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.

Embracing the truth of Dhamma to rise above the COVID catastrophe

Reproduction

Embracing the truth of Dhamma to rise above the COVID catastrophe

May 2, 2020, 12:00 pm

by Randima Attygalle

As the entire world is clouded by the COVID-19 fright, Vesak full moon poya falling on May 7 brings a beacon of hope to Buddhists all over the world beckoning them all to revisit the timeless truth of Lord Buddha's words transcending ethnic and religious differences, that 'every human being is the author of his own health or disease' and 'health is the greatest gain.'

As a nation with a heritage nourished by the Buddhist philosophy for thousands of years, braving similar epidemics and pandemics in the history, we Sri Lankans are blessed with the gift of Dhamma to sustain us holistically through these testing times-physically, mentally and economically.

As custodians of a value system crowned with 'ayubowan' (may you live long) which is validated more than ever before and even acknowledged by the West in the wake of the present pandemic, time has dawned for us to rise once more as a resilient nation as we had done many a time before, drawing strength from the 'best Sri Lankan practices' which have stood the test of times and in the spirit of Buddha's words, sabbe saththa bhawanthu sukhithaththa or may all living beings be happy and free from suffering.

The multi-pronged solutions entailed in the teachings of Lord Buddha to enlighten us all during these turbulent times are many.

We spoke to Ven. (Prof.) Wijitapure Wimalaratana Thera, former Head of the Department of Economics, University of Colombo and the Vice President of the Sri Lanka Economic Association (SLEA) to reflect on them. 
Following are the excerpts:

Q: How does Buddhism explain and bring insights to the current plight of life and uncertainties while enabling the world to see things as they are?

A: Buddhism maintains that the cosmic principles or natural laws (Niyama) regulate everything in the universe including pandemics such as COVID-19. The natural laws are brought under five clusters as weather (Uthu Niyama), foods or seeds (Bija Niyama), actions (Kamma Niyama), mind or knowledge (Citta Niyama) and physical and spiritual matters (Dhamma Niyama).
The origin and the spread of the COVID-19 can also be analyzed applying those five laws. The widely accepted cause of the origin of the ongoing virus is the food consumption in Wuhan, China. Similarly, human actions, physical and spiritual matters, mind or knowledge and weather contributed to the spreading and also the successful management of the pandemic.

The good health (Nirogi) is highly appreciated (Arogyamada) in the Buddhist texts. The high life expectancy is considered as an important achievement in modern economic development indicators including the well-known Human Development Index (HDI) of the United Nations Development Programme (UNDP). The blessings for longevity (Ayurarogyasampaththi), absence from sufferings (Nidukkho), happiness stemming from good health (Nirogananda), and freedom from all illness (Sabba roga nivimuththo) are a few concepts visible in Buddhist texts.

The following verse highlighting the good health in Dhammapada (Verses of doctrine), a section of the Khuddaka Nikaya, is popular among the Buddhists in almost every country:

"Arogya parama labha-santhutti paramam dhanam vissasa parama nati- Nibbanamṃ paramamṃ sukhamṃ"

The English translation of the Pali verse renders as 'health is the ultimate profit, happiness is the ultimate wealth, a trusted friend is the best relative, Nibbana is the ultimate bliss. '

Q: How best can Sri Lanka be placed in this situation in the world map reflecting different kinds of maturity, considering the concept of discipline associated with the Buddhist philosophy?

A: The Sri Lankan government took early preventive measures with the consultation of several specialists from diverse disciplines, so that it was very successful at the beginning of the crisis. There was no resistance from people against the lockdown and other measures taken by the government. There have not been large social and religious gatherings after government announced of the coping mechanism against the pandemic. People were also ready to maintain the minimum consumption levels as ordinary supply chains had been broken or interrupted.

Dedication and spirit of the frontline workers have also been very high. They were not complaining of the minimum facilities they had in discharging their duties. This was a major plus point in implementing national level policies to address the unexpected problems created by the virus. Lord Buddha said that if someone cares for a sick person, he is the one who cares for the Buddha (Yo gilanam upateyya, somam upatteyya).

Donations have been flowing for needy people from the very beginning. Buddhist priests, different types of societies and individuals including those with moderate means were engaged in welfare activities for the needy. There was not a single report on starvation related deaths in our country. The public utilities such as water, electricity, gas, sewage, and telecommunication have been provided uninterruptedly up to this point of time.

