The New Nation - Internet Edition

Jamayet Ali

Sarpogandha (Chandra) is a very familiar medicinal plant found growing in fallaw lands, jungles and also in forests in our country. It also grows in India, Pakistan, Sri Lanka, Myanmar, Malaysia, Thailand and Java. Although the range of distribution of this plant is very wide, its occurrence is sporadic. The plants grow scattered, very seldom close to each other. It can grow under a wide range of climatic conditions both in the open and in partial shade. It can not stand the full open sun. In its native habit, the plant thrives under the shade of forest trees or at the very edge of the forests where three of the four sides are protected against too intense on illumination.

Botanical name of Sarpagandha (Chandra) is Rawolfia serpentina. The plant grows in a wide variety of soils from sandy alluvial loam to red lateritic loam or stiff dark loam. In its natural habitat, it prefers clay or clayey loam with a large percentage of hurnus and other organic debris which ensure uniform moisture levels and a good drainage. This plant can be propagated by seeds, root cuttings, root stumps and stem cuttings. Roots of exploitable size are generally collected 2-3 years after planting. It is reported that the roots dug out in winter when the plants have shed their leaves, are far richer in the total alkaloid content than the roots harvested in August. Roots are dug up, freed from the adhering soil and thoroughly air-dried and packed usually in gunny bags. On air-drying, the moisture content of roots drops to 12-20 percent, but the roots containing less than 8 percent of moisture store better; this can be brought about by artificial drying.

Though roots are widely used as ingredients of medicine, they are commonly adulterated with other parts of the plant such as the stems and root stumps with some portions of the stem attached to them. Roots having an excess of moisture content are also used. Among commercial supplies roots of types from coastal plains are reported to be moderately or grossly adulterated. Stems of the plant contain less quantity of alkaloids and hence adulteration of roots with stems lowers the total alkaloidal content of samples. The roots can be easily distinguished from the stem since they have a more wrinkled surface, are less flexible. thicker, more tortuous and less branched.

Medicinal Properties: The root is bitter, acrid, heating, sharp, pungent; anthelmintic; cures "tridosha", ulcers, the poisonous effects of scorpion-sting and snake-bite (Ayurveda). A decoction of the root is employed in labours to increase uterine contractions. In Java, it is used as an anthelmintic. The juice of the leaves is instilled into the eyes by the natives of India and Java, as a remedy for the removal of opacities of the cornea. In Bombay, most of the labourers who come from the Southern Konkan keep a small supply of the root, which they value as a remedy in painful affections of the boils. In the Konkan the root with Aristolachia indica is given in cholera, in colic, I part of the root with 2 parts of Holarrhena root and 3 parts of Jatropha Curcas root is given in milk. In fever the root with Andro graph is, ginger and black salt is used. The dose of the combined drugs in each case is from 3 to four tolas. The root is used by the Mundas as a snake remedy. The inhabitants of Macassar use the petioles as an antidote for ipoh. (Indian Medicinal plants, KR Kirtikar BD Basu, 1550, 551).

Medicinal values: In recent years, Rawolfia and its preparations have become important therapeutic agents, both as antihypertensives and as sedatives. It is an important source of the active alkaloid, reserpine, which is also extracted commercially from the roots of R. vomitoria and R. tetraphylla. Reserpine content of R. vomitoria is twice that of R. serpentine. Rawolfia has been employed for centuries for relief of various central nervous system disorders, both psychic and motor, including anxiety states, experiment, maniacal behaviour associated with psychosis, schizophrenia, insanity, insomnia and epilepsy. Extracts of the roots are valued for the treatment of intestinal disorders, particularly diarrhoea and dysentery and also an anthelmintic. Mixed with other plant extracts, they have been used in the treatment of cholera, colic and fever. The root was believed to stimulate uterine contraction and recommended for use in child birth in difficult cases. The juice of the leaves has been used as a remedy for opacity of the cornea.

In India and the Malayan Peninsula the root of this plant has been from ancient times, much valued as an antidote for the bites of poisonous reptiles and the stings of insects, also as a febrifuge, and as a remedy for dysentery and other painful affections of the intestinal canal.

