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Dishonest doctors

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The arrest of a female neurosurgeon working in Sri Jayewardenepura Hospital with two accomplices, for fraud, has created a media frenzy about dishonest doctors—not surprisingly! In social media, she is being castigated with the strongest of words, sometimes in raw filth, and curses that may befit even worse crimes. No one will disagree that she deserves to be castigated, in addition to being committed to a long prison sentence, if even some of the charges are proven.

My words of caution, in no way, are an attempt to defend a member of my chosen profession; in fact, in my past writings, I have vented my frustrations over the ignoble acts committed by some members of the noble profession. I am simply trying to point out that before castigation, perhaps, we should pause and consider honouring the long-cherished legal principle of ’innocent till proven guilty.’ Further, we cannot afford to forget the lessons learnt, if at all they were, from the ‘Dr Shafi incident’ This doctor, accused of much worse crimes, was hung and quartered by the media as well as the public inflamed by mass hysteria ignited by some ill-informed or scheming politicians, to be cleared of all charges! Attempts at selective justice, due to politicisation, seems to be an underlying problem.

For more reasons than one, I became surprised by a follow-up news report which stated that this doctor has operated, to place a shunt to relieve the increased intracranial pressure, on a patient who was brain dead for five days. If she, as the consultant in charge of the patient, has informed the relatives of the clinical state of being brain dead, it is an act of utmost stupidity to then suggest the insertion of a shunt. Further, it was reported that this was detected at the post-mortem examination which is the other reason for my concern. The pathologist doing the post-mortem examination, obviously, has the best look at the brain but, unfortunately by then, it is too late. On the other hand, clinicians who treat during life must go by clinical findings aided by investigations like the EEG, which records the electrical activity of the brain, as well as imaging studies like CT and MRI scans, which show structural abnormalities.

According to the NHS.UK website, following are the criteria for diagnosing brain death:

The person must be unconscious and fail to respond to outside stimulation.

The person’s heartbeat and breathing can only be maintained using a ventilator.

There must be clear evidence that serious brain damage has occurred that cannot be cured.

Brain death, therefore, is a clinical diagnosis supported by investigations. It is diagnosed by two doctors after doing the following tests to establish brain stem death, repeated once more for confirmation:

* a torch is shone into both eyes to see if they react to the light

* the eye, which is usually very sensitive, is stroked with a tissue or piece of cotton wool to see if it reacts

* pressure is applied to the forehead and the nose is pinched to see if there is any movement in response

* ice-cold water is inserted into each ear, which would usually cause the eyes to move

* a thin plastic tube is placed down the windpipe to see if it provokes gagging or coughing

* the person is disconnected from the ventilator for a short period of time to see if they make any attempt to breathe on their own

Admittedly, a pathologist could opine that the extent of injuries to the brain, found in a PM examination, is incompatible with survival but it is beyond my comprehension how the post-mortem examination was able to establish the time of brain death!

A related issue that needs addressing is the increasingly common practice of requesting the purchase of drugs and devices from the private sector as well as getting tests done in private laboratories, all of which should not happen, ideally, in a free health service. However, even the present ‘socialist’ government does not seem to be doing anything to stop this practice. However, as there are no established guidelines, it could lead to malpractice. Even worse is the possibility that some honest clinicians who have no choice but to engage in this practice with the best of intentions could be wrongly accused! Therefore, it is no surprise that medical trade unions are demanding clarity. It is high time the Health Ministry with other stakeholders drew up guidelines to protect not only the public but also honest clinicians. At the same time, steps should be taken to establish reasonable charges for services rendered in the private health sector as, at present, exploitation of an ignorant public seems to be the norm!

These corrupt practices are nothing new. I am reminded of a famous cardiologist requesting one of my well-to-do cousins to meet the representative of a pacemaker company, in his government hospital office, to buy an appropriate pacemaker for his wife! When my cousin rang me for advice, after listening to the story, I stopped him from doing this as she did not need a pacemaker anyway. She had a slow heart rate due to a drug, beta-blocker, which normalised on stopping the medication. The cardiologist had wanted to do this as a safety precaution!

It is not only our chaps who are up to no good. A very famous cardiologist of Sri Lankan origin, who worked for a long time in the USA, brought a team of experts to help us, during the time I worked in the Cardiology Unit. He got one of the team members to implant a pacemaker, in a private hospital, on a mega-rich businessman in Colombo. This was done on the recommendation of the businessman’s personal physician, a non-cardiologist, who did not consider me clever enough to do it, though I had already pioneered by setting up the permanent pacemaker service in Sri Lanka! Although I initially refused to take over follow-up, I had no choice because I could not disregard the pleas of his family members, some of whom were well known to me. Unfortunately, the pacemaker failed prematurely and I was able to get a replacement unit, paid for by the implanting team, only after threats of reporting them to the US authorities. I implanted that and it was still functioning when I left Sri Lanka.

