Features
Dining at the Victorian Bar and some racist encounters
Excerpted from A Life In The Law
by Nimal Wikramanayake
When I joined the Victorian Bar I wasn’t quite sure whether to attend the Annual Victorian Bar dinners. I thought that they might be the same rowdy affairs as they were in Ceylon. I had not attended the Bar dinner for 40 years until I received a wonderful invitation from that gracious lady, Melanie Sloss, then Chairperson of the Victorian Bar Council, and now a Supreme Court judge.
As I mentioned earlier, late in 1975 a number of us decided to leave the Calnin list and form a new list, the Duncan list. Dick McGarvie QC was our new chairman and Leo Lazarus QC was the vice-chairman. Dick decided to have a dinner so that he could meet and become acquainted the members of his new list.
The dinner was held, as far as I can recollect, in February 1976. Considerable quantities of alcohol were consumed by the new members before and during dinner. After dinner Dick McGarvie got up to speak. There were a number of inebriated rowdy barristers at this dinner. Several of them started shouting and bellowing “shut up” and “sit down” and made rude comments which I will not reproduce here.
With considerable aplomb, Dick stretched his hands out and said, “Gentlemen, please, no applause. Please no applause. You can applaud my speech when I finish.” This statement was greeted with roars of laughter and Dick went on with his speech uninterrupted. Afterwards he walked around and introduced himself to all the members of the new list. He walked up to my friend John Bolton and said, “My name is McGarvie.”
Bolton replied, “Arsehole, I’m not interested in your surname, what the fuck’s your Christian name?”
This story does not end there, for a month later Dick McGarvie was appointed to the Supreme Court. And who do you think appeared in the first case before Dick McGarvie? Bolton! Fortunately for Bolton, Dick McGarvie was a wonderful gentleman and he was extremely cordial to Bolton when he appeared before him.
Dick was no pushover. I remember one day appearing before him in the Practice Court when a young barrister turned up at 10.45 am to find that his case had been dismissed for non-appearance. He apologized to Dick and told him that he was sorry he was late but his watch was slow. Dick looked at him and asked, “What is the time on your watch now?” The young barrister went red in the face and started stammering. Dick told him never again to try to pull that chestnut on him.
The years rolled by and in 1982, although I had been at the Bar only ten years, I was appointed chairman of the Wayne Duncan list. We decided to have our annual dinner at a restaurant in Queen’s Road, which had formerly been a large family home. The meal was excellent, the speeches were good and we all had a good time. But, as usual, after the dinner, things began to deteriorate considerably. I was chatting with a few of my friends when someone came running up and told me that there was a disturbance between two barristers. Again, you must pardon me if I provide you with their names, for a good story is useless without names attached to it.
I was called to the disturbance to see a flaming row going on between the late Peter Jones and Betty King. I hope Betty will pardon me, as she has now retired as judge of the Supreme Court. Betty was sobbing and crying at the time. When I asked her what happened she told me that Peter Jones had flung her expensive shoes out of the hotel dining room and into the car park. It transpired that while Betty and Peter were having a dreadful row, Betty had pulled off one of her shoes to hit Peter with it. Peter promptly picked her shoe up and threw it out of the restaurant window, at which Betty pulled off the other shoe and tried to hit him; it suffered the same fate.
Several of us then went into the car park and spent about twenty minutes until we finally found Betty’s shoes. ‘thus list dinners in Victoria may sometimes, and I emphasize sometimes, be as bad as the Voet Lights dinners in Ceylon.
But don’t get me wrong, I had some very good times and some very interesting times at the list dinners. If one were to listen to the news every day, there is no good news reported on, because good news is not newsworthy. People would turn their television or radio sets off if they saw or heard about a couple walking happily through the Flagstaff Gardens. This is something I did regularly in my early years at the Bar with my two dear friends, Clive Rosen and Tony Lopes. In summer we would walk to the gardens and sit down to eat our sandwiches. But this is not newsworthy. It is thoroughly boring.
In 1982, my friend David Levin informed me that a young lad had arrived from England and wanted to join the Victorian Bar. He asked me if I could have him as a reader. His name was Richard Phillips and had been at the English Bar for a year. Richard’s period off reading with me was uneventful, save for one interesting incident. He would keep calling me “Nimal” as in “Malcolm’: I kept telling him that my name was “Nimull” as in “Mull” of Kintyre. I told him that “Nimal” a was Sanskrit word, and that Sanskrit was the mother of most European languages, coming from Mohenjo Daro in Central Asia over 5,000 years ago.
Richard looked at me, grinned and told me that I did not look 5,000 years old. Sadly, Richard Phillips died last year in the prime of his life. I expected my reader to bury me; I did not expect to have to bury him.
In September 1986, my second young man, Grant Holley, came to read with me. Life with my new reader was uneventful, save that when I moved rooms early in 1987, he moved all my law books by carrying about fifteen books at a time in his arms. He was and still is a delightful gent.
