Technology and Health Care - Issues and Perspectives: An Approach Paper
Item
- Title
- Technology and Health Care - Issues and Perspectives: An Approach Paper
- Creator
- Ravi Narayan
- Date
- 1989
- extracted text
-
r
mfc annual meet 1989; alwaye
TECHNOLOGY AMD HEALTH CARE—ISSUES AND PERSPECTIVES
:an approach paper
,‘tavi narayan*
This is a background paper written as a supplement,
to the note on "questions and issues for discussion"
circulated for the mfc annual meeting. It is not
exhaustive nor comprehensive but attempts to-list
out some points and occasional readings that will
help all participants to understand- the basis for
t.
some of the concerns and issues related to the
theme. It will probably be more useful for all
those who are exploring this theme for the first
time.
Participants are requested to read all the.
flt
additional background that has appeared in mfc
bulletins 143-144 and 145.
Those with access to earlier issues of mfc bulletins
would find additional stimulus in bulletin numbers
57, 60, 62, 65, 88, 115 & 121/7
A
£
5,
1
*Community Health Cell
47/1 St Mark's Road
Bangalore 560601
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CONTENTS
1.
Why discuss Technology and Health Care?
1.1
1.2
Health for All by 2000 AD
1.3
Technology Missions
Urban-Rural disparity in medical technology
1.4
1.5
Proliferation of Diagnostic Centres
1.6
Doctor-Medical Technology axis
1.7
1.8
Misuse of Medical Technology
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Technology and Health Care
2.1
Technology and Health status
2.2
2.3
Health Care Technologies
A focus for the meet
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Assessment of Technology
3.1
3.2
Variable nomenclature
Appropriate Technology? What it is and What it
is not (Box 1 & 2)
3.3
Criteria for assessment
4
Clinical Investigations and Dangerous Diagnosis
4.1
Recognising limitations of Lab tests
4.2
"Dangerous Diagnosis" (Box 3 & 4)
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Surgical Technology and Ritual mutilations
5.1
5.2
Assessing Surgery
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Technology for Community Health? Difficult Choices
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Social Issues and Health Care Technology
7.1
7.2
From micro to macro analysis
A social critique (Box 6)
Exploring social links in technology choice
7.3
Over-use/unnecessary investigation and surgery
Medical/Health Care is not only drugs
"Ritual Mutilations" (Box 5)
Policy Statements;
9 Conclusions
10. A Reading list
Inadequate, assessment
1.
Why_discuss_Technology a2c1- Health Care?
THERE are many reasons why the ‘technological1
dimensions of medical/hea1th care in India need
to be critically examined and assessed. Some of
these ares-
1.1.
Health for all by 2000 AD
India's commitment to this lofty goal
demands a critical appraisal of all aspects of the
existing health care service and an evaluation of
alternative approaches and options. With the
increasing awareness, that the Western high
technology-institutional model of health care is
inappropriate, this appraisal becomes very important.
1.2
Technology Missi'ons
In recent years the concept of ‘Technology
Missions* has grown and seme options have been
made and are ,being actively promoted; Atleast two
of the present missions are directly related
to health care—immunizations and drinking water.
1.3
Urban-Rural disparity in Medical Technology
In keeping with our inequitous social structure
and planning priorities, there has been a greater
advancement of the techn .'logical status of medical/
health centres in the urban area in both the
governmental/non-governmental sectors and a stagnation
in the Rural Primary Health Centres.
1.4
Proliferation of Diagnostic Centres
In recent years due to various aspects of a
liberalised industrial policy, there has been a
massive growth of diagnostic technology centres in
the urban areas, all over the country. Most of these
centres promote sophisticated technology like
CAT scan, Ultrasound, Echo etc., and are all in
the private sector. What are its implications?
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1.5
Cveruse/unnecossary investigations and surgery
As elsewhere in the world and particularly
in countries where there is a well developed private
sector in medical care, there is a growing concern
that unnecessary investigations and, often unnecessary
surgery are taking place to support profit margins
of hospitals, laboratories and medical practitioners.
1.6
Doctor-Medical technology axis
The ICMR-ICSSR Health for All report
warns’
that 'eternal vigilance' is required against the
growing Doctor-Drug Producer axis.
