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Sri Lanka must sustain its health gains: malaria a case in point
by Prof. Kamini Mendis
Today, April 25, is World Malaria Day, and as many countries in the tropical world are laboring to control malaria and others racing towards the finish line to eliminate the disease, we in Sri Lanka are enjoying the prestige of being malaria-free. More importantly our people, possibly unknown to many of them, are benefiting from being free of a scourge, which destroyed lives and livelihoods, which took away most of our health budgets for insecticides, which stifled the cognitive development of our children and which greatly hindered Sri Lanka’s economic development for centuries past.
Today, we may be beleaguered by many health problems, not least, by the SARS-CoV-2 epidemic, but malaria is no more. The year 2012 saw the last case of malaria transmitted by a mosquitoe in Sri Lanka – a colossal achievement by any standards. And despite anxieties and worries whether the disease will return, the country has been kept free of malaria transmission for nearly nine years now, thanks to an exceptionally robust programme within the Ministry of Health, the Anti Malaria Campaign.
What we should be talking about today, though, is not the globally acclaimed achievement of malaria elimination from Sri Lanka, but whether and how the country can sustain its malaria-free status. A famed example etched in global public health chronicles is the historic achievement of Sri Lanka in 1963 of nearly eliminating malaria, and of the disease returning with a vengeance, to devastate the country for the next 50 years. This is a poignant reminder that malaria could still return.
Why so? The mosquito that transmits malaria is prevalent in parts of the country that were previously malarious. Even a new and highly efficient vector mosquito, which transmits malaria in India has been recently and inadvertently introduced into the country. Its implication is that if malaria returns to Sri Lanka it will affect cities as well as rural areas to which it was confined in the past. The threat of malaria becoming endemic again comes from imported malaria patients – those who acquire the infection abroad and return to Sri Lanka with the disease.
Most imported malaria infections are acquired in neighbouring India and African countries, and brought to Sri Lanka by such persons as business travelers, pilgrims, imported labour, and members of the armed forces and the Police Department who return from United Nations Peace Keeping Missions in malarious countries. Unless such infected persons are detected and treated without delay they could infect mosquitoes, and malaria could become endemic again – a possibility, that many health experts agree, must be averted at any cost.
What then must Sri Lanka do to remain free of malaria? It is to sustain a state-of- the art surveillance system to detect malaria patients returning from overseas and treat them without delay so that they will not infect mosquitoes and thereby transmit the disease to other people. Malaria can be easily diagnosed by testing a sample of blood using a rapid antigen test or by examining a blood smear under a microscope. Such diagnostic facilities are widely available throughout the country, and highly effective medicines are available to treat the disease.
Yet, simple as it might sound, the task of maintaining a rigorous programme of malaria case surveillance and treatment is fraught with challenges. This is because malaria is a rare and forgotten disease in the country today. Medical doctors fail, only too often, to test for malaria when a patient presents with fever. No blame to the physicians here, because there are so many other far more common causes of fever in the country – dengue, and a spate of other viral and bacterial infections to be explored as a cause of fever rather than malaria. But the clue to suspecting malaria is taking a history from the patient of recent travel overseas, which if present should place malaria high on the list of diseases to be tested for.
So, a combination of fever and having recently returned from overseas should be the signal to test for malaria. This is a message that the Anti Malaria Campaign is vigorously transmitting to its medical colleagues throughout the country – “when a patient presents with fever, ask for a travel history and test for malaria”. The Anti Malaria Campaign does far more than reminding doctors. It screens high-risk traveler groups for malaria throughout the country year round, and when a patient is detected it sets in motion a series of activities to ensure that the patient is cured, and that the infection has not spread to others in the country. it keeps track of the mosquito vector in all parts of the country and even controls it where necessary. It provides prophylactic medicines for travelers free-of-charge, and is the sole custodian of antimalarial medicines in the country, its staff being on call 24 hours a day seven days a week to keep the country malaria-free.
