Health-care for all now

THE right to health and medical service, without distinction of race, religion, political belief, economic and social conditions, constitute the vital articles of the Universal Declaration on Human Rights, adopted by the General Assembly of the United Nations (UN) and the preamble to the Constitution of the World Health Organisation (WHO).

In 1948, the WHO defined health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. To this three-dimensional state of positive health, India has added the fourth dimension of our traditional spiritual well-being to make it a comprehensive concept of health.

In 1978, as many as 178 members of the international community (including India) had a utopian dream at Alma Ata to provide "Health for All by 2000 AD".

As we will soon step into the new millennium (next year), we may ponder over for a while, how near or how far we are from our cherished goal of "Health for All by 2000 AD". What are the challenges and problems obstructing the fulfilment of our dream? What should we do to make up for the lost strides in the race for health for all and to stand abreast with the developed countries?

Let's have a glimpse of our national health through the wide open windows of some of the available health indices.

Our mortality rate of 14/1000, though about half as much since Independence, is still one and a half times higher than that in any developed country. Our life expectancy of about 60 years has yet to catch up to 70/75 of the developed world. Our infant mortality rate of 105/1000 live births (10/1000 in Japan), the mortality ratio of 410/100,000 live births, though much better than what it was five decades ago, is still about three times, compared to most developed countries.

Our morbidity profile is gloomier than our mortality state. Surveys indicate that almost one person in every seven of our population is sick at any time, particularly in rural areas. They used to be sturdier than the city-dwellers 50 years ago. About 60 per cent of our hospital admissions are due to preventable viral, bacterial and parasitic infections. About 90 per cent of our rural and slum population defecates in the open. Where are the "sulabh shauchalyas"?

Preventable gastroenteritis infections, diarrhoeas, dysenteries, enteric fevers and helminthic infestations are endemic in the neglected rural areas and ever-mushrooming slums. The national tuberculosis, malaria, kala-azar, leprosy and blindness control programmes be blessed. There are 15 million cases of TB, three million annual occurrences of malaria and kala-azar, four million leprosy patients and 10 million blind people in India. There are 30 million cases of diabetes and 10 million cases of hypertension and allied cardiac ailments. In spite of the National AIDS Awareness and Control Programme, there are 3.5 million HIV positive cases which are likely to increase to 10 million by 2010.

Our nutritional profile is pathetic. More than 50 per cent of our population is below the poverty line. The physical output of our work force, about one third of our population is smaller compared to those of the developed countries, due to protein-calorie malnutrition, which is the most important cause of much of our morbidity.

More than 85 per cent of our children suffer from protein-calorie malnutrition and avitaminosis, especially vitamin A deficiency, causing night blindness and even total blindness.

More than 50 per cent women in the reproductive age group, especially in rural areas and slums, suffer from nutritional anaemias. Goitre, due to the deficiency of iodine in dietary items and lack of iodised salt, is an ugly sight amongst women, especially all along the Himalayan foothills.

While people die of over-eating in developed countries, in India, alas many of us, in all age groups, particularly children, are dying of under-eating.

Our drugs and pharmaceutical profile raises certain pertinent questions. Are the consumers getting newer, essential and life-saving drugs easily and at a reasonable price? The answer is a harsh NO. Is our indigenous pharmaceutical industry and technology self-sufficient? The answer is again NO. Are we playing into the hands of multinational pharmaceutical corporations? The answer is a shameful YES.

With state-auctioned liquor vends in cities, towns, rural areas and even on national highways, the international drug mafias and smugglers, there is an annually increasing number of alcoholics and drug addicts, gradually shattering the health of the young and the old alike. The menace has infiltrated even into our institutions of higher learning.

In spite of the Hathi Committee Report and the National Drug Policy (1978), there is a plethora of over 20,000 formulations flooding the market. We need hardly 200-300 drugs to be included in the ideal National Pharmacopoeia. There is cut-throat competition among more than 6,000 pharmaceutical manufacturers of all categories. And yet the prices are galloping every year beyond the pocket-scope of the common man. Even the essential and life-saving drugs are not spared. The policy and control of drugs and pharmaceutical management are primarily the Central Government's responsibility.

Demographically, with an unmanageable human resource of one billion, we are on top of the world, at least in this field, if not elsewhere. China has already achieved a zero growth rate while, demographically, we are adding one Australia to ourselves every year.