Rumphius speaks of it under the name of radix musteloe, and says that in his time it was widely used in India and Java as an antidote against every sort of poison. it was administered both internally in the form of decoction of the root and externally by making a plaster of the roots and fresh leaves and applying them to the soles of the feet. For snake poisonous effects of even the cobra's bite were viewed as rendered harmless by the administration of this wonderful root. It is said by him to have been universally employed as an internal remedy against fevers, cholera and dysentery, and the juice of the leaves was instilled into the eyes as a remedy for the removal of opacities of the cornea. He states also that this is the plant to which the mongoose is believed to have recourse when beaten by poisonous snakes.

Sir W. Jones gives a similar account of the supposed medicinal virtues of the plant, but expresses a doubt as to whether it really is the so-called Ichneumon plant. Roxburgh states that it is used by the "Telinga Physicians, first, in substance, inwardly, as a febrifuge, secondly, in the same manner, after the bite of poisonous animals and thirdly it is administered, in substance to promote delivery in tedious cases." Horse field remarks that the root yields a strong bitter infusion and that its sensible properties indicate considerable activity. Altogether the popular beliefs with regard to this plant and the testimony of medical men in India who have practically tried it as a remedy for fevers, seem to indicate that it possesses strong and well-marked properties; it might, therefore, be advantageous to have a more complete analysis of its composition and more careful determination of its actions.

The pharmacological activity of Sarpogandha is due to its presence of several alkaloids of which resetpine is the most important. Resetpine has a depressant action on central nervous system and produces sedation and a lowering of blood pressure, accompanied by bradycardia. Administered orally, in hypertension, the effects of resetpine are slow, seldom appearing before 3-6 days of administration and continuing for sometime after withdrawal of the drug; it has a cumulative effect. It is most valuable in young patients with mild labile hypertension associated with tachycardia.

Resetpine is used for its sedative action in mild anxiety states and chronic psychoses. It has a tranquillising rather than hyphotic action and produces less somnolence than do barbiturates. Patients with chronic mental illness treated with reserpine often become relaxed, sociable and cooperative. Reserpine is now being used as a tool in physiological studies of other drugs. It is effective against ligation-induced fibrillation of dog heart. It exerts bacterio static action against Grampositive bacteria (The Wealth of India, Raw Materials, Dictionary of the Economic Products of India).

As the population of Bangladesh ages, greater numbers of people are likely to be living with chronic illnesses. We assessed population-based data on prevalence of chronic disease and causes of death from two rural sub districts in Bangladesh. Overall, 73% of those surveyed in Mirsarai and 44% in Abhoynagar reported being diagnosed with at least one chronic condition. Arthritis (37%) and hypertension (27%) were the most common chronic conditions reported. Verbal autopsy data show that at least 42% of all deaths in these areas in this age group were due to chronic conditions. In contrast, hospitalizations of persons aged over 60 in the upazila health complexes were rare. In order to improve the lives of older people in Bangladesh, the national health system should allocate resources and design strategies to prevent and treat chronic disease.

The age structure of Bangladesh's population is changing markedly. Rapid fertility declines in the 1980s have decreased the proportion of young persons (1), and reductions in child mortality have increased life expectancy from 44 years in 1975 to 60 years in 2001 (2). The population aged over 60 years currently represents about 7% of the 140 million population of Bangladesh (1) and is projected to represent 16% of the total population by 2050 (3). As the older population grows, the prevalence of chronic disease is also likely to grow. Understanding the burden of chronic disease in Bangladesh will guide the design of strategies to prevent chronic illness and provide health care to increasingly larger numbers of older people with chronic conditions.

