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|| APPENDIX (CH-29)
Health is fundamental to national progress in any sphere. In terms of resources for economic development, nothing can be considered of higher importance than the health of the people which is a measure of their energy and capacity as well as of the potential of man-hours for productive work in relation to the total number of persons maintained by the nation. For the efficiency of industry- and of agriculture, the health of the worker is an essential consideration.
2. Health is a positive state of well being in which the harmonious development of physical and mental capacities of the individual lead to the enjoyment of a rich and full life. It is not a negative state of mere absence of disease. Health further implies complete adjustment of the individual to his total environment, physical and social. Health involves primarily the application of medical science for the benefit of the individual and of society. But many other factors, social, economic and educational have an intimate bearing on the .health of the community. Health is thus a vital part of a concurrent and integrated programme of development of all aspects of community life.
State of Public Health
3. Statistics of positive health are difficult to obtain. Information in regard to morbidity is available only to a limited extent. We have, therefore, to rely mainly on mortality statistics in assessing the state of public health. Compared with other countries, the expectation of life at birth in India is low as the following statement would indicate:
* Estimeted on insufficient data.
Statistics relating to the expectation of life indicate a low level of health in the country because they express in terms of the average length of life the cumulative effect of the specific mortality rates at different ages in respect of the two sexes. The level of health as indicated by the death rate and the infantile .mortality rate is low. The specially vulnerable groups in any community are children and women at the reproductive age groups and old people. Nearly 40 per cent of the total deaths are among children under 10 years of age and of the mortality in this age group half takes place within the first year of life. The percentage for England and Wales in every age group is very much smaller.
Deaths at specific age periods shown as percentage of total deaths at all ages :
Maternal mortality is estimated to be 20 per thousand live-births which is a very high figure. About 2 lakhs maternal deaths occur annually. The morbidity resulting from causes associated with child bearing would run to about 20 times this figure or 4 millions. The average annual number of deaths in India during 1940-49 from epidemic diseases and certain groups of causes is shown below:
Epidemic diseases together account for 5 .1 per cent of the total mortality. India continues to be the largest reservoir of these epidemic diseases. More than half the deaths are recorded under fevers by the reporting agency which has no means of proper diagnosis of the cause of death. Respiratory diseases are numerically the next important group. There is a large prevalence of bowel disorders and parasitic infections. It is estimated that 100 million people suffer from malaria and the annual mortality is estimated at about I million. It is similarly estimated that about 2 -5 million active cases of tuberculosis exist and about 500,000 deaths take place every year. The present low state of public health is reflected in the wide prevalence of disease and the high rate of mortality "in the community as a whole and in particular among vulnerable groups such as children and women in their reproductive age period. A large part of this represents preventable mortality.
4. The output of the industrial worker in India is low compared with that of the worker in other counries. The productive capacity of the agricultural worker is comparatively low. The loss caused by morbidity in working time is enormous. To this must be added the expenditure to the individual and to the State in the provision of medical care.
CAUSES OF LOW STATE OF HEALTH
5. The causes of this low state of health are many. The lack of hygienic environment Conducive to healthful living, low resistance which is primarily due to lack of adequate diet and poor nutrition, lack of proper housing, safe water supply, proper removal of human wastes and the lack of medical care, curative and preventive, are some of the more important factors, besides lack of general and healch^education and low economic status. There are serious impediments to rapid progress. The country's financial resources are limited, trained personnel are lacking and the whole programme of health development is bound up with a broader programme of social improvement.
6. One of the serious difficulties to be overcome is the shortage ot personnel. This is clearly brought out in the following table :
The Proportion of Medical Personnel to Population***
75 per cent. of doctors are in urban areas and their distribution in rural
areas is very sparse.
Increased training facilities for all these types of personnel are a matter of vital importance. In many areas the use of sub-professional auxiliary personnel is clearly indicated as an approach to a solution of the problem. It is of the greatest importance that the work of sub-professional personnel should be guided and supervised by qualified persons.
7. "Curative medicine of an effective scientific type must rest on good hospital facilities as its basis and preventive medicine must depend in a large measure on out-patient services for the ambulant case and on centres for health promotion through individual instruction in the principles of personal hygiene." * The number of medical institutions at present available is far too small to provide a reasonable standard of medical service to the people, particularly in the rural areas. While there is a considerable disparity between the States in the ratio of institutions to population in respect of both urban and rural areas, the average for the country is one institution for 24,000 urban population and one for 50,000 rural population in 1949.
The ratio of bed accommodation available in these institutions is one bed for 3,135 of the population or 0-32 bed per thousand in 1949. "More hospital facilities are needed but the hospital services which do exist need to be developed in the most economical manner (consonant with high standards), intra-mural care needs to be correlated with clinical and home care, effective integration with the public health programme as a whole must he secured and hospitals must become health centres in the full sense of the term"*.
8. In the circumstances, a programme with the following priorities may form the basis of the plan:
ORGANISATION AND ADMINISTRATION
9. The pattern of development has been suggested by the Health Survey and Development Committee. It is to consist of peripheral primary health units catering to both preventive and curative care of the people with secondary health units-and district units providing better and more complete facilities and supervision. The development of the primary and secondary health units is of the greatest importance in providing broad-based health services to the community. Such centres are proposed in connection with the community development projects contemplated under the T.C.A. programme. They provide water supply and sanitary improvements, personal health services, particularly for mothers and children and health education to the public so that they may participate in the programme of development. A progressive spread of these institutions son a countrywide scale in a given number of years would go a long way in meeting the health needs of our rural population. In addition, it is necessary to convert some of the existing dispensaries into primary health units by the addition of necessary bed accommodation and preventive health staff. A definite number of such dispensaries may be converted each year according to a well-laid programme. Mobile dispensaries will have to be associated with these rurr.1 health units in order to take medical care to the population. The mobile dispensaries can also be utilised for carrying specialist services to the rural population.
10. Though health is largely the responsibility of the States, the Central Government are responsible, among other subjects, for higher education and research. The Central Government have also the overall function of the development of health services in the country as a whole. In order to develop the closest co-operation between the Centre and the States a Central Health Council has been constituted with the Central Minister of Health as chairman and the Ministers of Health of the States as members. Measures have to be devised to meet the needs of certain States for trained and experienced personnel for teaching, research and administration. There is an insistent demand for ensuring adequate health services for the vast rural population of the country.
MEDICAL AND PUBLIC HEALTH PROGRAMMES
11. The provision for the medical and public health plans of the Central and State Governments amounts to Rs.99-55 crores of which the Centre's share is about Rs. 17-87 crores. Medical and public health measures being primarily States' subjects, the Central Government have limited their activities to higher education and research and aiding the State Governments in specific schemes such as control of malaria on a national scale. The following table gives the distribution of expenditure on medical and public health schemes in the plan:
The total amount of Rs. 99 -55 crores shown above is not all that will be spent for medical and public health measures in the country. Local authorities in all the States are executing medical and.public health programmes. International agencies like the W.H.O. and the .U.N.I.C.E.F. are taking part in the development of medical and public health schemes in various parts of the country.
The total expenditure of the Central Government during 1950-51 was nearly Rs. i crore of which Rs. 7 -5 lakhs has been reckoned as development expenditure. Though a number of schemes have been formulated in the past only very few of them and that too on a very modest scale could be taken up by the Central Government. This development expenditure ofRs. 7-5 lakhs is expected to be increased to an annual average ofRs, 3 '57 crores during the next five years. The bulk of the plan is accounted for by (l) the All India Medical Institute, a central institution for higher research and post-graduate studies, estimated to cost Rs. 3 -59 crores and (2) the National Malaria Scheme estimated to cost Rs. 10 crores. Though the malaria scheme is a Central scheme the beneficiaries will be the States.
In the medical plans of the States, Rs. 35-69 crores will be on Revenue account and Rs. 6 -72 crores on Capital account. Of the amount of Rs. 42 -41 crores to be spent on medical schemes, Rs. 33 crores will be on schemes in progress. But in the public health programme of the total expenditure ofRs. 39 -23 crores Rs. 17 crores will be on schemes in progress, the balance on new schemes. This is mainly because a number of new items of water supply and drainage works is being undertaken in various States under the plan.
12. The following table gives the proportion of the increase contemplated under the plan on medical and public health expenditure in the States over that in 1950-51.
The proportion of increase for both medical and puclic health for Part `A' States appears comparatively low because the level of development expenditure in 1950-51 had already increased very considerably in the period 1946-47 to 1950-51 on account of the undertaking of post-war reconstruction schemes.Perhaps the small proportion for medicalll schemes in the case of Part `B' States is also attributable to the level of already attained in 1950-51 on account of the operation of the post-war reconstruction plans in States like Hyderabad, Mysore, Travancore and Cochin, Gwalior and Jaipur. The proportion appears phenomenal in the case of Part `C' States because such services on a large scale are almost new filds of effort.
The comparatively larger proportion of increase contemplated under public health measures in all the States over that for medical programmes indicates the greater importance attached to public health measures by the State authorities. This shift in emphasis is in the right direction.
13. The following table indicates the expenditure on various categories of medical schemes undertaken by both the Central and State Governments (excluding Jammu and Kashmir State) as compared with the position obtaining in 1950-51 :
(Rupees in lakhs)
Out of the total expenditure contemplated, more than 50 per cent will be on hospitals and dispensaries and nearly 40 per cent of the total provision will be for medical education and training. It will be seen from the table above that the proportion of the distribution of the total expenditure under the Plan amongst the various categories of schemes will be almost the same as that obtaining in 1950-51 as a majority of the schemes in the States'sector continues from 1950-51 onwards.
