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.
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