Little is
documented about the growing links between practitioners
and diagnostic centres. The kick-back available for
ordering a CT scan is a glaring example.
1.7
Misuse of Medical Technology
The growth of amniocentesis/sex determination
centres highlighted by health activists in recent
years is one among many such examples which need
further investigation.
1.8
Medical/Hcalth care is not only drugs
In recent years, drugs and consequently Rational
Drug Policy and Rational Therapeutics has received
much attention from health and development activists,
consumer groups, professional associations and. policy
researchers. Groups like mfc and others have also
-looked at medical education and policies like
TB control. Family Planning, Child Survival and so on.
But the technological dimension of medical/health care
particularly diagnostic technology, surgery and
related aspects have never been scrutinized critically.
Considering that these form quite a major part of
the cost of medical care, they need immediate
assessment.
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2.
Technology and Health Care
The theme can be explored in many ways.
2.1
Technology and Health status
A major area of exploration can be the
relationship between advances in health care
technology and the health of people—their longevity,
morbidity, alleviation from pain etc. McKeown in
his book "The Role of Medicine" distinguishes five
groups of measures while assessing the impact of
science and technology in health status (refer 10.e.)
i. Measures which are scientific but
owe little to professional science—
manuring of lane by farmers and limitation
of family size by parents.
ii. Measures leading to environmental'
improvements derived from the observations
on relations of living conditions to health.
iii. Mon-medical science and technology—
chemical fertilizers, insecticides,
herbicides in agriculture and' engineering
technology which contribute to control of
the environment..
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iv. Bic-medical research which extended
non-personal measures like food and
water hygiene.
v. 6io-medical research which resulted in
immunization and treatment.
He concludes that atleast in the West items iv. & v.
have had
‘ross
contribution to change in health
status while i. to iii have had more impact.
This is not an easy hypothesis to discuss in such
a tnect but some issues like those raised in the
note on questions could be considered.
has development of preventive/promotive
measures been neglected? If so, why?
Xs health status improvement to be
expected by technological intervention'
or by socio-economic-cultural changes/
interventions?
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How has the growth of medical/health
technology affected social values, medical
ethics and so on?
2.2
Health Care Technologies
Without going into the differences between
Medicine and Health and Medical Care and Health Care,
the meet could explore some of the technologies from
a wide variety of types which come under the term
health care technologies. Broadly speaking there are—
i. Investigative technology (diagnostic)
These include routine investigations like
blocd, urine and stool, x-rays, ECG, sputum
for AFB, routine microbiology, needle
aspiration and blood chemistry. These would
also include the more recent and sophisticated
technologies like CAT scan, Endoscopy,
Ultrasound, Coronary angiography, Echo etc.
ii. Curative Technology
The whole gamut of drugs and the range of
surgical techniques and the associated
technological paraphernalia would be included
in thi s group.
iii. Preventive technology
This would consist of vaccines, occupational
health safety measures’, iodized salt,
vitamin A, ORT, contraceptives and so on.
iv. Rehabilitative technology
This includes a wide range of both sophisticated
as well as simple technologies for core and
rehabilitation of disabled.
v. Other technologies
These include health education technologies,
water and sanitation technology, health
records technology, communication, transport
and so on which supplement and support
organizational dimensions of health/medical
work in the hospital and community level.
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2.3
A Focus for the meet
For the mfc meet, it has been decided to
focus on a few areas?
a. common investigations at Primary Health Centre
and general practice
b. more sophisticated investigations in hospital
and consultant practice
c. therapeutic technologies like injections and
many forms of surgery
d. technologies for community health/community
level interventions
Drugs which form a major part.of therapeutic
technology will not be considered at the meet
since it has been adequately examined at other
mfc meetings and in many other health forums.
Though mfc is open-minded on other systems of
medicine—non-allopathic —the meet will focus mainly on
hospital/health care practice developed on the
technological/institutional model inherited from
the West and attempt a critical analysis of the
technological dimension of this model.
3.
Assessment of Technology
While assessing technology various authors and
policyresearchers have used different terminologies
and included in their assessment a combination of •
different criteria and factors.
