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Medical education in Sri Lanka: Then and now

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From the Art of the Stethoscope to the Science of the Screen. What Today’s Young Doctors Can Learn from Yesterday’s Medical Leaders.

by Dr B. J. C. Perera
MBBS(Cey), DCH(Cey), DCH(Eng),
MD(Paediatrics), MRCP(UK), FRCP(Edin),
FRCP(Lond), FRCPCH(UK), FSLCPaed, FCCP, Hony.
FRCPCH(UK), Hony. FCGP(SL)
Specialist Consultant Paediatrician and Honorary Senior Fellow,
Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.
An independent freelance medical correspondent.

It is a more than likely observation in this day and age, displayed as a scene that may be noted if one walks into a ward at any of the National Hospitals of Sri Lanka or any major Teaching Hospital. It is perhaps a sight that would look somewhat alien and unfamiliar to a doctor who graduated forty to fifty years ago.

Where once Senior Consultants stood surrounded by eager students scribbling furiously in notebooks, today’s clinical ward rounds are accompanied by glowing electronic tablet screens, instant smartphone access to medical databases, and digital reports downloaded from cloud servers. In some cases, before a young Medical Student or a junior doctor even reaches the patient’s bedside, they may already know the patient’s exact blood chemistry, genetic markers, and even three-dimensional cross-sectional images of the patient’s internal organs.

Medical Education in Sri Lanka, celebrated for over a century and a half since the founding of the Colombo Medical School in 1870, has undergone a profound transformation. The transition has been from the era of ink, paper, and physical signs to an age dominated by advanced imaging, high-throughput blood tests, the internet, and Artificial Intelligence (AI). It has brought unimaginable speed and electronic precision to modern healthcare. Yet for all that, as Sri Lanka’s medical faculties train the next generation of doctors, a vital question emerges: In our rush to embrace the digital future, are we losing the timeless and precious human art form that defined the great physicians of the past?

The Era of “Then”: The Sacred Art of the Bedside

To understand what has changed, one must travel back quite a few decades to even the 1970s and 1980s.

In those days, medical diagnostic equipment was sparse, expensive, and often unavailable outside major metropolitan centres. Computed Tomography (CT) scans were a rare luxury, Magnetic Resonance Imaging (MRI) was virtually unheard of locally, and ultrasound machines were in their infancy. There was no internet to search for rare syndromes, no AI to suggest differential diagnoses, and no automated laboratory machinery to return fifty blood values within an hour.

How, then, did the legendary medical teachers and consultants of that golden era diagnose complex, life-threatening illnesses with astonishing accuracy? The answers lay in two fundamental, painstaking skills: taking a detailed history from the patient and performing a thorough physical examination.

The Patient’s Story as the Guiding Compass

Decades ago, medical students were taught that 80 per cent of all diagnoses could be made simply by listening to the patient. History-taking was not merely ticking off a quick checklist of questions; it was an immersive, structured narrative art, delving deeply into many aspects of the patient’s life. Students were trained to stand at the edge of the hospital bed, look the patient in the eye, and let them tell their story. A doctor needed to know not only when the fever started or where the pain was, but also what kind of work the patient did, what they ate, the conditions of their home environment, their emotional worries, and their family background. Every word mattered. A subtle clue, such as a patient mentioning that her joint pain worsened in the cold morning dampness, or that a child’s cough grew louder after playing outdoors, could set off a train of clinical reasoning that pointed directly towards a diagnosis.

The Human Senses as Diagnostic Tools

Once the story was told, the physical examination began. Doctors of yesterday trained their own five senses to function like a living diagnostic laboratory:

=Observation (Inspection): Before touching the patient, the doctor observed everything. The colour and texture of the skin, the tint of the whites of the eyes, the subtle shaking of an outstretched hand, the shape of the fingernails, or the rhythm of breathing, all of which revealed volumes about the functioning of many organs.

=Touch (Palpation): Using their bare hands, physicians learned to feel the precise boundaries of an enlarged liver or spleen, gauge the temperature and texture of skin, and map out subtle muscle spasms or localised pain.

