A Preliminary Outline of a Pilot-Model of a Comprehensive Health Care for the Gas Victims
Item
- Title
- A Preliminary Outline of a Pilot-Model of a Comprehensive Health Care for the Gas Victims
- Date
- 1986
- extracted text
-
4S
326 V Main I Block
Koramangala
Bangalore 560034
5 NOV 1985
Dear
Enclosed is a preliminary tentative outline of
a pilot model of a comprehensive health care for
victims of the Bhopal gas disaster prepared by Anant
and friendso
Kindi 7 review it and send your comments to
Anant Phadke, 50 LIC Quarters, University Road,
Pune 411 016, latest
There is an urgent need to evolve a more
comprehensive plan of care and your considered opinion
and ideas will help this process greatly.
We very much appreciate the promptness with
which you have participated in these exercises of
collectivity in the past and look forward to your
prompt response.
With best wishes.
Yours sincerely,
Encl:
Ravi Narayan
Convenor
Bhopal
30.8.1985
A MEETING of different groups involved in the Bhopal work
was convened in Delhi by Mira Shiva on 19th August to discuss
future possibilities of work on health issues. Representatives jf
the ZGKSM and NRPC, the two Bhopal based organisations and
representatives of a number of Delhi based groups as well as
some concerned individuals participated in the meeting. Five
doctors from the Drug Action Forum West Bengal and one from
the medico friend circle were present. It was suggested to
these doctors that they prepare a plan for comprehensive health
care to the gas victims of Bhopal. It was noted that though
the Jana Swasthya Samiti has been interested in other modes
of medical intervention besides Inj. Sodium Thiosulfate, the
Samiti has not so far prepared a plan for Comprehensive Health
Care primarily because there has not been sufficient human
power to implement any such plan. However, it was argued that
it may be more probable to get more doctors if any concrete
plan is there. Praful Bidwai informed that the Bhopal Relief
Trust can collect funds for implementation of such a plan, and
also agreed to circulate the plan amongst different groups.
It was agreed that if NGOs can work out and implement a model
pilot plan for "Comprehensive Health Care" for gas victims,
pressure can be brought on the Government to adopt such an
approach on a wider scale. But the doctors were unwilling to
do this exercise unless there is some real possibility of
getting doctors for this work. Neither mfc nor DAF—WB has the
resources for such a scheme. It was however pointed out that
Mira Sadgopal was already preparing a similar plan in Bhopal
in connection with the SOC. writ petition. Smarajit Jana and
Anant Phadke agreed that when they go to Bhopal after 4 days,
they would go through this plan and will help to improve it
if necessary.
ACCORDINGLY, MIRA’S draft was discussed in Bhopal. It
lays down the essential principles and approach towards
comprehensive scheme. This has been incorporated in the present
draft. The purpose of this draft is two fold - i) To give
some concrete idea to the different groups doctors about the
method to prepare such a scheme. Some operations, logistical
details have been given by way of .example about two of the
aspects (care of respiratory and paediatric problems) of health
problems to give an idea about what it involves to implement
such a scheme. This draft,, it is hoped, would thus give an
idea about the resources that would have to be mobilised by
the NGOs for such a pilot scheme. If sufficient numbers of
doctors, other health workers are available, a larger group
can sit together and work out an improved, detailed scheme for
pilot model, ii)- The NGOs may not be able to mobilise such
resources but may lobby, pressurize the Govt, to adopt a
Comprehensive Health scheme. This draft can be a starting point
for a systematic discussion amongst NGOs with the aim of
preparing a full-fledged improved scheme for comprehensive
health care for gas victims to be presented to the•Government.
THIS DRAFT has been prepared with the help of Dr PV Goon,
Dr Debashish Chakroborty, Satinath Sarangi and Vijay Kanhere.
Anant Phadke
Smarajit Jana
*
Mira Sadgopal
( Nd
A PRELIMINARY OUTLINE
OF A PILOT-MODEL OF A COMPREHENSIVE
HEALTH CARE - FOR THE GAS VICTIMS.