Schemes for medical education and training relate, in addition to the Central All-India Medical Institute, to the completion of the new medical colleges in Assam, at Poona, Ahmedabad and Baroda in Bombay, at Guntur and Madura in Madras, in Madhya Pradesh, West Bengal and Travancore-Cochin, expansion of existing medical schools and colleges and provision of training for auxiliary medical personnel like nurses, midwives, compounders, etc. The execution of the schemes is expected to increase the total number of personnel trained annually in the country during the period 1951-52 to 1955-56, as follows :
Schemes regarding hospitals and dispensaries relate to the construction of a few new hospitals and dispensaries, expansion of existing ones with increase in the number of beds, provincialisation of hospitals and dispensaries hitherto under non-government agencies and provision of mobile dispensaries: for rural areas. The increase in the number of hospitals and dispensaries and the number of beds in them is anticipated to be as follows :
Other schemes under the head relate to the opening of a number of T.B. clinics and sanatoria in almost all the States, opening of leprosy clinics and hospitals in a majority of States where the disease is prevalent and provision for the prevention and treatment of venereal diseases
14. The following' table gives the expenditure on different categories of public health schemes undertaken by the Central and State Governments (excluding Jammu and Kashmir) as compared with such expenditure in 1950-51 :
(Rupees in lakhs)
It will be seen that water supply and drainage and anti-malaria schemes account for the bulk of the expenditure. The development expenditure in 1950-51 will increase by nearly four times every year in the plan period. The rate of annual expenditure on water supply and drainage will increase by more than 70 per cent and the rate of expenditure on anti-malaria operations will be increased by more than 750 per cent.
Under public health education, provision has been made in certain States for training of medical graduates in public health, training of .health, visitors, sanitary inspectors, etc. The number of sanitary inspectors trained annually is expected to increase from 346 in 1950-51 to 450 by the end of 1955-56.
Water supply and drainage works under the public health plan comprise mostly measures for improving drinking water supply, the provision for urban and rural areas being Rs. 12.12 and Rs. 11-37 crores respectively. Madras and Bombay account for a major share of the programme.
operations comprise expansion of the Central- Malaria Institute, large-scale
spraying of D. D. T. and distribution of anti-malaria drugs by tfce State
Governments. The State Governments' activities would be augmented by large
Other schemes under the head relate to the establishment of primary health centres in some of the States, establishment of maternity and child welfare centres, the most important being the Central Government's scheme for child health care at Calcutta, and provision for nutrition research in certain States like Madras, Bombay, Uttar Pradesh and Assam. The Central Government are providing for a number of mobile health units in the rural areas of several Part *C' States.
15. The provision of an environment conducive to healthful Iiving is an essential requirement for the maintenance of public health. In countries where water supplies and waste disposal have been attended to cholera, typhoid fever and dysentery have almost disappeared and are cases occur due to personal contactor food handling by healthy carriers. These measures have also their effect on the infant mortality rate and the intestinal parasitic infection rate. In India these problems largely remain to be solved.
16. The provision of a safe and adequate water supply is a basic requirement and should receive the highest priority. Though the provision of protected water supplies was started in India about the same time as in England and U.S.A., the progress made has been little. Only 6 per cent of the total number of towns in India have protected water supplies which serve 6'15 per cent of the total population or 48.5 per cent of the urban population. The position of the water supplies has deteriorated considerably in fte larger towns. In the rural areas and small urban areas, the water supply continues to be unsatisfactory. The Environmental Hygiene Committee \ roposed a Five-Year Plan based on certain priorities like water scarcity, cholera endemicity, pilgrim centres, intensive development projects, etc. The scheme as suggested by the Committee would cost about Rs. 16.77 crores per annum.
17. The introduction of protected water supply alone will not be sufficient for achieving healthful living. It is also essential to adopt measures for the hygienic collection and disposal of community wastes. Only 23 cities out of 48 having a poFufeflBon of over I lakh have sewerage systems. There are 12 other towns which are partially sewered. About 3 per cent of the total population is now served by sewerage systems. A five-year programme has been suggested by the Environmental Hygiene Committee. The total outlay required for this programme may be about Rs. 15 crores in five years.
18. While it has not been possible to make a provision on this scale in the plan, it would be seen that a substantial effort is being made by the States. Among Part 'A' States Bombay, Madras, West Bengal and Bihar, among Part 'B' States Rajasthan, Madhya Bharat, Mysore and Travancore-Cochin and among Part 'C' States Bhopal, Vindhya Pradesh, Himachal Pradesh and Manipur have devoted considerable sums for water suppply and drainage improvements. The five-year programme of water supply and drainage works of the States provides Rs. 23-49 crores.
Out of the total provision, Rs. 12-12 crores is for urban water supply and drainage and Rs. n -37 crores for rural water supply. States have, as in the case of Madras, set up Commissions to determine priorities of water supply and drainage schemes over a long term and have made their five-year plans to fit in with such programmes. Governments help the local authorities to take up the schemes in the order of priority giving grants-in-aid and loans.
19. In rural areas. States aim at providing simple types of safe water supply for almost ail villages within a certain period. In Madras, for example, a special fund with an initial contribution of Rs. one crore for the development of rural water supply has been constituted. The fund is supplemented by a grant of Rs. 15 lakhs annually. In the Five Year Plan of the Central Government there is a provision of Rs. 30.00 crores for local development loans for assisting local authorities. About Rs. 10-0 crores out of this may be assumed to be available for water supplies. Contribution by the people by way of voluntary labour or money will enable the provision to go a long way in the improvement of water supplies.
20. Just as in the case of rural water supplies, rural sanitation requires a special emphasis. Hardly 5 per cent of the houses have latrines. Simple types of latrines which require no special servicing have been found suitable. The State Governments can offer technical service and some inducement like supply of water-seal squatting slabs on a subsidised basis. The aim is to provide latrines in each house and only an absolute minimum in the way of public sanitary conveniences. The education of the individual in sanitary habits is deemed far more important.
21. A large part of the investment in water supplies and sewage systems will go towards the provision of pipes and the stepping up of production of materials required is one of the important considerations to be kept in mind.
22. For the implementation of the programme, it is essential to organise public health engineering services on a strong and sound basis in order to design, execute and r'caintam water supply and drainage works. All part 'A' States except Assam have a public health engineering organisation. Most of the part 'B' States also have a public health engineering set up, while part 'C' States have none. The services of a public health engineering consultant have been obtained from the United States of America for a period of one year by the Central Government.
23. Nutrition is perhaps the most important single factor in the maintenance of health and resistance to disease. The state of nutrition has a direct bearing on the productive capacity of an individual. Several studies carried out in different parts of the world give a direct correlation between calorie consumption and accomplishment of workers. There is reason to believe that both under-nutrition and malnutrition exist widely in the country.
24. The availability of cereals in 1950 was about 13-71 oz. per adult per day taking into account the internal production, imports and offtake from carry-over of stocks. The availability of gram and pulses was about 2-1 oz. per adult per day. Thus the availability of cereals as well as pulses was below the nutritional standards of 14 oz. and 3 oz. respectively. The plan aims at the production of 7 -6 million tons offoodgrains with a view to make internal production self-sufficient in 1955-56. A satisfactory diet should include, in addition to food-grains, adequate quantities of other foods such as milk, vegetables, fruits, meat, fish and eggs. The quantity of milk available has been estimated at about 5 -5 oz. per adult per day, a quantity much below that necessary for adequate nutrition. The availability of fruits is about 1-5 oz. per day per adult, and vegetables about 1-3 oz. per adult per day, while the requirement is 3 oz. and 10 oz. respectively. They are very short of the requirement. Sugar at the rate of 1-6 oz. per adult per day is available while about 2 oz. is required. To raise consumption to the nutritional standard additional quantity required in 1955-56 is estimated at 2-2 million tons., about 0-7 million tons of which would be made up in the plan period. The availability of vegetable oil and ghee is of the order of not more than i oz. while 2 oz. is the actual requirement. As regards fish, roughly 0-3 oz. is available per adult per day whereas the requirement is 3 oz. The production of eggs, meat and fish is grossly inadequate and it is common knowledge that the intake of these foods by the majority of the population in most parts of the country is small or negligible. The existing food production data show clearly that the total food supply is-insufficient in quantity and that the diet of the population as a whole is defective in quality since the protective foods which are needed to supplement the staple cereal grains are not produced in adequate amounts.
25. The results of diet surveys in India from 1935 to 1948 have been recently published. The conclusions reached are : "The Average diet of an Indian is lopsided primarily because of its extremely high cereal content. The other noticeable feature is that the diet lacks in adequate amounts of protective foods leading to inadequacy and very often to total lack of proteins of good quality. Inadequacy of minerals and most of the important vitamins in more or less varying degrees is the other important feature. It has not been sufficiently realised ihat the inadequacy of B group of vitamins is of the most serious import in view of the large intake of carbohydrates. Intake of vitamins A and C also is often inadequate". These surveys have led to the following observations: "It appears that two-thirds of the families did not consume-any fruits and nuts at all. About one-third of the families did not consume sugar and jaggery t meat, fish or flesh foods, and a quarter of the family groups did not consume milk and milk products or leafy vegetables. Again, amongst the groups»of families consuming particular foodstuffs the intake of leafy vegetables, other vegetables, ghee and vegetable oil and pulses was below the desired or recommended level. Only in about one-fifth of the groups of families surveyed was the intake of pulses and other vegetables up to the recommended level. Though any generalisation on the data presented is not desirable for reasons more than one, yet it may be stated that in about four-fifths of the families surveyed the intake of protective foods was either nil or below standard".
