1. health and fitness

2. Conceptualization, Methodology and Sample Characteristics
The theoretical approaches dealt in the earlier chapter will be used as the basis for
conceptualising the present study on fever talk and fever care in Kerala. The present
chapter is broadly divided into three sections. The first is a brief description of
Kerala's social development, its morbidity profile, its nature of epidemiological
transition, availability and utilisation of health services by sector and by systems and
lastly on the kind and nature of allopathic health services in the State. This is because
conceptualisation of the study and methodology should be feasible and relevant to the
socio-cultural context of the study area. The above description will be based on
secondary data published by government bodies as well as on secondary literature
together with the pilot study carried out in the area to examine the feasibility of the
methodology. The second part deals with the conceptualisation and methodology of
the study. Here, based on the understanding about the approaches on disease,
medicine and medical care this section attempts to conceptualise fever talk and fever
care in Kerala's socio-cultual context. This will help to refine the conceptualisation as
well as the broad objective of the study. In order to accomplish this objective, the
study was proceeded in a certain way (operationalising) by using specific methods of
data collection whose description will be made. As the study uses both quantitative
and qualitative methods of data collection the sample characteristics and the setting
will be focussed in the third section ofthis chapter.
2.1 Kerala Scenario
2.1.1 Social Development
Kerala, known for its development despite its low per-capita income has many of the
social indicators comparable to that of developed countries (Franke and Chasin 1991,
Tharamangalam 1998). These include improvements in education reflected in the
higher literacy rate, and health indicators like low infant mortality rate, low birth rate
and significantly good life expectancy (ibid.). Another notable feature within Kerala
is the fact that the achievements are distributed more or less equally across rural and
urban areas, male and female population and the inequality is comparatively less
between classes (Tharamangalalm 1998). In other words, the majority of Kerala
families are in middle-income groups with fewer families among the extreme poor as
compared to other Indian states, which implies that income disparity is less severe
43
than other states (Pillai et al. 2003). The above state of development, also known as
Kerala model o.f development is traced back to the historical movements and people's
struggles leading to land reforms and social reformation movements which took place
in the state along with its unique ecological and geographical factors (Tharamangalam
1998, Franke and
Chasin
1991 ).
These culminated in increased
political
consciousness, which resulted in the demand for the basic facilities like education,
health and food by the people as the right of their citizens. The following section will
be confined to the debates surrounding the nature and characteristics of the health of
the people and health services prevalent in the state.
2.1.2 Morbidity Profile
A brief outlook of the pattern of morbidity will give a better picture of the health
situation in Kerala. The disease patterns during the 1990s remain more or less same as
that of the 1980s. There has been a slight increase in non-communicable disease load
indicating that health transition is taking place in the state. Detailed analysis on the
pattern of communicable diseases and fevers in particular help us to understand the
situation better. There has been a decline in the water-borne diseases especially
diarrhoea, which is attributed to the improved sanitation and water supply
(Kunjhikannan and Aravindan 2000). The prevalence of Measles, Mumps, Tetanus
and Filaria was less than 0.5 per 1000 population. TB prevalence is bit high at around
1.32 per 1000 population, whereas that of Fevers is 67.95 per 1000 population (ibid.)
Fevers include diseases like viral fevers, upper and lower respiratory tract infections,
simple cough and runny nose, which are quite common. At any point of time, 6. 7
percent to 7.9 percent of the state's population suffers from these illnesses (ibid.).
This they estimated based on the community survey conducted in a two-week period
that included questions on the symptoms of fever. This becomes convincing when
looks at the data on outpatient (OP) attendance of Primary Health Centres (PHC),
where nearly 30-40 percent of all outpatient attendance in PHC and other peripheral
institutions is solely due to fevers and/or respiratory infections (ibid.). Despite the fact
that fevers are the most prevalent illness in the state, it was not adequately studied.
The reason for this could be probably the fact that fever has been there since antiquity
and is considered a symptom by the public and so there is a notion that it is a
common, natural problem. Another reason is the notion among doctors and health
planners that the disease is over-reported because of its specific features that it can be
44
a symptom for a range of diseases therefore a possibility that many other diseases can
be reported as fevers.
Non-communicable diseases or diseases of affluence are also on rise in the context of
Kerala. This has been a consistent feature as revealed by the studies of Panicker and
Soman (1984 ), Kannan et al. ( 1991)
and later by Kunjhikannan and Aravindan
(2000). Though the diseases due to poverty have reduced over the period, there has
been resurgence of new epidemics in the state during the 1990s. Thus, it is said that
the state is facing a dual crisis with diseases of poverty and diseases of affluence that
raises questions on whether epidemiological transition is really happening in the state
(Panicker 1999).
~.1.3
On~
Epidemiological transition
of the factors scholars have identified, which contributes to the development of
health of the people is demographic transition (Ratcliffe 1978). This later broadened
to health transition that encompasses demographic, epidemiological and health care
transition (Panicker 1999). The major characteristics of demographic transition are
low mortality and low fertility with significantly lower infant mortality and greater
life expectancy (ibid.). The above demographic transition is considered as the key
aspect as this is offered as an explanation for the decrease in communicable diseases
and rise in non-communicable diseases, a feature of epidemiological transition (ibid.).
Here, the shift in age structure of the morbid population is seen also as an outcome of
the above demographic transition. From an epidemiological point of view, it was
found that after 1970s, there was a tremendous improvement in the health indicators
of the state.
It is a paradox in Kerala that despite the increase in morbidity rate, its mortality rate
has been very low. This is attributed to the greater coverage of health services system
in the state and also the higher health consciousness of the people (Panicker and
Soman 1984, Kannan et al. 1991, Kunjhikannan and Aravindan 2000). Another
argument is that this increased morbidity in Kerala is due to the perception factor that
has been the feature of societies where access to health services is greater (Murray
and Chen 1992). In other words, the higher health consciousness of the people is
conceptualised as an individualistic parameter as perceived morbidity. This gets re45
asserted when some scholars argue that the perceived morbidity for Kerala is very
high (Kunjhikannan and Aravindan 2000). It is worth mentioning at this juncture that
perception factor when examined in the social context appears to be nothing other
than the effects of a medicafised society, a characteristic of modem society
extensively dealt in the earlier chapter (chapter one).
2.1.4 Availability and Utilisation of Health Services by Sector
A brief understanding about the availability and utilisation of health services with
respect to the sector to which the hospitals belong will give a picture of the prevalent
utilisation pattern of the state.
Table 2.1: Availability of health services by sectors in Kerala (in percentages).
Kerala
Public Sector
Public Hospitals
PHCs
Private
Hospitals
Rural
41.02
2.36
53.4
Urban
54.97
41.79
0.88
nu
Source. NSS 42 round 1986-87, p. 28 & 29.
Private Sector
Nursing
Charitable
Homes
2.96
0.26
1.92
0.63
Regarding availability of hospitals, it was found that from Table 2.1 that in rural areas
56.62 percent of total hospitals belong to the private sector and 43.38 percent to the
public sector. In urban areas, public hospitals are the majority, which comes to 55.85
percent of total hospitals with 44.43 percent belonging to the private sector.
Table 2.2: Utilisation of health services by sectors in Kerala (in percentages).
Public Sector
Kerala Public PHCs Public
Disp.
Hosp.
4.32
Rural
27.5
2.32
Urban 32.83
2.43
0.43
Source. NSS 42 nu round 1986-87,
Private Sector
Pvt. Hasp. Private
ESI
Nursing Charitable Others
Practitioner Homes
hosp
0.11
0.38
41.64
20.57
1.04
2.12
0.12
40.21
19.87
0.66
2.82
0.63
p. 31 & 32.
Coming to the utilisation pattern ofhealth facilities by sector, it was found that around
34 percent use the public sector and 63 percent use the private sector in rural areas,
which for urban areas, it was 35 percent and 60 percent respectively (Table 2.2). The
utilisation pattern of hospitalised cases (in-patients) with respect to sector of the
hospital shows that 39.5 percent and 59 percent use public and private sector
respectively in rural areas, which for the urban areas is 37.3 percent and 59.8 percent
(NSSO 1998: A-66 and
A~l71).
The same figures for non-hospitalised cases (out-
patients) are 29.8 and 70 percent in rural areas and 30.5 and 69.4 percent in urban
areas (ibid. A-77 and A-182). It is worth mentioning here that the classification
AL
followed for the kind of health serv1ces by NSS while providing data on the
availability and utilisation of health services were different whose reasons are not
mentioned.
2.1.5 Availability and utilisation of Health Services by System
On examining the availability and utilisation with respect to the systems of medicine
in the state, Allopathic systems constitute 96.8 and 98.28 percent in rural and urban
areas respectively with Ayurvedic hospitals contributing to 1.73 percent and 1.27
percent in rural and urban areas respectively (Table 2.3).
11 yof h ea lth serv1ces b y S;yst ems m K era Ia ('m percen t ages ).
T a bl e 2 3 Ava1'I abTt
Others
Allopathy
Unani
Kerala
Ayurveda
Homoeopathy
96.8
0.84
0.11
1.73
0.52
Rural
98.28
0.07
Urban
1.27
0.38
no
Source. NSS 42 round 1986-87, p. 9 & 10.
Regarding utilisation by systems of medicine, the people of Kerala depend mainly on
three systems of medicine viz. Allopathy, Ayurveda and Homoeopathy. Based on the
NSS 42nct round, more than 90 percent in both rural and urban areas of Kerala utilise
Allopathic systems of medicine, with only 4 percent and 2 percent respectively
seeking treatment in Ayurvedic and Homoeopathic systems (NSSO 1989, Table 2.4).
