MEDICAL SERVICE VOL. 41 No. 8 SEPTEMBER-1984.pdf
Media
- extracted text
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life in unity : work and bread: political conditions for an economic
translation: of .an ecumehic.almandate#the two: halves of rural .health •
people, pills and prescriptibns-IV • legal edubbt ion 7^11 • bacterial
. contamination df rural rehydi-ation solution • medical ethics fofum-35
vol 41
no. 8
September 1984
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p.q rnr'j
official house journal
of the catholic
hospital association of India
medical
service
"the love of Christ
urges us” 2 cor 5 :14
vol 41
editorial board
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
contents
1
editorial
2
2
life in unity : work and bread : political conditions
for an economic translation of an ecumenical
mandate
jan p pronk
5
the two halves of rural health
meera Chatterjee
11
people, pills and prescriptions IV-a
hospital chooses
si jaon matheikal, dr v r sinha, dr r g ramaiya
17
3
4
editor
fr john vattamattom svd
5
6
cover design
printed at kalpana printing
house new delhi-110016
legal education—11 :
do you know your fundamental rights
p d mathew
•
bacterial contamination of oral rehydration solution
21
29
medical ethics forum-35
fr george lobo s j
31
8
chai news and notes
32
9
beg
7
p m isaac bangalore
published by the catholic
hospital association of india
c b c i centre, goldakkhana
new delhi-110001
september 1984
no 8
dr rajaratnam abel
10 emphysema : the facts about your lungs
38
40
"Articles and statements published in this Journal
do not necessarily reflect the policies and views of
the catholic hospital association of India"
EDITORIAL
Convention with a difference
We are coming closer to our 41st Annual Convention of the Catholic Hos
pital Association of India. The members of the association gathering together
annu ally to discuss various matters of common interest particularly for the
interest of the common man was a regular feature from its inception in 1943.
Hence we are here now preparing for our 41st Convention, to be held at
St. John's Medical College, Bangalore f rom 23-26th November 1984.
Over the years a new element of exhibition (of hospital equipment, furnitu
But organisationally this became
res, vehicle etc) was added to this event.
increasingly difficult to have it every year.
However, there is going to be a d ifference in this year's convention.
There will be a serious
The usual 'glamour' of exhibition wll not be there.
workshop for two days and the topic selected for this convention is the
"Drug Issues".
During these two days we will try to understand the issues
relevant to drug prescribing and drug distribution and pharmacy policy
in our institutions in the context of the ICMR/ICSSR warning in the "Health
for AH" report that “Enternal vigilance is required to ensure
health care system does
not get
that
the
medicalised, that the doctor-drug
producer axis does not exploit the people and that the abundance of drugs
does not become a vested interest in ill-health" •
In order to arrive at a certain policy decisions and to decide upon some
definite follow up action, we have* already requested that persons with
decision making power on these issues to attend this years convention.
Accordingly it is hoped that the workshop will be able to pay attention
to the health situation in India, role of drugs in health care, pattern of drug
production vis-a-vis the people's health needs, the dynamics of the drug
industry, the patterns of drug distribution/availability in the health care
system, the national drug policies and laws etc.
It is also hoped that the
workshop will create an awareness of the growing irrational use, over use,
misuse of drugs by health personnel etc.
The workshop will also look at
these issues in the context of the CHURCH HEALTH SERVICES and from
the common man's point of view.
The workshop will discuss on the
practical and possible solutions to these problems.
In order to do this, serious preparations are undertaken by the local com
mittee. Already in our journal 'Medical Service’ we have started the column-
"Peoples, Pills and Prescriptions".
The next issue of our journal will be
completely dedicated to the various aspects of drug issues. It is also hoped
that the participants of this year's convention will come with certain amount
of preparation to be shared in the workshop so that based on this and their
vast experience more meaningful conclusions and decisions can be arrived
at.
However the main difference of this years conve ntion should be seen
and measured, not by the programmes of the convention days only but by
what happens afterwards, i.e. the follow up action taken by our member
institutions. Let us hope that after this convention we will be a bit more
closer to our aim of making our health care services accessible to all our
people in a more acceptable and affordable way and with their involvement.
pioneers of Ayurvedic research in* Medical* Dental •Veterinary fields
from
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Pre-operative: as prophylaxis to minimise
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in divided doses)
etkicaL pibaducts
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as Gum massage. Dentifrice, Rinse & Gargle
Relief in 2-3 applications
Remarkable improvement in 2-3 days.
in easily crushable tablet form
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Masticating trouble leads to: Indigestion,
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GUMS Gingivitis : Bleeding, swollen, spongy, painful Gums
TEETH: Painful, Aching, shaky & Hypersensitive;
prevents plaque formation.
ORAL hygiene : in disease or drug induced conditions,
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G32 is an excellent supportive & follow up treatment:
to consolidate the gains of Surgical & Systemic management
of Gum & Teeth conditions and ORAL Hygiene.
syndrome (nausea, vomiting ptyalism)
SOOKTYN helps assimilation, degestion,
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as Anti-inflammatory, Analgesic & Antibacterial
Quicker relief without side effects Complete relief within 5-7 days
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after teeth extraction. Trismus, Odontitis, Dental Pulpitis,
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DOSE: 2 tablets tds for 7 days.
September 1984
I
ALARSIN MARKETING P. LTD.
V
12. K. Dubash Marg. Fort Bombay-400 023.
3
41st Annual Convention of CHAI and
Workshop on 'Drug Issues'
St. John's Medical College
Bangalore 560034
Venue
:
Dates
23rd—26th November 1984
Last date to receive
registration for
October 30, 1984
A ccommodation
will be arranged as per request ,
:
Fees
Registration (non-returnable)
rs.
Food
110.00
Accommodation
70.00
Local Transport
20.00
Total
Rs. 250.00
(Payable by crossed cheque/draft/MO in favour of Catholic
Hospital Association of India)
Return travel
arrangements
50.00
as per request. The request with
details together with approximate
amount should reach us latest by
20th October. No guarentee for
requests
received after 20th
October.
Executive Director
CHAI CBCI Centre
Goldakkhana
New Delhi 110001.
Please register immediately
Convention local office:
Sr. Anna Maria
Secretary, CHAI Annual Convention
Committee 1984
St. Marth's Hospital
Bangalore 560 009.
Life in Unity: Work and Bread
Political Conditions for an Economic Translation of
an Ecumenical Mandate
Jan P. Pronk
"Life in Unity" means work and bread for
all. That requires a fair distribution of scarce
resources and this, in turn, a fair distribution
of political power. Life in unity is an
ecumenical mandate of major economic
significance, to be realized in political terms.
In the past, until some centuries ago, a
just distribution of the earth's resources was
neither an economic nor a political pre
requisite to manage the world. There was
one earth, but it contained many worlds
which were hardly dependent on each other.
Life or death in one of them did not affect
the others. If one part of the earth suffered
a decay, others could still flourish.
The
distribution of the world's resources was not
subjects to global political decision-making.
Two factors changed this pattern: coloni
alism and the technological revolution in
communications.
Both originated in the
West as the result of political decisions in
western economic interests.
The earth
became one world : technically a small one,
economically a managed one, politically
dominated by a centre in the West. It became
a global feudal society, controlled by an
industrial elite which did not share resources,
work and bread with the numerous havenots.
Then came World War II : death and
destruction in a divided world. After that,
new era started with, for the first time in
the history of humankind, a world-wide
effort to rationally manage international
September 1984
relations by creating a new international
economic order on the ruins left by the Great
Depression and the War. It was a deliberate
effort to create more work and more bread
for more people; more life and more unity,
not for ethical reasons but because of the
enlightened self-interest of the then elite,
who could only flourish under conditions of
economic and political stability.
And so the Bretton Woods system was
created: a World Bank and an International
Monetary Fund together with an international
organization dealing with world trade. The
United Nations was established, with its
Security Council and Specialized Agencies,
enabling the nation states to negotiate
stability and growth. The Marshall Plan
injected new life into Western Europe.
Development aid was provided to poor
countries to help them build an infrastructure.
New institutions were created to foster
economic cooperation : OECD and the Euro
pean Communities. The development of the
Third World was stimulated by the adoption
of the Strategies for the First and the Second
Development Decades. It was also the era
of decolonisation of the South and, after the
Cold War, detente between East and West.
Of course, we should not glorify the past.
Life in unity remained far from reality. But
there was some progress towards more work
and more bread for more people, due to
concrete action—even if insufficient—for
about 25 years.
5
The situation is different now—it changed
about 10 years ago. The new international
economic order which had been created in
the 1940s crumbled, and the call for another
new one was not heard. Instead, there was
a North-South dialogue, which resembled
a dialogue between deaf and dumb, or even
worse because deaf and dumb indeed do
communicate with each other. The United
Nations lost credibility as a forum where
economic and political problems could be
negotiated and solved. Negotiations pro
duced only words, not policies. Tension
between East and West increased. The arms
race got out of control. Economically the
world is in a crisis, with double digit
unemployment figures in the North and
negative economic growth in the South. The
beginning of the 1980s is characterised by
less work and less bread for more people.
Economic forecasts for the turn of the century
are gloomy: even under the least pessimistic
assumptions, the number of people living
below any decent level of existence will be
higher than one billion in the year 2000.
Concrete action is necessary to fight the
crisis, to build a new order—as we did after
the Great Depression and after the War. But
now we shy away from action. Even mee
tings organized for that very purpose, like the
Cancun Summit or UNCTAD VI, fail.
How did this come about ? What are the
basic reasons for the collapse of progress
towards more life and more unity, more work
and more bread ? We have to know the
answer to this question if we really want to
work in the right direction.
In my view the reasons are twofold.
Firstly, the structural economic crisis in
which the world finds itself today is rooted
in the international economic system itself,
which was created after World War II. For
more than two decades that system served
its purpose for those who created and
6
controlled it: stability and growth. But at
the same time the system had a number of
basic structural deficiencies which eroded it.