Introduction; It is widely acknowledged that even eight months
3fter the disastrous gas-leak, a very large number of people in
Bhopal, especially in the worst-affected bastis are still com
plaining of a variety of disabling sufferings. Though polyclinic^
and hospital facilities have been specially opened up for gas
victims, they are woefully inadequate. Secondly what is necessar*
is not this clinic-based approach, but a community based compreherisives Health Care Programme. The health care facilities can
not be set up arbitrarily but the type and athe amount of health
facilities must be based on the quantity and type of health problems of these people. As pointed out in the introduction, '.n
this draft - outline we have tried to give an idea about the me th J
of preparing a Comprehensive Health Care Programme.
Before we proceed, we would like to point out that apart
from our personal limitations and time constraint," there are sc .ie
other important limitations imposed on us - lack’of sufficient
published scientific information as to the exact nature of the •
toxic gases; their exact mechanism of action on human body and
on health of the people in Bhopal; limited scientific information
on the quantity of the problem as of today; lack of a relevant or existing model of such a comprehensive programme in such a situa
tion.
Inspite of these limitations, we need to proceed as follovss
I)
To formulate the overall objective of this comprehensive
Health-Care and the approach towards achieving this objective.
II) To determine the quantity and type of health- problems
(morbidity pat tern) caused by this disaster;
Ill) To establish the interrelationship between different healt i
problems, sufferings and their causation - to make a,!community
diagnosis".
IV) To put these special health-problems created by the gas-di-saster, in the frame - work of pre-existing health-problems of e
poor urban community;
V)
To outline "vertical programmes" to take care of the differs
specialhealth-problems (for example respiratory, gynaecological
etc.) created by this disaster along with the operational and loc stical considerations;
VI) To integrate these vertical programmes to’ dissolve them ir tc
a holistic comprehensive Health Programme; integrating it with, tl
Primary Health Care Approach for pre-existing health - problems.
In this preliminary outline, we- do riot intend to systemati
cally develop all these steps. But an attempt has been made tc
deal very briefly with most of them. As regards, the vertical
programmes, we have dealt with only the respiratory problems cnc
the problems of children in some detail, just by way of example.
Health-Care for other problems has been only cursorily enumerator
to be improved and developed upon later. The final step of inte
gration of various vertical programmes and Primary Health - Care
for pre-existing diseases has not been attempted for obvious rcaeson that this can not be done unless all the vertical programmes
have been worked out.
' l) OBJECTIVE AND APPROACH
The over~'1 objective of this scheme is to provide integrate
preventive, curative and rehabilitative services at the doorstep
2
2-
of the gas victims.._inorder to relieve .the-i-r-sufferings, prevent/
restrict further damage and to rehabilitate them for meaningful
social life.
-----
"T6 tackle this multidimensonal vast health problems of the
gas victims and to achieve maximum benefit from this comprehensi
health programme some definite, guidelines have to be followed?
1)
The approach of medical intervention should not concentrate
purely and solely on individuals or on organs rather it should
try to integrate personal-care with community level care.
The very specific situation in Bhopal highlights the necess +
2)
- of strengthening primary health care and integrating it wi.th spe :
. ■ Used health care.
Health education will be an integral part of every inter
3)
vention and management techniques. In every sphere of preventiv ,
curative, or rehabilitative services -1 education part” will play
an important role to build up patients' awareness and will provi €
requisite knowledge and skill based on which they will be able t
take an active part in the programme.
1
4)
People's participation is and always will be a determining
factor for planning andimplementation of this type of scheme. I
would have been better if they could participate in planning,'pr
gramming and implementation of this, comprehensive scheme. At
least we can presume that they should play active role in imple
mentation and supervision part of the programme.
5)
]Multisectoral approach will be one of the guiding principle.
Regarding some part of preventive aspect as well as in rehabili
tative part we are stressing more on intersectoral activities
where urban development authority water and pollution Control Bo r
legal aid bodies, Ministry of P.W.D. and welfare and NGOs must wc r
hand in hand.
6)
The role of paramedics and other health personnel' (besides
doctors) in the comprehensive health scheme should get proper
importance.
7)
The scheme must cary an inbuilt system of evaluation, and it
is not some specialists or some administrator who will be the on'.y
person to judge the programme. The reciepients will take the
leading role in evaluation.
B)
The results of evaluation and all information regarding the
programme will be made available to the common people and as wel?
as to professionals and through a process (bf regular exchange with
different sectors of population, we feel the 'model1 of the scher. c
will be evolved.