26. The bulk of the population cannot afford to purchase a satisfactory diet. In terms of average income it would hardly be possible for more than 30 per cent of the population to feed themselves on an adequate scale.
27. A joint committee of the Indian Councils of Medical and Agricultural Research have suggested an integrated plan of human and animal nutrition in relation to agricultural production. They indicated the target requirements in 1956 as in the following table:
Target Requirement for 300 Million Adult Units
They took into account the food requirements ofihc animal population for the production of milk, meat, for work animals; for the follower stock and for maintenance. Large gaps were found between the requirements and the available supplies. As it was found that the deficiencies could not be made up, a modified plan has been suggested on the basis of utilising maximum potentialities of cultivable acreage, scientific methods of increased crop production and a modified target of human requirements. The modifications in the daily requirements suggested are :
28. There is no doubt that malnutrition occupies a very prominent position in the causation of high infantile, maternal and general mortality rates in India. Specific food deficiency diseases are m themselves a serious public health problem. In addition to well-recognised deficiency diseases, there are numerous other diseases in the causation of which nutritional factors are concerned. The general effect of malnutrition in lowering resistance to microbic and parasitic diseases must also be emphasised. Numerous investigations among school children in India have shown that a large percentage of children are in a poor state of nutrition with consequent impairment of physical and mental growth. Again in the adult population the ill effects of malnutrition are widely evident in the shape of low level of general health and reduced capacity for work. On the other hand, the striking improvement in the condition of Army recruits which takes place after a few months of abundant and satisfactory feeding is highly significant.
29. The creation of a nutritional section in the State public health departments is an essential first step in organising work. The prevention of deficiency diseases is an important responsibility of public health nutrition sections. It is the responsibility of public health departments to supervise through their maternity and child welfare services, feeding of mothers and infants. The development on a wide scale of school feeding schemes is strongly recommended. In all institutions where large-scale catering is done, the appointment f dietitians would be an important step. The education of specialised nutrition workers, workers, in food trades and of the general public is very important.
The bulk of the provision under this head is from Bombay and Madras. The provision by the States is Rs. 11-9 lakhs.
30. The development and manufacture of synthetic vitamins in India is recommended. Similarly, improvements in the shark liver oil industry should be taken on hand and the possibility of manufacturing carotine preparations of high vitamin A activity from cheap and abundant vegetable resources should be investigated. The possibility of developing the production of food yeast is under examination. The processing of milk and fruits is of course of particular importance.
31. The widespread malpractices which affect the purity of food articles available in the market are an aspect of the food problem which should be attended to with vigour and a sense of urgency. The noxious substances which are often used as adulterants are doing insidious harm to the health of the people and the evil appears to be growing. This must be tackled on the footing of a principal priority both by the administration armed with adequate powers and the organised force of public opinion and social action. The Central Government have introduced a bill on the subject in the Parliament.
32. Malaria is the most important public health problem in India and its control should therefore, 'be assigned topmost priority in any national planning. It has been estimated that about a million deaths are caused in India every year by malaria among the 100 million people who suffer from this disease. The economic loss is estimated at several hundred crores of rupees every year. Vast fertile areas remain fallow and natural resources remain unexploited largely due to the ravages of malaria. Aggregation of labour in irrigation, hydro-electric and industrial projects is attended with severe outbreaks of malaria if special steps are not taken for its control.
33. The use of D.D.T. as a residual insecticide has brought about far-reaching changes in the technique of the control of malaria and 't has been successfully controlled with dividends several times the expenditure involved. The various Central and State projects and the Demonstration Projects of the W. H. 0. and the U.N.I.C.E.F. have tackled only a fraction of the countrywide problem. It has not been possible to extend protection to the entire population in malarious areas due to lack of adequate finance, staff, equipment and supplies. So far only about 30 million out of the 200 million population exposed to malaria have benefited by the existing malaria control schemes. A comprehensive project for the nationwide control of malaria is now put forward.
34. The full malaria plan envisages a continuing programme consisting of co-ordination of all malaria control activities into the malaria control programme under the overall administration of the Central Government, strengthening of the existing malaria control programmes in the several States and establishment of malaria control programmes in the remaining States, providing malaria engineering consultation and other services to appropriate Central or State authorities concerned with development of irrigation, hydro-electric and other projects, extending training facilities and expanding the staff and facilities of the Malaria Institute of India to provide overall consultation and assistance to the States. The operational programme is based on the use of insecticidal residual spraying measures applied in rural areas protecting 200 million people and treatment with anti-malaria drugs. These operations are to be carried out by 125 field malaria control teams organised and directed by the State Directorates of health services. The plan includes the construction of a D.D.T. plant to supplement the one already programmed by the Government of India with the W.H.O. and the U.N.I.C.E.F. assistance, in order to ensure sufficient supply of D.D.T. at reduced costs to meet the needs of the country. Financing of the project is to be the joint responsibility of the Central and State Governments. The amount of money spent annually by the State Governments on malaria control is approximately Rs. i -41 crores. There is a vast disparity from State to State in the provision of funds for the control of this disease. The total provision made in the five year plan by the States is Rs. 7 -04 crores. Madras, Bombay, Uttar Pradesh, Bengal and Mysore account for the bulk of the expenditure. The plan now proposed for nationwide malaria control would involve a commitment of Rs. 15 crores over a period of 3^ years. This would be followed by a maintenance programme the cost of which would be on a much lower level. The local expenditure by States for the period would amount roughly to Rs. 5.00 crores but the scheme involves an expenditure of Rs. 10 -oo crores from the Central Government including aid from T.C.A. It is expected that with the supply of D.D.T. and equipment during the programme period, the States would be in a position steadily to expand their anti-malaria activities and would be further able to supplement the expenditure from the increased resources which the immense improvements in the economy of the country would provide, as a result of the introduction of the nationwide malaria control programme.
35. The disease is widely prevalent in India particularly in some of the coastal regions, with high humidity and moderately heavy rainfall. It also occurs, with a patchy distribution, in the moist and humid Gangetic valley and Bengal Basin, in the foothills of the eastern districts of Uttar Pradesh and Bihar, as also in parts of the Deccan plateau and Southern India. It is difficult to state the number of cases of Filarial infection in India, but it has been estimated that there are about 157 million cases in Asia, of which the quota for India may run into many millions. The predominant type of infection is caused by W. bancrofti. Less commonly, the infection is caused by W. malayi. In the case of the latter infection, the larvae of the Vector mosquito breed in association with aquatic plants and therefore the control measures would diner from those called for in the case of the other infections. In the case of W. bancrofti infections, the long-term control measure is the provision of efficient drainage. As a short-term measure D.D.T. spraying is indicated. The measures, therefore, can be carried out by the_same organisation which is meant to tackle the malaria problem on a nationwide scale :
36. Tuberculosis is a major public health problem next in importance only to malaria. While accurate data are not available, it is estimated that about 5,00,000 deaths occur even7 year and about 2^ million people suffer from active disease. It is estimated that about 900 to 1000 million man-days are lost. The economic loss is therefore incalculable. Besides, it causes a mass of human misery. Measures needed to combat tuberculosis may be classified as general and special. Measures directed towards the improvement of the standard of living come under general measures. These include improvement of nutrition, housing, sanitationeach involving very large-scale commitments. Under the special measures may be mentioned the provision of isolation and treatment of the sufferer and introduction of preventive measures. It is an extremely difficult problem to provide either the institutions or the staff needed on the standards obtaining in other countries. A minimum programme in the order of priorities would be :
37. Emphasis has to be laid on preventive measures as these will yield the best return for the limited resources now available. Carefully tested experience in many countries over a period of 20 years shows that B.C.G. vaccination is an effective and safe preventive measure. The States should make this programme a part of their public health services. The Government of India have entered into an agreement with the U.N.I.C.E.F. and the W.H.O. to carry out a countrywide B.C.G. programme. It is estimated that if a mass B.C.G. campaign is worked out on the lines indicated it would be possible in a period of about 15 to 20 years to reduce the mortality from tuberculosis to a fifth of its present level and the bed accommodation necessary for the isolation of cases could similarly be cut down to about a fifth of the total requirements. For the expenditure involved therefore, B.C.G. vaccination would give a very hig i return and considerable saving in the other control measures.
38. Among the institutions, we accord the highest priority to the clinics. The dinics will have to undertake preventive, diagnostic and curative functions. The clinics must have some beds at their disposal and also an adequate staff of doctors and health visitors to provide domiciliary services. Although it would be advisable to have one clinic for 1,00,000 of the population the effort in the next five years may be directed to the establishment of the clinics as special departments of teaching hospitals, district hospitals and other general hospitals, where X-ray and laboratory facilities pyist.
39. The establishment of a certain number of model tuberculosis centres which will serve the purpose of teaching and demonstration is regarded as important because of the shortage of personnel for manning tuberculosis services. Each centre should consist of a clinic with attached beds and the clinic should provide fully comprehensive laboratory services and facilities for epidemiological investigation by mass radiography etc. in co-operation with X-ray departments. It is advisable to locate these centres in association with medical college hospitals. Three such centres are being established with international aid in Delhi, Trivandrum .nd Patna It is suggested that similar centres may be established in Calcutta, Bombay, Madras, Punjab, Uttar Pradesh, Madhya Pradesh, Hyderabad, Mysore Madhya Bharat, etc.