3.1
Variable nonmenclature
The different terminologies used are?a. appropriate or inappropriate
b. relevant or irrelevant
c. modern or intermediate
d. people-oriented/people supportive/people
oppressive
Of all these probably 'appropriate technology'
seems the best choice. 'Appropriateness' of a
technology is for a particular need, a particular
situation, a particular level. It does not have
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the value judgments which are common to other
terminologies.
3.2
Appropriate Technologys What it is and What
it is not?
However, even 'appropriateness' can have
different connotations. At the ICMR National Workshop
On 'Appropriate Technology for Primary Health Care'
'VO experts tried to define what 'Appropriate
Technology' 'was' and 'was not'. Between them they
explore all the important dimensions as well as the
misconceptions.
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Appropriate Technology ; ; What it is
"To be appropriate for the circumstances
in which it will be used, a technology
must be—
1. scientifically effective (it works)
2. culturally acceptable (it fits into
the hands' and minds of the people
and does not endanger a social
fabric that may already be fragile.)
3. economically feasible (they can
afford it within the resources
available)
4. have an evolutionary capacity (it.
can be extended and built upon and
is likely to lead to other changes)
5. should be environmentally harmless
or atleast, minimally harmful."
—Katherine Elliott/
Nicolas Jequier (10.b.)
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Appropriate Technology : :
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What it is not
"Appropriate technology is not against
industrialization or against modern
technology. It does not represent a return
to traditional technology.
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It is not restricted to production,
hardware and industry but it also involves
products in all sectors such as agriculture,
health, communication and others.
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It is not primitive or low technology and
does not imply undermining basic research.
In fact it emphasises an even greater
stress on basic research because in the
absence- of the beaten Western path in
conventional technology, there is no .
alternative but falling back on fundamental
• research and new insights.
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It is not a matter of just experiences or
transitory, temporary devices to cope
with the current predicament. It is a
crucial part of a new vision."
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—A.K.N. Reddy (10.b.)
3.3
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It is not pointless within the present
frame work of society because it becomes
the key. to the transformation of society.
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It is not a substitute for ttie socio
economic changes required for ..real
development.
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Criteria for Assessment
There cannot be a fixed list of criteria
for assessment of the appropriateness of a
technology or for a choice between competing
options since technology in health care is of .
different types and at different levels of
health care (refer 2.2). For each exercise
the assessor has to pre-define the set.of
criteria which he/she thinks is relevant to the
situation. However, the larger list of factors/
criteria from which the" selection could be made
would include:
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i. relevance to health need
ii. ease of manufacture
ease of repair/maintenance
iv. ease of operation—professional
control or lay person
v. cost of production—to the system
to the user
vi. relevance to socio-cultural conditions
vii. ecological sensitivity
viii. adapted to local conditions, raw
materials
ix. acceptance by community
x. availability to all segments of society
xi. adapted to local knowledge and skills
xii. hazards in operation
xiii. iatrogenesis if any
xiv. ethical issues involved if any
XV. who has determined choice? Who has control?
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There could be many other criteria and
participants to the meet could add to the list/
or make a selection depending on the issue or
problem under consideration.
4. Clinical Investigations and Dangerous Diagnosis
4.1
Recognising Limitations of Lab Tests
The pathological, microbiological and bio-chemical
investigations of ill health as well as the study of •
Internal anatomy of the diseased body have revolutionized
npt only the understanding of disease, but,' today they
are the she- t anchor of medical treatment aiding
diagnosis, assessing cure and predicting prognosis.
However, there are some basic facts about the
measurement of biological parameters and or the
visualization of internal anatomy that is commonly
forgotten. All laboratory tests have their own
limitations. They are sensitive and specific to
different extents. In simpler terms, it means that
there anc false positives and false negatives, ie.,
normal findings in ill health and abnormal findings
in health. Since most biological parameters follow normal
distribution and the ranges for assessment are narrow,
there will always be a few healthy subjects with levels
ai; the lower end or higher end of normality or just
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outside the range. All tests need to be done
by specific, well-defined procedures and routines.
In the absence of quality control and when corners
are cut due to haste, poor training, over work
or disinterest by laboratory personnel the
reliability of the tests decrease. In addition,
when the test is given significance out of context
of patient history or is substituted for clinical
judgment based on good physical examination then
the reliability and'hazard'
potential increase.
