MEDICAL SERVICE VOL. 42 No. 10 DECEMBER-1985.pdf
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COMMUNITY HEALTH CELL
326, V Main, I Block
• ?Kora rnung
A&ng ;kdh»"560034
■ ■
&&
they must increase : we must decrease • let my people go > you did it
to me • smoking • to pull down and build new • child survival here and
now • what's new in health care management
medical
service
official house journal
of the catholic
hospital association of India
“the love of Christ
urges us“ 2 cor 5 :14
vol 4^
no
editorial board
december 1985
contents
dr c m francis
dr ravi narayan
dr prem chandran john
dr daleep mukarji
mr augustin veliath
fr george lobo sj
prof george joseph
dr paul neelamkavil
fr edwin m j
1
editorial
3
2
they must increase : we must decrease
4
3
lucknow declaration
9
let my people go
10
you did it to me
13
smoking
17
to pull down and build anew
23
child survival here and now
27
what's new in health care management.
33
editor
fr john vattamattom svd
cover design
6
9
p m isaac bangalore
illustrations
joe fernandez
published by the catholic
hospital association of india
c b c i centre, goldakkhana
new delhi-110001
printed at kalpana printing
house new delhi-110016
"Articles and statements published in this journal
do not necessarily reflect the policies and views of
the catholic hospital association of india"
Dear friend,
Birth of Jesus aroused different responses in different
people.
The shepherds were overwhelmed with joy
as they foresaw their liberation at hand.
The wisemen left everything
in order to start on a search to find Him
The powerful Herod was in panic
and he tried to do away with the potential threat
In our times,
Do the one crore forty lakhs of infants
born yearly in our land
receive a warm welcome to our midst?
What is our response
to the three thousand one hundred fifty infants
being crushed to death everyday by our insensitivity
and lack of political will?
MAY THE CHILD JESUS
STIR AND AWAKEN US
TO THE ''SILENT EMERGENCIES 11
OF THESE LESS PREVILEGED INFANTS
AT THIS CHRISTMAS
AND IN THE COMING YEAR
In solidarity with you and your endeavours
in this direction during 1986.
EDITORIAL
'WHO
DO
PEOPLE
SAY I AM'
’Who do people say / am?’ Jesus paused this question in Caesare Philippi.
2000 years later a similar question surfaced again in Lucknow at the
42nd National Convention of the Catholic Hospitals. The question: 'Who do
people say we are ? or more appropriately whom do people say we serve ?
One of the answers came from the Union Deputy Minister for Health
and Family Welfare (see Box on page 5). The other came from Mr. David
Haxton one of the speakers on the second day, (see box on page 6). Both
overwhelmingly flattering and both inviting participation and seeking alliance.
The question came back more powerfully at one of the seven half day
workshops and from there to the plenary session.
There were several attempts at answering this question. Inconclusive
as the answers are every participant I hope carried the question home to
ponder over it, to answer for herself or himself and for one's own institution,
congregation, association diocese and the church.
For more than 200 hospital administrators, doctors, pharmacists, nurses
and health professionals who assembled in the capital of India's most populous
state this basic and perhaps uncomfortable question raised again and again
at the convention should be the torch that they carry home and bequeath to
their friends.
Of what significance is our presence in the health scene of this country
if we cannot make an impact on one out of every ten children who dies need
lessly in the very first year of his birth ?
Or on the thousands of children who are maimed or disabled or are born
idiots due to easily preventable diseases ?
Is not this a corollary to the question
"who do people say I am ?"
They must increase : We must decrease
Convention calls for parish based health action—a report by Augustine J. Veliath
"We are not just an association of hos
pitals and dispensaries. We are the health
wing of the church, the largest health care
organisation in the world. Health is the basic
human rights guranteed by the Indian cons
titution. Denial of health is denial of the king
dom of God".
We have worked miracles in the past. We
have eliminated small pox from the face of the
earth; we have added 22 years to life expec
tancy and brought down death rate from 27
per thousand to 11 per thousand.
Tough word in the given circumstances,
but not unexpected from a convention that was
discussing "silent emergencies of our times."
A Different Birthday Card
For the key note address delivered by
none less than the Dr. Harcharan Singh, the
Advisor to Government of India on Health
had painted the grim scenario in its true color.
He reminded the audience during the
time the previous speaker addressed the meet
ing (about 30 minutes) 200 children had died
in India of needless and preventable causes.
One out of every ten infants born failsto cele
brate his most coveted first birthday. This is
unacceptable.
in 1971, 9 to 10 million people crossed
over to India from what was then East Pakis
tan. Overwhelming world opinion then en
dorsed military action on the part of India as
no country can carry such a load. We ourselves
add about 14 million children year after year.
One out of ten of these children die before
her first birthday. Two others die in the next
two years.
Inviting the catholic institutions to parti
cipate in the universal immunisation scheme,
the new Union Deputy Minister for Health
and Family Welfare Mr Krishna Kumar assured
us that the portals of the Health Ministry is
open to CHAI and other voluntary organisa
tions. He said soon the Ministry will invite
Most of those death are preventable. important health care organizations, CHAI
There are many no cost and low cost solutions among them, to participate in Child Survival
and health related activities. 'You are welcome
to these overwhelming problems. Home based
diarrhoea management, universal immunisation, to take over the Primary Health Centres and the
Government will allow the same financial
improved infant feeding practices, mothers mo
nitoring their own children's growth are some allocations provided to Govenment PHCs,
of those techniques; Dr. Singh pointed out.
he said.
4
Medical Service
Largest
Presiding over the inaugural function
Dr. Alan de Lastic, Bishop of Lucknow spoke
of the unutilised resources within the com
munity. Schools, he said provided the best
example.
Dr. C.M. Francis, Director of Continuing
Education Christian Medical College, Vel
lore, raised a few soul searching questions
(please see article on page 13). Dr. George
Joseph stressed on true Christian response of
the followers of 'thewoundeds aviour' in a
world where death and illness seem to be
having a field day.
Describing the Catholic Church as a
major ally in promoting child survival revolu
tion, Mr. David Haxton, Regional Director for
South Asia UNICEF stressed action was
feasible here and now. He outlined what our
institutions can do right now and how the
priests, the religious and parish communities
support them.
Painless, Fearless births
Mr. S. Krishna Kumar, Union Deputy
Minister for Health.
"The Catholic Church is the single
largest health care organization in the
world. Its role in India has been pivotal.
"The priests and nuns and other
Church workers are working in difficult
terrains and remote rural areas, sacrific
ing their personal comfort and rendering
devoted service."
"Our approach has to be that of a
mass movement and in this government
and voluntary organizations have to be
co-partners."
December 1985
Dr. Leboyer, the well known French ex
pert and author of Art of Breathing was a
special guest at our convention. According
to him painless and fearless child births are
possible. If the child comes into this world
with the feeling that it is beautiful to be born
the feeling is likely to stay.
A woman who is fully relaxed and is
trained to fix her attention somewhere else
during the child birth can make this possible.
Breath and sound are the two keys to
birth becoming an ecstatic experience. Breath,
not merely the physical act of breathing, but as
Prana as understood in India is deeply con
nected with life. Religions know the signifi
cance of inner sound. The Aum of the Hindus
and the Amen of Christians are not too far
apart.
5
If a woman learns to awaken her inner
sound pregnancy becomes a pilgrimage. Con
tinued training allows you to reach to what is
more beautiful than the sound itself — Silence
genuine silence where the minds stops acting.
Tanpura the Indian musical instrument is to
sound, what rainbow is to light.
Major ally
Pain is not a necessity. What is expe
rienced as pain is the intensity. Once the wo
man learns to ride "the waves" this intensity
itself can be ecstasy.
Dr. Leboyer cautioned against what we
learned from the West. Deliveries in clinical
situations are usually done in a hurry, because
the assisting doctor at that moment is con
fronted with his own birth trauma.
This year the convention participants had
seven different workshops to chose from:
I.
Strategising for IMMUNISATION
and
Communicating Diarrhoea
Manage
ment to Mothers lead by Dr. Valerian
P Kimati, Health Section, South Asia
Region.
(An issue of Medical Service will be
devoted to this subject)
II.
Community Health
Fr. Thomas Joseph
Sr. Mariamma
Mr. John T Samuel
All from the community health team of
CHAI
III.
Child Care Priorities
Dr. K.R. Antony
CHAI
IV.
Health Care Management : What's
New
Mr. Sam Thangraj
Development Consultant, New Delhi
See article on p. 33
(Continued on page 7)
6
David Haxton, Regional Director, Unicef.
(I am here) "mainly to learn from the al
most unequalled richness of experience in
health-care under the inspiration of the
Roman Catholic Church.
I am not surprised that in 1973, five
years before the Alma Ata Declaration on
primary health care, your Association chose
for a similar annual convention the theme :
Health for the Millions.
I am aware that your member units have
struggled, particularly in the years that follow
ed, to make this slogan a reality. You have re
cognised earlier than most others that hos
pital care and other ways of dispensing
medicines, are only a small part of health
promotion.
Encouraging reports appear periodically
how your health workers, in association with
the nuns and priests spread out even in re
mote areas, have tried to organise communi
ties of optimal size in compact areas, regard
less of religious affiliation, and engaged them
in the effort to rebuild their lives through
better access to the means of health."
Medical Service
ACTION POINTS FOR PARISH COMMUNITIES
they receive continuous uninterrupt
ed treatment until they are whole.