Another study that looked at the change in health transition between 1987 and 1997,
showed that there has been a tremendous increase in the utilisation of the Allopathic
system from 72 percent to 82 percent during the period (Kunjhikannan and Aravindan
2000).
Table 2.4 Utilisation of health services by Systems in Kerala (in percentages).
Kerala
Allopathy
Ayurveda
Homoeopathy
Rural
93.27
2.07
4.12
92.61
Urban
4.4
2.58
no
Source. NSS 42 round 1986-87, p. 13 &14.
Unani
0.21
0.26
Any
combination
0.09
0.15
Others
0.14
-
The utilisation with respect to socio-economic status show that poor people rely more
on modem medicine than the better-off group (Kannan et al. 1991, Aravindan 2006).
As the socio-economic status goes up there is more recourse to other types of
treatment probably indicating that the more affluent have greater choice when it
comes to treatment systems. The recent survey carried out by KSSP reveals that there
is a tendency of low utilisation of Allopathic system (79.9 percent) when a significant
increase is seen in the utilisation pattern of Ayurveda (9.1 percent) and Homoeopathic
system (6.6 percent) (Aravindan 2006). These trends could be probably due to the
47
strengthening of dissent towards allopathic system as well as the changing nature
(transformation) of other systems in accordance with the dominant system, a kind of
Allo-Ayurvedopathy (Jayarao 1986: 165) that is in practice. This is a tendency where
Ayurvedic practice mimics the etiquette of Allopathy in terrils of diagnosis, drug
production as well as prescription and so on without adequately considering the basic
epistemological difference between the two systems. There was a small proportion
(4.4 percent) of patients who utilised more than one system of medicine during illness
indicating the new trend in mixing of systems. This is a reflection of shopping of
medical care where all the available products in the market will be tried for relief,
largely the behaviour of the better-off.
Another important feature that was observed among the Kerala society was that there
are specific preferences in people's health-seeking behaviour. This is obvious from
the treatment-seeking behaviour for paralysis and rheumatism, where people seek
treatment mostly in the Ayurvedic system whereas in the case of childhood illnesses,
Homoeopathy has been the treatment of choice (Kannan et al. 1991, Sushama 1989,
Sankar 2002).
2.1.6 Type and Kind of Allopathic Care in Kerala
As the study is confined to allopathic hospitals, only fever care rendered in allopathic
hospitals will be examined. A brief description about the various types of allopathic
care rendered in the state will help us understand the characteristics of medical care in
the state. The types of allopathic care in the state can be broadly divided into the
public and the private sectors. Within the public sector, there are Sub Centres, PHCs
and Community Health Centres (CHCs) at the primary level, district and taluk
hospitals at the secondary level and medical colleges at the tertiary level.
In the private sector, there are General Practitioner's (GP) and small clinics, whose
major beneficiaries belong to the middle-class and upper-middle class. In addition to
this, there are small hospitals managed by a single physician and at times two, who
will be the key person, with basic laboratory facilities and bed occupancy of 10-15.
This is quite similar to the CHCs, highly utilised by people from all socioeconomic
sections, especially the lower socio-economic class due to reasons of proximity,
48
familiarity and time saved (less crowded and evening clinics). All the above facilities
together form the primary level within the private sector.
There are also speciality hospitals where all the major specialities are available with
modern technologies with bed strength ranging from 300 to 750, with wards ofvatied
ranges, along with 24-hr casualty facilities comparable to the district and taluk
hospitals in the public sector constitute the secondary sector. Besides, big corporate
hospitals as well as trust hospitals that provide major facilities comparable to those
provided by the secondary sector, but well known for one or two specialities also
come under the tertiary sector.
Medical colleges in the state with several specialities and teaching facilities constitute
the tertimy sector. Public as well as private medical colleges function in the state. In
fact the boundaries between the secondary and tertiary sectors within the private
sector often overlaps and it is difficult to make a strict demarcation. It has to be noted
that though fever clinics were established only in public hospitals, the pilot study
carried out revealed that the newly established fever clinics are not functionally
different from the pre-existed OP departments. This led to the situation in which the
comparability of the OP departments of the public and private hospitals, both at
primary and secondary level became feasible.
It is obvious that majority of the acute illnesses are managed mostly at the primary
and secondary sectors. Here it is worth mentioning that the CHCs and taluk hospitals
in the public sector and General Practitioner (GPs) at the private sector are the ones
who are forced to prescribe for tests to be carried out from the private laboratories
outside. This facilitates market that helps the growth of private laboratories in the
state. The reason is the inadequate functioning of the existing infrastructure at the
public sector (Varatharajan, et al. 2002) and for GPs, a laboratory is non-existent. The
above health facilities together with the district hospitals and medical colleges provide
ample market for the chemists. In the private sector, especially at the secondary
sector, the hospital as a single institution has the autonomy of the market for
laboratory and drugs through which the division of labour and therefore the profit in
medical care actually works. The health-seeking behaviour, burden, and expenses
incurred due to the illness with respect to public and private hospitals will be the
49
focus of the fourth chapter. The present study will be conceptualised based on the
approaches to disease, illness, medicine and medical care reviewed in the earlier
chapter together with the socio-cultural context prevalent in the state of Kerala,
especially those influencing health and health services.
2.2 Conceptualisation of the Study
2.2.1 Fever as Discourse
Fever, understood as an illness will be examined as that which acquires meaning
depending on the actors and the context involved. In other words, fever will be
approached sociologically as that whose meaning will be explored based on the
discourse in which it is embedded. This is because fever for the medical fraternity,
could be largely influenced by the prevalent discourse on medicine where fever could
be treated as a symptom with a physiological indication of raised body temperature
(greater than 98.4 F). The same for a person affected with the illness can be that
which prevent him/her from his/her day-to-day behaviour and action as part of their
normal livelihood. It is interesting to note that the media as well as health staffs
consider fever as an epidemic that can cause death during epidemic outbreaks. Thus,
the present study calls for an examination of fever as understood by the medical
fraternity, common men, public health experts, media and so on in order to situate
their understanding in their respective contexts. In addition to this, how the everyday
activities of individuals produce certain notions about fever which in tum also
determine the everyday actions regarding the distress along with the policies of the
government will be analysed. In other words, fever has to be understood as a
discourse within Kerala society where the very notion about fever among various
social groups has to be historically and culturally situated within the prevalent societal
discourse on health, illness and medicine.
2.2.2 Context of Establishment of Fever Clinics
As mentioned in the introduction, while tracing the epidemic of fevers, it was found
that as a response to the epidemics, Government of Kerala established fever clinics in
the state in 2004. In the present study, fever clinics are new medical establishments
set up as a solution to a series of events that hamper the daily life of the public. As
part of the changing nature of medicine, a clinic is viewed as a medical institution
with functions of surveillance and care capable of imposing disciplinary power
50
through the process of labelling. Thus, fever clinics will be examined as a response to
a public health emergency where the social, political and administrative context
becomes primordial as also its nature and characteristics and its implications on the
expected outcome.
2.2.3 Fever Care as Provisioning
The study approaches Fever care as part of medical care addressing both the
provisioning as well as the culture aspects of medical care. As mentioned earlier, the
study is confined only to the allopathic system of care, which is the widely-used
system of medicine in the country especially in the state of Kerala, the study area.
This is to say that by fever care, the study limits itself to the care rendered by
allopathic system alone. Provisioning implies the distribution of public and private
sector institutions as well as primary, secondary and tertiary levels of medical care
where all these need to be situated in the larger context of government policies in
general and health care in particular. This is because government policies have a
direct impact on the changing nature of health services and therefore on medical care,
a major component of health services. Here it has to be noted that the weakening of
the public sector or the growth of the private sector has to be subjected to an analysis
that incorporates government policies, socioeconomic and cultural context of the
people who utilise this services and lastly the outcome of medical care. This is
because it is obvious from the review of literature carried out in the earlier chapter
that the health service system was constrained by the vertical programmes for the
control of communicable diseases. Additionally, the impact of structural adjustment
policies during 1990s along with the corporatisation of medical care, a new form of
medical-industrial complex, together have tremendously changed the nature and
characteristics of medical care.
On the other hand, from a patient perspective, the factors affecting the access and
utilisation of health services gain significance, as this is a direct indicator of the
patients' socioeconomic, political and cultural characteristics. The burden of any
illness can be seen both from the health services' point of view as well as that of the
patient and his/her family. Both become largely a reflection of the policies of the
government and its provisioning, whereas in case of the latter, the social groups to
which the patient belongs have a tremendous influence on their access and utilisation
51
of medical care. It has to be noted that the notion of quality of medical care,
depending largely on the outcome, is a relative concept. This is because it largely
depends on the context of medical care provided, the access to the patients and more
importantly, the outcome in terms of cost, cure as well as assurance of long-term
health. In short, health-seeking behaviour comprising of illness behavior and
treatment-seeking behaviour as dealt in the earlier chapter has to be examined within
the socioeconomic and cultural context of the patient for adequate understanding of
their access and utilisation.
