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RF_COM_H_83_SUDHA Cj£>rv) H >A33 - I

Book - Post

SOUTHERN REGION PUBLIC HEARING
ON

THE RIGHT TO HEALTH CARE

To

Contact Address:

Tamil Nadu Science Forum
245, Awal Shanmugam Salai, Gopalapuram, Chennai - 600 086.
Phone: 044 - 2811 3630 e-mail: tnsf2@eth.net

The National Human Rights Commission &
Jan Swasthya Abhiyan (JSA), [ Peoples Health Movement -PHM ]
Cordially invite you to the

SOUTHERN REGION PUBLIC HEARING
ON

THE RIGHT TO HEALTH CARE
on Sun ’'

<1

St. .

7

'

2004

«itreat And Pilgrimage

is Internatio'i
•:l( top, St. T>.

‘,'.’>tnai - 600 016.

Phone: C.:

22345803.

r
9.00 am

Registration

10.00 am -11.00 am

Inaugural Session

11.00 am-1.30 pm

Two Parallel Session on Denial of Health Care
Chairs

Justice Sri Y. Bhaskar rao,
Honable Member, NHRC
Smt.S. Jalaja, Joint Sec, NHRC

Co-Chairs

:Dr.B. Ekbal - National Convenor
&Joint Convenors, JSA

Testimonies, case studies and state reports
from Tamilnadu, Pondicherry, Kerala, Andhra
Pradesh and Karnataka and responses from
the panelists


1.30 pm-2.15pm

Lunch

2.15pm-4.30pm

Parallel session conf....

4.30 pm - 5.00 pm

Concluding Plenary

5.00 pm - 6.00 pm

Meet - the - press

The National Human Rights Commission &
Jan Swasthya Abhiyan (JSA), [ Peoples Health Movement -PHM ]
Cordially invite you to the

SOUTHERN REGION PUBLIC HEARING

ON
THE RIGHT TO HEALTH CARE
on Sunday, 29,h August 2004

at
St. Thomas International Centre For Retreat And Pilgrimage

HUI top, St. Thomas Mount, Chennai • 600 016.
Phone: 044 - 22344756 / 22345803.

Programme
9.00 am

Registration

10.00 am-11.00 am

Inaugural Session

11.00 am-1.30 pm

Two Parallel Session on Denial of Health Care
Chairs

Justice Sri Y. Bhaskar rao,
Honable Member, NHRC
Smt.S. Jalaja, Joint Sec, NHRC

Co-Chairs

:Dr.B. Ekbal- National Convenor
&Joint Convenors, JSA

Testimonies, case studies and state reports
fromTamilnadu, Pondicherry, Kerala, Andhra
Pradesh and Karnataka and responses from
the panelists
1.30 pm-2.15pm

Lunch

2.15pm-4.30pm

Parallel session cont....

4.30 pm - 5.00 pm

Concluding Plenary

5.00 pm - 6.00 pm

Meet - the - press

Route Map to St. Thomas International Centre
Road

Poonamallee High

Koyambedu

Butt Road

Kathipara Jn.
St.Thomas Mount
Bus Stand

St.Thomas Int.,
Centre Hill Top
Road to Airport

To reach the Venue:

From Chennai Central railway station :Take a prepaid auto (fare - Rs. 100 approx)
and ask for St. Thomas Mount - "HILL TOP"
(or)

Take a city route bus No 54 or 254 and get down at St.thomas Mount bus stop.
From the bus stop, either walk up the steps leading to "HILL TOP"
or take an auto (auto fare - Rs. 35 approx)

For further Assistance/details contact: TNSF - 044 - 2811 3630

------- ---

------

SOUTH REGION PUBLIC HEARING ON RIGHT TO HEALTH CARE
29-08-04

REGISTRATION FORM
STATE:

S.NO

CONTACT ADDRESS
WITH PH NO & EMAIL ID

NAME & ORGANISATION NAME

. .

SIGNATU1RE

SOUTHERN REGION PUBLIC HEARING
ON RIGHT TO HEALTH CARE
29™ AUGUST 2004
Jointly organised by
National Human Rights Commission (NHRC) &
Jan Swasthya Abhiyan (JSA) [People’s Health Movement - India]
at
St. Thomas International Center for Retreat and Pilgrimage,
Hill Top, St. Thomas Mount, Chennai-600016

PROGRAMME SCHEDULE
INAUGURAL SESSION
Venue: Justice Tarkunde Hall (Main Hall)
TIMINGS

SESSION

09.00 - 10.00 a.m.

Registration

10.00 -10.45 a.m.

»

Welcome : Dr. G. K. Pandian, JSA (Tamil Nadu)

Introduction : JSA Representative - Dr. B. Ekbal, National Convenor, JSA

Inaugural Address : Justice Shri Y. Bhaskar Rao, Member, NHRC.

‘KalaJatha’ - Book Release by Hon’ble Justice Shri Y. Bhaskar Rao

10.45 - 10.55 a.m.

Case Presentation on Mental Health - Basic Needs

10.55 - 11.20 a.m.

TEA BREAK
PUBLIC HEARING (PARALLEL SESSION I)
Venue: Anandi bai Hall (Hall II)

States: Andhra Pradesh, Karnataka
TIMINGS

STATE

11.20 a.m - 12.50 p.m.

Karnataka

SESSION
1.

2.

3.

12.50 pm. - 01.20 pm.
01.20 p.m. - 2.10 p.m.

Testimonies of the individual
cases of health care denial.
State Report on Public Health
Services
by
JSA
state
representatives
Responses from the State
Health officials

PANELISTS

|

Chair:

,

Justice Shri Y.Bhaskar Rao

Co- Chair:
Dr. B. Ekbal, JSA

&
Senior Health officials of
Andhra Pradesh and Karnataka

Responses of the panelists to the above presentations

Lunch Break

PARALLEL SESSION I
TIMINGS

2.10-3.40 PM

Cont’d...

STATE

SESSION

PANELISTS

Andhra
Pradesh

1. Testimonies of the individual
cases of health care denial.

Justice Shri Y.Bhaskar Rao

2. State Report on Public Health
Services by JSA state
representatives
3. Responses from the state
Health officials.

Chair:

Co- Chair:
Dr.B.Ekbal, JSA
&
Senior Health officials of
Andhra Pradesh and Karnataka

Responses of the panelists to the above presentations

03.40 p.m. - 04.10 pm
04.10 p.m. - 04.30 pm

TEA BREAK

PUBLIC HEARING (PARALLEL SESSION II)
Venue: Justice Tarkundc Hall (Main Hall)
States: Tamil Nadu, Pondicherry, Kerala

(

TIMINGS

STATE

SESSION

PANELISTS

11.20 am. - 12.50 pm

Tamil Nadu

1. Testimonies of the individual
cases of health care denial.
2. State Report on Public Health
Services
by
JSA
state
representatives

Chair:
Smt.S.Jalaja,
Joint Secretary, NHRC

3.
12.50 pm. - 01.20 pm

the

State

Responses of the panelists to the
above presentations

01.20 pm - 02.10 pm
02.10 pm - 03.40 pm

Responses from
Health officials

Co-Chair:
Dr. T. Sundararaman, JSA
&

Senior Health officials ofTamil
Nadu, Pondicherry and Kerala

Lunch Break

Pondicherry

1.

Kerala

2.

3.

Testimonies of the individual
cases of health care denial.

State Report on Public Health
Services
by
JSA
state
representatives
Responses from the state
Health officials.

3.40-4.10 PM

Responses of the panelists to the
above presentations

4.10-4.30 PM

Tea Break

Chair:
Smt.S.Jalaja,
Joint Secretary, NHRC

Co-Chair:
Dr. T. Sundararaman, JSA &
Senior Health officials ofTamil
Nadu, Pondicherry and Kerala

CONCLUDING PLENARY
Venue: Justice Tarkundc Hall (Main Hall)
4.30-5.00
PM

1. Observations and responses by Dr. Thelma Narayan, JSA
2. Concluding remarks by Justice Shri Y. Bhaskar Rao, Member, NHRC
3. Vote of thanks by JSA representative.

ANANDIBAI JOSHI was India's first woman doctor to be educated in the
US. Anandibai Joshi's life spans just about twenty-two years, from 18651887. She was educated at the Women's Medical College of Philadelphia,
USA.

Life in the late nineteenth century in Maharashtra was preoccupied with
the ancient rituals and traditions with no hope for independent thought or
action, thus preventing all progress. Outside Pune there was a poor postal
clerk, and a widower named Gopalrao Joshi who was possessed by the
thoughts of widow-remarriages and education of women.
Having failed in finding a widow for remarriage, Gopalrao was forced to
marry a 9-year- old pockmarked girl named Yamu. This is the story of that
young girl Yamu who was renamed ANANDI after her marriage.

It was a struggle to get Anandi to share a room with her husband during'
the day for her lessons. Meetings between a husband and wife during the
day were unheard of in those days. But once she learned to read Anandi
discovered for herself the joy of reading and knowledge. They moved
from Kalyan to Alibaag to Calcutta, any place where they would be left
alone to learn together. The story of Anandi is the story of a woman’s
transformation from a reluctant pupil and obedient and scared wife to selfassured and independent woman.
On one level, Gopalrao and Anandi were facing oppressive society, but for
Anandibai the struggle was much more complex. She soon realized the
superficiality of traditional rituals and learned to probe deeper for the
meanings in them.

By remembering Anandibai today, we are not only celebrating her
achievement of becoming a doctor, but her insurgence as an intelligent,
and independent woman that makes her an inspiration to the world, even
today.

JUSTICE V.M. TARKUNDE was bom in Saswad near Pune on July 3, 1909.1
He graduated from Fergusson College, Pune. He went to the UK and joined
the renowned London School of Economics and subsequently passed the Bar­
at-law. Returning home, he started his legal practice in Pune. He was a
member of the Congress Socialist Party. But meeting M.N.Roy radically
changed the political outlook of Shri. Tarkunde. Roy founded the radical
Democratic Party and Tarkunde gave up his legal practice to work with him.
Neither of them had faith in party -politics and they believed in
conscientising people at the grass root level to promote democratic ethos.
Shri Tarkunde resumed his legal practice in 1948 and became a judge of the
Bombay High Court. He resigned in 1969 and set up practice in the Supreme
Court of India.

In 1974, Shri Tarkunde with Shri. Jai Prakash Narayan (JP) founded Citizens
for Democracy with the latter as President and Shri Tarkunde as General
Secretary in 1976. During the Emergency, People’s Union for Civil Liberties
and Democratic Rights (PUCL & DR) was set up with JP as President and
Shri Tarkunde as Working President. As a legal luminary, he was committed
to civil liberties. He retired from legal practice in 1997.

Shri. Tarkunde was a man of vision rooted in idealism. He believed that
humanism was the fountainhead of democratic ethos. He wanted this to be
the basis of civil society. He symbolises a spirit of humanism and human
rights. Being a rationalist, he had little patience for religion. In its stead he
upheld values that transcended all faiths.
Shri. Tarkunde upheld the rights of labour and never appeared for the
management. He was among the few who recognised early the genocidal
nature of communalism and was uncompromising in his opposition to it. His
sympathies lay with the rights of the people of Kashmir and North East. Shri.
Tarkunde was one of those who kept alive The hope of a new day dawning’
with the ‘recognition of the inherent dignity of the equal and unalterable right
of all the members of the human family in the foundation of freedom, justice
and peace in the world’.
Justice V.M.Tarkunde passed away on 23rd March 2004 in New Delhi. It is a
fitting Tribute to the indomitable spirit of V.M.Tarkunde to keep green his
memory and sustain his vision.

SOUTHERN REGION PUBLIC HEARING ON THE

RIGHT TO HEALTH CARE
Co-organized by
Jan Swasthya Abhiyan (Peoples’ Health Movement, India) and
The National Human Rights Commission (NHRC)
on 29Ih August 2004 at Chennai

STATUS OF HEALTH AND HEALTH SERVICES
OF

THE PEOPLE OF KARNATAKA

Submined on MMI behalf of the

JAN SWASTHYA ABHIYAN

C/o Community Health Cell
# 359. Jakkasandra 1“ Main_l“ Block, Koramangala, Bangalore - 560 034
Tel.: (080) 25531518 Telefax : (080) 25525372 Email: chcasochara.org Website : www.sochara.org

Status of Health and Health Services of the

People of Karnataka
Karnataka is considered to be just above the national average as regards the overall

health status of the people and just below the average among the states in the southern

region. There has been improvement, as in other states, in the health status of the
people over time, as shown by indicators such as life expectancy at birth, crude birth
rate, crude death rate, Infant mortality rate and under - five mortality rate. There has

been control, to some extent, of vaccine preventable diseases, through widespread
immunization. In family welfare, the couple protection rate has increased to a large

extent. There is a wide network of health care institutions in the public and private

sectors, functioning at the primary, secondary7 and tertiary levels. There are also a
large number of professional educational institutions, affiliated to the Rajiv Gandhi

University of Health Sciences, training doctors, nurses and other health personnel.
1.

Issues of Concern that impact on the Right to Health Care

There are many issues of concern requiring urgent action.

These have been

brought out by the Karnataka Task Force on Health and Family Welfare in its
report of April 2001. .Among them are:

neglect of public health and distortions in primary health care

widespread corruption; inequity' ip.,access to health care that widen

the

existing disparities in health and health care; implementation gaps between
policies and practice

inadequate emphasis on quality of health care

absence of attention to ethics

improper development of human resources for health, and

inadequate allocation and utilisation of funds and resources.

Other important problems in the health sector include:

inadequacy of the health budget,

unacceptable quality of health care services

inadequacy of certain categories of health personnel, both in numbers and

quality

poor nutritional levels, particularly among infants, children, adolescents and

pregnant women

inequitable access to health care and

non-involvement of the community in planning, monitoring and evaluation of
the health services.

2.

Health Services Facilities (Governmental)
Primary Health Care
The following facilities and infrastructure have been established by the State, are

expected to provide primary health care:
Subcentres: 8143

=> Primary Health Centres (PHC): 1676 + 9 (urban)
■4> Community Health Centres (CHC): 249

=> Primary Health Units (PHU): 583

(Source: Annual Report,
Department of Health and Family Welfare, 1999-2000)
Of these health centers, the first three follow generally the norms of the

Government of India as regards staffing pattern and infrastructure, even though

there are many vacant posts and lack of buildings to house them. The availability

of essential drugs has been a perennial problem. This affects the poor, who do not
have the means to purchase the drugs from outside, with the prices of drugs rising
constantly.

This leads to avoidable deaths, permanent damage to health and

indebtedness.
Lack of buildings; or geographically inaccessible locations of
PHCs; poor construction and maintenance, and the non­
availability of drugs are major structural obstacles to fulfilling the
Right to Health Care.

3

Primary Health Units are peculiar to Karnataka (from Mysore State before the

formation of Karnataka)
3.

Vacancies of Health Workers

There are numerous vacancies in all cadres of health workers.

An important

group of professionals providing health care are the Junior Health Assistants female i auxiliary nurse midwife. ANM) and their supervisors, the senior Health
Assistants, (the Lady Health Visitors-LHV).

Vacancies of Female Health Workers (ANMs and LHVs)

Gulbarga District: Talukwise
ANMs

Taluk
Sanctioned

Vacant

LHVs
%

5
Sanctioned

Vacancies
vacant

Vacant
Gulbarga Taluk

58

6

Jee\ argi

39

12

30.8

10

2

20.0

Aland

57

18

31.6

6

4

66.7

Afzalpur

40

11

27.5

9

7

77.8

Chinchoii

41

10

24.4

8

1

12.5

Chitapur

57

15

263

10

5

50.0

Sedam

35

13

37.1

7

2

28.6

- 48

17

35.4

7

5

71.5

Surpur

56

18

32.1

10

7

70.0

Yadagiri

53

20

37.7

10

7

70.0

Gulbarga Dist

484

134

27.7

83

40

48.2

Shahpur -----

.

Source: Ibid
Shortages of Male Health Workers, Lab technicians and other field staff are also
significant. Mismatch between qualifications and postings I job responsibilities
causes frustration and wastage of resources.
Absence of trained and motivated Health Workers is the single most

significant systemic obstacle to Right to Health Care, putting great
additional strain on available health workers and leading to referrals
to private health care.

4

4.

Regional Disparities
There is wide disparity in the provision of sendees between the various districts.

A sample from 3 selected districts is shown below

a) RCH Survey : Selected districts; selected indicators in percentage

Family

Institutional

Children not

planning

Deliveries

immunized

knowledge of

Full ANC

District

methods

Udupi

78.9

76.6

0.5

70.7

Tumkur

68.7

48.4

0.5

40.8

Gulbarga

21 9

27.9

31.1

27.2

52.4

8.3

46.1

Karnataka State

(Source: Rapid House hold survey, RCH, 1998, Kanbangi, et al.,)

ANC : Antenatal care

b) RCH Survey, 1998 : Selected districts; selected indicators

Children 12-36

District

CBR

Women using

Safe

contraceptives

Deliveries

CDR

months fully

immunized
Udupi

19.7

7.0

63.7%

91.5%

86.0%

Tumkur

24.1

8.2

61.3%

63.5%

88.0%

Gulbarga

30.1

10.7

39.2%

47.7%

25.3%

Karnataka

22.5

8.5

58.1%

68.2%

70.5%

State
(Source : Human Development in Karnataka, 1999)
CBR-Crude Birth Rate, CDE-Crude Death Rate

Regional disparities that are not effectively and adequately addressed by
proactive, regional, need based planning, but continue to be driven by
normative planning focused on the whole state, is a policy obstacle to the
Right to Health Care

5

Public and Private health care institutions in Karnataka

Institutions

Beds

Public

2624

43.868

Private

1769

40,900

(Source : Health Care facilities in the Non-Govemment Sector, STEM 1996)

There has been a gradual increase in private sector health care facilities in the

state. There is a need for regulation, incentives and other means to ensure
quality of care in the public and private sector, and access to health care for
the poor and vulnerable.

5.

Some Indicators related to Basic Determinants of Health
a)

Nutrition, Karnataka
There is considerable amount of undemutrition in Karnataka, leading to or

contributing to death and disease. According to the National Family Health
Survey, Karnataka, 1992-93. babies with low birth weight constituted 22% of
all live births.

Children under 4 years
Under weight for age

54%

Under height for age

48%

Wasted

17%

o

Nutritional grade distribution of children (12-71 months), 1996-97

Status

Percentage

Normal (>90%)

9.4

Mild malnutrition (75-90%)

39.0

Moderate malnutrition (60-75%)

45.4

Severe malnutrition (<60%)

6.2

Total

100

Source: NNMB Rural, 1999 (Gomez classification)

Inadequate food and nutrition security in the state due to agricultural
policies that promote cash crops over basic staple-foods (eg : ragi, oil seeds
and dhal production in the state are inadequate, while production of silk,
tobacco, and horticulture, for export are increasing); an inadequate public
distribution system; and inadequate nutrition supplementation to
vulnerable groups among under 5 populations result in a major denial of
the Right to Health, since a low cost balanced diet is a minimum
requirement and basic determinant of health.
b)

Health Revenue Expenditure, Karnataka, 1995-96

As percentage of state budget: 5%
As percentage state GDP : 1.48%
Distribution of health expenditure based on level of health care

Percentage
Primary Health Care

:

37.94

Secondary and tertiary case

:

31.08

Family Welfare

:

19.65

Medical Education and Training

:

9.26

Administration

:

2.08

(Source : Human Development in Karnataka, 1999)

7

While this may be slightly higher than in some states, it is very inadequate.

Though costs of health care are rising, over the years the health budget and
health expenditure per capita are declining, with most of it going for salaries,

leaving very little for programmes and sendees reaching people.

Public sector financing which is much below the norms is the main policy

obstacle to operationalising the Right to Health Care in the state. Low
health budgets and expenditure are directly correlated to structural and
systemic inadequacies, resulting in poor quality of health services, and

impacting negatively on the Right to Health Care.

6.

Water Supply and Sanitation

There is inadequacy of water, both in quantity and quality. 71.68% of the
households had access to potable water : 81% urban and 67% rural (1991).

Improvement in some regions have taken place in the last decade through
government programmes. The situation however is likely to become worse with

drought and climate change resulting in further reduction in water availability.
There is increasing chemical and microbial contamination, which require urgent

steps to be taken.

Inadequate access to

water has also important social

dimensions, with women, the rural poor, scheduled castes and scheduled tribes
being more adversely affected.

Only 34% of the households have access to toilets: rural 6.85% and urban 62.5%
(Human Development in Karnataka, 1999).

Others use open spaces for

defaecation. Poor access of households to sanitation facilities (toilets) and lack of
environmental sanitation (sanitary waste disposal, drainage) are closely associated
with microbial contamination of water. This is a major cause for diseases such as

worm infestations, diarrhoea, typhoid, etc. Many of the slums in the urban areas

have common toilets but they are poorly maintained and , hence, not used.
Sanitary latrines were constructed under the Nirmala Grama Yojana, starting in

October, 1995.

8

It is essential to link water supply and

sanitation.

Often measures for better

sanitation fail because of lack of water. And. efforts at better water supply and

absence of sanitation lead to faeco-oral spread of infection.

Inadequate attention to universal water supply, availability of
potable water and sanitation rank next to inadequate
food/nutrition security as a major policy I structural / systemic
obstacle to the Right to Health Care. Without adequate food and
water, a healthy environment and a minimum wage - all basic
determinants of health, the Right to Health remains a dream.

7.

Health Services

The present structure of Karnataka Health Sendees has evolved over the years.
The importance given to preventive and curative sendees has varied at various
times. Earlier, there was an emphasis on and promotion of public health. But it

disappeared in more recent times. The present structure of health sendees has the

Ministers for Health and Family Welfare, Medical Education and Indian Systems
of Medicine and Homeopathy.

Next to the ministers, there is the Principal

Secretary, Health, the Secretary', Medical Education and the Commissioner.
Health. There are the Director of Health and Family Welfare, Director of Medical

Education and Director of Indian Systems of Medicine and Homeopathy. There

are Additional, Joint, Deputy and Assistant Directors. At the districts, there are
the District Health and Family Welfare officers, the District Surgeons anc
Programme Officers.
The following deficiencies have been observed in the organization of the Health

Services.

❖ Not enough importance to public health, with steep decline in the number of

trained and experienced public health professionals in government sendee.

❖ Neglect of the North Karnataka Region in relation to health needs
❖ Not enough accountability to the public.

9

❖ Too wide a span of control for the Director of Health Services and the

Commissioner, making the controls ineffective.
The many challenges identified by the Karnataka Task Force
on Health and Family Welfare include the gross neglect of
public health orientation to health teams; neglect of public
health human power development,; gross regional disparities;
and an all pervading corruption. Though these are deep rooted
policy and structural obstacles, they need to be addressed at the
highest level to fulfill the Right to Health Care.

The Karnataka Task Force on Health and Family Welfare (KTFH 2001) has
suggested changes in the organizational structure, keeping the following principles

in view:
❖ The emphasis on public health should be revived.
❖ Separate cadres would be constituted for public health and medical (clinical)

responsibilities of the Department.
❖ All health personnel up to the district level will form the District Cadres.

❖ The higher posts would constitute State cadres; selection based on competence
and not only on seniority' will be the mode for filling these posts. The state
cadres will constitute the Karnataka Health Sendees.

❖ National Health Programmes would be integrated into the health system,
ensuring better supervision, management, and health outcomes.

❖ The expertise and morale of the staff will be built up, enhancing skills and

through a transparent transfer policy.
❖ Northern districts will get special attention, with an additional Director under
the Commissioner.

(Not surprisingly the KTFH report was entitled ‘Towards Equity, Quality and
Integrity’)

10

8.

Karnataka Panchayat Raj Act, 1993
An important step in decentralization of health care services was taken with the
enactment of the Karnataka Panchayat Act, 1993. The Panchayat’s promote local

initiatives to meet the local needs, vesting power with the people.
According to the Act, the Zilla Panchayats are to look after hospitals and

dispensaries, excluding district hospitals and hospitals under direct government

management (those with more than 50 beds) and the implementation of schemes
for maternity and child health, mainly family welfare and immunization. They

are expected to deal with the district sector budget and other state sector schemes,
entrusted to them by the State Government. The Zilla Panchayats have a standing
committee for education and health. Taluk Panchayats are to look after health and

family welfare programmes and promote immunization; supervise health and

sanitation at village fairs and festivals.

The Taluk Panchayats look after the

maintenance of the health subcentres and anganwadi centers. Gram Panchayats

deal with family welfare programmes, preventive measures against epidemics,
participation in immunization programmes, regulation of sale of food articles,

licensing of eating establishments and the regulations of offensive and dangerous
The Panchayat also deals with rural drinking water and sanitation

trades.
schemes.

Strong commitment to Panchayiti Raj Institutions and their
orientation and involvement in basic health care can be one of the
most significant policy commitments to establishing the Right to
Health Care in the state.

11

9.

Health situation in the Southern States

It is useful to compare the health situation in the four major southern sates

(selected indicators)

IMR

CBR

CDR

(1996)

(1996)

(1996)

MMR*

State

Sex

Ratio

(1995)

(1991)

Andhra Pradesh

73

22.8

8.4

436

972

Karnataka

53

23.0

7.6

450

960

Kerala

14

18.0

6.2

87

1036

Tamil Nadu

53

19.5

8.0

376

974

(Source : Family Welfare Programme in India, GOI, 1996-97; The progress of

Indian States, UNICEF, New Delhi, 1995)

Life
expectancy

State

Human Development index
at birth
1993

1

2

3

Andhra Pradesh

61.5

0.400

0.392

0.413

Karnataka

62.5

0.448

0.442

0.468

Kerala

72.9

0.603

0.597

Tamil Nadu

63.3

0.438

0.432

.

0.628

0.511

Source : Human Dvelopment in Karnataka, 1999. l.Shivkumar (19981-92);
2. HDR of South Asia( 1992-93); 3. UNFPA( 1992-93))

12

Underweight children below 4 years
Andhra Pradesh

49%

Karnataka

54%

Kerala

29%

Tamil Nadu

48%

While Karnataka, Tamil Nadu and Andhra Pradesh differ from each
other marginally in different indicators, they are all still significantly
behind the health indicators of Kerala - the fourth southern state which
continues to demonstrate good health at low cost with focus on land
distribution, female literacy, a functioning Public Distribution System
and a network on rural libraries that provide community information.
This should be studied, reviewed and emulated

10.

Health Policy

The Karnataka Cabinet approved the Karnataka Integrated Health Policy in
February' 2004. The focus is on strengthening comprehensive primary health care
and public health. The state government has initiated several measures over the
past years to implement recommendations of the Task Force and other
governmental programmes.

have been initiated.

Several linkages with NGOs and the private sector

These have been positive initiatives, which need to be

followed up with implementation of the state health policy and the integrated
health, nutrition and family welfare project.

13

C-OTV-J y.\

Tamil Nadu’s Health Sector

A brief note presented to the National Human
Rights Commission.
Prepared by the Tamilnadu Science Forum
on behalf of

Jan Swasthya Abhiyan -Tamilnadu

Based on inputs from
Dr. V. R. Muraleedharan and Dr. T.Sundararaman.

Submitted to

NHRC
August 29th 2004

1. Introduction
amil Nadu’s health status and healthcare services witnessed major significant
improvements in 80s. The gains were most dramatic in state’s total fertility
rate which fell to near replacement level by the early nineties.

T

Tamil Nadu’s healthcare infrastructure has 1400 primary health centres, and about
8500 health sub-centres, with a large number of secondary healthcare institutions in
the districts. This compares favourably to most other states. Adjusting for urban
populations, very few states have comparable public health facilities in proportion to
population.

The state has also the distinction of having initiated many health interventions that
have served as models for other states to emulate.
2. Reasons for Concern: Stagnation in health status improvements
From mid-1990s, there has been considerable slow down. There were no further
reductions in birth rate, death rate, or infant mortality rates which have remained
static. The share of neonatal deaths (which account for more than 60 percent of the
infant deaths) has remained static. 11 is very difficult to obtain an official estimate of
MMR for the state. Estimates range from 450 deaths per 100,000 deliveries to around
140 (1999). The wide divergence between rural and urban rates is also a cause for
diquiet as health inequity is unacceptable in itself and point to a huge rcmdiable rural
health gap.

Very few new institutions are added in the public sector, though growth in the
unregulated private sector has been enormous.

The reduction of fertility rate in TN is one of its best known achievements but even
here the birth rale has not fallen further during the last 7 years.
The average nutritional status in TN shows an even more worrying picture (Table 1
below). The nutritional status as such is lower than its neighbouring states. For
example, the calorie intake per capita in TN is 1814, compared to 2231 in Kerala,
2196 in Karnataka, and 2430 in Andhara Pradesh (1999 figures).
Tabic 1: Average Food Intake in Southern States

Item

Tamil
Nadu

Kerala

Karnataka

Andhra
Pradesh

Calories
Protein (gms.)
Calcium (mg)
Iron (mg)
Vitamin C (nig)
Vitamin A (mg)

1X14
44.4
455
20.2
29.9
1X4

2231
57.1
696
22.X
50.3
214

2196
55.5
X39
30.6
32.7
2X6

2430
57.6
51X
26.2
34.0
352

Source: Data extracted from a survey conducted b\ the Ministry for Consumer and Public Affairs,
1999, as reported in the Monthly Report of family Welfare Department. GOTN (November
2000).

National Family Health Survey (NFHS) 1998-99 showed the highest level of
moderate or severe anaemia among the pregnant women (32%), and among the
children, (47%).
Access to and Utilization of primary health services:

47% of total inpatient days in Tamil Nadu (rural and urban) is met by public
hospitals - all India average is 51%. This is less than one would expect but still
represents a very large use of public hospitals. In terms of number of
hospitalization, public hospitals in Tamil Nadu account for only 28% of the total
12 million hospitalizations - the average for India (rural and urban) is reported to
be 44% of the total. SC/ST populations account for about 20% of the total number
of hospitalization, while the national average is around 24%;
•. Public institutions in TN cater to 29% of all outpatient care (rural and urban),
compared to the all-lndia average of 19%. In rural TN, they account for 32%
compared to Indian average of 18.3%;
• In all these, more than 50% of the total hospital care is utilized by patients from
the richer expenditure groups. This should not be read as a case for so -called
better targeting. Indeed the 50% of the poor are able to get some quality of care in
public hospitals only because other sections also use it and thereby sustain public
accountability. There is a need to cover invisible’payments in addition to public
provisioning of health care. Transport, cost of stay for patients and relatives and
illegal payments are three major payments whose costs can be so high as to
exclude a significant portion of the poor from any public care.
• Public institutions account for 52% of total inpatient days for,childbirth (rural and
urban), while they account for about 35% of the total institutional deliveries in the
state; 77% of the total inpatient days for childbirth among SC/ST populations is
accounted for by public institutions, while the corresponding figutje Tor all-lndia is
61 %;

Only 60% of PHCs in the state actually conduct deliveries. About 35% of
PHCs conduct one delivery per month. Overall, only 9% of PHCs conduct
more than 10 deliveries per month. On average each doctor or ANM conducts
only 1.7 deliveries per month.

Public service is also the major if not only service provider for most villages for
immunization and for antenatal care.

Critical Gaps in Manpower; Infrastructure in Primary Health care:

Manpower gaps still need to be addressed. The vacancy position of doctors in PHCs
continues to remain at 20%. A substantial number of PHCs do not have laboratory
assistants. 336 positions (35%) are vacant. Some districts have a vacancy of more
than 80% for these positions. Vacancy for laboratory technicians is at 58% ;
Pharmacists and ophthalmic assistants vacancy about 10% and Staff nurse vacancy in
PI ICs is about 8%.

As for infrastructure out of 1400 PHCs, only 65 are functioning in rented buildings,
but only 400 of them have staff quarters. As for HSCs, nearly 3000 are still working
in rented buildings and closing this gap is an urgent necessity.

Failure to organize secondary referrals for Emergency Obstetric and

for sick neonates:
The stagnation of health statistics on infant mortality and maternal mortality may
relate to the serious failure to provide quality referral services to those child-birth
cases and those newborns who require immediate hospitalization and emergency care.
Most community health worker programmes have shown that a reduction of IMR can
be achieved from high levels to about 50 per 1000 by simple community level steps.
They have further shown that further decreases are slow and require high degrees of
referral back up. The government is committed to the provision of one such back up
for every 1 lakh population.- the CMC concept. Unfortunately there has been
inadequate thought and effort in this direction. By the existing norms, TN should
have more than 400 such institutions, but it has only 59 at present. Few of these are
functional as per norms. A move a few years back to open 24hour services for PHCs
and strengthen them with an additional doctor and an ambulance did not result in
adequate improvements and was not followed up adequately.
Recently, the government of Tamil Nadu has announced the up-gradation of 40 PHCs
to 20-bedded hospitals but not only will they take time to complete they will face
problems of getting the required specialists.

The first referral unit concept for providing CS sections on a priority basis has also
floundered. In the year 2001, out of 163 FRUs in the state, 75 did not perform
caesarian operations, 21 of them had specialists but did not perform any caesarians.
About 45 FRUs have performed caesarian operation without blood bank facility.
Clearly, mal-distribution of medical personnel is one of the major causes for lack of
emergency care in these institutions - for example, the state has 243 obstetricians, yet
nearly 40 FRUs have no obstetricians
Ambulance services is another major part of this aspect. Yet Ambulance usage for
emergency services is abysmally low at 0.2 cases per PHC per month. Only 70%
(983) of 1410 PHCs have sanction for vehicles. Of these, only 76% are road worthy.
Only 894 (90%) have sanction for drivers, of which 24% are vacant. On average, each
vehicle was used only for 9.6 days per month.

Overcrowding of the district hospital:
As a result of failure of referral arrangements and district and taluk level the district
hospitals arc overcrowded and unable to perform tertiary or indeed good quality of
any care. Instead of being referral centers- they serve as urban primary healthc are
centers and secondary centers for the entire district. An average district headquarters
hospital has more than 2000 outpatients per day, averaging not more than 2 minutes
of consultations per patient. Stale level hospitals should perhaps have even a lower
average..
3

In addition to this overcrowding all secondary and tertiary hospitals there is a serious
shortage of staffat lower levels (conservancy staffs in particular) leading to dismal
sanitary situation.

The role of the private health sector:
In recent times, policymakers have made frequent references to the need to
collaborate with private sector in order to achieve public policy goals. What options
exist for the government to collaborate with the private sector. There are four
constraints to effective partnership between private and public sectors. These are: (1)
weak regulatory regimes to over-see the behaviour of private health sector; (2) weak
capacity of government to design and implement contractual arrangements with the
private sector; (3) lack of a research and information base on the dynamics of private
providers; (4) lack of a policy framework for engaging private health sector in health
- till date, the private health sector has grown passively, without any proactive policy.

And finally, the "private practice of public doctors during office-hours". The
government has not dealt with this issue with adequate determination. What is most
objectionable is private practice during office hours, which requires stern disciplinary
action against those guilty of such mistakes. The talk of public private partnership
when even this minimum cannot be done is fraught with danger.
What TN health department needs to be congratulated for:

The TN Medical Services Corporation (TNMSC) in 1995. It was created as an
autonomous body, under the Companies Act 1954, This was the most pragmatic
response to the dire situation in pharmaceutical supply for government institutions at
all levels. It is goycrned by a Board chaired by the Health Secretary and is managed
by a Managing Director.
Prior to the formation of TNMSC, hospitals purchased
drugs on their own, directly by the three directorates, namely the Directorate of
Medical Education, Medical and Rural Services, and Public Health and Preventive
Medicine. There were frequent complaints about misuse of funds and
misappropriation of funds for non-essential drugs. Once TNMSC was established,
these three budgets were put together for drug procurement. Now, drugs procured
through open tender process are delivered directly by the suppliers to the district
warehouses. District officers are given fixed transport allowances to transfer these
drugs to respective institutions.
After the formation of TNMSC, the drug list has been rationalized, and the number of
drugs on the list has been reduced to about 250, all of which were generic drugs.
Excellent transparent procurement and distribution and quality control systems have
made this the benchmark for all states. Over the years, TNMSC has been able to
finance purchase of diagnostic instruments for hospitals across the state in a similar
transparent manner. It is a shame that though this is acknowledged by all studies and
reports and repeatedly cited as a bench mark worth emulating very few states and
even the central government have moved to make their procurement and distribution
arrangements as effective. There is a need to make the implementation of a similar
system mandatory as part of the enjoyment of the public's right to access essential
drugs.
4

In order to increase the mobility and thereby the effectiveness of VHNs employed in
HSCs. Ioans for acquiring mopeds were extended to VHNs in 5 different districts.
This scheme was introduced in late 1990s, with funds from DAN I DA. As part of this
scheme, special training sessions on "mobility and campaign" were also introduced on
a pilot basis in Dharmapuri district. An evaluation study of this "mobility scheme"
shows that VHNs were able to save up to 60% of their time on travel. As a result they
were able to cover 3 to 4 villages a day compared to 1 to 2 villages a day. They are
also reported to have increased time spent on patients and attend to more emergencies.
Needless to say, this programme encountered certain difficulties: A major constraint
faced by VHNs was the expenditure for fuel. This needs to be overcome.

5

KA 16

Testimony of late P

Ms. P. a young woman aged 20 residing at Srirampuram slum in Bangalore went to Primary

Health Unit in Srirampuram for her antenatal check up. The patient's aunt said, as they could
not conduct the delivery there the} referred her to Vanivilas Hospital. When she went to
Vanivilas Hospital on 28lh June 2004. the junior doctor came and examined her and said she

would deliver the next day. But the senior doctor came and told that she had to undergo an

emergency surgery, as he felt the foetus not ok. The junior doctor came and said she would
do the next day the surgery.

They gave her glucose the whole night. The next day before they could do the surger} her

stomach bloated, the}' informed the doctor, and he came and saw and went away. About 7.3o
am Papu died in the hospital. When She ate well her dinner in the night and went to bed and
she passed away in her bed. When hospital authorities came to know that she is dead, they

told the relatives to take the body immediately.

Though the senior doctor told to do the emergency surgery, since the junior doctor delated
the surgerw Papu died on Is1 Jul}' 2003. The doctor or nurses were not available during

emergency. The} were not aware of the moments when she breathed her last. The family
sources said they spent about 3000 rupees during her hospitalization. Il seems the famil}
members questioned the authorities for the negligence but did not get any satisfactory-

responses.

" They did not even do the cut open her stomach (post mortem) to remove the

baby. In the grave yard ire had to get one man to cut open the stomach, remove the baby and
bitty the mother and the baby separately. " Now' it is just over since the incidence took place.

her husband has been married to Papu’s younger sister.
Denial of health care: Negligence
Delay in health care in the emergency

Non -peformance of postmortum and delivery of the ‘dead' baby.
Consequences:

Death of the baby and mother
Psychological trauma

Unnecessary expenditure.

KA l«

Testimony of Ms. D

Ms. D. aged 25 \ears. residing at Thippasandra. Bangalore -560 074 went to the Austin town
maternity home to deliver her Third child on 25'1' July 2004. She said she went around 6.30
am. immediately she was taken to labour room and was asked to lie down on the labour table.
She requested the nurse on duty that she would like to walk around for some time, as the pain
is not sex ere. The nurse forced her to lie down on the table and started doing PV which was

very painful. Added to that the nurse called the ayah and other female worker to press her
stomach and forced her to push the baby. Finally a boy baby was pulled out around 10.30 am.

She said the nurse forced her like this because she wanted to finish conducting the
delivery before she finished her duty and take the money. She said she was afraid that she

would die for the way they treated. " 1 was suffering from pain, I was exhausted, when I

dosed, they sprinkled water on my face and woke me up. They scolded me like, are you a
woman, you would deliver without problems only when you give alms to the poor, go first

give alms to the poor. I was very tired, they pinched with hands and the instruments, and

there were scars on my legs." She said she says all these because she doesn't want these
things to happen to other women.

The baby had scars on the head, which they suspect happened while pulling the baby
out by the nurses. When they asked the nurse for explanation she was told it w'as nothing but

dirt. “ I am worried if my child would have any problems in future because of this”
The nurse demanded Rs.500. Her husband works as a coolie, he had borrowed Rs.
250 from his work place and came to pay. They insisted that he paid the remaining amount
while discharging. During hospitalization HIV test w'as done for which she had to pay Rs. 15.

She was prescribed an ointment and tablets for pain, which she had to buy from the private
medical store for Rs. 50.

Finally while leaving the hospital she had paid Rs. 250 for the nurse who conducted
the delivery and 30 for giving injection. Rs. 20 for the helper and ten for the watchman.

Denial of health care: incompetence and negligence
Forcing delivery', leading to harm to baby.

Bribery

Consequences:

psychological trauma to mother
Possible trauma and after effects to baby.

KA 19

CASE HISTORY OF ER

I am a widow with 4 children and am a victim of HIVAIDS. I was happily married to
Mr. V an auto driver. Though we hailed from KGF and Jolarpet we settled in Bangalore
to earn a living. Our family life was good until my husband started falling ill often . He
started getting fever and handaches and was taken to a Private hospital where he was
treated for jaundice. Later the doctors told me that he was also infected with T.B, we
were asked to buy the medicines, which we could not afford. We then went to Jolarpet to
seek help from his people. His brother took him for treatment for two months and later
returned to Bangalore. By now I was pregnant and expecting our fourth child.