Can our parish community ensure
that every infant in our parish area
is immunised before his/her first
birthday?
Can we ensure that every village in
our parish/area have at least three
drinking water sources?
Can we inform every mother in our
parish/area about preparing and ad
ministering salt sugar solution to
children with diarrhoea?
Can we introduce low cost latrines
and other sanitary measures in each
of our villages ?
Can we ensure that every infant in
our area is fed adequately by insist
ing that he/she receives breast
milk from the first hour of birth and
receive supplementary feeding from
four months onwards?
Can we ensure that undernourished
and
malnourished,
particularly
pregnant women and children re
ceive food supplements like vitamin
A, Iron, Iodine, Folic Acids etc.
Can we take measures that lessen
the drudgery of women by measures
like smokeless chulha.
Can we ensure that all children under
five in our area are weighed and that
the children whose growth is de
clining receives special care.
Can we introduce appropriate in
come generating programmes for
the community, especially for the
families with the least income.
Can we ensure that all T B and lep
rosy patients are identified and that
THEY MUST INCREASE WE MUST DECREASE
THE FOCUS MUST NOW BE ON THE PARISHES
(Continued from page 6)
V.
Patient Support Systems :
Dimensions
Holistic
Sr. Pauline Yadav
Holy Family Hospital, New Delhi
See next issue of Medical Service
VI.
Legal Aid and Health Professionals
Fr. P.D. Mathew sj
Indian Social Institute, New Delhi
(See next issue of Medical Service)
December 1985
VII.
Myths about Food and Hunger
Mr. Korah Mathen
Lalbhai Trust, Ahmedabad.
Workshops were very highly appreciat
ed and the subsequent group and plenary dis
cussions and convention resolution
reflect
the impact of these workshops.
7
LUCKNOW DECLARATION
We, the representatives of Catholic health
institutions of India consisting of doctors,
nurses, pharmacists, hospital administrators
and health activists representing around 1900
member hospitals and health care institutions,
gathered at St. Fidelis School, Lucknow from
10 —14, November 1985 for the 42nd Na
tional Hospital Convention :—
— reminding ourselves that we are not
just an association of institutions but the
health wing of the Church in India
gramme. We, through our member
institutions and their infrastructure,
express our willingness and keen
ness to collaborate with the Govern
ment in this endeavour.
2.
draw up a health policy which will
include a code of conduct for our
professionals and institutions. We
authorise the Executive Board to
take necessary steps.
3.
increasingly identify ourselves with
very poor and make available pri
mary health care to all in the neigh
bourhood of our institutions. Low
cost health care facilities may be
provided within the existing insti
tutions and outside them.
4.
prepare appropriate communication
materials that are required to inform,
educate, and persuade win over
institutions communities, commu
nity leaders, health professionals to
principles and practice of commu
nity health.
5.
take the initiative to catalyse the
formation of central or regional
puchasing agencies to ensure the
availability of essential drugs and
health accessories.
6.
draw up appropriate plans to be in
partnership with schools, associa
tions, like minded action groups and
governments in promoting commu
nity health.
— recognizing that health is a basic human
right guaranteed by the Indian Consti
tution and a denial of health is delaying
if not denying of the Kingdom of God.
— having in mind the overwhelming emer
gencies that stare at the humanity every
day particularly (very specifically) in the
form of needless child deaths and the
preventable damage done to their future
health and well being
— recognizing the efforts of our big and
small institutions all around the country
and pointing that these efforts can be
linked together with that of various allies
going to scale of national impact; re
solve that We:
1.
respond to the call of child survival
and development by strengthening,
expanding and linking up the efforts
of our communities and institutions.
In this regard we welcome the laun
ching of Universal Immunisation pro
December 1985
9
LET MY PEOPLE GO
Dr. C.M. Franci's Report on the Workshop on
"Towards a People Oriented Drug Policy"
The convention was preceded by a work
shop on Drugs as a follow up of 1984 con
vention. Like the Bangalore convention the
workshop highlighted the complete hold, the
all powerful pharmaceutical industry has over
the profession, the prescribing habits of doc
tors, production pattern of drugs, and over the
dissemination of information.
judicious bulk purchase, the
brought down.
price can be
Mr. Augustine Veliath of CHAI spoke on
drug information and drug action and exhort
ed the members to see that they are not ex
ploited by the drug companies. This was fol
lowed by an open discussion with clarifica
tions and questions and answers.
Drugs will continue to become more
expensive inaugurating the workshop Dr.
M.M. Dhar, Director of Central Drug Research
Institute, Lucknow said.
Dr. Dhindel, the Drug Controller of U.P.
then outlined the developments in the drug
industry. What was a 10 crore industry has
grown into 2000 crore a year industry and yet
essential drugs are in short supply. Though
Hathi Committee had already favoured a res
tricted drug production programme and that
too in generic names the country has done
very little in that direction.
Mr. Mira Shiva, from VHAI, who is also
the coordinator for Drug Action Net work of
India described how shortage of vitamin A
not only blinds 40,000 children a year but also
is responsible for 12 per cent of the infant
mortality in the country.
She highlighted the need for a good na
tional formulary, which is updated frequently.
She gave the examples of U.K. and other count
ries, including developing countries.
This was followed by talks by Mr. S.
Srinivasan, Coordinator LOCOST, Gujarat
and Mr. M. Sarcar of West Bengal V.H.A.
who gave the examples and experiences of
Gujarat and West Bengal respectively. By
10
The members then broke up into four
groups for discussion on three issues which
had been identified. At the end of the work
shops, the rapporteurs presented the recom
mendations of the groups.
The workshops found that essential drugs
are often not available. Examples were given
of common drugs against tuberculosis and
leprosy. Production is often less than the
quantity of drugs required.
Each member institution must have a
formulary containing the essential drugs. The
Medical Service
lists given in Medical Service or "Contact'
could be used.
representation should be made to the Govern
ment.
it was recommended that the manu
facturers must be made to produce the more
essential drugs. Since the new Drug Policy
was about to be announced by the Govern
ment of India it is necessary to ensure that the
policy be people oriented. The Members
of parliament and other influential people
must be contacted by CHAI and member
institutions.
One question which came up again and
again was about the banning receiving gifts
and samples from medical firms. The members
were of the opinion that the institutions should
not be carried away by the pressures put on
by the medical representatives or the glossy
advertisements put out by the manufacturers.
CHAI could catalyse the formation of
one or more central or regional purchasing
agencies, to make use of the purchasing po
wer of our institutions to buy economically
the essential drugs so that the benefits may be
passed on to the community. The same pur
pose could be served by co-operative move
ments.
Purchasing Power
There were suggestions of starting fair
price shops under the Government at Primary
Health Centres, or under our health centres in
the rural areas, to make drugs available at
reasonable, price even in the remote areas.
Problems as to who will manage the fair price
shops and the impact of the rules and regula
tions will have to be studied.
The availability of essential drugs in the
remote areas was tied up with the availability
of health personnel. One deficiency noted was
that of qualified pharmacists. A suggestion
was made about the possibility of CHAI
starting a school of pharmacy or other appro
priate courses.
The institutions of CHAI should colla
borate with the Government in all the health
activities and especially with the immuniza
tion programmes launched by the Govern
ment. The Government should be requested to
supply the vaccines, as and when needed;
December 1985
Drug Authority
There was discussion about the more
liberal use of home remedies and traditional
medicines. The members should be open to
the use of more effective medicines used by
other systems of medicine.
The members resolved that 'banned' or
'bannable' drugs should not be used. Some
proposed a boycott of such firms. The mem
bers wanted information regarding the alter
natives for the banned drugs.
The drugs are under the Ministry of Che
micals, Petroleum and Fertilisers. It is neces
sary that the Ministry of health should be
equally, reasponsible. A central drug Autho
rity with enough powers might be the answer.
The prescribing of drugs should be by
generic name; the pharmacist sholld be free
to substitute if a particular brand is not avail
able.
There is need for quality control and
checking. The Government or CHAI must set
up facilities for checking the quality.
It is necessary that correct information
must reach the institutions, regarding the drugs
and the reactions or contraindications. Regio
nal groups could exchange information with
one another. Information is being made
available by CHAI, VHAI, Pune Journal of Con
tinuing Education and others. It is necessary
11
to motivate doctors and others to use proper
drugs.
There was a suggestion that the concept
of essential and rational drugs should be in
cluded in the medical curriculum.
Dr. K.B. Mathur, Deputy Director of
Central Drug Research Institute spoke on the
development of new drugs and drug utilisa
tion. It is necessary to educate people against
indiscriminate use of drugs. Dr. P.K. Sarkar
of the Drug Action Network of India and Mr.
Augustine Veliath spoke on the topics of
"role of doctors to achieve health for all by
2000 AD in India" and on "communicating
with patients and consumer education". These
talks were followed by discussions and a
"fish bowl" on the "drug action strategies for
CHAI". These discussions and conclusions
reinforced the findings of the workshops.
from^^ggg^g^ pioneers of Ayurvedic research in* Medical* Dental •Veterinary fields
AL patients '
SimpTe idrugs c^
<
etAicoL pnxrcLucts
for • GUM • DENTAL • ORAL Hygiene
as Gum massage. Dentifrice, Rinse & Gargle
Relief in 2-3 applications
Remarkable improvement In 2-3 days.
in easily crushuble tablet form
GUMS Gingivitis: Bleeding, swollen, spongy, painful Gums
TEETH: Painful, Aching, shaky & Hypersensitive:
prevents plaque formation.