=Sound (Percussion and Auscultation): Tapping fingers against a patient’s chest wall produced distinct sound notes, dull, resonant, or booming, which allowed doctors to virtually “see” fluid in the lungs or air in the chest cavity without a single X-ray. Through the stethoscope, they listened for the delicate, rhythmic murmur of a leaking heart valve or the fine crackles of fluid in the lungs and airways, fine-tuning their ears to the sounds like gifted musicians.

The entire clinical encounter was documented by hand on paper in Bed-Head Tickets (BHTs). These handwritten records were masterpieces of clinical reasoning, clear, organised, and detailing the doctor’s step-by-step thought process from initial suspicion to even a final diagnosis.

The Era of “Now”: High-Tech, High-Speed Medicine

Now, let us go fast-forward to the present day. Today’s medical undergraduates and postgraduate trainees enter a medical world transformed by technological marvels. That transmuted scenario is unbelievable and almost too good to be true.

The internet gives students instant access to a wealth of medical journals, clinical guidelines, and global expert consensus statements at their fingertips. Artificial Intelligence tools can analyse electrocardiograms (ECGs) in seconds, flag abnormal lung nodules on chest X-rays, and cross-reference rare genetic mutations faster than any human mind ever could. Point-of-Care Ultrasound Scans (POCUS) plug into smartphones, allowing doctors to view heart valves in motion at the bedside within seconds.

This technological revolution has delivered undeniable benefits:

=Unrivalled Accuracy: Internal bleeding, microscopic tumours, and early-stage blockages that were once completely invisible to the human eye can now be detected electronically long before they cause obvious physical signs.

=Speed in Emergencies: In acute stroke, heart attacks, or severe trauma cases, automated scans and rapid blood tests save precious minutes that may mean the difference between life and death.

=Standardised Care: Digital protocols and evidence-based software guidelines help prevent human error and ensure that patients across different hospitals receive consistent, modern care.

However, this shift in the way the practise of medicine has progressed with the advent of tools with immense potential, has also delicately and subtly altered how we look after our patients and the way we get about in providing healthcare to our nation. We need to realise that it also has an interesting and intriguing flip side. There is no such thing as a free lunch. There are certain other factors that need to be taken into account as well.

The Hidden Costs of Digital Dependency

While no one would wish to return to an era without modern scans or life-saving tests, the growing reliance on technology in medical education has introduced some troubling side effects.

1. Treating the Screen; Not the Patient

In many busy modern hospital wards, a curious shift occurs. Young doctors often spend more time looking at computer screens, lab reports, and scan images than sitting at the patient’s bedside.

It has become tempting to order a battery of high-tech investigations right away and wait for the results, rather than spending 30 minutes taking a detailed history and performing a methodical physical examination. A patient may sit in a clinic room feeling largely ignored while the doctor punches data into a system or scrolls through digital files.

2. Withering of Clinical Skills

Physical examination is like a muscle: if you do not use it, it weakens. When every respiratory symptom immediately prompts a high-resolution CT scan, students risk losing the refined auditory skills required to detect early abnormal lung sounds with a stethoscope. When an echo machine is always nearby, the subtle physical signs of early heart disease can easily be missed or overlooked.

If young doctors rely entirely on machines to tell them what is wrong, what happens when those machines are unavailable?

3. The Challenge of Resource Constraints

Sri Lanka is a nation where healthcare resources are precious and somewhat unevenly distributed. While major teaching hospitals in Colombo, Kandy, Jaffna or Galle may possess state-of-the-art diagnostic machinery, smaller rural hospitals and peripheral clinics often operate with basic facilities.

Young doctors trained strictly to rely on immediate CT scans, complex blood panels, or specialised software will find themselves paralysed when posted to a remote rural clinic where even the electricity might fluctuate, and the nearest scanner is hours away. In such settings, clinical skills – the ability to diagnose using eyes, hands, stethoscope, and intellect, are not just academic traditions; it is a life-saving necessity.

What Today’s Trainees Can Learn from the Teachers of Yesterday

The goal of modern medical education should not be to reject new technology, but to ground it in the wisdom of the past. Senior Professors and Consultants who practised four to five decades ago possessed insights that remain deeply relevant for today’s medical undergraduates and postgraduate trainees too.