My husband started falling sick once again, and this time his condition worsened. He
was rushed to NIMHANS from were he was later referred to Bowring hospital. The
treatment meted out there was very hurting. We were made to wait for a long time in
order to get admission. The hospital staff did not bother to attend on us in spite of our
pleading to them to give us admission. After a lot of pleading and bribing, my husband
was put in the ward, where no one even came to check on him. Even though beds were
available he was asked to sleep on the floor. This experience w'as very painful and
frustrating. My husband did not want to stay there and we got him discharged and went
back to the concerned doctor at NIMHANS who then referred us to Freedom Foundation
where he was admitted and treated. It was here that I was tested positive, however my
children were tested negative. 1 lost my husband two years ago.
Positive people undergo a lot of difficulties. They not only have to face the trauma of
being positive but also face stigma and discrimination. On behalf of our positive group
I request the panel to help us get treatment with any discrimination

1

KA 20

Case history of I I
I am a victim of HIV/AIDS. I am 25 years old and come form Davangere. I have studied
till class 10. My husband Mr.X is an auto driver who hails from the same place. I come
from a large family and my parents thought that 1 should get married even though I was
not interested in getting married at that time.

After four years of marriage 1 conceived, but here I was told that I was infected with T.B.
It was routine to do a HIV test for all pregnant women an when it was done it was found
that I was tested positive. My husband was also asked to undergo the test, but he tested
negative. Instead of telling us our results the doctors called my family members and told
them that it have AIDS. This created a commotion in the hospital between both families.
thus causing them to disown us and ill-treat us mentally. Dejected with life we left our
hometown Davangere and came to Bangalore in search of a living. Ismail found it very
difficult to get a job and I did not show any interest in taking a job as I thought that my
days were numbered and death was nearing.
I was 2 months pregnant I went to Arogaya Kendra center near my house. After knowing
my status the doctor there did not want to treat me and referred me to Vani Vilas hospital.
My husband Ismail was tested and was found to be positive, by then. Thinking that my
child would be orphaned we decided to terminate the pregnancy. When we requested
them to terminate my pregnancy they refused and asked me to go to a private clinic who
demanded Rs.5,000/- which 1 could not afford. 1 went through a lot of mental strain not
knowing what to do. After sometime with help of my neighbors contacted a doctor at a
NGO. wiio was willing to help me. but by now it was too late and I went ahead with the
pregnancy and had a normal delivery. However I lost my child.

Today our lives have changed and we are now back in our hometown Davangere and it's
all thanks to MILANA. Here w'e underwent counseling and this helped us look at life in
a positive way.

My humble request to the panel is to make the hospital authorities treat us with respect
and concern. Infections come through many routes but the attitude of people remains the
same that of ill-treating us. Counseling and confidentially plays a very important role,
which has to follow strictly. All those would help us lead a positive life.

Denial of Health Care :

Stigma and discrimination
Refusal to provide treatment
Demand fro bribe
Violation of confidentiality

KA 21

Testimony of Late. Mr. II

Mr. H, 35 years old. a chronic alcoholic and chain smoker, was suffering from stomach pain. His
wife was interviewed on 16lh August 2004 at 2.00 pm at her residence in Ragigudda slums, in JP

Nagar.

His wife Mrs. H took him to Jayanagar General Hospital six months ago; she does not remember
the exact date. Since she showed her yellow colour ration card they had taken only 50 Rupees for

registration. She said otherwise one has to pay for everything.

He was taken to the hospital at about 9 am. The doctor examined him and said he has ulcers in
stomach and told her to admit him. When she complained to the sisters that he suffers from pain

they would come and give an injection. They gave six injections, which she bought, from a
private medical store by paying Rs. 100. He was also prescribed tonic, which he bought for

Rs.55. With all these his pain never subsided. X-Ray and blood test were done. She said she did
not pay anything for the X-Ray but for the blood test the lab technician took 500 rupees and told

her, not to tell any body that he had taken 500 rupees. He told her to tell if anyone asks that she
had paid Rs. 100 only. The patient was given 3-4 bottles of glucose every day for five days. She9

wife of the patient) said she decided to bring the patient home, as he was feeling better.

She again took him to the hospital as he started complaining of pain after two days. This time

also they admitted him and administered glucose. He was suffering from pain, many times he

himself would go to the sisters to call them to come and attend. To this the sisters would respond,

“you are a headache, if we have four patients like you, our lives would be gone." She ( wife of
the patient) said many times when she went to call them (the nurses) to come and attend to her

husband when he was suffering from pain, they had scolded her and said why did she come to
disturb their sleep? The doctor was not available when needed. The sisters (nurses) demanded 20

or 30 rupees ever}' time they came to give him injections or came to attend, “if you don’t pay
they will not attend to you ”

1

KA 21

This time he was there for 5 days. The doctor sent them away by saying he would get better if

she buys tire medicines and tonic they had prescribed. She bought half of them from inside the
medical store and half from outside the hospital by spending Rs. 200.

He was brought back home in a bad condition. She immediately took him to Bowring hospital.
She paid Rs. 65 for the auto. They admitted him and put a tube through his nose and removed 45 bottles of fluids every day. She spent here about 1000 rupees for medicines. They did not have

pain killer injection when he was suffering from pain; she had to buy from outside. After a week
she decided to bring him back home as it was too far. She had four little children to care for. She

was also afraid of seeing patients dying in front of her. The doctors told her that he still needs

treatment and investigations had to be done on him.

She kept him at home for four days and took him to Shekar hospital in Jayanagar as he became

very serious. They admitted him after taking Rs. 3000 as deposit. They immediately operated on
him by telling her that he had appendicitis. After surgery they told her that had ulcers in his

intestine and it is not appendicitis. They brought and showed her pieces of his intestines. One
month they kept him there. She spent about 5000 rupees for medicines. The doctor there by

seeing her condition of poverty gave her 3,000 rupees. When the final bill came it was about

28,000 rupees. Since she did not have the money, they discussed and told her that she need not
pay. They arranged an ambulance and sent them back home by saying it is difficult for them to

manage. He died the next day at home. She had spent about 10,000 rupees for medicines. She

has borrowed about 5000 rupees and 5000 rupees was give to her by known people.

Denial of health care: bribery, corruption and poor response to patient’s need, mismanagement,

and incompetence.

Consequences:

Death (avoidable) if proper treatment had been given in time.

Loss of money: becoming indebted, dissatisfaction with public health
care services

Recommendation:

Greater vigilance and supervision by senior staff of the Health Services
and Medical Education Departments.

2

KA 22

CASE PRESENTATION
(Bv a NGO Health Care Provider)

SUBJECT : DENLAL OF HEALTH CARE
Name of the patient: Mr K.

Wife Lakshmi 32 years, 5 children

Age: 35 years
Sex: Male
Address: Vivekanagar Post, Kormangala, Bangalore 560047

Maritial status: Married

Origin. Duration and progress:

We have a Charitable Health Centre in Viveknanagar slum for last 2 !4 yrs. The patient
first visited our clinic in or around September 2003.
He was a chronic alcoholic with recently diagnosed Diabetes.

❖ Episode I
On 14.11.03 at around 8.00 pm Mr. K came to our clinic with h/o vomiting blood
(haematemesis) and passing black stools (malena). Immediately after attending 2
patients I advised and accompanied them for hospitalization. We reached Bowring
Hospital Casualty at around 9.00 pm.

❖ At Bowring Hospital after issuing his card he was examined by the doctor in the
casualty. As he was a known case of Diabetes before starting any treatment his
blood sugar level examination was a must.

Ironically there was no Glucometer in this Tertiary Care Government Teaching
Hospital!!
Approximately an hour was wasted without any single treatment. Poor, ignorant
relatives couldn’t understood the severity of the situation.
Then doctor on duty asked the relative to go and get the blood sugar level done from
another private hospital (that too at 10.00 pm)

1

KA 22

As I was accompanying the patient I asked the doctor on duty if they can suggest any
private laboratory from which we can get the investigation done.
Above all not a single sister/nurse was ready to take the blood sample so that we
could go and give the blood sample for the test promptly.

They were also not having bulbs for the blood sample collection (for Random blood
sugar test).
None of the doctors were having information about the private laboratory which
would be open at 10.00 pm.
They suggested two laboratories where we went but they were closed and by that time
it was 11.00 pm.

Then I decided to go to Wockhardt Hospital. We went there and got the bulb and
syringe for patients blood collection.

Reached Bowring Hospital at 11.30 pm

Ultimately a patient who was admitted with hemetemesis and malena with Diabetes
Mellitus at 9 pm was tested for blood sugar at 2.00 am. All the cost of the
investigation + Commutation was bome by the poor patient, adding one more
expense to the already worried family.
Patient was diagnosed as having - Type I Diabetes Mellitus + Pseudo pancreatic Cyst
+ alcoholic liver disease Total Hospital stay was from 14.11.03 to 19.11.03.
> Episode: 2 In next episode of illness in the same patient because of severe poverty,
grave illness and inadequate treatment he developed diarrhoea and vomiting on
8.6.04. This time he also had severe jaundice. He was examined by me at his home
and I referred them to get immediately admitted to Bowring Hospital. He was
admitted there on 10th June 2004 with history of severe weakness, severe jaundice,
dehydration and pedal edema.

Within last few months patient had lost almost 6-7 kgs of weight

When he was admitted this time they really had quite a painful and horrifying
experience at Bowring Hospital
In 4 days of stay the patient was given only 2-3 pints of intravenous fluid. That too
was purchased by relatives. The Doctor on duty also suggested more 25% Dextrose;
the relatives purchased them, but they were not given to the patient neither was any
other IV solution suggested.

2

KA 22

In a patient with severe dehydration jaundice and Diabetes Mellitus careful
intravenous treatment is a must. But except 2-3 pints of IV solution, no other IV
infusion was given in those 4 days of hospitalization.
Because of negligence the patient's condition worsened in the hospital. The jaundice
got worsened and probably he might have developed hepatic encephalopathy as he
stained rowdy behavior from the 3ra day of admission.

.And this is not all.

In a general ward, with continuation of diarrhoea (black stool) and jaundice because
of negligence and irresponsibility' he was worsening day by day.
.All through his admission his 12 year old son was there with his ailing father mother
could not stay in the hospital as she had a small child and other 3 children to take care
of.

No other relatives were there when they readily needed them. On 4th day of
admission, because of the rowdy behavior of the patient one of the ward boy gave a
strong punch on the chest of the patient. Poor 12-year-old boy could not tolerate
this. He was shocked as his father immediately after that punch the patient had a
blood vomit. The small, tender boy was afraid that the ward boy may kill his father.
He was so much afraid and shocked that he did not inform anybody (not to
nurse/doctor) he did not even take any of the case papers and took his father home
and explained to his mother with his continuous cry, about what had happened in the
hospital.

This is not only a denial; it is case of great negligence on the part of the public health
system.
For this illness the patients’ wife spent Rs.600.00. Their son went for begging and
wife for extra work.

Story is not yet over.
3 days after they came from hospital, which is on 16th June 2004, the patient died at
his home.

Now his wife and 5 children are living in immense poverty with no hope.

■A

*

3

KA 22

Issues:
No Glucometer to test for blood sugar is a tertiary care
teaching hospital.
2. No special tubes to coilect blood sample for blood sugar
test is a tertiary' care hospital

1.

3.

Referred to a private hospital from a public hospital for
blood collection and sugar test at extra cost for patient.

Inadequate intravenous hydration of the severely ill
and inadequate communication of severity and requirements to patients relatives.
5. Violence on a patient with mental health complications
due to worsening diabetes.
6. Inadequate response? supervision of case and behavior
of case and behaviour of health staff by senior health
staff.

4.

}
} Denial
}
}
}
}
}

}
}
} Negligence
}
}
}
}

4

KA 23

Testimony of Ms. L

Ms. L 37, years eld. lives in Ragigudda slums. She is a widow and she works as a housemaid.
She was admitted 1 '/2 years ago at (Sanjay Gandhi Hospital) Jayanagar General Hospital for

hysterectomy. The admission was free. They gave her all the medicines and told her that she
needs blood. " Trey are doing operation like business." They asked for AB negative blood

which Ms. L's family could not find any where. They had agreed to do the surgery by taking
the signature of his children a 20 years old daughter and 18 years old son. She was in the

hospital she stay ed 11 days after the surgery'. The anesthetist came and told her before the

surgery that she must give him Rs. 200. The helpers demanded Rs. 50 to shift her to the ward
from the operation theater, otherwise he tells the patient to walk and go. “ How could we

walk? So we had to pay”. The X ray technician and the lab technician took money from her.
The nurse who gave her injection demanded Rs. 5 be paid to her every time she gave an
injection. “ They do surgeries and throw away the patients like animals.
XVTiile discharging they demanded Rs. 2500, she did not have that much money. She paid

only Rs. 1500. While taking the money they said, “ we have saved your life, is this much
worth only". She said the doctor who does the surgery earns through bribe every week 7-8
thousand rupees. How much they would be earning in a month? She asked.
She was told to stay in the hospital till her scar was healed and go away. The sutures came of
the next day when she came back home. She was profusely bleeding. She immediately went

to a private hospital because she did not want to go to that hospital again after experiencing
the ill treatment and improper care from the staff at the Jayanagar General Hospital. "I do not

want to go to a Govt. Hospitals they ill treat the patients. ”

She said at Jayanagar General Hospital they do suturing without giving anesthesia. “ I have
seen patient reeling under pain while they did the suturing. " She said she spent about 20000

rupees for treatment both at Jayanagar General Hospital and Private hospital where she went

twice. She is still repaying the debts.

Denial of health care: bribery, corruption, and ill treatment of patients.

Negligence: suturing coming off

Consequences: dissatisfaction with the service in the Government hospital, loss of money,
debt to be repaid.

I

KA 24

Testimony of Mr. D
Mr. D. aged 10 years is suffering from epilepsy. He lives in Wahab Garden in Benson

town. He went to NIMHANS for treatment on 29th February 2002. He had to wait for a
long time and the end was simply sent away without prescribing or giving any medicines.

He went to a private practitioner who prescribed him the medicines for epilepsy.
He used to get the fits more than 10 times a day. With the medicines prescribed the
attacks were reduced but he has to buy more than 300 rupees worth of drugs every' week

from private medical stores. After he came to NIMHANS and started treatment his father
expired. Since then the economic condition of the family has deteriorated. He went agam

to NIMHANS with his mother and this time examinations were conducted on him. They
asked them to produce yellow colour ration card and told them that he would be given
tablets free of cost only if they produces it. With great difficulty he managed to get his

name included on his aunts family’s ration card with the help of civil supply department

Even though they produced the yellow card, they are giving them the prescription to buy
the medicines from private medical stores. Each week he has to spend Rs. 100 for the

tablets. The family finds it difficult to buy the tablets.

Denial of access:

Not given free medicines even though he produced the yellow

card.
Delay in care (not attended in the first instance)

Consequences:

Huge, unaffordable expenses for the purchase of medicines.

Recommendation:

Doctors must be trained and instructed to provide the care to which
the patients are entitled.

Institutions must supervise and ensure that the rights of patients are
respected.

1

A 2i>

—- ---Testimony of Mrs. Da

Mrs. Da aged 45 years was admitted in Jain Hospital after a wall near her house collapsed

and fell on her. She had undergone tubectomy few months ago in a Gon. hospital. When the
wall fell on her. the suturing gave way. She was bleeding and her uterus came out. Treatment

was given to her immediately and medicines were continued for five days but she got no

relief. As the family members insisted, the doctors to do a scanning, a scanning was done.
The scanning results showed a tear in her uterus. Doctors told her the uterus was poisoned

and she needed an emergency surgery'. They demanded that she paid 16. 000 rupees for the
surgery. Since the family was unable to pay, they requested the doctor to refer them to

Bowring hospital. She was referred accordingly on 20th July 2004. When she reached
Bowring hospital it was about 3.00 pm. About 12 doctors at Bowring hospital teased her for
going first to Jain hospital, her inability to pay and for coming to Bowring hospital. By the

time the consultants came to see her it was 5.00 pm. He suggested emergency surgery. But
the other doctors refused to take her for surgery by saying; already there are so many patients
are waiting. They decided to admit her at 7.00 pm. after her begging for a long time. She had

to wait for a long time for the surgery. When she agreed to pay Rs.5000 to the doctor, all that
she needed for the surgery' was brought. All the medicine they prescribed, she had to buy

from private medical stores spending Rs.5000. She spent almost Rs.15000 in the hospital.

Apart from spending she had to spend a lot of money, every nurse who attended to her
demanded 50 rupees and the nurse who put glucose also demanded 50 rupees.

Type of denial:

Bribery at the government Hospital to get the sendees
Demand for huge payment at the private hospital.

Delay in investigation in the private hospital;

Delay in admission at the government hospital.

Consequences:

Huge expenditure.

Recommendation:

Institutions must supervise and ensure that the rights of patients are

respected.

Greater vigilance and supervision by senior staff of the Health Services
to check bribery.

KA 26

Testimony of Mrs. A
Mrs. A w/o Mr. N, 24 years residing at Sriramanahalli, Sasalu Block, and post,
Doddabalapura taluk. Bangalore Rural district went to prenatal care at Saslu Primary
Health Center (PHC) three times. The last visit was on 25th February 2004. Medical
officer was not available at the PHC. The patient was made wait 2-3 hours at the PHC.
During the prenatal care no weight was taken. She did not get any drugs from the PHC,
she was given a prescription and she had to buy them from a private medical stores. The
medicines bought were tonics, antibiotics, tablets and Vit.A syrup. No documents
available were available at the PHC. no registration was made during the visit only
patient's name w'as entered into a register. If money is not paid the patients are referred to
the taluk hospital under some pretext. The patient was not given any transport facility
when referred.
The doctor comes at 11. 00 am to the PHC and leaves at 1.00 pm. There are neither
ANM nor any other staff available at the PHC. The PHC lacks good building, equipments
and drugs. There is no privacy for the patient while being examined. There are no
furniture in the center. There are no drugs available at the PHC. Dr. Ramraj Urs is not
available during emergencies.

Denial of health care:
Consequence:

Prenatal care unavailable.
The foetus died during 8±e month of pregnancy in the

Recommendation;

Make the medical officer available at the PHC.
Make all the drugs available at the PHC
Stop the practice of bribery from the PHC.

1

KA 27

Testimony of Smt. T
A lady by name Smt. T aged 38 years of Sriramanahalli died after undergoing abortion.
She had gone to the PHC to get her fore pregnancy aborted. The doctor was not available
and the ANM who was not well versed in conducting the abortion. During abortion the
lady died. The ANM had dragged the dead body and made it to squat in the bathroom
and locked the PHC and absconded.

1

KA 28

User Fee & Denial of Health Care

Mr. V was denied access for de addiction at National Institute of Mental Health and Neuro
Sciences, Bangalore.

Mr. V a 28 years old young married man currently resides in a registered slum at Sudhamanagar,
near Hindustan Aeronautical Limited (HAL), Bangalore. As the result of many years of
excessive drinking from the age of 13 years onwards, he has severe physical, social and
economic problems. Mr. V is a coolie worker at a scrap collection centre. He earns Rs. 100 per
day and spends all the money for alcohol consumption. If he has no money gets it from his wife,
who is the breadwinner of the family. She earns money by doing domestic work. He has 6 years
old son and 9 years old daughter. His wife and children are psychologically affected.
Mr. V went to NIMHANS on 23rd August 2003 to get treatment for alcoholism. Since Mr. V was
a chronic alcoholic with severe withdrawal symptoms, Mr. V needed admission for treatment of
his physical and psychological dependency. He was asked to deposit Rs. 2000 for the treatment
as per the policy of NIMHANS. For patients submitting Below Poverty Line (BPL) ration card
the deposit was Rs. 250. and for all others without the BPL card, including urban poor and
migrant people the deposit was Rs. 2000. Since Mr. V did not have a BPL (yellow coloured)
ration card and could not deposit Rs. 2000, he was NOT admitted and treatment was denied to
him.

Now Mr. V is miserable and sick, not being able to receive the treatment due to the ‘user fee’
Policy at government hospitals. He again visited NIMHANS on 03/05/04 with very severe
condition and this time too he was denied treatment because of not having a BPL card and
because he was not able to deposit Rs. 2000.
Denial of Healthcare: Refusal to admit and give treatment, because the patient could not
produce BPL card or deposit Rs. 2000/-

Consequence:

-

Continued dependence on alcohol
Loss of money
Psychological trauma of the patient and family

Recommendation: The insistence of‘user fee’ and ‘deposits’ should be waived in such cases.
The availability of BPL cards should be improved, so that people like Mr. V and migrant labour
have access to them and through them to the needed healthcare.

1

STUDY ON IPP VIII CENTER - KORAMANGALA

Back ground
Koramangala slum is one of the biggest slums in Bangalore. More than
70,000 people are living in this slum. More than 10 Non-Governmental
organizations are working in this slum for these people's development. This
shows the status, need of the koramangala area people and the extent
of the area. One IPP-VIII health center is located inside the slum. The
Center is situated in a strategic place; from center the peripheral point of
the target area is one Kilometer far away from the center. In Jansunwai,
which is going to be held in koramangala slum with officials and people,
the denial of health care testimonies and the status of this area health
center will be presented. For this purpose S.D.Rajer.diran, member, board
of visitor of BMP and Community Health Cell team and Ameer khan .K,
fellow in Community Health Cell visited this health center on 20/07/04 and
03/08/04. They met the health center staff and dccumented the current
status of the health center.
Purpose of the Visit
Jan Swasthya Abhiyan (India chapter of People's Health Movement) has
organized a country wide public hearing along with NHRC. The theme for
the public hearing is 'Denial of health care". This campaign is part of the
Right To Health Care (RTHC) campaign, initiated by Jan Swasthya
Abhiyan. Joining in the National movement the NGOs working in the
Koramangala Slum decided to conduct public hearing for Bangalore
slums. The purpose of study about IPP VIII center is to contribute to this
campaign.

Need of the Health center
In this biggest slum there is no hospital (includes private hospitals) other
than this IPP -VIII health center. In the slum 4 clinics are run in the daytime
by non-qualified persons and one clinic in the evening by a qualified
allopathic medical practitioner. Due to this reality Koramangala people
are much dependant on this health center. For this locality people this
health center is the first contact point and for any emergency these
people have to first step into this health center. For any kind of
Government initiatives in preventive, promotive and curative health care
this is the only government institution as a medium for intervention.
Expected Services from IPP VIII Health center
1. RCH/Antenatal services / Post natal services
2. Family Welfare services like Copper T', Oral Pills & condoms
3. Immunization services
4. Outreach programmer
1

KA 15

5. School Health Service:
6. Awareness Programme
-Environmental Health
-Nutrition / Breast feeding
-Epidemic diseases
- Gastro entities
-Malaria, Tubercu osis
-HIV / AIDS
7. RNTCP
8. Referral Services
9. IEC / Counseling
10. Camps for HIV/ Eye Defects / Cancer Detectfcn, etc.
11. Minimum Laboratory services
12. Family Health Awareness Campaign for HIV / AIDS.

Services Available in the IPP-VIII Center- Koramanqala
This in formation was elicited from the health center staff.
1. Ante - natal care, post natal care for the pregnant women,
includes the medical care and lab medial investigations. Family
welfare Services like Copper T, Oral Pills & condoms are available in
this center.
2. Immunization services to the Children.
3. Regular medical check ups (once in a year) for school going
children with immunization program. For this year the center has not
done the program and they don't have planned to do at that time
of visiting.
4. Referral services. But this center is not provided with ambulance,
staff will refer the patients to the Austin fawn maternity home and
other hospitals.
5. Services for TB patients.
6. Minimum laboratory services are available in this center like Urine
test for Pregnancy confirmation, blood test for hemoglobin, and
blood group identification by the laboratory technician from Austin
town maternity home. But due to the lack of lab technician the
tests are not done for more than 3 months. (Lab technician went on
maternity leave}. So, all the patients are referred to Austin town
maternity home for these tests, which is located at one - and- a half
kilo meter away from this center.
7. Apart from these services center has provided assistance and
space for the health camps (for instance, in July month Jain
Mahaveer hospital conducted surgical health camp in the premises
of the center with the help of the staff) and other health related
programs.

KA 15

8. The last family health awareness camp (STD identification camp for
Ladies) was done on August 2003.
All the above services are provided at free of cost. For lab services
user fees are collecting. (Information about the User fees is given
separately)
Services not available in the center
1. This center had nutrition promotion program many years ago.
now this center is not having any nutrition promofon program.
2. This center is not equipped to provide treatment for any type of
minor ailments.
3. Neither the health center staff got any training on environmental
and sanitation management nor the center -.ave program on
environment and sanitation.
4. The center did not form any Social Health anc Environment (SHE)
clubs.
5. Though the center is formed for preventive and promotive care
now-a-days center did not involve with any kind of awareness
program.
6. One of the responsibilities of the center is referral service it does
not have ambulance.
7. Center does not provide any counseling services and IEC
activities.
8. Center is not equipped for conducting camp for identifying eye
defect and cancer detection.
9. The previous doctor was doing Medical Termination Practices
services. The in charge doctor is not showing interest to do MTP, and
the reason they said was, they are not provided with any
emergency medicine and sen/ices. So, they don’t want to tcke any
kind of risk.
Poor Utilisation
The out patient register shows very small numbers of people were
accessing the facilities provided in this center (population of this slum is
more than 70,000).
Information gathered on 20th July 2004; Number of users : OPP
20/07/04
-None of the ANC & PNC patients were treated (All the ANC
&PNC patients were asked to come on Thursday because the
doctor went on leave). 25 general patients are treated by
ANM.
19/07/04
-Eight patients
18/07/04
-Sunday
17/07/04
-32 patients
16/07/04
-17 patients

15/07/04

-18 patients

Information gathered during on 3rd August 2004; Number of users: OPP
26/07/04
- 27 general patients. All the ANC patients were sent back
due to the non-availability of the doctor.
27/07/04
-19 general patients
28/07/04
-No patients
29/07/04
-30 patients
30/07/04
-5 patients
All the general patients are looked after by the ANM. Through the
dialogue with her we were able to understand that most of these patients
are given only paracetamol tablets.
Allotted staff member for the center
Lady Medical Officer
-1
Lady Health Visitor
-1
ANM
-3
Link Workers
-10
Peons
-3
One Pourakarmika and one helper is deputed from Bangalore
Mahanagarapalike

Availability of staff member
1. Lady Medical Officer
One lady doctor was appointed. Now she is on maternity leave.
Instead of her one doctor was deputed to this center. Both the days
of the visit, the doctor was not available. She was on casual leave.
Due to the doctor's non availability, center is not able io do its duty.
All the ANC patients were not treated for long. No drugs
requirement was sent from the center. All the patients were referred
to the other centers.
2. Lady Health Visitor
One lady health visitor was appointed; both days of the visit, she
was not available in the center.
3. Junior health assistants / ANM
Two junior health assistants were appointed: one has gone on
maternity leave and no one is deputed on her place, one post is
yet to be filled. Both the days we were able to meet the ANM
present.
4. Pourakarmika
One Pourakarmika was available in this center while we visited.
5. Helper
One helper is available in this center while we visited.

4

KA 15

6. Lab technician
One lab technician will come once in a week from Austin Town
Maternity home. Now she is in maternity leave.
7. Peon
Three peons were appointed for this center. When we visited first
time to this center, both the peons were not available, while at the
second time one peon was available. Staff said that, one peon is
always irregular and nobody is able to control him including the
doctor.
One post is vacant.
9. Link worker
This center had link workers at the time of running of the center
under IPP-Y1I1 scheme. As soon as that scheme period was over, the
link worker concept was stopped..
Infrastructure
This government building is provided with regular electric supply, water
supply, autoclave facilities, refrigerators and toilet facilities. When we
visited the center, inside of the center premises was clean and
maintained property.
Between the center compound wall and the building there was lot of
bushes. People used the open place as lavatory. Health center wastes
are burned in ore corner of the building. The drainage was fully blocked.
Health center is affected with severe water scarcity. There is no bore well
in the center. The center has to meet its water need through the
corporation wate' supply, mere is an over head tank but the tank is not
capable of storing the water. Toilets are not in useable condition due to
the non-availabiilty of water. There is no drinking water supply too. There
are no drainage or rain water pipes and drainage tank iron covers. It is
probably stolen and not replaced. Ar the window glasses were broken.

Investigation facilities
Health center is providing investigations facilities for urine test for
pregnancy confirmation and blood test for Hemoglobin, blood group
identification and VDRL test. But due to the non- availability of the lab
technician from last 3 months there is no test is done. Patients are referred
to Austin town maternity home for the blood and urine test.
For Urine test (Use' fees) - Rs. 10
For Blood test (Use' fees) - Rs. 10

Availability of medicines
Health center is supplied with anti rabies medicine, drugs for TB, antibiotics
and other drugsfor the services that they offer. Medicines for ear and eye
infection are no' available. The health center offers temporary family

KA 15

planning services through issuing condom, pills and providing copper - T
facilities. List of the medicines available at the center on the day of visit is
enclosed.
Suggestions for improvement (Staff’s View)
When staff were asked to give suggestions to improve the health center,
they are able to tell us the need of the link worker and big walls to prevent
the people coming into the premises in order to keep the premises clean.
Community’s view
There is strong dissatisfaction among the people about this center. They
said that, by 12 noon they would not get treatment from this center (The
working time of the O.P unit is 9.a.m to l.p.m). Usually they will get
treatment only after waiting long time. Two pregnant mothers complained
that one day they waited more than two hours. When they were waiting
staff do not look after any other patients too, they added. Some gave five
to ten rupees for injection. All of them are not satisfied with the way they
are treated in the center. As a whole, there is no surprise that the center
does not get any co-operation from the people.

Visitor's Observations
. Though the center’s doctor is on leave, the ANM seems to be
committed to run the center as much as she can.

.

The surroundings of the health center are in dreadful
condition; it is stinking and people are using the place as
toilets.

.

Two men were lying besides the building and playing cards at
the time we visited.

The behavior of the peon and inability to control him seems
to be because of some vested interest of the authorities on
him. So, the burden of work is shared by the other staff.

.

There is no community participation in the center’s activities.

.

There is no citizen’s or patient’s charter available.

Denial of Health care
Antenatal care denied to' those who came to the centre as also other
health care, because of absence of medical officer. No laboratory test
because of absence of laboratory technician. No school health program.
Poor environment and no water supply.
6

KA 15

Consequences
Non - utilization of services, dissatisfaction with the services and non co­
operation with the centre.

Suggestions
. Doctor should be available on all the days and the center
should create confidence among the people about the
services and the doctor's availability.
.

The link worker concept would be useful to provide effective
services to this big slum.

.

Developing proper relationship between the center and the
Community is very important for the smooth functioning of this
center.

7

KA 12

Study on Austin Town Maternity Home

Date of Visit: 12-07-2004 & 16-08-2004
Austin Town Maternity Home is easily accessible for people belonging to Jayaraj Nagar.
Koramangala. Vivek Nagar and Neelachandra area. In these areas the majority of the
population belongs to lower stratum of society economically. It is not easy for them to
pay 5 to 6 thousand rupees for a normal delivery in a private hospital. (The nearest
private hospital in this area is St.Philominas Hospital. Here the patient has to pay 5 to 6
thousand rupees for a normal delivery). So. the people need and depend on the maternity
home for deliveries and other health care services.
The services offered at the above centre are as follows.
Out patient
Treatment of minor ailments, immunization for women and children, antenatal
and post natal care for women.
In patient
I. Deliveries
2. Tubectomies (Every Wednesday;
3. Cesarean sections and Hysterectomies, where indicated.

Personnel allotted for maternity’ home
• One doctor (gynecologist)
• One pediatrician for two maternity homes
• Four staff nurses
• Three ayahs
• Three pourakarmikas

Five peons
• One Lab technician
• Second division clerk
• One Dhobi

Persons available in this maternity’ home
Doctors
Dr. Shobha is the Lady Medical Officer. She is available in the centre from 9.00 am to
1.00 pm (duty hours are from 9.00am to 4.00 pm). In addition a Paediatrician is also
available. In their absence in case of an emergency a corporation doctor (Dr.Siddappaji,
who work in an other corporation hospital) who resides nearby is called.
Staff Nurses
Two staff nurses are on duty while two posts are vacant. Among the three posts of ANMs
two are filled.
In addition to the above the following personnel work at this centre.
Lab Technician -1
(In charge available on Mon and Fri from 9.00 am to 1.00 pm.
Regular Technician is on Maternity leave)
Pourakarmikas -

While there are three posts of Pourakarmikas only one was
available on duty

1

KA 12

First Division Clerk- 1
(The post is vacant for almost 5-6 years)
Second Division Clerk-2 (One is deputed to DHO Malleswaram and another works for 4
hrs here and 4 hrs at another centre)
Aayas-3
-Three Aayas are available in the home
Dhobi-1
- One dhobi is available in the home
Peon
- Three peons are available in the home and Two posts are yet
to be filled.
The peon whom we met stated that the deliveries were conducted by the staff nurse
herself (We are not sure whether this was in the presence or absence of the doctor)
Infrastructure
The centre operates out of a corporation building. Regular water supply and
electricity is available. The building suffers from leakage. Due to this, the plaster has
started to peel off from the roof and the walls. The toilets are in a very’ dirty condition and
in one of them the taps were leaking. The numbers of beds available are thirty (The
allotted beds strength is 34) and all of them seemed to be in a usable condition. The
lockers provided for the inpatients were in a rusted and dirty condition. While the Labour
Room was in a working condition, the Labour Cot had begun to rust and the rubber
sheets used were in a very bad (unhygienic) state. The staff explained there was a
shortage in the supply of these rubber sheets. The Garbage bin in the Maternity ward was
full and not emptied. Hot water provided for the patients was very little and only in the
mornings. The inpatients said that clean drinking water was not available at the centre
and hence they preferred to bring water from their homes.
When we had a look at the registers we found something interesting. On certain
days (4-5 in a month) a large number of outpatients had come to the Maternity Home
whereas on other days the number dwindled to a handful. The Staff nurse with whom we
interacted had no explanation for this surprising phenomenon. We were left wondering
whether it could be because of the availability of the doctor only on those days for
outpatient sendees.

Service Charges
According to the staff present the following were the services that were charged,


Lab Tests
MTPs

Rs. 10/Rs. 100/- (these are the actual amount fixed by the corporation)

All other services were offered free of charge.
'
However on enquiry among the inpatients one of them told us that they had to pav money
for the delivery that was conducted there. Bevond this they were not willing to divulge
any information as to how'much thev had to pav.
.
.

Access the center bv the people
While visit the center on 16lh August the following details were collected.
From 9/08/2004 to 13/08/2004 the following number of people access different services;
OPD services
-81

2

KA 12

No. of ANC patients
No. of In patients

-78
-18

No. of deliveries
No. of referrals

-16 (The baby delivered with highest weight is 4.4
Kgs on 9th August 2004)
- 03

NO. of MTP services

-03

No. of IUD services

- 08

iui

NO. of TO services
-2
Apart from the above services immunization services were also given.

This is being filed after a visit to the Community
While visiting the maternity home the question as to why only a minimum number of
people were using this maternity home arose. This was in spite of the services being
provided free. Neither the doctor nor any of the other staff of this maternity home had an
answer for this question. The only answer the doctor had was that the patients were not
slaying in the home for more than a day after delivery. Hence, beds were always vacant.
This points to the fact that the patients are very poor and even after delivering a child,
they couldn't take rest in the hospital. They had to go back to earn money for their daily
living. So, obviously poor people should show much interest in making use of the
services, but the picture is just opposite.
To know this on I3lh July 2004 Mr.S.D.Rajendiran, member board of visitors of
Bangalore Mahanagara 1’alike health centers and community health cell team and
Ameerkhan.K. I?ellow in community health cell were visited Jayaraj Nagar, which is
besides the maternity home. Four women ( Ms.D, Ms.I, Ms.S, Ms.Sa) were selected
randomly and interviewed, Some of the comments collected from them are,

A pregnant women says positively that she is going regularly for Ante
Natal Check up, she is getting folic acid tablets and checking at free of
cost, but she is receiving treatment for maximum of two minutes, where as
(he pregnant women has to get blood test, urine test every month, detailed
advice from the doctor about nutrition, anemia, sexual relationship with
husband, bleeding and other problems are missing.

The other woman who delivered a male baby one year ago at Indira nagar
hospital is not using (he home for her child immunization but all the other
women are accessing (he facility of immunization from maternity home.

3

KA 12

Most of the women said most of the lime they have to buy medicine and
disposable needles from the medical shop. I here is a strong feeling among
them (hat the staffarc not showing even a '.mall amount of concern.

One lady got a slap from the staff muse al the time of delivery, when she
was crying due to the labor pain.

A woman who stayed for two weeks in the home for delivery and
lobectomy was given one bed sheet for the whole period of her stay. This
has happened even though there is a dhobi appointed especially for this
home.

User Fee in the Maternity Home

1 his information has been collected from the women who were interviewed.
The amount they paid for accessing the services in the home are as follows.
Services

1. Male child delivery

Amount Paid by the
Patients (In Rs.)
500

(Government
Fixed charge (In Rs.)
Nil

2. Female child delivery

300 to 400

Nil

3. M i l’

400

100

4. Tubectomy

400

Nil

5. Blood test
6. t trine lest

20
20

10
It)

7. Polio drops

2

8. Any Injection (If the patient doesn '(
cany any disposable needles)

5

.

Nil

Nil

Apart horn these while the patients ate discharged from (he maternity home they have to
pay to each hospital staffabout 25 to 30 rupees.
Suggestions for Improvement (Staff’s view)
On being asked if there if (hey had any suggestions to offer for improving the service
at the Maternity I Ionic, the staff who interacted with us said that availability of more
medicines (antibiotics), and equipment (Warmer), a contract dhobi (as (he government
appointed dhobi was not doing the work properly). Availability of rubber sheets and
repairing the leakages would help them to serve the people better.

4

KA 12

Visitor’s observation and suggestions
After many interactions with the Dr. Shoba. we felt that she is keen to improve
the quality of the senices provided in this home. The opinion has been further
strengthened at that lime of second visit to the maternity home on 9th August 2004. The
water filters are cleaned and filled with water. Bed sheets are washed and dried under the
sunlight and home is maintained as dirty free environment.
People who are on duty are not available. Vacant posts need to be filled up. It looks like
an abandoned hose and three dogs were making the OPD department their resting place.
It seems that the people coming to this place are coming there only when they have no
other alternatives.
Tough the Maternity Home has a very big infrastructure: the number of patients making
use of it is very low. It could be because of the patients are provide only a room and a
trained birth attendant. There is no facility for a caesarian delivery. The patients also have
to pay for a delivery in spite of the services being free (We arrived to this conclusion
after met the community). On the whole they don't seem to be getting many benefits and
hence they prefer to pay and make use of private nursing homes. The Lady Medical
Officer seems to be unavailable and probably' it could be one of the reasons why the poor
people are staying away.

The Maternity' Home we visited was an example of the extent to which the Government
Health Sector could do for the marginalized as well as its failure to rise up to the
situation. With the infrastructure and facilities available at this centre they could very
well cater to the needs of the poor women from the surrounding slums. It had/has the
potential to develop into a centre for women run by the Government. Instead of providing
infrastructure. I feel the need is a change in the altitude of the service providers, be it the
doctor, staff nurse or anyone who works here. Unless the staff have the right motivation
things will continue to be the same. The tap that needs to be turned off is the corruption
and mindset that is present among some of the Government employees that they are
Lords and Masters and others have to pay respect and adoration to them. Unless they
have a sea change in their minds and hearts and decided to serve the people nothing much
can be done. We may provide any number of material resources but the condition will
continue to be the same.
Actions to be taken
1. Create awareness among people about the services of the maternity home.
2. A Monitoring system by the people themselves should be created.
3. Each centre should have a governing body, comprising of the local people that includes
the corporators, ward member and leaders of various people’s organization working in
that area.
4. The Corporation should rank the maternity and medical centers and arrangement
should be made to give awards for the people who render good service to boost their
morale.
5. According to the people the staff should immediately stop of getting unofficial money
for deliveries.

5

KA 04

Campaign and Struggle Against Acid Attacks on Women (CSAAAW)
No. LF 1'6. BDA Flat. Opp. MICO layout Police Station. B.T.M. Layout. Bangalore - 560 078.
Ph: 9448444252. 6786754. csaaaw arediffmail.com

"This ear is burnt completely. I can hear in only one ear now. Even this eye is partially burnt. I
can "t see very clearly. My eyelids were also completely burnt. They were replanted four times
with skin from elsewhere. My lips were also burnt and I had to have several operations to get it
reconstructed. The skin around my neck had also tightened, with my head being pulled to one
side. Another four operations to straighten my neck, but even now without this belt, the skin pulls
my head to one side. Klien that happens, the skin around my lips and lower eyelids are also
pulled don nwards. That is why I have to wear this collar all the time. "
-Shamhi M.G.. Mysore District. Karnataka

Following 14 years of sustained domestic violence. Shanthi was attacked by her husband in 2001
with concentrated sulphuric acid at her residence in Periyapatna Taluk. Mysore District,
Karnataka. Immediately following the attack, Shanthi was taken to the taluk level government
hospital in Periyapatna and shifted from there after the medical staff at the hospital admitted to
their inability to treat Shanthi. She was taken to the K.R. Govt. Hospital in Mysore where she
remained for the next 19 days.

