medico friend circle bulletin 125 - February 1987

Item

Title
medico friend circle bulletin 125 - February 1987
Date
February 1987
extracted text
medico friend
125 circle
bulletin
FEBRUARY 1987

Confusion—A Way to Knowledge
U.N. Jajoo

The Annual MFC meet at Bangalore on tuberculo­ ed, previously untreated residents of Bangalore City,
sis (1985) has provoked much critical thinking to the judged as active by two miniature X-ray film readers.
extent that a consensus on the crtique of NTP is yet Half of these were randomly allocated to treatment
to emeige. Anant and Binayak tried to prepare a regimen of INH and TCZ and the other half were on
note which Anil Patel found uncompromising. I add placebo. 31 % of those who were initially sputum
to the confusion here by placing some facts and figures negative by one smear examination were found to be
with the hope that it will pave the way to knowledge. sputum positive on second examination. 10.7% by
smear and 20.8% by culture alone. Even those
Question I: What is the fate of radi©logically posi­ patients who were not read as active by any of the
tive and sputum AFB negative patients, two readers, 2.8% proved to be sputum positive on
if untreated?
second examination. A few more became sputum
Let me quote an editorial from the Indian Journal positive or showed radiological progress of the disease
of Tuberculosis (1). “For many years there has been during the course of follow-up with no treatment.
an increasing awareness of a need to study the fate Thus about 40% out of initially sputum negative
of sputum negative patients who seek treatment at continued to be sputum negative, while 60% of them
various centres for symptoms suggestive of chest proved definitely to be active tuberculous at some
diseases. Some workers have recommended that stage or the other, more often within first four months
following detection. Among sputum negative treated
such patients should be kept under observation while
many clinicians prefer to put them on prolonged group, regression of lesions was more frequent than
in the untreated.
intensive anti TB drug therapy. In July 1974, this
problem was discussed in the pages of this journal.
In rural areas where follow-up for observation is
The National Conference at Hyderabad in 1975 de­
not
easily possible and is hardly ever done, patients with
voted a full session to this important problem. A
highly
suspicious X-ray shadows should be offered
study based on a long term follow-up by the New
anti
TB
drug therapy if clinical picture is also sugges­
Delhi TB Centre showed most of such patient to be
tive
since
tuberculosis continues to be the most co­
definitely active and tuberculous.
mmon pathology. Mistakes in diagnosis though few,
A study carried out in Hong Kong recently with will continue to occur even in the best of hands, the
the collaboration of the British Medical Research question is which is less risky and likely to be more
Council has shown that 34% of the patients whose five profitable generally—to treat or not to treat.”
sputum specimens were negative by direct smear be­
The conclusions drawn are;
came sputum positive during the course of one year
when left untreated.
—The radiological reading of active tuberculosis in
A controlled study of such patients was undertaken
suspect cases must be considered fairly sensitive
recently by the National TB Institute, Bangalore also.
(more/than 2/3 at least) and if coupled with clinical
The patients included in this study were freshly detect­
judgement should be regarded as reliable tool.

NTP banks on those patients who themselves re­
port to medical opinion for relief of sufferings and
presupposes that all who take action will come to these
centres for their expertise. The erdibility ‘enjoyed’ by
these centres is obvious from the fact that, “out of
those registered at the DTC. only 27% have not rece­
ived treatment earlier” (7). It is not only the dis­
tance of the diagnostic centre but the behaviour, the
care, the concern shown towards human sufferings
that attracts the poor ill person, the absence of which
is obvious from the figure that only 23% seek relief
from the nearest health centre. The inefficiency of
case detection, the non-availability of drugs/detectors
erode the credibility of these peripheral units. It is
this faith in the healer that matters for the patient and
not merely a free technical expertise. At the time
NTP was conceptualised this important sociological
dimension of patient care was forgotten.

—The epidemiological surveys done till date are based
on the evidence of ‘active pulmonary TB lesion’
in X-ray, and therefore stand as fairly reliable
evidence of quantum of pulmonary tuberculosis in
the community.

