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Does man live by bread (or rice) alone?

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What is missing from our dinner menu is not the fault of the kitchen keepers!

By B. Nimal Veerasingham

There was this gentleman who lived on the lane behind our house. Let’s call him ‘Chella’, and unrelated to his acquired name, he was a tall and burly strapper. Chella was the chef or chief cook at the local Teachers’ Training College, where, obviously, meals must be prepared for a larger crowd. The legend is that ‘Chella’ uses his bare hands to crush large quantities of garlic, ginger, curry leaves and green chillies to be put in boiling cooking vessels. His curries were graded ‘A’ by the future educators and that possibly enhanced their ability to enlighten students and in turn helped in an indirect manner to build a country with greater resolution and mission. While Chella’s role at the college kitchen was not widely realised, there was another side which became a legacy of his. On pay day, Chella, became another beast, howling, singing, swearing, kicking fences over—a driverless bulldozer in motion. The booze takes complete dominance over him, so much so his family members had to take refuge in neighbouring houses.

There was another gentleman—let’s call him ‘Nada’—who worked with us many moons ago. Unlike Chella, Nada was at the helm of finance with many professional acronyms adorning his name. Tall with well-oiled hair, combed back, his forehead always had light holy-ash markings. People have noticed that his posture, while standing, in relation to the ground, is not 90 degrees, unlike that of other fellow Homo sapiens; he stood at more or less an obtuse angle. When he was under the influence of liquor, which became a daily evening ritual, his angle became pronouncedly more obtuse, perhaps qualifying as a new Yoga posture. Friends swear that once he ended up in the hospital mortuary because he lacked vital signs. In the middle of the night the mortuary attendants heard heavy banging from inside and ran for their dear lives to fetch a ‘kattadiya’. His friends further swore that Nada was finally rescued from ‘death’, fully sober and the news appeared in the local newspaper, though nobody believed it.

My paternal grandfather was a man of few words, literally. During our childhood, other than the warnings he yelled at our climbing the many tall guava trees in his garden and during our ‘hide and seek’ episodes, fleeing down his low roof and side verandah, he hardly spoke. I attributed this to his habit of chewing betel. He was a jack-of-all-trades, a handy person who could fix anything, be it our broken leather soccer ball or a stuck bicycle axle. On his ‘pension day’ he would go to the local grocery store to settle the monthly grocery bill and would get us the best sweet chewy muscat in town. On his way home, he would stop at the ‘corner bar’ to have his quick dram, and the man would become even quieter afterwards.

Legend

Alcohol, or rather the escapades resulting from the effects of the ethanol is the foremost conversational topic in the vast majority of gatherings, at times beating the banter on a recently held cricket series. Of course, alcohol has a complicated history. Traces of alcohol has been detected in archaeological evidence unearthed from Chinese pottery as old as 7,000 to 6,000 BC, and further evidence proves that a part of the wages of Great Pyramids of Giza workers were paid in beer. The distillation of wine is alluded to in Arabic works, attributed to Al-Kindi (c.801-873CE) and Al-Farabi (c.872-950 CE), and in the 28th book of Al-Zahrawi. Southern Europe developed a taste, (pun intended), for the distillation methods introduced by Middle Eastern Muslim chemists by the early 14th Century. During the same period the methods were introduced and widely used in India, during the Delhi Sultanate rule.

The four main reasons for raising glasses and toasting, then and now are, to create a positive mood, to be social, to ‘cope and to confirm’. ‘Coping’ and ‘confirming’ usually considered as negative motives while to cope will likely lead to alcohol use disorders depending on the identity, social norms, and self-image of the drinker.

Chemistry

In 2018, the Global alcohol industry was valued at a trillion dollars. And no matter what the marketing tools of the industry tout as joyous in flowery melodies, the liquid in the bottle is simply disguised ethanol or ethyl alcohol, colourless, odourless and flammable in its pure form. A formula born out of fermentation, which could slow the blood flow to the brain, resulting in slow response of the body’s systems. It also triggers the release of dopamine, a neurotransmitter that is associated with pleasure and satisfaction, and what’s more, stress relief is also associated with another neurotransmitter released under the influence of alcohol, Gamma aminobutyric acid (GABA).