II) QUANTITY AND TYPE OF HEALTH-PROBLEMS
It is well known that hospital-based, dispensary baseddata
are inappropriate for determining the quantum and type of health
problems in the community as a whole. For this 1
. purpose cf
determing themorbidity-pattern at the community level, we have
with us, two epidemiological investigations carried o~t by randor
sampling method (along with a control - population). Both these
surveys are by volunatary groups - one conducted by doctors and
technicians from KEM Hospital, Bombay (organised .by NRPC, VHAI,’
BRT and referred to here after as study I) and the other by the
Medico Friend Circle.(referred to hereafter as study IT). Public x
results of clinical and toxicological studies carried out by thd
ICMR and others on . hospital-based pa-tlerits would be used to estab
lish the nature of damage and the possible line of medical
intervention.
....3.
3
The two surveys mentioned above have reported the following
pattern of health problems in the doderately and severely affected
bastis, about one hundred days after the•disaster.
It is clear from the accompanying table that majority of tl e
people in these severely affected basis were still suffering fr m
a variety of complaints, refering to different systems of the b d- .
It is not known whether even today the quantum and the type of : xr blems remain the same. But voluntary workers working in the ba: t.'s
report that there has not been much improvement in the situatior.
In absence of any adequate scientific data about the recent mor? idity-pattern we would have to rely on these studies conducted f iv<
months back. In devising the vertical programmes, these data
would give us an idea about how many persons will have to be
specially taken care of for example in case of respiratory care
we can say that about 70% of the adult population would require
periodic check up, vigilance and some from of medical intervent'a
either in the form of proper health educational inputs, prevent v
care (avoidance of dusts, fumes etc.) or urgent curative interv ntions whenever necessary.
' Apart from these physical disorders, national Institute of
Mental Health and Neurological Sciences (NIMHANS) has reported
that 10-12% of affected persons visiting the medical clinics at
Bhopal presented with .a psychiatric manifestations. .The preval n-.c
of this at the community level.is not known.
III) COMMUNITY DIAGNOSIS
It would require an in indepth.and detailed analysis of th_s
very controversial subject to arrive at a community diagnosis.
The MFC report has gone into this controversy at certain depth.
Here we would just state our opinion based on study of available
’published studies and on the basis of prolonged, intensive dis
cussions with many people.
a.) Majority of the people aresuffering from damage to the lungs-either restrictive or obstruc
tive in nature. Moreover isocyanates are known to sensitize
affected people and some of the patients are also suffering
from bronchial asthma due to this sensitization. This lung
pathology has also led to decreased oxygenation of blood and this
can lead to systematic changes in the other systems of the body*
ii) But this alone can not explain the amount and type of breath
lessness; the amount of muscular weakness and fatigue (even taking
into account psychological depression); the involvement of gastro
intestinal system; the menstrual disturbances and above all
inflammation of cervix and the pelvic organs unaccompanied by
infection; (Non-infective pelvic Inflammatory Disease)and £vide: o
of carbamylation of Haemoglobin andother proteins in the body b;
MIC aH3ifferent pointers to the possibility • of ’’recurrent cyanide
poisoning"; e pecially the results of the double blind clinical
trial started by ICMR in january 85 (and still being carried out
empirically establishing the effectiveness of Inj . Sodium•Thiosulfate shows a multisystem ic involvement (chronic Cyanide - like
poisoning) amenable to Inj j Sodium Thiosulfate. iii) Psycho
logical disturbances due to this disaster mainy anxiety neurosir
and depression. iv) Reduced resistance due to effect of MIC an^
malnourishment due to socio-economic deprivation has probably in
creased the incidence of various infections, v) Toxic‘gases thr>u<1
some obscure mechanism continue to affect the watering of eyes
and the acuity of vision. vi) Biologically vulnerable groups
children, old people pregnant women are more likely to be worst
sufferers.
IV) Placing the special problems caused by the gas-disaster
within the setting of pre-existing health problems in Bhopal.
This exercise has not been attempted here
4
V DEVELOPMENT OF VERTICAL PROGRAMMES.
Based on the morbidity pattern and the community diagnosis
lined above, different vertical programmes need to be worked out t
be dissolved later into a holistic comprehensive programmes.
