Monday, November 30, 2015

Social obligations and professionalism

You must have experienced being assigned to do tasks and your name being put into committees without your consent. When making a program, many times we do not approach people before printing their names in the program. When organizing an event, we do not request people first before assigning them as in-charge of this or that. And when you see your name being printed and distributed, you feel ‘socially obligated’ to carry out the assignment. This is the way things work. If we ask people beforehand, they may refuse, so we first print their names.   

If you feel socially obligated and carry out the work well, chances are that you will be assigned more and more in the days and years to come. We ought to do our best whatever assignment we are given to do. But when such assignments become unlimited and uncontrolled, things can go wrong. We see people hopping from one meeting to the other. One can be so occupied with attending meetings, organizing programs and events, involving in this committee and that union works, and end up having no time for family or doing one’s primary work/vocation. If we are not focused and are involved in too many activities, chances are that the quality of our work will go down. 

To excel in one’s profession, there is a need for detachment. We need detachment from external disturbances so that we can focus and concentrate on our professions. But the way our society is, it is so hard to detach ourselves from the many social obligations. If some people do not show up for some social events, people start to talk behind their back. So, many times, we have to say ‘Yes’ when we want to say ‘No’.

We end up having people who are generalists but without any specialty. We produce mediocre and average people who are not excellent at anything. For example, a person may be a middle ranked government employee. He is also a wedding steward, treasurer of a youth organization, assistant general secretary of village welfare union, in-charge of accommodation for a church mission conference, and so on besides the many unofficial family responsibilities. We produce a lot of average ‘Jacks’ who know a little bit of this and that, and are in shortage of ‘Masters’, people who are really good at their trade and are known by it.   

We also end up trying to fit square pegs in round holes. I sometimes am assigned duties for which I have neither the training nor the experience. For instance, not all have the gift of public speaking. But if someone is rich enough, we make them speakers. Our chief guest speeches are generally awful. We overwhelm talented people to do all sorts of unrelated and irrelevant things and do not allow them to develop in a focused area.  

A friend in a city said that he was sometimes threatened by his tribesmen for not being active in the tribe’s activities. They asked him silly questions like, ‘who will carry your dead body home?’ But he was not deterred. His focus in his calling made him to excel and he has become the person to go to, when it comes to his line of work. The courage to say ‘No’ when we want to say ‘No’ is not easy because of the many social implications. But refusal to toe the line of the society has become a necessity if we want to excel at anything. Our society should also learn to allow the space for people who need detachment, be it a government office worker, thinker, entrepreneur, artist, writer, or a farmer so that he/she should engage his undivided attention to excel in his/her trade. It is for the good of everyone that we have quality people over quantity.

Thursday, November 26, 2015

Current Nagaland healthcare budget status

 This newspaper carried a news article last month saying that Nagaland State figures among the highest per capita health expenditure by the government. That was surprising when one considers the amount of resources which are actually available for service delivery. Therefore, it is important to do some analysis so that we can arrive at some sense of the prevailing reality of the health budget.

For the financial year 2015-16, there was slashing of the union health budget by 15%. The Lancet reported that as many as 15 national health programs were put under the National Health Mission umbrella during the year without allocation of even a rupee. The main reason for the cut was said be the rising fiscal deficit. Another justification given was that the States were allocated more shares in central taxes (from 32% to 42%). It was expected that the State will use its discretion and invest this money on healthcare. The ball for increasing health budget was thrown into the State’s court.

Slashing of central budget allocation on health (mainly through National Health Mission) has not been accompanied by commensurate increase in the State budget on health. The State’s budget allocation to health sector as a percentage of its total expenditure has reduced from 3.8% in 2014-15 to 2.9% in 2015-16. This is not a healthy trend that Health which is an important driving force for economic development should be ignored. India’s public health sector has always struggled for attention from policy makers and has performed poorly, except for a few States like Kerala and Tamil Nadu. Still that doesn’t say much about the high per capita spending on health which was in the news. The disaggregation of the State health budget will show under which heads the budget is being spent.