The overwhelming human tendency to associate the experience of getting drunk with pleasure, draws them into a mirage, plunging them into disease, disaster, and worse, death. The rush is like the stock market, does not let you remain high forever, and the gravitational pull would not guarantee a soft landing. Driving after two drinks (assuming one drink equals 12 ounces of beer or five ounces of wine or 1.5 ounces of spirits), when the blood alcohol concentration (BAC) exceeds 0.08 percent, is a punishable criminal offence that entails many penalties in many jurisdictions around the world. In 2010, 31 percent of all driving fatalities in the US were alcohol related.

Consequence

The body absorbs alcohol relatively quickly, but it takes longer to get the alcohol to flush out of the body. The liver needs about one hour to process one drink, where enzymes break ethanol into acetaldehyde and acetate. Consuming several within a short span causes the body to saturate with alcohol yet to leave the body, resulting in longer hangovers. Muscles absorb alcohol faster than fat, as a result people with muscles and less body fat have higher tolerance. Dark liquors, such as red wine or whiskey are more likely to result in severe hangovers, while white or clear ones much less. The abuse contributes to well over 200 diseases, injury related health conditions and unintentional injuries such as motor vehicle accidents, falls, burns, assaults and drownings. In 2016, three million deaths or 5.3 percent of all global deaths (7.7 percent men and 2.6 percent women) were attributed to alcohol consumption.

While the negative impact of alcohol abuse is very much tabulated with numerical data, the positive side of alcohol consumption in moderation, for example, the many indirect economic, health and collective societal asset building advantages of alcohol induced socialising, is not readily available.

Magic of red wine

In market studies on all spirits, there is a huge following for red wine and it tempts the novice with a reason to drink. The amount of sugar usually added to red wine should be taken into consideration, as studies conducted by King’s College London shows that brands with excess sugar could lead to irritability of the bowels and inflammation. It could also lead to bacterial overgrowth leading to bloating, pain and other discomforts.

Wine, depending on the culinary pairing at the dining table, has become a part of the standard European diet. Both as a ubiquitous social lubricant and a digestive enhancer, wine’s role in typical European backgrounds enhances societal binding and togetherness. Grapes, which grow well in Mediterranean and Southern European climatic conditions, have taken firm root in their diet. It is evident that most Italian, Greek, Portuguese and Spanish households, wherever they live, have grapevines in their back garden. Though 71 percent of the world’s grape production is used for wine production commercially, individual households take pride in producing their own.

European influence

The influence of wine was felt in Asia by way of European imperialism, in the name of trade expansion, through the sequential spread of religion. Christianity, notably Catholicism celebrates Eucharist, wherein the Last Supper, when

Christ requested his followers to remember him through bread and wine, is commemorated. As a result, wine, which is a part of the European diet, has now entered the lives of the followers at least on Sundays. The jury is still out on whether the wine served at the Last Supper or, for that matter, the wine mentioned in the very first miracle Jesus performed, in turning water into wine at a wedding, is indeed alcohol or just grape juice. I had friends at school who were alter-boys, whose ability to siphon off left-over wine after the mass, was legendary.

Most of the Protestant Churches do not serve wine during ‘communion’ as the occasion calls for coming together in remembering the death of Christ, the wine being only a symbol. The Salvation Army does not have communion or consume alcoholic beverages as per the calling of William Booth outside the ‘Blind Beggar’, a tavern in the infamous East End of London. Most of the converts of the early days were alcoholics and the denomination does not want to tempt them once again into poverty, disease, and dependence.

As part of their attempt to Europeanize the Asian culinary scene, the Colonial capitalists tried to pair the curries with wine, resulting in a disastrous outcome. Washington Post columnist Greg Kitsock describes it as, “Spices distort wine flavours, turning white wines hot and red wines bitter.” Rather than living on negative results, the capitalists discovered beer to match the fiery curries. “Curry’s main ingredients, garlic, chillies, coriander, lemon grass, turmeric, ginger…. All those warming spices meld wonderfully with the toasty flavours of malted barley. The richness of coconut milk and palm oil can’t knock out the crisp texture of carbonation …. Plus, a beer is often served chilled, which is a refreshing contrast,” says Lucy Saunders, writer contributing to many Asian magazines.

But the irony is that barley and hops, the main ingredients in beer, are not native or produced en masse in Asia but must be imported from Europe.