To begin with we must stress the necessity of mass-detoxifi cation with inj. Sodium Thiosulfate based on the ICMR
recommen ■
dations without any further delay. The ICMR and other ,research bodies must publish studies as soon as the research is over. Th. s
is necessary to find out to what extent inj. Sodium Thiosulfate s
still effective. It is learnt that ICMR has just started a secc .c
double blind clinical trial to determine this and the results
should be available in two weeks.
Vertical programmes need to be worked out for the following
respiratory care, paediatric care, obstetric and gynaecological 'i
opthalmic care, care of psychiatric problems. We have worked ou
some of the details of respiratory and paediatric care by way of
example to give an idea about the method to develop a plan of
such programmes. For the other three types of problems vie have
just enumeratedaspects of such a programme for these problems.
A) PAEDIATRIC CARE.
Children being biologically vulnerable group, are expected x
be more affected. Surveys have confirmed this suspicion. Study -7
havs reported that children residing within a distance of 1/2 tc •<
km. complained of cough (96%) breathlessness (75%), as compared /
a lesser percentage of adults complaining of these symptoms.
Moreover, on examination, respiratory system was found to be aff x
ted in 50% of these children and 67% had abnormal X-ray finding
them. Surprisingly, children living at a distance of 2 Kms. frc
the factory had been affected maimally.
Study-II reported that 50% of the lactating women from the
sample - population in J.P. Nagar complained of varous degrees c : „
lactation - failure. An earlier study by Rani Bang and Mira sac
in a temporary clinic set up for the survey, had reported 57% 1? ci
tation failure.
The paediatric age group therefore requires special attenti >:
The approach of health - intervention would be, active and complo
implementation of principles of primary health care for childrc-r.
This would consist of (i) proper care of menther during pregnane./
safe delivery and adequate care of the new born baby immediately
after delivery since ICMR has reported low-birth-weight babies.
(ii) 100% coverage'of immunization including measles vaccinatior
in view of reduced resistance due to a variety of reasons.
(iii) Breast - milk substitutes to-be supplied
adequate quant i’
ties for .all children whose mothers have reduced lactation. Thi s
* supply must be- accompanied by adequate health-education about tlx
proper, hygienic use of these substitutes.
(iv) Growth moni
toring through periodic weigh ing and appropriate clinical,
laboratory investigation to find out the cuase of failure of
growth (when detected) followed by appropriate interventions
including nutritional supplementation when needed.
.Ov) Early diagnosis and proper treatment of all infections espe
ally the respiratory infections.
(vi) Proper counselling to parents and teachers about -the psycho
logical impact *of this disaster on children.
5,
- 5 -
All these measures can not of course be carried out without t? ;
active co-operation of parents which is to be elicited by intesiv
health-education about these medical interventions.
OPERATIONAL AND LOGISTICAL CONSIDERATIONS.
We would concretize this aspect to a certain extent just to
demonstrate how this can be done.
The overall operational structure of the comprehensive Healt
programme would be four-tiered and the paediatric care would alsc
be a part of this structure - (i) community health workers
(ii) community Health Assistants (iii) Community.Health polyclini
(iv) specialized hospital care.
(i) Community health - worker-(CHW)
A team of one male and' one female community health workers
would perform-the following functions -
' (a) Preparation of health— card of each member of the family ir.
eluding all children. These cards would remain in the family and
a corresponding paper with identical printed layout will be taken
away by the CHWs. CHWs would just put a carbon beneath this pape
to get identical entries made on the carris.- •
(b) 'To visit each family once in a week to enquire, about health.
problems.
To treat minor illnesses present at the time of’ home visit.
In case of children, to enquire about immunization status ar.
to convince, motivate the parents for complete immunisation;,..
To warn family-members about dangerous- symptoms (for example
purulent sputum) and advice them, about various facilities availab. a
To do health-education related to all the above functions.
The preparation of health-cards for all members of a family
would take a lot of time. But after this initialperiod, each
family visit can be completed in half an hour by this team. 'This
team would spendonly half of their eigth hours of working day in
this regular visit is thus covering eight families in a day and
'therefore 50 families a weak, Thus one- team of CHWs can cover a
population of 250. The rest of their working time would be spenton managing minor illnesses as reported on their own .by-the rest
of the 42 out of' the 50 families allotted co. each" team of CHWs.
