Sudip Bhattacharya

So near, yet so far: access to safe abortion services remains elusive for poor women in India

In this case study, we describe our experiences with a woman employed as a housemaid who sought unsafe abortion services from a private doctor. This was her sixth pregnancy, after previously giving birth to one son and two daughters and undergoing two induced abortions. Her husband remained opposed to the use of contraception. Initially, she had sought medical termination of pregnancy through a government hospital but was denied because of procedural delays, specifically the non-availability of an ultrasonography report consequent to a lack of proof of identity (ie, the AADHAAR card, a unique identification card for recording biometric and demographic data in India). She finally sought the services of an unqualified private physician and received oral abortifacient agents. Consequently, she was required to seek treatment for bleeding per vaginum from the dispensary staff at a government hospital. We note that many such incidents occur in our daily practice but remain unnoticed and undocumented. Although this patient was eligible for sterilisation (ie, tubectomy), her husband was uncooperative. This case illustrates the lack of decision-making power experienced by Indian women who have a low societal status.

Time to revisit the strategy of massive vitamin A prophylaxis dose administration to the under five children in India – An analysis of available evidence

Childhood blindness due to corneal ulceration has historically been prevalent among poor Indian children. To tackle this situation the National Institute of Nutrition (NIN), Hyderabad, India, launched (after field-testing) massive dose based national vitamin A (Vit-A) prophylaxis program. Over a period of time reduction in childhood mortality was also hailed as a beneficial effect of the program. Data from the Indian Council for Medical Research (ICMR) indicate that in most Indian states there has been a gradual reduction in the prevalence of Bitots spots. However, it was not attributed to the prophylaxis program because of its low and patchy coverage. It was, rather, attributed to the control of malnutrition, along with measles vaccination and improvement in healthcare access. Various studies have concluded that massive dose vitamin A prophylaxis does not reduce childhood mortality; this may have been due to the Hawthorne effect; whereby beneficial effects arose from frequent contact of health workers with community members. Paradoxically, harmful effects of massive doses of Vit-A are documented, e.g. acute toxicity in certain groups of children, ranging from increased intracranial pressure, mental retardation (postnatal period), and even death. Vit-A also intensifies bone demineralization, and increased levels can lead to calcium deficiency and, hence, growth retardation in vulnerable children. According to the present authors, for children who have Bitots spots or who have just recovered from an attack of measles, the best approach is to give Vit-A in therapeutic doses along with adequate daily intake of vegetables and fruits. Public-spirited citizens, along with the scientific community, must ensure the scrapping of the universal massive dose Vit-A prophylaxis approach, to avoid Vit-A toxicity and reduce economic burden to the health system.

‘The more we change, the more we remain the same’: female feticide continues unabated in India

In North India, preference for sons has been blamed for repeated incidents of female feticide, despite the legislation in the form of the Pre-Conception and Pre-Natal Diagnostic Techniques Act, 2002. We describe how a team of local private doctors offer package deals to pregnant women and their families in rural areas. The fetal sex is determined at night using a portable ultrasonography machine. If the fetus is a girl, an immediate induced abortion is offered in the clients’ home. If complications arise, women are advised to attend hospital. Such a patient visited us with a history of bleeding per vagina following incomplete induced abortion. This case study highlights the fact that female feticide continues to occur in India.

Anticonvulsant and Monoamine Oxidase Inhibitory Activities of some Triazene N1-Oxides

Thirty-three N3-2-, -3- or -4-substituted aryl-N1-(alkyl/aryl/substituted aryl)-triazene N1-oxides were synthesized and evaluated for their anticonvulsant and monoamine oxidase (MAO) inhibitory activities. Most of the compounds exhibited MAO inhibitory activity in vitro, and kinetic studies conducted with N3-4-chlorophenyl-N1-methyltriazene N1-oxide, the most potent inhibitor, showed that the inhibition is non-competitive in nature. The MAO inhibiting activity of the compounds correlated well with their anticonvulsant effect against maximal electroshock-induced seizures in rats. Acute toxicity studies indicate that the compounds have a wide margin of safety.

Knowledge attitude, and practice regarding dietary salt intake among urban slum population of North India

Introduction: Hypertension is an important modifiable risk factor for cardiovascular disease. High salt intake is an etiological factor for hypertension. Any effective salt reduction strategy will be based on peoples mind-set about salt use. Our objective for this study was to assess the knowledge, attitude, and practice for dietary salt intake by urban slum populations in Indira Colony, Chandigarh. Methodology: In 2015, we conducted a cross-sectional survey among a representative sample of 300 adults aged 18–69 years using a standardized questionnaire. Variations in the knowledge attitude and practice by gender and residence location were compared using the Chi-square tests. Results: Most of them (96%) took processed foods and 99% did not bother about the salt levels in the food. They also added salt on table. They did not buy low-sodium salts. Majority of them (75%) perceived that they are taking right amount of salt. They were clueless about the daily recommended allowance. Many participants (43%) did not know about the harmful effects of dietary salt. One-fifth (18%) of them had wrong information about dietary salt. Majority of the participants (64%) considered that lowering salt in diet is not important. Conclusion: Overall awareness level about optimal salt intake in diet was very poor among the slum residents. Recommendation: Development of effective public education initiative is the need of the hour for combatting hypertension.

