CHAPTER - I

ENVIRONMENT AND HEALTH

CHAPTER - I

ENVIR ONMENT AND HEAL TH ENVIRONMENT HEALTH

Physical environment refers to the non-living parts of the environment-the climate, soil, water, minerals and other physical characteristics. Climatic factors such as temperature and humidity have a direct effect on man, his comfort and his physical performance. The influence of the physical environment, through the biological environment has an indirect effect on man. It determines the distribution on plants and animals which provide him with materials for food, clothing and shelter. It determines the natural distribution of the predators which prey on him and other animals which compete with him for food; and it determines the prevalence and distribution of parasites and their vector. Man alters the natural characteristics of his physical environment; sometimes on a small scale, but often on a very large scale. He may clear a small patch of bush, build a hut and dig a small canal to irrigate his crops or he may build large cities, drain swamps, irrigate arid zones, dam rivers and create large artificial lakes. Many such changes have proved beneficial to man but some of them also induce new hazards. For any systematic study of the geographical distribution of diseases, a resume of the physical environment of geomedical relevance is in order.

POSITION AND EXTENT

Bijnor district is situated in the northern part of the Moradabad division of Uttar Pradesh. The district lies between 29 0 2' N to 29 0 58' N latitude and 78 0 E to 79 0 59' E longitude embracing an area of 4848 sq. km. with holy river Ganga forming the entire western boundary. Its length from North to South is 79.2 Km. and breadth from West to East is 89.6 Km. It is bounded by districts of Haridwar in the northwest, Pauri Garhwal and Udham Singh Nagar in the northeast and east, Moradabad and J.P. Nagar in th south, and Meerut, Muzaffarnagar and Saharanpur in the west. The district has been subdivided into five tahsils- Bijnor, Najibabad, Nagina, Dhampur and Chandpur with eleven development blocks viz Najibabad, Kiratpur, Mohammadpur Deomal, Khari Jhalu, Jalilpur, Noorpur, Nehtor, Kotwali, Afzalgarh, Allehpur and Seohara (Fig. 1.1). It is inhabited by 3.13 million people (2001) and supposed

to be 3.67 million in 2011 in 2989 villages in total of which 841 are uninhabited. There are 21 towns in Bijnor district of which 12 are municipality towns and 09 Nagar Panchayats. Here more than 25 per cent of the population belong to scheduled caste and scheduled tribe community. Legendary history ascribes the foundation of Bijnor to Raja Ben who raised a part of the revenue by the sale of bijnas (fans) manufactured by himself and because of this, the place obtained its present name. Most probably the word Bijnor is a distorted form of 'Bijna nagar' (town of fans). The confluence of the holy Ganga and river Malin happens to be

[3]

situated in Bijnor district which stores the sweat memories of Rishi Kanwa Ashram where the Pranaya-Vivah of King Dushyant and rishikanya Shakuntala took place and as a result the great 'Bharat' was born here on whose name our country was named 'Bharat'. 'Abhigyan Shakuntalam' the immortal creation of Maha Kavi Kalidas was the outcome of that great historical event. The study area is interspersed by several rivers like Ganga, Malin, Kotawali, Chhoiya, Ban, Gangan, Karula, Khoh, Ramganga, Banali and Pili rivers. (Fig.1.2) The study area is facing problems of poor environmental sanitation and low standard of nutrition resulting in substandard health of masses. There are several areas in the district where epidemics are undermining the health of people. Various diseases like malaria, filariasis, gastroenteritis, infectious hepatitis, measles, thyrides and Tuberculosis etc. are posing problems of health, specially in rural areas where majority of population dwell without proper drinking water and medical treatment facilities. The villagers have very limited knowledge of personal hygiene, proper infant-feeding and family planning practices due to lack of education. Under such circumstances, Bijnor district is said to be the best suitable study area for evaluating the factors of geomedical studies at length. 1. PHYSICAL ENVIRONMENT OF GEOMEDICAL RELEVANCE Physical factors that affect the health of the population of [4]

the area can be studied under two heads : A. B. INORGANIC FACTORS ORGANIC FACTORS

A. INORGANIC FACTORS I n o r g a n i c f a c t o r s p r i m a r i l y c o m p r i s e g e o l o g y, physiography, hydrology and the soil. The climate has long figured prominently in efforts to explain disease occurrence. Mills (1944 : 1-5) argues that mans general wellbeing is profoundly influenced by the effects of the climate. 1 People living on poor or worn out soil have poor health and are poverty-stricken 2 (Agarwal 1965 : 1). It influences food and nutrition, and may contain pathogenic bacteria. The relief exercises indirect influence through ruggedness and slope but certain physiological changes in the human body are directly related to the altitude. 3 Drainge as a geomedical factor is recognized in conjugation with relief and climate as exemplified in the distribution of Malaria and Filaria.4 PHYSIOGRAPHIC REGIONS Bijnor district possesses diverse physical characteristics. The greater portion of the district lies in Ganga plain. The surface of the ground is very uneven throughout the tract. To the south of the forest belt which forms a fringe along the north and northeastern boundary, there lies an open plain which extends upto the southern margin of the district. The slope of the study area is from northeast to southeast. The average height of the [5]

surface from sea level of Bijnor district is 253 meters but some parts of Najibabad and Nagina tahsils are 275 to 332 metres high whereas most of the parts of Bijnor, Chandpur and Dhampur tahsils have from 200 to 240 metres height. M.V. Pithwala (1939-40), Kaji, S. Ahmad (1942), Stamp (1967), Spate (1951) etc. have shown this area in the upper Ganga Valley region whereas Dr. U Singh and R.B. Verma (1971) have considered this whole area in 'Tarai and Moradabad Plain'. Taking the physiographic diversities and drainage pattern of the study area, Bijnor district may be divided into ten following physiographic regions :1- Tarai - Bhabhar Region 2- Banali - Reharh Region 3- Kho - Ramganga Doab 4- Ramganga - Khadar Region 5- Kho - Khadar Region 6- Ban - Chhoiya - Ganga Region 7- Gangan - Karula Region 8- Bhur Region 9- Malin Riven Region, and 10- Ganga - Khadar Region 1. TARAI - BHABHAR REGION This region is spreading over the area from Kotawali river to Reharh in Najibabad and Nagina tahsils in the breadth of 5 to 10 Km. having the altitude of 305 metres. This wet and fertile tract [6]

is called Tarai where 'Kans', 'Mooj' and Bhabhar grass are grown. 2. BANALI - REHARH REGION This wet and fertile region spreads over Afzalgarh plain of Banali and Pili rivers with an altitude of 265 to 285 metres. To the north of this region lies Tarai and Bhabhar region and in the west and south there extends the Ramganga khadar tract. 3. KHO - RAMGANGA DOAB This is also a wet and fertile plain of Badhapur which is rough, undulating, barren and sandy tract having the height of 290 metres. This tract is situated in the middle of kho river in west and Ramganga Khadar in the east. 4. RAMGANGA KHADAR REGION This region is spreading from Kalagarh in the north to Jatpura in the southeast along both the banks of Ramganga river in the form of a narrow strip. New alluvial soil gets deposited here every year due to the floods in the eastern part of Nagina tahsil. 5. KHO - KHADAR REGION Right from Kotdwar in the north to Sherkot in the middle, a long but narrow strip is stretching called Kho-khadar Region which has fertile sandy soil. In rainy season, kho river and many rainy drains cause here a havoc. 6. BAN - CHHOIYA - GANGAN REGION This tract has a spread over from Malin river in the west to the Kho river in east with a slope from north to southeast. It has [7]

an altitude of 240 to 290 metres. This region starts from Tanda Maibas to Dhampur in the middle with sandy tract. 7. GANGAN - KARULA REGION This is the largest region with a very fertile alluvium soil of Bijnor district mainly in Dhampur tahsil and to the eastern parts of Bijnor and Chandpur tahsils with a sea level height of 200-235 metres. 8. BHUR REGION This is a less fertile sandy and loam soil broad strip dry tract spreading from Kiratpur in the northwest to Moradabad district with an altitude of 205 to 250 metres. 9. MALIN RIVER REGION This region has undulating and rough upland with an altitude of 240 to 320 metres spreading in the Najibabad tahsil having almost unfertile soil but the middle part of the region is somewhat fertile. Malin river is dominant in this region. 10. GANGA KHADAR REGION In between the Ganga and Bhur and Malin River regions, a thin khadar tract of sandy and loam soils spreading from north to south is called Ganga khadar region which has a slope from north to southeast. This region has a height of 200 to 280 metres from sea level. (Fig.1.3) Hydrology Hydrology signifies the availability of water and drainage system influencing the spread of water borne diseases and [8]

outbreak of epidemics in the region and that too, in view of large number of fairs held annually along the rivers of the study area. Groundwater Groundwater is the only meaningful source of drinking water, specially during the summer season. Quality and quantity of available water for drinking purpose determines the health status of the people. Low depth and seasonal fluctuation of groundwater table lead to water logging and water contamination causing serious health hazards to the local people. The average depth of water-table in the district varies from 5 mts. in the central part of Bijnor district to 8.3 mts in the Ganga Khadar, Ramganga Khadar and Kho Khadar regions. The depth of the water-table is controlled by various surface and sub-surface factors such as topography lithology, stratigraphy and rockstructure. The whole district of Bijnor is rich in groundwater resource. Ganga, Ramganga, Malin, Chhoiya, Ban, Ganga, Karula, Khoh, Banali and Pili etc. are main rivers. The drainage pattern is dendritic in general. (Fig.1.4) Climate The seasonal variations of pressure, temperature, rainfall, humidity, winds and storms and other climatic conditions are very effective to the geopathological and health phenomena. Variations in peoples health form season to season are so important that a close association is marked throughout the study area. The important diseases of winter season are common cold and [9]

pneumonia while infantile paralysis, gastroenteritis and measles are common in summer and in severe winter few communicable diseases such as malaria and filariasis show close correspondence to rainy season. The role of climatic conditions is significant in deciding the mentality of human beings. Temperature The temperature plays a vital role in human physiology as it controls the body temperature and circulatory system. 24 0c isotherm passes through Bijnor and Dhampur tahsils. After October, both day and night temperatures decrease rapidly and in January (the coldest month) the mean daily maximum temperature is about 210c (69.8oF) and the mean daily minimum about 80 0c (46.4
oF

). When the district is in the grip of cold

waves, the minimum temperature occasionally drops to about the freezing point of water and frost also occur. Temperatures of the hot season, May and the early part of June constitute the hottest period of the year, the mean daily maximum temperature being about 40 0c (77 oF) in May. The dry dust laden winds which often blow at this time of the year add to the intensity of the heat, the maximum temperature going upto over 450c at times. There is an appreciable drop in day temperatures by about the third week of june, when the monsoon advances into the district (Fig. 1.5 ). Rainfall The distribution of rainfall is uneven both spatially and temporally. The mean monthly distribution of rainfall reveals that [10]

more than 90 per cent rainfall is received from late June to mid October. The mean annual rainfall varies from 1100 mm. in Chandpur tahsil to 1300 mm. to Najibabad tahsil. The normal rainfall of the region is 1200 mm. of which the bulk is received during July, August and September (750mm). Generally, the northern and eastern parts of the district receive more rainfall and it decreases towards south-west (Fig.1.6). Humidity A large amount of humidity present in the air, offers the control to evaporation from the lungs and skin. The moist climate being favourable for the growth of micro-organisms, is considered less suitable for health. For good health, 75 per cent of humidity is considered as the best. August is the highest humid month recording 84 per cent relative humidity while minimum humidity 31 per cent is observed in the month of May. The annual average of relative humidity varies from 65 per cent to 80 per cent and 48 per cent in May. the driest part of the year is the summer season when the humidity in the afternoon can be as low as 30 per cent. Seasons District Bijnor experiences monsoon type climate through well marked three seasons : (i) The Hot-Dry Season (Summer Season) During summer season (March to June), the average seasonal temperature varies from 22.50c in the month of March [11]

to 39.6 0c in the month of June. By March, both maximum and minimum temperature start rising and continue to increase throughout April and May. In the high temperature, the human body functions less efficiently. There is decreased ingastric secretions accompanied by constipation, and impaired appetite and digestion causing dysentery, diarrhoea and other intestinal disorders. Violent thirst and rapid loss of water make the people an easy prey to dehydration. There is oxygen per cubic foot in hot than in cold air which reduces the effectiveness of all body functions. (ii) Hot-Wet Season Of South-Westerly Winds (Rainy Season) The ecological conditions of rainy season (July to October) provide an ideal condition for the multiplication of disease causing microbes and their vectors. The excessive humidity and temperature make internal tract sensitive to gastro-intestinal disturbances. Thus, during rainy season, human health in the study area remains at its lowest ebb. (iii) Cool-Dry Season Of Northerly Winds (Winter Season) The winter season (November to February) is more pleasant and invigorating which promotes physical and mental activities and the prospects of life. The winter cyclones bring cold waves and hail storms which lesson the temperature to considerable extent. In calm and dry clear nights, the cold waves cause chilling effect and frosting resulting in cold, cough, pneumonia, swelling of muscles and joints and respiratory infections. [12]

During rainy season, high relative humidity associated with high temperature makes an oppressive and sultry weather when people feel uncomfortable and prickly heat eruptions are caused.
5

the human body feels difficulty in dissipating internally generated heat. This results in depression of body functions, lowering of vitality and predisposition to infections. October is transitional month, the atmosphere remains humid till late October and temp. remains uniform at about 25 C and thus weather during the months of Sep-Oct. remains unhealthy and unpleasant. This excessive warmth and humidity make intestinal tract sensitive to gastrointestinal disturbances. This climatic condition furnishes ideal conditions for multiplication of diseases causing microbes and their vectors. In summer gastric and biliary secretions are diminished resulting in the loss of appetite and impaired digestion causing dysentery, diarrhoea and other intestinal disorders. The 80 cm isohyet is significant for Malaria and Cholera. Endemically in the part of the eastern plain receiving more than 100 cm of annual rainfall appears conductive to Malaria and Cholera. The unreliability and seasonal variability of rains associated with the monsoon climate often bring floods and drought and influence the epidemic rhythm of Malaria and Cholera in the region.
6 0

[13]

Soils Soil is a complex of mineral and organic substances. Distt. Bijnor has alluvial soil cover. The alluvium of the plains has undergone but little pedogenic evolution since deposition by fluvial agency in the sub recent times. These are still largely immature and have not developed any characteristics soil profile or zonal differentiation, particularly in the Khadar And Bhur soils. These soils have a common origin and almost identical ecological environment. They show, in general, minor variation in colour, texture, porosity and moisture content. B. ORGANIC FACTORS Human health is affected still more indirectly by biologic environment comprising organic factors, trough influence on mans habits and customs, the type and relative importance of agriculture in his economy and his actual occupation and attitude towards health and disease. Among the organic factors that include living beings, plants, and animals are particularly important for health as are the pathogenic parasites plant and animal life influence the health of man much less directly but often in an interrelated way. With moderate rainfall and fertile soil it is the natural habitat of dense forest cover of Shisham, Jamun, Bel, Mango tree, Neem, Peepal etc. Natural Hazards The climatic hazards include mainly droughts and floods. [14]

Drought and flood affected area becomes disease infested, resulting in general lowering of the health of the people. Mohd.pur Deomal, Bijnor, Kiratpur and Afzalgarh blocks are the well recognised flood prone areas. The floods have been a regular menace in this area. The Ganga and Ramganga are the main rivers here and has a perennial supply of water. Chhoiya, Ban, Malin, Khoh, Karula, Gangan and Banali rivers are its other tributaries. The Flooded plain provides the breeding place of mosquitoes causing diseases like malaria and filariasis. The region also comes in the grip of severe cold waves causing death due to unbearable cold stress. Hot speedy winds blowing in the month of May to mid-June take the toll of human life. In the rainy season the rains are excessive and cause heavy floods, damaging the low lying Khadar tracts. Thus floods apart from causing loss of human lives and damage to crops, property and cattle are generally followed by the degradation of environmental sanitation, resulting in epidemic outbreaks of water borne disease as malaria, filaria and encephalitis. Cold and Heat waves The weather condition of this region is influenced by both the tropical and mediterranean cyclones. The cyclonic storms and depressions which take their origin from Bay of Bengal visit this region both in pre monsoon and S.W. monsoon season. The cyclonic storms which form over the Bay of Bengal during the transition develop an inner core of a calm centre. Monsoon rainfall [15]

changes rhythmically from wet to dry spells as these depressions arrive and pass away. Cold waves account for a number of deaths in the area. About 35-40 lives, depending upon the severity of the cold spell are lost every season due to cold wave. (Fig.1.7) Summer months are characterized by hot sun over the longer days with hot high velocity westerly winds (Called Loo) and dust storms in the late afternoon. In summer season when humidity is as low as 2 to 3 heat exhaustion of heat stroke which often result in death. Population Structure and Health The nature and man are jointly responsible for deciding the health status and quality of life of a society. The influence of physical environment on human health has been discussed earlier. It is essential now to make a detailed study of factors in relation to human host or community being affected by total environment, as they are largely responsible for the occurrence of various diseases and maladies in the human beings. This section, therefore, aims to study the demographic features and their vital characteristics affecting human health. Age Structure One of the widely and strongly correlated attributes of human health is age structure of the population which influences diseases by its relation to susceptibility and exposure. Age, as an index of personal capacity, determines reproductive as well [16]

as a working capacity of a population group. The age structure is basically determined by the fertility, morality and mordibity. It is necessary to evaluate the age structure of the population in Bijnor district. In order to know the disease in relation to the susceptibility and exposure, difference in age composition must be taken into account. As per 1999 and 2001 census, 39.43 and 40.12 percent population of district Bijnor comprises infants and children belonging to the group of 0-14 years. Out of it 20.93 percent comprise male and 17.87 percent female. The age pyramid of Bijnor has a broad base but curves sharply upward. This is the main characteristics of pyramid in developing countries. This is due to higher rate of infant mortality in these countries, mainly for lack of primary health care facilities. A large number of population (8.6 percent males and 7.3 percent females) comes in the lowest group of 0.5 years. Population Density Density of population may be considered as the indicator of health status of the people. The people of densely populated area due to poor sanitation are more susceptible to epidemics and other diseases. The areas of high density usually have a adverse man-land ratio which in turn leads to poor living standard and ill health. About 3.67 million people (2011) reside in the Bijnor district making it one of the most densely populated districts of the state. There are great variations in the population density in different [17]

tehsils of the study area. The density varies from 400 persons per km in Kotwali block to 939 persons in Dhampur. The Growth rate during 1999-2001 varies between 26.20% and 30.09%. The growth rate has registered sharp increase in Bijnor, Allehpur and Khari Jhalu blocks as compared to the previous census decades. Regionally, the density of population is low in the Ram Ganga Khadir where as the northern and northeastern parts of Bijnor tehsil are densely populated. Regionally, the density of population is low in the Kotwali and Azalgarh block. The middle parts of the study area are densely populated. (Fig. 1.8 and 1.9) Literacy Literacy influences personal health practices which are based on knowledge of causes of diseases and preventive measures. The level of education and literacy decide the attitude and awareness of people towards health and hygiene. The control of many diseases has been facilitated by positure change in health behaviour. The map of illiteracy coincides closely with map of poverty, malnutrition and ill health. Degree of literacy of population is being considered as one of the determinants of specific health education. Health education is an essential tool of community health. The W.H.O. (1983) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Health education has been defined as a process which effects changes in the health practices of people and in the [18]
7 2

knowledge and attitudes related to such changes. A great deal of ill-health in the area and elsewhere is due to ignorance of simple rules of hygiene or of indifference to their practical application. Health education aims at bridging the gulf between the health, knowledge and health practices of the people. Literacy among people is thus of paramount importance. The study area of district Bijnor, on an average, has 59.37% literacy according to 2001 census reports. The highest literacy is found in Bijnor tehsil which is about 63.00 per cent and the lowest literacy percentage is found in Kotawali and Afzalgarh blocks, 53.12 and 49.90 respectively. The literacy rate varies sharply across genders. (Fig. 1.10 and 1.11 ) Nutritional Density The nutritional density is a more refined technique of calculating man-land ratio and is expressed as the ratio of total rural population and total cropped area. In the study area where agriculture is the mainstay of the people, a study of population pressure on land resource attains special significance to assess the degree of undernutrition and malnutrition. The over population area are likely to have food scarcities at least at local level and therefore are likely to suffer from under nutrition. Fig. 1.12 shows the nutritional density of the region, The different shades show the density variation in the different blocks of the study area. In Bijnor district as a whole, the nutritional density is about 446 persons per km of cropped area which shows that there is more [19]
2

pressure of population per km of cropped area here than at the state level which records nutritional density of 340 persons per sq. km. This indicates pressure on agricultural land and low nutritional level of the region. The middle part of the region is the area of high nutritional density. (Fig.1.12) B. THE CULTURAL FACTORS OF HEALTH All people whether rural or urban have their own belief systems and practices concerning health and disease. It is now widely recognised that cultural factors are deeply involved in all affairs of men, including health and sickness. Not all customs and beliefs are bad. Some are based on centuries of trial and error and have positive values, while others may be useless or positively harmful. Some of these cultural factors, hallowed by centuries of adherence have stood in the way of implementing health programmes. Where a change of behaviour is involved, the resisitance of people is the maximum. However, systematic information about these factors; customs, cultural modes, habits, beliefs and superstitions is still woefully lacking. Available Transport Facilities Infectious diseases are generally communicated with the movement of people. At present increase in volume and speed of travel has spread the infectious diseases on a much larger scale and in comparatively shorter period. Means of quick transport, on the other hand, are helpful in providing timely medical aid. But in the Ram Ganga Khadar particularly in the eastern part of [20]

the area, availability of transport facility is poor and uncertain. Therefore, most of the people of rural areas are unable to avail of proper medical aid in help. During monsoon season, availability of transport facility is still adverse. The delivery of health service becomes poorer when they are most needed. The rail and road traffic is generally the cause of spread of epidemics. In 1957 flue progressed all over U.P. in marriage season. Problerm of rush and congestion is further aggravated resulting in big crowd of passengers affecting population in the vicinity of bus and railway stations; the centres of transmitting infection. Etiology & Cure The socio-economic conditions have fairly influenced the geomedical landscape of the region. Due to low percentage of literacy; people are dogmatic and superstitious and do not realize the significance of family planning. On account of religious customs and beliefs, human health is generally impaired. Agriculture, dominant occupation of the people is, generally associated with fatalistic attitude towards life. There are many people who still believe that certain diseases are due to the wrath of some God or Goddess. Small pox and Chicken pox are considered to be the expressions of anger of Bari Mata and Chhoti Mata respectively. They conduct Devi worship following an attack of small pox. Venereal diseases are considered to be the outcome of illicit sexual intercourse with a woman of low caste or a woman during menstruation while [21]

sexual intercourse with a virgin is considered to cure Venereal diseases. Disease such as leprosy and Tuberculosis are considered by some as a result of past sins of the suffering individual. Physical factors are also considered to be responsible for certain disease. Exposure to heat during summer is responsible for an attack of Loo (heat stroke). Certain food-stuffs are considered to heat up the body system such as meat, fish and eggs. On the contrary, certain foods are considered to cool the body like curd, lemon, cow milk and vegetables. The wrong combination of foods may give rise to diseases such diarrhoea, dysentery and cholera; skin diseases are considered to be due to impurity in blood. Eating neem leaves and flowers is considered to purify the blood. Disposal of Human Excreta About 78 percent of people in rural areas go to fields for defecation. Ladies confined to their courtyards get an opportunity to meet their friends and renew contacts during dawn and dusk combining a physiological with a social need. The health hazards associated with improper excreta disposal through soil pollution, water pollution and transmission of diseases by flies, unclean hands and polluted food, are well known. Disposal of Wastes The waste water from houses is permitted to collect in ditches and overflow into the streets. As there is usually no [22]
8

drainage in villages, mosquitoes breed in pools of dirty water providing chances like malaria, filarial of even incephalitis. Water Supply Tube wells, handpums, ponds, rivers are places where people go not only to draw their supply of water but also to meet friends. It is also a place where human and animal beings bathe and people wash their dirty clothes. These practices lead to the pollution of well water. Tanks and ponds are also used frequently for washing, bathing of humans and animals and even as a source of drinking water. Housing Rural houses are usually Kaccha and damp, ill-lighted and ill-ventilated. Animal keeping is very common in villages. In many cases human-beings and animals live together under the same roof. Food Habit The diet of the people is greatly influenced by the local conditions, religious customs and beliefs. The method of cooking of food materials and habit of eating are mostly regulated by local customs. There are two main types of food consumedvegetarian and non-vegetarian. The use of meat, onions and garlic is a taboo for certain castes. Regular fasting constitutes an integral element of the religio-cultural mode of life. The term fast implies a complete abstinence from all food or nourishment liquid or solidfor a greater or lesser period. Muslims observe day fasts during [23]

the month of Ramzan. People of the working class take country liquor, now and then leading to serious diseases among the addicts. Mother and Child Health In India a barren woman is looked down upon in society. The prevalent notion is that every female must be married and every couple must have a son to perpetuate the family. During child birth in the rural areas, cowdung is used as a dressing for the cord which leads to tetanus. The practice of applying Kajal mixed in oil on the eye-lids is common; partly for beautification and partly for warding off the evil eye. This custom has been blamed for transmitting trachoma and other eye infections, specially in children. Personal Hygiene Hygiene aims not only at preserving health but also at improving it. The purpose of hygiene is to allow a man to live in healthy relationship with his environment. Use of twings of neem tree as a tooth brush is very common in rural areas. Offering pan leaves smeared with lime and kattha with or without tobacco is common social custom indicating hospitality. Shaving is done by traditional barbers who do not have razors sterilized. Smoking and putting raw tobacco mixed with lime under lips is very common is urban as well as rural areas. Hookka or Biri is generally used in villages and cigarette or cigar in urban areas. This is usually the cause of mouth cancer or tuberculosis. [24]

Fairs And Festivals Religious fairs and festivals are of special importance in the cultural landscape. The pilgrim centres are often centres of potential disease outbreaks. Periodic fairs and festivals in Nav Durga puja or Nav Ratri draw big crowds. These fairs are specific in time and space and are organized on special occasions. Festivals like Durga Puja. Id and Diwali are annually held according to religious calenders. On such occasions people come in close contact with each other. Cholera and other water borne diseases have been closely associated with these fairs and festivals. Often these fairs have served as starting points of Cholera epidemics. Most of the fairs make a quick diffusion of Cholera in the event of epidemic outbreak of the disease. In the present industrial-technological era when all round natural environment has been profoundly changed and modified with mans ever increasing involvement with his physical environment, the health of the people appears to be a matter of direct social concern. Thus, recognition of the impact of social and economic conditions on health and disease, is an urgent need for investigating scientifically casual relationship between cultural factors and diseases. The social condition and customs which have been indicated above are most important factors in cultural environment. There are some other factors besides these traditional ones that leave [25]
9

effect on modern society and make a certain type of cultural environment in which the population of the region lives. These factors change from time to time because of sense of healthy living developing by education. So, literacy, religion, caste system, concept of disease and treatment, fairs, festivals and economic conditions of the people; their income; nature of job, the development of means of transport by which they fulfill their medical service needs are equally important.

[26]

REFERENCES
1. Mills, C. (1944), Climate Makes the Man, Gallanoz, London, P. 1-5. 2. Agarwals, R.S., (1965), Soil Ferrility in India, Asia Pub. House, New Delhi, P. 1. 3. Basu, B.B., (1968), The Concepts and Contours of Geomedical Study, the Deccan Geographer, Vol. No. 2, P. 118-182. 4. Learmonth, A.T. A. (1958), Some Contrasts in Regional Geography of Malaria in India and Pakistan, Trans and papers Inst. British Geographers, 23, P. 37-39. 5. Sinha, S.C. (1981), Medical Geog. of U.P., An unpublished Ph.D. thesis, submitted to Gorakhpur University. 6. Spate, O.H.K. and Learmonth A.T.A., (1967), India and Pakistan-A General and regional Geography, Methuen London, P. 41. 7. 8. W.H.O. (1967), Tech. Rept. Sr. No. 302. Park, J.E. et al. (1972, 1985), A text book of Social and Preventive Medicine, P. 26. Banarasidas Bhanot Publishers, Jabalpur. 9. Roger, L., (1928), The Incidences and Spread and Control of Epidemics Ind. Med. Res. man. No. 9.

[27]

CHAPTER - II

ECOLOGY OF MALNUTRITION

CHAPTER - II

ECOLOGY OF MALNUTRITION
Good nutrition is a basic component of health. Nutrition is assuming increasing importance in our country where nutritional deficiency diseases are widely prevalent. On community medicine, nutrition is of paramount importance. The effects of mulnutrition on a community are both direct and indirect. The effects manifest in nutritional deficiency diseases and indirect effect is seen in people with low vitality and arrested growth, high infant mortality, neonatal and still birth rates and lower expectation of life. The terms food and nutrition are sometimes used synonymously. But food is a composite mixture of various substances. The quantity of which may vary from a fraction of a gram in certain cases to hundreds of grams in others. Nutrition, on the other hand, signifies a dynamic process in which the food that is consumed is utilised for nourshing the body. Energy, the most fundamental requirement of the human body is derived from the consumption of food of the required caloric value. Growing children and women during pregnancy and lactation period require extra energy. Undernutrition results in loss of weight and such disturbance as low basal metabolic rate, slow pulse, lowered blood pressure, suppression of menses in women, skin complaints, blood shot eyes, etc. Nutritional endemic, burning sensation in the feet and hands and a sore

throat with increased salivation are common symptoms in cases of chronic starvation. A poorly nourished child lacs behind in critical learning and perceiving things, whether or not his brain has been physically damaged. NUTRITIONAL STATUS OF BIJNOR DISTRICT The dietary constituents of food are proteins, fats, carbohydrates, vitamins, minerals and water. Most of the foods contain all these constituents. After discussing the dietary pattern of the district, it seems necessary to analyse the different aspects of nutritional condition in Bijnor district. CALORIES The diet survey pattern shows that the people of this district get a daily per capita average of 1940 calories. The state Nutrition Survey Division reports an average of 2200 calories. The state caloric intake (2200 calories) is higher than nutritional average (1980 calories). The regional caloric deficiency is the effect of poverty. Most of the caloric deficient tahsils are such rural areas where the people are poor, backward and illiterate. Lack of educational facilities keeps them unaware of the advances already made in agriculture. As a result, their per acre average production is low and thus per capita income level is also low. They live in unhygenic conditions. Educational backwardness influnces their dietary pattern. They do not know about balanced diet. That is why, nutritive value of their diet is below national or recommended avarage.

[30]

The caloric requirement depends upon nature of work, climate, age and sex. There is special requirement of calories in pragnancy, lactation, infancy and pre-school stage. BALANCED DIET A balanced diet is defined as one which contains different types of food containing calories, amino acids, vitamins, minerals, fats, carbohydrates and other nutrients in such quantities and proportions as is adequate for maintaining health. If the diet lacks one or some of these elements, malnutrition results and proper physical and mental development is retarded showing illness or low capacity of work. TABLE 2.1 BALANCED DIET (ICMP- 2001) (IN GRAMS) S. No. Food items adult men Moderate Work 1 2 3 4 5 6 7 Cereals Pulses Leafy veg. Other veg. Milk Oil & Fat Sugar 520 50 40 70 200 45 35 adult women Moderate Work 440 45 100 40 150 25 20 childern (10-12 years) Boys Girls 420 45 50 50 250 40 45 380 45 50 50 250 35 45

Food and nutrition problems are in general related to the food resources of the area and the people. To study the ecology

[31]

of malnutrition, it is necessary to consider the daily requirement of dietary constituents (Protein, Fat, Carbohydrate, Vitamins and Minerals) and different food production and their nutritive value in relation to population. The main functions of food are : 1. 2. 3. Provision of energy Body building and repair Maintenance and regulation of tissue functions

THE CONSTITUENTS OF FOOD ARE (A) PROTEINS Proteins are complex organic nitrogenous substances. They contain carbon, oxygen, nitrogen and sulphur in varying amounts. A human adult contains about 10 kg of protein. PROTEINS ARE NEEDED BY THE BODY FOR 1. 2. 3. Growth and development Repair and maintenance Synthesis of certain substances like antibodies and hormones. When excess protein is consumed by body, it is used as energy. THE SOURCES OF PROTEIN ARE 1. Animal sources -- Milk, eggs, meat, fish, liver of animal based sources. 2. Plant sources -- Pulses, nuts and cereals are main sources of protein. 3. Non-conventional sources - Groundnut, oil seeds, cotton seeds, coconut are additional sources of protein.

[32]

TABLE 2.2

Nutritive value of main whole cereal grains

(Value per 100 G)

Cereals (mg) 12.2 7.5 9.5 10.1 3.3 30 4.3 12 5.0 6.2 18 15 2.8 2.3 30 3.5 .40 .25 .33 .40 (mg) (mg) (mg) (mg)

Calories

Protein

Fat

Calcium

Iron Thamine

Naicin (mg) 5.0 4.0 1.5 3.5

Riboflavin Vitamin (mg) 0.17 0.12 0.13 0.12 A Traces Traces Traces

[33]

(mg)

Wheat (Whole meal)

334

Rice (husked)

35

Maize (whole meal)

356

Millet (Sorgham)

343

Source - A.O. Lucas Gills H.M. - A short text book of prevetive Medicine fot the Tropics - p.242.

DAILY REQUIREMENT OF PROTEINS Nutritional expert group of Indian council of Medical Reseach (ICMR 1968) recommended that daily requirement of protein for a normal male adult of about 55 kg body weight is 55 g. An average women weighting 45 kg. required 45 g. of protein per day, but during pregnancy, she requires 90 g. and infants 2.3 g. protein per kg of body weight. Deitary allowance of protein for different age groups as suggested at present are for a normal person in good health. But as it happens, many adults, nursing mothers and pregnant women in our country possess low body stores of protein. Higher intake of protein especially by pregnant women and nursing mothers would be certainly to their advantage. (B) FATS These are an important items in the diet of people. They contain carbon, hudrogen and oxygen. They are composed of fatty acids which are saturated or non-saturated fats are essential for body because : 1. They are concentrated and palatable sources of food energy. 2. 3. Fats carry fat-soluble vitamins. They provide essential fatty acids which are required for growth and maintenance. 4. Fats provide support for many organs in the body such as heart, kidney and intestine. Fat beneath the skin is an insulation against cold. [34]

SOURCES OF FATS The sources of fat include 1. Animal Sources - Ghee, Butter, Curd and fish oils have more saturated fats than vagetable fats. 2. Vegetable sources - Groundnut, cotton seed, coconut oil, mustard are general vegetable fats. Vanaspati which is a popular cooking medium in India is manufactured by hydrogenation of vegetable oils, mostly groundnut oil, coconut oil and cotton seed oil. On hydrogenation the liquid unsaturated oil is converted into solid fat. By government legislation, the vanaspati that is manufactured in India, is fortified with vitamin A and D and provides 2500 i.u. of vitamin A and 175 i.u. of vitamin D per 100 grams. REQUIREMENTS The Nutrition Expert Group (1968) in India have suggested a daily intake of 15 grams of Visible fats But excessive consumption of fat results in obesity and vascular diseases. Diet surveys show that in average Indian diet only 913 per cent calories are derived from fats. (C) CARBOHYDRATES Carbohydrates are the cheapest source of energy. They are composed of carbon, hydrogen and oxygen. Our Indian diet have excess amount of carbohydrates providing 90 per cent of calories. In the Indian adult carbohydrate reserves are only about

[35]

500 grams. When a man is fasting, this exhausts rapidly. In average balanced diet carbohydrates provide not more than 5060 per cent of total calories. THE SOURCES OF CARBOHYDRATES Starches, sugar and cellulose are main sources of carbohydrates. Starches are present in roots, cereals and plant stems. Sugar comprises monosacchartides (glucose, fructose and galactose) and the disaccharides (sucrose, lactose and maltose). Cellulose is the fibrous substances lining cereals, fruits and vegetables. It comes under polysaccharides. (D) VITAMINS Vitamins are complex (Jagannathan, 1968) chemical substances required by the body in very small amounts. They do not yield energy, but act as catalysts in various body processes. There are thirteen vitamins needed by the human body and these are widely distributed in foods. Vitamins are divided into two groups : 1. 2. Fat soluble vitamin - They are A.D.E. & K. Water soluble vitamin - B & C group are of this type.