(ii) Community Health Assistants
One—of” them would be involved in the work of • monitorings -carrying a weighing machine, a measuring tape and a portable elqctronic spiromet re. Children would be weighted once in a month’
and lung function tests of all family members would also be carri-a
out in the same visit. After initial teething troubles are over
come, thirty families can be covered in a day; 750 families in a
month,covering a population of 3750.
--A second CHA would check up in a random manner, the entries
made by CHWs, guide and superivse-their work, solve their diffi
culties, prepare a report of the work done by eight * earns of CHWs
A"third CHA would run a community Health dispensary where
routine dressing, routine injections prescribed by doctors from
the polyclinic (for example - streptomycin) and immunizations
triple, meeasles etc.) would be given. With the help of one
assistant, he/she can give about '.150 injunctions a day. We wcul'
have to calculate the number of injections to be done ( mainly
immunizations) per say 200 families to determine as to how many
persons would be required to do this work in the 1st year of this
programme.
*
C
TABLE NO. 1
STUDY
Health
STUDY
1
Problems
II
Health Problems.
% of
People
with
complaints.
% of
people
with
complaint s
Respiratory symptoms.
79.7
Cough with or without
expectoration.
Cough
83
Breathlessness on
accustomed exertion.
Breathlessness
(grade II to IV)
80
Eye Symptoms.
Persistent vision
affection
Gastrointestinal
symptoms
65.6
67.7
Gynoecological,symptoms75.5
Vaginal discharge with
out infection
60.3
Pulmonary function abnormallLties(both obstructive
and restrictive).
70.2
55
87.16
58.78
77.02
Fullness after- seal
66.21
' 68.21
Weakness in extremeties
Fatigue
Tingling and numbness
65.54
81.08
54.72
Loss of appetite
60.3
Neoromuscular symptoms 54.5
X-ray chest various
types of deposits
Lacrymation
Blurred vision
Photophobia
75
Changes in the menstrual all stacycle length, menstrual tistica' flow, colour of menstrua-lly sicnjif icar.t
tignj, white-discharge.
after
gas leak.
Pulmonary function tests
restrictive changes in t
the age group of 15 to
60 years and obstructive
changes above 60 ySars.
6 -
(iii) Community Health Polyclinic
This will be staffed by several M.B.B.S. medical officers
and one specialists from each special field-paediatrics gynaecology
surgery etc. These cases which can not be managed by CHW or by C
CHA would come to this clinic* They will be’ first seen by an
M.B.B.S. Doctor and only selected cases, would be referred to the
paediatrician.
Children below 5 years of age constitute 15% of our population
Study-I reported that about 75% of the children below 12 years of
age are suffering (§rom respiratory problems. But we do not know
the present status, neither do we know the incidence and prevalence
of other infections and how many of them need a care at polyclinic
level and at a specialists* level. Theratio of population to
M.B.B.S. doctors and to the specialists will have to be worked
out by a detailed, involved exercise. The principle however
should be clear-to cater to all patients in a
proper manner, tc
refer to a higher level only when necessary, all health - personnel
and other resources to be fully andefficiently engaged (but not
over worked).
(B) RESPIRATION CARE
The main objective is to provide integrated preventive, cura
tive & rehabilitative respiratory care services to all gas victims.
All efforts should be made to provide all possible relief facili
ties and the approach will be such that in the process they will
be acquinted with their own respiratory problems and its manage
ment techniqure, They will be guarded with necessary preventive
measures. Suitable rehabilitative services should be sought for
those who need it most.
Preventive care
The first and foremost part of this- care will
consist of a study to identify the specific hazardous elements
(smokes, fumes dusts, fibres etc.)
for all of those who were
exposed to the toxic gases and particularly for those"who have al-r
ready developed T mg damages. Appropriate health education materi
als .have to be prepared both for victims and for professionals.
The education maojrials will include all information regarding
irritants audits Effect on lungs; possible .cumulative or sensitis
ing effects of many other irritaunts and its long-term effects
on lung tissue wi _1 be dealt with in more details. Emphasis
should also be gt /en on hazards of smoking on lung tissue. All
types of mass-med .a should be mobilised-to have an impressive
effect on victims as-well as on professionals. Specific protect
tive measures may be necessary for some, but some general measure s
have to’be undertaken to protect these victims from further expo
sure to irritahts , These.irritants may be of different types.