ORAL hygiene .* in disease ordrug induced conditions.
where oral hygiene has to be improved & corrected.
G32 is an excellent supportive & follow up treatment:
to consolidate the gains of Surgical 8 Systemic management
of Gum 8 Teeth conditions and ORAL Hygiene.
AYAPON
Oral Herbal Haemostatic & Coagulant
in all Bleeding Conditions of Gums, where
the patient needs systemic heamostatic
Pre-operative: as prophylaxis to minimise
bleeding.
Dosage can be adjusted according to the
severity of bleeding (up to 6-12 tabs a day
In divided doses)
SOOKTYN
for immediate 8 lasting results in
• HYPER ACIDITY • ORAL ACIDITY
relief within 5-15 minutes even in severe
ceses with 3-6 tabs at e time
Masticating trouble leads to: Indigestion.
Flatulence, Constipation, Hyper-acidity
syndrome (nausea, vomiting ptyallsm)
SOOKTYN helps assimilation, degestion,
morning evacuation
DOSE: 2 taba tds between or after principal
'R; COMPOUND v/>
Oxyphenbutozone
meals.
far Rx all availahlt la N1111 tabs PACKS at Chrmixti
as Anti-inflammatory, Analgesic & Antibacterial
Quicker relief without side effects Complete relief within 5-7 days
In all Inflammatory & Painful conditions of Oral cavity:
after teeth extraction. Trismus, Odontitis. Dental Pulpitis,
Cellulitis, Periapical abscess, T. M. Jt problems.
DOSE: 2 tablets tds for 7 days.
12
for Hospitals & Clinics: Supply from factory only.
1000 tabs PACKS except G32.
for h'ff
tl»(a. £
f'.eifui-u' ■. indc 'T Pricelist 'P'ejre tie *cr
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ALARSIN MARKETING P. LTD.
IL K.
Mar|. Fsrt. B««bay 4MI23.
Medical Service
You did it to me
— Dr. C.M. Francis
The Catholic Hospitals, dispensaries
and health centres in India had been providing
good medical services for a long time, when
such services were rare and poor in the country;
they were well known for the quality of care
and the sympathy for the sick and the suffer
ing.
With the advances in science and tech
nology, the emphasis changed to the pro
vision of sophisticated and expensive techno
logies for the diagnosis and treatment of dis
eases. The tender, loving care which was the
hallmark of our institutions receded to the
background.
Today, there is a worldwide change in
the concepts of health, health care and health
care services. There is a rude but welcome
awakening. We are becoming aware that more
and more sophisticated equipments and more
and higher specialists with the modern tech
nologies (many of which are inappropriate
even in the affluent countries) do not neces
sarily provide the answers.
The earlier assumption that we are on
the right track and all that was needed was a
good deal more of the same things and that
we will be able to achieve our goals, if'more
funds are provided, is proving to be wrong.
There is a growing realisation that what we
need is not more of the same but something
"qualitatively different".
We are caught in the desire for moder
nisation, which unfortunately has been equat
ed with the provision of expensive diagnostic
and therapeutic technologies to the exclusion
or, atleast, reduction of many other important
qualities. We often try to imitate the West,
little realising the irrelevance of these pro
cesses and procedures to our situation (often
December 1985
after they have been discarded in the West).
The expenses involved make our budgets to
haywire.
I would like to narrate a true incident which
happened to a friend of mine. He had started
on a fairly long journey by road. Even before
he had covered one-fifth of the distance to his
goal, he found that his purse was stolen; he
had also lost his way; the route he was follow
ing was taking him away from his destination.
Are our hospitals in the same situation ?
Have we lost or squandered the money
by the purchase and use of these expensive
gadgets ?
Have we lost our way?
Goats : There seems to be a dichotomy
between our professed goals which are ex
plicitly stated and to which generous lip ser
vice is provided all the time, and the hidden,
implicit goals which we really pursue. Our
professed goals state that we shall provide
health care with equity, if not equality and res
pecting the dignity of the person, irrespective
of the social status or capacity to pay. We talk
of serving the poor.
Do we?
Or, are we busy serving the well-to-do
preferentially, so that we can
'survive' or
increase our assets,
influence,
power or
prestige ?
Is there a divergence between what we are
doing and what we ought to be doing ? We
must give up double-think and double-talk.
13
Do our hospitals have an assumption
that we should serve the well-to-do as a prio
rity and the provision of health care for the
under privileged and the poor should be
thought of to the extent possible, only after
the demands of the well-to-do are first met;
otherwise, how can we make enough (?)
money to run our hospitals? Are we prepared
to cut down the conspicuous expenditure, so
that with our limited resources, we can pro
vide adequate care for the needy people? I
have nothing against the provision of health
care for the well-do-do. It is good. They need
our services and can pay for the services. We
can and should make use of the finances so
gained to take better care of the poor. But we
should have our priorities right.
If at present 80 percent of the inpatients
are paying fully or partially, we may like to
place the goal of reducing this to 70% (and
the remaining 30% too poor to pay anything)
within the course of the next 3 years. We may
also consider the possibility of establishing
more cost-effective peripheral units, making
them accessible and free to the poor.
Many of our hospitals have expanded the
technological facilities,
providing super
specialities, making them so costly that we
have effectively driven out the poor. Health
care programmes should really benefit, in
planning as well as implementation, the poor
and deprived people living in rural areas or
urban slums.
The talisman that Gandhiji had suggested
is very relevant in this context "Whenever one
has to decide the priority or desirability of a
plan, one must always relate it to the extent to
which it will actually benefit the poorest and
the lowliest of the low". It has been beautifully
putand urged by our Lord when he said "When
ever you have done it to the least, you have
done it for me".
Technologies : The world is witnessing
tremendous expansion of technology — good,
bad and indifferent. Most of them do not make
any significant improvement in health care
and are discarded soon.
Where are we going ? Away from
our decleared goal
Beneficiaries : Our
hospitals should
state, beyond any shadow of doubt, who the
beneficiaries will be. There are complaints
that the largest number of beneficiaries of the
Catholic hospitals (as other institutions) are the
rich and the influential. There is also a ten
dency for their numbers to increase, edging out
the poor. We should carry out a little exercise
and see who the actual beneficiaries are at
present. We can then set our goals and the
timeframe in which to achieve them.
14
The policy adopted so far (and this is
true of all spheres of life, including health)
has been to consider technology as sacrosanct.
We have tried to introduce in India, the most
sophisticated technology the world has dis
covered (though often at a time when others
are giving it up) on the assumption that our
people should have nothing less than the
absolutely first rate available anywhere else
in the world. We buy them and often are un
able to use them because there is no one to
operate them or repair them, when they break
down.
Medical Service
The choice of technology is extremely
crucial because it affects priorities, target
groups, investment levels and the character
of the personnel. A higher level of technology
requires a larger investment; it needs a more
trained and sophisticated specialist and tech
nologist whose services have to be bought at
a huge price. The benefits of the costly
technology tend to accrue to a smaller and
more privileged social group.
William Wordsworth pointed out two
types of the wise : THOSE THAT 'SOAR'
UPWARDS TO THE STARS AND THOSE
THAT 'ROAM' FAR AND WIDE ON THIS
EARTH. Can we have both? While we look
for the higher technologies, can we also
provide the larger number of people, needing
the minimum acceptable?
Do the use of
these technologies tend to reduce the humane
qualities for which our hospitals had been well
known ?
Health is a fundamental human right. It
is also a world wide social goal. People have
the right and the duty to participate indivi
dually and collectively in attaining health and
maintaining it. It is our duty to help them in
this task.
Health indicators : Many indicators are
in use as indices for health monitoring, though
none of them are fully satisfactory. They do
not directly measure the state of health; they
give indications in an indirect way, pointing
to the lack of health.
in the vicious cycle of poverty, illiteracy, mal
nutrition and disease; they are below, what is
popularly known as the poverty line, which
itself is very low. It provides for mere suste
nance.
A good system of health service will have
to be an integral part of a wider programme to
improve the standards of living of the people
and will have to be linked to programmes of
abolishing poverty, improving production,
better distribution of food and universal basic
education.
Socio-economic factors : Health and
socio-economic problems are intimately in
terlinked. There are tremendous disparities
and the gap between the haves and havenots
is increasing. The economic situation has a
direct bearing on health. The gross national
product may not reveal the disparities between
different groups of people; it does not in
dicate the degree of equality in the distribution
of resources. Yet, it is a crude economic
indicator for health. Countries with a high
national product have a low infant mortality
rate and high life expectancy.
The opposite is true for countries like
India with low per capita gross national pro
duct. The prospect for the growth of the gross
national product is not bright in the near
One of them is infant mortality rate.
While it is only 10 — 20 per 1000 live births
in the developed countries, it is about 105
per 1000 in India being greater in the rural
areas than in the urban. The average life ex
pectancy at birth is about 75 years in the ad
vanced countries, while it is only 56 years in
India. India lags behind even our neighbouring
countries like Sri Lanka in the health status.
Health and Development : More than
300 million people in this country are trapped
December 1 985
15
future. Greater efforts are needed to ensure
better productivity and much better distri
bution.
