314

I was pleasantly surprised to see that highly selective vagotomywas included. I had begun to think that the indications for thisoperation (gastric outlet obstruction not being one of them) hadlargely disappeared. In the chapter on benign bile duct stricture,magnetic resonance cholangiography as a diagnostic procedure ismissing. Wherever available, it has replaced percutaneoustranshepatic cholangiography. The non-inclusion of radical gas-trectomy for benign diseases may also be an oversight that hasslipped through the editorial net. In the chapter on anteriorresection of the rectum, greater stress could have been placed on

Correspondence

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 14, NO.5, 2001

washing out the rectal stump distal to the line of transection inorder to eliminate luminal cancer cells.

Professor Kaushik has done the surgical community proud inbringing out this book. Priced at Rs 300, the reader is assured ofgood value for money.

V. SITARAM

Department of SurgeryChristian Medical College

VelloreTamil Nadu

Pandits (priests) as links in improving thereproductive health of women:

An alternative strategy

The health care infrastructure existing in the Himalayan region ofIndia is far from satisfactory. Despite the provision of primaryhealth care with the principle of equitable distribution, as pro-pounded in the National Health Policy of India, I there are onlyskeleton services in the Uttaranchal state of north India. Theproblems that plague the health services in this region includeinadequately trained health manpower (doctors, health workers,laboratory technicians), inaccessibility of the existing health carecentres due to the difficult terrain, underdevelopment of commu-nication facilities including lack of vehicles for transportingpatients in an emergency, as well as inadequate life-saving andessential drugs in the primary health care centres and sub-centres.Other factors such as illiteracy, poor socio-economic conditionsand cultural taboos hamper the process of achieving a satisfactoryhealth status of the people, especially women in the reproductiveage group.

A study conducted among 300 ever-married mothers aged 20-34 years in 5 villages each from 6 districts of the region (Pauri,Almora, Pithoragarh, Chamoli, Tehri and Dehradun) revealed ahigh morbidity; anaemia (77.3%), leucorrhoea (55%), pain in thelower abdomen (42.7%) and dysmenorrhoea (42%).2 The studyalso found that 49% of women were illiterate, the mean age atmarriage was 17.3 years, and only 13.3% received completeantenatal care. The majority of deliveries were conducted byuntrained dais (traditional birth attendants) or family memberswho cut the cord with unsterilized blades, sickles, bamboo slivers,knives, etc. Deliveries in a cowshed were widely prevalent and57% of women did not have access to health care services.

In December 1999, aworkshop was organized jointly by the SriBhuvaneshwari Mahila Ashram and Research, Advocacy andCommunication in the Himalayan Areas (SBMA-RACHNA) toaddress the reproducti ve health problems of women in Uttaranchaland discuss strategies to improve their health status, and find outthe possibility of involving pandits for the same. Thirty panditsrepresenting all areas of the Uttaranchal region participated in theworkshop.

Pandits are a group of educated, respected, religious leaderswho propagate the Hindu religious doctrines by reciting versesfrom ancient scriptures, performing religious rites and ceremo-

nies, and advocating the prevailing socio-cultural customs andpractices. They also work in various other capacities, especially aspriests in temples and school teachers. They represent a group ofprogressive people facilitating social transformation by way ofeducation and creating awareness among people on various as-pects of life. They have good communication and public relationskills. In view of the lack of trained health manpower inUttaranchal,pandits could act as 'link persons' between health care providersand the community. The workshop exposed various social andcultural traditions, practices and customs prevalent in the regionwhich adversely affect the health of women during the antenatal,natal and postnatal period. It also discussed the possible Tole ofpandits in determining the composition and size of the familyincluding the preference for a boy child and the acceptance ofcontraceptive measures among the people.

The workshop showed that pandits were willing to learn scien-tific facts about dietary habits, and the phenomena ofmenstruation,pregnancy and childbirth. They. were also eager tp review andinterpret religious texts linked to these events. It was brought to thenotice of the participants that there is a list of taboos and socialrestrictions on the eating of certain foods by pregnant and lactatingwomen. When the scientific viewpoint on these food items wasbrought to the notice of the participants, a discussion ensued on theorigin of these food taboos in the context of religious scriptures andayurvedic principles. Finally, it was agreed that religion andayurveda did not oppose the consumption of these food items andthey could be safely advised for pregnant and lactating women.This showed the flexibility in the interpretation of food taboos thatcould be removed by integrating science and religion.