In order to asses the burden of chronic disease in people over 60 years of age in Bangladesh, we examined the prevalence of chronic disease and causes of hospitalization and death in this age group using data from Mirsarai Upazila of Chittagong District and in Abhoynagar Upazila of Jessore District. To assess the prevalence of chronic illness we surveyed persons aged over 60 currently enrolled in ICDDR,B's surveillance sites in Mirsarai and Abhoynagar. In these two sites, demographic events, marriage, pregnancies, births, deaths and migration are routinely collected; the sampling procedure of the demographic surveillance system has been described elsewhere (4). All people aged over 60 years in the households were listed and then divided into three age groups, 60-69, 70-79, and over 80. Two hundred and fifty males and 250 females from each of these age groups were randomly selected from the populations of each surveillance site for inclusion in the survey. From July to October 2005 respondents were asked to report having ever been medically diagnosed with selected chronic diseases.

We obtained data on causes of hospitalization for persons aged over 60 years from 2002 to 2005 from the Bangladesh government's statistics from Mirsarai and Abhoynagar upazila health complexes. Data on causes of death were also obtained from the government system at these two facilities from 2002 to 2005. Cause of death data from verbal autopsies carried out at the Mirsarai and Abhoynagar surveillance sites from 2000 to 2003 were also examined. Two public health physicians following the 9th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-9) assigned causes of death from verbal autopsies. Surveillance data on causes of death from 2004 to 2005 were not included because of the revision in data collection methods since 2004.

A total of 1515 people over age 60 enrolled in surveillance in Mirsarai and Abhoynagar, out of the 3000 selected for the study, were surveyed. (Table 1) We were unable to survey all persons selected for the study due to resource constraints. The proportion of participants from each age group included in the survey was similar to the proportion of that age group in the population under surveillance. The majority of respondents lived with extended families. Although life expectancy for men and women in Bangladesh is similar, many more women than men had experienced the loss of a spouse. Smoking was commonly reported by male respondents (Table 1).

Overall, 73% of those surveyed in Mirsarai and 44% in Abhoynagar reported being diagnosed with at least one chronic condition; prevalence varied by sex. (Table 2) Participants most frequently reported being diagnosed with arthritis (54% in Mirsarai, 17% in Abhoynagar) and hypertension (32% in Mirsarai, 20% in Abhoynagar) (Table 2). Women in Mirsarai reported the highest rates of chronic disease (82%).

From 2002 to 2005, 988 persons aged over 60 years were admitted to the Upazila Health Complex in Mirsarai, representing 5% of total hospitalizations for that time period. The majority were males (57%) and 21% of hospitalizations were due to chronic disease complaints, including hypertension and lung and heart problems. During the same time period, 1,554 people aged over 60 were admitted in Abhoynagar, representing 7% of all hospitalizations at that facility. The majority (66%) were also males and 38% of those hospitalizations were due to chronic disease complaints.

Verbal autopsy data from the Mirsarai and Abhoynagar surveillance sites showed that at least 42% of all deaths in persons aged over 60 from 2000-2003 were due to chronic conditions. Cardiovascular diseases (26%), senility (22%), respiratory diseases (15%), malignancy (7%) and neurological conditions (6%) were the most common causes of death in people aged over 60 years during this time period (Table 3). It is quite likely that many deaths categorized here as respiratory disease and senility were also caused by chronic conditions.

There were 67 deaths among people over age 60 years at the upazila health complexes in Mirsarai and Abhoynager combined from 2000-2005. Cardiovascular diseases (33), bronchial asthma (19), and cerebrovascular accidents (10) accounted for almost all deaths.

Evidence from Mirsarai and Abhoynagar suggests that chronic illness is common in persons aged over 60 in Bangladesh. This population-based survey found that 73% of persons aged over 60 were living with at least one chronic disease complaint in Mirsarai and 44% were doing so in Abhoynagar. It is unclear why differences in disease prevalence existed between the two sites surveyed and between males and females; however, other studies have also observed higher proportions of females with chronic illness than men (5,6,7). Estimated prevalences reported here and in other studies from Bangladesh based on reported illness (7) are likely to be underestimates given that they are based on participant reports and that this population traditionally has poor access to regular medical care necessary to diagnose chronic illnesses. Studies conducted with similar populations in neighbouring India, which included a physician diagnosis, report that nearly all persons aged over 60 surveyed were living with some morbidity (5). Further studies, including physician exams, are required to accurately document the prevalence of chronic disease in Bangladesh.

