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It’s time for epidemiologists to lead battle against Covid-19

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Dr. Pradeep Kariyawasam’s recent article on the pandemic prompted me to pen this letter. I met the good doctor 20 long years ago as a rookie medical rep. He was the chief MOH in the Colombo Municipal Council at the time. I was awed by the Town Hall building itself, entering it for the first time in my life. Somehow, I managed to find the MOH offices in its labyrinth, tucked away in a corner on the second floor. Dr. Kariyawasam, in his plush office, welcomed me, listened patiently to my practiced jargon about my products, which we’re expected to deliver to doctors, and soon put me at ease. His joviality was infectious and though he was not swayed by any of the marketing gimmicks the drug companies employ to sell products, he was courteous and kind enough to give me the time to deliver my monologues on my products every time I went to meet him. He was a busy man, rarely found warming his seat. He was always at some meeting or the other, returning to his office well past lunch time. At the time I didn’t realise he was an epidemiologist too. But even then, I noted he was a manager besides being a doctor. Always seeing the big picture and its problems, and finding answers to them, rather than fighting fires here and there.

Reading the contributions, he has made to the papers since the beginning of the -Covid Pandemic, especially The Island article encompassing Sri Lanka’s whole tryst with Covid from the beginning, it is very clear, its him, or people like him that is needed, to get us out of the woods. It was an eye-opener, rendered by an expert who was able to decimate data as well as grasp the situation and see how, when, and where we can get out of this nightmare. The broken up and mostly narrow angled, and sometimes even opposing views the medical fraternity has given on this pandemic has created more confusion. Everyone from union leaders, PHIs, to nurses to laboratory technicians, to medical specialists had a different take, or a partial solution to the same problem. All are divided as government, unions, individuals, associations, medical specialties, political parties etc.

Sri Lanka doesn’t need different opinions or advice. What the country needs is expert handling of the crisis. Expertise in epidemiology to be in charge of this pandemic situation. The country has become rudderless in the Covid situation, because the rudder, the Task force, has proved inefficient. This in spite of the massive effort and brave plodding on by the Army Commander and his men in the fight against Coronavirus. This is because of the lack of experienced and effective epidemiologists in the battle front, people who can see the big picture and know the trends of an epidemic. This can be only achieved by years of experience fighting different epidemic wars, not just knowing about the viruses and their behaviour.

One thing that stands out in Dr. Kariyawasam’s solution is the ‘community participation’. His care and kindness to the community is astounding. After I left my job, I lost touch with Dr. Pradeep for many years. Then he was brought to my sphere of life again about 15 years later, without him even ever knowing about it. I was looking for the Japanese Encephalitis vaccine for my 10-year-old, which at the time was out of stock everywhere in Sri Lanka. After drawing negative at almost all MOH offices in my area of Rajagiriya/Borella, and all private hospitals in Colombo, I was directed to call the CMC head office. The call from a community member like me, was directed right to the top guy, Dr. Kariyawasam. I never identified myself/or told him that he knew me. But I told him of my fruitless search to find this vaccine. He acknowledged the stock out situation and said he would let me know as soon as he can get it. That is the stock answer many of us get from most government officials. We’re so used to this stock response that we never expect to hear anything afterwards. So, rather mad and disheartened, I gave up on this mission of mine and forgot about the matter myself.

I nearly fell off my chair when a week later Dr. Kariyawasam himself called me. He said he had managed to find a single vial at an MOH office in a remote corner of Colombo, Jinthupitiya. If I could get my son over there, he could have it. I stood flabbergasted at this man’s commitment to just one mother, in his sphere of care. I never got to tell him who I was, even then. I found Jinthupitiya, and got my son the vaccine. For me that is the true spirit of an epidemiologist. We are not just numbers or statistics on paper. To him we were human beings in need of care and protection.

An epidemiologist needs to be Sherlock Holmes. Not only did Sherlock gather data, but connected them together to give the correct story as well as solve the crime. That’s what Dr Kariyawasam has done in his article in The Island of 19th August. His expertise on this matter is evident. This kind of expertise is gathered by experience rather than learning. He talks of a ‘gut feeling’. This is only achieved by experience. A rookie can fly a plane as well as a seasoned pilot. But when bad weather hits, that’s when you need the Captain, the experienced. The years count then. The ‘gut feelings’ come into play. That’s when a rookie pilot will bow out and hand over the controls to the captain. I’m an avid watcher of Air Crash Investigations and it is horrifying to see the human errors that cause a crash. 99% of the time it is lack of experience that contributes to it. Either not seeing the glaring signs of trouble or panicking and making more errors.

In Sri Lanka, many errors have been committed in the handling of the pandemic, for it to reach this horrific proportion. In spite of the brave Army Commander and his task force doing everything possible to combat it, they have lacked the guidance and expertise expected from the epidemiology personnel. We need to identify this glaring shortcoming in the Task Force, and make rapid course correction, if Sri Lanka is to avoid a nose dive into the quagmire of uncontrolled Covid deaths. We need Captains of the epidemiologists, the experienced ones to take over the controls. Who can read the clouds/trends, who have ‘gut feelings’ on when and where the virus can pop up, and knows what’s best to do when it does. They have experienced it before, handled it, failed at it, succeeded in it and seasoned by it.

I’m sure there’s many Dr. Kariyawasams in Sri Lanka. Find them and install them at the controls. If called, any captain will volunteer to save the plane if it’s crashing, even if they are sitting as passengers in an aircraft. As the saying goes, when the going gets tough, the tough gets going. Please give the controls of Sri Lanka’s Covid flight, over to the hands of these. Recall them from retirement if necessary. Fly them back, if they are abroad. Transfer them from outposts. Get these to the helm – the Task Force. They are the ones to take charge. Not the government or all parties or opposition or trade unions.

SDZ



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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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