—In a clinic situation (PHC or DTC), it is fairly logi­
cal to treat suspect cases i.e., radi©logically positive
but smear negative.

Under NTP, a person with tuberculosis who mat­
ters is one who brings out AFB in sputum smear.
The efficacy of case detection by microscopy in the
present situation is as follows: (2,3)
—Total number of sputum positive cases in average
district (infectious cases only)
= 5,000

—Potential of case detection by meti­
culous sputum examination (passive
case detection in clinic setting)
= 2,000 (40%)

Question 2:

—Number of cases detected in actual
field situations
*
=776

Isn’t it true that Indian and WHO
documents say that MMR does not help
in detecting more cases than is possible
by microscopy alone ?

Let us not confuse between active case finding and
passive case detection in a clinic situation. The above
statement is true only for active case finding. To
quote verbatim. “For sputum positive cases, large
majority of patients could not be found even if ser­
vices were provided close to their villages. The
number of patients found under such conditions was
considerably short of estimated total prevalence. It
was not possible to diagnose even about 50% of the
existing cases in the community i.e. number that was
already reporting to the PHC for examination because
of their chest symptoms by any of the currently avai­
lable methods (community development approach—
active detection of symptomatics and referral to micro­
scopy centres or mass campaign with X-ray available
at few miles distance) (9).

Thus, those who do not bring out AFB in sputum
smear (thanks to our inefficiency), are very graciously
shown the way to DTC for MMR which in practice is
out of the reach of the majority. It has been found that
only 20% report to DTC (4) and much less turn up to
collect the report, since patients are not prepared to
travel more than 5 kms (5) unless symptoms are very
pressing. The wage loss implicit in such action is
never taken care of. In reality what it boils down to
is, if you have faith enough to take pains to reach the
peripheral microscopy centre, and bring out AFB in
smear detectable by our microscopists, only then you
matter us enough for inclusion under NTP. We
(the NTP) full of sympathy for your sufferings, will
send you back with tonics and cough mixtures and will
consider it your fault if you fail to turn up again for
unrelenting symptoms. NTP merely looks at the
impact of the strategy on the prevalence of TB and
forgets the agony of the sufferers.

However a situation in an accessible clinic where
static MMR facility is available will be entirely diff­
erent. The purpose of installing an MMR machine
in these peripheral clinics is not to mop up the ‘non­
action’ taking cases of the community but to detect
precisely the action taking group (52% smear posi­
tive). The moot question is whether we expect bonus
of this radiological support or not. It is a known
fact that 70% of the registered cases every year are
AFB negative (radiologically diagnosed) in DTC.
This is a clear indication that the concept of case
detection by microscopy has not even been conceived
by the district centre and that radiological support

The reliance of microscopic examination alone for
the diagnosis of TB must be weighed against the foll­
owing considerations, (i) microscopic detection of
AFB is a tool which requires sincerity of human ele­
ment involved—something which cannot be legislated
in our setting, (ii) There is a phenomena of ‘intermit­
tent positivity’ (6) which further reduces the reliability
of one sputum examination, a general practice in
PHCs.

• 20 to 30% of expected potential or 15% of the total infectious pool.

2

has considerable potential of dividends to be paid in
our existing inefllcency.

Question 3:

The radiological facility at the PHC has an added
spin-off benefit in the early diagnosis of bronchopneu­
monia in children—the number one killer in under
fives. While limitations of financial stringency to­
wards non-recurring cost is put, at least principally a
need of radiological back-up support must be accepted
and its feasability must be tested in field situations.
I suggest the strategy given below.

The radiological facility at PHC (accessi­
ble clinic) is a costly proposition and
should its appropriateness not be judg­
ed before it is pleaded for?

The logic that recurring cost of MMR static unit
will be too much is negated by the following observa­
tions: (10)

Question 4:

The cost in USS of diagnosing one case by different
methods
Examination

Approximate
cost per exa­
mination
0.21

3.4

Culture exam
70 mm x-ray
film (static unit)
passive detection

0.49

12.1

0.26

70mm x-ray film
(mobile unit) ac­
tive detection)

0.50

Not much really, due to the following reasons—

(i) Out of 20 cases/1000 population, 2.5/1000 are
smear positive and 1.6/1000 are only culture positive.
In passive case detection at PHC where around 52%
of infectious pool is expected to turn up, the bonus of
‘only culture positive’ will be reduced further.

