MEDICAL SERVICE VOL. 41 No. 7 AUGUST-1984.pdf

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role of the ministry of healing—a perspective • respiratory tract infection
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medical
service

official house journal
of the catholic
hospital association of India

"the love of Christ
urges us" 2 cor 5 :14

vol 41

no 7

editorial board

august 1984

contents

dr c m francis
dr ravi narayan
dr prem chandran john
dr daleep mukarji

mr augustin veliyath
fr george lobo sj
prof george Joseph
dr paul neelamkavil

fr edwin mj

1

editorial

2

2

role of the ministry of healing—a perspective
dr george Joseph

5

respiratory tract infection in children
k n shah

11

people, pills and prescriptions-!II :
prescriptions as they should be
mira shiva

21

legal education—10 :
do you know your fundamental rights—part-1
p d mathew

25

chai news and notes

33

3

4
editor
fr john vattamattom svd

5

cover design

6

p m isaac bangalore

published by the catholic
hospital association of indie
c b c i centre, goldakkhana
new delhi-110001

printed at kalpana printing
house new delhi-110016

"Articles and statements published in this journal
do not necessarily reflect the policies and views of
the catholic hospital association of india"

Guest EDITORIAL
A new philosophy, a new name

It is indeed gratifying that the recently held readership survey has
helped to reveal the useful role that the journal plays, particularly for those
directly or indirectly involved in the ministry of healing. To us, more than

anything else, it serves the unique purpose of unification of goals, ideals
and values among our institutions.

This assumes greater significance in

today's context as there is a marked shift in values seen all round us. There
is an increasing tendency for commercialisation of the health institution and
the health profession itself to a large extent.
In the context of changing concepts of health care and the norms per­
taining to it, the relevance of a rethinking on the role of our existing institu­
tions assumes special significance. The emphasis today is on 'health for
all'. This should no more remain a sublime goal or a pious wish, but has

to be translated into a reality as expeditiously as possible.

The health

profession and the agencies that are concerned with the welfare, dignity
and development of man face no greater challenge than this, today. The
net work of our institutions bound by traditions of yester-years are called
upon to play a new role and act as agents of change realigning their own

priorities. They should have a more meaningful role in the context of our
pledge to make primary health care a reality, in an all our effort to see that

the message of health reaches every home.
Our journal should subserve this interest and should serve as a power­

ful instrument to assist in this process of transformation. It is in this context
that the suggestion made by some of our esteemed readers that the title of
the journal require a change needs consideration. It is indeed heartening
that a good majority of the alternatives in the title suggested goes in con­

formity with the emerging philosophy on health which have been referred

to.

To cite a few examples :
'Our Healing Ministry'

'Health Care'
'Help to Health'
'The Healing Touch'

'Health and Development'

While we fully appreciate their views and share their concern, we do
feel that it is more important that the contents of the journal should be in
tune with this new orientation, to justify and change in name.
guard against serving old wine in a new bottle.

We have to

Earnest attempts are being made to bring about qualitative changes in
the contents befitting our overall goals. Although rarely resorted to, change

of

certainly is permissible within journalistic traditions.

title

ushers in a policy change or portends one.

It either

We would certainly give due

weightage to the candid suggestions made by our learned readers when the

question of a change of title of the journal is taken up.

Letter from a patient

Dated today

To
Doctor/Nurse
Your hospital

Your town

Dear Doctor/Nurse,
This is the most critical stage of my life, and I am at your mercy.

whole body is paining.
attention.

I need care.

I need affection.

My

I need personal

Will you deprive me of these and consider me a specimen for

your practice ?

My family is starving at home.

My purse is empty.

I am embarrassed

and frightented to step in to your nursing home and subject myself for tests

by your imported equipments.

Also I am afraid how far I can afford the

medicines you prescribe. Last time I was told by you to take nutritious food.
I listened to you carefully and I decided to follow your instructions
strictly.

Would you pardon me ?;

I could not take any of them at least

once.

Dear doctor/nurse, how can I find solution to the illness I have been
suffering from all through the years ?

I remain, disturbed and totally confused.

Sincerely,
Your Patient

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Medical Service

Role of the Ministry of Healing—A Perspective
—Dr. George Joseph

During the past few decades, nations of
the world particularly those that have won
political freedom and are free to guide the
destinies of their people are engaged in an
all out effort to improve the quality of life of
people by pursuing strategies of development
akin to their ideologies. The socio-political
upheavel, meant to liberate man from all that
'cabins, cribes and confines him' has led to
increase his longing and aspiration for a
better life. Technological break-throughs
and speedy advances in the Communication
media have had their inevitable contribution
to make.
In India, during the post-independence
era major efforts were made to provide basic
health care to its people particularly those
spread over the 6,00,000 villages. The entire
rural India was divided into Community
Development Blocks accommodating, appro­
ximately, 100 villages per Block for integrat­
ed development and a primary health centre
allocated to each of them for providing inte­
grated health services. We have today over
5,400 PHCs engaged.in this effort. In spite
of the substantial investments made, the
health status of our people today is far from
satisfactory. No doubt, we have made im­
pressive achievements in many crucial areas
particularly in the areas of control of commu­
nicable and pestilential diseases and Family
Welfare Planning. The sheer magnitude of
the task that still remain is so great that one
almost despairs of meeting our health needs
or realising our aspirations on the basis of
the broad models of health care, we seemed
to have accepted. *An alternate strategy of
development of health care services was
* Report of the Group on Medical education
1975.

August 1984

therefore evolved which marked a major
departure, based on the following principles.

— A universal and egalitarian programme
of efficient and effective health ser­
vices cannot be developed against the
background of a socio-economic
structure in which largest masses of
people still live below the poverty
line. Therefore there should be sus­
tained and vigorous attack on the
problem of mass poverty and for crea­
tion of a more egalitarian society.
— Development essentially means the
development of man and not of things:
Emphasis should be on the develop­
ment of human rather than the material
resources. The most significant tools
for the purpose are education and
health. Taken together they form the
most powerful instruments for the
development of man and human re­
sources.

— Adoption of the model of health ser­
vices from the industrially advanced
and consumption oriented societies of
the west has inherent fallacies. Health
gets wrongly defined in terms of
consumption of specific goods and
services, basic values in life which
essentially determine its quality gets
distorted; over-professionalisation in­
creases costs and ultimately has an
adverse effect even on the health and
happiness of people. We have to take
a conscious and deliberate decision to
abandon this model and strive to

and support man power—Government of India, April

5

create instead, a viable and economic
alternative suited to our conditions—
the new model will have to place
greater emphasis on human effort
rather than on monetary inputs.
— Health is essentially an individual
responsibility in the sense that, if the
individual cannot be trained to take
proper care of his health, no Commu­
nity or State programme of health
services can keep him healthy. The
issue is basically one of education.

— The community has the great respon­
sibility in the sense that, if the indivi­
dual cannot be trained to take proper
care of his health, no Community or
State programme of health services
can keep him healthy. The issue is
basically one of education.

— The community has the great respon­
sibility to provide a proper environment
for helping each individual to be
health—supply of safe water—ade­
quate measures for disposal of human
excreta and the like. These social
aspects of health need strengthening
and the highest emphasis.
— The over emphasis on the provision of
health services through professional
staff under state control has been
counter productive. It devalues and
destroys the old tradition of part-time
semi-professional workers which the
community used to train and throw up
and which with certain modification
will have to continue to provide the

fou ndation for the development of a
national programme of development in
our country. We have to have large
bands of semi-professional workers
from among the community who
would be close to the people live with
them and provide medical services.
This bold Indian experiment roused the
attention of planners and administrators all
over the world. In fact, there was great
concern expressed by the International
Community of experts who came forward to
assist the third world countries in evolving a
health care strategy to match the health
needs of communities particularly, those who
have long been denied the benefits of even
elementary health care. The Alma-ata decla­
ration (1978) by the WHO has emerged out
of this concern. The concept of Primary
Health Care
*
gives a positive direction to
planners and administrators in this regard
and even provides operational guidelines.
Government of India came out with the
National Health Policy in 1982, which by and
large is dictated by the emerging world
opinion about the need to evolve a health
care strategy to match the needs. The task
that we are addressing ourselves today is
the building up of a multi-tier health establ­
ishment that has its very roots in the rural
homes. Administratively, the peripheral most
unit is the village level family health and
welfare centre and whence the services
trickle down further through the agency of
the village volunteers who help carry the
message of health to the rural homes. The
peripheral units are backed by a referral
system that provides for the upward and

* Primary Health Care is essential health care made universally accessible to individuals and families
in the community by means acceptable to them and at a cost that the community and country, can
afford. World Health Organisation, Primary Health Care, WHO, Geneva, 1978.

Medical Service

downward flow of services. The PHC's the
Taluk and District hospitals and the institu­
tions that make provision for specially and
super speciality services at the apex, are all
linked together in a bid to provide regionalised health care services, each link in the
chain, meant to provide clinical care at a
given level of expertise.

Admittedly, the building up of a health
care hierarchy of such magnitude need
stupendous efforts and
resources. The
growing importance of the voluntary sector
in supplementing the national efforts is at
once obvious. It is against this background
that ’ one has to look at the present day
activities of our institutions under the Minis­
try of Healing. How do they conform to the
goals as laid down by the national health
policy ? The foremost task ahead of the
Ministry today is to assist in this effort to
bring primary health care within the effective
reach of people. The present day health
care institutions under the church namely our
hospitals—are required to provide the leader­
ship in operationalising the programme of
extending primary health care to communi­
ties. With the courage of conviction, let me
state that the church and its Healing Ministry
has hitherto faced no greater challenge at
any time.
It may be recalled that our hospitals, re­
present pioneering efforts on the part of
dedicated medical missionaries mostly from
abroad to provide the much needed medical
relief and succour to large segments of
humanity at a time when health efforts by
governmental agencies in the various states
were barely rudimentary. Suffice to say that
our institutions had a decisive and historic
role to play as forerunners of the present day
health establishments in the different states,
particularly in terms of quality, content and
coverage of health care.

August 1984

We have today as per information avail­
able from the Synod Secretarial, 69 hospitals
*
and 111 out-reach clinics in the 4 regions of
the Synod. Now let us come'to the crucial
question about the role of our institutions
under the Healing Ministry as an extended
activity of the church. Time has come when
one has to critically look at their present day
activities and style of functioning and their
relevance in today's national context—more
than that, their role as an extended activity
of the church. Do we need to sustain and
perpetuate them purely for historical reasons
or do we envisage a new role for them as
powerful 'agents of change' in the context of
development?
I have attempted in the presentation so
far to highlight the scope and relevance of
not only continuing the activities of our hos­
pitals but also the great role they are expect
ed to play in the context of the present-day
national efforts to implement primary health
care. What is needed today is to bring about
a different orientation in our thinking to en­
able us in our future planning. Can we not
offer leadership at this crucial phase? This
calls for, among other things, a realignment
of our priorities.