40. The bed accommodation sliould be in ^h: form of simply designed and cheaply constructed institutions. Priority of admissio. should be given to those for whom domiciliary isolation or treatment is impossible. Non-official organisations should be encouraged to establish and run tuberculosis institutions and Governments should give them building and maintenance grants provided these institutions are run on non-profit basis.
41. Voluntary organisations should be stimulated to set up, with State aid, after-care colonies at suitable places in association with tuberculosis institutions.
42. For the proper development of tuberculosis control programmes, a special T.B. Adviser should be employed in each State.
43. It is estimated that a reasonable programme on the lines set out above would cost about Rs. 8.00 crores. Available resources limit the scope of the programme. However, the Centre and the States have made substantial provision -and 'have shown considerable progress in their schemes. West Bengal has the highest provision followed by Bihar, Madhya Pradesh and Bombay. Among Part ' B' States Saurashtra has the highest provision and Mysore and Hyderabad come next. Among the Part ' C' States Delhi has a considerable
T.B. programme. The schemes, generally are concerned with the provision of sanatoria, hospitals and clinics, increase in the bed-strength and B.C.G. vaccination teams. Compared with 1950-51, the plan envisages an approximate increase by 1955-56, as shown in the following table :
The number of B.C.G. Teams is expected to increase from 73 in 1950-51 to 137 in 1955-56. The States' schemes would cost Rs. 3-80 crores and the central schemes Rs. 51-43 lakhs.
44. The incidence of venereal diseases in India is unknown, though a rough survey made some years ago indicated a high incidence. Sufficient data now exist to suggest that in the large cities of India, particularly Bombay, Calcutta and Madras, venereal disease prevalence is high reaching 5 to 7 per cent of the population for syphilis alone. The problem in rural areas is not defined but the hill tracts extending from Kashmir to Assam (especially Kashmir, Kulu, Himachal Pradesh and Assam) appear to have an alarmingly high prevalence of syphilis. The importance of venereal disease from the point of view of producing sickness and incapacitation cannot be overemphasised. The measures for the control of these diseases are :(i) the provision of medical carepreventive and curative, and (2) social measures to discourage promiscuity and to control prostitution. The measures would include free and efficient treatment case finding and follow-up services, adequate diagnostic facilities, education and training of personnel and lastly th-' education of the people in regard to the spread and control of these diseases.
45. The creation of the post of a Provincial V.D. Control Officer with suitable assistance on the establishment of each Director of Health Services is necessary to plan the campaign against these diseases as part of the health administration. West Bengal and Himachal Pradesh have a full time V.D. Control Officer on the staff of the Directorate of Health Services. In Madras, the State Government have nominated the Lecturer in Venereology, General Hospital as consultant with the right of inspection of existing facilities in the State.
46. V.D. clinics with requisite staff should form part of the general health facilities provided in a district hospital. For the purpose of case finding and follow-up, it is essential To employ nurses, health visitors and social workers in connection with the V.D. clinics. For the period of the plan, it is proposed that each State should provide such clinics in the district hospitals. For the treatment of patients necessary provision should be made for the purchase of anti-biotics in adequate quantity. The importation of penicillin in bulk and the projected penicillin plant are intended to answer this purpose.
47. Diagnostic facilities should be provided in the public health laboratories at the State headquarters, and in the regional and district laboratories. Such facilities should be made available free of charge not only to institutions but to all private practitioners. It is considered necessary to set up an advisory body to assist in ensuring comparable serological performance in the main laboratories of the country. The Indian Council of Medical Research may serve this function. It is also essential to provide standard antigen to State institutions as well as to private laboratories to maintain a high standard of technical performance. The Government of India have sanctioned an antigen production unit in collaboration with the W.H.O. and the U.N.I.C.E.F. The cost of the project is Rs. 72,000 for the production unit and Rs. 28,000 for the staff or a total of about Rs. I lakh.
48. The proposed extension of treatments facilities will be possible only when a sufficient number of doctors and other personnel have the necessary special training for the purpose. Such training should also be made available to private practitioners. These facilities may be organised as follows :
(1) Training facilities in venereal diseases will be available in.the upgraded V.D. department. General hospital, Madras. The Government of India have concluded an agreement with the W.H.O. for the upgrading of the V.D. Department of the Madras Medical College.
(2) Improvement in existing facilities may be considered at the following places where teaching and training activities are undertaken :
These training centres will train V.D. control officers who will take charge ofthe'State V.D. programmes.
49. Education including sex education and provisions, legal and institutional, for the control of immoral traffic are important measures.
50. The V.D. schemes of the States and the Centre included in the Five Year Plan would cost Rs. 1-03 crores and Rs. 5'79 lakhs respectively. West Bengal is practically the only State with a comprehensive V.D. control scheme costing Rs. 84.30 lakhs.
51. Yaws is a non-venereal disease closely related to syphilis and amenable to the same treatment. It is known that Yaws is fairly widely prevalent in certain tracts of India, particularly among the tribal population in Madhya Pradesh, Madras, Hyderabad and Orissa States. A plan of operation has been agreed to by the State Governments and is awaiting the approval of the Government of India and the signing of an agreement with the W.H.O.
52. It is estimated that the number of cases of leprosy in the country is probably at least one million. About one-fourth of a million may be lepromatous cases The highly endemic areas of leprosy in India are certain parts of West Bengal, Orissa and of Madras and Travancore-Cochin. There is moderate incidence of the disease in the Himalayan foothills and Central India. The incidence of leprosy is remarkably small in the rest of the country. In highly endemic areas the incidence may range from 2 to 5 per cent of the population.
53. The existing anti-leprosy work is being carried out largely by voluntary organisations. The mission to lepers is the largest agency engaged in anti-leprosy work. Lately, State Governments and even local authorities have started the establishment of in-patient accommodation for leprosy. The total accommodation available is about 14,000 beds for the whole country. The Hind Kusht Niwaran Sangh. has actively helped in carrying out anti-leprosy work. The Gandhi Memorial Trust has established a Leprosy Committee and taken up work in earnest. They have set apart a sum of Rs. 95 lakhs for combating the disease.
54. As a first step, it is necessary to carry out investigation of leprosy as a public health problem in local areas. Secondly, in those areas in which the prevalence of the disease is shown to be high, curative and preventive measures have to be organised and thirdly, there should be stimulation of voluntary effort and education of the public to secure their cooperation. To promote these objectives, special training at the under-graduate and postgraduate stages of medical education and facilities for leprosy research will have to be. provided. The creation of a Central Leprosy Institute for post-graduate training and research has been included in the plan. It is essential that, as a preliminary step towards organising anti-leprosy work on sound lines, a leprosy organisation should be created at the headquarters of each State in which the disease is a definite public health problem. Provision for the isolation and treatment of all infectious cases is not possible with our present resources and efforts should be directed towards the provision of reasonable bed accommodation in institutions in heavily endemic areas for leprosy. Such accommodation is needed for the treatment of infective patients and for the remedial treatment of crippling and deformities. In considering any additional accommodation the recent advances in the treatment of leprosy have to be taken into consideration. The introduction of sulphone drugs in the treatment of leprosy marks a distinct advance. It is possible with this treatment to have a comparatively quicker turnover and to continue treatment in the out-patient departments. We have to depend for the solution of the problem mostly on the organisation of clinics, from which treatment and preventive care of leprosy patients and their contacts has to be carried out. Children are much more susceptible to leprosy than others and every effort should be made during home visits by the doctors and others to impress this fact on the people and to secure that children are safeguarded. The clinics should bs established in hospitals in areas in which the incidence of the disease is high. Attempts at group isolation of the rural colony type by voluntary efforts may be encouraged and voluntary efforts should be supported by definite provision of grants-in-aid. The schemes of the States and the Centre would cost Rs.ro2 crores. West Bengal, Bombay, Aladhya Pradesh and Bihar among Part 'A' States, Hyderabad and Mysore among Part ' B ' States, Vindhya Pradesh and North-east Frontier Agencies among part 'C' States account for the bulk of the provision. The provision of Rs. 15 lakhs by the Centre relates to the Central Leprosy Institute.
55. The incidence of malignant disease is much the same in India as in Western Europe and North America. The annual death rate from cancer in most countries varies from 100 to 150 per 1,00,000 living persons of either sex. 2,00,000 per year is a conservative estimate of cancer deaths in India. The death rate from cancer may probably go up in future with an increase in the proportion of population in older age groups. While the rate of incidence in various countries may show small differences, the incidence in various parts of the body is markedly different in different peoples. There is a greater frequency of oral cancer in Indians. Cancer of exposed portions of the skin is less common than in the fair-skinned people. Cancer of cervix uteri is much less common in certain communities in whom breast cancer is more common.
56. Early diagnosis and prompt treatment based on the knowledge at present at our disposal will definitely result in many cures. The detection of the early stages of the disease can be achieved by education of the public and better cancer education for the general medical profession. For the better understanding of the diseasethe phenomenon of abnormal growthits initiation, etiology, pathology, further development and treatment, persistent research appears to be the only solution. Cancer education and cancer research require considerable organisation and financial as well as moral support from the Government and the public.
