Recent address by
Dr. Sarath Gamini De Silva
to the Galle Medical Association

It is indeed my privilege and pleasure to be given this opportunity to address the members of the Galle Medical Association (GMA). I am grateful to the President and the Council of the GMA for inviting me as the guest of honour at the inauguration ceremony of your annual academic sessions.

Coming here today is like getting back to my roots again. I was born and bred in Galle and had my entire primary and secondary education at Richmond College. Between 1982 and 1995 I was associated with the GMA in my capacity, first as a senior lecturer in medicine for two years and then for nine years as a Consultant Physician at the Teaching Hospital, Karapitiya.

I was the President of the Galle Medical Association in 1994.My colleague Prof. Ariyananda and I were the first two senior lecturers in the Dept. of Medicine, with Prof. Hettiarachchi as the head. We knew almost every student in the first few batches by name, taking a personal interest in their welfare, to make sure that they did well as doctors.

The academic and non-academic staff took it up as a personal challenge to prove that the Ruhuna Medical Faculty, though rather hastily established, was second to none in the island. Looking back, we can be happy that all did very well, most of them becoming very competent specialists in various fields, later on, and are providing an exemplary service here and abroad.

We started in the dilapidated buildings at Mahamodera and then moved into modern facilities at Karapitiya, which at that time was still a building site. The long-established Galle Clinical Society later merged with the relatively new Galle Medical Association under the presidency of the late Prof. Tommy Wickremanayake, the Dean of the Medical Faculty, at that time. This wonderful auditorium, named after him, is a tribute to the late Professor’s energy and determination to see that we had the best facilities in the Southern Province. He took me round this building site on several occasions, and I once nearly had an accidental fall trying to mount this stage, only half built at that time. Today I feel quite confident standing here on a firm foundation, a podium graced by many medical luminaries over more than 40 glorious years, in the service of medical education.

The Galle Medical Association has done justice to the ideals and aspirations of its founders. As a life member, I receive regular information of your activities. The Association is meeting amply the academic and non-academic needs of its membership. Your lecture series on beyond medicine; religious and sports activities, musical programmes, leisure trips, etc., would provide much relaxation outside the exhausting routine of medical practice. Your annual academic programme is not second to that of many professional Colleges and Associations based in Colombo or elsewhere in the country. This wide array of activities is indicative of an Association keen on providing an all-round service to its members and their families, as well as to the medical students. My congratulations to all concerned.

Your theme this year, “Preventing the Preventable,” is very timely. With the economic crisis we are experiencing, the age old saying “Prevention is better than cure” is more relevant today than ever before. Certainly, true in the case of prevention of diseases, I am concentrating today on other aspects of healthcare the doctors have overlooked and to a great extent failed to prevent their decline.

Preventing the Preventable; Preserving the Healthcare Services is my concern today.

All the remarkable achievements in the fields of communicable and non-communicable diseases, with world acclaimed health indices, are now being nullified by the economic crisis in which the healthcare services appear to be caught unawares. The shortage of drugs and other equipment, costing more and more with every passing day, has made it near impossible to give proper treatment to needy patients. I will not be surprised to hear of deaths due to lack of treatment in the near future. We already hear allegations, though authorities keep refusing to accept their responsibility, of deaths due to poor quality of drugs hastily imported to overcome shortages in a poorly planned system.

This is compounded by poor household incomes, high transport costs and other difficulties the patients experience in seeking medical care.

While most of the blame for this unfortunate situation falls on poor planning and corruption by the rulers, the medical profession, too, has failed in preventing this calamity. They have contributed by their irrational prescription habits, doing unnecessary investigations and the like, leading to a high cost in the delivery of healthcare. Irrational prescriptions contribute in a big way to multidrug resistance to antibiotics, as well. Poorly regulated private practice by doctors needs an overhaul. Exorbitant fees charged by some specialists are the talking point in the society. I need not bore you with details which should be well known to all of you by now.