2.2.4 Culture of Fever Care
Fever care will also be examined as that which represents the culture of fever care,
viewed as part of the culture of medical practice, by taking into account the medical
knowledge during different periods as it varies tremendously and has strong
implications on patient care. The major components covered under the culture of
medical practice are the modalities of diagnosis, prognosis and therapeutics for those
patients coming to any health institution with fever (self-reported). In this case, the
study largely confines itself to the hospital as a microcosm, situated as a
representation of a unit of modem medical practice. Here the sector to which the
hospital belongs, other supporting infrastructures like laboratories, pharmacies and so
on along with the physician, the patients and their relatives together form the actors in
the whole process of fever care. It has to be noted that each actor, his/her actions and
'talk' together is seen as everyday ordinary activities organised in a certain way to
attain specific goals.
Any analysis of this sort can never be independent of the social milieu of the actors
and the health institutions as allopathic medical care is expected to follow the
overarching biomedical philosophy of medical practice. It is through this medical
work that the lay categories of illness get transformed into an expert category of
disease, attributing to the latter a scient(fic character. Not only does this categorisation
exert social control through the process of labelling but it also adds to the corpus of
medical knowledge that guides future medical work (practice). Thus, the present
study intends to explore the factors (external and internal) that influence the culture of
fever care and how these contribute to the prevalent medical knowledge about fever.
52
2.2.5 Doctor-Patient Interaction
It is well known that physicians and patients are the major actors in the process of
fever care. This could be due to the prevalent faith that medicine can cure illness
leading to the expectation that patient should seek care during illness. Though the
dialogue between physician and patient has reduced over time, conversation between
physician and patient if occurring, is considered by medical practitioners as cardinal
not only for better diagnosis but also for aiding cure. In the study physicians and
patients are seen as the representations of two different knowledge systems trying to
articulate about a same event in a naturally occurring day-to-day activity. The two
knowledge systems may not necessarily be mutually exclusive; rather both may
influence each other sometimes as contributory and at times in conflict. Thus the
present study examines patients' and physicians' expression and description about
illness/disease as a narrative shaped by the social institutions, their earlier experiences
and practices with the illness. These narratives will be analysed as a text in the present
study by the researcher.
2.2.6 Fever Talk and Fever Care in Totality
Thus the present study is an attempt to interpret the talk about fever in Kerala society
as understood by different social groups so as to understand the concept better.
Further, the inquiry into the nature and kind of diseases- epidemic fevers, will
complete the above initiative as the complexity within the understanding of fever is
closely linked with the dominant understanding of those diseases with fever as the
major symptom. The media and more importantly, the biomedical health facilitythe dominant medical system, will be subjected to rigorous analysis under fever care
as its functioning can influence the dominant understanding. The interrelationship
between the notions about the epidemic and the nature and characteristics of the
prevalent health services system is further linked to the prevalent social structures and
the government policies together with the changing nature of biomedicine. This is to
re-assert the fact that any kind of analysis in isolation will be inadequate to
demonstrate the problem completely.
2.3 Methodology
Thus the present study conceptualises fever as a discourse in Kerala society that has
varied meanings depending on the context where fever care comprises of provisioning
53
and culture of fever care. This calls for an analysis that situates provisioning largely
as a question of government policy as well as people's access to services and the
culture of fever care as what ought to be fever care (practice of medicine) and its
contribution to medical knowledge. With this the broad objective of the study was to
explore how the fever patients are rendered care by allopathic hospitals in the
present scenario, giving due consideration to the socio-cultural context of the
patients and doctors as well as the prevalent discourse about fevers in the society.
As part of this broad objective, the following specific objectives were addressed:
1) To understand the context with which fever clinics were established in the
state of Kerala.
2) To explore the wayfever patients are managed (treated) in health institutions
and their reasons (rationale) for the kind of care rendered.
3) To understand how doctors understandfevers in the health facility (allopathic)
and their sources of knowledge (understanding).
4) To assess the procedures involved (comprising of laboratory diagnosis and
physical examination) in diagnosis of fevers in allopathic institutions of
Kerala.
5) To inquire into the part played by the medical fraternity and medical discourse
in fever care.
6) To interpret the doctor-patient interaction during fever care m allopathic
hospitals.
7) To assess in detail the cost incurred for the patient in one episode of fever.
8) To inquire into the reasons for the patient to choose a particular health facility,
if shifting happens in between, then the reasons for that.
9) To understand how patients of different social groups experience fevers and
their responses to it (illness behaviour).
2.3.1 Operationalising the Study
In order to accomplish the above objectives, the study was carried out broadly at four
levels. First, the various discourses on fever at various levels were examined. As
mentioned before, discourses need to address the medical fraternity, health
professionals, lay public and the media. This was predominantly based on the archival
reports and documents on fever brought out during the epidemic collected from
54
government institutions and other libraries. The way fever is understood by public
health officials is based mostly on government documents, official statistics, minutes
of government level meetings and so on. This is supplemented with semi-structured
personal interviews with government officials about fevers and the state level
initiatives to control the problem. Additionally, newspaper reports on fever, fever
clinics and fever deaths were an excellent source to understand the discourse among
the lay public as well as in the media, as the vibrant role of newspaper in Kerala
society is acknowledged by scholars (Jeffery 1997). Besides, focus group discussions
at different stages with various groups helped in understanding people's perspective
on fevers and the difficulties faced. As the context of the establishment of fever clinic
in May 2004 was one of the focuses of the study, minutes of all inter-sectoral and
health official meetings held during 2002-04 at the directorate of health services were
reviewed.
Second, a hospital-based study was carried out to understand fever care rendered by
allopathic hospitals, defined as the procedures carried out by the hospital to those who
come to the hospital with the complaint offever (self reported) with a view to cure the
ill person of the illness. This itself was carried out at two levels, first to address the
issue of provisioning of care and secondly to examine the culture of fever care. For
the former, survey research was the technique used where fever patients coming to the
hospitals were the sampling unit. Fever patients were identified from the hospitals,
where patients took treatment. This is because NSS data has shown that in the state of
Kerala, around 90 percent of those having any illness seek treatment in some health
facility or the other (NSSO 1998: A-40 & A-145). It was also found that among those
who seek treatment, around 80 percent were treated at the allopathic system for acute
illnesses (Aravindan 2006). Thus, allopathic hospital-based study of fevers in Kerala
can ensure more than 72 percent' coverage of the total fever patients in the
community.
1
This is because in a community where 90 percent reach hospital in case of illness, of which 80 percent
go to allopathic hospital. Based on this information, it can be deducted that 72 percent (90*80= 72) of
those with acute illness seek treatment at allopathic hospitals.
55
The study was carried out in an urban area with the assumption that the rural-urban
divide in the state of Kerala is meagre as there is hardly any rural area completely
detached from the nearby town, a characteristic that led to the consideration of the
state having the feature of an extended town (Kannan 1999). As mentioned in the last
chapter, public and private sector care as well as primary, secondary and tertiary level
care will be focussed on while examining the provisioning of medical care. In order to
accomplish this, four hospitals were selected from the Kollam Corporation (City)
area.
2.3.2 Selection of Hospitals
The selection of hospitals was such as to ensure the representation of both the public
and private sectors as well as the primary and secondary sectors. Keeping this in
mind, all the hospitals in the corporation area was stratified into big (more than 200
beds) and small (less than 30 beds) hospitals based on the number of beds available
with respect to the sector to which each belong (public and private sectors). This
information was collected from the Kollam corporation office. From this group, one
hospital each from the public and private sectors was randomly selected from both
categories of big and small hospitals. Thus, four hospitals in total, two from the public
and two from the private sector were selected. Under the public sector hospitals was
one rendering primary care that is a CHC and another, a district hospital rendering
secondary level care. Within the private sector, Sivani hospital- a small hospital
rendering primary level care and Immanuel hospital, which renders secondary level
care was selected (these names of the hospitals will be used in all future descriptions).
The details of each hospital and their infrastructure facilities will be dealt with in
detail at the end of this chapter, when the hospital setting, as the context to examine
culture of fever care is examined.
2.3.3 Selection of Patients
Those patients coming to the outpatient department for the first time with symptoms
of fever viz. headache, raised body temperature, body pain, nausea etc. and whose
fever is not due to early infections like TB, Asthma, etc. meet the criteria of.fever
patients for the study. The study has eliminated paediatric cases (less than 12 years)
for convenience. As the study confines itself only to fever patients, forty fever
patients were selected from the outpatient departments of each hospital together
56
making a final sample of 160 patients from four different hospitals. This was carried
out by dividing the total outpatient time of each hospitals into four phases and
randomly picking up a specific number of cases (probability proportionate to size)
from each phase.
Th.e number was determined based on the number2 of fever patients came to the
hospital with fever during the preceding days of the study. Here, it was found that
there was not much difference in the number of fever patients visiting in each phase
of the outpatient time. In the case of bigger hospitals where there was more than one
doctor consulting in the outpatient departments, patients consulting different doctors
got selected on their own as the selection of patients happened at the registration
counter. After selecting the hospitals and patients, a preliminary analysis of the
hospital facilities like laboratory facilities, procedures involved in taking treatment
especial1y for those patients coming with fever and those facilities outside the hospital
used by the patients of that hospital was carried out. Lastly, the patient's consent and
their contact address for follow-up was collected at the hospital premises.
