Wednesday, June 23, 1999

Diabetes-care in the elderly
By Dr R.J. Dash
ALMOST one in every two men and women, aged 65 years and above, has diabetes. With an increase in the elderly population and a decrease in the joint family structure, the problems related to diabetes-care in the elderly need careful handling.

Wrong decisions
By Dr Ivan Hattingh
Since the early 1960s the use of underground water by drilling wells for irrigation has been greatly increased. And when used in dry lands at village-level, the results can frequently be very beneficial. But ingenious man does not seem to be able to get too much of a good thing.

Policies, innovations and population
By Anita Anand

THE panchayat is the only constitutionally mandated body of local self-governance," says Dr Swapna Mukhopadhyaya, of the ISST (Indian Social Studies Trust), New Delhi, speaking of local structures of governance.

From the United Nations headquarters to national, regional and international organisations, there is an active debate and dialogue about the role of civil society in governance. Traditionally, policy has been seen as the task of governments. But with advances in development, technology, and information about rights, individuals and communities are participating in governance — be its policy-making or carrying it out.

The field of reproductive health is part of this change.

"NGOs can play the role of catalysts. Panchayats need to be made more accountable. Any large-scale initiative has to involve the panchayats, for whom health is at present not a priority," says Mukhopadhyaya.

If health is not a priority for panchayats, is it for State Assemblies or Parliament?

India developed and adopted a family planning programme in the 1950s, long before many countries even thought about it. Over the years, there has been criticism of the government's "target" approach, in which health workers were given targets — or numbers who have accepted family planning — and judged by these. Targets also meant sterilisation.

Since the 1980s, NGOs and community groups have devised small-scale approaches and practices alternative to the government's target centred one. In the absence of public health centres and facilities, women's organisations, activist health groups, and medical professionals have shown that the reproductive system is more than just about stopping or encouraging births. It involves the socialisation of women and men, the status of women in society, the issue of rights etc.

Besides India, many other developed and developing nations have felt the need to re-define reproductive health. The culmination of this came at the ICPD(International Conference on Population and Development) in 1994, where the historic term "reproductive health" was given its widest ever and far-reaching definition.

Altogether 184 nations, including India, committed themselves to rethinking their policies on reproductive health.

At the national level, in a far-reaching move, the Ministry of Health and Family Welfare, in March, 1996, announced a "Target Free Approach"(TFA) followed by the "Community Needs Assessment Approach"(CNAA). This has meant a more "client-centered" approach with emphasis on the "quality of care".

This policy shift has given a boost to individuals and organisations working at the community level. Some of these are supported by the India programme of the US based John T and Catherine D MacArthur Foundation's "innovative" reproductive health work in India.

The ISST's project is one such. In the villages of the hilly north-western state of Himachal Pradesh, the ISST team helped women collect date on sanitation, drinking water and health, through Mahila Mandals (women's committees).

The women were barely literate, and Government health sub-centres were located according to population size. In the mountains where hamlets are scattered, this did not make sense. Modifications according to local conditions can be channelled through panchayats, the ISST found. After all, it was the base level and accountable tier of governance.

Another project preceded the ICPD, influenced and in turn benefited from the Government's policy shift.

In Dindori village in Nasik district of Maharashtra, in 1978, Shyam Ashtekar and wife Ratna, both medical practitioners, started private practice for people from small towns, distant villages and hamlets. Maharashtra has 42,000 revenue villages of which only 12,000 have either a PHC or a sub-centre.

"In this void, irrational, exploitative services were fast developing uncontrolled in the villages," says Ashtekar.

To beat this, the Ashtekars set up the Bharat Vaidyak Samstha (BVS) to train health workers and a low-cost yet tastefully constructed hospital at Dindori. The health workers were motivated to start practice in villages on a paid-for basis.

Has the Government's new RCH(reproductive and child health) policy affected Ashtekar's work?

"To start a good dialogue on reproductive health we need a service in place. How can we even think of starting a new programme on the shoulders of auxiliary nurse midwives (ANMs), who do not reach out even to 30,000 villages?", he asks.