We as a profession should not allow ourselves to be exploited by the profit-oriented private healthcare services and the pharmaceutical industry. The patients are compelled to pay a heavy price for our shortcomings in this regard. Thus, by our inaction in dealing with such, we have failed to prevent the gradual deterioration of the respect the society has for the profession.

Has the medical profession knowingly or unknowingly colluded with the misdeeds of the politicians? As an example, I wish the institutions, like the drug regulatory authority, NMRA, did more to prevent corruption and irregularities in the procurement of drugs. They have remained mostly silent knowing very well how their decisions regarding the registration of drugs are overruled or circumvented by politicians and administrators with ulterior motives.

Functioning of the Sri Lanka Medical Council is being looked down upon by many in the profession itself. The amendments to the Act governing the SLMC has been proposed over many years to broad base its membership to include non-medical professionals and make it more effective in its primary duties of regularizing medical practice, maintaining discipline in the profession and maintaining good standards of medical education. Politicians have so far failed to enact them. With poor standards of medical education, due to shortages in staff and other facilities in hastily established new medical schools, SLMC has been largely silent on these aspects. At present it appears that the medical trade unions and indirectly the political influence are hampering its proper functioning. As a result the SLMC remains mainly a body for holding the ERPM for foreign medical graduates and registering the medical practitioners. Our professional associations should be more involved in its affairs and add their voice for reforms.

I have been a member of the SLMC for 10 years in the past. But your chief guest as its immediate past president, who was removed from the post in a most unprofessional way by the politicians, with perhaps the connivance of our own colleagues, will be in a better position to address these issues. That action initiated by our own professional colleagues has now established a precedent for the Health Minister to have a bigger say in the SLMC affairs, seriously undermining its autonomy.

In my address to the Colombo Medical Congress a year ago, I stressed how our Professional Colleges and Associations kept a blind eye without getting involved and having their say in the administration of the health service. Even when there was an uprising asking for a system change, the medical profession remained largely silent without adding their voice. This was in stark contrast to the legal profession who stood up with the people asking for justice. By remaining ‘respectable’, confining ourselves to academic activity only, we have allowed our efforts at improving services to the public and training postgraduates to become meaningless. As a result, we are now spending tax payers’ money for training specialists for service abroad. With an unprecedented exodus of locally trained doctors and other healthcare staff, we are helping richer countries to serve their citizens better. The world-acclaimed health indices we have achieved by hard work over the years are becoming irrelevant with rampant malnutrition and other maladies affecting a significant proportion of the people.

Even the few medical men who dared to warn the authorities publicly on impending childhood malnutrition in their area had to face disciplinary action. The services of an alumnus of the Ruhuna medical faculty have been terminated as a result. Unfortunately, there is hardly any protest heard from the trade unions or other medical organizations against such action, at a time when elsewhere numerous unlawful activities and rampant corruption remain unpunished.

As much as the people are asking for all 225 in the Parliament to be thrown out, there are loud whispers in the society that the medical profession, too, is corrupt exploiting the people in various ways. There is no use in our grumbling about any shortcomings of doctors and incidents of medical negligence being highlighted in mass media regularly. Naturally, the good work done by the doctors will not be talked about with praise as that is the minimum the society expects from us.

It is high time our annual conferences and other meetings had a regular session or symposia on various aspects of the doctor in society, discussing our own faults and ways of rectifying them. All Colleges, especially those dealing with clinical disciplines coming into direct contact with the public daily, should communicate regularly with their members on these issues. They should also keep a close watch on the activities of health-related institutions like the SLMC and the NMRA already referred to, and intervene where necessary, without waiting till it is too late.

Thus, prevention in broader terms involves not only prevention of diseases but also prevention of other irregularities in the administration of health and questionable practices of our own colleagues that have a direct bearing on the health of the people. The medical profession, despite its many shortcomings, is still respected and influential. Our strong voice will be heard by the rulers, medical administrators and the general public.With these thoughts let me conclude by wishing you all a very successful and enjoyable annual sessions. I wish you all a very good evening.