Morbidity and mortality: Most deaths in
India still result from infectious diseases. Ill
ness due to infectious diseases is enormous
and especially so in childhood. About one
tenth of the life of an average person is se
riously disrupted by diseases. The infectious
and parasitic diseases are chronic and debili
tating. Almost all the childhood infectious dis
eases could be prevented by immunization,
but the present coverage by immunization is
low.
Diarrhoeal diseases are very widespread
and often with serious and fatal consequences,
though it need not be so especially now with
the easily available oral rehydration therapy.
A large proportion of people has no depend
able access to sufficient, safe drinking water
and adequate sanitary facilities.
dity. Our efforts at controlling it inspite of the
national and district programmes have not
been successful. Since B.C.G. vaccination has
proved to be not successful in preventing tuber
culosis, case-finding and case-holding are
most important. Our institutions should col
laborate with the Governmental efforts in re
ducing the prevalence from the current 20
per 1000 population. Voluntary institutions
can profitably utilise the shorter therapy, which
can lead to better compliance and more comp
lete treatment.
Blindness is also a big scourage, though
most of it is preventable, with adequate intake
of Vitamin A and cataract removal.
Leprosy is a socio-medical problem. The
Christian hospitals and centres have been in
the forefront in solving this problem. Renewed
vigorous efforts with the multidrug therapy
should be made to control, if not eradicate,
this disease.
Incidence of malaria, which had been
brought down dramatically in 1965 has shown
a resurgence. It has also brought about re
sistance to drugs and resistance of the vector
to the pesticides and greater efforts are now
needed.
Accidents are among the ten highest
causes of death. They also result in disability
and loss of income. The care of injured and
disability and loss of income. The care of in
jured and disabled people uses up consi
derable resources.
Undernutrition afflicts many millions,
and is one of the main contributing causes to
the very high infant mortality and young child
deaths. Infants who survive have their physi
cal and mental development retarded. Under
nutrition reduces the energy and activities of
the people, undermining their performance or
achievement in school, work or sports. It
reduces the resistance to disease. It is essen
tial to ensure good food, adequate in calories
and quality and good dietary habits.
With changes in life style and increased
longevity, the degenerative diseases are on
the increase. Deaths from cardiovascular and
pulmonary diseases and cancer are on the in
crease. There is a steady increase in mental
disorders and in social pathology such as
alcohol and drug abuse.
India has identified certain diseases which
have to be tackled on a priority basis and in
cluded them in the 20-point programme:
Tuberculosis is rampant and is one of
the major killers as also responsible for morbi
16
Smoking is one of the gravest man
made evils; it is the prime example of man's
greed. The producers, distributors and retailers
are aware of the havoc cause by smoking;
so also the advertisers.
Multinational and
Indian firms exploit man's weakness by ad
vertisements, the main focus of which has
been turned now to the developing countries,
because the developed countries are slowly.
Medical Service
but surely acting against smoking through
education and legislation. Smoking is the cause
for many serious, crippling diseases of lung,
heart and blood vessels. The association for
lung cancer is well-known. Even the unborn
baby is affected. Can we remain silent spec
tators of this tragic drama ?
in another society where the bulk of the people
is illiterate. The Catholic institutions are in a
happier position because many congregations
and orders which run hospitals and health
centres have educational institutions also.
If a combined effort is made, our health prob
lems will be solved better.
SMOKING
Who
Match
is
mocking
whom?
with
A
B
GOVERNMENT
PEOPLE
MEDICAL PROFESSION
HEALTH EDUCATORS
UNBORN BABIES
LUNGS
HEARTS
BLOOD VESSELS
MANUFCTURERS
DISTRIBUTORS
RETAILERS
ADVERTISING AGENCIES
GOVERNMENT
SNOKERS
AU your answers are correct.
Education : Literacy is a major factor in
promoting health. It enables the people to
understand their problems and ways of solv
ing them. Whereas the adult literacy rate in
the advanced countries is almost 100 percent,
only about 35 percent are literate in our count
ry. The nature of the health care system in a
society where every individual receives a good
basic education will be very different from those
December 1985
Comprehensive health care : Our ins
titutions have been providing curative care of
a reasonably good standard, though there is
considerable scope for improvement. Many of
our institutions have also started providing
certain amount of preventive care. Some of
the better institutions are now involved in
promotive care and a few in rehabilitation.
17
Medical Care : There is need for good
medical care to treat the sick and suffering.
To alleviate pain and suffering, to heal the sick
and make them whole again should always be
one of our major objectives. Improvements
can be made such that we make the proce
dures effective and efficient discarding obso
lete measures. According to the data released
by the socio-economic monitoring system of
the American Medical Association, 37 per
cent of the physicians surveyed adopted new
procedures during a twelve-month period; most
of them also dropped certain procedures that
they had been providing earlier. Improvements
in medical care are taking place fast all over
the world.
referral hospitals, which is an essential pre
requisite for good primary health care. The
hospitals should also see to it that, either di
rectly or through other village health workers,
they provide primary health care to the entire
neighbourhood in which the hospital is situat
ed; adopting villages is a good idea.
The Catholic hospitals have been, to a
large extent, characterised by the excellent
nursing care by the religious sisters who form
a good proportion of the nurses, and by
example, the lay nurses. We should build on
this great asset of service. They can and should
provide compassionate, loving care.
Our hospitals should adopt procedures
which are more effective and cost efficient.
This can be done only by continuing educa
tion of the health professionals; All categories
of health workers need updating of knowledge,
skills and attitude.
One area which is important is the proper
and rational use of drugs. The market is flooded
with all kinds of drugs: the India drug market
has about 30,000 formulations, compared to
less than 3,000 in the Scandinavian countries.
The drugs are being pushed by aggressive
marketing. Many of them are useless and quite
a large number positively harmful.
Most of our k
• i .
structure and
nosPitals have good infraariY of them can function as
It is seldom that the Government bans a
drug (because of the pressures and lobbying
18
Medical Service
by the manufacturers); but even when bann
ed, they continue to be marketed and used.
Recently, there was a prosecution in the
High Court of Kerala. We can expect more
and more such prosecutions when banned
and unnecessary drugs are used. Can each
of our hospitals have a reasonable formulary
and stick to the drugs contained in it ?
Preventive Care : Prevention
is very
effective and the Government have now taken
up, in all seriousness, the expanded prog
ramme of immunization. A few days ago there
was a report of a very large number of deaths
from the complications of measles from Tamil
Nadu. These deaths could have been prevent
ed by immunization and the complications
avoided by good care. Our hospitals and health
centres should be in the forefromt of immuni
sation. Detailed schedules are available and
they should be followed up.
St. John's Medical College and now the
Catholic Hospitals Association have been
training community health workers. They are
committed people, motivated by the urge to
be of better service. More of such training
programmes, especially in the local languages,
must be started. The services of these Com
munity Health Workers can be used effectively
in providing care and especially preventive
care at the periphery. Some of them may
become 'liberators of the people'. It is all to
the good.
In addition to primary prevention, our
institutions can participate effectively in se
condary and teritary prevention. An example
can be the detection of essential hypertension
on routine health check-up or when the blood
pressure is measured when the person had
come with some other illness. We can advise
the patient with respect to his dietary and other
habits such that the hypertension is controll
ed and does not lead to symptoms and signs
of disease. Or again, when an illness has oc
curred, we can institute prompt measures such
December 1985
that disability does not occur, as in cases of
pulmonary diseases.
Many of the diseases are water-borne or
water-related. We might think that we can do
little in this area. This is not true. As know
ledgeable people, we can create an aware
ness of the need for safe drinking water, good
drainage, disposal of waste and prevention
of pollution of water; from this awareness
can arise action by the people, which can
solve the problem. Similar is the case with
respect to control of air pollution. Can we not
raise our voice, united with the community,
against this vitiation of nature ?
Among specific population groups, the
protection of the health of mothers and children
should get our priority because of the special
biological and psycho-social needs inherent
in the process of human growth which must
be made to ensure the survival and healthy
development of the child.
Concerning the elderly, the process of
aging with its increased risk of disease under
lines the need for a healthy life-style and the
preventive measures become all the more
important.
Promotive Care : Everyone of our insti
tutions must become places of health edu
cation. The people should be made aware of
actions that they can take to promote their own
health; they should be motivated to under
take such action and become agents of change.
Without it, the efforts at health care will not
be effective in making the people healthy.
Health is dependant on adopting opti
mum life styles; when we transgress the laws
of good living, we pay the penalty of disease.
Regular habits, proper nutrition, self control
and proper exercise are important. Where the
individual is allowed every licence like smok
ing, overindulgence in alcohol, overeating
leading to obesity, sedantary habits, he or
19
she needs correction through medical or other
intervention.
The declaration of Alma-Ata on primary
health care mentioned education concerning
prevailing health problems and the methods
of preventing health problems and controll
ing them as the first of eight essential compo
nents of primary health care. The obstacles
which impede individual and community
action for health range from lack of know
ledge of basic hygiene, cultural taboos, un
healthy life-styles and insufficient encourage
ment of cultural factors that promote health
to inadequate and ineffective health educa
tion, motivation and public information efforts,
all too often operating in isolation from the
mainstream of the health systems. Aggressive
advertising of products such as cigarettes and
baby food formulae, harmful to health usually
overwhelms the feeble educational efforts
aimed at fostering healthy life-styles parti
cularly among the young.
Spirituality : In the mad rush for socalled modernisation and imported tech
nology, do we tend to forget the eternal values ?
