A tale of two epidemics: Malaria (1930-1960) and COVID-19 (2016 – 20??)

Reproduction

by Rajan Philips

Giving a little background to the topic of my article today would be in order. I am neither an Epidemiologist nor a Historian. I am unrepresentable and incurably infected by politics, and my professional work straddles policy development informed by Urban Planning and Civil Engineering. In the course of reading and writing about the coronavirus outbreak and its economic implications, I have been struck by the need for and the ease with which many developed countries moved to repurpose their established assembly lines (vacuum cleaner manufacturers in England, automakers in Germany and the US, and so on) to produce ventilators and personal protection equipment (PPE) to meet the demand for them among hospital ICUs and frontline health care workers, just-in-time for treating Covid-19 patients. The demand has now expanded beyond repurposing and national requirements, which are substantial themselves. The UN has set up a new supply task force to ensure a monthly global supply of "at least 100 million medical masks and gloves, up to 25 million N-95 respirators, gowns and face shields, up to 2.5 million diagnostic tests and large quantities of oxygen concentrators and other equipment for clinical care." The UN’s World Food Programme will airfreight the PPEs and testing kits to the world’s hot spots from about eight hubs.

Being somewhat familiar with Sri Lanka’s industrial sector both professionally and personally, given my fortuitous association with a number of my Peradeniya contemporaries (N.G. Wickramaratne, B.A. Mahipala, and the late Lakshman Tilakaratne, among others) some of whom played a pioneering role in the development of export products during the 1980s and 1990s, I wanted to elaborate in my Sunday Island column, the idea of using Sri Lanka’s manufacturing knowhow to take advantage of the growing global demand for health care products and open a new and somewhat altruistic avenue for earning desperately needed foreign exchange. 

Needless to say, a number of Sri Lankan firms are already into action, making these products to serve domestic requirements and for exporting overseas. Men and Women of productive action do not wait for government policy or political commentaries.

And thankfully so.

Yet, there is much to write about manufacturing for export in the context of the current epidemic and economic crises. Being more reflective than innovative, I have often thought about two insightful observations by Tanky (N.G.) Wickramaratne, former Hayley’s Chairman, during our occasional conversations. One is that those in the industry do not generally receive product or market specific ideas from economic policy discussions. A point that resonates with Prof. Kumar David’s call for a ‘product mix’ for Sri Lanka’s export industry, that he made with pedagogical persistence throughout the life of the yahapalana government. 
Nothing worthwhile came out of that regime for the country’s economy, other than Ranil Wickremasinghe’s tedious mantra of a million jobs. 

Is the new Administration capable of using the current opportunity to come up with something less empty, more strategic and practically innovative ?

That brings me to Tanky’s second observation that former President Premadasa’s 200 garment factory initiative was a ‘game changer’ (I am paraphrasing) in the export business. Is there anything from the Premadasa playbook that would be of relevance now? That became my question. Looking for answers, I started with Lakshman Watawala’s (the late President’s handpicked man to lead the GCEC/BOI and to launch the 200 Garment Factory Programme) accounts of the garment factory initiative. Then I began going through standard writings on Sri Lanka’s trade, industrial exports and balance of payments, along with new additions like Saman Kelegama’s comprehensive symposium – Ready Made Garment Industry, and Caitrin Lynch’s penetrating ethnography – Juki Girls, until I stumbled on a table of figures in Donald Snodgrass’s 1966 classic: Ceylon: An Export Economy In Transition.

Table 4-3 in Snodgrass’s book: Malaria Mortality and Morbidity, 1930-1960, which I have not previously remembered as a source for anything, suddenly became the source for everything in the current coronavirus context. The rest is outlined below as a short tale (after this rather lengthy background) of two epidemics: Malaria and Covid-19, under three topical headings: epidemiology, economic impacts and political response. The original purpose of revisiting President Premadasa’s garment factory initiative will have to wait for another Sunday. Except to say that I have generally been critical of Mr. Premadasa’s urban and housing development initiatives and his creation of the Urban Development Authority with its national mandate at the expense of Local Government. The garment factory initiative is something else, and is worth revisiting in today’s situation.