By Dr Laksiri Fernando

For the second time, Ranil Wickremesinghe has inaugurated a National Evaluation Policy (NEP) for Sri Lanka. The first one was in 2018 and also in September at the Global Parliamentarians Forum for Evaluation (GPFE) held in Colombo. As its website said, “The National Evaluation Policy (NEP) of Sri Lanka, was launched by Prime Minister Ranil Wickremesinghe at ‘EvalColombo 2018,’ the first ever global conference on evaluation organized by the Global Parliamentarians Forum for Evaluation (GPFE).”

Blocked Website?   

He inaugurated the same or a different one as the President of Sri Lanka on 8 September 2023 at Temple Trees with the participation of some key Ministers, Officials and Foreign Delegates. The Presidential Secretariat’s website quite genuinely titled the posting of the speech as “Sri Lanka’s long-awaited National Evaluation Policy finally commences after seven years.” However, there was no policy document posted on the website. When I searched on the President’s website (president.gov.lk) the following was the message I got.

“Sorry, you have been blocked. You are unable to access president.gov.lk.”

It is still difficult for me to figure out why I have been blocked. Is it a technical error or a political decision? Is the website closed to everyone or only for me? My primary objective was to see the details of what they called ‘National Evaluation Policy Implementation Framework.’ That is what the President mentioned in the Speech.

However, on the website of the Ministry of Finance, Economic Stabilization and National Policies, (Ministry of Finance – Sri lanka (treasury.gov.lk) there was a pdf titled, the ‘National Evaluation Policy of Sri Lanka.’ It is only a four-page document even without page numbers or a date. Two pages were devoted to a long glossary and references. There were five references all being websites accessed in 2017. This is quite intriguing.

For Good Governance

A National Evaluation Policy (NEP) is part of good governance. In the case of Sri Lanka, such evaluations should particularly address corruption and misuse of funds. Without an NEP, governance accountability to the people and to the international community cannot be achieved. In 2009, the UNDP (United Nations Development Program) said, “There is general consensus that evaluating the performance of public policy is an important instrument for good governance. There is, however, a gap between this general agreement and the actual implementation, use and sustainability of monitoring and evaluation (M&E) systems, processes, and tools on the ground.”

This was after an international conference held on the subject in Casablanca (Morocco) in December 2009. Sri Lanka participated at the conference represented by the Director General of the Ministry of Finance and Planning, Velayuthan Sivagnanasothy. He presented a well-prepared paper, titled “Sri Lanka: National Monitoring and Evaluation System: Experiences, Challenges and the Way Forward.”  As Sivagnanasothy assured, there was a national monitoring and evaluation system in Sri Lanka at that time. I also can remember its existence participating at several meetings and conferences as the Director of the National Centre for Advanced Studies (NCAS) and a Director of the Colombo Stock Exchange (CSE).

It is possible that the above situation changed when unreliable persons like Mahinda Rajapaksa and Basil Rajapaksa became controlling the country’s Ministry of Finance. A large number of projects were undertaken with foreign loans without an evaluation of the project plans and the progress of their implementation. When countries like Norway, Canada, Japan, and Australia gave aid, grants, or loans to Sri Lanka, they themselves conducted their independent evaluations. However, there were some other countries and agencies who didn’t want this requirement. This is one reason why and how Sri Lanka became heavily indebted and failed to repay loans.

Avoiding politicisation  

There is no question that national evaluation policies can easily become politicised. The best way to avoid the infection is to develop these policies independently and as part of management science/studies. There can be an independent commission on national evaluation. Project planning, management, monitoring, and evaluation are already subjects taught in universities. There are a good number of Sri Lankan people who are qualified in this field at least at the graduate level. What is needed is to introduce postgraduate degrees and develop the subject to be useful to the country and others.

Various sectors in Sri Lanka should have clear national policy/policies. In 2012 the World Bank published a book titled ‘Building Better Policies’ focusing mainly on monitoring and evaluation. It is fully available online (Building Better Policies – Google Books).  It says in the foreword, “This book is useful to anyone who cares about the quality of public policies and who wants to learn and understand how public policies and programs can be shaped with the objective of improving people’s welfare.”

