Think Sri Lanka. One of two images instantly flash — a bloody civil war which ravaged this tiny island-nation till recently, or breathtaking beach holidays. The war is over. The beaches beckon. And the country now has another big accomplishment.
This week, Sri Lanka made headlines when the World Health Organisation certified it has eliminated malaria, a life-threatening disease that plagued the island for years, just as it plagues India. After the Maldives, Sri Lanka is the second country in WHO’s Southeast Asia region to eliminate malaria.
This hasn’t happened by chance. For years, even during the turbulent civil war, Sri Lanka managed to provide decent primary healthcare to most of its people at a low cost. Its latest feat is an inspiring public health story as in the mid-20th century it was among the most malaria-affected countries. Dramatic public health gains, including success against malaria, have been made possible in this island of about 22 million as successive political leaders, whatever else be their faults, prioritised public health. Equally important: grassroots community engagement and the country’s willingness to learn from past mistakes.
Sri Lanka is bang in the middle of the malaria-endemic tropics. Most of its people live in rural areas. In the 19th and 20th centuries, epidemics were rampant as plantation, irrigation and agricultural projects taken up by the British administration and then the Sri Lankan government opened up many forested areas. Major epidemics took place every few years. The infamous 1934-35 epidemic killed over 1.5 per cent of the population, Lancet points out. “My dad, then two years old and now 83, is a survivor of that outbreak,” recalls Nalaka Gunawardene, a well-known Sri Lankan journalist.
In 1945, Sri Lanka introduced what is known as “indoor residual spraying” (IRS). That helped. In 1958, Sri Lanka signed up for WHO’s Global Malaria Eradication Programme. In the early 1960s, the number of reported malaria cases in the island plunged. The few seen there were imported. That led to a spell of complacency, scaling back of IRS, and malaria cases soared once again in the 1970s and 1980s.
Sri Lanka had learnt a lesson. It changed track. It switched from the single-vector control method to a more holistic and integrated vector-control management. From 2000, it further stepped up advocacy and surveillance.
How did Sri Lanka successfully combat malaria?
“The reason for success is getting the basics right. Many people have the recipe. But success is about execution,” says Dr Risintha Premaratne, till recently director of Sri Lanka’s Anti-Malaria Campaign (AMC). It also helps that over 92 per cent Sri Lankans are literate.
The “basics”, as Dr Premaratne calls it, can be unbundled into a whole series of small and big initiatives in the past two decades or so. These include vector control in irrigation and agriculture projects, health education, community engagement, rigorous surveillance and mobile malaria clinics in high transmission areas. Prompt and effective treatment helped reduce the parasite reservoir and the possibility of further transmission. All this took place alongside support from international agencies and key partners like WHO and Global Fund to Fight AIDS, Tuberculosis and Malaria.
By 2006, Sri Lanka recorded less than 1,000 malaria cases a year. In the past three-and-a-half years, no locally transmitted cases had been recorded.
Many of the imported cases reported in the country since 2013 have been among Sri Lankans travelling overseas. That triggered increased vigilance for imported malaria, prompt appropriate treatment with radical cure for the imported cases.
Sri Lanka now has a real-time Web-based surveillance system for malaria. It is compulsory for private healthcare providers to notify the AMC of any case detected as anti-malarial drugs are only available with AMC. Sri Lanka relied heavily on microscopy as the main tool to detect malaria cases. There is regular in-service training of Public Health Laboratory Technicians (microscopists). Programmes on malaria awareness specially target groups like pilgrims, travel industry and armed forces personnel.
The mobile malaria clinics reached those who normally would be unreachable. Sri Lanka has had the support of several international organisations, but it is important to stress that Sri Lanka’s government had put in most of the money in its battle against malaria.
What lessons can India learn as it grapples with a huge upsurge of mosquito-borne infections like chikungunya, dengue alongside malaria, not to mention all the other ailments?
The first lesson is: prioritising public health pays. Despite the prolonged conflict and relatively low per capita incomes, Sri Lanka never let go. It invested in health. Its health success isn’t just in the battle against malaria. The island nation deployed public health midwives effectively across the country. No surprise then that Sri Lanka has high scores on maternal and child health relative to the rest of South Asia and the developing world as a whole.
India hopes to eliminate malaria by 2030. There are numerous examples where India demonstrates it can act when it wants to. One telling example is Surat. The city bounced back from a horrific plague in 1994 and rejigged its health delivery system.
Last year, I went back to the city and climbed a long flight of stairs with a primary health worker in Surat Municipal Corporation’s Vector Borne Diseases Control Department for company. His job was mosquito and larvae surveillance. He rang every doorbell on every floor.
Recently, we have seen how India pulled out all the stops to fight polio, and succeeded. India’s polio workers had fanned out in every lane, in every block in vulnerable areas.
The bottom line — public health success stories have two key ingredients: sustained political commitment and community engagement. Support and technical assistance by international agencies help, but the key is the local and national leadership. It’s not rocket science.