Approximate
cost of diagno­
sing a case

Direct microscopy

Can culture facility at PHC add signifi­
cantly to case detection at PHC?

3.5

(ii) Culture report takes at least 6 weeks—a time
lag which will shift the ailing patient elsewhere in pur­
suit of relief.

73.0

(iii) The cost involved in detecting a case is 4 times
higher than that by smear examination or static MMR
(10).

Symptomatic patient
one sputum smear
1
[
AFB positive
AFB negative
|
1
subject to MMR
confirm by MMR
and treat
1______
1
normal

1

non tubercular

tubercular

I

repeat AFB

I______
I
negative
I

positive, treat

put on broad spectrum
antibiotics for 10 days
repeat MMR after 3 weeks
along with smear exam.

Radiological
resolution

Not resolved
or increased
or AFB positive

I

Treat for TB

3

Question 5:

Letter from a friend
Health and Agriculture—a literature review

Can tuberculosis prevalence be brought
down by medical intervention ? Should
the aim of NTP be only alleviation of
human suffering?

In the 1981 census it was established that 70.6
percent of the working population in India are em­
ployed in Agriculture and related occupations. Vari­
ous reviews of Occupational Health Research in India
show, however, that the agricultural worker has
generally been neglected and that the main focus of
research has been on the industrial workers and factory
jobs. The situation is similar in most of Asia.

Socio-economic factors being important in causa­
tion of tuberculosis, we are tempted to argue that any
amount of medical intervention alone cannot reduce
the prevalence of tuberculosis. However, the figures
drawn up after careful analysis do not favour this
hypothesis. If the full potential of microscopic detec­
tion is tapped and all geographical area is covered by
NTP, estimated probable reduction in prevalence of
TB is 6.4% per year. With the present case detection
rate (30% of the expected), 4.8% reduction can still be
achieved (3). NTP is epidemiologically a sound
proposition but has failed to make a dent due to opera­
tional failure in case detection/case holding.

In recent years another aspect of this complex
relationship between Health and Agricultrual deve­
lopment is coming into focus—the detrimental health
effects of some aspects of modern agricultural deve­
lopment policies—be it agrochemicals, mechanisation,
dams, irrigation projects and so on. Evidence on
References:
marginalisation of the rural poor and the ecological
1. Editorial ‘Sputum negative patients', Indian Jour­ changes consequent to agro-technological develop­
ment have been well established in the last decade.
nal of tuberculosis: 26,173, Oct 1979.
What is less well established is the effect on the health
2. ‘Potential yield of pulmonary tuberculosis cases by and the nutrition of rural communities and particularly
direct microscopy of sputum in a district of South the underprivileged among them.
India’, GVJ RBaily etal, Bull. Wld. Hlth. Org.:
1967, 37, 875-892.
Both these problems indicate that the multi­
3. ‘Tuberculosis in India-A perspective', D.R. Nag­ faceted, intersectoral relationship between health and
paul, J. of Ind. Med. Assn: 71,44-48, 1978.
agricultural development needs further critical study.
I am spending a year working on a a literature review
4. ‘District TB Control Programme in concept and of the health of Agricultural workers as well as
outline’, D.R. Nagpaul: Ind. J. of Tub. XIV, the detrimental effects on Health and Nutrition of
196-198.
some aspects of agricultural development policy. The
5. ‘Prevalence of symptoms in a South Indian rural main focus will be on India and Asia. The review will
Community and utilization of area health centre’, evolve in a participatory view so that a network of
people interested in these issues and hopefully a study
Ind. J. Med. Res.: 1977, 66, 635.
group too, focussing on Health and Agriculture linked
6. ‘Some aspects of sputum examination in tubercu­ research areas will evolve in Asia in the years to
losis case finding’, D.R. Nagpaul, et al, Ind. J. come.
of Tub.: 26, 11, 1979.
7. ‘Socio-Cultural Context of TB treatment’, Ind. J.
Tub.: 1982.