"They did not give me any first aid. just wiped my face, my eyes were fully red and my face was
burnt black. They gave me IVfluids for the next nineteen days. They didn "t do anything else. They
didn t dress it or apply any ointment. Yes. this was K.R. Govt. Hospital. "

Mother of two children. 32-year-old Shanthi today is struggling to live by herself and bring her
two children up. Her problems both physical and psychological have been compounded by acute
lack of medical attention immediately following her attack. Several doctors have confirmed that
not receiving appropriate immediate medical attention has infact worsened her condition.
Growing medical costs and lack of adequate facilities required for functional plastic surgery in
public health institutions has meant that Shanthi today struggles to live. Shanthi. however
considers herself lucky. Four other acid attack survivors across Karnataka, all of them women,
have in fact succumbed to their injuries.
The initial fact finding reports from Campaign and Struggle Against Acid Attacks on Women
(CSAAAW), a coalition comprising several organisations, academicians, lawyers, journalists,
women's rights activists, reveal that there are 35 women who have been attacked by acid in the
past ten years across Karnataka. CSAAAW activists categorically maintain that this number is
only an indicator, there are I were many others who have been silenced by society and are
unwilling to come out in the open with the horrifying facial distortions.

CSAAAW is committed to action on two fronts - seeking legal and socio-economic justice for
the survivors and more importantly to fight for prevention of such attacks on women. “Acid
attacks is only a more violent extension of the existing crimes on women like rape, dowry
harassment, sexual harassment by the patriarchal society'.

1

■•t

KA 05

Testimony of MR’s mother

Ms MR aged 14 years, daughter of Mr. M from Koramangala slum. Bangalore -560 042

went to Dr. Sumangala Hiremath of Vibhava Clinic (270. 5<h Main. Ambedkar Sagar
Koramangala III stage Bangalore- 560 042) with complaints of vomiting and diarrhoea on Ist

June 2004 at around 5.00 pm. MR's mother w as interviewed by S J.Chander of Community

Health Cell on 4.8.2004 at about 3.00 pm and on 12lh August 2004 around the same time.

MR's was busy the whole day washing clothes and cleaning the house. At about 3.45 pm she
complained of stomach pain and had diarrhoea. The stool was like water and the quantity was

about 2 liters. After 15 minutes she vomited. She complained to her mother that all that she
had eaten in the morning (chithranna) was vomited. After vomiting she complained of pain

all over her body (she explained the pain as pulling)
At 5 pm her mother took her to Vaibhav Clinic. The mother said that though she did not have

good report about the doctor at Vaibhav Clinic, she chose to go to her because as she noticed

as she was passing by that the clinic was empty. She was not sure if the other clinic near by

would be free. As soon as MR was taken to the clinic the doctor, without examining MR.
started he on IV fluids. Four bottles of IV fluids were given before 9.00 pm and five
injections were given through the IV fluid bottles. The doctor promised that the girl would be

all right.

In the meantime MR’s mother called up the father who is a daily wage earner at city market
and informed him that their daughter was very ill and asked him to bring some money
immediately. The father arrived at about 5.30 pm with Rs. 500 which he borrowed from his

employer. He sent his wife home and stayed with his daughter in the clinic. At about 9.00

pm when it was time for the doctor to close the clinic, the doctor demanded Rs.500 be paid to
her for consultation and medicines. He replied that he did not have that much money and

said he would pay Rs.300. She did not agree and scolded him. She insisted that he pay Rs.

500. The father had to pay all the money that he had borrowed and took the daughter home
on his shoulder.

The mother said that, as soon has her daughter was brought home, she made the bed in the
room

(the only small room the house has). Before the bed could be made she was asked to

stand for few minutes, while standing she again passed watery stools. “ Seeing this I shouted
what is this even after getting the treatment from the doctor and paying so much money she is

having diarrhoea". Her husband told her to be quiet.

KA 05

While sending MR home, the doctor told them to give 4 tablets at 1.00 am and another dose
at 3.00 am. She also told them to give her hot coffee and keep her warm. As she could not eat

anything. they continued give her glucose water, but she continued having watery stools. The

mother made a sanitary pad of cloths and put it on her. She kept checking if the pad was wet.
Every time it was wet she cleaned and changed then she does not know how many times she
had watery stools. At 1.00 am four tablets were given. MR with difficulty opened the mouth
and swallowed the tablets. The mother sat next to her observing the daughter. She found her
daughter restless, not sleeping. At-about 3.00 am they ga\e the second dose of tablets. This

time she took the tablet with difficulty. She appeared very tired to the mother. The mother
noticed that few minutes after taking the tablets, her body movements almost stopped and she
appeared to be in deep sleep. She poured little glucose water but the daughter did not drink.

" I thought the tablets were working and she is sleeping. I was checking at her nostrils ifshe
was breathing ". At 5.00 am when she tried calling her daughter by name she did not respond.

The mother said she held a candle in one hand and held her daughter in her arms and started

praying, asking Mother Mary to spare her life. Her daughter's body became chill and she
stopped responding. Her husband told her that their daughter is no more. As soon as she

heard this she fainted. She recouped after few minutes. By the time she gained consciousness
it was about 5.30 am. The father took his daughter in an auto to isolation hospital in

Indirinagar. She said the staff at the hospital checked and said " She had died half an hour

ago. IT7n- have you brought her here? "
The mother said " The doctor could have told us that she would not be able to manage my

daughter. We would have gone to another doctor, or she should have guided us to another
hospital or doctor " The mother said the lady doctor's husband is also a doctor and he was
also with her when her daughter was treated.

In front of the clinic where the address is

mentioned there is a board carrying the following information “ Vaibhav Clinic” Dr.
Sumangala Hiremath, clinic timing. No degree of the doctor was mentioned on the
board.

Denial of health care:

Incompetent and negligent care; ^doctor not qualified to practice
allopathic medicine.

Not informing patient and guardian/relative of the condition of the

patient.
Consequences:

Death of the patient: which may have been avoidable with proper

care.

2

KA 06

Case Study of Mrs. S

Mrs. S. 23 years old was admitted to Jagjeevanram Nagar Maternity Home in October
2003 for delivery. There was no doctor on call and she was attended by the attendants
and duty nurses. Two pain killers were given they had to be bought from outside for
Rs. 120 -. Later when she developed severe labour pain, the night duty nurses were
called. But they were asleep and refused to attend to Mrs. S. The baby was delivered
with the help of the attendants. The baby slipped from the delivery table and fell in the
bucket at the foot of the table. The baby died. To add further misery, her husband had
suffered an accident during the wife's pregnancy and it has been confirmed that he will
not be able to produce any more children.
The deficiencies were:

a. Lack of attention.
b. Gross negligence on the pan of the nurses and attendants
c. No medical care on time
d. Doctor not informed
e. Patient had to purchase medicines from outside.
This resulted in
a. The baby's death
b. Mental trauma to the mother due to loss of the child.
c. Financial loss
d. Trauma suffered by family as they are unable to have another child.

I

KA 10

Testimony of Mrs. G
Smt. G, aged 58 years residing in Anandapuram slum was being treated in

Kidwai Memorial Institute of Oncology for treatment of cancer of the

esophagus.

She went there five days in a week for the past three months.

The last visit that she made to KMIO was on 19th July 2004.
Initially she paid Rs. 50 for the registration.

After that, for even- visit she

had to pay Rs. 10 as a bribe to send her chart to the treatment room. Failing

to pax- Rs. 10 would lead her to waiting for long hours. Many days, in order

to avoid paying Rs. 10, she had brought the chart back home and took the

chart directly to the treatment room the next day. For IV drugs she had paid
Rs.400 and administering charges for the person who administered them
was Rs 110.

Even- time when she went for radiation therapy, the nurse told her to find

herself an empty bed and lie down. " Many clays for putting Intra Venous line
they allowed the trainee nurses, they could not do it properly, as a result I

suffered with swollen hand (rattham kattipochu) veins with blood clot."
She said the doctor who gave her the radiation therapy, on seeing her
wearing mangalsuthra (thaali) he was irritated and told her " It is only a

traditional symbol, Remove it, Do you know the disease you got is a dying
disease, Why do you need all these ornaments."
The person who gave the radiation demanded Rs. 100. He shared the amount
with the other staff who were with him. The next time when she went she

did not have money so she offered to give him the sarees tied to the statue of
mother Mary. The staff took two such sarees from her.

She said the person who did the X-Ray too did not talk to her with respect.

He asked her to buy her powder for Rs.90 from a private medical store. She

had to pay Rs. 20 for the auto for transportation to get the powder.

The

powder is given orally before taking the X-Ray. When she brought the
powder, and consumed it she was asked to go. The X-ray technician

1

KA 10

demanded money. She gave him Rs. 10. She said she saw using the powder

that she brought for other patients and saw him taking Rs. 100 from them.

During the last stages of her treatment she said she was given radiation
without a shield being put around the unaffected area. " I felt the burning so

severe and I had boils all around the area"

She had to get her blood test done twice in two weeks. She paid Rs.275 for

the blood test. The next time the blood test was asked she did not have the
money. The doctor told her to get it done from any hospital. Since her
husband was an ex army man. she went to the army hospital and got it
done. The doctor at the army hospital had given her a prescription but the
person at the drug store did not give her the drugs. She said she went for

about 25 days for radiation. The doctor would come at 12.15 p.m. and go

away at 1.00 p.m. The doctor came back later some time after 4.00 pm ’

Some times I had to wait from 9.00 am to 4.30 p.m. to meet the doctor.'
She said the total amount that she spent during the past three months
would be about Rs. 25,000, which includes money for medicines, bribes.
and travel costs. " In spite of the fact that I was introduced to KMIO by an

organization known to them and I am a social worker I had to go through so

much of sufferings, How about people who do not know anything". She said
she liked the doctor, Dr. Govind Babu, who treated her well. There was an

attender who told her not to pay money to any body for anything.
Denial of health care: Bribery, Demand of Payment, when it should have

been free.
Disrespect; Psychological trauma.
Incompetent/negligent care
Consequences: excessive expenditure; loss of time, waiting the doctor

2

KA II

Case Study of Sonnenahalli PHC, Vivekanagar, Bangalore
Population: 22.000
1.
2.
3.
4.
5.

6.
7.
8.

9.

Male Multipurpose worker is not available.
Disposable Delixery kit is not axailable.
No specific date and time of the visiting Doctor.
No prior intimation regarding doctor's visit to residents of the locality.
Traditional trained dais do not get any co-operation from ANM while
conducting home delivery.
There is no supply of disposable delivery kits to the TBA (trained birth
attendant) by the PHC
Emergency obstetric care is not available round the clock.
No ANM or trained dais accompany the women in labour while shifting them
the from PHC to other referral hospital for further treatment.
Facility of blood smear examination is not available to confirm Malaria.

Survey form: VHAK. Co-op Aid Trust

-a-

KA 03

User Fees and Denial Of Healthcare
Introduction

The ingestion of alcoholic beverages for their so-called “enjoyable” effects is a very
common phenomenon especially among youngsters. Later on, it leads to chronic
abuse of alcohol
An enormous amount of damage can be attributed directly to
alcohol abuse. It results in the ruin of the physical, social and mental health of
individuals and families, besides eating into the family income of the drinkers.
Alcohol also contributes to other problems; an estimated 25% to 4C% of hospital
patients have problems caused by, or recover}' delayed by alcohol abuse (Maltzman
2000).
/

Alcoholism is a chronic progressive illness, which manifests itself as a behaviour
disorder. It is characterized by repeated and excessive drinking of alcohol beverages. If
not treated in time, an alcoholic can die of medical complications like gastro intestinal,
liver, pancreas, central nervous system and cardiovascular system problems, accidents
and even to suicide. The treatment consists of detoxification, counselling after care
and rehabilitation.

Case Study
Das (name changed to conceal his identity) was denied access to de-addiction
treatment at National Institute of Mental Health and Neuro Sciences, Bangalore.

Das is a 54 years old male, who currently resides in a registered Sudhamanagar slum
(close to Hindustan Aeronauticals Limited, Bangalore). As the result of numerous
years of excessive drinking, he has severe physical, social and economic problems. Das
is a construction mason whose job. seasonal. Now, a days he works for the sake of
fulfilling his alcohol needs. He frequently falls sick and eats at the most once a day.
He starts drinking soon after he wakes up. Around 5 a.m., he walks directly to the
alcohol retailers and consumes one quarter i.e., 180 ml of brandy or whisky (Rs 28) to
help his hangover. If there is no problem in the working place, he consumes another
quarter at noon and repeats this in the evening and at night. He earns Rs. 150/- per day
and spends all the monev on alcohol. If he has no money he tries his best to get it
from his wife, who is the breadwinner of the family she earns money doing domestic
work. His wife and children are psychologically affected. His wife says that she finds it
difficult to provide one meal a dav for the family. Their only 14 year old son stopped
going to school due to poverty. Social stigma makes them keep away from the
community and their relatives. Now' Das feels helpless, isolated by the community and
has no plans for the future.

KA 03

Patient History

Das was the youngest child of eight children in a small farmer family in Mugaur,
Villupuram district, TamilNadu. At the age of six, he was sent to Bangalore to live
with his elder brother, who was doing plumbing work. His brother consumed
alcohol each day in the evening. Sometimes he asked Das to get alcohol beverage from
the shop. On Sundays, his brother used to drink toddy and offered toddy to Das a few
times, saying that it was “good for health”.
Thus he started to taste alcohol and whenever he went to the retail shop to get alcohol
beverage for his brother, his thinking was “Why shouldn’t I drink as well?” Day by
day this urge was increasing with him and finally one evening he got courage, enough
to by consuming 92 ml of Brandy. He felt good and thrilled. Slowly he started to
drink twice in a week and it increased to a daily evening basis. At this stage his family
became alert and arranged a marriage for him as a solution to this problem. After the
marriage for two years he did not consume alcohol. When his wife was sent to her
parent’s place for the delivery of the first baby, he started to drink again. As a result,
he was forced to move out from his brother’s home. This was a very sorrowful
matter to him and he started consuming alcohol even more (from morning to evening,
e. morning 18C ml (quarter) afternoon one quarter and the same in the night). The
i.
heavy consumption continued through the following years.
Then, one day his teenage daughter disappeared; she ran away with a boy who lived in
the nearby slum.
It made him miserable and he started ‘binge drinking’.
(Psychologically daughters long for their father’s love and affection. When they do
not get this affection and love, they try to get it from others of the opposite sex. It
happened to Das’s daughter as well. At the age of 16, she eloped with the teenage
boy.) Today, Das’s health condition is very poor and he cannot live without alcohol.
Delaying consumption also creates heavy withdrawal symptoms in him, which is an
advanced or chronic stage of alcoholism.

When the social workers tried to motivate him to quit drinking, he never accepted that
alcohol consumption was a problem. But at the sessions of the Alcohol Antonymous
members sharing, he finally did accept that his drinking is a mistake and a problem,
and he was willing to get treated.
Denial of Health Care
Das went to NIMHANS on 17.5.03 to get the treatment. Since Das was a chronic
alcoholic with severe withdrawal symptoms, he needed admission for treatment of his
phvsical and psychological dependency. But he was denied the inpatient treatment,
reason given being “no beds” in the de-addiction ward. A prescription for medicine
was given to him. He was asked to come next week for inpatient treatment. When he
went to NIMHANS the following week he was asked to deposit Rs.2,COO/- for the

KA 03

treatment. The World Bank’s prescription of ‘user fee method’ was introduced at
NIMHANS from this financial year. The policy of NIMHANS was that the patients
submitting BPL (Below Poverty Linelcard would get the treatment with a deposit of
Rs.25C/- and all others including the urban poor (migrants people) not holding BPL
cards should pay for treatment, with a deposit of Rs.2000/-. Das could not deposit
Rs.2C00/- for the treatment. Since he did not have ration card even though he was
living in one of the Bangalore slums and could not provide a BPL (yellow) card,
health care was denied to him. Das is now suffering from fits due to his alcoholism,
not being able to receive the treatment due to the ‘user fee’ method set in motion at
Government Hospitals. He is miserable and sick. There is no health program or
scheme to deal with this important and widespread public health problem. His wife is
the main earner working as a domestic help in three houses. Thev have 3 children.
/
Conclusion: The urban population in the country especially slum dwellers, is very
large. .Alcoholism among them is also very significant. As a result of inward
migration urban slums spring up without any infrastructure. Most of the slum
dwellers do not have a BPL card. So, in the scenario of ‘user fee' pay system in the
Government hospital, most of the slum dewellers are denied health care even
though they have all the rights to get it. Because Das could not pay, he returned
home frustrated that he had gone to the hospital but denied treatment. He says that
he has given up hope of getting treatment and is prepared to die.

KA 02

CASE PRESENTATION ON MENTAL HEALTH

Issues:
1. Centralized Mental Health Care Eg. NIMHANS -KIMI IS
This does not help the poor especially the rural poor, as they don’t have access to these
facilities. The problem becomes even worse in the case of OPD patients as they are not able
to come every month on the fixed day due to money and non availability of the care giver
hence they miss their treatment get back to their previous state and lose trust in the medical
profession

2.

Stigma and Discrimination
People are chained and locked in hospitals and care homes in all the 21 districts where Basic
Needs operates.

3.

Lack of Awareness about Mental Illness
No public education or awareness programme even though the prevalence is around 10-15%

4.

Lack of training for Medical Professionals
Non-identification at an early stage leads to chronic illness and disability.

5.

Non availability of trained personnel
In Koppal district there is not a single qualified Govt, psychiatrist where many cases have
been identified by Basic Needs

6.

Non Availability' of drugs

Ln Karnataka there have been instances of doctors not indenting drugs for treatment of
psychiatric patients. Recently there was a case of psychiatric drugs lying at the Central Stores
gening expired without being supplied by the Govt, of Karnataka
7.

Ignorance among Medical Professionals
.Another important issue is that the very curriculum for MBBS has the bare minimum on
mental health. Plus interns are giving only 15 days of posting in a mental health facility and
this is optional.

S. Physical & Sexual Abuse

9. Denial of Property rights

KA 02
A BRIEF NOTE ABOUT THE ORGANISATION
Background
Basic Needs India was conceived of in 1999. Groundwork began in 2000 and the organization was registered as a Trust
in March. 2001.
Vision
Basic Needs seeks to satisfy the essential needs of all people with mental illness in India and to ensure that their basic
rights are respected and fulfilled

Coverage
Basic Needs works with partner organizations in parts of rural Tamil Nadu, Karnataka, Andhra Pradesh, Jharkhand and
Bihar. They have started working in two districts of Kerala
Methodology

I.

Community Mental Health

2.

Capacity Building

3.

Sustainable Livelihoods

4.

Research and Advocacy

(details of the above four are available in their booklet)

Partner Organisations
1. NIMHANS Bangalore
2. KIMH Dharwar
3. Shristi Madurai
4. IMH Chennai
Psychiatrists working with Basic Needs
Karnataka
1.
2.
3.
4.

Dr. Kishore Kumar
Malli Patil
Dr. Ajay Kumar
Dr. Karur

NIMHANS
Raichur Dist Hospital
Koppal Distirct (Private Practitioner)
Medical Superintendent KIMH Dharwar

Tamil Nadu
I. Dr. Anbarasu
2. Dr. Elangovan
3. Dr. Radha Sekhar
4. SCARF

‘Banyan’
Thanjavur District Hospital
Private Practitioner
(Schizophrenic Research Foundation)

Andhra Pradesh
1. Dr. Vijaya Kumar
2. Mastan Valli

Anantpur (Private Practitioner)
District Hospital Anantpur

2

KA 01
Com )V

Denial of Health Care in the PHCs of Hungund Taluk, Bagalkot District of the
Karnataka state.
/
------------------------

Nature of problem-Denial of treatment:
1) Inaccessibility of PHC
2) Infectious diseases not treated
3) Immunization coverage incomplete
Type of Denial:
1) Treatment not given
2) Vaccinations not given due to inaccessibility of PHC.

Consequences:
1) Death
2) Financial Loss
3) Spread of chronic diseases like TB. children not vaccinated
Severity of the denial;
1) Serious
What is needed:
1) Re-structuring & re-distribution of their PHC
2) Upgrading the PHC staff.

An appeal to the NHRC by two villagers and their signatures. This will be submitted at the
time of hearing.
Denial of Health Care
(Inaccessbility)
Denial of health care can occur in various forms. Denial of health care occurring in Hunagund
taluka of Bagalkot district causes great inconvenience to the thousands of people and prevents
them from getting the most necessary medical care. This is being brought to the kind attention of
NHRC.

Kindly refer to the the attatched map of Hunagunda taluka. There are four PHCS at a distance
of 3 k.m. from one another.
PHC HAVARAGI
PHC MAROL
PHC DHANNUR
PHC TANGADAGI
Villages of HAVARAGI PHC are 40-50kms away from HAVARAGI, but very near (2lOkms) to KARAD1.
Villages of KARADI PHC are 25-30kms away from KARADI.
Villages of MAROL PHC are 30-40kms away from MAROL, but very near (2-10kms) to
HUNAGUNDA Genera! Hospital.
Villages of DHANNUR PHC are 25-30kms away from DHANNUR, but nearer to
AMINGADA.
Villages are far away from PHC they belong to but nearer to other PHCS.

83-G

This causes great inconvenience for people to go and get medical care from their PHC'S.
They have to spend 30-50 rupees per person per visit on bus fare to attend to their PHC'S. It
takes almost a full day for a person to come and go back to their \ illage.

Meanwhile there are other PHC'S nearer to the PHC they belong to. People are often refused
medical care on the grounds that they belong to other PHC'S.
People in the locality have tried various methods to convince the authorities to include them
under nearest PHC'S.
Eg: 1) Hemavadagi:
Population - 687
PHC- HAVARAGI.
Distance from PHC - 45 kins.
Nearest PHC - KARADI.
Distance from the nearest PHC - 3kms.

2) Palathi:
Population - 600
PHC-HAVARAGI
Distance from PHC -50kms.
Nearest PHC - KARADI
Distance form the nearest PHC - 2kms.

3)

Amaravadi:
Population PHC-MAROL
Distance from PHC - 30kms.
Nearest PHC - HUNAGUND
Distance form the nearest PHC -2kms.

4)

Islampur;
Population - 693
PHC-HAVARAGI
Distance from PHC - 55kms.
Nearest PHC - KARADI
Distance form the nearest PHC - lOkms.

Therefore there is a need for reorganizing and redistributing PHC and their villages otherwise
this leads to denial of health care.

DENIAL OF HEALTH CARE
(Infectious Dieseases untreated)

I) Name of the patient - Rajappa Amarappa Walikar,
Age - 45 years
Village - Amarawadagi.

2

He was suffering from pulmonary TB for I year. He was not able to come to the
HAVARAGI PHC w hich is 50kms away, because of financial difficulties and geographical
inaccessibility. People from these \ illages are denied treatment at KARADA (8knis away)
Hence he couldn't get the treatment and ultimately he died. Many others are also facing same
kind of problems since many y ears.

Because of long standing untreated illness like this many such communicable diseases are
transmitted in communities.
2) Name of the patient - Amarayya .C. Math
Age - 55 years.
Village - Lavalasar.
PHC - HAVARAGI.
He was diagnosed as having Pulmonary' TB at district TB hospital. Bijapur. He was asked
to go to the nearest PHC for treatment. He was unaware that to which PHC his village
belongs to. One and half months passed before the treatment for TB was started.

Name of the patient - Chandrawa
Age - 60 years.
Village - Palathi.
PHC - HAVARAGI.
Having pulmonary' TB since one and half years, she is not able to go to the PHC and get
the treatment because of financial difficulty and geographical inaccessibility'.

3)

DENTAL OF HEALTH CARE
(Immunization incomplete)
As the villages are far away (40-55 kms) from PHC’S, people are not coming to PHC for
vaccinating their children and also there is inadequacy of health staff, hence majority' of the
children are not getting fully immunized. This amounts to denial of health care to the
children.

Eg: 1) Dasabal Village:
Children bom after 2000 : 44
Children completely immunized : 4
Percentage of immunization : 9 %
2) Amaravadagi:
Children born after 2000 : 79
Children completely immunized : 14
Percentage of immunization : 17.7%

,

Kerala Health Profile
Indicator
Area (Sq. km)
Population
Households
Sex Ratio
General
Child (0-6 yrs)
Growth Rate %
Decadal (1991-2001)
Natural Growth Rate 2001
Life expectancy (years)
Total
Females
Males
Effective Literacy rates %
Total
Females
Males
Birth Rate - 2001
Death Rate-2001
Infant Mortality Rate -2001
Maternal Mortality Rate 1998
0-5 Mortality Rate
1-4 Mortality Rate
Neonatal Mortality Rate
Perinatal Mortality Rate
Suicides per 1 lakh population per
year
People above 70 yrs of age %
Childhood Malnutrition < 3 yrs %
Weight for Age < -3 SD
Weight for Age < -2 SD
Height for Age < -3 SD
Height for Age < -2 SD
Weight for Height < -3 SD
Weight for Height < -2 SD

Kerala
38863
31841374
6595206

India
3166285
1026443540
191963935

Source
'Census 2001
Census 2001
Census 2001

1058
960

933
927

Census 2001
Census 2001

21 .3
17 .0

Census 2001
2SRS 2002

9.4
10.6

JKer Eco 2003
Ker Eco 2003
Ker Eco 2003

72 .4
75 .8
69.3

90 .9
87 .7
94 .2
17.2
6.6
11 .0
.80
18.8
2.6
13 .8
2.5
31 .0

64.8
53 .6
75 .2
25 .4
8 .4
66 .0
4 .07
94 .9
29 .3
43 .4
24 .2
11 .0

Census 2001
Census 2001
Census 2001
SRS 2002
SRS 2002
SRS 2002
4SRS 2000
’NFHS-2
NFHS-2
NFHS-2
NFHS-2
Econ Rev-03

4 .95

Econ Rev-03

4.7
26 .9
7.3
21 .9
0.7
11 .1

NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2

18 .0
47 .0
23 .0
45 .5
2.8
15 .5

1 Census of India 2001, Final Population Totals, India, State and Districts, Directorate of Census
Operations, Kerala (2004)
2 Sample Registration System Bulletin October-2002; Vol 36 no. 2; Registrar General, Govt of India
3 Kerala Economy 2003; Department of Economics and Statistics, Kerala
4 Sample Registration System April 2000; Vol 33, No. 1; Registrar General, Govt of India
5 International Institute for Population Sciences (UPS) and ORC Macro 2001; National Family Health
Survey (NFHS-2), India 1998-99; Kerala, Mumbai UPS.

1

f

Indicator

Kerala

India

Anaemia (>-35 milts g% of 1 ll>
Total (< 1 1)
Mild (> 10 < 11)
Moderate (> 7 < 10)
Severe (< 7)
Married Women %
Received ANC (% of mothers)
Institutional deliveries
Average Height in cm
Height < 145 cm
Nutritional status
Average BMI
Underweight (BMI < 18.5)%
Overweight (BMI >25<30)%
Obese (BMI >30)%
Anemia (g% of Hb)
Total (< 11)
Mild (> 10 < 11)
Moderate (> 7 < 10)
Severe (< 7)

BPL families (%)
Total
Rural
Urban
ICDS units 2003

Infrastructure in Govt
Total
Institutions
Beds
Inpatients
Outpatients
Beds per 1 lakh population

Source

NFHS-2
43 .9
24 .4
18 .9
0 .5

74 .3
22 .9
45 .9
5 .4

98 .9
93 .0

65 .3
34 .0

NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2
NFHS-2

152 .6
8 .8

151 .2
13 .2

NFHS-2
NFHS-2

22 .0
18 .7
20 .6
3 .8

20 .3
35 .8
10 .6
2 .2

NFHS-2
NFHS-2
NFHS-2
NFHS-2

22 .7
19 .5
2 .7
0 .5

51 .8
35 .0
14 .8
1 .9

NFHS-2
NFHS-2
NFHS-2
NFHS-2

9.38
20 .27
163

27 .09
23 .62
5652

bNSSO 55lh
NSSO 55th

Number

Percentage

Source

2712
50805
1935696
80940260
160

100
100
100
100

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

1310
46224
1842642
39054674

48 .3
91 .0
95 .2
48 .3

Econ Rev-03
Econ Rev-03
Econ Rcv-03
Econ Rev-03

Allopathy
Institutions
Beds
Inpatients
Outpatients

6 National Sample Survey Organisation, 551'1 round (1999-2000)

2

Infrastructure in Govt
Number
Beds per 1 lakh population
145
Ayurveda
Institutions
845
Beds
3411
Inpatients
68450
Outpatients
17976627
Beds per 1 lakh population
10 .6
Homeopathy
Institutions
557
Beds
1170
Inpatients
24604
Outpatients
23908959
Beds per 1 lakh population
4
Allopathic Institutions
Number
Under DHS
1299
Beds
37646
Primary Health Centres
5060
Comm. Health Centre
4726
Hospitals
22636
Other institutions
5224
Personnel
Total Doctors
3032
Administrative position
PHC doctors
Secondary healthcare
Specialists
Dentists
60
Senior Nurses
1416
Junior Nurses
6165
Lady Health Inspectors
872
Pharmacists
1589
JPHN
5272
JHI
3017
HI
811

Primary Health Centres
Community Health Centres
Hospitals
Dispensaries and others

933
115
130
121

Subcentres

5094

Medical colleges institutions
Beds

11
8578

Percentage

Source
Econ Rev-03

31 .2
6.7
3 .5
22 .2

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

20.5
2 .3
1 .3
29 .5

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rcv-03

Percentage
31 .7
13 .4
12 .6
60.1
13 .9

1 .7
29 .0
69 .3
58 .0

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

72 .0
9.0
10.0
9.0

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

7 .2

Econ Rev-03
Econ Rev-03

3

Infrastructure in Govt
Co-operative Hospitals
Beds
E.S.I Hospitals
Beds
Regional Cancer Centre
Beds
Sree Chitra Institute of Medical
Science and Technology
Beds
Private Sector
Beds
Total
Beds

Number
69
3306
12
1113
1
320
1

217
4288
67517
5681
118697

Percentage
2 .8

0.9
0.3

0.2
56 .9

100 .0

Health Personnel (Jan 2001)
Registered Doctors
Allopathy
Ayurveda
Homeopathy
Siddha
Unani
Dental
Nurses
ANM/ JPHN
Dental Mechanics
Dental Hygienists

29656
7356
6704
135
5
3776
60760
12907
245
242

Immunization coverage %
BCG
Measles
DPT
Polio
TT of Preg. Women
TT for 5 year olds
TT for 10 year olds
TT for 16 year olds

2001-02
103 .8
86.2
93 .1
92 .8
89 .9
93 .9
97 .6
96.5

2002-03
103 .0
90 .6
95 .8
95 .3
86.1
89 .2
98 .1
95 .0

1980-81
2 .02
5 .22
1981

1998-99
0.95
3 .25
1991

Public spending (% of GDP)
Health
_____ Education
Development Index

Source
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rcv-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

'Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal
Cyber journal

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

sNHDR-2001
NHDR-2001

7 www.cvberioumal.org.in
’National Human Development Report 2001; Planning Commission, Government of India, March 2002

4

_

Public spending (% of GDP)
Human Development Index
Human Poverty Index
Gender Disparity Index

1980-81
0.50
32 .1
0.87

Prevalence of Diseases of Public
2002
Health Importance (per 1000)
Leprosy
0 .71
Filaria
1 .02
Tuberculosis
1 .2
Acute Diarrheal
17 .63
diseases
Pneumonia
0.66
Enteric fever
0 .23
Measles
0 .10
Respiratory Infection
216 .62
Outbreaks in 2003
Number affected
Dengue
3332
Leptospirosis
1343
Diarrhoea including
463094
39 cholera cases
HIV/AIDS (total till 2003)
1219

1998-99
0 .59
19 .93
0.82

Source
NHDR-2001
NHDR-2001
NHDR-2001

2003

0.66
1 .28
0 .70
16.96

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

0 .60
0.26
0 .07
221 .42
Deaths
66
96
13

Econ Rev-03
Econ Rev-03
Econ Rev-03
Econ Rev-03

411

Econ Rev-03

Econ Rev-03
Econ Rev-03
Econ Rev-03

5

Ki.ni

ELOOR CASE STUDY: GREENPEACE HEALTH STUDY REPORT IN AUG 2003
Testimonies:

Name: P
Address: Eloor South.

As told by herself. It was in 1961 that her parents returned to their ancestral home in
Eloor from Bombay. She was a student of class 1 then. The only factory in the area was
FACT. She had no health problems whatsoever when she came here. It was their father’s
death that had brought them to Eloor where they had an own house and some property to
call their own. When she was in class 8 there was a chlorine leak from the TCC factory.
Recollecting memories of that day, she says she remembers running to school and falling
faint in the school corridors. The school authorities admitted her in JNM hospital and she
regained consciousness three days later. Her health woes have started ever since then.
She gets breathing difficulty and bouts of unconsciousness whenever the fumes are very
strong. Chronic Cough has been with her ever since then. She spends around 400 rupees
every month on barely keeping away from the major bouts of breathlessness and cough.
None of the doctors have conclusively told her that her health will see a fine day. Her
husband too suffers from breathlessness.
Talking of her surroundings, she still can remember the number of domestic animals that
were seen in and around Eloor in those days. She does not believe that the local
community has benefited from all the factories. A few that got jobs carried on in their
jobs and hence traditional livelihoods have totally been wiped out. The factories and the
pollution have also led to a serious water shortage. The ground well in their house no
longer can be used for the quality of water it has. But she cannot use the water supplied
by the authorities for its chlorine content. So she manages with the well water available.

Factories have led to varied problems not to mention the spate of health complaints it has
caused to the people living here. She wonders how she can inch forward her difficult life.
Testimony of Parent about affected Children:
Name of Child: IJT
Age: 2 years
Address: Eloor
As told by the father: It was in 1965 that the family settled down in Eloor. The wife’s
maternal home is in the district of Alleppey. They had a baby boy by tubular pregnancy
the delivery of which was by caesarean section. The baby, IJT was diagnosed as 40%
mentally retarded. Two years old now, he still has difficulty in walking. There are
occasional attacks of fits in between. Doctors in Amrita Hospital, Cochin are treating the
baby. He has speech difficulties as well. The medicines being administered are Norma
Brain and Digital?.5mg.
Others in the family do complain of severe headaches and bouts of breathing difficulty.
They have already spent around 2 lakhs on the child’s treatment. Though Physiotherapy
was also advised they have discontinued the same due to its high costs.

1

KT , 01

The child’s aunty , S has been in Eloor for the past six months. She is pregnant now and
ever since she has been here she has acute headaches and breathing problems. Previously
a resident of Cherthallai locality, S admits that she has never ever had such health
complaints. Living in the vicinity of the Leather factory and inhaling the ammonia fumes
has led to a major deterioration of their health, the family avers.

Response of the health care system in Eloor:
There is routine pollution in Eloor due to release of smokes by chemical and pesticides
industry. The response of the health care services has been very poor. The people have
been going through the brunt of callous attitude of the system. There is one PHC with
poor infrastructure in the area according to Jose, resident of Eloor. The PHC doesn’t have
sufficient medicine. The PHC sends the patients to the DHC as there is no facility for
admitting the patient. There is no regular surveillance system. People mostly get
medicines from private medical shop.
Since Eloor is an industrial belt, known for chemical contamination in the area the non­
availability of essential drugs is cause of concern for 30,000 people living in the area.
Response in the emergency situation like gas leaks and accidents is even worse.

I.

EXECUTIVE SUMMARY

An Introduction to Eloor:
Eloor is a river island on the river Periyar around 17 kms from its mouth at the Arabian Sea
near the city of Cochin. It occupies an area of 11.21 square kilometres. Eloor supports the
largest industrial belt in Kerala with over 247 chemical industries. The industries make a
range of chemicals- petrochemical products, pesticides, rare-earth elements, rubber
processing chemicals, fertilizers, zinc/chrome products and leather products. Most of these
industries are over 50 years old and employ the most polluting of technologies. The industries
take large amounts of fresh-water from the River Periyar and in turn discharge concentrated
effluent with very little treatment. This leads to the large-scale devastation of aquatic life in
the river and the farmlands in the region. There are 35 illegal pipes spewing effluent into the
river directly from the industry.1 Air emissions range from acid mist to sulphur dioxide,
Hydrogen Sulphide, Ammonia and Chlorine gas.2 There are close to 40,000 people living and
working on the island, 29,064 of whom are part of the village community not employed by
the industries. The rest are employees and stay in the company quarters. The Woman to Man
ratio is 1000:1054?

1 From a joint assessment done by the Periyar Malincekarana Virudha Samithi and the Kerala State Pollution Control Board.
” There are many unidentified chemicals that are in the plumes of the industries of the area The Pollution Control Board has not
comprehensively monitored these.

14,144 women and 14,920 men. Most people are employed in the services industry-serving the government or private industry.
Many run local businesses. Traditional occupations including fishing and farming have been entirely wiped out by polluting industry.
There is a section of people that are migrant and are involved in illegal sand-mining from the bed of the river. A small population on
the island is unemployed..

2

KI,01
The Background to the Community Health Assessment:
Despite the fact that the pollution of the River Periyar and the land has been established
unequivocally there has been little action by regulatory authorities.'1 It seemed to us at the
beginning of the research like there needs to be stronger arguments and actions from the
community that backs up the new research. We decided to back our existing research on
contamination by the local pesticide industry, Hindustan Insecticides Ltd and Merchem
Ltd. Meanwhile a resident of Eloor was appointed by Greenpeace as the Riverkeeper for
the Periyar to monitor water quality of the river and alert local government, regulatory
authorities and the pollution control boards of the need to take immediate action to stop
pollution.4*6
The fact that the Community Health Problems of Eloor were quite apparent and that a
similar reality was observed across the country along the 24 hotspots identified by
Greenpeace India prompted us to go for a health assessment that shall establish primafacea
the problem.78Greenpeace initiated an alliance with Occupational Health and Safety Ccll-

Mutnbai, which has prior experience in the matter of Epidemiological Research. The broad
framework of OHSC taking the lead with Medical Verifications of the primary data
collected using a questionnaire research was arrived at jointly, with Greenpeace taking the

primary role in the field based research and the survey. The Ethical Guidelines developed
by the National Committee for Ethics in Social Science Research in Health (NCESSRHf

The Proposed Research Question in the first round of discussions was: “What is the prevalence of
Chronic Respiratory Illness and Cancer in the affected community around Eloor Industrial
Estate?” This evolved into the more broad and exploratory research question later as we
interacted with the advisory board: “What arc the Health Problems faced by the resident
community of Eloor Industrial Estate, due to increased pollution of the air and water by chemical
industries?” The meetings with the advisory board also discussed and thrashed out issues like
scientific biases, sampling sizes/ratios, training module for interviewers, ethics and statistical
analysis.

The Findings: The one simple and basic finding is that we observed is that without exception, all
body systems are adversely affected in Eloor as opposed to Pindimana. This shows that the
cocktail of poisons in the air and water of Eloor as opposed to Pindimana is exerting synergistic
effects on the local population and these effects seem to be unpredictable especially across
particular age groups.
4

The local pollution control board has been entirely ineffective in ‘controlling pollution’ if not preventing it. Therefore the local
community agitations have more often focused on the pollution control board to initiate immediate action against polluting bodies
Refer the Kerala Pollution Control Board Website for developments: http://www.kspcb.nic.in

After the Greenpeace Sampling mission of 1999 when it was established that a large amount of polluting chemicals have been
released by certain specific industries (Hindustan Insecticides ltd, Merchem Ltd), the local community took direct action against the
polluting agencies by damming the polluting stream-Kuzhikkandam Thodu. The companies have ever since been forced to enter into a
dialogue with the panchayat and local people to come up with a plan to clean up the mess along the stream. They have failed to come
up with a safe protocol for doing so. Their current plan involves dredging the sludge and dumping it in a nearby wetland permanently
destroying the water table. There is currently a court injunction on any such action.
6 He has also addressed the people of Cochin city with the dangers of using the polluted river water for drinking purposes.

