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Delta, Drugs, Dematagoda, Data, Disorder and Deluge

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By Dr. Pradeep Kariyawasam

(Former Chief Medical Officer of Health)

Chairman, Standing Committee on Health, Colombo Municipal Council

The Delta virus, which sneaked into the country by the middle of June this year, has made its way to almost all four corners of the country, due to lack of proper control measures. How did this happen? It is an interesting question as we have taken many measures to check on passengers that can bring it to this country from India, the UK or other countries where it is spreading fast these days. Although the guidelines changed with time about PCR tests and quarantine periods for foreign travellers, and locals who re-enter our land, they are quite adequate to prevent any entry of the virus with such travellers. Then how it was found in the Dematagoda area, in Colombo, was the million-dollar question.

Alpha variant

Previously, when the Alpha Covid-19 virus started to spread in the country, the Health Authorities always said they could connect the patients to a previously ill one and that there was no community spread. Some blamed the tourists who came from Ukraine or airline crew who rested in a hotel near Katunayake for spreading the virus in this country. These are far-fetched ideas considering that they were traveling in Bio-bubbles and were tested, and the locals involved in that operation also were monitored. Then the blame was put on the firm Brandix.

True they were lax in not understanding the importance of keeping away employees who were down with flu symptoms. If they did that under proper guidance, they would have helped at least to slow down the spread in the country as I believe that virus was in the community before entering their facility. I wonder whether a proper epidemiological investigation was ever conducted on how the virus entered that factory and then spread all over the country. Anyway, the results were never made public. So may be that there were other sources that spread the virus here.

Indian experience

How could that have happened? Our neighbour is India. Both Alpha and Delta variants were in India and at first the Alpha was the predominant variant which was later replaced by the Delta variant. Considering that our airports were on the lookout for passengers with the Covid-19 virus that was a little chance that it could sneak into the country easily. This disease is a communicable disease – spread from one person to another. It cannot come from the wind, blowing through India, although they say it remains in the air for 16 hours and that also obviously not in open air but in closed premises. I believe that this disease came to our island through the unofficial travelling between India and Sri Lanka. When one checks even today for the places where the disease is found, most of them are from coastal areas, even in the East or North. The lowering of the number of PCR, or antigen, tests carried out may be the reason why this was not detected earlier in these areas and this is the price that we have to pay. Talking of PCR and antigen tests I think carrying out random tests is like trying to find a needle in a haystack. What we should do in this late hour is target high risk areas, and, to do that prepare a grading system even for the city where history has shown where the communicable disease outbreaks happened before.

Unofficial travelling between the two countries was in existence for over 50 years. I remember when I was a school- boy, I visited Jaffna and found that people travel by boat to Madras just to watch a movie and then return the same night. Smuggling of sarees, cloth, shoes, etc., were well known and Valvettithurai was notorious for that. Coconut oil and soaps left our shores as far as I remember. Even during the war, arms were smuggled from India. Now I believe that the Delta virus arrived in Sri Lanka with the smugglers of heroin, or Kerala Ganja, when they creep into the country somehow despite many efforts by the Navy to stop it. Of course, it is the people who are infected with the virus from India that may have given it to our people, both smugglers and fishermen, but internally it was spread again from well-known drug selling areas. Dematagoda is one such well-known area for drug distribution. Patients were also found in Galle and Jaffna districts initially. These also could be areas where drugs are unloaded by the smugglers. So, there is an obvious nexus between drugs and the Delta virus spread in this country.

Dematagoda detections

When the Delta virus was found in Aramaya and Albion Roads, in Dematagoda, the obvious thing to do was put all resources to that ward and try our best to stop spreading it to other areas. A lockdown was imposed but when I checked at that time, I was told that people were roaming the streets nonchalantly. PCR testing was conducted but we do not know the numbers and no proper special vaccination programmes were conducted in that area. I think the Colombo Municipal Council and the Ministry of Health lost a golden opportunity to either stop the spread, at least in the city of Colombo, and the district, or at least slow the transmission to controllable levels. The reason is there were no Epidemiologists who have previous field experience involved in the decision-making and lack of understanding how epidemics can create havoc within a short period and of the need to nip them in the bud. What should have been done was firstly make the people in Dematagoda aware of the situation by getting the Public Health staff go from house to house and at the same time get the information out about people who have symptoms of Covid-19 from the residents or the community leaders. In the past, when I was the Chief Medical Officer of Health, I used this tactic to control disease outbreaks.

