Features
Betel chewing a cardinal pleasure
Bulath in Sinhala, Vettila in Tamil and Malayalan, Paan in Hindi, Plu in Thai, Sirih in Malay are local names for betel (Piper betle) the tender leaf of which is the main ingredient in a chew. The other common additions are arecanut (Areca catechu), either raw or dried, sliced, shredded or cut into pieces and chunam from burnt chalk, coral or sea shells (slaked lime) and a piece of sun dried tobacco leaf for an added ‘kick’. The tobacco is said to have been introduced to the chew, also called a quid, by the Dutch when they were in these parts of the world as traders or rulers.
According to the region and availability fennel, turmeric, cumin, melon and cucumber seed, tamarind juice, coriander, nutmeg, ginger, cardamom, cinnamon, cloves and grated copra are added as desired. Lately, particularly in India, menthol, rose water and mint essences are added. In Sri Lanka `Saravita’ with many of these spices are sold off lighted trays by men signing songs with catchy tunes during peraheras and other similar events. High class Indian hotels offer such spiced and fragrant ‘vitas’ in place of After Eight Mints.
Some authorities believe that about one tenth of the human race is in the habit of chewing betel- some from morning to night, others at frequent intervals or after their main meals and still others on occasions only. The estimate is plausible as the habit is common throughout India, Pakistan, Bangladesh, Sri Lanka, Malaysia, Myanmar, Indonesia, Singapore, the Philippines, Papua New Guinea, Micronesia, Fiji, Maldives, Caroline Santa Cruz Island etc. Asian migrants have introduced the use of betel to the Middle East, some African and European countries and the USA as well.
For how long has the use of betel been known as a masticator – things people chew? A very long time indeed; well before smokes or fumitories known in the Eastern World for about ten centuries before the 1600s when Columbus introduced it to the West.
The Buddha in one of his reincarnations as a hare, according to a Jataka story, offered himself to God Sakra. The God was so moved that he painted the likeness of a hare on the moon and threw away the brush which fell on the world of Nagas or snakes. The King of the Nagas swallowed the brush (for what reason we do not know) and due to the consequent unbearable pain in his throat he died a few days later. A plant sprouted where he died and it was called giri-da-daly (throat burning leaf) now known as the betel vine.
Another origin of betel, according to others, is that it was created from the tip of a little finger of a Naga Queen. Irrespective of the origin it is said that the leaf was brought to the world of humans from the Naga’s world, thus called Nagavalli, by a snake holding the stem and leaf tip by its teeth. Others believe the snake held the leaf tip only. Whichever it was the older generation of betel chewers particularly in India and Sri Lanka, through fear of snake poison, discarded the leaf tip or both stem and tip when preparing a chew. Some removed even the prominent leaf veins close to the stem.
Just as much as betel is mentioned in the Jathaka story mention of it has been made in the Mahabaratha, Ramayana and Mahavansa as well.
Anthropologists have found traces of betel in the Spirit caves in Northwest Thailand dating back to 5500-7000 BC, which is even before systematic and organized agriculture came to be practiced. There have been similar findings in Timor in Indonesia going back to 3000 BC and in the blackened teeth of human skeleton in Palawan in the Philippines going back to 2600 BC. Even today some hardened betel chewers in Thailand, Myanmar and Indonesia with black teeth as a result of long years of chewing are proud of the discoloration as they say only animals have white teeth!
Betel chewing was prevalent in many parts of China up to about the 19th Century when the use of opium took its place. That was with the ‘kind assistance’ of the British for their ultimate benefit.
Even in the ancient Islamic civilization betel was known in Persia and some Arabic countries. But the habit died a few centuries ago as the leaf and ingredients had to be imported at great cost and it was also considered to be against Islamic teaching. However, followers of the religion in Sri Lanka, India, Pakistan, etc. are known to chew betel. In fact Sri Lanka exports considerable quantities of leaf and arecanut to Pakistan, the Maldives etc.
Betel has been a great social equalizer since ancient times – emperors and their subjects, landlords and their tenants, high officials and their subordinates all indulged in the habit without restrictions. Then and now it is not subject to taboos by any race such as various kinds of flesh and alcohol are. Even priests are allowed its use. To unmarried Brahmins it was taboo while Burmese children were encouraged to chew in the belief that they would speak their language well. However, some Sinhala elders of a few decades ago discouraged children from chewing in the belief that it would hinder their ability to pronounce English words correctly!