In truth, and the inspiration for me to write this article is that Sri Lanka has not had the most impressive record of sustaining its health gains, which have been made with enormous effort and major financial investments. We eliminated leprosy in 1995 but the disease has now returned to concerning levels in most parts of the country. We eliminated lymphatic filariasis a few years ago, but there is evidence that the disease may be lurking in parts of the country, with a risk of its transmission being resumed. Intestinal worm infestations, which sapped the nutrition of children for generations, have greatly declined in incidence, as have many other sanitation-related infectious diseases such as hepatitis. But, can we follow these achievements through to the point of extinction, and even more importantly, can we sustain the gains made?
“Out of sight, out of mind” is, unfortunately, a slogan, which most poor developing countries seem to live by when it comes to controlling diseases. They function on flimsy and short-sighted grounds that when a disease is not a health burden any more, the limited budgets for health are better assigned to other more prevalent health problems and diseases. Such thinking is clearly flawed on many counts: As careful studies and estimates have shown the price of preventing the return of malaria is only a mere fraction of the cost that Sri Lanka will have to bear if malaria returns to the country. It is estimated that the return on an investment of one rupee to prevent malaria will be 13 rupees in terms of the savings gained by preventing the return of malaria.
Developing countries must also desist a poorly informed but fashionable idea promoted in health circles even globally, of promoting the integration of dedicated disease control programmes into the general health services no sooner than the disease has been eliminated. Disbanding of these excellent programmes, the very ones which once eliminated the disease has been to the peril of countries as in the case of leprosy in Sri Lanka. Assigning the work of the leprosy campaign to the general health services too soon may not have been the most judicious of actions, and it may have contributed to the rapid return of the disease.
It is obvious that the workforce that was needed when a disease is highly prevalent would not be required to the same magnitude or degree of functionality when the disease is no longer a major burden. A carefully planned transition over time to shift work programmes from intervention delivery to surveillance, and share work time of staff with other related diseases has to be made, if it must, whilst maintaining a core of dedicated expertise on the disease at a central programme level.
The challenges of sustaining a malaria-free Sri Lanka and of keeping at bay other infectious diseases that we have successfully eliminated are many, but none that cannot be overcome by continued investment in, and maintaining the focus on, these diseases. It is an issue that falls broadly under the umbrella of “health security’, a term that has risen in importance with the SARS-CoV-2 pandemic, in the highly connected world that we live in. Today public health has come to the fore of our consciousness with the SARS-CoV-2 pandemic. Let our policy makers not forget that eliminating diseases is not the end-game, and that keeping those diseases at bay is as important as fighting other prevailing health problems.
About the author
Kamini Mendis is an Emeritus Professor and an international expert on malaria. She was instrumental in launching a Global Initiative to eliminate malaria in 1998 while working for the World Health Organisation Geneva. She has provided expert guidance to Sri Lanka and many countries on combatting malaria, and is gratified by the success achieved in the past few decades in many parts of the world. She continues to be engaged in advising the global and regional health communities and the Ministry of Health of Sri Lanka on the subject.
… arrest those named in court proceedings
By Shamindra Ferdinando
The Colombo High Court Lawyers’ Association intends to move the Fort Magistrate’s court against the inordinate delay on the part of the Criminal Investigation Department (CID) to arrest those who had been named in the ongoing court proceedings as suspects.
The Fort Magistrate’s Court has issued a travel ban on ex-Prime Minister Mahinda Rajapaksa, Namal Rajapaksa, Pavithra Wanniarachchi, Johnston Fernando, Sanjeewa Edirimanna, Rohitha Abeygunawardena, C.B. Ratnayake, Sanath Nishantha, Kanchana Jayaratne (Pavitra Wanniarachchi’s husband), Sampath Athukorala, Mahinda Kahandagama, Renuka Perera, Nishantha Abeysinghe, Amitha Abeywickrama, Pushpalal Kumarasinghe, Dilip Fernando and Senior DIG Deshabandu Thennakoon.
The Magistrate also imposed a travel ban on seven others who had been wounded in or were eye-witnesses to the attacks.
