Chapter 1 Environment and Health Environment in this book refers to the natural and manmade elements and factors
which affect health of an individual. As there are many books and publications on the general health environment of the world this book will draw elements and factors from the tropical environment with specific examples from Sri Lanka. Tropical environments of the world are generally identified as warm and underdeveloped. The natural environment of Sri Lanka is identified as tropical and the societal environment is defined as developing. The tropical environment has its own systems of health and disease and the developing countries in the tropical environment are subjected to poor health environment due to prevailing corruption and poverty. A discussion on environment and health within the context of environmental management cannot be discussed without referring to development as health status is a product of level of development of a society. When the development is properly conducted there is a status of good health and unplanned development results in the formation of a poor health status. Environmental Management perspective of Environment and Health In a study of environment and health it can be argued that the managed environment has a higher level of health than the unmanaged environment. The managed environment has a well organised habitat and a population governed by behaviour suitable for the sustenance of that habitat. This type of environment is more secure and long-lasting than an unmanaged environment. The unmanaged environment is in chaos with no cohesion between habitat, population and behaviour, which is constantly troubled by poverty and disease.
Health began in the domain of culture and medicine originated from healing. Health was identified as “ being well”, “lack of disease” or “no illness” (the conception of illness as dis-ease is derived from the old French word aise meaning ‘comfort’). Medically, health can be defined as “not sick”, but even the modern definitions of health cannot be neutral as even the concepts of medicine are constantly influenced by metaphors of the society which it is situated. However, health is a “state of freedom” or “being well”, which is a stage of management. Though medicine became secular and highly influenced by modern discourses, it is not totally free from culture. Then it is this medicine-culture connection which is important in the study of environment and health within environmental management. This is because the need for environmental management is higher than ever in the history of man as his habitat is threatened by many known and unknown forces of human development. There is enough evidence that management of environment has reduced the threat of disease in the old kingdoms and empires and once this balance was destroyed there was chaos (Page 55). Modern developed world provide ample examples to the need for environmental management for the reduction of health threats. The Health Belief Model identifies the validity of personal environmental factors like level of concern, motivation and previous experience (Rosenstock 1965), in behaviour which result from the evolution of the living environment of an individual. This living environment varies over space and time but the level of management at each step shapes the behaviour. Theory of Reasoned Action (Fishbein 1967), the Theory of Planned Behaviour (Ajzen 1985), and the Health Action Process (Schwarzer 1992), have developed and clarified the Health belief Model but the importance of personal environmental factors remained unchanged. The most important part of environment and health is the relationship between social factors and health. Social factors are generally associated with environmental management because it is the society which decides the process of
management required by them. The relationship between poverty and health was discussed in Marx (Doyal 1979; Navarro 1976), when Engels observed the close relationship between the distribution of poverty and the distribution of illness. The strict management of the environment was also required both in the capitalist Marxist and Socialist Marxist state. Both these groups of states have achieved higher levels of environmental management and health. Health Health is commonly known as “not sick, staying fit or I am OK”. It is commonly known that good health is a complete physical, mental and social fitness. World Health Organisation (WHO) defines health as “a status of complete, physical, mental and social-well being and not merely the absence of disease and infirmity”, which is linked to socio-political aims and objectives of the organisation, but difficult to achieve. This book is written for the purpose of providing information on the health environment of developing countries and to store information on the local environment (Sri Lanka), which will be used as teaching and reference material for students following the courses related to environment and health at University of Rajarata Sri Lanka. This course taught within Environmental Management uses approaches from Medical Geography and Health Geography, which are widely taught disciplines in the developed world. These researchers from the developed countries are engaged in detailed research on the relationship between environment and health as this form of knowledge is required to prevent epidemics which may affect developed world in an age of high mobility of populations. In addition drug manufacturers in the developed world support the study of environment and health, as they conduct all the fundamental research on future requirement of drugs. Health in a developing country
Health in the context of developing countries is a status, where disease is not serious enough to seek medical attention. In here the status of disease is also weighed according to its long term or debilitating effect. As there is no regular health check-up system and continuous medical record system the treatment is conducted in an isolated sphere from the natural and social environment of the person. Therefore it is believed that the health measured by commonly known variables like life expectancy at birth, child mortality and maternal mortality may have only a marginal picture on health status of the developing world including Sri Lanka. In addition availability of unregistered medical practitioners and pharmacy network facilitates some sick to be not counted at any stage in studies of environment and health. In addition poverty in the developing world makes some people with good physical health to have hidden mental sicknesses which are not detected until they are subjected to certain stresses. For example newspaper reports collected from some dailies of Sri Lanka indicate that a bus conductor (passed 8th grade in school) has behaved in an indecent manner to a passenger and was discovered to be suffering from the problem of sadist behaviour under medical examination. A university student has acted like a mafia person in an attack on another student. A minister with a degree in Sociology has used abusive words on his opponent in politics. Therefore people with good physical health may be mentally unstable under stress or inbuilt hidden mental status. Then health or being healthy has no universal truth and health cannot have universally acceptable definition. It is because that behavioural development of man is a valuable factor responsible for the status of health. In general terms for the purpose of this book we use a definition made in the survey of health status of a sample of farmers from Sri Lanka (Seneviratne, 2003). “ Sick is defined in this book for the Sri Lanka environment as the status of health identified by a registered medical practitioner” and all people reported not sick were considered
healthy, though they had minor illnesses which required no continuing medical attention (Seneviratne, 2003). Health environment management: theoretical overview Health environment management is required today more than any other time in the human civilisation because the balance between resources and man is weaker than any other time of the human civilisation. Further it is required for the reason that there is an environment of imbalanced development process in the developing or poor countries of the world where more than two thirds of the people live. Environment is rapidly changing as a result of human and geological influences resulting in chaos and hazards. This raises the need for a study of environmental management for health, which aims at preparing a healthy environmental with the use of best available scientific methods and technologies. Environmental management began as a response to major problems like air pollution, water pollution, soil erosion and emergence of new diseases. It is clear that all the environment problems around us are linked to these three basic damaging activities. However, we cannot conserve as we like and the rising populations demand that more and more resources are to be utilised if they are to be provided with the basic necessities of life. The traditional health environment management The traditional health management system of the era of modernisation is based on the provision of modern health facilities with bio-medicine. Environmental management of this period was conducted through the establishment of Strict Natural Reserves, Protected Forests and Grassland, Sanctuaries etc. it was more of protecting bio-resources than a true holistic plan. However the emergence of ecological management, development of geomorphology and organisational structures in business management led to the construction of the field of environmental management in the early 1980s.
However this phase has to mature into a more organised way of managing the environment if we are to feed the rising populations, provide employment and provide a healthy living environment. The new health environment management The new environmental management treats environment as a multi faceted resource with enormous capacity to provide many types of items from a single unit of the resource. Here the resource is blended in to the systems of economic development, where each and every product can acquire a value. For example, a tree was treated as a source of wood or crop or a unit in the protection of water source in the old system of environmental management system. Today a tree is part of a harvest system which produces wood, wood chips, compost raw material, preserve water and soil. Then a tree is treated as an object to interfere with and looked after according to the principles of forest harvesting. Within the technology of forest harvesting tree is checked for disease regularly, cleaned to avoid fungi formation, broken or damaged parts or branches of the tree (by wind, rain and animal action) are removed and cut at the prime maturity level to obtain the best wood or wood chips for paper industry. The provision of healthy environment is established through the construction of systems of drainage for all types of waste, provision of clean drinking water, keep air within the acceptable limits of pollution, noise control, identification of carcinogens, and provision of proper housing with strict control on building materials and designs suitable for climate where they are built. To achieve the above conditions firstly there should be proper use of standards in all types of human activities. The health authorities should be empowered to check product and service qualities of all types of consumptions. For example the public health service should be able to investigate and prosecute any break in these standards.
Secondly, independent academic bodies should be activated with full public powers to monitor and make recommendations to the health authorities on public health problems. In addition concepts of environmental change and change of environment are also considered here as important in the study of new environmental management, because of their spatiotemporal impact on health. Environmental change Environmental change is the process of changing environment through physical and human activities with use of technology, social and political ideology. Physical changes are initiated by geological changes of landforms and climate which in turn lead to changes in biological environment (Seneviratne, 2006). Human activities are controlled by the available technology, social structures and political ideology. For example the ancient civilisation of Sri Lanka was based on the concept of irrigation and a strong monarchical rule, which arranged the environment to suit the sustainability of a hydraulic civilisation. This civilisation has experienced periods of climatic fluctuations which were controlled through the cascade system of irrigation. But there were times of extremities where famine and flood has created havoc and destabilised the settled environment (Seneviratne, 2005). Recovery from these changes were easier than today because there was only a minimal amount of chemical pollution and any other forms of pollution were controlled through very strict system of environmental control (Read Case study 1). After the fall of the Ancient kingdom the survivours have made an attempt to adjust and adapt to the new wet environment of the south, south west and the mountains. However the technology of tank cascade system was not applicable to the new wet areas and dry phases of climate made them to drift more into the wettest areas of the country. They managed to use the canal irrigation but drainage systems suitable for hill ranges and mountains were difficult to master. Survival was difficult in the new environment and population dropped to an all time low due to exposure to new endemic diseases of the wet zone for
which they had very low immunity. It is believed that a population of about 6 million around Ad 1200 has dropped to about a million in and around 1400 AD. Major diseases which led to this destruction of population were malaria, dysentery and typhoid fever which originated as a result of destruction of water supply and drainage system. Since the arrival of western colonists environment of Sri Lanka was changed to suit the cultivation of tree crops and spices. We are still in this environment and have begun to introduce an unplanned urban and rural settlement expansion. Therefore our environment is becoming more and more polluted, dangerous and chaotic to live (Read History of Disease Environment – page 55). Change of environment is the change of living environment by migration for the purpose of living and economic activity. Migration to farm settlements, urban areas and emigration result in change of environment. Again if these activities are not planned properly, the new environment is subjected to pollution, becoming dangerous and chaotic to live. When emigration is not conducted in a proper manner the emigrants are subjected to many legal and social difficulties, which may result in abuse and trauma. The holistic view of the environment is utilised in the new concept of health environment management, where value of health environment is weighed on the basis of its long-term sustainability within the environment. Therefore the new concept is constantly linked to agriculture, industry, investment, monetary policy, livelihoods and economic planning. This enables the health environment manager to begin at the point of investment and end at sustainable control (Figure 1.1). Figure 1.1, Flow of activity of the new environmental management system Investment programme
Economic, social (health) and institutional policies
Government agencies and other resources users (including health care providers)
Theoretical background to principles of health environment management Health environmental management is required to organise and utilise the environmental resource with optimum benefits to the populace. In the process of this organisation and utilisation system two major principles are to be followed. 1. Understand the dynamics of natural and societal systems of health and the effect of them on disease scenarios 2. Understand the causes of disease and the organisational structure of disease management systems best suitable for control, recovery and rehabilitation from health threats 1. Understand the dynamics of natural and societal systems of health and the effect of them on disease This is the primary task of health environment manager because without a proper understanding of the dynamics of natural and societal systems of health and the effect of them on disease, the health manager cannot provide the direction required for the progress of the users. Firstly there is the presence of ever changing nature of value of natural and societal resources based on the technology available. It is now clear that the traditional measures of
national income have a very limited relationship to the well being of people. This is primarily a result of not accounting the cost of health on real income. For example unless the infectious diseases are controlled wellbeing of the people are degraded. This is exactly the situation almost all the poor countries of the world including Sri Lanka. There are two major forces in action in a given environment in the formation of disease: Physical systems and Societal systems. These two systems should operate on a highly complementary state if success is to be achieved in the programme of health environment management. The physical systems operate on the principles of natural sciences and form many types of risks. The endemic environment is decided upon by the climate and topographic environment of a given place. For example malaria in the dry zone is formed from a combination of seasonally dry climate and even landscape with slow flowing streams. Respiratory diseases in urban environment result from lack of control of air pollution and living in houses without proper ceilings where droplet spray settles in the night. Amount of water available in a given country is of utmost importance to its health and development. The amount of water available in a given country is related to its rainfall, runoff and storage. This amount of water changes over space and time. For example in Sri Lanka, its ancient civilisation depended on a total forest cover of the highlands, which enabled them to receive large quantities of spring water to the rivers flowing across the plain. At that time there was slightly higher rainfall in Sri Lanka, runoff was low due to thick forest cover and storage was high due to non-clearance of upper catchment forests and a well designed settlement plan. Since the movement of civilisation to the wet zone, gradually the highland forests were destroyed and today Sri Lanka is an area of constant water shortages. This is due to inability of the present environmental managers to understand the true dynamics of the water supply system of Sri Lanka. The designs of the countries where problem of water is minimised indicate that the holistic view they have incorporated into their environmental planning has yielded
expected results. These planning systems utilise the value of upper catchment conservation and settlement planning as an integral part of conservation of water. Modern settlement utilise massive quantities of water and water supply in them cannot be maintained well without recycling of water. 2. Understand the causes of disease and the organisational structure of disease management systems best suitable for control, recovery and rehabilitation from health threats Once the change is properly identified the health environment manager has to investigate the causes of the disease systems and the disease management systems best suited for control, recovery and rehabilitation. Principal cause of disease is the unplanned process of human development which is not based on development ideology. Two major development ideologies have been used since the industrial revolution to develop human environment with an aim of improving health. They are modernisation and alternative development which can be used to improve environment and health. Though Sri Lanka has made a serious attempt to raise the living standards and improve health status of its citizens since independence poor quality national planning and corruption has made it a dream which is yet to be fulfilled like in all the other developing countries. Environment, development and health: geography to environmental management It is clear from the discussions on macro-economic development, health sector development, demographic and epidemiological transitions and poverty, that all these processes are notably affected by the physical environment of the tropics, which are capable of year round breeding of vector borne and bacterial pathogens. Further, poverty has its own array of conflict, which enhances the possibility of continuing morbidity as Sen (1999) has indicated. The
poverty itself has to be eliminated with the help of the physico-ecological environment of the developing world, because the primary step towards alleviation of poverty is to provide food and shelter. In this context migration becomes a necessity as the present areas of habitat are not sufficient to provide these basic requirements of food or shelter in the developing world, where rapidly rising populations and epidemiological puzzles are common. Mayer (1990), in a general evaluation of the traditions of geographical and medical geographical thought, discuses the utilization of spatial, human environment, physical and regional traditions in medical geography and explains the value of an ecological approach in the study of disease patterns within the human environment tradition. He further indicates that there is a close association between the human environment tradition and disease ecology. Curtis and Taket (1996) identify two major traditions in medical geography and two strands under each of the two traditions. Spatial patterning of disease and health and service provision is categorized as the two strands of traditional medical geography. Contemporary medical geography is studied within the humanistic tradition and the structuralist/materialist/critical turn. The final strand under contemporary medical geography is named transgressing the boundaries – the cultural turn. The cultural turn has begun to pay more attention to place and health, reviving an old tradition in a new perspective. Kearns and Moon (2002: 612-613) have investigated this changing nature of medical geography and the emergence of health geography. They explain that the complexity of theory in medical or new health geography arises from the nature of health and health related problems themselves, which keep changing with changes in development and natural ecology. This diversity of approaches in medical and health geography is provided by writers such as May (1954 and 1982) Mead (1976), Kjekshus (1977), Turshen (1984) Mayer (1996 and 1999), Gatrell (2001), Kearns and Moon (2002) and Seneviratne (2003).