2.3.4 Follow-up of Patients
In order to examine the provisioning aspect offever care from the patient perspective,
those patients identified and selected at the hospitals were followed back to their
respective homes and a detailed study on their understanding and perceptions about
health, illness, cure and care were collected using survey method. A detailed
structured interview of those patients at the household level was carried out which
covered areas on how people respond to fever at the time of ill health, viz. their
health-seeking behaviour, the difficulties faced as well as their understanding with
respect to its cause, possible cure and treatment facilities available. This helps in
understanding the difference in the burden of fevers among different social groups as
well as the difference in the nature of care rendered. In short this kind of information
of the fever patients from four different hospitals will help in understanding the
general features of the fever patients in the community and how far the medical care
2
This is because the number of fever patients coming for treatment varied considerably with respect to
the hospital. Those patients coming to the district hospital satisfying the study criteria per day was
around 80 to 100 whereas that coming to the Immanuel hospital were five to ten patients per day. The
same in the case ofCHC was around 40-50, which at Sivani hospital the number was 15- 25 patients.
57
rendered in health institutions served the felt need of the people and was therefore
capable of ensuring public health.
The Third aspect of the study viz. culture offever care, was based on the study of
hospital as a microcosm where each hospital in itself is treated as the unit of study and
hospital as a whole will be the focus with special reference to fever care. This is
despite the fact that regarding fever care there are diverse factors that can influence
the hospital functioning depending on the sector (public or private) as well as the level
to which each hospital belongs. However, it is obvious that there can be commonalties
also among these hospitals in tenns of the procedures involved and the nature of
outcome, precisely their medical function (medical practice). This is not only because
the evolution of hospital as a care-giving institution has a common lineage but also
because the system of medicine practised in all these hospitals is the allopathic
system, which is premised on a common philosophy of biomedicine. These diversities
and commonalties can be revealed only through the procedures involved in fever care,
which has been the concern of the researcher. This calls for a detailed ethnography of
the hospital, which covers the procedures (events), the actors and artefacts involved
and the dynamic interaction of all these together constituting medical work. The major
tool used in this was passive participant observation. This method can be traced to
Spradley ( 1980: 58-60) who argues that participant observation as a method itself can
be of different kinds depending on the degree of participation (passive, moderate,
active, complete) in the social situation. He elaborates that passive participation is a
situation· where the researcher finds an observation post, from where he finds and
records what is going on, taking the role of a bystander or spectator.
Fourth aspect is about the doctors and patients who are the major actors in the process
will be given additional focus. The interaction between physicians and patients was
observed and recorded and their conversation was treated as a text and was subjected
to narrative analysis (Czamiawska 2004). Here the process of clinical decisionmaking as well as the response of the patient was examined within the context and
also its influence on the outcome of fever care. A detailed description on the nature
·and characteristics of narrative analysis and the basic presumptions and its utility in
doctor-patient interaction will be dealt in Chapter 6.
58
2.3.5 Tools of Data Collection
The present study undertaken in the above-mentioned way required a range of tools
for collecting data. The First and foremost was the secondary literature that offered
a range of approaches within public health and the sociology of health and illness that
was reviewed in the earlier chapter. Additionally, literature on the history of Western
medicine in general and fevers in particular, was an important secondary source in
understanding the evolution of Western medicine in the West, India and more
importantly in the state of Kerala. The notion about fevers among the government
officials and the discussions that took place as part of the establishment of fever
clinics were traced based on government documents, minutes of government-level
meetings held among different groups and other relevant reports of the four study
hospitals. This was supplemented by semi-structured interviews of personnel at
different levels ranging from policy makers, to those who implement control
programmes, those responsible for data consolidation at different levels, paramedical
staff of various institutions and the common public at different levels. Newspaper
reports facilitated the understanding of various discourses on fever prevalent in the
society among different sections as well as the official declaration of professional
bodies of the medical fraternity on the epidemic together with the role of media per se
in the whole event. Schedule (Appendix I) was the major tool through which the
provisioning of fever care was addressed where patients' access and utilisation of the
seryices and their perception of fever at various instances, its perceived cause,
treatment, its cure and their socio-economic, political, cultural and ecological context
were covered. Supplementing this were in-depth interviews of a few patients on
specific issues and also with the doctors on their day-to-day work, government-level
interventions to control the epidemic and other relevant issues (Appendix II). The
major tool to understand the culture of fever care was participant observation
where the procedures involved in fever care in the four hospitals mentioned before
were observed closely and the events recorded (ethnography of the clinic). In addition
to it, several interviews (mostly informal) as part of clarifications from the doctors,
patients and other actors involved in the events were made. Moreover, the doctorpatient interaction during clinical encounter for a considerable number of cases was
recorded on the spot giving due consideration to the context of interactions. This was
later used as a text for analysing doctor-patient interactions as a narrative.
59
2.3.6 Limitations of the Study
As mentioned earlier, the study confine only to those patients that reach hospitals,
especially Allopathic hospitals, which leaves aside a small proportion of cases that
may not even reach the hospitals as well as those who seek treatment in other systems
of medicine. Besides, as the study confine only to fevers alone some of the results
cannot be generalised to other diseases as the nature and characteristics of the diseases
as well as the medical intervention are different for different diseases.
While operationalising the study, a few cases from each hospital selected were later
cancelled that resulted in the reduction of the cases from 160 to 151 patients. This was
because of the inability to follow-up some of the patients, the information collected
from some was later found incomplete and a few patients fail to follow the study
criteria that became obvious only in the latter phase of the study.
2.4 Sample Characteristics and the Setting
2.4.1 Area of the Study and Sample Characteristics
The study was restricted only to Kollam district, one of the southern districts of the
State due to time and cost constraints. The district is located geographically with
Pathanamthitta and Alappuzha districts covering the Northern boundary with Arabian
sea on the West and sharing the boundaries of the adjacent state of Tamil Nadu on the
Eastern side. Thiruvananthapuram district in which the Capital City of Kerala is
located is on the Southern part of Kollam (Map 1).
Kollam district. was selected, as there was greater familiarity with the health
institutions as well as the geographical area that becomes important to get sanction as
well as to follow-up patients. The district has five blocks distributed in a total land
area of 2,491 Sq. km. The population of Kollam district is 25,84,120 as per 200 I
census and constitutes about 8.1 percent of the population of the State. The district has
a population density of 1037 persons per sq. km., which is very high compared to 819
for the state. The population of the district living in urban areas is 18 percent
compared to 25.97 percent in the state. The sex ratio of the district is 1070 females per
1000 males, which for the state is 1058. Scheduled Castes (12.70 percent) and
Scheduled Tribes (0.16 percent) constitute 12.86 percent of the population of the
district and this is slightly higher than the state average of 11.02. The literacy rate
60
(population age 7+ years) of the district is 91.5 percent, with 94.6 percent for males
and 88.6 percent for females, which is higher than the respective rates for the state
(Census 2001 ). The recent District Level Household Survey (DLHS) report
published by the International Institute for Population Sciences (liPS) along with the
Government of India whose major focus was on Reproductive and Child Health
(RCH) situation in the country, covers data on the demographic and socioeconomic
characteristics at the district level. This report for the Kollam district will be used as
the population characteristics of the whole district within which the sample
characteristics of fever patients studied will be situated. As per the DLHS report the
district is having a birth rate of 15.7 with a death rate of 4. 7 and an Infant Mortality
Rate (IMR) of8:53.
The district is divided into five taluks in which Kollam corporation belongs to the
Kollam taluk. As mentioned earlier, although the hospitals selected for the study was
located within the corporation area, the patients who came to the four hospitals spread
around Karunagapally, Kottarakkara and Kollam taluks (Map II). This resulted in a
wide coverage of patients from various social groups within the district that ensured
maximum variance. Kollam corporation covers an area of 57.34 sq. km. with a
population of 3,61 ,441 persons with a density of 6310 persons per sq. km. (Kollam
Corporation 2000). The birth rate reported for the corporation area is 16.45 with a
death rate of 4.75 and Infant Mortality Rate (IMR) of7.1 (ibid.).
As the study confines only to Allopathic hospitals, their availability within the
corporation area was explored. It was found that within the public sector there were
four hospitals at the secondary level and four at the primary level were facilities for
treating in-patients are available. In addition there are four dispensaries of which three
are Employment State Insurance (ESI) dispensaries where there are no facilities for
in-patient care (ibid.). As mentioned earlier, two hospitals from the former two groups
in which in-patient care is rendered was randomly selected for the study. In the
private sector there are around eight hospitals rendering secondary care and more than
20 hospitals within the primary sector ranging from maternity homes, nursing homes
and small clinics. From both these groups one hospital each was selected as
mentioned earlier. The location of the hospitals selected for the study is also shown in
Map III.
61
1: MAP OF KERALA SHOWING KOLLAM DISTRICT
N
Source : www.mapsofindia.com/maps/kerala.htm
II: MAP OF KOLLAM SHOWING KOLLAM CORPORATION
D
D
D
D
D
r,;;,rur.~g:a.pp'a!ly TiliU~
Kur.nifti"';~Jr T::.I•Jk
l<oll~r,-, T:t~luk
Kortarakkltra TaiiJk
P:~th~r.:e.pt;r:r.m T:;,luk
Thiruuao•otQogqrom
Dilftrk:1
Source : www.kollam.nic.in/map.html
62
Ill: MAP OF KOLLAM CORPORATION SHOWING SELECTED HOSPITALS
N
4
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~;~~r"*l,llkrtg:X,l '"~~~10
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EB HOSPITAL
I<OllAM CORPORATION MAP
Source : Kollam Corporation (2002-07): Vikasenarekha
63
2.4.2 Demographic Characteristics of the Patients (Sample).
The patients' age and sex distribution, religion and caste to which they belong and
their occupation together constitute the demographic profile.
Table 2.5: Age and Sex characteristics.