We had Health Educators who deployed Health Instructors, a category of public health workers who were only at CMC, courtesy the late President Ranasinghe Premadasa, who did this work. They formed Community Development Councils trained community leaders on community development, provision of basic amenities, hygiene, disease control and the need of Community Participation for the greater good of the people. Today instead of the 600-odd Community Development Councils that we had at that time just a handful are left and that also thanks to the senior Members of the Municipal Council. The cadre and the numbers of Health Educators, instructors have been reduced by people who have not an iota of an idea of the importance of such people in controlling disease outbreaks, creation of awareness and getting community participation. Unfortunately, in their hour of need the residents of Dematagoda did not get that help although MMCs in that area did their best to help the people. No Health Education work or awareness campaigns were done in the area except a vehicle going around announcing the outbreak just on one day according to residents.

New health instructors

The CMC appointed new Health Instructors recently but unfortunately those who got the appointments were already CMC staff members but it should have been young school leavers as it happened during the Premadasa era as the Minister wanted some knowledgeable youngsters to educate the public in slums and shanties.

Now, we have the Delta virus which is officially making around 3500 persons ill every day and perhaps double that number with symptoms are not seeking medical attention, and a further two to three thousand, who do not realise that they have the virus, are in the community. In any epidemic this is the case according to studies. Already we have 150-170 deaths a day, again officially, which is causing a mounting concern about the next few weeks where we may have around 600 deaths a day according to some sources.

Third wave

Lack of proper data is a great concern and I have been mentioning this issue for a long time now. When the third wave started there were nearly a 100 patients who died in their homes without either seeking medical help or not getting it. This is the lack of communication between the CMC and the city dwellers that I had highlighted earlier. In order to find out the reasons for home-deaths I wrote to the Chief Epidemiologist as the Chairman of the Standing Committee of Health & Sanitation to give me data about such deaths so that we at the Municipal Council can discuss the issues and take appropriate issues. I never heard from him. Some of this information is also available with the Municipal Council but it is a jealously guarded secret! Knowing the value of data and information I initiated the GIS for Health Information, way back in 1998 at the CMC as the Epidemiologist for CMC, a newly designated post created by former CMOH, the late Dr. Suranjan Silva. If that system was properly developed, by now we could have been in a position to indicate where the virus is and where it would go next and take appropriate action. We cannot control this epidemic with cooked up data. Every patient is important and so are their contacts. Unfortunately, today when someone gets ill and when they are asked to stay at home sometimes no one contacts them and the contacts are left alone to do whatever. This has become an impossible task and at least in the future the government should take measures to increase the numbers of PHIs, Midwives, Health Educators by 100% at least rather than have management and development assistants in their hundreds in offices.

Then comes the fact that now it is time to apply the theory that if humans don’t move the virus will also not move. But see what happened in the recent past. Protests, demonstrations and marches were allowed to take place in many areas in the country. It is a shame that teachers took the government to ransom to settle a 24-year dispute giving a wrong message to the society and no wonder we have undisciplined citizens in the country who have been brought up by the education system and that is clearly seen by the way they behave on the roads.

Shunning responsilibity

Although Inter-provincial travelling was banned, people got down from busses and walked across bridges and later hopped into a bus on the other side. Where is the social responsibility of the people who should understand that there is something that every one of us should contribute to get rid of this scourge? At least now let them realize that it is not the busses that move the virus but people! This is a land like no other.

All this points to a deluge of death and morbidity that we may have to face in the next few weeks if some thing different will not be done soon. We have a new Minister of Health and may be there should be new faces in the Covid-19 Task Force. They should infuse new thinking of how to prevent the spread than increasing the PCR testing and vaccination. The people should take part in this exercise and all local social organisations in the profiting from respective areas should be taking part in such activities but not be vigilantes so as to not push people who go down with Covid-19 out of their areas. While we encourage people contributing to this cause, we also have to get rid of people who profit illegally from this national disaster.

Already there are allegations of selling of vaccines, profiting from PCR testing, handing over the disposal of dead bodies from private hospitals to funeral parlours for considerations, hotels paying commissions to officials for directing patients and many more. These should be investigated properly and if the allegations are true then the culprits should be brought to book.