Here are four essential lessons that yesterday’s masters can teach today’s generation:

Lesson 1: History-Taking is an Act of Human Connection

Technology can analyse data, but it cannot empathise. When a doctor sits down, establishes eye contact, and listens patiently to a suffering fellow human being, two things happen: the doctor gathers vital clinical clues that no scan can reveal, and the patient feels cared for and understood.

The therapeutic value of listening is immense. Anxiety decreases, trust is built, and patients are far more likely to follow medical advice when they feel their doctor truly knows them as a person, not just a bed number or a case file.

Lesson 2: Physical Touch Builds Trust and Reveals Truths

The physical examination is a powerful bridge between doctor and patient. A reassuring hand on a pulse, a gentle examination of an aching joint, or a careful abdominal touch conveys warmth and competence.

Furthermore, physical signs often precede what machines detect, or explain discrepancies in test results. A doctor who masterfully detects early clinical signs can save the health system thousands of rupees in needless investigations and save the patient unnecessary anxiety.

Lesson 3: Technology should be a Servant: Not a Master

The great teachers of the past taught that investigations should be ordered to confirm a clinical suspicion, not to go about to find one blindly.

Today’s young doctors must learn to form a strong clinical hypothesis first, using their brain, history, and examination, before ordering tests. Falling into the debacle of subjecting a patient to a blanket set of tests without a clear idea of what one is looking for leads to over-testing, incidental false findings, unnecessary treatment, and wasted healthcare funds.

Lesson 4: Resilience and Resourcefulness

Medical Teachers from decades past worked through difficult times with limited resources, yet delivered exceptional care. They cultivated incredible resilience and mental agility. They learned to rely on core scientific principles, basic anatomy, and physiology to solve complex medical puzzles. Modern trainees who learn this mindset become adaptable, confident doctors who can excel anywhere in the world, from an advanced research hospital in London to a remote rural clinic in Monaragala.

The Golden Middle: Fusing Bedside Art with Digital Science

Medical education in Sri Lanka stands at a vital crossroads. We do not need to choose between the past and the future; the true path forward lies in combining the best of both worlds.

Imagine a medical graduate who possesses the deepest empathy, sharp observational skills, and clinical acumen of a 1980s consultant, seamlessly combined with the ability to interpret cutting-edge AI algorithms, read complex MRI scans, and utilise the latest medical research available online. That is the ideal physician for Sri Lanka’s future. It is a medical professional:

=who uses AI as an assistant, but trusts their own trained senses at the bedside.

=who reviews the digital scan, but never forgets to look at, speak to, and touch the human being sitting in front of them.

=who writes clear, thoughtful clinical notes, whether on paper or on a screen, reflecting a mind that truly understands the patient’s story.

The Unchanging Heart of Medicine

Languages change, medical curricula may evolve, and diagnostic tools will continue to grow more sophisticated with every passing decade. Tomorrow’s doctors may well work alongside AI systems that predict illnesses before symptoms even appear. Yet for all that, and despite these changes, the fundamental essence of medicine should remain unchanged. That is the scholarly and empathetic bond between the patient and the treating physician; the hallowed Doctor-Patient relationship.

When a person falls ill, he or she does not seek a connection with a computer screen, a lab machine, or a diagnostic algorithm. They seek a caring human doctor; someone who possesses both the scientific competence to diagnose their illness and the humanoid warmth to comfort their pain and anxiety. By honouring the timeless bedside arts of yesterday while mastering the modern tools of today, Sri Lanka’s medical students and young doctors can ensure that our nation’s proud medical tradition continues to shine ever so brightly for generations to come. It would produce a set of medical professionals who really care and are so competent that suffering mankind would be the ultimate beneficiaries.



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Features

‘Lord Edgware Dies’

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It has been some time since I read an Agatha Christie, the plot of which I cannot remember. So, I was delighted to find on the shelves of a friend Lord Edgware Dies, which I had a vague memory of, but no certainty about who had done it.

When I read it, I found that my memory of who was probably the killer was correct, but I could not be certain and the red herrings Christie threw in were so diverting that until almost the very end I wondered if I had been wrong.

The plot is very simple. Jane Wilkinson, who is married to Lord Edgware, tells him that she is desperate for a divorce since she is in love with a very proper Anglo-Catholic peer, Lord Melton, but Edgware refuses to divorce her. She asks Poirot to talk to him, which he does, and is surprised to find that Edgware has told Jane he is prepared to give her a divorce. This was, after he had categorically refused, through a letter, which Jane said she had not received.

