field
(MCH care) to promote it. When
due to health reasons, artificial
feeding has to be resorted to, vari­
ous breast milk substitutes are avai­
lable such as raw milk (from cow,
buffalo, goat, camel and in some
regions even from donkey), evapo­
rated milk (concentrated cow’s milk
prepared by heating) and various
brands of powdered milks. Cow’s
milk should be preferred for artifi­
cial feeding particularly in families
belonging to low socio-economic
status. Milk powders are quite ex­
pensive although these have the ad­
vantage of less contamination and
adulteration. In such cases, the
mothers must be specially health
educated on preparation technique,
amount and frequency of feeding,
precautions in respect of feeding
bottle and observance of strict hy­
gienic measures.

Lastly, in the context of our glo­
bal aspiration to achieve the goal
of Health For All by 2000 AD,
breast feeding has got a special sig­
nificance. One of the targets is re­
duction of Infant Mortality Rate
(1MR) to 60 or less. As already
brought out earlier that breast feed­
ing plays a key role in breaking the
vicious cycle of malnutrition-infec­
tion—malnutrition, it thus helps im­
mensely in reducing the infant mor­
tality. Before concluding, it will be
appropriate to remind that “Each
child comes with a message that
God is not yet discouraged of man”.
If that be so then all of us are mo­
rally bound to look after the health
and welfare of our children, the fu­
ture of our mankind, and cannot
afford to disregard the crucial role
of breast feeding in discharging our
duty.
O

Swasth Hind

exclusive breastfeeding

—The Need for Promotion
A. M. Mehendale

Exclusive breastfeeding is a situation where the only nourishment the baby
receives is the mother’s milk. Even water is considered as extra mammary
nourishment. In fact, breastfeeding alone is adequate as the sole source of food
for an infant upto the first four to six months of age. It protects against the
interrelated syndromes of marasmus and diarrhoea and offers the child spacing
contraceptive effect to some extent.

nfant’s natural
food is breast
milk. This is not only true in human
beings but also holds true for the
young ones of the whole mamma­
lian group. After almost a decade
of controversy over the bottle
and the breastfeeding, it is now
an accepted medical and scientific
fact that breastfeeding is the best
way to feed infants.
Therefore,
every effort should be made
to
promote and protect this salutary
traditional practice
everywhere.
WHO/LJNICEF have emphasised
breastfeeding of infants, both in the
interest of health of the mother and
child.

I

Exclusive breastfeeding is a
situation where the only nourish­
ment the baby receives is the
mother’s milk. Even water is con­
sidered as extra mammary nouri­
shment.
In fact, breastfeeding
alone is
adequate as the sole
source of food for an infant upto
the first four to six months of age.
The desirability of breastfeeding
for at least four to six months is

October—December, 1995

more important to the resources
of poor countries as it protects
against the interrelated syndromes
of marasmus and diarrhoea and
offers the child spacing contracep­
tive effect to some extent.

If a baby has no other food or
drink except breastmilk, this is ex­
clusive breastfeeding. The baby
should not have even a pacifier
or dummy.
Composition of Breast milk

Breast milk contains all the
nutrients that a baby needs for the
first 4-6 months of life.

(a) It contains the most suitable
protein and fat for a baby
in the right .quantities.

(b) It contains more milk sugar
than most other milks and
that is what a human baby
needs.
(c) It contains enough vitamins
for the baby.

(d) It contains enough water for
a baby even in hot climates.
(e) It contains
the baby.

enough iron for

(f) It
contains
the
correct
amount of salt, calcium and
phosphate.

(g) Breast milk is clean and free
of bacteria.

(h) It contains a substance called
the bifidus factor which
helps special bacteria called
lactobacillus bifidus to grow
in the baby’s intestine. These
prevent other harmful bacte­
ria from growing and caus­
ing diarrhoea.
(i) It contains antibodies which
help to protect a baby aginst
infection until he can make
his own antibodies.
(j) It contains leucocytes which
help to fight infection.

(k) It contains lactoferrin
binds iron.

which

159

Advantages of
feeding

exclusive

breast­

Exclusive breastfeeding has bene­
fits both for the mother and for the
baby.

(1) It protects the baby against
infection and diarrhoea which
can lead to malnutrition, hos­
pitalization and mortality. Ex­
clusive breastfeeding gives the
best protection as compared to
partial breastfeeding and arti­
ficial feeding.

(7) Exclusive
breastfeeding
is
most effective in preventing
pregnancy in the first six
months after a baby is born.

(8) Artificial feeding is expensive
for the family. Hence exclu­
sive breastfeeding can save
money for the family.
(9) Breastmilk is quickly and
easily digested and it is always
ready to be given to the baby.
An exclusively breastfed baby
may not pass stool but this
means that it is almost absorb­
ed.

(2) Exclusive breastfeeding pro­
tects the baby against respira­
Exclusive breatsfeeding is thus
tory infections like pneumonia fundamental to child health and
and infections of the middle survival and important for the health
car like otitis media.
of women breastmilk is a very valua­
ble
commodity which we should pro­
(3) It helps to prevent malnutri­
tect
and support the mothers who
tion. Exclusive breastfeeding
produce it So as to promote exclu­
provides all the nutrients that
a baby needs to grow well for sive breastfeeding it is important
that the new born should suckle at
atleast the first four to six
the mother’s breast within an hour
months of life. Artificial feed­
after delivery.
ing can make a baby over­
weight, which is also un­
WHO/UNICEF believe that of
healthy.
the many factors that effect the

(4) Breastfeeding is important for normal initiation and establishment
the normal development of the of breastfeeding health care prac­
anybodies and cells of the tices perticularly those related to
baby’s immune system. Breast­ the care of the mother and infant,
fed babies have a better res­ stand out as one of the most pro­
ponse to immunizations than mising means of increasing the pre­
valence and duration of breastfeed­
artificially fed babies.
ing.
(5) They are less likely to develop
allergic problems such as ecze­
Ten steps to successful breastfeeding
ma and asthma.

municated to all health
staff.

care

2. Train all health care staff in
skills necessary to implement
this policy.

3. Inform all pregnant women
about the benefits and mana­
gement of breast-feeding.

4. Help mothers initiate breast­
feeding within half an hour of
the birth.
5. Show mothers how to breast­
feed, and how to maintain lac­
tation even if they should be
separated from their infants.

6. Give newborn infants no food
or drink other? than breast
milk, unless medically indi­
cated.
7.

Practice rooming-in,
allow
mothers and infants to remain
together 24 hours a day.

8. Encourage
demand.

breast-feeding on

9. Give no artificial teats or
pacifiers (also called dummie’s or soothers) to breast­
feeding infants.
10. Foster the establishment of
breast-feeding support groups
and refer mothers to them on
discharge from the hospital or
clinic.

(6) Breastfeeding has important In view of protecting, promoting
supporting
breastfeeding,
REFERENCES
emotional benefits for the and
WHO/UNICEF
have
recommend
­
mother and baby. It helps
1. Protecting, Promoting and Support­
ing breastfeeding, joint WHO/
them to form a close living ed the following ten steps to success­
ful
breastfeeding.
Every
facility
pro
­
UNICEF Statement, WHO 1989.
relationship known as bond­
viding
maternity
services
and
care
ing. Babies cry less and deve­
2. Helping Mothers to Breastfeed—
lop faster if they stay close for newborn infants should:
F. Savage King African Medical
to their mothers and breast­
1. Have a written breast-feeding
and Research Foundation (1985),
Nairobi.
Q
feed.
policy that is routinely com­

160

Swasth Hind

Diet for Pre-school
Children
Dr (Mrs) Inderjit Singh

Malnutrition in early child hood causes irreparable damage to the development
of child and results in wastage of human resources. Hence, reduction in the
high rate of child mortality and morbidity due to malnutrition becomes an
important task of policy makers and social development planners.

The high prevalence of protein
energy malnutrition among pre­
school children is the result of lowfood intake and poor environ­
mental hygiene, with the resultant
high infection rate as well as the
ignorance about the nutritional
needs of the vulnerable sections.
Thus the main reason for giving spe­
cial attention to the pre-school child
is that he is an easy victim to mal­
nutrition. Secondly, the nutrition of
pre-schoolers is of paramount im­
portant since the foundation for life
time health, strength and intellec­
tual vitality is laid during that
period. Thirdly, malnutrition of the
pre-school children can be a hurdle
to the socio-economic development
The malnutrition in early child­ of the nation itself. Surveys carri­
hood causes irreparable damage to ed out by a large number of workers
the development of child and re­ in the developing countries have
sults in wastage of human resources. shown that the diets consumed by
As development of the human re­ a large majority of pre-school
sources is vital for the economic and children are deficient in calories,
social development of a nation, re­ proteins and several essential vita­
duction in the high rate of child mins and minerals, particularly vita­
mortality and morbidity becomes an min A, riboflavin, folic acid and
important task of policy makers and iron. In our country, gastro­
social development planners.
enteritis constitutes about 10-13%

hildren below the age of
five years form a major seg­
ment of the population i.e. about
40% of the total population. Pre­
school children are nutritionally vul­
nerable due to their easy suscepti­
bility to malnutrition and infection.
Malnutrition is widely spread in the
developing countries of the world.
In India, 1 to 2% of the pre-school
children suffer from severe forms of
protein energy malnutrition, 4.6%
suffer from different grades of vita­
min A deficiency and 40 to 60%
are found to be anaemic. About 35
to 40% of the total deaths occur
among children below five years of
age.

C

October—December, 1995

of all the hospital admissions and
has a significant mortality. Unhy­
gienic feeding practices are found
to precipitate gastroenteritis. The
rate of prevalence of intestinal para­
sites has also been found to be very
high, i.e. 80% in Indian rural pre­
school children and is one of the
important causes of prevailing mal­
nutrition. Poor environmental hy­
gienic conditions play a very impor­
tant part in undermining the nutri­
tional status of the rural popula­
tions. Infant and child mortality
and morbidity rates are higher in
rural areas than in the urban areas.
Surveys conducted in the rural
areas of India reveal that about
90% of the children suffer from
different grades of malnutrition and
about 15% of them are in extreme
degree of malnutrition. This poor
state of affairs is prevalent in the
rural areas due to ignorance, poor
resources, cultural factors and lack
of education.

The normal requirements of diffe­
rent foods and nutrients should be
known if the nutritional deficiencies
and their prevention in any group
are to be determined. Table I and
Table II give the balanced diet and
daily recommended dietary’ allo­
wances for pre-school children.

161

TABLE I
Balanced diet for pre-school children

Pre-school children

Food items

1-3
years

4-6
years

Cereals ........

175

270

Pulses.................................................................

35

35

Leafy vegetables...............................................

40

50

Other vegetables...............................................

20

30

Roots & tubers

......

10

20

Milk.................................................................

300

250

Oil and fat........................................................

15

25

Sugar & jaggery...............................................

30

40

(g)

Source: ICMR, 1984-

TABLE II
Daily recommended dietary allowances for pre-schoolers

Nutrients

Children

Net energy (Kcal) •

1-3 years
(Wt.
12.2 kg)

4-6- years
(Wt.
19 kg)

1240

1690

Proteins (g).........................................................

22

30

Fat (g)........................................................

25

25

Calcium (mg)

.....

400

400

Iron (mg)........................................................

12

18

Vit. A— Retinol

400

400

1600

1600

0.6

0.9

.

......................................

—B—carotene J ug

.

.

.

Thiamin (mg)..................................... .•
Riboflavin (mg)

.

.

.

.

0.7

1.0

.....

8

11

.

.

0.9

0.9

.

.

40

40

30

40

.....

.

0.2—
ljp|

0.2—
1.0 '

Nicotinic Acid (mg)

Ryridoxine (mg)

Ascorbic Acid (mg)

Jg&ea
.

.

.

Folic Acid (mg)

Vit. B-12 (ug).
Source: NIN, 1995.

162

Swasth Hind

Knowing which vitamins, mine­ to good nutrition. The second step tions of many important nutrients
rals and other major components of is knowing where to find them. and the foods which contain them.
food a child needs is the first step The following chart tells the func­
Function

Which foods

Essential for normal grouth in
children, for good vision, for
healthy skin and hair

Liver, milk; fortified margarines; orange,
yellow and dark green leafy vegetables;
watermelon, strawberries, pumpkin, and
papaya.

Helps keep heart and nervous
system healthy

Liver, meats (especially pork), eggs, fish
leafy green vegetables, whole or enriched
breads and cereals, peanuts, wheat germ.

Riboflavin (Vitamin B2)

Needed for healthy skin, helps
build and maintain body tis­
sues, protects eyes from over­
sensitivity to light.

Milk, cheese, liver, meats, eggs, fish, leafy
vegetables, whole or enriched breads and
cereals.

Vitamin Be

Important for healthy teeth
and gums, blood, and nervous
system, helps break down
proteins.

Found in most foods,
nuts, and whole grains.

Vitamin B12

Helps prevent certain types of
anaemia, helps maintain a heal­
thy nervous system, essential
for proper growth in children.

Liver, kidney, milk, cheese, eggs, saltwater,
fish and seafood, meat.

Vitamin C (Ascorbic Acid) .

Essential for healthy teeth,
gums, and bones, helps build
healthy body cells and blood
vessels, prevents scurvy.

Citrus fruits and citrus juices, tomatoes,
Amla, potatoes, cauliflower, cabbage, dark
green vegetables.

Vitamin D

Needed for strong teeth and
bones, helps body use calcium
and phosphorus, prevents ri­
ckets.

Milk fortified with vitamin D, margarine
fish liver oils, the body makes some of its
own vitamin D when exposed to sunlights.

Needed for strong bones and
teeth

Milk and other dairy products, leaiy greer
vegetables dried pea-* and beans.

Vitamin or mineral
Vitamins

Vitamin A

.

Thiamine (Vitamin Bx)

especially meals,

Minerals

Calcium
Copper

.

.

.

.

Helps the body use its energy

Fish, seafood, me At, nuts, peas, beans.

Iodine

.

.

.

.

Helps the body use its energy

Iodized salt, shellfish, ocean fish.

Essential component of each
body cell; builds body tissue,
some types of protein regulate
body functions.

Meat, poultry, eggs, fish, milk, cheese,
dried peas and beans, peaunt, butter.

Provides energy

Cereal, breads, rice, noodles, flour, potatoes
dried beans and peas, vegetables, fruits,
candies.

Provides energy and essential
fatty acids, helps you feel full

Milk, butter, margarine, cooking oils, fat
in meats, poultry and fish, fried foods,
chocolate.

Other Major Components of Food

Protein

.

Carbohydrates

Fats

.

.

.

October—December, 1995

163

—

—

Parents are often concerned
about changes in their child’s
appetite. Pre-schoolers are not
growing as fast as they did
in infancy and their appetites
reflect this.
Small appetites
may also result from a child
being overly tired, excited, ill
or being in strange surround
ings. Serve a wide variety of
foods to be sure that the child’s
diet is nutritionally complete—
fruits*
vegetables,
protein
foods, unsweetened cereals,
etc.

Children eat better in com­
fortable surroundings. Proper
furniture is important to this
comfort. Since dangling feet
are tiring, your child’s chair
should provide firm support
for feet and legs. Be sure to
provide child-sized, non-breakable eating ware. A small,
broad-based cup (4-6 ozs) is
easy for children to hold and
will help avoid spills. Spoons
should have short handles and
shallow bowls.

—

—

Finger foods are good because
they encourage self-feeding.
Bite-size pieces and finger
foods are well accepted and
easy for tiny fingers to han­
dle. To prepare finger foods,
cut cheese into small pieces,
vegetables
into strips, and
fruit into sections. Mornings
in homes with young children
are often hectic, parents are in
a rush and breakfast is often
missed.
Breakfast, however,
is the most important meal of
the day. Children need break­
fast to provide them with the
energy they need to play and
to learn. Children whoi eat
inadequate breakfast often
become tired, irritable and
listness as the morning pro­
gresses. Breakfasts can be sim­
ple and quick to prepare—
sandwiches, stuffed parantha
with butter, breakfast cereals
with fresh fruit, or blender
milk drinks can ‘kick off’ a
great day. Some breakfasts can
be partially or fully prepared
the night before. Such doahead meals can be a real
meals can be a real boost to
those extra-busy mornings.

— Children are great imitators
and often mirror their parents’
actions. Your children’s food
habits, like and dislikes, fre­
quently reflect your own.
Children can learn to accept
foods you dislike if you .pre­
sent them positively and take
a few bites yourself.

| — 1 slice bread
1
tablespoon each per
year of age of fruit, vegeta­
ble, protein food.
—

There is need to plan a spe­
cial meal for your pre-schoo­
ler, as he or she will generally
enjoy eating the same foods
as the rest of the family. Pre­
school children should have
the following number of serv­
ings from each of the four
food groups daily:

Cereals and grains

—

164

—

4

Fruits & vegetables —

4

Protein foods

—

2

Dairy foods

— 2—3

Although pre-school children
are no longer growing as fast
as they did in infancy, they
still need iron for their in­
creasing blood supply. Iron is
need to form haemoglobin.
Few foods contain iron in
large amounts, so it is diffi­
cult for young children to get
all the iron they need. Good
sources of iron include liver*
dry beans, chicken, raisings,

Hectic scheduled make it diffi­
cult to always have a plea­
sant, relaxed eating environ­
ment. Children like a calm
meal time as much as you do.
Pre-school children enjoy eat­
ing with the rest of the family
and should be included when
possible. Try to serve children
soon after they are seated at
the table. If the meal is not
quite ready, serve a small glass
of juice or raw vegetables as
an appetizer.

—

Large portions of food can
reduce appetites. So remem­
ber to keep portions small.
Serve a bit less than you think
your child can eat and
let
him or her come back for
more.
Suggested first serv­
ing sizes for pre-schoolers are:
4 — J cup milk

(both different foods and the
same food prepared different
ways). For example: boiled
egg, scrambled egg, poached
egg, sunny side up etc). Gra­
dually
introducing a wide
variety of
foods
increases
food acceptances. This is espe­
cially important during the
early years when food likes
and dislikes are being formed.

green leafy vegetables and
whole wheat and enriched
grain products.
Non-meat
sources of iron are not absorb­
ed well by the body. The
amount of iron absorbed from
plant sources can be increased
upto four times, however,
when these foods are combin­
ed with a food high in vitamin
C.

Some tips for feeding the pre-school
children

—

Help the pre-schooler deve­
lop good food habits by offer­
ing a wide variety of foods

—

We have all experienced the
frustration of having
new
foods rejected by our pre?
schoolers. New foods will be
accepted more readily if you
follow the following:
—

Introduce only one new
food at a time.

—

Serve the new food with
familiar foods.

— Serve only small amounts
of the new food.

—

Begin with one teaspoon.

—

Only introduce new foods
when your child is hun­
gryTalk about the new food­
taste* colour, texture.

—

— Let your child see you eat
and enjoy it.
—

Encourage your child
taste the new food.

to
If

Swasth Hind

rejected, accept the re­
fusal and try again in a
few weeks. As foods be­
come more familiar, they
are more readily accept­
ed.
Kind out what is not liked
about the food if rejected.
Often the food will be
accepted if it is prepared
in a different way.

Pre-schoolers usually prefer
mild-flavoured
and simple
foods. Vegetables which deve­
lop stronger flavours during
cooking (e.g. cauliflower, cab­
bage, spinach) are often better
accepted raw or steamed until
just tender. Meats with soft
textures (e.g.f chicken, ground
meats) are easier for young
children to chew.
Pre-schoolers are famous for
their unstable eating habits.
They will often accept foods
they have rejected earlier if
the refusal is treated casually.
Forcing a child to eat an un­
wanted food can result in a
long-lasting dislike of the re­
jected food. Children will
use food to get what they want
if they know refusing food
upsets you. To help avoid im­
mediate and future headaches,
try to accept the refusal without coaxing. After a reasona­
ble amount of time (25-30
minutes) remove food from the
table. Then wait until your
next planned meal time to
offer food.
Simple tasks for pre-schoolers
related to food preparation
and service help develop co­
ordination and generate inte­
rest in eating. These contri­
bute towards good food habits,
e.g. two, three, and four years
old can place non-breakable
items on the table. Four and
five years old can help vege­
tables, spread butter on bread,
and help carry food to the
table. So involve your child
in meal time preparation.
Most
pre-schoolers
enjoy
helping in the kitchen and
readily become welcome help.

October—December, 1995

DR SINGHAL PASSES AWAY
DR. V. S. SINGHAL, Director, Central
Health Education Bureau (CHEB),
Delhi passed away on 28 September 1995.

Bom on 21 December, 1938 at Mainpuri
in Uttar Predesh, Dr. Singhal has had his
early schooling at Lucknow and Aligarh. He
obtained his B.Sc. Degree from the Aligarh
Muslim University in the year 1956.
Dr. Singhal was awarded M.B.B.S., degree from S. N. Medical
College, Agra in 1962 and M.S. (Surgery) degree in 1965 from the
same college.

Dr. Singhal worked in the Deptt. of Cardiothoracic Surgery,
G.B. Pant Hospital, New Delhi from 1966-1971. He joined the
Deptt. of Surgery, Maulana Azad Medical College and Associated
LNJP, Hospital, New Delhi in 1971 and continued to work there till
November, 1989.
Dr. Singhal served Deen Dayal Upadhyay (DDU) Hospital,
West Delhi from November, 1989 to August 1992 as the Medical
Superintendent.