The evolution of the study of health related issues in geography therefore originated from the epidemiological method, but geographers have utilised a more human approach and have begun to move away from physical epidemiology. However, the value of ecology remains extremely important in studies of the development world where the incidence and prevalence of environment related diseases have not been adequately controlled. This situation demands the continuation of an ecological model either in full, or as it becomes relevant to a particular study. The settlers in this study, and in most parts of the developing world, encounter a change of environment and an environmental change which results not only in a change of developmental level, but also a physical one. As explained earlier under the sub topic of development strategies, the resettlement programme of Sri Lanka is a product of its political authority. This is because the present state of landlessness in the wet zone is a product of colonial land policies, and the continuation of the same policies beyond independence. Recent high demand for land by farming families of the wet zone can be linked to the early achievement of better health status among them, which resulted in a population explosion between 1950 and 1970. Therefore it is evident that an environmental change for the better in the wet zone has increased its farming population rapidly, and that the excess population has to be accommodated in the dry zone to prevent them being a challenge to plantation land or feudal land. This situation leads to provision of land in the dry zone for the farmers who wish to continue their paddy rice cultivation. This situation is common to many developing countries where land is a commodity of the rich and powerful and national planning has not prepared land for the use of the poor. Disease Ecology/ Political Ecology These types of changes have been studied within a framework of disease ecology and/or political ecology of disease by many authors in Africa, Latin America and Asia,
which inspired the adoption of a similar approach in this study. In his presentation of the disease ecology approach, May (1954) identified the importance of biology and material aspects of culture in disease complexes, and the interaction between humans and their environment as a progenitor of disease in humans. Hughes and Hunter (1970) have dealt with the impact of modernization and socio-political development in relation to understanding disease, implying the importance of development in change of environment or environmental change. Turshen (1984) gives a presentation of the political ecology of disease in Tanzania, and emphasizes the importance of development strategies and ecological consequences in the study of health. Kjekshus (1977) and Desowitz (1981) have presented strong empirical evidence for the importance of ecology within a geographical and historical and context. Meade et al (1988:19) utilizes the ecological model in a discussion of resettlement and health: Packard et al (1989) indicates the increase use of geographic, climatic, economic and political factors in studies of health and disease. These theoretical submissions rely on the importance of ecology in the construction of disease scenario of the tropical developing world. The development of resistant varieties of bacteria and viruses, and encounters with new diseases as discussed earlier, further enhance the value of investigating the role played by change of ecological environment due to modern developmental process. The use of an ecological model of disease and its evolution is summarized by Mayer (1996), who explains the use of social and psychological contexts by both geographers and epidemiologists. Further he presents a detailed investigation of research connected to disease ecology. As suggested by Packard et al (1989), disease ecology can be taken a stage further by incorporating geographic, climatic, economic and political factors that affect disease patterns.
Studies of health and disease have recognized the limitations of research, which depends on narrow biological determinants of disease. This type of inquiry has resulted from the increasing link that is made between political process and development, which results in health implications from epidemics and the high prevalence of easily controllable infectious diseases. Brownlea (1981) indicate the neglect of this aspect of power and politics in the analysis of health care systems and epidemiological questions. In a study of environmental change and disease in Tanzania, Turshen (1977) has criticized May (1954) for neglecting politics, and Kjekshus (1979) uses a political economy approach without much consideration of disease ecology. The way to find an approach is through the understanding of May (1958) in a context that he was a medical doctor and implicitly or explicitly excluded the role of politics in health (Mayer, 1996). Studies on malaria in Trinidad (Fonaroff, 1968), and Malaysia (Meade, 1976) emphasise the importance of political policy making in the proliferation of disease, but have not incorporated the full contribution of politics in the formulation of disease scenarios. However, these studies can from a basis for the political ecology of disease, which will be flexible and allow political and economic considerations to be included in ecologically based studies. Political ecology is used in this type of study by Mayer (1996:454): Political ecology as popularly defined by Blaikie and Brookfield (1987) combines the concerns of ecology and political economy within a spatio-temporal perspective. This is a powerful basis for the analysis of disease ecology, especially in the developing world where many facets of national and local politics may override optimum resource use, as detailed by Grossman (1981). Political ecology emphasises the role of individuals and collective action, and it acknowledges that these different types of action are constantly affected by socio-political processes.
Another aspect of political ecology is its ability to accommodate varying scales ranging from the local to the global. The important place of historical analysis in political ecology provides an understanding of structural change over time and its effect on social structure and social relations. These characteristics enable political ecology to be used as an alternative to disease ecology, when socio-political factors have an overwhelming influence on the formation of health and disease scenarios. Studies by Meade (1976), Turshen (1977), Kjekshus (1979), Grossman (1988), Packard (1989) and Mayer (1996) have contributed to the emergence of this valuable approach, which is applicable to developing areas of the world where ecological considerations have become secondly to political programmes, resulting in many troublesome health and disease scenarios. Resettlement and encroachment on marginal land in the developing world has increased the prevalence of infectious diseases, and these programmes either directly or indirectly have been initiated by sociopolitical forces operating within societies and from outside. Prothero (1994:661) discusses the health problems associated with resettlement in detail and his analysis applies well to the situation under study in this book, because the macro scenario of disease prevalence in the study areas indicates higher morbidity among settlers than their siblings in the home villages. This high morbidity arises from the high prevalence of infectious diseases in resettlement programme areas, which can be explained as resulting from changes in physical environment and the core-periphery relationships of modernization. The impoverishment risks/restoration model presented by Cernea (1996:21) identified increased morbidity as one of the eight factors which can contribute to multifaceted impoverishment. Kjekshus’s work (1977) is very relevant to the situation under discussion in this book, as a basis for discussion of the environmental change associated with poor to middle income groups of people. In his study attention is focused on the issues relating to man and his environment, and the role played by the economic basis of indigenous
initiatives in the evolution of change in new environments. The study shows that far from being initiators of a defensive reaction to a crisis situation, nineteenth century East Africans were on the offensive against a hostile ecological system, and until the end of the century they were the victors in the struggle. Within this structure early settlements of the region were organized around permanent water, and more advanced agricultural societies had narrow border strips of forest between the tribal heartlands. The cattle were kept on the savanna, which was burned annually to prevent disease and provide fodder. Prior to land acquisition for plantations, the environment of the wet zone villages in Sri Lanka was in a state of balance equivalent to that of late 19th century East Africa. The land acquisition of the colonial period in the wet zone of Sri Lanka resulted in a loss for villagers of fodder, medical, timber and other forest resources. The aftermath of this environmental change was the fragmentation of ancestral land. The rapid increase in population in the early 1950s caused modern development planners to utilize resettlement as a solution to landlessness. This type of expansion of the farming habitat in the developing world began with the establishment of independent states after the Second World War and was primarily encouraged by policies of food production. These were implemented using irrigation farming in dry areas, cash crop cultivation in forest areas, expansion of grazing lands and provision of energy through the production of hydro electricity. The development of dam and canal systems in Asia, Africa and Latin America was based on the principle of multipurpose utilization of natural resources, as developed in the Western model of river basin development. The initial rapid implementation/development of the programme was further accelerated by a rapid expansion of population, resulting from control of the most deadly infectious diseases like smallpox, measles and cholera. Meade (1976) identifies five major hazards of resettlement in the tropical rain forest in Malaysia, resulting from change of environment and environmental change. The construction
of canals in the dry zones of India and its impact on malaria incidence is explained in detail by Whitcomb (19950. The rise of ground water and associated rise in soil moisture and humidity due to canal construction is given as the major reason for high malaria incidence in this area. All the canal areas were extremely malarious and fever mortality was high. A similar scenario occurred in the Punjab with the construction of the Triple Canal Project. The impact of change of environment and environmental change on health has been identified in relation to development in many parts of the developing world. One of the paths to marginalisation is through the loss of economic power due to ill health. III health can create a situation where a large portion of income is lost to treatment and because of an inability to farm. As observed by Cernea (1996), health contributes to impoverishment in resettlement related development due to exposure to change of environment. These studies indicate that neglect of the health implications of resettlement exposes the settler to serious health hazards. This is primarily due to lack of understanding of the process of environmental change, or neglect of the ecological factor in planning resettlement. Therefore, resettlement can lead to the creation of a group of people who are vulnerable to disease and marginalisation due to neglect of the ecological factor. A similar scenario is suspected in the study area, as even the resettlement schemes established more than 50 years ago in Sri Lanka have not shown a marked change in the disease prevalence profiles. The theoretical basis for the environment and health in this book is based on the principles of environmental management, which is supported from the concepts of medical and health geography. The existing concepts of medical and health geography provide the basis for studies of environment and health within environmental management, when these studies are kept in the theoretical domains of disease ecology and political ecology. However the theoretical domain of political ecology is better suited for the study of environment and health in the developing
countries, because health is more a political issue in these countries where development is guided by political decisions than environmental planning.
