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Bangkok - Seared into Southeast Asia's collective memory is the iconic image of the 1997-98 Asian financial crisis, where International Monetary Fund (IMF) chief Michel Camdessus towered with crossed arms over a bent-down Indonesian President Suharto as he signed a sovereignty-eroding bailout agreement for his distressed economy.
Patients with hematological malignancies are at high risk of infections due to both the disease and the associated treatments. The use of immunoglobulin (Ig) to prevent infections is increasing in this population, but its cost effectiveness is unknown. This trial-based economic evaluation aimed to compare the cost effectiveness of prophylactic Ig with prophylactic antibiotics in patients with hematological malignancies.
Methods
The economic evaluation used individual patient data from the RATIONAL feasibility trial, which randomly assigned 63 adults with chronic lymphocytic leukemia, multiple myeloma, or lymphoma to prophylactic Ig or prophylactic antibiotics. The following two analyses were conducted to estimate the cost effectiveness of the two treatments over the 12-month trial period from the perspective of the Australian health system:
(i) a cost-utility analysis (CUA) to assess the incremental cost per quality-adjusted life-year (QALY) gained using data collected with the EuroQol 5D-5L questionnaire; and
(ii) a cost-effectiveness analysis (CEA) to assess the incremental cost per serious infection prevented (grade ≥3) and per infection prevented (any grade).
Results
The total cost per patient was significantly higher in the Ig arm than in the antibiotic arm (difference AUD29,140 [USD19,000]). There were non-significant differences in health outcomes between the treatment arms: patients treated with Ig had fewer QALYs (difference −0.072) and serious infections (difference −0.26) than those given antibiotics, but more overall infections (difference 0.76). The incremental cost-effectiveness from the CUA indicated that Ig was more costly than antibiotics and associated with fewer QALYs. In the CEA, Ig costed an additional AUD111,262 (USD73,000) per serious infection prevented, but it was more costly than antibiotics and associated with more infections when all infections were included.
Conclusions
These results indicate that, on average, Ig prophylactic treatment may not be cost effective compared with prophylactic antibiotics for the group of patients with hematological malignancies recruited to the RATIONAL feasibility trial. Further research is needed to confirm these findings in a larger population and over the longer term.
The historiography on South Asian overseas migration in the colonial era has focused extensively on the history of indentured labour. This was a system of recruitment of workers on a fixed contract of three to five years with a single employer, at the end of which they could re-indenture, find other employment or have their passage paid home. These contracts were prominently used by private employers to hire plantation labour in sugar, rubber, tea and coffee plantations following the abolition of slavery and by rural Indians to escape from poverty and/ or discrimination. They were also used in government public works departments, in railway construction and in the military. Those who signed such an agreement (known as a girmit in north India) described themselves as girmitiyas. Although guaranteed food, shelter and employment, and subject to periodic inspections, those in the hands of private employers overseas could be exploited as they were often working in remote locations and were legally not free to leave until their contract had expired or they (or their family) had bought their way out of it. Although never allowed in Sri Lanka or Myanmar, and superseded by other forms of migration by the beginning of the twentieth century, more has been written about South Asian indentured labour than any other form of historical migration from India, partly because it was subject to government regulation and is therefore unusually well documented in colonial archives.
Within the literature on indentured labour, most of the writing has revolved around migration statistics and the debates between anti-slavery campaigners, planters, British imperial officials and, latterly, the complaints of Indian nationalist politicians, leading up to the effective abolition of indentured overseas labour contracts by 1920. The voices of the migrants themselves are not so often heard, nor those of the many other Indians who were not on contracts of indenture who migrated at the same time. A classic text, Hugh Tinker’s A New System of Slavery, drew its inspiration from the early campaigns against indentured migration launched by the anti-slavery movement in Britain. However, in recent years, a new scholarship has been emerging, especially from within the diaspora – most prominently in South Africa – which sheds light on the highly varied social lives of migrants.
This book concerns what has been called the ‘first wave’ of Indians who travelled overseas to work on colonial plantations in the nineteenth and early twentieth centuries. It was a migration facilitated and supervised by the British colonial government of India under what became the indentured labour scheme. Under this scheme, workers would sign a contract, popularly known as a girmit, or agreement, which bound them to work for a single employer at a fixed wage for a fixed period of three–five years. Indentured migrants identified themselves with specific terms such as angaze in Mauritius, kontraki in Suriname and girmitiya in Fiji. However, the British commonly called them ‘coolies’ – a term already familiar to them from its usage in South India and China.
The indenture system was introduced to overcome the crisis that emerged from the banning of slavery in the British Empire by the British Parliament in 1833. The system attracted huge criticism and opposition from the very beginning; however, it continued until 1917 when it was finally abolished, under pressure from Indian nationalists and the greater importance of moving troops and supplies during the global conflict of World War I. Another reason was the crisis in the sugar industry as the production of sugar beet undermined the demand for plantation sugar cane in global markets.
This volume explores the transformative experiences of those who migrated, and the memories of those who did not return after expiration of their contract, but chose to stay in their respective host countries. These communities of South Asians abroad struggled to adapt to their new situations, standardizing the languages spoken and preserving some cultural and folk traditions, whilst discarding others (notably many of the distinctions of caste) – in short, forging for themselves entirely new identities as ‘diasporic Indians’.
Many books and essays concerning the history of Indian indentured migration in the colonial period begin with numbers. They attempt, with overused tropes, to generalize in a few lines the experience of labour migration across multiple destinations throughout the globe and a period of more than a century. However, the numbers themselves are uncertain. Many more millions of South Asians migrated without contracts of indenture as ‘free migrants’, otherwise known as ‘passenger Indians’. And many re-indentured, or re-migrated from colony to colony, without ever returning home (what Reshaad Durgahee has termed ‘subaltern careering’) – thus evading enumeration in official statistics.