The government has also provided a relief package in cash for needy households despite certain shortcomings of the programme. Generosity or charity (Dana) is the first among the ten royal virtues (Dasa Raja Dhamma). It says that the government has to look after the welfare of the needy people. This principle is practiced by the government of Sri Lanka.

Q: In what ways can the economics principles of Buddhism help us overcome this situation individually, at organizational and at national level?

A: The mainstream economics highlights that the modern free societies are driven by the maximization of utility (self-welfare, gains or happiness) either through increased production or consumption. It focuses on a society dominated by rational people with maximizing behavior. The center of gravity in such a society is consumerism and the economy is driven by this behavioural pattern with a huge social, spiritual, economic and environmental cost.

The locking down strategy of the country was only a second option to the administrators of free economies. Even people were agitating against the lockdown in some countries as they lose their free moment and consumerism practices. As we know some countries paid a huge cost as a result of this behaviour.

Buddhist economics challenge the self-interest maximization behaviour as it focuses on no-self (Anatta) principle and minimizing of sufferings while ensuring the wellbeing of all living beings and protecting the living environment.

The rational people of the mainstream economics concentrate on material wealth and income inspired by growing desire or avarice. Buddhism accepts needs of life such as clothes, food, shelter, health, education, transport etc. but it does not promote insatiable wants of life. Buddhism emphasizes sustainability and happiness of life rather than pusuing materials.

Q: How could we capitalize on the Buddhist philosophy in order to brave the challenges in the post-COVID era?

A: Society needs sustainable happiness through community participation. The rulers, community leaders, clergy as well as those who are affluent and privileged, should give examples to the ordinary masses through their daily behavioural patterns rather than preaching or making public speeches. A collective voice will reduce the cost of waste, corruption, mismanagement, over consumption and the breeding of poverty. The message of Buddhist texts should be a part of the practical life to achieve this noble goal.

The world experienced the influence of isolation, uncertainty, fear, anxiety and sudden departures of loved ones. The physical and mental implications of the COVID Virus will remain in the human society for a few generations.

The moral conduct of Buddhism is centered on the individual. Self- discipline is highly endorsed in Buddhism. Dhammapada endorses that 'good is restraint in deed; good is restraint in speech; good is restraint in mind; good is restraint in everything. The monk, restrained at all points, is freed from sorrow.'

Q: What are areas we should be focusing on in order to raise from this catastrophe as a nation?

A: There are a number of areas in this exercise including the health sector itself. Re-commencement of the economic activities which are currently at a standstill both at personal as well as national level, education, infrastructure development, social sector, tourism and international sectors, private sector issues of the country etc. should all be focused on.

Sri Lanka records a high literacy rate; it is just to read and write. Still many people do not have sufficient health literacy, economic literacy, and political literacy. Making good health related decisions are essential even after the COVID. There are so many issues relating to our consumption and behavioural patterns. The level of non-communicable diseases may have gone up as people are confined to their houses. Similarly, ordinary health services carried out by the public and private sector have been disrupted during this period of time, so that certain health related matters such as treatments, surgeries have been accumulated now. It is essential to clear up the accumulated cases as one cannot postpone health concerns unlike any other commitments.

The country has to initiate strategies to regain most of the micro, small and medium scale COVID affected enterprises. Similarly, large scale enterprises need certain strategies to bring them back to operational level. Economic stimulation packages are being introduced by many countries in addition to short term handouts to selected households. Sri Lanka should also prioritize the key economic sectors which generate more income, employment, government revenue and foreign exchange to the country.

Unemployment and poverty that the pandemic will entail will require expeditious channels to address them. Moreover, some of the Sri Lankan migrant workers are back in the country while many others are still waiting to come back. Their unexpected presence will aggravate not only the unemployment problem but also the decreasing foreign reserves of the country due to decline of foreign remittances. In addition to that, the Middle East job market is shrinking along with the unprecedented low global crude oil prices.

The biggest casualty would be the tourism sector in the country, so that industry specialists should formulate novel strategies to resurrect the main driver of the economy. There is a huge unexploited potential in the sector which can be exploited with the collaboration of local and global investors.

