INTRODUCTION:

You must keep a strict eye on your health; let everything else be subordinated to that.

Swami Vivekananda.

As defined in the constitution of the world health organisation (WHO)” health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”

The health of a society is intimately related to its value system, it’s philosophical and cultural traditions and its social economic and political organisation.

Since each of these aspects has a deep influence on health and since health in its turn, also influences all these aspects, it is not possible to raise the health status of a people unless such efforts are integrated with the wider effort to bring about the overall cultural, social, economic and political transformation of the society as a whole. Such coordinated and simultaneous efforts to improve health status and change the entire social order generally yield better results because they are interdependent and mutually supportive. This is the entire more so if one is planning for the health of the people and not merely for health services. In fact, good health good societies go together. The district of south 24 parganas has been facing the problems of disparity in the distribution of the health service which create regional imbalance in development of the sundarban south 24 parganas District. In fact, west Bengal in general and the Sundarban south 24 parganas, in particular, suffer from the long jam of disadvantage in term of both quality and quantity of health care infrastructure. Due to lack of government and private health service facilities, poor remote villagers compelled to go the quake doctors. Provisioning of health service to the community is therefore crucial in developing economy. In particular, policy makers must ensure equitable access to the health care system, by providing cost effective health services and facilities to the poor especially in rural areas.

Figure 1 Availability of medical facilities in south 24 parganas

STUDY AERA AND GENERAL FEATURES:

Figure 2. Map of the Sundarbans

The present district of South 24 Parganas came into existence on 1st of March, 1986. It then comprised of two sub divisions- Alipore and Diamond Harbour and of 30 blocks. Presently there are five sub divisions (Alipore, Baruipur, Canning, Diamond Harbour and Kakdwip), 29 blocks and 7 Municipalities South 24 Parganas is, indeed, a complex district, stretching from the metropolitan Kolkata to the remote riverside villages up to the mouth of Bay of Bengal, Apart from its staggering size and population, the district administration has to contend with problems to of metropolitan living in the urban area& mdashsuch as high population density and overloaded civic infrastructure &mdashand in complete contrast, in the rural area the lack of transport and communication facilities and weak delivery systems. 84% of the population lives in the rural areas, where development is taken care of by the panchayat bodies. The remaining 16% population is looked after by the Kolkata Municipal Corporation and seven municipalities. The scheduled caste comprises 39% of the total population and B.P.L. families constitute 37.21% of the population.

The Sundarbans, the largest mangrove forests on earth, are spread over thirteen of the twenty-nine development blocks in the district. Due to its peculiar geographical location and the dictates of geography, the means of transport and communication in this region are not well developed, with all the attendant consequences. Lack of irrigation has meant mono-cropped agriculture. Breaches in earthen embankments and cyclonic storms mean loss of life and destruction of crops and property on a regular basis.

OJECTIVE AND METHODOLOGY:

The general objective of the study is set to provide an evidence base for the policy makers in support of the formulation of a Master Health Plan customized for Sundarbans.

1. To provide a detailed understanding of the prevailing disease profile including; minor illness, hospitalization, situation of maternal and child health, non-communicable diseases and mental health.

2. To understand the health seeking behaviour of the inhabitants and to identity the barriers to access health care services encompassing social, physical and economic aspects.

3. To study the heath system responsiveness of the higher tier government health facilities across the blocks, especially in terms of preparedness;

4. To understand the role of rural medical practitioners in the entire gamete of healthcare delivery and utilization; and

5. To provide advocacy to the policy makers along with a budget for the implementation of the health plan.

METHODOLOGY:

This study is based on primary as well as secondary data. The secondary data has been collected from several publications of various years, statistical hand book of the districts, Bureau of Applied Economics & Statistics, Government of West Bengal, Economic Review, Human Resource Development Report, District Census Book etc. To strengthen and develop the Secondary Data the primary data has been collected mainly from the dwellers of almost the villages of the Sundarban south 24 parganas district with structured questionnaires. Generally the inquiring was performed during my two months visit to the Sundarban region of South 24-Parganas district.

THE PEOPLE OF THE SUNDARBANS AND THE THEIR HEALTH CONDITION:

This chapter presents a brief overview of the demand side issues related to the health system of the Sundarbans. More specifically, it focuses on three interrelated components of the system: (1) socio-economic environment, (2) health status, and (3) health seeking behaviour.

