Wednesday, January 19, 2011

A Very Simple Life Story (Updated Version)

My name is Razuhii* and I know exactly where the sun rises. The sky turns yellow over the mountain, and then the sun appears in between the guava tree and the thatch house. Wait for minute. Now, it is in front of the house. It is time to go home.

I washed my face, filled my pots and went home. As the water in the kettle started to rumble, I have finished cleaning the rice. I replaced the kettle from the fire place with the rice pot and added some firewood. With a cup of strong tea, I went round my house, strolling leisurely as I made a list in my mind of what I'll do today. Hmmm... I'll check the water channel to the paddy field, dig some fish holes and weave a new net at the water outlet. On my way back, I must remember to collect mushrooms for dinner. I fed my chicken and prepared my meal.

After my early lunch, I packed my tiffin and whistling my favorite tunes I walked down to the paddy field which is on the bank of the Thikhapii River. In its lower course, the river is called Sidzii. Along with rice cultivation, I rear fish in the paddy field. Also I have orange, guava and banana trees in plenty. In season, I pluck them and distribute to friends and relatives. Especially the kids love them. Hungry hunters also feast on them, but I don’t mind as it is too far away from the village and I can carry only a little. Let them enjoy the fruits with wild animals and birds.

After my day's work, I got some extra time and I did some fishing in the river and took a bath. Even though I am rearing fish, the small variety that I catch in the river is tastier.

By the time I returned home, the sun was setting. I cooked dinner- fish and mushroom- and shared some with my neighbor as we chatted about our day's work. We also enjoyed together listening to the local news on radio.  I was tired and went to bed early. After all, I've to wake up early tomorrow and go down to the pool to watch the sunrise.

My name is Razuhii and I know exactly where the sun rises.

(*Many people think that my Dad is the only son of my Grandparents. But I was told that dad had a brother whose name was Razuhii. He died when he was just a small boy… The story is one in a series of short stories. The others are, ‘A Very Scary Ghost Story’, ‘A Very Romantic Love Story’, ‘A Very Killing Killer Story’, ‘A Very Slow Tortoise Story’. They can be read at )

Thursday, January 13, 2011

The Estimated Cost of Common Cold in Nagaland

‘It’s just the Cold’, we say. We know we will up and about in a week. It goes away without any medicine. Most of the times, we don’t go to see a doctor but send someone to a pharmacy to buy some Cold tablets. Some famous brands of these over-the-counter drugs are Sinarest, D-Cold, SumoCold, and NamCold. Some go for Crocin, Diclowin Plus, Diclomax, Sumo etc which are more specific for pain and fever; cough formulas like Grillinctus, Ascoril, Hatric3 are also used. The combinations and brands are numerous that no doctor can have all the names in one’s brain. If it is just Cold and fever, doctors usually don’t prescribe antibiotics but they are consumed widely and indiscriminately with/without prescriptions.

Common Cold does not catch our attention like HIV/AIDS and Cancers. However, let us do some math here which may garner some awareness for this common condition. For calculation, I went to a pharmacy and noted the price of the common brands that are used in Nagaland. There is a sales competition between the brands and to make sure that I am not endorsing any company, let me not mention the price of any particular brand. To calculate the average price of a strip of Cold tablets, I took the mean of a set of 6 brands and it came to ₹ 26. The costliest brand costs ₹ 46 while the cheapest cost ₹ 10. Three cough syrup brands cost ₹ 49, ₹ 52 and ₹ 53, so let’s take ₹ 50 as average for easy calculation. Plain Paracetamol is much cheaper, but for fever associated with pain, combination with an analgesic is usually taken. Even if not associated with pain, such combinations are commonly used, so let’s take ₹ 20 as the price of a strip of tablets for fever/pain. For Antibiotics, a brand containing Ciprofloxacin costing ₹ 64 is taken for our calculation. Many antibiotics will cost much more, for example, the commonly used Cephalosporins like Cefixime; while some are cheaper. A very commonly used multivitamin syrup costing ₹ 77 is used for this exercise.