Chapter 2 Human Ecology of disease Studies on human ecology treat habitat, population, and behaviour as the vertices of a triangle that encloses the state of human health. Habitat is the living environment of people. Landforms, climate, vegetation, animals, health care facilities, transportation and communication systems and systems of government control are included under this topic. Population studies humans as an organic unit and a group which can be hosts of disease. Natural immunity levels of the population in relation to genetics, nutritional status, immunological status, and its immediate physiological status with regard to time of day or year are also considered within this topic. The effects of age, family composition and the personnel habits can also be considered under this topic. Behaviour is the area of culture which can be clearly identified through the way of life of people. This is related to cultural precepts, economic status, social norms, and
individual psychology. It includes mobility, roles, cultural practices, and technological interventions. Habitat Habitat contains all the elements of the physical and biotic environment, which affect human health. However, today, most of the humans live mainly in built-up environment of housing and other infrastructure. Therefore today our health is primarily controlled from the built-up environment, clean or dirty. Frequency of intestinal infections is reduced when proper drainage facilities are constructed and droplet infections are increased when a proper ceiling is not installed in the house. Malaria disappeared from Southern Europe after all the swamps were drained and Dengue is on the increase in Sri Lanka as unplanned filling of lowlands have blocked drainage. Viral infections are on the increase in Sri Lanka due to breeding of viruses by all the city and town waste dumps due to low environment literacy of urban area dwellers and administrators. The occurrence of dysentery, tuberculosis, dengue, influenza, viral fever and typhoid are directly associated to poor housing, which is confirmed by the economic status of the patients. A survey conducted on three base hospitals in Sri Lanka revealed that 64.4 percent of the patients treated for infectious diseases came from low income households with less than 40000 rupees monthly income. An investigation into the prevalence of chronic diseases also related to income levels. Hospital mortality records confirm that about 84 percent of the people with chronic diseases are from the income group above 20,000 rupees per month. Tables 2.1 to 2.3 indicate the present status of habitat in general, where no place on earth is free from some form of chemical or organic disturbance. This is because, the global environment is surrounded by all types of waste produced by geological and human forces.
Table 2.1 Nature and habitat
Physical characteristic Lowland humid Limestone aquifer Limestone basement in Dry Zone Highland wet Lowland wetlands Health Problem Respiratory Diarrhoea Renal failure Respiratory Helminthic Reason Lack of proper housing Rapid drainage Weak filtration system Exposure to mist and drizzle Poor drainage Exposed population Poor and low income All categories All categories Estate workers Poor urban dwellers
Table 2.2 Development and habitat
Habitat Type Natural Economic status Developed Fast developing Management level Controlled and harvested Initial control and harvesting has begun Very limited inconsistent control No control Health status Protected Fairly protected Major health effect Chemical pollution Low chemical and high organic pollution Low chemical and high organic pollution High chemical and organic influx Chemical pollution Low chemical and high organic pollution Low chemical and high organic pollution High chemical and
Developed Fast developing
Controlled and managed Initial control and management has begun Disorderly
Well protected Fairly protected
Table 2.3 Extremely dangerous habitats Habitat Tropical forests Tropical savanna Semi desert – Sahel Migratory work camps Southeast Asian Chicken an duck farms Disease Malaria, Filaria, viral fevers and possibly AIDS Schistosomiasis, onchoriasis Cerebro Spinal meningitis AIDS Bird Flu Origin Mosquito, monkeys Snail, fly Virus from faecal deposits Careless sexual activity Careless animal rearing
For example Dust raised by storms in Taklamakan desert in Central Asia is found deposited in the ice sheets of European Alps and sometimes they drift over Sri Lanka. The effect of Ozone hole in the Antarctica is felt in Sri Lanka through the activities of El Nino weather systems. These dust flows and El Nino occurrences lead to an increase in respiratory diseases and failures in children and old age people. Therefore today we cannot identify any place or space as natural, though locally a few areas may have natural characteristics identified by biologists. For example, the Clod forest of Samanala Range and Rain forest in Sinharaja are considered by biologists as natural, but the air and water in them are found to be contaminated with sediments from the surrounding areas.
Man has effectively interfered with the natural systems and made the habitat orderly or disorderly, but he is not capable of keeping it truly natural. This affects the health status of people living all over the earth. The resurgence of old diseases like Tuberculosis and emergence of new diseases like Dengue and Avian Flu confirm the poor control man has over his natural domain. Settlement patterns Settlement is the unit where people live together in a constructed environment. Settlement has primary and secondary units of constructions. Housing, roads, communications, drainage, sewage systems and waste disposal systems are the major constructed items in a settlement. The micro climate, aerodynamics, flow hydraulics and biology of the settlement form the secondary environment, which affect people living in the settlement. These constructions are made from chemical mixtures and the designs formed by these constructions can affect the health of the dwellers. Today most of he housing is constructed with cement and iron related material and applied with paint manufactured from petroleum residue. Most of the furniture has plastic coatings or paint coatings made from various types of chemicals. Roads in and around settlements are constructed with bitumen and concrete, which are manufactured from chemical mixtures. Communication equipment is primarily plastics and metallic in nature. We hold communication equipment very dear to us and connect them to some form of electricity. The story of the ability of portable communication equipment in the formation of some bodily stresses is studied in detail and some of these stresses are found to be harmful to health. For example in Sri Lanka noise generated from bus stereo systems and music system in town areas have higher noise
levels, which can harm ears and brain. The impatience of the transport operators (drivers and conductors) may be linked to “ beta music” played and “ language used” FM radio networks. Vary many accidents occur as a result of use of these equipment on the run as attempt to play the equipment can deviate your mind from controlling a vehicle. Field data collected on 100 traffic accidents has revealed that about 8 percent of them were caused by attempts to use communication equipment while driving. Drainage, sewage and waste disposal systems are the measures which can be used to identify the risk of infectious diseases in the settled environment. The basic difference between development and poverty is measured from the rate of presence of infectious diseases. For example Colombo was known as the Garden city in the 1960s, because its drainage and sewage system was sufficient enough to keep the city clean even after a very heavy rain storm. But lack of proper planning since then has made Colombo to be one of the dirtiest cities in Asia, with a common presence of Filaria, Tuberculosis and Dengue. Poor planning of city and town landscapes lead to accumulation of heat and dust which forms unhealthy microclimates. Non-utilisation of aerodynamics and flow hydraulics leads to local flooding in the settled areas. Accumulation of waste material in large quantities can attract various types of micro-organisms and animals into settled environment. There are constant reports of increase of diarrhoea in and around urban garbage dumps in the developing countries. The settlement form can be a factor in health. Nuclear settlement is the most economical form of settlement type in the provision of modern facilities. However it has to be constructed well with a highly organized system of waste control. If not there is high risk from infectious diseases. The dispersed settlement is one of the best models for healthy living but large populations cannot be accommodated in this type of settlements. Therefore they cannot be used as an example of healthy settlement type in a modern habitat. A linear settlement is also not a suitable option as it consumes a large area of land and as in developing countries when they
are formed along main roads they cause congestion and death from cross-road movement of people. For example in Sri Lanka about 30 to 35 deaths and 300 to 400 injuries are caused by this type of behaviour in linear settlements. The relationship between health and settlement is clearer when it is studied within a given developmental region. This is because level of technological development decides the level of health threat in a settlement. Most human infectious diseases survive in urban areas, because only cities have a large enough population to support the continuing circulation of disease agents. Today disease agents can easily cross continents and oceans on an airplane and space agencies have special “bacteria detectives” to prevent contamination from space travel. The airplanes and ships are regularly sprayed with anti-bacterial cleaning fluid and goods are quarantined. The accelerating mobility of the human population also seems to have created different disease entities by the sheer intensity of transmission that has been made possible, as is illustrated in the discussion of the development of dengue hemorrhagic fever in Sri Lanka in page. Population Genetics, Age, weather and behaviour are the most important factors within a population with reference to its health status.
Genetics Human genetics is a new science but the value of genetics in health has been under observation for a long period of time. Knowledge on DNA (deoxyribonucleic acid) has changed the way medical science approaches problems of health and made possible to have a deeper understanding of health. Immunity, tolerance and sometime behaviour are also related to genetic information, through collection of data on certain
general problems of populations. Immunity of the people of poor countries to certain types of diarrhoea, intestinal infections are believed to be related to genetic evolution. This may be a result of historical exposure to these diseases in the areas where sanitation has not improved. Lactose intolerance or resistance to milk is identified as a geographic puzzle in human ecology. This may be a result of inability to rear animals due to humid tropical climate where animals are subjected to permanent wet ground, which lead to foot and mouth diseases. The inability of Europeans to eat hot food may also be a result of loosing their natural taste system after they have migrated to cooler climates where hot chillie will not grow. Some believe colour, size and hair are strictly controlled by genetic factors. African hair and height of the Nordic Europeans are considered to be two very strong genetic systems in relation to cross marriages. Though many people relate various types of factors to genetics, we are yet to discover the true nature of genetics in life. However the genetic scientists are hopeful of the unlimited value in genetics in the treatment of serious disabilities which affect children and young. Our face, walk and talk are related to genetics in gossip, but this type of resemblance may or may not be true some times. Therefore any information on genetics of populations should be treated with care. Age is an important factor as health is constantly related to the life cycle of a human being. Life cycle has its own health capacities and threats in relation to age. Infant is highly susceptible to infectious diseases and almost 80 percent or more infant deaths occur due to them. Bacterial and viral diseases affect the childhood as the child is always experimenting with new products, environments and behaviours. Adults are the most threatened in the modern world as they are exposed to many types of environments within a day and some even travel between two types of endemic environments daily. For example a bus driver travelling from Vauniya to Colombo, begins his journey from the malaria endemic
environment and ends his journey in a filarial endemic environment. Someone travelling from Kandy to Anuradhapura to work leaves a non-endemic environment for malaria and enters the malaria endemic environment around Nalanda on route A 9. Adults also experience with alcohol, sex and other adventures when they are between teen and late 30s, and most of them encounter accidents and diseases related to those experiences. Marriage is another break point in adult health life as they have to cope with increased expenses and psychological support for children. Today this has become a serious problem in poor countries where life has become a continuous struggle due to socio-political corruption in them. Family is seriously under pressure from the cultural infiltration from western modernist ideals and lack of proper law and order makes the life of a father and mother in poor countries a serious threat to individual health. For example it is estimated that about 80 percent of the families in Sri Lanka is under serious psychological threat due to culture clash originating from uncontrolled modernization. This is very clear among the students of Public Universities, where uncertainty arising from poor rate of economic development due to political corruption makes them to be uneasy and boisterous. The aged are the most vulnerable to ill health as the age after 60 is considered to be the time of loss of control in the body system. Control of food, behaviour and ready availability of treatment are the only ways to combat serious health threats at this age. This type of health environment is not readily available in the developing and poor countries of the world and the aged living in these countries suffer and die from easily curable illnesses and diseases. Behaviour Cultural behaviour is the most important factor in the environment and health as it forms the basis of the level of development of environment. Cultures can be identified in
many ways in relation to health and in this study it is identified as developed world culture and undeveloped world culture. This division is adopted, because the author believes that we are today at a stage of development which we have never witnessed in the history of human evolution and the only way to achieve a satisfactory status of health is to follow the modern system of health care with sufficient help from traditional health care systems. When this type of approach is made there will be only a minimal amount of conflict between culture and health. Control of waste in the habitat has to be made safe with all the possible applications from both systems. It is clear from the experiences of the developed world the only way to keep the habitat safe is to remove corruption and utilize law and order in managing the environment. For example the solid waste removal is a responsibility of the local authorities and they must plan properly and enforce rules and regulations in a free and fair manner. The settlement design is paramount to environmental management, expenditure on the provision of essential services like water, electricity, transport and communications. Therefore all habitat related activities should aim at providing a healthy environment. Modern world is a massive mix of life styles. However these many types of life styles can be divided into two major groups: Safe and unsafe. It is the responsibility of the governance to encourage safe life styles and strictly limit unsafe life styles with the use of powers available to public order and security. The unsafe life styles should be controlled with the use of modern technology available and rehabilitation from unsafe life styles can utilize local cultural support. Waste is the most important variable in the management of a healthy environment. Where there is unattended or untreated waste there is always a health risk. Therefore the behaviour of populations should be guided in a way that the authorities should be able to collect and dispose of it orderly. People have managed to evolve many protection systems through their culture and religion and these are very valuable in the formation of a healthy environment. In modern times
the use of alternative medicine has sometimes reduced the health cost of nations by a considerable amount. The role of these treatment systems are not clearly indicated in research but if there is no harmful element in them these systems can be utilized with guidance from elders or traditional healers. It is estimated that there may be more than 20,000 to 30,000 unregistered traditional healers in Sri Lanka and the occurrence of malpractices are rare. Protection also comes from food habits, cleaning systems and dress. Buddhism and Hinduism prohibit meat, Islam prohibits Pork and Christians are not supposed to eat meat on Friday. Giving alms to poor people and taking care of the disabled is preached in all the religions, which indicate universality in helping the poor to be healthy. Modern developed societies utilize a social security system for the purpose of care o the poor, which is primarily supported by the funding from religious and cultural societies. Terrorist behaviour has become the most destructive human behaviour of the word today. It is estimated that annually about 60,000 die, 300,000 are injured and another 100,000 are traumatized by terrorism or terrorism related activities. Though terrorism has been an integral part of human existence, today it has become one of the major problems in the health environment. Corruption in governance also lead to a serious weakness in the health environment through misuse of funds allocated for the provision of preventive and curative medicine in the developing world. The high prevalence of infectious diseases in the developing world is partially a result of corruption in governance which diverts funding away from essential services to private use.