SOCIO-ECONOMIC ENVIORMENT:

Although geography plays a very important role in defining the socio-economic environment of the Sundarbans, it is important to note the variations in geographical challenges across the blocks. People, who live in the ‘remote’ Sundarbans - the blocks adjacent to the forest area or the Bay of Bengal – face much harder problems compared to those who live in the ‘peripheries’ (and closer to Kolkata). Typically in the delta region rain-fed, single-crop agriculture and fishing are the two main sources of livelihood. Nearly 95 per cent of the population primarily depend on agriculture. About 50 per cent of agriculturists are landless labourers. For the blocks bordering the reserve forest, during agricultural lean season, substantial part of the population depends on forest and river resources. During April - May, some people enter the forests with permits for collection of honey and bee-wax which is partly purchased back by Forest Department. Besides, some households entirely and some partially engage in catching fish and crab in the rivers and creeks. Both of these operations are perceived to involve considerable danger due to tigers in the forest and crocodiles in the rivers. It can be perceived that these people directly depend on the forest as a last resort for their livelihood and are almost always very poor with nil or unsustainable landholding.

HEALTH STATUS:

The most concerning feature is the low reliance of the public on the sundarban south 24 parganas District healthcare systems. In the absence of a survey of District Hospitals, it is not possible to identify all the causes of this phenomenon. We would recommend that the Health Department undertake a regular stock taking to identify the nature of deficiencies in different units – where functional machines are lacking, where beds are in short supply, where posts are lying vacant, where attendance of doctors are irregular – and take steps to remedy the shortcomings. This would rejuvenate the District health infrastructure and build trust in the system among the public.

MORTALITY:

The estimated crude death rate in the sundarbans is 7.6% which is higher than that of rural West Bengal. As expected, the rate is much higher among people above 60 years of age(62 per 1000)followed by the under children (9.3 per 1000).Above 40%of this deaths could be attributed to symptoms related to whole range of digestive problems almost all those who died 85%recived some short of medical attention before death although only 30% of them were hospitalized before death implying that the underlying cause of death might have remained largely unknown.

VECTOR BORNE DISEASES:

Inhabitants of backward villages of South 24 Parganas, especially of the riverside blocks of the Sundarban area, suffer from malnutrition and various diseases of which vector borne diseases and water & food borne diseases are of prime importance. Due to their poor socio economic status, low level of education, inadequate sanitation, unsafe water supply and poor housing facilities, people of this district suffer from vector borne disease like Kala-azar. Malaria is also on the rise, while the incidence of Filarial remains another area of concern.

Another vector borne disease that recurs with regular frequency in South 24 Parganas is Malaria. In 2006, 951 cases were reported, mainly from Canning Sub Division (Canning-I, Canning-II, Gosaba, Basanti), Diamond Harbour Sub Division (Diamond Harbour-II, Magrahat-I, Kulpi, MathurapurII) and Namkhana blocks. One fatality each was also reported from Canning-I, Sagar block and Kulpi block in 2006. Attempts to combat such diseases fall under the National Vector Borne Disease Control Programme (NVBDCP). Regular spraying programmes are carried out in Kala-azar and Malaria prone areas. National Anti Malaria Programme (NAMP) is another attempt to eradicate Malaria. Attempts are made to sensitize residents about the benefits of using mosquito nets. Radical treatment for those who have caught either of the two diseases has usually managed to avert fatalities. Advocacy workshops are also conducted on a regular basis in the ten affected blocks for Kala-azar (Figure-4).

WATER AND AIR BORNE DISEASES:

Among water borne diseases the incidence of Diarrhoea in the District is alarmingly high, with 1.27 lakh cases being treated in 2006. The number of fatalities that year was 32; this amounts to 6.53% of the total diarrhoea cases occurring in West Bengal and 4.93% of total death due to diarrhoea occurring in the state. A review of diarrhoeal diseases for the last 5 years show that the incidence of the disease reported to hospitals has decreased gradually regarding number of cases. However, the number of cases reported to indoor due to Diarrhoea has increased substantially over the last three years (31862 in 2006 compared to 21206 in 2005 and 9134 in 2004). The incidence of death has also increased compared to last year.

