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Yes indeed, Hippocrates is turning in his grave

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My mind time travelled thirty-seven years to the auditorium, Rahula College, Matara. Being one of the two surgeons at the Base Hospital I was a man in demand whom the service receivers respected. My good lady and I were seated in the VIP row of seats and when the curtain raised there was a man hanging from a lamp post in an ill lit left hand corner of the stage. The narrator was late the H.A.Perera and in his inimitable style and signature voice loudly exclaimed “this man hanging here was the last honest man in the country”. The stage play was Maghatha. This was a satirical play depicting the hight of corruption and lawlessness prevailing at the time.

Sri Lanka even at this moment of time is not any better. There will come a time when honesty and truthfulness would make one disqualified to continue to live here. The country is full of dishonest people. Finding an honest man might well prove an exercise that would put Kisa Gothamie in the shade.

It was Monday the 7th November 2022, a public holiday and I had to visit the NHSL,Colombo to see a man who is a distant relative of ours but more importantly a man who did some excellent salvage job for me to make a brand new bathroom screwed up by the previous workmen, up to scratch again. As a result, in a way, I am indebted to him. Having recently had some Deja vu of the thel polim yugaya, I ventured out to bus and walk the trip which I enjoyed very much as the buses were almost empty.

I got to the hospital all right but finding the ward I needed to visit would have been an uphill task if not for an ex-trainee of mine who is at present a top orthopaedic surgeon at the NHSL, whom I met at the Consultants’ lounge. He said “Sir things are very different compared with the time you were a Consultant here. Even after introducing yourself as an ex senior surgeon the response, you receive might embarrass, frustrate, or even anger you. So let me call the ward” and so he did.

It was a medical ward shared between two consultant physicians. There was an air of busyness about the place because they were probably on acute take. Ward had been partitioned into what they called ‘cubicles’ but they were more like solid rectangles or cuboids. Patients of both consultants seemed haphasardly distributed in each ‘cubicle’. Normally in such situations the responsible Physicians name is displayed on the wall at the head end of the bed. No such name boards were visible in this ward. There were three intern house officers on the ward. They knew which cubicle they were responsible for but would definitely have not known the details of patient distribution in the ward. Apparently, the consultants did independent ward rounds but from what I saw those must be reminiscent of the doctor in the house or doctor on the go series. This arrangement is ideal for the two consultants to take every other day off unofficially. I don’t know whether this happens, but I would be very surprised if it didn’t.

My patient’s ordeal exemplifies the degree of confusion that was prevailing amongst the Medical staff of this ward. He is a 51 year old previously healthy teetotaller building supervisor who was suddenly struck down with an acute coronary ailment six weeks ago. Though there has been some delay he eventually had a stent inserted into one of the main arteries of his heart. After a few days in the cardiology unit, he was discharged with a number of tablets and capsules to swallow on a daily basis. All was good till 04 November, when he developed pain under the rib cage radiating to the back of the chest and up between shoulder blades. For all intent and purposes, it was a cardiac (heart) pain and he should have been admitted to the cardiology ward. Not to be. He was bundled into this medical ward. An ECG done on admission had shown some new changes signifying reduced blood supply to a part of the heart with no biochemical evidence of permanent damage to that part of the heart. The biochemical marker of heart muscle damage is Troponin. Hence this condition is called Troponin negative Acute Coronary Syndrome. The medical team in consultation with the cardiology Registrar has started him on anticoagulants (blood thinners). ECG done next mane was normal. Thank goodness for that. Cardiology Registrar never saw the patient physically. Telemedicine at its peak!

Even after my talking to the Consultants personally who promised that a transfer to cardiology would happen, the patient continued to camp in the medical ward for a few more days before being discharged. The scenario made me feel that the Registrars functioned independently of the consultants or communication between senior and junior medical staff was happening only at a very low ebb. Either way it was a dismal state of affairs. I am not sure whether this patient’s management conforms to the accepted norms currently used in the developed world.

My visit was a little over 24 hours after all this had happened. Thanks to my ex-trainee, current Consultant Orthopaedic surgeon, I was greeted well by the doctor at the front desk who passed me on to the doctor my friend and ex-trainee had spoken to over the phone. She and the doctor in charge of the ‘cubicle’ escorted me to my patient. They were two lovely innocent looking girls who seemed trying to find their way around still.

