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Indian Journal of Community Medicine

Vol. 29, No. 3 (2004-07 - 2004-09)

Editorial

RCTs, Mahatma Gandhi and Public Health

On the face of it the caption of this editorial looks preposterous. But I intend to show that it is not. In fact, Gandhiji had a lot to say on matters pertaining to public health and most of it was based on his real life experiences or 'experiments' as he liked to call these. As he wrote, in his autobiography entitled "The story of my experiments with truth - It is not my purpose to attempt a real autobiography. I simply want to tell the story of my numerous experiments with truth and as my life consists of nothing but those experiments."

Though it is clear that what Gandhiji did were not randomized controlled trials (RCTs) - there were no controls or randomizationyet trials they were indeed, with profound sense of scientific rigour as far as inductive logic, expressed need of replication, an inherent element of pretest/pilot and confession of a lack of finality about conclusions derived from his experiments are concerned. On this, Gandhiji wrote, " - - but as I have all along believed that what is possible for one is possible for all - my experiments have not been conducted in the closet but in the open - " and "- - far be it from me to claim any degree of perfection for these experiments. I claim from them nothing more than does a scientist, who, though he conducts his experiments with utmost accuracy, forethought and minuteness, never claims any finality about his conclusions, but keeps an open mind regarding them - " He wrote further "- - - I am far from claiming any finality or infallibility about my conclusions - at every step I have carried out the process of acceptance and rejection and acted accordingly." and

"The experiments narrated should be regarded as illustrations in the light of which everyone may carry on his own experiments according to his own inclinations and capacity." Thus, here we see the scientific approach of Gandhiji. He does not force us to agree to the results of his experiments. Rather, he encourages us to revalidate his findings by our own experiments.

Gandhiji experimented with various aspectes of life (with non-violence, celibacy, satyagraha, dietetics and various home remedies.) His experiments on dietetics started after when he was in England." I saw that writers on vegetarianisn had examined the question very minutely. Here I came in contact with those who were regarded as pillars of vegetarianism and began my own experiments in dietetics I stopped taking sweets and condiments many such experiments taught me that the real seat of taste was not the tongue but the mind - there were many minor experiments going on along with the main one - giving up starchy food at one time, living on bread and fruit alone at another".

On unnecessary medication he wrote" - - I believe that man has little need to drug himself; 999 cases out of a thousand can be brought round by means of a well regulated diet, water and earth treatment and similar household remedies." and" He who runs to the doctor, vaidya or hakim for every little ailment and swallows all kinds of vegetable and mineral drugs - not only curtails his life, but by becoming the slave of his body instead of remaining its master, loses self control and ceases to be a man". Gandhiji was also a midwife to Kasturba. He had himself delivered his fourth son. Gandhiji also experimented extensivelv an husband-wife relationship, celibacy etc. On Brahmacharya he wrote" - The more or less successful practice of self control had been going on since 1901. But the freedom and joy that came to me after taking the vow had never been experienced before 1906" (when Gandhiji adopted celibacy at the age of 37 yrs.)

He further writes -- "Six years of experiment have showed me that the brahmachari's ideal fruit is fresh fruit and nuts. ---I have not the least doubt that milk diet makes the brahmacharya vow difficult to observe."

Thus, it is clear that Gandhiji incorporated an element of pretest and pilot before undertaking the full-scale trials ego 1901 onwards 'pilot' on self- control - and final declaration of celibacy in 1906. Similarly, his work on non-violence, civil disobedience, non-cooperation c. during his 20 years sojourn in S. Africa, can be considered as a 'pilot study' before the final onslaught through his role in India's freedom struggle after 1916. Or we can say that he replicated his successful experiments of S. Africa in India.

