f-
methods of health EDUCATION
In the implementation of Health Programme, Health' of Education
is .of paramount importance and in, the process of Health Education, various
methods are employed. When we are dealing with human beings, the method/
methodology is very important in achieving the end results. If the
methods are good and sound the people accept and act in the direction we
T’-e tical methods of
Health Education which could be employed by the P.H.C. field staff ir?
The lecture is an oral presentation by a speaker to deliver
organised thoughts and ideas.
ft ft ft ft ftftftft
rftft ft ft ftftftft
In this process of speech, thoughts will be initiated, problems vail be
IV. Group discussion wethod:-
VE .Demonstration fethod.:-
iC
A
1. Method demonstration;.
Primary Health care and Family Planning
Programme in Rural Gujarat s Some Issues.
In the post-1961 are fertility control seems to have become
the main objective of the health plans in India shadowing
the efforts to contain morbidity and mortality among the
population in general and infants in particular. Plan
allocations for the Family Planning (FP) programme jumped
from Rs 22 million in the second Five year' (FY) Plan to
Rs 2M-9 million in the Third FY Plan - more than 10 fold
increase '. During the Sixth FY Plan - the allocation was
Rs 10,000 million. The share of FP programme in the
total health plan outlay, increased from 1.5^ percent
during the second FY Plan to 35-67 percent during the
Sixth FY Plan. (Appendix Table 1). Such a massive
allocation for FP Programme at the Centre obviously had
an impact- on the state plan expenditure on FP programmes
in the states. Gujarat, too, experienced a steep rise .
in the central allocations for the FP Progtamme since the
beginning of the Fourth FY Plan. During the first, second,
third FY Plans and the three annual plans (ending 1968-69).
The Gujarat state plans allocated modest sums for the FP ■
programme (not exceeding 3.5 percent of the total states
health plan outlays). From 1969 onwards almost entire
allocation, constituting 37 to 55 percent of the state’s
total health plan outlays, started flowing from the centreThe seventies -fend- eightees witnessed plethore of FP
compaigns, drives, camps, prestige camps etc. in Gujarat
to achieve the targets set for sterilizations and other
methods of fertility .control. Not only that hundreds of
FP centres and sub-centres were created and manned by
doctors and other para-medical staff in all parts of the
state, the primary health machinery, village, taluka and
district level machinery including teachers, officials
non-officiais etc. were geared to work for achieving
the FP targets set by the bentre. Persuation overt and
convert pressures and all types of tactics were and are
being used to achieve the targets.
Background paper for XIII Annual "Meet of the MFC at
Udaipur. 26-27,.January 1987. Prepared by Sudarshan
Iyengar and Ashok Bhargava.
That there is an urgent need, for
a\comprehensive
*
Health
the family welfare programme in the state is known.'
Relatively high'infant mortality, generally poor health
conditions of pregnant women, lactating mothers and all ‘
other women in generail and inability to create effective
demand for primary health care services necessitate the'
state’s intervention in creating health and family welfare
of the population. How far the government has. been able
to achieve in last 20 years needs a proper review and
assessment. The scope of present discussion is mainly
limited to a review of family planning programme' in the
state. Nevertheless, the review on FP programme itself
will have definite bearing on other facets of primary
health care and the paper intends to bring forth-relevant
issues in that regard too. Specifically the objectives .
of the paper are the following.
to present a brief! review of the health and FP
programme in Gujarat and examine the likely future
to show the neglect of primary health care consequent
upbn the emphasis on FP programme in Gujarat.
The paper is divided into three sections. The first
section discusses the theme and objectives of the paper.
In the second section a review of physical and financial
aspects of health and FP programme are presented. In
tiie third and final section relevant issues are raised. '
Health and Family Planning Programme in GujaratAn Overview!______________;__________________
As stated e.arlipr, direct efforts to check the population
growth in Gujarat started with the beginning of the fourth
FY plan. The draft fourth FY plan of the Government of
Gujarat states "rapid growth of population has the effect
of diminishing the impact of economic growth. During
1951-61, the population of Gujarat registered a growth of
'
_26.88 percent or 2.7 per annum against the all India growth §£■
21.5 percent or 2.2 per annum. The. rapid growth points
to the need for intensifying the measures for .controlling
the growth of population through family planning methods.
High priority, therefore, needs to be accorded to the.
Family Planning Programme. This will be fully centrally
sponsored scheme in the Fourth Plan". The financial
allocations for the FP programme thus experienced a
spurt from the fourth FY Plan. The financial outlays
for health and FP programme during plan periods for
Gujarat are presented in Table.
Following observations may be made on the basis of .
Table 1.
1.
Control of communicable diseases was the single most .
important plan component till fourth FY plan and
since then it was relegated to second place.
2.
Almost one half of the total Plan outlays (all plan
outlays•taken together) has been allocated for FP
programme.
Building.new'Primary Health Centres (PHCs) and stren
gthening old' ones received third priority largely due
to minium needs programme (MNP).■ About "one seventh
of the total ;Plan Outlays (all plan outlays taken
together) has been allocated for MNP. It should be
mentioned that from sixth FY plan onwards MNP included.
a major outlay for multi-purpose health workers
scheme with an objective to integrate the services
of vertical programmes like maleria, TB, Control etc.
into- primary health care at village level.
Both the Control of communicable diseases and the FP
programme are centrally sponsored. The formed programme '•
was fully•centrally' sponsored till the sixth FY plan.
Since then the state has to provide $0 percent of the
total outlay for the programme. The FP programme is
almost fully centrally sponsored. The state provides
a very smal^ portion for FP for incentives to the accep
tors and mqtivatSrs..Table 2 shows the
"centre
*
’s.
share in the total health plan outlay.
3.
Table ; 1:
Major Heads.
1st FI
Plan.
(1951-56)
a
b
1. Control of Commun
N.A
icable
Diseases.
2. Medical Educ
N.A
ation Research
and Training.
3. Hospitals,
N.A.
Dispensaries
and.PHC.
h-. Indian System
N.A
of Medicines.
Financial Outlays for Health and Family Planning
During Plan Periods in Gujarat.
( Rs in lakhs)
2nd FI
3rd FI
Annual
Plans.
Plan.
Plan.
(1966-61)
» >(1961^66) '
(1966-69)
a
a
b
a
b
b
_
*♦31 ■V *1-3.0 .
220
13.3
597
68.5
-
-3**
170'
10.3
107
12.3
_
108
175
10.6
10 ..8
-
28
62
7.1
*f0
*f.6
*t.h-
5. Minium Needs
Programme.
*6. Other Health
Programmes
7. Family
Planning.
N.A.
_
? ?2>+2
2*1-. 1
270
16.3
N.A'
-
187
'18.6
739
M4.8
38
1
Neg
50
3.0
28
3.2
Total
*=1652
ijo3
. 100.0
1652
100.0
872
100.0
N.A
100
Table 1 Contd.
♦Includes W-ater Supply, (a) Outlay (b) Percentage to total Outlay
N.A. Not Available.
Sources: 1. Health Statistics of Gujarat. 2. Draft Seventh. FY Plan.
Uth FY
Plan
a
b
6th FY
. . . Plan
5th fy
Plan
a
b
1. Cohtrol of
Communicable
Diseases.
1,615 35.9 1,912 31.3
2* Medical Educ
ation, Research
262 ; ^•3
& Training
269 6.0
3. Hospitals,Dispel
saries & PHC
607 9.9
283 6.3
4.-Indian System
of Medicines.
80 1.8' r
203 3.3
J. Minimum Needs
Programme
592 9.7
30 0.7
6. Other Health Programmes
138
135 2.2
2,M-00 39.3
7. Family Planning 2,085
i
TOTAL
h-,500 100.0
7th FY
Plan '
in lakhg)
. .Total
2nd tq^ 7th FY
•
a
b
a
b
a
_b_ _
6,573
36A
6,905
20.6 .
18,253
27.7
690
3.8
1,357
^.0
2,QQ9 5
M-A
620
' 3A
1,021
3'4M
2;,8^fi
h-A
120
0.7
325
1.0
796
2,910
16.1
5,3^2'
15.9>5|
9,386
396
6,702.'
2.2
37A
6,iit :loq.;©. 18.071 loq.'o' 33.58M-
l.’^J
A.3
0.3
55.2
l,7h-3
‘29,-859^ »4-5A
100.0
65,793.
100.0/
Table 2 : Centre’s Share in
j’s Health Plan Outlays
Plan Period
Health and
Second FY Plan
Percentage.
Third FY Plan.
.1,003
(100)
Annual Plan
Percentage.
Fourth FY Plan
Percentage
Fifth FY Plan ■
Percentage.
Sixth FY Plan '
Percentage.
Seventh FY Plan
Percentage.
872
(100)
h-,500
(loo)
6.111
(100)
•18.071
- /(IPO)
*+33.58
(100)
Source : Plan Documents.
FP
Nil .
Centre's Share
Others ■ • Total
h-31 '
. (h-3.0)
",(h-3.6)
720.
,08?
h-6.3)
,h-00
39.3)
,h-77
35.8)
; h-31
. *+( 3.0)
720
(h-3.6)
597
(68.5)
1,615
(35.9)
I,86?.
(30.6) •
*+
*+,59
*+)
C25.
.232 .
+.3)
5.Oh-3
.(I5.O) .-: ’
23.275
X69.3.)
Nil
Nil.
597
•(68.5)
>+,269
(69.9)
11,071
(61.2)
(Bs./in Lakhs)
FP
State's Share
Others
Total
572
, 571
' (56.9/ C57.0)
882.
. 932
(53A)
(56A)
28
Or
W ■
' (28.3)
(31.5)
800 ,
800
(I7.8)
(17.8)
Nil'" 1,841 t 1,8
* eL
(30.1)
(30.1)
285
6,715-' • 7,0'00 -■
(1.6.) :W?t) - (38,18)
293 10,017 10,309
(0.9) (29.8)'
(3O.7)?
(0.1)
(3.0)
28
(3.2)
Nil
Columns 5 and 8 show the share of centre and the state
respectively to the total health plan outlay. It may
be observed that centre’s share has been more than
60 percent since the Annual Plan Period. The centre's
share is very high mainly ’due ’to’ the allocation for the
FP Programme. It maybe of some interest therefore toexamine changing priority of the health programme in
the state's total plan allocation, for all the programmes.
Table 3 below shows the changing share of health plan
allocation.to the total xafc state plan.
It may be observed that the share of health plan alloca
tions show a falling trend since Annual Plans. If .
one excludes FP programme, the falling share is more
pronouncely evident. During the seventh FY plan the
share of allocation for health programing shows an all
time low of 2.5 percent to the total plan allocation
in the state.
Let us noir turn our attention to the physical achieve
ment in the field of health as well as FP programme. For
the purpose of this discussion we shall< mainly report on
the status: in rural Gujarat. Table >+ below contains
information on.some -of the physical health infrastructure
’in Gujarat.
Table b : Establishment of Primary Health Centre
and Sub-Centres in Gujarat.
PHC
MCH
Beginning of 1st FYP
6
~MNP~
Sub Centres
FP
T?tal
FP as
. 18
18
2nd ,,
96 288
3rd ,,
Beginning of Three
Annual Planning
lh-2 b26
2U4 732
-
350
.1082
32.3
Beginning of bth FYP
251 786
251 786
13>+
13b
1000
1920
1000
.1920
.52.1
: 52.1
251 886
251 986
13b13b
1000 1600
2020.
2720; .
b9-5
58.8
5th ,,
' 6th ,,
* As on March 1983
-
-
288
•-•'260
686
.
-
-61.0
25 more PHCs have been sanctioned under MNP that are
not included in the figures'on PHCs.
8 ource: Health Statistics of Gujarat 198b-.
The Government of Gujarat has. accepted certain norms for
providing the physical infrastructure. We present below
An Table 5 the norms and the actual statue us'Snj'^983
Hwjea! achico“"~
*^"
«eaj.n»t 1981 rural
population which ws 23b,0hTU?h. persons.
Table 5 s Norms and Actual Status of Health
Infrastructure in Rural Gujarat.
Actual Status
Norm
Particular
' '-3#
19,50,000
30,000
1;
93,000
• 5,'doo
. is .
8,600
Upgraded PHC
PHC -
1:
1:
100,000
Sub-Centres
_ JL-:
1,000.
is
Community Health
Volunteers (CHVs)
1:
1,286 43
Sources Health Statistics of Gujarat 198U- (for norms
and. Number of Establishments).
health infrastructure widens as one moves towards the
upgraded facilities. The establishment of sub-centres
appears to be near the norm largely due to ...the 'FP sub
centres which constitute 58.8 percent of all types of
sub-centres. Assuming that the FP sub-centres catre.
only to FP services the ratio of other sub-centres to
■ the population works', out to the is 21,0001
•■
Target and Achievements of FP Programme in Gujarat ; The
major flank of the FP programme in Gujarat is fertility
control through by and large terminal method. The pro
portion of couples currently protected during a given
year seems'to'have‘increased substantially since
1966.6?,# . Table-6 contain the relevant information.
Couple protection through terminal method i.e.
• sterilization, has generally risen.steadly, over :
■years. However, within a span of 17. years (1966.67
' .to 1982-83;) two years may be noted for sharp incre
ase; the year are 1971-72 and 1976-77,.
2. _The.proportion of couples currently protected during
any year through spacing ‘method has
* been very low- .com
pared with the terminal method. The couples prote
cted through IUD have been fluctuating with in p. range
couples. The proportion-of couples protected through
conventional contraceptive (CO) methods have been
to 3.9 percent. What is apparent from Tanle 6 is
that the efforts to control fertility have been
: largely concentrated on terminal method rather than
on-spacing method. This particular, aspect in further ■
. confirmed’when one'looks at the FP Acceptors' profile
Reading Table 6 and 7 together for terminal method
•
one can-.: note some inconsistency which is not explained;.
.The .number of acceptors of terminal method rose sharply
in 1967.68, 1971-72, 197^-75 and 1976-77 (Table 7).
However the number of couples currently;protected
..
*
through terminal method (Table 6) rose sharply only
in two years viz. 197.1-72 and 1^§&77. : One fails to :
understand as to .how. the large relative .^increases
*
in
* 1967-68. and. I97I4-75 were absorbed.
Table 6 : Number of Couples Currently Protected Due to Various
Methods of Family Welfare by the Respective Year.
Year
1
Estimated
Couples ir
retroductgroupg(in
’000)
2
3
b-
c.c.. Users
IUD
Sterilisation
Number Per-
Num
ber
5
Pertage
6
Num
ber.
7
Per
centage.
8
Total
Number
9
Per' centage
'9 1oM|
b-,b-05
2.1
3.2 86,87b31,672
0.8
1966-67
1,28,797
6.-12A7,3b-3
1.9
1967-68
2,05,268
b-,lb2
1.0
5.0 81,b-8b. b-0,990
.3,27,7^2^ 7.9
1.6
2,93,050
1968-69
b-, 18,169
1.3
9.8
b-,239
6.9 70,852
5b-,267
1 1+
b-,316
1969^70
3,70,3^
8.6 61,512
61,121;
b-, 92,981 • 11 A
1.2 f
£3L97O'. 71
b-,37b_b-,Ub-,005 10,1 53,6b-0
1.8 p
5,7b-, 378 13.1
76,733
1971-72
8,83,3b|^ 19’J
1.0 1,27,173 - 2.7
b-,719 9
7,09^113 15.3 ^7,056
1 .7
:-0-.,9
7,67,962 16.2 b-2,b-16
b-,7b-7
81,818
1972-73
8,92,19^ 18.8
b-,850
7,88,061 16.3 b-6,211
-1973.7b1.0
1.6
78,263
9,12,535, 18,1
8,99,5^6 18.2 55,299
197b-. 75
2.b1,18,5b4
b-,953
10,73,-389^ 21.7
1975-76
10,03,768 4 19.8 61,219 : 1>2 1,8b-, 789
5,057
12,b-9,776.
3•7
12,62,76b- 2b-. 5 69.52b1.3 ■ 1,99,837 | 3-9
, 1976-77 . 5,161'-' .
15,^2,133 29.b5,26b-.
1977-78
13,08,63b- 2b-. 9 78,315 ■ 1.5 1,5b-,,966
2.9
15,b-i,9i5 2-9»3
15,78,636 <26.7 88,755 . 1.6 2,05,379 . 3.8
5,^9
1978.99
18,29,770^ 32.1 '
*.
1980.81
16,9b-, 562
1.7
5,b-33
92,361
18,78,982 3^.6^g
92,059
*
1981-82
5,689
ii8 - 89,-639 • 1.6 ’ 20/27r,358 ' '^7
18,35,392 32,3 1,02,327
5,8b-2
19,6b-,lb-9 '33-6 1,12,230
*
1982-83
1.9 1,23,277
2* 1 - 21,99,756 37.6-;^
* Couples Effectively Protected.
Source : Directorate of Health, Medical Services and Medical Education
(Health Seqtion), Ahmedabad.
Table 7 : Methodwise Number of Acceptors in ''
Gujarat by year.
Year
Terminal
1966.67
1967.68.
1968.69 ...
1969-70
1970.71
197K72
1972-73 J
1973-7^
.197^75......
575-74
1976-77
1977-78
1978-79- ,
1979-80
1980-81
1981-82
1982-83
. Uo - .
85
101 ..
9^
95
295
97
60-
' 153
317
.112 ■ ■
■7197
220
•201
237
2h-2
Total (1971-72
■to 1980-81) 1807
All India Average
for (1971-72-to
1980-81)
Spacing
Ratio
66 1:
1.65
!:•
0.72
o
. .■ 61 .
. . ■- 66
1:
0,65
72
if . O.77 ■ . ’
86
1: » 0.-91 ' *23
136
1:
0.U6
90 ■’ ■
1:
,0.93
:' .96.
' 1:,/ -1.60
128
.1: ■ 0.83
■
208
- 1:
1.3h228
1: . 0.-72
- 185
1:
1.65
2^1
1: \i;.22.--.^
208
1:
0.95 ’ '
1:.. 1.12
225
1:
0.96
227
1:.,. 1.17
-’F
. 283
17h-5
1:
. 0.96 . '
1:
l.h-5
Source: 1. Health statistics of Gujarat 198>+.
2. Diagnostic study of Population Growth
Family Planning and Development,- Gujarat'
‘ 1971-82, P. Jb-, for All India Estimates.
-15 -
2. It is established, beyond doubt that the emphasis
by the Gujarat Government has been on terminal
method rather than the spacing method.
Assuming for a moment that the emphasis-- on. terjniiial ' ' ’
method of family planning was correct -ini the context of
high fertility rate iri Gujarat',’ it would be of some
interest to examine the profile of acceptors of terminal
method in Gujarat. We present below two characteristics
of acceptors that will reflect upon the possible impact
on fertility. The two characteristics are age of wife
at the time of acceptance and the number of living
children.
Table B : Percentage of Acceptors of Terminal
Methods Above 30 Years of Age-Gujarat.
Year
Tubectwmy
Vasectomy
. 59.8
197^-75
1975-76
*<■3.3
60.6
-1976-77 1977-78
55.8
- 60.M1978-79
1979-.8O
58 • 3
1980-81
55.1
58.2
59.2
5*<-.i
51.9
; ' ■ 56.3
56.8
53.8
; -
*
Weighted
’
Average of
Vasectomy and
Tubectoniy
58.5
56.0
55A
52.7
57.1
57.1
5U-.1
.
We have used 0.8 and 0.2 as weights for Tubsectomy and
Vasectomy respectively. They are the actual weights •
for the year 1981-82.
Source: "Diagnostic Study of Population Growth, Family
Planning and Development in Gujarat". The
Family Planning Foundation Study 198M-. p.62.
■
- 16 It may be observed that the intensive efforts to moti
vate couples for sterilisation has resulted in acceptance.
of the method largely by couples where wife.’ s age has
crossed 30 and the couple already has L- or more living
children. This group constitutes JO percent of the
total sterilisations performed over number of years
since 197U-7J. Rambadhran categorically states, "the
tubectomy programme (in Gujarat) is still focussed on
women with high parity,
+ which could be cases of
’■
‘complete family’
.•
Table 9: Percentage of .Acceptors of Terminal Methods
with h- or More Living Children - Gujarat
Year
Vasectomy
^7-7Q.
h-1.8 '
1978-79
1979-80
1980-81
.. 36.7;
36.7
1981-82
37.7
Tubectoniy
*
Weighted
Vasectomy and
Tubectoiny
57.7
^.6‘
57.5
57.8
57.8
51.5
.
5^.1
53.6
53.6
*+■8.7 7:.
We have used 0.8 and 6.2 as weights for Tubectomy and
Vasectomy respectively. This are the actual weights
for 1981-82.
Source: Same as Table 8.
1/ Rambadhran V.K. "Diagnostic Study of Population
Growth. Family Planning and Development Gujarat”
November 198h- p. 63.
17The characteristics of the acceptors thus show that
the emphasis on fertility control efen if carrect, islikely' to have had a very limited impact on fertilitycontrol.
Such a lop.sided performance may now be viewed in the
context of financial allocations on health in general
and FP programme in particular. Earlier we have shown
relatively higher increases in the planned expenditure
on FP. We now examine the trend in. per. capital expen
diture on FP during different plan periods. Table '10 *
contains the details.
Following observations may be made on the basis of
Table 10.
Per capita expenditure has increased both for health
as well as family planning, but overall increase has
been more rapid for family planning. The changes
between sixth and seventh five year plans deserve
special attention. Per capita allocation during the
seventh plan period is more than the per capita
allocation for all programmes of health. Viewed in •
the context of lopsided approach of the FP programme
in Gujarat, such a significant increase in' allocation
for FP programme should be. a cause for concern-. . - ®
1.
Allocation to FP programme implies allocation’ for
eligible Couples (With the hope that the FP drive
would leave alone the singles, unmarried, old and
the children'.). We thus calculated the allocations
Table 10 : Per Capita Expenditure on Health and Family Planning
During different Plan Periods in Gujarat.
II Plan III Plan Annual
Plans
• 1956-61. 1961-66 1966-69
1, Control of Communi ’
1.2k
cable Dieses.
2. Medical Education,
0.18
Research & Training
3. Hospitals Dispen
0.56
saries and PHCs.
k. Indian System
j.o^oo
of Medicines.
5. Minimum Needs
1.26
Programme
* Other Health
*6
0.97
Programme.
TOTAL. _
5.21
IV Plan V Plan VI Plan
VII Plan
1969.7k 197k-79 1980-85
1985-90
7.27.
6.35 '
19.03
18.30"
O.hk
0.78
0.8?
2.00
3.60 33
0.81
0.26
1.06
2.01
■ 1.79 '
2.7! 3S
• 1*'°V
2.k8
0.78
0.13 '
0.17
0.30
0.6?
0.35
0.86,.
1.2k
0.00
0.11
1.99
8.k2
Ik .15^3®
3.k0
-0.16
0.52
O.k2
1.15
0.29-
:
10.0k
7 • 37
32.7k_ __ 39.91‘
3.51
12.31
Family Planning
a,. Au .Population,
7.81 ' 7.97
19.58
k9.O9
Si0’01 0.23 ‘ .. ; 0.12
N.A
N.A
b. Eligible Couples
309.93 '&
0.68
k5-32 •- M-6.50 119.58
c. Currently Protected
N.A
Couple
277.59
818.55
NOTES: 1. For
~ estimating population during plan periods average annual exponential growth
rates have been used. The growth rates were worked out for 1951-61, 1961-71 and
1971-81. For VI and VII plan periods we have used mid-year estimates given in
Health Statistics of Guj.arat 198>+.
2. For eligible couples upto VI plan the estimates given by the Directorate Health
are used. For the seventh plan the average annual exponential growth has been k
calculated for 1? years to 1966-6? to 1982-83 and the same rate has been used
. to project the growth during VII plan.
3. Similar exercise as donw for estimated eligible couples has been done fo.r->
currently.protected couples figures given by the Health Diventorate.
>
-19 Per eligible couple which shows that the allocation. ■’
since fourth five year plan has been much higher
than the per capita allocation for all the health
programmes taken together.
Assuming that the actual expenditure in.almost
equal to the allocations made,.we have estimated
the amount likely to have been spent after each
protected couple. Date on protected couple by
year from 1966-67.to 1982-83 and estimating figures
for the year upto 1990, we have worked out the
allocation for each protected couple. The rise in ■
the allocation per currently protected couple is .
astronomical. One is tempted to go a little
■
further; and perform some more arithnr'-.ic' on these
figures. Of the currently protected couples in
any year, 90 percent are protected through terminal
method i.e. sterlisation. Further, the records
suggest that atleast 50’ percent of the sterilisations':
have been performed on those couples who fall in the
category of 'complete family'. The money spent son
those couples are less likely to make any' positive
dent on fertility control that has been the avowed
policy of the government of Gujarat. In effect the
actual expenditure on each protected couple is to
be read as double the amount reflected in row- 'O'
.
The argument may have been stretched a little t.oo for |
but the’point one wishes to make is that FP programme
in Gujarat should be considered a failure even judging
through government's cwn ^bjec.tiye'.of fertility control.
One more aspect that needs attention at this stage,
relates to the-method of implementation of FP pro
gramme. It is generally contended that.the programme
is for family welfare and not’for family planning and.
hence it is only motivation through which'., the FP'
methods are pushed. Under such' relaxed circ*mstance^
one would expect that«^he acceptors would' by and large
belong to relatively ■ more literate class -with better
socio-economic conditions. The tables below will indi-'
centage of couple that are covered by sterilisation by.
district for the years 1980 and 1983.
by the conventional regions, Kachchh-, Saurashtra (2 to
7), centr§l Gujarat (8 to 11), North Gujarat (12 to 1U-)
and South Gujarat (15 to 18). Gandhingar belongs
to Central Gujarat but we have listed it at the end
since it has only one taluka consisting of a few
villages and it is the capital town of the state. ’ ‘
One can clearly see that the coverage in South Gujarat
districts is highest. A special feature of the dist
ricts in South Gujarat is that all of them are partially
or fully tribal and socio-economically backward. Obvi
ously one would not be required to go through the Census
female literacy in particular. It may be alleged that
the government functionaries are pushing the sterili
sation into tribal areas taking advantage of the poverty
(through incentive) and ignorance (overt and covert
presures). The question is; how far such steps are
justified?.
Two districts Dangs and Gandhinagar deserve special
attention. They are comparable in one major respect.
Both are one taluka districts. The Dangs in located5
in the remotest south-west corner of the state and.it
is irihabitated by tribals alone. The facts reagarding
the abject poverty over there is well known. Gandhi
nagar is located centrally adjoining Ahmedabad and
22% population lives in the state capital. How is
that official machinery can not motivate couples^in
^
*
villages spread within a radius of 10 kms where as the
couple protection in remote Dangs is as high as.57;-$s&§£
percent - double the rate of, the one obtained for ...
Gandhinagar? Another dis trict which has gained popu
larity on the success count of FP programme in
< .
Gujarat is Bharuch. The district and state officials
are never tried of quoting statistics on this district.
It has turned into a showpiece which has been put. .on
display byofficials for the outstate visitors and
visitors from centre. The district hag, a large popu
lation of tribals and acceptance of FP is more' among
them due to abject poverty.
One should not be surprised to find number of cases
where both the husband and wife have been sterilised'
The analysis is sufficient to establish that the FP
programme in Gujarat is basied in approach, implemen
tation and performance. It seems to be providing, expen
sive, and to a great extent ineffective (in relation to
what it sought to achieve). With a two and a half time
increase in allocation in seventh plan over the sixth
and that the population pressure is likely to adversely
.effect the efforts to improve socio-economic conditions
-is well taken. However, one should think for a rational
approach to the problem rather than a hurried and baised
approach of fertility control.
The desire to have more
*
children is a result of (a) total
uncertainty regarding the survival of children atle^st .
u’pto the age of 5 and (b) lack of adequate opportunities
; for livelyhood, Coupled with these are the. socio-cultural
traditions-all ’ofwhich cultimate into the desire.
for having more children. At the .conceptual level
atleast the Health and Family Welfare Programme is
designed to take adequate care of the first factor
namely improving the child survival and other health
By more children one does not mean any number of
children. The couple and/or family does seem to
consisder various factors’ in determining the size of
the family. An- all India survey conducted by
Operational Research Group (ORG) Baroda, in 1982^
on attitude of people towards FP and composition of
families etc. came out-'with a finding that 82 per
cent of the respondents considered small family tobe happy family-small being. 3.2 children and large *
being h-.8 children.
aspects. However, in implementations overemphasis on
fertility control through FP methods' seems to have com
pletely shadowed all oth^r integral parts
of
*
the progra
mme. The implementing machinery has failed even to implment successfully the MGH programme which is an
important component of the FW programme. A study X/
conducted by the the Extended Programme of Immunization
(EPI) division of the Health Directorate of Government
of Gujarat shows that upto 1981 the percentage of
children who completed three does of Polio, DPT and BCG
was 22.M-, 1+0A and 26.0 respectively.
The community health norms for gaining herd immunity
is 80 percent i.e. if 80 percent of the children in the
community are immunishd, the changes of occurances of a
particular disease are reduced significantly.
Among the other health programmes the control of commu
nicable diseases has been important all along the Plan
periods atleast in terms of allocations.
The communicable diseases covered under this programme
are : Malaria, Tuberculosis, Leprosy, Filaria and
blindness prevention. Since the sixth five year plan
the state governments are supposed to provide matching
contribution (50-percent) to the'allocation’.-But the
fact remains that state governments not only fail to
.contribute the 50. percent share but they also' do
make use of provisions made by the centre. For inst
ance, the states have not even lifted their full qunta
Malaria).
X/ Health Statistics of Gujarat 198h-.
1/* Parenthesis added. V.N. Rao and others "Indepth
Evaluation of.Report of the Modified Plan of
Operation under NMEP", Ministry of Health and.
Family Welfare, Government of India 1985.
Regarding another communicable disease namely T.B.
'too the performance'has been far from satisfactory.
Suring 1981-82out.of«69,,150 new’ cases registered
under twenty point programme 9,996 or 1M- percent com
pleted treatment which means that the 'case holding'
in Gujarat is far behind the national average of
S'© ’to 35 percent.
The gross neglect of most of the health programme is
cause of serious concern. The FP programme receives
a very high priority and adversely effects the implementioned of all other health programmes. This has
been sharply brought out by a study of Ministry of Health
Government of India itself. The study, which is an in- •
depth evaluation of the Modified Plan of Operation under
/National Malaria Eradication Programme, states that
» after the introduction ofmultipurpose health workers
the implementation of Malaria programme suffered.
in large areas due to totally absent or inadequate
case detection even in the transmission season". The
report -Cakes'note of the inadequate staff, vacant
posts.,- staff in position avoiding field works etc.
,and4!inally statesj working in NMEP has reached a low
.by them (workers); but also because of the:%Lpw priority ■
being given to malaria with the Family Planning Programme
What xLs." “true for Malaria programme is true for all
.other programmes. If the Government has accepted
Pre no signs of achieving ft with the present state
of affairs in reaching the health and family welfare:
schemes to the rural areas.
There is need for a-drastic change of priorities both
in allocation of funds and approach and strategy of impl
ementing the health and family welfareprogramme in ah
integrated fashion.
MEDICO FRIEND
CffiClE.
PO: GOPURI, DISTT.WARDHMM.S.)’
Ref.No.
Date:
Janua ry11980
We are glad to note you are attending, the Medico-Friend
Circle Meet in Jamkhed from the 2>+th to 26th January'1980.
Attached kindly find a-little information about ihe Front
Line Workers and a few questions which come to our minds.
Kindly go through the paper and think ovqr the questions
and possible answers based on your experiences,^ would perhaps
find answers to some of these questions,when we -see Jamkhed.
This little spadework would help to make discussions
more likely and the sharing more useful.
( LUIS BARRETO )
Medico Friend Circle
ER ONT LINE
INTRCDUCTION:
1. The Health status cf hundreds of millions people in the
world is far from satisfactory and in fact unacceptable. More
than half the population does not have the benefit of adequate.
health care. There is ' id< gap t
the developed and the deve
loping countries in the level of health and in the resources they
are devoting to the improvement of health. Moreover within indi
vidual countries whatever their levels of development,wide dispari
ties exist between health facilities and health conditions .of diff
erent groups of population.
2. The present met it il 1 npo 1 1 iu ed bo h in the developed
and in the developing countries has been inadequate and more impor
tant still,incapable of delivering health care to the people who
need it and in places where it is needed the most.
3. The World Health Assembly has in its 31st Meeting in 1976 , .'A
decided that the main social target oi 50 run ts and W.H. 0 in the
coming decades should be"the attainment by all citizens of the world
by the year 2000 of a level of health that will permit them to ,, lead a socially and economically productive life? t ..
i-. The Alma-Ata declaration stressed the need' to the provide
Primary Health Care. This was to be the key to attaining the
target of health for all by the year- 2000.
..
The main people for delivery of primary health care would
be th^Eron^^L'i-ne Workers. It is to’ be noted however that neither
primary health care nor front 1 !.ne worker., are a new concept.- At
BiestL.G^e could say it is a new jargon. But new jargon
*
is-not a
bad thing,for it evokes renewed interest. But,. itejpis' bad,i'g.-it
does not take into consideration onr past experiences. It is
based on the sharing of experiences of various countries on utilisation of front line workers in delivery of primary health care
piLLqps of the National Health Care Delivery System. One must also
note that in India projects like Jamkhed in particular and others
like Mandwa,R.A.H.A.etc. have been utilising front line workers
even before the Alma-Ata Conference.
£„
The Governn’ent qfilndia launched the C.H.W.'s Scheme on
Oct. 2,1977 in an attempt to strengthen the health services at
the grass,roots
*
and solve the two main problems our 1 countr 1 es»■
health services has been facing namely:
a)
Outreach
h) Active community participation.
7.
Projects in various countries like Bangladesh,Burma,
Thailand,Indonesia,Nepal,Ceylon and India and in some latin America
2countries have since lo-ng been trying to deliver primary health
village health volunteers, village health nromotsrs etc. These .
workers are either part-time or full time,paid or unpaid,litetate
or illiterate or both, male or female or both etc.
8.
In our co
1
the C.H.W.'s
scheme on Oct. 2nd,1977. This new rural health policy incidentally
is supposed to.reflect the ideological concept and rural bias in the
■ field of health. By September,1979, it was estimated that 180,000
C.H.W had been trained. The scheme had been extended to 981: PHCs.
The scheme covers all states in India
*
Except Kerala,T-.N. & Jammu
.that. m
It is to be noted before we proceed? 123 blocks (out of 892 blocks
in the tribal areas) PHCs. have yet to be set up.
The front line workers in different projects in India are:
a)
Village Health Workers in Jamkhed & Mandwa.
b) The village health promoters in Raigarh(RAHA).
c)
The Anganwadi workers in the 100 Integrated Child Develop
ment Services Scheme in the various tribal,rural and. urban
blocks in different parts of the country.
g)
The Community Health workers in different parts of the
country in our villages, etc.
primary health care? Different projects have assigned different r
roles varying from mainly, a role .of an informant and an educator-,
of data and treatment of malaria,sanitation and health education .?
•as in the case of village health promoters,C.H.W1s etc. In projects
^jLike Jamkhed the VHW
*
s have besides delivery of primary health care,
also been involved in total socio-economic development and in social.
change in the community.
a)
What according to you should be the role of these front
line workers,taking into consideration in particular the
C.H.W.’s Scheme?
- Should they involve inactivities besides health?
b)
11. ^riteriaTurocess of selection: y
Jamkhed;the community
is informed about the typp of worker required by the doctor/a'nd
the social workers, and ANMs. and the community select the worker.
In the plantation, the selection is made by the supervisor and
the manager of the tea garden in consultation with the medical officer
and the community.
w-V-’ 'lathe Integrated Child Development Service Scheme,the Block
Development Officer and Child Development Project Officer are the
main selecting authorities. In Raigarh Ambikapur Health Association
the church authorities in collaboration with their social worker
and community select the worker- The CHW’s should ideally be selected
bythe Gram Sabha- but this seldom happens and it is largely the
Panchayat workers and the Medical Officers and other politi'cal workers
who eventually select their protegees.
a)
Which system according to you is better? Why?
b)
Do you have any suggestion as to how the workers could be
_•?
selected?
c)
Considering C.H.W.'s scheme in particular -how could one en
sure that the right people get selected?
d)
What should the sex/caste/ecohomic class/educat ion of the ..
worker be?
12. TRAINING: The mode of training differs from place to place.
In Jamkhed^an initial training in the headquarters for. a week
is followed by in service training in the field in their respective :
villages and coupled with refresher session they work for a whole \
day, where working come to the headquarter every Friday stay and -eat
together(this gives them an opportunity to share their problems
and .occasionally find solution from each other experiences).. This.
0 is followed by anot'
ti iy) of review of the weeks’ work,
collection of data and checking of records (done by.M.O, and A. N.M,
Social Worker), teaching of a-new lesson and solving their problems^-^
1^,-gor-^rather helping them to find solutions.
Link workers from different#gardens come in batches to the
headquarters in Cbonoor or to their respective garden hospitals fgr '
weekly training mainly in data, collection,-sanitation and are also
thought the methods-of^production and transmission of disease and
treatment of the same by the Medical Advisor or the Medical Officers.
In R.J-.H.A. -training is given by social workers and Nurse-Mid
wives in one of the villages for 1? days and followed up with
The Anganwadi Workers are trained in different institutions
selected for the purpose by the Project, staff. They are trained by
doctors^, social workers etc. for 3 months. .. Some of them receive in
service training.
The CHW's are trained by the M.O. ard M.H.W. with occasional
guest lectures at the P.H.C. and some field training.
Most of the projects utilise Audio-visual aids, but muuh stress
is laid in Jamkhed and plantations and R.k.HA. and some of the PHCs.
Jamkhed utilised locally relevant audio-visual aids.
The methods of training vary from mainly didactic lectures
with not much stress on in service and field training to much stress
on field training and purposeful,problem,solving meetings as in
Jamkhed and Plantations.
a)
Who should actually give the training?
b)
Are the doctors in our PHC capable of imparting training
I
to CHW's.
■
= • , c) Should these doctors receive a training themselves?
e)
What type of training should they be given?
f)
Shoui the PHC-MO's train their MHW'S to teach the CHW?
•g ) Could Medical colleges involve themselves in training of
h)
What according to you would be the- best way of training
the G.H.W 's.
,i) Contents of training,skills imparted to VHW's and the
level to which they should be trained. Should the train
ing be uniform?
j)
What educational methods and principles should be utilised
in training the VHWs.
k)
Main training emphasis on professional(health work) skills
or on how to conscientise people about socio-economic
problems and actions? or Both?
c)
d)
If paid., how much? -SRj^/Kind?
Who should contribute the momey and through whom should
the payment be done? Owe who dcy payment will effectively
control V.H.W.
J
Reactions of .community -to CHWs. : In projects like Jamkhed,
l.A. ,Mandwa and Plantation-majority of people are happy to ?.
However there, is large amount of dissatisfaction with the
government in various parts ofrfhe^countj'y also in some of, the^?>;. |
projects. Some of the reason are: i)
Not a dedicated worker- ii) Not enough knowledge
iii ) Does not give injection iv) Not accepted by the community
v) Helps only the rich and affulent.
What according .bo-,yp-u are the main reasons for^this?
*
b)
c)
Could religion/educational status/sex/age affect performance?
Should socio-economic conditions be a criteria for selecti'^nM
Evaluation:
What should be the methods of evaluation of
Decrease in morbidity and mortality in the *community/yuE- ’
nerable groups.
b)
Immunisation status of the community
jc) Nutritional status of children?
a)
e)
f)
Changes in Knowledge Attitude Practices in the community.
Acceptance by the community. .
On going cvaluatipn/terminal evaluation (for projects)'?^
Who should evaluate? How can the community participate
in evaluation of CHW and in supervision and control of
their workers.
17. REMUNERATION; Workers are most often part-time and are expe
to devote 3-A hour s a day per month.
In
*,^.
I-^Dy.Sthe workers are full-time drawing about
Rs. 100/1 tQ^Rs.IJO/- per month.
per month. The Govt. CHW get Rs. 200/- per month (full time during
their initial training) and Rs
per month later on after their
^initial training.
In R.A.H.A. and Plantations the workers are honorary. Eva
luation Sf workers in most projects and PHCs, shows that the SK
workers/higher honorarium.
17. i)What population should each worker cover?
ii) How many villages should he/she cover?
-
'.a) ShouRai the CHW be responsible to the village? On the
MHW's and PHC- M. 0?
Should village health committees Ebe formed?
c)
Should Block Development Officer supervise?
19. a) Should CHW's shheme be part of the PHC- set up?
b)
Should it be independent?
c)
What should be the interphase between the District Health
authorities and other development authorities and CHW's.?
d)
What should be the interphase between the C.H.W. and the
community?
20. a) Should the^be refresher training for the workers? How
frequently? For how long?
b) Should avenues for promotion/and increment in wages be
worked out for CHW’s? If so how.?
•21. a) How could medical colleges with the new schemes for take
*
over of 3 PHCs. - take responsibility for the scheme?
evaluation of the scheme?
22. Primary health care envisages the involvement of health
department with various departments like agriculture,social we
etc. in development of the community.
a)
b)
How could front line workers do this?
Are the doctors capable of functioning in unison?with
other development agencies.
questions to stimulate discussions in view of what we have observed
in Jamkhed which perhaps is one of the best projects today. We
must attempt however to project how some of the things done here,
could be implemented in other pockets and parts of India.
Primary Health Care it has been said, marks the changing
point which a future historian would perhaps call the beginning
of health revolution.
Let u.s- all hope the future historian gets an opportunity
to do this’ *
ib/ks.
r
FRONT LINE
WORKERS
INTRODUCTION:
1. The Health status of hundreds of millions people in the
world is far from satisfactory and in fact unacceptable. More
than half the population does not have the benefit of adequate
health care. There is wide gap between the developed and the deve
loping countries in the level of health and in the resources they
are devoting to the improvement of health. Moreover within indi
vidual countries whatever their levels of development ,wide dispari
ties exist between health facilities and health conditions of diff
erent groups of population.
’ 2. The present medical manpower produced both in the developed
and in the developing countries has been inadequate and more impor
tant still,incapable of delivering health care to thetpeople who
need it and in places where it is needed the most.
- - 3. The World Health Assembly has in its 31st Meeting in 1976
.decided that the main social target of governments and W.H. 0 in the
coming decades should be”the attainment by.all citizens of the world,
by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life.
The Alma-Ata declaration stressed the need to the provide
5.
The main people for delivery of primary health care would
be the Front Line Workers. It is to be noted however that neither
primary health care nor front line worker, are a new concept. At
hest one could say it is a new jargon. But new jargon is not a
bad thing,for it evokes renewed interest. But it is bad,if it
does not take into consideration oar past experiences.. It is
based on the sharing of experiences of various countries on utili
sation of front line workers in delivery of primary health care
..that this concept has come to be envisaged as one of the main
pillars of the National Health Care Delivery System. One must also
note that in India projects like Jamkhed in particular and others
like Mandwa,R.A.H.A.etc. have been utilising front line workers
even before the Alma-Ata Conference.
6.
The Government of India launched the C.H.W.'s Scheme on
Oct. 2,1977 in an attempt to strengthen the health services at
the grass.roots
*
and solve the two main problems our countries’
health services has been facing namely:
a)
Outreach
b) Active community participation.
7.
Projects in various countries like Bangladesh,Burma,
Thailand,Indonesia,Nepal,Ceylon a$d India and in some latin America
countries have since lo-ng been trying to deliver primary health
care through front line workers known as either village health
village health volunteers, village health promoters etc. These
workers are either part-time or full time,paid or unpaid,literate
or ^illiterate or both, male or female or both etc.
8.
In our country the former government launched the C.H.W.'s
scheme on-Oct. 2nd,1977. This new rural health policy incidentally^
is supposed to reflect the ideological concept and rural bias in the
field of health. By September,1977, it was estimated that 180,000
C.H.W had been trained. The scheme had been extended to 981> PHCs.
The scheme covers LI st
s i India
*
J cept Kerala,T.N. & Jammu
and Kashmir,Karnataka agreed to the implementation of the scheme £
only since April,1979.
proceed?1123 blocks(out of 892 blocks
• in the tribal areas) PHCs. have yet to be set up.
9- gront_Linc Workers in_India:
a)
b)
c)
Village Health Workers in Jamkhed & Mandwa.
The village, health promoters in Raigarh.(RAHA.).
The Anganwadi workers in the 100 Integrated Child Develop-
blocks in different parts of the country.
.Link workers in the Tea and Coffee Plantation in the South.
d)
§) The Community Health workers in different parts of the
'
country in our villages, etc.
What is the role of the front line workers in delivery of *
10.
primary health care? Different projects have assigned different
jollies--varying from mainly a role of an informant and an educator,
as in the plantatii'S to treatment of minor ailments and^collectipn
of data and treatment .of malaria,sanitation and health education . r
as in the case of village health promoters,C.H.W1s etc. In projects
like Jamkhed the VHW's have besides delivery of primary health care,
also beenfemvolved in total socio-economic development and in social
change in the community.
a)
What according to--you. should be the role of these front
line workers,taking into consideration in particular the
C'. . H 1,1 I e
'v* b) Should they involve . in .activities besides health?
IH
and
11.
grjteria^process of., selection;
In Jamkhed the community •
is informed about the type of worker required bythe doctor,and
the social workers and ANNS. and the community select the worker.
In the plantation, the selection is made by the supervisor and
the manager of the tea garden in consultation with the medical officer
and the community.
In the Integrated Child Development Service Scheme,the Block -.
Development Officer and Child Development Project. Officer are the
main selecting authorities. In Raigarh Ambikapur Health Association
the church authorities in collaboration with their social worker '
and community select the worker- The CHW's should ideally be selected
by the Gram 8abha- but this seldom happens and it is largely the
Panchayat workers and the Medical Officers and other political workers
who eventually select their protegees.
a)
Which system according to you is better? Why?
b)
Do you have any suggestion as to how the workers couira. *be
' j x
selected?
c)
Considering C.H.W.1 s scheme in particular -how could one en
sure that the right people get selected?
,» 4
d)
What should the sex/caste/economic class/education of the
12.
TRAINING;
The mode of training differs from place to place.
In Jamkhed an initial training in the headquarters for a week
is followed by in service training in the field in their respective
villages and coupled with refresher session they work for a whole
day, where working come to the headquarter every Friday stay and eat
together(this gives them an opportunity to share their problems'
and occasionally find solution from each other experiences). This
is followed by another day(Saturday) of review of the weeks' work,
Collection 'Of data and cheeking .of records (done by M. 0. and A.N.M,
Social Worker),teaching of a new lesson and solving their problems
or rather helping them to find solutions. •
.Link workers from, different gardens come in batches to the
headquarters in Coonpor or to their respective garden hospitals for
weekly training mainly in data collection,sanitation and are also
thought the methods of production and transmission of disease and
treatment of the same by the Medical Advisor or the Medical Officers.’
-training is given by social workers and Nurse-Midrefresher session for 15 days every 6 months.
The Anganwadi Workers are trained in different institutions
selected for the purpose by the Project. staff. They are trained by
doctors^ social worker>etc. fop 3 months. . Some of them receive in.
service training.
j
The CHW's are trained by the M.O. and M.H.W. with occasional
Most of the prefects utilise Audio-visual aids, but much stress
is laid in Jamkhed and plantations and R.k.HA. and some of the PHCs.
Jamkhed utilised locally relevant audio-visual aids.
The methods of training vary from mainly didactic lectures
on field training and purposeful,problem,solving meetings as in
Jamkhed and Plantations.
a) Who should actually give the training?
b)
Are the doctors in our PHC capable of imparting training
to CHW’s.
c)
Should these doctors receive a training themselves?
e)
What type of training should they be given?
f)
Shoui the PHC-MO's train their MHW'S to teach the CHW?
•g ) Could Medical colleges involve themselves in training of
the M.0, + M.H.W's.
h)
W
rc j to you would be the best way of training
i)
Contents of training,skills imparted to VHW's and the
^urwaevel to which they should be trained. Should the train
ing be uniform?
j)
What educational methods and principles should be utilised
in training the VHWs.
k)
Main training emphasis on professional(health work) skills
or on how to conscientise people about socio-economic
problems and actions? or Both?
a) Should workers be part time/full time?
c)
Sfe
If paid, how much? 'Wih'/Kind?
Who should contribute the momey and through whom should
the payment be done? One who dcy payment will effectively
:control V.H.W.
■< -
1b-- Actions of. community to CHWs. : In projects like Jamkhed,
U.A.H.A. ,Mandwa and Plantation majority of :people are happy to fig
have some body to give them basic h- 1th cure.
However there is large amount of dissatisfaction with the
government in various parts of the .c-q^ntry^also in some of the
projects. Some of the reason are:
a dedicated worker ii)^ Not enough knowledge
iii ) Does not giv,e- ii^^'iS^iv) Not accepted by the community
v) Helps only the rich and affulent.
What according to yo-u are the main reasons for this?
a) What should be the sex/age of the worker?
b)
Could religion/educational status/sex/age affect performance? ,
c)
should socio-economic conditions be a criteria for selection?
”1 6. Eyaluation; What should be,the methods of evaluation ©£1.' 5
performance of front line workers?
a) Decrease in morbidity and mortality in the community/vulnerable groups.
c) Nutritional status of children?
d)
Socio-economic changes
e)
Changes in Knowledge Attitude Practices in the community.
f)
Acceptance by the community.
g)
On going evaluation/terminal evaluation(for projects)?
j) Who should evaluate? How can the community participate
in evaluation of CHW and in supervision and control of
their workers.
1
i
mott often part-time and are expected
In the I.G-.D-.8.S. the workers are full-time drawing about
Rs,. 100/- ■ to Rs.1?O/- per month.
In most other projects workers are paid Rs.30/-.*to
Rs.5O/g, //<
per month. The Govt. CHW get Rs. 200/- per month (full time during
their initial training) arid Rs. 50/- per month later on after their
initial training.
In R.A.H.A. and Plan
t
rl rs are honorary. Eva
luation 6f workers in most projects and PHCs, shows that the
workers/higher honorarium.
17. i)What population should each worker cover?
ii) How many villages should he/she cover?
a) ShouRsi the CHW be responsible to the village?
Or the
| '■ b) Should village health committees be, formed?
S^fec) Should Block Development Officer supervise?
19. a) Should CHW’s shheme be part of the PHC- set up?
• b) Should it be independent?
c) What should be the interphase between the District Health
authorities and other development authorities and CHW’s.?
d)
What should be the interphase between the C.H.W. and the
community?
20.
1)
21.
b) Should avenues for promotion and increment in wages be
worked out for CHW's? If so how.?
a) How could medical colleges with the new schemes for take
Should the^be refresher training for the workers? How
b) Could they involve in the training of the workers and
22. Primary health care envisages the involvement of health
department with various departments like agriculture,social welfare
I etc. -in development o'f the community.
a) How could front’ line workers do this?
.b) Are the doctors capable of functioning in unison?with
other development agencies.
j
|
quest lofts.,to; stimulate discussions in view of what we have observed
in Jamkhed which perhaps is one of the best projects today. We
must attempt however to project how some of the things done here,
could be implemented in other pockets and parts of India.
Primary Health Care it has been said, marks the changing
point which a future historian would perhaps call the beginning
of health devolution.
Let us all-hope the future historian gets an opportunity
to &b this’. .
Ib/ks.
*
%
Relative Risk of Pregnancy vs.
Risk of Contraception.
In the note I shall first discuss the possible adverse
effects of childrearing on maternal health (and on the
health of the child), and then exemine contraception
method-specific problems or risks. I draw on available
studies and research on these two themes. In the final
section, various issues which emerge are outlined for
discussion.
I. Effects of Child bearing on Maternal Health;
It has been a common wisdom that childbearing, the aspect
of human reproduction which is unique to female sex,
good health and good medical care to minimize maternal
risks. The factors which increase these risks are :
i) pregnancy at the two extremes of childbearing span,
i.e. before age 20 or teenage pregnancy and after age
30, but really speaking, after age 35; (ii) high parity,
i.e. large number of children; and (iii) short inter
pregnancy inervals.
It has been shown that these pregnancies are more likely
to cause hemorrhage or high blood pressure, which lead to
maternal death. Also, closely spaced pregnancies may
lead to anemia and malnutrition among women.
Many surveys are replete with findings that support this
list of risk.factors. "Risk" is measured in terms of
maternal mortality, and there are many studies both in
developed and less-developed countries which indicate that maternal mortality or complications arising due.toB?
pregnancy are higher among teenagers, among older women,
at the time of deliveries fourth and subsequent children
and when the birthinterval or inter-pregnancy interval
is very short. However, in developed countries-, thanks
to good or excellent medical or obstetric care, maternal
mortality even in these "high risk" categories has been
brought down considerably, although compared to the risk
Background paper for XIII Annual Meet of the MFC at
undaipur 26 - 27 January, 1987 prepared by Leela Visaria
of maternal mortality in the ideal age group 20-30,
deaths in the presence of these factors are still several
times higher.
Maternal mortality rates for select countries or areas
shown in Table 1, suggest that the overall problem is
quite massive in Asia compared to any other region of
the world. However, one must concede that the estimates
based on vital statistics may underestimate the
levels of maternal mortality compared to the survey
results.
In developed countries, the low level of maternal morta
lity is believed to be achieved by reduction in the
number of high-risk pregnancies; i.e. only..a small
fraction of births occur in the presence of the four
high risk'factors . In the 'developed countries, mater
nal deaths account for less than 2 percent of all deaths
among women in the age group 15-b-b-. In Mexico, this
proportion is 10 percent and according to Matlab data,
maternal deaths accounted for 27 percent of deaths
among women in the reproductive ages.
Further, in addition to those who die, many women proba
bly .suffer from serious illnesses related to pregnancy,
abortion or childbirth. A survey in Aiwa region in
Rajasthan state conducted between 197b- and 1979 found
that, for each maternal death, there were 16.5 illnesses
related to pregnancy, childbirth and the paxp puerperium.
Wherever relatively good quality data are avilable.,.
maternal mortolity rates form' a J-shape when plotted
against age and when plotted against parity. However,
the scales for developing countries are two to four times
higher than those" for developed countries at.every age,
although the shapes are similar.
.
i
Table - 1
Maternal Deaths per 100,000 Live Births,
Selected Areas, 1951 - 1982.
Country or Area
Year
Rate
Kenya
Mauritius
Hong Kong
Philippines
Costa Rica
•Ecudar
Mexico
Egypt
Australia
Japan
Sweden
U.S.
1970
1979
1980
1976
1980
1977 ,_r
1978
1978
1980
1980
1979 .
1978
20k99
5 •
Ik-2
2k199.
103
83
10
.21; Z.
Area Surveys
Matlab, Thana, Bangladesh
132 villages.
Total Matlab
1967-68
1976-85
770
570
Villages of Bakripalnagar
Aiwar, Rajasthan, ^-ndia
Bali, Indonesia
197k-79
1980-82
592
508
Vital Statistics
.
10
Note: Maternal death rate is the annual number of deaths
among women per 100,000 live births, caused by deli
veries and complications of pregnancy and childbirth
and the puerperium. Deaths resulting from complic
ations of induced abortion are also included in these
statistics.
Source: Rinehart, Ward and Kols, Adrienna, "Healthier Mothers
and Children Through Family Planning " Population
Reports, Series J., Number 27, May -June 198^.
P. J-661.
However, in recent years, there are certain studies,
which do question this model of "too many, too early or
too late, too quickly" leading to high maternal mortality,
Increasingly, it has been found that atleast in developmed
■world, teenage pregnancy per se is not risky or is » any
more or less risky than childbearing in the’ early twen
ties. The factors causing higher mortality are not-the
age but socio-economic and environmental factors. The
methodogical problems related to measuring effects of
childbearing on maternal health are discussed in the - •
last section.
The life-threatening complications affecting the mothers
are hemorrhage, pregnancy-induced hyper-tension and sep
sis. Hemorrhage is much more common among older women
with many children. Pregnancy-induced hypertension or
pre-eclampsia affects mainly women with no children and
older women with several children.
Sepsis or infection
on the other hand, is not directly linked to maternal
age or parity and can accompany any delivery.
In developing countries, the major problem among mothers
is believed to be malnutrition and anemia, or.often
•referred to as maternal depletion syndrome, by Jellife.
Given the estimated extra untritional demands due to
pregnancy and breast-feeding, it is assumed that closely
spaced pregnancies, when work, are a cumulative drain, on
nutritional status of women. If a woman cannot recover
fully from the effects of her last pregnancyand period
of breast-feeding before .becoming pregnant-' again, her
nutritional status might be expected to deteriorate with
each successive pregnancy.
The" evidence on this syndrome of maternal depletion is,
however, is inconsistent and weak. Studies conducted
in El Salvador, Bangladesh, Sudan, Thailand.support this
hypothesis. On the other hand, the WHO studies on Family.
Formation Patterns and Health (using a height for weight .
as a measure of malnutrition, and hemoglobin level as a
measure of iron -deficiency anemia) found no link between
malnutrition or anemia and age ornumber of children.
Childbearing Patterns and Infant Mortalitys- ■
The patterns of childbearing which are statistically
found to be risky for mothers, are also found to be
risky for the infants. When pregnancies occur before
age 18, after age 3f? or in women with four or more
children or within two years of another pregnancy, there
is a greater risk of stillbirth or death during infancy.
Most research that has examined the affects of the birth
interval has done so in the context of the interval
before the birth of the child under study. Such studies
undertaken in most developing countries (thanks to the
World Fertility Surveys) point to the conclusion that a
short preceding birth interval is dangerous to the infant
and that shorter the birth interval, the higher the
infant death rate.
When this is examined in the context of the mother's age
and birth order, it was shown that birth spacing had more
impact on infant mortality than either birth order or
mother's age.
However, it has been shown that early antenatal care,
a nutritious diet, safe delivery conditions, etc. do
compensate for some of the risk factors, Also, socio
economic status of the.families is believed to be an
inportant confounding variable, and yet, due to pro- •
blems of small numbers., the. socio-economic differences
are hot taken into account in most, studies.
It has often been stated in literature that relative to
the risk of childbearingthe risk of contraception as ,
an alternative to' maternity - is minimal.. Not only that,
some methods are- even considered, tp be prophlactic and;
thus help in reducing the risk of mortality.
However, it has been recognized that the contraceptive .
methods are equally safe; they very in their risks, and
side effects. Before we examinemethod-specific risks
or dangers as well as advantages, tew two’ methodologicalpoints should be made.
One, the relative safety of'contraception compared to
pregnancy and childbearing has been established statis
tically so far for developed western countries. Further,
it has been assumed that in the developing countries, the
safety of contraception is even greater because the dangers
associated with childbearing are high. This set of pre
mises are being increasingly questioned now as more and
more research is done on the effects of some of the
contraceptives oh women's health.
Two, there are disparities in the safety of various con
traceptives and therefore, the .relative risks of each
method should be assessed in different ways. Often
people simply add up the relative risks of each method,
but this procedure is clearly faulty. Adding up deaths
directly caused by each method is to an extent, warranted.
However, since the various methods do very in their relia
bility, a realistic assessment should take into account
deaths associated with pregnancy and childbirth when
contraceptives’fail.
Table 2 presents the relative risk of each contraceptive .
method. This exercise, was’undertaken in the early 70s
and since.'then medical research has brought to light
certain risks which were unknown then. The long term
effects,. of certain methods have become known only recen
tly. Also®! the data are for developed countries, where
the health status of women is relatively good. The same
method may, in the presence of certain physiological
conditions, increase the risk factor. For example, IUD
was considered a fairly safe method even through it is
associated with’increased blood loss and infection.. In
a developing country, where anemia or iron deficiency .
among women is highly prevalent, excess blood loss can
be dangerous for the already anemic women. x
A check-list aiam comparable tollable 2 for developing coun
tries is in order. However?good.quality method-specific
large data set is needed to generate such probabilities '■
or simulation methods. Also recent evidence on the side
effects or complications which do,pot manifest themselves
in the short run, but which become evident in the, long
run has to be built in such a model. This is, however,
not the place or time to undertake such an exercise,
although its need is very great. I shall at this juncture
draw on redent evidence to examine contraceptive method
specific risks.
Safety of Family Planning Aleternati- es for Women Beginning
Birth Control at Age 30 (Developed Countries
*
Method of Fertility
Control.
Cumulative Repredduction Related
Deaths from Age 30 to End of
Reproductive years J7
(Deaths per 100,000 women)
1. No. contraception
2. Legal abortion (first
trimester )£/
3. Oral contraception to
end of reproductive years3_Z
M-. Oral Contraception to age L-0,
followed by diaphram or
condom use.
J. Intrauterine devise (IUD)
6. Diaphram or condom
7. Diaphram or condom with
leval abortion as back up
8. Tubal sterilization.
9. Vasectomy (male risk-)
2h-5
92
188 .
80
22
10-20
0
JL/ Includes contraceptive-associated deaths, abortionassociated deaths and birthsassociated deaths in case
of contraceptive failure or nonuse.
2/ Assumes abortion is the only fertility contj?ql used,
resulting in an average of 13 abortions per women.
3/ Oral contraceptives are not recommended for women over h-O in
developed countries, where safer alternatives are available.
SOURCE! Based on data from the United States and Great Britain
and adapted from : Tietze, C., Bongaarts, J. and Scheater, B., "Mortality Associated with th'e Control of
'Fertility", Family Planning Perspectives, Vol. 8 No.l
Intra-Uterine Device or IUD:
I® the mid-1970's after more than a decade of experience,
1DU, was considered to be the ideal contraceptive for
world wide use. It has not quite lived upto its promise,
although a lot of research has focussed on improving its
performance. Three areas where research has been concerntrated are: (1) improvements in technique and training
fur insertion ( to reduce perforation and infection),
(2) optimal size and’configuration of the device itself
and (3) addition of bioactive substances to reinforce the
contraceptive effect or reduce heeding and pain.
After a lull period, IUD appears to be coming back again
world wide as sone of the safest, and effective forms of
birth control. The basic problems of IUD - increased
menttrual bleeding, expulsion soon after insertion, •
pain and increased frequency of pelvic infection - remain
unresolved.
In addition, problems that tre rarer but mora serious
than pain, bleeding and expulsion have emerged now when
long term and widespread use has made it possible to
detect these events. The serious complications are a
higher risk of ectopic pregnancy, a septic second trimester
abortion (in cases where pregnancies occur with the device
in situ), and a higher, risk of subsequent infertility
caused by pelvic infection than among women not.using
IUDs.
Survey d^ta on pregnancy and expulsion of various types
of IUDs world wide ade available and indicate that preg
nancy rate per 100 women is relatively low; it falls in
the range of Oih-Jbo 3.0. Expulsion rate for certain types
of IUDs is relatively high. Lippes loop is the worst
among various IUDs on this, score. The expulsion rate per
10.0 women has ranged from 2.2 to 19.3. ’>V.S;
However, due to bleeding and pain, women opt for removal
and it is estimated that 8 to 18 percent of the women
have the device removed within one year. It has also been
estimated that these problems are more serious or that
both expulsion and removal rates are higher in developing
countries like India and Bangladesh than in European
countries or.in the US.
As far as the newer problems which have come to light,
the available data base is scant and there is need to
<Qlbsely monitor the performance of the device in a given
population. The need for better, health service support
and follow-up is very very essential if the method has
to become acceptable as a safe reversible spacing method.
In the last thr.ee yea.rs, -the number of yearly acceptors
of IUD - mainly Copper T - have increased from 751,000
in 1981-82 to 2,562,000 in.198U-85,. indicating nearly
three and a half fold increase in just three years.
Continuation rates remain very low, but if the device
has to gain popularity, better follow-up and health r+-.< :
service support must receive priority.
Sterilization
i) Vasectomy
As indicated in Table- 2,' the male risk in vasectomy a
surgical sterilization, is zero or nil. Vasectomy is
acclaimed as the safest, simplest and most effective
method of contraception. Yet, 'it is a neglected method
in much of ihe world, including India. After becoming
quite, popular, through camps in India in the early. 1.970's,
the number-of. vasectomies has been declining, as the ..
emphasis has shifted to female sterilization.
ranged between 879 thousand and 2613 thousand during 196773- Since then'barring the emergency period of 1976-.77',
this number has steadily declined and iq.thearound 500 thousand vasectomies are performed every year.
There are several possible .reasons ,for the recent declines
in the annual number of vasectomies. The increasing avai
lability of other methods, new proqediares making female
sterilization sfifer and simpler than before (although, still
more complex compared to vasectony) arc- some of the possi
ble reasons for the popularity th^t, vasectomy has lost. ■<
Equally, if not more important are the male attitudes’or
fear that vasectomy will adversly affect their sex lives '
or virility. Even though such fears are totally unfounded,
nothing much has been done to counter these attitudes..