Each vitamin has a specific function to perform and deficiency of any particular vitamin leads to specific deficiency diseases. (E) MINERALS The body contains more than 19 minerals all of which must be derived from food (ICMR 1968). Many of them are widely distributed in food stuffs so that a well balanced diet will supply

[36]

sufficient quantities of the same. The minerals include Calcium, Phosphorous, Iron, Sodium, Potassium, Chlorine, Sulphur, Megnesium, Iodine, Zink, Magnese, Molybdenum, Cobalt, Selenium, Chlromium, Bromine, Fluorine, Aluminium, Arseni and few others. The minerals are necessary for body for various purposes, viz : 1. For formation of bones and teeth eg. calsium, phosphorous and magnesium. 2. 3. 4. Iron is necessary for blood formation. Iodine for normal functioning of thyroid gland. Copper is needed along with iron for the formation of blood cells. 5. Some minerals are present in body fluids and play a physiological role minataining osmatic pressure. SOURCES OF DIFFERENT MINERALS 1. Calcium - milk and milk products, fish, vegetables, fruits, cereals, drinking water, betal leaves are the sources of calcium in differrnt quantities. 2. Iron - Animals liver and meat, poultry eggs, yolk and fish are rich in iron. Cereals, pulses, vegetables particularly leafy vegetables and nuts oil seeds all contain iron. A significant amount of iron can also be derived from cooking meals in iron vessels. 3. Iodine - The dietary sources of iodine is food and water. The iodine contents of food depends upon the iodine

[37]

countent of soil. The rich natural sources of iodine are crude iodinised salt, sea fish and cod lover oil. Water also contains traces of iodine. 4. Sodium, potassium and magnesium - More than 60 per cent of human body consists of water. The water allowances of healthy persons is about 1 ml per calorie of food. In tropical countries, the requirement may be higher. In the tropics, the daily requirement of sodium is about 15 to 20 grams for an adult who works hard (Swaminathan 1960). Magnesium is essential for normal metabolism of potassium and calcium. Total daily requirement is estimated to be 10 mg which is easily available in food. CAUSES OF NUTRITIONAL DEFICIENCIES (1) BIOLOGICAL The nutrional requirement of human body may be considerd to be the product of mans adaptation to environmental opportunities in his evolutionary history. The balance between human, animal and plant population was so optimal that the chances of nutritional deficiency could at best be rare. (2) THE MAN-FOOD RATIO Availability of food is an important detrminant of the nutritonal level of the people. But increase in food production does not necessarily improve the nutritional status of a community. The structure of society and manner in which production, distribution and consumption are organised, are often equally, if not solely important factors. [38]

(3)

CULTURAL CASES Cultural factors are also of consequence in determining

the nutritional status of the population. The very attitude of life and living, the food habits, concept of health and disease and taboos on food and drink have serious implications for health and nutrition. Polluted drinking water, inhygeinic living conditions and many other similar factors can create conditional malnutrition. UNDER-NUTRITION IN BIJNOR DISTRICT In this district of Bijnor, people eat heigher proportion of cereals. An average Indian needs 2225 calories per day to keep his body healthy while ICMR surveys show that he gets only 1945 calories. This Food is short of animal protiens and fats and hence they take more per centage of carbohydrates. They get 79 per cent of calories from this source and very little from other foods. The inadequate consumption of protective foods like meat, milk, fruits and vegetables shows the low nutritive value of Indian diet. Over cooking leads to loss of nutrition and overspacing to indigestibility of food. The nutritional survey on personal level shows that there are four major deficiency diseases prevalent in this region. These are Anaemia, P.C.M., avitaminosis & Goitre. Lack of protien is also responsible for Anaemia, Malaria and Hook worm which create favourable conditions for its development. The deficiency of vitamin A is responsible for night blindness. It is more common in low income groups and pregnant women. Goitre is highly endemic in this study area. [39]

It is estimated that 10 per cent of maternal deaths are due to nutritional anaemia. Many factors are responsible for that as discussed below : FACTORS The background of nutritional deficiency conditions are very wide and can be seen to be more dependent on the socioeconomic level of the society than particularly any other disease factor. It is the deficiency in total quantity of quality of foods consumed that leads to poor nutrition and therefore, the epidemiology must be dependent on the chain of food production, processing, distribution, preparation and consumption. FOOD PRODUCTION AND DISTRIBUTION The availability of food per capita is average in Bijnor compared to other developed parts of U.P. Cereals are cheapest source of calories in diet. They provide 30-80 per cent calories of human diet not only in our country but also throughout the world. Even now, production of food is largely dependent on the monsoon in India. About 74.6 per cent population is engaged in agriculture but climatic conditions, such as rainfall, temperature, winds and soil erosion go a long way to determine the outcome of agriculture. The development of high yielding stains of cereals and millets in recent years is a major break-through in nutritional improvement. The new strains are not only high yieling but they contain more protein, amono acid and lysine than the local varieties.

[40]

TABLE 2.3 Food production of Bijnor 2010 (in Lakh Quintals) 1 2 3 4 5 Cereals Pulses Potatoes Sugercane Oilseeds 35.37 12.86 66.20 415.70 17.00

Sources - Statistical Handbook of distt. Bijnor 2010. District Bijnor produces more than its average food grain requirement. The cereals constitute better food and the richer in carbohydrates as well as protiens. Their storage and transportation do not pose the same extreme problems as are posed by root crops. Food grain requirement has been worked out as per I.C.M.R. Recommendations for a balanced diet i.e. 480 grams (17 oz) cereals and 60 grams (2.0 oz) pulses per capita after converting the regional population into adult consumption unit. When we analyse the situation in terms of dietary requirements (ICMR, 1968) after substracting the wastage (for seed, animal feed etc.) of 20 %, we find the region is surplus in food grains.

[41]

TABLE 2.4

Food Grains Situation in 2001-2010

(Lakh Quintals) 1. Average annual production (a) Cereals (b) pulses Total 2. Allowances for Seed, Wastage and animal feed etc.(20%) (a) Cereals (b) pulses Total 3. Net Quantity available (a) Cereals (b) pulses Total 4. Population (In Lakh) 5. Adult Consumption Unit 6. Food grains requirement (a) Cereals (b) Pulses Total 7. Surplus/Deficiency (a) Cereals (b) pulses Total [42] +6.82 +4.98 +11.80 +3.72 +5.69 +9.41 16.24 3.50 19.74 24.58 4.60 29.18 23.06 8.48 31.54 29.44 109.00 28.30 10.29 38.59 36.71 144.00 5.76 2.12 7.88 7.07 2.57 9.64 2001 28.82 10.60 39.42 2010 35.37 12.86 48.23

Analysing the situation of grains production we see that the region is surplus in cereals by about 3.72 lakh tonnes and in pulses by 5.69 lakh tonnes per years but low economic development and low per capita income is responsible for caloric deficiency in the region. The distributional pattern is also responsible for that. The facilities for transport and communication are very poor in the study area specially in the north and northeastern part of the region. The area is able to produce 90 per cent of their calories requirements, but the fact ramains that a good number of people still suffer from caloric deficiency because the setup of distribution and consumption among the people is defective and faulty. Although the district Bijnor as a whole may have more of its caloric requirement available but poor feeder roads, poor trunk roads and absence of marketing and distribution facilities, and above all, the purchasing power of the landless rural poor may make for a situation where large quantities of food products may be rotting in one place while there is actual starvation in another. A similer situation often exists within individual families. In many stances, in spite of the fact that enough food is going into the family pot, the main adults often receive a high production of their caloric and protein requirements while the childern and female get much less than what is required for them.

[43]

2. FOOD STORAGE AND PROCESSING There are severe losses in the field which may be due to climatic conditions or social factors. Post harvest losses of food grains and for the starchy roots and vegetables, this may be an underestimate. Such losses are due to poor storage and transportation facilities and lack of processing facilities in Bijnor district. 3. DEMOGRAPHIC PROBLEMS RELATED TO FOOD Towns and cities are growing at a very high rate and people from villages continue to pour into the towns creating a situation where proportions of the population are not food producers but are buyers of the same. Our modern towns are such that no real food production activity can be undertaken in or near them. Within the town itself, cash is the major dererminant of the level of feeding and it is a fact that casual labourers and the urban poor and their families are among such groups whose nutrition is unsatisfactory. The consumption of cereals and pulses in rural areas is much greater in comparison to the urban areas. Their diet is rich in milk and milk products. The urban area diet survey showed that in general 64.9 per cent of total income was spent on food items but many failed to buy or have a balanced nutritive diet in the cities of Bijnor district. 4. EDUCATION AND SOCIO-CULTURAL FACTORS Education is a very important factor in the choice of food. It acquaints people with better choice of food and better cooking

[44]

practices within the family. After analysing the epidemiological aspects of protein-caloric malnutrition in this region, we found that 90 per cent mothers were not educated and their childern had protein-caloric malnutrition. Lack of formal education also appears to hinder good nutrition practices in another way, and many of the people hesitate choosing new and unfamilar food. 5. FOOD PREPARATION AND CONSUMPTION Methods of preparation sometimes improve the quality of food. Sometimes there is an adverse effect e.g. fermentation of the group of vitamins. There are certain foods which are not considered good food for certain physiological groups, yet the same foods may be nutritionally just what other groups require. A child requires more of every thing than the adult. Sometimes mothers who work for some salaried employment away from home stop breast feeding quite early. At present problems of P.C.M. in the urban areas are quite severe. The highest incidence of P.C.M. occurs in the postweaning child. 6. THE ROLE OF INFECTION Infection may contribute to the nutritional status of an individual through two possible avenues direct or indirect. When a person suffers from an infection, there is loss of appetite which means that his intake is reduced and if his previous nutritional state has been unsatisfactory and infection rather

[45]

prolonged, weight loss will result. These combined reasons may help to drain sick child of valuable nutrients and lay the foundation for nutritional deficiency conditions. 7. MILK AND MILK PRODUCTS Milk is an important source of protein in predominantly vegetarian population of the region. The number of cattle in this area is considerable but due to low yielding capacity per milch animal, the total milk production about 27 per cent is converted into ghee, butter and other puposes. This means that the area is deficient in milk products per capita per day. 8. MEAT, FISH, EGGS The majortiy of population is conservative with regard to the choice of food and the people are orthodox about non vegetarian food. About 73 per cent of population come in this category. The total production of vagetables comes to hardly 3.8 gram per capita per day. However, in recent past egg eating has become more popular. several poultry farms have cropped up in this region. It is estimated that 79 per cent of total population of this area is egg eater. According to this information, the total production of the region comes to one egg per day per capita (personal computation).

[46]

TABLE 2.5 Showing Tahsilwise Number of cattles in Bijnor District-2010 (in Lakh) 1. 2. 3. 4. 5. Najibabad Bijnor Nagina Dhampur Chandpur Total Source : Statistical hand book of distt. Bijnor-2010. 9. FRUITS Seasonal fruits like mango, papaya, banana, pine apple, guava, citrus, melon, cumcumber, lemons are very important in their nutritive value. Mango, banana, papayas, lemons are the fruits available to common man generally. 10. VEGETABLES Almost all the vegetables which are popular in this district 2.06 3.80 2.30 3.90 3.77 15.83

potatoes are widely grown in this region and this is the vegetable which is available throughout the year. About 66.20 Lakh tonnes (district statistical hand book 2010) of potato is annually produced in this region. Brinjal, turip, gourds and pumpkin are available almost throughout the year. But some vegetables such as french beans, green peas, radish, cabbage, cauliflower, carrots and tomatos are seasonal. Leafy vegetables are also grown in abundance.

[47]

11. SUGAR This is an important source of carbohydrates. Bijnor district produces 415.70 lakh tonnes of sugarcane. So, in terms of availability per day this comes to about 1230 gm. which is 29.2 times more than recommended quantity per day. 12. FAT AND OILS Balanced diet also includes fats and oils in some quantity. This is a concentrated source of energy. On the basis of total production, the average per capita per day works out to 63 grams. It is much more than ICCMR recommendation of 35 grams per day per capita. DIETARY PATTERN OF BIJNOR DISTRICT The dietry pattern of a regional complex both physical and social factors including soil and climate, tradition and culture, the structure and pattern of the economy, communication and disease geography. In other works, we can say that the dietary pattern is much influenced and shaped by physical and socioeconomic factors weather it may be production availability or intake of food in some area. It is very difficult to assess the nutritional status of some regional population for the obvious reason that reliable data are not available. Dietary pattern is based on diet surveys of all the five tahsils and personal investigations. The regional variation (table 2.6) shows that diet of the people in this district consists mostly of cereals. They eat very

[48]

TABLE 2.6

Tahsilwise variation in food consumption

Area Pulses Veg. 65.0 42.0 51.7 41.0 39.5 44.4 45.5 46.6 89.2 196.0 12.2 35.5 34.5 154.0 46.0 Ghee Fruits & Oil &

Consumption

Diet consumption in grams Milk & Milk Products 49.4 41.6 34.9 31.0 30.0 Meat, Eggs, Fish, etc. 32.0 18.2 14.1 13.0 12.2

Units

Cereals

[49]

176

502.0

151

398.0

109

458.0

105

385.0

Total

98

351.0

Source : Based on dietary field survey in June, 2010

little amount of animal protein, vegetables, fruits and milk. For want to proteins, the dietary conditions is poor. The dietary pattern shows that cereals and pulses toghether fulfill the 75 per cent of caloric requirement of the region. They contribute nearly 85 per cent protein (Most of thiamine and niacine) about 70 per cent of fat, 40 per cent of calcium, 15 per cent of vitamin A, 50 per cent of riboflavine and negligible proportion of vitamins C and D. The dietary pattern varies from region to region depending upon geographical, cultural and socio-economic conditions. Conditions of physical environment have led to great variations in cropping systems and food production which, in turn have led to wide regional variation in the staple food of the people. Rice is a staple food in Bijnor district. The protein requirements are largely met by pulses. Though milk and milk products are always available but their average intake is a too far off the recommended quantity. The total production is less than what is needed for a healthy society. Meat, fish and eggs are consumed in a small section of society. A large number of people in the district are Brahmins and they refuse non-vegetarion food. The Hindus object to beef, the Muslims to pork and jain and Buddhists to all kinds of meat. So the proportion of intake of animal protein is very low except that of Muslim and Sikh communities mainly. Green vegetables

[50]

are an important source of protein and phosphorus but they are absent in common mens food. SAMPLE STUDY For the analysis of regional variation, seasonal variation, influence of community and diet-consumption between different income groups, it was necessary to conduct survey of family groups in different regions and protein-caloric-malnutrition. Lack of formal education also appears to hinder good nutrition practices in another way and not too well known foods. A sample survey was carried out involving 90 families by the patients visiting a clinic. Patients from urban and rural areas come to the clinics. 90 families with 419 members as adults Consumption units were surveyed for this purpose. The surveyed families were equally distributed in urban and rural areas. Items like cereals and other main foods were weighted before cooking. The childern below 12 years were counted as half a unit but inflants were not included. Nutrition is the basic factor for healthy life and building up the resistance against environmental stresses. The inadequacy of nutrition in the human body results from inadequate quantity or quality of food consumed. The diet survey reports show the regional and community wise effects of income groups on the dietary pattern of the population. REGIONAL VARIATION Per capita consumption of cereals is highest in Ganga

[51]

TABLE 2.7

Community wise diet (Daily food intake per head per day) in Bijnor district 2009-2010

S. Grams Mg. mg I.U. mg.

Name of

Calories Pritein

Fat

Carbohydrate Calcium

Iron

vitamin Riboflavin

Nicotinic mg.

Thiamine mg.

No.

Community

Grams Gm

[52]
32.0 40.2 46.8 46.2 25.0 46.0 290.0 722 211.0 47 244.6 672 275.0 689 12.9 12.4 10.0 11.8 494.6 679 11.0 253.5 565 06.2

Jats

2500

63.0

1907 2490 1725 2094 995 2777

1.9 2.2 2.3 2.4 1.4 1.9

6.2 7.6 6.4 8.0 7.1 7.7

1.1 1.4 0.9 1.4 10.87 1.4

Muslims

3900

61.5

Sikhs

3300

74.0

Christains 3000

63.2

Vaish

2950

52.5

Others

2400

63.8

Source : Based on personal observation and dietary survey in June-2010.

Khadar region i.e. 502 gram per day per capita. Cereals consumption is the lowest in Ganga-Karula region and consumption of fruits and vegetables is the highest 89.2 gram per day per capita in Bhur region. Rice is the leading cereal in this region and wheat and rice equally preferred in this region. Consumption of egg, fish and meat is the highest in KhoRamganga doab region. This is the result of urbanisation and educational status of the population. COMMUNITY WISE VARIATION IN DIETARY PATTERN The Jats, Gujars, Yadavs, Brahmins, Kayasthas, Muslims, Christians and Vaish are major communities that live in the study area. But their dietary pattern is different. The table 2.7 shows that due to their feeding habits or their religious belief the caloric intake also differs among the different communities,Muslims, kayasthas, Sikhs and Christians are mostly non-vegetarian and therefore the protein content is more in their diet than that of others. They eat more fat. The caloric intake is highest in the Muslims, whereas the Sikhs and Christains rank 2nd and 3rd respectively. This communitywise variation shows the effect of social customs and their religious pattern on feeding habits. An appreciable proportion of the Indian population has religious objection to meat of one kind or the other. INCOME AND DIETARY PATTERN Income is an important factor. Level of income in any

[53]

society affects the dietary pattern. Lower income groups are mainly based on cereals, as evident from sample survey. They have very low proportion of leafy vegetables, ghee and oils, milk and non-vegetarian food. This shows their poor capacity of purchasing these things. The dietary pattern of lower middle class consists of higher intake of cereals and lower intake of protective foods in comparision to the ICMR recommended balanced diet (Table 2.8). The consumption of fat and protein also rises in middle income groups. They take higher proportion of cereals, fats and milk but per centage of protective foods increases in higher income group. They take higher quantity of fats, non vegetarian food and milk or milk products because they have higher purchasing capacity. TABLE 2.8 Income Groupwise Diet Components
S. Income No. Group Sample Size Diet components in grams Cereals Pulses Fruits Ghee Milk & Veg 1 2 3 <4000 4000-6000 6000> 75 47 29 486 407 362 28.00 59.00 94.00 & & milk Meat Fish

Oil Product Egg 20.9 123.0 187.0 3.7 13.3 189

49.0 72 173.5 23 280.0 26

Source: Based on sample survey of different Income Groups and Personal Observation and Investigation.

[54]

SEASONAL VARIATION The seasonal variation of crops have some bearing upon

the variety and quantity of food stuff available for human consumption. Winter season is called a healthy season. In this season intake of sugar, leafy vegetables, meat, egg, fish increases. Average consumption of protective foods also rises. Diet becoms rich in caloric value. But in summers, the food intake (or caloric value) of general peoples diet comes below normal level due to lack of supply of milk, vegetables and non vegetarian food. Climatic factor also has influence on general appetite of common people. Due to hot weather the consumption of cereals and sugar goes down, but intake of fruits goes up. Thus the nutritive value of general peoples intake becomes lower than the recommended requirements. In the rainy season there is generally a short supply of vegetables and food items. So the consumption of all components comes lower than normal. (Table 2.9). TABLE 2.9 Seasonal Variation in Diet Components S.No. Diet components 1 2 3 4 5 6 7 8 Cereals Pulses Leafy Veg. Other veg. Fruits Milk & Milk products Meat, Egg, Fish Sugar & Jaggary Winter +18.34 +8.49 +83.24 +9.8 +12.9 +10.4 +65.79 +39.6 [55] Rainy +3.1 +14.6 -18.0 +24.0 +9.3 +15.7 -22.4 -19.6 Summer -13.9 +23.4 -69.4 +4.6 +73.8 -39.4 -31.9 -14.6

The sample survey was taken of different family groups in different seasons in the months of December, May & Sep. in 2010. NUTRITIONAL STATUS OF BIJNOR DISTRICT To assess the nutritional status of India, we depend basically on ICMR reports. But the diet surveys conducted and the results by the State Nutrition Division simply show that this region is caloric deficient. Caloric deficiency may be due to shortage of vegetables, animal proteins, milk and milk products. As a result, people base themselves only on cereals for their caloric requirements. They derive 58 per cent of it from cereals and pulses. The region, thus, suffers from caloric deficiency especially in protein, vitamins and calcium. According to State Nutrition Surveys Division, the actual starvation in the state is rare but about 68 per cent people of the region suffer from malnutrition and undernutrition. A sample survey was carried out involving 90 families in differnt parts of the region who come to the clinics. According to the survey results, the Tarai-Bhabhar region lacks in caloric (-1.4 per cent), Protein (-8 per cent), Calcium (-26 per cent) Vitamin A (-36 per cent) and Riboaflavin (-11 per cent). The people of Bhur region have different dietary pattern. They suffer, as a whole, in caloric intake by 2.1% 4.6% in protein by 3 per cent, Calcium by 2.6 per cent, Vitamin A by 28 per cent and Riboflavin by 13 per cent. This regional difference in dietary pattern and deficiency is due to lack of

[56]

protective foods. They are mainly based on cereals. The deficiency is prevalent throughout the region in different degrees, according to consumption of protective foods. The deficiency pattern shows seasonal variation. During winter the diet of people improves and degree of deficiency becomes low. The higher income groups eat more protective foods. The general status of deficiency in higher income groups lowers. The child bearing mothers and infants are especially recommended for higher caloric intakes. About 90 per cent of this type of population suffers from iron deficiency in Vitamin A and B group. Riboflavin deficiency comes in growing children. Thus, the average food intake in the region is below the recommended normal level. This is confirmed by state nutrition survey reports and sample survey reports.

[57]

REFERENCES
1. Brock, J.F., (1961), Recent advances in Human Nutrition, Churchill, London. 2. Cathcart, E.P., (1961), In Encyclopaedia Britanica-16, p.651. 3. Stamp, L.D., (1994), Some aspects of Medical Geography, Oxford University press London, p. 71 4. I.C.M.R. (1968), Dietary Allowances for Indians, Spt. Rept., Serial No. 6, Nutrition-2, No. 2. 5. Gopinathan, V.P. et., al., (1984), Malaria continuing problem in tropics, Journal of I.M.A., p. 3. 6. Swaminathan, M. et, al, (1969), Our food, Ganesh and co., Pvt. Ltd, Madras-II. 7. Park, J.E. et. al. (1972), A text Book of Social and Preventive Medicine, p. 26, Banarasidas Bhanot publishers, Jabalpur. 8. Gopalan, C. et, al, (1971), Nutritive Value of Indian Foods, National institute of Nutrition, Hydrabad, India. 9. Goldsmith, G.A. (1964), The Medical Clinics of North America, pp.11, 19-48. 10. Havard, CW.H. (1970), The Medical Anual, pub. Jhon wright and sons Ltd. 11. 12. Kundu, S.C., (1970), Jr. Ind. Med. Assoc. Vol. 26, p. 13. Mishra, R.P., Gills H.M., (1973), A short Text Book of preventive Medicine for the Tropics, The English Universities Press Limited, St. Pauls House, Warweek Lane, London, E.C., 4 PUAH, pp. 38, 244. [58]

CHAPTER - III

ECOLOGY OF MAJOR DISEASES

CHAPTER - III

ECOLOGY OF MAJOR DISEASES

The disease may be defind as a condition in which body health is seriously attacked, deranged, impaired, a departure from a state of health and an alteration of human body interrupting the performance of vital functions. It is the symptoms, not the case of ill health, A disease, termed as pathological imbalances of man, is caused due to convergence of environmental stimuli in time and space. The Oxford English Dictionary defines diseases as a condition of a body or some part of organ of the body in which its function are disturbed or deranged. These definitions are worth consideration, as they provide criteria by which to decide when the disease state begins and ends. Disease is not a static entity, it is a process with a dramatic or insidious onset, a short or prolonged course and ending in recovery, disability or death. There are two traditions recognised for the study of Medical Geography (Jones and et al. 1987) 1Disease ecology tradition attempting to elucidate the social

and envirenmental causes of ill-health. 2Tradition related to the Geography of medical care which

is concerned with the consumption of care in respect of such matters as distribution and accessibility (Jones et al. 1981). In

this chapter Ecology of major disease will be discussed, in the light of the first tradition. From an ecological point of view, disease is considered, mal-adjustment of the human organism to the environment. The disease process is initiated by a disturbance of the balance between man and environment. Illness is also a social

phenomenon (Suchman, 1963). The values and customs of a community of social group strongly influence their paraception of the symptors of disease, their interpretation of these symptoms and their techniques for treatment. Different social classes and different ethnic and religioud groups respons differently to illness. It signifies the way in which a disease evolves in the absence of intervention. The human host is refferd to as Soil and the disease agent as seed (paul 1966). The association of a particular disease with a specific set of host factors frequently provides insight into the cause of disease. The environment which influences the disease or in which the disease spreads, is not merely the air, the water and the soil that from our environment, but also social and economic conditions under which we live. The environment is defined as the aggregate of all external conditions and influences affecting the life and development of an organism, as well as human behaviour of society (Leavell 1965). The external environment consists of three main components-physical, biological and social-all closely related (Park 1972). [61]

The term physical environment is applied to non-living things and physical factors (water, air, soil, climate, heat, light, radiation, noise, topography etc.) with which man is in constant interaction. Man is becoming more ingenious. He is also creating new environmental hazards such as, air pollution, rediation hazards, industrial effluents, and food additives. These interaction have frequently led to the occurrence of endemic and epidemic diseases. The social environment, includes a complex interplay of factors and conditions-cultural values, customs, habits, beliefs, moral attitudes, religion, education, occupation, standard of living, community life, availability of health services and social and political organisations. The prevention of major chronic, degenerative diseases depends more upon changing mans way of life, as his psycho-social environment, than his physical environment. For example, the medical cause of lung cacer may be a chemical substance in cigarettes, but the psycho-social cause is the behaviour of smoking. Similarly, mental illnss and the whole host of psycosomatic ailments can be attributed largely to mans attitude and behaviour. Thus disease is a maladjustment of the human organism to his physical or social environment which represents a maldjustment resulting from misperception, misinterpretation and misbehaviour. The concept of multicausality of each effect has a number of causes and each cause can produce number of effects. For example, consider the causal

[62]

model in whic a single-handed arrow signifies a possible causal relationship from cause to effect. Here, there are multiple causes and multuple effects, and effects in one causal model can be causes in other, (Jones, 1987). It is clear that disease is due to multiple factors and these factors may be related directly to the agents, host and environment. DISEASE CYCLE The course of most communicable disease is marked by certain stages : 1. Incubation peroid It is the time interval between the entry of disease agent in the body and manifestation of chemical signs and symptoms. The length of incubation period is peculiar to each disease. There is minimum incubation period for every disease before which no illness occurs. That is incubation period varies for different infectious disease and also from one person to another with the same disease (Park 1986). Non-infection diseases, like cancer, heart aliment or mental illness also have incubation periods which may be months or years. In noninfectious diseases the incubation period is called latent period. Latent period has been defined as the period from disease intiation to disease manifestation. (Fig. 3.1 and 3.1-A) 2. Prodromal Period This is a short period ranging from 1 to 4 days and is

[63]

charactcrised by rather vague signs and symptoms such as headache, fever, body restlessness. 3. Fastigium The period when signs and symptoms are clear cut and there is no difficulty in diagnosing the condition, is known clinically, as Fastigium stage. 4. Defervescene In this period the body defences begin and patient begins to feel better. 5. Defecation The patient recovers from illness and in some cases may continue to harbour the disease agent for varying periods (Anderson, 1961). A disease is caused due to the convergence of environmental stimuli in time and space (Flix, 1958). Thus in the analysis of various aspects of environmental conditions, in relation to health and disease, it is appropriate to deal with the ecology of major diseases. MODES OF DISEASE TRANSMISSION There are five modes of transmission : 1. By Air Coughs and sneezes are said to spread and thus they can do if the host is infected. Diseases which spread in this way include viral diseases viz, mumps, measles, colds, chicken pox and influenza and bacterial diseases viz, whooping cough, diptheria, tuberculosis. [64]

2.

By Physical Conact Diseases transmitted in this way include Syphilis and

Gonorrhoea which are bacterial and herpes viral. Leprosy is also transmitted this way. 3. By Food And Water Examples of diseases that spread in this way are the cholera bacillius which is transmitted b sewage-infected water and infectious hepatitis -a viral infection. 4. By Insect Malaria and plague are this type of diseases. Malaria results from injection of the protoza plasmodium into blood stream by mosquitoes. 5. By Being There Already Many organism may be living quite happily within the host as commensals but changes, such as, illness of drug treatment may lead them to multiply to produce disease. Venereal diseases are case in point. PREVIOUS WORKS ON DISEASE ECOLOGY IN INDIA In the field of diseases ecology Leannonth has done pioneering work. His regional geography of Malaria in India and Pakistan (Learmonth, 1961) and disease ecology of Indian Subcontinent (Joshi, 1972) have highlighted the significance of watershed in the distribution of diseases in Southern Asia. They attempted to study the diffusion of cholera in India. On the meso scale Hyma and Ramesh (1976) conducted studies on the spatial

[65]

patterns of Cholera in Tamil Nadu State. The Geography of Cholere in West Bengal was studied by Banerjee and Hazra (1974). Sinha contributed a paper on the Geographical Congress held in Moscow. Hyma and Ramesh (1976) contributed a joint paper on Malaria in Tamil Nadu to the 23rd International Geographical Congress. This paper highlight various factors which contributed to the resurgence of Malaria in certain regions in the state of Tamil Nadu. Resurgence of malaria in Tamil Nadu has also been studied by Dutta et at. (1979). A collaborative study on the resurgence of malaria in India by Akhtar and Learmonth (1979) resulted in the Publication in Geographical journal of the first joint paper to cover the country as a whole. later a monograph entitled Malaria Annual Parasite Index map of India by Malaria Control Unit Areas 1965-76, by Akhtar et at. (1979) was published by the Open University, Milton Keynes, UK. Two short papers of Indias malaria resurgence by same authors appered in Medical Geography (Akhtar and et al. 1982) Another joint which deals with the geographical aspects of malaria incidence in M.P. and Gujrat States in India by Dutta et al. was publised in Social Science and medicine (Pacholi). Other important infectious diseases, such as leprosy and small pox also attracted geographers attention. Banerjee and Hazara worked on geo ecology of leprosy in West Bengal (Banerjee et al. 1982). Mathur (1969-71) studied on this medical

[66]

aspect of small pox in Rajasthan during 1969-71. Singh and Dutta (1981) also made similer studies on the aspect of Patna city. These are no doubt the significant contributions to the development of medical Geography in India. Hazara and

Banerjee jointly published a paper on the environmental health of Glass and Cermic workers in Calcutta metropolitan district. Goitre is a public health problem in the mountainous, tarai and northern plain areas. Akhtar studied goitre zonation in Kumaun region (Akhtar 1978). Singh carried out investigations on the special distribution of the thyroid problems in Eastern U.P. (Singh et al. 1980). Indrapal presented a paper on cancer distribution in India, at the 22nd International Geographical Congress, Commission on Medical Geography which was held in Canada in 1972. The paper was a general commentary on the incidence of Cancer in India and the other parts of the world. Akhtar (1978) contributed a paper on the distribution of lung cancer in India at the 22nd World Congress on lung-cancer held at Copenhagen in 1980. Again Akhtar and Nilofar Izhar (1981) presented a joint paper on environmental factors and cancer distribution in India which was discussed at the 7th Meeting of the French Society of Environmental and Geocancerology held in Paris in 1981. The recent issue of the international jouranl of Environmental studies published a paper by Akhtar (1983) on the geographical distribution of cancer in India.

[67]

CLASSIFICATION OF MAJOR DISEASES There are several methods of classification of diseases. The following classification was proposed by the Department of Epidemiology of Central Institute for Post Graduate Medical Training Moscow based on the localisation of the causative agent in host. 1. 2. 3. Deficiency diseases Communicable diseases Non-communicable diseases Communicable diseases were classified into the following sub groups : Anthroponotic Zoonotic : diseases peculier to man : diseases peculier to animals, but to which man is also susceptible Anthroponotic 1. Zoonotic

Respiratory tract Measels whooping cough infections influenza 1. Cholera 2. Typhoid Helmentiasis (where there are host besides man) 3. Disentery 4. Infections Hepatitis 5. Food poisoning 6. Helminthiasls (where there is no second host) Ascarisis Hookworms [68]

2.

Intestinal infections

3.

Blood infections 1. Malaria 2. Filaria 3. Relapsing fever

4.

Surface infection

1. Venereal diseases Tetanus 2. Scabies Foot and mouth diseases

A. B.

Deficiency diseases Arthopodal and Helmenthic diseases 1. Malaria 2. Japanese Incephalitis 2. Filaria 4. Helmenthic diseases

C.

Communicable diseases : 1. Cholera 3. Epidemic Jaundice 5. Tuberculosis 7. Venereal diseases 2. Gastro-entritis 4. Tetanus 6. Leprosy

D.

Non-infectious diseases : 1. Cancer 3. Industrial diseases Gills and lucas classified the diseases, according to the 2. Cardiovascular

route of infection as 1. Infections through the Gastro-intestinal tract. 1. 3. 5. 7. Infectious hepatitis Gastro-entritis Cholera Ascariasis 2. 4. 6. Typhoid fever Bacillary Disentery Amoebiasis

[69]

2.

Infections through Skin and Mucous Membrane 1. 3. 5. 7. Conjuctivitis 2. Trachoma 4. 6. Leprosy Hookworm

Venereal Diseases scabies Tetnaus

3.

Arthopod borne Infection 1. Malaria 2. Filariasis

4.

Air-borne infections 1. 3. Measles Tuberculosis 2. 4. Influenza Pertusis

5.

Nutritional Diseases 1. 3. Anaemia Avitaminosis 2. 4. PCM Goiter

So far the diseases have been classified by different authors based on (1) Iccalization of the causative agent (2) geomedical point of view, and (3) the route of infection, but looking to the importance and prevalance of the major diseases in the study area of Bijnor they may be classified in the following manner based on the causative factors of the kind of organism involved which seems to be more-scientific as well as pragmatic. A. Deficiency diseases 1. 2. 3. 4. Vitamin deficiency Protein caloric and malnutrition Goiter Anaemia

[70]

B.

Parasitical diseases 1. 3. 5. Malaria Hookworm Scabies 2. 4. 6. Filaria Asscaris Amebic dysentery

C.

Bacterial diseases 1. Tetanus 3. Typhoid fever 5. Leprosy 7. Dysentery Bacillary 2. Tuberculsis 4. Gastro entries and cholera 6. Venereal diseases 8. Whooping Cough

D.

Viral diseases 1. Cancer 3. Cardiovascular disease 2. Diabetes 4. Blood pressure

A.

Nutritional Deficiency Diseases Good nutrition is a basic component of health. It is of prime

importance in the attainment of normal growth and development and in the maintenance of the health throughout life (park, 1972). The discovery of vitamins at the turn of present advance researches show that a number of diseases that have a genetic background can be made less severe by dietary measures (Brock, 1961). Malnutrition has been defined as a pathological state resulting from a relative or absolute deficiency or excess of one or more essential nutrients. This state can be clinically manifested or detected only by biochemical tests (Jaellifle 1966). Nutrition signifies a dynamic process in which the food that is consumed is utilized for nourshing the body (Brock, 1971).

[71]

The effects of malnutrition on the community are both direct and indirect. The direct effects are the occurrence of evidently nutritional deficiency diseases, as such Kwashiokar, marasmus, vitamin A deficiency, anaemia, beriberi, pillagragoitre and rickets. The indirect effects are a lowered vitality of the people, arrested growth, high-infant mortality still birth rates, high incidence of low birth weight, high sickness rates and a lower expectation of life (Park, 1972). Malnutrition predisposes the host of infection like tuberculosis, diarrhoea and parasitic infestation. In recent years the influence of malnutrition in the area of mental ratardation is being actively investigated. So it is obvious and the prevention and treatment of numerous diseases states (Park, 1972). In developing countries the death rates are the highest in 1-4 year and old group, and often 100-200 times more than those recorded for this age group in developed countries (Gupta, 1979). General mortality among pre school childern (1-4 years of age) is closely related of nutrional status. The findings of various scientific studies indicate that malnutrition results in retardation of physical growth and development causing a high degree of nutritional dwarfism in childern. Malnutrition in childern under five year of age is frequently accompanied by varying degrees of mental retardation as well. Malnutrition may be due to inadequate food intake, defective absorption, poor dietary habits, food traditions etc. The

[72]

most common nutritional deficiencies and those involving deficits of calories are due to defeciency of proteins and vitamins. Since in these parts proteins and caloric deficiency both are common, the terminology of protein caloric malnutrition has been used by Gupta (1979). CLASSIFICATION OF NUTRITIONAL DISEASES To classify nutritional diseases is difficult because they can exist in any variety, to any degree and in any combination. They are often complicated by the presence of other diseases, such as intestinal parasites are infection. WHO experts committee on Nutriton in 1962 proposed the following classification of nutritional major diseases : 1. 2. 3. 4. Protein-caloric malnutrition diseases Mineral deficiency diseases Vitamin deficiency diseases, and Nutritional deficiency diseases.

PROTEIN CALORIC MALNUTRITION The word protein by derivation means that which is of first of prime importance (Gopalan et al. 1961). This is complex organic, nitrogen and sulphur in varying amount, A Human (Goalan and et al. (1971) adult contains about 10 kg. protein. It is needed by the body for (1) growth and development (2) repair and maintenance and (3) sythness of antibodies, enzymes and hormones. Ptotein paly a major role in maintenance of a good nutritional status. At present protein malnutrition is the greatest threat to health especially among children. [73]

SOCIAL FACTORS Defective dietary habits about the nutritional needs, cultural patterns, habits, and the attitudes of the family towards food contribute to malnutrition. Economic strain on the family an resultant inability to buy adequate food is an important factor. Non availability of food as may occur during famine and droughts is an addes consideration. Working mothers bring food by additional means but the child suffers from early weaning and inadaquate feeding and care. TYPES OF PROTEIN CALORIC MALNUTRITION (P.C.M.) DISEASES Marasmus and Kwashiorkor were considered to be due to caloric and protein deficiency untill Gopalan and Coworkers (1974) postulated that the various clinical pictures caused by malnutrition are infact due to predominant caloric deficiency, and their evolution occurs in a step wise process from less severe ones to more malignant forms. According to this concept nutrional dwarfism forms the earliest detecable effects of malnutrition which is followed by marasmus. Till this stage, the body tries to compensate by retarding physical growth and burning subcutaneous fat and muscle for the required energy. This has been termed as compensated stage of P.C.M. However, this balance is disturbed by same factor like infection or increased is demand of the body. Thereafter the patient passes from the stage of Kwashiorkar in

[74]

the stage of dysadaptation and probably depends on the predominant deficiency of protein (Gupta 1979). Protein caloric malnutrition is one of the most serious health problems in many areas of the world (Park,1972) especially in early childhood. A large number of people according to ICMR (1987) report suffer from malnutrition. In U.P. about 42 % are in the grip of P.C.M. (Broker 1957). ANAEMIA Anaemia is defined as quantitative and qualitative deficiency of haemoglobin, characterised by reduced oxygen carrying capacity of blood cells resulting in tissue anoxia producing various symptoms. Anaemia is a symptom which can be the result of various causative factors (Gupta 1978). This is very common blood disorder which occurs when the haemoglobin concentration in blood falls below the lower limit of normal (Beutler 1963). The causing factors of Iron deficiency anaemia are : 1. Increased Demand Of Iron Iron deficiency anaemia occurs among child-bearing women belonging to the poorest class of the cummunity. The W.H.O. (1959) study group has suggested that anaemia can be considered to exist in the pregnant female when the haemoglobin concentration is below 10 gm per 100 ml. Severe anaemia in the mother may lead to the formation of inadequate iron stores in [75]

the foetus. It has been calculated that almost one gm of iron is needed for every pregnancy. This is equivalent to an average daily requirement of between 5 to 6 mg throughout the last trimester of the gestation period. A good mixed diet with an average quantity of meat and vegetables and an egg daily contain 12-15 mg of Iron. 2. Inadequate Iron Intake Inadequate iron intake may cause iron anaemia which is most common nutritional deficeincy in infancy, childhood and old age (Thomman, 1979). It results iron inadequate intake and defective absorption or increase demend of iron (Maxwel 1967). In early infancy, it can appear as six to ten weeks of age. Its incidence and severity increases with increasing age but it remains common throughout infancy and childhood. It is more common in prematures, twins, low birth weight babies and babies of high birth disorder born especially to severely anaemic mothers (Gupta, 1979). Indian diet (milk, rice, wheat) is rich in phosphates and phytates which combine with iron turning into insoluble iron lost into stools. A good amount of iron is also lost through skin in excessive and prolonged sweating in summer (Davidson, 1969). 3. Inadequate Absorption Of Iron Under some circumtances as in haemochromatosis and in alchoholism particularly when pancreatitis is present excessive

[76]

iron absorption may occur, and since iron is only excreted in small amounts iron overload results (Beutler, 1963). So iron deficiency anaemia may arise from recurrent ulceration and malabsorption of iron may take place. Such regional lifeitis may be acompanied by bleeding as well (Cartewright 1966). 4. Anaemia Due To Vitamin B 12 & Folic Acid Deficiency (Price, 1973) A. Due To Inadequate Intake The Folic acid deficiency is very common in the elderly poor persons consuming alcohal. B. Due To Inadequate Absorption Vitamin B 12 can not be absorbed from the terminalilium. Unless castlel intrinsic factor produced by the stomach is also present in pernicous anaemia there is failure to produce intrinsic factor. C. Inability To Utilize Folic Acid This occurs with the folic acid antogonists methotrexate and pyrimenthamine and also in patient receiving antipileptic and using trimethaprim which prevents the conversion of folic acid into active derivative folic acid. PREVELANCE OF DISEASE Acute infection of malaria, tuberculosis, leukaemia etc. also causes anaemia as well as enlargement of spleen. It may overact and destory red cells in variety of diseases which again causes anaemia.