7 The local people have been complaining of large-scale health problems on the island. These include respiratory disorders, cancers,
congenital problems like mentally/ physically challenged children, chronic depression and reproductive problems.
8
Ethical Guidelines for Social Science Research in Health: By National Committee for Ethics in Social Science Research in Health
(NCESSRH).
www.cehat.org/publications/ethiciil 1 ,html
Also see, Notes on Qualitative Research and Ethics of Research On Disaster and Complex Political Emergencies by Fatima
Alvarez-Castillo, Professor,University of the Philippines Manila, Email: fatima.castillo@up.cdu.nh

3

KT, 01

The Conclusion: Immediate punitive action need to be initiated by the Government on the
companies that are criminally violating the right to Life of Communities and workers in the
Industrial Estate and around. Remedial action which includes, life-long medical rehabilitation,
compensation and clean-up of contaminated sites must be taken up by the polluting companies.
Zero Discharge on the Periyar must ensure that the people of Cochin are not poisoned

II.
MAIN RESEARCH AND POLICY FINDINGS:
Contrary to the expectations based on the initial literature survey on increases in particular
types of diseases due to air and water pollution; this health assessment has discovered that
there is a general increase in all types of systemic diseases across Eloor (target village) when
compared to Pindimana (reference village). Broadly one can say that the cocktail of poisons
in the air and water of Eloor affects all body-systems adversely. Potentially the immune
system seems to be affected too.9 Increased prevalence and incidence of diseases and
symptoms at Eloor have been observed from the database of health information of the
community and workers at Eloor and Pindimana generated by the Field Investigation based
on an exploratory format questionnaire.1011
A Stratified Random Sample of the Eloor" (target) population when compared with those at
Pindimana12 (reference) shows a significant increased disease incidence in many body
systems. The key systems that are affected are the Neoplasm13 (2.5 times odds), Blood &
blood forming organs14 (2.1 times odds), Endocrine, nutritional and metabolic system15 (1.17
times odds), Mental and behavioural16 (3.03 times odds), The Nervous system17 (1.59 times
odds), The eye & adnexa18 (1.21 times odds), The Ear & mastoid process19 (1.49 times odds),
The Circulatory system20 (1.59 times odds), The Respiratory system21 (1.29 times odds), The
Digestive system22 (1.69 times odds), Skin & subcutaneous tissue23 (1.69 times odds), the
Musculo-skeletal system & connective tissue24(l. 17 times odds), the Genitourinary system25
1.09 times odds), Congenital malformations, deformations & chromosomal26 (2.63 times
odds), Injury, poisoning & certain other consequences of external causes27 (2.65 times odds),

’ Despite the fact that Pindimana, the reference village, was going through an epidemic of Leptospirosis and Dengue Fever, the rale of
occurrence of infectious diseases under Category-1 of the ICD(International Classification of Diseases) in Eloor Section A and Eloor
Section B, two target areas within EIoor(which was not facing an epidemic) was slightly more than die rate at the reference! This
clearly shows that there is an ongoing live epidemic in Eloor which is not being perceived as one that requires attention as it is on all
the time.
10 Please see Appendix 1 for details.
11 Sampling Ratio was 1:4
12 Sampling Ratio was 1:7
13 Chapter-2 of the International Classification of Diseases, the ICD, Version-10,
http://www.wellcool.demon.co.uk/ltmhi/PBarkerICD
10.htm
14 ibid Chapter-3
15 ibid Chapter-4
16 ibid Chapter-5
17 ibid Chapter-6
18 ibid Chapter-7
19 ibid Chapter-8
20 ibid Chapter-9
21 ibid Chapter-10
22 ibid Chapter-11
23 ibid Chapter-12
24 ibid Chapter-13
25 ibid Chapter-14
26 ibid Chapter-17
27 ibid Chapter-19

4

KT, 01
External causes of morbidity & mortality28 (1.36 times odds). All systemic classification was
based on the International Classification of Diseases-10 (ICD-10).

One of the body systems worst hit seemed to be the nervous system when combined with the
mental and behavioral effects (odds- 1.59:1 & 3.03:1). Congenital malformations,
deformations and chromosomal aberrations follow (odds- 2.63:1). Accidental injury and
poisonings are leading causes of mortality (Odds- 2.65:1). Diseases affecting the Neoplasms
(2.5:1) and Blood and blood forming organs (2.1:1) are significantly greater in Eloor.

Clinically confirmed29 Cancer Incidence is greater in Eloor in a statistically significant rate.
When 13 cases of incidence were reported in the Eloor set, only one was reported in the
sampling set at Pindimana. The combined odds ratio across Eloor and Pindimana is (2.85:1).
This is alarming to say the least.
Medical Verifications were performed using the lung function tests (Spirometry) on a random
sample of the reference and target populations. These confirmed high rates of actual
incidence.30
It is clear that the nature of illness spreads across practically all body systems in an almost
unpredictable manner. This is clearly due to the fact that it is a cocktail of chemicals (a few
score heavy metals, a few hundred organic chemicals) and that are in the air and water of
Eloor. There is very little medical research globally that accounts for synergistic effects of
synthetic chemicals in human beings. The evidence that one finds at Eloor clearly shows that
the synergistic effects of these chemicals are more devastating than expected.31

a ibid Chapter-20
” Clinical Confirmations were obtained by follow-up house visits with a team of doctors from the Occupational Health and Safety
Centre- Mumbai using Spirometry for Respiratory Illness (Chapter-10, ICD-10) and examinations of medical records (Chapter-10,
ICD-10) for ascertaining Cancer Incidence.
30
For Eloor the figure was 10- severely affected under FEV1 or FVC or both below 60% of the predicted values, the expected values
in healthy persons. 7 are moderately affected and 9 showed that their values for lung function are just below the 80% of predicted
values. Totally 26 out of 45 tested for lung function are affected ie 57.8% confirmed respiratoty illness rates. Lung function test could
be administered to 43 persons. Three persons were obviously affected and could not perform the test. Eight had reported respiratory
problems but did not want to go through the lung function test. Four persons were in good health with no problems so tests were not
administered. Totally 28 persons interviewed (and tested or only checked) have respiratory system affected.

3' See www.ourstolenfuture.orq/NewScience/synerqv/svnerqv.htm
Also http://www.health.state.mn.us/divs/eh/qroundwaler/hrlmix.html for some new action on groundwater
contamination and synergistic effects.
Also http://www.nmenv.state.nm.us/aqb/proiects/Corrales/ DOH Synergistic Effecls.pdf

5

KT, 02
How prepared are the public health services to respond to chemical
exposure and disasters/ accidents.

Observations from the HIL Endosulfan plant fire Eloor, Kochi, Kerala.
(Annexure contains detailed Fact finding report)

1

Factfinding Report
(7-8 July, 2004)
Industrial Fire at Hindustan Insecticides Ltd
Udyogmandal, Kerala on 6 July 2004

Team Members
Nityanand Jayaraman, The Other Media
' Shibu K. Nair, Thanal
Shweta Narayan, Community Environmental
■, Monitoring (The Other Media)
R. Sridhar, Thanal
Dr. R. Sukanya, Public Health Specialist

July 2004

“At 2.30 a.m. on 6 July, 2004, Thanal received a
desperate call from V. V. Purushan, an Eloor resident
and member of the Periyar Malineekarana Virudha
Samiti (PMVS), a community environmental group. He
said HIL’s endosulfan plant is on fire, and people are
running away and that many are stranded at Eloor
Ferry, unable to cross the river. "What do we do?" he
asked.
We called up officials from regulatory authorities who
had no clear idea on how to react to the crisis either.
Legally mandated disaster prevention and anticipatory
emergency response mechanisms were clearly not in
place. The fire was treated as a regular fire, rather than
a major incident involving toxic chemicals and a
potentially explosive situation.

Eloor residents are already besieged by pollution
problems, and live in constant fear of a catastrophic
incident. Despite repeated demands by residents for
disclosure of factory-specific emergency plans, no such
information has been made available. Such requests
have been ignored by regulatory authorities or
projected as anti-worker and anti-development by
factory management.
Thiruvananthapuram-based Thanal and New Delhi­
based The Other Media constituted a fact-finding team
to enquire into the incidents leading up to and following
the industrial fire at Hindustan Insecticides’ Ltd. The
factfinding report enclosed here contains lessons for
preventing and responding to chemical industrial
disasters in the future.
Sincerely,
The Fact Finding Team

Thanal

The Other Media

L-14;?Jawahamagar, Kawdiar.P.O.
Thiriivananthapuram, Keralanri,India PIN-695 003
TfefAFax; 0471-2727150. E-riiail: thanal@vsnl.com

A1/125 (1st Floor), Safdarjung Encl
New Delhi, India PIN-110 029
Tel: 011-516524517 51652452 .
,

u

Introduction
On 6 July, 2004, a little after2 a.m., residents living downwind of the Hindustan
Insecticides Ltd (HIL) pesticide factory in Eloor, Kerala, were alerted to a fire
in the factory’s endosulphan plant. Based on varying accounts, the fire raged
for between three and four hours and gutted most of the five-storey
endosulphan plant. Twelve fire tenders, including units from Fertilisers And
Chemicals Travancore (FACT), the Indian Navy, the State Fire Department
and Kochin Refineries, were deployed and the fire was brought under
control using large amounts of water.

A westerly breeze carried the thick grey smoke plume over at least 250
dwelling units in Pallipuramchal and all the way across the river to the
Varapuzha panchayat. Smoky conditions prevailed in Varapuzha as late as
7 a.m., well after the fire was put out.
Neither HIL nor the district authorities initiated any off-site emergency
response procedures. HIL also had no onsite emergency response, and fire
control did not begin until the FACT fire tender arrived at 2.35 a.m. As will be
outlined in the report below, Hindustan Insecticides Ltd is guilty of
negligence on several counts. The Eloor Police has, however, registered a
simple case of "fire occurrence." No action has been initiated against the
company for negligence.

The Eloor industrial area hosts about 250 industries, of which more than a
dozen, including Hindustan Insecticides Limited, are large chemical
factories.
The authorities - particularly, the Kerala State Pollution Control Board and
the Factories and Boilers Inspectorate — have sought to treat community
demands for information about the hazardous chemicals and processes as
unnecessary interference rather than legitimate concerns. Repeated requests
for information on emergency preparedness, and for the building of a bridge
across the River Periyar at the Eloor ferry point to escape the island during
emergencies have fallen on deaf ears.

The absence of emergency response procedures, the casual attitude of the
district authorities and the industry, and the lack of appreciation of the
magnitude of the incident and what it embodies is a shocking reminder that
no lessons have been learnt from the 1984 Union Carbide disaster in Bhopal.

Twenty years after the world's worst industrial disaster, communities and
workers continue to operate in complete ignorance when it comes to the
hazardous substances stored and processes deployed in their
neighborhoods. Throughout India, if more communities are not being wiped
out by chemical disasters, that is not because of the legally mandated
precautions or policing by regulatory authorities, but by sheer chance,
favourable wind conditions and the communities’ good fortune.

The factfinding team observed sludge dumped in
a three-walled structure without a roof near a
wastewater lagoon. Empty chemical drums and
sacks lie strewn around near the incinerator site.
Open, rotting drums of tarry wastes were found
carelessly dumped on the roadside in at least one
location.

The Factory
Hindustan Insecticides Ltd is a public sector
undertaking fully owned by the Government of
India and it operates four plants at Eloor,
Udyogmandal, Kerala. The plants produce:

Pesticide
DDT Technical
DDT (Formulation)
Endosulfan Technical
Endosulfan 35 EC
Dicofol (Technical)
Dicofol EC
Mancozeb (Technical)
Mancozeb (Forumulation)

Capacity
1344 tpa
2688 tpa
1600 tpa
1S10 kilolitres/year
150 tpa
600 kilolitres/year
1000 tpa
1800 tpa

The Fire
In its press release dated 6 July, 2004, Hindustan
Insecticides Ltd states that “At about 2.45 a.m. on
6.7.04, a fire was noticed by the workers on the
2nd floor of the plant building."1 However, reports
by local residents, the police and people involved
in firefighting contradict HIL's assertion. They peg
the time of start of fire at around 2 a.m.

HIL is the sole producer of DDT in the country,
and has cited DDT’s criticality to the National
Malaria Program to secure temporary
postponement of DDT phaseout from the United
Nations under the Stockholm Convention. HIL
manufactures DDT at its plants in Udyogmandal
and Raigad district, Maharashtra. The DDT plant
at Udyogmandal was inaugurated in 1957.

Eloor police station sub-inspector Abdul Rahim
says he received information about the fire at 2.44
a.m, by which time the fire had already reached
the 5lh floor.2 Mr. O.T. Verghese, plant safety
manager at FACT, says he received word of the
fire around 2.30 a.m.3

General State of the Factory
The factory is generally poorly maintained. The
condition of the effluent treatment plants and the
incinerator are appalling. The incinerator is little
more than a furnace. Oily liquids are stored in open
sumps at two separate locations near the
incinerator. At least one was identified as furnace
oil for the incinerator.
Chlorinated wastes, among other things, are burnt
in the incinerator. Ashes are reportedly stored in
drums onsite. The exhaust is carried through a pipe
from the incinerator house to the endosulfan plant
about 20 metres away, and then runs along the
wall of the five storey building to the chimney stack.

According to proponents of incineration, dioxin
formation can be minimised , among other means,
by quenching the exhaust gas rapidly to below 250
degree Celsius to reduce the time the exhaust
gases spend in the opitimum temperature window
for dioxin formation. Viewed even from the
unsatisfactory approach to dealing with the
deadliest chemical known to science, the HIL
incinerator’s exhaust pipe and smokestack are
virtual dioxin factories. The poor upkeep of the
area surrounding the incinerator does little to
inspire confidence in the technology or its
proponents’ faith in theoretical conditions.

Based on extensive interviews with residents
living around the HIL factory, the Fact Finding Team
was able to ascertain the following facts about the
drift of the smoke plume, and the reaction of
residents.
The smoke plume was not very wide and blew
across in a west-southwesterly direction across
the river Periyar. The smoke was felt by people
resident in a triangular area flanked by the two
Eloor ferry roads, which joined at the ferry
terminal due west of HIL. This area is a wetland
with houses located in clusters on the dry stretches,

■Disasters aside, HIL’s poor housekeeping poses an

ongoing source of pollution to the general environment.

Industrial Fire at Hindustan Insecticides Ltd

Families who fled to the ferry invariably had rela­
tives across the river. The elderly and families with
no relatives across the river did not leave their
houses.
The ferry point was in the direction (west-southwest) in which the smoke from the blazing factory
was blowing. Most didn’t feel safe to go against
the smoke (which would have meant running
towards the Factory).

'Empty chemical drums and sacks are strewn around near the
furnace oil tank fueling the incinerator."

or along the two main roads and along the
Kuzhikandam thodu. The Thodu is a natural stream
that now carries the combined toxic effluents from
FACT, HIL and Merchem factories to the River
Periyar.
In 1990, a large-scale toluene spill into the Thodu
caused a fire in the stream that left several people
living adjacent to the stream with serious health
effects. The
toluene spill was reportedly from
Hindustan Insecticides Ltd.

A few families cut across the breadth of the plume
to reach the safety of their relatives’ houses. Most
families started returning home by sunrise when
the fire was put out.
Residents in the houses (50-100m) nearest to the
factory could see the smoke blowing above their
houses and didn’t leave. Some said they did not
feel any major effects of the smoke. However, the
same households also
reported soot deposits
on vegetation and inside the houses.

Endosulfan Production

The fact-finding team was permitted to tour the
facility and take pictures on 8 July, 2004, despite
the lack ofprior appointment. HIL's deputy produc­
Residents recall that on July 6, 2004, the smoke tion manager Vincent D. Paul, escorted the team
left the
factory at a height, blew westwards around the facility and the scene of fire, and was
and downwards for
between 500-750 metres knowledgeable, open and helpful in explaining the
before
settling down in the residential area of production process and filling in the details of the
Pallipuramchal. Residents of this area were either
incident.
awakened by the siren or by their neighbours.
Some of them-approximately, one in three houses
visited by the Team — in four streets in the For every ton of Endosulfan technical that is manu­
Pallipuramchal area and alongside the factured, raw material in the following approximate
Kuzhikandam thodu were not aware of the quantities is used:
incident, and had slept through the fire with all
Quantity Required
Quantity Charged
doors and windows closed.
(Theorctlcally)ln
Raw Material

Some men went to the HIL plant to verify the
details of the fire accident and were uncertain as
to whether people should evacuate immediately.

Many families with children decided to flee the area
and crossed the river to the Varapuzha Panchayat
by ferry. Residents at the farthest point (ferry point)
had not heard the siren or felt the smoke. Between
100-200 people may have crossed over in three
ferry trips, before the ferry stopped making the river
crossing. The first ferry trip was made between
2.45 a.m. and 3 a.m. By the time they had crossed
A
over, the smoke plume too had crossed
i
the nver' and PeoPle could smell and feel
1
the smoke on the other side.
Fact finding report

tons/ton of
Endosulfan tech

In tons(1.5 x
required quantity)

Hexa Chloro Cyclo Pentadiene
(HCCP)

0.78

1.17

Butene diol

0.25

0.375

Thionyl Chloride

0.34

0.5

Toluene

0.1

0.15

Source: Vincent D. Paul, Dy Production Manager, Endosulfan plant,
HIL, Udyogmandal.

Toluene, a petroleum derivative, is used as the
medium for the reactions. Going by the
consumption figures, it appears that for every ton
of endosulfan produced, approximately 1 ton of
waste is generated.
5

Residents living along the fenceline of the factory
said the fire started with a series of loud
splattering noises. One woman described it as the
sound of "water falling on stone;” another person
likened it to firecrackers; yet another said it
sounded like someone was hammering metal.

All reactions are carried out in two reactors each
for Het diol, endosulfan and for recovery of mother
liquor. Roughly 1.7 tonnes of endosulfan
technical is produced per batch.
Endosulfan is manufactured through a two-stage
reaction.

The final explosion was accompanied by fire and
thick dark smoke that smelled like burnt tyres.
Residents living as far away as 300 and 500 metres
■ .Stage 2: Het Diol + Thlonyl Chloride = Endosulfan
from HIL reported seeing the flames. As the smoke
quickly changed to a narrow plume of thick
As and when endosulfan is manufactured, it is grayish cloud, the "burnt-tyre” smell was replaced
piped out to a unit outside the production building by a cocktail of pungent odours of chemicals,
for further processing. Similarly, only the raw ma­ identified by many people as the smell of sulphur.
terial required for the current batch production is According to one resident, the sulphur smell
brought into the production unit from the storage persisted on her skin for hours after she had fled
units housed in separate buildings.
the smoke plume. Many residents said the smeh
was a more intense version of the familiar odours
How the Fire Started
characteristic of the industrial estate.
Stage 1: HCCP + Butene Diol = Het Diol (Intermediate)

While we were unable to ascertain the source of
combustion, HIL Deputy Production Manager
Paul’s account provides some insight into what
fueled the fire and the course of events leading
up to and in the immediate aftermath of the fire.

Putting Out the Fire

It is not known whether safety systems to shut
down the flow of toluene in the event of a leak
existed. If they did, it is not known whether and
when they acted.

Eloor resident and member of the community
environmental group Periyar Malineekara Virudha
Samiti V.V. Purushan was among the
crowd at the gates of HIL. He says:
I

It appears that FACT was the only agency
contacted by HIL for first response. According to
Verghese, the FACT fire tender left for HIL by 2.30
“At the time, the second step reaction was a.m. and reached HIL by 2.35 a.m. The tender can
ongoing. The reaction for het diol [Stage 1] was carry up to 4000 litres of water, and also has two
completed in one reactor, and crystallisation was separate compartments carrying foam and carbon
going on. In the other reactor, there was butene dioxide for special emergencies.
diol. Both the endosulfan reactors were engaged.
At 2 a.m., a worker on the second floor noticed a In recounting the day’s events, Verghese
leakage from the [toluene] vapour lines. He identified a major safety lapse on the part of HIL:
reported the matter, and the supervisor came there “We lost time because HIL’s hydrant system had
to assess the leakage. Such leakages come up failed. There was no current [electricity] coming,
from time to time. Suddenly, the fire started and and they had no standby for the hydrant. So we
began spreading. About 20 people were working had to make three trips back to FACT to refill the
tank until HIL was able to get the hydrant pump to
at that time, and they all ran away.
work. . .At FACT, the fire hydrant works on a
Eloor Sub-inspector Rahim likened the Toluene diesel set and is not dependent on electricity. ”
release to the pressure release system in a
pressure cooker, indicating that the spill within the By 3 a.m., the sub-inspector of police Abdul Rahim
plant may have been substantial and at high had reached the site. Simultaneously, male
pressure. The FACT plant safety manager, who residents from Eloor had also gathered at the
was the first to send a fire tender to HIL, also factory gate to get more details about the disaster
corroborates Rahim’s account. “Toluene was and the expected response. Many of them had sent
falling on the floor in a spray," said FACT'S their children and women in the family away on
Verghese.
foot to relatives' houses or other safe zones.

■6 • 7

;

Industrial Fire at Hindustan Insecticides Ltd

' SSOEEi

“No information was provided by the company.
People who ran did so without knowing if they were
running into danger or away from it. The siren was
weird - rather than the continuous siren like an
ambulance, the siren from HIL would start, stop,
then start again after a few minutes. People were
confused.

Fact Finding Team members were invited to
inspect the inside of the 5-storey Endosulfan
building on 8 July, 2004. However, the team
declined the offer because only helmets and no
gas masks were provided. At the time of the team's
visit, the floor of the Endosulfan unit seemed damp,
with fumes rising from the ground. The pungent
smell was intense even from outside the plant.

“Many people woke up because of the siren, then
smelled the smoke and ran. Others, nearly 250
people, were gathered outside the factory gate.
We didn't know what had happened.

Two out of three team members reported
immediate symptoms - throat irritation and
headache - that persisted for at least 3 days. One
of the members reported spells of dizziness that
“We wanted to talk to the management. continued for more than a week. HIL's casual
Somebody came and said ‘We’re busy trying to attitude to the deadly chemicals it handles is a
put off the fire. We don't have time to talk to you serious cause for concern because it may have
now.' Later, the police came from inside and told exposed others who came to inspect the site.
us there was nothing to worry about, that five fire
engines were working inside and more are on their Some HIL staff say that the toxicity of chemicals is
way. By 4 a.m., a fire official came and told us that highly exaggerated, and that their experience
the fire was under control, but smoke will continue. doesn’t bear out popular tea's. According to Paul,
“Workers handle sacks of technical grade
“What was alarming is that the HIL security - not endosulfan with bare hands. They’re fine. 1 myself
CISF, but private - did not have the telephone have been working here since 1984. Nothing has
numbers of any of the fire tenders. The other fire happened to me, my wife or children.”
tenders [other than FACT] were called only after
the police arrived."
The Company’s Response

According to HIL, the fire was "totally extinguished
by about 5.30 a.m.”5
The absence of an onsite and offsite emergency
plan at HIL is evident from the fact that fireworkers
battled the fire without any knowledge about the
burning chemicals or the precautions that need to
be taken. According to a rough estimate by
Verghese, at least 40 fireworkers were engaged
in combating the fire. None worked with breathing
or other safety equipment.

In a frightening reminder of Union Carbide's
response in the immediate aftermath of the Bhopal
disaster, HIL company spokespersons misinformed
the community to allay fears rather than share
accurate information and appropriate response to
avoid or minimize poisoning of residents.

According to Purushan, initial reports at the
factory gate by company staff underplayed the
seriousness of the fire and the toxic nature of the
smoke cloud:

The statement by Verghese of FACT is revealing: “They first said that it was only some rubber sheets
“When we went in, our priority was to battle the that burnt down. Then they said it is only toluene
fire. We just treated it as a regular fire and battled that was burnt in the fire, and that toluene when
it. Fireworkers were stationed all around the unit, burnt will release only carbon dioxide and steam.”
and they were drenched in water and soot. Only
next day, we knew that there were toxic On 8 July, 2004, the Fact-finding Team interviewed
chemicals. Most of us just wore our kerchiefs to HIL senior management including Sivadasa
cover our noses. HCCP’s toxicity increases when Shenoy, GM, and Dy GMs Venugopal Pillai and
it comes in contact with water. But nothing K.K. Joseph. Questioned two days after the
happened to us. I was there for three hours. disaster, the company spokespersons continued
Nothing happened to me. However, next day when to downplay the magnitude of the fire and its
I went there, I couldn't stay there. There impacts on community and the environment.
i k was too much toxicity... There was a huge However, neither the company nor the regulatory
1
flame- Some chemicals may have been authorities had conducted any scientific
released."
assessment to support their casual response.

1*5

tljjyj

Fact finding report

7

Specifically, HIL stated that:
a) there was no endosulfan in the plant at the
time of the fire;
b) the raw material HCCP is non-flammable.

The Factfinding Team was unable to establish
whether on-site and off-site emergency response
plans exist, or if the management is even aware
of this requirement.

However, no mention was made of the toxic
thermal degradation products such as phosgene
that is released when HCCP is heated, or reactive
products such as sulphur dioxide and hydrogen
chloride that are released violently when thionyl
chloride comes in contact with water. Neither does
the concern about long-term contamination by
dioxins and furans feature in the list of concerns
of the company or the regulators.

In-House Safety Team

HIL has no fire tender. The closest firefighting force
is in FACT across the road. However, FACT’S
Verghese observes that it is imperative for
companies to have their own trained safety and
firefighting units for immediate response until
assistance arrives.
"I don’t know about the firefighting unit at HIL,” he
said. "They probably have something, but how
good I don’t know.”

When asked about the symptoms of poisoning
reported among the people living downwind (west)
of the HIL facility, HIL’s deputy general manager
was very remarkably vague:
“We’ve not been told by the medical authorities
about any problems. Probably, one girl was admit­
ted in a nearby hospital. The district administra­
tion took initiative and brought two teams of doc­
tors and examined many people. If there is any­
thing, we'll do whatever has to be done. We're a
PSU. Government is party. Our response will be
more favorable than private sector. ”

It appears that no trained HIL staff were involved
either in initial or subsequent firefighting. However,
this is an issue that needs to be verified:
1. How many trained safety personnel were present
in the plant at the time of the fire?
2. How did the company’s emergency team (if such
a team existed) respond to fire until the fire
tenders arrived?

Environmental Contamination

However, as is clarified in the sections on health,
interviews among the exposed community in Floor
has thrown up substantial evidence of the
prevalence of immediate and persistent symptoms
among individuals.

The potential for short- and long-term
environmental contamination from the incident is
very real. Besides the air-borne deposit of
persistent pollutants at least along the path of the
plume, the mode of firefighting and the lack of
containment procedures after the fire was put out
also means that water bodies and wetlands in the
area, including the River Periyar, may have
received substantial loads of toxic runoff from the
factory site. Given the persistence of these
chemicals and their ability to travel through the food

Emergency Plans

Section 41B of the Factories Act requires the
occupier of a factory to prepare an onsite
emergency plan, and to disclose to workers and
general public living in the vicinity the safety
measures to be taken in case of an accident.
Rule 15 of the Manufacture, Storage and Import
of Hazardous Chemicals Rules, 1989, mandates
the provision of a detailed off-site emergency
response plan by the occupier of a hazardous
facility to members of the public.
When questioned about disaster management
plans and on-site and off-site management plans,
HIL GM Shenoy was confused and his response
was incomprehensible. “The disaster management
plan, the coordinator is the district collector. We
don't have anything to do With that. That is for the
Whole district. It should be there on the website. . .
..
,

Offsite plans is a new development.

Sacks of material labelled endosulfan were found lying In
«POOl of water adjacent to the bumt-down endosulfan unit
two days otter the fire.

Industrial F’re at Hindustani-Insecticides Ltd

chain, it can be safely assumed that the
contamination will spread from the originally
deposited areas and will, overtime, travel far from
the source.
Water-borne Contaminants

Initial remediation efforts should involve
preventing migration of contaminated rainfall
runoff and contaminated leachate from the debris.
The former can be done by digging rainfall runoff
interception ditches around the site, and the latter
by removing and/or covering the fire debris.

The Kerala State Pollution Control Board is
reported to have taken air samples on 6 or 7 July,
2004. However, no details are known as to where
the samples were taken from, and what they were
analysed for. According to Dr. Chernaik, given the
presence of the highly toxic air pollutant phosgene,
near-term ambient air quality should be monitored
for phosgene using detection tubes.

Health Effects in the Community

A sub-group of the Fact Finding Team led by
public health researcher and physician Dr. R.
The Fact Finding Team documented abysmal Sukanya visited the affected area within Eloor on
conditions inside the factory, both in respect of the 7-8 July, 2004, to:
site of fire and the general state of the HIL factory.
a) Map the area under the toxic plume, and
On 8 July, the team found many sacks of material
roughly estimate the number of dwelling
labeled “Endosulfan Tech” lying in a pool uf water
units within that area;
alongside the burnt down endosulfan unit. (See
b) Document the symptoms manifested after
photos)
exposure to the toxic fumes;
c) Document the adequacy of medical relief
Many residents raise milch cattle, chicken and
provided to the community.
ducks on the island. Many residents live
alongside the Kuzhikandam Thodu that can be
The Poisons
expected to drain the contaminated run-off from
HIL manufactures several chlorinated pesticides
the factory.
including DDT. The fire
consumed or affected
In 1999,Greenpeace surveyed and sampled the material in the endosulfan unit including HCCP,
Thodu. It found 111 chemicals. Thirty-nine of these butene diol, thionyl chloride, toluene and
were hazardous organochlorine compounds, endosulfan. From this, it can be inferred that at
including DDT and its metabolites, endosulphan least the above mentioned chemical pollutants of
and its metabolites, and their respective concern were released.
degradation products.
Namo of
Por»l»tont In
Symptom* .

Target Organ*'

PhosgenNo
e

Eye irritation; dry burning throat;
vomit; cough; foamy sputum;
dyspnea; chest pain; cyanosis

Eyes; skin; respiratory
system. , •;

Sulphur.
Dioxide

Eye, nose, throat Irritation; rhinitis;
choking; cough; reflex
bronchoconslriclion

Eyes; skin; Respiratory
system'

Hydrogen
No
Chloride

Nose, throat,’larynx Irritation; cough;
choking; dermatitis

Eyes; skin; respiratory
system

HCCP

No

Eye, skin, mucous membrane
Irritation; in animals, kidney damage
and fiver cancer

Eyes; skin; kidneys;
respiratory system

Endosulf­
an

Yes

Skin Irritation; nausea, confusion;
agitation; flushing; dry mouth; tremor;
convulsions

Skin; Central Nervous
system; liver; kidneys;
reproductive system

Thionyl
Chloride

No

Eye, skin, mucous membrane
Irritation; eye’, skin burns

Eyes; skin; respiratory
system

Po.iulant

Air-borne contaminants

Residents in the immediate vicinity said their
houses and nearby trees were dusted with soot
from the factory. It may be recalled that after the
World Trade Centre burnt down, many houses in
Manhattan, New York, had to be wiped clean to
eliminate health hazards to residents from the
soot-, ash- and dust-borne contaminants.
Dr. Mark Chernaik, staff scientist at ELAW-US,
places issues of immediate, short- and long-term
contamination in perspective:
"Probably a lot more burned during the fire, such
as chemical solvents and building materials, than
just endosulfan and HCCP. So, the fire would also
pose a short-term risk through exposure to excess
ambient air levels of particulate matter (especially
if the fire is still smoldering) and a long-term risk
through exposure to high levels of
persistent
organic pollutants (such as
dioxins) in the soil. These should be
monitored as well."
Fact finding report

Environment

NO

Source: Pocket Guide to Chemical Hazards. US Department ofHealth
and Human Services. February 2004

Besides the chemicals in the table above, the most
significant long-term threats probably come from
the emission of polyaromatic hydrocarbons (PAHs),
dioxins and furans. The latter are two categories
of compounds comprising some of the most toxic
chemicals known to science. Dioxins and furans
are inevitable byproducts of combustion involving
chlorinated material. These chemicals are
9

persistent, bioaccumulative and are capable of At least one 16-year old girl was admitted to the
exerting transgenerational effects. They are known hospital reportedly after she suffered convulsions.
human carcinogens, and their effects target However, the Fact Finding Team could not meet
her or her family to ascertain the facts and course
virtually every system in the human body.
of events after the fire leading to the patient’s
PAHs are usually grouped as short-chain PAHs hospitalisation. Neither could the Team meet any
and long-chain PAHs. The former, including of the HIL workers or the firefighters who were
chemicals such as naphthalene, are acutely toxic exposed to the toxic gases to assess if there were
especially in the aquatic medium. Long-chain PAHs any health problems among them.
include many chemicals that are known
carcinogens. PAHs are common emissions The acute respiratory and gastrointestinal
symptoms reported by people may have been
associated with fires.
caused by particulate matter or any of the toxic
The Symptoms
gases from the fire. Headache is a prominent
symptom due to the effect on the Central Nervous
The Fact Finding Team interviewed residents (ages System.
ranging from 18 to 60) in 15 houses in the area
reportedly covered by the smoke plume. Medical Relief
Households that did not flee the scene kept their
children indoors, with sheets covering them, and A medical team of doctors from the District
buckets of water nearby. Some people covered Medical Office conducted a camp that began in
their faces with wet towels.
the forenoon of July 6. They provided basic
primary symptomatic care for problems reported
Men and women who came out to check the fire by people. Around 200 people attended the camp.
and/or remained outdoors reported a “feeling of The few outpatient slips examined by the Team
suffocation” down the throat that was persistent had no mention of any diagnosis or advice of
even two days after the incident. This was follow-up to the patients. The medical team had
associated with difficulty in breathing and cough. been informed that there were 'patients with burns’
All these symptoms were exacerbated among the and had come prepared with huge quantities of
elderly and those with chronic respiratory dressing material.
problems. All interviewed residents reported a
burning sensation as if someone were “rubbing The Fact Finding Team visited the Primary Health
chilli powder in the throat and eyes.” Many Centre and met the doctor, who said she was not
complained of a chest discomfort as "something in Eloor on the day of the incident; she was
irritating," “chest pain,” “burning sensation in the working in the District Office on July 6. The doctor
chest’ and ‘weight over the chest’.
had not received any feedback from the Medical
team and also said that she had not noticed any
Nausea and vomiting were commonly reported unusual health problems in the subsequent days.
symptoms. Young adults and the elderly Many people were taking symptomatic medical
complained of a feeling of fullness of the stomach treatment from the private practitioners for the
associated with nausea and vomiting. Persistent persistent symptoms of throat burning, difficulty
headache was also frequently reported.
in breathing and nausea.
All residents reported having experienced similar
problems, and that the nearby chemical industries
emit different types of smoke every night. On July
6, the smoke was thick, the visibility was poor, and
the breathing problems, feeling of suffocation and
burning of eyes were more severe and persistent.
Unlike the symptoms associated with routine
pollution, residents said that the intense feeling of
burning sensation down the throat was new. This
symptom was persistent among many residents
even two days after the fire.
to

I

No attempt was made to address the problem as
a case of chemical poisoning, or to assess the need
for long-term health monitoring and care. Neither
was the area under the toxic plume identified to
get a sense of the number of affected people. In
the absence of such mapping, any future plans tc
assess long-term health effects related to the fire
incident, would be difficult to implement. It is
evident that the medical care accessible to the
people is incomplete and inadequate.
,

Fire at Hindustan Insecticides Ltd

'

The chemicals that are likely to have been released
are known to cause a range of sub clinical
enzyme changes to overt organ damage of the
respiratory (pneumonitis, bronchiolitis),
gastrointestinal (elevated liver enzymes to full
blown jaundice), genitourinary (proteinuria,
oliguria, severe metabolic acidosis to kidney
failure) and central nervous systems (headache,
convulsions, coma). Contact with the chemicals
on the skin could cause dermatitis and skin burns.
Absorption by contact with the eyes could also
cause optic neuritis. Any damage to the organs
could have been detected only by a complete
clinical examination and appropriate laboratory
investigations.
Some of the chemicals are known carcinogens.
The types of delayed health effects due to acute
exposure of many of these chemicals are not
known. New evidence implicates that “endosulfan
exposure may delay sexual maturity and interfere
with hormone synthesis in male children”6.

The fact-finding team has only documented the
reported morbidity of the people. The extent of
organ injury and the consequences on the health
status of the people exposed is not known. There
is a grave need for long-term health monitoring
and disease surveillance to identify and address
the health problems of people exposed to the toxic
chemicals.

Conclusion
The HIL fire raises as many questions about the
negligence of the company as it does about the
complicity, complacency and, ultimately, the total
failure of regulatory authorities such as the
District Administration, the Pollution Control Board,
the Factories Inspectorate and the Controller of
Explosives. In enquiring into this incident,
investigation into the failures of these departments
would be critical to preventing such disasters from
recurring.
The response of the District Administration and
regulatory authorities in dealing with medical
emergency caused by the fire was ad hoc and
uninformed. This indicates that the administration
is totally unprepared in terms of medical response
in the event of such emergencies. It is also clear
that the medical professionals who led the
health camp on 6th July had little or no
j jEs understanding of the special needs of
victims of chemical poisoning.
'Fact finding report

Government departments have done nothing to
win public trust. Moreover, they have treated
community concerns with contempt and viewed the
public as adversaries. It is imperative that in Eloor,
any attempts to address the public interest
concerns raised by the HIL incident in particular
and industrial safety and environmental quality in
general has to involve community representatives,
environmental groups, workers representatives
and labour organizations. Leaving matters in the
hands of committees comprising the industry and
Government have proven disastrous.
Workers, particularly in factories such as HIL, are
fearful of losing their jobs either as a result of
closure due to environmental reasons, or as a
result of privatisation. The threat of job loss
prevents them from fighting for improvement of the
environment in their place of work. Worker health
and safety concerns at the workplace are closely
linked to the health and safety of the community.
However, the insecurity faced by today’s workers
prevent them from fulfilling their responsibilities
beyond their own workplace, and often pits them
against community residents concerned about the
pollution caused and hazards posed by the
factories. Corporations take advantage of this
divide to go about business-as-usual. To change
corporate behaviour, therefore, this confrontation
between communities and workers, both of whom
are victims of pollution, needs to end.

Recommendations

1. Hindustan Insecticides Ltd and its senior
executives should be criminally charged
with negligence for having failed to take
adequate steps to prevent the fire that
injured a yet-to-be-determined number of
people and polluted the environment.
2. Criminal action must be taken against the
Occupier and Manager under Section 92
of the Factories Act for violating the
provisions of the Factories Act.
3. The Central Government should conduct
a formal enquiry into the “causes of the
accident" and should coopt one or more
persons possessing legal or special
knowledge as assessors in such enquiry.
The Centre can order such enquiries
under Section 9-A of the Explosives Act,
or section 41-A of the Factories Act.
4. The District Administration, along with
relevant authorities and community groups,
should establish a system for long-term
health monitoring, disease surveillance and
treatment of people in the impact zone of
the HIL smoke plume. Firefighters, police
personnel and HIL staff exposed to the fire
should undergo a complete medical
examination, monitored on a long-term
basis and provided with specialised health
care. The company should be directed to
compensate at those affected, whether
directly or indirectly, by the fire.
5. The Kerala Pollution Control Board should
submit a report prepared at HIL’s cost, on
pollution containment measures, and
short-term and long-term environmental
monitoring plans deployed by it in response
to the HIL fire. (See footnote for more
details)6
6. The Factories Inspectorate must be asked
to submit a report on steps taken by it to
assess the adequacy of safety systems in
HIL.

The District Administration should explain
why it failed in preparing people for an
appropriate response in the event of such
emergencies, and what steps it is taking to
avoid a repeat of such haphazard response
in the event of future emergencies.
8. Companies that do not have or do not
disclose onsite and offsite emergency plans
to workers and members of public should
be ordered to do so within a set time frame
or shut down after presenting a plan for
rehabilitating its workers.
9. Infrastructure for mass evacuation from
Eloor Island to the mainland at crucial
points in Eloor should be set up for use in
the very LIKELY event of an industrial
disaster.
10. The District Administration should prepare
a comprehensive disaster response plan
to react to such disasters. The plan should
include components dealing with mass
evacuation, disaster containment,
emergency environmental response,
emergency medical response, and shortand long-term medical and environmental
monitoring and rehabilitation. Suitable
experts should be consulted for the
development of each of these components,
and the plan should involve significant
participation from workers, community
residents and community groups.
11. Given the high levels of existing pollution
in Eloor, and the incremental burden added
by ongoing pollution and incidents such as
the HIL fire, the KPCB should develop a
comprehensive environmental remediation
plan for Eloor and the River Periyar. The
development and execution of the plan
should be led by workers and residents and
be paid for by all Eloor industries
each
contributing in proportion to their pollution
output.
7.

Industrial Fire at Hindustan Insecticides Ltd

End Notes
’ Press statement 06 July, 2004, Hindustan Insecticides Ltd, Udyogmandal, Eloor, Kerala.
2 Interview at Eloor Police Station with Sub-inspector Abdul Rahim. 10.30 a.m. 08 July, 2004.
3 Interview at FACT with Plant Safety Manager O.T. Verghese. 3.30 a.m. 08 July, 2004
' Interview at HIL Endosulfan unit with Vincent D. Paul, Deputy Production Manager, Hindustan Insecticides
Ltd. 12 noon. 08 July, 2004
5 Press statement 06 July, 2004, Hindustan Insecticides Ltd, Udyogmandal, Eloor, Kerala.