In measurements that use technology requiring
electricity, changes in voltage can affect
readings. With more complex technologies repair and
regular maintenance become crucial. Standardization
of apparatus, checking for zero error and a host
of other such important preliminaries all decide
the validity of the investigation. It is significant
that many of these limitations are not known to
the medical personnel as well and even less to the
patient or consumer public. With the proliferation
of diagnoscic centres and theubsence of any quality
controlling authority, the situation of 'dangerous'or
'wrong'
diagnosis can become 'epidemic' in
proportion in countries like ours and it is time
we
recognise them. When investigations get
ordered for profit motive and get routinised this
problem will increase phenomenally.
4.2
dangerous Diagnosis
Mendelsohn in his now famous booksConfessions
of a Medical Heretic? records a series of
very reliable surveys done on the situation of
diagnosis in the US. Using the term Dangerous
Diagnosis he quotes from' studies of monitoring/
. regulating by Centre for Disease Control on
less than ten percent of the best labs in the
country.
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Danqerous Diagnosis
ECG
"A survey revealed that the reports
of expert ECG interpreters varied by
twenty percent among individuals and
by another twenty percent when the same
individuals re-read the same tracing
at another time.
In one test the ECG delivered a positive
finding in only twenty five percent
of cases of proven myocardial infarction
an equivocal finding in half and a totally
negative finding in the rest.
In one test, more than half of the
readings taken of healthy people were
grossly abnormal."
EEG
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"About twenty percent of people with
clinically established convulsive
disorders never lave an abnormal EEG.
Yet fifteeen to twenty percent of
perfectly normal people have abnormal
EEGs!"
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X-RAYS
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"Conservative estimates peg the number
of deaths each year directly attribu
table to medical and dental radiation
at 4000.
A survey showed that as many as
twenty four percent of radiologists
differed with each other interpreting
the same chest film even in cases of
extensive disease. Thirty one percent
of them even disagreed with themselves
when re-reading the same films.
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A 1970 Harward study showed that the
^oing rate of disagreement among
radiologists was still atleast twenty
percent."
—Mendelsohn (10.d.)
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LABORATORY TESTS
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"in 1975, the Centre for Disease Control
(CDC)reported that its surveys of labs
across the country demonstrated that
ten to forty percent of their work
in bacteriologic testing was unsatisfa
ctory, thirty to fifty percent failed
various simple clinical chemistry tests,
twelve to eighteen percent flubbed
blood grouping and typing, and twenty
to thirty percent botched haemoglobin and
serum electrolyte tests. Overall,
erroneous results were obtained in more I
than a quarter of all tests.
In a nation wide survey, fifty percent
of "high standard" labs licensed for
Medicare work' failed to pass. A large
scale retesting of 25,000 analyses
made by 225 New Jersey labs revealed
that only twenty percent of them
produced acceptable results more than
ninety percent of the time. Only half
passed the test seventy five percent
of the time.
For $12 billion worth of lab tests each
year, thirty one percent of a group
of labs tested by CDC could not identify
sickle-cell anemia.' Another test group
. incorrectly identified infectious
mononucleosis at least one third of
the time. From ten to twenty percent of
the tested groups incorrectly identified
specimens as indicating leukemia. And
from, five to twenve percent could be
counted on to find something wrong
with specimens which were healthy.
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In one study 197 out of 200 people
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were "cured" of their abnormalities
simply by repeating their lab tests. "
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—Mendelsohn (lO.d.)
Some of his findings are rather revealing.
The situation in India would definitely be
worse. It is time consumer groups and
professional authorities recognised this
danger.
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At the mfc meet, it may not be possible
to make a quantitative assessment of the
situation but a qualitative assessment based
on the experience of participants would be
a good beginning.
5.
Surgical Technology and Ritual Mutilations
5.1
Assessing Surgery
Surgery has been a major contributor to
the alleviation of pain and suffering over the
last few decades. The technology for surgery has
made great advances in keeping with the
development of more complicated and sometimes
more intricate forms of surgery. Obstetrical
surgery, accident surgery and now cardiovascular
and brain surgery all have made their contribution.