[77]

THE VITAMINS Vitamins are organic substances present in small quantities in food and which are necessary for the normal nutrition of the body. These are divided into two groups : those which are water soluble and those which are fat soluble. The role of many vitamins has been described. They act as coenzyme from part of the structure of a coenzyme involved in vital metabolic pricessess. Deficiency of the vitamin and hence of the coenzyme interferes with the enzymatic process involved, leading to impaired synthesis of some metabolite or to the accumulation of ececssive amounts of the precursors of the reaction which themselves may be toxic. OCCURENCE Vitamins are complex chemical substances required by the body in very small quantities. Since vitamins cannot be manufactured in the body (at least in sufficient quantity) they have to be supplied throughthe diet. Thirteen vitamins are needed by the human body and these are widely distributed in foods. Each vitamin has a specific function to perform and deficiency of any particular vitamin leads to specific disease (Govil, 1958). 1. VITAMIN 'A' DEFICIENCY DISEASES It causes night blindness, xerophtalmia, bilots sports and Keratomalcia. All these conditions have been frequently found in India. Keratomalcia is most common in children below the age of 5 years. Vitamin A deficiency is often associated with moderate

[78]

of severe protein-caloric malnutrition. Per centage of Xerosis of conjunctive is found in higher grade in West plain of U.P. (Govil, 1958). The diseases incidence was also in high per centage in Kotwali and Afzalgarh blocks where 7.2 per cent of children are suffering from xerosis of skin. 2. VITAMIN 'B' GROUP DEFICIENCY DISEASES Beriberi is most common diseases due to thoamine deficiency. The minor degree of thiamine deficiency such as loss of appetite, absence of ankle, jerks, knee jerks and presence of calf tenderness have been found in nutrional surveys. Angular stomatitis frequently occurs amongst the school going children. Rice dominating are suffering from this disease (Park, 1972). 3. VITAMIN 'C' DEFICIENCY DISEASES Survy which is characterised by spongy bleeding gums, haemorrhages in the skin and other haemorrhages are developed due to vitamin C deficiency. Large number of scurvy cases are reported from Seohara and Afzalgarh blocks. 4. VITAMIN 'D' DEFICIENCY DISEASES Rickeats and Ostomalacia are common diseases due to vitamin D deficiency. Lack of adequate exposure, faulty diet, poor housing, pardah system etc. are the factor affecting the occurrence of this disease (Jeffile, 1966). This diseases is common in children in India. On an average 4.7 % children are affected by rickets. Ostemalacia is a form of adult rickets and generally occurs to women who observe

[79]

Pardah system and remain indoors specially during pregnancy (Swaminathan, 1962). GOITER Deficiency of iodine leads to goiter. The W.H.O. reports that in 1960 about 200 milion goitreous were found in the world Endemic goiter is widely prevalent in Tarai Region. The highest prevalence is observed in girls between 12-18 year of age and in boys between 9-13 years of age (Elements et al. 1960). It is an enlargement of the Thyroid gland and is directly related to iodine deficiency. ENVIRONMENTAL FACTORS 1. Iodine, water and soil - Environmental iodine is the main

reason of endemic goiter. Iodine deficiency in drinking water is the main causing factor (Murray et al. 1948). 2. Pollution of water -pollution of water due to animal or

human excreta resulting in bacterial pollution of water may cause the disease. 3. Hardness of Water - Hard drinking water in U.P. may

cause the goiter (Murray). 4. Seasonal varition in areas of mild endemicity goiter

manifests selectively in groups exposed to physiological stresse (Stott, 1931), such as, school going children and pregnant women. There is seasonal fluctuations in incidence due to varriation in iodine deficiency (Gibson, 1960).

[80]

PREVALENCE OF DISEASE India has the largest goiter belt which extends to a distance of 2400 km. along the southern slopes of Himalayas and the adjoining plains. The average prevalence rate is 40 per cent, but in certain places, it is as high as 90 per cent. SOCIO - ECONOMIC FACTORS Higher prevalence of endemic goiter is common in low economic group of school children. Beckess described a probable association between genetic factor and endemic goiter. Greig (1956) has suggested in his study that genetic factor is responsible in females but not so critically important. REGIONAL DOMINANCE OF DEFICIENCY DISEASES In order to find out regional variation of deficiency diseases in Bijnor, the regional dominance of diseases (deficiency) was dereminded. It was based on the comparision of patients under different diseases. Their ranking was worked out in order of importance. Again their distribution pattern was brought out with a view to assessing the intensity of concentration of different deficiency diseases by relating the disease density in each of the areal units. It is based on reports of PHC. in distt. Bijnor. Aneamia, Goiter, Avitaminosis and P.C.M. are the prominent diseases. Data of hospital records were collected for a period of 10 years (2000-2010). THE FIRST RANKING DISEASES Fig (3.2-A) shows that four deficiency diseases, viz. Anaemia P.C.M., Avitamiosis and Goiter hold first rank in one or [81]

more tahsils of Bijnor. Anaemia is the most common in this area while P.C.M. and Avitaminosis occupy second position and Goiter stands at third. They cover 5,4,3 and 2 blocks respectivaly. Anaemia is a major dominating disease by which about 5 blocks are affected. P.C.M. occupies the second place dominating in the area. They are Najibabad, Kiratpur, Kotwali, Jalilpur and Afzalgarh. Goiter occupies fourth place dominating in blocks where the areas are damp and climate is humid. THE SECOND RANIKING DISEASES Fig (3.2-B) shows the second ranking of diseases, viz. Anaemia, P.C.M., Avitaminiosis and Goiter. In the second rank anaemia and Avitaminosis are the most common deficiency diseases. Khari Jhalu, Nehtor, Allehpur, Seohara and Noorpur blocks are the blocks where anaemia stands in second place. Mohd.pur Deomal and Kiratpur blocks are the a Avitaminosis dominating blocks where P.C.M. occupies second rank. Goiter stands at the second place in Nagina tahsil. THE THIRD ORDER RANKING Fig. 3.2.C shows that avitaminosis is the dominating deficiency diseases in third order. Khari Jhalu, Nehtor, Noorpur, Seohara and Jalilpur are the blocks where avitaminosis stands in the third rank. P.C.M. and Anaemia are in third rank in Najibabad and Kiratpur respectively. Goiter occupies the third rank in only two blocks of Kiratpur and Najibabad.

[82]

B. PARASITICAL DISEASES 1. MALARIA The country has celebrated one hundred years of malaria research at Calcutta in January 1980 counting from the discovery of malaria parasite in 1880 by Leveran. Prior to 1950, approximately 100 millon persons were reported to be victims of malaria every year with an annual mortality of 1 million. The morbidity came down significantly by 1965 onlyto rise in subsenquent years. The diseases are found in countries between 600 N and 40 S. In India, it is found only in areas lying below 1830 m above sea level. Temperature below 20 0 C & above 33 0 C is neighter favourable to mosquito, whereas larve forms develop in between 120 C and 350 C. oof the 45 species of Anopiline vectors found in India, Only nine are responsible for the transmission of the diseases (Gopalan 1984). Malaria is a communicable disease caused by sporogoon parasites of the genus plasmodium and transmitted to man by certain species of infected female Anopheline mosquitoes. The disease is characterised by periodic chills and fever. It also leads to the enlargement of spleen and secondary anaemia with a tendancy to relapse. Malaria was well known to the ancients; Charak and Susruta who gave vivid descriptions of the disease and associated it with

[83]

the bites of mosquitoes. Hippocrates in the fifth century B.C. gave classical descriptions of malaria. In accient Italy people associated malaria with bad air; mala-aria, from which the name malaria is derived. In 1880, Lavercan, A French Army suegeon discovered the malaria parasite in Algiers, North Africa. In 1891 Ramanwaski in Russia developed a new method of standing blood films which made possible complete studies of the malaria parasite. In 1884, Manoon hypothesised that mosquitoes transmitted malaria. Ross completed his work on the life cycle of the malaria parasite in Calcutta with Birs in 1898. Malaria was regarded a major public health problem and the greatest single cause of death in India. In 1939, Sinton wrote that the problem of existance in many parts of India was the problem of malaria. In U.P. till recently, malaria has been one of the most dreaded diseases. The royal Commission on Agriculture (1928) reported that 25 % of the population in U.P. suffered from malaria. Before Independance death rate due to malaria was recorded to be as high as 10.71 per million. After implementation of malaria eradication programme, diseases mortality has been reduced to be a major health problem as during the period 1965-76 on the average, about 4 lakh malaria cases were reported every year. VECTORS OF MALARIA It was assumed that malaria was caused due to a toxic of

[84]

foul air that comes out of a marshy or wet land. But the concept has changed and it has been estabilished beypnd doubt that malaria is a tri factor complex involving man as host, Arapeles mosquitces as vector and plasmodium as the causative agent. Out of 44 anopheline mosquitos in India, only six are regarded as vectors of primary importance. These are (Park, 1972) : 1. 2. 3. A.Culicifacies A.Fluivatilis A. Stephensi 4. 5. 6. A.Minimus A.Philippinensis A. Sundaicus

These vectors vary in habits and require different environmental conditions for breeding (Sharma, 1961). MODE OF TRANSMISSION Malaria is transmitted by the bites of certain species of infected female, anopheine mosquitoes. The mosquito is not infective unless the sporozoites are present in the salivary glands (Park, 1972). NATURAL HISTORY : AGENT FACTORS : (A) AGENT - Malaria in man is caused by four species of the malaria parasite viz. P.vivax, P.falciparum, P. malariae and P. Ovale,. In our country, infection is more due to P. Vivax (about 65-96 per cent and due to falciparum), (25 to 30 per cent). (B) LIFE HISTORY - The malaria parasite undergoes two cycles of development - the human cycle (a sexual cycle) and the mosquito cycle (sexual cycle). Man is the intermediate host and mosquito the definitive host. [85]

(C) RESERVOIR OF INFECTION - A person who harbours the sexual forms (game tocytes) of the parasite is called the reservoir of infection. (D) PERION OF COMMUNICABILITY - Malaria is communicable as long as mature viable gametocytes exist in the circulating blood in sufficient density to infect mossquitoes. In Bijnor district malaria sickness was recorded 1 per

cent and 5 per cent of fever cases (Sinha, 1981). The record of District office Bijnor shows decreasing slide positivity per centage from 1991-2010. In 1991, 0.70 per cent slide positivity was found in Nagina tahsil but it decreased to 0.30 per cent. Decreasing per centage is same in Bijnor and Chandpur tahsils where in 1991, slide positivity per centage was .54 and in 2000 it dropped to .054 and .07 per cent respectively. This decreasing slide positivity per centage of Najibabad and Nagina show lower incidences in Bijnor district. The disease has almost vanished from the region (Table 3.1). HOST FACTORS 1. Age 2. Sex Malaria affects all ages. Males are more frequently exposed to malaria than females because of the outdoor life they lead. 3. Race - In India it is reported that haemoglobin E- Thalassemie sufferers are significantly vulnerable to induced P. Vivax infection (Hinmann 1966).

[86]

TABLE 3.1 Slide positivity percentage of total fever cases YEAR NAJIBABAD NAGINA BIJNOR DHAMPUR CHANDPUR 1991 1996 2001 2005 2010 0.51 0.25 0.62 0.81 0.78 0.70 0.12 0.11 0.03 0.03 0.58 0.23 0.14 0.54 0.53 0.30 0.25 0.18 0.23 0.40 0.54 0.20 0.15 0.07 0.06

Source- District malaria office record of Bijnor-2010 4. ECONOMIC CONDITION Where economic condition is good, the incidence of malaria is low. Low economic condition may cause poor ventilated, less lighted and less areated houses which may be good shelter for mosquitoes. 5. MOVEMENT OF POPULATION People may import malaria parasites in their blood and reintroduce malaria into areas where malaria has been eradicated or controlled. The movement of population is an important factor in the epidemiology of malaria. The inner migration of a large number of non immune population into malaria endemic. Digging of soil for the building of railways, roads, embankments, dams or construction of houses promote malaria if it cretes fresh breeding sites for mosquitoes by interfering with the naural drainange of the locality.

[87]

6. IRRIGATION Irrigated areas are the source of malaria particularly when they are negelected (Sinha, 1981). The close net work of canals, developed in the drier parts of the region has made the area malarious as the stagnant water in the irrigation channels has become favourite nurseries for the breeding of Anopheles fluviatilles. 7. AGRICULTURAL LANDUSE The high malaria endemicity in the western part of the region seems associated with the rice cultivation. The methods used

for growing rice require flooding of the field during th growing period. This provides an ideal condition required for the breeding of anopheles. Thus, misues of land provide breeding grounds for malaria vectors (Learmonth and et al. 1958). 8. HABITS The habits of sleeping out door may make a person vulnerable to mosquito bite. ENVIRONMENTAL FACTORS The geographical position and climatic conditions of Ramganga Khadar tract has been, for long, favourable to malaria. 1. Season- There are two seasons in the area favourable for the spread of malaria. (i) july to October coinciding with the season of general rains.

[88]

(ii)

February to April in late spring when snow starts melting over the Himalayas and water in the rivers rises and canals run water for irrigation purposes.

2. Temperature- The optimum temperaturee for the development of parasite in insect vector is between 200-300 (680-990F). When temperature is below 160 C, the parasite stops its development in mosquitoes and temperature more than 300 may cause death of the parasite. 3. Humidity- The humidity has direct effect on mosquitoes to live their normal span of life (Park, 1970). 4. Rainfall- Rain increases the atmosphere humidity which is necessary for the survival of mosquitoes. The effect of rain is not uniform on the breeding of mosquitoes though rain in general provides favourable condition for mosquitoes breeding. FILARIA Filariasis is a parasitical disease commonly caused by nematodes W bancrofti and B malai in our country. It is

transmitted by mosquitoes. The disease is not fatal but causes considrable suffering and disability. There is inflammation of lymphatic channels, swelling of lymphglands, filarial fever, elephantiasis of the genital organs, legs or arms are common in this disease. Only the type of filarial infection caused by W. Bancroofti is prevalent in U.P. The microfilarice W. Bancroofti displays a nocturnal period; they appear in large number at night and they

[89]

are either absent or scarce during the day. The meximum density of micrifilariac is reported between 10 P.M. and 2 A.M. (Raghavan, 1957). Epidemiologically the disease is classified into several types of which only Bancroftian filariasis is prevalent in this area on an extensive scale (Krishnaswami, 1954). The former is transmitted by night biting mosquto, called culex fatigans and the latter by the day biting of Ades. HOST FACTOR The man is definitive host and mosquito is the intermediate host of the microfilariae W. Bancroofti. The adult parasite is usually found in lymphatic system of man. Where females give off larva of microfilari which get their way into blood stream. The female mosquitoe bites the man causes ingestion of blood meal along with microfilari and the indisposition takes place. So the infected man with circulating micrifilari or W. Bancrooft in peripheral blood is the reservoir of infection. AGE FACTOR All ages are susceptible to filarisis. The infection has been reported in even infants, the earliest age in children being 6 months. It is found that the infection rate rises with age upto 2030 years of age but inconsistently thereafter (Chand, 1961). SEX FACTOR Male and female, both are affected equally but male infection rate is slightly higher due to their habits of sleeping out side, farming etc. (Chand, 1961).

[90]

MOVEMENT FACTOR The movement of people for occupations, pleasure trip or pilgrimage, importing parasite into areas previously non endemic is also an important factor in the spread of infection (Mudaliar, 1961). GEO - ECOLOGICAL FACTOR The geo-ecological factor of filariasis differs from that of other vector borne disease in that several infective bites are required to produce infection in man (ICMR 1980). CLIMATE FACTOR Climate plays an important role in epidemilogy of filariasis. It influences the breeding of mosquito, their longevita and also determines the development of parasite in the insect vector. Good number of mosquitoes was seen in between 70 01000 F temperature while longevity was found when the relative humidity was 70 per cent. DRAINAGE FACTOR The mosquito breeds rapidly in polluted water leading to spreed to filariasis in poor drainage of water. Urbanisation, industrialisation and densely populated area with no proper drainage or without adequate management of savage disposal leads to favourable conditions in urban areas, septic tanks, open ditches, burrow pits, soakage pits, open dark drains etc. Mosquito can fly easily up to 5 kms. from their breeding place (Raghavan 1961). Though C. Faligans usually breeds in water polluted with

[91]

organic materials it has been noted that they can breed in clear water as well. MODE OF TRANSMISSION When the infected mosquito bites the parasites are collected near the bite, and pass through the puncured skin. DISEASE INCIDENCE As early as 1940, the filarial survey in U.P. had recorded pretty high infection rate (16.5 per cent) in Rohilkhand region. But subsequent surveys (1952-61) and hospitals record shows that the disease is widely prevalent in this region (Health Statistics of India, 1955). Statistical Survey of India (1957) reported that out of about 88.34 million population 54.46 million (61 per cent) is exposed to the risk of the disease. Surveys carried out during the past to decades indicate that areas previously known to be free from filariasis are showing evidence of low degrees of transmission. RURAL-URBAN DISTRIBUTION In 1976, the estimates showed that nearly 236 million people of the world are currently living in known filarious zones of which 62 million are living in Urban areas and 174 million in rural areas. About 18 million are estimated to harbour microfilariae and 14 million have filarial disease. Overcrowding is an important factor in filaria transmission, poor Drainage for the disposal of waste and sevage aggravate the problem. The vector breeds profusely in polluted

[92]

water (Park 1972). Now a days the urban areas attract the filarial carriers. The labour class of the cities who live in slums is the most affected population in dense populated areas. But according to Mudaliar (1961) in due course of time it promotes centrifugal spread of disease from urban to rural areas, surveys have revealed that Bancroftin filariasis spreads from urban to rural areas (Mudaliar 1961). DISEASE INCIDENCE IN REGION The prevalence of disease is located in the western blocks of the region. The degree of concentration (average of ten years data) shows that Jalilpur, Kiratpur, Noorpur and Afzalgarh blocks are dominating filaria prone areas of the region. Percentage of Disease rate of different years in Bijnor of U.P. is givin in table 3.2. TABLE 3.2 Percentage of Disease Rate (2008-2010) Year 2008 2009 2010 Bijnor 1.8 2.8 1.8 Najibabad 2.1 2.4 2.0 Nagina 8.2 3.78 4.2 Dhampur 3.1 3.5 2.9 Chandpur 77.2 67.51 80.7

Source : Office of the District filaria office, Bijnor. INTESTINAL PARASITICAL DISEASES Intenstinal parasites are adversely affecting the health of the people in all parts of the world specially in tropical countries (Dutta, 1961). They are prevalent under conditions of overcrowding, poverty and poor sanitation (Gopalan, 1965) The

[93]

increasing incident of intenstinal parasite infections may be due to various reasons which are deeply seated in the village, towns and various groups of population (Seal, 1961). Two kinds of helminthic infestations in Hookworm and ascarasis are important from communities health point of view. Hookworm (Ankylostomaiasis) infestation is endemic in U.P. by virtue of its location in the infective zone (360 N to 300 S Isyiyufrd) of Hookworm endemicity (Gosh 1961). A. ASCARIS LUMBRICOIDES It is most prevalent in hot humid tropical countries (Dutta, 1961). Bijnor division has recorded higher rate of infection due the humid climate and soil pollution (Seal, 1961). The infection takes place by ingesting embryonated eggs from contaminated food and drinks. The eggs are resistant to antiseptics and heat. They easily spread with dust and air (Sen and et al. 1963). SYMPTOMS The adult worms about 20 cm. long live in small intestine. The presence of ascaris in human intestine may causeabdominal cramps, loss of appetite, nausea, vomiting and diarrhoea. Heavy infestation of ascaris may cause intestinal obstruction,appendicular inflamation and intestinal perforation (Gopalan, 1965). Sometimes they move in stomach and come out with vomiting. Heavy ascaris infestation with toxic and obstructive feature may be fatal (Tampoli, 1976).

[94]

FAVOURABLE FACTORS A b o v e 7 5 0- 8 5 0 F i s f a v o u r a b l e t e m p e r a t u r e f o r development of parasits. The moisture is necessary for the survival of the parasite. It is an important cause of environmental pollution also. Ascariasis is not only a burden of the community in terms of sickness, mortality and a low extectation of the life but a basic deterrent to social and economic life is a human excreta, therefore is a fundamental environmental health service without which there cannot be any improvement in the state of community of health (Park, 1972). This intestinal disease claims about 5 million lives every year and about 50 million people suffer from these infections. DISEASE INCIDENCE Bijnor district is highly endemic, 30 per cent to 50 per cent of people are known to be infected in Chandpur tahsil alone. Seohara, Allehpur and Noorpur are highly endemic. The Hookwarm endemicity decreases from north to south and east to west (Khare, 1951). Maplestone (1931) found highest hook worm infection in July when parasite infection increased under hot and wet climatic conditions and lowest in march when humidity conditions are lowest. The concentration is highest in Dhampur and Nagina tehsils. They have higher incidences of asscaris. The region has agro based economy and these diseases are soil borne or faecal

[95]

borne. The agricultural labourers are the main sufferers of this disease. Working bare foot on their farm is the main source of infection. MODE OF TRANSMISSION The faecal borne diseases are transmitted to new host through various channels. 1. Water 2. Fingers 3. Flies 4. Soil & 5. Food B. ANKYLOSTOMA DUODENALE (HOOK-WORM) It has been estimated that about 45 million people are infested with hookworms in India (Gill, 1969). It is believed that 60 to 80 per cent of the population of U.P. are infested with hook worms. The blood sucking activities of the worms along with prevalent malnutrition substantially contribute to prevalence of anaemia. The disease may also be partially responsible for retarded mental and physical growth of childern, occasionally seen in the eastern part of the state. The adult worm 8-10 mm long lives in the upper part of small intestin attached by their mouth to the internal layer intestine and from which they suck blood. Hook worm suck .03-.1 ml blood per day causing anaemia (blood loss), heart failure and variety of metabolic disturbances. The eggs of worm leave the human body with the faeces, the larvae develop in the ground and then they enter the human body through the skin of feet and ankles of persons walking on contaminated soil.

[96]

GEOGRAPHICAL DISTRIBUTION It is distributed in all tropical countries between 350 N and 30 0 S of the Equator. A Duodenale is prevalent in the east and mediterranean south America and Tropical Africa. It is thought that about 25 per cent of worlds population is infested with A Duodenale (Mishra and et al 1985). ENVIRONMENTAL FACTOR Hot and humid areas are highly endemic areas of this disease. Temperature between 75 0-85 0 F is favourable for the development of the parasite in soil. Moisture is necessary for its survival. Larvae live in upper 1/2 inches of the soil. Soil rich in organic matter favours the development of Laevae in to parasite. Porosity of soil helps in parasite respiration. Shade protects the larvae (Gills, 1969). AGENT FACTORS Man is only definitive host. A person harbouring the worms is the sole reservoir of infection (Park, 1972). Faeces containing the ove of hookworm is the source of infection. The immediate source of infection is soil contaminated with infective larvae. MODE OF TRANSMISSION The infection is aquired mainly per cutaneous route. The infective larvae penetrate the skin and gain access to a host. anekylostoma infection may be contracted percutaneously or orally (Gilla, 1969).

[97]

SOCIAL FACTORS Poverty illiteracy, ignorgance, low standard of living and traditional customs of defecation in the open are associated with the prevalance of the disease. The use of human excreta as a fertilizer is another important factor in the spread of the infection (Park, 1972). The habits of people is one of the most important factors

in epidiomology of ankylostomiasis. The disease is associated with feacal contamination of the soil owing to indiscriminate defecation in open fields and near human habitations. Childern defecate usually in the immediate neighbourhood of the home and even in places where they play. This creates highly polluted area around the family dwelling. Such rural areas where people do not use latrines, the habits of walking bare feet is a major contributory factor in the spread of the disease. PREVALENCE OF DISEASE It is a helmenthic disease of warm humid regions. The geographical distribution of the two human hook worms. A. Duodenale and N. americanus used to be regarded as relativity distinct, the former being prevalent in U.P. During past two decades parasites have become widely distributed throughout the tropics and sub-tropics (Gills, 1969). It is belived that 60-80 per cent population in U.P. are infested with hook worms (Dutta, 1965). Megaw, as early as 1920 found hook worms infestation

[98]

varying between 60 to 80 per cent of the population in U.P. (Saxena, 1971). The highly endemic areas (about 30-50 per cent) are tarai belt of mountainous region. It is found that highest infection is in July under high temperature and high relative humidity conditions and lowest in March (Maplestone, 1931). SKIN Skin is the biggest organ of the body doing many vital functions without which life is not possible for more than fifteen minutes. There are about 2000 entities due to congenital, trummatic, nutritional neoplastic idiopathic, endocrinal and infective causes. COMMON INFECTIVE DERMATOSES It is estimated that more than 10 per cent of hospital attendance is in the skin clinics and skin diseases are highly prevalent (more than 80 per cent) in the population (Sardarilal et al. 1980). In general, there are 50 per cent of cases of different infective skin disorder. These are such as. A- VIRAL DISEASES HERBS SIMPLEX This acute viral infection which may be recurrent of the same location for years are proveked by fever, sunburn, indigestion, fatigue, menstruation or nervous tension. The principal symptoms are burning and stinging. Neuralgia may precede and accompany attacks. The lesions

[99]

consists of small grouped vesical which can occur any where but mostly on lips, mouth, nose and genitals. WARTS It is usually seen as solitary or lustered lesions usually on the exposed parts, such as , fingers or hands. There are watery elevation any where on skin or mucous mambranes. Recurrence is frequent. BBACTERIAL INFECTION A. B. C. D. E. F. C. Staphalococal infection Streplococal infection Coryne bacteriaceae Mycabacterial infection Venereal infection Special varieties systemic infection

FUNGAL INFECTIONS A. Superficial 1. 2. B. C. D. E. Non-dermatophytoses Dermatophytoses

Deep mycosis Piedra (black or white) Ringworm Candidisis occur

The above diseases are common in this area which

due to climatic conditions or inhygenic condition, or low standard of living. The environmental pollution-water, air-are the major factors for spread of disease.

[100]

SCABIES Scabies is the most common childern skin disease which causes itchy disorder in skin. It is caused by an eight legged eyeless parasite, Saircoptis, scabei which is able to complete its life cycle in the human skin only, (Park, 1972). DESCRIPTION OF PARASITE It is a small parasite about 500 micron in diameter. The female is oval in shape. The male has no role in the spread of the disease in man. It is the female which produces the disease scabies, an itchy conditions worse at nights. The female burrows into the layers of skin about 0.5 to 1.0 cm in length. It stays till fertilization by male. After fertilization it, migrates at the rate of 2.5 cm. per per hour to certain sites of body to form a burrow where it starts laying eggs about 2-3 per day for a month and then dies (Burn, 1947). The eggs hatch in 3-4 per day for a month and the larvae come out from the skin burrow and burry themselves in adjacent skin mainly around hair follicies. When larvae come out, there is intensive irritation and scratching. MODE OF TRANSMISSION It is usually transmitted by close with an infected person. The disease may be acquired sometimes from contaminated clothes and bed linens. EPIDEMIOLOGY OF HUMAN SCABIES Over crowding, lack of personal hygiene are two important

[101]

factors responsible for spread and maintenance of disease in a community. The disease is transmitted by skin to skin contact. Transmission of disease by clothes and bedding is very rare. DISEASE INCIDENCE The highest concentration is found in Nagina tahsil and lowest in Bijnor tahsil. But the occurrance of disease is common in every tahsil of the region due to hot and wet climatic conditions and lower economic condition of the people. Mostly labouurers reside in the region in rural areas. They have no sense of personal hygiene, so the occurance of disease is most common in them. AMOEBIC DYSENTERY Amoebio dysentery is caused by the entamoeba histolytica which is found in two phases. (i) Vegetative form (ii) Cystic form Vegetative form is actively motite and present in faecal blood and mucus, while cysts are found in the lumen of bowel and in faeces. The lesions are usually maximal in the caecum but may be at anal canal. Ulceration of mucus membrene takes place. Amoeba enters intothe blood stream and reaches the liver. In liver, amoeba multiply and causes liver abcess (patel, 1945). The matacystic trophozoite is released from the cyst in the lumen of small intestine after the cyst has been ingested and passed through the stomach (Kedarnath, 1955). Infection is

[102]

aquired by ingestion of the cysts in food or drink contaminated with infected faecal matter. Trophozoites are destroyed by the gastric secretion. On the other hand, cysts pass through the stomach unharmed. As they reach the small intestine, the cyst wall gets dissolved in enzyme trypsin and trophozoites emerge which divide into 4-8 amoedulae. The young tropozoites are carried to the caecum and panetrate the caecal wall. ENVIRONMENTAL FACTORS OF DISEASE PREVALENCE Amoebiosis is a public health problem of international importance. It is known to occur in every part of the world, and is estimated to affect 10 per cent of the world population (WHO 1969). In areas devoid of sanitation, the prevalance rate may be as high as 50 per cent or even more. Amoebias is a disease of bad environmental sanitation, of bad customs and lack of sanitary awakening among the people. The cause of endemicity are social, economic and cultural. Defecation of open fields and lack of sanitary latrines coupled with ignorance and a low standard of living are main factors responsible for the endemicity of the disease in the area (Park 1972). MODE OF TRANSMISSION Man acquires infection by the ingestion of cysts in food or drink. Contaminated water is belived to play a major role in the transmission of ameobiasis, vegetables from fields irrigated with polluted water are liable to carry infection (WHO 1969). In most instances, washing with detergents will remove cysts from fruit

[103]

and vegetables, it is not practically possible. Flies and cockroaches are capable of carrying the cysts and contaminate food or drink (Chutani 1955). DISEASE INCIDENCE The concentration of patients is highest in Bilari tahsil as tahsil hospital records show. The prevalance of disease is higher in the inhygienic conditions and the areas where proper sanitation facilities are not available. There is lack of sanitary latrines in rural areas of the region where defecation in open fields is very common. Labourers often go bare foot in the field which is the main source of infection. In the northern belt of the region the disease is highly endemic due to above factors and low standard of living. These regions are hot and wet regions and this is ideal condition for development of entamoeba histolytica. The causes of Amoebic dysentery per thousand population is highest in Mohd.pur Deomal block (3.72), followed by Kotwali (1.2), Afzalgarh (1.1), Kiratpur (1.02). It is lowest in Allehpur block as hospital records show. REGIONAL DOMINANCE OF PARASITICAL DISEASES The regional dominance of disease forms as interesting study for geographers since it focuses attention to particular area associated with leading diseases. In order to bring out the region of dominant diseases, the relative strength of various diseases as determined by ranking them in order of importance (Fig. 3.3).. [104]

FIRST RANKING DISEASES Hook-worm scabies, Ascariasis and amoebic dysentery hold first rank in most of the blocks of Bijnor and Chandpur tahsils. Ascariasis in a dominant disease which is wide spread in over half of Bijnor. Scabies and hookworm are predominant in Chandpur, Dhampur and Nagina tahsils. Amoebic dysentry is predominant in only Bijnor tahsil. SECOND RANKING DISEASES Hook worm is the second ranking in Khari Jhalu and Jalilpur blocks. Ampebic dysentery, scabies and Ascariasis occupy the second rank in 4,3 and 2 blocks respectively. THIRD RANKING DISEASE Hook worm holds the third rank in maximum tahsils. Amoebic dysentery Ascariasis, scabies have the same rank in 5,4 and 4 blocks respectively. C- BACTERIAL DISEASES TETANUS It is an acute disease induced by the exotoxin of clostrdium tetani. The mortality tends to be very high, varying from 40 to 80 per cent. It is a soil borne infection associated with poor envitronmental sanitation and low standard of living (Park 1972). Whenever there is unfavourable condition for the growth of organism the spores are formed which remain dormant for years and under favourable conditions the spores germinate and organism multiply (Achar 1977).

[105]

MODE OF TRANSMISSION Infection enters the human body through wounds often trivial such as those caused by the splinter a nail in the boot or a garden fork or following sceptic infections such as a dirty abrasion. This disease is most commonly found in agricultural workers, villagers and gardeners and if child birth takes place in an unhygienic environment, the infection may result from infection of umblical stump. The route of infection can also be through vaccinations. The tatanus bacillus is also a normal inhabitant of the intestine of many herbivorous aniamls as cattle, horses, goats and sheep. It is frequently found in the intestine of man without causing any ill efect (Park, 1972). SOCIAL FACTORS Poverty, religious prejudices and traditional unhygienic customs and habits, lack of mother and child health services and health education are important social factors which play an important role in disease prevalance. The neonatal tatanus infant typically contracts the disease at birth when deliverd in unhygienic or contaminated conditions especially when the cord in cut with unclean instrument of the umblical stump is dressed with ashes, soil or cowdung or tied with infected of dirty thread. Sucking and swallowing excessive crying and trismus may take place. Soon after spasms develop and body becomes stiff and utimately the condition reaches to fatal stage.

[106]

ENVIRONMENTAL FACTOR While in temperate climates no seasonal fluctuations are seen in neonatal tetanus in India, the number of cases tend to cluster in the monsoon season. It is speculated that this may be related to an increased risk of contamination of the cord stump with tetanus spores in environment which becomes increasingly contaminated and crowded in the rainy season (Khubehandani 1988). DISEASE INCIDENCE This is soil borne infection. The incidence is higher in the areas of soil infections. Hospital records show that highest incidence is found in Najibabad and Nagina tahsils. Frequency of incidence is higher in rural areas of the region where the risk of contamination of the cord stump in higher. The low standard of living or unhygienic conditions of living of the rural areas attracts much disease incidences. In the western part of the rural areas occurs much disease indidences. In the northern part of the region there is lack of medical facilities which is an important social factor of disease prevalance in the area. TUBERCULOSIS Tuberculosis is a major health problem in developing countries like India. It still continues to take a major share of 6.6 per cent of total hospital admissions (Udani 1961) and inspite of all major efforts to control the disease the prevalance rate has not shown any decline.

[107]

It is specific communicable disease caused by Mycobacterium tuberculosis. It is a disease that is found almost everywhere through it is a major health problem, the exact clinical data is not available due to lack of diagnostic facilities. AGENT FACTORS Mycobacterium tuberculosis is non-moblie human and bovine type of strain. The human strain is causative factor for most of cases in our country. They can remain alive for years as dormant vacilli without causing any damage to the host but in favourable condition they multiply and cause damage to the host as active disese (Park, 1972). Human being is the main source of infection and the sputum of the patient is the commonest material spreading the infection. The disese is infectious till the bacilli are excreated through an infected person and this period may extent several months to a few days. MODE OF TRANSMISSION The bacillus of tuberculosis spreads by transmission through the air and has a waxy coat (Kissen, 1958), so that it does not dry out and can lie dormant in dust for many years untill it finds a suitable environment for multiplication. It may not harm a well nourished and otherwise healthy person. This would account for the low level of disease in industrialised countries. SOCIAL FACTOR Standard of living plays an important factor in spreading of T.B. Substandard houses which lack cross ventilation,

[108]

inadequate lighting and space uncleanliness favour the spread of infection among the resident of that house. Tuberclosis is higher in low income groups. So poverty and malnutrition are important social factors in spreading the T.B. The larger the family size the larger will be number of contacts in home, especially where people are living in one or two rooms. Meanwhile large families face poverty and malnurishment. DISTRIBUTIONAL PATTERN Tuberculosis is a public health problem of major importance in almost all countries. There is no single country which has succeeded in reaching the point of control, that is less than one per cent tuberculin positivity. Among in the age group of 0-14 years, it is still a major problem even through its prevalance has been greately reduced. Ten to twenty million cases of infectious tuberculosis is found in the world. It is reported that about 1 to 2 million deaths occur each year due to this infection (WHO 1957). The problem of tuberculosis is acute in the developing counties. In some developing countries of the world more than 70 per cent of childern are infected by the age of 121 years as against less than 2 per cent in economically more favoured countries. DISEASE INCIDENCE Tahsil Bijnor has the highest concentration of 26 cases per thousand population as hospital records 2000-2010 show. Tahsil of Chandpur (21 and 20) occupy 2nd and 3rd palces in

[109]

the region. The highest mortality was recorded in Bijnor tahsil in 2010 and the lowest in Najibabad tahsil. TYPHOID FEVER Typhoid fever is an acute communicable disease caused by Salmoaella typhi characterised by fever abdominal symptoms enlargement of spleen and sometimes eruption of rose spots, it is transmitted by contaminated water or food. MODE OF TRANSMISSION The disease is transmitted through the oral route from contaminated drinking water, milk or other foods. These sources of infections are patients suffering from the diseases or from urine or faeces of carriers. The house fly helps in disseminating the infection. 20-30 per cent typhoid cases occur in children below 10 years (Park, 1981). It is rare in infants (Achar 1977) but the toddler and school going children are exposed to the infection by the consumption of contaminated food specially exposed sweets from street vendors. ENVIRONMENTAL FACTORS SEASON Although it may occur all through the year, the peak incidence is reported in July, August and September. This incidence in much related to the rainy season and increase in population of July (Park 1972). WATER Typhoid organism S. Typhi does not multply in water, many

[110]

of them die out within two days and some may survive upto 7 days. They do not survive for long in contaminated water. The S. Typhi is not destroyed by freezing (patnik, 1967). They may survive for over a month in ice and ice cream while the bacilli may multiply and survive in food for some time because food is not a good counductor of heat (Park, 1981). SOIL It has been seen that S typhi may survive upto 70 days in soil irrigated with sewage under most winter condition and for about half that period under drier summer conditions. Flies carry the bacilli from faece to food. The bacilli have been found to remain viable on the external surface of housefiles for as long as 20 days. The organism may also be excreted by the housefly in almost pure culture (WHO 1969). MILK Milk is very good media for the growth of typhoid Bacilli.