'(Environ Health Perspect 111:1958-1962 (2003).)
7 The following resources may be helpful for developing long-term environmental monitoring programs.
"Environmental Follow-up of Industrial Accidents." A report prepared by The Institute of
Terrestrial
Ecology, October 1997. United Kingdom Department of the Environment, Transport and the Regions.
http://www.fraw.org.uk/library/004/indaccid/followup.html
www.fullsense.com/Products/BD9000/9500/GasDetectorTube%5CshortTermGasDetectionTubesP_Z.htm

If local officials would like to liaise with international experts about responding to industrial fires involving
pesticides, they may want to contact the following offices:
a) United Nations Environment Programme
Awareness and Preparedness for Emergencies at the Local Level (APELL) Programme
Branch Head: Fritz BALKAU
e-mail: fritz.balkaul@unep.fr
Consultant: Ruth Zugman Do COUTTO
e-mail: njth.coutto@unep.fr
b) OECD Environment EHS contact
ehscont@oecd.org
Fax: +33 (0)1 45 24 16 75

Fact finding report

13

KT. 04
ENDOSULFAN POISONING DUE TO COMMUNITY EXPOSURE FAILURES IN RESPONDING TO THE HEALTH PROBLEMS AND
PROVIDING PUBLIC
HEALTH CARE AND SERVICE.

The incidence of the endosulfan poisoning at the Kasargod villages in Kerala is
exposing many limitations, negligence, failures, lack of accountability, responsibility,
casual and careless attitude of officials, lack of information and knowledge, system
failure, lack of systems, buy outs, etc.

The attempt in this presentation is to look at the failure in the public health sector.

1

Safeguarding children from
pesticide exposure
Lessons from the Endosulfan tragedy
in India

Dr Sukanya R, Sridhar R

Thanal Conservation Action & Information Network
3rd ICCHE 2004, London

Obj ectives
• Review the incident of Endosulfan spraying and
vulnerability of children to pesticide exposure in
Kasaragod district,Kerala in India.

e Review the environmental protection system in
India to safeguard people’s health from pesticide
exposure in terms of
- A. Legal and constitutional provisions,
- B. The implementation and monitoring mechanisms
of pesticide use in agriculture.

• Review the policy implications for safeguarding
children’s right to healthy living.

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Picture of cashew plantations

Conclude on two important findings:
1. Long term exposure to Endosulfan
Exposure is continuous and long term. Residues of Endosulfan were
found in the water, soil samples (more than the MRL) taken 10
months after the last aerial spray in Dec 2000.
Favourable watershed characteristics for endosulfan to persist in
soil and water.

2. Excess morbidity among the people
Case studies
Department of health study
National Institute of Occupational Health

Epidemiologic evidence
An epidemiological study was conducted by the NIOH
to explore the effect of Endosulfan on the growth and
development of school children (10-19).
Study group'. School children residing in the Endosulfan
sprayed areas
Comparison groups'. School children from an area 25 km
north of the sprayed plantations; similar socio-economic
background. This area also grew cashew but did not
have any streams or aerial spraying.

Investigations by
1 .Media
2.Environmental organisations -THANAL and
Centre for Science and Environment
3.Kerala Sasthra SahitHya Parishad
Kerala Agricultural University
4.
5.Plantation Corporation of Kerala
6.Government of Kerala -Achuthan committee
7.National Institute of Occupational Health
Pesticide Action Network-Asia Pacific (PANAP)
8.
Department of Health,Kerala
9.
lO.Central Committee-Dubey committee

The incident - Endosulfan spraying
• Aerial spraying of Endosulfan, was done in cashew
plantations spread over 4500 hectares around 15 villages in
the northern part of Kasaragod district in the state of Kerala
since 1976.
• The cashew plantations belong to the state owned public
sector company - Plantation Corporation of Kerala (PCK).

• Since 1979, the local community have noticed
health effects in the animals and also among
the people.
• Significant neurological impairment among
people aged <20 years.
• School children - physical and mental
development affected (School Annual
meeting 2000)
° The first ban on aerial spraying - sought by an
affected mother
• People’s movements against spraying and ban
on use of endosulfan.

Methodology of the study
1. Estimation of mean weight, height,skin fold thickness
and body mass index of the two groups
2. Assess reproductive development by
a.Sexual Maturity Rating (SMR) using the Marshell
and Tanner’s classification
b.Estimation of serum levels of Testesterone,LH and
FSH.
3. Assess the neurobehavioral development by reported
learning ability by teacher and objectively by a screening
test (Draw a Man) for IQ
4. Estimate the prevalence of congenital abnormalities by
clinical examination by Paediatrician.

Relationship of environmental endosulfan exposure
and reproductive development in male children and
adolescents (10-19)
EHP 111 (16); (Dec 2003) 1958-1962
Parameters

Control (n=90)

Study (n=117)

Age (years)

13.10 ± 2.12

12.80 ±2.07

Height (cm)

141 ± 10.60

139 ± 13.30

Weight (kg)

30.70 ±7.44

29.50 ±8.93

Body Mass Index

15.30 ±1.98

15.00 ±2.11

Skin- fold
thickness

7.31 ±2.15

7.40 ±2.28

Sexual maturity of male school children
EHP 111 (16);(Dec 2003) 1958-1962

Multiple regression analysis :
SMR score,Age,Aerial exposure
Testosterone levels,age,aerial exposure

SMR score for pubic hair,testicular and penis development
lower for study group for the same age .

Serum Testosterone levels of the study group were
statistically lower than the control group for the same age.

Endosulfan levels in blood
EHP 111 (16);(Dec 2003) 1958-1962

Serum endosulfan detected in 78% samples in
study group as compared to 29% of control
group.

Mean levels of Total endosulfan in study
group is 7 Al + 1.19 as compared to control
children 1.37 + 0.40 (p < 0.001).

Conclusion
1 .Endosulfan is a known testicular toxin in animal studies
2.Children have been exposed —
PRENATALLY -mothers of affected children who are
residents in the sprayed areas.
ENVIRONMENTALLY - water, playing in soil and
inhalation during the spraying
3.Endosulfan exposure may delay sexual maturity and
interfere with hormone synthesis in male children.
Biological plausibility is evident.No other causal factor
4.
identified.
Limitations : Small sample size

The incident - Endosulfan
spraying and the ban
• Due to media and public pressure, the State
brought in a ban on endosulfan in August 2001
° Under pressure from industry,the State removed
the ban in February 2002, finding excuse from the
loopholes of the Insecticide Act.
° The High Court heard petitions from varied
Environmental groups and ordered a temporary
ban on Endosulfan in State of Kerala in December
2002.

Review of the Environmental
Protection System
• Constitutional Provisions - Right to Life,
Right to healthy environment
• Environmental laws - Air Act, Water
Act, the Environmental Protection Act,
Public Liability Insurance Act.
• The Insecticide Act,1968

The Insecticide Act, 1968
1 .Regulates
registration,licensing,manufacture,transport and
storage of pesticides.
No stipulations on use of pesticide
- who can buy or procure and use.
- Inadequate rules on the preventive and safety
mechanism for any pesticide use.
- No monitoring mechanisms for pesticide use.
- No precautions to prevent exposure of people
indirectly exposed.
2.Rules on aerial spraying

Violation of the Act!!
• The regulations were completely violated in
Kasaragod (Achuthan Committee, 2001).

• Spraying had occurred at heights which aided wind
drift and settling of the endosulfan chemical on soil
surfaces.
• Adequate notice to the community before spraying
was sparingly followed.
• Protection of water bodies was difficult to implement.
• The Insecticides Act and the Rules failed in
protecting the people from exposure.

Failure to Protect Public health
• In 1991 and 1999 government committees to review
the continued use of pesticides [Banerjee 1991 .R B
Singh 1999, Interministerial committee 1999] have
recommended the use of endosulfan in the country with
a condition that it not be used near any water bodies.
This part of the order was never implemented in any
part of India.
• The Central Insecticide Board which reviews aerial
spraying had not extended its recommendation to aerial
spraying after 1993, but aerial spraying continued in the
PCK plantation.

The Environmental and other laws
• These Acts deal with industrial pollution than pesticide
exposure in agri-business settings.
• Pollution from agri-business settings is not covered
specifically under any law in the country.
• Even case laws do not exist to invoke these Acts for a
pesticide exposure issue.
• Most of these laws are not preventive or precautionary
in nature and enables justice through a weak regulatory
mechanism of “penalties and restraints”.

Constitutional Provisions
• Article 21 - Right to Life - “No person shall be
deprived of his life or personal liberty except
according to procedure established by law”.
• Article 32, 51(g), - Public Interest Litigation These articles empowered a very useful tool in the
country for the public to seek justice by increasing
the accessibility of the judicial system.
• The Indian Judiciary has time and again resorted
to invoking the fundamental rights to provide
justice in environmental issues.

The Endosulfan Ban
• The Local Court used the provisions in the civil
law to protect the public property from poisoning
by pesticides - stopped aerial spraying of
pesticides.
• The High Court creatively used the “Precautionary
Principle” and banned the sale and use of
endosulfan in the State.
• Article 21 invoked inspite of lack of specific
provisions in the Insecticides Act.
• Remarkable judgment clearly upholding the need
to stop potential harm to public health over the
need to profit through sale and use of endosulfan.

Endosulfan -viewpoint of
agricultural science and industry
l.Ban — Loss to the Industry.In India endosulfan is
used in cotton,cashew,tea and vegetable cultivation.

2.Agriculture scientists propagated endosulfan as a
‘Safe chemical’ -effective against pests,less persistent
and not known to cause health effects.
3 .Department of Agriculture recommends the use of
endosulfan and also subsidises its sale to farmers.

The wrong prevails... dangerously
* Central Government - Failed to extend the
ban to the whole of India or even start the
process of the phasing out this persistent
chemical
• The State Government - is ineffective in
implementing the ban and sale of the
chemical continues.
• The Central Government committee headed
by an Agricultural expert, rejected all
evidence on the health effects and causal
link to endosulfan.

The wrong prevails... dangerously
The Committee .....
• Allows the continued use of endosulfan in all
crops (in India a major porportion of endosulfan
is used in cotton cultivation)
• Suggests that the Plant Protection Division
(under the Agriculture Department) conduct a
health study in the future !!
(Clear case ofInterests of the industry and bias
of the agricultural scientists against the need to
protect human health and environmentfrom
harm)

Children tn the vulnerable world of
pesticides...
• The Pesticide Regulation agencies refuse to recognize
the availability of new scientific evidence regarding
children's vulnerability - blatantly so because it
challenges the very premise of “safe use of pesticides”
propagated by agriculture scientists.
0 Lack of Policy and laws- on Environmental issues of
pesticide use, exposure, contamination and
safeguarding human beings.
• Safeguarding Children from EXPOSURE to pesticides
is not addressed in any policy or legislation.
V

Children in the vulnerable world of
pesticides
The Endosulfan case-study showed that
• Specific epidemiologic evidence of endosulfan
affecting the reproductive development of
children.
• Children are the most affected by the use of
endosulfan.
• The Safeguarding mechanisms did not address
public health and did hot protect children from
exposure.
• The Safeguarding mechanisms do not recognize
enhanced vulnerability of children in pesticide
exposure impacts.

The most important lesson from this tragedy
Communities are led to believe that safe use of
pesticides is possible and that accidents and
poisoning incidents are an issue of regulation.
The scientific tools of MRL,ADI,LD50 have
been developed to regulate the health impacts.
The different settings of exposure and health
impacts of children show that the science and
policy have not effectively addressed ground
realities.

Children’s vulnerabilities
1. Children are involved in family based activities, like
agriculture.

2. Child labour in agri-business settings

3. Living environment and activities of adults
4. Susceptibilities - Behaviour,Physical size, Metabolism,
Intranatal exposure
5. Lack of political commitment to understand
environmental threats and protect the environment for the
future children.

Community action for Pesticide Elimination
(CAPE)
Documentation and expose the different ways by which
communities especially children are exposed.
Community monitoring of pesticide-related health effects.
Communicate the issue of pesticides and their impact on
human health.

Develop strategies to eliminate the use of pesticides in house
and in agriculture.
Reveal the interests of different stakeholders -industry and
agriculture departments to the public.

To influence policy changes to eliminate the use of pesticides.

Thank You

KI. OS

TESTIMONY ON USE OF IRRATIONAL DRUGS

At present,many drugs which do not find a place in any standard text book of medicine or
pharmacology are prescribed to patients under considerations other than scientific
indications.This increases the cost and many a time prove to be hazardous to health.Anti
oxidants,tonics,irrational combinations of drugs are prescribed and used.The recent
controversy where gynaecologists prescribed Letrozole for infertility is another,
eg.Letrozole is an anti cancer drug and its label carries the warning : To be prescribed
only by an oncologist.The MIMS also carries a list of drugs prescribed in India which are
either irrational or not recognized by the Drugs Controller General Of India.A study
conducted by SCTIMST,Trivandrum has found 66% of prescriptions to be irrational.
Since SCTIMST is a national institute of repute, this has to be given due importance.
Another study recently released by Dr.Indira of Medical College,Trivandrum1 Clinical
Epidemiology Unit has brought out the irrational use of antibiotics in respiratory
infection in children.
INDIAN MEDICAL COUNCIL REGULATIONS 2002(NOTIFIED ON 11-3-2002
PUBLISHED IN GAZETTE OF INDIA DATED 6 APRIL 2002 1.5 says

Every physician should as far as possible prescribe drugs with generic names and ensure
that there is a rational prescription and use of drugs.

Denial of Health Care: Irrational use of drugs
Consequences: Impairment of health

Recommendations:

The Medical Council India (MCI) must be directed to implement this statutory
regulation in letter and spirit and institute a Prescription Audit..
The Drugs Controller General India must publish the list of drugs approved by him
for use in India with indications.
The MCI shall direct all doctors to prescribe only those drugs which are given in
standard text books and approved by DCG till a National Formulary is accepted..
MCI must publish a National Drug Formulary or accept, the already available ones
Eg: IMA Drug Formulary,CHAI-CMAl Formulary.

All prescriptions should be from within this Formulary. This must be made
mandatory.

1

KT. 06

NEGLIGENCE IN PESTICIDE USE AND ABUSE - RESULTING EXPOSURE
TO COMMUNITY & ENVIRONMENT
Need for preparedness to avert disasters and provide relief for victims.

There were several cases of poisoning in cashew factories in Trivandrum last
year; 1500 women workers were hospitalized. The response was limited to just
first aid and acute poisoning mitigation.

Over 100 students were hospitalized in Wynad resulting from the pesticide use
by a farmer in the compound next to the school. The timely intervention of the
District Collector saved the lives of 8 serious exposure cases.
Exposure and access to pesticides in the plantation areas of Idukki makes it the
district with highest suicide rates in the state. The district also reported the rise in
cancer patients resulting from pesticide use.

Denial of health care: Absence of regulation in the purchase and use of pesticides.
Consequences: Ill health of the people.

Recommendations: Regulations of the production, sale and use of pesticides.

1

KT, 07
lack of a forum where patients can lodge complaints

REGARDING TREATMENT
There is no effective forum where patients can lodge complaints regarding treatment
(consumer forum is only for compensation) eg: unnecessary drugs, unindicated drugs or
other treatment, unnecessary costly investigations deviations from accepted treatment
protocols etc. eg; Caesarean Sections are in the range of about 30% though the accepted
range is only 10%.

As patients are not capable of assessing the scientific validity of the treatment meted out
to them, expert panels need to be constituted under each medical council to address this
issue.
Denial of Health Care: Absence of forum to lodge complaints of mismanagement and
malpractice, other than the courts of law or the consumer redressal forums.

Consequences: Issues of general nature of mismanagement in health care are not heard
or taken care of.
Recommendation: Have expert panels under each Medical Council (State), who will
listen these complaints and ensure that proper action is taken.

1

Cj>> m h ~ 3 3 -

ANDHRA

HRADESH

'ASSESSMENT OF INFRASTRUCTURE IN PUBLIC HEALTH INSTITUTIONS
Infrastructure creates the basis for growth. It will play a critical role in

achieving the vision for Andhra Pradesh. Every objective, whether it is
developing the growth engines, improving the education and health services or

augmenting the services in villages and cities can be achieved only if the
necessary infrastructure is created (Vision 2020). Given this mandate, all the
development related efforts should contribute in translating the vision into a
reality. This is pertinent to health sector because it occupies a pivotal position in

the developmental process. Hence, Health System Reforms should be

recognised as significant

“processes” in which structural and organisational

changes would be taking place with the expressed intention of achieving health
care objectives.

In India, the establishment of Primary Health Centres (PHCs) in each

Community Development Block was launched on October 2, 1952. Since then
health service organization and infrastructure have undergone extreme changes.

As per the population norm, a subcentre health facility should be provided for
every 5000 population in plain area and 3000 population in hilly/tribal areas. The

corresponding population for PHC is 30,000 & 20,000 respectively. Similar
population norm for CHC indicates a total of 120,000 & 80,000 for plain and

hilly/tribal areas in that order. Providing service in the area of public health
sanitation, hospitals & dispensaries are the responsibilities of the state
governments as per constitution. However, population control and family

planning are concurrent subjects. Further, the quality and quantity of health
personnel and infrastructure facilities are furnished by state governments. Thus
the success of this programme depends on many factors. Currently the Ministry'

of Health and Family Welfare (MoHFW), Govt, of India is implementing the RCH
programme in the country.
The current RCH programme is implemented mainly through primary

health care approach. Infrastructure assessment and its utilisation provides an

opportunity to understand the supply and demand dimensions of the programme
in the state.
Status: At present, the state has a large health care infrastructure in the form of
public health institutions mostly created in the post-independence era. There are

about 11,000 Subcentres and 1400 PHCs at the primary level. About 230 health
facilities are functioning at the secondary tier to support the primary level. Atleast

40 hospitals are providing tertiary care.

Table -1: Existing Infrastructure in A.P.

Number

Under Commissionerate
Welfare
Subcentre

i)

ii)

, iii)

I

IV)

V)

vi)

of

Family

10,568

Under Directorate of Health:
PHCs
CHCs
Govt. Hospitals
Govt. Dispensaries
Mobile Medical Unit
Project Hospitals/Dispensaries

1,386
47
67
104
45
24

Under APVVP
District Hospitals
Area Hospitals
MCH Hospitals
Paediatric and CD
CHCs
Civil Dispensaries

21
56
7
3
117
24

Under Directorate of Medical Education
Teaching Hospitals
Rural Health Centres

31
6

Under University of Health Sciences
Medical Institutions

5

Autonomous Institutions
NIMS, SVIMS, Cancer Hospital

3

(DFID, Impact & Expenditure review; Health sector; draft final report;
March 2001; p18)

The existing infrastructure can be compared with the planned activities of
Government of India, in this aspect. Government of India has envisaged the

requiremgnDof Health Infrastructure in A.P. for the year 2002 in the following
patternj^,
.• ;

Table ^y^equirement of Infrastructure as per GO!

s u bcqrifre'
"S-


•1

-z-y

Af^

India

PHCs'- -C

CHCs

S

R

P

S

R

P

S

639

1868 '

1636.’

232

467

238

229

1-37271 ■ -‘22927

25907

229.75

'4323

6479

2935

3553

^1056?"

($■) Infrastructure "required in 2002 as per projected population and in
position ~^-&P30-06~1999:::(Bulletin on Rural Health Statistics in India, Issued'by
Rural Health Division, Directorate of Health Services, Dept, of Family Welfare,
MOHFW,'^O:rJune. 200'bT:tdBle18,p 40).

*RH Required; P: Position; S: Shortfall

Ina similar way, Health Systems Resource Centre of DFID, has estimated
a shortfall ot about l300 Subcentres, 500 PHCs and 250 CHCs in the state.
Further, if has highlightecTtfi'at only 85 PHCs and 15 CHCs were established
during ninth plan period out-of proposed 300 New PHCs and 60 CHCs.
Table-3: Current Infrastructure and Norms - DFID
Facility

Norms

Current

Required

Shortfall*

1/5000 (PI)

10568 ?

11885

1317

1386**

1889

503

'

Subcentres

■1/3000 (Trb)
PHCs

1/30000 (pl)
•1/20000

(Trb)
Govt. H osp. N.o_ norms

. 144

Proj. Hosp. No norms

6

1/100000
218
* as per norms and 1991 population figures

472

CHCs

** includes

Upgraded PHCs
Old PHCs
MPHCs

53
391
439

254

380
55
20

New PHCs
Subsidiary HCs
Govt. Disp.PHCs
LF Disp.PHCs

48

However, with a rural population of 55,223,944 (72.92%) in A.P. as per
Census 2001 and calculating the requirement with the set norms for health care
institutions, it can be estimated that approximately 11044 subcentres; 1840
PHCs and 552 CHCs may be required.
Thus, a shortfall of atleast 476.
subcentres, 472 PHCs and 332 CHCs may be worked out.
Access to health facility is crucial in terms of health seeking behaviour.
National Family Health Survey (NFHS -2; 1998-99) reported that median
distance from a nearest PHC in the state is 5.4 Kms. while about three-fourths of the rural population have access to a subcentre within a distance of 5 Kms. The
survey also reported that 48 percent of rural women live in a village with either a
PHC or a sub-centre. ?
Table - 4: Distance from Nearest Health Facility

Distance

Within
Village
<5 Km
5-9Km
10+Km
Median
Distance

SC

PHC

Either SC or
PHC

Hosp.

Disp/

Any Health
facility

46.3
29.6
14.5
9.6

14.1
32.4
32.4
31.1

48.3
31.8
12.8
7.1

15.4
28.9
23.6
32.0

45.4
21.6
15.4
17.6

64.2
23 S
7.8
4.1

-

5.4

-

5.8

1.3

-

(NHFS-2;t 2.13;p31)

Table - 5: Percentage of rural residents living in villages that have
selected facilities and services, A.P.
Primary Health Centre
Sub-centre
Hospital
Dispensary/clinic
Private doctor
Visiting doctor
Village health guide
TBA
Mobile health unit
STD
Medical shop/Pharmacy
Cable connection
(NFHS-2;t2.14,p32)

14.6
45.7
15.7
47.1 Z
60.8 \Z
57.3 V
43.7 Z
72.7 Z
31.2
16.6
39.7 r
88.4 J

laboratory facilities; about one-third are having a labour room; and less than 10
percent are having a telephone.

Table - 8: Percent of PHC having following infrastructure
Facility

Percent

Water (continuous supply)

52.3

Electricity

96.3

Labour Room

40.6

Laboratory

55.8

Telephone

8.6

Vehicle (functional)

30.5

-

(Facility Survey 1999, under RCH;ASCI, April 2000, Vol 1 & 2)

A study in AP, conducted by Institute of Health System (Structure and
Dynamics of the Primary Health Sector) identified "that auxiliary services like
telephone facilities and Ambulance services are available in 6 add 26 percent of

PHCs respectively. However, under APERP and local area programmes, the
situation must have improved in the last 2 years. For example 1^00 external

telephone lines are expected to be made available under APERP (Action plan
document for 2001-2002, item No. 32, Rs. 3,600 million, procurement through

direct contracting); and Generators to 315 PHCs (item 29, 5 KVA Generators).

Similar facilities at CHCs and FRUs show a better status. But, one in 4-5

of these institutions are not having continuous water supply and less than onethird of them are having functional vehicle. About two-thirds of FRUs and onehalf of CHCs are having separate aseptic labour room and an adequately

equipped laboratory facility.

IHS study, 2000 noted that Mean floor space in PHC is 2,198 square feet

while the mean land area is 3,543 square yards. These figures indicate by and
large adquacy of the health institutions in term of space and floor area for the
present and near future requirements.
In order to strengthen the secondary level health care system, the

Government of Andhra Pradesh, has developed infrastructure facilities through
AP First Referral Health System (APFRSH) project.
Table - 6: Position after upgradation of hospitals

Category

Before project

After project

No. of His.

No.of beds

No. of His.

No.of beds

District H

17

4354

23

5800

Area H

11

1085

51

/non
HOUV

CHCs

113

3981

120

5130

Speciality H

06

540

10

824

Civil dispens

25

00

24

00

Total

172

9960

228

16734

(APVVP; Departmental manual, VVP 115;DRMCRHRD!AP,p 76)

The year 2002 being the end of the project period, it is encouraging to
observe that very high proportion of hospitals have already been commissioned
under APWP.

AP Economic? Restructuring Project (Health Component):
i)

Construction of 627 PHCs with compound walls: Out of 627 PHCs
601 are completed.

ii)

No. of compound wall to old PHCs 561 Nos.: Out of 561 PHCs 553
are completed.

Facility Survey (1999) under RCH project, evaluated the infrastructure
facilities available in the state. A total of 622 PHCs spread in 12 districts were
surveyed. About one-half of the PHCs are having continuous water supply and

Information available regarding RCH related supplies and equipment kits both at
PHC and secondary tier reveals that there are apparent gaps even at these
levels.

Table -12: Percent of PHCs having supplies and equipment.
Percent (N=622)

Supplies

I.

31.6
44.9
6.2
9.26
62.1
84.3
25.3
63.8

Kit G (IUD insertion)
Kit I (Labour room)
Em 0 C drug kit
Mounted lamp 200w bulb
Oral pills
Measles vaccine
IFA tablets (large)
ORS packets
II.

Equipment (at least one functioning)

89.0
97.0
84.3
78.8
14.7
73.4

Deep freezer
Vaccine carrier
BP apparatus
Autoclave
MTP suction aspirator
Labour room equipment

(Facility Survey 1999 under RCH; ASCI, April 2000, Vol 1 & 2)

Table -13: Supply and equipment at Secondary level institutions

I. Supply

Tubal rings
Std. surgical kit (all 6 kits)
Em 0 C Drug kit
RTI/STI Lab kit
New born care equipment kit
Labour room kit

FRU

(Per cent)
CHC

DH

2.1
27.1
11.9
2.1
15.2
35.8

4.5
37.2
37.2
12.4
19.1
37.6

0.0
25.0
16.6
16.6
16.6
33.3

36.9
43.4

46.1
47.2

100
100

II. Operation Theatre equipment

Boyles apparatus
Oxygen cylinder

Shadowless lamp

88.0

77.5

91.6

(Facility survey 1999 under RCH; ASCI April 2000, Vol 1 & 2)

IHS study 2000, revealed that family planning, AN care and Immunization
services are available in atleast 85% of Primary Health Centre in the state. But,
availability of intramural diagnostic services are observed in only 10 percent of

PHCs.

Information on the availability of supplies of medicines, contraceptives

and equipment at subcentre also indicate shortages. The shortages are mostly

for antibiotics or cotrimoxazole and equipment like weighing scales. Stock outs
for one month or more are frequent in tribal areas.

Table - 14: Percent of Sub center reporting supplies and equipment

Percent (N=58)

1

2

3

Medicines
I FA tablets (large)

72.2

ORS packets

81.0

Vitamin A syrup

75.4

Antibiotics or cotrimoxazole

41.1

Antimalaria drugs

41.6

Paracetamol

72.9

Deworming medicine

68.4

DDK

28.7

Contraceptives

OCP

73.9

Condoms

11.4

IUD

48.7

Working equipment

Infant Weighing scale

62.4

Adult weighing scales

66.2

Syringes

98.5

Steam sterilizer

90.2

BP apparatus

59.9

(CARE, INHP, Final Evaluation, AP, 2001, IIHFW)

Table - 15: Subcentres Reporting Stock Outs on Medicines/Contraceptives

Available

Stock out 1 month or
more
Rural
Tribal
IFA Large
72.2
52.8
90.9
IFA Small
80.6
52.8
81.8
ORS packets
81.0
50.0
100.0
75.4
Vitamin A solution
50.0
90.9
Antibiotics (Cotrimoxazole)
41.1
72.7
90.9
Anti Malaria drugs (Chloroquine)
41.6
75.0
63.6
Paracetamol
72.9
63.6.
90.1
Deworming Medicine (Mebendazole)
68.4
47.7
6?.6
Oral Contraceptives
73.9
43.2
72.7
Condoms
11.4
71.8
90.9
IUDs
48.7
52.3
81.8
DD Kits
28.7
75.0
100.0
UIP
76.6.
32.8
63.6
T67 (8.2.3) CARE INHP QS. AP 2001
Medicines/Contraceptives

Drug and equipment procurement for public health institutions in A.P.:

Centralised Drug procurement and supply: In September 1998, a centralised
drug procurement was formed in APHMIDC. The drug wing operates its own
warehouses in 22 districts of the state with Executive Engineer as administrative
head supported by pharmacists. The budgets to the individual hospitals are allo­
cated by their respective Heads of Department i.e., DME, Director of Health and
Commissioner of APWP. The hospitals heads in turn utilise the budget to
purchase drugs, surgical items and medical consumable. This budget is
distributed between APHMIDC, individuals hospitals and DMHOs on the lines of
general procurement, emergency procurement and procurement as per
requirement changes. Out of 100 percent budget 2 percent is given to APHMIDC
towards supervision charges. From the balance, APWP keeps 90 percent with
corporation for procurement of drugs and allots 10 percent to individual hospitals.
DME keeps 80 percent with APHMIDC and the balance 20 per cent is allotted to

the hospitals under control. Director of Health keeps 80 percent with corporation
but the remaining 20 percent is equally allotted between individual hospitals and
DMHO i.e., 10 percent each. Drugs are distributed to user institutions as per the
allocations made by the Heads of the respective departments. Institutions draw
drugs on a quarterly basis budget through a passbook system. The user and the
warehouse maintain identical copies of the passbook.

PHCs are permitted to obtain drugs from the approved list of 33 drugs;
while secondary level hospitals from 103 drug-list and for tertiary care institutions
from 171 drug list. At PHC level the drug are grouped under antibiotics, IV fluids
and general drugs.
Drugs under national health programmes are not supplied through the
Central Drug Stores. By and large PHCs are eligible for drugs worth Rs. 1.2 lakh
annually. Lifting of drugs from District Drug Stores is done once in a quarter.
Drugs are provided to APWP hospitals from three different sources.
First, Rs.2000 is allocatted per bed per quarter under centralized drug
procurement system. The seconcj source of drugs is from the emergency
provision of Rs. 100 per bed provided every month directly to the hospital. The
third source is from the DCHS store'where drugs are procured under project are
stored and supplied. In addition to the above, separate allocation are made for
procurement of ARV and ASV.
i

Only recently, the corporation is involved in procurement of equipment and
consumables also. From February 2002, this organisation is procuring MCI
identified deficiency equipment.

In A.P. under Sukha Parivaram scheme of Social Marketing programme
12,000 condom vending machines are obtained.

Urban Health Centres also obtain drugs once in 6 months from the 33
drug list after centralised procurement. But the drugs are supplied through the
office of DMHO. In addition, “Emergency funds” to a maximum of Rs. 10,000 per
year will be released to each UHC for providing treatment and drugs for
emergency cases of maternal an infant care at FRU/private clinic. A maximum of
RS. 750 can be incurred for each beneficiary. For each UHC 34 items of drugs
and 13 items of furniture are supplied.
Equipment and Drugs for PHCs from APERP:

16 items of furniture and equipment like microscopes, centrifuge Hb
metre, Haemocytometre' ESR stand etc. for 668 PHCs are part of the goods
procurement for the year 2001-2002.

135 items for 315 Round-The-Clock PHCs consisting mainly clinical
equipment and consumables like syringes, face masks, bed linen sets etc. are in
the process of finalisation. For 1336 PHCs mechanical needle cutters (3 per each
PHC) and white cotton bedsheets (10 each for PHC) are also figured in the
goods to be procured in the action plan. Epidemic drugs valued Rs. 6,775
millions (as when required) are ear marked by APERP.

B.

UTILISATION OF INFRASTRUCTURE:

In A.P., only one out of five persons who fall sick utilise the health facilities
in the public sector, while majority of them seek services from the private sector.
NGOs and others play a very insignificant role.

Table -16: Percentage distribution of households by main source of health
care, when household members get sick, according to residence

Residence
Source

Urban

Rural

Total

Public Medical Sector

15.3

14.6

14.8

NGO or Trust

0.8

0.6

0.6

Private Medical Sector

81.2

81.9

81.7

Other Source

2.7

2.9

2.8

(NFHS-2, table 9.1;p 200)

However, the assessment of services by the users in public sector seems

to encouraging. Other factors may be dominating in expressing such a
favourable opinion.
Table -17: Quality of care during the most recent visit to Health Facility
(Public sector)

Indicator

Urban

Rural

Total

1. % who received the service they went for

98.4

98.0

98.1

2. Median waiting time

29.7

29.5

29.6

3. % who rated facility not clean

6.7

2.6

3.6

(NFHS-2, t9.51, p 206)

However, Public sector health facilities play a major role in providing

immunization

and family planning services. It is alarming to observe that in

conditions like reproductive health problems, more than two-thirds of women do

not approach either the'public and private sector.

Table -18: Source of childhood vaccinations by residence (per cent)

Urban

Rural

Total

Public Medical Sector

59

80

74.4

NGO or Trust

1

1

0.9

Private Medical Sector

38

18

22.9

Other Sources

2

2

1.8

Source

(NFHS-2; f 6.5;p 134)

Table -19: Sources of family planning among current users of modern
contraceptive methods - Percent distribution
Urban

Rural

Total

Public medical sector

64.9

83.4

78.5

NGO or Trust

1.1

0.6

0.7

Private medical sector

29.8

15.4

19.2

3.6

0.7

1.5

0.7

0.0

0.2

Source

,

Other source

Don't know

(NFHS-2;f5.2, p97)

Table - 20: Treatment of Reproductive Health Problems
(Among women with RH problem, the percentage who sought advice or

treatment from specific providers by residence.)

Urban

Rural

Total

Public medical sector

6.1

7.1

6.8

NGO worker

0.2

0.2

0.2

Private medical sector

36.0

30.1

31.5

Other

0.4

0.7

0.6

Provider

58.3

NONE

64.0

62.6

(NFHS-2,t 8.13,p 186)

RCH programme encourages deliveries under proper hygienic conditions

under the supervision of trained health professionals. Every second birth takes
place in health facilities. But utilisation of public health facilities is one-quarter of

the private sector in institutional deliveries.

Table - 21: Per cent of Place of delivery
Public institutions

13

NGO/Trust hospital

2

Private Institutions

35

Own home

25

Parents' home

24

Other

1
(NFHS-2; figure 8.4; p 185)

Even out of institutional deliveries', urban women utilise this type of service
two times than of rural women.

Table - 22: Per cent distribution of Institutional deliveries by residence
Urban

Rural

Public health facility

18.6

10.5

NGO/Trust

3.6

1.7

Private

56.4

29.8

12.4
8.7

29.8
29.0
1.1

Institutional :

Home deliveries:

Own home
Parent’s home
Other

_________________ 0.3

During

the

last two years,

GOAP

has

launched

an

innovative

“SUKHIBHAVA”, improvement of institutional delivery services scheme to assist
the rural pregnant women who are below the poverty line. This scheme will
enable them to access the service of hospitals for conducting of deliveries which

helps in reducing the maternal mortality in the state and also in long run helps in
positive attitudinal shift in health seeking behaviour of the poor, rural women.

Similarly “AAROGYA RAKSHA”, a health insurance scheme aiming at
strengthening the confidence of poor and illiterate in their ability to get health
care for their children. It also seeks to remove any fears in their minds about any
risk to survival of their children.

Like wise, JANANI programme was initiated to ensure micro-level
planning and implementation with the participation of local resources towards
universal immunization of eligible in the state. The impact of these schemes is
yet to be documented.
Diarrhoeal disease contribute for almost one-fourth of under five mortality
in the state. Usage of ORT including ORS remains to be the main stay in
preventing deaths due dehydration and electrolyte imbalance. Inspite of limited
ORS usage, public sector is the major source of ORS p'ackets in such situations.

Table-23: Source of ORS packets among children under age 3 who were
treated with a solution from ORS packets for diarrhoea
Source

Per cent

Public Medical Sector

43.3

Private Medical Sector

30.9

Other Source

25.7

(NFHS-2;t 6.14; page 142)

Terminal method of contraception is the most popular family planning

method in the state. About 95 % of acceptors are women. However, the role of
public and private sectors in motivating the users of contraceptives is very
limited.

Table - 24: Motivator of current users of modern contraceptive methods
Urban

Rural

Total

12.2
4.3
0.0
29.1
54.4

25.8
2.4
0.1
25.2
46.4

22.2
2.9
0.1
26.3
48.5

Public health sector
Private sector
NGO
Other
NO ONE

(NFHS-2;t9.7,p208)

Facility survey 1999, also provides useful information on the utilisation of
RCH services in the public health care institutions.

RCH programme envisages provision of pregnancy related services; first

trimester abortion services; and management of RTI/STI through syndromic

approach in addition to family planning services . At PHC level 97 per cent of
institutions are providing sterilisation services.

In only

42 percent of PHCs

deliveries are conducted. About one-third are utilised for RTI/STI problems. Only
1.5% of PHCs are conducting MTP services.

Table-25: Utilisation of services at PHCs (during the last three months)

a. Percent conducting

b.

Average

No.

Deliveries

MTP

RTI/STI

ARM

Sterilizations'*.

42.2

1.5

34.2

18.5

97.5

27.0

4.8

70.9

99.2

113.2

conducted
(Facility surveyl999 under RCH; ASCI April 2000)

Similar utilisation at secondary level institutions does not reveal any

changes in the pattern. The proportion of deliveries to total admissions (Delivery

Rate) in APWP hospitals remain constant at 0.12% over the last several years.
Table - 26: Delivery Rate in APWP Hospitals

Year

No. of Deliveries Conducted

Delivery Rate

1996

59,710

0.12

1997

65,996

0.13

1998

62,578

0.11

1999

68,570

0.12

2000

90,019

0.13

2001

94,690

0.12

(O/o. APVVP- MIS Division)

Infrastructure will be put to optimum utilisation only when supply of drugs and
consumables etc. are regular; adequate and functioning equipment is available

and the staff are in position and trained. Taking into consideration these critical

indicators, assessment of health facilities in the state revealed a situation of

inadequacy. None of the facility shows presence of 100% critical inputs, even
presence of 60% critical inputs is noticed in only one-fourths of the institutions.

Table - 28: Percent of Health Facilities Adequately Equipped
(having >60% Critical Inputs)
fi’HC

FRU

CHC

Infrastructure

31.6

84.8

63.4

Staff

50.4

24.9

33.3

Supply

16.3

8.7

11.1

Equipment

83.9

55.7

52.3

Training

21.3

All items

24.5

22.8

25.3

(Facility survey!999 under RCH; ASCI April 2000)

MAINTENANCE OF INFRASTRUCTURE

C.

Maintenance of the available facilities is critical in enhancing the credibility
of organisations. Data available identifies a need to improve the maintenance of
the infrastructural inputs.
Table - 29: Percent of PHCs with adequacy in maintenance of selected
indicators

1.

Regular building maintenance

14.46

2.

Fumigation done regularly in OT

67.20

3.

Fumigation done regularly in LR

65.54

4.

Dial thermometer is kept in ILR

42.24

5.

ILR with daily temp, is maintained

58.00

6.

Sufficiency of stocks

Nirodh

40.51

OCP

51.26

IUD

53.85

DDK

37.00

Measles vaccine

52.57

IFA (large) tablet

15.91

ORS packets

33.11

.

(Facility survey1999 under RCH;ASCI April 2000)

Equipment maintenance:The

state

has

different

levels

of

equipment

maintenance units with different capacities. There are 7 Health Equipment Repair

Units (HERUs).

under Director of Health.

4 Equipment Maintenance and

Training Centres (EMTCs) are functioning exclusively for APWP hospitals. In

addition, one district mechanic besides private contractual arrangements are also

made available at this level. Tertiary hospitals have its own maintenance capacity
and contract out to private facilities. The equipment strength at PHC is around
20 items. Maintenance cost of equipment in hospitals is around 2-3 percent of
the total value of the equipment.

APERP while supplying the equipment issued specific guidelines for

acceptance and routine testing of medical electrical equipment. Project inputs are
based on the PHC Needs Assessment Study carried out at the beginning. The
requirements at the PHC level are considered under major, minor equipment;

furniture, instrument kits and others.

Table - 30: Arrangements for the maintenance of equipment
Existing maintenance and repair
arrangements

Facility

1.

* HERU

PHCs

* District mechanic
2.

Secondary

level

* Repairs by hospital staff

Hospitals

* EMTCs
* AMCs and contracting out on need basis

* Warrants
3.

Tertiary level hospitals

* Repairs by hospital staff
* HERU

* AMCs and contracting out on need basis
* Warranties
At PHCs and Hospitals under Directorate of Health guidelines are issued

for Drawing and Disbursing Officers regarding responsibility of maintenance of

Stock Registers including medicines, linen, equipment, annual verification of

stocks, quarterly verification of costly articles like surgical instruments etc. (Under
Subsidiary registers and records attached to the cash book Item 8 (c)). PHC
Medical Officer is not empowered for condemnation procedures.
In APWP institutions, as laid down under Art 135 of APFC vol 1, as the
furniture and other equipment will stand distributed in the various wards, theatres

and other departments of the hospitals, entries should be made, attested by the
head of the organisation. Any addition or alteration in the list will be made only by
him under his initials (H.S.O. 494). For condemnation of equipment, furniture
etc. Further, through Pro. Rc. No. 90/HEM/89 procedures for condemnation are
laid down. Rules for auction of unserviceable articles are laid down, in H.O.S.
402 to 425. These can be implemented through Condemnation committee.

General Maintenance:

Advisory Committee set up in different levels of health

care institutions monitor the general maintenance of the institutions.

G.O.Ms. No. 151, dt. 21-050-1998, item (x) provides provision for
utilisation of hospital revenues for toilets maintenance, sanitation of the hospital

wards etc.
In A.P. every third Saturday of the month is observed a clean and green

day for all the government institutions for upkeeping the premises.