Causes of death from verbal autopsies showed that at least 42% of all deaths in ICDDR,B's surveillance sites in Mirsarai and Abhoynagar are due to chronic conditions. Deaths reported as respiratory illness and senility were also likely caused by chronic disease. Future reports might be better able to categorize deaths due to chronic disease because the definition used for senility was revised in 2004, based on the 10th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Almost all deaths recorded at the health complexes in these two upazilas were attributed to chronic disease. Our ability to compare causes of death between verbal autopsy data and data from the health complexes is limited due to differences in definitions of cause of death and the extremely small numbers of deaths that occurred in the health complexes.

Hospitalizations of persons over the age of 60 accounted for only 5% of all hospitalizations in Mirsarai and 7% in Abhoynagar. Despite the fact that most deaths at these facilities in people over 60 are attributed to chronic illness, hospitalizations for this age group for chronic illness were rare. Another study from Bangladesh found similarly low proportions of hospital admissions from this age group (8). This could be explained in a number of ways. It is possible that these people are receiving treatment elsewhere since upazila health complexes usually do not have the resources to treat chronic conditions. Another possibility is that these people simply are not seeking care for their illnesses, either because they do not have the resources to do so or because they are unaware of their condition and the need to seek treatment. Anecdotal evidence suggests that community members are reticent to seek care for older members of the family. While conducting the survey for this study, interviewers were often requested by younger adults in the household to collect information on the health of younger family members instead. They said, "What is the use of collecting such data for older people, as no intervention is likely to bring them back to a normal life. It is better to keep him/her with the family and leave them alone to perform rituals as long as they survive".

As Bangladesh's population ages, increasing numbers of people will be living with chronic conditions. The Government of Bangladesh is committed to sustainable improvements in health, nutrition and family welfare especially for vulnerable groups such as the elderly. These commitments are outlined in the Health, Nutrition and Population Sector Programme (2003-2010) (9) and the national Strategy for Accelerated Poverty Reduction (10). Given evidence of the current burden of chronic disease and the predictions for growing numbers of people with chronic illness, the government should work to increase resources for diagnosis and treatment of these conditions and initiate strategies, such as lifestyle change, for preventing them. One step could be to discourage smoking, a common habit among men found in this study and others in Bangladesh (11,12). The future holds many challenges for Bangladesh's health care system, which will have to cope with high rates of infectious disease and increasing rates of chronic disease. Further studies to generate more accurate estimates of the chronic disease burden and track trends will assist the government in facing this challenge.

-HSB/ICDDR,B

Victoria Colliver

Medicare beneficiaries who fail to examine next year's changes to their prescription drug plans may find the price of their pills tougher to swallow come Jan. 1.

Enrollment begins Nov. 15 for the new crop of drug plans, and health advocates warn that people are likely to see increases in their monthly premiums - and no guarantees that drugs covered under their plan this year will be covered in 2008. Among the changes:

Monthly premiums for drug plans paired with traditional Medicare will increase in California by an average of 24 percent.

Nationwide, about 75 percent of enrollees in drug plans face premium hikes if they stay in the same plan next year.

Millions of low-income and disabled people covered by both Medicare and Medicaid - about 500,000 of whom live in California - automatically will be switched to new plans that may or may not cover their drugs.

"It may feel like the same old thing and not worth changing. But, in fact, plans are changing, and consumers may find themselves better off making a switch," said Tricia Neuman, vice president of the Kaiser Family Foundation.

Since the federal government added prescription drug coverage to its Medicare benefits in 2006, about 24 million of America's 43 million seniors have taken advantage of the new option. The program, known as Medicare Part D, is administered by private companies that are approved by the federal government to sell drug plans.

Medicare is available to people 65 and older and those who qualify because of disability or income level.

There are two main ways to get drug coverage under Medicare. One is to be covered by traditional Medicare and buy a separate Part D drug plan for an additional monthly fee. But a growing number of plans combine health and prescription coverage under one roof, which means medical and drug services are handled by a private company.

Under this free-market approach, more than 1,800 plans are available nationwide. In California, seniors have their choice of 56 stand-alone plans, all of which are available statewide.