They grow rapidly in milk without changing in appearance, taste or smell. So, raw milk may contain typhoid Bacicilli and therefore it is dangerous to consume raw milk. Simultaneously, raw vegetables are also dangerous because vegetables gorwn on sewage farm may be infected with typhoid Bacilli and are a source of infection if eaten in raw form (Park, 1981). SOCIAL FACTORS TO SPREAD THE DISEASE The disease spreads due to lack of the safe drinking water. Open air defecation and urination causes spread through soil,

[111]

water, food and files lack of awareness of personal Hygiene such as not washing hand after toilet. Unhygienic health practice as washing soiled clothes in tanks, river and near wells, low standard of food and kitchen hygiene, illiteracy and health ignorance all these factors are responsible for spread of typhoid in the area (W.H.O. 1969) GEOGRAPHICAL DISTRIBUTION The data collected from the Govt. hospitals do not indicate any clear case of cholera incidence, this is probably due to the fact that the symptoms of cholera are generally confused with those of the Gastroentritis. As such even the cases of cholera seem to have been entered in the name of Gastroentritis in the hospital records. Therefore, the study made herein pertains to only Gastroentritis, as they are based on the data collected from hospitals. It is very common infectious disease affecting intestine due to ingestion of contaminted food. The symptoms of disease are diarrhoea, vomiting, nausea, abdominal pain with fever. The diarrhoea and vomiting may lead to dehydration which may cause circulatory failure (Gupta). In chemical and toxin type of food poisoning the onset is sudden and severe, while in infection type the symptoms develop more slowly. There is a rise in body temperature. The stool is watery and offensive with little blood and mucus (Ghai, 1982). The causative agent make difference between these diseases.

[112]

Sallonopnella group of organism are mainly responsible for this disease while bacteria. B coli and Shigella proteous may also cause acute symptoms in more than 50 per cent children of under one year of age (Gupta). The disease is most common in malnourished infants. Incidence is higher in bottle fed babies probably due to poor cleanliness of bottle. MODE OF TRANSMISSION The infection may be transmitted by flies (as they sit on infected excreta or vomits and carry the causal organism). The food may be contaminated directly with infected excreta of mice or rat etc. When the food is exposed to infection and remains in kitchen or room for several house or days. Then there are much more chances of bacterial growth in it. When consumed, it may cause infection. The infected food also transmits the infection through flies which usually occur in suburban or rural areas or under poverty and unhygienic of poor hygienic living condition. Hens eggs are not infected soon while duck's eggs are easily infected as duck is carrier of Salmona organism. The out-break of infection is very common in social functions. ENVIRONMENTAL FACTORS The incidence of infection is very common during summer and rainy season. The peak incidences are recorded in August. Among all factors water is the single important factor that has always played a prominant role in the spread of disease. The flies help in disseminating the infection. [113]

SOCIAL FACTORS Several social factors are responsible for spread of the disease. (1) Fair & Festivals Every state of India or any area of India or any area has its own fairs and festivals. These centres attract millions of people. The infection has originated in the past from these fairs. (2) Marriage Parties Marriage parties and feasts have also been important social factors in the spread of the disease. (3) Drinking Sacred Water In this manner people carry infection far and wide. (4) Socio-Economic and Educational Factor Most people live in dwelling with over crowding and bad sanitation and undernourished conditions. So it is a disease of poor and underprivileged. (5) Habits The habit of washing clothes near wells, tanks and rivers plays an important role in contamination of water. (6) Personal Hygiene The lack of personal hygiene is another important social factor in the spread of the disease. (7) Disposal of Excreta Open air defecation and lack of sanitary latrines lead to the water and air pollution.

[114]

(8) Movement of Population It often results in transportation of infection from one place to another. The disease cases generally occur in rural areas of water deficiency/scarcity and in those parts of cities where water supply arrangement is not adequate or drainage is poor or environmental conditions are not satisfactory. DISTRIBUTIONAL PATTERN The hot and humid climate, slow flowing rivers (Rodenwalt 1955) charged with organic matter, dense population, poor socioeconomic conditions and low level of environmental sanitation provide suitable geo-ecological conditions in Ramganga Khadar tract for gastro entritis out breaks. The rural areas of the region have no proper facility of drinking water or sanitary conditions so the cases are most frequent of Gastro enteritis in those parts of region. The rainy season is the ideal season to spread up the disease. Droughts and floods play an important role in erruption of the disease. Kotwali and Kiratpur blocks have higher incidence of the disease. Mortality is higher in those areas of the region where there is shortage of water supply or problem of sewage disposal and poverty. LEPROSY It is an infectious disease of ectodermal tissue caused by Mycobacterium Leprace. First, it is probably mentoned in

[115]

Egyptian records of 1350 B.C. among Negro slaves from Sudan and Dafew who were brought to Egypt. The disease is endemic in tropical and sub-tropical Asia. South America, parts of Africa, pacific regions, and in India (Grove 1976). In India general incidence has been estimated as 5.4 per thousand population (1954). Infants and the young children are more susceptible to this infection than adults. Disease in the mother is the most favourable circumstances for transmission to the child due to prolonged contact. Thus the change of getting disease from lepromatus patient is 8 times greater than from contact of neural cases. Intimate and prolonged contact is necessary for transmission of the disease only 3 per cent of persons living with lepers develop the disease (Krupp, 1980). It is a chronic bacillary infection of man. Leprosy occupies a special position among communicable diseases because of the long duration of disease (Park, 1981). Leprosy is caused by Mycoleprce (W.H.O. 1967). The leprosy bacilli could multiply to limited extent when inhected into the foot pads of mice which were kept in a low temperature (200C). It occurs in all human races. Infection takes place at any time depending upon the oppurtunities for exposure in endemic areas, the disease is aquired commonly during infancy and childhood. ENVIRONMENTAL FACTORS (1) Climate : It is more common in warm and humid climatic [116]

regions. This type of climate may favour the spread of infection indirectly. (2) Social Factors : It is mostly found in lower socio economic groups. The low standard of living, poverty, substandard housing; over crowding, lack of education, low personal hygiene, unhygienic personal habits, the use of common clothing, prejudices etc. are the affecting social factors. MODE OF TRANSMISSION (A) Contact Transmission : The factors which influence the contact transmission is the closeness and duration of contact, as well as individual susceptibility. (B) Other Possibilities : The rarity of infection amongest doctors, nurses and other workers in Leprosy hospital are seen. (C) Healthy Contacts : Acid fast bacilli have been reporyed in skin smeare from healty contacts, more frequently in contacts of the Lepromatous cases than non- lepromatous cases. GEOGRAPHICAL DISTRIBUTION PATTERN It is wide spread disease and affects almost all countries in the world. It is estimated that about 2.5 million cases of laprosy are in India. Mathur mantioned in his report that in the east plain, according to general findings the worst revages of leprosy are encountered in the tarai districts. The problem of leprosy is equal in rural and urban areas. Kumhars (Potters by profession) have shown a relatively higher disease prevalence in U.P. (Sharma 1967).

[117]

VENEREAL DISEASE Venereal diseases are almost invariably contracted during coition with unexpected persons. A. Gonorrhea : It is is most commonly communicable

disease caused by Gram negative deplococus (bacteria) and Neisseria gonorrhoeae (Homes, 1978). It is most commonly transmitted during sexual activity. It has its greatest incidences in 15-29 year old age group (Krupp, 1980). IN MAN There is burning in urination and a serus or milky discharge 3 Days later the Urethral pain is more pronounced and discharge becomes yellow, creamy and profuse. IN WOMEN Pain during urination, frequency of mituration takes place. Inflammation of vagina and cervix is common. Most commonly however the infection is a symptomatic with only slightly increased vaginal discharge and inflammation of cervix. Rectal infection is both as spread of organism is from the genital tract because in female there is less distances between Anus & Vegina. (Holmes, 1978). SYPHILIS It is complex infectious disease caused by Traponema pallidium. Transmission occurs during sexual activity. It can be tranferred through placenta from mother to foetus after second to third month of pregnancy of body causing protean clinical

[118]

menifestation. It is devided in 2 stages (Krupp 1980) : (1) Early infection, and (2) Late syphilis. Early stage includes the primary lesion (Chancre and regional lymphadinopathy) while late secondary lesions (involving skin, mucos membrane, bone, central nervous system of liver). MODE OF TRANSMISSION Venereal diseases are tranmitted by direct contact sexually. Transmission by indirect contact is not of much importance. It is also transmitted congenitally. SOCIAL FACTORS Venereal diseases are a symptom of a wider social pathology in the community.Prostitution, broken homes, easy money, emotional immaturity, subnormal intelligence, sexual disharmoney. frustration, urbanisation and industrialisation, travellers and migrants, changing behavioural pattern, social stigma, misconceptions, alcoholism and local marriage customs are the main social factors which paly an important role in the spread of V.D. DISEASE PREVALENCE Inspite of excellent methods of diagnosis and treatment veneral diseases are still wide spread. It is estimated that there are about 150 million cases of Gonorrhoea in the world today and about 50 million cases of early infectious Syphillis (Wigfield

[119]

1971). A W.H.O. study (WHO 1970) concluded in 1970 shows that the spread of the venereal infections can be mainly attributed to the rapid environmental, social and behavioural changes

that the world has undergone in the last decades. PROBLEM IN THE AREA Venereal disease constitute a major problem in India among communicable diseases (WHO 1971). This disease is widely prevalent in large cities, ports and industrial areas. Its prevalance is estimated to be about 5 per cent of the population. V.D. incidence and prevalance in U.P. is in between 1 & 2 per cent (Sinha 1981). It is predominantly an urban disease specially in industrial cities where large number of laboures and workers are forced to remain separated from their families due to high cost of living and lack of family quarters. DYSENTERY BACILLARY It is caused by genus shigaella which has 3 main pathogenic group known as shigaella flexner and sonne, the last two having numerous strains. The shigaellac are small nonmotile gram negative becilli (Kuzmixheva, 1980). ENVIRONMENTAL FACTORS It is found that the disease is most prevalent between July and November and two-thirds on exposure to sunlight, drying, high temperature and under the effect of disinfectant. At low temperature in a humid medium and in the dark day are

[120]

preserved for a long time for weeks and even months on damp lines chamber pots and dishes, upto 15-30 days on food stuffs, for nine days in water and upto 3 months in the soil. MODE OF TRANSMISSION It occurs in epidemic form wherever there is a crowded population with poor sanitiation. The infection is spread mainly by flies, contaminated food convalscent carriers and by unrecognized or typical cases. Commonly a case of carrier contaminates water or food. Milk and milk products, cooked vegetsbles and fruits are the usual vehicles of infection. Baciliary dysentery is a general infectious disease, but the local inflammatory changes develop in large intestine mainly in its lower part. The dysentery bacilli enter the body through the alimentry tract in which they are partly destroyed.It is assumed that the Toxins released as a result of this process are absorbed into blood through mucos membrane of the large intestina. The dysentery bacilli toxins forming in the intestine cause a direct effects on its vascular and nervous apparatus. On being absorved into the blood they also have an effect on the central nervous systems, circulatory systems and disturbances in water and mineral metabolism. DISTRIBUTIONAL PATTERN It is distributted equally all over the region. But highest concentration is found in Nagina tahsil of the region. About 5.10 per cent people suffer from this disease. Bijnor tahsil has

[121]

0.48, .43 per cent cases respectively. As hospital records show the lowest concentration is found in Bijnor tahsil which is about 16 per cent. The prevalence of disease is higher in rainy season due to hot and humid climate. Mostly, cases occur in children. The unhygeinic condition, low standard of living, and wet climate are the factors which play an important role in occurrence of disease in the district. WHOOPING COUGH It is highley communicable disease. Whooping cough is caused by respiratory tract infection by Bordetella pertussis. It occurs all over the world. It seriously influences in infancy and childhood (Park, 1972). The highest incidence is found in below 5 years. Males and females are equally affected but fatality is observed to be more in female children. One attack of whooping cough usually gives a solid and prolonged immunity. ENVIRONMENTAL FACTORS It occurs throuhghout the year. But the maximum incidence is seen in March and April. Incidence of whooping cough is lower in tropical countries. Socio-economic and life style also play an important role in the epidemiology of the disease. Lower social cases are more prone to the disease because they live in overcrowded condition. MODE OF TRANSMISSION The droplet of infection usually spreads by direct contract. Through patients cough sneezes of talks the bacilli are

[122]

sprayed into air (Park, 1981). It is entirely human disease. The infection spreads more of less by mild, missed and unrecognised cases. It occurs endemically and epidemically. It is principal cause of death among infant and children. Over 70 per cent of deaths from whooping cough occur during first year of life. The majolity of death, over 90 per cent occur during first three years of life. In India, the annual incidence of pertussis has been estimated to be 587 per 100000 population (W.H.O. 1978). DISTRIBUTIONAL PATTERN Whooping cough is a highly infectious disease.

Occurrence of disease is most common in children below 5 years. The unhygienic condition of lower income group is a major cause of the infection. Densly populated regions of the area are more prone in this disease. The highest incidence is found in Dhampur tahsil due to over crowding unhygienic living condition and hot and wet climate. REGIONAL DOMINANCE OF BACTERIAL DISEASES In order to bring out the regins of dominance of diseases, the relative strength of various diseases is determined by ranking them in order of importance. The first second and third ranking diseases thus obtained for each tahsil are mapped and the redulting patterns of their distribution are shown in Fig. 3.4. FIRST RANKING DISEASES Bacillary dysentery is dominating in Nehtor and Allehpur

[123]

blocks. Whooping cough is dominating in Seohara block. T.B. is dominating in Khari Jhalu block. SECOND RANKING DISEASES Gastroentritis is dominating at the second rank in 4 blocks of the region. T.B. stands on the second rank in 2 blocks of Bijnor. Whooping cough is dominating only in five blocks of the region. THIRD RANKING DISEASES Gastroentritis is the disease which holds third rank in two blocks. T.B. is dominating in five blocks of the region. Whooping cough dominating in 8 blocks of the region. VIRAL DISEASES Infection is a wide phenomenon among living organism ; human, animal, insects and plants. Infection is caused by various micro organisms which include viruses. Bacteria, protozoa and rickettsiae. The viral infectious become so prevalent that new independent problem of virology known as virus persistence was formed in the last 20 years and is now well established. The presence of virus in host agent may not show clinical symptoms or many be attended by one or more symptoms typical of a given causative agent. Morever, latent persistence may result in the development of progressive pathological processes the symptoms of which caused by this infectious agent. As a rule this interaction between the infections agent and the host ends in severe disorder or death.

[124]

Thus viruses are chains of nucleic acid surrounded by a protein coat. They cannot reproduce themselves without entering the cells of plant or animals. They produce such diseases as influenza, measles, rebies, herpes, small pox encephelities and different types of viruses are communicated from person to person or animal to human being. Communicable temporary morbid conditions but could be major killers if the host is in poor general health. MEASLES Measles is a cruptive fever caused by a specific virus. It is a self limiting preventible viral disease and one of the major killing disease of the child population of the world. In India, it is estimated that 200000 children die each year due to post measles complications with an annual mrobidity to the tune of 14 millions (UNISEF 1984). In United States, the disease has been controlled by effective immunization (Amber, 1984). Incidence of measles however, ocntinues to remain high in the developing countries. Indias share in the developing worlds annual death due to measles comes to 39 per cent (John, 1985-86). MODS OF TRANMISSION It takes place mostly by droplet infection and direct contact which is common in Catarrhal stage. Contaminated things with saliva or nasal dischage play important role in the spread (Park, 1972). ENVIRONMENTAL FACTOR It is very common in winter season. In the poor [125]

condition of environment children are more prone to measels at an earlier age. In the middle class families the incidence is delayed to school going age or later. Epideomelogy of measles is dependent on population size, density, movement and social behaviour. Measles virus only survives in human body. It is highly infectious during pre-eruptive stage and at the time of eruption. The period of infectivity may be stated to be approximately 4 days before and 5 days after the appearance of rash (Shah, 1972). Children of pre school age are more prone to disease. However, disease takes place at any age if there is no previous immunization (Siddqui, 1974). Varous seroepidemiological surveys located medium age of infection between 2 & 4 years (John, 1980). One attack of measles usually causes immunity. DISTRIBUTION It shows a wide variation. Highest incidence is found in Chandausi tehsil. It is a viral and mostly occurs in children below 5 years. The school going children are most prone to this disease because they carry infection from other students. INFLUENZA It is one of the communicable diseases still not conquered and often called the modern plague. The disease is worldwide in distribution. It can occur endemically giving rise to sporadic cases, occasional small out breaks or it can occur in serious epidemics (Park, 1972).

[126]

Influenza viruses are classified into three types designed A, B and C type. A type viruses are the main culprits responsible for epidemics of influenza. Type B viruses are usually responsible for relatively small epidemics or localized out breaks. Type C viruses of negligible epidemiological importance (Perlira, 1967). Influenza affects all ages. In 1918-1919 pandemic, there was a high incidences in young adults and in 1957 pandemic, there was a high morbidity among children and young adults. ENVIRONMENTAL FACTORS (1) Season - In India epidemics have often occurred in summer. In temperate climate epidemics tend to occur during winter and spring. (2) Over Crowding - The attack rates are high in close population, for example, institution, ships etc. (3) Role of Animals - Animals and birds are the reservoir of infection. MODE OF TRANSMISSION Influenza is spread by droplet infection or droplet nuclet from person to person. Contaminated handkerchiefs, towels, drinking cups can also spread the infection. DISTRIBUTIONAL PATTERN It occurs in all coutries. Its incidence is higher in temperate climate than tropical climate. It it often said that outbreaks of influenza occur once in two or three years but the periodicity is not regular (W.H.O. 1959).

[127]

INFECTIOUS HEPATITIS Infectious hepatitis is an acute communicable disease which is transmitted by faecal-oral serum and possibly by air droplet route. It is characterised by predominant involvement of hapatic reticulo-endothelial system (Park, 1972). It is known from ancient times. In the past, however, it was undescinible among the common mass of Jaundice syndromes. Hippocrates already mentioned jaundice syndromes and their contagious forms. The story of hepatitis was founded over a century ago and several main stages have been distinguished. There are two different causative agents, virus AR. and virus B. They survive heating to 560 C for 30 minutes and are resistant to drying low temperature (Virchow, 1949). Many chemical agents and ultraviolet rays survive over long periods of time in blood and serum collected from patient. SOURCES OF INFECTION The sources of infection are a hapatitis patient and a virus carrier. A patient with infectious hepatitis is contagious from the end of the incubation period (Jawetz, 1980) and through him, the chain of infection in the community is maintained (Sinha 1981). MODE OF TRANSMISSION The faecal oral route is most common mode of virus transmission by consumption of contaminated water and food.

[128]

The virus is brought into the body by contaminated hands of objects or toys. Virus is excreted in faecus for 1-2 weeks before the onset of disease and upto 4 weeks thereafter (W.H.O. 1963). HOST FACTOR Susceptibility to infectous hepatitis is very low in children of the first year of life, then it sharply grows to maximum in children from 2 to 10 years old and gradually diminishes in adult to 30-40 per cent. The patterns of disease vary from population (Dienhardt 1982) and depend upon living conditions. Due to improved socio-economic and hygienic condition, the pattern of spread of disease is changed from children to adult (ICMR 1980) and both sexes are equally affected. The disease takes place by non specific symptoms such as fever, chills, headaches, fatigue, weakness and bodyyaches. Then after a few days loss of appetite, nausea, vomiting, highly colorded urine and yellowing of conjuctiva and body follow. It may terminate into hepatic coma and death in severe case. ENIVIRONMENTAL FACTOR Infectious hepatitis occurs in temperate climates, a peak is reported in autumn and winter. The lower socio-economic groups have shown a higher prevalence of infectious hepatitis in childhood. GEOGRAPHICAL DISTRIBUTION It is major problem with frequent report to minor or major cases (Park, 1983). It is estimated that about one million cases

[129]

occur in the state. Sinha has mentioned that since independence, seven or eight Jaundice epidemics appear to have occurred in U.P. These epidemics were related to natural calamities like flood and drought followed by hunger and environmental sanitation (Pioneer, 1980). The occurrence of disease is highest in Afzalgarh and Kotwali blocks which have more incidences than other parts of the region. The poor environmental condition appears to be the major responsible factor in the occurance of the disease. CONJUNCTIVITIS Conjunctivitis is the most common eye disease in this region. It may be acute or chronic. Mostly, it is exogenous due to bacterial, viral or chlamydial infection (Vaugham, 1977). Some times indogenous inflammation may occur, as in case of phyctenular conjunctivitis. Concunctivitis may occur due to allergy, chemical and fungal or parasitic infection. The bacteria which commonly causes conjunctivitis are streptocosus pheumoniae, staphlococcus aureus, koch weeks bacilus and Morax Axenfeld bacillus, the viruses mostly invlove in conjuctivitis is a adenovirus type-3, B and 19. MODE OF TRANSMISSION The mode of transmission of infectious conjuctivitis is usually direct contact via fingers, handkerchief etc. Conjuntivitis may be transmitted from eye to eye by contact with contaminated spectacles, pillow, fingres, towels and eye cosmetics or other objects. [130] deterioration of

Children are more often affected than adults and contaminated swimming pools are a frequent source of infection. DISTRIBUTIONAL PATTERN It is most infectious viral disease and transmitted by direct contact. Maximum number of patients are reported in Bijnor tahsil hospital. The working population as well as the school going children are more often affected than order people due to direct contact with other inrectious people. A large number of population is affected by this disease every year. ENCEPHALITIS Viral encephalitis includes seasonal encephalitis, tick borne and mosquitoe borne and lethargic encephalitis . Each of these disease has its own specific feature but they are included in one group because they have a common symptom, the involvement of brain matter and damage to nerve cells and in some cases resulting in death. INCIDENCE Mosquito borne or Autumn (Japanes encephalitis) common in our country, was discoverded in Japan where 6000 cases of the disease were registered in 1924 with a high mortality rate. In U.S.S.R. it is encountered in Maritime territory sporadic cases and small out breaks. Peack incidence falls (Kuztricheava, 1980) at the end of summer and autumn. MODE OF TRANSMISSION The reservoirs of this virus are birds, pigs and carriers

[131]

are ticks and mosquito who infect human being mostly children. Disease is transmitted by Culex vishnul complex mosquitoes which can frequently feed on infected man. Man is infected only incidentally as the mosquito, transmitting the virus is indifferent to man (Sinha, 1972). It has been shown in India, as in Japan, that the basic cycle of JE. Virus is pig-mosquito-pig symptoms of encephalitis are suggestive of functional involvement of brain causing delirium, drowsiness, coma, convulsion, fever and stiffness of neck with headache. Sometimes vomiting and diarrohea also occur. EPIDEMIC CYCLE It is clear that Encephalitis has eleven week epidemic cycle. In the first week the epidemic remained confined only in the western part of the district. In the second week the cycle shows that the area was seeded much before the official recognition of the disease. During third week the disease declined and cases remainned low. By the forth week ending Nov. 13 encephalitis cases continued to flare up in newly affected areas. In this week the cases went down below 50 per cent. The declining trend was mainained during 5th, 6th & 7th week. After 7th week, when winter season started and intensive B.H.C. fogging was done, no out break was reported in any fresh district and grandually by the 11th week epidemic cycle came to an end.

[132]

SEIZUERD CASES & DEATH In 1985, the hospital records show that a maximum of over 200 cases were seized in Bijnor and Chandpur tahsils. The degree of concentration was the highest in the blocks of Bijnor tahsil. An average of ten years data of the concentration shows that western part of Bijnor is most affected (Fig. 3.3). This area suffers from encephalitis from the very beginning of epidemic cycle till end. (Fig. 3.3). An average of 50 per thousand cases are seized in this region during peak period. This area accounted and also reported maximum per centage of death. OCCURRENCE OF DISEASE IN BIJNOR DISTRICT In 2009, 61 patients were seized in Kiratpur block in Bijnor. Out of them 3 death cases were reported. In Mohd.pur Deomal block, 55 cases were seized and 2 death cases were reported in P.H.C. hospital. In all, 333 cases were seized and 106 death cases were reported in Bijnor district and about 272 villages were affected from encephalitis. After analysing the incidence of disease in different blocks of Bijnor district, it is found that maximum number of cases were reported in eastern blocks of the district. The hot wet climate, water logging and forests have produced the ideal conditions for breeding the mosquitoes. The rice growing farms are also an ideal place for mosquito breeding. So when kharif season ends, the mosquitoes are more active in populated areas. It is found that october is the peak season of the disease incidence due to this reason. Therefore maximum cases are reported from the [133]

rural areas due to unhygienic living condition, water logging, foods, sewearage or other factors given above. TABLE : 3.3 Encephalitis cases per thousand population (2010) 2005 2008 2009 2010 Source : District Hospital, Bijnor (2010). TABLE : 3.4 Encephalitis cases in Different Blocks of Bijnor (2010) S. No 1 2 3 4 5 6 7 8 9 10 11 Name of Block Najibabad Kiratpur Mohd.pur Deomal Khari Jhalu Kotwali Afzalgarh Nehtor Allehpur Seized cases 06 04 05 04 06 08 04 05 Village affected 2010 02 02 02 02 04 03 04 03 04 02 04 32 Death cases 2010 01 01 01 02 03 02 01 02 01 02 03 21 .26 .32 .09 .10

Budanpur Seohara 04 Jalilpur Noorpur Total 04 05 45

Sources : District Hospital, Bijnor (2010). [134]

REGIONAL DOMINANCE OF VIRAL DISEASES This is an attempt ot find out regional variation of viral diseases in order to their importance in Bijnor district. This survey is based on P.H.C. records. In order to bring out the regions of dominant diseases, the relative strength of order of importance, there are measles, encephalitis, conjunctivitis, infectious hepatitis which hold different ranks in Bijnor district. THE FIRST RANKING VIRAL DISEASES Conjunctivitis stands on the first rank. It occupies 5 blocks on the first rank. These blocks are Jalilpur, Noorpur, Seohara, Afzalgarh and Kotwali. Eastern and Northern part of the study area is affected by this disease. Other tahsils are mostly affected by infectious hepatitis. Nagina tahsil stands on the first rank in other five tahsils. SECOND RANKING Conjunctivitis and infectious hapatitis are the major diseases which hold maximum tahsils of study area. Only in Najibabad block, measels stands on the second rank. THE THIRD RANKING At a glance of ranking map, we see that measles encephalitis and infectious hepatitis are the more important diseases. Measles is dominating disease in 3 blocks, encephalitis in 2 blocks and infectious hapatitis holds third rank in only one block of the region. (Fig 3.5) OTHER DISEASES Non infectious diseases are a diverse group and [135]

include the chronic degenerative diseases such as cancer, heart disease, bronchitis, diabetese and genetic diseases. In economically advanced countries of the world chronic degenerative diseases are major killers with bulk of the death occurring to people aged over 60. It is important to realise that remarkable contrasts can also be found within countries. CANCER It is a group of diseases caused by many factors (Park, 1987). Cancer is the most dreaded disease of modern times. The real cause of human cancer is still unknown but recent researches have shown that the disease bears some association with physical and cultural environment (Stamp, 1964). Cancer can occur in any site or tissue of the body and may involve any type of cells (W.H.O. 1964) ENVIRONMENTAL FACTOR 1. Climate : Excessive and prolonged exposure to radiation from the sun has been associalted with cancer of skin (paul,1969). 2. Air Pollution : It is an important factor causing lung cancer (paul 1969). More than 55 per cent cases occur due to environmental pollution (Eisenbud Merril, 1978) that includes water supply, soil radiation (Allen 1960). On the other hand, the cultural environment is responsible for the disease occurance. Smoking habit and tobacco chewing in rural areas are the major cause of mouth cancer. Cancer is regarded as an emerging cause of death.

[136]

Jussawala (1973) observes that cancer is one of the 10 leading causes of death today in India. Incidence rate is about 1 per thousand population in India. Mouth cancer is most popular in U.P. because of poor hygiene with tartar over teeth and advanced pyorrhoea (Wahi 1973). CANCER TYPES There are wide variation in the distribution of cancer throughout the world. Different social conditions feeding habits and environmental factors play an important role in distribution of different types of cancer. Lungs cancer is more common in industrialised countries like U.S.A., U.K. and France where air pollution is an important cause in the occurence of the disease (W.H.O. 1979). 1. Hapatic cancer : Rare cases are reported of this type in our country. Major causes of this type of cancer is severe malnutrition and cereals which are contaminated by fungus. 2. Cancer of Stomach : It is a disease of cold climate. It is frequently found in cold climate and lower socio-economic level (Brockington 1967). It is more common in Japan, Iceland and Russia. 3. Oral Cancer : It is more common in the study area. Tabacco smoking and chewing, reverse smoking, betelquid chewing are some carcinogenic factors involved (Wahi 1968). 4. Lung Cancer : Incidence of lungs cancer is lower in India in comparison to other developed countries (Paymaster 1984). The

[137]

smoking of tabacco in the form of cigarettes and atomospheric pollutions is the major cause of this type of cancer. 5. Cancer of Cervix : Early marriage, repeated child birth, vitamin deficiency and poor genital hygine are the factors that play an important role in occurance of this cancer (Reddy 1968). 6. Cancer of Breast : It is common in Indian women. Breast cancer is generally reported to be high among those ladies in India who do not breastfeed their children. DISTRIBUTIONAL PATTERN Sinha (1981) reported that cancer problem of the state is related to aging and large naumber of cancer deaths are generally reported from this district headquarter having specialised treatment facilities. Recently some ecologists have raised the fear that byproducts of the excessively used nitrogen fertilizers in the ganga paain, trapped into nitrosamine through the action of sunlight, may give rise to large number of cancer in the region as the chemical even in minute amount is said to cause cancer (Krishanmurty, 1979). Maximum cases were reported in Bijnor tahsil of the region followed by Dhmapur tahsil. Among families more cases of cancer of cervix are reported on acount of multiple deliveries at short intervals. Breast cancer cases are few. Among males mouth and lung cancer is common due to smoking or tabacco chewing. DIABETES According to Ayurveda abnormalties in urination have been

[138]

recognised as Prameha and one variety caused by the derangement of Vata is called Madhumeha or honey urine. The Hindu physicians of yore knew of the fact that urine of diabetes tastes sweet. Sushruta (600 B.C.) classified diabetes into two groups, One he states is congenital which is due to a defect in the seeds of the parents and other is due to injudicious feeding and an irregular way of living. In former condition the individual emaciated and dehydrated and suffers from loss of appetite, increased thirst and urinations. (Ahuja 1984). Years of research and painstaking investigations reveal that Diabetes mellitus is a chronic disorder of metbolism due to an absolute of ralative lack of internal secretion from B cells of the pancreas harmone insulin. It is characterise by hyperglycemia and in its most florid form is accompanied by ketoacidosis and coma (Vishawanathan 1978). In 1972-75 a study was done by Indian Council of Mediacal Research at different centres to determine the incidence of diabetes. It was found that among 2.1 per cent people in urban areas and 1.5 per cent in rural areas diabetes was detected. Over all prevalence was 1.8 per cent. The male ratio in India was 2.3 per cent while female ratio was 1.4 per cent. Prevalance below 30 years was .5 per cent, between 30-39 years one per cent and over 40 years it was 4 per cent.

[139]

CAUSAL FACTORS The Indian Council of Medical Research assigns the following causes for diabetese : FAMILY HISTORY Family history stands on first rank on causal factors. 18.3 per cent people in urban and 6.4 per cent in rural areas have positive association with family history. BODY WEIGHT Out of detected diabetics 31.5 per cent were qbove weight range of 115 per cent (average weight of an Indian male being 55 kg and of female 49.5 kg.) Higher prevalance rate was noted amongst literates, vegetarians and group suffering from chronic infections (Ahuja, 1983). Prevalance was not low in under weights or with low caloric intake or persons of poor socio-economic status. ENIVIRONMENTAL FACTORS (ALBIN 1982) Generally obesity, physical maturity, urbanisation stress and strain (Geevarghese et al 1962) and chronic under nutrition have been recognised as the factors that may precipitate diabetes mellitus. A. OBESITY AND NUTRITION Diabetes is more closely associated with consumption of calories in excess of requirement while diabetes also tends to occur in young subjects with chronic undernutrition. Incidence of diabetes is 4 times higher in persons with moderate obesity

[140]

and 30 times higher in persons with severe obsesity. Over nutrition and obesity is the most important risk factor to develop Diabetes (Geevarghese and et al 1962) B. AGE AND SEX The incidence of diabetes in any population rises steadily with age except a slight decline in the eighth and ninth decades (Ahuja 1983). There is a steep rise around 35th year and futher at 45th years of age. Incidence at the seventh decade may be 40 to 50 times higher than in the second . There is a female prepondrance with MF. ratio around 1:4. C. GENETIC ASPECT OF DIABETES There is a strong familial aggregation of diabetes and the stronger family history, the greater the prevalence of diabetes. Positive family hostory can be obtained from 25-50 per cent of diabetes. Compared to controls the disease is 4 times more common among parents, 9.5 times among siblings and twice as common among other relatives of known diabetes. The current view is that the interitence of diabetes is multifactional and due to multiple genes acting at several loci. This means that there is a strong genetic factor upon which environmental factors operate leading to diabetes (Vishwanathan 1981).38 DISTRIBUTIONAL PATTERN It is common in India as in other parts of the world. The industrial development, loss of physical exercise, obesity, family history and chronic under nutrition cause diabetes. Inspite of

[141]

these factors, the genetic factor also strongly affects the occurence of the disease in the region. It is distributed equally all over the region but disease incidence is highest in Bijnor which is 1.22 per cent. Chandpur, Dhampur and Nagina tahsils also show high incidence of diabetes. CARDIOVASCULAR DISEASE It is known as the 21st century disease of developed countries but day by day, it is becoming the disease of developing countries also. They are the leading cause of death among men and second and third leading cause of death among women (Park, 1972). The younger cause of death among women (Park, 1972). The younger age groups are increasingly being affected and it has been stated that if present condition persists, every second person born alive will die of C.H.D.(WHO 1969). Coronary athrosclerosis and hypertension are the principal causes of heart disease in middle and old age. Rehumatic fever is by far the most common cause in childhood and adolescence, while congenital heart disease is the commonest cause in infancy. In developing countries C.H.D. is coming up as a major public health problem while Ischaamic heart disease in 11-15% (Padmavati 1967). But regional variations in the country are found. CHAEMIC HEART DISEASE (C.H.D) It is the condition where there is impairment of heart function due to inadequate blood flow to the heart compared to

[142]

its needs caused by obstructive changes in the coronary circulation to the heart (WHO 1982). Coronary heart disease is the most important cause of premature death and disability. As coronary supply blood to the myocordium, artery diseases which narrow or block the coronary vessels will give rise to Ischaemia of the myocardium (Ischaemic heart disease or coronary heart disease). In 95 per cent cases common pathological process affecting coronary vessels is athrosclerosis (Narrowing the vessels) though syphlitic aoritis leading to coronary osteal narrowing. Periarteritis nodusa or embolic occlusion may produce same parthology. CAUSAL FACTORS OF C.H.D. DIET The progressive increase in the intake of edible fat with increasing preference for hydrogenated fat in palce or veg. oils (in the case of middle class) and in the most prosperous segemnts, relatively high intake of ghee is the major causal factor of C.H.D. It could be computed that fat intakes in the diet of the top income bracket could well be so high as to provide over 30 per cent of the calories in the diet level (Hindu 1988). There is a marked relationship with palsma cholestrol. Mass elevation of blood cholestrol is considered a factor necessary for the occurence of severe coronary athropsclerosis on a mass scale

[143]

(Masironi, 1979) whereas population studies revealed strong relationship between diet of the population and hypercholestremia. Studies of individuals have not shown such a relationship (Mann 1977). Since the lipid present in at athrosclerotic plaques are qualitatively similar to those circulating in blood, it raises the blood pressure. The diet in which unsaturated fats, egg, veg oils from soybean, maize or sunflower seed (substituted for saturated fats) may lower the level of cholestrol of triglyceried in blood. The diet consisting of unsaturated fat leads to a decrease in blood coagulability in contrast to that with a saturated fat. Millets (coarse gains) are progessively substituted by fine cereals, wheat and rice, with the increasing preference for the highly polished varieties of the lattar. With increasing socioeconomic advancement, these changes could result in significant deficiency in the diet which could lead to increased serum lipid level (Burkelt, 1974). HIGH BLOOD PRESSURE Studies from experimental observation & clinical trials show that high blood presure plays major role in the development of C.H.D. (WHO 1978). SMOKING Tobacco consumption of cigerette smoking was found closely related to C.H.D. and pathogenic leasion was postulated due to the ill reaction of nicotine carbon monoxide (WHO 1982).

[144]

INDUSTRIALIZATION With growing industries and the development and wide spread use of motor vehicles, the proportion of people who take vigorous exercise has declined and the proportion of sedentary workers including office and business oxecutives has increased. Inactivity may be an important factor in the causation of increased weight. Physical exercise lowers the plasma cholestrol as well as weight (Davidson 1972). ENDOCRINE FACTORS Ischaemic heart disease is rare in women before the menopause and after the age of 55 the difference in the incidence between the sexes becomes less. This suggests the possibility that oestrogens harmone have some protective infeuence (Davidson, 1972). The increased incidence of diabetes and myxoedea where palsma cholestrol is increased shows that secretion of thyroid gland and hyperglycema has its own importance in C.H.D. (Friendberg 1966). DISEASE INCIDENCE Maximum .061 per cent cases of C.H.D. reported in Dhampur tahsil hospital and about 219 deaths have been reported during 2009-2010 in the Bijnor district hospital. HYPERTENSION (BLOOD PRESURE) Hypertension represents an increase in presure of blood in arteries above the accepted levels. But there is no unanimity on the figures for normal levels. Not only in different geographic

[145]

areas, societies, families and sexes but also shows definite change from birth to old age in the same individuals (Wilson 1973). It is yet controversial to regard hypertension as a disease. it has assumed great importance of late not only because of its present and frequent incidence in intelectuals. CAUSES AFFECTING HYPERTENSION Heridity, diet, climate, occupation, stress-strain of life and obesity are the causing factors of hypertension (WHO 1970). In most causes of hypertension, the exact cause is unknown and some cases are secondary to recognisable disease. Studies from experimental observation and trials, an pathological changes show that high blood pressure palys major role in C.H.D. REGIONAL DOMINANCE OF OTHER DISEASES Regional dominance of the above non communicable diseases shows that Diabetes, B.P. & Heart, Cncer are dominating diseases. To bring out regional variation, the relative strength of various diseases is determined by ranking them in order of importance. Blood presure stands on the first rank in Khari Jhalu and Allehpur blocks of the region. Diabetes occupies second place in order of dominance. On the second rank diabetes and blood pressure are the dominating disease in the district.