Representatives of 21 dioceses have met
and discussed the futuristic role of the exist­
ing institutions and have reached a consen­
sus that the greatest challenge that faces us
today is to assist in the national endeavour
of extending primary health care to the rural
population.
Plans have been drawn to
develop models of health delivery systems
suitable in the various social and cultural con­
texts. The general pattern that has emerged
is to bring under the purview of the existing
rural hospitals the responsibilities of extend­
ing basic health services to communities in
their catchment areas. The operational
mechanism suggested is the development of
satellite centres manned by basic health

7

workers. The activities of the satellite centres
will be supplemented by the activities of the
village level workers selected and trained by
the local health team. With this the role and
style ot functioning of the hospitals will be
greatly altered. They will no longer wait for
patients to come to them but reach out to
the periphery, identify the needs and assume
responsibility of supervising the health of
people in the rural homes.

suitable to the needs of people, relevant and
feasible in the social context, under the aegis
of the existing institutions namely, the rural
hospital. In the 21 dioceses the needs vary
vastly. There are dioceses where even sembolance of a health system does not exist.
We are called upon to extend care to those
who are denied these all their lives, imbued
with a spirit of dedication and upholding
Christian ideals.

Adoption of this new role to foster the
development of health of communities marks
a major departure from the traditional one.
The success of such an attempt will depend
on the dedicated endeavour of the health
team. Development of health man power,
therefore, is almost a pre-requisite to the
success of such programmes. Our dioceses
are concerned about this need for developing
appropriate health man power. The existing
training institutions which hitherto were res­
ponsible for turning out personnel for institu­
tionalised services have now to employ their
training resources for preparing the required
man power representing competence at
different levels. Dioceses where such facili­
ties do not exist will have to develop training
capabilities or utilise available facilities of
sister dioceses preferably of the same socio­
cultural background. This pooling and shar­
ing of resources should become an accepted
norm between institutions within the dioce­
ses or between dioceses not only confined
to this area of training but even to the service
programmes.

The concept of primary health care, is in
essence inspired by the loftiest Christian
ideals which our Lord Himself demonstrated
during his earthly life and mission, namely
'reaching out' for the lowliest and lost. Let
me refer to one such instance, the healing of
the impotent man at the pool of Bethesda
who bore his infirmity for 38 years, most of
which probably he spent at the pool of
Bethesda next to the sheep gate. He passes
before us nameless and seen as one among
the crowd, John's description of that crowd
is graphic. He says that in the porches lay
a multitude of sick, blind, halt, withered.
Here, we see a company of the unfit, the
derelict, the outcaste, all probably waiting,
desiring a cure. Christ that day chose to go
that way to meet the impotent man. It is
said, that it is not his usual way to go to
Jerusalem. Going out to meet the people in
need is therefore our Christian goal, carrying
the message of love and hope. Our job then
is to develop a model of health care in a
given context so that others can emulate that
example. It is the job of lighting a lamp and
keeping it on a pedestal.

Responsibility of evolving/developing
'models'

Apart from the prime task of assisting in
the process of extending primary health care
especially among the socio-economically dis­
advantaged groups, there are some other
vital issues that deserve consideration of the
Healing Ministry as a matter of policy.

I for one, an convinced and I am sure
there are many here who share the same
conviction that the task ahead of us today is
to evolve and develop 'models' be it in rela­
tion to health, education or development.
Can we help evolve models of health care
8

— identification of newly emerging com­
munity health problems brought about

Medical Service

by rapid changes that are occuring
both in the demographic and socio
economic seenes and evolving models
of care feasible within the frame of
reference of the church and the heal­
ing ministry.

bilitation as part of the total health responsi­
bility to the community. Planning of such a
programme would, inter alia, include the
training of the required personnel for under­
taking comprehensive
rehabilitation pro­
gramme at the regional centres.

For example the care of the aging and the
aged. The problem is vast and complex with
serious social implications. However the
gravity of the problem has not been appreci­
ated even today. It is timely and opportune
for the ministry of healing to evolve feasible
models of care relevant in the given social
context.

— Comprehensive health programmes for
the control of diseases like leprosy,
tuberculosis.

— evolving patterns of care for vulnerable
groups in our society as part of health
related social welfare programmes.
For example day care centres, creches,
nurseries for children of working women.
This is visualised as part of comprehen­
sive family welfare scheme especially
among labour populations such as planta­
tion workers, fishermen in the coastal
areas, agricultural labourers, tribal popula­
tion etc., where women go for work
ordinarily or can seek gainful employment
at least during seasons.

— Health and welfare programme for the
disabled.

This should be viewed as a very challeng­
ing task ahead of the church and the ministry
of healing. A comprehensive programme
should include not only assessment of the
nature and the extent of the problem in a
given area. Say, under the jurisdiction of
the local churches and the comunities direct­
ly under its influence, put also the identifi­
cation of local 'resources, training of local
leadership as well as local volunteers who
could help in a comprehensive rehabilitation
programme. The ministry should visualise
service for the disabled including their reha­
August 1984

Activities of the ministry of healing should
lay continued emphasis on programmes for
the control of diseases like, leprosy, tuber­
culosis especially those which have a social
dimension. However, one has to strike a note
of caution in that such efforts should fit into
the national strategies for the control or era­
dication of such diseases. Any such pro­
gramme should make adequate provision for
the rehabilitation of the individual as well as
the family.
Quality
church

of

care-challenge

before the

I shall confine myself to two aspects of
this question which are of immediate rele­
vance to our ministry.
Here, quality, refers to 'acceptable'
standards of care—and even so, is very diffi­
cult to define, as it is highly variable accord­
ing to the context in which it is used. There
is a growing tendency among the lay public as
well as the profession to always equate equa
lity with enhanced cost of services. Services
given at a low cost are branded as 'second
quality' and substandard. This has serious
implications in the field of health services. It
even helps to demoralise the personnel who
provides such services. Let us accept that
'quality of care' refers to what is best for the
person, and is feasible to be administered in
a given context and which is scientifically
sound. A family health worker who advises
a village mother, to compound a home

9

remedy to rehydrate her child ailing from
vomiting and diarrhoea, from the commonest
of household provisions readily available to
her (salt and sugar) is practising high quality
scientific medicine. In fact she is practising
better scientific medicine than the private
practitioner who prescribes a combination of
antibiotics and other drugs with brand names,
—the bane of over-professionalisation and
high technology.

The second aspect is of equal if not
greater relevance to our ministry.
It is a common experience that in our
quest to provide quality of care of our
patients, to make our institutional services
acceptable to public at large, we often tend
to lose sight of our Christian calling and
ideals. Let me illustrate : for e.g.—the service
we extend to our patients in the general
ward and the non-paying ones—the apparent
discrimination shown in the quality of care.
Often resource contraints are blamed. It is
a common experience that we deny even
basic amenities to these persons. We try to
save on ceiling fans and even mattresses and
pillows on the plea that these are luxuries to
which these people are not accustomed to.
In such matters there can be only one
standard to be set as a' guide before us—
namely, what would Christ want us to do?
Thus as a matter of very great concern. I
often feel that if Jesus Christ were to seek
admission in one of our hospitals, of nece­
ssity, will have to be a general ward patient
and that too, a non-paying one. if he
happens to walk in alone into a casualty
department, exhausted after a long day's toil,
with bruises on his feet due to the long walk
through the rugged country side, what would
be the type of welcome we extend to him?
Of course, he wouldn't have enough to pay
the caution deposit or even to buy the O.P.

10

card. We know the instance when he didn't
have enough to pay the temple tax. I am
afraid, as per rules of the establishment he
will be sent to a dingy ward.

Now, let us look at the resource—impli­
cations. If we consider the general ward
patients especially the non-paying ones as
our guests of honour, guests of the church
and of the diocese, these problems can easily
be resolved. Then it becomes incumbent on
the church and the parishioners to welcome
them, to treat them, to feed them and take
care of them demonstrating the tender loving
care of Christ and meet the cost thereof.

Mother Teresa has said that she tries to
see the face of infant Jesus in every child
picked from the street, from under the
garbage or from the gutters. We in the
ministry have to be guided by nothing less
than this standard of Christian service. The
responsibility should be basically that of the
whole church as it should serve as a living
example. to demonstrate Christian love in
action. This, then is the present day challenge
before our institutional ministry and let us
look forward to an era of dedicated endeav­
our on the part of our institutions to reach
out to even the remotest needy villages in
our dioceses with the message of 'health'
inspired by the Love of Christ and to be
qualified to receive his commendation on the
final day of judgement 'Come and posses the
kingdom which has been prepared for you
ever since the creation of the world. I was
hungry and you fed me, thirsty and you gave
me a drink, I was a stranger and you received
me in your homes, naked and you clothed
me; I was sick and you took .care of me, in
prison and you visited me. Whenever you
did this for one of the least important of
these brothers of mine, you did it for me.'

Medical Service

Respiratory Tract Infection in Children
—K.N. Shah

General Considerations

Respiratory tract infections are extremely
common in paediatric practice. They may
occur at any age but are more common in
infacy carrying high mortality and morbidity.
This is because of poor resistance in younger
age group and anatomical and physiological
variations of infancy. It can involve any
part of the respiratory tract but upper respir­
atory infections are more common than
lower respiratory tract. Many different
organisms can infect respiratory tract but
viruses are the commonest invaders. They
may be acute or chronic. Chronic infections
are commonly due to resistant bacteria,
fungus, parasites etc. They are more com­
mon in lower socio-economic group carrying
high mortality and morbidity because of poor
nutrition, poor hygiene, over-crowding, lack
of medical facilities etc. In this article, only
non-tuberculous infections will be conside­
red.
Classifications

Two classifications are in common use :

Anatomical

Respiratory tract is divided into upper and
lower respiratory tract. Upper respiratory tract
includes nose (rhinitis), ears (otitis), sinuses
(sinusitis) and pharynx (pharyngitis). Lower
respiratory tract includes epiglottis (epiglot­
tits), larynx (laryngitis), trachea (tracheitis),
bronchi (bronchitis), alveoli (alveolitis) and
pleura (empyema). This classification is not
ideal because it is common for any organism
to involve more than one anatomical part
or even the whole respiratory tract and
the diagnosis is made from the part that is
August 1984

macimally involved e.g. pneumonia althou­
gh there is associated pharyngitis, rhinitis
etc.

Aetiological
Many agents e.g. bacterial, viral, fungal,
spirochetal, mycoplasma, parasitic etc. can
affect the respiratory tract in the same way.
Since it is difficult to identify the exact
pathogen in majority *of cases because of
poor laboratory facilities and inaccessibility
of the anatomical part involved, this classi­
fication is obviously not ideal.