The report in the Presidential Secretariat’s website on the so-called inauguration says, “The President acknowledged a significant void in Sri Lanka’s governance system – the absence of a national policy.” This is very true as the immediate circumstances categorically revealed the situation.

On the day of ‘inauguration of NEP,’ it was reported “Sri Lanka will be transformed into an education hub in South Asia,” an assertion made by the Minister of State for Education, Dr. Suren Raghavan. People are not unknown to various dreams of ‘hubs’ declared by different politicians from time to time. Raghavan cannot be the same type given his educational and professional background. Yet, he has also stated “the focus of the new education reforms is on creating a system that enables students studying in the arts stream to attain a bachelor’s degree in science.” This is completely intriguing and no further information was given on how it could be done.

Four days later, Dr Wijeyadasa Rajapakshe made a similar declaration about educational reforms and said, “vocational institutions to be given the same recognition as universities.” Wijeyadasa Rajapakshe primarily is the Minister of Justice, Prison Affairs and Constitutional Reforms. However, he is also the Chairman of the Parliamentary Special Committee on the Expansion of Higher Education and perhaps he made this statement in that capacity.

Conclusion

What is clear from these statements and declarations is that the present government or politicians in general in the country do not have any idea of expanding the university or higher education system. Renaming vocational institutions like Technical Colleges as universities is not a solution. Quality of higher education and integrity should be preserved. Also, giving the arts students just BSc degrees is not a solution for the problems associated with that stream. Sciences and social sciences should be promoted and developed. Immediate evaluation of the whole educational system is necessary. There can be an independent commission on the subject with capable people. Most important is the promotion of the English medium in higher education without discriminating against anyone who wants to study in the Sinhala or Tamil medium.

By Capt. G A Fernando
gafplane@sltnet.lk
RCyAF/ SLAF, Air Ceylon, Air Lanka, SIA and SriLankan Airlines.
Former Crew Resource Management (CRM) Facilitator, Singapore Airlines Ltd.
Member, Independent Air Accident Investigation Pool 

(The first part of this article appeared in The Island of 18 Sept., 2023)

In 1982, an Air Florida Boeing 737 crashed into the Potomac River, Washington D.C., after takeoff from Washington National Airport in icing conditions. Erroneous engine thrust readings (higher than actual), and the co-pilot’s lack of assertiveness in communicating his concern and comments about aircraft performance during the take-off run were among the factors cited (NTSB/AAR 82- 08).

Experts say that one needs to be ‘aggressively’ safe. All communications (verbal or written) and standard operating procedures (SOPs) should be proactive, predictive and preventive. Some of the accidents mentioned could have been prevented.

As can be seen in the diagram shown, the SHELL boundaries are not smooth but inherently full of serrations, and much effort is needed to interact efficiently and seamlessly. Some experts stress that it is Communication in the form of SOPs that ‘lubricate’ the system for smooth interaction between elements’ while the captain (team leader) sets the tone. In fact, where air safety is concerned, Capt. Tony Kern, a human factors expert, says in his book Redefining Airmanship that to maintain air safety, it is imperative that the team leader knows himself, knows his team, knows his aircraft and equipment, knows his mission and, above all, evaluates the risks involved with the task at hand.There can be problems with the interaction within the team (Liveware and Liveware). Sometimes the Captain (Leader) has to be an expert in conflict resolution! (See Figure 01)

Threats and Hazards

Almost every situation in life is full of ‘threats’. When it involves one personally, it becomes a ‘hazard’. In the aviation context, if there is a flock of birds in the vicinity of an aircraft, they constitute a ‘threat’. However, if that flock of birds starts crossing the flight path of the aircraft, it becomes a ‘hazard’ and avoidance action needs to be taken. Remember the ‘Miracle on the Hudson’? The engines failed because of bird ingestion.