Development and Health Socio-economic development is aimed at constructing a healthy living environment. However the programme of development is not universally active due many social and political reasons. Therefore there is always a difference of health status between developed and developing countries. International evaluations on health and development are based on some selected criteria like rates of total mortality, infant and child mortality case prevalence or incidence at hospitals national health and population surveys local or regional health surveys estimates from combined services Environment of the developed world and developing world are taught under many courses in environmental management and the following description provides the reader a summary of the environment in a tabular form. Environment and health in the developed world Developed world is where public sector services are run on the principles of environmental and economic planning. They have long term plans for environmental control and economic stability supported by the selected resource
1. 2. 3. 4. 5.
utilisation systems. The following tables will provide you with the major characteristics of the environment and health in the developed world where impact of infectious diseases are minimised to the level Table 3.1 Environment of the developed countries of Europe, North America, Japan, Australia and New Zealand
Category Latitude in degrees north of Equator From 35 to 45 degrees North and South Majority of the People (more than 80 percent) Low immunity to unclean environment and water. Fair skinned and can be subjected to sun burn Very Low immunity to unclean environment and water. Fair skinned and can be subjected to sun burn Extremely low immunity to unclean environment and water. Very fair skinned and can be subjected to sun burn Extremely Low immunity to unclean environment and water. Extremely fair skinned and can be subjected to sun burn Nature of living environment of the majority (more than 80 percent) Planned drainage and sewage disposal. Very good quality health support systems.
Warm and cool south
From 46 to 55 degrees North and South
Planned drainage and sewage disposal. Very good quality health support systems
Cool to cold north/south central
55 to 65 North and South
Planned drainage and sewage disposal. Very good quality health support systems
66 to 90 North and South
Planned drainage and sewage disposal. Very good quality health support systems
that they are incapable of causing more than 0.5 percent of the deaths. However the industrial pollution and comfortable lifestyles have increased the incidence of chronic diseases in them. Table 3.2 Socio-economic and immediate environment in the developed countries
Area Urban areas Status Fairly clean Health status Good – low risk of infectious diseases Reason High literacy and income. Strict enforcement of environment law High literacy and income. Very strict enforcement of environment law High literacy and income. Extremely Strict enforcement of environment law
Very good – very low risk of infectious diseases Excellent - very low risk of infectious diseases
Table 3.3 Developed countries: Nature of basic construction required for a health living environment
Construction Housing Status Planned and properly built Health status Good with proper drainage and waste disposal Good with safety Reason High literacy and income. Strict enforcement of environment law High literacy and income. Very strict enforcement of environment law High literacy and income. Extremely Strict enforcement of environment law
Planned and properly built
Planned and properly built
Good with safety and speed
Developing world - Tropical environment
Developing world is synonymous with tropical world as almost all the countries categorised as developing are situated in the tropical world. These areas of the world are constantly ravaged by environmental mismanagement, wastage of resources and imbalanced income distribution. However, it is abundantly clear that these areas have enormous resources of natural resources which are able to provide a sound basis of development for their inhabitants, but prevented due to socio-political corruption. Rapid development in Singapore from a developing nation to a developed nation revealed that it is the establishment of an organisational structure for development which was required in this minute island nation. Malaysia has shown that there developing status is not physical, but social and political. The tables 2.4 to 2.6 provide the basic details of tropical developing world with reference to the majority of the population which live under constant threat of ill health or disease. This book will concentrate on the details of this majority of the people who have very little or no health security in case of ill health or disease in the present socio-economic environment of their respective countries or nations. The group of people under study form about 90 to 95 percent of the population of the developing countries, which are politically marginalised by the organisational structure of the public service system in them. These people have a minimum of about 1 US Dollar a day (monthly Sri Lanka Rupees 3000) to about 7 US Dollars a day (monthly Sri Lanka Rupees 20,000) income per family, though their earnings can fluctuate heavily when affected by ill health or disease. These people lack social security in health and only a handful have some form of medical insurance. Most of these people live in unhealthy housing and drainage environment. Fast developing Malaysia and Taiwan are the only countries which have an acceptable level of living environment among developing tropical countries. Some of the countries like Sri Lanka and Cuba have established a
heavily subsidized treatment system but the living environment of majority of the people remains dirty resulting in the heavy presence of diarrhoea and dysentery.
Table 3.4 Climatic and immediate living environment of the tropical developing areas
Category Vegetation Majority of the People (more than 80 percent) Poor live unclean environment water. in and Nature of living environment of the majority (more than 80 percent) No planned drainage and sewage disposal. Very poor quality health support systems. Tuberculosis, Filariasis, Cholera, Dysentery, high infant and
Ultra humid average relative humidity above 60 percent
Equatorial Rain forest or monsoon rain forest
maternal mortality Humid average relative humidity above 45 percent and below 60 percent Monsoon forest and savanna wood land Poor live unclean environment water. in and No planned drainage and sewage disposal. Very poor quality health support systems. Tuberculosis, Cholera, Dysentery, Schsitosomiasis, Onchocerciasis, Leishmaniasis, Trypanosomiasis, Heaptitis high infant and maternal mortality No planned drainage and sewage disposal. Very poor quality health support systems Tuberculosis, Cholera, Dysentery, Meningitis, Heapatitis, very high infant and maternal mortality Very Poor live in unclean environment and water No planned drainage and sewage disposal. Very poor quality health support systems Tuberculosis, Cholera, Dysentery, Meningitis, Heapatitis- very high infant and maternal mortality
Dry average relative humidity above 25 percent and below 45 percent Arid relative humidity below 25 percent
Monsoon woodland, scrub and thorny bushes. Under threat from desertification
Very Poor live in unclean environment and water
Semi arid and hot desert/ oasis living
Table 3.5 Socio-economic environment of the low and middle income people in the tropical developing countries Area
Poor - high risk of infectious diseases
Low environment literacy and income. Non application and enforcement of environment law Low environment literacy and income. Non
Fair – moderate risk of infectious diseases
application and enforcement of environment law Conserved areas Fair Fair - very low risk of infectious diseases Low environment literacy and income. Non application and enforcement of environment law
Table 3.6 Developing countries: Nature of basic construction required for a healthy living, working and travelling environment
Construction Housing Status Unplanned and hastily built Health status Risky with poor drainage and waste disposal Very risky with poor drainage and waste Reason Low environmental literacy and income. Lack of enforcement of environment law Very low environmental literacy and income. Lack of enforcement of
Unplanned and hastily built
disposal Transport Unplanned and hastily built Extremely risky with poor road surfaces and lack of traffic control
environment law Extremely low general and environmental literacy and income. Lack of enforcement of environment law
The detailed study on development and health is presented under the headings of Agent-host relationships Domesticated animals Immediate living environment Nutrition Literacy The traditional belief system of health and Health behaviour, which are established in the living environment through the efforts of development. Table 3.7 Factors of developmental environmental factors and their status in relation to development Factor Agent-host relations hips Type of developed control/ Type of control/developing Low to no control as the systems in action are disturbed by corruption Low to no control as the systems in action are disturbed by corruption Low to no control as the systems in action are disturbed by corruption Low to no control
Heavily controlled through use of management and technology
Domesticated Heavily controlled animals through use of management, technology and law Immediate living environment Nutrition Heavily controlled through use of management, technology and law Provide required
nutrition through good economic programmes Literacy Provide quality literacy through education, training and governance.
as the systems in action are disturbed by corruption Do not provide quality education and training due to bad governance
The traditional belief system of health
Is utilised for the Is not properly development of organised and modern medicine developed other than in a few fast developing countries Regulated through Regulated only at education and law times of sickness or in the families with quality education.
Table 3.7 indicates the major differences between developed and developing countries with reference to factors of developmental environment. Table 3.8 show the basic differences in two primary factors used in the differentiation between developed and developing. Table 3.8 Development and health Country Norway Sweden Japan Sri Lanka China India Life expectancy at Child (under 5) birth mortality per 1000 77 79 80 73 69 62 9 6 6 19 43 99
Bourkina Faso Sierra Leone
Sri Lanka has a very high level of health when compared to other developing nations due to high quality dedication of majority of the medical personnel and a low priced private sector “private practice doctor” service provided in the semiurban and rural areas of the country. Further the tradition of limited contact between animals and humans in a majority Buddhist population and early acceptance of western medicine may also have contributed to this high state of health (Seneviratne, 2003). Environment and health of the tropical underdeveloped areas Case study - Disease environment of Sri Lanka The disease environment of Sri Lanka is primarily a product of its island location, ecological characteristics, development of social services and belief system of health. The island location, macro level landform structure of a central hill country surrounded by plains, heavy social welfare spending, literacy level, gender equality and the existence of a pluralistic belief system of health are identified by many researchers as factors responsible for the relatively better health situation in Sri Lanka, in comparison to its South Asian neighbours (Nordstrom, 1988; Wolffers, 1988 and Caldwell, 1993). The island location reduces the risk of transmission of diseases and epidemics, and its advantageous effect is clearly shown during the outbreak of epidemics of cholera, typhoid and measles in the neighbouring countries. The ecological characteristics formed by the macro level landform structure with a central hill country, which constructs fast flowing rivers, has been identified as a factor for very low incidence of malaria in the wet zone of Sri
Lanka (Farmer, 1957 and Litsios, 1996). Furthermore, the ridge and valley nature of the plain topography and the extensive spread of acidic soils may have helped the quick out flow of flood water and rapid fermentation of vegetative matter, which limit the formation of unsanitary pools of water. In the global context of disease environment, Sri Lanka is situated within a region of high prevalence of tropical diseases. Malaria, diarrhoeal diseases, intestinal infections, tuberculosis and anemia dominate its regional and local disease prevalence scenario (Ministry of Health, 2000). The discussion on disease environment of Sri Lanka is presented under sub-chapters on agent-host relationships, immediate living environment, nutritional status, literacy and gender, to link it with the tropical setting and explain the presence of many types of infectious diseases. Agent-host relationships The tropical humid climate of Sri Lanka facilities the breeding of many types of disease causing agents common to its south Asian neighbours, but the severity of infection is reduced by cultural practices like use of traditional antiseptics, low consumption of raw food and adherence to advice on health. The breeding of agents causing dengue and diarrhoeal and respiratory diseases are always associated with heavy rain, flooding and poor sanitation. The high incidence of rabies in Sri Lanka can be related to nonchalant attitudes in the rearing of dogs and the existence of a large rat population, specially in the urban areas of the country where rabies has been identified as a serious health risk (Ministry of Health, 1996). However, a definitive agent-host relationship cannot be established due to dearth of research. Malaria, dengue and influenza causing agents have shown drug resistance in recent decades, but their effect on the disease scenario is reduced mainly due to early identification and improved health care support as noted by Abayasekara
(1948). The “emerging disease” (Mayer, 1999) and disease causing agents have not shown a market impact on the disease system as HIV / AIDS has not made a substantial impact in Sri Lanka for the last decade. Increases are recorded in chronic disease especially in the categories of heart, diabetes and cancer. The largest increases are recorded in the category of road accidents, insecticide poisoning and war related injuries, which are results of socio-political manifestations (Ministry of Health, 1996). Malaria is the disease with the highest morbidity, with three protozoan parasites, Plasmodium vivax, P.falciparum and P. malariae, causing benign tertian, malignant tertian and quartan fevers (Dissanaike, 1984). The parasite is transferred from an infected person through the female anopheline mosquito, through the vector of the Anopheles culicifacies, though A. maculatus, A varuna and subpictus are now present in the vectorial scenario in Sri Lanka (Carter, 1930 and Amarasinghe et al, 1997). These vectors are mainly present in the dry zone of Sri Lanka and rarely found over 1000 meters above sea level. The peak prevalence of mosquitoes begins with the rainy season in mid October and reaches a maximum in January, but they can live and breed continuously in the water logged areas, shallow riverbeds, irrigation canals, quarries, wells and pits throughout the year. Therefore the vector ecology of malaria is a product of climate and drainage of the dry zone and the wet zone is invaded only at times by epidemics of malaria. As mentioned the wet zone rivers have rapid gradients and year around flow, which prevents the breeding of mosquitoes and it also seems feasible that the heavy use of chemical fertilizers and pesticides in the plantations may also has an important controlling effect. The studies carried out in new settlements in the north central and eastern provinces of Sri Lanka clearly indicate a continuous high prevalence of malaria associated with irrigation and reduction and selectivity of certain species of anopheles with time, though its consequences have not yet been identified. Ramasamy et al (1992) and Amarasinghe and Indrajith (1994 and 1995) have come up with recent
evidences from the Mahaweli Development areas on the reduction and selectivity of certain species of Anopheles mosquitoes. Furthermore, researchers have discovered a historical and recent significant relationship between the intensity of the south west monsoon activated by EI-Nino activity and increase of malaria incidence in Sri Lanka, indicating its relationship to climatic fluctuations (Bouma and vanderKaay, 1996). Filariasis is concentrated in the wet zone coastal wet land areas, while viral hepatitis and tuberculosis are common in urban areas. Filariasis is concentrated on a particular habitat where agents are supported by the wet land ecosystem. The presence of tuberculosis is related to poverty as majority of the cases are reported from poverty stricken urban poor households (Ministry of Health, 1996). Domesticated animals The connection between many infectious disease and animals is well established as the epidemics are traced back to some of the nodes with a special animal-man relationship. The role of animals in the disease environment of the farming villages of the Sinhala Buddhist community is examined within this understanding. This because the presence of a belief that the low prevalence epidemics of infectious disease in the home villages is due to their low level of contact with animals. Though specific data is not available, observations made during the field visits led the researchers to investigate this contention. Cattle and water buffaloes were kept mainly as a source of “beasts of burden” to be used in carts and work respectively. Pets were rare though a small number of dogs and cats were seen occasionally. A few households kept chickens to collect eggs and occasional use for meat. The wet zone with its heavy annual rainfall and forest type of vegetation has limited supply of fodder and is known to harbour many animals disease arising from high humidity. The dry zone environment is suitable for animal rearing, but scarcity of forage in the dry season limits its expansion.