Although none of the classifications is
satisfactory but because of lack of better
one, combination of both is commonly used
e.g. acute viral bronchiolitis, chronic staphy­
lococcal pneumonia etc.
Aetiological Classification

Most acute respiratory tract infections are
caused by viruses and mycoplasma. Influenza
type A and B cause upper rather than lower
respiratory tract infections. Adenoviruses
type 1, 2, 3, 5, and 7 account for 10% of
respiratory tract infections. Rhinoviruses
and coronarviruses mainly involve the nose
causing "common cold'
*
syndromes. Coxsa
ckie A and B commonly cause nasopharyn­
geal infections. Parafluenza viruses types
1, 2, 3 and 4 account for the majority of
cases of the croup syndrome but may also
produce bronchitis, bronchiolitis and upper
respiratory tract infections’ Respiratory
syncytial virus is the principal cause of bron­
chiolitis and may also be a cause of pneu­
monia, croup and bronchitis. Other viruses
e.g. measles, german measles, chicken pox
etc. may be associated with varying amounts
11

of upper and lower respiratory tract infec­
tions as part of a general clinical picture
invilving other organ systems.

invaders. Diphtheria organisms are also
primary invaders but less common because
of immunization.

Bacterial infections primarily involving
respiratory tract are not as common as viral
infection. Acute epiglottitis is commonly
due to H. influenzas. Pneumonias are comm­
only due to gram positive and gram nega­
tive organisms. Pharyngitis and tonsillitis
may be caused by streptococci or diphtheria
organisms. Whooping cough bacilli involve
upper as well as lower respiratory tract.

Clinically actue pharyngotonsiliitis is
characterized by fever, malaise, headache,
loss of appetite, sore throat, mild to severe
redness and exudation, nodular or ulcera­
tive lesions of the soft palate, tonsils and
pharyngeal wall. Cervical lymphadenopathy
may be present. Illness last from one to
seven days. Differentiation between viral
and bacterial pharyngitis is extremely diffi­
cult on clinical grounds.

Upper Respiratory Tract Infections

Rhinitis

Acute rhinitis is always viral in aetio­
logy. It is characterized by fever, sneezing,
running of nose etc. and
may involve
other parts of respiratory tract. After couple
of days, secondary bacterial infections may
occur giving rise to thick purulent discharge.
Allergic rhinitis also presents with sneezing,
running of nose, courgh etc. and is difficult
to differentiate from viral rhinitis on clinical
examinations. Since acute rhinitis is of viral
origin and a self limiting condition, only
symptomatic treatment with antipyretics is
necessary. Antibiotics are indicated when
there is secondary bacterial infection.

Pharyngotonsiilitis
Acute pharyhgotonsillitis is one of the
most common illnesses of childhood.
Because of infections of mass of lymphoid
tissue encircling the nasal and oral pharynx
known as Waldeyer's ring, 80% of infections
are viral e g. coxsackie, influenza, parain­
fluenza and respiratory syncytial adenoviru­
ses and Epstein-Barr virus of infectious
mononucleosis. The commonest bacterial
infection is due to group A beta haemolytic
streptococci while H. Influenza, pneu­
mococci and staphylococci are secondary
12

W.B.C. count, throat swabs for micros­
copy and culture for diphtheria and strepto­
coccal organisms and blood for rising anti­
body titre for various viruses, are some of
the useful investigations. Other .conditions
e.g. infectious mononucleosis, herpangina,
leukaemia, agranulocytosis may give similar
clinical picture.
Complications due to viral pharygitis are
rare. In case of streptococcal pharyngitis,
local abscess or spread to retropharyngeal
space, sinuses, middle ear, mastoid, menin­
ges and mesentric glands can occur. Rhenumatic fever and acute glomerulonephritis are
late complications.
Treatment is symptomatic for viral phary­
ngitis e.g. bed rest, extra fludis, antipyretics
and analgesics, warm saline gargles, etc.
For streptococcal infections, penicillin either
oral or parenteral, or erythromycim, if penici­
llin is contraindicated, for 10 days is adequ­
ate and will prevent rheumatic fever and
acute glomerulonephritis.

Chronic Pharyngitis and Tonsillitis

These are characterized by recurrent
cough, sore throat, fever, cervical adenitis,
middle ear infections, mouth breathing and
adenoid facies as a result of adnoid enlarge­
Medical Service

ment and foul breath may be present. Retro­
pharyngeal and peritonsillar abscess may
develop. Fatigue, loss of appetite, less of
weight, arthralgia, postnasal drip etc. are
other symptoms. Allergic pharyngitis is
difficult to differentiate from infective pharyn­
gitis. A careful history and follow up of the
cases are useful in such cases.

Treatment is adenotonsillectomy after
considering carefully its indications and
contra-indications.
Retropharyngeal Abscess
Potential space between the posterior
pharyngeal wall and prevertebral fascia con­
tains several small lymph glands which may
be infected secondarily .to upper respiratory
tract infection and suppurate. It may occur
from vetebral osteomyelitis. Staphylococcus
aureus and group A haemolytic streptococci
are common pathogens.
Clinically acute nasopharyngitis is follo­
wed by high fever, difficulty in swallowing,
refusal to feed, severed distress with throat
pain, hyper extension of head, torticollis,
laboured respiration and accumulation of
secretions in the mouth. A bulge in the
pharyngeal wall is usually seen. A digital
examination may reveal fluctuation. Lateral
view of nasopharynx will reveal retropharyn­
geal mass on X-ray. In differential diagnosis
meningitis because of neck retraction, various
causes of torticollis, T.B. spine etc. should
be considered.

Treatment
Treatment is surgical with extensive
course of proper antibiotics against staph,
aureus or streptococci e.g. injection penicill­
in in doses of 1,00,000 units/kg./day in 3-4
doses or erythromycin 50 mg./kg./day in 3-4
divided doses for 7-10 days, infections, of

August 1984

sinuses and ears are beyond the scope of
this article.
Lower Respiratory Tract Infections

Group (Epiglottitis, Laryngitis; Laryngotrac­
heitis, L a ryngotra cheobronchitis)
Croup is a syndrome characterized by
inspiratory stridor, peculiar brassy cough,
hoarseness and respiratory distress due to
varying degree of laryngeal obstruction.
The obstruction in infectious croup is due to
inflammatory oedema and spasm. It includes
acute epiglottitis, acute laryngitis, acute
laryngotracheitis, and acute laryngotracheobronchitis and spasmodic laryngitis.

Acute Epiglottitis

it is a severe life threatening, rapidly
progressive infection of
* the epiglottitis and
surrounding areas. Commonest aetiological
organism is type B, H. influenza. Onset is
abrupt, preceded by upper respiratory tract
infection in some cases. Child is usually
between 2 and 12 years of age. . Child is
normal when he goes to bed but awakens in
the middle of the night with high fever,
hoarseness, cough, stridor and respiratory
distress. Course is very rapid leading to
shock-like state characterized by pallor,
cyanosis and impaired consciousness, coma
and death. On examination there is marked
respiratory distress with inspiratory stridor'
flaring of alae nasi, and retraction of supras­
ternal notch, supraclavicular and intercostal
spaces. The pharynx is inflamed. Cherry
red, swollen epiglottis can be seen when the
tongue is depressed. Swollen epiglottis can
also be seen on lateral X-ray of upper air­
way. Acute epiglottitis is a real paediatric
emergency and death can occur within few
hours on onset. There is striking polymor­
phonuclear leucocytosis and throat and blood
cultures are positive for H. influenza type B.

13

Acute Laryngitis, Acute Laryngotracheitis
and Acute Laryngotracheobronchitis

They will be discussed together as they
have common viral aetiology e.g. parain­
fluenza viruses, adenoviruses, influenza
viruses, enteroviruses, respiratory syncytial
viruses and measle viruses.
Viral croup usually occurs between 6
months and 3 years. There is preceding
upper respiratory infection, consisting of
rhinorrhoea, coryza, fever etc. After few
hours to 3 days child develops typical croup
syndrome. Children are anxious and rest­
less but never so toxic as in acute epiglotti­
tis. Signs of bronchitis and bronchiolitis like
rales and rhonchi with marked respiratory
distress and expiratory stridor and diminis­
hed breath sounds are common in acute
laryngotracheobronchitis. Temperature may
be normal or very high, chest X-ray may be
normal or emphysematous. Illness may last
for few days.

Spasmodic Croup
Children between one and three years
are often affected. Clinically it resembles
acute laryngotracheobronchitis but there is no
evidence of viral infection in family members.
It occurs commonly in anxious and excitable
children and hence allergic and psychologic
factors should also be considered. Onset is
sudden at night with brassy cough and respi­
ratory distress with minimal coryza on the
previous day. There is usually no fever.
Illness lasts for few hours and the child is
normal the next day. Similar attacks are
repeated with less severity for another night
or two with eventual complete recovery.

Differential Diagnosis of Croup Syndrome

Diphtheritic laryngitis should be ruled
out by smear and culture of the throat and
laryngeal swab. Croup of measles is ruled
out by other signs and symptoms of measles.
Foreign body, retropharyngeal abscess.
14

extrinsic compression by masses angioneu­
rotic oedema, endotracheal intubation, tet­
any, trauma to the lower respiratory tract etc.
can give rise to croup and should be kept
in mind while analysing a case of croup
syndrome.

Prognosis
It depends upon the type, severity of
croup, age of the child, duration of illness
and extent of respiratory tract involvement.
Mortality of epiglottitis is 10 to 15% while
prognosis is excellent in other types of
croup.
Treatment
Mild cases of croup may not need admis­
sion but those in respiratory distress should
be admitted. As children are anxious and
restless, minimum handling should be done.
High humidity and O2 are most important.
Humidity is maintained by giving steam
inhalation and moist O2 should be adminis­
tered in high concentration
preferably
in a tent. Mild sedative if carefully given
helps the anxious children. I.V. fluids are
very useful because it prevents dehydration
and liquefies the respiratory secretions.
Syrup ipecacuanha has been recommended
by some authorities to treat the laryngeal
spasms. Corticosterioids reduce the inflam­
mation and improve airway obstruction but
has no effect on the duration of illness.