Epidemiology

Sri Lanka, then colonial Ceylon, was ravaged by malaria for over two decades starting in 1930. The disease was on a decline after about 1952, but persisted until it was officially eradicated in the 1960s. We have all heard about the malaria epidemic of the 1930s, and endemic malaria has been a fact of Sri Lankan life from pre-colonial times. But in today’s Covid-19 world, it is truly startling to recall the extent of the mortality and morbidity of the malaria epidemic almost a century ago. Snodgrass’s account of the malaria epidemic is part of his discussion of the "revolutionary changes in the island’s pattern of population growth" during the 1930s and 1940s, which together with World War II and independence brought the "classical era of the export economy to an end and ushered in a period of transition to an uncertain future."

Snodgrass (Table 4-3) provides morbidity and mortality data for three decades, from 1930 to 1960. The first two decades (1930-1950) were the worst, when nearly 150,000 people died over the twenty-year period. The number of reported cases were generally over two million every year during the two decades, when the country’s population was only 5.6 million. In 1935 alone, the peak year of the epidemic, a total of 5.4 million malaria cases were treated according to case records in hospitals and dispensaries. Obviously, the recorded cases would have included multiple visits by the same patients, but it is a staggering number relative to the national population. According to a surprisingly brief account of the epidemic in the University of Ceylon, History of Ceylon (Volume 3), Kurunegala and Kegalle were the worst affected Districts, and in one month (1935 January), Kurunegala alone suffered 27,735 deaths.

The malaria statistics from the 1930s should be a sobering reminder to the decision makers of today, political as well as professional, and to their military executors. They are a reminder that if it could have been so bad with malaria, which was not a global pandemic when it ravaged Sri Lanka, how worse things could turn with Covid-19 if the coronavirus were to get out of control now. 
No body wants to see tens of thousands of deaths in a single month anywhere in Sri Lanka now, as people in Kurunegala helplessly did during the fateful January of 1935. 
The question is how confident the people can be that the worst is behind them and that their government has the coronavirus under control. 

The fact of the matter is that no one has the coronavirus under control.

Malaria, a disease transmitted by infected mosquitoes, the deadlier female Anopheles, is now a known quantity and one that is preventable and curable. Sri Lanka is among the countries that are certified by the WHO for eradicating the disease. 
But malaria is still endemic in many parts of the world, mostly in Africa, (including India which export it to Ceylon) and according to the WHO, there were 228 million malaria cases worldwide in 2018, with 405,000 deaths. The current prevalence of malaria is entirely due to socioeconomic factors.
(Pulmonary Tuberculosis also kills large number in Africa and India).
When malaria ravaged Sri Lanka the main causes were also socioeconomic, but there were other factors also. The therapeutic treatment was not as developed as it is now and the use of DDT as insecticide was just being developed. Both made the difference in Sri Lanka, first to mitigate malaria and then to eradicate the disease.

According to the WHO’s description, Malaria is an acute febrile illness whose initial symptoms are fever, headache, and chills, and if not treated early it could get severe and oftentimes fatal. Unlike Covid-19 which primarily targets the elderly, children, especially aged under five are the most vulnerable against malaria. Quinine was the main treatment against malaria during the epidemic. Prepared from the bark of a Peruvian tree, cinchona, and intercontinentally bandied around by Jesuits, quinine has been in use to treat malaria from the 17th century. 
In colonial India, gin was added to minimize quinine’s bitterness and the gin and tonic English cocktail was apparently born.

For the tens of thousands of Sri Lankan victims of malaria there was neither gin nor tonic. Redemption came only with DDT, which was used as a spray to kill mosquitoes. Killing the mosquitoes (vector control) has been the most successful method to reduce malaria transmission. First synthesized as an organic chemical compound in Austria in 1874, the use of DDT (Dichloro-diphenyl-trichloro-ethane) as an insecticide was not discovered until 1939 in Switzerland. DDT was available for the first time in the US in October 1945, and by November a spraying program was inaugurated in the Anuradhapura District. The DDT’s effect was dramatic and within two years the program was extended to cover the whole island. 1.8 million houses were sprayed in 1947, and the number increased to 3.4 million the following year. By 1953/54, deaths had dropped to under 1000, for the first time in almost twenty five years, and the number cases fell below 100,000.