India has a strong spiritual heritage. It is our
duty to foster it, understanding the higher
purpose of life. Our Lord went about healing
people and making them whole, physically
and spiritually. We, the followers must try to
emulate His example, seeing in each person
the divine presence. This will make us show
respect for the person and not see him or her
as a broken down machine, needing repairs.
Our efforts in every field should be permeated
with moral, ethical and spiritual values.
Our hospitals have a large number of
health workers, from the Medical Superin
tendent to the helper. Everyone of them can be
a health educator. We also usually have a
large captive audience, who have to spend
Care of the terminally Hi: An area which
time in the hospital, as patients or relatives and needs increasing attention is the care of the
friends of patients. We should be able to uti terminally ill. Francis Bacon said: "I conceive
lise this opportunity (some are already doing it the office of the physician not only to restore
so) of health education (in addition to patient the health but to mitigate pains and dolours;
education), by showing slides, distributing and not only when such mitigation may con
pamphlets, giving appropriate talks or by duce to recovery but when it may serve to
videotapes and films.
make a fair and easy passage. It is even more
true for our hospitals because more and more
Rehabilitative care : It should be our
people are spending their last days in the hos
endeavour to provide rehabilitation. It can
pitals. Do we give them our loving care? Or,
take many forms, including educating the pa
do we interfere with them unnecessarily with
tient, his or her family or his or her employer.
useless heroic measures.
It could also be through re-training for a more
Hospital administration .'To achieve all
appropriate job or to carry out his daily routine.
Good placement programmes can help by those which have been stated, we need com
finding suitable jobs, which can be perform mitted and dedicated people for the healing
ministry. We also need good administration
ed efficiently by this person.
December 1985
21
and management. Often, the institutions are in
the hands of good people but who have no
knowledge or skills in administration. It is
necessary to have well-trained, knowledgeable
and committed administrators, so that health
care and health care services can improve,
with optimal utilisation of the available re
sources.
What should be done! As a large na
tionwide organisation, the Association should
sponsor a debate on the existing system of
health care services provide by the member
institutions,
the reasons for the failure
to provide the needed care and the gene
ral principles and
programmes which
must characterize our institutions.
The
association should set up a competent
group to prepare a draft plan of health care
services. It should provide the details which
tend to be ignored. The member institutions
should review their health care system with
22
the aim of meeting the health needs of the
people, for primary care and referrals. The
most promosing aspect is that many persons
involved in providing health care, are aware
of the need for drastic changes. This awareness
should be extended to larger numbers and
translated into action so that all our institutions
become willing partners in progress to be true
agents for health. A wise poet of our country
said, long ago, that there are three classes of
people:
The lowest do not begin for sheer fear
of failure
The middle ones begin but stop as soon
as difficulties arise
The highest begin and never abandon,
inspite of repeated blows from difficul
ties, till success is won.
To what class does this Association belong ?
Medical Service
TO PULL DOWN AND BUILD ANEW
—Fr John Vattamattom looks at the prophetic role
of the Church's health work
Catholic Church is the single largest
organisation in the world in providing health
care. This is true to a great extent even in our
own country even though we form only a tiny
minority in India. With 2000 and odd health
care institutions we are certainly contributing
a major share in the country's health care
efforts, particularly in remote rural areas.
"Union gives Strength" — was the catch
word with which 43 years ago this organisa
tion began in a very modest way with 16
religious sisters. It was the dream of Sr. Mary
Glowry, belonging to the congregation of
Jesus, Mary and Joseph, an Australian doctor
turned nun, the founder of the Catholic Hos
pital Association of India, that Catholic hos
pitals and health care institutions to be at the
service of people particularly the needy and
the poor and the poorest of the poor.
The hard realities which she saw, i.e.
people dying particularly women and children
without proper health care, brought out ano
ther dream, ie., the establishment of a Catholic
Medical College, in order to train health care
personnel to meet the needs of our insttutions particularly in rural areas. This dream
was later on realised in what we have today,
the St. John's Medical College, in Bangalore.
All these point out to one reality, i.e. our com
mitment to carry on the mission of Christ as
our Association's motto is "The Love of Christ
Compels us".
It is this compulsion, this urgency that
throw open many a challenge before us as
we stand, so to say at the cross roads, after
42 years of dedicated service, to find our way
out, to forge ahead with added enthusiasm
and commitment, to meet the challenges of
December 1985
tomorrow. The Catholic Hospital Association
of India and its member institutions and health
care personnel are called upon to play a criti
cal and prophetic role in the field of health
care.
Our role is a critical one, because we are
faced today with hard realities of life. We are
committed, along with our country, to the
implementation of the global strategy of Health
For All by 2000 AD. We are also committed to
the new health policy of the Government
which is a challenging document, and if imp
lemented, we can achieve our goal of health
for all by 2000 AD. At the same time we are
also aware of the constraints that block the
implementation of this health policy because
of the inadequacy of the present health care
system, the medical education system and
the nurses training system wich caters more to
the elite classes.
We also have to play a prophetic role be
cause of our commitment to Christ's own
concern for the people. We need to stand for
justice, love and human values. At a time when
values are thrown to the winds, corruption,
unethical practices etc. are rampant, parti
cularly in the medical field, we need to stand
for values. Our prophetic role is all the more
clear when we are only a tiny minority in our
country.
Because of this specialised roles we have
to play in the future, my dear friends, our this
year's convention assumes greater importance.
The theme we have chosen is the "Silent
Emergencies of our Times — Our Response".
We shall spend these coming two days in
analysing some of these silent emergencies
and fixing up our priorities.
23
"The theme 'Effective Hospital in the
Community* was chosen for the dual
purpose of emphasising that a hospital
is a health centre, meant to meet the
community health needs, preventive,
curative, rehabilitative and promotive —
and bringing to focus the necessity for
operating such a unit as an effective or
ganization" — Convention 1970
"The CHA considers the promotion of
Community Health, which includes the
preventive, educational, and curative as
pects, also mental, emotional and spiritual
health, as a primary objective of our
Association and of each member hos
pital, dispensary and health centre".
—Convention 1971
The subject is not new. The world discuses
it, the nation has its own plan. We our
selves talked about it for many years.
One way we respond to these emer
gencies and that which requires continued and
added care and attention is the promotion of
Primary Health Care or Community Health
which is of vital importance in our country.
It is gratifying to see, and I am very happy
to inform that this has been so dear to CHAI,
from its inception. This concern was that
prompted the founder of CHAI to organise our
selves as a force. Over the years this has been
stressed and stressed again. And today we
have a full fledged department with necessary
qualified staff, though we are aware of our
limitations as against the demands of the time.
This concern for Primary Health Care and Com
munity Health was repeated year after year
during conventions in the past. Following are
a few examples:
"The CHA accepts the goals implied in
the concepts of Community Health, and
agrees to give priority to projects that
help to further this development in health
care" — Convention 1969
24
"The CHA considers the promotion of
Community Health as one of the primary
objectives of the Association and of each
member hospital, health centre and dis
pensary. There should be a certain prio
rity of emphasis for care of children under
five years of age. Patient retained health
record cards should be encouraged. Our
Association gives priority to service in
areas of greatest need, such as the widely
neglected rural communities and the
deprived sections of the cities." — Con
vention 1972.
Friends, what I was trying to do was to
place ourselves in the present context basing
on the past in order to look ahead for a bri
ghter future. Let us all open ourselves to the
spirit that is guiding us; let us listen to His
promptings, let usalso open our ears to listen
to the groanings of the people who are neg
lected, poor, oppressed; let us open our eyes
to see the miseries of the people around us,
the malnourished, the voiceless, the children
that are blind because of lack of proper nou
rishment, lame due to polio; let us extend our
arms with a healing touch with Christ like
concern following the example of our Master.
Medical Service
Let us have a good look at ourselves as
an organisation of long standing, perhaps the
biggest and oldest in the world in the field of
health care in the private sector as individual
institutions, as individual health care person
nel. Let us see where we stand. Let us read
the signs of the times and see our role in the
field of health care. Let us realise our great
strength. Let us make use of it in loving ser
vice to others. Let us spend these two days
with a sincere search, search for values, search
for relevance. Because, as our motto says,
"The Love of Christ Compels Us" to
do so.
"Today we are"
Today we are committing ourselves before
the entire world: we are committing ourselves
to preventing, during the next five years, the
deaths of 60,000 children ever/ year. To
achieve this, we are going to put all the re
sources of our nation, under the leadership
of the Ministry of Health, behind a Plan for
Child Survival.
This plan will be the most spectacular
advance in Colombia's health for many years ..
We are going to reach each house, each
one of our 3.6 million children under five
years of age.
We are going to reach them in order to
work with them, and with their families,
towards implementing simple actions of pro
ven effectiveness in the protection of child
ren's health.
We are going to distribute oral rehydration
salts to all corners of Colombia so that no
children die from diarrhoea.
We are going to keep immunizing our
children until there are no more cases of
vaccine-preventable disease.
We are going to give food supplements
to our children, to babies under two, and to
pregnant women in nutritional danger. And
we are going to provide adequate treatment
to children suffering from acute respiratory
infections.
But above all we are going to make an
even greater effort with all the mass media,
with the participation of all of you, and of the
entire community, to educate fathers and
mothers so that they acquire simple know
ledge and simple methods for guaranteeing
the health and life of their children.