Although it can be true that per capita expenditure on health is high in Nagaland, the amount available for service delivery may be disproportionately low. This is because the disaggregation of the State budget shows that 87.5% of the State budget was spent on salaries in 2013-14 and in 2015-16, it is set to rise to a staggering 94.68%, which amounts to Rs. 321.75 crores. The nominal increase (in absolute value) in budget allocation over the years goes to salary increment. Thus, as far as the State’s budget is concerned, most of the expenditure goes to salary and very few is left for infrastructure development, materials and supplies, trainings, etc. The health service delivery in Nagaland is heavily dependent on central schemes and projects like National Health Mission and its flagship programs, and National AIDS Control Program. Cutting of health budget at the Centre, if not accompanied by increased State budget allocation to Health sector will make the health services delivery extremely difficult to improve or sustain.

World Diabetes Day, 2015

November 14 is World Diabetes Day and this year, the focus is on ‘healthy eating as a key factor in the fight against diabetes and a cornerstone of global health and sustainable development’. Healthy eating helps to prevent type 2 diabetes mellitus, the more common form of diabetes. In those who already have diabetes, healthy eating is important for keeping blood sugar under control and prevention of complications.

Diabetes is a serious disease condition where the body cannot produce insulin or cannot use the insulin which is produced. Insulin is a hormone which regulates blood sugar. So, when this ‘regulator’ doesn’t work as it should, the excess sugar accumulated in the body over time leads to serious damage of the body, especially the blood vessels and nerves. One of the main factors which lead to this condition is unhealthy diet, besides lack of physical activity, tobacco use, etc. By ‘unhealthy diet’ here we mainly think of the calorie-rich, fatty, fast foods which are cheaply available and are consumed by both the rich and the poor, more in the urban areas but rapidly increasing in rural areas too. 

The global prevalence of diabetes is said to be 9% among adults 18 years and above. The number is set to rise. India already has the highest number of diabetics in the world and has earned the dubious title of being the diabetes capital of the world. India Diabetes Study is an ongoing ICMR project which aims to study the burden of diabetes in India. In the second phase which covers the North East, the prevalence of diabetes in Assam, Arunachal and Mizoram range from 5.2% to 5.7%. Nagaland is next in line for survey.  Earlier data shows that the prevalence maybe high in Nagaland. In 2012-13, 11.6% of adults (18 years and above) were found to have high blood sugar, suspected for diabetes (random test which was not confirmatory diagnosis). Screening of healthy office goers in Kohima in September 2015 showed that 29% of the 348 people screened were found to be suspected for diabetes. It was also found that 24% were overweight and 22% were obese among these office goers. Hospital records and routine department reports show that diabetes is on the rapid rise.

A  healthy  diet  containing  leafy  vegetables,  fresh  fruit,  whole  grains,  lean  meat, unsweetened yogurt and nuts can help reduce a person’s risk of type 2 diabetes and reduce complications in people with diabetes. We should encourage children to develop healthy eating habits and provide healthy food choices which are home-prepared. The opening of fast food chains and the easy availability of restaurant and processed food stuffs, being pushed by advertisements makes it extremely difficult in deciding to follow a healthy dietary lifestyle. Price rise of healthy food items like fresh fruits and organic vegetables, and the flooding of our markets with cheap processed foods also determine the type of diet that people consume. Therefore the world diabetes day campaign goes beyond the individual choice and appeals to stakeholders so that there is improved access to healthy food by the population.

A healthy diet is found to be costlier than an unhealthy one by about 1.5 USD. In a year, that translates to about 550 USD per person. Therefore, to adopt healthy eating habits, the affordability of the healthy food stuffs and the purchasing power of the people have to be improved. Encouraging local food production and businesses, regulation of food prices, food quality and advertisement, generating employment, and increasing income in general will all go a long way in facilitating healthy eating habits.

Cancer burden in Nagaland

The shock value of a cancer diagnosis is decreasing with improvement in technology and treatment modalities. The diagnosis of a cancer case was similar to receiving a ‘death warrant’ which incited fear and despair in the patient and relatives. Bollywood movies have used it to induce similar feelings in the viewers. We have come a long way from that. Many cancers have become potentially curable. But the good news of progress made in cancer detection and treatment is tempered by the bad news that the burden of cancer is on the rise. It is estimated that cancers in India may increase five-fold by 2025. The economic burden of cancer is also growing. The average cost of treatment of cancer in a government set-up is about half the annual income of an average Indian. And cancer centres with adequate facilities are far from adequate. So, cancer care is out of reach for millions of Indians.  