Quite the contrary. By officially promoting female
sterilization, on a mass scale, an indirect support is
being given to the prevailing attitude on vasectomy, even
when the procedure is extremely simple and the medical
problems are non-existent or minimal at best.
It. is possible that vasectomy- would become popular and
more acceptable if it were a reversible method. Theore tically, surgical rejoining of the vas is possible but as
of today, its reversibility cannot be guaranteed on a
large scale.
Female. Sterilization?
In recent years, female sterilization - tubectomy, laparo
scopy or minilaparotmy - is the most widely used methou
all over the world. In India, out of 32.3 percent of effe
ctively protected couples (in 198
*t-85,),
25.0 percent (or
77 percent of all protected couples) were protected, by
sterilization procedures. Of these 85 percent depended
upon female sterilizationto control their fertility.
This rapid spread of female sterilization., in the last .
decade or so has been made possible partly by improve
ments in the technique of sterilization. The new techniques
are believed to be'highly effective and safe.
K-It is stated that female sterilization^does not cause any
long-term complications. Some discomfort or pain is.llkely
after surgery. The risk of complications depends not only
on the type of procedure 'but also'on the experience of the
doctor and the characteristics of the women. Female steri
lization should cause very few deaths, if performed by.
trained, skilled doctbrs in a'cceptic situation and if.the,
clients are carefully screened before hand. Large surveys
have reported 3 to 19 deaths per 7100^)00 procedures, n in
developing countries. In India, an ICMR survey of feLjXJ
teaching hospitals, however, reported higher mortality .
rates of ever 70 per lOQpOO procedures. It is possible
that many of these deaths could have been prevented by
following certain guidelines effor proper selection and
insisting on asceptic conditions during surgery, since
infection and hemorrhage are the major causes of death.
Among the procedures of female sterilization, laparoscopy
is being promoted in the national family planning programme
because it can be performed very quickly and requires
a small indision and no hospitalization. However., it has
of laparoscopy is quite high -may be as high as 20 percent.
It appears that some of the assential preconditions are
overlooked in a mass drive to promote family planning.
Laproscopy is suited to a specilized setting with the
performing it should, have experience in abdominal surgery
us, on the other hand, are aware of or have personal
experience of situations where laparoscopy has been condu
cted in camps with minimal facilities by doctors whose
skill is also less than optimal. While the sufferer is
the poor women who has opted for sterilization, the long
term effect of such instances ofi the programme would be very
adverse.
In sum, Table 3 attempts to present rather succinctly the
comparative advantages of vasectomy ahd female steriliz
ation. It is time, in my opinion, to prorogate and popu
larize vasectomy as a permanent method ,of family plann
ing mainly because of its very low score ofassociated
risks, iffforno other reason.
- 12 , Table - 3.
Comparison of Vasectpny and Female Sterilization.
Vasectomy.
Female Sterilization
Effectiveness.
Very effective, but slightly
higher rate of spontaneous
recanalization and pregnancy.
Very effective; slightly lower
failure rate
Effective 6.to 10 weeks after
Effective immediately
Complications
Procedure involves almost no
Procedure involves slight risk
risk of internal injury or
of serious internal injuries
other life -threatening
and other life-threatening
complications. .
complications
Very slight possibility of
serious infection
Slight possibility of serious
infection.
No anesthesia-related deaths
Few anesthesia-related deaths.
Acceptability.
Minute scar.
visible. ■
Slightly more reversible
Less expensive
Slightly less reversible.
More acceptable in many cultures.
Personnel.
Team needed including one
trained person with or without doctor, one trained anesthetist,
an assistant
and at least two assistants with
more training than needed for
vasectomy assistant.
Safely performed by
trained paramedics
Can usually be performed in ...
half the time of most female
sterilizations
More difficult for paramedics
to learn and \to perform,
Usually only physicians with
training in gynecology can per
form laparsscopy and laparotomy
*
Minilaparotomy is simpler.
Equipment
Laparoscopy requires expensive,
Requires no specialized
complex equipment, which needs
equipment. Equipment
to be carefully maintained.
readily available
Manilaparotomy requires only
Gan usually be performed.
under local anesthesia
Systemic sedation necessary as
well as local anesthesia.
Back-Up Facilities.
No. back-up facilities needed
for immediate complications.
Back-up facilities needed in case
of damage to abdominal organs and
blood vessel? or bthercomplications that require laparotomy.
Possible Long-term Side Effects.
None demonstrated. Uncertainty Slight risk of ectopic pregnancy
about effect of increase in
sperm antibodies.
Source: Liskin, Lauria, "Vasectomy - Safe and Simple",
Population Reports, Series D, Number 4, November December 1983, p. D-69.
Oral Contraceptives:
In India until recently, oral contraceptives or OCs were
essentially available frail private sources only; they
were not part of the .national programme until- 1974’;A1though
oral pills were included in the programme on a small pilot •
project basis in 196''j the project was extended to; urban
centres and to thos« PHCs which had "adequate monitoring
facilities" in- 19r4 only. Since then, pills have been
promoted as a fbrin of birth control initially .rather
'Cautionsly. and in the last, two to three years quite
vigorously. Compared to the distribution performance in
1982-83 of 2.L million cycles of oral pills, the number
increased to 9.5 and 16.8 million during 1983-84 and
1984-85, respectively. This several fold increase has
hoc.^ possiMe because the pills are now distributed by
all the health personnel associated with the.PHCs and
their svocentres.’ Th^pniy- condition is that the acceptor
three months of acceptance.
Knowledge of the benefits and risks of the pill has grown
considerably in recent years. Pills are acclaimed as the
most effective reversible means of preventing pregnancy
(effectiveness depends upon regular use). It has also
been noted that oral pills protect women.against pelvic
inflammatory disease and also against ectopic pregnancy
(IUD fares badly on both these counts), against uterine
and ovarian cancer. In addition, pill provide relief
from a wide range of common menstrual disorders.
As far as risks are concerned, it has been found that
age, there is a significant increased risk of problems.
. of. circulatory system. More specifically, pill users
who smoke and are over 35 years of age, non-smokers who
are above U-0 years of age reported significantly higher inci-;
dence of venous thrombo-embolism, heafct attack, stroke and
hypertension. A large study undertaken in Britain reported
that these high risk women (i.e. older smokers)
latory system cilment than nonusers of oral pills, Pfilsare therefore not re.commedned as a method of ■ birth con--.'
However, most of the research on oral, pills, has been done
in the US and the UK .and the large surveys: have been con
ducted in these countries. It is difficult ..to know the ,
extent to which these findings hold> true for women in
developing countries like India. It is often, hypothe-. • sised that women in developing countries, do not. smoke as:.
much as they do in d?veloped countries or that they do •>
not suffer from heart diseases to the same extent, and .
therefore, they.are likely to be less adversely-.affected •
by the problems of o'aial;(pills.. All the same, one ought
to be very coutious before prescribing pills t,o all and
sundry. A lot more medical, research, is..,.still needed with .
the specific health conditions of Indian women in mind
before promoting them for wider usd.
Injectables and Implants?
The place of injectables in family planning has remained
quite incertain. While the manufacturers consider them' to be.
quite effective and convenient, controversy surrounds *
their safety. Depo Prcvers was until recently used as
the most popular injectable and was pushed in countries
like Thailand. However the controversy over the injectables in the'US, ranged for more, than-a decade, and
finally 'the Public Board of Inquiry on Depo Provera .
recommended in its report to the Food-and Drug Admini-.
stratioh tha.t it not.be approved for use as a contracep
tive in the US. However, this has internatiorial implica
tions and the injectable has come under attack ip many
other areas.
The risks associated with the injectables are breast and
endbrmer'ial cancer, although most of the studies are
animal studies. Studies on women suing Depo "'rovera are
hot of long duration or of adequate number to positively,
assets that its use leads to malignancies. Other prob
lems associated with the use of injectable are' excessive
bleeding, depression, headache, weightgain, etc. These
.side effects, important in themselves, are not considered
to be
ofserious
*
medical, consequences. -in India, another injectable known by the name of NETEN
'is be.^ng triedj^t^g Several phases of clinical trials-.' '4have been underway, and a decision to include NETEN
in the official family planning programme has been taken.
fThe results of the earlier.trials , are not in the public
domain. What is known is that the ICMR conducted as a
part of the WHO project, a two.year study C1981t8'3).
This study pointed to a high pregnancy rate among the usep.s &
a high dropout rate because of menstrual prbblesm. ■ !*■
In addition to these,, of course, are the conventional. .
contraceptives such as condom, diaphragms, foam tablets .
etc. which are, if used correctly, quite effective and
at the same time safe. They, however, requir<e *a fairly
high level of motivation and mutual understanding. Since
the risks associated with them are minimal, I have not
touched upon them in this rote.
What the brief foregoing discussion points to is that the
risk of mortality due to different methods, of fertility
control varies, that the risk varies also between various.
age groups, i.e. a given method may be quite safe during
a certain phase of the reproductive span, but not towards
the beginning or the end of the period.
Further, any method which tampers with the normal hormo
nal balance carries greater risk than the mechnical
methods. This is quite evident in Table b-.
What is noteworthy is also that the risk of childbearing
is higher at most ages than the risk of mortality due to
contraception use except for pills used by smokers. It
is tempting to conclude that the safest (in terms of risk
factor) approach is to use the condom and to. back it up<
Table
Cumulative Risk
*
of Mortality per 100,000- Nonsterile Women, by
Fertility Control Method, According to Age - Group.
Regimen
•
15-^ 15-3^ 15-19 20-2^ 25-29 30-3^ 35.39 ^O-U-l
No control
14-62
Abortion
■
U1
Pill/nonsmoker 251
Pill/smoker
192
35 G
\26fjk 3
21
3
132
12
37
6
3
.18
b-6
7
5
£&3^
7^ g 129
10
9
10
70
277
68 257
7
10
1
6
*6
6
Condom
. 23
19
6
8
UDiaphragm/
spermicide
28
10^', 66
6
6
11
Condom and
Abortion
1
1
@
@
@
@
@
Phythm
68
36
12
8
8^J * 8
Ik* Calculated by multiplying the age-specific annual death
rares by five.
@ Less than 1.0
Source: Howard W.Ory,"Mortality Associated with Fertility
and fertility Control': 1983", in Family Planning
perspectives, Vol. 15, No.2, March/April 1983,
6 >
16,0
288
r
@
with abortion in the event of method failure. However,
women or individual couples do not make choices soley on
the basis of perceived risk of mortality. Similarly, the
decision to have children or to postpone childbearing is
generally make independently of the mortality risks asso
ciated with such choices.
What seems the most humane approach is to make available
various methods to the couples without zealously promot
ing one over the other in order to fulfill certain tergets
along with knowledge about the associated risks,
failures etc. Equally important can be a sound education
on childbearing under certain risk conditions.
Methodologically, one must not hdd up the relative risks
of each method to arrive at a figures of contraceptive
risks because a given couple uses only one method at a
time. We must not
cloud the issues unnecessarily.
Extracts from "Tuberculosis in Children ; Diagnosis.,. jand follow up.1
by Susie Graham J :nes, Medical Officer, Save the Children Fund,
Chaufara Project, Sindhupalchowk: Souvenir Nepas J. 1984, 3 (1)
61-73.
Tuberculosis in Children
Diagnosis,
and follow up
Intrcauction
The incidence and prevalcnc of tuberculosis (TB) in children
in Nepal is net known. The adult prevalence is about 1.6% (sputum
positive) Diagnosis in children is a problematic affair, as there
are n' r liable diagnostic tests.. Chest x-rays are net diagnostic
in children; Mantoux tests arc unreliable, especially in malnouri
shed children; and. .the pick up rate from laryngeal swabs and
gastric washings is poor, even when facilities are available. Sputum
tests are rarely of any use in children.
Nevertheless the experience of the Save the Children Fund (SCF)
Mother and Child health clinics in 4 districts in Nepal shows that
childhood TB is common and carries a high mortality. This report
*
of the TB cases diagnosed at the new SCF clinic in Sindhupalchowk
between Srawan 2039 and Kartik 2040 (15 months) is a follow up
to a report on TB child patients at the Surkhct SCF clinic (Wiseman,
1980). We emphasise- that health workers can bo trained to make a
clinic-1 diagnosis of TE without any laboratory investigations, and
that progress can be monitored by weight gain as well as regression
of symptoms. A search has been made for factors associated with
good cr poor outcome of tr.atment.
I.
Diagnosis of TB in Children
Fell-wing Wiseman (1980), we lock first for. a history of illness
cf mor. then one month in duration, and make enquiries for a
suggestive family history cf chronic illness. On examination, we
leak for signs cf localized disease in lymph nodes and lungs, and
fcr chrnic atypical skin lesions, We also maintain a high index
cf suspicion in children who. arc- chronically undernourished cr
unwell, but who- de net have localized symptoms or signs,. These
children may show deterioration and anorexia after measles cr
whooping cough. There arc also the children who do not respond to
xconventional treatment for chest infections, diarrhoea, or skin
lesions.
W~ rarely diagnose TB, except for obvious gland TB, on a child's
first visit to the clinic. But if we suspect it, we call patients
back to the clinic within 2 weeks for a repeat history and examina
tion. Family history is often elicited more fully at this second
interview, and we ask for sputum tests from suspect adults. We also
use the BCG vaccination as an abjunct to diagnosis. Unfortunately,
scarpositive BCG' does not seem to give a very good protection
against TB in children in South India (WHO, 1979 b).But an early
reaction to BCG taking the form-of skin ulceration over the injection
site within 2-'weeks of vaccination (as opposed tothe normal reaction
which takes .1-2 months to develop as a small scar) may indicate
active tuberculosis. This is a rather more sensitive test than
the standard Mantoux.test (Miller, 1978).
Training for clinic staff, health post staff and field workers
in cur programme has included much discussion and comparison of
the sign,6 and symptoms of TB in adults and children. We use posters
and flij( charts including emphasis on BCG vaccination, for children
and referral of patients to health services. These visual aids, and
training booklets produced by the Britain-Nepal Medical Trust
(BNM’W Biratnagar, and by the Shining.Hospital, Bokhara, are also
used/ in health education sessions in schools, for patients at health
posts, and in the clinic. Wo encourage health workers and field
■wqckers to attend the weekly TB follow up clinics at the Chautara
clinic to see patients at various stages of treatment. The parents.
/of these TB patients are often the most enthusiastic teachers.
..... 2
II.
Treatment
We continue to use the standard TB drugs available to hospital s
and health pests through the Tuberculosis Control Project (HMG),
The mainstay cf treatment in children is ISONIAZID (Iscncx) which
is both bactericidal and bacteriostatic and causes very few side
off cts in appropriate doses. It is combined with THIAC TAZONE
(TB 1) in most cases, <a convenient formulation being RD-ZONE
FORTE (isoniazid 300 mg + TB 1 150 mg): but in order to avoid
the side effects associated with thiacetazone we use the following
d-.-s~.gc schedule according to the child's weight, including
extra isoniazid- and a relatively smaller dose cf thiacetazone.
TABLE 1
Dosage of TB Drugs (Oral) According to Child's Weight
RD-ZONE FORTE + Extra Isoniazid
Weight less than 5 kg
6-14 kg
15-20 kg
21 kg upwards
\
%
h
1
tab
tab
tab
tab
+
+
+
50 mg
100 mg
100 mg
—
This oral regimes seems sufficient for many children with
pulmonary disease,
gland TB, skin TB and f.--r those with non-'
specific signs and avoids the necessity for injections and
frequent clinic attendances. In seriously ill children, especia
lly these with bone cr meningeal disease, wc start streptomycin
injections (40 mg/kg up to a maximum desc for children of 500 mg)
daily for in patients or 3 times weekly for cut patients, always
combined with the- above- oral regime. .Streptomycin is given for
2 m.-nths, if possible. Isoniazid alone is given occasionally to
children less than two years cld who are not seriously ill,
have no localized symptoms and are unlikely to develop resistant
strains of myc bacteria. All patients arc expected to continue
treatment’ for a minimum cf 12 months and this is made clear at
the start. A special review is undertaken at 12 months to decide
which patients should continue for a further 6 months. In a few
cases with persistence cf symptoms, ethambutol has been given fcr
a two month trial period at 20-25 mg/kg.
Other medicines are kept to an absolute minimum in order
not to.
confuse the parents. Anemia (Hb -$£10g%) is treated
with ferrous sulphate, and nutrition is discussed with all
parents,.
/
VI. Treatment regimes and side effects cf TB drugs
Nc severe side effects have been reported during the study
pericd, and drugs have not had to be changed because cf side
effects. Mild side effects were reported in 5 cases within
2 months of starting treatment:
1. vomiting in a thr-.c year old on oral INH and TB 1
2. vomiting in a 9 m nth old on streptomycin and oral
INH and TB 1
3. diarrhoea and vomiting in at 2 year cld on oral INH and
TB 1
4. itchy rash at 2 weeks after starting oral INH and TB 1
in a 2 year cld
5. fever in a five year old- on streptomycin and oral
INH and tb 1
This low incidence of side effects is probably due to the
care with which dosage is related to the child's weight.
3
3
The iseninzed only regime- has been used in 4 children
under 2 yers of a^e wh have been fcllcwc.' up. Twe have- dune
well end twe have shown only slight improvement. This regime
c-~nn~t yet be properly assessed.
Ethambutol has been added to cral INH and TB in. 3 elder
children with persistent symptoms after 6 mont'hs of the
standard regime, Two are new improving end ther-. have bean
no side effects.
VII. DISCUSSION
Diagnosis of TB in Children
With specific training for clinic health workers, TB
diagnoses have risen from 3 to ab at 18 cases per month at
the Chautara MCH clinic, cut of an average of 225 new patients
seen per month. We now estimate- that about 10% of the total
work loa-’ of the clinic is associated with TB diagnosis and
fellow up. This is one of the main topics for the in-service
training programme for HMG health workers at the Chautara MCH
project.
Follow up of TB in children - whose job?
i
Follow up rates in most TB programmes are disappointing,
since patients have, to be exceptionally well motivated to
continue attending hen symptoms have subsided. In this study,
30% of newly diagnosed TB patients (under 10 years old) were
not followed up at .all; and there was a 45% drop cut rate at
2 months after diagnosis, by the time the programme had running
for 15 months.
At present, the defaulter chasing duties of Tuberculosis
Control Project staff (HMG,) are restricted to sputum positive
adult cases, who are the most infectious group. In this field
district, we are working together with TBCP staff, health
post staff, MCH/FP workers, and other agencies to try to ensure
that 1 at risk1 individuals such as TB defaulters of all ages
can be rapidly contacted.
Outcome of Treatment
Symptomatic improvement was marked in 40% of patients
fllowed up to at least 2 months in this-study. The mortality
rate was 10% in the 15 month study period. Improvement in
nutritional status was well defined. Wasting was present
in 42% of newly diagnosed TB cases but only 14% in those
followed up at 2 months and 6% in those followed up
at
6 ;n- nths. Once weight gain has started, pro ress can be rapid;
of those who gained weight at all, the average weight gain
was 269% of refer .nee weight gain at 2 months, and 169% at
6 months. More than half of all patients followed up gained
weight faster than the expected reference rate of weight
gain for children of
similar ages.
Correlation of weight gain with reported clinical progress,
however, was not reliable. This is partly clue to reporting of
intercurrcnt illness, and partly also to imprevement unrelated
to weight gain.
The search for facte,rs indicating likely outcome of
treatment
In this study, factors such as sex, previous bcg
immunization, family history, ethnic qr:up, presenting symptoms
.... .4
4
and different drug regimes were found not tc carry predictive
power. The < nly useful indicator so far discover d is age of
the child TB patient.
Younger children definitely bear a higher risk than elder
ones.
peer clinical outcome is found in 21% of the TB
patients under 3 years old at the time of diagnosis, but in
only 9% cf chose aged between 3 end 10 years. And there are
relatively more 'under threes', in all the poor outcome groups'
than in the good outcome groups, whichever- outcome measure
is used.
Malnutrition at the time cf diagnosis may be followed
by ropic. weight gain during the first few months cf-treatment,
and is net per se an indicator of poor prognosis. When cutcome
is assessed clinically the good and peer outcome groups both
contain approximately 30% of waste;': children. This percentage
falls faster in the good outcome group than in the poor-outcome
group.
There may be a small group cf wasted children who dp net
gain weight well on TB treatment. Further analysis on a
larger sample will be needed to see if there are ether charac
teristics of this group which would help to detect them early
on as needing special care.
P.E TERENCES
- Wiseman, David (1980) J. Inst Med, 2, 31-36 Tuberculosis
Report for Surkhet District
- WHO (1979b) Bull Wld Hl th Org., 57, 819-82i7
Trial of BCG vaccinations in South India for tuberculosis
prevention; first report
- WHO (1979a) Publication FAP/79.1, Geneva
A gudeline for the measurement of nutritional impact of
supplementary fe...ding programmes aimed at vulnerable
groups.
- Miller F J W (1978) Tuberculosis in Children. London-.’
Churchill Livingstone
- Shining Hospital, Pokhara (1979) TB 'Handbook (English
—
and Nepali versions)
W
-• Britain Nepal Medical Trust (1981) Treatment cf Tuberculosis
- Ratliff, W. (1981) d Base II. California; Ashton Tate Ltd.
Note; Nos. Ill (Presenting f atures of children diagnosed
as having tb); IV (Follow up of TB patients); and
V (Outcome assessment) are not included in this
extract. For full text,
refer the journal mentioned.
J
d'OMEN AND HEALTH
4 Pr aLiminary Annotat-jd Bibliography
This is not an exhaustive or even a selective bibliography. It is a list of
books anl documents available at thj Jawaharlal Nehru Library, Bombay University
Women's Studies Unit of the S.S.D.T University ant with me. Some of these are
are available at the Feminist Resource Centre,”«F.R.C .H, The only oriteria used
is that most of these either acknowledge a broadly feminist- perspective or
could well contribute to it.
SSxism in Medicine and Health Care
T
17 Bart, Pauline. Biological Determinism and Sexism; Is it all in the Ovaries.
In Biology as a Social tfe.apon. Burgess Publishing Co. 1977. 69-83
Shows how science in the IJth century operated in the interest of status quo
Includes a content analysis of gynaecological textbooks.
2. Doyal, Lesley and Pennell, Imogen. Tho Political Economy of Health-Pluto Press
1979.
Places wonen's health issues within a global, historical v.iSw
of health
and health care contributing to the emergence of a feminist perspective on
health.
*
33
Duffin, Lorna. The Conspicuous Consumptive: Jomen as an invalid^ In The
Nineteenth Century fomin. Ed by Sara Delmont and Lorna Duffin. 1978
Croom Helm. London. 26-56
Based on content analysis of Lancet between 1850-90, a feminist analysis of
women's illnesses such as consumption, neurasthenia, chlorosis, amennorrhoea
and their reco 'mended treatment.
4" Easlea, Brian. Science and Sexual Oppression. Viedenfeld and Nicolson. 1
51
*
'lhe chapter on Biology, Medicine and Viniculture in 19th century Britain
.deals with how social myths about women's weakness and proneness to fall ill
were incorporated into medicine and suit 1
biological explanations fabrica
ted to lend scientific credibility.
Ehrenreich, Barbara and English, Dierire. ..Complaints and Disorders:. The
Sexual Politics of Sickness . Glass Mountain Pamphlet no. 2. ’’’he feminist .
Press. 1973New York. 1973
s
Medicine stands between biology and social policy and is one fof the most
powerful sources of sexist ideology in our society. This is .a sociological
anl political analysis of the history of women's ill health and how society
has dealt with the problems.wh
6.
Jacoby, Robin Miller. Science and Sex Roles in the Victorian Era. In Biology
as a_Social Weapon, Burgess Publishing Co., Ann Arbor Science for the People
Collective. 1977.5
*8 -6$
Examines the mutually reinforcing relationship that existed between 19th
century biological theories and 19th century ideology on sex roles
7.
Leibowitz, Lila.
Perspectives on the Evolution of Sex Differences. In ”ow
Thwart Anthropology of rfomen edited by Rayna R.Reiter. Monthly Review Press
f9'757 20-35
Counters the hypothesis that women's sex-role destiny is determined by their
anatomy. Proposes a new hypothesis accounting for the evolution of physical
differences.
6. Messing, Karen. Dor.emen and women have different jobs because of their biolo
gic 1 differences ? International Tournal of Health Services. 12(1 ^43-52,1982
fell-researched facts ani convincing arguments demolish myths — weaker sex'
myth, 'fairy fingers' myth, 'raging hormones' myth and the myth of orotecting
- 2
*
pregnant workers —vfaich are used to keep women in specific jobs.
"
9.
Rothman, Barbara Katz, Nomen, Hoalth and Medicine. In Hnnim: A
nergPOOtive. edited by Jo Freeman. Mayr'.ed Publishing Co.7 2nd. edition. 197,
27-40.
7 '
An excellent analysis showing how the .individualist and mechanist 'world v±ew
of medicine directly results in medical procedures and treatment which contri
bute to the oppression of women.
Women's health status
10.
Gupta, J.I. The problem of Burns in Women. Annals of Indian Academy of Meli
cal Sciences, 12(4 ): 260- 197
*6
In a span of ten years more than 31 per cent of the burn victims in a B-.lhi
hospital were women and 45 Per cent children. Causes include badly designed
kitchens and equipment, lack of safety devices on household gadgets
11.
Jussawalla, D.J and Jain,D.K. The problem of Cervical and mammary cancer in
India. Annals of Indian Academy of Medical Sciences, 12(4); 239-50, 1976
Reviews statistics from 42 hospitals in 15 states. Cancer, is the ninth cause
of mortality among women in Bombay in 1,71. Recards the predominance of cervi
oal and breast cancer.
12.
Kulk^rni, Suresh,N. Demographic and Nutritional Background of the Health
status of
women
*
in India- Mimeo. Institute of Economic Growth. New Delhi
Some analysis of statistical data from 1,21 on health indices with reference
to w»men. Demonstrates that declining sex ratio is a function of health
status. Sex-wise health care of population of age group
’ has received
little attention as compared to that given to age group 15-44. Lack of appro
priate data ensures that female mortality is examined only in terms of preg
nancy management.
13.
Mohanty, Bidyut. W»men, Disease and De i.th in Historical Perspective; A case
study of Orissa (1881-1921) . Paper presented at the Conference on Women's
Studies, 1981
—
A very brief paper about what .appears to be an exhaustive study showing that
more aen than women died in the 19th century. Oil diseases have changed and
several' social" factors have resulted in their intensification killing mtre
more women
14.
Nathanson, Constance. Sex, Illness and Medical Care.: A review of data, theory
and method. In Health, Illness and Medicine edited by Gary Albrecht and
Paul.c. Higgind- 16-40
Examining data f mostly from developed countries, presents a picture of sex
differences in health indices. Method "f treatment of data could be a model
15.
Shatrugna, Veena. Health status .of. women and children and the role of commune
ty health volunteers scheme. Paper presented at tne Workshop on Women and
Health , Bombay 1981
Briefly describes the major health problems of women and expresses a reserved
approval of the community health programmes.
you don't eat ...."
16.
Batliwala, Srilatha. Rural Energy Scarcity and Undernutrition: A new pers
pective. Economic and Political Weekly, 17(Feb.7,1982 ):
Relates women's undernutrition to wtheir actual energy expenditure obtained
from a field study. Suggests that nutritional intake insufficient to make
up for energy output may have long term effects such as higher morbidity,
shorter life span etc.
17.
Eide, rfenche B et al. Nomen in Food Production, Food Handling .and Nutritiofi
(with spr ref. to Africa} Food and Agricultural Organisation. Rome .1,79
Critically analyses the problem of women's nutrition in the context of the
history of coloniaiism in Africa and the political, economic and social
changes and how they affected women's role in production.
- 4 scientific medicine, dominated by men.
Leeson, J ani Gray.Judith.
30.
fomen,in Medicine . Tavistock Publications.1978
Reviews historical role of women in health care and an analysis of the begin
ning 01 unionisation among nujses. Also deals with nurse-women doctor, nurse
women patient, women doctor-women patients relationships
Navarro, Vicente. Nomen in Health Gare. In Health, Illness and''Mad-i ci n« Ed. bv
Albrecht and Higgins. Rand McNally, Chicago. 1979. 327-37
~
J
31.
Describes the situation of the women in the U.S.health labour force. This can
be understood in the context of an analysis of the socio-economic and politi
cal structures.
Sadgopal, Mira. Training of Dais. In Health Care: Nhich way to go . MedicoFriends Circle. 1982 197-206
———————— _x-------- a.
32.
A critical oomnent on the dai training programme.
Nomen's Biology and its Consequences
Menstruation
Reigrove, June. Menstrual Cycle. In Biological Rhythns and Human Performance
edited by N.P.Colquhoun. Academic Press.London. 1971. 211-49
33.
A well-referenced '’study asserting that menstruation does effect performance
but its extents depends on other socilogical and psychological factors as
shown in experimental studies and experiments on women athletes.and sports
34.
Shuttle, Renelope ani Reigrove, Peter.
Everywoman■ Victor Gollancz Ltd. 1978.
The Vise found: Menstruation and
A complete book on a phenomena which effects half the human population and has
only recently been'subjected to comprehensive reseirch. Draws from scientific
psychological, mythological and anthropological, historical sources. A never
before analysis.
I Rsproduction
Gordon, Linda. Jorian's Poly, Neman's Rights Penguin Boo^s. 1977.
35.
A socio-political . ■ history of the birth control movement in America. Sees
three distinct periods in the last 100 years— 'voluntary motherhood', legali
sed abortion and the period of commoditization of birth control.
36.
Lahiri, Di. ani Sonar,M. Abortion Hazards. In Journal of Medical As ociation of
India. 66(11): 288-294- 1976
Sepsis accounts ■. for 20$ of all abortion hazards. 50 per cent of random
abortions admitted were ilegally induced. Data from one hospital, many years.
37.
Lawrence, Virginia. Contraception. In Nomen's Undercurrents , U.K. 29., "26,1978
Short but significant. Offers that the tchnology which provided contracepti
ves is a male technology . Nomen must infiltirate the scientific network
and influence priorities and methods.
38.
Newland, Kathleen.
fomen and Population Growth: Choice _b.gyo.nd -^i^lkgaring.
,-forld Natvh Paper 16, December.1977
A critical review reassessing existing information. FP programmes do not
recognise women as individuals but as mothers ani yet they seek to diminish
the only role that they explicitly recognise for women.
39.
Rao, Kamala Gopal. Status of women in India related to the_studx. of W
I3SSR Mimnc. Undated.
Th^r« exists a two-way relationship, between FP programmes and women's status
•Jhi ■ is explored here. Considers such questions as: does co tracaption redefine the^female role in society and alters the meaning of marital relationship
„
rr--,
, a
40- uSeioiSiX
Tainn
fomen's Liberation, Reproduction ani the
^ssLBssjLSae:
London. 1976
Exposes the inherent sexism of new developments in reproduction technology
f
'
- 5 -ini challenges the viewpoint hell by some radical feminists that technologv
is neutral and sc can be male use of as such.
41.
Savage, Neniy. Taking Liberties <ith Nomen: Abortion, Sterilization ani
Contraception. International Journ'.l of Health Services. 12(2); 293-308,1982
Analyses four area of concerning reproluctive freedom , based on U,K data.
42.
Savara, Mira.
/omen, Health ani Reproduction: Some issues. Paper aresented
at the ■/omen ani Health workshop in 1981.
Discussion paper with a fe.ninis perspectiveSuggest action programmes.
43.
Sc'iiff, Jill.
Vasectomy. Newsletter Cultural - Survival■ 5(4): 198I . op8
' here appears to be a Link between atherosclerosis ani vasectomy. Could there
be acardiovascular disease epidemic on the horizon ?
44.
Serlin, Renee.
281-84. 1981
Contraceptives: Back to the barriers. New Scientist, July30
An anniversary article on Marie Stopes wh» f«ught for birth control in the '30
'30s. Notes Ljow- fertility control todyy is surrounded-by a 'morass of prejudice.
45- Vandenbroucke , J.P et al . Oral contraceptives and rheumatoid arthritis: further
furtherevidance for a preventive effect. Lancet. 1982 ii 839-42’
Report of a case control study of women with a history of oral contraceptive
use and diagnosis of probable rheumatoid arthritis or soft tissue rheumatism
Confirms earlier findings of that )C use halved rates of rheumatoid arthritis
drgst etrios and child care
46. Cohen, Marlge. "ook Review of M3n Nho control womeh's ehalth by-Diana Scully
Reproductive Rights Newsletter , Fill 1980 20-21
Analyses the practice and training of in Ob and Gyn at two major urban hospi
tals
'47. Comer, Lee. The Myth of Motherhood. Spokesman Pamphlet. Undated.
A feminist critique of society's definition of motherhood.
48. Frankfort, Ellen. vagin*l Politics. Quadrangle Bros. New York. 1972
Ah early book on how women are breaking the medicine's grip on their bodies.
Haire, Doris. The'cultural warping of childbirth. In The cultural Crisis of
modern medicine El by John Ehrenreich. Monthly Review Press. 1978. 185-200
Excellent article examines current Ob practices such as use of anaes+hesia,
insistency on the^^^^o^o.nyposition during childbirth, use of forcedps etc.
51» Hewell, Mary C. Paediatrician and Mothers. In /he cultural Crisis of Modern
Medicine• Edited by J.Ehrenreich. Monthly Review Press. 1978 201- 222
Informal content analysis exp of teaching material .in paediatrics.
5:1. Miller, Barbara.
'/hat hospital admission s tell us about childcare in India
Syracuse University.Mimeo.
Higlights the difference in male-female care from the analysis of secondary
data on hospital admission from regional and area studies.
5p>. Scully, Diana and Bart, Pauline. A Funny thing Happened on the Nay to the
Orifice: Nomen in Gynaecology Textbooks. In The Cultural Crisis of Modern
Meiioine. Ed. By John Ehrenreich. Monthly Review Press. 1978• 212-28
A report on the content analysis of 28 gynaecological textbooks for sexist
bias. T)je emphasis is on how female sexuality has been dealt with
53. Sebastian, E.V. Health Services for Nomen. Annals of Indian Academy of MediMal Sciences, 12(4): 222-34, 1976
Begins with a historical review of health services for women but the focus
shifts to a discussion of health services for children and their mothers'.
-6 5jp Sethna, N.J'. Maternnl_^d_Chill Health Serving in India. All India Institute
of Hygiene and Public Health. Bacfegroupd paper for the ICSSR-tCMR Committee
on Health and Medical Services. 197.8.
Describes the development of MCH services in India, reviews the reports of
committees on health and the ir reconmeniations for MCH betweenl947-1968
5-5. Singh, Gayatri and Savira,Mira. A caso study on Child Care Facilities in
Metropolitan Bombay. Asian and Pacific Centre for Women and Development, I9S0
Studies the functioning of a creche runa by a textile mill, a balwaii program
me, a mobile creche run for construction workers. Highlights drawbacks for
instance, women workers given only half-an-hour to feed babies, when ±t takes
ten minutes to get to the creche alone.
55. Singh, Shamer.
Environmental hazards during pregnancy and birth defects.
Annals of National Academy of Medical Sciences , 14(2): 53-65. 1978
Environmental hazards are a major or contributing factor in 65-70 per cent
of birth defects. Also discusses the effects of drugs and chemicals.
decent Issues concerning Women's health and Biology
. Chhachi, Amrita and Sathyamala,C. A World without fomen? Sex determination
tests - a technology1 which will eliminate women. Hindustan Times, Aug.8,1982
Explains amniocentesis in non-medical language and offers a socia-paJ.i lio-VJ
background to the issue.
—
5g. Hosken, Fran P. Female Genital Mutilation in the World Today; A global review
International Journal of Health Services, 11(3); 415-30, 1981.
A well-documented review of the ethical and health issues posed by female
genital mutilation which affects at least 74 million women and female children
■-A. Minkin, Stephen. Depo-Provera: A ;ritical analysis. Institute of Food and
Development Policy. U.S.A. 1980
A comprehensive review on Depo-Provera, an injectable contraceptive, which
many studies show lowers resistance to viral infection and worse, causes
cancer. Attempts to clarify some of the political and economic issues invol
ved in the ongoing controversy.
Sathyamala,C and Shiva, Mira. Are Hormonal Pregnancy Tests safe ?
Health Association of India. New Delhi. 1982
Volunteer
This was a background for many other articles on the same subject apoearing
in newspapers and journals on ar around March 8,1982, launching the successful
campaign focussing on the dangerous side effects and relative.irrelevance V
6L. Sipe, Patricia. The wonder Drug we should know about. Science for the People
’ 14(6 ):9-16,30-32. 1982
DES or stilbestrol, prescribed to millions of women to prevent miscarriage
was,in the late '60s, suspected of having caused cancer in the daughters of
women who used them. Written by aDES daughter, this article discusses the
history of DES but also the health issues affecting DES daughters.
63.
,
Wilson, Mark. Bottle Babies and Managed Mothers. Science for the' People ,
13(1): 17-24.1981
An analysis of the structural elements in capitalism and patriarchy which
give rise to the problem of babyfood/infant formula. This is one feature of
th“ larger problem of malnutrition, disease, oppression of women and the
exploitation of the Third World. More proof that technological develooments
are not necessarily liberating.
f Britain: Foreign Husbands and Virginity Tests. ISIS International
’’ Bulletin, 14: 23-24, 1980
A short report’on ’virginity tests' which were introduced for Asian women
immigrants to Britain, and. the protest actions that have taken place m
Britain and in India.
- 7 Regaining Control of Health Care : Some Alternatives
64.
Boston lemon's Health Book Collective. Our-"'Boo.lleH, OursHives. Simon and
Schuster, Naw York, 1979- (Available from Manushi, New Delhi J-
A pioneering book on women's biology, anl their health written by a group of
non-medical women who clarify misconceptions perpetuate! by the medical sys
tem. Its an all-you-ever-wanted-to-know book which has already made history.
65.
Eve' s Weekly. Special issue on Health atd Fitness . Eve's Weekly Ltd. March
13-19, 1982.
Mainly a 'how-to' i.ssue with a cut-and-keep section on comnon ailments and
emergencies, but includes a discussion of 'sensitive' topics such as psychia
tric care of women .and sexuality.
6’6. Fee, Elizabeth. Nomen and Health Care: A comparison of theories. International
Journal of Health Services, 5(3): 397-415, 1975
Discusses three distinct approaches to women's health in the U.S — liberal
feminist, radical feminist and Manxist-feminist. May not be mutually exclusive
67Health for the Million. Special issue on Nomen and Health. Voluntary Health
Association of India, New Delhi, 8(4); 1982
A representative collection of articles covering the entire range of health
issues concerning women. Nell researched and collated issue, Includes /renortd
of efforts at organising women on the health front
6'q. TCSSR-ICMR Study Group.
Health for All; An Alternative Strategy Indian Insti
tute of Education, Pune. 1981
Incorporates a more comprehensive understanding of women's role than other
similar health plan documents in the past. Attempts to view women'as indivi
duals rather than only as mothers. Does not wholly succedd.
§5. Jha^ Saroj.S. The development of Health Education programmes for women, in a
om
olum. paper presented at the x,ational Conference on Nomen's Studies
, S.N.D.T University, 1981.
Brief description of health education programmes directed at women
7jj. Kay, Bonnie anl Regan, Carol. Steering Clear of the Medical Mainstream.
Seience for the People, 14(6): 28-9, 1982
How an experiment at providing abortion servies grew.into an alternative
health service for women in a city in the U.S.
71. Lok Viinyan Prakashan. Stree-Aarogy (in Marathi) Lok Vidnyan Sanghatana, Pune
Pune branch, I98I
Deals with women's health problems — including infertility, VD, cancer----in non-medioal terms. A
* easy-to-understand booklet.
7j. Parsons, Patricia and Hodne, Carole. A collective Experiment in Nomen's
Health. Science for the People, 14(4): 9—13, 1982
Describes and successess of establishing an alternative health service for
women in a town in th,e U.S. Offers some guidelines which may be of use
7^. Prakash, Padma. Nome
*
and Health: Some issues . Paper presented at the
Conference on a Perspective for a women's movement in India, Bombay.1980
A discussion paper attempting to show that health issues for women's movement
in India are different from those in the West and highlighting t ie need for
a feminist critique of 'alternative developments i* health care e.gCH,etc.
-. Sen, Ilina and Sen, ^inayak. An Experimental health course for riural Nomen
7 4 Paper presented at the Nomen and Health Workshop, Bombay 1981.
- A note oh theexperiences of organising an experimental health course for
woman. Qpen to all women with no selection of candidates with the intention
of avoiding the creation of a new .
. hierarchical level in health .care
AND MANY MORE
If there exists a comprehensive bibliography on women and health, please make
it more accessible!
A<and, MFC £X Annual Meeting, 1983
Padma Prakash
-fOMiSN AMD HEALTH
•
A PraLim.inary Annotated Bibliography ■
This is not. an exhaustive or even a selective bibliography. It is a list of
books anl documents available at the Jawaharlal Nehru Library, Bombay Univarsity
Women's Studies Unit of ths S.S.D.T University ant with mo. Some of these are
are available at the Feminist Resource Centre,’cF.R.C.H, Ths only criteria used
is that most of these either acknowledge a broadly feminist’ perspective or
couli well contribute to it.
SSxism in Medicine and Health Care
Bart, Paulins. Biological Determinism and Sexism: Is it all in the Ovaries.
In Biology as a Social Jsapon. Burgess Publishing Co. 1977 • 69-83
Shows how science in the l$th century operated in the interest of status quo
Includes a content analysis of gynaecological textbooks.
2. Doyal, Lesley and Pennell, Imogen. The Political Bcinomy of Health.Plut
*
I979.
Press
Places women's health issues within a global, historical view
of health
and health care contributing to the emergence of a feminist perspective on
health.
33.'Duffin, Lorna. The Conspicuous Consumptive: rfomen as an invalid. In The
Nineteenth Century /toman. Sd by Sara Delmont anl Lorna Duffin. 1978
Cro«m Hqlm. London. 26-56
Based on content analysis of Lancet between I85O-9O, .a feminist analysis of
women's illnesses such as consumption, neurasthenia, chlorosis, amennorrhoea
and their reco imended treatment.
*
4
Saslea, Brian. Science and Sexual Oppression. Jiedenfeld and Nicols«n. 1^51
The chapter on Biology, Medicine -and Viniculture in 19th century Britain
.deals with how social myths about women's weakness and proneness to fall ill
were incorporated into medicine and suit :
biological explanations fabrica
ted to lend '•scientific credibility.
Ehrenreich, Barbara and English, Dierire. Complaints and Disorders:. The
Sexual Politics of Sickness . Glass Mountain Pamphlet no. 2. T'he feminist ■
Press. 1973New York. 1973
s
Medicine stands between biology and social policy and is one fof the most
powerful sources of sexist ideology in our seci-ety. This is a sociological
ani political analysis of the history of wofhen's ill health and how society
has dealt with the problems.wh
6.
Jacoby, Robin Miller. Science and Sex Roles in the Victorian Era. In Biology
as a Social tempon. Burgess Publishing Co., Ann Arbor Science for the People
Collective. 1977-58“69
Examines the mutually reinforcing relationship that existed between 19th
century biological theories ani 19th century ideology on sex roles
7.
Leibowitz, Lila.
Perspectives on the Evolution of Sex Differences. In kw
Toward Anthropology of /fomen edited by Rayna R.Reiter. Monthly Review Press
19'75 ’ 20-35
’
’
Counters the hypothesis that women's sex—role destiny is determined by their
anatomy. Proposes a new hypothesis accounting for the evolution of physical
differences.
8.
Messing, Karen'. Dor.emen ani women have iifferent .jobs because of their *
biol —•
gio 1 differences ? International Tournal of Health Services. 12(11:43-52', 1982
toll-researched facts ani convincing arguments demolish myths — weaker sex'
myth, 'fairy fingers' myth, 'raging hormones' myth and the myth of -oroteoting
- 2 pregnant workers —which are used to keep women in specific: jobs.
•'
9. Rothman, Barbara Katz. Women, Health and Medicine. In Woman i. A. ,.faari.ni Ri-parppective. edited bv Jo Freeman. May led-Publishing Co.7 2nd. edition. 197?
27-40.
An excellent analysis showing hew the individualist and mechanist 'world Vxsw
of medicine directly results in medical procedures and treatment which contri
bute to the oppression of women..
Nomen's health status
. .
.
18. Gupta, J.L. The problem of Burns in Women. Annals of Indian Academy of Medi
cal Sciences, 12(d): 260- 1976
5n a span of ten years more than 31 per cent of the burn victims in a. D^lhi
hospital were women .and 45 per cent children. Causes include badly designed
kitchens and equipment, lack of safety devices on household gadgets
Jussawalla, D.J and Jain,D.K. The problem of Cervical and mammary cancer in
India. Annals of Indian Academy of Medical Sciences, 12(4); 239-50, 1976
11.
-
4
’
•
.»
Reviews statistics from 42 hospitals in I5 states. Cancer, is the ninth cause
of mortality among women j.n Bombay in 1971- Records the predominance of cervi
cal and breast cancer.
12.
x
Kulkarni, Suresh,N. Demographic and Nutritional Background of tire Health
status of women in India. Mimeo. Institute of Economic Growth. New Delhi
Some analysis of statistical data from I92I on health indices with reference
to w«men.- Demonstrates that declining sex ratio is a function of health
status. Sax-wise health.care of peculation of age group 0-I4 ' has received
little attention as compared to that given.to age.group I5-44. Lack of appro
priate data ensures that female me tality is examined only in terms of preg
nancy management.
13.
Jfahanty, Bidyut. Ramen, Disease and Death .in Historical Perspective: A case
study Of Orissa (1881-1921) . Paper presented at the Conference on Women's
Studies, 1981
A very brief paper about what appears to be an exhaustive study showing that
mor? nen than womorj died in the 19th century. Odd diseases have changed and
several social"
*
factors have resulted in their intensification killing m»re
more women
14.
Nathanson, Constance- Sex, Illness and Medical Care.: A review of data, theory
and method. In Health, Illness and Medicine editel by Gary Albrecht and
Paul.c. Higgind. 16-40
Examining data f mcstly from developed countries, presents a picture of sex
differences in health indices. Method "f treatment of data could be a model
15.
Shatrugna, Veena. Health status of women and children and the role of communi
ty health volunteers scheme. Paper presented at the Workshop on Women and
Health , Bombay 1981
Briefly describes the major health problems of women and expresses a reserved
approval of the community health programmes.
you don't eat ...."
16.
Batliwala, Srilatha. Rural Energy Scarcity and Undernutrition: A new pers
pective. Economic and Political Weekly, 17(Feb.7,1982):
Relates women's undernutrition to wtheir actual energy expenditure obtained
from a field study. Suggests that nutritional intake insufficient to make
up for energy output may have long term effects such as higher morbidity,
shorter life span etc.
17.
Bide, Wenohe Bat al. Women in Food Production, Food Handling and Nutritiofl
(with spr ref. to AfricaJ Food and Agricultural Organisation. Rome .1J79
Critically analyses the problem of women's nutrition in the context of the
history of colonia£isni in Africa and the political, economic and social
changes ani how they affected women's role in production.
- 3 -
18.
ICMR. Anaemia in Pregnancy.
5 (11 ): 1-4, 1975
Indian Council of Helical Research Bulletin.
-------------------------
Comprehensive review article on a health problem which accounts for 20 p°r
cent maternal deaths.
19. Jayarao, Kamala. Who is Malnourished: Mother or the Woman ? In Health Care
care :-Jhich way to Go. Medico Friends Circle. 1982. 5J-74
Welfare activities concerning women never attempt to bring them into the main
stream of developmental activity. Their nutritional status is rooted in their
their inferior status in society, although nutritional programmes treat them
only as mothers or potential mothers. Examines effect of new technologies on
women's nutritional status through changes in their employment.
"-fork(outside the_home) causes ill health"
?0. Ansley, Ited an! BeTTT Bren laDiagnosis: dork relate! diseases. In Science
for the People. 7(5 )s 19-21,34-5-----------Examines workihg conditions of women in cotton mills in the U.S and domonstra
tes that 'women's illnesses
*
are in fact, roots! in their social location,work
21.
Feminist Network Newsletter. The Sandoz Strike. In Feminist Network Newsletter
1979-i
Describes health damaging conditions If work of women in Sandoz plant.
22.
SftP East Bay. Danger: Women's dork. In Science for the People.12(2) 1980
Anlysis of workpkalce hazards in new and traditional industries in the U.S
where women work in large numbers.
23.
CALL, Women and Labour Law . Committee'for the Advancement of Legal Literacy
Brief introduction to welfare measures and protection afforded to working
women under the Factory Act, Maternity Benefits Act and 3SIS ACT.
"It's all in the mind"
24.
Chesler, Phyllis. Marriage and Psychotherapy. In Internation?.! Socialist
Review. November 1980. 32-34
Traditional psychoanalytical theories about women are at best—confused and
at worst, false. The ethic of mental health is masculine. We need to seek
a new, a first , csychology of women.
25
Fee, Elizabeth.
Psychology, Sexuality and Social Controlin Victorian England
In Social Science Quarterly, 58(4): 632-46.
A roll-documented article with extensive reference showing how psychology
was used to impose social control as-well as male bourgeois norms of sexuality
26. Mackay, Judith Longstaff.
Women and Madness
.
Hong Kong 1979- Mimeo
A good overview of how social and cultural norms influence psychiatryo diag
noses and the solution of psychiatric problems of women. The normal woman of
psychiatry is an emotional, weak, passive, non-aggressive wife or mother.
Women as Healers
27- Bang, Rani. NursesL The cursed women in Medical System. In Health Care
way to Go. Medico Friends Circle. 1982. 75-9O
Discusses the current distressing status of nurses in 'India and suggests that
their low status within health care may be because of the nature of their
job. Nurses have a key role to play in women's struggle.
28. Gamarnikov, Sva. Sexual Divsion of Labour: the case of nursing. In Feminism
and Materialism. 3d by Annette Kuhn and AnnMarie Wolpe. Routledge, Kegan and
Paul, London. 1978. 96-123
Under capit lism patriarchal re .ations are reproduced in the sexual division
of labour in the health care system. The occupational ideology of nursing
necessarily genderises the division of labour y—associating meo- with science
and authority and women with oaring and maintenance. Sontributes towards a,
theoretical understanding of nursing and nurses/
29: Shrenreioh, Barbara and English, Dieire.
Jithhes, Midwives and Nurses.
Glass Mountain Pamphlet no.l. The Feminj st-Press. New~Tork." 1971
A short feminist history of women healers from witchcraft to the rise of
s
- 4 scientific medicine, dominated by man.
30.
Leeson, J
Gray.Judith.
jomen in Medicine . Tavistock: Publications.1978
Reviews historical role of women 1.1 health care and an analysis of the begin
ning of unionisation among curses. Also deals with nurse-women doctor' nurse
women patient, women doctor-women patients relationships
31.
Navarro, Vicente. Nomen in Health Sara. In Health, Illness and Ms^ioine Ed
Albrecht and Higgins. Rand McNally, Chicago. 1979. 327-37
~
-----------'
bv
y
Describes the situation of the women in the U.S.health labour force. This can
be understood in the context of an analysis of the soci«-economic and politi
cal structures.
32.
Sadgopal, Mira. Tr lining of Dais. In Health Care: Nhich way to go
Friends Circle. 1982 197-206
'——————————“------- a _•
Madino
A critical comaent on the dai training programme.
fom en's Biology and its Consequences
Menstruation
33.
Redgrove, June. Menstrual Cycle. In Biological Rhythns and Human Performance
edited by N.P.Colquhoun. Academic Press.London. 1971. 211-49
A well-referenced -’study asserting that menstruation does effect performance
but its extents depends on other socidogical and psychological factors as
shown in experimental studies and experiments on women athletes.and sports
34.
Shuttle, Renelope and Redgrove, Peter.
Everywoman. Victor Gollancz Ltd. 1978.
I
'
The Vise found: Menstruation and
A complete book on a phenomena which effects half the human population and has
only recently been subjected to comprehensive reseirch. Draws from scientific
psychological, mythological and anthropological, historical sources. A irever
before analysis.
I Reproduction
35.
Gordon, Linda, Neman's Body, foman's Rights Penguin Boolps. 1977.
A socio-aolitical . • history of the birth control movement in America. Sees
three distinct periods in the last 100 years— 'voluntary motherhood', legali
sed abortion and the period of commoditization of birth control.
36.
Lahiri, Di. and Konar,M. Abortion Hazards. In Journal of Medical As ociation of
India. 66(11): 288-294- 1976
Sepsis accounts : for 20$ of all abortion hazards. 50 per cent of random
abortions admitted were ilegally iniuced..Data from one hospi+al, many years.
37.
Lawrence, Virginia. Contraception. In Nomen's Undercurrents , U.K, 29, 26,19"
*
8
Short but significant. Offers that the tchnology which provided contracepti
ves is a male technology • fomen must infiltirate the scientific network
and influence priorities and methods.
38.
Hewland, Kathleen.
fomen and Population Growth: Choice be,yo nd .childbearing
.forld Natch Paper 16, December 1977
A critical review reassessing existing, information. FP programmes do not
recognise women as individuals but as mothers and yet they seek to diminish
the only role that they explicitly recognise for women.
39.
Rao , ‘ Kamal a Go pal. Status of women in Indi a r elated to . t^he_s tudy o.f ro
I0SSR Mimeo. Undated.
There exists a two-way relationship, between FP programmes and women's status
■/hie is explored here. Considers such questions as: does co tracaption rede
fine the female role in society and alters the meaning of marital relationship
.n
4
Rn<^ Hilarv ’nd Hanm-r ,Jslna. fomen's Liberation, Reproduction and the
|o^elo^4
^^litioal Economy of Seienoe. The Macmillan Press
London. 1976
Exposes the inherent sexism of new developments'in reproduction technology
- 5 -
mi challenges the viewpoint hell by some radio'll feminists that technologv
is neutral and se can be made use of as such.
41. Savage, Jendy. Taking Liberties nth Toman: Abortion, Sterilization and
Contraception. International Journ ■! of Health Services. 12(2); 293-308,1982
Analyses four area of concerning reproductive freedom , based on U,K data.
42. Savara, Mira.
domen, Health an 1 Reproluction: Some issues. Hauer aresented
at ths Tomen mi Health workshop in 1981.
Discussion paper with a feminis perspectivaSuggest action programmes.
43- Schiff, Till.
Vasectomy. Newsletter Cultural Survival■ 5(4)? 198I . pp8
here appears to be a link between atherosclerosis and vasectomy. Could there
be acardiovasiular disease epidemic on the horizon ?
44. Serlin, Renee.
281-84. 1981
Contraceptives: Back to the barriers. New Scientist, July30
An anniversary article on Marie Stopes wh
*
ught
f*
for birth control in the '30
'30s. Notes
fertility control todyy is surrounded by a 'morass of prejudice.'
- 45. Vandenbroucke, J.P et al . Oral contraceptives and rheumatoid arthritis: further
furtherevidense for a preventive effect. Lancet. 1982 ii 839-42"
Report of a case control study of women with a history of oral contraceptive
use and diagnosis of probable rheumatoid’ arthritis or soft tissue rheumatism
Confirms earlier findings of that )C use halved rates of rheumatoid arthritis
dBstetrics and chili care
46.
Cohen, Marlge. ""bok Review of Men Jho control womeh's ehalth by- Diana Scully
•Reproductive Rights Newsletter , Fall 1980 20-21
Analyses the practice and tr lining of in Ob and Gyn at two major urban hospi
tals
47.
Comer, Lee. The Myth of Motherhood. Spokesman Pamphlet. Undated.
A feminist critique of society's definition of motherhood.
48.
Frankform, Ellen. vagin*l Polities. nuairangle Bros. New York. 1972
An early book on how women are breaking the medicine's grip on their bodies.
Haire, Doris. The cultural warping of childbirth. In The cultural Crisis of
.modern medicine Ed by John Ehrenreich
*
Monthly Review Press. 1978. 185-200
Excellent article examines current Ob practices such as use of anaes+hesia,
insistence on thej^j10^ofnyposition during childbirth, use of forcedps etc.
51. Hewell, Mary C.
Paediatrician and-Mothers. In /he cultural Crisis of Modern
Medicine. Edited by J.Ehrenreich. Monthly Review Press. 19/8 201- 22-2
Informal content analysis exp of teaching material in paediatrics,
5;1. Miller, Barbara. 'That hospital admission s tell us about childcare in India
Syracuse University.Mimeo.
' Higlights the difference in male-female care from the' analysis of secondary
data on hospital admission from regional and area studies.
5p. Scully, Diana and .Bart, Pauline. A Funny thing Happened on the Jay to the
•rifioe: Tomen in Gynaecology Textbooks. In The Cultural Crisis of Modern
Me Heine. Ed. By John Ehrenreich. Monthly Review Press. 1978. 212-28
A report on the content analysis of 28 gynaecological textbooks for sexist
bias. T&e emphasis is on how female sexuality has been dealt with
53
Sebastian, E.V. Health Services for Tomen. Annals of Indian Academy of Meii’ 0al Sciences, 12(4): 222-34, 1976
Begins with a historical review of health services for women but the focus
shifts to a discussion of health services for children and their mothers.
-6 5^. Sethna, N.f. Maternal anl.Chiljjknlth Services in India. All India Institute
01 Hygiene and Public Health. Background paper for the ICSSR-1CMR Committee
on Health and Medical Services. 1978.
Describes the development of MOH cervices in India, reviews the report? of
committees on health and the ir recommendations for MOH betweenl947-1968
5-5. Singh, Gayatri and Savara,Mira. A case study on Child Cara Facilities in
Metropolitan Bombay. Asian and Pacific Centre for Women and Development, 1980
Studies the functioning of a creche runa by a textile mill, a balwadi program
me, a mobile creche run for construction workers. Highlights drawbacks for
instance, women workers given only half-an-hour to feed babies, when it takes
ten miniites to get to the creche alone.
56 . Singh, Shamer.
Environmental hazards during pregnancy and birth defects.
Annals of National Academy of Medical Sciences , 14(2): 53-65. 1978
Environmental hazards are a major or contributing factor in 65-70 per cent1
of birth defects. Also discusses the effects of drugs and chemicals.
decent Issues concerning Women's health and Biology
57. Chhachi, Amrita and Sathyamala,C. A World without ifomen? Sex determination
tests - a technology which will (eliminate women. Hindustan Times_. Aug.8,1982
Explains amniocentesis in non-medical language and offers a socio-poJ.i tin-fj
background to the issue.
5g. Hosken, Fran P. Female Genital Mutilation in the World Today; A global review
International Journal of Health Services, 11(3); 415_3O, 1981.
A well-documented review of the ethical and health issues posed by female
genital mutilation which affects at least 74 million women and female children
-A. Minkin, Stephen. Depo-Provera: A
Development Policy. U.S.A. I98O
ritical analysis. Institute of Food and
A comprehensive review on Depo-Provera, an injectable contraceptive, which
many studies show lowers resistance to vi>al infection and worse, causes
cancer. Attempts to clarify some of the political and economic issues invol
ved in the ongoing controversy.
Sathyamala,C and Shiva, Mira. Are Hormonal Pregnancy Tests safe ?
Health Association of India. New Delhi. 1982
Volunteer
This was a background for many other articles on the same subject appearing
in newspapers and journals on ar around March 8,1982-, launching the successAjl
campaign focussing on the dangerous side effects and relative irrelevance “
Q_ . Sipe, Patricia. The wonder Drug we should know about. Science for the People
14(6 ):9-16,30-32. 1982
DES or stilbestrol,'prescribed to millions of women to prevent miscarriage
was,in the late '60s, suspected of having caused cancer in the daughters of
women who used them. Written by a DES daughter, this article discusses the
history of DES but also the health issues affecting DES daughters.
. 62. Wilson, Mark. Bottle Babies and Managed Mothers. Science for the People ,
13(1): I7-24.I98I
An analysis of the structural elements in capitalism and patriarchy which
give rise to the problem of babyfood/infant formula. This is one feature of
th° larger problem of malnutrition, disease, oppression of wqpen and the
exploitation of the Third World. More proof that technological developments
are not necessarily- liberating.
.
, Britain: Foreign Husbands and Virginity Tests. ISIS International
Bulletin, 14: 23-24, 1980,
A short report on 'virginity-tests' which were introduced for Asian women
immigrants to Britain, and. the protest actions that have taken place m
Britain and in India.
- 7 -
Regaining Control of Health Cars : Some Alternatives
64. Boston lemon's Health Book Coll active-. Our~Boodi9a, Oursnlves.rSimon and
Schuster, Hew York, 19?9. (Available from ManushTTHieW DelhiF
A pioneering book on women's biology, and their h’ealth written by a group of
non-medical women who clarify misconceptions perpetuated by the medical sys
tem. Its an all-you-ever-wanted-to-know book which has already made history.
65.
^giy‘
SPeoial issue on Health and Fitness . Eve’s Weekly Ltd. March
Mainly a 'how-to' issue with'a cut-and-keep section on comnon ailments and
emergencies, but includes a discussion of 'sensitive' topics such as psychia
tric care of women and sexuality.
6’6- Fee, Elizabeth, iomen and Health Care: A comparison of theories. International
Journal of Health Services, 5(3): 397-415, 1975
Discusses three distinct approaches to women's health in the U.S — liberal
feminist, radical feminist and Manxist-feminist. May not be mutually ovd™,)....
67-Health for the Million. Special issue on Nomen and-Health. Voluntary Health
Association of India, New Delhi, 8(4); I9U2
A representative collection of articles covering the entire range of health
issues concerning women.
Nell researched and collated issue, Includes reports
of efforts at organising women on the health front
6'g. ICSSH-ICMR Study Group. Health fcr All: An Alternative Strategy Indian Insti
tute of Education, Pune. 1981
Incorporates a more comprehensive understanding of women's role than other
similar health plan documents in the past. Attempts to view women'as indivi
duals rather than only as mothers.
Does not wholly succedd.
§9. Jha, Saroj.S. The development of Health Education programmes for women in a
-omp-y Slum. paper presented at the ^ational Conference on Women's Studies
, S.N.D.T University, 1981.
Brief description of health education programmes directed at women
7(j. Kay, Bonnie and Regan, Carol. Steering Clear of the Medical Mainstream.
Seience for the Peo>le, 14(6): 28-9, 1982
How an experiment at providing abortion servies grew into an alternative
health service for women in a city in the U.S.
71. Lok Vidnyan Prakashan. Stree-Aarogy (in Marathi) Lok Vidnyan Sanghatana, Pune
Pune branch, 1981
Deals with women's health problems — including infertility, VD, qancer----in non-meiical -terms. A< easy-to-understand booklet.
Parsons, Patricia and Hodne, Carole. A oollective Experiment in Homan's
Health. Science for the People, 14(4): 9-13, 1982
Describes' and successess of establishing an alternative health service for
women in a town in the U.S. Offers some guidelines which may be of use
7-,. Prakash, Padma. Home
*
and Health: Some issues . Paper presented at the
Conference on a Perspective for a women's movement in India, Bombay.I98O
k discussion paper attempting to show that health issues for women's movement
in India are different from those in the West a
d
*
highlighting t >.e need for
a feminist critique of 'alternative developments i< haalth care e,gCH,etc.
Sen Ilina and Sen, -^inayak. An Experimental Health course for ^ural Nomen
74’ Paper presented at .the Women and Health Workshop, Bombay 1951.
A note oh theexperiences of organising an experimental health course for
, -womyn. ©pen to all women with n- selection of candidates with the intention
’ of avoiding the creation of a new .
. hierarchical level in health care
AND MANY MORE
If there exists a comprehensive bibliography on women and health, please make
it more accessible!
A<and, MFC IX Annual Meeting, I983
Padma Prakash
A Discussion Paper on
"Targets and Coercion in the Family Planning Campaign"
Manisha Gupte
Target planning and coercion (directly during the
period of Emergency and indirectly through motivational
strategies) are integral components of the Indian Family
Planning Campaign.
What needs discussion is whether target
planning or motivation for the 'voluntary acceptance’ of
the small family norm are well intentioned strategies of a
government that truly believes in its own goodness or
whether coercion in Family Planning (FP) is a reflection of
more basic maladies in society.
Though Mamdani (1972)
conclusively proved that motivation and coercion are not even
practically able to reduce population numbers, the Indian
Government has continued to base its FP programme through the
setting of targetstconveniently glossing over the socio
economic factors that are responsible for. population growth.
Coercion, whether explicit or implicit, is
riddled with prejudicial biases, be they of gender,
nationality, class or ethnicity.
This explains why the
targets of population control programmes are the poor, the
coloured, the tribals, the dalits and their women. Dumping
of dangerous contraceptives in Third World countries and their
testing on poor women without proper informed consent, the
selection of Puerto Ric'ns or Mexicans for sterilisation in
the United States or the distribution of a chicken alongwith
each shot of Depo provera in the Phillipines are examples.
