Striving for Equity: Healthcare in Sri Lanka from Independence to the Millennium, 1948–2000 [Internet]

Margaret Jones Striving for Equity Healthcare in Sri Lanka from Independence to the Millennium, 1948–2000 Last Updated: 2020 Orient Blackswan Hyderabad (IN) Orient Blackswan, Hyderabad (IN) Orient Blackswan PVT. Ltd This book is open access under a CC-BY license. Monographs, or book chapters, which are outputs of Wellcome Trust funding have been made freely available as part of the Wellcome Trust's open access policy International Standard Book Number-13: 978-93-90122-04-2 This is the manuscript of a title accepted for publication by Orient Blackswan published in 2020. Registered Office 3-6-752 Himayatnagar, Hyderabad 500 029, Telangana, India e-mail: [email protected] Other Offices Bengaluru, Bhopal, Chennai, Guwahati, Hyderabad, Jaipur, Kolkata, Lucknow, Mumbai, New Delhi, Noida, Patna, Visakhapatnam © Orient Blackswan Pvt. Ltd. 2020 First Published by Orient Blackswan Pvt. Ltd. 2020 Series cover and book design © Orient Blackswan Pvt. Ltd. 2011 Typeset in Minion Pro 10/13 by Jojy Philip, New Delhi 110 015 Published by Orient Blackswan Private Limited 3-6-752 Himayatnagar, Hyderabad 500 029, Telangana, India e-mail: [email protected] NLM Citation: Jones M. Striving for Equity: Healthcare in Sri Lanka from Independence to the Millennium, 1948–2000 [Internet]. Hyderabad (IN): Orient Blackswan; 2020. iii Focusing on the period from independence in 1948 to the millennium this book is an historical analysis of the process by which Sri Lanka became a model of how a nation with limited resources could nevertheless achieve health indicators on a par with the developed world through the development of a primary healthcare system. In so doing it had to interact and negotiate with global health actors such as the World Health Organization while maintaining its own agency. Based on a close reading of original archival sources it is an in- depth exploration of these questions viewed through a series of case studies which highlight both the successes which contributed to this outcome and the inadequacies of those efforts when seen at the micro level. A primary health care infrastructure is an essential prerequisite for the delivery of preventive health care; how this was developed and delivered to the entire population forms the first substantive chapter. Since the incidence of tuberculosis in a community serves as a marker of a country’s achievement in meeting basic needs and establishing social justice there follows an examination of policies to control TB. The most vulnerable group in a nation are its children and they are also the source of a nation’s future human capital. Two chapters discuss children’s health; firstly the problem of childhood malnutrition and secondly the implementation of the successful immunization programme. Demographic change means a double disease burden of non-communicable diseases alongside communicable diseases and how this considerable challenge is met is the subject of the last chapter. Furthermore these topics enable a discussion of the significance and problems of an international policy transfer to less well-resourced environments. iv Striving for Equity Table of Contents Abbreviations.................................................................................................................................................................................................... v Glossary ............................................................................................................................................................................................................. ix Acknowledgements.......................................................................................................................................................................................... xi Introduction: Sri Lanka as a Model for Health Equity.............................................................................................................................. 1 1 Delivering ‘Medical Services for Health and Not for Disease’ .............................................................................................................. 9 2 ‘Public Enemy Number 1’: Governmental, Medical and Societal Responses to TB .......................................................................... 37 3 ‘The Protection of Child Health is the Protection of the Nation’: Malnutrition and Child Health ................................................... 61 4 The Technological Fix for Child Health: Immunisation............................................................................................................................. 