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What ails Community Health, is it ignorance?

Dr. U.N. Jajoo, a reader at the Mahatma Gandhi Institute of Medical Science, India in an article on Health Eduction in the WHO publication World Health Forum Vol. 6 writes:

Poverty cannot be tackled by preaching alone. A coordinated effort by all, it has to be

"In our enthusiasm we often deliver sermons and preach preconceived solutions to illiterate and (presumably) ignorant masses. Frustrations set in when we realise that all our good advice goes unheeded and our work shows no results at all. why? because ignorance is far from being the cause.

In this article Dr. Jajoo describes how he found this out in a study he had done in India.

As you read this article you'll find that we too have so much to learn from this study in dealing with community health matters.

Dr. Jajoo in the article: Most of us engaged in providing primary health care to the needy nurture, either consciously or subconsciously, a naive notion that what ails community health is ignorance and that if there are sincere attempts to provide scientific know-how most community health problems will find a solution.

In our enthusiasm we often deliver sermons and preach preconceived solutions to illiterate and (presumably) ignorant masses. Frustrations set in when we realise that all our good advice goes unheeded and our work shows no results at all. But ignorance is far from being the cause.

The following examples from our field work in the Sevagram area of the Wardha District of India make this quite clear.

Two is enough, three is a burden

"India has recorded remarkable progress in food grain production but, alas, human over production has devoured all the gains." With this lament in mind, government policies give top priority to restricting family size, and vast resources are mobilised for family planning campaigns. All possible media are used to carry this message to the rural poor - after all, they account for 80 per cent of India's population.

We thought it's our duty to promote the idea of a small family, using all the means at our disposal. A film show was arranged, posters were distributed, and the target group was visited: we guaranteed transport to and from the hospital, personal attention during hospitalisation, and nothing to pay.

Our expectations crumbled when we found no-one turned up in spite of our persuasion. We tried to understand why the villagers did not seek our advice.

A mother of six children - all girls - asked us bluntly "Will you support us when we get old?" An ideal candidate for surgery, a woman with one son and a daughter, put it this way:

"Doctor, have you seen a bullock cart with only one bullock? You need at least a pair, then if one succumbs the other will drag the cart alone." And a farmer said, "We must have more children, doctor. Labour is too costly these days, and I need dependable manpower to help me."

The entire exercise taught us that unless under-five mortality is reduced, unless security for old age is provided, and unless agriculture becomes profitable, no amount of propaganda or incentives will convince poor village people about the benefits of a small family.

Malnutrition is the greatest killer among the under-fives. The rural folk consider it the curse of an evil spirit, Satavi, for which there is no remedy in modern science, only in worship. An exorcist is the only one to benefit from the process.

A house-to-house survey revealed that almost all infants were below their expected weight and those severely malnourished were all girls. We embarked on an education campaign, using a slide show to demonstrate the various signs of malnutrition.

We emphasised that poor nutrition was to be blamed and not the evil spirit, explaining that a child should have a balanced diet. We recommended milk as the best food, not forgetting green vegetables, fruits and eggs. We told them to use oils freely, as a high energy source, and to see that a child is fed at least five times a day.

Imagine our disgust

To make our point more vividly we selected five infants, all girls from landless families, and started on-the-spot feeding with a supplementary food providing 300-400 calories every day as recommended by the Indian Council for Medical Research. Imagine our disgust when the children did not show a weight gain as expected. It was a rude shock.

We went again from house to house, inquiring carefully the amount of food, the child was receiving at home prior to the supplementary feeding program. Does she receive the same amount now?

The answer explained everything: ours was not a supplementary food but a substitute for whatever the child had been getting at home. With the assurance that the child would be fed under our program, the mother preferred to divert her share of home food resources to others.

We did our best to convince the mothers that they still had to ensure adequate food for the malnourished child. Here the education campaign took a different turn, and we found ourselves at the receiving end.

The women had a lot to teach us: "We do not own cattle, and milk sold in the village is diluted and sold at an exorbitant cost that we cannot afford. The same goes for eggs, oil, sugar, vegetables and fruits. Do you know, doctor, oil costs 20 rupees a litre and sugar 6 rupees a kilo?"

It seems that the villagers were not so far wrong when they attributed malnutrition to the work of an evil spirit - the evil spirit of poverty.

The key to improvement

Poverty is the greatest sin. To live, and even to die, with dignity is a luxury permitted to few. The root cause of two major killer diseases in children - diarrhoea and respiratory infections - is the underlying malnutrition, an illness that cannot be treated by drugs but only by adequate food.

Untiring and enthusiastic management of these killer diseases in hospitals without an attack on the social cause - poverty - is like attempting to mop up a flood with the water tap full on above.

We took pains to sit down with the farmers, individually and in groups, calculating their income over the last three years. We found the majority of them incurring perpetual losses and barely 5 per cent of the families owning economic land (that is, more than 18 acres for a family of five persons in this area).