[146]

FIRST RANKING DISEASES Blood pressure is dominating disease in Khari Jhalu, Nehtor, Allehpur, Noorpur and Jalilpur urban centres. Diabetes holds first rank in Bijnor and Dhampur urban centres. SECOND RANKING DISEASES Blood pressure is the second most dominating disease in all the blocks of the region. Diabetes melitus is dominating in 2 tahsils of the region. B.P. and heart hold second rank only in Khari Jhalu block of the region.

[147]

REFERENCES
1. Jones, Kelvyan and moon Graham, (1987), Health, Disease and Society- A Critical Medical Geog., P 107, Poutlidge and Kegan paul, New York, 10001. 2. Suchman. E.A. (1963), Sociology and Field of public Health Russel Sage Foundation, New York. 3. Paul. J.R. (1966), Clinical Epidemiology, The University of Chicago press. 4. Levell, H.R. and Clark E.G., (1965), Preventive Medical for the Doctor in his community, Mc Graw Hill Book Co., New York. 5. Park, J.E. et al. (1972), A text book of Social and Preventive Medicine, p. 26, Banarasi Das Bhanot Publishers, Jabalpur. 6. Felix Marti, (1985), Ibanez Forward to Ecology of Human Disease by J.M. May, American Geographical Society, New York, XVII. 7. Learmonth, A.T.A., (1961), Medical Geography of India and Pakistan, The Geographical Journal, 127, pp 10-26. 8. Joshi, M.J. and Deshpande. C.D., (1972), Geographical Distribution of some Disease common in Southern Asia, Geographical Medica, 3 pp. 5-29. 9. Hyma, B and Ramesh, A., (1985), The Geographical Distribution of trend in Cholera Incidences and the Mortality, Indian Geographical Journal, 51, pp. 1-32, 1976. 10. Akhtar, R. and learmonth, A.T.A., (1979), Malaria Annual [148]

Parasite Index maps of India, by Malria Control Unit Areas 1965-1976. Research paper No- 3, Social Sciences Faculty, The Open University, Milton Kaynes, 1979. 11. Pacholi, S. (1977), Vector Species of Malaria and its C o r r e l a t i o n w i t h t h e d i s e a s e s i n J a b a l p u r, T h e Geographical, 24, pp. 31-42. 12. Mathur, H.S. (1969). Geographical Factors of Incidence of Smallpox in Rajasthan, Indian Journal of Geography, 46, pp. 36-46, 1976-1971. 13. Brock, J.F., (1961), Recent Advances in Human Nutrition, Churchill, London. 14. Gopalan, C. et. al. (1971), Nutritive value of Indian Food, National Institute of Nutrition, Hydrabad, India. 15. Gupta, S., (1979)Gastro Industrial Symptoms, A Text Book peadatric, P.255, Vikas pub. House, Pvt. Ltd., New Delhi. 16. 17. W.H.O., (1967), Tech Report, Sr. No. 302. Swaminathan, M. et. al. (1962), Our food, Ganesh and Co., Pvt. Ltd., Madras-11. 18. Stotl., H. et.al. (1931), Distribution and Causes of Endemic Goitre in U.P., India, Jr. Med. res. 18, 1959. 19. Gopalan, et. al., (1957), Report on short General Health Survey of Rangia block, Assain, Govt of India Press (1965), pp.9-140. 20. Sinha, S.C. (1981), Medical Geog. of U.P.- An Unpublished thesis submitted to Gorakhpur Univ., 1981. 21. Krishnaswami, A.K. and Raghvan, (1954), N.G.S., Bull., Nal., Soc. Ind., Dis., No. 9.

[149]

22.

Chand, D. (1961) Report on state of Health in U.P. with particular reference of filariasis., Deptt. Of Med. and Health, U.P., Lucknow, pp 118-126.

23.

I.C.M.R., (1980), Viral Hepatitis, Proceeding of Task Force, held on Jan. 1980.

24.

Dutta, S.P. and Gupta, S.C., (1961), Indian J. Public Health, pp. 5-90.

25.

Ghos. B.N. (1961), Treatise on Hygienic and public Health, Scientific pub. co., Calcutta, P.-371.

26.

Khare, S.B. (1951), Ankylostomasis Indian Jour. Med. Science, vol. 5, pp. 6-12

27.

Mishra, R.P., (1970), Medical Geog. of India, Natioanl Book Trust, New Delhi.

28.

Meplestone, P.A., (1931), Further Observations on Seasonal Variations in Hookworm Infection, Ind-Jour., Med., Res., vol.19, pp. 1145-51.

29.

Patel, J.C. (1945), Incidence of Chronic Amoebiasis in Bombay, Ind. Phys., 4, P. 249.

30.

Kedarnath and Sarikawal, V.K. (1955), Jr Ind., Med. Assoc., 44., P. 133.

31.

Chutani H.K. et. al. (1965), Jr Assoc., Phisians India3,p.96.

32.

Achar, S.T., (1977), Tropical Diseases, p. 98. Pub., V. Abdull, Orient Longman, Ltd., 36, Anna Salai, Mound Road, Madrass.

33.

Patnaik, K.C. and Kapoor, P.M., (1967), Incidence and Endemicity of Guinea worm in India, Ind. Jr. med. Res. 55, 11, 1231. [150]

34.

Rodenwaldt, E. and H. Justaz, J., (1965), World Atlas of Epidemic Diseases (1952-61) Jumbarg, Folkverby, Geomedical Research Unit, Headerber Academy Sciences.

35.

Kurpp. M.A., (1980), Current Medical Diagnosis and Treatment, Infectious disease Bactitreal, p. 854, Lange Med., Pub., Maruyen Asia Pvt. Ltd.

36. 37.

Stamp, L.D., (1964), Some Aspects of Medical Geography, Oxford Univ. Press, London, p 71. Ahuja, M.M.S., (1984), Melting Down of Flesh and Limit into Urine, P.22, Pub., By K.S. Mani for B.I. Pub., Pvt., Ltd., 54, JANPATH, New Delhi.

38. 39. 40.

Viswanathan, M., (1981), Prevention of Diabetes, II Journal of Assoc. of Phy-of Ind., 29. pp. 251-261. Davidson, (1972), Disease of Cardiovascular System, P.238. Wilson, C., (1973), Text Book of Practice of Medicine, Oxford University Press.

[151]

CHAPTER - IV

ENVIRONMENTAL POLLUTION AND SANITATION

CHAPTER - IV

ENVIR ONMENT AL POLL UTION ENVIRONMENT ONMENTAL POLLUTION AND SANIT ATION SANITA
Mans physical and mental health depends on the genetic and environmental factors. The agents, the hosts, the vectors and reservoirs which are so closely related to human diseases and hence to human health are parts of overall geographical environment.1 Environment is defined as the congeries of forces and influences upon an organism. The health status of an individual, a community or a nation is determined by the interplay and integration of the ecological universes the internal environment of man himself and the external environment which surrounds him. The modern concept ascribes a disease to be a disturbance in the delicate balance between man and his environment. Of the three ecological factors (agent, host and environment) responsible for disease, the disease agent is usually identified in the laboratory; the host is available for study; but the environment from which the patient comes, is largely unknown. Yet frequently, the key to the nature, occurrence, prevention and control of disease lies in the environment. ENVIRONMENTAL POLLUTION Any disturbance in the bio-geo-chemical cycles creates ecological imbalance which is the root cause of environmental pollution. Pollution of environment is increasing at a terrific rate particularly during post-industrial period and has created a serious

environmental crisis threatening the very survival of mankind. The air, water, sunshine, minerals, animals etc., are natural resources of earth and their extraction, use and disposal by man modify the cycles so as to add a composite heavy waste materials which the ecosystem is not able to recycle easily. 2 It is well known that environmental pollution is growing at exponential rate; even higher than the rate of population growth. Main pollution include mercury, lead, oil, carbon dioxide, nitrogen, waste heat, pesticides, nuclear radiation and noise etc., which have caused immense damage to three natural resources-air, water and soil-which support animal and plant life. WATER POLLUTION Water is never pure in a chemical sense. It contains various kinds of impurities, such as, dust particles, dissolved gases (e.g., hydrogen sulphide, carbon dioxides, nitrogen, amonia, oxygen); dissolved minerals (e.g. salt of calcium, magnesium and sodium); microscopic plants and animals, suspended impurities (e.g. clay, mud, silt, sand etc.) and bacteria. Level of impurity is not available in official record of any centre of the region. It can only be seen in personal observation. According to Indian standard 1622-1987, in drinking water : 1. 95% of water sample should not contain any coliform organism in 100 ml. throughout any year 2. 3. No sample should contain Ecoil in 100 ml. No sample should contain more than 10 coliform organism per 100 ml. [154]

4.

And coliform organisms should not be detectable in 100 ml. of any two consecutive sample

Where it is unpracticable to supply water to consumers through a piped distribution network and where untreated sources such as well, boreholes and springs which may not be naturally pure have to be used, the requirements for piped supplies may not be attainable. In such circumstances disinfection although desirable is not always practicable and considerable reliance has to be placed on sanitary inspection and not exclusively on the result of bacteriological examination. Everything possible should be done to prevent pollution of water, obvious sources of contamination should be removed from the immediate catchment area; special attention being given to the safe disposal of excrement. Wells and storage tanks should be protected by lining and covering, surface drainage should be diverted, erosion prevented and surrounding area paved. Access of men and animals should be restricted by fencing and should be so designed that fouling is prevented while drawing water. Although not supplied through pipes water from other sources is likely to undergo further deterioration in quality during transport or storage before drinking. Containers used for water should be kept clean, covered and clear of floor. The most important factor in achieving these objectives is to insure cooperation of local community and the importance of education in simple sanitary hygiene should be strongly stressed.

[155]

Bacteriologically, the objective should be to reduce the coliform count to less than 10/100 ml. but more importantly to ensure the absence of fecal coliform organisms. If these organisms are repeatedly found or if sanitary inspection reveals contamination obvious source of drinking water would be sought whenever possible. Greater use should be made of protected ground water sources and rain water catchment ground which are more likely to meet the requirements for potable water quality. The more serious aspect of water pollution is that caused by : (a) (b) (c) (d) Sewage Industrial effluents Drainage from agricultural areas Physical pollution These are the result of urbanisation and industrialization. Undoubtedly, the sewage occupied the foremost place and major portion of inland waters in the region are polluted by it. Infections or disease causing organisms are other pollutants of water. The germs of diseases like typhoid, dysentery, cholera and tuberculosis etc. go into the water through sewage wastes and are transmitted to human beings when such waters is used for drinking and bathing purposes. The main causes of water pollution in the region are sewage and industrial discharges surface run off containing traces of dissolved pesticides. The rivers of this region receive sullage and sewage and also receive plenty of Industrial toxic waste from a number of sugar mills and the fertilizer factory. The rivers during [156]

summer become heavily polluted, and therefore, are unfit for direct use even for bathing purposes. On the other hand, heat and radioactivity are the most important physical pollutants. 3 Heat contributes to the deoxygenation of water with marked effect on the fauna and flora of the water. Radioactive substances have far reaching carcinogenic, toxic and physiological effects on man. Solid waste is a significant source of pollution in the region. It includes a large number of old and used articles ranging from small pins, glasswares, shoes, toys, plastic containers, polythene bags, water paper, old garments, tyres to machine parts and automobiles etc., which are dumped over the land or thrown into the rivers and water bodies. Very small particles of macro organisms and others like plastic, nylons and polythene, etc. pose a serious problem of non-degradability. In cities, garbage are seen dumped on road crossings and city dwellers are yet to develop a habit of keeping it at a proper place in municipal garbage cans. But in rural areas garbage is mostly left open near the dwelling site to create foul smell during its decomposition during rainy season and make the rural folk vulnerable to several diseases. In villages, major source of water supply are wells and hand pumps. In rainy season stinking garbage containing germs of diseases finds its way to village tanks which are used for bathing and drinking purposes. Generally, the dead domestic and farm animals' carcasses

[157]

are thrown in the open around the village habitations and drains which create problems of both air and water pollution. Human excreta from service latrines in the thickly populated urban areas and their improper disposal create pollution problems in areas where flush latrines are nonexistent. Similarly, the rural population easing themselves near havitations, bathing tanks and roadsides also cause similar problems. AIR POLLUTION The immediate environment of man comprises air on which depends all forms of life. Apart from supplying the life giving oxygen, the atmospheric conditions influence in several ways. The human body is cooled by air contact, the special senses of hearing and smell function through air transmitted stimuli and disease agents may be conveyed through air. Pollution of air by dust smoke, toxic gases and chemical vapours resulting increasing sickness and death rate. Air, a mixture of different atmospheric gases is the life blood of man, Burning large amount of fossil fuels, cutting forests and reducing ocean planktons have not only disturbed the proportion of atmospheric gases, but have left out thousands of tons of solid wastes in the form of dust, smoke and toxicant matters which form atmospheric impurities. The chief pollutants of air are carbon dioxide and monoxide, sulphurdioxide, nitrogen oxide, certain hydrocarbons and particulate matter. 4 Carbon monoxide is highly hazardous to human health. When inhaled, it

[158]

combines with the blood haemoglobin about 219 times faster than oxygen resulting into oxygen defficiency and suffocation. The hydrocarbons and particles like fly ash, soot and lead etc. obtained through incomplete combustion are believed to be a major cause of cancer. All these pollutants arise specifically from exhaust emission from motor vehicles, aeroplanes and chimneys of factories. It is well known that when they exist in combination, their danger is greater than the sum of their individual dangers. They sometimes produce smog in industrialized area blanketing the sunlight and making the citizen vulnerable to respiratory diseases. The industrialized cities are today gripped by the problems of air pollution causing high incidence of deaths and diseases. Karan5 has measured industrial air pollution in Chotanagpur and Blanden and Karan in Bombay industrial areas where respiratory diseases, like asthma, bronchitis etc. are abnormally high. Similar studies have also been done in case of Kanpur. Recent scientific studies on air pollution in Agra city has proved the occurrence of 17 micro grams of sulphur-dioxide in every cubic metre of air which has posed a serious challenge for the world renowned monument of Taj Mahal. In rural areas, the air is still fresh and invigorating, but with the gradual removal of forest cover, greater use of petroleum products and local air pollution is increasing in recent years. According to U.P. Air pollution Board, Lucknow, the classification of the areas on the basis of

[159]

land use and other factors, the various areas shall be classified into following categoriesA. Industrial and mixed-use areas will become self evident on the intensity of industrial activity in area and is bound to have somewhat inferior quality of air, compared to other categories. B. Residential and rural areas will cover station tourists resorts, sanctuaries, national parks, national monument, health resorts and other such areas where the nation would wish to conserve its clean environment even if that implies some curbs on economic activity. In Bijnor district, industries like Sugar Mills and Fertilizers, Chemicals have sprung up. These industries create air pollution on account of various gases and vapours. At a height of 3 metres from the ground, there is enough concentration of sulphur-dioxide and nitrogen-dioxide in the industrial area of Dhampur. It is estimated that even residential areas of Chandpur city are polluted. This increases the occurrence of asthma, bronchitis and T.B. cases in the city. According to U.P. Pollution control Board, Lucknow, automobiles emissions standards are 1. For motor vehicle powered by compression ignitions diesel engine, smoke density shall not exceed the level. (a) For vehicles operating in Urbon areas, the smoke sensitivity shall not exceed 65 Hartidge smoke units as measured by free acceleration method or 5.2 Bosch or [160]

75 Hartidge smoke units as measured by full load method. (b) For vehicles in non-urban areas, the smoke density shall not exceed 70 Hartridge smoke units as measured by free acceleration method of 55 Basch or 80 Hartridge units measured by full load method. 2. Vehicles powered by spark ignition engine shall comply with emission standards for carbon Mono oxide not exceeding 3 per cent by volume of exhaust gases during oiling. Vehicles which have completed 5 years of life or 80,000 km. distance, whichever is earlier shall comply with emission standard of carbon Mono oxide not exceeding 4-5 per cent by volume. Domestic smoke is responsible for about 50 per cent of the air pollution in the region. Smoke occurs in industries, bio loco-sheds, fertilizers and sugar mills in Seohara. Motor vehicles are a major source of air pollution throughout the urban areas of the region. Motor vehicles, trucks, trains, air crafts and other forms of transport contribute to air pollution by emitting hydrocarbon, Carbon-mono oxides, lead, nitrogen-oxides and particulate matter. In strong sunlight, certain of these hydrocarbons and oxides of nitrogen may be converted in the atmosphere into a photochemical pollutant of oxidizing nature6 (In addition, diesel engines, when mis-used or badly adjusted are capable of emitting black smoke and malodorous fumes in Dhmapur. [161]

Burning of refuse, agricultural activities e.g., crop spraying, pest control etc. also contribute to air pollution in the region. SOIL POLLUTION Contamination of soil is due to excessive use of fertilizers, pesticides, herbicides and improper disposal of solid wastes. It is posing a serious problem. Soil is becoming increasingly polluted with toxic chemicals and heavy metals which reach the food chain. The chemical fertilizers are used in order to meet the chemical need of the soil. In this way many varieties of pesticides and insecticides cling tenaciously to particles of soils for many years and do not vaporize, wash away or decompose easily and thus their residue goes into the soil contamination through plant leaves, roots, fruits etc. and is transmitted to animal or human being. Soil pollution is also seen in urban areas due to improper dumping of city garbage, industrial wastes, using sewage water for irrigation and unscientific use of fertilizers and insecticides etc. But in rural areas social habits connected with open drains, garbage disposal and field lavatories are no less responsible for contaminating the village lands. The heavy concentration of sugar mills and crashers in Bijnor district, the effluent from sugar mills as crashers is rich in suspended solids, BOD & grease and thus has a great pollution potential. 8 On an average, it has been estimated that sugar mills discharge 300 litres (600 gallons) of waste per ton of cane crushed and 4 per cent of the cane crushed is turned into molasses. [162]
7

On the other hand, in the boiling process the obnoxious effluent that comes out from rice mills, contains high degree of suspended of dissolved matter. This matter pollutes water or soil. Many types of helmenthic infections occur in this region due to this infection. This is the major cause of intestinal disorder and hook worm, thread worm, round worm and infectious hepatitis. In these circumstances the Amebiosis is more common in this region. ENVIRONMENTAL SANITATION The objective of environmental sanitation is to create and maintain conditions in the environment that will prevent disease and promote health. Mans external environment contains elements which are essential for life and for the maintenance of good health. In addition, the environment contains potential hazards. Man has a wide range of tolerance to environmental conditions because of his ability to adapt. Such biological adaptation has its limits and the breakdown of adaptation represents the on set of disease, e.g. the human being can tolerate wide fluctuations in environmental temperature, he has various mechanisms (sweating, shivering) for coping with these changes. If However, the heat stress is excessive, then adaptive mechanisms breaks down and disease results, may be in the form of heat stroke. The breakdown of adaptation can be prevented by9(a) Increasing the hosts ability to withstand stresses in the environment, e.g. by good nutrition.

[163]

(b)

Reducing the hazardous and hostiles elements in the environment.

ENVIRONMENTAL SANITATION It is a way of life for healthy living. This is the process of taming the environment so that it no longer constitutes a hazard to man. In particular, environmental sanitation deals with: (1) (2) (3) (4) (5) (6) Provision of a safe and adequate supply of water Safe diposal of wastes Provision of good housing Control of insect vectors and other pests Control of animal reservoir of infection Air hygiene and prevention of atmospheric Pollution (7) Elimination of other-noise, radiation etc

WATER SUPPLIES Each community needs a safe and adequate supply of water. In general, source of water in this region is tube wells, tanks or rivers. In urban areas water from underground or surface source is transmitted through mains, submarine and branch lines to every street. The community life in any area cannot provide this function themselves and thus it is a responsibility of the community. Water is a physiological necessity and had got a high place for the healthy maintenance of human body.10 SOURCE OF WATER SUPPLY In Bijnor district, wells and rivers are the main source of

[164]

water supply. Wells furnish cool and playable water to most of rural areas. But rivers are more or less unfit for drinking pupose. In 95 per cent villages, wells and hand pumps are main source of drinking water. In the villages, open wells (20-30 metre deep) and ponds are the main source of water supply. This affects the environmental sanitation and hygiene of general people. They do not take daily bath in the western part of the region and they often suffer skin diseases and stomach disorders (Sample Survey). Thickly populated eastern plain region has hand pumps, tube wells and ponds as the main sources of water supply. Shallow wells tap the ground water above the first impermeable of soil, hence they are easily polluted. This is why the people of this region suffer from helmenthic diseases. In general, the untreated water of this region is slightly hard disagreeable in taste and is not very safe for drinking. QUALITY OF WATER Calcium and sulphate are most common constituents causing hardness of natural water in the Ganga Khadar region. But the concentration varies in different places from 4 ppm to 384 ppm in Bijnor. BIOLOGICAL GROWTH Water becomes unfit for drinking purpose due to growth of different organisms. These bacteria are harmful for human health. Provincial Hygiene Institute, Lucknow examined the water of different areas of U.P. The report shows that 65.1 per cent samples

[165]

were of excellent quality, and rest 34.9 per cent were satisfactory having 1 to 2 coliforms per 100 cc of water. The sources of drinking water in urban areas are deep tube wells. It is the responsibility of Municipality to supply safe and adequate drinking water to urban community. Infected water creates all sorts of gastro intestinal problems like diarrhoea, cholera and jaundice (hepatitis) which are caused by micro organisms carried through water. These infections are essentially borne by food and drinks exposed to bacterially contaminated water and the hazards of such infections rise with the scarcity of water in summer. The direct link between water borne diseases and supply of potable water is so intimate that the incidence of water borne diseases is directly proportional to supply of safe drinking water and health education. DRINKING WATER SUPPLY URBAN AREAS On an average, majority of towns in the state share 80 litres which is about one third of the daily recommended requirement of 210 liters per head. The Environmental Hygiene Committee has made the following recommendations about the requirement of water as per size of the urban community giving allowance of 20 per cent for the functional characteristics of the town and cultural activities of the people. RURAL SUPPLY OF DRINKING WATER Rural population depends upon unpurified and unprotected water supply. The progress of extending the facility of drinking water supply in the rural areas has been rather slow. Mostly

[166]

villagers depend upon wells (which are open) for drinking water which are source of infection. In Bijnor district, 74.33 per cent village population depends on humdrums. And only 25.67 per cent on wells for this purpose (Table 4.1) TABLE : 4.1 Villages According to General Sources of Drinking Water in %
Source of Drinking water Hand Pumps Wells 16.88 23.35 26.77 27.49 28.72 25.67 83.12 76.65 73.23 72.51 71.28 Najibabad Nagina Dhampur Bijnor Chandpur Total Bijnor Distt. 74.33

Source: Water supply regional statistical magazine, Bijnor- 2010 But the per centage varies from tahsil to tahsil and block to block. Najibabad block has the highest per centage of villages having 83.12 per cent hand pumps and only 16.88 per cent wells, but the number of villages having hand pumps is the lowest in Chandpur tahsil (71.28 per cent). The Nagina tahsil stands at the second place both in the number of hand pumps as well as wells. 74.33 per cent villages have hand pumps and 25.67 per cent villages have wells in district Bijnor. The unpurified drinking water supply is the main factor for frequent recurrence of water borne disease in the rural areas. About 2.81 per cent villages of the region do not have sufficient water supply throughout the year. Table 4.2 shows the variation

[167]

among different blocks in sufficient water supply all over the year. The scarcity of water is the highest in Afzalgarh block (11.72 per cent) in the district of Bijnor. TABLE : 4.2 Percentage of Villages According to Sufficient/lnsufficient water supply all over the year 2010
Types Najibabad Nagina Dhampur Bijnor Chandpur Total Bijnor

Sufficeint Insufficient

83.12 16.88

76.65 23.35

73.23 26.77

72.51 27.49

71.28 28.72

74.33 25.67

Source: Based on water supply regional Magazine-Bijnor-2010 The progress of extending the facility of drinking water supply in the rural areas has been rather slow. WATER SUPPLY AND DISEASE Bijnor district has frequent cases of malaria, cholera, gastroenteritis, hepatitis and dysentery. However, a close study of the mortality rate of the urban as well as rural areas of the six blocks indicates that the per centage of mortality in the rural areas in all the blocks of the region exceeds significantly the mortality rate in the urban areas (Table 4.3). This is probably due to the fact that the urban population enjoys better water supply and sewerage facilities than the rural areas.

[168]

TABLE : 4.3 Rural/Urban Death Rate per Thousand Population S.No. 1. Tahsil Najibabad Rural 2. Nagina Rural 3. Dhampur Rural 4. Bijnor Rural 5. Chandpur Rural Death Rate 3.0 5.2 3.5 5.8 3.8 6.2 4.4 6.6 4.9 7.6

Source : S.R. Bulletin Volume IX, No. 3, Registrar General of India, New Delhi-2009 SEWER SYSTEM, SANITARY, DRAINGE AND DISEASE Proper covered drainage system is necessary for disposal of wastes, sullage water excreta and other wastes. The marshy tract of Ram Ganga Khadar due to water logging leads to water contamination and pollution. This water logging gives foul smell and encourages mosquito and housefly breeding that results in high incidence of filaria, malaria and encephalitis, cholera gastroentritis, infectious hepatitis and dysentery in Bijnor district. EXCRETA AND REFUSE DISPOSAL Human Excreta is a potent source of infection. It is an important cause of environmental pollution. This problem is equally [169]

distributed in rural and urban areas. There is hardly any satisfactory arrangement for collection of excreta in the rural area. About 8 to 10 per cent village houses have some type of latrines and the rest of the people use open land and drains for defecation. The problem of excreta disposal is almost the same in the towns also. About 28.3 per cent houses (Table 4.7) do not have any latrine and majority of the remaining houses have conservancy system which entails handling of the fecal matter with large outlay of manual work. Thus, from the health point of view as well as for social reform, scavenging system needs urgent replacement by septic tank. In rural areas, refuse dumps are found jointly within many houses and mixed with cowdung compost manure pits, which are often found near settlement. It is the ideal place for breeding of flies and mosquitoes. But in urban areas the refuse disposal problem is more serious. It has been estimated that on an average in a town of 1 million populations, 40-50 tonnes of refuse is thrown out daily which requires at least 5 trucks to remove it. The bulk of refuse consists of garbage, stable litter and street sweeping which contain 25.30 per cent organic matter with a lot of humidity. 11 These disposals give an offensive smell and provide ideal place for breeding of flies and insects. This condition further deteriorates in rainy, season specially during floods. Therefore, epidemic outbreaks of water borne diseases come often after rainy season.

[170]

Recently made Sulabh Sauchalayas play an important role in excreta refuse disposal in urban areas. These Sauchalayas are made by government, generally in public or slum areas of cities. Their roles are satisfactory in refuse disposals. RESIDENTIAL ENVIRONMENT Housing is one of the basic amenities that man needs for his survival in the world. But the kind of housing facilities available vary widely depending on the individuals capacity to pay for them. The contrasting housing situation mainly exists in the cities of the region Certain sections of the community are living in appalling living conditions. On the other hand, a small section of the community enjoys housing facilities exceeding their real needs. To find real housing situation existing in the study area, a sample survey was carried out personaly in summer 2010 of 400 families of the different part of the district. The families are equally distributed in urban and rural areas of the region. The housing facilities have been divided into : (a) (b) (c) (d) Type of residence Number of persons living in the house Number of rooms Bathroom, latrine and water facilities

TYPE OF RESIDENCE Residences have been divided into pucca and kachha structure. A pucca house is one which is built by stone or brick and cement with the roofing either made of concrete or tiles. A

[171]

Kachha house is one which is m'ade of mud and has a thatched roof. Higher income groups are more likely to live in pucca houses and poor income groups are more likely to live in kachha houses. Table 4.4 shows the distribution of type of houses occupied by households of different social classes in urban areas of the region. For collecting the data of residential environment in the urban areas of district Bijnor, a survey was done involving all the five tahsil towns of the region, viz, Bijnor, Najibabad, Nagina, Dhampur and Chandpur. A random sampling of different income groups was made in different towns. In the tables incorporating these data, the mode of the values have been shown. All the high class households had pucca houses to live. The analysis to table 4.4 shows the poor housing conditions of very low class. These housing conditions would create health problems such as communicable and respiratory diseases. The social class of the families are classified by their income groups; flat in a multistoried building is considered as a single house, whereas, a building constructed as a house for single household but is divided into portions and occupied by more than one household is considered as a single house. Majority of low class households were found to be sharing their houses with other households. On the other hand, majority of very low households were living in independent houses.

[172]

TABLE : 4.4 Income Groups and Social Classes S.N. 1. 2. 3. 4. Income in Rupees 10,000 - 15,000 > 5000 - 10,000 3000 - 5000 <3000 Social Class High Middle Low V. Low

Source : Based on personal survey (2010) TABLE : 4.5 Social Class and Type of Residence in Urban Areas of Bijnor District Type of Residence Social Class Pucca (%) Kuchha (%) Mixture of (%) Pucca & Kuccha structure High Middle Low Very Low Total 100 89 67 40 296 11 20 53 84 13 7 20 100 100 100 100 400 Total

Source : Based on Sample Survey (2010). NUMBER OF HOUSEHOLDS IN A HOUSE Such a condition leads to lack of facilities and privacy to households. Often several households share a small house and this creates heavy congestion in such leading to ill-health requiring medical care. Table 4.5 explains the distribution of number of households living in a house by their social class position. [173]

In order to tackle these poor housing problems, the state government of U.P. implemented many housing schemes, like industrial Housing in 1952. Low Income Housing Scheme in 1954 and Slum Clearance Scheme in 1956. In addition to the houses constructed under the above mentioned schemes, substantial programmes were undertaken by the state government and number of local bodies e.g. Corporations Improvement Trust and Cooperative Housing Schemes etc. During different five year plans housing shortage which was already quite acute, continued to grow with rapid urbanisation and industrialisation. The analysis of the table 4.5 showed the appalling living conditions of the low class households in the region. It is very difficult to lay the scale of housing requirements as it varies with climatic conditions, family structure, socioeconomic status and cultural development etc. Environmental Hygiene Committee has suggested a minimum of two living rooms in a house, each having a floor area of not less than 4.65 sq. metres (50 sq. ft.) per individual with a maximum of two persons in a room. According to this norm, there is great scarcity of living accommodation in the region. In the rural areas plain where due to joint family system, people live in big ancestral per centage of households living in one or two room house is comparatively low.

[174]

TABLE : 4.6 Social Class and Number of Households Living in a House Social class
Number of House- High holds in a house One Two Three Four Five Six Seven & above Total 78 9 11 2 100 78 14 4 1 1 2 10 100 56 10 5 10 6 8 5 100 57 6 1 3 7 6 18 100 266 421 11 15 14 16 34 400 Middle Low Very Low Total Total % 67.00 80.50 2.80 3.80 3.40 4.00 8.50 100.00

Source : Personal survey (2010). NUMBER OF ROOMS The number of rooms per household excluded bathroom, latrine and kitchen, but if a portion of living rooms was used for cooking purposes, it was considered as a room. A majority of households in the sample survey had only one room to live but the distribution noticed within each social class differed from the total picture. Most of High class households (81 per cent) live in a house of 2 to 5 rooms. A majority of middle class households dwell in 2 to 3 room houses. Most of low and very low income group households were living in one room houses, and it was observed that most of these households did not have separate

[175]

kitchen and they made use of a portion of the room for cooking purposes. The analysis of table 4.6 clearly shows the poor living conditions of the low and very low classes. This congested living condition of the poor is one of the causes of spread of many diseases especially respiratory diseases. TABLE : 4.7 Social Class and Number of Rooms in a House in the Region Number of Rooms Social Class One (1) High Middle Low Very Low Total Total in % 6 41 88 89 224 (56.0) 2-3 (2) 49 54 11 11 125 (31.3) 4-5 (3) 32 5 1 38 (9.5) 6-7 (4) 11 11 (2.7) 8-9 (5) 2 2 100 100 100 100 400 Total

(0.5) (100.00)

Source : Based on personal observation in the different parts of the district-(2010) BATHROOM, LATRINE AND WATER FACILITIES These are basic amenities that every households needs to have a healthy living. The analysis of these faculties by social classes showed a very different picture. None of the very low class households had these three basic amenities for their own dwelling and most of them did not have these three facilities at all. On the other hand, all the high class households had separate bathroom, latrine and water supply for their dwellings. [176]

The low and very low classes especially in the villages utilized the open space around their homes or the dirty public lavatories which are the major causes for the spread of communicable diseases. On the whole an area survey (Table 4.7) showed that the housing condition of low and very low class was appalling. They not only lived in overcrowded surroundings, but their dwellings were also overcrowded and they lacked in all the basic amenities needed for healthy living. TABLE : 4.8 Social Class and Presence of Bathroom, Latrine and Water Supply in the Study Area Presence of Bathroom, Latrine and water Separate Bath Absence of Bath No Bath room Social Class room+Latrine room+Latrine or + No Latrine +Tap or well water supply or the combination of any two High Middle Low Very High Total % 100 85 17 202 (50.5%) 10 11 4 25 (6.3%) 5 72 96 173 (43.2%) 100 100 100 100 400 (100%) +No Tap or well or handpump Total

QUALITATIVE CONDITIONS OF THE HOUSE It is difficult to assess the qualitative condition of houses in any area. But it is a fact that most of the houses in rural areas are made of mud and the houses of the urban areas are constructed almost without planning. The Housing reports (Census [177]

of India 1991, 2001) and tables show that pucca houses per centage is increasing about 9.06 per cent houses even in urban areas are Kachha. Most of them are dark and devoid of fresh air and light. The low level of housing sanitation, narrow lanes and by-lanes without any planning has made the housing conditions in rural areas extremely unsatisfactory. The low quality of damp houses with stagnant air, lower the vitality of the inmates and make them more susceptible to diseases like cholera, typhoid, diarrhoea, dysentery, scabies, ringworm and other skin diseases. At last, the level of environmental sanitation in Bijnor district is quite low. About 27 per cent city dwellers and 83 per cent of villagers do not have adequate arrangements for good quality of drinking water supply. The excreta and refuse disposal is a problem both for rural and urban areas of the region as majority of houses have conservancy system of latrines. Housing condition is also poorer than other parts of the state or country. On account of overcrowding and congestion, lower and middle class population in towns and cities live in ill ventilated rooms and the people often suffer from headache, anaemia, tuberculosis and asthma etc. Rapid urbanisation is the major cause of environmental pollution in the region. The industrialization encourages the insanitary habits and improper disposal of solid and liquid waste specially from sugar mills causing soil pollution in the region.

[178]

POLLUTION AND DISEASE Infectious diseases like typhoid, dysentery, cholera, jaundice, gastro-entritis and tuberculosis are transmitted by sewage and water pollution. On the other hand, due to air pollution influenza, bronchitis, asthma and cancer diseases are spread. Soil pollution is the major cause of intestinal disorder, hookworm and thread worm and infectious hepatitis. This is why Amebiosis is more common in Bijnor district.

[179]

REFERENCES
1. Gupta, S.C. and Chug, M.L,. (1986), Behavioural Sciences and Community Health Problems, Swasth Hind, Vol xxx, No. 10, P. 250. 2. Tiwari, R. C. and Yadav, H. S., (1982), Pollution and Environmental Management-An Introductory Survey, Proceedings of National Symposium on Environmental Management, Allahabad (July-23-25), P.61. 2. 3. W.H.O., (1978), Tech. Rept., Sr. No. 302. Eisembud Merril, (1978), Environmental Technology and Health, The Mecmillan press Ltd., U.S.A.P.187. 5. Karan , P.P. (1977), Perception of Environmental pollution in Chhotanagpur Industrial Area-India, National

Geographer, vol. 12, 1, P. 17-24. 6. 7. W.H.O., (1978), Tech. Rept., Sr. No. 302. Kayastha, S.L., and Lumara, V.K., (1981),Soil pollution-A case of Kanpur, National Grographer , Vol.16, No.l, P. 21-28. 8. Charkrabarty, R. N., (1964), Cane suger wastes and their disposal, Environ., Health, VI, P. 265-273. 9. Lucas, A.O and Gills, H.M.(1973), A short text book of preventive Medicine for the tropics. The English Universities press Ltd., St. Pauls house, Warwic k Lone, London, E.C.,4 PUAH . P .38, P. 244. 10. Sinha, S. C., (1981), Medical Geography of U.P.,- An unpublished thesis, submitted to Gorakhpur University. 11. Bhide, A.D.et.al.,(1975), Studies on Refuse in Indian Cities, Ind. Journal, Enviromental Health, vol.15,No.3, P. 215-22, Quoted In Medical Geography of U.P. by Sinha, 1981. [180]

CHAPTER - V

CONCENTRATION AND INTENSITY OF DISEASES

CHAPTER - V

CONCENTRA TION AND CONCENTRATION INTENSITY OF DISEASES

CONCENTRATION ZONES In the preceding chapter the major diseases of Bijnor district were divided into 5 groups and the ecological aspects of each group were discussed. It is essential, however; to have clear view of the combination and concentration of these groups in different regions of the study area. There are many techniques for making such combinations which have been applied by geographers in different branches of geography. However, in the present study the method formulated by Siddqui 1 and Sharma 2 have been employed for arriving at the degree of concentration of diseases found in five different tahsils of the region. SIDDIQUIS METHOD In order to find out the concentration of different diseases based on ten years data 1991-2001, the method suggested by Siddiqui has been adopted in the present case. For this, all the five tahsils and eleven blocks of the district have been divided into different categories. The concentration for each disease has been worked out by the following formula: D I= S I = Index of concentration for any disease in tahsil;

D = Incidence of a particular disease as a percentage of total diseases for the blocks; Bijnor district, S = Total for a particular disease as a percentage of total diseases are falling into different categories. DEFICIENCY DISEASES The major deficiency diseases which affect the population in this area are four which are shown in ranking order in the Regional Dominance. By the above formula the value are falling into five categories (Table:5.1) TABLE : 5.1 Showing concentration of Deficiency diseases Anaemia Avitaminosis P.C.M. Goiter Degree of Concentration 189.31 149.17 109.03 68.89 28.74 Note: ANAEMIA It is a wide spread disease. There is one tahsil and two blocks of high concentration of this disease. Most of the blocks show low and very low concentration index of the disease. However, Chandpur and Nagina tahsils show high concentration index. Lack of balanced diet is the main cause of the disease. 176.03 142.02 108.01 74.00 39.99 137.96 111.24 84.52 57.81 31.09 223.66 174.50 125.35 76.20 27.05 V. High High Medium Low V. Low

P.C.M. = Protein, Calory, Malnutrition

[183]

AVITAMINOSIS Concentration of avitaminosis is found to be high in Najibabad and Nagina tahsils. Bijnor tahsil shows very low concentration. P.C.M. The tahsil of Najibabad displays very high concentration of this disease. Kiratpur block is of high concentration index. Undernutrition is the main cause of this group of disease. GOITER North-eastern parts of the district are Goiter prone zone. Nagina tahsil shows very high concentration index of goiter. Other tahsils of Chandpur and Dhampur show high concentration. The main cause of the disease is deficiency of iodine in the water of the region. PARASITICAL DISEASES The major parasitical diseases which affect the population of district Bijnor are malaria, Filaria, Hook worm, Asscaris and Scabies. An effort has been made to illustrate the general dominance of diseases in regional dominance. But in order to find out concentration of parasitical disease, the same method has been adopted. By this method the values are falling into following categories (Table 5.2).

[184]

TABLE : 5.2 Showing Concentration of Parasitical Diseases Malaria Filaria H.W. Asscaris Scabies Degree of Concentration 177.81 136.79 95.76 54.74 13.71 Note: MALARIA It is a widespread disease in the western part of the region. Bijnor and Chandpur tahsils show very high degree of concentration of Malaria while Najibabad and Nagina tahsils show very low concentration. The higher concentration is due to hot and wet climate where ideal conditions obtain for mosquito breeding. FILARIA Southern part of the region show Very high degree of concentration whereas southern tahsils have very low concentration index. Hot humid weather is the main factor for the spread of disease. HOOK WORM Is is a common disease in the region. Very high degree of concentration of this disease is found in all the tahsils but its concentration is very low in the northern part of the region. Poor [185] 180.48 143.71 106.94 70.17 33.40 166.40 181.27 133.54 140.28 100.68 67.83 34.97 99.29 58.29 17.30 47.99 116.94 85.89 54.84 23.80 V. High High Medium Low V. Low

V = Very, H.W. = Hook worm.

environmental sanitation and pollution of soil and green vegetables are the main factors that cause of disease. ASSCARIS Asscaris concentration is higher in the western part of the region due to unhygienic living conditions or poor standard of living. SCABIES It is a most common disease in the study area and almost all tahsils show very high degree of concentration due to hot and wet climate. CONCENTRATION OF BACTERIAL DISEASES A glance of ranking reveals that tuberculosis (T.B.) dysentery, gastro-entritis (G.E.) and venereal disease(V.D.) are the most important bacterial diseases in the region. It highlights the areas of regional distributional pattern of the diseases. The values of the concentration of the bacterial diseases fall into following categories (Table 5.3) TABLE : 5.3 Showing Concentration of Bacterial Diseases T.B. G.E. V.D. Dysentery Typhoid Degree of Concentration 127.88 105.71 83.54 61.37 39.20 143.89 121.49 99.10 76.70 54.31 137.19 250.91 113.17 198.91 190.40 146.39 102.39 58.38 14.38 V. High High Medium Low V. Low

89.15 146.77 65.13 41.11 94.61 42.50

Note : V.D.= Venereal Diseases G. E. =Gastro-Entritis T.B.= Tuberculosis

[186]

TUBERCULOSIS It is a bacterial disease in the region. Bijnor and Chandpur tahsils have very high degree to concentration of the disease. Poor environmental sanitation overcrowding and undernutrition are the major causes of the disease. GASTRO ENRITIS It is a bacterial disease which is found all over district Bijnor. Afzalgarh, Kiratpur and Seohara blocks have very high degree of concentration of the disease. Water pollution, water logging in flood affected areas, food poisoning and flies are the main responsible factors for the spread of the disease. V.D. Its concentration is very high in Khari Jhalu block. Industrialization and urbanization are the main factors responsible for the disease. DYSENTERY It is most common disease of Bijnor. Soil pollution and improper disposal of sewage water or poor knowledge of eating habits are the factors responsible for the disease. TYPHOID It is a disease which is most common in some blocks of the district. Nehtor and Allehpur blocks have very high degree of concentration of this disease. It is due to poor knowledge of sanitation and defective diets. CONCENTRATION OF VIRAL DISEASES A glance of ranking indicates that conjunctivitis and

[187]

infectious hepatitis are more important viral diseases in the region. The study highlights the areas of regional intensity of distributional pattern of the diseases. The values are falling into following categories-(Table 5.4). TABLE : 5.4 Showing Concentration of Viral Diseases Measles Infectious Hepatitis 178.91 141.03 103.15 65.27 28.27 MEASLES The Concentration of this disease shows that it is a wide spread disease. Measles holds very high degree of concentration in only five blocks and other blocks of the western part of the region show high degree of concentration. This is so because people of the area regard the disease to be the wrath of Devi or Sheetla Mata and do not come to hospitals. So, the hospital records indicated very low degree of concentration. INFECTIOUS HEPATITIS Very high degree of Concentration is found in Bijnor. Due to lack of poor hospital facilities, many cases are not reported in the northern belt. So, the concentration is very low in this district. 177.99 140.56 103.13 65.70 28.27 150.85 125.04 99.24 73.43 47.63 143.95 110.79 66.63 44.46 11.30 Conjuntivitis Encephalitis Degree of

Concentration V. High High Medium Low V. Low

[188]

CONJUNCTIVITIS It is an infectious disease and its concentration is very high in all the five tahsils due to unhygienic living conditions. ENCEPHALITIS Eastern part of Bijnor district is mostly affected by this disease. Northern belt of Ram Ganga Khadar shows very high concentration. Mosquito plays an important role in spreading the disease. Humid and hot climate produces favourable conditions for breeding of mosquitoes and thus five blocks of the district show very high degree of Concentration of the disease. CONCENTRATION OF OTHER DISEASES A glance at concentration indicates that blood pressure, heart and diabetese are more important than other diseases in the district. The regional intensity of distributional pattern of other diseases shows regional variations in area. The values are falling in following categories- (Table 5.5). TABLE : 5.5 Showing Concentration of Other Diseases Cancer B.P.& Heart Blood Pressur Diabetes Attack 185.83 145.70 105.57 65.44 25.31 283.50 218.49 153.49 88.48 23.48 161.43 131.88 102.34 72.80 43.25 171.77 138.24 104.71 71.18 37.65 Degree of Concentration V. High High Medium Low V. Low

[189]

CANCER It is more common in Khari Jhalu, Allehpur, Nehtor, Seohara and Chandpur blocks of the region where tobacco chewing or Bidi smoking is more common. Thus the region of the occurrence of mouth cancer mostly are reffered to cancer hospital at Meerut and Delhi. B.P. & HEART ATTACK Its highest concentration is in Bijnor tahsil. Other tahsils like Dhampur, Chandpur and Najibabad have similar reasons for the occurance of disease. Industrialization and urbanization are responsible for the occurrence of disease. BLOOD PRESSURE It is more common in District headquarters where urbanization is more common. Mostly daily workers are affected by this disease. Loss of physical labour and rich diets are responsible factors for occurrence of disease. DIABETESE It is mostly found in urban centres of Bijnor, Dhampur, Chandpur and Nagina etc. Mechanization, loss of physical labour, rich diets are responsible factors of diseases of in the district. SHARMAS METHOD In order to demarcate the disease intensity regions, disease ranking coefficient values (Rt 1 , Rt 2 , Rt 3 , Rt n ) were calculated for all the constituent tahsils and grouped in different classes according to their magnitude. The concentration of these

[190]

values was done in four steps. Firstly, disease wise norbidity and mortality figures in a tahsil were converted into percentage of total for the particular disease. Secondly, all the tahsils were arranged in descending order under the head of each tahsil was allotted a rank for each disease. Lastly, all the ranks taken by a block were added up and averaged to determine its disease ranking coefficient value, using the following formula suggested by J.P Sharma. Dr +Dr +Dr +.Drn Rt =
1 1 2 3

Rt 1 is the disease ranking coefficient value of tahsil t 2 N is the total number of diseases taken into consideration and Dr 1, Dr2, Dl 3. Dr n are the ranks occupied by the tahsil t1, diseases, r 1, r 2, r 3.rn. Disease ranking is very useful in understanding the distributional pattern of diseases in a area because it provides an idea of relative dominance of different disease in order of importance. Bijnor district displays noticeable regional variations not only in the distribution and ranking of disease but also in the intensity of diseases. (Fig. 5.1) VERY HIGH DISEASE INTENSITY Northern parts of Najibabad, Kiratpur, Seohara and Noorpur blocks constitute the V. high disease intensity zone. These are the regions which have lowest coefficient value of disease ranking

[191]

index. Bijnor, Chandpur and Dhampur tahsil have 8.14, 8.21, 8.28 coefficient values respectively. HIGH DISEASE INTENSITY Eastern part of Nagina tahsil from north-west to south east have High disease intensity than other parts of the region. Thus Seohara and Afzalgarh (9.14) blocks have lower coefficient values. Sharma J.P.- incidence ranking and intensity of major diseases in district Tehri, U.P.- Geographical Aspect of Health and disease in India. Edited by R. Akhtar Concept Publishing Company , New Delhi 1985. MODERATELY HIGH DISEASE INTENSITY REGION Only two blocks Kiratpur and Kotwali fall into this rank. These blocks have coefficient values of 10.35 and 10.78 respectively. MEDIUM DISEASE INTENSITY REGIONS Only Mohd.pur Deomal block has 12.35 coefficient values. LOW DISEASE INTENSITY REGIONS The Western part of Jalilpur and Khari Jhalu blocks with 13.072 and 12.07 coefficient values come into this rank. VERY LOW DISEASE INTENSITY REGIONS Chandpur and Dhampur tahsils have highest coefficient value. So these tahsils have lowest disease intensity.

[192]

SAMPLE SURVEY In order to analyse the occurrence and causal factors of different diseases in the district of Bijnor, a sample survery of eleven specifically selected villages of Bijnor district (U.P) was carried out in June 2010. Many authentic information had to be collected directly from the villagers with the help of questionairie and interview in eleven selected villages of the study area. One village from each block was selected on a random sampling basis. Interviews were carried out with the male head of the household or in his absence with the female head of the family. Although an interview Proforma was used for the collection of informations, separate notes were also prepared:- wherever necessary. A Majority of rural adult population is still illiterate or barely literate. Since a substantial number of interviews belonged to scheduled castes, it was necessary to explain the purpose of survey at length in most cases in order to gain their confidence and get correct information. The purpose of this sample study is to identify geomedical aspects, environment and agriculture life styles, the factors contributing to the disease occurrence in Bijnor district. A brief account of the geographical characteristics and the information collected from different villages is given as under. The population figures of the villages are based on district census handbooks of the Bijnor district-2001 (Fig.5.2).

[193]

1. BHAGUWALA It is a village situated in the nothernmost part of the Malin River Region in Najibabad tahsil of study area. It is about 30km. distant from Najibabad tahsil headquarters in the foot hill of the Shivalic range of the Himalayas. About 5279 persons were residing in 876 households in June, 2010 in the village. There is one Junior High School and one Primary school in the village. There is no C.H.C. or P.H.C. in the village. Najibabad town is the only nearest service centre for medical as well as other necessary services. Only 50 persons constituting 10 families were surveyed. There are wide gaps in the standard of living among different economic groups. About 76 per cent of population uses drinking water from open wells. Encephalitis and Gastro-entritis are the main diseases which occur frequently in the village. According to villagers there have been 11 deaths due to Gastro-entritis and 21 deaths due to Encephalitis only last year. It is a village which is surrounding by waterlogged areas in the rainy season offering ideal place for mosquito breeding. The villagers have fear complex for encephalitis disease, 79 deaths occurred during last five years. It is found that the cause of epidemic out-breaks is the poor economic condition and utterly unhygienic living condition. Non availability of pure drinking water, water logging and absence of medical services are the major factors contributing to the spread of disease.

[194]

TABLE : 5.6 Showing Number of Families Interviewed During Survey

S. Sellected Total Number of Households Total Number of persons surveyed % of surveyed persons to population

No. Villages

1. 2. 3. 4. 5. 6. 7. 8. 9.

Bhaguwala Budgara Rawali Pawati Datiyana Shivala Kiwar Mankua Baserha Khurd

10 10 10 10 10 10 10 10 10 10 10 110

50 100 100 50 75 50 50 50 100 50 100 775

5.44 6.66 5.53 6.18 5.80 8.83 1.88 6.61 6.32 4.70 12.00 6.35

10. Harganpur 11. Reharh Total 2. BUDGARA

This village is situated in the North Western tract in Najibabad block of the same tahsil. It stands 20 km. away from Najibabad. The population of the village is 3278 and 50 persons were interviewed. Source of drinking water in this village is mainly (93%) handpumps. Due to unhygienic conditions, ignorance, poor economic status and poor drainage, the occurrence of water borne and arthpood borne diseases is frequent in the village.

[195]

Gastro-entritis is common in this village. Due to poor economic condition, the general health of population is very poor. About 23 patients of T.B. were detected among the persons interviewed and 7 deaths were caused by this disease during last year. Encephalitis also breaks out frequently; 3 deaths occurred during last one year in the village due to this disease. The patients of this village go to Chandak, Kiratpur and Bijnor for treatment. 3. RAWALI This village is situated at the confluence of Ganga and Malin rivers in Mohd.pur Deomal block of Bijnor tahsil with 1850 persons in 351 households. It stands 10 km. away from Bijnor district headquarters. It falls in moderate disease intensity region. 75 persons of ten families were interviewed. Fifty per cent population depends upon hand pumps for drinking water. Wells are another source of drinking water. Mostly scheduled castes and backward castes people reside in the village. Jaundice is more common disease in the village. Lack of potable water supply and water logging is the major cause of diseases occurrence. Patients go to Bijnor for all type of medical services. There is no P.H.C. or C.H.C. in the village. 4. PAWATI It is situated in Gangan-Karula Region just 14 km. from Bijnor district headquarters with 1800 persons in 296 households. It falls in moderately low disease intensity region. 48 percent population of this village depend on handpumps for its water

[196]

supply. 87 persons of 10 families were interviewed. During personal observation, it was found that the morbidity is more common than mortality. All types of medical facilities are available in the city but traditionally the villagers do not care for minor troubles. They come to the health centers when their condition becomes very serious or when the disease becomes an obstacle in the daily routine. Malaria, Jaundice and Helmentic disease are the common disease in the village. Asscariasis is a common problem which creates morbidity in the village. Out of 78 percent 43 reported this trouble due to which they have many related health problems. Loss of appetite, vomiting and many intestinal disorders take place which are associated with this disease. 5. DATIYANA It is situated in Jalilpur block about 16 km. away from the tahsil headquarters of Chandpur with 2025 persons in 310 households. This village enjoys the status of Nyay Panchayat seat with a P.H.C. medical facility. It falls in moderately low disease intensity region. 100 persons of 10 families were interviewed. Due to unhygienic condition, Malaria is the major disease and main cause of mortality in the village. Shedule castes and Tyagi Barhmins generally reside in the village. This village is situated in Ganga-Khadar Region. Due to poor drainage system, water logging is the major cause of the occurrence of the disease. 6. SHIVALA This village is situated in Noorpur block only 14 km. away

[197]

from Chandpur tahsil headquarters. It falls in moderately low disease intensity region because the villagers are almost literate here with 75 per cent literacy. Beside handpumps, wells are also a source of potable water supply. The rainy season, when the wells overflow, is the peak time for the spread of the epidemic outbreaks of water borne diseases. Gastro-entritis occurred two times and spread seriously in the village during the last 10 years. There is no P.H.C. or C.H.C. here. The people depend on Noorpur, Chandpur and Bijnor for medical facilities. 7. KIWAR It is situated on Seohara-Dhampur road in Seohara block. It is about 15 km. away from Seohara. It also falls in the very low disease intensity region. Only 100 persons out of 2832 persons of 10 families were interviewed here. 48 per cent population depends upon wells for drinking water. Due to unhygienic conditions, Malaria is the major disease. It is also the main cause of mortality in the village. The dietary habits and poor knowledge of sanitation and nutrition are the major causes of the occurrence of diseases. Jaundice frequently occurs in this village. 8. MANKUA It is a medium sized village where 1991 persons reside according to 2001 census. It falls in very low disease intensity region of Allehpur block. A puccka link road connects it with Noorpur and Dhampur which are at the distance of 15 and 8 km.

[198]

respectively. 50 persons of 10 families were interviewed for the purpose. It is located at the distance of 09 km. away from block headquarters. Here occurrence of water borne diseases are more common. According to the persons interviewed Gastro-entritis occurred three times during the last ten years. But the availability of P.H.C.s, C.H.C., tahsil hospital at Dhmapur and private clinics at Dhampur, Nehtor and Noorpur have rescued the general morbidity. 9. BASERHA KHURD This village of 3035 population to its credit, is situated in centre of Nehtor block with a distance of 9 km. from here. This village has deep interaction with Nehtor town. 96 persons of 10 families were interviewed. It falls in moderate disease intensity region. 100 persons of 10 families were interviewed. The general condition of soil is dry. 6 per cent of population depends upon handpumps which are very deep. But the poor group constituting 34 percent depends upon open well. The lack of proper knowledge of sanitation and nutrition are the major causes of the occurrence of diseases. Jaundice frequently occurs in the village. 10. HARGANPUR This village is situated in the north western part of BanChhoiya-Gangan Region in Kotwali block of Nagina tahsil. It is about 38 km. away from Bijnor district headquarters. It falls in the moderately high disease intensity region. Out of 1890

[199]

inhabitants of this village, 50 persons of different castes and different economic status were interviewed. Literacy rate of this village is 36 per cent. Hot and wet climatic condition is the major cause of parasitical and arthropod borne diseases. Encephalitis is more common during July-November for the last five years. October-November is the peak period. On an average, 7 deaths occurred every year in the village. But the easy availability of means of transport has reduced the number of epidemic outbreaks of the disease which occurred twice during last 6 years. At that time, the villagers availed medical facilities of P.H.C. here. Serious patients were taken to the district hospital at Bijnor. 11. REHARH This village is situated in Eastern part of Banali-Reharh Region in Afzalgarh block at the distance of 19 km. from Nagina tahsil headquarters and about 35 Km. from Bijnor district headquarters. It also falls in the very high disease intensity region. About 3500 persons reside in this village. Out of them 100 persons were interviewed. So the accessibility to medical health centers P.H.C., C.H.C. or private clinic is unsatisfactory. 89 persons of 10 families were surveyed in the village. T.B. and skin disease are more common in the village. The pardah pratha is the major responsible factor for the occurrence of T.B. in females. 12 ladies are affected by this disease among the surveyed persons of the village. Another

[200]

disease which is more common in rainy season in gastro-entritis. In rainy season, the problem of accessibility becomes more serious. Non-availability of health services is the major cause of epidemic out-break of the disease. The patients of chronic diseases do not have treatment facilities due to poor economic condition coupled with ignorance. THE GENERAL CONDITION OF THE REGION The western Ganga Khadar from north to south in Bijnor, Chandpur and the Tarai-Bhabhar Region in Najibabad and Nagina tahsils fall into very high disease intensity region. The climatic condition, poor economic condition and non-availability of medical services were also found to be the major factors causing spread of diseases in the region. The occurrence of epidemic outbreaks is frequent. The other group of high and moderately high disease intensity region falls in Dhampur tahsil. The general condition of the most of Najibabad tahsil represents very low disease intensity region. The location of villages and environmental conditions are responsible for this category. From the table 5.7, it is clear that maximum percentage of child population falls in the high disease intensity region (46.5) The high frequency of epidemics reduces the male and female population.

[201]

TABLE : 5.7 Disease Intensity Regionwise; Position of Family Members; Their Marital Status Alongwith Source of Drinking Water.
Disease Intensity Region % Total High Medium Low 487 310 250 Male 30.75 34.03 29.00 % % % Married 58.05 62.66 57.05 % Unmarried Wells 41.05 37.33 42.05 28.05 24.00 15.02 H.Pums 71.05 76.00 84.08 Person Affected Marital Status Source of Drinking Water facility

Female Children 27.75 27.06 28.05 46.05 38.01 42.05

It is clear that handpumps and wells are the main source of drinking water in the high disease intensity regions. The areas having high percentage of pumps (84.08) have lower disease intensity in Najibabad tahsil. Thus, the disease occurrence is related to the unhygienic environmental conditions, specially with regard to water supply. TABLE : 5.8 General Education and Immunization (in percentage) in the Village Surveyed
Disease Intensity Region High Medium Low Edu. 22.18 35.42 66.33 Unedu. Prim. 77.00 64.80 33.66 11.75 19.00 30.00 Jr.High 06.50 08.33 19.50 High 03.00 04.66 12.50 B.A. Yes No 95.00 Education Immunization

00.93 5.00

03.93 33.30 66.60 04.33 21.20 78.08

[202]

Table 5.8 shows the general educational standard of the population where the percentage of illiteracy is higher, the disease intensity is also higher. Increase of educational standard in parts, better knowledge of personal health care and thus, as a result, the region has lower disease intensity. The table 5.8 also shows that higher percentage (33.3) of immunization is in areas around urban centres because they have better health care facilities. But the rural areas of Bijnor tahsil where educational standard is high the percentage of immunization is better than other areas. TABLE : 5.9 Types of Houses And Average Number of Persons Living in a Room
Disease Intensity Region Kachha High Medium Low 72.50 70.00 60.20 Pucca 07.50 13.33 18.00 Mixed 20.00 16.66 22.80 6.4 4.3 9.8 House type in % Average number of persons living in a room

Table 5.9 shows that more than 70 percent of population have Kachha house with no bathroom and latrine facility. They generally use open spaces around the village for that purpose. In the rainy season when there is water logging, these open spaces become major cause of infection. It is the time when water borne infactions frequently take place in the region. The average number of persons living in a room is quite high in the

[203]

disease intensity region and poor economic status. Social customs, food habits, religious practice of drinking unpurified river water provide condition for Gastroenteritis or jaundice which are caused by water or food contamination. GENERAL VIEWS REGARDING TREATMENT About 65 percent population feels that diseases occur due to unhygienic conditions in the high disease intensity region where educational standard is low. But in low disease intensity regions more people (53.33%) feel that there is no need for treatment facilities for minor ailments. More than 55 percent population does not consult a doctor owing to their poor economic status. Table 5.10 also shows that maximum percentage of population goes to private clinic because they are easily available and there is personal care for the patients. The government doctors are not easily available. They generally go out for private practice and the dispensary often remains closed. Generally the medicines are also not available at P.H.C.'s. The public usually purchase medicine from the market. There is no tradition of (Table 5.11) pregnancy check up. 49.5 percent deliveries take place at home in the presence of local Daies or under the supervision/presence of other ladies of the family. Now-a-days the concept has changed and percentage of pregnancy check up is increasing (20.0) in the low disease intensity region where educational standard is high and the knowledge of health care is increasing. The poor economic condition is another major cause of of home delivery.

[204]

TABLE : 5.10

General Treatment Views in the Different Disease Instensity Regions

Disease Intensity No Treatment Germs Troubles 17.5 18.66 53.33 10 23.33 7.5 45.0 41.6 33.33 Others in Minor Poor

Cause of Illness in %

Treatment Views in %

Treatment Place in % Private P.H.C. Distt. Doctor Hospital

[205]
55.0 58.4 66.68

Region

Fate

Unhygienic

C ondition

Economic Condition

High

10

65.0

12.0 6.66 43.33

70.0 23.33 23.33

9.0 23.0 20.0

Medium

8.0

50.0

Low

3.33

33.3

TABLE : 5.11

Mother and Child Care Situation in the Village

[206]
Delivery Place in % No At Home Hospital 95.00 72.20 52.00 26.20 75.00 85.00 15.00 25.00 73.80

Disease Intensity

Pregnancy Check

Cause of Home Delivery % No tradition Poor Economic Condition 55.00 32.50 15.00 45.00 65.50 85.00

Region

Uup in %

Yes

High

05.00

Medium

24.80

Low

48.00

TREATMENT DIFFICULTIES The unhygienic condition of villages helps in the spread of different communicable diseases. Table 5.12 shows that about 87 percent population do not go for treatment because they are very poor. They can not improve their living conditions. Most of patients of different illness who go for health services utilize the allopathic medical system. Mostly, villages are dissatisfied with the health services offered by health centre. But the treatment at private health clinic is expensive. This is a major cause for going without treatment. P.H. Cs. are located at block head quarters. So, a patient who wants to take medical facility at P.H.C. has to lose one days income. In the opinion of the villagers nonavailability of medical care, long distance and expensive allopathic medical system is the major cause for poor health and mortality. More than 80 percent households feel that medical services are not easily available in the villages. TABLE : 5.12 Treatment Difficulties in Percentage
Disease Intensity Region Cause of Epidemic Outbreak Unhygienic condition Poor economic Condition Reasons for No Treatment Expensive No time Loss of daily income Long NonabailDifficulties

distance ability of medical facilities

High Medium Low

12.50 36.66 39.20

87.50 63.33 60.80

42.50 40.00 46.66

10.00 13.33 03.66

47.50 46.66 46.66

07.50 18.20 06.66

92.50 80.60 93.33

[207]

69.5 percent of population in Bijnor tahsil have their medical expenditure between Rs. 100-1000 during last one year. 32 percent population incurs the highest expenditure of Rs. 1000 and above in the high disease intensity region. This increase in expenditure is due to long distance. From table 5.13 showing views for better treatment, it can be inferred that maximum percentage (47.8) of population wants the improvement of general hygienic condition in high disease intensity regions. They also feel the necessity for increasing the numbers of P.H.C's. But at the end, they wanted the improvement of their economic status. TABLE : 5.13 General Views for Better Treatment (in per cent) and Treatent Expenditure (in Rupees) during 2009-2010
Disease Intensity Region Treatment Expenditure View for Better Treatment Social Increase Improve Feeling ment of ment of P.H.C. Economic Status 5.0 3.33 22.50 16.66 36.66 25.0 30.0 22.33

500 500-1000 >1000 Improve ment of Hygienic Condition

High Medium Low

8.2 6.5 48.2

58.8 69.3 36.6

32.0 24.2 15.2

47.5 50.0 41.0

PROBABILITY OF DIFFERENT DISEASES IN BIJNOR DISTRICT Composite Index Of Disease Probability An analysis of the spatial distribution of various indices of disease probability of Bijnor district presents interesting regional [208]

contrasts in all indices. But a general idea about the total disease probability cannot be formulated through above study. Construction of composite index with the help of twenty five indicators is shown at a glance, the regional disparity among the geographical units. Level Of Disease Probability The level of disease probability in form of coefficient of composite index is shown in Fig. 5.2 The Fig. shows that out of five tahsils, three tahsils record the value of coefficient of disease probability more than 4 which show that about 77.2 per cent of tahsils have more disease probability. The remaining two tahsils of the study area have less disease probability. It is obious from the fig. 5.3 that Najibabad and Nagina tahsils have more probability of disease occurrence due to their climatic conditions and poor economic coditions. Only Dhampur has low disease probability because its location and medical facilities are better than other tahsils. It is also apparent from fig. 5.4 that the northern parts of Najibabad and Nagina tahsils show more disease probability which have more than 6 value of C.C.I. which shows higher probability than other parts of Bijnor distt. Najibabad and Kotwali blocks have .4 - .6 C.C.I. value. Bijnor tahsil has the lowest .2 C.C.I. value which shows lower disease probability. The western tahsils have more disease probability due to poor economic condition and poor medical facilities, long distance and ignorance. Dhampur tahsil and western parts of Chandpur tahsil have medium

[209]

disease probability because this region is well drained and has better medical care facilities. Disease Intensity And Disease Probability The disease intensity shows that the western parts of Jalilpur, Khari Jhalu, Mohd.pur Deomal, Noorpur and Seohara blocks have very high disease intensity, the eastern parts of the same blocks have high disease intensity while the central eastern parts of Allehpur, Nehtor, Najibabad, Kiratpur, Kotwali, Afzalgarh and Khari Jhalu have moderately high disease intensity. This disease intensity region map is worked out on the number of patients visiting the government hospital or P.H.Cs. When we compare it with the map of disease probability, the regions of high disease probability differ. The major cause of this difference is the indicators which are selected for the probability and intensity ranking. The disease probability of diseases is based on physical, cultural and medical indicators which ultimately are responsible for the occurrence of disease in any particular region. For example, a region has high disease intensity but the improved medical care facilities, increase in percentage of literacy, minimum rise of water table in post monsoon season, higher per capita income, increase in per acre productivity have improved the general economic condition of the villagers. This is why, the probability is lower. The southern part of the region has lowest probability in the study area. Khari Jhalu and Nehtor blocks fall in this category which has better medical facilities and hence lower probabilities. (Fig. 5.4)

[210]

REFERENCES
1. Siddiqi, M.F., (1985), A paper Concentration of

Deficiency Diseases in U.P., The Geographer, P. 18, 9098, Concept pub. Co., New Delhi. 2. Sharma, J.P., (1985), Incidence, Ranking and Intensity of Major Diseases in district Tehri, U.P.- Geographical Aspects of Health and Disease in India, Ed, by R. Akhtar, Concept Pub. Co., New Delhi.

[211]

CHAPTER - VI

MEDICAL FACILITIES

CHAPTER - VI

MEDICAL F A CILITIES FA
Medical facility or health care is defined as a programe of services that should make available all facilities of health and allied services necessary to promote and maintain the health of mind and body. The distribution of health care services and modern medical facilities is highly centralized. Though about 75 per cent of the Indian population lives in rural areas, only 11 per cent of the physicians practise in these areas. Health care, being an integral part of socio-economic conditions, has a major role in the prevention of diseases and promotion of health. Hence, health care facilities available in any regional unit, manifest itself in the level of health and human well being. Health care infrastructure rests upon different medicine systems. In the present chapter, an attempt has been made to focus on the medicine systems and different aspects of health care facilities available in Bijnor district. Indias health service system is neithter of the capitalistic nor socialistic type, but a mixture of the two. Public health service and private health service system co-exist in this country. Our governments political ideology of democratic socialism allows both public and private health services to function side by side. Our socialistic principles impel the states to provide for the health services to its citizens. At the same time our

democratic principles protect the individuals right to practise a profession including medical care. So, here, both public and privarte health services cater to the health needs of various sections of the society. Since with the limited resources, the states are not in a position to provide satisfactory health services to all the citizens. The private health services have to supplement the public health services by meeting the health needs of those who can afford to pay for it. As is evident from the foregoing health problems in developing countries like India, are predominantly reflections of poverty. Substantial decrease in morbidity and mortality in the short run is more likely to be accomplished through an improvement in the system for health including preventive services. Ultimately, comprehensive improvements are likely to result from all round environmental sanitation in society. Therefore, the necessity of suffcient availability of health services such as hospitals, helath centres, beds, doctors and other health personnel can hardly be over emphasized. Comprehensive health care has been defined as the community guaranteeing all groups of population the best available medical care and the maximum coverage for the prevention of illness and promotion of health. Recognizing the various causes of ill health and their interaction leading not only to disease but also to disability, discomfort, or even death, the need for a comprehensive approach

[214]

to health care is self evident. This requires broad spectrum of types of services related to the different root causes as well as their results in ill health. Such a variety of services can only be provided by involving all categories of health workers as well suitable participants from family and community. All this requires differnt forms of services of institutions where the services are performed for the individual and the community. In previous chapters, an attempt has been made to survey the geomedical environments leading to various types of diseases, their causes and distributional pattern. The geomedical environment of this district is unsatisfactory leading to poor health status. This needs improvement in medical facilities in a planned and systematic way. However, medical services and centres must be equipped with facilities to contain or combat the prevalent diseases. MEDICINE SYSTEMS There are three types o medicine systems prevailing in the area under study : 1. 2. 3. Megico-religious medicine system. Indigenous medicine system, and Modern medicine system.

MAGICO-RELIGIOUS MEDICINE SYSTEM It is the earliest and most primitive form of medical thought and is based on casual explanation of the occurence of a disease or ill helath given from magical and religious point of view. The

[215]

causual factors, said to be responsible for diseases, are wrath of God or goodesses, ghosts, hot and cold conditions of the body, wind, violation of taboos, etc. In Bijnor, the system gets due recognition among tribals, backbard classes and even educated people to some extent. INDIGENOUS MEDICINE SYSTEM The indigenous medicine system consists of three basic concepte of medicine, i.e., Ayurvedic, Unani and Siddha. Besides, naturopathy and yoga also attract followers for their therapetic values. Among three indigenous systems, ayurveda is most commonly accepted. The unani system privails predominantly in area of Muslim culture. Siddha is extensively practised in the southern states. MODERN MEDICINE SYSTEM The system comprises allopathic and homeopathic medicenes. Allopathy is the most modern type of medicine system based on sound explanation of the cause of health and illness. The system is gaining momentum among rural community as an integral part of our social system. CLASSIFICATION OF MEDICAL/HEALTH CENTRES OF BIJNOR DISTRICT Medical facilities of Bijnor distirct are based on modern allopathic system of treatment. The study is based on the data of government hospitals. There are different categories of health centres in this district. These centres as a whole, provide the medical infrastructure and medical treatment in the region. There

[216]

is no Medical College in the study area so far. Generally five categories of health centres are notieed in Bijnor district. (Table 6.1) DISTRIBUTION OF HOSPITALS/DISPENSARIES Most of the hospitals are located in district and tahsil headquarters and towns of the study area. Hence, medical facilities in urban areas are much better than that of rural areas. At present there are 22 allopathic, 20 Ayurvedic, 04 homeopathic and 31 Unani hospitals and dispensaries besides 73 PHCs & 37 Maternity and child welfare centres in the district. From table 6.1, it is evident that about 94 per cent of the whole population of this region dwells in the rural areas but the number of health care units in the rural areas is less than 76 per cent of the total numbers (Fig. 6.1). HOSPITALS Hospital play an important role in providing the preventive, promotive and rehabilitative services to local community including training and research. The organizational system of hospitals consists of regional hospital, district hospitals and local hospitals. Since there is no regional hospital in Bijnor, people of this district have to go to Meerut or New Delhi for highly advanced treatment and diagnostic and intensive care facilities. The district hospitals in addition to general treatment and surgical facilities provide specialists service of ENT, pediatrics, dental surgery, adiology, V.D. clinic, pathhology, blood bank etc. The civil hospitals are generally located at tahsil headquarters providing medical and surgical facilities like pathological tests, X-rays and dentl surgery, etc.

[217]

Table - 6.1 Organizational Frame of Medical/Health Centres in Bijnor

Function Nil Referral Services with District, Town, Average Consulted Facilities 30 Lakh Treatment With limited Tahsil Headquarter town Pathological Facilities Average Hinterland Population of 3-4 Lakh Preliminary treatment Block Headquarter/Central Primary Care with monor operation village, Average Hinteland population of 80-100 Thousand Preliminary Treatment Central village/City ward Average Hinterland population of 25-30 Thousand No treatment Facilities Central village, Average hinterland of population 10,000. Periferal Services Elementary Care Secondry Care Hinterland Population of about Nil Location and Coverage Level of care Nil Teritary Care

S.No Order of Health Centre

Nomenclature

Regional

Medical College and

Associated Institutions

Sub Regional

District Hospital

Community Hospital

Tahsil/Town Hospital

Community Health

[218]

Centre

Community Health

Primary Health Centre

Local Health Centre

Dispensary

Sub Health Centre

Maternity and Child

Welfare(MCW) and

Family Welfare centre

(FWC).

There are 18 hospitals in the area under study consisting of 03 allopathic and 08 ayurvedic, 06 homepathic and 01 unani. PRIMARY HEALTH CENTRE Primary health care is a practical approach making essential health care universally available to individuals and families in the community in an acceptable and afforable way and with their full participation. 3 Primary health centre holds a key position in the health care system emphasizing preventive rather than curative services. It provides comprehensive health care services to the people living in remotest areas. Primary health centred extends both outdoor and indoor treatment facilities as well as field services as vaccination family health care, family planning, blindness and leprosy control etc. Every community development block has a P.H.C. that has a key position in the health care system. Each P.H.C. has three dispensaries (Allepathic, Ayurvedic, Unani of Homeopathic). District Bijnor has 3.7 P.H.Cs. as per one lakh persons (Table : 6.5). School Health service is also one of the functions of P.H.Cs. but it is not been well established in want of adequate staff of examining all the school going children, giving health education and training to the teachers. There are 38 primary health centres (including mini primary health centres) in the area under study, out of which 32 are located in rural areas. DISPENSARIES Dispensaries are forth order medical facilities providing normally outdoor treatment with the help of one physician and

[219]

one pharmasist. There are 158 dispensaries in the district Bijnor comprising 139 Alopathic, 6 Ayurvedic, 03 Unani and 8 Homeopathic dispensaries. Dispensaries are mainly concentrated in rural areas. HEALTH SUB - CENTRE Each primary health centre commands over number of subcentres known as maternity and child welfare and family welfare centres. The main functions of the sub-centres are maternity and child health, collection of vital stastics, treatment of minor aliments, health education is respect of common communicable diseases, family welfare, immunization, etc., with adequate field staff. There are 158 family welfare and maternity and child welfare centres existing mainly in rural areas. Table 6.2 shows that there is a wide gap in the distribution of health care facilities between the population of the study area and existing medical facilities. Table : 6.2 Population Density of Health Care Facilities (per Lakh persons) (2010) Sl. Tahsils No. 1 2 3 4 5 Bijnor Najibabad Nagina Dhampur Chandpur 2.24 1.20 1.50 0.63 0.98 1.82 0.90 0.99 1.40 1.16 1.51 5.05 3.10 3.65 4.54 4.20 3.89 Hospitals P.H.C. Dispensary Health Sub Centre 6.89 5.40 5.77 5.90 6.30 6.40

Distt. Bijnor

Source : Statistical year Book, Bijnor district- 2010. [220]

Table - 6.2-A

HOSPITALS, DISPENSARIES AND BEDS (2009-2010)

S. Hospital 68 60 66 34 40 3 3 8 3 2 4 1 15 4 16 3 7 5 16 1 1 1 1 5 2 8 2 Beds Doctor Hospital Beds 4 4 4 -

Tahsil

Allopathic PHC

Beds

Doctor

Ayurvedic

Unani Doctor 1 1 1 -

Homeopathic Hospital 4 1 5 Beds Doctor 4 1 4 -

No.

