FRCH NEWSLETTER VOL.1-No. 1-5-JAN - DECEMBER-1988.pdf · Community Health

FRCH NEWSLETTER VOL.1-No. 1-5-JAN - DECEMBER-1988.pdf

Media

extracted text: COMMUNITY HEALTH CELL
47/1. (First Floor) St. Marks Rcad,

Bangalore - 560 001.

FrEHi EWSLETTER
January-February, 1988

Vol. 2

No. 1

Vaccines: Fact, Fancy & Fallacy
By Dr. N. H. Antia

Life is a perpetual struggle for survival and the immune
system is the body’s defence against bacteria and other
parasites which cause disease. This protection which is
mediated either by antibodies or cells is highly specific
for each invasive organism, contact with which induces
a memory for subsequent recognition and destruction. In
fants and children who have not yet developed such im
munity are therefore more susceptible to many of the com
municable diseases that affect us like diphtheria, pertussis
(whooping cough), tetanus, tuberculosis, and measles. Ex
posing them to a minute dose of the same infectious
organism, either killed or attenuated, which without pro
ducing the disease will nevertheless activate their immune
system and protect them subsequently from the same
disease. This process of immunization was known in
China and India several thousand years ago for protec
tion against smallpox.
Vaccines therefore provide an attractive means for pro
tection of individuals and populations from com
municable diseases and are a useful tool for their control.

Continuing the Dialogue
The FRCH newsletter was launched a year ago
on an experimental basis not just to disseminate
information on varied aspects of health, but also
to create awareness among the people on a wide
range of issues, from nutrition, drugs, therapeutics,
child health and primary health care to finance,
education planning and policies.
This, we hoped, would generate feedback from
readers and also engender stimulating dialogue
between interested individuals and groups. From the
encouraging response we have received so far from
readers, doctors and health experts we are spurred
to continue and make the newsletter a permanent
feature.
We will be dealing with varied issues of topical
interest and concern. In this issue we are discussing
different aspects of vaccines in view of the con
siderable interest created recently and the subsequent
controversy. We are presenting here facts already
publicised and some not so well known. We hope
to state both sides of the coin and let the readers
make their own judgement. The newsletter also
contains information on the different activities of
the FRCH.

The worldwide eradication of smallpox, a major human
scourge, through immunization has undoubtedly been a
major achievement. This success however, remains an ex
ception because of the nature of this acute disease con
fined to the human host and for which simple tools such
as a highly potent vaccine which could be lyophilized and
given by scratching the skin with a forked needle was
available. Yet it took 175 years from knowledge to its
implementation.
We have also had vaccines for tetanus, whooping cough,
diphtheria, tuberculosis, poliomyelitis, rabies, measles and
yet these diseases continue to take their unremitting toll.
500,000 die yearly of tuberculosis, 250,000 of tetanus,
30,000 of measles and around 200,000 new cases of polio
are detected each year.
It is common knowledge that the root cause of com
municable diseases lies in poverty and the associated
malnutrition, lack of proper water supply, sanitation and
unhygienic housing and environment. The following tables
show how most diseases like tuberculosis, diphtheria and
measles had started declining in Europe'even before the
cause of the diseases were discovered and had practically
disappeared by the time vaccines and drugs were available.
In contrast, the same diseases continue to take their toll
in the poorer countries despite far better scientific
knowledge as well as highly effective drugs and vaccines
for their prevention and treatment. This clearly
demonstrates the pre-eminence of socio-economic factors
in the control of these diseases.
While vaccines and drugs are useful tools, experience
reveals that they cannot by themselves solve the problem.
Those well-to-do nations or those within each nation who.
do not wish to choose the correct and honest path of ac
tion because of personal vested interest in the existing
order, continue to promote vaccines and drugs while on
ly paying lip sympathy to the other far more important
factors. Among these are the medical profession, the scien
tists, the bureaucracy and the politicians who see the poor
only as a means of justification for their own comfor
table existence.
India despite its vast scientific manpower and large
research institutions has not yet produced a single new
vaccine after Haffkine discovered the ones for plague and
cholera at the turn of the century. We still have to go to
We wish our readers
A Happy New Year

FOR PRIVATE CIRCULATION ONLY

900..

4000 —

x

3500 -

3000 2500 2000 1500 1000 500 01______ I---------- 1----------1---------- 1---------- 1---------- 1---------- i------- "ouerol II
1870 1880 1890 1900 1910 1920 19.30 1940 1950 1960
Veer

oL. —I-------- 1-------- i-------- 1------- J-------- --------- 1-------- ;--------1-------- l
1838

Year

Diphtheria: death rates of children under 15,
England and Wales

i
*x=x ।
1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970

Respiratory tuberculosis: death rates, England and Wales

a small country like Yugoslavia to purchase a strain of
the measles vaccine and also for the technology for its
mass manufacture. And perchance as in the case of
leprosy we develop our own vaccines, we are discouraged
by both our own peer scientists leave aside those of the
West who while being sold almost entirely on recombi
nant and synthetic vaccines have no qualms on imposing
a first generation armadillo derived vaccine on our peo
ple for experimentation. This despite the indigenous vac
cine which is infinitely cheaper and in every other
technical respects comparable to its western counterpart.
Our public sector drug industries cannot even after four
decades produce sufficient vaccines for our needs while
a ten year old private sector company can outstrip them
using in a great measure indigeneous production
technology. The recent much-publicised co-operative Vac
cine Action Programme by our bio-scientists for produc
ing the latest third generation vaccines only means giv
ing a helping hand to their Western counterparts to try
out their vaccines on our people, some of which are not
approved for use in their own country. An illiterate
population, a readymade scientific infrastructure and a
tradition for overzealous and reckless committment to
anything Western may fast turn India into a vast ground
for human* experimentation. While this may serve the
needs of WHO and the USA, a few million dollars and
a few scientific jaunts and exchanges will do little to
enhance the self-respect of our scientists or stimulate
original research. We are assured that the interests of the
poor, who are invariably the subjects of these trials, will
be protected. Reports such as of the Lentin Commission
demonstrate how helpless our poor are even in the hands
of those who are elected or paid to protect them.
There are also several inherent scientific problems and
dangers with vaccines which scientists have often failed
to realize or overlooked in their enthusiasm. Several
disease processes are still ill understood and most vaccines
developed are far from ideal. The advent of AIDS in both
the first and the third world and the several acquired defi
ciency syndromes already present in the third world makes
the danger of using live recombinant third generation vac
cines a real one.
Technical uncertainties such as variation in vaccine ef
ficacy dye to either genetic or geographical factors, or lack

of ways to measure protection or the hazards of im
munization are never laid open to public view by our ex
perts. Indeed one must be also open to the possibility that
in certain conditions vaccines may not work at all.
The smallpox eradication programme provides a good
case for enumerating factors that would allow vaccines
to work. Acute diseases are more prone to vaccine con
trol than chronic ones. The presence of diverse natural
reservoirs of the pathogen may thwart eradication pro
gramme and a single shot delivery of life long protection
is ideal for delivery logistics.
Dazzled by the glamour of quick technological solu
tions, good science for the understanding the basic
pathological process of these diseases and developing of
laboratory tests for preliminary screening of potential vac
cines has been neglected. The need for the latter is a must
particularly if second and third generation vaccines are
to be tried out in multiple combinations. It would be vastly
wasteful if not impossible to submit lay populations to
trial vaccines and wait a number of years to see if there
is a satisfactory significant reduction in cases of disease
in that population. Epidemiology, the basis for understan
ding of community health as also field trials of vaccines
is the most neglected of all our medical subjects so that
we have to seek the help of western experts even after 40
years.
In the haste for using the ‘latest’ recombinant
technology we seem to have lost sight of the simple
technology such as the use of readily cultivable organisms
which have been the basis of all our tried and tested vac
cines to date.
Seventy per cent of our health services in India are in
the private sector which is entirely curative oriented and
caters for only a limited portion of our population who
can pay for their services. Since communicable diseases,
the most common killers and maimers chiefly affect the
poor, their prevention and even treatment is almost en
tirely relegated to the public sector. Despite a eleven-fold
increase in the Primary Health Centres from 725 to 8496
in 40 years together with the availability of drugs and vac
cines for most of these diseases, communicable diseases
continue to take an unacceptably high toll. There are often
shortages of drugs and vaccines and it is difficult to main(contd on p. 12)
2

From Holism to Eradication & Beyond
Merges Mistry

The practice of vaccination in China probably arose in
the belief of the co-existence of species, a wise forebearer
of the theory of natural selection. A disease was invited
to enter the body so that it would not then ravage the per
son in its more deadlier form. This kept the vital forces
of the body in balance and contributed therefore to its
well-being. This then was the principle of immunization
against smallpox which consisted of introducing pustular
crusts of pox lesions in powder form into the nostrils.
The method was introduced into neighbouring India
through the perennial trade traffic where it was sustain
ed in the form of skin punctures or tikas. Active im
munization, though never redundant, remained for subse
quent centuries localized to the Orient probably due to
other dominant advances in the West and was introduc
ed to the Western world through Turkey via Arab men
dicants and by adventurers such as Marco Polo. The same
practice was baptised newly in 1812 by Edward Jenner’s
success in preventing human smallpox by injection of a
related virus that infected cows. The procedure became
known as vaccination from the term ‘la vacche' meaning
cow: this time, however, there was a difference. From the
time of the ancients the goals of science had been wisdom,
understanding the natural order and living in harmony
with it. In the 17th century, guided by the doctrines of
Francis Bacon, this attitude of integration was replaced
to one of self-assertion. The goal of science became
knowledge that could be used to control and dominate
nature.
Diverse discoveries led to the resurgence of active im
munization. Darwin’s theory of evolution made meaning
of why big fish eat little fish. Jacob Henle first and then
Louis Pasteur showed that micro-organisms caused disease
and that they themselves arose from other microorganisms. Pasteur also introduced the concept of
modified or attenuated vaccines.
One of his successors Albert Calmette utilised at
tenuated germs for anti-tuberculosis vaccination now
popularly known as -BCG. Another dimension was add
ed by the team of Roux and Yersin who treated diphtheria
with a serum raised against bacterial toxins; i.e. passive
immunization with antibodies raised in another animal
such as a horse.
Thus .the purpose of vaccination was to provoke a
specific immunological response to a selected agent or its
component (antigen) with the expectation that it would
result in the formation of protective serum factors (anti
bodies) or the development of immunity that is mediated
by cells in blood and tissues known as lymphocytes and
others that eat and digest micro-organisms; the amoeba
derived phagocytes of Metchnikoff. With time, sufficient
residual immunity remains, so that a heightened and more
rapid immune response occurs upon a subsequent ex
posure to the same micro-organism (memory).
These findings suffered from two flaws: the very em
phasis on immunological mechanisms equated im
munology absolutely with protectivity. Secondly, the
discovery of immunology and infectious micro-organisms
around the same time made possible the empirical con
clusion that immunity was in evolutionary terms largely

an anti-infectious entity. The first premise holds true to
this day and may be selected by future science chroniclers
as of one of those conclusions that led science astray. Jules
Bordet moved beyond the second concept when he
demonstrated alongwith Tchisovich that anti-bodies could
also be induced by non-infectious agents like red blood
cells and proteins and thus established that the immune
system “could respond beyond limits of its happy interven
tion with infectious disease”.
It seemed to many in the early half of this century that
infectious disease could be controlled chemically rather
than immunologically. By 1950s it was said that the earth
was literally bathed in a dilute solution of antibiotics. A
viable example of the theory of natural selection was seen
by the spectacular response of the endogenous bacterial
population to their catastrophe—transmissible antibiotic
resistance first identified in Japan in 1959. This coupled
with the striking lack of anti-viral compounds, the
epidemics and pandemics of smallpox, polio and influen
za and the failure of alternative measures, such as vector
control in malaria favoured the immunological approach.
The conflict culture engendered by the two World Wars,
the antibiotic era and the likening of the immunological
apparatus to an army may have brought forth the transfor
mation of not only the control of the enemy (ie
bacteria/viruses/parasites) but eventually its eradication:
In the clamour, one point was probably forgotten. With
the exception of Jenner’s trials on cowmaids, most of the
land mark experiments were performed as successful
therapy of ongoing disease (immunotherapy). The jump,
was towards preventive vaccination.

First Generation Vaccines
The years between 1970 and 1984 witnessed the develop
ment of 9 viral and 11 bacterial vaccines (Refer box on
pg. 7). The first generation vaccines consisted of live at
tenuated or killed preparations of whole organisms grown
either in synthetic medium or in human or animal em
bryo cultures or cell lines. In conditions such as tetanus
where disease activity depended not on bacteria but on
their toxins, chemical modification of toxins was achieved.
Global eradication of smallpox was realised with the
last outbreak in Somalia in October, 1977. In May 1980,
a certificate of eradication was issued by WHO. The story
on man’s part was that of a techno managerial triumph.
A vertical special immunization programme, better quality
vaccines, personnel trained in preventive aspects of
medicine, efficient delivery, reliable epidemiology and
flexible operation tactics all helped towards defining the
zero-incidence end point. Nature played a role too.
The most explicit question at the onset of the programme was whether there was a natural reservoir of the
smallpox virus which. would thwart the objective of
eradication. Except for the human monkey-pox virus
which could not sustain itself by inter-human transmis
sion, none other was found. The second natural aid was
the inherent acute nature of the disease itself, its quick
infectivity and short incubation period which allowed anti(contd on p. 6)
3

Need for Alternative Approaches in
Vaccine Development
Tannaz Birdi

The discovery that infectious diseases were caused by
micro-organisms, provided the necessary explanation for
the earlier observation that individuals could be protected
against smallpox if they had been infected with cowpox
earlier. In other situations also, injections of killed
bacteria or live organisms of modified disease producing
potential (attenuated) were shown to prevent disease. This
resulted in the belief that the causative bacteria had only
to be identified and isolated and a wide variety of diseases
could be prevented and eradicated. Even though disease
causing bacteria have been identified effective vaccines
against most intracellular parasites are the goals of the
future. The few vaccines, that have proved effective, are
against toxins and viral infections, and the only spec
tacular success has been of the smallpox vaccination
programme.
Why have the approaches used in the vaccine develop
ment against smallpox resulted in only limited success in
other communicable diseases? In fact, in some cases the
results were disastrous. The deep respiratory tract virus
infection is one such example, where formalin inactivated
virus was used to immunize children. Upon exposure to
the live virus the requirement for hospitalisation in im
munized children was 40% compared to the normal figure
of 1%7.
An effective vaccine must counter the methods by which
pathogens (disease causing organisms) evade the body’s
defences, so that protective immunity can be generated.
Let us examine the various methods of evasion used by
pathogens and the importance of this in the designing of
vaccines.

Cholera

Influenza Virus

Malaria

On encountering a pathogen, the body produces an
tibodies which are specific to the exposed antigens of the
organism. Certain micro-organisms evade neutralisation
by antibodies by frequently changing the antigens on their
surface. The most well-known example of this is the in
fluenza virus. To develop a suitable vaccine in these cir
cumstances certain antigens which remain constant have
to be identifed and purified or synthesised in sufficient
amounts. Such antigens are then modified either structurally or by combining them to suitable carriers so that
they evoke a strong protective immune response. The inherent problems in the designing of suitable carriers has
been discussed in the previous article.

From the moment it enters the blood stream the .
malarial parasite takes only a few minutes before it reaches •)
the liver, where it infects the Red Blood Cells (RBCs.) If
the vaccine has to prevent infection of RBCs a high level
of circulating antibody must be present to neutralise the
parasite before it reaches the safety of the liver. The only
way to maintain this high level of antibody is by regular
boosters. Failure to achieve this is one of the major
obstacles in this kind of vaccine. Therefore vaccines have
to be developed against later stages of the parasite’s lifecycle. Despite using a combination of antigens from different stages of the parasite’s life-cycle there is reason to
be cautious since it has failed to produce uniformly high
levels of antibodies in volunteers. Even individuals with
high antibody levels are not always protected against infection. Thus we cannot afford to rely merely on an antibody response and a cell mediated immune response is
also required. Synthetic peptides have been used to
generate such a response. The limited success-has
highlighted the problem that MHC (antigens which
discriminate self from non-self) restriction of the immune
response poses for peptide vaccines.
The phagocyte must present on its surface the antigens
of the invading organism as well as MHC antigens. These

The recognition that cholera was a toxin mediated
disease inspired hope that it could also be prevented by
an inactive toxin vaccine. Studies are still in progress to
find a suitable method to inactivate the toxin without los
ing its potential for generating an immune response.
Meanwhile, the search also continues for alive attenuated
vaccine. For such bacteria to be able to provide local pro
tection they must be able to withstand the acidity in the
stomach and penetrate the mucous secretions which are
normally present in the small bowels.

Schistosomiasis
Schistosoma mansoni, the cause of intestinal flat worm
infection exhibits on its surface the tissue antigens of the
host. This allows the adult worm to escape recognition
by the immune surveillance system. On the other hand,
the disease itself can largely be ascribed to the hosts im
mune reaction to the schistosome egg. The hosts immune
cells gather in large numbers around the egg and secrete
toxic factors in an attempt to destory the egg. This results
in inflammation leading to tissue damage with little ef
fect on the schistosome egg. Therefore, vaccines which
boost this reaction might be harmful. There is also
evidence that certain kinds of antibodies (IgM) are
generated in susceptible individuals that block the kill
ing of the larvae by other antibodies (IgG). Under these
circumstances an anti-idiotype (described in the previous
article) vaccine may prove useful. Pilot studies in animals
have reported success using such an approach.

Tetanus and Diphtheria
Both these diseases are caused by the secretion of a tox
in by the pathogenic bacteria. For these diseases vaccina
tion has proved relatively simple and effective. An inac
tive form of the toxin is used to generate antibodies which
are able to neutralise the toxin. After smallpox, these vaccines have proved to be the most effective even though
environmental factors do pose a problem (e.g. tetanus in
India).
4

rested on human volunteers for their ability to generate
an immune response. Since these volunteers cannot be"
ethically challenged with the pathogen the two most com
monly used parameters are antibody titres and hypersen
sitivity (allergy) reactions as measured by skin test positivi
ty. An increasing number of studies have now shown that
both these parameters are unreliable since they do not
necessarily reflect protection.

two antigens must combine in order to stimulate lym
phocytes. If the individual’s MHC antigens are unable to
combine with the peptide then no response is generated.
No single peptide sequence can be guaranteed to contain
regions with the ability to bind all MHC antigens.
Therefore, a cocktail of peptides that can bind to all MHC
antigens must be developed.

Leprosy and Tuberculosis
Factors Influencing Response to Vaccines

Both these diseases are caused by Mycobacteria. The
causative agent for leprosy is M.leprae while tuberculosis
is caused by M.tuberculosis.
Mycobacteria exemplify those organisms which have
evolved multiple methods of not only protecting
themselves from attack by phagocytes but survive and
multiply within them.
M.leprae, has also developed a number of other ways
of survival viz. Besides invading macrophages, M.leprae
also finds protection from attack in immunologically
privileged tissues such as the nerves where the immune
response generated by vaccination may not be able to
reach. In addition, some M.leprae antigens also generate
suppressor cells. Because of the multiple means by which
the organism protects itself from immune attack vaccine
development is made increasingly difficult. In addition,
as in the case with malaria, MHC restriction may also
be involved.

Environmental Variation

Poor hygienic conditions and malnutrition which are
inherent in most underdeveloped or developing countries
would itself be a stumbling block. Nowhere is it
demonstrated so well as in tetanus. Because of the life
long ingestion of the tetanus orally due to unhygeinic con
ditions, the Indian population is unable to respond to the
tetanus vaccine.
Non-pathogenic bacteria in the individual’s environ
ment also influence the efficacy of a vaccine. This is
highlighted by the results obtained in the vaccination trials
with BCG. In Uganda 80 Vo protection against leprosy was
obtained after BCG vaccination while in Burma and In
dia there was only 20 Vo protection with the same vaccine.
This discrepancy in the response to BCG was explained
on the basis that environmental bacterial flora had precon
ditioned the individuals immune response to BCG.

Genetic Variation

Methods Used for Testing Vaccines

The influence of genetics on the immune response and
The monitoring of candidate vaccines so that only the
consequently on the disease profile is seen most striking
most promising ones undergo field trials is imperative
ly in yellow fever, where only the Negroid population is
since large numbers of different vaccines are at present
prone to this disease and the Caucasian races are not
being developed. At present none are perfect since we can
affected.
not mimic disease processes completely in the test tube
It has been observed that though many people are
or in animals that are not naturally susceptible to the
sometimes exposed to disease causing bacteria only a few
disease. Besides, immunology today offers no criteria to
finally manifest the disease symptoms. Recent studies in
measure protection. The methods utilised fall into two
basic immunology have shown that this is due to the
broad categories. In the first, the reactivity of cells in vitro
genetic make-up of the individual. This results in each
(isolated in a test-tube) is measured. The memory
person handling the same cocktail of antigens different
generated and the possible interactions between various
ly. Therefore, some individuals because of their genetic
tissues and their cell types is studied in vivo in animal
make-up will not be able to respond to a given antigen
models and human volunteers.
and
for them a vaccine is of no use. This is particularly
In Vitro Studies; These are especially important in in
important
for diseases where the symptoms are due to a
fections where disease is the result of an absence of im
lack
of
response.
An example of this is seen, in
mune response to the pathogen or due to generation of
lepromatous
leprosy
which is the result of a lack of
suppressor cells. In such situations lymphocytes respon
response
to
M.leprae
antigens.
The figures of vaccination
ding to the vaccinating antigen are checked for their ability
trials
for
leprosy
have
consistently
shown that 40 Vo of the
to respond to the pathogen using a variety of im
non-responders
could
not
be
converted
into responders
munological tests. This approach though it appears to be
suggesting
that
this
group
may
be
genetically
incapable
relatively direct has limitations since it does not account
of
responding
to
M.leprae
antigens.
for memory or the interaction of cell types and can only
serve as a preliminary test for the screening of various an Effect of Multiple Vaccinations.
tigenic preparations.
Increasing effort and finances are being channelised in
In Vivo Studies; Disease or the lack of it is normally
to vaccine development as a measure to combat infections.
the outcome of the inter-play of a number of cell types.
This will result in individuals being vaccinated against a
This interaction is difficult to mimic in the test tube and
number of differing antigens. Basic immunologists have
recourse has to be taken to experimental animal models.
already recognised that an immune response generated
The animal most widely used is the mouse. Undoubted
against one set of antigens may reflect on the response
ly, while useful information for vaccine development is
to a second group of antigens. If this is applied to the
obtained by this approach it cannot always predict the
future vaccination scenario where an individual will be
kind of response that would be generated in man especial
vaccinated for a large number of diseases it is conceivable
ly if the animal is not the natural host for the pathogen.
Therefore, ultimately the vaccine preparations have to be
(contd on p. 11)
5

(con id from p. 3)

bodies induced by vaccination to neutralise the pathogen
before establishment of infection. It was suggested that
the smallpox eradication programme should serve as a
template for other disease control or eradication program
mes. This was not simply feasible since each disease had
its own unique characteristics and methods of control that
required strategies and tactics specific to that disease.
The success story of smallpox was shared by a few other
acute viral and toxin dependent diseases. However, it was
in the majority of diseases where vaccination failed where
the rules of the survival game were drawn out.
The influenza virus played games by transforming itself,
BCG worked (or did not work) unpredictably in different
geographic locations. A type of attenuated polio virus
reverted back to its pathogenic form and the whooping
cough germ was found to be toxic for use. Apart from
the technical flaws of vaccine design, most affluent coun
tries controlled diseases through the fiat of improved
socio-economic measures. Paradoxically, the failure of
vaccination was manifested most in the poorer countries
whose populations were affected the most.
Even with technically effective vaccines, there remain
ed in these countries the problems of timing and delivery.
Again for reasons not understood, induction of antibody
in tropical countries was poor with live vaccines and many
could not afford the protection accorded by expensive kill
ed vaccines (polio). Toxoids given in areas where incidence
of parasitic infection was high gave rise to life-threatening
complications just as measles immunization could not be
given to children with depressed cell-mediated immunity.
It was especially difficult to make vaccines against diseases
which were chronic or developed slowly. Even today no
vaccine has been developed against any tropical parasitic
disease.

against such organisms causing childhood diseases would
be a failure since immune response to sugars develops only
after the age of three. One approach was to couple the
sugar to a protein carrier. Another was the brain-child of
Bordet and the fertile field of immunogenetics.
In the 50s and 60s, Oudin identified protein deter
minants on anti-bodies to a given antigen which were uni
que in an individual or groups of individuals. These were
fortuitously placed next to sites where anti-body bound
antigen. He coined the term “idiotypy” meaning distinc
tive to describe this structure upon which Niels Jerne bas
ed his theory of immune regulation in 1974. It simply
meant that several generations of anti-body responses were
created to an antigen, each succeeding generation
recognizing the unique determinant (idiotope) on the
anti-body of the preceeding generation. In practice, it
meant that antigens would not have to be constructed
since the second generation of anti-bodies would contain
the internal image of the antigen in the idiotope. These
imaged antigens riding on human anti-bodies would be
safe and effective. Though experimental results have been
variable, historically, the impact has been resounding. Vaccinology could now move away from infectious diseases —
to attempt prevention of tumours or even auto-immune
diseases where a causative agent need not be identified.
The old observation of Border that anti-bodies could
be raised against self-proteins and cells was utilised by
Ostergard 41 years ago for raising anti-bodies to animal
reproductive hormones. Chemical modification of hor
mones that maintained fertility induced immunity that
impaired female reproductive function. The first candidates were unsafe since they produced anti-bodies reac
ting to many more hormones than was intended. Using
peptides to confer specificity, three female anti-fertility
vaccines hit clinical trials in 1986; a male anti-fertility vac
cine is also being pursued as is the expectation of ultimate
ly producing vaccines for fertility. For the first time the
greater risk lies in the use of successful vaccine.