The result of such biases can be genocidal when for instance,
tribals who are already a persecuted section are tricked into
mass sterilisations
(FRCH 1987).
Incentives and disincentives;
,
Explicit coercion in the Family Planning programme
in India can be seen in the form of incentives and disincen
tives to assure that the required targets are achieved.
Incentives, be they an extra portion of rations, a few
hundred rupees or a pair of new clothes can work wonders in
impoverished societies.
Ironically the leanest agricultural
period coincides with the financial year ending (the month
of March) when FP activity at the Primary Health Centre (PHC)
level has reached to hysterical proportions.
An incentive based FP programme can understandably
create distortions.
In North Arc cl 20,000 government
employees signed a pledge to observe
a 'childless
.
*
year
They pledged to register one lakh sterilisations1 in
1984-85, doubling the number of operations from the previous
year
(The Hindu, Sept. 25,1984).
The Punjab government
introduced a raffle for a lakh of rupees as well as the
slogan 'Get sterilised and win'
(Indian Express,Jan.1,1985).
Laparoscopes and their accesories have been exempted from
customs duty 'in view of the growing popularity (sic) of
laparoscopic sterilisation among women'
During 1983-84,
80% of those sterilised were women
(Hindustan Times,
Nov.25,1984).
There was.also a proposal by Mr.Krishna Kumar,Ex
Minister of State for Family Welfare, to give income tax
concessions to private sector companies who offered to set
up PHCs and who showed significant results in the FW
programme (The Times of India, June 26,1986).
2
The ridiculous emphasis on incentives not
surprisingly has also led to malpractice.; A Bangalore
based doctor has arrested in 1985 for issuing bogus
sterilisation certificates to 220 employees <6f the New
Government Electric Factory (NGEF).
The cash incentives
offered by the NGEF for vasectomies was Rs. 1700 per
person (Deccan Herald, Jan.12,1985).
Dr.Khandwala,
General Secretary of the Indian Association of Gynaecolo
gical En'd^copists criticised surgeons in mass
sterilisation camps and doubted as to how they could
perform 300-500 laparoscopies in a single day when the
maximum possible was only 50 (The Daily, Dec.1,1984).
The depressing results of such callous operations is only
too well known through the case of the. eighteen deaths
in the Solapur PHC following laparoscopic sterilisations
and similar such reports.
The pressure of completing
,
targets can be seen through incredible figures of
acceptors shooting up at year ending by 4.4 million
(only for the period of the month of March, 1986) when
the average monthly figure of acceptors is 1.33 million
(The Daily, May 5,1986).
The Copper-T fraud of the
Maharashtra Government is only too well known.
/tribals
Disincentives for motivators in the form of
humiliation, punishment transfers, delays in salaries
as well as promotion, and sexual harassment can reach
dangerous limits when motivators as single women, sometimes
sole financial supporters for their families and living
in alien villages cannot fulfil the prescribed targets.
In March 1986, Manda Padwal, a female health functionary
(an ANM) in the Talasari PHC of Thane district committed
suicide after a reprimand and order from the doctor in
charge to sterilise twenty/(Barse,1986).
In November 1986,
thousands of primary school teachers from rural
Maharashtra gathered for two days in Nagpur and while
voicing other grievances clearly demanded for a withdrawal
of FP work (Date, 1986). 'Doctors attending the first
national conference on 'medico legal and social problems
in professional services associated with infertility and
fertility control' were critical of the government for
setting targets in the FP programme (TOI, Nov.10,1986) .
Hundreds of Haryana government employees are fighting
orddrs that force them to arrange voluntary sterilisations.
The new monthly target for a woman worker in Haryana is
four vasectomies, twenty IUDs and forty nirodhs. For
males the target is four vasectomies and a hundred
nirodhs each
(IE, Jan.16,1986).
The protests are
numerous.
The government has introduced the concept of
Net Reproduction Rate Unity (NRR-1) in its Family
Welfare Programme "..... after considerable experience
in this regard (need to control population growth, the
country has set before itself the long term demographic
goal of achieving NRR unity by 2000 AD, with a birth rate
of 21.0, death rate of 9.0 (life expentancy at birth
being 64.0 years) and infant mortality rate less than
60.0" (GOT, 1985, p.164).
Implicit forms of coercion;
The official acceptance of NRR-1 by the
government is especially sinister because in lay persons'
terms it spells that only one daughter should replace her
mother. Whereas the concept of NRR-1, is explicitly
coercive, the implicit meaning is dangerous for women
especially.
Female foeticide through sex determination ~r
sex selection is inbuilt in this strategy.
3
The government mak&s no bones about the fact
that inspite of Dr.Karan Singh's lofty slogan of 'Development
is the Best Contraceptive' at Bucharest in 1984, population
control is seen as a substitute for development.
Sarla
Grewal, the then Additional Secretary, Ministry of Health
and Family Welfare writes that "..... A reduction in human
fertility per se has to be regarded as an important component
of, if not an essential prerequisite for, socio economic
development.
To assume that socioeconomic development will
automatically bring about a reduction in fertility is perhaps
too optimistic to hope.
In any case, the country cannot
afford to wait for socio economic development to take its
course and show up its impact“(emphasis mine) (Grewal,1984).
Against this background it is not surprising
that maternal and child health services, female literacy
and employment opportunity, or child'survival are seen by
the State as the means to reduce population.
MCH and child
survival therefore get reduced to 'spacing methods' and
therefore most basic services such as ante, peri and post
natal care, immunisation or for that matter even primary
health care are covertly and overtly used as a screen to
achieve fertility control.
The Centre in an attempt to
create the Neighbourhood Big Brother decided to finance the
raising of 1.5 million strong corps of women volunteers to
catalyse the FP programme at grass roots.
The volunteers
would be mothers above 30 years of age wi-th not more than
two children each and would themselves be acceptors of FP.
To achieve NRR-1 by 2000 AD, each woman would, in rural and
urban areas, monitor sixty families (TOT, June 4,1986).
Targets and Primary Health Care
The integration of FP with primary health care
has had an adverse effect on the utilisation of the latter.
A substantial majority of the rural population utilises the
private practitioner in times of illness and the major
reason for nonutilisation of government services is the
absurd emphasis of the latter on FP (FRCH, 1987).
Women
still prefer to be delivered at home by traditional dais or
relatives one reason being that any contact with a woman in
peurperum is seized for FP.
For the same reason, many
children stay without immunisations.
The overshadow of the population control
programme over all other essential public health services is
naturally resented and feared by the poor.
With low access
to health services,, the public health services are the only
ones that most people can really afford for utilise.
Through
a worsening of access and utilisation to these essential
services, a double crime against the rural working class is
committed by those in power.
Those sections who require
health care most and who have little choice in choosing health
care facilities are prevented from utilising basic health
services that are in principle provided by the government for
the people.
They are denied what is rightfully theirs.
It is angering that public health services,
especially maternal and child services are used as a' bait
to lure people towards reducing population growth. K.K.
Pooviah, a member of the Central Council of Health and FW,
while writing about enforcing the two child norm, states
that the fourth Pay Commission had suggested a discontinuance
of maternity benefits to employees after the second child.
It had also been suggested to the various ministries that
K
while selecting beneficiaries under the poverty alleviation
schemes, preference be given to those who accept the small
family norm.
For instance, the agriculture ministry was
required to give FP acceptors preference in loans for buying
agricultural employment.
In all schemes of employment only
4
those who accepted the two child norm were to get training
or jobs (Pooviah, 1986).
Coercion and human relations:
The entire fabric <bf human relations is eroddd,
especially in rural areas due to motivational strategies.
Since health workers, petty bureaucrats and all government
employees are burdened with the completion of targets
throughout the year, most of their conversation with any
human being ends with FP motivation.
It is not a rare
scene when motivators pay from their own meagre salaries
or honoraria to escort 'eligible' individuals to the PHC
and on some occasions there are fist fights among
motivators over potential cases (FRCH, 1987).
Human
relations of motivators vis a vis the targets and amongst
motivators themselves are full of mutual mistrust and
contempt.
This hatred that the working class harbours for
their own kind helps the real oppressors to escape without
being questioned.
To the rural masses the only visible
oppressors are helpless motivators such as Manda Padwal,
and it then becomes easy to forget that she too is a victim
of the entire design of a coercive population control
programme.
This anger directed towards each other helps
the ruling classes through a divide and rule strategy.
Coercion thrives on the helplessness and the inability of
the unorganised oppressed sections to rebel and further it
breaks working class solidarity.
Choice versus coercion:
a
The concept of coercion is by definition based
on the concept of choice..
It is implicitly understood that
if coercion as we understand it, is absent, then people
are free to choose what they want.
It is therefore
necessary to discuss and debate whether choice in the form
that it exists today, allows for most people, even in the
absence of overt coercion, to make decisions regarding
their own lives.
The working class today have no choice except to
live in subeistance, they have no choice today to produce
those commodities which they need most, and neither do they
have the choice to decide in a socio economic vaccum as
to how many children they will have.
Working class women as a gender also suffer from
the unavailability of the above mentioned choices, but in
addition they have no choice regarding their own sexuality,
reproduction, child rearing and other family labour. For
instance, a woman does not have the choice to mother a
child outside of marriage and conversely, she does not have
the- choice to stay childless within marriage.
Her choice
is snatchedsway from her at either end: infact within
marriage a woman's control over her own sexuality is
markedly reduced.
Similarly, she does not have the choice to use or
not to use contraceptives or the type of contraceptive she
desires, nor does she universally nave the choice to
undergo abortion.
These decisions are often made through
the top down political structure.
5
The concept of 'choice' as we understand today
therefore is a capitalist concept, where in a 1cafetaria
approach' one can 'choose' from amongst the available limited
options. These options are seen as commodities and not as
active decisions to be.taken.
Thus we have the choice of
birth control which really means that women choose the lesser
evil among the available contraceptives when the family or
the state decides that she must not have a child.
The
tussle between the wage market and the family leave the
couple and especially the woman on a constant tight rope
walk about child bearing and on that shaky ground she makes
her 'choice' of pregnancy, contraception and abortion. In
the same context, with an enforced small family norm and in
a woman hating environment the woman 'chooses' to abort a
female foetus.
In the absence of the true freedom for the majority
of the people of the world to be able to make decisions
regarding their own lives, it is possible to narrow down the
horizon of choices in the very name of giving the right to
choose.
Thus along with the freedom of child survival come
motivations to use spacing methods for birth control. In the
same manner, sex preselection replaces sex determination
techniques under the guise of giving a woman the 'choice'
of pre-selecting the sex of her unborn child to 'avoid
bloodshed through the abortion that follows sex determination'.
In the absence of a thoughtful definition of choice, coercion
and choice do not as expected, stand poles apart from each
other, but ironically are separated from each other only by a
thin line.
★ ★ W A- ***********
References:
1.
Barse Sheela: The Afternoon Despatch and Courier,(A Report),
April 21, 1986.
2.
Date Vidyadhar: The Times of India (A Report), Nov.10,1986.
3.
The Foundation for Research in Community Health: NGOs in
Rural Health Care, Vol.II (under publication), Jesani
Amar, Gupte Manisha and Duggal Ravi, 1987.
4.
Government of India: Ministry of Health and Family
Welfare, /Annual Report, 1984-85 (1985).
5.
Grewal Sarla: In 'Population Policy in India', Compiled
by Gandotra M.M. and Narayan Das, Population Research
Centre, Baroda, pp.3-7 (1984).
6.
Pooviah, K.K.: The Times of India, Dec.13,1986.
A Discussion Paper on
"Targets and Coercion in the Family Planning Campaign"
Manisha Gupte
Target planning and coercion (directly during the
period of Emergency and indirectly through motivational
strategies) are integral components of the Indian Family
Planning Campaign. What needs discussion is whether target
planning or motivation for the 'voluntary acceptance1 of
the small family norm are well intentioned strategies of a
government that truly believes in its own goodness or
whether coercion in Family Planning (FP) is a reflection of
more basic maladies in society.
Though Mamdani (1972)
conclusively proved that motivation and coercion are not even
practically able to reduce population numbers, the Indian
Government has continued to base its FP programme through the
setting of targets,conveniently glossing over the socio
economic factors that are responsible for population grwwth.
Coercion, whether explicit or implicit, is
riddled with prejudicial biases, be they of gender,
nationality, class or ethnicity.
This explains why the
targets of population control programmes are the1’poor, the
coloured, the tribals, the dalits and their women.
Dumping
of dangerous contraceptives in Third World countries and their
testing on poor women without proper informed consent, the
selection of Puerto Ric'ns or Mexicans for sterilisation in
the United States or the distribution of a chicken alongwith
each shot of Depo provera in the Phillipines are examples.
The result of such biases can be genocidal when for instance,
tribals who are already a persecuted section are tricked into
mass sterilisations
(FRCH 1987).
Incentives and disincentives;
Explicit coercion in the Family Planning programme
in India can be seen in the form of incentives and disincen
tives to assure that the required targets are achieved.
Incentives, be they an extra portion of rations, a few
hundred rupees or a pair of new clothes can work wonders in
impoverished societies.
Ironically the leanest agricultural
period coincides with the financial year ending (the month
of March) when FP activity at the Primary Health Centre (PHC)
level has reached to hysterical proportions.
An incentive based FP programme can understandably
create distortions.
In North Arc c J 20,000 government
employees signed a pledge to observe 1985 as a 'childless
.
*
year
They pledged to register one lakh sterilisations'in
1984-85, doubling the number of operations from the previous
year
(The Hindu, Sept. 25, 1984) .
The Punjab government
introduced a raffle for a lakh of rupees as well as the
slogan 'Get sterilised and win'
(Indian Express,Jan.1,1985) .
Laparoscopes and their accesories have been exempted from
customs duty 'in view of the^growing popularity (sic) of
laparoscopic sterilisation among women1
During 1983-84,
80% of those sterilised were women
(Hindustan Times,
Nov.25,1984).
There was also a proposal by Mr.Krishna Kumar,Ex
Minister of State for Family Welfare, to give income tax
concessions to private sector companies who offered to set
up PHCs and who showed significant results in the FW
programme (The Times of India, June 26,1985).
I
2
The ridiculous emphasis on incentives not
surprisingly has also led to malpractice. A Bangalore
based doctor teas arrested in 1985 for issuing bogus
sterilisation certificates to 220 employees cSf the New
Government Electric Factory (NGEF).
The cash incentives
offered by the NGEF for vasectomies was Ps.1700 per
person (Deccan Herald, Jan.12,1985) .
Dr.Khandwala,
General Secretary of the Indian Association of Gynaecolo
gical Endoscopists criticised surgeons in mass
sterilisation camps and doubted as to how they could
perform 300-500 laparoscopies in a single day when the
maximum possible was only 50 (The Daily, Dec.1,1984).
The depressing results of such callous operations is only
too well known through the case of the.eighteen deaths
in the Solapur PHC following laparoscopic sterilisations
and similar such reports.
The pressure of completing
targets can be seen through incredible figures of
acceptors shooting up at year ending by 4.4 million
(only for the period of the month of March, 1986) when
the average monthly figure of acceptors is 1.33 million
(The Daily, May 5,1986).
The Copper-T fraud of the
Maharashtra Government is only too well known.
/tribals
Disincentives for motivators in the form of
humiliation, punishment transfers, delays in 'salaries
as well as promotion, and sexual harassment can reach
dangerous limits when motivators as single women, sometimes
sole financial supporters for their families and living
in alien villages cannot fulfil the prescribed targets.
In March 1986, Manda Padwal, a female health functionary
(an ANM) in the Talasari PHC of Thane district committed
suicide after a reprimand and order from the doctor in
charge to sterilise twenty/(Barse,1986).
In November 1986,
thousands of primary school teachers from rural
Maharashtra gathered for two days in Nagpur and while
voicing other grievances clearly demanded for a withdrawal
of FP work (Date, 1986).
Doctors attending the first
national conference on 'medico legal and social problems
in professional services associated with infertility and
fertility control’ were critical of the government for
setting targets in the FP programme (TOI, Nov.10,1986).
Hundreds of Haryana government employees are fighting
orddrs that force them to arrange voluntary sterilisations.
The new monthly target for a woman worker in Haryana is
four vasectomies, twenty IUDs and forty nirodhs. For
males the target is four vasectomies and a hundred
nirodhs each
(IE, Jan.16,1986).
The protests are
numerous.
The government has introduced the concept of
Net Reproduction Rate Unity (NRR-1) in its Family
Welfare Programme "..... after considerable experience
in this regard (need to control population growth, the
country has set before itself the long term demographic
goal of achieving NRR unity by 2000 AD, with a birth rate
of 21.0, death rate of 9.0 (life expentancy at birth
being 64.0 years) and infant mortality rate less than
60.0" (GOI, 1985, p.164).
Implicit forms of coercions
The official acceptance of NRR-1 by the
government is especially sinister because in lay persons'
terms it spells that only one daughter should replace her
mother. Whereas the concept of NRR-1, is explicitly
coercive, the implicit meaning is dangerous for women
especially.
Female foeticide through sex determination -r
sex selection is inbuilt in this strategy.
3
The government makes no bones about the fact
that inspite of Dr.Karan Singh's lofty slogan of 'Development
is the Best Contraceptive' at Bucharest in 1984, population
control is seen as a substitute for development.
Sarla
Grewal, the then Additional Secretary, Ministry of Health
and Family Welfare writes that "..... A reduction in human
fertility per se has to be regarded as an important component
of, if not an essential prerequisite for, socio economic
development.
To assume that socioeconomic development will
automatically bring about a reduction in fertility is perhaps
too optimistic to hope.
In any case, the country cannot
afford to wait for socio economic development to take its
course and show up its impact"(emphasis mine) (Grewal,1984).
Against this background it is not surprising
that maternal and child health services, female literacy
and employment opportunity, or child survival are seen by
the State as the means to reduce population.
MCH and child
survival therefore get reduced to 'spacing methods' and
therefore most basic services such as ante, peri and post
natal care, immunisation or for that matter even primary
health care are covertly and overtly used as a screen to
achieve fertility control.
The Centre in an attempt to
create the Neighbourhood Big Brother decided to finance the
raising of 1.5 million strong corps of women volunteers to
catalyse the FP programme at grass roots.
The volunteers
would be mothers above 30 years of age with not more than
two children each and would themselves be acceptors of FP.
To achieve NRR-1 by 2000 AD, each woman would, in rural and
urban areas, monitor sixty families (TOI, June 4,1986).
Targets and Primary Health Care
The integration of FP with primary health care
has had an adverse effect on the utilisation of the latter.
A substantial majority of the rural population utilises the
private practitioner in times of illness and the major
reason for nonutilisation of government services is the
absurd emphasis of the latter on FP (FRCH, 1987) .
Women
still prefer to be delivered at home by traditional dais or
relatives one reason being that any contact with a woman in
peurperum is seized ..for FP.
For the same reason, many
children stay without immunisations.
The overshadow of the population control
programme over all other essential public health services is
naturally resented and feared by the poor. With low access
to health services, the public health services are the only
ones that most people can really afford for utilise.
Through
a worsening of access and utilisation to these essential
services, a double crime against the rural working class is
committed by those in power.
Those sections who require
health care most and who have little choice in choosing health
care facilities are prevented from utilising basic health
services that are in principle provided by the government for
the people.
They are denied what is rightfully theirs.
It is angering that public health services,
especially maternal and child services are used as a bait
to lure people towards reducing population growth. K.K.
Pooviah, a member of the Central Council of Health and FW,
while writing about enforcing the two child norm,: states ,
that the fourth Pay Commission had suggested a discontinuance
of maternity benefits to employees after the second child.
It had also been suggested to the various ministries that
while selecting beneficiaries under the poverty alleviation
schemes, preference be given to those who accept the small
family norm.
For instance, the agriculture ministry was
required to give FP acceptors preference in loans for buying
agricultural employment.
In all schemes of employment only
4
those who accepted the two child norm were to get training
or jobs (Pooviah, 1986).
Coercion and human relations;
The entire fabric Of human relations is eroddd,
especially in rural areas due to motivational strategies.
Since health workers, petty burcadcrsOts and all government
employees are burdened with the completion of targets
throughout the year, most of their conversation with any
human being ends with FP motivation.
It is not a rare
scene when motivators pay from their own meagre salaries
or honoraria to escort 'eligible1 individuals to the PHC
and on some occasions there are fist fights among
motivators over potential cases (FRCH, 1937).
Human
relations of motivators vis a vis the targets and amongst
motivators themselves are full of mutual mistrust and
contempt.
This hatred that the working class harbours for
their own kind helps the real oppressors to escape without
being questioned.
To the rural masses the only visible
oppressors are helpless motivators such as Manda Padwal,
and it then becomes easy to forget that she too is a victim
of the entire design of a coercive population control
programme.
This anger directed towards each other helps
the ruling classes through a divide and rule strategy.
Coercion thrives on the helplessness and the inability of
the unorganised oppressed sections to rebel and further it
breaks working class solidarity.
Choice versus coercion;
The concept of coercion is by definition based
on the concept of choice.
It is implicitly understood that
if coercion as we understand it, is absent, then people
are free to choose what they want.
It is therefore
necessary to discuss and debate whether choice in the form
that it exists today, allows for most people, even in the
absence of evert coercion, to make decisions regarding
their own lives.
The working class today have no choice except to
live in subsistence, they have no choice today to produce
those commodities which they need most, and neither do they
have the choice to decide in a socio economic vaccum as
to how many children they will have.
Working class women as a gender alsb suffer from
the unavailability of the above mentioned choices, but in
addition they have no choice regarding their own sexuality,
reproduction, child rearing and other family labour. For
instance, a woman does net have the choice to mother a
child outside of marriage and conversely, s.he does not have
the choice to stay childless within marriage.
Her choice
is snatched«way from her at either end; infact within
marriage a woman's control over her own sexuality is
markedly reduced.
Similarly, she does not have the choice to use or
not to use contraceptives or the type of contraceptive she
desires, nor does she universally nave the choice to
undergo abortion.
These decisions are often made through
the top down political structure.
5
The concept of 'choice' as we understand today
fherefore is a capitalist concept, where in a 'cafetaria
approach' one can 'choose' from amongst the available limited
options.
These options are seen as commodities and not as
active decisions to be taken.
Thus we have the choice of
birth control which really means that women choose the lesser
evil among the available contraceptives when the family or
the state decides that she must not have a child.
The
tussle between the wage market and the family leave the
couple and especially the woman on a constant tight rope
walk about child bearing and on that shaky ground she makes
her 'choice' of pregnancy, contraception and abortion. In
the same context, with an enforced small family norm and in
a woman hating environment the woman 'chooses' to abort a
female foetus.
In the absence of the true freedom for the majority
of the people of the world to be able to make decisions
regarding their own lives, it is possible to narrow down thd
horizon of choices in the very name of giving the right to
choose.
Thus along with the freedom of child survival come
motivations to use spacing methods for birth control. In the
same manner, sex preselection replaces sex determination
techniques under the guise of giving a woman the 'choice'
of pre-selecting the sex of her unborn child to 'avoid
bloodshed through the abortion that follows sex determination'.
In the absence of a thoughtful definition of choice, coercion
and choice do not as expected, stand poles apart from each
other, out ironically are separated from each other only by a
thin line.
* ★ *,V ★
******
References;
1.
Barse Sheela; The Afternoon Despatch and Courier,(A Report),
April 21, 1986.
2.
Date Vidyadhar; The Times of India (A Report), Nov.10,1986.
3.
The Foundation for Research in Community Healths NGOs in
Rural Health Care, Vol.II (under publication), Jesani
Amar, Gupte Manisha and Duggal Ravi, 1987.
4.
Government of India: Ministry of Health and Family
Welfare, Annual Report, 1984-85 (1985) .
5.
Grewal Sarla; In 'Population Policy in India', Compiled
by Gandotra M.M. and Narayan Das, Population Research
Centre, Baroda, pp.3-7 (1984).
6.
Pc-oviah, K.K.: The Times of India, Dec. 13, 1986.
CONTRACEPTIVE CHOICE ; SAFETY VS EFFICACY.
(Background paper prepared for the XIII Annual Meet of MFC,Jan 1987) .
- Sathyamala
There is a general belief that contraceptives reduce maternal morta
lity rates considerably.
Statements such as -
"Like all medicines, birth control pills occasionally cause
serious problems in certain perons.... Of the 15,000 women who
become pregnant, 75 are likely to die from problems of pregnancy
or child birth; of the 15,000 women who take the birth control
pills only one is likely to die from problems related to having
taken the pill.
Conclusion:
It is much safer to take the pill
than to become pregnant.11
are made to highlight what a boon the modern day contraceptives are
to the procreating women.
Even when attempts are made to discuss
complications or mortality rates in relation to contraceptive methods,
they are usually rationalised as "..It may be emphasised that though
the mortality of interval sterlization is much higher than that of
post partum sterlizations, the mortality of either of the two proce
dures is much lower than the maternal mortality for this country
(India) which is the risk the patient (emphasis added) would be
exposed to if she were not sterlized."
(2). Complacency is also
expressed in statements like-contraceptive 'X' has no life threaten
ing side effects and therefore it is safe.
The underlying assumption
in all these statments is that the contraceptive methods that are
currently being promoted are far safer than the 'risk1 of becoming
pregnant.
While it may be true that child bearing adds a certain risk to the
woman population, it becomes a definite risk in only those population
which has an already high overall
mortality rate : and it is the
purpose of this paper to present the hypothesis that while contrace
ptive use may theoretically decrease the possibility of pregnancyrelated deaths,
the quantum of morbidity it produces is far too high
to justify its wide use in developing countries where the very
factors responsible for the high maternal mortality rate would lead
to an increase in mortality due to contraceptive use as well.
Morbidity load due to the currently available female methods of
contraception:
An estimate of the probable morbidity load can be made on the basis
of the data available on the incidence rates of complications arising
from the use of contraceptive methods.
The morbidity rates have been
calculated on the number of acceptors in 1980-81.
-2No. of women
No. of accep
tors in 1980-81 who would
have suffer ■
ill health
Con traceptive
method
Morbidity
Incidence
lUCDs
Bleeding
and pain
10-15/100
users
PID
10/100
users
II
60,000
Infertility 10/100
users
II
60,000
6,00,000
Ectopic
pregnancies 0.8 to 4% of
method failure
Tubectomy
60,000 to
90,000.
tl
240 to 1200
Spontaneous 50% of method
abortions
failure
It
15,000
Perforation 1/2500 users
of uterus
II
240
Post op.
menorrhagia 5.1%
Pelvic
infections
1,550,000
II
12.42/1000
79,050
19,251
Total morbidity due to these two methods
; 293781
Total number of acceptors
s 2150000
Morbidity rate due to these two methods
s 137/1000 acceptors
Morbidity rate due to IUCD alone
s 326-377/1000
acceptors
(ref No.3)
The incidence rates used in these calculations are probably an
underestimation of the actual incidence in rural areas.
lations have also not taken into account
The calcu
the total morbidity
subsequent to contraceptive failure. It should be noted that the
complication rates for tubectomies are from surgeries, performed in
The incidence rates in the field situation ie.
teaching hospitals.
Primary Health Centres and FP Camps would probably be much higher
than the ones quoted.
The morbidity due to oral pill use was not included in the table
because the acceptance and the continuation rate for oral pill use
in India has generally been very low.
Infact it is so low that oral
pill use rate is not included in the assessment of eligible couple
protection rate.
In 1983, to overcome the problem of the non accep
tance of the pill,
the Health Ministry came up with the bright idea
of distributing the pills through the Village Health Workers.
This
plan was dropped later because of the opposition from the Indian
Women's Scientists Association on the grounds that such a plan would
neither be safe nor effective.
However from the report of the
‘Revised Strategy for National Family Welfare Programme1, it appears
that there are definite plans to expand the use of the pills through
-3social marketing and by using a new cadre of workers, the'Village
Level Women Volunteers Corps'.
Reports have also come from several
parts of the country that this new cadre has swung into action and that
the pill is being promoted through .the door to door sales technique.
I
An even more worrying aspect of the strategy is for the first time an
official policy states “acceptance of oral pills in rural areas can
be expanded if medical consultation is not prescribed."(4)
The potential morbidity and mortality due to oral pill use should this
scheme become successful can be seen from data available from other
countries.
The following table presents the episodes of hospitalization
and mortality rates in a group of oral pill users from UK.
Serious side effects associated with the use of
combined oral contraceptive.
Side effect
Excess morbidity and mortality per year
Deaths____ _
Diagnosis
Hospitalizations
Stroke
31
35
9.7
Deep Vein Thrombosis
or Pulmonary Embolism
91
Superficial or unspeci
fied thrombosis
125.
70
3.4
Heart attack and other
non-rheumatic heart Dis.
17
17
8.0
Gall bladder Disease
(surgically confirmed)
79
79
-
Kidney Infection
383
-
-
Benign liver tumor
1
1
0.1 .
Hypertension
406
-
1.7
Total
1133
202
22.9
(Ref. No. 5)
This data indicates that "one out of every 500 pill users are hospita
lized annually due to serious side effects caused by this method. An
estimated one out of every 5000 users die annually from pill caused
strokes,
thromboses and heart attacks... roughly two thirds are among
smokers and one third among non smokers".(5)
It is generally alleged that these risks do not apply to Asian Women
because they do not have the same problems if heart attack and throm
botic disease.
This assumption is unfounded because according to the
ICMR report of 1981,.Available data on Indian women with CVD(cardio
vascular disease) show that though their .lipid levels were higher- than
the normal Indian women,
the levels were far below their Western
counterparts".(6) and concludes that epidemiological studies arc needed
to confirm if Indian women using oral contraceptive might be at a lower
risk of developing CVD. Epidemiological studies from Hong Kong have
-4shown that .there has been an increase in heart ailments among women
between 1969-75 or since the pill was introduced..
If the pill progra
mme indeed becomes successful one could still expect complacency
because Indian women especially from the rural areas will neither be
diagnosed nor hospitalized to the same extent as their British Counter
parts for obvious reasons.
But one can say with surety that should
the programme become successful the mortality and morbidity rate in
women users under unsupervised conditions will be very high.
A recently released report (1982) from the Centre of Disease Control
USA has shown that for the first time in the USA contraceptive-
related deaths outnumber pregnancy - related deaths.
This could
very well be the situation in India if the trend towards pushing
even more hazardous contraceptives persist.
The report of the 'Revised Strategy for National Family Welfare
Programme'makes its intentions very clear.
Under 'Family Planning
—
Research' it states
"New technologies like injectables,
sub-dermal implants,etc,
are currently undergoing trials before introduction in the
programme.
The procedures and the protocols and the time
scales of induction of new technologies will be revised to
enable faster introduction of such technologies in the
programme."
"Development of simple,
reversible,
safe and
long acting contraceptives such as the anti-fertility vaccine
would seem to offer great potential.
Research efforts in
developing such a vaccine will receive high priority."(7)
Anyone with even a rudimentary knowledge of the mechanism of action
of these methods would know that the complications arising out of
their wide-use will be of a magnitude never witnessed before in
contraceptive history.
"
An added problem with these contraceptives
is that the morbidity and mortality risks will not be confined to
the women alone but is going to be extended to their progeny as well.
The question that gets posed is why then this strange attachment to
hazardous contraceptives when available data already indicates that
they are a definite threat to women's lives.
This is when the red
herring in the form of "effectiveness" is thrown up to confuse every
one.
It is stated that more and more invasive a method is bettor and
better is its effectiveness because it will act at so many levels
that conception will not stand a chancel
The following taolu shows that if one compares the lowest observed
failure rates for the currently available methods, the effectiveness
is almost similar.
-5-
Lowest observed failure rate(%)
Method
Tubal sterlization
0.4
Vasectomy
0.4
Combined pills
0.5
IU3
1.5
Condom
2
Diaphragm with spermicide
2
Cervical cap
2
Fertility awareness
2 -20
(Ref. No. 8)
That means that theoretically at least in a well'controlled'
situation the effectiveness of invasive contraceptives are very
similar to the non-invasive barrier methods.
The problem comes
when effectiveness is discussed in terms of actual use.
For instance
if a woman takes the pill everyday and does not miss ever? once then
the theoretical effectiveness would apply to her.
But in a real
situation in a group of pill takers the effectiveness would be
influenced by the irregularity or the regularity with which each
member takes the pill.
from 5 (IUD) to 10
Hence the actual failure rate can range
(Condom) to 19
(Diaphragm).
This is what the
population experts are really concerned about! the performance of
a method in a population which they may not be able to "control”.
Hence the attachment to invasive methods which hopefully will not
be affected by the vagaries of human nature.
The medical establishment however rationalises in a different way
the need for a method whose theoretical use comes closer to the
actualise.
It is argued that if the failure rate is high with
contraceptive use, the women accepting a method with the high
failure rate would continue to run the risks of pregnancy. A com
parison of cumulative risk of deaths associated with fertility
control methods which includes both maternal deaths susequent to
contraceptive failure and method-related deaths show that despite
the additional risk of high failure rates, condoms backed by abortion
is the safest method available.
Cumulative Risk of Death Associated with Fertility Control Methods
(per 100,000 nonsterile women)
Method
15-34
35-39
40-44
15-44
Pill/smoker
Pill/nonsmoker
Rhythm
Diaphragm/spermicide
IUD
Abortion
Condom
C on dom/abortion
No method
132
21
36
28
25
26
19
1
192
257
70
14
11
10
. 9
2
1
129
588
160
18
14
10
6
2
1
141
977
251
68
53
45
41
23
1
462
(Ref. No.9)
-6-
It is obvious that if a Family Planning policy is really concerned
with the health of the women,
then it would stop viewing hysterically
the possibility of an inadvertant pregnancy due to contraceptive
failure as a national disaster.
Till such time it does that, the
attempt of the population controllers will be to develop methods
which tend towards the mythical 100% effectiveness leaving the
concept of safety to the four winds.
The question that remains to be answered is - is pregnancy really
such an enormous risk that the wide use of hazardous contraceptives
can not only be justified but should in fact be promoted in the
In this context it must be remembered that
interests of women?
while comparing mortality and morbidity risks in contraceptive use
and pregnancy there are two different populations at risk.
Only
women who become pregnant can die of pregnancy related causes.
A much larger number of women is at a risk of death from contrace
ption related causes,
and this population would have already faced
the risks of becoming pregnant before they accept a method.
Finally
it must also be remembered the complications arising from contra
ceptive use are generally long-term effects and could lead to
permanet disability.
Notes and References a
1.
"Where there is no doctor",Indian adaptation, by Sathyamala,VHAI.
2.
ICMR Bulletin,June 1982, P 59.
3.
(a)
Incidence Rate(IR) for bleeding and pain,‘Contraceptive
Technology,
1986-1987,1
13th Revised Edition,
Irvington
Publishers, p 202.
(b)
IR for PID,'Population Reports,
p. B-121,
'Series B, No.4,July 1982,
"Other recent studies in developed countries have
found the relative risk of developing PID ranges from 1.5
to 10 for IUD users." I have takenthe higher figure because
in developing countries it must be higher than this.
(c)
>
(d)
IR for infertility, population Reports, Series B, No.4,July
1982, "Thus ectopic, pregnancy or infertility may occur even
after only one episode(of PID in the fallopian tubes)"
IR for ectopic pregnancies, Population Reports, Sereies B,
No.4, p, B-125.
(e)
IR for spontaneous abortions, Population Reports, Veriest,
No. 4 p. B 124.
"About 50% of uterine pregnancies spontaneous
abort if the device is not removed". In some studies over
. half of the spontaneous abortions inlUD
users is in second
trimester and a spetic second trimester abortion is 26 times
more likely in women with an IUD in place.
in actual users of IUD is 5/100.
The failure ir.te
-7(f)
IR for perforation of uterus, Contraceptive Technology,
1986-1987, p 208.
£g)
IR for post op. menorrhagia and Pelvic infections,
ICMR
Bulletin June 1982, p 59.
4.
"Revised Strategy for National Family Welfare Programme, "
GOT. 1986
5.
(?) p. 6.
"Contraceptives and Developing Countries : the role of-Barrio
Methods," Bruce and Schearer,
International Symposium on
Research on the Regulation of human fertility, Sweden, Feb.1983
p 407.
6.
7.
ICMR Bulletin, Dec. 1981.
"Revised Strategy for National Family Welfare Programme,-"
GOI 1986 (?), p 123.
8.
9.
Contraceptive Technology,
"Out look", Vol 1, No.
1986 - 1987, p 102.
3, Sept. 1983, p 4, Figures adapted
from Oxy of the US Centres of Disease Control.
A contribution to the discussion :
T.B. and society
— B.K. Sinha.
The writer wishes to unite with other participants in under
standing and taking the necessary steps leading to the elimination
of T.B.
Although significant strides in medical science has under
lined the fact that almost every body has a chance of winning the
battle of life and health against T.B., yet is continues to take a
heavy toll of men in productive age.
The situation is worse in
countries like India.
Technical and scientific mastery over the disease and people
is a reality of our social
succumbing to it, often helplessly,
life.
This phenomenon,
a unity of opposites.
like every thing that exist in nature is
All things contain two contradictory aspects
and have contradictory, mutually exclusive, opposite tendencies,
constantly struggling against and getting transformed into each
other, leading to the dissolution of the phenomenon i.e., resolut
ion of the contradiction and transformation thereby of the
phenomencn itself.
We must therefore ask the question; why do people succumb
to T.B., in a situation in which it is claimed that the drugs
have been discovered to eliminate the disease ? Is the claim
unreal ? Is the treatment and drugs with which to eliminate the
disease do not reach those who cuccumb to it ? or, are there
inadequacies which are being ignored ?.
Let us go into these questions further.
The claim of mastery
over the disease presupposes that the 'causes leading to the disease
are fully understood and that all of them are accounted for in
the treatment leading to its cure.
But bodily process are-
understood in a number of narrowly defined and distinct terms
like biochemistry, neurophysiology.etc. and no unifying theory has
been put forward in medicine that interrelates all these ways
of looking at human organism.
Besides, the very instruments
we use can impose a limitation on the kind of information we
can obtain.
Moreover, with the advances in science, unknowabi-
lity has become a factor in complex computation.
In view of
all this it may not be scientific enough for a scientist to
point physical cause of the disease.
On the other hand, there is growing awareness to define
health as a state of physical, mental and emotional well being
rather than a mere absence of disease and infirmity.
It means
that any thing that distrubs the harmonious functioning of
physical,.mental and emotional functioning of life should be
considered as a cause of disease.
It is therefore easy to see
that the greatest source of such imbalance lies in the relation
:
2 ;
that men enter into with ether men in the society in the process of
production and exchange cf material and spiritual values necessary
for man's existence and growth.
It is this relationship which is
at the roots cf the needy and the sick not getting the treatment
and cure : the reality of cur social life.
Various aspects cf the reality of cur social life have been
sufficiently debated and desribed from various angles providing
quite a lot cf information.
Some of them is given below:
- Most of the people are forced by the circ*mstances to live in
extreme poverty.
- Govt., policies concerning handicrafts and small scale industry
is such that most of them must keep ccnsuption or wages at the
lowest failing which they must go bankrupt.
- "he percentage of Govt., expenditure on public health and other
services cf public utility has been declining.
It means that
fewer and fewer people are in a position of availing these facili
ties.
It means that those able to avail these facilities must
have links with the rich and the powerful or must have sufficient
means to bribe the authorities.
The other part,
services from the private institutions and
professionals are prohibitively costly and ruinous to the people.
- Taxes by the provincial as well as the Central Govt, has been
increasing and theratio cf direct tax to the indirect tax has
been decreasing.
It means that the poorer ones are more heavily
taxed forcing them further deep in poverty and want.
- Drug manufacturing companies are extremely exploitative and
profit oriented and go to any length for profit including the
advertisem*nt and sale cf useless and harmful drugs at exherbi-
tant price.
And in this the Govt., often lets them do what they want.
If we look more closely then we find that all these aspects
of the reality are interrelated and that they together serve the
interests cf those who control the means cf production either
through individual ownership or through the Govt.
This ought to
give rise to another question : is it possible that the claim
that science has advanced to such an extent that a disease called
T.B., has been conquered and therefore no one need succumb to it
is put forward to serve this very interest ?
It seems to be so.
Otherwise, the reality cf the disease having been conquered and the
disease taking its toll cannot exist side by side.
This drives us to a conclusion that on the one hand we should
look into the very claim critically, i.e., whether or not the claim
cf having discovered the remedies for cure of T.B., is correct;
and on the other hand lock for an alternative system of cure
which will not suffer from the same antimony i.e., which all can
get if they so desire.
Another conclusion underlines the need of
s
3 :
waging a struggle against the social reality in which people
succumb to such disease which are thought to be curable.
This should also be kept in min-'', that any single work of the
above outlined can achieve its objective in isolation from the
rest; all the three must go together to give the desired result.
hom*oeopathy seems to offer the solution.
It not provides a
frame work for locking into the claim critically, i.e., whether
or not the remedy for T.B., has been discovered leading to its
elimination but it holds the premise of making the remedy universa
lly available in terms of cost.
And what's more, it can be a tool
in the hands of the people struggling against the exploiters by free
ing the people and the centry's economy from the chains of exploitab
le n to a great extent.
As manufacture of these drugs does not
require such technology in which monopoly can be established lead
ing to super prefit and monopolistic exploitation.
But it is not only on these ground that this system of
treatment is being recommended.
Important though these grounds
are, but in the context of treatment, its recommendation rests
primarily on its effectiveness in practice.
Many case can be
cited to demonstrate the effectiveness cf this treatmen but I
cite only two examples :
1.
Mrs. S.K.Suman Khcnkar,
40 year old,
from Scnegaon Wardha,
came to Dr. Bhongade with following complaints:
Buring in throat, dry cough,
ion,
amelioration with cold applicat
feverish, rigour of chill, recurrent coryza, pain in
chest, both apex, more in left with pain in back, left side
at the region of scapula, stitching and ulcerative pain,
agg. slight cold,
sour food,
slight air current, amel.
salt water gargling, tea, lying down, hot application,
pain in chest aggravating while coughi.ng, weakness with
trembling of whole body agg. at morning, ame'l. after eating;
Rhumatic trouble, pain in lumber region, at circ*mscribed spot,
both sides, more in the left side, aggr. during sleep, touch,
changing sides,
pain in legs,
amel. hot application; spasm and rhumatic
agg. sitting, during sleep; amel. hot applicat
ion. Burning pain in soles,
eyes, cracks in soles;
Thirst : more than normal.
Sleep ; disturbed easily, sleepless for 2 hrs. after 2-3 am.
dreams :
fearful, weeping during sleep.
History cf profuse
menses, presently having early mensfcs after 3 weeks lasting
for 4 days, clots, intermingled with red blood.
Lukeria : milky and thick, after loop insertion.
Had suffered from T.B two times, both lungs were affected.
Uncle too- had T.B.
Children very succiptible to cold and coryza, lasting for long.
4.
Physian's observation ; lean and thin,
Temp. 98.5; Pulse 88 ; B.P. 110 - 60.
Weight : 41 Kg. on 11.9.'81.
She came to the Doctor on 9.10.'80
Treatment : Phosphorus 200
1 close .
Bleed and Sputam tests on 14.10.'80 indicated :
Blood :
59
H.B.
P.
51
L .
46
E.
9600
T.L.C.
Sputam : A.F.B. Positive.
Treatment :
18.10.'80.
phosphorus 200
1 dose
II
II
1 . 11.
26.11.
Complained loose motion
Aloes 200
3 doses.
30.11.
Aggravation of cough, sleepless after
3 - 4 am., no remarkable change
Phosphorus 1 rn
1 dose
13.12
More cough, harshness, pain in chest,
tickling in throat.
Rumex 200
1 dose.
16.12
17.12
II
II
Constipation,
ineffectual urging
Nux Vomica 200
6 doses
30.12
Cough aggravated, tickling in threat,
pain in abdomen and chest
Phosphorus Im.
1 dose
15.1.'81.
Cough reduced. Pain in left leg,
constipation, ulcerative in vagin*,
sensitive to cloth
Phosphorus Im
1 dose
13.3.
Teeth ache, cough
Phosphorus Im 1 dose
1 .7.
Feels better
Phosphorus
Im
1 dose.
18.7.
Cough agg. tickling in throat
Kali carb. 200.
11.8.
Kali carb.
20.8.
Feels better, back ache, cough day time
Sujbphur 200
19.9.
Alrcund improvement
Sulphur im
1 dose.
Improvement continues.
200.
The patient is cured.
Blood and sputam test were done in the meantime, on 16.4.'81
Blood :
H.B.
P.
L.
E.
T.L.C.
56
56
41
3
11200
Sputam s
A.F.B. Negative
Even after the cure, the patient was given globles for
some more time.
. .
5
I',; tc i;)
*»/VJ
.1,.'
.
: 5 :
2.
The ether example is from Mozari, a village in Amravati
District. Ratnamala Tat Sheika,
38 year old, came to Dr.Gumble with
following complaints ;
extreme weakness, cough, white sticky but easy expectoration,
aggravation of cough after delivery and in the summer,
burning during urination, urine yell w, worms in stool, un
satisfactory motion, loss of appetite, continious feverishness,
thirst, sweat on chest,
face and head, regular 5 day menses.
Had been treated tor T.B. before.
Physician's observation ; lean and thin,
Treatment :
26.5.'84. Nitrum sulph
slow.
3 doses
200
1 .6.
Rhustox 30
3 .6.
feels better
Tubcrculinum 200
4 times daily for 2 days
3 doses
29.6.
Improvement continues
Tubcrculinum 200
14.7.
Complains of cold, loose motion
Nitrum sulph
30.8.
30.11.
lm.
Complains subsided
Tuberculinum
lm.
3 doses
3 doses
feels much better, -put on weight, cough,
feverishness, weakness reduced.
Nitrurn sujbph 1000 3 doses.
Blood test shows the reduction of Esnophelia
and increase of Hemoglobin
The patient is almost cured but the treatment is
continuing.
There are many more case histories of treatment that can be
cited for the proof of effectiveness of this treatment.
But the
difficulty is that pathological tests have not been done and there
fore the kind of proof that is demanded from them is not available.
And the reason for this lack of pathelogical test is that hom*oe-
paths following the logic of hom*oeopathy do not believe in
pathelogical tests.
Moreover, these two case histories will reveal the difference
of medicines given to patients.
The reason is that hom*oeopathy does not believe in entities
called disease (S).
It treats patients'
totality of symptoms
rather than a small group of them which give rise to such entities.
After all, they merely represent an arbitrary selection of certain
manifestations of illness that appear together with a certain degree
cf frequency.
Prescribing in hom*oeopathy is solely based on actual
observation cf the effects cf hom*oeopathic medicines on healthy pers
ons.
Such observations define the range of the action cf the medi
cines and provide all the information needed to help select a proper
remedy for an individual patient.
But this does not mean that the
suitable medicine for the symptoms categorised as T.B. could be any
one from some 2000 odd proved medicines listed in Materia Medica.
6
: 6 .
Paradoxical though it may sound, but there are nearly 20 medicines
from which the most suitable medicines for most patients can be
selected depending cn peculiarity of symptoms in individual cases.
Then there is a ncscde, Tuberculinum, which is found to be
helpful in many cases when there is a history of infection either
in the individual patient or in his parents.
Although routine
prescribing of the nosodes along isopathic lines is not consider
ed to be good hom*oeopathic paactice, it can be of great help.
It
can be used not only to break up the lingering effects of the
disease, but also to reach deep into the constitutional pattern of
a patient and clear a chronic miasm that may have been implanted
long before through exposure.
It builds body 'resistance against
the disease.
hom*oeopathic treatment holds a great promise for the suffer
ers and those interested in removing the causes of suffering but
ft.
all this lies buried in the heaps of abuse and ridicule against
hemoeopathy.
It is true that advocated of hom*oeopathy and hom*oeo
paths themselves provided some basis for it,
and did almost nothing
to counter and expose the abuse and ridicule, most of which is
motivated not by science but by counter-science.
But neither evidence
nor logic has been put forward to refute the basic premises of
hom*oeopathy.
On the contrary,
fresh insights have been gathered
from laboratory experiments to uphold the effectiveness of the
system and cure.
Science is defined as "the cognition of necessity".
prime task, therefore,
Its
is to investigate and analyse the needs of
the society and to pave the way for its fulfillment.
The signifi-
a
cance of a scientific discovery depends solely upon its importance
to society in the context of its needs,
towards its needs.
and the society’s awareness
But the social needs and its awareness often
depends on the recognition of the class in power.
It is they who
decide what constitutes social needs and use the resources under
their command to fulfill it.
If their policies produce such results
which are contrary to the social needs then it reflects a stage of
development of the society in which the ruling class in existence,
its ideas and theories,
its forward march.
live.
its '
science 1
cannot lead the society in
This precisely is the situation in which we
In such a situation,
the essence of science consists in
taking the theory forward by basing itself firmly on such experience,
Such data obtained in pracice which articulate and meet the social
need in a better way but are not considered 1scintific1
ruling ’science’
take up.
of the day.
enough by the
It is a task that society will have .to
My submission is that hom*oeopathy should be examined in this
context, I hope, M.F.C. will come forward in doing the needful.
OoO
B.K. Sinha,
C/o Dr. M.N. Gumble,
Gurukunj Ashram,
Dist. Amravati, Pin : 444902.
Jan 20th 1985.
xus-kCLi-XOCRAMME
:some problems and issues;
Binayak Sen, C'-'SS, Dalli Rajhara, MP 491228
1. conceptual problems
IN THUR seminal 1962 paper on symptom awareness in
tuberculosis, Banerjee and Anderson, re-emphasized the
probelm of tuberculosis as a problem of human suffering,
and outlined a strategy for tuberculosis control based on
this concept. This strategy, abjured a policy of active case
finding. Instead, it concentrated its attention on greater
diagnostic sensitivity towards and adequate treatment for
those people . uffering from symptoms suggestive of tuberculosis
who presented themselves at the existing hospitals and clinics.
Together with the Madras chemotherapy Centre study on domiciliary
treatment, it forms the theoretical basis of our present day
tuberculosis programme.
THE CREDIBILITY of this system rests on the adequacy
with which the entire range of presenting symptoms is
handled. The logical corrolary of the adoption of this approach
would, therefore, be the dev. lorment of an integrated and
well-defined system for tackling the entire range of tuberculosis
symptomato1ogy.
INSTEAD, THE National Tuberculosis programme has set its
sights on a Mirage - the interruption of bacterial transmission.
To this end, it defines a'case' of tuberculosis as. a person
excreting tubercle bacilli, in his sputum. This approach is
unscientific because it is only at a much later stage along
the exponential curve of falling prevalence that the interruption
of transmission becomes even a remote possibility. It also
ignores the fact that never in the history of human tuberculosis
has a reduction in transmission been brought about by a
specifically medical intervention.
AS A result of my four yc?rs experience of working in
voluntary institutions participating in district tuberculosis
control programmes - in Hoshangab.ad and in Durg - I am familiar
with the way in which this approach works in practice. A person
who presents himself at a Public Health Institution with symptoms
suggestive of tuberculosis is not regarded as a person suffering
from a disability and consequently in need of help but simply
as an entity to be categorised, ie., TB or not TB. After a
cursory physical examination he is sent for a sputum test. If
he obliges by producing a positive sputum, that is the end of
the matter. Ho can then be placed on a standard treatment
regime (gr-n-z-ni 1 y inh and Thiaoetazono daily) and forgotten
about. Once in a way his sputum may be checked but the treatment
regime is not affected thereby. I have .documented evidence
of patients, sputum .positive after a year1s treatment with INH
and thacetazonc, being continued on the same drug. When challenged,
the government doctor has explained, "that is the only regime
available". In point of fact, in practice this is often true.
BUT WE will come to problems of chemotherapy later. The
point I am trying to make is that from the point of view of
of a desperately sick man, frightened by a dreaded diagnosis,
it is cold comfort to be given 30 tablets nnd told to come
back again after a month's treatment and assured that he will
get well in 18 months time. This is particularly so since
A note prepared for the mfc core group meeting (July.84)
at Wardha.,
B.1971984
2
there are doctors nt every street corner assuring patients
(with considerable honesty) that they will g^t well with some
private tr a.tm^nt in six months or less.
LET US now come to the -case cf those who were sputum
negative. The cost of a 'free' MMR X-ray from Durg tc?
person in Rajha.ra, is well over Rs. 50-00. The cost of
. local private X-ray is Rs. 35-00. Which should the patient
choose?
IT SHOULD be noted that I have been talking all 'along of
the ideal case. We hove not taken any account cf the
government doctor nudging the patient towards his private
clinic; the laboratory technician asking for his 'fee1; the
X-ray technician's rudeness, or the irregularity in drug
supply.
THE PATIENT of tuberculosis is basically -a suffering
person. It is the least of his concern that he is
excreting M tuberculosis in his sputum. What he is much more
worried about is the fact that he has cough, chest pain,
fever, body ache and nausea. He cannot work. He feels weak. He
loses his sexual potency. His children starve and often fall
ill in their turn. A physically distant and emotionally remote
health centre can offer him nothing. It is well to remember
that the Madras Chemotherapy Centre study on domiciliary
treatment had weekly heme visits as part of their protocol.
It is a great pity that this investigation has formed the
basis for a programme that thinks it sufficient to throw
seme tablets once a month at a desperately sick man.
2. primary tb and extra-pulm nary tb
. TREATING THE problem of tuberculosis as a problem cf
suffering people, rather than as a preblem of successfullyeliminated parasitic mycc-bacteria brings us to two sets cf
illnesses often neglected in the current programmes.
primary tuberculosis
Between 10 & 20 percent of Indian children are tuberculin
sensitive by the time they arc five years old, though some
surveys (Raj Narayan) yield a lower estimate. The popular
(medical) concept! n of primary tuberculosis is cf a mild
intercurrcnt illness that is only incidentally detected ino. chest X-ray arid attains clinical significance only in the
'progressive' form. This is not true. In malnourished children
net only is infection itself accompanied by significant
morbidity but it is the 'interaction' between infection and
nutrition—that is the factor that needs to be considered.
When we consider that, according tc ICMR, 65% of Indian, children
ar. severely malnourished,
the dimension of the problem
became a little mere plain.
It is a common raise.-nceptic-n (even, as I have discovered,
among TB ’Specialists’), that clinically.apparent primary
tuberculosis can safely be' treated by a short c- urse of INH
clone. This is a notion that goes against all bacteriological
logic. One only creates a. population cf INH resistant bacteria
strategically situated tc subsequently preducc reactivation
disc ~se.
3
3
b.
Extr- Pulmniry Tuberculosis
The chapter ■ t. Epidemiology in the Text Bo k of TubcrcuL; sis
(by the Tuberculosis Ass ' ciati- n rf India) has nothing tc
say about extra pulmonary disease. In my experience this forms
a significant proportion cf c'ses i f tuberculosis. In particular
scrofula burnt cut tuberculous cervical lymphadenitis is still
a common finding in backward areas cf the country.
3.
staff pr-blems
SUCH CASES of ignorance among people working in the field
of tuberculosis are not rare. This is because almost the
entire field level medical staff cf the tuberculosis progrmmc
are 'dead-beats' people whe have been promoted t. on admini
strative position because their seniority has become an
administrative embo.rassment.
©
IN A Government District Hospital, despite all the other
problems one- can atlcast meet do ctors whr arc- inter.sted
in their work in the medical, sur-.ical, gynaecological and ether
specialist departments. Net sc in tuberculosis. The department
which should, by all epidemiological logic, claim the most
brilliant and dedicated cf cur technical manpower, is invariably
academically dead. In Hcshangabad, the District Tuberculosis
Officer was simply absent for a long period of time.
THE PARA-MEDICAL staff on the other hand ar often
exceptionally dedicated and able. They -often run the
programme practically independent-ally. However, they have tc
pay the price for their competence. In Durg, the statistical
assistant—a key person and in this case extremely competent
and dedicated—has been on full time deputation to the Civil
Surgeon's office, helping tc administer the hospital.
4.
chemotherapy
a.
Existing patterns
In theory, the National Tuberculosis programme provides
a wide choice among several alternative regimes. These include
daily INH and thiacetazcne with er without an initial period
of intensive treatment with daily streptomycin and/or PAS.
The bi-weekly supervised regimes c nsisting cf INH/SM and
INH/PAS, have been designed specially tc ensure patient
compliance.
Even according tc the treatment manual supplied to the
district Tuberculosis Officers, only sputum positive patients
are eligible for all these regimes. X-ray positive, sputum
negative patients often just as sick as their 'positive'
brethren and about 5 times us numerous, are eligible- nly
for the daily self-administered INH/-TH regime. Presumably
compliance isnet a consideration where they arc concerned.
In actual practice, the only regime available with any
regularity is daily INH/TH. (Incidentally, pyridoxine tablets
necessary tc c- unteract INH induced pyridoxin deficiency
are practically unheard cf. Patients are told to eat lots of
peanutsl )
PAS I have not seen in the past one year.
Streptomycin is constantly in short supply sc that pate mts
arc often randomly shuffled back and f- rth between regimes
containing SM and'those without. The effect of such■regime
changes in 'midstream', on treatment effectivity, bacteria
4
4
sensitivity, and patient compliance remains, as t iey say,
a subject for research.
Coming to the INH/TH regime, TH is by no means an
uncontroversial drug. Its use is banned in some countries
but let that pass. The incidence of 'major1 toxicity in
a study in Madras showed the following incidence of side
effects:
Cutaneous hypersensitivity reactions - 7%;
Jaundice - 3%;
Intractable vomiting - 3%
Apart from these, there are minor side effects such as
anorexia, nausea, vomiting and head ache. Weight gain and
rise in haemoglobin level arc less in patients on TH as
compared with those on PAS. The effect of such minor side"
effects on patient compliance, especially in the absence of
adequate medical supervision and reassurance, can only be
imagined.
We w^ll consider possible alternative regimes in the
next section. For the moment let us stick to the first
line/second line chemotherapy model. We have already noted,
some of the problems with the bi-weekly INH/SM regime not
available for sputum negative patients, and limited and
irregular supply of SM. In addition, there is a rul^ that
SM injections can only be given at the PHC level. In other
words, this regime is effectively available only to those
who live within about 5 kms of a PHC.
b.
Drug resistance
Coming now to the problem of resistant tuberculosis
there arc a number of problems in the existing framework.
(1)
Drug resistance in tuberculosis is not a rare
phenomenon. Existing studies show that the
prevalence of primary drug resistance to both INH
and SM in India are (individually) of the order of
5 to 10 percent. The prevalence of acquired drug
resistance is not known to me. But the . success rate
of the standard first line treatment regime is of the
order of 80 to 85 percent under ideal conditions.
(2)
There is evidence to show that pro-treatment drug
sensitivity tests do not affect the outcome of
treatment provided standard two phase regimes are
used, with an initial intensive phase using three
drugs. However in my experience such regimes are
available only to a very small proportion of patients even
in the district centres, and to practically none in the peripheral centres. Most patients go on a standard
two drug regime (general INH-TH).
(3)
When a patient fails to respond clinically to a
particular regime, there ar. no facilities for drug
sensitivity testing even in these selected cases.
Theoretically, in the existing model, they can be
referred to Tuberculosis Sanatoria for treatment with
2nd line drugs. In practice, however, (a) practically
none of these patients do get referred to Sanatoria;
and (b) even among those who arestarted on second
line drugs at such centres, there are no facilities
to continue such drugs after the patient is discharged.
The lone patient I managed to get referred to a Sanatorium
in Bhopal emerged after two months looking much better and
clutching a prescription for rifampicin and ethambutol.
.....5
c.
Possible Alternatives
co co
It is well known that there now exists a wide variety
of alternative drug regimes, for the treatment of tuberculosis
many of which result in euro of a higher proportion of patient
in a much shorter period of time than existing stand'.rd regime
The convent!'nnl wisdom is that these alternative regimes
comprise a 'second line' of treatment for patients resistant
to the standard regimes.
Thu fact that the government its..If does not take this
argument seriously is shown by the free availability of the
so called 'second line' drugs in the open market. Of ccurs.,
the price is far beyond the reach of the ordinary tuberculosis
p^ti^.-nt. As a result, we have in India the ironic situation,
where the District Tuberculosis Officer and the PHC Medical
Officers are the only medical practitioners who (in their
official capacity) have no access to the newer drugs fo$
the treatment of tuberculosis.
In effect there are today, in tuberculosis, as in every
other field of medical and indeed of public life, two sets
of policies in operation—one- for thc’po'T and one set for ■
those who can (even if only with difficulty) pay.
The argument against the newer regimes can now be seen
plainly for what it is a question cf cost. It is worth
going into this question in seme details.
5. the question of cost
a.
How '.much?
The cost of a complete ucurse cf treatment with the
newer drugs at current market prices is cf the order of
Rs.500-00 to Rs.1000-00. Regimes containing Streptomycin
are liable t<: cost mcr-_ because of the administrative cost
of giving the injection.
We are not talking of enormous sums of money. The cost
of bi-weekly INH/SM with --n initial intensive phase, is not
much-less. Neither is the cost cf INH/PAS regimes. The logic
of the exclusive dependence on INH/TH now become clear.
Put an: ther way, the cost cf treating a case of
tuberculosis with the newer drugs and the cost of treating a
case cf intestinal cbstructicn or pyogenic meningitis is
about the same. The cost of treating a case cf ischaemic
heart disease or lung cancer or brain turner cr diabetes
mellitus or chronic renal failure is several times higher.
The emp-ris-n becomes ridiculous when one carries the contrast
t-~ fields cutside medicine—say, to defence cr CHOGM.
b.
Cost to whom?
'
The second aspect cf the cost equation. Whatis the 'cost'
cf a twenty pcrc.nt relapse rate which is the best result
• btainable with standard 'first lino' regime? What is the 'cost'
cf a c*
sc ■ f thiacetazcne induced agranulocytosis or StcvensJchnsan Synd.r mu? What is th_ 'cost' cf travelling up and down
frm village t PHC, village to District centre, village tr
wherever, for 18 months as a ainst the six me nths with newer
regimes? What is the 'cost' in bus fare? What is the 'cost'
in lost inc- me? What is the 'cost' in the suffering cf a
peer man? This is
.ucsti n which the policy makers cf
tuberculosis must answer.
;
............ 6 (objectives cf the meet)
6
A note on the objectives cf an mfc annuel meeting on tubcrculcsi
(1) The objectives cf the conference sb- -uld net include the
framing c/ alternative policies tc g 'vc:-nrrK.nt programmes.
The existing policies are ^faulty both in cincept and in
implementation. Any alternative
systems we may be able
to formulate will inv Ivc a restructuring toe radical
for their acceptance to be feasible, quite apart from any
ether factors militating against their acceptance.
(2) An important part of the programme for the conference
should be the understanding of the problem of tuberculosis
in its national perspective. Not many mfc people have much
an understanding. Unless we can shore a common understanding
cf the problem, io is useless to try to devise programmes
of action.
Possible programme outcomes of the c nfcrencc;
a.
A concerted effort to work cut a solid critique
of existing government policy and its implementation.
The rosy ns'ibility would largely be on academics
with access to literature and data.
b.
Working out and executing pilot projects based on
alternative approaches tc the problem cf tuberculosis,
utilising newer technological as well as sociological
insights. These would include intensive small scale
field level studies.
i.
Surveying the problems of tuberculosis, including-"'
the much neglected epidemiological implications
of primary tuberculosis in pre—sch cl children,
extent and implications cf drug resistance etc.
ii.
Monitoring government activities intensivelyincluding the actual cxccuticn.of treatment guide
lines, patient compliance in government programmes
etc.
iii.
Working ut alternative approaches including
newer ways tc irnpr ve patient compliance, newer
treatment regimes-, newer diagnostic approaches,
including newer approaches to diagnosing drug
resistance.
Part.-_.II
REVIEW
SYMPTOMS ;
OF
LITERATURE ON CYANIDE
AND TREATMENT
POISONING
Early stages of acute poisoning resembles
an anxiety state with headache, giddiness, excitement
and tachycardia.
Tachypnoea is a sign of low cyanide
concentrations.
In severe poisoning drowsiness, coma
and convulsions precede death.
Reduced oxygen consump
tion diminishes the arteriovenous oxygen content differ
ence, rendering the retinal artery and vein a similar
colour.
Palpitations, hypotension, pulmonary oedema and
hypoxic ECG changes can occur and a smell of burnt or
bitter almonds may be detected on the breath.
(The
ability to detect such a smell is, however, genetically
determined and lacking in a large fraction of the popula
tion.^
In one test 3 out of 5 pathologists and 9 out of
11 members of a biochemistry department could not identify
2
cyanide by smell. )
Clinical abnormalities can occur when cyanide exposure is
high or when there is abnormality of detoxification or
when there is a combination of both factors.
Abnormalit
ies in detoxification may arise from paucity of substrate
arising from malnutrition.