In India in early times betel chewing was considered one of the eight cardinal pleasures of a man or woman. Its value to enhance the quality of life was considered equal to food, sex, music, sleep, incense, flowers and perfume.
The Father of Indian Medicine, Sushruta in the first century AD said betel chewing tends to “cleanse the mouth, imparts a sweet aroma to it, enhance its beauty, cleanse and strengthen the voice, tongue, teeth, jaws and sense organs and acts as a general safeguard against disease.” An ancient writer in Sanskrit wrote that betel has twelve desirable qualities which are pungency, bitter, sweet, spicy, salty, astringent, it expels wind, kills worms, removes phlegm, eradicates odours, purifies all organs of the body and even induces passion!
A chew of betel is said to kill hunger and relieve tiredness which perhaps is the reason why some manual workers are often found chewing throughout the workday. This is certainly true of plantation workers. Robert Knox wrote that Sinhala men and women indulge in betel chewing to while away the hours of darkness before they went to sleep. He also had noted that an illicit lover indicates to the other their secret rendezvous by placing a betel leaf there. In the Caroline Islands experts were able to establish from fresh betel spit the sex of the spitter, what and when the last meal was, whether the person was walking leisurely or running and even more.
What is the modern thinking on betel chewing? Extracts from the lengthy essay ‘Betel Nut’ by the poet, scholar, script writer and critic Stephen Fowler are quoted below to give the views of a present day American.
Quote “Maybe you’re an ageing speed freak, too paranoid and out-of-touch to score the hard stuff anymore. Maybe you’re a khaki preppy looking for an alternative to espresso. Maybe you’re the hippie type optimistically attracted to a multi-cultural lift. Or maybe you just like to salivate. However, you kick it, betel is the ticket.
I was introduced to betel chewing six years ago in a bookshop in San Francisco’s Mission district. My instructor was a cynical young bohemian type prematurely returned from a visit to India.
The active principle in areas is the alkaloid arecoline. In pharmacological terms, arecoline stimulates the parasympathetic nervous system, resulting in a contraction of the pupils and an increased secretion of tears and saliva. The later is especially encouraged by areas, as is evident from this description of an early 20th century experiment in which a horse was injected with pure arecoline, “the saliva gushes forth from the animal’s mouth in a solid stream”. (Erich Hesse, Narcotics and Drug Addiction)
The acreca’s sister in crime, betel leaf, comes from a tree climbing vine (piper betle) of the pepper family. The shiny green leaf is heart shaped, and about the size of the palm of your hand. Its essential oil contains a phenol (betel phenol) similar to the aromatic eugenol found in the oil of cloves. Betel-phenol probably contributes stimulant properties of its own, but scant information is available on its pharmacology.
Like the coca-chewers of the Andes, betel users somehow discovered that the addition of lime helps to extract the vital essence of the plants into the saliva (and from there, of course, through the mucous membranes of the mouth and straight into the bloodstream). The catalytic lime is either powder (calcium oxide) or paste (calcium hydroxide). In either case, it is typically made from kiln-baked seashells.
What is it like to chew betel? Enthusiasts recognize three delightful aspects of the experience; the exhilarating lift; the mysterious flavour; and the cleansing; compelling salivation.
In the rare instances where scholarly literature mentions its subjective effects, the news about betel is uniformly good; “it imparts the repeatedly described sensation of well being, good humour, excitation and comfort. The consciousness, of course, remains unimpaired, and the chewer’s capacity for work is in no respect affected. (Hesse) It creates a feeling of energy, appeases hunger and assuages pain. (Henry Brownrigg)
Betel is not an amphetamine, after all. It is a complex of dilute plant alkaloids absorbed slowly through the mucous membranes of the mouth. The result is subtle and “natural” and offers none of that teeth-clenching, palm sweating, eye bugging over stimulation so familiar to users of stronger drugs. Betel is less jarring than espresso and it never leaves you feeling jangled.
Betel, or specifically areca, is an acquired taste; but for those who have acquired it, the flavour is darkly fascinating. It is spicy, though not hot spicy like cinnamon or ginger. It is tannic, but without sourness. It is sweet, though in no way is it sugary. It is a little reminiscent of chocolate, and a little reminiscent of dirt. Above all, the flavour of betel is exotic; and maybe it’s best left at that.