That night Edgware is murdered, after Jane had been to see him, or so the butler said, and also Edgware’s secretary. But Jane had been that evening at a grand dinner many miles away, where a dozen fellow guests could swear to her presence.

There was a solution however to the mystery of two Jane Wilkinsons, namely a skilful impersonator called Carlotta Adams who, in the opening chapter had impersonated Jane Wilkinson, who had also been at the performance. But when Poirot goes to see her, he finds that she had been found dead on the morning after Edgware had been killed, of an overdose. And in her bag was a gold case, with a strange inscription, that contained the drug, along with a pair of pince-nez.

Her maid said she had written a letter to her sister in America and posted it the previous night. Poirot asks Inspector Japp to get the letter, and a transcript is received from America, and in it the name of Edgware’s nephew Ronald Marsh is mentioned; he had taken Carlotta to dinner after her performance, with which the book opens, and had then set her a challenge. Japp arrests Marsh, but Poirot is not happy and asks for the original of the letter, which the sister sends him. That shows that a page is missing, and the tear is obvious, though that raises the question as to why it had not simply been cut.

Matters are further complicated by the fact that Marsh had gone in a taxi to the Edgware house, along with Edgware’s daughter Geraldine, in the interval of an opera which had previously seemed to provide them with cast iron alibis. Geraldine had gone in to fetch her pearls so that Marsh could raise money he needed, and thus had an opportunity to kill Edgware, as did Marsh, for the driver said he had got out of the taxi while waiting and gone into the house.

Agatha Christie

Marsh explained why he had gone to the house on the night of the murder as having followed Bryan Martin, an American actor, who had been in love with Jane, whom he saw go into the house with a key. But there was no one visible when he entered, and Geraldine almost immediately came down and they left together. And Martin too has become an object of suspicion to Poirot, for he had been to see him before the murders were discovered with a story of being followed by a man with a gold tooth – a story Poirot immediately realized was false when he was asked how old the man was, and was told he was young, for young people did not have gold teeth.

A heap of French money Edgware had got for a trip to Paris was missing, but since Marsh had no need for it after his cousin’s offer of help, Poirot deduces that it must have been taken by the butler, who has disappeared. Christie has stressed that he is astonishingly handsome, unusual in a butler, and Poirot notes a resemblance to Martin, so he thinks the mysterious man going into the house must have been him.

Incidentally, later Poirot assumes that Edgware’s change of mind was because he was involved in some scandal, and I believe Christie intends us to see the cause of this in his handsome butler, though this is not specified.

Meanwhile, Poirot has asked Japp to find out the provenance of the case found in Carlotta’s handbag, and it turns out to have been made in Paris, specially commissioned, and collected by a woman with pince-nez.

But then another murder occurs—that of another guest at the grand dinner, which provided Jane with her alibi. The victim is an actor who had been bemused when Jane, at a lunch, thought the Judgment of Paris referred to the city. He told Hastings he wanted to see Poirot, but was killed before he could get to the appointment. Poirot had rushed there when told about his request, but it was too late.

Meanwhile, Poirot has tried out the pince-nez on Edgware’s secretary, but she could not see through these. It was only a chance remark heard outside the theatre that led him to try them out on Wilkinson’s maid Ellis, a spare pair that had been appropriated for the night of the murders.

Poirot then lays things out, having summoned Martin and told him that he probably suppressed Edgware’s letter, as he had been dropped by then and he did not want Jane to marry another. But after teasing Martin, Poirot says that Jane was in fact the murderer, and she got Carlotta to impersonate her at the dinner while she went to the house and killed her husband. After meeting Carlotta later and checking with her through a call that she had not been rumbled, Jane had gone ahead with the murder – she put veronal into her drink and the case with veronal into the handbag. She forgot to take out the pince-nez she had used earlier to imitate an American. Carlotta had registered as the American in a hotel and Jane had gone to see her, and there they exchanged identities. After seen the letter, she made use of it by tearing off the page that referred to her, and the S of She, so that the person who had challenged Carlotta to impersonate her seemed to be a man.

There is a coda in which Jane, condemned to death, writes to Hastings, still full of pride at her ingenuity hoping she will be remembered.