Such situacxons can give rise
to tobacco amblyopia, Leber's hereditary optic atrophy,
inherited optic atrophy and subacute combined degeneration
_
*
4
of the cord.
LETHAL DOSAGE AND BLOOD CONCENTRATIONS ; The minimum
lethal dose is 0.5 mg/kg of body weight and the minimum
lethal concentration in air is 0.2 - 0.3 mg/1 (200 - 300
*
7
Oral ingestion of 250 mg of cyanide salt is
ppm).
usually fatal within minutes as is inhalation of 50 ml
(1.85 mmol) of HCN gas.1
A blood cyanide level of greater than 0.2 microgram/ml
is considered toxic.
Acute toxicity may occur as blood
cyanide concentrations approach 0.5 micrograms/ml.
Fatalities are usually associated with concentrations
exceeding 1.0 micro.gram per ml (John D. Bauer, Casarette
& Doull).
* See also additional notes at the end.
1
Jt
2
TOXIC ACTION ;
Cyanide has a high affinity for the
ferricJLon of cytochrome oxidase (a^) within the mitochon
By combining with the aa^ complex, cyanide prevents
dria.
0„ from reoxidizing reduced cytochrome a^ thus inhibiting
electron transfer and preventing both oxidative phospho
rylation and oxygen utilisation and cellular respiration
(for conversion of glucose to energy).
As a result of the
inhibition of oxidative phosphorylation, mitochondrial
utilisation ceases and arteriovenous
abolished.
differences are
The loss of ATP generation in the mitochondrial
electron transport chain evokes anaerobic metabolism
(Pasteur effect).
This increases lactic acid generation
leading to lactic acidosis.
The buffering of lactic acid
leads to a progressive fall in plasma bicarbonate concent
All organs are affected; eventually there is cent2
ral nervous system anoxia and finally, death.
ration.
Cyanide may also have a direct,
though reversible, toxic
effect on pancreatic P cells resulting in hyperglycaemia.
DETOXIFICATION ;
2
The major pathway for detoxification is
the formation of thiocyanate from the combination of sul
phur with the cyan!de-cytochrome complex by the enzyme
thiocyanate oxidase in the liver.
The respiratory enzyme
is released and thiocyanate undergoes renal excretion.
The rate limiting step is the production of sulphur from
the limited body store of thiosulphate by the rhodenase
catalysed reaction which may also explain recurrent and
1 10
prolonged toxic symptoms despite antidotal therapy. '
An alternative pathway is the conversion of hydroxocobalamin
(Vitamin B12 ) by cyanide ions to cyanocobalamin
(Vitamin B^2)• which undergoes renal excretion, and to
hydrogen cyanide which is excreted via the lungs.1
ZNTIDOTES ; The intrinsic toxicity of antidotes should be
carefully considered in case the diagnosis of cyanide
poisoning proves to be erroneous.
It must also be borne
in mind that as of 1977 in only 4 out of 61 cases reported
in the last 100 years, was the magnitude of poisoning by
cyanide documented quantitatively, and that inferences of
a causal relationship between antidotal use and successful
2
outcome were till 1977 based on such data.
The situation
has improved somewhat subsequently.
3
SODIUM NITRITE :
This oxidises nearly 30 - 35% of blood
haemoglobin with a ferrous
(M-Hb) with a ferric
(3')
(2‘)
ion to methaemoglobin
ion which has a greater attrac
tion for free CN“ ions than does cytoch.ome oxidase. M-Hb
thus binds the CN- ion to form cyanomethaemoglobin thereby
decreasing CN- combination with cytochrome oxidase.
The
weak CN-MHb bond allows the slow release of cyanide within
the liver, where increased sulphur requiremenis for detoxi
fication are met by exogenous thiosulphate which has slower
tissue penetration than cyanide.
Normal M-Hb blood levels
are 1%, and 300 mg of sodium nitrite will produce a level
of 10% when cyanosis will appear.
The optimum cheraputic
M-Hb level of 25% may be increased to 40% if symptoms of
cyanide poisoning are severe.
1
anoxia, corfia and death.
Greater levels may produce
»
Although attended with low allergy risk, sodium nitrite
has considerable intrinsic toxicity and its use in patients
with cardiovascular collapse or vascular haemorrhage is
It involves a large sodium load and presents
hazardous.
problems in monitoring therapy whilst maintaining near
died
toxic levels of M-Hb.
A child treated with nitrite.because
2-4
Ox. overwhelming methaemoglobinemia.
Recent observation,
4 5
'
that the antidotal combination of
sodium nitrite and thiosulphate with or without M-Hb forma
tion were equally effective against cyanide poisoning has
triggered investigations which seem to indicate that the
antidotal action of sodium nitrite is due to vasogenic
action rather than methaemoglobin formation.
SODIUM THIOSULPHATE ;
It combines with cyanide in the
presence of the enzyme thiosulphate transulphurase
(rhodanase)
cyanate.
and 02 to produce relatively nontoxic thio
It is relatively nontoxic although impurities
in production may produce allergic reaction in 1 out of
1000 or 10000 persons.
As a single agent its efficacy is
.
in acute poisoning
about that of sodium nitrite but accepted practice^is to
use it in combination with sodium nitrite, which increases
its efficacy, in these patients for whom the diagnosis of
1
overwhelming cyanide poisoning is clearly established.
sodium thiosulphate
cyanomet. .aemoglobin
rhodanase
— - ---- --- —.. ... -^thiocyanate oxidate
, .. .
methaemoglobin -I- thiocyanate
4
OXYGEN :
Inhalation of 100% oxygen increases arterial
PC>2 and increases tissue 0? delivery.
It may reverse the
binding of cyanide with cytochrome oxidase and may also
help increase the conversion of cyanide to thiocyanate by
2
thiosulphate.
Oxygen can markedly enhance the efficacy
of -the nitrite - thiosulphate combination, so that oxygen
should be made an in tegral part of antidotal combination
3
Oxygen toxicity is unlikely
1
with use over periods less than 48 hour's.
in cyanide poisoning therapy.
HYDROXOCOBALAMIN
(VITAMIN B. „ )
: It combines with cyanide
forming cyanocobalamin (Vitamin B-j^) but has limited pro
tein binding and a short half-life of 5 min.1 It has the
overwhelming advantage that it is essentially nontoxic
although in large doses it may produce facial acne.
Thus
even in the face of erroneous diagnosis or dosage, the
patient is not at increased risk because of therapy.
It
2
has been called the most promising antidote.
For maximum
effect it must be given in equimolar proportions that are
7
approximately 50 times the ingested amount of cyanide.
There seems to be disagreement over its use in combination
with sodium thiosulphate.
In reference 1 we find the state
ment that it is inactivated when mixed with soduum thiosul
phate, whereas in reference 2 we find the assertion that
in animal studies this agent is found to be especially
useful when combined with thiosulphate.
COBALT EDETATE ; It rapidly chelates free plasma and tissue
bound cyanide producing cobalticyanide and monocobalt which
are excreted within 24 hours renally.
While not free from
side effects, it can be employed in severe poisoning with
out close biochemical monitoring or reduction in oxygen
1
carrying capacity.
High concentrations of cobalt salts
have their own intrinsic toxicity, therefore, great caution
2
must be exercised in their use.
A simple chemical test on gastric aspirates to establish
oral cyanide poisoning is described in reference 2.
A
detailed description of the mechanisms of cyanide toxicity
and antagonisms is given in reference 5.
Reference 8 deals
with the treatment of cyanide poisoning by the administra
tion of 4-dimethyl-aminopheriol
(DMAP) whose action is
similar to that of sodium nitrite in that it helps in the
oxidation of the ferrous form of blood haemoglobin to
5
3
3-5
Use of pyruvate , mercatopyruvate
to methaemoglobin.
and chlorpromazine
3
as antidotes is also described in
the literature.
ADDITIONAL NOTES ;
The current OSH A exposure limit to
hydrogen cyanide is 10 ppm (eight-hour time-weighted
average)
ed.
although a reduction to 5 ppm has been recommend
Short-term inhalation of air levels of 50 ppm HCN
causes acute symptoms of gastric and respiratory tract
disturbance; 130 ppm can be lethal.
Lower doses, in the
range of 10 to 20 ppm can cause complaints similar to
those experienced at 50 ppm although longer exposure times
9
may be required to elicit them.
It has been suggested that vitamin B12 may be a protective
factor in cyanide neurotoxic effects.
Long-term cyanide
intoxication leads to thyroid enlargement and interferes
with iodine metabolism.
It can also lead to weight loss,
easy fatigue and sleep disturbance.
It must be remembered
that cyanide exposure inhibits a wide variety of enzyme
systems in addition to the cytochrome oxidase system.
Reference 11 contains a detailed account of the treatment
of an episode of acute acrylonitrile poisoning.
This is
an important paper as it documents that a single incidence
of acute cyanide poisoning can give rise to recurrent cya
nide toxicity.
As a result of this recurrence the patient
required 15 treatments with sodium nitrite and sodium thio
sulphate during a 72 hour period, along with additional
therapy involving hydroxocobalamin and supplemental 02,
with constant monitoring of methaemoglobin levels.
This
case emphasizes that prolonged treatment of cyanide poison
ing may be required and that many doses of sodium nitrite
and sodium thiosulphate can be given safely over a prolong
ed period with adequate monitoring.
AGENT
MECHANISM
Sodium
nitrite
NaNO^-l-Hb
M-Hb
M—Hb-!-CN—
CyanoM-Hb
J
POTENTIAL TOXICITY
Sodium
thiosulphate
NazSzOg-l-CN" (rhodanase)
Oxygen
more 02 in arterial
blood
Tachycardia, vomiting,
hypotension, severe
methaemoglobinemia,
hypoxia, vascular
collapse
none known
Oxygen toxicity unlikely
,
, j.
when used for less than
.„ ,
48 hours
more 0-, in tissues
2
may reverse CN~ bind
ing with cytochrome
potentiates activity
of sodium thiosul
phate
Hydroxocobalamin
OH-8^2 + CN
Cobalt salts
chelates cyanide
CN-B^2 none known
significant loss of
Ca'', Mg''' plus
intense purgation,
cardiac toxicity
7
WT AKE. OF CYANIDE, (PER INHALATION , ORALLY, PERCUTANEOUS
FATE
OF
CYANIDE
Adapted from
Williams R.T., Detoxification
Wiley, Nev? York 1953, pp 393.
ION
IN
THE
BODY
Mechanisms, 2nd Ed,
*■
GOVERNMENT GF ICARWAILA
DIRECTORATE OF HEALTH AND FAMILY WELFARE SERVICES, B.AHGALORE
HEALTH AID FAMILY LELFARE COMPONENTS .AVAIIAELE FREE FOR HEALTH CARE DELIVERY THROUGH VOLUNTARY ORARTSATIONS
SI.
No.
1___
Programmes
Beneficiaries
Methodology
Objective
2
___________ 3____________
4
5
Remarks
Role of the voluntary''
organisations
•
6
7
NUTRITION HlOHiYLAXIS PROGRAMMES
1
Iron and Folic acid
tablets for mothers
(lron-60mg; Folic
acid 0.5 ng.)
Expectant and Nursing
■□others, women Family
Welfare acceptors.
1 tabldt to each of
Prophylaxis against
these women daily for Nutritional Anaemia
100 days.
2.
Iron and Folic acid
tablets for children
(Iron-20 ng Folic
acid 0.1 ng)
Chi 1dren below 12
years of age School
going and pe-school
1 tablet daily for
100 days
do
3
Vitanin ’A1 concentr
ated Sol.2 lakhs units
strehght.
All children iron
1 to 4 years.
Once in 6 months
in the fora of
capsule or liquid
For preventions of
night blindness,
Keratomalacia and
other complications
due to Vitamin ’A*
deficiency.
Voluntary organisations
can distribute these
drags to the beneficia
ries .
1
Monthly quota
to be distri
buted cnce in
a month. List
of beneficiaries
to be maintained
in prescribed,
form.
2. To be obtained
from D.H. & F.W.O./
P .H .0 ./Sub-centre.
do
d'o
1
2
.Con-td/2'
•i
This programme is
taken up in the
rural area at pre
sent .
To be obtained
fron Pji*z). or
sub-centre.
: 2 :
4
2
'
IPSAT ION HlOGFLi KZ3S
Prevention of
Diphtheria,
Tetanus, per
tussis (whoo
ping cough)
.. D .P.T.
All children from 3 months
to 3 years.
Start at 3rd month
and 3 doses at an
interval of L, to 8
weeks with a booster
dose 18 to 24 months
later.
2- D & T
All children between 3-S
years.
Two doses at an in
Prevention of
terval of 4- to 8 weeks Diphtheria and
(Primary Vaccination
Tetanus.
i.c. no DPT previously
given) Booster dose in
case of previous DPT
after an interval cf
one year.
CompxLetion of 2 doses
or one booster dose
Voluntary Oranisations
can organise immunisa
tion campaigns in the
rural areas and slums
in urban areas and
carry out the immuni
sations .
In case of antenatals
3 doses-starting 1st
dose at 16-20 weeks,
2nd dose at 20-24 .
weeks & 3rd dose at
36-38 weeks.
Prevention of
Tetanus
Voluntary organisations
can t ake up as a part of
MCH Service and immunise
anatenatals•
Earliest at the age
of 3 months
Prevention of
Tuberculosis
Voluntary organisations 1. Vaccine to be str
can arrange mass immuniin regrigerator.
sation programmes with' 2. Vaccine available
the assistance of Dist>
Dist. T.’ . Centre:
T,B. Centres.
3- T.T.
4.. B .0 .G. Vaccination
.Antenatal cases
3 months to 19 years
Completion of 3 doses. 1 . Vaccine to be
Voluntary organisations
stored in re
can organise immunisa
frigerator at t.
tion campaign in the
of 4°c to 10°c.
rural area and slums in 2. To be obtained f.
D.H.& F.W.0./P.P,
the urban areas and
carry out the immunisa
tions .
.. .Contd/3-
do
do
; 7
2
3
4
5
*. Smallpox Vaccina
Primary only
.t the age of 3-9 months
To prevent smallpox
C.. folio Orel Vaccine
LU children 3 to
9 months
Start at 3rd month and
3 doses at an interval
of 4 to 8 weeks with
a booster dose at 18 to
2Z, uonths.
To prevent Polio-
myelitis
7
Voluntary oranisations o.-n take up
as part of MCH
services and con
duct Primary
Vaccinations.
do
1. Vaccine to be
stored in refri
geration.
2. Vaccine available
at the PEC
1. Vaccine to be stored
at - 20°c.
Likely to bo available
during next financial
year .
IMPLY WELEAIS PEOGEUiMSS
1 Sterilisation
Couples with two
children and above
Vasectomy, Tubectouy
Eternanent method
for limiting the
family.
1. Voluntary Organisations can organise
sterilisation camps with the assistance
of local Primary Health Centrc/Orban
Family Welfare Centre.
2. Loop
Ccuplcs with one or
two children.
Loop insertion
For spacing the
children Temporary
nethod of Fanily
Planning.
2. Motivate eligible couples for undergoing
sterilisation, IUD insertion at the
nearest Primary Health Centre or hospital.
They can act as depot holderns for distri
bution of contraceptives. They can ensure
follow up services by the staff by closely
associating with Primary Health Centre/
Urban Centres and the Community.
3. 1-fi.rodh
Newly married couples, 6picces or core at a tine
depending on usage. Distri
and couples with one
bution once a nonth.
child.
For spacing the
children Temporary
method of Fanily
planning.
3. They can establish Urban Family Welfare
Centres in areas left uncovered by
Government institutions after approval
by Government. 100% assistance will be
provided by Govt.
....Contd/4-
: 4 :
2
Oral Tills
Modical Tcrmi-’
nation of Prcgnancy.
3
Couples with one or two
children.
Pregnant woman upto 20
weeks where pregnancy
is unwonted.
4
5
For spacing the
Oral pills-first 3 cycles to
be distributed directly under c hildr on-T empothe supervision of doctor and rary method of
Family ELanning
when there is no untoward
effect, pills may be distric
ted by non-medical porsonellc.
Beneficiaries to be examined
by a doctor once in 6 months
or earlier whenever indicated.
Medical institutions (Private
or Government) recognised
under M .T .P. Act can taken up
this programme.
To safeguard the
health of the
beneficiaries as
a welfare measure•
7
6
4- Volutary organisations having their own
hospital, approved by Government for
conducting tubcctony operation can main
tain sterilisation beds for which bed
maintaiponco charges will be paid by
Government as per rules.
5. Private Practitioners recommended by
Local Indian Medical Association and
approved by Government can take up
vasectomy operations and IUD insertion.':
The beneficiaries eligible for compensa
tion amount. The Private Practitioners
are eligible for service charges at the
prescribed rate fixed by Government
provided the services are rendered free
to the community. They can also take u:
distribution of contraceptives includin'
oral pills.
6. Nursing homes run by private practitionand voluntary organisations, satisfying
all the conditions as for M.T .F. Act
and recognised by Government can tike up
M .T .P. Services.
-
(1) Iron Folic acid tablets, D.P.T. Vaccine, Dipthcria and Tetanus, Vaccine, Tetanus Toxoid, E'.C.G. Vaccine, Small-pox Vaccine
B.C.G. Vaccine Contracc; tivos arc available free:
(i) depending on the availability of stock with Government.
(ii) depending on refrigerator facilities available with the organisation.
and (iii) provided the services are rendered free to community.
■Contd/5-
: 5 :
Subsequent supplies will be made, after the previous supply is properly
(2)
ATI the supplies made have to be accounted.
accounted.
(3)
List of beneficiaries under nutritional prophylaxis, immunisation programme, family welfare programme have to be
maintained in the prescribed registers and forms.
(4)
14onthly statistical data in the proscribed forms have to be furnished to the concerned Primary Health Ccntres/Urban
Family Welfare Centres within the due dates.
(5)
Apart from the assistance rd ready approved by State and Central Government, no other monetary assistance will be
be given to the honorary staff/organisation.
(6)
For further details the nearest Primary Health Ccntrc/Urban Family Welfare Centrc/the District Health and Family Welfare
Officcr/City Family Welfare Bureaux nay kindly be contacted.
Dr. J.S. Salcsena
Director
Directorate of Health & Family Welfare Services
Ananda Rao Circle
Bangalore - 560009-
k
r
2
27 Jan 85
Sunday
11.00 am
Session I (four groups)
Small group discussion on:
a. expectations of participants;
b. focus/scope of discussions;
c. issues in tuberculosis and its control
2.00—
2.30 pm
2.30—
4.00 pm
4.30—
6.30 pm
28 Jan 85
Monday
Final outline of programme
Session II
a. Critique of National Tuberculosis
Control Programme
i. conceptual; ii. organizational
b. Identifying true/false limitations
in studying the programme
8.30 pm
Getting to know the Circle I
(sharing of experiences/action)
8.3 0 am
to
9.30 am
Plenary Session 'A'
(putting together the critique)
9.30 am
to
11.30 am
Session III'(small group discussions)
11.30 am
tc
1.00 pm
&
2.00—
3.00 pm
Plenary Session 1 B'
(reporting and discussion on group
reports of Session III)
3.00—
5.30 pm
Session IV (Alternative Approaches)
Two Groups
a. Case finding/Case holding
b. TB - rational therapy and rational
drug policy
c. TB awareness building (professional,
para professional education and
public education)
d. TB and Socio-economic and political
factors
a. Alternatives in TB Control - 1
(diagnostic, treatment regimes,
patient compliance at field or
project level)
b. Alternatives in TB Control - 2
’ (at non project Is-els ie.,
awareness building, raising issues
with government and in mass media
etc.)
5.30—
6.30 pm
8.30 pm
Plenary Session 1C
(future strategy/fellow up/action
pion or members/participants)
Getting to iknow the Circle II
(sharing of experiences/action)
3
3
29 Jan 85
Tuesday
9.00 am
Annual General Body Meeting
MEMBERS ONLY
The Agenda, has already been circulated
All India Drug Action Network Meeting
(same venue)
30/31 Jan 85
Wed/Thvrs
Aprendix I
Some questions for discussion:
Sccpe/Focus of Meeting
Session I
a.
b.
What is the expectations of participants from the
discussion on TB?
What is the minimum that we should achieve?
a better academic understanding;
a better grasp of grass root level realities;
a more concerned view of people's sufferings;
a bettor understanding of related socio-economic
and political factors;
- all or a combination of the above.
-
c.
D^ we want to discuss? how we can lend cur helping hand to improve the
working of the existing strategy of TB control
in India?
ii. how to link up the question of the strategy
of tuberculosis control with the question of
social revolution? Is the question of social
revolution really involved? how? why?
i.
to evolve an alternative pec pie-oriented
scientific strategy if we find the existing one
fundamentally misconcciyed?
d. what can bo .the role of such a meeting?,,. •••"'
—evolving a critique, evolving rn•alternative
approach, both-, any other?
hovz
iii.
Session II
;
...
Critique of N T P
a.
Is the existing strategy of tuberculosis control
working properly in India? If yes, what evidence?
If not, why not?
b.
Is tl e failure because of some flaws in the strategy
itself? Conceptual/technical?
c.
Is it because of lack of implementation? If yes,
which factor: within the medical/hcalth care system
and outside it act as impediments?
d.
Even if the ccnstraints put by the existing
vested interests are removed, would there be any
problems in the strategy of control of TB in India?
What are these? Can thc^se be isolated in practice? How?
e.
Are there any regional differences in programme/]5erformance/
implementation? If so, how and why?
4
Scssi n III:
Session IV
jU^stions for group discussions will be
circulated cn the 27 th. Depending bn
expecations of,participants seme other aspects
may be added.
:
Alternative Approaches
a. The aim cf the session is tc identify various alternative
approaches t' the problem cf tuberculosis utilising
newer technological ns well as sociological insights.
Those could involve intensive small scale field level
studies or field projects; eg
i.
Culd surveys be undertaken to better ■
understand the TB epidemiology nt field
level? including much neglected implications
of primary tuberculosis in pre-school
children and extent/implications cf drug
resistance?
b. Could government programmes be monitored intensively
including actual execution cf treatment guidelines,
patient compliance/follow up etc?
c.
Could alternative approaches
—
—
—
—
d.
be tested out in
case finding;
newer ways tc improve patient compliance;
newer treatment regimes;
newer diagnostic approaches including approaches
to diagnosing drug resistance?
Can awareness of programme be increased .among the
general population? Can petential/actual TB patients
increase the demands on the system in terms of not
only utilisation but efficiency etc? Can any further
measures be demanded cf the government?
ii.
How con different-mfc members involved in
different situations contribute to some or
more the approaches (to help in analysing the
existing strategy and forging an alternative
in the context of fundamental social ■ change?
What could be the role of a medical student/
, •
intern/a socially concious doctcr/a government
medical officer/health workers/- community hcal+-^
project team members/fcacher in a medic.il college/
3. journalist/n development or political activist?
Appendix II
Backgrcund-.ppers for meeting on 'TB AND SOCIETY'
1. National Tuberculosis Programme:
S.me problems "nd Issues—Binayak
Sen, Dalli Rajhara
s mfc bulletin 105
(September 1984)
2. Tuberculosis and Society—
Mira Sadgcpal, Bankheri."
: Circulated at VJardha
Meeting—July 1984
(available from author
at Kishorc Bharati,
PO Bankcri, Dist.
Hcshangabad, MP 461990)
5
5
3. Discussing Tuberculosis
C ntr• 1--Why?—Anant Phadke,
Pune
; mfc bulletin 108
(December 1984)
4. The llati nal Tuberculosis
: mfc bulletin 108
Programme--What cur experts
(December 1984
say?
(cn socio logical basis,
' cpidcmi"logical dimensi ns,
organisational plan, evaluation,
anti-tb drugs, p litied
economy and ultimate solution)
5. Understanding TB - a check list
of questions
(understanding the situation,
assessing awareness, understanding
technicalities, discovering bottle
necks, un lorstand.ing the health
system, discovering new approaches)
mfc bulletin 107
(November 1984
Supplement)'
6. Selected Reading List
(NTI, VHAI, Indian Journals,
WHO)
mfc bulletin 107
(November 1984
Supplement)
7. Case Finding and Case
Holding in TB control
programme—UN Jajoo, Wardha
Background Paper I
8. Case Holding and Patient
Compliance and Motivation-Marie D1Souza, Nandurbar
Background Paper II
9. Public Health Perspectives in
:
the formulation of NTP of
India—D Banerji, JNU, Nev/ Delhi
Background Paper III
(Source: NTI)
10. TB in Ayurvedic system of
Medicine—Dhruv Mankad, Nipani
Background Paper IV
11. TE in Siddha—Prabir, Nemur
Background Paper V
12. Tuberculosis Control in India
-—current problems and
possible solutions
—CVJ Baily, NTI, Bangalore
13. A Perspective for Discussion
of NTP in India—D Banerji,
. JNL, New Delhi
Background Paper VI
(ScurcesNTI)
:
Background Paper VII
14. Comments cn Perspective
Paper No.3—Anne, VC Talwarkar,
S Kashalikar
15. Options cn TB Chemotherapy—
Paul Shears, Oxford
16. Tuberculosis in Children
(Susannah Graham Jones, Nepal)
... .6
6
Fr- m bock issues of mfc bulletin
17. Health Core Vs. the Struggle
for Life—-Mira Sadgcpal
s mfc bulletin 93 and 94
VHAI Special Issue
IS. Is BCG vaccination useful?
—Kamala Jaya Rao, Hyderabad
•: mfc bulletin 89
19. Is anti-tubercular treatment
really very expensive? N N Nngar, Dahod
; mfc bulletin 96
Additi' nal background papers and case studies which will
be available at the meet are:
i. TB and Society - a historical review - Mira Sadgcpal
ii. TB and Immunity (Anil Patel)
iii. TB and Homeopathy (Amravathi group)
iv. Rational TB Therapy and Rational Drug Policy Issues
(Mira Shiva)
F P PROGRAMME: WOMEN AS 'TARGETS'
This discussion note addresses the following:
1.
Women have been the focus of the family planning programme
not just in the last decade but ever since its inception.
last decade this emphasis has been intensified.
In the
Whatever the
changes in the policy over the years women have remained the
'target population' for the family planning programme.
2.
This focus on women has had several consequences for
women - on the one hand while it has made contraception available
and legal, it has placed a heavy burden on them of having to deal
with the coercive practices incorporated in the programme, and of
the high load of morbidity associated with the unsafe methods and
practices being promoted.
And it is highly debatable whether
the mere availability of contraception has given them any control
over their reproduction.
2.
What do we do about this situation? Should we oppose the
programme for its large ideological fundamental ideological
reasons and in so doing also accept that we would not then may
not then have access to contraception at all? Or do we seek to
make it less coercive and more relevant to our needs?
Women as focus of programme.
India was one of the first countries to promote family
planning as a national programme, Even before the formal process
of planning began, it had been recognised by the health committees
that were set up that in order to ensure the health of the mother,
it was necessary to bring down the number of pregnancies she
underwent. Towards that end contraceptive advice was one of the
components of the maternal and child health programmes. In the
50s family planning was made an integral part of the MCH programmes.
In the early years when the family planning unit and its several
clinics were set up the only method promoted was the rhythm
method; but soon the FPU began to test contraceptives for effacacy,
safety and acceptability and to undertake work to develop newer
contraceptives. Between 1958 and 1962 the clinics of the FPU
tested a variety of foam tablets, spermicidal jellies and
diaphramgms.
The emphasis right from the beginning was on getting
women as acceptors.
So much so that at the end of the first plan
when an evaluation study was carried out it was found that the
clinical approach which had been adopted had 'medical, feminine
and middleclass bias'.
...2....
- 2 By the third, plan family planning was a more serious issue
and. became more firmly integrated, into the national programmes
with an allocation of forty times that of the previous plan.
The approach also changed - on the advice of the Ford
Foundation.
It was during this time that sterilisation was
adopted as part of the programme and Lippe's loop, which had
already been discarded in the west, was introduced with
manufacturing facilities set up with the help of the Population
Council.
The changes in approach also included the starting
of the post partum family planning programme, funded by the
Council and put into action around 1968.
The programme was
launched with the intention of using the hospital base to
promote direct fp assistance to women either after child birth
or after MTP. Inevitably this reinforced the female bias of
the programme.
At the same time it brought with it an element
of coercion - services could be and were withheld if women
did not accept sterilisation.
The accompanying table shows these various trends in this
period. After an large increase in the number of IUD acceptors,
the device fell into disrepute and even the incentive schemes
could not revive it. From a record number of over 910,000 IUDs
acceptors, in 1966-67 it fell to about >+595000 by 1968-69.
The initial emphasis on sterilisations showed up as a sharp
increase in the number of vasectomies which constituted
55 per cent of all methods. By 1969 a combination of factors
served to push the only other female method (other than IUD)
female sterilisations - which constituted 26.per cent of all
sterilisations. In 1967-68 with the USAID supplying condoms
for the Nirodh marketing programme the number of condom users
went up comprising 9-0 per cent of all acceptors. At the same
time, the introduction of the newer methods iso meant a
deemphasis of the diaphragm (the diaphragm-jelly combination
had shown good results,in the FPU tirals). From combination
had shews geed
onwards the device almost disappeared from the scene although
on paper at least, it is one of the methods offered in the
'cafeteria' approach of the programme. The last half of the
60s thus saw the introduction of two new contraceptive methods
for women neither of which really took off at this stage; at
the same time it also saw the demise of the then, but the stage
was set for a tremendous expansion of the fp services.
3...
- 3 By the Fourth Plan population control became an integral and.
important component of development programmes. The government
policy set definite goals - bringing down the birth rate to
25 per oelOOO in 10-12 years. The fp programme from this point
has made no pretensions of being anything other than a means
of reducing numbers - since goals have to be achieved in
specified periods 'targets' had to be set and the evaluations
were in terms of 'births averted'.
The objective of providing
birth control measures is thus a far cry from the current fp
objectives directed at controlling population growth.
The 70s was the decade of the camp approach introduced to
get quick results. In the early 70s the technique of conducting
tubectomies by the vagin*l method which did not require more
complicated surgical procedures was only just being introduced,
and most tubectomies were conducted at hospitals on part of the
past partum service. The sterilisation camps therefore were
for vasectomies. While the first such camp was in Maharashtra
in the early 60s, it was the 1971 vasectomy camp in Kerala which
was spectacular - 15,000 vasectomies in a one-month period.
The fact that it was during the lean period and that higher
compensations and extra rations were given had not a little to
do with these numbers. Several other states organised such
camps until 1972 when in one. such camp, 11 people died of
tetanus, and the camps were promptly discontinued. In the two
years between 1971-72 and 1972-73 the number of vasectomies
jumped by 197 per cent.
But as a backlash of the vamp-associated
deaths there was a drastic drop in vasectomies and the programme
only 'recovered' during the emergency.
Tubectomies constituted
only 16 per cent of all sterilisations in 1971-72 although in
the following two years they made up about half not because
there was any major increase in their humbers but because of
the reduced total of sterilisations.
The early 70s also saw the introduction of the MTP act which
was aimed at reducing the number of illegal abortions.
It
resulted in servere problems including death. It allowed for
abortions not only for therapeutic reasons but also for 'social'
reasons - contraceptive failure.
However, the committee which
was constituted to formulate the Act categorically stated that
this was not being mooted as a family planning measure. It is
possible that because of the non availability of safe and
effective contraceptive methods MTPs are being resorted to as
an fp measure.
.... 4...
- h- The impact of the emergency on the fp effort is too well
known to need elaboration. It must be mentioned that during the
period 1975-77 there was, of course, a fantastic increase in
vasectomies, but also an increase in tubectomies and condom users
while the number of IUD users actually dropped in 1977 after a
h-0 per cent increase in 1975 and 76, probably because the pill
which was introduced in 197^-75 was being pushed vigorously then.
The post -emergency period brought a drop in all acceptors and
the fp programme was on a low key for a while.
In 1976 a National
Population Policy was formulated. It advocated a set of incentives
and disincentives and also stipulated that for grants allocation
to the states the 1971 population figures would be taken into
consideration and some proportion of the aid would be linked to
fp performance. This led to all kinds of atrocities in achieving
'targets' and Maharashtra even tabled a Bill to make sterilisation
after two children compulsory.
The fp programme in the Sixth Plan was directed at aspects
ether than merely the control of population. However it also set
the target of achieving Net Reproductive Rate (NRR) of unity; in
order to achieve this the birth rate had to be brought down to 21.
Other components of the programme included other targets- death
rate to 9, infant mortality to 60.
FP targets were set as
sterilisations 22 million, IUD 7.9 million acceptors.
The Sixth plan targets have been ever achieved in the case of
IUDs and very nearly fulfilled for sterilisations. The new
policy for the seventh plan has set more fantastic targets
especially for oral contraceptives and IUDs.
Since the 1980s the fp programme is being pursued with a new
intensity and has finally 'recovered from the emergency excesses.
There has been an 129 per cent increase in all acceptors since
1980; a 239 per cent increase of IUD users; l>+0 per cent increase
in tubectomies; and a 365 per cent increase in equivalent pill
users as against a mere 50 per cent increase in vasectomies and
106 per cent increase in condom users. There is every reason to
believed that of late the emphasis has shifted from terminal
methods to spacing methods such as IUDs and oral contraceptives.
The IUD has found new acceptors for the first time after its
70s debacle. This has become necessary partly because of the
changing age structure whereby a larger number of younger women
- 5 are making up the eligible age group where terminal methods are
not acceptable. Another reason is perhaps the realisation that
despite the increasing numbers of sterilisations, this has not
made much of an impact on numbers mainly due to the fact that
acceptors have already had more than the 'right' number of
children.
There can be no doubt that women have been the targets of
the family planning programme - as acceptors and as gunguinea
pigs for a variety of testing programmes involving contraceptives
ahormonal and devices. But strangely there has been very little
interest in investigating simple barrier methods such as
diaphragms - there seem to be no evaluation on whether the
device is in fact, as inconvenient to all sections of women.
Moreover, there has been little research on male methods.
However, not withstanding all this the total number of
acceptors of female methods comprise only about AA per cent in
1983-8A of all acceptors and in fact have never been more than
that since 1965.
In some years as in 1971-72 proportion has been
as low as 15 per cent. But this however, is not so much because
there was a deemphasis on female methods as because there was a
tremendous increase in vasectomies during the 'camp' phase.
Similarly it may be argued that tubectomies although they
comprise 0 per cent of all sterilisations only make up 26 percent
of all acceptors. Are we then justified in stating that women
are the major focus of the family planning programme?
Here we must go beyond the numbers on apaper.
Firstly, it is generally known that of all fp statistics on
acceptors those for sterilisations are the most reliable. The
figures for condom users is based on number of piece distributed
and not on any feedback on usage. It is also well known that the
targets for condoms is the easiest to achieve because all the
officers have to do is dispose of them.
The statistics on IUD
users too is something of a myth. In 198A - for these numbers
include a large number of women who have had the device removed.
In 198A an Indian Express report revealed that the number of
accepters of Copper T was much larger than the number of eligible
couples in the state; and there are innumerable accounts of how
the numbers have been fudged. Oral contraceptives users again
are based on numbers distributed. Effectively therefore, it is
the number of sterilisations which are indicative of what is
really happening.
...6
- 6 Secondly we see from the table that there has been a steady
and almost consistent increase in the number of tubectomies
(ignoring the aberration of the emergency years 75-78). No such
trend is seen in the number of vasectomies which has been exwith
sudden and large increases when it was being vigorously promoted
followed by sharp decreases in the aftermath.
In other words
it is not unreasonable infer that regardless of other features
of the policy, female methods sterilisations have been
consistently promoted. Interestingly also the introduction of
the laporoscopic method and the camp approach in 1980 has not
resulted in the kind of increases which occurred for casectomies
in say, I97I-73.
This, probably indicates that the steady
increase in tubectomies is not really a result of the camp
approach.
In evaluating the impact of fp on women, we must take into
consideration the risk associated with each method. Apart from
vasectomy the only other male method being offered is the condom
which has no risk whatsoever. Vasectomies too cause fewer
problems than do tubectomies. And it is significant that
vasectomies camps were promptly given up when there were deaths
in one such camp in 1972, whereas tubectomies camps are being
actively promoted despite the increasing incidence of morbidity
and mortality associated with these camps. 'Since early 80s the
introduction the simpler and shorter procedure of laparoscopic
sterilisation has parodoxically contributed to the increasing
risk involved. According to surveys the infection rates in these
camps is as much as per cent when the theoretical incidence
rate is only about
. Sathyamale’s papaer describes the
incidence of risk associated with each of these methods. In
short all the methods being offered in the mass programme add to
the women's burden of ill health. Even if they comprise only
W per cent of all acceptors the fact remains that women face is
far greater risk than men in using the available means of
contraception. And the irony is that it is some extent avoidable
risk.
For instance, with proper checks for contraindictaions
and good supportive health care some of the IUDs may be very
effective. Similarly, tubectomies particularly laparoscopies,
can be safe and effective (although they do not do away with the
other problems of sterilisation) provided enough attention is
given to the women during and after the operation.
7...
- 7 -
Another factor which must be considered, is the fact that
the newer methods being introduced - such as injectables or
implants - are not only harmful potentially but are also methods
which a woman has little control over. What do we then do about
this: There is no gainsaying the fact that women need contra
ception and it is our right to demand that the Government make
safe and effective contraception available on demand. In that
sense, that the government is making available a choice - at least
theoretically - of methods for women is not objectionable. What
is to be criticised and condemned is that women today are coerced,
overtly and covertly, to accept certain method irrespective of
their personal and specific needs both in respect to the size of
jjheir family and the choice of method.
And then again can a mass
programme in a country like ours can only be useful, effective
and safe if supported by an efficient public health system?
Should there must be a greater emphasis on encouraging men to
accept and use birth control measures?
Would this necessarily
tilt the balance the other way so that there are fewer
contraceptive choices for women. And most importantly, the
introduction of long acting hormonal contraceptives, which are
known to be a health burden on the women, must not be allowed.
The note has drawn on data, ideas arguments from the following:
1.
Socialist Health Review Issue on Politics of Population
2.
Control, March 198b-.
Vimal ^alasubrahmanyan: Contraception as if women mattered
and Towards £ a woman's perspective on F.P.E.FW. Jan.11, 1986.
3«
Alaka Basu- Family Planning Leacy of the Emergency E P W.
March 9,
198?.
All these are available for sale or are on display at the Meet.
Padma Prakash.
/Chavan/
Mpn.
Tables
IVD
Insert
ions
ernily Planning ^ecj^ors - By An Methods
(Sincfx I.165;
(Numbers in Thousands)
Condoms
sterilisations
%
Total
tors.
Vasectomies
ifo
'
Tubectomies
ao
>ta
Total
jfo
'
pin
5
671
diaphragm
ORAL
this
Mb
J*8A
£TA
Total
Acceptors
(TA)
Total FA *g
Fenale percent
Accep of TA
Ito.
/-TA
■33
532
23
2066
907
44
Ji Jo
March
1965
Jan,
1966
813
39
577
23
1966-6?
910
40
785
35
102 ’
5
887
39
465
21
2262
1012
45
1967-68
669
22
1643
55
192
6
184o
62
4-75
16
2984
861
29
1968-69
**79
15
1383
45
232
9
1665
54
322
27
3105
778
25
1969-70
**59
Ik
1056
31
366
11
1422
V2
1366
40
17
3390
837
25
1970-71
476
13
879
23
4;/X
12
1330
35
1846
49
7
3769
934
25
1971-72
488
10
1620
32
567
11
218?
44
2262
45
5
5029
1060
21
1972-73
355
6
2613
44
509
9
3122
53
2321
40
5
5375
869
15
1973-74
372
9
403
9
539
13
942
22
2M4.9
68
5
4324
916
a
1974-75
*83
10
612
14
742
17
1354
31
24-90
53
3
26
0.6
4308
1206
28
1975-76
607
1438
21
1230
18
266S
39
>79
51
2
32
0.5
6804
1872
28
1976-77
581
9
«r
y
6199
5o
2062
17
6261
66
3623
29
1
58
°.5
12534
2702
22
1977-78
326
7
188
4
1761
17
94«
a
3164
70
1
78
0.7
4528
1166
26
1978-79
552
10
391
7
1093
20
1484
w
3371
61
1
82
x*5
5505
1728
31
1979-80
635
12
473
9
1305
24
1778
2976
54
0.5
82
1.5
5482
2023
37
1980-31
623
10
439
7
1614
25
2053
32
1
32
3707
57
0.5
91
1.4
6490
2334
36
1931-82
751
9
573
7
2219
27
2792
35
•:428
55
0.5
120
1.5
8102
3091
38
1982-83
1097
10
535
5
3393
31
3933
36
5757
52
0.5
183
1%7
11028
4679
42
1983-84
2131
1**
661
4
3871
26
4532
31
7652
51
0.5
555
3.7
14876
6557
44
Source: Compiled From:
Family Welfare Programme Xear Book 1983-34
and Annual Reports of the department.
Mote:
\
Figures for Condoms, Diaphrapas and Oral Hills are in terss of Equivalent Users.
For Condoms and diaphragms Equivalent user, is derived by dividing off take by 72 and 2 resp
A NOTE ON TEACHING OF COMMUNITY MEDICINE ;
A CRITIQUE AND A FEW SUGGESTIONS
One of the criticisms MFC faces is that it is always criticising
and there have not been enough constructive suggestions.
Hopefully
10th annual meet of MFC at Calcutta will help correct this impression.
A Clarification on Use of Terms.
At the very beginning we would like to clarify that the terms
‘Community Health' and 'community medicine' have been rather loosely
used in the sense that they are both interch ngeble.
They both may
have different shades of meaning in different contexts, but for our
argument, we would like to skirt the whole debate on precise defini
tion of the terms 'community health' Vs 'community medicine' simply
because they serve no purpose other than diverting the attention from
much more crucial and difficult problems.
What is Community Health ? ; A Problem and Its Scope.
A friend, final year medical student, fine fellow, sensitive,
intelligent, concerned; and eager to know about the wrongs in existing
health system once asked " but what is community health ? how does
one 'practice' it ? I can understand and make clinical diagnosis but
how can I make 'community diagnosis' or how can I 'do' community —
treatment ? "
This note keeps these and similar questions and similar medicos
in mind whose concern for social ills is beyond question, who are not
self-seekers or purely carrier-oriented.
They are not blind to pro
blems of neglected, exploited unorganised poor people.
These simple
looking questions are, in fact, loaded questions.
These questions
have to do with teaching of community medicine in the medical colleges
in our country today.
Before we go further we must stress one point
that it is not and can not be a thorough-going, fully-developed
argument.
The teaching of community health is too vast and complicated
a problem to be dealt with full justice by a small group like us with
a limited experience in community health.
Hold of Traditional Medica 1__Educ ation on Its Critics 1
We start with the very choice in this meet of teaching of commu
nity medicine as one of the subjects in medical education.
This is a
mistake in our opinion and reflects the strong-hold, the orthodox and
traditional mode of teaching health sciences still has on our minds
despite our valiant efforts to throw away the hidden assumptions and
theories of teaching health sciences in traditional ways.
Another aspect of the same phenomenon of hold of traditional mode
of medical education on our minds is to be seen in the fairly wide
spread belief even amongst the critics of medical education that a
number of progressive changes have been made in the series of recomm
endations made by various high level committees on medical education
since independence.
The critics feel that atleast part of the
problem can bo solved by implementing the progressive changes honestly
and sincerely.
We believe that far from being progressive, they are
merely cosmetic changes.
They provide for no progress in medical education.
In the traditional teaching, science of health has been broken
down into a series of rigid pigeon-holes (e.g. anatomy, physiology,
pathology, medicine, surgery, OB and GY, community medicine...etc.)
precluding almost any interaction among them.
The organic unity of
all disciplines in the context of their theoretical relationships as
well as in the context of their application in practice is disrupted
mindlessly for all practical purposes.
...2/
-2—
A sort of divisions of disciplines is necessary on practical
grounds only, but when community medicine is included as one among
many subjects to be learnt, the situation begins to approach absurdity.
A couple of years ago, a well-known community health worker in India
made a very significant observation that creation of Departments of
Preventive and Social Medicine and subsequent. separation of a subject
of PSM in the medical colleges (a progressive change) had dealt a sev
ere blow to the development of the concept of teaching and practice of
community medicine. Now since the Departments of PSM were there, it
was their sole responsibility to teach community medicine; other depa
rtments could carry’ on as they liked i
The /.armful harvests of such
thoughtless and shortsighted decisions are being reaped now.
The notion of a community medicine as a separate subject has its
roots in the way the problem of dealing with ill health has been posed.
This particular way of posing problem generates other assumptions, the
ories and action programmes which ultimately mould ideas of both suppo
rters and critics of existing medical education 1
Of course, the
interests of various power centres in the society do influence and
mould particular form of medical education; but clearly this is not
an adequate explanation, because it still leaves open the interesting
problem of explaining criticism of a segment of critics whose align
ment with power structure is unthinkable, voiced within the same frame
work which is problematic essentially because it poses problem in one
way and not in another way.
The critics must challenge the way the
problem is posed.
Problem Posing (of Ill Health) - The Traditional Way.
Traditional medical education largely seeks to equip students to
deal with an individual patient who comes to doctor for help. Virtually
whole medical education starting from anatomy, physiology through path
ology and pharmacology to individual clinical subjects is geared towar
ds an individual who perceives illness and seeks help from a doctor at
a predecided place called dispensary or hospital.
(here again mostly
hospital.)
Ofcourse, what can be called basic sciences like physiology, bact
eriology, pathology, biochemistry, parasitology,
immunology, pharmaco
logy ... etc in their usual settings outside the world of medical colleges do not operate on such a narrow base and in such a disjointed
manner as they do in medical colleges. Their stupendous growth has been
possible in the first place because they have successfully blended
study on populations with study on individuals.
One without another is
ofcourse, impossible.
The pundits of medical education seem to have
achieved impossible to wit, sever individual from his social,physical
biological settings !!
Alas i
The interpenetrating reality is no
respector of such arbitrary human divisions 1
In this framework illhealth is seen in a person in the hospital ward.
His^/and his blood,
heart, liver, lungs, intestines, brain, stool and urine only is ^body
brought under incredibly deep scrutiny.
This narrow focus-unfortunately the only focus-on an individual and his bodily functions keeps out
this person as a member of his family, of much larger social groups to
which he belongs through kinship, residence, occupation, religion,
beliefs...etc. and his conditions of life, his work, his economic and
social placement and culture, his physical and biological environment.
The whole education is a gigantic exercise in bedside pathology and
therapeutic methods.
The disease in a person who presents himself to
a doctor in hospital is more often than not a tail end of the whole of
disease process in an individual.
Natural history of the diseases..in
individuals has no place.
Some of the most common diseases and less
..
3/
-3lethal diseases like scabies, malaria, mild anemias, moderate malnu
trition and beginning of diseases are hardly ever taught since they
are considered 'poor teaching material.'
Health and sickness in the
population with their possible correlations with significant social
and occupational influences are outside its province.
Problem Posing (of Ill Health)-A Community Health Way,
Community health far from being a 'subject' is a point of view,
a definite way of looking at the problem of dealing .with ill health
in individuals in their social, biological and physical setting.
Community health has at its focus both individual and his environ
ment.
Community health is after all about the health of all indivi
duals in the community and not in an artificial and unrealistic
setting called hospital.
This way of looking at a problem of illhealth
in individuals in the society cuts across the largely confused and,
therefore, sterile debate on dichotomy like curative Vs preventive
medicine.
As a logical corollary to this shift of focus a similar
shift also occurs in remedial measures to be instituted.
The problem changes - consequences follow.
Having thus made a point that community medicine is not to be
treated as a separate' subj ect'—a grave mistake made in the traditional
medical education because of narrow (and unreal) way of looking at
problem of ill health in individuals - to be taught but should form
an overall framework within which the problem of illhealth in indivi
duals is to be posed and examined, we should now like to derive a
broad principle from it; the principles and methods appropriate to
understanding the disease not only as an end point of pathological
processes in an individual who seeks, on his own, medical help but
also, indeed mainly, as a disease process which gains an entry in the
community, spreads its tentacles, consolidates and entrenches itself
in different individuals in different forms and intensities, in diff
erent social groups, in different environments (used in a wider sense
as used above), in the community must permeate through all subjects basic sciences and socalled clinical subjects.
At this stage we would
like to touch yet another controversy in the current debate on medical
education ; whether the basic sciences should be taught at all ?
If yes, what? how much; and at what stage ?
In our opinion it would
be nothing less than monumental blunder to do away with the teaching
of basic sciences.
We also express our deep reservations about the
tendencies to suggest deep and extensive cuts in the basic sciences
on very superficial grounds of their supposedly limited utility in
actual practice.
The community health must remain rigourously sci
entific.
The deep insight they have developed in the life processes
are vital for the development and growth of community health. Although
wo are proposing that basic sciences must be taught within the frame
work of community health, we hasten to add that we do not know enough
to suggest precise manner in which this can.be achieved.
Ours is an
attempt to establish a proximate principle; the detail working-out
will call for much larger efforts by people of various skills, expe
riences and background.
Another major consequence that follows from our main thesis that
ill health of man in society and not ill health of man in the hospital
ward should be in the focus of medical education, the next logical
question we want to raise is ; what arc the health problems medical
education should be focussing on ?
This point is of crucial importance if the foregoing argument
is to retain its validity and sharpness.
Indeed, without the unambigious answers to these questions, the thesis we have proposed can be
..4/
twisted to serve more or less current model of medical education.
Disingenuous interpretations may be attached to it to mean ; who
soever comes in the hospital, his/her social setting will be taken
into account, succeeding thereby in retaining more or less intact
the present model of medical education.
Paler versions of such
'society-oriented1 teaching programmes (progressive ?) are to be
seen in today's family visits or integrated clinics (a teaching
session in the wards jointly conducted by a staff member each from
clinical medicine and PSM).
A Selection of a case in this exercise
is a function in the first place of selection of patients for admi
ssion which has little relation to health problems prevalent in the
society.
To avoid such deceptions, we should say a little more precisely,
it is not ’man in society' in the hospital who moves under the focus
of medical education rather the focus of medical education now moves
out of the hospital to be trained on ' man in society. '
Selection for medical education of health problems in society
should naturally depend on society's experience of most common and
significant disorders which cause most mortalities, suffering and
disabilities.
Selection of such problems is not always easy—even
if we ignore the pulls and pushes exerted by powerful interests in
the society.
Some give and take is always inevitable.
Even so what
goes on in today's medical education is so out of place, so otherwordly (we mean the worlds of rich and powerful in the cities of
India, USA & UK), so unrelated to India's major health problems
that it can not be criticised enough.
The actual regulative
principle which guides the design of curriculum is completely at
varience with this regulative principle to which most of those who
are somebody in medical education pay a lip service only.
Let us try to take a stock of health situation in India and see
how medical education measures up to.
Mortality is heavily concentrated in young age groups. 45 to 50%
of total mortality occurs in children below 5 years of age who consti
tute 15 to 18% of total population.
Of thes ? deaths more than 90%
deaths are preventable, should be prevented eventually.
In any deve
loped country children below 5 years contribute less than 1% of the
total deaths.
Comparative high proportion of death rate is found to
be concentrated in elderly population (more than 65 years).
What is
more, very little can be done to prevent these deaths, or to prolong
life very substantially.
Deaths associated with pregnancy in our country is atleast 20 to
Again as large as
30 times more than in well-developed countries.
95 % of these deaths can be prevented by intelligent human intervention.
Why these preventable 'deaths occur ?
The most important causes of infant deaths (deaths below 1 year)
are ; (1) complex interplay of Protein-Energy-Malnutrition (PEM) and
most common infections like diarrhoea, respiratory infections, and
skin infections, and (2) babies bom with low birth weight ( less
than 2.5 kg.) which is substantially a function of maternal malnu—
trition ( P.E.M.)
Deaths in children (1 to 5 year) which is 50 to 60 times more
common than in well-developed country is almost exclusively a function
of common infections and PEM.
...5/
-5-
High maternal mortality is again a function of iron deficiency
anemia which is almost hundred percent; PEM; infections after
delivery and inadequate monitoring and care during pregnancy and
labour.
Hundreds of thousands of children lose their vision due to Vit.A
deficiency.
Communicable diseases like gastroenteritis, pneumonias,
scabies, malaria, T.B., leprosy, measles, and many others continue
to play havoc with community without meeting any significant resistence or fight.
The list of the problems can be made much longer than
this, but suffice it is to say that most mortalities and morbidities
are due to either deficiency diseases or infectious diseases or both.
Many fair-minded people might think that we arc stretching our argu
ment too far.
They might argue that many progressive changes have
been introduced - more rural orientation, more about common diseases
etc.
We would like to assure them again that it is not so.
Several years after smallpox was eradicated from India.
Ono
wonders how many medical students or for that matter members of tea
ching staff except perhaps members from PSM Dept, know the most out
standing elements of strategy and rationale of it which achieved such
amazing results.
A pretty dangerius disease was conquered (without
any active involvement of medical colleges) and we have taken no note
of it.
The history of malaria eradication is even more instructive.
The ambitious grand strategy was based on one of the finest epidemio
logical models man has developed of infectious diseases.
Superb orga
nisational efforts went into it.
Fine statistical and epidemiological
tools were developed to implement the strategy.
It reached a dizzy
height of success and then came tumbling down.
Why it achieved what
it did ?
and why did it fail ? While this great drama was being
played out in the five lacs and seventy five thousand villages, batches
after batches of medical students were going through the motion of
medical education without much ado about malaria epidemiology and the
strategy.
And this is not merely a question of teaching malaria.
A full 10 years after the elegant model of malaria epidemiology was
perfected and grand strategy to eradicate it, was pieced together;
the expert committees one after another were recommending 'progressive
changes' in medical education to make it more responsive to social needs
taking not so much a note of malaria epidemiology and eradication
strategy.
As we shall see presently the teaching of sound epidemiology
is so fundamental to teaching of community health; malaria epidemiology
and use of epidemiological and statistical tools in the eradication
strategy could have provided a strong base and an impetus to the robust
teaching of community health to medical students, but it seems nothing
was further from the minds of these experts than this relationship.
The result was loss of great opportunity on the one hand and adding
trivial notions in medical education, on the other hand.
Those who
are still convinced about 'the progressive changes' should ask one
question to themselves ; what weight is given to these changes in the
examinations both written and oral ?
Medical education in U.S. puts Ischemic Disease of Heart (IHD) on
priority list, so does (almost) our medical education.
IHD is 2nd most
prevalent disease in U.S., first being hypertension. IHD is number one
killer in the U.S.
In the U.S. infant mortality is 7 times less than
in India.
There are not any reliable studies in India to give us reli-able prevalence rate of IHD; but it is almost certain that prevalence
is bound to be much lower than two percents found in U.S. because of
the simple reason that a proportion of adult population at risk in India
is so much lower than in the U.S.
Also most of the adult population
which lives in the rural areas is too poor, and too hard working to
carry the load of risk factors which the U.S. adult population carries.
Contribution that IHD could be making to total mortality in India is
bound to be infinitesimal.
In any well-developed country, where infant
mortality is approaching 10/1000, in a population of the size of
Gujarat there would be less than 10 deaths in infants because of
...6/
-6-
diarrhoea every year; where as in Gujarat where infant mortality is
much more than 100/1000 the total number of deaths in infants every
year because of diarrhoea is expected to be 60,000 11 (based on B.
Nicholas and H. Soriano in The American Journal of Clinical Nutri
tion 30 : September 1977).
Another false notion which has gone round
in recent years and this time mainly from the critics of health system
that most prevalent diseases in India are simple.
If there was a
case of more simplification than is possible or necessary this is the
one.
This injurious belief we suspect is even shared by medical esta
blishment.
The dangers of such beliefs are clear.
They may well lead
to a kind of smugness and complacency in whi h it is not considered
necessary to understand thoroughly the dynamics of diseases most pre
valent' in the society.
This undertaking can be as trying as - if not
more - the one that has to be undertaken to understand the diseases
which dominate western medical education as well as ours.
This argu
ment is not to be interpreted to mean that the study of degenerative
and neoplastic diseases is to be completely removed from the medical
curriculum; it is to argue only that sense of proportion is needed.
In this connection let us stress again that basic sciences are as
basic to understanding our diseases as they are in degenerative and
neoplastic diseases.
Protagonists of their drastic curtailment must
pause and ponder.
The ignorance of medical students and teaching
staff of medical colleges about the dynamics of infectious diseases
and deficiency diseases which cause most of the mortality and morbi
dity is to be seen, to be believed.
It is impossible to defend the current focus of medical education
in India rationally.
One may, ofcourse, invoke the argument of bala-ce of power in the society but it is not a rationale as the word is
normally understood.
Instead of meeting this massive challenge of infections and nutri
tional disorders which kill and maim children and women of poor famil-ies in rural and urban areas and sap the energy of working men and
women all over the land and lead to their premature deaths, what wo
have done is to insert one subject called community medicine to be
learnt by and large from one text book of preventive and social
medicine (Textbook of preventive and Social Medicine by J.E. Park)
in the medical curriculum.
This, to say the least, is mockery of
the concept of community medicine.
The Methods and Tools of Community Health.
What we have said so far in this note is to state the objectives,
the rationale thereof and overall framework in which the problem of
ill health in society should be viewed.
We have also briefly alluded
to values that normally should go with this.
The real question now is;
how to transfer these objectives and
values into tangible reality ?
The methods and tools by which the objectives as described above
are to be realised, assume the importance and receive attention they
deserve; only when they are viewed in such conceptual framework of
values and problems.
In absence of such overall framework, as is
the case now, the vitally important methods and tools are tucked away
in neat and well-circ*mscribcd chapters of textbook of preventive
and social medicine.
These methods and tools -.are then converted into
one of the countless topics to be studied during the whole course of
medical education.
(endless debates go on amongst experts as to at
which stage of medical education these 1 topics 1 are to be taught !
7/
-1Instcad of forming the skeleton and sinetvs of methods and logic
upon which is built the knowledge of commonest disorders of body and
mind in a society, they are turned into trivial, peripheral, dull,
mechanical, bothersome, puny little things to be borne with fortitude
until the time of examination.
Once this ritual is over they are
permanently forgotten and discarded without any sense of loss.
How many times we have peon total incomprehension writ largo on
the faces of otherwise intelligent, well-established doctors at the
mention of words like 'epidemiology1, 'demography1, 'statistics'... etc.
After a prolong silence and rummaging their memories all they can
recall are words, they have heard in distant past and unarticulable,
unpleasant associations with them 1
Yes 1 they are the tools and methods of learning and doing commu
nity health plus the core theories and elements of social sciences.
There are yet others but we will not discuss them here.
Epidemiology is neither a bundle of definitions nor a kit of
tools nor is it merely a lifeless schema of triangle of agent, host
and environment as it is naively made out to be.
It is the method
and logic of health sciences rather than a science itself.
It is in
the framework of epidemiology that one can understand, study and
analyse happenings like various health disorders in man in society.
It is with the help of epidemiological concepts and tools of analysis
like, prevalence; incidence, incubation period, period of infectivity;
carrier rates; risk ratios; cohort analysis; longitudinal and cross
sectional studies; case-control studies and methods and tools borro
wed heavily from demography, we can understand as to why a particular
disease gets established in certain age, sex, social groups at a
certain place, at a certain time; what keeps it going ? when it
changes these characterstics, why it does so ? ; and how it relates
to other diseases in the society ? The understanding of distribution
and determinants (causes) of most important disease complex of a given
society provides us clues, pointers and methods to intervene so that
their hold on the society may lessen progressively until the time
when they are eliminated completely or tamed considerably.
Similarly Statistics is not to be looked upon as highly abstruse
mathematical formulas which are largely irrelevant for our purpose
and loaded with jargon.
It should bo viewed as an invaluable aid to
introduce necessary rigor in collection, arrangement, and analysis of
observations in human or any living/non-living populations and deri-ving accurate inferences from them.
It is said about statistics in negative sense that it can be used
to prove anything, therefore not to be relieduupon.
There is some
truth in this charge but fault is not of statistics as a method or a
mean but of faulty way it is used.
The best and rational way to fight
abuse of such a fine tool as statistics is to understand it ourselves,
know its limits and worth.
Ever-growing literature of health sciences
is full of contending theories, ideas and interpretations.
A doctor
must be able to make reasonable assessment of these competing ideas
herself.
This is possible only when they have sound grasp of basic
epidemiology and statistics.
When this is not so, most of the doctors
are reduced to either fall prey to any claim that appears in
' pestigious ' journals or to stick to his outdated textbooks or to
adhere dogmatically to his own clinical experiences which is very often
a ragbag of impressions only or to accept meekly what drug industries
tell them, through the flood of literature which many times is dubious,
deceptive, and dishonest.
Demography as alluded above provides many tools and methods to
epidemiology.
In the present medical education they have degenerated
into another bundle of informations to be learnt by rote without under
standing or insight in these concepts, (e.g. life expectation at birth
-8-
or at one year of age, crude death rates, birth rates, standardisation
—direct and indirect, sex-ratio, fertility rates, infant mortality,
childhood mortality, life tables...etc., etc.)
These are not merely
numbers to be memorised because a pedantic or eccentric professor
chooses to ask such silly questions in the examination.
These statisticks, in fact, represent in a distilled form information about cha
nges in the size and structure of population and the forces which
mould them.
They help shed light on immensely complex and subtle
processes of health and disease in the society.
For instance, high
rate of infant mortality in one society as against the low rate in
another society says so much about the possible differences in two
societies which otherwise would not come to our notice and we could
not have guessed the role they play in shaping the events.
Life
expectation at birth is not merely two digit number, which changes
mysteriously every decade.
It is a composite figure arrived at by
taking into account mortalities at different ages in a population.
It should prompt us to ask further questions of pattern of mortality
at different ages and the reasons thereof.
The term 5 year survival
rate we have come to be familiar with in cancer treatment and progn
osis is based on the methods of demography.
Needless to say its
utility is not confined to cancer only.
Thorough analysis of the processes that determine the values of
these statistics has attained high degree of refinement amongst
health professionals in the West whereas we still do not have a
reliable system of collecting information continually from the whole
population on such vital events as births and deaths, let alone an
adequate analysis of these events to tell us what is going on in
the community.
It is symptomatic of deep malaise that has set in
our medical education with its totally upside down priority of
problems and methods, that major and crucial debate on causes,
extent and effects of such vital events as infant mortality, mal
nutrition in children, reversed sex-ratios is being conducted in
non-health journals like Economic and Political Weekly.
Need it
be said that barring a few notable exceptions the participants in
this marathon debate are non-health professionals ? Medical profe
ssion has by and large no competence and no will to discuss such
issues which are at the heart of the health of the society.
With this we come to yet another tool of community health ?
the theories and methods of social sciences.
They are indispensable
to grasp social processes as they affect the health of the community.
In the foregoing discussion we have stressed the heavy inter
dependence of the methods and the tools of community health.
This is
true of social sciences also.
If epidemiology is the study of distri
bution and determinants of health and disease in population, part of
its province is the study of social factors.
Indeed every epidemio
logical variable in some sense is a sociological variable.
The
factors affecting the distribution of disease in population may be
biological and/or environmental and both have social implications.
Attributes such as sex, age...etc. have traditionally—in the
etiology section of most of the textbooks of clinical subjects—
been treated as biological attributes only; but they obviously
have social meaning.
Concentration of diseases and deaths in certain
sex and age groups may also mean that they suffer from certain dis
advantages because of status in the family and society and norms
associated with them. (e.g. greater female infant mortality, greater
prevalence of severe forms of PEM in female children, reversal of
sex-ratio, extremely high prevalence of iron deficiency anemia in
young women, and higher rate of PEM in women are not function of
biology but a result of the status of women and children in family
and society.).
.... 9/
-9-
Disproporticnate concentration of deaths, diseases, and dis
abilities in rural poor-landless labourers, marginal and small
farmers, unorganised labourers in urban areas, tribals, harijans,
their women and children can not be understood by such dull and
monotonous intonations which occur regularly with little change in
the different chapters of text book of preventive and social medicine
like 'poverty, ignorance, superstition, lack of personal hygiene,
overcrowding, poor housing, poor sanitation.... etc. 1 '
These amorphous concepts don't tell
s what sort of economic
and social processes are at work which produce huge differences in
economic and social opportunities to different social groups, situ
ated at different places which all have a close bearing on the health
statuses of the groups concerned.
Further more these factors are in
urgent need of more refinement and differentiation in relation to
each disease.
They call for much harder work and analytical skills
than today's medical schools are ready for.
The Result 1!1
When a conceptual framework like the one discussed above is
missing and perception of need to incorporate the tools and the
methods of community medicine in a manner such as discussed above
is very dim? what, happens can be seen even if hazily by a few exa
mples given below.
1.
It was a health camp of medical students.