Second Generation Vaccines

Third Generation Vaccines

The efficacy of heat killed vaccines and the paramount
need to abolish side-effects compelled replacement of con
servative vaccines with second generation sub-unit vac
cines. The concept practised since 1982 first in the
tobacco-mosaic virus was the heir of two important ad
vances viz. the development of in vitro tests purported
to indicate protective immunity and the ability to separate,
sequence and synthesise proteins. The second generation
vaccines thus consist of one or several appropriate short
sequences of bacterial or viral proteins (peptides) which
by themselves can give rise to protective immune
responses. In this way, besides conferring safety they
would circumvent the strategy of the micro-organism to
evade the immune system.
The protection and efficacy of such vaccines was
reported in animal models and in vitro systems for diseases
such as malaria, herpes and rabies amongst others. Their
prime drawback was that when injected, some of these
peptides were rapidly degraded by enzymes in the body.
So another need of carriers was begetted.
Another worrier for the vaccinologists around the same
time was the finding that organisms such as those causing
pneumonia and typhoid amongst others had antigenic activity in non-proteins such as sugars and lipids. Vaccination

If second generation vaccines are to populate the earth,
then how would they be produced in bulk amounts that,
would render them economically feasible. The search for "
growth material was helped by molecular genetics which
allowed isolation of specific genes from organisms and
placing them between genes of other live organisms
(vehicles). The vaccinia virus of Smallpox fame, BCG,
the unassuming coliforms that populate our intestines and
yeast are all entrants to that exclusive vehicular club. The
first attempt by Klein in 1981 was carried out with the
virus of foot and mouth disease. Experimental- recombinant vaccines have now been constructed for diverse entitles as the cholera toxin and a protein of the leprosy
bacillus. All are potentially third generation vaccine candidates. Potentially a single shot with live vaccinia BCG
may serve as or a life-long vaccine for several diseases. •
These are our desires on the fact of the inscrutable. But
what will be the effect of these on the vehicle itself. Will
it remain safe or evolve to a monstrous form beyond our
control. In less dramatic circumstances, will the immune
responses generated by several antigens block each other
and how are these live vehicles to behave on trial with
immuno-compromised individuals not only of the third

From Holism to Eradication

6))

gy

(con id on p. 11)
6

It Can be Done, Says UNICEF
Nearly a quarter million children die every week in the munizing the child as soon as it is nine months old.
Death due to tetanus, which usually occurs in the first
developing countries due to vaccine-preventable diseases
and malnutrition. While in 1950, the number of deaths week of life, and kills 0.8 million babies, can be prevented
of children below five was a whopping 25 million, the
by giving anti-tetanus injection during pregnancy and by
figure in 1980, fell to 16 million because of immuniza
ensuring that vaccination is available as part of basic ante
tion; this despite an increase in the number of births.
natal care.
Immunization, according the UNICEF, has been the
About 2.9 million children die from respiratory infec
success story of this decade. Only ten years ago, less than
tions. Over half a million deaths due to whooping cough
5 per cent of children in the developing countries were
can be prevented by immunization. Most other respiratory
vaccinated against diseases which took a toll of 4.5 million deaths too can be prevented at a low cost if parents
infants annually. In 1987, immunisation reached 50 per
recognise the danger signs and use simple antibiotics.
cent for DPT and 40 per cent for measles, thus saving over
One million deaths occur from malaria which can be
1 .3 million babies a year. The U.N. target for immuniz
drastically
reduced at low cost if parents know the symp
ing all children by 1990 seems now possible. Most of the
toms and seek timely help.
deaths can be prevented by immunizing children against
the diseases.
Diarrhoeal diseases take a toll of five million lives.
Measles takes a toll of 1.8 million lives. Almost all the Seventy per cent of the deaths are caused by dehydration,
deaths can be prevented by a single injection—if vaccina which can be prevented by oral rehydration therapy (ORT),
tion is available, and parents know the importance of im a simple and cheap method that can be followed by all.

Immunization Schedule

A MATTER OF LIFE AND DEATH
Beneficiaries

Age

Vaccine

No. of
doses

Annual deaths 3,260,000
measles

Infants

•

DPT
Polio
BCG

3
3
1

whooping
cough

Measles*
DPT
Polio

I
I
I

tetanus

DT
Typhoid

.1**
2

10 years

TT
Typhoid

P*
P*

whooping
cough

16 years

TT
Typhoid

P*
P*

tetanus

TT

pt

. 3-9 month

9-12 months
18-23 months

Children

Pregnant
Women

•

. 5-6 years

. 16-36 weeks

.

1,900 000

"3
560,000

■MM
i

I 800,000

Annual lives saved by vaccines 1,200,000
measles

700,000
300,000

200,000

Graphics: Phil Green
Sunday Times London

Bacterial Vaccines

* Measles vaccine is available only at selected centres
** Two doses are given if not vaccinated previously.
Synopsis of development of viral vaccines

Years

Disease

1700-1900

Smallpox +
Rabies +
Yellow Fever +
Influenza —
Mumps +
Polio ±
Measles ±

1935-1945
1955-1964

1965-1974
1975-1984

Rubella +
Hepatitis B +

Years

Disease

1885-1896

Diphtheria +
Tetanus +
Cholera - .
Typhoid ±

1900-1921

Bacterial Meningitis ±
Pneumonia ±
Tuberculosis ±

1933

Whooping cough ±

1948
1968
1972

Bacterial Dysentry ±
Burns Organism Bacterial Influenza

•

Vaccine worked wholly (+), Partially (±) or not at all (-)
7

Panacea or Palliative?
Amar Jesani and Ravi Duggal
Universal immunization by the year 1990 (85%
coverage) is being pushed as a vital key in the ‘Health For
All’ (HFA) strategy. Four vaccines against six major
diseases that affect a large proportion of the third world
have because of UNICEF pressures become the interna
tional cornerstone of child survival programmes of na
tional governments.
The DPT, BCG, polio and measles vaccines to protect
against diphtheria, pertussis (whooping cough), tetanus,
tuberculosis, poliomyelitis and measles, have been taken
up by the Indian government under the Universal Im
munization Programme (UIP).
Why this sudden interest and pressure now to protect
the child population from these deadly diseases when
these vaccines have been available for over two decades?
Further more, why this concentrated high-profile pro
gramme of UIP when historically it is well established that
vaccines have not been used wherever these diseases have
been eradicated or controlled. First, we will look at the
political economy of this new strategy, and then try to
answer these questions.

The Political Economy

by it. The ideological diversion that such orientation
creates must be fought.
In this context, it is necessary to mention two more
points. Firstly, the western nations pushing these
ideological and techno-managerial orientation themselves
never brought under control or eradicated these six
diseases through immunization or drugs. It is proved
beyond doubt that these diseases, and for that matter most
major communicable diseases came under control as peo
ple’s standard of life improved. Health technology and
health management played a very minor role. For that
matter even in post-revolutionary USSR, China, Cuba or
even the more recent case of Nicaragua which cannot be
credited with controlling these diseases through mere
universal immunization. And that proves the point fur
ther that though immunization was an extremely useful
tool, as was the case in post-revolutionary societies, it is
not sufficient in itself to control or eradicate major
diseases in the underdeveloped world. In these countries,
EPI is only a temporising palliative measure to avert
deaths, predictably not for too long.
Secondly, in the context of the need of the capitalist
system to stabilise to the last small village in the rural area
and the need of expanding capitalist (private sector
oriented) allopathic medicine to strike roots to the last
person in the rural society (of course, to the detriment
and bankruptcy of the indigenous and folk-healers), im
munization carries its medicine with the syringe and
needle very effectively to win people over to allopathy
No doubt the indigenous medicine and folk-healers are
on the retreat since long: immunization will, however, ac
celerate their death. And this .is not just a figment of im
agination. Immunization did perform this function in
Western society in the late 1940s arid the 1950s. There is
no reason to believe that it would not do so in our coun
try too. The pharmaceutical companies, both multi
national and Indian, would only expect further expansion
of their domestic market. And we all know what kind of
drugs they push to maximise their profit. And the newly
capitalised drug industry of ayurvedic medicine, we must
. add, is also not lagging behind. We know they have also
come out with their brand of injections! And we must
also add that none of the third world countries has the
technology to produce any of these vaccines on a mass
scale, not even India. So a bountiful booty awaits the
multi-national drug companies with the implementation
of UIP.

The HFA strategy that emerged out of the Alma-Ata
declaration and the proclamation of a new international
economic order (NIEO) by the United Nations are both
significant departures in social, economic and political
thinking. However, they have remained at the level of an
intellectual exercise and a radical rhetoric without any
ideological commitment. In actual practise it has only
resulted in another medical techno-managerial exercise
aiming at achievement of targets.
Like our society, health has also been divided and sub
divided into target groups for each of whom specific pro
grammes have been designed for achievement using (or
if necessary even misusing) the technology. What is ironic
is that many devotees of the Illichian critique of medicine
of yesteryears have uncritically accepted this new super
ficially plausible approach. The EPI vaccine programme
is another of these fetishes. Technology and the new
ideology of modern medicine has succeeded once again
and there is little to mourn about the death of the super
ficial critique advanced by Illich and his fellow thinkers.
This turning of tables has also inevitably brought about
a setback to the liberal concept of holistic medicine. The
germ theory has once again become the predominant
ideological force, and the welfare of the human being as
a whole, especially the under-privileged, has been relegated
to the background and only suitable for lip sympathy. Child Survival or Population Control?
It is officially argued that by undertaking an ambitious
We have already mentioned that the diseases against
project with high technological and managerial inputs, which immunization is available have been controlled or
at least some benefits will accrue to the people. Is this eradicated in the affluent countries without vaccines or
pragmatism in its extreme form as articulated by the pro drugs. A significantly improved standard of living was
fessionals and intelligentsia or is it an admission of the responsible for this. Therefore, why are the
programme’s impending failure? We are not arguing here underdeveloped countries being asked to launch a highagainst the immunization against the six vaccine-preven profile UIP and that too on the advice of countries
table diseases and prevention of infant death. What is which did not use these vaccines to control the diseases
mooted here is the distortion that it injects into the public concerned?
health services—the neglect of other vital health functions
The real reason is population control. In the sixties a
8

6
V

0)
7

high-profile population control programme was launch
ed in the third world. In spite of the phenomenal aid by
advanced capitalist countries, right through the seventies,
the expected fertility decline did not result. These coun
tries are worried by the threat of “population explosion”
in the third world (a nightmare for capitalism!) which will
affect their own political system and quality of life. They
are not wrong in thinking so because how would they be
able to enjoy their luxuriant life-style (even when millions
die of hunger) if their slice of cake has to be further sub
divided. The irony is that even with a growing third world
population (in comparison with the first world) their (first
world) share of the cake has not declined; if at all, their
share has grown, and that of the third world reduced, in
spite of the latter’s proportionate increase in numbers.
Even the World Bank figures say so. And on the other
hand, with a growing political and economic strength of
the third world the amount of wealth that advanced
capitalist countries can expropriate from the third world
is at least apparently on the decline. Hence, the concern
to drastically, reduce the population numbers of the third
world.
The overt attempts at population control up to the pre
sent have failed as a strategy. In the mid-seventies, sim
ple home economics dawned upon capitalism. It was
realised that high infant and child mortality is a visible
deterrent against fertility control so a new logic has emerg
ed: if infant mortality is reduced drastically then, eureka!
people will become active supporters of a small family

size. Hence the answer that emerged was universal im
munization against the major killer diseases. We too ap
preciate the basic concern for saving our children, and
they must be saved. But not through immunization alone.
They must be given a significantly better quality of life.
This would mean a radical economic transformation and
not universal immunization or Oral Rehydration Therapy
or a small family size. And this would also mean an un
paralleled structural change in society.
As stated earlier, HFA and NIEO talk about such
changes (though not as radical as we think they should)
but have not demonstrated an ideological commitment
to put them into action. For instance, WHO has resorted
to only techno-managerial solutions in promoting health
development programmes. In its economic analysis, it
stops at cost benefit analysis of, for instance, tropical
disease programmes. Never has WHO actively supported
economic transformation programmes as a pre-condition
to child survival programmes. But its aim is not to change
the social order, only perhaps to preserve it and make it
more efficient for, as is increasingly evident, WHO is more
of a Western than a world oriented health organisation.
Thus, we must reject the politics of immunization and
the ideology behind it, though not the vaccines. There is
no short cut to health, and definitely not through universal
immunization.
Dr Amar Jesani, a medical doctor, and Ravi Duggal, a sociologist, are
both research officers with the FRCH.

Designing Field Trials
Dr M Uplekar

It is these intricacies that make field trials a must before
application of any vaccine on a large scale.

Does leprosy vaccine protect a person against leprosy?
Do influenza vaccines prevent a person from getting flu?
Only a field trial with a large number of vaccinated people
can answer such question provided the trial is correctly
designed, carefully monitored and scientifically evaluated
for its effectiveness.
A field trial is the penultimate stage.in the development
of any drug or vaccine. But little do people know about
the huge amount of inputs needed in terms of time, money
and energy before any drug or vaccine comes to the stage
of trying out in the field for its effectiveness. Equally, they
are unaware of the numerous factors that influence the
outcome of the action of a drug or a vaccine on a group
of subjects. While most of these are related either to the
host (people), the parasite (disease causing organism) or
the environment, even the scientists are in the dark about
. many of these chiefly because of the gaps in our
knowledge about the immune systems and the defence
mechanisms of the human body. For instance, trials to
evaluate effectiveness of BCG as a protective vaccine
against tuberculosis showed that while BCG provided
about 80% protection in the U.K. and U.S.A., it gave lit
tle, if any, protection against tuberculosis to a sample of
population in South India*. While scientists have explana
tions for some of these discrepancies, they just do not have
answers for many other questions like why yellow fever
is absent or why is there not a single case of overt AIDS
• in India?

How is a field trial conducted?
Experience over the years has helped develop a general
protocol for field trials of vaccines, the finer aspects of
which do vary depending upon the material to be tested.
Any vaccine trial would generally be conducted in four
stages:a) Pre-clinical phase: This is the most important one as
the further phases of testing vaccine in human beings
depends on the outcome of this phase. It involves testing
safety and potential toxicity of test material in animals.
It also includes evaluating pharmacokinetics (its fate on
entering the body) and pharmacological responses (its ac
tions on different body systems) in animals.
b) Phase 1— On establishing its safety in animals, the vac
cine in this stage is administered to healthy human
volunteers to assess (in normal human beings) its safety
and immunogenecity or its ability to provide immunity.
c) Phase 2 is designed to determine the appropriate dose
and frequency of administration on a larger number of
subjects.
d) Phase 3 consists in testing the vaccine in well defined
population with proper controls.
The classical design has two aspects: Control and Ran
domization. We control experiments by making the

9

tors which control the natural evolution of the disease are
incompletely understood, the incubation period is much
prolonged and there is no diagnostic method currently
available to identify sub-clinical leprosy. Some studies
show that after vaccination, intercurrent infection, injury
or stress in general may precipitate a reaction in patients
suffering from leprosy. It is possible that a leprosy vac
cine itself may precipitate reaction in sub-clinical leprosy,
making it a ‘manifest leprosy case*. This factor in itself
will tend to increase the incidence of leprosy in the vaccinated
group compared to the control group. A mistaken inclu
sion of undiagnosed cases or wrongly diagnosed cases of
leprosy have also been shown to affect the statistical in
terpretation significantly. Increased efficacy in detection
of new cases in a population under trial may itself lead
to an artificial increase in disease incidence.
Complications of vaccinations, although uncommon,
have been well documented in the smallpox vaccination
programme. These include secondary infection at the site,
cellulitis, generalised, vaccina and cozeme vaccination.
Post-vaccinal encephalitis is a rare but fatal complication.
In treatment trials with immunogenic agents like in
terferons and interlenkin two adverse reactions are com
mon and include fever, malaria, chills, dyspnose, chest
pain and tightness, wheezing, nausea, vomiting, tremor
and skin rashes. Other toxic manifestations include
hypertension, tachycardia, acute renal failure, diffuse
capillary leakage, profound weight gain and pulmonary
edema.

treatments in two groups similar for factors that we
already know influence the outcome. Randomization is
a way of combating the misleading effects of conditions
with an unknown influence that we cannot control. It is
only after a candidate vaccine is tried in the above stages
successfully, that it is permitted for commercial use.

Importance of epidemiology
It is the epidemics and pandemics of killer diseases
which first called for international co-operation. The big
childhood killers are recognised in all parts of the world,
the causative agents known and the immunological ap
proaches are in the hands of experts. It should not come
as a surprise that the most important killer diseases in
the non-industrialised world are very similar, if not iden
tical to the most important diseases the industrialised
world knew in the last century. They are tuberculosis, diph
theria, pertussis, tetanus, measles and typhoid to men
tion some.of the most important. These diseases could
be controlled with the vaccines we already have. Natural
immunity which is achieved by very early infection that
either leaves a baby immune or dead occurs in a majority
of children when their respective countries become
developed nations.
Some of the important aspects of epidemiological in
formation has become a subject of hot debate now in the
context of the Indo-US vaccine action programme. It is
stated that the project includes the conducting of field
research on certain communicable diseases and their cor
responding vaccines for which it will be useful to have
access to well-defined populations of which an intensive
health profile and demographic information will have to
be made available. This epidemiological data which in
cludes samples of blood, sera and cells are indicators of
the genetic make-up of the population, collectively known
as the herd structure It is this structure which makes In
dians immune to yellow fever and to some extent to AIDS.
Those knowledgeable about developments in biological
warfare resent parting with information on the im
munological herd structures of our people that apparently
provides a natural barrier against certain infections.
Epidemiological data thus forms a vital part of assess
ment before any vaccine trial commences. It is only on
the basis of this data that a target population .of ap
propriate size can be chosen.
The very purpose of conducting a vaccine trial
systematically in the stages mentioned above is to establish
its ability to prevent a disease. Immunological tests on
blood or serum samples and cells must be available to
determine the effects of vaccine such as skin testing or
measuring the anti-body levels in vaccinated persons. It
is not ethically possible to challenge vaccinated humans
with a live organism or a virus directly, therefore a long
term prospective study is needed to determine a vaccine’s
ability to prevent infection.
The different phases of a vaccine trial may appear sim
ple from what is discussed above but the interpretation
of their outcome is not without complexities. The result
of the BCG trial is one example of the differences in the
U.K., U.S.A, and India. It could be increasingly difficult
if the disease for which a vaccine is being tried is
misunderstood. In case of leprosy for example, the fac

Cost effectiveness of vaccines
In the U.S.A, and U.S.S.R., a study was done on health
and resource savings due to vaccination against measles
during the periods 1963-72 and 1967-72 respectively. The
net economical benefits for the periods covered were
calculated at $ 1.3 billion for the U.S.A. and $ 266 million
for the U.S.S.R. Cholera is a major contribution to the
economic problems of many underdeveloped countries.
It is estimated that an effective vaccine which would pre
vent the spread of cholera would reduce world expenditure
for medical purposes by billions of dollars. It is widely
accepted that successful vaccination programmes, such as
the one which essentially eliminated polio in the U.S.A.,
resulted in a ratio of $ 100.00 saving of public tax money
per year for every dollar spent on developing the vaccine.
Control and eradication of a disease are two distinct
end points of vaccination procedures. Control to the point
of eradication even in diseases such as tuberculosis, where
vaccination is only partially effective can be achieved with
intensive use of other control measures such as
chemotherapy.
A comparison of the effect of vaccination on infectious
diseases in a West Germany demonstrated that infections
for which there is excellent treatment but no vaccination
do not disappear (infections mononucleiosis and bacterial
meningitis) while those" for which there is no treatment
(polio, diphtheria) are close to eradication because of
vaccination.
Source: New Trends and Developments in Vaccines
Editors—A Voller and H. Friedman (1978)
10

Our Many Projects
A major activity of the Foundation is its many projects
on health, both in urban and rural areas, sponsored by
various funding agencies, including the government. We
give below a few of them.
SCHOOL HEALTH

A school health project is being conducted by Dr
Mohan Deshpande. It aims at giving school children of
std. V, VI and VII basic knowledge of the human body,
mind, nutrition, common health problems and correct
health habits. Started in July ’87, it will cover two urban
and a rural school.
According to Dr. Deshpande, the existing concept of
school health programme is inadequate. The present cur
riculum has very few topics on health, which do not of
fer comprehensive knowledge in an interesting manner
and so fail to create health consciousness in students.
The six handbooks currently in circulation for teachers
emphasise clean and healthy habits without scientific
details of the body, diseases and environment, while the
syllabus chalked out begins with the evolution of human
beings, structure and function of the body and the effects
of nutrition and environment on the body. This will
logically lead to clean, healthy habits and create communi
ty health consciousness and responsibility, says Dr.
Deshpande.
The preliminary study has been carried out as part of
a grant from the Ford Foundation.

HEALTH EXPENDITURE
A Study by Ravi Duggal on health expenditure was
started in September ‘86 to understand health financing
at the household and macro level. The first part conducted
in Jalgaon district sampling one per cent of the popula
tion has just been concluded and the data will soon be
published and summarised in the future newsletter.
A new macro-level study to examine state health finan
cing, with an overview of health services, including public
health, medical and family welfare, has just commenced.
This will last for a year. Case studies of selected states
from different parts of the country is being undertaken
to understand the performance of various health program
mes within the perspective of their financing and
planning.
This four-year study has been sponsored by the ICMR.
SEMINAR ON NGO’S’ ROLE IN HEALTH CARE
A three-aay seminar on the role of non-government
organisations in health care is proposed in March 1988.
Nearly 15 voluntary organisaions, representing different
approaches and well known in their fields of activity, will
participate alongwith government and funding agencies.
The objective is to gain better understanding of the
various types of NGOs working in the field of primary
and basic health care through discussions and to enable
the major funding agencies to know the problems of the
NGOs and, in turn, enable them both to utilise their funds
to greater advantage.

(con id from p. 5)

(conid from p. 6)

Need for Alternative Approaches

From Holism to Eradication

that there may be interference amongst them and the out
come may, fall short of expectations.
Vaccines are no longer sought on a hit-or-miss basis but
by a painstaking process spanning many stages. A vac
cine has to circumvent the strategies developed by
pathogens to evade the hosts immune responses. The
greater the number of strategies used by the pathogen,
the greater is the difficulty in designing'the vaccine.
Therefore while some measure of success has been achiev
ed with bacterial vaccines, where minimal evasion
mechanisms are operative,* no vaccines are available for
parasitic diseases such as malaria where evasion of the
immune response is achieved by multiple means.
Besides the disease process itself, the major stumbling
blocks in achieving protection through vaccination are 1)
the genetic and environmental variations encountered 2)
the necessity of boosters to maintain immunological
memory especially since live vaccines may not be feasi
ble in the global AIDS scenario.
Even if a design conferring life-long memory is not
possible, then short-term memory coupled intensively with
other control measures such as antibiotics and or vector
control maybe quite sufficient for the breaking of several
transmission cycles of the pathogen.

world but with the advent of AIDS also in the first world.
We now try to ensure that our weapons grow powerful
but that they do not recoil. We mutate the vehicles to
render them safe, we clone within them growth factors
that make them give long memory, we try out high speed
micro-projectiles for delivering nucleic acids into living
cells. Who knows, one day our own cells may carry genes
for theses antigens.
Whilst we may philosophise on the past and the future,
the present we must analyse. Vaccination has resulted in
the eradication of one pathogenic species; of a few more
it has brought their day closer and thus alleviated human
suffering. For some diseases like leprosy and cancer, it has
provided a possible form of therapy, not entirely without
risk and also provided us with an additional tool to ex
terminate ourselves.
Perhaps it will even lay some evolutionary pressures
selective enough and great enough to spur pathogens to
develop new defences. Some day, however, when we have
understood our ecological niche in the living world bet
ter, this very technology may show ways that allow us to
co-exist with our pathogens. A revolution of minds gave
us the first vaccines. It will take a second to get us out
of them.

Tannaz Birdi, a research officer at the Foundation for Medical Research,
is an immunologist, working on the neuro-immunological aspects
of leprosy.

Nerges Mistry, immunologist, is a research officer with the Foundation
for Medical Research and is currently working on neuro-immunological
aspects of leprosy.

11

Books
1. Rosemary, Robert, "Nulkapetta struggle for a safe en
vironment (struggle for justice series)”—New Delhi:
Indian Social Institute, 1986, p 17.
2. Matthews, CME, “Changing health beliefs and prac
tice in rural Tamil Nadu’—New Delhi: Indian Social
Institute, 1981, p. 55.

3. Jeffery, Patricia, “Contaminating states and women’s
status: midwifery, child bearing and state in rural
North India”—New Delhi: Indian Social Institute,
1985, p. 36.
4. Huff, Darrell, “How to lie with statistics’—England:
Penguin books, 1973, p. 124.
5. World Commission on Environment and Develop
(contd from p. 2)

Vaccines: Fact, Fancy & Fallacy
tain the cold chain even in cities. There is a sharp drop
out in the receipt of second and third doses of immuniza
tion and the figures are often inflated because of pressure.
But the major cause of failure has been the personnel.
The medical officer of the Primary Health Centre is com
pelled to evaluate his immunization programmes purely
on the number of vaccines delivered rather than the overall
drop in the incidence figures. Unlike the family planning
programmes people by and large seek protection of
their children by immunization, yet the public services
have been unable to deliver the goods which have been
a part of their routine duties. Hence the vertical Expand
ed Programme of Immunization, an imposition by the
UNICEF and WHO. Experience reveals that such pro
grammes not only disturb other routine Primary Health
Care activities but that they return to the original status
when discontinued as observed in the case of malaria
under the Multi-Purpose Workers Scheme. Without
peoples participation and monitoring, the public system
remains unaccountable except to their superiors. Socio
economic, educational and political factors therefore not
only create the conditions for such diseases but also af
fect the delivery of the available drugs and vaccines.
The era of drugs and drug research for these diseases
is now being replaced by that of vaccines. The substan
tial investments by WHO in its Tropical Diseases Research
Programme has provided a great boost to scientists for
research into newer and better vaccines and drugs for
almost all tropical diseases while virtually neglecting
research into social, economic and cultural factors which
ultimately determine their control. This together with the
decrease in research fundings of Western countries,
Western scientists have taken in a large way to vaccine
, research for diseases of the developed world. It is in
teresting to note that countries like the USA are suppor
ting research from military budgets for diseases they ex
pect to encounter only when they enter the developing
world.
We must realize that there are many other means of con

ment (WCED), “Our common future’—New Delhi:
Oxford University Press, 1987, p. 383.
6. Brown, Lester, "State of the world: 1987’—New York:
World Watch Institute, 1987, p. 268.
7. Cochran William G., “Sampling Techniques’—New
Delhi: Wiley Eastern Limited, 1985, p. 428.
8. Bhatnagar, S.C., “An experiment in activity planning
at Singapur primary health centre’—Ahmedabad: In
dian Institute of Management, 1980, p. 50.
9. Mathew, P.D., “Medical negligence”—New Delhi: In
dian Social Institute, 1986, p. 14.
10. Matthai, Ravi J. et al., “The rural university: the Jawaja letters 1975-79”—Ahmedabad: Indian Institute of
Management, 1981, p. 291.

trolling communicable diseases like chemotherapy and
chemoprophylaxis, vector control and isolation which are
well within our grasp. Our most important resource are
our own people. The expereince at Mandwa revealed that
given the knowledge and technology semi-literate women
could within five years transform the health status of their
community and achieve many of the targets our health
system hopes to achieve at the end of this century. The
immunization rate rose 15 to 85% when they started giv
ing the injections on a routine basis within their own
villages. This also helped in the control of diseases like
tuberculosis, leprosy, malaria and gastroenteritis and
respiratory tract infections besides treating minor
ailments. The infant mortality reduced from 122 to 66 the
birth rate from 33 to 19 and the death rate from 14 to
5 per thousand.
Vaccines at best will provide us with an additional tool
for reducing the high mortality from communicable
diseases which affect the poor countries. But let us be clear
that vaccines are also not the sole answer as some scien
tists will have us believe. To the scientists in the West, vac
cine research provides an interesting intellectual problem
as well as money, and jobs. A country like India cannot
afford such elitist pleasures.
The newly propagated strategy of child survival using
medical technologies like immunisation, and oral rehydra
tion therapy the G.OBI/FF of UNICEF without cor
responding effort for socio-economic change can only be
construed as another means of persuading the poor to
accept the population control policy since all other means
have failed; for this is an obsession with the West as well
as with our own elite who see in the inevitable popula
tion explosion a threat to their life style and even survival.
The almost unlimited international support for such pro
grammes along with the rest of the international and na
tional economic policies and programmes which are bias
ed against the poor and the wretched of this earth only
reveals the emptiness of the humanitarian facade of such
programmes.
Dr. N.H. Antia is a surgeon interested in medical research and in Com
munity Health. He is at present Director of the Foundation for Medical
Research and also of the Foundation for Research in Community Health.