Racism at the Victorian Bar
Racism is an interesting topic and is usually spoken about in this country in hushed tones. However it has suddenly reared its ugly head in this wonderful country of ours. And thank God for that.According to some Queensland senators in the National Party, it would appear to be non-existent in Australia. Some Australians will never admit that they are racist, and racism is unfortunately swept under the carpet. In 2004, a neighbour of mine on the ninth floor of Owen Dixon Chambers West told me that he finds it quite distressing when he goes to see his parents-in-law. They are both bigoted and racist, and often talk in disparaging tones about migrants, whether black, brown, yellow or white.
A human being’s unusual physical features, be it a man or a woman, can always be the subject of derision. A fat man, a shortsighted woman, a boss-eyed person, a hunchback are all the subject of twisted humour by their more fortunate peers. Colour has always been brought into this equation. Does the fact that one person has peculiar physical features make the other person without these characteristics a better or superior person? Is a person with dark skin inferior to a person with white skin?
John Howard said Australians are not racist. I beg to disagree. A fair number of Australians are racist although a large number aren’t. It reminds me of an incident that occurred in the late 1940s in Ceylon. We had all gone to see and hear the famous Methodist preacher, Dr Leslie Weatherhead, speaking. After he finished his talk he called for questions. A friend of mine who fancied himself a humourist got up and asked Dr Weatherhead, “Can Christians dance?” It was a poorly phrased question and Dr Weatherhead came back quickly with this answer: “Some can, some can’t:’ My friend disappeared from the hall quite sheepishly, followed by loud applause.
The Australian male often delights in denigrating a man or woman with a darker complexion. His humour is both callous and insensitive, and he may not be aware of the hurt he is causing because he thinks his remarks are funny. Some white members of parliament who have not been the subject of racial innuendo want to amend the Racial Discrimination Act so that I can be called a “nig-nog” without any adverse repercussions. Fortunately I have had only a few bad experiences of racism at the Victorian Bar during a career of over 40 years, but these experiences are more than enough.
My friend Tony Lopes, who unfortunately has now left the Bar, had a room on the seventh floor of Owen Dixon Chambers in the 1970s. I would often go up to his room to talk to him or he would come down to my room on the third floor to visit me. On the seventh floor there was a barrister who was known as “Fascist Bob” because of his foul mouth. Whenever I went up to see Tony Lopes, Fascist Bob would say, “Hello, blackie!” This was the normal way in which he greeted me. I could never fathom why he greeted me like this. I did not pay much attention to it as it was just a fleeting greeting and I rarely saw him.
However, in 1982 Fascist Bob got a room on the third floor where I had my chambers. Shortly after he arrived on my floor, I was coming out of the lavatory when I met Fascist Bob. He said, “Hello, blackie’
I was angry and I knew that I had to nip this behaviour in the bud. I said, “Good God, if you are the epitome of the white Anglo-Saxon race, God help your race, because you are an ugly-looking bastard. In fact, I am much better looking than you,” and I walked away.
A few days later we met again in the lavatory and Fascist Bob opened the batting by repeating, “Hello, blackie.”
I replied, “You’re the sort of skunk who, if he saw a hunchback, boss-eyed girl, would say, ‘Jesus Christ, what an ugly-looking bitch you are:”
Fascist Bob said, “What’s that got to do with the price of fish?” I retorted, “What has my colour got to do with the price of fish?” and walked off.
A few days later we again met in the lavatory. This would appear to be our only meeting place. And he began by saying, “Hello blackie:’
I was very angry and told him I was getting pretty fed up with this and to stop it at once. All this occurred, I believe, in the year 1984 when Owen Dixon Chambers West had just been completed.
Early in 1984 a room had been advertised for viewing by members of the Bar who wished to take rooms in Owen Dixon Chambers West. A number of us on the third floor decided to go over and have a look at these rooms.
They were Maurice Phipps, now a Federal Court magistrate, John Coleman of counsel and his secretary Judy as well as another secretary, and a lady barrister, Rose Weinberg, the wife of Justice Weinberg, formerly of the Court of Appeal. I also went up to see this room. There was insufficient bookshelf space and I remarked to the person who was showing us around, “There aren’t many bookshelves in this room”
Just then Fascist Bob walked in and said, “A black bastard like you with no brains, what do you need bookshelves for?”
I was livid and just exploded. Maurice Phipps and John Coleman had to escort me out of the room. I wonder whether Phipps and Coleman remember this incident as it happened over 35 years ago. Unfortunately, Robert Johnstone is dead and cannot contradict my version of the events.
After this encounter, whenever Fascist Bob tried to talk to me I would stop, look him up and down, insult him and walk away. Maurice Phipps should remember this because he was in the room opposite me and spent a considerable amount of time trying to pacify me and get me to make up with Fascist Bob. I steadfastly refused to do this for over a year. Instead, I would make it a point to insult him. He never called me “blackie” again. I remember John Coleman also trying to patch up this quarrel.