It is from there, Dr. Singhal became Director, Central
Government Health Scheme before joining C.H.E.B. in August
1993. O

— Since pre-school children have
small stomachs and small ap­
petites, snacks are an impor­
tant way of making sure that
the child gets many nutrients
he or she needs. Pre-school
children may need two or
three snacks daily. Snacks
should provide more than just
calories. The sweet or salty
foods we often think of as
‘snack foods’ are poor choices
for young children. Fruit and
raw vegetables with cottage­
cheese dip, butter toast, sand­
wiches, nutritious ladoo, pea­
nut chiki and basen bitrfi. are
all good snacks.
— The poor appetite and disin­
terest in food shown by the
pre-school children are self­

limiting, they need not be of
major concern with most chil­
dren, although it is wise to be
sure that foods of high nutri­
ent density are given priority.
If the pre-school child appears
healthy, is normally energetic,
and grows at an acceptable
rate, the parents may accept
the change in eating pattern
as an expected characteristic
of this age group. On the
other hand, if the child is
lethargic, has repeated and
persistent infections, or has a
prolonged
period without
weight gain, a physical exa­
mination and appropriate labo­
ratory tests should be done.O

165

Food Service Sanitation :
R. K. Bansal

Food and water are the main vehicles for the entry of environmental pollutants
into the hunan body. Hence, the physical chemical and bacteriological safety
of food is of paramount importance for healthy living. The continued occur­
rence o' food borne diseases is due to changes in the food service industry alongwith changes in the people’s lifestyle and eating habits.

ood-borne illnesses
are per­
haps the most widespread pub­
lic health problem in the contem­
porary world, despite substantial
advances in the knowledge and
applications of food hygiene and
safety. Food and water are the
main vehicle for the entry of en­
vironmental pollutants into the
human body, hence the physical,
chemical and bacteriological safety
of food is of paramount importance
for healthy living. The continued
occurrence of food-borne diseases
is due to changes in the food ser­
vice industry alongwith changes in
the public’s lifestyle and eating
habits. These changes have resul­
ted in a more diversified food ser­
vice industry, including fast food
and carry-out preparation, cafeteria,
and complete restaurants1.

F

Traditionally in India, while go­
ing for long journeys and pilgri­
mages, it was customary to take
home prepared foods which had a
long shelf life, or else meals were
cooked on the spot by the family
; members. However, now it has

166

become fashionable to eat foods
available in the prevailing settings2.
This is coupled with the growing
usage of food service establishments
by the general population conse­
quent to higher economic induced
mobility, more number of women
in the work force, working pa­
rents, nuclear families, hostel ba­
sed education of the children and
so on.

World Health Organization has
estimated that in 1980 alone there
were more than 1000 million cases
of acute diarrhoea in children un­
der 5 years of age in the develop­
ing world (excluding China). Out
of these 5 million children died,
which is roughly equivalent to a
rate of 10 diarrhoeal deaths every
minute of every day of the year
and a substantial number of these
cases were due to microbially con­
taminated food.
In addition to
mortality, it can have disastrous
effects on the health and disease pro­
file and nutritional status as well.
The situation becomes appalling

when the total food-bo rile diseases
such as typhoid fever, food-poison­
ing. infective hepatitis, parasitism
etc., are taken in view1'*, and besi­
des this, the food-borne illnesses are
on the increase throughout the
world. At the level of individual
family units, food-bome diseases
can also be catastrophic in subsis­
tence economies. Debilitating illness
in the family of a farmer at.the time
of planting or harvest may result in
a nearly total loss of crops, not only
for sale but also for family use3.

However, judging the magnitude
of food-borne diseases is a formid­
able task even in developed coun­
tries with nation-wide reporting and
surveillance systems.
Studies sug­
gest that the ratio of actual to repor­
ted cases varies between 25: 1 and
100:13.
...

Sanitation in food processing, pre­
paration and service, i.e. catering
establishments and food-handlers
play an integral part in the control
of food-borne disease agents5**.
Though model regulations and legis-

Swasth Hind

A Growing Public Health Concern
lation for the food-hygiene in cater­
ing establishments have been laid
down7, however these are broad gui­
delines only and need to be transla­
ted into specific details at the natio­
nal level.

Rules for food safety

India increasing use is made of stain­ thened and linked to medical col­
leges, wherever possible.
less steel utensils.
A weaker link in the food service
chain is cleaning and sanitizing of
equipments and utensils. In the de­
veloped countries like U.S.A, mini­
mum standards have laid down for
the cleaning and sanitizing of equip­
ments and utensils13. Unfortunately
in our country not much attention
has been focussed on this important
aspect.

REFERENCES
1.

Frank J.F.
and Barnhart H. M.
Food and dairy sanitation. In:
Last J.M., ed. Maxey Rosenau—
Public health and preventive medicine.
Appleton Century Crofts. Connecticut:
765-806, 1986.

2.

Bansal R.K. and Arya R.K.

Food

Attempts have been made to de­
hygiene and safety practices of catering
establishments during Kumbh festival.
velop a comprehensive quantifiable
Ind J Prev Soc Med 23(4); 137-J 40,
1992.
scoring system for the appraisal of
3. WHO. The role of food safety in
the food hygiene of catering esta­
health and development.
WHO,,
blishments2’8*9.
W.H.O. has laid
Geneva, 1984.
down 10 Golden rules for safe food
4. WHO.
Intestinal protozoan and
heminthic infections. WHO, Geneva,
preparation10, however these rules are Proper disposal of garbage
1981.
blatantly flouted with impunity2’8’9.
Proper handling and disposal of 5. Longree K. Quality food sanitation.
It has been observed that generally garbage is critical to a good sanita­
3rd ed. John Wiley, New York, 1980.
the hygiene and safety procedures tion programme lest it attracts in­ 6. Charles R.H.G. Mass catering. WHO,
Geneva, 1983.
observed by the largely illiterate sects and rodents, contaminates food
Food
food handlers and hawkers in India and utensils and acts as a nuisance. 7. FAO, WHO and UNEP.
hygiene in catering establishments:
are scant, if any, with high attendant Again, various studies have docu­
legislation and model regulations.
WHO, Geneva, 1977.
risks of transmission of food-bome mented that most of the smaller and
infections.
Similarly the physical medium sized catering establish­ 8. Bansal R.K. and Arya R.K. Food
hygiene and safety practices of catering
structure and the environs of cater­ ments do not give much heed to
establishments during Bhadbhut pil­
grimage.
Medicine and Surgery,
ing establishments may also be con­ garbage disposal problem2’8’0. Simi­
32(8-10): 47-48, 1993.
ducive to the above risks2’8’9. The larly the control of insects and ro­
9. Bansal R.K. Scoring system for eva­
usage of untreated surface water or dents is also sadly neglected, though
luating food hygiene of catering esta­
blishments. Karamsad, 1993. Un­
ground water sources, such as guidelines are available in the deve­
published document.
wells, in food service establishments loped countries14.
10. WHO. Food safety can save lives.
World Health Forum 12: 403-405,
have been incriminated to lead to
1991.
It is recommended that food hand­
several incidences of water-borne
Centres for Disease Control. Water—
disease outbreaks.
Unsafe water lers should be adequately educated 11. related
disease outbreaks: Annual
summary 1980-1982. CDC, Atlanta,
can act as a vehicle for disease trans­ and trained in food hygiene and
mission as well as to contaminate safety. They should be motivated
National
Sanitation Foundation.
food, equipment, utensils and the to realise that strict sanitation stan­
equipment standards.
cue, Michigan, 1978.
hands of employees11. The national dards should prevail over other con­
sanitation federation in U.S.A.?2 has siderations. Necessary food safety 13. Georgia Department of Human Re• Rules and regulations for
recommended that multi-use equip­ laws should be framed to protect
of
Georgia Department
ot Human Resources, Georgia, 1985.
ment and utensils should be desig­ the health of the consumers. The
» R°dent—borne disease control
ned in a manner to minimise health health department of the various 14.
through rodent stoppage.
CDC
risks.
Fortunately now-a-days in civic authorities need to be strengGeorgia, 1977..

O

Qctober-tvDecember, 1995

167

REACHING OUT TO RURAL CHILDREN
—MID-DAY MEAL SCHEME
utritious food is what growing
children need. Malnutrition is For the first time, Mid-Day
pervasive among school going chil­
Meal Programme will be
dren belonging to poor rural popu­
operational
in all States and
lation. Clearly, neither a child that
is hungry, nor a child that is ill can Union Territories, giving an
be expected to learn. Realising this impetus to primary educa­
need the National Programme of tion programme
through
Nutrition Support to Primary Edu­
improved school attendance,
cation—popularly known as the
and a
Midday Meal scheme has been laun­ reduced drop-outs
beneficial
impact
on
child­
ched in primary schools during
ren’s nutrition.
1995.

N

low female literacy blocks. In the
second . year, 2005 blocks will be
brought under the scheme which
have female literacy rates lower than
the national average of 40 per cent.
The remaining 828 blocks are to be
covered in 1997-98. Phasing the
programme would help inbuilding
up administrative arrangements for
effective delivery.

Significant role for panchayats

For the first time mid-day meal
programme will be operational in all
States and Union Territories, giving
an impetus to Primary education
programme through improved school
attendance, reduced drop-outs and a
beneficial impact on children’s nutri­
tion.

A significant role is envisaged for
the Panchayats and Nagarpalikas
Under the scheme, foodgrains at who are expected to set up the
the rate of 3 Kgs minimum per child necessary infrastructure for prepar­
are provided per month subject to ing cooked food.
They have the
an attendance of 80 per cent in the flexibility to organize the programme
concerned school. The Central Go­ with the association of NGOs,
vernment supplies the full require­ women’s groups and parent-teacher
ment of foodgrains for the pro­ councils. They can also decide the
A Committee under the Chairman­ gramme free of cost As an incen­ type of food to be served. The
total charges for cooking, supervi­
ship of the Union Education Secre­ tive to facilitate the movement of
sion and kitchen are eligible for
tary, had considered nutrition sup­ foodgrains to villages, the Centre
assistance under poverty alleviation
port to education from the larger reimburses the State Governments programmes.
perspective of comprehensive child at the rate of Rs. 25 per quintal to
care related programmes of primary cover transportation and handling
The scheme is expected to has­
education, nutrition, health and In­ charges.
ten the move to the goal of univertegrated Child Development Services
salisation of elementary education
(ICDS).
by reducing drop-outs and improv­
Reaching out to 2408 blocks
ing nutrition. Although the drop­
The scheme covers around 11
The scheme has been started in
out rate has been declining, at 36
crore children in class I to V in 2408 blocks (covered under Em­
per cent in Class I to V it is still
over five lakh government, local ployment Assurance Scheme) hav­ high.
body and private-aided primary ing large proportion of poor people
schools in a three year period.
in remote and tribal areas and 40
(Contd, on Page 170)

168

SwasthHind

WORLD FOOD DAY—16 OCTOBER

FEEDING THE WORLD
Daya Krishna
he astounding growth of popu­
lation during the last 200 years,
especially its accelerating rate of
growth, is causing serious doubts
about the earth’s ability to feed its
people.