Key observations on infrastructure during Field visits in policy review
activities have are as follows:

1.

Some PHCs buildings are located away from the periphery of the villages
which discourages people to utilise the services in late hours. Directions

for the location of PHC and hospitals are not found on the main roads.
2.

Amount paid towards house rent for subcentres will not provide required
accommodation for ANM to function effectively.

3.

Rarely one can find a PHC with plantations in the yard.

4.

Atleast one to two rooms in each PHC are used as store rooms mostly for
unserviceable goods like old sterilisers, broken furniture etc.

5.

Most of the drugs meant for Subcentre from the quarterly budgets are
being utilised at PHC only.

6:

PHC kits have not reached districts in a few places.

7.

At present, most of the PHCs do not have telephone facility.

8.

Continuous water supply though very essential, many a times water for
only limited hours is available in number of PHCs.

9.

Drug budgets are strongly felt to be inadequate at both PHC and FRU
level. In one district hospital a detailed assessment done recently on
requirements of drugs from all the consuming units revealed a shortage of
Rs.2 lakhs per quarter in comparison to the existing budgetary allocations.

10.

Though essential drug list also mentions about the availability in adequate
quantities and all the times, stipulated eligible number of drugs as per the
list are not available in the drug stores. The shortages become grave
during summer months.

11.

Though PHC staff take the attestation of district authorities on drug
indents, neither the officials keep a copy nor conversant with issues of
drugs at the district stores.

12.

District pharmacists at district stores are not exposed to any training
during the last three years. The reports on drugs lifted by the Drug
Inspector for quality control never reach drug stores.

13.

PHC staff are totally ignorant of the mechanisms for verification when the
quality of drug is suspected.
Significant compromisations are noticed in Safe injection practices of
health staff in the public health institutions. Boiling of disposable needles
and syringes

14.

is not an infrequent site. Syringes and needles are used again and again
without resterilisation.

15.

Minimum Essential items for clinical examination (like a set of
stethoscope, BP apparatus, thermometer, torch, weighing machine, height
measuring scale, examination couch with screen and steps) are hardly
noticed in any of the half-a - dozen PHCs visited.

16.

Special health campaigns like Janmabhoomi etc. drain the meagre drug
allocations from the health institutions because of change of decisions in
reimbursements after the events.

17.

Though government discourages prescription of drugs from outside, very
often consumable are made to be purchased by the patients from outside.
At FRU it becomes inevitable in items like urobags, ryle’s tubes, infant
feeding tubes. Sometimes drugs like mannitol and higher group antibiotics
are prescribed outside. Even non-emergency items like hematinics are
prescribed because of high demand from users.

18.

At PHC, in addition to the centrally procured drugs, drugs and items are
supplied under the following different subheads:

MCH programme
UIP programme

RCH programme
APER programme

School Health programme

Under Epidemics
JB drugs

FW programme
Emergency drugs/life saving drugs

General items (Subcentre wise)

Supplies under these heads are erratic. This leaves a room for confusion
about the assessment of drug availability.
19.

Most of the health units staff have expressed difficulties in maintenance of
equipments. There are cases of ultrasonographic scan even if certified
condemned no replacement is done for three years. Sophisticated

instruments like endoscopy remain unutilised because of very high cost

for repair. Boyle’s apparatus being regularly used equipment are also
never serviced during the last 5 years. Generators are another set of
equipment which often need repairs.

20.

Atleast in one CHC, equipment like sterilisers are kept in a corner without
opening for long months.

21.

In very few PHCs/CHC shadowless lamps are made to use as prescribed
They are simply hanged from a wire.
All the temperature charts of the coldchain equipment show fixed pattern
of recordings over several months.

22.

23.

Diluents and other lab chemicals are also noticed in the cold chain
equipments

24.

Hb scale books (Tallquist) are frequently seen for supply to even
subcentres. Urine exam in some places done with uristicks,jotherwise no
attempt is made for such analysis at PHCs.

25.
26.

Delivery tables with bricks and cement plastering are noticed.
In the health centers and hospitals height is measured against the
marking made on the wall rather than with height measurement scale.
Attempts a identify the center where facilities for complete available
antenatal checkups (including Haemoblogin estimation, Urine examination
for Albumin and Sugar, Height and weight measurements are accurately
followed) were not successful.

27.

No village other than subcentre headquarters is having facilities for proper
storage and maintenance of required supplies for rendering RCH services.

SUGGESTED POLICY OPTIONS:

1.

Enhance the budget for renting subcentre accommodation.

2.

Storage shelves at every village with

required

supplies and

equipment to enable ANM to conduct outreach services.

3.

Use the principle of SIGNAGE by display boards on the main roads
indicating the location of FRUs and RTCs. This helps in improving
the visibility of the organisation.

4.

Permit ANMs to give Intramuscular antibiotic injections.

5.

Hiring private services for maintenance of building, water, sanitation,

electricity, security at PHC level by contracting out. Necessary
budgetary allocations may be identified as a part of regular

expenditure.
6. .

Provide communication and transport facilities at every

particularly telephones
emergency situations.
7.

and

arrangements

PHC

for ambulances

in

Prepare and implement standard pattern of layout of usage of space
in PHCs.

8.

Establish a standard norm for equipment to be available at different

levels of institutions and create annual appraisal systems for the
adequacy. Create a cadre of Biomedical engineer for maintenance,
using services on co-terminus basis for primary and secondary level

organisations. Identify the list of essential items at every OP unit in
the state so that thorough physical examination cdn be conducted.
9.

Increase the essential drugs in the list from the existing number of
34at PHC,103 at FRU and 171 at tertiary care units to 54, 140 and 270

to meet the demands. Even budget should be enhanced by 75 per
cent at all levels to meet the growing demands and costs. Create a
second pass book system to monitor the drugs and other supplies

reaching the health units from other sources through DMHO to

enable streamlining supply and planning for coming years. Drug
education and information activities should be initiated immediately

to curb improper prescription practices in the light of drug
resistance because of re-emerging infections.

These steps will

ensure safe, effective and prudent use of essential drugs.

10.

A practice of noting provisional diagnosis even for O.P. cases at all
health units (Eg. 150 disease list recommended by WHO) will

facilitate

furtherance

of scientific

prescription

practices

and

appropriate usage of essential drugs and their dosages. Whenever

necessary standard therepeutic protocols should be developed for
management of cases related to RCH services.
11.

Mandatory safe injection practices should be ensured in all health
units of the state. Awareness campaigns can also create an

environment of demand in this regard. This does not mean
encouraging disposable needles and syringes but focus on properly

sterilised needles and syringes and injection techniques.

12.

State should take up voluntary blood donation campaigns to the
district and rural areas on priority basis which can save precious

maternal deaths.

Access to blood in rural areas can be strongly

considered for public private mix ventures.
Status in A.P.:

Number of cases referred among high-risk pregnant women, newborns,
ARIs, diarrhoeal diseases, VPDs and adverse events following immunization
RTI/STI etc., find a place in the reports and records at SC and PHC under RCH
Programme.
The GOAP through its Lr. No. 11077/Ci/96 and Lr. No. 11593/Ci/96,
issued a referral manual on behalf of Dept, of Health, Medical and Family
Welfare which states that patients may be referred from one level to the next for:

1.

Clinical examination or specific examination

2.

Consultation or expert advice

3.

Intervention or patient care

The manual mentioned referral procedures using slips, referral register,
transportation norms, counselling, referral network preference and back referral
slip. Referral manual provides summary of recommended clinical services at
primary/secondary/tertiary health care institutions. It includes

33 medical conditions (from convulsions to STDs)
9 surgical procedures (from 1/D to gastrointestinal)
5 newborn/child conditions (LBW to severe diarrhoea)
11 obst/gyn conditions (complicated deliveries to malignancies).

Referral zoning of district hospitals to tertiary hospitals is done in the A.P.
The review of existing literature on referral system in A.P provides the
following relevant information:

Evaluation study on First Referral Health Systems in AP(1997) observed that in
referral practices:

Out of 66,937 OP cases treated on an average by each CHC, only 133
(0.20 per cent) cases are referred to District hospitals, while Private hospitals out
of 10,335 cases 91 (0.88 per cent) only are referred to District Hospitals. This is
certainly not an encouraging performance. However, percentage of specific
cases referred to DHs is more. About 5 per cent of ARI cases, 3 per cent of
delivery cases, 100 per cent of cancer cases and 57 per cent of DUB are referred
to DHs by CHCs.
The linkage between PHC and CHC also appears to be weak. There is no
information in the CHCs records as to how many OP cases are referred from the
PHCs. However, informations on how many cases of some specific diseases are
referred from PHCs is available. About 12 per cent of diarrhoea cases, 67 per
cent of infertility cases and 100 per cent of cancer cases are referred from CHCs.

Out of 1,486, illness episodes (Non-hospitalisation cases) 945 (63.6 per
cent) have reported to have consulted another doctor before consulting the
FRUs.
The preference of the people at the first level as well as the secondary
level consultation is clearly towards the private hospitals. While only 71 per cent
of the OPs consulted private doctors at the primary level. The percentage
increased to 78 per cent at secondary l^vel. While 69 per cent shifted from one
private hospital to another private hospital. 8 per cent shifted from government to
private ones.

As regards the use of referral systems in the government hospitals, while
25 per cent approached government hospitals in their former visits, only 17 per
cent visited them in the current visits. Only 16 per cent retained the referral status
with the government hospitals.

Turn over of inpatients shows that while 70 per cent visited private
hospitals earlier to the hospitalization. Those who have shifted from government
to private are 15 per cent. In the government hospitals only 6 per cent have
retained the referral status which means that only 6 per cent of the patients
continued to go to government hospitals.
The study concluded that the linkages between sub-centre, PHC, CHC
and DH are very weak or almost nonexistent. Even though the system of issuing
referral slips at PHC level is in vogue, none seems to issue them nor they are
accepted or given preferential treatment at FRU. The study recommended that

referral ship system should be revived and implemented according to agreed
procedure (6).

Facility Survey (1999) AP observed that
The district hospitals (12) have conducted a total of 4,677 deliveries
averaging 389 per DH in the previous three months of the survey. Out of the total
of 612 complicated deliveries, 532 were direct admissions and only 80 were

referred. Of the total 1063 Caesarean deliveries, directly admitted were 976 and
87 were referred.

At FRUs out of the total number of deliveries conducted 7843 ( in 92
FRUs) spread in 12 districts, out of 616 were complicated deliveries directly
admitted and 91 were referred. The C-section deliveries directly admitted and
referred are 252 and 112 respectively.

At CHCs, 16,176 deliveries are conducted during the three months

preceding the survey in 63 centres spread in 12 districts, complicated deliveries
directly admitted are 2385 (14.74 per cent) and referred are 256 (1.58 per cent).
A total of 4591 C-sections are conducted and 31 are referred.

Table - 31: Number of women received services for the three months
preceding the date of survey in APVVP hospitals in 12 districts of AP (199899)

Category

Total no. of deliveries
Conducted
Admission
Direct
Referred

C-Section
Admission
Direct
Referred

DH(12)

4,677

532

80

976

87

FRU

7,843

523

93

252

112

CHC

16,176

2,385

256

4,591

31

Total

28,696

3,440

429

5,819

230

(11.9%)

(1.49%)

(20.27%)

(0.80 %)

(Facility Survey 1999 under RCH; ASCI, April 2000, Vol. 1 & 2)

IHS sutdy, 2000 on Referral linkage has noted that 72 per cent of PHCs

received patients regularly referred by other providers. 98 per cent send patients
to other hospitals. The departmental manual of APWP in its future prospects
and vision identifies improving the referral system by establishing proper linkage
between primary, secondary and tertiary levels of health care system. The
following ultimate benefits are expected:
1.

Improved efficiency and effectiveness of health care services.

2.

Optimum resource use, avoid duplications, reduced waste and over
crowing on tertiary facilities.

3.

Improved health status, specially of the poor by reduction in mortality,
morbidity and disability.

4.

First referral hospitals becoming more client-friendly and patients seeking
timely care resulting in higher cure rates at lower costs.

5.

Regulated patient flow and reduced cost of treatment by reduction in­
patients flow to tertiary hospitals where treatment is more expensive.

6.

Improved quality of treatment at a level where sustained linkages with
private health care can be established

AP07

Case study: Pesticide use in Warangal
Warangal in Andhra Pradesh is the second largest pesticide-consuming district in the
state. Compared to other states like Punjab, pesticide use in this district is a relatively
recent phenomenon and this is borne out by the number of years of exposure reported by
the mothers of the children studied in the Greenpeace health study “Arrested
Development.” Warangal shot into national headlines with the large number of suicide
deaths that cotton farmers in the area committed during the last decade.

Many deadly pesticides still continue to be used in India. Exposure to even low doses of
pesticides is associated with a wide variety of health effects. Since regulations are not
adhered to and monitored, not only public health and the environment pay the price but
the livelihood of farmers is also jeopardized.

The health care scenario in Warangal is extremely poor. The RMP is able to provide only
basic medical treatment like vaccinations, vitamin and mineral deficiencies and maternity
advice.
The PHC has barely any facilities and so the farming community has no choice but to go
to the private hospitals for treatment.
The practitioner of the PHC comes in for only about a few hours and leaves before 5
o’clock in the evening leaving the community with no medical facility available in case
of emergencies.
During the pesticides spraying season the rate of acute poisonings increases drastically
and lack of timely medical health often leaves farmers in extremely grave situations.

1

AP07

ARRESTED DEVELOPMENT -An Executive Summary
In the cotton-growing season between April and December 2003, Greenpeace India studied the
chronic effects ot pesticides on the development of children growing up in cotton cultivating
areas ol six states oi India. The results of this study, published in April 2004 as Arrested
Development, reveal that exposure to small doses of pesticide during childhood years has
severely impaired the analytical abilities, motor skills and the concentration and memory, of
children from farming communities. The 1648 children who participated in this study are
representative of the popu lation of Ind ia.
Most studies in the past have focused on pesticide residues in food and water, instead of which
this study attempts to correlate the indiscriminate use of pesticides with the health of
unsuspecting little children (4-5 years) and older ones (9-13 years); children who appear normal
and happy but whose mental development lags far behind their counterparts in pesticide-free
environments. The study focuses on children, as they are particularly vulnerable, given their
physiology and behaviour patterns

A total of 899 children from six locations in the cotton-growing belts of the country, (which
implies the intensive and high use of dangerous pesticides cocktails) were compared with 749
children of the same age, economic background and ethnicity in a different location (within the
same state) where the pesticides usage was far less.
The researchers arrived at the data for this study through using a Rapid Assessment Tool.
Through this tool, the children were asked to participate in a wide range of tests using a play
approach, where the tools were individually and verbally administered to each child.
Widespread documentation on neurological effects of pesticides including effects on memory,
judgment and intelligence as well as personality, moods and behaviour determined the kinds of
tests administered.

The tests included the use of wooden blocks and jigsaw puzzles to measure mental abilities, ball
catching and balance tests to test motor abilities and memory games to assess the level of
concentration and memory.
The study found a remarkable difference between the abilities of the two groups of children, with
more or less consistent trends across different locations in both the age groups. With all other
possible confounders controlled for, the only significantly accountable reason tor these disturbing
findings is the children’s exposure to pesticides.
The findings of Arrested Development make a strong case for the application of the Precautionary
Principle. In the case of hazardous and toxic substances like pesticides, Precautionary Principle
needs to be applied in their manufacture, distribution, marketing, storage and use. The current
legislations, policies and practices in India do nol adhere (o this precautionary principle.

The report strengthens the evidence against pesticides and calls for a ban on all pesticides,
starting with those banned in other countries. As cleaner, safer alternatives lor farming have been
well demonstrated by farmers in the country, the study is a wake up call to the government and a
demand for them to provide greater support to organic farming in terms of resources, mechanisms
for more research, extension and crop loan support and infrastructure.

2

AP08

HOSPITAL ENVIRONMENTS CONTROL OF INFECTIONS
(K.A. NARASIMHAM, Vice-President, Human Rights Council, Elamanchili, Visakhapatnam - 530 122)

A hospital is place where good hospitality with no extra sufferings and infections is
given to the patients. To achieve this, it is essential that the staff should be aware of infections
acquired in the Hospital and its environment and must be in a position to control the infection to
a maximum possible extent.
Hospital Environment & Planning of Ward:
The wards as well as the special rooms should be designed in such a way to allow free
entry of fresh air and sunlight as these naturally available sources cure many of the infections.
The floors, walls and ceilings of the rooms including its surroundings should be easily washable,
so that it provides no room for dust or moisture. The hospital should have an isolation ward or
room for badly infected patients, this isolation can control cross infections. The bed should be
laid in the centre of the room, to facilitate free approach of staff from all sides of the patient.
Control of Infection:
Many patients admitted in the hospital are getting infected during their stay in the
hospital. Such infections are called Nosocomial Infections. The causes of such infections are :
ENDOGENOUS: In which the causative organism comes from another part of the patients
body. The causative factors are :
Debilitated condition of the patient.
Extremities of age (Paediatrics & Geriatrics)
Compromising the person's immune system (by disease of following immune
suppressive therapy).
Breach of the individuals skin/mucous membrane barrier. (Severe bums,
Surgical wounds, catheterization, intubation).
Following Diagnostic and treatment procedures.
Malignant disorders and Diabetes mellitus.
Prolonged broad-spectrum antibiotic therapy.
EXOGENOUS: In which the causative organism comes from outside the body and acquired
from another person or object. Also referred to as Cross-Infection or hospital acquired infection.
The causative factors are :
Improper aseptic environment, equipments and instruments.
Poor sterilization and disinfection techniques.
Invasive monitoring and therapeutic procedures.
Transmission of infection by staff.
Consumption of infected food and water.
Epidemics arising in the community and spreading to the hospital.
NOSOCOMIAL INFECTION:
The Nosocomial Infection commonly occurring are :
Urinary tract infections.
Respiratory tract infections.
Wounds/Burns
Gastro-Enteritis/Dysentery
Bacteraemia and Septicaemia.

ROUTES FOR TRANSMITTING EXOGENOUS INFECTIONS:
Air Borne: Dusty particles, droplet nuclei are common modes of transmitting
respiratory infections and wound infections.
Contact with cases or carriers especially applicable for wound infections.
Through contaminated food, water etc., enteric infections.
Instrumentation, usage of contaminated/un-sterile instruments cause wound
infection, urinary tract and respiratory tract infections.

AP08

PREVENTION OF HOSPITAL ACQUIRED INFECTIONS:
1.
The greatest single factor in the spread of nosocomial infections is the failure of health
care workers to wash their hands often enough between patient contacts. It effectively
prevents most of the cross-infections which tend to occur between patients.
2.
Adequate disinfection of the environment and proper sterilization of instruments, and
other materials is a necessity. The use of a large number of disinfectants especially
without knowing the proper concentration should be discouraged. In situations when the
use of disinfectant is indicated it is important to ensure that The choice of the disinfectant is appropriate.
The concentration used must be adequate.
The contact time should be enough.
3.
Adhere strictly to aseptic techniques. These are :
A strict "NO TOUCH" technique while changing surgical dressings, insertion or
removal of a drain, catheterization.
Use of properly sterilized material.
Periodical removal and reinsertion of sterilized catheters and drains.
Proper handling of catheters, suction tubings and other equipment.
4.
Keep the contaminated instruments aside for disinfection, cleaning, repacking and re­
sterilization. Infected materials should be discarded and incinerated wherever possible.
Soiled infected linen should be washed separately using steam and sterilized. Sputum
cups to be incinerated (If disposable) or disinfected and autoclaved. Bed pans and
urinals to be washed and disinfected between uses.
5.
Isolation ward facilities should be available for admitting patients with communicable
diseases.
6.
Indiscriminate and inappropriate use of antibiotics should be discouraged as this leads to
spread of drug resistant strains of bacteria. The following are the main points in
determining an antibiotic Use of antibiotics, only when clearly indicated.
Use of antibiotics in adequate dosage, for sufficient period of time.
7.
Staff with infections should be discouraged from operating on a patient. Monitor all the
personnel employed in high risk areas bacteriologically.
8.
Control of movement and number of personnel mainly in theatre and also in the wards.

INFECTION CONTROL COMMITTEE:
The hospital infection control committee plays an important role in laying down policies
for the control of Nosocomial Infections.
The members of the Committee are :
Medical Superintendent
Surgeon & Physician
Operation theatre In-charge
Nursing Superintendent
Microbiologist
The committee formulates policies to be followed in relation to :
General cleanliness.
Maintenance of proper aseptic techniques.
Disinfection procedures, including uses of chemicals disinfectants.
Antibiotic use, control of indiscriminate use.
Periodical immunization of personnel.
Notifiable disease.
And the Committee will:
Conduct periodical review of statistics on nosocomial infections.
Supervise epidemiological investigations.
Review Current Policies.
Convey infection control information to hospital staff.
For achieving better control of infection, brushing up classes should be conducted to all health
care workers periodically and by rotation. Thus we can achieve Vision 2020 without any extra
investment.

2

AP09

The state of the Public Health System in Patancheru and Jinnaram
Mandals of Medak District, Andhra Pradesh
Prepared by
Abraham Thomas, BDS
Staff, Community Health Cell, Bangalore
The preliminary study was done to understand the functioning of the Public
health system in the Industrial Blocks of Medak District and to understand the
relevance of the health system in light of the health report made by
Greenpeace India. Patancheru and Jinnaram Mandals were covered in the
study.

For this...
-

The distribution of the Primary Health Centres (PHCs) and Rural health Centres
(RHCs) in the area were examined

-

The services rendered at the PHCs and RHCs were examined

-

The functioning and efficacy of the sub centres were taken into
consideration

-

A preliminary tool evaluation of services rendered to women and children
were evaluated thorough a screening for Vitamin A deficiency

-

Observations were made on the availability of staff of the health centres -

PHCs, RHCs and Sub centres

Add pic of bhanur PHC

AP09

The investigators chief observations
The area is most certainly in chemical crisis with all water sources being polluted by
a variety of cocktails of chemicals. The stench in the ground water and the colour
speak clearly of the pollution without the aid of studies and reports. There are many
children, women and men, both young and old having many health disorders
affecting all body systems. There are children having arthritic pains, allergies,
eczema, rashes and scabies. Many women whom we came across complained of
severe skin allergies and rashes and reproductive disorders, which were chronic,
and they had little money to approach private doctors for medical or surgical care.
This certainly speaks of a lack of primary health care and lack of awareness among
people of the neglect. There is big need for a change in tact of the health services
in Patancheru to make healthcare available to those already under tremendous
pressure from pollution, lack of livelihood opportunities, and the lack of clean air to
breathe. Staff should be trained to report different cases of pollution related health
risks and monitor the quality of life of the people in the Mandal by assessing the
situation regularly with the necessary tools.

The whole of IDA Bollaram area of Jinnaram Mandal has a combined population
(migrant population plus local population) of more than 30,000. The official figures of
the PHC show it to be less than one fourth that figure. To add to it, there is no sub
centre building or staff member posted in the IDA Bollaram area (the post remains
vacant). The interior location of the Jinnaram Mandal PHC makes it inaccessible to
the far-off sub-centre areas. On the brighter side, the Jinnaram Mandal PHC
medical officer is residing at the PHC staff quarters and is one of the very rare
doctors in the public health system to do so. He is available at the PHC on at least
350 days of the year, as some locals put it. He is one of the very rare Government
Doctors who do so in Medak District.
The RHC at Patancheru is manned mainly by staff from the Osmania Government
Hospital in the Hyderabad city and has no direct binding to share responsibility with
the staff of the sub centres under the Bhanur primary health centre. On enquiry, the
RHC staff didn't have data on sub-centres fall under the purview of the Bhanur PHC.

If I was a doctor in the Public Health System, 1 should constantly build awareness
among locals about the dangers of living with such toxic chemicals and also report
these findings regularly to officials to act immediately, but this is not easy for a
doctor in a system that does not give that kind of leverage for free thought and
feedback. I think the staff and doctors in the Public Health system in all these areas
need to be motivated to wake up the health system in the Industrial Areas and
deliver now. First cover the backlog, and then keep the system crisp and sharp.
The need of the hour is an apology from the Government to its little children for
neglecting them and their healthy futures to such a great extent that they have
permanent damage to eyesight, their psyche and to each cell in their body that
has taken chemical insult that was preventable. I wish these children wouldn't have
to feel guilty for being so helpless, really helpless.

2

AP06

Greenpeace Health Study: Medak District, Patancheru/Jinnaram/Kohir Mandal
Executive Summary':
Patancheru and the adjoining study areas are located on the North-Eastern part of Andhra
Pradesh. It covers an area of 222 Sq. Kms in Medak district and is 40 km away from
Hyderabad. It was predominantly an agricultural landmass located on the banks of river
Manjira, a major tributary of River Godavari, but transformed into an industrial area as
part of the governments’ drive on industrialization. The Patancheru Industrial Estate was
set up in 1975 as part of the government initiative to bring in more industries to the state
of Andhra Pradesh. Over a period of 29 years, about 320 industries that are
manufacturing pesticides, chemicals, pharmaceuticals and steel rolls have come up in this
area. While arguments in favour of this expansion were and are being presented from an
economic standpoint, like always no consideration was given to the possible
environmental and public health impacts. Amongst communities located in the midst or
periphery of vast Industrial Zones, there is a strong perception that pollution generating
activities at these facilities result in a direct negative impact on the health of residents.
Representatives of the communities at Patancheru Mandal, Medak District, have
repeatedly voiced statements to this effect, but, citing absence of extensive hard data in
existing records, no action has been taken by concerned authorities to investigate further.
From it’s inception to date, most of the Industries here, have not shared information
regarding pollutants, their chronic and acute effects, to the local residents, the local
authorities -the village Panchayat, workers and doctors, as envisaged by the Factories
Act and rules under the EP act. The plan for ‘disaster management and emergency
preparedness’ inclusive of information on products, storage of hazardous substances,
effects and antidotes, again has not been made public (with a few exceptions), as it
should be. The medical fraternity of the local area is not oriented or equipped for
diagnosing and treating health problems due to environmental pollution. Despite the fact
that the pollution at Medak district has been established by sampling missions and studies
by various organizations in the past decade or so, there has been little action by the
regulatory authorities.

In the light of the failure to address this issue and the fact that community health
problems of Patancheru were quite apparent, Greenpeace decided to undertake an
epidemiological health study that would prima facie establish the problem1. Greenpeace
initiated an alliance with Occupational Health and Safety Centre (OHSC)- Mumbai and
the Community Health Cell, who have prior experience in epidemiological research. The
broad framework was of OHSC taking the lead with medical verifications of primary data
collected using a questionnaire research was arrived at jointly, with Greenpeace taking
the primary role in the field based research and survey.
The results of this study demonstrate that all body systems without exception are
adversely affected in the Study areas as opposed to the control locations, a result of a
cocktail of poisons in the water and air of the study villages, which has had considerable
effects on the health and well being of the local population. The incidence of cancer and
1 The local people at Medak have been complaining of large-scale health problems.

1

AP06

heart disorders is greater in the study group at statistically significant rates. For
respiratory disorders such as asthma and bronchitis, the incidence is 4 times higher in the
study group in comparison to the control group.
A stratified random sample of the study group (9 villages) when compared with those
from the Control group (4 villages) shows a significant increased disease incidence in
many body systems. These include
1. The presence of Diseases of skin and subcutaneous tissue in the study group is at
least two times higher than the control group.
2. One in every eleven, in the study group is afflicted with Diseases of the
musculoskeletal system and connective tissue.
3. Clinically confirmed cancer incidence and respiratory disorders are greater in the
study group at a statistically significant rate. While 11 cases of incidence were
reported in the study group, no such case was reported in the sampling set in the
control group. The occurrence of Asthma and Bronchitis is 4 times higher in the
study group.

This report, further, uses available and existing research to demonstrate: o The presence of a wide range of chemicals in the land, air and water in Medak.
o The ways in which the local community are being exposed to these toxins.
o The increased exposure has increased the potential for detrimental health impacts

The implications of these findings, amongst others, are serious. In brief, the study
demonstrates that serious damage is being done to the health of the residents of Medak at
current levels of Industrial activity, and this damage potentially correlates with location, a
measure of exposure to Industrial activity-generated pollution. It is incumbent on State
regulatory authorities responsible for the public health to investigate this matter, to
further define the scope and severity of the problem, and initiate processes which will
return the community to the state of health enjoyed by them prior to this reckless
industrialization era and pressurize industries to follow all environmental and ethical
norms and implement clean production and closed-loop systems in their production cycle.
The evidence presented here contributes to a growing repository of research that
reinforces the conclusion of this report that serious damage is afflicted upon the local
community potentially through the pollution stemming out of reckless industrial activity
and necessitates the need to ensure that Industrial estates of the nature of Patancheru, not
be replicated elsewhere.
Comments from the Visiting Team of Doctors:

1.

Incidence of cancer in the affected area is significantly higher than in the control
area. The incidence of cancer was validated by senior surgeons from Mumbai.
This is an underestimation because; we did not add the cancer incidences which
was detected in hospitals and nursing homes and autopsy data. It was based on
house to house survey with validation of pathology reports of all cancer detections
in a year.

2

AP06

Lung function tests were affected significantly (p<0.01), both Fevl and Fvc of the
affected population as compared with the control group.
3. Environmental Asthma was validated in a few cases but due to logistic problems,
could not be confirmed by Lung Function tests in a larger population.
4. Allergic Contact dermatitis, which was validated by doctors from Mumbai, was
significantly more in the affected group.
5. The other medical conditions like mental health, gastrointestinal conditions etc...
showed a pointer to a possible higher incidence in the affected population, but a
medically validated comment cannot be made, at present, hence there is a need for
a more elaborate and validated study preferably with the governmental health
infrastructure.
6. Local medical facilities are very inadequate and people spend a sizable percent of
their income on private, mostly irrational treatment. Only when it comes to the
final advanced stages, they are shifted to a major hospital in big cities like
Hyderabad.
7.
It is urgently required to upgrade local government medical facilities and provide
free medical treatment to people of the affected communities.
2.

Dr Murlidhar V
Dr Ashwini
Dr Deepali
Dr Archana

Lokmanya Tilak Municipal college and general Hospital, Mumbai.

Denial of Health Care:

Increased incidence and prevalence of diseases such as cancer, asthma and
dermatitis as a result of pollution of the environment,
No effective control of pollution by the industries. Inadequate public
health care facilities to deal with the health problems posed by the industrial
pollution.

Consequences:

Increased death and disease among the people living/ working
in the area.
Increased expenditure on health care by the people of the area.

3

AP02

ALARMING PREVALENCE OF VITAMIN A DEFICIENCY AMONG
CHILDREN IN CHEGUNTA MANDAL, ANDHRA PRADESH
Investigating Team :
Address :

Sanghamitra
Chegunta Mandal, Medak District
Andhra Pradesh 502 255

A detailed door-to door survey on the eye health status of people in the region is completed in
Chegunta Mandal and is being conducted in Toopran, Ramayampet Mandal’s of Medak District.
Medak is one of the most backward districts of the Telengana region of Andhra Pradesh. A
detailed eye health status of the area is being assessed for the first time in the entire region and
the position investigated is dismal. The biggest service provider in the region is the Lion’s Eye
Care programme and the coverage is about 15 percent, and that too through organized mass
camps. The rest of the services are unorganized and self financed. Knowledge about eye health
and diseases in the region is poor. Most children in their teens suffer from poor evenings vision
usually going undiagnosed or unnoticed. The below 7 children are the current sufferers of the
failing supplementation programme of the Governmental Public Health System. In Chegunta
Mandal alone there are more than 388 Children suffering from Vitamin A deficiency, Vitamin
supplementation programme supported by UNICEF, has been underway in the region since over
ten years.

According to past public health studies conducted in Andhra Pradesh the prevalence of Vitamin
A deficiency is approximately 5-7 percent in Children..

(Kapil U. and Bhavna A., (2002), “Adverse effects of poor micronutrient status during
childhood and adolescence”, Nutrition Reviews, May, Vol.60, no. (5 pt 2), pp,S84-90). But
little is documented in medical literature about this deficiency among children of our country, the
very eyes of those who have to mould tomorrow.
Criteria for Vitamin deficiency: Bilot spots, wrinkling of sclera, and skin lesions.

Many individuals were unaware of the Vitamin A supplementation programmes even though
they had children in the age groups (01-06 years age group).





Total population covered (public interviewed) Adult Males 14,216 + Adult Females
14,284) + (Children Male (below 15 years) 6,362 Male + 6175 Female Children)
Total population with eye problems - 7365
Children suffering from vitamin deficiency (below 8 years) in Chegunta Mandal - 388
This survey was done by 12 young individuals of the area aged between 20 and 24, with
adequate training on basic eye care and primary detection of eye diseases. They were
trained at LV Prasad Eye Institute, Hyderabad
They have been receiving continuing education on eye care and eye related rehabilitative
programmes
According to the general survey, eye related diseases were going undetected and cases of
vitamin. A deficiency were on the rise as a result of poor supplementation programmes
by both the ANMs and the Anganwdi workers in the programmes.

Denial of Health Care: Poor Vitamin A supplementation, even though it is a National
Programme.
Consequences : Poor Vision, including night blindness.

1

AP03

HEALTHCARE FOR THE GUNDALA TRIBAL POPULATION COMES AT A COST
-IF NOT IT DOES NOT REACH THEM
Date February 25th 2004
Mandal—Gundala
District—Khammam

People's voices raised the issue of gross neglect of the Primary health
Centres in Gundala Mandal of Khammam district. The people brought to
the notice of the District Collector the state of the PHC functioning in a
public hearing in Februray. This was reported in ‘The Hindu' on 25 February
2004.
The public hearing was organized to ask for basic amenities for the
people in the tribal villages of the Mandal.

It highlighted the poor functioning of the PHCs
1. No doctor in that area had served longer than a fortnight in that
PHC.
2. PHCs functioned only once in a week, on Tuesdays, the market day.
3. The paramedical staffs were present on other days, and no
deliveries are conducted there.
4. Private Medical practitioners demanded sums of Rs.6, 000/- to
Rs.10, 000/- from women for normal deliveries. This had taken its toll
on many of the people there. Most of them who were affected by
this were those below the poverty line (BPL families). Borrowing paid
off these sums from moneylenders. Many people's hard-earned
money was going in for healthcare.

This case study is being further investigated to see if there was any change
in the functioning of the PHC after the District Collector's reassurance. It
would be extremely important to view this case as a continuing fight
against the laxity in the Public health system, and not a case by itself. It
needs to be viewed with a dimension of financial damages caused to
people as a result of denial. Cases like this do not occur in isolation—Most
PHC doctors live in nearby cities and often travel to and fro to their PHCs,
some of them even cover up to 200 kilometres. This kind of travel wouldn’t
in anyway help the efficiency of the doctor or his services, but kill the
energy to function normally.

1

AP03

Gundala tribals seek basic amenities:
Even after trying hard for many years to change the way in which the
Government Health system works, the Gundala Tribal population sill
haven’t seen any change in which the Doctors in the Public Health
System Function.
The Gundala tribals in the forest areas of Khamman district of Andhra
Pradesh have been silent sufferers of the agencies of health care and all
costs involved. The doctors posted there have never stayed on beyond a
fortnight. The PHC was built without conforming to the beliefs of the local
people and as they put it, it was having "some defects in the vaasthu'
The women were changed anywhere between Rs.6,000/- and Rs. 10,000/for even routine deliveries in the private hospital. (All because the Primary
Health Centres were open only once a week and otherwise managed by
the paramedical staff).
Encl: News Report, The Hindu, 20 Feb 2004

Denial of Health Care : Absence of Government medical officer at the
Primary Health Centre
Consequences : Avoidable Huge expenditure to be treated by the
private practitioners.

Poor functioning of the Primary Health Centre

2

AP04

Undetected and unreported cases of blindness among children belonging to
scheduled castes (BPL, Below poverty line families)

Child—Sukanya
Daughter of Satayya
Age—5-6 years
Economic Status - Below Poverty Line
Scheduled Caste
Diagnosis:
Near total blindness due to childhood cataract
Child—Banu (Brother of Sukanya)
Son of Satayya
Age—7-8 Years
Diagnosis:
Near complete blindness due to childhood cataract with the

cataract affected lens in the left eye being dislodged.

Prognosis(both): Treatable cause of blindness—surgically with lens implants

Available Government programmes—National programme for control of blindness
These children have suffered from adverse effects on physical, social and
psychological growth while trying to interact with other children with normal vision.
Sukanya has a very different style of walking, because of her constant extracautious walk (steps) fearing a fall, a fall into a large open well near her house. This
child has been denied the basic services for normal living.

Banu, Sukanya's brother, is also suffering from severe stress on his eyes because he
cannot see anything but blurred images of objects, yet he attends school and
finds it extremely difficult to find things, do his duties and cannot study.
To the others around and to the health department, Banu is a blind child with no
hope. This is a lack of will to send this child to a specialist's facility in the District
Hospital.
The primary health centre ophthalmic assistants in almost all areas are beginning
to depend upon private hospitals for surgical treatment of cataract cases, solely
depending upon the mass camps and occasional follow up.

This case study does not intend to personally attack a health worker or an ANM or
an Ophthalmic Assistant in the area (Chegunta Mandal of Medak District), but
looks at a paradigm shift of policy of the health department to look at basic
indicators of health more seriously, stress on local decision making by the PHC
Medical Officer and improve availability of the staff at actual duties. Effective
reporting, quick response, and an effective monitoring mechanism should be in
place soon.

1

AP04

Denial of health care:

These children have been denied the Right to Sight because of the failure of the
Public Health System of having an effective surveillance system in place.
The reluctance of the staff to explore the whole simple world of Primary Health
Care needs is emphasized by such an occurrence.
Failure of School health programmes
Consequences:

Blindness in the young children (siblings), avoidable by surgery with implants.
Failure in Physical, Psychological and social development and well-being.
Needed:

Effective School health programmes, village awareness programmes, people
contact programmes, and health campaigns should be made high priority. The
department of health has to change tact to reach its vision 2020. It cannot be
caught denying children their Right To Sight.

2

AP05

Hysterectomies for Money
Ovaries are not spared
Mrs. S is about 28 years and underwent a month’s ordeal with lower abdominal pain and
bleeding due to a uterine infection. She, like many others, did not go to the primary health
centre, as they were unaware that treatment was available. Instead, she went to a private
medical practitioner in the nearby town, Chegunta. She was advised an ultrasound of the
lower abdomen. Two days later she underwent a hysterectomy at the local medical
practitioner’s clinic, which was performed by a visiting surgeon. Mrs. S took a loan of 8,000
rupees for the treatment cost and investigation and borrowed more money for medicines after
she was discharged.
Mrs. S, thinks that the doctor did the right thing by performing a hysterectomy. But the
ultrasound diagnosed a normal study with absolutely normal uterus. The echo-texture

of the uterus, dimensions and the position of the uterus conformed to a normal
anatomical structure.

Q. But why was a hysterectomy done :n a 28-year-old woman who had a medically
treatable infection of the uterus?

Mrs. S is one of many such women who are undergoing hysterectomies as a primary
treatment for uterine infections. In Pothensettipalle, her village, there are 10 such women in
the reproductive age group of 20 and 35 who have already undergone the procedure. The
belief that hysterectomy is to take away a useless organ, and that it is a normal practice, is
there among the women. Some of the women believe that its reproductive function is over
with a tubectomy or ligation or the fallopian tubes. Many private practitioners not just in Medak
District but also in the entire state of Andhra Pradesh, are exploiting this belief among the
women, which has been ingrained in their minds by widespread practice of the procedure
without warning women about the long-term implications of a total hysterectomy.

Q. Why didn’t she go to the PHC for treatment?
She says that many in her village have been treated badly at the PHC in the past and
therefore they prefer to consult private practitioners.

Q. Was Mrs. S satisfied with the treatment given to her?

Yes. She feels it was better that she underwent the surgery, except that she suffered financial
loss. She feels the infection and pain came down only because of the procedure and could not
have been done with medicines, which she took for a while by prescription of the local
registered practitioners. But she definitely would have been happier if she had been rid of the
infection with simple medicines.

1

| APOS

|

Q. Does this warrant a paradigm shift of the public health system to deal with a large
social issue of rejection of the public health facilities?

Yes. A people friendly and practical health department is necessary for people to come to
avail ethical treatment at the PHCs and sub-centres. A clear and acceptable method of
referral of more complicated cases to Area Hospitals and Community Health Centres should
be practiced to change the existing failure of the treatment referral system.
Enclosures:
1. Report of the Ultrasound Examination
2. Prescriptions following surgery
3. Complaint on health service personnel in the sub-centre area not visiting the
village in 2 years.

Note: Mrs. S was a signatory in the complaint in February 2004 to the Mandal and District
Health Authorities and the District Collector that the ANM (Auxiliary Multipurpose Nurse)/ Male
Health Assistant from their sub-centre had not visited their village in two years. Mrs. S feels
that the ANMs could direct a lot of women with problems to Govt, facilities in the future for
cheaper and ethical treatment. The report obtained by the PHC authorities regarding the

complaint has been still not communicated with the SHG (Self Help Group members) and the
NGO (Sanghamitra), who were signatory to the complaint.
Denial of Health Care:

Unnecessary operation, removing the uterus, when the condition could have been
tackled with simple medicines.