I sent the explanted unit to the manufacturer, in view of unexpected failure, and the feedback I got shocked me. They informed me that it was a unit given to a Californian University for animal experimentation after expiration of shelf life, stating further that it should never have been implanted on a human! When I mentioned this to the patient and stated that I may consider reporting this malpractice to the US authorities, he begged me not to do so, in spite of having paid a huge sum for the date-expired pacemaker, which I am sure covered the cost of hotel stay of the entire team. What a contrast: the humaneness of the businessman versus the corruption of some members of my profession!

Dishonest doctors are everywhere, though still a minority. Prosecuting a few will not make any significant change, but taking action to eliminate the root causes surely will. This is badly needed as judging by the stories I hear, unfortunately, members of my profession too seem to be increasingly following the path of most other Sri Lankans, led by politicians. Will we be able to see an end to this malignancy?

by Dr Upul Wijayawardhana ✍️



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Features

‘Lord Edgware Dies’

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It has been some time since I read an Agatha Christie, the plot of which I cannot remember. So, I was delighted to find on the shelves of a friend Lord Edgware Dies, which I had a vague memory of, but no certainty about who had done it.

When I read it, I found that my memory of who was probably the killer was correct, but I could not be certain and the red herrings Christie threw in were so diverting that until almost the very end I wondered if I had been wrong.

The plot is very simple. Jane Wilkinson, who is married to Lord Edgware, tells him that she is desperate for a divorce since she is in love with a very proper Anglo-Catholic peer, Lord Melton, but Edgware refuses to divorce her. She asks Poirot to talk to him, which he does, and is surprised to find that Edgware has told Jane he is prepared to give her a divorce. This was, after he had categorically refused, through a letter, which Jane said she had not received.

That night Edgware is murdered, after Jane had been to see him, or so the butler said, and also Edgware’s secretary. But Jane had been that evening at a grand dinner many miles away, where a dozen fellow guests could swear to her presence.

There was a solution however to the mystery of two Jane Wilkinsons, namely a skilful impersonator called Carlotta Adams who, in the opening chapter had impersonated Jane Wilkinson, who had also been at the performance. But when Poirot goes to see her, he finds that she had been found dead on the morning after Edgware had been killed, of an overdose. And in her bag was a gold case, with a strange inscription, that contained the drug, along with a pair of pince-nez.

Her maid said she had written a letter to her sister in America and posted it the previous night. Poirot asks Inspector Japp to get the letter, and a transcript is received from America, and in it the name of Edgware’s nephew Ronald Marsh is mentioned; he had taken Carlotta to dinner after her performance, with which the book opens, and had then set her a challenge. Japp arrests Marsh, but Poirot is not happy and asks for the original of the letter, which the sister sends him. That shows that a page is missing, and the tear is obvious, though that raises the question as to why it had not simply been cut.

Matters are further complicated by the fact that Marsh had gone in a taxi to the Edgware house, along with Edgware’s daughter Geraldine, in the interval of an opera which had previously seemed to provide them with cast iron alibis. Geraldine had gone in to fetch her pearls so that Marsh could raise money he needed, and thus had an opportunity to kill Edgware, as did Marsh, for the driver said he had got out of the taxi while waiting and gone into the house.

Agatha Christie

Marsh explained why he had gone to the house on the night of the murder as having followed Bryan Martin, an American actor, who had been in love with Jane, whom he saw go into the house with a key. But there was no one visible when he entered, and Geraldine almost immediately came down and they left together. And Martin too has become an object of suspicion to Poirot, for he had been to see him before the murders were discovered with a story of being followed by a man with a gold tooth – a story Poirot immediately realized was false when he was asked how old the man was, and was told he was young, for young people did not have gold teeth.

A heap of French money Edgware had got for a trip to Paris was missing, but since Marsh had no need for it after his cousin’s offer of help, Poirot deduces that it must have been taken by the butler, who has disappeared. Christie has stressed that he is astonishingly handsome, unusual in a butler, and Poirot notes a resemblance to Martin, so he thinks the mysterious man going into the house must have been him.

Incidentally, later Poirot assumes that Edgware’s change of mind was because he was involved in some scandal, and I believe Christie intends us to see the cause of this in his handsome butler, though this is not specified.

Meanwhile, Poirot has asked Japp to find out the provenance of the case found in Carlotta’s handbag, and it turns out to have been made in Paris, specially commissioned, and collected by a woman with pince-nez.

But then another murder occurs—that of another guest at the grand dinner, which provided Jane with her alibi. The victim is an actor who had been bemused when Jane, at a lunch, thought the Judgment of Paris referred to the city. He told Hastings he wanted to see Poirot, but was killed before he could get to the appointment. Poirot had rushed there when told about his request, but it was too late.