The blocks of Canning I/II, Mandirbazar, Budge Budge-I as well as Magrahat I are diarrhoea prone blocks reporting high incidence through the year, peaking substantially during the rainy season from June to October. Poor water supply and environmental sanitation are major causes of the high incidence of diarrhoea in these above-mentioned blocks. Since diarrhoeal infections spread through the use of contaminated water, the District Health Action Plan 2007-08 is emphasizing on focused intervention that combines the provision of safe drinking water to rural residents with improved sanitation and mass education on the effective use of oral rehydration therapy.

Water borne and air borne diseases, there are other concerns where environment plays a major role. For example, according to the survey, about 60 persons per 1000 population were estimated to be affected by accidents or injuries in a year due to poisoning, animal bites, or any other reasons. The number underestimates the true incidence since the survey was carried out in winter when the incidence of snake bites is less common. The threat of animal bites (tiger or crocodiles) is grave especially among those who frequent the swamps and waterways of the Sundarbans for fishing and collecting forest products.

Enteric fever is another water-borne disease posing a severe health hazard problem. A total of 2546 cases were reported in 2006 compared to 7152 cases reported in 2005 – that is a decrease of 35.6%. The maximum number of cases of this water borne disease has been reported from the riverine blocks of Gosaba, Canning I and II, Mandirbazar, Namkhana, Sagar and some blocks of Alipore Sub Division like Budge Budge-I & Bishnupur-I. The lone death due to Enteric Fever has occurred in Canning-I block during 2006. The main causes for the endemicity of the disease is contaminated food and water, particularly in remote riverine blocks and slums in Budge Budge-I block.

Low education levels in blocks like Magrahat-I and II, Mathurapur-I and II and high rates of migration from other neighbouring areas pose major problems in controlling the spread of enteric fever.

Viral Hepatitis is another major disease in the district. The total number of cases reported of Viral Hepatitis in 2006 was 314 (with no death) compared to 531 reported cases in 2005, with 1 death. There has been a decrease of 59.1% in the reported incidence of the disease. The majority of the cases have been reported from Matherdighi, Namkhana, Sarisa, and Amtola Rural Hospitals and Vidyasagar State General Hospital. There has been one outbreak in Matherdighi between September to December last year due to flood and cyclone in the first week of October. The main reasons behind the endimicity of disease in Canning-II block are poor quality of food and water supply and low level of education (Figure-5).

Arsenicosis is another major health issue in South 24 Parganas. The geo climatic environment of the sundarbans and people health is evidenced by prevalence of a few environmental health problems. For example, skin related problems, such as itching in hands and legs were found to be very common across all blocks. The impact of arsenic poisoning was quite visible in the blocks were groundwater is heavily contaminated with arsenic. A total of thirty-six cases with one death in have been reported till June 2006. In earlier years thirty-eight and ninety nine cases were reported in 2005 and 2004 respectively, without any deaths. In 2004 the highest number of cases had been reported from Baruipur (58 cases) followed by Bhangar-I (38 cases). In Baruipur 14 GPs and in Bhangar-I and II 34 GPs had been affected by this problem. All the Arsenic affected nine blocks have completed advocacy training and BCC for NGOs and panchayat personnel, AWW and CHGs and are running Arsenic clinics.

CHRONIC AND NON – COMMUNICABLE AILMENTS:

Ailments related to communicable and acute health conditions, however, present an incomplete health scenario of the Sundarbans. To complete the picture one needs to look at the non-communicable and chronic ailments which usually remain neglected by the policy makers despite significant poverty dimensions of these ailments. The present study, which investigated the prevalence of six major chronic ailments (Arthritic pains, Cardio-vascular problems, asthma, diabetes, skin related problems, and vision problems) among 834 persons of more than 40 years old (413 male and 421 female members), came up with some serious concerns in this regard.

Table 3. Percent of people aged 40 years and more with high risk for three selected chronic diseases, the Sundarbans 2009

People’s vulnerability to chronic and non-communicable diseases is no less severe in the Sundarbans in comparison to other parts of the state. In other words, the Sundarbans now face the dual burden of communicable and non-communicable diseases like urban West Bengal. For example, coronary heart diseases, which are usually linked to urban lifestyles, are estimated to affect 6 percent of population aged 40 years or more.

