• No results found

PUBLIC HEALTH, NURSING, MEDICAL SOCIAL WORK

N/A
N/A
Protected

Academic year: 2020

Share "PUBLIC HEALTH, NURSING, MEDICAL SOCIAL WORK"

Copied!
10
0
0

Loading.... (view fulltext now)

Full text

(1)

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 part

of 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

(2)

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 the

states

(

in towns and rural areas) treat children, who constitute about half of the

attendance, 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

(3)

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 qualified

midwives, 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.

(4)

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- to

18-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

(5)

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 the

British 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.

(6)

and Child Welfare and awards a diploma

(

DMCW). The course takes one academic

year 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 still

concentrating 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

(7)

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

(8)

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

(9)

1957;19;317

Pediatrics

Pinchas Robinson

INDIA IN 1955

PUBLIC HEALTH, NURSING, MEDICAL SOCIAL WORK: PEDIATRICS IN

Services

Updated Information &

http://pediatrics.aappublications.org/content/19/2/317

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(10)

1957;19;317

Pediatrics

Pinchas Robinson

INDIA IN 1955

PUBLIC HEALTH, NURSING, MEDICAL SOCIAL WORK: PEDIATRICS IN

http://pediatrics.aappublications.org/content/19/2/317

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

Related documents

At her 2-week postpartum visit, whole blood glucose values were again indicating progressive hyperglycemia, and insulin was restarted. Based on her ethnic back- ground, weight

namely C4.5, and Naïve Bayes Algorithm are used to analyze the training data set to build the prediction models.. and tested on the testing

From the figure-4 it is clear that 50% of the sampling station ratio of sodium and chloride are high and equal indicating that there is intrusion of salt water and

Pupils taught using concept mapping teaching strategy did not only draw good concept maps but also developed a deeper and meaningful understanding of genetics

Stimulation cum Creativity is a fundamental feature of human intelligence, and an.. inescapable challenge

schools of thought are of the opinion that increased government expenditure on healthcare promotes good health, reduce poverty and inequality, while the other

A range of solvents from non-polar to polar (n-hexane, ethyl acetate, methanol) were used to attained the extract by employing conventional and modern methods

Identifying the need to support mobile and non- traditional sources of learning and to host tracking information for each user’s learning curve, ADL