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ECONOMIC SIGNIFICANCE; "OF MALA- RIA TO AN INDUSTRIAL CONCERN: A RAILWAY. / /
By G. R. RAO, jjfjfcM. (Cal.). (La/e Malaria Medical Officer, B. B. Railzvay),
Medical Officer-in-Charge, Leper Asylum, Cuttack?
Introduction.?To the clinician and to tne
purely laboratory worker, the question of " Ec0'
nomics," is apparently of no significance. But,
to the prospective malaria expert, it is the mos
important question to be answered. For, he haS first to convince the shrewd industrialists, the pr?' prietors of large industrial concerns, who refuse to think of anything but rupees, annas and pieS that it pays to eradicate malaria and has thus
to
justify his position. To do this successfully he has to estimate first, the precise economic loss
caused by malaria, to the industrial concern which appoints him. Herein lies the importance of the
" Economic survey of the disease." That such a survey is an essential preliminary
to any preventive scheme has been stressed by Sir Ronald Ross, who, in his book
" The Prevention of Malaria"?1911, p. 252, writes:
"
What precisely is the economical loss to the
community caused by malaria? From the pre* ventive point of view, that is perhaps the most important question before us, because, obviously it governs the question of the expenditure, which may be demanded for the
'
Anti-malarial cam-
paign.'" _ . .
No apology is, therefore, needed for submitting this short note. Area of Survey.?The Lalmanirhat district of
the E. B. Railway has an unenviable reputation of being the most
"
feverish district." When the
writer was first appointed in October, 1926, as the Malaria Medical Officer to conduct preliminary survey, the opportunity was taken to collect as far as possible accurate figures?representing the incidence of malaria?amongst the staf? through- out the district. Before touching upon the
methods employed to secure these figures, it may not be out of place to describe briefly the nature of the area surveyed. The
"
District" comprises parts of the civil districts of Bogra and Rangpur from Bengal and parts of the civil districts of Goalpara and Kamrup from Assam, besides the state of Cooch Behar, the Duars, and the terais of the Jaintia and Bhutan Hills. Two important rivers course the district, the Brahmaputra and the Teesta, besides numerous small rivers and jungle streams. The
physical features of the district present several variations from absolutely flat plains to the slopes of the terais and the marshes of the jungle, with
varying incidence of malaria.
1928.] ECONOMIC SIGNIFICANCE OF MALARIA: RAO. 569
For descriptive purposes 1:he ^b^tures^nto divided according to the physica
_
t^e several sections and a brief ^scriP. together chief physical features of each sec with its malarial incidence
isrg*ven-f?uichhari is Section (1).?From Gabtali to
CPn-level Wrly flat, slightly under 1,000JM ?fT highest, 18 per
"^(2 "m Bonarpara ? Kaunia?is also practically flat, wit 1 danga>
here and there. Only one station, tsan ^ shows rather a high incidence, about ou y fe\er index.
.
Pm-batiour Section (3).-From Ka"T on a higher level
Junction (exclusive) is slightly a sl;ghtly
than the preceding sections and lower incidence. T_ .
otr, nnci Section (4).-From Teesta to Rung ^
Teesta to Lalmanirhat is also practical y *s
comparatively free from malaria. iin1-tPrs Station Lalmanirhat being Jfa big rail- station of the metre gauge and ha g ?.
em_ way colony with a population ot a ?
^ ^rQm Payees and their dependents, who various parts of Bengal with d ffereitfcally of
malarial incidence shows ma a exacerbations. throughout the year with season -1
,? Section (5).?Gitaldaha to Cooch Beha^ l e within the state of Cooch Betar and ? different degrees of malarial mcic ent stations with seasonal exacerbation .
Section (6).-Cooch paJa Bhatkhawa comes
f'- j romes within the From Raja Bhatkhawa to Jainti come
kh terais of the Jaintia Hills and Raja Bliat^ t?
Dalsingpara comes _
wit un
worst of the Bhutan Hills. This section trom the malariologist's point o
notice station Raja Bhatkhawa deserves special
^ as malignant tertian malaria ^ P
iem}c is throughout the year and a ful!?" unishment to
he rule. The staff consider it a pu ^
^ posted to Raja Bhatkhawa ^?Jme across section in which one could not ^ jnci-
several cases of blackwater te^rn* acticaiiy 90 (lence 0f malaria in this section P ^ area
per cent. Any one coming to serv { JJ sure to wire for sick leave within a month bis arrival.