[221]

Najibabad

Dhampur

14

Bijnor

15

Nagina

Chandpur

Source : - Statistical Magazine of Bijnor District-2010

On perusal of data in table 6.3, it appears that the number of hospitals per lakh population is the lowest (2.9) in Bijnor district where as Mohd.pur Deomal block occupies the top position (6.9). These figures of hospitals present a gloomy picture of health services. Table : 6.3 Allopathic Hospitals (per Lakh persons) (2010) S.No. Tahsils 1 2 3 4 5 Najibabad Bijnor Nagina Dhampur Chandpur 1999-2000 1.9 0.9 2.3 4.4 2.3 2.6 2004-2005 1.9 2.5 3.1 4.0 2.0 2.5 2009-2010 6.9 4.7 3.2 6.2 5.3 2.9

Distt. Bijnor

Source : District Bijnor Statistical year Book - 2010. Table : 6.4 Distribution of Beds in Urban And Rural Dispensaries -2010 Sl. Tahsils No. Urban Urban Rural Population % 75.42 76.85 77.48 76.22 76.39 75.48 Rural Beds % 29.75 30.90 31.80 30.10 34.50 34.33

Population Beds % % 70.25 69.10 68.20 69.90 65.50 65.67

1 2 3 4 5

Bijnor Dhampur Najibabad Nagina Chandpur

24.58 23.15 22.52 23.78 23.61 24.52

Distt. Bijnor

Source : Field survey and Statistical year Book of Bijnor- 2010. [222]

In Bijnor district, 65.67% hospital beds are available for 25.52 % urban population and for the 75.48 % rural population, there are only 34.33 5 hospital beds. Table 6.4 shows a large gap in the distribution of hospital beds between rural and urban areas as a whole in the district. As indicated earlier, government and private health services exist side by side. in urban areas, both the services are widely utilized bu different sections of the population depending upon their needs, educational status and resources. It was found in a sample survey that the freely available government health services are mostly utilized by the low and very low classes health services are mostly utilized by the low and very low normally more expensive, are availed of by high and middle income groups. On the other hand most of the low and very low income group patients go to public health centres which include government hospitals, municipal dispensaries, infectious diseases hospital and E.S.I. hospitals and dispensaries for treatment of chronic diseases, too, a majority of high and middle class patients seek the services of the private hospitals and clinics and most of the low and very low class patients utilize the public health centres. DISTRICT HEALTH CENTRE The district headquarters have a general hospital. There are special hospital, such as mental hospital, maternity hospital, tuberculosis sanatorium, eye hospital, E.S.I. hospital, childrens hospital and clinics to provide free health services to such patients rich or poor. [223]

The health services provide by the municipality is poor both in quality as well as quantity. The municiple dispensaries supposed to work at the periphery of the community. But it is found that these dispensaries lack proper equipments and health personel. Many dispansaries do not have permanent doctors. Doctors visit these dispensaries for one or two hours in the morning otherwise they are run bu junior staff, nurses and midwives. They have neither proper laboratory facilities nor equipments to attend to natal cares. Only a small per centage of sample household utilize municiple dispensaries. Though a good number of low and very low calss suffers from communicable diseases, only a few avail of the infectious disease hospital services provide by the minicipal corporation. THE PRIMARY HEALTH CENTRES The primary health centres are dotted in the district located at an interval of 10-20 Km. The tahsil hospitals are located at the interval of about 40 Km. and the regional district hospitals about 60 Km. away. The hierachical distribution of medical centres of the state bear a close relationship with the hierachy of the centre and population size of the settlement (Singh 1968). The transport net-work has also influenced the groth and development of these facilities, as regional and sub-regional hospitals are located at nodal centres.

[224]

Table : 6.5 Primary Health Centres (per One Lakh persons) (2010) S.No. Tahsils No. of P.H.Cs. (per 100000 persons) 1999-2000 1 2 3 4 5 Bijnor Najibabad Nagina Dhampur Chandpur 2.9 2.2 2.3 2.5 2.3 2.3 2004-2005 3.9 2.5 2.1 3.5 2.3 2.9 2009-2010 4.9 3.7 3.2 4.4 3.9 3.7

Distt. Bijnor

Source : District Bijnor Statistical year Book - 2010. The hieraarchical distribution of medical centres of the state bear a close relationship with the hieracy of the central places and population size of the settlement (Singh 1968). The transport net-work has also influenced the growth and development of these facilities, as regional and sub-regional hospitals are located at nodal centres. HOSPITAL SERVICE AREAS Mainly three types of health centres are found in the region. These are region, district, tahsil and primary health centres. The identification of these regional centres is based on the number of patients and overall facilities available in these hospitals Serious cases reported to the district hospital and ocassionallyto the medical college and AIIMS ttc. at Meerut and New Delhi respectively.

[225]

HOSPITAL & BEDS Medical facilities provided to the state which had only 15 per cent of total hospital and 10 per cent beds, against 16 per cent of the total population of the country are poor (Sinha 1981). The different decades proved significant for the development of health facilities as it brought more than 95 per cent increase in the bed strength. At present (2010) the region has different ratio of hospitals-beds per lakh of population given in the table below ( Table 6.6). The district has only 18 per cent female beds against 30 per cent of female population out of which 28 per cent beds are located in rural areas. This shows the negligence of female health care in the rural areas. Table 6.6 Beds per Lakh persons in Different Hospitals in Bijnor District Sl.No. Tahsils 1 2 3 4 5 Bijnor Najibabad Nagina Dhampur Chandpur 1999-2000 2004-2005 17.5 2.5 9.3 9.2 9.3 11.5 30.6 10.0 22.4 19.2 19.0 4.00 2009-2010 36.1 16.3 26.5 33.6 28.4 15.8

Distt. Bijnor

Source : Statistical Magazine of Bijnor District 2010.

[226]

The availability of allopathic hospital beds in the region varies in different blocks from 15.8 to 36.1 to per lakh population. Some tahsils are the most neglected areas where average of beds per lakh population is much below the district average. These areas are neglected areas as regards the rural health care facilities. However, the bed population ratio is much proper in the region in comparison to the state or the whole nation (Table 6.6). DISTRIBUTION OF HEALTH PERSONNEL The health centres generally care for out-door patients only. A few beds are provided for maternity cases or for patients who need observation for sometime or for carrying out various types of promotive health programmes. There are different types of Primary Health Centres depending upon the size and function. The staff consists of one or several workers from the following categories of personnel. 1.Medical assistant, 2.Doctor, 3.Nurse, 4.Midwife, 5.Health Visitor, 6. Pharmacist and other as needed and as are available. The district hospital with about 50 to 150 beds handle general indoor patients Medical assistans nurses and other staff as needed are generally available here. The chief medical officer is responsible for the supervision of the primary health centres.

[227]

Table 6.7 Health Personnel - Population Ratio (2010) (per one lakh persons) Sl.No Tahsils 1 2 3 4 5 Bijnor Najibabad Nagina Dhampur Chandpur Doctors 3.9 1.8 2.2 2.8 2.9 14.6 Para Medical workers 9.54 3.20 4.40 4.80 4.50 30.04

Distt. Bijnor

Source : Statistical Year Book, Bijnor District-2010. HEALTH CENTRE Before 1950, on an average 7 doctors per lakh population were at service in the hospital of U.P. But after independence the ration substantially increased both in the state and the region (Sinha, 1981)5. At present 0.97 allopathic vdoctors are available per lakh population in the region. This figure still falls below the national average of 0.25 per lakh population and in the state 0.7 doctors per lakh population (Table 6.7). Doctors by and large (73 per cent) are settled in towns and are employed in government and semi-government hospitals. Distribution of doctors in urban and rural areas is inadequate as well as unsatisfactory. Qualified doctors are not satisfied with the facilities available in rural areas. The government do not provide them proper facilities according to their qualification or their needs. As a result large number of patients from the rural [228]

areas take risk to cover long distances to city hospitals. Lack of quick means of transport is yet another major defficiency in the availability of medical facilities. EXISTING HEALTH FACILITIES IN COMPARISION TO MUDALIAR COMMITTEE RECOMMENDATIONS It is very well known that Bijnor district has acute problems of human health where there are endemic areas having serious diseases. The Major part of the population resides in the villages where poverty, illiteracy, unempolyment and lack of transport facility add to their health problems. The health facilities provided by the state are inadequate and there is great imbalance in respect of doctor population ratio. Hospital/Dispensaries population ratio and Hospital beds -population ratio when compared with the recommendations of the Mudaliar Committee (Table 7.5) indicates that 16607 persons are taken care of by one doctor as against 3500 persons per doctor recommended by the committee. The number of doctors in the District is alarmingly low (-) 78.9 per cent according to Mudaliar committee recommendation. This reveals that a large number of population remain deprived of proper medical care. The number of lab technicaians is also not up to the mark. As regards health centres there is not a single medical college in district Bijnor. Similarilly the position of civil hospitals, uban dispensaries is also deficient by (-) 82.5 per cent and (-) 71.5 per cent respectively. The Number of hospital beds which is (-) 57.4 per cent is much below satisfaction. All

[229]

these figures are clear indication of very poor health/medical services provided by the state in the region. GROWTH OF MEDICAL CARE FACILITIES The ratio of doctors, beds, hospitals and dispensaries per thousand population shows the growth and development of medical care facilities during last 25 years. There are wide differences in the growth of medical care facilities areas. The maximum growth of medical care facilities in last to decades is found in urban areas. Table 6.8 Existing Health Facilities in Comparision to Mudaliar Commitee Recommendations
Health Personnel Centres Health Personnel Doctors Nurses Health workers Lab Technicians Health Centres Medical Colleges Civil Hospitals 1:5,750,000 1:40,000 NIL NIL NIL 27 205 159 38 6129 NIL (-) 92.5 (-) 71.5 (-) 6.11 (-) 18.44 (-) 157.4 1:3,500 1:5,000 1:5,00 1:0,000 1:16607 1:33919 1:2312 1:11607 4109 2896 2877 1438 866 424 6220 1239 (-)78.9 (-)85.3 111.1 (-) 13.8 Mudalier Existing Recom ended Existing Numbers Remark

Committee Ratio Norms (2010)

Numbers (2010)

1:522665 360 1:704997 19

Urban Dispensaries 1:20,000 P.H.Cs. 1:80,000

1:855100 180 1:2329 1:2346 66.5 14381

Rural Dispensaries 1:20000 Hospital beds 1:1,000

Source : Based on Field Survey (2010). [230]

First rank facilities are not available in the study area. The district headquarters enjoy more and better medical facilities than the rest of study area. Little seems to have been done towards improving the health services in rural areas. Remarkble improvement is found in the availability of medical facilities in the district hospital. But the improvement level is not equal in all tahsil hospitals. This study is highlights that thers are imbalances in availability of health facilities in different areas. Not only rural to urban but even rural to rural and urban to urban variations are evident. Although considrable growth in health facilities is recorded the uneven distribution has resulted in disparities in their availability. The developed areas enjoy high per capita expenditure on health at the expense of rural and undeveloped areas. Villagers constituting about 75 per cent of population have to travel large distances in order to secure health care. For the purpose of health planning, population of these areas seems to have been ignored. Moreover, the hospitals and health centres are not rationally located. In order to provide better health care to the people, the prevalent diseases of the area and the health consciousness of the population have to be closely studied before making any desicion on the mangnitude and the type of health care needed for region. It has been reported that Malaria, Filaria, Encephalitis and Leprosy prone areas on the region need hospital facilities in

[231]

order to treat such specific health problems. Goiter in Ram Ganga khadar region provides a particular example in this context. The means of communication and transport are also important and deserve considration, as patients prefer easily accessible hospitals or health centres for treatment. Patients prefer to travel longer distances where quick and good transport facilities rather than nearer hospitals even at a slightly higher cost. As part of providing promotive health services, the health centre should have close coordination with the sanitation department and water supply department of a municipality. Proper disposal of sewage and potable ensured supply of water to the area be supervised by the health centres and they should inform the rspective departments whenever there is a laxity in carrying out these functions. Environmental sanitation is one aspect where community cooperation is very much needed to keep the surroundings clean. Here the basic health workers organise the local community and explain the need for keeping the environment clean. DEVELOPMENT OF MEDICAL FACILITIES AND POPULATION GROWTH As has been discussed in the foregoing, the development of medical facilities is not sufficient in comparison to the population growth. Growth of population between 19012010 in Bijnor district is about 120%, although it is lower than

[232]

the state average growth durinh the same period which is about 128% . Only one district hospital at Bijnor has health facilities equal to the state overage. This means that an optimum level of health facilities has not been achieved. It is also significant that sparesely populated northern part of the district has the lowest beds (0.13 per thousand population). However the southern densely populated areas of the region has the average of 120 beds per thousand population. SURVEY OF HOSPITALS AND DISPENSARIES A sample survey of district hospital and six tahsils hospitals and 13 P.H.Cs. of each block of this region was carried out to assess the number of patients coming for treatment, the equality of medical facilities available at Government hospitals and dispensaries and the service care of the hospitals in rural and urban areas (2010). The findings are given below : WORK LOAD OF DOCTORS IN DIFFERENT HOSPITALS : On an average 380 patients come for treatment in the district hospital. The district hospitals, Tahsil hospitals, Primary Health centres and mother-child welfare centres have a daily average of 380, 145, 93 and 65 patients per doctor respectively. Normally a doctor in the, hospital or district hospital centres devotes 3-4 hours for outdoor patients, but in rural areas a doctor devotes 2-3 hours for the out door patients. So a patient hardly has few minutes to express himself during the period of examination by any doctor. A patient who comes all the way

[233]

covering long distances from rural areas is naturally not satisfied by the behaviour of the doctor. On the other hand the doctor is helpless because he has much heavier work load. THE QUALITY OF HEALTH SERVICES The medical service provided by government are very poor in comparison to private clinics. There is no pathological or Xray or medical check up facility at PHCs and dispensaries. Even district hospitals lack adequate facilities. Generally the hospitals, dispansaries and public health Care Centres do not have doctors specialised in different diseases. Even if such doctors are available in any hospital they do not have good laboratory facilities. Almost all the hospitals are running short of good medicines and the patient has naturally to go out for the purchase of medicine from the market. The sanitary condition of most of the hospitals is very poor. It may be attributed to the shortage of sanitary staff, equipments etc. In the absance of adequate number of beds the patients have to be accommodated in varandas by clossing the doors. This renders the rooms inhabitable due to poor ventilation. SPECIALIZED MEDICAL FACILITIES In addition to general health are provisions, the study area, likewise the other parts of the country, is facilitated with some specilized diseases cradication and treatment programmes. The diseases taken inder these programmes are malaria, filaria, leprosy, tuberculosis and venereal diseases.

[234]

MALARIA A national programme to control malaria was initiated in 1953 which later on in 1958 was converted into National Malaria Eradication Programme. The programme includes house spraying of insecticides as well as treatment facilities. The malaria eradication programme has been organised at two levels. First is the malaria control unit located at district headquarters of Bijnor district under the administration of District Malaria Officer with assistant staff consisting of Asstt. Malaria officer, senior Malaria Inspector and technical personnels. Secondly, there is one sub-control unit under the charge of Malaria Inspecter at each PHC headquarters with adequate number of field workers engaged in spraying, blood slide collection and distribution of medicine. FILARIASIS National Filaria Control Programme was incorporated in the First Five Year Plan with the objectives to delimit in filariology to medical officers and inspecters engaged in this programme. As the implementation of the programme, large number of control and survey units have been established. Bijnor is the only treatment cum survey centre of the study area with the facility of filaria clinics. LEPROSY In 1955, the Government of India implemented National Leprosy Control Programme with the objectives of survey and early diagnosis of cases, facilities for mass treatment and [235]

prophylaxis, education of people and traning of medical and paramedical staff. There is one leprosy centre (urban) attached to district hospital at Bijnor reconstructive surgery unit and temporary hospitalization ward and advanced leprosy treatment facilities are provided at Medical college, Meerut. There are 295 patients suffering from leprosy in the study area.* (*Data collected from Leprosy Centre, Bijnor- 2010). TUBERCULOSIS Tuberclosis eradication programme is based on providing permanent diagonstic and domiciliary treatment services with effective anti- T.B. drugs organised through district T.B. centre at Bijnor in collaboration with general health and medical services and with integrated B.C.G. Vaccination. One more T.B. hospital has been established at Bijnor by U.P. Government exclusively for bidi workers in the district. Bidi workers in Chandpur, Noorpur and in the surrounding rural areas have a tendency of suffering from tuberculosis due to tobacco use in bidi making and insanitation. About 1987 T.B. patients were registered and being cured in this hospital in 2010. VENEREAL DISEASES There is no proper arrangement of diagnosis and treatment of sexually transmitted diseases in this district though there are patients in significant number suffering from such V.D. diseases. One V.D. clinic has been established and attached to district hospital.

[236]

SERVICE CORE AREAS The survey results show that health centres attract patients from out side. Majority of patients come from longer distant villages. The survey map shows that maximum of patients come to P.H.C. from 6-9 Kms. These centres are block centres or marketting centres of the area. So the people come to these centres from more than 14-18 kms. The district hospital attracts general patients mostly from the urban areas but serious patients come from longer distant villages. Majority of patients coming from outside to the district hospital are from roadside villages which are well served with transport facilities. From the preceding analysis. it may be concluded that the availability of health care facilities in the study area is inadequate from all standards. The number of medical and health personnels, hospital and bed population ratio, specialized treatment facilities and quality of services provided are sub-standard. The health care facilities are mainly concentrated in urban areas serving only 24.52 per cent population. The distributional pattern of facilities does not follow the trend of disease distribution. Lack of specialized treatment facilities is a common phenomena of Bijnor district. It is to be noted that health services are under utilized due to various reasons of physical distance, inaccessibility, lack of awareness, cost and social distance. Under such circumstances, there is an urgent need for planned development of medical facilities in Bijnor district.

[237]

REFERENCES
1. Banerjee, Guha, S. and Joshi, S., (1985), Health Facilities in Pune, Geographical Review of India, Vol. 47, No.4, P.57. 2. Pillai, K. Mahadevan and Dutta, P.R., (1976), Sociology of Medicine and social change in India, Bulletien of the Gandhigram Institute of Rural Health and Family planning, Vol.X, No.3, P.73. 3. Ramchandran, L., (1979), Health Care in the Rural Community A Pragmatic Approach, Bulletin of Gandhigram Institute of Rural Health and Family planning, Vol.XIV, No.1, P.8. 4. Sinha, S.C., (1981), Medical Geography of U.P., An unpublished Ph.D. thesis submitted to Gorakhpur University, 1981. 5. Government of India (1962), Ministry of Health, Report of Health Survey Committee.

[238]

CHAPTER - VII

PLANNING FOR IMPROVEMENT OF ENVIRONMENTAL CONDITIONS AND MEDICAL HEALTH CARE

CHAPTER - VII

PLANNING FOR IMPR OVEMENT OF IMPRO ENVIR ONMENT AL CONDITIONS ENVIRONMENT ONMENTAL AND MEDICAL HEAL TH CARE HEALTH
While palnning and more particularly while implementing various health programmes, it is logical to know health needs of the people, their ways of life and factors directing their health behaviour. Health needs have been defined as deficiencies in health that call for preventive, curative, control or eradication measures. Though the health status of the study area district Bijnor ameliorated considerably during the last fifty years, there is still a gap between health care facilities available and required both in urban and rural areas. Most of the centres serve rather large population with very meagre resources. In 1946, Joseph Bhore Health survey and development committee made an interprising effect to bring together curative and preventive medicive and to provide comprehensive health care to the people. The recommendations of the committee laid the foundation of modern health palnning including public health in India. The Mudalier Committee suggested certain norms for planing which have been accepted by the palnning Commission with slight modifications. The most recent effort, however, was the international conference on primary health care held in U.S.S.R. (Alma Ata) in 1978. The conference recommended to bring to the people a package of services consisting of at least

the eight essential elements of primary health care. The government had declared the historic goal Health for all by 2000 A.D. It is a social goal of providing an acceptable level of health which will permit all the citizens to lead a socially and economically productive life. NORMS FOR PROPOSAL OF HEALTH CARE FACILITIES On The basis of recommendations made by different health committees, objectives of Sixth five year plan and personal observations in the field, following norms have been accepted for proposals of health care facilities : (i) One regional hospital for 50 lakh persons at divisional headquarters. (ii) One community Health centre / Community hospital for one lakh population or over three PHCs. (iii) One primary health centre or urban hospital for 30000 population over 6 sub centres. (iv) (v) (vi) (vii) One subsidiary health centre for a group of 10,000 persons. One health sub-centre for a group of 5,000 persons. One multi-purpose worker for a group of 5,000 persons. One community health guide for 1,000 persons.

(viii) One hospital bed for 1,000 persons. (ix) One doctor for a group of 3,500 persons, one nurse for 5,000 persons, one pharmacist and one lab technician for a group of 10,000 persons, and (x) One trained Dai (midwife) for a group for 500 persons.

[241]

Although all types of medical facilities are available in the region, they are unevely distributed due to illiteracy, poor economic condition and poor knowledge of health in the region. In this chapter the measures for planning of medical facilities will be discussed. These are : A. 1. (a) PREVENTIVE MEASURES IMPROVEMENT OF ENVIRONMENTAL CONDITIONS Water-logging- It is major problem in the northern parts

of the district. The problem of water logging has aggravated mainly due to constructions of canals whereby natural drainage has been hampered by the physical barriers created due to canal imbankment, besides roads, railway tracks, channels, buildings etc. The situation is further worsened due to rise in the water table which does not permit excess water to percolate in to the soil. Accumulation of water on the surface creates health problem in many ways. It provides natural breeding palces for mosquitoes and flies which in turn, spread serious infection causing water borne orthopod borne diseases. On the other hand, the rise in water table besides aggravating, the water logged condition creates deficiency diseases viz. goiter, avitaminosis, anaemia, P.C.M. etc. if a scheme is planned to improve natural drainage system, this problem can be solved to a great extent. Such a master plan to improve natural drainage system will help to prevent water borne and othopod borne diseases in the present water logged areas of the region.

[242]

B.

EMPHASIS ON DEEP WELLS AND HANDPUMPS The shallow wells or handpumps which are generally used

in rural parts of the region, are notoriously liable to pollution through neighbouring sources of contamination such as latrines, urinals, drains, cesspools, soakage pits and collection of cowdung or house garbage. The water of these wells and handpumps is harmfull to human especially in rainy season. Emphasis should, therefore, be given on sanitary well. A sanitary well is one which is properly located, well constructed and protected against contamination with a view to yield safe water. C. WATER SUPPLY A more serious aspect of water pollution is that which is caused by (1) sewage (2) industrial wastes (3) drainage from agricultural areas (4) Physical pollutants. These are the result of human activity and urbanisation. Pollution of water resources by sewage is a serious hazard to the health. The harmful infections and parasitic agents expose larger communities to the risk of water borne diseases and epidemics. Much of ill health in the underdeveloped regions is due to lack of safe drinking water supply. Therefore, money spent on water supply schemes is a sound investment which will pay huge dividents in the form of improved health. Water intended for humam consumption should be safe and wholesome. It is a basic health need. Therefore the emphasis should be given on safe water supply in rural as well as urban centres, because it is an essential factor in the

[243]

economic, social and cultural development of the community. A daily supply of 150-200 litres of water per head is considerd as adequate. The consumption of water, however, depends upon climatic conditions, standard of living and habits of the people. The larger quantity and better the quality of water, the more rapid and extensive is the advance of public health. 2. NUTRITIONAL STATUS (a) Food Production- This is the essential item which

can be achieved by better landuse, better farm practices and better seed selection. Recent experiments are very useful in producing high yielding cereals. Better storage of agricultural produce, especially of cereals will also help to cut down food losses by a substantial percentage and thereby lead to an increase in the available food supplies. The meat, fish, eggs, vegetables and fruits also have their nutritive value and play an important role to maintain the public health. (B) Need to Implement Beneficial Schemes for Labour Class

- Increase of per unit area production is not more beneficial for labour class, because the large number of holdings are with the farmers of higher income group. The landless labourers who mark more than 60 per cent of the population do not have any employment in agricultural off seasons. So per capita income decrease and the general standard of living becomes very low. Stress should be given on some

[244]

employment schemes in the off seasons to improve per capita income as follows : (1) Especially in rice growing areas emphasis should be given

on fish production in rice growing holdings. If such variety of fishes which grow up in the three months can be introduced to the problem of nutrition can be partially solved. The landless labourers can achieve better income and nutritioanl status by this method and thus the general condition of the health of poor people can be improved. (2) The general water logged areas of public sector or

government sector can be used as main source of fish production in off season. This scheme can improve employment conditions as well as general nutritional standards of people. The fish production, its stroage, transportation and marketing can employ more of labour class and thus per capita income of this class can improve. The protein deficeincy of general deficiency diseases can be prevented by this scheme and goal of high per capita income can be achieved. Only food can not provide total nutrition for human health. The substitute of fish and vegetables are needed to fulfil the requirements of nutrition for human body. (3) Poultry farming is another source of augmenting income

of the low income group in the village and around the towns. For this fowls of improved breeds can be introduced which will provide eggs and fowl meat and will thus add to the monitary status of the person concerned, besides improving the nutritional quality of food.

[245]

(4)

Piggery or pig farming is also an easy source of income

to the poor class of the society. There are state schemes which supply pig or improved breed on subsidised prices. (5) Dairy farming near the big towns is a definite source of

good income to the cattle owner. There is great demand for milk, butter, curd, cheese, now a days, both in big restaurant and roadside tea stalls. A properly planned dairy scheme can be started even on cooperative basis. (6) Banana cultivation with intercropping of vegetable is quite

popular. It is very beneficial method to combat nutritioal deficiency. More production of banana and vegetables should be emphasized in the region. It is helpful in prevention of vitamins and potassium deficiency diseases. By this method of mixed cropping, there will be bright chances of employment and improvement of standards of living. Therefore, it should be encouraged and extended to other parts also. Good varieties of banana which produce good delicious fruits and yield high tonnage per unit area should be introduced in consultation with the department of horticulture. Similarly, suitable varities of vegetables which may suit such system of intercropping may be obtained from seed producing agencies. 3 (a) HEALTH EDUCATION Health education is one of the basic objectives of primary health care system which is, at present, facing the neglected attitude of the health administrators, specially due to

[246]

lack of trained man power. The responsibilities for imparting health education should be assigned to multipurpose workers and community health guides. The co-operation of school teachers should be requested. It is desirable to introduce para medical courses at 10+2 level which will not only help in creating general awareness about health problems and their remedial measure, but may also provide a trained brand of health workers at grass root level.6 The W.H.O. has formulated the aims of health education as follows : abTo ensure that health is valued as an asset in the community. To equip people with skill, knowledge and attitudes to enable them to solve their health problems by their own actions and efforts. cTo promote the development and proper use of health services. The major goals of health education would be : (i) To e n s u r e t h e c l i m a t e l e a d i n g r i s k f a c t o r s ,

preventable diseases and injury, preventable death and human suffering through effective health education communication, strategies and technologies. (ii) To forge an effective and balanced net work among

education of public health, health care and allied disciplines through professional collaboration. (iii) To extend the benefits of health promotion and

[247]

education to the vulnerable population groups and the weaker sections of the society. (b) FOOD POLICY All the above measures can only take place satisfctorily if there is a national food policy which has been envolved after the integration and coordination of the views and experiences of national specialists in nutrition, agriculture health economics and sociology. A Major role of the doctor is to use his status to bring to the attention of policy makers, the actual needs of his community in the respect. (c) SUPPLEMENTARY FEEDING PROGRAMMES Such programmes may be enrtirely local or be supported by international aids. Skimmed milk, corn, soya and milk preparations as well as ordinary cereals and pulses of various kinds may be used in these programmes. (d) NUTRITIONAL EDUCATION Large emphasis would be required on 1. 2. encouraging breast feeding. emphasis should be given to the points for satisfatory weaning. 3. teaching better nutrition for pregnant and nursing women. (e) EDUCATION AND TRAINING There is need for formal education and training of nutrition workers at all levels. Education of the public as to what

[248]

constitutes good nutrition should be based on what is good and available and the realities of the economic situation. HOUSING Housing is a part of total environment of man and being a part, it is to some extent responsible for the status of mans health and well being. It is difficult, however, to demonstrate the specific cause and effect relationship as housing embraces so many facts of environment. The environmental Hygiene Committee (1949) in India defined A house means a residential house flat or tenement designed for family life. More than 74 per cent of the people reside in rural areas of the region. IMMUNIZATION Increasing the resistance of human-herd by immunization is an important strategy in the control of communicable diseases. Vaccination has, therefore, to be properly planned according to the needs of the situation. Vaccination is an important measure for breaking the link in the chain of infection. (a) The knowledge of immunization and access to

immunization centre is a problem in rural areas of the region. So, there is a need for proper vaccination facility at P.H.C. level. From this facility the villagers can avail the immunization facility to prevent the communicable diseases. (b) Money is an important problem due to which the

villagers can not reach the immunization centres. therefore, there is a need for mobile dispensaries with immunization facility. By

[249]

increasing the number of paramedical workers, this problem can be solved. They can go to every house of the village and teach them the need and value of immunization in prevention of different diseases. NEED TO REALISE THE IMPORTANCE OF WOMEN Most health functions are vested in family or househols unit and the role of women in household health is crucial. In the presence of satisfied social structure, while women provide health care inside the home, they have limited access to health services outside. Thus, health workers must be selected, trained and organised to develop a systematic interface with women by visiting home on a regular and frequent basis. OTHER PREVENTIVE MEASURES Generally, low income is the main cause of malnutrition among masses. In rural areas the per capita income of the landless labourers and marginal farmers can be increased by training them in cottage industry items. Rope making, basket making, carpentary, black smithy, gold smithy, pottery, oil extraction, rich milling, lumbering etc. are some of such job items which can be taken up-solely or as part time business during off season. They will boost the earning of the weaker section and help in tiding over the food crisis and malnutrition. The typical situation of Bijnor district has rendered it vulnerable to the out break of some specific diseases. In order of importance, they are tuberclosis goitre, jaundice, amoebiosis and malaria/filaria. [250]

Goiter, an endemic disease very commonly found in this area, is caused by iodine deficiency in water and food. It can be easily tackled by incorporating iodine in media like salt. Jaundice is also very important from the health point of view in this region. Its spread can be checked by ensuring clean water supply and disinfected food stuff. Among the diseases causing stomach disorder amoebiosis occupies first position in this region. It can be controlled by educating the masses to use potable and clean drinking water and avoid use of raw and contaminated food matter. Malaria which is commonly located during and after rainy season in this area assumes large proportions. Besides, being fatal in acute cases it incapacitates the patients even after complete cure and renders him unfit for normal work for a long time. It spreads only through mosquito bites. Therefore mosquito breeding places like open drains, stagnant water should be taken care of by regular spraying of insecticides. Whereever manageable, one should make use of mosquito nets and repellants especially during nights. Since filaria is also caused by mosquito bites a similer protective measure will have to be adopted against it also. B- HEALTH SERVICE FOR PREVENTION & TREATMENT 1- Services

[251]

TABLE : 7.1 Existing and Required Health Facilities In Bijnor (2010)

Facilities Existing Facilited Required Facilities (As per Mudalier committee Recommendations) HEALTH PERSONNELS Doctors Nurses Health Workers Lab. Technicians Medical College Health Centres Civil Hospitals Urban Dispensaries P.H.C. Rural Dispensaries Hospital Beds 28 43 232 07 NIL 153 08 18 38 38 252 428.50 300.00 300.00 150.00 NIL 300.00 37.50 18.39 50.00 56.61 1500.00

Source : Based on Field Survey in June 2010. The purpose of health planning is to meet health needs and demands of the people. Mudalier Committee suggested certain norms for the planning and development of medical and health facilities which have also been accepted by the Planning Commission with slight modifications. [252]

2.

PLANNING

FOR

HEALTH AND

MAN

POWER

REQUIREMENT There is increasing awareness that medical education in itself is only a means and not an end; that advancements in medical education both in quality and quantity have not resulted in parallel achievments in the field of health care, and that the vast potential of human resource for health still remains to be harnessed through the functional inter linkage of health objectives and educational strategies. A systems approach to health planning clearly demonstrates the role and place of health manpower planning as an essential component to function by optimum of such output system. It has been proposed to enhance the number of doctors to 429 as suggested bu Mudaliar Committee. Special emphasis should be given for removing existing imbalance of (table7.1) doctor-nurse population ratio. Lack of socio- cultural amenities, job satisfaction and prefossional isolation for the doctor and their inability to adjust to rural life are the major factor that confine doctors mostly to urban areas. The housing problem, unhygienic living conditions, lack of educational facilities are other important factors for not attracting doctor to villages. But if special allowances, concessions and promotions are granted these areas will become more attractive for them.

[253]

INCREASE OF HEALTH CENTRES The primary Health Centres provide a minimal of infrastructure for the delivery of comrehensive health care to the people living in rural areas. The centre is located usually at block headuarters and is the focus from which health services radiate into the area coverd by development block i.e. approximately 100 villages and about 80000 population. If this ratio is reduced, better medical facilities may be available to villagers. There is a need for (a) Decentralisation of Health Services Privatisation is proposed in both rural health extension effort and the development of speciality and superspeciality services. However, the limited coverage of vlountry health sector programmes makes them less useful in improving regional health that is proposed. Their major contribution will continue to be in the area of experimentation with and demonstration of alternative approaches. As Collaboration between the government and nongovernmental sectors is limited in scope, the government would best reserve its energies to improve its own health efforts. (b) Redistribution of Health Resources The distribution of funds within the health sector has been discriminated against rural health care and favoured Sophisticated urban health facilities and family planning. The critical issue of imbalances needs to be addressed by bringing on par at least the per capita rural health expenditures

[254]

of the region. There are several related needs. For one, an accounting system that examines the health sector as a whole (including public and private components at all levels) would be useful for allocating health resources. For another strict control on resources allocations within the health sector are required. (c) Rationalisation of Health Care System The Bhore Committee (Health Survey and Development Committee) established in 1943 (G.O.I., 1946), infact laid down norms for a rural health infrastructures with short (10 years) and long term (20-40 year) goals. In the long term, a Primary Health Unit (P.H.U.) with 75 beds and a staff of six medical officers, six public health nurses and six Auxiliary Nurse Midwives was to serve ten to twenty thousand population. The construction of Primary Health Centres (P.H.Cs) commenced in early 1950s in accordance with the Bhore Committees recommendations. The pattern adopted envisioned one PHC for every community Development Block which at that time had a population of 60000 on an average. By the 1970s this ratio (one P.H.C. per block) had been achieved but now the average population of a block has also increased. The National Planning Committee suggested a sharp increase in the number of medical personels through expansion of training centres and absorption of traditional practitioner into the scientific medical team. It recommended that a ratio of one worker with, elementary training in practical community health

[255]

per thousand people be achieved within five years and that within 10 years, there should be a qualified medical practioner for every 300 people, and a hospital for every 3000 people, and a hospital bed for every 1500 people. The Alma Ata Conference defined Primary Health Care as essential health care based on practical scientifically sound and socially acceptable methods and technology, universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self determination. Primary health care icludes at least Education concerning prevailing health problems and the methods of preventing and controlling them. Promotion of food supply and proper nutrition. An adequate supply of safe water water and basic sanitation. Maternal and child health care, including family planning. Immunization against the major infectious diseases. Prevention of control of locally endemic diseases. Appropriate treatment of common diseases and injuries. Provision of essential drugs. One P.H.C. is proposed for a population of 80 thousand in rural areas. Sinha (1981) has suggested P.H.Cs. at urban service centres with a population of 30,000 thousand, rural dispensaries at service villages (hinterland population 10,000) and sub centres/

[256]

big villages (hinterland population 3500). According to physical conditios and means of transport and communication 5 to 10 per cent adjustment of hinterland population can be made. There should be a mobile dispensary attached to P.H.Cs for weekly visits. PLANNING FOR HEALTH CENTRES The primary health care means access for every body to all levels of the health system and if it means the participation of the people, then it is of paramount importance to train all types of health man power from the sophisticated specialist to the individual family members. In other words, Primary Health Care approach applies to all level of the health service system. But in contrast , the primary health care has become entirely a responsibility of the primary health centres and their sub centres. The larger referal hospital still remain exclusively the centres for specialized medical care of the privileged. These specialized referal hospitals can, however, be re-oriented without any extra financial burden to incorporate the components of primary health care. Urban areas having a hinterland population of one lakh should have a 30 bed hospital with normal facilities and smaller ones should have dispensaries. IMPROVEMENT IN ACCESSIBILITY TO HEALTH CENTRES The condition of the availability of medical facilities in the study area is still worse. About 0.74 per cent villages have their own Allopathic hospital or dispensaries, 3.75 per cent villages

[257]

are located within 1 km. from hospital and dispensaries; 10.05 per cent villages in between 8 and 5 km. About 62.42 per cent villages do not have hospital/dispensary within 5km. redus. If we see in terms of accessebility, we find that only 18 per cent villages are located in 30 minitues reach to the nearest hospital/dispensary and 30 per cent trail within 30 minutes to 1 hour isochrone, assuming that short distances in rural areas are covered on foot or bicycles. In emergency, more than 60 per cent villages located in the interior can not avail hospital or specialised medical facility within one hour. S0, there is need to improve means of transport and communication for availability of better medical facilities to bring P.H.Cs. within easy reach of villages. NEED FOR SPECIALISED TREATMENT FACILITIES District Bijnor is suffering from high intensity of the disease like malaria, filaria, filariasis, tuberculosis goiter, jaundice, leprosy amoebiosis, cardiovascular, cancer and veneral diseases. The available facilities for the treatment of these specialised diseases are inadequate both qualitatively sand quantitatively in comparison to the number of patients and that beyond the easy reach of the rural community in the whole district in general and Afzalgarh, Kotwali and Jalilpur blocks in particular. The availability of safe drinking water to the rural population considerably reduces the incidence of Cholera. So, there is a need for clean drinking water supply. In order to check up epidemics, specialised medical service is necessary in this disease prone areas. The existing

[258]

health facilities may be improved by providing facilities for specialised treatments of specific diseases and increasing the number of hospital beds. A CASE STUDY OF DHAMPUR TAHSIL FOR HEALTH CARE FACILITIES To present the spatial organisation of proposed health care plan, a case study of Dhampur tahsil of district Bijnor has been performed. The study follows the central place system, as it provides the basic frame work for rational distribution of cluster of services and functions accessible to the maximum profit areas in command at different hierarchical levels of settlements. (Fig. 7.1) CENTRAL PLACE SYSTEM Central place is regarded as such a foal point of distinguished status which extends functions and services to its own population as well as to its surrounding areas. Central places perform certain functions which decide their levels of importance. On the basis of four levels of functional hierarchy, four orders of central places have already been decided. FIRST ORDER CENTRES - REGIONAL TOWN 1. Dhampur (Tahsil Head Quarters) PROPOSED

SECOND ORDER CENTRES - LOCALITY NODES 1. 3. Nehtor Seohara 2. 4. Allehpur Nidarhu

THIRD ORDER CENTRES - MARKET CENTRES 1. Baserha Khurd 2. Sherkot 3. Mankua

[259]

4.

Manpur Shivpuri, and

5.

