FRCH NEWSLETTER VOL.11-No. 1-6-JAN - DECEMBER-1997.pdf
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The F oundation for R esearch in C ommunity H ealth
NEWSLETTER
" 3
7/yolXI,No.1
Jan-Feb 1997
Professional Competence vs. Local Health Care Needs
The (Il)legality of Cross-Practice
Dr. Anant Phadke
There has been a hue and cry by non-allopaths and
themselves with their respective councils. These councils
others over the circular by Mr. A.K. Lakhina, Commissioner,
are statutory bodies formed to regulate the practitioners of
Food and Drugs Administration, Maharashtra, instructing drug
their particular pathies and there is no provision in their statutes
shops not to honour prescriptions of allopathic drugs by non
for cross-practice. Secondly, the medical colleges set up under
allopaths. This circular is an attempt by Mr.
the respective acts are meant to train doctors in
Lakhina to implement the Supreme Court
their respective disciplines. Ayurvedic and
verdict declaring the prescription of allopathic
drugs by non-allopathic doctors as illegal. In
a landmark judgement on 22nd April’92, the
Supreme Court, in response to an appeal by
Happy New Year
to
all our readers
homeopathic medical colleges have been
encouraged to foster these systems of medicine.
Since allopathic treatment gives quick relief
in a majority of cases and has been developed
Dr. A.K. Subhapathy, struck down the legality
of the Kerala Government’s permission to allow persons not
in a professional manner, it is has become a popular and
qualified in modern medicine to practice allopathy. Again,
remunerative profession. Hence, there has been an increasing
in the Pramod vs. Dr. Ashwin Patel case, the Supreme Court
tendency among non-allopaths to do allopathic practice.
ruled that the homeopathic doctor was guilty of negligence
Presently, almost all non-allopaths indulge in such cross-
per se because section 15 (3) of the Indian Medical Council
practice. Very few non-allopaths seriously study or do
Act prohibited any person without the requisite
qualification in the allopathic system of medicine to
research in their own discipline and develop it further. Instead
practice that system.
disciplines, these colleges have become conduits for back
of acting as a means to develop and popularise non-allopathic
door entry into the lucrative allopathic medical profession.
Illegal Cross-Practice
Though such entry has been illegal, organisations of
allopathic doctors like the Indian Medical Association
Technically, there should be no reason
have surprisingly, not taken any legal
for any confusion about the illegal nature of
cross-practice (use of allopathic drugs by nonallopaths and vice a versa). Graduates of
allopathic, ayurvedic, homeopathic and unani
systems of medicine have to register
Dr. Anant Phadke is a member of the Medico
Friend Circle and was the Principal Investigator of the
Drug Supply Study undertaken at FRCH
in this Issue
♦The (D)legality of Cross-practice.......1
Dr. Anant Phadke
action on this issue.
This inaction may be partly due to the
fact that while the allopaths have mainly
♦ Maternal and Child Health - II ................4
Anuradha Gupte
confined themselves to the cities, a majority
♦ India aur Bharat
exceptions, settle in rural areas. Thus, the
(Article in Hindi
Devraj Chauhan and Dr. N.H. Antia
of the non-allopaths, barring a few
former do not constitute a big threat to the
allopathic practitioners as competitors and there has not been
much direct clash of interests between the two. On the
contrary, for post-graduate allopathic doctors, non-allopaths
constitute a source of referred cases and fresh non-allopathic
graduate doctors as cheaper night-duty trainees in their private
hospitals.
practice allopathy scientifically. The claim by some
spokepersons of non-allopaths that they have been trained
to use allopathic drugs is thus misleading. Moreover, given
their very limited exposure to allopathic science, especially
allopathic pharmacology, they arc far more vulnerable to the
misleading propaganda of the drug companis, and hence, more
likely to do irrational practice.
In recent years however, competition amongst doctors
has increased a great deal and allopaths are now more
resentful of cross-practice by non-allopaths. Even post
The Impasse and the Way Out
graduate allopaths now feel the pinch because some ayurvedic
Almost all non-allopaths in rural areas practice
post-graduates have started posing as ‘consulting
gynecologist’, ‘consulting physician’ etc. with their ayurvedic
training indicated in small print.
allopathy and most practitioners in rural areas are nonallopaths. The mere implementation of the Supreme Court
judgement as such would create a social dysfunction because
rural people would be deprived of whatever allopathic care
they are getting today. State health-services are for too
inadequate, especially for curative symptomatic care.
However, continuation of the state of affairs would amount
to perpetuation of low quality and often wasteful and
sometimes hazardous health care for rural areas.
Grossly Inadequate Training
As regards the quality of allopathic medical care given
by non-allopaths, it is generally of a poorer quality than that
given by qualified allopaths. In our study of prescriptions
in Satara district, we found that the average score per
prescription for MBBS, post-graduate allopaths and nonallopaths was 15.34, 15.64, 11.28 respectively out of a
possible maximum of 30. This poor score by non-allopaths
is not surprising since non-allopaths do not get any systematic
training in allopathic pharmacology. Though homeopaths are
taught all other subjects, the clinical subjects, especially
surgical, are taught far less intensively than in the MBBS
course; they are more in the nature of an introduction to
allopathic diagnostics. Homeopathic students have to appear
for examination in gyneacology, obstetrics etc. but here again,
the expectations are much less as compared to those in the
MBBS course. In the ayurvedic medical colleges such
introduction is even less intensive. Prior to 1970, an
integrated course was taught at the ayurvedic medical colleges
which included some training in allopathic pharmacology.
Since 1970, the pure ayurvedic course has been introduced
in which there is no systematic training in allopathic
pharmacology and no examination for it. Students are to be
introduced to modern concepts of pharmacology but the aim
is not to teach modern pharmacology as such or to train
them systematically to use allopathic drugs. This introduction
to concepts in modern pharmacology is not given by allopathic
experts but by ayurvedic doctors and there is no examination
for this subject. The knowledge is not sufficient for ayurvedic
doctors to diagnose and confidently treat patients with
allopathic drugs. Ayurvedic graduates therefore, try to get
some practical training by working under willing allopathic
practitioners for a few months and by going through the
propaganda literature of the drug companies. But such ad
hoc, somewhat perfunctory exposure, is not sufficient to
FRCH NEWSLETTER. VOL XI. NO.!. JAN-FEB '97
Fortunately, there is a way out of this impasse through
training of non-allopaths in rural areas in a systematic manner
to use say about 50 allopathic drugs routinely required for
the treatment of common illnesses in rural areas (table l).
Though the table contains a list of 85 drugs required for
OPD level general practice in rural areas, a few of these
drugs will have to be ignored because non-allopaths would
cither not be able to or not really need to use them. For
example, the BCG vaccine is administered by a paramedic
and hence need not be used by a non-allopalh. Secondly,
in diseases like tuberculosis, proper diagnosis, especially
of sputum negative cases or pcrcdiaslic cases, is often
difficult. Hence, anti-tubercular drugs may not be included
in the training of non-allopaths, given the fact that antitubercular therapy is costly and is to be continued for a long i
period which makes it worth while for the patient to approach
an allopathic graduate/post-graduate before starting this
therapy. On the other hand, anti-venom and neostigmine
injections may. be included in the curriculum of this
licentiate course, as they are life-saving drugs in the rural
situation. This list may be finalised by a concerned team
of experts.
The training should also include detailed diagnostics
required for the use of these drugs. Since these doctors have
received some exposure to allopathic science, this detailed
training would be easier to imparl. Medical colleges should
start such a course consisting of both distance and contact
training. This course can be recognised under seclion-28 of
the Maharashtra Medical Council Act as a licentiate course.
2
Drugs Required in Out-Patient General Practice in Rural Areas
(Category as per WHO's essential drug list)
NO.
1.
NAME OF THE DRUG
NO.
NAME OF THE DRUG
Local anaesthetics
32.
33.
34.
35.
36.
37.
38.
39. '
40.
41.
Isoniazid
Pyrazinamide
Streptomycin
Thioacet azone
Griseofulvin
Miconazole oint. Pessary.
Diloxamide
Chloroquine
Primaquine
Sulphadoxine +
Pyrimethamine
Gamma BHC
Lidocaine
Analgesics, antipyretics,
NSAID’s and antigout and
antimigraine agents
2
4.
5. .
6.
7.
Acetylsalicylic acid
Ibuprofen
Paracetamol
Ergotamine
Inj. Diclofenac
Pyrimidine (urinary
analgesics)
41
Chlorpheniramine
Inj. Epinephrine
Inj. Hydrocortisone
Prednisolone
Ferrous salt +
Folic acid
Glyceryl Trinitrate
45.
46.
47.
48.
Anti-infective drugs
21.
22.
23.
24.
15.
26.
27.
28.
29.
30.
31
69. .
70.
Anti-venom sera
BCG vaccine
DPT vaccine
DT vaccine
MMR vaccine
Measles vaccine
Oral polio vaccine
Tetanus vaccine
Rabies vaccine
(human diploid)
Typhoid vaccine
49.
50.
52.
53.
54.
55.
56.
■ 57.
58.
Inj. Aminophylline
Beclomethasone inhaler
Inj. Epinephrine
Salbutamol
Codeine
Betamethasone
Calamine
Tetracycline eye oint.
Chloramphenicol eye oint.
71.
71
73.
74.
75.
Disinfectants and antiseptics
Solution for correcting water,
electrolyte and acid-base
imbalance
Chlorhexidine
iodine
Gastrointestinal drugs
51.
Ergometrine
Oxytocin
Drugs acting on the
respiratory tract
।
Dermatological and
Opthalmic drugs
Activated charcoal
Mebendazole
Diethylcarbamazine
Amoxycillin
Inj. Procaine Penicillin
Chloramphenicol
Erythromycin
Metronidazole
Contrimoxazole
(Sulfamethoxazole +
Trimethoprim)
Doxycycline
Ciprofloxacin
Norfloxacin
Furazolidone
Gentian violet
Neomycin + Bacitracin oint.
Gentamicin
Clofazimine
Dapsone
Rifampicin
Ethambutol
59.
60.
61.
61
63.
64.
65.
66.
67.
Oxytocics and tocolytics
44.
13.
14.
15.
16.
17/
18
19.
20.
Vaccines and sera
68.
Antiallergics
Antidotes and other drugs used
in poisoning
NAME OF THE DRUG
Drugs affecting the blood
43.
8.
9.
10.
IL
NO.
76.
77.
Dried Aluminium hydroxide
gel + Magnesium hydroxide
Ranitidine/ Famotidine
Metoclopramide
Anti-haemorrhoidal
Compound topical
preparation
Atropine
Bisacodyl
Oral rehydration salts
(for glucose-electrolyte solution)
78.
79.
Contraceptives
84.
85.
1. V. Normal Saline
I. V. Glucose (1. V. 5%.
20%)
1. V. Ringer Lactate
ORS Powder
Vitamins and minerals
80.
81.
82. •
83.
Ergocalciferol (Vit. D)
Retinol (Vit. A)
Vitamin B Compound
Calcium carbonate
Neurotropics
Diazepam
Inj. Neostigmine (Snakebite)
Ethinylstradioa +
Levenorgestrel
Non-allopathic doctors undergoing this course can use these
50 drugs legally. If they prescribe drugs beyond the list covered
in their training, it should be considered as a legal offence.
entry into lucrative allopathic practice in urban areas. If pulling
such restriction is not possible legally, these licentiates
This course should be open only to those non-allopaths
should be required to work in rural areas for a fixed period
of say five years. (A similar condition had been instituted
upon allopathic doctors, requiring them to do compulsory
who have opted 10 settle down in rural areas. This is to slop
the use of non-allopathic colleges as conduits for back door
( ontd. on page S
3
FRCH NEWSLETTER, VOL XI. NO !, JAN-IIB 97
Inter-Linkages Between Socio-Economic Aspects and Access to Health Care
Maternal and Child Health - II
Anuradha Gupte
This is the concluding part of the article under the
same title that appeared in the Nov.-Dec. '96 issue of FRCH
Newsletter.
Dynamics of SES and Child Health
The social conditions of life are major determinants
of child survival. These determinants make a biological impact
through a set of Intervening processes that can be decomposed
analytically.
Many studies show that on an average, each one year
increment in the mother’s education corresponds with a seven
to nine percent decline in the mortality of under-fives.
However, education exercises a stronger influence in post
infancy childhood.
In one study, mothers attending an out-patients'
department in a programme of primary health care in rural
West Bengal were interviewed and anthropometric
measurements made on them and their accompanying children.
The uneducated group was found to have experienced a greater
rate of child loss at 130/1000 births as compared to 58/
1000 births in the educated group.
Under the Demographic and Health Surveys
Program [DHS], child health was measured through
indicators such as infant and child mortality, diarrhoeal disease
and treatment, immunization coverage, birth spacing, breast
feeding and child nutrition. The findings showed high risk
factors for infant mortality to be : maternal age under
18 or over 35, parity of 4 or more, birth intervals of less
than 2-4 months and uneducated mothers. Rural
immunization lagged behind the urban and overall,
immunization increased with mother’s education. Rural
children were more likely to drop out without getting second
and third doses of vaccines. The paper concluded that the
success of child survival programmes depended more than
anything else on the strength of their health education
activities.
A study carried out in Nicaragua has identified the
factors affecting child mortality. The study showed that while
Anuradha Gupte has done her postgraduation in Economics
and is a researcher on the Public Information Project at FRCH.
FRCH NEWSLETTER, VOL XI, NO.!, JAN-FEB. '97
income is not an important factor, there was an inverse
relation with the number of siblings and simultaneously, a
positive association with calorie intake, schooling, availability
of refrigeration and quality of sewage systems. It was also
observed that the strategies used by the educated mothers
were significantly more appropriate than those of their non
educated counterparts with regard to pregnancy and childbirth,
diarrhoea, immunization, family planning, and source of
treatment in illness.
During illness, significantly more educated women
chose to consult a medically-qualified person instead of the •)
traditional healer. There was also a greater trend for educated
women to be able to exercise autonomy in decision making
on health related matters.
The intermediate factors which explain how a mother’s
education influences the health and survival of her children
include reproductive health patterns, more equitable
treatment of sons and daughters and economic advantages
associated with education like sanitation, income, water,
housing quality etc.
Comparing experiences in Kerala and Manipur (states
with lowest IMRs) with the rest of India, it has been found
that infant survival is crucially dependent on maternal
capabilities and women’s freedom to act in ways that are
beneficial to their children. Hence, literacy and occupational
and marital choices influence child survival. This calls fore)
public action for women’s empowerment, for improved access 7
to and improved techno-managerial efficiency of health care
systems.
Access to Health Care and MCH
With regard to access to health care the basic question
is, how much of the increase in health status is attributable
to health care delivery systems ?
Trends in several different factors which might have
led to a fall in child mortality have been examined in
one more study carried out in Nicaragua. The factors
studied included income, nutrition, breast-feeding
practices, maternal education, immunization, access to
health services, provision of water supplies and sanitation
4
and anti-malarial programmes. Of these, improved access
to health services appeared to have been the most
important factor.
Where maternal mortality is concerned, apart from
early marriages' and low health services utilization, poor
quality of health care received during pregnancy contributes
to higher neo-natal and maternal mortality. Reproductive
morbidity profiles indicate high incidence of gynecological,
obstetrical and contraceptive morbidities. High mortality rates
amongst women, as revealed by maternal deaths due to sepsis,
anaemia, toxemia, hemorrhage and abortions indicate that
reproductive health in particular is largely neglected.
Hemorrhage, sepsis and obstructed labour are the leading
causes of mortality world-wide. A number of studies have
shown that 30 to 80 per cent of women die before they
reach any health care facility.
In Africa, improved nutrition and health care is
)
expected to result in increasing the rate of fetopelvic
disproportion for a generation or more, before it falls. Thus,
if there was a failure to provide safe operative delivery, there
would actually be an increase in the incidence of obstructed
labour, uterine rupture, obstetric fistula and still birth with
improvement in socio-economic status.
Statistics show that increased literacy (U.S.A, and
U.K.) does not seem to have had any effect on maternal
mortality. The decline in maternal mortality in these countries
has in fact coincided with the discovery of antibiotics for
the effective treatment of obstetric complications. In this
case maternal mortality haas been more sensitive to the
standards of obstetric care than changes in the levels
of socio-economic deprivation as seen in Britain over
the last 150 years.
Conclusion
The above information reveals the equal importance
simultaneous effect of maternal education and accessibility
to, variety of and quality of health care delivery sytems upon
maternal and child health and the intermediate factors through
which the impact is felt. Linkages between deprivation and
poor health shows that dimensions like education, social
educators etc. for improving the community health status
through the following means :
* Improving health through education by demystifying
knowledge, endorsing certain health behaviour like breast
feeding, well informed timing and spacing of births, equal
treatment of boys and girls, regular immunisation, maintaining
proper sanitation and hygiene and correcting faulty eating
habits, improving methods of food processing and preparation,
supplementing food/diets with nutrients found to be low in
the food consumed etc.
* Improving health by giving economic, social or medical
aid wherever needed.
Most important, in the long run, the good health
of the community will depend upon sustainable
development for which equity oriented economic growth
strategies are essential as have been effectively used in
Japan. On the other hand, economic growth strategies linked
to great and perhaps ever increasing economic inequities are
“unhealthy” and result in a level of health far below what could
be expected considering available economic resources.
□
( "With inputs from Vaijayanti Aphale )
Bibliography
1. Shiva Kumar A.K., Mukherjee Vanita.N., Health as Development :
Implications for Research, Policy and Action, Economic and Political Weekly,
April 17, 1993 pp 769-774.
2. M.Doornbos, F-Van-Dorsten, M.Mitra & P. Terhal, Dairy Aid and
Development: India’s Operation Flood.
4. S.Batra, Operation Flood : Impact on the Delhi Milk Market.
5. K.Visweswara Rao, Statistics in Nutrition.
6. Delgado HL, Garcia B, Hurtado E, Nutritional Improvement Without
Better Health: Santa Maria Cauque, 15 Years Later [letter], Lancet, 1988
Dec 3, 2(8623): 1303-4.
7. Gopalan C, Maternal Health, Fertility Control and Child Nutrition,
Bulletine of the Nutrition Foundation of India, 1985, Jan; 6(l):l-4.
8. Sandiford P, Morales P, Gorier A, Coyle E, Davey Smith, Why Do Child
Mortality Rates Fall? An Analysis of the Nicaraguan Experience, American
Journal of Public Health, 1991 Jan; 81(l):30-7.
9. Child Health Indicators : Demographic and Health Surveys Program,
Demographic and Health Surveys Program
10. Goodbum E, Ebrahim GJ., Scnapati S, Strategies Educated Mothers
Use to Ensure the Health of their Children, Journal of Tropical Pediatrics,
1990 Oct; 36(5):235-9.
freedom etc, apart from the purely medical, need to be
addressed for improving health status.
11. Wolfe B.L., Behrman J.R., Determinants of Child Mortality, Health and
Nutrition in a Developing Country, Journal of Development Economics, 1982
Oct, 11 (2): 163-93.
This information is especially useful for health
planners in deciding upon where to concentrate the limited
12. Nicholas D.D., Child Survival Depends on Health Education Design, Paper
presented at National Council for International Health Annual Meeting,
Washington, D.C., May 21, 1988 National Council for International Health
Annual Meeting; Papers [Unpublished], 1988 May.
resources to get optimum results regarding the health status
of the community. These findings would be useful in designing
interventions by government, voluntary organisations, health
5
13. James McCarthy, An Analytical Model of Maternal Mortality, Safe
Motherhood Programmes : Options and Issues, 1993.
□
FRCH NEWSLETTER, VOL XI, NO.!. JAN-FEB* 97
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The contents of this newsletter may be
abstracted without prior permission.
However,
we
would
appreciate
acknowledgement of the source and
copies of any abstractions
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
(nm 9 ooo silf- qaR)
7
FRCH NEWSLETTER, Vol. XI. No. 1 JAN-FEB *97
Contd. from page 3
service in rural areas). It must be borne in mind that training
the need to start standardised courses for VHWs to train
them to use about 10-15 drugs for the most common and
non-allopaths in rural areas in the use of a limited list
simple ailments in rural areas, and to educate the community
of allopathic drugs is only a compromise measure to
overcome the social impasse created today.
in basic health issues. This is the only way to provide-first
contact care to such areas, under the prevailing socio-
economic situation.
