Doctors Opposed This Ambulance Service
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FEATURE BMJ: first published as 10.1136/bmj.m4592 on 4 December 2020. Downloaded from Colombo, Sri Lanka COVID-19 [email protected] (@Zin10SantaFe on Twitter) Cite this as: BMJ 2020;371:m4592 Doctors opposed this ambulance service; now it’s essential in the http://dx.doi.org/10.1136/bmj.m4592 Published: 04 December 2020 pandemic Sri Lanka had no prehospital emergency medical service until 2016. The arrival of a new ambulance service changed that, and it has proved vital in the pandemic, writes Zinara Rathnayake Zinara Rathnayake independent journalist In 2013, Harsha de Silva was travelling with his Yet ambulances are few and they mainly belong to friends and family in Kuchchaveli, a small town in expensive private hospitals in the cities. Most citizens, eastern Sri Lanka, 297 km from the capital, Colombo. particularly those in rural areas, have to fend for They found themselves driving in a cyclone warning. themselves in emergencies. One of their vehicles skidded, hitting lamp posts and “In a car accident, another vehicle on the road will a tree. His friend was thrown out of the back window transfer the injured patient to the hospital,” says on to the road, critically injuring herself. Sabith Liaquat, a medical officer working at the state She required immediate surgery. They went to the run Base Hospital in Puttalam, 138 km north of Base Hospital in Kanthale, requesting an ambulance. Colombo. In remote areas of the country, he adds, But there was none, so they had to drive her to when patients had any sort of pain they would rely Colombo. on over-the-counter painkillers such as acetaminophen and wait until the next day. “You Thankfully, his friend had successful surgery and wouldn’t realise it in Colombo, but when you work recovered with time. But things could have been in outstations, you realise that some patients waited different. An ambulance would have made all the the entire night to come to the hospital. They didn’t difference. “That day I thought if I could do anything have the means of transport.” to change the prehospital emergency healthcare system in Sri Lanka, I will do it,” says Harsha, who Working in remote areas early on in his career, was then an opposition member of parliament. Liaquat saw the impact this had. “Patient admission delays during an accident will result in blood loss. In 2015, Harsha became deputy minister of national http://www.bmj.com/ With no emergency care before the patient was policies and economic affairs. The Indian government admitted to the hospital, on very unfortunate had offered a grant of $7.55m (£5.65m; €6.34m) to Sri occasions, it means we were losing a life that could Lanka as a token of friendship between the two have been saved.” countries.1 Harsha presented the prime minister with a proposal: a modern emergency medical service with The situation is not uncommon in South Asia. In an ambulance network. Pakistan, ambulance services are mostly offered by non-profit organisations.6 In India, they are publicly On 28 July 2016, 1990 Suwa Seriya—which translates on 28 September 2021 by guest. Protected copyright. funded by the central and state governments, but the as the telephone number and “vehicle of services including drivers and paramedics are health”—was launched as a free emergency employed through private agencies. According to a prehospital healthcare service along with a toll-free report in the Indian social science journal Economic hotline (the 1990 in the name). Eighty-eight and Political Weekly,7 India’s service suffers from ambulances operated in Western and Southern unattended calls, poor response times, and frequent Provinces. It was a collaborative effort between conflict between employees and contracting private Harsha and engineer Dumindra Rathnayake, who agencies, leading to an increase in the “risk of volunteered as the technology expert of Suwa Seriya. medical errors and consequent loss of clinical quality “Initially we faced a lot of difficulty and criticism of EMS [emergency medical services].” from the Government Medical Officers’ Association, Sri Lanka’s service is modelled on India’s 108 representing doctors working in public healthcare emergency medical service, but has “gone beyond facilities, and the opposition party,” says Harsha. that,” says Harsha, with better equipment and “When they didn’t let us park the ambulances in continuous staff training to ensure services run hospitals, I decided to speak with the police.” efficiently. He sympathises with his Indian Filling a void counterparts, who serve a population of over one billion. Sri Lanka has a free healthcare system, and in spite of overcrowding, long waiting times, limited With 297 ambulance units, Suwa Seriya covers the specialised care, and an unequal distribution of entire island, allocating ambulance units based on resources,2 it achieves impressive results, with a high the area