T

tion level. In future, the report says,

production at 1.6 per cent per annum
was lower than the growth rate of
1.8 per cent for population. Dur­
ing the nineties, the growth rate of
foodgrain production is expected to
further decline to 0.9 per cent, which
is about half of the anticipated
growth rate of 1.7 per cent for popu­
lation.

are causing much damage to crop.
It is estimated that the world could
be losing 14 million additional ton­
nes of grain output each year be­
cause of this damage to land and
crops. This does not include losses
caused by hotter summers as expe­
rienced during the eighties and pro­
jected for the nineties.

India, at present, has no more and more people in the world
reason to worry as far as will be eating as less as the Indians
quantity of foodgrains is con­ do.
cerned. At the time of inde­
pendence, India was a net Grim scenario
Between 1950 and 1990, world
Growth in world output of food­
population has risen from 2.5 billion importer of foodgrains and
grains
is decelerating on account of
to 5.3 billion, indicating an annual it continued to be an impor­
environmental degradation; a reduc­
growth rate of 1.9 per cent. During ter for a long period of over
tion in crop land; constraints on irri­
the same period, production of food­ 30 years. But in January,
gation; and diminishing response to
grains has recorded a higher growth
1995 Government had a chemical fertilisers. All forms of
rate of 2.5 per cent which raised the
record stock of over 30 global environmental degradation are
per capita production of foodgrains
million
tonnes of foodgrains. adversely affecting food production.
from 246 kgs. in 1950 to 316 kgs.
This was double the mini­ Soil erosion is slowly undermining
in 1990the productivity of an estimated
mum norm of 15.4 million
However, the annual growth rate tonnes. India is now export­ one-third of world’s cropland. De­
forestation is leading to increased
of foodgrain production has been
ing
foodgrains
to
other
rainfall runoff and crop devastating
declining after 1960. During the
countries.
floods. Air pollution and acid rains
eighties, the growth rate of foodgrain

Worldwatch report
The latest report of the Worldwatch
Institute in Washington is titled
“Full House: reassessing earth’s
population carrying capacity’’-. This
report predicts that the world will be
having a gradually growing deficit

October—December, 1995

of foodgrains, and this deficit will
lead to fierce competition among
importing countries leading to large
increases in prices of foodgrams.
The report puts the annual per
capita grain use in 1990 at 800 kgs
in America; 400 kgs. in Italy; 300
kgs. in China; and 200 kgs. in India.
• The projected world grain harvest of
2.1 billion tonnes in 2030 can sustain
2.5 billion people at American con­
sumption level; 5 billion people at
Italian consumption level and 10
billion people at India’s consump-

The irrigated land had risen from
94 million hectares in 1950 to 236
million hectares in 1980.
There­
after, the gains from new capacities
are being largely offset by losses
from water logging and salinity
falling water tables and the silting
of existing reservoirs. During the

169

eighties, the irrigated area per per­
son shrunk by 8 per cent. The crop­
land area per person has also been
falling steadily since mid-century.
This trend of shrinking irrigated
area per person is a new phenome­
non which makes eighties the first
decade during which cropland and
irrigation have both declined. This
partly explains the markedly slower
growth of foodgrains production dur­
ing the eighties.

foodgrains is concerned. At the
time of Independence, India was a
net importer of foodgrains and it
continued to be an importer for a
long period of over 30 years.
But in January 1995, Government
had a record stock of over 30 million
tonnes of foodgrains, which was
double the minimum norm of 15.4
million tonnes. India is now ex­
porting foodgrains to other coun­
tries.

lion tonnes, or 67 per cent, has
been realised after the introduction
of high yielding varieties (HYVs)
since 1965-66. The HYVs give op­
timum yield only with the applica­
tion of high doses of chemical fer­
tilizers under conditions of plenti­
ful supplies of water. The cultiva­
tion of HYVs therefore, has been
confined to the water assured areas
of the country.

Since mid-century on, chemical
The irrigation potential of India
During 1950-94, India’s popula­
fertilisers have been the engine of
growth for the world food output. tion had risen from 36 to 90 crore, has risen from 23 million hectares
Between 1950 and 1989, use of ferti­ indicating a growth rate of 2.1 per in 1951 to 88 million hectares in
lisers had risen from a meagre 14 cent per annum. In the same period, 1994-95. The consumption of che­
million tonnes to 143 million tonnes. India’s production of foodgrain had mical fertilisers has risen.
If, for some reason, fertiliser use risen from 51 to 185 million tonnes
But India has also to watch out
were abruptly discontinued, world indicating a growth rate of 7.8 per
food output would fall by about 40 cent per annum. Consequently, the for the trends that threaten food­
per cent. It has been observed, how­ per capita availability of foodgrain grain production in other parts Of
ever, that once the new fertiliser re­ had risen from 395 grams per day in the world. Top on its list of priori­
sponsive varieties are planted on all 1951 to 475 grams in 1994. India’s ties has to be controlling 'both po­
suitable land, growth in use of fer­ growth rate of 3.0 per cent of food­ pulation and pollution levels. How­
tiliser slows down. Many countries grain production for the period ever, this has not only to be a gov­
in the world are experiencing dimi­ 1950-94 has been higher than the ernment-sponsored effort, its suc­
nishing returns on fertiliser use. growth rate of 2.5 per cent for the cess will depend on the cooperation
All these factors make for a grim world production of foodgrain for of the common man. Such efforts
the period 1950-90.
scenario.
will have to be replicated in coun­
Outlook for India
Between 1950-94, India’s food­ tries the world over—if we have to
India at present, however, has no grains production had risen by 134 survive as a race on this planet.
reason to worry as far as quality of million tonnes, out of which 90 mil-

—PIB

one and a half times from Rs. 977
crore in 1991-92 to Rs. 1825 crore
in 1995-96. The Prime Minister has
already announced the Govern­
ment’s decision to raise the alloca­
tion for education to six per cent
of GNP by the end of the Ninth Plan.

visited almost all the States for re?
view.

Contd. from page 168)

Top priority to poverty

alleviation

The mid-day meal programme is
Emphasis on quality
in tune with- the top priority being
Production units of Modem Food
given to strengthening anti-poverty
Industries Ltd (MFIL) at Faridaprogrammes. While the outlay in
bad, Delhi, Kanpur and Bhagalpur
the first year will be Rs. 610.40
have been directed to step up pro­
crore, when fully operational, the
Under the Mid-day Meal Pro­ duction Of high nutritious processed
scheme will cost Rs. 2084.90 crore. gramme FCI has issued 91 million food to meet the additional require­
tonnes of wheat and 147 million ment to provide mid-day meal to
The Central Government’s Plan
tonnes
of rice feetween August 15 school going children, pregnant wo­
outlay on education has increased
and October 31. Central teams have men and lactating mothers. —PUB.

170

Swasth Hind

SOCIAL ASPECTS OF MILK
Brig. (Dr) N. L. Sachdeva Retd
I

Milk is the best and as nearly a complete food as exists in nature. It is unique in
nutritive value when compared with other foods. The author, in this article, dis­
cusses the social aspects of milk, highlighting the positive points, social and
religious beliefs and practices. Other areas discussed are the advantages of breast­
feeding, weaning practices, milk allergy, milk-borne diseases etc.

MILK AS A COMPLEI E FOOD—POSITIVE POINTS
* It is the best and as nearly a
complete food as exists in nature.
It is unique in nutritive value when
compared with other foods.

* Milk fat is a good source of
retinal (Vitamin ‘A’) and Vitamin D.
However the content of Vit. A
depends on the feed of the animal.

* Cow’s milk is the complete * It contains almost all minerals
phosphorus,
natural food for its young calf and such as calcium,
can conveniently be given to human Isodium, potassium', magnesium,
infants as a substitute for breast cobalt, copper and iodine.
milk. Buffalo milk is richer in
protein, fat and carbohydrate con­
tent while goat’s milk is almost * Although it is an animal food,
similar to cow’s milk.
it is considered to be part of vege­
tarian diet which is a healthy pra­
* Milk proteins contain all the ctice for predominantly vegetarian

essential amino acids of high bio­ Indians.
logical value.

casein is precipitated. This is due
to action by an enzyme secreted by
certain micro-organisms in the milk.
This can be prevented if milk is
sterilized or pasteurized and kept at
refrigerating temperature.

* Buffalo’s milk is richer in total
solids and fats, less digestible and
less pleasant to take.

* Milk being poor in iron and vit­
amin C, it cannot serve as the com­
plete food.
* Infants fed exclusively on milk
after four months of age become
anaemic and flabby in 7 or 8 months.

• The carbohydrate in milk i.e. Negative Points
* Being a good growth medium for
lactose or milk sugar is found no * Exposed to air and certain tem­ bacteria, it can transmit many com­
perature, lactic acid is formed and municable diseases.
where else in the world.

October—December, 1995

171

* Due to the gap in its production milk and this has reduced bias * Collostrum i.e. the milk which
and consumption, its price is soaring against its use. It is commonly comes out of the mother’s breast
during first 1-2 days is a very con­
at a very fast rate; hence adul­ given to children, sick people, old
centrated and rich source of anti­
teration has become the rule. Com­ and the invalid.
bodies and other protective nutri­
mon adulterants are water (polluted/
ents. It is a wrong practice to dis­
contaminated), cane-sugar, removal * Regular intake of milk is believed card it and deprive the child from
of cream and addition of starch.
to prevent stomach ulcer and cancer. this very vital and rich food pro­
This is given as one of the reasons duced by nature for the infant.

Religious Beliefs

for lower incidence of these diseases
in Gujaratis.

* Milk is used in all religious fun­
ctions and given as ‘Chamamrut
* Consumption of milk and mango
after Pujas*.
together is considered good for

* Feeding bottle is covered by a
napkin or cloth to avoid ‘Nazar’ to
the infant child. If the feeding
bottle is properly sterilized and pro­
per personal hygiene is practised
there is no risk of any untoward
ill-effects on the child.

health probably because it makes the
* It is considered so sacred that
people swear by milk as ‘Dudh combination a more balanced diet.
putar ki Satin’ i.e. swearing by milk
Most of the negative social beliefs
or son alike. Some swear by * When prices were not high, milk by and large are based on supersti­
‘Mother’s milk’.
or milk preparations like butter­ tions, ignorance and irrational rea­
milk were given free to neighbours soning. These need to be curbed
* A Hindu house-hold should have or friends. Now many people sell by health education. Milk should
the milk and keep hardly any qua­ be kept covered as it can be conta­
atleast one cow in the house.
minated by dust, insects, etc., and
ntity for consumption at home.
lead to preventable diseases.
* Cow is respected as ‘mother’ and
its slaughter is considered irreligious.