They were asked to
carry out nutritional survey (anthropometric) of under 5 children.
They came back bitterly complaining, 'it was no use.
No mother can
remember the birth dates of her children.
What sort of mothers
they are ?
If they can't remember the dates even, what can we teach
them to care for tHeir children better ?'
This is not an isolated
experience.
It is a part of a pattern.
City-bred medical students
can not imagine let alone understand that poor mothers in the vill-ages do not organise their lives by Gregorian calendar (loosely
spoken as English calendar.)
They are not in the habit of being
asked such 'pointless' and isolated questions.
If you have time,
patience and understanding of their time f amework then you get
birthdates of their children which are accurate enough for the pur
pose of either monitoring growth or assessing their nutritional
states.
They recall vividly the days and weeks when their children
were born in relation to various points of season's cycles, agricul-tural cycles of various crops, Hindu or Muslim calendars or festi
vals, provided we know about these cycles and calendars ourselves.
Not many of us know this ofcourse.
This is a very small example,
but it illustrates rather well that medical education has no use of
social knowledge and experiences.
2.
A mother comes to hospital out patient with a moribund child
in her hands.
Child is severely dehydrated because of diarrhoea.
Almost immediately a chorus of indignant voices arise from doctors,
nurses and medical students.
' how ignorant is she...how callous of
her to have brought child at such a late stage...when these people
will learn to be more responsible and caring.She will not
and cannot say that she has to go to fields every morning until
evening to earn wages which arc always much less than stipulated
by minimum wages act which nobody wants to see implemented seriously.
She leaves the small ones in care of elder ones.
If she does not go
to work they go without food.
Behind this dumb mother and moribund
child lies the hideous social reality which nobody wants to know or
cares about.
ORT or I.V. drip ? This is not a purely technical question.
It is certainly an instance of imbalance of salt and water, of acid
and base in child's body fluids but we should remember that similar
.... 10/
-10-
imbalances occur throughout the year in millions of human bodies who
are scattered in hundreds of thousands of villages who have no access
to health services.
When thousands die because of such imbalances
they (these imbalances) no more can remain confined to biochemistry,
and medical education must impart this perspective to the students.
(How many medical colleges today teach ORT with intensity and inte
rest it deserves ?).
3.
Sometimes ago we were invited to a meeting where the question
of high infant mortality in Gujarat was to be discussed.
(Gujarat
has 3rd highest infant mortality in India.)
Question was put to a
panel of paediatricians.
Pat came answer; without a moment's pause;
'because people are ignorant and superstitious.
For instance in
measles people believe that it is duo to visitations of a goddess
and child cannot be taken to a doctor for treatment, they therefore,
don't seek early medical help.'
Again this is not an isolated instance.
We have heard this
same theme in many variations many times.
Either those who make
such statements are careless or they betray serious gaps in their
knowledge of the type we have been discussing.
a)
; It is true that a child suffering from measles
is not taken to a doctor once rash begins to appear
on the body; but then at this stage of disease
doctor cannot do anything to alter the course of
disease either, even if the child is brought to him.
b)
z Most of the deaths occur because of bacterial- pneumonias which occur after rashes have begun
to disappear; the time when parents are quite ready
to take the child to health service provided it is
readily available and reasonably cheap.
The question
is: when epidemic of measles sweeps through the remote
villages are there adequate health service networks
to cater to their needs ?
Larger and more loaded questions like why measles which is supposed
to be a minor ailment without any consequence in well-nourished chil
dren extorts heavy price of mortality (15 to 20 %), extensive and
serious morbidities such as loss of vision in thousands of children
and precipitation of severe nutritional crisis in high percentage
of poor parent's children ?
A camp was organised to understand ecology of PEM and infant
mortality.
Two bright medicos asked : is measles really a problem ?
Isn't it supposed to be a mild disease after all ? We were not
surprised to hear these questions.
Look for the reason — if you
are surprised-in the textbook of preventive and social medicine
(Referred above) on pages 356-53 (4th edition) where measles is
discussed.
How casually and cursorily it has been discussed J One
almost gets an impression reading his account of measles that he is
writing for and about upper socio-economic stratum of the society.
His chapters on history of community health, epidemiology, concepts
of community health in which on page 48 occurs a paragraph of about
200 words on community diagnosis which is not so bad as far as
contents go; but which is clearly meant to be memorised by medical
students and not to be taken more seriously, sociology and health,
nutrition and health, and so on not withstanding; a great violence
is done to the cause, concept and theory of community health.
This book is supposed to be main source of 'knowledge' of community
medicine for the medical students in India 1
...11/
-11CONCLUSI ON
Q <•>->
In this concluding part wo would like to discuss two points
;-
A) THE ROLE OF VOLUNTARY HEALTH GROUPS
It is true that voluntary health groups like MFC have done a
good job to help focus on grave problems that beset health system
in India.
These groups have either implicitly or explicitly criti
cised the system for 'its
excessive biases for ; (1) curative medi
cine, (2) hospital-based health care, (3) ci Les, (4) the rich and
powerful sections in the cities, (5) disease pattern predominent in
the West, and in a tiny fraction of the population in India.
The logical compulsions arising from such damning critique are
now pushing these groups to move foreward, extend their role into the
uncharted territory of alternatives to present health system whose one
subset is medical education.
Let there be no misunderstanding here
that those who discuss critically the present medical education and
alternatives to it are under obligation to run a medical college based
on different objectives, values, curriculum and methods.
This is a
false alternative; it can lead to inaction.
However, the groups themselves have to respond intelligently and
sensibly to basic issues of ill health in society discussed in this
note.
It is through continuing analysis and actions of various groups
on atleast some of these problems in similar perspective that relevant
durable, and realistic pieces of knowledge are going to be built.
Without such necessary ground work even a crude prototype of relevant
alternative medical education is not feasible.
At this point we would like to direct a searchlight of criti-cism on ourselves.
We all know that medical colleges as institutions are far too
rigid and too bogged-down in quagmire of unhealthy values, wrong pri-orities and practices to give a new lead.
To expect them qua
institutions to initiate relevant changes away from such tendencies
is unrealistic at the moment.
What has been the performanc e of volu
ntary health groups in this regard ?
Two broad responses can be discrened.
One response has consi-ostently been to lament the fact that forces generated by a particular
form of social and economic organisation are responsible for this
state of affair.
As long as they remain in force, any well meaning
attempt to look for an alternative or to try to evolve one-even if
rudimentary- is bound to fail or to be crushed by the powerful system.
This position has a degree of plausibility when a problem of ill
health of community is seen at .a very broad level and analysed in
terms of categories like gradient of morbidity and mortality along
the social classes, unjust characteristics of economic system mani
festing itself in income disparities, poor sanitation, poor housing,
poor nutrition...etc.,etc.
Its truthfulness is not in question, as
is the truthfulness of monotonous slogan 'poverty, ignorance, lack of
sanitation, poor housing...’ which we have felt compelled to criti
cise in the foregoing part of note.
Second response has been to take certain health activities in
the fields.
The common elements of such efforts are broadly as
follows ; (1) They work mainly amongst rural poor, (2) they have a
team of village health workers, (3) they carry out activities like a) immunisation of children and pregnant women, (b) run ante-natal &
under 5 clinics and (c) do health education.
Now there is nothing
objectionable against these elements of activities perse. Doubtlessly
they are the steps in the right direction.
The real problem does not lie in actual activities but lies in
the theoretical understanding of complexity of disease processes in
the community that inform these activities. Even more pertinent point
...12/
—12 —
of view is whether the understanding of diseases considered insufficient
and therefore in need of continual improvement which can be done only by
conscious development of abilities and competence in the methods of —
community health.
Voluntary groups are under obligation to learn new methods and
tools to further'extend and develop relevant, useful and durable knowle
dge of diseases in the community. Whatever are the restrictions of the
system it does provide enough scope to develop such actions. The trouble
seems to lie somewhere else? voluntary groups are by and large tied down
by their own training (this we have discussed at length above) and have
also accepted uncritically the notions such as 'most of the diseases are
simple and can be treated easily.'
The 'felt need' of voluntary health
groups excludes these methods and tools.
The result is only growth of
mechanical, lifeless structures of activities and flourishingof stereo
types without any insight or understanding. The uncritical acceptance of
notions such as 'diseases are simple...;' which themselves are product
of the ideology of 'ill health in man in hospital' have pushed them if
unwittingly into extending outpatient to door-steps of individuals.
The criticism which applies to the structure, the content and the
methods of teaching of community medicine in medical colleges applies to
voluntary efforts also, if with diminished force.
The glaring gaps in knowledge, the blind spots in epidemiology of
diseases, as they are found in our situation, the methods of translating
this knowledge into useful health activities, knowing the society and
social processes which affect the acceptance or rejection of such health
activities await serious exploration and trials on a large scale.
Only in this context we say to ourselves : it is not enough to
interprete and criticise the health system as it is today; the point
is to change it.
Speaking of change brings us to second point of concluding part
of the note.
B) THE ROLE OF MEDICAL EDUCATION IN _CHANG E OF COMMUNITY HEALTH.
Improvement in the health of society is a function of understan
ding of diseases in community and social actir1 informed by this under
standing. We believe the role of medical education is to develop such
understanding. It cannot be a substitute for social action.
Chadwick's sanitary revolution in mid 19th Century in England is
a classical example of this combination.
By mounting systematic nationwide studies, Chadwick produced a
massive indictment of working population's sanitary conditions in a book
known as 'The Sanitary Conditions of the Labouring Population (1842)'.
Advent of cholera epidemic in Europe from India created a lot of appre
hension in Europe. Doctors began to connect ill health more specifically
with pollution of environment (this was at a time when the discovery of
germs still lay in future.
The evidence was only epidemiological.)
There was a growing consciousness and demand from public for public
measures of control. Chadwick was able to marshall these forces which
ultimately culminated in Chadwick's Public Health Act (1848), which
ushered in sanitary revolution in England.
PREPARED BY s
Ashvin Patel and Anil Patel,
Action Research in Community Health,
Mangrol, Tai: Rajpipla, Gujarat,
PIN: 393 150.
-mFc-
December 27,
1934
A PERSPECTIVE _FOR DISCUSSION OP INDIANS
N ATfON AL~'TUBERCULOS I S~'" PROGRAMME
Debabar Banerji
Professor
Centre of Social Medicine & Community Health
Jawaharlal Nehru University
New Delhi-110067
Introduction
I have been engaged in writing on health service
development in India for quite some time.
has
This
enabled me to bring together some of the main
ideas which I have developed in the course of my
work of over three decades.
I am preparing this
note because India's National Tuberculosis
Programme
(NTP) provides a very good example of
an aspect of health service development in India.
I
am hoping that this perspective is given due
consideration in any discussion of NTP.
Incidentally,
study and analysis of the
approach to NTP also raises very interesting and
fundamental questions: Why was
this approach
Why was this
adopted in the case of tuberculosis?
approach not adopted in the case of Community
Health Workers.’1
Scheme,
Multipurpose Workers! Scheme
or health service research for rural health develop
ment?
Why was
this approach not adopted in the
formulation of the National Family Planning Programme
the National Malaria Contro1/Eradioation Programmes,
the National Leprosy Control Programme,- the National
Programme for Control of Blindness,
Filaria Control Programme,
the National
and so on?
Two fundamental considerations emerge from
the instance of the NTP.
Fir.' t,
it is the ,;e'?le
who provide the primer1’ motive force for social
revolution or social transformation.
There are
three types of persons who are directly or indirectly
related to this dynamic movement of the people.
There arc. those ’■'be oppose the social revolution with
2
all their might.
Ironically,
there are other
persons who are well-meaning and have radical creden
tials,
but because of their inability to think clearly
they create more confusion and in this way obstruct
the march of the people.
Finally,
there are those
who have the humility to understand the primacy of
the people and who are prepared to make their modest
contribution in facilitating that march.
My feeling
is that while discussing issues
that concern health of the people we have to under
stand the momentum of the movement among people
themselves
and try to find out how to minimise the
hurdles that are put on their way and how to contri
bute to the march through our own inputs.
The second fundamental consideration arises
from the first.
It concerns the technological,
epidemiological,
social and political competence of
those who venture to formulate people oriented health
programmes under the conditions that exist in a
country like India.
it’.-, some of the
This note ’-.•ill first deal
positive gains made by the people of India in terms
of developing a public health approach to the problem
of tuberculosis in the country.
T is will be
followed ■ •ith a brief account of the way a group
of interdisciplinary scholars have got together to
formulate a nationally applicable,
socially accept
able and epidemiologically effective tuberculosis
programme for India.
Then there will be analysis
3
of the factors which have come in the wav of imple
mentation of the NTP and how pressure from the people
is
at work in overcoming those hurdles.-
Some Positive Aspects of Tuberculosis
Why is it that as early as
in India;
in 1951 an effort was made
to develop epidemiological approach to the problem
of tuberculosis in India?
prevailing at that time,
as
the approach
but considering the situation
was very modest,
culosis workers
Admittedly,
it is remarkable that tuber
even dared to deal with tuberculosis
a public health problem by launching the Mass FCG
Campaign .
Why is
it.,
again in the early fifties,
that
India could launch the National Sample Survey of
Tuberculosis
in the country which,
obvious shortcomings,
despite its many
can still be considered as a
classic epidemiological study carried out anywhere
in
third world, countries?
Why should India have
undertaken the classic study of comparison of home
treatment and sanitorium treatment of tuberculosis
cases by establishing the Tubcrculoais Chemotherapy
Centre at Madras in the mid-fifties?
Why is it that
some of the pioneer tuberculosis workers
in India
had already started providing domiciliary care to
tuberculosis patients well before the findings of
the Madras study became available?
Finally,
perhaps
as
dynamics of the movements
a culmination of the
referred to above,
why is
it that as early as in 1959 the Government of India
established N '.tic-nal Tuberculosis Institute
(NTI)
giving it the specific mandate to make an inter
disciplinary
applicable,
approach to formulate a nationally
socially acceptable and epidemiclogically
effective NTP for India?
Then,
why should NTP
become a part of the Prime Mini te-r- s Twenty Point
Programme?
The Work of Womc .socially Sensitive .Community
Phvs\clone in the Field of Tuberculosiss
Perhaps one of the very significant features of
tuberculosis work in India has been that throughout
the past several decades there have been many dedi
cated and committed tuberculosis workers who had
been ceaselessly trying to deal with tuberculosis
as
a public he alth problem.
It is. t’.i" momentum c
work of the pioneers which led people in NTI to adopt
the approach of "going to the people and learning
from them" in fomulitin-
culosis Programme.
India's National Tuber
This in fact was a major landmark
in health service development.
It she -cz. vividly
how those who have a vested interest in perpetuating
the old order had been making people the scapegoat
to explain away their inability to develop a tuber
culosis programme in the country.
injury,
Adding insult to
they had been using their biased concepts
about the people to create a market for the sale of
mass-radiography units in the country.
Providing a sociological foundation to the
formulation of the NTP not only added, a very vital
social dimension to understanding the epidemiology
5
of the disease in the country,
but it also was
instrumental in formulating a people oriented
technology to deal with, the problem of tuberculosis
under the then existing conditions and also providing
a direction for development of the programme as more
ant, more res -urocs are made available to it.
The last portion of the previous sentence is
being underlined to emphasise that conceptually r’TP
is
a dynamic entity and it does not accept any limi
tations as such;
its advantage'■ is that it ensures most
effective use of whatever resources that could be
made available at a given time.
I would stress once
again it does not in any way impose resource limita
tions as a permanent constraint.
Data about people also showed us where to
provide tuberculosis services .
People told us that
they will like to have tuberculosis services as an
integral part of the general health service system,
and not as
a vertical programme.
Apart from the very challenging t«.sk involved
in working out the details
of a people-oriented
tuberculosis programme for the country as
a whole,
socially concerned tuberculosis workers ..had also to
contend with very complex questions concerning defi
nition of a case of a tuberculosis,
place of radiology
in the diagnosis of tuberculosis efficacy of different
combination of chemotherapeutic agents,
the problem
of drug resistance and the problem of treatment
default.
6
Each one of the above problems was used by
the vested interests,
who wanted to thwart the
efforts of the people to have a tuberculosis
It goes to the credit
programme for themselves.
of tuberculosis workers in India that they had had
the epidemiological and. social competence to
withstand these efforts.
Their success is reflected
in the fact that NIP is not simply accepted as the
national programme for I-bi.,
' it b
has
also been
accepted virtually everywhere in the world.
result of its
acceptance in India,
As a
there has been
an astonishing demystification of tuberculosis work.
Tube re.'. 1
b
as
ably devalued.
a medical speciality has got consider
Sanatorium construction,
'which was
once such a massive component of the programme,
has
now tapered off.
The Nc.tj
nsl Lc. i
Control Programme
(HLC.-)
contrasts sharply with NTP in terms of clinical,
epidemiological,
cal inputs.
administrative as well as sociologi
Significantly,
the call for strengthen
ing NLCP came from the political leadership - from
the then Prime Minister herself.
But the response
of the scientists was patently inadequate and
unscientific - e.g.
"essentiality of verticality",
"»ulti-drug therapy" and "immunomodules" for
developing a vaccine.
What was the response of
socially sensitive community physicians to such
recommendations?
Indeed,
how did they respond to
the ICSSR-ICMR Report on Health For All by 2000 AC?
7
Obs tractions in the Implementation ci '.'.TI-;
Obstructions were expected,
as
because FTP was designed
an integral part of the general h alth services
of the country and it was
anticipated that because o'
the power structure and the class character of the
medical and social science establishment,
there would
be considerable opposition to the implementation of
the NTP.
How many of the physicians in the country
are familar with NTP?
How many of the social
scientists in India are familiar with the social
science studies in relation to the NTP?
how many professors
matter,
For that
of sociology or of tu?oc.r-
culosis or of preventive and social medicine in Inf-,1a
are familiar with NTP?
What is the political economy
of such a crass ignorance?
There is
also the question of default.
who is the prime defaulter?
But
Those who are still
allowing millions and millions of cases,
who are
knocking at the doors of the various health insti
tutions,
to be dismissed with a bottle of cough
mixture are the ^rch defaulter5.
Big defaulters arc
also those who deprive people of facilities for
dignosis and treatment because of administrative
neglect.
Ironically,
these defaulters are not taken
note of by crusading social scientists and tuber
culosis workers
and voluntary social workers who
rush forward to heap abuses on the people for not
taking the treatment prescribed by ill-informed
phys icians.
8
The muddle headed thinkinc
among obviously
revealed
well-meaning social physicians also cots
when they fail to understand. NTP in its wider pers
pective and get preoccupied with the minutacs.
People have taught us
that their needs
for
dignosis and treatment arc- not met by the establish
for not meeting that need are quite
The causes
ment.
apparent.
It is this failure to meet people's need
which should become the prime instrument for belabour
ing the system.,
It is conceded immediately that once
the needs are met,
one keeps on the pressure by
insisting on better and better services
people.
However,
for the
if this basic weakness of not
meeting the pre-existing needs of the people is
ignored and a case is made for better and better
treatment for those who happen to get their needs
met,
we would unwittingly be doing damage to the
people at large by putting the cart before the horse.
We will go on demanding cakes
for the few while vast
masses arc ibeing denied even bread.
This
is one of
the major failings of those who are concerned about
the people but who have not acquired the epidemiologi
cal competence to see the entire problem in its
perspective.
Recent Developments;
The launching of the Multipurpose Workers' Scheme and
the Community Health Workers' Scheme,
strengthening
of the staff at the sub-centre level and inclusion
of NTP in the Twenty Point Programme present yet
- 9 -
another facet of the victory of the people in wresting
their rights
from their oppressors.
Significantly,
the oppressors have hit back once again by bringing
the cart before the horse.
by the drug industry,
Presumably encouraged
they are showing concern for
the tuberculosis patients in the country not by
widening the base,
therapy,
but by talking of multi-drug
which includes
rifap.icin.
MggXgQ FRIgHD CIRCLE a 13TH AEBTU-AL. MEBTy 26-27TH JANUARY,
1987.
1
POPULATION VERSUS RESOURCES-AN APPARENT PROBLEM
*
V
•••
«
>
*
•
t «••■•• •
t •••• t
• * • * •
-Anant R.S.
Many people believe that the increasing population in
the world,specially in the Third World can not be properly
supported because we just do not have enough resources to do this.
According to this belief, unless the population-increase in the
countries like India is rapidly and drastically controlled, we
would not be able to achieve a descent life for all our countrymen;
on the contrary we may end up in a catestrophy.
hurriedly written note,
In this somewhat
it is my intention to critically examine
this apparent problem of Population versus Resources-population
eating so much into availability of resources that descent human
life for everybody remains a pipe-dream.
The historical experience in the West
It would be quite revealing to go into the historical
experience of the problem of population versus resources.
Malthus
put his theory of population explosion in 1798./1/It was used as a
political weapon against the French Revolution and against various
liberal,
radical theories which sought to explain the poverty in
Europe in terms of the decaying feudal order.
Malthus's theory,
however, explained poverty in the " Natural law " of population
The feudal.,
oligarchy therefore used this theory in its
political struggle.
Malthus was rewarded with a professorship at
growth.
the East India Company's College.
History proved Malthus wrong.
With the growth of capitalism, there was an all-round increase in
food-production and there were not those kinds of famines due to
shortage in food-production which Malthusian theory had predicted.
In the twentieth century,
in the West,
there was so much
increase in food-production compared to the purchasing porer of
the mass of the people that the era of notorious schemes of giving
incentives to fanners to reduce food production ( to prevent the
steep slump in food-prices and the resulting bankruptacies ) began
and banished Malthusian theory finally and once for all from
Western Societies.
The Experience of Colonial India
Though disproved,
laughed at and banished from the West,
the Malthusian theory was imported, into the Colonial countries to
explain away the increasing poverty and hunger in these countries.
It is now; well-known and well-established that the increase in
poverty and hunger in India was due to the
" Plunder " through
different mechanisms, of the Indian society by the British Colo
But the defenders of this colonial rule attributed
nialists.
this poverty and hunger to overpopulation in India.
Dutt in his
India Today "
Rajani Palma
classic on British Rule
( the famous,
in India and the movement against it ) gives a classic account of
this story of " overpopulation " in British India.
better than quote him briefly.
I can not do
Vera Anstey, one Malthusian
economist wrote " Where is the Indian Malthus who will inveigh
against the devastating torrent of Indian children ? " ( AnsteyEconomic Development of India " p.475).
Another such economist
L.C. A.Knowles declared " India,-seems to illustrate the theories
of Malthus..... " /I-a/
Dutt gives incisive statistics and expert opinion by a
number of British and other academicians ( including those vdao
believed in Malthus ) to show how foolish it was to take a position
that Indian poverty was due to overpopulation.
I would only quote
a couple of key statistics : During 1872-1931, the population
increase in India was 30% whereas in England and Wales an increase
of 77% took place, during the same period.
Europe also,
( except France ) the population-growth was faster
than that in India during this period.
in 1941,
As for population density
the population density was 246 per square mile in India as
compared to 703,
Wales,
In the rest of the
702,
639,
348 per square mile for England and
Belgium, Holland, Germany respectively.
As for food produ-
ction-the production of foodgrains increased by 19% during 1891-1921
as compared to a population-increase of 9.3 % during tho same
period. /2/
-
"
Along with economic exploitation, there was physical
deprivation of the Indian people by the colonial rulers.
In spite
of famine conditions food-exports from India to Britain went on
increasing from £ 0.86 million in 1849 to £ 3.8 million in 1858,
£ 7.9 million by 1877, £ 9.3 million by 1901,
and £ 19.3 million
in 1914, or an increase of twentytwo times over 1 /3/
Population Vs Resources in Independent India
Though proved once again to be in the wrong, even in the
context of the Third World, this theory was once again revived in
a revised form and is being propogated vigorously in India since
the early sixties to explain away the increasing unemployment,
poverty and hunger.
But again facts belie
the propogandists'
hue and cry against the " crushing weight of the teeming millions."
Before we briefly enumerate these facts,
let me make it clear that
3
I am net assining that relative rapid increase in population is not
at all a problem.
Even if development occurs not in a distorted
and hence truncated form ( as has been happening in India ) but in
a planned and healthy way, even then population-problem may perhaps
be one of the obstacles in such a development.
But to be sure,
it is not at all a primary and one of the most important causes
of increasing poverty even in today's social system.
the
" Population-explosion "
Evon today,
is basically a symptom and not a
cause of distorted and truncated development.
Let us now see whether the increasing unemployment,
poverty...etc. in Independent India is due to
" Population - explosion. "
The population in India has increased from 46.1 crores
in 1951 to 65.8 crores in 1981 - i.e. by 83% /4/ ; whereas the
foodgrain production has increased from 48.1 million tonnes to
113.4 million tonnes during the same period, /5/ i.e. an increase
of 135%.
The per capita availability ( which includes production
plus imports, however,
imports have been negligible during last
15 years ) of foodgrains has increased brom 395 Gms. per day to
454 Gms per day during the same period. /6/
inequality,
But due to economic
this food is not distributed evenly and hence there
is extensive malnourishment duo to extensive poverty.
The unemployment in India has increased many more times
than the population-increase—The number of job-seekers registered
with employment exchange increased from 3.29 lakhs in 1951 to
40.69 lakhs in 1970,
to 165.84 lakhs in 1981; to 262.7 lakhs in
Though there are many limitations to these data,
1985 I /7/
( like any other Indian, data ) there is absolutely no doubt that
the unemployment has increased at a fantastically faster rate than
the population-incre'ase.
This unemployment problem is not due to
population-increase but due tc the very pattern of growth of the
Indian economy.
Due to population-increase the population-density in
India has increased from 117 per Sq.Km. in 1951 to 216 per Sq.Km.
in 1981. /8/
countries—U.K.
It is. still less than that of some of the rich
(224), West Germany (244)
and of course Japan (327)./9/
Thus the propaganda that India is. a terribly overpopulated country
and hence is poor is false.
Incidentally, there is no relation
.4.
between population-density of a country and its economic status.
For example, most of the African countries are very thinly
populated ( e.g. Ethopia 35 persons per Sq.Km.) and yet are
extremely poor;
so is the case with some of the Asian countries
(e.g. Burma 54 persons per Sq.Km.
) /10/
Many of the European
countries are much more densly populated and still far better off.
The poverty, unemployment,
is thus not because of
that we see in India today
" too much of population " as compared
to the resources to support it.
As seen above,per capita avai-r
lability of food has increased; but yet there is extensive mal-
nourishment because of the inequality in our existing system.
The industrial production has, of course,
increased many times
compared to the production of foodgrains but the standard of
living of the majority of the Indian people has hardly increased
to any appreciable extent;
for a large section, there has
actually been a decline.
Cmpariaon with China :-
Apart from inequality,
the Indian economy suffers from
the problem of distorted and hence truncated'development.
India
has vast natural resources and trained human-power but these
resources are not being utilized rationally because of a myriad
of vested, exploitative interests.
Since China and India are
quite comparable for a number of reasons,
a comparison with China
One
would give an indication of what can be achieved by India.
finds that the people's Republic of China ( PRC ) has achieved
a far rapid development of its resources as compared to India.
It is difficult to measure the development of resources by a
mere couple of indicators.
But the following two tables would
give some idea.
TABLE-1. /Il/ : Sectoral Growth Rates
1965—1984.
( Annual percentage increase )
(
!
(
( Country.
19651973
Agriculture
19731980
19801984
19651973
Industry
19731980
India
3.7
2.0
2.8
3.7
5.0
fChina
2.8
2.8
10.1
12.1
8.6
( Contd
)
1980-)
1984 )
4.2J
9.3 j
.5.
TABLE-II. /I2/
Production of Coal ,____ Stool and Crude Oil in
India and China.
( in Million
tonnes. )
f-------------------------- —
(
( Country)
(
( India
( (1951-84)
“)
STEEL
COAL
1950
1950
1985
1985
CRUDE OIL
J
1985 _)
1950
34.90
144.80
1.10
5.70
0.26
)
)
30.20 X/
)
J
70.00
813.00
2.00
47.00
1.00
125.00
1
\
( China
( (1950-85)
L
In the Industrial sector as a whole, the industrial
production in PRC has increased at an annual growth rate of
12.2% during 1950 to 1985, /13£f
was only 5.8 %. /14/
whereas in India, this rate
It is clear from those statistics that
both in Agriculture and (much more)
in Industry, the PRC has
achieved a much more rapid increase in the development of
its resources.
China has used this development of its productive
capacities in a much more rational way.
This is evidenced
by the fact that though the average per capita income in PRC
is not much higher compared to India, there is not the kind
of poverty, hunger,
squalor, unemployment as we see in India.
This has been reported by all sorts of analysts and visitors
to China.
I
do'nt believe that the Chinese development is an
ideal one;
far from it,
there are certain nagging problems
with it. But if PRC has achieved this much,
starting from a
very backward economy encircled by a hostile capitalist world,
India,
( after its revolution )
starting from a better base
standing also.
can now achieve far better,
and with perhaps a better under
The problem of " not enough resources I
11 to
support the increasing
population is now potentially much more
superfluous than hitherto.
( Contd....
.6.
DRASTIC CHANGE IN CHINA'S POPULATION-POLICY
The Chinese government, during last few years,
has drastically
changed its attitude tc population-growth and has started a
vigorous population-control programme.
We must answer the
question : Does not the new population-policy in China vindicate
the view point that population must be vigorously controlled in
developing countries ?
Let me try to answer this question
Earlier Policy & New Policy :
The Policy of the Government of the newly liberated
People's Republic of China ( P.R.C.) was to denounce the
" nco-malthusian bogey " of population explosion but at the
same time to spread the knowledge of the contraceptive tech
nology and even to control the rate of
According to Chi Lung,
population-increase.
one of the representatives of the PRC
in the 1973 ECAFE meeting in
Tokyo—" Population increase in
a planned way is China's established policy.
We follow such
a policy not because the question of 'Over-population'
in China.
In China,
exists
social production is carried cut in a
planned way and this requires that the population increase is
planned too.
It is also necessary to have a planned population
increase in order to promote thorough emancipation of women,
care of children, mothers and women; and bring up and educate
the younger-generation well,
and improve the people's health
and bring about national prosperity..... . ..." /15/
But from 1970
*
s,
this policy has changed; pressure
was put on the people to have not more than two children per
couple.
Further drastic change occurred from 1980,—the policy
changed over to ' Only One Child Per Couple.1
Does this new
policy stem from a real resource constraint or a false limita
tion imposed on themselves by the decision-makers ? If we go
i
into the reasons given by the Chinese demographers who advocate
this new policy,
we would get some inkling into this puzzling
drastic change.
" China's population problems and prospects " is an
official publication from China which takes a review of the
Chinese population policy from the new angle and advocates :
' One Child Per Couple ' policy.
It says : " Considering the
present area of cultivated land, pasture-land and surface-water
in China and taking into account the speed and level of agricu
ltural development attained abroad over the last hundred years.
.1
we estimate that a century from now, China1s total food production
could increase to be 150 per cent above that of today..
Taking
into account both the average physical characteristics of the
Chinese people and the proportion of protein in the diet of
industrially and agriculturally developed countries, we estimate
that each person in China should consume about 85 gms. of protein
per day.
( At present the level is about 56 gms.)
from both animal and plant foods.
Protein comes
The proportion of animal protein
in the French diet is 70% and in the United States,
it is 80 %.
In China today, the protein-intake is comparatively low. It should
gradually increase,
as production improves, to reach the amount
adequate for each person each day, with animal protein making
I
upto 70-80 per cent of the total.
On this basis,
a century
from now, the population should not be more than 680 million."/16/
(Note that this figure is much lower than the current population
»
of China of about 1000 million.)
Unscientific basis :
This estimation is unscientific-nutritionwise,healthwise.
The average per capita availability of food in PRC today is suffi-
cient-quantitatively and qualitatively.
Vaclav Smil's calculations
show that in 1983, the daily per capita availability of food energy
in China was 2710 Kilo Calories with 77 grams of proteins including
11 Gms.(14%)
from animal sources./17/
Ramesh Awasthi /17.a/ in
a recent compilation, quotes the foodgrain availability in China
m 1983 as 669 gms. per capita compared to 450 gms. in India.
Smil has calculated the daily per capita energy and protein requi
rements of the Chinese population on the basis of FAO/WHO recomme
ndations.
These ares 2210 K.Cal. of food-energy.
55 grams of
dietary proteins-with the assumption of the current Chinese pattern
of diet./18/
It is clear that on an average the Chinese diet
today is more than sufficient nitritionally.
Where is the great
need of increasing the protein-consumption to 85 grams per day ?
To be sure,
1983 was one of the best years as far as
food-availability in PRC is concerned, because food-production in
PRC has started rising very rapidly from 1978 onwards.
But even
during the earlier period of relatively rapid population growth
accompanies by not much more rapid growth in food-production,
daily per-capita
availability
of food was 2075 K.Cal.
in 1957, lOUQ in 1960-61 ( after a period of " probably world's
worst drought.")
the
2G45 in 1964-66 and 2125 in 1969-71. /19/
Because of much less inequality as compared to India, China
didn't experience the kind of extensive malnourishment (except
during 1958-61) as we see in India.
There was a need to increase
food production at a faster rate to abolish malnourishment
altogether and to have safety margins for drought conditions.
This has been achieved from 1978 with continuous rapid increase
in food production through economic reforms in agriculture.
There is thus no rationale for enforcing the one-child-norm
except for this unwise, unhealthy projections by their
policy-makers for protein requirements in the future.
The most important problem lies in the aim of of the
China's new policy makers to get 70-80 % of the proteins from
Animal source.
This is clearly
" aping of the West "
since
nutritionally so much of Animal protein is not at all required.
On the contrary this much of animal food will produce ill-health.
The American Medical Association has recommended a one-third
reduction in the meat consumption of the American population i
Animal foods are ecologically extremely taxing as compared to
vegetarian foods.
It takes 20 & 8 Lbs. of grain to be fed to
the animals to get 1 Lb. of beaf and pork respectively 1 /20/
It is therefore necessary to keep the proportion of animal foods
to the minimum necessary.
If the Chinese decision-makers abandon
the perspective of aping the dietary habits created by Agribusiness
in the West, then they need not opt for the current dastardly
policy of enforcing
" One Child Per Couple."
As has happened elsewhere in the world with increasing
modernization, education and general development, the Chinese
population would increasingly adopt a small-family norm.
That
the birth-rate has already markedly come down from 41.3 per
thousand in 1950 to 21.3 per thousand in 1982 has been confirmed
by an independent American academic study./21/
A part of it has
been due to incentives and disincentives from 1970s.
But socio
economic development has certainly played a a direct er indirect
role in the success of their population-control programme.
With these achievements on the food-front and in birth-
control, there is no real need for PRC to adopt the drastic policy
of 'one child per couple.' This new mistaken policy therefore does
not prove that the theory of
" population, explosion " is valid.
.9,
THE PROBLEM AT THE GLOBAL-LEVEL
There are many statistical projections meant to
frighten us to believe that if the population-increase in
developing countries is not drastically curtailed,
the world
would face a catastrophe because 11 there are not just enough
natural resources "
to support the projected world-population
of 48 billion by 2100 A.D. from the current level of 4.6 billion.
Firstly it is wrong to make such purely arithmetical projections
to draw strategic conclusions from them :
Increasingly condu
cive socio-economic conditions and hence the desire to control
births,
as well as the means to do so is a part of modern
social development.
Why do we assume that the third-world
people would continue to remain at the deprived end of the
development process,
as is happening today,
continue to have high birth-rates ?
and hence would
Even if they do, even
then the real threat to world's resources would not come from
these marginalized toilers.
Take for example, the case of energy.
Schumacher in his famous book,
that in 1966,
'Small Is Beautiful1'has shown
the " rich " countries accounted for 31% of the
world's population but consumed 87% of the energy utilized in
the world.
He now argues--suppose the population of these
developed and developing countries grows at a rate of 1.25%
and 2.50% per,year respectively and their fuel consumption per
head increases at the annual rate of 2.25% and 4.5% respectively;
with these rates, by 2000 A.D. the world would require thrice as
much additional energy as in 1966 and out of this increase, more
than two-thirds would be consumed by the rich countries 1
I do not share Schumacher's overall perspective; but his
calculations show how wrong it is to talk about the need for
drastic reduction in the birth-rates in the third-world " to save
the world from catastrophe."
As far as India is concerned, even
though we arc the second most populous country in the world, our
share in the World's commercial energy consumption is only 2.1 %
(1985), whereas the share of the U.S.A., with a population amounting
to not more than a. third of India's,
is 24.3 % ! /22/
The per capita availability of calories at the world-level
was in 1985,
111% of the requirement./23/
But due to unequal dist
ribution, millions and millions are underfed,
due to malnourishmont.
lakhs of children die
on the one hand whereas the developed world
consumes millions of tonnes of grain in a wasteful and unhealthy
way.
If the current state of affairs is changed into a sane and
.10
*
egalitarian society, there is no need to increase food production
any more.-Per capita energy demand increases many many times with
industrialisation but the per capita food requirement should not
increase beyond a level if we are not to fetch ill-health with
extra calories.
MILITARY WASTES
Most of the conventional discussions on resource-const
raints do not mention,
leave aside question,
the mind boggling
military expenditures. " World Military and social Expenditures"
1985 by Ruth Sivard (just quoted above) gives a very good account
of the military expenses the world over.
Let me quote a few
figures from this compilation s-
World military expenditure as expressed in the value of
U.S. dollars in 1982 (thus eliminating the influence of inflation)
increased from 339 billion dollars in 1960 to 709 billion dollars
in 1983 i.e. it
more than double.
The share of the developing
countries in the military expenses during the same period increased
from 33 to 152 billion dollars (at constant-1982 prices) i.e. a
more than four-fold increase,
(p.34)
Compare these figures with
the requirement of only 20 billion dollars to provide safe water
sanitation to all of those in the world taho do not have it today 1
(p.33)
During this same period,
arris-exports (most of which go
to developing countries) by developed world increased from 2.5 to
33.5 billion dollars (p.34) whereas per capita afd (most of it is
in'the form of loans)
from developed to developing countries didA
not rise in real terms (i.e./we discount inflation)
these 24 years 1
(p.23).
at all in
In the developing countries, military-’
expenditures per soldier in 1982 averaged 9810 US Dollars, compared
to educational expenditures of only 91 US dollars per school-age
child,
(p.29)
India's military expenditure shot up from 312 crores in
1961-62 to 816 crores in 1963-64
■ due to the Indo-China war.
It however continued to rise rapidly in the late sixties and 701s.
During last few years, there is again a fantastic rise from 2472
crores in 1975-76 to 7136 crores in 1984-85. /25/
This is due to
" Modernization of the Indian Defence Capabilities."
In reality
India is becoming a big military power in Asia to protect 'Indian
interest' here&abroad. India's military-expenditure in 1982 was
more than its expenditure on education and more than three times
its expenditure on Health. /26/
11.
Even if there is partial disarmament. ......
Some may argue that it is utopian to think that there
But even if partial disarmament -
will be complete disarmament.
occurs, plenty of resources would be released for abolishing
poverty, unemployment,
ill-health.
At any rate, in any case,
nuclear weapons must be abolished from this planet.
The nuclear
powers have today enough nuclear weapons to kill every person
in the world 12 times 1 /27/
The danger of nuclear war even
by accident has been increasing day by day./28/
Nuclear dis
There has been a great
armament is therefore an absolute must.
world-wide movement towards this goal and in the recent Riekjavik
Summit,
the USA and USSR almost came to an agreement to reduce
nuclear weapons by 50% (1) to begin with.
would be set free even if only
nuclear
*
Billions of dollars
disarmament takes place
and hundreds of millions of dollars more,if disarmament of
conventional weapons also takes place.
There have been many estimates of the impact of partial
disarmament.
Let us see a couple of typical of such estimates :
" The U.N. experts estimate that 8-10 per cent of world military
expenditure would be enough to eliminate hunger, disease,
illiteracy. ..... it would be possible to finance eight major
projects similar to the WHO-programme for eliminating smallpox
on earth solely with the funds allocated by the U.S. Air-force
for developing and designing the F-16 fighter.
The cost of one
Trident Submarine equals that of teaching 16 million children in
developing countries for one year./29/
A comprehensive study
made by a study-group of the United Nations in 1980 has registered
that " by the year 2000 even a modest degree of military restraint
the scenario modelled only assumed a progressive decline from
current levels in the share of military expenditure in gross
national product ( GNP ),
not a decline in the level .of world
military expenditure in absolute terms-could result in 3.7 %
increase in world GNP,
a larger■capital stock,
and an increase
in ’world agricultural output, to mention only a few of the mere
obvious economic p-gains." /30/
In conclusion, one may say~’that the talk of 11 PopulationExplosion " leading to the problem of '
resource-constraint 1
is
only a bogey to hide the bankruptcy- of the existing social-order.
( References continued....)
.12.
R E F E R E N C E S ....
Eosexup Mogens- Fear of doomsday;past & prosent.
Population and Development Review, Vol.4, No.l,
pp.133-143.
This is a good short account of the
controversy during that period.
/I-a);
As quoted by R.P.Dutt,
Publishing House,
India Today, People's
2nd edition,
/2/
s
R.P.Dutt, op.cit. pp.45-47.
/3/z
■
R.P.Dutt, op.cit.p.106.
/4/
:
1947, p.43.
Basic statistics Relating to the Indian Economy Vol.I
Bombay,
Centre for Monitoring Indian Economy,
Table 1.1.-
( C.M.I.E.
Aug' 86,
)
/5/
:
Basic Statistics...op.cit. table 13.10.
/6/
:
Basic Statistics...op.cit. table
8.1.
/7/
:
Basic Statistics...op.cit. table
9.9.
/8/
:
Basic Statistics...op.cit. table
1.1.
/9/
:
" World economy & India's place in it," C.M.I.E.,
October186; table 4.1.
/io/ :
World economy...op.cit. table 4.1.
/ll/ s
World economy...op.cit. table 3.3B
/12/ :
World economy...op.cit. table 3.10-1 and
BS.sic Statistics...op.cit tables-4.9, 4.17 Sc 16.3.
/13/ :
World economy...op.cit. table 3.10
/14/ s
Indian Economy since 1950-51, CMIE, Feb'86, p.2.1(iii).
/15/ :
Population Theory in China (Translations from
" Renkou Lilun ") Ed. H.Yuan Tien; M.E.Sharpe Inc.
White Plains New York; Croom Helm; London,
/16/ s
™
1980, p.9.
China's Population Problems & Prospects by Liu Zheng,
Song Jian and others; New World Press, •Beijing,1981,p.29.
/17/ :
Vaclav Smil, Food Production and Quality of Diet in China,
Population and Development Review, Vol.12, No.l, March'86,T.4
/17-a/
Dr. Ramesh Awasthi,
India and China-a comparison; "Frch
News letter," Bombay, Vol.I, No.!..
/IB/ :
Vaclav Smil, op.cit. tables 8,
/19/ i
Smil- op.cit. table No.2
10 and p.40.
/20/ 5
" How the other half dies," Pelican,
/21/ 8
Rapid population change in China,
Academy Press, Washington,
1977, page 305.
1952-1982, National
1984.
/22/ :
World economy...op.cit. table 6.3
/23/ :
World Military and Social Expenditures,1985;
10th Anniver
sary edition, Ruth Leger Sivard, World Priorities, Wash
ington, 1985,.p.39.
.13.
/24/ :
Suhas Chattopadhyay ; Inflation,
stagnation & crisis.
Social Scientist, No.29, p.7.
/25/ :
Basic statistics...op.cit. table No.7.ISA.
/26/ :
World Military and.... op.cit., p.36.
/27/ :
World Military and.... op.cit., p. 5.
/28/ :
Medico-Friend Circle Bulletin, No.122, November,
1986
New Delhi, p. 5.
/29/ s
R. Faramazyan; Disarmament and the economy; Progress
Publishers, Moscow; 1981, p.140-141.
/30/ :
U.N. Disarmament Yearbook,
1981, p.355.
MEDICO FRIENDS CIRCLE
XIII ANNUAL MEET
Family Planning and. Health Care s A Case Study from Rajasthan.
- Ritu Priya.
I.
INTRODUCTION :
I approached this filed work with an idea of using it as an
opportunity for filling a gap in my understanding of the
health system by getting a first-hand knowledge of the
functioning of the Primary Health Contres, studied from
a perspective other than that of a medical student ( the
only ether exposure I have had to a PHC).
The Block in which the PHD is situated, falls in the tribal
belt of Rajasthan, comprising approximately one third popu
lation of tribalsmainly Bhils. Most of them live in distant
■fillages in the hilly, rocky part of the Block.
Some have
settled down in the plains but live in seggregated 'bhilwaras'
The village in which the PHC is situated as well the village
around it do not have any Bhils- The poor condition of the
tribals were in sharp contrast to the others ir. the village;
while most of the houses are pucca in the village, the
bhilwaras were always of dilapidated, small huts of mud and
tiles. No tribals were ever seen in the buses through they
could be seen walking to tie distict town with Deadloads
of firwood or grass. They were n^vpr seen at the PHC either.
Though a drought-prone area,, the last two years havd been
especially dry and so part 6f the block has been declared
famine-hit, Famine relief work was seen in progress
(building and repair of ro-is).
Perceptions about the
famine showed a great polarisation in the society. While
one heard of the tribals who had lived on boiled leaves
cf trees before famine relief work started, most of the
people travelling in uhe buses seemed only midly affected and x
some were almost unaware of it.
In the district town,
people laughed at the suggestion of a famine at their
doorsteps. The famine influenced the PHC work only by
helping fulfil FP targets. People same in for the
incentive money, the MO said, sometimes both the husband
and the wiefe coming in for sterilisations.
Working in this setting, the PHC is bringing a number of
'private practitioners' into the area (the unofficial role)
and in implementing the Govt. Health Programmes. Provision
of medical care in a negligible function as the PHC
itself catered to only 9922 OPD cases (an average of
33/ day) which is insignificant for a population of
1 lakh. The MFWs are given almost no drugs and are
perpetually short of supply of even aspiring and parace
tamol, But all of them, keep a stock of their own meidcines
....2...
2
and. do private practice, of the 227 in-doors patients, 180 were
cases of laparoscopy sterilizations and vasectomies.
(vasectomies had been registered as in-patients to inflate
the figures, ) No deliveries had been conducted at the PHO.
The two AKMs attached to the PHO attend to the deliveries
at home itself. In the other villages, the ANMs are called
only in case of emergencies by those who. can pay at least
Rs. 50/- per delivery.
Implementation of the health progra
mmes is the official function the PHC is engaged xa in.
It basically means a primary focus on family welfare a
euphemism for Population Control, and some attention to EIP,
Malaria and guinea worm control. The NTP, leprosy and school
health programmes are conspicuous by their absence.
Since the primary focus of work is aon the achievement of
targets in Family Planning, it was clear that all the other
activities of the PHC suffered in consequence. Firstly,
the greater amount of time spent on FP activities meant
there was a reduction in time for other activities. Secondly,
the frequent 'drives' and FP camps were not conducive for
carrying out systematic work. Thirdly since supervision
by the higher level staff was limited to checking on the
fulfillment of targets, the other activities were considered
non-important by default.
In the-.s paper, by comparing the performance of FP programme
with EPI and NIP, an attempt has been made to show that the
Primary Health Centres are functioning primarily as exten
sion centres for population control.
II. THE FAMILY WELFARE PROGRAMME; Promotion of birth
control is the major preoccupation of all workers at the PHC.
Motivating cases, and keeping them ready for a sterili
zation camp, bringing them there and later following them
up, takes up most of their time. While little pressure
tactics have been employed so far, the workers can see which
activityxii receives priority at higher levels -- the
enquiries the officials make whenever they come on tour,
the intensive drives organized at state and district
levels, the incentive money giben to the 'cases', motiv
ators. and the PHC, — all emphasize the importance
ef family planning above all other programmes. The official
circulars of minutes of the meetings and of instructions
to all the staff by the Collector are illust-ractive of
this. Results can be seen from the targets achieved.
FP achievements ; April
Nov. 198^.
Sterilizations
Target
800
Achievement
690 (86^)
IUD
Condoms
250
*2(21$)
Orall
pill
1^+80
Contd..3. ..
- 3 The district data show that in the previous year results
were very different as the official instructions had a
different emphasis.
..
District Targets and achievements; 1985-1985.
-
Sterilizations'
Target '
% achiived
IUD
Target
% (achieved.
A.pr.'85-Mar '85
19-,5-OO
5-3.8
5,83©
57.8
Apr.'85-Nov '85
19,5-00
62.9
5,830
55-.0
Sterilization Operation?
The sterilizations conducted so far have teen performed
relatively 'honestly' in that the over age persons, and
sterilizing both the husband and wife together, etc., have
net been used to achieve targets. But as ' cases'become
more difficult to come by, the more compliant having been
motivated and sterilized, and as targets set by authoriti
es increase, the MOs were heard telling the workers,
- get both husband and wide,
- over age will also do,
- Motivate those with copper T to get sterilized (thus
the same person can be counted twice as an IUD and
sterilization acceptor).
*
The scheduled tribes get Rs. 150/- over and above the
usual Rs. 150/- which each tnbectomy case and Rs. 130/- which
each vasectomy case gets. From the drive starting in Jan.
1986, it has been declared that the scheduled castes
will also get the extra Rs. 150/As <*
ther governmental agencies, workers of the agricul
tural department, school teachers, revenue staffetc. Ksxd
have all been allotted targets to motivate case tension
have built up^ in a number of aareas between these and the
health workers, one accusing the other of'seducing their
cases away.
In a number of instances this has become the
cause of personal enimity and physical assault and the
police were called to diffuse the situation. The health
workers also complain that these other workers offer ince
ntives to get cases by promising them loans while they being
health workers have nothing, not even'medicines, to offer.
The FP Camps?
The sterilization camps are a curious mix of public relat
ions drama and mechanical assembly line. On the day of
the Camp, a vehicle is made available by the ER Dy CMHO(FW)
office which brings each case from their homes. A medical
college team consisting of 3 gynaecologists, an anaesth
etist, and a theatre technician come with the linen and
5-
- U -
equipment. The PEGS M0s have the patient ready with a
preliminary check up, a gynae exam., and a TT injection. Two
operating tables are set up. While the equipment is set up
the patients are assembled, given pre-,edication and lined
up outside the. J theatre '. Once everything members get
into their place in 'assembly line's one for giving' inject
ions, one for holding the uterus, one to use the laparoscope,
and ligate the tubes, andf the fourth to put sutures. The
unconscious patient is then transferred to a stretcher and
carried out by two male-workers (class TV or MEW.s) to be
promptly replaced by the next patient. The sterilized
patient is taken to the ■'recovery' room (generally another
room but may be the verandah or the open) where a dari
is laid out on the floor. With the relatives standing arou
nd the patient is picked up by the two male workers by her
ankle and wrist and put on the floor. Her ' lengha' flies up
and is pulled back in place by the male worker at her feet and
she is covered by her 'odhni1. Soon the next is brought in .
and placed down beside the first one avoiding as much of
space as possible so that soon the room looked like a
morgue. The relatives, some of them crying and trying t4
sooths the women's brow or mass.age her feet (and adding
the only human touch to the proceedings) are shoodd out.
During one such comp, The junior gynaecologist looked in
before leaving which was as soon as the cases were all done.
Money and certificates whe were given to the cases by the
EEE. The PHC staff went home only after all the cases had
been taken home. The Sarpanch of the area came in to take
a look once during the first camp and the one held during
the intensive FP drive was visited by the SDO, EDO and CDPQ.
The staff present at the camp were the 3 MOs, 2 LHOs, the BEE,
and MI, 3 Sector supervisors, h- ANMs, M- MEWs (male), sweeper, one
peon, 2 drivers and the projectionist, 5 members of the
medical college team, i.e. 2? in all. In the first camp
there were only '<+ tubectomies and 1 vasectomy and in the
second (held on the first day of the intensive Ff drive)
there were 7 tubectomies and 2 vasectomies.
In the first
camp a patient had eaten before coming and also had a
history of amenorrhoea and a bulky uterus on PV examina
tion but was undertaken for MTP and sterilization because
there were only four cases.
FOLLOW UP; The incentive money is given in two
instalments, one at the camp and the second one- when the
follow up visit is paid by the EHC staff 7-10 days later
when stitches are removed. During one such visit, there
were 8 cases to be followed up from 4 different villages.
We literally had to chase after them into the interior
illages and even to their fields to make the payment and
for the doctor to enquire if "everything was OK, No? One
r
i
5
woman who complained, of burning abdomen was told that to take
less chillies but to eat everything, roti, curds, butter
milk, Another woman for whom we had waited because she had
gone to cut grass, was at the end of the interview, pattend
on tbe back and told "gb take rest". At another place we
found that one of the women had died a month after the oper
ation ''why has more than a month elapsed before follow up?).
The doctor immediately ruled out the operation as the cause
of death without even trying to.find the conditions under
which she had died. No attempt'was made to verify the cause
and we drcve off to another village, The BEP', informed the
MO in-charge that the relatives were entitled to Rs.5000/if death occurred within six months of operation. The MO
promptly told him not to put such ideas into people's heads
because "it will mean another headeche for us and we don't
want any such reports".
OTEER METHODS;
IUD insertions are done by-the ANMs
themselves at the home of the willing persons and rarely
brought to the PHO or- the camp. There are very few regular
users of condom (60) and because of the poor attention
paid to this method, even these-acceptors break away as the
regular supply is not maintained.
The oral pill is not being propagated because of the fear of
side effects and the fact that the initial medical check-up
by the MO is necessary. No target was set up for it till
Jan. 1986, during which the requirement was of making 57
regular users. But this attempt was made useless from the
start because the workers were told to distribute 3 cycles
each to women with a child more than 1 year old (i.e. non
lactating) whether they will use it or not. The MO
suggested that this could be done easily through the school
children by sending the pills home with them for their
mothers.
The Achievement s The PHO has an excellent performance to
its credit in terms of.targets achieved this year.' Many
of the workers metioned of entire villages where all eligible
couples had been sterilized xlThis village is complete" . ■
The MO felt that this year many more cases were coming
and death rate because of famine conditions.
Birth and death rates are not known and so impact of -fee
the programme is difficult to assess. The registration of
births is mostly incomplete but no steps are being taken to
improve the condition. The degree of coverage by terminal
methods should have resulted in some impact but as the Dy.
CMHO (.11) said, most operations are done after 5—5 children
and sc may be the impact is not as great as it would
appear from the achievement of targets.
III.
The EPI programmes
The EPT is linked to the MCH programme but the two are
dealth with separately from the W programme. Other than
BCG all other immunizations are done by the MEWs (both male
■- *
6..
- 6 -
and female) during their day to day work and through special
intens ive drives.
The Cold Chain; A room at the CMHOs office has been conver
ted into a cold storage for the vaccines and there is a
refrigerator at the PHO. Each worker is provided with a
thermocol box to keep the vaccines. The referigerator had
a defective lock and so the door remained partially open
all the time. Electricity supply was erratic, and the MO
was unable to say how long the electric supply actually
was abailable to the PHC.
The Intensive Drives; During a drive, the workers are
divided into 3-!+ teams of 3->+ workers each and the team
goes to each village and collect all the children and given
them the first dose of DPT and Polio. A similar exercise
is undertaken three times at 1 month intervals. The first
round had just been completed when this study was begun'and
the second round was due to start soon after it ended.
Seme experiences of the first round as narrated by the
MFW s were;
-
There was lack of facilities to sterilize syringes and
needles; generally 2-3 syringes were available per team
ard were sterilized before the team left but it was not
possible to sterilize them in the villages.
Abscess formation were reported but treatment (drainage)
was possible only in the FHCs or the dispensaries;
the
workers had not antibiotics either.
Paracetamol was in short supply and so not given to
many or given only 2 doses, so that all or most had
fever and no treatment(All this would tell on the
acceptance of the second dose).
-
Some parents had refused the immunization.
One worker
submitted the list of children of an entire fillage
which had refused. The official explanation was that the
refusal was due to their "ignorance and illiteracy".
But on probing it was found that during the previous
drive one child had developed an absecess and another
developed convulsions after DPT.
Through the problems related to the short supply of drugs
and syringes were promptly attended to in view of it being
an intensive drive, there was little or no follow up,
althrough in case of sterilizations, the PHC team travelled
miles to check on complications and to giveincentive money.
7
- 7 ifiact during th one such follow up visit to a tubectomy
patient, the MO side-treacked an MEW's request to see a
child who had developed a swelling at the vaccination site
and whose house was no our route.
The two children seen coming to the PHC with abscesses werg
prescribed drugs to be purchased from the market (even whgn
substitutes were available from the PHC.) The parents sgemed
alittle bewildered because the injection was supposed to
prevent diseases but infact had given rise to a another
problem for which they now had to spend money on treatment.
Data on the EPI performance is collected and reported to the
district office by the SI. It was not possible to contact
him because he was 'absconding' for a large part of the time
and was drunk at other times. The Dy. CMHO office had rgegived data from the PHC only till lune which is given below.
Immunization from April to June 1985•
Target
DPT
Achievement
1st dose
2nd dose
3rd dose
2210
h-06
131
Pflio 1st dose
2nd dose
TT (pregnant women)
22100
40kU8
1st dose
2nd dose
1535
73
65
h-1
The data shows how even the few immunizations done become
useless because the 2nd and 3rd doses are not administered.
The side effects with the first dose were perhaps the
i^ason for this.
It was not possible to assess the impact of this programme
because no data with regard to the communicable diseases
in childhood was available. But from the way the cold
tftain was maintained for polio, one could say that the
polio vaccines were probably useless by the time they
Cached the.village.
♦
THE TB CONTROL PROGRAMME:
While a few of the workers were aware of the symptoms Of TB
none of them had brought a patient to the PHC for examina
tion. Only 5 sputum examinaions had been done during the
year 1985, on the MO's advice. The malaria technician does
Vie staining and examination for AFB but asks the sweeper
to collect the sputum and make the slide because he is
afraid of catching the infection.
8
- 8 -
The previous records show that in 198!+, 135 sputum slides
were examined. But the technician freely admitted that
it was falsified data put in by the previous compounder. No
check could be made because the slides were not preserved.
No patient is under treatment from the PHC for TB.
BCG vaccine is not supplied to the p PHC and is administered
inly by the BGG team of the District TB centre which is
supposed to visit the villages once in three years.
The district TB Programmes
The district TB centre (DTC) is supposed to oversee the
NTP work in the whole of the district. The district TB
officer assisted by the second TB officer is in-charge
•f the DTG for clinical as well as supervision and corrdination work. The district has a sanatorium to which TB cases
needing hospitalization is sent. 29 microscopic centres (the
PNGs and dispensaries which have facilities for sputum exam
ination) and 17 referral aid posts (which only disburse drugs
tu confirmed cases) are also attached to it.
It was a pleasant surprise to learn that the DTG has a
post graduate degree in thoracic and chest diseases from
Udaipur medical college. But his knowledge about the NIP
and the subject was shocking. For instance, his statements
that - 57$ of the diagnoses are made by X-ray because
*ases are mostly asymptomatic symptoms appearing only on
cavitation sanatorium treatment is given so as to isolate
eases and to provide them with fresh air, hygienic conditions;
TB is difficult to control because of poor hygiene,
inability to isolate the patients, default due to illiteracy
and ignorance etc seemed to underline his 'ignorance' and
his 'illiteracy'. He was unaware of the U- symptoms on
which sputum examination is prescribed in the NTP and
believes that resistence appears only in the late stages
and so there is no need to do sensitivitytests.
The second MO has been here for 2 years having joined
immediately after his house job. But he was not confident
about telling me the details of the TB programme since
he was not really 'interested'.
V. CONCLUS ION
The ebservations made show clearly that the PHO is perform
ing only one function efficiently i.e. to 'protect' the
eligible couples with the terminal methods of birth control.
The functioning of the PHO is skewed in favour of populat
ion control because of several reasons.
- the insistence and emphasis placed on meeting FP targets.
- monetary incentives given to the health workers for 'moti
vating' the 'eases'.
- Playing on the economic vulnerability of the poor people,
in the present famine situation, by giving relatively
large sums of money, (the tribals were paid even more to
get sterilized),
The same attention is not being given to immunization
programmes which is supposed to be an integral part of
Family Welfare Services. The third component, the materrh al
health does not get even the Little attention that is paid
to immunization programme. The description of the NTP leaves
one with a sense of disbelief. After studying the functioning
of the PHC from 'a perspective other than that of a medical.
student1 one is forced to end with the cynical remark that
the survival of the rural population has been independent
of and despite the functioning of the PEICs.
(This paper has been condensed from the report prepared
as part of the field work requirements for PHD in
Community Health and Social Medicine from Jawaharlal Nehru
University, New Delhi.
ABBREVAT IONS
USED
IN
THE
TEXTS
1.
ANM - Auxiliary Nurse Midwife.
2.
BEE.
3.
DPT Diphtheria, Portusis (whooping Cough) Tetanus vaccine
h-. Dy. Cin & HO (FW)
5.
Deputy Chief Medical and
health Officer (Family Welfare)
EPI Extended Primary Immunisation.
6.
FP
7.
LHO
9.
MO Medical Officer,
10.
MFW Multipurpose Worker.
11.
M3?P Medical Termination, of Pregnancy.
Family Planning,
8)
•< I
12.
NTP
13.
PHC Primary Health Centre.
National Tubercalcsis Control Programme
1M-. SI
Sanitary Inspector.
15. TT
Tetanus Toxoid.
Chavan./
FAMILY PLANNING IN TRIBAL AREAS; SIMPLE ACCEPTANCE OR CORSION?
The planners of the family planning policy felt that the
different segments of the Indian polity had accepted the family
planning programme in verying propotion and thereby contributed
differently to the ultimate outcome of the same. This was consi
dered to be particularly applicable to backward and lower income
communities i.e. scheduled caste and scheduled tribes, who it
was believedbad a very low rate of family planning acceptance.
HOWEVER, Several tribal districts in various states of India for
example Bharuch in Gujarat, Gadchiroli in Maharashtra and Dungarpur
and Banswara in Rajasthan have mostly ranked highest or second
highest in achieving the family planning targets during the last few
years.
This paper attempts to examine the possible reasons for this
phenomenon and its probable long term implications on tribal
demography.
Family Planning Acceptance Higher in Tribal Aceas 1- A Statistical
computation was done by Pref. K.G. Jolly to identify that, various
social and economic variables that explain differential performance
in family planning programmes in all the districts of the states of
Gujarat, M.P., Maharashtra and Rajasthan. These together contain
52% of the total tribal population of the country. The study based
on figures mainly available before 1981 census considers several
social and economic variables viz. general literacy rate, female
literacy rarw, percentage scheduled caste population, percentage
Scheduled Tribe population and ownership of land, agricultural
productivity, male and female participation rates, surfaced roads,
cropped area etc.
According to this study based on stepwise regression
procedure for a combined social and economic variables and analy
sis, the third most important various affecting the cumulative
acceptance rate of family planning at the district level is the
percentage of scheduled tribe population. Percent literacy rate
was found to be the most important variable influencing the
cumulative acceptance rate of family planning at the district
level, followed by percent female participation. Other varit'.bles
like percent s rfaced road, percent electrified villages,
percent commercial crop and other economic variables had a
lesser effect on the family planning performance at the district
level.
This study indicates two significants trends:
the acceptance of family plan ling ?s significantly high
in districts with higher S.T. population.
although comparable
in economic status to the S.T.population
the existence of a higher Scheduled Caste population has
- 2 not been a sifnifleant variable on the performance of F.P.
in such districts.
Prof. Jolly's study does not ventrue into the reasons for
this higher performance of F.P. in the districts with a large
population. Conventionally, some of the important factors for
higher acceptance of F.P. in an area have been high female literancy,
high economic status, effective health services and better infras-
trictural facilities. Tribal areas lack alll these factors to a
major extent. Yet, tribal areas show a significantly higher family
planning performance in comparision to other backward communities.
What could be the reasons for this situation?
State Policy of Coercion - Various social marketing strategies
have been used for the promotion of the F.P. programme. In tribal
areas an important strategy is that of giving higher monetary
incentives. The amount is almost doubled for tribals accepting
terminal methods of F.P. Cash incentives exploit the economic
need of the poor and thereby indirectly coerce them into accepting
terminal methods without much choice and without any consideration
to their specific F.P. needs. The economic deprivation combined
with a higher one time monetary gain offered for sterlizations
result in a double catch for tribal people from which they can
hardly escape. In a study done by the Tribal Research Institute,
Udaipur it was found that the tribals showed a greater willing
ness to accept family planning if higher incentives were given.
In some states, the Government has blatantly linked the provision
of employment in famine affected areas with adoption of sterlization.
In a recently issued notification in Rajasthan which is
a chronically drought prone state, the Government has declared
additional employment generation programmes worth Rs. 10,000.00
to each village which has achieved its F.P. targets.