The absence of the socialist countries of
Eastern Europe and of the Third World
countries from the negotiations of the basic
elements of the system was such a defici
ency. The international economic order was
basically a Western one, with Western
values—such as free markets and private
enterprise—and was controlled by Western
countries. If these countries tried to acco
mmodate themselves by shifting domestic
instability onto other countries, by exporting
inflation, by manipulating exchange rates or
by protecting weak and declining industries,
they could easily do so because there were
no sanctions on bad behaviour.
That is the first reason: the deficiencies
of the system made it highly unstable and
weak. The second reason is that govern
ments, instead of trying jointly to rectify
these basic deficiencies, „ produced more
chaos by short-sighted,
inward-looking/
unilateral "beggar-thy-neighbour" policies.
For the last 10 years we have been
paralysed. To quote Mr. Ramphal, Secretary
General of the Commonwealth: "The form
of the North-South dialogue has been about
what should be done, but the real argument,
the often unspoken question, has been about
why we should do anything". And at the
same time the rich have helped themselves.
To quote Ramphal again: "There was no
inertia or lack of innovation when the North
felt its immediate interests endangered. The
(Western) International Energy Agency was
established within months of a perceived
'energy crisis'. Those elements of the debt
crisis which most threatened major Western
banks or Western strategic interests produced
urgent intervention and impressive coordina
ted response. Meanwhile, facilities, deni
grated when urged in support of Southern
Medical Service
economies, were at hand to serve Northern
interest'. No substantial additional financial
resources were committed to the least
developed countries at the United Nations
Conference on the Least Developed Countries
in Paris (September 1981) but, shortly before
that, new money (Special Drawing Rights)
was made available to support European cur
rencies or to prop up a weak dollar.. And at
present, due to an artificially high interest
rate in the United States, to very low commo
dity prices and to protectionist measures
hampering access to markets of industrialized
countries, the flow of resources from the
poor to the rich is bigger than the other way
round. There is no unity and there is even no
effort to hide this fact. "Why should we do
anything at all 1" is the present answer of
the North to the demands of the South.
Well, there is one reason : that is interde
pendence beween countries or, in the words
of the Brandt Commission, a "common inter
est" of all countries in the survival of the
world economy and of the world itself. It
may seem doomsday, language, but indeed
survival is at stake. The present international
economic crisis, for a number of reasons
which I will not elaborate now, is more fun
damental and more complex than any
previous one. The economic problems ahead
are enormous. The transition from traditional
energy to new and renewable sources of
energy, from negative to neutral environ
mental effects of economic growth and,
above all, from a world population of at
present for billion people to eight billion one
generation later (all of whom have to be fed)
—all these transitions are necessary but will
not take place automatically.
The world food problem in particular has
not yet been solved. Sub-Saharan Africa is
hungry; it does not receive adequate support.
If no major investments in food production
and no changes in food policies are made,
September 1984
there will be substantial food shortage in
other parts also of the world in a decade or
two from now. Further more, work has to be
created for all these people—an additional
four billion in four decades—which means
that nine out of ten new jobs globally have
to be created in the Third World itself. These
are challenges which demand joint global
action in an interdependent, united world. If
that action does not take place, then survival
will certainly be at stake.
Of course, this has already often been
said by scientists, by United Nations expert
groups, by the Brandt Commission, at our
previous Assembly and on many other
occasions. Interdependence has by now
become official jargon. All the Ministers
addressing UNCTAD VI in Belgrade, in June
this year, expressed their belief in interde
pendence and common interests. Nearly all
the Western politicians at the Conference
explicitly agreed with Mr. Clausen, President
of the World Bank, that world economic
recovery, including economic recovery in the
Western industrialized countries, would be
unthinkable without a major economic
upheaval in the Third World. But all this
talk turned out be just lip service. During the
UNCTAD VI negotiations themselves, the
rich countries refused, after the beautiful
speeches in plenary, to make the resources
for such an upheaval available—they even
advocated conditions and economic policies,
such as for instance within the framework of
the International Monetary Fund, which
would strangle developing countries and
force them to cut expenditures intended to
benefit their poorest population strata.
Countries such as Brazil are on the verge of
bankruptcy, and for poor people in these
countries bankruptcy means death. The
tragic aspect of this situation is that these
developing countries, which are highly inde
bted and at the mercy of their rich creditors,
hardly dare to demand fundamental structural
7
change, as, for example, in international
financial and monetary relations, let alone a
new international economic order.
Many
delegates of rich countries told us in the
corridors at UNCTAD VI that they were very
much at ease because pressure from the
South had never been so weak as at present.
And again it became crystal clear that life
in unity is still far away. More work and
more bread is not being simply given by the
rich to the poor. It has to be fought for, it
has to be negotiated, just as the labour
unions had to after the industrial revolution
in the West. But negotiations only make
sense if three conditions are met.
Then the international community will be
united—united in insecurity—owing to scarci
ties as the result of inadequate economic
policies; to increasing economic inequalities
resulting in violence caused by the arms race;
to increasing political tensions between
superpowers which give, higher priority to
strengthening and enlarging spheres of influ
ence than to solving globa
roblems; and
owing also to the aggressive policies of
individual countries which answer all these
threats by creating more "Lebensraum" for
themselves—territorially and economically—
guaranteeing themselves access to already
scarce resources, to the sea bed, to the
Arctics and 10 space—which will undoubtedly
lead them into confrontations with other
countries.
There should be a common or mutual
interest between the parties; there should be
some degree of equality in power between
So the trend should be. reversed, away
them; and there should be political will. The
from crisis and confrontation towards survival
common interest between rich and poor in
and unity. What option do we have ?
survival is still being overlooked by the rich
We could return to the choices made in
or only being paid lip service to. The poor the 1940s, when we created a new inter
are weak: they lack negotiating power more
national economic order as an answer to
than ever. The political will of the forties and
the then prevailing crisis. This option-l call it
the sixties has faded away. The tragedy is . "international democratic capitalism"-wouid
that the international economic crisis is
be a step- out of the present chaos by
parallelled by a crisis in political decision
strengthening the policy principles and insti
making and political institutions, due to the
tutions which were established at that time.
paramount- import of short-term horizons in
However, this option would not be in the
decision-making; to the almost exclusively
interest of the poorest countries and of that
inward-looking orientation of policy makers;
part of the world's population which pre
to the inclination towards shifting each one's
sently has only marginal relations with the
burden on to the shoulders of weaker groups,
market.
to alienation of elites from the grassroots;
We could return to the choices made in
due also to prisoner dilemma situations and
the 1950s, when political decolonisation
to the fact that in politics greater weight is
started (''international literalism'') and an
given to aims conceptualized in terms of
international community of nation states
power—which by definition is a zero sum
was shaped, by drawing the economic conse
game—than in terms of welfare.
quences: the creation of an international
If these trends are not reversed, there
social welfare state with the help of inter
will be increasing economic and political
national income transfers in the form of
insecurity not only for the weaker countries
development aid. This, however, would not
or for the poorer population strata, but also
be adequate because it would not deal with
for the international community as a whole.
the causes of inequality.
8
Medical Service
We could implement the pleas made in
the 1960s, combining international aid with
a strategy for international development
which should also contain policy changes in
the fields of trade in manufactures and com
modities. This option ("international eco
nomic democracy") would be a major
improvement, but still would only imply
changes within the framework of the prevai
ling international economic order.
We could return to the model of the early
1970s by seriously striving, on the basis of
economic cooperation between developing
countries, towards more collective selfreliance for the South, possibly even some
degree of delinking from the North. However,
this would imply some confrontation between
North and South and would not contribute
to a solution of world-wide global crises,
threats and insecurity.
So the only promising option is one which
would enable us to cope with the problems
of the 1980s. You may call it a new inter
national economic order, or internationally
democratic socialism, or life in unity, or a
just, participatory and sustainable society.
Can the Church play a role in this ? Yes
indeed. To negotiate and build a system
which guarantees work and bread for all
should not be left to bureaucrats, technocrats
and diplomats. Neither can it be left to
politicians, not only because of the political
crisis phenomena which I mentioned, but
also because such a system needs an addi
tional dimension. In the words of Thomas
Beckt, in T.S. Eliot's "Murder in the
Cathedral" •: '
Temporal power, to build a good world.
To keep order, as the world knows order.
Those who put their faith in worldly
Not controlled by the order of God,
In confident ignorance, but arrest disorder.
Make it fast, breed fatal disease.
Degrade what they exalt.
That is indeed what happened in the
seventies: after twenty-five years, worldly
September 1984
order with fatal disease. That is what should
be avoided in the remaining years of this
century.
The Church can help; the Church is a
value guardian. Values such as survival,
social justice and equitable sharing of
resources are easily forgotten during negoti
ations. Churches can constantly highlight
their crucial significance.
Churches are people's movements which
can challenge power, act as vanguards and
as advocates for change. That is essential
because people, and in particular the poor,
are easily forgotten during negotiations Did
we not speak about a church of the poor ?
That is the cynical lesson of the last ten
years. We talked and negotiated about work
and bread, about welfare and development,
but the basic values and the fate of poor
people were not on the agenda.
One could argue that this always will be
the case and that any effort to negotiate
more work and more bread for more people
would be a waste of time. I agree that
people's participation at the grassroot level
is a conditio sine qua non. It is an essential
but not a sufficient condition, because the
unequal distribution of power, together with
the rapid technological revolution of the last
couple of decades, has given the elites at the
top a nearly insurmountable advantage over
the people at the grassroots. Action at the
grassroot level may help to challenge power,
but should go hand in hand with action to
influence that power. Life in unity requires
meticulous and dedicated action at all levels
as a united movement by all peoples.
Moreover, life in unity should not only be
seen as the aim of a process, as its final
outcome. It should also characterize the
process itself.
Sharing work and bread with each other,
and with the yet unborn generation, is an
ethical ecumenical mandate. It always has
been. But whether the mandate was imple
mented or not, did not, in the past, have con
sequences in terms of survival. Now it does.