In acute epiglottitis due to H. influenza,
amplicillin in doses of 200 mg./kg./day i.v.
ii*i 4 divided doses with chloramphenicol
in doses of 50 to 100 mg./kg./day i.v. in
divided doses are very useful. In proved or
suspected cases of diphtheria ADS plus ery­
thromycin should be administered.
If there is no improvement, then intuba­
tion and tracheostomy may be necessary.
Acute Bronchitis
Acute bronchitis may not exist as a
separate entity in children. It is usually

Medical Service

associated with tracheitis and infection of
other parts of respiratory tract. Aetiological agents are mainly viral as mentioned
previously with other conditions but trachei­
tis may be commonly seen with such speci­
fic infections like influenza, whooping
cough, salmonella, diphtheria, scarlet fever,
measles etc. Allergy, poor health, climate,
air pollution and chronic infection of upper
respiratory tract may be predisposing factors
for repeated attacks of bronchitis.
Clinically acute bronchitis follows upper
respiratory tract infection. It starts with
hacking dry cough after 3-4 days of acute
nasopharyngitis. Anterior chest pain is
frequently present and may be aggravated
by coughing. Within several days the cough
becomes productive and sputum becomes
purulent. After a week or two, sputum
becomes thin and child is alright. On clinical
examination throat is congested and there
are rales and rhonchi with mild ' respiratory
distress. In healthy children no complica­
tions occur but' in malnourished children,
child may get otitis, pneumonitis etc.

Differential Diagnosis
Acute bronchitis should be differentiated
from asthmatic bronchitis which is a form of
asthma. Such children show exaggerated
response of bronchi to various respiratory
tract infections, with exudates and spasms,
as in bronchial asthma.
Treatment
There is no specific treatment for bronchi­
tis as it is of viral aetiology. Symptomatic
line of treatment for cough e.g. atmosphere
with high humidity may help, antihistaminies,
expectorants and antibiotics are not useful,
unless secondary bacterial
infection is
present.
Chronic Bronchitis

Chronic bronchitis as an isolated entity is
doubtfull. With repeated attacks of acute

August 1984

bronchitis, anomalies of respiratory tract,
foreign body, bronchiectasis; immune defici?
ency, T.B., allergy, sinusitis, tonsillitis and
cysticfibrosis should be ruled out.
Acute Bronchiolitis

It is a common disease of lower respira­
tory tract in infacy. It occurs during the
first two years of life with a peak incidence
at 6 months of age. The incidence is highest
during the monsoon and may occur sporadi­
cally or in epidemics. Aetiologic agents are
always virus and in majority of cases, respira­
tory syncytial virus is thecause. Parainfluenza
type 3 virus, mycoplasma and adenoviruses
are other causative agents. Usually minor
respiratory tract infection is present in other
family members.

Clinically, it starts with mild upper res­
piratory tract infection followed within few
days by respiratory distress, paroxysmal
wheezy cough, irritability, continuous crying,
extension of neck and difficulty in taking
feeds. Usually fever is mild or absent, in­
fant is very apprehensive and restless. On
examination, there are rales, rhonchi, dimini­
shed air entry, expiratory wheeze, marked
tachypnoea, other signs of respiratory
distress and severe air hunger. Liver and
spleen are pushed down due to severe
emphysema.

Chest X-ray shows emphysema with
scattered small patches due to small atelecta­
sis secondary to obstruction of bronchioles.
W.B.C. count is within normal limits. Naso­
pharyngeal culture will grow the causative
virus. Frequent serum levels of rising anti­
body titres are also useful.

Differential Diagnosis

Bronchial asthma is usually considered
but it is uncommon below the age of one

15

year. Family history of asthma, repeated
attacks in the same patient, eosinophilia and
dramatic response to bronchodilators may
suggest asthma. Excessive crying and exten­
sion of neck may mimick meningitis.
Course and Prognosis

Infant is very ill for 3-4 days and then
slowly improves over a period of few days.
Mortality is less than one per cent and
occurs due to respiratory failure, associated
congenital heart disease, respiratory acidosis,
profound dehydration due to tachypnoea etc.

Treatment
All cases of acute bronchiolitis with res­
piratory distress should be hospitalized. As
it is of viral aetiology, treatment is sympto­
matic. Humid atmosphere and moist 02 are
very useful to relieve hypoxaemia, allay
anxiety, restlessness and relieves dyspnoea
and cyanosis. Sedatives should be avoided.
V. fluids are useful in preventing dehydra­
I.
tion due to tachypnoea and liquefy the
secretions in respiratory tract. Soda-bi-carb
is useful in respiratory acidosis. Antibiotics
are not useful because of viral aetiology of
the disease. Corticosteroids have also not
been found to be useful. Bronchodilators
are, in fact, contra-indicated since they
increase restlessness, O2 requirement and
cardia output. Tracheostomy is also of
doubtful value since obstruction is at the
level of bronchioles.
Pneumonia

Pneumonias are classified into two types:

Anatomical

16

a.

Lobar pneumonia

b.

Lobulan pneumonia

c.

Bronchopneumonia

d.

Interstitial pneumonia

Aetiological

a.

Bacterial—gram positive and gram
negative such as pneumococcal, stre­
ptococcal, Staphylococcal, H. influen­
za, klebsiella, pseudomonas.

b.

Viral or probable viral infections, e.g.
respiratory syncytial virus, parain­
fluenza, ademo, entero, rhino in­
fluenza, herpes simplex.

c.

Other infections—e.g. pneumocystis
carinii, Q fever, mycoplasma pneumo­
niae, actinomycosis.

d.

Mycotic infections—e.g. candidiasis,
cryptococcosis-.

Clinical Signs and Symptoms
Clinical pattern varies in infants and older
children. In infants after an initial period
mild upper respiratory infection, there is
abrupt onset of high fever, restlessness and
respiratory distress. Patient appears ill with
air hunger, cyanosis, grunting, signs of
respiratory distress; cough may be mild.
Clinically there may not be any sings of
pneumonia but for few rales. Gastric disten­
sion is common and may develop into
paralytic ileus. Meningism may be present.
Apnoic spells are common in young infants.

In older children, signs and symptoms
are those found in adults. After a brief mild
upper respiratory infection there is high fever
with rigors, respiratory distress, restlessness,
a dry hacking cough and sometimes delirium.
Pain in chest may be severe. Initially there
is dullness with diminished air entry followed
by bronchial breathing and increased vocal
fremitus. As resolution occurs, moist rales
appear with the disappearance of signs of
consolidation.
In bronchopneumonia, apart from scatter­
ed rales all over, no other findings are present
on auscultation.

Medical Service

It is very difficult to diagnose the aetio­
logy of pneumonia from clinical examination.
Polymorphonuclear leucocytosis rpay suggest
bacterial aetiology. Leucopenia may suggest
viral aetiology or fulminating bacterial pneu­
monia. Blood cultures are sometimes positive
in bacterial pneumonias. Positive throat
cultures cannot be considered a proof of
bacterial pneumonia.

Prognosis
It depends on the age, nutrition of the
child, type of pneumonia and the aetiological
organism. It is poor in infancy, in malnouri­
shed children, in bronchopneumonia and in
staphylococcal and gram negative bacterial
pneumonias.
Treatment

Chest X-ray only helps in anatomical
classification of pneumonias. Pleural fluid
smear and culture or lung aspiration through
needle may help in finding the aetiological
diagnosis.
Some Important Differentiating Points •
1.

Pneumococcal
and
streptococcal
pneumonias occur in older as group.

2.

Staphylococcal
pneumonia occurs
commonly below one year of age, is
rapidly progressive and carries high
mortality and morbidity. It has a
tendency to progress to empyema,
multiple cysts, lung abscess,, pneu­
mothorax etc.

3.

Pneumonia due to gram negative
bacteria are common in immunodefi­
ciency syndrome or in those who
receive antibiotics, prednisolone etc.
for a long time.

4.

Bronchopneumonia is common in
infant while lobar pneumonia is
common in older age group.

5.

Viral pneumonias on chest X-ray show
diffuse infiltration especially in perihilar regions. Effusion is rare.

6.

Tuberculous pneumonias have insiduous onset. Other evidence of Koch's
g. positive mantoux test and gastric
e.
lavage may be there.

AugUst 1984

General line of treatment includes good
nursing care, i.v. fluids, O2, antipyretics and
sedatives.

Special treatment depends on the aetiolo­
gical organism. There are no specific drugs
for viral infection. For pneumococcal pneu­
monias penicillin in doses of 50,000 units/
kg./24 hrs. either orally or i.v. or cephalos­
porin in cases allergic to penicillin in doses of
50 mg./kg./24 hours, either i.v. or orally for
7 to 10 days. In mild cases oral and in
severe cases parenteral administration is
preferred. For streptococcal pneumonia peni­
cillin in the drug of choice. For staphyloco­
ccal pneumonia penicillin G in doses of
100,000 units, kg./24 hours is used if orga­
nisms are not resistant. Otherwise, semi­
synthetic penicillinase resistant penicillin like
methicillin in doses of 200 mg./kg./24 hours
or cloxacillin doses of 150 mg./kg./24 hours
or cephalosporin in doses of 50 mg./kg./24
hours parenterally is very useful. Sometimes
trimethoprim sulpha in doses of 6-10 mg./
kg./day in two doses and erythromycin 50
mg./kg./day in three to four doses have been
found to be useful. For empyema and pneu­
mothorax, drainage with a thick tube is very
useful. For H. influenza, chloramphenicol in
doses of 100 mg./kg./24 hours or ampicillin
doses of 200 mg./kg./day i.v. should be tried.
For klebsiela, kanamycim in doses of 15 to 20
mg./kg./day i.m. or gentamicin in doses of 6
to 8 mg./kg./day i.m. should be administered.
For pseudomonas carbenicillin in doses of

17

400 mg./kg./day or gentamicin or amikacin
should be tried.
Suppurative Diseases of Lung

Empyema
Empyema means collection of pus in
pleural cavity. Infection of pleura occurs
from adjacent pulmonary and subdiaphragmatic foci by contagious spread or via bron­
chopleural fistula or from a distant focus by
haematogenous spread. Common organisms
are staph, aureus, H. influenza, streptococci,
pneumococci while E. coli, klebsiella and
pseudomonas are rare organisms.

Clinically patient is very toxic with high
swinging fever with rigors and on examina­
tion there is stony dullness, diminished air
entry and mediastinal shift on the opposite
side. There is marked polymorphonuclear
leucocytosis. Chest X-ray shows effusion on
the effected side. T.B. pleural effusion is
difficult to differentiate clinically in empyema
and diagnostic tapping should be done which
shows plenty of polymorphs, and culture
shows the causative organism unless the
antibiotics are administered previously.

tuberculosis foreign body, lymph nodes press­
ing on the bronchus, chronic lung infections,
lung abscess, cysts, bronchial
asthma,
immune deficiency syndromes with recurrent
chest infections and chronic sinusitis are well
known precursors.
Clinically cough is always present and
produces copious mucopurulent discharge
during acute infections. It is severe in the
morning. Coarse, buddly rales are present.
Fever is present in the acute stage. Clubbing
of nails is present in chronic cases. Recurrent
respiratory tract infections are very common.
Haemoptysis may be mild or severe. It
follows intermittently improving and relaps­
ing course. Blood count may show anaemia
with polymorphonuclear leucocytosis, sputum
for smear and culture may show infective
organisms, plain chest X-ray may show
honeycombing or collapse, consolidation and
bronchoscopy and bronchograpy are diag­
nostic.