Lastly, it may be pointed out that even non-allopathic
doctors do not reside in smaller villages especially in
economically backward areas. In such villages, the best way
to provide first contact care for common diseases is through
well-trained Village Health Workers (VHWs). Many
innovative experiments in rural areas have shown that VHWs
can diagnose and treat simple common ailments competently.
Secondly, they can be very good health educators, being far
more accessible, physically and culturally. There is therefore,
Simultaneous efforts have to be made to reduce the
concentration of qualified allopathic doctors in cities and
increase their availability in rural areas through a series of
incentives and disincentives. But till such a situation arises,
and qualified doctors are available in adequate numbers in rural
areas, trained VHWs and non-allopaths turned licentiate
allopaths seems to be the answer to the problem of unavailability
of first contact care of reasonable quality in rural areas. □
Perhaps, a better means of taking care of basic health problems at the grassroots level is to train the village
people themselves in integrated medicine, including simple local treatments, so that the community can address its own
basic health problems without depending on formally trained doctors - competent or otherwise. Of course, simultaneously,
they have also to be trained to recognise when a particular case requires referral to formal health practitioners so that
the danger of inadequate care is minimised. As we have already written in detail in the previous FRCH Newsletters, the
FRCH is implementing such a project at the Parinche village in Pune district, where some interested local women are being
trained in basic medicine and other related subjects so as to make basic health care accessible in the rural areas.
- Editor.
BOOK-POST
(PRINTED MATTER)
If undelivered, return to :
The Foundation for Research in Community Health
3&4 Trimiti B Apts., 85 Anand Park,
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Editor: Vaijayanti Aphale
Assistance: Rajesh Ingle
Publisher : Foundation for Research in Community Health
Mumbai/Pune
Printer: Abhyankar's TypeServe
The F oundation for R esearch in C ommunity H ealth
NEWSLETTER
Vol. XI, No.2
March - April 1997
A Perspective Beyond 2000 A.D.
Cancer Control in India
Dr. Indraneel Mittra
The average life expectancy of an Indian male for the
period 1991-1996 was 60.6 years and that of a female was
61.7 years. It is estimated that by the years 2021-2026 the
average life expectancy would increase to 69.6 years for
males and 71.0 years for females. This works out to an
increase of about nine years for both sexes. Assuming that
the currently available prevention, detection and treatment
facilities remain unchanged, death rate from cancer will rise
by 284.5% between the years 1991 - 2026, simply, as a
function of aging of the population.
Rechard Peto, the Oxford epidemiologist and his
colleagues, in their projection of the annual increase in cancer
deaths attributable to the use of tobacco, have calculated
that while tobacco related deaths would increase by only
0% between the years 1995 - 2025 in developed countries,
this increase would be a staggering seven-fold in the
developing world. This is because, while large scale cigarette
smoking became prevalent in the West during the early part
of this century, cigarette smoking became fashionable in the
developing world only 40 to 50 years later. Since there is
a latent period of several decades before tobacco
kills the abuser, the full impact of tobacco use
in the developing countries is yet to be realised.
In the developed world death rate from lung
cancer peaked in the 1950s and 1960s for males
and is still rising for females (the latter having
started smoking about 3 to 4 decades later).
Dr. Indraneel Mittra, MBBS., PhD. FRCS,
is a practising surgeon at the Tata Memorial Hospital,
Mumbai_________________________ _ ______________
It is not clear whether such a seven-fold increase
in tobacco related deaths estimated by Peto et al for the
developing world applies strictly to India. However, if
it does, and given the fact that approximately 34% of
all cancers in India are related to tobacco use, a seven
fold increase would lead to an approximately 200%
increase in overall cancer deaths by the year 2025.
Although it may not be appropriate to calculate the overall
increase in cancer deaths by simply adding up the increase
in cancer death rate due to population aging (about 300%)
and that due to increase in tobacco use (about 200%),
such an estimate would suggest that there would be
combined increase of about 500% in cancer deaths by
the year 2025. This estimate is supported to some extent
by figures from WHO which suggest that the current
mortality from cancer in the developing world which is
approximately 2.5 million is likely to rise to 6.5 million
by the year 2015.
The crude incidence for cancer in India is between
70 and 80 per 100,000. Given a population of more than
900 million, this works out to about 750,000
In this Issue
new cases in advanced stages when a cure
is not possible - there are approximately
♦Cancer Control in India-- ----1.
Dr. Indraneel Mittra
350,000 deaths from cancer each year. To
♦ Involving Voluntary Organisations
put these figures in a different perspective,
in TB Control.---.----------.-----3 ",
while the age adjusted incidence of cancer
A. K. Chakraborty
♦ Malaria : Great Success Great
is 125 per 100,000 in India, it is
Fallur---.... -----------------6
approximately 300 per 100,000 in the United
Vishwas Rane
States (figures for the year 1989). However,
♦ Kushiha RogNirmulan: Ek Samiksha
because the population of India is nearly four
. (Article in Hindi)....10
Dr. K. R. Mutatkar ______ ______
Q, '
times that of the United States, the total number of cancer
cases occuring in India every year exceeds that in the U.S.
Unfortunately, the available resources to face the challenge
of cancer are vastly disparate; the developing world, including
India, carries 50% of the world’s cancer load but has only
5% of the world’s resources to fight the disease.
For any programme for the
control of cancer to succeed in India
the priorities must be clearly defined
both in terms of the types of cancers
to be tackled (depending on their
prevalence) and the methods to be
adopted to do so. Thirty-five percent
of all cancers prevalent in Indian males
are those of the head and neck which
is almost entirely related to tobaco use.
In females, nearly 50% of cancers arc
of the breast and the cervix. Any cancer
control programme must, therefore,
focus on these three cancer sites.
for the control of oral, cervical and breast cancer.. Although
prohibition of tobacco use remains the most direct approach
to the prevention of oral cancer, studies conducted in Kerala
suggest that, visual inspection of the mouth can lead to earlier
detection of oral cancer at stages in which standard treatment
methods are likely to be more successful. The economic
and social realities of our country are
" My mother had a long and difficult
such that apparently simple tests, such
illness which she bore bravely and patiently
as PAP smear for screening for
for many years. The last two weeks were
cervical cancer, are not viable
particularly painful. Ventilator, catheter
propositions. It has been estimated that
and all manner and sizes of tubes ran all
even if the available resources were to
over her frail form as she lay battling with
be increased 12-fold it would be
life in the ICU. I had never felt more
possible to give only 25% of women
acutely the senselessness of the medical
above the age of 50 one PAP smear
profession to which, ironically, I belong. As
lest in their entire life time. Initial
a practitioner there was nothing I could do
studies conducted by the ICMR which .
to relieve her, and as a daughter, very little.
suggest that visual inspection of the)
With regard to primary prevention, control of tobacco
use is clearly the first priority. Unfortunately, tobacco in
our country is classified as a food product and the farmer
gets a subsidy of 400% on tobacco compared to 250% for
sugarcane and 135% for wheat. This unacceptable situation
needs to be changed through an unrelenting campaign to bring
about legislative changes. Cigarette advertising in the form
of sports sponsorships needs to be challenged as research
has shown that tobacco sponsorship of sports influences children
much more than adults. Anti-tobacco campaigns must target
the citizens of tomorrow rather than adults who are already
addicted to the drug.
The potential effectiveness of public education leading
to greater awareness about cancer and consequent clinical
presentation at earlier stages of the disease has been
demonstrated in a pilot study conducted in the district of
Barshi in Maharashtra with respect to cervical cancer. The
study showed that intense public education can lead to an
increase from 26.6% to 44.% in three year survival in cervical
cancer within a span of 4 years.
Chemoprevention of cancer is an area which needs
to be researched. There is evidence that haldi (turmeric),
a standard ingredient of Indian cuisine, can prevent cancer
in animals and reverse oral leukoplakia when given in
pharmacological doses.
With respect to secondary prevention, i.e. early
detection, simple and inexpensive methods need to be defined
FRCH NEWSLETTER. VOL XI, NO.2. MARCH-APRIL97
cervix may lead to detection of cancers
in the early stages when the disease is
curable need to be pursued further. Mammography for early
detection of breast cancer is inapplicable in the Indian situation
for obvious reasons. Instead, physical examination of the breast
conducted by trained health workers may be a viable alternative.
A random trial involving 70,000 women, to test the effectiveness
of visual inspection of the cervix by health workers, is soon
to be launched at the Tata Memorial Hospital in Mumbai.
A Doctor
With regard to tertiary prevention, i.e. treatment of
cancer, worldwide experience over the years has indicated
that while this is the most expensive form of cancer control
from which the public has the greatest expectation, tertiary
prevention of cancer is likely to bring the smallest return.
Although there have been dramatic improvements in the
survival figures for leukodaemial, lymphomatic and childhoo@)
cancers with the use of modern multi-drug chemotherapy,
these cancers form only six to seven percent of the overall
cancer load. It is now clear that improvements in survival
figures for common cancers are likely to come in small
increments and the imaginary “magic bullets” are unlikely
to materialise. Nonetheless, small increments in survival figures
can be important if the cancer is a common one as they can
translate into thousands of lives saved worldwide. One such
example is a modest 8-10% improvement in 10 year survival
from breast cancer with the use of adjuvant systemic therapy
which is having a global impact on the reduction of deaths
from this disease. Treatment has, however, led to very little
improvement in the overall control of common cancers
worldwide. Nevertheless, on humanitarian and medical grounds
(Contd. on pg. 5)
involving Voluntary Organisations
in TB Control
A. K. Chakraborty
The existing National Tuberculosis Programme does
not leave much scope for Non Governmental Organisation
(NGO) involvement in the scheme of things. With a revision
of the ideas generated and the work plan chalked out.
NGOs working in TB
currently being envisaged for the National Tuberculosis
Amongst those NGOs working in the field of health
Programme (NTP) in India, there was increasing expectation
among NGOs about an enhancement in their role in the formal
TB control as part of their activities in general health. In terms
TB control programme. As part of the deliberations preceding
of area covered, some NGOs work more at the macro level,
the Revised National Tuberculosis Control Programme
i.e., the national and state levels while others operate at the
(RNTCP) Pilot Phase I, a workshop was held at Delhi in
grassroots level. Those functioning at the macro level are by
September 1993 on the role and involvement of voluntary
and large more specialised than those at the grassroots level.
are some who specialse in TB control and others who include
organisations in NTP, followed by a second one in September
1995. This was welcomed as a step in the right direction.
At the top of the list of macro level institutions is
However, the RNTCP is currently developing in a
the TB Association of India, which specialises in the field
of information dissemination (both scientific as well as
manner as if nothing at all had transpired at these workshops.
social) as well as research and advocacy regarding TB. It
Save for the initial flutter and the good intentions proclaimed
also carries out research funding and lends technical support,
from time to time by both the Government and the NGOs,
if necessary, to other institutions. It works at the national
nothing concrete has so far emerged with regard to
as well as state levels through its branches in various slates,
involvement of NGOs in RNTCP. Though all the principal
performing more or less similar functions. The Voluntary
stake holders are no doubt aware of the scope for NGOs
in policy making, the old mindset persists when it comes
Health Association of India (VHAI) is another institution
to actual policy formulation. In fact, the term NGO itself
its activities include health in general, they also work in TB
is so negatively couched an expression, that the organisations
control, focusing on advocacy and information dissemination.
covered by it, immediately position themselves subservient
to the Government. In other words, Government is the key
player and others are its dispensable units, looking upto the
Government for financial support on the one hand, and for
jobs to be entrusted by the Government to them, on the other.
The NGOs fail to assert their rightful place under the National
Programme, when in actual fact the very nature of such
programmes calls for participation of voluntary organisations
in it, the Government willing or not!
The Action-Aid, India had held a national level
which operates both at the national and state level. Though
A large number of grassroots level workers operate
in this field. By and large, they are multi-sectoral workers
working on integrated programmes with health as one
component (as in Action Aid, India). Even within health, not
all of them are addressing the TB problem. Further, of those
who are involved in TB, the majority concentrate on case
finding activity; very few are involved in treatment.
Deficiencies in Performance
The main deficiencies in the performance of NGOs are :
workshop in 1995 at Bangalore as a further effort to force
1. Collaboration and integration between Government and
the pace of development. A situation analysis was prepared,
NGOs remains very weak. Even where it exists, such a
followed by a set of recommendations, which were forwarded
collaboration is more at the individual level. A formal
to the Government of India in a booklet form, namely,
systematic approach to collaboration is lacking.
‘‘Tuberculosis Control in India: Developing Role of NGOs”
2. The NGOs working at the district and sometimes, even
(1996, Ed. Chakraborty AK, Daniel TD, and Chaturvedi Gunjan,
the state level, lack networking and coordination.
Action-Aid, Bangalore). The summary of the analysis as well
3. Most organisations are not focused on TB. Among those
as. conclusions are presented here for wider dissemination
NGOs, who are involved in TB control or those who have TB
The author, an international expert in TB control is a retired
as one component of health, there is no common understanding
Additional Director of the National Tuberculosis Institute, Bangalore.
on the approach to be adopted for TB control in their areas.
3
FRCH NEWSLETTER, VOL XL NO.2, MARCH-APRIL97
Basic Concepts in Epidemiology
Epidemiology is a science which provides an
understanding of the distribution and determinants
of disease and its natural history. Epidemiological
expertise is necessary for the diagnosis and
measurement of the health needs, both present and
future, for determining priorities and for monitoring
and evaluation of prevention and control programmes.
To study extensively how and why diseases are
caused, epidemiology uses the concept of triad. This
concept takes into consideration that an interaction
between three factors - agent, host and environment
- determines the occurrence of a condition, disease,
disability or death. The- component 'agent* refers to
the agent(s) responsible for the causation of a disease
and may be classified as physical, chemical or biological.
Host factors describe the characteristics of the
persons who are affected or not affected and include
factors
like
genetic
characteristics
and
predispositions, age, sex, caste, religion, marital
status, nutritional status and immunity status. The
environmental factor refers to the external
environment which can be divided into physical,
biological, social, cultural and other components and
is an important determinant of health of an individual
and community. The interaction between the agent,
host and environmental factors needs to be, studied
to understand the causation of a disease, both of
communicable and non-communicable type, so that
measures can be taken for preventing its recurrence/
occurrence.
Uses of Epidemiology
Epidemiology has made a very substantial
contribution to medical sciences and public health
practice. The principal uses of epidemiology are:
1. To study the rise and fall of diseases in a population.
Estimates of future expectations about the disease.
can be made based on past and present information.
2. It enables a diagnosis of the health problems of
the community by studying the presence, nature and
distribution of health and disease among the
population and their dimensions in morbidity and
mortality. The nature and relative size of the problems
can thus be described.
3. It helps in the study of functioning of health
services. It assists in determination of needs and
resources, in the analysis of services and in evaluation.
FRCH NEWSLETTER, VOL XI, NO.2, MARCH-APRIL97
Incorporating NGOs in TB Control
1. There should be an action forum at all levels, right from
the district to the state level, involving both the Government
as well as NGOs to chalk out common action plans.
2. It is possible that the Governmental authorities are not
aware of the NGOs operating in their area. On the other
hand, NGOs may not be fully aware of the functions of
Government institutions or the facilities available to the
NGOs at the District TB Centres (DTCs). To start the
collaborative approach a directory of NGOs should be made
available to all concerned and simultaneously, NGOs be made
aware of the functions and facilities available under the NTP.
3. Respective areas of responsibility need to be identified
for NGOs and Governmental organisations prior to
collaboration. There could be four areas to start with :
* Augmenting the use of existing facilities and mobilising
local resources.
0
* Improving case finding : NGOs can help in this regard
in two ways - firstly, the field workers can identify and refer
symptomatic patients to the nearest clinic or centre where
adequate services are available. Secondly, they can take the
help of Government facilities to see that adequate services
are provided with a humane face. The Government, on its
part, should tone up the facilities for diagnosis and treatment.
* Ensuring treatment adherence. NGOs could assist in the
following manner : a) doing follow-up of cases at the
community level and b) ensuring treatment regularity. The
NGOs could be provided with a list of TB patients in their
respective areas and be given the responsibility of monitoring
the drug intake by patients. Also, the NGOs can mobilise
the community towards treatment completion and help build
up social pressure in the community for treatment seeking
and completion. At the same time the government has to
ensure a regular and adequate drug supply. Wherever possible, 0)
the NGOs can be of help to Public Health Institutions (PHIs)
in tiding over shortages in drug supply.
4. Enhancing information, education and communication (DEC)
activity and organising the community. Since a majority of
the NGOs operate at the grassroots level and are involved
in organising the community, they should be able to motivate
the community towards TB control. This will be greatly
facilated with the advent of Panchayati Raj wherein, the
Panchayats are made responsible for village health care. The
NGOs can also work as catalysts for improvement of service
facilities at the existing clinics. There is a lot of training
activity that NGOs are already undertaking at the grassroots
level, both for the members of the community as well as
for NGO personnel who are working for the communities.
Training helps the NGOs to achieve long-term sustainability
4
4. It enables to estimate the probability of disease
occurrence for an individual from community
experience. This is useful in bringing about a
modification in health behaviour, e.g. in those with
high risk of coronary heart disease.
5. It is useful in the search for causes of diseases,
starting with the discovery of groups with high and
low incidence and attempting to find the origin of
disease. The “cause” may be discovered even before
the exact nature of the disease in understood. The
search for cause also enables identification of certain
risk factors in order to take preventive measures.
The measurement of disease frequency of cases
occurring in a population is often necessary and has
the following dimensions :
* Prevalence denotes the number of cases of a diseasei
or of a certain condition, both old and new, in a
given population at a given time.
* Incidence denotes the number of instances of illness
commencing, or of persons falling ill, during a given
period in a specified population. Thus, it denotes the
number of new events.
* Outbreak and Epidemic : An outbreak is defined as
a localized occurrence of increased disease incidence.
An epidemic denotes the occurrence in a community/
population of a specified geographic area, of cases of
an illness(s) similar in nature or other health-related
events clearly in excess of normal expectancy.
Steps in the Investigation and Control of An Epidemic
The following steps are involved in the
investigation of an epidemic :
1. Confirmation of the occurrence of an outbreak or
epidemic.
2. Rapid preliminary collection and analysis of data
to evaluate the epidemic with reference to place,
person and time. For endemic diseases the magnitude
and distribution of the disease has to be known.
3. Collection of other relevant information with
reference to factors favouring transmission and favouring
epidemics, unusual environmental events etc.
4. Formulation of tentative hypotheses based on
collected information
5. Based on tentative hypotheses, planning/taking the
action necessary to treat the sick, prevent the spread
of and contain the epidemic. The population at risk
of suffering has to be identified and protected.
6. Testing the accepted hypothesis further for
additional confirmatory evidence, if necessary.
□
5
of their programmes.
Whether this activity can be
formally included into the TB control programme, has to
be looked into. On the part of the Government, the
activity involves enhancing the expertise and distribution
pattern of PHIs as well as improving services at the existing
family health care centres. Training of PHI workers as well
as community leaders through Government effort also needs
to be tried, perhaps with NGO collaboration wherever possible.
Also, suitable IEC material could be developed through mutual
collaboration.
Conclusions Regarding NGO-Government Interface
1. The state Government should create a forum for working
out a Common Action Plan with NGO representation at all
levels.
2. The Government should involve NGOs right from the stage
of planning.
3. The NGOs will motivate the community and enhance the
role of Panchayats through group organisation in case finding
and case holding activities.
4. The NGOs should publish the relevant DEC material for
the community.
5. The NGOs should be involved in training of trainers at
State TB Centres (STC) in community health aspects.
6. The Government at all levels should undertake training
of all NGOs who are addressing the problem of TB.
7. District and state level committees should be formed with
NGO representation and control strategies.