* Milk preparations like Khir are Breast Feeding
served as a must to a guest even by
The best food for infants is breast
* Spilt milk is immediately removed poor people.
milk. The advantages of breast
by wet swapping probably because
feeding are that the infanf gets nou­
it is considered sacred and no one
* Consumption of milk along with rishment direct from the mother at
should step over it.
fish or meat is believed to cause a suitable temperature and in an
leucoderma/leprosy.
assimilable composition; it is bacteSocial Beliefs/Misbeliefs/Practices
riologically or otherwise pure; it
* Cow’s milk is considered good for
contains protective antibodies and
* Some people believe that if milk
those who are studying or doing
it gives psychological satisfaction to
is licked by a cat and then consumed,
intellectual work; buffalo milk is
the infant If the quantity of breast
it causes rabies/leprosy.
believed to make a person dull,
milk available daily is not enough,
while goat’s milk is considered
then the infant’s diet should be
safer than others because it does • There is a common belief that supplemented with some other milk
not cause tuberculosis. Some peo­ consumption of raw milk leads to suitably modified. It is essential that
ple do not like buffalo’s or goat’s ‘Dharan’ i.e. shifting of umbilicus
milk for its unpleasant flavour. from its natural site which causes
Mahatma Gandhi used to take goat’s abdominal discomfort.

172

milk given to infants is boiled and
all utensils used for feeding Be

boiled in clean water.

Swasth Hind

Weaning Practices
Weaning is the process in which
an infant's diet is gradually changed

the foster infant as well as for her by ensuring proper health and clean­
liness of milch animals, their envi­
own child.
ronment, milk vessels, milk hand­

from liquid foods to cooked solid Milk Allergy
foods. It can be started as early as
Milk may cause gastro-intestinal,
at the age of 3 months. The food respiratory or skin manifestations
should be cooked soft and mashed due to one of its proteins. Boiling
to a thin consistency. However, it of milk diminishes its allergic power.
must start from 4th and latest by 6th Allergic symptoms may also be
month. It is a good practice to con­ caused due to contaminants or che­
tinue breast feeding as long as it is micals/drugs excreted in milk.
possible and atleast till the child is
of one year age.

lers and

finally by pasteurisation

and proper storage of milk.

Conclusion

Milk is an ideal food for infants
and children. It is also a good
supplementary food for adults, parti­
cularly vegetarians.

Milk Borne-Diseases

The buffalo milk contains more
fat as compared to cow’s milk. Milk
given to infants should be boiled
and all utensils used for feeding
should be steamed or boiled in clean
water. Breast milk should be given
to the infant as long as it is possible
but weaning process should start
nation of milk in the same way as as early as from the age of 3-4
through water and food. Examples months. Proper milk hygiene can
are typhoid, cholera, viral hepatitis prevent almost all milk-borne di­
O
and so on. These can be prevented seases.

Certain infections of animals
which can be transmitted to man are
Prolonged breast feeding leads to
tuberculosis, brucellosis, strepto­
lactation amenorrhoea which is
coccal infections, staphylococcal en­
taken advantage of as a natural
terotoxin poisoning and salmo­
spacing method for family planning.
nellosis. There are some others
which are primary to man and may
Foster Mother Wet (Nursing)
be transmitted through contami­
Lactation Amenorrhoea

The wet nurse should be free from
communicable diseases like Tuber­
culosis, leprosy, STD, etc. She
should have enough milk both for

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October—December, 1995

173

World AIDS Day

INTERNATIONAL CONFERENCE
ON AIDS—Law and Humanity
INAUGURAL SPEECH By :

am happy to be present here
today with many distinguished
participants from India and abroad
at the International Conference on
AIDS—Law and Humanity, which
is being hosted by the Indian Law
Institute. I would like to thank the
organizers for giving me the oppor­
tunity of sharing my thoughts on
this important subject.

I

Man’s eternal quest to understand
mind and matter by the pursuit of
.knowledge, science and technology
has been the hallmark of civiliza­
tions through the ages. Great strides
have been made in comprehending
the human condition by the sages
and savants of yore, as well as
modern day scientists and discover­
ers, inventors and innovators. Some
of the greatest advances have been
in the field of medicine. The dis­
covery of penicillin and the vaccines
against small-pox and polio, to name
only a few, have helped immensely,
in safeguarding human life.
Of the challenges facing our scien­
tific community today, indeed soci­
ety per se9 the AIDS pandemic is
among the most complex and seem­
ingly intractable. It is important
to appreciate that AIDS is not mere-

174

DR Shanker Dayal Sharma
President of India

“A necessary condition for any successful AIDS control
programme is the need to lift the veil of ignorance which
is draped around the disease. Bapu often said that
ignorance was one of the root causes of disease. What
has made the situation more difficult in the case of AIDS
is the social stigma it carries. This again is due to
ignorance.”

ly a disease; it is a phenomenon
which touches upon almost every
facet of our lives. AIDS affects all
humanity — individuals, families,
communities, nations and the world.
Nor, in this age of superfast travel
and transportation, does it know
any boundaries.

loping countries. Women, children
and the more disadvantaged sections
of society are becoming increasingly
vulnerable. If adequate efforts are
not undertaken to prevent the spread
of the disease, the human and eco­
nomic cost borne by society will be
of mammoth proportions.

It is estimated by expert agencies
Combating this virus and curbing
that in recent years, the scourge of its spread, through a mass action
HIV has infected more than 18 programme, is the challenge we face
million individuals worldwide, and today. The disease has raised a
that by the* year 2000 A.D., this
plethora of issues relating to ethics,
number could swell to 40 million.
morality and law, life-styles and
There is apprehension in the scienti­
fic community that as many as ten social mores, women and children;
million individuals could succumb economic growth and development;
to AIDS. Trends indicate that the human rights and fundamental free­
predatory virus is spreading its ten­ doms. The virus has brought sen­
tacles rapidly, particularly in deve­ sitive questions from the private and

Swasth Hind

personal lives of individuals, into
the public domain.

a targeted approach aimed at the
high risk sections of the population,
In the Karna Parva of the
many of whom comprise tlie most
Mahabharata, verse 58 of Chap­
The absence, so far. of any cure productive members of society.
ter 69 says :
or vaccine, which can conquer the
virus has made the prevention of
I understand, the National AIDS
ETTWR
UHf UPTOt 5F5fi:
the disease vitally important. Clear­ Control Organization (NACO) in
SRT FTTS
H HR
ly, if we are to address these comp­ India is doing commendable work in
II
lex questions effectively, a compre­ generating greater awareness of the
hensive multi-sectoral and multipro­ disease and in propagating preven­
(Dharma is for the stability
nged approach is required. The battle tive measures. In their campaigns,
of
society,
the maintenance of
against AIDS has to be fought on they are making effective use of the
social
order
and
the general well­
all fronts — medical, social, legal, idiom and language of the youth,
being and progress of humankind.
informational, educational and eco­ who are the most vulnerable to the
Whatever
contributes to the fulfil­
nomic. To achieve success, it would disease. NACO is contributing sig­
ment
of
these
objects is Dharma,
be necessary to involve every sec­ nificantly to a more informed and
that
is
definite.)
tion of the population — women. frank national debate of issues that
men and children, and above all. were hitherto not discussed openly.
those who are infected with the virus.
The participation of Government
Since the virus has raised ques­ preserves the social order. On the
institutions, public and private tions of fundamental concern to other, it acts as a dynamic instru­
sectors, non-governmental and vol­ society, it is important to develop ment in fostering social change, pro­
untary organisations would be an appropriate legal framework gress and modernization.
essential.
which could facilitate ways and
The AIDS/HIV virus as it spreads
means of addressing these concerns.
A necessary condition for any
and
grows in magnitude, threatens
Some of these need to be very spe­
successful AIDS control programme
to
undermine
social stability and
cifically postulated. How can law
is the need to lift the veil of ignor­
progress.
It
is upto the interna­
be used to protect individual rights
ance which is draped around the
of the infected as well as members tional fraternity of legal luminaries
disease. Bapu often said that igno­
of the general public? Is it advisa­ and medical minds to ensure that
rance was one of the root causes of
ble to develop a protective rather Law becomes a major factor in de­
disease. What has made the situa­
than a proscriptive or punitive termining the efficacy of efforts to
tion more difficult in the case of legal framework?
overcome and eradicate AIDS. I
AIDS is the social stigma it carries.
am told that experience in other
This again is due to ignorance.
Can Law not be used as an in­ societies, which have a longer his­
Proper surveillance of the oiscase is strument of change in social behavi­ tory of dealing with this disease,
essential for preventing its spread, our patterns? These are some of has shown that a punitive legal
but the lack of information about the questions which, I am confident, framework is not the best method
the virus and its implications, inhi­ you will deliberate upon at this Con­ of prevention. It may be useful to
bits these efforts, it is, therefore, vital ference.
evaluate whether laws which prohi­
to develop an awareness campaign,
bit certain types of activities or call
spelling out the nature of the disease,
Law has been defined as “the for detention of those infected have
its causative factors, and steps that body of rules, whether proceeding been adequately successful in con­
can be taken to prevent infection. from formal enactment or from cus­ trolling the epidemic. Personally.
The support of mass media in pub­ tom, which a particular state or I would endorse a humane appro­
licizing this campaign, particularly community recognizes as binding on ach, one that regards those suffer­
television and radio, which reach its members and subjects.’’ (A ing from the disease as its victims,
out to the entire population, is cru­ New English Dictionary or Histo­ rather than a danger to society.
cial. In addition to creating general rical Principles ed. J.A.H. Murray).
awareness, it is important to adopt On the one hand, Law protects, and
(Contd. on page 178)

October—December, 1995

175

Dispel Fears and Misconceptions Aboiat

HIV/AIDS
in the country. Multi-partner sex is
is responsible for the majority of

Excerpts from the speech delivered by Shri P.V. Narasimha
Rao, Prime Minister at the Inauguration of the International these infections except in the NorthConference on AIDS - Law & Humanity, held in New Delhi, Eastern States where intravenous
drug use is the primary causative
6—10 December, 1995.
factor.

N the recent years, AIDS has has misled many countries to an
become the most dreaded word AIDS catastrophe.
around the world. After nearly 15
The first HIV infection in India
years of the epidemic, a cure for
AIDS is yet to be found. Tn the was reported in May 1986 from
meanwhile, it has continued to spr­ Madras, Tamil Nadu. Since then
ead its tentacles, as the virus does HIV infection has been reported
inside the body, to the entire world. from almost all States and Union
According to WHO, over 18.5 mil­ Territories of the country. It is
lion people are infected with the currently estimated by WHO that
virus in the world, of which 3.5 mil­ over 1.75 million people in India

I

lion are estimated - to be in South
and South East Asia alone.