President of Columbia as quoted in:
"THE STATE OF THE WORLD'S CHILDREN 1986"
December 1985
25
Child Survival Here and Now
David P. Haxton UNICEF Regional Director for South Central Asia
I accepted with pleasure the invitation
to participate in this convention mainly to learn
from the almost unequalled richness of ex
perience in health-care under the inspiration
of the Roman Catholic Church.
I am not surprised that in 1973, five years
before the Alma Ata Declaration on primary
health care, your Association chose for a
similar annual convention the theme: Health
for the Millions.
I am aware that your member units have
struggled, particularly in the years that fol
lowed, to make this slogan a reality. You have
recognised earlier than most others that hos
pital care and other ways of dispensing medi
cines, are only a small part of health piomotion.
Encouraging reports appear periodically
how your health workers, in association with
the nuns and priests spread out even in re
mote areas, have tried to organise commu
nities of optimal size in compact areas, regard
less of religious affiliation, and engaged them
in the effort to rebuild their lives through better
access to the means of health.
The concept of holistic health, embrac
ing the dimensions of social, economic and
moral development, owes not a little to the
practical philosophy that guides you in your
daily work. It is thus natural for us in UNICEF
to look upon you as a major ally in the con
quest of ill-health especially of children and
mothers.
You have chosen for this convention the
theme: Our Response to the Silent Emergencies
of Our Times. I would like to invite your point
ed attention to one such emergency and to
the many-sided response to it, that is feasible
December 1985
in our own time. In doing so I shall focus mainly
on India which has the largest national ag
gregate of victims of this particular emergency.
As you know the health system in India
is large and fairly developed and continues to
grow. I understand there are over 660 thou
sand registered medical practitioners from
different health disciplines, in addition to well
over a million other health workers of one kind
or another including traditional birth atten
dants. The public health expenditure per
capita has doubled in the course of the last
decade. And the number of privately organis
ed hospitals and health centres has been steadily
increasing.
In spite of all this, one out of every 10
babies in India dies before his first birthday.
Two more die before the fifth birthday. This
rate of infant and child mortality is unaccep
tably high by any standard — medical, ethical
or international. This emergency is silent only
in the sense that it is dispersed in space and
time, it happens mainly among the lowliest
and the lost, and therefore mostly muted. Be
fore the emergency can be ended, we must
make it heard. The silence must first be broken.
A high infant mortality rate is a reflection
of many aspects of the social, economic and
political environment. There are two familiar
schools of opinion on the means to change
the adverse situation. One view sees structural
impediments coming in the way of any lasting
situational improvement. Another view puts
economic growth as a precondition for social
development, including a reduction in infant
and child mortality rates.
While changes in the skewed structure
of society as well as growth of the national
27
The poof of this prospect can be seen in
the community health projects organised by
committed health workers, including some
members of your Association, in different parts
of India. Some of them are hospital-centred
while the others are community-based. The
mix of activities may vary depending on the
local needs and resources but almost invariably,
they have a basic orientation towards the pri
mary health care approach, with accent on
prevention — prevention not only of suffering
but equally of an irreversible loss of time,
money, material resources, peace of mind, and
above all, human potential.
economy are essential to assure proper human
development it is inconceivable that infants
and children should wait upon either, for meet
ing the simple basic needs of their natural
healthy growth. More so at a time when nei
ther economic development nor social reorder
ing seems to be picking up pace. This is the
context and reason why UNICEF seeks to
mobilise opinion, resources and action, to
come to the rescue of children at risk — des
pite present poverty and social inequalities. As
the children of the materially poor survive and
grow up better fed, healthier and better edu
cated, economic development will naturally
be hastened and social inequalities are bound
to weaken. Different priorities can thus be
harmonised.
28
The concept of community health is
perhaps still in its infancy in India, but the
initiative taken by some of the community
health projects hold the promise of steady
spread and durable effect. For example: the
training and equipping of traditional birth at
tendants; training of community health wor
kers to identify high-risk mothers and infants
for intensive care; greater attention by com
munities to environmental sanitation;training
of health workers in home management of
diahorrea; equipping health workers in ante
natal and infant care, especially immuniza
tion and basic education in health and nutri
tion.
Some have gone farther to tackle the
deeper sources of malnutrition and ill-health
through awareness and capacity building,
through cooperative organisation of productive
activity. Health workers, communicators, edu
cators and social workers have taken a lead in
establishing such basic services, often with
professional help from outside, sometimes with
government support. In areas of such activity,
poverty may not have disappeared, but its
hold has loosened, infant mortality rates have
come down, communicable diseases have
been controlled, nutritional status has improved,
levels of literacy have risen. To multiply these
local successes on a national scale is the
developmental answer to silent emergencies.
Medical Service
In meeting this challenge your Association
has a distinct opportunity to set an example.
The times appear propitious to make a
bold and renewed initiative. The National
Health Policy, passed by Parliament in De
cember 1983 seems to make a valuable distin.
ction between conventional medical ser
vices and simple health related technologies
More and more people recognise that modern
medical services are too expensive for the
generality of the people even when these are
appropriate to their health needs. There are,
in contrast, inexpensive and scientifically
sound alternatives to safeguard child health
and development.
It is encouraging therefore to see that
the seventh national plan aims at universal
immunization by 1990.
Also, a national programme for home
based diahorrea management is being launch
ed, to reduce diahorrea related child deaths
by half by the end of the dacade.
Another national commitment seeks to
iodinate common salt in endemic areas of
iodine deficiency which puts some 120 mil
lion or more people at risk in India. The inverse
relationship between iodine deficiency and
brain development, in the womb and early
childhood, has been brought out only recently.
In parts of eastern Uttar Pradesh and Bihar,
some 4-15% of all children born are in danger
of mental retardation to the point of becoming
cretins. The health profession, not to speak
of the public opinion, is yet to respond in any
significant way to this “silent epidemic".
Roughly half the children and mothers
of India may be anaemic to an extent that
significantly depresses physical and mental
efficiency. A nationwide programme, is ye
of crystallise on anaemia. But that need not
come in the way of the non-government sector
taking a determined initiative in areas of their
active presence.
December 1985
CWLD
Every Priest in Columbia asks this question
to every child brought for baptism. Can
we not do the same ?
The risks that I have touched upon are
by no means an exhaustive list of threats to
child life and development. There are others
like Vitamin A deficiency, perhaps more ex
tensive in its spread among the population
and in its damage to the human system than
hitherto suspected. Not only does it lead to
degrees of blindness in the very young but is
also destructive of the lining of the alimentary,
respiratory and urinary channels, fuelling the
interaction of infection and malnutrition.
Peculiar to each environment there are
numerous other obstacles to child life, like
respiratory infections which take a heavy toll
in child health and child lives.
Maternal malnutrition, as an impedi
ment to child survival and development, is
highlighted by the fact that about a third or
more of all children born in India have a birth
weight below 2.5 kg, which means some 7-10
million children each year. Such babies are
three times more likely to die in infancy than
babies of normal weight at birth. It is a deeply
disturbing inference that about 18% of all
deaths in India are contributed to by low birth
infants. Clearly, infant mortality is unlikely to
be lowered significantly unless birth weights
can be increased.
29
Perhaps, among all the possible responses
to factors threatening child-life, the most
natural, the least difficult and the most impor
tant is allowing the infant access to his mother's
milk. While we await legislation of the Indian
National Code for protection and promotion
of breastfeeding, many of its principles are
violated by manufacturers of breast milk
substitutes, by advertising media and, I reg
ret to add, by hospitals themselves.
For example, hospitals ought to encourage
“rooming in", to initiate breastfeeding within
the first hour of delivery and to minimise sepa
ration of the new born from the mother even
in cases of abnormal delivery and operative
intervention. Equally, the health system ought
to encourage the use of home-made weaning
foods from the age of 4-6 months in addition
to breastfeeding — as a matter of greater
priority than "medical" attention.
I mentioned earlier, the opportunity
that presents itself to a health network such
as yours. You have the strength not only in
technical manpower but uniquely in the so
cial concern, motivation and credibility pro
vided by thousands of parishes. Centered on
this local presence, community health projects
can come into their own, provided people are
organised and made aware of their inherent
capacity to preserve and promote health even
in adverse circumstances.
Your hospitals and health centres can
promote a series of innovations, supportive
of people-based primary health care. For
example, the National Code on breastfeeding
could even now be faithfully and rigorously
implemented in your hospitals, health centres
and community health projects. A similar
effort could be made in heralding the practice
of a strict code for essential drugs, of which
principles and examples are available. Every
contact of the hospital with a child or woman
could be used to check and ensure that im
munization of pregnant mothers and young
30
Your Hospital
Can
Implement national code on breast
feeding
Practise a strict code of essential
drugs
Use every contact with a child or wo
man to check and ensure that pregnant
Mothers and Children are immunized
Welcome every child with
rehydration drink
an oral
Train mothers and other family mem
bers to prepare and administer Salt Sugar
Solution
And above all shift from
practices to health practices
medical
children is proceeding to schedule or has been
completed. Every child brought to hospital
with diahorrea could be welcomed by a drink
for oral dehydration before initiating any other
procedure. The occasion could also be used
for training the mother, or other family member,
in the preparation and administering of the
salt-sugar solution. In fact, the orientation
of the hospital could shift from medical prac
tice to health practice.
And in this the social support through
parish priests and the nuns could make the
difference. The number of community health
projects could be increased by activating the
people themselves through social communi
cation and community organisation, and with
out having to resort to monetary investments
on any large scale.