The key roles identified for pandits in improving the healthstatus of the women in this region were:

1. As health educators in removing prevalent food taboos bymotivating people to consume a balanced diet during preg-nancy and lactation;

2. To impart information on the availability of basic healthprovision in the public sector and promote better utilization ofhealth services such as immunization, screening for high-riskpregnancy and the need for referral, avoidance of unwanted andunsafe abortions, promotion of gender equity, contraceptivesfor spacing of pregnancies and limitation of family size. Suchinformation can be provided by the pandits during their homevisits while performing rituals, ceremonies and during ses-sions for reading horoscopes.

CORRESPONDENCE

The future strategies identified for achieving these goals in-cluded:

1. Provision of short term orientation programmes for pandits toacquaint them with the facilities provided in public sectorhealth centres and hospitals, principles of a balanced diet,basic information on the process of menstruation, pregnancy,childbirth, lactation, and the identification of danger signsduring pregnancy and the postnatal period.

2. Incorporation of these issues in the teaching and trainingprogrammes of pandits while studying in Sanskrit colleges.

The involvement of pandits may thus help to improve thereproducti ve health of the underpri vileged in the difficult terrainsof the Himalayan region.

15 September 2001 M. Meghachandra SinghDepartment of Community Medicine

Mauland Azad Medical CollegeNew Delhi

megharita@yahoo.com

P. C. JoshiDepartment of Medical Anthropology

Institute of Human Behaviour and Allied SciencesDilshad Garden

Delhi

REFERENCESNational Health Policy. Ministry of Health and Family Welfare, Government ofIndia,NirmanBhavan, New Delhi, 1983.

2 Srivastava SK. Reproductive health of women in Uttarakhand. Mountains and People2000;1:15-19.

Comparison of reported drug use and urinalysisin the assessment of drug use

A valid assessment of drug consumption is critical for evaluatingsubstance abuse treatment programmes and interpreting treatmentoutcome data. Self-reported drug use is a principle measure in theevaluation of treatment outcome. As there have been concernsabout the accuracy of self-reporting, 1-7it is necessary to establish itsvalidity by an objective method. Also, drug-dependent subjectstend to falsify their pattern of drug use. Currently, urine testing hasgained popularity for validating self-reported drug use.5•6•8•9

We examined the concordance between reported drug use andurinalysis among drug-dependent subjects undergoing treatmentat the Drug Dependence Treatment Centre, All India Institute ofMedical Sciences, New Delhi. Opiates (heroin, morphine) werethe focus of our study as they are the most commonly used drugsin north India.

Urine samples were collected from outpatients and inpatientsseeking treatment at our centre. Clinicians who examined thesubjects referred them for urine analysis. Information was re-corded on the nature of the specimen to be tested, time of samplecollection, brief clinical history of drug use, diagnosis, route ofadministration, quantity and frequency of consumption, last in-take of drug in the past 24, 48 and 72 hours and the medicinesprescribed. Immediately after the clinical interview, the patientwas requested to give a urine sample (50 ml) under close super-vision, which was sent to the laboratory for analysis. A modifiedhydrolysis method was used for the detection of opioids.P:'?

315

Heroin was not measured directly, as most of it is metabolized tomorphine, but was estimated in the form of morphine. Afterhydrolysis, the samples were screened for drugs by thin layerchromatography (TLC). This method detects recent drug use, i.e.within 48 hours of the last drug use.

All the subjects were men and diagnosed as having opioiddependence syndrome. Their mean (SD) age was 30 (8.2) years.Over a period of 6 years (1990-1995), 7728 urine samples weretested. Of the total samples screened, 43% of the urine sampleswere from outpatients and the rest from inpatients. Table I showsthe comparison between the results and self-reported drug use.Among the patients who did not report recent drug use, 18.2% ofoutpatients and 10.6% of patients had positive urine tests. Inter-estingly, the number of patients reporting recent drug use wasmore than those detected on TLC. While 60% of the urine testresults matched with self-reported drug use, 44% of outpatient and37% of inpatient samples were discordant. These could be due toover-reporting or under-reporting of drug use by the subject.v"However, it may also be due to the limitations ofthe method usedfor analysis of the urine samples. Of the subjects who admitted todrug use in the past 48 hours, 26% had negative results on urineanalysis. This may be due to actual over-reporting or due to alimited sensitivity ofthe TLC procedure. However, we have foundthe TLC procedure to have a moderate degree of sensitivity asconfirmed by gas liquid chromatography. 12Thus, it is reasonableto assume that the majority ofthese subjects did over-report theirdrug use. Some of the TLC negative results may be due to a lowconsumption of the drug or because the time between use of thedrug and urine collection was short. 12.13

At our centre all patients receive free medications for treatmentand hence they may have over-reported drug use in the hope ofobtaining more prescription drugs.