.
pnWk- Section (7).?Gitaldaha (exclusive) ^ ^ere
ganj is also flat with patches of J^tion. and there with a patchy malaria _ _ , Section (8).?Golakganj to Dhubri is'
tQ sloping towards the Brahmaputra ?n ^ere js
the Gauripur State. Malarial inci
comparatively low. . ,
, cnr_ Action (9).?Golakganj (e^lus,^) traverses hhog is a gradual ascent and the 1Un d
thiek forests, mostly " Sal " Son Jungles common to the tropics. throughout
shows a fairly high malarial incidence t & the year with seasonal exacerbations.
Section (10).?Sorbhog to Rangiya and Tangla. Here the line passes through an area full of the bushy weeds of Assam fed by numerous jungle streams, and malaria exists practically throughout the year.
Section (11).?Rangiya (exclusive) to Amin-
gaon slopes towards the Brahmaputra and is
rather hilly. This area shows comparatively very little malaria.
Amingaon (Station) by virture of its being the terminal station contains a fairly large staff (about 480). Except the large borrowpits in
the vicinity of the station, there is practically no depression of land and no possible breeding grounds. The land slopes towards the river and so there is a natural drainage of the subsoil
water into the river. This station can be said to be almost free from indigenous malaria. But
the large staff coming from different districts of varying malarial incidence with varying degrees of infectivity and immunity is responsible for
a slight amount of malaria. Now it is clear that one has to deal with tracts
of different physical features with varying mala- rial incidence.
Collection of Figures.
For administrative convenience the district is divided into several units?Lalmanirhat, Kaunia, Cooch Behar, Fulchari, Raja Bhatkhawa, Sor-
bhog, Rangiya and Amingaon. Each unit is under the medical charge of a travelling sub- assistant surgeon, who is responsible for the collection of malarial statistics and for the treat- ment of cases in his unit.
Lalmanirhat and Amingaon each have a hospital in addition, with a medical officer (assistant surgeon) in charge, to deal with the station staff These medical officers are responsible for the collection of statistics for these stations only and for treatment.
The number of cases of malaria treated by the travelling sub-assistant surgeons and medical officers in their respective units, together with the number of days of certified sickness and other particulars, were submitted to the Special Malaria Medical Officer of the district, every month, on special forms. These figures form the basis of this present paper. For comparing the malarial incidence from
year to year, in addition to the figures for 1926, those for two previous years 1924 and 1925 were also collected. The figures representing the incidence of
malaria throughout the district, month by month, for the 3 years 1924, 1925, 1926 are given below in Table I. To give an idea of the proportion of malaria to all other sickness, the total number of cases of sickness from all other causes for the whole district, month by month, is also given side by side. Graph ̂
I shows the same, viz., pro- portion of malaria to sickness from all' other causes for. the district, month by month, for the
570 THE INDIAN MEDICAL GAZETTE. [Oct., 1928.
three years 1924, 1925 and 1926, more vividly than Table I.
Tabids I.
Months.
January February March
April May- June July August September October November December
1924
All cases.
355 284 236 338 344 410 403 437 364 591 563 415
Mala
ria.
195 154 151 144 210 201 230 305 243 327 386 287
1925
All cases.
542 385 354 326 437 400 380 497 359 435 417 532
Mala
ria.
223 125 187 178 195 118 229 340 356 347 .307 268
1926
All
c.'i
ses.
381 261 239 364 351 372 422 418 451 512 480 380
Malaria.
180 97
94 126 162 176 203 160 187 231 224 122
From a study of Graph I it is evident that the
proportion of malaria to all other sickness is the same in the years 1924 and 1926. The curves for malaria and for all other sickness, in both the years, run almost parallel. But the year 1925 is rather peculiar. Both the curves in the
year 1925 begin rather high and it seems that the
year 1925 began with bad luck to the railway. The curve of malaria follows more or less closely the curve of all other sickness up to July. From
July the curve of malaria begins to rise con*"
paratively higher and follows the rise of the all- other-sickness curve up to August and in Sep- tember, while the latter comes down consi-
derably the malarial curve does not come dovvn.
On the other hand it rises still higher than in
August. From August to November, the curve is more or les? maintained and the proportion 0* malaria to all other sickness during this period is obviously higher in comparison with the same period in the other two years, which means that there was comparatively more malaria in the
year 1925 during the period August?November than in the years 1924 and 1926. ,
This holds good not only for the district o*
Lalmanirhat, but also for the whole line exclud- ing, perhaps, Calcutta, as will be seen from the
report of the then Chief Medical Office^ Dr. Slaclen, who, in his
"
Report on Methods Malaria Control, on the E. B. Railway
"
page ~
observes: "
The year 1925 was a bad one * *
,
There were 120,000 cases of sickness compared with * * * 112,258 in 1924. The year 1926 has been marked by considerable efforts to lessen the
scourge of malaria in this railway, which has
been the largest single factor in causing sickness and unfitness for service."