I experienced several nasty incidents of racism with ‘ABC” He came to the Bar in the early 1970s and considered himself to be eccentric. I met him one day near the lift in Owen Dixon Chambers and he suddenly blurted out, “Hello Sambo, down from your tree?” I was completely shattered by this unnecessary and unseemly remark. I quickly left the foyer. I met him a few days later again in chambers, and we were walking towards each other when he repeated his remark: “Hello Sambo, down from your tree?”
I said, “ABC, I came down from my tree 5,000 years before you did. For if you remember your history, Mohenjo Daro in Central Asia is the cradle of civilisation.” I walked away in disgust.A few days later I went up to the coffee bar on the 13th floor to get myself a cup of coffee. There was a long table adjacent to the coffee bar and seated at it were a number of barristers. I remember three of them – Robert Richter, Boris Kayser and, of course, our young hero, ABC. ABC shouted out, “Hello Sambo!”
I had had enough and walked up to him. “What did you say?” He began to reply when Robert Richter told him, “ABC, look, you had no business talking to Nimal like that’
This incident happened over 40 years ago; I wonder whether either Robert or Boris remembers it. I pulled a chair up to their table and sat down, looked ABC in the eye and asked, “How old are you?”I believe he replied “Twenty-four.” I then proceeded to dress him down in language which cannot be repeated here. The incident cannot be denied.
As I was putting these incidents with ABC in writing, I decided to investigate this matter further. I telephoned Robert Richter and discussed this incident. Robert had a clear recollection of the incident. However he told me that unfortunate as this incident was, ABC had a warped sense of humour and a bad mouth. This was ABC at his worst. He thought he was being funny. Robert told me that he had cautioned him on numerous occasions about his bad mouth. He told me that ABC did not have a racist bone in his body. He was a strong supporter of Aboriginal rights and had been for many, many years. Why then did he have to hurt me?
I was invited to an exhibition of paintings on the thirteenth floor in 1982. I took my wife, Anna Maria, along with me and we walked into the exhibition. Who do you think we saw? It was our hero wearing a Singapore rickshaw coolie’s long blue shirt. I burst out laughing when I saw him and I told Anna Maria, “Look who’s here? It’s that racist shit, ABC.”
Features
Social justice in suspense: Sri Lanka’s welfare legacy in an era of austerity
by Prof. M.W. Amarasiri de Silva
The evolution of Sri Lanka’s social policy framework represents one of the most compelling, paradoxical, and debated case studies in the global political economy of development. Often celebrated as an exceptional model among developing nations, Sri Lanka achieved human development indicators, such as high adult literacy, elevated life expectancy, and low infant mortality, that rivaled those of industrialised Western societies, despite maintaining a low-to-middle per capita income. This distinct trajectory was fundamentally sculpted by the establishment of an extensive welfare state, characterised by universal healthcare, free education, and pervasive food subsidies.
However, the long-term impact of this historical welfarism on present-day Sri Lanka presents a complex matrix of social triumph, economic vulnerability, and systemic crisis. To fully comprehend how the historical welfare state has shaped contemporary Sri Lanka, one must trace the institutional genesis of these policies through the critical frameworks provided by eminent social theorists, notably Ralph Peiris in his analysis of Asian development styles and Laksiri Jayasuriya in his landmark work on Sri Lanka’s experience of social development directed toward equity and justice.
Foundation of welfare state
The structural foundation of Sri Lanka’s welfare state was not a post-colonial luxury, but rather a late-colonial construct deeply interwoven with the dynamics of democratization and constitutional reform. As Laksiri Jayasuriya meticulously argues in his historical and theoretical explorations of Sri Lankan social policy, the trajectory of the country’s social development was rooted in the state-building exercises of the late British colonial era. The introduction of universal adult suffrage under the Donoughmore Constitution of 1931 served as a pivotal catalyst. By enfranchising the local population decades before formal independence in 1948, the colonial state altered the political elite’s incentives.
Politicians were suddenly forced to seek electoral legitimacy from a vast, rural, and economically disadvantaged populace. This constitutional shift institutionalised what Jayasuriya terms a culture of ‘welfare politics,’ where competitive electoral democracy became intrinsically linked to the provision of social goods.
During the period spanning from the 1930s to the 1950s, the state laid down the three pillars of its social safety net: free state-provided healthcare, free universal education from primary to university levels (championed by C.W.W. Kannangara), and a heavily subsidised food rationing scheme, most notably the rice ‘polu’ (haal polla) system. In the popular Sri Lankan vernacular and historical memory, these restrictive barriers and checkpoints became closely associated with the rationing culture surrounding the rice distribution and cooperatives where state-allocated rice rations were obtained via coupon books.
Jayasuriya highlights that these measures were conceived not merely as safety nets for the destitute, but as fundamental rights of social citizenship modeled partly on the egalitarian principles of the British post-war welfare state yet adapted to a post-colonial environment seeking equity and social justice. This social democratic commitment was maintained across alternating political regimes, creating a broad cross-party consensus that state-funded welfare was an untouchable social contract between the state and its citizens.