Regarding his choice of interventions and strategies, it is worth noticing that these were quite appropriately steeped in Indian culture (- - - and were not a borrowed 'foreign' idea imposed from outside) eg. Fasting, maun vrata, non-violence, remunication and asceticism are a part of Indian culture. Even the choice of SALT making as a symbol of civil disobedience deeply touched the masses since salt is such a basic part of our lives through its role in diet, coupled with the concept of 'namak halal / 'namak haram'. His ideas on spinning wheel and Khadi still survive in villages. Actually, he had a knack to connect with masses, which we in public health sadly lack. All his 'community based trials' were well thought of. He also appears to have modulated all his interventions on deep understanding of human psychology (which again is sadly lacking in contemporary hurriedly patched up interventions). The whole idea of civil disobedience, non-violence, non-cooperatio:ysatyagraha seem to directly address the basic human nature and psychology (of the participants as well as of the British administrators) - - - eg. On non-violence, Fischer has written:

"The British beat the Indians with batons and rifle butts. The Indians neither cringed nor complained nor retreated. That made England powerless and India invincible". This, from the pen of a westerner speaks volumes of the power of non-violence as a weapon---

On penetrating the villages in Bihar Gandhiji wrote" - These volunteers had to look after medical relief and sanitation. The women folk had to be approached through women. Medical relief was a very simple affair. Castor oil, quinine and sulpher ointment were the only drugs provided to the volunteers. - No patient was permitted to take home any medicine. - Quinine was given after an opening does of castor oil." i.e. here we see the seeds of 'directly observed therapy' much before DOTS of today. Further he writes "- -prevailing ailments were amenable to simple treatment, by no means requiring expert help .." Thus, the primary health care concept is also amply visible here.

Community participation / involvement (for sanitation) was also discussed by Gandhi ji "- - I saw that I could not it to do its own duty, as I could in claiming for its rights - - - It was too much for people to bestir themselves to keep their surroundings clean. To expect them to find money for the work was out of the question - - - . Without infinite patience it was impossible to get the people to do any work. It is the reformer who is anxious for the reform and not society, from which he should expect nothing better than opposition, abborrence and even mortal persecution ..."

On education also, Gandhiji had radical views.

"- - - the education that children naturally imbibe in a well ordered household is impossible to obtain in hostels - To impose a knowledge of alphabet on children of a tender age, before they gain general knowledge, is to deprive them - while they are fresh - of the power of assimilating instructions by word of mouth -- " and " Higher education makes us foreigners in our country" , "Education today is calculated to wean us from our traditional culture - " I would destroy all textbooks - - -"

Gandhiji did not arrange for formal education for his children,. Though his sons were not satisfied by the quantity and the extent of education provided to them, Gandhiji still said" These experiments were all inadequate since I could not devote to the children all the time I wanted to give them" Thus, the failure of this experiment was not accepted by him as a proof against his views which he still cherished. After Gandhiji had returned to India from S.Africa, when CF Andrews asked him, when would the time come for Satyagraha in India, he replied

" - - - for one year I am to do nothing - for Gokhale took from me a promise that I should travel in India for gaining experience and express no opinion on public questions until I have finished the period of probation - even after the year I will be in no hurry to speak and pronounce opinion I do not suppose these will be any occasion for satyagraha for five years or so" ( Thus, Gokhale asked Gandhiji to first understand the Indian masses by touring India through train before intervening. This shou1d be kept in mind by those public health experts who are always in a hurry shouting 'mission mode' to implement various interventions without having done the adequate groundwork - or having acquired a feel of the community.

So, are there any lessons for public health experts/ researchers in the life and works of Gandhiji. Definitely, yes. People have said about Gandhiji "He had the soul of an Eastern prophet and the spirit of a Western pioneer". This clamour for experimentation needs to be imbibed by us all. In fact, there are many more views of Gandhiji which are of immense relevance to Public Health ego his views on health and hygiene,leprosy, scavenging, self contained, self sufficient villages as models of cleanliness, self help, Swadeshi purchase requirement locally - not to buy imported) spinning wheel, self-reliance; children should work to 'repay' Ashram life' absolute personal and civil cleanliness, punctuality and physical labour (advocacy for long walks)

References:

  1. Gandhi MK. An autobiography or the story of my experiments with truth. Ahmedabad, Navjivan Publishing House, 2003.
  2. Fischer L. The life of Mahatma Gandhi. London, Harper Collins Publishers, 1997.
  3. Gandhi MK. Towards new education. Ahmedabad, Navjivan Publishing House, 1980.
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