1 invite you to send me reports, papers, articles,
reprints, case studies or any other materials that you
8. ‘Symptom awareness and action taking of person feel should find a place in this review. Even just re­
with pulmonary TB in rural community surveyed ferences if they have been published would be wel­
repeatedly to determine epidemiology of the come. Some of you may have been sent a more de­
disease’, Radha Narayan & H. Shrikantaram; tailed note about this review. Others can receive it if
they ask for it.
Ind. J. of Tub.: 28, 1261, 1981.

9. ‘An operational study of alternative methods of
case finding for tuberculosis control, National
Institute of Tuberculosis, Bangalore, Ind. J. of Ravi Narayan
C/o Ross Institute of Tropical Hygiene
Tub.: XXVI, 26, 1979;
London School of Hygiene and Tropical Medicine
10. A Case finding by microscopy’, D.R. Nagpaul, Keppel Street
et al, WHO/TB/Tech. information: 68, 63.
London WC1ETHE
4

Worthless Therapy : A Case Study
— Elina Hemminki

(Medicine provides many examples of therapies
that have been condemned after earlier acceptance and
wide application.
This study from Finland consi­
ders whether anything can be learnt from one such
therapy, the use of diuretics for the prevention and
treatment of toxaemia of pregnancy.)

Toxaemia of pregnancy is an important problem in
antenatal care: it is common, its etiology is largely un­
known, and it is connected with increased morbidity
and mortality in infants and mothers. Today, many
experts reject the whole concept of toxaemia and divide
it into several diseases and symptoms. I use the con­
cept as it was commonly used in the 1960s and 1970s:
when a pregnant woman had hypertension, protei­
nuria and/or oedema, she was said to have toxaemia.
Toxaemia was divided in two main categories: (1)
pre-eclampsia and eclampsia, and (2) chronic hyper­
tensive and renal diseases. In this article the interest
is in pre-eclampsia.
It was believed by many that excess salt intake and
retention caused pre-eclampsia. Because diuretics
were known to promote the excretion of sodium and
to decrease oedema and blood pressure in non-pregnant people, it was assumed that diuretics would be
beneficial in toxaemia.
In Finland, diuretics were already being recomm­
ended for toxaemia of pregnancy in the 1950s. Not to
give them for marked oedema was considered a devia­
tion from accepted practice. Diurectics were widely
used during pregnancy in the 1960s and 1970s in Fin­
land, as in many other countries. In 1969 and 1975,
Therapia Fennica stated that hydrochlorothiazides
should be given if oedema existed despite the avoidence of salt. Similar, but more reserved recommen­
dations were given in the Finnish textbook for mid­
wives. Starting from the first drug catalogue in 1962,
pregnancy oedema and/or pregnancy toxaemia were
given as indications for most diuretics. Diuretics
were still prescribed in 1983, but not prophylactically;
in cases of established oedema and pre-eclampsia they
were given less readily than in earlier years.

* improvement reported by mothers;
* neglect of the results of controlled clinical trials.
Changing attitudes

Reservations about the use of diuretics in preg­
nancy were already being voiced in the late 1950s.
Epidemiological surveys found that oedema was
common during pregnancy and that normotensive
oedematous women had heavier babies and fewer pre­
mature births. In a trial it was found that pregnant
women advised to use more salt had less toxaemia
than women advised to use little salt. Because of
methodological problems and contradictory results,
controlled clinical trials conducted during the 1960s
did not clearly answer the questions raised about the
prophylactic value of diuretics for mothers. There
was no reliable evidence about benefits for infants.
Studies were also undertaken on the possible harmful
effects of diuretics used in pregnancy. Pharmacologi­
cal and physiological information suggested that diure­
tics were harmful both to mothers and fetuses, but
quantification of the harm was not possible from the
data sources used.