The most unusual (and visible) aspect of betel chewing is its effect on the salivary glands. You don’t just salivate, you pour; and the saliva emerges from your mouth tinted a deep brick red. It is not at all uncommon to spit four fluid ounces of ‘betel juice’ in a single session. And spit it you must; swallowing is not recommended, since it may cause an undesirable sensation of heartburn.
Perverse as it may sound, betel drooling is quite pleasurable indeed. There is an almost orgasmic satisfaction to be found in the experience of saliva-ducts open to full throttle. Delicious above all is the aftermath; when the chew is finished, your mouth is left astonishingly fresh and sweet. You feel uniquely cleansed, drained and purified.
Despite its charm for the initiated, however, this saliva rush is probably the greatest obstacle to betel’s acceptance in the West. Salivation is just too “primitive” for the sanitized First World. Travellers to India are frequently shocked by the red splotches that cover the streets and side walks; clearly this secretory excess strikes many Westerners as not just unaesthetic, but downright filthy. But how do those sidewalks really differ from our own, studded as they are with flattened grey globs of chewing gum? At least betel spit doesn’t stick to the sole of your shoe.
Then there’s the more serious accusation brought to bear by the US Food & Drug Administration; the betel contains “a poisonous or deleterious substance (arecoline) and that habitual chewing may be linked to oral carcinoma. Despite its authoritative tone, the FDA does not provide any medical data to support its allegation, and an examination of the available literature indicates that no conclusive studies have been carried out.
Some medical authorities even contradict the FDA. Dr. B.G. Burton-Bradley wrote in the Lancet that “Betel chewing is practiced daily by no less than 200 million people, the vast majority of whom do not have oral carcinoma” German pharmacologist Hesse stated that “Chronic excesses (of betel) do not cause any permanent health disorders.” Unquote Many Sri Lankan and Indian doctors will, of course, vehemently disagree with Burton- Bradley and Hesse.
Betel chewers specially the hardened ones have five essential utensils. They are the betel tray (in Sinhala thattuwa), container for chunam with an attached spatula (killote) aercanut cutter (giraya) spittoon or caspidor (padikkama) and if needed by the elderly without all their teeth a small mortar with attached pestle (bulath vangediya). In the days gone by in Sri Lanka these were all made of brass. The wealthier folk had some of these with inlaid designs in copper and sliver or gold in Myanmar and Indonesia.
In the Phipippines betel and the other ingredients were placed on intricately carved wooden trays and in some other countries in carved metal or wooden boxes. In the past when high officials or men or women of wealth had formal photographs of themselves taken they had these items close at hand on a table. Such was the importance of betle in their lives.
Of the paraphernalia used by betel chewers, Colombia University’s Prof. Samuel Eilenberg paid a special attention to arecanut cutters. He collected 187 cutters (now in the Metropolitan Museum of Art in New York) from several South East Asian countries which Henry Brownrigg describes in his book “Betel Cutters”. The book could however have been more appropriately titled “Arecanut Cutters”.
In the Anuradhapura Museum an arecanut cutter dating back to 993 AD is on display.
In Sri Lanka the most popular and commercially cultivated verities of betel are kahamaneru, ratadalla and galdalu. They are planted in well-managed irrigated beds under light shades and trained to climb up wooden stakes of about five feet in height for easy harvesting. A single vine yields about ten leaves every two weeks, six months after planting. However, village home gardens produce appreciable quantities of leaf for domestic consumption from vines, which climb up a variety of trees in the garden.
The leaves of some of these are somewhat coarse when compared to the cultivated varieties.
The economic importance of betel and arecanut to Sri Lanka is significant. In the first half of 1999 our export income from it was over Rs. 64 million and the Gross Domestic Product value of betel and arecanut in 1999 was 1% of the total rubber and tobacco in comparison were 1.6% and 0.2% respectively.
Arecanuts are generally not cultivated on a commercial scale and nuts come mainly from trees of self-sown seeds in practically every village garden in most parts of the country except those in the high elevations or very dry areas. The value of dried arecanut from exports in the first six months of 1999 amounted to over Rs. 330 million.
In 1999 the average price of 1000 betel leaves (medium) was Rs. 475.55 while 100 raw arecanuts sold for Rs. 99.65 (Source Dept. of Census & Statistics).
