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!

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.

by Prof. Ranjith Bandara, PhD (Qld.)
Emeritus Professor of Economics, University of Colombo

An International Monetary Fund delegation is currently in Sri Lanka to hold discussions relating to the Seventh Review of the country’s economic reform programme supported by the Extended Fund Facility (EFF). The mission, which runs from 10 to 23 September, is led by Evan Papageorgiou, the IMF Mission Chief for Sri Lanka.

Successfully completing this review and continuing the IMF programme as planned are important. Nevertheless, it is our considered view that Sri Lanka cannot build a sustainable economy over the long term merely by following the path prescribed by the IMF. Macroeconomic stability is an indispensable foundation, but it cannot be treated as the ultimate objective of national development.

Since the economic crisis of 2022, Sri Lanka has regained a degree of macroeconomic stability. Notable progress has been made in containing inflation, increasing government revenue, strengthening the primary fiscal balance, rebuilding foreign reserves and restructuring public debt. These achievements should not be underestimated. However, they are not the final measures of the country’s development success. They are merely the foundations upon which the next stage of economic progress must be built.

This article therefore examines why Sri Lanka must move beyond the macroeconomic targets of the IMF programme and undertake a broader economic transformation founded on production, exports and national capabilities.

What the IMF Programme Can—and Cannot—Deliver

The primary purpose of an IMF programme is to help a country manage a balance-of-payments crisis and restore macroeconomic stability. Its main areas of focus therefore include narrowing the gap between government revenue and expenditure, restoring debt sustainability, safeguarding price and financial stability, rebuilding foreign reserves, strengthening public financial management and reducing vulnerabilities to corruption.

On 27 May 2026, the IMF Executive Board completed the combined Fifth and Sixth Reviews of Sri Lanka’s economic reform programme. This decision provided the country with access to approximately US$695 million, bringing total disbursements under the arrangement to nearly US$2.4 billion. At the same time, the IMF projected that economic growth could slow to around 3 per cent in 2026 because of adverse conditions, including the conflict in the Middle East and the effects of the cyclone.

The crucial point is that macroeconomic stabilisation and economic transformation are not the same. Stabilisation prevents the economy from collapsing; transformation enables it to move forward.

Determining what goods and services Sri Lanka should produce, identifying the sectors in which it can compete globally, providing domestic entrepreneurs with access to technology and capital, and connecting rural production to international value chains are not the primary functions of an IMF programme. These decisions are a national responsibility belonging to the Government of Sri Lanka, the business community, universities, research institutions, professionals and the people.

The IMF’s recommendations should therefore be incorporated into the national economic plan as important components. However, it would be misguided to assume that those recommendations alone should determine the country’s future direction. Sri Lanka’s development strategy should not become an extension of the IMF programme. Instead, the IMF programme should become one component of a much broader national development strategy designed and owned by Sri Lanka.
The Real Lesson of the 2022 Crisis

Sri Lanka did not collapse economically merely because its debt had become too large. The country also failed, over several decades, to build a sufficiently strong production and export base capable of earning the foreign exchange required to service that debt.

Export revenue did not grow at the pace required, while the country remained heavily dependent on imports for fuel, medicine, food, machinery and industrial inputs. Consequently, the gap between import expenditure and export earnings continued to widen, creating an economic structure increasingly dependent on foreign borrowing to bridge that gap.

Foreign loans may be used to expand consumption, real estate, import-based trade and construction projects that generate inadequate revenue. Such activities may produce the appearance of economic growth for a limited period. However, they do not necessarily generate the foreign exchange required to repay the debt incurred. What happened in 2022 was the sudden exposure of this long-standing structural weakness.

The relief gained through debt restructuring is not permanent. Foreign-currency debt-servicing pressures are expected to increase again from 2028, while principal repayments will rise progressively in the years that follow. In addition, certain payments on Sri Lanka’s macro-linked bonds may vary according to the country’s nominal GDP measured in US dollars and its real economic growth during the 2025–2027 assessment period.

If the economy performs better than projected, the degree of debt relief may decline and the returns received by creditors may increase. This could affect the fiscal space available for education, healthcare, research, infrastructure and industrial expansion.

The temporary breathing space now available should therefore not be used merely to celebrate the return of stability. It must be used to build a foreign-exchange-earning economy capable of meeting its obligations when the next cycle of debt repayments intensifies.