population density, with a total workforce life expectancy of 77 years3 and the lowest maternal of 1500. The ambulances are parked at police stations mortality rate in South Asia.4 The country achieved around the country, a step taken by the project malaria-free status in 2016.5 initiators after the Government Medical Officers’ the bmj | BMJ 2020;371:m4592 | doi: 10.1136/bmj.m4592 1 FEATURE Association first rejected the service on political grounds. Still, he says, conducting more awareness campaigns for the public BMJ: first published as 10.1136/bmj.m4592 on 4 December 2020. Downloaded from would help spread the message to the remotest corners of the The association, who backed the opposition party at the time, country, which electronic media does not reach. He adds that criticised the inclusion of a defibrillator as part of the ambulance’s improving the quality of life of the ambulance staff by giving them standard toolkit, worrying that staff were not properly trained to proper accommodation, washrooms, and other facilities would also use it. The association’s secretary, Nalinda Herath, warned the have considerable impact on their service. public not to board the “Indian Ambulance Service” because they ran the risk of getting electrocuted.8 They also expressed anxieties about a flood of Indian employees, although the staff at Suwa Seriya Commissioned, not peer reviewed. are entirely Sri Lankan. 1 Ministry of Economic Reforms and Public Distribution. Annual report 2018. 19 Mar 2019. But perseverance has won through. Although initially drawing on http://www.merpd.gov.lk/images/Downloads/Annual-Report-2018-Ministry-of-Economic-Reforms- the Indian grant, Suwa Seriya is now funded entirely by the Sri and-Public-Distribution-ENGLISH.pdf 2 RoarMedia. Sri Lanka’s healthcare system: everyone, everywhere? 10 Apr 2018. Lankan government as an arm’s length body with autonomy from https://roar.media/english/life/in-the-know/sri-lankas-healthcare-system-everyone-everywhere the health ministry and has won over the Government Medical 3 World Bank. Life expectancy at birth, total (years)—Sri Lanka. 2018. https://data.worldbank.org/in- Officers’ Association. dicator/SP.DYN.LE00.IN?locations=LK The service has proved highly effective, particularly during a terror 4 World Bank. South Asia’s quest for reduced maternal mortality: what the data show. 13 Jan 2015. https://blogs.worldbank.org/health/south-asia-s-quest-reduced-maternal-mortality-what-data- attack on Easter Sunday 2019, when several places in Sri Lanka show including churches and luxury hotels were bombed, leading to more 5 World Health Organization. Malaria-free Sri Lanka. 2016. http://origin.searo.who.int/srilanka/ar- than 250 casualties, including 38 foreign visitors, and injuring at eas/malaria/malaria-free-sri-lanka.pdf least 500 people. 6 Shackle S. On the frontline with Karachi’s ambulance drivers. Guardian 2016 Dec 11. https://www.theguardian.com/world/2017/apr/06/on-the-frontline-with-karachis-ambulance- Harsha says more than 650 000 patients have been transported by drivers the service so far, with an estimated 66 000 lives saved. It also 7 Rajasulochana SR, Maurya DS. 108 in crisis: complacency and compromise undermine emergency counts over 200 successful emergency childbirths in its ambulances, services’ potential. 28 Jun 2018. https://www.epw.in/engage/article/108-services-are-plagued- coinciding with Sri Lanka lowering its infant mortality rate from complacency-and 9 8 Devapriya J. The GMOA’s wrath against the defibrillator in the ambulance. DailyFT 2016 Aug 27. 7.5% in 2015 to 6% in 2019. One of the mothers even named their www.ft.lk/article/564106/The-GMA’s-wrath-against-the-defibrillator-in-the-ambulance newborn baby after Harsha: “I told my wife I had nothing to do with 9 World Bank. 2019. Mortality rate, infant. https://data.worldbank.org/indicator/SP.DYN.IMRT.IN it!,” he says. 10 Clun R. Ambulance response times continue to increase in NSW, productivity commission report finds. Sidney Morning Herald 2020 Jan 31. https://www.smh.com.au/national/nsw/ambulance- Tested by the pandemic response-times-continue-to-increase-in-nsw-productivity-commission-report-finds-20200131- Suwa Seriya fields 5300 calls and handles 1000 cases a day on p53wnf.html 11 average. This has increased during the pandemic to 9000 calls and Sri Lanka’s Suwaseriya paramedic ambulances in coronavirus frontline. Economy Next 2020 Mar 27. https://economynext.com/sri-lankas-suwaseriya-paramedic-ambulances-in-coronavirus- http://www.bmj.com/ 1500 cases a day, said Sohan de Silva, chief executive officer of frontline-62447/ Suwa Seriya in a Facebook Live on 20 June. The service has an average response time of 11.25 minutes across the island, This article is made freely available for use in accordance with BMJ's website terms and conditions for outperforming places like New South Wales, Australia (11.4 the duration of the covid-19 pandemic or until otherwise determined by BMJ.