In Sri Lanka and many of the countries in which betel chewing is common betel it is intricately woven into their cultures. From the young man who seeks a woman’s hand in marriage until after death itself betel plays a significant role. In India in the days gone by parents of young men visit the homes of girls whom they seek in marriage for their sons taking betel. In the course of conversation a tray of betel is offered to the visitors and if the proposal is rejected the host overturns the tray as if by accident! Also if a visitor is unwelcome the offer of betel is unduly delayed and when it does appear it indicates the visitors should take their leave. In Indonesia, in the past, a man could express his wish to divorce by giving his wife three pieces of arecanut. It was as easy as that then.
Sri Lankan Buddhists decorate a Pirith Mandape with betel leaves and offer a tray of betel to the senior priest requesting commencement of chanting. A couple at the end of the marriage ceremony drop betel leaves on the Magul Poruwa to indicate to Mother Earth of their marriage and place betel leaves on the hood of the Poruwa to inform the Dewas of the union. Along with the traditional items of food, betel is placed on the dining table on Sinhala New Year day. After the meal the elder in the family hands over a coin placed on betel to each member of the family as a token of good wishes for the New Year. In their turn the young offer betel to the elders asking forgiveness for any lapses in the past year. They also offer betel to their parents to announce their success at examinations and such other important events. Elder relatives are invited to family weddings with betel.
In the past physicians, astrologers, high officials teachers, landlords etc. were offered a sheaf of betel consisting of forty leaves by those seeking assistance and with the stem end facing the recipient. Similarly, Buddhist Priests are invited to an Alms Giving with a sheaf of betel. A member of a bereaved family asks an elder relative to assist in the funeral arrangements with betel while in the funeral house itself betel leaves are placed under-side up in the thattuwa.
Betel chewing and its virtues have been expressed in the most glowing terms in the East from the very earliest of time and Westerners like Fowler and others do not look at the practice with the abhorrence they once did. In fact they too seem to share the views of ancient medical men such as Sushruta describing the flavour of betel as exotic and imparting a feeling of well being. Hence, an occasional ‘vita’ particularly after a hearty meal can be better than the once fashionable fumitories which are now universally frowned upon.
(This article was first published in 2002)
Features
Who Owns the Clock? The Quiet Politics of Time in Sri Lanka
(This is the 100th column of the Out of the Box series, which began on 6 September, 2023, at the invitation of this newspaper – Ed.)
A new year is an appropriate moment to pause, not for celebration, but to interrogate what our politics, policies, and public institutions have chosen to remember, forget, and repeat. We celebrate the dawn of another brand-new year. But whose calendar defines this moment?
We hang calendars on our walls and carry them in our phones, trusting them to keep our lives in order, meetings, exams, weddings, tax deadlines, pilgrimages. Yet calendars are anything but neutral. They are among humanity’s oldest instruments of power: tools that turn celestial rhythms into social rules and convert culture into governance. In Sri Lanka, where multiple traditions of time coexist, the calendar is not just a convenience, it is a contested terrain of identity, authority, and fairness.
Time is never just time
Every calendar expresses a political philosophy. Solar systems prioritise agricultural predictability and administrative stability; lunar systems preserve religious ritual even when seasons drift; lunisolar systems stitch both together, with intercalary months added to keep festivals in season while respecting the moon’s phases. Ancient India and China perfected this balancing act, proving that precision and meaning can coexist. Sri Lanka’s own rhythms, Vesak and Poson, Avurudu in April, Ramadan, Deepavali, sit inside this wider tradition.
What looks “technical” is actually social. A calendar decides when courts sit, when budgets reset, when harvests are planned, when children sit exams, when debts are due, and when communities celebrate. It says who gets to define “normal time,” and whose rhythms must adapt.
The colonial clock still ticks
Like many postcolonial societies, Sri Lanka inherited the Gregorian calendar as the default language of administration. January 1 is our “New Year” for financial statements, annual reports, contracts, fiscal plans, school terms, and parliamentary sittings, an imported date shaped by European liturgical cycles and temperate seasons rather than our monsoons or zodiac transitions. The lived heartbeat of the island, however, is Avurudu: tied to the sun’s movement into Mesha Rāshi, agricultural renewal, and shared rituals of restraint and generosity. The result is a quiet tension: the calendar of governance versus the calendar of lived culture.
This is not mere inconvenience; it is a subtle form of epistemic dominance. The administrative clock frames Gregorian time as “real,” while Sinhala, Tamil, and Islamic calendars are relegated to “cultural” exceptions. That framing shapes everything, from office leave norms to the pace at which development programmes expect communities to “comply”.