(To be concluded)

Dr (Brig) Kataria is a socio-medical specialist who has revolutionised health-care in forgotten slums of North India.

A man-centric issue
By Ritu Bhatia

“WOMEN'S reproductive rights cannot be realised unless we bring men back into the discussion," said Juliana Oyegun, Professor at the University of the Western Cape at South Africa, speaking at a Swedish-African regional seminar on "Sexuality, Fatherhood and Male Identity in a Changing Society", at the recent Hague Forum to review the Cairo agenda on population and health.

In fact most of the participants at the seminar agreed that it is necessary to focus on the role of men. "If we don't shift the focus to men we are in danger of perpetuating the idea that women can put things right, that the whole story/solution lies with women," emphasised Oyegun.

Compared with the issue of women's rights and its dense networks of organisations at many levels, men are given little or no attention in international dialogue. There are few popular men's movements to work for change, and those there are rarely invited to --- or participated in -- such dialogues. No government departments have been created for men, and men do not figure in international relations.

Men have managed so far to keep themselves apart from the target population for behaviour change.

But men's needs, understanding and constraints must be understand to understood the issue of gender. Interestingly, even when the focus is on men, it is only on their role as supporters for women. "The ultimate goal is to accomplish a power equity and empower women to attain economic and emotional autonomy," says Oyegun.

The Cairo Declaration states that men need to be more responsible and participate more. Men's roles in reproductive decision-making vary greatly, depending on social and cultural factors, and the individual couple's relationship.

Research done in Namibia shows that men feel strongly about making all-important decisions, including those about family planning.

Throughout the world the importance of involving men as partners and clients in reproductive health services has been gaining attention.

In October, 1998, an international conference called "Men's participation in Sexual and Reproductive health: New Paradigms" was held in Mexico. The conference was organised around three topics: male sexuality, fatherhood and violence.

Today family planners say that these issues are connected. But getting men involved in reproductive health issues has not been easy, according to Judith Frye Helzner, Director of Sexual and Reproductive Health at the International Planned Parenthood Federation, who helped plan this conference. This is because in many parts of Latin America the role of men is traditional.

Italian men too find it difficult to be partners. "It's been easier to change legislation than the Italian male," says Daniela Colombo, President of the Italian Association for Women in Development (AIDOS). Italian women continue to be primarily responsible for household work and children, even if they work outside the house. Younger women are reacting to their unsupportive husbands by having fewer children: Italy now has one of the lowest fertility rates in the world.

Men are becoming more supportive in family planning in other parts of the world. Dorothy Aken Ova of WHON (Women's Health Organisation of Nigeria) says: "Women in the Middle Belt of the country are doing much better because men have been convinced of the benefits of family planning." This was achieved through a process of educating the community. Even older children were made aware of the problems of having too many siblings.

The men are now under considerable pressure from the entire family, to participate in reproductive health decisions. Condoms are now a popular commodity, and the incidence of HIV/AIDS has dropped considerably.

The urgency for dealing with the issue of male responsibility has sharpened with the worsening of the HIV/AIDS epidemic. Gender issues are being incorporated in the national AIDS programmes of many countries. SWAA (Society for Women against AIDS in Africa) had a meeting on "Men are our Partners, signifying the recognition that men must be involved in any discussion on women's health and HIV/AIDS. Interestingly, in South Africa where the female condom is a popular contraceptive, men are actively involved in its promotion as a decision made by a couple rather than a woman alone.

"The idea isn't to replace the male condom with the female one, but rather, to add another option," says Dr Awa Marie Coll-Seck, Director, Department of Policy, Strategy and Research at the UNAIDS.

The highest levels of participation of men in reproductive health decisions come from the younger generation. This is largely because young women are less reticent about discussing contraception than their mothers were. As Denise Barnes of the Family Planning Association of the Bahamas says, "The ability to pre-negotiate before entering a relationship has given younger women the ability to stay healthy."

"Before the ICPD (the 1994 International Conference on Population and Development at Cairo) women were too shy to talk about condoms," says Carine A Mbong of the Cameroon, "now their negotiation skills are much stronger."