They were thorough with the patient’s condition but didn’t seem to know much logistics around it. They didn’t know if an official referral had been made to the cardiologist who performed the index procedure. They perused the notes but couldn’t find one. They didn’t know which of the two consultants was on call. No consultant has visited the ward on Sunday. I was there till past midday on Monday (07) and didn’t see any consultant doing a round. My patient told me no consultant had gone round the ward on the whole of Monday too. Apparently, the young sweet innocent doctor was not that innocent, after all. She had made a long scribble in the notes without asking the patient a single question and without examining him at all. What a country and what a department of health services!

My response to the two young ladies was this. “Doctors, as budding consultants please remember these are the most vulnerable of human beings because they are acutely unwell. It is our duty to do our best for them. Always try to recognise an urgent situation and treat it to prevent it becoming an emergency. Public holidays are public holidays in which microorganisms are still active causing infection, blood clots still form on ulcerated plaques inside arteries causing acute arterial insufficiency in different parts of the body including the heart, blood pressures and sugars still keep going up and down unconcerned and a whole lot of other known and unknown pathological processes still go on unrelenting. Hence, if you are rostered for the weekend or the public holiday, please make sure your services are physically available. When I was here at the NHSL about twenty years ago there used to be a weekend and public holiday roster made by a man called Mr. Gamage without whom the director felt crippled. There were no computers and printers installed. A simple cyclostyling machine did the job. All wards, all consultants all clinical and other departments received a copy each. So, everybody knew who was on call. Every on-call consultant did a full ward round in the morning. If an emergency cropped up with one of his patients (rarely the case) needing a re-operation he did it himself without handing it over to the casualty team. Exotic investigations and high-tech interventions may well be needed but not the bread and butter of patient care. Awareness, availability ability and empathy constitute holistic care. Please don’t hold them back. Shower your patient with all of the above and you would be a great doctor”. They listened to me so intently in pin-drop silence that they looked as if they were devotees listening to a sermon delivered by Ven. Narada Thero of Vajiraramaya in the distant past.

Unlike in my active working days, in this day and age, even consultants get paid for extra duty they perform. They do get paid for working on holidays as well. Those who get paid for work they haven’t done are as guilty as those who wilfully robbed the country to drag us into economic doldrums. Also, crimes can be perpetrated by commission or by omission. Those who hold back their services to the sick, when rostered, commit a grave crime by omission specially if the juniors who have been entrusted the boss’s job miss an urgent situation which later becomes an emergency to which the poor patient succumbs.

This is in stark contrast to the time I was a trainee and then a consultant and a trainer. The second half of my internship in 1973 was with a tough boss but a great obstetrician Dr. D. E. Gunatilleke, who was to become the Professor of Obstetrics and Gynaecology, University of Ceylon, Colombo, the following year. We had a post MRCOG (part l) Registrar (called SHO those days) who came down to the De Soysa Hospital for Women to take up the job from being MOH Atakalampanna, an area in the Ratnapura Health District. He was a gentleman par excellence too. Being an inexperienced trainee, he was very worried about taking the lead so I almost became his equal instead of his intern. He used to talk to the boss through me. This was one of our emergency admission days and we had already done four Caesarean sections for the night when we received a patient transferred from the Base Hospital, Horana with the baby lying crosswise and the mum in labour. Baby’s hand has prolapsed into mum’s vagina. Baby was still alive but in distress. My Registrar the late Dr. Shanthan Perera said, “Machan boss has just returned home after doing the fourth section. I don’t feel confident to call him. Could you please help me with this? I readily obliged as I had a great rapport with my boss. I picked up the phone and spoke to him. “Sir I am awfully sorry to bother you at this ungodly hour especially knowing you have just returned home from hospital. We got this young lady whose second pregnancy has been complicated by her going into labour with a transverse lie of the foetus, hand prolapse and foetal distress. I have resuscitated her with intravenous fluids and intermittent boluses of 50% dextrose. She is on oxygen and an indwelling catheter is showing a good urine output. I have got blood cross matched and the theatre is ready” “Don’t worry Janapriya, I will be there in 10 minutes” Lo and behold he was there in little over five minutes––he lived at Rosemead Place––did a Caesarean section and extracted a healthy baby. It was 5 am and the fifth Caesarean section was done and dusted! Time for a cat nap before the next day starts.