9
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'
The Two Halves of Rural Health
Provision and Participation—Studies in Social Dynamics of
Primary Health Care
— Meer a Chatterjee
Time is short for the journey towards
'health for all', not because the year 2000 is
sacrosanct, but because the vicious relation
ship of disease and poverty will make the
task increasingly difficult. The travellers are a
motely crowd—politicians and planners,
health professionals, development specialists,
social scientists, "the people"—all in search
of the goal but presently out ot step with
one another. Studies in Social Dynamics of
Primary Health Care maps the terrain, des
cribes the obstacles and the alternative paths
for India. We are left to believe the road
is not impassible, provided visibility improves.
The past is succinctly summarised in a
chapter on the evolution of health policy in
India. Over the years, the country has
accumulated infrastructure, personnel and
programmes. The emphasis has been on
centralised facilities rather than on far-rea
ching services, on hardware and not on
software, on quantity and not quality. The
orientation of the .health system towards the
urban
rich, its curative, clinical, pharma
ceutic and technologic bias, its Western
derivation at the expense of indigenous
methods, its isolation from related sectors
and its distance from social and economic
realities are now acknowledged candidly by
government health documents. The recent
(1982) Statement on National Health Policy
calls this health system "inappropriate and
irrelevent" to the country's needs.
There have been efforts at providing
health care to the poor. Foremost among them
is the Community Health Workers Scheme,
September 1984
initiated in 1977, in which the authors have
been intimately involved. Here they present
their observations, gleaned during several
years of field work, from the perspective of
both providers and beneficiaries. To this they
ass an analysis of the rural health system
which is expected to provide back-up
services for the primary care imparted by
village level workers. When, during the
course of their field-work, the state govern
ment of Punjab substituted, the CHW
scheme with a pilot "mobile health team"
project, that too become a subject for study.
The authors also focus attention on two
important national programmes, the National
Malaria Eradication Programme and the
National Family planning Programme, which
have been in operation for over two decades.
The book delves into the workings—and
non
workings—of the
CHW scheme.
Although the effort is generally welcomed by
village people, including the poor, who have
felt helpless in dealing with their health
problems, the demand is for curative medical
care of the allopathic variety, and there is
little enthusiasm for the preventive or
promotive tasks which are the crux primary
health care. Consequently, there is meagre
evidence of basic improvements even in, say,
sanitation, both providers and beneficiaries
are responsible. It is linked to other wellknown ^weaknesses of the scheme—the
inadequacy of CHW training, the quandary
about supervision of the workers, and the
passivity, as opposed to participation, of the
community. Clearly, the scheme has not
brought about a change in the medical
11
professional bureaucratic approach to rural
health care. In fact the authors contend, the
CHW is "another rung added at the bottom
of the existing health service hierarcy". And,
given this situation, the failure of the delivery
system to meet the functional requirements
of the village-level worker (training, infor
mation, guidance, supplies, salaries) renders
the scheme practically important.
Another critical defect, noted but not
emphasized by the authors, is the scheme's
failure to induct women—the vast majority of
CHWs are men; even the authors use the
pronoun "he" throughout to refer to the
CHW, despite /their avowed concern for
women. This naturally means that the pres
sing tasks of primary health care which are
focused on women and children remain
largely undone.
To overcome some of these inadequa
cies, it has been proposed to set up village
health committees as part of the revised
Health Guides Scheme in the Sixth Plan
period (1980-85). It is hoped that this will
elicit greater community involvement, includ
ing that of women, and clarify the relation
ship between health worker and community.
Whether this will change the CHW's role
from paramedic to social worker engaged in
generating social awareness, organisation
and action, which the authors see as most
important, remains an open question.
The trend to the "professionalization of
barefoot medicine" was also manifest when
the Punjab Government opted to replace the
CHW with a mobile health team. Led by a
doctor, the health team was charged with
delivering "total health care" at the village
level. The authors evaluated the first fifteen
months of this pilot project. They concluded
that, as an extension of the "provider
approach", this 'alternative' too remains
largely cl inical-curactive in nature, inaccessi
ble to many, and isolated from the commu
12
nity despite its intention to involve the people.
They suggest that a combination of this
effort and a well-run CHW programme would
be efficacious.
Raising their sights from the primary to
the secondary level of health services, the
authors present their onservations in three
blocks in Haryana. They find the rural health
delivery system rife with problems. It is
hierarchical. Decision-making for health is
dispersed, making coordination
difficult.
Programmes are introduced in an ad hoc
fashion and consequently management of
logistics and personnel is grossly deficient.
Certain basic concepts such as a uniform
service-to-population ratie,
are deemed
impracticable and, hence, inequality of access
to services remains a major drawback. These
problems also affect the vertical programmes
concerned with malaria and family planning,
on which much effort has been expended
nationally, but which have failed to make
adequate impact.
By this time, the authors have marshalled
considerable evidence regarding provision of
and participation in health care. The overall
picture is one of inadequacy on the part of
providers, which spells poor programme
implementation; and of insufficient informa
tion to and organisation of communities,
which prevents their participation in health
care. In sum, although the present perspec
tive on health envisions greater participation
among the people for improved health, the
attendent schemes have largely been exten
sions of the "provider approach" of the past.
The future begins with the philosophy of
Alma Ata, and the "Alternative Strategy" of
the ICSSR-ICMR Study Group on Health
For All, (See FUTURE 1,p 53-55 for a
review). Both are concerne'd with the
relationship of health to development outside
the health sector. On the other hand, primary
health care also seen as a point of entry
Medical Service
in the effort to remove poverty and inequality
as the ''vanguard of the development
process". The authors too perceive primary
health care more as a "social rather than a
medical problem" which calls for the
"transformation of social organisation" and
the "integration of health care into the
overall social-economic development of the
community".
The sum of evidence and philosophy in
a series of prescriptions by the authors for
rural health. These are the directions with
which we are armed; until we come to the
next intellectual turnstile.
First, the existing rural health service
system must be "reorganised, reoriented,
rationalised and restructured". This is a
priority emanating from the precedence given
to primary health care. The purpose of such
change in the health infrastructure is to
decentralise decision-making, shifting respon
sibility to beneficiaries, thereby making them
participants. The authors support the alterna
tive model proposed by the ICSSR-ICMR
group which called for a "radical change"
in the health service system. This model is
commnnity-based, linked to referral services,
synthesizes traditional and Western medicine,
integrates preventive and promotive aspects
of health with curative care. However, the
structure proposed differs only marginally
from the present pattern of health services.
The strength of the alternative model thus
lies more in the principles it espouses. These
are that the majority of health complaints
should be dealt with at the village level; that
a system of referral to specialist centres
should give those in need adequate access
to medical care, ensured by proper* location
of facilites; that the responsibility for the
functionning of this system be vested in the
people and their representative institutions.
Second, the authors propose that a
change in the attitudes and motivations of
September 1984
health personnel is more important than
"mere" restructuring of health services. The
urban, bureaucratic, professional-clinical bias
must be replaced by the rural, decentralised,
participatory and preventive orientation of
primary health care. Discussing how the
national health care delivery system can be
democratised, the authors are certain that the
elites—administrators, planners, intellectuals,
and especially doctors—must overcome their
alienation from the masses, identify with the
cause of the people, and establish their
bona fides.
This prescription encompassed the third
proposal, to reform medical education so that
community health and epidemiology preside
over sohpisticated speciality medicine.
Founh, the authors are in favour of
integrating -indigenous medicine with the
modern allopathic system because of the
"holistic" and "culturally-relevant" approach
of traditional practitioners. Left to them
selves, the traditional system have clearly not
been able to deal effectively with the most
pressing rural health problems. They have
also been subject to the strains of moderni
zation. The legacy of the national health
effort is the rising, if misguided, expecta
tion, even in the remotest rural area or
among the poorest, for sophisticated, profes
sional medical treatment—paraphernalia of
'scientific' medicine. Thus, a return to
traditional medicine which has been concur
rently devalued is unrealistic. While its
"revitalisation and integration" may be
desirable, it is difficult to see who can be
charged with responsibility for dispensing
this prescription. '
Fifth, the authors Propose the regulation
of private medical practice and controls on
the drug industry. "In the long run" they
say, "the objective should be to absorb all
private professionals in the public provision
of health and medical services". This bitter
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pill is unlikely to be swallowed by many
concerned with their individual health rather
than with health for all.
These five prescriptions are related to the
infrastructural modifications and improvement
of performance with which the authors
suggest the "formidable task" set forth by the
ICSSR-iCMR group should begin. They are,
it must be noted, contained in some form in
the new National Health Policy which the
authors have appended but not analysed as
their book was already in press when the
policy was announced. They comprise only
one part of the authors' overall strategy to
bring about change in health care and health
status, the half concerued with provision.
The other half of the strategy has to do with
participation, and must also commence
without delay. This entails enhancing the
capacities of rural communities to take
responsibility for their health and includes
generating "health consciousness" through
health education, and improving community
organisation so that people can participate in
the assessment of their health needs, in
planning, organising and monitoring health
services, and even conttibuting financially to
them.
This last hope brings up a question of
vital importance, on which the authors as
well as the Policy Statement, are largely
silent.
How is Health for All to be financed?
Although primary care services are "lowcost" relative to the price of sophisticated
medicine, a sizeable increase is called for in
the health budget. The ICSSR-ICMR Group
proposed that the two to four per cent of
past plan budgets be increased to eight per
cent in subsequent plan periods. The
authors reiterate this plea. It will be neces
sary ensure that within the health budget,
primary health care for the poor receives a
large share, that this is not absorbed by the
specialist centres for the urban rich. This is
a matter of political, professional and popular
commitment.
Dr. Meera Chatterjee is Senior Fellow,
Centre for Policy Research, New Delhi
110021. Health For A!I-An Alternative
Strategy, reffered to in the review, is the
Report of a Study Group set up by the
Indian Council of Social Science Research
and the Indian Council of Medical
Research. . It was published in 1980
Country future, UNICEF
The Indian market is flooded with at least 25,000 formulations which are
produced by 5156 drug manufacturing units. By the end of this year the drug
production is expected to touch an all time high of Rs. 1800 crores, yet only 20%
of our bretheren have get a tablet of Paracetamol from cradle to coffin. Can we
afford to have the luxury of 25,000 formulations? More so when it is wellknown that if 98% of these are thrown in the sea it would be better for mankind
and worse for the fishes.