Today it is widely accepted that in pre-eclampsia
there is hypovolaemia and that administration of
diuretics aggravates pre-eclampsia rather than pre­
vents or treats it. However, in the early 1970s there
were warnings against sodium restriction and diuretic
therapy in only a few countries (e.g., the USA). In
Finland even though the proper indications diuretics
had been discussed at local and national meetings of
obstetricians since the mid 1960s, and despite growing
opposition to the use of diuretics during the 1970s,
major changes in practice seem to have occurred only
at the end of the 1970s.
Information was slow to emerge in the non­
commercial and commercial literature. In the Finnish
medical journals the first articles cautiously warning
against diuretics appeared in 1978, and articles clearly
condemning their use appeared some what later. The
literature has emphasised the importance of the drug
industry in determining doctor’s prescribing habits.
In the 1960s and 1970s, however, promotion by drug
firms did not seem important in this connection.
Drug firms possibly did influence prescribing through
the leading physicians.

The widespread use of diuretics in pregnancy was
apparently favoured by:

* enthusiasm generated by the introduction of new
diuretics considered better than the old ones;

The opinion of the chief obstetricians in the central
hospitals seem to have been crucial in the rejection of
diuretics. When they formed new opinions, these

* acceptance of the theory that salt retention was
crucial in the pathology of toxaemia;
5

and comes back with a diuretic prescription, it is a
clear message... ”

were rapidly and effectively communicated to practi­
tioners. Prior to the 1970s, the chief Finnish ob­
stetricians exerted influence through the education
fo medical students and specializing doctors, through
articles in medical journals, and through their ad­
visory positions in drug firms. The chief physicians'
influence in determining therapeutic practice has
apparently increased as a result of the increased re­
gionalization of health care, frequent referral for
consultation in hospitals, acceptance of the concept
of local responsibility by central hospitals, and the
increase in postgraduate education.

With hindsight the whole episode of the widespread
use of diuretics in pregnancy could have been avoided
*
The results of the controlled clinical trials carried out
in the 1960s. not to mention their methodological
deficiencies, should have alerted critical minds. Fur­
thermore. epidemiological evidence suggested that
oedema was a good prognostic sign, and all the time
cogent critical arguments based on physiological and
clinical findings were being expressed against diuretics.

Since the 1970s an effective educational system and
The use of diuretics is just one outcome of a common
frequent referrals to antematal outpatient clinics have form of reasoning in medicine: if a laboratory result or
meant that the opinion of the chief obstctrictian in clinical sign correlating with poor health can be modified
each central hospital has largely determined the pre­ by a drug, it is often assumed that the drug is bene­
scribing of diuretics in his or her area. The opinion ficial. The example of diuretics in pregnancy shows
of these key obstetricians seem to have been passed that this is not necessarily so. It also shows the import­
quickly to the antenatal care providers. This is well ance of not only determining the facts of a situation,
illustrated in the following comment given by a general but also of informing practitioners about them.
practitioner: “Prescribing habits arc determined by the
Source : World Health Forum, Vol. 7, 1986.
practice in the central hospital of the area and by local
postgraduate education, even if the latest information
in the literature goes against them. When a mother is
*It is to be noted that in India, doctors still swear by
sent for a consultation to a hospital outpatient clinic
diuretics for toxaemia - ed

MFf-R

________
at least the minimum possible about TB. They are
taught—that it is caused bygerms, affects the lungs, is
diagnosed by sputum examination and x-ray, is curable,
treatment should last for at least 12 months and that
the diagnostic and treatment facilities can be obtained
free from the government health institutions. CHVs
are advised to refer persons with cough and fever of
more than 15 days, and are informed that infants arc
to be vaccinated with BCG.

Tuberculosis and Paramedical Workers
(Review of Training Manuals of Health Workers)

—Marie D’souza.
From the review of the training manuals prepared
by the Ministry of Health and Family Welfare listed
at the end of the article certain facts emerge clearly.
(I was not able to get hold of the ‘Manual for Health
Workers, Female, Vol. II’ and the ‘Manual for Health
Workers, Male Vol. I).