No evidence of adequate information being given and informed consent.

Lack of faith in the Public Health System.

Consequences:

Removal of an organ, which was avoidable and unnecessary expenditure.

Case Study Prepared by
Dr. Abraham Thomas
Community health Cell, Bangalore
At Sanghamitra, Chegunta Mandal, Medak District, Andhra Pradesh

2

C sv'-i H '' 'BZ ■ < |
APOI

Chegunta MandalMedak District Andhra Pradesh
Study by Sanghamitra on the Primary health Centres and their sub-centres

In Chegunta Mandal like many other mandals of Medak District, the health staff do
not visit small villages with population below 1000 for immunization because they
would waste some amount of vaccine. This is the case of many small hamlets where
knowledge of immunization is less and coverage is low. Complaints lead to further
denial in terms of intimidation and denial. Attached are copies of the complaints to
the District Medical and Health Officer and the District Collector, Medak.

Sanghamitra studied the health system in Chegunta and finds it disturbing with each
new case of hysterectomy combined with appendisectomy, with each new case of
Caesarean-section, and every new case of Vitamin A deficiency in the below 8 age
group. In this direction, Sanghamitra studied the system in four areas
1.
2.
3.
4.
5.

Functioning of the sub-centres and their resources
PHCs and their functioning, resources and supplies
Exploitative practices by private medical practitioners and surgeons
Denial of treatment or referral to Children suffering from curable blindness
Denial of Health to Children below 6 and 7 by denial of supplementation with
adequate Vitamin A supplementation

1. The sub-centres, a case of denial of health

The 14 sub-centres in Chegunta Mandal of Medak District in Andhra Pradesh are
distributed and organized totally failing to have the confidence of the people at
large and the leaders of the region. The location of 5 sub-centres within the PHC
premises throws to light the lost purpose of an outreach sub-centre. This is the case of
many of the sub-centres in the region, clearly indicative of failure of the public health
system. Structurally the system is failing the people as indicated by the extent of
neglect of its infrastructure and outreach planning.
The subcentres do not have basic facilities such as a building, sign boards, time-table
indicators, electricity, toilets, water, examination tables, BP Apparatus, Stethoscope,
boilers, stoves, gas connections, sub centre kits, cupboards, and proper lighting. This is
the condition of the observed subcentres in Chegunta, and is indicative of the rest of
the district and the Andhra Pradesh State in general. Supervisory staff (Community
Health Officers, health Supervisors, etc.) visiting these facilities does not effectively
report these findings to higher authorities and indirectly deny village people the basic
amenities.
The people in Chegunta Mandal are not aware that silently a public health system is
failing them - Vitamin A deficiency is being seen in a large number of Children, DPT
and MMR Vaccines are not being supplied to the PHCs regularly, some health and
have still not a building or rented house for the sub-centres and the coverage of
immunization is still below standard. Women turn to private practitioners for routine
gynaecologic disorders and are treated often surgically instead of primary medical
treatment. This is not an isolated occurrence but regular. Normal deliveries are not

1

AP01

common anymore, like in most places. Caesarian-sections are common and regular.
If the public health system begins to act now, people will utilize the services far more
than the existing usage.
Regular clinics for women and child health could pave the way for better referral
services and far better utilization. The basic trust in doctors and paramedics is what
anyone would look for and assurances alone would not be enough. Actions should
be taken through sustained efforts at all levels from the people up to the Authorities in
each block or district.

2

AP01

Distance from PHC

OPD Clinics held

Coverage
adequate (study)

ANM accompanies
NO

No

Along with
PHCtherefore
cant tell

NIL

2. Chegunta ‘B’

ANM
Available

Housed in PHC,
No building

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not Avbl.

NO

No

Along with
PHCtherefore
cant tell

NIL

3. Chetilathimmaipally

Both
Available

No sub centre
building

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not Avbl.

NO

NO

NO

14 kms

4. Chandalpet

Both
Available

No Govt Building/
In panchayat
room

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Regularly
Supplied

NO

NO

NO

10-1 Ikms

5. Makkarajpet

Both
Available

NO Govt. Bldg.
In a Rented
Room (6 ft X 8 ft)

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Regularly
Supplied

NO

NO

NO

7kms

6. Wadiyaram

Both
Available

No Subcentre
building

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Regularly
Supplied

NO

NO

NO

3 kms

7. Gollapally

ANM
Available

In a Rented
building (since
April 04) before
which no
subcentre

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not Avbl.

NO

NO

NO

9 kms

Is Immunisation

Not
Regularly
Supplied

deliveries

Not
Avbl.

complicated

Not
Avbl.

Sub-centre Kits

Not
Avbl.

Treatment of
Pneumonia

Sign Board/
Standard Visiting

Not
Avbl.

hour hoard

Equipment *•

Housed in PHC,
No building

1. Chegunta ‘A’

___________

Building

Both
Available

Each covering
approximately
population of five
thousand

Government
Rented/ Own

ANM, MHW

Service/lnfrasfrucfure
Village

24-hour service of
deliveries

Service Availability in the PHCs and Subcentres in Chegunta Mandal

3

AP01

Not
Avbl.

Not
Avbl.

Not
Avbl.

Not
Avbl.

10. Bonala

ANM
Available

Shared room

Not
Avbl.

Not
Avbl.

Nof
Avbl.

11. Govindapur

ANM
Available

Rented Room

Not
Avbl.
Not
Avbl.
Table
purch
ased
by
ANM

Not
Avbl.

Not
Avbl.

Not
Avbl.

12. Narsingi
Subcentre A

Both
Available

Govt. Bailing

Availa
ble

Not
Avbl.

Not
Avbl.

Avlbl

13. Narsingi
Subcenfre B

Both
Available

Shared subcentre
with Narsingi A
subcentre

Share
d

Not
Avbl.

Not
Avbl.

Avlbl.

14. Narasampally
Subcentre/ Narsingi C

ANM
Available

NO building

No
Equip
ment

Not
Avbl.

Not
Avbl.

Not
Avbl.

Nof Avbl. -

Not Available
Table/ Chairs/ Fan/ Tube light/ BP Apparatus/ Weighing Scale/ Delivery Table/ Examination Room/BP Apparatus/ Stethoscope/
Boiler/Torch/Scissors
Out of the 14 subcentres 5 are housed In the 2 PHCs reducing the access drastically. Moreover, the sub-centre areas are not
accessible to PHC services because of the distances involved.
Only two of the 14 ANMs are stationed in the sub-centre premises, and they belong to the Narsingi subcentres locatied in the
PHCs
(Enclosed Chegunta Mandal Map and distribution of sub-centres as file APIA)

Not Avbl.

Not
Regularly
Supplied
Not
Regularly
Supplied
Not Avbl.

Distance from

Is Immunisation
Coverage
adequate
fstudvl

PHC

Rented Building

OPD Clinics held

ANM
Available

accompanies
complicated
deliveries

9. Ibrahimpur

Not
Regularly
Supplied
Not
Regularly
Supplied '

ANM

Not
Avbl.

Sub-centre Kits

Nof
Avbl.

24-hour service
of deliveries

Not
Avbl.

Treatment of
Pneumonia

Nof
Avbl.

hour hoard

Sign Board/
Standard Visiting

No sub-centre
building (Rented
or Govt.)

Building

Both
Available

Government
Rented/ Own

8. Reddipally

Each covering
approximately
population of five
thousand

ANM, MHW

Equipment ••

Servlce/lnfrastructure
Village

NO

NO

NO

3 kms

NO

NO

NO

14 kms

No

NO

NO

17kms

No

NO

NO

21 kms

NO

NO

NO

NIL

NO

NO

NO

NIL

NO

NO

NO

5 kms from
Narasampally

4

Map. Medak District
The orange coloured area is indicative of Sanghamitra's presence

k

DUBBAK

L.

CHINNAKODUR

KALHER

J

MEDAK

\.

(

RAMAYAMPET

SIDDIPET

MIRDODDI

dHANKARAM!

\

PAPANNAPET

SI

MANOOR

I KARAMP!

JHEGUNT/

>TEKMAL

KONDAPAK

DOULTHABAt

KULCHARAM

REGODE

YELDURTHI

1URG

KOWDIPALU
NYALKAL

TUPRAN

RAJKODE

GAJWEL

ANDOLE

SHIVAMPET
NARSAPUR

WARGAL

JHARASANGAM L MU.NIPALU

PULKAL

(

ZAHIRABAD

j

Lt

MULUGU

y—SADASIVAPET

^-sJINNARAM \

SANGAREDDY
KOHIR

KONDAPUR

PATANCHERU

RAMACHANDRAPURAM

'
NANGNUR

JAGDEVPUR

Structural Failure of distribution and resource monitoring / reporting
©

-

C V -

Primary Health Sub-centre stiil not present/not taken on rent
Primary Health Sub-centre with rented building/panchayat building
MPHC (Mandal Primary Health Centre)

Total Population
- 56,000
Number of PHCs
- 2
Number of Primary health sub-centres
- 14
Number of Staff ANMs/MHWs
- 18
Number of Medical Officers
- 2
Number of CHOs (community Health Officers)- 2

2

Date : 24-08-2004

To,

Dr.Theima Narayan,
Community Health Cell,
367, Srinivasa Nilaya,
Jakkasanra First Main, Koramangala Is' Block
Bangalore- 560034.

Public Hearing on Health Care.
National Human Rights Commission.

Jan Swasthya Abhiyam.
Dear Sir/Madam,

Kindly refer to your Notice- Public Hearing On Right To Health Care of
Swasthyam Abhiyam in

National Human Rights Commission- Jan
Deccan Chronicle dated 18th July, 2004.

At the outset, before I start this communication, I would like to introduce
myself as one .Thongath.Raju, who retired from Airports Authority of India
on 30Ih June, 2001 in the Scale of Deputy General Manager

As per the existing Regulations of Airports Authority of India, a Public
Sector Undertaking under the Civil Aviation Ministry, I was enrolled
myself as a Member of the Retired Employees Medical Benefit Scheme
which the authority mooted vide their letter No.AALNAD/MED/REMBS/
dated nil by paying a Lump some Contribution of Rs. 2000/- payable by the
Deputy General Managers and above. Accordingly, I was issued with a
Photo Identity Card for myself and my spouse Dr.(Mrs Sarojini Raju, along
with a list of empanelled Hospitals and Rate for O.P and I.P. treatment
vide AAI Letter NO.AAI/NAD/M/REMBS/GC dated 29-11-2001, a copy of
which is enclosed for your ready reference. Subsequently, the rate for OP
was raised to Rs. 19,900/- and a fresh Laminated card was issued to myself
and my spouse

The above being the case, the harassment by the Airports Authority of India,
Hyderabad Airport started in the beginning itself when they refused r my
Medical claim which I submitted for the first time one year after my
retirement vide AAI. Letter NO.AAI (NAD)HY/REMBS/03/7056-57 dated

28-5-2003 a copy of which is enclosed for your ready reference When I
sought certain clarifications on the subject, the Authorities released the Intra
Office Note AAI/NAD/HYD/F&A/MEDICAL,’2003-04 dated 20-5-2003
prepared by the Senior Manager (Finance &Accounts) to deny my claim.
A copy of the ION which is self explanatory is enclosed for your ready
reference.

In the ION, the Senior Manager (F&A) states that I was paid a Sum of
Rs. 19,900/- as traveling allowance for shifting myself and my family to my
home town in Kerala and hence he says that I cannot fall sick anywhere in
India.. HOWEVER, THIS CLAUSE IS NOWHERE MENTIONED IN
THE REGULATIONS SUPPLIED TO ME WHILE JOINING THE
SCHEME.
In addition to above, what was astonishing was that after recognizing my
wife as my dependant for 38 long years by the Department, having paid
DA/TA to her to go to Home Town after my retirement and having issued
Photo Identity card to her along with me, the authorities suddenly said that
my wife is not dependant on me to deny the Medical claim.

Further, In order to deny my medical claim, the authorities assumed the role
of drug inspectors to declare that the medicine I purchased were without
drug licence and bills given by the medical shop owner was without proper
address. They also brought the name of my daughter into the picture to
deny my medical claim.
This is the first time in my 38 years of service that I came across a foolish
and ludicrous excuse devoid of any semblance of reasoning to deliberately
deny the medical claim of a retired Senior Citizen. However, the authorities
relented and advised me to resubmit the claim when I sought certain
clarifications on the subject.
The Harassment did not stop here. Again the authorities kept the bill
pending for nearly three months on the pretext of clarification although they
had the printed REMBS regulations in their possession.
Not satisfied with the above ignoble acts, again the authorities harassed me
and stopped my Medical claim when I submitted
my second bill on
account of a very simple mistake in total calculation. The owner of the
Medical shop made the bill for Rs.1301/- instead of Rs.1310/- a profit of
Rs.9/- for the AAI. But still, the AAI authorities of Hyderabad Airport
refused to pass my bill despite my numerous reminders on telephone and in
writing. Finally, instead of passing the claim or returning the same to me
for correction and re-submission, 'the AAI authorities iniquitoUsly chose to
send some office Thugs and Musclemen to the shop owner to threaten and

KA31
intimidate him for selling medicines to me. They also threatened him with a
police complaint and demanded his entire bill book to be carried to the AAI
office for calculating Rs. 9/- less in the bill Now, the shop owner is
refusing to sell Life Saving medicines to me.

In this connection, it is brought to the Commission’s notice that the decision
to indulge in such obnoxious activities were devoid of any iota of civility
expected from the Officers of a Premier Public Sector Undertaking. It was
also an Horrendous Betrayal of Confidence the AAI Management reposed
on these Officers for Good Governance. The entire above inept and
vindictive actions of concerned Officers show that their Administration is
devoid of any Accountability due to the Perversion of Rule of Law.

The four lower rung Officers who indulged in the above atrocities are S/S.
G.G.S. Rao, Senior Manager (P&A), S.K Ravindran Senior Manager
(F&A), Lokeswar Rao Asstt.Manager (Accounts) and finally Mrs. Kasturi,
Junior Executive Trainee.
In view of the above Indiscreet and Indefensible actions of the above four
responsible officers of Airports Authority of India, Hyderabad Airport I
request the National Human Rights Commission to take effective steps to
avoid the recurrence of such harassment to the Senior Citizens in their
Health Care.
Thanking you,

Yours faithfully,

(Thongath Raju)
136, S.P. Colony ,Trimulgherry,
Secunderabad - 500 015 A.P

CoT-l

The state of the Public Health System in Patancheru and Jinnaram
Mandals of Medak District, Andhra Pradesh

Prepared by
Abraham Thomas, BDS
Staff, Community Health Cell, Bangalore
The preliminary study was done to understand the functioning of the Public
health system in the Industrial Blocks of Medak District and to understand the
relevance of the health system in light of the health report made by
Greenpeace India. Patancheru and Jinnaram Mandals were covered in the
study.
For this...

-

The distribution of the Primary Health Centres (PHCs) and Rural health Centres

(RHCs) in the area were examined

-

The services rendered at the PHCs and RHCs were examined

-

The functioning and efficacy of the sub centres were taken into
consideration
A preliminary tool evaluation of services rendered to women and children

-

were evaluated thorough a screening for Vitamin A deficiency
I
Observations were made on'the availability of staff of the health centres PHCs, RHCs and Sub centres

Add pic of bhanur PI IC

.(J

The investigators chief observations

The area is most certainly in chemical crisis with all water sources being polluted by
a variety of cocktails of chemicals. The stench in the ground water and the colour
speak clearly of the pollution without the aid of studies and reports. There are many
children, women and men, both young and old having many health disorders
affecting all body systems. There are children having arthritic pains, allergies,
eczema, rashes and scabies. Many women whom we came across complained of
severe skin allergies and rashes and reproductive disorders, which were chronic,
and they had little money to approach private doctors for medical or surgical care.
This certainly speaks of a lack of primary health care and lack of awareness among
people of the neglect. There is big need for a change in tact of the health services
in Patancheru to make healthcare available to those already under tremendous
pressure from pollution, lack of livelihood opportunities, and the lack of clean air to
breathe. Staff should be trained to report different cases of pollution related health
risks and monitor the quality of life of the people in the Mandal by assessing the
situation regularly with the necessary tools.
The whole of IDA Bollaram area of Jinnaram Mandal has a combined population
(migrant population plus local population) of more than 30,000. The official figures of
the PHC show it to be less than one fourth that figure. To add to it, there is no sub
centre building or staff member posted in the IDA Bollaram area (the post remains
vacant). The interior location of the Jinnaram Mandal PHC makes it inaccessible to
the far-off sub-centre areas. On the brighter side, the Jinnaram Mandal PHC
medical officer is residing at the PHC staff quarters and is one of the very rare
doctors in the public health system to do so. He is available at the PHC on at least
350 days of the year, as some locals put it. He is one of the very rare Government
Doctors who do so in Medak District.

The RHC at Patancheru is manned mainly by staff from the Osmania Government
Hospital in the Hyderabad city and has no direct binding to share responsibility with
the staff of the sub centres under the Bhanur primary health centre. On enquiry, the
RHC staff didn't have data on sub-centres fall under the purview of the Bhanur PHC.
If I was a doctor in the Public Health System, I should constantly build awareness
among locals about the dangers of living with such toxic chemicals and also report
these findings regularly to officials to act immediately, but this is not easy for a
doctor in a system that does not give that kind of leverage for free thought and
feedback. I think the staff and doctors in the Public Health system in all these areas
need to be motivated to wake up the health system in the Industrial Areas and
deliver now. First cover the backlog, and then keep the system crisp and sharp.

The need of the hour is an apology from the Government to its little children for
neglecting them and their healthy futures to such a great extent that they have
permanent damage to eyesight, their psyche and to each cell in their body that
has taken chemical insult that was preventable. I wish these children wouldn't have
to feel guilty for being so helpless, really helpless.

The Profile of the number of health facilities in Medak District

S/. No.

Item

Units

Particulars

1
2
3
4
5
6
7

ELECTRICITY
No. of villages electrified
Domestic services
Commercial
Agricultur
Substation 33/11 KV
Substation 132/33 KV
Substation 220/132 KV

No.
No.
No.
No.
No.
No.
No.

1262
2445804
21598
130531
153
16
3

1
2
3
4

RURAL WATER SUPPLY
Habitations covered with P.W.S.
Habitations covered with C.P.W.S.
No of Handpumps
No. of seasonal Borewells

No.
No.
No.
No.

1464
13
12753
263

1
2
3
4
5
6
7
8
9
10
11
12

EDUCATION
Primary School
Upper Primary Schools
Secondary Schools
Higher Secondary Schools
Junior Colleges
DIET (TTC)
Degree Colleges
Medical colleges
Engineering Colleges
I.TI.
TTI
Polytechnic colleges

No.
No.
No.
No.
No
No.
No.
No.
No.
No.
No.
No.

1687
622
389
5
23
1
8
1
3
5
1
2

1
2
3
4
5
6
7
8
9
10
11

MEDICAL FACILITIES
Government Hositals
Civil Deispensaries
Primary Health Centres
Sub centres
Bed strenth In Hospitals & Dispensaries
Docts
Hospitals for Lepracy
T B.Control Centres
malaria units
Urban Health Centres
Round the clock women health centres

No.
No.
No
No.
No.
No.
No.
No
No.
No.
No.

12
4
57
331
8G9
180
1
2
2
4
15

I.

PATANCHERU MANDAL

Structural Deficiency (what do you mean by deficiency)

Lack of planning on the distribution, location, and services Patancheru and Jinnaram Mandals-arejocated in the southern part of Medak District
adjacent to Hyderabad. The distribution and functioning of the Health facilities in the area was found to be quite illogical or inadequately planned
considering various factors. In addition, they were grossly inadequate.

In view of the local population and a large additional migrant population in the region
At the Rural Health Centre (RHC), people from the Patancheru town and many other little towns are refused treatment and referred for
treatment follow up to the Bhanur PHC because the town area does not come under the jurisdiction of the RHC.
- The Mandal Primary health Centre is located deep inside the southern half of the Mandal and very far from its sub centres located in
the northern part of the Mandal. One could simply put it as “inaccessible" without much research.
- Primary healthcare and messages of primary health is not reaching a large target population in Patancheru Mandal
Refer: The screening of children from around Patancheru area (lylapur and Gandigudem, Photos attached)
-

The Patancheru Mandal has one small PHC catering to 20 sub centres and to a population of more than 80 thousand (each sub centre catering to
approximately 4600 to 5000 population).»

Since the industrial area is catering to heavy traffic, the roads are extremely bad and the people have very few transport facilities. The system
therefore has not taken this into consideration before making Bhanur the location for the PHC. Added, the PHC infrastructure should have been set
up beginning operations.
The location of the Bhanur PHC makes it totally irrelevant and unused. This PHC was set-up a year ago and has no services to offer (surgical or
medical). The PHC is simply located wrongly.

'"Ref
Source: GIS FOR ENVIRONMENTAL AUDIT OF HYDERABAD METROPOLITAN REGION, RAFGA REDDY & MEDAK DISTRICTS OF ANDHRA PRADESH, INDIA

The RHC [rural health centre) run by the Osmania Medical Hospital is located in an old building in Patancheru caters to 2 sub-centres in the Mandal
and one in the adjacent Sangareddy Mandal.
MB: The RHC refuses treatment to those hailing from villages that fall under the Bhanur PHC. Please refer the Map of the area.

The structural deficiency in the Public Health System in the Mandal is obvious to everyone except the department.
Lack of services for Women’s Health

The RHC has 70 staff members on its rolls including gynaecologists, paediatricians, medical officers, senior house surgeons, staff nurses, administrative
staff members, Male health workers, peons, ayahs, and paramedical staff members like lab technicians and pharmacists.
j
Here DPL (family planning operation) camps are conducted regularly to meet family planning operations and a few deliveries are done. The 70staffed health centre does not have an anaesthetist to aid in hysterectomies, other emergency operations like C-sections. The private hospitals in the
neighbourhood have 5 staff members but have theatres to cater to the people, though at a cost. Hysterectomies are being performed in the area
indiscriminately for costs between 7 and 10 thousands.

The RHC timings are very arbitrary and often unsuitable for use. The days o’ur investigators went to the RHC (20th and 21s1 August, 2004), the RHC
closed services at 12:15 pm sharp. When we took some pictures of the RHC, the peons were offended and made a big scene.
The RHC evidently did not deal with treatment of people living with HIV/AIDS. The stress was completely on DPL camps and tubal ligation procedures
and uncomplicated deliveries.
Lacunae specific to Patancheru, Jinnaram and Gummadidala PHCs

The PHCs and RHCs do not assess the health status of the people in the Mandal in view of the increased pollution. They are not geared or equipped
to do so, while they could best perform surveillance, referrals, and follow-ups and also monitor and assess the impact of industrial pollution on the
people's health in the region. This is again a deficiency because of the uniformity with which all PHCs and RHCs are treated with their duties in view.

The responsibility of the PHCs and RHCs .to regularly make impact assessments on the health of women, children, men, young and old, has
significance when they are under tremendous pressures from environmental damage and livelihoods are drastically changed.

Is
immunisation
Coverage adequate

accompanies
complicated

PHC
Equipment

Not Avbl.

Not Avbl.

Not Avbl.

Not
Regularly
Supplied

NO

No

NIL

2.

Nandigaon

ANM Available

Old

No
building

own

No
Equipment

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

NO

No

8-10

3.

Rudraram

Available

Old

No
building

own

No
Equipment

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl

NO

NO

10 kms

4.

Lakdaram

Both Available

New

No
building

own

No
Equipment

Not Avbl.

Not Avbl.

Not Avbl.

Not
Regularly
Supplied

NO

NO

11 kms

5.

tsnapur-

Available

Old

No
building

own

No
Equipment

Not Avbl.

Not Avbl.

Not Avbl.

Not
Regularly
Supplied

NO

NO

8 kms

6.

Muthangl

Available

New

No
building

own

No
Equipment

Not Avbl.

Not Avbl

Not Avbl.

Not
Regularly
Supplied

NO

NO

5 kms

7.

Patancheru A

ANM Available

Old

No
building

own

No
Equipment

Not_Avbl.

Not Avbl.

Not Avbl.

Not
supplied
regularly

NO

NO

10 kms

(study)

ANM

Distance from PHC

None are own
and functional

deliveries

Old

ANM

24-hour service
deliveries

Available

Sub-centre Kits

Treatment
Pneumonia

of

Standard Visiting hour
hoard

of

Equipment **

Bhanur PHC /Sub
centre

Each covering
approximately
population of five
thousand

Sign Board/

Building Government
Rented/ Own

New or old sub centre

1.

Service/lnfrastructure
Village

from

Distance

PHC

Not Avbl.

(study)

Not Avbl.

adequate

Not Avbl.

immunisation

Not Avbl.

Is

Not Avbl.

Coverage

Not Avbl.

deliveries

Not Avbl.

accompanies
complicated

Not Avbl.

ANM

Not Avbl.

Sub-centre Kits

24-hour service
of deliveries

of

Treatment
Pneumonia

Not Avbl.

Sign Board/
Standard Visiting
hour hoard

Equipment *•

ANM, MHW

8.

Patancheru B

Available

Old

9.

Patancheru C

ANM Available

Old

10. Patancheru D

ANM Available

New

11. Patancheru E

ANM Available

New

12. Patancheru F

Available

New

13. Ameenpur

Available

Old

14. Beeranguda

ANM Available

New

15. Kistareddipet

ANM Available

Old

16. Sultanpur

ANM Available

Old

17. Indreesham

Available

Old

18. Pocharam

Available

New

19. Kesharam

ANM Available

20. Indreesham

ANM Available

Old

No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building
No
own
building

No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment
No
Equipment

Not
Regularly
Supplied
Not
Regularly
Supplied

NO

NO

10 kms

NO

NO

lOkms

Not Avbl.

Not Avbl

No

NO

10 kms

Not Avbl.

Not Avbl.

Not Avbl.

No

NO

21 kms

Not Avbl.

Not Avbl.

Not Avbl

NO

NO

lOkms

NO

NO

11 kms

NO

NO

5 kms

Not Avbl.

Not Avbl.

Not Avbl.

Not
Regularly
Supplied

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not
Regularly
Supplied
Not
Regularly
Supplied
Not
Regularly
Supplied
Not
Regularly
Supplied
Not
Regularly
Supplied
Not
Regularly
Supplied

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

Not Avbl.

30 kms

28 kms
33 kms
5 -7 kms

None of the sub centres have examination tables, adequate illumination, signboards, tables, chairs, delivery tables, and adequate infrastructure to cope with an
emergency to provide primary care. The sub centre rent provided monthly to the sub-centre staff is being grossly misappropriated. No health education camps
were conducted in the sub-centre areas of Sultanpur and Ameenpur and Kishtareddipet in the last one-year. (Date: Aug 20 2004)

I. A
Screening of Children with Vitamin A deficiency in Gandigudem Village in
Patancheru Mandal
Total screened 36 children
Examined on Saturday, 21 August 2004.
Dr. Abraham Thomas, Community Health Fellow, CHC Bangalore.
The examiner is Telugu speaking

The Criteria for identification of Vitamin A deficiency are

z

-

Bitot Spots (small white plaque-like patches on the sclera)
Brown to black discolouration of the sclera with wrinkling and dryness
Severe if - an Infected eye with damage to the sclera and the cornea
Children who give a history of poor vision and night blindn ess

Available resources for examination and documentation
Torchlight
Good sunlight
Camera

NB: All children came along with their parents for the screening

l

Chart showing the details of the screening
Age

Bitot Spots

Brown
Wrinkling
of Sclera

1. Pothagiri
Divya
2. Santu

4 '/2
yrs
5 yrs

Negative

Negative

Negative

Positive

Vitamin A Defficiency

3. Golla Anusha
4. Mouinika
Godugu

3 yrs

Positive

Vitamin A Defficiency

Positive

Wrinkling

Vitamin A Defficiency

Wrinkling,
Severe
Discolorati
on
Wrinkling,
Severe
Discolorati
on

Vitamin A Defficiency

Name of child

5. Aslam Sheik

4 yrs

1 '/z
Yrs

1 yr
6. Akram Sheik

Remarks/Diagnosis

Vitamin A Defficiency

Brown
Wrinkling
of Sclera
Negative

Name of child

Age

Bitot Spots

7. Vani

5 yrs

Negative

8 yrs

Positive

5 yrs

Negative

Negative

3’A
yrs
i yr
11 12 Yrs

Positive

Positive

Negative

Negative

Positive

Positive

Positive

Positive

14. Sravanti

7-8
Years
5 yrs

Positive

Positive

Severe Vitamin A
Deficiency with vision
defects and Night
Blindness, Insensitivity to
light Excessive Tears
Severe case of Vitamin A
deficiency
Vitamin A Defficiency

15. Shabbir

4 yrs

Negative

Positive

Vitamin A Defficiency

Positive

Severe discoloration of
Sclera

8. Baby Shalini
9. Shashi Kumar

10. Sai Kumar
11. Lahari

Discolorati
on

12. Shaheen

13. Nusrat

16. Tarun
17. Pinky
18. Tayyab

19. Sai Kumar
20. Anusha
21. B Mounika
22. Naresha

4 yrs

Remarks/Diagnosis

Vitamin A Defficiency

Vitamin A Defficiency

1 %
yrs
3 yrs

Negative

Negative

Positive

7 yrs

Positive

Positive'
Positive)

5 yrs

Positive

Negative

11 12 yrs
6 yrs

Positive

Positive

Vitamin A Deficiency

Positive

Positive
Positive

Poor Health, with Scabies,
fever and cough
Vitamin A Deficiency

Positive

Vitamin A Deficiency

Vitamin A Defficiency

Severe case of Vitamin
Deficiency

25. Navaneetha

2-3
yrs
12
mont
hs
7 yrs

Nil

Nil

Nil

26. Kalyan

4 yrs

Positive

Positive

Vitamin A deficiency

Positive

Weakness in limbs, inability
to walk, and Vita A
deficient

23. Priyanka
24. Nazeema

2yrs

27. Madhhu

Name of child

28. Poojifha
29. Harish Yadav

30. POChiaiah
31.Radha
32. Sruthi

33. Pravalika

Age

Bitot Spots

11
mont
hs
3 yrs

Negative

Brown
Wrinkling
of Sclera
Negative

Negative

Positive

Severe joint aches (non
specific??)

3 yrs

Positive

Positive

3-4
Yrs
10
mont
hs
4
years
4 yrs

Negative

Negative

Negative

Negative

Negative

Negative

Positive

Positive

2 yrs

Negative

Positive

34. Meena
35. Anisa
D/o Anganwadi
Teacher Ms.
Hussein Bi
36. Madhuri

Remarks/Diagnosis

3 yrs

. Positive

Positive

Vitamin A Deficiency

Severe case of Vitamin A
deficiency (belongs to
Dayaram village under
Sultapur Subcentrej
Mild case of Vitbmin A
deficiency

Vitamin A Deficiency

Our assessment showed that most children 3 years and older suffered from
severe Vitamin A deficiency. On enquiry, it was found that the ANM, as a
practice, visited the village only once a month and the Anganwadi was
set up only 2 years ago.

Observation: This kind of occasional visits to villages is dismally inadequate
keeping in mind the necessity of community awareness building. These
are the reasons for poor access and poor utilization of services from the
government too.

Gandigudem is a little village of 1400 people with around 170-200
households. The Anganwadi centre caters to around 34 children below 6
years. The Anganwadi Worker, Ms. Hussein Bi, was posted there two years
ago, when she came to the village after her marriage. She has reduced
the incidence of Vitamin A Deficiency since the last two years.
Question: What is the fate of the children in the villages/hamlets that do
not have an Anganwadi centre and an Anganwadi Teacher like Hussein Bi
as yet?

The Jinnaram PHC and Gummadidala PHCs are located in the Northern
half of the industrial block. The Gumadidala PHC is catering to a thirty
thousand people and the Jinnaram Mandal is officially catering to about
35,000 people.
Glossary

PHC - Primary health centre
RHC - Rural Health centre
ANM - Auxiliary Miltipurpose Nurse
MPHA (M)- Health Assistant Male
MPHA.(F)- Health Assistant Female
AWW -Anganwadi Teacher
Vit A -Vitamin A
Bitot Spots -Eye lesions diagnostic of Vitamin A deficiency

Attachments
1. Photographs of children with vitamin A deficiency, (lylapur and
Gandigudem Villages)
2. Photographs of woman with burn like scars during planting paddy
3. Children having scabies and skin lesions
4. Photographs of PHC of Patancheru at Bhanur and its surroundings
5. Attendance register at PHC at Bhanur
6. The distances and population wise distribution of sub centres from the
Jinnaram PHC (note population of IDA Bollaram that is unrealistically
calculated)

References
■ The Profile of the number of health facilities In Medak District, fwww.opind.com/medok.pdf (commissionerale of industries.
Govt of Andhra Pradesh) Accessed on 22 August 2004)
■ NHFS report 1999
- GIS FOR ENVIRONMENTAL AUDIT OF HYDERABAD METROPOLITAN REGION,
RANGA REDDY & MEDAK DISTRICTS OF ANDHRA PRADESH, INDIA
Dr Kausalya Ramachandran, D.Sai kiran, M.Purnend & M.Kolpana Central Research Institute for Dry land, agriculture.
Santoshnagar. Soidabad P.O. Hyderabad -500 059. E-mail: KausalyarQyohoo com

hltp://www.incaindiQ,Qrq/qisforenvirQnmental.himl (accessed on 24 August 2004)
' PHC, Bhanur and ANM available at the time of visit. Since no doctor or other administratve staff members were available on
Friday. 20 August 2004

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TAMIL NADU HEALTH REPORT
Health Profile of Tamil Nadu

As on 1st March 2001, the population of Tamil Nadu stood at 62110839,

according to provisional results of the census of India 2001. In population it holds
the sixth position among the states in the country. The Density of population was
478. As against all India decadal growth rate of population 21.34% during 1991 -

2001, in Tamil Nadu this has further slipped to 11.19% from 15.39% during 1981

- 91. The sex ratio (ie, the number of females per thousand males) of population in
the State has improved from 974 in the previous census to 986 in the present
census. During 2000 - 2001 the Birth Rate (per 1000 population) was 19.2; the

Death Rate was 7.9; Infant Mortality Rate was 51. Expectation of life at Birth :
64.85 for male and 65.20 for female. Still Birth Rate : 16.1. Fertility Rate : 2.0.

Couple Protection Rate : 58.7. Tamil Nadu State reveals morbidity incidence rate

per 1000 in rural area as 52 and in urban area as 58.

The Literacy rate in the State has shown remarkable improvement. This has

increased to 73.47%, when compared to 62.66% ten years back during 1991

census. The per capita income at current price is Rs.20975, in 2002.

Health Budget

The provision under the Medical(792.96 Crores) and Public Health
demands (541.76Crores) in Budget Estimate 2001-2002 was Rs.1334.72 Crores,
which worked out to 5.44% of the total expenditure on the Revenue account of
Rs.24522 Crores in Tamil Nadu State budget. The provision for Health and Family

welfare for 2003-2004 is Rs. 1380.29 Crores.

1

J'2—

Primary Health Care

In Tamil Nadu 1411 Primary Health Centres and 8682 Health Sub-Centres
are functioning. These Institutions provide preventive, promotive, curative and

rehabilitative health care services. Between April 2002 and February 2003, 498
lakhs outpatients were provided treatment in the Primary Health Centres. All
Block Primary Health Centres have been provided with telephone facilities. To

involve the community in the maintenance of Primary Health Centres,
Participatory Community Health Committees have been formed in all the Primary

Health Centres.

Upgradation of Primary Health Centers

This Government has decided to provide at least one 30 bedded Health
Institution in each block. These Institutions will have specialist doctors and

modem equipments like Ultra Sonograph, Portable ECG, and X-Ray, along with
improved laboratory facilities and ambulance. During the year 2002-2003, 58

Primary Health Centres have been taken up for upgradation.

Improving Quality of Primary Health Care

To improve the quality of Health Care at Primary Health Centres, each

Block is provided with a Portable ECG machine to diagnose cardiac problems. A
Glucometer is also provided to each Block Primary Health Centre to enable early

detection of diabetic patients. The Operation Theatres attached to the Primary
Health Centres have been provided with Anasthesia apparatus, operating table and

surgical instruments to enable them to perform minor surgeries.

The Village Health Nurses at Sub-Centres have been trained to take Blood

Pressure and each Health Sub Centre is provided with BP Apparatus and

2

Stethoscope. The Sub-Centres are also supplied with a Medical Equipment Kit
consisting of basic instruments and weighing scales.

The Health Sector is equipped to maximize the use of Information

Technology. All the District Offices are provided with Computer and E-Mail

connectivity. Computers have been provided to Primary Health Centres in
Madurai, Theni, Salem and Namakkal Districts.

To meet the manpower needs of the Primary Health Centres, Government
has proposed to recruit 500 more doctors to fill the existing vacancies.

Speciality Medical Camps

Specialised Treatment is not easily available to rural people for illnesses
like cancer, and diabetes. Specialty Medical Camps to detect diseases like cancer,

diabetes, heart ailments, hypertension and geriatric problems are conducted at the
rate of one per Block. During 2002-2003, 385 Speciality Camps have been

conducted and 7.98 lakhs people were screened. 5.24% were found to be affected
with diabetes, 5.02% with heart ailments and hypertension, 0.54% with cancer and

22.4% with geriatric problems.

Mobile Health Services

In order to ensure that people living in tribal, remote and inaccessible areas

get medical facilities, 25 Mobile Health Units have already been launched and 20
more Mobile Health Units are being established in the current year. So far

1,79,571 patients have been provided with treatment by the Mobile Health Units.

3

Maternity and Child Health Care Services

Maternal and Child Health Services are the most important of the services

provided by the department. The services provided are Antenatal registration and

check up, administering vaccination against Tetanus, immunization against
vaccine preventable diseases, delivery care and post-natal care. At present the
institutional deliveries account for 89.9% of the total deliveries in the State.

Immunization against vaccine preventable diseases are sustained at 100%

every year. Apart from routine immunization, Pulse Polio Immunization is
conducted every year and two additional doses of oral polio vaccine are given to
all children below 5 years of age. In the current year the first round of Pulse Polio
Immunization was conducted during 5111 January and 9Ih February covering 73
lakhs of children under 5 years of age. The successful implementation of Pulse

Polio Immunization added with sustained coverage in routine immunization has

made the State free from polio for the past three years. Other vaccine preventable
diseases are also under control.

Hepatitis B Vaccination has already been started in the city of Chennai

from February,2003. This will be extended to 4 more Districts viz. Virudhunagar,
Ramanathpuram, Madurai and Nilgiris during 2003-2004.

Malaria

Malaria is prevalent mainly in urban, coastal and riverine areas in the State.

In Tamil Nadu more than 70% of the total malaria cases occur in urban areas.

Chennai is the major problem area.

4

The cases in Chennai city are mostly confined to North Chennai. To

eliminate the Malaria parasite so as to make Chennai free from Malaria, the
Directorate of Public Flealth and Preventive Medicine and Chennai Corporation

jointly organized a “Malaria Free Chennai Campaign” from September 15 to
December 15 last year. A total number of 1228 Malaria cases were detected and

treated during the campaign. People were advised to adopt measures for the

reduction of Vector breeding sources.

Filaria

The National Filaria Control Programme is implemented in Tamil Nadu

since 1957. The recent advances in the field of Filariasis Control have indicated

that annual single dose Mass DEC administration for at least 5 years is one of the
most cost effective methods of eliminating this disease. Mass DEC administration

has been carried out to 2.3 crores of people in March 2003 to eliminate lymphatic
filariasis in 13 filaria endemic Districts.

National Leprosy Eradication Programme

The National Leprosy Eradication Programme was launched in 1954-55.

The programme is marching towards achievement of the target of less than 1 per

10,000 population and ultimately total elimination of leprosy. Towards this MLEC
IV was launched to detect hidden cases in the community, with a specific focus on

tackling urban leprosy with the help of Non-Governmental Organisations as

facilitators.

Diarrhoea

Acute Diarrhoeal diseases and suspected Cholera are common among the

water borne diseases in Tamil Nadu. 2232 Anti Cholera inoculations were given

5

and 60,507 water sources were chlorinated in 2002 as preventive measures.
Administration of Oral Rehydration Salt during epidemic outbreaks of Acute
Diarrhoeal diseases has been popularized through Intensive Health Education.

Conclusion

Inspite all these health care arrangements by the government, people are
affected by the structural deficiency in public health care services. Public hearings
are organized by National Human Rights Commission in association with JSA to

streamline the public health care systems on one hand and to increase awareness

about health rights in the community on the other. The Public hearings will also
facilitate dialogue between the public and the government health officers.