□
(Contd. from pg. 2)
cancer treatment facilities must be made available to all those
who are afflicted by the disease. Consequently, tertiary
prevention of cancer must necessarily form an important
component of any cancer control programme. Moreover, early
detection of cancer can only be worthwhile if prompt
treatment facilities are available.
The major thrust of our national public health policy
so far has been the control of communicable diseases. With
the current estimate that infectious diseases would be reduced
by half by the year 2015 while cancer deaths would increase
three fold, a rethinking of our national health priorities is
called for. In the past there has been a lack of political
commitment for cancer control. The already meager
resources allocated for cancer control were mostly
concentrated on the least effective stage of cancer control
- treatment of cancer. What is now urgently needed is a
comprehensive programme which puts sufficient emphasis
on primary and secondary prevention through public awareness
and simple approaches to early detection of common cancers
with the best use of the currently available infrastructure and
human resources.
□
FRCH NEWSLETTER. VOL XI. NO.2, MARCH-APRIL^?
Malaria:
Great Success and Great Failure
Dr. Vishwas Rane
Malaria Control in the Early Phases
An assessment in 1952 indicated that about 7.5 crore
Indians suffered from malaria with a death toll of 8 lakhs.
In April 1*953, the Government of India launched a
comprehensive indoor residual spray programme known as
the National Malaria Control Programme (NMCP), in
collaboration with some bilateral and international agencies.
The Control Programme was. a success and it was felt that
malaria could be controlled in India by emulating other
countries who had attained this' objective. The NMCP was,
therefore, converted into the broader and more ambitious
National Malaria Eradication Programme (NMEP) from April
1958. The NMEP progressed satisfactorily and malaria
incidence was brought down to as less as 1 lakh cases in
1965 with complete elimination of deaths due to malaria.
The goal of ending the transmission of Malaria by totally
eliminating the reservoir of infection and preventing its reemergence by 1968-69 began to-seem-feasible.
Deterioration Sets in
Unfortunately, after reaching a near vanishing point
and coming close to eradication the situation started
deteriorating rapidly and there was a resurgence of the disease
in the country. Since 1971, focal outbreaks of malaria began
to occur and the annual incidence began to increase. New
strains of malaria appeared and existing plasmodia strains
started developing resistance to the standard drugs - the
mosquitoes were no longer afraid of DDT ! The number of
malaria cases in the country which stood at 13.2 lakhs in
1971, steadily increased in subsequent years and reached
a peak of 64.7 lakhs with 59 reported deaths due to malaria
in 1976. As a result of the recommendations of the
Consultative Committee of Experts (1974),- the government
embarked on a Modified Plan of Operation (MPO) for NMEP
in 1976, which was implemented with effect from april 1977.
Simultaneous to the implementation of the MPO, there was
the development of the Primary Health Care System with
the introduction of the Multipurpose Worker Scheme (MPE
Scheme) and Village Health Guides Scheme. Also, the urban
malaria scheme under the NMEP was sanctioned by the
A medical doctor, the author is a leading member of Arogya
Shiksha Mandal, Pune and is also involved in the rational drug movement
since the past two decades
FRCH NEWSLETTER. VOL XI. NO.2. MARCH-APRIL97
government of India, Ministry of Health and Family Welfare,
during the third year of the Fourth Plan. To contain the spread
of P. falciparum (plasmodium falciparum) incidence, a special
scheme called the P. falciparum Containment Programme
(PFCP) was launched in October 1977.
With the introduction of all these programmes in 1977,
the number of cases came down to 21.82 lakh in 1982 and
by 1987 the number of reported cases was 16.63 lakh, of
P.falciparum cases, 6.2 lakh and of deaths due to malaria, 188.
The MPO in India during 1977 was a bold step to
decentralise and involve the general health services under
the primary health care system in NMED operations and to
solicit the active voluntary participation of the community
in malaria eradication activities. But in the last ten* years
there has been a major distortion in the public health policy
with the result that after 1987 there has been a progressive
rise in malaria cases to 28 lakh reported cases, 10.9 lakh
P. falciparum cases and 1061 deaths by 1995.
The priorities in terms of manpower and resources have
been given to certain vertical programmes eg. Family Planning
and AIDS at the cost of other communicable diseases like TB.
In 1991 to 1992, the year of the New Economic
Policy, the ADDS budget was increased from 4.5 to 70 crores
and the malaria budget actually decreased from 70 to 50
crores. Not surprisingly, the highest number of malaria deaths
were recorded that year - economic depressions are known
to be associated with worsening malaria outbreaks. The
vertical implementation of health programmes virtually
destroyed the primary health care system. To top it all, the
World Bank recommended the privatisation of curative care
which if implemented, would have been disastrous for the
poor majority which is already highly vulnerable to disease
due to poor nutrition and poverty. WHO itself, in its 1995
annual report, recognised the obvious fact that poverty was
the greatest cause of disease and government policies
worldwide were worsening economic disparities.
Decentralisation
The present system is centralised and highly
bureaucratic and does not involve participation of the common
man. On paper it might appear that health services are fulfilling
6
their goal, but in reality our economic resources and
per packet so as to keep it within the people’s budget and
administrative structures pose a big hurdle. Health care
increase demand. Whereas, for the treatment to be effective,
planning needs to be decentralised at all levels from the centre
a single dose has to contain three tablets of the drug (1500
to the district and grassroots level planning needs to be
mg sulphadoxin + 75 mg. pyrimethamine). Taking 2 tablets
encouraged. The issue of budget allocations for health and
(1000 mg + 50 mg) per dose is not sufficient to kill all the
for malaria specifically and its transfer from centre to the
parasites, with the result that the patient improves for some
state and districts and
time only to relapse back.
Role of the Community In Vector Control
ultimately to panchayats
With any antineeds to be encouraged
The role of the community in vector control programmes can be .
malarial
drug it takes
as malaria, or any other
considered at three levels :
about
50
hours for the
illness for that matter,
1. Support for national, provincial or municipal projects - This type
body temperature to reach
cannot be seen as a
of support can take several forms depending on the programme
the normal level, and also
and socio-economic level of the community. It can spring from
vertical health programme
the disappearance of the
payment of taxes for vector control, self-help contribution, or
but as an issue closely
collaboration
with
the
vector
control
personnel,
e.g.,
assistance
parasites from the blood.
linked to sustainable
in house spraying or in geographical reconnaissance previously
This is not known and the
development of the people.
carried out by specialised bodies. House spraying with insectisides
practitioners often repeat
has always been carried out by specialised operational staff
Malaria Chemotherapy
the drug. This results in
through a vertical system of administration. Instead, this operation
severe toxicity due to an
Dr. U.K. Seth, a
may gradually be entrusted to the community provided that
over-doseof
world renowned clinical
adequate training, guidance and supervision are given to the
sulfadoxin+pyrimeth amine,
pharmacologist who has
individuals responsible. Community participation may take the form •
leading
to bone marrow
of provision of volunteers or subsidised labour or the full recruitment
worked as a Clinical
of labour to conduct spraying.Operational activites that require
(repression and
Monitor
for
the
CHEMALRTI
(Chemotherapy
of
Malaria) Malaria Action
Programme of TDR,
sustained effort, such as larviciding, mollusciciding or trapping, could
be community based and entrusted to a responsible member of the
community who would have access to a vector control specialist.
2. The community, if properly motivated, can contribute actively
to the elimination of breeding-places In and around dwellings and
villages. Simple engineering methods such as filling, draining,
maintenance of the sanitary facilities, and care of water tanks
can be undertaken by the community and be supported by
legislation as needed.
particularly a marked
decrease in platelet
count. Initially, the
pharmaceutical
companies introduced
this combination for any
malaria leading to its
over-exposure.
No
wonder,
resistance
to
says that we are not far
3. Individual measures. Prevention of man-vector contact by the
this drug combination
from the situation in
use of mosquito nets will be much encouraged if the net material
has also been reported.
Thailand and Vietnam
is subsidised or produced locally and sold at a low cost which the
That leaves quinine as
where he has seen
community can afford. Screening of houses and elimination of wall
the main drug for the
cracks as also use of commercially available aerosol formulations
malaria cases dying
treatmentof P.falciparum
of
insecticides
or
mosquito
colls
may
also
provide
useful
and
within 24-48 hours of
affordable
measures
of
preventing
contact
between
man
and
vector.
cases
as it is believed
admission
in
the
that as yet P.falciparium
^Absfrycted from * integrated Vector Control ; 1583, WHO, Geneva)
hospital. The main
in India is sensitive to
mortality is due to
quinine.
Having no
P.falciparum, causing cerebral
published
data
on
the
degree
of
sensitivity
to
quinine by
malaria, kidney failure, hepatic failure and during pregnancy,
WHO, in one of his
essays, has very elaborately
discussed the flaws in
malaria treatment. He
death of the mother and the fetus.
In India, resistance to chloroquine by P.falciparum is
well accepted, which leaves only two drugs for treating
P.facliparum malaris - sulphadoxin + pyrimethamine and
quinine. Sulphadoxin + pyrimethamine are only available as
tablets, and not for parental (injection) use which is very
important for patients who are unconscious. Also, the dose
recommended and made available in the market is 2 tablets
7
P.falciparum, it is difficult to gauge whether quinine should
be administered alone or with tetracycline.
Six hundred milligrams of quinine each has to be given
eight-hourly round the clock for 7 days which would give
a total cost of about Rs. 147. The cheapest brand available
is Quininings of Inga, costing Rs.35.00 for 10 tablets of
300 mg. each. Clinically, after treating the patient with quinine
for 3 days, the fever disappears, the blood paracetomia
FRCH NEWSLETTER. VOL XI, NO.2, MARCH-APRIL97
Laboratory and Statistical
Epidemiological Studies
Support
to
Laboratory Support
Laboratory support becomes essential in many
epidemiological studies, especially clinical, and may
be necessary for arriving at the diagnosis, for obtaining
confirmatory evidence supporting a provisional
diagnosis or for obtaining certain circumstantial
evidence for or against some hypothesis, for eg.,
examination of sputum for diagnosis of pulmonary
tuberculosis or examination of skin by slit and scrape
method for diagnosis of leprosy.
Statistical Support
Analysis, interpretation and presentation of
numerical data has to be done in epidemiological work.
Methods by which inferences are drawn; methods of
classification and grouping to facilitate data handling;
tabulation and graphical presentation of data to help
the reader to grasp the data easily etc. all require
statistical knowledge.
Also, when observations are made, generally,
only a fraction of the group, i.e. a sample, is examined
and inferences are drawn for the total group from
which the sample has been derived. The process and
methods of satisfactory sampling and the
' o
•
determination of an adequate size of the sample also
require statistical knowledge.
Vital statistical data including rates, ratios and
proportion, have to be very commonly used in
epidemiology.. Demography heavily leans on statistics.
Standardization of rates to compensate for age and
sex distribution of populations has to be done while
making comparisons. Life-table methods derived from
statistics have wide application in epidemiology.
Statistical methods are used to study
associations between different variables and a cause
and effect relationship is sought for by collection of
further evidence. In case of association of a
characteristic and a disease, the extra risk of the
development of that disease amongst those in whom
the characteristic is present, for e.g. the risk that
smokers run of lung cancer, is calculated. Again, using
statistical methods, it is possible to know much of
that disease in the community can be attributed to
the influence of that characteristic which permits
intervention for control of the disease for e.g. eliminating
stagnant water bodies to control malaria.
□
FRCH NEWSLETTER. VOL XI, NO.2. MARCH-APRIL97
reduces to an extent that it may be missed microscopically
and the patient feels better. Meanwhile, the side effects of
quinine like ringing in the ears and partial deafness, become
evident. This makes the patient discontinue quinine.
Unfortunately, unless quinine is given for 21 doses (i.e. 7
days) a relapse occurs after a period of 3-4 weeks. This
is considered a fresh attack of malaria and the inadequate
treatment starts again. Unfortunately, the need to continue
quinine for 7 days is often not known to family physicians
and patient compliance too is very poor.
In serious cases, quinine has to be given by intravenous
drip. Quinine can be given intramuscularly but the usual
method is to use the quinine solution as available in the
ampoule and inject it in the gluteal muscle. This often leads
to severe pain, tissue necrosis (death of tissue) and even
abscess (localised pus formation). It is hardly known that
quinine can be given safely intramuscularly if the solution a
is diluted 6 times with normal saline and injected into the "
thigh muscle at 2-3 places. This method is quite painless
and without any tissue damage.
Dr. U.K. Seth, from his experience in Thailand, strongly
feels that mefloquin should be administered in the treatment.
His experience shows that full protection can be given to
P.falciparum patients at least for 10-15 years, and later the drug
could be used safely in combination with other drugs like artmether.
Resistance to Insecticides
Malaria control has been rigidly equated to the spraying
of residual insecticides, irrespective of its effectiveness,
correct application and totality of coverage keeping the
appropriate time for transmission in mind. It is an established
fact that vector mosquitoes when under continuous exposure
to any insecticide, eventually develop resistance; yet there .
are no plans for the systematic cycling of different V2
insecticides so as to prevent emergence of resistance.
Environmental Control
The major man-made causes for the spread of malaria
are neglect of water management in development and
construction activities. An important example of this is the
construction of the Indira Gandhi Canal which was largely
responsible for the outbreak of the malaria epidemic in
Rajasthan in 1994 - the major reasons being water leakage,
collection of large water bodies, migrant labour, etc. Hence,
it becomes equally important to check the creation of an
environment conducive to the growth of the malaria parasite
and its transmission, especially in view of the fact that in 2000
AD, 50 percent of India will be urban. Taking due cognisance
of the bionomics of the vector species at the local level, human
8
Stages of Managing Communicable Diseases
activities and environmental conditions, operational research
for promoting community participation for appropriate social
I. To control a disease means to exercise restraint
or regulation, to correct or restore to normal. Thus
it is a planned reduction in the prevalence of a disease
to a level which is low but transmission may occur at
that level to maintain it in nature. The criterion of
what constitutes control of a disease depends upon
the level of development, knowledge, technology, will
and resources available for the control operations.
General Measures for disease control include :
action could pave the way for a solution through progressive
* Measures directed against Reservoir/Source
including treatment of infected humans/animals,
quarantine, vaccination, health education etc.
* Measures for interrupting transmission include
avoidance of close contact, disinfection/disinfestation
avoidance of overcrowding, vector control etc.
elimination of malariogenic factors in the environment.
References :
1. All relevant
publications by VHAI, Delhi
•
(Contd. from pg.12)
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2. Elimination is the second step following control
of a communicable disease and has to be defined
separately for each specific disease. It denotes
eradication of disease, as in the case of measles, from
a large geographic region or area of political
jurisdiction. In poliomyelitis, elimination may denote
the absence of paralytic disease without reference to
extermination of poliovirus, if the transmission takes
place at such a low level that it is devoid of paralytic
disease.
faqa # 31P115 chi a- 31/q94c 8 1
3. Eradication of a disease or infection implies
termination of all transmission of infection by
extermination of the infectious agent through
) surveillance and containment. It denotes total,
absolute, irrevocable extinction of the biological agent
without any possibility of its circulation in animals
or human hosts or persistence in the environment.
Smallpox is the solitary example of successful
eradication.
The actual measures taken for prevention/
control/eradication of a disease will be selected
depending upon the understanding of epidemiology
of the disease and the available resources.
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□
FREE ABSTRACTING
abstracted from 'Epidemiology and Management of Health
The contents of this newsletter may be
abstracted without prior permission.
However,
we
would appreciate
acknowledgement of the source and
copies of any abstractions
Care for AH' by P.V. Sathe and A.P. Sathe, 1991,, Popular
The views expressed in the articles are those of the
( AU material on epidemiology in this issue has been
Prakashan Pvt. Ltd., Mumbai. )
9
□
authors and not necessarily those of FRCH
FRCH NEWSLETTER. VOL XI, NO.2. MARCH-APRIL97
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The F oundation for R esearch in Community Health
NEWSLETTER
oia
Vol. XI, No.3
May-June 1997
Health in the Hills : Then and Now
Strong Medicine Weak System
This is the reproduction of a lecture given by Dr. Hallelohim Ghonglah as part of a Special
Lecture Series by distinguished social scientists organised by the North-Eastern Centre of ICSSR
Most people avoid hospitals, which to them are more
like “antechambers to the tomb” - a notion borne by history.
In earlier limes, most hospitals were associated with
monasteries run by the church. The nature of hospitals then,
was mainly as custodial institutions to keep infectious people
off the street. Naturally, crowding, filth and high mortality
among both patients and attendants was the rule.
Renaissance and Reformation loosened the church’s
stronghold on both the hospital and the conduct of medical
practice which slowly gave way to general hospitals and
medical schools. But the real turning point towards a new
understanding of the health of the people (public health) came
only in 1821. It was only then that it was realised that
cleanliness could prevent infection. Amazing, considering that
ideas of cleanliness have been recorded in both the Old
Testament as well as the Ayurvedic texts.
later than hospitals and doctors, most historians attribute the
improvement of health and longevity of the people in
developed countries not to curative but to preventive and
promolive medicine. The conquest of infectious disease,
one of the triumphs of medicine in this century, is something
for which the hospital as an institution can take no pride.
The North Eastern hills, especially Shillong, are some
of the lucky few places in the country where the medical
missionary from Wales opened the first dispensary at
Mawphlang in 1878. In fact, Shillong got the advantage of
the latest technology and tools to fight against disease and
ill health almost at the same time as the West.
During those days health care in these hills was taken
care of primarily by two bodies, the Church and the East India
Company. Secondly, even though the then Indian Medical Service
ran the show, it was clearly demarcated into two distinct areas
of operation - curative and preventive. The Inspector General
looked after the curative side whereas the Director of Public
Health, a person trained both in clinical as well as preventive
medicine, looked after the public health aspects.
Public health, as opposed to hospital care, is not
so much about drugs as it is about people. While hospital
care is essentially curative, public health involves changing
altitudes and motivations, safe water supply, basic sanitation,
good nutrition and an improved economy based
on high literacy - all what is today known as
In this issue
preventive and promotional medicine. As
opposed to this, curative medicine, by its very ♦Strong Medicine WeakSystem..........1
Dr. Hallelohim Ghonglah
nature, is a passive system treating whoever
comes to its door but seeking no one out. In ♦The Rockefeller Foundation and
Nursing in India .................................3
fact, inspite of the fact that it has come much
The author belongs to the Directorate of Health
Services, Government of Meghalaya and is a Sr. Research
Scholar on Community Medicine from JNU.______
Shirish N. Kavadi
♦Swasthya Kanni
(Article in Hindi )..... ...7
Dr. N.H. Antia
The achievements of Public Health in
these hills included :
* Water Supply and Public Health Engineering
- The water supply scheme was fully under
the control of the health department since
most of the health problems in developing
countries are water-borne. There were
engineers not only to connect pipe systems
but also to see that the water was safe for drinking.
They were also trained in the design of malaria-safe nullas
and sewage disposal systems.
* Public Health Laboratory - It is hard to visualise this,
but during those days, more than a hundred years ago, Shillong
had one of the best health analysis systems in Asia where
the biochemical and bacteriological reports of Shillong’s
water system were submitted every week for the knowledge
of the public.
* Bylaws for Shillong Town - Unlike today, incinerators
were used for destroying waste. They had laws for keeping
the town clean, for the number of vehicles allowed to ply
on the roads and the maximum speed permissible. The Sanitary
Commissioner in the cholera epidemic of 1879 even
threatened the then Syiem of Mylliemin, in the name of public
health, to taken away the Tewduh* from him if he did not bother
to clean it up! Inspection of markets and eating places was
also a part of public health maintenance.
* Health Research - The importance of basic health surveys
and research can never be exaggerated as far as the practice
of public health is concerned, and judging by the times in
which they lived, the health managers a hundred years ago
did well. There were sanitary surveys for Kalaazar, spleen
index survey for malaria and a host of other studies. In fact,
Shillong was selected as a location for the Pasteur Institute
mainly because its spleen index then was nil whereas Hatlong,
another contender, had a spleen index of 60.