57. Cancer education for the lay public may be organised jointly by the Indian Cancer Society, Indian Cancer Research Centre and cancer hospitals in the country. An efficient social service should be established where a group of trained social workers would work under the direction of an experienced research worker from the research centre. Efficient means of spreading knowledge about cancer to the public may be by the use of the radio, the film and the press, and by work in co-operation with existing organisations for social services, women's societies, etc. Under cancer education for the medical profession, better attention should be paid to cancer education of under-graduate medical students ; refresher courses should be given to members of the medical profession of some standing and for well established scientists interested in cancer research. Another step would be to train fresh graduates who like to devote time to training in some phase of cancer work. A few traineeships should be made available for this purpose.
58. Cancer research may be divided broadly into (i) fundamental research in the laboratories, and (11) applied or clinical research in the clinics. Integration of these two activities is very important. Clinical research would include the diagnosis of cancer, the treatment and cure of cancer, and clinical investigation on cancer patients. Fundamental research includes : (a) the biological and biochemical study of cancer cells, and (A) the etiology of cancer. Research on the above lines is in progress at the laboratories of the Indian Cancer Research Centre which is financed by the Central Government. However, tor a proper carrying out of all the items enumerated, the research centre would require further financial help. At present the annual budget of this research centre is only Rs. 1,45,000. No national research institute in India can be expected to advance our knowledge and serve the whole country on a budget so small as that available to the Cancer Research Centre. The annual recurring grant to the Indian Cancer Research Centre would require to be increased by about Rs. i -5 lakhs. The institute would also require a non-recurring grant for purchasing essential apparatus and equipment. This equipment may cost about Rs. 2 lakhs.
59. The different States could play a very important role by organising their activities, in association with their health services. The training of the personnel can be undertaken at the Tata Memorial Hospital with a small subsidy for scholarships to the trainees, partly from the Central and partly from the State Governments. The Tata Memorial Hospital and the Chittaranjan Hospital at Calcutta are the only two special institutions for cancer. The Women's Indian Association at Madras has been making vigorous attempts to start a cancer hospital in Madras and some assistance (Rs. 1,00,000) to them would appear desirable. The All India Cancer Association would also need some assistance (Rs. 50,000) to carry out its publicity work.
60. Although little information is available regarding the incidence of mental ill-health in the country, there is no doubt that mental disorder and mental deficiency are prevalent on a wide scale. The number of persons suffering from varying degrees of mental disorder who may not require hospitalization but should receive treatment and of those suffering from mental deficiency is likely to run into several millions. The existing provision for the medical care of such persons is altogether inadequate and unsatisfactory. Each State health administration, through its mental health organisation, should attempt collection of information. It is estimated that hospital accommodation should be available for 800,000 mental patients but the existing provision is a little over 10,000 beds for the country as a whole. Radical improvements are required in the existing mental hospitals in order to make them conform to modem standards. Provision should also be made for all the methods of diagnosis and treatment. Apart from such remodelling of mental hospitals, the Central Government are upgrading two mental institutions, viz; one in Bangalore and the other at Ranchi. The establishment of an All India Institute of Mental Health in association with the Bangalore Mental Hospital will involve an expenditure during the five year period of Rs. 9-7 lakhs non-recurring and Rs. 3 -4 lakhs recurring. This expenditure is to be shared between the Central Government and the State Government of Mysore. There are hardly any psychiatric clinics. A beginning should be made in special and teaching hospitals and later extended to district hospitals. There are no facilities for training in psychological medicine in the country. It is necessary that a certain number of selected medical men with some experience of work in mental hospitals in India should be sent abroad for training.
61. The provision made by the various States and the Centre for mental hospitals is indicated below :
MATERNITY AND CHILD HEALTH
62. Maternity and Child health is a service that is kept in the forefront in the planning of health programmes. The protection of the health of the expectant mother and her child is of the utmost importance for building a sound and healthy nation. The maternal mortality of India is very high and is estimated at 20 per thousand live births. Maternal morbidity is also very high being nearly 20 times the mortality. The infant mortality rate is of the order of 127 per thousand live births. The corresponding rates in progressive countries are very low and have been achieved by concentrated effort on the improvement of the health of the mother and child.
63. The-lack of trained personnel like women doctors, health visitors, midwives, dais, etc., and of institutional facilities for training them add to the handicaps to provide an efficient service. The growth of maternity and child health work has been mainly through voluntary efforts and Governments and local authorities have taken it up only recently. Maternal and child health services should form an integral part of the general health services. Many of the States have developed the service in varying degrees, Madras, Uttar Pradesh, Bombay and West Bengal, leading. It is essential to have on the staff of each Director of Health Services a specially trained woman medical officer. At present it is understood that only 9 States have got such organisation at the headquarters of the States. In a very few States, women doctors are employed in both urban and ' rural areas. The pattern of organisation for urban and rural areas may be considered separately.
64. While it is desirable to develop community centres which can cater to the needs of all members of a family and the whole community, such a development may not be possible except gradually. We have, therefore, to develop the ordinary type of maternity and child health centres. An adequate number of such centres properly equipped and staffed should be provided in all the urban health organisations. One centre with a minimum staff of one health visitor, 2 midwives, a peon and a part-time sweeper to serve a population of 10,000 is recommended. In addition, there should be a woman doctor preferably with post-graduate training in maternity and child health to be in charge of these centres. There is ordinarily overcrowding in practically all the maternity hospitals and the number of maternity .beds should be increased to double its present strength in order to'accommodate more delivery cases and to give post-natal care for a longer period, 10 per cent of the maternity beds should be reserved for ante-natal cases. It is also essential to reserve for children at least loper cent of the beds where there is no separate children's hospital with adequate number of beds. Ante-natal and post-natal clinics should form an essential feature of all hospitals with maternity beds. Provision should be made for day nurseries to look after infants and children of working mothers with the help of voluntary organisations or under the provisions of the Indian Factories Act. Private nursing homes established by doctors should be licensed.
65. In rural areas the present trend is to provide integrated curative and preventive health services and to organise them on the basis of health centres of different grades. There should be a unit for 10,000 to 12,000 population for efficient service. This will yield a total of 300 to 400 births a year. The maternity and child health staff in such a centre should be two midwives. A number of such primary centres would come under a higher unit for the Thana or Taluka. Here the staff for maternity and child health work should be a woman doctor and 2 health visitors. Their main functions would be training of dais, supervision of midwives and dais, care of maternity cases needing hospitalisation and conducting the clinics in the different peripheral units. One of the important activities of health units in intensive development areas like the community projects is the provision of adequate maternity and child health services, both in the primary centres and at the headquarters of the project areas in the secondary centres.
66. All doctors engaged in maternity and child health work should have training in this branch of preventive medicine for a period of at least three months, and must have done a house job in an obstetrics department for at legst six months. The'practical training should cover both rural and urban fields. The period of field training will vary according to the total period the course covers. The department of maternity and child health of the All-India Institute of Hygiene and Public Health in Calcutta is to be-expanded as a Centre for post-graduate training for maternity and child health doctors ^nd for public health nurses with the aid of the U.N.I.C.E.F. Rural and urban training fields for nurses and midwives in the Delhi area and pediatric training centres in Madras, Bombay and Patna (Hyderabad is also under consideration) are being developed by Government with the W.H.O. and the U.N.I.C.E.F. assistance.
67. Voluntary organisations have played an important role in the past. They were responsible for starting the training of dais, midwives and health visitors. Voluntary bodies have also been responsible for the establishment and maintenance of a large number of maternity and child health centres. But the responsibility for providing such services rests upon the Government. The activities of the voluntary bodies should supplement the functions of Government. Government should have power of supervision and control to ensure that health activities of voluntary organisations are maintained at a satisfactory level and they should extend the fullest support to these organisations. The provision made by the various States for maternity and child health work is Rs. i -35 crores and by the Centre Rs. 53.48 lakhs.
68. All progress in public health depends ultimately on the willing assent and co-operation of the people and their active participation in measures intended for individual and community health protection. Considering how much illness is the result of ignorance of simple hygienic laws or indifference to their application in practice, no single measure is productive of greater returns in proportion to outlay than health education.
69. To be effective, health education should be addressed to the different sections of the public in a manner suitable to each. Women and children constitute the most important section. Educating the woman is educating the whole family. The formation of healthy habits in growing children in their formative years is most important. No agency is better equipped to reach this class and carry the message of health than the maternal and child health staff, the woman doctor, the public health nurse" or health visitor, the midwife oT the dai. The extension of this service on the widest scale is therefore of the greatest benefit. The school-going population is a large and important section. The most important thing in the primary schools is not so much the academic instruction but the inculcation of health habits. These cannot be fostered without minimum hygienic facilities in the school premises. The instruction in hygiene is graded to suit the class of pupil in the higher standards and project methods may be adopted. It is important to include the subject in teachers' training. Publicity may be addressed to the adult population in places of work, recreation or at home. Part of the educative work is intended for the professional class and those engaged in health work. They should be kept informed of what is happening in all progressive communities.
70. It is of the greatest importance that not only all available modern methods of publicity should be adopted but that they should be as attractive as possible and intelligible to the large section that are not literate. Audio-visual aids, the radio, the cinema, and the press should be extensively utilised. Television would come into use in due course. Gramaphone records, cinema films, film strips, lantern slides, picture posters, leaflets, book marks and picture cards should be produced and spread widely to the public in any attempt at effective publicity. The material prepared for imparting health knowledge to the people should draw upon all available sources, including the traditional practices and Ayurvedic texts. Nature cure cart furnish useful help for the maintenance and improvement of health and vitality. The testing and standardization of this scattared knowledge offers an important field for research. The provision of health museums in the Centre and in the States is an extremely important measure. These could produce useful publicity material as well as educate and entertain the public. The organisation of-health exhibitions on all occasions when large congregations of people take place is very useful. Theatricals and variety entertainments can form part of interesting publicity campaigns.