Prof. V.S. Mathur
M.D., D. Phil (Oxon) M.A.M.S.
September 1984
Courtesy : Drugs Bulletin Vol. 6
15
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People, Pills and Prescriptions IV
A Hospital Chooses
(Kurji Holy Family Hospital—Formulary and Therapeutic Guide)
By Sr. Joan Matheikal, Dr. V.R. Sinha, Dr. R.G. Ramaiya
(The following is from the introductory
part of the detailed 'Formulary and The
rapeutic Guide' by the staff of the Kurji
Holy Family Hospital. We thought it would
be of some use and also would serve as
an inspiration to those who would like
to take similar steps as this praise worthy
one by the Kurji Holy Family Hospital—
Editor)
We will encourage our doctors, nurses,
paramedical and all co-workers to rise to this
challenge. We recognize that with the
publication and implementation of fhis
Formulary at KHFH, we take one step in that
direction. By taking this one small step, we
can be sure that we are strengthening those
forces working for social justice and peace
in the world today.
Introduction
Forward
The laudeble achievement of Kurji Holy
Family Hospital in preparing the 'Formulary
and Therapeutic Guide' is the result of the
unstinted cooperation and hard work that
went into the making of this document. It
is heart-warming to see a united effort bear
fruit and to know that the full backing of all
the medical staff is behind this Formulary.
Kurji Holy Family Hospital will continue
its efforts to transform itself into a more
community-centered Hosoital. We see this
happening through building the image of the
Hospital as a centre for health education,
leadership-training,
conscientization
and
social reform rather than that of merely being
a Centre for curing diseases. A wholistic
approach to health which emphasises the
participation of the community/individual for
taking responsibility for his own wellness
will be the basis for examining to create a
dependence of drugs for the continued health
and wellbeing of the people.
September 1984
This Formulary is the result of the accu
mulated experience of our Senior Medical
Staff over the last 10 years. We know that
96-98% of conditions admitted to our hospi
tal can be treated by drugs included in this
updated Formulary. It is being presented
in a new format giving the generic name,
dosage, indications, contraindications, main
side-effects all in the same page. Informa
tion about comparative cost of treatment is
also provided.
We present below certain considerations
which should be kept in mind by Doctors
while prescribing drugs.
1.
Is the drug really necessary!
(a)
Does the patient need any drug at
all?
(b)
Is the drug being given to relieve
symptoms, to treat the underlying
conditions, or to make the patient
feel that something is being done?
17
Bill
Bill
CashICredil Memo
CashlCredit Memo
Ph. 322364
Ph. 322064
Dated 22.1.1983
Date 22.1.1983 .
No.
No.
Name__________________________ :____ _
Name ;____________ ‘
Address
•
_____________________
Qty
Particulars
100
Calmpose
(Made by
Ranbaxy
Rate
Total
18
Address_______________________________
Amount
Rs. P.
Qty
Particulars
20
00
100
Diazepam
(Made by
Ranbaxy)
20
00
Goods once sold are not returnable
(c)
Is the drug the most suitable for that
patient and that conditions?
(d)
Is the drug the cheapest drug of that
type? If it is not, could a cheaper
drug do the job as well?
(e)
What side effects may the patient
suffer?
(f)
Do the possible benefits to the
patient out weigh the possible risks
of the drug?
(g)
How may the drug interact with
other drugs, the patient is receiving?
_____________
Rate
Total
Amt>unt
Rs. P.
5
15
5
. ' ■
15
Good once sold are not returnable
2.
Cost consideration
Many patients who visit our hospital are
very poor. They simply can not afford the
exorbitant cost of treatment. It is the duty
of every Doctor to keep this awareness in
mind, while prescribing. Diagram given
above gives you an idea of how some very
similar preparations may vary in cost by a
factor upto 25%. Surely, a cost conscious
Doctor can help considerably to lighten the
burden of treatment cost to the patient.
3. Generic names
It is the policy of the hospital to use
generic names for prescribing. Most drugs
Medical Service
cost very much less in its generic form, for
example, Calmpose (Ranbaxy) costs 0.13
paise per tablet whereas the same drug in
its generic form Diazepam (Ranbaxy), cost
only 0.05'paise per tablet. Lyraymcin (Lyka
cost Rs.10/-per vial which in its generic form
Gentamycin (Hindustan Antibiotics) cost only
Rs.7.50/We request all Doctors to abide by the
Hospital Policy of prescribing drugs in its
generic name. Further, it may kindly be
noted that even if a drug is prescribed in its
brand name, the pharmacist is authorised
to dispense the same drug in its generic form.
Introduction and deletion of drugs
The procedure for introduction or deletion
of a drug from its Formulary is :
* low cost
* easy to administer.
For practitioners of rational drug therapy,
the drug industry in India presents a bewilderingly chaotic picture :
* The drug market in India is flooded
with more than 30,000 formulations,
majority of which are exotic formula
tions boosing up the cost to the patient.
* Drug advertisements and contacts with
drug representatives are the source of
information on drugs for most Doctors.
However, such information has been
found to be very reliable. According
to WHO "such information is always
influenced by commercial interests.
(a) Any Senior Doctor may recommend
a new drug in writing to the Phar. macy and Therapeutic Committee
giving its indications, contra-indica
tions, main side-effecfs and advan
tages over existing drug in the
formulary.
A WISCMHIOM forw
waite out you A
(b) Pharmacy and Therapeutic Committee
will carefully consider the suggestion
from the point of view of Pharmaco
logical efficiency, cost and other
relevant criteria and decide to include
or not to include the recommended
drug in the Formulary
PROBLEMS.
SUGGESTIONS etc
on drug issues
Rationale and objectives.
It has been stated that rational drug the
rapy is the art and science of prescribing the
best suited drugs to individual who n eed
them, not to those who merely want them*
The drugs used will be :
* efficient
* safe (with
effects)
September 1984
low
incidence
of
side
AMD
SENb
To
DRUG COLUMN
MEDICAL SERVICE
C.H.A.I., C.B.C.I. CENTRE
NEAR GOLDAKKHANA
NEW DELHI-110001
19
The basic theme of promotional material
is that drug will provide the answer to
a distressing clinical problem. Little
attention is given in aiding physician to
use his clinical judgement. Unfavou
rable aspects and complications of such
treatment rarely receive
sufficient
attention**.
* There is reportedly one drug represen
tative for every 4 doctors in India as
compared with one drug representative
for 30 doctors in developed countries.
* Diseases that affect the people in India
are mainly nutritional infectious or
communicable, gastro-intestinal, diar
rhoea, malaria, filaria, measles, leprosy
and T.B. However, in 1976 out of
total production of Rs. 700 crores,
25 percent was spent on vitamines,
tonics, health restorative and enzyme
digestants, 20% on antibiotic and only
1.3% on sulphonamides and 1.4% on
anti TB drugs. This data confirms how
irrational the pattern of drug production
is in comparison to health needs of our
people.
* Drugs banned in their parent countries
or proved inefficacious continue to be
marketed by multinational companies in
under developed countries such as
India.
20
Given above confused situation, a hos
pital interested in promoting and sup
porting rational drug therapy among its
doctors is compelled to do the follow
ing :
—* Restrict the drug made available
through its pharmacy to a short list of
basic and essential drugs
— Provide realiable clinical, pharmacolo
gical and therapeutic information about
these drugs.
— Encourage doctors to prescribe through
generic names.
— Educate doctors on the cost of drugs.
Objectives
KHFH Formulary and Therapeutic Guide is
an an attempt in that direction, ft has been
brought out after considerable amount of
discussion among senior medical staff of
KHFH. Its objectives are :
— To provide a list of drug that will be
stocked in KHFH Pharmacy
— To provide reliable pharmacological
and therapeutic information about
these drugs.
— To name the above listed drugs in its
generic names whenever possible,
— To provide information about comprarative costs of drugs wherever possible.
Medical Service
LEGAL EDUCATION—11
Do You Know Your Fundamental Rights
(Part II)
P.D. Mathew
VIII. CULTURAL AND EDUCATIONAL
RIGHTS (Art. 29-30)
1.
Protection
(Art. 29)
of interests
of
minorities
a.
Any section of citizens residing in
India and having its distinct language,
script or cultures has the right to
conserve the same.
b.
Educational institutions maintained
or aided by the State cannot deny
admission to any citizen on grounds
only of religion, race, caste and
language.
Right to minorities to establish and
administer educational institiutons
. (Art. 30)
2.
This Article guarantees :
a.
All minorities based on religion or
language have a right to establish
and administer educational institu
tions of their choice,
b.
In granting aid, the state cannot
discriminate
against
educational
institutions managed by minorities
based on religion or language.
Rights of Minorities Based on
Religion and Language
* Religious and Linguistic minorities have
the same rights under Art 30 (1)
September 1984
* Admission of students from other
communities to educational institutions
conducted by minority communities
does not affect the minority rights of
that institution
* Right to establish educational institu
tions of their choice includes the right
to establish and conduct educational
institutions for general secular education
and shools and colleges
* Freedom of choice of the medium of
instruction in education institutions is
also guaranteed by Art. 30 (1)
* The right given to minorities is a
positive one giving special privileges.
Any unreasonable abridgement of it is
unconstitutional. The minority rights
are subject to reasonable restrictions in
the interest of efficiency of instruction,
discipline, health, sanitation, morality,
public order etc.
* Affiliation though not provided for in
Art. 30 cannot be denied to a minority
institution without sufficient reason.
* This right cannot be lost by its non-use.
It cannot be effectively waived either.
