317
PUBLIC HEALTH, NURSING, MEDICAL
SOCIAL
WORK
Myron E. Wegman, M.D., Contributing Editor
\Vhen this column presented the paper by Dr. Lowe on “Observations on the Care of Children
111 Afghanistan,” there was considerable interest in the rather unusual conditions presented. The \vay chiltlren live and are cared for in other countries of the world interests pediatricians, both because of their catholic interest in child health and the possible lessons to be learned from such a study which can be applied in one’s own situation.
Dr. Robinson has been serving as Consultant in Maternal and Child Health in the Regional Office for South East Asia of the World Health Organization, one of the most populous regions
1ITI the world. India itself, as Dr. Robinson indicates in the cold figures of his opening paragraph, has a population larger than that of the 21 American republics, that is of North and South Anierica coml)med. It is clear that variations within the region must be great and that generaliza-tions flTllist be made with great care. Dr. Robinson’s sober analysis and provocative statements,
such as the existence of the problem of rickets in a country noted for its sunshine, make inter-esting reading. Tremendous progress in improvement of health services and health conditions is being macbe in Ifl(lia today. A comparison 10 years from now, with the conditions described in this article, will be illuminating.
PEDIATRICS
IN INDIA
IN
1955
By Pinchas Robinson, M.D.
M. E. W.
T
HE Union of India covers the major partof the subcontinent of India and the
islands of Andaman and Nicobar in the Bay of Bengal. The total area is 1,174,116 square
miles and the total population at the last
C(’DSUS
(
1951) numbered 356,691,000.The Union consists of 29 states with a
pp11latio11 ranging from a few hundred thousan(ls to over 60,000,000. Plans to re-organize the state structure of the Union
are being fiuialized at present.
The available vital statistics are officially stlt(’(I to l)e of relative validity. The main reason is that only in the states south of Bombay and Hyderabad, as well as in Uttar Pradesh, Bihar, East Punjab, and a
small part of Orissa, is registration of births
and deaths compulsory in both rural and urban areas, while in the rest of the country it is compulsory in urban areas only, or is voluntary altogether.
Estimates by various workers, and some
published and unpublished data from pilot
health centers, indicate the following
aver-age round numbers for the country as a
whole as being near the truth: Births, 40
per 1,000; maternal mortality, 14 per 1,000;
infant mortality, 200 per 1,000. The Office
of Population Research of Princeton
Uni-versity arrived at similar numbers through
detailed scrutiny of available official and
unofficial statistics. The Union Government
estimates the number of children in the country of the age group 5 to 14 at
90,000,000, which will make the total child
population nearly 130,0()0,000.
There is approximately one medical prac-titioner for every 6,000 of population. In addition to graduates of recognized medical
colleges (M.B., B.S.), the following
cate-gories may practice medicine in the coun-try: licentiates of medicine, e.g., graduates
of medical schools with a shortened
been abolished); “vaidyas” and “hakims,” practitioners of indigenous medicine; and
homeopaths.
OUTPATIENT SERVICES
In private practice children are treated
by general practitioners, practically without
exception. Very rarely is a pediatric con-sultant called in even to a complicated case, not only because the majority of the
popu-lation cannot afford it, but also for the reason that there are few consultants avail-able, with the exception of the chiefs of pediatric departments, who may devote
part of their time to private practice. Uttar Pradesh, with a population of 63,000,000,
is an extreme case-there appears to be only one pediatrician in the whole state.
Outside private practice, children are
treated in general outpatient clinics, and in barge hospitals in special children’s clinics.
Those clinics are usually very crowded, and
in the period of two to four hours, more than 200 children are seen by one doctor.
Some clinics have even a much larger
at-tendance, a record of 1,400 in a single day
having been achieved in Hyderabad. The
pressure of work in the wards and the extreme shortage of staff do not, under
pres-ent conditions, permit a more satisfactory service.
Dispensaries run by municipalities or voluntary agencies
(
in cities) and by thestates
(
in towns and rural areas) treat children, who constitute about half of theattendance, among other patients. A num-ber of maternal and child health centers also render some curative child care. The
doctors in charge of MCH centers are usually qualified physicians and
occasion-ally “graduates” in indigenous medicine.
Where the centers are run by voluntary
agencies, the doctors are usually also
volun-tary. X-ray, laboratory, or consultative hos-pital facilities are, as a rube, not available
to the practitioner or dispensary and MCH doctor, even in towns and cities; however,
the necessity is realized and efforts in this direction may be made.