Treatment

Specific treatment depends on the aetiological agent and should be continued for 4
to 6 weeks. Intercostal tube drainage is a
must.

Treatment is to administer antibiotics for 7
to 10 days during acute stage depending
upon the causative agent, and prophylactic
antibiotics for few weeks. Ampicillin and
tetracyclines can be given for a long time in
older children. Postural drainage is very
helpful. Surgery is only advised when medi­
cal treatment fails.

Bronchiectasis

Lung Abscess

Bronchiectasis refers to dilatation of
bronchi due to inflmmatory destruction of
bronchial and peribronchail tissue. It is usu­
ally the result of chronic pulmonary infection.
It may be congenital either due to an arrest
of bronchial development or associated with
dextrocardia and sinusitis (Kartagener synd­
rome). In majority of cases it is acquired
after birth. Measles, pertussis, pneumonia,

Lung abscess is a suppurative process
resulting in destruction of pulmonary paren­
chyma with formation of a cavity containing
purulent material. It commonly results from
aspiration of infected material and occurs
commonly in the most dependent parts of
the lung e.g. posterior segments of the upper
lobes and the apical segments of the lower
lobes. Common organisms are bacteroids.

18

Medical Service

fusobacterium, anaerobic streptococci, staph,
aureus, klebsiella. Amoebic abscess is rare
in children.
Clinically the onset is insidious with fever,
malaise, anorexia and weight loss. Foul
smelling sputum is characteristic in untreated
cases. Haemoptysis is not uncommon, onset
may be acute in staph, aureus and klebsiella.
Spiking fever, toxic look, respiratory distress,
chest pain etc. are common. On examination
dullness and diminished air entry are present.
Polymorphonuclear leucocytdsis common and
chest X-ray typically shows thick walled

cavity with., or without fluid level with
surrounding infiltration sputum may be posi­
tive on smear and culture examination.

Treatment
For anaerobic bacteria penicillins in doses
of 1,00,000 units/kg./24 hours for 4 to 6
weeks is the drug of choice. In penicillin
resistant strains chloramphenicol is useful.
Metronidazole i.v. has been found to be quite
useful. Abscess takes several weeks to dis­
appear on chest X-ray. Surgical drainage is
rarely necessary.

—(Courtesy : The Bombay Hospital Journal)

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With little scope for misuse

(8)

Easily administered

(See article on Rational Drug Ther­
apy-Drug Issue-April-June 1982HfM). Therapeutic Guidelines, Upanda, J. Yudkin, G Brown, AMREF.)

Rational Therapeutics is based on :

(c)
(a)

As accurate a diagnosis as possible
under the constraints of diagnostic
facilities and supportive staff and
costs. (Relative contributions of his­
tory taking, physical examination and
lab investigation to diagnosis and
management of medical outpatients,
B.M.J. 2, 486-89).

(In 83% new hospital outpatients the
final diagnosis was reached on history
and referring doctor's note. Only 5%
diagnosis was reached after investi­
gations).

Hamptom, J.R., Harrison, MJG„
Mitchell, JRA, Pritchard, J.S. and
Seymore C. (1975).
(b)

Appropriate use of Drugs
Drugs available should be :
(1)

Effective

(2)

Safe

(3)

Economical

(4)

Essential

(5)

Easily available

(6)

Effective Communication
patient about usage of drugs

to

the

Various studies have shown that bet­
ween to 10% 9% patients with an
average of 50% do not take prescri­
bed treatment, they forget or reject
their doctor's advice. (Ref. Psycho­
logical studies of doctor-patient
communication in contributions to
medical psychology Ed Rachmann,
Oxford Pergamon Press, Page 9-42).
Dr. George J Caranasos et al in the
Journal of the American Medical
Association (JAMA) talking about
lack of communication between Doc­
tor and patient says :
"Patients also cannot identify correctly
60% of their medicines. Forty percent
of patients receive drugs prescribed by 2
or more physicians, increasing the possi­
bility of drug interactions. Twelve per­
cent of patients take drugs prescribed for
someone else and 60% of the patients
consider their drugs completely safe".

Coranasons, George J et al. Drug Induced
Illness Reading to Hospitalization, JAMA,
228-713-717, 1974.

Dr. Hulka an epidemiologist at the Univer­
Acceptable (culturally and soci­ sity of North Carolina and others revealed
ally to the patients)
that 58% of the total number of patients

August 1984

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studied made mistakes in the way they took
their medication—they took either too much,
not enough or at the wrong tim e.
* In our Indian context, effective communi­
cation with illiterate, often ignorant patients,
for whom what we consider superstitions is
a reality, requires special skill and on this
depends whether the drug will be taken
— at the times suggested
— in correct amounts
— in a correct way

Eg. Lifting of price restriction category III
drugs by the Govt, in return of dissolving of
the foreign equity shares by certain multi­
national from 70% to 40% and having their
demand met. Finding more and more unes­
sential but profitable drugs flooding the
market is but a natural outcome. (For cate­
gorise of Drugs and Drug Price Control Order
see Drug Situation in India).

Another example is the enability of the
Govt, to ban the 23 irrational combination
drugs which the Drug Consultative Com­
mittee recommended for withdrawal, because
of vested interest (list available with VHAI).

— for the correct duration and that the
patient would be above to report
back any serious adverse reaction and
not consider it worsening of the dis­
ease or consider the diagnosis to be
wrong.

Most of our rural patients who are used
to home remedies, traditional systems of
medicine—western medicine is alien even
though it is often associated with the "awe"
and "mystery" accorded to white man's
medicine. The dangers of these medicines
and the importance of taking it properly is
often underestimated. In this social context
our responsibility as effective communicators
and educators obviously increases. The need
to shoulder and appropriately delegate some
of these responsibilities to other trained staff
is very pivotal in rational drug therapy.
What Encourages Drug Misuse ?
1. Drug Policies which allow; hazard­
ous and irrational drugs to flood the market;
which allow their heavy promotion and crea­
tion of false needs are very much to blame.
Even concerned Health Personnel have so far
never felt the need to express their opinion
in all this. The power of the drug industry
is obvious from some of the following
examples :

22

The drug companies getting a stay order:

— on Govt, decision to allow sales of 5
single ingredient drugs only under
generic names
— on Govt.'s decision to ban high dose
estrogen-progesterone combinations
involved in the hormonal pregnancy
test scandal (the tests are officially
banned since (1976).
The fact that Bangladesh heavily dependent
on foreign drug imports but could manage to
ban 1707 hazardous and irrational drugs,
maker our indifference and apathy all the
more pathetic.
2.

Number of Drugs

There are 30,000 drugs in the market.
Hath Commission recommends 116 essenti­
al drugs while WHO recommends about 200
essential drugs to deal with 90% of the pro­
blems in most hospitals. Studies based on
information recall showed that it was not
possible to remember important information
of more than 100 drugs—this being the
highest estimate. Most of us can remember
much less.

A survey of 92 hospitals conducted by a
Church Agency indicated that 25 drugs were
Medical Service

3 Questions
? Wkal good does
Inis drug do

or more. Less than 5% of drugs in the
WHO's Essential Drugs List are combination
drugs. In combination drugs many of the
most important ingredients are in sub-thera­
peutic doses or the combinations are totally
irrational and nonsensical.

APRESCMMION porvcw

? Wfiat harm can
Inis drug do

V./AITE OUT you

*PROBLEMS
SUGGESTIONS etc
ON

? Can lliis patient
afford it
adequate to take care of most' of the pro­
blems according to WHO working group on
Rational Drug Therapy.
What are the Deciding Factors Guiding
the Choice of the Drugs that we Pre­

AMD

DRUG ISSUES

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Many times it's not the principles of
rational drug therapy, but the subtle influence
of the drug representatives and their biased
medical literature. When confronted with
too many diverse unfamiliar drugs, with each
drug being sold under 50 to 200 different
names—confusion and misuse is the expected
end result.
3. Combination Drugs
Kinds of diugs with expected misuse
potential are Combination Drugs. 60-70%
of the brand products in the market are not
single ingredient drugs but combinations of
August 1984

— the cost of combination drugs is any
day more than cost of single ingredient
drugs.
— what is probably worst is the potential
for adverse reactions it is known that
changes of drug interactions increase
with the increase in number of drugs
prescribed. The chances of drug
interaction increases by 40% when 6
or more drugs are prescribed. The fact
that 2 or 3 combination drugs may
easily contain 6 or more known or un­
known ingredients is often over looked.
23

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LEGAL EDUCATION—10

Do You Know Your Fundamental Rights
(Part I)
— P.D. Mathew

Your Fundamental Rights

Which are Your Fundamental Rights

1.

The Constitution of India, Part III, guaran­
tees Fundamental Rights to the citizens.
These rights represent the basic values cheri­
shed by the people of this country since
Vedic times and they are meant to protect
the dignity of the individual and create
conditions in which human beings can
develop their personality to the fullest extent.
Without these rights the citizens, moral and
spiritual life will remain stunted and they will
not be able to develop their potentialities.

2.

Right to Freedom (Articles 19&358)

3.

Protection Aganist
Conviction
(Article 20)

4.

Protection of Life
and Personal
(Article 21)
Liberty

5.

Protection Against
Arrest and
(Article 22)
Detention
Right Against
(Articles 23-24)
Exploitation

6.
These rights are wide ranging and compre­
hensive and they fall under six heads, namely,
right to equality, right to freedom, right
against exploitation, right to freedom of
raligion, cultural and educational rights and
right to Constitutional remedies.
These are not privileges or favours but
basic rights to which every citizen is entitled.
However, since they are not absolute or
unlimited, their exercise can be reasonably
restricted by the State on various grounds.

The purpose of this leaflet on Fundamen­
tal Rights is to raise the legal consciousness
of citizens with regard to their rights so that
they may exercise them responsibly and
prevent government authorities and others
from encroaching on them, and in case of
their violation, find redress through legal
remedies provided in the Constitution.
August 1984

(Articles 14-18)

Right to Equality

7.

Right to Freedom (Articles 25-28)
of Religius

8.

Cultural and
Educational
Rights

9.

Right to Constitutional Remedies (Articles 32-33
and 359)
I.

(Articles 29-30)

Right to equality

(Articles 14-18)
Under these Articles the Constitution
guarantees the following rights.
1.

Equality before the law

This means the absence of any special
privilege in favour of any individual and the
equal subjection of all classes of citizens to
25

the ordinary law. In other words it means,
that there shall not be any discrimination
before the law on the basis of rank, office
etc.

2.

Equal Protection of the Law

It implies equal treatment in similar
circumstances both in the privileges conferred
and in the liabilities imposed between one
person and another if, as regards the subject
matter of legislation, their position is the
same.