Edited by Saroj Iyer with the co-operation of Manish Mankad and secretarial assistance from Anuradha Naik. Produced by the Foundation
for Research in Community Health, 84-A, R. G. Thadani Marg, Worli, Bombay - 400 018, registered under the Bombay Public Trust Act. Printed
by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.

March-April, 1988

Vol. II No. 2

Towards Computerised Medicare
By Dr. M.W. Uplekar, Dr. N.H. Antia, P.S. Dhumale

Can a personal computer undertake the work of a doc
tor and offer treatment for common ailments to patients?
Though the very concept seems dubious and fraught with
danger, SYMPMED I, an experimental project undertaken
by the FRCH in conjunction with the Computer
Maintenance Corporation proves otherwise, much to one’s
surprise. In the wake of the positive results, trials are being
conducted at the government Primary Health Centre at
Malshiras near Pune.
What is SYMPMED I?

SYMPMED I is an experimental computer programme
capable of identifying cases which can be treated symp
tomatically and offering treatment. To document the
safety involved in offering such a package, SYMPMED
I was evaluated by comparing the prescriptions offered
by the programme with those prescribed by a general prac
titioner after examination of the patient. The evaluation
demonstrated that 78 per cent patients were offered
prescriptions comparable to the ones given by the doctor
and the rest advised to see a doctor. In no case was a
patient offered treatment when s/he actually needed a
doctor’s attention. The evaluation confirms that a
majority of problems encountered by the first-level
medical personnel in developing countries are simple and
repetitive in nature and are treatable at home or by a para
medic using a few safe essential drugs avoiding un
necessary visits to a doctor and thus expenses.
It has been amply demonstrated by many a community
health project in the developing world, including our own
“Mandwa experiment”, that given simple training, en
couragement and support, even a semi-literate villager can
effectively provide primary health care to the people. This
is possible because a majority of day-to-day health problems encountered by the ‘first-level’ medical or
paramedical personnel are simple and minor in nature.
These ailments are mostly self-limiting or treatable using
a few safe and effective drugs. Providing ‘primary’ care
for such illnesses needs neither the expertise nor expensive investigational support because of the very simple
nature of the ailments and also because the treatment
chiefly remains symptomatic. In most such instances, all
that is needed for selecting drugs to provide relief is a good
clinical history. The skills for elicitation of clinical signs
are usually not called for. Frequently, examination using
a stethoscope or other similar aids remains a part of the

ritual chiefly for a patient’s mental satisfaction. For a
para-medic, the important task lies in identifying those
minority of cases which need further examination and
investigation by a doctory or referral to a hospital.
The efforts in making use of computers in medical
diagnosis and treatment have hitherto been directed
chiefly towards developing a tool to provide an aid to the
memory of a clinicians and to widen their knowledge to
help them formulate the differential diagnoses, investiga
tions and treatment. Some higher programmes have also
been employed for “applied symbolic reasoning” (artificial
intelligence) for interpretation of clinical and laboratory
data. Here, in view of the simple nature of a large pro
portion of problems encountered by the first-level medical
personnel, the aim has been to translate a third world
G.P. ’s real-life approach in the dispensary into a com
puter programme. The. objective is to provide awareness
of a para-medic or even a lay person; to promote safe and
informed self-medication, to avoid unnecessary visits to
a doctor for trivial problems and costs involved in it as
well as to promote use of home-remedies and ethical and
essential drugs alone.
An analysis of outpatients case papers maintained by
village health workers of the ‘Mandwa project’ and
records of outpatients attending some G.P.s’ dispensaries
in Bombay helped to identify common symptoms en
countered by the ‘first-level’ medical personnel (Table 1).
It was found that a vast majority of the problem could
be treated symptomatically — safely and effectively, using
only those essential drugs listed by WHO that could be
administered by a semi-literate community health worker
even without a doctor’s supervision. (Table 2). It was
necessary only to prepare a list of instructions to go with
the prescriptions, including use of home remedies whether
possible and also side-effects of the drugs to caution the
users. It was then possible to construct programmable
algorithms for each symptom with a view to extract relevant information from the users about their illness for
deciding the contents of the final prescription, The first
step, for each symptom entered, was invariably to make
users aware of those symptoms or sometimes signs, which
if associated with the presenting symptom call for the attention of a doctor or reference to a hospital. This step
helped in weeding out cases which cannot be handled by
the computer. The remaining steps included questions to

FOR PRIVATE CIRCULATION ONLY

entered and prescription offered. The software includes
MS-DOS (Micro Soft Disk Operating System) and Dbase
III. It may be possible to eventually devise a portable hard
ware for the programme.
A preliminary evaluation of SYMPMED I is complete.
The programme has been evaluated to compare the
prescriptions given by the computer to those by the at
tending doctor after examination of the patient. For the
preliminary evaluation only patients above 12 years of age
were included. The evaluation has been done after first
500 cases.
Each new patient entering the G.P. ’s dispensary where
a personal computer was installed would first go to the
computer. The G.P. ‘s assistant, who was also a doctor,
would enter the symptoms of the patient, without guiding
or leading him. The printouts of symptoms entered and
treatment advised for each patient were numbered serially
and kept aside. The patient would then go to the G.P. who
would examine him and put down his notes and treatment
prescribed on his own case paper numbered to match the
computer printout for the same patient. The computer
printouts and doctors notes for each patient were attached
together. The comparison and analysis for evaluation of
the programme was done after completion of 500 cases.
It was a blind study as the prescribing doctor was unaware
of the contents of the computer printouts.
In 78 per cent cases, the computer prescriptions
generally matched with those given by the doctor. The
actual drugs prescribed were not compared but the groups
to which drugs belonged like analgesic-antipyretics, tran
quillizers and hematinics, Non-essential drugs prescribed
by the doctor, vitamins and tonics in most instances, were
not taken into account while comparing. Of the remain
ing 22 per cent, half were advised by the computer to con
sult a doctor. Two per cent found that their symptoms
were not included in the programme, while nine per cent
presented with signs only like neck-glands, a swelling
somewhere, doubtful yellowness of eyes, dental caries and
so on where a doctor’s confirmation after examination
was essential before offering a prescription.
The important observation that merits mention is that
among those 11 per cent who were advised to go to a doc
tor, there were a few who could have been given symp
tomatic prescription safely but in no case a prescription
was offered by the computer where a patient actually
needed doctor’s attention.
Experience with SYMPMED I has confirmed our im
pression that for majority of day-to-day health problems
of the masses in the developing world, a visit to a doctor
can be avoided. A package like this would not only reduce
a doctor’s burden but also allow him to spend more time
on cases which deserve his attention most.
Some important shortcomings of SYMPMED I ap
proach for self-care merit mention. It is agreed that this
approach defies certain principles of medicine as no
clinical examination or investigation is performed or no
diagnosis is committed before handing out the prescrip
tion. A step giving a list of probable diagnoses based on
history alone could have been incorporated in the present
programme also. However, the question is that whether
diagnosis is necessary? Computer programmes are being
developed as an aid to the process of decision making for
rural health workers. But under circumstances such as this,
if one goes by virtue of parsimony, diagnosis could be

probe deeper into the symptoms to make users elaborate
on the problem exactly the way a doctor asks for the
medical history.
The SYMPMED I knowledge base is thus designed to
permit the programme td construct a symptoms file and
a medicine file. The building block for SYMPMED I is
an individual symptom. For each presenting symptom,
there are sub-levels as mentioned above. For each symp
toms or associated symptoms there is a set of drugs and
instructions to be prescribed and one not to be prescribed.
This constitutes the medicine file.
An IBM compatible personal computer with standard
configuration is the only hardware requirement. A printer
if made available will help to get printouts of symptoms
TABLE 1
List of symptoms included in the programme:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Fever
Cough
Running nose, blocked nose or sneezing
Headache
Diarrhoea
Sore-throat
Chest pain
Abdominal pain
Low backache
Burning or frequency of passing urine
Vomit ting
Giddiness
Gas or indigestion
Constipation
Joint pains
Weakness
Itching
Miscellaneous: Passing worms
Ear pain or discharge
White discharge from private parts (women only)
Painful menstrual periods
Night-blindness
Tingling of hands and feel
Hiccups

TABLE 2

List of drugs included in the programme:

1. Acetyl salicylic acid
2. Alkaline mixture
3. Aluminium hydroxide
4. Aminophylline
5. Ampicillin
6. Benzyl benzoate
7. Chloroquine
8. Chlorpheniramine
9. Ferrous sulphate
10. Ispagula husk
11. Mebendazole
12. Metronidazole
13. Noscapine
14. Nystatin
15. Oral rehydration salts
16. Oxyphenonium bromide
17. Paracetamol
18. Pencillin
19. Piperazine
20. Promethazine
21. Salbutamol
22. Senna
23. Trimethoprim
24. TUrpentine liniment
25. Vitamin A
26. Vitamin B-Complex
2

a pointless diversion in the therapeutic process which is
after all the one that interests the patient. Different ex
pressions used by patients for a common symptom need
to be considered while making the symptom file. Most
importantly, the possibility of translating the programme
into local languages needs further investigation lest the
presence of a para-medic interpreter is always required.
A busy G.Rs limitations are the limitations of SYMPMED
I as well. Just as a G.P. may miss a diagnosis of pulmonary
tuberculosis if a patient presents with cough and fever of
less than a week’s duration and no physical signs, our pro
gramme may also send the patient off with a prescrip
tion for a simple respiratory infection, of course with a
warning to report to a doctor if the symptoms persist
despite treatment, as the G.P. would do.
Would not simple flow-charts be useful and cost effec
tive? If our own experience with village health workers
of ‘Mandwa project’ is any indication, the diagnostic flow
charts could never be popularised among the workers
despite conscious efforts to promote their use. The reasons
found generally were that they had always to refer and

cross refer to more than one flow-chart for each patient
and that most charts ended up at the probable diagnoses
when it was the suggestions about treatment they were
most interested in. When computers are coming in a big
way, even to the remote areas of the developing world and
being used for administrative purposes and epidemio
logical data collection, it is only fit to develop program
mes for a para-medic that could also be used by a lay
person.

After refinement of the knowledge base and a larger
field trial, SYMPMED I would prove useful to broaden
a. para-medic’s or even a lay person’s knowledge and
awareness of a data for the treatment of illness. Its other
cost-effective applications includes promoting safe, in
formed, primary, curative self-care with the use of home
remedies and a few essential drugs, limiting dangerous
self-medication, providing primary medical care to the
workers of industrial units which do not employ a doc
tor and as an aid to the memory and knowledge of a
village health worker.

Readers’ Views
4. How long should we go on finding scapegoats for our
own inadequacies?
5. Are there any instances where developing countries
were used as guinea pigs for immunisation program
mes because of which they suffered?
6. Do multinationals only exploit out people? Are not our
kith and kin doing the same?
7. What constitutes indigenous medicine? What is its role
in reduction of morbidity and mortality in the country
side? What hard evidence do we have to espouse its
continuation?
I would very much like to be enlightened on these issues.
Dr. Umakant Warerkar
Civil Hospital, Solapur.

Dear Editor,
I saw your newsletter on vaccination (January-February
’88) and found it very interesting with excellent articles.
I congratulate you and your organisation for bringing out
this newsletter.
Please also give me more information on the three-day
seminar on the role of NGOs in health care.
I am personally interested in health expenditure and
would like to have your report on this.
Dr. Nisar A. Siddiqui
Chief Executive Officer
Aga Khan Foundation
New Delhi.

*

*

*

*

The immunisation schedule mentioned by you in the
Jan-Feb newsletter has been slightly modified. BCG is to
be given from birth to one year and triple and polio vac
cine from 6 months to one year, the interval between each
of the three doses remaining the same. Measles is advis
ed between 9 and 15 months. (Government of India, 1987).
The newsletter was thought-provoking and raised cer
tain questions in my mind after reading the articles by
various authors. These are:
1. Is population control against the interests of India?
2. What were the intentions of the six five-year plans if
not socio-economic development?
3. If the plans failed, was it the fault of western coun
tries, our intellectuals, our leaders, our people or our
political system?

*

*

We read with interest about your school health project
being conducted by Dr. Mohan Deshpande. One cannot
deny the importance of such a project in moulding at
titudes towards personal and community health.
Our association is keen on carrying out this educational
experiment in Wardha city. Could you therefore send us
detailed information on this. Our medical consultant will
follow it up. Please also send us information about the
seminar on NGOs’ role in community health care.
A Patil
Rural & Urban
Development Research
Association, Wardha.

3

In Search of Cure
Vimaltai lives in Malshiras near Pune. The village with
a population of nearly 2,500 has a primary health centre
(PHC), with two qualified (M.B.B.S.) doctors, two multi
purpose workers (MPW), a nurse mid-wife and an aux
iliary nurse mid-wife. There are three community health
workers in the village. The PHC implements the national
programme for the eradication of tuberculosis.
When Bhanudas Jadhav of Arogya Shikshan Kendra
spoke to six people suffering from T.B. what emerged was
a sad reflection of the woeful lack of basic awareness
among the patients about the disease, ignorance about the
importance of continuing the treatment and the serious
consequences of discontinuing it. Needless to say this is
mainly due to socio-economic reasons. But sadly the
results can be fatal.
Frequent breaks in the. treatment exposes one to the
danger of the tuberculosis bacilli becoming immune to
the drug which eventually has no effect on the patient,
and the patient more often that not dies a slow death.
Another dangerous trend observed is the frequent
change of doctors when quick improvement in health is
not noticed. This leads to avoidable expenses and time,
not to mention the hazards caused in the long run. Such
a search for immediate cure is irrational.
Vimaltai is a representative case. In the last four years,
she has visited any number of doctors from whom she
started and discontinued taking Streptomycin injections
several times. Finally she visited the PHC, and on the in
sistence of the doctor there took the complete the course
of 90 injections. Yet her condition has not improved. The
45-year-old woman who had only recently completed the
course of 90 injections still complains of persistent dry
cough, giddiness, shivering and fever.
Did you consult the doctor about your persistent
complaint?
Yes, I did. He has given me these blue pills and a bot
tle of medicine. He says my illness persists because I did
not complete the course of injections four years ago.
Why did you discontinue the treatment?
I was feeling slightly better and the nurse was to be
transferred. I was also getting bored in Satara, so I came
back to Malshiras.
Why did you go to Satara for treatment?
Four years ago, I was suffering from cough and
breathlessness. So Dilip’s (son) father took me to a private
practitioner, Dr. Kamble in Saswad. The doctor examined
my sputum, took my X-ray and gave me some pills and
medicine and also prescribed a course of 90 injections.
Did you take the medicine and injection regularly?
No, I took them whenever I had the money, may be
three or four times a week for about three months. Vasant
(son) then took me to the public hospital in Satara. With
the help of the nurse next door I saw a good doctor who
again advised me to take 90 injections.
So you restarted the injections there?
I took about 40 injections and stopped. I was feeling
a little better and the nurse was to be transferred. So I
saw no point in going to another doctor. Moreover, I was
getting bored, so I returned home.
Did you fall ill again?

Yes. A few months later, I went to Aptebai (a retired
nurse who has a private practice now) and she too told
me to take the same injections three or four times in a
week. So I started the injections again.
Did you feel better then?
No, I didn’t. But I didn’t get any worse either. At that
time one Dr. Ukhali, a private practitioner, came to our
village and I started taking injections from him for some
time.
Did your health improve?
A bit. Then I went to Pune to the municipal Tarachand
hospital as I was scared of going to the government-run
Sasoon Hospital. They took my x-ray and again told me
to take the injections. I then returned home and once
again started taking injections from Aptebai. Around that
time, Dr. Khandale came to the PHC here and I went to
consult him. He too told me to continue with the same
injections and I took 90 injections for 90 days from him,
but still I don’t feel better.
Did any of the doctors tell you what you are suffering
from?
The PHC doctor told me later.
How much have you spent on treatment so far?
About Rs. 4,000/- to Rs. 5,000/-.
What did you feel when you first fell ill?
I wondered if I would survive.
Vimaltai now plans to continue with the blue pills given
to her. In due course, she will perhaps consult more doc
tors and spend more money. But the moot question is will
she be cured and when?

I HMP
The Institute of Health Management, Pachod
offers
A Unique Learning Opportunity

6-Week Training Courses in Community Health

(1) Management of health programmes for senior
level personnel. Held twice a year in January and
August.
(2) Health Supervisor course. Held in June every
year.
For further information write to:

The Director
I H M P
P. O. Pachod
Dist. Aurangabad, 431 121
Maharashtra.

4

Are vitamin supplements necessary?
Many people believe they can improve their health by
supplementing their diet with vitamin and mineral pills.
Medical experts, however, continue to discourage the use
of such supplements for several reasons. First, if you have
a balanced diet and expose your skin to plenty of sunlight
to increase vitamin D reserves, you will probably obtain
all the vitamins and minerals your body requires. Pills that
contain vitamins and minerals may not harm you, but you
are unlikely to need the extra-large doses of vitamins and
minerals that they usually provide. In some cases the very
high doses that are often taken can be harmful. This is
particularly true of vitamins that the body can store efficienty, such as vitamins A and D. Too much vitamin A
causes skin changes, hair loss, enlarged liver and various
symptoms in muscles and joints. Too much vitamin D
leads to excess calcium in the blood, which can cause
gastrointestinal and nervous disorders. An excess of
vitamin B can cause nerve damage. Large doses of
minerals may also be harmful. An excess of calcium, for
example, may increase the need for magnesium, zinc and
iron. Too much iron can lead to gastrointenstinal
disorders.
The most important reason for discouraging the use of
vitamin and mineral supplements is that such pills are
unable to give you the health benefits that a well-balanced
diet provides. A healthy diet is one that gives you most
of your energy requirements from foods containing
natural fibre and mostly unsaturated rather .than saturated
fats. Such a diet reduces the risk of heart disorders, many
gastrointestinal disorders, and some forms of cancer. If
your diet consists mainly of “fast foods,” your risk of
developing heart and various other disorders increases,
regardless of how many vitamin tablets you take.
Vitamin and mineral supplements may possibly be of

benefit to someone attempting to lose as substantial
amount of weight over a relatively long period by dieting.
In these circumstances, a physician should be consulted
for advice on a safe weight-reducing programme and on
the possible need for vitamin and mineral supplements.
While vitamins are useful in some diseases like beri
beri and rickets these are rare and can be treated after
diagnosis.
Unfortunately, the production and sale of vitamins over
the counter has become a multicore business and tremen
dous pressue is brought on the consumers by extensive
advertisement by the pharmaceutical industy who profit
by the sale of unnecessary and expensive vitamins. Doc
tors too prescribe vitamins without any restrain to their
sales for the benefit of the pharmaceutical industryat the
cost of innocent people who place their full faith in them.
The public must be aware of this and safeguard their
own interest.
Children in normal health do not need extra vitamins
and minerals. Parents should encourage their children to
eat a varied diet that includes as much fresh fruit and
vegetables as possible. A child who has a piece of fruit
rather than a chocolate as a snack will not require vitamin
or mineral supplements or treatment for dental carries.
It is only natural that in a consumer oriented market
economy an uncontrolled pharmaceutical industry will,
like the tobacco industry, promote the use of unnecessary
and even harmful vitamins, tonics and digestives using the
the mass media like television rather than single nutritions
diet or warn people against the danger of smoking.

In a consumerist economy we must be on our guard
by obtaining correct knowledge from those who are in
terested in the welfare of the consumer.

FRCH invites applications from doctors
with postgraduate degree in Medicine to
work on a project for the Use of Computer
in Health Care.

FRCH is a voluntary organisation that has been in
volved in health services research for over a decade.

FRCH invites applications from junior and senior
researchers trained in social science and medicine.

Knowledge about computers preferable but
not essential.

The nature of research will be—field based action
research, anthropological studies, surveys and
evaluations. The areas of research includes primary
health care, health financing and health education.

Attractive remuneration is offered. Those
interested may kindly write to:

Attractive remuneration is offered.

Director,

Those interested may kindly write to:

The Foundation for Research in
Community Health

DIRECTOR
THE FOUNDATION FOR RESEARCH IN
COMMUNITY HEALTH

84-A, R.G. Thandani Marg,
Worli,
Bombay - 400 018.

84-A, R.G. Thadani Marg,
Worli,
Bombay - 400 018.

5

Women’s Work, Fertility and Access to
Health Care
A socio-economic study of two villages in Pune district
data depicted a direct relationship between the death of
children and the number of live babies that a women had.
When all the children survived, the modal value of live
births per woman was two and every dead child meant
an added responsibility of two more live births on the
woman. It is sad to know how many conceptions, abor
tions, still births and live births a rural woman in India
underwent to finally have the desired family size of three
children—two male, and one female offspring!
The study reflected the poor access to health care even
during the crucial period of childbirth. Most of the
women delivered at home not because they wanted to but
because they had no other choice. Inadequate stocks of
medicine at the Primary Health Centre, lethargic health
workers and the fact that the government health services
were invariably linked with family planning had a negative
impact upon the access or utilisation of these services.
Hard earned v/ages were thus spent on private practi
tioners’ fees.
Most of their lives, the women in the project area were
simultaneously performing five tasks—paid wage labour,
unpaid agricultural work, housework, child-bearing as
well as child-rearing. A woman’s life was so linked to her
work and vice versa, that it was virtually impossible to
separate the two. Unless a holistic view of women’s lives
was taken into consideration, most well-meaning reforms
would work against women.
In conclusion, what is essential is not just reform or
better implementation of existing legislation bur a
thorough requestioning of women's roles within and out
side the home. Only then it will be possible for women
to voice their political demands, to refuse alms and to
demand what is their rightful due.

The FRCH was represented on the Task Force on
Health, constituted by the National Commission on Self
Employed Women (and women in the unorganised sec
tor) and conducted a study on the status of the rural
labouring women. The Arogya Shikshan Kendra, a field
based action research project of the FRCH, provided the
study area in the drought-prone Purandar taluka of Pune
district.
Few definitions are as controversial as that of ‘women’s
work’. It is rather unfortunate that in most societies, except
for that part of ‘work’ which fetches wages, all other
labour performed by women, be it domestic, child-bearing
or child-rearing, is considered ‘non-work’. This makes her
exploitation easier both inside as well as outside the home.
This study was an attempt to bring visibility to the
varied aspects of work that rural labouring women per
form all throughout their lives and its effect on women’s
health in terms of nutrition, maternity, access and utilisa
tion of health services.
The study utilised a non-traditional methodology. The
structured questionnaire though important is inadequate
as a means of collecting information that is intimate and
non-quantifiable. Hence, group meetings and personal
interviews with women were initiated to gain an insight
into their lifestyles. Expressions found through such in
formal discussions were relied upon as much as the
responses in the structured interviews. This judicious mix
of quantitative and qualitative data revealed interesting
facts.
The project area has an agriculture based economy.
Because of persistent drought, more than one fourth of
the total population is engaged in some kind of wage
labour. Significantly, female wage earners outnumbered
male wage earners. There were 102 female wage earners
for every 100 male wage earners; 93 per cent of the female
wage earners were employed under the Employment
Guarantee Scheme (EGS). While the men preferred private
work because it fetched them higher wages, more often
than not, women preferred EGS work because it
guaranteed wages and provided equal wages to both men
and women. Many a times, the wheat coupons were an
added incentive for women to go in for EGS labour.
Contrary to the widespread belief that women’s wages
are only marginally supplementary to the family income,
the study revealed that 20 per cent of the households were
entirely supported by women. Significantly all these
households had at least one adult male member.
The women contributed entirely to non-paid domestic
labour (housework). Cooking, fetching of water and fuel
as well as the daily household chores were done exclusively
by the women with little or no help from the men. The
other aspects of social labour that women performed were
child-bearing and child-rearing, which were considered ex
clusively women’s work, so were devoid of any contribu
tion from the men of the household. .
The study revealed that every woman paid a high per
sonal price for the loss of each child that she bore. The

FDA’s Dilemma
The National Institute of Health (NIH), U.S., recently
released a study concluding that an aspirin every other
day dramatically lowered the risk of a first heart attack
in middle-aged men. Preliminary results were announc
ed by the NIH in late January and published in the New
England Journal of Medicine. Much to the dismay of the
NIH and the FDA, drug companies in the U.S. immediate
ly launched major advertising campaigns claiming that
taking aspirin regularly can reduce the risk of a first heart
attack.
The FDA chief immediately wrote to the ten aspirin
firms warning that such advertisements would be harm
ful to public health and a violation of the federal law.
Yielding to pressure from federal regulators ten major U.S.
aspirin makers later agreed to drop such advertisements.
Heaving a sign of relief Frank Young, head of FDA, said;
“There is a tendency for people to try to change their
behaviour on a single study. This is dangerous’’

6

Study of Primary Health Centres
in Maharashtra
The nationwide network of primary health centres
(PHC) constitutes the backbone of health infrastructure
in the rural areas. Success and failure of all public health
programmes and the medical care services largely depend
on the health of these PHCs. No plan for health care
reform can ignore this strategic position occupied by the
PHCs.
In 1984, a great expansion of the PHC infrastructure
was carried out by the government. In one stroke the
number of PHCs in Maharashtra was raised from 500 to
1,500, a three-fold increase. The population coverage of
each PHC was brought down from around 100,000 to
about 30,000. Further, the government decided to upgrade
one out of every four PHCs. However, such a massive ex
pansion of the PHC, though necessary in itself, is not suf
ficient to solve the problems faced by the health services.
Moreover, expansion does not necessarily ensure improved
quality of services. These may even deteriorate if the ex
pansion is too rapid. The question of the quality of ser
vices and the reliability of data supplied by the PHC has
been repeatedly questioned. It is also felt that the quality
of services should keep pace with the expansion and the
growing responsibility of managing the increasing number
of health programmes. This is also intimately linked to
the quality of health personnel, the problems faced by
them and the support provided by the government and
the local leadership.
The government of Maharashtra requested the FRCH
to undertake a study to look into the qualitative and
especially into the human aspects of the services, work
ing conditions and the socio-political context in which the
PHCs function. The government put at the disposal of
the FRCH necessary funds to carry out the study.
The study was started in December 1986. The field work
was carried out in two phases. In the first phase, two
PHCs and one upgraded PHC now known as rural
hospital (RH) were selected in consultation with the Direc
torate of Health Services. These three centres were treated
as case studies and information collected using an
thropological techniques.
The team consisted of a senior member of our staff,
Dr. Amar Jesani a doctor with a strong sociological
background, a trained female social scientist and a male
investigator. Besides the quantitative data special emphasis
was made to understand the human factors which play
a predominant role in the operation of the PHC services,
eg. interpersonal relationship between various categories
of the staff, the perceptions of their role in the PHC set

up, the interaction between them and the public, the
political leadership and the higher echelons of the health
services, the perception of the people about the PHC staff
and services etc. The approach used was more of a
qualitative understanding of an anthropological nature
rather than the usual quantitative study and reaching of
targets. This could only be achieved by a prolonged stay
within the PHC and winning the confidence of the staff.
The health personnel were interviewed using an interview
guide. Small group meetings and individual interviews
were carried out in the selected villages covered by
the PHC. The first phase lasted from March *87 to
December *87.
In the second phase, ten PHCs and two RHs were
selected. The study team spent three to four days at each
centre. Some of the important observations made in the
first phase were inquired into and their reliability verified.
The second phase was started in January 1988 and com
pleted by mid-March.
B) This larger sampling was in order to eliminate any
biases that may have arisen from the study of only three
PHCs and to reconfirm .the findings. The personnel of
health bureaucracy of all levels were also interviewed.
A detailed report of the findings and recommendations
will be published and submitted to the government of
Maharashtra by September 1988.