INPATIENT SERVICES
The number of children’s beds in the country is unknown, mainly because, out-side medical college hospitals, only a few other hospitals in barge cities have separate
children’s wards. In most smaller hospitals, children are admitted to the general wards.
The total number of children’s beds in 30 of the 34 medical college hospitals, which have separate children’s wards, is a little
bess than 1,500. A part of these are surgical beds not under pediatric supervision. The
state of Bombay (population 37.5 million) has 20 children’s beds listed per million of
population; West Bengal (population 27.5 million), including the city of Calcutta
(6,000,000), 9 beds per million; and Uttar
Pradesh (63 million), 6 beds per million. Best off is the city of Hyderabad with over
200 children’s beds for a population of
1,000,000. The cities of Madras and Delhi come next. The small number of available beds permits the admission of very sick
children only.
The best staffed unit in India consists of
34 general beds and 22 isolation beds, and has one physician in charge, two paid
assist-ant physicians, three honorary assistant physicians, six housemen, and four post-graduate students. These doctors also take
care of 250 outpatients per day. The
num-ber of staff nurses in the general ward is three and they are assisted by seven pupil nurses. There are two nurses each in the isolation ward and the outpatient clinic.
This is, however, an exception. In another
city of 1,000,000 population, a 60-bed chil-dren’s unit and an outpatient department with a daily average attendance of 200 are run single-handed by one young pediatri-cian (with the assistance of a recent gradu-ate), who, in addition to his pediatric duties, is also responsible for an 80-bed medical
ward. The number of nurses is also usually
much smaller than in the first described
PUBLIC HEALTH
With the exception of some teaching
hospitals, records, beyond a temperature
chart with occasional remarks OD
admin-istered drugs, are rarely kept; this is mainly (lue to shortage of staff.
sIothers of infants and toddlers are
usu-ally permitted to stay in the wards and sonJetinles their presence is encouraged or
even demanded. This was originally because
of the shortage of nursing personnel, but there is some realization of the advisability a’id potentialities of this procedure, which
in the western world is theoretically ac-knowledged but so far hardly practiced.
However, in only two hospitals are the
mothers now utilized for such services as
washing, feeding, or bed making, and in
these hospitals an attempt is made to teach
them essentials of child care. One of these two hospitals has also made provision for a
rest and recreation room for the mothers, and a play room, where they can play with
the children. There are indications that this
practice may spread.
PREVENTIVE
AND
PROMOTIONAL
SERVICES
Although a few clinics run by voluntary
agencies are cabled child welfare clinics, most of the work in preventive and pro-motional child care for infants and toddlers
is done in combined maternal and child health centers. These “MCH” or “MCW”
centers vary in degree from a unit, which
is merely a better name for a station staffed l)y an untrained midwife (dai) to a full
fledged center which compares favorably
with some in western countries.
The pediatric routine consists of
weigh-ing and measuring, advice on nutrition, and
of mothers’ classes. Milk is usually distrib-uted and sometimes other foods are given. In some centers there is a limited degree of
curative care; some refuse to deal with sick
children altogether; and some are actually
dispensaries which do not concern
them-selves with well-baby care at all.
Vitamin D prophylaxis is not carried out as a routine; the vitamin is given only to a
selected group of weak infants. Vitamin D
is also given sometimes to babies and toddlers who show signs of frank rickets. In many parts of the country ultraviolet radiation is popular. Reluctance to expose children to the abundant sunshine present
is associated with local customs and beliefs, as well as the fact that in some areas the
temperature is 118#{176}in the shade. Further work needs to be done on how exposure
can be carried out safely to derive the needed protection.
Immunization procedures are seldom an integral part of the activities of the centers. Smallpox vaccination is done by special
“vaccinators” who make tours of groups of villages for this purpose. Other preventive
inoculations are not yet systematically
ap-plied on a nationwide scale.
The staffing of the various centers varies not only from state to state, hut from cen-ter to center. While in the more advanced
states some are supervised by full- or
part-time medical officers and others by health
visitors
(
public health nurses) and qualifiedmidwives, many centers in other states are in charge of second-class midwives or dais.
Q
tiantitatively, the amount of service given is limited; with few exceptions, only the surface is touched so far.Most centers in the cities are run by voluntary societies and some by the munici-palities. The present trend is for the state
government to take over the administration of the centers. For this purpose 12 states have appointed Assistant Directors for
MCH at their Health Directorates, and a few additional states have sanctioned, but have not yet filled, such posts.
