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To be realistic, there are only two options

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by Kumar David

There are only two political options (for want of a better word, though “trepidation” highlights another side of the matter) worth taking seriously – the President Ranil Wickremesinghe (RW) led outfit and the National Peoples’ Power (NPP) public face of the JVP. The RW-outfit may manifest itself in many forms such as a UNP-Sajith (SJB) alliance under some tactical leadership plan that may or may not include a Rajapaksa rascally rump. Whatever be their specific expositions, there are only two “camps” that matter up to and including the next election cycle. Let me call them the RW-outfit and the JVP-outfit – the Sinhala “kandavuru deka” captures the sense better. All other options (Champika, Sarath Fonseka, small left, and ethnic minority platforms) will have negligible electoral impact if they do not align with one of these big outfits. This is in respect of a presidential election; in parliamentary or provincial polls ethnic minority platforms will, of course, have a substantial impact in the areas of domicile of their communities.

It is necessary to state these encampment options prior to dealing with programmes and strategies. I will call the broad manner in which each camp presents itself to the people its National Strategy and this includes an ‘ideological orientation’, economic development plans, foreign trade priorities, and relationships with the IMF and ADB/IBRD to escape the stranglehold of debt. Approaches will need to be formulated by each side for state-owned enterprises. Foreign policy, especially in respect of India and the US is absolutely crucial. When I say ‘ideological orientation’ I am referring to democracy, militarisation, curbing Sinhala-Buddhist excesses and the democratisation of state-power. All this is a big canvas and strategists, planners and scholars will contribute to this discourse in the next 12 months. I will only make a simple start here; not in any particular order.

RW is a capitalist-roader in the sense that he subscribes to the view that “by letting market-forces run their course, to enhance their own gain capitalists, will as though by an invisible hand, promote the public good”. (Adapted from Adam Smith’s ‘Theory of Moral Sentiments”). Faith in the free-market with minimal state intervention is gospel among modern bourgeois ideologues and that RW belongs here is no surprise. Unconstrained by other pressures, this is where RW will lead the nation as JR did and Felix tried. However, I refrain from calling RW a neo-liberal (neo-conservative extremist) despite his penchant for using the military to subdue political dissent because he is influenced by liberal intellectuals in his personal and political entourage. The obscenity of outright dictatorship is best practised by Generals (gorillas); vide Chile, Pakistan, Argentina, Burma, and Indonesia and so on and so on. A military regime in Sri Lanka will not fail to string-up RW alongside the left, the intelligentsia, the liberals and the feckless Fourth Estate. Having said this it is frightening to observe that Netanyahu and his simple majority in Parliament are driving Israel (of all countries) in a neo-fascist direction less than 70 years after the fall of Nazism. I will deal with extremism and global threats to liberal values in my next essay in September – I intend to write less than weekly from now on.

The other camp, the JVP/NPP; how shall we designate it? It is not Stalinist in the sense that it harks to the discredited Soviet-style all-embracing central plan, it no longer subscribes to any variant of Maoist dementia (Cultural Revolution); it acknowledges that 1971 and 1989-90 were wild excesses unrelated to real world possibilities. This is what the JVP now is not; but what IS it? It, itself doesn’t know yet, but the demands of approaching electoral challenges will force the JVP/NPP to define and declare its programme; to define its ideology, to publish an economic programme and to declare what it proposes to do about pesky minorities and pestilential Sinhala-Buddhism.

Allow me to move to a few economic topics. It’s a no brainer that exports need to be an engine of growth. There is a huge amount of experience in other developing countries (Korea, Mexico and South Africa to quote at random from three continents) and indeed in Sri Lanka in the past before Rajapaksa era sleaze snuffed it out. Both the private sector and government agencies were coordinated in the past and this needs to be revived. It may already be on the move behind the scene, but why behind the scene? Participants, product lines (industrial, fruit, marine products etc.), benefit from agreements between countries and future plans should be made explicit. If we intend to give the invisible hand a leg up (sorry, bad pun) let us make it more visible. Neither the RW-camp nor the JVP-camp have published or made their proposals explicit.

Moribund state-owned enterprises need an action plan and this is likely to be contentious between the two camps. There are rotting corpses like Sri Lankan Airlines that it is universally agreed must be cremated. Mahinda’s recklessness and Gota’s witlessness have brought it to the crematorium and the point now is quick disposal. But there are other cases which are complicated, the CEB for example. The government, for social and political reasons, offers electricity at heavily subsidised prices to low income households. The burden has to be borne by the CEB which does not receive corresponding compensation on imported fuel costs (coal, furnace oil and diesel). Therefore, on the books it appears that the CEB is a huge loss making enterprise but this impression is incorrect. This ambiguity is true though to a lesser extent in the petroleum corporation and the railways. A distinction has to be made between culling white elephants like Sri Lankan Airlines and other state-owned enterprises for each of which separate plans must be prepared.