Trjbal Economy- Tribal economy is generally a combination of
settled agriculture, shifting agriculture, animal husbandary
collection and marketing of forest produce. For tribals the
forest continues to sustain them through loan periods. Fertility
behaviour among poverty groups is largly determined by the
necessity to have enough hands that can ensure the survival of
the family as a unit especially in periods of searcity. For the
Tribal communities inhabiting hilly and forested regions, the
forest economy takes care of this aspect to a great extent.
This probably affects the choice of family size. (However, with
the changing forest policy of the Government and depleting forest
resources, what turn the situation will take is a matter of
speculation.)
...3
- 3 Social Organization
Historically, tribal communities have lived.
in isolated pockets and a culturally hom*ogeneous evironment,
The social structure inherently provides Social and psychological
security, irrespective of their relation with non-tribal
communities. It is probable that they are thus saved from feeling
the 'minority syndrome' which creates the desire to have more
hands, and find security in numbers. Such a minority syndrome has
are in minority to the dominant population.
Status of Women : Most tribal communities are known to have (aleast
upto recent times) less discriminatory social structures for women.
Living within hemegenous and a more or less self dependent
economic system, the women work very hard and therefore are
significant economic assets. The mean age at marriage for tribal
women is higher (16.39 as compared to 1^.39 for the general
population).
The sex ratio emong S.T. population is higher (983 as
compared to 933 for total population).
Further some tribal
communities have matrilineal/materiarchal social structures. It
is probable that such position of tribal women provides greater
acceptance of F.P.
The above mentioned probable reasons for the higher F.P.
acceptance can be classified into (1) these that are external state imposed and (2) those which are internal to the tribals as
an ethnic group.
Impact on tribal population
If infact certain secial, cultural
and ecnomic factors are somehow contributing to higher accepta
nce of F.P. among the tribal population, then the invasive,
coercive state intervention in promoting mainly sterilizations
of tribal men and women in the country can lead to serious
implications for the existence of these
ethnic groups in the
long run. The Government of India hopes to achieve a target of
h-2% "effective couple protection rate" by the end of 7th five
year plan. Being politically and economically weak, the tribals,
having already higher acceptance of F.P. will mainly bear the
brunt of this. If the present policy of monetary incentives and
disincentives of the State continue in the present form, the
tribal communities will be affected more than any one else. Even
the present growth rate indicates that the tribal population is
declining in proportion to the total population.
U-
In comparision to 1971 census, the 1981 census figures
show this declining trend in some states. In Bihar the
proportion of tribal population to the total population has
declined from 8.75% to 8.31%; in M.P. from 23.56% to 22.97%;
in U.P. from 0.22% to 0.21% In the predominately tribal distriests
of Rajasthan too, this situation seems to hold true.
In Chittorgarh
district the percentage declined from 19.67% to 18.16% and in
Banswara district from 72.93% to 72.63%.
However the proportion of the tribal population to the total
population for the country as a whole seems to have gone up from
7A% in 1971 to 7.76% in 1981, but these figures are misleading
as they do not take into account the increased number of
communities brought under thenetified list of S.T. during this
interval. For example at the begining of sixth plan in 1980,
thenumber of primitive tribes identified rose from 52 to '72 thus
increasing the actual and proportionate tribal population in the
country.
Although other factors such as high mortality could also
be influencing this proportion, there is no doubt that the
aggressive. F.P. operation will further accentuate this gap.
This could result in a disequil ibrium in the population pattern
to the disadvantage of the very community that is both anthropo
logically and econologically significant.
At the moment tribals
constitute only 7.^% of the total population.
Therefore is it
morally and ethically right to adopt such aggressive methods
to reduce their numbers?
Conclusions There is need to seriauly reconsider the monetary
incentive policy. If additional incentives are infact found to be
an important factor for higher acceptance of F.P. in tribal
communities, should they not be dispensed with? Also should the
Government be allowed to use this inhuman practice of linking
compulsive F.P. with provision of employment in scarcity situat
ions like famine?
N 0 IE ; No conclusive corelations are being made in the above
paper. Certain issues are being raised, which need to be prebed
into and examined further.
NARENDRA GUPTA.
- 5 REFilRENCES ;
1.
Seventh Five Year Plan 1985-90 Volume II (Draft), Govt.
of India,
2.
A few Points e for Consideration in Respect of Tribal
Demography in Central and Western Belt- B.K. Roy Burman
(unpublished) XSX IaSP Symposium 198^.
3-
Family Planning Performance in Tribal Areas - K.G.Kolly,
IASP Symposium 198M-.
h-.
Family Planning Programme and Motivational Factores,
A study of Jhadol block of Udaipur District. T.R.I. Udaipur
5-
District Census
Handbook, Chittorgarh, Census of India
1981 (6) Provisional Population Tetals; Series 18 Rajasthan,
Bensus
/Chavan./
Npn.
of India 1981.
FAMILY PLANNING IK TRIBAL AREAS; SIMPLE ACCEPTANCE OR GOESION?
The planners of the family planning policy felt that the
different segments of the Indian polity had accepted the family
planning programme in verying propotion and thereby contributed
differently to the ultimate outcome of the same. This was consi
dered to be particularly applicable to backward and lower income
communities i.e. scheduled caste and scheduled tribes, who it
was believedhad a very low rate of family planning acceptance.
HOWEVER, Several tribal districts in various states of India for
example Bharuch in Gujarat, Gadchiroli in Maharashtra and Dungarpur
and Banswara in Rajasthan have mostly ranked highest or second
highest in achieving the family planning targets during the last few
years.
This paper attempts to examine the possible reasons for this
phenomenon and its probable long term implications on tribal
demography.
Family Planning Acceptance Higher in Tribal Areas
A Statistical
computation was done by Prof. K.G. Jolly to identify 'thaii various
social and economic variables that explain differential performance
in family planning programmes in all the districts of the stales of
Gujarat, M.P., Maharashtra and Rajasthan. These together contain
52% of the total tribal population of the country. The study based
on figures mainly available before 1981 census considers several
social and economic variables viz. general literacy rate, female
literacy rarw, percentage scheduled caste population, percentage
Scheduled Tribe population and ownership of land, agricultural
productivity, male and female participation rates, surfaced roads,
cropped area etc.
According to this study based on stepwise regression
procedure for a combined social and economic variables and analy
sis, the third most important various affecting the cumulative
acceptance rate of family planning at the district level is the
percentage of scheduled tribe population. Percent literacy rate
was found to be the most important variable influencing the
cumulative acceptance rate of family planning at the district
level, followed by percent female participation. Other -variables
like percent s rfaced road, percent electrified villages,
percent commercial crop and other economic variables had a
lesser effect on the family planning performance at the district
level.
This study indicates two significants trends;
the acceptance of family plan ling ?s significantly high
in districts with higher S.T. population.
although comparable
in economic status to the 8.T.population,
the existence of a higher Scheduled Caste population has
2
- 2 -
not been a sifnificant variable on the performance of F.P.
in such districts.
Prof. Jolly’s study does not ventrue into the reasons for
this higher performance of F.P. in the districts with a large
population. Conventionally, some of the important factors for
higher acceptance of F.P. in an area have been high female literancy,
high economic status, effective health services and better infrastrictural facilities. Tribal areas lack all! these factors to a
major extent. Yet, tribal areas show a significantly higher family
planning performance in comparision to other backward communities.
What could be the reasons for this situation?
State Policy of Coercion - Various social marketing strategies
have been used for the promotion of the F.P. programme. In tribal
areas an important strategy is that of giving higher monetary
incentives. The amount is almost doubled for tribals accepting
terminal methods of F.P. Cash incentives exploit the economic
need of the poor and thereby indirectly coerce them into accepting
terminal methods without much choice and without any consideration
to their specific F.P. needs. The economic deprivation combined
with a higher one time monetary gain offered for sterlizations .
result in a double catch for tribal people from which they can
hardly escape. In a study done by the Tribal Research Institute,
Udaipur it was found that the tribals showed a greater willing
ness to accept family planning if higher incentives were given.
In some states, the Government has blatantly linked the provision
of employment in famine affected areas with adoption of sterli-
zation,
In a recently issued notification in Rajasthan which is
a chronically drought prone state, the Government has declared
additional employment generation programmes worth Rs. 10,000.00
to each village which has achieved its F.P. targets.
Tribal Economy- Tribal economy is generally a combination of
settled agriculture, shifting agriculture, animal husbandary
collection and marketing of forest produce. For tribals the
forest continues to sustain them through loan periods. Fertility
behaviour among poverty groups is largly determined by the
necessity to have enough hands that can ensure^ the survival of
the family as a unit especially in periods of searcity. For the
Tribal communities inhabiting hilly and forested regions, the
forest economy takes care of this aspect to a great extent.
This probably affects the choice of family size. (However, with
the changing forest policy of the Government and depleting forest
resources, what turn the situation will take is a matter of
specii! lation.)
...3
- 3 Social Organization ;
Historically, tribal communities have lived
in isolated pockets and a culturally hom*ogeneous evironment,
The social structure inherently provides social and psychological
security, irrespective of their relation with non-tribal
communities. It is probable that they are thus saved from feeling
the 'minority syndrome' which creates the desire to have more
hands, and find security in numbers. Such a minority syndrome has
are in minority to the dominant population.
Status of Women : Most tribal communities are known to have (aleast
upto recent times) less discriminatory social structures for women.
Living within hemegenous and a more or less self dependent
economic system, the women work very hard and therefore are
significant economic assets. The mean age at marriage for tribal
women is higher (.16.39 as compared to 15-39 for the general
population).
The sex ratic emong S.T. population is higher (983 as
compared to 933 for total population).
Further some tribal
communities have raatrilineal/materiarchal social structures. It
is probable that such position of tribal women provides greater
acceptance of F.P.
The above mentioned probable reasons for the higher F.P.
acceptance can be classified into (1) these that are external state imposed and (2) those which are internal to the tribals as
an ethnic group.
Impact on tribal population
If infact certain secial, cultural
and ecnomic factors are somehow contributing to higher accepta
nce of F.P. among the tribal population, then the invasive,
coercive state intervention in promoting mainly sterilizations
of tribal men and women in the country can lead to serious
implications for the existence of these
dthnic groups in the
long run. The Government of India hopes to achieve a target of
U-2% "effective couple protection rate" by the end of 7th five
year plan. Being politically and economically weak, the tribals,
having already higher acceptance of F.P. will mainly bear the
brunt of this. If the present policy of monetary incentives and
disincentives of the State continue in the present form, the
tribal communities will be affected more than any one else. Even
the present growth rate indicates that the tribal population is
declining in proportion to the total population.
1+
- h- In comparision to 1971 cansus, the 1981 census figures
show this declining trend in some states. In Bihar the
proportion of tribal population to the total population has
declined from 8.75% to 8.31%; in M.P. from 23.56% to 22.97%;
in U.P. from 0.22% to 0.21% In the predominately tribal distrieets
of Rajasthan too, this situation seems to hold true. In Chittorgarh
district the percentage declined from 19.67% to 18.16% and in
Banswara district from 72.93% to 72.63%.
However the proportion of the tribal population to the total
population for the country as a whole seems to have gone up from
7.U-% in 1971 to 7.76% in 1981, but these figures are misleading
as they do not take into account the increased number of
communities brought under thenetified list of S.T. during this
interval. For example at the begining of sixth plan in 1980,
thenumber of primitive tribes identified rose from 52 to 72 thus
increasing the actual and proportionate tribal population in the
country.
Although other factors such as high mortality could also
be influencing this proportion, there is no doubt that the
aggressive. F.P. operation will further accentuate this gap.
This could result in a disequil ibrium in the population pattern
to the disadvantage of the very community that is both anthropo
logically and econologically significant.
At the moment tribals
constitute only 7.1+% of the total population.
Therefore is it
morally and ethically right to adopt such aggressive methods
to reduce their numbers?
Conclusions There is need to seriouly reconsider the monetary
incentive policy. If additional incentives are infact found to be
an important factor for higher acceptance of F.P. in tribal
communities, should they not be dispensed with? Also should the
Government be allowed to use this inhuman practice of linking
compulsive F.P. with provision of employment in scarcity situat
ions like famine?
N 0 TE ; No conclusive corelations are being made in the above
paper. Certain issues are being raised, which need to be prebed
into and examined further.
NARENDRA GUPTA.
- 5 REFERENCES :
L.
Seventh Five Year Plan 1985-90 Volume II (Draft), Govt,
of India.
2.
A few Points e for Consideration in Respect of Tribal
Demography in Central and Western Belt- B.K. Roy Burman
(unpublished) 3SX IASP Symposium 198!+.
3.
Family Planning Performance in Tribal Areas - K.G.Kolly,
IASP Symposium 198!+.
!+.
Family Planning Programme and Motivational Factores,
A study of Jhadol block of Udaipur District. T.R.I. Udaipur
5•
District Cenaas Handbook, Chittorgarh, Census of India
1981 (6) Provisional Population Tetals; Series 18 Rajasthan,
Bensus
/Chayan./
Npn.
of India 1981.
POPULATION POLICY IN CHINA;
THEORY AND PRACTICE
- Hina Sen.
(Paper prepared for the M.F.C. Annual Meet January 198?)
As the world's most populous country (According to the
1982 Census China had 22,6$ of the world's population - a total
of 1,031,882;J71 people (1)) China has been a focus of interest
for statesmen, economists and demographers throughout the world.
In particular, interest has centered around the way in which
China after the revolution has coped with the combined legacies
of a high population and an under developed economy ravaged by
war and colonization.
And for us in India, of very special
interest has been the fact that China has faced these issues
under a socialist state ideology, quite unlike our own post
colonial experience.
However, it has not been easy to interpret
population data from China.
Throughout the late 1990s through
the 1970s there was a lot of confusion and disagreement over
the basic facts about China's population.
The Chinese
government did not publish statistics or policy documents, and
the scraps of information picked up by (mainly Western) China
watchers were often contradictory.
It was only in the late '70s
that documentation began to come out of China.
This paper is
based is mainly on this documentation although it draws in
addition on analytical articles articles, in population/Sinology
journals.
Population policy in post-revolutionary China has a
complex .and tortuous history. Broadly speaking, population
policies passed through the following major phases (2):a)
FIRST PHASE 19^9-9^- This was the immediate post-revolution
-ary period.
In general it may be said that the government was
too busy restoring the wartorn economy and did not promulgate or
even consider a clear-cut population policy.
Nevertheless,
there was a change in the pattern of population growth.
.
In old
China, population had been characterized by a high birth rate,
a high death rate and a low rate of natural increase.
.In 199-9,
China had a birth rate of 36 per thousand, a death rate of
20 per thousand and a rate of natural increase of 16 per thousand.
By 1992 however, the death rate had fallen to 17 per thousand,
while the birth' rate remained high at 37 per thousand.
of natural increase thus went up to 20 per;thousand.
The rate
- 2 b)
SECOND FdASE 1953-6?-■- In 1953? China embarked upon her first
five-year plan. China's population had increased by nearly 61
millions over 1959 by 1955«
As part of the theoretical debate
then raging on national reconstruction Ma Yinchu put forward
his "Eew Population Theory"in 1955- This document pointed out
contradictions between excessive population growth and the
improvement in living standards, and advocated "
improving
the quality of population and controlling its size
"
*
Very
little evidence is available now about the actual implementation
of this policy or of the kind of response it elicited in public
life in China.
We do however have records of the Chinese Women's
Federation's letter to the Central Government in 1954(5)
expressing their (i.e. women's) unwillingness to mother a great
number of children.
Liu Shaoqi is known to have dovened a
birth control foum in Dec. 1955 in which he declared that the
Communist Party endorsed birth control and felt that it should
be promoted and not opposed.
In 1955 the government began td
manufacture external use contraceptives and relaxed restrictions
on induced abortions.
In 1956
the health department launched
a campaign to provide information on birth control and
contraception.
In the same year Zhou en lai in his report on
the proposals for the 2nd 5-y®ar plan at the 8th Congress of
the C.P.C said that1' to protect women and children and br?ng
up
our younger generation in a way conducive to the health
and prosperity our nation,, a certain measure of birth control
is desirable." In 1957 Mao Zedong also appeared to favour
birth control when he remarked (enlarged 3rd Plenary Session of
the C.P.C.'s Sth Central Committee)" as far as procreation is
concerned the human race has been in total anarchy and has
failed to exercise control".
However, even during this second phase, a counter
ideology in population theory existed, and towards the end of
the period, denunciations of Ma Yinchu and others associated
with a policy of birth control took place.
c)
THIRD PHASE 1966-7Dt-
This.was the period when-the so
called leftist or socialist population bheory gained predom
inance.
The main arguements in this were an ■.fellows!
i
- 3 -
It was stated, that people were not a liability but
1.
a strength.
A socialist country did. not fear population
growth, on the contrary sought to prepare favourable condit
ions fior it.
More people would build socialism faster, by
making it possible to create more accumulation through
socialist labour and develop the socialist economy at greater
speed.
2-
An theories of population control were motivated by
imperialist' design and prompted by Malthusian ideas.
While between 1958 and 1965, it was possible to note
the conflict of this ideology with one of birth control,
after the cultural revolution began in 1966, the work of
the state family planning agencies came to a total standstill.
Their personnel were disbanded, and any mention of family
planning became taboo.
For example in 1962 the natural growth
rate reached the 25 per thousand mark indicating that not
much success was being had with FP.
In the same year
however, the state council was calling on various localities
to promote FP, and as late as 1965, Chou en lai went on
record to say that FP work was progressive.
d)
FOURTH *
PHASE;
(From 1971 to the Present);
This period saw great political changes in China.
The
extreme 'left' line of the cultural revolution was completely
given up, and social and economic policies that were much
more moderate were introduced.
Large scale implementation of
a policy of birth control began once more to be encouraged,
and far more rigorously than was ever done before.
The
resolution of the population problem was stated to be
important for economic reconstruction, social development,
and socialist modernization (5).
In 1972, Hebei Province
hosted a small national conference on Family Planning, in 1973,
population targets were for the first time made part of
national economic planning, and in 1975-, Chairman Mao Zedong a
once more emphasized that population growth must be controlled.
In 1978 the new constitution explicitly stipulated that 'the
state advocates and encourages family planning.'
The new family planning policy lays down the specific
requirements of 'Late, sparse and few', i.o. la^e marriage, few
children and widely spaced out births.
Marriage age was offici
for men and 23 for women in the countryside
ally raised to
and 26 for men and
25- for women in towns.
At the third session
of the fifth national Peoples' congress, in 1980, the State
council put forth the call of only one child per couple and
made the one child family compulsory for all State and party
cadres.
As a means of motivation of couples to adhere to the
one child family norm, special incentives like extra work points
in rural areas, additional benefits like preferential access to
housing,extra rations have been in use.
To judge by results, China's new population policy has
achieved what it set out to achieve, viz reduction in fertility
levels.
According to the result as of the 'One per thousand
population fertility sampling survey' carried out in
1985,(6)
the Total fertility rate (TFR) which was at the level of
in the 195-Gs fell to 2.6 in 1981.
$ ,U-
At the same time,
'ideological education' or propaganda has also-gone jon.--
For example, a people's Daily editorial in March 1982
reaffirms the nation’s commitment to the one child' family
norm (?). This document is notable also for its strident tone,
its advocacy of disincentives if positive incentives did not
work, as well as for its strong emphasis on the eugenic
goals of fertility control.
What methods have been most commonly used in
China for birth control?
From the table below, (®) it appears
that the major stress has been on female mechanical
contraceptives, notably IUDs, although male and female
sterilizations
have also been in use.
We can conclude this brief survey with a few general
observations.
From what has
been said above,
it is obvious
that there has been in China since the success of the revo
lution, a conflict between two lines as far as population
policy is concerned, and which line has predominated at a
particular moment has depended on the larger ideological
orientation of state policy. It is also apparent that Chinese
- 5 socialist theory has failed, to work out clearly the relation
ship between population and resource base, having swung from one
extreme to another. This, is an area in which Marx's own
writings are incomplete (9).' Our last observation concerns the
way in which the women's question has surfaced along with
population policy in China.
In the first period of pro FP
policies in China, birth control was seen much more in the
context df women's and children's health and also in the context
of freeing women from a situation in which they were bonded to
bearing children only.
It must be remembered that this was
also a period in which Chinese women made great strides in
emerging in public life and throwing off feudal shackles.
In
the later, post 1971 period however, FP is seenmuch more as an
issue of state planning. It is also a period of relative
withdrawal from public life for Chinese women.
The One child
family norm has also reportedly led to an increase in female
infanticides, patriarchal values and a desire for male children
still being strong in the Chinese family and social structure.(10)
To what extent Chinese population policy is more humane and
equitable in spirit is an issue for debate and discussion, a
discussion that it is hoped will be set in motion by this paper.
REFERENCES;
1.
China; facts and figures. Foreign languages Press, Beijing,
2.
Liu Zheng, Soong Han and others (eds)
1989. PP
237.
. •
.
Chine's population; problems and prospects. New World Press
Beijing, 1981.
3.
Bianco, Lucien. La transition demographique en Chine
populaire et en Taiwan.
h-.
Revued 'etudes comparatives est-
ouest. Juin 1989. PP 10.
Hou Wenruo. Population Policy, in Liu Zheng...op cit.
9.
Liu Zheng. Population Planning and demographic theory, in
Liu Zheng ... op cit.
6.
Vlass of, Carol. Recent fertility research in China. Econ.
and Political Weekly. Sept 13, 1986. pp, 3r$ 1699•
7.
Chinese Population policy; a People's Daily editorial.
Population and development Review. 8s3- Sept. 1982.
8.
Zhang Lizhong. Birth control and late marriage, in Liu- Zheng.
op cit.
Me cjfel? a-n r>^-- ’
■ ■
9.
Table 15.
THE FOUR MAJOR METHODS OF BIRTH CONTROL
Method of
Contracep
tion.
1972
1973
1975
I.U.D
6,172,889
(1+7.4$)
9.220,297
(51.7$)
13.9^-9,569
(58.2$)
12 579,886
(59.I/0)
Vasectomy
1,223. *+80
(9A$)
1.715,822
(9.6$)
1.933.210
(8.1$).
1.555.251
(6.8$)
Tubal
Ligation.
1,7W.6W
(13.^$)
2,087,160
hi.7%)
2.955,617
(12
Induced
Abortion
3,910.110
' (29.9%)
5.813^2
(27.0$)
17,836,821
(10C$)
TOTAL
*
. 197?
1976
1977
16(W
MXr
11,620,000
(51.9$)
12,97
+
*
,000
(55.0$)
1,1+90.000
(6.7$)
2,616,000
(11.1$)
2.275,751
(10.7$)
3,260,01+2
(11.8$)
2,700,000
(12.1$)
2,776,000
(11.8$)
5,110,505
(21.3$)
5, 985, 565
(23.4$)
5,081-1-,260
(18.3$)
6,570,000
12>. -j/o?
5,229,000
(22.1$)
23,958.801
(100$)
21,285.552
(100$)
27,750,658
(100$)
22,380,000
(100$)
23,595,000
(100$)
* If a person rises more than one method, it is reflected in the total.
.frayan
BIRTH CONTROL AND LATE MARRIAGE.
1971
1971 - 1977
-
circle_Annual Meet__1985
Back_ground Ea2e£ ZZ
flASE_WPJNG.3ITO_PATIENT_C0MPLIANCE & MOTIVATION
MARIE D'SOUZA
In India today we see a situation of extreme poverty
of the masses and one of the highest rates of Tuber
culosis in the world.
For every 1000 population
there are 16 persons with active tuberculosis lesions,
4 of whom are infectious.(sputum positive)
Yet is is said that success in treatment of
Tuberculot s depends on quality and duration of
chemotherapy.
It is also established that hospitalisation,
rest and special dietsare not needed in the majority
of cases.
I will not consider here the’ fact that in deve
loped countries the number of cases showed a decline
when the standard of living improved.
Nor will I
dwell on the fact that the basic needs of food,
water and health care are lacking for 80% of our
population living in rural areas.
If success depends on quality and duration of
chemotherapy then case-holding forms a very important
part cf TB contort.
100% case-holding is however
very difficult to attain.
The early sixties saw the evolution of the
concept within the NT'f of offering TB services as a
part of comprehensive health care by the general
services.
This was done so that treatment centres
could be nearer the houses of patients, who could
take treatment without disrupting excessively their
normal life. The belief that Tuberculosis is a
problem of thickly populated cities and slums is a
thing of the past.
Pulmonary Tuberculosis is as
prevalent in rural areas as in cities.
And on the
basis of distribution of population one can except
2 to 3 cases in each village, with a higher rate in
tribal areas.
CASE_FII®ING_
Tuberculosis is classified as one of the biggest
health problems among our vast ill-served rural
population.
So case-finding in the rural areas
needs to be established, and it is here too that
CAS.T-.-10LDII.G has to be given importance so that the
best benefit can be drawn from the available
resources of men, money and materials.
To-day every PHI is supposed to have a ^micro
scoping centre’1 . . . though there is a query as
to how efficient they are where established.
Baily
says that each PHI should diagnose nearly 2000
bacillary cases in a year.
This can be achieved by
examining the sputum of all new patients attending
with symptoms of chronic cough.
If the real aim of case-finding is treatment,
then that of case-holding is completion of
treatment, while the aim of treatment is both relBf
as well as closure of _sources__of
infection.
The NTP stresses on the’ latter.
It is
the depth of suffering which makes people report to ■
health centres (felt need) as well as influences
the regularity with which treatment is subsequently
taken (.though this statement has been questioned) .
... 2
... 2 .. .
Treatment efficiently administered and taken will
relieve suffering and also have an epidemiological
impact.
Efficient treatment requires free availabiligy
of drugs, suitable drug regimens, freedom from toxic
reactions, regularity of drug intake and adequate
duration of treatment.
This implies health services
easily accessible, daily, with health personnel who
are capable and able to deal with patients with
sympathy and consideration.
Unfortunately thr®efourth of patients who have
a felt-need are being denied opportunities of getting
their suffering alleviated due to faulty diagnosis.
In many instances the sputum of patients with chronic
cough is not examined.
Ind of the patients who are
diagnosed as having Tuberculosis 70% are lost during
the entire course of treatment.
A moderately infectious Tuberculosis patient is
capable of infecting 10 to 12 individuals within a
periods of one year.
This patient untreated has .a
survival time of 2 years (it is capable of infecting
24 individuals) Again, this patient treated irregularly
has his life span prolonged and the number of people
he infects keeps multiplying.
In terms of human suffering, the loss caused by
TB is incalculable for the individual patient himself
- physical, psychological, social, material and for
his family too.
Economically TB accounts for an
estimated loss to the nation of Rs.1000 crores in
man hours.
All this should make us realise the urgency of
" Case - Holding-'
NATION.\L_TUBERCULOSIS PROGR
A step in this direction was tdken when the NTP
brought treatment centres closer to patients homes.
Further in order to ensure regular and adequate drug
intake by patients for a period of atleast 12 months,
a treatment organisation with limited supervision
and machinery for defaulter retrieval has been
provided.
The main objective is detection of a
maximum number of tuberculosis patients, specially
sputum positive, and efficient treatment.
Here follows a synopsis of the programme
1. Every person reporting to the PHI with cough of
more than 2 weeks duration is requested to give his
sputum for examination.
If sputum positive,
treatment is started din the same day.
Every MPW is required to collect the sputum of
eligible symptoms tics (i.e. cough, fever or
chest pain of more than 2 weeks or haemoptysis)
prepare the smear and referal slip and hand it
over to the PHI.
The sputum positive cases are
refered back to the MPW who is required to
bring the patients to the PHI for check-up.
The
M.O. also communicated directly by post with
sputum positive patients.
...3
...
2.
3 ...
The sputum negative patients who are suspects are
sent to the nearest Government Health Institute
with facilities for X-ray/ MMR/ Screening.
NTP has 5 drug regimens R^ to .
3.
for sputum
positive patients.
Those who are sputum negative
are treated with R^.
Drugs are supplied free of
cost.
4.
At initiation of treatment the patient is moti
vated by the M.O. and health visitor in the clinic
with emphasis on completion of treatment.
Repeat
' motivation is done at each collection every month.
5.
If the patient does not collect the drug within 2
days of the appointed date, a postal reminder is
sent 'and if there is no response for 7 days, then
home visits and fresh motivation about importance
of regular treatment is given.
6.
There is an effective "transfer " system which
enables any patient to receive treatment from any
peripheral centre convenient to him.
7.
A new patient put on treatment becomes eligible
for first follow-up exam and sputum exam at 6
months.
X-Ray exam is optional.
Second follow-up
exam is due after 12 months when both X-Ray -and
sputum exam can be ordered.
Default
The above is what the NTP requires.
Whether these
requirements are achieved is the big question.
And
achievements vary from state to state.
From reports
it appears that the NTP functions very poorly in the
north of the country, a little better in the south.
It is not surprising that as a result there is
a very high defaulter rate - 70% of patients
diagonosed as having Tuberculosis.
Banerji defines 'defaulter' as one whose actions
even after being provided "optimal'^ services go
against his own welfare or against the welfare of the
community or both.
In this sense there are very few patinet defaul
ters because the major impediments to acceptance of
NTP appear to be organisational, managerial and
technical rather than behavioural factors or short
comings in motivation of patients.
Therefore there
are more organisation defualters.
This is proved by the many instances where
recommendations laid down by NTP are not carried
out.
Very often patients are not told the result of
the sputum exam on the same day.
A study has
shown that 11% positive causes do not return to learn
the result of their exam. Whyr should they? Since
no indication or motivation is given and the drugs
...4
4
given for their cough have not been effective.
After
all patients are not worried about TB bacilli in
sputum. They are worried about fever, cough, chest
pain, anorexia, loss of weight, children starving,
loss of sexual potency, etc.
They expect to be cured
quickly and so decide to go elsewhere for "better"
treatment.
In fact it has.been shown that 52% of infectious
Tuberculosis patients seek medical help of their oWn
accord and of these 90% are sent away with cough
\
syrups and tonics.
It tells badly for the health professionals who
are not properly trained/motivated. Add to this the
fact that many of them resort to private practice or
corruption. Why should any patient have confidence
in them? The same can be said of para-medical
personnel, inadequately motivated, trained and
utilised, mal-functioning or lacking (eg. lab tech
nician) Lack of proper supportive supervision, as
opposed to inspection, adds to the problem.
Lack of communication on the part of organise- tional personnel leads to misunderstandings,. This
is further heightened by rudeness and results in
default.,, specially so among the poor who are the
larger number and yet are pushed aside while preferen
ce is given to the middle class;;
Often a patients arrive at the PHI to find it
closed - either the doctor is away for a meeting so
the rest of the staff also take a holichy, public
holidays are suddenly declared on the radio, a camp
is organised and all the staff are involved / no
one attending to the general health services, much
less to Tuberculosis patients.
Druse rP'
**
°
' giments are prescribed but ijo health
education or motivation is given in many instances.
Patients are asked to return after a week or two
because the drugs are exhausted. When they do return
they find that the colour and form and even the
number of the tablets has changed (eg. INH 100 mg
3 tabs, changed to INH 300 mg 1 tab) No explanation
is given and literate as well-as illiterate patients
are not sure whether their drugs have been given
correctly.
They dare not question the health perso
nnel and often consume the wrong dosage.
Not all the fault lies with the PHI.
They are
isPswz influenced by decisions from above. Highest
priority is given to Family Welfare Programs, with
ample funds and monetary inducements to promoters
etc.
Though on the 20- Point.Programme, low
priority is given to TB.
Drug manufacturers have their part to play too
in default. There is not much margin of profit in
the production of first line drugs and only one third
of the required quota is manufactured. While second
line drugs, not included in the NTP, are available
easily on the market.
Add to this the wrong prescri
bing habits within the country by private practi
tioners systematically adding tonics and other fanci
ful tablets, as also free sale of TB drugs by
chemists without prescription.
How is a patient to
judge whether 2 or 3 kinds of tablets given at the
PHI are enough to cure him of his disease when his
neighbour takes 5 or 6 kinds, wrapped in silver foil,
prescribed by a private practitioner.
(-
. . 5
All the above adds up to organizational default.
it surprising then that there is lack of patient
complinance and motivation?
Is
This leaves just a few instances of patient
"default".
Though, can he be said to "Default" when
he is not provided with 'optimal' services?
Studies show that drop-outs are maximum within
the first 3 months of treatment irrespective of the
type of regimen the patient is on. However a large
proportion of these drop-outs resort to subsequent
treatment either immediately or after some time
either at the same PHI or at other health institu
tions public or private.
Studies also show that
relief of symptoms, as commonly believed, was not a
cause of default.
Distance of patients home from the treatment
centre exerts a continuous process of selection.
Patients living more than 5 Kms. from treatment
centres take treatment irregularly.
Add to this the
monsoons when travel is difficult as bus services
are stopped and even walking on mud roads requires an
effort.
Emigration in search of work is another
cause of default.
Poverty has a large part to play. How is patient
to pay for bus fare, corrupt practice, X-Rays etw.
when he draws no income because of his inability to
work.
CASE—HOLDING
Improvement in case-holding demands that technical
and organisational methodology ol c. se-holding will
have to be improved, and methods of preventing
default, specially organisational, must be intensified.
For with proper organisation case-holding could
increase by 40%.
.
Studies have shown that there is a positive
interaction between good organisation, low default
rate and effective treatment, each supporting the
other.
In 1983 the Government of India launched the
new National Health Policy in co-ordination with the'
new 20-Point Programme of which Point 14 says
"substantially augment universal primary health
care facilities and control of Leprosy, TB and
blindness".
Government funds need also to be provided (as
in the NFPP) to "motivate" professional and para
medical health personnel.
For example, CHVs and
MPWs bringing sputum positive patients to PHIs
could be "rewarded".
While patients themselves
who complete treatment could be given a gift.
Government has the money to spend on research and
treatment of Ischaemic Heart Disease Cancer,
Diabetes, Chronic Renal Failure, as also CHOGM,
Asian Games etc. so why not on treatment of TB?
Health personnel, in general, definitely .
need better orientation, and up-dating as regards
TB treatment.
The para-medical workers also need
.. .6
.. . 6 .. .
clear job d .scriptions, training, proper actionoriented supervision (not fearentented inspection).,
technical and administrative supports with authority
to remove impediments sc that the program functions
smoothly and effectively.
In this respect medical students and interns too
need intensive input as regards TB treatment and
human relations.
Clean, accessible PHI with a welcoming kind
staff who
e punctual, conscientious and knowled
geable will ensure the whole-hearted co-operation
of patients till successful termination of treatment.
Patients convenience and not that of the staff is
what matters most.
There should be no question of shortage of drugs
if Government take suitable’ action the number of
patients to be treated should be calculated realisti
cally at PHI and DTC so that purchases are made for
one full year.
Standardisation cf regimens helps
ensure permanent availability., as also proper
provision of drugs.
Preferably the colour and form
should remain unchanged., and if changed a clear
explanation should be given to the paiint.
One
institution has a drug tray for display and instru
ction.
An effective regimen is one that is accepta
ble to the patient
and does not interfere with
his family and social life.
Therefore technical
instruction need to be laid down and means taken in
order to monitor efficacy of treatment.
This inclu
des -also interruption or change of treatment, dete
ction and correction of undesirable effects.
It cannot be stressed enough that the right
type cf chemotherapy and right type of organisation
for delivery near patients homes have emerged as
key factors in case-holding.
At_the_very firsfj visit proper history taking,
physical check-up "("including weight) health education
and motivation is needed.
The message provided to
the patients must be understood in order to be
remembered and acted upon.
It should also be make
clear to tiie patient that he needs to take treatment
for atleast one year to be cured of TB.
Not the
least is nothing down his full address or giving
him an address card to be filled in by the post
man or literate person in his village.
This will
help in tracing the patient if he defaults.
Action taken at first default is crucial for
case-holding.
It generally occurs at the second
collection.
A patient contacted within 7 days of
first default will generally be regular there
after.
Relatives, friends and acquaintances'at
work should also be contacted, health education
given and motivated to encourage the patient to
be regular.
MPWs on their monthly visits to the
village should contact patient, spouse, elder
brother, sister and community to impart health
education.
This shc'Jld be systematic, repeated and
integrated with othep health activities..
The
family members can definitely influence the
patients decision to continue treatment, so they
too should be informed about the number of tabs.
to be taken, frequency of visits to the PHI,
progress of disease, etc.
. . .7 °
... 7
...
patients support each other in taking treatment.
So
meetings could be held of patients in each village,
where common problems could bo discussed, misunder
standings cleared and difficulties solved where
possible.
They also help to remind each other of
visits due to the PHI besides supporting each other
in cases of corrupt practice by health personnel or
getting their rightful demands met.
This has been my
experience in one village.
Studies need to be conducted to improve community
participation in TB control.
One factor which promotes patient compliance
and motivation is sputum examination done periodica-_
lly.
In one study where sputum exam was done on 3rd
6th and Sth month after initiation of treatment,
drug collection sent up in the period immediately
following it.
A physical
check-up with weight
taking at every drug collection each month would also
probably help.
At present, in many instances the
patient is just sent to the dispensing window-where
he is merely told "Come again next month".
Is this
enough motivation?
In case of patients sent for X-Ray exam., proper
instruction to reach the Health Institution, person
to contact, fee to be paid, etc. should be clearly
given.
The Referral Centre should also make clear
to the patient that he is being referred back to the
referring centre, presumably more convenient, for
treatment.
In case of transfer to another PHI, more
convenient for the patient, he should be similarly
clearly informed of the person to contact at the
transferred address.
OUR ROLE
What role can we of MFC and the Voluntary Health
Sector play in Case-Holding? There are some that
feel that the Gove .nment HI cannot handle the TB
control program alone.
NGOs and other have to
pool in.
As long as NGOs are treating middle class and riesh
patients their pooling in will certainly help.
They
should follow the guide-lines laid down by the NTP
as ....
which are good as sputum positive
patients are concerned.
In the case of sputum nega
tive patients it would be well to •remember that XRay alone is not enough to confirm diagnosis of TB.
Studies have shown that defaulters among these
"cases" based on radiological findings is very high
and that tney need strong and more effective moti
vation.
Also as many as 98% of sputum negative so
called X-Ray positive cases continued to be sputum
negative after 3 years.
The question arises when treating poor pati
ents.
Should they be refused treatment by NGOs?
. . . . specially when they profess to be meant
for the poor? Financially they would go under, I
think, if they give free treatment to the poor.
On
the other hand the poor cannot afford the whole
course of treatment and would soon become defaulters
. . . . . .
with eventual increase in suffering.
One solution could be a cl^ser relationship with
the NTP, which through the DTC Centre, is willing to
supply free drugs on fulfillment of certain
conditions.
. . .8
8
Another solution is to make sure that poor
patients really make use of the PHI services.
They
have a right to free treatment and we could help
them get it.
One way to do so that we, at Janseva,
have found helpful is a slide show on TB which,
besides emphasising completion of treatment also
informs the commpnity on the different steps TB
suspects will have to go through for diagnosis eg.
sputum exam., possible X-Ray, the form, filled in by
the doctor, they will have totake to the referral
centre, and bring back filled in, signed and stamped
and eventually, free treatment.
When some patients were asked a fee at colle
ction of drugs - they refused to pay saying 'we are
from Janseva' they were never pestered again.
The same slide show helped motivation . . .
yet we had patients defaulting in spite of home
visits by us.
and
We , hould realise that even the most refined
advertisem*ntal techniques using deep motivation,
subliminal perception, etc.
have never claimed
100% success.
Personally, I feel that we of MFC
and others in the Voluntary Sector should being
pressure on the Government., so that sufficient
funds are provided to carry out effectively the
National tuberculosis Programme.
This would mean
an increase in work load 3 times the present, and
hence increase in personnel, with proper training,
etc.
Above all, pressure has to be brought on the
Government to in turn pressurise the Drug Manufactu
rers into producing the necessary quota of first
live drugs based on a realistic calculation of the
number of patients to be treated.
Marie D’Souza
Janseva Mandal
Nandurbar 425412
MAHARASHTRA.
REFERENCES:
Anderson S. & Banerji.D-
(1963) Bull.Wld Hlth
Org. 29, 685 - 700
Nagpaul.D.R. Ind. J. Tub.,
Banerji D.
Vol. XIV,
No. 4
(Apr 1969) Proceedings of XXth Inter
national Tub. Conference
Nagpaul D.R., Vishwanath M.K. & Dwarakanath G.(1970)
Bull. Wld. Hlth Org. 43, 17-34
Baily G.V.J., Samuel G.E.R. & Nagpaul D.R. Ind.
J. Tub., Vol. XXI, No.3
Nagpaul D.R.
(Jul.1978) Jour. I.M.A. Vol. 71,
pp44-48
Aneja K.S. & Srikantan K.
(1980)
NTI newsletter
17, 78
Banerji D.
(1981)
NTI Newsletter 2 18,
Aneja K.S.
(1982)
NTI Newsletter 19,
Baily G.V.J.
(APr.1983)
No.2
Ind. J. Tub.,
50
58
vol.XXX.No.2
Chaulet P. WHO/TB/83.141
Banerji D.
(Apr. 1984) Background Document for
VHAI meet
Sen Binayaks National Tuberculosis Program: some
problems and issues
Shiva Miras Towards Rational TB Care - a continuing
Committment
CMC Ludhianas An approach to TB care
Seetha M.A. of NTI s VHAI D-10. 344/MS-cb/10.383
* V * ii
*#
*
!»
i
Background Paper-II
XIII ANNUAL MEET OF MEDICO FRIEND CIRCLE
-
FINANCING
FAMILY ' PLANNING
- Ravi Duggal.
Population control under the guise of Family Planning
began in India with planned development.
India prides itself
as being the first free nation in adopting an official popul
ation (Control) policy.
The importance accorded to population control in
India's planning process is seen in the fact that each sub
sequent J year plan has witnessed an increased and a more
organised effort in averting births, culminating in violent
erbreian during the 'emergency' and subtler forms of
coercion presently.
Further, though family planning is part of the
health sector (a state subject) it is under the 'jurisdiction'
of the central government and consequently funded almost
entirely by the centre.
Also, family planning is largely
supported through 'plan-expenditures' - this means develop
ment funds that are mostly generated through debts.
Each 5 year Plan in its turn has never failed to
* e..
comment that India's development or growth has been the best
possible with the given resources but uncontrolled population
growth has always been the stumbling block.
Thus, each 5 years
Plan raises allocations to Family Planning in the hope that the
fruits of development are not eaten away by unchecked popula
tion growthl
However, it must be noted, that the pressure
to raise FP allocation is not only internal economic const
raints but to a large extent pressures from international
private, multilateral and bilateral agencies.
Contd...2...
2
T A B L E -1
PLAN ALLOCATION AND EXPENDITURE
(Rupees Million)
__
Plan
Allocat
ion.
FIRST PLAN
19?l-?6
Plan
Expendi
ture .
%FP Expen
diture of
FP Alloc
ation
________
Proportion
FP Expendi
ture of
total Plan
allocations
(Percents)
6.5
1.1+5
22
• .005
50
22
M+
0.05
SECOND PLAN
1956,61
THIRD PLAN
1961-66
3 ANNUAL PLANS
1966-69
270
21+9
92
0.29
829
705
85
l.»6
FOURTH PLAN
I969-7I+
2858
281+1+
99
FIFTH PLAN
197^79
397M-
5166
130
1.31
ANNUAL PLAN
1979-80
1162
1185
102
0.97
10100
13952
138
l.h-3
32563
——
——
1.81
SIXTH PLAN
1980.85
SEVENTH PLAN
1985-90
Source: Complied from
.
1.80
GOI, 1985.
Plan Expenditures
It is clear from the above table that allocation
and expenditure for family planning has increased at a pheno
menal rate from the 1st to the 7th Five''Year Plan periods. The
increase between these 7 Plans has been 5010 fold for FP whereas
the total Plan allocations increased only 92-fold -it may be
noted that Plan allocation to the health sector has increased
only 52-fold.
Further, the table reveals that until the Fifth
five Year Plan, expenditure on FP was less then what was
allocated but during the ?th Plan (the Emergency Period) for
the first time Plan expenditure outstripped allocation (by 3C$)
In the 6th Plan expenditure was 38$ excess of what was alloca
ted for F .P.
Contd,. .3
I
- 3 -
The first 5 Year Plan had, an insignificant allocation
of 65 lakhs and only 22% of it was utilised - this too to set
up a family planning cell in the Planning and Development
section of the Directorate General of Health Services.
The
Second Plan witnessed a 15-fold increase. The two significant
developments during this period were substantial foreign'funding, mostly private, being made available for FP, and
experimental trials of oral pills and methods of sterilisation.
In the first two Plan periods birth control promotion was
mostly done by voluntary organisations under the aegis of
FPAI which received funds mainly from IPPF, Population Council
and the FPA of Britain. It was only during the third plan
that government agencies began to actively participate in
pushing population control.
It was at the end of the third
plan that Family Planning became an independant department.
The camp approach was tried out for the first time under the
advice of the Ford Foundation. In this period Rs 25 crores was
spent accomplishing 1A million sterilisations (78% vasectomies)
and the camp approach got established. The end of the third
plan saw a massive echhomic and political crisis emerge,
especially the contradictions of the green revolution and the
naxalite movements. Planning was dropped but FP expenditure
witnessed a major leap to over Rs.70 crores in the three years
of the 1Pjan Holiday1. Also the number of sterilisations sky
rocketed to 5-.5- millions (or 1.5-6 million a year in
comparison to 1.5- million in 5 years of the 3rd Plan).
The Fourth, fifth and sixth plans were pumped with a
volume of funding for FP that no other development programme of
the government has matched. Totally Rs. 2315 crores was spent
(Plan expenditure) in these three plans on FP and the
achievement too was phenomenal - 5-3 million sterilisations
and 12 million IUDs. By the end of the Sixth Plan, with over
68 million births averted since inception of the F.P. programme,
demographers have estimated that the population growth rate
for the first time has shown a downward trend. Encouraged by
this the plan outlay (revised) for the Seventh Five Year Plan
(1985-90) was bolstered to a phenomenal Rs 3500 crores, for
the first time F.P. getting a plan allocation more than
the health sector.
Contd.. .5-....
- 5 -
Foreign assistance too has been a substantial proportion of
F.P. plan expenditure. Table 2■indicates only bilateral and
multilateral assistance for F.P.
T A B L E- 2
Bilateral and multilateral Foreign Assistance for F.P,
( Rs
Crores)
Rs in crores
Year
1972 - 73
7.35
1973- 7^
+
*
197
- 75
5.63
7.78
1975 - 76
11.77
1976 - 77
13.27
1977 - 78
20.01
1978 - 79
25.58
1979 - 80
29.08
1980 - 81
1981 - 82
12.79
25. u5
1982-
83
53.65
1983 - 85
55.21
1985 - 85
62.89
'
Sources Same as Table 1 and G0I, 198I.
For the Fifth and Sixth Plan periods foreign
assistance accounted for 19.55$ and 19.66$ of the Plan
outlays, respectively.
Details of private foreign assistance in not available but
it is clear that upto the 3rd Five Year Plan foreign
assistance for F.P. in India came mostly form international
private Foundations such as Ford, Rockefeller, IPPF,
Population Council, FPA's, Pathfinder Fund, Hugh Moore Fund
etc. However by mid-sixties bilateral and multilateral
agencies had made their entry, becoming significant funders
for F.P. in India from the IV -Five Year Plan onwards.
More than the proportion of foreign funds in
India's,F.P. programs it is the policy influences that are
more significant,
India's population control strategy
changed its content in keeping with influences exerted on
it's policy makers by the foreign funding agencies. (See
Appendix I which details the Area Projects that foreign
■agencies are directly implementing).
Contd
5
- 5 Disaggregated F.P. Expenditure
The major thrust to the F.P. programme towards
a target oriented camp approach began in 1966. It was in
this year that 'Family Planning' was elevated to the status
of a 'department' under the Ministry of Health and Family
Planning.
Table 3 gives year wise expenditure on Family
Planning alongwith number of sterilisations and JR IUDs
'accomplished' in that year.
T A B L E - 3
FP
YEAR
Expenditure and 'Achievement'
FP EXPENDITURE
(Rs. crores)
EXPENDITURE
PLAN-PERIOD
(Rs. crores)
1966-^67
1967- 68
1968.69
13 A )
26.5 )
30.5 }
1969-70
1970-71
1971-72
1972-73
1973-71+
36.2
48.9
61.8
79.75
57.85
1974-75
1975-76
1976-77
1977-78
1978-89
68.60
89.40
172.80
97.00
no.4o
5th Plans.
1979-80
121.80
1980-81
1981-82
1982-83
1983-81+
1984-85
146-40
192.CO
294-60
438-80
554-20
1985-86
*
*
1986-87
546.20
579.30
70.4
8.9
18.4
16.6
9.1
6.7
4.8
284.5
14.2
13.3
21.9
31.2
9.4
4.6
4.8
4.9
3.6
3.7
538-2
13.5
26.7
82.6
9.5
14.8
4.3
6.1
5.8
3.3
5.5
Annual Plan.121.8
17.8
6.3
20.5
27.9
39.8
45.3
40.8
NA
NA
6.3
7.5
11.0
21.3
25.6
NA
NA
Plan
Holidays
)
>
5
STERILISATION IUDS
(Lakfis )
(Lakhs)
4th Plans
6th Plans
1626.2
*Allocations only.
Seurce: Some as Table-2 and Performance Budget 1986-87 of
MHFW, GOI, New Delhi 1986.
The difference between the Plan -period expenditures
xn Table-1 and 3 are due to additional expenditures incurred
by the states apart from the centrally sponsored programme. 1
This is mainly due to the states enhancing the amounts of
scompensation to be paid from its own'resources.
Contd
6...
- 6 It may be noted that the expenditures indicated in
Table 3 exclude FP expenditure by other ministries and
departments, public sector undertakings,'municipal corporations
and panchayati raj institutions, private organisations and
voluntary agencies.
The expenditure incurred by these
•rganisations are substantial but the amounts of expenditure
are not easily available.
For instance, in 1985-85, the defense ministry
allocated Rs 13.5 million on FP, the railways Rs 16.6 million
and the Ministry of Labour Rs.5 million. (GOT,1985)s Source
■
1
•f Table -1.)
Further it also needs to be emphasised that the
health sector resources are largely at the disposal, especially
at the PHO level, of the F.P. dept. Ask any PHC doctor,
paramedic or other health worker and t]jey
will tell you
that between 80$ and 90% of their time is spent on F.P. work!
Also school reachers, petty bureaucrats and other officials spend
a substantial proportion of their time on meeting the
targets of the F.P. program, this largely due to pressures
from the top.
These are also resources apent on Family
Planning and are never accounted in F.P. expenditure!
What is the expenditure for Family Planning spent on?
Table 5 gives the break-up for the V and VI 5 year Plans.
TABLED
Disaggregated F.P. Expenditures
Item of Expenditure
5th Plan(1975—75^ to 1978-79)
Allocation
Expenditure
6th PlanC 198 0-W
to 1985-85
Alloc- Expenditure_
ation
1. FP Services &
supplie s(Includes
Compensation)
5-19. 5-2
9
*
537.
687.70
23.13
*
1
2. Training
13.07
16.92
13 .52
7.06
7.3M-
§&.8O
9.99
35.98
11.77
182.87
25-55
11.11
32.00
11.50
250.30
19.50
25-. 75-
23.60
0.20
• .73
106.11
TOTAL
5-97.36
Source: Some as Table -2.
516.55
1010.00
1395.12
3. Mass Eaucation
13.13
5. Research & Evaluation 9. *
3
5. MCH Services
8.57
9 Al
6. Organisation
?..IPP
8. VHGs
Gontd...7...
-7The above table clearly shows where the focus of the
se called Family Welfare programme lies. In both the V and VI
Plan periods 'FP services and supplies' was the single largest
expenditure accounting for 85.6% and 73° 3% of the expenditure,
respectively.
In the V plan period expenditure on FP services
exceeded allocation by 5% but in the sixth plan the excess
expenditure was a phenomenal 58%, out stripping the entire FP
plan allocat ion..-. In both the plan periods expenditure on MCH
services under which F.P. was to be integrated, was not only a measly
amount but was also underspent. In the $th plan expenditure
on MCH services constituted only 1.5% of the Family Welfare
expenditure, and was underspent by 15%. In the VI plan the
expenditure was aised to 13% (that too because of the
incorporation of EPI program) but it was again grossly
underspent by 27% I
Greater details of expenditure are only available
at the state level, The following Tables (5 and 5a) give
details of expenditure on Family Welfare programs for
Maharashtra State. It is clear from the Tables that MCH
is a very small proportion of expenditure under 'family
welfare'. The two years, 1977-78 and 1985-85 both record
•nly 5% expenditure for MCH services. This inspite of the
fact that after 1978 EPI was added on 'to the MCH program.
Table - 5 Maharashtra State
Major Heads of F.P, Expenditure (actuals)
(Rupees Lakhs)
Pygram
1977-78
1985—86
1. Direction & Administrator
2. Ru^al F$ Centres
59.99
261.89
1117.96
737.25
3. Urban FW Centres.
5. MCH Services,
12,21
31.9M-
105.28
J. Transport
6. Compensation.
15.83
*
5
159.
1600.31
7• Other Services & supplies
50.63
335.19
8. Mass education
5.21
——
9. Training,Research &
Statistics
35.35
158.39
10. Other Expenditure
251.30
38.57
105.12
16.78
Total
635.86
(Source: Govt. Maharashtra, 1981, 1985, 1986.)
5528.37
Contd. .8,,..
■
8
Table 5a Maharashtra State
Administrative break-up of F.P. Expenditure (1983-8 h- actuals)
(Rupees Lakhs)
Expenditure Category
' •
1. Direction and Administration
a) Salaries
b) Travel & Vehicle
c) Office Expenses,
d) Materials & supplies
e) Other.
»
327.96
39.21
50.50
3MB. 17
178. M-6
2, Program Components
*
’
a) Salaries'
b) Travel & Vehicle
c) Office expenses.
d) Materials & supplies
e) Other
f) Compensation paid
3. Grant in Aid.
808.69
10M-.20
65. Oh515.61
171.68
17h-O.h-3
3M-O5.35
35M-.M-9
35h-.h-9
93.05
h-63.97
557.02
h-. Other.
a) Salary
b) Other
5261.16
(
i
*ncludes
USAID & CHG component of Rs.866.35. Lakhs)
Source: Same as Table-5.
4
Further, table J also shows reverse for other program
heads. Direction and administration that accounted for only 3%
of ..the expenditure in 1977—78 skyrocketed to
This increase
was largely due to a much lower proportion of expenditure on
rural family welfare centres which got reduced fr<3m k-1% to 17%
of'family planning expenditure. It may be noted that this does
not mean a decline in F.P. services in rural areas 'because under
the 6th Plan the rural health sector was greatly expanded and
a substantial proportion of this infrastructure is 'used for
family planning, therefore the decline in proportion of rural
FW expenditure.
Compensations paid to acceptors, motivators and doctors
increased to 36% of FW expenditure in 198M—85 from 25% in
1977-78.
This is-indicative of greater pressure being exerted
by., providing larger monetary incentives. Two-thirds of' the
compensation in 198h-85 was paid to acceptors of sterilisation
and IUDs.•
Contd...9*••
- 9 Table 5a gives the administrative break up of FP
expenditure for 1983-81+ revealing that compensation constitutes
tne single largest category of expenditure grossing 33%
followed by salaries (23%) and material and supplies (16%).
The program component, excluding compensations, accounts for
36% of the expenditure, and direction and administration 18%.
As indicated earlier states in recent years have
smarted spending on FP beyond what the centre allocates them.
This is more so true of Maharashtra which has been in the
forefront of target achievement. The table below show's this
difference.
/d n , v >
(Rs
lakhs)
TABLE -6
----------------------
Central
Assistance
received
Expenditure
incurred
Fifth Plan (197I+-79)
Annual Plan (1979.80)
Sixth Plan(1980-85)
Sources
>+232.86
3725.32
1250.13
722.90
l>+588.82
10897-39
Government of Maharashtra, 1986.
% Excess
of Central
expenditure
11+
73
35-
The excess.expenditure incurred by the state comes
from its own resources. The. increase in excess expenditure
from 11+% of the central allocation in the V plan to 3*+%
ir the VI Plan is indicative of mobilising extra resources
to push with greater vigor the targets of FP.
The MGH component in the family Welfare expenditure,
as indicated earlier, accounted for only 5% of the total FW
expenditure - the rest was on family planning. MGH component
includes largely immunisation of children and mothers. It
has three sub-components (a) Immunisation of infant and
pre-school children with DPT and immunisation of expectant
mothers against tetanus (b) Prophylaxis against nutritional
anaemia for mothers and children and (c) nutritional program
for control of blindness. Expenditure for Maharashtra State
incurred in 1977-78 and 198>+-85 on the MCH is given below.
Political Economy of MGH and Child Survival
The primary health care structure that India has built
very gradually for its rural masses has the subcentre as the
basic health extention unit. Realising that women and children
are the most vulnerable groups to disease and disability,
the subcentre was organised as a unit to tackle this basic
issue. As a consequence ANMs were placed at these subcentres
Contd...10...
10 T A B L E -7
MCH Expenditure under
FW
CRs. Lakhs)
1977-78
198U-89
1) Immunisation against
DPT of expectant mothers
against tetanus.
21.19
19M-A7
2) Prophylaxis against
nutritional anaemia
8.89
b-6.83
3) Nutritional program
for control of blindness.
1.90
—
31.9b-
2>+1.30
Sources Same as Table-J.
and were given the responsibility for the health care of
women and children. By the HI 5 year Plan the ANM- subeentre
health scheme was in the 'take-off stage' but got grounded
because population growth appeared to be a larger threat,
and therefore, henceforth, ANMs were to be utilised for
pedalling targets of the family planning program.., This was
done under the guise of integrating FP with MCH. But the end
result was that MCH became a mere tail of the F.P, program.
Why did this happen? At the end of the III five year
plan (1966) IUD (the loop) was nut of its experimental stag®
and ready for a massive launch. Women workers, as a
consequence, were required to push this new device and
ANMs were the obvious choice.
There were two reasons for pushing the IUDs. Firstly,
it was relised that sterilisation, being a terminal method, was
largely being resorted to by people who already had a
completed family size (no.of children) of four or more,
therefore there was an urgent need to push a spacing method
that would not only reduce fertility but also in the long run
assure a samaller family size.
Also until then sterilisation
had been largely a 'male-method' and there was need to involve
women in the family planning programs so as to make it
f*
broadbased.
Secondly, in 1966 a United Nations Advisory Mission
very strongly recommended that population growth must be
curbed immediately and for this the resources of the health
sector were to be used. 'The Directorate (of Family Planning)
Contd...11. ..
-11 should be relieved from other responsibilities such as material
and child health and nutrition. It is undoubtedly important
for family planning to be integrated (it had been integrated with
MCH in 1963) with maternal and child health in the field,
particularly in view of the 'loop' program, but uritil the family
planning campaign has picked up momentum and made real progress
in the states, the Director - General concerned should be
responsible for family planning only'.
This recommendation is
reinforced by the fear that the program may be otherwise used
in some states to expand the much needed and neglected material
and child welfare services'
(U.N.'Advisory Mission, (1966.)'
Report ofi the Family Planning
Taking the cue the Indian government for the first
time evolved a target oriented approach for sterilisation and
IUD programs. Resources were considerably enhanced (Plan
Holiday period) and in the first yearof it's implementation
the £ 'loop' program netted a phenomenal 8.13 lakh acceptors
(much more than sterlisations which had started 10 years
before it).
At the same time tubectomy acceptors also
increased gradually and women increasingly became victims
of this target practise..
As indicated earlier the target approach became
increasingly vigorous, and inspite of the experience of the
emergency, it has stayed - only the target has shifted from
men to women. Also coercion of health workers to fulfil targets
has become the via media of coercing the people.
In the 197^ Bucharest Population conference the third
world countries banded together and emphasised that the limited
available resources should be chanellised to economic development
programmes, especially rural development - and that this in itself
would be the best contraceptive.
Though India took the lead in
propagating this line of thinking it was the first country to
use brutalised coercion in getting acceptors for the FD<
programme within a year of the Bucharest conference.
However, international F.P. funding’agencies (post
Bucharest) began to review the F.P. programmes in the third
world and realised that inspite of substantial allocation of
resources directly for F.P. activities the results were very
Contd...12
12 or
*
p
as population growth had not taken the expected plunge.
The World Bank in its review of population growth,
in the mid seventies, rejected the earlier hypothesis that
better health necessarily results in accelerated population
Instead an alternative hypothesis, as a result of
growth.
the Bucharest conference, received emp^irical support - that
high rates of infant and child mortality motivate high birth
rates (world Bank, 1980).
Thus, a new direction to population policy was evolved
and 'child survival' became the new focus »f attention for the
population control proponents. Therefore, international
agencies began directing their resources increasingly to MCH
and child survival programs. The Area Projects in India (See
Appendix I) are the best example of this new approach which
(
is in currency today. Break up of resource allocation for
these projects is not available but in all the projects it is
very clear that antenatal care and child immunisation has top
priority.
The current national campaign of universal child
immunisation in collaboration with UNICEF is a good indicator that
MCH and child survival are going to become prime areas of
investments for Family Planning.
* * # * # * ## *
R E F E RENCES
1.
Govt, of India? Year Book 1977-80 Ministry of Health and
Family Welfare,(MHFW ) New Delhi, 1981.
2.
Govt, of India: Year Book 198U-85, MHFW, New Delhi-1985’.
Govt, of India: Performance Budget 1986-87 of MHFW,
New Delhi- 1986.
M-. Gevt.of Maharashtra: Performance Budget of 1979-80 of
MHFW, Aurangabad, 1981.
3.
5.
Govt, of Maharashtra: Performance Budget 1985-86 of MHFW,
Aurangabad, 1985.
6.
Govt, of Maharashtra: Performance Budget 1986-87 of MHFW,
Aurangabad, 1986.
7.
U.N.Advisoiry Mission: Report on the Family Planning
Programme in India, New York, 1966.
W'erld Bank? Health Problems and Policies in the. developing
Countries - world Bank Staff working Paper
Nw.M-12 by frederick Golladay, world Bank
Washington 1980).
8.
Contd..13....
-13A P PE ND I X-I : (Extracts -£3- from Govt, of slndia 1985)
AREA
2 0 J E C T S :
To give a fill-up to the National Family Welfare
Programme particularly in the backward areas of the country
districts in 15 States (as detailed at next page) have been
taken up for intensive development of health and family
welfare infrastructure and expansion and upgradation of services
in five Area Projects with partial assistance from DANIDA,
ODA (U.K.) UNFPA? USAID and World Bank. These projects are
designed to increase and strengthen in about five years, faci
lities and manpower for delivery of Health and Family Welfare
Services in an integrated manner to reach a level that over a
longer period will ultimately be reached in the'entire country.
The objectives of these projectsare reduction of fertility and
reduction of material and child mortality.
This will be achieved bysi)
Expanding the Health Care delivery system both
kksxx quantitatively and qualitatively by
providing one Health Guide and one trained Dai in
every village (1000 population). One sub-centre
will be provided for every 5,000 population and
will be manned by one male and one female MPW.
For every four male and female workers, there
will be one male supervisor and one female
supervisor under this project. Additional
. manpower will be given basic
DISTRICTS COVERED UNDER AREA PROJECTS
Name of the Area Project.
1. World Bank
Assisted Area
Project.
States/Districts covered
1• Andhra Pradesh
3. Kerala
1. Anantapur
2. Chittor
3. Cuddapah
1. Wynad
l.Bardhaman ,
2. Idukki
2.Birbhum
3. Malappur- 3-Bankura
-am
M-. Prulia
h-. Palghat.
2. Karnataka
>+. Uttar Pradesh
1.
2.
3.
5-.
5.
6.
1. Deoria
2. Ghazipur
3. Mirazipur
Varanasi
5. Basti
6. Azamgarh
/
2. U.K.Assisted
Area Project
Belgaum.
Bijapur
Gulbarg.
Bidar
Raichur
Dharwar
Orissa
1.
2.
3.
H-.
5-
Cuttack
Ganjam
Kalahandi
Phulbani
Puri.
Contd.. .1!+...
5« West Benga
- 11+ 3. UNFPA
Assisted
Area Project.
1+. DANIDA
Assisted
Area Project.
J. USAID Area
Project
BiUax
Rajasthan
1. Monghyr
2. Santhal
Parganas
3. Saharsa
4-. Purnca
5. Bhagalpur
6. Katihar
7. Khagaria
8. Madhepura
9« Sahibganj
10. Godda
11. Deogarh.
1.
2.
3.
>+,
Madhya Pradesh
Tamil Nadu
1.
2.
3.
U.