Centers in towns and rural areas,
wher-ever they exist, are almost without excep-tion run by the state. However, most of these are maternity centers rather than
maternal and child health centers.
Practically nowhere, so far, is there a referral system from MCH centers to
out-patient clinics or hospitals.
mid-die and upper classes do not as a rube seek
advice in well-baby and well-child care,
and as a result of this private practitioners do not concern themselves with supervision
of healthy children.
Wherever available, lady health visitors
(
LHV) are in actual charge of the centers. A lady health visitor is a qualified midwife who, in addition, has received a 12- to18-month course in public health aspects of maternal and child care. As a result of her
original training, she is usually biased in the direction of maternity services. There is an acute shortage of lady health visitors.
Outside large cities and some pilot centers,
they are not available, and child care is
left to trained or semi-trained midwives.
Services for the pre-school age do not exist, but there are a few scattered school health services, usually separate from the
MCH centers or any other organized health activities.
In some schools teachers are expected to do a certain amount of health supervision, and also sometimes administer simple drugs. The students have a diary where they enter
particulars of daily routine, such as wash-ing, using the toilet, etc. This is, however, not common.
Part-time doctors, where available,
ex-amine the students and note the detected defects. So far few facilities for correction
of those defects are available. Parents are
usually advised of the findings on a printed form.
Regular school meals are not given, but in
a few schools the “needy,” approximately
20% of the total, are given a snack, usually a glass of milk.
With the acute shortage of pediatric per-sonnel and the fact that some of the
medi-cal college hospitals have as many as 10,000 deliveries a year, it is understandable that the chief role of the pediatrician, in
rela-tion to the newborn, is as a consultant.
PSYCHOLOGICAL ASPECTS
Breast feeding seldom produces any prob-lems of the pattern usual in the West. On
the other hand, the practice of prolonging breast feeding up to the age of 2 or 3 would appear to be of psychological importance. There is, however, practically no
competi-tion between two children of different ages at the breast since the older child is weaned
as soon as the mother becomes pregnant
again.
Separation of the child from the mother
is not usual. Except for factory workers, the
working mother usually takes the infant and
toddler along with her wherever she goes, not infrequently even when she is hospi-talized. For the children of mothers work-ing in industry, mines, or plantations, the law prescribes the set-up of creches, but in
practice this is done, so far, on a very small scale. Joint family living is still frequently practiced and ensures that, even when left
behind, the child remains in the usual en-vironment. It may be assunied that the
fed-ing of insecurity when the mother is away
is often avoided. On the other hand, the
oldest female members of the joint family frequently exercises great authority and
may interfere to a degree with the normal
mother-child relationship.
In some families of higher income brackets the child is sometimes left to the
“ayah” and this, if European psychology is
applicable in India, may be expected to result in competition for the child’s affection
between the ayah and the mother. In some of the better class families, there is an ayah
who brought up the mother or the father of the child and her prestige is, as a result,
considerable.
Separation through hospitalization of the child does not usually occur due to the nearly universal practice of having the
mother stay with the child in children’s wards.
There are no figures available on mother-less children, but, due to the high maternal
and general female mortality rates, the number must be high.
It is not an uncommon practice for widowed men, especially of the poorer
a fair number of stepchildren in the country. Divorce is not regarded as a solution of
I1i1ha))y marriages.
There are scarcely any child psychologists
lfl India, and the few pediatricians are much
too l)tlsy to concern themselves with the
psychological aspects of childhood. There are a number of child guidance clinics in
SOIflC of the larger cities, and, as far as
Coul(l l)e ascertained, meet such problems as the preference of parents for boys and for children with lighter skins, particularly girls.
The problem of unwanted children is
now receiving SOfl1 attention. In fact, the
leaders of the nation consider that too many children are 1)orn in India; this is supported
by IBIICI1 enthusiasm for “family planning.”
FAMILY
PLANNING
The rationale for the concentrated effort on family planning may be summarized in
a few words. The population living within
the present boundaries of the Indian Union
has increased from 235.5 million in 1901 to 351 million in 1951, 52.2% in 50 years.
Con-sidering the increase in number of women
of childbearing age as life expectancy goes
up, and the expected decrease in infant and child mortality, the number of children will
go up even more in the future. The opinion is that as there is little hope for food pro-duction to increase sufficiently in the near
future to meet the needs, the population
problem must be faced.