The CHVs who are closest to the people infact
one of the community, are not taught, much less
motivated towards the preventive aspects of TB. Nor
are they expected to give any health education to the
people.
Common beliefs and superstitions regard­
ing TB are not discussed with the CHVs. Their tasks
seem to be to report suspect cases to the Health
Worker (HW) and advise patients to continue treat­
ment.

Family Planning is the programme to work for.
Tuberculosis is not given any extra attention as com­
pared to other diseases, though malaria holds prece­
dence over tuberculosis in importance.

In a suggested schedule for a training programme
for Community Health Volunteers (CHV) lasting ten
weeks (4-day weeks), the time table is detailed.
Family Planning is allotted 9 hours, malaria 7 hours,
smallpox 5 hours, while tuberculosis is not even men­
tioned. I suppose it is included in the one hour allo­
tted for immunization (6) (Why 5 hours for smallpox?)
However, the ‘Manual for Community Health Workers
does have a chapter on tuberculosis from which it
can be concluded that the CHVs are expected to know

All the training manuals emphasise only the germ
theory of tuberculosis. HWs are informed that
crowded and dirty living conditions help spread the
disease (3). That the germ finds fertile soil in under­
nourished individuals is not even mentioned. To
expect that the manuals will discuss causes of under­
nutrition (poverty, unemployment, unjust society)
6

J

J
J

is of course asking for too much. Nowhere is an
understanding of the medico-technological aspects of
TB attempted with any grade of health workers.
‘Theirs is not to reason why
seems to be the general
attitude. In their training, viewing the bacillus under
a microscope is not even suggested.

?

The ‘Manual for Health Workers' is available only
in English, at least in Maharashtra. An enterprising
Health Instructor in Dhule District translated it into
Marathi and got it cyclostylcd. HWs in training
eagerly bought copies and it is now out of stock.
The manual does have several lessons on tuberculosis
(3). However in the training programme for Health
Assistants and Health Workers lasting 6 weeks, (6-day
weeks), 26 hours are for Family Planning, while only
4 hours are for TB (7). This is of course somewhat
better than that allotted for CHVs.

m ? ??? ? 7 7

The HWs are expected to carry out the preventive
measures for TB control i.e., case-holding, BCG
vaccination, and health education. The storage
preparation, administration and the results of BCG
vaccination is explained in great detail (2). As regards
to health education, except for a film on TB no aids
are available. But the Health Assistants are asked to
check on the educational programmes on TB organized
by the HWs whether talks, group meetings, exhibi­
tions etc. And in their training, while the HWs have
guidelines in plenty for educating the community on
Family Planning, there are none on TB (7).

-J
-a

7 7 77 7 7 7 7 7 7 7 7

7niTLVLTm-L'J

The focus of all the teaching and instructions on
TB in the Health Manuals is the services offered to the
community in the line of diagnosis, treatment, and
prevention through BCG. As mentioned earlier, no
stress is laid on health education of the community,
for which purpose the CHVs should be trained and
aids provided. In the preparation of aids it will be
useful to keep in mind what is mentioned in their
own manuals (5). Aids should be simple with em­
phasis on one idea. Therefore, EITHER treatment
is free OR treatment must be taken for 18 to 24 mon­
ths OR the result of indiscriminate spitting etc., must
form the single messages. The health education
material available so far have either too many mess­
ages incorporated into one presentation (eg. film by
the TB Association, the slide show by Janseva Mandal), or only one message prepared by different or­
ganizations—“TB is curable” (eg, CMC, VHAI,
CHETNA). VHAI does have two other sets on
‘childhood TB’ and ‘BCG vaccination’ which I have
not been able to review.

In the Health Manuals, the following are some of
the lacunae which needs to be filled in while preparing
health education aids.
1. Relatives of TB patients to be checked for TB.
2. Patient to cover the mouth while coughing and to
spit into a receptacle; sputum to be later disposed
off.
3. Study made of local diet habits in order to suggest
improvements on what foods the patient should
take more of. (The Manuals only say there is no
need for expensive or extra nutritious food.)