 Many airports, too, contain manmade threats and hazards which are usually eliminated only after an accident. In fact, pilots say that blood has to be spilt for changes for the better to occur. At many airports high-rise or security-sensitive buildings are built without planning, and no consideration given to air safety, thus violating the law.

The Ratmalana International Airport is a case in point. On the landing approach from the Attidiya side there is the Parliament and Akuregoda Military Headquarters which are prohibited over flying areas. In the vicinity of the Ratmalana International Airport, there is the Kotelawala Defence Academy and Hospital. At the Galle Road end a solid wall creates a hazard for landing and departing aircraft. Elsewhere, at the Puttalam-Palavi airbase a cement factory is in line with the runway, whilst at China Bay-Trincomalee the silos of a flour mill obstruct landing and take-off paths. These hazards at the latter two airports render them useless as ‘alternate’ (alternative) international airports. If sufficient thought had been given to air safety planning, the loss-making Mattala Rajapaksa International Airport in the Hambantota District would never have been built.

The Swiss Cheese Model

Just as one proverbial swallow doesn’t make a summer, one error alone will not create an incident or an accident. Rather, it will be caused by a chain of unsafe events not picked up by the system. The triviality of one such potentially disastrous cause or lapse is echoed in the words of a poem from the 17th century, later popularised by Benjamin Franklin in his Poor Richard’s Almanac: (See Figure 02)

Reasons for accident occurrences are similar. In fact, the Toyota Corporation asks ‘why’ at least five times when determining the ‘root cause’ of a problem.Aircrew members are regularly taught to recognise unsafe patterns highlighted in past accident investigations, so as to nip them in the bud if and when identified.

Professor James Reason postulated the ‘Swiss Cheese’ model, which states that in any organisation, the layers of safety and security controls in place should be able to block, or cover, one another, to prevent accidents. But unfortunately, there are random holes of all sizes in these layers, like slices of Swiss cheese. Hence, the possibility that with the presence of latent conditions and active failures, these holes will align and allow a potentially dangerous situation or practice to go through without being trapped, thus creating an accident or incident. (See Figure 03)

As illustrated in Reason’s ‘Swiss Cheese’ diagram, latent failures of the system are those that compromise safety, having existed and been taken for granted for short or long periods of time; active failures are immediate, unsafe human acts. In fact, the crew (human element) is the last line of defence before an accident or incident occurs.

To illustrate these points, I shall revisit the 9-foot/3-meter concrete wall that was erected several years ago at the Galle Road end of the runway at Ratmalana International Airport.

This wall could be regarded as a man-made hazard. The runway is 1,833 metres (6,014 feet) in length, not long enough by worldwide standards for a so-called ‘international airport’. By international law, at a pre calculated critical speed (known as the go/no-go speed) pilots are allowed only two seconds in which to make a critical decision whether to stop or continue the take-off. According to calculations by the Boeing Company, a decision to stop any later than two seconds (called ‘dither time’) will result in an aircraft reaching the end of the runway at a speed of 60 knots (69 mph).

On a rainy day, if pilots of a medium-sized aircraft decide to abort the take-off three seconds late, they are unable to stop within the paved runway, with deployment of maximum braking and other stopping devices such as reverse thrust, and the aircraft will ‘overrun’. Because the grass in the overrun area is wet and slippery, the brakes are rendered ineffective. Consequently, in the case of Ratmalana, the aircraft will definitely impact the wall and perhaps catch fire as fuel tanks are usually full during departure.

So, the delay in making a decision to reject the take-off rather than continue would be an ‘active’ failure by the crew. The presence of a solid wall at Ratmalana is the presence of a ‘latent’ condition caused by the Airports Authorities. Although the wall is an ‘accident waiting to happen’, the Sri Lanka Air Force (SLAF), which earns ‘welfare’ money from advertisements on the wall, stubbornly refuses to replace it with a frangible fence, that would break on impact and reduce damage to an over-running aircraft and even vehicular traffic on the Galle Road.