Alleging that the CID probe was progressing at a snail’s pace, Attorney-at-Law J. Tenny Fernando, Convenor has, in a letter dated 15 May, requested Attorney General Sanjay Rajaratnam, PC, to expedite the process. The copies of the lawyer’s letter have been forwarded to IGP C. D. Wickremaratne, Chairperson of the Human Rights Commission Justice Rohini Marasinghe, and Prime Minister Ranil Wickremesinghe.
The Association has asked the AG whether the delay in taking those who had influenced the unprovoked attacks on protesting public into custody was because of their political status, political intervention hampering investigations or any other reason.
The association’s President and Attorney-at-Law Lakshman Perera told The Island that the public was seriously concerned about the double-standards in the CID’s response to the unprovoked attacks obviously carried out at the behest of those at the helm of Temple Trees and retaliatory violence.
Referring to the association’s letter to the AG, lawyer Perera said that the police headquarters over the weekend declared the arrest of over 200 persons in connection with retaliatory attacks whereas none of those whose passports were impounded were taken. Lawyer Perera noted that Police Spokesman and Attorney-at-Law SSP Nihal Thalduwa on Sunday (15) announced the arrest of a 49-year-old employee of Moratuwa Municipal Council in connection with the attacks on protest sites. SSP Thalduwa said that the CID took him into custody at Moratuwella, Moratuwa.
The Colombo High Court Lawyers’ Association has requested the AG to instruct the CID to take those who had been named in the court proceedings into custody without delay.
The IGP directed the CID to inquire into the incidents following a missive from the AG, who drew attention of the Police Chief to the domestic and international ramifications of the May 09 mayhem.
The association has queried whether the AG could file charges against some of those politicians who had allegedly instigated attacks in terms of Section 03 of the International Covenant on Civil and Political Rights (ICCPR) Act No 56 of 2007.
Convenor Fernando warned the AG that the integrity of his Office is in question against the backdrop of both the legal fraternity and the citizenry relentlessly demanding expeditious handling of the Temple Trees case.
The association has emphasised that the ongoing investigations are under the purview of the AG in terms of Section 393 of the Code of Criminal Procedure Act No 15 of 1979. Referring to the extensive coverage of the incidents in the mainstream as well as the social media, the association has questioned the honesty and the efficiency of the CID.
Appreciating the swift action taken by the AG’s Department in respect of principal suspects to secure a travel ban, the association has reminded the President’s Counsel Rajaratnam that the outfit is about to file action against the same lot and some additional suspects when the AG intervened.
Lawyer Perera said that if not for the AG initiating action, the association would have done the needful. The entire world was watching how the government handled this situation, he said, adding that it would be the responsibility of the AG to ensure justice.
With the country caught in a fiscal crisis, where it is unable to find dollars even to buy lifesaving drugs, Prime Minister Ranil Wickremesinghe yesterday declared some urgent steps that he proposed to take like privatising the money draining national carrier SriLankan Airlines.
The loss suffered by SriLankan for the year 2020-2021 alone amounted to SLR 45 billion. By 31 March 2021, the total loss was at 372 billion. “Even if we privatise Sri Lankan Airlines, this is a loss that we must bear. You must be aware that this is a loss that must be borne even by the poor people of this country who have never stepped on an airplane”, he said.
In his address to the nation, Premier Wickremesinghe said
the coming few months will be the most difficult times that Sri Lankans have experienced in their lives.
He said Sri Lankan economy is in an extremely precarious state and that the budget deficit for 2022 will be 2.4 trillion Sri Lankan Rupees.
“At present, the Sri Lankan economy is extremely precarious. Although the former government’s budget projected a revenue of SLR 2.3 trillion, SLR 1.6 trillion is the realistic projection of this year’s revenue,” he said.
Wickremesinghe said that the estimated government expenditure for 2022 is SLR 3.3 trillion. However, due to the increase in interest rates and additional expenditure of the former government, the total government expenditure is SLR 4 trillion.
He said that the government needs to find 75 million U.S Dollars in the next few days to provide the basic necessities for the people.
“At the moment, we only have petrol stocks for a single day. Due to the diesel shipment that arrived yesterday, the diesel lack of diesel will be resolved to some extent. Two more diesel shipments are due to arrive on the 18th May and 1st June. In addition, two petrol shipments are expected on 18th and 29th May,” he said.