Way forward

What should be the way forward? I am totally against Lockdowns by the types we had earlier. That also promotes indiscipline as Lankans love to somehow circumvent the law and have their own way. It is better to have curfews but not for long periods but maximum for about a week and that would be better than loose four weeks travel restrictions and or so called-lockdowns. So let it be a curfew from this Saturday or Monday! This will also not harm the daily wage earners much. But please give at least three days of notice and see that the elite also not travel through provinces by this date armed with travel permits. In the future we have to take quick, strong and timely action to stop the transmission of the disease. For that we need proper data and maps before taking decisions. We must put the Epidemiology Unit in the fore-front of Covid-19 control now. If necessary, the Government should bring back those who have retired and put each province under one of them. The data provided now is not worth to take informed decisions. There should be enough young medical officers with IT knowledge who can bring out great analysed data and maps who can be put to work at the main Unit. But please share the data with others. Show the people where the disease is so that they avoid such places.

Data has shown that eight out of 10 people should stay at home for the corona virus to be controlled. This is an important message as sometimes even the vaccinated get ill. So, what can be done? What can be suggested is that at any time or any day both the Public and the Private Sectors should have only 20% of their office staff at work at least until the end of the year after the initial curfew. All government departments, businesses or institutions should have their own Covid-19 prevention health protocols in place catering to the specific needs of such places.

This is important especially for government institutions. Not only inter-provincial travel should be banned but even inter-district travel should be only for the essential staff. The manufacturing industry can have all their staff in bubbles by providing the staff with lodgings. The factories should reduce staff levels to 50% of the staff but with longer working hours having weekly rotations. The same goes for the building industry. They can have night shifts. The staff can be allowed home once a fortnight after being tested with a rapid antigen test. Private transport for the staff is important and that goes for the government workers also. They can use the school vans which are idling now. Those drivers and conductors in the transport services also should be vaccinated as a priority.

Task Force

As I had mentioned in an earlier article, the Covid-19 Prevention Task Force should work in smaller sub-committees: Disease Control; Security; Logistics, Vaccine procurement and delivery; Hospital Management; Economics, Manufacturing, Agriculture and Trade; Ambulance Service, etc., and meet the Task Force with their own decisions which should be conveyed at the meetings with the Head of the Govt. That meeting should be for only the key officials from these sub-committees or those who are invited specially to hear their opinions. Public Health staff should engage with local communities in the MOH areas to build trust for evidence-based actions to detect possible cases and encourage local leaders to support outbreak control response measures. Strategic decisions with regard to control measures should be taken at central level by an Expert Panel comprising of Epidemiologists, Virologists, Public Health and Hospital administrators. Keep out the ‘Wannabe Epidemiologists’ stupid ideas such as vaccinate people in ‘Virgin Areas’. They do more harm than good as too many cooks spoil the soup. A true Epidemiologist with years of experience gets a gut feeling of what should be done next. All vacancies for health staff should be filled at least temporarily especially, those in the public health workforce. Border control should be strict especially in the northern seas to prevent Delta virus entering the country. Fishermen should be told not to mix with Indian fishermen. All decisions should be based on guidelines, policies and decisions of the Task Force or Presidential directives based on worked out strategies, the analysed information, maps, risk assessments, and the epidemiological situation. The basic messages to the general public should be to wear a mask, wash the hands, keep social distance, get vaccinated, go for self-isolation and get medical help if they suspect they have the disease, home quarantine if required, etc. It is a must to have proper communications with people in the area and the health staff comprising of the field officers are the best to do this. Private or Government institutions not following guidelines and causing outbreaks should be taken to task severely. Stop all gatherings of people.

Natural decline

This epidemic will only stop due to natural decline that will happen when most of the people will get ill even mildly and have immunity against Covid-19 or by vaccination of the population as Israel did for their citizens. Considering the fact that even people in Dambane are down with the disease I think the former will win the race. But the latter should be our priority. People should as early as possible get their doses of the Covid-19 vaccine, whether it is the AstraZeneca, Sputnik V, Sinopharm or Pfizer vaccine that is available in their area. If we want to stop a deluge of deaths in the country this should be done immediately. All people over the age of 18 in high population density areas where the disease affected large numbers should be vaccinated and people in Colombo’s poorer areas should be given the priority and not the people with connections, power or money. We have to prevent Covid-19 but not at the cost of ruining the livelihoods of the people, especially the daily wage earners.



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Opinion

Mr. President, please let this be a turning point!