Water resources are scarce, and the farmers are at the mercy of monsoons at least once every three years. Irrigated land requires heavy investment, which a farmer finds difficult to make as the banks will not lend him money while he has outstanding debts. Government-subsidized prices for his produce bring little profit, and he is dependent on the fluctuating market.

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Foot, health and shoes:

Where the shoe pinches

When was the last time you bought a pair of shoes? How did they fit you? Were they comfortable? How long did it take you to choose them? How helpful was the shop assistant or fitter? Did you buy them for style rather than comfort? How do they feel now that you have worn them a while? Do they pinch you anywhere?

Buying shoes is not as simple as it sounds. And getting the right size is almost like stepping into a labyrinth. Why is that?

The right fit

First of all, which is your larger foot-right or left? You think they are both the same? Think again! Another factor to take into account is that each foot has four phases of fit: static fit, weight-bearing fit, functional fit, and thermal fit. What are the differences?

Regarding static fit, the book Professional Shoe Fitting says: "This is the fit of the shoe with the foot at rest (the customer seated)." As the expression "weight-bearing fit" suggests, it is measured when the person is standing. This position changes the size and shape of the foot.

The above-quoted reference states: "The foot at rest is essentially a loose bag of bones and gristle that suddenly 'solidifies' on weightbearing, becoming a foot of different fit requirements." But there are two more fits.

The functional fit is the fit under dynamic conditions - when walking, running, jumping, or doing other exercise. This "creates a foot of different combinations of size, shape and proportions." The fourth fit is the thermal, which refers to the alterations that take place as a result of heat, humidity, and moisture.

These can cause an increase of 5 per cent in foot volume. Little wonder that it is a relief to take your shoes off at the end of the day, especially if you are wearing the wrong size! And often that is the case.

How are your feet measured?

For years Eric had been buying shoes sized 10 and a half or 11, medium width. During that same period, he was constantly bothered by both a corn on a hammertoe and an ingrown toenail on the left big toe. His podiatrist suggested that he have his feet measured by a professional shoe fitter. To Eric's amazement, for comfort his size should have been 12 and a half, A width! "A" indicates a narrow foot. But are two linear measurements, length and width, enough to ensure a comfortable fit? How should you measure your feet?

A popular tool in some countries for assessing size is the Brannock device.

This can be used to obtain three basic measurements: the overall length of the foot, the distance from the heel to the ball joint, and the ball width. But, of course, each foot has its own shape and volume. For that obvious reason, we try shoes on before we buy them. Herein can lie a trap.

Have you ever had the experience of trying on shoes that you really like, only to find that they pinch slightly? "The shoes will stretch," says the salesman. You buy them and begin to regret it a few days or weeks after you start wearing them. And there is the beginning of your next corn, ingrown toenail, or bunion!

Are you getting that perfect fit?

Is it possible to find a perfect fit? Professional Shoe Fitting gives the quick answer no. Why not? "Because of several insurmountable obstacles ... No person has two feet of exactly the same size, shape, proportions or functional character." So if a shoe is perfect for your larger foot, it will not quite fit the bill for the other one.

"This does not suggest that good fit isn't achievable, but only that we should be more cautious about the term or idea of 'perfect' fit."

If you want to see where your feet are causing pressure in a shoe, take a look at some of your old, used shoes. Look inside the shoe at the lining.

Where do you notice the most wear? Frequently, the evidence will point to the heel seat, behind the heel, and to the ball of the foot. What does this mean? It means that "certain sections of the shoe are not properly mated with the corresponding sections of the foot. Some sections are getting excessive wear while others are virtually untouched".

Even the throat of the shoe is important for comfort. Have you noticed that shoes can have different throat-line styles? With the bal style, the two upper quarters are pulled together at the lowest lace point. However, if you have fleshy feet, then the blucher style is more comfortable, since the sides remain separated at the lowest lace point. Why is this detail important?

The same source says: "Many or most heel irritations from the shoe are often the direct result of a shoe being too tight at the throat, thus crowding the heel back against the counter."

What about women's high-heeled shoes?

The female preference for high heels imposes different stresses on the body. High heels tend to alter body posture, often causing a forward tilt, which, in turn, demands more knee bend in order to keep the body straight. High heels also contract the calf muscles, which then become more prominent.

Thus, the heel is often the crucial part of a woman's shoe and the key to her comfort or discomfort. Professional Shoe Fitting says that there are three prime reasons for the heels on shoes: '(1) "status", such as adding to one's height, (2) cosmetic purposes - an added design or style feature on the shoe, and (3) enhanced appearance - such as women's high heels giving more contour to the legs.'

Women should be particularly conscious of the heel pitch, which determines where the line of the body weight passes through the heel. If that line is at the rear or front edge of the heel, trouble could result. Why is that? Because it can lead to the heel buckling and causing a nasty fall.

From this brief discussion, it is evident that getting the right fit of shoes takes time and perhaps even extra expense, since a good shoe requires more time to produce. But your shoes can mean so much to your general comfort and even to your health. So take your time. Get proper measurements. Be patient. Do not be fooled by fashion or appearances.

(Courtesy: Awake! March 8)

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