Policy trajectory in perspective
To place this unique policy trajectory in a broader comparative perspective, Ralph Peiris’s conceptualisation of ‘Asian Development Styles’ offers a critical lens. Peiris examined how different Asian nations navigated the tensions between Western models of modernisation, economic growth, and indigenous social structures. Many East Asian economies—such as South Korea, Taiwan, and Singapore—adopted a development style centered on ‘growth-first’ imperatives, state-directed capitalism, and the deferral of widespread social expenditure until after rapid industrialisation was achieved. In contrast, Sri Lanka pioneered a distinct ‘social-led’ development style within South Asia. Peiris observed that Sri Lanka’s development style prioritized human capability, social redistribution, and basic needs over raw capital accumulation. This style reflected a socio-cultural ethos that viewed social harmony, equity, and state paternalism as integral to governance, resisting the purely utilitarian or market-driven metrics of economic progress.
The immediate consequences of Sri Lanka’s socio-centric development style were undeniably positive in terms of human wellbeing. By the late 20th century, Sri Lanka had achieved a physical quality of life index that far surpassed its South Asian neighbors. Maternal and infant mortality rates dropped precipitously due to widespread access to free public health facilities and midwife networks. Universal education fostered a highly literate electorate, dramatically closed the gender gap in basic and secondary education, and enabled significant upward social mobility for marginalized caste and rural communities. Jayasuriya emphasizes that this commitment to equity and justice transformed the social fabric, democratising access to public life and cultivating a politically conscious citizenry that viewed education and healthcare as non-negotiable entitlements.
However, the enduring legacy of this historical welfare state is dual-edged, carrying deep-seated economic contradictions that directly contributed to present-day Sri Lanka’s socio-economic landscape. The central paradox of the Sri Lankan welfare state lay in the disconnect between social expansion and economic productivity. While the state committed huge fractions of its national budget to social consumption, it failed to build a resilient, diversified industrial export base capable of generating the revenue necessary to sustain these expenditures over generations. The primary revenue source funding the early welfare state was the taxation of the colonial-era plantation export economy—primarily tea, rubber, and coconut. As global commodity prices fluctuated and deteriorating terms of trade eroded plantation revenues in the post-independence decades, the state faced severe fiscal deficits.
Macroeconomic imbalances
The fiscal strain of maintaining universal subsidies led to severe macroeconomic imbalances by the 1970s. The state attempted to manage these pressures through import-substitution policies, strict price controls, and state monopolies, culminating in the closed economy of 1970–1977. While this period sought to preserve the egalitarian principles articulated in Jayasuriya’s analysis of social justice, it resulted in severe shortages of essential goods, economic stagnation, and rising unemployment among the newly educated youth. The inability of the economy to absorb the expanding class of literate, ambitious young citizens created a structural mismatch between educational output and employment opportunities.
This socio-economic disjunction erupted into violent political crises. The educated yet economically disenfranchised rural youth became the primary base for insurgencies, such as the Janatha Vimukthi Peramuna (JVP) uprisings in 1971 and 1987–1989. Concurrently, the failure to extend equitable socio-economic and political opportunities to the Tamil minority—compounded by language policies that prioritized the Sinhala majority in public sector employment—fueled ethnic marginalization, eventually escalating into a devastating nearly three-decade-long civil war. Thus, as both Jayasuriya and Peiris observe in their respective analyses, while the welfare state was designed to promote social cohesion and equity, its economic unviability and politicization contributed to social frustration and structural conflicts when the economy failed to fulfill the aspirations created by universal social programs.
Janasaviya, Samurdhi and Aswesuma
A profound structural turning point occurred in 1977, when Sri Lanka became the first country in South Asia to abandon import-substitution and embrace neoliberal market-oriented economic reforms. The advent of the ‘Open Economy’ signaled a major shift in the state’s social policy regime. As Jayasuriya notes in his critique of the post-1977 retreat from the welfare state, universal welfare policies were systematically dismantled or reconfigured into targeted, means-tested poverty alleviation programs. The universal food subsidy was replaced by food stamp programs and later by targeted cash transfer schemes such as Janasaviya and Samurdhi, and eventually Aswesuma.
This transition from universal social citizenship to targeted safety nets marked a fundamental redefinition of the social contract. While the 1977 open market policies stimulated economic growth, foreign investment, and infrastructure development, they also led to rising income inequality, regional disparities, and the commercialization of public goods. The state’s fiscal commitment to public education and health gradually eroded as a percentage of GDP, leading to a dual-track system.
Underfunded state healthcare and education systems remained free but suffered from resource constraints, overcrowding, and quality decline, while a burgeoning private sector in health and tuition-based education emerged to cater to the affluent. Jayasuriya argues that this marketization of social services undermined the egalitarian ideals of social justice that had historically anchored the nation’s social policy.