North East India is a hot bed of cancer incidence. As per the Population Based Cancer Registry (PBCR) 3 years report (2009 to 2011) of the ICMR, the highest incidence of many cancers are located in the North East Region. Aizawl district of Mizoram recorded highest incidence at 250.6 new cancer cases per 1,00,000 population every year. For Nagaland, the incidence rate is 98.15 per 1,00,000 population (males:126.1, females: 70.2). The incidence rates given here are age-adjusted incidence rates which give a clearer picture of the cancer situation because cancer incidence is influenced by the age of the population. The top 3 cancers in Nagaland among men are Nasopharynx, Stomach, and Oesophagus, and among females they are Cervix, Stomach, and Breast. Incidence rate of Cancer Nasopharynx among males in Nagaland is very high (21 per lakh population) and is only next to the highest incidence in the world which is in China (26.9). 

The four major risk factors of non-communicable diseases viz tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol are the major risk factors of cancer. The above data from ICMR correlates well with the Global Adult Tobacco Survey (GATS) 2009-10. The top 5 States in India in tobacco use are from the North East. Tobacco is by far the single most important risk factor of cancer which is responsible for 22% of cancer deaths. Mizoram (67%) has the highest percentage of tobacco use followed by Nagaland (57%).

WHO notes a ‘westernization’ trend in the progress of cancers, that as countries undergo societal and economic changes, the pattern of cancer also changes to become more like the scenario in the western countries. Cancers resulting from infections tend to decrease while cancers resulting from lifestyle and dietary habits, reproductive and hormonal factors increase. However, in the North East States, traditional and cultural food habits/lifestyle like smoked meat, salted fish, fermented food items, indoor smoke pollution, etc also still contribute heavily to the incidence of cancer. 

Wide spectrum of interventions, ranging from promotion of healthy lifestyle, prevention of risk behaviors, and early detection, to onco-surgery, chemotherapy, radiotherapy and palliative medicine are required in handling cancer. Political commitment and action are also vital in cancer control. Dr. Mohandas Mallath,  lead author of a series of reports on the cancer burden in India published in The Lancet said, ‘The need for political commitment and action is at the heart of the solution to India's growing cancer burden…The extent to which death and illness from cancer will actually increase in the next 20 years will depend a lot on the investments made in future decades in tobacco control, healthcare delivery, cancer research, clinical trials, and increasing the public awareness as to how we can all help to reduce the risk of cancer by eliminating risky behaviors such as smoking, vaccinating those at risk of cancer causing infections and following a healthy diet and lifestyle’.

Acting holy, holy

The paradox of the voice against corruption in Nagaland is that those who speak out against corruption are also the practitioners of corruption. If people shout against corruption from the rooftops, those who practice corruption would willingly join the chorus on the rooftops. A corrupt person can deliver a wonderful sermon on the evils of corruption if given a chance on a Sunday morning. The funny thing is that he/she won’t shy away from preaching if given a chance. Hypocrisy has become a normal behavior and we don’t seem to have any problem changing colors as the situation demands.

Tax collectors and prostitutes had a better chance of entering heaven than the holy, holy Pharisees. Those who are corrupt but at least do not act holy are at a better chance than many of us who act holy, holy. Those who drink alcohol, chew tobacco, beat their wives, play cards, and roam late in the evenings doing all sorts of evil deeds during hornbill festival may be closer to finding a solution to corruption than those who are hyperactive in various church committees, participating in holy land tours, donating huge amounts for various mission projects, and doing their best on church sales days. The intended point to be made here is that both can be corrupt, but at least one group does not try to act holy.

Maybe some people try to buy their way into heaven. They believe service and money will somehow make God a bit more lenient on them. They perhaps try to bargain and do business with God. If I give this much percentage to the poor and needy or to missionary work, it will somehow justify the remaining percentage that I keep for myself. Perhaps fasting and prayers are used to try to twist the arms of God, and think God will purify our wealth through those spiritual exercises. Perhaps some people think that wealth is equal to blessings and therefore more wealth means more blessings. Perhaps ‘greed’ is justified as ‘blessing’. When the Bible says, ‘ask and it shall be given’, maybe we think that we can have it all. 