1. South Arcot
2. Salem
Sagar
Tikamgarh
Gwalior
Morena
Shivpuri
6. Guna
•7. Bhind
8. Datia
Gujarat
5.. Panch
Mahals
2. Bharuch.
Haryana
Bharatpur
Swai-Madhopur
Kota
Dholpur
Punjab
1. Bhatinda
1. Bhiwani
2. Faridkot
2. Slrsa
3. Mohindergarh 3- Sangrur.
Himachal Pradesh
Maharashtra
1. Kangra
2. Hamirpur
3. S irmur
1. Osmanabad
2. Parbhani
3 • Latur
Training and the existing staff will be provided
with inservice training for upgrading their skills.
ii)
Construction of sizeable number of subcentres
with quarters for MPW (F) and H.As(F) within the
villages to ensure regular service as well as
security to the female workers, construction of
certain number of R.F.W.Cs. upgraded PHCs with
operation theatre and 10 bed ward, quarters for
medical and para medical staff of some PHCs as
well as hostel for MPW (F) training schools,
provision of operation theatres in some of the
PHCs, etc., form a major input of these projects.
iii)
Improving the managerial skill of Doctors of
PHCs, supervisory ditrict staff as well as para
medical personnel through proper training at
appropriate institutions so that the available
resources can be utilised property.
Contd...!?...
i
-15iv)
Improviding the Information Education and
Communication System by propr training cf
extension staff like district media officers,
district extension educators and the block
extension educators in appropriate institutions
followed by refresher courses.
v)
Evolving an appropriate Management Information
and Evaluation System (MIES) for concurrent eval
uation of the programme of the perpheral units
through regular feedbacks to these units so that
the deficiencies can be rectified by taking
adequate measures.
vi)
For the purpose of evaluation, the projects
envisage a Baseline Survey to be undertaken at
the beginning of the projects and an end line
survey at the end of the projects so that the
effect of the project inputs can be evaluated.
vii)
Funds are also provided for undertaking properly
designed Unnovative Research Studies the results of
which, if favourable will enable the State to
extend it to other districts.
>
The project period is of 5 years' duration following which
the States will have to bear the cost of the expanded services.
World Bank assisted area projects
Six districts of Uttar Pradesh and three districts of
Andhra Pradesh have been taken up with partial assistance of
the World Bank (IPP-II) at a cost of Rs. 82 crores approximately
including contingencies. Out of this, Rs. >+6 crores approximately
will be the World Bank assistance. The Project in both the States
have been started from April, 1980 and shall end in December
1985 when the development credit closes. The proposal to
extend the Project till 31st March, 1986 is under consideration.
A project in six districts of Karnataka and four districts
of Kerala has been introduced with effect from 1st April, 198^with the assistance of the World Bank (IPP-III) at a cost of
Rs. 120.U-3 crores approximately including contingencies out
of which Rs. 70 crores approximately will be the World Bank
assistance.
Another Project has been taken up with World Bank
Assistance (IPP-IV) in four districts of West Bengal. The total
cost of the Project will be Rs. 107A? crores out of which
World Bank contribution will be Rs. 61.20 crores approximately.
The Project in the State has started from 1st September, 1985 and
is of J years duration.
&ANIDA
Assisted area Projects
Eight districts of Madhya Pradesh and two districts of
Tamil Nadu Have been taken up with partial assistance of
DANIDA at a total cost of ^2.10 crores out of which 36.06 crores
will be the contribution of DANIDA. The Project works in
Madhya Pradesh and Tamil Nadu were started on 1st Nov. 1981 &
shall endon 31-10-1986.
Contd...16.
- 16 -
U.K, ODA Assisted area Projects
Five districts of Orissa have been taken up under the
Area Project assisted by Overseas Development Agency (ODA)
with effect from August, 1980 at a cost of Rs. 39•>'+2 crores
including contingencies, out of which Rs. 18.27 crores approx
imately will be the U.K. contribution, The project is due for
termination on 31-3-1986.
UNFPA Assisted Area Project?
Four districts of Rajasthan and Eleven districts of
Bihar have been taken up with thepartial assistance of UNFPA
at a total cost of Rs. 69.66 crores out of which Rs. 60.79
crores will be the UNFPa contribution. The project in Rajasthan
commenced from July, 1980 and in Bihar from January, 1981. The
Project in Rajasthan is to end on 31-3-1986. The Bihar Project
is being rescheduled and is likely to end in March, 1988.
USAID Assisted area Projects
Three districts each of Punjab Haryana, Himachal Pradesh,
and Maharashtra and two districts of Gujarat have been taken up
under the USAID Assisted Area Project at a cost of Rs. 51-79
v crores approximately including contingencies out of which
Rs. h-0 crores approximately will be the contribution of
USAID.
Due to extension of the project period upto 30-9-86 and
also due to increase in cost uf construction and initial
equipment the Project cost is setup to be revised to Rs.69»57
v crores. The Project commenced from August, 1980. The
project in the State, shall terminate on 30-9-86.
Baseline Survey under Area Projects;
Baseline surveys have been completed in the fourteen
states covered under Area Project. In West Bengal (IPP-IV)
Baseline Survey work is in progress. Draft/final reports have
been received in respect of Andhra Pradesh, Uttar Pradesh,
Bihar, Rajasthan, Orissa, Maharashtra, Himachal Pradesh,
Haryana and Punjab.
The basic objective of these surveys is to provide
information on the current levels of fertility and mortality,
identify socio-economic and infrastructural variables effecting
fertility and mortality, attitude and practice of various
birth control measures, utilisation of institutional facilities
such as MCH, extent and pattern of existing communication
channels, and to assess the extend of the exposure of the
population to the Mass Media.
/Chavan,/
* * . . . ... *
,*,*# ## j*c >;< *' #
*
# * #* #* #
* *
UBLIC HEALTH PERSPECTIVES IN THE FORMULATION OF
HE NATIONAL TUBERCULOSIS PROGRAMME OF INDIA
*
D. BANERJI
Professor and Chairman
Centre of Social Medicine and
Community Health
Jawaharlal Nehru University
NEW DELHI - 110 067
*A paper prepared for publication in the special
issue of NTI Bull r I, Hi.
Public Health Perspectives in the Formulation
of the National Tuberculosis Programme of India
introductionThree major steps were taken in tackling the
problem of tuberculosis in the country, These laid
the foundation for India's National Tuberculosis
Programme (NTP).
Findings from a nation-wide tuber
culosis-prevalence survey (1) brought about basic
re-orientation of many of the then prevailing notions
concerning epidemiology of the disease.
A very care
fully designed clinical trial by the Tuberculosis
Chemotherapy Centre, Madras (2) revealed that, in
clinical, epidemiological and social terms, ti'-berculosis patients could be treated with antituberculcsis
drugs as efficaciously at home as in a well-equipped
sanatorium.
An interdisciplinary team of scholars was
brought together at tne National Tuberculosis Institute,
Bangalore (NTI) to use the findings of the national
survey and the clinical trial, and collect additional
data required to formulate a. nationally applicable,
socially acceptable and epidemiologically effective
tuberculosis programme.
The NTI has also been
successful in performing the task assigned to it.
It adopted an approach of operational research (4) to
formulate the national programme.- .It also conducted
research studies to obtain crucial data from such di
verse disciplines as epidemiology, social sciences,
clinical phthisiology, microbiology, radiological
diagnosis and radiological engineering, public health
nursing and health administration.
The National Tuberculosis Programme, which
emerged out of these efforts, turned out to be a very
potent instrument for alleviation of the suffering
caused' by this disease.
There has been considerable
discussion among tuberculosis workers about different
facts of the NTP and of various factors which have
hampered its effective implementation. However, many
aspects of the NTP, which are of much wider signifi
cance to the entire discipline of community health,
have not received adequate attention from those
concerned.
Some of the perspectives which appear of
considerable relevance to the practice of community
health are being presented here.
An_Epiderniological ..Anproapb to a Community Health
Problem “
The problem of tuberculosis has been dealt with
in its entirety as a whale in terms of its size, dis
tribution and the dynamics of the quilibrium formed by
various host, parasite and environmental considerations.
The natural history of the disease (5), worked out
cn the basis of a study of the epidemilogical beha-■
vior. of the disease, has provided a framework for
evolving a strategy of intervention in the various
phases (promotive, preventive, curative and rehabili
tative) for obtaining greater impact on the problem
through the resources made -available for the
programme. (6)
The problem or tuberculosis has also been
projected in a time dimension to synchronize the stra
tegy for intervention with other social, economical
and ecological forces which are likely to influence
the epidemiology of the disease over time (6), (7),(8)
problem o
the,
** tuberculosis patients in a community. By adopting this approach,
The use of the BCG vaccine as a tool for preven
tion of tuberculosis in the population is an illumi
nating instance of changes of strategy in using this
tool in the package of intervention under changing
circ*mstances.
In the early fifties, when the epide
miological dimensions of ■problems became known and
findings from Madras an- Bangalore studies were not
available, BCG vaccination was considered the onlv
tool to make any worthwhile impact or the epidemiology
of the disease. (9)
This consideration formed the
basis of launching'the unipurpose Mass BCG Campaign
of India.
However, with the formulation of the NTP '
in the early sixties, the BCG vaccination programme
became an integral part of the package in the form
of the ''District Tuberculosis Programme .
BCG vacci
nation also became part of the nationwide programme
of providing a package of immunization services to
the new b'olrn (10) Operational studies also led to
major breakthroughts in the logistics of providing
*
the services. The costly process of prior tuberculin
testing only to t’fbse who were below twenty years of
age. (11) Pin-ally, on the basis of an extensive BCG
preventive trial, which can be considered as a land
mark in the field of experimental epidemilogy, date
were adduced to question the epidemiological validity of
carrying out BCG inoculation amongst adults, atleast
in India. (12)
So£ial_Science_Dimensions of_a_Cpmmunity_Eeolth
Problem -L^oing. to the People^and^LearnYn^g fpom^them
This has been the most outstanding among impor
tant community health perspectives which emerged in
the course of formulation of the NTP.
Going to the
people in a community and learning from them what they
felt about the problems of tuberculosis has provided
insights which brought about most radical changes in
dealing with tuberculosis as a community health problem.
(13) By identifying the area where the •felt-needs”
of tuberculosis patients for the services overlaps
with epidemiologically defined needs, it has been
possible to develop an entirely new strategy which
gives primacy to the meeting of ths felt needs among
**
tuberculosis was defined as a problem of suffering.
4s, by implication, the suffering caused by this
disease is a component of the suffering caused by all
health problems withir a community as a whole, a
programme for alleviation of the suffering caused by
tuberculosis has to be an integral component of the
bigger package dealing with all other community health
problems.
Indeed, the tuberculosis patients themselves
showed the way to integration of services as they
sought help more often from institutions for general
health services than from specialised tuberculosis
institutions.
The very process’ of meeting felt needs of tuber
culosis cases in a community generates greater felt
needs among them, thus further extending the area .
of overlap.
If, however, generation of new felt needs
falls short of the capacity of tho programme to offer
services, one can be justified in taking active steps
to generate more felt reed by launching carefully
designed health education drives.
It has ks also been
possible to conclude from an analysis of the data on
the social science dimensions of epidemiology of tuber
culosis that a felt need-oriented NTP has a poten
tial of encompassing over 95 percent of all the cases
within a community. (1J.)
It thus has a potentially
greater epidemiological impact on the problem than the
conventional and more expensive method omass case
finding and treatment vith the help of mass radiography.
a
r.i
i-i
Q
rj
co
o
o3
h
CO
r+
O
C
P-r+
Oj
o
h
B
B
Q
...5 ...
At the operational level, data on behaviour of
tuberculosis patients in a community were used to
devise a method of diagnosing tuberculosis patients in
rural areas which was both very simple and sciantifically very sound.
Those data were also of help in
working out the details oforganizing treatment of the
diagnozed patients.
Subseouent social studies of what
is termed as "treatment default (15), (16) had opened
up newer facets of this problem which bi :herto had not
received adequate attention from programme administr- '
ators and health educators.
Integration of NTP with General Health Services
As pointed out above, consideration of tuberculosis
as aproblem of suffering and patient's recourse to
general health services provided the underlying logic
for integration of NTP with general health services.
There is, in addition, sound administrative justifica
tion for dealing with all the health problems of a
community as an integrated whole, demanding an integra
ted approach. (17), (18).
The NTP was made to sink or
As a result, if the
sail with general health services.
latter are inadequate, NTP also suffers from the same
in a equacies.
The solution thus does not’lie in.
attempting to remove inadequacies in NTP alone but
rather in the entire health services system.
Speci
alised mass campaigns, ar vertical programmes against
specific diseases teno to weaken general health
services by diverting disproportionately large quant
ities of scarce health resources to these programme.
Most often these specialised programmes are not (even
relatively) cost effectiv
,nd also suffer from the
same mal idles which are th? causes of inadequacies in
general health services.
NTP h=<s thus been a pace setter in integration of
programmes fqr specific diseases within general health
services.
Indeed, after not so successful experiences
with specialised "vertical" programmes against speci
fic condit:ons, such as malaria, smallpox, rapid
population growth, cholera and blindness the union
ministry of health had endorsed the philosophy of
integrating specialised programmes with general health
services by launching the "Multipurpose Workdrs' Scheme
(119). Because of its very design, this scheme reinfor
ced the basic postulate of the NTP, namely strengthing the general health services,
Because of the
same considerations, NTP found itself in harmony with
the decision of the union government to entrust
"Peoples Health in Peoples' Hands" by launching the
"Community Health Workers' Scheme". (20) This
approach received further impetus from the Alma-Ata
Declaration (21) and from the launching of a progra
mme for providing "Health For ill-2000 A.P." (22)
NTP can thus claim to be a forerunner of the philo
sophy of primary health care.
of _a_T<£f erral System-Through Regionalisation_of Services
The most outstanding feature of the NTP is
that in this programme a specific effort has been
made to subordinate technology to the people, rat’ier
than the other way found. By analysing the then
available technology or by generating specific
technology, the programme formulators took special
care to ensure that technology used in the programme
emerged from a consideration of' (a) limitations
...4
... 4 ...
of the resources; (b) knowledge about cultural
meaning and cultural perception of the problem; and
(c) the health behaviour that is generated by the
cultural factors and access of people to technology.
Because of this people-oriented approach to techno
logy, they were able to withstand pressures for
inclusion of the then emerging advances in this
field, such as tomography,mass radiography, advanced
thoracic surgical techniques and expensive second
line drugs.
Based on data on the cultural, social, economic
and epidemiological situation in the country, diagno
sis of tuberculosis patients through examination of
„
sputum smears from the symptomatica and their
treatment at home vith not very expensive combination
of anti-tuberculosis drugs, formed the sheet anchor
of the NTP. This led to considerable decrease in
dependence of people on professionals and on sophisti
cated, imported equipment, apart from drastically
reducing the cost. (23) However, the more elaborate
services that are available at higher levels were
also mobilized as referral agencies to support work
at the periphery.
Though the bulk of the patients
could be treated efficiently at the periphery, those
needing more sophisticated diagnostic techniques or
special treatment regiments were referred to the
District Tuberculosis Centre (DTC).
The OTO, in turn
can count on support if even more sophisticated
services available at she State Tuberculosis Centre
or super-specialities available at teaching hospitals,
to deal with the very small fraction of cases which
did require'such interventions.
As 11 these specia
lized
agencies formed an integral component of the
NTP, they too have reverse referral linkages with
the periphery. Thus, while avoiding unnecessary
professionalization and mystification, the NTP also
includes sophisticated tcchology in a measured way.
A Health' Information System
There- are two notable features of the health
information system of the DTP: the postulates of the
NTP provided a framework' of identifying the pieces
of information to be collected; and the details of
information system were worked out on the basis of the
capacity of the programme organization to generate,
transmit and process the information.
The information
system was used for monitoring, evaluating and taking
the indicated corrective actions.
There are three ma jor. components of the informa
tion system.
One relates ma.nly to data on administ
rative end operational aspects of the NTP in a given
population. The second to the actual process of
implementation of the NTP, for example, preparing
index cards, monitoring of treatment and keeping
track of the cases that are transferred from one instituion to another. The thirl component relates to
epidemiological analyses of she impact of the NTP on
the problem of tuberculosis vithin a population.
T'22S Training for Implernentiag a Community Hea 1th
Programme
.
A team approach to training of personnel of a DTC
s, another distinguishing feature of the NTP.
A team
for a DTC is lead by a District Tuberculosis Officer
-nd it consists of a treatment organizer, a radiologist,
a laboratory technician, a BCC- Team Leader and a stati
stician.
NT I has formulat"
*
r %-ox-jr
ma
■»■•!««
... 5 ...
for 'training of a DTC team (24) .
Broadly, it consi
sts of exposing the entire team to the general philo
sophy underlying the NTI in such a way that it could
be understand by every member of the .team. This
enables individual members of the team to identify
what his/her role is and how his/her workcontiibutes
to the programme as a whole. This is followed by
training of individual members in their own specific
fields where emphasis is laid ,;n aspects particularly
relevant to the NTP. Finally, each DTC team is
reassembled and the team is trained to. work as a DTC
team under actual field conditions, they are likely
to face on their return to their posts.
Use .of^.Opera.ti.onal R^£e_arch__Methodolc gy_.for„Solving_
a. Oommur itjr
The most significant aspect of this approach
was that it was evolved in NTI in the course of
attempts to solve the problem assigned to it.
The
starting point was not operational research as
enunciated by experts in this field; (25) the star
ting point was the problem and it turned out that the
approach of operational research’ provided a very
valuable framework for finding a suitable solution
to the problem. (4), (26) It was realized quite early
that solution of the problem required consideration
of. a large number of variables which pertain to a
number of disciplines and which are in complex interraction with one another.
Pdr this purpose:
1.
The problems of tuberculosis in India are
elaborately defined, both in conventional epidemiolo
gical terms as well ns in social terms (as a problem
of suffering or as a felt need).
2.
The factors that are relevant for finding a
solution to the problem were identified and special
studies were conducted to obtain data concerning
those factors for which data were- not already
available.
3-
An attempt was then made to put these
factors together in the form of a model (not nece
ssarily '’mathematical;t) to depict the major intera
ctions amongst them and work, out alternative ways
of solving the problem through alternative ways of
influencing different components of the model within
the constraints of the available resources.
4.
The model was then used to make forecasts
concerning outcome of the alternative ways of
problem solution in order to choose the or.d which
offers nest effective use of the available
resources.
5.
The chosen alternative (solution) was then
put to practical test (test run) under rea.l_li.fe
conditions (as opposed to condition of a pilot
.. .6
... 6 ...
study), to test the validity of the assumptions that
had been made in choosing the solution.
6.
The findings of the test run were fed into the
chosen solution and the letter was then put into normal
operation.
A feedback system, which was built into
t’ne programme, ensured continued monitoring of the
implementation.
It thus so happened that this approach was the
one that is followed in operational research.
This
experience of programme formulation can also be used
for formulating other health programmes - eg.
programmes to deal with specific health problems, such
as malaria, leprosy, maternal and child health or
family planning or programmes for improving working
of health organizations such as hospitals, rural
health centres and the Community Health Volunteers'
Scheme.
Provi_dinc Institutional Fram.ework for Solving, a.
Communi. ty Hea.lth_Problem_
' ~
"
The three institutions, namely the Indian Council
of Medical Research, conducting a nationwide prevelance
survey of tuberculosis, the specially established
Tuberculosis Chemotherapy Centre carrying out to be a
historic clinical trial in the' field of community
health and the National Tuberculosis Institute
performing the pivotal role of formulating the NTP
(and following it up to provide training, research and
consultation support to the NTP), have made crucial
contributions in dealing with tuberculosis as a
community health problem in India. This underlines
the need for developing similar institutional frame
works for dealing with other pressing community
health problems (such as malaria, nutrition, maternal
and child health, leprosy, filariasis, blindness and
family planning).
Conclusion—
Formulation of a nationally applicable, socially
acceptable and epidemiologically effective national
Tuberculosis Programme for India involved use of a wide
range of principles of the discipline of community
health.
These principles can also be very profitably
applied in the formulation of nationwide programmes to
deal with other major community problems.
Government.
commitment to strengthening rural health services in
India by using multipurpose health workers and by
employing community health volunteers has further
strengthened the case for adopting the approach deve
loped for formulating the NTP on a much wider scale.
This approach also gets further endorsem*nt from the
concept; of Primary Health Care contained in the Alma. ta Declaration.
Indeed, the approach to formulation ■
of NTP, developed in the early sixties, had antici
pated the approach that is now being advocated world
over for attaining the goal of Health For All by
2000 A.I.
...7
... 7
REFERENCES
1.
Indian Council of Medicci Research (1959) ■ Tuber
£ulosis. _in_.Tndic_o A Sample_Surv£yx 1955-1958,
New Delhi, Indian Council of Medical Research.
2,
Tuberculosis Chemotherapy Centre, Madras (1964) :
A Concurrent Comparison of intermittent isoniazid
plus streptomycin and daily isoniazid plus PAS
in the domicilliary treatment of pulmonary .
tuberculosis, Bulletin_of World Hoalth_Organisa-_
tion, Vol. 31, PP 2’4'7-271.
3.
Chakraborty, A.K. (1979)’ Twentieth anniversary
of NTI-What has the NTI achieved? NTI Newsletter,
vol. 16, No. 4, Dec. pp 104-110.
/
Banerji, D (1972) : Operational research in the
field of Community Health, Qpsearchx vol. 9, Nos.
3-4, Sept-Dec., pp 135-142. ’
”
5.
Leavell, H.R. (1965); Levels of application of
preventive medicine, pp 14-38 in Leavell, H.R
and Clark, E.G. (ed) - Proventive___Medi.ci.ne for the
Doctor_in this_Community)”“7Au EpidemioTo_gi£al
Apjaroacji^ ’3rd ed, New York", McGraw-Hill Book Co.
6.
Banerji, D (1965); Tuberculosis; A problem of
social planning in developing countries, Medical
Carex vol. 3, No. 3, July - Sept,, pp 151-15'9.
7.
Grigg, E.R.N. (1958); Ame._R£v. Tuber and Pul._
Dis., Vol. 78, pp 151-172, 426-4537 583-503.
8.
Dubos, R and Dubos, J (1952); The white pla_guex
Boston, Little Brown.
9.
Rao, K.N. (1980) : History of tuberculosis in
Rao, K.N. (ed): Text_book on__Tub£r£ulosis, Rev.
ed., New Delhi, Vikas, Chap. 17
10.
Nagpaul, D.R. (1967) : District tuberculosis
programme in concept and outline, India_n_Journ_al__
of Tuberculosis, vol. 14, No.4, op 186-1987
11.
Belly, GVJ etel (1973); Integration of BCG
vaccination in the general hsJ.th services in
rural areas, ,Tudian_Journ21 _of Tubercul£sisx
Vol. XX, No. 4', pp 155-150.
12.
Tuberculosis Pr. vention Trial, Madras (1980) :
Trial of BCG vaccines in South India for
tuberculosis prevention, ^ndi£n__Journ£l_of
Medical ?.“se2rchx vol. 72, Sunpl, July, pp 1-74.
13- Banerji, D (1980): Social aspects of TB Problems
in India in Rao, K.N. (ed) : Text Book_on Tuber
culosis, Rev. ed., New Delhi, Visas',“"Chap. 97
14.
Banerji, D and Anderson, S (1963); A sociolo
gical study of the awareness of symptoms sugge
stive of pulmonary tuberculosis, Bulletin of
World_Hoalth Organization, vol. 29, No.5’,~
pp 665 - 6'83.
. . .8
. . . 8 .. .
15.
Banerji, D (1970) - Effect of treatment default
on result of treatment in a routine practice in
Indio, Proceedings of_the_XXth International
Tubarculosis Conference",' Pa r is,'"internnTiona1
Union Against Tuberculosis.
16.
Singh, M.M. end Banerji, D (1968): A follow up
study of patients of pulmonary tuberculosis treated
in on urban clinic, Indian_Journal of Tuberculosis
vol. 15, pp 157-164.“
’ " ~
~
~
~ "
17.
Government of India, Health Survey and Develop
ment Committee (1946): Re^ort^ vol. II, pp 6-16,
Delhi, Manager of Publications,
18.
National Institute of Health Administration and
Education (1971) : An_®3P-L0£3i0£y_.Study of Integra
ted 3£'21i^_S_eryi£es in_.tndi.a_: A Report)” New Delhi,
National Institute of Health administration and
Education.
19.
Government of India, Committee bn Multipurpose
Workers under Health and Family Planning
Programme (1975) Report_ (Kartar Singh Committee)
New Delhi, Min. of Health and Family Planning.
20.
Government of Iftdi.a (1978): Annual^Report,..197778, New Delhi, Ministry of H~nTth and Family
Welfare,
21.
World Health Organization (1973): Primary H®21th_
Care_r RsJ20£^_0.£ i'n®. .international Conference^on
Primary A-^lth^Care/^Almy-Aty, USSR,“Sept. 6-1?,
1978, Geneva, World Health Organization.
22.
Government'of India, Working Group of Health For
111 by 2000 i.D. (1981) : Renortj. New Delhi,
Ministry of Health and Family Welfare.
25. Banerji, D (1967): Health Economics and developing
countries, Journal p_f._the__.Ind Lan Medical Asspciation, vol. 49, No. 9. Nov. 1, pp 417-421.
24. Narayan, R (1972): Team training in a job-oriented
course, NT I News_Le_tter, vol. 9, No. 1, ppl-525. Churchman, C.W etal (1957): Introduction__of Opera
tions Res.earchx New York, John Wiley.
26, Luck, G.M. etal (1971) ; Pqtiyntsx Hospitals and
Operational Reyea_r_chx London, Tavistock
Publications.
mOIDi’CO FaIjJiRL CimCmE — AImNLiaL LziET 1985
BACKGROUND
EVvliuTxvh
dHt
'i'ixji NAT xvi.AXj TUBHRC LimUbla rliuGxiAI.-LB
.As in most other countries of the world, the first anti
tuberculosis Leasures taken in India were of an unplanned adhoc
nature, confined mainly to the establishE.ent of hospitals and
sanatoria.
Partly due to lack of resources and partly to
preoccupation with epidemics such as plague, smallpox, cholera,
etc. scant attention was paid to the development of a tuberculosis
policy.
In most places, even rudimentary diagnostic facilities
were absent.
The colc ept of control ^f tuberculosis in the country was
first mooted in 1920 and efforts for control were through the
organisation of the King George V Thanks Giving Fund.
The Funds
so collected were utilised through the Indian Red Cross Society
primarily for preventive and educational activities, establish
ment of clinics, training of health visitors and preparation
of health education material.
In 1939, the Tuberculosis Associa
tion of India was established with the object of providing
expert advice, evolving standard methods to deal w ith the
disease, setting up of model institutions for training of tuber
culosis workers, education of public regarding preventive
measures and organising meetings and conferences for scientific
discussions.
The activities -st the Association at its inception
were to chalk out programmes , encourage establishment of clinics,
dispensaries and sanatoria, undertake research in community wide
management of tuberculosis and to serve as an advisory bureau.
Recognising the enon_ity and complexity of the disease and
to meet the needs of large number of tuberculosis patients, the
Tuberculosis Association conceived the idea of domiciliary treat
ment as early as in 1940.
It established the New Delhi TB Clinic
(now known as New Delhi TB Centre) to try out the efficiency of
domiciliary treatment by offering collapse therapy from out
patient department ana to guide patients aid their contacts
regarding preventive measures.
The method was found acceptable
and applicable and the experiment satisfying.
The Association established Lady Linlithgow Sanatorium in
Easauli, Simla Hills, to demonstrate model sanatorium services.
These institutions were also entrusted with the responsibility of
training medical and para medical workers.
si1' CWXmTixvL
vF
i'rnm LxoEaHE
At the instance of the Central Government, the Health
Survey and Development Committee headed by Sir Joseph Shore (1),
for the first time, outlined a conventional phased scheme for
management of tuberculosis in 1946.
For reasons of scarcity of resources tn d impracticability,
the scheme could not be imp! a.® ted.
The administrator, however,
could not ignore the suffering -f patients and the public demand
for definite action, even though the facilities for diagnosis
and treatment were lacking. After independeic e, in 1948, the
Tuberculosis Sub-Committee of the Health Panel of the National
Planning .Commission, drew up a programme for dealing with
tuberculosis and suggested application of BCG vaccination, which
was considered to be the only measure for prevention and control
of the disease and was expected to yield good results within the
resources available in the foreseeable future.
Following the
. . .2.
G.D.Gothi, Director, New Delhi Tuberculosis Centre, New Delhi
Source - h.T.x. Newsletter (1981)18.22
2
acceptance >f the proposal by the Planning Commission,a nationvice BCG programme was started in 1951.
On the assumption that
fee cisease was primarily a problem of thickly populated urban
areas, ana slums, the programme was first introduced in cities
and towns.
Thereafter, the BCG teams were shifted to rural
areas. As per conventional procedure, the population was
tuberculin tested prior to vaccination to identify tuberculin
non-reactor eligibles for BCG vaccination.
The country-wide
tuberculin testing revealed high prevalence of tuberculous
infection both in rural (2) arid urban areas which was contrary
to the earlier impressions that tuberculosiswas mainly a problem
of crowded urban cress. A country-wide tuberculosis sample
survey (3) to get information on prevalence of disease in
various strata of the country was therefore considered necessary.
jfeTIkAi'xvh
'ih.b<
oF Tx^S TuBEkCllmOblB t’fcCBmaSM
A large scale sample survey was conducted in six zones of
fee country covering urban and rural populations under the
auspices of the Indian Council of Ledical Research (3) in '
1955-58 to cet as precise an information as possible about the
magnitude of the tuberculosis problem in the country.
The
survey covered^, total population of about 3,CC,GGC persors
residing in urban, semi-urban ard. rural areas of the country.
The survey confirmed the impression of high prevalence of
tuberculosis morbidity in rural areah, feat had earlier been
revealed by large scale tuberculin testing.
It was estimated
that of the eight million people suffering iron tuberculosis
about 80% were in fee rural areas.
TOoih
TBCifhIQUJaS
The discovery of specific, potent, cheap and readily
available anti tubercular drugs ard the efficiency of domiciliary
treatment proved by the New Delhi TB Centre (4) and Tuberculosis
Chemotherapy Centre, Madras (5) completely changed the outlook
for TB patients.
The probability of formulating a comprehensive
ruberculosis programme to combat the disease on a community-wide
basis seemed possible.
Hoe control measures for tuberculosis could not be different
from those commonly known for control of any other infectious
disease, i.e., preventive vaccination, case-finding and treat
ment.
The cvailable to_>ls for the control of tuberculosis
consisted of BCG vaccination for prevention, chest radiography
end sputum microscopy for casefindirg and ambulatory domiciliary
chemotherapy for treatment.
The problem was how to apply these
tools.
There was a wide gEp between knowledge end its applica
tion.
An objective end systematic approach for formulation of
sound policies for t£.ckling the problem. of tuberculosis was
urgently needed.
What should be the organisation and resources
in terms of trained personnel, equipment, drugs etc.
The mamer
the tools were to be applied and techniques to be employed were
some of the questions that remained to be answered.
The National
Tuberculosis Institute (NTI) was estehlished in 1959 in Bangalore
by the Government of India, to evolve a programme which would
answer these questions and be feasible and suitable for both
rural and urban areas of the country.
The Institute was given
fee responsibility «zf training tuberculosis workersand conti
nuing research for modification and evolution of the programme
in the light of newer knowledge.
rxx vu
jiVvxj’uTiOh1
The evolution of the National Tuberculosis Programme (DTP)
was based in a. number of factors related to epidemiological,
sociological, o... ex?ti .• n al, technical and administrative aspects.
Information on those aspects was obta._ned froi: studies corf ucted
in different farts of the country which were reviewed prior to
formulation of the ..rogramme.
In addition, the NTI conducted
epideaioloL icrl, Sociol-g.ical and operational studies to enun
ciate suitable methods lor large scale application of BCG
vaccination, case-file ing. a.nd case-holding . Salient findings
of s-me of tile studies that were made use of for planning the
NTP are presented below.
xz.ii'.-fl'Lvv
Bzoxb
The epidemiolog 1ca.1 data that were considered were obtained
from tuberculosis surveys conducted by ICiux (1955-58) (3).
Studies were also undertaken in Delhi (6), Kadanapalle (7) and
Bangalore (S).
These studies r evealed^ that infection and
disease were widespread.
Out ■ f the total population of the
country, about 50% was infected with lu.tuberc ulos is and about
G.5% aged 5 years and above suffered from bacillary disease.
The disease was evenly distributed in rural and urban areas and
was more frequent in calcs, especially in the high er a.ge groups.
The annual ire idence of disease was found to be 1-3 per thousand
(9) i.e., l/3rd of the prevalence at any point of tine.
There
was a. time la.g between infection and development of the disease
suggesting that new cases of tuberculosis would continue to
develop from the already infected, population for marv years
toe one.
These epidemioluc ical findings demao ded that tuberculosis
services be so organized as to cover the entire country, on a
permaneii basis slice cases would continue to arise all ’file
time, all over the country.
Priority had to be given to finding
sputum positive patience to prevent the spread of infection.
8 Oo IvLOuxG/jj
CoiibxLiiJXfxTxolxS
Socio-economic conditions in any country have wide inplicati ns for programme planners.
The importance of the tuber
culosis problem from the social angle has to bo considered
in relation to other health aid social needs of the country.
Resources are the main constraints for formulation of the
programme.
Z sociol,t, leal study (1G) conducted at the NTI had shown
that 95% of sputum positive patients were aware of the r symptoms
and t-:a.t nearly half of then had reported at various health
iis titutionsin search of relief for their chest syeptors .
On
the la sis of uiis infer.:, at ion it was estimated that about half
of the t ot d 5000 infectious cases in an average district with
a population of about 1.5 million attended the general ie alth
in. titutions.
Out of these about 2000 could be easily discovered
through sputum microscopy, at the first point of contact in a net
work of general health services.
Ideally, all die 5000 cases should be found in the shortest
possible time b..t operationally this was not considered likely.
Finding of 2006 cases however, per district per year, it was
thought, would be a good achievement.
Their satisfactory
treatment arid sputum conversion could be expected to result
4
4
in reduction of the tuberculosis problem within a tow jeers.
However, the service, t~ be effective, has to be offeree neeir
to the pat lew ts ’ reside nee .
l.Z.XJ
Uv 1. Im ju*i£urJi l x v 1'0
Case-ifndiig , to ^reduce any impact on the problem of
tuberculosis Lad to be aimed at discover irg a substent iel number
of cases per unit time aid was required to be carried ^ut both
in rural and urban areas on a long term basis rrther than
as a one-time effort.
Operatiotcl studies (II) for case-finding
thro ugh mobile tetrns , with or without tuberculin test, the use
of mass miniature radiography and exan.irati on of sputum alone
or in various c ^i_.binations were carried. out in villages, primary
health centres and at the district head-quarters hospitals,
The
application of mobile X-ray units for tuberculosis case-fird iig
through specialised peripetetic tuberculosis tea s in villages
was found operationally iirractible and infructuous.
The nur.’fte
of cases fount: was no better than that found at the primary
health centres anti otner rural dispensaries arc hospital , from
amongst those who-report by themselves for relief of their
allmeit (12).
Operationally, for reasois of poor ap.roafa roads
to villages, ina.cequa.cy or absence of facilities for raintenarce
and repairs, shortage of X-ray files, and staff to operate the
X-ray unitsand exorbitant running cost, the is e of mobile mass
miniature X-ray. units for case-f inc'irg was not f ound feasible .
In the NTP the methodology r>.coll ended for case-find iig was
examination of sputum of patients rep -rtirg with chest symptoms
at the institutions of general health services.
This procedure,
though simple, economical r nd ap.-lie able all over the country
was found practicable and technical ly sound.
T xviaA. xi.iL Is T ( Cz-b
m vxjL x IGr )
The main aim of case-find irg is to treat patients, alleviate
their suffering and to put down the transmission of infection.^
The priority in th o iTf? had to be t ivento fiid irg aa d treat iq. ™
sputum positive patients, since they constituted the immediate
public health problem.
The sputum negative patients, however,
seeking relief under pressure of symptoms have not been denied
the benefit ^f diagnosis t nd curetive services.
The pre-requisites of an effi ci enp- domic il iary treatment ser
were I ound to be regular supply of drugs as near to patients
homes as possible and proper guidance there with regard to pro
longed arid regular treatment.
Efficacious regimens free from
side effects and free availability of drugs were sore uther
crucial factors for endixiig regular treatment and itsconple t ion.
L~e care was taken for meeting, these r equ ir er.ents.
/.n operational study (13) on case-fiid iag was coidicted
by the hiTI.
The patients residing, in villages were divided into
four groups, eats group consistiig of resida ts of adjacent
villages.
The drugs for one grouxj of patients were st.ored at th.
area health centres.
To start wife, the patients were taken to
tie r.e< 1th centre where they were introduced to the Medical
Officer, given detailed its tructiors to continue regal?, r treat
ment for one.year, given a fortnight’s drug supply and were
adsised to collect drugs regularly every 15 days for ote full
year.
In another area the drigs were stocked with the village
zanchayat mombers.
miter motivation, the patients wereadvised
to collect drugs from the Panchayat members fortnightly.
For
the third group, arr angei,e nts wore made for distribution of drug.
*
. ..5.
5
tixough ths ville.( c- level workers, curirg the course if their
regular fcrtijig tly visits to the vilia<es.
To the fourth
gr<>u_.-, the drugs wer e distribut ed, thr jU£ll cv Sp6C ially appointed
health visitor, in the patients homes fortnightly. The
regularity of drug intake through all the four channels was
similar: hardly 36% to 40% of patients took fee drtgs. This
was so tven in the case where the pills mere distributed at
the doors of fee patients by the spacial staff.
The efficiency
of the primary health cert re wife regard to treatment regularity
being similar to tie services provided by specialised tuber
culosis agencies, it was concluded that the primary heath
centres are as well a.ccegtable as centres for tube rculosis
services. In the hfr, therefore, the general institutions
were activated, drugs were stored and the treatment was de
centr alisedto be given on ambulatory domiciliary basis. Erugs,
mostly for self-administration, were supplied free of charge
near fee patients home .
XlJTjSGiut-'f id k
Specialised services were found impracticable as ftese
would consume substantial proportion of resources, depriving
development of essential health programs es ard social services
of their share.
Further, taking into account the secukr trerd
of tuberculosis in the country, the k’xV has to continue for
years ;o come, rhe diagnostic services (sputum microscopy)
simplified end curative service standardised for their easy
applicability all over the country.
These besides be irg simple,
were within the technical competence of gene rd. practitioners.
The programme, in order to meet fee above requirerect was
conceived as an integral part of overall developr.e rt of general
services instead of functioning in isolation as a specialised
vertical programme for control of tuberculosis alone.
BCG V/.UCxHA'JIUN (i3iua;VhhTz-Txobi)
Prior to formulation of KiT? BCG vaccination in India was
started in 1951 as a mass campaign with fee help of special
BCu teams.
These teams were mobilised from area to area to
set up temporary centres at a central place in every locality.
Those who attended fee centre were offered tuberculint est
at first attendance.
BCG vaccination were given to tuberculin
non-reactors at secutd visits, after 72 hours.
Only those who
attended fee centres for readitg of the test at secord visit
could be given BCG.
BCG vaccination coverage by thisprocedr re
was inadequate.
Subsequently, the BCG vaccination programme
was integrated with the curative services of the district
tuberculosis programme as a part of the comprehensive tuber
culosis control programme. Louse to house vaccination (14)
was recommended at first. Later, in 1904, direct BCG vacci
nation witirout tuberculin testing (15) restricted to the age
group of C-19 years only was advised.
These modif icat lots
improved coverages as well as output and brought down the
cost of BCG vaccination -rogramme, due to abandoniig of prevaccination tuberculin test.
Further modifications in BCG
vacciration program e recommended were simultaneous smallpox
aid BCG vaccination (16) of the new-borns in the cities and
feat of the school
e children in schools. All these aired
at maintaining higp BCG vaccination coverage. Site e 1977 ,
BCG vaccination has been made an integral part of the expanded
^rograame of im unization, to be delivered by the staff of
6
6
general health services through multipurpose health workers all
ever tae country, aimitt at vacciratijt of all new-borns in the
first year of t-.eir life.
jm-w-liA ‘J
ULvumJ
a. permanent KTr having these features and a country-wide
coverace of which tare Li*
1? (17) and (18) was the unit, was
coi.veivec and evolved in 1962 by the wTI.
The objective of the
i.rocra_..e was systematic reduction of tuberculosis through
finding mazii-um number of sputum positive patients (probably
more than t.e yearly incidence), converting them through effective
treater t, as well as prevention of large proportion of the
susceptible^ through BCG vaccination.
Briefly, the principles (19) underlying the DTP were (a)
sociological meetisg. "felt-need" of "action taken" patients:
provision of permanent service as rear to path sits' residence
as possible through integration with institutions of general
health services (b) epidemiological : halting transmission of
infection by findijg and treatiig direct smear sputum positive
patients to be followed by culture and abacillory tuberculosis
patients, (c) administrative: the resource inputs to be in
consonants with operational output and programme efficiency,
(d) operational, to stay within the outlires laid for the
programme allowing modifications for local sociological, admi
nistrative and operational variations.
x&x-Tj-vK
Ox1'
Di’P
The two main components of the LTr which is a unit of the
DTP are (i) the district tuberculosis centre ard (ii) the
per iphe ral c e ntr es .
(1) Is
TxtxC'x1 i?U-jjjxiC UxjvB.kb gibi. ixcm (x/TC )
The erstwhile tuberculosis clinics at district he ad-quarters
were recommended t o bo upgraded to BTC.
Such upgraded centres
besides continuing, their earlier activities of providing diagnostic
and curative services, have been entrusted wife the additional
resppre ibility of plenniig , implementation end supervision of
tuberculosis ^rogranx.e throughout the d_strict.
The senior
medical officer (IB ^specialise), the X-ray technician, a laboratory
technician, a health visitor, a statistical assio taut aid the
BCG team leader of each T3 clinic are fciven in-service job-oriated
training at the hTl so that they may organise aid supervise the
LTxJ in their respective districts,
in the wider context of
respons ibilitt es the upgraded TB clinics have <e en provided
additional facilities like transport, additional drt^s, record
forms and ot.& necessary items of equipment and supply.
The
ti aimed teams are responsible for visiting the peripheral health
institutions to guide the staff of gereral health services in the
diagnostic, curative and preventive work relatitg to tuberculosis.
They have to supervise the institutions for the general health
services regularly to ensure satisfactory techniques of casefinditg , diagnosis, treatment, recording and reportiig .
The
district centre provides necessary items of supply like drugs,
stains, record forms etc.
(ii ) rBixxr-iiim-L rea/il Cmi.llvES
all tie institutions run by the general health services
of a district participate in the LTP and ar e d esignated as
'Peripheral health Centres'.
Those offeriig X-ray centres',
7
:
fee ones done only sputums so. ear microscopy is possible have been
entrusted with respoisibility of sputum examination and are
designated as 'microscopy centres'.
Ofc er s were neifc er X-ray
nor microscopes are available, are entrusted with the responsi
bility of collecting sputa, from symptomatic .a tients of preparitj
smears and s-u.iLg them to the nearby institutions haviig micro
scopes far smear examination: such ire t it ut ions have been
designated as 'referral centres'.
These centres are advised
to send patients to the le arest X-ray centre if their sputa are
negative or they are unable to produce sputum.
/.Il the dare 3
catefaorie- of peripheral centres treat the patients on ambulatory
domiciliary basis.
The drugs for their treat Lent are supplied
by tie District Tuberculosis Centre.
The District Tuberculosis officer and his tear, have teen
rade reb.^itiblc- isr tra.ininL, co-or di lation of work, arrangirg
supply, supervision and compilation of the reports in respect of
the working -I h. c tuoercul^sis programme in the entire district.
i-ostint,
socialised staff at the peripheral centre for
anti tuberculosis wmrk has so far not beenr econuended as the
estimated additional expenditure on special staff did not appear
to sc-. commensurate with the quantum of work load.
The regular reports on tie performance of DTP, compiled
quarterly Jjy the Director General of health Services, at the
national level reveal th at the achievement regarding case
finding arm case-holding aspects are about 30% of the expecta
tions .
/. review of the LTaj was undertaken by the ICItin Expert
Committee in 1976.
The Committee highlighted some inadequacies
regarding operational aspects, the almost complete absence of
supervision by the staff of DIG, the District and State health
administration, the inadequacy ^f posting of staff and supplies.
Lack of interest in the programme at all levels was also reported
Some corrective actions were also suggested, the results of whirh
still remain to be seen.
ih/yLVEi-miJ T wF C01.L-Dii.iTY nExiuTja GiJlLHo .zllil TLE j/.DLTl—PUmPObE
«/ viuikLSiuu?
In order to bridge the gap between expectations aid a& ievement attempts are now been ma.de to avail of the services of the
newly set up infra-structix e of multi-purpose health workers and
community health guides under tie "Primary Health Care" programme
o i 6 £. e c j unt r j/ •
. ..
Tuberculosis case-finding which was of a somewhat passive
nature earlier can new be carried ->ut more actively wifc the
involvement of multi-purpose health workers.
During their
routine beat in villages for health activities they can question
the population fur pres etc e of chest symptoms aid identify those
who have c.ugh of two weeks j i.-re duration.
They can collect
sputum specimens from such persons, make smears aid send these to
the rriuary Health Centre for microscopy. This strategy will
augment tuberculosis ca.se detection considerably,
/.recently
conducted study (20 ) fr-m. h'i'i has shown that multi-purpose health
workers can perform this function along, with their ofc er cuties
aurin, their routine visits to the households. /.It; ough in the
. . .8.
8
first three months or so the wjrk load would te substantial,
after the completion of the initial ore jr two rounds of
i. tensive case-finding, the workload durirg subsequent visits
will become manageable involving, on an average, 2-3 steers
per week per multi-purpose health worker.
By this method toe
case detection will be augmented considerably.
The multipurpose workers can also be trailed for case
holding. Luring, the routine visits to their areas they can
supervise and guide the patients about treatment regularity,
retrieve the defaulters and motivate then. to continue treatment
regularly.
It is expected that their involvement in the programme
will definitely improve the reguirity and completion of treatment.
Lulti-purpose workers under the expanded programme of
inaiinizatiou are entrusted with the responsibility for BCGvaccination along with other vaccinations,
All infants between 3 to
9 months of age will be vaccinated by then in the villages ■otn e
in a year.
I
The programme perferuai.ee and potential studies (21)
have shewn th at the Of®
-f we general health institutions is
capable discovering in one year 46% of the entire pool of infect
ions cases in the district, about one and a half tines the
annual incidence i.e. 65% ^f the sputua smear positive cases.
regards the case-holding potential of infections patients, 63%
become sputum negative, 20% continue to remain positive at the end
of one year of treatment and 1C% Llk.
The actual performance
fell considerably short of the potential, specially in respect
of case-firdi ig .
The objectives, principles potential and performances of
the hTr make it an optimum programme. Although primarily a
Government programme it needs active co-operation and assistance
of the voluntary organisations, private health institutions and
private medical practitioners.
Only then can it hope to achieve
its objectives speedily and effectively.
press
release
medico friend circle
organization & bulletin office
326 V Main I Block Koramangala
Bangalore 560034
30.3.1985
The medico friend circle (mfc), an All India group of socially
conscious doctors and health workers has just completed a
systematic study of the continued effects of toxic gas in two
bastis in Bhopal.
The observations of the study conducted between March 18-25
in the highly affected Jayaprakash Nagar and the less affected
Anna Nagar are yet to be fully analysed. However, the initial
findings definitely indicate that :
(i) the affected population
is already showing signs of reduced breathing and working capacity
which is likely to be permanent unless remedial measures are
urgently introduced;
(ii) pregnant women who had been exposed to
the gas in the first three months of pregnancy or have become
pregnant since the disaster have still not been informed about
the possible dangers to the foetus. Moreover, detoxification
measures recommended by the ICMR over a month ago—the administra
tion of sodium thiosulphate has not been implemented. The mfc
is deeply concerned and agitated about the situation.
Reduced breathing and working capacity among the affected
population
The mfc's study team has observed that men are not able
to go back to work because of breathlessness on accustomed
exertion (exertional dyspnoea). Those who have returned to work
report definitely reduced working capacities. Most women find it
difficult to carry on their usual household chores. The team
has noted with particular concern that very few of the children
can even play or participate in normal physicial activity in
the affected bastis.
It is well known that a large proportion of the MIC affected
population is likely to develop, fibrosis of the lungs (develop
ment of scars)
following inflammation of the lungs due to
irritation. This condition permanently- affects, breathing and
hence working capacity. Such a condition is already in evidence
in the population covered by the mfc study.
Simple breathing exercises are known to help., to reduce
this disability. Information abcsut these exercises must be
widely known and their importance stressed.
.2
2
Mass detoxification by sodium thiosulphate
More than a month ago the ICMR had recommended the administra
tion of sodium thiosulphate for detoxification of all patients
suffering from symptoms of MIC poisoning. This recommendation
was based on conclusions drawn from a double-blind clinical
study. But as yet, there appears to be no strategy in action
with regard to administration of sodium thiosulphate to the
vast majority of affected people. Only a tiny fraction, consist
ing of the seriously ill are receiving the injection.
mfc emphatically feels that as suggested by the ICMR, all '
patients suffering from symptoms of ‘mid poisoning should be
urgently administered sodium thiosulphate so that their
suffering is reduced and they may go back to work. This service
and other medical facilities should be urgently provided in
a decentralised way, close to the bastic in affected areas.
The insight that sodium thiosulphate may well be
effective was known even in the first week after the disaster.
It is extremely disturbing and deplorable that decisions on
vital issues like this which affect the lives of thousands of
people should have been so long delayed. Even more shocking is
the fact that even now, a month after the recommendation was
publicised, mass detoxification of MIC victims has not begun.
Possible risks to the foetus
Another disturbing feature is that pregnant women who have been
exposed to MIC have not been given any advice regarding the
possible risks to the foetus. Given the fact that the first
three months of pregnancy is the most sensitive period, it is
likely that these women as well those who became pregnant'
immediately after the disaster are likely to give birth to
deformed babies,
since MIC or its breakdown products are
very reactive chemicals. Moreover many of these women have
received several types of drugs when as a rule in the first
throe months no drug should be given for fear of drug induced
deformations. Somce of these drugs, especially steroids are
known to cause deformities.
There is an urgent need to inform people, especially
women about these dangers and to. advise them to undergo
medical termination of pregnancy. Adequate and free facilities
should be made available to those women who opt for it without
...4.3
3
coercing them to undergo sterilisation. Further, those couples
who have lost children and want reversal of 'sterilisation must
be offered these facilities free of charge.
■'
'\
Doctors belonging to mfc had pointed out these dangers
,
t
*
in anearlier t note - sent to the concerned authorities a
month ago. But to date nothing seems to have been done.
Many of these womfen have by now crossed the five month limit
of pregnancy beyond which MTP is unsafe. But there are some
who can still terminate their pregnancy although the risks
are greater than in the first weeks. Facilities for ultra
sonographic examination should be made available to these
women immediately tc detect gross abnormalities in their foetuses.
That thi'sx is not being done is ’a reflection of the indifference
of health authorities towards the health problems of poor women.
Moreover mfc feeds that the ICMR study designed to follow
up these women on a long term to assess the percentage of
deformities without informing women about the possible risks
or the advisability of MTP is unethical. The dangers to pregnancy
are well known and poor Women should not be used as guinea pigs
in medical research.
Contraceptive advice to affected ^couples
Most of the MIC affected population is still suffering
from symptoms of cyanide likg poisoning indicating, therefore,
the persistence of the biochemical changes which have- occured
due to MIC poisoning. It is safer to avoid pregnancies till
complete detoxification has
taken place. Since a large
proportion of the women are suffering from menstrual disorders
and other gynaecological problems, male contraceptives (Nirodh)
should be/ recommended rather than Copper T or oral contrace
ptive pills by the women.
We demand that the health authorities should give serious
and urgent consideration:to the issues raised here.
released by the convenor of mfc
REPORT - 1
ANTI DIARRHOEAL FORMULATIONS
; A RATIONALITY STUDY
Shishir J Kodak,
M.D., D.C.H.
Contents
press release - Introduction - Materials and
Methods - Results - Discussion - Conclusions
- References
Rational Drug Policy Cell
Medico Friend Circle
50 LIC Quarters
PUNE -
Rs 5/-
411 016
x
October 1984
RATIONALITY STUDY OF ANTIDIARRHOEAL FORMULATIONS
Shishir J.Modak
PRESS RELEASE
Dr. Shishir Modak of the Medico Friend Circle, in his
recent, rigorous scientific scrutiny of 47 proprietary drug
preparations sold as antidiarrhoeals, has found that only
7 of these 47 commercial preparations were justified from
scientific view point.
The preparations given in the
issue of Current Index of Medical Specialities (CIMS) May, 1984 (used by thousands of doctors for ready reference
to commercial preparations) under the heading 2
"antidiarrhoeals" were taken for this study.
Recent research has questioned the usefulness of many
antibiotics and other drugs in the treatment of diarrhoea.
Basing himself on this latest authentic expert medical
opinion in this field, Dr. Shishir Modak found that mot'of
the " antidiarrhoeal " preparations available in the
market were scientifically unjustified on one of the
following grounds:
i) _insufficient__d_os_e
or wrong proportion
- of_dose
ii) _irra_ti_on_al_i.nclusion
in_some drug_s
; for example - of
Neomycin in mm y .
- preparations: wrong
proportion between
Furazolidone and
Metronidazole.
s for example Chloropheniramine
maleates or inorganic
salts of Sodium,
Pottasium «.. etc.
or Chloroquin.
iii) -inclusion of drugs not
s for example Streptomycin in the
-indicated in_d_iarrihoea
famous " Chlorostrep "
and some other prepa=
rations of the same
formula.
iv) -inclusion _of a_drug
which is_too toxic for
_its use in_fixed-dose
combinations o_f anti-
: for example - inclusion
of antiperistaltic drugs
and of 4-aminoquinolines
(diodoquin, quinidochlor
... etc) in many antid arrhoeal preparations.
- - diarrhoeal -
NOTEs This is a very brief announcement prepared for
M.F.C. Bulletin.
Fo: ■ the lay press, it will
have to be demedical ized.
Diarrhoea is frequent passage of loose stools.
Diarrhoeas are extremely common and endemic in our
country.
Almost every child upto the age of 5
years gets 1-2 episodes of acute diarrhoea in a
year.
It is a number-one killer in infants and
small children.
Therefore, every doctor is actively
involved and should be thoroughly trained regarding
proper management of acute diarrhoeas.
.2
2
A large number of formulations are sold in the market
as antidiarrhoeal agents.
They are usually broad spectrum
and claimed to be effective in diarrhoeas due to different
aetiological factors ranging from bacterial, protozoal,
nonspecific..etc.
However, doubts are always raised about
rationality of all these preparations.
The purpose of
this study is to assess the rationality and effectivity
of multiple antidiarrhoeal preparations available in the
market.
Material & Methods
The 47 different formulations listed under the heading
: 1 Antidiarrhoeals ' in current Index of Medical Specialities
(C I M S) - May 1984 issue were studied.
Each ingredient cf
every formulation was evaluated separately on its own
merit.
The comments are based on the available scientific
literature on this topic, published in recent standard
text books and periodicals.
Finally, each product was
graded according to the resultant rationality of its
ingredients.
Antimicrobials as single ingredients (e.g. Ampicillin,
Tetracycline...etc.) are not included in this assessment.
RESULTS
Please see the accompanying Table and the' resultant
gradation cf each formulation in the table.
The overall
resultant gradation of each formulation has been done
as follows
A;
Use of the product is justified.
B:
Electrolytes of other irrational
ingredients should be deleted.
C:
The proportion of the ingredients
should be altered.
D;
The drug should be avodided and it
should be available strictly against
prescription.
E:
The formulation should be officially
banned.
The _rcsultjanjt tally of these formulations was
as follows
Grade;
A B C D E
No. of products:? 698 20.
The (Total products studied 47.
Excess number in
above table is due to some products having
more than one grade.at a time).
.. .3
Sr.No/
1)
Brand Name 'Composition
Aristogyl F
(Aristo)
‘’
Pectin - 20 mg
Light Kaolin-1-gm
: Of cosmetic use if at all,
inadequate dose. May actually
increase electrolyte loss.
Per 5 ml:
suspension
(Anglo-French).
Light Kaolin-1 gm
Pectin-50 mg
60 ml
Neomycin - 50 mg.
6.H
■ ~Di-iodo-450 mg.
Tincture belladona
- 0.06 ml
3) Chlorostrep
(Cap..& Sus
pend on)
(Pgrke Davis)
6 0-ml: Rs. 10.59
C
Furazolidone 30 mg
Chlorambin
Shotgun therapy, incorrect ratio
bet; Fura, & Metro.
The ratio
di ould be 1: 5.
/
E
-"-
13,
14, 2,
1?
1A
3,
'
17,
5.
: Inadequate dose of Neomycin,
Many strains are becoming resi
stant to Neomycin.
: Di-iodo. not a safe drug especially
in children. May produce SMON.
Should not be used in fixed dose
combination.
: Antimotility drugs should be
avoided in childhood diarrhoea;
should never be. added in fixed dose
mixtures.
:
Per Cap.per 4 ml
(Chloramphenicol-12 5mg Chloro-not useful in Salmonella
gastroenteritis; severe side
effects; carrier state may be
prolonged after chloro.
Streptyomysin
sulphate-125 mg
Reference
Grading
Per 5 ml:
90 ml : Rs.8.00
2)
Comments
E
5, 7, 1,
2, 10,12.
: Shigella & other enteropathogenic
organisms have,become resistant to
(contd....
Sr.No,
Brand Name
Coirposition
Reference
Grading
Comments
Streptomycin; rapid development of
resistance; sensitization; should not be
combined with Chloramphenicol for fear
of increased risk of optic neuritis.
4)
Combactin
(CFL Pharma)
6 0-ml; 5.19
Per 30 ml:
E
Neomycin-300 mg
:
Dose of Neomycin inadequate; Many strains
resistant to Neo.
Dicyclomine-10 mg
:
Antispasmodic drugs should not be added
in fixed dose mixtures.
Light Kaolin- 6 gm
Pectin-130 mg
:
As in (1)
Electrolytes should not be included in antidiarrhoeal preparation; inadequate and
wrong proportion.
5) Darzin with
Neomycin
(Chemage)
Per 10 ml:
Light Kaolin-2 gm
Pectin - 43 mg
:
As in (1)
/
above.
6 0—ml s 6•88
Neomycin - 125 mg
:
As in (2)
above.
Sod.Lactate - 267 mg:
Sod.Chloride-157 mg
Pot.Chloride-100 mg
As in (4)
above.
Piptal - 4 mg
Antispasmodic drugs should not be added in
fixed-dose mixtures.
Per tablets
Furazo lidone-100 mg.
12 tabs: 2.91
Quiniodochlor-200 mg:
17.
-±> ove
Sod.Lactate-800 mg
:
Pot.Chloride-300 mg :
Sod.Chloride-470 mg
6) Dependal Tabs
(Eskaylab)
3,5,12,
Effective antibacterial agent,
useful in Giardiasis.
See WHO furmula
E
5,
E
2.
2 and 12
also
May produce SMON; not confined to Japan;
7 cases were reported in Bombay; not a
safe drug; should not be used in fixeddose combination.
Tcontd.
(4
Sr.No.
7)
Brand Name
Diarmycin-N
(Nicholas)
Rs.
60 ml: 5.10
____ Comments
Composition
C
Per 10 ml:
Neomycin Sulph. 100 mg
Sulphadimidine - 134 mg
:
:
Pectin-6 7 mg
Light Kaolin-1.34 gm
8)
Diarrest
(Ebers)
Rs.
50 ml: 7.00
9)
10)
Dysenchlor Tab.
(S.G.Pharm)
Rs.
10 tabs’.1.32
Emantid
(MM Labs)
Rs.
60 ml: 6.25
Grading
As in (1) ±ove
Most of the bacteria are resistant
tc|sulphas by now.
As in (1)
Same as in (1)
above.
Per tds
:
As in (6)
Furazolidone - 200 mg
;
__
Effective antibacterial agent;
also used in Giardiasis.
Pectin - 130 mg
Light Kaolin - 6 gm
:
As in (1) above.
Chloroquinaldol - 100 mg
5,
2
12
17,
'
'
C
:
3,
--
'
above.
Per 5 ml:
Metronidazole - 100 mg
Furazolidone - 33 mg
Pectin - 75 mg
Kaolin - 700 mg
References
13, 14, 2.
12.
D
2.
E.
2,
above.
Per 30 ml:
Tincture belladona-0.6 ml :
Sod.Lactate-800 mg
Pot.Chloride-330 mg
Sod.Chloride-470 mg
:
Same as in (2)
As dm (4)
12,
3, 7
±> ove.
above.
(contd...
(..5
Sr. No.
11)
Brand Name:
Enteromac
(Mac)
Composition
Comments Grading
Per 5 ml
C
• • •
Neomycin - 75 mg
Same as in (2)
Light Kaolin - 750 mg
Pectin-30 mg.
See (1)
Diphenhydramine-3 mg.
Irrelevant & useless as
antidiarrihoeal.
'
5,
References
17,
2,
12
daove.
64 ml: Rs. 4.21
12)
Enterosan
(Wcckhardt)
above.
Per tab .
Berberine HC1-40 mg
May cause hemolytic jaundice.
Di-iodo - 300 mg
As in (2)
E
3, 7.
E
Same asin
Chlorostr ep
10 : Rs. 1.86
Homatropine-0.8 mg
13)
14)
Enterostrep
(.Dey's)
Per Cap .& per 4 ml:
12 : Rs. 5.16
60 ml: 6.36
Chloro - 125 mg
Strepto - 12 5 mg
Enterovioform
(Ciba)
Per tab
Quiniodochlor - 250 mg:
above.
—11 —
•••
Same as in Chloros trep( 3)
=bove.
D
As in (6)
above
500 ; Rs. 54.00
(contdd..
i
Sr.No. Brand Name
Comoosition-
15)
Per tab.
-
Furamide Compound
'(Boots)
Strepto - 120 mg
Shigella & other entero
-pathogenic organisms have
become resistant to stre
ptomycin; rapid develop
ment of resistance;
sensitisation.
Dilo.Furoate - 250 mg.
Neomycin Sulph - 80 mg
57 ml : Rs.4.90
Reference
16,
5.
: Unnecessary; not indicated
in amoebic dystentry.
Per 10 ml:
6 0 ml : Rs. 5.18
Furoxone Susp.
(Eskay|'ab)
B & C
...
Useful in cyst-passers;
not the drug of choice
in acute amoebiasis.
Chloroquine - 50 mg
17)
Grading
Diloxamide Furate-2 50 mg
10 : Rs.4.55
16) Furamide Susp.with
Necbmycin (Boots)
Comme nts
"(..6
...
B. & C
3,
5.
A
2,
18 .
: Not the drug of choice
for amoebiasis.
Very inadequate dose; many
strains becoming resistant
to neomycin.
...
Per 5 ml:
FurazaLidone - 35.7 mg
: As in (6)
Pectin-7 5.mg
Light Kaolin-1 gm
: As in (1) above.
above.
(...contd.
S r. N o.
18)
Brand Name
Imotil
(Cevee pharma)
Comments
Loperamide HC1-2 mg
caps«.
4: Rs 2.75
19)
Kaltin with
Neomycin
(. Abbott)
Grading
Reference
Antiperistaltic drugs should not
D
be used in children below 2 yrs.
Even in older children they should
be avoidxed.
7,
E
2, 18,
3,
3,
5.
Per 5 ml:
• • «
Kaolin-1 gm
Pectin-22 mg
:
As in (1)
above. ■
Belladona-0.05 ml
Neomycin-50 mg
:
As in (2)
above.
Sod.Lactate-133 mg.
Sod.Chlor.67.2 mg.
Pot.Chlor.-55 mg.
:
As in (4)
above.
7,
3
6 0 ml; Rs. 5.20
20)
Lactisyn
(.Griffon)
6 amp; Rs. 12.7 3
21)
Laviest
(Franc0Indiaa)
12 caps.
Rs. 10.04
WHO formula
Per airpoule ;
Lactobacillus ladfcis-490 milli.
Lac tob ac i 1 lus
acidophilus-490 milli
Streptoeoccus
thermophillus-10 mmilli
S treptococcus
Lactis-10 million
Per Capsule:
:
A
18.
A
18.
May be useful in infectious
diarrhoeas but results
are not proved by controlled
trials.
Dried yeast powder10 million cells
of saccharomycc-s
Cerevisiae - 250 mg.
(cor td<> o o.
i
Sr.No. Brand Name
15)
-
Furamide Compound
(Boots)
Comoosition-
Comrre nts
3,
5.