Jigsaw Puzzle of Production-Based Economy

The economic model best suited to Sri Lanka must be founded on production. However, building such an economy involves much more than opening a few factories, granting tax concessions or repeating the slogan, “Let us increase exports.” It must be a carefully designed and integrated national programme in which every component is placed correctly—like the pieces of a jigsaw puzzle coming together to form a complete picture.

Fiscal discipline is one piece of this puzzle. A stable exchange-rate and interest-rate environment is another. Energy security, transport and logistics networks, technology, research, skilled labour, entrepreneurship, long-term industrial finance, access to export markets, quality standards and policy consistency constitute the other essential pieces. If these components are implemented separately and without coordination, the complete economic picture will never emerge.

The IMF’s recommendations must also be placed correctly within this jigsaw puzzle. A production-based economy cannot be built without fiscal discipline, debt sustainability, effective control of corruption, sound public financial management and price stability. However, assembling only these pieces will not complete the picture. Productive capacity, technological transformation, market access, industrial financing and human capital must be aligned with them.

Sri Lanka should not attempt to produce everything. It should strategically select sectors in which the country possesses a comparative advantage, existing capabilities or access to growing global demand.

These may include value-added agricultural and food products, pharmaceuticals and medical equipment, electronic components, rubber-based products, high-value apparel, boatbuilding, value addition to mineral resources, information technology, digital services and equipment required by the green-energy sector.

Attention should also be given to import substitution where it is economically justified. However, this must not become an excuse to maintain inefficient businesses indefinitely behind protective tariff walls. Incentives should be time-bound, performance-based and linked to measurable outcomes such as exports, employment creation, technology transfer and domestic value addition.

Lessons from East Asia

The economic transformation of Japan, South Korea, Taiwan, Singapore and China was not simply the automatic outcome of an entirely free market. These countries accepted market competition, but their governments also provided a clear strategic direction.

Their transformation involved identifying priority industries, directing credit and financial facilities towards those sectors, investing in research and technology, developing a skilled workforce and helping domestic firms enter global markets. Businesses receiving state support were also expected to deliver measurable results in exports, productivity and technological advancement.

Nevertheless, the experiences of these countries cannot be copied blindly. Global trade rules, technology, automation, environmental constraints and international supply chains are very different from those that existed several decades ago.

Sri Lanka therefore needs a developmental state suited to the twenty-first century. This does not mean a state that makes every decision in place of the market. It means a state capable of identifying market failures and providing the strategic direction, infrastructure, technological foundations and institutional strength required to overcome them.

Neither a Small State nor a Large State—but an Effective State

Sri Lanka should no longer remain trapped in outdated binary debates such as “privatisation or nationalisation?” and “a smaller government or a larger government?” What the country needs is an efficient, capable and results-oriented state.

Where the state engages in commercial activity, it should do so on the basis of a clearly defined national interest, professional management and measurable performance targets. Activities that can be carried out more efficiently by the private sector should be entrusted to it, while the government must safeguard fair competition, consumer protection, environmental sustainability and national security.

A National Council for Production and Exports could be established to guide this economic transformation. Such a council should bring the relevant ministries, the Central Bank, the private sector, professional associations, universities and research institutions to the same table.

A five-year action plan should be prepared for every selected priority industry. Each plan should clearly define export-revenue and employment targets, technological and training requirements, necessary infrastructure, financing arrangements and the institutions responsible for implementation.

Progress should be independently evaluated each year. Incentives and projects that repeatedly fail to deliver their intended results should not be preserved indefinitely for political reasons. State support must cease to be regarded as an entitlement and instead become a responsibility tied directly to performance.

From Stability to Transformation

The current visit by the IMF delegation reminds Sri Lanka once again of the importance of fiscal discipline. Yet it also raises a far more important question: What kind of economy will Sri Lanka have become by the time the IMF programme comes to an end?

If the country simply returns to its old import-and-consumption-driven economic model, the stability achieved today will amount to little more than a brief pause before the next crisis. However, if this opportunity is used to build an export-oriented production economy that integrates technology, knowledge, industry, agriculture and modern services, the IMF programme can become more than a mechanism for crisis management. It can serve as a bridge towards national economic transformation.

The IMF is an essential piece in the jigsaw puzzle of a production-based economy. But it is not the complete picture.

The complete picture is a productive Sri Lanka that is capable of servicing its debt, supplying internationally competitive goods and services, creating dignified employment for its young people, and distributing the benefits of development fairly across all sections of society.

The responsibility for creating that picture does not belong to the IMF. It is entirely our own national responsibility.