An additional 180 Medicare health plans, which can come in the form of a health maintenance organization, or HMO, are sold throughout the state, but where those plans are offered varies by county. In addition, there are newer forms of Medicare benefits known as private fee-for-service plans, some of which have come under fire from consumer groups and the federal government for marketing abuses.

This dizzying array of options offers beneficiaries both choice and confusion. But Medicare officials say more choice means competition.

"There are a lot of choices because the market is robust," said Jeff Nelligan, spokesman for the Centers for Medicare and Medicaid Services. "Why go into a supermarket and only confine yourself to the first two aisles? More choices mean more value."

According to Medicare officials, the average monthly premium for Part D coverage in 2008 will be $25, up from $22 this year.

This is far lower than the $41 monthly premium predicted by the federal government at the beginning of the program. But consumer and health advocates say the numbers are misleading because they include both the stand-alone plans and the Medicare health plans, also known as Medicare Advantage, which are more highly subsidized by the government and are eligible for rebates not available to standard Part D plans. Some Medicare Advantage plans have no premiums.

Californians who stay in the same stand-alone prescription drug plan will experience an average 31 percent premium increase next year, said Chris Perrone, senior program officer for the California HealthCare Foundation.

Advocates found the average cost of a stand-alone plan in California for 2008 will increase by 24 percent.

The cheapest plan available this year in California will go up 96 percent. People who choose that plan, WellCare's Classic plan at $9.70, will find themselves paying $19 a month if they stay the course in 2008. Next year, First Health Part D Secure offers the state's lowest cost plan at $14.30 a month.

"Every single beneficiary is exposed to instability and unpredictability," said Kevin Prindiville, an attorney with the National Senior Citizens Law Center in Oakland. "Everyone should be looking at their plan changes and making sure the plan they enrolled in is really the best plan for them."

Prindiville's group is most concerned with the 1.2 million poor and disabled Californians who are covered by both Medicare and Medicaid, a joint state and federal program for the indigent known here as Medi-Cal.

About 600,000 of these dually eligible residents are enrolled in plans that didn't have a monthly premium in 2007, but now cost too much to be offered to these recipients in 2008.

The bulk of these beneficiaries automatically will be switched to new plans, but those who are not will face higher premiums. Prindiville said there's no guarantee that their new plans will cover the drugs needed by this vulnerable population, which tends to be the sickest and poorest in the state.

Health advocates also are concerned about the low number of plans offering brand-name as opposed to just generic drug coverage through the infamous "doughnut hole," a coverage gap built into the program to reduce the cost of the benefit.

If consumers hit the hole, they are responsible for 100 percent of their drug costs until - or unless - they spend themselves out of the hole. Next year, plans pay 75 percent of drug costs until a beneficiary's total drug tab hits $2,510. After that point, seniors must pay all drug costs until their out-of-pocket spending hits $4,050 and comprehensive coverage resumes.

Despite their differences, both advocates and Medicare officials agree that consumers need to be aware of the changing Medicare marketplace.

"Every year, we talk about having your annual checkup for your health. Every year, through this open enrollment period, you should have an annual prescription drug checkup," said Dr. Charlotte Yeh, acting director of Medicare's San Francisco regional office.

You'd better shop around

Open enrollment to choose a new Medicare prescription drug benefit is Nov. 15-Dec. 31. Those who want to switch plans should do so by early December to ensure their benefits start smoothly Jan. 1. Many senior centers offer counseling services. Other resources:

Medicare.gov offers the most comprehensive online tools to help consumers pick a plan. The same information will be available at (800) 633-4227.

The Health Insurance Counseling and Advocacy Program offers free individual counseling. Call (800) 434-0222 to be directed to HICAP in your county, or go to calmedicare.org.

The Medicare Rights Center provides Medicare Part D information at medicarerights.org.

Benefitscheckup.org is maintained by the National Council on Aging and supported by major drugstores, insurers and pharmaceutical companies.

AARP does not offer individual counseling but does help with general information about Part D. Visit aarp.org or call (888) 687-2277.

Source: Chronicle research