We have all experienced Common Cold, even in the last year which just flew by-almost all of us have. Some have probably had it twice/thrice already. Let’s say, all of us experience a single episode of Cold each year (some who have more than one balancing those who have none). Nagaland has a population of 20 lakhs approximately. So, if each individual needs one strip of Cold tablets in one year, we spend Rs. ₹ 5.20 crores/year. That is about the total cost of medical reimbursements that the Nagaland government paid in 2009 for patients getting treatment outside the State. If you think I am too ambitious let me add more. Let’s say, in some people, Cold tablets alone don’t work, and appropriately or inappropriately a third of the population needs one course of antibiotics. The new expenditure would then rise to about ₹ 9.46 crores/year, which is slightly more than the total reimbursement paid by the government for patients treated both within and outside the State in 2009. Even in the US, doctors inappropriately prescribe antibiotics in a third of Cold patients and so, my taking a third for calculation did not come from nowhere. This may be too much but let us speculate that this third of Nagaland population while buying antibiotics also bought one multivitamin syrup to boost up the healing process. By now, the State’s expenditure will have raised to ₹ 14.59 crores/year on managing Common Cold. This would be about ₹ 3 crores in excess of the combined budget of the National Rural Health Mission (NRHM) for the national health programs (TB, Leprosy, Iodine Deficiency, Malaria, Blindness and Disease Surveillance) in the State.

Only a few countries have the data of Common Cold incidence rate because it is very difficult to measure and many countries may not even feel the need for it. So, a website called did some mathematical exercise to calculate the incidence/prevalence of Common Cold in other countries using the rates from US, Canada, UK and Australia, and projecting them on other countries’ population sizes. The website admits that they in no way are accurate figures as they do not take into consideration the genetic, cultural, environmental, social, racial or any differences across various countries. They are only meant for a general indication. Through Projecting the US incidence rate to the population of Nagaland, the incidence of Common Cold in Nagaland comes to 4,55,882 new cases of Common Cold per year.

So, if Nagaland were like the US and the medicines were at Indian rates, Nagas would still need ₹ 1.18 crores calculating 1 Cold tablet strip per case. Addition of antibiotic in a third of the cases comes to ₹ 2.15 crores, i.e. still more than twice what the NRHM spends on child immunization. This means even when Nagaland develops into a US-like situation, the expenditure on Common Cold is going to be huge. No wonder, Americans spent $ 3.6 billion in 2009 for Common Cold medicines. The most amusing figure about Common Cold expenditure however is a pamphlet titled ‘The Cost of Common Cold and Influenza’ in the UK during World War II. The pamphlet reads:

On an average, 2 days work are lost a year by each worker
Say there are 10 million people on vital war production
That means 20 million days lost each year
The work of 50,000 men for one year
If one third of all the men and women who lost these days were making tanks, one third bombers, and one third rifles, then in that time, they could make
3500 tanks
1,000 bombers
1,000,000 rifles
That is the cost to our war effort.

The pamphlet ends with an advice to use handkerchief while coughing or sneezing and to ‘HELP KEEP THE NATION FIGHTING FIT’. Likewise, in the Nagaland exercise if we were to count the school/office/business days lost due to Common Cold, the cost probably will more than double.

Now, using the actual reported cases in the last 12 months, we may get a glimpse of what the reality is at present. In the disease surveillance weekly reports, 77,348 cases of ‘Only Fever Less Than 1 week’ and 35,070 cases of ‘Cough Less Than 3 Weeks’ were registered in the health centers across Nagaland in 2010. The two figures records a sum of 1,12,418 cases/year. This figure is not exclusively for common cold and includes similar ailments like viral fever and respiratory tract infections. But they are allied diseases and largely of viral origin, and the only data we have for common cold. Most of these cases are prescribed not less than 2 or 3 medicines. Hardly any patient is sent away with a strip of Cold tablets. So, if each of these is prescribed a Cold tablet strip and a multivitamin syrup, that would have cost about ₹ 1.16 crores. Like former exercises if a third of the patients are also prescribed antibiotic, the new total is about ₹ 1.4 crores. This is not an over-estimate because using a third as having prescribed antibiotics is from the US experience. WHO reports that worldwide up to 60% of people with viral upper respiratory tract infection receive antibiotics inappropriately. As mentioned before, this does not take into account the economic loss due to loss of workdays or special diet and other expenses incurred in managing the condition.

The most common illnesses that we suffer from are the simpler and less fatal ones like running nose, sore throat, fever, cough, headache, loose motion, etc. But when we think of health and diseases, we think only of big diseases like Diabetes, Cancer, and HIV/AIDS. Not that I am unconcerned for these diseases, but I am an ardent advocate for the provisioning of adequate basic health services. As I used to say that good water supply is more basic than uninterrupted 3G mobile signal, a well functioning general health services to tackle the common illnesses is more important than multispecialty diabetes care hospitals or cancer research centres though we will certainly need the later two once the first is in place.

Many people may be put off by the use of too many numbers in this article but that is where the point is: the argument for the case of common ailments like Common Cold lies in the numbers. We may not be aware but in calculation, because of the sheer number of people who suffer from them, the cost can be staggering.

For BlogSpeak in Eastern Mirror newspaper