This means that about 240,000 people in the Sundarbans are highly vulnerable to coronary heart diseases. Similarly, about 2.4 percent of adult population indicated high risk of arthritis while 42.4 percent were already diagnosed which was higher than the corresponding state average (35.3%). Bronchial Asthma chronically affects the elderly population at 8 percent prevalence rate. The inequalities in the spread of these ailments are also worth noting. For all of these ailments, the poor and the women (except coronary heart diseases for biological reasons) were more likely to be affected. For example, the prevalence of bronchial asthma among poorer section was about six times higher than among the better-offs. The data also suggest that, contrary to the conventional beliefs, the prevalence of coronary heart diseases risk would be considerable high among the poorer people.

Analysis of risk factor for cardiovascular disease shows that throughout the sundarbans, the prevalence of tobacco and alcohol use is higher among the poor, which increases their risk of cardiovascular, disease. In the future, these higher risks may lead to higher rates of cardiovascular (Figure-6) disease, and cancer, liver disease, and injuries among the poor relative to the non poor.

Figure 6. Prevalence of tobacco and Alcohol use among > 40 years in the sundarbans

There are several other chronic problems which are often overlooked possibly due to their low perceived severity. Ailments related to vision are one example which loads the Sundarbans’ health with significant burden. The extent of vision difficulties is evident from the results that the prevalence of farsightedness in the Sundarbans was much higher for all age-groups above 45 years than that in West Bengal (Figure-7). The pattern was similar in myopic cases except in the 70-79 age group10 where the prevalence in West Bengal (42%) was higher than the Sundarbans (33%). The prevalence of diagnosed cataract among the elderly male population (60 years and above) was also found higher in the Sundarbans (20%) in comparison to the state (17%).

Figure 7. Percent of adult population who have severe vision problems (short distance) in the Sundarbans and West Bengal

MENTAL HEALTH:

Mental health problems threaten to be one of the most critical public health issues in the Sundarbans. Prevalence of mental health problems is high and seeking attention from public health leaders. Deliberate self-harm cases have increased in the last few years. Significant presence of psycho-social stressors may have triggered the spread of these problems. The most visible indicator of psychiatric disorders is the prevalence of deliberate self-harm (DSH), or grossly the ‘attempted suicide’ cases, which, despite its severe limitation in capturing the total mental disease burden, projects the severity of the problem to a large extent. Deliberate Self-Harm is however an extreme manifestation of mental ill-health and affects only a few. Lying underneath Deliberate Self-Harm remains a complex set of psycho-social stressors which are closely linked to the gripping livelihood challenges in the region and may trigger a pandemic of mental health problems. Several studies have indicated high presence of such stressors in the Sundarbans. Besides poverty and economic stress, these include marital conflicts, alcoholism and resultant torture, extra-marital affairs, and growing insecurity against nature’s challenges. The most common diseases, as found in one study, are major depressive disorders, followed by Somatoform pain disorder, posttraumatic (animal attack related) stress disorder, and adjustment disorder Chronic neglect of these problems, women’s low status, and easy availability of pesticides in an agro-based region may explain why an increasing proportion of affected persons – mostly women - have been seeking solace in self destruction. In villages adjacent to forest, where communities depend on fishing and collecting forest products, people are especially unsecured against animal attacks which often make them adopt a fatalistic coping strategy such as superstitious responses and dependence on local god / goddess (such as, Banbibi) and traditional faith healers (such as, Gunin) which probably act as protective shield against mental disorders. However, these do not cancel out the combined effect of the above-mentioned stressors, which have left the mental health of the people of this region in a highly vulnerable state.

Figure 8. Estimated percentage of stunted children (< 5 years) in the Sundarbans, West Bengal (NFHS – 3) and India (NFHS – 3)

MATERNAL AND CHILD HEALTH:

Maternal and child health is crucial in health care related issues and provisioning of health care facilities. The reason is that both are crucial in determining the health and productivity of future generations. Maternal and child health services in rural areas of the country are delivered mainly by government-run Primary Health Centres and Sub-centres. The health status of the children’s of the sundarbans is in a sorry state. This is partly reflected in the nutritional status of the children under the age of 5 years. Based on the weight, age, and height data of 632 children, the anthropometric indicators reflected that about half of the children in the sundarbans(52%)were stunted or in other words, were suffering from chronic malnutrition(Figure-8). The proportion of chronically malnourished children is higher than both state (45%) and national average (48%) implying that in the sundarbans a comparatively higher proportion of the children are growing up with serious nutritional retardation.