Beliefs of a traditional rural Indian family towards naturalistic and faith healing for treating epilepsy: a case study

In this case study, we describe our experiences with a rural poor family from north India that initially contacted faith healers for treatment of their child who was having symptoms suggestive of epilepsy, but the seizures continued even after this. The family migrated to a city, where they started allopathic treatment, but eventually they had to discontinue it as there was no apparent relief. Again, they went back to their native village and restarted the treatment from the faith healer. This case study highlights the fact that in spite of the significant development of medical science, many questions pertaining to epilepsy treatment are still unanswered. Such dissatisfaction with the allopathic treatment of epilepsy is very common. Complexity of the disease and high cost of modern medication, side effects of drugs, efficient but heavy treatment protocols and unpredictable outcome are responsible for continued practice of people consulting faith healers for treatment of epilepsy. However, these remain unnoticed and undocumented.

Phasing out of the Universal Mega Dose of Vitamin-A Prophylaxis to Avoid Toxicity

Childhood blindness due to corneal ulceration was prevalent among poor Indian children. To tackle this situation, the National Institute of Nutrition (NIN), Hyderabad, India, Vitamin-A (Vit-A) prophylaxis programme was launched nationally in 1970 after field testing. Research of Indian Council for Medical Research (ICMR) documented that prevalence of Vit-A deficiency signs such as Bitots spot decreased among children, over a period of time. However, this decrease cannot be ascertained is due to mass Vit-A prophylaxis programme. This is because coverage was low and patchy. Improved nutrition status, wider vaccination coverage, increased rate in breast feeding and improvement of healthcare services played a crucial role. Rather many studies revealed that (mass prophylaxis to the child who is having adequate Vit-A level) it may be harmful to certain group of children as a result of acute toxic symptoms. High dose of Vit-A is capable of loss of bone density-hence retarded growth may be observed in susceptible individuals. To tackle this issue food based approach should be promoted (which includes breast feeding) along with timely measles vaccination. The children who have signs of Vit-A deficiency (e.g. night blindness, xeropthalmia, Bitots spot) or post measles children should receive Vit-A in age specific daily doses for two weeks along with Vit-A rich food, like green leafy vegetables, red palm oil, liver etc. Public spirited citizens, together with scientific community in India, should discourage this “one size fit to all” approach. It will not only avoid the ill effects of high dose of Vit-A but also it will help us optimal utilization of health resources in a resource poor country like India.

Why tuberculosis control programmes fail? Role of microlevel and macrolevel factors: an analysis from India.

India accounts for one-fourth of the global tuberculosis (TB) burden. The National TB Program was started in 1962. Over a period of time, some lacunae such as poor case detection rate and incomplete treatment were observed. Later, the government formulated the Revised National Tuberculosis Control Program (RNTCP), which achieved a case detection rate of 70% and a cure rate of 85%. Still, the problem of relapse and defaulter cases persists. In 2014, 6% defaulter cases were reported from India. RNTCP has also focused on microlevel aspects, that is, newer diagnostics such as GenXpert, line probe assay and medicines such as bedaquiline for drug-resistant TB. Action on the macrolevel aspects, for example, social determinants, is ignored. This is natural because these are out of the purview of the health sector. This case study reflects how a resident doctor in a rural clinic of North India tried to resolve the macrolevel and microlevel issues pertaining to defaulter TB cases.

Dietary salt intake estimation by routine healthcare workers in an urban slum of Chandigarh: A feasibility study

Context: Hypertension is an important modifiable risk factor for cardiovascular disease (CVD). From numerous studies, it was observed that excess dietary salt is responsible for 17-30% of high blood pressure and increases the risk of blood pressure-related CVD events in normotensives also. Employing the most appropriate method is important to assess the baseline consumption as well as to evaluate the impact of potential salt reduction initiatives. Aim and Objective: The aim and objective of this study is to collect salt data at population level by health workers, with a standard questionnaire, as they regularly visit household level for other national programs. Methods: A cross-sectional study was conducted in an urban slum of Chandigarh for salt data collection using the WHO STEPS instrument version 3.1. Sample size of 255 was calculated by Epi Info software. However, we have taken 300 participants for our study. Six health staff from Urban Health Training Centre, Indira Colony, Department of Community Medicine, PGIMER, Chandigarh, were involved. They were trained regarding filling the questionnaire. Investigator then re-interviewed 20% of the respondents interviewed by health workers, and a comparison of agreement was done. Results: The range of agreement was observed to be 55-90%, and percentage agreement varies between 63% and 83%, except in 3 questions which could be considered reasonable for initiating public health interventions. Conclusion: From this study, we can conclude that even in resource-poor settings, it is possible to collect salt data by proper training of health workers, and thus, we can initiate evidence-based salt reduction interventions in the community.