Why should a criminal be nearer to heaven than the man who acts religious? The Pharisees had more access to the knowledge of the kingdom of God. To know Jesus, they had quite a lot of background information, so to say. Although not in the true spirit, they have been performing the commands of God in spiritual worship. So, although not inside the kingdom of heaven yet, why should it be said to them that the criminals, prostitutes, and tax collectors are entering heaven before them? It is for the fact that criminals are nearer to repentance than the people acting holy, holy. For the criminal, there is condemnation from everywhere. Families condemn them, society condemns them, and their own conscience condemns them. Left and right, front and back, they face rejections and their crime is always before their own eyes. But not so for the hypocrites who think they are righteous and the hypocritical society which honors them.

We all know that our society is laden with corruption. But how many of us think that ‘I’ and ‘we’ are the source of the problem? We tend to think that someone else, or something else is the culprit and point fingers. But how about questioning if I/we may be also a contributor of the problem of corruption? We can ask ourselves, ‘If everyone were like me, will the society be any better than the way things are?’ If we look into the mirror and scrutinize ourselves, grill through our own motives and behavior, and find that we are not doing very well; we are nearer to finding a solution, not just for our own, but for our society. But if we continue our pharisaical or chameleon-like behavior, playacting high spiritual piety along with unbridled greed; we still have a long, long way to go. 

On Donations

Donation is not the same as taxation but it can drain you as much if you are in Nagaland. There are too many contributions, pledge cards and donation drives for this jubilee celebration and that church building project, this sports meet and that get-together. In the month of August 2015, there were some guys who came for donation in aid of a charitable centre. They handed me a calendar and asked me to donate whatever amount I wished to pay. I thought that these guys were early. But when I looked closely at the number, it was not calendar of 2016 but of the current year. Who sells calendar in August when the year is crossed the halfway mark? They left with their ears full without receiving a paisa.

I can’t understand that some unions and associations would sell calendars where they have written, ‘in aid of fund raise’. What kind of aid is it to raise fund for the sake of fund raise? If it is for fund raise, it is not an aid. I remember some years back when a family member had to sell calendars to raise fund for an association. The consequence of this is that she had to buy back calendars of other unions and associations since she had sold to them. It doesn’t matter if you have 10 calendars at home; you have to buy from the ones who bought yours. You don’t need too many calendars because they all tell the same date (unless it is a government calendar with those beautiful days marked in red). So, you can end up exchanging something which both the buyer and the seller don’t need and both are drained by it. 

A kilogram of pork is sold at a very high price in the name of donation. A cheap memento is sold at exorbitant price to raise fund. Villagers go hunting to kill wild animals and birds to gift officers for getting special favour or money. Many endangered species of our animal kingdom land up on the platters of our leaders in the Capital. One may say that donation drives are not done by force. But our social structure and functioning is such that most of us feel obligated to respond positively to such demands. There is always an element of overt or covert compulsion. A relative of mine was asked to sponsor a big religious event (we don’t know how to plan small programs). I would have refused but in his condition, it became difficult to turn them down.     
Some unions/associations and churches don’t even try to raise their own fund. They simply make a list of politicians, officers, and contractors and head to their offices and homes. In many instances, the donations are fixed! By category of income or position, the amounts are all fixed beforehand. But given that there are multiple demand groups and the ones donating are also not similar, it becomes a problem. For example, an honest government officer just by his salary may be struggling to support his family. And if a public leader donates a huge sum of money, one also may suspect where the money is coming from. Multiple demands for donation therefore have the danger of driving corruption.     
Donations are not altogether bad. Through the strong social fabric that we are knitted in, people have come forward to help the community and one another in times of need. Through freewill contribution and donation drives, we are able to fund mission projects and reach out beyond our borders. We need to learn to build our case and be able to persuade people to warm up to our ideas so that people can donate freely and willingly. Philanthropic spirit should increase and we do have people who are willing to contribute and be partner to a worthy cause. But just as we have got it wrong with selling of calendars ‘in aid of fund raise’, many of our donation drives are becoming increasingly unjustifiable.