Therefore, animal rearing is limited by ecology and culture, both in the dry zone and wet zone. Buddhism advocates a vegetarian diet and eating of meat is prohibited, which limits the use of meat in the diet of Buddhist farming families. Their special requirements are supplied by the Moslem or Christian traders in the nearest village centre or town. Further, the traditional belief system has a caste association to animal rearing as hunters and nomads are treated as of low caste and farmers were not expected to rear animals for meat. Although, a change in this traditional system can be observed today, it is extremely rare animals for meat in this community. Another aspect of culture controls the distance between the animals and humans as the Buddhist farmer keeps his animals away from his house either in a shelter or tied in the open limiting contact between him and the animal. Therefore, it is possible to conclude that these factors limit the man-animal contact and the consumption of man-animal products, which reduce the capacity for origin and spread of diseases in the Buddhist farming community. Immediate living environment The immediate living environment is identified by many researchers as a very important variable in disease origin and spread. Although there is no set model to the immediate living environment, it consists of the house and garden. Three major types of immediate living environments can be identified in Sri Lanka in relation to prevalence of infectious diseases. Firstly, the urban and rural rich and middle class, which makes up about 10 percent of the population live in modern housing and rarely affected by infectious diseases. Secondly, farmers, labourers and other low-income groups live in small units of nuclear family houses with a small garden, a toilet and a well for drinking water, which is normally, is shared with relatives or neighbours. Bathing is normally done in a communal well, stream or river. Only
about 30 percent of the village settlements have safe drinking water and more than 80 percent have no safe bathing water facilities (Department of Census and Statistics, 1994). Housing is mainly in the categories of mud or mud brick or partial brick and cement with no ceiling or proper arrangement of ventilation facilities. The pit toilets are not properly built or maintained and pose a serious health risk in terms of breeding of diarrhoea related bacteria. Lund (1979), Marga (1988) and Konradsen et al (1977) have identified the impact of poor living environment in relation to the abundance of malaria and diarrhoea in the Sri Lankan environment, and this is confirmed in the most recent available health data (Ministry of Health, 1996). Thirdly, the marginalised groups live in specific geographic areas such as remote rural communities, fishing communities in coastal areas, estate communities, communities in urban slum areas, village expansion colonies and areas affected by ethnic conflict. Studies on these groups have begun recently (Ariaypala, 2000 and Sarath Ananda, et al 2000) however the conclusion so far is that the immediate living environment of these people is considered to be harmful to their health. There are no detailed studies on the impact of immediate living environment on disease prevalence in Sri Lanka, but the grouping of the population on the basis of their major contact environment reveals that there is a variation in infant and child mortality rates between rural and urban areas, and between urban and rural and estate environments (Figure). These three categories and based on the identification given by administrative authorities and used in the national surveys on data collection (Department of Census and Statistics, 1993). District level disease prevalence data suggest that resettled people can be placed in between rural and estate in this profile, but no definite conclusions can be made due to lack of specific data. Figure 2.1 Infant and Child Mortality rate per 1000 by residence, 1993
70 60 50 40 30 20 10 0 Urban Rural MR CMR Estate
Nutrition Nutrition or level of nutrition is an indicator of the state of health and form an integral part of the disease environment because of the established relationship between nutrition and health. It is evident from macro data that the marginalised groups are more vulnerable to malnutrition and under nutrition than the rest of the population. General surveys indicate as an important factor in nutritional status. Gunasekera (1996) using DHS data stresses the importance of literacy of the mother in general and in relation to plantation areas in particular. There is high rate of stunting in the category of mother not attending school and the rate of stunting is reduced where the mother has received the secondary level education. In the estates where there is a large concentration of mothers with no schooling, 45 per cent of children are stunted compared to 18 per cent in the urban sector and 13 per cent in the category of some education beyond secondary level. Loganathan (1990) and Gajanayake et al (1991) have both indicated the relationship between low literacy and high mortality of Tamil plantation workers, which stresses the role of poverty for this deprived population.
The observations of Gunasekara (1996) add an additional dimension to the nutritional status, which he associates with the geographical distribution of the population. He indicates that Uva, Anuradhapura and the north- western provinces have recorded the highest levels of stunting. There is a reduction in the categories of moderate and severe stunting between 1987 and 1993, but insufficient data on instability of residence may hide the exact nature and distribution of stunting, when compared with the data from the established old village environment. Ariaypala (2000) identifies the plight of children in a slum area in Nugegoda in relation to nutrition and discover that 62 per cent of them are malnourished. The nature of the meal in this group of people is decided by the daily wage of the income provider and girls suffer from malnutrition more than boys. A similar study in the Kandy slum revealed an alarming 99 per cent of malnutrition among children (Sarath Ananda et al, 2000). The nutritional status of the children living in the north and east is definitely poorer than the national levels. Under – weight in the age group of 0 to 5 years is 50 per cent for the children in the conflict area compared to 37.6 per cent of the country average (W.H.O., 2002). Fernando et al. (2000). Found that school children in the rural areas of the Moneragala district are affected by malnutrition and high rates of hook worm. Further they have evidence to show that the girls are more underweight than the boys. The iron intake of the adolescent school girls in the rural periphery of southern provinces is a good indication of the nutritional deficiency among the poor (Jayatissa and Piyasena, 1999). The studies on nutrition are conducted within different groups of people in the category of marginalized. However, valuable information concerning like living environment and its resources, which can be utilized for improving the nutritional condition is yet to be fully investigated. Literacy
Education has played a vital role in the construction of the present disease environment of Sri Lanka, mainly through general increase in literacy. Universal free education and adult education, which was supported by the extensive health education programmes of the 1950s and 1960s, have enabled most adults to acquire knowledge of reading and writing. This has developed a keen interest in reading newspapers which are the primary tool in the rapid dissemination of advice on health. Table 2.10 Attainment of education by sector 1996/1997 (As a percentage of population aged 5 years and above) Sector Primary above 94.1 92.1 76.1 91.4 and Secondary and Post above secondary 66.7 29.6 56.7 20.5 20.2 2.1 56.2 20.7
Urban Rural Estate All sectors Source: Central Bank of Sri Lanka, 1996
The rural sector in which the farmers live has a high literacy level, when compared to the South Asian situation. The level of primary and secondary education among the farmers is almost equal to the all sectors literacy levels. It should be noted that the lower age groups are presented as noted in the source material and the sole purpose of this table intended only to compare values between the groups (Table). This high level of literacy has resulted in the schooling of girls and this had an effect on efforts of decrease in birth rate and maternal and infant mortality rates from the 1960s, through birth control and postponement of marriage. Throughout the 1970s and 1980s, the average family size was reduced from 6 to 4, and at the end of 1994 it was further reduced to 3.2 (Statistical Abstracts, 1996), and this can be explained by a lowering of fertility due to heavy use of birth control.
The traditional belief system of health Records on the history of traditional medicine go back to the beginning of civilization in Sri Lanka. Evidence reveals there was a well organized medicare system with hospitals, rest homes, herb gardens and conserved forests of medicinal trees and shrubs located in various parts of the island. These are well recorded in various inscriptions and chronicles (Paranavitana, 1959). Two major sub-systems can be identified in the traditional medicine: The first system is the herbal-ritual system based on many beliefs such as deities, telepathy, sound, herbs etc., which is identified here as the ancient system. The deity (God) is at the centre of this treatment system where an edura (faith healer) is the messenger between the deity and the patient. The treatment process involves either a full ritual with a sacrifice or a promise to the deity of an offering. Sometimes the ritual may accompany herbal treatment. A full ritual programme is composed of offerings, sacrifices and chanting, which is mainly used in the treatment of mental disorders and spiritually-caused sicknesses resulting from shock and depression. Ritual and herbal treatment are used in the treatment of many other sicknesses and diseases, especially communicable diseases like chicken pox, measles and mumps. In the treatment of these traditional infectious diseases, the patient is strictly forbidden to ingest any animal products, the patient is kept in a dark room without any contact with other than a selected group of people and is given many herbal mixtures. The faith healer (edura) is called for to chant verses. Finally a promise will be made to make offerings at the nearest shrine of the goddess Paththini and to give alms to seven or more women devoted to the worship of goddess Paththini. The herbal tradition is utilized by a group of practitioners who live in the villages and practice their method of treatment (Jayasekara, 1957 and Ambatalawa, 1994). The most common specialties are available in from of anti-venom, asthma and fracture treatment, which are utilized heavily by the general populace. There is very little written knowledge in this
tradition and the practice is considered a family tradition, which is given only to male members of the family. Herbal medicine in the form of mixtures, pastes and oils are used in the treatment along with strict dietary control. However, in recent times the influence of Ayurveda has made these practitioners to use some Ayurveda has made these practitioners to use some Ayurvedic medicine in their practice (Gnanawimala, 1950; Ramanayake and Ponnamperuma, 1985 and Ambatalawa, 1994). The second system is Ayurveda, which is of Vedic origin and believed to have originated in the second millennium BC, probably in the land between present-day Pakistan and Iran (Ariyadasa, 1982). The traditions and teachings of Ayurveda entered Sri Lanka with the arrival of the Aryans and developed steadily through continuous contact between India and Sri Lanka. Since its establishment in Sri Lanka, Ayurveda and traditional medicine were practiced together probably with the same patronage, but seeking the higher level of Ayurveda when needed. In the civilization of the early Anuradhapura period the physician was considered an important professional. During this period a notable feature of civilization was the importance attached to the establishment and maintenance of hospitals for the treatment of sick. Among the kings of ancient Sri Lanka King Buddhadasa (circa 337-365 B.C) was reputed to be a skilful physician and he appointed a physician for every ten villages. (Paranavitana, 1959). This tradition continued throughout the ancient and modern history and by the time of arrival of Western medicine there was a well established health care delivery system in Sri Lanka (Ramanayake, 1985). Antibiotics are not mentioned in the Ayurvedic medical literature, but some of the mixtures used in it are found to be antibiotic in nature (Silva, 1991). The term indigenous medicine is official used today to identify a system of medication and treatment, which include both the ancient and the Ayurvedic systems. The continuing struggle of the organized group of activists of indigenous medicine led to the establishment of the Department of Indigenous Medicine even before independence (Ramanayaka
and Ponnamperuma, 1985). The establishment of Ministry of Indigenous Medicine, Institute of Teaching and Research in Indigenous Medicine and registration of indigenous medical practitioners as government physicians have enhanced the value of traditional and Ayurvedic medicine among the local populace and foreigners. Today it is estimated that more than 40 per cent of the total out patients registered daily, use indigenous medicine related services and among the poor the percentage may be as high as 60 per cent (Kannangara, 1962). Today, indigenous medicine is the most important health service system at first referral level for most of the poor until their economic status is elevated. For the rest of the richer classes its use is restricted to times of special need. Recent modernization of herbal preparations have actually led to an increase in popularity of indigenous medicine and associated treatment systems (Ekanayake and Chandrasekara, 1989). With the impact of developmental change, the existence of the pluralist tradition of medicine has negated most of the ill effects of the tropical disease environment of Sri Lanka. Health behaviour Aitken and Jellicoe (1989). They identify environmental, cultural, group and personal factors as the four major factors, which construct the health behaviour of a social group. The environmental and cultural factors were discussed under the topics of immediate living environment and domesticated animals in the previous sub-sections and this discussion intends to investigate group and personal factors in relation to farming population of Sri Lanka. Health is highly valued in the farming community as there is no proper social security benefit system in operation for farmers in Sri Lanka. Therefore people depend on siblings, relatives and friends for advice and selection of treatment as identified by Wolffers (1988). The self-control, hardiness and coping skills are included in the personal life style factors within health behaviour.