* Only if a minority community has estab
lished an institution does it have the
right of administering it under Art. 30
(1)
COMMUNI FY HEALTH CE' L 21
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* The right to administer means the
effective administration of the affairs
of the educational institution and it
does not include the right to maladminister
2.
taking oyer the management of any
property by the State for a limited
period either in the public interest or
in order to secure the proper manage
ment of the property, or
* The minority communities have the
right to form their own Governing
Bodies to manage their educational
institutions without interference from
the State
3.
amalgamation of two or more corpo
rations for proper management or
public interest
4.
removal or modification of any rights
of managing agents, secretaries,
managing director,
director and
managers of corporations or of any
voluntary rights of shareholders, or
5.
extinguishment or modification of
any rights arising from any-agreement
lease of licence for the purpose of
searching for, or winning, any mineral
or mineral oil or the premature termi
nation or cancellation of any such
agreement, lease or licence, cannot
be declared void on the ground that it
takes away or abridges any of the
rights conferred by Arts. 14&19.
* Although the State has no power to
interfere in the internal management
of the minority institution. It has
power to make regulatory measures to
ensure the excellence of the institution
and to issue guidelines to guarantee
security of service to teachers
Is Right to property a Fundamental Right!
Till 1977, right to property was held to
be one of the Fundamental Rights in
the Constitution. The 44th Constitutional
Amendment removed the right to property
from Part III (the chapter on Fundamental
Rights) by deleting Articles 19 (1) (f) and
31 and by inserting in Part XH a new chapter
IV on right to property under Art. 300 A.
Art. 300 A. states : "No person shall be
deprived of his property save by authority of
law."
Note
The right to property is no longer a
Fundamental Right but only a leagal right.
This change would not affect the right of
minorities to establish and administer educa
tional institutions of their choice
Saving of laws providing for acquisition
of states (Art. 31 A)
A law made by the State regarding :
1.
22
acquisition of any estate, extinguish
ment or modification or any rights
related to the estate, or
Note
* If a law regarding the above matters is
enacted by a State Legislature it cannot
be enforced without the President.
* The State through legal provision cannot
acquire an estate' in which a person,
holds land within the ceiling limit for
personal cultivation, and has building or
structures, unless he is paid adequate
compensation for the land or building
at a rate not less than the market value.
Validation of certain Acts and Regula
tions (Art. 31B)
Art. 31 B provides that certain Acts and
Regulations specified in the nineth Schedule
Medical Service
to the Constitution relating to the acquisition
of estates and modification of rights therein
cannot be made void on the ground that it
infringes any of the Fundamental Rights
guaranteed by the Constitution.
This article was incorporated in the Cons
titution to remove the Zamindari system and
to remove all Constitutional obstacles to land
reforms
Saving Laws giving effect to certain
Directive Principles (Art. 31 C)
According to this new Article introduced
in the Constitution through the 25th Amend
ment any law made for the promotion of all
or any of the Directive Principles cannot be
considered invalid on the ground that it
infringes any of the rights conferred by Arts.
14 and 19.
State, while implementing these principles,
should take care to see that the Fundatmental
Rights are also protected at the same time.
IX. Right to Constitutional Re
medies (Arts. 32-35 and 359)
The Constitution of India guarantees not
only Fundamental Rights but also adequate
provisions to enforce them. Accordingly, the
right to entorce all the Fundamental Rights is
itself made a fundamental Right in the Cons
titution, under Art. 32.
Note
a.
every citizen has the right to move
the Supreme Court for the enforce
ment of the Fundamental Rights (Art.
32 (1).
b.
The Supreme Court has the power to
issue directions or orders or writs
including writs in the nature of
Note on Directive Principles of State
Policy
habeas corpus,
mandamus,
prohibition,
quo warranto, and
certiorari.
* They form part IV of the Constitution
* They are considered fundamental prin
ciples in the governance of the country
and it is the duty of the State to apply
these principles in making laws for
socio-economic and cultural reforms.
Whichever is appropriate, for the
enforcement of any of the Fundamen
tal Rights under Art. 32 (1)
* They indicate the policy which the
Union and States ought to follow but
they cannot be enforced through legal
action in the Courts,
Conflict between Directive Principles
and Fundamental Rights
The Supreme Court has held that in case
of irreconcilable conflict between the two, the
Fundamental Right shall prevail
The Court proposed that an attempt must
be made always to harmonise the two and the
September 1984
c.
Parliament has the right to appoint
any other. Courts to exercise power
and function mentioned in Art. 32
(2) and Art. 32 (3)
Constitutional Remedies
1.
Writ of Habeas Corpus (to have the
body)
* The writ is one of the most important
safeguards of the liberty of a person.
This remedy is always available in case
23
of deprivation of personal liberty or an
illegal detention. On an application,
the court is empowered (to direct that
the detained person be produced before
it and is entitled to enquire into the
grounds of his detention is illegal, it
can order the immediate release of
that person.
tribunal' compelling them to do something
specific pertaining to their office and duty.
It commands the person, to whom it is
addressed to perform some public or judicial
duty which he has refused to perform and the
performance of which cannot be enforced by
any other adequate legal remedy
When are writs of mandamus issued?
* his writ is meant only to determine the
legality or illegality of a detention
* Normally, it is for the arrested person
to make an application for “Habeas
corpus'" Bu t if for any reason he is
unable to do so, a relative or a friend
can also make an application for his
release.
* Under Art. 226 High Courts, too, have
power to issue writs for the enforce
ment of Fundamenta I Rights and for
any other purpose
A writ of mandamus may be issued under
the following circumstances :
1.
the petitioner must have the legal
right to compel the performance of
some legal duty owing to him by the
respondent
2.
The legal right of the applicant must
be existing on the date of his
application,
3.
The duty imposed on the opposite
party must be one emerging from a
statue. It cannot be issued to enforce
departmental instructions or orders
not having any statutory foce.
4.
The Petitioner must satisfy that he
has already demanded the perfor
mance of his duty but the authority
has i efused to act.
5.
He must also satisfy that there is no
effective alternative remedy.
* Reasons which can prompt the court to
issue writs of “Habeas corpus' are
2.
i.
the law under which the detention is
made is invalid (ultra vires)
ii.
the law, under which the order of
detention has been made violates
Arts, 14, 19, 22 (1), 22 (2), 22 (5)
etc of the Constitution;
iii.
the authority who issued the order 3. Writ of Prohibition
of detention has on jurisdiction;
* It is also known as Judical writ'.
iv.
the intention of the authority is mala
fide;
v.
the detention is without any legal
justification,
Writ o f mandamus (we command)
A writ to mandamus is a command direct
ed by the supreme Court of High Court to
any person, corporation, inferrior court or
24
* It is issued by a superior Court to an
inferior Court to prevent it from exerci
sing jurisdiction with which it is not
legally vested. In other words itcomples
the courts entrusted with judical duties
to keep within the limits of jurisdiction.
* It is issued in respect of pending
proceedings forbidding the tribunal or
the Court from continuing the proceed
ings
Medical Service
* A writ of prohibition may be issued on
an application
supported by an
affidavit.
* If a judge or any party proceeds with
the case in spite of writ of prohibition,
contempt of Court proceedings can be
started against the person concerned.
4.
Writ of "Quo Warranoo" (by what When can the Fundamental Right be
order)
suspended?
* It is issued to prevent illegal assumption
or use of public office by anybody.
* It is issued against a person who claims
or usurps any office, franchise or
liberty.
* The writ requires the person to show
on what authority he supports his claim.
It can oust him from the office if the
claim is not well founded.
.* It is in the nature of an injuction.
Conditions requisite for the issue of
Quo Warranto
5.
subordinate court. It enquires the subordi
nate Court to transfer the record of a procee
ding pending before it to the Superior Court
to be tried there, in order to ensure the
applicant sure and speedy justice. In India
the writ of "certiorari'* is mostly used for
quashing the decision of the inferior Courts
or Tribunal.
1.
The office must be public.
2.
The office must have been created by
a statue or by the Constitution itself.
3.
The respondent must have assumed
the office on his own.
4.
The respondent is not appointed to
the office in accordance with the
law, or he is not legally qualified to
hold the office.
5.
The respondent continues to exercise
the office till data of the application.
Writ of Certiorari (to be more fully
informed of)
This writ is issued by a Court and is direc
ted to the judge or other officers of its
September 1984
* While the proclamation of Emergency
is an operation the Fundamental rights con
ferred on citizens by Art, 19 will remain
suspended. Besides, under Art. 359, when
the proclamation is in operation the president
may declare the suspension of the right to
move any Court for the enforcement of the
president must be laid before each House of
parliament for their approval.
* At normal times, the Constitution allows
the State to impose reasonable restric
tions of the Fundamental Rights on
grounds of the soverignity and intergrity
of India, the Security of the State,
public order, decency, morality etc.
* To maintain discipline and to ensure the
proper discharge of their duties, the
Parliament is empowered to restrict or
abrogate the Fundamental Rights of
Armed Forces and Forces charged with
the maintenance of public order.
* Parliament has power to suspended
Fundamental Rights of citizens residing
in areas under martial laws. This gives
right to soldiers and other forces to
violate Fundamental Rights in the
course of the discharge of their duties
(Art. 34)
Power of judical Review
In India, the power of judical review is
vested in the Supreme Court and High Courts,
25
always rely on
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V
Poona-1
>
under Arts. 32 and 226. By the exercise of
this power the Supreme Court can examine
the Constitutional validity of a legislation
and declare it invalid if it violated Constitu
tional safeguards.
Art. 13 of the Constitution provides that
if any law, rule or order, which is inconsistant
with part III of the Constitution, is void.
Under Art. 32 the Superme Court and under
Art. 226 High Courts can give relief in the
nature of writs to any individual whose
Fundamental rights are infringed.
These Courts can also examine whether
restrictions imposed on Fundamental Rights
are reasonable and whether they are imposed
in the interest of certain subject like public
morality, order etc.
For the purpose of enforcement of Funda
mental Rights a citizen may either more the
High Court of Supreme Court as their juris
diction is concurrent in this matter. A person,
whose petition is dismissed by the High
Court, cannot move the Supreme Court under
Art. 32 on the basis of the same facts.