Those were the days. If I fall seriously ill, I will use my time machine and go back in time to be treated by one of those doctors and gentlemen. They had no flashy cars. They had no private practice or indeed extra duty payment or holiday pay. They had no CT and other scanners to help them with diagnostic work up. What they had in plenty were knowledge, skill, empathy and duty consciousness. They were honest, worked very hard and placed patient welfare at the pinnacle. Even a physically diminutive figure like the boss of mine I was referring to, stood head and shoulders above self-conceited big burley medical men of today proudly plying around in expensive top of the order automobiles.

It was Lord Moynihan, a pioneer surgeon who, seeing patients with advanced bladder cancer suffer with excruciating pain due to the cancer invading pelvic nerves said, “Lord, if you want to take me please do not take me through my bladder” I have modified this as per below,

Lord, if you want to take me please don’t torture me through the corridors of the hospitals of Sri Lanka, be it state run or privately owned but simply knock me down with a train, a bus, a lorry or a truck. I will accept it with grace and the drivers will go scot-free too.

Dr. M. M. Janapriya



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Opinion

Are ‘clients’ of irrigation projects (farmers) dying of diseases caused by agrochemicals?

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By Chandre Dharmawardana
chandre.dharma@yahoo.ca

Engineer Madinda Panapitiya (MP), writing about “Using existing resources for agri-food sector in Mahaweli areas” in The Island (30-11-2022) makes a number of claims and suggestions.

1.    One such claim is that “the main clients of irrigation projects (farmers)” are “dying of diseases caused by indiscriminate use of agro-chemicals”?

This is an unsubstantiated claim propagated from at least 2011, as seen from a discussion in the Kalaya website of Dr. Nalin de Silva where he claims precedence to Ven. Ratana in fear-mongering, stating that “Sri Lanka’s food is poisoned by arsenic and other toxins introduced by agrochemicals”. This theme was pushed forward by Dr. Jayasumana, the Natha-Deviyo Clairvoyant Ms. Senanayake, Dr. Sanath Gunatilleke, Dr. Anurddha Padeniya, Dr. Ranil Senanayake and others, various NGOs, as well as Champika Ranawaka, Chamal Rajapaksa and other politicians who launched a program to create a so-called “Toxin-Free nation”, i.e., free of agrochemicals, while ignoring the more important toxin. Many news agencies joined the fear-mongering. The toxins emitted by traffic that burns fossil fuel,  submicron dust, or the vast mounds of urban garbage that emit toxic leachate, toxic fumes,  generate pathogens and spontaneously explode spewing poison into the ecosystem were ignored.

The final banning of all agrochemicals was done by President Gotabhaya Rajapaksa. Agricultural outputs quickly dropped by 40%. When he fled the country due to Aragalaya riots in July 2022, 7 out of 10 families had cut down on food, and 1.7 million Lankan children risked dying from malnutrition – 17% of them from deadly chronic wasting.

That farmers in the Mahaweli area (or anywhere else in the country) are dying of diseases caused by agrochemicals has been discussed and debunked many times in The Island newspaper, as well as in an excellent U-tube emission by the renowned naturalist Rohan Pethiyagoda. I invite Eng. MP to go through Rohan Pethiyagoda’s U-Tube at https://onedrive.live.com/?authkey=%21AJp%2DCX5bpWS4LUo&cid=B41356F321656C67&id=B41356F321656C67%2192406&parId=B41356F321656C67%2192398&o=OneUp so that further misleading statements are not made.

However, if Eng. MP has field data or information that are not well known to substantiate that farmers are dying of diseases connected with agrochemicals, then he should publicise that information.

In fact, the rampant chronic kidney disease of unknown etiology (CKDu) that affect various settlements in the dry zone (e.g., in the Mahaweli C program) are a result of NOT providing clean drinking water to settlers. Those who settled in higher ground away from irrigation water sources dug their own household wells and consumed the well water without knowing that it was rich in fluoride and other electrolytes that cause kidney diseases (see https://arxiv.org/abs/1704.07906 ). So, the blame must transfer to the planners, engineers and politicians who settled farmers in these newly opened areas (in the 1970s) that had not been previously used, even in ancient times.