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By Rohana R. Wasala

When I pen these words, most Sri Lankans are still sleeping. I am ahead of them and awake. That is because of the time zone difference between where I live and Sri Lanka, my country of birth. As usual, as the first thing I do in the morning, particularly these days, I glanced at the headlines in The Island epaper, and was depressed to read the banner headline “Ratwatte remains a state minister despite resignation over running amok in prisons”, with the following underneath it:

“State Minister of Prison Reform and Rehabilitation Lohan Ratwatte yesterday told The Island that he had informed President Gotabaya Rajapaksa that he would step down immediately from his post as the State Minister of Prisons. However, he will continue to be the State Minister of Gem and Jewellery Industries”.

Having earlier read and heard over the media about Lohan Ratwatte’s alleged escapades in prisons on Sunday (12) night, I have been eagerly waiting to read a newspaper headline like “Deputy Minister remanded; a good start to meeting challenge to rule of law”, for I expect nothing less from President Gotabaya Rajapaksa. As a disciplined and determined executive, with a military background, he, I assume, tries to handle the toughest cases with the strictest adherence to the law. He appears to rely on the ministers and the government servants, serving under him, to follow his perfectly lawful commands in a spirit of military discipline, mutatis mutandis, in the context of civil government. Whatever the likely or actual response to the extremely embarrassing deputy-ministerial episode (not the first involving LR), it should be of a kind that contributes to a restoration of the fast eroding public faith in the hoped-for Gotabaya rule. The Island editorial of Thursday (16) under the arresting heading “Arrest them” offers sound advice. I drew some solace from that. For I realised that there is at least another person of a like mind.

I was even more shocked and disappointed by the Commissioner General of Prisons Thushara Upuldeniya’s attempted absolution of the Deputy Minister. According to the online Lanka C News (September 16), the Commissioner has said that the Minister visited the prison to discuss pardoning some prisoners and that the he has the right to visit the prison to discuss with the inmates at any time of the day. The Commissioner might be technically right, but I am doubtful about the lawfulness of what the Minister has done, especially in his alleged inebriated state. Upuldeniya was handpicked by the President for the extremely demanding job. His coming to the defence of LR was a bolt from the blue to the innocent peace-loving law abiding citizens of the country who have been for decades persecuted by the persistent menace posed by the unholy alliance between criminals and some jailors and a handful of politicos providing together an impregnable bulwark for the first.

However, since the case hasn’t yet been verified or investigated, we don’t know for sure whether the Deputy Minister is guilty of going berserk under the influence of liquor as alleged. As a person embroiled in politics, he could be a victim of some calumnious effort of his detractors, and we must be cautious in passing judgement on him. But again, as he, who has a previous thuggish reputation, has virtually accepted guilt in this case by tendering his resignation, citizens are justified if they expect, as I do, a tougher reaction from the President.

At this moment we should anticipate a presidential response different from the mild rebuke “Anthimai!” (equivalent of a sarcastic “Great!”) that the then President Mahinda Rajapaksa greeted the hospitalised Labour Minister Mervyn Silva with, on December 27, 2007. (I eagerly hope that the President’s deterrent reaction would be known before this reaches The Island readers.) The latter was admitted to hospital after being given a taste of his own medicine following a rowdy interference he committed with the work of a news editor by the name of T.M.G. Chandrasekera at the state-owned Rupavahini TV station over not giving enough coverage as he alleged to a public event that he had organised in Matara the day before. Though very close to MR, he was not an elected MP; he was only a national list MP from the SLFP that MR led. In any case, it was inexcusable that he conducted himself the way he did, for what he did was bound to reflect badly on the President himself. The other employees of the TV station, angered by the uncouth highhanded behaviour of Mervyn Silva, forced him and his notorious sidekick, suspected drug trafficker Kudu Nuwan or Lal or someone (I am not too sure about these trivial details now) to a room and held them there, handling them roughly. Mervyn Silva was heard pleading : “I will tender an apology if you say I have done wrong”. He had. The workers were providing manual proof as best they could.

Mervyn Silva was beaten up right royally, and bundled into his prestigious ministerial Pajero and was briskly driven away to hospital safety. The state Rupavahini telecast the proceedings live for the whole world to see in repeated ‘news flashes’ most of the day that day, as my older readers might clearly remember. It was a sort of news carnival for the wrathful Rupavahini broadcasters and for the scandalised viewers. While watching the scenario live, I convinced myself that President Mahinda Rajapaksa would kick his you-know-what-I-mean within the hour, or at least after his discharge from hospital. To my utter disgust and disappointment, nothing like that happened. The fellow flourished for another eight years under MR’s wing until he betrayed him utterly in 2015, after having abused his well-known humaneness and his reluctance to abandon people who have helped him in the past. Lately, Mervin seemed to try to cozy up to the boss he so treacherously let down; but MR’s brothers have saved him from his erstwhile unequal friend.