Both from the railway administrators' as wen as the economist's point of view, the number oi
days lost on account of sickness is of greater importance than the actual number of cases ill-health. Therefore, the number of days ?*
certified sickness from malaria alone, is given below in Table II. For the sake of comparison the number of days of certified sickness froin all other causes is also given side by side. ^ comparative study of both these figures in Table II will reveal the proportion of certified sick
days due to malaria to the certified sick days due
to all other diseases, but the same information can be more easily obtained by a reference to
Graph II.
Table II.
Months.
January February March April Alay June July August September October November December
1924
All
cases.
2111 2181 1817 2164 2456 2561 3130 3225 2950 3315 3809 2110
Malaria.
1041 876 745 726 1344 1077 1311 1679 1335 1092 1623 940
1925
All
cases.
2571 1991 2085 2074 2738 3009 2803 3592 3549 3478 3447 2821
Malaria.
1169 634 746 824 1086 1120 1456 2071 1976 2319 2390 1411
1926
All
cases.
3359 2159 2218 2457 2586 2681 3181 3223 3092 3526 3763 2867
Malaria.
953 459 423 517 813 899 1523 1284 131/ 1624 1676 919
A cursory glance through Graph II will show
that the curves of certified sick days, i.e., <Jays
J
Graph I.
Graph showing the relation between the number of cases of malaria and the number of cases of sickness
from all other causes.
Graph I.
Graph showing the relation between the number of cases of malaria and the number of cases of sickness
from all other causes.
Oct., 1928.] ECONOMIC SIGNIFICANCE OF MALARIA: RAO- 571
lost to the railway, due to malaria and to
all
other causes, follow closely in the years
1926 as was the case in Graph I, w ic
that the proportion of malarial casesto all other
sickness and the proportion of number y
lost due to malaria to that from all other sick
ness was identical in both the years
1926. But 1925 presents _
a differen p ?
Not only was there a relatively higher
of malaria, but there was a d|sProP???nr^iwaV
crease in the number of days lost to r
administration and the economic sigmhcance
this cannot be over-estimated.
The correlation between the num ei o
malaria that occurred and the num er
lost to the administration by malaria a
from 3 years 1924, 1925 and 1926
can be learnt
a study of Table III, which shows both
figures, month by month.
Table III.
Months.
1924
Cases of
malaria.
195 154 151 144 210 201 2.30 305 243 327 386 287
Number o
f
clav
s 'lost.
1091 876 745 726 1344 1077 1311 1679 1335 1092 1623 940
1925
C a se s of
ma
lari
a.
223 125 187 178 195 118 229 340 356 347 307 268
Number of
days lost.
1169 634 746 824 1086 1120 1456 2071 1976 2319 2390 144
1926
Cases of
malaria.
180 97 94 126 162 179 203 160 187 231 224 122
Number of
days l
ost.
January February March April May- June July August September October November December
953 459 423 517 813 899 1523 1289 1317 1624 1676 919
The same is represented graphically in Graph III which shows the relationship more clearly. A reference to the graph will show that a fairly constant relationship has been maintained between the number of cases of malaria and the number of days lost to the administration in the years 1924 and 1926. But in the year 1925, as is to be expected, this relationship is disturbed. A considerably greater number of days have been lost?due to malaria?in this year in comparison with the other two years, particularly during the period August?November, as is evidenced by the extreme height of the curve of "
days lost" during these months. When this is evaluated in terms of rupees,
annas and pies what a tremendous loss it repre- sents will be manifest. To appreciate the amount of loss caused to the
railway by the absence of the staff on sick leave, it is necessary to translate the figures represent- ing the number of days lost into rupees, annas and pies. To do this successfully is rather diffi- cult. Because, it is a well-known fact that of all the factors, the human factor is the most difficult one to monetise.
_
Several points have to be considered in monetising human labour:?
(i) Whether skilled labour or unskilled labour. (it) If skilled, what degree of skill is re-
quired to do the work. (Hi) Whether an experienced worker or a
raw recruit.