Meanwhile, Poirot has tried out the pince-nez on Edgware’s secretary, but she could not see through these. It was only a chance remark heard outside the theatre that led him to try them out on Wilkinson’s maid Ellis, a spare pair that had been appropriated for the night of the murders.

Poirot then lays things out, having summoned Martin and told him that he probably suppressed Edgware’s letter, as he had been dropped by then and he did not want Jane to marry another. But after teasing Martin, Poirot says that Jane was in fact the murderer, and she got Carlotta to impersonate her at the dinner while she went to the house and killed her husband. After meeting Carlotta later and checking with her through a call that she had not been rumbled, Jane had gone ahead with the murder – she put veronal into her drink and the case with veronal into the handbag. She forgot to take out the pince-nez she had used earlier to imitate an American. Carlotta had registered as the American in a hotel and Jane had gone to see her, and there they exchanged identities. After seen the letter, she made use of it by tearing off the page that referred to her, and the S of She, so that the person who had challenged Carlotta to impersonate her seemed to be a man.

There is a coda in which Jane, condemned to death, writes to Hastings, still full of pride at her ingenuity hoping she will be remembered.

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Desilt reservoirs, learn from our ancient irrigation systems

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Polgolla

by Prof. O. A. Ileperuma

Silting of reservoirs is a major problem today affecting our hydropower production and irrigation systems. The main Mahaweli reservoirs are silted to a considerable extent reducing the water holding capacity of them. Due to poor soil management practices, floodwaters deposit large amounts of silt in these reservoirs. When the Polgolla reservoir was fully drained about two years back, one could see mountains of silt in the lower reaches of the reservoir. A rough estimate is that 50% of the total capacity of these reservoirs has been lost to siltation. This is a serious issue which affects not only power and agriculture but also flood control.

Our ancient irrigation systems ensured that desilting of reservoirs took place under royal decree where all users of the reservoirs were ordered to carry out desilting of reservoirs during the dry season. The clay thus collected was used in making bricks for the construction of great stupas which dot the landscape of our ancient kingdoms. This ensured that the reservoirs had their full capacity filled with water for the next cultivating season. Our ancient kings were clever enough not to construct reservoirs by blocking main rivers such as the Mahaweli. A classic example is the Minipe left canal where they tapped only the surface water of Mahaweli. Even the bigger tanks such as Nuwara Wewa and Parakrama Samudraya were fed with minor rivulets. There were also other ingenious features in the cascade irrigation systems built by the ancient kings, such as mud sluice canals and forest reservations between the reservoirs in the cascade system. These reservations helped trap silt and remove excess nutrients, which could otherwise contribute to increasing salinity as water flowed from one reservoir to another.

Victoria

Moragahakanda

A classic engineering marvel is the former Yoda Ela, which carries water from Kalawewa to Nuwara Wewa and Tissa Wewa. It is 87 km long although the straight distance between these points is only about 40 km. The gradient of this canal is about 10 cm per km or 6 inches per mile. Yodha Ela functions as a moving reservoir and feeds about 4,600 hectares of paddy lands. It is a winding canal with about 120 smaller reservoirs on its way. It was constructed during the reign of King Dhatusena around 459 AD and later expanded by King Parakramabahu by connecting more reservoirs to the network. Unfortunately, during the Mahaweli project our modern-day engineers constructed a concrete canal replacing the winding path of this Yoda Ela also called Jaya Ganga. This effectively removed the ability of the old Yoda Ela to remove silt and nutrients. The bank of this Ela has wet zone trees such as jak and areca nut growing well. They take up the nutrients from the flowing stream making the water suitable for irrigation later.

Ancient Mesopotamian civilisations depended on dams constructed along the two main rivers, Euphrates and Tigris. After continuous irrigation of their fields over several thousand years, salinity of the irrigated lands increased making them unsuitable for agriculture. People died due to famine and this clearly illustrates the danger of blocking main rivers for agriculture. There is scientific evidence that the salinity of paddy soils in the Mahaweli C area is increasing.

We saw the devastation caused by Cyclone Ditwah. The sluice gates of the Kotmale Reservoir were opened, and Kandy and Peradeniya were flooded. If the reservoir had had greater storage capacity, couldn’t the opening of the gates have been delayed? This may not be an argument that modern-day engineers would readily accept, and I am not an irrigation expert. These ideas may well be naïve. But most of us tend to think of reservoirs mainly in terms of hydropower generation and irrigation, while their role in flood control receives much less attention. The question therefore deserves serious consideration. Could restoring lost reservoir capacity through desilting help improve our ability to manage extreme rainfall and reduce flood risks?

Desilting our reservoirs should be considered a national priority.