A crucial matter for heavily indebted countries like Sri Lanka is debt restructuring. I will summarise a Reuters report datelined June 2023 about a deal to restructure debt owed by Zambia to other governments and private creditors around the world. The biggest slab, $6.3 billion owed to China’s Export-Import Bank, underlines the importance of Beijing’s agreement to support the plan. The agreement calls for Zambia’s debt to be rescheduled over 20 years with a three-year grace period during which only interest payments will be made. Private creditors too are expected to likewise restructure the $6.8 billion owed to them. The exercise is viewed by the Group of 20 wealthy nations as a test case. I will make no further comment but ask whether the RW-side or the JVP-side is actively following up the Zambian example

The most significant advantage of the Zambian plan will be a sharp recovery of the value of the Kwacha against international currencies. This will impact prices of imported goods and domestic production. Here in Sri Lanka prices of essential goods and inflation are driving the poor and the middle-classes to desperation. The one matter about which every political actor agrees is prices of food and essentials (medicines, cooking fuel, school uniforms and so on) must be addressed. A debt restructuring programme supported by the IMF and other multilateral agencies is essential. Is it unrealistic to imagine the value of the LKR appreciating to 200 to 250 to the US dollar within a year?

The government (Central Bank and Treasury) from all reports is in thick of it. The RW-camp therefore is involved, but I doubt if JVP/NPP policy makers are giving their minds to these concerns. Since the JVP/NPP is a contender for state power there will be persons of intellectual ability and professional experience who will be willing to cooperate, but the trouble is that it is foolishly dragging its feet.

There are several such policy matters deserving a short discussion in a draft programme. For example a new constitution, inflation targeting, price control of essentials, state-owned enterprises, sovereign wealth funds, and energy policy. I will devote the rest of this essay to energy pricing and policy because a draft programme for the electricity sector is before parliament right now.

The Ceylon Electricity Board is called a huge loss-making enterprise. How fair is that allegation? For social and political reasons the government provides low income households with heavily subsidised electricity. The average generation price is far higher. If the government hands out electricity to low income households at X rupees per kWh but the average generating (net of cross subsidy from affluent customer) is say Y rupees (average generation costs depends on coal, fuel oil and diesel prices), and if the energy so handed out is Z billion kWh per year, the CEB will unavoidably incur a “loss” of (Y-X)*Z billion rupees annually. If Y is 20, X is 5 and Z is 20, it will appear that the CEB is a public sector enterprise “losing” Rs350 billion per annum. This of course is bollocks! Will the energy ministry make available a detailed breakdown of X, Y and Z? Given the data a child can do the calculations on the back of a postage stamp.

The term that echoes across the government’s thought processes is “privatisation”; anything that moves or breathes, grab it, privatise it. While there is a case for handing over some failing state enterprises to private management, the experts on the government’s lobby have little knowledge of the concept of Public Goods. There are some things which by their intrinsic nature belong to the public domain, to the people; scenic beauty, forests, the courts of law, the military, the police, a nation’s communications backbone and the transmission grid and system control infrastructure. The concept of Public Goods has not been discussed or understood in Sri Lanka or for that matter in many countries.

A related matter pertains to privatisation of the electricity distribution systems which like the transmission backbone and system control facilities should remain under public ownership. In the UK for example where the distribution system was privatised, terrible complications have arisen. Once a private owner acquires control it has the right to sell onward into markets where it is chopped, spliced with bits and pieces of other financial assets and sold onward into a maze. Since the financial crisis of 2008 these instruments called ‘derivatives’, and other speculative and ‘leveraged’ financial products have become prominent and it is no longer easy to say where ownership lies. In simple words if we privatise into this fog it’s a maze where ownership of our distribution assets is murky with loss of control and inability to repossess. In the UK, chasing up who owns the now privatised one-time Regional Distribution utilities has become a nightmare.

I need to bring this discussion of electricity sector options into line with my opening theme that there are only two realistic political options – liberalism and the left. True RW liberalism bears the blemish of potential military excesses and the JVP is haunted by its rebellious past. Nevertheless the public and trade unions will be increasingly enthused by the upcoming elections than by these theoretical abstractions as the months pass; let’s wait and see how things pan out in the months ahead.

The privatisation of the Central Electricity Generating Board (CEGB) has turned out to be another of that Thatcher woman’s ideologically driven blunders to rival her privatisation of British Rail. Throughout Europe the railways are state-owned and excellent. Western Europe’s SNCF, Deutsche Bahn, Trenitalia, as well as the networks in Eastern Europe are state-owned. It is in the UK alone that that Thatcher woman careened from Hayek driven blunder to blunder. In Lanka Privatisation seems to be the government and Minister Kanchana Wijesekera’s buzzword; so it seems Lanka is treading the same road? In context, I also do wish people would stop talking about renewable energy projects solar and wind in MW (power) and deal in expected annual MW-hours (energy). What’s the use of a 1000 horse power -Ferrari in your garage if your fuel tank is empty?

To tie up these threads to my opening theme, the government hopes that people are so fed up with the CEB and presumed CEB corruption that it believes there will be overwhelming support for privatisation. That may be incorrect. When all the facts as I have outlined here come into focus in the public mind, I believe that support for privatisation of public goods such as the CEB’s key assets, the telecommunications backbone and the petroleum industry will evaporate.



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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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