Farming population have acquired many health practices of western medicine and have used them successfully to enhance their self-control, hardiness and coping skills. This is a result of increased literacy over the last two to three decades and constantly improving living standards. Further, they have accepted family planning and increased their resistance to common aliments and sickness through extensive use of western and traditional medicine. As shown in the hospital utilisation data in the Ministry of Health (1996), 37 million patients were treated at the Government facilities and the total number receiving treatment from registered health service both the public and private health care facilities may be as high as 45 million. The health behaviours of personal nature are learned through the process of family living, and the mother-daughter and mother-child relationship as identified in Liiman (1974). In the farming community under study health of the family is observed mainly by the wife as men spend only a limited time with children. It is the women, who teachers children health behaviour, prepares home remedies, accompany children to immunization, dispensary or hospital and even take care of the man’s health by washing his clothes, cleaning his room etc (Baker, 1998). Drug utilization surveys conducted in the South Asian region refers to the common practice of misuse and over-prescription of pharmaceutical drugs in Sri Lanka. This situation is common to almost all the developing nations and misuse and Organization, 2002, Daily News, 2002 and International Planned Parenthood Federation, 2002). This type of abuse occurs mostly in the pharmacy system, which is mostly operated by unqualified or under-qualified personnel. Further, the unregistered medical practitioners of various types use western medicine in their treatment system in the rural areas where the authorities are less vigilant. The present situation is well summarized by Laing (2001:3) It is not pertinent to leave this discussion without a presentation on suicide and alcohol abuse in Sri Lanka, as they contribute heavily to the increased incidence of health risks within the disease environment through causing chronic
diseases and contraction of infectious diseases. It is believed that the farming community is highly affected by these two behavioural traits, though detailed studies are yet to be conducted. The suicides are responsible for about 6 percent of all the deaths registered in Sri Lanka (Department of Census and Statistics, 2000). Therefore, Sri Lanka has one of the highest suicide rates in the world and it is difficult to relate to any single cause. The most common cause is identified as depression arising from failure. Kearney and Miller (1988) has conducted a study on the internal migration and suicide in Sri Lanka and concludes that there is a strong association between suicide and the percentage of migrant population in the dry zone of Sri Lanka. The medical professionals identify alcohol abuse as a serous threat to the health of adult males. The primary effects leads to chronic diseases in the liver by drinking poisonous preparations brewed by the illegal alcohol traders. Secondary effects are less serious, which originate through the contraction of infectious diseases by consumption of locally made food or wild meat while drinking alcohol. Many research workers and media publications identify alcohol abuse and alcoholism as two of the major behavioural factors in the increase of health risks in men of Sri Lanka. Hettige (1990) and Wickramasinghe (1993) have given some recent information on this issue though many medical articles appear in the Ceylon Medical Journal regularly. Hettige (1990), indicates that there is an increasing trend of alcohol use in Sri Lanka, which has not been duly recognized by the socio-political institutions. However, the diseases or deaths originating from alcohol abuse are not recorded properly in the medical records and therefore it is impossible to understand the true effect of alcohol abuse in the Sri Lanka society. It is clear that most of the families with extreme poverty in Sri Lanka are affected by the alcohol abuse of the householder, but the status of the alcohol as a cause or effect cannot be properly understood due to lack of detailed research.
Development and health in Sri Lanka Modernization and alternative development Structural functionalism has combined naturalism and rationalism to form the philosophical basis for an evolutionary theory of modernization covering all aspects of social activity (Peet and Hartwick, 1996). Both sociological and economical and economic modernization theories are built on structuralist ideology where societies are expected to utilize normative systems in development by limiting the place of affective expressions. Linguists and social anthropologists have attempted to study the deep structures present in many languages and cultures, and this type of structuralism, which is interested in the universal and basic structures of the human mind, is known as structure as construct. However, the type of structuralism that investigates structures at societal level has had a stronger impact on geography (Johnston, 1986). Structuralists hypothesise that there are hidden mechanisms which produce divisions within society based on ethnicity, gender, class and age. Power relations are established within these groups, and some groups attempt to dominate other. This domination is achieved mainly through developing ideologies which are supported by the hidden mechanisms. There are two major variants of economic modernization which believe in authoritative intervention through the use of economic growth models and aid mechanisms. Firstly, Keynesian ideology paved the way for intervention through the new idea of the role of the government in managing the economy (Preston 1996). Keynes was of the belief that government borrowings could finance expenditure, which in turn would generate more revenue, which together with higher tax returns from increased revenue, could be used for the repayment of these borrowings. Myrdal (1957) brought forward the concept of circular cumulative causation, which became popular through the notion of the vicious cycle of poverty. He regarded development as a social process, and stressed that the power structures of the developing world have to be changed either by evolution or revolution as a
prerequisite for development. Rostow (1960), presented a model based on five stages, which will be experienced by all societies in the transformation of their economies from undeveloped to developed. It assumes that increased production leads to growth, and that redistribution of capital will occur in the process of this growth. Capital accumulation. Growth of the labour force and scientific and technological advancement are woven into the process of development I five major stages outlined in this theory. It was still a pre-eminent theory of modernization in the early 1960s (Preston, 1996). Secondly, the dependency school formulated an underdevelopment theory through the writings of many radical researchers, which contained Marxist language, mode of analysis and ideological and theoretical projects. In parallel to the theory of under-development, the problems of modernization were discussed in structural Marxism, which originates from the French school of Marxist studies. This theory explained the importance of class relations in development gave a strong critique of capitalism and explained the process of development. The influence of structural Marxism can be seen in some other critical traditions of the dependency school (Frank, 1966 and Dos Santos, 1970) and world systems theory (Wallerstein, 1974). The dependency approach explains the way in which the capitalist world exploits the periphery and keeps the developing world in a state of underdevelopment. The world systems theory views the spatial relationships between the core, semi-periphery and periphery as exploitative. The spatiality of modernization was studied by geographers in detail to identify this centre - periphery relationship. Hagerstrand (1952) and Gould (1964) saw modernization as a spatial diffusion process beginning at the cities and administrative centres, and transmitting along transport routes. The rate of progress was measured by a set of statistical indices related to the development of economic and social status. The continuing poverty of the developing world led to a rethinking of the validity of the modernist and dependence
theories, and a search for a better alternative in development ideology. The Cocoon conference in 1974 discussed the idea of sustainable development, and the International Foundation for Development Alternatives (IFAD) recommended the establishment of a humanist model of development. Following this conference, many world gatherings were convened in the 1980s to find a serious alternative to the current development strategy. The need for a paradigm which could focus on ways of improving the productivity of the poor through social, economic and political empowerment became vital. Therefore, the alternative development approach became an action oriented programme based on humanistic and poststructuralist methods. Among many poststructuralist sociologists, Giddens (1979 and 1984) had the most marked influence on human geography. Health and under development in Sri Lanka A development strategy, which emphasizes social services is the key to the current better health status of Sri Lanka. The social welfare programme was an extensive programme and was operated in the 1950s and 1960s by a group of leaders, whom Framer (1957) identified as “very able Ceylonese”. This socially oriented development has helped the poor to escape from extreme poverty and live on a welfare system provided by the government. Caldwell (1993) clearly formulates the value of societal and political commitment in establishing a healthy environment and concedes that both are available in Sri Lanka. Wolffers (1988) believes that the secret of the better health situation in Sri Lanka rests in its well-established cosmopolitan system of public health. Table 3. 1 Some basic socio-economic indicators related to disease environment of Sri Lanka and its closets neighbours. Country GNP per capita Expenditure on Life health and expectancy at
(US $) 1
Sri Lanka India Bangladesh Pakistan
620 386 325 445
education (percent budgetary allocation) 4.8 3.8 3.8 3.6
72 63 60 61
Sources: World Bank, 1996: 1 data from US census data base, 2000 Table 3.1 clearly shows the high expenditure on welfare and public sector employment in Sri Lanka, which may have laid the foundation for the better health and living conditions of the poor. Further, it is my belief of the researcher, that the close association with the extended family and friends and the acceptance of the positive health practices by the majority of the people have enabled the construction of a disease environment of moderate risk in Sri Lanka. In addition, rapid rise in literacy, early empowerment of women, and a comparatively less corrupt political system have also been noted by some researchers as a reason for the batter health situation of Sri Lanka, since the 1950s. Macro-economic development strategies In a global context, Sri Lanka is unique in achieving remarkable success in the health sector without affecting economic growth. A spectacular transition from high to low mortality in Sri Lanka, which has been recorded since 1946 despite its low per capita income, reflects the achievements of the health services and health care systems. Since independence, successive government in Sri Lanka have committed themselves to providing free and promotive, preventative, curative and rehabilitative medical care through a systematic network to the whole population. Therefore, within a South Asian context, Sri Lanka has achieved impressive high life expectancy at birth, the lowest infant,
maternal and child mortality rates (World Bank Report, 1998/99). Sri Lanka is diverse in terms of social and cultural context, and is frequently cited as a plural society because it has different religious and ethnic groupings, each possessing distinctive characteristics based on language, historical antecedents, and cultural variations. The ethnic distribution of 18 districts which were fully enumerated in the 2001 census, records that the Sinhalese constitute 81.9 per cent, Sri Lanka Tamils 4.3 per cent, Moors 8.0 per cent, Indian Tamils 5.1 per cent, with Burghers, Malays and others making up the balance of Sri Lanka’s population in 2001. The lasted census of population in 2001 estimated a population of 18.7 million, with an average annual growth rate of 1.1 per cent. The population in 1981 was 14.85 million. Unlike prior to 1946, Sri Lanka experienced rapid population growth during the post-independence period. Over a period of 54 years from 1871 to 1925, the first scientifically enumerated population of 2.4 million in 1871 doubled. The second doubling of the population took place in only 37 years from 4.6 million in 1925 to 9.6 million in 1960. The highest annual growth rate ever recorded in Sri Lanka (2.8%) was recorded in the inter-censual period of 1946-1953. As a result of this high growth rate, doubling of the population from 6 million in 1946 to 12 million in 1971 has taken only 25 years. However, the growth rate has declined by 1.7 per cent during 1971-1981. Even though the present trend indicates a further slowing down of the population growth rate, it is estimated that at least another 1.8 million people will be added to the population between 2000 and 2010 at the rate of 180,000 a year, leading to a population of about 23 million around the year 2030. From independence to the introduction of the open market economy in the 1980s, the development process in Sri Lanka has been guided by a structured set of strategies. Keynesian ideology, Rostow’s theory, Marxism and dependency thinking have been utilized by the development planners of the respective capitalist and socialist governments of Sri Lanka during this period. Myrdal’s thinking was of great importance to development planning in the 1960s, where his
notion of a vicious cycle of poverty was regularly utilized in development rhetoric. The salient feature of this time period was an attempt to construct time related planning programmes in the form of three-year, five-year or ten-year developing plans. Development planning was a strategy used by both development and developing nations in the post war period. This was aimed at initiating structural changes in the systems of production, and to promote social development (Fernando, 1997). The first exercise in planning was presented in a document entitled “Ceylon Today – A government by the People” in 1952. The “National Plan” was a section of this document, which outlined action related to agriculture industry, transportation, post and telecommunications, health, education and food subsidies. The second planning programme was the six-year programme of investment, 1954/55 – 1959/60, published in 1955, which only dealt with government investment expenditure, and which was abandoned by the newly elected government in 1956. The Marxist orientation of this government led to the formulation of a ten-year plan. A policy of working towards a socialist society and a mixed economy in the spheres of trade, industry and agriculture was proposed in this plan. Major strategies that were identified were the development of the export sector, development of the dry zone, improvement of productivity in non-estate agricultural and industrialization. Social service sector expenditure was maintained with a limited reduction in food and nutritional subsidies. The weakest point in the plan was the lack of explanation on the modalities of private sector participation, though the private sector was invited to invest in the national economic development programme. This plan was abandoned in 1965 by the newly elected government, but state control of development was continued with the allocation of control of the national budget to the Planning Ministry. The foreign exchange budget became the responsibility of the Department of Foreign Aid, and a dual rate of foreign exchange was introduced to exert more state control on the import-export trade. This was aimed at controlling the fast dwindling foreign
exchange, which had resulted from a fall in income from the export of traditional plantation products like tea and rubber. The 1966-70 Agricultural Development Proposals and Plan of Development was prepared with the aim of achieving self sufficiency in rice and other food crops. Green revolution ideology was used, and particular attention was paid to the dry zone resettlements by provision of high yielding varieties, chemical fertilizers, agro chemicals, tractors, other agricultural machinery, increased extension services and agricultural credit. A change of government in 1970 did not exert a major change on the strategies, although a Five Year Plan (1972-76) was initiated in 1972. Like the Ten Year Plan, this was a comprehensive plan covering all sectors of the economy. However it was centred on public sector programmes and was not detailed enough on the role of private sector participation. The effect of the petroleum price increases and drought of 1973 affected its implementation, and the set goals and objectives were not given priority by the government (Radhakrishnan, 1979). Therefore from the time of independence to about 1977, Sri Lanka adhered to programmes of modernization based on a structuralist mode. The global change of development strategies in the 1970s towards alternative development was not immediately felt in the economy of Sri Lanka. This was primarily a result of two major factors. Firstly, the inward looking economic policies of the 1970s were aimed at achieving self-sufficiency in the face of declining foreign exchange income from the plantation sector. These policies were intended to increase local farm production, develop cottage industries and establish a heavy industrial base. Secondly, the strong influence of ‘Warsaw pact’ economic aid during this period guided Sri Lanka away from the new policies of open market economics. However, by 1977, it was clear that the inward looking economic policies had not achieved their objectives, and a change of political leadership resulted in an attempt in 1977 to introduce the alternative development strategies of the western developmental model into the Sri Lankan economy, through the establishment of an open market economy.