I personally believe that we are not going to see such wretched characters protected under President Gotabaya Rajapaksa during the remainder of his term.

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Opinion

20-year war swelled arms industry coffers

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Five US arms producers made US $ 7 trillion, equivalent to 350 years of Sri Lanka’s annual foreign earnings, at US $ 21 billion per year from wars to counter 9/11 attacks

By M.M Zuhair, PC

The world’s most powerful country, the United States, remembered the 20th anniversary of the 9/11 attacks last Saturday while Sri Lanka, supporting the remembrance, expressed solidarity with the US. Significantly, the truth that emerged from the post-9/11 wars; in terms of deaths, of refugees and of those who benefited from the wars that the US-NATO launched in response to the attacks, is absolutely shocking when compared with the figures relating to 9/11!

The US-NATO counterattacks appear, unbelievably, more catastrophic than the 9/11 attacks, blamed on US-educated Saudi businessman Osama bin Laden and his Al Qaeda. In four coordinated attacks, 19 hijackers, working in four groups, wantonly targeted the Twin Towers and the Pentagon with hijacked planes, leaving all 2, 977 persons dead. According to Newsweek, as of April 2021, the subsequent US-NATOled counter-attack invasions left an additional 7,442 persons from the US and allied forces, plus American contractors, dead. The invasions took away exactly two and a half times more US lives than those lost on 9/11! “I don’t know why!” would have been the likely response of Sri Lanka’s famed singer, the late Sunil Perera!

What about the destruction on the side of the attacked? No clear record, or estimate, of the number of Afghans, including civilians, killed in the US-led war, is available from Afghan sources, but Western estimates place it at between 1/4 to 1/2 million deaths! According to Nicolas Davies, writing for Mint Press News, the Bush-Blair aggression in Iraq, without Security Council approval, caused an estimated 2.4 million Iraqi deaths!

Davies wrote, “But no crime, however horrific, can justify wars on countries and people who were not responsible for the crime committed,” quoting former Nuremberg prosecutor Benjamin Ferencz of the United States.

The US Watson Institute of International and Public Affairs has disclosed 30,177 suicides among US services personnel and veterans who returned after war assignments post 9/11, citing, among others, difficulties in re-integrating civilian life. In combat, 30,177 suicides versus 7,442 deaths are shocking figures, indeed! Today elements within the Taliban, after confronting 43 years of wars and foreign occupation are struggling to reintegrate back to civilian life!

What about the refugees and the displaced? Studies by the Watson Institute have also disclosed that the invasion of Afghanistan had resulted in 2.61 million refugees, 1.84 million internally displaced persons (IDPs) and 330,000 asylum seekers totalling 4.78 million! The total number of refugees and IDPs in Iraq were 3.25 million and in Syria 12.59 million, all of them a result of the US-led invasions post 9/11!

Challenges before the countries that Western powers invaded, killing over an estimated three million, rendering as refugees several millions with many more millions internally displaced, all of whom had nothing to do with the 9/11 attacks, are many. The most urgent priority would be rebuilding the lives of the surviving millions, and in addition, in the case of Afghanistan, preventing its economy from crashing!

Of the refugees, 1.3 million are in Pakistan, two million in Iran, 3.5 million in Turkey and the balance in Europe! They are the innocents dehumanised by the Bush-Blair aggressions when they could have easily captured bin Laden if they had subcontracted the job to the Israeli Air Force and the Mossad. Bush and Blair were fully aware of how on July 4, 1976, the Israelis successfully launched a counter-terrorist hostage rescue mission at the Entebbe airport in Uganda rescuing 102 out of 106 Israeli hostages.

If bin Laden was in fact the mastermind of 9/11, that ‘changed the world’, surely nothing prevented his capture to recover invaluable intelligence of his operations and network! It would soon be evident as to why the US did not want to capture bin Laden when the unarmed man was in the hands of the US marines and did nothing to countervail!