When calendars enforce authority
History reminds us that calendar reforms are rarely innocent. Julius Caesar’s reshaping of Rome’s calendar consolidated imperial power. Pope Gregory XIII’s reform aligned Christian ritual with solar accuracy while entrenching ecclesiastical authority. When Britain finally adopted the Gregorian system in 1752, the change erased 11 days and was imposed across its empire; colonial assemblies had little or no say. In that moment, time itself became a technology for governing distant subjects.
Sri Lanka knows this logic. The administrative layers built under colonial rule taught us to treat Gregorian dates as “official” and indigenous rhythms as “traditional.” Our contemporary fiscal deadlines, debt restructurings, even election cycles, now march to that imported drumbeat, often without asking how this timing sits with the island’s ecological and cultural cycles.
Development, deadlines and temporal violence
Modern governance is obsessed with deadlines: quarters, annual budgets, five-year plans, review missions. The assumption is that time is linear, uniform, and compressible. But a farmer in Anuradhapura and a rideshare driver in Colombo do not live in the same temporal reality. Monsoons, harvests, pilgrimage seasons, fasting cycles, school term transitions, these shape when people can comply with policy, pay taxes, attend trainings, or repay loans. When programmes ignore these rhythms, failure is framed as “noncompliance,” when in fact the calendar itself has misread society. This mismatch is a form of temporal violence: harm produced not by bad intentions, but by insensitive timing.
Consider microcredit repayment windows that peak during lean agricultural months, or school examinations scheduled without regard to Avurudu obligations. Disaster relief often runs on the donor’s quarterly clock rather than the community’s recovery pace. In each case, governance time disciplines lived time, and the least powerful bend the most.
Religious time vs administrative time
Sri Lanka’s plural religious landscape intensifies the calendar question. Buddhism, Hinduism, Islam, and Christianity relate to time differently: lunar cycles, solar markers, sacred anniversaries. The state acknowledges these mainly as public holidays, rather than integrating their deeper temporal logic into planning. Vesak is a day off, not a rhythm of reflection and restraint; Ramadan is accommodated as schedule disruption, not as a month that reorganises energy, sleep, and work patterns; Avurudu is celebrated culturally but remains administratively marginal. The hidden assumption is that “real work” happens on the Gregorian clock; culture is decorative. That assumption deserves challenge.
The wisdom in complexity
Precolonial South and East Asian calendars were not confused compromises. They were sophisticated integrations of astronomy, agriculture, and ritual life, adding intercalary months precisely to keep festivals aligned with the seasons, and using lunar mansions (nakshatra) to mark auspicious thresholds. This plural logic admits that societies live on multiple cycles at once. Administrative convenience won with the Gregorian system, but at a cost: months that no longer relate to the moon (even though “month” comes from “moon”), and a yearstart with no intrinsic astronomical significance for our context.
Towards temporal pluralism
The solution is not to abandon the Gregorian calendar. Global coordination, trade, aviation, science, requires shared reference points. But ‘shared’ does not mean uncritical. Sri Lanka can lead by modelling temporal pluralism: a policy posture that recognises different ways of organising time as legitimate, and integrates them thoughtfully into governance.
Why timing is justice
In an age of economic adjustment and climate volatility, time becomes a question of justice: Whose rhythms does the state respect? Whose deadlines dominate? Whose festivals shape planning, and whose are treated as interruptions? The more governance assumes a single, imported tempo, the wider the gap between the citizens and the state. Conversely, when policy listens to local calendars, legitimacy grows, as does efficacy. People comply more when the schedule makes sense in their lives.
Reclaiming time without romanticism
This is not nostalgia. It is a pragmatic recognition that societies live on multiple cycles: ecological, economic, ritual, familial. Good policy stitches these cycles into a workable fabric. Poor policy flattens them into a grid and then blames citizens for falling through the squares.
Sri Lanka’s temporal landscape, Avurudu’s thresholds, lunar fasts, monsoon pulses, exam seasons, budget cycles, is rich, not chaotic. The task before us is translation: making administrative time converse respectfully with cultural time. We don’t need to slow down; we need to sync differently.
The last word
When British subjects woke to find 11 days erased in 1752, they learned that time could be rearranged by distant power. Our lesson, centuries later, is the opposite: time can be rearranged by near power, by a state that chooses to listen.
Calendars shape memory, expectation, discipline, and hope. If Sri Lanka can reimagine the governance of time, without abandoning global coordination, we might recover something profound: a calendar that measures not just hours but meaning. That would be a reform worthy of our island’s wisdom.
(The writer, a senior Chartered Accountant and professional banker, is Professor at SLIIT, Malabe. The views and opinions expressed in this article are personal.)
Features
Medicinal drugs for Sri Lanka:The science of safety beyond rhetoric
The recent wave of pharmaceutical tragedies in Sri Lanka, as well as some others that have occurred regularly in the past, has exposed a terrifying reality: our medicine cabinets have become a frontline of risk and potential danger. In recent months, the silent sanctuary of Sri Lanka’s healthcare system has been shattered by a series of tragic, preventable deaths. The common denominator in these tragedies has been a failure in the most basic promise of medicine: that it will heal, not harm. This issue is entirely contrary to the immortal writings of the Father of Medicine, Hippocrates of the island of Kos, who wrote, “Primum non nocere,” which translates classically from Latin as “First do no harm.” The question of the safety of medicinal drugs is, at present, a real dilemma for those of us who, by virtue of our vocation, need to use them to help our patients.
For a nation that imports the vast majority of its medicinal drugs, largely from regional hubs like India, Pakistan, and Bangladesh, the promise of healing is only as strong as the laboratory that verifies these very same medicinal drugs. To prevent further problems, and even loss of lives, we must demand a world-class laboratory infrastructure that operates on science, not just sentiment. We desperately need a total overhaul of our pharmaceutical quality assurance architecture.
The detailed anatomy of a national drug testing facility is not merely a government office. It is a high-precision fortress. To meet international standards like ISO/IEC 17025 and World Health Organisation (WHO) Good Practices for Pharmaceutical Quality Control Laboratories, such a high-quality laboratory must be zoned into specialised units, each designed to catch a different type of failure.
* The Physicochemical Unit: This is where the chemical identity of a drug is confirmed. Using High-Performance Liquid Chromatography (HPLC) and Gas Chromatography-Mass Spectrometry (GC-MS), scientists determine if a “500mg” tablet actually contains 500mg of the active ingredient or if it is filled with useless chalk.
* The Microbiology Suite: This is the most critical area for preventing “injection deaths.” It requires an ISO Class 5 Cleanroom: sterile environments where air is filtered to remove every microscopic particle. Here, technicians perform Sterility Testing to ensure no bacteria or fungi are present in medicines that have to be injected.
* The Instrumentation Wing: Modern testing requires Atomic Absorption Spectrometers to detect heavy metal contaminants (like lead or arsenic) and Stability Chambers to see how drugs react to Sri Lanka’s high humidity.
* The injectable drug contamination is a serious challenge. The most recent fatalities in our hospitals were linked to Intravenous (IV) preparations. When a drug is injected directly into the bloodstream, there is no margin for error. A proper national laboratory must conduct two non-negotiable tests:
* Bacterial Endotoxin Testing (BET): Even if a drug is “sterile” (all bacteria are dead), the dead bacteria leave behind toxic cell wall products called endotoxins. If injected, these residual compounds cause “Pyrogenic Reactions” with violent fevers, organ failure, and death. A functional lab must use the Limulus Amoebocyte Lysate (LAL) test to detect these toxins at the parts-per-billion level.
* Particulate Matter Analysis: Using laser obscuration, labs must verify that no microscopic shards of glass or plastic are floating in the vials. These can cause fatal blood clots or embolisms in the lungs.
It is absolutely vital to assess whether the medicine is available in the preparation in the prescribed amounts and whether it is active and is likely to work. This is Bioavailability. Sri Lanka’s heavy reliance on “generic” imports raises a critical question: Is the cheaper version from abroad as effective as the original, more expensive branded formulation? This is determined by Bioavailability (BA) and Bioequivalence (BE) studies.
A drug might have the right chemical formula, but if it does not dissolve properly in the stomach or reach the blood at the right speed, it is therapeutically useless. Bioavailability measures the rate and extent to which the active ingredient is absorbed into the bloodstream. If a cheaper generic drug is not “bioequivalent” to the original brand-named version, the patient is essentially taking a useless placebo. For patients with heart disease or epilepsy, even a 10% difference in bioavailability can lead to treatment failure. A proper national system must include a facility to conduct these studies, ensuring that every generic drug imported is a true “therapeutic equivalent” to the brand-named original.