83 5 Non-communicable Diseases: The Double Disease Burden ...................................................................................................................107 Conclusion: The Challenge of Health for All in the Twenty-first Century.............................................................................................129 Bibliography......................................................................................................................................................................................................135 v Abbreviations BAT — British American Tobacco BCG — Bacillus Calmette-Guerin CARE — Co-operative for Relief and Assistance CDC — Centers for Disease Control and Prevention CDs — Communicable Diseases CHD — Coronary Heart Disease CNAPT — Ceylon National Association for the Prevention of Tuberculosis CTC — Ceylon Tobacco Company CVDs — Cardiovascular Diseases DDT — Dichloro Diphenyl Trichloroethane DGHS — Director General of Health Services DHS — Director of Health Services DMS — District Medical Superintendent DNA — Deoxyribonucleic Acid DT — Diptheria DPT — Diphtheria, Pertussis, Tetanus ECG — Electrocardiogram EPI — Expanded Programme of Immunization FAO — Food and Agriculture Organization FP — Family Planning GDP — Gross Domestic Product GHC — General Hospital, Colombo GPEI — Global Polio Eradication Initiative HVs — Health Visitors IHD — International Health Division IMF — International Monetary Fund INH — Isonicotinic Acid Hydrazide IPV — Inactivated Polio Vaccine ITC — International Tuberculosis Campaign IUAT — International Union Against Tuberculosis vi Striving for Equity JP — Justice of the Peace LHV — Local Health Volunteers LTTE — Liberation Tigers of Tamil Eelam MCH — Maternal and Child Health MCI — Maharagama Cancer Institute MDGs — Millennium Development Goals MO — Medical Officers MOH — Medical Officer of Health MP — Member of Parliament NCCP — National Cancer Control Programme NCDs — Non-communicable Diseases NCP — North Central Province NGOs — Non-Governmental Organisations NHDN — National Health Development Network NICE — National Institute for Health and Clinical Excellence NIDs — National Immunisation Days NIHS — National Institute of Health Sciences NPTCCD — National Programme for Tuberculosis Control and Chest Diseases NWP — North-western Province OPV — Oral Polio Vaccine ORT — Oral Rehydration Therapy PAS — Para-aminosalicyclic PHC — Primary Health Care PHIs — Public Health Inspectors PHMs — Public Health Midwives PHN — Public Health Nurse RDHS — Regional Divisional Health Services RF — Rockefeller Foundation SHS — Superintendent of Health Services SP — Southern Province SPHC — Selective Primary Health Care Abbreviations vii STDs — Sexually Transmitted Diseases TB — Tuberculosis TCP — Tuberculosis Control Programme TMPs — Traditional Medical Practitioners TOPV — Trivalent OPV TT — Tetanus Toxoid UK — United Kingom UN — United Nations UNFPA — United Nations Population Fund UNICEF — United Nations International Children’s Emergency Fund UNP — United National Party US — United States USAID — United States Agency for International Aid USSR — Union of Soviet Socialist Republic WER — Weekly Epidemiological Review WHO FCTC — WHO Framework Convention on Tobacco Control WHO — World Health Organization WP — Western Province WSB — Wheat Soy Blend WWC — Well Women’s Clinic viii Striving for Equity ix Glossary Aggala — a traditional snack beedis — cigarettes cunjee — conjee or rice porridge Desiya Chikithsa — the indigenous system of medicine that existed in Sri Lanka before the advent of Ayurveda Dhal — pulses Dinamina — a Sinhala-language newspaper in Sri Lanka gramodayamandalaya — the main organisation for all community development activities including health Kola Kande — a nutritious herbal porridge Mandama — cases of kwashiorkor when travelling outside Colombo suruttu — cigars Tamil Eelaman — autonomous region for the Tamils Triposha — food supplement x Striving for Equity xi Acknowledgements I would first like to extend my gratitude to the Wellcome Trust for their generous support in funding my research (Grant No. 097737/Z11Z). A special thanks must be extended to the World Health Organization (WHO) Photo Library, as they have generously granted us permission to use their image for the cover of this book. I owe the opportunity of conducting this further research into Sri Lanka’s healthcare systems to Sanjoy Bhattacharya, Director of the Centre for Global Health Histories, University of York. I am also grateful to the Department of History, University of York, in particular, Henrice Altink, who provided moral support and practical help. My time at the University of York was immeasurably enriched by the wonderful friendship of Alexander Medcalf and Monica Saavedra at the Centre. Their ongoing support, insightful discussions and reviews of my work made the task so much easier and more fruitful.

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