Gender of the patient
Total
Age Category
Female
Male
12-18
12(18.2)
21 (24.7)
33 (21.9)
19-21
21 (13.9)
8 (12.1)
13 (15.3)
22-30
21 (31.8)
21 (24.7)
42 (27.8)
31-40
27(17.9)
10(15.2)
17 (20.0)
41-50
7 (8.2)
14 (9.3)
7 (10.6)
51+
8(12.1)
6 (7.1)
14 (9.3)
Total
66 (100.0) 85 (100.0) 151 (100.0)
Source: Pnmary Survey, 2005.
Note: parentheses denote percentages.
As per Table 2.4, it is clear that more patients are in the age group 22-30 years and
among males', similar proportion of patients are from the 12-18 year age group.
Except in the 12-18 age group, the proportion of males and females is similar. In
short, there is a skewing of sample towards the younger age group. This could be
probably due to the selection criteria of fevers, where only patients with complaints
of raised body temperature, who had fever and/or weakness and who did not have a
past history of any other chronic diseases were selected. In a state like Kerala where
the morbidity is very high compared to other states, the chances of chronic diseases
like diabetes and hypertension among people aged thirty and above are much greater
(Panicker and Soman 1984, Kannan et al. 1991, Kunjhikannan and Aravindan 2000).
These results in cases with.fever alone being mostly reported among the younger age
!:,'Toups (less than thirty). Additionally, as per the DLHS report, 25 percent and 15
percent of the total population belong to the 0-14 age group and 10-19 age group
respectively, indicating the greater proportion of younger age group as a population
characteristic of the district itself (www.rchindia.org/rep/kerala/kollam/chep l.pdf
2006).
2.4.3 Religion and Caste characteristics
From Table 2.6, it is obvious that Hindus are the majority (67.6 percent) and
Christians and Muslims comprising 19.25 percent and 13.15 percent of the population
respectively. This dominance of the Hindu religion and especially the OBC
community is itself a reflection of the inhabitants in the districts as revealed in the
64
DLHS survey that recorded 72 percent Hindus, 15.1 percent Christians and 12.8
percent Muslims (ibid.).
Religion
of the
patient
Table 2.6: Religion and Caste distribution of the patients.
Caste of the patient
Total
General
SC/ST
OBC/OEC
Rural
Urban
Urban
Rural
Urban
Rural
Urban
Rural
50
26
12
51
16
8
18
21
(32.0)
[69.6]
Hindu
(35.3)
[81.8]
4
7
5
14
Christian
(44.4)
[18.2]
(33.3)
[30.4]
(55.6)
[14.7]
(66.7)
[26.9]
8
12
Muslim
0 (0)
0 (0)
(100.0)
[23.5]
(100.0)
[23.1]
22
23
Total
Total
(Caste)
(32.4)
(27.7)
[100.0] [1 00.0]
45
(29.8)
(41.2)
[61.8]
(52.0)
[50.0]
(23.5)
[1 00.0]
(16.0)
[1 00.0]
(100.0)
[75.0]
(100.0)
[60.2]
9
21
0 (0)
0 (0)
(100.0)
[13.2]
(100.0)
[25.3]
8
12
0 (0)
0 (0)
(100.0)
[11.8]
(100.0)
[14.5]
Total
(Religion)
101
[67.6]
30
[19.25]
20
[13.15]
34
52
12
8
68
83
151
(50.0)
[100.0]
(62.7)
[100.0]
(17.6)
[1 00.0]
(9.6)
[100.0]
(100.0)
[1 00.0]
(100.0)
(100.0]
[1 00.0]
86
20
151
(56.95)
(13.25)
(100)
Source: Pnmary Survey, 2005.
Note: ( ) denotes row percentage and [] denotes column percentage
The caste distribution among the patients studied also shows that around 56.35
percent were from the OBC/OEC category with 50 percent in the rural areas and 62.7
percent in urban areas. The caste distribution among the district population based on
the DLHS also showed similar trends that is 52.7 percent of OBCs, with 47.7 percent
in rural and 64.9 percent in urban areas (ibid.). In the study population, SC/ST
community together constituted 13 percent with rural and urban distribution being
17.6 and 9.6 percent respectively. This, for the whole district was 14.8 percent with
17.9 percent and 7.3 percent for rural and urban areas respectively (ibid.). In the study
sample, those belonging to the general community are 32.4 percent and 27.7 percent
in rural and urban areas. The same proportion for the whole district was 32.5 percent
for the whole district distributed into 34.5 percent and 27.8 percent in rural and urban
areas (ibid.). The extent of similarity in the religion and caste composition between
the sample offever patients and the district level population indicates that the sample
is a better representation of the district population.
2.4.4 Occupation pattern of the patients
The notion about Fever is that it can affect anyone irrespective of their occupation. On
examining the occupation pattern, it can be seen that majority were students and next
were the daily-wage labourers with unskilled labourers being the major group. The
65
dominance of the student community can be due to two reasons. It can be a reflection
of the predominance of younger ages in the sample and also a characteristic of the
district population.
Ta bl e 2..
7 0 ccupa t'1on ofth epat'1ent an d Reg1on ofth e h ouse ho ld
Region of the HH
urban
Rural
18 [21.7]
23 [33.8]
Student
16 [19.3]
Daily wage labourer (unskilled)
20 [29.4]
Daily wage labourer (skilled)
9 [10.8]
6 [8.8]
Informal sector/office jobs
19 [22.9]
2 [2.9]
1 [1.2]
Service/Professionals/ Business
Small trade/ Commission agents/ Agriculturist
3 [4.4]
4 [4.8]
Unemployed
14 [20.6]
16 [19.3]
68 [1 00.0] 83 [100.0]
Total
Source: Pnmary Survey, 2005.
Note: parentheses denote column percentage.
Occupation of the patient
Total
41 [27.2]
36 [23.8]
15 [9.9]
21 [13.9]
1 [0.7]
7 [4.6]
30 [19.9]
151 [100.0]
On examining the occupational pattern, it was found that the daily-wage labourers get
exposed to extreme climatic conditions and other susceptible environment conducive
to contract fevers as part of their work and that this can result in greater susceptibility.
The rural-urban distribution clearly shows the type of work people are engaged in,
where daily-wage labourers (unskilled) are mostly from the rural background whereas
informal/office jobs and service professionals are from urban areas.
Thus, the demographic characteristics of the patient in the backdrop of the districtlevel demographic characteristics reveals that there is a major representation of the
younger age group [(12-18) and (22-30)] in the sample. The religious and caste
distribution of the sample appears to be in tune with the district-level characteristics,
indicative of the representative character of the sample to that of the district
population. The occupation pattern poses a possible linkage of daily-wage labourers'
wOFking condition and their susceptibility to fevers. After examining the patientcharacteristics, an attempt will be made to examine the household characteristics of
those patients selected for the study. This will enhance an understanding of the
standard of living of the persons under study and the socio-economic and cultural
context to which they belong.
2.4.5 Household Characteristics
In order to understand the socio-economic and cultural context of the patients, their
occupation pattern, the occupations of the household members as well as the number
of members employed will be examined. Besides, the educational status of the
household members, the total household income and the nature of association each
66
household is engaged with will be examined. The debt situation, if any, for the
households and purposes of taking loans will give a picture of the economic security
of the households. In the following section, each of the above details will be dealt
with.
2.4.6 Occupation pattern of the household members
It is obvious that occupation not only determines income but also the social status.
The various occupation in which people are engaged were broadly classified into
unemployed, daily wage labourer (unskilled), daily wage labourer (skilled), small
trade/ commission agents/agriculturists, informal sector/office jobs and service sector/
professionals/business. Only members aged eighteen and above were considered with
the assumption that child labour is least in Kerala since the school attendance is very
high. As the pattern shows diverse nature, scaling was used in such a way that
according to the hierarchy of jobs and the social mobility each job assures, values (v)
from one to five were given to the above jobs in ascending order with zero given for
the unemployed [Table 2.8 (a)].
Table 2.8 (a): Household Member's Occupation and their Corresponding Values.
Household members' Occupation
Unemployed
Dailv waae unskilled
Daily waqe skilled
Small trade/ commission aaents/ aariculturists
Informal sector/ office iobs
Services/ professional/ business
Values
(v)
0
1
2
3
4
5
Then for each household based on the number of members (n) employed in each job,
their corresponding values were added together so that finally values ranging from
one to fifteen were attributed for each household. Later, these values were further
grouped into categories of poor, not so poor, moderate, moderately better and betteroff households by attributing values one to three, four to six, seven to nine, ten to
twelve and thirteen and above respectively [Table 2.8 (b)].
Table 2.8 (b): Occupation Category of Households based on the Number and Nature of
th e 0 ccupa f 1on of th e House ho ld M em bers
Occupation
New value of the hh based on the number of
members (n) engaged in each occupation (v)
category
(scaling) [n x v)
1-3
Poor
Not-so-poor
Moderate
Moderately better
Better-off
4-6
7-9
10-12
13-15
67
This remains the occupation category for each household, an indicator of its social
status and mobility. The proportion of households belonging to each occupational
category is shown in Table 2.9. There were also ten patients who were staying away
from their home-towns (migrants) and staying alone in urban areas as part of their
jobs whose household details were not available and are hence denoted as Migrant
Employee (ME) in the subsequent tables.
