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care, the pyramid is stood on its apex, with the concept of descentand failure as you move down to hospital care. It might affect theattitude of medical students who still, in the less developedcountries, love to get to their prestige institutions and have not gotthe taste for the wider interests of general practice that has swayedtheir British counterparts. To persuade doctors to work in ruralIndia for longer than a year or so is very difficult. There are limits tothe technical interest of medicine that can be practised under a tree:endless immunisations, persistent leprosy, treatment fordiarrhoea-the remedies are simple and the work is repetitive.Anything at all complex has to be referred elsewhere for

investigation and there is little reporting back. This is communityservice, a vocation, and you have to want to do it. Just 20% of India’sdoctors are looking after 80% of its population-and that in acountry with only 1 doctor per 4370 population overall. Onemedical school in Vellore reported on its programme of sendingstudents out on training in rural areas, but it is not a common

pattern.Sadly, even those who do not want to be involved in primary

health care (the conference heard of one very successful scheme totrain nurses as anaesthetists) sometimes criticise the efforts of lesshighly trained personnel. But there is an acute shortage of nurses inIndia-just 1 per 9000 population-largely caused by the very lowsocial status accorded to them. The solution has been to maximisethe use of villagers and to build on the skills of traditional birthattendants. Village girls are being trained to give immunisations,and village boys are sent on courses to teach them to detect leprosyin its early stages.The conference was oversubscribed, with hospitals vying with

each other to present the successes of their outreach programmes.This was no question of geeing up a community medicinedepartment: they were more interested in abolishing such

departments so that every hospital specialist had a responsibility forservices outside the hospital walls as much as for those inside.Those who had not fully absorbed the PHC philisophy were still

talking about mobile units-everything from a mobile chest X-rayunit to a mobile scanner. They were given short shrift for theirinability to see that hospitals cannot decide what is wanted and sendit out-even if they do have adequate management and logisticsupport. They must respond to the demands of the community theyserve.

Perhaps the most pleasingly "grassroots" scheme was one inGujarat which grew from villagers realising how healthy their cattlewere under the care of the mobile veterinary clinics run by the milkcooperatives! They wanted maternal and child care and

supplementary feeding for themselves. Initially, 15 villages paidhalf the salary of a health worker and supervised her work. Out ofthat the need for a referral hospital became evident: a hospital whichnow has 800 beds for a population of 2 - 6 million, but whichconcentrates on its work in 250 villages, funded by the Aga KhanFoundation. Its main problem, however, is the high turnover ofmedical staff-100% in the past three years-primarily because theyare attracted to private practice in the cities of Gujarat, a rich area,historically of diamond traders.

It is perhaps in the slums and the shanty-towns that the greatestproblems arise. Here, there is no stable community network onwhich to build. Shacks of corrugated iron and plaster-board may notexist when the door-to-door survey worker returns to follow up a

willingness to accept family planning or immunisation. Anyattempt at community mapping or epidemiology is likely to bescanty in its success, and no physical structure is permanent enoughfor clean water and good sanitation to be organised.

It was noticeable that the most imaginative initiatives came fromthe voluntary organisations and the churches, and that the mainmessage of the new Minister of State for Health and Family Welfarewas that the Government could not achieve the PHC target withouttheir help-a speech hardly different from those given by Ministersin Britain. Nonetheless, the Government has set itself the target ofupgrading one in four health centres by 1990 and of training healthworkers, though by no means enough.Typical of the wealth of initiatives presented at the conference

was the one based on the Christian Welfare Centre at Malapurramin Kerala, in the very south of India. The 20 poor and mainly

traditionally Muslim villages served by the scheme have always hadhigh rates of population growth, infant mortality, and tuberculosis.Its activities are comprehensive: weekly antenatal clinics offer

check-ups, detect toxaemia, anaemia, and nutritional deficiencies,teach personal hygiene and nutrition, and provide immunisationagainst tetanus. Under-five clinics provide immunisation, maintaingrowth charts, and detect and correct anaemia, malnutrition, worminfestation, and other ailments. Paramedical workers provide healtheducation through regular house-visits and classes, and training isgiven to traditional birth attendants and basic health workers.This project provides injections twice a week for 400 tuberculosis

patients who gather at the roadside, as well as clinics and screeningfor members of patients’ families. Vaccination has been given to25 000 people. About 150 leprosy patients are seen; special shoesare supplied when necessary, and an early detection programme,including house visits, has been instituted. Hospital deliveries areencouraged and family planning is offered.Nor does the project ignore the infrastructure which is an

essential prerequisite to health. 42 wells have been deepened andrepaired, 2000 latrines supplied, and 2500 compost pits dug. Thenutritional programme includes the supply of food to children, anexhibition, a teaching demonstration on balanced diet, low-costmenus with food that is available locally, and the supply of seeds.The health care programme extends even to vocational educationand economic assistance: sewing classes, training in basket-makingand embroidery, and interest-free loans for buying goats or chicken,making charcoal, or fishing.The workers reported that dynamic changes are taking place

among the traditionally Muslim women as a result of their

participation in community health activities. Worm infestations,diarrhoea, respiratory disorders, and nutritional deficiencies havebeen reduced. The infant mortality rate is declining (mothers usedto ask why the doctors immunise just to make the child cry; why notwait until he is ill?), and younger Muslim women are showing awillingness to accept sterilisation while their own mothers go onhaving babies.Without more active government support, what Miles Hardie

refers to as "projectitis" will remain a problem. There were enoughsuccessful projects reported at the conference to show what needs tobe done and how hospitals can help. But they must be replicated anddeveloped regionally and nationally. Even in India, Mr Hardiepoints out, the main obstacle is not financial: it is resistance to

change, fuelled by the four Ps-politics, paternalism,professionalism, and private practice. I went to the conference

expecting rather poor-quality papers that attempted to mimic theBritish way of doing things. I returned humbled and ashamed at mycolonial arrogance.

JILL TURNER

International Diary1985

International conference on Safety and Health: London, UK, April 18-19(International Fire Security and Safety Exhibitions and Conferences Ltd,Cavendish House, 128/134 Cleveland Street, London WIP 5DN).

22nd congress of the European Dialysis and TransplantAssociation-European Renal Association and 14th annual conferenceof the European Dialysis and Transplant Nurses Association:

Brussels, Belgium, June 25-29 (Secretariat, Nephrology Department,Akademisch Ziekenhuis, De Pintalaan 185, Ghent, Belgtum).

12th symposium of the International Association for ComparativeResearch on Leukaemia and Related Diseases: Hamburg, WestGermany, July 7-11 (ProfFnednch Demhardt, Max v. Pettenkofer Institut,Pettenkoferstrasse 9a, D-8000 Munich 2, FRG).

International conference on Aluminium in Renal Disease: Surrey, UK,Sept 16-18 (Mrs Janet Williams, Robens Institute, University of Surrey,Guildford, Surrey GU2 5XH).Annual meeting of the Eurotransplant Foundation: Leiden, The

Netherlands, Sept 21 (Eurotransplant Office, c/o Bloodbank, UniversityHospital, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands).