By Dr. Pradeep Kariyawasam

(Former Chief Medical Officer of Health)

Chairman, Standing Committee on Health, Colombo Municipal Council

The Delta virus, which sneaked into the country by the middle of June this year, has made its way to almost all four corners of the country, due to lack of proper control measures. How did this happen? It is an interesting question as we have taken many measures to check on passengers that can bring it to this country from India, the UK or other countries where it is spreading fast these days. Although the guidelines changed with time about PCR tests and quarantine periods for foreign travellers, and locals who re-enter our land, they are quite adequate to prevent any entry of the virus with such travellers. Then how it was found in the Dematagoda area, in Colombo, was the million-dollar question.

Alpha variant

Previously, when the Alpha Covid-19 virus started to spread in the country, the Health Authorities always said they could connect the patients to a previously ill one and that there was no community spread. Some blamed the tourists who came from Ukraine or airline crew who rested in a hotel near Katunayake for spreading the virus in this country. These are far-fetched ideas considering that they were traveling in Bio-bubbles and were tested, and the locals involved in that operation also were monitored. Then the blame was put on the firm Brandix.

True they were lax in not understanding the importance of keeping away employees who were down with flu symptoms. If they did that under proper guidance, they would have helped at least to slow down the spread in the country as I believe that virus was in the community before entering their facility. I wonder whether a proper epidemiological investigation was ever conducted on how the virus entered that factory and then spread all over the country. Anyway, the results were never made public. So may be that there were other sources that spread the virus here.

Indian experience

How could that have happened? Our neighbour is India. Both Alpha and Delta variants were in India and at first the Alpha was the predominant variant which was later replaced by the Delta variant. Considering that our airports were on the lookout for passengers with the Covid-19 virus that was a little chance that it could sneak into the country easily. This disease is a communicable disease – spread from one person to another. It cannot come from the wind, blowing through India, although they say it remains in the air for 16 hours and that also obviously not in open air but in closed premises. I believe that this disease came to our island through the unofficial travelling between India and Sri Lanka. When one checks even today for the places where the disease is found, most of them are from coastal areas, even in the East or North. The lowering of the number of PCR, or antigen, tests carried out may be the reason why this was not detected earlier in these areas and this is the price that we have to pay. Talking of PCR and antigen tests I think carrying out random tests is like trying to find a needle in a haystack. What we should do in this late hour is target high risk areas, and, to do that prepare a grading system even for the city where history has shown where the communicable disease outbreaks happened before.

Unofficial travelling between the two countries was in existence for over 50 years. I remember when I was a school- boy, I visited Jaffna and found that people travel by boat to Madras just to watch a movie and then return the same night. Smuggling of sarees, cloth, shoes, etc., were well known and Valvettithurai was notorious for that. Coconut oil and soaps left our shores as far as I remember. Even during the war, arms were smuggled from India. Now I believe that the Delta virus arrived in Sri Lanka with the smugglers of heroin, or Kerala Ganja, when they creep into the country somehow despite many efforts by the Navy to stop it. Of course, it is the people who are infected with the virus from India that may have given it to our people, both smugglers and fishermen, but internally it was spread again from well-known drug selling areas. Dematagoda is one such well-known area for drug distribution. Patients were also found in Galle and Jaffna districts initially. These also could be areas where drugs are unloaded by the smugglers. So, there is an obvious nexus between drugs and the Delta virus spread in this country.

Dematagoda detections

When the Delta virus was found in Aramaya and Albion Roads, in Dematagoda, the obvious thing to do was put all resources to that ward and try our best to stop spreading it to other areas. A lockdown was imposed but when I checked at that time, I was told that people were roaming the streets nonchalantly. PCR testing was conducted but we do not know the numbers and no proper special vaccination programmes were conducted in that area. I think the Colombo Municipal Council and the Ministry of Health lost a golden opportunity to either stop the spread, at least in the city of Colombo, and the district, or at least slow the transmission to controllable levels. The reason is there were no Epidemiologists who have previous field experience involved in the decision-making and lack of understanding how epidemics can create havoc within a short period and of the need to nip them in the bud. What should have been done was firstly make the people in Dematagoda aware of the situation by getting the Public Health staff go from house to house and at the same time get the information out about people who have symptoms of Covid-19 from the residents or the community leaders. In the past, when I was the Chief Medical Officer of Health, I used this tactic to control disease outbreaks.