2.4. 7 Per-capita annual income of the households
Another aspect that was examined at the household level was the per-capita annual
income. This was calculated by summing up all sources of income per year for each
household to calculate the annual income. Then per-capita annual income for each
household was calculated by dividing the annual income with the family size. The
per-capita annual income was then categorised into five categories, viz. less than
rupees 8,000, rupees 8,000 to 12,000, rupees 12,000 to 24,000, rupees 24,000 to
36,000 and rupees 36,000 and above. The occupation category and the per-capita
annual income category was cross-tabulated to identify those households with lower
income and poor occupation status as well as with higher income and better
occupational status and other combinations (Table 2.9).
annual income of the households.
hh members (in
Total
Source:
ary Survey, 2005.
Note: Parentheses denote percentage of the total households,
*ME denote migrant employees those who migrated from their home town to the study area
as part of their job whose household details were not available.
2.4.8 Socio-Economic Status (SES) Categorisation based on Occupation and Percapita Income
The above table (Table 2.9) shows the occupation status and per-capita annual
income of the households. The distribution reveals the relationship between the two
variables. It is clear that around one quarter (24.5) of the total households belongs to
the poor occupational status group whose per-capita annual income is less than rupees
68
12,000. In other words, these are the households that are more deprived (Lower Class)
in the whole sample population denoted in Table 2.9 with horizontal grid lines.
On the other extreme are those households with per-capita annual income above
rupees 12,000 and belonging
~o
moderately better and better-c{f occupation category
together constituting 7.9 percent of the total households. Besides, also included in this
category are those households ( 1.4 percent) with moderate occupation status
households with per-capita annual income of rupees 24,000 and above. The above
two categories together (9.3 percent) constitute the better-off (Upper Class) category
in the sample households. This is denoted in the Table 2.9 with vertical grid lines.
The middle class among the total households include those with per-capita annual
income falling between rupees 8,000 and 24,000 and also belonging to the not-so-
poor and moderate occupational category. These constitute 34.5 percent of the total
households. Additionally, those with per-capita annual income between 12,000 and
24,000 rupees but belonging to the poor occupation category (9.3 percent) are also
included in this group. In addition to these, those with per-capita income less than
12,000 rupees but belonging to moderately-better occupation category constituting
1.4 percent is also included in this group. This is based on the assumption that despite
the fact that the per-capita income is less, the better occupational status gives these
households better mobility and social capital ih the society thereby ensuring better
access to services. Thus, the above three categories together form the category of
Middle Class constituting 45.2 percent of the total sample households. This is denoted
in Table 2.9 with up-diagonal grid.
Of those remaining, there are 10 households constituting 6.6 percent of the total
households whose per-capita annual income is less than 8, 000 and belonging to the
not-so-poor and moderate occupation status that forms the Lower Middle Class
category denoted by blank cells in Table 2.9. Further, there are 12 households (7.9)
whose per-capita annual income is above 24,000 indicating better economic stability
but belonging to the poor and not-so-poor occupational status therefore classified as
Upper Middle Class category denoted in the Table 2.9 with dark trellis.
69
Thus the Socio-Economic Status (SES) distribution of the sample population selected
for the study based on the occupational status and per-capita annual income of the
household is as shown in the table below (Table 2.1 0). As mentioned earlier, the ten
households indicated as ME are those patients whose household details were not
available as they were all staying alone inthe study area, far away from their hometowns as part of their job. It has to be noted that these household members who
migrated from their home-town are all working in informal sector/office jobs
indicating the possibility of their belonging to middle class and above with a
possibility of them being inclined towards the better-off status.
T abl e 2 10 SES 0 f th e st udJy house hold s
SES ofHH
No. of HH Percentage
Lower Class
37
24.5
10
Lower Middle Class
6.6
Middle Class
68
45
Upper Middle class
12
7.9
Upper Class
14
9.3
ME*
10
6.6
151
100
Total
Source: Pnmary Survey, 2005.
*ME denote Migrant employees.
The above socioeconomic characteristics of households show some similarity with the
pattern of the DLHS, which used Standard of Life Index (SLI) to indicate social class.
The standard of life index was based on the sources of drinking water, lighting,
cooking fuel as well as the type of house, household possessions and type of toilet
facility. As per the DLHS, the standard of life index was categorized into low,
medium and high with 26 percent, 43 percent and 32 percent households respectively
belonging to each group (www .rchindia.org/rep/kerala/kollam/chep 1. pdf 2006).
Besides, another survey conducted by the Kollam corporation to identify the
households belonging to the Below Poverty-Line (BPL) category based on social
indicators 3 also showed that around 15,000 (20 percent) households in the corporation
area belong to the Below Poverty-Line (BPL) category (Kollam Corporation 2007).
Therefore, it appears that the socioeconomic status of the present study sample is in
tune with the low and medium category of the DLHS RCH survey. It is worth
mentioning that the latter survey confines itself only to the Corporation area,
predominantly urban-centric, where the sample population that covers both rural and
3
Social indicators like type of house, drinking water availability, toilet facility, occupation pattern of
the household, Scheduled Caste/Tribe households, presence of illiterate members, families that cannot
have two square meals, those having less than five cents of land and so on were the criteria used for the
survey.
70
urban will obviously have more households belonging to the lower socioeconomic
class, as is the case.
2.4.9 Education of the Household Members
Education, one of the important social indicators in social research will be examined
3;t the household level. It is used widely to understand the socioeconomic
characteristic of the household. Kerala, known for its literacy rate, gives education
greater value and primary education has been a priority for all the governments. Thus
it is expected that the class-factor have lesser influence on basic (till high school)
education. The reasons were that free education at the primary level was introduced
before the state fonnation in the early 201h century and then free primary education
and later secondary education was provided by the government during the 1950s and
60s respectively (Ratcliffe 1978, Franke and Chasin 1991). In the present study,
education is considered as a factor that can influence decision-making in the
treatment-seeking behaviour of the people during illness. In this study, based on the
education status of the household members, households were categorised into five
categories: those with no high school educated members, at least one member having
high school, higher secondary, professional/graduate, more than two professionally
qualified {Table 2.11 ). These categories are based on the assumption that at least one
member's education within the family can influence the decision-making at the time
of illness.
The education status when analysed with respect to SES revealed the uniqueness of
the Kerala scenario. The data (Table 2.11) reveals that while moving from the lower
to upper classes, there is also a simultaneous movement towards households with
better educational status. This is clear from the lower SES category households, where
their members' education constrained up to high school level summing up to 86.5
percent of the total lower SES brroup. The same for lower-middle and middle SES
being was only around 50.0 and 61.8 percent respectively, which for upper-middle
and upper SES was around 33.3 and 14.3 percent respectively. Similarly, taking the
case of at least one professionally qualified/graduates, it is obvious that the upper and
upper-middle SES constitute 71.4 and 58.4 percent of their total group. These for the
middle, lower-middle and lower SES was 17.6, 30.0 and around 3 percent
respectively.
71
Table 2.11: Educational status and SES.
Socioeconomic category of households (SES)
Education qualification
Upper
Lower
of the household
Middle
Upper
ME
Lower
middle
middle
members
class
class
class
class
class
Total
Not even a single high
school
5
(13.5)
2
(20.0)
11
(16.2)
1
(8.3)
0 (0)
0 (0)
19
(12.6)
at least one high
school
at least one higher
secondary
27
(73.0)
3
(30.0)
31
(45.6)
3
(25.0)
2
(14.3)
0 (0)
66
(43.7)
4
(10.8)
2
(20.0)
14
(20.6)
1
(8.3)
2
( 14.3)
0 (0)
23
( 15.2)
at least one
professional/ graduate
1
(2.7)
2
(20.0)
10
(14.7)
2
(16. 7)
3
(21.4)
0 (0)
18
(11.9)
Two or more
professionally qualified
0 (0)
1
( 10.0)
2
(2.9)
5
(41.7)
7
(50.0)
0 (0)
15
(9.9)
ME*
0 (0)
0 (0)
0 (0)
0 (0)
0 (0)
10
(100.0)
10
(6.6)
37
10
68
(100.0) (100.0) (100.0)
Source: Pnmary Survey, 2005.
Note: Parentheses denote column percentage.
*ME denote Migrant Employees.
Total
12
(100.0)
14
10
151
(100.0) (100.0) (100.0)
There are also certain households that lie outside the above pattern, which is clear
from the 28 percent of the upper SES households who get constrained by their
members' education up to higher secondary level. Besides, it is interesting to see that
among the lower middle and middle SES, 20 and 14.7 percent ensured that at least
one member of their households are graduates. Moreover, of the total sample
population, it has to be noted that it is those households with at least one member
having high school education that was the maximum (43.7 percent). These patterns
that lie outside the normally expected pattern reassert the earlier argument that
education status of household members cannot necessarily be based on their
socioeconomic condition, especially in Kerala where almost every family educates
their children up till the middle school level (ibid.). To examine the factors affecting
the educational status of the members of the households, a detailed analysis on the
factors influencing education is beyond the scope of this study.
2.4.10 Household possessions and SES
In order to validate the SES categorisation, household possessions were examined.
These include land ownership, availability of telephone, Television, newspaper and
72
vehicle ownership. The table above shows the household possession of the sample
population (Table 2.12).
Table 2.12: Household possessions among various Socio-Economic Class.