Has the Parliament power to abridge
the Fundamental Rights?
In Swami Kesavananda B ha rati's case, in
1973 the Supreme Court held that the Parlia
ment has power to amend the Fundamental
Rights including property rights.
However it has emphatically ruled that
Art. 368 does not empower Parliament to
alter 'the basic structure' or framework of the
Constitution.
Power under Arts 32 and 226
The Supreme Court, under Art. 32 has
power to issue all directions, or orders, or
writs for the enforcement of fundamental
Rights only, but under Art. 226 the High Courts
have the power to issue order, or writs for the
enforcement of Fundamental Rights and for
any other purpose.
For futrher information in Legal matters
contact:
Director, Legal Aid
Indian Social Institute
Lodi Road, New Delhi-110003.
Tel : 622379 : 624760
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September 1984
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28
Medical Service
Bacterial contamination of oral rehydration solution
The value of Oral Rehydration Therapy in
The results are presented in the Table 40
the treatment of acute diarrhoea and dehy and can be summarised as follows .
dration is now well recognised. WHO has
1. Samples of well water showed high
recommended that the rehydration solution
coliform counts indicating fecal contamina
should be prepared with potable water.
tion. This finding confirms our earlier obser
However, most people in rural areas have no
vations and shows that untreated well water
access to clean water and the only available
is not fit for drinking purpose.
well water is often contaminated with fecal
material. A study was undertaken to deter
2. During storage, the well water showed
mine the degree of bacterial contamination of
further multiplication of bacteria but the
Oral Rehydration Solution prepared from
increase in coliform and E. Coli counts was
untreated well water and the same water
much greater in Oral Rehydration solution
used after boiling. Children consuming the
prepared from it. This indicates that addition
solutions were observed to see if there was of glucose and electolytes promote rapid
any difference in diarrhoeal morbidity.
bacterial growth.
This study was conducted in a village near
3. Oral Rehydration Solution. prepared
Hyderabad, where a project on feasibility and
from boiled well water also showed an in
acceptability of oral rehydration therapy is in
progress. ORS packets with a standard crease in bacterial counts during storage, but
the E..Coli counts were significantly lower
composition of glucose and electrolytes were
compared to the solution prepared from un
given freely for all children with acute diarr
treated well water at all time points.
hoea, and the mothers were advised to dis
solve the mixture in one litre of drinking
These results indicate that it is safer to
water, preferably in boiled water. Samples
use boiled water for preparing ORS. Prac
of ORS were collected from 23 subjects in tical feasibility of this adproach however,
the field, immediately after constitution and
needs to be evaluated in field.
transported to the laboratory for bacteriolo
4. In children consuming ORS prepared
gical examination, fn 12 cases, untreated
from contaminated well water, severity and
well water was used for preparing the solu
duration of diarrhoea was not different from
tion, while in the rest well water was boiled
that observed in the other group consuming
and cooled before use. The samples , ware
clean ORS. However, this is a short study
tested for total viable counts, presumptive and a longer trial in larger number of children
coliform and E. Coli counts by standard pro in needs to establish the inoccuousness of
cedures. The counts were reported at 6 an d
such solution.
24 hours after storage in the laboratory, at
by National Institute of Nutrition
ambient temperature. Statistical analysis was
Indian Council of Medical
done using *t' test after square root trans
Research,
Hyderabad 500007.
formation.
September 1984
29
Table 40
Bacteria! counts in oral rehydration solutions
Time of
storage (hr)
Untreated
well water
ORS in
well water
ORS in
boiled water
Total viable counts
X 10s/ml X 106/ml
Presumptive coliforms
X 103/ml
0
24
6
0
0.4± 0.4± 5.5±
0.34 0.38 4.1
6
24
14± 54± 1.3±
10
32
1.0
95±a 230± 119±
60
117
102
1.3±b 482± 60±a
0.56 332
15.2
E. Coil
Counts/m I
24
6
a 136±
7.9± a 81.3±
84
60.3
3.86
2292±b
7.±a 58 ±
778
36
3.3
0
0.3± 2.8± 331 ±a
0.18 0.18 187
7.5±b
2.36
100±
53
Calues are mean ± S.E.
* counts <0.1/ml
a P <.01
1 Compared to ORS in boiled water
b P <.001
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Medical Ethics Forum-35
By Fr. George Lobo, S.J.
Selling Organs for Transplantation
Case : An unempi oyed man with several
children offers to donate one of his kidneys
for a fairly big some of money. He also
donates his corneas to be taken after his
death for a recompense. Is such sale Heit?
With the discovery of a new anti-rejec
tion drug, cyclosporine, the incidence of
organ transplants and the corresponding
demand for organs is likely to rise. The
donor system in vogue till now does not
seem to provide the needed supply. To
meet the shortage. Dr. Barry Jacobs of the
U.S.A, has set up an International Kidney
Exchange Ltd., which would pay individuals
or families for organs.
There is no ethical objection to trans
plant of corneas or other o.rgans taken from
cadavars provided the respect due to the
dead human body is maintained and due
premission is obtained from next of kin
unless the person himself or herself had
donated the organ while still living. When
organ transplantation from living donors
was first introduced, there was reluctance
on the part of many ethicists to find this
procedure morally acceptable because it
involved mutilation or the loss of an organ,
e.g., kidney which is an integral part of the
body. After some time, most ethicians con
ceded its acceptability provided the functio
nal integrity of the individual was not
compromised. The donation of one of a pair
of healthy organs, such as the kidney would
be licit, as it did not in itself imply the loss
of functional integrity since the remaining
healthy organ could readily carry out the
required kidney function for the individual.
September 1984
The risk to which the donor was placed by
the loss of one kidney if the remaining one
were later to become damaged by disease
or accident was considered acceptable in
the light of the tremendous benefit to the
receiver who was joined to the donor by
charity or human solidarity. But would the
giving up of an organ be ever justified by
the motive of monetary compensation?
Those who oppose the payment system
hold on practical grounds that, as the experi
ence with blood transfusion shows, the
quality of organs with a price tag would go
down because the givier would be inclined
to hide a disease which if known would make
the organ unaccepatable for transplantation.
A volunteer donor would not likely be seri
ously tempted to hide such relevant
information. Besides, as some fear, this
would tend to make the poor a source of
spare parts for the rich which would be
against social justice.
But would it be intrinsically evil to accept
financial recompense for.an organ donated
for transplantation? Can one donate an
organ out of human solidarity and at the
same time accept money in exchange?
Many persons perform a work of charity or
minister to the sick and yet will accept a
salary. They would generally be willing to
work gratis if all the necessities of life were
otherwise provided. The salary need not be
the prime consideration.
The main point is that organ donation
with the implied risk must be motivated by
suitably virtuous reasons which must be
proportionately serious. An organ donation
for the sake of money destined to be used
(Contd. Page 37)
31
CHAI
NEWS
NOTES
Indian Academy of Pediatrics Policy Statement Based on
Report of Special Committee (1983)
Recommendations on Breast-Feeding
1. Breast-feeding remains the best
feeding for all Indian children. Mother’s milk
supplies all nutrients needed for the first
four to six months of life, including water.
Even inadequately nourished mothers provide
milk of sufficient quantity and quality during
this period. In the second year of life,
breast-milk continues to provide atmost
half of the child’s total nutritional require
ments. Breast-feeding also helps in spacing
children.
2. Pediatricians should actively co-operate
with their obstetric colleagues in spreading
correct information on breast-feeding to all
mothers during the antenatal and postmatal
period. They should assist the mother
prepare for breast-feeding during pregnancy.
Pregnant and lactating mothers should be
provided with extra calories in form of.
locally available food preferences, dietary
habits and meal patterns.
3. Obstetric practices that may interfere
with proper loctation should be discouraged.
4. Baby should be put to breast pre
ferably in the labour room itself but definitely
within four hours after delivery. This is true
for all babies whether delivered normally or
after Caesarean section.
5. To promote proper lactation, rooming
in of babies and 'on demand’ breast-feeding
schedule is strengly recommended. Practice
of isolating normal babies for fear of infec
32
tion from visitors and for other reasons in a
separate nursery and feeding babies by
clock should be discouraged.
6. Prelacteal and supplemental feeding
particularly when given through a feeding
bottle, should be strongly discouraged as
such practices interfere with successful
lactation.
7. Normal newborns do not need any
type of prelacteal feed with glucose or
artificial milk as clostrum is enough to meet
the limited needs of the newborn baby in the
first few days of life. However, if found
essential, the same could be given with a
spoon rather than through a feeding bottle.
8. Most infections in the mother and
commonly used drugs taken by her need
not always come in the way of breast
feeding. Thus in case of maternal tuber
culosis also, breast-feeding can often be
continued. However, treatment of the mother
and close observation of the infant is essen
tial.
9. Restriction of breast-feeding for any
length of time before and after the adminis
tration of oral polio vaccine is not required.
10. Normal exclusively breast-fed babies
may pass several loose motions each day.
This is not diarrhoea and does not necessi
tate the use of any medication. In the
early weeks of life, the stools may even be
green in colour. Similarly, some normal
Medical Service
breast-fed infants have very
motions. The stools are loose.
not be treated as constipation.
infrequent
This need
/11. Infectious diarrhoea can occur in
children who are on a mixed diet or those
given contaminated water. However, breast
feeding should be continued in such cases.
12. In an exclusively breast-fed child
who is gaining weight adequately, routine
administration of water and vitamins, and
addition of outside milk, weaning foods,
juices and soups is not needed until the age
of six months as early addition of such
i terns interfere with proper lactation and
increase the risk of diarrhoea and allergic
disorders like eczema and bronchial asthma.
13. A baby demands feeds frequently
especially in the first few days after delivery.
This is physiological and should not be
taken as a sign of inadequate breast-milk.
Crying in a baby is mostly due to colic and
not necessiarly due to inadequate milk.