Ceylon arrack

Irrespective of whether the word ‘arrack’ is derived from the Arabic word ‘Arak’ (distillate) or the arecanut tree, being the base for many varieties of arrack, ‘Ceylon arrack’ made from coconut sap is the most popular among Sri Lankans.

Collecting sap from coconut and Palmyra trees is physically exhausting and left to experienced climbers and tappers who venture to climb countless trees to collect relatively small volumes of syrup from each tree. Arrack is one of few liquors that has a distillate of a 100 percent natural fermentation and, unlike whisky, distilled at high strength. Unfortunately, it is said that half of all Asians lack the active enzyme which breaks down acetaldehyde within ethanol found in most forms of alcohol. Most Westerners have this enzyme and as a result should drink more than Asians to have an equal buzz.

According to the World Health Organization’s data repository, in terms of alcohol consumption, South Koreans (over age 15) lead the pack, with 10.9 litres a year on average, while Vietnam follows with 8.7 litres. Although Sri Lanka and India scores closer with 4.5 and 4.6 litres, the numbers collected from legitimate and regulated bodies sometimes do not convey the real story.

There is a greater distribution of locally and illicitly brewed, cheap varieties that do not make it into the national statistics. A 1997 study in eight Sri Lankan villages revealed that 71 percent drink on a regular basis and 93 percent of the respondents consumed locally brewed alcohol. Another study on the urban poor showed that in families wherein members consumed alcohol, more than 30 percent of the total income was spent on alcohol.

Though rice, sugar cane and coconut sap, the three main locally available commercial agents, could be used in mass production, the local illicit brews do not source them due to high cost. Consequently, in many cases, cheap jaggery, coconut water, rotten greens and fruits are used.

Sovereigns of our nourishment

The business of feeding the household, for many generations, was entrusted to women, mostly the grandmothers of the family. It is their domain and they assumed the responsibility of keeping everyone cared for and nourished, through the act of feeding. One may call it a maternal hierarchy, but victors and successes always had their origins in kitchens that are shaped and sustained by women. ‘Masculinity’, in the historical context or current, is shaped by the mundane activities and experiences of the kitchenettes that played the role of second womb.

Both my grandmothers had kitchens, narrowly separated from the main house and almost the size or bigger than the living room. That was their territory and their friends visited them there directly to have tea, chat and to exchange home grown vegetables, seated on a mat, or low stools. The place was spotless-clean and neatly kept, and we hardly knew what was kept where, and even the pets, cat and dog, would never dare cross the kitchen entrance. I have overheard from my grandmothers that, long before childbirth was considered an ‘illness’ that required hospital admission, people always gave birth in their kitchens.

Under this regime of established womanhood in our part of the world, it is not difficult to understand the underpinnings of a family meal. What is approved and served by the matriarch at the dinner table becomes the benchmark of decency.

Women from our part of the world did not have control over the production of any variety of alcohol, and therefore were denied the ability to regulate or to add to the menu, unlike their European counterparts. The main ingredients, sugar cane, coconut sap and rice were beyond the boundaries of individual home gardens. The prime objective of rice cultivation is feeding the hungry rather than quenching the recreational thirst, which would require large volumes for alcohol production. The working class that taps toddy was kept at the lower rungs by a hypocritical society that had no qualms about consuming their laboriously made toddy.

The culture that influences how people consume alcohol is not determined arbitrarily but rather by the circumstances under which ingredients are made available for the women to regulate or to determine the form it needs to be presented in the family menu. My grandmother made awesome ‘hoppers’, with toddy replacing yeast, but it had to be procured through a neighbour who was a regular at the toddy tavern.

What if, as in Italy, our home gardens also produced grape wine? Would wine have become part of our menu? If that was the case, I doubt that ‘Chella’ would have kicked over fences, or ‘Nada’ got a cold reception at the mortuary, not to mention, my grandfather, who would not have had to wait in line for his quick dram on pension day at the ‘corner bar’.



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Features

Social justice in suspense: Sri Lanka’s welfare legacy in an era of austerity

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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.

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Cholesterol lowering statins: Scope for use widens

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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!

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‘Mortal Causes’ Tales of Mystery and Suspense 20

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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.

Ian Rankin

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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