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Losing out to Ethiopia

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From Trailblazer to Tailender

Export diversification – Missing the wood for the trees – Part III

by Gomi Senadhira

In Sri Lanka, the word “Ethiopia” is often used as disparaging slang to describe individuals or areas experiencing extreme poverty, starvation, or severe economic hardship. This linguistic habit originated in the 1980s with the Western media coverage of the devastating Ethiopian famine of 1983-85. That media coverage shocked the world but also left an outdated and offensive global stereotype that the country is permanently starving. Much has changed since then. By now, with an annual growth rate of around 9%, it is the fastest-growing economy in sub-Saharan Africa. Ethiopia has also emerged as a highly competitive exporter and is challenging not only its competitors in the region but also countries like Sri Lanka. This article is on how Sri Lanka has lost ground to Ethiopia (and a few other countries) in the GCC markets for agricultural and floricultural products.

Sri Lanka – A Pioneer in the Agriculture and Floricultural Market in the GCC

As discussed in Part II of this article, by the mid-1980s Sri Lanka had established a strong foothold in the GCC’s fruit, vegetable, and floricultural market. Geographical proximity and well-established shipping and air links gave Sri Lanka a strong comparative advantage over Southeast Asian and African nations. Thailand, Vietnam, and Kenya were not even in the market. At that time, Ethiopia was experiencing (as BBC news reports described) “a biblical famine”.

The market was not very large, but it was lucrative and growing. Trade Minister Lalith Athulathmudali as well as the Chairman of the Export Development Board, Victor Santiapillai, who visited Kuwait (and the GCC countries), recognised the market potential for these products and encouraged us to continue with our work. The minister was particularly keen to further develop links between the market for these products, exporters, and his Export Production Villages (EPVs). So, it was becoming a successful case not only for export diversification but also for transferring gains from exports directly to rural households.

From Trailblazer to Tailender

As a result, even by the beginning of this century Sri Lanka had a larger market share than most of its competitors from Asia or Africa. But since then, our competitiveness has weakened significantly. The tables below provide a comparative snapshot of Sri Lanka’s performance vis-à-vis Thailand, Vietnam, Kenya and Ethiopia in the GCC market for vegetables, fruits and floricultural products. As illustrated therein, in 2001 Sri Lanka was ahead of Thailand, Kenya and Ethiopia in this small but rapidly growing market. Since then, we have fallen behind Thailand, Kenya and many other countries in that lucrative market. If this trend continues, Sri Lanka will fall behind Ethiopia within the next few years. (See Table 1)

In the GCC market for vegetables (covered in HS chapter 07), Sri Lanka was ahead of most other competitors in 2001. As illustrated in Table 1 , Sri Lanka had failed to develop this market, while Thailand, Kenya, and even Ethiopia had very efficiently increased their market shares. The GCC is a market to which Sri Lanka can supply some vegetables, like cabbages, by sea. It appears Sri Lanka had also failed to exploit this mode of supply.

We can see a similar trend in the market for fruits. Vietnam, Kenya, and Thailand have emerged as major players, while exports from Sri Lanka have staggered on slowly. In this segment, Vietnam has emerged as a leading player during the last twenty years and the GCC imports from Viet Nam have shot up from US$44 thousand in 2001 to US$346 million by 2024. In part one of these articles, I discussed the remarkable increase of jackfruit exports from Vietnam “…just $3 million in 2015 to an impressive $236.8 million in 2023” while most of our jackfruit production rots under the trees. This explains how countries develop their markets, geographically and product-wise. (See Table 2)

Sri Lanka’s performance has been weakest in the market for floricultural products (HS Chapter 06), which groups live trees, cut flowers, and ornamental foliage. When we first entered the market in the 1980s, the market was dominated by the Netherlands, and Kenya and Ethiopia were not even in the market. At that time, we identified the Gulf states as a market where Sri Lanka could have a dominant presence due to geographical proximity. Even in 2001, Sri Lanka was ahead of Kenya, Ethiopia, and Thailand. But by now, Kenya has emerged as the dominant supplier. Ethiopia is also expanding its market share and is the third-largest exporter. (See Table 3)

Missing the Wood for the Trees

In the mid-1980s, Sri Lanka first established its foothold in the GCC market. Since then, Thailand, Vietnam, Kenya, and even Ethiopia have moved well ahead of us and have become leading players. Why did we lag behind in our export diversification efforts in general and, more particularly, in the GCC market?

The reasons are very clear. After the initial attempts in the 1980s and early 1990s, Sri Lanka has not been proactively involved in identifying, developing, and promoting new products and markets, or protecting and further developing new markets already established. The focus has simply been on traditional exports: tea, coconut, cinnamon, and garments, while other products were almost ignored. In essence, we have been and continue to focus intensely on a narrow group of products and markets, and we have lost sight of the bigger picture.

(The writer can be reached at senadhiragomi@gmail.com)

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