Why are so many children stunted or chronically malnourished? Stunting, this is usually regarded as the best indicator of children’s long run health status and well-being is a biological adaption to inadequate food, frequent episodes of disease, or both during the first few years of life. In other words, a high stunting level among the children in the sundarbans mirrors chronic poverty and food insecurity among a large part of the population.

Chronic malnutrition usually has a spiralling effect on the vulnerability of the children to respiratory and gastro-intestinal ailments.(Figure-9) Re-established this phenomenon in the present context and reveals a disproportionately higher burden of these ailments in the sundarbans. The inequality in the spread of the common childhood ailments across age, location and socio-economic status is also worth noting. For example, a child in the age group 12-13 months was more likely to be affected by Acute Respiratory Infection (40%) compared to his /her younger counterpart (28%for 0—6 months).Similarly, girls were more vulnerable to diarrhea (8.2%) than the boys (6%).The same held good for the children from the relatively poorer section who had suffered all of these aliments at a disproportionately higher rate. Children from the south sundarbans were also found in worse condition compared to their north counterpart.

Figure 9. Percentage of children under 5 years suffered from common ailments in the last 2 weeks

Figure 10 Number of meternity and child welfare centers

MATERNAL HEALTH:

Increasing institutional delivery is one of the top priorities to the policy makers of the state although National Family Health Service estimates show only a little progress in this case (in the state) – the rate of institutional delivery just increased by 3% points in the last ten years, from 40.1% in 1995-96 to 43.1 percent in 2005-06. The more recent evidences from the survey however recorded a better progress of the state in this direction 49.2% overall, 43.2% in rural areas.

In the sundarban rural areas, a female paramedical worker, called an auxiliary nurse midwife (ANM), is posted at a Sub-centre to provide basic maternal health, child health, and family welfare services to women and children either in their homes or in the health clinic. Her work is overseen by the lady health visitor posted at the Public Health Centre. With regard to safe motherhood, the ANM is responsible for registering pregnant women, motivating them to obtain antenatal and postnatal care, assessing their health throughout pregnancy and in the postpartum period, and referring women with high-risk pregnancies. The ANM is assisted by a male health worker whose duties includes motivating men to participate in the family welfare programme and educating men about reproductive tract and sexually transmitted infections. The ANM and LHV also assist the medical officer at the PHC where health services including antenatal and postnatal care are provided.

The evidences from the Sundarbans, however, paint a gloomy picture. Out of sample 569 mothers, who delivered at least one child in the last five years, only 29 % delivered their last child at public or private institutions. This is comparable to the rural areas of the most backward district in west Bengal such as Uttar Dinajpur 23.6% or Malda 26.4% but much lower than North 24 parganas 43.4% the two district the sundarbans are part of. Regarding institutional deliveries, there are two other crucial points to be noted first-most these deliveries (about 71%of all institutional deliveries) were conducted at government hospitals. Second the incidence of caesarean section was exorbitantly high among the users of private hospitals-55% of all private users had delivered caesarean baby compared to 14%of public users.

This may be due to either or both of the following possibilities- a) the complicated pregnancy cases self-selected private hospital pushing up the rate of caesarean section to a naturally high level, and b) there might be high degree of supplier-induced demand for caesarean section due to excessive greed of the private providers.

What factors are responsible for such a low rate of institutional deliveries in the sundarbans? On the demand side, poverty or economic constraint plays an important determined behind choice of place of delivery. The above evidence points out to a glaring dichotomy: while the utilization of general inpatient care was high, maternity inpatient care remained significantly low. Two plausible explanations for such discrepancy are: (1) a cheaper option home delivery is available in the latter case while non-maternity inpatient care has no alternative except accepting death or disability (2) the perceived risk or, opportunity cost of not seeking institutional care is much less in case of maternity cases. The second explanation could be reconfirmed on the ground that the most common reason elicited from the mothers who delivered at homes for not delivering at hospital was ‘not necessary’ implying that birth delivery is still treated by a large section as a ‘normal’ affair for which hospitalization is not required.