But some irritant s like fumes, smokes and vehicular pollutants
need to be mantio led here. The general environmental pollution
of Bhopal (where . a few more industries are situated in the heart
of the city) has - :o be dealt with appropriate measures with
urgent seriousness 3.
.
We would li< j to specify some measures which can be provided
to some specific tjroups of population -
Women who a.r 2 involved in working with chullah have to be
protected from siiikes and fumes. Here provisions for smokeless
^hullah and/or cooking gas facilities will serve the necessary .
purpose.
Those who r~ still involved in some specific hazardous
jobs (jobs whic) involves exposure to fumes, dusts, fibres etc.)
should be provic ed with substitute jobs.
Law can be enforced to provide reserved quotafor some jobs
suitable for ga. victims both in Govt. andNon-Govt. services.
.7.
9
- 7
Medical and Surgical Care;(i) Early diagnosis and prompt treatment of all respiratory ill
nesses is necessary since infection of any type will certinly’ crea
more problems and further damage for persons with already damaged
lungs. Appropriate intensive health-education must be carried out
to explain the people why they must report early in case of any sy
ptoms related to the infection of respiratory system. One of the
important functions of the community Health workers would be to re
inforce this message in their daily work.
All the treatment must be easily available and free of cost.
(ii) Appropriate surgical intervention when needed (for example cer
tain cases of bronchiactesis, pulmonany abscess)
(iii) Respiratory physiotherapy;- A very large percentage of vict r.i are with different types of respiratory problems. For many of the
respiratory physiotherapy may provide help to alleviate sufferings,
(iv) Monitorings- Investigation facilities should be provided tc
assess the damage already done by the poisonous gases and to find u
whether such process is still continuing in them. . Investigative a- d
monitoring facilities also be provided to assess the prognosis of
those cases, and for the evaluation of medical and surgical inter
ventions. This will act as a feed-back mechanism which will help
initiate necessary changes in the intervention technique.
7v) Special care must be undertaken for those who are suffering
from chronic respiratory illnesses like Br. Asthma, Chronic BrochitTuberculosis etc.
Rehabilitative services;- For many patients, curative measures wi.'.l
be of little or no value. For them, rehabilitative services is a
matter or greatest importance. For this,
this. an expert team of specia
lists is necessary. Such a team will assess the damage to the lun;
and will advise, guide and provide appropriate rehabilitative ser
vices so that they can lead a meaningful social life. Specific sug
gestions are ;-
Operational aspects;(1)
(2)
Development of new appropriate jobs for disabled persons ;
Compensatory incomes scheme for those gas victims'who can not
earn as much as earlier inspite of medrcal treatment;
Long term pension scheme.
A four tier system would be an effective procedure to deliver
comprehensive respiratory health care to the victims.
Monitoring part can be taken up by a team called monitoring uni*
(explained in operational part).
The Medical intervention part can be divided into the subunits like (i) Medical sub-unit (ii) physiotherapy sub-unit
(iii) Investigative sub-unit. The three sub-units will work in cc_
ordination at the Community Health polyclinic levpl.
(3)
The respiratory care unit as a whole will consists of ;-
Two or three M.B.B.S. doctors, and a Chest specialist, a physiotherapist, a pathologist, a paramedic,j a Radiologist, an X-Ray
education), ard attendents (maletechnician, a Social worker (Health
.
and female).
8.
8
One chest unit will be able to treat 40 patients and one phys o-therapist will, deal with 30 patient a day. Later he will help a
group of patients on one sitting and hence his efficiency will in
crease manyfold.
Based from the community diagnosis and from .earlier statistic 3,
number of chest patient per-thousand population'can be calculated nc
out of them how many will need physiotherapy can also be determine .
Based on those figures, how many chest care units are needed for t .e
affected population can be calculated.
(C) OPTHALMIC CARE
The objective of this care is to provide a comprehensive optt. 1mic care to all gas victims.
1.
From available studies it seems clear to u >
that even months after the exposure to toxic gases, a high percent
age of exposed population was suffering from a variety of symptoms
ranging from burning sensation of eyes, lacrimation, to diminished
vision. Special care must be undertaken so that further exposure .o
any type of irritants (fumes, smokes, etc.) can be eliminated. Wc e:
involved in cooking and tobacco Industries and Industrial workers n
chemical industries are the two specific vulnerable groups.