In the U.K. there has also been a change in attitudes over the past five years. "Using a condom is so much a part of sex that separating the two is difficult," says Roni Liyanage of the U.K. — WFS (from the Hague)

The white patches !
Dr Gurinderjit Singh

THE origin of the term vitiligo is obscure — like the disease itself. Some believe that it is derived from the Latin word “vitelius”, meaning vale, i.e., pale-pink flesh of a calf, while others think that it originated from the word “vitium”, meaning blemish. It is interesting to note that the Rigveda named vitiligo as Kilas, meaning a white-spotted deer.

Vitiligo, also called leucoderma, is an acquired disorder of melanocytes (pigment-producing cells) of the skin, when these cells degenerate and then disappear, leading to white patches over the skin, not infrequently the hair over the patch turning grey.

Vitiligo affects all races of the world but reports vary widely on its incidence in the general population.

The highest incidence has been recorded in India and Mexico.

In the states of Gujarat and Rajasthan, the prevalence of almost epidemic proportions have been reported. In India there is a popular but erroneous notion that the dietary intake of vitamin C worsens vitiligo. Similar is the wrong concept that drinking milk after eating fish leads to white patches.

There are reports of female predominance probably reflecting their greater concern for cosmetic disfigurement.

The stigma related to vitiligo is very severe. This disease alone has led to much more marital disharmony and divorce than tuberculosis and leprosy, the disease with which it is often confused.

The ailment may start at any age. The onset has been reported as early as at birth and as late as at 81 years of age. “A significant percentage of the patients give a family history of vitiligo. Most often one or two family members are affected but the cases of 39 members in three generations of a family are on record. A relationship between vitiligo and diabetes mellitus as well as the thyroid disease has been mentioned. The significance of the association of vitiligo with bronchial asthma is far from clear.

Vitiligo manifests itself as a well-defined depigmented lesion without any change in the skin texture. The hair over the patch, if these turn grey, indicate a poor prognosis. The onset of the disease in usually insidious. As a rule, it is progressive and the course is unpredictable. Some lesions may show signs of repigmentation but simultaneously new lesions may develop on other parts of the body. There may occur a rapid extension of lesions after remaining quiescent for years. Although no definite reason can be attributed for such occurrences, many factors have been incriminated. These include local causes like trauma, itching and friction, abdominal problems, emotional problems, psychic trauma, pregnancy and surgery.

Vitiligo may involve any part of the body but the lesions tend to be

predominantly distributed on the fingers and the palms, toes and soles, besides one or more spots localised around eyes. Sometimes the lesions are restricted to the lips and the distal parts of fingers and toes when the condition is called lip-tip vitiligo.

The management of vitiligo: In the absence of a clear understanding of the cause of the disease, there is no ideal treatment. Many indigenous medicines have been used. An oily extract of the seeds of psoralia corylifolia (Bavachi) was used in India by ayurvedic practitioners. This herbal product containing photosenisitising furocoumarin chemicals was able to produce pigmentation when applied locally over depigmented patches. Modern treatment may be divided into the following four categories.

1. General aspect

The patient must take a balanced and nutritious diet enriched with adequate good-quality protein, vitamin B complex and minerals such as copper, zinc and iron.

2. Medicinal treatment

The medicines which are used to treat vitiligo include psoralen compounds, corticosteriods, placental extract preparations and immunosuppressives like cyclophosphamide and azathiorprine, but these medicines should be taken only under strict medical supervision.

3. Surgical treatment

The surgical approaches comprise:

(a) Thin thiersch grafting

The split thickness grafts are performed in cases of long-standing quiescent lesions, which are resistant to medical treatment.

(b) Epidermal grafting

Normally, pigmented epideremi is separated from the dermis of the donor site by the suction blistering of the skin by a negative pressure. This procedure does not cause any scarring but is time-consuming.

(c) Minigrafting

Punch-grafting has been found useful for stable forms of vitiligo. The pigment cells proliferate and migrate from the minigrafts into the adjacent white skin. Minigrafting is performed by implanting small punch grafts 3-4 mm. apart within minute beds perforated in the depigmented recipient area. Minigrafts can be harvested from donor sites at a distance of 1-1.5 mm from each other. Pigment spread occurs gradually after one month and full repigmentation is seen within three to six months.