The contemporary manifestation of this historical trajectory became starkly apparent during the unprecedented economic crisis that engulfed Sri Lanka in 2022 and its continuing aftermath. The crisis—characterized by sovereign debt default, hyperinflation, severe foreign exchange shortages, and acute shortages of fuel, medicines, and food—exposed the fragile structural foundations of the country’s political economy. The roots of this crisis are inextricably linked to the unresolved tension between public expectations built by historical welfarism and modern neoliberal fiscal mismanagement.
Welfare and populism
Over recent decades, successive governments continued to rely on populism to secure electoral victory, promising subsidies, tax cuts, and public sector employment without building a sustainable tax base or correcting structural economic deficits. When the state faced catastrophic revenue declines following ill-advised tax cuts in 2019, combined with the shock of the COVID-19 pandemic and debt-driven infrastructure spending, the fiscal apparatus collapsed. The resulting austerity measures, mandated under International Monetary Fund (IMF) stabilization programs, forced sharp reductions in energy subsidies, increased indirect taxation, and deep spending cuts that severely hit vulnerable populations.
In present-day Sri Lanka, the legacy of the welfare state manifests as both a vital buffer and a site of intense political contestation. On one hand, the historical infrastructure of universal health and basic education has prevented an even more catastrophic loss of human life during the peak of the recent economic collapse. The enduring social capital, public health institutions, and high literacy rates provided a baseline of societal resilience that assisted communities in coping with immense economic shock. The persistent popular memory of social entitlement has also fueled widespread civic mobilization, as demonstrated by the Aragalaya mass protest movement in 2022, which demanded accountability, social justice, and an end to political corruption—echoing the deeply ingrained political culture of democratic accountability that Jayasuriya identified as a byproduct of early welfarism.
Challenge of restructuring social policy
Contemporary Sri Lanka faces the immense challenge of restructuring its social policy framework in an era of stringent fiscal constraint. The rollback of state subsidies and the rising cost of living have pushed millions of citizens below the poverty line, threatening to reverse decades of hard-won human development gains. Malnutrition rates among children have spiked, access to essential imported life-saving medicines has been compromised, and the real value of state pensions and social assistance has been severely eroded by inflation. The targeted social safety nets, such as the Aswesuma welfare scheme introduced to replace Samurdhi, have faced significant administrative challenges, exclusion errors, and public resistance, reflecting the ongoing difficulty of transitioning from universal rights-based social protection to targeted relief mechanisms in a deeply distressed economy.
Furthermore, the contemporary economic crisis has intensified a major ‘brain drain,’ as highly educated medical professionals, engineers, university lecturers, and skilled workers migrate abroad in large numbers. This mass emigration directly exposes the present-day crisis of Sri Lanka’s historical social model: the state continues to invest significant public resources into providing free secondary and tertiary education, but the domestic economy fails to offer economic stability and professional opportunities to retain this human capital. Consequently, the social returns on the state’s educational investment are increasingly captured by developed nations, leaving domestic public institutions further depleted.
In evaluating the contemporary impact of Sri Lanka’s social policy through the theoretical insights of Ralph Peiris and Laksiri Jayasuriya, it becomes evident that Sri Lanka’s history is neither a pure success story nor an absolute policy failure. Ralph Peiris’s emphasis on Asian development styles reminds us that development cannot be reduced merely to economic output metrics; the deliberate choice to prioritize human capabilities and social equity established an enduring standard for human welfare in the global South. However, as Jayasuriya’s critical analysis reveals, a welfare state cannot exist in an economic vacuum. The failure to integrate social policy with a productive, sustainable, and equitable economic strategy created structural vulnerabilities that ultimately undermined the very social justice the state sought to achieve.
Socio-economic contradiction
This socio-economic contradiction has entered a critical new phase under the administration of President Anura Kumara Dissanayake and the National People’s Power (NPP) government, which assumed office with an explicit mandate focused on systemic corruption reform and equitable development. Facing the stringent structural constraints of post-default economic management, the administration has adopted a pragmatic, hybrid economic framework designed to reconcile Sri Lanka’s historic social protection legacy with strict international fiscal discipline. Rather than abandoning structural reforms, the government maintains continuity with the Extended Fund Facility agreement managed alongside the International Monetary Fund (IMF), adhering to primary budget surplus targets and progressive revenue-mobilisation goals. However, it attempts to reorient macroeconomic priorities away from elite-driven financialization toward a state-regulated, productive market economy centered on public sector transparency, digitalization, anti-corruption legislation, and the revitalisation of local agriculture and manufacturing.
Policy of rebalancing
This policy rebalancing directly reflects the enduring relevance of Peiris’s ‘Asian development style’ framework, as the state seeks to build export competitiveness while retaining public oversight of basic social safeguards. Yet, as Jayasuriya cautioned in his critiques of targeted safety nets, managing fiscal austerity within a political culture historically accustomed to universal state entitlement poses severe domestic challenges. High living costs, continuous pressure on public sector wages, structural poverty, and the persistent outflow of skilled human capital leave narrow margins for error. Contemporary Sri Lanka’s economic policy thus represents an ongoing attempt to construct a viable, modern economic model—one that generates sustained productivity and debt sustainability while preserving the foundational democratic imperative of equity and social justice that has defined the nation’s post-colonial identity.