Various voluntary societies have estab-bished family planning centers, but lately the Union Government has appointed a
Family Planning Research and Program
Committee with wide terms of reference. So
far four meetings have been held, under the chairmanship of the Director-General
of Health Services. At the meeting April 14
to 16, 1955, it was decided to appoint a
Medical Officer for Family Planning whose
task, among others, will be to integrate
family planning in maternal and child health centers. A $12 million drive is being launched in 1956. This includes the opening
of 558 urban centers, a central family
planning training clinic, and a special cen-tral research institute.
UNDERGRADUATE AND POSTGRADUATE
TEACHING IN PEDIATRICS
Pediatrics is taught in 32 of the 34 ex-isting medical colleges; two are recently established and are not yet fully operating.
Three pediatric teachers have the title of professor, and another, though still a lee-turer, is in full charge of his department. In
the other 28 colleges, pediatrics constitutes
for all practical purposes a sub-division of the medical department. In ten colleges, the professor of medicine provides all the teach-ing in pediatrics himself. In the other 18, he is supported by an assistant with
post-graduate pediatric training or an honorary
physician, usually a private practitioner
with training or experience in pediatrics.
The subject is normally taught in the final
year, mostly at the bedside, for a period of
four to eight weeks; in only two colleges is the period three months. From 6 to 24 theoretical lectures are given, in addition,
in 14 colleges. Teaching in outpatient clinics and well-baby centers is practiced to a very
limited degree in one or two colleges. Five teaching hospitals train a small
num-ber of postgraduate students, usually three or four at a time, for an examination for a
diploma in child health
(
DCH) on theBritish pattern. The course takes one aca-demic year. In addition, one of these hospi-tabs also provides facilities for two years training for the degree of M.D. in pedi-atrics.
The great majority of physicians who practice or teach pediatrics have had their
postgraduate training abroad, mainly in Britain for a DCH or MRCP (Member of
the Royal College of Physicians). A few have been to the U.S.A. and have earned the title of Licentiate of the American Board
of Pediatrics. One or two were trained on the European continent.
and Child Welfare and awards a diploma
(
DMCW). The course takes one academicyear and is intended mainly for future State
or Municipal Maternal and Child Health
Officers. This is the only postgraduate course in which the preventive and promo-tional aspects of child care receive
atten-tion.
PROFESSIONAL SOCIETIES
There are two pediatric associations in
India, not geographically divided, and in both membership is not restricted to pedia-tricians. Each holds an annual meeting devoted solely to scientific problems.
The reasons for the unorthodox structure
of these societies are as follows
(
indian Journal of Paediatrics, 1955):1. In the domain of pediatrics, it is diffi-cult to define a specialist, because this disci-pline is not confined to the narrow limits of an anatomical organ. Therefore pediatric socie-ties should offer a forum to all medical men.
2. The purpose of a specialized professional society is to provide facilities for meetings, ex-change of views, and learning, and not to create trade unions for safe-guarding of
pro-fessional interests.
3. “Competition is better than regimenta-tion” and “Unity must be sought in diversity”
-therefore, it is not advisable to have one All-India Pediatric Association.
AYURVEDIC PEDIATRICS
Ayurveda, “the science of life,” originates
from the Atharva Veda, one of the four Vedas, which are a collection of early In-dian knowledge and thought. The Atharva Veda was, in Indian belief, handed down
by Brahma through his son Atharva. Ayur-veda developed through a period of some
1,000 years, beginning about the Seventh Century B.C., to a medical science, largely
religious in nature, and is concerned more with promotion of health than cure of dis-ease. Although more and more herbs were
added to the ayurvedic pharmacopoeia, there appeared to have been in the early
days a strong skepticism concerning
treat-of keeping healthy-in mind, spirit, and body.
The present Ayurveda practitioners
(
Vaidyas) seem, however, to dispense herbs mainly, although the teaching in the 55 colleges throughout the country is stillconcentrating on the study of the ancient texts. In most colleges pediatrics is taught
as a special subject.
There was an early specialization in
Ayurveda, and the the original text of ma-ternal and child health, the Kasyapa Sam-hita, was compiled long before the
Chris-tian era.
The Sanskrit text has recently been
trans-bated into Hindu. It is divided into 8 sections and 120 chapters. The following are the main subjects of the book: Mother’s
milk; dentition; differential diagnosis of pain in infants and children; constitutional types, embryology, normal growth and
development; medication of drugs in
chil-dren, and a number of descriptions of cer-tam diseases in infancy and childhood.