It is noteworthy that of the 19 hijackers, none were from Afghanistan! Importantly, the Taliban condemned the 9/11 attacks, soon thereafter, which was ignored by Western powers! The Taliban’s offer thereafter to facilitate the Organisation of Islamic Cooperation (OIC) to put Osama bin Laden on trial in a neutral country was also rejected by the US. But then the object was war and wars as long as possible and not capturing the enemy, which would otherwise lead to the US having to finish off the wars, to the detriment of the arms industry!

Felix Salmon, in a piece dated September 11, 2021, in Axios, says that after 9/11, defence contractors made $7.35 trillion (equivalent to Sri Lanka’s annual foreign revenue for 350 years at US $ 21 billion per year!) The vast majority of this money, he says, came from the Pentagon. The top five US arms manufacturers who benefited from 9/11 are Lockheed Martin, Raytheon Technologies, Boeing, Northrop Grumman and General Dynamics.

Countries that manufacture arms and explosives include the USA, the UK, France, Germany, Israel, Russia, China, Australia, Japan, India, South Korea, UAE, Norway, Sweden, Canada, Turkey, Singapore, Brazil, Spain, Italy and Ukraine. They are the beneficiaries of wars fought in other peoples’ lands, often based on false accusations.

Many foundations, fronts and forums, are allegedly funded by the arms industry. Substantial sections of the Western media are also at the forefront, beating war drums. People believe the conversations marketed through electronic and print media, with no time to cross-check fake stories often planted by those with vested interests. Very few journalists, in third world countries, have time or the means to cross-check stories. Hate and prejudices are built up over time against the victims of wars and conflicts. ‘I don’t know why!’

They have amongst war veterans, academics and other so-called experts who create false perceptions, hatred and conflicts amongst people in otherwise peaceful countries. People who resist are portrayed as extremists and terrorists. Ultimately, countries that need peace, harmony and unity to revive their economies and the quality of life of their people, find themselves embroiled in worthless conflicts. These conflicts are engineered by agents who mislead those in power and authority, probably getting kick-backs from the agents of these powerful forces, who hop around in vulnerable countries.

But there are exceptions. They are not known nor are they even duly heard. Barbara Lee in 2001 was the only member of the US Congress to vote against the War on Terror. On September 14, three days after 9/11, Lee voted against the 2001 ‘Authorisation for Use of Military Force’ (AUMF) that started the 20-year war in Afghanistan, even before any credible investigations into 9/11 could even begin! Twenty years later, on August 15, 2021, the US-NATO forces abandoned an economically collapsing Afghanistan!

Lee said on September 9, 2021, “Each hour, taxpayers were paying US $ 32 million for the total cost of wars since 2001 and these wars have not made the Americans safer or brought democracy or stability to the Middle-East. For too many years we have outsourced our foreign policy to the Pentagon. I cast the lone vote in Congress against the authorisation because I feared it was too broad, giving the President the open-ended power to use military force anywhere, against anyone.”

(The writer can be reached at mm_zuhair@yahoo.com)

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Opinion

Ivermectin and Covid: no time to lose and lives to save

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By Prof. Saroj Jayasinghe,

MBBS, MD (Colombo), FRCP (London), MD (Bristol) PhD (Colombo), FCCP, FNASSL

Consultant to the Faculty of Medicine

Sabaragamuwa University of Sri Lanka.

Former Professor of Medicine, University of Colombo

It is with a degree of reluctance that I am stepping into the controversy relating to Ivermectin use in COVID. Unknown to many, the pros and cons of Ivermectin in COVID have been discussed in private forums of physicians, academia and doctors from 2020. It has been in the international media ever since laboratory studies in Australia showed that the drug inhibits the growth of the virus. However, the public in Sri Lanka became more aware of the controversy recently, when a confidential letter sent to an official of the Ministry of Health appeared in the social media. I had written this in June 2021 as an individual professional after several months of raging controversy among professionals. It was about treatment of COVID, and I firmly believe vaccination is the best option to prevent the illness. One reason for the very cautious approach of not approving the use of Ivermectin in the West could be because anti-vaccine groups are promoting it as an alternative. Sri Lanka has no such problems, and our population is willingly getting vaccinated.

Proposals to use Sri Lanka as a large study area as a clinical trial or as an observational study were made as far back as early 2021. I understand a clinical trial has begun in patients admitted with COVID, after considerable delays due to procedures related to clinical trials. Such studies are scrutinised by independent ethics committees, the drug must be approved by the National Medicinal Drugs Authority, and the study must be registered in an entity that makes is publicly available for anyone to read about it. This study will at least take another few weeks to months to yield results.