Wickremesinghe said that Sri Lanka produced 25% of electricity through fossil fuels.
Thus, if the country is not able to purchase adequate amounts of diesel soon, there is a possibility that the daily power outages will increase to 15 hours a day.
He added that the government incurs a loss of 84.38 rupees per liter of 92 octane petrol, 71.19 rupees per liter of 95 octane petrol, 131.55 rupees per liter of diesel, 136.31 rupees per liter of super diesel, and 294.50 rupees per liter of kerosene oil.
“The Petroleum Corporation can no longer bear this loss. Similarly, although the Electricity Board charges SLR 17 per unit of electricity the cost of production is at around SLR 48 amounting to a loss of about SLR 30 per unit. This is also a serious problem,” he said.
Given below is the speech in full: “Last Thursday, I accepted office as the Prime Minister. I did not request this position. In face of the challenging situation facing the country, the President invited me to take up this position. I assumed this duty not only as a political leader, but also as national leader who has benefited from free education at the Faculty of Law of the University of Colombo.
“At present, the Sri Lankan economy is extremely precarious. Although the former government’s budget projected a revenue of SLR 2.3 trillion, SLR 1.6 trillion is the realistic projection of this year’s revenue.
“The estimated government expenditure for this year is SLR 3.3 trillion. However, due to the increase in interest rates and additional expenditure of the former government, the total government expenditure is SLR 4 trillion. The budget deficit for the year is SLR 2.4 trillion. This amount equals 13% of the GDP.
“The approved debt ceiling is SLR 3200 billion. By the second week of May, we had spent 1950 billion. Therefore, the remainder is SLR 1250 billion. Yesterday, a cabinet decision was made to present a proposal to parliament to increase the approved limit for issuing treasury bills from 3000 billion to 4000 billion.
“In November 2019, our foreign exchange reserves were at USD 7.5 billion. However, today, it is a challenge for the treasury to find USD 1 million. The Ministry of finance is finding it difficult to raise USD 5 million required to import gas.
“Amidst all these issues we are faced with several grave concerns. To ease the queues, we must obtain approximately USD 75 million within the next couple of days. At the moment, we only have petrol stocks for a single day. Due to the diesel shipment that arrived yesterday, the diesel lack of diesel will be resolved to some extent. Under the Indian credit line, two more diesel shipments are due to arrive on the 18th May and 1st June. In addition, two petrol shipments are expected on 18th and 29th May. For over 40 days 3 ships with crude oil and furnace oil have been anchored within the maritime zone of Sri Lanka. We are working to obtain dollars in the open market to pay for these shipments.
“A quarter of electricity is generated through oil. Therefore, there is a possibility that the daily power outages will increase to 15 hours a day. However, we have already obtained money to avert this crisis. We must also immediately obtain USD 20 million to provide gas to consumers. The situation of kerosene and furnace oil is even more urgent. At present, the Central Bank, local state and private banks, and foreign banks functioning in Sri Lanka are all facing a dollar shortage. As you are already aware, we possess a very low amount of US dollars. Nevertheless, we succeeded in bringing in a diesel shipment yesterday despite these adverse circumstances with Indian assistance. Therefore, you can obtain that diesel from today onwards. We will also work towards making a payment for the gas shipment that arrived on Tuesday. Therefore, you will have some respite from the gas shortage.
“Another grave concern is the lack of medicine. There is a severe shortage of a number of medicines including medicine required for heart disease as well as surgical equipment. Payments have not been made for four months to suppliers of medicine, medical equipment, and food for patients. The payment owed to them amounts to SLR 34 billion. In addition, payments have not been made for four months for medicine imported by the State Pharmaceuticals Corporation. As a result, pharmaceutical companies are taking steps to blacklist the SPC. Unfortunately, our Medical Supplies Division is unable to provide even two critical items of the 14 essential medicines that we currently need. These two are a medicine used in treating heart disease and the anti-rabies vaccine. The latter has no alternative treatment.