Scheduled Castes, Scheduled Tribes etc. Thus
the provisions of maternity relief for women
workers (Art. 42) free education for children
(Art. 45) or measures for prevention of their
exploitation, [Art.39(f)] reservation of seats
for Backwaid Classes of citizens and special
provisions for their advancement, do not
violate Article 15.

4. Equality of opportunity in matters of
public employment (Art. 16)
* This Article guarantees :

This principle does not take away from
the State the power of classifying persons
on the basis of their legitimate needs. Thus
the State can make special law for the bene­
fits or protection of Scheduled Castes,
Scheduled Tribes etc. Differential treatment
to this class of citizens does not violate
Article 14 which guarantees equal protection
only when there is no resonable basis for
such differentiation.

3. Prohibition of discrimination on grounds
of religion, race, caste, sex or place of birth
(Art. 15)

Equal opportunities for all citizens in
matters of employment and appointment
to any government office [Art. 16 (1)].
* No discrimination be made on grounds
only of religion, race, caste, sex,
descent, place of birth, residece or
any of them in respect of any
employment or office under the State
[Art. 16(2)].
Exceptions

* The State has power to reserve posts
in favour of Backward Classes of
citizens if they are not adequately
represented in Government services.
[Art. 16 (4)].

The State cannot discriminate against
any citizen on grounds only of religion, race,
caste, sex, place of birth or any of them.
Under this right the State has guaranteed to
all citizens adult suffrage(Art. 326) equality
in employment, equal eligibility for the office
of President, membership of Parliament etc.
It also gives every citizen right of access to
and use of institutions, places, roads, wells,
restaurants, hotels, etc., maintained by State
funds intended for the use of general public.
The Article does not authorise any citizen
to use somebody else's private property like
wells or roads or swimming pools etc. At
the same time Article 15 (3) and (4) gives
power to the State to make any special laws
for the benefits of women and children.

26

* Offices connected with religious or
denominational institutions, are to be
reserved for members of any particular
religious or denomination [Art. 16(5)]

♦ Parliament has right to prescribe any
requirement regarding resdience in a
State in respect of any particular class
or classes of employment in that State
[Art. 16(3)].

5.

Abolition of Untouchability (Art. 17)

This Article declares :
Medical Service

i.

Untouchability is abolished and its
practice in any form is forbidden and

ii.

if a person tries to *enforce Untou­
*
chability
in any form, he will be
guilty of an offence, punishable in
accordance with Law.

Note

The word' untouchability
*
is not defined in
the Constitution but it is meant to denote
different practices in different parts of India,
as developed through the ages.
The Parliament passed the 'Untouchability
*
(Offences) Act in 1955 which was amended
in 1976. It is now known as the Protection
of Civil Rights Act 1955. This Act prescribes
punishments for various types of 'Untoucha­
bility' offences.
6.

Abolition of Titles (Article 18)

This article prohibits : (i) the State from
conferring titles on citizens except military
or academic distinctions, (ii) citizens from
accepting titles from foreign States, (iii) non­
citizens who hold any office of profit or
trust under the State from accepting any title
from any foreign State without the consent
of the President.

1.

Freedom of Speech and Expression

2.

Freedom of Assembly

3.

Freedom to Form Associations or Unions

4.

Freedom to move
India

5.

Freedom to Reside and Settle in any part
of India.

6.

Freedom to Practise any Profession

Freely Throughout

Note

There are the liberties of every citizen. They
are not absolute as they are qualified and
may be limited by the State, e.g., my right
to move anywhere does not enable me to
enter any premises I like.
The restrictions
imposed on these liberties are supposed to
be for the public good. Let us now look at
the restrictions that the State can impose on
these rights.

1.

Freedom of Speech and Expression

The right to. freedom of speech and
expression of citizens is subject to the power
of the State to make any laws impossing
reasonable restrictions in the interest of :

i.

Security of the State,

Note

II.

Soverignty and integrity of India,

Titles are abolished as they tend to
create unnecessary distinctions among the
people, and such distinctions would not be
in line with the ideal of social, economic and
political justice. What Article 18 prohibits
is the conferment of titles and not of awards.
Hence we have such awards as Bharat
Ratna, Padma Shri etc.

ili.

Friendly relations with foreign States,

vi.

Public order,

v.

Decency, and

vi.

Morality.

II.

Right to Freedom

The right to freedom guaranteed under Arti­
cle 19 can be classified the following six
heads :
August 1984

The State can also make reasonable
restrictions on 'freedom of speech and
*
expression
in relation to contempt of Court,
defamation and incitement of offence.

* Two conditions have to be satisfied if
a restriction is to be held Constitutional :
27

, a.
b.

3.

it must be reasonable,
the restrictions must relate to one
of the matters mentioned above.

* Whether a restriction is reasonable or
not can be decided only by the Courts.

* restrictions could include
also,

Our Constitution gives all citizens the
right to form associations or unions. But the
State has power to make resonable restric­
tions on this right in the interst of

prohibition

* freedom of the press falls within 'Free­
dom of speech and expression' and is
therefore available to the same extent.

4.

2.

Freedom of Assembly [Art. 19(1)
(3)]

&

♦ It includes :
a.

right to assemble peacefully and
without arms,

b

right to hold meetings, and

c.

right to take out processions.

* These rights are guaranteed subject to
three limitations, namely :
a.

the assembly must be peaceful,

b.

its members must be unarmed, and

c.

the State may impose reasonable
restrictions in the interest of pubic
order, or the sovereignty or integrity
of India.

* The State can declare an assembly of 5
or more persons unlawful when it
intends to achieve any of the following
by means of criminal force;

28

a.

to overpower the government.

b.

to overpower any public servant in
the exercise.of his lawful powers.

c.

to take possession of any property.

d.

to deprive any person of the enjoy­
ment of his incorporal rights.

Freedom to form Associations [Art. 19
(1) (c) &19 (4)]

i.

Sovereignty and integrity of India,

ii.

Public order, and

iii.

Morality.

Freedom to move freely throughuot India
[Art. 19(1) (d) & (5)]

Every citizen has a right to move freely in
any part of the Indian territory. But the
State can impose restrictions on this right
for the following reasons :

5.

i.

In the interst of the general pubic, and

ii.

For the protection of the interest of
any Sheduled Tribes.

Freedom to reside and settle in any part
of India [Art. 19 (5) a (1)]

on this right also the State can put reaso­
nable restrictions on the basis of the interest
of the general public and the protection of
the interest of any Scheduled Tribes.
6.

Freedom to practise any profession
[Art. 19 (1) (g) a(6)]

Under this, every citizen has the freedom
to practise any profession or to carry on any
occupation, trade or business of his choice.
Note

* In the interest of the public welfare, the
State can place restrictions on this
right.
* The Article does not guarantee a mono­
poly to any individual or association to
carry on any occupation,

Medical Service

* Carrying on of any trade, business,
industry or service by the State would
not be questionable on the ground that
it is an infringement of the rights
guaranteed by Art. 19 (1) (g)

. * The State may (a) impose reasonable
restrictions of profession in the interest
of the general public : (b) prescribe the
professional or technical qualifications
necessary for carrying on any occupa­
tion, trade, bussiness : (c) carry on any
trade, bussiness or industry or service,
by itself or through a corporation,
owned or controlled by the State to
the exclusion of private citizens. [Art.19
(6)]

iv.

A person accused of any offence
cannot be compelled to be a witness
« against himself [Art. 20 (3)]

Note

* There is no punishment within the me­
aning of Art. 20 (2) unless it is pre­
ceded by prosecution of a criminal
nature.
* Art. 20 (3) grants the privilege against
self-incrimination.

* The expression "to be a witness'1 is not
limited to the evidence given in court,
but also covers testimony previously
obtained by force from the' accused.

Can freedom guaranteed under Art. 19

be suspended ?

Article 358 provides that during the Pro­
clamation of Emergency, the State including
legislative and executive authorities, will be
free from the restrictions imposed by Art. 19.
In other words during the period of Emergency
the provisions of Art. 19 are liable to be
suspended.
Protection in respect of conviction
for offences (Art. 20)

III.

This Article guarantees that:
i.

A person must not be convicted of
any offence except for the violation
of law in force at the time of the
commission of the act;

ii.

A person -must not be subjected to a
penalty greater than that which might
have been inflicted under the law in
force at the time of the commission
of the offence [Art. 20 (1)]

iii.

A person cannot be prosecuted and
punished for the same offence more
than once [Art. 20 (2)]

August 1984

* The protection of Art. 20 (3) also ex­
tends to the documentary evidence
obtained by force from the accused.
IV.

Protection of life and personal
liberty (Art. 21)

The Article states :
* No person shall be deprived of his life
or personal liberty, except according to
procedure established by law.

* This Article restraints the Executive from
proceeding against the life of personal
liberty of the individual except under
the authority of law made by the State.

* When a person is deprived of his life or
personal liberty in accordance with a
law prescribing a procedure for the
same, Art. 21 is not violated. It is for
this reason that the confinement of an
under—trial prisoner or the arrest and
detention of a person by the police
under the code of Criminal Procedure is
considered legal.
29

Note

* This Article confers on the citizen the
Fundamental Right to life and liberty,
the most cherished and prized posses­
sion in a civilised society.
* It requires that no one shall be deprived
of his life or personal liberty, except by
procedure established by law and this
procedure must be reasonable, fair and
just and not arbitrary.
♦ It is for the Court to decide by the
exercise of its power of judicial review,
whether the deprivation of life or per­
sonal liberty in a given case is by pro­
cedure which is reasonable, fair and
just or otherwise.
V. Protection against arrest and
detention in certain cases (Art. 22)

Under Ordinary Law

1.

When a person is arrested, under the
ordinary law of the land he must be
informed soon after arrested of the
grounds of his arrest, and

2.

An arrested person must be given the
opportunity to consult a lawyer of his
choice and to be defended by him
[(Art. 22) (1)]

3.

4.

injurious to the security and safety of State
or the interest of the public.
* Clauses (4) to (7) of Art. 22 impose
certain limitations upon the power of
the Union and the State Legislatures to
make any law providing for detention
without trial.
* Ordinarily a person cannot be detained
for more than 2 months unless the
detention is approved by an Advisory
Board.
* A state law cannot authorise deten­
tion beyoned the maximum period pres­
cribed by Parliament under the powers
given to it under Art. 22.

* Parliament may by law prescribe the
circumstances or type of cases in which
a person can be detained beyond 2
months without the consent of the
Advisory Board.

* A person detained under a preventive
detention law has right to obtain in­
formation about the reasons of the
detention and to make a representation
protesting against the order of deten­
tion.
Powers of the Courts

An arrested person must be produced
before a Magistrate within 24 hours
of his arrest (excluding the time re­
quired for bringing him to the Magis­
trate).

i.

The Court can examine the Constitu­
tional validity of the law on preven­
tive detention

ii.