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Desilt reservoirs, learn from our ancient irrigation systems

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Polgolla

by Prof. O. A. Ileperuma

Silting of reservoirs is a major problem today affecting our hydropower production and irrigation systems. The main Mahaweli reservoirs are silted to a considerable extent reducing the water holding capacity of them. Due to poor soil management practices, floodwaters deposit large amounts of silt in these reservoirs. When the Polgolla reservoir was fully drained about two years back, one could see mountains of silt in the lower reaches of the reservoir. A rough estimate is that 50% of the total capacity of these reservoirs has been lost to siltation. This is a serious issue which affects not only power and agriculture but also flood control.

Our ancient irrigation systems ensured that desilting of reservoirs took place under royal decree where all users of the reservoirs were ordered to carry out desilting of reservoirs during the dry season. The clay thus collected was used in making bricks for the construction of great stupas which dot the landscape of our ancient kingdoms. This ensured that the reservoirs had their full capacity filled with water for the next cultivating season. Our ancient kings were clever enough not to construct reservoirs by blocking main rivers such as the Mahaweli. A classic example is the Minipe left canal where they tapped only the surface water of Mahaweli. Even the bigger tanks such as Nuwara Wewa and Parakrama Samudraya were fed with minor rivulets. There were also other ingenious features in the cascade irrigation systems built by the ancient kings, such as mud sluice canals and forest reservations between the reservoirs in the cascade system. These reservations helped trap silt and remove excess nutrients, which could otherwise contribute to increasing salinity as water flowed from one reservoir to another.

Victoria

Moragahakanda

A classic engineering marvel is the former Yoda Ela, which carries water from Kalawewa to Nuwara Wewa and Tissa Wewa. It is 87 km long although the straight distance between these points is only about 40 km. The gradient of this canal is about 10 cm per km or 6 inches per mile. Yodha Ela functions as a moving reservoir and feeds about 4,600 hectares of paddy lands. It is a winding canal with about 120 smaller reservoirs on its way. It was constructed during the reign of King Dhatusena around 459 AD and later expanded by King Parakramabahu by connecting more reservoirs to the network. Unfortunately, during the Mahaweli project our modern-day engineers constructed a concrete canal replacing the winding path of this Yoda Ela also called Jaya Ganga. This effectively removed the ability of the old Yoda Ela to remove silt and nutrients. The bank of this Ela has wet zone trees such as jak and areca nut growing well. They take up the nutrients from the flowing stream making the water suitable for irrigation later.

Ancient Mesopotamian civilisations depended on dams constructed along the two main rivers, Euphrates and Tigris. After continuous irrigation of their fields over several thousand years, salinity of the irrigated lands increased making them unsuitable for agriculture. People died due to famine and this clearly illustrates the danger of blocking main rivers for agriculture. There is scientific evidence that the salinity of paddy soils in the Mahaweli C area is increasing.

We saw the devastation caused by Cyclone Ditwah. The sluice gates of the Kotmale Reservoir were opened, and Kandy and Peradeniya were flooded. If the reservoir had had greater storage capacity, couldn’t the opening of the gates have been delayed? This may not be an argument that modern-day engineers would readily accept, and I am not an irrigation expert. These ideas may well be naïve. But most of us tend to think of reservoirs mainly in terms of hydropower generation and irrigation, while their role in flood control receives much less attention. The question therefore deserves serious consideration. Could restoring lost reservoir capacity through desilting help improve our ability to manage extreme rainfall and reduce flood risks?

Desilting our reservoirs should be considered a national priority.

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Losing out to Ethiopia

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From Trailblazer to Tailender

Export diversification – Missing the wood for the trees – Part III

by Gomi Senadhira

In Sri Lanka, the word “Ethiopia” is often used as disparaging slang to describe individuals or areas experiencing extreme poverty, starvation, or severe economic hardship. This linguistic habit originated in the 1980s with the Western media coverage of the devastating Ethiopian famine of 1983-85. That media coverage shocked the world but also left an outdated and offensive global stereotype that the country is permanently starving. Much has changed since then. By now, with an annual growth rate of around 9%, it is the fastest-growing economy in sub-Saharan Africa. Ethiopia has also emerged as a highly competitive exporter and is challenging not only its competitors in the region but also countries like Sri Lanka. This article is on how Sri Lanka has lost ground to Ethiopia (and a few other countries) in the GCC markets for agricultural and floricultural products.