Our region too has not been spar­

Various studies have indicated
that Sexually Transmitted Diseases
(STDs), which are a co-factor for
HIV transmission, are not only

limited to the high risk groups but
also extend to general populations
and that the prevalence of STD is
not specific to urban areas alone.

HIV

predominantly

affects the

most productive population. There­
fore. it is imperative that preventive
measures are taken at the very be­
are infected with HIV. Not only is
ginning failing which we may face
the infection present in all regions,
a severe socio-economic setback.
but it has also spread beyond the
identified “high risk groups” to the
With the emergence of HIV in

general population. The rate and most of the developed countries,
extent of the spread has been dra­ the Govt, of India launched a pilot
every country in the region has re­
matic and now HIV infection is as screening programme for detection
ported cases of HIV and AIDS. It
indigenous as any other disease in of HIV infection as early as in
is only matter of time before the
1985-86. After the detection of the
virus, if unchecked, will make its the country.
The seropositivity rate among first case in 1986, the government
way to much of the population of
various
specific groups like com­ launched the National AIDS Con­
the region. It is time for us to rea­
ed. Over the last few years almost

lise that we will Have to tackle this mercial sex workers, Injecting Drug
problem in a practical and realis­ users, truck drivers and pregnant

trol Programme in April, 1987 with
three major components, namely

tic way and not take refuge in mor­ woman shows the alarming trend
ality and cultural heritage which of increase in the infection levels

serosurveillance, ensuring safety of

176

blood and

blood

products

and

Swasth Hind

health education. The National people who by virtue of their ac­
AIDS committee also was constitu­ tions constitute the high risk popu­
lation. Priority is being given to
ted at the same time.
NGOs working with people at high
In the year 1991-92, a Medium risk to themselves.
Term Plan was evolved and imple­
In the case of HIV infection and
mented with the assistance of WHO

in five priority states and Union
Territories. Realising the gravity of
this situation, this programme was
reviewed at a meeting held under
“my chairmanship** and thereafter
the steps for setting up the priori­

AIDS is the availability and disse­

mination of information regarding
the HIV status of particular indivi­

duals. Information regarding any
individual’s HIV status also imp­

lies a great responsibility upon the
persons possessing this information,
AIDS, the experience of country
be they laboratory technicians, nur­
after country has confirmed that the
sing personnel, treating physicians,
general protection of the commu­
or even the media.
nity from the spread of this epide­
It is incumbent upon the persons
mic is directly linked to the pro­
tection of the rights and dignity of involved in HIV screening or HIV
HIV infected persons and persons testing and to whom such informa­
with AIDS. To the extent fears and tion is made available to ensure

ties and further strengthening of the
programme were initiated. As a
consequence, a comprehensive Stra­ misconceptions direct public attitu­ that the rights to privacy and con­
tegic Action Plan for the prevention des and policies, the task of protec­ fidentiality of the persons being
and control of HIV and AIDS in ting individuals and the communi­ screened or tested are protected and
India has been drawn up by the ties in which they live, from the that the system of counselling and
in collaboration epidemic only becomes more diffi­ care which must be provided as a
support to such testing is available
with WHO. The National AIDS cult
and effective.
Control Programme, operational
Most of the fears and misconce­
since 1987, has been further stren­
It is important that health care
ptions which lead to discrimination
gthened and consolidated in 1992
related to HIV and AIDS are the professionals dispel the fears and
at an estimated cost of Rs. 222.60
result of a lack of, or faulty infor­ misconceptions currently prevailing
crores for the period 1992-97. This
mation regarding the nature of the with regard to HIV infection and
project is being funded through as­
virus (HIV) and the resultant syn­ AIDS. It is only thus that they can
sistance from the World Bank by a
drome (AIDS). HIV infected per­ fully discharge their duties not only
soft loan of US $ 84 million and
sons and persons with AIDS are, in­ with respect to HIV infected per­
financial and technical assistance
correctly, portrayed by some as sons and persons with AIDS, but to
from WHO. For an effective imple­
threats to society rather than as the the society as a whole.
mentation of the project, a separate
unfortunate victims of the disease.
The need to promote the human
wing called the National AIDS
The wealth of experience from
rights and dignity of HIV positive
Control Organisation has been set
across the globe however, indicates
persons and persons with AIDS
up in the Ministry of Health &
that after ten years of dealing with
and to avoid any sort of discrimi­
Family Welfare.
AIDS, a few lessons have been
nation against them has been widely
learnt.
The emphasis in the AIDS pre­
recognised and accepted, by the

Health

Ministry

vention programme is being placed
on Information, Education and

It is commonly accepted around

world community as a cornerstone

the world that an individual’s right for the successful prevention of the
Communication as well as behavi­ to privacy extends to matters of his spread of HIV and AIDS. I recall
our change. A good measure of or her own health. Thus, the rele­ that during my tenure as Health
these programmes are directed at vant issue in the era of HIV and Minister, India voted in support of

October—December, 1995

177

seeking help, and treatment, and as their usefulness to society and
this only further threatens the their families.
health of the whole community by
We have to reconcile rights of
encouraging further spread of the
the individual and of the society.
infection.
In fact, experience in many coun­
Commitment to rights of the indivi­
The tendency to hide one's HIV dual is not antithetical to interests
tries of the world to date has only
reinforced the opinion that non-dis­ status is created by the fact that the of the society and must form part
society doesn’t need such a person.
crimination of HIV infected per­
of our fight against AIDS.
Therefore that feeling of unwanted­
sons and persons with AIDS is the
ness creates the desire to hide his
The law dealing with issues rela­
only way of effectively dealing with
disease. In addition, since HIV in­ ting to AIDS is at best in a for­
the challenges of this epidemic.
fected individuals have, potentially mative stage. An array of legal is­
The issues of information and at least, upto ten more productive sues such as those of liability in tort
non-discrimination with regard to years ahead of them before the real and criminal law, and duty of care
employment, housing, education, disabilities of AIDS begin to set in, of blood banks or hospital or health
social services, travel and other rela­ it is important for society to learn care personnel may arise for consi­
ted issues are being intensely deba­ to accept and interact with such deration of the courts. They may

the World Health Assembly Reso­
lution on the Avoidance of discri­
mination in relation to HIV infec­
ted people and people with AIDS.

ted in India. Draconian measures persons as useful, productive, valu­
to arrest, imprison or otherwise iso­ able members of the society. Fears
late HIV positive individuals, whe­ of HIV or AIDS transmission,
ther in legal or health institutions, based upon misperceptions, can be
are misconceived and counter pro­ dispelled with clear information
ductive. Attaching stigma to per­ campaigns. HIV infected persons
sons with HIV infection or AIDS
only serves to discourage them from

fSontd. from Page No. 175)

A punitive, regulatory approach
could understandably promote a fear
psychosis amongst those infected and
drive the disease “underground”, and
hamper preventive efforts.
Indeed, there is experience in some

merit treatment depending upon
social and economic conditions of
the societies concerned. I hope that
this Conference would provide use­

ful inputs to the administrators and

legal advisers alike for finding via­
and persons suffering from AIDS ble solutions suited to circumstances
can thus retain their dignity as well of their own people.
O
Courtesy : AIDS IN INDIA
Dec. 1995.

central element has to be the full lities”,, encapsulates the idea that
cooperation and
participation of any meaningful steps taken to handle
infected individuals. Therefore, a this issue, must recognize the rights
supportive legal environment built and responsibilities of bothj Indivi­
on the basis of laws which protect duals and Society. All this involves
their individual rights, self-esteem very complex tasks—sustained inter­
and dignity, will assist us in our disciplinary efforts and cooperation
on a global basis. I am sure your
efforts to curb the disease.

countries that a protective environ­
deliberations will be productive and
Throughout the world and in fruitful and will lead to the build­
ment which treats individuals suffer­
ing from the disease, with care, com­ India, we have observed the World ing of a safer and healthier world.
passion and understanding is more AIDS Day on 1st December. The With these words, I have great
effective. For the success of any slogan selected for this occasion, pleasure in inaugurating this Con­
prevention or control programme, the “Shared rights, shared responsibi­ ference.
O

178

Swasth Hind

HIV/AIDS PANDEMIC:
THE INDIAN CONTEXT
Dr Shiv Lal and Dr D. Sengupta
National AIDS Control Organisation
TJT1V pandemic has come a long
way since the first cases of a
Since the detection of first AIDS case in Bombay in 1986,
strange form of immunodeficiency,
a cumulative total of 2109 cases of AIDS have been
now indentified as Acquired Im­
reported from different parts of the country by the end of
mune Deficiency Syndrome (AIDS),
the terminal stage of human
December, 1995. Of the 27.68 lakh samples screened,
immunodeficiency
virus
(HIV)
21,564 have been found to be HIV Anti-bodies positive.
infection, were reported in 1981
from California and New York
in the USA. World Health Orga­
nisation (WHO) estimates that to the insidious and covert nature Indian Context
as of mid-1995,
18.5 million of the disease, the problem is com­
The HIV entered India in midadults and more than 1.5 mil­ pounded by a pervading attitude of
lion children have been infected denial or resistance or complacency 1980s, a relatively delayed entry
with HIV world wide since the be­ at all levels. Unlike epidemics of when compared to other parts of
ginning of the epidemic. The pro­ diseases such as cholera, plague the world. However, it spread quite
gressive increase in HIV infection, and polio, which manifest acutely rapidly in certain States viz. Maha­
particularly in Southern and Cen­ and overtly and elicit concrete res­
rashtra, Tamilnadu and Northtral Africa and Southern Asia, it is
ponses, the visible manifestations of Eastern States, especially Manipur.
feared, will accentuate the dispro­
HIV infection occur only at the late Since the detection of first AIDS
portionate impact of HIV/AIDS on
the developing world. WHO further stage. As a result there is visible case in Bombay in 1986, a cumula­
estimates that the HIV has infected lack of realisation of the problem in tive total of 2109 cases of AIDS
3.5 million people in Asia with the society. The reactive responses, have been reported to National
India and Thailand among the therefore, do not match with the
real magnitude and gravity of the AIDS Control Organisation (NACO)
worst affected countries.
problem. Another major challenge from different parts of the country
The HIV/AIDS pandemic has in the context of HIV/AIDS and by the end of December, 1995. Of
posed many unprecedented challen­ sexually transmitted diseases (STD) the 27.68 lakhs samples screened,
ges before the mankind. We are
is their intimate association with the 21,564 have been found to be HIV
confronted with a problem which
issues of sexuality which continue to Antibodies positive. Since the
has no curative or palliative treat­
ment or a preventive or therapeu­ be taboo in our society and not dis­ spread of virus is determined by a
tic vaccine, at least for now. And cussed openly. It has complicated multitude of factors viz. (i) extent
there seems to be no hope for one the process of finding viable solu­ of prevalence of risk behavi­
ours
and
(ii)
socio-economic
in the near future. Further, owing tions to the problem.