The Ashtekars, medical practitioners and health activists, have presented their model of community-based primary health care in the villages, to the government of Maharashtra. Villages without resident health facilities were selected, and trained health workers from the communities were presented. The Maharashtra Health Ministry has, in principle, accepted the model.

"This will have implications on (the IRCH) policy," says Ashtekar.

While there is some reservation about the importance of an RCH policy, there are other voices in public health policy that feel otherwise.

"When India became independent, the health-care policy was based on prevention of diseases and promotion of health. Sometime along the way, it got lost and the emphasis came more and more on curative medicines," says Dr Mohandas, Director of the Sree Chitra Tirunal Institute for Medical Sciences and Technology in Trivandrum, whose innovation was a two-year course in public health policy.

The focus of the course is on public health management, epidemiology, biostatistics, health economics, health policy and health technological assessment.

"Reproductive health is a major aspect of public health. In 50 per cent of the population, one of the commonest problems is reproductive diseases," says Dr Tangappan, a faculty member of the Institute, pointing out that there is hardly any database on reproductive health problems, for example the extent of reproductive tract infections (RTIs) in India. Actual figures are essential for a realistic policy.

Changing social conditions also need policy responses.

For example Kerala's demographic structure has been undergoing a gradual change, requiring a shift in policy. More than 10 per cent of the population is over 60, and the life expectancy for women is 72 years and for men, 64.

The village-level ANMs could monitor blood pressure or sugar levels. But, at present they cater only to women in the reproductive age group, mainly pregnancy care or contraception.

"The health needs of elderly women need a more sensitive policy conceptualisation, based on the realities at the ground level," points out Dr Tangappan.

Another kind of ground reality is presented by Jashodhara Dasgupta of the NGO Sahayog in the Almora district of Uttar Pradesh.

"The TFA has been interpreted to mean no accountability and no work targets. But new performance indicators have to be evolved," she says. NGOs complain that the government sees them as service providers in areas where their machinery has failed. But, not in policy development.

"We wished to interact with government health functionaries and help orient them to the new approach to reproductive health. While the Chief Medical Officer was willing, Medical Officers at the PHC level were reluctant and even resentful of our intervention," says Dasgupta.

Health Watch, a network of voluntary organisations, researchers and development activists, was asked by the Government to generate a nation-wide debate on the new approach to health and family planning.

It recommended a gender sensitive multi-department and NGO convergence; community participation, with special emphasis on reaching out to women, seasonal migrants and tribal populations; recruiting ANMs from local communities, providing necessary facilities, and strengthening basic primary health services.

"In the absence of health services, we are forced to fill in the gaps. We have no option but to provide iron and folic acid tablets, or identify high-risk pregnancies, since we can't stand by and watch anaemic women deliver babies," says Dasgupta.

And, NGOs feel, this prevents them from being more innovative or actually stepping in to make policies such as reproductive health more achievable.

But making health services available to a population of almost a billion is no small task. Weak infrastructures, lack of services, health personnel, and cooperation among different levels of the civil society, require a policy. However, lack of policy has never stopped people and communities from innovating. The task lies in making catalytic programmes more widespread and accountable.

In the last few years a far-reaching policy, research, training, local governance, and consciousness raising at the community level has shown that it is possible to begin to meet the reproductive health needs of women, men and children. And, both innovation and policy are needed, side by side — WFS

Diabetes-care in the elderly
By Dr R.J. Dash

ALMOST one in every two men and women, aged 65 years and above, has diabetes. With an increase in the elderly population and a decrease in the joint family structure, the problems related to diabetes-care in the elderly need careful handling.

The elderly patients with diabetes belong to two categories: one, who carry their diabetes together with one or the other complication of diabetes to this age and two, in whom diabetes is diagnosed for the first time at an advanced age. The first category of patients is much larger than the second.

The importance of diabetes control in the elderly is underestimated for the consideration that they have a shorter life span and that diabetes in them is "mild". These are false beliefs as life expectancy is steadily increasing to 80 or 90 years in many developed and some developing countries. The complications of diabetes in the elderly develop faster.