TRENDS AND FUTURE OUTLOOK
In discussing present trends and future
outlook, a certain degree of criticism-constructive, not derogatory-appears in-dicated.
Awareness of the necessity to strengthen
pediatrics is growing. Various medical col-beges have approached outside agencies with requests for assistance in developing
their pediatric departments. The Central Government is planning an All-India Child Health Institute in the capital. One of the leading pediatricians is setting up, with private means, an Institute for Child Health in Calcutta. The medical college in Madras is planning to develop the pediatric section
into a pediatric postgraduate center. Although all three projects have more
ad-PUBLIC HEALTH
purpose, one is to be established in the north, one in the center, and one in the south of the country. Ample provision has been made for and much thought given to the buildings for these centers, less to equipment, and even less to personnel. And yet the crucial problem is the personnel.
Of the pediatricians known at present, there
are, in addition to the three professors, another three pediatricians who could
im-mediately qualify for professorship, and
some of the younger people could no doubt be encouraged and assisted to assume teach-ing responsibilities in the future. Qualified assistants and tutors are practically not available at all for expansion of services since most of the pediatricians with post-graduate training are either fully occupied elsewhere or unwilling to leave their pri-vate practice. The major aim of the future
institutes is, no doubt, to train such assist-ants, but important questions still remain:
Who is going to train them? How can one overcome the handicap of inadequate un-dergratuate teaching in pediatrics?
It would seem that in the first instance concentration on improvement of
under-graduate teaching in pediatrics is indicated. Postgraduate training can then be de-veboped organically wherever possible and
practical under the circumstances. This
indeed appears to be the thinking in the
Madras project.
The recently introduced term, “Child Health,” implies a realization of present shortcomings-concentration on clinical pediatrics. Integration of promotional and
preventive aspects is certainly called for, but thinking in regard to this problem has not yet been carried to its logical conclu-sions. Teaching in nonclinical aspects of pediatrics cannot be introduced just by a decision. Existing field services are not available for teaching purposes, being
con-trolbed by the civil authorities not
neces-sarily linked with medical colleges, and the
quality of the services is not sufficiently developed for teaching purposes.
Obvi-ously, upgrading of the child health aspects
of maternal and child health work is
es-sential, preparatory to using the centers for
teaching. In order to bring this about. it will be desirable for the pediatric
depart-ments of the large hospitals to assume responsibility for the child care aspects of
the urban and rural centers on a service or
consultative basis. The already mentioned Madras project is taking into consideration
these reflexions. It is envisaged to
decen-tralize outpatient services and to use the
MCH centers to provide both preventive
and curative care. The hospital in- and
outpatient clinics will serve in a consultant capacity for these peripheral units, which
will be supervised by the pediatric teaching staff and their assistants. A two-way
re-ferral system will be introduced. Teaching will take place both in the service and
con-sultative units.
It is not for teaching purposes alone,
in-deed not even primarily, that the
develop-ment of the child health aspects in the MCH centers of the large cities is called
for. As already mentioned above, the pres-ent practice pays little attention to the supervision of children in these centers. It is
practically impossible to introduce
im-provements on a nation-wide scale before
a solid basis is laid in a few places, an effec-tive routine is introduced, and sufficient
adequately trained supervisory personnel is available.
Another trend is the setting up of rural health services in villages where such did not exist hitherto. The “rural health unit”
is the slogan of the hour. Such “primary
units” are planned usually for a population
of 15,000 to 60,000 and will concern
them-selves in the first phase with environmental
sanitation and maternal and child care. Not
many such units actually function at pres-ent outside the State of Mysore, but even there the weak link is, as is openly ad-mitted, the establishment and supervision
of the child health services. In Mysore, a
number of primary units is supervised by a secondary unit with more elaborate
rea-sons mainly, the establishment of secondary units is not envisaged in the Government’s
second five-year plan, beginning in 1956.
Malnutrition and infectious disease are
well known to be the two main problems in child health. Protein malnutrition and Vitamin A and iron deficiencies received
considerable attention. A number of re-search workers are concerning themselves
with the search for a solution to these problems, but a co-ordinated effort is still
awaited. An example: With a quarter of a billion cows in the country, milk is both
scarce and expensive.
Some spectacular advances have been made in the eradication of malaria, and
more attention is being paid lately to tuber-culosis and syphilis. All efforts in this
direc-tion are still mainly confined to mass cam-paigns, but the realization of the necessity and possibility of better use of admittedly
limited resources for individual care is growing.
Development of balanced child health services may, it is felt, point the way to a