Where there are no doctors

By Sandhya Srinivasan

Sandhya Srinivasan reviews a manual on primary health care written for primary health workers

Health and Healing: A Manual of Primary Health Care
By Shyam Ashtekar
Orient Longman Ltd., Chennai, 2001. 626 pp including appendices, colour plates and index

Health and Healing: A Manual of Primary Health Care is meant to be a reference source for primary health workers. It first appeared in Marathi, as Bharatvaidyaka; for the English edition, the author, Shyam Ashtekar, was supported by Oxfam India and a fellowship from the MacArthur Foundation. Ashtekar, who runs a hospital in Nashik, Maharashtra, is a long-standing member of the Medico Friend Circle, and committed to the cause of community-based health care.

One of the first books of this kind was David Werner's Where There is No Doctor, which became a kind of textbook for health workers the world over, and Ashtekar acknowledges Werner's influence in his own work. Health and Healing has evidently taken the concept further. Among the important additions are the ayurvedic and homoeopathic perspectives in each section.

Why do we need this book? Elsewhere, Ashtekar points out that more than 50 years after independence, 70 per cent of India's villages still have no access to proper basic health care. Over the years, the government has tried to bridge the gap with community health guides, link workers and auxiliary nurse midwives. But these schemes have not received strong support. There are too few workers, they are not used effectively, and they are poorly paid and given little other support. Further, any effort to provide basic health care will have to contend with competition from trained and untrained private practitioners.

Still, a number of innovative efforts have demonstrated that people from the community can be trained to provide most health services, and to refer people with complicated problems to centres with the appropriate facilities. Such efforts will benefit from a training manual such as Health and Healing. It is designed towards building a training curriculum for community health workers. The long-term goal, Ashtekar writes, is to help "provide accessible primary care at affordable cost, prevent illnesses, promote good health, reduce the burden on hospitals, manage a large number of health problems economically, utilise alternative healing systems like Acupressure, Ayurveda and Homoeopathy, and alter the equations of health care in India." So it builds upon books like Werner's by adding information specific to India.

Indeed, the manual covers the spectrum of health problems, from the common infectious diseases to the cancers and more obscure ailments, from reproductive health to mental health and of course first aid. While it makes reference to more complicated diagnostic and treatment options, the focus is on simplicity, and the use of available options. Hence flow charts for various common symptom complexes help decide the course of action to be taken. A short section on health services and the law raises important questions of the health worker's responsibilities in medico-legal cases. The chapter on 'at-risk groups' looks at the special needs of (and responsibilities to) children, the old, workers and victims of domestic violence. This last group is rarely acknowledged, and Ashtekar should be commended for recognising this need. As for treatment options, there are chapters on modern medicine as well as Ayurveda, Acupressure and Homoeopathy. The modern medicine drugs for primary health care are chosen from the WHO's essential drug list, and a reasonably detailed guide is given on their use.

There is much valuable material contained in Health and Healing. The question is: is the material presented in a manner that can be easily understood by a community health worker? What level of education should that person have in order to use this book well? This is perhaps a question best answered by the future community health workers of India.

InfoChange News & Features, August 2002