Land owned
(in cents)
<5
5-15
15-30
30+
ME
Total
Socioeconomic category of households (SES)
Total
Upper
Lower
Lower
Middle
Upper
ME*
middle
middle
class
class
class
0 (0)
31 (45.6)
2 (16.7)
2 (14.3)
62 (41.1)
24 (64.9)
3 (30.0)
0 (0)
3 (25.0)
11 (29.7)
55 (36.4)
28 (41.2)
7 (50.0)
6 (60.0)
0 (0)
1 (2.7)
4 (33.3)
3 (21.4)
15 (9.9)
7 (1 0.3)
0 (0)
3 (25.0)
1 (2. 7)
1 (10.0)
2 (2.9)
2 (14.3)
9 (6.0)
0 (0)
0 (0)
0 (0)
0 (0)
10 (100.0)
10 (6.6)
0 (0)
37 (100.0) 10 (100.0) 68 (1 00.0) 12 (100.0) 14 (100.0) 10 (100.0) 151 (100.0)
Households having telephone
Yes
No
ME
6 (16.2)
31 (83.8)
Total
2 (20.0)
8 (80.0)
21 (30.9)
47 (69.1)
10 (83.3)
2(16.7)
12 (85.7)
2 (14.3)
37 (1 00.0) 10 (100.0) 68 (100.0)
12 (100.0)
14 (100.0)
Households having Television
Yes
No
ME
18 (48.6)
19(51.4)
Total
37 (100.0)
6 (60.0)
4 (40.0)
45 (66.2)
23 (33.8)
10 (83.3)
2 (16.7)
14 (100.0)
10 (100.0) 68 (100.0)
12 (100.0)
14 (100.0)
News paper availed households
Yes
No
ME
11 (91.7)
1 (8.3)
11 (78.6)
3 (21.4)
37 (100.0) 10 (100.0) 68 (100.0) 12 (100.0)
Total
Source: Pnmary survey, 2005.
Note: Parentheses denote column percentage.
14 (100.0)
4 (10.8)
33 (89.2)
2 (20.0)
8 (80.0)
23 (33.8)
45 (66.2)
Total
51 (33.8)
90 (59.6)
10 (100.0)
10 (6.6)
10 (100.0) 151 (100.0)
Total
93 (61.6)
48 (31.8)
10 (100.0)
10 (6.6)
10 (100.0) 151 (100.0)
Total
51 (33.8)
90 (59.6)
10 (100.0)
10 (6.Q)
10 (100.0) 151 (100.!))
From the table on land ownership, it can be noted that a large majority (65 percent) of
the lower socioeconomic class possesses less than five cents4 of land- the same for
lower-middle and middle class being 30 and 46 percent respectively. It is interesting
to see that a significant percentage of households from all the SES category belong to
those possessing five to fifteen cents of land. The percentage ofhouseholds belonging
to this category for lower-middle SES (60 percent) and upper class (50 percent)
indicates the distribution pattern of land in Kerala that not necessarily always depend
on class especially in regions that have high density like Kollam district5 • The land
distribution pattern in the state is explained usually as an outcome of land reforms
despite the problems in its implementation, as well as less divide between the rural
4
Cent is the smallest unit of acre where 100 cents make one acre, a widely used measurement of land
in Kerala.
5
In Kellam district it has to be noted that the density of population is I 037 persons per sq km.
compared to the state average of 813 (200 I census).
73
and urban areas, the general features of the state (ibid.). This could be true in the
current context also.
As expected, telephone, television and newspaper possession shows an increased
percentage of households while moving from lower SES towards upper SES. It has to
be noted that television becomes a widely possessed media among all classes (62
percent), which for lower SES households is around 50 percent. It is also possible that
many of the households might have shifted from newspaper to television as their
major media of information (Table 4.8).
Table 2.13: Percentage of household possessions in two different surveys.
Household possessions
* District level household
survey (DLHS) (percentage)
Study population
(percentage)
51.2
31.5
16
10.6
4.6
1084
61.6
33.8
15.2
9.9
Television
Telephone
Bicycle
Motorcycle/ scooter
. Car/ four-wheeler
Total households covered
5.3
151
Source: Primary survey, 2005.
*Based on the evaluation study of RCH.
A comparison between the household possessions at the district level based on
District Level Households Survey (DLHS) conducted for RCH and the sample
households selected for the present study will be attempted here. Table 2.13 shows the
percentage
of
households
possessmg
Television,
Telephone,
bicycle,
motorcycle/scooter and car or any other four-wheeler. The percentage of households
with the above mentioned possessions and its comparable nature with the DLHS data
re-asserts the earlier argument that the sample under study is a true representation of
the district. An exception is found only in the case of television, which shows a tenpercent difference. The above feature was also seen in the earlier distribution of
religious and caste distribution as well as in the SES category.
2.4.11 Membership with any association
In order to understand the social mobility as well as the cultural capital of the
households, the status of membership with any association and the purpose of the
membership were examined. This is because scholars have identified membership
74
with any association as an indicator of cultural capital (Oakes and Rossi 2003). This is
true because being a member of any association will build a group-feeling and
societal concern to those in the group resulting in extending help among households at
the time of difficulties. These groups, if formed on the basis of religion or caste, can
result in a possibility of clash among different groups on communal lines if any
turmoil occur in the society. The details of the extent and purpose of the households
having membership with various associations is given in Table 2.14.
From the table, it is clear that the lower SES groups are the ones with greater
proportion (71 percent) of households having membership, which among the upper
class were only 21 percent. After examining the purpose of membership, the reasons
for above trend became very clear. For the lower class (73 percent), the lower middle
(50 percent) and the middle class (59.6 percent) the major purpose of membership is
economic support whereas for the upper middle class (50 Percent) and upper class (66
percent), it is social support rather than economic support.
Table 2.14: Extend and purpose of membership of households according to SES.
Socio-economic
Whether
status of
Member of
households
any
association
(SES)
Yes
Lower class
Lower-middle
class
No
Total
19 (51.4)
3 (8.1)
4 (1 0.8)
Yes
No
3 (50.0)
0 (0)
2 (33.3)
0 (0)
Total
3 (30.0)
2 (20.0)
Yes
Middle class
Upper-middle
class
Upper class
ME*
Purpose of the association
Economic
Social
NA
Both
benefit/ micro- group/ peer
Qroup
credit
0 (0)
19(73.1)
3(11.5)
4 (15.4)
0 (0)
0 (0)
0 (0)
11 (100.0)
Total
26 (100.0)
11 (100.0)
37 (100.0)
1 (16.7)
0 (0)
11 (29.7)
0 (0)
4(100.0)
4 (100.0)
1 (1 0.0)
4 (40.0)
10 (100.0)
0 (0)
29 (100.0)
39 (100.0)
39 (100.0)
39 (57.4)
0 (0)
68 (100.0)
6(100.0)
No
17 (58.6)
0 (0)
5(17.2)
0 (0)
7 (24.1)
0 (0)
Total
17 (25.0)
5 (7.4)
7 (1 0.3)
Yes
No
2 (33.3)
0 (0)
3 (50.0)
0 (0)
1 (16.7)
0 (0)
6(100.0)
6 (100.0)
Total
2 (16.7)
3 (25.0)
1 (33.3)
0 (0)
2 (66.7)
0 (0)
6 (50.0)
0 (0)
12 (100.0)
Yes
1 (8.3)
0 (0)
0 (0)
11(100.0)
11 (100.0)
Total
1 (7.1)
2 (14.3)
0 (0)
11 (78.6)
14 (100.0)
ME
0 (0)
0 (0)
0 (0)
10 (100.0)
10 (100.0)
Total
0 (0)
0 (0)
0 (0)
10 (100.0)
10 (100.0)
No
Source: Primary Survey, 2005.
Note: parentheses denote row percentage.
*ME denote migrant employees.
75
6(100.0)
3 (100.0)
2.4.12 Debt Situation
After examining the socio-economic status, educational status, household possessions
and lastly the membership of each household with any association, it becomes
imperative to examine the debt situation of the households. Thus, the debt situation of
each household according to their SES will be looked at. The table below shows the
extent of debt among various households (Table 2.15).
The debt situation of the study households was examined and it was found that around
50 percent of the total households were in debt during the study period. On close
examination of the extent of debt, it was clear that around 21 percent of the total
population was in debts ranging from rupees l 0,000 and 50,000 whereas around 11
percent had to repay amounts ranging between rupees 50,000 and 1,00,000. This
distribution shows that Kerala society is a debt-prone society where at any point of
time, a significant number of households have debts (Aravindan 2006: 58-62). It is
worth noting to see that the majority of the debts were taken either for constructing
house or for the marriage of daughters.
Table 2.15: Debt situation of sample households and SES.
Debt of hh.
(in hundreds)
<25
25-100
100- 500
500-1000
1000<
No Debts
Total
Socio-economic category of households (SES)
LowerUpperUpper
Lower
Middle
middle
ME
middle
class
class
class
class
class
0 (0)
2 (5.4)
0 (0)
0 (0)
0 (0)
0 (0)
4 (10.8)
5 (7.4)
1 (8.3)
1 (7 .1)
0 (0)
2 {20.0)
0 (0)
1 (7 .1)
9 (24.3)_
4 (40.0) 16 (23.5) 1 (8.3)
2 (5.4)
1 (10.0) 10 (14.7) 1 (8.3) 2 (14.3)
0 (0)
2 (5.4)
1 (10.0)
5 (7.4) 2 (16.7) 2 (14.3)
0 (0)
18 (48.6) 2 (20.0) 32(47.1) 7 (58.3) 8(57.1) 10 (100.0)
12
14
37
10
10
68
(100.0)
(100.0)
(100.0)
(100.0) (100.0) (100.0)
Total
2 (1.3)
13 (8.6)
31 (20.5)
16 (10.6)
12 (7.9)
77 (51.0)
151
(100.0)
Source: Pnmary survey, 2005.