Also, there was a body called the Assam Scientific
Research Society which, along with the Indian Tea Association,
was instrumental in moving for the establishment of the Pasteur
Institute, the Malaria Research Institute and other such projects
in Shillong. The Pasteur Institute then not only produced the
antirabies vaccine, but also carried out research into local health
problems like Naga sores, helminthiasis, kalaazar etc.
* Herbal Products - Much criticism by many health scientists
on the neglect of traditional medicines by the British Raj
can be found everywhere. But as far as these hills are
concerned, the evidence is otherwise. In 1923, a list of
medicinal and economic plants of Assam was prepared and
sent to the British Empire exhibition at Wembley.
The words quoted below of Rai Bahadur KL Barua,
then Minister of Local-Self Government, give an idea of public
health involvement then : “Nothing is more certain than the
fact that physical advancement and health of mankind is
dependent, not upon a doctor’s stunt here or a sanitary
institution there, but upon the whole social evolution of the
people?’ Continuing, he said, “if the people want to know their
birth rate, their death rate and their infantile death rate, should
not their be some expenditure and staff to collect such statistics
and see that the figures collected are correct?”
FRCH NEWSLETTER, VOL XI, NO.3, MAY-JUNE '97
Sadly, after independence, the destruction of all that
was laid by these public health men was carried on slowly
and gradually, and today it is almost complete. We no longer
have competent men or women even at the national level
who understand the basic concepts of public health. This is
unfortunate, for even though health is a state subject, ninety
percent of its programmes are planned and directed as well
as financed from Delhi. Whereas, as far as health is
concerned, there was complete decentralisation during the
British raj, today there is almost complete centralisation!
We had a terrific national health policy in 1946 (Bhore
Committee) which talks of the “managerial physician” and
the role of the community, but all that remained only on
paper and did not get translated into reality. The whole training
of doctors is geared towards making them hospital based
clinicians, not managerial ones.
It is interesting to note that just three years after
independence, the Assam Government adhoc decided that the
health department was loo big, so the Public Health
Engineering Department was created as a separate ministry.
The source of your polluted water can perhaps be traced
to that year!
Secondly, the Indian Medical Service has given way to
the IAS wherein any generalist without any knowledge of basic
public health can head a health system covering 900 million
people. Even those who are essentially medical persons, rarely
have any extra degree in public health. So the rot in the system
starts right from the lop and percolates downwards.
The Pasture Institute today is a mere ghost of its
former self, its library being stacked with ancient outdated
material. The Malaria Institute has nearly been destroyed.
The Public Health Laboratory is gone, and if you want to
know the chemical composition of the water you drink, you
would be lucky to get it without much running about. Even
if one gets it and the result is unsatisfactory, it would be
a miracle to get the PHE Department to clean it up. Health
research too is conspicuous by its absence; whatever data are
collected by rural health workers arc at best unreliable statistics.
All is not lost though. There is an increasing awareness
about public health throughout the country. Health is now
going more and more interdisciplinary. Literacy, economic
status, accessibility to health care are all seen as vital
ingredients of good health care, besides a good research
department. Academicians too cannot absolve themselves of
their responsibility. To end by quoting John Kenneth Galbraith,
‘Those who do not foresee change are bound to become victims
of change.” Let us not he victims for a change.
□
2
The Rockefeller Foundation
and Nursing in India (1930-1950)
Shirish N. Kavadi
The success of the Rockefeller Foundation’s (RF)
public health programme worldwide, depended on the
availability of skilled public health personnel (of which nurses
formed an important component) trained in the RF’s own
philosophy. Establishment of public health/medical teaching
centers and the institution of fellowships to train such
personnel was therefore, an important component of the RF’s
international health programme.
During the 1930s, the Government of India extended
an invitation to the RF for assistance in training female health
visitors and public health nurses. This was in response to
a growing realisation among the Indian officials and nursing
leaders that it was vitally necessary for Indian nurses to
receive belter and higher training in hospital administration,
greater responsibilities and higher nursing posts. The RF
responded positively to this invitation as it saw' in this an
opportunity to extend its own philosophy of public health
nursing to India. The RF believed that any programme of
public health nursing in India should be a part of the general
public health programme. It outlined the functions of public
health nurses as consisting of, "Health supervision, maternity
service, and the teaching of home nursing ... classified
according to the nature of the problems presented." It also
considered supervision of midwives as one of the functions
of nurses in India. .
As a part of its efforts the RF carried out three surveys
of existing nursing conditions in India : 1) by Ms. Mary Beard
in 1933, 2) by Ms. Mary E Tennant in 1941 and 3) by Ms.
Janet D. Corwin in 1945. The last survey was primarily
undertaken to help the RF formulate a long-term policy on
the public health programme in India. These were followed
with such tangible assistance as a fellowship programme,
advisory services and developmental aid to enhance the standards
of the nursing profession in India. What was the outcome of
these efforts? Was the RF successful in influencing the course
of nursing in India? Did the RF make any specific contribution
to Indian nursing ? This article attempts to answer these
questions in the process of describing the efforts of the
Rockefeller Foundation to shape and direct nursing policy
in India between 1930-1950.
The author, M.A., Politics, is the Principal Investigator of the
study
3
'Rockefeller Foundation and Public Health in India* at FRCH.
Survey Findings
The combined outcome of the surveys by Miss Beard,
Miss Tennant and Miss Corwin was a comprehensive
delineation of the status of general and public health nursing
in India. The three reports between them listed various
deficiencies in nursing education and shortcomings of the
nursing profession in India as elaborated below.
Professional Shortcomings :
■ Custom and social circumstances restrained women
from upper classes from participating more fully in nursing
which was considered a degrading type of work while on the
other hand, in some hospitals, racial prejudices discouraged
women from communities other than Anglo-Indians or
domiciled Europeans from applying and working. Moreover,
for most Indian women who joined the profession, nursing
was more a means of livelihood rather than an area of interest. *
Deficiencies in Training :
Training of nurses for hospital service and of health
visitors, was observed to be in a backward state both
quantitatively and qualitatively. The scientific concept was
lacking in India and scientific methods were alien to nursing
students who had inadequate exposure to science courses .
and laboratory work. Training was casual and superficial,
lacked tie-up between classroom teaching and hospital ward
practice and emphasised curative aspects of health care at
the expense of community medicine. As a result, women
who entered nursing were not really equipped to do
constructive work and tended to undermine the quality and
prestige of nursing. The RF surveys also highlighted the
inadequacy of nursing schools in preparing nurses for
leadership in teaching, supervision and administration. Nursing
control was administratively and educationally in the hands
of doctors. Whatever leadership positions in the profession
were available were dominated by non-Indian nurses, prompting
the RF to argue in favour of India developing the strength of
her own people rather than counting on outside help forever.
The Rockefeller Foundation’s surveys also commented
on other training deficiencies such as the absence of libraries,
leaching equipment, separate nursing school budgets, modern
diagnostic equipment, lack of importance attached to
theoretical education for nurses etc.
The three surveys made quite an accurate analysis of
FRCH NEWSLETTER, VOL XI. NO.3 MAY-JUNE ‘97
the nursing scene in India and managed to generate awareness
about and interest in the issue amongst government officials
and nursing leaders in India.
Government-RF Interface
RF officials met nursing leaders, medical professionals
and government officials to discuss the nursing situation and
various aspects concerning RF aid. Government officials
generally responded favourably to the RF’s ideas although
a complete agreement on the issues was not always possible.
For instance, there were differences regarding the nature and
quality of training for nurses. While the Indian Government
favoured RF assistance for a postgraduate school of nursing
in Delhi, Ms. Tennant clearly stated that the International
Health Division (IHD) was not interested in supporting a
postgraduate school unless steps were first taken to improve
the quality of undergraduate training.
The Bhore Committee and Nursing Education
In 1943, RF officials put nursing education on the
agenda of the Health and Development Survey Committee
(HSDC), also known as the Bhore Committee. This Report
is important for it provided the framework for health policy
in independent India. Dr John Grant, RF employee, Director
of the All India Institute of Hygiene, Calcutta and a member
of the Committee, noting with great vision that the Committee
would mark a turning point in Indian health care, insisted
on the formation of a subcommittee on nursing education
which would report to the Bhore Committee with its
recommendations. Amongst other things, the subcommittee
recommended the institution of a graduate course of nursing
leading to a degree which would provide highly qualified
leaders for the nursing profession from among the Indian
women. The recommendations drawn up by the Nursing
Subcommittee were incorporated into the main Bhore Report
which was submitted in 1946 and a nursing college was
established soon after. Thus, the report was acknowledgedly
a factor in spurring up the establishment of the college. What
of public health nursing? The RF appears to have had less
success here.
RF Aid to Nursing Education
College of Nursing :
By the end of 1945, stimulated by RF prodding, the
interest and activity of the Indian Red Cross, and the Bhore
Report, the idea of an All India School of Nursing (later
college) under the auspices of the Central Government began
to gain ground. The school was to offer a graduate course
of*university level in nursing. A committee consisting of
nurses, doctors and representatives of the Delhi University
FRCH NEWSLETTER, VOL XI, NO.3, MAY-JUNE '97
was formed to frame the curriculum for a training course leading
to a B.Sc. (Hons.) of the Delhi University. The course would
be of four years duration comprising of theoretical leaching
of the university level; practical nursing ; experience in hospital
wards and departments; and field work in public health and
midwifery. The emphasis in the training programme was to
be on teaching new concepts and practices, through demonstration.
Janet Corwin saw the proposal for the setting up of
the School as “a most hopeful development” for she believed
that the most concentrated aid by the IHD to nursing in India
should be made to a specific educational project such as
that proposed. Given that the college was viewed as the core
around which sound developments in nursing education in
India would take place, Corwin suggested that the RF assist
in the organisation of its degree course, offer fellowships
for staff members and provide for an Assistant Director of
Public Health Nursing, the services of a nursing consultant
and a suitable nurse from UK or USA. These suggestions
appeared to have been accepted, for the RF made fairly extensive
contributions to the establishment of the College of Nursing.
Fellowships :
In 1943, when the Government of India decided on
a programme for training nurses abroad, the RF offered
fellowships for a few. According to the RF thinking and plan,
nurses trained abroad through the programme would on their
return, be expected to occupy key positions in their
specialised areas of nursing and subsequently influence the
future development in those fields.
At this stage too the question of quality came up though
it pertained essentially to the abilities and capacities of the
individuals to be chosen for the fellowships. Miss Tennant
was for selecting candidates of high calibre whereas M.C
Balfour, Regional Director of RF, Delhi argued against the
RF insisting on quality saying that it was far more important
to train nurses in modern methods abroad who, on their return,
would contribute to the strengthening of the knowledge base
and skills of local nursing students. He opined that no case
could be made for insisting on more than first class candidates
and favoured compromise on quality. As later experience showed,
the problem of locating ‘intelligent’ candidate fellows was real
- there were instances of fellows failing to complete their
training and returning to India: unable to cope with their courses.
Between 1943 and 1946, six nurses returned to India
after studying on RF fellowships and two who had received
travel grants. Meanwhile, two other nurses were studying
public health nursing at Toronto. Once the College of Nursing
in Delhi came up and the Vellore Nursing school introduced
a graduate degree course, RF officials decided that future
4
fellowship aid would be given to further assist these two
institutes and the Government of India in preparing Indian instead
of foreign nurses for key administrative positions.
Through the Fellowship Programme, the IHD
facilitated the training of the core staff of the new College
of Nursing in Delhi. RF Fellows also occupied key positions
in various health training institutes in the provinces of
Madras, Mysore etc. and managed to influence the course
content and training methodology therein.
And yet, in the years that followed, RF officials such
as R.K.Anderson, Regional Director of RF, Delhi began to
wonder if their foreign fellowship programme would yield
any results. Instead, he favoured support to training facilities
which he argued, would give greater returns in the long run.
In rare cases, fellowships could be considered, if the Fellows
were to return to positions where the modern view of nursing
would be acceptable. He wrote, “Training abroad appears to
have given these nurses, a belief they can speak with authority
plus a zeal to put their American type of nursing into effect
more rapidly than local conditions will permit leading to
frustration and antagonism.” Anderson observed that training
received abroad could succeed only if the fellows had
sufficient local support to put their training into practice and
if the fellows in turn had sufficient ability to adapt their efforts
to the local situation on their return. (A parallel can be drawn
to our medical personnel mostly trained in urban areas and
summarily imposed on the rural community - Editor).
Consulting Services :
The College of Nursing started functioning in July 1946
with an independent budget and independent of hospital service
demands. The Rockefeller Foundation loaned the services of
Miss Corwin as Nursing consultant to the College of Nursing.
She was to serve in the capacity of Honorary Vice-Principal
for Public Health Nursing and make possible the desired balance
between public health and curative nursing therein.
Once the college came into being RF officials sounded
hopeful and optimistic that their aid would lead to the desired
ends. Miss Corwin wrote, " The support which the Rockefeller
Foundation has given does not seem misplaced” and her own
advisory activity “has also been of value in extending a
philosophy of nursing education in keeping with that of the
IHD”. However, there were practical difficulties at the ground
level. The philosophy of nursing education which the college
was trying to follow was so new to some of the Indian staff
that they needed a good deal of guidance. The students on
the other hand, were unable to meet the standards demanded
by the training. The course based on Miss Craig’s work at
Toronto was found to be too heavy for most of the students
5
as compared to the usual hospital nursing courses.
Developmental Aid :
While the fellowships were expected to prepare
personnel in modern concepts of nursing, the RF also offered
developmental aid to develop modern infrastructure so
essential for nursing education for which it created the Fund
for Developmental Aid. While planning distribution of support
from the Fund for Developmental Aid, the RF policy was
to reinforce assistance which the IHD had already given in
the form of fellowships, and to distribute books basic to
public health nursing more widely.
In her report to the New York office, Miss Corwin
suggested that IHD aid could be extended to developing nursing
libraries and upgrading teaching equipment. Regarding the
provision of a fund for books and magazines she wrote, “It
would make possible the distribution of books of our choice
to schools and public health agencies, would help bring in
American points of view in nursing and would render goodwill
towards the IHD.” In 1946, this Fund was used to supply sets
of related books to the central and provincial medical institutes.
However, by end of 1946 there were doubts as to
whether continuation of the Fund was necessary, for until
lines of nursing development became clearer in the Provinces
and States, it was difficult to know where help should be
given. It was hoped though, that if a later request to revive
the Fund was made, it might receive favourable consideration.
Backsliding
Beginning 1946, political and constitutional
developments leading to India’s independence made the RF
want to move cautiously and gradually with respect to their
intervention in India’s nursing programme. The feeling was
that any advance planning and constructive programme for
further IHD nursing activities in India would have to be deferred
till limes became more conducive to any positive development.
Over the next few years, the RF programme began
to face difficulties. RF officials began to experience less
hope for the future of nursing developments. Their efforts
created awareness and enthusiasm among Indians but the
expected change in altitude and perceptions did not take
place. They complained of the lack of understanding of the
philosophy and purpose of nursing education on any level;
lack of attempts to define nursing; to revise and reform
nursing education in India and to promote public health
training in nursing. The Government’s emphasis on quantitative
needs and production of nurses appeared as naive enthusiasm
and seemed to reflect superficial thinking. There was still
too little realization of the importance of basic good nursing
FRCH NEWSLETTER. VOL XI. NO.3 MAY-JUNE ‘97
to the advancement of medicine in India and hence, a demand
for improvements in these fields did not sufficiently develop
among officials or the public in general.
Plans were made for large new hospitals without
previous plans for enlarging and bettering the training schools
in order to be able to staff them. In most schools of nursing
public health emphasis was conspicuously absent, as
succouring the sick and the needy was the more obvious
and traditional service to be rendered. The situation was more
or less the same both at the central and provincial levels.
Indeed in some states as in Madras, Mysore and Travancore
the situation was actually backsliding.
RF plans for future activities appeared uncertain as
a result of these problems. It was felt that specific
recommendations as to the kind of help which might be
requested could be made until the Government made its
decisions about the future of the College. The fellowship
programme faced a dearth of fellowship material.
By 1948, the College of Nursing began to encounter
several problems. The B.Sc. course remained in an unsatisfactory
stale so much so that, RF officials began to wonder if it could
and should be continued at all. The Government, although
providing for an adequate budget, appeared unable or unwilling
to provide the minimum conditions necessary for nursing
education on a university level. The other problems were related
to staffing - there were vacancies for want of suitable staff,
existing staff was inadequately trained to teach, there was lack
of classroom space, the teaching of science courses was
unsatisfactory, and there were difficulties relating to hospital
practice, midwifery and public health nursing practice.
of nursing in India. After a thorough effort to understand
the deficiencies and shortcomings of the nursing profession,
the RF officials stressed the need for minimum level of school
education, the teaching of scientific methods, community health,
undergraduate training and the creation of Indian leadership
within the profession. The RF offered to provide fellowships,
advisory services, developmental aid and personnel.
The RF attitude was quite in contrast with that of the
Government officials who, while interested in a quantitative
increase in nurses to meet the growing demand, were indifferent
towards the quality of training and public health nursing.
Amongst provincial governments, the attitude varied : while
the Government of Bombay showed interest in public health
nursing the same could not be said about the health department
in Madras; the Government of Mysore showed considerable
interest in public health nursing and the State look pride
in the fact that it had a staff public health nurse in the public
health department, but the Government did not feel the need
for doing anything to correct the deplorable conditions of
nursing and nursing education within the State.
center and its failure at this lime would undoubtedly retard
further attempts at nursing education on a truly professional level.
He therefore urged continued and increased support by the IHD.
■ Clearly, RF intervention did not bring about any
perceptible change in the basic attitude of the people
concerned. There were no efforts made to bring about even
essential reform, leave aside any drastic changes, in nursing
education and activity in India. This attitude of the
governments appears to have hampered the RF’s efforts the
most. Thus, inspite of the assistance they extended , nursing
and especially public health nursing, could hardly make any
progress. The government was more interested in receiving
tangible assistance and was less receptive to ideas about
nursing or public health nursing. Government accepted
assistance for infrastructural development which would
contribute to quantitative production of nurses. Ideas and
philosophy appear not to have permeated amongst the nursing
sections as seen with the experience of the RF fellows who
faced antagonism from their colleagues. RF Fellows
themselves were dissatisfied with their work for their inability
to put into practice the training they had acquired abroad.
The college, till 1949, had not offered a public health
nursing course because of inadequate leaching staff and field
work facilities, as any public health nursing training required
house visits and health centre experience. Finally, in 1950,
the Najafagarh Health Unit began to be used as a rural practice
All this is not to say that the RF failed to contribute
and influence the course of nursing activity in India. But
this influence was limited. The RF was able to stimulate
sufficient interest in government and nursing circles to want
to improve the standards of nursing in this country. The most
field though no urban demonstration centre was created.
significant aspect of the RF’s intervention was, however, their
stress on reducing India’s dependence on non-Indian nurses
and, even more important, on producing leaders from amongst
Indian nurses in which they succeeded to an extent.
In his semiannual report for 1948, Anderson wrote
wondering whether the starting of the Nursing College in
Delhi was too a hasty a decision. However, Anderson also
strongly believed that there was extreme need for this training
Conclusion
The RF’s interest in nursing education in India was
related to both their concern for quantitative increase in
female public health workers and in improving the standards
FRCH NEWSLETTER, VOL XI. NO.3, MAY-JUNE '97
References :
Documents from the Rockefeller Archive Center, New York
•
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FRCH NEWSLETTER, Vol. XI, No.3 MAY-JUNE *97
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The contents of this newsletter may be
abstracted without prior permission.
However, we would appreciate
acknowledgement of the* source and
copies of any abstractions
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
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Dr
V
46
C
y
he F oundation for R esearch in Community Health
NEWSLETTER
Vol. XI, No.4
July - August 1997
Needed : A Give and Take
Local Health Perceptions and Practices
Seema Deodhar
In the course of our training project al Parinche, our
mis (local women trainees) had the opportunity to interact
with other local people and gain an insight into their
understanding of various diseases, the indigenous remedies
for these diseases, their preferred health care providers etc.