Q: What are the opportunities we will have in view of all the changes taking place around the world in terms of lifestyle, new thinking patterns and economic powers?

A: The world economic power will be shifting towards Asia, especially the East Asia led by China and to some extent by Japan and other regionally growing economies such as South Korea. It is widely accepted that this is the 'Asian Century' and the region will be generating more than fifty percent of the global income by the middle of this century. India is the economic power house in south Asia and some of the massive western companies are planning to invest more and more in India.

The western life style will not change markedly in the future even though COVID remains in the world for quite some time and consumerism society will be back on the track after sometime. Even though it is not the best economic system for the global sustainability in the future, Sri Lanka has to exploit her warranted opportunities in the global economy while emphasizing unutilized and underutilized resources of the country.

Subsistence economies or self-sufficient economies are outdated coins and no country will go back to the old system. However, many countries, at least in the short-run, will reformulate their economic policies to guarantee their pride and survival with the COVID experience they are faced with during this troubled time. When it comes to medical supplies, even the most advanced countries are facing difficulties in procuring certain essential items to run their health services smoothly.

Sri Lanka is heavily dependent on drugs and other related medical supplies from India, Pakistan and Bangladesh. The Health Ministry is the biggest importer of those items to maintain its free medical services in the country. Imports have been the long standing norm due to unexplained factors even though local private sector and the public sector is in a position to produce high quality medicine in the country. Now it is high time we promoted these products locally along with the other suitable products such as buses, railway compartments, and agricultural equipment with the support of local or overseas private sector rather than importing each and everything to the country.

The country is maintaining cordial relationships with many global economic power houses. The post COVID environment will provide global investors to reformulate their investment strategies. Sri Lanka is in a good position to exploit the emerging opportunities, if investor friendly environment is guaranteed. This will be a game changing opportunity for the country, if it is exploited prudently.

COVID has incidentally taught a lesson to Sri Lankan migrants and the diaspora that their country of origin is the best. It seems that some are contemplating their return either to live peacefully with their savings or to earn profits out of investments in the country. Sri Lanka has to guarantee a congenial atmosphere to attract them back to the country.

The Central Bank of Sri Lanka took a wise decision to attract foreign currency trough tax free Special Deposit Accounts (SDAs). When we mooted this strategy a few years ago, the official response was 'what to do with this money?' Depending on the availability of the quantity of foreign currencies, the country can go one more step further by allowing banks to invest in reliable international bonds.

Q: What are the unique strengths we have as country to be among the strongest in the emerging new post-COVID world?

A: We can exploit our strategic location, educated labour supply and untapped resources such as uncultivated lands in dry areas. The potential areas would be pharmaceuticals, high quality handlooms production in rural areas catering to unemployed women in rural areas. The migration dream of young people has been shattered by COVID to a great extent and such youth could be channelled towards employment in their own neighbourhoods if decent salaries are offered. It is also essential to introduce Professional Diploma Programmes with the participation of the private sector not only for industries but also for agriculture and other services.

Q: Finally, how can we change the Sri Lankan mind set from the survival mode to that of a growth mode to lead the others, from a Buddhist perspective?

A: The people of Sri Lankan had neither the ‘survival mind set’ nor the ‘dependent mind set’ well before political independence. The incumbent governments spoiled the mind set of people by introducing different types of universal welfare policies without targeting the qualified people for them. Within two-three decades, Sri Lankans developed the 'dependent mentality' described in literature as the 'dependency syndrome'.

Under native monarchs, ordinary people paid taxes either to the monarch himself or to the nobles appointed by him in addition to looking after family responsibilities by themselves. They did not have the expectations of government support and worked hard to build irrigation systems, temples, pagodas and other artistic master pieces.

Buddhism encourages hard work rather than dependency. The self-liberation can be achieved by one's own hard work. The minor collection (Khuddka Nikaya), the last of the five collections of Sutta Pitaka, describes ten noble qualities (ten perfections) associated with Bodhisatvas. The diligence (Viriya parami) is the fifth noble quality of Bodhisatvas. Similarly, the noble eightfold path, the path for ending the suffering of life and achievement of self-awakening, emphasizes the right livelihood. It says that ‘ do not earn your living by harming others, and do not seek happiness by making others unhappy.’