October— December, 1995

179

conditions and other socio-cultural nadu). New areas where the pre­
factors, the HIV epidemic in India valence among high risk groups is
reported to be escalating sharply,
has taken a varied course in different
are being identified. Vishakhapatregions.
nam and Tirupati in Andhra Pra­
While in the main cities of some desh, Nagpur in Maharashtra and
states such as Maharashtra. Mani­ Hubli in Karnataka are such new
pur and Tamilnadu, the epidemic is places where HIV prevalence among
already in its advanced phase; in STD clinic attendees has been re­
other States the problem is only in ported to be in the range of 5-20
per cent.
its early stage.

cance of timely action, the strategies
of the government of India for con­
trol of HIV/AIDS have been formu­
lated in line with global strategies
evolved by WHO. The National
AIDS Control Programme (NA
CP)
which
is
in operation
since 1987, has been strength­
ened and consolidated with as­
sistance from the World Bank.
An extensive network of 62 surveil­
lance centres has been established
in different parts of the country to
monitor the trends and extent of
spread of HIV infection in the coun­
try. To ensure supply of safe blood
to every single recipient, 150 Zonal
Blood Testing Centres with stringent
regulatory mechanism, have been
established. HIV testing has been
made mandatory for the
Blood
Banks.

These findings indicate that HIV
According to the available infor­
mation and the latest sentinel sur­ epidemic is spreading fast not only
veillance reports, the major concen­ geographically but also increasing
tration of infection remains in cities numerically among different risk
like Bombay (Maharashtra), Im- groups and from these infected highphal (Manipur) and Madras (Tamil­ risk groups it is finding its way to
nadu). The surveys conducted general population mainly through
among the commercial sex workers the sexual route. A study of the
in Bombay have indicated an alar­ pattern of spread of HIV infection
ming increase in the rate of HIV in the other countries of Africa,
prevalence. In a recent study, the America and Europe, whefe the
prevalence of HIV infection has epidemic is in its advanced stages,
Keeping in view the catalytic role
been found to be as high as 52 per makes it clear that spread of HIV of STDs in the transmission of HIV,
cent among commercial sex wor­ infection in these countries in the the .Government have embarked
kers. In the same city, the preva­ general population was preceded by upon a multi facet approach to deal
lence of HIV among STD clinic steep increase in HIV infection with the problem of STDs. On the
attendees has been reported to be among the high-risk groups. As one hand the existing 372
STD
36 per cent. The alarming feature is discussed earlier, the evolution of clinics are being strengthened in
the HIV prevalence among low-risk the epidemic in various parts of terms of providing good quality spe­
groups such as Ante Natal Clinic India is not uniform. Many States cialised services, on the other a con­
(ANC) attendees found to be as have reported HTV prevalence main­ scientious effort is being made to
high as 2.5 per cent. In Manipur, ly confined to high risk groups. provide non-stigmatizing services at
the sentinel survey carried out among These are the States where preven­ the first level of contact i.e. Primary
the injecting drug users (IDUs) has tive interventions are expected to Health Centres (PHC) by training
confirmed the earlier findings of prove most productive and cost-eff­ the health functionaries in STD syn­
ad hoc surveys. The prevalence of ective.
This necessitates preven­ dromic management. A positive
HIV among this high-risk group tion of furflier spread of HIV health seeking behaviour in respect
is found to be as high as 55 per among high-risk groups and thereby of STDs by way of an intensive
cent. Here also, the prevalence plugging the channel of transmis­ Information, Education & Commu­
figures of around 0.8-1 per cent sion of infection from high-risk nication (EEC) campaign as also
among the low-risk group like pre­ groups to general population.
provision of better services are the
gnant women are alarming. In
hallmarks of current strategy for
Madras, the HIV prevalence among
HIV/AIDS Pandemic and National control of STDs.
pregnant women has been reported
AIDS Control Programme
to be 1.5 per cent; Other known
The most difficult but significant
Realising the gravity of the trends task is to bring about positive be­
hot spots identified so far are Pune
(Maharashtra),
Vasco-de-Gama of spread of the epidemic in certain havioural changes among those who
(Goa), Madurai and Vellore (Tamil­ risk groups and areas and signifi­ indulge in high-risk behaviours. The

180

Swasth Hind

activities under, the programme are
not restricted tQ generation of awa­
reness but also aimed at effecting
changes in the practices which put
the people at risk of acquiring
HIV. In the Indian society where
any discussion on sex and sexuality
is forbidden, this task requires in­
novative approaches and unswerv­
ing commitment. A major concern
has been to have access and initia­
tion of interventions among groups
such as commercial sex workers and
injecting drug users who practice
high-risk behaviour and provide en­
try points for the epidemic to grow.
Since these groups are marginalis­
ed and are therefore difficult to ac­
cess for interventions, the task of
enlisting cooperation from such
groups becomes very difficult if not
impossible. Nevertheless, the success
we have had in our projects at
Sonagachi in Calcutta and Baina in
Vasco-De-Gama is promising. It is
hoped that the results are replicated
in other places.

The Government of India also
realise that the efforts being made
in the direction of containment of
the epidemic will be successful only
when ready support and active parti­
cipation of the community in com­
bating HIV is ensured. To involve
the different sections of the society,
the Government have taken measu­
res which are in various stages of
implementation.
Spectrum of Opportunistic
tions in AIDS

TAB.LE 1

DISTRIBUTION BY AGE AND SEX
Age Group
(Years)

Total

0—14

27

15—29

728

30—45

856

46 and above

50

Total

1661

October—December, 1995

Female

1293

368

TABLE 2

AIDS DEFINITION* (WHO)
Major Signs

♦ Weight loss > 10 % of body weight
♦ Chronic Diarrhoea > 1 month

♦ Prolonged fever > 1 month
(remittent or intermittent)
Minor Signs

♦ Persistent cough for. one menth
♦ Generalized pruritic dermatitis
♦ Recurrent Herpes zoster
♦ Oropharyngeal candidiasis

♦ Chronic, Progressive and disseminated
Herpes simplex
♦ Generalised lyphadenopathy

♦Any two of the Major Signs and one Minor Sign.

ever, necessary precautions which
are required for prevention of infec­
tion in hospitals and workplace, are
judiciously followed in line with the
universally accepted principles in
infec­ this respect.

Clinical management of HIV in­
fection and AIDS is also being ac­
corded importance it deserves. The
patients with clinical manifestations
of HIV/AIDS are provided treat­
ment in hospital settings for the
general public. They are being
treated like any other patient. How-

Male

Clinical manifestations of HIV
disease/AID are many and vary in
different continents. In Americas
and Europe Kaposi’s sarcoma
has been a common feature of AIDS
whereas in Asian region it is not as
prominent. Mycobacterium tuber­
culosis, according to available re­
ports, is the most common oppor­

tunistic
infection in developing
countries. An effort has been made
to ascertain the main clinical mani­
festation of late HIV disease which
are common in AIDS patients in
India. By the end of September,
1995, 2009 cases of AIDS were re­
ported from different States to the
National AIDS Control Organisa­
tion (NACO). One thousand six
hundred sixty one (1661) cases
(Table 1) presenting with opportuni­
stic infection(s) and/or malignancies
confirmed by laboratory investiga­
tions are discussed here. Eight
hundred of these patients were dia-

181

gnosed on the WHO criteria (Table
2) and the rest on the basis of
AIDS Diagnosis criteria adopted
for India (Table 3).
The information available with
NACO indicates that most common
opportunistic infections in HIV in­
fected individuals (Table 4) in India
are Mycobacterium
tuberculosis,
both pulmonary and extra pulmo­
nary (59.24 per cent), and Candida
albicans, oral and oesophageal (54
per cent) followed Cryptosporidium
infection (20.83 per cent).

TABLE 3

AIDS DIAGNOSIS CRITERIA APPROVED FOR INDIA
A. Positive test for HIV infection by two tests based cn preferably two
different antigens.

B. Any one of the following :

1. (a) Weight loss > 10% of body weight or cachexia
(not known to be due to a coalition unrelated to
infection)

HIV

AND
(b) Chronic Diarrhoea > 1 month
(intermittent or constant)
2. Disseminated or miliary or extra-pulmonary tuberculosis
3. Kaposi’s Sarcoma

Other opportunistic infections re­
ported in relation with AIDS viz.,
Cytomegalo virus,
Toxoplasma
gondii, Amoebiasis, Giardiasis and
Strongyloidosis and Herpes zoster
accounted for < 10 per cent of the
reported cases. The least common
was Pneumocystis carinii pneumo­
nia, a common infection and a lea­
ding cause of mortality in HIV in­
fected individuals in Africa, was
reported in 1.56 per cent of the
cases. The small percentage of pati­
ents reporting with these infections
may not be indicative of actual rate
of incidence. It may be due to
under diagnosis. It may also be due
to the reason that the patient pre­
sented with a superimposed infec­
tion and PCP skipped the attention
of the clinician. Their incidence,
however small in number at pre­
sent, indicate that in a few years
from now, as the diagnostic facili­
ties are upgraded, we may be wit­
nessing a rise in their incidence.
Persistent generalised syndrome
(PGL) accounted for 20.46 per cent
of the reported cases. AIDS demen­
tia complex accounted for 6.62
per cent of the cases. Kaposi’s sar­
coma and non-Hodgekin’s lympho­
ma accounted for a miniscule 0.60
per cent of the patients.

4. Neurological impiirmmt preventing daily activities, not known
to b3 due to a condition unrelated to HIV (c. g. trauma)
5. Candidiasis of the oesophagus (Diagnosable with a dysphagia,
odynophagia and oral candidiasis)

TABLE 4
OPPORTUNISTIC INFECTIONS AND MALIGNANCIES REPORTED IN
AIDS IN INDIA

Number of Cases

Percentage

(Pulmonary & extra-pulmonary)

984

59-24

Candida albicans (oral & oesophageal)

897

54-00

Cryptosporidium

346

20-83

Cytomegalovirus

64

3.85

Toxoplasma gondii

70

4-21

Cryptococcal meningitis

42

2-52

Pneumocystis carinii pneumonia (PCP)

26

1-56

Other parasitic infection viz. Amoeba,
Giardisis, Strongyloidosis-

134

8 06

Herpes r zoster

135

8.12

Kaposi’s sarcoma

10

0-60

Non-Hodgkin’s Lymphoma (NHL)

10

0-60

AIDS Dementia Complex

no

Infcction/Maliguancks
Mycobacteruim tuberculosis

6-62

It may be tentatively concluded
Persistent generalised lymphadenopathy (PGL) 340
from the available information that
Total number of cases analysed
1661
the Mycobacterium tuberculosis in­
fection is going to be the most in India and be a serious problem, already burdened resources availacommon infection in AIDS patients for it would significantly drain the ble for health sector.
5
20-46

Swasth Hind

Prevention of HIV Transmission
in Health Care Setting
—Universal Precautions
Q. What is “universal precaution” and why is it im­
portant for the prevention of HIV infection?
“Universal precaution” means that all blood and
body fluids of patients should be considered as infec­
tious and all precautions should be taken, since it is
not known who is infected with HIV. Even the anti­
body tests like ELISA and rapid tests may be nega­
tive and still the person may be infected as he may
be in the “window period”. The most important way
by which HIV transmission can be prevented in the
Health Care setting is by the use of universal blood
and body fluid precautions.