However, it is true that surgical technique has
also begun to be misused, overused and routinised
for a variety of motives to play safe, greater
profits, impatience of patient or doctor with
medical treatment and other such questionable
reasons.
To the medical profession and even more so to
the consumer public, it may seem even more
surprising that such a development could actually
take place. What is also not commonly known
that many surgical techniques now in common
application have not been adequately tested for
effectiveness or for providing better prognosis.
As more controlled studies are being done and
costs measured against relative benefits, many
surgical techniques are coming under critical
assessment and are proving to be unnecessary or
of 'unproven efficacy' or 'effectiveness'.
Episiotomy, tonsillectomy, adenoidectomy,
some forms of gastric surgery, radical mastectomy
and so on are now under increasing suspicion.
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In a country like ours, in the absence of good
clinical records, record linkage and efficient-'
professional quality control, this problem
is very difficult to assess but many surgeons
are concerned about the problem.
5.2
"Ritual Mutilations"
Mendelsohn in the book mentioned earlier
(refer 4.2) lists out some interesting surveys
done again on the American scene. He uses the
terminology "Ritual Mutilations" to indicate
how like branding, circumcision and other forms
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RITUAL MUTILATIONS
J"Conservative estimates by a congressional
• sub-committee say that about 2.4 million
operations performed every year are unnecessary;
and that these operations cost $4 billion
\ and 12000 lives or five percent of the
quarter million deaths following or during
. surgery each year.
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The independent Health Research Group says
the number of unnecessary operations is more
than 3 millions. Various studies have put the
number of useless operations 'between eleven
and thirty percent.
One study closely reviewed people who were
recommended for surgery. Not only did they
find that most of them needed no surgery but
fully half of them needed no medical
treatment at all.
In six New York Hospitals, forty three
percent of the hysterectomies reviewed were
found to be unjustified.
A seven year study by the Veterans Administra- i
cion of more than 1000 people found that
except for high risk patients with rare left
main artery disease, the coronary bypass
provided no benefit. Mortality rates for
Surgery patients were not significantly •
different from those medically treated.
In fact among the low risk patients, the
mortality rates after four years were
slightly higher among those receiving
the operation.
....contd..,
.T.T7T.. .. .”15
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Ritual Mutilations cont4...
The rate of Caesarean deliveries in
US Hospitals is aroyjasistwenty five
percent. In some hospitals, it is
reaching fifty percent.
Studies of comparable deliveries show
that Caesarean .deliveries occur three
to four times more often in births
attended by electronic fetal monitoring /
than in those monitored with a stethescope. II
—Mendelsohn (lO.d.)
of ritual surgery linked to socio-cultural
beliefs, we continue to accept, promote and
inflict forms of surgery which should have
been discarded based on informed and critical
professional opinion.
Why does this happen? To what extent could
this be a problem in a country like ours?
All this could again be assessed qualitatively
at the mfc meet pooling in experiences of
participants.
6.
Technology for Community Health; Difficult Choices
Critical assessment of options in the choice of
technology becomes particularly crucial when one is
planning for community needs—be they local, regional
or national. Mass health care and national programmes
require more careful planning and the choices,
because of cost, accessibility and availability of
services, logistics, etc., are rather difficult
(refer 10.b.).
This paper will, however, not explore this dimension
in detail since much of these choices and the analysis
of issues has been considered in mfc bulletinsand
mfc meetings in the context of child health, family
planning, tuberculosis programme, immunization,
diarrhoea control and so on,
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Choices like sputum AFB vs. x-ray or MMR; ORT vs. iv
fluids and antidiarrhoeals; which vaccines to include
in immunization programmes; oral polio vaccine vs. ■
injectable polio vaccine; cholera vaccine vs. safe
water programmes; iodised salt or iodised oil
injections; choice of contraceptives etc. all
exemplify the technical,epidemiological, social,
economic, and managerial factors that need to be
considered in making such decisions. Very often, the
choice is not really based on a detailed analysis of
all the factors‘and is based on more adhoc or empirical
decisions and these need to be constantly scrutinised
and critically debated.
7.