(iv) Individual efficiency. (v) Last but not least the mental state of
the individual while performing his duty, has also to be considered. Suppose, for example, the dependents of a railway employee are sick. Naturally, the quality of work turned out by the employee while in a* state of mental per- turbation (brought on by domestic calamities) could not be on a par with what he may turn out in his normal mental state. We are apt to be- little the significance of this, and while it may not have any tangible effect on unskilled labour, the case is different with skilled labour'.
Graph 11.
i i ' ??
Graph showing the proportion of certified sick
mS fS 19M (monthly).
?*= rear 1925 during the period August?Novetnfier tnan
in the other two years.
Graph II.
Graph showing the proportion of certified sick days due f rna'aria to certified sick days from allother diseases for the three years 1924, 1925 and 1926 (monthly). ? ?The proportion of sick days from malaria to
tho ys frorn a11 other diseases was relatively year 1925 during the period August Novembe in the other two years.
572 THE INDIAN MEDICAL GAZETTE. [Oct., 1928.
The writer knows the case of a station- master whose wife was suffering from a bilious remittent type of malaria. Though calm and sober-minded always, he lost his mental equili- brium to such an extent (due to the illness of his wife), that he gave orders to his pointsman to receive the mail train on the platform line, while a goods train was shunting on the same line.
Fortunately, the pointsman was an intelligent man and he averted a serious collision by disobeying the station-master. In a big railway adminis- tration with thousands of skilled employees, the mental factor has a definite significance.
Therefore, it is necessary to consider all the factors enumerated above in assessing the loss due to malaria.
It is admitted that the ideal method of calcula- tion of the loss is to find out the number of days lost on account of malaria, for each employee and evaluate the loss in terms of rupees, annas and pies, bearing in mind the several factors
enumerated above. But considering the magni" tude of the figures representing the number ox
employees, the different grades of pay, the varia- tions in each grade, individual variations in^ pay and the number of days lost, etc., the idea' method becomes impracticable.
Further, it is doubtful if such a mathematically accurate estimate is necessary for practical purposes. Moreover, it is extremely difficult to
assess the value of individual efficiency and the mental factor?both of some importance?in a
big concern like this railway. So, making due allowance for all these factors, an easy method of calculation has been adopted:?
All the employees have been grouped into 3
broad classes:?
Class (I) Employees whose pay ranges from Rs. 250 and upwards per mensem-
Class (II) Employees whose pay ranges from Rs. 30 to Rs. 250 per mensem-
Class (III) Employees whose pay is below Rs. 30 per mensem.
The number of days lost to the railway op- account of malaria among Class I employees is
comparatively small, for most of them protect themselves by the use of mosquito nets and take all other precautionary measures. Further, they are not exposed to the same risks as the em-
ployees of Class II and Class III, viz., night duty entailing loss of sleep, exposure to all sorts of weather in the performance of their duties,
"
running duties," involving travelling to endemic areas at night and halts at such stations en route, etc. The main loss is from the sickness of Class II and Class III employees. The ratio of the number of days lost from
malaria by the three different classes of employees for the 3 years is given below:? 1924 1925 1926
^lass I do. do.
Class II :
do. do.
Class III: do. :
do. :
: 1 : 38: 91 1:45:94 1:37:92
l^iviumg tne total number of days lost to tne
railway from malaria by the same ratio and
multiplying the resulting figures by the average pay per day for the respective class of employee, we arrive at the following figures:?
1924.
Total number of days lost by malaria 13,789. This divided by the ratio 1: 38: 91 and multi- plied by the average pay per day, i.e., Rs. 20 for Class I, Rs. 4 2|3 for Class II and Rs?. 2|3 for Class III employees, the loss caused by malaria is Rs. 27,367 or Rs. 27,000 (approximately).
1925.
Method of calculation same as before. The
loss caused by malaria is Rs. 35,957 or Rs. 36,000 (approximately).
1926.
Method of calculation same as before. The loss caused by malaria is Rs. 24,248 or Rs. 24.000 (approximately).
Graph III.
270o
FEB
GRA
MAR AF
PH III
MAY JUN JUL SEP
1924 I92S- 926-
OCT DEC
2too
1950
1800
1650
ISOO
1350
I20O
1050
9 00
750
too
?V
\ 1
\
^r- . V
X
T
450-
300
150
y
No. o casts of Vlalar
Graph showing the relation between the number of cases of malaria and the number of days lost thereby to
the railway. N.B.?There is a fairly constant relationship between
the number of cases of malaria and the number of certified sick days in the years 1924 and 1926. But in the year 1925, this relationship is disturbed. Compara- tively a greater number of days were lost from malaria in this year than in the other two years, particularly during August?November.
Graph III.