In many nations, children are without food or health
care or schooling because of a financial famine which
cannot easily he captured by the TV cameras. In 1981,
the net transfer of resources from rich to poor coun
tries was over $ 40 billion. By 1985, the position had
almost reversed.
Rich to poor aid $ 14 billion + loans $ 13 billion = $ 24
billion. Poor to rich repayments of the debt and
interest $ 54 billion.

3. Selected candidates should have a degree in
Sociology or Economics or Social work and a
minimum of five years experience. Salary negotiable.
Apply with full details to:

PROJECT OFFICER
FOR

VOLKART FOUNDATION
The Volkart Foundation established in 1952 supports
charitable causes and projects specially in the fields
of health, education and medicine concentrating
primarily on rural areas. It works in administrative col
laboration with the Tata Trusts and Voltas Limited.

2. The Foundation needs the services of an officer
with experience both of office administration and
of project evaluation. Duties involve the scrutiny of
applications, bn site assessment of project and
monitoring of assisted programmes. The job entails
about a week's travelling to rural areas in each
month. The offices of the Foundation are located in
Bombay and the person selected will be one of the
two whole-time employees but will not be expected
to handle the accounting.

PO. Box 421, G.P.O., Bombay 400 001.

Envelop should be marked:

Volkart Foundation
Project Officer.

7

Books
1. Roy, Bunker, "Tilonia movement: profile of an alter
native approach’—Tilonia: SWRE; 1988, p.39.
2. Bhasin, Kamala and Khan, Vighat Said, “Some ques
tions on feminism and its relevance in South Asia”—
New Delhi: Kali for women; 1986, p.22.
3. Banerji, J., “Climate and world order: an inquiry into
the natural cause of under-development’—New Delhi:
South Asian publishers; 1986, p.22.
4. Malaria Research Centre, “Community participation
for disease vector control’—New Delhi: Malaria
Research Centre; 1986, p.256.
5. Fulop, T. and Roemer, M., “Reviewing health man
power development (Public health papers series)”—
Geneva: World Health Organisation; 1987, p.138.
6. Louis James, W., “Essential guides to prescription
drugs’—New York: Hasper and Row Publishers; 1987,
p.933.
7. Maharashtra, Government of, “List of major and
minor heads of accounts”—Bombay: Government of
Maharashtra; 1986, p.296.
8. Mason, J.K., “Law and medical ethics”, London:
Buttesworth, 1987, p.344.
9. India, Government of, “Census of India: 1989, series
I, part IV A, social and cultural tables’—New Delhi:
Registrar General and Census Commissioner, India;
1988, p.686. 10. Basner, J.A., “The ethics of inquiry
in social science: three lectures’—New Delhi: Oxford
University Press; 1977, p.67.
Publications available at FRCH library
Gupte, Manisha, Borkar Anita, “Women’s work, Fertili
ty and Access to Health Care: socioeconomic study of two
villages in Pune district’—FRCH, p. 210, Rs 20.

Patel Ashwin J., “In search of diagnosis: analysis of pre
sent system of health care’—MFC, p. 174, Rs. 15.00.
Sathyamala C., “Taking sides: the choices before the
health workers’—ANITRA, p. 320, Rs. 70/-.
Sarin, Madhu, “How to make and use the Nada chulha:
chulha mistri’s manual’—VHAI, 1984, p. 73, Rs.

Medico Friend Circle, “Effect of Bhopal gas leak on
women’s reproductive health’—MFC, p. 6, Rs. 2.00.
Reprints
1. Bhaskaran Nandini, “The greening of Beed” — Im
print; 40-45, 51, June, 1987.
2. Mohan Dinesh, “Disaster management: lessons from
Bhopal”—Business India; 76-85, Nov. 30 — Dec. 13,
1987.
3. Hubley J. H., “Barriers to health education in
developing countries’?—Health Education Research;
4, 233-245, 1986.
4. Balgopal K., “An ideology for the provincial proper
tied class’—EPW; 1554-1546, 5th September 1987.
5. Shaligram S.V., “Pain killers’—Science Today; 17-20,
43, September, 1987.

6. New England Journal of Medicine, “Court-ordered
obsletrical interventions”—NEJM; 316(19), 1192-1196,
7th May 1987.
7. Lancet, “Decisions to limit treatment”—Lancet;
11(8562), 787-88, 3rd October, 1987.
8. Smith Richard, “Why do research and which research
to do?”—BMJ; 295(6608), 1248-52, 14th November
1987.
9. New England Journal of Medicine, “Protecting the
liberty of pregnant patients”—NEJM; 316(19),
1213-14, 7th May, 1987.

Book Reviews
1. World Commission on Environment and Development
(WCED), “Our common future”. — New Delhi: Ox
ford University, Press, 1987, p 383.
WCED re-examines the critical environment and
development problems on the planet and formulates
realistic proposals to solve them to ensure that human pro
gress will be sustained through development without ex
hausting the resources of future generations.
2. World Watch Institute (WWI) and Brown, Lester, “State
of the world: 1987”. — New York: W. W. Norton, 1987,
p 268.
The 1987 report assesses human-caused disruptions of
global chemical cycles, evaluates the worldwide reappraisal
of nuclear power after Chernobyl accident, profiles the
accelerating urbanisation of the world’s population,
discusses the shift to reliance on markers in a growing
number of countries and advocates new incentives in
recycling materials and raising agricultural productivity.

Health Status of Indian People
Health Status of the Indian People, commissioned by
the Indian Council of Medical Research (ICMR) has been
produced by the Foundation for Research in Community
Health (FRCH), Bombay. It is a data based document that
provides an overview of health conditions in India, as well
as of the state of its health care services. It is a supple
ment to the previous report of the Indian Council of
Medical Research (ICMR)—Indian Council of Social
Science Research (ICSSR), ‘Health for all: An Alternate
Strategy’, published in 1980).
This publication presents data, collated from govern
ment sources, published research studies and evaluation
reports, on the different dimensions of health that form
ed the scope of the ICMR/ICSSR Study Group’s delibera
tions. Starting with an historical analysis of the develop
ment of health services in India, the existing organisa
tional structure, and the nature of health expenditure pat
terns it briefly looks at such aspects of health as morbidity
and mortality patterns, drug production and consump
tion, the state of the indigenous systems of medicine, the
problem of hunger, the state of the environment, the
health status of women and children, and issues in health
education.

Edited by Saroj Iyer with the co-operation of Manish Mankad and secretarial assistance from Anuradha Naik. Produced by the Foundation
for Research in Community Health, 84-A, R. G. Thadani Marg, Worli, Bombay-400 018, registered under the Bombay Public Trust Act. Printed
by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.

COMMUNITY HEALTH CELL
47/1. (First Floor) St. Merks Read,

May-June, 1988

Vol II No. 3

•

Target Orientation in Health Care
Dr Amar Jesani

Setting goals for rapid achievement of better quality
of life for the people of India has been a favourite past
time and populist activity of our government and its func
tionaries. After all, who can question the proposition that
people deserve a better quality of life? This rhetoric, for
mulated and propagated as a part of the package of
Nehruite socialism, has enabled the government to get the
support of a broader cross-section of social and political
currents in the first decade and a half, following in
dependence. In the field of health care the slogan was the
one raised by the Bhore committee and later incorporated
in the policy statement of the first five-year plan: “that
the service should be available to all citizens, irrespective
of their ability to pay for it and that it should be a com
plete medical service, domiciliary and institutional, in
which all the facilities required for the treatment and
prevention of disease as well as for the promotion of
positive health are provided”. (Bhore committee report,
vol. II p.6). Based on these principles and political slogans
short-term and long-term goals were set to build an in
tegrated health care service in the context of the so-called
mixed economy model. It should also be noted that these
goals set at that time are qualitatively different from what
is currently prevailing under the name of targets. These
goals were for plan implementation which did not frag
ment health care into targets for “health” but assumed
that provision of integrated health care is one of the con
ditions, for improving people’s health. And above all these
goals were for the progressive (time-bound) establishment
of the national health service as a dominant sector of
health care.
The currently prevailing target orientation has nothing
to do with the above mentioned principles and goals. In
fact, these principles and goals were never taken serious
ly and hence never implemented in true spirit. They were,
in effect, buried with the publication and acceptance of
the Mudaliar committee report in 1961. The history of
health care from this year onwards is nothing but pro
gressive replacement of these goals and principles with
targets. The goal is no longer to provide universal free and
quality integrated health care, but to achieve targets to im
prove certain indicators. Thus, at a broad policy level,
target orientation is many many steps backward.
Health reduced to indicators
The WHO definition of health as "a state of complete
physical, mental and social well-being” is not made a basis
to evaluate achievements in the field of health care. For

the concept of complete physical, mental and social well
being. is so threatening that it immediately brings into
focus not only the actual state of health care services and
the state of socio-economic development, but also the
quality of life of the common citizens of this country.
Thus, for all practical purposes, attainment of health is
reduced to indicators. This is not to say that indicators
have no use in assessing achievements of health care. The
improvement in the health status necessarily leads to the
improvement in indicators. And health status improves
not only due to the provision of health care, but rather
due to general improvement in the quality of life. But the
single-minded attack on the indicators does not necessari
ly lead either to the improvement in health status or to
better quality of life for the people.
Thus, indicator-oriented targets take precedence over
the health and achievement of targets over the care of peo
ple’s health. The health care gets fragmented into in
dicators and targets. No amount of lip service to the in
tegrated and community health can conceal such an ugly
impact of target orientation.

People reduced to target groups
Inequality is a hallmark of all class societies. Inequali
ty permeates in to all aspects of social life. Even in
developed capitalist societies inequalities in health care
is a well-known feature. Forty years of development in our
country has in many ways accentuated inequality and ma
jority of our people live below poverty line.
Those who are at the bottom of the socio-economic lad
der are also at the bottom of the health ladder and are
also more or less outside the care of health services. Con
sequently, they are not so healthy and therefore their
health indicators are the worst. Naturally, they need
special care, not only integrated health care, but also in
tegrated socio-economic and political care. Hence such
social stratas become “target groups”. However, their
health is misused by indicators and for indicators there
are targets. Therefore, the targets are mainly for target
groups, though in many other ways the targets stand on
their own too. Targeting health care for target groups is
desirable, even essential, but targeting targets for target
groups can lead to unhealthy consequences. For such an
approach ignores their real-life situation. It can substitute
their real health needs by the heed's of the indicators. Certain targets like population control targets can introduce
newer methods of oppression and exploitation, and
general terrorisation. This again puts statistics above the

FOR PRIVATE CIRCULATION ONLY

@y

stics of target achievement. They cannot do so because
they know that the data is not accurate. Not only that we
have seen some bureaucrats teaching doctors and super
visors how to report target achievement without actually
achieving it. For instance, in the copper-T programme,
Rs 9 as incentive money is used to buy a woman’s
signature on the form and a guarantee that if by chance
any one comes for verification to testify that Copper-T
is really inserted.
(3) In addition to reporting false achievements, the
workers are compelled by the target orientation to com
pete with each other. As the quantum of target is bigger
than the actual readiness of the people to accept the pro
gramme, such competition usually degenerates into con
flicts, paying extra incentive (bribe) to the ‘case’. There
is no competition to take better care of the people. People
are only objects of targets. Thus, such unhealthy com
petition leads to dehumanised relationship between the
health workers, and between the health workers and the
community.
(4) The unachievable quantum of targets empowers the
higher bureaucrats to use non-achievement as a tool to
punish those who are not in good books with them. The
more vulnerable a health worker, the more harassment
s/he faces. Thus, the auxiliary nurse midwife, socio
economically the weakest cadre, is always at the receiv
ing end. This punitive use of targets has made life
miserable for most of our lower-level cadres.
Undoubtedly, target orientation has created havoc in
our health care services. It has left such a deep impact
on the minds of our health workers that they just cannot
think of their work in any other way. Mere suggestion of
abolishing targets scandalises our health managers. Over
two decades of target practicing has created such a situa
tion that to affect any radical change in the health
workers’ Orientation will be a very painful and time con
suming task.

care of the target groups; getting work done by any means
rather than educating people on health.

New bureaucratic culture
Target orientation is a favourite work method of all
bureaucrats, including supervisors. The planners love it,
too. For it absolves them of the moral and political burden,
of taking care of people’s health. An illusion of achieve
ment can easily be created. A false sense of well-being can
be displayed. The new bureaucratic culture essentially sub
stitutes statistical well-being in the place of human wellbeing. The bureaucrats and supervisors no longer manage
and supervise health care but chiefly manage targets. For
them the answer to corruption, irregularities, illegal
private practice and scarcity of resources is not effective
managment and rooting out corruption, but privatisation.
Since statistics become supreme (and not human be
ings), the medical paternalism is stretched to the extreme.
Thus the size of the family is not determined according
to the number of children people prefer to have (which
in turn is determined by the socio-economic and cultural
milieu in which people live), but according to the statistics
of population growth. In labour abundant economy, who
cares seriously for morbidity? But mortality is an issue
which can get easily politicised. So mortality indicators
and targets are important but morbidity and curative ser
vices are neglected. Population control yes, but enpowering women by giving contraceptive education is neglected.
Our health services have enough money to pay huge in
centives for sterilisations and copper-T but not enough
for free Curative services.
In short, the choice of indicators and targets is more
to fulfil political and ideological needs rather than to
operationalise integrated free health care for the people.
Such target orientation and neglect of curative care leaves
room wider open for the free operation of expanding
private sector. Lastly, the target-oriented bureaucracy
leaves no room for democratic interaction.
Target orientation seriously distorts the condition of
workers and their work at the primary health centre level.
(i) In his presidential address to the Indian Association
for the Study of Population, published under the title “For
Whom the Target Tolls?” (1987), Prof. Ashish Bose criti
cised target orientation. He said, “On the basis of our
study of both published data and the field situation, we
can say that the performance figures are far from accurate
and the target setting is ad hoc, erratic, arbitrary and unscientific” (emphasised in the original). The PHC workers
are never able to comprehend the rationale behind the
quantum of target given to them. Most of them are so
confused that they have now found a ready answer: Target
is part of the duty, part of the routine Not only that, since
supervisors, from the medical officer to the district health
officer, insist only on targets, they have come to equate
targe, practicing as the only routine work they have to do
in the health services. The rest is cosmetic. Nobody ques
tions them on why deliveries are not conducted or subcentre clinics are not organised. Thus, arbitrariness in
target setting has led to a new work method—only targetoriented work.
(2) Our experience in the health' service is that nobody
is ready to give a guarantee on the accuracy of data, save
for the data on sterilisation cases. Thus, although statistics
is supreme, nobody is ready to own his or her own stati

_
•

Women’s Awakening & Health Yatra
SEARCH, a voluntary organisation, involved in health
care and research on rural and tribal health problems in
the tribal block of Gadchiroli in Maharashtra, organised a •
two-week awareness campaign, "Women’s awakening and
health yatra”, With the help of the local villagers and four
like-minded organisations. The educational and cultural
‘yatra’ included poster exhibitions on various issues related
to women’s health, immunisation, deforestation, environment and the employment guarantee scheme. A
demonstration on the effective use of herbal medicines
and a slide show on sexually transmitted diseases were also
a part ©if the campaign. Blood examination for detection
of anaemia, healthy child contest and clean-home-andsurrounding competition were an added attraction in the
yatra. Group-songs, a programme on demystification and
superstitions, a play enacted by SEARCH team entitled
“When husband gets pregnant” and a keertan on ‘pover
ty’ drew huge crowds. The yatra moved to nine places.
Altogether 25,000 people (almost half the population of
the area) participated in the yatra. Nearly 1,500 people
from 70 villages signed a memorandum against the recent decision of the Maharashtra government to charge
heavy fee to all patients in the government hospitals and
submitted it to the local M.L.A.s present.

2

Readers’ Views /Replies
The questions raised by Dr. Warekar in the March-April
newsletter merit a reply. We are prompted to do so because
they represent the views of a majority of our intelligensia.
Q.l: Population control is not against the interests of In
dia provided it is a free choice of the Indian people and
not something foisted on them by technocrats to fulfil the
expectations of their fiction technologies or to justify to
western people the use of life-saving vaccines. The follow
ing paragraph represents some opinions of Dr. Barry
Bloom, a reputed immunologist from the U.S. It is il
luminating for several aspects.

“If highly effective and low-cost vaccines were
developed, there are two major impediments to their use.
One is the view in the developed countries that immunisa
tion of children will only lead to more babies and simply
exacerbate the shortages of food and resources in the
Third World, and hence should not be supported. There
are a number of objections to this line of argument, of
which we shall mention only two. The first is a matter
of historical fact: birth rates in no country of the world
have decreased prior to a decrease in death rates. It is
simply not possible to persuade people effectively not to
have large families unless one can demonstrate that
children will survive with sufficient frequency to care for
them in old age. This persuasion may not take genera
tions. There is data from Bangladesh indicating that
reducing infant and child mortality has a profound ef
fect on increasing the spacing between births. Finally, it
may well be that immunology has an even more crucial
role to play. Although not widely known by im
munologists, there are two vaccines containing antigen
determinants from the B-chain of human chorionic
gonadotrophin) a hormone required for implantation,
which are about to undergo clinical trials to learn if one
can safely and effectively immunise the produce long-term
but reversible reduction in fertility. Perhaps it will be possi
ble some day simply to immunise against babies?

was responsible for their failure): If there has been a failure
it is the joint responsibility of all Indians. However, since
our intellectuals are expected to have acquired a process
of thought and capability of analysis and speech, then
our gullibility, short-sightedness and silence make us bear
the largest burden of responsibility. It is we who have fail
ed in our commitment to our underprivileged coun
trymen. As for other countries all we can say is that even
nations have to occasionally look at themselves in mirrors.
Q.5 (instance of a developing country being used as a
guinea pig for which it suffered): The most recently
publicised instance is of the genetically engineered rabies
vaccine produced by the Wistar Institute and tested surreptiously on cattle in Argentina in 1987. When the Argen
tinian govt, discovered that the tests were being conducted,
all inoculated cattle were destroyed and the Wistar per
sonnel thrown out of the country.
If there are any more instances, we would not expect
to hear of them. But given the instances of marketing and
trials of banned drugs in Third World countries and the
experience of Bangladesh with the drug multinationals,
there is little reason to accept genetically engineered vac
cines in good faith. Particularly so since their efficacy,
at the moment, is of dubious value.
Precedents or not, should our people be guinea pigs
or ethical bypasses.

Q.6: I agree with the question that Indian companies, like
multinationals, also exploit our people, though I fail to
see why the existence of two exploiters should justify con
doning either one of them. Unfortunately, multinationals,
with all their potential for good, are aligned with the centre of what the Norwegian anthropologist Galtung refers
to as the network of global exploitation. It is considered
good strategy to oppose the bigger exploiter.
Q.7 (on indigenous medicine and its role in reducing mor
bidity and motality): For indigenous medicine, we walk
more by faith than by sight. By all means let us review
the evidence. Would the editor please take note.

Those who prepare vaccines for population control
must recognise the responsibility that they bear since
because of their- very ease, they have vast potential for
misuse. The borderline between scientific arrogance and
dementia is sometimes a thin one as proved by the Nazi
holocaust of not too long ago.

Nerges Mistry & Tannaz Birdi
Research Officers,
The Foundation for Medical Research
Bombay.

If population-land ratio, limited world resources and
poverty psychology are to be the criteria for overpopula
tion, then it is also true that some of the most overpopulated countries are also the richest and that all
population control effort should be aimed at the Westernindustrial economies whose energy consumption levels are
manifold higher than that of India. Thirdly, overpopula
tion is not yet the pause of poverty and must not be made
its whipping child while blithely forgetting our apathy to
bring about other meaningful changes. Our people in fact
are still our one abundant capital resource.

* * ♦
Dear Sir,
Your newsletter on vaccination was very informative as
I too am involved in community medicine in Manchester
and lecture in primary health care at the university. I am
also doing work in immunisation at present and was interested to read the article by Dr. Antia in the Jan/Feb issue.

Dr. Di Chisholm
Senior registrar,
Community medicine.

Q.2, 3 & 4 (On intentions of the six-year plans and who

3

community HEALTH CELL

47/1. (First Floor) St. Marks Road,

Bangalnr . FRO 001

Better Use of Medical Care
Dr. M.W. Uplckar
Patients themselves cannot escape the charge that, they
by their own attitude and actions, have contributed in a
devastating fashion to the incidence of needless drug
use... They have pressured a physician to prescribe, even
against his better judgement. They have become prescrip
tion shoppers, going from one physician to the next to
obtain a multiplicity of medication.
M. Silverman & P.R. Lee
Pills, Profits and Politics.

Most practising doctors would readily agree with these
views, particularly the general practitioners’ or the ‘family
doctors’ who represent the initial contact between the pa
tient and the medical establishment. Few realise that the
root of this problem in the practice of medicine lies in
its professional structure itself. Over the centuries, both
the public and doctors themselves are convinced that the
very nature of the profession is such that its actions are
certain to be beneficial. Medical knowledge is not thought
to consist entirely of factual or technical information. It
is claimed to be both an art and science. Few realise that
there are reasons for becoming ill and very often the doc
tor is not the most appropriate person to consult. Don’t
we know of the many instances where not only a cure is
elusive in a disease state but the consultation(s) lead to
a worsening condition and perpetual patienthood?
The public has had scant education in acknowledging
that it’s they who have to be in charge so far as their own
health is concerned. It’s they who have to decide how to
live, whether to see a doctor, which doctor to see, how
soon to go and whether to take the advise offered. Peo
ple have been left incapable of determining themselves,
when outside help is needed and when it is not! ... Who
else but the medical community itself can perform this
role of educators in an appropriate manner? Is it expec
ting a bit too much from the so called noble profession?
Unfortunately, the answer seems to be yes... in the pre
sent circumstances at least!
Finding the right doctor
In no other country probably, sb many systems of
medicine are practised and that too with official sanction,
as they are in our country. There are all kinds of doctors
and the distinctions among them must be confusing to
the doctors themselves, leave apart the lay people. The
problem is compounded by making the field of medical
practice—free for everyone! Anybody is allowed to prac
tice anything that s/he feels will fetch profit although it
may or may not be related at all to the many years of train
ing and qualifications received. Haven’t we reached the
extreme now with the innumerable quacks with fake
medical qualifications establishing their unaccountable
flourishing practices even in the metropolitan cities of our
country?... with thousands of those, having spent almost
half of their lives in getting a questionably meaningful
medical education already frustrating in surplus!
This undoubtedly can lead people nowhere but to a
state of utter confusion. Having asked to write a few tips
for the patients to help them choose a right doctor, this
writer, despite.being a doctor himself is worse confound
4

ed and would rather look upon experienced patients in
a community for a word of advice. Our doctors are fond
of putting up boards displaying their names and their
“hard earned” sesquipedalian qualifications. Can we not
just make them spell out all their degrees and in which
system of medicine they are trained, making them write
it down in the language of the community they serve? This
may help solve many problems. Otherwise streptopenicillin injections given for TB and B-complex injec
tions given for weakness will continue to take their toll
unchecked.
A few tips may be mentioned to warn against poor
medical practices. If you are taking more than three
medicines daily, you are probably receiving poor medical
advice, unless you have a serious medical problem. If near
ly every visit to the doctor results in an injection or a new
prescription, there may be a problem. Fortunately, we have
a free choice of doctors. If you cannot communicate with
your doctor effectively, seek another. Ask about any tests
you do not understand. If your questions are not ade
quately answered, go somewhere else. Be wary if the doc
tor recommends a costly service when you are not aware
of any problem. Find a doctor who suits you, even if you
must change doctors several times. But when you find a
satisfactory situation stay with it. Change early but not
often.
Remember that your doctor is human too. The doctor
is faced with a continual barrage of complaints about pro
blems that may not have solutions. Don’t use doctors for
trivial problems.
Most illnesses are symptomatic and the treatment too
remains symptomatic. Be happy to receive just words of
reassurance from your doctor if s/he feels that no drug
treatment is going to serve any purpose and also be will
ing and prepared to pay for the words of advice.