Returning to Reason’s ‘Swiss Cheese’ postulation, air accident investigators usually work backwards from the incident/accident, using the ‘model’ to find the root cause, unsafe acts and any failed defences. The best witnesses are, of course, the crew themselves, although they may not want to voluntarily give information if a punitive attitude is adopted by accident investigators and the authorities. It is a long-held belief that the crew involved are damned if they tell the truth and damned if they don’t. In the recent past in Sri Lanka, the Law and the Police were quick to ‘criminalise’ air accidents. Almost two years ago the accountable manager and chief engineer were arrested and remanded for failure to prevent an accident. That is another story.

The protocol should be for an independent team to do a non-punitive inquiry, and if and only if elements of negligence are highlighted in the final accident report, then the law should take its course under the direction and oversight of the Attorney-General. In short, the authorities in Sri Lanka need to get their act together and conduct themselves in a professional, impartial, fair-minded manner.

Accidents don’t only happen to “other people”, and with threats everywhere we have to learn to mitigate and manage them. While it is human to err, could we eliminate error completely? I think not. But pilots can learn to trap and minimise their ability to make errors by using their team effectively, including pre- and post-flight briefings. A common question that should continue to be asked is: “Could we have (as a team) done things better?”

Will automation of some tasks help? Instructors often repeat the adage, “Fly the aircraft and don’t allow the aircraft to fly you.” Conversely, “The aircraft flies by itself. You assist it to fly”. I believe it is the level of automation that matters, depending on circumstances.Bernard Ziegler, a French pilot and engineer who served in Airbus Industrie as senior vice president for engineering – and was the son of Airbus founder Henri Ziegler – was well known for his evangelical zeal for the application of computerised control systems in Airbus airplanes, commencing with the revolutionary A320 airliner. Bernard Ziegler attempted to design the human out of the flight deck in Airbus’s so-called ‘fly-by-wire’ airplanes, which in their early days were involved in a series of incidents and fatal accidents, due mainly to the mismatch of the man/machine interface. So much so that the A320 was called the ‘Scare-bus’ in jest. Even today many Airbus pilots are heard to ask while flying, in perplexed tones: “What is it doing now?” or “I have never seen this happen before.”

A more recent story is that of the Boeing 737 MAX. When I flew the basic Boeing 737-200 many years ago, our Irish instructor called it the ‘thinking man’s aircraft’, a perfect match between man and machine. Somehow, due to design quirks in the newly designed 737 MAX, an automatic system called MCAS (Manoeuvring Characteristics Augmentation System) was incorporated. If the aircraft got into an unusual and unsafe nose-up attitude, MCAS would be automatically activated and lower the nose to a safer angle.

Unfortunately, during the somewhat rushed introduction of the 737 MAX onto the market, many airline crews were not sufficiently trained in how to override the system – if MCAS was activated due to false indications from, say, a computer or instrument malfunction. Worse still, some airlines’ pilots were not even told that their new airplanes were fitted with such a system, and therefore unaware of what to do if and when MCAS became activated for no apparent reason. This ignorance, through no fault of the pilots, resulted in two disastrous MAX crashes, in Indonesia and Ethiopia, with a total loss of 346 lives.

As the ‘cold hard facts’ later emerged, it became apparent that although the ‘MAX’ was arguably a totally new type of aircraft, it was designated as a Boeing 737-800 to minimise legal crew-training time on the type. This extra training was seen as an undesirable burden for Boeing’s customer airlines, who would have to withdraw captains and first officers from the line for training, thus incurring loss of productivity and revenue for the airlines.

Boeing’s intent was, therefore, for the training (non-productive) period to be as short as possible. But in practice corners were dangerously cut. The US regulator, the Federal Aviation Administration (FAA) – in this case the ‘human element’ – went along with the manufacturer’s sales and training programme, which ultimately resulted in incidents, accidents, and loss of life.

In summary, statistics show that although accidents have decreased to a small percentage in terms of flights and hours flown, the number of certified air operators is also increasing, which causes the number of accidents to increase. Difficult as it is to contemplate, it wouldn’t be wrong to say that the potential exists for more human factor-based accidents to occur in future.