Sahaspur

FOURTH ORDER CENTRES - CENTRAL VILLAGES 1. 3. 5. 7. 9. 11. 13. 15. 17. Mahua, Aakoo, Mukeempur, Tibarhi, Raipur Malook, Navada Kesho, Sadafal, Rasulpur Dehra-Bulandi 2. 4. 6. 8. 10. 12. 14. 16. 18. Papsara, Paharhpur Akherha, Beramabad, Nurpur Chhiparhi, Nagla Budhava, Chakrajmal Vajirpur Jagir Shahpur Kherhi Bagwada

ORGANIZATION OF HEALTH CENTRES To obtain a balanced health care infrastructure, tahsil Dhampur requires for community health centres, 10 primary health centres, 30 subsidiary health centres, 61 health sub centres and one community hospital. It is proposed to establish a community hospital in the regional city of Dhampur. Four community health centres are proposed at second ordre centres i.e. Nehtor, Allehpur, Seohara and Nidarhu. Third order five centres as central villages selected on the basic of functional hierarchy have been considered for the proposed location of primary health centres. Eighteen central villages and eighteen other semi-independent villages have been chosen as proposed location of subsidiary health centres. All the centres of above

[260]

proposed location and 18 semi-dependent villages of functional importance of health sub-centres. Figure 7.1 presents the spatial organisation of health centres in Dhampur tahsil which may be taken as the model for deciding location of proposed health care facilities in Bijnor district. PROVISION OF AN ECONOMICAL AND EFFECTIVE EMERGENCY SERVICES The casualities stand in a class by themselves. They comprise injuries by accident and sudden attacks of illness which require immediate attention and treatment. Therefore, it is inevitable to have the fastest mode of transport, especially in emergencies such as snake bites wherein every minitu counts. The patient must be taken to a place where atleast first aid facilities are available. Alternatively, a medical person must reach the site of emergency in the shortest possible time. This calls for effective communication and transport facilities and trained man power. The provision of emergency services in rural and urban areas are radically different. In rural areas, snake bites and accidents due to the cattle confrontations are more common. In urban areas, road accident, assaults and heart attacks cause emergencies. Thus emergencies in rural and urban areas differ with respect to their nature as well as the resources available to treat them. In brief, provision of emergency in medical care involves the following :

[261]

Bringing the patient to appropriate centre or institution

where treatment facilities are readily available or alternatively taking the medical person to the site of emergency. In either case, communication and transportation facilities are the limiting factors. Further action is affected by formal arrangements

between other emergency centres concerned with other services such as ambulances, police, fire-brigade, civil defence and perhaps the armed forces. For specialised emergency treatment, quick and easy

r e f e r r a l s y s t e m b e c o m e s a d e c i d i n g f a c t o r. E ff i c i e n t communication should exist between the emergency centre and the medical staff of different specialities who may be on duty at any given time. Availability of equipment, staff and other emergency

requirements is crucial irrespective of the nature of emergency. Thus emergency services must be well staffed, well equipped and well stocked at al times. Post emergency observations and monitoring is essential

if treatment has to be made effective. It requires skilled nursing care and monitoring equipment to note changes in the patients condition. Post emergency monitoring requires specialised nursing

skill and equipments. This is expensive but essential in certain types of emergencies such as cardic arrests, head injuries, pelvic

[262]

peritonitis convulsions, and high fever etc. An intensive care unit is always the best facility for post- emergency observations. It may be concluded with a remark that the proposed health

care paln of Bijnor district, if happens to be implemented successfully, will provide healthful living to the people in future and this region will emerge as a model of complete health and happiness.

[263]

REFERENCES
1. World Health Organization (1972), Approaches to National Health planning, public Health papers no. 46. 2. Government of India, (1962), Report of the Health Survey committee, Ministry of Health. 3. Government of India (1974), Draft of fifth five year plan (1974-75), vol- I and II, Planning Commission. 4. Khaparde, s., (1988) Public Health for community care, swasth Hind, Vol. XXXII, Nos. 3 and 4, p.65. 5. Singh, N.K., (1983) Planning Health for all by 2000 AD., Swasth Hind, Vol. XXVII, No. 10, p. 241. 6. Bajaj, I.D., (1983), primary Health care-role of communicable Diseases control, swasth Hind, Vol. XXVII, Nos. 3-4, p.62. 7. Sinha, S.C., (1981), Medical Geography of U.P. An Unpublished thesis, Submitted to Gorakhpur University.

[264]

CONCLUSION
Medical geography has been defined by several Geographers. According to Rais Akhtar, Medical Geography, also known as Geography of health, offers a synthesis by bringing together the work of medical scientist,

environmentalists, geographers, social scientists and planners on the problems having a bearing on human health from a wider perspective. Here the medical geography of district Bijnor is somewhat typical with regards to its climate and soil which in turn has given rise to some such diseases which are very specific for the region. It was with this view that this problem was undertaken for detailed study. Bijnor district is situated in the northern part of the Moradabad division of U.P. District Bijnor of Uttar Pradesh extends from 290 02' N to 29 0 58' N and 78 0 00 0 E to 79 0 59' E embracing an area of 4848 sq. km. over eleven blocks viz Najibabad, Kiratpur, Mohammadpur Deomal, Khari Jhalu, Jalilpur, Noorpur, Nehtor, Kotwali, Afzalgarh, Allehpur and Seohara which are integral parts of five tahsils - Bijnor, Najibabad, Nagina, Dhampur and Chandpur. River Ganga forms the entire Western boundary. It is inhabited by 3.67 million people (2011). It is one of the most densely populated districts of the state. The total population of the district forms about 1.75 per cent of state's population. It has 0.89 per cent [265]

area of the state. Physiographically the district is divided into ten distinct regions1- Tarai - Bhavar Regions 3- Kho - Ramganga Doab 5- Kho - Khadar Region 7- Gagan-Karula Region 9- Malin Riven Region, and 2- Banali - Reharh Region 4- Ramganga - Khadar Region 6- Ban-Chhoiya - Ganga Region 8- Bhur Region 10- Ganga Khadar Region

North Eastern tract resembles more or less the Tarai area of Haridwar, Nanital and Udham Singh Nagrar districts covering the whole of Najibabad and Nagina tahsils. with a population density of more than 400 persons per sq. km. The soils of the study area are deficient in iodine which disturbs the Thyroid functioning of the human body causing goiter. In this region some areas are more plain and riverain, while northern and western blocks have appreciable forest cover. This provides the ideal condition for the breeding of blood sucking arthopods which play an important role in the transmission of various diseases. In this region during floods, the movement of man and material becomes restricted. Socio- economic activities are hampered and the environmental sanitation deteriorates which often leads to epidemic outbreaks. It is worthnoting that about 15 per cent gastroentritis cases of the state occur in this region. District Bijnor is rich in ground water resource. Low depth and little seasonal fluctuations of ground water often leads to water logging and water contaminations. The prevalence of fever,

[266]

soon after rains in the Ganga khadar Region and Kho-Ramganga Doab may have some association with the sluggish and stagnant waters of the region. The natural drainage of the region is carried out by the rivers - Ganga, Ramganga, Kho, Chhoiya, Malin, Ban, Gagan, Karula and Banali with their tributaries. The region enjoys the monsoon climate often brings floods and drought and influences the epidemic outbreak of encephalitis, malaria and gastro entritis in the region. The prevalence of diseases in rainy season when relative humidity and temperature touches high, remains at its peak. The region is densely populated. The density of population is the highest (664 per sq. km.) in Dhampur tahsil. The presuure of population is higher in the south eastern part of the region. It has 75-80 per cent of rural population. The distribution of population is very uneven. The nutrition density of 426.86 km2 observed in some areas of the region indicates greater pressure on the agricultural land leading to low nutritional level. The literacy per centage of the region is lower than the state. The poor knowledge of health or well being is the major cause of disease occurrence in the region. At presence the general economic condition of population is very low on account of natural climatic condition. The distribution of diseases related to the physical, biological, social and economic conditions of the region and hence particular diseases are found to be concentrated in specific regions and they occur intermittently in that region. [267]

The environmental sanitation in Bijnor district is far from satisfactory. On account of overcrowding and congestion, lower and middle class population live and work in most unhygienic condition and thus often suffer from bronchitis, measeles, influenza, tuberculosis and deficiency diseases. About 71 per cent village dwellers do not have their own latrine and bathroom facilities. They normally use open fields. And thus in rainy season the water gets polluted in water logged areas. This is the ideal time for water and arthopos borne infections in the region. Some of the communicable diseases like gastro entrties, jaundice, leprosy and venereal diseases found in the region are indications of poor environmental sanitation. Drinking water supply is another major problem in villages. More than 25.67 per cent villagers usually use wells. It has been seen in sample survey that the population depending on wells for drinking water, is more affected by diseases. The survey indicated that 56 per cent houses in the region have one room in the house. This gives an estimate of the degree of congestion found in the region. The low quality of kachcha and damp houses with stagnant air, lower the vitality of the inmantes and make them more susceptaible to diseases like gastro-entritis, typhoid, diarrhoea, dysentery, scabies and other skin diseases. Increasing level of urbanisation and industrialisation may cause increasing level of air pollution which induces attack of

[268]

diseases of the respitatory system. The polluted water of domestic use or industrial waste and other toxic material causes diseases like gastro entrities, jaundice and typhoid. Improper use of fertilizers, pesticides or improper disposal of waste causes soil pollution in the region. The increasing number of vehicles is main cause of air and noise pollution which causes tension in urban areas specially. Heavy concentration of sugar insustries is found in the region. Its effluents are generally spread on land and pollute the soil and water increasing number of population in urban centres of the region have no proper sanitation facility which is the major factor responsible for some major diseases. The diseases have been classified by different authors based on localization of causative agent in host, geomedical point of view and the route of infection, but looking to the importance and prevailence of major disease in Bijnor district of U.P., they have been classified in the following manner based on the causative factors or kind of organism involved. THE MAJOR DISEASES ARE Sl.no. Classification
1Deficiency diseases

Name of diseases found in the region

Goitre, Avitaminosis, Anaemia, protein-caloric Malnutrition (P.C.M.)

2-

Parasitical diseases

Malaria, Filaria, Amoebiosis, Hookworm, Scabies.

3-

Bacterial diseases

Tuberculosis, Gastro entrites, Infectious hepatitis, Typhoid fever, Tetanus.

[269]

4-

Viral diseases

Infectious hapatitis, Measles, Encephalitis, Influenza.

5-

Others

Cardiovascular diseases, Blood presure, Cancer, Heart and Venereal diseases.

Defective dietary habits about the nutritional needs, cultural patterns, habits and the attitudes of family towards food contribute to malnutrition, P.C.M. Anaemia is a symptom which can occur as a result of various causative factors. These are very common blood disorders in the region which may overact and destory red cells in a variety of diseases which again cause anaemia. The prevalence of endemic goitre is very common in the region. According to Sinha (1981) over 30 million people live in goitrous districts of tarai region of U.P. One of the most important pockets of goitre concentration lies in Najibabad tahsil. The hospital records sho that anaemia, goitre avitaminosis and P.C.M. are the predominant diseases in the region. The parasitical diseases like malaria, filariasis hookworm, asscariasis amoebic dysentery and scabies are more common in the region. The records of decreasing per centage of slide positivity from 1978 to 1987 in different blocks and tahsils, shows lower incidence of malaria due to Eradication programme but still it continues to be a health problem. Filariasis is another parasitical disease which is common in the region. The over crowding is an important factor in filaria transmission. The vector breeds profusely in polluted water. The

[270]

labour class of cities and agricultural labourers of the rural areas who live in unhygienic conditions are mostly affected by this disease in densely populated areas. Inspite of Eradication programme the permanant cure lies in the provision of adequate drainage facilities for disposal of waste water and sewage. Intestinal parasites are adversely affecting the health of the people in the region. Bijnor district has higher rate of infection due to the humid climate and soil pollution. The agricultural labourers are the main sufferer of this disease. They work ware footed on their farm which is the main source of infection. The use of human excreta as a fertilizer is another important factor in the spread of hookworm infection are highly endemic areas of hookworm infection. Amoebiasis is another disease of bad environmental sanitation of bad customs and lack of sanitary awakening among the people. Skin diseases mostly occur due to hot and wet climate conditions and lower economic conditions of people because they have no proper sense of personal hygiene. So, the occurence of diseases is most common in them. Defecation in the open fields and lack of sanitary latrines and low standard of living are the main factors responsible for the endemicity of disease in the area. Tuberculosis is a health problem in the region. Disease incidence is higher in low income groups with larger family, poverty and space uncleanliness favour the spread of infection.

[271]

Tahsil Bijnor has highest concentration of disease and tahsil Nagina has highest mortality. Gastro entries is a very common infectious diseases in the region. The hot and humid climate, slow flowing rivers charged with organic matter, dense population, poor socio-economic conditions and low level of environmental sanitation provide suitable geo-ecological conditions in Jalilpur block of Chandpur tahsil for this disease. Infectious hepatitis is very important viral disease which occurs in temperate climates. The occurrence of disease is highest in Kotwali, Najibabad, Afzalgarh, Seohara, Jalilpur, Mohd. Pur Deomal and Noorpur blocks also have more incidences than other parts of the region. The poor environmental condition found in the lower socio-economic groups is the cause of a higher prevailance of infectious hepatitis. Conjuctivitis is most infectious viral disease. The working population and the school going childrens are more often affected. Maximum number of patients are reported in Kotwali and Afzalgarh blocks. Viral Encephalitis is now very common in the region. In 2009 over 149 cases were seized in Kotwali and Afazalgarh blocks. The region is mostly affected by this disease from the very beginning of epidemic cycle till end. 203 cases of seizures and 86 of death were reported from 72 villages in Bijnor district in 2010.

[272]

Cancer cases are more frequent in females than males. Among males mouth and lung cancer is very common due to smoking or tobacco chewing. Diabetese is equally distributed all over the region by disease incidence is highest in Khari Jhalu, Allehpur and Noorpur blocks. The industrial development, loss of physical exercise, obesity, family history and chronic under nutrition cause diabetese in the region. Heredity, diet, climates, occupation, stress, strain of life and obesity are causing factors of Hypertension in the region. For regional synthesis, the method formulated by Sharma has been employed to determine the concentration of the diseases found in different blocks of the district. This way all tahsils of the region have been divided in different categories : 1. V. High, 2. High, 3. Medium, 4. Low and 5. V. low. In order to demarcate the disease intensity region, disease ranking coefficient values were calculated for all constituent blocks using Sharmas method. Bijnor district displays noticeable regional imbalances not only in the distribution and ranking of diseases but also in intensity of diseases. The different intensity regions are : 1. Very high, 2. High, 3. Moderately High 4. Medium, 5. Low and 6. Very low. In order to anlayse the occurence and causal factors of different diseases in district Bijnor, a sample survey of eleven villages selecting one from each block was carried out in summer

[273]

2009. A total of 130 households, 900 persons were interviewed. The villages are as : 1. Bhaguwala, 2. Budgara, 3. Rawli, 4. Pavti, 5. Datiyana, 6. Shivala, 7. Kiwar, 8. Mankua, 9. Basera Khurd, 10. Harganpur, and 11. Reharh. The poor climatic conditions, poor economic set, non availability of medical services are found in high disease intensity region during personal observations. It has been found that in high disease intensity regions the hand pumps and wells are the main source of drinking water ; the disease occurrence is very frequent due to unhygienic environmental conditions. Per centage of illiteracy is higher in high disease intensity regions. The higher average number of households living in one room house is a reflection of unhygienic living condition and poor economic standard. 65 per cent villagers feel that the cause of frequent disease occurrence is unhygienic conditions. More than 55 per cent population do not consult doctors due to poor economic conditions. On an average more than 35 per cent persons go to private clinics because thay are easily available and they personally care for patients. 79.4 per cent deliveries take place at home due to tradition. Mostly villagers are dissatisfied with the health services offered by health centres. In their opinoin long distances, non-availability of medical care and expensive allopathic medical system are the major causes of frquent epidemic outbreaks.

[274]

An analysis of the spatial distribution of various indices of disease probability in Bijnor district present interesting regional contrast in all indices. The taxonomic method of regionalization is used for this study. The level of disease probability in the form of coefficient of composite index shows that out of 11 blocks, 6 blocks record coefficient of disease probability more than 5, which shows that about 77.2 per cent of blocks have more disease probability. It is also clear that northern and north eastern part of the region has more disease probability. In the southern part, there is low disease probability because these areas have better location and medical facilities. Medical facilities in this region are based on modern allopathic system. Five categories of health centres are found in the region. Primary Health Centres (P.H.C.) have key position in health care system. There is one district hospital, 5 tahsil hospitals and 38 upgraded P.H.Cs. located in the region (2010). There is too much disparity in rural urban distribution of medical facilities. Only 34.33 per cent beds are available for 75.48 per cent rural population and only 31.22 per cent doctors are available to 75.48 per cent rural population. Only 3.89 per cent dispensaries are available for one lakh population. This is a clear indication of very poor health/medical services provided by the state for the region. The number of doctors (14.6 doctors on one lakh patients)

[275]

and the number of hospital beds (65.67 per cent), are inadequate according to norms of Mudaliar Committee which show that inadequate health facilities have been provided by the State Government. About 15,816 persons are taken care of by one doctor. The distribution of P.H.Cs. is not satisfactory because there is much disparity in their location. Improvement in agriculture production and health education is necessary in this area. only a literate person can effectively describe his discomfort, communicate his needs, understand heath concepts. Unless the population at large can read the spread of health concepts; preventive procedures, acceptance of modern and constantly changing medical system can not be achieved. The special allowances, promotions, concessions should be granted in rural areas for attracting qualified doctors. More emphasis should be given on decentralisation of Primary Health Centres. Strict controls on resources allocations within the health sector are required by 1970s one PHC per block (according to the recommendations of Bhor Committee) had been achieved significantly. But the average population of block had increased substantially since then. So the regionalisation of health care system is now necessary. It is recommended that ratio of one health worker per thousand people be achieved within five years and that within 10 years, there should be a qualified medical practitioner for every

[276]

3000 population, a hospital for every 3000 persons, and one hospital bed for every 1500 persons. In the end, it is emphasised that medical and health care services should be developed as a comprehensive health care system and due consideration should be given for keeping the family welfare programme alive. From the foregoing narrations, it is concluded that Bijnor district in relation to its Medical Geography represents interesting area for deeper studies. The nature, by and large, has been unkind towards it creating numerous health hazards. That is why it has become a fertile bed for deadly diseases and human sufferings. To amend the quality of life, horizontal and vertical linkages have to be established among all interrelated programmes like drinking water supply, environmental sanitation, nutrition, education, family planning, maternity and child welfare. Lastly, it may be remarked that proposed health plan of Bijnor district, if implemented successfully, will provide healthful living to the people in future and the study area will emerge as a model of complete health and happiness.

[277]

BIBLIOGRAPHY
1. Achar, S.T., (1977), Tropical diseases p. 98, pub. V. Abdull Orient Longman ltd., 36 Anna Salai Mound Road, Madras. 2. Adams, F., (1849), The Genuine works of Hippocrates, Vol. (Translated) London Sydenham Society pp. 180-222. 3. Agarwal, D.K. et. al. Current Status of Endemic Goitre in Baroach, India, paedt 20, pp. 479-483 Quoted by park in Text Book S P,M (1981). 4. Agarwal, R.S., (1965), Soil Fertility in India, Asia pub House New Delhi. p.l. 5. Agnihotri, R.C., (1983), Geomedical Environment and healthcare, A Published thesis, Bundelkhand Univ., Jhansi. 6. Ahuja, M.M.S., (1984), Melting Down of Flesh and Limit into Urine, p.22, Pub.by. K.S. Mani for B.I. publication, Pvt, ltd. , 54, JANPATH, New Delhi. 7. Akhtar, R., (1978), Goitre Zaonation in Kumaon Region- A Geomedical Study , Social Science and Medicine, 12 pp 157-163. 8. Akhtar, R and Learmonth A.T.A. (1979), Malaria Annual Parasite Index Maps of India by Malaria Control Unit Areas 1965-1976, Reserch paper no. 3, Social Sciences Faculty, The Open University, Milton Keynes. 1979. 9. Akhtar, R. (1980), Spatial Distribution of Lung Cancer in India, Abstracts II world Conference of lung cancer, Compenhagen p. 13. [278]

10.

Akhtar, R. Izhar N, (1981), Environmental factors and Cancer Distribution in India, paper presented at the 7th meeting of French Society of Environment and Geocancerology held at Paris.

11.

Akhtar, R. and Learmonth A.T.A., (1992), Malaria Returns to India, Geographical Magzine, 54, 135-139.

12.

Akhtar, R., (1982), Colonization and its Impact on the Incidence of malaria, 12 pp. 59-77.

13.

Akhtar, R., (1983), Geographical Distribution of Cancer in India with special reference to Stomach Cancer, International

14. 15.

Journal of Enviromental Studies, 20, pp. 291-298. Akhtar, R. and Learmonth, A.T.A. (1985), Geographical Aspects of Health and diseses in India, Concept publishing Co. New Delhi. pp. 12-17.

16.

Anderson C.L.(1968), School Health practice , ed. 4 st. Louis The C.V. Mosly Co.Baldan, W.A. and Karan P.P. (1982), Air pollution and Health in

17. 18.

Bombay, National Geographer, Vol. 17, No. 1, pp 1-4. Banerjee, A.C., (1951), Note on Cholera in United Provinces (U.P.), Indian Jour. Res. Vol. 39, p.17.

19.

Banerjee, B. and Hazara, J., (1974) Geography of Cholera in West Bengal-A Study in Medical Geog. Calcutta, 1974.

20.

Banerjee, B. and Hazara, J., (1982), Geography of Leprosy with special reference to West Bengal : Geographia Medica, 12, pp. 26-28.

[279]

21.

Banerjee, D. (1985), Indian Jour. of Comm. Med. Vol. X, No.2. p.91.

22.

Basu B.B., (1968), The concepts and contours of Geomedical study. The Deccan Geographer, vol. VI, No. 2. pp. 118-182.

23.

Bhide, A.D.et.al., (1975), Studies on Refuse in Indian Cities, Ind. Jour. Environ. Health Vol. 15, No.3. pp. 215-22. Quoted in Medical Geog. of U.P. by Sinha, 1981.

24.

Brock, J.E., (1961), Recent-advances in human nutrition churchill, London.

25. 26.

Brockington, C.F., (1967), World Health, Churchill, London. Brokar, G.I. (1957) Health in Independent India Min. of Health, New Delhi.P. 298.

27.

Burger, D. Gorhan, J.R., (1980), slow Latent and Temperate Virus Infections, N.I.N. D.B. Monograph, Washington, pp. 307-313.

28.

Burn, J.L., (1947), Recent advances in Public Health, J. and A Churchill Ltd. pp. 313-326.

29. 30. 31.

Cambell, M., (1965), Brit. Med. Jr.2,895. Cathcart, E.P., (1961), In Encyclopaedia 16, p. 651. Census of India (1991 and 2001), Series 21 part IV Housing Report and tables.

32.

Census of India, part XIII, A and B, District Moradabad (from 1971 to 2001).

33.

Chand, D., (1961), Report on State of Health in U.P. with particaular reference to filariasis. Deptt. of med. and Health U.P. Lucknow, pp. 118-26. [280]

34.

Chatterjee, Meera., (1988), Implementing Health Policy, Manohar Publications, Ansari Road Daryagang, New Delhi.

35.

Cujetanovie B. et. al. (1978). Bulletin W.H.O. 56. (Supit.) a, p.11.

36.

Davidson, (1972), Disease of Cardiovascular System, p. 238.

37.

Davidson, S., (1972), Priniciple and Practice of Med. p. 366, Churchill Livingstone, Edinbourgh.

38. 39.

Dienhardt. F. et al, (1982), Bult W.H.O. pp. 60-661. Directorate of Animal Husbandry U.P., Lucknow, Census. (1986).

40. 40.

District Planning-Moradabad, Nc. A.E.C., New Delhi, 1968. District Statistical Hand books of J.P. Nagar and Moradabad. (1981 to 2001).

41.

Dutt, A.K. et al., (1980), Malaria in Indians with particular reference to two West Central States-Social Science and Medicine 14, pp 317-330.

42.

Dutt, M.et.al, (1979), The Resurgence of Malaria in Tamilnadu, Social Science and Medicine, pp. 13, 191-194, 1979.

43.

Dutta, M.K., (1930), The diffusion and ecology of Cholera in India, Geographical review of India, pp. 35, 243-262.

44.

Dutta. P.R., (1965), Rural Health services in India Primary Centre, Central Health Education Bureau, Ministry of Health, New Delhi. [281]

45.

Dutta, S.P. and Gupta, S.C. (1961). Indian J. Public Health, pp. 5-90.

46.

Editorial (1980). B.C.G. Bad News from India. Lanceet Vol.I. pp.73-74.

47.

Eisenbud Merril, (1978), Environment, Techonology and Health, The Mcmillan press Ltd. U.S.A. p. 187.

48.

Elements F.W. et. al. (1960), Endemic Goitre Geneva, W.H.O. Monograph Series, No. 44, Geneva.

49. 50.

F.A.O./W.H.O. (1967), Tech. Rept Sr. No. 302. Fayress, J., (1982), Climate and Fevers of India, J. and A. Churchill, London.

51.

Fox, J.P. and et. al., (1970) Epidemology : Man and Disease, Macmillan Gompany, London, pp. 73-75.

52. 53.

Gazetteer of India, Uttar Pradesh, Moradabad, 1966. Geddes. A., (1929), The Population of India-Variability of Change as a Regional Demographic Index, Geographical Review, pp. 4. 81-102.

54.

Gelyakova, T.M. et, al., (1974), the present state of Medical Geography in U.S.S.R., Soviet geography Review and translation, Vol. VIII No. 4. pp 228-33.

55.

Ghosh, B.N., (1962), Treatise on Hygienic and Public Health, Scientific Publishing Co. Calcutta. P. 371.

56.

Gibson, H.B., (1960), Seasonal Epidemics of Endemigoitre in Tasmania, Med. J. Austr. pp. 1- 875.

[282]

57.

Gopalan, C. et al. (1974), Dietary Allowances for Indian I.C.M.R. Report No. 60.

58.

Gopalan, C. et. al. (1971), Nutritive Value of Indian Foods, Natioanl Institute of Nutrition, Hydrerabad, India.

59.

Gopalan, C., (1981), Goitre Control in India, fourth Quarter, pp.1, 46-48.

60.

Goldsmith, G.A., (1964), The medical clinics of North America, pp.48, 1119.

61.

Gopinathan, V.P.et.al., (1984), Malaria Continuing Problem in Tropics, Journal of I.M.A., p.3.

62.

Gupta, S., (1979), Gastro Intestinal Symptoms, A text Book peadiatric,p.255. Vikas publishing House, P.Ltd. New Delhi.

63.

Harzara, J. and Banerjee, B., (1980), Environmental Health of Glass and Ceramic Workers in Calcutta Metropolotan District, Geographia, Medica, pp. 10, 40-60.

64.

Health Satistics of India, C.B.H.I., Dir. Gen. of Health Services, New Delhi (1955).

65.

Hinmann, E.H. (1966), World Eradication of Infectious Diseases, American Lecture Series. C. Thomas. Quoted.

66.

Hippocrates, On Airs, waters and Places, in Genuine work of Hippocrates, Vol. 1, New York, pp. 158-81. by J E Park in Text Book of social and preventive Medicine, P. 262.

67.

Hirch. A Hand Book of Geographical and Historical pathology, 3 vols, New Sydenham Society, London, pp. 1983-86. [283]

68.

Holmes, K.K. Corey, L. (1978), Venereal Infections Clinical Concept of Infectious Disease, 2nd ed Editor Cluff, L.E. Quoted by J.E. Park, 1972. P. 245.

69.

Hussain, Majid, (1994), Medical Geography (Ed.) Anmol publications Pvt. Ltd. New Delhi. of the community, W.H.O. Monograph Series No 53, Geneva.

70.

Hyma, B. and Ramesh, A., (1985), The Geographical distribution of trends in cholera incidences and the mortality, Indian Geographical Journal, 51, pp. 1-32, 1976.

77.

Quoted in Geograhical aspects of Health and Disease in India, Edited by R.Akhtar (1986).

78.

I.C.M.R. (1958-71), Nutrition Survey Reports and unpublished nutrition survey of the state, Nutrition Survey Division of the state public health Deptt. Provincal Hygience Institute, Lucknow.

79.

I.C.M.R., (1975). Final Reports on study on diabetese mellitus in India.

80.

I.C.M.R., (1980). Viral Hepatitis, proceeding of task force held on Jan. (1980).

81.

I.C.M.R., (1988) Dietary allowances for Indians, Spl. Rept. Serial No. 6. Nutrition, 2, No.p.6.

82.

Jarcho, G.M., (1972) Man, Environment and Disease in Britain, Barnes and Noble Books, New York. pp. 1-6.

83.

Jarcho, S., (1969). The contribution of Jernrich and Herman Berghaus to Medical Cartogrraphy, Journal of the History of the Medical. Vol. 24. No. 4. pp. 412-15.

[284]

84. 85.

Jellifle, D.B., (1966), The Assessment of nutritional status. Jones, Kelvyan and Moon Graham (1987), Health Disease and Society, A Critical Medical Geog. P. 107. Routliedge and Kegen Paul New York 100001.

86.

Joshi, M.J. and Despande, C.D., (1972), Geographical Distribution of Some Diseases Common in Southern Asia, Geographica Medica, 3, pp.5-29.

87.

Journal of Environment, Disease and Health Care Planning, Ed. Rois Akhtar (1996-2001) New Delhi.

88.

Karan, P.P., (1977). Perception of Environmental pollution in Chotanagpur Industrial area, India, National Geographer, vol. 12, 1, pp. 17-24.

89.

Kayastha, S.L. and Kumara, V.K., (1981), Soil Pollution, A case of Kanpur, National Geographer, vol. 16. No. 1. pp. 21-28.

90.

Khan, Razia, (1971), Purpose, Scope and progress of Medical

91. 92.

Geography, Indian Geographical Journal, vol. 46. pp.1-9. Khare, S.B., (1951), Ankylostomasis Indian Jour. of Applied Medicine, vol. 14. no. 7.

93.

Krupp. M.A.,(1980), Current Medical and Treatment, Infectious Disease Bactirial P. 854. Lange medical publications, Maruyen Asia (Pvt) Ltd.

94.

Kayastha, S.L. and Singh, M.B., (1984), Saptio-Temporal Analysis of Health Facilities in India, National Geographer, Vol. 19, No.2. pp. 115-125.

[285]

95.

Kumara, V.K. (1982), Kanpur City- A study in Environmental Pollution, Tara Book Agency Varanasi.

96.

Learmonth, A.T.A. (1958) Some Contrasts in Regional Geography of Malaria in India and Pakistan, Trans, and papers inst. British Geographer. 23, pp. 37-59.

97.

Learmonth, A.T.A. (1981), Medical Geography of India and Pakistan, The Geogrpahical Journal 127. pp. 10-26.

98.

Learmonth, A.T.A. and Akhtar R., (1979), Indias Malaria Resurgence Geogrpahy of Health Disease in India, Concept New Delhi.

99.

Level, H.R. and Clark E.G.,(1965), Preventive medical for the doctor in his community, Mc Graw Hill Book co. New York.

100. Lucas, A.O. Gills, H.M., (1973), A short text book of Preventive Medicine for the tropics, The English Universities press limited, St. Pauls House, Warwiek Lane. London, E.C. 4 PUAH, pp. 388-244. 101. Macnamara, F.N., (1980), Climate and Medical Topography in Rotation to disease, distribution of Himalayan and subHimalayan districts of British India : With reasons for Assigning a malarious origin of Goitre and some other diseases, Longmarns Green and Co. London. 102. Meplestone, P.A., (1931), Further observations on seasonal variations in hookworm infection. Ind-Jour, med. Res. vol. 19. pp. 1145-51. 103. Masironi, R., (1970), Bull. W.H.O. 42, pp. 103-114.

[286]

104. Mathur, H.S., (1969), Geographical Factors of Incidence of Smallpox in Rajasthan, Ind. Jour. of Geography 4-6, pp. 36-46, 1969-1971. 105. Mathur, H.S., (1982), Leprosy Report on the state of Health of U.P. Directorate of Medical Health Services, U.p. pp. 94-100. 106. May, J.M., (1974), The Goegraphy of Nutrition in Geography of health and Disease, pp. 32-45. (Edited by J.M. Hunter) University of North Carolina, Department of Geography, Chapel Hill. 107. Mc. Clelland, J., (1959), Sketch of Medical Topography or Climate and Soil of Bengal and North West provinces, 8 Vols., Jhon Chuchill London. 108. Mc Galashan, N.D., (1969), The Nature of Medical Geography, pacific view point, Vol. 10. No. 2. pp. 60-64. 109. Melvin Ramsay A. and Ronald Emons, T.D. (1967), Infectious Diseases, Helemann London. 110. Mills, C. (1944). Climate Makes the Man, Gallancz, London, pp.1-5. 111. Mishra, R.P., (1970), Medical Geography of India- A.D. 1950-2000. Jouranl of human evolution 7, 85-93, 1978. 112. Moore, Sir, W., (1982), Tropical Climate and Indian Diseases, J. and A. Churchill, London. 113. Mukerji, A.B., (1960), The Disease Ecology of Samll cul. de. S.A.C. Chandigarh Dun, Social Science and Medicine 14, pp. 331-336.

[287]

114. Mc Galshan, N.D., (1984), Towards a Medical Geographical Agenda for India, Geog. Review of India, Vol. 46. No.3, pp.1-7. 115. Newsletter, Common Wealth Human Ecology Council, No.3, (1976). 116. Pachoii, S., (1977), Vector Species of Malaria and its Correlation with the diseases in Jabalpur, The Geographer, 24, pp. 31-42. 117. Park, J.E. et. al., (1972,1985), A Text Book of Social and Preventive Medicine, pp. 26, Banarasidas Bhanot Publishers, Jablapur. 118. Patel, J.C., (1945), Incidence of Chronic Amoebiasis in Bombay, Ind., Phys., p. 249. 119. Patnaik, K.C., (1966), The Geographical Pathology of India, Central Bureau of Health Intelligence, New Delhi. 120. Paul, J.R., (1966), Clinical Epidemiology, The University of Chicago press. 121. Prothero, R.M., (1964), Geographical Factors and Malaria Eradication, The case of Morocco, Pacific view point, vol.5, No.2, pp. 183-204. 122. Pyle, G.F., (1976), Introduction : Fundetion to Medical Geography, Economic Geography vol. 52, p. 95. 123. Rimon, D.L., (1971), Diabetese Mellitus, Theory and Practice, McGrawHill Publishers, pp. 64-581. 124. Rodenwaldt E. and H., Hustaz. j., (1965), World Atlas of Epidemic Diseases (1952-61), Humbarh-Folkverlay, [288]

Geomedical Research Unit. Headelberg Academy of Sciences. 125. Rogers., L., The incidences and spread and control of epidemics, Ind. Med. Res. mem No. 9. (4928) 126. Sardari Lal et. al. (1980), Management of Common Infective Dermatoses, The Antiseptic, vol.80, pp, 2-75. 127. Sharma, R.C., (1981), Available Health Facilities in Bulandshahar district, gographical observer, vol. 17, pp. 1-7. 128. Sinha, S.C. (1981), Medical geography of U.P., an unpublished thesis, submitted to Gorakhpur University 1981. 129. Satur, D.M. and Bhat S.- A Review of work Done in Infant Mortality. I.C.M.R. (1975) pp. 36-38. 130. Shafi, M. (1960), Land Utilization in Eastern U.P., Aligarh Muslim University, Aligarh. 131. Sharma, J.P. (1985), Incidence, Ranking and Intensity of Major Diseases in district Tehri, U.P., Concept publishing Company, New Delhi. 132. Sharma, M.I.D. and et. al., (1961), Vectors of Malaria in India, National society of India for malaria and other mosquitoes borne disease, Delhi p. ii, quoted by Sinha in Medical Geog.of U.P., Unpublished Thesis, Gorakhpur University, 1981. 133. Sharma, V.K., (1967), Leprosy in U.P., International Leprosy Seminar. Agra. [289]

134. Siddiqui, M.F., (1985), A Paper-Concentration of Deficiency Diseases in U.P., The Geographer, Vol 18, pp. 90-98, 1971. Concept Publishing Company, New Delhi. 135. Singh, J. (July 23-25, 1982), Environment Management, preceedings of the National Symposium of Environmental Management, Allahabad. p. 40. pub. Vasundhara Prakashan, Gorakhpur. 136. Singh, B.P. et. al., (1980), spatial Pattern of Thyroid Disorder in Eastern U.P., India, A Geomedical Analysis, Geographia Medica, 10, pp. 61-65. 137. Singh, R.L. et. al. (1978), Approaches Towards Geography of Health, Banaras Hindu University Journal, vol. 23. No. 228, Vol. 24, No. 1, pp. 183-94. 138. Singh, S. et. al. (1981), Smallpox Pattern and Its CorrelatesA case study of an Indian city, Geo-Jour.5, pp. 77-78. 139. Srivastava, Saroj, (1993), Medical Geography of Saryupar Plain, A Published thesis, Gorakhpur Univ. Gorakhpur. 140. Stamp, L.D., (1980), The Geography of Life and Death, Collins, London. 141. Stamp, L.D., (1964), Some Aspects of Medical Geography, Oxford University Press, London, p.71. 142. Statistical year Book, district Moradabad (from 1991 to 2001) 143. Statistical Diary, State Planning Institute, U.P. 1999, p. 136. 144. Stott, H. et. al. (1931), Distribution and Causes of Endemic Goitre in U.P. India Jr. Med. Res. 18, 1959. [290]

145. Suchman, P.V. (1965), Feeding Indias Growing Millions, Asia, Publishing House, Bombay. 146. Tiwari, R.C. and Yadav, H.S., (1982), Pollution and Environmental management, An Introductory Survey, Proceedings of Nanital, sysmposium In Environmental Management, Allahabad (July 23-25), p. 61. 147. Udani, P.M., (1961), Incidence of T.B. in Children-Indian Jour. of Child Health, 10, p-. 515. 148. U.N.I., C.E.F., (1984), Analysis of Situation of Children in India, New Delhi. pp. 36-37. 149. U.P. at a Glance-District wise Statistical overview, 2001. (Jagran Presentation). 150. Vaugham, D. et. al., (1977), General Opthomology pp, 58-85. 151. Vishwanathan, M., (1981), Prevention of Diabetes, II, Journal of Assoc. of Phy. of Ind. 29, pp. 251-261. 152. Wegnar and Laroix, (1958), Excreta Disposal for Rural areas of Small Communities, W.H.O. monograph Series, No. 39. 153. Wilson, C., (1973), Text book of practice of medicine, Oxford University press. 154. W.H.O., (1972), Approaches to National Health Planning, Public Health, paper, No. 46. 155. W.H.O., (1972), Health Hazards of the Human Environment, Geneva. [291]