71. To organise the work, it is essential to have health publicity bureaus in the Centre as well as the States. They should be properly staffed and equipped. It is of importance that they should have the aid of a good library service as well as a museum and units for the production of the requisite educational aids and materials. Health publicity should form an integral part of the district health organisations' work. Full advantage should also be taken of voluntary effort in this work. Several States have excellent organisations. The Centre has a scheme which includes in its scope the establishment of a health publicity bureau and facilities for the production of health educational material (film strip production unit and printing unit) at an estimated cost of Rs. 15 lakhs.
MEDICAL EDUCATION, MEDICAL RESEARCH AND MEDICAL RELIEF
72. Medical education, medical research and medical relief are intimately interconnected. It is generally accepted that the quality of medical relief is vastly improved by the presence of a teaclrng hospital and college in any area and again the quality of medical education improves greatly in an atmosphere of medical research. It is, therefore, obvious that the planning of these activities should be taken up together. Pointed attention has been drawn to the extreme shortage of all types of health personnel like doctors, dentists, nurses, health visitors, pharmacists etc. Top priority has, therefore, to be given to the training of health personnel in order to develop a reasonable health service in the country.
73. There are at present 30 medical colleges training candidates for the M.B.B.S. degree. There are also 4 medical schools for the training of licentiates. It is expected that these would be upgraded into colleges. Only one uniform minimum standard of training and qualifications prescribed by the Indian Medical Council should be adopted throughout the country. All the medical colleges provide for the admission of 2,500 students annually and nearly 1,600 qualifid doctors pass out a year. It is suggested that the training facilities should be extended so that at the end of 5 years there may be provision for 4,000 admissions in the medical colleges. New medical colleges should be established where large hospitals exist to minimise the cost.
74. There is considerable dearth of teaching personnel even in the existing medical colleges, particularly in non-clinical subjects. These posts should be made more attractive. It is suggested that whole-time teaching units may be established in medicine, surgery and midwifery. The officer in charge'ofa whole-time unit will devote all his time to the organisation of teaching and research work-in his subject. It is understood that the Indian Medical Council is contemplating the introduction of a system of compulsory internship in the medical course leading to the degree of M.B.B.S.- It is recommended that certain selected hospitals in the States may be upgraded so that they can be utilised for this purpose. Throughout the course of instruction in the medical colleges, it is necessary that emphasis should be laid on tlie importance of preventive and social aspects of medicine and rural health. For this purpose the following steps would be necessary :
Although most of the universities with medical faculties have instituted post-graduate degrees and diplomas, existing facilities are neither adequate n'or of the required standard. The establishment of an All-India Medical Institute is for providing adequate facilities in this field. It is at the same time considered necessary to upgrade certain departments of existing medical colleges and institutions for post-graduate teaching and research. For standardising and co-ordinating post-graduate medical training Government of India have instituted an All-India Council of post-graduate medical education.
75. Practically all the teaching hospitals in the country impart training in nursing. A college of nursing for the purpose of giving training of the University standard has been opened in Delhi. There is a similar college in Vellore. Public health nursing is specially included in the instruction imparted in the B.Sc. course in the two nursing colleges. The department of maternity and child health of the All-India Institute of Hygiene and Public Health in Calcutta will also be a centre for the training'of public health nurses. It should be possible to train a larger number of nurses than is done at present even in the existing teaching institutions. The deficiency can be overcome if a larger number of probationers are admitted to the training schools attached to the teaching hospitals. The number should at least be doubled. Larger number of sister tutors should be employed not only in the teaching hospitals but also in other hospitals where probationer nurses are trained. Increased facilities for the training of auxiliary nurses will greatly help in building up the personnel required. The community projects that are to be started immediately will call for a large number of personnel of this type. The expansion of maternal and child health services in the rest of the areas outside the community projects, even on a modest scale, would require very considerable numbers. The usual courses of training will take up a considerable time and short-term courses would therefore appear to be the only solution. Besides, persons with requisite, preliminary educational qualifications may not be coming up in sufficient numbers to meet the demand and the auxiliary courses where the preliminary educational qualification required is less than for the normal courses would facilitate recruitment of sufficient number of candidates. It may not be possible for the Government alone to deal with the question fully. Non-governmental agencies may therefore be invited to take up this work and adequate assistance given to them for running these short-term courses. In view of the urgency of finding personnel for various development schemes, the training 01 ancillary personnel of this type should receive very high priority. A beginning has been made by a voluntary organisation in Madras with the aid of the public, the State and the Central Government. This type of activity may be taken up by other States.
76. There are training schools for health visitors in Delhi, Luc,know, Calcutta, Madras, Poona, Bombay, Nagpur, Hyderabad, etc. The conditions of training vary greatly in these institutions. In the training of health visitors and in the training of public health nurses provision should be made for instruction in subjects such as tuberculosis, etc. The opinion is gaming ground that as far as possible in future health visitors should be trained public health nurses.
77. The training facilities for midwives have to be considerably expanded. Each of the existing institutions with maternity beds can take in larger numbers of trainees. The training of auxiliary midwives would be a contribution to the solution of this question. Domiciliary midwifery should form an important part of the training of midwives. The training of indigenous dais has also been attempted in certain States. Under proper supervision the local trained dais may turn out satisfactory.
78. Facilities should also be provided for the training of medical social workers.
79. Public health engineering is a very important aspect of public health. It has not received due consideration so far in teaching centes in India. The All India Institute of Hygiene and Public Health has been giving training to qualified engineers in sanitary engineering as a'post-graduate course. The course in this institution trains the candidates for the degree of Master of Engineering in public health given by the Calcutta University. Similar facilities should be provided in other States as well.
80. The bulk of the health personnel in a State is composed of qualified sanitary inspectors. There is need for standardizing this course. There is also an obvious need for the training of a larger number of Sanitary Inspectors.
81. There should be a specific allocation of funds both from the Central revenues and from the State revenues for medical research in the country. This money should 'be spent in the research institutes and medical colleges. The various departments in the medical colleges should be encouraged to take up research work in addition to their routine teaching duties. Adequate staff should be provided for this purpose. The creatton of full-time units in medicine, surgery and midwifery will facilitate research work in those departments. Necessary technical assistance and equipment should be provided in non-clinical departments to participate in such programmes. Both for purposes of teaching and research in medicine an up-to-date library with sufficient number of journals and books is imperatives, The history of medicine should be taught and a chair should be instituted in every university with a medical faculty. The research institutes. Central and State, will be- concerned in the carrying out of researches in special subjects and investigations into the social and environmental factors affecting health and disease. We suggest the provision of improved laboratory services in the different States, through the creation of regional laboratories to be linked locally with other organisations in connection with the health programmes and for technical direction with the central laboratory at the headquarters of the State. The Indian Council of Medical Research initiates programmes of research in several fields on urgent problems facing the country. It also creates a nucleus of trained research workers. The recruitment, training and utilisation of research workers has been a problem of some importance in this country. Fellowships are offered by various international bodies, by Governments of several countries, as well as the Government of India and the Indian Council of Medical Research and a well-considered plan is necessary in order to take the fullest advantage of the scheme. It should consider the requirements of :
The fellows should be ultimately assured of absorption in the services. There should be a survey of such needs and a tabulation of the programme of fellowships for a definite period. There should also be a follow-up to ensure that the fellows are employed for the purpose for which they are, trained. The Central Government have provided Rs. 57 "05 lakhs for research.
82. The Central Government have provided for the establishment of an All India Medical Institute, including a dental college, upgrading the existing departments of medical colleges, Lady Hardinge Medical College, College of Nursing, establishment of departments of social and preventive medicine in certain medical colleges, increased training facilities for nurses, nursing home and training centre for auxiliary nurses and midwives at Madras and Lady Reading Health School. Central expenditure is Rs. 5'13 crores on medical and Rs. 86-99 lakhs on public health education and training. The States have included schemes under education and training to the extent ofRs. 13 "79 crores (medical) and Rs. 44*53 lakhs (public health).
83. The States have a programme of improved medical relief by the expansion of existing institutions and the provision of new institutions. The provincialisation of existing dispensaries, provincialisation and improvement of the thana or taluk hospitals, the expansion of district hospitals and of teaching hospitals at the headquarters of the State or other important centres constitute the components of this expansion programme. The greatest emphasis should be on rural health and the development of primary health units. The States and the Centre provide Rs. 24'10 crores and Rs. 52*2 lakhs respectively.
INDIGENOUS SYSTEMS OF MEDICINE
84. A great deal of uncertainty exists about the position and the future course of development of indigenous systems, homoeopathy and nature cure. It is desirable that this should be cleared up as early as possible. The controversy with regard to the truth and merits of any particular technique of cure or approach to the problems of health and disease can only be settled on the touchstone of research. Scientifically conducted investigations will, in course of time, decide the value and validity of the different techniques and those which can justify their existence will necessarily become branches of an integrated system of medicine. In the five year plan a provision of Rs. 37 -5 lakhs has been made for research into indigenous and other systems. Government of India have sanctioned a central institute for research in indigenous systems of medicine at Jamnagar. It is considered necessary, however, to promote research at more than one such centre, particularly at places where plenty of clinical material and high standard of professional talent are available. Provision has to be made specially for a comparative clinical study of different techniques. A nucleus for this purpose already exists in Bombay and has the support of eminent representatives of the various systems. Steps should be taken to strengthen and expand this institution. Besides assessment of the area of utility of these systems, there is a large scope for research in order to improve and eolarge their special contribution to medical science, to define, interpret and standardise the content of their theory and practice and to bring them in line with modern scientific advances. Research into all aspects of indigenous systems including drugs, principles and practices should be fostered not only in institutions devoted to the study of indigenous systems but also in modern medical institutions.