The Sri Lankan malarial epidemic, or ‘the Ceylon epidemic’ as it used to be called, has been extensively studied, and in the 1950s the British epidemiologist George MacDonald used the Ceylon case study in developing the first application of ‘basic production number’ (or rate) for epidemics, the celebrated R0 (R naught or R zero). R0 represents the number of additional infections that one infected person can generate in a population. MacDonald has used estimates of 7.9 and 10 as R0 the malaria epidemic. Based on these numbers the herd immunity [(R0-1)/R0] for malaria without DDT would have been around 90%.

R0 for Covid-19 is considered to be between 2.5 and 3.5 ( depending on countries and locations), and that would suggest a herd immunity threshold of 60 to 70%,i.e., 60 to 70% of the population will have to be infected before virus transmission can be stopped. Until a vaccine arrives on the scene, social isolation and lockdown measures are the only tools available to reduce the value of R0. 

Virus transmission ends when R0 is reduced to being less than one, but that is not the end of the virus.

There is optimism that a vaccine breakthrough might come as early as January 2021. There is ‘ethical’ potential for a new therapy in Remdesivir, a "broad-spectrum antiviral medication" with established safety profile which has been previously developed as treatment for SARS, MERS and Ebola. These efforts may or may not come to fruition, and in the desired short time line, according to experts. The same experts also acknowledge when nothing else is working against the coronavirus it is natural to be enthusiastic about every new development that is going on.

Whither Covid-19

Outside South Asia, the general assessment is that the first wave of the virus is now over, the transmission has either stopped or is significantly slowing, and the affected countries can begin to ease up, while being fully prepared for the next wave. 
For South Asian countries, including Sri Lanka, there is no certainty as to whether or not the first wave is past them, and there is no clarity about what is ahead in the next few weeks and months. 
There were 600 cases in India, when the Modi government began the lockdown, on March 25. Now, just over a month after, the cases have multiplied fifty times and the total is past 33,000 and the number of deaths is upward of 1000. 
The stories in Pakistan and Bangladesh are not any different.

Sri Lanka’s Covid-19 numbers - less than 700 cases and seven deaths - are mercifully lower than what would have been the daily tally during the malaria epidemic. The low numbers should be a cause for cautious optimism, and the country should be in a position like New Zealand. The island country of five million people has about 1000 cases and 19 deaths, and it is confidently returning to normalcy but fully prepared for the second wave of the coronavirus. New Zealand’s much larger neighbour, Australia, an island continent, is almost equally well placed.

In Sri Lanka, there is no certainty or assuredness about what lies ahead. 
The country is under a prolonged curfew to enforce social isolation. 
As many people are in custody for breaking the curfew as have been tested for Covid-19, or sent to quarantine without being tested. Every time there is an announcement of relaxation, there is a spike in the number of cases and the curfew is extended. And the most recent spikes in cases are among the custodians of Covid-19 quarantines – the armed forces.  
There is growing skepticism about even the Covid-19 statistics that are put out by the officials. 
In yesterday’s Island, Dr. Vinoth Ramachandra called it strange that after six weeks of lockdown, "the ‘official’ deaths have remained static for the past two weeks and ‘official’ infections are miniscule in comparison with other countries." 

He went on to ask the officials "is there another purpose that the lockdown serves?"

(my assessment is doctoring data for political reasoning and advantage)!
 
The Alliance of Independent Professionals have been raising similar questions in their periodical ‘statement of facts’ on the Covid-19 crisis. Is testing being deliberately kept under capacity to keep the case numbers low? 
Are clinical case definitions being ignored or tampered with where Covid-19 testing is not available? 
Are patient deaths being properly recorded with causes prior to cremations? 
It is unethical and illegal to tamper with official data or their collection. Where data involve helpless patients, it is also heartless and immoral to tamper with them or destroy them. 
And monkeying with data involving Coronavirus will boomerang spectacularly, because without reliable information there cannot be a plan to break the chain of transmission of the virus.