Sri Lanka – A Pioneer in the Agriculture and Floricultural Market in the GCC

As discussed in Part II of this article, by the mid-1980s Sri Lanka had established a strong foothold in the GCC’s fruit, vegetable, and floricultural market. Geographical proximity and well-established shipping and air links gave Sri Lanka a strong comparative advantage over Southeast Asian and African nations. Thailand, Vietnam, and Kenya were not even in the market. At that time, Ethiopia was experiencing (as BBC news reports described) “a biblical famine”.

The market was not very large, but it was lucrative and growing. Trade Minister Lalith Athulathmudali as well as the Chairman of the Export Development Board, Victor Santiapillai, who visited Kuwait (and the GCC countries), recognised the market potential for these products and encouraged us to continue with our work. The minister was particularly keen to further develop links between the market for these products, exporters, and his Export Production Villages (EPVs). So, it was becoming a successful case not only for export diversification but also for transferring gains from exports directly to rural households.

From Trailblazer to Tailender

As a result, even by the beginning of this century Sri Lanka had a larger market share than most of its competitors from Asia or Africa. But since then, our competitiveness has weakened significantly. The tables below provide a comparative snapshot of Sri Lanka’s performance vis-à-vis Thailand, Vietnam, Kenya and Ethiopia in the GCC market for vegetables, fruits and floricultural products. As illustrated therein, in 2001 Sri Lanka was ahead of Thailand, Kenya and Ethiopia in this small but rapidly growing market. Since then, we have fallen behind Thailand, Kenya and many other countries in that lucrative market. If this trend continues, Sri Lanka will fall behind Ethiopia within the next few years. (See Table 1)

In the GCC market for vegetables (covered in HS chapter 07), Sri Lanka was ahead of most other competitors in 2001. As illustrated in Table 1 , Sri Lanka had failed to develop this market, while Thailand, Kenya, and even Ethiopia had very efficiently increased their market shares. The GCC is a market to which Sri Lanka can supply some vegetables, like cabbages, by sea. It appears Sri Lanka had also failed to exploit this mode of supply.

We can see a similar trend in the market for fruits. Vietnam, Kenya, and Thailand have emerged as major players, while exports from Sri Lanka have staggered on slowly. In this segment, Vietnam has emerged as a leading player during the last twenty years and the GCC imports from Viet Nam have shot up from US$44 thousand in 2001 to US$346 million by 2024. In part one of these articles, I discussed the remarkable increase of jackfruit exports from Vietnam “…just $3 million in 2015 to an impressive $236.8 million in 2023” while most of our jackfruit production rots under the trees. This explains how countries develop their markets, geographically and product-wise. (See Table 2)

Sri Lanka’s performance has been weakest in the market for floricultural products (HS Chapter 06), which groups live trees, cut flowers, and ornamental foliage. When we first entered the market in the 1980s, the market was dominated by the Netherlands, and Kenya and Ethiopia were not even in the market. At that time, we identified the Gulf states as a market where Sri Lanka could have a dominant presence due to geographical proximity. Even in 2001, Sri Lanka was ahead of Kenya, Ethiopia, and Thailand. But by now, Kenya has emerged as the dominant supplier. Ethiopia is also expanding its market share and is the third-largest exporter. (See Table 3)

Missing the Wood for the Trees

In the mid-1980s, Sri Lanka first established its foothold in the GCC market. Since then, Thailand, Vietnam, Kenya, and even Ethiopia have moved well ahead of us and have become leading players. Why did we lag behind in our export diversification efforts in general and, more particularly, in the GCC market?

The reasons are very clear. After the initial attempts in the 1980s and early 1990s, Sri Lanka has not been proactively involved in identifying, developing, and promoting new products and markets, or protecting and further developing new markets already established. The focus has simply been on traditional exports: tea, coconut, cinnamon, and garments, while other products were almost ignored. In essence, we have been and continue to focus intensely on a narrow group of products and markets, and we have lost sight of the bigger picture.

(The writer can be reached at senadhiragomi@gmail.com)

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