Medical Service
Every Church-related health unit and
health worker could assume the educational
and promotive responsibility for the health
of all the people living in their own defined
geographic area. To the extent government or
other health facilities are available in the area,
the common responsibility becomes easier to
discharge through a cooperative working re
lationship. Indeed the search for allies could
and should go beyond the health sector and
involve, through patient striving, the range
of public and private agencies active, one way
or another, in the area — government insti
tutions, the business community, the school
system, professional groups, social workers
from sister religions or of secular persuasions.
The aim could be to ensure that all the
elements of primary health care, as spelt out
in the Alma Ata Declaration, are built up in
steady progression, starting with primary
child health care. When the community, the
health professionals, the hospitals and the
Church have rallied to the support of the child,
we would have left behind issues of child
survival, and be concentrating on child deve
lopment.
The message I would like to leave with
you today is that this need not be a distant
dream but feasible as of now; and achievable,
in a country of India's strength, ahead of the
century's end.
Planning of New Hospital ?
Expanding Existing Nursing Home ?
Modernising facilities ?
Consider "JANAK" for fine Patient Care Beds such as Intensive Care Bed,
Recovery Bed, Hi-Low Bed, Modified Fowler's Bed, Bed with backrest,
Emergency & Recovery Trolley, Obstetric Labour Table 2 Section, Medi
cal Tables, Trollies Wheel Chair and other Ward furniture
METALBEDS INDIA (in association with Janak Mfg. Works)
Janak House, Opp. Indian oil Corpn Depot,
Sheikh Misry Road, Wadala (East)
Bombay-400037
Tel : 8820171/8820769
Cable : JANAKBED (MT)
Telex : 011-71584 JKMG IN
December 1985
31
What’s New in Health Care Management
— Sam Thangraj
As CHA! attempts to work out "Strate
gies for Tomorrow" through its 42nd Natio
nal Convention and Workshop, this paper is
an attempt to identify what is new, or rather
what is relevant to health care management.
This is by no means a detailed discussion of
issues but only an effort to identify issues and
factors that should lead to detailed discussion.
A popular definition of health is the one
given by WHO : "A state of complete physi
cal, mental and social well being and not just
absence of disease and illness." TheWHOUNICEF Conference in Alms Ata considered
Primary Health Care (PHC) as an ideal vehicle
to deliver such a health for all by the year
2000. While emphasising PHC as "essential
health care made universally accessible to
individuals and families in the community by
means acceptable to them through their full
participation and at a cost that the community
and country can afford." Such a PHC, accord
ing to the Conference, should include:
1.
Education about prevailing health
problems and methods of preventing
and controlling them.
2.
Promotion of food supply and nutri
tion.
3.
An adequate supply of safe-water
and basic.
4.
Maternal and child health including
family planning.
In as much as the Conference pointed
out that good health is a fundamental human
right and its attainment a most important
worldwide social goal, the realization of the
goal requires the interaction of the health
system with many other social and economic
factors. Provision of PHC, like politics, be
comes the question of "who gets what, when,
where and how." This is particularly so as
the interaction of social and economic factors
that influences the power relationship within
the international system and within a country
as well as a community has implications for
health care management.
This would mean that while a country
like India has the capacity and technical skills
to provide PHC to all by the end of this cen
tury, its policies and efforts are to a very large
extent influenced by the structure and pro
cess of the political system of which health
sector is a part.
Before this is discussed further, it is
necessary to identify other issues such as the
interaction of health with environment and
ecology, the importance of child development
and the need for appropriate policy for the
provision of essential drugs. These issues need
to be linked with human resources develop
ment so that PHC becomes a real process of
full community participation, and is not affect
ed by social, economic and, therefore, politi
cal factors.
Once these issues had become inherent
aspects of health care management it would
lead to awareness of PHC by all sections of
6. Appropriate treatment of common
people in the country leading to provision of
diseases and injuries.
health to all. Let me mention these issues
7. Provision of essential drugs.
briefly.
5.
Immunization against infective
seases.
December 1985
di
33
SPELL
ELEMENTS
FOR
PRIMARY
HEALTH CARE
Education on Health
Local disease control
Epidemiology
Maternal and child Health
Essential Drugs provision
Nutrition and food supply
Treatment of Minor diseases and
ailmets
Safe water supply and sanitation.
It is generally assumed that while there
exists socially and financially effective tech
nologies to provide PHC, the main obstacles
are related to political and organizational fac
tors. A clearer understanding of health system
in India is an important aspect of health care
management. As Dr. Imrana Qadeer points
out, inspite of "an extensive infrastructure,
an army of trained personnel and well equipp
ed institutions for research and education"
and despite "professed commitment to serve
all — specially the
poor/* the system has
many inequalities—inequality of distribu
tion, inequality of access, inequality of parti
cipation and inequality of health status.
Such inequalities have arisen because it
is politics that determines who gets what,
when, where and how. And politics, of course,
is concerned with people and more impor
tantly with economics. "The science of eco
34
nomics pre-supposes a given political order
and can not be studies in isolation from po
litics." In as much as economics pre-supposes
a particular order that involves the creation
and distribution of wealth, it also pre-deter
mines the process of development. As politics
determines the development process and ch
annels it in the direction intended to serve
the interest of the dominant groups, the ex
ercise of power through the distribution of re
sources becomes a major factor in health care
management.
The inequalities and characteristics of the
health care system that find expression through
its processes such as the provision of PHC,
particularly to those in rural areas, are the
manifestations of the science of economics
through the political system. It is no wonder,
therefore, 79% of the Indian population who
live in the rural areas is served only by 30%
of the hospitals, 20% of the doctors and 10%
of the total number of beds.
Seen through a holistic perspective one
could see the importance of issues related to
environment and ecology to development in
general and the management of health care in
particular. Ecology is very much the core of
environme nt and is concerned with the full
spectrum of human life, including physical
resources, necessary to its existence. Since
the health sector interacts with social and eco
nomic sectors, it is necessary to understand
the effect of population on resources such as
food and energy, its impact on their produc
tion, consumption and management together
with the use of appropriate technology for
self-reliance.
At the same time, the creation and pro
tection of a safe environment are essential to
PHC. Any of the aspects of PHC mentioned
earlier could suffer in an unhealthy environ
ment. In the absence of environmental health
programmes the elimination of poverty, hunger
Medical Service
and diseases is likely to suffer in the process
of development.
Environmental health issues exist on
three levels. The first level deals with health
effects, the second with comfort, convenience,
efficiency and esthetics and the third level
with natural resources and the ecosystem as
Prof. Emil Chanlett points out. Environmental
health programmes that do not address each
level while attempting to improve particular
conditions may fail. A community that needs
help act on all these three levels and do not
respond to programmes that they perceive as
being too narrow or insensitive to important
factors.
While a detailed analysis of these three
levels would involve considerable time, it is
necessary to emphasis the importance of the
first level as it has effect on the health of all.
These effects are biological pathogens which
cause infective or parasitic diseases resulting
in physical deformity, malnutrition, severe
disease and death. Toxic chemicals are some
other factors. Though, unlike biological pa
thogens, they are considered to be controlled
relatively easy at the point of use or discharge,
the tragedy that occurred in Bhopal when MIC
from the Union Carbide Factory leaked and its
continuing effects are too fresh in our memory
to be recollected.
But then, this is not the only way that
toxic chemicals pollute the environment and
effect health. They also reach food through
fertilization, food processing and storage. In
this age of consumersim, the significant in
crease in the use of organic chemicals from
everything in plastic wrappers to heat ex
change liquids has increased the risk to health
that exposure to these chemicals entails.
The various environmental health mea
sures needed to attack these first level diseases
should design to stop the transmission of bio
logical disease and the control of chemical
D ecember 1985
discharge. The isolation and disposal of hu
man sewage, provision of a safe drinking water
supply and the proper disposal.of solid waste
are also important.
Child development is another important
aspect of the management of health care.
Here the main emphasis is to enable parents to
protect their children from preventable death
and disablement. This would mean that the
parents should be given not only the informa
tion they need but also easy access to the
structure and process of the health care system
so that they can fully participate, among others,
in the survival and development of their child
ren leading to what UNICEF call Child Sur
vival and Development Revolution.
Programmes designed to immunize ail
children, control of diarhoea so that children
would no longer die or crippled, by acute
dehydration, particularly as simple and cheap
means are available, and the increasing of na
tural immunities through breast feeding and
better child bearing and rearing through child
spacing, improving knowledge of weaning,
nutrition and household hygiene form the
basis for this Revolution.
The politics of the formulation of a
policy to provide essential drugs is an issue
that is becoming increasingly important in the
management of health care. Since greater
emphasis has been given to this topic in the
Convention, there is no need for me to go
further except to say that the role of the Mul
tinational Corporations which to a large ex
tent affect the formulation of a rational drug
policy is in accordance with its own role in
the political economy. The application of
"location theory" relating to centralization of
control within the Corporation to centraliza
tion of control within the international eco
nomy would mean that it enables the MNCs
to weaken political control, escape national
regulation and reduce options for develop35
Wocpilals
20^ Doct vs
ment such as formulation of rational drug po
licy in a Third World country.
If programmes related to various aspects
briefly discussed above are to be very effec
tive, it should be complemented by human
resources development and use it to have the
maximum impact at national level.
Human resources development needs to
be implemented at three levels — at the na
tional level so that it has maximum impact on
the structure and process of the health system,
at the level of provision of PHC through,
among others, non-governmental organiza
tions such as those present here and at the
community level.