Health Education
Health education must be a priority, as
sharing knowledge will empower
people to take charge of their own
health. But attitudes change
slowly. To try and change too much at
once will be self-defeating; first
concentrate on changing those
attitudes which will make the most
difference to the people’s health.
Health education is allocated
Rs. 13.2 crores of the
total health budget
of Rs. 3,393 crores.

Helping Doctor Help Yourself
Dr. M.W. Uplekar
A visit to a doctor can* be a mysterious experience. A
medical consumer must try to understand the procedures
a doctor follows when she comes across a patient. It is
only with the active participation of a patient that a doc
tor can come to a precise conclusion and based on it, give
a correct prescription.
Most people do not realise that every doctor uses a
similar process to learn a patient’s medical history. An
allopathic doctor, whether a family doctor or a super
specialist, is trained to organise information about an il
lness under five headings.

medication that are frequently not reported. On occasion,
each of these may be important in diagnosis or treatment
of your problem. Prsonal history includes bowel and other
habits, sleeping patterns etc. Family history is important
in predicting or diagnosing conditions like bronchial
asthma, diabetes, heart disease, migraine etc.
General and systemic examination

This is the next step in which the doctor will check your
pulse, blood pressure and look generally for any abnor
mal findings from top to toe like yellowness of eyes a
swollen gland or a skin patch etc. He will then perform
examination of different systems like the nervous system,
cardiovascular, respiratory system etc. Mostly, a detailed
examination of the affected system will only be done with
a cursory examination of other systems. This will be bas
ed on the clues provided by you while narrating the history
of your illness.

1. Chief complaint(s).
2. History of present illness.
3. Past, family and personal history.
4. General examination.
5. Systemic examination.

Chief complaint(s)

A doctor has three major sources of information. The
medical history, the physical examination and laboratory
tests. Depending on the illness any one of the three may
be the most important. For instance, diseases like
migraine, epilepsy or angina pectoris may be diagnosed
on history alone and there may not be any abnormality
detected either on examination or in the laboratory tests.
This is all about what a doctor trained in allopathy
should follow when s/he looks after patients. Does this
really happen when you go and get treated by your doctor?
It’s for you to remember and see when you visit your
doctor next time.

This is usually the first information sought by the doc
tor. The purpose of this is to establish the priorities for
the rest of medical history process. Be sure you express
your problem clearly. Know in advance how to state your
chief complaint or what bothers you most. Sometimes you
may go to the doctor with more than one problem and
you may not know if the problems are related. Be clear
and precise about it”. The doctor can then investigate each
of these areas. Tell your problem as it is. If you have a
sexual problem, do not say that you are “tired and run
down”. If you are afraid that you have cancer, don’t say
that you came for a “routine check-up”. Patients who ram
ble on about irrelevant details are their own worst enemies.
An honest description of your problems is your best
guarantee that your problems will be attended to correctly.

Since it’s you who is going to consume the medication,
it’s for you to understand the .importance of each drug
and treatment. Ask your doctor to write out the instruc
tions. It’s all the better if you know the name of each drug
you are taking. In case the drug doesn’t agree with you
or produces any unwarranted effects, you could safely
avoid it’s use in future. If you are confused ask questions:
“Could you go over that again? How much will this cost?
Are. there any risks to this drug? I don’t understand what
this medication is for?” And once you are convinced, stick
to the doctor’s instructions. Sometimes patients take too
much medication. They feel that if a little bit is good, a
lot is better. If pills are good, injections are better. All
drugs are alien to the body and basically must be con
sidered poisonous. When used in excess, you may en
counter increased side-effects.

History of present illness
Here the doctor wants to establish how long you have
had the problem. Cough or fever of a few days, a few
weeks or a few months duration have different connota
tions for the doctor. Be sure that you know the answer
to this question in advance. If you are uncertain as to the
date the problem began, state the uncertainty and tell what
you can. Don’t just say “I don’t remember”. Tell what you
can, “I began to feel feverish in the middle of last month
but the cough started only a week ago”. The doctor can
then determine the starting point for the illness. You must
then provide the information about how your illness has
progressed. Remember that its entirely on what you tell
that the doctor reaches a conclusion and decides your
treatment.

Today, visits to the doctor frequently are requests for
medication. If your satisfaction with the doctor depends
on whether or not you are given medication, you are work
ing against your own best interest. If you go to a doctor
for a cold and request a shot of injection, you are asking
for poor medical practice. Is it not common sense that
for the same disease there cannot be a strong medicine
that will ensure a quick cure and a weak medicine that
will entail a slow recovery? Then, why force a doctor
prescribe unwanted medication? Why not help the doctor
help yourself?

The past, family and personal.history

The doctor also needs more background, information
about your general health. Here, the information that did
not appear important, earlier may be relevant. Patients
often try to hide information about previous medication.
Birth control pills, analgesics, vitamins and laxatives are
5

SUPERSPECIALISTS

ONCOLOGY
(Cancer specialist)
ENDO
CRINOLOGY
(Diseases of en
docrine glandsThyroid, Pituatry,
eta)

HEMATOLOGY
(Diseases of
blood)
PLASTIC & RECONSTRUCTIVE SURGERY

GASTROENTEROLOGY
(Diseases of
digestive system)

(D.M.)
(Correction of disfigurement)

(2 years afterM.D.)

UROSURGERY
(Urinary system)

NEPHROLOGY
(Urinary system)

(M,Ch.)
(2 years after
M.S.)

NEUROLOGY
(Nervous system)

NEUROSURGERY
(Surgery of nervous system)

CARDIOLOGY
(Heart & blood vessels)
General Physican
(General Medicine)

CARDIOTHORACIC SURGERY
(Heart & chest)

Paediatrician
(Child
specialist)

Psychiatrists
(Mental
disorders)

Deratologist
(Skin &
Ven era 1
diseases)

E.N.T.
(Ear, Nose,
throat)

Anesthesia

(M.S.)
(3 years after
M.B.B.S)

(M.D.)
(3 years after
M.B.B.S)

Radiologist
(X-ray, Sonography, scan)

MEDICAL SPECIALIST

Opthalmology
(Eye)

Orthopaedic
(Bono)

Gynaecology
& Obstetrics
(Pregnanes' &
disorders of
female
reproductive
system)

(M.D./M.S.)

(M.S.)

Pathologist
(Examination of Blood
urine, body tissues etc.)

ALLIED SPECIALISTS

GENERAL PRACTITIONER (GP)
(Family Doctor)
(M.B.B.S.)

Note:

Gent•ral
Surg cry

Publication titled
Social Aspects of Leprosy " is
available at FRG® and "Health in People's @nd" will
shortly available."

SURGICAL SPECIALIST

School Health: Which Way to Go?
Dr Mohan Deshpande
“The child shall enjoy special protection and shall be given
opportunities and facilities by law and by other means,
to enable him to develop physically, mentally, spiritually
and socially in a healthy manner.,

In these words the United Nation declared the rights
of the child in the 1950s. Will this dream be ever realised
in our country where a large number of children are left
without education, proper nutrition and health care?
Children who go to school are not better off in these
respects.
The School Health Committee was appointed by the
govt, of India to assess the present standard of health and
nutrition of school children and suggest means of improv
ing them. Emphasis was laid on health education in its
report. But the school health programme since then has
been reduced to ‘health-check up’ and ‘mid-day-meals’.
It has become almost an aimless routine exercise as a part
of reaching ‘targets’ filling up of school health cards, with
undue emphasis on routine, hurried check-ups by busy
doctors. The programme goes without any participation
of teachers and students. Despite some lessons in the text
books, at the end of the schooling, the student is left
without basic knowledge about health and disease in ac
tual practice. Therefore, learning is reduced to merely pass
ing the examinations. This makes no impact on applica
tion of health education in actual life. In fact, school
health programme has had an implied negative connota
tion viz., creating more educated people who are solely
dependent on doctors and are almost completely unable
to look after their health themselves. Sex education, un
fortunately, is still a topic of controversy and a clean
healthy attitude towards heterosexual colleagues is far
from reality. Menstrual superstitions continue to exist even
amongst educated people.
A very striking observation on this was made in a survey
conducted by the Homi Bhabha Science Education Cen
tre, Bombay. The survey on the areas of interests of school
children found that 72 per cent of all questions (about
science and technology) that the children asked were
health related. This shows that school children have
greater interest in human biology and health. It is sad that
the elders involved in school health do not satisfy this need
of children.
We do not see any reason why school teachers and
students cannot actively acquire health knowledge, when
semi-literate village women health workers can. They
should do even better. This would also help proper impiementation of all our national health programmes.
This has been amply shown by the Kerala experience.
The mere spread of education to girls has resulted in effective family planning, reduced infant maternal mortality,
and optimum utilisation of medical services. It should,
however, be noted that education is hot the only factor
in improving health standards. Other factors viz., socioeconomic situation, nutrition, sex-biases and other cultural factors, sanitation and drinking water are certainly
important. Health education will have a qualitative impact on all these factors if aimed at ‘self-awareness, confidence and demystification of health knowledge. In fact,

getting educated in health should become a cultural asset
for an individual and society.
School teachers are almost completely ignored in our
school health programme. We feel that teachers are of im
mense importance. They certainly have great potential to
get trained in health and are already equipped for impar
ting health education as they command respect and love
from the children. But today, they are diffident about their
own health. They do not even question their own family
doctors and their prescriptions which often are irrational.
They even harbour older and newer superstitions about
health. Their role in school health is confined to measur
ing of weights and heights of the children.
So we need to have a radically different and fresh
perspective if we wish to see any visible improvement in
school health programme. The methods and techniques
of health education will have to be radically different from
the outdated traditional ones, which only have a deaden
ing effect on learning. The lessons on health in text-books
need to be rewritten and modified and more important
ly, they should be taught in a different way. Children
should be able to relate whatever they learn to their own
observations and experiences.
One of the most important and essential ‘equipment’
for health education is most widely and easily available:
one’s own body. Observing one’s own body, feeling
(palpitation) and listening (auscultation) will give the most
authentic experience. Experiments in nutrition, optics,
dissection of animals will add to the knowledge. Apart
from imparting this knowledge, other methods can be
employed for self-expression and evaluation viz., group
discussions, group poster-making, essay competition, oner
act plays and health games. Fortunately, now there is a
wide range of new well-tested effective techniques of participatory education, which can be used even in health
education.
So the objectives of school health should be:

1. To impart simple but comprehensive knowledge about
health and diseases to teachers, and via them to students.
2. To remove the fear-complex about health knowledge,
to demystify medical knowledge, and to teach how to
question.
3. To make the teachers and children to take active interest
in their own and community’s health.
4. To help them know the existing medical services, how
best they can be utilised, their deficiencies and limitations.

* * *
Traditional Medicine
At least two-thirds of illness are treated first by traditional
methods, either by consultation with a healer or at home.
Although the intention is to integrate this major source
of health care into the national PHC programme. Only
Rs. 43 crores out of a total health budget of Rs. 3.393
crores have been allocated to the development of Indian
systems of medicine.

What is New?

Book Reviews

5. Maheshwari Shriram, “Rural development in India:
a public policy approach”—New Delhi: Sage
publishers, 1985, p.231.
6. Faden Ruth R. and Beauchamp Tom L., “A history
and theory of informed consent”—New York: Oxford
university press, 1986, p.392.
7. Taylor Steven and Bogdan Robert, “Introduction to
qualitative research methods: the research for mean
ings’—New York: John Wiley, 1984, p.302.
8. Khandewale S.V., “Small farmers and viability
schemes”—Nagpur: ICSSR, 1984, p.158.

1. Faden Ruth R., “A history and theory of informed
consent”—Now York: Oxford University Press, 1986,
•p.392, Price Rs.345A
Informed consent has often been a perplexing area of
biomedical and research ethics. In this volume authors
provide an analytical framework for reasoning about in(formed consent, clarify the ambiguities surrounding the
'rights of patients and subjects, and enable physicians and
research investigators to place ethical decisions on a prin
cipled basis. This framework is based on philosophical,
psychological and legal considerations.
2. Taylor Steven J. and Bogdan Robert, “Introduction to
qualitative research methods: the search for meanings”—
New York: John wiley and sons, 1984, p.302, price Rs.320.
This is the 2nd edition of the book, first being in the
year 1975. The book can be used as a guide to important
non-statistical research tools for the social sciences. The
first half of the text focuses on the application of the
techniques—how to actually conduct a study. The second
half of the book is selection of articles that provide
specific examples of research reporting drawn from the
author’s experience; these studies illustrate, how the
methods presented earlier are employed in actual practice.

1. Reed Evelyn, “Problems of Women’s liberation: a
Marxist approach”—New York: pathfinder’s press,
1970, p.96.
2. Reed Evelyn, “Sexism and science”—New York:
Pathfinder’s press, 1981, p.190.
3. Hanson Joseph and Reed Evelyn, “Cosmetics,
fashions and the exploitation of women’—New York:
Pathfinder’s press, 1986, p.138.
4. Reed Evelyn, “Woman’s evolution: from matriarchal
class to patriarchal family”—New York: Pathfinder’s
press. 1981, p.491.

Health in People’s Hand
This novel and unique work was undertaken by Dr. Guy
Poitevin of the Centre for Cooperative Research in Social
Sciences, Pune.
Sponsored by the. Indian Council of Social Science
Research (ICSSR), New Delhi, this report qualitatively
analyses the scheme of "health by the people” conducted
in the remote Velhe and Mulshi areas Pune district.
The study concentrates on primary health care as a mat
ter of social process and observes the emergence and
evolution of “self-health”. Primary health care issues have
been investigated by focussing on the dialectical relation
ship existing between the levels of health consciousness
and the forms of mass organisation on the one hand and
the prevalent local social, cultural, administrative and
power structures, including those of the public health
system, on the other.
The reciprocal determination of the following factors
has been highlighted as a necessary pre-requisite for the
success of any health development scheme;
—spreading of health knowledge
—awakening of a socio-cultural and socio-political
consciousness
—autonomous and self-reliant alternative efforts of health
care.
This study surveys the nature, extent and forms of the
mutual correlation while considering health as an in
alienable dimension of an overall process of socio-cultural
and socio-political awakening.
A specifically important aspect was the inclusion of
gender dimension. Anthropological analyses of women’s
role in the traditional and ritualistic cure practices where
they occupy pivotal position provide a rationale for an

almost exclusive priority workers. This study shows us the
necessity of the gender parameter as one of the main
sociological criteria for evaluation of any primary health
care system.
The report in its analysis mainly concentrates on the
following three categories
i. Identity and role of health animators.
ii. Health practices as activities of health care and col
lective health actions as attempts of mass mobilisa
tion on community health issues.
iii. Health action.

Social Aspects of Leprosy
Leprosy as a disease has a unique feature in the sense
that unlike most other diseases it stigmatises the afflicted
person. This study aims at exploring and critically
understanding the socio-culturai, economic and political
correlates of this stigmatising disease. The study has been
carried out in both leprosy high endemic and low endemic
areas and focuses around differentials, if any, due to
endemicity.
The study places stigma in the context of political
economy and the entire social structure. It rejects the
behaviourist approach and examines the stigma against
leprosy in terms of the general discrimination existing in
an exploitative society—a society in which the basis of
relations of production are differentiation, discrimination,
domination, alienation and ostracism.
The survey was carried out in 22 villages spread over
six districts.
The principal objective of the study was to explore and
understand the stigma associated with leprosy, both from
the perspective of the patient and the general population.

Edited by Saroj Iyer with the co-operation of Manish Mankad and secretarial assistance from Anuradha Naik. Produced by the Foundation
for Research in Community Health, 84-A, R. G. Thadani Marg, Worli, Bombay-400 018, registered under the Bombay Public Trust Act. Printed
by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.

COMMUNITY health cell
<7/1. (First Floor) St. Marks Road,

Bangaloro , 560 COL

NEWSLETTER.
July-August," 1988

Vol. H

No. 4

The National Tuberculosis Programme and Its
Implementation
Debabar Banerji*

India can justly be proud of its achievements in develop specific,mandate to make tuberculosis services available
ing a public health approach to the problem of tuber to the larger masses of the patients who are at that time
culosis in the country. There are three distinguishing unable to gain access to the services. Apart from the
features of this achievement: very early in the process, In disciplines such as epidemiology, health administration,
dia had moved away from the traditional methods which clinical medicine, therapeutics, microbiology. public health
were being applied in Western countries and develop its nursing and X-ray engineering, a still more distinctive
own approaches to suit the local conditions; India has feature of NTI was that it also had positions for a social
made the pioneering effort to develop an interdisciplinary science group to make contributions to the formulation
approach to formulate a nationally applicable, socially of the National Tuberculosis Programme by giving what
acceptable and epidemiologically effective National Tuber can be called a social science dimension to the data ob
culosis Programme (NTP) for the country; India’s con tained by epidemiologists. This was most remarkable.
tributions in the form of formulation of the NTP was Social science data were used to demonstrate that a large
globally recognized and these have formed the bases of proportion of the existing tuberculosis patients in the
tuberculosis programmes in many of the developing as country are actively seeking help from diferent health in
well as developed countries of the world.
stitutions all over the country—in other words, they have
B.K. Sikand of the New Delhi Tuberculosis Centre had a “felt-need” for the services; social science data also
pioneered organized domiciliary treatment of tuberculosis made a critical contribution in evolving a procedure for
cases in the early forties. P.V. Benjamin (an Indian) of the diagnosing tuberculosis cases in remote rural areas; the
Union Mission Tuberculosis Sanatorium, Madanapalle, data also made it apparent that a tuberculosis programme
had started conducting epidemiological surveys using the must be built up as an integral part of the general health
obeiously rudimentary tool of tuberculin test in the late services—as it dealt with the problem of suffering of the
thirties. When, in the wake of the Bhore Committee tuberculosis patients, the programme was designed to sink
recommendations, he became the Advisor in Tuberculosis or sail with the general.health services; and the data also
to the Government of India, he took the initiative, along demonstrated clearly the enormous epidemiological
with C.G. Pandit, to conduct the national sample survey potential of a “felt-need” oriented tuberculosis
of tuberculosis in 1954-56, which is still considered a programme.
classic epidemiological study. This tradition of
Diagnosing tuberculosis cases in rural health institu
epidemiological survey was continued by scholars like Raj tions through sputum examination of chronic cough cases,
Naraian and Frimodt Moller, who have carried out treating the diagnosed cases with chemotherapy by
outstanding longitudinal surveys and experimental building a sound system of treatment organization in rural
epidemiological studies, which once again gave India the areas, and developing a system to refer the doubtful cases
distinction in offering conclusive evidence to the scien for more refined diagnosis and treatment at the Tuber
tific world that B.C.G. does not provide protection to culosis Centre at the district headquarters (DTC), form
adults against tuberculosis.
ed the sheetanchor of the NTP. The DTC was entrusted
Before the findings concerning B.C.G., Halfoan Mahler with the responsibility of providing training and logistic
had joined Benjamin in launching the National B.C.G. support to workers in the health institutions, apart from
Campaign in the fifties. India, again, has the distinction having a sound information system'to keep track of all
of carrying out the path-breaking study to demonstrate the tuberculosis cases who are diagnosed and treated in
that home treatment of tuberculosis patients is as ef- the district, including the two way referal of the cases with
fecacios as sanitorium treatment at the Tuberculosis the health institutions.
Chemotherapy Centre at Madras in the late fifties.
The contours of the NTP were finalised after they were
Benjamin and Mahler, again, provided a perspective to field tested in the entire Anantapur district of Andhra
the then Prime Minister of Jawaharlal Nehru and the Pradesh. NTI served as the training centre for the staff
Health Minister Rajkumari Amrit Kaur to set up the Na of the DTC and by 1983-84, the programme has been im
tional Tuberculosis Institute in Bangalore in 1959 with the plemented in 353 districts of the country; in that year

FOR PRIVATE CIRCULATION ONLY

13,08,880 tuberculosis patients were treated under the
NTP
Almost a quarter of a century after the formulation
and implementation of NTP, it is apparent that still a very
large proportion of the infectious tuberculosis patients,
who are literally knocking at the doors of the health in
stitutions of the country, are still being thrown back with
bottles of cough mixture. This is a cruel irony. While
health workers are ordered by national and international
authorities to catch hold of children and immunize them
against the six diseases about whose size and extent we
know so little, the organization finds itself helpless in pro
viding services to the hundreds of thousands of tuber
culosis patients who are literally begging for treatment in
various health institutions.

services they got in different health institutions were found
to be grossly inadequate, the patients were forced to fall
prey to the exploitation of X-ray centres and
bacteriological laboratories, private medical practioners
and the drug industry. The most heartrending aspect of
this dilemma of the tuberculosis patients is that, in spite
of their efforts, they finally do not get the needed relief
and they continue to suffer till they die of the disease. This
dilemma was graphically described in the case study
presented in the FRCH Newsletter of March-April 1988.
Imrana Qadeer, who had worked for over a year in nine
villages in Sonepat district of Haryana also got numerous
instances of such cases of inadequately treated tuber
culosis. Earlier, Klaus van der Veen, working in .Valsad
district of Gujarat, also provided numerous such in
stances. One can say on the basis of the data available
that the suffering of the tuberculosis patients due to cruel
neglect of those who are supposed to implement the NTP
has reached epidemic proportions, calling for urgent action.
The solutions are very obvious and straightforward.
There is a crying need to improve the quality of public
health practice in India. This will ensure strengthening
of health services, right down to the level of the health
guides. Along with this strengthening of health services,
there will be almost automatic strengthening of the NTP,
which will ensure that those who are seeking services at
various health institutions received effecacious treatment
so that their suffering is allievated and they do not have
to fall a victim of various types of medical exploiters.

Worse still, of the limited number of tuberculosis pa
tients, who are finally diagnosed in the various health in
stitutions and DTCs, only a small fraction are offered the
treatment services as envisaged in the NTP. The health
organizations at the national and state levels should thus
be considered as the biggest of the ‘defaulters’: they are
responsible for death and agonies of hundreds of
thousands of the tuberculosis patients of the country. The
principal reason for this unforgivable default of the health
services of the country is the indifference of the political,
bureaucratic and the public health leadership. Over and
above, has been their pre-occupation with such massive
“vertical” or target-oriented programmes as those for
malaria, family planning and mass immunization.

* DEBABAR BANERJEE is the Professor and Chairman, Centre of
Social Medicine and Community Health, Jawaharlal Nehru University. New Delhi.

The consequences of this neglect has been devastating
for the sufferers of tuberculosis in this country. When the

The Mandwa Experience
over charge the poor who eventually default, there
exists in every village the potential for the early
detection and regular treatment and prevention of
dissemination of tuberculosis as of many other
major diseases at very low cost.
For this the medical profession needs to develop
respect for the intelligence and ability of village folk,
to give them information in a simple manner and
language which they can understand and encourage
and support them to undertake those functions
which are within their capacity and yet beyond the
reach of the health professionals; not to mystify a
and create fear about health and illness.
Since it is virtually impossible for a patient to have
regular access to the available health services and
self help is feasible in health it is time we move from
the top-down delivery of health approach to make
health a people’s own programme in which the
medical profession participates in the manner
required by the people. Why cannot the village
woman be trained to give streptomycin injection lor
tuberculosis and for immunization as done in
Mandwa?

FRCH conducted a ten year experiment in
30 villages of north Alibag district known popularly
as the Mandwa project. Since neither the public
nor the private health sector could provide the
services needed by the villagers, one woman from
each village was trained to undertake as many health
functions as possible. About 80% of all health
needs could be met by them even for diseases
like malaria, • leprosy, gastroenteritis, including
tuberculosis.
Surprisingly they could detect tuberculosis in the
early stages most effectively by observing the
cardinal symptoms. Following confirmation of
diagnosis by the FRCH doctor they not only ensured
regular treatment including the giving of strepto
mycin injections but also convinced the patients to
take precautions for spread of the disease to others
like, disposal of sputum and sleeping away from the
other family members. They also detected new cases
in the family in the arlier stages.
While the vast infrastructure of the public health
care system fails to ensure early detection and
regularity of treatment and the private practitioners.