4. The bacilli find fertile soil in a malnourished indi­
vidual.

5. Taking irregular and haphazard treatment builds
resistant strains of bacilli with the resultant resis­
tance to drugs.
6. As a result, responsibility of the community to see
to that the patients avail of the treatment available
at the Govt, health institutions.
7. This requires awareness on the part of the co­
mmunity about the TB Control programme, the
funds available for TB Control in the District
and the drugs available at the PHC so that if drugs
run short.. as often happens with streptomycin
injections demands be made for allocation of the
required amount of drugs.
Lately, in Nandurbar Taluka of Dhule District,
people diagnosed as having TB, receive their tablets at
home, every month, delivered to them by the HW.
Presumably this is one activity now included in the
NTP all over India. Surely case-holding will have
improved since previously patients had to cover long
distances to reach their PHCs losing their wages etc.
Hopefully the NT1, who had decided at their
Silver Jublee Proceedings that one of their future
efforts will be health education, will take note of the
above recommendations.
Materials reviewed:

1. Manual for Community Health Workers.

2. Manual for Health Worker (Female), Vol. I.
3. Manual for Health Worker (Male), Vol. II.
(Continued on p. 8)

7

R.N. 27565/76

From the Editor’s Desk
Like the proverbial wolf, the drug policy when
finally announced, has taken the pro-people drug
networks by surprise. Since discussions were going
on for the last three years, since announcement had
been postponed often, and since active campaigning
seemed to make a headway, it was thought that the new
policy would settle issues pending for long. Surpri­
singly (perhaps not so surprisingly, if one considers
the other economic policies of the present govern­
ment), it is silent on most issues directly affecting the
common people.
The policy does not specify production quotas for
essential drugs so that there is no shortage; on the
need to abolish brand names there is no mention;
about quality control, there is no mention of improv­
ing and strengthening the extremely weak and corrupt
drug-regulatory machinery nor is there any policy on
research on medicine especially dangerous new con­
traceptives.

The only important change spelt out is about price
controls. Earlier there were three categories of drugs
under price control with different rates of profit—40%
for life saving drugs, 55% for ‘essential drugs' and
100% for new and ‘other useful' drugs. The rest had
no limits to profits.
The new policy has
proposed only two categories—drugs required for
the National Health Programme (a list of 40 drugs)
at 75% profit-rate and “essential drugs" (not speci­
fied ) at 100% profit rate. The rest, which form the
majority, are being decontrolled. According to the
government’s own admission, this would lead to an
increase in prices of life-saving and essential drugs by
a range of 12 to 25%. According to IMA., the price
rise would be from 60 to 320 %. The price rise among
decontrolled drugs is anybody's guess!

Editorial Committee:

Anil Patel
Abhay Bang

Dhruv Mankad

Padma Prakash
Vimal Balasubramanyam
Sathyamala, Editor

It has been argued that the earlier profit-rates were
unremunerative and hence the present hike is justified.
But this argument is misleading for two reasons.
Firstly, as much as 33% of the toatal costs is spent on
sales promotion, overhead and administrative expen­
ses of the drug companies. Secondly, most medicines
are in the form of drug combinations leading to un­
necessary increase in prices.
The simple scientific demand made by the All
India Drug Action Net-work that all irrational com­
bination drugs should be banned so that drug prices
could come down substantially (even if profit rates are
increased to a certain extent) has been completely ig­
nored.

It is certainly not because of a lack of data that the
present policy is skewed in favour of the drug industry.
One is tired of criticising the policy again and again.
It is clear that only if a concerted effort is made by all
consumers to pressurise the government, can a change
in policy, as if people mattered, take place.

—Anant R. S.
(Rational drug policy cell).
{Continued from p. 7)
4. Manual for Health Assistants (Male and Female).

5. Primary Health Centre Training Guide, Part I,
Training Methodology.
6. Primary Health Centre Training Guide, Part II.
Training of Community Health Volunteers.
7. Primary Health Centre Training Guide Part IV,
Training of Health .Assistants (Male and Female)
and Health Workers (Male and Female).

(All are published by the Ministry of Health and
Family Welfare. GOI).

Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organization.
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