No person can be detained in custody
beyond 24 hours without the auth­
ority of the Magistrate. [Art, 22 (2)]

It may also examine the grounds of
detention to- see whether they are
relevant to the order.

iii.

It can interfere with the order if it is
mala fide.

iv.

The Court may inquire about the
grounds conveyed to the detainee to
see if they are sufficient to enable

Preventive detention [Act. 22 (4) to (7)]

Its main object is to prevent a person from
committing an illegal act which is likely to be

30

Medical Service

him to make an effective represent­
ation.
Vi. Rights Against Exploitation
(Art. 25-28)

These Articles prohibit

a.

Any form of forced labour, and

b.

Children below 14 working in facto­
ries or mines or in any other hazar­
dous employment.

But the State can impose compulsory
service for public purposes without making
discrimination on anyone on grounds only of
religion, race, or caste or class etc.
VII.

Right to freedom of religion
(Art. 25-28)

1. Freedom of conscience and free profes­
sion of religion
India is a Secular State. Equal rights are
therefore given to all citizens in respect of
freedom of conscience and religion. Art. 25
(1) provides that

i.

all persons are equally entitled to
freedom of conscience and,

ii.

ail have the right to freely profess,
practise
and
propagate
religion
subject to public order, morality and
health.

* But the State has power to make laws:
(1) to regulate or restrict any economic,
financial, political or other secular acti­
vity which may be associated with
religious practice; (2) to provide for
social welfare and reform; or (3) to
permit all classes and sections of
Hindus to enter into Hindu religious
institutions of a public character.

* The wearing and carrying of kirpans is
included in the profession of Sikh
religion.

August 1984

* References to Hindus, includes persons
professing the Sikh, Jain or Buddhist
religion.

2. Freedom to
(Art. 26)

manage religious affairs

Subject to public order, morality and
health, every religious demoination or any
section has the right:

a.

to establish and maintain institutions
for religious and charitable purposes;

b.

to manage its own affairs in matters
of religion;

c.

to own and acquire movable and im­
movable property, and to administer
the property in accordance with law.

3. Freedom as to payment of taxes for pro­
motion of any particular religion (Art. 26).
This Article secures that the public funds
raised by taxes shall not be utilised for the
benefit of any particular religion or religious
denomination Suppose the State imposes
tax for the promotion of say Hindu religion,
it would be quite lawful for a person to refuse
to pay such tax.

4. Freedom as to attendance at religious
instructions (Art. 28)
* Religious instruction is forbidden in
educational institutions wholly main­
tained by State funds.
* Institutions which are maintained or
aided by the State cannot compel any­
one to attend religious worship con­
ducted in these institutions.
for further informations in legal matters
contact:

Director, Legal Aid
Indian Social Institute
Lodhi Road, New Delhi 110003
Tel : 622379 624760
Gram : INSOCIN

31

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NOTES

Thirty-Seventh World Health Assembly
Over 1,000 delegates, including 114
Ministers of Health and 26 DirectorsGeneral of Health attended the Thirty-seventh
World Health Assembly which completed its
session in Geneva on 17 May.
Meeting under the Presidency of Profes­
sor Guillermo Soberon Acevedo, Secretary
of Health and Social Welfare of Mexico, the
Assembly heard the Director-General of the
World
Health Organisation, Dr. Halfdan
Mahler, appeal to all industrialized countries
to demonstrate absolute solidarity with the
developing countries.

By far the most substantial debate was
devoted by the Assembly to the global
strategy of Health for All and country reports
on monitoring progress in its implementa­
tion. It was the first evaluation exercise since
the strategy was launched, in 1981.

"If there were any doubts about the
wisdom of starting such an open monitoring
and evaluation process, I think there should
be none now. You have called your own bluff
without fear, and have clarified the extent of
the dramatic gap between the health situa­
tion to which we all aspire and the situation
which actually exists in most countries",
said Dr. Mahler. But he warned that "the
prospects for the less developed countries
are not at all bright, unless they are able to
take dramatic action and unless the inter­
national community is able and willing to
take equally dramatic action".
The World Health Assembly urged all
Member States to speed the reorientation
and the modifications of health systmes

August

1984

towards primary health care and to give the
highest priority and assure full responsi­
bility for the continuing monitoring and
evaluation of their strategies.
The following are some of the highlights
of the Assembly :
Action Programme on Essential Drugs

The Assembly urged Member States to
intensify action to implement national drug
policies and strategies with WHO support.
Many delegations reported activities which
reflect the commitment of Member States
to the lines of action recommended at
previous Assemblies and indicate that the
WHO Action programme on Essential Drugs
and Vaccines is rapidly accelerating and
unstoppable.
The Assembly also called for the dissemi­
nation of unbiased and complete information
on drugs and an exchange of information
between Member States on drug use and
marketing practices.

It requested the Director-General t to
arrange a meeting in 1985 of experts repre­
senting the parties concerned—including
governments, the pharmaceutical industry,
and patients and consumers, organizations-"
to discuss the means and methods to ensure
rational use of drugs . . . and the role of
marketing practices in this respect, especially
in developing countries.".
Prevention of Blindness due to Vitamin
A Deficiency

Some 10 million children are affected by
vitamin A deficiency and xerophthalmia in
33

Asia alone and more than a million become
blind every year. The disease is also preva­
lent in Africa, the Western Pacific and
limited areas of the Americas. Safe effective
and cheap techniques exist to control
Vitamin A deficiency. The Assembly therefore
urged all Member States to give high priority
to the prevention and control of Vitamin A
deficiency and xerophthalmia wherever these
problems exist, through appropriate nutritio­
nal programmes, as part of primary health
care.

very few persons are prepared to do any­
thing about it in the matter of rehabilitation
and giving the blind an equal opportunity to
do any kind of work. The worst calamity to
befall a person to have eyes and fail to see.

The National Association for the blind
(Haryana state Branch) functioning in Faridabad since 1980, gives education, train­
ing, shelter, employment, services to the
blind by organising sheltered Recanning
workshop, Telephone Operators Training,
Cassettes recorded Library & Placement etc.

Importance of Technical Cooperation

The Assembly reaffirmed the importance
of technical cooperation among developing
countries and called upon developed coun­
tries to continue to provide technical coope­
ration and financial resources, particularly
to the least development countries.
Abuse of Narcotics and Psychotrophic
Substances

The Assembly, recognizing the dramatic
increase in drug addiction, all the more
alarming in that the young are the chief
victims of narcotics dependence, noted with
satisfaction the development of the WHO
programme on drug dependence, and reques­
ted the Director-General to strengthen
epidemiological surveillance systems.
Infant and Young Child Nutrition

Recogning that the implementation of the
International Code of Marketing of Breast­
milk Substitutes is an important action to
protect healthy infant and young child feed­
ing, the Assembly requested WHO to
intensify collaboration with Member States
in their efforts to implement and monitor
the Code.

'An Appeal'
All over the World a lot of misconceived
sympathy is extended to the blind but a
34

Unemployment problem among blind
community is one of the human courages.
There are about 150 blind persons registered
with us for Peons, Musicians, Teachers,
Packres, Press operators. Chippers, Duplcator
operators and Waterman etc.
In this respective we appeal to your
goodself lend your support in this humani­
tarian endeavour.
—Francis Xavier
Placement Officer.
National Association for the Blind
1C/99, N.l.T Faridabad (HS)

During our convention held at Ranchi in
1981 we had resolved that our institutions
should give employment opportunities to
the disabled. Here is an opportunity to do
something. Please do the needful and help.
—Executive Director

Hospital Sunday Celebration
and Inaguration of Community
Health Development Programme-Ooty
The Diocesan Unit of Catholic Hospital
Association of India celebrated the Hospital
Sunday on 1st July at 10 a.m. in Udhagamandalam
Social
Service
Society,
Ootacamund. About 40 participants who are
Medical Service

in-charge of Hospitals, dispensaries in
Ootacamund Diocese, and Centres in charge
of the Targetted Mother and Child Health
Education Programme participated.
The
function started with a Mass.
Then Rev. Fr. Joseph Antony Samy,
Treasurer, Catholic Hospital Association of
India spoke on "RESPECT LIFE". He said
"Man is created in the image of God and
has been redeemaed by the death and
resurrection of Jesus Christ. This is the
ultimate source of human dignity. Everybody
has to respect each one's life."
He stressed the statement made at the
time of our convention in Bombay in
November 1983 "We have to respect life at
conception, life in the unborn child, life at
birth, life ip the growing and developing
child, life in pain and suffering, life in the
physically and mentally retarded, life in the
socially rejected, life in the terminally ill
patients, life in the addicted, life in the Poor
or the economically disadvantaged, life in
the exploited, life in the aged, life in the
dying". A discussion was then followed.

Community Health
ment Programme

Develop­

The inaugural function of the Community
Health Development Programme started at
4 p.m. with Prayer Song. Rt. Rev. Dr. Arul
Das James, Bishop of Ootacamund presided
over the function. Mr. Jagadeesh Ramasamy,
District Health Officer was the Chief Guest.
Rev. Fr. Joseph Antony Samy, Director,
Udhagamandalam Social Service Society
gave the welcome speech. Mr. Jagadeesh
in his speech said that we must give
importance to prevention and promotion of
health and assured his assistance when ever
needed and inaugurated the Community
Health Development Programme.
August 1984

Rt. Rev. Dr. Arul Das James lighted the
Kuthu Villaku and in his talk appreciated the
work of U.S S.S. and also he wished best
future so that programme would play a
prominent role in the midst of the poor and
the downtrodden especially for the women
folk irrespective of caste, class and creed.
Mr. Fernandes also appreciated the service
rendered by U.S.S.S. and also he assured
his help and wished good success. Plans
are made to train the necessary health
workers to realise the following objectives :
To give new thrusts to the existing health
institutions with a stress of shifting from the
Medical work to preventive and promotive
health work community organization and
community action for development. Health
is seen in the total perspective of develop­
ment.

To give reorientation to the personnel
involved in Medical and Health Education
work (including TMCHEP—Targetted Mother
.and Child Health Education Programme) in
the diocese on the need and significance of
community health development programme.
To co-ordinate the health care services
being rendered by various religious congre­
gations in the diocese
To create awareness among the urban
and rural poor and to organise them for
concrete and specific social action by bring­
ing out the latent/potentialities of the people
through this Community Health Development
Programme.