Q. What are the components of “universal precau­
tions”?

The universal precautions starts with
—Hand Washing
—Creating appropriate barrier by use of gloves, masks,
gowns, eye protectors, etc.
—Careful handling of sharp objects.
—Proper sterilization and disinfection
—Disposal of instruments after use/Decontamination
of instruments including syringes, needles and equip­
ments.
—Proper disposal of infected wastes.
Q. Who should take Universal Precautions in Health
Care Settings
As medical officer you must ensure that you and all
level of health care workers should take Universal
precautions with all patients. This would mean Doc­
tors, Nurses, Laboratory* technicians, Multipurpose
workers, traditional birth attendants, laundry workers
and cleaners all be told about the universal precautions
and instructed to follow them strictly.

Q. What are effective cleaning and sterilizing proce­
dures?
This is of paramount importance for health staff direc­
tly involved in invasive procedures that effective infec­
tion control is practised in all situations. Simple mate­
rials like soap and bleach can be effective. Utmost
care should be devoted to personal hygiene:
O Wash hands after contact with the patient. Use
a mild soap when possible.
O Use protective equipment devices (he. gloves,
masks, gowns or aprons, and protective eye wear)
as indicated in specific procedures.
O Handle sharp objects carefully.
O Sterilize and disinfect or dispose of used instru­
ments.

October—December, 1995

Q. How should the instrument be sterilized?
Sterilization
Steam'. Autoclave instruments at a temperature of
121 C, at 15 Ibs/sq inch pressure for 15-20 minutes
in specially modified pressure cooker.
Flame'. Heating with flame until red hot sterilizers
metal instruments such as knives and other skm-piercing instruments.

Q. What are the various methods of Disinfection?
Disinfection can be achieved by:
Boiling'. Completely immerse instruments in water,
boil for 20 minutes. Boiling is sufficient to inactivate
(destroy) HIV, and bacteria, but not for spores pre­
sent in large numbers.
Chemical: Virus causing HIV infection is highly
fragile and easily inactivated by various chemicals
like:
1. Ethanol
70% (dilute accordingly^
2. Glutaraldehyde
2% (available commer­
cially as CIDEX (R) 2 %
solution).
3. Household bleach 1 % solution (Available
in market as 3’5%
ready made solution
POLAR (R) Dilute
with 2*5 volumes of
tap water t0 give 1 %
solution)
4. Formaldehyde
8% (dilute formalin
1.5)
5. Chlorine-sodium
10% solution
6. Isopropyl alcohol 3*5% solution
Q. In what situations universal precautions would
be required?
Universal precautions would be required to be. taken
whenever contact with blood or other body fluids of
any patient is anticipated. These situations could be:
O While giving injections/Immunization
O While collecting blood samples
O While carrying out invasive procedures
O While conducting delivery
O While examining a patient when touching blood
or any other body fluid, mucous membrane or
non-intact skin of patient is anticipated
O While carrying out laboratory work
O While collecting and cleaning soiled linen
O While disposing off infected waste material.

183

Q. What precautions are needed while using gloves?

Precautions to be taken while using gloves are as
follows:
1. Gloves should be worn while:
O Touching blood and body fluids, mucous mem­
branes or non-intact skin of all patients.
O Handling items or surface soiled with blood
or body fluids.
O Collecting blood, inserting intravenous (IV)
line and other surgical procedures.
2. Gloves should be changed after contact with
each patient.
3. After use, rinse the gloved hand with 0.5%
hypochlorite solution.
4. Then rinse your gloved hand with water to re­
move the disinfectant.
5. Wash your hand immediately after removing
the gloves with soap and water.
6. Hang the gloves to dry and test them for holes
before reusing them.
7. Sterilize them by autoclaving or high temp
disinfect by boiling them for 20 minutes.
Q. What precautions to be taken while using syringes
and needles?
Precautions to be taken while using syringes and
needles are as follows:
1. For each: injection or immunization remember
to use sterilised needle and syringe.
2. After use, to avoid needlestick injuries or skin
puncture, disposable needles should not be re­
capped, bent or broken by hand. They should
be collected in a container with bleach solution
and destroyed.
3. Once used, reusable syringes and needles should
be decontaminated by soaking in 0.1% sodium
hypochlorite solution for 20-30 minutes.
4. After this wash and clean them thoroughly.
5. Needles and syringes should be sterilized by
autoclaving, and if an autoclave is not availa­
ble, then in specially modified pressure cooker
at 15 lbs/sq inch pressure at 121 °C tempera­
ture for 15-20 minutes or by boiling in water
for 20 minutes.
Q. Are there any precautions that we should take
even when using disposable needles or syringes?
Yes, precautions to be taken while using disposable
needles and syringes are as follows:
1. Use disposable needles and syringes whenever
available.
2. After use, to avoid needle stick injuries or skin
puncture, needles should not be recapped, bent
or broken by hand.
3. All used needles and syringes should be destroy­
ed by either burying them ot should be inci­
nerated whenever facilities are available.
4. Both, autoclaved re-usable and disposable,
needles and syringes are equally safe.

184

Q. What precautions to be taken while collecting
blood sample?
Precautions while collecting blood samples.
1. Wear gloves while taking blood samples.
2. Use sterilized syringe and needles for drawing
blood.
3. Needles should not be recapped, bent or broken
after use and should be collected in a glass jar
containing disinfectant.
4. Then they should be sterilized.
5. Wash hands with soap and water after blood
collection.
6. Avoid direct contact with blood and body
fluids of patients.

Q. What precautions are necessary while using sharp
and invasive instruments?
1. All health care workers should take precautions
to prevent injuries caused by scalpels or other
sharp instruments or devices during procedures
and after procedures.
2. All reusable instruments should be put in a
disinfectant solutions for 20-30 minutes before
washing.
3. Wash and clean the instruments thoroughly with
plain water.
4. Sterilize all instruments except scissors by auto­
claving for 20 minutes.
or
Boiling the instruments for 20 minutes.
Q. What precautions to be taken by Laboratory
Workers?
1. All laboratory workers should wear gloves,
masks and gowns while handling blood and
other infected specimens.
2. Laboratory technicians must not do mouth
pipetting of blood.
3. Working surface should be covered with nonpenetrative material like glass, stone or synthe­
tic sheet that is easy to clean.
4. Any spill of blood or of body fluid should
immediately be covered with 0.5% hypochlorite
solution for 20 minutes. Then an absorbent
material like cotton or newspaper should be
placed over the spill. Then using gloves, soak­
ed absorbent material can be appropriately dis­
carded and area further wiped with disinfectant.

Q. What precautions to be taken while conducting
deliveries?
All Universal Precautions should be followed strictly
as chance of splashing of blood on body, is there. No
other special precaution is required.
Q. Should only surgical gloves be used?

Surgical gloves should be used for situations requiring
sterility or asepsis. Clean, disinfected gloves can be
used for other situations.
•

Swasth Hind

BOOK REVIEW
School Health Education to
Prevent AIDS and Sexually
Transmitted Diseases
(A Resource Package for Curriculum Planners)
This three-part package of resource materials has
been designed to facilitate the planning of health
education programmes aimed at helping school children
protect themselves against the risks of HIV infection
and sexually transmitted diseases. Addressed to cur­
riculum planners, the package explains how to design
a culturally relevant prevention programme as an
integral part of a school system. To this end, the
manuals draw together a rich variety of examples of
curricula, classroom activities, and learning materials
that can be adapted to local or regional school systems.
Materials are suitable for use with students aged 12—
16 years.

checklists, agendas, criteria for the selection of
teachers and peer leaders, and instruments for pro­
gramme evaluation. The second part presents a series
of fifty-three illustrated proposals for classroom acti­
vities that can help students develop responsible atti­
tudes, say “no” to risky behaviours, recognize and
avoid discrimination, and care for people living with
AIDS. The final Teachers’ Guide offers advice on
how to teach each activity effectively.
School Health Education to Prevent AIDS and Sexually
Transmitted Diseases

A Resource Package for Curriculum Planners

Information ranges from a model agenda for a meet­
ing with parents to advice on how to select peer leaders
and use them effectively, from a list of crucial ques­
tions and answers about HIV and STDs to proposals
for a series of lively classroom activities, role plays, and
demonstrations. Throughout, emphasis is placed on
the acquisition of behavioural skills through the use
of participatory methods of learning.

The first part, on curriculum planning, outlines the
main steps in curriculum planning and offers exten­
sive practical guidance in the form of model letters,

Document issued jointly by the WHO Global Pro­
gramme on AIDS and UNESCO
1995, 275 pages (available in English; French in
preparation)

WHO/UNESCO/GPA/94, 1/2/3
Sw. fr. 18.—/US § 16.20
In developing countries; Sw. fr. 12.60
Order no. 1930061

Authors of the month
Dr Devi Saran Sharma
Dr K. D. Gautam and
Dr S. C. Gupta

Krishna Institute of
Medical Sciences
P.O. KARAD-415124

2 Gopal Kunj
Bagh Muzaffar Khan
AGRA-282002

Dr A. M. Mehendale

Assoc. Professor of
Community Medicine
M. G. Institute of Medical Sciences
Sevagram.
WARDHA-442102

Dr Ruchika Kuba

E-22 South Ex tn. Pt-I
New Delhi-110049
Dr (Miss) V. Patfl
Dr (Mrs) Y. R. Kadam
Dr (Miss) S. N. Shinde

C/o Deptt of PSM

R. K. Bansal

Dr (Mrs) Inderjit Singh

and

Assoc. Professor
Deptt. of Foods & Nutrition
College of Home Science
PAU. LUDHIANA (Pb.)

Asset. Professor
P. S. Medical College
Karamsad-388325
GUJARAT
Brig. (Dr) N. L. Sachdeva (Retd.)

Prof. & Head
Deptt. of PSM
Pravara Rural Institute of
Medical Sciences & Research
LONI (BK)-413736
Ahmednagar, Maharashtra

ISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES) KOTLA MARG

NEW DELHI - 110002

AND

PRINTED BY THE MANAGER, GOVERNMENT

OF

INDIA PRESS.

. *• \

o’4''

rniunATnor <41 mo
- I'MB A TOR E - 641 019

>

/

SWASTH HIND

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

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