2

Lessons from BCG
Nerges Mistry*
The story of BCG is a multi faceted one: of history, per
sonalities, science, and also of confusion, surprise and
disbelief. This story is worth telling because it has an im
portant but often overlooked message of basic research and
for practical disease control policies today.
BCG owes its origin to the transformation (attenuation)
of the bovine tubercle bacillus Mycobacterium bovis dur
ing the course of 231 passages in a broth containingoxbile. This process took 13 years from 1906-1919. The
resulting organisim was called Bacillus-Calmette-Guerin
(BCG) after the two Frenchmen, who had nurtured it. It
proved non-pathogenic in calves and guinea-pigs and in
1921, it was administered live into the mouth of a young
baby whose mother had died of tuberculosis (TB). The
infant survived both, disease-free and without apparent
side-effects. Encouraged by these results, Calmette con
ducted a series of tests in animals which suggested that
ithe vaccine was safe and that it imparted a degree of
resistance to challenge with virulent tubercle bacilli when
given in a live form but not when killed chemically or
by heating. By 1928, vaccination by BCG was delivered
to 50,000 French children—some still contracted tuber
culosis and some died but Calmette claimed that most
were effectively protected by his vaccine.
Then trouble began. At first came a vitriolic attack from
Greenwood claiming that Calmette’s evidence of protectivity through the vaccine was flawed. In 1929, there occur
red a disastrous incidence in Lubeck, Germany, where a
laboratory accident led to the mistaken labelling of human
tubercle germs as BCG: of 251 children inoculated, 72 died
with fulminating tuberculosis. Confidence in BCG
evaporated and Calmette died broken-hearted in 1933.
Nevertheless, interest in BCG remained unshaken and
in the 1930’s a series of controlled trials were organised
in several areas of the world in order to assess objectively
the protection imparted by BCG against TB. The results
have been confusing in their lack of consistency, providing
upto almost 80 % protection in some populations—but
little or no protection at all in others. The most quoted
examples are the Medical Research Council trials of BCG
against TB in British school-children, begun in 1950,
which showed good protection for over 20 years and the
most recent trial carried out in south India by the WHO
and the Indian Council for Medical Research in which
no protection was evident. In the United States, two trials
initiated in 1937 and 1950 gave protective values ranging
from 73-6% respectively. The favorable result of 73% was
manifest only over a follow-up period of 30 years.
As is often the case, the experts disagreed on the reasons
for these differences. But through these very differences
arose several theories that have laid the norms for in
vestigation of both basis and procedure of prevention
schedules not only for tuberculosis but for other tropical
diseases with complex pathogenesis.
BCG vaccination successfully delineated diseases which
were caused as a direct result of specific metabolic activi
ty of viable/active causative agent. Since killed BCG failed
to bestow protection, it meant that pathways mediating

protection were also activated via specific albeit undefin
ed activities of the live BCG vaccine. An extension of this '
reasoning implies that in such diseases (tuberculosis,
leprosy), generation and administration of so-called in
ert protective determinants of the causative agents even
through the most sophisticated technologies is not likely
to succeed in preventing the disease.
The second important fall-out of the variation in results
of the BCG trials was in the framing of the concept that
vaccination was not “writing on a blank slate”. Some '
theories attributed the variation to flaws in trial designs,
differences in the genetic background, to M. tuberculosis
between populations. These matched the general obser-.
vation that protection by BCG increased proportionally
to the distance from the equator.
A more favored explanation however is the variation
in the structural components (antigens) of the tubercle
bacillus in'different parts of the world. The apparent
failure of BCG in south India has. been attributed to the
fact that a high proportion of the tubercle bacilli are of
a strain which is less virulent in guinea pigs than is the
organism of Europe and N. America. The most popular
explanation today however would attribute these dif
ferences to regional differences in the atypical or en
vironmental mycobacteria which sensitize local popula
tions and alter their response to BCG.
This argument is acceptable since it is widely recognis
ed that BCG strains maintained in different laboratories
have changed over the past 60 years and now differ con
siderably between one another. It should be expected that
some of these changes have significant immunological im
plications and as with all live vaccines, there is always a
looming risk that the organism through extensive passag
ing may recover its disease causing properties or through
selection processes mutate to a form with unpredictable
ones.
A sharper analysis of the BCG control programmes
reveals that satisfactory protection is apparent when the
vaccine is administered to younger age groups (even in
south India, protection could be detected in children below
5 years of age) or if the programme has been evaluated
for a period of over twenty years. The former indicates
that vaccination may be most efficacious in some popula
tions when superimposed on a background of minima:!
environmental sensitization. Indeed some environmental
mycobacteria are suspected to suppress subsequent attempts at immunisation. This scenario is not exclusive to
TB. and is known to occur in tetanus infections. The lat
ter highlights the problems in judging the efficacy of a
vaccination programme. Since the long term duration of
BCG afforded protection is virtually unknown, it becomes
difficult to judge the contribution of other factors such
as improved chemotherapy, or rise in socio-economic
status as harbingers of health vis-a-vis BCG.
Another singular disappointing feature to this whole
puzzle is our inability to predict whether a given BCG
will impart a useful degree of protection versus tuber(contd on p. 7)

3

Tuberculosis Control in India: A Bird’s Eye View
Mukund Uplekar*

Problem

Factors: Private Level

Factors: Government Level

Possible Remedies

a) Poor detection and reporting.
Delayed diagnosis

Lack of awareness: Patient neglects cough and fever as ‘usual’
Low morbidity in early stages: Symptoms do not hamper their routing
Who knows ‘TB’ is notifiable?
Doctors delay the detection by not investigating in early stages.
Prohibitive costs of investigations
Facilities for investigation available only at PHC. Patient prefers to go
to private doctors.

Lack of awareness: Patient neglects cough and fever as ‘usual’
Low morbidity in early stages: Symptoms do not hamper their routine
Overcrowded OPDs in public hospitals. Early case easily missed
X-ray facilities and supply of films irregular and limited
Sputum examination unreliable
General lack of commitment and indifference to patients.

1. Study patient’s perceptions about the
disease, their knowledge and
awareness about the treatment
2. Preparing health education material
essentially keeping in mind patient’s
perception.
3. Making sputum examination
compulsory for all cases of
productive cough more than fifteen
days duration. All cases of
cough more than fifteen days to be
X-rayed.
4 Continuing education for private
doctors about diagnosis and
treatment.
5. Seeking active participation from
private doctors; making notification
of TB mandetory.
o. Giving clearcut guidelines about
administrating BCG vaccine to
private doctors in particular.
7. Suggesting a few effective and
uniform drug regimes all over the
country;
8. Providing health education material to
doctors for distributing to patients,
9. Helping private doctors trace
defaulters.
10. Ensure regular supply of drugs and
X-ray films.
11. Promoting drug regimes containing
Streptomycin in view of patient’s
love for injection,
12. Allowing health workers give
injections at patients’ own houses.

Private doctors do not refer to PHC for fear of losing the case.
b) Improper treatment

Lack of knowledge among doctors about correct drug regimes
Stress on injections and tonics alone as the returns are good

Lack of knowledge among doctors about correct drug regimes
Too many drug regimes are ‘recommended1—confusion about which
regimes
forgbich patient.

c) Poor patient compliance

Diagnosis and implications of the disease not disclosed.
Patients gets complete relief very soon and stops treatment on their

Diagnosis and implications of the disease not disclosed.
All drugs not made available to all TB patients. When the patient
discovers
that ‘better’ drugs are available in ‘private’ he goes to private. But
when the money gets over he runs back to government dispensary.
All drugs are not available at all places. Patients tend to go to bigger
hospitals
‘Undue’ faith in injections. Patients feel that when injections are over
the treatment is over.

own.

Costs of treatment prohibitive
Undue’ faith in injections. Patient feel that when injections are over
the treatment is over

d) Inadequate treatment

Lack of knowledge and confusion about drug regimes and their
correct duration and the rationale of short course chemo-therapy
High default rate

Inadequate/unreliable supportive investigational facilities..
Costs prohibitive.
e) Inefficient prevention

Lack of knowledge and awareness about protective effect of BCCvac
cination and environmental sanitation.

Lack of knowledge and confusion about drug regimes and their
correct duration and the rationale of short course chemo-therapy
Criteria for cessation of therapy not well defined.
Inadequate/unreliable supportive investigational facilities.

LacKof knowledge and awareness about protective effect of BCG
vaccination and environmental sanitation.

* MUKUND UPLEKAR, a medical doctor, is the medical consultant to the Foundation for Research in Community Health.
PROBLEM OF TUBERCULOSIS IN INDIA

Morbid Statistics of
Tuberculosis

- Uninfected 62.0 %
- Infected and Not Diseased - 36.0 %

— Non Infectious Cases - 1.5 %
- Infectious Cases - 0.4 %

*
*
*
*

10 million Indians suffer from TB
Amongst them, 2,2 to 2.5 million age infectious
4,00,000 Indians die of TB every year
19 out of every 1000 Indians suffer from TB

Source: National Tuberculosis Institute, “Defeat TB, now 4 for
ever",Bangalore: NT1, 1985

"Health Atlas oj India: 1986”. New Delhi: GOI, 1986.

4

5

COMMUNi I Y HSAL 1:1 c:
LL
47j1. (Fist Floor) St. Noors | 6^
Bannaler . 660 C01.

Health Education: Blaming the Victims
Mohan Deshpande*

“Anybody can get TB.
Rich people and poor people can get TB.
Young children and old can get TB.
People in villages and people in cities can get TB.
Good and bad people can get TB.
Men, Women and children can get TB"
—A health message
Health education seeks to induce changes in personal
and community attitudes and behaviour that promotes
healthier living. It aims at making people behave in a man
ner which is different from their present behaviour. This
change in behaviour is required when there exists a big
information-gap between the current medical knowledge
and the knowledge amongst the people. Therefore the
health-messages are based on information. Information
provides justification for the message. Where the laws,
orders and instructions fail, information works. The logic
is fine and appropriate in a democratic society like ours,
but this logic has allowed selective information to be us
ed for getting across convenient messages, taking advan
tage of popular ideas and emotions.
The effects of such selective information are disastrous.
Selective information although utterly factual in itself, is
utterly false when seen in the context of the socioeconomic milieu, as amplified by the health-message
quoted above. Such a health-message completely conceals
the relationship between poverty and Tuberculosis (TB).
People also happen to know some examples of rich peo
ple getting TB, although rare. They remember these cases
because they are worth remembering. Thus the half truth
becomes the whole truth.
People, by now, also know that it is the germs and not
the fate that causes TB. (Thanks to the ‘health education*).
“Mycbacterium tuberculosis (human type) is practically
the only causative agent of tuberculosis in our country”
(Defeat TB, Now and For Ever, National Tuberculosis In
stitute, Bangalore, 1985), and then how can the germs
discriminate between the rich and the poor? So, the germ
theory of disease comes as a great help to ‘educate* peo
ple. Thus “... rich or poor, villager or cityman, woman
or man, young or old can get the disease (TB). (Defeat
TB, Now and Forever). But who do the germs enter and
cause disease in a particular person? Surely, it must be
his fate. Why do poor people get TB more often? It must
be their fate.
Another message that TB is curable and controllable
in the present socio-economic situation, is based on
various bacteriological and sociological half-truths such
as:
* People are superstitous and irrational. They do not
go to doctors in time. Those who follow doctors instruc
tions will get cured fast and completely and will lead a
healthy life.
* Although TB is curable (since it is caused by germs
and we have very effective anti TB drugs), people are un
willing to take the treatment and solve the problem. “No
programme howsoever feasible and scientifically sound

it may be, could possibly succeed if the community for
which the programme is meant, do not accept it and do
not co-operate with health agencies and do not utilise the
available facilities to the maximum extent” (Defeat TB,
Now and Forever).
All the following central issues thus are concealed:
* Relationship between poverty and TB.
* Nonavailability and lapses in the health services. As
D. Banerji writes “The community diagnosis revealed that
because of weakness in the services, a very large number
of tuberculosis cases who were actively seeking help were
not even diagnosed as cases of tuberculosis”
Similarly studies of treatment defaulters in TB pro
grammes indicated that organisational, managerial and
technological lapses rather than lapses on the part of the
patients account for the bulk of the problem. Yet health
educators focussed upon the lapses of the. patients and
were the instrumental in diverting attention from the far
more serious lapses in the services. (D. Banerjee: Health
Education & Community Health Behaviour)
* Cost of the treatment from the so-called efficient
private health sector. The treatment of the disease itself
is very expensive at the private hands. It is further
escalated by the addition of irrational drugs like malts and
tonics, and the cost of prescribed food, such as milk, eggs,
chicken etc.
* All the other problems involved in continuation of
treatment including transport and loss of wages.
* Inability to follow the instructions of health educa
tion (if any) because of socio-economic problems. Then,
if the patient does not get well, it is his fault (or fate, if
the blaming authority is more magnanimous).
* Inability and unwillingness of the private doctors to
solve the problem. Wide scale malpractice. Failure to
notify the disease. (No where in the booklet “Defeat TB,
Now and Forever**, there is any reference to notification
of TB as an important duty of the doctors. The booklet
is meant for the general practitioners.)
* Low morale of the patients on account of all above
factors and the disease itself.
Barring all the above factors, health education today
is well and fine, presenting a rosy picture—an almost
afairy tale of cure arid control of TB. If the fairy tale fails
to be realised, blame the victims. That is the easiest way
out.
Health education imparted by many private doctors is
no less important, as usually a general practitioner is the
first contact for many TB patients. Apart from his
epidemiological knowledge (the celebrated germ theory)
he'also has several prejudices against the poor, which af
fects the health education he gives. Also the profit motive
plays a havoc. Implicit in his behaviour at every stage of
management, there is an attempt to hide the information
or create false impressions about the disease. Many times..
the doctor does not provide diagnosis of TB even when
suspected. Delayed diagnosis prevents patients from go(contd on p. 8)

6

SANJEEVANI
Rupashree Sinha*
Sanjeevani, a twenty-year old Auxiliary Nurse Midwife very good relations with the Sarpanch and often shared
(ANM). She had heard about the nursing course on the his cup of tea with him. So he did not have a heart to
radio and applied. Her small world had earlier consisted severe this congenial relationship. One of the new LHVs
of housework and tailoring. Her idea of a nurse’s job con tried to support her efforts. But she was severely threaten
sisted of a hospital complex, dedicated patient care and ed by the Sarpanch. When the LHV was gone, the
fixed hours of work. When she joined the ANM course, Sarpanch called Sanjeevani and told her that she was like
she found that a different kind of nursing skill was being his daughter so why should she trouble herself with all
imparted to her. Nevertheless she adjusted to the idea of this. She should live quietly in the village and do her work.
Thus Sanjeevani bears this carrot and stick game.
rural health work.
It is not that she never got to live in the sub-centre
Her first placement was in a sub-centre. Luckily, her
building
earmarked for her. Once when (USAID) senior
sub-centre had a building built by USAID, albeit opposite
officials
were
visiting, the Sarpanch had obliged her by
a cemetery. But she soon found that the sub-centre
giving
her
access
to the quarter for two full days. After
building was occupied by the Sarpanch whose field was
adjacent to the building. Her clinic room was full of that she had to go back to the village but which had no
Sarpanch’s family and henchmen. The village had also water and toilet facility. Still she. has adjusted. She has
been generously granted a quarter for the Lady Health other worries. She has to walk 8 kms. to and from the
Visitor (LHV), by USAID. But this was being occupied sub-centre, five days a week because none of the villages
by workers who were constructing a temple nearby and she visits has public transport facility. She hardly has any
for which villagers had collected one and half lakh rupees. medicines to distribute except ferrous sulphate. She also
The LHV quarters had gradually become bare of electric has to motivate atleast six family planning (i.e. steriliza
wires and fan. The previous LHV had left in haste after tion) cases every year. Last year (her first year) she work
a lot of harassment and threats, leaving behind unused ed hard and promoted three sterilisation cases. But at
the end of January she faced a lot of pressure from district
medicines and instruments.
officials and was therefore forced to buy three more cases
But like several enthusiastic newcomers, Sanjeevani took for Rs. 600/-. She had to borrow the money from her
upon herself to behave efficiently and put things in order. parents. At the end of the year she was awarded Rs. 50/She spoke to the Sarpanch about her right over the sub for her efforts. Sanjeevani has nothing else but to cry and
centre building. The Sarpanch in turn reminded her that laugh alternately at her helplessness and absurdity of the
she belonged to the same community as he. He even trac situation. She moaned, “when my parents were advising
ed back a distant relationship with her parents.
me not to, I had defiantly taken up this job. I wanted to
She sought the Medical Officer’s help who told her to prove myself’.
The question is, “does Sanjeevani have to suffer for her
do whatever she could. She was puzzled, since she was
taught in the training school that she could look up to dreams?”
the Medical Officer Incharge, in case of any trouble. She * RUPASHRI SINHA, is a research officer at the Foundation for
soon found out the reason for the doctor’s inertia. He had
Research in Community Health.
(contd from p. 3)

Whether all this is a policy of statistical hope or despair
is a debatable point. The range of results appear to sug
gest that BCG is likely to give some degree of protection.
On the other hand, it is maintained that BCG is the only
available tool for prevention of TB in much of the world
today and that just a chance of protection is better than
no protection at all. Currently, India seeks to locate a BCG
strain more compatible to the indigenous make up of its
inhabitants. It is almost a certainty however that beneficial
effects will never be 100% either with BCG or any other
vaccine. The cause offailure to some extent is technical,
otherwise it lies chiefly in poverty, ignorance and errors.
Where benefits of vaccination are marginal and their
source ambiguous, a country with fragile economic
resources is justified in asking-at what cost BCG vaccina
tion. To invest extravagantly in dubious immunization
programmes either self-made or foisted is loss enough.
To divert precious resources towards these from more
tested and obvious measures such as general betterment
of health through sociQ-economic uplift borders on
foolishness on part of our policy planners. The lessons
from BCG are clear. Do we have the wisdom to grasp
them?

culosis. Prediction through skin testing with protein
derivatives of tubercule bacilli-cultures (PPD) is reportedly
proven to be misleading: even so it is extensively used as
a surrogate measure of immunity in several ongoing
leprosy vaccine trials. The fact is that till today we have
no test-tube measurement of protective immunity.
Despite the continued uncertainty, BCG has been us
ed increasingly widely throughout the world, its use be
ing expounded incessantly by'the Expanded Programme
of Immunisation conducted by the WHO. More recent
ly, the scope of prevention by BCG has been widened to
include leprosy because of the similarities in the etiological
agents of these two diseases. Astonishingly, protection to
leprosy via BCG is more consistent than protection against
tuberculosis. Moreover future third generation vaccines
aim to protect against several tropical diseases by introduc
ing so-called “protective” genes of organisms in BCG
which will serve as a vehicle.
Dissemination of this message of vaccination has been
excessively effective.and therefore also counterproductive.
It has left health personnel at all levels, let alone the
layman, so mesmerized, that they can see no alternative
to vaccines in disease control programmes. To dissent from
this view is to be considered a victim of delusion.

* NERGES MISTRY, an immunologist, is a senior research officer at
the Foundation for Medical Research.

7

Books
Book Reviews
Manish Mankad*
1. Maiti Asok Kumar (Dr.), “Rural Profile: Halting
Change in Mode of Production: A Study of the Com
prehensive Area Development Strategy’—New Delhi:
Intel India publications, 1987, p. 249; Rs. 190/-.
The main objective of this micro study is to examine
some social and economic consequences of the Com
prehensive Area Development Strategy in the rural
backwaters of West Bengal. A wide range of social,
economic, ecological and agro-economic information col
lected in bench-mark survey (1975) before the corpora
tion started working and in our re-surveys in 1980 and
1981, after five years of experimentations were examined
to analyse the “forces” and “relations” of production and
to evaluate the efficiency of the strategy. In the light of
this examination, this study seeks to indicate the future
scope of the strategy aimed at the removal of poverty,
unemployment and reduction of disparate
income-distribution.
2. Laws Priscilla, “X-rays: More Harm than Good?’—
Philadelphia: Rodale press, 1977, p. 248; Rs. 100/-.
Author, herself, an environmental activist, has written
this book after her consumer’s guide to x-rays, 1974 receiv
ed a great response.
This book was written in the hope that describing &
discussing the common problem encountered by x-ray
users will help others to avoid some of the pit falls, and
to understand and evaluate currently accepted x-ray prac
tices. It offers an unbiased consideration of the problems
associated with the use of diagnostic x-rays, from the
perspectives of both patients and health care professionals
in the broader context of our moder health crisis.
* MANISH MANKAD, is the Documentation Officer with the
Foundation for Research in Community Health.

New Additions
1. Cutting Pauline, “Children of the Siege”—London:
Pan Books, 1988, p. 208.
2. Shakti, “Women: Self-help & Naturopathy”—
Bombay; Shakti, 1988, p. 69.
3. Kapoor D.P. (Dr.), “Kapoor’s- Family Medical
Guide”—Bombay: S.S. Publishers, 1988, p. 48.
4. Meghalaya Govt, of, “Census of India: 1981, series-14,
Maghalaya, General Population Tables and Primary
Census Abstract”—Meghalaya: Director of Census
Operations, 1988, p. 172.
5. McDonnell Kethleen (Ed.), “Adverse Effects: Women
and the Pharmaceutical Industry”—New Delhi:
Ashish Publishing, 1987, p. 206.
6. Jolly K.G., “Family Planning in India, 1969-84: A
District Level Study”—New Delhi: Hindustan
Publishing, 1986, p. 287.
7. Swaroop Satya, “Introduction of Health Statistics’—

Edinburgh: E & S Livingston Ltd., 1969 p. 343.
8. Flavin Christopher & Durning Alan B., “Building on
Success: the Age of Energy Efficiency’—Washington:
World Watch Institute, 1988, p. 74.
9. Sarkar R.L. & Lama Mahendra, “The Eastern
Himalayas: Environment & Economy”—New Delhi:
At ma Ram & Sons, 1986, p. 647.
10. Ford Foundation, “Action for Welfare and Awaken
ing in Rural Environment (Anubhav series)’—New
Delhi: Ford Foundation, 1988, p. 36.
Following publication are available at FRCH library.

1. “Health Status of Indian People'—Sonya Gill (Ed.), p. 225.
2. “Social Aspects of Leprosy'—Manish Gupta, Amar Jesani,
Ravi Duggal, p. 123, Rs. 35/-.
3. "Women’s Work. Fertility and Access to Health Care—
Manisha Gupte & Anita Borkar, p. 200. Rs. 20/-.

(contd from p. 6)

ing elsewhere. Patient is hooked on symptomatic treat
ment for a variable initial period. No X-ray or sputum
examination is done, because the patient loses his meagre
resources in these investigations. Anti-TB treatment is
started only on the basis of history and clinical examina
tion. Patient feels better in a few days. The‘doctor takes
the credit of “catching the disease in time, otherwise it
would turn into TB”. Patient feels lucky and relieved. He
is also saved from stigma, isolation and probable dismissal
from job. Patient stops the treatment when he feels bet
ter. It is also very expensive, especially with irrational
drugs like malts and tonic injections. Naturally, there is
no need to notify the disease which goes undiagnosed.
No word is spoken against superstitions about the disease.
A clever doctor knows that rituals and sacrifices, do not
seriously threaten a patient’s life. Patient comes back to
him eventually. Some doctors allow and even encourage
superstitions. These are just a few instances of malprac
tice but they have adversely affected the knowledge and
notions of the disease amongst people.
We ought to know that people will not follow the health
messages as there is a wide gap between health messages
and their reality. The content and the intent remaining
same, health education—however interesting and novel,
will not make a dent on people’s lives. But on the con
trary, “through a continuous persuasion, people are en
couraged to adopt attitudes and beliefs which create an
acceptance of the conditions in society and further create
an impression that these conditions are the result of their
own behaviour. Over a period of time, people come to
accept these myths unquestioningly and passively accept
illhealtn as an inevitable part of their lives”. (Taking Sides).
In the absence of people’s health movement, we do not
expect a different picture inspite of the health—education
as it exists in its present form today.
* MOHAN DESHPANDE, a medical doctor, is a research officer at
the Foundation for Research in Community Health.

Edited by Anita Borkar with the co-operation of Manish Mankad and secretarial assistance from Anuradha Naik. Produced by the Foundation
for Research in Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay-400 018, registered under the Bombay Public Trust Act, Printed
by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.

WSLETTE
September - December, 1988

Vol. 2

No. 5

High Technology in Medicine
In this issue, eminent members of the medical profes
sion have expressed their thoughts on the controversial
subject which generally goes under the term of High
Technology in medicine. While High Technology is com
monly equated with the glamorous and much publicised
latest expensive dramatic innovations, whether it be equip
ment like CT or MRI scanners or operations like coronary
artery bypass or kidney transplantation, Dr. Sethi informs
us that this so called High Technology is seldom
synonymous with efficacy and certainly not with cost ef
fectiveness. The advent of simple, cheap, safe and highly
effective measures such as anti-turberculosis drugs like
streptomycin and rifampicin has not only permitted the
vast majority of tuberculosis patients to be treated on a
domiciliary basis eliminating the need for prolonged
sanatorium treatment, but has also eliminated the need
for major surgical intervention like thoracoplasty and lung
resection at one time considered as the latest High
Technology. If detected early and with proper compliance,
diseases like tuberculosis, leprosy and malaria can be
readily cured and the disease controlled. Immunization
at a cost of Rs. 17/- per child can also prevent the mor
bidity and mortality from most of the prevailing
childhood diseases like tetanus, whooping cough, diptheria or poliomyelitis. Likewise home made oral rehydra
tion therapy can vastly reduce the toll of annual lives from
gastroenteritis. If effectiveness and cost are the chief con
siderations then these and a host of many similar examples
are surely the outstanding high technologies of today
which if properly utilised could transform the health status
of our entire nation even under the existing appalling
social and economic conditions which are the causes of
the majority of the killing and maiming diseases that af
fect our people today.
Instead of reaching this cheap and effective high
technology to our people, the major emphasis as well as
the medical manpower and financial resources have been
diverted to the glamorous but extremely low cost-effective
technologies imported from the affluent countries. Those
countries have solved most of the problems that are still
our major health hazards. Even in affluent countries it
is questionable whether prolongation of life ‘at any cost’
using expensive technology is justifiable among the ag
ed, when the quality of resulting life is often a vegetative
existence. Even in these countries the exponentially in
creasing cost of such ‘High Technologies’ is now under
question. Instead low cost, more effective methods like
prevention of smoking, healthier diet and pollution con
trol are preferred to uncontrolled expenditure on the treat

ment of cancer or heart disease.
Why then the rapidly increasing trend for adopting
these low cost-effective technologies in a country where
the major disease pattern is eminently suitable for cheap
low cost yet highly effective technologies which are readily
available to us? The answer lies in many factors that work
for the former and against the latter. The introduction
of technologies is initially determined by the medical pro
fession which looks to the West for all new ideas and in
novation like the rest of our elite. They are unaware, or
deliberately choose to ignore the problems of the majori
ty of our people who live in rural areas or even in the ad
jacent urban slums. Having adopted the expensive Western
habits and lifestyle, it is more conducive for them to cater
to tne small affluent section of the urban society than to
the poor masses. The small segment of our society which
has the capacity to pay for service suffers more from the
diseases of the West like cancer, heart diseases and stroke.
The mass media which caters to their tastes has with the
help of the medical profession succeeded in dramatising
developments of medicine in the West and thus creating
a demand: unfortunately neither the cost, the dangers,
nor the poor long term results which are published in
reputable international scientific journals are conveyed to
the uncritical audience. They are not informed that 20 to
40 per cent of the vessels dilated by coronary angioplasty
will reocclude within four to six months (New England
Journal of Medicine, 22 September, 1988) and that a ma
jor epidemiological evaluation of cancer by the National
Institutes of Health in the USA has revealed that except
in a few rare cancers of childhood there has been no
significant increase in survival in the past two decades
despite the expenditure of billions of dollars in research
and treatment (Blair III J.C and Smith E.M., “Progress
against Cancer”,-New England Journal of Medicine, 8
May, 1986). Information is seldom provided to the lay
public on simple and cheap remedies as this is not
newsworthy nor on the dangers of overinvestigation like
excessive exposure to x-rays, overuse of vitamins and an
tibiotics or of dangerous drugs like EP forte banned in
other countries. All this tends to create a false impres
sion that modern medicine is necessarily High Tech and
expensive. This is fostered not only by the medical pro
fession but also by the other beneficiaries viz. the phar
maceutical and instrumentation industry.
The Sree Chitra Tirunal Centre for Science and
Technology, Trivandrum, a centre of excellence in cardiac
surgery has demonstrated that even coronary bypass
surgery can be undertaken at much lower cost than in the

FOR PRIVATE CIRCULATION ONLY

private sector. Their indigenous development of the car
diac pump and heart valves has greatly reduced the cost
of open heart surgery. It is unfortunate that this is not
emulated or even appreciated by the professionals in other
centres who insist on imported equipment.
Costly sophisticated equipment often lies unutilised for
lack of servicing and spare parts and is improperly used
because of lack of trained manpower. There is also temp
tation to overutilise expensive equipment, especially in the
private sector, to recover the cost of the investment and
earn profit. ‘Unnecessary reference’ and ‘kickbacks’ are
common knowledge with investigations like CT scan in
private diagnostic centres. Another unfortunate example
is when terminally ill and aged patients are kept alive by
artificial measures.
The exercise in the latest expensive imported technology
is not only restricted to the private sector; this has set a
trend which is copied by the public sector in the medical
college hospitals diverting the meagre public health
resources from cheap and effective, preventive, promotive
and curative health services which would serve the needs
of the masses. This also inculcates wrong values in the
education of doctors for the needs of our country.
Technologies like CT scan, lithotripsy or kidney dialysis
and transplantation has created moral and ethical pro
blems for those who cannot afford them but who never
theless will go into massive debt to provide these for their
near and dear ones. There is no limit to the consumer
demand that can be generated by “pushing” these
technologies as well as drugs in an area where consumer
resistance is at its lowest. It has also led to unscrupulous
practises in obtaining donor kidneys from the poor for
the rich; this has been well documented in the medical
as well as the lay press (Bombay, November 22-December 6,
1987).