Source

1. Census of India,2001 (Provisional)
2. Ministry of Health and Family welfare Reports, 2000, NewDelhi.

3. Health and Family welfare Department, Government of Tamil Nadu.
4. Statistical Hand book of Tamil Nadu 2002.

6

<f.<r>m

. ^3 J 3

TN 02

SIPCOT, Cuddalore: Special Needs of Pollution Impacted Communities Ignored
The SIPCOT chemical industrial estate in Cuddalore is one among many such clusters of
polluting industries in India. The needs of communities and workers in such areas is remarkably
different from those of communities not living in polluted places. In unpolluted places, the health
of communities would be the responsibility of the municipality and/or the health department. In
pollution-impacted communities, the causes and sources of pollution are often within the
jurisdiction of agencies such as the Pollution Control Board and the Factories Inspectorate,
whereas the health of the workers outside the factory and residents comes under the purview of
the District Administration and the public health system. Given the peculiarities of this situation,
it is important that any approach to addressing health issues in such areas is done in coordination
among these bodies.
The pollution-related health problems in SIPCOT, Cuddalore have been mentioned by
community residents since at least 1984. However, till date no official study has been
commissioned to enquire into the reported health problems in the area.
In her submission to the Indian People’s Tribunal on Environment & Human Rights, Dr. R.
Sukanya, a public health specialist notes of the SIPCOT environment:
"Health problems among people due to exposure to environmental toxins is an important
public health problem. Threat of emerging antibiotic resistance, eye problems, chronic
compromise of lungfunctions, high morbidity among children, lack ofproper medical care and
rehabilitation, medical apathy are all highlighted in the case studies from Eachangadu." In
conclusion, Dr. Sukanya notes the need for a comprehensive health assessment of the villagers
and SIPCOT workers, and "active measures to stop the contamination from the nearby factories
and to restore the quality of the water to prevent further damage to health of all."

While the kinds cf industries and the number of people living within the impact range of
pollution may differ from place to place, the problems faced by and the demands of workers and
communities living along or near the fenceline of polluting factories is identical throughout the
country.

The following issues inevitably arise with regard to health in pollution-impacted communities:





High rates of morbidity among exposed people, especially women and children.
Because women, children stay at home and, hence, in a polluted atmosphere all day
long, they (along with factory workers living within the pollution-impacted
community) are worse affected than men or others who may leave the pollution area
to work elsewhere.
Children are routinely identified as one of the most affected groups in SIPCOT,
Cuddalore.
Symptomatic treatment for chronic illnesses caused by exposure to pollution
No specialized treatment for cases of industrial poisoning
Medical expense disproportionately higher than income
Loss of income due to lost work days

1

TN 02

Standing the Precautionary Principle on its Head: Anecdotal evidence, testimonies of
pollution-impacted people, complaints and even simple studies seem to be inadequate
to move district authorities, the health department and the Pollution Control Board
into action. Rather than act on this evidence, they demand conclusive proof of harm
from complainants or belittle their claims as exaggerated.
No preventive action: Ongoing exposure - Many officials at regulatory authorites
believe that pollution is inevitable. They also recommend “reason” and “patience”
saying that the pollution has to be reduced gradually keeping in mind the need to
balance the interests of the industry and the community. In a sense, this attitude
condones pollution and authorizes the ongoing exposure of communities to pollution.
Alarmingly, the Health Department is noticeably absent from the discussion around
the issue of health in pollution-impacted communities. In the absence of any steps to
stop exposure to pollution, there is little that can be done to improve the health status
of pollution-impacted communities.
Lack of specialized infrastructure in the event of a disaster or emergency.

This case will be a presentation by Nityanand Jayaraman based on documented and referenced
interviews with representatives of the District, Health and Environmental administration, and
testimonies gathered from residents of SIPCOT.
Recommendations:
• Operationalise the Precautionary Principle, and use the Precautionary Principle rather
than a cost-benefit analysis to guide decision-making on the matter of environmental
health.
• Notify areas around polluting industries as “Zones of Environmental Health
Concern.”
• In the health administration infrastructure (ESI, PHC, GH etc) covering “Zones of
Environmental Health Concern,” deploy specialised environmental health cells or
retrain existing health department staff to deal with a) long-term monitoring health
among pollution-impacted communities; b) providing long-term specialised health
care to people living, working within such Zones; c) cases of acute poisoning by
industrial chemicals.
• Deploy an emergency plan to contain the damage already done to children’s health,
and initiate measures for the rehabilitation of children’s health.
• Operationalise the Polluter Pays Principle: Polluting industries maximize their profits
by externalizing the costs of pollution to the community in the form of transferred
health care costs to repair pollution-related health damage. These industries should be
made to pay for the health care of pollution-impacted communities and for the
specialized health care infrastructure required in such communities.
• Take steps to eliminate exposure by stopping pollution
• Involve representatives (particularly women) from the pollution-impacted
communities and local public interest organizations in monitoring health and
reporting pollution incidents.

2

TN 03

Industrial Accident Leading to Death

On 9 April, 2004, Mr. R — a contract worker from Periyapillaiyarmedu, SIPCOT,
Cuddalore - began work as a daily-wage labourer hired by a contractor at Tanfac
Industries Ltd.
On 11 April, 2004, Mr. R was exposed to concentrated sulphuric acid fumes while
cleaning an acid tank at TANFAC Industries Ltd. Immediately upon exposure, he
climbed out of the acid tank and fainted. After he recovered, he was given something to
drink and sent back to clean the acid tank where he was exposed further.

Upon returning home, his wife reports that he was coughing and complained of heaviness
in the head, and difficulty in breathing. The problem worsened, and he was taken to the
Government Hospital in the early hours of 12 April, 2004.
On the same day, the doctors at the GH recommended his relocation to a private hospital.
He was moved to Karman Hospital, Cuddalore. No ambulance or hospital vehicle was
provided to convey him to the Private Hospital.
On 22 April, 2004, Mr. R was transferred to JIPMER, Pondicherry, after his
complications failed to subside. He succumbed to his exposure on 30 April 2004.

His post-mortem report identifies the cause of death as “chemical pneumonitis.” A
chemical analysis report prepared by the chemical examiner of the Public Health
Laboratory, Pondicherry, confirms the “presence of corrosive acid such as sulphuric
acid.”
This case demonstrates a prevalent problem - failure of regulatory authorities such as the
Factories Inspectorate to sincerely implement the rules relating to industrial safety, health
and hygiene. Victims of such failures are almost always workers, particularly contract
workers.
Mr. R, an untrained contract worker, was sent to do a highly specialized and hazardous
job. The acid tank was not certified free of toxic fumes as required by law. There was no
first aid available, and the worker was sent back to the toxic work atmosphere.
Denial of Health Care :

Lack of preventive care: Ensuring health practices within industries is the
mandate of the Factories Inspectorate. In practice, this department serves as
the Government’s arm on onsite industrial health and hygiene. The Factories
Inspectorate failed to ensure the rules in TANFAC, thereby eliminating any
possibility of preventing harm from happening. The absence of substantial
punitive measures against violators is tantamount to condoning violations and
represents a failure to prevent injury or health damage.

1

TN 03

Lack of emergency response: Again, the failure of the Factories Inspectorate
to rigorously implement the rules has led to a situation where Mr. R had no
access to first-aid and sensible advice after the accident.
Lack of adequate and appropriate facilities in Government Hospital: Despite
its proximity' to an industrial area notorious for its pollution- and accidentrelated injuries and deaths, the Government Hospital in Cuddalore seems illequipped to deal with cases of chemical poisoning. This is clear from the fact
that Mr. R had to relocate to a “better” hospital within hours of getting himself
admitted at the GH.
Challenges in Accessing Redressal: If accessing health care for Mr. R was
difficult, the task of accessing compensation and assistance from the District
Authorities and the ESI is proving to be even more complicated. The widow
has received no interim relief. No case has been filed against the violator Tanfac. Pension under ESI is still several files away. These complications are
very' much related to the failure in regulating industrial safety and health, and
in maintaining appropriate health systems.

Consequences: Death (avoidable if proper first aid and treatment facilities were available
and used)
RECOMMENDATIONS:

1.

2.

3.

4.

5.

The Health Department should play a proactive role in ensuring that
practices to prevent harm are followed within industries. They should do
this by coordinating with the Factories Inspectorate.
The Health Department should facilitate the routine monitoring of workers
health data required to be collected under the Factories Rules to identify
problems (if any) of occupational diseases among them.
The Factories Inspector should be directed to diligently perform his/her
functions, particularly in regard to maintaining industrial safety and
ensuring emergency response by industry. The Inspector should also
ensure that only trained workers are deployed on hazardous jobs and
contract workers are not used for such activities.
Hospital infrastructure in the areas near polluting industries should have
trained personnel and equipment to deal with cases of industrial injury and
poisoning.
The District Administration should be instructed to assist the victim or
his/her survivors in accessing compensation and/or pension.

2

TN 04

Injury to Fishermen as a Result of Water Pollution

In September-October 2002, fisherfolk working in the river Uppanar, that runs behind
SIPCOT, Cuddalore, stopped fishing after all active fishermen began developing serious
skin problems. They attributed the problems to an illegal discharge of acidic effluents
from Pioneer Miyagi Chemicals - a routine occurrence, according to them.
The company uses large quantities of hydrochloric acid to dissolve bones (and
manufacture Ossein). The New Jersey Department of Health warns: "Contact [with
hydrochloric acid] can cause severe skin burns and severe bums of the eyes, leading to
permanent damage with loss of sight. Exposure to dilute solutions may cause a skin rash
or irritation."

A submission by the Joint Director of Health Services, Cuddalore, corroborates the
charges by the fisherfolk against Pioneer Miyagi for discharge of untreated acidic effluent
into the river. "On 20.9.02, 13 persons (fishermen) suffered chemical burns due to the
effluents/discharge from SIPCOT industries into Uppanar River," the statement read.
The fisherfolk said medicines from the Government hospitals and private hospitals did
little to ease their problem. No systematic treatment was provided for the victims of acid
bums.

When the fisherfolk approached the District Collector for assistance, the Collector is
reported to have dismissed their concerns and advised them to look for an alternative
livelihood. This attitudinal malady that afflicts many bureaucrats and people in regulatory
agencies is the most serious obstacle to implementing the Precautionary Principle, or
taking any sensible steps in the matter of health.

In October 2002, NGOs FEDCOT and CorpWatch requested public health specialist Dr.
R. Sukanya (M.D) to look into reports of the September 2002 occupational injuries
among fisherfolk, and the general state of health in SIPCOT. In her report submitted to
the Indian People’s Tribunal on Environment and Human Rights, Dr. R. Sukanya states:
"In the fishing village ofSonnanchavadi, chemical contamination of the river poses a
serious and ongoing occupational health threat. The fact that the villagers have been
forced to stop fishing - and suffer wage losses - is a violation of their fundamental and
constitutional guaranteed right to livelihood. "

Denial of Health Care :
1. Lack of preventive care: Adequate efforts have not been made to eliminate
pollution-related health injury.
2. Absence of appropriate treatment: Fisherfolk received no effective
treatment for their ailments.

1

TN 04

Consequences:
1. Prolonged skin problems
2. Difficulties in accessing redressal (including compensation)
3. Lost wages and added expenses due to health care costs

Recommendations:
1. Action to be taken as suggested in Case/ and as applicable to this type of
chemical pollution.
2. Primitive action against the industry as deterrant to future violations.

2

TN 07

Testimony of S.J.

Name : S.J
Age : 45, male
Address : N.Punjampatti, P.O Dindigual-644503, Tamil Nadu
Date : 30.6.2004

S.J met with an accident and went to Dindigul Government Hosptial for treatment at
10.30 p.m. with head injury. They did the first aid but did not take CT Scan to diagnose
head injury even though the patient had severe pain and swelling of face. There was
delay for attending the patient. Consequence of the delay caused blood clots in the eye
and reduced eyesight, severe pain and his condition become serious.
Finally operation was done after paying the bribery amount. The medicine was bought
outside for the operation and it costs Rs.750.00. CT scan also taken outside. The patient
paid money to all level of people at the hospital. They borrowed money for high rate of
interest and spent Rs.5,500/- for getting treatment. Proper care was not given when he
was getting the treatment and whenever medical attention was needed the hospital staff
ignored him.

Denial of Health Care:

Negligence
Bribery
Delay in health care
Unnecessary expenditure: purchase of medicines and taking
.of CT scan outside.

1

TN 09

Name : S.G
Age : 45, Female
Address : Pullampadi P.O, Lalgudi, T,K. Trichy Dt. Tamil Nadu.
S. G was suffering from TB. First she went to PHC of Pullampadi and after the check up
her disease was found to be pulmonary. Then she was sent to Government Rajaji TB
Prevent Centre, Trichy for continuous treatment. Last one year she was going to Trichy
from her village for getting treatment. Important medicines were bought from outside
medical shop. 8 times ‘scanning’ were taken from outside.
She did not get any
improvement now she is getting treatment at private clinic called Madha Clinic,
Pullampadi.
For the treatment she borrowed Rs. 15,000/- and sold 24 gram gold
jewellary, 10 goats and one milch animal

Denial of Health Care : Ineffective treatment
Asked to get medicines and tests done outside.
Consequences : Delay in improvement of health
Heavy indebtedness, borrowing money and selling assets.

1

TN 10

Patient’s Name: H.S.
Adddress : Lalkudi Taluk, Trichy (Dist), Tamil Nadu

For more than 2 years, H.S. suffered from cold and Asthama. He used to go to
Pullambadi Government Hospital. But he could not overcome his disease through the
medicines and services, given by the Government Hospital. So, he went to private
hospital in Lalkudi. He spent nearly Rs.30,000/-for his complaints. In order to raise the
amount he sold his cattle, land and jewels.
Denial of care

1. No proper services available in Government Hospital
2. Unnecessary expenditure of Rs.30, 000/-, making the patient sell his assets.

1

TN 11

Treatment without Examination

Case 1: P, aged 50 years, went to Government General Hospital at Manaparai in Trichy district.
She is suffering from high blood pressure. Earlier she was taking treatment with a private clinic.
At present due to economic crisis in the family she is going to Government Hospital. She said the
doctors at the governmental hospital are without checking her blood pressure, giving her
medicines. She takes the tablets and goes to the private clinic to check her blood pressure and
takes the tablets according to the doctor’s advice there.
Case 2: M, aged 38 years, is going to the Government General Flospital for diabetes. They give
her the tablets without examining her urine and blood. She goes to a private clinic to get her
urine and blood examined and take the tablets according to the doctors’ advice there.
Denial of Health Care :

Negligence
Absence of simple diagnostic aid (B.P. apparatus) not performing;
the needed tests, before the administration of drug

Consequences

Unnecessary expenditure to get the tests done at the private clinic.
Delay in administration of drugs.

1

TN 12

M, aged 20 years, went to Government General Hospital at Manaparai in Trichy district
tor first delivery. The baby was delivered through caesarean. The day when delivery was
conducted she suffered from more pain but they did not give her any medicine. She had
to wait till the doctor came the next day to give her the injection.

Denial of health care: Delay in health care and relief of suffering.

1

TN 13

Name : NS

Address : Manaparai, Tamilnadu

He was admitted in Manaparai Government Hospital. The staff did not give him proper
food. They are selling the food and other things. Due to this patients are not getting
proper services from hospital.

Denial of care: Negligence and corruption

1

TN 14

Name : Natarajan
Age : 45, male
Address : Pungawadi, Manapparai, Tamil Nadu
Hospital visited : Manapparai Govt. Hospital, Manapparai, Tamil Nadu

He got ‘bad damage’ in the spinal cord due to hit by the bullock. He was admitted in the
Manapparai Government Hospital for 4 days . Hospital staff told him that, ‘ he need Rs.
10,000/- to rectify his complaint, but he could not pay that amount, so he was discharged
from the hospital. Now his two limbs are not useful to him. He is living without the
usage of his legs.
Denial of health care :

Medical attention denied because the patient could not give the ‘bribe demanded’ by the
staff of the Government Hospital.
Consequence :

Disability; unable to use the legs.

1

TN 15

Patient’s Name : G.P.
Address : Sangralingapuram, Tamilnadu
For the heart complaints she used to go to Aruppukottai Government Hospital. On 8.8.03
she was admitted in the above hospital for treatment. There she had an X-ray taken. Due
to the non-availability of doctor and the deficiency of the medicines, she didn’t get timely
treatment. As a consequence she died.
For the treatment of her complaint she spent almost Rs.20,000/-. She raised this money
through selling her land and borrowings.

Denial of Care

-

Non availability of doctor and medicines in the Government Hospital
Free health care if not given; so, she had to spend more than Rs.20,000/-

Consequences : Death

1

TN 16

Patients' Names :
1.
2.
3.
4.

A.S
A.L
V. M
KG

Hospital Visited : Cuddalore , Government Hospital
Among the four, two of them went for delivery and other two went for Family Planning
operation. The Cuddalore Government Hospital is the District Hospital. All of them
gave Rs.700 to Rs.500 rupees as bribe to avail the services. They received good
treatment and other services from the hospital.

Denial of Care : Bribery

1

TN 17

Case Study of Theni, TamilNadu:
The situation in Theni, the largest cotton producing district of Tamilnadu is very unique
since pesticide use in cotton growing areas is higher than in any other crop in India.
Such high pesticide use which goes up to 25 sprays in one season brings with it a large
number of health related issues ranging from cases of acute poisoning to a high rate of
fainting due to inhalation of pesticide fumes and chronic disorders like impaired mental
developmental abilities in children.

The health care scenario in Theni District:
Three to six villages have a representation of the Village Health Nurse (VHN) who are
provided with living quarters next to their small dispensary. They have the capacity only
on issues like vaccination, vitamin and mineral deficiencies and maternity advice. The
villagers too do not depend on them for any serious health problems. Even for common
illnesses like fever, they might either go directly to the PHC (Public Health Centre) or to
the nearby private doctor. Approximately three or four of these VHN’s come under a
PHC. They have a few beds and a doctor is assigned to each PHC, who hardly comes on
time and leaves by lunch. By and large, they do not admit patients and send them to the
district General Hospital. Even first aid is mostly not administered on the pretext that
they are anyway going to the GH. Most of the cases who have been admitted in the
PHC’s seem to have got some political pressure exerted by the local party men.
As observed by the Greenpeace study “Arrested Development” in Theni, in three
villages, the effects of pesticides are highly pronounced on the mental abilities of
children. An issue, which needs to be taken up seriously, is the faulty system of health
care, which consists of callous professionals who have been risking the life and health of
the future generations.
Denial of Health Care
Exposure to toxic and hazardous chemicals (pesticides) without adequate preventive and
precautionary steps.

Inadequate health care to tackle the adverse effects of the chemicals.
Consequences
Arrested development of children.
Impaired mental abilities.

Recommendations
Apply the precautionary principle at all stages for the pesticides.

1

TN 17

ARRESTED DEVELOPMENT - An Executive Summary
In the cotton-growing season between April and December 2003, Greenpeace India
studied the chronic effects of pesticides on the development of children growing up in
cotton cultivating areas of six states of India. The results of this study, published in April
2004 as Arrested Development, reveal that exposure to small doses of pesticide during
childhood years has severely impaired the analytical abilities, motor skills and the
concentration and memory of children from farming communities - the 1648 children
who participated in this study are representative of the population of India.

Most studies in the past have focused on pesticide residues in food and water, instead of
which this study attempts to correlate the indiscriminate use of pesticides with the health
of unsuspecting little children (4-5 years) and older ones (9-13 years); children who
appear normal and happy but whose mental development lags far behind their
counterparts in pesticide-free environments. The study focuses on children, as they are
particularly vulnerable, given their physiology and behaviour patterns
A total of 899 children from six locations in the cotton-growing belts of the country,
(which implies the intensive and high use of dangerous pesticides cocktails) were
compared with 749 children of the same age, economic background and ethnicity in a
different location (within the same state) where the pesticides usage was far less.

The researchers arrived at the data for this study through using a Rapid Assessment
Tool. Through this tool, the children were asked to participate in a wide range of
tests using a play approach, where the tools were individually and verbally
administered to each child.

Widespread documentation on neurological effects of pesticides including effects on
memory, judgment and intelligence as well as personality, moods and behaviour
determined the kinds of tests administered.
The tests included the use of wooden blocks and jigsaw puzzles to measure mental
abilities, ball catching and balance tests to test motor abilities and memory games to
asses the level of concentration and memory.

The study found a remarkable difference between the abilities of the two groups of
children, with more or less consistent trends across different locations in both the age
groups. With all other possible coniounders controlled for, the only significantly
accountable reason for these disturbing findings is the children’s exposure to pesticides.

The findings of Arrested Development make a strong case for the application of the
Precautionary Principle. In the case of hazardous and toxic substances like pesticides,
Precautionary Principle needs to be applied in their manufacture, distribution, marketing,

storage and use. The current legislations, policies and practices in India do not adhere to
this precautionary principle.

2

TN 17

The report strengthens the evidence against pesticides and calls for a ban on all
pesticides, starting with those banned in other countries. As cleaner, safer alternatives for
farming have been well demonstrated by farmers in the country, the study is a wake up
call to the government and a demand for them to provide greater support to organic
farming in terms of resources, mechanisms for more research, extension and crop loan
support and infrastructure.

Notes:
The six locations were chosen from states and districts where cotton cultivation and pesticide use
are high, and from where earlier reports of pesticide-related problems have emerged. The
problems here could have been environmental, human health or agronomic. These locations are:





Bharuch in Gujarat (Halder, Kavitha and Samlod villages)
Bhatinda in Punjab (Bangi Nihal Singh, Jajjal and Mahi Nangal villages)
Raichur in Karnataka (Khanapur, Manjerla and Poorthipli villages)
Theni in Tamil Nadu (Rassingapuram, Silamalai and Visuvaspuram villages) .
Yavatmal in Maharashtra (Dahelitanda, Kopamandvi and Sunna villages)
Warangal in Andhra Pradesh (Atmakur, Oglapur and Peddapur villages)

3

TN 19

Testimony of Mrs. P

Mrs. P aged 20 native of Rosalpatti village Virudhunagar block -studied upto
12th standard -doing agricultural collie work. She was admitted to Municipal
maternity hospital Virudhunagar in July 2003.,for delivery of baby and there
was no doctor in the night. Only health nurses attended in a rough manner.
After
3
hours doctor
came
and
did
caesarean
operation
and
still bom baby was taken out. Unusual delay caused the death of the baby. Later
Mrs. P had to district general hospital, Virudhunagar to remove the fluids in
the stomach. After one month she recovered and now is pregnant again with 5
months baby.Since the fluid came out from the uterus, the baby had to die after
a few hours. The timely treatment was denied.

1

TN 20

R aged 22 was admitted to Government Hospital Virudhunagar due to labour pain,
in August 2003. The doctor was not available. Relatives were waiting right from 7
a.in. in the morning, (more details awaited)

1

TN 21

PRIMARY HEALTH CENTER STUDY

Name of the interviewer

Kaniyambadi in Vellore
district,Tamil Nadu.
Sri.Syed kaleem Ahmed

Date of documentation

4th August 2004

Location

of

Primary

Health

Center

Infrastructure

This primary health center has all the staff except the lady doctor. All the
staff are staying within the campus of the PHC. The condition of the building
is good with water and electricity condition. The road to this PHC is good
and is well accessed by public transport facility. This center has an
ambulance. The vehicle number is TN 09G1537

No information is given regarding the ownership of the building and water
problem. The center is clean. The center has toilet facility with water supply
and the people who visit the center are allowed to use it. It is reported that
the beds and the labour room is in good condition. The Operation Theater
and the operation table also are in good condition. The refrigerator is in
working condition. The center has facility for autoclave. The microscope is in
good working condition. The ambulance is working condition and it is made
available for patients free of cost.
Part II
The center has always anti snake venom for snakebites and anti rabies
vaccine for dog bites. There is no information regarding anti malarial
medicines. TB medicines are available. There is no information given if all
the medicines are given free of cost and prescription is given for any specific
medicine.
Part III
The center conducts cataract surgeries. No information is given if the center
provides first aid, does sutures and facility for putting the cast for fractures.
The interviewer does say that the center treats fractures cases. He also says
that first aid is given for bum cases and snakebites.

Part IV

Health camps are regularly held for pregnant women and children. The
center has facility for conducting normal delivery round the clock. There is
facility for conducting both vasectomy and Tubectomy.

Treatment is given for women's health problems such as white discharge
and problems related menstruation and if women attend the center for these
problems. The report says that the center has facility for medical
termination of pregnancy (MTP) but it does not give any information
regarding about the conditions for MTP, such as that the patient must

1

TN 21

accept planning after MTP, need the permission of the husband, family. It is
reported that no fee is charged for MTP.
The center provides childhood immunization, and provides treatment for
pneumonia and diarrhoea and dehydration. The center has facility for
treating childhood disease.
Laboratory facilities
The center has facility for diagnosing anemia, malaria, and tuberculosis. It
also has facility for doing urine examination for pregnant women.

During the past three years, there is no report of any epidemic of the
following diseases; malaria, measles, cholera, jaundice. The report says that
that the staffs of the PHC are kind and polite with the patients. None of the
doctors from this center do private practice either during office hours or
after office hours. There is no report of this center ill treating dalits, traiblas,
and other marginalised people. People affected by TB, Leprosy and
HIV/AIDS are not discriminated. The center has private place for examining
women with their attendants and they are treated with respect. The center
has facility for treating in-patients. The centers provide complete treatment
for chronic illnesses. The center refers immediately the patients to the
nearest hospital at times of emergencies and when they feel they cannot
manage. The center has complaints register. No information regarding if
there are any complaints written.
In the any other information column the interviewer recommends this center
and Dr. Palani Bhushneshwai for conferring any award.

NB- further clarification have been sought from Sri. Syed Kaleem Ahmed, to
fill in some aspects that are incomplete.
Testimonies:

I belong to a minority community. I have admitted my grand daughter S at the PHC
for family planning surgery. They do not discriminate because we belong to Islam. I
vouch that there is no human right violation in this center. I thank Dr. Mrs.
Bhuvaneswhari, Mrs. Subbalakshmi and Mrs. Vijayakumari for whole-heartedly giving
us the treatment lovingly.
Signed

Mrs. S
Saidapet
Vellore-12
V.Subbalakshmi ANM
Kaniyambadi PHC

Dr.Bhuvaneshwari
Civil surgeon.
Govt. Primary Health Centre

2

TN 21

I am R related to Mrs. B who was admitted at the Kaniyambadi PHC for family
planning surgery. Dr. Bhuvaneshwari and her colleagues ANM Mrs. Subbalakshmi
and Mrs. Vijayakumari treated us lovingly. They did not discriminate me because I
belong to a tribal community. I vouch that in this PHC there is no violation of human
right for people belong to dalit and tribal communities.
Signed
Mrs. B
Karugamputhur Village
Vellore Taluk

Dr. Bhuvaneshwari
Civil Surgeon
Govt. Primary Health Centre
Kaniyambadi.

V.Subbalakshmi
ANM, PHC Kaniyambadi.

3

Com H

PY01

Name: Mrs. M
Age : 60. female
Address: Karaikal
Mrs M. received treatment at Karaikal Government Hospital for her eye defect. She visited the
hospital six times for checkup and treatment, and every time she did not have to wait more than
15 minutes to get the treatment. Both her eyes were operated on one after another, and on both
occasions the operation was done the day after admitting her as inpatient. Good care was given
at the Centre, and staff of the Centre rendered good service whenever required. They were
available in their duty time.

According to the patient, all equipments were kept ready in working conditions for diagnosis and
treatment. Except eye ointment, all medicines were supplied from the hospital. The expenditure
was only on their own transport, food and for purchasing spectacles. They did not pay any bribe
to the doctors or any other hospital staff. Mrs. M was satisfied about her treatment and
experience at the Karaikal Government Hospital.
Result: Patient satisfaction, when there is quality of care
PY02

Name: Mrs. IM
Age : 49, Female
Address : Sonampalayam, Pondicherry

Mrs. IM visited the Pondicherry Government Hospital twice at Chenchsalai, Pondicherry twice,
to get treatment for excess bleeding (uterus related).
Without any delay her check up was done with scanning etc. She was happy with the care she
received and have no complaints about the hospital. Care and attention was given when she was
at the hospital, the equipment were in usable condition, and she received all the medicines at the
hospital. She mentioned that she did not spend any money for this treatment. She is happy about
the treatment received by her.

Result: Patient satisfaction with the services provided in the public health facility.

PY 03

Name:
Age :
Sex:
Date of interview:

Mr.N
29 years
Female
3rd July 2004

1

Problem:

chest pain and stomach pain

She visited the Othiyansalai Primary Health Center in Pondycherry to get the treatment. She said
there was delay of about 30 minutes in attending to her after she reached the PHC but she
received the necessary treatment. The doctor checked her Blood Pressure and did an ECG. She
received good care and treatment from all the staff in the health center. She was given free all
the medicines necessary. All the equipment at the center is functioning condition and kept ready
for use. Regarding expenses she said, she did not spend any money for her treatment, she spent
only for transportation. She is happy with the treatment provided to her at this PHC.
Result: Patient satisfaction

PY 04
Name:
Age:
Sex:
Problem:

Ms. AK
44 years
Female
fracture of the hand

She received the treatment for fracture of her hands at the Karaikal Govt. General Hospital. She
said proper treatment was given to her at the general hospital. She said she unnecessarily spent
money for buying oil from the traditional healer before she went to the general hospital.
Result: Patient satisfaction

PY 05
Name:
Age:
Sex:
Problem:

Mr. DA
30 years
Female.
throat pain

He received the treatment for his throat pain. He said, though the doctors attended to him but
they were not very attentive, as there is ego problem among the doctors. Otherwise everything at
the General hospital was good.

PY 06
Name:
Age:
Sex:
Date of interview:
Problem:

Mrs.K
36 years
Female.
26th June 2004
abscess

She visited five times the Primary Health Centre at Censalai in Pondicherry for treatment. She
says that proper treatment is given to her.

2

PY 07
Name:
Age:
Sex:
Problem:

Mrs.L
35 years
female
Chronic headache

She visited Thuppurayapatti Primary Health Center to get treatment for her headache. She also
said proper treatment was given to her.

PY 08

Name:
Age:
Sex:
Problem:

Mrs. R
38 years
Female
chest pain

Radhika says that she received good treatment from the oliyansalai Primary Health Centre in
Pondycherrry.

PY 09

Name:
Age:
Sex:
Problem:
Date of documentation:

Ms. S
24 years
Female
not mentioned
25th May 2004

She did not mention for what she received treatment at Karaikal General Hospital. But she said
she received proper treatment.
PY10
Name;
Age:
Sex:
Date of documentation:
Problem:

Ms.T
40 years
Female
30‘” June 2004
Not mentioned

Comment:

The stalls at the Nedunagar Primary Health Center do not
give proper care and treatment with concern.

3

PY 11
Name:
Age:
Sex:
Problem:

Ms. ER
45 years
Female
Diabetes

She says that she is receiving proper treatment from Karaikal General Hospital.

PY 12
Name:
Age:
Sex:
Problem:

Mr. S
38 years
Male
Tuberculosis

He says he received proper treatment for tuberculosis.
PY 13

Name:
Age:
Sex:
Problem:

Ms. GS
38 years
female
ulcer of the stomach

Comment:

She says she has received proper treatment from
Mummombakkam Primary Health Center.

PY14

Name:
Age:
Sex:
Problem:

Ms.S
40 years
Female
White patches

She says she has received treatment for white patches from Villianur Primary Health Center. She
went there four times. As she was not cured, she went to JIPMER in Pondicherry. She says,
though she did not get cured at the Primary Health Center she was treated well by the staff there.

4

1.
2.
3.
4.

5.
6.

7.
8.
9.

Kuppampatti village
Rosalpatli
Sivakas family planning operations
Ansar case - Bribery
Rami- heart valve
Grace Mary
JesuRaj
Selva Kumar
Prasanna

No 6. Grace Mary, N. Panjsmpaiti village, Dindugai district

Grace Mary delivered a still bom baby in the auto on the way to Alamaratfaupatti
PHC, two kins away from her native village. She spent one ni$it at the PHC and was
referred to Dindugal district hospital. She was told by flie PHC staff that she needed
Hood transfusion as she had lost Hood after her delivery and was very weak. No
ambulance was provided from the PHC to the district hospital. The patient took an
auto. She spent one week at the Dindqgal GJH. No blood transfusion was provided
When she asked the attendant nurse, she was abused verbally by her “Why do you
want to live? Why don’t you commit suicide? What are you goipg to achieve by
living?”. Then after one week, she was referred to the Madurai G.H for further
treatment. She was unable to go because of the expenses involved
Grace Mary has one living child and two abortions. She is a very poor woman who
survives by coolie labour.
Denial of care

No ambulance at PHC
No life saviig blood provided at dstricthospital.
Verbal abuse by staff iflDifKhigal district hospital.
Incomplete and inadequate treatment provided

MJesa Raj, NJanjampatti, Dindugai district

MJesu Raj (age 41) is a vegetable vendor from a poor family of 6 members. He
suffered an accident on 8.6.2003 on the way to Pargampatti in the night MJesu Raj
was hit by a lony and was left Ueedng for half an hour on the road. He was taken to
local doctors in A.Vellodu village who refiised him treatment He was then taken to
Dindugal governmert headquarters hospital. Doctors told him that they cotdd not treat
ism. Even first aid was not provided. One of the doctors referred him to a private
hospital - Raja Rajeswari, where the same doctor works in the evening;. He finally
went to GaiKsh hospital. Without knowing that there was a skull injury, he was given
stitches and sent home. No scan was taken. His face started swelling and he suffered
bead aches. So he went back to Dindugpl govt hospital where a scan was taken after
payment .of Rs.550. He found out that he had suffered a skull fracture. Due to
continuous problems, he went to the Madurai G.H for treatment He was treated well
at Madurai and recovered.
Denial of care

Denial of care at Dindugal Govt hospital - Govt doctor referring him to a private
hospital.
Due to delayed care and negligence, he has lost three months of work.

Ramu (23 yrs), Malavarayanpattl village, THruvarangidan Hock, Pudukottai
district

Ms_Ramu suffered from chest pain, dizziness and fatigue. At the general hospital
Pudukottai, she was told that she had no problem. But her synptoms continued. She
was admitted in a private hospital in Pudcottai for 15 days and treated. She was told
that she had a valve problem. So she underweti heart valve surgery at the Thaqavur
Medical College hospital four years back She spent 45 days there -15 days after the
surgery. She had to pay fee nurses for any kind of services during ter stay in the
Thanjavur hospital. Sometimes, die had to pay each nurse upto Rs.50 per day.
Paymert in kind was also demanded- tamarind, coconut from ter village.
For three years, die was okay. She has started feeling the symptoms again. She went
to Pudukottai G.H where she was not given proper care. Finally at Trichy GU she
was told that rhe had a leak again. She was referred to the General hospital in
Chennai. At Chennai, it took her three days in the hospital to see the concerned
doctor. She was asked to come back on the 16'h of Jiiy (15 days away) for admission
for surgery. When ste returned on the 16th of lily, she was told to go back and come
again after 15 days. On her third visit, she was informed that the machine was faulty
and surgery will be possible ody in December.
Dental of care

No proper treatment in Pudukottai General Hospital.
Illegal payment to nurses in Than; avur Med cal college hospital.
Denial of treatment at Chennai General hospital - harassment of patient through
repeated visits from her village in Pudukottai to Chennai.

SeKakisitar (13 years), Koofhirtpattl vfflage, Annavasai taluk, Pudukottai
district

He was diagnosed as having a heart valve problem in Thaqavur Medical College
hospital three years ago. He kept returning for treatment to Thanjavur for 6-7 months
after diagnosis. Then he discontinued as his family could not afford the travel and
treatmeri. His mother is a widow raising two children through coolie work. He has
been getting merf dnes from Pudukottai G.H for the last two years. It costs him Rs.22
to travel by bus from his village to Pudukottai G.H. He makes two visits in a month.

EGs mother says that there is no proper information about his current health status
from’ the doctors in the Pudukottai G.H She does not know if his condition has
improved or worsened. Both mother and child are suffering from gpeat anxiety due to
1 ack of any information.
Denial of care

Rigjht to information of patient and patient’s family violated which is leading to
anxiety and trauma of mother and child
Non-availability oflife saving drugs at PHC level

Prasanna, Thfruthanl block, ThlrnvaHur district

Prasanna conceived in May 2002 after tndergoing two abortions. She went to a
private clinic for ante natal care. At the ninth month, she wait to file Egmore Mother
and Child Hospital for a check up. The doctor who checked her said that the heart
beat of file child was fine and there was no problem When Rrasanna’s sister
explained that she had undergone two abortions earlier and requested special
treatment, the doctor checked her again and asked her to get admitted. She spent the
night on the floor along with 17 other pregnant women The same blade was used on
all the women for shaving. Prasanna asked for a new blade and was refused. All the
women had to pay Rs. 10 for the use ofthe blade.

Another doctor checked ha the next morning and said that her child had died and
there was no heart beat The doctor, who checked Prasanna on the previous day and
dedared her normal, suddenly announced that the child had actually died 14 days ago.
Even afier finding out that the child was dead, Prasanna was kept in the ward for two
days witboil any treatment or surgery. On file second day, delivery was induced and
the baby was born dead. She was told that the baby had died because of her diabetes.
The private doctor die had seen had
her for diabetes. She suffered pain
and injection for more than a month because file stitches were not properly done.
Dental of care

Poor quality of ante natal care in the private clinic. No counseling about diabetes.
Trauma suffered by patient After informing ha that the child bad died, no treatment
was provided for two days.

VIjayan, 40 years, Periakadambnr vtliage, Thtruthaitf Nock, TMrtrvaHur district

Vijayan went to Kasavaraj pettai PHC for treatment for snake bite six months back.
For far days be was given injection and medicine. But no blood test was done. He
went to file Hsruthara Talik hospital about 4-5 times. Blood test was done and
patient was declared normal. But the swelling did not subside. So he went to a private
hospital where he was given injection and medicine after which the swelling subsided.

Rajeswaii
Beriya Karappal (Mother tn law)
Kipp amp attl village
Virndn nagar Mock

After suffering in 12 hours pain (die town bus will come to their village only in the
7.00 a.m. Ms. Rajeswari was admitted in the Virudu nagar hospital on 11/08/2003
around 12.30 p.m she delivered male baby. But the mother had been kept in the labour
room upto 3.30 in the evening and was deprived of food. In this concern the relatives
and staff had exchanged hot words. Even the nurse tried to beat her mother in law. At
4.30 p.m she got pain in her abdomen. So, the nurses gave her two tablets. All the
relatives called the staff No body attended the patient The staff said that we don’t
want to enter into the Sinking ward. So for more than 90 minutes she suffered terrible
pain. At last she died. The doctor finally arrived when the staff informed him. He told
to the relatives that if the staff would have called and hour before her life could have
been saved. Now the drild is with his grand mother and they are spend ng lot of
money on the chi1 d* s health.
Denial of care

Strong negligence of care
Negative attitude of the staff

Name :J. Pandeeswari, W/oJayaseelan
Age :23
Rosal patti vilage
Vtnuhmagar district

Having been tnable to conceive for three years after marriage of Pandeeswari, sou^it
treatment for infertility. She finally conceived and for her ANC she approached
private hospital for five months, following, which she went to a Municipal hospital.
on 19th November. 2003 she got admitted for her delivery. The doctor examined her
and said it will take 2 more hours for delivery and she left. After she left immediately
pandeeswari went into labor pains and was not attended by file nurses who insisted
that the delivery is only' conducted by the doctor. Ute labor got prolonged and half the
fetus body had progressed. Inorder to facilitate the delivery around 13 staff member
gathered around her and hit her and used abusive words. After 3 hows the fetus was
pulled out with the aid of forceps, which was obviously dead.
She did not urinate for 5 days and her abdomen was bloated and went to file same
hospital from where she was referred to district hospital. After bring catherised, her
scan was taken which revealed she has stone her bladder was damaged and infected
Thai they refened ha to Madurai Gov ernemeat hospital for further treatment But
she don’t wart to go to Govt hospital and went to private hospital. There they took
scan and said that die had bad damage in the bladder and infected. She was at the
home for more than 45 days and she pass urine through tube. Now she is getting
treatment in the private hospital of Virudu nagar and still continuing with the sam^
problem. She spends around 15,000 rupees for her treatment so for.
De trial of health care

Negligence of timely cares which leads to death of the child and chronic infection on
the bladder.
Strong negative behavior of the staff towards the patient in an un human way.
Spends 15,000 thousand money in private hospital which adds her economic burden.

SUMMARY OF RECOMMENDATIONS TO STRENGTHEN THE
PUBLIC HEALTH SYSTEM
1. Implement the Karnataka Integrated Health Policy, focussing on primary
health care and public health.

2.

Incrementally increase public sector expenditure on health care, bringing it up
to the norms of the National Health Policy, 2002.

3.

Focus on the basic determinants of health - food, water supply and sanitation,
environmental pollution.

4.

Ensure quality' of health care by regulation of the public and private sector

services and improving the quality' of training and medical education.

5.

Improve governance and social accountability of the health sector, reducing

corruption and improving utilization and impact.

6.

Reduce disparities in access to health care by increasing sensitivity' to needs of
women, children, elderly, disabled, scheduled caste and scheduled tribe

groups.

***
**
*

14

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Introduction: My name is Ms. Lucile Johns, I am a successful, friendly, friendly, homely, adventurous, handsome, delightful person who loves writing and wants to share my knowledge and understanding with you.