We had Health Educators who deployed Health Instructors, a category of public health workers who were only at CMC, courtesy the late President Ranasinghe Premadasa, who did this work. They formed Community Development Councils trained community leaders on community development, provision of basic amenities, hygiene, disease control and the need of Community Participation for the greater good of the people. Today instead of the 600-odd Community Development Councils that we had at that time just a handful are left and that also thanks to the senior Members of the Municipal Council. The cadre and the numbers of Health Educators, instructors have been reduced by people who have not an iota of an idea of the importance of such people in controlling disease outbreaks, creation of awareness and getting community participation. Unfortunately, in their hour of need the residents of Dematagoda did not get that help although MMCs in that area did their best to help the people. No Health Education work or awareness campaigns were done in the area except a vehicle going around announcing the outbreak just on one day according to residents.

New health instructors

The CMC appointed new Health Instructors recently but unfortunately those who got the appointments were already CMC staff members but it should have been young school leavers as it happened during the Premadasa era as the Minister wanted some knowledgeable youngsters to educate the public in slums and shanties.

Now, we have the Delta virus which is officially making around 3500 persons ill every day and perhaps double that number with symptoms are not seeking medical attention, and a further two to three thousand, who do not realise that they have the virus, are in the community. In any epidemic this is the case according to studies. Already we have 150-170 deaths a day, again officially, which is causing a mounting concern about the next few weeks where we may have around 600 deaths a day according to some sources.

Third wave

Lack of proper data is a great concern and I have been mentioning this issue for a long time now. When the third wave started there were nearly a 100 patients who died in their homes without either seeking medical help or not getting it. This is the lack of communication between the CMC and the city dwellers that I had highlighted earlier. In order to find out the reasons for home-deaths I wrote to the Chief Epidemiologist as the Chairman of the Standing Committee of Health & Sanitation to give me data about such deaths so that we at the Municipal Council can discuss the issues and take appropriate issues. I never heard from him. Some of this information is also available with the Municipal Council but it is a jealously guarded secret! Knowing the value of data and information I initiated the GIS for Health Information, way back in 1998 at the CMC as the Epidemiologist for CMC, a newly designated post created by former CMOH, the late Dr. Suranjan Silva. If that system was properly developed, by now we could have been in a position to indicate where the virus is and where it would go next and take appropriate action. We cannot control this epidemic with cooked up data. Every patient is important and so are their contacts. Unfortunately, today when someone gets ill and when they are asked to stay at home sometimes no one contacts them and the contacts are left alone to do whatever. This has become an impossible task and at least in the future the government should take measures to increase the numbers of PHIs, Midwives, Health Educators by 100% at least rather than have management and development assistants in their hundreds in offices.

Then comes the fact that now it is time to apply the theory that if humans don’t move the virus will also not move. But see what happened in the recent past. Protests, demonstrations and marches were allowed to take place in many areas in the country. It is a shame that teachers took the government to ransom to settle a 24-year dispute giving a wrong message to the society and no wonder we have undisciplined citizens in the country who have been brought up by the education system and that is clearly seen by the way they behave on the roads.

Shunning responsilibity

Although Inter-provincial travelling was banned, people got down from busses and walked across bridges and later hopped into a bus on the other side. Where is the social responsibility of the people who should understand that there is something that every one of us should contribute to get rid of this scourge? At least now let them realize that it is not the busses that move the virus but people! This is a land like no other.

All this points to a deluge of death and morbidity that we may have to face in the next few weeks if some thing different will not be done soon. We have a new Minister of Health and may be there should be new faces in the Covid-19 Task Force. They should infuse new thinking of how to prevent the spread than increasing the PCR testing and vaccination. The people should take part in this exercise and all local social organisations in the profiting from respective areas should be taking part in such activities but not be vigilantes so as to not push people who go down with Covid-19 out of their areas. While we encourage people contributing to this cause, we also have to get rid of people who profit illegally from this national disaster.

Already there are allegations of selling of vaccines, profiting from PCR testing, handing over the disposal of dead bodies from private hospitals to funeral parlours for considerations, hotels paying commissions to officials for directing patients and many more. These should be investigated properly and if the allegations are true then the culprits should be brought to book.