Altogether 17 lais collected information from five
different villagers each, which was then pooled together.*
Our main intent in gathering this knowledge was to find out
the anomalies in the health care behaviour of the people
and accordingly decide where intervention was necessary to
"correct” (his behaviour and also, to inculcate a rational altitude
in them. However, in the course of the study, we ourselves
learned and gained a lot of useful information which is otherwise
denied to us by the modern urban knowledge inputs.
We also gained a wider perspective of health behaviour.
People have their own rationale for their particular actions;
We also learned that many of our expectations from
the people regarding daily hygiene and health consciousness
arc sometimes totally unrealistic and useless in the village
context. If a person has to travel something like 10 miles
to fetch even a pail of drinking waler, il is ridiculous to
talk about maintaining personal hygiene through daily baths.
Similarly, it is illogical to expect someone to buy expensive
medicines when she/he cannot even afford the simplest of
meals.
Many of the traditional customs are health promolive
even when seen in the modern context, some of which the
urban society could very well emulate :
* Breast-feeding the child for a considerable span.
* Ealing different varieties of food on festivals which ensures
that they get different kinds of vitamins, minerals etc.
* Using home remedies for simple illnesses which would
mean avoiding running to the doctor for every little problem.
once we get to know their menial framework it becomes
easier to understand their behaviour during illness which
On the other hand, some local customs definitely need
otherwise seems totally irrational and out of context. After
to be changed through greater awareness :
all. there are many diseases for which allopathy
* Not cleaning the hands after going to the
has no cure and at limes even gives disastrous
In this Issue
toilet •
results, yet, our belief in allopathy remains ♦ Local Health Perceptions and
* Giving the pregnant lady less food so as
unshaken. How different then, is the attitude
Practices......... ............................... 1
to control the size of the placenta.
of the villagers, who continue to expect their Seema Deodhar
* Using tobacco powder for cleaning teeth etc.
♦ Effectiveness of Public Health
faith to work miracles for them inspite ol
Functionaries at the Grassroots
It is not as if there has been no change
evidence to the contrary.
Level.---------------------Dr. S. N. Morankar
whatsoever.
Over the years, modernisation and
Seema Deodhar has done B.Sc Nursing and
♦ Chikilsa Ki Bharatiya Pranaliyan Aur
greater awareness have made some
conducts health training sessions as part of the
Homeopathy
improvement. An old lady was found to be
.8
Parinche Project of FRCH______
(Article in Hindi).
Dr. N.H. Antia
complaining of an increased work load on the women due
to the spread of the habit of daily bathing and washing of
clothes among the people. This improvement was possible
because of an increase in the per capita income which has
made soap more affordable, an improvement in the water
supply system which has made water available more regularly
and right at the doorstep of the people, and also, an increase
in literacy as well as general awareness due to the penetration
of media which stresses the importance of personal hygiene
for maintaining good health.
Every change has not necessarily been for the better,
though. About 50 years ago, carrots which are rich in vitamins,
formed an important part of the regular diet of the people.
Today, agricultural development has led to the availability of
a variety of foodgrains and vegetables and the carrot has been
branded as the food of the poor. Consequently, less and less
people now eat carrots which are mainly used as animal feed.
Also, the availability of polished grain as well as the
tendency to use extra fine flour has reduced the intake of
chaff which is very nutritious.
Besides observing health behaviour we also gained an
insight into the health perceptions of the people which
revealed their concept of health to be very simple yet
surprisingly comprehensive. Health, according to them, is
not merely defined in negative terms as the absence of illness
or disease, but rather, is related to all aspects of life including
the physical, emotional, mental, spiritual, social as well as
economical aspects.
Factors denoting good health as delineated by the
people are :
1. Happiness
6. Respect in the village
2. Pleasant mood
7. Well knit, happy family
3. Wealth
8. Physical fitness - no illnesses,
4. Married status
diseases or deformities
5. Children (especially a son)
Classification of Various Health Problems
Health problems are basically divided into two
categories - illness and disease. An illness is defined as a
minor health problem lasting for about 8-10 days which
can be cured with home remedies or doctors’ medicines.
This includes ordinary fever, headache, diarrhoea etc. A
disease is classified as a major health problem which either
persists for more than a fortnight, is chronic or incurable,
or leads to permanent disabilily or death. TB, leprosy, asthama,
infertility and the like, fall into this category.
As very rightly pointed out by the villagers, over the
years, due to advancement in medicine and belter access to
health care, some diseases have turned into illnesses. Cholera
is now curable with timely medical assistance, hence, it has
become more of an illness than a disease. The same holds
true for pneumonia.
Health problems are further classified according to their
source:
1. “Heavenly” wrath/ “Displeasure” of Gods
2. Astrological reasons/ “Unfavourable” stars
3. “Ancestral” wrath
4. “Possession” by “ghosts”
5. “Casting” of the “evil eye”
6. Physical reasons
The illnesses/diseases caused by the above causes and
their typical symptoms:
1. Heavenly wrath - If the Gods are not propitiated as
promised, the person for whom the Gods were propitiated
is made to suffer to remind her/him of the promise - the
person is either bitten by a snake, becomes accident prone,
cannot beget a child (especially a son), gels some disease
or the other, suffers from rash or bumps on the skin or may
even die.
2. Unfavourable stars - When the stars are unfavourable, one’s
efforts do not yield any success, their is loss of income,
the peace at home is lost due to constant bickering, things
continuously get lost or stolen from the home etc.
3. Ancestral wrath - If the ancestors are not duly appeased,
their spirits enter the successors or trouble them in some
way or the other. While children who are affected cry
constantly and do not open their eyes, adults suffer from
cramps and shooting pain in the legs.
4. Possession by ghosts - If a child gels possessed it becomes
heavy lidded, it gets fever and cries continuously. Adults who
are possessed stare vacantly, become extremely lethargic,
talk to themselves, generally behave strangely and sometimes
get fever.
5. Casting of the evil eye - This results in strange and/or
unfavourable happenings in the house. If one is the victim
of the evil eye one feels like vomiting, gets stomachache
and suffers from diarrhoea.
6. Physical illness - Something goes wrong with the working
of the body or their is a physical deformity present right
from birth.
People have various cures for different health problems:
1. When possessed by a ghost, they worship lord Dutta.
FRCH NEWSLETTER, VOL XL NO.4, JULY - AUGUAT '97
2
2. When troubled by the evil eye or ancestral wrath they visit
the religious mendicants or oracles and follow certain rites
prescribed by them to remove the ill effects.
3. When one is facing the Gods’ wrath due to failure to
propitiate them, the oracle gives the necessary advise regarding
which God to worship; the particular rites to be performed
like sacrificing a goat, offering food and clothes to the
Goddess, inviting people to sing bhajans etc.*; all of which
cost an estimated Rs. 5000 to 6000.
4. When the stars are unfavourable, the people approach the
brahmin who tells them exactly which star is unfavourable and
what has to be done to counteract its influence.
5. In case of physical illness or infirmity, the people practice
home remedies like eating nutmeg paste to cure diarrhoea etc.
If these remedies do not work, they visit the local
healer and in rare cases, approach the doctor.
The local healers use various indigenous medicines
including a) Herbal medicine :
1. Jaundice -Wearing a necklace made of the Gul (Tinospora
Cardiofola) creeper.
3. Headache - Tea with ginger
4. If pierced with a thorn - Rui (Calotropis Procera) milk.
5. Continuous bleeding from a wound - Aina (Terminalia
Tomentosa) powder
6. To heal a wound - Dagadi Pala (Licopodium)
7. Excessive menstrual bleeding - Powder made from .
descending shoots of banyan tree (Ficus Bengalensis)
8. Excessive white discharge - Rice water bath
9. Passing of blood/mucus with stools - Erand (Jatropa
Curtus) milk with tea
b) Medicines prepared from animals/animal parts :
1. On being bit by a scorpion or rupture of the eardrum Apply oil in which a scorpion has been boiled.
2. Pneumonia - Drink rabbit blood
3. Non-lactation - Drink earthworm curry
4. Arthritis - Massage the stiff joints with bat blood
5. Asthama - Eat Pigeon blood and meat
6. Leprosy - Eat snakes (a person who has eaten snakes is
believed to be immune to their bites)
7. If the animals start shedding their tails - Apply paste made
of snake skin.
8. If an ox gets a wound on its shoulders - apply lizard oil etc.
Their are special local healers for particular diseases:
* Some healers do the work of modern day orthopedists
and physiotherapists
* Some local women are specialists in conducting deliveries
and offer cure for some typical women’s health problems. They
also treat cases of pneumonia, which the people believe to be
a stomach problem, and of children suffering from stomach spasms.
* There are healers who chant mantras to cure headaches,
stiff muscle joints, pneumonia, scorpion bites etc.
How do these local healers acquire their knowledge
or professional status ?
1. Brahmin is a caste. Hence, a person born into a brahmin
family automatically acquires that status. The knowledge is
generally gathered from within the family itself.
2. Those healers who chant mantras for cure, invest the mantra
with the power to heal by concentrating on and continuously
chanting some words during an eclipse. These words then
automatically turn into effective mantras.
3. Local healers who prescribe medicinal herbs as well as
local massagers generally acquire their knowledge from
within the family itself and sometimes from outside experts.
4. Women who have gained wisdom due to age and/or
experience are approached for deliveries and for solving
women’s health problems. Similarly, women who are
possessed by a God or Goddess, are considered to have acquired
healing powers and are approached for various health problems.
All local healers e.cept brahmins, accept payment in
•
,
2
s,
:r
kind. In most of the cases, the payment to be made for a
particular cure is preordained as per custom. Brahmins are
usually paid Rs. 20 - 25 for consultation and offered food.
Generally, the healers avoid charging exhorbitantly as
they believe that it will invite the displeasure of the Gods
and reduce their healing powers. Whenever they are faced with
any health problem, the people first try out home remedies.
If they still do not feel better they go to some oracle or religious
mendicant who diagnoses the problem and suggests the remedy
for it. For eg., if the source of the problem is diagnosed as
heavenly or ancestral wrath then they are directed to visit a
brahmin, if it is some physical problem then they are asked
to go to the doctor and so on. Thus, there is a kind of indigenous
referral system working at the local level. What is needed is
to add modern inputs to this local health system and remove
the harmful practices through education. On the other hand,
there is a need for documenting and dissemination information
about indigenous medicine that is effective, inexpensive, easily
accessible and with almost no side-effects.
□
* There are local massagers who give relief from stomachache
* This information has been assimilated and presented to the best of our
as a result of tightening of abdominal muscles.
knowledge. any misinterpretation or fiHission of data is regretted.
* Their are special healers to cure rickets by rubbing certain
With inputs from Baby Khandkar and Bharati Sonavane
English Translation : Vaijayanti Aphale
medicinal herbs on the suffering child.
3
FRCH NEWSLETTER, VOL XL NO.4 JULY- AUGUST '97
Effectiveness of Public Health Functionaries
at the Grassroots level
This article is based on a study of grassroots level public health functionaries
conducted by Dr. S.N. Morankar at Supa, Pune district in 1991
In the primary health care services provided by the
Government, the community health volunteer (CHV) and the
dai (traditional birth attendant), are the backbone of the PHC.
The CHV is a member of the community who is delegated
to undertake certain tasks, covering a population of 1000,
requiring special skills, time and attention. The dais are
trained in simple and practical aseptic techniques and provided
with simple kits to conduct deliveries. Despite the existance
of a large number of nurses and auxiliary nurse midwives
(ANMs), more than three-fourths of the deliveries in the
rural sector continue to be undertaken by the traditional birth
attendants. This is natural, as one ANM is expected to attend
to a population of 5000, which is physically impossible. The
dai. who is available within the locality itself, is comparatively
easily accessible. Hence, her role in maternal and child health
care cannot be ignored.
In addition to these two PHC functionaries, an
anganwadi worker and helper delivers the package of services
provided for children and mothers under the Integrated Child
Development Services (ICDS) programme. The ICDS
programme covers supplementary nutrition, health check-up,
primary health care/referral services, immunisation, nutrition,
health education and non-formal pre-school education.
Approximately one Anganwadi worker for a 1000 population
is sanctioned in the rural areas. Thus, there are four important
primary health care functionaries at the PHC level - the CHV
and dal belonging to the primary health care services and the
anganwadi worker and helper of the ICDS programme.
We had conducted a study at Supa village in Baramati
taluka of Pune district in 1991 to understand the functioning
of these grassroots level health workers. We held a few
meetings with these workers at the sub-centre level in the
presence of an ANM. The functioning pattern, difficulties
(social as well as technical) faced while delivering health
care and suggestions for effective work, were the main topics
discussed in the meetings. Observations and informal
discussion methods were also employed to collect
information pertaining to the functioning of the system. A
few community leaders* were also interviewed informally
Dr. S.N. Morankar has done his PhD in Anthropology and is a
researcher on the TB project carried out by FRCH
FRCH NEWSLETTER, VOL XI, NO.4. JULY - AUGUAT '97
regarding their role and community participation in primary
health care.
Recruitment
CHVs :
The selection of the CHV is a complex process
involving the community, local leaders and the medical officer
and is of great significance. There is a general understanding
that the CHVs need to be local workers, broadly representative
of the community they are to serve as well as acceptable
to all the major sub-groups in the community. Also, the CHVe
has to be preferably middle-aged, literate, willing to render7
service without caste biase and without any encumberance
so as to spare enough time for health work.
The health committee of the Gram Panchayat of Supa
had chosen the CHVs according to a few criteria like middle
age, literacy and time to spare. Though the selection criteria
was apparently adhered to, during the actual selection process
many caste/class biases tended to creep in. The health/village
Panchayat committees selected the majority of the CHVs
belonging to the dominant caste since most of the community
workers themselves belonged to that caste and the CHVs
had personal connections with the community members.
In fact, that the dominant caste/class in the community tended
to look upon the job as a means of providing employment
to one of its caste members.
Some of the CHVs themselves belonged to the villag.@)
committee. Thus, the impact of the selection process, which
is expected to ensure community participation in CHV
selection, is lost and community participation is reduced to
decision making by a few dominant people with the minority
groups almost completely excluded. Naturally, the villagers too
had lost faith in the CHV personnel to fulfill their health needs.
Anganwadi Workers :
The anganwadi worker is a women selected from within
the local community. The selection committee consists of
the Panchayat Samiti president and two other members, the
child development officer and the block/taluka development
officer. The selection committee asks the village committee
to forward the most suitable applications from the total
applications received by the woman candidates. The main
4
selection criteria for the anganwadi workers are : the female
should have finished her matriculation, should be a local
inhabitant and have some experience as a teacher even if
it be for a balwadi. Preference is given to someone who
is a widow, deserted, separated or disabled.
Though the actual selection criteria were adhered to,
the applications forwarded by the village committee were
Patterns of Employment
It was observed that there were a few health workers
who functioned only in one category of health workers, while
in other cases, the same persons simultaneously played the
role of two or more categories of health workers.
Functioning
invariably those of women belonging to the dominant caste
and having connections to village leaders, despite many other
eligible candidates available in the village.
The implications of this are :
1. Many CHVs remain non-functional.
2. PHC functionaries are unable to take action against such
non-functioning CHVs due to the latters’ connections with
the village leaders. It has also been seen that a few CHVs
have not attended training and many of them also do not
attend monthly meetings but they continue to receive their
honorarium as usual. If the medical officer tries to withold
payment, he is threatened by the respective committee members.
3. Health/village committees refuse to take any action against
the non-functional CHVs.
4. Though, technically, the CHVs have to report to the PHC
functionaries, this rule is not adhered to many times, and
the latter do not insist for fear of displeasing the community
in which they have to function.
Community Participation
The CHVs, being a part of the community, are expected
to involve the people in the promotive, preventive and curative
activities of the PHC. Unfortunately, no real impact has been
seen at the community level - at the most, the individuals
have been roped in only as passive beneficiaries. Their is
no attempt to lake the community towards self-reliance and
I no instances of the community voluntarily contributing in
cash or kind towards promoting community health.
Village Health Committee
It was expected that the village health committee would
take part in promotive and preventive health aspects in
collaboration with CHV and PHC functionaries.
Unfortunately, even a relatively active member of both the
village committee as well as the village health committee,
educated upto second year of graduation, has this to say,
“I do not really know what are the functions of the health
committee and how to collaborate with CHV and PHC
functionaries.” If this is the state of an active and educated
committee member, one can imagine what must be the
awareness level of the other members.
5
From the detailed job responsibilities of CHV and
Anganwadi workers which have been described in table 1.
it will be seen that many vital functions are overlapping such
as maternal and child health, immunization, health check-up,
nutrition, health education, referral services etc.
It has been found that these overlapping functions are
being carried out more effectively by the health workers who
arc CHVs as well as Anganwadi workers as opposed to those
who function as either a CHV or an anganwadi worker alone.
The reasons the workers who play a dual role (CHV
+ anganwadi worker or CHV + anganwadi helper) are more
effective arc :
1. Vital functions assigned to both categories of workers
are overlapping so the total work gets reduced when pooled
together. Also, more services get provided under one roof
which makes the health care provision more efficient.
2. The social status of the worker is enhanced as a medical
kit is provided to anganwadi workers.
3. The anganwadi worker has to regularly report to the
anganwadi supervisor (Mukhya Sevika), which introduces
some discipline in the work carried out.
4. The total honorarium increases to either Rs. 275 (Rs.
225 for anganwadi worker + Rs. 50 for CHV worker) or Rs.
160 (Rs. 50 for CHV worker + Rs. 110 for Anganwadi helper).
Similarly, workers who play the role of dai as well
as CHV worker are more effective. Since the dais conduct
deliveries they get more respect in the village and hence
a better response for their CHV work like immunisation of
the children, nutrition, health education and post-parlum care.
In contrast, when the roles are separated various
problems arise :
1. Their is a tendency to push the responsibility of overlapping
functions on each other. This happens particularly during
immunisation wherein both categories of workers are
supposed to inform people and induce them to get immunised.
They are supposed to provide a rough estimate to the ANM,
who has to actually administer the vaccine, of the number
of people likely to come for immunisation on a particular
FRCH NEWSLETTER. VOL XL NO.4 JULY- AUGUST *97
Table i. Comparison between Job Responsibilities of CHV and Anganwadi Workers
No.
CHV
Anganwadi
Overlapping junctions :
v
Maternal and child health
1.
2.
immunisation. health check-up, referral services
immunisation, health check-up, referral services
3.
Nutrition and health education
Nutrition and health education
4.
Identify children needing nutrition
Identify children needing nutrition
5.
Birth and death records
Birth and death records
Maternal and child health
Non-related Junctions :
v
6.
Family planning
Make a survey of children below 6 years of age and
pregnant and nursing mothers within the community
every month and note down their weight to identify
those at risk.
7.
Environment, hygiene and sanitation:
i) Disinfection of drinking water ii) Insectiside spraying
iii) Cleaning of surroundings iv) Soak pits v) Latrines
vi) Kitchen garden vii) Smokeless chulha
viii) Larvicide of stagnant pools etc.
Organise non-formal pre-school education in the
anganwadi for children in the age group of 3-6 years
8.
Arrange for regular supplies of medicines, chemicals etc.
Organise supplementary nutrition for children
(6 months to 6 years of age) and expecting as well as
lactating* mothers
9.
Indentify and report cases of malaria,
tuberculosis, leprosy and epidemic diseases to health
workers and PHC
Make home-visits to educate the parents, especially
of those falling in the risk group, so that they are
enabled to take proper care and minimise the health
risks of their children.
10.
Involve community in its own health care
Elicit community support and participation for
government run health programmes
11.
Advise on common ailments
Maintain liason with other institutions and
individuals in the village e.g. Panchayat, Mahila
Mandals, School Teachers, Dais etc. and seek their
support and participation in running the programme.
12.
No formal reporting to the PHC
Maintain the prescribed registers and records. Report
any developments in the village which require further
attention to the Child Development Project Officer
or Supervisor.
day. The workers tend to shift the responsibility on each other
which results in faulty reporting to the ANM. This creates
lots of problems as the vaccine is contained in an ampule
which has to be administered to about 12 people at a time.