The small Westernised affluent section of our society
demands that the latest technologies must be available for
their benefit regardless of the cost. The medical profes
sion which also belongs and caters to this minority is more
than willing to oblige, as this provides them kudos as well
as a highly lucrative source of income. Who then must
decide the appropriateness of technology for the need of
our people as a whole under the existing financial
restraints of our country’s economy? This should be the
task of those who have been elected by the people as well
as of the bureaucracy who are paid to look after their
interests.
Unfortunately, even our highest elected leaders and of
fice bearers from the Presidents to the Chief Ministers are
themselves responsible for distortion of the health scene
because while paying pious lip service to the improvement
of the health of our people, and especially of the under
privileged, they are willing accomplices of those who wish
to promote inappropriate technology. It is they who lend
their support by inaugurating expensive private medical
institutions and equipments which service their needs; and
even here while they proudly acclaim that these institu
tions and their doctors are next to none in the world, when
it comes to their own treatment they have no hesitation
in going abroad utilising the scarce resources of our poor
country and its precious foreign exchange. How can
elected people’s representatives who misuse our public
resources prevent the enormous drain of our country’s
wealth by the rich in the name of Health for All by 2000
AD? It is time the people themselves were made aware
of this, for only they can decide as to how they can best
protect their own health and interests.
* N.H. ANTIA, FRCS, FACS (Hon.). Director, Foundation for Research
in Community Health, Bombay.

Privatisation and New Medical Technology
Ravi Duggal
*

Defining Privatisation

centres has been a dominant trend globally since the late
seventies. This is increasing in India at a very fast pace.
(4) Strengthening the Private Sector: This form of
privatisation is the historically dominant form. Its main
characteristic is that public resources are used for the
development of the private sector-the public sector pro
vides the inputs (medical education, soft loans, tax con
cession, etc.,.) and the profits are appropriated by the
private sector from the population.
There is also another emergent trend, which however
cannot be labelled as privatisation. The trend is one of
corporate control of the health sector. This has been aided
largely by the new medical technology and more efficient
forms of administration and management which has made
the operation of private health services more profitable.
One may call this process "corporatisation".

Privatisation does not mean only the existence or the
growing of the private sector. It refers to a relationship
of the private sector with the public sector. Thus privatisa
tion is a process. It is a process that has been going on
for a long time and has accelerated in recent years due
to certain developments in the health sector globally.
Privatisation may be best expalined through the forms
it takes.
(1) Divestiture (transfer of ownership): This involves the
selling out of public provision to the private sector.
Isolated cases of such privatisation may be cited from the
past but this form of privatisation is still in an infantile
stage in India, but it could become a major trend in the
coming years.
(2) Contracting: This is a very common form of privati
sation that exists globally. Certain hospital functions, con
struction activity, purchasing, programme implementa
tion, management, leasing out for a short period, etc., are
the common types of this form of privatisation which is
rampant in India even in the health sector.
(3) Source of income: Privatising the source of income,
like "fee-for-services" in public hospitals and health

Relationship Between New Medical
Technology (NMT) and Privatisation
The new high technology medicine along with more efficient managerial and administrative methods is accelerating the process of privatisation.
(Contd. on p.12)

2

0)

Humane Technology Needed
P.K. Sethi*

pensive, and socially just health care.
The often-cited spectacular advances in medicine, in
cluding organ transplants, coronary bypass surgery, and
joint replacement surgery, really stem from the fact that
we have not understood the basic causal mechanisms of
most diseases. We do not know why kidneys fail, why cor
onary arteries get choked, what causes rheumatoid ar
thritis, or why cancer occurs. We deal with effects rather
than causes and so we resort to some very expensive
technical interventions that can be likened to fire-fighting.
If we understood the basic causes, the expansive methods
would not be needed.
How then can one label such interventions as hightechnology medicine? It is true that the instruments and
machines employed may incorporate some of the latest
developments in applied engineering, but they do not
unravel the. mysteries of disease. We tend to equate ex
pensive instrumentation with high-science medicine. I
would categorise such interventions as using halfway
technology, not high technology.
True high-technology medicine, to my way of thinking,
is that in which the basic disease processes have been
unravelled. Treatment then quickly becomes simple, in
expensive and effective. The treatment of some vitamin
deficiency diseases, common endocrinal disorders, and a
limited number of bacterial infections are cases in point.
History will show that these examples truly represent the
great achievements of modern medicine.
Let us distinguish, therefore, between halfway tech
nology and high-science medicine. The former is impres
sive but expensive and does nothing to the disease pro
cess perse; the latter is disarmingly simple, much less ex
pensive, and directly affects the disease.
Of course, a lot of expense may be incurred in research
wprk that ultimately leads to the tackling of disease
mechanisms in a fundamental way. Modern research is not
cheap but this is where scarce resources should be used.
The crucial instrument needed for such work is an incisive
intellect capable of asking the right questions. What we
need to support and encourage is the creation of an en
vironment where pointed questions can be raised fearlessly
without the risk of being smothered by powerful lobbies
representing the interests of the medical-industrial
complex.
It has been repeated ad nauseam that there is a very
intimate relationship between technology and society, each
influencing the other. What is often overlooked, however,
is the stratified societal structure of developing countries
with an upper 10% consisting of the urban affluent class
and a lower 90% of poor urban and rural people. The
former wield political power and are the decision-makers;
the latter are often treated as if they do not matter.
The upper 10%, many of whom have adopted the life
style, culture and value systems of the West, look to the
advanced countries and want their own countries to have
the same kinds of medical facilities as are available there.
Being the decision-makers, they control the technology
filter (1) that allows only their needs to be referred to

I always feel a little uneasy when it is claimed that
modern medicine has achieved a high-technology status
and that, if all countries could spare more money and
manpower for health care, the benefits of high technology
would reach everyone. It seems to me that the use of ex
pensive and complicated gadgetry in medicine is being
confused with sophistication and good science. The com
mon assumption that modern medicine possesses a high
scientific content can, with good reason, be questioned.
It was only comparatively recently, perhaps during the last
century, that a scientific approach to medicine was
adopted; this has undoubtedly resulted in some quite
remarkable achievements. However, I suspect that some
of them have thrown us off balance and that we have
become not only rather proud but also disdainful towards
traditional healing practices.
While I hold no particular brief for traditional
5 medicine, I am quite clear that, by and large, most
medicine, even as practised in the affluent societies of the
West, remains largely empirical. The facade of modern
medicine tends to overwhelm us; the inner content has
so far remained rather weak and tentative. What family
doctors were supposed to do in the past with very little
technological back-up, modern hospitals are attempting
to do by making use of ever more impressive-looking
gadgetry. This has resulted in very expensive health care.
It does not require much insight to realise that the replace
ment of a simple mercury manometer with an electronic
digital display system in no way improves our understan
ding of disease or even the accuracy of our technical
interventions.
It is rather humbling to realise that some of the most
valuable components in the art of healing remain
nontechnological; one hopes that they will continue to be
so. This is what Professor Attinger identifies as the sup
portive role that healers have always been called upon to
fulfill. It is what providing comfort and reassurance is all
about. The actual methodology used has little to do with
) the causal mechanisms of disease. Some may argue that
this role perpetuates superstition and often obstructs pro
gress but it cannot be denied that it is none the less a very
important and necessary function of medicine. Call it the
placebo effect if you like, or invoke the induction of en
dorphins to explain and legitimise its success in painful
situations, but its value cannot be denied. In fact, a lot
of research in medicine ultimately leads to explanations
of practices which our forerunners found useful, mainly
as a result of accurate observation and correlation.
It is in this context that one has to understand and
respect the beliefs and cultures of diverse societies and
not reject traditional healing methods as outright
quackery. It seems unreasonable to force the belief system
of Western society on to other societies with very different,
but in no sense inferior, belief systems. Honest heart
searching is necessary by advocates of modern institu
tional health care. How much of their success depends
on totally nontechnological interventions with dubious
scientific foundations? Once the intellectual cobwebs are
removed, restructuring can lead to more humane, less ex

(Contd. on pJl)

3

Technology in the Service of Indian Patients
M.S. Valiathan*

What distinguishes the twentieth century practice of
medicine from that of earlier centuries is its growing
dominance by technology. Technology has cast its mantle
not only of medical superspecialities but also on the prac
tice of medicine at the village level. The fact is that no
branch of modern medicine, urban or rural, can dispense
with technology today. No one would deny that a rural
dispensary would or should have a blood pressure ap
paratus and a supply of disposable devices such as
crystalloid packs, syringes and needles, gloves and urinary
catheter. These and many other items are the product of
technology which has more to it than meets the eye. The
design and development of a reliable and durable blood
pressure apparatus which a dispensary needs is as difficult
as the design and development of disposal syringes and
urinary catheters. As we go further, we would discover
that the problem of design and development are a mere
fraction of the challenge of manufacturing these articles
without sacrificing their quality or escalating the price.
The demand in India for medical devices of all kinds,
ranging from simple disposable syringes to complex
pacemakers, has already crossed Rs. 350 crores and is ex
pected to reach a staggering figure of Rs 1,000 crores by
2000 AD when the Indian population will exceed 900
million. This is a distributing prospect from the point of
view of what is not happening in India in the field of
research, development and manufacture of medical
devices today.
. While the rural sector in medicine is much larger and
much less supported than the urban sector in our coun
try, it is clear that neither can be ignored by the health
planner. Whereas the rural sector must be provided with
basic health care needs at the primary level, one can hardly
dismiss the health care demands of a steadily growing and
vocal middle class who are admittedly a minority. How
ever, as Dr. Gopalan has pointed out ‘a minority of even
just five per cent means over 40 million people’ in India!
Therefore a survey of the demand for medical devices in
the country must take a total view of all societal needs
and speciality requirements.

Table 1: Market Survey for Medical Devices
Field of Application

Vascular Surgery
Nephrology
Orthopedics .
Cardiology & Cardiothoracic Surgery
Ophthalmology
Anaesthesiolo gy
Transfusion Devices
Dental
Devices for general use
TOTAL

Cost of the An
nual consump
tion of devices
(in lakhs)

30.0
65.0
224.0
541.2
824.4
1000.0
5060.0
12360.0
14415.0

34539.6

The global demand for medical devices according to
American estimates was reckoned to exceed three billion
dollars a few year ago. As the Indian demand was
unknown, Sree Chitra Tirunal Institute, Trivandrum con
ducted a survey in 1985 on the basis of information ob
tained from teaching and non-teaching hospitals, medical
and surgical specialists, trade organisations, published
literature and a questionnaire. The survey was urban
oriented but did not altogether leave out the demands of
the rural sector for dental materials, catheters and many
other items. A summary of the findings of the survey is
given in Table 1 which speaks for itself. It is true that a
variable proportion of the demand is currently unmet
simply because the products are too expensive for the pa
tients and hospitals. If a Foley catheter costs Rs. 45, a
bottle of dental filling material Rs. 370 and a box of
surgical sutures Rs. 200, it is not surprising that they re
main beyond the reach of many institutions. The high cost g
of medical devices is a direct result of our policy of •
meeting the demand by imports or by the production of
items under licence. The negative consequences of this
policy are many and they will continue to multiply. In the
first place, it will oblige us to pay hundreds of crores in
hard currency for the import of devices and technology
and limit their benefits to the affluent among our patients.
Secondly it will ensure that our payments will support the
research development effort for biomaterials and devices
in Western countries and Japan. Thirdly it will act as a
soporific for our scientific and industrial communities
who would feel no compulsion to harness their capabilities
for the indigenous development and production of bioma
terials and medical devices.
Medical technology goes beyond biomaterials and
medical devices and covers instrumentation which is a vast
field in itself. Medical devices range from humble
disposables such as catheters, syringes and plastic bags
to complex disposables such as oxygenators. They also in
clude surgical implants for every speciality, heart valve,
hip prosthesis and hydrocephalus shunts being prominent •))
examples. Similarly instrumentation ranges from
sphygmomanometers and portable ECG machines to
highly complex CT Scanners. A policy on the develop
ment and production of medical devices and instruments
has been crying out to be made and implemented because
the present conditions are highly unsatisfactory. The
policy must identify the categories of devices and in
struments which should be developed on the basis of large
scale or day to day needs and indicate those which are
infrequently needed and could be left for imports. The
strategy for development must operate at three levels to
enfranchise the talent which undoubtedly exist at the col
legiate, professional and industrial levels. At the primary
level, medical and engineering colleges can and should
conduct research jointly on a wide variety of basic
problems in relation to devices and instrumentation
technology which will work to their mutual benefit and
the advancement of medical technology. The strength of
biological materials, adaptation of biological form and
(Contd. on p.11)

4

X-rays: More Harm Than Good?
S.G. Kabra*

It is plain to even the most casual observer that
“Diagnostic Clinics” or “X-ray Clinics” pepper the streets
of urban, and a good deal of semi-urban India. More
often than not, these clinics are independent of hospitals
and have made X-ray facilities as readily available as
photocopying services. From an estimated 10,400 units in
1975, the number now exceeds 30,000, according to a
report of the Bhabha Atomic Research Centre (BARC).
It is estimated that about 9 crore persons are X-rayed in
our country, every year, out of which 5 crore are less than
30 years of age. This proliferation of X-ray services is apt
to be regarded as “a sign of progress” and public
awareness of X-ray is such that an X-ray examination of
fers a tremendous psychological boost to a patient much
the same way as an injection would.
What is not generally known is that diagnostic X-rays
today constitute, as a whole, the biggest man-made source
• of ionising radiation, whose potential for harm equals that
of ionising radiation emanating from a nuclear explosion.
Judiciously and safely used X-rays are, of course, of im
mense value in modern medicine. Used otherwise, X-rays
cause more harm than good not only to patients, but also
the public at large and their future generations. Ionising
radiation in any form and in any dose increases the risk,
in exposed persons, of developing cancer and their pro
geny of being born malformed.

ionising radiations envisaged in the Atomic Energy Act
1962.
The status of radiological protection in small hospitals
and clinics that constitute 95 Vo of the total diagnostic
units in the country “is so poor that most of the excessive
exposure cases are reported from them” says the survey
report of the DRP. The causes of excessive exposures
detected are improper layout of these installation (85 Vo
of the small hospitals and clinics surveyed and 60% of
the large hospitals), and lack of protection measures in
25 Vo to 90 Vo of the small units.
The reports says: “in short, the unawareness of radia
tion hazards, inadequate plan of installation, poor per
formance standards of the equipment, lack of necessary
protective devices, and above all a commercialisation of
the use of X-rays for medical diagnosis and consequent
indiscriminate use” are some of the major factors to un
wanted exposures.
The results of the prevalent improper use of diagnostic
X- rays are:.
1. Excessive radiation dose to the individual to be
X-rayed.
2. Radiation of parts of the body other than those re
quired to be exposed to X-rays.
3. Radiation to persons other than the patient.
The “WHO Manual of Radiation Protection in
Hospitals and General Practice” prescribes clear-cut
guidelines for X-ray personnel which have also been
prescribed by the AERB in its safety booklet for
diagnostic X-ray units (AERB Code No:SC/MED-2, Safe
ty Code for Medical Diagnostic X-ray Equipment and In
stallations). These safety measures are almost universal
ly ignored in India. Though the flouting of these basic
safety norms is so open and obvious, it is most unfor
tunate that it does not attract the attention of the health
authorities.

The Division of Radiological Protection (DRP), of
BARC, entrusted with the task of surveying X-ray units
in the country to detect, and advice about, radiation
hazards, found it impossible to keep up with the explosive
increase in the number of these units. Though started in
1957, DRP had, till 1976, surveyed only 9% i.e. 946, of
the estimated 10,400 X-ray units in existence at that time.
The situation has only worsened over the years.
The Atomic Energy Regulatory Board (AERB) con
stituted by the Government of India in November 1983
. is now entrusted with the responsibility of developing and
• implementing appropriate regulatory measures aimed at
ensuring radiation safety in all applications involving

* DR. S.G. KABRA is the Director-Research, Santokba Durlabhji
Memorial Hospital, Jaipur.
(Abrigded version of the article “Beware of X-Rays", SDMH Journal,
Vol. 11(4) pp. 249-54. Reproduced with the permission of the author.)

In the Electromedical field, 86/87 has been a successful
year with a 55% growth in turnover over the last year,
a major portion of the growth coming from exports. The
Division got a prestigious order for installation of a
CAT—Scanner, a Catheterisation Laboratory, and Gama
Camera at the Bir Hospital, Kathmandu. For the first time
in the country the Division has installed a new product
for crushing kidney stones with the success rate of 85%
through extra-corporeal shock waves called LITHOSTAR.
This has already started treating patients with kidney
stones. The Division also installed sophisticated Bi-plane
Angiography with digital subtraction angiography, CAT—
Scanner and Gama Camera at Batra Hospital, New Delhi,
which was inaugurated by our Hon. Prime Minister.
Thanks to the emphasis laid on health in recent Govern
ment budgets, the business prospectsfor this Division will
continue to be good.

TECHNOLOGY An association of methods,
techniques and equipment together with the
people using them.
APPROPRIATE HEALTH TECHNOLOGY
Technology that is scientifically sound, adap
table to local needs, acceptable to those who
apply it and to those for whom it is used, and
that can be maintained by the people themselves
in keeping with the principle of self-reliance
with resources the community and country can
afford.
Adapted from the Alma-Ata Report on Primary
Health Care (from the Seventh general pro
gramme of work covering the period 1984-1989,
Health for All Series, No. 8, 1982).

Source*. Siemens Annual Report, 1986-87.

Source: World Health Forum Vol. 8 1987.

Medical Engineering

5

Tragedy in Transplantation
.lerges ..
Mistry *

P, a 23 year old harijan girl suffered from chronic renal
failure for a period of three years. By virtue of familial
connections, she was maintained on hemodialysis at a
leading private hospital in the city by Dr T. whom she
came to like and depend on. As her condition deteriorated
the frequency and duration of the dialysis sessions increas
ed bringing in its wake several complications. It was in
early 1988 that Dr. T first suggested the possibility of P
undergoing renal transplantation. Because of a modicum
of education, P was aware of the cost this would entail,
both to herself and her family and was initially reluctant.
It was then that Dr. T informed her that she had little
choice since her dialysis would be stopped from mid 1988.
The will to live, the pressures of a fiancee and the terror
of her condition if dialysis was stopped made her agree
to undergo renal transplantation.
Her large coterie of brothers and sisters vehemently
refused to test themselves as donors, despite persuasion.
Faced with the task of finding a donor for herself, P took
account of her financial burden. Along with the im
munosuppressants that would have to cover her for a post
operative period of one year, the total wavered at an im
pressive sum of Rs. 75,000-1,00,000. An agent, supposedly
vetted by Dr. T, materialised and informed her that the
donor which he would procure would have to be paid at
least a sum of Rs. 40,000. The agent also assured her that
his part of the fees would be a paltry sum of Rs. 3-4000.
The hospital authorities were also quick to notify her that
she would have to bear the charges of private day and
night nursing a month after the procedure. And after she
was discharged she would have to reside in the premises
of a recuperation sanatorium at the rent of approximately
Rs. 300 a month.
For a girl whose life vacillated between ‘home’ under
a building staircase and the dialysis room, life became ar
duous. A session of dialysis was often followed by trudg

ing long hours through town armed with addresses of
Trusts, Institutions, Service Clubs and individuals. Each
day the arrival of the postman was a momentous event
rocketing to hope and a rosy future or abject despair.
Some did not even reply, others were sympathetic but
unhelpful-the chief cause being that they could not aid
cases where the donor was extrafamilial. On that
knowledge a leading nephrologist who had offered to help
out with the supply of immunosuppressants also suddenly
withdrew his offer. Some aid was however obtained and
the end of the summer left P with a sum of approximately
Rs. 40,000.
With no thought given to the gaping deficit, the doctor
went ahead with his efforts to seek a donor. P was here
after hospitalised. Tissue typing was performed and the
agent forthwith found a donor who was for reasons
unknown, not selected.
A month later a second donor, a man of about 30 years .
of age was earmarked and admitted for investigations. •
With a probability of a tissue match less than 1:500, it
appeared astonishing that he shared a partial match with
P. The acid test of cross-matching was performed thrice.
At the first instance it appeared to be a failure. P was told
by the hospital staff that it did not work because her blood
was too ‘hot’ probably due to her ‘intemperate diet’. After
the third try however he was declared to be a suitable
donor. The cost of his investigations, his hospital stay and
medications were also laid additionally at P’s door.
P was worried about the funding. The funds collected
would be totally decimated after the procedure, leaving
nothing for post operative medication. Moreover, the
agent’s patience appeared to be running out. Pressuris
ing for payment was resorted to almost daily. Being ap
praised of P’s condition, a reputed doctor belonging to
the same hospital strongly advised against her undergoing
(Contd. on p.7)

Unrelated Living Donor Kidney Transplantation
B . N Colabawala*

Advances in medical technology always generate im
pacts on societal structure and its ethical values. To ig
nore this interaction between society as a whole and the
part of it constituted by the medical profession, would
be intellectual dishonesty. The evolution of kidney
transplantation programmes in our country is one such
example today.
The social, economic and moral impacts of kidney
transplantation programmes are perhaps not fully ap
preciated. To sustain such programmes the medical pro
fession needs the help of society in various facets such
as economic, social reorientation of attitudes, legislation,
rehabiliation of patients and many other areas. The pro
fessionals therefore duly obliged to society to set norms
and standards which can be acceptable within the ethical
values of society.
Ethical and other issues will always be there even in
areas of living related or cadaver kidney transplantation
programmes; but they are reasonably amenable to com
promise. On the other hand the onset of unrelated living

0)

donor transplants with its abhorrent aspect of “sale of
human organs” poses a different set of ethical values. The
fundamental issue in these unrelated living donor
transplants is whether society is prepared—or should—
condone this commercialisation and trafficking in human
organs. The process is medicated by unscrupulous brokers
and agents. The donors are picked up from the
economically weaker and educationally lacking sectors of
society. They are lured by the offer of Rs. 20,000 to
40,000/- for the sale of one of their kidneys. It is more
doubtful if he has given well informed and uncoerced con
sent. Do his family members know about the procedure
and do they agree? Does the kidney go to the best match
ed recipient or to the highest bidder? Is a long term follow
up of such donors maintained? Is there a possibility of
subsequent blackmail by the donor or his family?
Organisations and societies concerned with transplan
tation all over the world have condemned such transplants
(Contd. on p.7)

6

Opportunity Costs of High-Tech Medical Diagnostic Equipment
Ramesh Awasthi
The costs of most of the modern diagnostic equipments
like Computed Axial Tomography (CAT) scanner or
whole body scanner run into several millions of rupees.
The total investment with all the establishment that goes
with these high-tech machines such as the special building,
shielding and air conditioning is even greater.
When we go in for high-tech diagnostic equipment we
never consider the opportunity costs, i.e. to what alter
native uses the same money be put and what arc the
returns. A small exercise of comparing opportunity costs
reveals startling results.
Let us consider a base of 10 million investment in a hightech medical equipment such as CAT scanner and
calculate the expected turnover per year:

Rupees
(in thousands)
Depreciation @ 10%
Interest on capital @ 15%
Maintenance @ 5%
Operating personnel
Running costs
Other overhead expenses
Total costs
Profits on investment @ 25%
Total turnover per year

In order to consider the alternatie uses of an annual ex
penditure of Rs. 6 millions in other fields of health care
we have examined the Performance Budget of the Govt.
of Maharashtra, 1988-89.

Comparison Table
For an annual expenditure of Rs. 6 million:
CAT Scan Primary
Health
Centre
No. of patients
diagnosed
No. of patients treated

Rural
Hospital

4,000

25,000

40,000

*
Nil

20,000

40,000

* The CAT Scan is only for diagnostic purposes and has no
therapeutic use.

Alternatively, an annual budget of Rs. 6 million can
provide:

10,00
15,00
5,00
1,00
3,00
1,00
35,00
25,00
60,00

Basic medicine requirement of
77 Primary Health Centres, including
462 Subcentres and
2310 Health Guides covering 2.3 million population.
Source: 1. Performance Budget, Dept. of Health & Family Welfare Govt.
of Maharashtra, 1988-89.
2. NGOs in Rural Health Care, Vol. One: An Overview. Amar
Jesani, Manisha Gupte and Ravi Duggal.; FRCH; 1986.

Average charge per patient = Rs. 1,500.
Number of patients to cover costs—4,000 per year.

* DR. RAMESH AWASTHI is the Senior Research Officer at the Foun
dation for Research in Community Health, Bombay.