Features
Cholesterol lowering statins: Scope for use widens
by Dr Upul Wijayawardhana
In my medical practice of just under 57 years, divided almost equally between Sri Lanka and the UK, I have been fortunate enough to meet some remarkable patients who demonstrated indomitable fortitude. Not that there were no nasties, but, fortunately, they were extremely rare. Now well into my retirement, I can still vividly remember some remarkable cases as if they happened yesterday. One of them well illustrates what happens when prescription warnings are ignored; that can result in drug interactions producing nasty, sometimes lethal, side effects.
A man in his sixties was admitted under my care to Grantham Hospital with progressively increasing muscle pain and weakness, being almost bedbound by the time of admission. It was pretty obvious that there was extensive damage to muscles which was confirmed by huge elevation of markers of muscle damage. A careful history, one of the vital steps needed for diagnosis, revealed that he was on long-term statin therapy following a heart attack and his GP has recently prescribed an antifungal agent for an infection in the groin. This was before the computerised prescription era and is not likely to have happened now, as a red-alert would be displayed as antifungals are known to produce severe interactions with statins. Both drugs were stopped, and with supportive therapy, he recovered fast and walked out of the ward two weeks later. He was started on a different statin later with no problems.
Would this experience make me join the vast numbers of YouTubers who are harping on the dangers of statins? Definitely not. I say so because the benefits of statins far outweigh the rare side-effects. All drugs have side effects and, in some trials, placebos producing more side effects than the active drug itself! Drugs need to be prescribed by those with education and experience whilst prescribers need to be updated regularly. Statins, perhaps, are the most widely used class of drugs and the scope for use is widening with the reporting of new clinical trials, two significant trials being presented at the European Society of Cardiology Congress held last month in Munich.
It was known for a long time that elevated levels of cholesterol in blood leads to damage of arterial walls (atherosclerosis) which manifests as cardiovascular disease including heart attacks, cerebrovascular disease including strokes and peripheral vascular disease. Various attempts at lowering cholesterol effectively by diets, drugs and surgery were largely unsuccessful till statins were discovered and it was soon realised that cholesterol synthesis by the body is more important than ingestion of cholesterol rich foods and saturated fats. Statins inhibit cholesterol synthesis in the body and the first statin released for therapeutic use was Lovastatin in 1987, but wide use of statins started only after the release of results of the landmark 4S trial in 1994.
The Scandinavian Simvastatin Survival Study (4S) was a multicentre, randomised, double blind, placebo controlled clinical trial which used Simvastatin, the second statin released for use a year later in 1988. 4444 patients, who previously had a heart attack or were having angina with moderately elevated levels of cholesterol, in spite of rigorous dieting, were recruited from 94 centres in Scandinavia. After follow-up of 5.4 years, compared to the placebo group, it was shown that the group treated with Simvastatin showed lowering of LDL cholesterol (Bad Cholesterol whereas HDL cholesterol is protective) by 35% and, more importantly, lowering of death rate by 30%. A follow-up study of 10 years showed continuing benefits. More trials and more statins followed.
Though Simvastatin had widespread use initially, the more powerful Atorvastatin, launched in 1997, overtook producing more dramatic results in subsequent clinical trials. Till the introduction of monoclonal antibodies (mAbs), laboratory produced proteins that mimic the immune system and capable of targeting antigens in cells or pathogens (which can be identified as the drug names end with ‘mab’) Atorvastatin was the highest grossing drug of all time, in spite of prices dropping sharply. There had been a proliferation on mAbs as many are used in a number of cancers and auto-immune diseases, earning more money as they continue to be expensive.
I remember a meeting I attended, just after the results of the 4S trial was released, where fears were expressed whether the NHS would go bankrupt if all eligible patients were prescribed Simvastatin. Widespread use has brough prices tumbling down, a tablet of Atorvastatin now costing in UK only 3p!
Though the initial trials were for secondary prevention, reduce recurrence after the disease has manifested, subsequent trial were aimed at primary prevention, preventing or delaying disease occurrence in those with high risk factors. These too showed significant benefits and the scope for use of statins continue to expand. Two significant trials were presented at the ESC congress.
The first was the STAREE study, which enrolled 5000 persons, over the age of 70 in Australia, with no history of cardiovascular disease, diabetes or dementia and half got Atorvastatin 40mg daily, the other half getting a placebo. Results showed a significant 30% reduction of a composite end point of death from cardiovascular causes, nonfatal myocardial infarction, stroke or coronary revascularization. Interestingly, incidence of serious adverse effects was similar in both groups being 2.6%. There was no significant reduction of death rate by itself. Perhaps, this is explained by most deaths being due to non-cardiac causes in this age group.