If the number of people turning up at the PHC is lesser than
that, then the vaccine goes waste as an ampule once opened
cannot be reused. On the other hand, at times, the number of
people turning up is so much that they have to be sent back
without being vaccinated.
2. Another major problem is the disparities in payment, what
with the anganwadi worker getting paid Rs. 225 while the CHV
worker a measly Rs. 50 for almost the same amount of work.
3. Medical kits are provided to anganwadi workers but not
to CHVs which increases the status of the former among
the people at the cost of the latter. This trend seems to be
increasing over the years.
Conclusion
The varied experiences documented by us offer an
insight into the functioning of the primary health care workers
FRCH NEWSLETTER. VOL XI. NO.4, JULY - AUGUAT 97
at the village level. The main observation is the dichotomy
between concept and reality. In concept, the PHC is supposed
to be community oriented but in actual practice it inevitably
becomes programme oriented. In concept, the PHC is an
outcome of the felt needs of the people but in reality, the
PHC planners hardly take these into account. In concept,
the PHC is expected to be self-sufficient and supportive
of the community but this is hardly the case. Lastly, the
PHC is expected to encompass a multi-sectoral approach,
which in reality is seldom realised.
The role of the CHV in PHC programme would have
been easy to define if the PHC was genuinely communityoriented and an outcome of the felt needs of the people.
Unfortunately, as the PHC has become mainly programme
oriented, the CHV is largely placed in a situation where
role expectations and performances do not match.
In reality, the PHC was introduced to reduce the
widening gaps between those who have access and those
who do not have access to resources such as income, food,
6
employment and education. It postulates a redistribution of
resources and a strong sense of self-reliance among the
people. But seldom has this been understood by the
implementing authorities of the health programme. Therefore,
the role of the CHV has been reduced to mainly serving
as a link between the main programme and the people - to
motivate and refer the people who need medical care.
The approach of CHVs is largely individualistic or
family oriented, little impact has been felt at the community
level. Therefore, since no responsibilities of the health
committee are defined and no definite control mechanism has
been defined, the CHVs could not meet the expected challenges.
This shows that there is an urgent need for a
reformation of the existing cadres and system for which the
following need to be clearly spelt out :
9) Increase the health awareness of health committees.
10) Most important, the people themselves need to be
educated on the various aspects of health care including its
socio-political, cultural, economic ramifications and also
informed about the public health services available to them
so that they learn to demand these services as a right.
* The Gram Panchayat consists of various committees at the village
level such as health committee, environment and sanitation committee, water
supply committee etc. The Gram Panchayat members form these committees
which consist of a chairman, secretary and other members, through mutual
discussions. Each member can serve on more than one committee,
simultaneously. These committees are supposed to look after the overall
management of the services falling within their perview.
□
References :
1. WHO-UNICEF, Alma Ata 1978, Primary Health Care : Report of the
1) The role and job responsibilities of the cadres
International Conference on Primary Health Care, 1978, Geneva.
2) Remunerations and personal profile of the cadre
2. Ramprasad Vanja, Community Health Worker: Critique of an Experience,
3) Selection procedure to neutralise the bias of the dominant
caste.
3. Indian Institute of Education, Health for All : An Alternative Strategy,
4) Functions and responsibilities of the village health
Report of the joint study group of ICSSR-ICMR, 1981, Pune.
committee
4. Department of Women and Child Development, Government of India. A
5) Record keeping and reporting to an appropriate supervisor.
1985, OXFAM Trust, Bangalore.
Guide Book for Anganwadi Workers, 1986, New Delhi.
5. Ministry of Social Welfare, Government of India, Integrated Child
6) Taking action against non-functional workiers and health
committee members.
Development Services Scheme (Revised), 1982, New Delhi.
6. Rural Health Division Ministry of Health and Family Welfare, Government
7) Coordination at higher levels such as PHC/block, District,
State and Union with the PHC functions
of India, Job Responsibilities of Staff of the Primary Health Centre, 1986,
8) Improvisation in the training content and period of training
of health workers.
7. Department of Health and Family Welfare, Government of Maharashtra,
New Delhi.
Guidelines for Community Health Volunteers (in Marathi), 1980, New Delhi.
(y S 3 377)
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The Foundation for Research in Community Health
Sept. - Oct. 1997
Vol. XI, No.5
A New Approach to Pharmacological Evaluation of Medicinal Plants
Re-searching Indigenous Medicine
Dr. K. C. Sharma
•
.What is the truth behind the mysterious legends claiming
the existence of panaceas for all diseases ? What is the source
for all the titbit formulae or informal remedies which reach
me frequently from patients, attendants or relations when
I go visiting a patient ? At the base of it all lies the age-old
wisdom of India promising a cure for many of the diseases
which modern medicine, even in the 20th century, has failed
to deliver.
The sciencea of medicine originated with man, and
developed as civilisation advanced. As such, it is not a
discovery, but an evolution, born out of man's struggle
throughout the centuries.
As life and disease coexist, so must remedy have always
followed any disease. After all, it is ridiculous to expect
a person from Calcutta to have visited Kashmir for treatment
of a shake bite ! This is especially true of geographically
isolated areas such as Tibet and China. Each civilisation
developed its own method of treatment by investigating locally
available plants and other sources, leading to the simultaneous
existence of a variety of plant medicines and their
combinations to treat a particular disease.
It is obvious that man must use the most
easily available material as remedy. As plants
fitted the bill, medicinal properties of plants
were discovered first. Indians have shown
amazing depth and accuracy not only in
Dr. Sharma, MBBS, MS, is a specialist
surgeon at the District hospital, Udhampur, J&K.
acquiring this knowledge but also successfully transmitting
this knowledge through verbal discourses even to the smallest
household in the country. This has only been possible by
acute power of observation, thinking, analysis and extensive
trials by our persevering ancestors.
Today, there still exists a vast treasure of information
regarding various medicinal plants and their preparations,
metals and their compounds and many animal products,
though, in the course of time, much knowledge has been
lost. Those who possessed such knowledge have also played
a part in its disappearance by keeping the knowledge
exclusively to themselves or within the family, regardless
of whether their successors were genuinely interested and
capable.
The advent of allopathic antibiotics coupled with advanced
surgical techniques has relegated plant medicine to the
background. The current fast pace of life with a premium
on quick results, regardless of ill-effects in the long run,
has compounded the problem.
Being trained in Western .therapy and after practicing it
for about 30 years I have realised that it
is still a far cry from being a satisfactory
in this Issue
means of curing. Most available drugs have
‘Re-searching Indigenous
unwanted side effects, a short expiry date,
Medicine.........................................1
Dr. K. C. Sharma
are not very palatable and of course, terribly
costly, taking them beyond the reach of the
♦Udupa Committee Report Dr. Shipra Banerjee
common man. I am convinced that
notwithstanding the mad race for synthetic
*Paramparik Chikitsa Ko Samajhna
(Article in Hindi)................................ 6
drugs, which often cure but occasionally kill,
Darshan Shankar
ultimately, natural products (particularly plants) alone will
come to the rescue , of man.
A large proportion of the world population continues to
use-herbal remedies such as folk medicine; Yet, estimates
say that out of 2,50,000 to 50,00,000 species of higher plants
available on earth, only about 5 to 10% have been.investigated .
pharmacologically and that too,, usually, only for one potential
specific remedy. There are many reasons to account for such
inaptitude on our part :
I. No inclination to explore this field of medicine;
2. Existing research being limited to short tours and enquiries
which are of no use;
3. Mere reproductions of existing Ayurvedic works paraded
as original research;
4. Inadequate medicinal stock inspite of many facilities
provided over the last 30 years.
5. Modern scientists too cannot absolve themselves of some
blame. Used to their city comforts, they are not inclined
to squat on grass or stones, sleep on leaves and eat maize
with whey or boiled leaves; .in short, go close to nature,
which is generally essential for any serious research on the
subject. Not to speak of their apathy for the simple, at
times unkempt locals, even if they be a storehouse of
information!
Here, I wish to emphasise that “Research is a dignified
profession to be pursued only by the consecrated and the
inspired, in quietitude, at a leisurely pace and away from
prying eyes. It cannot be placed on a business footing where
one new fact is to be returned for each quantum of rupees
invested.” Original research can only be the product of a
constantly active creative mind. And creativity is at its best
when it is not burdened by external pressures and constant
prodding. Great discoveries evolve; they are not delivered on
call. Hence, for any meaningful research to take place, the
present approach has to be redefined, recast and reoriented.
It is imperative to change the present working pattern
by improved collection, management, development and
application of existing knowledge to achieve quick and better
results. Government must encourage and finance those already
working in this field, even if they have a small informal setup.
This could prove more cost-effective than supporting big
formalised laboratories.
For best results, the following research methodology
should be adopted :
* Studying and collecting data on plants, the use of various
parts of a plant, the best time for collection, method of
FRCH NEWSLETTER. VOL XI, NO.5, SEPT.-OCT. '97
administration, the right dose, proper identification' of the
disease to be treated and side-effects if any. Observing the
practitioners and interacting with the patients will be of great
" help in the verification of the results claimed. This will narrow
'the time gap between finding a useful plant and its trial on
human beings. J
.
* Mapping the existence of the various plants in the natural
environment (marking only bulk availability).
* Cancelling out all false unprovable prescriptions, avoiding
and possibly exposing publicity mongers, jugglers and
self-styled healers.
* Maintaining a detailed collection of plants and their various
parts, based on the above information,. As far as possible,
the persons actually involved in collection should be well
versed in the field and not mere hired staff who have no
knowledge of the subject. Of course, in places which are
normally inaccessible due to difficult terrain the help of locals e)
and army personnel would be necessary for collection of Y
plants the year round.
* Honest and tireless efforts at the laboratory for extracting
the medicine from the plants for various diseases. The
isolation of the active principal should be done in a technically
sound manner.
* Experiments on animals.
* Finally, trials on human beings with the cooperation of
clinicians and the patients themselves.
The stages before the lab work are the most important
and difficult. They require immense hard work and patience
and building up of a good rapport with the locals to make
the most of the knowledge they posses. The language and
expression of the locals will have to be followed keenly
to avoid misinterpretation. Care should be taken to avoid
confusing hearsay with facts, especially by those on a0)
time-bound tour to a particular area.
The best policy would be to assign the task to enthusiastic
and knowledgeable locals, giving them all the financial,
technical and moral support required. Senior scientists could
pay regular visits to them for checking and counter checking
their work. Only those plants which have passed this test
should be taken for laboratory examination. One should be
prepared to put up with some apposition from the city
dwellers who might resist the idea of allocating the research
work to locals, as it could decrease their monopoly over
the same.
A close relationship of unity and cooperation should be
established between the peripheral support worker, lab
Contd. on page 8
2
Problems Assailing Ayurveda and Possible Solutions
Udupa Committee Report -1
Dr. Shipra Banerjee
There were various forms of medical practices existing
in ancient India, the most popular of which was Ayurveda.
By the beginning of the Christian era, Ayurveda had even
spread to adjoining countries like China and the Middle East.
After flourishing for centuries, many factors led to its eventual
decline, the advent of modern medicine being a major blow.
Though the problems that assail Ayurveda are deep rooted
they are not insoluble and attempts have been made to
resuscitate it from the early part of this century. Various
Committees have been appointed by the Indian Government
after independence, to look into the problems assailing the
Ayurvedic medicinal system and find possible solutions to
help in its revival. One of the foremost of these was the
Udupa Committee commissioned in 1958, chaired by Dr.
K.N. Udupa, the noted surgeon and scholar in Ayurveda.
Terms of Reference
The terms of reference of the Committee were as follows:
1. To evaluate and assess the work already done in the field
of Ayurvedic Research, especially by those Institutions receiving
Central and State Government grants for the purpose.
2. To assess the existing facilities of training and research
in Ayurveda;
3. To assess the nature, volume and standard of the Ayurvedic
pharmaceutical products; and
4. To find out the existing status of Ayurveda regarding its
practice and the recognition accorded to it.
Based on postal questionnaires, direct observations and
interviews, besides personal contact as the main research
tools, the report was completed by the end of 1958. Some
of the major observations and recommendations of the report
are presented below.
attitude unnecessarily favours modern medicine, while denying
the trust of the people in Ayurveda. Instead, an effort needs
to be made to fill the inexplicable gaps left in it, if not by
current Ayurvedic knowledge, by modern scientific methods.
Ayurvedic Research
Observations :
Most of the research being done on Ayurvedic drugs from
the beginning of the 20th century has been directed towards
rediscovering useful medicine from the large mass of
Ayurvedic drugs suitable to be used by the practitioners of
Western medicine. While these efforts have enriched the
Western system of medicine, the traditional Ayurvedic
physician feels that nothing is being done for research in
the Indian system of medicine as a whole.
The research being presently undertaken at teaching
institutions and by individuals under Central or State schemes
is not very systematic either. Lack of collaboration between
professionals of various systems of medicine has resulted
in accumulation of a large amount of uncompared and
uncoordinated data. Adequate facilities do not exist in many
places. There is duplication in the diseases chosen for
investigations. Also, there is lack of complimentary research
like literary and pharmacological research on a planned basis.
Recommendations :
It is recommended that a Central Council of Ayurvedic
Research be established, as also three postgraduate training
institutes having research centres in the remaining three
regions of North, East and South India, on the analogy of
the Jamnagar Institute in Western India. The State
Governments should establish Boards of Research, which
may closely follow the various lines of research chalked
out by the Bombay Board of Research.
Observation on Recommendations of Previous Committees
Concerning the recommendations of the various
committees on Ayurveda, it is observed that the government
has kept the implementation of these recommendations on
hold until such time as its merit has been proved by authorities
on modern medicine. The Committee feels that such an
Dr. Shipra Banerjee, M.D., M.P.H., DARCP&S, is a
Research work in Ayurveda should be done under the
following seven heads: 1. Clinical; 2. Literary; 3. Chemical;
4. Botanical; 5. Pharmacognostical; 6. Pharmacological;
7. Basic Principles of Ayurveda. Clinical research should
precede every other type of research to be undertaken by
vaidyas, preferably in a separate wing of a modern hospital
in complete collaboration with the modern physicians there.
Senior Consultant in Community Health Management at the
Rural Medicare Society, Delhi.
3
Literary research may be undertaken including collection.
FRCH NEWSLETTER, VOL XI. NO.5, SEPT-OCT. ‘97*
Dr. Katil Narasimha Udupa (1920-92)
translation and review of old manuscripts and publication of
the more important ones, publication of suitable textbooks etc.
A graduate in Ayurvedic Medical Sciences from the
Banaras Hindu University (BHU) with a postgraduation in
surgery from abroad, Dr. Narasimha Udupa went on to become
one of the pioneers of integrated wholistic medicine in India.
A man with a great vision, Dr. Udupa worked tirelessly
throughout his life to put into practice what he thought was
best for the health system of India. Initially, he was criticised
by many Ayurvedic practitioners for trying to modernise and
westernise the Ayurvedic system of medicine but gradually his
model was followed almost all over India.
Starting to work in the field of surgery in various
capacities all over India, in 1 960, due to popular demand,
he accepted the principalship of the undergraduate Medical
College t the Banaras Hindu University. During the initial phase
of the growth of the institution, Dr. Udupa worked relentlessly,
not only as the builder of the institution, but also as a surgeon
and a teacher. Under his aegis, the Medical College was
eventually upgraded to form the Institute of Medical Sciences
in 1972 under which both the Allopathic and Ayurvedic units
flourished.In the Institute, Udupa pioneered research on several
subjects including experimental research in surgery. One of his
important researches was the role of the Arjuna plant in relieving
heart trouble. Dr. Udupa also authored many monographs and
even started and edited two medical journals.
After his retirement he did not bury himself in
academics alone but tried to apply his knowledge and
experience for the benefit of the community. Through the.
Integrated Rural Development Programme adopted by the BHU
in 1980, he organised to provide services to the community,
including health, welfare and employment generation. Similarly
he made full use of a project funded by ICMR (Operation i
Research Project) to work with the community on a larger scale
Modern scientists should take up chemical research on
indigenous drugs whose efficacy has been proved clinically,
taking the active help of vaidyas.
In the field of botanical research, steps should be taken
to undertake surveys of medicinal plants in different regions
in India in collaboration with the Forest Departments and
detailed maps prepared thereon. The Central Council for
Ayurvedic Researchshould then plan an extensive cultivation
programme on a scientific basis with the advice of botanical
experts in the country. In this context the treatises on
Vrikshayurveda may be studied with advantage.
The Council should assign the task of pharmacological
research on plants and herbs to 12 to 15 separate units, each
consisting of a botanist, a vaidya and a photo-artist, and should
aim at completing the work on the known herbs and plants
in about ten years time. Similarly, pharmacological research
on indigenous drugs should be planned and financed by the
Central Council of Ayurvedic Research in consultation with
expert vaidyas. This work should be allocated to
pharmacologists who should work in collaboration with other
science experts. It is very essential that in all this work the
basic principles and recognised practice of Ayurveda should
be investigated by learned Ayurvedic scholars.
It is also recommended that the Central Council may plan
research in the following branches of Ayurveda, which are
now in vogue among traditional vaidyas: Dietetics; Pediatrics;
Treatment of mental diseases; Treatment of eye diseases;
Orthopedics; Toxicology; Dentistry; Preventive medicine
including yoga and Oil and massage.treatment.
and try out many innovative and integrated approaches in health
care delivery combining indigenous drugs, yoga and surgery.
Pharmaceutical Products
(
His compassionate and intelligent nature and good
communication, administration and medical skills, allowed him
to mobilise and get fine cooperation from both the project staff
as well as the village community. He also started organisations
dealing in indigenous medicine like the Bharatiya Swasthya Sangh,
to serve the rural people and promote research in these fields.
Observations :
Pharmaceutical chemistry is one of the branches of
Ayurvedic medicine which was relatively well developed in
the past and includes medicinal preparations of both vegetable
as well as mineral origin.
He received many awards and honours in his lifetime
including the "Padmashree" in 1972. Dr. Udupa was invited
to deliver lectures and participate in various prestigious
conferences all over India and abroad on a wide range of topics.
Unfortunately, Dr. Udupa’s work was not appreciated
enough especially by his colleagues from modern medicine,
coming as he did from the ayurvedic backgroumd. But the
people of Banaras continue to remember him with love and
respect as a true "Dhanwantari" - a complete doctor.
*
FRCH NEWSLETTER, VOL XL NO.5, SEPT.-OCT. 97
Till recently, the practicing physician himself used to prepare
his own medicines. Following the introduction of Western
systems of medicine, gradually, an attempt has also made to
separate the Ayurvedic Pharmacy from the practice of medicine.
The overall number of pharmacies as well as production
technology has improved considerably after independence.
It is estimated that about eight million pounds of Ayurvedic
medicines are consumed in India per year; the annual sale
4
of Ayurvedic medicines in India being about Rs. 6 crores.
Unfortunately, there is lack of standardisation in the preparation
and application of medicines which differes from place to place.
Closely connected with the preparation of Ayurvedic
medicines is the problem of inadequate supply of raw
materials. Moreover, the absence of a standard and
comprehensive Ayurvedic Pharmacognosy as well as legal
supervision has increased the scope for imitation of raw drugs
and adulteration by sellers. The present system of collecting
Ayurvedic drugs and plants from forests and hills through
non-technical contractors and local men has caused
denudation of forests and hills of valuable medicinal.plants.
Recommendations :
The Committee recommends the compilation of an
Ayurvedic Pharmacognosy based on botanical surveys in the
various forest regions of the country and systemic collection
and storage of raw materials in collaboration with the forest
authorities and Botanical Survey of India. The Central Council
for Ayurvedic Research should standardise the formulary of
each medicine and compile a proper Pharmacopoeia.
Standards will have to be laid down for prepared medicines
too in order to ensure correct admixture of components.
The creation of Drug Farms and Museums by Governmc. :
would be the first step in this direction. There should be
well equipped laboratories for standard testing of raw
materials used in the preparation of medicines. The forest
department should keep certain hilly areas reserved for the
cultivation and preservation of medicinal plants to be made
available to the manufacturing firms as required.