Provision of protective applicance so that eyes can be protec .ec
from-- irritants when contact with irritants can not be avoided.
2.
Curative care s-
(i) Routine check up after say every three months for acuity of
vision and supply of corrective glasses when necessary.
(ii) -All eye ailments must, get prompt attention for treatment.
(iii) Necessary surgical intervention in cases of cataract, cornea-opacity.
'
"■ ■ _X:U-
3. Rehabilitative care s- For those who can not continue their
earlier occupation with the same case and efficiency as before in
spite of medical intervention should be adequately compensated wit
a monthly supplementary"pension. Severely disabled persons would
have^-td be given an alternative suitable employment.
(D) GYNAECOLOGICAL & OBSTETRIC CARE .1:
Care for gynaecological problems High percentage of non-in(1)
fective enocervicitis, pelvic inflammation and menstrual irregu
larities. have been reported by. ivestigations mentioned earlier.
Urgent and serious attempt should be made to find out treatment
for these disorders and this treatment be made a part of the com
prehensive Health programme.
Proper contraceptive,advice till these disorders are overcor
Condom should be advised rather than pills or Intra Uterine Device
in those women who are suffering from any of these problems.
Obstetric cares- 100% coverage to be aimed at in the usual
(2)
Maternal and Child Health programme.
Parents of deformed babies borne after the gas - leak to get
compensation to take care of such babies.
c
9
(E) CARE OF PSYCHIATRIC PROBLEMS
Experts at the National Institute of Mental He’alth and Neuro
logical sciences, (NIMHANS) Bangalore, have evolved a model of psy
chiatric care based on paramedics. This approach needs to be adoptc
to the Bhopal - situation. Emphasis should be on health-education,
counselling and not on drugging.
HEALTH CARE DELIVERY MECHANISM (OPERATIONAL PART)
This part might help to get some idea about the mode of deliv ?r
system, This operational aspect of the scheme is as important as sh
planning part, It must ensure a evaluation procedure and technique
of supervision, People's role in the total programme needs to be jit
phasised here.
This is of course a very tentativeprojection of a future deli^c
system based an objectives and approach put down earlier. Interest*,
groups and individuals can take serious steps to develop or re-bui’.c
a pro-people delivery system which can be used as a model for future
practice.
(A scheme of referral system).
Super specialist Deyt. In Medical College.
Community Health Hospital
»
~ 0)
CHPC
Community Health
CHPC
Polyclinic.
0
Community Health Assistant.
0
I
Monitoring unit
DSU
I
I
Door step unity
DSU
I
Monitoring Unit
In this section we have deliberately included non-medical asjbcct
of the scheme because even those who talk about comprehensive Health
scheme generally tend to include only the medical aspects of such a
scheme. Non-medical aspects of Health-care must be included if a
plan is to be a really comprehensive;
STRUCTURE OF HEALTH-CAREDELIVERY
At the grass roof level there will be the "doorstep Units"
(D.S.jU) consisting of one male & one female paramedical workers,
(community Health workers).
Fuction & Job description of community health worker.
They will notedown the symptoms of the patient, will treat
(1)
minor illnesses and will refer other cases to C.H.P.C,
(The above and the rest has been discussed in paediatric care.)
(2) The main objective of this unit is to influence & activate the
victims so that they can properly utlise the services provided to
them. Community Health Worker will arrange group meeting once in a
week with the affected people of the locality and will prepare a re' '
, criticisms etc.
port of the meeting which will include suggestions,
health worker will provide all necessary
by the’ patients. Community
<
help to build up patient's Actions
- ••
Group
~
(P. A. G.) of their own.
He/she will submit his/her monthly report-to community Health
Assistant.
Monitoring unit :- Will consists of one person only. It will pay
monthly visit to every house, His/her function has been discussed 2
paediatric & chest care part, This unit is supposed to cover 4000
population in a month.
Funtions of C.H.A.(Community Health Assistant)g-
.... 1(
10
Functions of CoH.A. (Community Health Assistant)
Under one CHA 8 units of DOS.U. & one unit of M.U. will sit
function' (part of the functions discussed earlier) (i) He will sifortnightly will PAG & will discuss, with them, will collect sugge tions criticism etc., (ii) He will compile & analyse all those re; c:
and records with the help of community health worker and P.A.Gs ard
3 months interval, and will prepare a comprehensive report which wil'
act as a starting point to initiate necessary changes or modifica=tion in the scheme.