So, in “using existing resources for agri-food sector in Mahaweli areas”, a priority concern should be to provide clean drinking water to the farmers, before trying to set up farm factories to get work from people facing CKDu epidemic.

 2.   Eng. MP says that “in this approach, the main purpose of managing irrigation systems is to deliver water to the farm gate at the right time in the right quantity.

That can only be done if there is enough water for the needs of agriculture and power generation. That currently Sri Lanka is not producing enough electricity to even meet its daily needs cannot be a secret to anyone. So any such plan must be integrated with the total management of the hydro-power supply in the context of the CEB national energy plan. Saving enough water and optimising irrigation needs and power needs constitute a major hurdle that will become worse with global warming. One possible inexpensive scheme, which involves saving of water in reservoirs now wasted by evaporation was discussed by me in an article in The Island (12- August-2021 https://island.lk/partitioning-water-between-agriculture-and-hydro-power-to-maximise-sri-lankas-clean-energy-output/). Until such schemes are set up to meet the demand, managers of the irrigation system will not be able to provide water at the right time in the right quantity.

3.   Eng. MP further clarifies that farmers should be treated as clients and not “the servants at the mercy of receiving water, according to rigid schedules decided by irrigation management staff”.

Clients of a utility are people who PAY for the product or service supplied to them. Does Eng. MP propose that eventually the farmers should pay for their water? While this may make sense in a strict market economy, the Mahaweli project, or other infra-structure projects (e.g., roads are not toll roads) in Sri Lanka have NOT been planned that way. Tax payer’s money as well as foreign aid from Colonial Powers who perhaps recognised their role in impoverishing these lands financed the Mahaweli Project. Hence any attempt to charge money from farmers must be purely on a nominal basis, if at all. Farmers should NOT be treated as clients, but as partners in the management process.

4.  Eng. MP also mentions “food production factories”, without explaining what they are. He says that there is a need to minimise the damages caused to the ecosystems where these food production factories are located. Therefore, he says that the management objectives should also be focused on producing multiple types of organically grown crops, profitably without polluting the soil and groundwater aquifers.

Many studies of the soil and water in the dry zone have shown that the levels of agrochemical residues are utterly negligible and far below the danger thresholds specified by the WHO.

Eng. MP supports “organic farming”, without examining the damage to the ecosystem that is inherent in organic farming. Organic methods yield much lower harvests, and hence farmers open up more land to survive, encroaching on the ecosystem.  Control of weeds using water (as in traditional paddy farming) increases the demand for water while manual weeding and tilling (instead of modern no-till farming), all lead to greater erosion.  Furthermore, factory processed organic foods is unsupported by organic markets.

Organic farmers resort to composting which produces large amounts of green house gases. Composting work inefficiently because every compost pit has significant anaerobic regions that produce unacceptable GHGs. As a typical example, research on pig-manure/straw composting shows that methane emissions can be as large as 64%. The obvious solution of ventilating the composter cools the compost bed, reducing the amount of good thermophile bacteria, while enhancing pathogens. More importantly, improving ventilation increases the output of nitrous oxide which is 300 times worse than CO2.

Prevention of formation of such parasite GHGs in composting is difficult even for experienced microbiologists because of variations in the composition of input organic waste, humidity and other factors. Hence more organic farming (now producing less than two % of the world’s food needs), more composting etc., have the potential to catastrophically increase GHG emissions.

5.   The “food factories” that Eng. MP envisages will surely need electricity for their operation as well as for refrigeration, etc. How much power is envisaged? Given the current economic crisis, many people who propose blue prints for progress talk of “rapid industrialisation”, introducing value-added transformations to Lanka’s agricultural and mineral exports and so forth.

 But these are all pipe dreams, as such schemes have two pre-requisites that many planners forget (i) industries need power, (ii) industries need trained technical people, managers, as well as efficient means of disposing their waste products and garbage. All three are currently absent in Sri Lanka, and no effective plans for correcting these short comings are discussed in these blue prints.

In the 1970s, during my time as President of the Vidyodaya University and Professor of Chemistry, I was part of the team that initiated food science, polymer science, and environmental science course units and diplomas. But most of our food science graduates have left the country and work in the USA, Europe, and Australia.  The present day universities, underfunded and firmly in the grip of the JVP and other political parties, are no longer the leaders of scientific education.