Status of Practice
Observations :
While various acts have been passed to control the practice
of modem medicine, legislation and implementation regarding
practice of indigenous medicine has generally been
indifferent. There is shortage of funds provided by the
Government, lack of building and other facilities, shortage
of Ayurvedic hospitals and dispensaries and failure of the
authorities to recognise and recompensate adequately the
services of the vaidyas.
On the whole, there is roughly about one vaidya for every
2500 people in the country, compared to one modern
physician for every 5000 people. More than one third of
the total population in our country, mostly from rural areas,
is still treated under the indigenous system by spending 5%
of the total medical budget. Since it is obvious that the people
still resort to this treatment because they find it beneficial
and more economical, it is our duty to approach the problem
with sympathy and encourage and recognise the system.
5
It.is to be noted that, while the services of modern
medical practitioners are profitably utilised in nation building
activities, the services of vaidyas are not being utilised in any
programmes for the development of rural areas although such
programmes are held up for want of trained technical personnel.
There are at present 11 states in India having Boards of
Indian Medicine for the control and practice of Indigenous
System of Medicine. The Boards maintain a register of
qualified Ayurvedic practitioners besides supervision of
Ayurvedic education, inspection of examination conducted
by various institutions, exercise of disciplinary control over
Ayurvedic practitioners and advising the state Governments
generally in all matters of Indian medicine.
About 22% of the total number of registered Ayurvedic
practitioners have received institutional training. But except
for a few states, their grades of pay and status continue to
be low in comparison to those of the modern medical graduates
as they are insensitively grouped with traditional vaidyas.
The present practice of Ayurveda is limited to general
practice though in Ayurveda eight branches of specialisation
“Ashtanga” have been described. Most of those having
received institutional training utilise both the modern and
ancient methods that are taught to them for the purpose of
diagnosis and treatment and the trend is increasing towards
usage of modern medicine. Unfortunately, Ayurveda continues
to be plagued by unethical practitioners who try to pass on
useless drugs as rare traditional cures or scientifically
researched remedies.
Recommendations :
The Government should revise their present policy and
fully utilise the Ayurvedic practitioners in implementing the
nation building activities. There should be separate high
powered Directorates for Indian Medicine in all the states
who should see to it that an adequate numbers of hospitals
and dispensaries, properly housed and well-equipped, are opened
and the vaidyas in charge of such institutions are well paid.
The Boards of Indian Medicine should register all
Ayurvedic practitioners in distinct categories and exercise
proper control over them. Educational aspects of Ayurveda
should be dealt with by the University authorities, who may,
however, take the advice of the Boards of Indian Medicine,
wherever necessary. The practitioner of Ayurveda himself
should strive to elevate his practice is moral terms and make
efforts to bring his knowledge of medicine up-to-date. Finally,
there should be a non-official All India Organisation of
Ayurvedic Practitioners whose aim should be to promote
the welfare of the science and its practitioners.
To be contd. in the next issuc.......
FRCH NEWSLETTER. VOL XL NO.5, SEPT.-OCT. "97
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FRCH NEWSLETTER. Vol. XL No.5 SEPT:-OCT. '97
Contd. from page 2
researcher and the clinicians. It is essential to create
favourable conditions for work and study, so that scientific
and technical personnel can devote themselves entirely to
the advancement of scientific research.
One should not fail to acknowledge the work of the locals,
for the major work in this scheme of things will have been
done by them. Otherwise, the lab scientist, who merely
confirms the original findings by isolation of active
principles and animal experiments, will walk away with all
the credit.
Serious efforts are needed to overhaul the administrative
setup for optimum utilization of inputs and safeguarding the
interests of young qualified scientists and other genuine arid
sincere workers of allied cadres.
It has been observed that immediately after studying the
properties of a plant, if found useful, we try to cultivate
it in the laboratory. It is likely that it may loose some of
its medicinal properties in the process, hence, as far as
possible, the plants should be retained in their natural
environment.
Any work done on indigenous medicine should be encoded
into a materia medica for further reference so that it is
not lost again. Reference museums should be established
and exhibitions of the plants held from time to time to create
greater awareness.
Finally, there should be identification, collection and
systematic documentation of all information.about individuals
and groups working in different parts of the country and
the world for closer coordination and mutual exchange
of knowledge.
Acknowledgement:
Dr. C.K. Atal, Director. Regional Research Laboratory. Jammu.
I
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The contents of this newsletter may be
abstracted without prior permission.
However,
we would
appreciate
acknowledgement of the source and
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The views expressed in the articles are those of the
authors and not necessarily those of FRCH
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NEWSLETTER
1 “I
Vol. XI, No.6
u gys
e.
K
.Nov. - Dec. 1997
A Critical Analysis
Health Education in Schools
Sangeeta Sachdeva
Formal health education imparted in schools is concerned
with the acquisition of knowledge about health and disease
as a part of secondary socialisation resulting in health related
behaviour.
in the science curriculum to determine whether the information
content and format actually served to fulfil the stated
objectives, and to evaluate the need for restructuring of the
same.
From the year 1989, Health Education has been
introduced as special subject in the school curriculum to
imbibe into the children the value of good health and develop
healthy habits leading to better health status. The specific
objectives are :
The exact impact was sought to be calculated by
understanding the following :
* To create awareness about the concept of health and factors
influencing health.
* To create awareness about personal as well as environmental
cleanliness.
To imbibe consciousness about exercise, rest, sleep, good
posture and proper diet for maintaining good health and
develop healthy habits in the students.
* Whether the distribution of health related information in
science curriculum followed the axioms a) whole to parts
and b) simple to complex.
* Students' knowledge and awareness about health and its
relation to scholastic achievements.
* Factors affecting students' awareness about health.:
Sampling Frame
Ten schools in Pune city formed the sampling frame seven following the State board pattern (four English medium
* To develop in them the right perspective about the principle
and three Marathi medium) and three, the Central board pattern.
and practice of health and physical well being.
Twenty students each from classes VII, Vin and IX from all
schools (except for total 40 students in one
* To acquaint them with the knowledge of first
in this Issue
school) were finally selected. The schools as
aid and safely and develop skills of providing
♦Health Education inSchools.~...M.......l
well
as students were selected to represent
first aid in the case of sport injuries.
Sangeeta Sachdeva
different socioeconomic backgrounds.
* To advocate immunisation against
communicable diseases as an important means
of positive health.
A study was conducted in 1996 to make
a critical analysis of health related information
The author has submitted the above report as
her desertation for MSc. in Health Sciences
♦Movement Education in Schools....... .4
Sandhya Jinturkar
♦Changing Health Education Through
School Health Education.....................5
Khalipha Bility et al
♦Udupa Committee Report -1
Dr. Shipra Banerjee
♦Anaupcharik S wasthya Prashikshan
kc model (Article in Hindi)............. 10
Vaishali Vaidya
Collecting Data for Analysis
To gel an idea of their exposure to health
knowledge outside of the school syllabus,
the material in their libraries including
several scientific journals, educational
journals, newsletters and textbooks as well
as reference books was analysed.
The data for analysing students’ general awareness of
health and the factorsaffecting them was obtained through
questionnaires and a retention test which was mainly, of a
qualitative type. Aquestionnarie was prepared to collect
information about the students’socioeconomic background)
which included questions on :
t, {
— Educational background of* the parents
♦ Occupation of the parents.
Who helped them in their studies.
How often did they read science textbooks at home.
Questions related to education were close ended with
various alternative answers being provided. For tallying
scholastic achievements with performance in the retention test,
we went through the school records for obtaining their marks
in the previous academic session and for some schools, also
those in the current academic session. Marks obtained included
overall marks as well as those specifically in science subjects.
Methodology
The retention test paper was first pretested on students
from standards VII, VIII and IX, prior to finalising it. The
students attempting the pretest were strictly not from the
sample schools in the study. If a particular question was not
attempted by any student at all, the question was deleted
from the final questionnaire. Thus about 4-5 questions had
to be deleted from the pretest paper, though the pattern and
distribution of topics and type of questions remained
unchanged. Also, yes/no type of answers were omitted by
reformatting the questions. For eg. the question “When
breathing through the mouth, does the air reach the stomach?”
was changed to, “When breathing through the mouth, how
does the air reach the windpipe and lungs?” Those questions
which most of the students answered were reviewed and
modified wherever necessary. Care was taken to keep the
language as simple as possible. Where difficult words were
used, it was seen that their meaning would come through
in the question itself. Finally, the modified questionnaires
were translated into Marathi.
The final test paper contained 20, 20 and 24 questions
for classes VII, VIII and IX respectively. The questions in
each paper had an equal proportion of questions based on
previous grade's science knowledge and awareness about
health. Prior to setting the questions the contents in science
textbooks for classes in to IX were reviewed and topics
containing information on health were identified. The
questions on previous grade’s science knowledge gave equal
FRCH NEWSLETTER, VOL XI, NO.6. NOV.-DEC. 97
weightage to each topic. Based on these questions; an equal
number of questions were framed to test awareness about
; health,taking into consideration all possible informal sources
of health information including TV, newspapers, slogans,
hoardings etc. Allquestions were of the short answer type
- either one word or a sentence. Six questions were common
to all the, questionnaires.
—
" Most important, those appearing for the test were given
no prior knowledge of it in order to get genuine responses.
Care was also taken to minimise copying.
Data Analysis
The data collected on parent education and occupation
etc. was either categorised or graded for analysis. The data
revealing the relationship between scholastic achievements
and retention test score was analysed on the computer
including application of correlation tests and drawing of g
scatter graphs. To understand the significance of correlation, •
the 't-test' was applied.
Limitations of the Study
* A retention test for previous grade knowledge of science
(only topics related to health) was conducted in the last month
of 1996-97 session. It should have been in the mid-term
of 1996-97.
* When selecting a unit from the school, the new admissions
for 1996-97 were automatically excluded.
* The questionnaire forms should have been filled by the
students immediately before or after they had taken the test.
Due to technical problems they could only be distributed
later on.
Results
To analyse the results, first, the health related information
in the text books (Class III - IX) was classified under five
broad heads namely : human biology, nutrition, environment,
disease and its prevention and control, and others. The analysis
revealed the following anomalies :
* Frequently, the topics are introduced in a complex manner
making them difficult to grasp. For instance, in the Vth std.
textbook, chapter 5, which deals with balanced diet, should
be introduced in a simpler manner.
* Complex topics have been introduced in earlier standards
while the basic explanations underlying these topics have
been given in more advanced classes. For eg. the functions
of the heart, lungs and brains included in chapter 8 of the
IVth std. textbook, should be taught only after the simple
organs have been explained first, which are, incidentally, taught
in chapter 19 in class VI. Whatever class the information
2
is imparted in, the order should be that of simple organs
followed by complex ones. Similarly, in class IX (chapter
21), salient features of the human body have been dealt with.
These should be taught at a much earlier grade before teaching
about the five important body systems - digestion, excretion,
circulation, respiration and coordination and regulation presently taught in class IV.
* Many of the topics have been dealt with in a scattered
manner with one aspect of it being covered in one standard
and the other aspects elsewhere. To give an example, digestion
of food covered in class IV (chapter 10) should be included
in chapter 18 of the Vllth std. textbook in which life processes
- photosynthesis, digestion and excretion have been covered.
* The axiom of whole to parts has been ignored in many
cases. In the 3rd std. textbook,-chapter 9 on food deals with
micro nutrients. However, no interrelationship has been
established with their role, which is described independently.
Also, in classes III to V, there is no mention of the five
food groups and their proportion in the diet, though they
are being taught topics dealing with food/diet.
* The same information has been unnecessarily repeated in
different classes or sometimes in different chapters in one
textbook itself. In chapter 7 in class III (our body) and chapter
19 in class IV (parts of living things) some of the content
has been repeated. In class V, chapters 9 and 5 repeat the
information on ideal diets for different age groups.
* Some important information has been left out completely.
In none of the classes, is there a mention of the immune system
though other systems in the human body have been described
repetitively. From class HI to X, there are many chapters talking
about micro organisms including beneficial and nuisance micro
organisms, spread of various diseases etc. but nowhere has
the concept of disease causation been dealt with.
* Nonscientific language has been used frequently,
inadvertently adding a touch of humour! Page 30 of the
3rd std. textbook mentions that the body structure of both
boys, girls as well as adults is similar ! While page 32 in
the same textbook reveals that everyone has skin, the 5th std.
textbook claims that a house that has been lived in does not
gather dust. Page 122 of the 4th std. textbook states that organs
of plants can all be seen from outside and also that in most animals,
one individual is either male or female (pg 125).
Students' Awareness about Health Related Topics
There were some questions in the retention test paper,
which were common to all the three classes (VII, VIII and
DC) and drew some peculiar answers from many of the students:
1. Q. In the alimentary canal/digestive track which organ
3
follows the stomach ?
Expected Ans : Small intestine/ intestine/ duodenum.
Actual Ans : Less than half gave the correct answer. Wrong
answers included kidneys, pancreas, liver, brain, heart etc.
2. Q. If a person generally takes balanced diet but occasionally
lakes a meal which is not balanced, what will happen?
Expected Ans: Nothing will happen since the meal that is
not balanced is taken only occasionally.
Actual Ans. Very few gave the right answer; One of them
wrote that if 2/3rd of the times the diet is balanced then
nothing will happen. One or two students mentioned about
stores in the body. Invariably, most students wrote that he
would fall sick, have a stomach upset, become fat, get pain,
get indigestion etc.
3. Q. Name the communicable disease that is spreading
very fast these days and for which there is.no cure yet.
Expected Ans. AIDS
Actual Ans. A little over half the students gave the answer
AIDS. Some of the students mentioned AIDS and other
diseases like blood cancer, dengue fever, plague, leprosy,
small pox etc.
4. Q. When breathing through the mouth how does the
air reach the wind pipe and lungs ? •
Expected Ans. Gullet, pharynx, the food and wind pipe are
connected/jointed/mix on the way, there is a gap that closes
the food pipe etc.
Actual Ans. Many of them gave the above answer though
there were others who wrote trachea, larynx, by nose or
through the wind pipe.
Scope for Change
* Teachers are basically from other disciplines and find it
difficult to convey the true concept of health education to
the children. Lack of adequate reference books on the subject
does not allow teachers to gain extra knowledge of the subject.
* While at the primary level, health related topics are woven
into environmental studies, at the upper primary and secondary
levels, the relationship between health related topics and
science and social studies is less systematic from the point
of view of health education.
* Another weakness of the present training programmes is
their ‘academic', ‘medical profession' and ‘service’
orientation in contrast to the desired ‘participatory’, ‘problem
solving’ and ‘life-skill’ focus. Very often, there is a wide
gap between what is recommended in the school health
programme and what can be practised in the existing living
Contd. on pg. 7
FRCH NEWSLETTER, VOL XI, NO.6, NOV-DEC. *97
Movement Education in Schools
Sandhya Jinturkar
Physical education, now known as ‘movement education’
concentrates on developing the physical fitness of the student
through various physical activities. Today, it forms an
important component of the formal health education system.
The following are the specific aims of physical education:
* Developing a liking for outdoor activities including specific
sports.
* Making free and easy movements possible.
* Developing flexibility, strength and body control through
gymnastics.
* Developing the power of concentration through yoga.
* Developing proficiency in particular sports at an early age.
* Developing the overall personality of the child - a sound
mind in a sound body.
Besides pure physical fitness, physical education
channelises the children’s overflowing enthusiasm in the right
direction which could otherwise lead to destructive behaviour.
It teaches the children to be self-disciplined and alert. It
also develops team spirit and cooperative behaviour, necessary
in professional life later on, something not easily achieved
within the four walls of the classroom.
Education Policy and Committees
Education, like development, is a continuous process and
an important ingredient of it. It is necessary that educational
policy is continuously upgraded to keep pace with the changes
in society. Since independence, in India, educational committees
have been appointed periodically to upgrade the educational policy.
The first such committee to be appointed was the
Mudaliyar committee in 1952-53. This committee is noted
for introducing the concept of multipurpose schools and
suggesting steps to be taken for the universalisation of
education. Amongst other things it also stressed on improving
the overall health and physical development of the children.
As per its recommendations, in 1965, the Ministry of
Education prepared the syllabus for physical education,
published in a book ‘The National Fitness Corps’
(NFC handbook) for standards 1 to 11.
In 1864-66 the Kothari Committee was appointed. It did
not do anything specific for physical education but it did
lay special emphasis on universalisation of education - taking
it to the rural areas, and also stressed on complete personality
The author, MA in Psychology & MPEd., is the Special Officer
for Health & Physical Development, Textbook Bureau, Maharashtra
FRCH NEWSLETTER. VOL XI. NO.6. NOV.-DEC
97
development. Naturally, the scope and importance of physical
education increased simultaneously.
In 1986, based on recommendations from many
committees, organisations and experts, the Government
announced the New Education Policy and requested the state
governments to structure their respective educational policies
accordingly. Following this, in 1988, the Maharashtra
Government prepared and implemented a new educational
curriculum which gave the student the prime importance in
the scheme of things and focussed on all round development
of the children. ‘Health Science’was introduced as a special
subject of which physical education is a part.
As per the policy, physical education has been made)
compulsory. The primary school has been allotted 5 periods
a week while the secondary school 4 periods, for physical
education. Most important, it is now compulsory to evaluate
the students development in this field. As part of the school
upgradation programme, playgrounds, games equipment, as
well as teachers with special training in various sports and
general physical education etc. are to be provided to the
schools. If necessary, special areas in the city would be
demarcated by the government for building playgrounds.
Special emphasis will be given to sports and related subjects
along with the usual curriculum, for which the necessary
organisations as well as hostels for students will be
established. Promising students in the sports field will be
given special encouragement. Traditional Indian sports will
be promoted and yoga introduced in all schools as a means
of improving and coordinating the mind and body.
Simultaneously the BPEd. syllabus will include yoga to mak@)
properly trained teachers available in that -discipline.
Conclusion
Though the importance of physical education has
increased, some important drawbacks remain, the most glaring
one being that though it has been made compulsory it does
not feature in the report card. Hence, it automatically gets
lesser importance as compared to academic subjects. Moreover,
its weightage in terms of actual classes allotted gets reduced
in higher classes where preference is given to academics. (Il
should be noted that in China, Mao Sie Tung has made physical
fitness compulsory for promotion to higher classes). It is lime
physical fitness is given its due importance and seen as one
of the major preventive measures in our health policy.
Contd.onpg.7
4
Changing Health Behaviour
Through School Health Education
This article by Khalipha Bility, Susan Burkhalter, Abbas Shaker, Nazeema Ahmed, Hans Onya and
Numvulo Masinyana has been extracted from the Urbanisation and Health Newsletter, No. 32, March 1997
How do children and adolescents perceive poor sanitation
and hygiene practices in the world around them? What
methods are most appropriate for identifying children’s
perceptions of water and sanitation conditions? How can
parents and teachers use these perceptions to support learning
and teaching about hygiene in school settings? This article
describes the South African School Hygiene Education
Project (SASHEP) which attempts to answer these questions.
This multi-phase research and demonstration project aims
at developing a child-oriented sanitation and hygiene
education curriculum that is informed by the perceptions
of children and adolescents in primary schools. The project
links research and demonstration : 1) To address skill gaps
between knowledge and the competencies of children to
promote positive hygiene behaviour; 2) To overcome the
didactic way hygiene education is currently taught in most
schools; and 3) To facilitate the widespread use of multimedia
in hygiene education. In the curriculum implementation phase
we seek to use culturally sensitive and multimedia-learning strategies
for stimulating the imagination and creativity of young people.
Though it will specifically address water and sanitation
problems, the framework can be applied to other health
problems, such as oral and dental health and teenage motherhood.
The project derives the inspiration for its study from
the importance that health education has in developing
communities struggling to improve their overall health status.
The period of transition they are going through has brought
forth various challenges on the health front, one of them
being inadequate physical infrastructure and facilities for
sanitation, especially in rural and semi-urban areas. However,
attempts to provide infrastructure without accompanying it
with an appropriate change in health behaviour has led to
less than optimum utilisation of facilities created. “Research
indicates that applying technology without addressing the
cultural factors or changes in behaviour can cancel out the
otherwise positive aspects of sanitation intervention.”