Note: Parentheses denote column percentage.
Going further on the class-based distribution of debt situation, it was found that the
better the class, the greater would be the amount taken as debts by the househods.
This becomes evident from the fact that among the lower and lower-middle class, the
maximum number of households (24 percent and 40 percent) has taken debts in the
range of rupees 10,000 and 50,000. Next to it was those who had taken rupees 2,500
to 10,000 ( 11 percent and 20 percent). For the middle class, the majority (24.5
percent) belonged to those who had taken debt in the range of 10,000 to 50,000, with
76
those who had taken rupees 50.000 to 1,00,000 (15 percent) coming next. The picture
becomes more vivid from the fact that among the upper middle class (17 percent) and
the middle class (14 percent) households, majority of the debts was above 1,00,000
followed by 50,000 to l ,00,000 ranges. The above data reveals that the consumption
pattern of Kerala society is much greater. Additionally, the reasons for taking debt
were for construction of houses and as dowry for marriages, the two major
expenditure categories among households, leading to indebtedness.
A brief explanation of the findings based on the household characteristics will be
carried out here. Firstly, based on the occupation of the household members and based
on the per-capita annual income, the socio-economic status (SES) of the households
were determined which was found to be in tune with other surveys carried out at the
district level. Secondly, the educational status and the land ownership pattern may not
necessarily depend on SES alone as a certain proportion of household lies outside the
SES pattern. Thirdly, as in the case of SES of the study population, the household
possession also showed similar patterns to that of the district level study (DLHS)
which re-asserts the fact that the sample households is an exact representation of
the district population. This is to say that there exist an analogous relationship
between the study sample and the district. Finally, the membership of the households
with various association and their indebtedness provide a picture of indirect factors
that influence the livelihood, where the former indicates the cultural capital as well as
economic support during crisis, whereas the latter determines the extent of burden.
2.5 The Hospital Setting
The description about the four hospitals at this juncture is inevitable, as making
explicit the settings of the field is the only way by which credibility of
anthropological studies can be achieved (Sanjek 1990). A general description on the
commonalties found in all hospitals will be attempted here and a detailed description
will be proceeded later. It is well known that hospitals in general perform a range of
functions of which those related to fever care alone would be focussed as the study is
confined only to that. Broadly, the procedures involved in all these hospitals can be
divided into two, viz. administrative function and medical function. The former
comprises of the process of registration leading to the making of a case record, which
remain as the identity of those who seek care and later the cost of the care rendered
77
collected as cash or otherwise. The remaining function of medical care comprising of
diagnosis accomplished through laboratory investigations, physical examination,
history taking and so on along with prognosis and therapeutics together treated as
medical work will be the major focus here. This is because the latter procedures are
considered as the core of medical practice where not only the objectification of lay
categories happen but also that which can contribute to medical knowledge. Thus, the
study will be concerned more on the latter aspect of the process of diagnosis and
therapeutic decision-making. It has to be noted that the names given for the hospitals
and the patients in the whole thesis is purposefully changed to ensure confidentiality.
2.5."1 Secondary level Hospitals: District Hospital and the Immanuel Hospital
The basic infrastructure facilities available for the four hospitals selected will be
elaborated in order to offer a better understanding of the features of the hospital. Both
the secondary hospitals (District and Immanuel) have bed strength of more than 300,
which for the District hospital was around 500. Both have emergency facilities and
laboratory facilities capable of doing usual biochemical tests. In addition to this, a
public health laboratory is attached to the district hospital where facilities for
Immunoglobulin and Enzyme Linked Immuno Sorbent Assay (ELISA) tests for
Dengue, Leptospirosis, AIDS etc are available, which is absent in the case of the
Immanuel hospital. In both the hospitals, there are specialisation for general medicine,
paediatrics, ENT, ophthalmology, orthopaedic, skin and VD and others. The
Immanuel hospital is specially known for its specialisation in the field of
ophthalmology and cardiology. Generally, both these hospitals do not depend on
laboratories other than their own for rendering fever care. In the Immanuel hospital
there were three physicians who were consulting at the general medicine everyday,
whereas in the district hospital, it was three physicians and three house surgeons, one
from each making a pair consult the patients every day depending on their allotted
days.
2.5.2 Public Hospital at the Primary Sector: Community Health Centre
The hospitals at the primary level in the government sector was a CHC, recently
upgraded, where 16 beds were available for in-patients which is also a centre that
implements and monitors public health activities (communicable disease control,
health education, etc) in the area. As this hospital is also responsible for community
78
level control programmes for TB, Malaria, Filaria and Blindness control programmes,
the laboratory has facilities only for sputum test for TB, blood smear test for Malaria
and Filaria and urine test for diabetes and eye testing. This led to a situation where the
physicians' in this hospital are forced to ask the patients to get simple lab tests like
routine blood and urine tests (routine biochemical tests) carried out from private
laboratories located in the hospital premises. This resulted in an additional burden for
the poor patients coming to this hospital who are the majority.
2.5.3 Sivani Hospital
Sivani hospital, the private hospital at the primary level, is run in a building that was
earlier a house now modified into a hospital, which itself give a different outlook to
the whole institution. The hospital is a very old one run by a single doctor, around 60
years old, known for his fame, who started his practice during 1970s with a good
reputation of being simple and effective in medical care. The hospital is a 18-bedded
one, with facilities for basic laboratory tests, dressing room for wounds, a pharmacy
and so on. This was the only hospital among the four where the doctor regularly used
a thermometer to record temperature for patients complaining of fever. In this hospital
generally the doctor treats a range of illnesses as well as in cases of serious illness and
that which fail to show response to his treatment he usually refer it to any other
hospital in consultation with the patient. Besides, if required, he also prescribes some
patients for certain laboratory tests to be carried out from other private laboratories.
2.5.4 Commonalties and Differences in Hospital Procedures
In all the four hospitals, registration of the patient is the first step for any patient
coming to see the doctor for consultation. The registration fee was Re 11-in a CHC, Rs
21- for the district hospital whereas it was Rs 65/- for the Immanuel hospital and for
Sivani hospital it was Rs 20-30, decided by the physician depending on the nature of
illness and the patients socio-economic condition.
In Immanuel hospital, of the total fees of rupees 65, rupees 50 is the consultation fees
of the doctor for a period of one-month. This means the patient can consult the
respective doctor any number of times during this period and the remaining rupees
fifteen is the registration fees of the hospital. It is worth mentioning here that this
could be a mechanism of marketing strategy that increases dependency to medical
79
care as consultation for a month for any diseases gets covered with rupees sixty-five.
In response to the registration process, a case record is made in which the name, age,
sex, address of the patient and the name of the doctor to be consulted is also depicted.
This is carried out by the clerical staff of the hospital thereby transforming the identity
of a person to a patient. This is followed by the waiting of the patient to consult a
physician in the space allotted within the hospital outside the consulting room. This
space and the facilities provided in the waiting room (area) vary widely for public and
private hospitals.
In the public sector (District hospital and CHC), the facility for sitting is often
inadequate resulting in majority of the patients standing for long hours before
consultation. Then, according to the order of registration, patients enter the consulting
room restricted by a hospital attendant in both the hospitals. In the case of private
hospitals (Immanuel and Sivani), physicians' attendants, specific for each physician,
allow the patients to enter the consultation room one by one based on the order of
registration.
The consulting rooms of the two secondary level hospitals (District hospital and
Immanuel hospital) are set similarly. There was a table set at the centre around which
chairs and stools are arranged in such a manner that one chair and one stool form a
pair, making two consultations possible at a time whenever two physicians are
available. In primary level hospitals (CHC and Sivani hospital), the arrangement was
set for only one physician at a time. On the table of all these hospitals were kept the
instruments for checking pressure, set of papers (forms) for prescribing lab tests and a
set of sample medicines given by medical representatives. In private hospitals
additionally instruments like tongue depressants immersed in a chemical solution
were also kept on the table. A thennometer immersed in a solution was kept only in
the Sivani hospital. It has to be noted that there is a huge difference in the quality of
facilities available in the public and private hospitals, though there is not much
difference in the quantity of articles. This becomes obvious when it was found that in
the District hospital, the whole consultation and the waiting room occupies space,
wh{ch is equal to that of the consulting room of the Immanuel hospital. In the former,
the consulting room and the waiting room is divided only with a screen made of cloth
with iron frame, where for the latter, there are two different rooms with separate
80
entrances. Moreover, in both the private hospitals, there is an examination table
arranged inside the consulting room separated with a curtain, which in the public
hospitals is a stretcher kept at the corner of the room that is occasionally used for
physical examination.
The procedures for consultation is such that doctors and patients interact with each
other for the first time and based on the patients' explanation, doctors record the
details of the illness in a particular fonnat in the case record. Subsequently, the
patients are subjected to physical examination and laboratory investigations as the
case may be and thereafter asked to meet the doctor with the results of investigations. ·
Then the doctors prescribe medicines for a short period and ask the patient to come
for a follow-up if required. The extent of physical examinations carried out,
laboratory investigations prescribed and prescription patterns all depend on each case
that calls for an analysis, taking into consideration the context as it is influenced by a
range of factors. The hospital setting discussed above will help to understand the
medical care scenario prevalent in the community and therefore help to understand the
context of fever care that will be explained in detail in Chapters 4 and 5.
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