So, while there is much to ponder in Eng. MP’s write up, his misleading statements in regard to organic farming, or the etiology of diseases in the dry zone, as well as his neglect of Sri Lanka’s short fall in power production that cripples any development plans, are serious lacunae that he needs to address.

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Opinion

Use existing resources for agri-food sector in Mahaweli areas

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By MAHINDA PANAPITIYA

Irrigation Engineer who has worked for Mahaweli Project since 80s

As originally planned, the present phase of the Mahaweli Project should be focused on social and economic development of the families settled in Mahaweli areas. It could be done by promoting food production in a sustainable way, to gain the return on investment of capital cost incurred on the infrastructure constructed for delivering water to fertile lands in the dry zone. The potential available in lands under Mahaweli Project, which cover about 1/3 of farming areas of the Dry Zone, could easily help the country to become self-sufficient in healthy foods, deviating from monotonous rice cultivation, provided it is managed with a right vision.

Concept

According to the concept explained below, there is a need to change the present management approach to a role focusing food production using limited water resources in the Dry Zone. For example, the term “Block Manager” in the Mahaweli Management System was used during the construction phase in the 70s, because areas were blocked for the purpose of managing construction and settlement activities. There are five such blocks, each of about 3,000 Hectares, under Kalawewa Reservoir. Now the project is in the production phase. Therefore, the Block Managers appointed earlier should now be named as Regional Production Managers, because the very word BLOCK implies negative at the production phase.

The role of a Production Manager replacing Block Manage is a completely different discipline from what was adapted during the construction phase. In the current production phase, Irrigation projects should be perceived as a Food Producing “Factory” – where water is the main raw material. A Production Manager’s focus should be to maximize food production, deviating from Rice Only Mode, to cater the market needs earning profits for farmers who are the owners of the “factory”. Canal systems within the project area are just “Belts” conveying raw materials (water) in a Typical Factory. Farm labor, fertilisers etc. are other inputs.

Required Management Shift

In order to implement the above management concept, there is a need for a paradigm shift at national level in managing large scale irrigation projects. In the new management paradigm, the farmers would be treated as clients, not the servants at the mercy of receiving water, according to rigid schedules decided by irrigation management staff. In this approach, the main purpose of managing irrigation systems is to deliver water to the farm gate at the right time in the right quantity.

It is also very pathetic to observe that main clients of irrigation projects (farmers) are now dying of various diseases caused by indiscriminate use of agro-chemicals. Therefore, there is a need to minimize the damages caused to the ecosystems where these food production factories are located. Therefore, the management objectives should also be focused on producing multiple types of organically grown crops, profitably without polluting the soil and groundwater aquifers.

Proposed Strategy

Existing Engineering staff should either be trained or new recruitments having Production Engineering background, should be made. Water should be perceived as the most limited input, which needs to be managed profitably with the farming community – jointly. Each Production Manager could be allocated a Fixed Volume of water annually, and their performance could be measured in terms of Rupees earned for the country per Unit Volume of water, while economically upgrading a healthy lifestyle of farmers. Staff of agencies such as Central Engineering Consultancy Burro (CECB), established in 80s at construction phase of the Mahaweli Project, can be trained to play the role of Production Engineering. CECB could be renamed as Central Food Production Burro (CFPB).

In addition to the government salary, the staff should also be compensated in the form of incentives, calculated in proportion to income generated by them from their management areas. It should be a Win-Win situation for both farmers as well as officers responsible for managing the food production factory. In other countries, the term used to measure their performance is $ earned per gallon of water to the country, without damaging the ecosystem. Another advantage of this approach is that the young generation of the farmers automatically get attracted to commercial agriculture because of high income generation.

Recent Efforts

We were able to introduce some of the concepts explained in this note during 2000 to 2004, under a program called Mahaweli Restructuring and Rehabilitation Project (MRRP) funded by the World Bank. It was done by operating the Distributary canals feeding each block as elongated Village Tanks. Recently we tried to modernize the same concept at Pilot Scale in System B, by independently arranging funds from ICTA. In that project, called Easy Water, we introduced an SMS communication system to the farmers, so that they can order water from the Maduru Oya Main Reservoir by sending a SMS, when they need rather; than depend on time tables decided by authorities as normally practiced.