(d) Cosmetic camouflaging

Suitable cosmetic preparations may help many patients in masking white spots. Tattooing helps in covering white patches over the dark skin areas like lips and the areoler region of the breast.

(e) Bleaching

In extensive vitiligo with scattered pigmented islands of skin and without any hope of recovery it may be cosmetically desirable to give the skin a uniform look without any hope of recovery. Depigmentation may be achieved with the daily use of a 20 per cent cream of monobenzene ether of hydroquinone for three to six months under medical supervision.

(The author is a Ludhiana-based skin specialist).

Buying immortality
by Maria Ciancia in London

The goal of cryonics is the transport of today's (terminal) patients to a time in the future when cell and tissue repair technology will be available and restoration to full health possible.

MARIA Camacho is hoping to buy immortality with good health for herself. Or, to be precise, immortality for her sound head.

The plan is that after her death, her head will be preserved in a freezing process. One day, she hopes, when science has advanced sufficiently to complete the job, her head will be defrosted and, with the knowledge that will then exist, her brain, which is perfectly normal now, will be treated to enable it to live forever.

Like most mothers, she is even more ambitious when it comes to her son, 16-year-old Michael. She plans to have his entire energetic body frozen some day.

The cost of this bid for eternal life is about $80,000. She pays an annual fee to one of several companies offering cyronics — the process of freezing bodies in liquid nitrogen. As is required, she has also made the company the beneficiary of her life insurance policy.

"I want to see the future and this is the only way to do it at the moment," she says in her London home. Her kitchen walls are plastered with newspaper and magazine cuttings about cyronics.

Michael agrees: "I also want to go to the future, to be with my mother and sisters because I think that life is too short; there is just not enough time to do many things."

He proudly sports a bracelet provided by the company. It is engraved with instructions about how his body should be dealt with in the event of his death and gives the company's US phone number. The instructions include: "No autopsy or embalming", but that would, of course, depend on the nature of death.

An estimated 80 people are paying for similar arrangements. Most live in the USA, where clients tend to be "young professionals, computer scientists and biotechnologists", according to Brian, another customer, who does not want to give his full name. "In the UK," on the other hand, "we have a computer analyst, an estate manager, a financial adviser, a retired engineer, a garden centre sales adviser, a chef...."

The bodies of British customers are frozen in England, packed in ice and flown to Arizona, where the final temperature drop to minus 196 degrees centigrade takes place.

There is one flaw in these plans: freezing and resurrection cannot at present be done.

"They are just hoping for the impossible, it cannot be done now," says Dr David Pegg of the cryobiology unit at the University of York in Britain. "There is no scientific basis that humans can be reborn..... Those who are interested in this can get so wound up in their hopes, they lose sight of this fact."

Although it is possible to freeze healthy individual cells, he says, nobody has managed to freeze a whole organ without damage.

"Freezing generates a lot of damage because of thermal expansion," he warns. "If you freeze a strawberry, which contains a lot of water like the body does, it turns into mush."

But the companies remain bullish (one pamphlet states: " The goal of cryonics is the transport of today's (terminal) patients to a time in the future when cell and tissue repair technology will be available and restoration to full health possible) and the clients unquenchably optimistic that reality will catch up with science fiction.

"Our brain and bodies will be repaired with nanotechnology when they bring us back to life in the far away future," Maria Camacho believes.

Nanotechnology holds out the dream of tiny machines small enough to be injected into the bloodstream that will build copies of themselves and then go about repairing a body's damaged cells.

"All of this will be possible with nanotechnology", she insists.

Faith that science will conquer all impediments is common to all would-be-immortal customers. Without it, they would not be willing to pay large sums of money for an outcome that is still beyond reach.

"I want to have my head frozen because I consider that a future technology that can bring me back to life won't have any problem in providing a healthy body, cloned or otherwise," says a customer, Jack.

They all also share a desire to cheat death.

"Why do we have to die in the first place? That is the worst calamity affecting mankind at the moment," says Brian. "Life is too short; death doesn't have to be the end of it."

Asked about the possibility of failure, he retorts: "We wouldn't have any chance of coming back if we were buried or cremated."

As for Maria Camacho, asked what she hopes for if she is successfully awaken after death, she replies: "I would like it to be peaceful without any wars or human suffering." — Gemini News

(Maria Ciancia is a Colombian journalist living in London).