This study also indicates that discordance was lower in inpa-tients compared to outpatients. This may be because of supervisedcare in the inpatient setting. Thus, self-reporting may not accuratelyreflect actual drug use for a number of reasons. The literature alsosuggests that there is a high degree of variation in the validity of self-reported drug use, depending on the methodological and researchcontext variable3.4.J3.14including the type of drug used, type ofmeasure (e.g. frequency or amount), and characteristics of thesample population. It is difficult to compare the results of previousself-reporting validity studies because of the differences in suchvariables. However, our study suggests that urine analysis may helpin substance abuse treatment programmes and better methods needto be evolved to assess recent drug use in drug-dependent subjects.

ACKNOWLEDGEMENTSWe are grateful to Dr D. Mohan, Head of the Department of Psychiatry andProgramme incharge, Drug Dependence Treatment Centre for his encourage-ment and Dr Rajat Ray for his suggestions. We are also grateful to physicians

TABLE I. Comparison of urinalysis and self-reported drug use(n=7728)

Reported opiate use Urinalysis

Positive Negative

Outpatients (n=3309)

Yes 391 (I 1.8) 864(26)

No 599(18.2) 1455 (44)

Inpatients (n=4419)

Yes 285 (6.5) 1166(26.4)

No 470(10.6) 2498(56.5)

Figures in parentheses are percentages

316

at our Centre for referring patients for urinalysis and the laboratory staff of theCentre for their technical assistance.

REFERENCESMaddux JF, Desmond DP. Reliability and validity of information from chronic heroinusers. J Psychiatr Res 1975;12:87-95.

2 BaieRN, van Stone WW,EngelsingTM,Zarcone VRJr, KuldamJM. The validity ofself-reported heroin use. lnt J Addict 1981 ;16: 1387-98.Magura S, Goldsmith D, Casriel C, Goldstein PJ, Lipton DS. The validity of methadoneclients' self-reported drug use.Int J Addict 1989;28:727-49.

4 Maisto SA, McKay JR, Connors GJ. Self-reported issues in substance abuse: State ofthe art and future directions. Behav Assessment 1981 ;2: 117-34.

5 Sherman MF, Bigelow GE. Validity of patients' self-reported use as a function oftreatment status. Drug Alcohol Depend 1992;30: 1-11.

6 Harrison L, Hughes A (eds). The validity of self-reported drug use: Improving theaccuracy of survey estimates. NIDA Research Monograph 167, US Department ofHealth and Human Services, National Institutes of Health ,NIDA Rockville, MD, 1997.

7 Darke S. Self-report among injecting drug users: A review. Drug Alcohol Depend1998;51:253-63.Martin GW, Wilkinson DA, Kapur BM. Validation of self-reported cannabis use byurine analysis. Addict Behav 1988;13: 147-50.

9 Digiusto E, Seres V, Bibby A, Batey R. Concordance between urinalysis results andself-reported drug use by applicants for methadone maintenance in Australia. AddictBehav 1996;21:319-29.

10 Jain R, Ray R, Tripathi BM. Opiate excretion profile among heroin-dependentsubjects. Indian J PharmacoI1996;28:220-3.

II Jain R. Anaytical methods. In: Jain R (ed). Detection of drugs of abuse in body fluids:A manualfor laboratory personnel. New Delhi:Drug Dependence Treatment Centre,All India Institute of Medical Sciences, 1998;18-44.

12 Jain R. Utility of thin layer chromatography for detection of opioids and benzodiazepinesin a clinical setting. Addict Behav 2000;25:451-4.

13 Preston KL, Silverman K, Schuster CR, Cone EJ. Comparison of self-reported drug usewith quantitative and qualitative urinalysis for assessment of drug use in treatmentstudies. NIDA Research Monograph 1997;167:130-45.

14 log HY. Self-reported drug use: Results of selected empirical investigations ofvalidity. NIDA Research Monograph 1997;167:320-43.