The second was a Danish observational study, where researchers assessed whether early initiation of statins after the diagnosis of type 2 diabetes was associated with a lower risk of dementia. Over 10 years, early statin initiation was associated with a 15% lower relative risk of dementia than no statin treatment, while late initiation was associated with a 10% lower risk. Though they studied the records of 132,585 patients, as this is an observational study, not a double blinded clinical trial, results are not as convincing and may have to be reaffirmed by further studies.
How will the results of these two trials affect clinical practice?
To act on the results of these trials is not difficult in the UK. Those over 80 years are already offered a statin and it would not be difficult for GPs to extend use to those over 70. Most diabetics, unless relatively young, are likely to be on a statin already, as they are categorised as high risk. There are no cost implications to patients as diabetics and those over 65 years get all their drugs free from NHS.
Unfortunately, things are likely to be very different in Sri Lanka. Diabetes is rampant and dementia is on the rise. As life expectancy is increasing and those over 70 being an ever-increasing group. Diabetics may be able to get a statin from government hospitals. However, there is no provision for free supply of statins for over 70 group, as this is for primary prevention. With exponentially increasing cost of living, retirees may find it difficult to afford a statin.
Ideally, Atorvastatin 40mg daily, the dose used in the trials, should be taken though one can argue that other statins may be effective as benefits are likely to be a group effect. As many trials used the 40mg dose, Pfizer decided to price 10mg, 20mg and 40mg Atorvastatin tablets the same, but this is unlikely in Sri Lanka, what is available being generics; Atorvastatin went out of patent protection in 2011. If 40mg tablets are significantly more expensive, perhaps, a lower dose could be considered as the average body size of Sri Lankans is smaller than that of Australians.
It can be argued that even a small dose is better than taking no statin at all. Maybe there is a good opportunity for our scientists, perhaps together with their Indian counterparts to do clinical trials to establish appropriate doses of statins and other drugs, rather than follow Western guidelines. Until then, it may be sensible to give anyone over 70 years an affordable dose, with some patient education on adverse effects could be minimized.
Statins are a valuable tool for the prevention of vascular disease. They not only reduce deaths but also improve quality of life by preventing debilitating illnesses. Like any drug they too have adverse effects and should be used under proper medical supervision. Worst thing to do is to listen to fear-mongers!
Features
‘Mortal Causes’ Tales of Mystery and Suspense 20
Tales of Mystery and Suspense 20
by Prof. Rajiva Wijesinha
After the elegance of Agatha Christie and Hercule Poirot, I revert to one of the least elegant detectives I have looked at. The first John Rebus novel by Ian Rankin I discussed here was Set in Darkness, though I think I failed to mention the title. That does not really matter for Rankin’s titles seem a bit interchangeable. Certainly, the title of the book I will explore today, Mortal Causes, could apply to most Rebus adventures.
But this too was a gripping tale, and also dealt with what used to be a disturbing social issue in the last quarter of the last century, namely violent clashes between Catholics and Protestants, which had their roots in the age-old question of Northern Ireland and its place in the United Kingdom. The root problem there was the influx, when Ireland was comprehensively taken over by the English, of Protestants from Scotland, who were so entrenched in the north of Ireland, the area known as Ulster, that they stopped Britain from granting independence to the whole of Ireland.
Ulster remained a part of the United Kingdom, but over the years the Catholics there, supported by the Irish Republican Army, the IRA, agitated for union with the Republic of Ireland. This was bitterly resented by the Protestants, and emotions ran high, as I found when I tried to bring together Catholic and Protestant friends when I was at Oxford.
The sixties saw the overthrow of three Prime Ministers of Northern Ireland, each succeeding one being more committed to the Protestants than his predecessor, for there was a preponderance of Protestant constituencies. But the Catholic numbers were proportionately increasing, and the IRA of course got support from the Irish Republic, with the border being porous and impossible to patrol. This led to vicious reprisals by British troops, and it was their failure to address excesses over the years that made clear their infinite hypocrisy in criticizing Sri Lanka for excesses during the civil war, demanding inquiries while signally failing to address the massacres of Catholics in Northern Ireland.
Mortal Causes
deals with the repercussions of this rivalry in Scotland, where the latent animosity between Catholics and Protestants was exacerbated by events in Ulster. Obviously Scottish groups were keen to help their fellow religionists, and the book is based on how money was collected and guns smuggled in to Ulster. But typically, Rankin also looks at how the proliferation of guns led to the strengthening of gangs, who engaged in extortion, with on occasion Catholic and Protestant guns maintaining a truce so that they could each exploit their own catchment areas.
A microcosm of what went on was seen in a youth club in a seedy housing estate in Edinburgh, to which a Catholic priest Rebus was friendly with sent a youngster who was supposed to bring the communities together. Though this resulted in a truce, it was in essence an arrangement that allowed both Catholics and Protestants to deal in intimidation of their different communities in the area. And the club was dominated by the protestants, led by a youth called David Soutar, who is endemically violent, and takes against Rebus on his very first visit, after he had promised Father Leary to look into the situation.