From around 1980, open market reforms began to result in some fundamental changes to the economy and employment structure. De Vroey and Shanmugaratnam (1984) investigated the nature of his economic transformation within the resettlement programme. In their view the need for colonization arose not only from population pressure on the land, but also from lack of investment in the economy for diversification of the labour market. Three other economic changes have resulted in the overall transformation of the economic structure from a state controlled to an open market system. They are the employment generated by the Middle East labour market, the establishment of export-orientated industries and the war economy. These three changes have resulted in the empowerment of the resettlement dwellers and the poor in general. The findings of researchers indicate the improved level of empowerment, through allowing their wives and daughters to be employed as ready-made garment factory workers, housemaids in the Middle East labour market and in the armed forces. Institutionalized attempts to provide development alternatives were introduced to facilitate the poor and the marginalized, through national programmes of small-to medium-scale animal rearing and ‘Samurdhi’ (a partially voluntary type of employment and an employment training programme established by the government). Private sector participation in export crop production, NGO support for community banking, water supply and maintenance of visiting health care professionals have emerged in the latter half of the 1990s, as a result of the changing structure of development strategies. Health sector development Health sector development during this period was guided by two major political programmes. Firstly, the health of the nation was treated as a primary responsibility of the government. Programmes for education, health, food, nutritional subsidy and free social security payments were maintained by successive governments between 1948 and 1970. These programmes consumed an average of 25 to 30
percent of total government expenditure during the period immediately after independence. Health expenditure amounted to 7 to 8 percent of total government expenditure on average, which was one of the highest in the developing world (Ministry of Health, 1996). This was a period which saw the establishment or improvement of the health sector’s infrastructure, and an accelerated training of doctors and auxiliary service personnel. Financing came from the nation’s healthy economic environment, which was supported by programmes like the Colombo Plan and Commonwealth Financial Aid. The recognition of Ayurveda as an alternative form of medicine, and the establishment of the scientific teaching of Ayurvedic Medicine in the 1960s, may also have helped Sri Lanka to achieve a better health status than many other developing countries. In general, therefore, within the period when modernization strategies were employed, health has achieved a remarkable level of improvement in contrast to the weakening economic status of the nation (Caldwell, 1993). Secondly, programmes related to community health, nutritional supplement, the eradication of parasitic and infectious diseases and immunization were vigorously pursued by the government. All these programmes were funded by public funds and foreign aid. Malaria and tuberculosis eradication, child and maternal immunization, and infectious disease control were the major preventive medical programmes in this category. The success of these programmes was notable in Sri Lanka compared to other countries in the developing world. Welfare policies were highly politicized and they remained in place despite many attempts to change or reduce them. This trend continued until 1977 without many alterations, although some peripheral changes were introduced into the social welfare programme. There was a revenue problem in the period from 1970 to 1977 (Jayasundera, 1986), but social services were sometimes supported from foreign borrowings and aid. Liberalisation of the economy led to the emergence of a powerful private health care service of a special category in Sri Lanka between 1980 and 2000. This private health care is operated by many types of qualified and non-qualified
personnel, and pharmacies have become places of treatment. The slack attitude of the law enforcement agencies and the lack of general policy in this area enabled some of operators to provide an illegal, but low cost service, which could be afforded by anyone other than the poorest people. Thus the population ahs created an enabling structure in response to economic realities, though it may non- yield a safe end result. The poorest are supported by social welfare, many nongovernmental organizations, and in the case of serious illnesses, by a Presidential Fund. In the last 5 to 10 years, public health services have begun to suffer seriously from a number of problems including lack of drugs, qualified staff, machinery, buildings and other infrastructure facilities, but most of the staff has remained in service by engaging themselves in private practice. Recent research (Alailima, 1997; Sarath Ananda et al, 2000; Ariaypala et al, 2000; and the Asia Development Bank, 2000), indicates that the situation of the marginalized has not considerably changed in the last 20 years. This is a result of continuing poverty and rising inflation, which leads to erosion of the buying power of the poor. These researchers further identify a rise in malnutrition, under nutrition and respiratory disease in Sri Lanka, which are linked to poor diet and housing. A high variation in mortality conditions by sectors such as urban, rural and estate is noticeable. Meegama (1980) has pointed out that the high level of infant mortality in the estates from 1946 to 1974 was due to malnutrition among mothers, the lack of antenatal care and trained midwives, and the low level of institutional births. The estates, where Indian Tamils live, had the highest mortality levels during the last few decades, especially infant and child mortality. According to the 1987 and 1993 Department of Health Services (1994) surveys, the infant mortality rate and child mortality rate were highest in the estates and lowest in the urban sector.
Demographic and epidemiological transitions The demographic transition theory was presented as a model by Notestein (1954), and suggests that there is a relationship between population change and socio-economic development. Population change within the model is initiated by spatiotemporal variations of death, birth and fertility rates associated with modern development. Development in the model refers to modernization conducted through a western-style economic development, which will transform an agrarian society into a modern industrial society. The model depends on three major postulates. The first is that decreases in mortality are the direct result of socio-economic change. Second, fertility is less responsive to socio-economic change, and decreases in fertility occur some time after decreases in death rates. Thirdly, the socio-economic process is evolutionary and agrarian societies will change to modern, industrial urban societies. Based on these three major postulates, a four-stage model is constructed. Stage one is a period of high death and birth rates resulting in a period of low stable population, which has been experienced by the human species throughout most of its history. Stage two is a transitional stage with falling death rates and high birth rates due to the initiation of the modernization process, which brings modern medicine and information, although fertility remains high because of its control by traditional belief systems. Stage three is another transition stage in which birth rates begin to fall as urbanization increases and low death rates are sustained by improved health. Stage four is a balanced state of low birth and death rates in which a high stable population live in a modernized industrial urban society. Recently, however, a fifth stage has been identified where birth rates fall below death rates, which leads to population decline. State one scenario of the demographic transition in Sri Lanka was established around 1946 by a shift from high to low mortality. This was a result of the achievements by the health services, which were heavily supported by the policies of free preventive, curative and rehabilitative medical care and social
support. Stage two lasted for about ten years between the census years 1946 and 1953, and stage three lasted from 1953 to the 1981 census. The fall of birth rates in the general populace is related to a heavy use of contraceptives, high general literacy and delayed marriage due to rising opportunities for higher education and employment for women (Siddhisena, 1989 and Silva, 1997). At present Sri Lanka is advancing towards stage four at an extremely slow pace and natural increase is still above 1 percent, which is expected to yield a heavy growth in actual numbers in the next decade. This slow pace is not yet fully understood due to lack of detailed research, but a considerable contribution is made by the tradition of having at least one child within a marriage. As discussed earlier in the sub chapters on strategies of modern socio-economic development, demographical change in Sri Lanka shows no agreement with its economic development or urbanization. Though there have been many investigations into this dichotomy, a final conclusion cannot be reached due to a lack of studies on marginalized groups like the rural and urban poor, estate workers, resettled population and people affected by conflict; and a detailed study to evaluate the role of statistics related to private medical care. Omran (1971) proposes a five stage epidemiological transition model. In stages one and two there is a strong presence of parasitic, bacterial and viral diseases, with women and children forming the high risk group. The third stage initiates a significant decline in mortality from infectious diseases, and non-infectious diseases become important. The mortality risk of women and children declines during this period, but is still higher than in the rest of the population. Stage four indicates the prominence of non-infectious diseases, and a decline in the mortality risk of women of all ages is recorded. Stage five is dominated by non-infectious diseases, but diseases associated with environmental pollution and viral infections begin to grow in significance. All members of the population are at risk, especially children. Data recorded in the Annual Health Bulletin (Ministry of Health, 1996) indicate that Sri Lanka has reached the third
stage in the epidemiological transition, but the case of the marginalized is less clear. A recent study by Siddhisena and Seneviratne (2002) has observed some striking differences between the health of children and mothers of the marginalized and general populace. Many researchers have observed these local variations, but a standardized result has yet to be produced on the health status of the marginalized. In addition, endemic malaria is a serious morbidity problem in the dry zone, and parasitic diseases cause regional or local epidemics, Lung infections and viral disease also remain a threat in urban areas, related either to pollution or congestion. Changes in the developing world have not shown much agreement with the general models of demographic and epidemiological transition. This is primarily due to the slowness of modernization, which result in the continuation of poverty and poor health service facilities. Modernization is based on the experiences of the Western industrial world, where urbanization, literacy, the rapid development of health facilities and social security systems were established in rapid succession. This form of development led to the formation of better sanitation, and maternal and infant health. Further, the modernization of Western culture allowed more freedom for both men and women in their choice of life style. The occurrence of this type of socio-economic change in the developing world was limited to the urbanized and literate, while the rest have lagged behind, resulting in only a partial achievement of the transitions as described by the models. Literacy is identified as the primary factor behind demographic transition in Sri Lanka, though the contributions made by many social and ethnic factors are yet to be fully investigated. The place of women in society and ethnicity has shown a close association with local variations in demographic transition, but true relationships cannot be established from the available evidence. Investigations are further delayed due to the difficulty of conducting research in a period of serious ethic conflict and a lack of trained personnel in the fields of demography, anthropology and health geography. Omran (1981) and Mc Glashan et al (1995) have indicated the complex scenarios which originate from
various patterns of socio-economic and health sector development in developed and developing countries. This is specially observed in the third stage and beyond, where local changes become important. Omran (1981) places Sri Lanka within the contemporary or delayed model, where dynamics of mortality and fertility change are mainly affected by social settings. There is no clear agreement between demographic and epidemiological transition and economic indicators in Sri Lanka. This has puzzled many, as discussed in detail in the previous sub-chapter on health. The resettled group seems to have a different status than the general model of demographic and epidemiological transition in Sri Lanka. At the commencement of resettlement, the demographic profile indicates an abnormality with many old and middle-aged, and very few young. The absence of young people is temporary as they will arrive once housing and schooling is ready. Within a period of about ten years of resettlement, a rapid growth of population is experienced due to natural increase brought about by second-generation marriages. With this growth of population the area enters the second stage profile, and most of the resettled areas stay in this stage for a long period of time adding a large number of young people to the population. Settlers in this study have left their wet zone home villages, which are in the late third stage epidemiological transition, and are more affected by infectious diseases at present than when they were living in their home villages. This makes the settlers revert back to the second stage where the effect of infectious diseases is important. The researcher attempts to present a case of ‘reversed process in the morbidity transition profile by the resettled people’, because of the higher morbidity from infectious diseases in the health profile of the settler. Poverty Development, health and environment in the context of this study have to be placed within a low-income situation, where poverty has an important role to play in the spatio-temporality