Most of those who could break the above two barriers are trapped by another important constraint – the geographical adversities – which are embedded within the economic and social barriers and are often difficult to assess from quantitative data. The results show that a woman, who delivered birth at home, would have to travel 8 KM on average had she decided to deliver birth at the nearest public hospital. However, the physical distance in the Sundarbans often fails to reflect the degree of inaccessibility as travelling a short distance in some pockets may mean quite a hardship due to broken transportation linkages or unavailable water transportation when it is most required. For example, a woman living at Lahiripur in Gosaba block would be required to visit Gosaba Block Primary Health Centre (hospital at the block headquarter) if she wants to deliver birth at a hospital . The shortest route to reach the Block Primary Health Centre would require her to walk or travel by van rickshaw a distance of 9 KM, cross a river, and then again ride a van rickshaw to cross a distance of 5.5 KM. In addition to hardships of cross-transportation, the whole journey would take about 3 to 3.5 hours. If she decides to avoid break-journeys and to travel by a single mode, she would take the river route from (Lahiripur to Bali, Bali to Gosaba Block Primary Health Centre) and reach the destination after a journey of 6-7 hours. A more viable alternative, in this case, would be to take a risk of delivering birth at home, or to helplessly wait for the morning if the problem starts at night. On the supply side, an effective and strong pre-natal carte is usually considered as one of the critical pre-conditions for increasing demand for institutional maternal care. The household data, however fail to establish the link despite commendable achievement in pre-natal care. For example, almost all mothers, interviewed during the survey, registered their pregnancies with a health worker (93.5%) received at least one antenatal care (93%) had at least one TT injection (98%) and consumed iron tablets during pregnancies (75%).Yet most of them delivered at home implying that improving routing maternal care-with cultural and geographical barriers intact-is not enough to bring in safer birth delivery practices in the sundarbans.

CONCLUSION:

The health scenario of the Sundarbans offers little to celebrate. A typical resident of the Sundarbans carries an extra load of ill-health and health risks compared to others living within the same district. Poverty, coupled with sharp geo-climatic challenges, make him/her especially vulnerable to health shocks caused by environmental and life style related agents. The sundarbans islanders are doomed to struggle with both communicable and non-communicable diseases often leading to complete disorder in priorities to tackle the problems. The children are the worst sufferers most of them are chronically malnourished and, hence, perennially suffer from disproportionately higher burden of respiratory and gastro-enteric troubles. Women and poor are especially vulnerable to the chronic and acute health conditions. In brief, with 4 million people currently estimated to live in the region, this neglected population has become a major reservoir for a wide spectrum of health conditions that are not always well recognized by the existing formal health sector. People’s response to these challenges is often perplexing primarily due to complex interface of the social, economic, and geographical barriers to access health care and perceived severity of the problem. For example, utilization of inpatient care in public institutions is remarkably high implying that the perceived severity and benefits of getting a seriously ill person admitted to a hospital is higher than the perceived costs and barriers of doing so. On the contrary, the family of a pregnant woman feels constrained to take her to a hospital for delivering a birth probably because the equation between benefits and costs is reversed. The village unqualified doctors dominate the outpatient market because people think it would be too costly, or unnecessary, or hazardous to seek treatment for a minor ailment from a qualified provider. The psychiatric disorders swell with increasing suicide attempts because neither the people nor the providers consider their prevention as a serious health action. In other words, physical accessibility to a government health facility apparently becomes a prohibitive issue when people seek ambulatory or birth delivery care (due to low perceived severity and benefit) but becomes non-prohibitive when they need admission to a hospital (due to high perceived severity and benefit). The clear implication of this complex response behaviour is that adding more health facilities to the less accessible areas may not improve ‘access’ unless the social barriers are simultaneously addressed to influence the perception about severity of health needs and increased benefits of accessing these facilities. Overall, the most concerning feature is the low reliance of the public on the District healthcare system. In the absence of a survey of District Hospitals, it is not possible to identify all the causes of this phenomenon. We would recommend that the Health Department undertake a regular stock taking to identify the nature of deficiencies in different units – where functional machines are lacking, where beds are in short supply, where posts are lying vacant, where attendance of doctors are irregular – and take steps to remedy the shortcomings. This would rejuvenate the District health infrastructure and build trust in the system among the public.

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Received on 19.08.2020 Modified on 09.09.2020

Res. J. Humanities and Social Sciences. 2020; 11(4):330-340.

DOI: 10.5958/2321-5828.2020.00052.2