Way forward

What should be the way forward? I am totally against Lockdowns by the types we had earlier. That also promotes indiscipline as Lankans love to somehow circumvent the law and have their own way. It is better to have curfews but not for long periods but maximum for about a week and that would be better than loose four weeks travel restrictions and or so called-lockdowns. So let it be a curfew from this Saturday or Monday! This will also not harm the daily wage earners much. But please give at least three days of notice and see that the elite also not travel through provinces by this date armed with travel permits. In the future we have to take quick, strong and timely action to stop the transmission of the disease. For that we need proper data and maps before taking decisions. We must put the Epidemiology Unit in the fore-front of Covid-19 control now. If necessary, the Government should bring back those who have retired and put each province under one of them. The data provided now is not worth to take informed decisions. There should be enough young medical officers with IT knowledge who can bring out great analysed data and maps who can be put to work at the main Unit. But please share the data with others. Show the people where the disease is so that they avoid such places.

Data has shown that eight out of 10 people should stay at home for the corona virus to be controlled. This is an important message as sometimes even the vaccinated get ill. So, what can be done? What can be suggested is that at any time or any day both the Public and the Private Sectors should have only 20% of their office staff at work at least until the end of the year after the initial curfew. All government departments, businesses or institutions should have their own Covid-19 prevention health protocols in place catering to the specific needs of such places.

This is important especially for government institutions. Not only inter-provincial travel should be banned but even inter-district travel should be only for the essential staff. The manufacturing industry can have all their staff in bubbles by providing the staff with lodgings. The factories should reduce staff levels to 50% of the staff but with longer working hours having weekly rotations. The same goes for the building industry. They can have night shifts. The staff can be allowed home once a fortnight after being tested with a rapid antigen test. Private transport for the staff is important and that goes for the government workers also. They can use the school vans which are idling now. Those drivers and conductors in the transport services also should be vaccinated as a priority.

Task Force

As I had mentioned in an earlier article, the Covid-19 Prevention Task Force should work in smaller sub-committees: Disease Control; Security; Logistics, Vaccine procurement and delivery; Hospital Management; Economics, Manufacturing, Agriculture and Trade; Ambulance Service, etc., and meet the Task Force with their own decisions which should be conveyed at the meetings with the Head of the Govt. That meeting should be for only the key officials from these sub-committees or those who are invited specially to hear their opinions. Public Health staff should engage with local communities in the MOH areas to build trust for evidence-based actions to detect possible cases and encourage local leaders to support outbreak control response measures. Strategic decisions with regard to control measures should be taken at central level by an Expert Panel comprising of Epidemiologists, Virologists, Public Health and Hospital administrators. Keep out the ‘Wannabe Epidemiologists’ stupid ideas such as vaccinate people in ‘Virgin Areas’. They do more harm than good as too many cooks spoil the soup. A true Epidemiologist with years of experience gets a gut feeling of what should be done next. All vacancies for health staff should be filled at least temporarily especially, those in the public health workforce. Border control should be strict especially in the northern seas to prevent Delta virus entering the country. Fishermen should be told not to mix with Indian fishermen. All decisions should be based on guidelines, policies and decisions of the Task Force or Presidential directives based on worked out strategies, the analysed information, maps, risk assessments, and the epidemiological situation. The basic messages to the general public should be to wear a mask, wash the hands, keep social distance, get vaccinated, go for self-isolation and get medical help if they suspect they have the disease, home quarantine if required, etc. It is a must to have proper communications with people in the area and the health staff comprising of the field officers are the best to do this. Private or Government institutions not following guidelines and causing outbreaks should be taken to task severely. Stop all gatherings of people.

Natural decline

This epidemic will only stop due to natural decline that will happen when most of the people will get ill even mildly and have immunity against Covid-19 or by vaccination of the population as Israel did for their citizens. Considering the fact that even people in Dambane are down with the disease I think the former will win the race. But the latter should be our priority. People should as early as possible get their doses of the Covid-19 vaccine, whether it is the AstraZeneca, Sputnik V, Sinopharm or Pfizer vaccine that is available in their area. If we want to stop a deluge of deaths in the country this should be done immediately. All people over the age of 18 in high population density areas where the disease affected large numbers should be vaccinated and people in Colombo’s poorer areas should be given the priority and not the people with connections, power or money. We have to prevent Covid-19 but not at the cost of ruining the livelihoods of the people, especially the daily wage earners.