A well-conducted recent study at Kumamoto University in Japan has shown a significant lowering of the incidence of diabetic eye disease, kidney disease and heart ailments with good control of diabetes. Further, good (diabetes) control is a deterrent to hyperosmolar coma in the elderly that carries a high mortality rate. Efforts, therefore, should be made for the control of diabetes in the elderly to improve their life-style and prevent blindness, kidney failure and acute heart attacks.

The general principles of diabetes care in the elderly are similar to those in younger individuals. These include: the maintenance of the ideal body-weight, the control of fasting-blood glucose, the prevention of high post-meal blood glucose, improved physical activity to optimise the insulin effect, the control of the associated hypertension and refraining from smoking.

Dietary management is the most difficult aspect of the process. A decline in taste perception and the loss of appetite contribute to the lower consumption of food. Left to care for themselves, elderly people often tend to become malnourished.

The gain in weight is as important for them as the loss of weight is for the obese diabetics. Some experience better appetite with an aerated cold beverage (Diet Coke/Pepsi) or bitter gourd juice before meals. Their diet should not only be palatable and sufficient in calorie; it should also be appropriate to any change in kidney function and the abnormal lipid profile.

The diet should comprise slowly absorbable carbohydrates from coarse grains (wheat and rice), proteins from pulses (rajmah, Bengal gram and channa dal) fat from mixed mustard and soya/sunflower/

groundnut oils and fresh vegetables and fruits in convenient preparations.

Small and frequent meals (three meals and two snacks) are preferred to large meals at lunch and dinner. A high-fibre diet may cause constipation, particularly as elderly people often drink less water. As dairy products — milk, curd or processed cheese — are rich in salt, they need to be given in smaller quantities at regular meal time. Proteins from animal sources should be restricted. The supplementation of the diet with iron, vitamins and calcium salts is essential.

Their exercise programme should be individualised considering their physical limitations. Keeping in view the fact that any physical activity is an improvement over a sedentary habit, a simple walk for 10-15 minutes twice a day would provide substantial physical well-being and improvement in diabetes control.

Treatment with long-acting sulphonylurea (SU) like glibenclamide (Daonil/Euglucon) or lente/protamine zinc insulin should be avoided as they carry a higher risk of hypoglycaemia. Patients wtih long-standing diabetes recognise hypoglycaemia poorly. Short-acting SUlike tolbutamide (Rastinon), glipizide (Glynase) and the new lesser insulin-stimulating SU, glimepiride (Amaryl) are safe for diabetes control in the elderly.

Metformin (Gluformin) should be used with caution, particularly in those with failing renal function.

Acarbose (glucoay) is safe and effective in monotherapy or in combination therapy. Insulin analogue (Insulin Lys-pro, Humalog) should be preferred to a soluble human/animal insulin preparation for the control of high blood glucose after meals.

The control of hypertension and the use of lipid-lowering drugs are important considerations. They are therapeutically beneficial. They are also credited with the reduction of the over-all death rate in elderly patients with diabetes.

The author is Professor and Head of the Department of Endocrinology at the PGI, Chandigarh

Wrong decisions
By Dr Ivan Hattingh

Since the early 1960s the use of underground water by drilling wells for irrigation has been greatly increased. And when used in dry lands at village-level, the results can frequently be very beneficial. But ingenious man does not seem to be able to get too much of a good thing.

In many of the more arid parts of the world, when one flies over in an aircraft, one is aware of vast green circles where rotating irrigation systems use ground water to produce crops in areas where previously no crop grew. Now, in this way , you can produce crops, for example, Saudi Arabia produces wheat, which is the most expensive wheat in the world, 30 times the price of any other wheat, but heavily subsidised.

I don't even begin to understand what the logic of that type of operation is. This too is being done at considerable yet largely unrecognised cost. The American Department of Agriculture estimated in 1986 that a quarter of all irrigated land was causing the underground water-table to drop from 10 cm to 1 m per year.

In the short term, this kind of exploitation unfortunately provides very rewarding crops, but in the long term, it's clear that only what is replenished can be used each year - a very, very old law of the nature that is. The same fall in the water -tables is matched in Africa, and is certainly matched in India and China. Ground water is being used at a rate that cannot be sustained by replenishment and at the same time the demands from rapidly growing cities with water-consuming industries ensure that the surface water is in short supply around the world.

(To be concluded)