He will send copies of his report to community Health Officer
at C.H. Clinic, to information and data processing centre at C.H.
Hospital to publication Dept. at COHOH. and to social welfare unit
at C.H.C.
Community Health poly-clinic
It is the nucleus through which
comprehensive health care services will be organised.
Functions
1)
2)
To provide primary care (not included in No. 2)
To provide iniigratcd primary and specialised health care.
3)
Health Education at all-levels.
4)
5)
Will act as information dissemination centre.
Will act as a co-ordinating centre through which all other
"welfare services will be integrated.
It will cater population of 25000
(approx.)
It will consists of these units;1)
Environmental health units-
(i) Water & sanitation sub-unit.
(ii) Environmental pollution sub-unit.
2)
3)
Primary Health Care unit
Integrated specialist health care unit -
Consisting of paediatric, opthatmic, Respiratory and
Obstetric and Gynaecological, Psychiatric unit, etc.
4) Information & data processing unit.
5) Social welfare unit.
1)
Environmental health Care unit.
Community Health Officer ‘(C.H.O.. ) will be incharge of this
unit.
Functions ;- i) To look after Environmental pollution problem.
i) To lookafter water and sanitation
facilities in the community. .
ii) To lookafter Environmental pollution problem
2)
Primary ^ealth Care Unit ; -
This will
of a second community
-. - _ _ be under the supervision
..
. .
Health Officer.
.. 1
- 11 Community Health Officer will supervise and guid the activities
community Health Assistant.
*
*
He will meet with the representatives of all those P.A.Gs at
monthly interval & will discuss with them; will take necessary
steps to "initiate—any change or modification in the delivery s; s* He will prepare his monthly report.
The copies will be sent b- c
to C.H.A. to D.S.U. to M.U. and to all P.A.Gs. ^e will also ic
copies to social welfare unit, to Data Collection and compi-lat:
Centre and to the publication Dept.
He will sit at regular interval with Social Welfare Officer ant
with the representatives from Urban Development authority from
P.W.D. and from water and pollution Control Board. He will tai
all initiative to build up a consultative body consisting of re
presentatives of all those bodies and with representatives fror.
P.A.G., D.S.U. and M.U.
*• He will be assisted with one sanitary Inspector, and one special
list in environmental pollution.
* An analytical Laboratory with Chemical & Bactriological investgational fa ilities will be under his supenssion. __
3)
INTEGRATED SPECIALIST-HEALTH-CARE UNIT (DISCUSSED EARLIER)
SOCIAL WELFARE UNIT
---
-
•
Social welfare officer will be in-charge g this unit.
Functions:- Ir will play the major role in co-ordinating differ .
units and their activities at C.H,C.
* Any other unit weeking any sort of help will be provided by this
unit.
(1)This unit will.be armed with one legal advisor,, one Health Educ itionistone environmentalist, one specialist in occupational heal
* Social welfare unit
and public Health unit will go in joint
ventures particularly in the field of water and sanitation and
in case of environmental pollution.
* Social welfare officer will meet with the representatives of
P.A.Gs. at monthly interval.
* He will prepare his monthly report & will send copies to all
units in C.H.C.^ & to the P.A.Gs.
* He will try to build up a consultative body consisting of member?
from trade Unions NGOs, members from legislative bodies, members
from UDA & P.W.D. and members from professional ’organisations a.ic
representatives from P.A.Gs.
5) INFORMATION AISiD. DATA PROCESSING UNIT.
Functions:- 1)’ Collection and completion of data & reports obtain.x
from different units of C.H.C.
2) Publication part:- It will publish a ]monthlybulletin in region ;1
language & will circulate to all unit in C.H.C.", to P.A.Gs, profe
sional bodies and to different N.G.Os. There will be a main data
processing centre at C.H. Hospital
This information centre will work under the proper guidance of the
that Centre.
Main data processing & publication Centre at C.H.H.
information Centre at C.H.P.C.
■> Professional Bodies.
P.fi.G Community health Assistant
D.STU.
^General population
---- 57
*
N.U.
To all units worki
at C.H.P.C.
Samaraj it- Jana
Anant Phadke
Mira Sadjc}. al
■
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