85. It is essential to make adequate arrangements for a systematic investigation into Indian medical herbs, from the point of view of identification, nomenclature, the area in which they are available and those localities in which individual herbs can be grown to the best advantage. It is recommended that, following this study, museums should be established centrally and regionally so as to enable students and practitioners ofAyurveda and other systems of indigenous medicine and Homoeopathy, to have access to all the information regarding these herbs. Early action is also needed regarding the collection, standardisation, storage and distribution of Indian medical herbs. Studies regarding these should be undertaken jointly by the Central Institute for Ayurvedic Research and by the Central Drugs Research Institute at Lucknow. Central agencies will have to be created for the purpose of co-ordination and direction of research which should be mainly in the hands of experts of the systems concerned.
86. Professional training for the practice of the indigenous systems is an important matter for consideration. The present approach to the education in Ayurveda has not produced satisfactory results. There is no uniform basis for the curricula adopted in different institutions. There is much room also for improving the quality-of the teaching staff and the terms of its employment. The introduction of honorary teaching may help to draw the best elements in Ayarveda for assisting the educational work. A curriculum drawn up for the purpose has to be designed primarily to enable the student to attain full proficiency in the practice of the particular system. But he cannot afford to ignore the body of medical knowledge which has grown up under the impetus of scientific methods. As has been well expressed, " it is not necessary that he should be able to apply these technical procedures himself at all times, particularly in surgical specialities, but it is essential that he should have the knowledge which will enable him to recognise the need for calling in the aid of these specialities in the interests of his patients ". The details of the curriculum which can satisfy both these conditions will have to be worked out with the help of the results of research and experience. It is evident that the Ayurvedic portion of the curriculum has to be considerably strengthened and enlarged under the direction of experts in this field. The minimum qualification for admission should include the equipment needed for acquiring a mastery of Ayurveda in addition to a knowledge of the basic sciences as the essential foundation of medical education. Early steps will have to be taken for upgrading of selected institutions. At least one of them should be fully equipped for high level research as well as education of the requisite standard. The consensus of opinion seems to be in favour of a full course extending over a period of five years. There is also demand for a three years junior diploma course to meet the immediate needs of the country. This, however, needs examination in view of a large body of opinion in favour of a single course of training. Besides the State Medical Boards appointed for the purpose of regulating registration and practice in these systems, which should also deal with the standards of education, with supervision over instruction and with professional conduct in the respective systems. Central Councils may be necessary. Rs. 95.23 lakhs have been provided for education and training in indigenous systems of - medicine, and Rs. 1.06 crores, for hospitals and dispensaries as well as other schemes of indigenous medicine by the States. Uttar Pradesh and Hyderabad have provided the maximum for hospitals and dispensaries. Bihar, Madhya Pradesh, Saurashtra and Travancore-Cochin devote considerable amounts for education and training, and account for the bulk of the expenditure of the States.
87. With regard to Homoeopathy, the proposals of the representatives of the profession appear to be reasonable and are, in the main, as follows:
88. The significance of what goes by the name of nature cure can be better appreciated if it is considered as a way of life rather than a system of treatment in the narrow sense. Its emphasis on positive health, conservation of vitality, self-help in matters of health and its advocacy of simple ways of using the varied forces of nature are elements of its special outlook. Many of its techniques have become assimilated in the general practice of medicine and it has much common ground with what has come to be known as physical-medicine. Nature cure is being practised in India both as a basic system embodying the simple approach made popular by Mahatma Gandhi and as a modern system, for which it is claimed that it is based on the fundamental curative principles which are inherent within the human personality. In dealing with the question of nature cure, we have to reckon with several viewpoints. It is contended that nature cure does not exist as an independent system. On the other hand, there is a school of thought which regards nature cure as self-sufficient, but so simple that it requires no elaborate provision for training or treatment. The practitioners of the modern system of nature cure insist, however, that it is a wide and vast field and it is necessary to create at least one central teaching institution in which the existing knowledge of the subject is standardized, research is carried on and instruction imparted to students. It appears, therefore, that these and several other aspects of the question require further enquiry. Immediate action in respect of nature cure may take the following lines:
DRUGS AND MEDICAL REQUISITES
89. The supply of therapeutic substances and medical appliances ranks very high among the priorities in the national health plan. The carrying out of medical and health programmes will be made impossible without adequate supplies of drugs and appliances. It should be possible adequately to provide for these essential needs through a combination of private enterprise suitably assisted where necessary, and production by the State where this is found to be in public interest. The final responsibility should rest with the Government for seeing that the essential needs of the country in respect of important medical requisites are met satisfactorily in regard to quality, quantity and price.
90. Under the Drugs Act of 1940 the responsibility of the Centre is to regulate the standard of drugs imported into the country and the establishment of the Central Drugs Laboratory and also to correlate the work of administering the Act in the States, the States being responsible for control over manufacture, sale and distribution of drugs. The implementation of the Act has reached various stages in the States. Bombay, Uttar Pradesh, Madras and West Bengal have shown greater progress than others. The provisions of the Drugs Act have been extended to Part' B ' and Part' C ' States. All the States should effectively implement the provisions of the Drugs Act by the employment of an adequate number of qualified Drug Inspectors and the establishment of well-equipped laboratories staffed by qualified analysts. Black-marketing in drugs is checked by test purchases and regular collection of information on the supply position of essential drugs from the States. Government also propose to enhance penalties for manufacturing and selling spurious and sub-standard drugs. Such offences will be made cognisable.
91. This country has long been recognised as a rich store house of vegetable materia medica. Though indigenous drugs have been in extensive use, there has been no co-ordinated effort in research and standardisation of these drugs. It is necessary to lay down standards as regards quality and active principles. Then they should be processed in a form suitable for administration. Remedies suitable for adoption in the pharmacopoeia should be discovered. In order to achieve these objectives, the Indian Council of Agricultural Research has established a Medicinal Plants Committee to develop the cultivation of important medicinal plants at suitable centres. Uttar Pradesh and Kashmir are also taking steps in. this direction. The Ministry of Health has established a pharmacognosy section of the Central Drugs Research Laboratory for the identification of indigenous drugs, and for detecting adulteration of crude drugs in the market. Samples of fifty commonly used drugs collected from markets all'over India have been investigated in the Drugs Research Laboratory in Kashmir and found to be spurious imitations of the genuine commodities. As a preliminary to the control of these drugs, their pharmacognostic and chemical standards should be established. The Council of Scientific and Industrial Research has established a Drug Research Institute at Lucknow. This Institute will investigate many of the commonly used indigenous drugs to work out their active principles and standards of potency and purity. The need for a national pharmacopoeia has been a long-felt want. The Government of India established a committee for the preparation of the pharmacopoeia. The pharmacopoeia will contain monographs not only on modern synthetic and other drugs but also on all vegetable drugs of indigenous origin. So far nearly a thousand draft monographs have been prepared.
92. Homoeopathic medicines are not prepared according to well-known pharmacopeeial methods. Moreover, these drugs are used in such diluted forms that they cannot be tested or standardised by any known chemical process. The only precaution that could be taken is to allow the manufacture and preparation in bonded laboratories under the supervision of qualified Homoeopaths.
93. The Pharmacy Act has been enforced in all Part' A ' States. Steps are being taken to enforce it in Part ' B ' and Part ' C ' States. Registration tribunals have been constituted by the State'Governments'and registration of pharmacists is under way. Educational regulations prescribing the minimum standards for pharmacists have been prepared. The Pharmacy Act should be effectively implemented in all States.
94. Private enterprise in drug manufacture in India started just after the World War I, though a beginning was made nearly 50 years ago. At the beginning of World War II, owing to restriction on imports the full resources of the country had to be developed. The Government of India gave all help to the manufacturing industry. Today India is self-sufficient in regard to all the galenical preparations, most of sera and vaccines, liver extracts, alkaloids like morphine, codeine, strychnine, etc. India is also self-sufficient in regard to the production of santonine, belladonna, digitalis and hyoscyamus preparations. India has made little or no progress in regard to production of basic chemicals required for the manufacture of synthetic remedies and chemo-therapeutic compounds largely used in the country. A few synthetic drugs are produced in small quantities, e.g. P.A,S., Novitrone, Luminal (Phenobarbitone), Para-acetylamino benzaldehyde thio semi-carbazone etc., which meets only a fraction of the demand, India imports essential drugs and raw materials valued at over Rs. 10 crores annually. Among them are principally penicillin, streptomycin and other antibiotics, sulpha drugs, gland products, vitamins, anti-leprosy drugs and insecticides. These are the most important items and if steps are taken to implement the production of the basic chemicals and raw materials required for these and for the production of the finished products, the import of drugs will be considerably curtailed and India will be fairly on the way to self-sufficiency. We may now consider the production of those drugs to which a high priority should be assigned.