A
2,
18 .
Strepto - 120 mg
:
Shigella & other entero
-pathogenic organisms have
become resistant to stre
ptomycin; rapid develop
ment of resistance;
sensitisation.
5.
: Unnecessary; not indicated
in amoebic dystentry.
Per 10 ml;
Neomycin Sulph - 80 mg
57 ml : Rs.4.90
B. & C
Useful in cyst-passers;
not the drug of choice
in acute amoebiasis.
Dilo.Furoate - 250 mg.
Furoxone Susp.
(Eskag|ab)
16,
:
6 0 ml : Rs. 5.18
Reference
B & C
Diloxamide Furate-250 mg
Chloroquine - 50 mg
17)
Grading
Per tab.
10 : Rs.4.55
16) Furamide Susp.with
Neomycin (Boots)
' ( . .6
...
: Not the drug of choice
for amoebiasis.
Very inadequate dose; many
strains becoming resistant
to neomycin.
...
Per 5 ml:
Furazlidone - 35.7 mg
: As in (6)
above.
Pectin-7 5.mg
Light Kaolin-1 gm
: As in (1)
above.
(.. .contd.
(,..8
Composition
22)
Linopec
(.Pharma
Research)
c omnants
Per 5 ml:
Light Kaolin-2 gm
Pectin-120 mg.
As (1)
Reference
Grading
B
2,
E
3, 7.
D •
3, 7.
D
3, 7.
E ■
18.
12,
above.
110 ml.
Rs. 5. 40
2 3)
Lomefen
(.Searle) .
10 tabs:
Rf. 1.97
Per t±>.
Diphenoxylate HC1-2.5 :
Atropine Sulphate-1™^
0.025 mg
Furazo lidone- 50 mg
24)
Lomotil
(Searle)
:
24)
Lopamide
Per tablet:
(Torrent Labs)
Loperamide HC1-2 mg
10 tabs:Rs. 3-00
Mabinol Complex
(Mac)
10: Rs.4.67
As (6)
Per tablet & per 5 ml:
Diphenoxylate HC1-2.5 mg
10 tabs:Rs.
Atropine Sulph-0.025 mg.
1.84
60 ml:Rs.6.59
2 5)
Antimotility drugs should not be
used in children below 2 yrs.
Even in older children they shouB
mat be avoided1 should not be
added in fixed - dose mixture.
above
•••
As in (18) above
•••
As in (18)
above.
Per tablec.t:> - ■
Chlorophenoxomide-0. 2 mg •
streptomycin Sul.0.16 gm
I od oc hl orhyd roxyqu i no Idin e
- 0.15 mg
As in (15)
above
As in (2)
above.
(contd
18.
/
__________________ _____________________________________________________________ '___________________________ 9__________
Sr.Nos/ Brand Name/
Composition/
Comments/Grading / Reference
27) Metrocuin F Suspension
(Noel)
6 0 ml : Rs. 8.9 5
28) Mexaform
(Hind.Ciba Geigy)
o.-
Per 5 ml:
Metronidazole - 100 mg
Furazolidone - 35 mg
:
Kaolin - 1 gm
Pectin - 75 mg
:
—K
As (1)
above.
As (1)
above.
C
•■•
P er tab:
13,
14,
12,
18.
E
3, 7
B, C
5,
3,
12,
18,
1,
above.
Quinodochlor - 200 mg
:
As (6)
Phanquone - 20 mg
:
Not the drug of choice; other
better drugs available for
amoebiasis.
10 = Rs. 1.80
Oxyphenonium bromide-2®ig :
29)
Neldar
(Phar-East)
6 0 ml: Rs. 8.18
As (23)
above.
above
Per 5 ml
Neomycin Sulph-50 mg
:
As (2)
Sulphadimidine - 100 mg
:
Most bacteria are now resistant
to sulfas.
As in (1) above.
Kaolin-1 gm, Pectin-30 mg:
Pot.Dihydrogen Phos-25 mg
Sod.Lat - 150 mg
Pot.Chlor - 60 mg
Sod.Chlor-100 mg.
13,
WHO formula
As in (4)
above.
(contd....
-10
/ .SSEESSlJiST:
30)
Neo Combactin
ICFL Pharma)
Z__ c2IT'?®Dtf_
/
Grading
Per 30 ml
Dicyclomine HC1-10 mg
E
O
As ( 4)
abo \e
•
As (1)
above.
•
As (4)
tove
.
/_ References
2,
12,
18,
3.
60 ml: Rs. 5.26
Light Kaolin - 600 mg
Pectin-130 mg
Neomycin Sulph-300 mg
Sod.Lact-800 mg
Pot.Chlor-330 mg
Sod.Chlor - 470 mg.
31)
32)
33)
34)
J
Pectokab
(.Cnemage) Rs.
100 ml: 5.98
---
Per 5 ml:
Pectin - 60 mg
Kaolin - 1 gm
s
Per 5 ml:
(Chemage)
Metronidazole - 100 mg
Furazolidone - 3 5 mg.
Light Kaolin - 1 gm
Pectin - 75 mg.
°
Loperamide HC1-2 mg
s
Pesulin-0
(Codila)
B
2,
12,
18
C
1,
13,
14
1. £ f
io •
As (1) above
a *..
Pec tokab-MF
Pelopem
(.Mercury)
WHO formula
As (1)
above.
As (18)
above
D
P thalyl Sulphathiazone-1 gm:
Most of the bacterial
are! now resistant.
Pectin-0.15 gm
Kaolin - 3 gm
As (1) ' above.
Tincture opium - 0.08 ml
E
•••
Per 15 ml:
»
3, 7.
12,
18,
3, 7
strains
As (2) above.
(Contdd....
Per 6 gm powder
(Dextromed)
Attapulgite-3 ggt
Pcotoquit
?■
Renokab Susp.
(Manners)
*
above.
As (4)
r
■
Per 5 mis
;
As (6)
••o
above.
lodochlo rhyd roxyqu i no
;
line-125 mg
As (2)
above.
s
As (1)
above,
Furazolidone-50 mg
'v
E
1,
I.
Per 4 ml;
-
•••
Streptomycin base - 50 mg;
NeOmycin base-25 mg
;
As (15)
above.
. ■
E
<
As (2) above.
Kaolin- 0.7 5 mg
Pectin - 50 mg
As (1)
above.
Belladonaiincture-0.05 ng:
As (2)
above.
Sod Chlor - 25 mg
Pot.Chlor-10 mg
Cal.Lact-10 mg.
As (4)
above
-
(. cc ntd
12, 18
t
nI
Reference
/
B
1.
Limited cosmetic value; does
not decrease fluid loss,'
Sod.Chlor - 120 mg
;
'Sod.Bicarb.-81- mg
Pot.Chlor - 99 mg
Pot.Dihydro Phos-99 mg
Cal. gluconate-2d[ mg.
Pectin - 75 mg
37)
erasing
ooe
,
(PFI)
« 0 ml: Rs. 7.50
/
1
■
1
.
1j
J
c
C
O1
•
i
•
I
01
C
O
•
1
Prone rod attaPulgite
• —
36 )
O!
35)
Comments
/
I
11
.No . / Brand Name
12
SI.No.
38)
7
Brand Name "' 7
Ridol
(Gufi:G)
Composition
/~
40) Salvarol
(Associated)
60 ml: Fs. 7.6 0
7~ Grading ~/~ Reference
D
Loperamide - 2 mg. tab
s
39) Salaao pyrin
P er tab£_
(Carter Wallace)
SO: Rs. 57.35
Comments
As (18)
A
*••
Salicylazosulphopyridin :
0. 5 gm
Per 5 ml:
3,7
above
Effective in ulcerative colitis
...
E
3,
18,
Neomycin Sulph-50 mg
:
Belladona tincture-0.05 mg
Light Kaolin-750 mg
:
Pectin-50 mg
As (2) above.
As (1)
5,
12.
3, 7
WHO formula.
above.
Sod.Lacate - 135 mg
Pot. 'Chlor-55mg. Sod. chlor.75mg. AS (4) abpve
41) Saril
(Rallies)
(TCE)
Per taa
Streptomycin Sulfate
-240 mg
E
:
As (15)
5, 2 , 1
above.
12,
Pthalyl Sulphathiazole-200 mg
:
As (34) above.
Tannic Acid-50 mg.
;
Not useful
Pectin-10 mg
:
As (1) above.
Di-iodo.12 5 mg
:
As (6)
18.
above.
(....contd.
D I S CU_S_S_I_O_N_ OF
C O MM_E_N_T_S_ •
In th
table, the comments are written in brief
against each ingredient.
There is a great amount
of repetition as similar ingredients appear again
and again in different formulations.
Here we would
discuss merits and demerits cf different group
of drugs.
A)
_ An ti b act e r i a 1_ d_rug s_:
As is now well known, these play little part in
the treatment of the acute stage of gastroenteritis
Certainly none in viral gastroenteriti s.
They may
infact do harm by further upsetting bowel flora.
They can't, in any case, act fast enough to stop
further loss of fluid in adehydrated child.
It
must therefore be seriously considered whether
they have any part to play in thetreatment of
gastroenteriti s5.
If no pathogens are isolated,
there is clearly no point in giving antibiotics,
and it is of interest to note that in 40 to 50%
of cases no organisms can be isolated from stool
s amoles.
Particular mention must be made about some
antibiotics which are inadvertantly used in
antidiarrhoeal formulations.
Chloramphenicol
It is a broad spectrum antibiotic effective
against several gram positive and gram negative
organisms.
However, it is a potentially toxic
drug, .
It can produce aplasic anaemia, other
blood dyscrasias, optic neuritis, super-infection
...etc.
There is always a danger of developjnfiQi,pf,
resistance.
Therefore, this drug should be used.
only in typhoid fever and its misuse in trivial
infections should be stopped nt once.
Contrary
to expectations, chloramphenicol is not effective
in non-typhoid salmonella gastroenteritis.5,7
If chloramphenicol is combined with s t rep t omyc in,
Therefore,
si risk of optic neutitis increases. 2
this combination should be condemned.
— ^2: eJ21 omycin
It is aminoglycoside antibiotic effective
mainly against.Mycobacterium; but also effective
against E.Coli, Proteus, H.influenzae...etc.
Formerly, this antibiotic was used in bacillary
gastroenteritis as many organisms were suscep
tible., bit now most of the strains of shigella
and other enteropathogenic organisms have becom
resistant to it.
Besides there is a danger of
rapid development of resistance and sensitisation
after oral usc.2 The use of this drug should be
reserved for the treatment cf Tuberculosis.
It
should never be combined with Chloramphenicol
as discussed earlier.
Neomycin
This is a-.locally acting -aminoglycoside.-----antibiotic.' 11 is effective against some strains
of E.Coli.
However, organisms are fast becoming
resistant to this antibiotic.
The recommended
therapeutic dose of neomycin is 100 to 150 mg/kg/
day.
However, almost all the antidiarrhoeal
preparations containing neomycin provide a very
inadeauate lose of this antibiotic.
Sulphonamides:
Some antidiarrhoeal formulations contain sulphonamide
preparations.
However, c-ffactivity of sulpha preparations
has recently gone down considerably.
Most of the organisms
are resistant to them and hence their use is wasteful and gives
rise only to side effects.
Furazolidone;
Furazalidono is an antibacterial agent effective against
a variety of bacteria.
Shigella, Salmonella, E.Coli, Enter
ococci are susceptible to it.
It is also effective against
Giardia.
It is a cheap drug with few side effects.
So, it
may be widely used as an antidiarrhoeal drug.
Metronidazole;
Metronidazole is the drug of choice in amoebiasis and
Giardiasis.
Therefore,.it is commonly found in antidiarrhoeal
formulations.
Ideally in each case of diarrhoea, stool should
be examined, organisms should bo identified and then specific
treatment should be started.
However, in our country, where
majority of people cannot afford the cost of stoclinvestigation
and hence, the stool is not examined, the causative organism
is not identified, the combination of metronidazole + Fura
zolidone may be justified as broad spectrum antidiarrhoeal.
Aminequinolines
Quinibdochlor or other hydroxyquinoline derivatives are
known to produce Subacute Myelo Optic Neuropathy (SMON) after
prolonged administration.
This side effect is not restricted
to Japaneese people but several cases have been reported in
Bombay.
The exact safe dose and duration of this drug is not
determined especially in children; and, therefore, this drug
shoull not be used routinely for any nonspecific diarrhoea.
Certainly it should not form part ofany fixed dose antidiarrhoeal
mixture.
B)
ANTIMOTILITY & ANTISPASMODIC AGENTS;
Lomotil (Diphenoxylate -I- Atropine) , Loperamide and opium
derivatives are antiperistaltic drugs. They stop the loose
motions temporarily.
They give a false sense of security without
curing the underlying cause.3
Paralytic ileus, respiratory
depression, cardiac toxicity etc. have been reposed in children
following ingestion of lomotil.
It is not possible to predict
the toxic dose in children and while some may have only the
mildest symptoms with relatively large'doses, others develop
severe toxicity on ingesting normal therapeutic dose.
Therefore, lomotil should not be used in children below 2
years; and even in older children these drugs should be avoided
in the presence of infection.
These drugs should be available
strictly against prescription.
The fixed dose formulations
containing these drugs may prove dangerous and should be banned.
Antispasmodic agerts like dicyclomine should be used very
carefully to relieve spasmodic pain.
They can cause paralytic
ileus and should n<sver bo included in an antidiarrhoeal fixed
dose combiration.
(c ontdd
As a rule any drug with higher risk of serious toxicity
shouii not be used in a fixed dose combination, since in such
a combination,, it is more likely to be used when not really
indicated.
Hence, it is recommended that all such preparations
be banned as has been pointed out above.
C)
Absorbents,
Astringents, binding agents;
Pectin, Kaolin, Bismuth salts are the drug belonging <bo
this group.
Light Kaolin is a hydrated and purified aluminium
silicate.
It is supposed to absorb bacterial and bacterial
toxms.
Pectin is purified carbohydrate product obtained from
citrus fruit extracts. It is claimed to form stools.
However,
the dose of these drugs provided in antidiarrhoeal mixtures is
too inadequate
*
Secondly, it is reported that these drugs may
cause loss of electrolytes by preventing absorption through
•gastrointestinal tract.
These drugs, if at all, are only of
cosmetic value and may actually mask the severity of the
disease.
D)
Eelctrolytes;
In the management of diarrhoeas, administration of
water and electrolytestakes precedence over all other forms
of treatment.
However, electrolytes should never be mixed
in antidiarrhoeal drugs.
Electrolytes must be administered
with water in proper formula and as per need of individual
patient.
Electrolytes provided in the antidiarrhoeal mixtures
are in wrong proportion and too inadequate.
They give rise
to false sense of security and may prove harmful.
CONCLUSIONS
Antibacterial drugs should be used very judiciously and
only if absolutely necessary in management of diarrhoea;
All formulations containing combination of chloramphenicol
anl streptomycin should be banned as antidiarrhoeal agents;
All formulations containing streptomycin or chloramphenicol
(alone) should be avoided;
All other antibacterial agents if combined in antidiarrhoeal
formulations,should be provided in adequate dosages e.g.
Neomycin, Colistin, Furazolidone, Cotrimexazole... etc.
Hydroxyquinoline derivatives should, not be added in any of
the fixed dose combination. As far as possible, these
agents should be avoided and should be available strictly
against precription;
Antiperistaltic drugs (lomotil, Loperamide, Opium) should
not be used in children below 2 years and when used in
children, should bo used very cautiously in proper dosage
and for very short period of time.
They shoull not be added
ia in any fixed dose formulations.
Antispasmodic drugs like
dicyclomine should be carefully used in children and should
never be added in fixed-dose combirations.
(contd
7.
Electrolytes should never be added in fixed-dose combi
nations with antiliarrhoeal agents.
That gives false
sense of security and mjry prove harmful.
REFERENCES
1) Goodman & Gillman, 'The Pharmacological basis of
Therapeutics', 6th edition-1980, Macmillan Publishing Co.
2. Satoskar, Kale, Bhandarkar's 'Pharmacology and
Pharmacothcrapeutics'.
3. Acute Gastroenteritis, Chapter 7, P-69 in 'Infectious
diseases of Children' by Saul Krugman Sc Samual Katz, 7th Edn;
The C.T.Mosby Co., 1981.
4. Current Paediatric Therapy-1.0 by Sydney Gells & Benjamin
Kagan-1982 WB Saunders Co.
(
5. Infectious diseases, Epidemiology & Clinical Practice
by A.B.Christie, 3rd Edn-1980, Churchil Livingstone-P 116,188,.190.
6. Textbook of Paediatric-Infectious Diseases by Feigin
& Cherry, Vol.1-1983.
7. 'Paediatrics' 17th Edn. by Abraham Rudolph-1982
(Appleton-Century Crofts), P-1549.
8.
NEJM 262-864-921/1960.
9.
NEJM 2 56,
1121,
New England journal of Medicine
19 57.
10. Vulman H.B., Wlman M.J., Use of Antibiotics in Acute
Gastroenteritis among Infants in Hospital, BMJ1.1969, 1122.
A
11. Goetzee M.Leary P.M. - Gentamyci.n in-E.E.Coli Gastroenteritis, Arch.dis .Child.46, 646, 1971.
12. Diarrhoeas in children: Indian Journal of Paediatrics
July-Agusut 1980.
13.
Essentials of Paediatrics-by O.P. Ghai/1980.
14.
Textbook of Paediatrics, Vol-2 by Forfar & Ameil,1984.
15. Report 1966: Annual Report on the work of the Infectious
disease hospital & their associated laboratory services. Western
regional board hospital, Scot-land, U.K.
16. Davis Joan R., Farrant W.N., Ufley Anne: Antibiotic
Resistance of Shigella Sonnci, Lancet, 2:1157:1970.
17)
Ibid,
18)
AMA drug evaluations: 1984,
1968, 479.
5th Edn.
19) Curtis JA & Goel KM-'Lomotil poisoning in Children'
Arch of Disease in Child: 54; 1979-p-222.
in
... 5 ...
PHO for exTin~tion because of their chest symptoms."’
i
i
1
Approximate
cost of one
e.xnraim tion
c
rj
t
-J
p-
1
3
’ td
1
Out of every 15-25 sputum smears. .examined ore
is expected to be smear +ve.
If oil the smear nega
tive patients were to be X-rayed, two or three
■ suspects could than be found (including those
•coses who could be culture +ve).
Even if every one
is referred only 20% may actually report to a distent
centre for X-ray examination .
\
The Cost in US $ of diagnosing one case by
d i 1ferent methods1
Direct microscopy
0.21
Approximate cost
of diagnosing
one cnse
Culture examination
0.49
■ 5.4
12.1
70mm X-ray film
(static unit)
0.26
5.5
70mm X-ray film
(mobile unit)
0.50
75.0
Method of case finding at DTO if■supplemented with
sputum collection from symptomatics on house visit
by multipurpose workers has shown encouraging results
in the preliminary trials (doubled)1’.
No matter what we do or say, some patients will
always first consult a private practitioner of one or
other systems of medicine. Therefore if we want to
diagnose and suspect early, all practitioners of all
systems must'be involved in the.health care plan-1.
D.SurveillancesEpidemiological groups of population ap’d their
contribution towards new c-ses in'a year1-
Category
Size of
population
Contribution
to new cases
X-ray normals
88.7%
48.2%
Probably active
TB shadow
1.5%
26.6%
•
Inactive X-ray
shadow
9.8%
..
Remarks
Most
rewarding
25.2%
Survielence of abnormal shadows (11.5% popula
tion) can at the best prevent only. 1/2 the inci
dence of cases that are expected to arise in the
community in a year.
E. Co se ..Hold ing_£~
It is a process of’ensuring that a case of
Tuberculosis completes the prescribed duration of
chemotherapy which is atleast 12.--months. The
efficiency of this component has been estimated
tc be about 50-55% in NTP.
Proportion of patients ma kin..- 9 out of 12
monthly collections in one year wag 52% from the
4
treatme?it centre neir at hand, compared to 7% when
patient hod to travel a long distance to collect
medicines^.
Drug collection was the same(30%) whether the
patient was asked to collect drugs from the nearest
primary health centre or from a local village p-mchayat
member'5. Organising periodic reminder services enhances
regularity in drug collection.
Making .just sno attempt at motivation at the
start of treatment was found to be rather inadequate ' .
Motivation of patients with household members a
every month for a period of 3 months was more rewar
ding (doubles drug collection)1 z'
Sizeable proportion of patients drop out irnrne
tely after starting the treatment 1-5.
Collection at which first default takes place
Centre
10
5
4
5+
19.1
8.3
17.0
J
DTC
I Obligatory
55.6
J
PHI
Tieatment failures were as often due to lapses
on the part of the patients.
Inadequate diagnostic
equipment., drugs and trained manpower could not
meet the felt need of patients.
in the small group
in which the lapse was on the part of the patients,
it was found that acute social and economic factors
were often responsible for the default, if it was
not caused by human forgetfulness10.
In punctual drug collectors- only 5 to 10% did ? ,
not properly consume drugs, rest did take regularly^’'
F. Drug^Man a_S£ra^2 ■Regimen-
•' — —
12 TH
Cost in
rupees
Efficacy in *
Efficacy in
field situa
experimen
tion %
tal situa—
“ —• - tisn-%- - - M ..V
60
51.19
82
12 PH
446.81
12 S2H2
136.24
2 SHT/10 TH
120.64
•
89
64
94
68
76
2 SHP/10 PH
516.34
96
"I
2 RSHZ/5S-2H2Z2
746.80
LOO
1 RSHZ/7 th
265.3,2
100
516.40
100
2
d.
Q’H'7/Rq
H 27,
bxi
./2b2tl
Z,2
19'. SM.75 g^(1.14), INH 300 mg(.O8 Rs.’u
inamide
500 mg (0.93 Rs.) Rifampicin 150 mg(1.28 Rs.),
Thioc.atav.one 150 mg (0,06 Rs.), PAS 500 ng
(0.05 Rs.), Ethambutol 200 mg (0.21 Rs.)
lose due to inefficient case holding
. . .5
e_ Prospects.•
Estimated sputum positive cases in an average Indian District with and
without a district tuberculosis programme, at the eno of one year'
No. of
cases at
- to preva
lence
s.
No. of
cases at
prevalence
Estima-
probable
reduction
Dead
(sputum -ve)
Cured
(sputum -ve)
Remaining
(sputum 4-ve)
Cases
added
5000
700 (14%)
1000 (20%)
3300
1700
5000
Nil
—can be diagnosed
2000 (40%)9
280 (14%)
920 (46%)
800
--cannot be diagnosed
3000
420 (14%)
400 (20%)
2180
5000
700
1320
2980
1700
4680
6.4%
"Without program
With programme
A. Potential
\
B. Field situation
Today
)Diagnosed
Nagpaul )
19
)
)Nct
)S6tgr.
)diagnosed
,. . .
Shrimvasan
20
\ Diagnosed
)
)
,
) Not
diagnosed
776 (2530% of the
OXpfot
potential)
147 (19%)
357 (46%)
272
4224
5000
590 (14%)
737
845 (20%)
1202
2789
3061
776
101
357
ote
1700
4761
4224
5000
_ _ _ _ _
4.8%19
845______
590______
2789
4%20
691
1202
3107
1700
4807
)
— — — — — —
_ _ _ _ _ — _ _ _ _ _ _ — _ _ _ _ _ _ _ _
x After applying differential cure rates for the sensitive and resistant cases as exist in field situations
With 50% geographical area coverage of NIP annual reauction will be 2% with growth rate of 24.75,
expected prevalence of pulrn. IB cases by 2000 AD will be 5/1000 total, problem and 1.2/1000 infectious
1.
Which component of TB control i.e.case detection,
case holding and drug management has the potential
of increasing its efficiency in field situations
and to what extend?
2.
Which component of TB control i.e. case detection,
case holding and drug treatment is likely to be
more rewarding if their efficiency is increased
in the field situation?
Estimate of overall success in'the treatment
programme for various levels of efficiency
20
of case finding, case holding and chemotherapy
_„
_ ..
-Levels of_efficiencjr
Component
Present With exoected
Q S timate improvement
of DTP
inefficiency
of finding
With
With W ith
best better all
case
chehoimot'ie
_rapy
.(ing_
_ _ _ _
Case finding
30%
70%
30%
30%
45
Case holding
35%
35%
35%
50%
50
Chemotherapy
75%
75%
95%
75%
95
8%
19%
10%
11%
21%
Overall succe ss
3.
What can be the role of (1) MP4R (Static & Mobile
units)' in augmenting case detection?
(ii) Village health worker in augmenting case
detection?
4.
How can private practitioners of all the systems
of medicine be actively involved in case detection
and management?
5.
If the distribution of antitubercular drugs is
centralized through the peripheral network of
government services only (Drug is not allowed)
to be sold in the open market) so that regist
ration of a case of tuberculosis is mandatory
before receiving treatment-whet will be its
impact?
1.
case finding by micros. o»y; D.R.Nagpaul, D.M.S-avic
X.F.RaO & G.V.J.Baily, w.H.O./T.B./Techn.Jnforma
tion/ 68.65.
2.
District 7.B.Control Programme in concept-& outline
D.R.Nagpaul, Ind J Tub.XIV. 196-198.
3.
-i S' lological Survey of .awareness of symptoms
Sun.~estive of Pulm. Tuberculosis': Bull. Wld.ill th.
Or: .29, 665-685, 1965.
4.
Sociological study of awareness of symptoms and
action taking of persons with pulm.T.B. Radha
Narayan S., S.Prabhakar, Susy Thomas, S.Pramila
Kurnari, T.Suresh and N. grikantaramu. Ind J. of
Tub. ?1XVI, 156, 1979.
5.
Socio-cultural context of T.B,. treatmenu :
Ind J Tub. 1982.
6.
Prevalence of Symptoms in a South Indian rural
community and utilisation of area health centre.
Ind J.Med.R-s. 1977,66,655.
7.
Symptom awareness and action taking of persons
with pulm.T.B. in rural community surveyed repea
tedly to determine the epidemiology of disease.
Radha Narayan & H. Shrikantaram. Ind J Tub.28,
1?61, 1981'.
i■
8.
Some aspects of sputum examination in T.B.case
finding: Dr. N-gr.aul, N. No genethan & .1. Prakash.
Ind J Tub. XXVI, 11, 1979.
9.
Potential yield of pulmonary tuberculosis cases by
direct microscopy of sputum in a district, of
South India.
G.V.J.Baily, B.Snvic, G.D. Got.hi,
V.B.Na’idu & S.S.Nair, Bull.Wld.Hlth Org. 1967,
57, 875/892.
10.
n operational study of alternative methods of
case finding for tuberculosis control, NTI
Bangalore. Ind J. Tub.XXVI, 26, 1979.
11.
Active case finding in tuberculosis as a. compo
nent of primary health care. K.S.Aneja,R.6handrasekhar,M.A.Seetha, V.C.Sunmuganandan & GE
Ruppert Samuel. Ind J Tub. 1984, 57, 65.
12.
Incidence of sputum +ve T.B. in different epide
miological groups 5 yr.follow-up of a rural
population in South India?GD Gothi, A.K.Chakraborty & M.J.Jayalaksbmi. Ind J.Tub.XXV.No.2,
85, 1978.
15. A.
I study of some aspects of treatment cards in
a DTP: Seetha et al. Ind J. Tub.25, 90, 1976.
15B.
Feasibility of involving multipurpose workers
in xnse finding in district tuberculosis
programme Aneja et al: Ind J.Tub. XXVII,
4, 158, 1900.
14.
Drug collection by patients through motivavation of the families: Seetha M.A.Srikantnrarnu M., Aneja K.S. and Harden Singh. Ind
J.Tub.XXVIII 4, 1981.
x
15.
Chenothernpy in nation'll tuberculosis progrrnriime.
K.S. In.-jV NT I Hows letter 19, 58, 1982."
16.
Effect of treatment default in India 1), Ban -r ,j i •;
Proceedings of the XXth. Ind T,B.Con Terence, Paris,
International Union against T.B, 1970.
17.
f study to determine the reliability of assess
ing the regularity of self administration of
drugs at home by patient's attendance st the
clinic.
S. Geh.ani, V.K. Perumal ft T).G. Mathur.
Ind.J.Tub. 1984. 31,74.
18.
Cost consideration in short course chenotherapy.
V.Sivoramn. Ind.J.Tub. Vol.XXX,9, 1983.
19.
Tuberculosis in India - A perspective,9.l.Nngpnul:
J. of the Ind.led.Ass. 71, 44-48, 1978.
20.
Tuberculosis in India - The prospectS.Shrinivasana Ind J.Tub.XXIX 71, 1981.
21.
Recommendations macle ,by tuberculosis Association
of India - A Scheme for primary health care in
tuberculosis: Ind J. Tub. 1981, 28, 218.
22.
Motional Tuberculosis programme - relative
merits of enhancing the operational efficiency
of different components of the treatment
programme. Ind. J .Tub.S.Radhal<rishan Vol.XX 3,1983.
ECONOMIC AND POLITICAL WEEKLY
Some Recent Articles on Health and Related Subjects
Health and Medicine
Status of the Drug Industry in India; Haseeb A Drabu,
January 25, 1986
The Drug Charade; S Srinivasan, January 18, 1986
Cantrailing Tuberculosis; N H Antia, January 4, 1986
An Alternative Strategy for Health Cares The Mandwa Project;
N H Antia, December 21-28, 1985
Maternal and Infant Mortality; Malini Karkal, October 26, 1985
How the Other Half Die's in Bombay; Malini Karkal, August 24,
1985
Infant Mortality in India; Levels, Trends and Determinants;
Leela Visaria, August 10, 17 and 24, 1985
Mortality Toll of Cities: -merging Patterns of Disease in
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Treatment Failure in Indian National TB Pragramme; Kashyap
Mankadi and Klass van der Veen, May 25, 1985
Famine, Epidemics and Mortality in India: A Reappraisal of
the Demographic Crisis of 1876-78; Ronald Lardinois,
March 16, 1985
Health Hazards of Cotton Textile Workers; Bharat Dogra;
February 16, 1985
Breast Feeding: Collage of Danger Signals; Vimal Balasubrahmanyan, August 25, 1984
Breakdown of Public Health System; D Banerji, June 2-9, 1984
Family Size, Levels of Living and Differential Mortality
in Rural Areas; Some Paradoxes; N Krishnaji, February 11,
1984
=J
Ban on Dangerous Pain-Killers; Padma Prakash, June 25, 1983
Drug Trials: Charade of 'Informed Consent'; Vimal Balasubrahmanyan, June 18, 1983
Impact of Social and Economic Development on Mortality:
Comparative Study of Kerala and-West Bengal; M'o'ni Nag,
Annual Number, 1983'
'
National Health Policy and Its Implementation; D Banerji,
January 22, 1983
New Patterns in Health Sector Aid; Roger Jeffery, Septem
ber 11, 1982
Little Girls and Death in India; Pranab Bardhan, September
1982
,
Bangladesh's New Drug Policy; John Cunnington, August 21, 1982
Health for All: A Review and Critique of Two Reports; Malini
Karkal, February 13, 1982
Leprosy Control and Eradication; Padma Prakash, November 28,
1982
Choice of Best or Cheapest Drugs? A Note on Regulating Drug
Supplies; Mahesh S Patel, August 22, 1981
Health for All: A Reaffirmation; N H Antia, August 15, 1981
Nutrition
Protein and Energy Requirements; P V Sukhatme, November 2,
1985
Bashing Nutritionists: The Small-but-Healthy Hypothesis;
Sol Chafkin, May 18, 1985
Ideology and the .Poverty-Line Debate; Sheila Zurbrigg,
December 3, 1983
Undernutrition, Energy Requirement and Adaptation: A Physio
logist' s Point of View; L Garby, • November 26, 1982
Estimation of Nutritional Intake; Rajaram Dasgupta, July 9,
1982
RDAs: Their Limitations and Applications; K T Achaya,
April 9, 1983
Measurement of Unde mutrit ion: Biological Considerations;
C Gopalan, April 9, 1983
Malnutrition of Rural Children and Sex Bias; Amartya Sen
and Sunil Sengupta, Annual Number, 1983
We Are Eating Better; K T Achaya, January 1-8, 1983
Measurement of Undernutrition; P V Sukhatme, December 11, 1982
Poverty and Undernutrition in Rural India: A Cross-Sectional
Analysis; Rajaram Dasgupta, September 25, 1982
3
Nutritional Norms and Measurement of Ma lmuri shinent and
Poverty; Jaya Mehta, August 1^, 1982
The Poor as a Social Stratum: Some Economic Criteria for
Studying Poverty; V M Rao and M Vivekananda, July 3, 1982
•
i
Administrative Constraints on Rural Development: a Field
View of the Applied Nutrition Programme; Amal Roy and
Vanita Venkatasubbaiah, Review of Agriculture, June 26,
1982
Some Nutritional Puzzles; C Ashok and Mahdav Kulkarni,
April'24, 1982
Rural Energy Scarcity and Nutrition: A Nev/ Perspective;
Srilata Batliwala, February 27, 1982
Calorie Norm Controversy; V M Rao and M Vivekananda,
February’■ 13, 1982
On Measurement of Undernutrition; V M Dandekar, February 6,
1982
Measurement of Poverty and Undernutrition; D Banerji,
September 26, 1981
On Measurement of Incidence of ilndemutrition; What is a
Consumer Unit?; N Krishnaji, September 12, 1981
Measurement of Poverty; V K R V Rao, August 29, 1981
On Measurement of Poverty; P V Sukhatme, August 8, 1981
Measurement of Incidence of Ilndemutrition; Santi K Chakrabarti and Manoj K Panda, August 1, 1981
On Measurement of Poverty; V M Dandekar, July 25, 1981
Some Nutritional Puzzles; V K R V Rao, July 11-18, 1981
On Measuring the Incidence of Ilndemutrition; P V Sukhatme,
June 6, 1981
l\C'
On Measuring the Incidence of Undernutrition; N Krishnaji,
May 30, 1981
Family Planning
...
Towards a Women's Perspective of Family Planning; Vimal
BalaSubrahmanyan, January 11, 1986
Two Decades of Sterilisation, Modernisation and-Population
Growth in a Rural Context; Stanley A Freed and'Ruth S
Freed, December 7, 1985
Case for Injectible Contraceptives?; Sujit K Das and Pijus
Kanti Sarkar, October 5, 1985
4
Case for injectible Contraceptives; Iris Kapil, May 11,
1985
Family Planning and the Emergency :>n Unanticipated
Consequence; Aleka M Basu, March 9, 1985
Retreat an DepoProvera; Padma Prakash, December 8, 1984
Problems Concerning Tubectomy Operations in the Rural -Areas
of Punjab; Joyce Pettigrew, June 30, 1984
Fertility Decline in Kerala; The Social Justice Hypothesis;
’P- G K Panikar, March 31 , 1984
Use of Laparoscopy for Sterlisation; Padma Prakash, March 17,
<■'1984
Excess Female Mortality in India; Tim Dyson, March 10, 1984
Mass Use of Injectible Contraceptives; Vim-il BalaSubrahmanyan,
March 3, 198A
’
Fertility Differentials in Kerala and West Bengal: The EquityFertility Hypothesis as Explanation; Moni Nag, January 1,
1984
Breast-Feeding and Family Planning Policy; Vimal Ba_la Subrah
manyan, December 10, 1983
Amniocentesis: The Debate Continues; Leela Dubey; Septem
ber 17, 1983
Amniocentesis Again; Dharma Kumar, June 11, 1983
Female Infanticide and Amniocentesis; Roger Jeffery and
Patricia Jeffery, April 16-23-? 1983
Fpesh Focus on ’Natural’ Family Planning; Vimal Balasubrah"manyan, April 2, 1983
;
Misadventures in Amniocentesis; L S Vishwanath, March 12,
1982
Misadventures in Amnioc'enjesis; Leela Dubey, February 19,
1983
Male Utopia or Nightmares?; Pharma Kumar, January l£, 1983
Hormonal Pregnancy Tests; One Mope Year's Havoc; Padma
Prakash, August 28, 1982
Where Have the Women Gone?' Insights from Bangladesh on Low
Sex Ratio of India's Population; Lincoln C Chen, March 6,
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Preliminary Demography
*
tf '498'1 Census; Tim Dyson, August 15,
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5
Environment
'
Environmental Conflicts and Public Interest Science;
Vandana Shiva and J Bandyopadhyay, January 11, 1986
Bhopal: The 'Worse Aftermath; Sujit K Das, December 14,
1985
Bhopal: Neglect of Women's Health Issues; Padma Prakash,
December 14, 1985
Bhopal: h -'orker’s Perspective; Rohini Banaji, December
14, 1985
Bhopal: Farce of Rehabilitation; Jagdish and Vijay,
’December ' 14, 1985
Eucalyptus in Rain-Fed Farm Forestry: Prescription for
Desertification; J Bandyopadhyay and Vandana Shiva,
October 5, 1985
From the Dam to the Chettoes: Victims of the Rihand
Dam; Satyajit. Kumar Singh, October 5, 1985
Bhopal Gas Disaster: Mockery of Relief andRehabilitation;
Sujit K Das, October 5, 1985
Project Tiger and People: A Report on Similipal,
-august 17, 1985
Population and Environment; Anil Aggarwal, June 15, 1985
Bhopal Tragedy: A Middle Word; Pushpa M Bhargava,
June 1, 1985
Anti-People Development: Case of Inchampalli Project,
J une 1 , 1985
Bhopal Tragedy: Failure of Scientific Community; Padma
Prakash, May 25, 1985
Facade and Reality of Environmental Protection; Bharat
Dogra, May 18, 5985
Bhopal Gas Didaster:
*
April 6, 1985
Continuing Nightmare; Padma Prakash,
Ecology and Social Movements; Gail Omvedt, November 3,
198^4
■ .
Women and People\s Ecological Movement: A Case Study
of .’/omen’s Role in the Chipko Movement; Shobita
Jain, October 31, 1984
Narmada'Valley' Pro-ject: -De velopment or Disaster?; Ashish
Kothari and Rajiv Bhartari, June 2-9, 1984
6
Forestry in'British and Fast-British India: A Historical
Analysis; Ramachandra Guha, October 29 and November 5,
1983
Energy in a Stratified Society: A Case'Study of Firewood
in Bangalore; a K N Reddy and V Sudharkar Reddy,
October 3, 1983
(
Meeting Basic Needs through Micro Planning: Central Role
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August 20 and 27, 1983
\Eucalyptus: Why?; Mahasveta Devi, August 6, 1983
Singhbhum: A Countryside Slowly Dying, Mahasveta Devi,
March 5, 1983
Ecological Crisis andEcological Movements; A Bourgeois
Deviation?; Ramachandra Guha, December 25, 1982
Political Economy of Technological Polarisation; Vandana
Shiva and J Bandyopadhyay, November 6, 1982
Ecology as Science and Science Fiction; Subrata Kumar
Mitra, January 30, 1982.
Encroachment on Forests: Government versus People; Sharad
D Kulkarni, January 16, 1982
Industrial Hazards Exported to India; Barry I Castleman,
Rakesh Madan and Robert Mayer, June 13, 1981
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Tonics : Mow Much An Economic Waste
KAMALA
MONG the pharmaceutical preparations that are
indiscriminately prescribed arc the vitamins, parti
cularly those of the B-complex group. “ Probably
no single class of drugs (Sic ) has been the target
of as much quackery, misunderstanding, misrepresen
tation and misuse as the vitamins.......... ’’’. There are
however a number of reasons for this, some in my
opinion condonable.
A
Patients often come with vague symptoms which
can be correlated to no known disease. The comp
laints may be genuine or psychosomatic, but the patient
expects treatment. For example, a common complaint
is pain in the back or pulling sensation in the legs.
Or, it may be a simple complaint of general fatigue
or loss of appetite due to no organic cause. What is
one to do ? One usually prescribes a multivitamin or
a B-complex preparation. This may be done for three
reasons. The physician may sincerely believe that
vitamins will help the patient or he may feel compelled
to prescribe something. Thirdly, the patient himself
may demand some medicine, generally a ‘ tonic ’.
What does a tonic mean, anyway ? In general parley
it has come to mean a liquid preparation. However
we do come across advertisem*nts of ‘ nervous tonics ’
‘tonic for muscle strength’ ‘for energy’ etc.. This
is pure baloney. One of the definitions given by the
Webster Dictionary for tonic -is ‘ something that
invigorates, restores, stimulates or refreshes ’. Could
it be the generous quantity of alcohol in these prepa
rations ?
If the physician believes that B-compIcx would be
beneficial, even if he has no scientific evidence or the
rapeutic basis, he need not in my opinion be casti
gated. We still do not know all the metabolic functions
for which one or more members of the B-complex
S.
*
JAYARAO
may be needed. Hence, we are probably not in a
position to recognize all situations which may respond
to vitamin therapy, though severe deficiencies of single
vitamin have been well characterized in most cases.
The trouble arises with the dose that is prescribed.
The physician should realise that in such undefined
situation, the therapy is purely empirical. The burden
rests on him to know whether he is prescribing the
right amount, less or more. This brings us to the
question of what the right amount is. Here we must
defferentiate between vitamins taken as nutrients to
ward off deficiency and taken for therapeutic purposes,
in established deficiency. The latter dosages are not
based on as careful a scientific scrutiny as the former.
They are prescribed for acute and severe, single defi
ciency states like beri-beri, pellagra, keratomalacia etc.
Since water-soluble vitamins are considered to be
relatively innocuous, the amounts prescribed are very
high, the main aim being to tide over the acute situation.
On the other hand, we have these various unde
fined situations which we attribute to vitamin deficie
ncies or anaemia. These are neither acute nor proven
states of deficiency. If the condition is due to a
nutrient deficiency, the deficiency is probably chronic
and marginal or moderate in nature. Here the impli
cation probably is that the individual is unable to
meet his nutrient requirements. This is perhaps a
justifiable premise since the prevalence of B-comlex
deficiency in our country is relatively high. According
to certain surveys the prcvalncc rate is 5 per cent in
pre-school children and 17.8% in pregnant women
( assessed by the presence of angular stomatitis and
glossitis )2. The percentage of those with less severe
deficiency is expected to be higher.
* National Institute of Nutrition, 1-Iydcra bad-500 007
What is a nutrient-requirement ?
The requirement for
a specific nutrient is defined as the smallest amount
of that nutrient that will ensure a good state of health.
This will however, vary from person to person.
Therefore, nutrient requirements are set down as reco
mmended dietary allowances ( RDA ). These levels
are believed to ‘ meet the known nutritional needs of
almost every healthy person. ' By experimental pro
cedures, the highest requirements in a population are
assessed, some further allowances are added and the
RDA for each nutrient is fixed. Thus for many
individuals the RDA will be higher than their actual
requirement. No person need take more than the
suggested RDA. The RDA for various nutrients have
been fixed by international organizations like the
FAO and WHO3 and by various national bodies
including the Indian Council of Medical Research4.
In the process of this search, I came across an
interesting or disturbing feature, depending on how
you wish to perceive it. Many advertisem*nts do not
say what ingredients the preparation contains, leave
alone their quantities. Many inform you that the
preparation is a unique formulation of generous
amounts of vitamins or that it is a vitalize,' with
balanced amounts of vitamin ( Incidentally, IDPL is
one of them ). The advertisem*nt merely proclaims
the efficacy of their product in specified condition.
There is one advertisem*nt by a leading company,
which reveals nothing about the formula but claims
that it is good for memory 1 It contains nothing but
vitamins Bi, Bo and B12.
The companies are pro
bably co*cksure that the physician will rely more on
their advice than on his own judgement ( and they
are dead right ).
I was interested to know how some of the comm
only available vitamin preparations fare when compar
ed to the RDA suggested by the 1CMR. Table I
shows the RDA for some nutrients, for various
physiological groups. For specific reasons, I have
not taken the RDA for infants and children but in
absolute terms these values will be less than those for
adults. In Table II, I have presented the quantities
of various vitamins purported to be present in each
commercial preparation. It is however not the complete
formula of the preparation. I have taken only some
important vitamins into consideratoin. The list is by
no means exhaustive. I culled them from some recent
issues of the Journal of the Indian Medical Associa
tion. They are marketed by leading pharmaceutical
companies.
This lack of needed information is one of the
reasons why Table //does not have more preparations
listed. But this is ample for what I have to say.
There is also no reason to believe that those which
escaped inclusion would be any different.
Recommended Daily Allowances*
Table-I
Thiamine
( B j ) mg
Man :
Sedentary
Moderate
Heavy work
The RDA for any nutrient is the amount which
if taken regularly will ensure that a deficiency state
of that nutrient will not develop.
For example if a
sedentary, house-wife takes 1.0 mg riboflavin daily,
she is expected not to develop riboflavin deficiency.
As I said earlier, 1.0 is the highest level and most
can afford to live on lesser amounts.
The situations
which are under discussion now, are considered to be
deficiency states of mild or moderate degree. The
individual might have depleted levels of the nutrient
and may need higher amounts than the RDA. What
Riboflavin
( B2 ) mg
N cotinic acid
mg
Folic acid
mg
Vitamin B.?
mcg
1.2
1.4
2.0
1.3
1.5
99
16
19
26
__
1.4
—
0.1
0.1
0.1
1
1
1
1.0
1.1
1.5
1.0
1.2
1.7
13
15
20
_
20
—
0.1
0.1
0.1
1
1
1
1.1-1.3
1.1-1.5
1.2-1.4
1.2-1.7
14-17
14-21
1.6
1.8
0.1
0.1
0.5-1
0.5-1
1.2-1.7
1.4-1.9
1.2-1.9
1.4-2.1
15-22
18-25
2.5
2.5
0.15-0.3
0.15
1.5
1.5
Woman :
Sedentary
Moderate
Heavy work
Pyridoxinct
( B6 ) mg
Adolescents :
13-15 yrs
16-18 yrs
Pregnancy
( Second half)
L elation
* Taken from reference 4
+ Taken from RDA of Food and Nutrition Board, U.S.A. 1968.
should this higher level be
For acute and severe
states like bert-beri or keratomalacia text-books
prescribe doses, empirically arrived at and found to
bring quick relief. These are usually much higher
than what would be required even for that degree of
amelioration.
Table III shows the prescribed thera
peutic doses, as obtained from various standard books
on nutrition and medicine.
For chronic, moderate deficiency states or for
situations where vitamins are prescribed empirically,
we may assume that levels much lower than the
therapeutic doses and slightly higher than the RDA
should be enough. Let us be generous and double
the RDA, remembering that the patient does receive
a certain amount from his diet too.
With this
information I would like you to critically compare
Table II with Tables I and III.
Much of the time drugs are not prescribed
according to any therapeutic schedule.
They are
usually prescribed as ‘ 1 dose or 1 tablet, three times
a day
Items No. 1-4 in Table II are close to the
RDA with respect to vitamins Bi and B2. Given as
Table-II
per the above mentioned schedule they supply 2-4
times the RDA, and it was argued above that double
the RDA should be enough in moderate or doubtful
deficiency states. We must also remember that when
a diet is considered to be low in a nutrient, it is not
totally lacking in that nutrient. The average diets of
the low socio-economic groups provide 0.5 to 0.8 mg
each of Bi and Bs.
Items 7-9 provide about '5-25
times the RDA in a single dose. If even such pre
parations are prescribed thrice a day, the intake
would be 15-75 times the RDA. Item 8 in a single
dose supplies thiamine in a quantity prescribed for
the whole day in beri-beri ? Moreover in beri-beri
it is not necessary to prescribe very large amounts of
other vitamins. Thus preparations like 8 and 9 are
not necessary at all.
An argument may be put forward that since
w'ater-soluble vitamins are harmless compounds there
is no necessity to raise a hue and cry about the
dosages prescribed.
This is no doubt true but,
‘ such practice is economically wasteful and in some
instances, causes financial hardship ”.
Composition of some multivitamin and haematinic preparations available in India.
Vitamin Bi ms
Vitamin B . mg
Vitamin Bs mg
Niacin mg
Vitamin B ■ mcg
Folic acid ms
Vitamin C mg
Iron
( Type of salt ) mg
1
Capsule
2
Cap.
3
5 nil.
4
5 ml.
5
Cap.
6
Cap.
7
Cap.
1
0.5
0.6
4
2
2
2
2
1
1.0
0.75
0.15
7
0.45
1.6
0.8
0.8
4.0
2.5
3.0
1.0
0.5
30.0
5.0
10
10
F.A.C
185
Gluco.
35
5
2
1
10
5
1
50
Sulp.
200
50
Sulp.
150
timed
release
Vit. A. LU.
Vitamin D. LU.
100
5
200
Sulp.
41
8
Cap.
50
25
10
100
5
0.5
300
20
5
2.5
100
5
1.0
100
10000
1000
25000
1000
250
90
9
Cap.
Table-11 ( Could )
10
5 ml
Vitamin B, mg
Vitamin B_. mg
Vitamin B(, mg
Niacin mg
Vitamin B,2 mcg
Folic acid mg
Vitamin C mg
Iron (Type of salt)
mg
Vitamin A
Vitamin D
11
Cap.
12
Cap.
13
Cap.
14
5 ml.
15
5 ml.
16
Cap.
10
25
2.5
Colloidal
oxide
100
25
2.0
200
Fuma
rate
350
15
2
150
Fuma
rate
350
50
2.5
100
Fuma
rate
300
7
1.75
15
2
Colloi
dal ox.
500
Fuma
rate
125
25
2.5
Fuma
rate
250
17
3. ml l.M.
18
5ml. I.M
100
100
27.5
25
1000
500
It must also be remembered that water-soluble
vitamins cannot be stored in large amounts unlike
the fat-soluble ones. This of course is one of the
factors underlying their low toxicity. ‘ In prescribing
thiamine it should be remembered that the healthy
human body contains only about 25 mg of the
vitamin. Furthermore, it has no means of storing
any -excess taken in the diet; the excess is lost rapidly
in the urine.
The human body is certainly an
effective machine for dissolving thiamine pills and
transferring the solution to the urinal ’5.
Moreover
it has been shown, atleast for riboflavin that intestinal
absorption is limited by saturability and that higher
the dose, smaller the fraction absorbed. This is no
case in favour of parenteral administration either,
because higher the amount in circulation greater the
excretion in urine.
Thus, most of the ‘ high-potency ’ or ‘ Forte ’
preparations of multivitamins are a sheer economic
waste. It is a drain on the patients’ purse and the
onus is on the doctor because he is making the
patient buy a specific preparation.
If bought by
goverment or public sector dispensaries, it is a
national waste. If preparations with smaller and yet
adequate quantities were bought, for the same money
more tablets could be purchased and a greater number
of patients benefitted. Manufacture of such ‘ highpotency ’ preparations must also use up an unnecessary
amount of the scarce foreign exchange resources,
since quite a few, and probably all vitamins ( raw
materials ) are imported.
Thus it is not proper if one merely prescribes
B-complex tablets and avoids brand name because he
is a ‘ conscientious objector ’ to brand names. As long
as there is no uniformity in the dosage employed in
various preparations, it is necessary to know which
brand supplies or claims to supply requisite quantities
of vitamins. Also, there is no need to blindly follow
Table-Ill
Suggested doses of vitamins for single,
severe deficiency
acute and
Condition
Vitamin
Dose (Oral)
Beri-Beri
B.
10-25 mg bid
or tds
5-10 mg
5-10 mg
5-10 mg
Riboflavin deficiency B.
Megaloblastic anaemia Folic acid
Bl 2
Megaloblastic antemia
Folic acid
of pregnancy
Corneal xerosis
Vitamin A
Bitot’s spots
Vitamin D
Rickets
10 mg
5000-10,000 I.U
1000-5000 I.U.
the ' one t.d.s. ’ schedule. How much and how
frequently, should be decided on the merits of the case.
1 also wish to draw your attention to one or
two additional points. There is a widely held belief
that a combination of vitamins Bi Ba and B,._. is
good for neuropathies and other nervous disorders.
I don’t think this is based on any solid therapeutic
evidence. The reason the three are combined, I think
is because each one has been shown to be effective
in a specific disorder of the nervous system. Hence
the triad is used as a short-gun therapy, indiscrimina
tely. In fact, the brand names of certain such prepa
rations incorporate Greek terms like ‘ encephalo ’,
‘ neuro ’ etc. The manufacturers of one preparation
even claimi ts efficacy in improving memory.
‘ It ( thiamine ) may be given, though without
expectation of dramatic results, in cases of nutritional
neuropathy. There is no reliable evidence that it is
useful in any other disorder of the nervous system.
The prescription of synthetic thiamine, either alone or
in combination with other vitamins, as a general tonic
or appetiser, is supported by no scientific evidence
and is now discredited. ’5
‘ Vitamin therapy is often given to patients with
polyneuropathy, although it is clear that polyneuro
pathy is not due to deficiency of vitamin Bi, B12 or
any other known vitamin. Such treatment has a
placebo value and probably no other, but is not to
be decried... ,’8.
For reasons mentioned right at the beginning
I too do not decry the use of the combination as
I do the dosage in such preparations. Items 17 and
18 in Table-11 are two classical examples. Both are
meant for parenteral use, another characteristic of
this triple combination, probably because of the
presence of vitamin B12. The conventional prescri
ption by physicians for parenteral B-complex is ‘ 2 ml
M.
I.
once a day or once on alternate days
Assuming the patient receives 6 ml in a week, he is
given 600 mcg to 2 mg of vitamin B,._. 1 What a
collossal waste considering that vitamin B12 is an
expensive substance. The prescribed dose even for
pel nicious anaemia is 2 mg weekly, even those who
may argue that unlike the other B-complex vitamins,
vitamin B12 is stored to a certain extent in the body
may note that with each 1 ml goes 20-33 mg thiamine.
Many of the oral preparation too contain unnece
ssarily high amounts of B12. The RDA for this
vitamin is 1.0 mcg and in pregnancy and lactation, 1.5
mcg. Even conceding that a majority of the popu
lation cannot afford animal foods and hence many
may suffer from vitamin B12. deficiency, I see no
reason why any preparation should contain more
than _ mcg. and at the most 5 mcg vitamin B12.
This ciiteria is met by only 7 of the 16 oral prepa
rations listed. It the preparations are haematinics
combined with iron, they have to be prescribed three
times a day. In which case the preparation should not
contain more than 2 mcg B12 . Items 10-13, 15 and
16 must be very expensive and those who really
sulfer fiom B12 deficiency can ill-afford then. 1 also
wish you to note that mixed haemanitics-iron prepa
ration containing vitamins and minerals, arc condemcd
by authorities in the field of anaemia. “ Recovery
of the patient with uncomplicated iron-deficiency
anaemia is not helped by vitamin supplements or
minerals’7. In our experience vitamin Bj.j and folic
acid arc not needed till haemoglobin levels come upto
Il gms. % or more.
Let us now consider the vitamin A content of
these preparations. The prescribed dose of vitamin A
for corneal xerosis and Bitot’s spots is 1500-3000 /tig
(. 5000-10,000 I.U ). daily8,9.
The RDA during
lactation, the maximum suggested for any group, is
3500 l.U. Notice the vitamin A content of items 7
and 9.
Who needs 25,000 l.U. vitamin A daily?
Severe cases of deficiency like keratomalacia are not
to be treated with oral preparations9,10.
Those who
really develop xerosis can never afford a pharma
ceutical like 7 or 9, w'hose price is further raised due
to presence of other nutrients.
Imagine to what
extent the price can be reduced simply by bringing
down the vitamin A content, even to 5000 I.U.,
which itself is a high amount.
Then, there is the practice of adding glycerophosnhates to liquid, multivitamin preparations. I do
not know of what therapeutic value these compounds
are. They are not mentioned in any standard text
book of pharmacology and therapeutics. As far as
I know (see any pharmacopoea) they only form basic
ingredients of syrups, possibly for flavour. However,
a widespread misunderstanding is that they are
‘ energy givers ’ or ‘ tonics ’. Some brand names
carry a prefix or suffix of ‘phospho’ and the advertise
ment says ‘energy givers’, ‘ vitalizer ’ etc. This in my
opinion is a fraud perpetuated by the drug companies
and worse still, an unpardonable ignorance on the
part of the doctor. The vitamins atleast, despite the
excess and the wastage, do some good.
1 see no
nutritive or therapeutic value for the glyceiophosphates. Their presence is needed for syrup preparation
but its name should not be included in the brand
name and no claims should be made for its therape
utic efficacies.
One of the nutrients commonly added to multi
vitamin preparations is iron. Witness that out of the
16 listed items, only 4 do not contain iron. It is
well-known that ferrous compounds are better absor
bed than the ferric, and it is heartening to note that
most arc ferrous salts.
A prcplcxing form is the
colloidal iron oxide (items 10 and 14 ) which finds
no mention in any book on pharmacology or iron
metabolism. Since it is a colloidal preparation I doubt
if the iron in it is easilly available to the body.
Of the various ferrous salts, ferrous sulphate is
the least expensive and should be the treatment of
choice, yet only 3 preparations contain it. It is said
that contrary to popular thinking and claims,
gastrointestinal intolerance to iron preparations depends
on the total amount of elemental iron in the gut and
on psychological factors;
it is not a function of
the form in which iron is administered.1,7 Thus claims
made for compounds other than ferrous sulphate,
of increased tolerance or decreased toxicity, are not
genuine.
Also, sustained - release ( timed-release )
compounds ( no. 2 ) take the compound beyond the
duodenum and proximal jejunum and thus reduce
iron absorption. Therefore it is wasteful to prescribe
such preparations.
The RDA for iron ranges from 20-40 mg per day
depending on age, sex, physiological state etc. This
of course is for food iron and for free inorganic
salts would be less. The therapeutic dose, on the
other hand, is 60 mg elemental iron, thrice a day.
Ferrous sulphate, fumarate and gluconate contain 20%.
33% and 12% elemental iron respectively. Items
11-13 and 16 arc probably meant for iron deficiency
anaemia. Prescribed twice a day they supply 250-350
mg elemental iron which is higher than the thera
peutic dose.
Thus taken,
13 supplies 150 mcg
vitamin B12. On the other hand, no. 7 supplies only
8 mg elemental iron per capsule. One may argue
that this may be used as for prophylaxis and not
treatment. Have a second look and tell me the
situation where in an individual is grossly deficient
in every vitamin one can think of and is yet not
deficient in iron ? This is a pure commercial gimmick
to claim haematinic value for the preparation.
As
early as 1936 Strauss said “shot-gun therapy is to be
deplored for a number of reasons. Most mixtures of
substances fail to contain enough of any one ingredient
to give maximal effects. The patient must pay not
only for the material he needs but also for the nonessentials ” (cited from ref. 1).
One can go on endlessly in this manner.
My
intention in writing this is to bring to the notice of
MFC members the fact that all multivitamin and
haematinic preparations are not same.
Thcie is no uniformity in dosage employed.
There is no authority to lay down criteria for
There is no authority to check whether the
claimed doses are actually present.
4. Doctors prescribe these preparations with total
ignorance of or indifference to principles of
nutrition and- therapeutics.
5. High-potency preparations should be available
separately for single vitamins.
Multivitamins
need not contain amounts much higher than
RDA. They are economically wasteful.
6. The false claims made for improvement of
unspecified and unproven conditions are perpetua
ted due to the ignorance or compliance of the
doctors.
7. Most of the companies have foreign collaboration.
Most of the raw ingredients are to be imported.
Could this be one of the reasons for the high
dosages employed ?
I tm sure you will find asking yourself many
more such questions.
1.
2.
3.
References
1. The Pharmacological Basis of Therapeutics. (L. S. Goodman
and A. Gilman, eds.). Fourth cdn. MacMillan Co.,
London. 1970.
2. Nutrition Atlas of India ( C. Gop.tlan and K. V. Raghavan
cds.) National Institute of Nutrition, Hyderabad, 1971.
3. Energy and Protein Requirements. WHO Tech. Rep. scr.
No. 522. 1973; Requirements of vitamin A, Thiamine,
Riboflavinc and Niacin. WHO Tech. Rep. scr. No. 362,
1967, WHO Geneva.
4. Dietary Allowances for Indians ( C. Gopalan, B. S. N. Rao)
Indian Council of Med. Research, Spl. Rep. Ser. No. 60, 1968.
5. D. Davidson. R. Passmore, J. F. Brock and A. S. Truswell.
( 1975 ). Human Nutrition and Dietetics, Sixth edn. Churchill
Livingstone, Edinburg and London.
6. W. G. Bradley (1975 ). The treatment of polyneuropathy.
Practitioner 215: 452.
7. T. H. Bothwell and C. A. Finch (1962) Iron Metabolism.
Little, Brown Co., Boston.
8. S. G. Srikantia ( 1975 ) Human vitamin A deficiency. Wld.
Rev. Nutr. Diet. 20: 184.
9. Reddy, V. ( 1969) vitamin
deficiency in children. Indian
J. Med. Res. Suppl. to vol. 57. p. 54.
10. M. F. C. Bulletin 8, August, 1976.
Reprinted from :
Medico Friend Circle Bulletin, November, 1976
Published monthly from 21 Nirman Society, Vadodara-390 005
Annual yici'i't 1935 TB and Society
3a ok ground. .fap^r^I
XL®T,^.cJJI,2sZs
& J1GAS®
CONTROL PROGRA^®
p > ,j
U.N. JAJOO
( Ct
•
The .S^tuati-Gn
Prevalence of the disease
= 20/1000 population
(X-ray diagnosis)
= 4.1/1000 population
(bacteriologically . j
Proved)
= 2.5/1000 population direct smear+
= 1.6/1000 population smear,- ve
culture +
Incidence of the= 1.5/1000 population (1/5 of
disease
'prevalance of bacillary cases)
(Roughly 2C% of the prevalence or the
number who leave the 'pool1 every
year due to death and spontaneous
cure resulting in state of near
balance in prevalence over a span of
few years)
Natural course of the disease = 50%'die in 5 year
20% continue to excrete
bacilli after 5 years
50% get cured spontaneously
Tuberculosis infection and-disease is uniformly
distributed in urban and rural areas.
30% of the disease occurs in the.age group beyond
55 years
There is. a gradual but slow, natural decline of
tuberculosis in our country.
Socio economic uplift nas brought dc.-vn tuberculo
sis much more drastically oven before control
programmes were introduced.
Community with well functioning programme has
shown fall in the prevalence.
Under T.B. control Programme, age of T.B. has
shifted up, though incidence/prevalence has not
shown any change.
Case .OetectiorK-
The case detection efficiency of PIP is esti
mated to be 'about 50% of the expected.
Potential risk of acquiring infection from oases
confirmed on culture only is considerably lower
than from cases with tubercular bacilli dete
cted in the smear .1
Of those who present with symptoms, like
tuberculosis (cough more than 15 days duration)
above the age of 20 years (4.1%'of total popu
lation), 50% show lesion like tuberculosis on
.. .2
MMR out of 'which i/4th (6.2%)
direct smear examination.1
are confirmed as cases by
In the population above the age of 5 years (82% of total
population) 1.8% have x-ray shadow like tuberculosis and
0.4% (l/4th) show sputum AFB positivity.2
As much as 95% of the infections pool (bacteriologically
confirmed cases) are aware of symptoms and as good as 52% come
themselves to seek medical opinion, out of which 96% cases can
be found by meticulous sputum examination.3
Action taking for relief in the symptomatic group was 50%
however, nearly 70% of those found to have bacteriological
evidence of active disease by x-ray took action.4
To seer, relief,
symptomatic group go to
Private practitioners
58%
Public Health facilities
35%
Do not seek any treatment
5%
If preliminary treatment fails: -
59% go to private practitioners
10% to public health facility
30% can not afford and do not seek treatment.
Those who seek relief from the nearest health facility
were only 23%.
Among patients registered at DTC, only 2.7% have not received
treatment earlier ie., 1/3 patients come to DTC, 3/5 to private
practiti oners.5
Patients were not prepared to travel more than.. 5 kms
unless•symptoms are very pressing. 6
Repeat sputum examination increases yield of the cases
(10% of initial yield with each successive specimen). Among
symptomatic:; attending TB Centre (relatively advanced cases)
two specimens examined discovered 85% of all smear positives
who could be found on examination of as many as'8 specimens
from each individual.4, 8. . Peripheral health institutions
(with microscope alone) have the potential of diagnosing within
one year 60% of total direct smear +ve cases or 10% of entire
number of cases estimated to be prevalente.in the district at a
point of time that could be confirmed by any bacteriological
method,9
C. Active Case Finding
For sputum positive cases, the large majority of patients
could not be found even if services were provided close to
their villages (0.5 to 8 miles).
Number'of patients found
under such conditions was considerably short of the
estimated total prevalence. By none of the methods (community
development approach ie., active detection of symptomatics and
referral to microscopy centre/or mass campaign with x-ray •
available at few miles distance) was it possible to
diagnose even about 50% of the existing cases in the
community ie., number that was already reporting to