To improve this situation, appropriate hygiene education
in schools, supported by good curriculum materials, needs
to go hand in hand with the development of infrastructure
and services for good sanitation. Unfortunately, the strategic
position of the school in society and the health education
5
opportunities schools provide have not been harnessed
adequately to promote the health of school communities.
The school can be an important setting for testing
innovative approaches to health promotion. School health
education, besides developing appropriate health habits,
should also encourage the construction of water, sanitation
and hygiene facilities that are properly used and maintained.
The role and importance of school health is also related
to demographic, health and education situation in the country
as more than 35% of its population is below the age of
25 and a large part of it is in school. Children are
disproportionately affected by poor sanitation and
inappropriate health education and many of them continue
to go to school with easily preventable and curable chronic
illnesses. These diseases, along with their causes, interfere
with the children’s ability to learn and enjoy school.
Increasing hygiene education among school-age children
will have the additional benefit of extending health promotion
knowledge to communities in two basic ways : Firstly, the
black school children in both urban and rural areas are usually
responsible for providing care for their younger siblings.
As care providers, school children can use the health
knowledge and skills acquired in schools to provide better
care for their siblings. Secondly, in most rural communities,
today’s school children are the first generation who can read
and write. In these communities, literate children are
influential members and are often listened to with respect
and dignity. Schools can use this status to promote health
and reduce the prevalence of many water, sanitation, and
hygiene-related diseases among children.
Appropriate education must place the child’s culture and
experiences at the centre of learning - it should be
developmental. Understanding the child’s perception should
provide an insight into the child’s learning experiences and
the connections children make between disease and daily
activities. The project research team will make a situation
analysis on hygiene education, water and sanitation on both
local and international levels. Information on prescribed health
education in the local schools will be compiled to identify
gaps in the curriculum. A summary of teaching and learning
materials from other countries will be gathered to benefit
FRCH NEWSLETTER, VOL XI, NO.6, NOV.-DEC. "97
School-Age Child Health Education ‘
and Teacher’s Training
FRCH has been doing constructive work in school
health education since 1988, through the implementation
of the School Health Education Project (SHEP) in 34
rural and urban schools in Maharashtra, with the aim of
evolving a model for health education in schools. The
experience of the teachers involved in this project, who
conducted various health education activities in schools
showed that if children in their receptive age are given
a broader, social health perspective along with health
information in a scientific and systematic manner, they
can become both enthusiastic recipients and efficient
transmitters of health knowledge. In 1994, this project
was extended into the School-Age Child Health Education
and Teacher’s Training (SACHETT) project to be
implemented in 4 selected districts of Maharashtra:
Ahmednagar. Solapur, Pune & Nashik. The three year
project, now coming to an end, essentially extended the
experience gained in FRCH’s earlier SHEP project to the
Teacher Education Institutes (TEIs). The project also aimed
at 1) improving the quality of the teaching material and
manuals produced during SHEP in TEIs and their pilot
schools 2) developing human resources for health
education in TEIs and 3) devising means of integrating
health education in the present curricula, especially helping
teachers to understand health concepts and how to integrate
them with other subjects.
A three-tier process of training was conducted under
SACHETT. First, a training workshop was held for the
D.Ed. college lecturers. These trained lecturers then
conducted various health education activities in their
respective colleges for their D.Ed. students, for one period
every week. The D.Ed. students in turn conducted health
from the experiences of other societies and projects.
The team will observe and document children’s behaviour
and decision making in matters of hygiene to enable them
to make healthy life choices concerning water, sanitation
and. hygiene. Results of the research with children will
influence the scope and sequencing of content. We assume
that the child’s readiness to learn about water, sanitation and
other matters depends on the most basic of all knowledge,
"how to learn*. The key is to identify psychosocial and
emotional barriers to learning and identify resilient factors
that enable learners to develop important health skills.
Problems and model solutions are approached, not in terms
of theory alone, but in terms of their real world effects.
In addition to chalking out the formal curriculum, the
research team is keen to look at the context or environment
in which it is to be taught.. Mounting evidence indicates that.
the school’s climate or ethos or environment plays a)
significant role in the learning process and outcomes.
In phase one, situation analysis on hygiene education,
water and sanitation will be done both on local and
international levels. Information on prescribed health
education in the local schools will be compiled to identify
gaps in the curriculum. A summary of teaching and learning
materials from other countries will be gathered to benefit
from the experiences of other societies and projects.
Phases two and three, which will run concurrently, involve
the final selection of pilot schools which will correctly reflect
the complexities of the sanitation situation, diversity and
multicultural realities of South African society. This will be
done to ensure that the curriculum and other products are
appropriate and relevant to the needs of the children in
specific areas. The criteria for specifying school type will .
depend on several variables, including location and type of •
education classes for school children of the pilot schools
attached to their colleges. The training of selected school
teachers was also undertaken by SACHETT in its four
districts, in order to extend the scope of health training
to those teachers not adequately covered by the in-service
training at D.Ed. colleges.
existing infrastructure for sanitation and water supply. These
factors will be coded in a matrix to define the characteristics
of school type and to help the research team identify hygiene
education priorities in different environments and schools.
About 15 primary and secondary schools will be selected
in each category.
The evaluation of teachers performance in the final
phase of the project showed the D.Ed. students of all four
districts to be better than their lecturers in the essential
Children’s perceptions and the meanings they associate
with-water and sanitation are studied using qualitative methods.
facets of health education. This was due to many factors
like the D.Ed. students being in direct contact with school
children unlike the D.Ed lecturers; most D.Ed. lecturers being
unwilling to accept newer concepts and means of
communication due to their age, job-complacency etc.
FRCH NEWSLETTER, VOL XI. NO.6. NOV.-DEC. 97
Several methods can be used to obtain this information introduction to the activities, explanation, drawing and writing
The last two involves asking children to draw or write about
all the things about water and cleanliness that make and keep
them healthy.
Water and sanitation conditions between and within the
6
different provinces vary considerably. Comparison of results’
from the provinces will allow the team to establish both
a generic curriculum and context-specific curricula. -The
generic curriculum would describe hygiene education for all
children. The context specific curriculum would describe how
learning should be made appropriate and relevant to the needs
of the learner in a particular environment. The research team
anticipates some tension between local and universal or national
health education priorities. In the end, the team will be guided
by several factors, including the results of phase-one. research.
Collaboration between home and school can enrich the
school health education curriculum and provide an
environment for children to practice what they learn in school.
The overall development process of children at home and
school is influenced by the way learning opportunities are
structured for children, parents and communities to be
involved in all aspects of school activity. Understanding
environmental influences on how children grow and develop
along the five most critical developmental pathways (physical,
social-emotional, psychological, cognitive and ethical) should
be central to how we plan for learning and bring up children
in the school setting.
In phase four, the health education and training materials
will be piloted in each of the research sites, in the same
schools where children were interviewed to gather data on
perceptions of sanitation and hygiene education. The testing
of these materials shall take place in the context of the School
Development Programme. The SDP is a comprehensive
process of school reform - the basic programme orientation
is that all activities in the school should be related to and
focused on enhancing the development of each child.
Implementation of this comprehensive approach will involve
in-service training related to child development, school
management and parent participation.
The project team will also work closely with the
community and school health nurses, health education
teachers, other health workers and students themselves.
Finally, in phase five, the team will compile the responses
to the pi lot-testing and revise and adapt the final products.
These products will include multimedia modes of learning
materials (print, audiovisual, radio drama).
Methodology
The project advocates the use of appropriate, child-friendly
school health education materials.
First, the project team will gather children’s perceptions
of water, sanitation, and ill health to identify obstacles to
and opportunities for improved sanitary practices. Second,
these findings will provide content for in-service teacher
training. Capacity development and research training of both
the practitioners and students are developed through a series
of short courses and workshops. Third, teachers and students
work together to develop supplementary health education
materials to be integrated in the curriculum, and produce
guidelines for extra curricular activities that involve parents
and communities. Finally, monitoring and process evaluation
activities will allow the project team to make improvements
at every stage of programme implementation.
□
Contd.from pg. 3
conditions of the learners (and in some cases, that of teachers).
* The underlying biological, social, cultural and economic
causes common to most diseases must be concentrated upon
rather than teaching a few diseases in detail. This will help
students to understand the importance of preventive measures,
including precautions to be taken at the individual and social
level, for good community health.
□
Contd. from pg. 4
Secondly, like other policies, the education policy too
is top-down in nature, where the grassroots level problems
in conducting physical education are ignored. The biggest
problem is that of low budgets, especially in rural schools,
where expensive equipment for special sports cannot be made
available. The government should allow for variation in the
syllabus according to the capacity of the schools and provide
special grants to rural schools for promoting sports.
There should be more variation in physical activities
introduced in school so that students get a wider choice.
For instance, Japan has recently introduced, on an experimental
basis, a free period for an hour everyday where the student
can pursue any constructive activities s/he wants. Thus physical
education can be used to increase the attraction for schools.
Another major anomaly is the difference between the
subjects taught at the BPEd.. course and the expertise required
in actually conducting the physical education class, especially
as per the revised curriculum. Thus along with the school
curriculum, the BPed. curriculum should also be revised periodically.
In the secondary schools the team will conduct focus group
interviews. With permission, these interviews will be recorded
Most important, the goal of universalisation of education
and the data analysed through the "Glasser and Strauss" method.
should be pursued relentlessly so that physical education is
automatically made accessible to children all over India.
Analysis of these codes provides the framework for developing
the hygiene and health education curriculum for secondary schools.
7
English Translation : Vaijayanti Aphale
□
FRCH NEWSLETTER, VOL XL NO.6, NOV-DEC. 97
Problems Assailing Ayurveda and Possible Solutions
Udupa Committee Report - II
Dr. Shipra Banerjee
This is the concluding part of the article on the Udupa
Committee Report that featured in the previous issue.
Observations and Recommendations on Training
Observations :
In 1958 there were 76 training institutions in Ayurveda
in both the Government and private sectors. Of these, 49
followed the Integrated Medicine pattern with a total student
strength of 7000 and 1100 graduates to its credit while 27
of the colleges adhered to Shudha Ayurveda with a total student
strength of 1500 and producing 300 title holders per year.
There were also six Sanskrit Colleges imparting teaching in Ayurveda.
The committee came to the conclusion that the main
areas to be touched in Ayurvedic training were the upgradation
of the content and teaching methodology vis a vis modern
medicine and standardisation of Ayurvedic teaching all over India.
Recommendations :
One of the first steps in the upgradation of Ayurveda
would be that the Central and State Governments make an
unequivocal declaration of policy recognising the training
and practice of Ayurveda.
A Central Council of Indian Medicine should be set up
as a very first measure of reform. This council will take
steps to lay down uniform standards of syllabus, degrees,
teaching, teaching institutions, etc. The Central Council,
Universities, Boards and teaching institutions must work out
details of curriculum of studies, based on the recommendations
of this committee, so that the students have comprehensive
knowledge and practice that helps them to become good medical
practitioners. The curricula should be somewhat elastic and
should be adopted by the authorities concerned, in consultation
with the Central Council, to suit local conditions.
An Ayurvedic student must learn the fundamental
principles of Ayurveda including Ayurvedic Sharir and its
philosophical aspects in relation to Darshana, Dravya Guna
and Rasa Shastra, Bhashya Kalpana, Rog Nidana and
Chikitsa, and Swasthya Vritha including Preventive Medicine.
It is important that the student realise that Ayurveda deals
not only with the physical body as in the case of modern
Dr. Shipra Banerjee, M.D., M.P.H., DARCP&S, is a
Senior Consultant in Community Health Management at the
Rural Medicare Society, Delhi.
FRCH NEWSLETTER, VOL XI, NO.6. NOV.-DEC. 97
medical sciences but it also deals with the metaphysical
aspects including the sense organs, mind and soul. A
knowledge of this aspect is necessary to comprehend the
basis for Nidana and Chikitsa. Simultaneously, an Ayurvedic
student must also be taught anatomy and physiology, in
addition to the principles of modern pharmacology and
therapeutics, pathology and bacteriology, modern medicine,
surgery, midwifery and gynecology, and medical
jurisprudence. Hence, the present integrated system should
continue. A broad-based curriculum for a five-year course
excluding an appropriate period of internship is suggested.
‘
The Shudha Ayurved system should also continue for
some time to come but with the addition of certain modern
subjects and increased facilities for practical training. This
will equip the general practitioner of Ayurveda to deal more
efficiently with present day patients, whose conceptions of '
life and environment etc. have changed considerably from
the past. In due course it is anticipated that one uniform
course of training in Ayurveda can be prescribed.
The basic qualifications for admission to the integrated
course should be Intermediate level with physics, chemistry,
biology and Sanskrit. The qualification for admission to the
Shudha Ayurveda course should be Matriculation with Sanskrit
or equivalent qualification. Persons successfully completing
the integrated training should be given a Bachelor’s Degree
and those completing the Shudha Ayurvedic training should
be awarded the title of Ayurvedacharya or Pravina. The
degree and the title should, however, be uniform in the
whole country.
By properly channelising the training of the Integrated
and Shudha Ayurvedic physicians and the traditional vaidyas
of known reputation, medical relief can be improved
considerably, especially in the rural areas. In fact, the students
of Ayurveda should also be given public health training in order
to enable them to render public health service in the rural areas.
For greater integration, the State Governments should
pursue the question of establishing Chairs of Indian Medicine
in undergraduate as well as postgraduate modern medical
colleges. In addition there may be an Ayurvedic ward in each
medical college hospital, so that the principles of Ayurvedic
treatment are better comprehended by modern people. This
will help to remove the bias in their minds towards Ayurveda.
,
8
f
()
For providing adequate number of efficient teachers at
an early date, the Central Government should, in addition
to the Post Graduate Training Centre at Jamnagar, establish
three more model Post-Graduate Training Centers at Banaras,
Poona and Trivandrum to cover the Northern and Eastern,
Central and Southern Zones respectively. In these centres,
a three year training course should be instituted for integrated
degree holders, Shudha Ayurvedic title holders and modern
medical graduates. In addition there should be special training
courses of one year duration for all existing teachers of
Ayurveda. Modern medical colleges should give facilities
to integrated graduates to undergo post-graduate courses in
modern subjects so that such graduates may leach modern
subjects to Ayurvedic teaching institutions. The Central
Council of Indian Medicine should work out the details of
such teachers’ training programme on a uniform basis.
Pending such a step, only the top personnel in modern medical
field holding M.D., M.S.., etc. should be appointed Professors
in integrated teaching institutions.
In addition, every Ayurvedic teaching institution or at
least one institution in each State should provide for post
graduate courses in Ayurvedic as well as in Modern subjects,
as part of the development programme of the State concerned.
Attempts should be made to immediately affiliate all
Ayurvedic training institutions to Universities with separate
faculties for Ayurvedic medicine. This will lone up the
standard of leaching and examination and improve the
buildings, laboratory equipment, practical facilities etc. The
Central Council of Indian Medicine should also take
appropriate steps at a very early dale to bring the status of
principals, professors, lecturers etc. in Ayurvedic Training
Institutions at par with the corresponding posts in modern
medical colleges.
9)
Teaching methods too require a great deal of
improvement. Two fifths of the lime should be devoted to
lectures and three fifths to practicals by students themselves.
The philosophical aspects of Ayurveda should be emphasised
throughout the undergraduate training. Teaching methods
adopted with success in foreign institutions like tutorials,
journal clubs and weekly or fortnightly staff rounds in every
teaching hospitals should also be introduced in these
institutions. Greater attention than at present should be paid
to the teaching of Ayurvedic subjects. Each group of subject
should be constituted into a separate department and one
subject should be taught by one professor, who should have
a lecturer and a demonstrator attached to him. It is important
The basic qualifications for admission of students into
Ayurvedic Institutions should be so fixed that they will be
well-equipped to understand the Ayurvedic subjects taught
and committed to practising Ayurveda in the future. It should
be ensured that the students admitted have interest in the
ancient science and aptitude for research and that they are
not joining the course merely as a last resort. Some of the
other conditions that will encourage students to take up
Ayurveda are that they are assured of equal prospects in the
profession as their compatriots in modern medicine and that
their privileges are the same as the modern medical
practitioners. Finally, the Government should encourage girl
students to take up Ayurveda particularly because gynecology,
obstetrics, pediatrics etc. have still to be introduced
scientifically in the Ayurvedic system. Along with other
financial help, governments should provide special
scholarships to attract the proper kind of students to improve
the present unsatisfactory position in Ayurvedic Training.
Immediate attention may be given to compiling subjectwise text books in Ayurveda on a uniform basis and
annotations of original texts, as part of the Literary-Research
Programme. Existing textbooks may be reviewed and whatever
is suitable may be accepted. A few concise textbooks on
modern medical subjects may also be prepared for use in
Ayurvedic institutions. Government should encourage
publication of textbooks by giving financial assistance, prizes
etc. All textbooks should be revised from time to time as
science progresses. Every Ayurvedic institution should maintain
a proper library under the charge of a trained medical librarian
and professors should encourage students to use them.
Research departments should become part and parcel of
Ayurvedic teaching institutions. Preparation of medicine and
practice should be separated if the Ayurvedic practitioner’s
status is to be improved. Special courses like B.Pharm
(Ayurveda) should be instituted.
In order to create a suitable atmosphere in Ayurvedic
studies, it is necessary to have proper buildings with adequate
practical facilities like a medicinal plants garden, museum,
pharmacy and hospital (with at least 150 beds for a studentstrength of 50). Students’ hostel and recreation facilities
should be provided in ample measure in all leaching centers.
Concluding Remarks
In its concluding remarks the committee wrote :
"We will be failing in our duly if we did not acknowledge
that a number of the suggestions and recommendations we
to teach basic facts and principles of the subjects rather than
have made, have already been covered by the conclusions
going into great details so that the student remembers and
arrived at by the previous Committees set up by the Central
intelligently applies the principles taught while treating patients.
Contd. on pg. 12
9
FRCH NEWSLETTER. VOL XI. NO.6. NOX.-DEC. 97
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□
FRCH NEWSLETTER, Vol. Xi. No.6 NOV.-DEC. ‘97
Contd. from pg. 5
frankly, the spirit of which, we hope, will be appreciated.
or State Governments. In the process of studying the various
problems involved, however, certain new ideas have come
to our mind which we have frankly expressed. We have also
tried to give more informative statistics, figures and tables,
which we feel will be useful to the Government and others
in any future action they may wish to take.
We are confident that an Independent India striving to
revive all our ancient culture will not fall behind in restoring
Ayurveda to its pristine-glory. and by trying to absorb the
best in other systems of medicine will produce one integrated
system of Indian Medicine as early as possible.
As has been mentioned earlier our task was to enquire
why the previous recommendations had not been put into
effect. In this connection we feel that the authorities
concerned have not tackled the problem in its entirety and
viewed the previous suggestions as a comprehensive whole,
thus leaving the deadlock in the development on indigenous
systems of medicine. unsolved. We now hope that earnest
and sincere efforts will be made by all concerned to
implement our suggestions to the full extent. The Central
Government, the State Governments, the Boards of Indian
Medicine and the practitioners themselves should squarely
face the huge task ahead of them and make honest attempts
to recognise the Ayurvedic system of medicine and to raise
it to a high status it deserves.
Our aim has been to find out ways and means of
resuscitating the ancient system of medicine in order that
it may benefit not only science but also the suffering
humanity. In this task we have expressed our views very
Our remarks about the ways and means of improving
the method of training, research, etc. in Ayurveda will apply
generally to other indigenous systems of medicine like Siddha
and Unani also.”
Expressing their thanks to the various organisations and
individuals involved in preparing the report, the authors closed
this chapter.
□
FREE ABSTRACTING
The contents of this newsletter may be
abstracted without prior permission.
However,
we
would
appreciate
acknowledgement of the source and
copies of any abstractions
The views expressed in the articles are those of the
authors and not necessarily those of FRCH
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Health Asst .
Community
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