The youth club turned out of course to be connected with the murder that set off the investigation, though this only became clear because of Rebus’ painstaking investigation of that crime. It was a brutal killing, in an underground section of the city, usually only to be seen by arrangement with the city council. The bodies were discovered by some youngsters, one of whom had purloined a key from his great uncle who was one of the custodians, who provides important information in the course of the investigation to make up for that lapse.
Before that Rebus had realized something bigger was behind the gruesome murder, for while part of the team at his own station he was asked by a Chief Inspector with the Scottish Crime Squad, Kilpatrick, to work also with his team. He had come to the site of the crime with an Inspector from London, Abernethy, who went back almost immediately to London. And though Abernethy mentioned the possibility of the killing being because of drugs, Rebus stuck to his view that it was terrorism related.
The body was soon enough identified, that of a youngster who lived with a couple called Murdock and Millie, and had Protestant insignia on his walls. And painstakingly Rebus established connections with diehard Protestants, one of whom, called Bothwell now which was his parental name, had edited a magazine while stationed in the Orkneys but now ran a dance club in Edinburgh. And he also deduced that SaS tattooed on the arm of the dead body stood for Sword and Shield, an extreme Protestant organization to which it transpired that David Soutar also belonged.
Alarmingly, it turned out that the dead Billy was the illegitimate son of Rebus’ old antagonist Ger Cafferty, who was now serving time in prison. But when he hears that his son had been murdered, he escapes, and makes it clear, through several contacts with Rebus, that he expects the killers to be found, and that he will take revenge on them.
Rebus and Inspector Smylie from the Crime Squad have to fly to Ulster to collect information which the police there refuse to transmit, and find nothing special though they confirm the existence of an extreme group called Sword and Shield, and that it has branches in America. And it seems that one of its leaders in Ulster has just gone to Scotland, while the Americans confirm that another leader will be flying to England and then to Edinburgh. Rebus asked Kilbride to tail the latter, and he says he will set two of his officers, who have no affection for Rebus, on to him.
When Rebus and Smylie get back from Ulster, Rebus is taken aside by one of these officers who says that Smylie’s brother Calumn, who was also part of the Crime Squad, and had been working undercover on arms shipments, has been murdered. This makes it clear that the arms smuggling is the key to the deaths, and also that there has been a leak from the Crime Squad.
And then Millie, who had taken a disk which Billie had hidden in his wall and fled, is also found killed. She had sought shelter with a friend who worked at Bothwell’s club, and the friend had told Bothwell about this, which was doubtless why she had been killed.
When the American organizer of Sword and Shield comes to Edinburgh Rebus manoeuvers a meeting with him, though not without rousing his suspicions. But the reports he receives from Kilpatrick of the surveillance say that he has just been doing touristy things.
The book is set during the Edinburgh Festival, and the police have been getting several calls to say a bomb will go off at its height. And Rebus now realized that this is precisely what Soutar is planning to do, having creamed off some of the weaponry, including explosives, that he had been collecting for transmission to Ulster.
These were stored in a facility provided for him by a friend whose father ran the group, but knew nothing about what Soutar was planning. The son, terrified by what he had been involved in and what the police knew, took Rebus to the warehouse which was where, DNA tests of the floor revealed, Calumn had been killed. And when Rebus and Abernethy, whom he had called up from London, confront Bothwell, it seems he too did not know of Soutar’s little sideshow, though it was also clear that he had known of Millie’s death, as well as Billy’s.
Her murderers had got the compact disk but her flatmate, though he had destroyed the backup, had looked at it before and that was how Rebus found out about the warehouse that Soutar had used. But then he goes with Abernethy to the warehouse in which the Crime Office had kept the weapons they had found, and they both confront Kilbride there and tell him that they know he too had been a member of SaS – the granduncle having shared his research with Rebus – and had passed on parts of what was confiscated to Soutar, since he was in a position to change the invoices.
But he too evidently did not know what Soutar was planning, and when Rebus goes to the youth club it is to find that Soutar had nearly killed him, and had then set off for the festival. There is great drama then as Rebus tries to stop him setting off whatever bomb he has and, though he is nearly killed, as happens in so many Rankin books at the end, Abernethy shoots Soutar dead.
Then however, when Rebus goes to the dance club for what he thinks of as final business, he finds it on fire. Bothwell has been killed. But he finds the American inside and pulls him out. When he goes further and finds the man from Ulster in a chair, tied up so he would burn, he tries to free him and then is again nearly killed, though this time he is rescued by Cafferty – who tells him it was not to save him that he had come in but to make sure he did not save the other man, the American having slunk away after Rebus had taken him outside the burning building.
The American is apprehended when he was trying to leave the country. But Kilbride is smothered in his hospital bed when he was recovering, so Cafferty’s vengeance for his son was almost complete.
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