Doctor’s manual : clinical and managerial by Lalitha D’souza, NS Deodhar, Mukund Uplekar, MP Dandhar. The Foundation for Research in Community Health, 1996. Part I : 300 pp, part II 156 pp

Rural India’s health needs are supposed to be met by a network of primary health centres (PHCs) and sub-centres, the number and location of which are designed to cover the entire population. However, a look at the people’s health profile suggests that services rare not meeting expectations.

This guide to the medical officer in charge of the PHC is written to bridge the gap between a doctor’s theoretical knowledge and the practical realities of providing health care to the rural community.

The book presents a precise discussion of each disease, with highlighted special instructions such as ‘advice to leprosy patients on discharge’ or cautions: ‘typhoid immunisation is not a replacement for personal hygiene’.

Doctors often believe that they are the custodians of health-related information, and discourage patients from obtaining such information. This manual identifies a minimum set of facts doctors must share with their patients.

The first section, which deals with common clinical problems and their management in a PHC set-up, is presented in a manner accessible to both medical readers and knowledgeable people looking for a supplement to the medical professional’s consultation.

In response to the profession’s preoccupation with curative medicine, the manual incorporates the concepts of preventive primary health care and community participation, shown to be more effective than medical treatment alone. A major burden of morbidity and mortality comes from communicable diseases which are spread by ignoring the role of the community in health.

The authors emphasise the influence of multiple factors in disease. “Modern high technology, sophisticated diagnostic and therapeutic procedures that are associated with specialisation and super-specialisation have undoubtedly helped in adding years to life, but have seldom rendered the community at large more health”. (part II, p 1). They hold that the “perception and attitude of the community is the greatest hindrance in promoting uptake and utilisation of health care facilities by apparently healthy people“.

The medical profession can change this situation by accepting that “primary health centres have been established to serve as a focal point through which integrated curative, preventive and promotive health care is to be provided to the entire population of a defined geographical area“. (part II, p 1). The medical officer in charge of the PHC should work to make health the joint responsibility of the community and medical profession. “Epidemiological surveillance, screening of the population for early recognition of selected diseases and registration of the vital events are necessary. All these activities can be done efficiently only if active involvement and participation of the community is achieved”. (part II, pp. 1-2).

The second section of the manual provides basic information necessary for medical officers of PHCs and also gives information on several national programmes.

While the manual makes a valuable, practical contribution to the functioning of primary health care, it does not have a comprehensive coverage of women’s health problems. Health services have confined themselves to seeing women in their roles as mothers. Maternal and child health is seen as “one of the most important measures for health promotion”.

Yet, a focus on “cent per cent early ANC registration, progressive increase in the number of deliveries conducted by trained personnel” (part II, p.78) will not assure positive health when 60 per cent of Indian women are anaemic, and also suffer from other health problems. The health care system must accept the need to go beyond such focussed services.

The manual also does not address the issue of the rising medicalisation of natural processes like menstruation, pregnancy, delivery and menopause. Young women are being advised to use hormones to manipulate their menstrual cycle; sonography is used indiscriminately and caesarean sections are becoming the norm, menopausal women are being advised hormone replacement therapy. Medical professionals could do with advice on the use of these interventions.

The National Family Health Survey reports that 25 per cent of women who have been tubectomised, or who are using oral contraceptives of IUDs, and 20 per cent of vasectomised men, experience health problems. The authors’ comments on the national family welfare programme should be evaluated in this context, as well the fact that he government of Indian was party to the decision taken at the 1994 International Conference on Population and Development at Cairo, doing away with targets for promotion of contraceptives and population control.

Despite these limitations, the book is a valuable contribution to the field of health. It must become a standard reference work of medical officers at PHCs as well as those in the community who want to be informed about their health.