Social Issues and Health Care Technology
7.1
From micro to macro analysis
While reviewing literature one comes
across constantly social, economic, cultural,
political, ecological, historical and ethical
factors which determine the growth and development
as well as the transfer, adoption and promotion
of technologies. This is applicable to all
technological development not only those in
health care.
It may not be possible to explore all these
issues at the meet for want of time and adequate
background information. However, it needs to be
recognised and emphasised that macro-factors
in society have often a greater impact on technological
choice than micro-factors--be they professional,
technical or managerial.
In our deliberations, therefore, we need to
constantly look at a macro analysis as well as
a micro analysis; a social analysis as well as
a techiiico-clinical or technico-epidemiological
analysis.
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7.2
A Social Critique
Professor Banerji in his recent book—HEALTH
AND FAMILY PLANNING SERVICES IN INDIA—outlines
some of the’ factors critical to a social choice
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MEDICAL TECHNOLOGY
! "One of the features of the development of the
[ Western system of medicine is the phenomenal
' growth and development of medical technology.
|| This technology is often projected as a liberator
of human beings from many dreaded diseases.
|l Treatment of a disease is considered to need some
sort of 'technological fix'. In the flush *of
!i major medical breakthroughs it was earlier
, believed that what one needed, for alleviation of
■' suffering caused by diseases, was a clever, well
equipped medical technologist, who would 'fix'
. most of the diseases.
As is the case with other products, in rapidly
industrialising societies, market pressures
: have been a powerful motive force in the
. spectacular advance in medical science and
[ technology. They have played a critical role in
l projecting problems of sickness, not simply as a
technological problems, as problems requiring a
'technological fix', but also as problems that are
amenable to the particular brand of technology
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‘ Thus, apart from having= elements, that are
undoubtedly rational and scientific and
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instrumental in alleviating suffering, the
j Western system of medicine also has many elements
■ Which are patently extraneous, imposed on it by
; market forces. Unnecessary hospitalization,
excessive or even totally unwarranted use of drugs,
■ tonics, vitamins and baby foods, excessive use
! of diagnostic tests and performance of unnecessary
surgical operations are some examples of the
, undesirable consequences of this. Probably even
more than being an instrument for alleviation of
suffering of the sick, the entire system cf
medicine in Western countries has taken the form
of an industry in which human suffering becomes
an object of profit and market forces 'create1
demands for the products of the industry among
the potential consumers."
—D. Banerji (lO.c.)
ol technology, emphasising particularly the effect
of •''arket forces and Industrial development on the
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growth of medical/health technology as well as'
the concomitant glorification of1 technological
fixes' to solve societal problems.
7.3
Exploring Social Links in Technology Choice an<5
Appiication
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Apart from the factors mentioned in the earlier
critique there are many other important ones as well:
a. Privatization: The transfer of provision
of 'health care from public sector or
government responsibility to private sector
has major effects on accessibility and
availability of health services, and on
costs as well. The latter is more likely
to respond to profit motive and market
pressures. The socially disadvantaged would
be less likely to be covered by adequate
health care.
b. Gender discrimination; The social ethos
which favours gender discrimination may
affect technological choice, eg., female
contraceptives being researched more than
male contraceptives. Also the promotion
of female sterilization surgery when male
sterilization (vasectomy) is easier, less
costly, safer and logistically more relevant
^.S a case in point.
c. -jumping of Technology; Third world countries
have become a1dumping ground1for .obsolete
?nd often hazardous technologies. This may be
equally-* true for medical technology transfer
Ln the country at present.
d. Class differences: In an inequitous social
set up where the upper classes control decision
making and choices, various coercive tactics,
disincentives and other organizational
procedures may be thrust into planning
affecting the lower income and socially
disadvantaged groups. Programmes of
compulsory sterilization during emergency
symbolised this best though a subtle
element of coercion continues even today.
This is not an extensive list and participants may
like to identify more factors and add to the same.
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8.
Policy Statements; Inadequate Assessment
8.1
National Health Policy 1983
(10.f.)
The National Health Policy Statement of 1983
refers to the issue of Technology in Health Care
in somewhat ambiguous terms. In the section on
PROGRESS ACHIEVED, it note' that 'significant
indigenous capacity has been established for the
production of drugs and pharmeceuticals, vaccines,
sera and hospital equipment'.