14. A continuous effort should be made
by all pediatricians to encourage freshly
made, locally available family foods to be
used as weaning foods as they work out to
be far better, cheaper and beneficial than the
marketed weaning foods (e.g. porridge
made with locally available cereals). These
foods should be started between 4-6 months,
preferably at 6 months in infants, who are
thriving well at the breast. Breast-milk is
continued along with solids.
15. Pediatricians should follow in enti
rety the 'Indian National Code for Protection
Promotion of Breast-feeding’ in its letter and
spirit. ■ Thus (a) hospitals, nursing homes
and doctor's place of work should not be
allowed to be used for the display of infant
foods, feeding bottles and teats, (b) pedia
tricians should refus a I types of induce
ments from the manufacturers and distribu
September 1984
tors of these products and (c) employees of
such manufacturers and distributors should
not allowed direct or indirect contact of any
kind pregnant women or with mothers of
infants and young children.
WHO Director-General Calls
1984 Year of Opportunities
for Health for All
WHO Regional Committee for SouthEast Asia, Thirty-seventh Session,
New Delhi, India, 18-24 September 1984
New Delhi : The WHO Director-General,
Dr H Mahler, has called 1984 a year of
opportunities for health for all.
Addressing
the 37th session of the WHO Regional
Committee for South-East Asia here today.
Dr Mahler said that for WHO, four major
events were noteworthy. These were the
start of the evaluation of the strategies for
health for all, the gathering momentum of
the Organization's Seventh General Pro
gramme of Work, preparation for the pro
gramme budget for the biennium 1986-87,
and the progressive introduction of the new
managerial arrangements for the optimal use
of WHO's resources by Member States.
Regarding the evaluation of strategies for
health for all. Dr Mahler referred to several
basic questions that needed to be asked
fearlessly. For example, "Are you expanding
the coverage of your population with primary
health care ? Are your people learning more
about health so that they can assume
growing responsibility for their own health
and for that of their family and the comm
unity in which they live ? Do women have
access to care before, during and after
pregnancy ? Do all your people have access
to the vaccines and essential drugs they
require at a cost that they and the country
can afford ?"
Dr Mahler stressed that
this way obstacles could be identified and
remedial action taken.
33
Referring to the principles underlying the
Seventh General Programme of Work, Dr
Mahler said that these principles for building
up national health systems had emerged as
a consensus at Alma-Ata six years ago.
They involved planning and carrying out
primary health care systematically until all
the population had access to motivated
health workers, who were adequately
trained, equipped and supplied to carry out
their duties.
with the Organization, and invited them to
experiment with them further.
He urged ail
the countries of the Region to carry out as
speedily as possible the regional plan of
action for making the WHO's resources
optimally useful for all of them.
Dr. Mahler called for a worldwide
solidarity for health for all. "There exists a
terrible danger that our strategy for health
for all will join the ranks of other initiatives
that started with bright hopes for better
social justice, only to lead to those who had
much having more, and those who had little
having less". This could be prevented if the
countries display solidarity and ensured that
the weaker were supported by the stronger.
Turning to the programme budget pro
posals for 1986-1987, the Director-General
said that one of the most disturbing facts
that had come to light recently was that
most countries did not know how their
resources for health were financed and how
much people [were able and ready to pay to
protect and restore their health. Unless this
was known, how could programme budget
decisions be made, he wondered.
This was
another obstacle that could become an
opportunity to make serious efforts to clarify
'Just how and where and when and why
and by whom we are spending on health as
a first step to putting right what is wrong/'
This was an area where WHO's resources in
each country could become a "key to many
doors", including
enlightened external
support based on equally enlightened identi
fication of priorities. The universality of
WHO offered the opportunity for fruitful
cooperation at the country, intercountry and
regional levels as well as the inter-regional.
and global levels, he added.
In his inaugural address, the Health
Minister stressed the need for a clear vision
of social goals with regard not only to the
quantiattive aspect of the population, but also
the qualitative aspects of life and human
development.
Referring to the new managerial arrange
ments for technical cooperation between
countries and WHO, the ‘ Director-General
said that these arrangements were aimed at
making optimal use of WHO's Seventh
General Programme of Work in support of
national strategies for health for all. He
paid tribute to countries that had experi
mented with these new ways o I working
Referring to the country's national health
policy, Mr Shankaranand said tha t it laid
stress on the preventive, promotive and
rehabilitative aspects of health care through
the primary health care approach. "It also
views health and human development as a
vital component of overall socio-economic
development with active community partici
pation", he added.
34
Thirty-Seventh Session of -the
WHO Regional Committee for
South-East Asia Opens
New Delhi: The thirty-seventh session of
the WHO Regional Committee for South-East
Asia was officially declared open by the
outgoing Chairman, Mrs Chandra Kala Kiran,
Secretary, and was inaugurated at World
Health House today by the Chief Guest,
H.E. Mr. B Shankaranand, Minister of Health
and Family Welfare, Government of India.
Medical Service
The Health Minister reiterated India's
commitment to attaining the goal of health
for all through universal primary health care.
Notwithstanding the economic constraints,
the current National Development Plan
provided a much higher allocation for health
and related sectors.
Referring to collaboration with WHO and
cooperation with developing countries,
Mr Shankarannad said that India, with its
vast reservoir of trained medical man-power,
was in a position to meet the immediate
requirements of friendly developing countries
and in organizing training programmes for
their medical personnel.
In his address, the Regional Director of
the WHO South-East Asia Region, Dr U Ko
Ko, referred to India's contribution to medical
sciences and said that the Indian systems of
traditionabmedicine continued to serve large
populations in the country.
India's determined efforts in health
development were reflected in the formul
ation of its national health policy and in its
emphasis on maternal and child health,
planning, control of tuberculosis and leprosy
as well as the provision of drinking water
supply and sanitation in the context of the
goal of health for all through primary health
care.
Regarding the health situation in the
Region, the Regional Director pointed out
that perceptible progress had been made in
all the countries. Tremendous efforts conti
nued to be made to improve and expand the
national health infrastructure and raise the
health status of the people through inter
sectoral collaboration for socio-economic
development; of which health was an integral
part.
Recognizing that positive health was
essential to the development of the human
September 1984
potential, the countries had been individually
and jointly formulating strategies for health
for all, developing plans of action based on
these strategies and taking concerted steps
to implement them.
"It is heartening that
many innovative
approaches
towards
initiating and assimilating desired changes at
the grassroots have already been evolved
and absorbed within the framework of
primary health care in many counties of the
Region", the Regional Director added.
In his address to the Regional Committee,
the WHO Director-General Dr H Mahler
called 1984 a year of opportunities for health
for all. The Director-General mentioned that
one of the main obstacles to attaining the
goal of health for all was the weakness of
the health infrastructure in most countries.
The recognition of these obstacles had given
rise to the opportunity to overcome them by
setting forth in the global strategy for health
for all the principles on which to build up
sound health systems based on primary
health care. .
To ensure that the goal of health for all by
the year 2000. was achieved, the DirectorGeneral called for a worldwide solidarity.
Unless this was done, the present disparities
in health care would continue. This could
be prevented if the countries displayed
solidarity and ensured that the weaker were
supported by the stronger.
WHO
Regional
Office- Bea re rs
Committee
New Delhi: The 37th session of the WHO
Regional Committee for South-East Asia
elected the following as office-bearers :
Chairman : Mr. C R Vaidyanathan
Secretary
Ministry of
Health and
Family Welfare, Government
of India.
35
Vice-Chairman : Dr S D M Fernando
Director-General of Health
Services Ministry of Health,
Sri Lanka
Dr H Mohammad Isa, Director-General of
Medical Care, Ministry of Health, Indonesia,
was elected Chairman of the Technical
Discussions which will deliberate on, "Inno
vations in primary health care within the
community".
The sub-Committee on Programme Budget
of the Regional Committee elected as its
Chairman, Dr Uthai Sudsukh,
Deputy
Permanent Secretary, Ministry of Public
Health, Thailand.
Option for Life in Mexico city
Following the heels of the UN Internation
al population Conference held in Mexico
City from August 6th-15th, 1984, PLAN
(Protect Life in All Nations—an International
Pro-Life group) organised its * third Inter
national Pro-Life conference in Mexico City
from 11 th-15th August 1984. A well above
20,000 strong Pro-Life strong rally by the
Mexicans and some of the participants of the
conference to the world famous shrine of our
Lady of Guadalupe, originating from the
Square of the Three Cultures, which flanks
the building (Foreign Affairs) where the
major UN sessions were held, marked the
beginning of the 5 day conference on 11th
August. While the over all tone in the UN
meeting was an anti-life one delegate from
various countries arguing for abort ion, steri
lisation etc, this march and the conference
that followed was one of Pro-Life. The
marchers walked along 10 km route in prayer
and chanting of hymns by the band conclud
ing that day's programme with the concelebrated Holy Mass at the New Basilica of Our
Lady of Guadalupe.
36
The conference began on August 12,
with a concelebrated Holy Mass at the
Cathedral of Mexico City. There after the
meeting was called to order by Paul A.
Brown PLAN'S Secretary. The time that
followed till the evening of 15th August was
spent in sharing the concerns and situations
in different parts of the world. More than
200 people from more than 20 countries
participated in the 4 days deliberations a
good number of them being mexicans. From
India Fr. John Vattmattom SVD attended the
meeting representing the Catholic Hospital
Association of India (CHAI). Fr. Paul Marx
OSB, Vice-President of PLAN, giving an
account of the situation in various countries
in the world in promoting abortion remarked
that "the West has lost its will to live". He
mentioned that two third of the world is pro
abortion. He asked the Mexicans to contiune their love for children as he found
Mexico, with a 5.4 birth rate, "rich in child
ren," as against US (1.8), Canada (1.7) and
West Germany (1.2). (It should be noted
that a birth rate of 2.2. is required just to
reproduce a country's population.