(Contd. from p.6)

(Contd. from p.6)

the transplant. Visits to other leading doctors for solutions/help were fruitless. Legal or ethical viewpoints did
little to ease P’s predicament.
For P, it was now the point of no return-she was com
mitted to undergo the transplant with her life. It finally
took place.
The isolation area where she was placed would have
done bedlam proud. Worse, the transplanted kidney
started showing signs of rejection after an uneventful
period of 3 weeks. The small stock of oral immunosup
pressants provided by the hospital became superfluous.
Injections of Cyclosporin A, worth Rs. 1,000 had to
be injected every 2 days. For those who cared for her,
getting sufficient injections became a race against time.
Over the next month or so, P’s condition sporadically
deteriorated to such an extent that even Cyclosporin was
stopped. Approximately five weeks later a second surgical
procedure was done and the rejected necrosed kidney
removed. The end seemed only a matter of time, never
theless for the next 5-6 weeks dialysis was performed
almost round the clock. About 3 months after the
transplantation, P breathed her last; sans life, sans hope,
sans everything.'

and some countries have laws prohibiting them. The pro
tagonist of such programmes in our country offer very
facile arguments to suit their purpose. It is argued that
an individual is free to donate his kidney and why should
society interfere. But the freedom of an individual to act
as he likes is always circumscribed by the needs of the
greater good and ethical values of society. They argue that
if a poor man earns some money thereby, what is the
harm? The question is, what does he do with that money?
In any case is our society reduced to such degradation that
the only way we can help a poor man is by asking him
to sell one of his organs? The final argument is that there
is shortage of kidneys for transplantation and hence why
not use whichever source we can to “save a life?”
It has been suggested that such transplants should be
allowed under strict supervision based on specific
guidelines and safeguards. The question is that in the cur
rent state of our morality who is going to form the
guidelines and who and how are we going to ensure the
safeguards.
It is true enough that both the profession and society
face this issue squarely, before the whole procedure goes
into the realms of criminalisation._________________

• DR. NERGES MISTRY is the Senior Research Officer at the Foun
dation for Medical Research, Bombay.

* DR. B.N. COLABAWALA is the Senior Urologist, Jaslok Hospital
and Hon. Secretary, Kidney Foundation of India.

7

Arogya Shikshan Kendra
FRCH involvement in community based health pro
grammes began with our first field based experiment at
Mandwa, a rural area in North Alibag, Maharashtra. This
primary health care project focussed on health education
as an important component to achieve its goals of health.
Based on this experience gained at Mandwa, a more detail
ed field action based Health Education Project was com
menced in April 1987, with two of our senior researchers,
Dr. Ramesh Awasthi arid Manisha Gupte setting up the
field office named Arogya Shikshan Kendra (ASK), at
village Malshiras in Purandar taluka, at Pune district. The
project area extend to 18 villages with a population of
30,000. The Indian Council of Medical Research (ICMR)
has sponsored this project for the next five years starting
from 1st January 1988.
During the first year the emphasis was mainly on col
lecting information through various base-lines surveys
and so far, the following eleven surveys were completed:

sons who dispense traditional medicines and/or con
duct rituals for health problems.
11 Survey of Balwadi Teachers:
The existing balwadis in the project area were con
tacted and all the balwadi teachers were interviewed
for their socio-economic background arid teaching
practices.

Other Activities
1 Training of TBAs:
In an effort to make an impact on the infant mortality
rate, monthly meetings of all the TBAs in the project
areas have been held wherein their experiences and
problems were discussed. Since June 1988, they have
started maintaining death and birth records of their
respective villages for ASK.
2 Starting of Balwadis:
—
The gram panchayats, Tarun Mandals and Mahila V )
Mandals were encouraged to start balwadis to facilitate
the monitoring of immunisation status, malnutrition
and other ailments of pre-school children as well as
the intellectual development of small children.
Balwadis have now started functioning in Pondhe,
Rise, Khopdewasti, Pise, Amble (Ramwadi) and
Vanpuri.
3 Training of Balwadi Teachers:
Balwadi teachers are now, being regularly trained in
the health care of children, innovative and informal
techniques of teaching.
4 School Health:
With a belief that school children can also, become
health conscious and can actively participate in the
management of their own health care, from June 1988,
a health education programme in schools was also
commenced .Th is programme has now been extended
to schools in eight other villages.
5 Ralegan Shindi and Prohibition:
Shri Anna Hazare who steered the development work
at Ralegan Shindi was invited by the village elders and
•
the Tarun Mandal. Anna Hazare came to Malshiras
and commended the efforts of the locals in the enforce
ment of prohibition. Since then, liquor has not been
sold in the village and this example has also been
followed by the neighbouring villages.
6 Tarun Mandal Guide:
It was found that misconceptions existed about the
procedures of registering a Tarun Mandal with the
Charity Commissioner due to lack of information. A
detailed guide in Marathi explaining the procedure of
registering a Mandal with cyclostyled copies of the re
quired application forms were prepared by ASK and
made available to aspiring youth groups.
7 Environmental Awareness:
During November 1987, ASK and Shri Bhuleshwar
Vidhyalaya (Malshiras) jointly organised an inter
school essay and poster competition on ‘Drought and
Trees’. Informative articles and documents on this issue
were cyclostyled and sent to all the schools in the 18
villages. This year, a survey of water resources in

1 Socio-Economic Survey of Balutedaar Families:
All the 685 Balutedaar families in the 18 villages were
covered in this survey.
2 Techno-Economic and Occupational Health survey of
artisan castes:
All artisan caste families in 18 villages have been
surveyed for their present technology, traditional links
as well as market relationships vis-a-vis' raw materials
and finished goods.
3 Women’s Work, Fertility and Access to Health Care:
This study conducted in two villages namely Mavdi
and Pondhe was sponsored by the Task Force on
Health of the National Commission on Self Employed
Women (And Women in the Unorganised Sector).
4 Child Birth and Child Death:
Every ever married woman has been surveyed in two
villages—Vanpuri and Tekavdi. Information has been
collected about morbidity, pregnancy, delivery, im
munisation and infant death.
5 Death and Birth Records:
Death and birth records maintained by the PHC and
Gram Panchayats for the last ten years have been
analysed.
6 Case Paper Analysis:
All case papers of Malshiras PHC for one full year
were studied.
7 Survey of TB Patients:
All TB patients on the records of the PHC were in
terviewed for their socio-economic background,
history of disease, its treatment and the changes occuring in their personal and social relationships
because of the disease.
8 Home Remedies:
Detailed information has been collected from women
about household remedies with regard to common
ailments like fever, cold and cough, diarrhoea and
other health problems.
9 Survey of Traditional Birth Attendants (TBAs):
Qualitative information has been collected on the
socio-economic background and delivery practices of
the TBAs in the project area.
10 Survey of Devrushis and Traditional Healers:
Extensive information has been collected about 25 per

6

8

supervision of Dr. Dwarkanath Lohia at ‘Manavlok',
Ambejogai, Dist. Beed.

Malshiras and Pondhe is being undertaken and a
display of exhibits as well as elocution and essay
writing contests are being organised on ‘Conservation
and Mangement of Water’. These programmes have
been sponsored by the Department of Environment,
Government of India.
8 Mahila Mandals:
The formation of Mahila Mandals have been encourag
ed so that through such regular contacts the health
of women and children can be improved. So far,
Mahila Mandals have been started in Vanpuri,
Waghpur and Malshiras village. Since March 1988, 50
to 60 women have regular weekly meetings in the
Gram Panchayat building at Malshiras. The Mahila
Mandal has discussed and acted upon many women’s
issues. The village leadership and the people of this
village have extended their full support to the Mahila
Mandal. A Working Committee was elected in May
1988. Women were motivated to open saving and
recurring deposit accounts with the bank and 55
women have opened their accounts with the bank.
9 Women’s Co-operative:
The Mahila Sahakari Udyog Mandal, a co-operative
economic activity has been started under the auspices
of the Malshiras Mahila Mandal with the land made
available by the village. NO RAD, the Norwegian
government’s agency for development has given the
grant-in-aid (for building, machinery and working
capital) to put up an industrial unit to prepare blankets
from raw wool which is locally available. The im
plementation of the project is in progress.
10 Training of women for the wool-project:
Training of women in every aspect of the economic
activity is essential if a women’s co-operative has to
be managed by women themselves. Hence three
women of the Mahila Mandal were sent for training
in wool processing, spinning and weaving under the

Future Programmes
During our work in the last one year cordial relations
have developed with various institutions like gram panchayats, the PHC, schools and banks and we have received
uninhibited co-operation from them in our work.
As per the requirements of the project, our work has
been extended to two other PHC areas namely Supa and
parinche. In Supa PHC area (Tal. Baramati) we shall be
working only through the health functionaries while the
Parinche PHC area (Tal. Purandar) will be the control
area.
Upon request from the Health Committee of the Pune
Zilla Pari shad, ASK has extended the health education
activities to 14 villages of Shirsufal PHC area, Baramati
taluka. In Malshiras PHC area, however the educational
activities will be enhanced with their content and extent
enriched further.
The main indicators chosen for evaluation of the health
education programme are as follows:
1 Ante Natal Care (ANC) Tetanus Toxoid (TT) immunisa
tion and self identification of high risk cases.
2 Supplementary feeding.
3 Immunisation of children (BCG, Polio, Triple (DPT)
and Measles).
4 Diarrhoeal deaths and deaths due to Lower Respiratory
Tract Infection (LRTI).
5 Tuberculosis incidence and regularity of treatment.
6 Utilisation of health services (curative and preventive).

Contact Address:
Manisha Gupte, Ramesh Awasthi
Arogya Shikshan Kendra,
At & Post: Malshiras,
Taluka: Purandar, District: Pune-4

Kas are Project
In an effort to find out whether such a similar self-help
process could be initiated and replicated, FRCH under
took this project at Kasare, a small village in Ahmednagar
district. This project is being initiated by a trained social
worker belonging to the same village.

The idea of Kasare Project originated from the socio
economic study of Ralegan Shindi undertaken by FRCH
in 1986-87. Ralegan Shindi, a small village in Parner
taluka of Ahmednagar district in Maharashtra is now
known as an ideal village, a model of rural development.
Special features of Ralegan's development have been its
local leadership, people’s participation in all development
programmes including voluntary offer of free labour
(Shramadaan) in the implementation of each project.
Moreover, the entire development effort has been taken
up without any significant funds from donor agencies;
the financial inputs have been from well-known govern
ment schemes which are also available to any other village.
This village, under the guidance of Anna Hazare, a village
elder, has paid special attention to the programmes of
reducing social and economic disparities in the village
society like removal of untouchability, community mar
riages, community lunch and special economic program
mes for Harijans. This process has laid the foundation
of all-ro.und development in Ralegan Shindi. The unified
drive of the village people themselves has brought about
the remarkable change in Ralegan over a short period of
ten years.

Mobilisation and Organisation

Development work based on Ralegan Shindi model
began in Kasare village from April 1987. The work was
initiated by holding regular discussions with the villagers
on the importance of various, features of Ralegan’s
development and motivating them for taking up similar
development effort in their own village.
Villagers from Kasare who are working and staying in
Bombay were motivated to get organised to contribute
towards the development of their village. A registered
society called the “Shree Biroba Gram Vikas .Society” was
founded by them. This enhanced the motivation of the
other villagers to make similar contributions for the cause
of development.
At the village level, a Central Village Advisory Com
mittee (CVAC) has been set up to inspire participation
9

of all people. In view of the critical importance of
women’s participation in all development activities, a
women’s group-Kalika Mahila Sangha’ has been organis
ed wherein all development schemes are discussed, deci
sions are taken and implementation reviewed. This group
contributes Rs. 28/- per month towards the running of
the public library in the village. They also run a chit-fund
scheme among the members and also supervise the func
tioning of the Balwadi.
The Balwadi has been reactivated with the joint col
laboration of the Tarun Mandal, CVAC and the Mahila
Mandal. Financial and other material support has also
been received from the parents and through donations.
Efforts are being made to organise a training camp for
Balwadi teachers from Kasare and other neighbouring
villages with the help of some institutions in Pune. After
reviewing the functioning of the primary school, dona
tions were raised to provide educational aids for the
school. Upon receipt of a grant of Rs. 12,000/- from the
Panchayat Samiti to construct additional class rooms, the
villagers unanimously decided to offer Shramadaan for
the required construction. An additional grant was also
sanctioned by the local MLA. Upon approval from the
villagers, a public library was started in the community
hall with contributions from the Gram Panchayat, local
individuals and organisations. A separate library room
is being constructed with financial help from the Biroba
society.

cows, pair of bullocks, bullock carts, oil-engines, af
forestation schemes and digging or deepening of wells are
also awaiting sanction. Two bore pumps have been set up
in two wadis (hamlets) of Kasare village with financial
assistance from the Social Centre and the full co opera
tion of the local residents. Both the bore pumps yielded
water and are in good condition. 35 women have been
motivated to install smokeless chulhas in their homes. Two
local potters have been trained by CASTFORD Pune, to
manufacture smokeless chulahs locally.

In Conclusion

The Ahmednagar based organisation called ‘Social
Centre’ also working in Kasare village, pays interest on
bank loans taken by people, lends it tractor free for land
leveling and also gives its oil-engines for irrigation pur
poses at a nominal rent. Thus, in every scheme sponsored
by this organisation, there always is an element of sub
sidy or free-gift to the people. This mode of development
has created a sort of dependence of the people on this
organisation. People look to every development pro
gramme as an opportunity to get some thing free and they
have started thinking that development by self-help or only
through government schemes is not possible.
It is a tough task to get people out of this dependence
syndrome and to bring them to accept the Ralegan model
of development by self-help. We are sure that committed
work with the people will bring about an attitudinal
change. Regarding the same, Anna Hazare also express
Economic Programmes
ed confidence that sooner or later people do not ap
During 1987, when the village was facing severe shor preciate the importance and dignity of self-help and start
tage of fodder, the Biroba society arranged for an interest participating whole-heartedly in the development efforts.
free loan of Rs. 10,000/- for a three year period and 5 per
In order to study to what extent an organisation could
sons were sanctioned loans for fodder cultivation. This create dependence among the people and how it affects
has helped the villagers in cultivating fodder as well as the development work, we have extended our work in two
in getting good quality jowar and bajra seeds at reasonable neighbouring villages where there has been no organised
prices. A sheep rearing programme sponsored by the development effort so far. At this stage, we are holding
Social Centre and a poultry scheme jointly sponsored by discussions with various sections of people to understand
the State Bank, the Panchayat Samiti and the Social Cen •the situation in these two villages.
tre have been undertaken by the Mahila Mandal. Sheds
The Kasare Project was initially supported from the
were prepared and 100 poultry birds were distributed to Ford Foundation’s general grant to FRCH. Presently the
each member. This scheme has succeeded in providing a “India Development Services” (IDS) has extended financial support to the Kasare Project for three years.
regular income to the women.
Several other loan proposals for the purchase of Jersey
Contact address: D.K. Panmand.

The World’s prescribing patterns

predicts that the success of generic preparations in
the United States will probably bring some changes
to the market: in 1984 their sale provided American
consumers with savings of about $ 236 m.

Between 1300 and 2500 million people out of a
world population of 5000 million have no regular
access to essential drugs. And according to the
World Health Organisation’s World Drug Situation
(1988), the immense inequality between north and
south has widened during the last decade: drug con
sumption has increased by an average of 9.6% each
year in the developed world and by 7.2% in the
developing world.
Leading therapeutic groups and products respond
to the needs of developed countries. In developing
countries there is little is litte effective demand for
the drugs that are most needed. (For example, H2
receptor antagonists were among the five leading
products in all the regions of the world in 1985.)
According to WHO, of the 500 new chemical en
tities marketed in the world between 1975 and 1984,
only 30 were real therapeutic advances. The report

Source: British Medical Journal, Vol 297, 30 July, 1988.

consumption

Developed countries

IS

sg Developing countries

g
•

(Contd. Jrom p. 4)

design to specific functions, matching of prosthetic
materials with tissues in terms of biomechanics, newer
methods to evaluate toxicology - the agenda for their joint
effort is endless. At the secondary level, surgeons and
engineers must interact with appropriate inputs from the
industry to create new devices and technologies such as
a Charnley prosthesis or a deBakey graft which improve
the lot of many thousands of patients. ‘Jaipur-foot‘ is an
excellent example of what can be achieved in India at this
level. The tertiary level in the scenario must witness the
emergence of an industry which will manufacture all that
had been identified for production in the original policy.
A policy for the promotion of medical technology can
scarcely be implemented unless one can forsee the possi
ble hurdles to development. The very absence of a policy,
weakness and lack of direction of research programmes
in the professional colleges, apathy of the medical and
engineering professions towards devices technology, lack
of confidence in oneself and the country’s technology,
obsession of the industry with production under licence,
state regulations which permit dumping by foreign
manufacturers in the name of free trade and many other
hurdles to development can be immediately identified.
They are listed not as a deterrent to effort. On the con
trary their identification in advance will make it less dif
ficult to overcome them.
Long ago our legendary King, Bhartrihari, described
three types of men in the increasing order of merit. Those
who never start because of the fear of hurdles: those who
retire half way when hurdles confront them; and lastly
those who persist in the face of hurdles. Let us therefore
begin and persist until the technological bounty makes
a qualitative change in the standards of our patient
services.

Sree Chitra Tirunal Institute for Medical Sciences
and Technology, Trivandrum

Sree Chitra Tirunal Institute for Medical Sciences and
Technology, Trivandrum represents a new trend which
seeks to promote the joint culttire of technology and
medicine and attempts to answer some of the problems
we have noted. Set up as an Institute of National Impor
tance by an Act of Parliament in 1981, the Institute has
a modern hospital for cardiac and neurologic diseases and
a technology wing which develops materials and devices
for medical applications. Whereas the bulk of hospital
services are claimed by poor patients who pay little or
nothing, the technology wing consists of a series of
laboratories for technical evaluation of materials, polymer
chemistry, polymer technology, biomaterials technology.
biosurface studies, thrombosis research, toxicology,
pathophysiology, vivarium and so on. These laboratories
interact with the hospital which provides the clinical in
puts for technology development at all levels. The
technology for disposable blood bags which is essential
for a national or regional transfusion service and was
developed by the Institute has already gone into commer
cial production with the annual capacity of two million
bags. A humidifier, disposable oxygenator, urine bag,
heart valve and several other devices are in the pipelines
thanks to the joint efforts of the engineers and physicians
on the one hand and the recent arousal of industrial in
terest on the other. The example of Sree Chitra Trirunal
Institute needs to be multiplied to meet the national
demands for development in biomedical technology.
* DR. M.S. VALI ATHAN is the Director, Sree Chitra Tirunal Institute
for Medical Sciences and Technology, Trivandrum.

results could be disastrous. This would amount to impor
technological and research institutions, which in turn look ting the belief system and culture of an alien society; the
strength of traditional knowledge and human relation
to the West for inspiration. The needs of the lower 90%
are ignored or set aside. Even if some of us learn to ships, which offer at least some solace and relief, would
distinguish between expensive halfway technologies of be eroded. High technology is almost always a double
dubious value and real high-technology medicine, the edged weapon.
Finally, the concept of the body as a mere machine
decision-makers will still favour halfway technologies in
response to intensive sales campaigns conducted by the should be questioned. It has -been useful in respect of
unifactorial diseases but is unlikely to be so against most
medical- industrial complex of the West, which treats
multifactorial illnesses.
health care as a market commodity. And so our scant
A technology is needed that is more humane, more
resources are frittered away as our hospitals are increas
philosophical,
more equitable and more in keeping
ingly equipped with advanced gadgetry that may be im
pressive to observe but is of very limited value in dealing with belief systems, while denying any place to supersti
tion and mythology. Self-reliant coping with illness should
with society’s health problems.
be encouraged; passive overdependence on expensive in
No technology is suitable for all cultures. Further
stitutional medicine should not.
more, as societies change, there has to be a perpetual
1 Reddy, A. K. N. Generation of appropriate technologies. In: Carr,
updating of the nontechnological role of medicine.
M., ed. The AT Reader. Delhi. Oxford University Press, 1985.
Why should hospitals or old people’s homes take
2 Arole, M. & Arole, R. A comprehensive rural health project in
over functions that families can and still do fulfill
Jamkhed. In: Newell, K.W.,ed. Health by the people, Geneva, World
in the developing world? Such family roles, considered
Health Organisation, 1975.
impractical in industrially advanced countries, should be
3 Warner, D. Where there is no doctor. Palo Alto, The Hesperian Founcarefully nursed and encouraged.
dation, 1977.
This requires a demystification of professional know . 4 Chowdhury, Z. Basic service delivery in underdeveloping countries:
ledge. Medical care and a healthy life-style can be explain
a view from Gonoshasthaya Kendra. In: Bhasin, K & Vimala, R., ed.
ed to ordinary people (2-4). Modern communication
Readings on poverty and development. Rome, Food and Agriculture
technology should be harnessed for sharing health care
Organisation, 1980.
information with people. There is, of course, a danger
* DR. P.K. SETHI is the Honorary Consultant in Orthopaedics, S.D.M.
here. If people in the Third World were shown how com
Hospital, Jaipur. He is also the receipient of the Magsaysay Award
and the inventor of the Jaipur Foot.
mon ailments are treated in the advanced countries the
11
(Contd. .from p.3)

Books
New Additions

1 Postel Sandra, “Defusing the toxics threat: controll- ?
ing pesticides and industrial waste’-Washington: I
Worldwatch Institute, 1987, p.69, Rs. 60/-.
2 Walker Roger S., ‘Understanding Computer Science”
Texas: Texas instruments, 1984, p.274, Rs. 18/-.
3 Ford Foundation, “Comprehensive labour welfare
scheme of United Planters Association of Southern
India” (Anubhav Series)-New Delhi: Ford Foundation,
1988, p.28.
4 Gore M.S. (Dr.), “Indian Youth: process of socialisation”New Delhi: Vishwa Yuvak Kendra, 1977, p.73,
Rs. 25/-.
5 Gayatri Singh and Rao Madhusudan, “Environmen
tal activists hand book’-Puntamba: Asha Kendra,
1987, p.203, Rs. 75/.
6 Kothari Devendra, “Rajasthan: estimated fertility in
dicators at the district level” Jaipur: Indian Institute
of Health Management Research, 1988., ’p. 117.
7 Sah C.G., “Ends and means"Bombay: Popular
Prakashan, 1972, p.61, Rs. 30/-.
8 .Clapsattle Helen, “The doctors of Mayo”-New York:
Pocket books, 1957, p. 484, Rs. 50/-.
9 Sardesai S.G., “Progress and conservatism in ancient
India”New Delhi: People’s Publishing House, 1986, p.
333, Rs. 40/-. ,
10 Central Bureau of Health Intelligence, “Health infor
mation of India: 1987”New Delhi: Ministry of Health
and Family Welfare, 1987, p. 308.

Reprints on Medical High Technology
2-WHO chronicle, “Diagnostic imaging for developing
countries”V.39, No.4, 1985, p. 143-148.
(Contd. from p.2)

By its very nature the new genre technologies (especially
of the electronic and computer aided variety) has made
concentration of monopoly capital even more simpler and
the control easier. This is true for all sectors of the
economy but more so for medicine.
The NMT has opened new avenues of corporate invest
ment that is going to bring out far reaching changes in
the structure of health care delivery. NMT has brought
various forms of privatisation are early signs, and cor
poratisation the virus that helps complete the cycle.
In a country like India where basic health care is still
a dream for the masses, the fast paced introduction and
proliferation of NMT is only strengthening unequal health
care distribution. NMT and privatisation go hand in hand.
Corporatisation follows and adds strength to it.
Historically the introduction of modern medicine, its
technology and practices have been characterised by an
enclave sector pattern of development. During the colonial
period modern health care was available/accessible to
those in civil and military services. Introduction to the
periphery was largely restricted to setting up of civil
hospitals at the district level which had very restricted ac
cess. Provincial governments did make some efforts in set
ting up dispensaries in ‘mofussil areas’ but they were too

1 Lele R.D., “Biomedical technology in patient care"
(Paper presented at Hyderabad seminar, June 28-29,
1986).
3 Kochar Vijay, “Diffusion of new generation medical
technology and its implications for Primary Health
Care for All” (paper presented at Hyderabad seminar,
June 28-29, 1986). *
4 Jennett Bryan, “High technology medicine: how defin
ed and how regarded”, Milbank quarterly, Vol.63, No.1,
1985.
5 - Trumka Richard L. “Prevention of dust diseases in coal
miners’-Journal of Public Health Policy, Vol. 5,
September 1984, p. 338-343.
6 Antia N.H., “Hospitals or Health” (lecture delivered at
the 2nd National Conference on Hospital administra
tion, 25th February, 1983), p. 11.
7 Chailash S. and Mays N.B., “The randomised controll
ed trial in the evaluation of new technology: a case
study’-British Medical Journal, Vol. 292, 29th March,
1986, p.877-822.
Following publications are available at FRCH library.
1. “Health Status of Indian People’— Sonya Gill (Ed.) p. 225.

2. “Social Aspects of Leprosy’—Manisha Gupte, Amar Jesani,

Ravi Duggal, p. 123, Rs. 35/-.
3. “Women’s Work, Fertility and Access to Health Care’—
Manisha Gupte & Anita Borkar, p. 200, Rs. 20/-.

Just Published
“Health in People’s Hand: Grass-root processes of a
primary health animation project in rural areas’- Poitevin
Guy and edited by Anantharam Saraswathy, p.169..
few to have had any impact. In fact it was the missionaries
who made successful attempts at introducing modern
medicine in quite a few remote and difficult access areas.
In the post-independence period, the State undertook the
responsibility of providing health care to the periphery
but the development has been very gradual to the extent
that even today there is only one 6 bedded PHC with two
doctors and about 8-10 paramedics placed at subcentres
for about one lakh population. In the public sector
hospital services are only available at the district level
through a 100 to 200 bedded civil hospital for 2 to 3
million population.
(To be concluded)
References:
This is an extract from the paper “Medical Services, Medical Technology
and Privatisation” to be presented at the Annual Meet of the Medico
Friend Circle to be held from 26-28 January 1989 at Alwaye.
1) Breilh, J. 1981: Community Medicine under imperalism: A new
medical policy in Imperialism, Helath & Medicine, Vicente Navarro
(ed.) Baywood, N.Y.
2) GOI, 1946 (Bhore Committee): Health Survey and Development Committe, GOI Press, New Delhi.
RAVI DUGGAL is the Senior Research Officer with the Foundation
for Research in Community Health.

Edited by Anita Borkar with the co-operation of Manish Mankad and Saraswathy Ananthram and Secretarial assistance from Anuradha Naik.
Produced by the Foundation for Research in Community Health, 84-A, R.G. Thadani Marg, Worli, Bombay-400 018, registered under the Bombay
Public Trust Act. Printed by Modern Arts and Industries, A-Z Industrial Estate, Lower Parel, Bombay.

Position: 4060 (2 views)