22 September 2001 Raka JainB. M. Tripathi

Drug Dependence Treatment CentreDepartment of Psychiatry

rjain@medinst.emet.in

Rajveer SinghDepartment of Biostatistics

All India Institute of Medical SciencesNew Delhi

The soap and water treatment of burns

In 1954, as house surgeon to A. B. Wallace at the Plastic Surgeryand Bums Unit at the Bangour hospitals (an annexe of theEdinburgh Infirmary), I had the opportunity to observe the 'expo-sure' treatment of bums being demonstrated by its originator tovisitors from all over the world. This was based on an elementaryprinciple used by microbiologists for the cultivation of microor-ganisms which consists of inoculating a petri dish containing arich medium such as plasma with a few bacteria, covering it toensure humidity and placing it in a dark incubator maintained atbody temperature. Since most organisms multiply about 6 hourlyunder such ideal conditions, they produce visible colonies consist-ing of millions of organisms within a day or two.

This is exactly what happens when a bum or any other woundis covered with a dressing which provides ideal conditions for thegrowth of microbes with the additional advantage of necrotic skinas a source of nourishment. The use of systemic and topicalantibiotics results in the rapid growth of resistant forms of organ-

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 14, NO.5, 2001

isms. Pseudomonas was virtually unknown in the bums ward tillantibiotics such as penicillin were used.

The combination of toxins secreted by the organisms and theproteolytic enzymes secreted by the leucocytes and macrophages inthe wound result in further damage as they digest the new epithelialcells growing from the deeper surviving adnexa of the skin.

The painful dressing of a bum wound, if undertaken every dayat considerable effort and expense, results in further damage as thedelicate regenerating epithelial cells which adhere to the dressingsget peeled off. It also encourages the growth of a variety of micro-organisms.

The exposure treatment of bums or any other wound receivesfurther support from the common observation that wounds on anypart of an animal's body which can be licked heal rapidly withoutresort to any dressing. The constant mechanical cleansing by thetongue, probably enhanced by the enzymes in the saliva, plays animportant role in the healing process.

The exposure treatment of a bum wound, which is originallysterile, is based on the natural covering of such wounds with asterile dressing of dried plasma. This has many advantages overartificial dressings. Yet it is difficult to maintain an intact crustover joint flexures and in circumferential bums of the body.

The soap and water treatment of bums which I devised in the1960s at the Bums Unit ofthe Tata Department of Plastic Surgery(TDPS) at the 1.1. Hospital in Mumbai, was simultanenouslyemployed to treat 1300 cases by Dr S. Arora who was then apostgraduate student and is presently the head of TDPS. Thisstudy, which was undertaken in two rooms at the Thane CivilHospital, demonstrated the advantages of a painless, soothing,low-cost and highly effective treatment. This is carried out chieflyby the patients themselves and consists of washing the woundswith soap several times a day under a shower and, if necessary,applying a bandage soaked in Eusol (bleaching powder solution)with the help of a relative or nurse. The bandage can be removedgently under the shower by the patient during the next shower.

The organisms are slow to grow when exposed to light and airand the area is kept cool by evaporation from the exposed woundor thin bandage soaked with chlorine solution to which theorganisms rarely become resistant. This is next best only to thenatural method used by cats and dogs of constantly removing themicroorganisms with their tongue.

This humane, pain-free and highly cost-effective method re-quires little nursing care, does not use topical and/or systemicantibiotics, and was 10 times cheaper compared to our ownsophisticated Bums Unit at the J.J. Hospital of Grant MedicalCollege. It was also interesting that the need for skin grafting wasreduced to about a quarter of that in our parent unit for reasonspreviously mentioned. The mortality was the same and the mor-bidity and contractures were much lower.

Together with the lhoola bed, this provides a new dimensionto the treatment of bums not only in rural hospitals but also in theunnecessarily expensive Bums Units which are sprouting in manycountries as well as our own.

20 September 2001 N. H. AntiaThe Tata Department of Plastic Surgery

Sir 1.J. Group of HospitalsMumbai

Maharashtra

REFERENCESI Antia NH. Early treatment of extensive bums. Indian J Surg 1958;20:543-8.2 Arora S, Antia NH. The treatment of bums: Treatment of burns in a district hospital.

Burns 1977 ;4:49-51.3 Antia NH, Daver BM, Arora S. Management of burns. Trop Doer 1999;29:7-11.