As far as testing goes, the current testing philosophy is best described as Reactive, rather than Proactive. The current Sri Lankan system is “reactive”: we test a drug only after a patient has already suffered. This is a proven recipe for disaster. To protect the public, we must shift to a Proactive Surveillance Model of testing ALL drugs at many stages of their dispensing.
* Pre-Marketing Approval: No drug should reach a hospital shelf without “Batch Release” testing. Currently, we often accept the manufacturer’s own certificate of analysis, which is essentially like allowing students to grade their own examination answers.
* Random Post-Marketing Surveillance (PMS): Regulatory inspectors must have the power to walk into any rural pharmacy or state hospital, pick a box of medicine at random, and send it to the lab. This could even catch “substandard” drugs that may have degraded during shipping or storage in our tropical heat. PMS is the Final Safety Net. Even the best laboratories cannot catch every defect. Post-Marketing Surveillance is the ongoing monitoring of a drug’s safety after it has been released to the public. It clearly is the Gold Standard.
* Pharmacovigilance: A robust digital system where every “Adverse Drug Reaction” (ADR) is logged in a national database.
* Signal Detection: An example of this is if three hospitals in different provinces report a slight rash from the same batch of an antibiotic, the system should automatically “flag” that batch for immediate recall before a more severe, unfortunate event takes place.
* Testing for Contaminants: Beyond the active ingredients, we must test for excipient purity. In some global cases, cheaper “glycerin” used in syrups was contaminated with diethylene glycol, a deadly poison. A modern lab must have the technology to screen for these hidden killers.
When one considers the Human Element, Competence and Integrity, the very best equipment in the world is useless without the human capital to run it. A national lab would need the following:
* Highly Trained Pharmacologists and Microbiologists and all grades of staff who are compensated well enough to be immune to the “lobbying” of powerful external agencies.
* Digital Transparency: A database accessible to the public, where any citizen can enter a batch number from their medicine box and see the lab results.
Once a proper system is put in place, we need to assess as to how our facilities measure up against the WHO’s “Model Quality Assurance System.” That will ensure maintenance of internationally recognised standards. The confirmed unfavourable results of any testing procedure, if any, should lead to a very prompt “Blacklist” Initiative, which can be used to legally bar failing manufacturers from future tenders. Such an endeavour would help to keep all drug manufacturers and importers on their toes at all times.
This author believes that this article is based on the premise that the cost of silence by the medical profession would be catastrophic. Quality assurance of medicinal compounds is not an “extra” cost. It is a fundamental right of every Sri Lankan citizen, which is not at all subject to any kind of negotiation. Until our testing facilities match the sophistication of the manufacturers we buy from, we are not just importing medicine; we are importing potential risk.
The promises made by the powers-that-be to “update” the testing laboratories will remain as a rather familiar, unreliable, political theatre until we see a committed budget for mass spectrometry, cleanroom certifications, highly trained and committed staff and a fleet of independent inspectors. Quality control of therapeutic medicines is not a luxury; it is the price to be paid for a portal of entry into a civilised and intensively safe healthcare system. Every time we delay the construction of a comprehensive, proactive testing infrastructure, we are playing a game of Russian Roulette with the lives of our people.
The science is available, and the necessary technology exists. What is missing is the political will to put patient safety as the premier deciding criterion. The time for hollow rhetoric has passed, and the time for a scientifically fortified, transparent, and proactive regulatory mechanism is right now. The good health of all Sri Lankans, as well as even their lives, depend on it.
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.
Joint Editor, Sri Lanka Journal of Child Health
Section Editor, Ceylon Medical Journal
Features
Rebuilding Sri Lanka Through Inclusive Governance
In the immediate aftermath of Cyclone Ditwah, the government has moved swiftly to establish a Presidential Task Force for Rebuilding Sri Lanka with a core committee to assess requirements, set priorities, allocate resources and raise and disburse funds. Public reaction, however, has focused on the committee’s problematic composition. All eleven committee members are men, and all non-government seats are held by business personalities with no known expertise in complex national development projects, disaster management and addressing the needs of vulnerable populations. They belong to the top echelon of Sri Lanka’s private sector which has been making extraordinary profits. The government has been urged by civil society groups to reconsider the role and purpose of this task force and reconstitute it to be more representative of the country and its multiple needs.