Others who presented papers and spoke
during the conference include : Dr. Carlos
Fernandez of Mexico, Sara Brown of Scot
land, Fr. Rene Bel of France, Alfonso Bravo
Mier, Manuel Zepeda,
Gabriel
Vera,
Ma. Aurora Guzmen of Mexico, Valerie Riches
of England, Fr. Antony Zimmerman SVD of
Japan, Martin Humer of Austria, Marijo
Zivkovic of Yugoslavia, Fr. Otto Maier of
Germany, Paul and Judie Brown and
Dr. Herbert Ratner of USA and Fr. Pedro
Richards of Urugaay. The delegates shared
the situations in their respective countries.
Dr. Herbert Ratner, advisor to the,Pontifical
Council for the Familly, warned the audience
that "the Social engineers are out to get
you. If you haven't been aborted, euthana
sia will get you yet". He continued his
warning reminding the audience tha t "the
M edical Service
World Bank, the Population Council IPPF,
US AID etc. don't like children. Neither do
drug firms. The pill is chemical warfare
against the women of the world".
Every morning the meeting started with
concelebrated Holy Mass and praying for the
needs of the various countries. On 15th
August, the day of India's Independence,
Fr. John Vatlamattom SVD of CHAI was the
main celebrant for the concelebrated Holy
Mass in the morning.
Fr. John in his
message requested the participants to pray
for India especially at this juncture when
respect for life is declining rapidly in spite of
the ancient rich religious heritage of the
country and the Principle of Ahimsa upheld
by its great leader Mahatma Gandhiji.
The final ceremony of the Third Inter
national PLAN Conference was a paraliturgy
(Contd. from Page 31)
for obtaining luxury items would not consti
tute an adequate reason. But if the money
were to be used for basic necessities and
other funds were simply not available, then
the donation need not be viewed as morally
unacceptable. Of course, it is lamentable
that some people are in such straights that
they have to resort to such extreme
measures to survive.
Years ago Pope Pius XII did not find
donation of corneas altogether illicit: "More
over, must one, as is often done refuse in
principle all compensation? This question
remains unanswered. It cannot be doubted
that grave abuses could occur if a payment
is demanded. But it would be going too
far to declare immoral every acceptance or
every demand of payment. The case is
similar to blood transfusions. It is commen
September 1984
wherein everyone in attendance held a
lighted candle as each of the eight priests
present expressed, in succesion, some
thoughts and prayers concerning right to
life. After each utterance, the group sang
the conference's "theme song," "The Light
of God," first in Spanish and then alternately
in English, French, and German.
The concluding message can be expressed
as foHows: "You must light your own
candle. Overwhelming problems become
opportunities when you trust in God. The
real heroes of pro-life are the people in the
trenches.
Take time to read and learn.
Spread the message. All organizations exist
to serve people. Say 'v/va la vida' once a
day. With Mary, let us always say 'Yes' to
the Lord’’, and therefore "Yes to Life".
—FR JOHN VATTAMATTOM SVD
dable for the donor to refuse recompense:
it is not necessarily a fault to accept it."
(Allocution to Eye Specialists, May 14,
1956.)
Because of the current climate of
dehumanizing attitudes towards the indivi
dual person, it would be wiser to avoid the
outright selling of human organs. Of course,
suitable compensation for the cost of the
donor's surgery and possibly for the loss of
wages could always be demanded. The
diminishing or risking one's physical integrity
for financial profit is to be avoided as far as
possible. But we could not outright con
demn a person who has recourse to it as a
last resort when he has to other way of
maintaining himself or his family. It is for
society to see that people are not driven to
such straights.
37
By Dr. Rajaratnam Abel, MBBS : MPH
B.C.G. is the vaccination that gives pro
tection against tuberculosis. It stands for
Bacilles-Calmette-Guerine, names after the
two scientists who discovered the vaccine.
In the past there have been many questions
and doubts expressed about the value of
B C.G. Many recent studies have now clearly
defined the role of B.C.G. in the prevention
of tuberculosis.
This vaccine is produced by a strain of
cattle tuberculosis bacteria. These bacteria
are repeatedly grown outside the body in
laboratones. This process of growth makes
these bacteria to lose their virulence or
capacity to produce disease. However,
because these are foreign to the human body,
when introduced by injection into the skin
the body responds by developing immunity
or specific resistance.
What happens is very much similar to
primary tuberculosis, only the site varies
from the lung to the skin. The injected
tuberculosis bacteria invade the lymph nodes
of the armpit. Actually a controlled disease
is allowed to develop. As the disease deve
lops the body also responds by producing
immunity. So what is done is the creation
of artificial immunity against tuberculosis.
The dose of the vaccine is 0.1 ml. This
is injected into the most superficial layers of
the skin. The usual site is just below the
shoulder. Successful vaccination is indicated
by a nodule that develops at the site of
injection, 10 days to 4 weeks after the
injection. Sometimes a small pustule of an
abcess may form at the site. If accidentally
the injection is given deeper under the skin
or into the muscle it may produce an unlcer
38
or wound. At such times the lymph node
in the armpit is enlarged significantly.
How much Protection?
B.C.G. vaccination does not give 100%
immunity. Also the results vary from the
time the injection is given. The protection
afforded is 80% over a period of 5 years
coming down to 60% over a period of 5
years. This means 60%—80% of the popu
lation will be protected against tuberculosis.
The protection is equal in both sexes. It
gives protection from all forms of tuberculo
sis. Should infection occur in spite of B.C.G.
vaccination, then the disease is of a very
mild nature. B.C.G. therefore gives a definite
though a partial protection.
It was thought that B.C.G. might give
protection against leprosy also in addition
to tuberculosis. But this is not proved yet.
Now attempts are being made to give B.C.G.
and small pox vaccination at the same time.
One injection may cover both tuberculosis
and small pox.
Who should receive B.C.G.?
The ideal person is a new born child.
This child has no contact with tuberculosis
and it is safe to give the child B.C.G. imme
diately after birth. The only precatuion is
when the mother has tuberculosis. In such
situations B.C.G. can be delayed or a difrerent'type of B.C.G. can be given. This is the
INH resistant B.C.G. This means the bacteria
will not be killed by INH. This child, after
receiving the vaccination can also be treated
with INH without affecting the development
of immunity.
Medical Service
In a country like India where the risk
infection is high it has been found usefu Ito
give B.C.G, Vaccination to all below the age
of tuberculosis by doing tuberculin testing.
But the process was cumbersome and many
children were missed. Further it was found
that even if the child had primary tuberculosis
B.C.G. was not harmful. So all below the
age of 15 years can sal ely receive B C.G.
vaccination even without tuberculin testing.
This is what is called mass B.C.G. vaccination.
In the western countries, where the risk
of infection is low, the above does not apply.
Here B.C.G. is given only to those in whom
the risk of infection is high. This includes
close contacts of a person suffering from
'open’ tuberculosis, or when a person goes
to a country where the risk of infection is
high.
B.C.G. should not be given in the fol ow
ing situation. When the child is prematurelyborn, when he is of low birth weight,
andwhen the children are suffering with skin
diseases.
The best example to show the value of
B.C.G. is an incident that took place in
Denmark during World
War II. B.C.G.
vaccination programme was being carried out
in a school of 300 girls. Initial tuberculin
testing showed 100 girls to be positive and
200 negative. Of the 200 girls who were
September 1984
negative 100 received B.C.G. vaccination.
The war suddenly intensified, and so the
school was closed. Hundred girls missed
B.C.G. vaccination.
The next school year the B.C.G. work
was restarted. The 100 tuberculin negative
girls were again tested. The health authorities
were surprised to see that 40 of the 100 girls
showed a positive reaction indicating these
girls developed infection since the last
vaccination programme.
The contacts of these 40 girls were check
ed. Their teacher had been changed that
year. This new teacher had cough during the
winter months. She reported this to her
doctor,who treated it lightly because he too
had a winter cough. The teacher was che
cked again and the preliminary tests showed
her to be all right. But one special test
indicated that she was suffering from tuber
culosis. She was the cause of infection
among the 40 girls who did not receive
B.C.G. vaccination.
Unfortunately, in India and other develop
ing countries due to poverty, ignorance and
technical and personnel difficulties B.C.G.
vaccination has not made much headway.
B.C.G. definitely gives protection against
tuberculosis and all children below 15 years
must be vaccinated.
Courtesy: HERALD OF HEALTH
39
Emphysema: The Facts About Your Lungs
Emphysema is on the increase. In eleven
recent years deaths from this disease almost
tripled. Over 20,000 die of it every year.
different patients at different times. Under a
doctor's care, most patients can get relief
from their attacks of breathlessness.
Who Gets Emphysema?
If a man’s job does not require heavy
physical labour, his doctor will usually say
that he can continue to work. It is very
important for the patient to stop smoking to
help avoid further irritation and lung
damage.
Persons with emphysema are, for the most
part, males between 50 to 70 years old.
Women get empysema, too, but not as often
as men. A very high percentage of the
people who have emphysema smoke cigaretees and have been heavy smokers for many
years.
How it Attacks?
The thing that usually brings the patient
to his doctor is that he has begun to feel
short of breath on exertion in the morning or
evening or both. He may think he has
asthma or heart disease.
Effects of Emphysema
Emphysema may begin with only a slight
morning or evening inconvenience in breath
ing. Next, a short walk may be enough to
bring on an attack of breathlessness. It may
reach a point where ever breath requires a
major effort.
Treatment
Doctors can help emphysema patients live
more comfortably with their disease. Diffe
rent treatments, including antibiotics, help
40
People with emphysema, with the help
of breathing retraining, carefully selected
exercises, and aid in keeping their lungs clear
of excess fluids, can learn to make the best
use of the breathing capacity they have.
Prevention
Continuing research is being conducted
to find answers to many questions about this
disease, but doctors do know that cigarettes
smoking is a definite cause, and that cutting
out smoking can avoid damage for many
who would otherwise develop the disease.
Controlling air pollution can also help.
Modern medicine can usually slow down
the progress of emphysema if patients are
treated early. It is always the doctor’s imme
diate concern to clear up any infection or
irritation of a patient’s respiratory system,
because these things set up possible starting
place for emphysema.
Courtesy: HERALD OF HEALTH
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