95. West Bengal and Madras produce about 1,00,000 Ibs. of quinine per year. The production should be expanded to 1,50,000 Ibs. to make up the gap between production and consumption. Government have appointed a special Cinchona Committee for the purpose of investigating the problems of Cinchona industry. Their report is expected shortly. Any enterprise proposing to produce synthetic anti-malarial drugs in the country should be given all facilities. The production of D.D.T. at rates comparable to foreign prices to the extent of about 5 or 6 thousand tons should be the target for the plan period. There is a proposal under way for the setting up of a D.D.T. factory, with the assistance of the W.H.O. and the U.N.I.C.E.F., for the production of 700 tons with capacity for expansion upto 1,400 tons. The setting up of another plant of the same capacity is essential to meet the requirements of a national malaria control programme and the target of production indicated. This is proposed under the T.C.A. programme.
96. Very nearly 35 per cent of the total value of imported drugs is in the form of antibiotics consisting of penicillin and streptomycin. The estimated consumption of penicillin is 8 million mega units per annum, which is wholly imported. The Indian Penicillin Committee have started a bottling plant at the Haffkine Institute, Bombay, where penicillin is imported in bulk. Government of India have entered into an agreement with the U.N.I.C.E.F. to set up a factory for the manufacture of penicillin and other antibiotics. The total cost of the project is estimated at Rs. 2-00 crores. The plant will be located at Pimpri near Poona. The production of penicillin at the rate of 4,00,000 mega units per month is expected by the end of 1954. Provision has also been made for the development of an important centre of research and training in antibiotic field. Certain commercial firms are also engaged in importing penicillin in bulk and bottling it.
97. Sulpha drugs should have a high place in the priorities for self-sufficiency. The volume of their requirements is very large. Private enterprise is entering the field for the production of sulpha drugs.
98. Diaminodiphenyl sulphone is being manufactured by some Indian firms. It is claimed that a process has been evolved by which the cost of production would be considerably reduced. The basic materials required for the preparation of this drug are said to be all available in India.
99. Among the glandular products, insulin takes rank as one of the most important, as it is necessary for the treatment of diabetes. It is now wholly imported. It is understood that an Indian firm has under consideration a project for manufacturing insulin with foreign technical assistance.
100. The need forjhe development of industries for the production of vitamins, food yeast, shark-liver oil has been stressed in the section on nutrition. There is a need for a co-ordinated programme of development of the pharmaceutical industry. Production of hospital equipment, surgical instruments, and dressings, and glass containers should receive attention and necessary aid.
101. Vital statistics constitute the foundation on which all constructive work in the field of public health must be built. Preventive and curative work can be organised on a sound basis only on accurate knowledge of mortality and morbidity statistics. The application of modern statistical methods 10 health administration is of supreme importance. It is necessary both for ensuring the collection of data on sound lines and a study and interpretation of the recorded statistics. Investigation of socio-economic factors in relation to community health and disease, the survey of health problems and the evaluation of the measures taken require the application of statistical methods. An adequate statistical service is required for the collection and compilation of vital and population statistics and the census.
102. The collection and compilation of vital statistical data are defective in completeness and accuracy. The agency for the collection of vital statistics in municipalities is a part of the municipal public health department. As regards rural areas the agency varies in different States. The recorded vital statistics are passed on through a series of officers to the Director of Public Health and compilation of the data is carried out at different stages of transmission in most cases. The collection and compilation of vital statistics is now to be a function of the Registrar General and Census Commissioner. The Registrar General has reviewed the recommendations of the Bhore Committee and the Vital Statistics Committee and has proposed a scheme. The scheme consists of an annual review of population records and annual census of sample house-holds. The data collected by these two operations and those yielded by the normal registration of births and deaths are to be centrally compiled, tabulated and studied and on the basis of such studies population reports are to be prepared and published every year. The organisation required for this purpose would consist of a central office of the census of India under a Registrar General and ex-officio Census Commissioner, branch offices of the Census of India each under a Superintendent of Census Operations and agencies of each State Government viz., a Director of Population Records for each State with necessary office staff and an organisation in each district consisting of chief Registration Officers, Registration Supervisors, Registrars and Additional Registrars, all appointed on an ex-officio basis. House to house visits and enquiries are proposed to be organised annually in order to effect 'Rotational Revision of the National Register' and the 'Annual Census of Sample House-holds'. The expenditure incurred is to be shared equally between the Centre and the State concerned. The tota Icost of the entire scheme can be limited to Rs. 30 lakhs per annum.
103. Though the Registrar General is to be in charge of the vital statistical organisation, the health organisations have an important role to play, particularly through health personnel at district and local levels in providing accurate data of births and causes of deaths and in introducing the use of more exact terminology in reporting them. The health directorates at the Centre as well as in the States have got a distinct need for a statistical organisation to carry out certain types of statistical studies and investigations having a direct bearing on essential health problems with which they are concerned, besides the study and analysis of recorded statistics in medical institution's of various types and of health departments.
104. The application of statistical methodology to problems of health administration is a highly specialised scientific discipline and requires the services of highly qualified and well-trained statisticians. There is, therefore, a need for organising facilities for statistical training in universities not only in the theory of statistics but also in applied statistics in various specialised fields. So far as health statistics go, there is provision in the All-India Institute of Hygiene for such training. There is clearly a need for developing similar provision in other centres like the All-India Medical Institute. The satisfactory fulfilment of the functions of the Bureau of Health Statistics in the Directorates of Health Services would need modern mechanical aids. A provision of Rs. 9-25 lakhs for the purpose is made in the plan. Experimental pilot studies for the improvement of vital and health statistical data will be taken up along with population studies for which provision is made.
105. The recent increase in the population of India and the pressure exercised on the limited resources of the country have brought to the forefront the urgency of the problem of family planning a^d population control. The application of medical knowledge and social care has lowered the death-rate, while the birth-rate remains fairly constant. This has led to the rapid increase in the growth of population. While a lowering of the birth-rate may occur as a result of improvements in the standards of living, such improvements are not likely t® materialise if there is a concurrent increase of population. It is, therefore, apparent that population control can be achieved only by the reduction of the birth-rate to the extent necessary to stabilize the population at a level consistent with the requirements of national economy. This can be secured only by the realisation of the need for family limitation on a wide scale by the people. The main appeal for family planning is based on considerations of the health and welfare of the family. Family limitation or spacing of the children is necessary and desirable in order to secure better health for the mother and better care and upbringing of children. Measures directed to this end should, therefore, form part of the public health programme.
106. All progress in this field depends first on creating a sufficiently strong motivation in favour of family planning in the minds of the people and, next, on providing the necessary advice and service based on acceptable, efficient, harmless and economic methods. Butthese presuppose (i) intensive studies about the attitudes and motivations affecting family size and techniques and procedures for the education of the public on family planning, and (2) field experiments on different methods of family planning as well as medical and technical research.
107. A programme for family limitation and population control should:
A sum of Rs. 65 lakhs has been allocated by the Central Government in the Plan of the Ministry of Health for a family planning programme.
This programme includes:
(1) The provision, in Government hospitals and health centres, of advice on methods of family planning for married persons who require such advice : Medical officers working at hospitals and health centres like maternity and child welfare clinics should give advice to women regarding family planning when such advice is necessary for health reasons. If a doctor feels that a woman patient cannot undergo again the strain of pregnancy and parturition without danger to health, it is obviously the duty of the doctor to give such advice as is necessary to enable the person to prevent conception. In these circumstances the doctor would be justified in suggesting any chemical, mechanical or biological methods of contraception or sterilization as may be indicated for the individual case. The giving of advice on birth control has been a procedure allowed by the Ministry of Health in U.K. in medical centres maintained by the local authorities.
(2) Field experiments on different methods of family planning for the purpose of determining their suitability, acceptability and effectiveness in different sections of the population: If it can be demonstrated that our people, particularly those living in rural areas, can be educated to accept the rhythm method and use it as a practical method of limiting family growth, Governmental support should be extended to the propagation of this method. From the point of view of avoiding enormous expenditure as well as that of securing the ethical values that community life would gain by the ^self-imposed restraint which the rhythm method involves, it would seem desirable to try out this method fully and thus ascertain its practicability. Whether the rhythm method is capable of wide application in the community with adequate results or not, actual experimentation alone can tell. Research and experiments need not however be confined to a single method. There are numerous voluntary agencies which are currently propagating the spread of information on family planning and the use of chemical and mechanical contraceptives. Their activities would need support.
(3) Development of suitable procedures to educate the people on faauly planning methods : Inexpensive means of rapidly educating the public in matters relating to family size will have to be evolved if large-scale reduction in the national birth-rate is to be obtained. Scientific techniques are available to assess the effect of mass educational campaigns. These techniques should be used to develop educational programmes suitable for the different economic and social sections of the population.
(4) Collection, from representative sections of the population, of information on reproductive patterns, and on attitudes and motivations affecting the size of the family ; The reproductive pattern in any population is largely determined by social and cultural factors which may differ from one area to another. A thorough investigation of the differences in attitudes and motivations towards family size and of the factors responsible for producing such differences is important. Research along these lines is necessary if we are to understand the particular sentiments and aspirations to which programmes of family limitation in various sections of the population should appeal.
(5) Study of the inter-relationships between economic, social and population changes. The information obtained by such studies will form the necessary background for the formulation of a national population policy and the development , of appropriate measures for population planning based on factual information.
(6) Collecting and studying information about different methods of family planning (based on scientifically tested experience in India and abroad) and making such information available to professional workers.
(7) Research into the physiological and medical aspects of human fertility and its control.
108. It is considered that the problems of population and family planning may be divided into those re'ating to:
Two committees have accordingly been constituted. It would also appear desirable to set up at a later date a population commission to assess the population problem, consider different views held on the subject of population control, appraise the results of experimental studies and recommend measures in the field of family planning to be adopted by the Government and the people.
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