While human resources development at
macro-level would enable the formulation and
proper implementation of policies related to
PHC, at the level of NGOs it should help to
complement the efforts of the Government,
experiment with new ideas and set out exemp
36
lars for the policy makers to see and follow.
Human resources development at this level
should aim to create among those involved an
awareness of all issues, social, economic and
political, related to development. In as much
as these issues greatly influence the process
of development those involved in the manage
ment of health care should be aware of their
manifestations that find expression through
Government policies.
At the community level, human resources
development will help to spread knowledge
related to all aspects of PHC, understanding of
power relations based on sex and caste that
affect the attitude and proper implementa
tion of PHC and other development activities.
A health care management that would
take note of these issues will have maximum
impact if attempts are made to "link" such
efforts. While "small is beautiful" it is not al
ways effective. This is particularly so as isolat
Medical Service
ed efforts are difficult to sustain over a period
and would lead to dependency. However, a
linkage would lead to what UNICEF call
“going to scale.”
Going to scale implies "a quantum change
involving an extension of programme objec
tives to reach national coverage.” It is also a
“process of education, motivation and mobi
lization. It is a process of national mobiliza
tion and education to achieve an objective to
which the majority of the population becomes
committed.” Needless to say that PHC is an
objective to which the majority of the popu
lation has become committed or should be
come committed if their needs and demands
can be articulated through their participation.
The members of CHAI here present are
in a unique position not only to implement
PHC because of their commitment and dedi
cation but also to take note of some of the
issues in health care management. I know that
some of you are aware of these issues. If you
could link together, involve yourselves in fur
ther human resources development, I am sure
that you could become an effective instru
ment for "going to scale.”
— SAMUEL THANGARAJ
BIBLIOGRAPHY
QADEER, I. “Health Services System in India:
An Expression of Socio-Economic In
equalities,” SOCIAL ACTION, JulySeptember 1985, Vol. 35, No. 3
PINEO C.S., SCHNARE D.W. AND MILLER
G.W. "The Healthy Environment” in
ENVIRONMENTAL SANITATION AND
INTEGRATED
HEALTH
DELIVERY
PROGRAMS, American Public Health
Association International Programs, Wa
shington D.C.
HYMER, S. “The Multinational Corporation
and the Law of Uneven Development"
in BHAGWATI, J.N. (Ed.) ECONO
MICS AND WORLD ORDER, CollierMacmillan, London (1972).
VARINDRA TARZIE VITACHI. "The demand
approach for the Child Survival and Deve
lopment Revolution."
ASSIGNMENT
CHILDREN, Vol. No. 65/68, 1984.
NYI NYI. "Going to scale: going national
Operationalization process and issues.”
ASSIGNMENT CHILDREN, Vol. No.
65/68, 1984.
The Catholic Church
The Catholic Church has been a major ally
in these efforts. Its 370 bishops and 5,000
priests, along with 14,000 monks and nuns
working in clinics and hospitals, backed by
newspapers, magazines and 120 radio sta
tions, make it a powerful presence in
Brazilian daily life. In 1985 the National
Conference of Brazilian Bishops established
a 'Pastorate of the Child' to disseminate child
survival measures. The Pastorate is expand
ing this year to tackle an ambitious goal
reaching a million children under six in the
impoverished north-east, where infant morta
lity is running at twice the national rate.
In other countries, the communications re
sources of organized religion—of the priests
and the Catholic Church in Brazil, Colombia
and El Salvador, of the imams and Muslim
leaders in Indonesia, Oman, and the Philip
pines, and of the Buddhist priests in the
villages of Burma and Sri Lanka—have also
helped to bring new knowledge about child
protection to many millions of parents, and
from a most trusted source.
"THE STATE OF THE WORLD'S CHILDREN 1986“
December 1985
37
New Board Members
Fr (Dr) Patrick Pais S.V.D. has been elect
ed Vice President of the Catholic Hospital
Association of India. He comes in the place
of Fr Joseph Kavalippadan, who completed
his second term with this convention.
Rev Sr Cassia who made her mark in
shouldering the responsibilities organizing the
Convention was elected the second Vice
President.
Both the President and the Executive
Director paid glowing tributes to Fr Kavalip
padan from whose guidance and maturity the
association has benefitted very much.
Fr K.C. George has the distinction of
being the first board member representing the
"seven sisters" of North Eastern Region.
Community Health
The 12th Basic course in Community
Health Work which began on August 12,1985
ended successfully on October 31st 1985.
There are 21 participants (13 Religious Sis
ters, 7 Brothers and 1 lay person). The empha
sis once more was to expose the participants
to a lot of field, practical and clinical assign
ments. The major subjects covered were first
aid, human biology, home nursing, basic lab
skills, clinical postings, institutional visits.
Natural Family Planning and rural mobile
clinics. In addition there was a month's resi
dential training programme at Bidadi PHC.
The innovative features for this Course which
were very successfully carried out, were —
Child to child health education at the Bidadi
secondary and high schools; Mother's moti
vation programme at Madya Dist; Nutrition
demonstration at Bidadi and surrounding pla
38
ces ; Socio-economic project reports covering
all aspects of health and its relation to csioeconomic factors, and Rural project planning
as a follow up after their course.
In addition to all the above, they were
exposed to a lot of clinical training at the rural
mobile clinics. Maternal and Child health care
at the MCH clinics of Bidadi and attending
to labour cases in the maternity section of the
rural centre. The Community Health Workers
also visited the existing CHW's centres at
Madya Dist. which are being run by our old
CHW students, who had passed out earlier.
In this manner, a practical demonstration of
what their future work would be, was also
included in this training programme. Pre
and post evaluation of the course have also
been conducted.
Medical Service
Vijayalakshmi Goes to School
Vijayalakshmi is a four year old cute
girl, quite active and healthy, thanks to the
Community Health work team of St. Thomas
Hospital, Chettupattu. During their village
visits, the Community Health workers met the
mother of Vijayalakshmi and noticed primary
complex of Tuberculosis in her body. Her
mother followed the advice of the CHW
and she is now a healthy girl ready to go to
school next year.
With the aim, "Prevention is better than
Cure", the Community Health Department
was started in St. Thomas Hospital, Chettu
pattu in December 1982. A group of women
were selected from various villages and train
ing was given to them for a period of three
weeks. These women were then sent back to
their villages and they work at least two hours
a day in their own villages by teaching other
women about health, nutrition, hygiene etc.
Every week these health workers come to the
centre for their weekly meeting and sharing.
Evaluation of work done and plans for future
work are made during these weekly meetings.
At present there are 27 village Health
Workers placed in 17 villages of Pernamallur
Block of Vandavasi Taluk, North Arcot Dis
trict. A total population of 11,000 people are
served by these workers.
The Community Health Staff make their
daily field visits and guide the Health workers.
Immunization of children is arranged in all
villages. Cases that need hospitalization are
referred to the main hospital at Chettupattu
for treatment.
The Community Health Department is
now planning to arrange some staff members
to stay in the villages and live with the people
in order to be more effective in their Com
munity, Health Apostolate.
Grass is green in this School
Our great Leader and Father of the Na
tion, Mahatma Gandhi, said "God comes to
the people in the form of bread". With this in
mind we take care of 10 villages and have
started education, health, nutrition and deve
lopment programmes.
We are much involved with the non
forma leducation of the school drop-outs in
and around Devikapuram village since 1981;
having trained 22 animators to help in this
December 1985
task of educating the children, we organise
meetings for these animators once a month in
our centre. About 500 children, school drop
outs employed for grazing cattle and sheep
or for various child labour, or those who have
never gone to school, benefit by this educa
tion. These children are encouraged to conti
nue their education programme and some of
them have appeared for VIII Std. examina
tion.
39
\Ne have formed youth groups and Mathar
Sangams in these villages. These groups have
meetings twice a month at our centre. Our
animators give them guidance and motivation.
We have arranged one day Seminar, cultural
items, competitions etc. for them and prizes
were distributed. We have invited resource
persons and Government officials to give them
inspiring talks on different subjects. The wo
men and the girls of the Mathar Sangams who
are involved in development and education
were given an excursion to another similar
project at Tiruvannamalai where the women
are engaged in handicrafts. This has proved a
great encouragement to our village women to
better their living conditions.
We have started a tailoring unit in 1984
where 35 to 45 young illiterate girls come regu
larly and learn cutting, embroidery and handi
crafts. After training, these young girls are
able to earn their own living with a sense of
human dignity and self respect. In order to
make them self-supporting we have provided
sewing machines for 8 girls through bank
loans. A trained teacher animates the group.
40
A certain amount of moral instruction is also
given.
Economic development projects are
made possible with the aid of bank loans to
purchase milk animals, cycles, petty shops etc.
Realising the need of self-employment for a
meaningful development we have started a
silk cooperative with our animators. Here again
we inculcate in them equality, justice and
human dignity by making them share-holders
of the Co-operative.
500 Mothers and Children under 5 years
benefit by our TMCHE Programme. We take
preventive measure for night blindness, mea
sles, polio, typhoid etc.
Evaluating our work, we plan to give
more emphasis to training of leaders and ani
mators who will be responsible for social
change and we do hope that our approach
will touch the man as a whole, the community
as a central focus in the process of liberation.
Sisters of Cluny Convent
Devikapuram
Medical Service
Position: 2866 (4 views)