Most discussions in Sri Lanka Centre around the question whether the evidence to prescribe Ivermectin in COVID-19 is strong or inconclusive. One group says there is inconclusive evidence to use Ivermectin while another group says there IS sufficient evidence. As with many issues, this is not black or white but shades of grey, i.e. there are grades on the ‘strength of evidence’ from the field of Evidence Based Medicine (EBM). A parallel in the legal field is when we say that the evidence is ‘beyond reasonable doubt’ or there is ‘proof of the crime’, vs. circumstantial evidence.

Let us assume that using the principles of EBM we find that the evidence to use Ivermectin in COVID is ‘inconclusive’. Such a dilemma is very relevant to a situation where a decision is needed immediately, but the stakes are high. In other words, how would doctors decide to treat in a situation when the evidence for efficacy of a drug is inconclusive, but the stakes are high? Let me share an example.

Imagine a doctor who sees a very ill-looking patient with features of a serious infection (e.g. high fever, vomiting and body aches). She or he requests tests to identify the cause of the illness and the bacteria that may be causing the illness. In such an instance, should the doctor wait till the reports of the tests (e.g. culture reports) are available before treating? If a decision is made to treat immediately, the doctor does not have the ‘strength of evidence’ on the cause of the illness. However, if treatment is delayed until the reports arrive in two days the patient may be dead. This hypothetical example highlights a common dilemma: How do doctors balance between reliance on strength of evidence vs. taking an immediate decision when the evidence is inconclusive. This is best addressed by theories of decision-making and is a question very familiar to practicing doctors.

Now I will demonstrate the parallel with Ivermectin. In the case of ivermectin let us assume that the current evidence for its efficacy in COVID is inconclusive. However, the stakes are very high because COVID is currently raging, hundreds are dying, and there are no alternative drugs to treat early disease. Furthermore, Sri Lanka needs to bridge only a short vulnerable period of 4-6 weeks during which time our vaccination programme would become effective.

Let us assume that doctors begin to prescribe Ivermectin for treatment and prevention of COVID, for the next 4 to 6 weeks, despite the inconclusive evidence. There are two possible key outcomes:

Outcome 1: Future research confirms that it is effective, and it would contribute to saving many lives.

Outcome 2: Future research shows that it is ineffective, and we would have wasted money on the drug. Therefore, Ivermectin could either save lives or waste money. Even the money wasted is miniscule because the cost of a course of Ivermectin is less than Rs 200.00 (i.e. less than one US dollar)! Is it safe to use over the next 4 to 6 weeks? We know it is a very safe drug that has been used for almost 40 years. It is used in mass scale by the WHO to eliminate ‘River Blindness’ and is in their Essential Drug List.

A combination of other factors add support to the decision to prescribe Ivermectin.

1. Evidence is evolving, and studies are in progress. Therefore, conclusive evidence may emerge to confirm its efficacy.

2. There is laboratory (in vitro) evidence that Ivermectin is active against the COVID-19 virus.

3. It’s easy to give (tablets and not injections).

4. Currently there are no effective drugs in Sri Lanka to treat early COVID or prevent it.

5. Certain regions in India and South American countries are using Ivermectin to treat and prevent COVID-19

Summary

Therefore, my humble question is, should doctors in Sri Lanka consider whether to use Ivermectin to treat or prevent COVID-19? We need this only for 4-6 weeks. During this period, rates of COVID are likely to increase due to the very rapid transmission of Delta variant. We have no time to lose, nothing to lose, and lives to save. There is no time for clinical trials. Those who wish to embark on trials to wet their thirst for more evidence are welcome to do so. By the time the results of a new trial are available the horse would have bolted, and hundreds would have died.

My suggestion is for patients to ask your doctors about Ivermectin. You have a right to do so. Doctors are divided on the issue because of their sincerity to the views they have about science, scientific evidence, and decision-making. Please do not assume that there is a conspiracy against the drug in Sri Lanka! I can vouch for the honesty of all the doctors who are having different views on the topic. This is a disagreement between professionals who have diverse views, and we seem to have dug into our lines of defence!

The Ministry of Health has allowed the use of Ivermectin under the direction of a doctor. A range of doses for treatment and prevention is available at BIRD-group.org a group working in the UK. The opinions I have stated here are my own independent views and not in any way linked to the institutions I am affiliated to.

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