Community Health Department
(CHD) Of CHAI with Training
Programme
Short term
Kerala

training Programmes

in

After a week's study and evaluation ses­
sion that concluded by the end of May 1984
35

the training team of the Community Health
Department moved onward to South for two
training programmes in Kerala—one in Nor­
thern Kerala and the other in Southern Kerala.
The programmes, organized by Kerala Social
Service Forum, were attended by health and
development workers representing all the
dioceses in Kerala. During the entire training
programme, it was a search to find out as to
how the existing infrastructure could be used
most fruitfully to work for an integrated
approach in health and development work.
Health and development are related integrally.
In the undeveloped Indian situations, deve­
lopment essentially means facilitating a
process of bringing about human living situa­
tions for the vast majority for whom they are
rejected. Hence, against this background, it
means that the health and development
workers who participated in the training pro­
grammes should take up a greater responsi­
bility and a deeper involvement in people
based programmes and movements. The
participants and the CHAI (CHD) team
thought together on the wider implications
of health and sought ways and means to
incorporate activities based on the new
vision.
The participants were grass root level
workers. The programmes were of 10 days
each. Regarding such programmes, it was
proposed that in future, it could be thought
to organize Orientation/training programmes
for diocesan policy level people who plan
and organize different programmes for the
dioceses and they would be able to develop
a core team of trainess to train the grass root
level bodies. Training programmes at this level
would help CHAI better to share the ideas
on Community Health with a wider area. By
the first week of July the CHD team started
the way back of Delhi.
Fifteen months training programme

Currently CHAI (CHD) is conducting two
training programmes of 15 months each. The

36

course schedule and contents were worked
out in December 1983. The programme is
titled "Community Health Team Training
(CHTT) Programme" and as the name itself
suggests, the course builds up teams to work
in village communities with a comprehensive
view on health and activities oriented towards
making "Healthy Communities". The para­
meters of a healthy community are related to
the Social, economic, political and cultural
realities of the population with which one is
working. The course starts with a critical
understanding of Indian reality at the macro
level with special reference to their local
situations. The 'unhealthy' individual is
situated in these millieu and modalities and
strategies are worked out to improve his
total life, thus enabling him to be a healthy
individual, a person in a state of complete
well-being.
The course has seven phases. It starts
with an introductory 3 weeks residential ses­
sion, after which the participants are sent to
respective Centres where they were already
working. Then, after evety third month they
are either visited at their respective centres
or brought together in general sessions. The
former one is called follow up meeting and
the latter one regional meeting. CHTT pro­
gramme has 2 follow up meetings and 5
regional-meetings. At each phase some input
sessions are given alongwith certain specific
assignments.
At each phase, the participants share their
experiences and their assignments apart from
the input sessions they are offered. Parti­
cipatory method of education, a joint search
made by the trainees and trainers together
effected through discussions, role plays, case
studies, games, etc., are used in the program­
me. This method serves for them a purpose
as they are to involve in a dialogical educa­
tion in all their activities in the field.
At present we have two groups for CHTT
programme started almost at the same time,

Medical Service

one by the middle of January '84 and the
other by the middle of February '84. The first
one was at the request of Mission Sisters of
Ajmer while the second one was organized
by the Bishop of Varanasi for Sisters of
different congregations working in his dio­
cese. The first follow up visit to both the
Centres were carried out in the months of
April and May.
Of late, we undertook the second follow­
up programme with the regional meetings
held at Ajmer and Varanasi, one week session
each, in the last week of July and the first
week of August. Now, both the programmes
have completed six months each and all the
participants are actively involved in field
level activities in their respective Centres. In
the month of October we will be contacting
them again, when they will be called toge­
ther for a regional meeting as part of the
third follow up programme.

Report of Review and Planning
Session of the Community Health Department of CHAI
held at Bangalore from
May 19th to 26th '84
CHAI had drawn up a new vision and
philosophy on health during the months of
April and June '83 in its annual review, plan­
ning and orientation session held at St. John's
Medical College, Bangalore. To promote this
vision across the country the Community Health
Department of CHAI took up specific tasks
and activities for the year 1983-84. After an
year, the department with its extended
team members and together with some
resouice persons gathered again in the same
venue to review the plan of action and the
conduct of activities against the background
of the objective of reaching the new vision
on health to as many individuals, groups and
organisations as possible.
August 1984

Apart from the staff of the Community
Health Department the session was attended
by the following resource persons: Prof.
George Joseph, Fr. Stan Lourde Swamy, Fr.
Claude D' Souza, Mr. Rudy Lobo, Drs. Ravi
and Thelma Narayan, Mr. Augustine Veliyath
and Mr. R.T. Rajan.
The discussions and deliberations of the
first half of the one week session were an
attempt to deepen our insights regarding the
current approach worked out by CHAISocial, economic, cultural and political
dimensions of health and on the importance
of using the church infrastructure and the
membership for the promotion of this vision.
Efforts should also be made to involve other
organizations and action groups. The role of
CHAI as a national organisation was viewed
against this background. CHAI's role would
be an effort to facilitate a process by which
health could be a right and responsibility of
all the citizens. Here emerges the concept
of making Community Health a national
movement. Health, conceptually a state of
total well-being, could be attained only
through total liberation. With this in view,
modalities and strategies were worked out
for a three year period and specifically for the
coming year. This constituted the theme of
the second half of the session.

On 19th May the session started with a
brief self introduction. Then a brief of the
current approach of CHAI was given. This
vision is very much in line with the spirit and
content of 'Alma-ata' and the various church
documents issued from time to time. It is a
philosophy of health envisaging the total
well-being of the individual which is directly
linked with the Social, economic, cultural
and political realities that condition the indi­
vidual. Hence the real and comprehensive
definition of health uses different terminolo­
gies and parameters which call all for the
necessity of an integrated approach. The

37

task is to promote this idea through the
member institutions and the Church institu­
tions and also through .various groups and
agencies involved in development work. Then
a brief view of the evaluation of the health
care system in India starting right from the
British period was made. The Bhor comittee
of 1944 rightly identified health as a facet of
development and hence advocated a multi­
faceted approach with regard to improving the
health condition of the people. Since then
various review committees were instituted
and recently Government of India has publ­
ished the Revised National Health Policy in
which due emphasis is laid on the concept
of Social justice and it is stated that priority
should go to the poor. The Policy statement
recognises the role of the village "dai" and
local personnel. It is a question of empower­
ing the people which might pose a challenge
to the so called professionals who alienate
and deprofessionalize others. In line with
this specific task, CHAI could think whether
it could develop model projects in community
health through its member institutions and
the Church structure. Being in the structure
let us work towards using it creatively and
meaningfully so that church could be made
relevant to the times and to the people, thus
making it really based on values. This would
also make a shift in Church's power base
from structures and institutions to the people.

In promoting the new vision on health,
rather than working alone, CHAI could
develop linkages with various individuals and
groups who hold a similar view. Then the
concept of making Community Health a
movement of the people in association with
various groups and agencies was introduced.

On the second day the Community Health
team spent the time with the doctors of the
rural placement scheme of SMJC. The report
on that is made separately. On the following
day CHD resumed its meeting with the re­

38

source persons. The day started with a brief
description of the annual report of the CHD
and the CHTT (Community Health Team
Training) Programme. In the past and to a
great extent even to-day the approach is
curative implement through hospitals equip­
ped with professionals and vested with
immense power by virtue of their control
over the resources. Some hospitals do have
CH Programmes, but that too are in a way
"colonial" in character in the sense that they
are not a process of empowering the people
but ultimately resulting in increasing the flow
of people to the Hospitals CHAI (CHD) is
trying to promote a concept and practice of
Community Health based on a social analysis
which recognises the existence of dehumani­
zing situations and institutional forces that
limit and alienate the life of the majority. In
this approach people are themselves made
"professionals" of their own health i.e., a
situation in which each one is responsible for
his health and each one can claim that as his
right. The diagnosis and treatment aie not
a non-participatory process, but a political
will is generated in which people see and
reflect upon their problems and take decis­
ions collectively. Here power goes to the
people and hence resources are not controlled
by institutional structures Health means life
which means existence in its entirity which is
related to the economic, social, political and
cultural forces which in the present contexts
subjugate and limit the life of the people.
Hence
health
inevitably
means
total
liberation.

Our approach is a process of moving and
working with people and disseminating and
promoting such activities throughout the
country. In essence this becomes making
community health a living movement. For the
realization of this CHAI could start working
with its 2000 member institutions, especially
1500 of them which are either small hospitals
or dispensaries. CHAI can contact the 110
Medical Service

dioceses and different congregations. It could
also contact different lay organisations and
groups. All these are the efforts to share the
vision with the whole nation. Here emerges
the relevence of developing regional groups,
resource pool or key trainees in difference
parts of the country. Few member institu­
tions and few groups and individuals in
different regions may share this view. We
will have to being with them. Development
means "second coming of Christ" and hence
definitely priests and sisters have got a crea­
tive role in making the Churdh relevent to the
current society since church essentially means
the people of God. With these deliberations
third day's meeting concluded.

On the next day discussions were oriented
towards making Community Health a move­
ment. There is cut-throat competition bet­
ween hospitals within the existing system
and in that process they are equipped with
the most sophisticated technological imple­
ments and highly qualified specialists.
Economic viability is a basic condition for his
and funding agencies are approached for this.
The poor are left in the society uncared and
not looked after. The Community Health
approach envisaged by CHAI tries to reduce
the number of the poor and their unmet
needs. Funding agencies are also becoming
increasingly interested in this. This approach
is realized through the participation of the
people and this requires more commitment
and creativity.

The political dimensions of health could
be understood by considering the ill-health
of the poor who are prone to diseases that
affect them due to variety of reasons as lack
of food, safe drinking water, hygenic and
adequate living conditions etc., all of which
could be changed only by a favourable poli­
tical will. It should be clearly understood
that when we speak of political dimensions,
it has nothing to do with the often unders­
tood party politics. Hence at times it may

August 1984

even lead to confrontation with the powerful
community that enjoys the fruits of the
economic, social and political power at the
cost of the poor.
The following day also was spent on the
same topics. The proposed movement is a
movement of the whole membership. At
present, money and personnel are invested
in starting sophisticated hospitals. Many
people engaged in hospital work started
thinking of the new vision on Community
oriented approach and this has created tens­
ion for them with regard to their present
activities and what they consider more desir­
able. And on the other side, there are small
rural dispensaries on the verge of expansion,
those that have started thinking of expanding
to highly institutionalized health centres. This
has created tension for them. Here CHAI has
a precise role of managing these tensions
creatively so that eventually these tensions
could be channelled to developing some
Community Health projects.

It is important that CHAI share these ideas
with policy makers as Bishops, heads of
religious congregations, heads of voluntary
groups. Government bodies etc. Organisa­
tions as Caritas, IGSSS, CRS, ISI etc, Medical
educators at different levels and Mass media.

The role of CHAI (CHD) as a national
organization was discussed in detail against
the background of the points mentioned in
the previous pages. CHAI has to identify
regional partners to work out different strate­
gies that may be found suitable for the reali­
zation of the vision and the objectives.

In the following days of the session,
specific strategies and action plans were
formulated. They are proposed to be worked
out at three levels, i.e., by the Central team,
with the partners and through the partners.
A note on this was already published in the
June issue of Medical Service.
39

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