Conclusion

The World Bank also recognised the above concept in 2003, as the best water management approach suitable for South Asian countries. Due to the lack of vision of existing managers in the irrigation sector focusing on food production, the above approach has not yet reaped the full benefits. What we need in Sri Lanka, is a political leadership to create challenges for irrigation officials to play a role of educated profit-oriented farmers, deviating them from Rice only mode, by promoting concepts similar to above. Also note that while I worked for a project in Azerbaijan funded by the International Fund for Agriculture Development, I was able to introduce the same concept and they are now using it successfully. I do not see any reason why we could not practice here.

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Opinion

Would anyone in power and sure to lose an election call for an election?

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If she/he would, why don’t tyrants seek election periodically?

(no kerena deege hevnallath adai! Even the shadows of a failing marriage are misaligned.)

by Usvatte-aratchi

I was mightily amused by the demands of several astute political leaders in and outside parliament that president Wickremasinghe uses his constitutional discretionary power and dissolve the parliament, after February 2023. Consider for a moment reasons why he simply cannot.

Wickremasinghe ignominiously lost an election to parliament from his district, after 45 years and after perhaps ten elections, all of which he had won handsomely. Not one member of the party he led, the oldest in the country and which unconventionally had made a president in 2015, won election to parliament in 2020. The party, as a whole, collected enough votes from the entire country to entitle it to nominate one person to sit in parliament. Bhikkhu Ratana’s hurriedly put-together party did equally well! Bhikkhu Ratana was as well entitled to be installed as president as Wickremasinghe. He had distinguished himself by advocating the production of crops without chemical fertilisers and pesticides (vasa visa nati kema). After 12 months of prevarication, Wickremasinghe decided to sit in parliament. He pleased himself in the House with some occasional clever witticisms. After more than two years, a vastly popular Prime Minister was forced out of office. Suddenly, this lone pine in the wilderness grew so tall that Wickremasinghe was appointed Prime Minister. Two months later he was President of the Republic, all constitutionally proper. But the framers of the constitution had made fools of the people, in whose name the constitution was made. In the constitution, there is no office of a vice-president who would be elected to the office along with the president and who would assume office as president for the rest of the period of five years, in the event the office of president felt vacant for any reason Nor was there a provision that in the event that a person not expressly elected by the people as president of the republic were to come to hold that office within the constitution, that he/she would hold the office of the president no longer than it was necessary to elect a new president, to wit, four calendar months. The great republic to the north of us has a vice-president and so has the oldest republic in the world, the United States of America. In our country, the lack of that provision paved the way for a politician who failed to win a seat in parliament in 2020 to decide the fate of that same parliament in 2022. How bizarre? Is that ironic or tragic? Do we laugh or do we cry?

There are two forces contributing to an equilibrium where it is in the interests of the president and a large group of members of parliament to avoid dissolving parliament. The first force is exerted by Wickremesinghe who is abundantly aware that he would lose in an election for president. Recall that two years ago, he could not win a seat in parliament. The other force comes from a majority of members of parliament who are sure to lose their seats in an election, any time soon. Among them, there is a large number of MPs who entered parliament for the first time and would lose the right to a lifetime pension which they would not earn if they did not complete five years in parliament. To most of them, this is a valuable asset which they loth to lose. I am advised that according to the Constitution, the president has the discretion to dissolve the parliament after a minimum of two and half years from the date of their election to office. Parliament itself has the power to request the president to dissolve parliament, provided more than two-thirds of all members of parliament adopt a resolution asking the president to do so. The second force discussed earlier prevents such motion. These two forces ensure that no matter the commotion created by those that seek the president to resign and parliament to dissolve itself, there is sufficient inertia to make the status quo stable. They are each perfectly dependent on the other for survival and they dearly crave survival. The president cannot dissolve parliament and survive. Nor can members of parliament survive without Wickremasinghe a president who, on his own, would not dissolve parliament. This hysteresis can last for about another 3 years legally and longer illegally. I would not rule out the latter probability.

Prime Minister Rajapaksa and President Rajapaksa were both thrown off their perches by forces outside parliament.

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