In the section on THE EXISTING PICTURE, it concludes
that 'the establishment of curative centres based
on the Western models are inappropriate and
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irrelevant, to the real needs of our people, and the
socio-economic conditions in the country'.
In the section on NEED FOR PROVIDING PRIMARY HEALTH
CARE, it plans to 'provide specialist services as
near to the beneficiaries as possible, within a well
planned network' and suggests that'expenditure should
be reduced....by economical investment in the purchase
of .machineries and equipment, ensuring against avoidable
duplication of such acquisitions. It is also necessary
to device effective mechanisms for the repair,
maintenance and proper upkeep of all bio-medical
equipments to secure their maximum utilization'.
In the section on MEDICAL INDUSTRY, it motes
Interestingly that''the practitioners of the modern
Medical system rely heavily on diagnostic aids
involving extensive use of costly sophisticated
tio-medical equipment. Effective mechanisms should
be 'istablished to identify essential equipments
required for extensive use and to promote and
enlarge indigenous manufacture, for such devices
beir.q readily available at reasonable prices for use
-?•
at ths health care centres'.
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On the whole the pronouncements are vague and do
not reflect a comprehensive analysis of the issues
of technological choice, use, misuse or policy.
In the section on PROBLEMS REQUIRING URGENT ATTENTION,
it does mention nutrition, prevention of food
adulteration, water supply and sanitation, environmental
protection, immunization, maternal and child health,
school health and occupational health as priority
issues but in all these, the issues of technological
choice and development are vague and lost in generalities..
8.2
ICMR/ICSSR Health for All Report (10. a,)
This document, which is meant to be an important
policy guideline for national health plannig, has
also not tackled this issue adequately. While drugs
and pharmaceuticals are given much importance, other
.aspects of medical/health technology are not adequately
researched.
The concept of Appropriate Technologies is, however,
mentioned and a somewhat ambiguous plea is made for
a balance between 'over sophistication' and 'under
sophistication' .
r*
j APPROPRIATE TECHNOLOGIES
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In the existing health system, there is an
emphasis on over-sophistication which
necessarily influences research. In the'alternative
model we have proposed, the emphasis is shifted
to the utilization of paramedical personnel and
the development of alternative, simple easy-to-use
technologies. The research programmes anc} policies
should besuitably modified to meet this need. This
does not imply a swing to the' other extreme of
under-sophistication. What is needed is a proper
balance between the two approaches to meet real
* social needs.
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--Health for Al]—An Alternative
Strategy (10.a.), ICMR/ICSSR
Study Group
L.
It is apparent that while science and technology
policy statements are the order of the day in the
20
20
country, Health Care/Medical Care policy statements
still suffer from an inadequate analysis and require
greater clarity and commitment to the difficult
choices that need to be made.
9.
Conclusion
The topic 'Technology in Health Care' is a complex
matrix of issues and problems, which cannot all be covered
in one meeting. The mfc meeting could, however, become a
focal point for a beginning of a process of technological
assessment. Issues and perspectives could be clarified
and an approach to assessment can begin to be explored.
It would be a good exercise, however, if participants
could arrive at some consensus on some of the issues
concerned sc that the discussions are not only debates
and the issues are not lost in polemics and ideological
stands.
In the present social ethos,
'Technology1 is subject
to glorification, high pressure sell, and, inequitous
Investment. Its impact on Medical/Health Care is bound
no affect the nature of Health Care development in India.
It is time for a'critical1 and 'informed' assessment
of onoices. Could we make a beginning?
10.
-1. Reading List
a. lealth for All—an Alternative Strategy, ICMR/lCSSR
study Group (1981), Indian Institute of Education,
hne.
b Appropriate Technology for Primary Health Care,
'Q4R Monograph (1981).
c. Health and Family Planning Services in India,
Sar.orji, d (1985), Lok Paksh, New Delhi.
d. Confessions of a Medical Heretic,
■tendelsohn, Robert S (1979), Warner Books,
lhe Role of Medicine, Mckeown, Thomas (1984)
--sil Blackwell, Oxford.
f. national Health Policy (1983), Ministry of
He th and Family Welfare, Govt, of India, New Delhi.
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