The group of high-powered businessmen initially appointed might greatly help mobilise funds from corporates and international donors, but this group may be ill equipped to determine priorities and oversee disbursement and spending. It would be necessary to separate fundraising, fund oversight and spending prioritisation, given the different capabilities and considerations required for each. International experience in post disaster recovery shows that inclusive and representative structures are more likely to produce outcomes that are equitable, efficient and publicly accepted. Civil society, for instance, brings knowledge rooted in communities, experience in working with vulnerable groups and a capacity to question assumptions that may otherwise go unchallenged.
A positive and important development is that the government has been responsive to these criticisms and has invited at least one civil society representative to join the Rebuilding Sri Lanka committee. This decision deserves to be taken seriously and responded to positively by civil society which needs to call for more representation rather than a single representative. Such a demand would reflect an understanding that rebuilding after a national disaster cannot be undertaken by the state and the business community alone. The inclusion of civil society will strengthen transparency and public confidence, particularly at a moment when trust in institutions remains fragile. While one appointment does not in itself ensure inclusive governance, it opens the door to a more participatory approach that needs to be expanded and institutionalised.
Costly Exclusions
Going down the road of history, the absence of inclusion in government policymaking has cost the country dearly. The exclusion of others, not of one’s own community or political party, started at the very dawn of Independence in 1948. The Father of the Nation, D S Senanayake, led his government to exclude the Malaiyaha Tamil community by depriving them of their citizenship rights. Eight years later, in 1956, the Oxford educated S W R D Bandaranaike effectively excluded the Tamil speaking people from the government by making Sinhala the sole official language. These early decisions normalised exclusion as a tool of governance rather than accommodation and paved the way for seven decades of political conflict and three decades of internal war.
Exclusion has also taken place virulently on a political party basis. Both of Sri Lanka’s post Independence constitutions were decided on by the government alone. The opposition political parties voted against the new constitutions of 1972 and 1977 because they had been excluded from participating in their design. The proposals they had made were not accepted. The basic law of the country was never forged by consensus. This legacy continues to shape adversarial politics and institutional fragility. The exclusion of other communities and political parties from decision making has led to frequent reversals of government policy. Whether in education or economic regulation or foreign policy, what one government has done the successor government has undone.
Sri Lanka’s poor performance in securing the foreign investment necessary for rapid economic growth can be attributed to this factor in the main. Policy instability is not simply an economic problem but a political one rooted in narrow ownership of power. In 2022, when the people went on to the streets to protest against the government and caused it to fall, they demanded system change in which their primary focus was corruption, which had reached very high levels both literally and figuratively. The focus on corruption, as being done by the government at present, has two beneficial impacts for the government. The first is that it ensures that a minimum of resources will be wasted so that the maximum may be used for the people’s welfare.
Second Benefit
The second benefit is that by focusing on the crime of corruption, the government can disable many leaders in the opposition. The more opposition leaders who are behind bars on charges of corruption, the less competition the government faces. Yet these gains do not substitute for the deeper requirement of inclusive governance. The present government seems to have identified corruption as the problem it will emphasise. However, reducing or eliminating corruption by itself is not going to lead to rapid economic development. Corruption is not the sole reason for the absence of economic growth. The most important factor in rapid economic growth is to have government policies that are not reversed every time a new government comes to power.
For Sri Lanka to make the transition to self-sustaining and rapid economic development, it is necessary that the economic policies followed today are not reversed tomorrow. The best way to ensure continuity of policy is to be inclusive in governance. Instead of excluding those in the opposition, the mainstream opposition in particular needs to be included. In terms of system change, the government has scored high with regard to corruption. There is a general feeling that corruption in the country is much reduced compared to the past. However, with regard to inclusion the government needs to demonstrate more commitment. This was evident in the initial choice of cabinet ministers, who were nearly all men from the majority ethnic community. Important committees it formed, including the Presidential Task Force for a Clean Sri Lanka and the Rebuilding Sri Lanka Task Force, also failed at first to reflect the diversity of the country.
In a multi ethnic and multi religious society like Sri Lanka, inclusivity is not merely symbolic. It is essential for addressing diverse perspectives and fostering mutual understanding. It is important to have members of the Tamil, Muslim and other minority communities, and women who are 52 percent of the population, appointed to important decision making bodies, especially those tasked with national recovery. Without such representation, the risk is that the very communities most affected by the crisis will remain unheard, and old grievances will be reproduced in new forms. The invitation extended to civil society to participate in the Rebuilding Sri Lanka Task Force is an important beginning. Whether it becomes a turning point will depend on whether the government chooses to make inclusion a principle of governance rather than treat it as a show of concession made under pressure.
by Jehan Perera
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