Graph showing the relation between the number of cases of malaria and the number of days lost thereby to
the railway. N.B.?There is a fairly constant relationship between
the number of cases of malaria and the number of certified sick days in the years 1924 and 1926. But in the year 1925, this relationship is disturbed. Compara- tively a greater number of days were lost from malaria in this year than in the other two years, particularly during August?November.
Oct., 1928.] BLACICWATER FEVER AND ITS TREATMENT: BELLGARD. 573
These figures represent fairly ac y ^
at least proportionately the amoun ..
^ the railway caused by malaria
in re
Ulmanirhat. That the estimate
errs, if at all, rather on the skle of
ment than on the opposite, will be eviden^ ̂
a comparison of the figures represeillt"ce mgs, said to have been
effected in conseq
of the saving in number of ceiti ets.. q?6-27
?vide E. B. Railway Annual Repoit /
Vol. I, Section I, p. 32, wherein the a^piro^
mate equivalent cost of 34,769 staff y \ i
t
mated at Rs. 37,000 which is acknowledged to
he an under-estimate. Also Vlfc^ Railway Methods of Malaria Control on
the E. ?
^
by Dr. R. J. U Sladen," dated 15th March
Page 3, wherein 8,377 days, representmg saving in days of certified sickness,
estimated at Rs. 8,377 which is admitted b>
Dr. Sladen to be an under-estimate. If the figures given by
the wrier ( ^
district of Ulmanirhat) represent the
Jy?m one district, what about the to a
Railway from all the districts combined. ^
course, the other districts may not Je
. ,
the one the writer was in charge ot. i ev ^
the total loss from the whole system ?
'
for
eonsiderablv greater than the figure* J,
?ne district Naturally such a great loss l ad it
effect on the balance-sheet, as is <
a nnual b' the Agent (vide E. B. Rai way ^
Report 1926-27, Vol. I, Section I, p. ?.
.It may be of interest to know wha f
jarja ot the total loss from all sickness , iost alone contributes. The total number
of daysio*
to the railway on account of all sickness,
* b
below for "2
1924.
31,829 1925.
34,158
1926.
35,112
Correlating these figures with those represent- lng the number of days lost from malaria alone, airive at the following percentage:
1924. 43 per cent.
1925.
?50 per cent.
iyzo.
35 per cent.
These figures support the v.1?cWtl^Pi925 was
an earlier part of this paper, ^ ihvay adminis- a very bad year, both from
the . , view,
tutors' and from tl.e staffs' pomte of Jie^
There is also a perceptii'ler"1^'" evidenced from malaria in the year
1926 from
the fall in the percentage of mala
3 in 1924 to 35 in 1926. ^is needless ^7
that this fall explains the ef^acy by the Chief ^nalarial measures started
in 19_ y rt 0{
Medical Officer with the enthusiastic supp
the Agent. Agent. Summary.
of y ) A hrief description of the physical
features
top-pff ̂ a^anirhat district of the E. B.
Railway
give lGr Wl*^1 ma^ar'ia^ distribution
has been
(2) The district comprises areas of varying physical features with different degrees of mala- rial incidence.
(3) The number of cases of malaria and the number of cases of all other sickness in the dis- trict for the 3 years 1924, 1925 aud 1926 are
given for comparison. (4) The number of days lost to the Railway
on account of malaria amongst the staff is given, and this is compared with the number of days lost from all other sickness.
(5) The monetary value of the number of
days lost from malaria has been estimated for the 3 years 1924, 1925 and 1926 and this has been shown to be not a negligible amount.
(6) What percentage of the loss from all sickness does malaria alone contribute? This has been calculated and incidently the anti-malarial measures started in 1925 have been shown to have been effective in reducing the loss due to malaria from 43 per cent, in 1924 and 50 per cent, in 1925 to 35 per cent, in 1926.
Finally, the writer takes this opportunity to express his indebtedness to Dr. R. J. L. Sladen, F.r.c.s., d.f.h., the then Chief Medical Officer, E. B. Railway, for kindly providing him with all the necessary facilities and for valuable advice and guidance. The writer's thanks are also due to Dr. C. D.
Newman, the D. M. O. of Saidpur for his help and advice.
REFERENCES.
(1) Sir Ronald Ross (1911). "The Prevention of Malaria," p. 252.
(2) R. J. L. Sladen, e.r.c.s., d.p.h. (1927). "Report and Methods of Malaria Control on the E. R. Railway."
(3) E. B. Railway Annual Report (1926-27). Vol. I, Sec. I.