“We have planned to present a new alternative budget to the development budget proposed for 2022. Intend to present it as a concessionary budget.
“I further propose to privatise Sri Lankan Airlines which is incurring extensive losses. The loss for the year 2020-2021 alone amounts to SLR 45 billion. By 31st March 2021, the total loss was at 372 billion. Even if we privatise Sri Lankan Airlines, this is a loss that we must bear. You must be aware that this is a loss that must be borne even by the poor people of this country who have never stepped on an airplane.
“In the short term we will have to face an even more difficult time period. There is a possibility that inflation will increase further.
“At present, the government incurs a loss of SLR 84.38 per liter of 92 octane petrol, 71.19 per liter of 95 octane petrol, 131.55 per liter of diesel, 136.31 per liter of super diesel, and 294.50 per liter of kerosene oil. The Petroleum Corporation can no longer bear this loss. Similarly, although the Electricity Board charges SLR 17 per unit of electricity the cost of production is at around SLR 48 amounting to a loss of about SLR 30 per unit. This is also a serious problem.
“Against my own wishes, I am compelled to permit printing money in order to pay state-sector employees and to pay for essential goods and services. However, we must remember that printing money leads to the depreciation of the rupee. Under the current circumstances, even the Petroleum Corporation and the Electricity Board are unable to obtain rupees.
“The next couple of months will be the most difficult ones of our lives. We must prepare ourselves to make some sacrifices and face the challenges of this period.
“I have no desire to hide the truth and to lie to the public. Although these facts are unpleasant and terrifying, this is the true situation. For a short period, our future will be even more difficult than the tough times that we have passed. We will face considerable challenges and adversity. However, this period will not be long. In the coming months, our foreign allies will assist us. They have already pledged their support. Therefore, we will have to patiently bear the next couple of months. However, we can overcome this situation. Doing so will require taking a new path.
“I thank the opposition leader and the leaders of the political parties who replied to the letters that I sent them informing them of the current situation.
“We must immediately establish a national assembly or political body with the participation of all political parties to find solutions for the present crisis. This will enable us to discuss with all parties and to arrive at decisions for short-, medium-, and long-term action plans that will enable us to rebuild our nation within a specified time frame.
“We will build a nation without queues for kerosene, gas, and fuel; a nation free of power outages, a nation with plentiful resources where agriculture can freely flourish; a nation where the future of the youth is secure; a nation where people’s labour need not be wasted in queues and in struggles; a nation where everyone can lead their lives freely with three square meals a day.
“I am undertaking a dangerous challenge. In the Caucasian Chalk Circle, Grusha crossed the broken rope bridge carrying a child that was not her own. This is an even more difficult undertaking. The precipice is deep and its bottom cannot be seen. The bridge is made of thin glass and there is no handrail. I am wearing shoes with sharp nails that cannot be removed. My task is to safely take the child to the other side. I am accepting this challenge for our nation. My goal and dedication is not to save an individual, a family, or a party. My objective is to save all the people of this country and the future of our younger generation. I will undertake this task willingly risking my life if needed and will overcome the challenges facing us. I ask you to extend your support to me in this endeavour.I will fulfill my duty towards our nation.”
By Norman Palihawadane
Security for Parliament and surrounding areas has been beefed up in view of Inter University Students’ Federation-led agitations against the government and President Gotabaya Rajapaksa.
During a special meeting, headed by Sergeant-at-Arms Narendra Fernando, with security experts and other stakeholders from Parliament, it was decided to enhance security during the next sitting week of parliament scheduled to start at 10 am today.
In addition the number of Navy boat patrolling in the adjacent Diyawanna Lake has been increased, parliament sources said.
The scope of intelligence observances and surveillance would be increased, sources said, adding that police and army men would be deployed in the surrounding areas of parliament premises.
Yesterday’s meeting also conveyed instructions issued by Defence Secretary General Kamal Gunaratne during his visit to the Parliament complex on Sunday.
Speaker Mahinda Yapa Abeywardena told The Island that the responsibility of providing security to the MPs had been handed over to the Police and the Army.
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