of disease prevalence. The meaning of poverty has changed from its definitions based on economic indicators, to one of a multidimensional nature as given in the World Development Report 2000/2001. In this new definition, health, education, vulnerability to risk and empowerment are placed alongside economic indicators in the identification of levels and location of poverty. This indicates the influence of structuration and alternative development strategies in the identification of poverty and planning for its alleviation. The structuralist strategies for poverty reduction used in Sri Lanka resulted in the achievement of high levels of human development at a relatively low gross national product. The present policies are within the structuration mode, and are directed towards strengthening households, remedying income disparity and increasing opportunities of empowerment. These actions are linked to observations made by Sen (1982, 1987 and 1999) and Chambers (1984 and 1997), who have identified various discrepancies in the existing strategies for alleviating poverty. The poverty of the farming population of Sri Lanka is linked to the rapid growth of their numbers between 1950 and 1980, and the inability of the socio-political authorities to find a strategy to accelerate economic development. Lund (1979 and 1989), and De Vroey and Shanmugaratnam (1984), have indicated the nature of existing poverty in the resettled population and relate it to a lack of access to markets and the failures of the socio-political authorities. Scudder (1995) reveals the relationship between corruption and poor resettlement planning with reference to the Mahaweli Development Programme. Empowerment as a strategy in poverty reduction is still a new enterprise in Sri Lanka, but the high literacy rate and access to democratic governance since independence has meant that the poor are better placed in society than in many other countries of South Asia. However, there are serious lapses in relation to ethnic and caste affiliations, as indicated by recent poverty research. The relationship between caste and poverty is widely discusses in Sri Lanka in the identification of marginalized
groups of people, but detailed research is limited (Peiris, 1968 and Morrison et al, 1979 and Lund, 1979). The loss of income from the export of agricultural raw material and the poor pricing and taxation policies of successive governments since independence, are the major causes of modern poverty in Sri Lanka. The poor pricing and taxation policies have resulted in corruption and a wide richpoor gap, which leads the landless and unemployed to depend on social benefits and suffer from social inequality. The programmes of resettlement attract this group of landless and unemployed, who are socially unprepared to either go abroad for employment or to migrate to urban areas as temporary labourers. A proposal for a environment and health environment management plan for present linear settlement system (Seneviratne, H.M.M.B. and Siddhisena, K.A.P., Control of Sedimentation of waterways through a household based programme, Relating environment to Regional Development, Programme and Abstracts, USJ-Sida/SAREC Research Cooperation Project and Ministry of Environment and Natural Resources Joint International Conference, 16 to 16th September, 2002, Trans Asia, Colombo) The primary objective of this paper is to present the available information on the value of household empowerment in the regional development, with special reference to the problem of sedimentation and its effect on regional and national development of Sri Lanka. The secondary objective is to present the experiences gained in this area of research and forms a strategy in the control of sedimentation, at the household level. The alternative development as presented succinctly by Friedman (1992) indicates the importance of household in the modern development process. The household and the farmland are identified as the major sediment supplier to the sedimentation system. Home gardens of Sri Lanka are poorly organized to prevent the flow of sediments to the local network of drains. In turn the authorities poorly maintain the local network of drains responsible for the prevention of soil erosion. In all the seven
provinces where the data was collected, none of the town, city and municipal council had clean drains and full of bad odour. It is the view of many medical practitioners that the increase in respiratory diseases in urban areas results mainly from poor air quality. The rapid increase in the population of the farming areas of Sri Lanka has increased the housing density of these two villages by an average of 30 to 40 percent in the last decade, but the removal of excess water produced by pavementation has not been considered important. Rural areas are seriously affected by chemical fertiliser pollution and poor quality drinking water. The paper will attempt to forward a long term program, which is aimed at reducing the maintenance cost of regional authorities on roads, minor irrigation works and increase the environment value through improved water situation which is hoped to be achieved through household based sedimentation control program. Chapter 4 History of disease environment History of disease environment is an important study in the identification of the evolution of the preventive and curative medicine in a given place or space. The history of the disease environment is presented with the expectation that it will provide information on the evolution of the present day disease environment. History of disease environment in Sri Lanka History of disease environment of Sri Lanka is constructed on many sources from the written records, inscriptions and explanations of ruins. This presentation is expected to shed light on the medical service and treatment systems from the time of the ancient kingdom of Rajarata to present modern medical treatment environment. However major part of this
presentation is referred to the Sinhala people as most of the written records of the ancient time is provided under their culture and governance. Historical material will explain the gradual development of the systems of health and strategies of environmental change in the Sinhala culture. Figure 4.1 provides an explanation to this interrelationship, which is constructed with the help of many sources quoted in the stage-wise discussion given below. The link between developmental change and disease in the ancient period is linked to the dynamics of hydraulic civilization. The hydraulic civilization was the pivot of settlement expansion, with its three interdependent structures: tank, canal and paddy. This is because mean annual rainfall was not sufficient enough to provide a sufficient among of food and maintain the infrastructure. This is the reason for veneration of some of the kings who have succeeded in uniting the warring fractions, defeat any foreign invaders and built water storage (tanks) and transmission systems (canals, aqueducts, diversion weirs and tunnels). The construction of many types of units of water storage and transmission led to a parallel increase in the human population (hosts), many disease agents and vectors (mosquitoes, domesticated animals, shallow water snails etc.) including malaria mosquitoes. Most of the evidences point to conclude that the hydraulic civilization was threatened by soil degradation, civil wars and invasions and the final push factor was a malaria epidemic. The individual or combined effect of these factors forced the centre of civilization to move first towards east and then to the South West. The destruction of irrigation infrastructure and any long delay in repair and rehabilitation lead to an increase in disease agents and vectors. The few venerated kings may have prevented this form of decline, but most of them were unable to provide a strategy to halt the decline making the system to edge towards collapse in and around AD 1200. The collapse may have come from either the disunity within the Sinhala kingdom or a massive outside invasion. However, the inability to re-conquer the invaders was a result of disunity among
Sinhalese and resulted in the abandonment of irrigation infrastructure. The landscape full of artificial depressions and dug-out canals became the ideal breeding grounds for malaria and associated diseases and by the time resettlement began the dry zone was a land full of many infectious diseases. Three stages are identified in the period between 250 BC to Independence, on the basis of the relationship between disease environment and development change. 1. Stage 1 – 500 BC to 1200, Ancient period 2. Stage 2 – 1200 to 1815, Intermediate period 3. Stage 3 – 1815 to 1948, British colonial rule Stage 1 – 500 BC to 1200, Ancient period The beginning of human settlement on Sri Lanka dates back to Neolithic culture where its existence in many parts of the island is quoted well in Allchin (1958) and Deraniyagala (1971). The arrival of Aryans and the environmental change and control, which they established in the ancient civilization and its relationship to the health environment of the ancient civilization of Sri Lanka, is discussed in this presentation on the basis of three major texts (Paranavitana, 1959; Perera, 1984 and Seneviratne, 1989) with supplementing material from many other case studies. The direction of movement of Aryans and their journey along the rivers Malwathu Oya and Me Oya in the north central province of the dry zone is shown in Figure 4.2, based on Paranavitana (1959). Population and wealth in this civilization grew steadily with the development of irrigated agriculture. The three major elements tank, canal and village formed the immediate living environment of the permanent settlement and the migratory pattern was highly restricted. Firstly, storage capacity of the tank or the supply capacity of the canal decided the size of the settlement. Secondly, the building of massive structures of religious symbols and royal monuments needed support from additional environmental resources, which were obtained manly from the forests and mineral resources within and outside
Figure, 4.1 Historical model of environmental change and disease environment
2. Natural environment – Endemic diseases up to BC 300
1. Technology of Ancient hydraulic ivilization
3. CONTROLLED ENVIRONMENT/ENDEMIC AND EPIDEMIC DISEASE UNDER CONTROL – B.C 300 TO AD 1200
4Temporarily disturbed controlled environment by war/ internal dissent / drought – resurgence of diseases
DESTRUCTION OF THE CONTROLLED ENVIRONMENT AND CIVILISATION BY AD 1200
Migration to a new habitat
NEW ENDEMIC AND EPIDEMIC ENVIRONMENT AD 1200 TO 1800
Colonial domination and moderen medicine
MODERN CONTROLLED ENVIRONMENT/ AD 1800 TO PRESENT TIME ENDEMIC AND EPIDEMIC DISEASES ARE CONTROLLED
the habitat. In this period habitat were divided into three major regions on the basis of geopolitical structure. The core of civilization was identified as Rajarattha (country of Kings) and the sub-kingdom in the south was named Rohana (country of heir to the throne). The central hill country was named Malaya and it was uninhabited and used mainly as a source for valuable timber, minerals and medicinal plants. The regions of present Kotmale, the middle Mahaweli valley complex and Matale hill complex were used as areas of retreat in the face of foreign invasions. The climatic history of the kingdom has not been investigated in detail, but on the basis of the density and selection of sites
for settlements, it is likely that the mean annual rainfall was higher than today. There are about 3000 tanks in an area of 7,752 square kilometres in the Anuradhapura district and as observed by Tennakoon (1974) has observed some of these tanks are so small, that they run completed dry if there is no rain for about two months. However, it can be estimated that a higher vegetation density of the catchment area and the total forest cover in the hill country would have supplied at least three to four times the present amount of water in the river system. The existence of three types of tanks-village tanks, big tanks and storage tanks in the cascading system of drainage was the basis for the ecosystem and the limited clearance of forest have caused a limited amount of environmental damage. The expansion of the kingdom in all directions from Anuradhapura in the early period and later from Polonnaruwa is an indication of a strategy adopted to disperse the population into every possible corner of the kingdom. This institutionalized dispersion in addition to evidence of restricted mobility between regions as given in inscriptions can be cited as planned action against uncontrolled urbanization.
Figure 4.2 Historical change of disease environments by Sinhala farmers between BC 500 to 1800 (based on Pranavitana et al, 1959)
Key: Direction of mass migrations Direction of minor migrations Major ancient irrigation works Capitals of historical times
Periods of mass migrations BC 500 to Aryan Landing circa BC 500
AD 900 to 1000 AD 1200 to 1300 AD 1400 to 1500 AD 1600 to 1800
Home village System C Present capital
Portuguese 1505 Dutch 1679 British 1796
Approximate Boundary of The dry zone
Ancient route of North south contact
In addition foreign invasions and frequent civil wars, long drought periods, crop failures and consequent famines, coupled with epidemics would have reduced the population and its continuous growth (Perera, 1948), although the chronicles have not indicated the occurrence of these disasters in detail. The macro health environment of the civilization can be described only on the basis of evidence of administrative structure and belief system as given in chronicles, depicted in stone inscriptions and existing ruins of hospitals and convalescence homes, which are quoted in, Parnavitane (1959) Deraniyagala (1971) and Seneviratne (1989). Sanitation and health was regarded as an important aspect of the general administration of the kingdom. In the city administration refuse collection and street cleaning were organized by special units, which utilized low caste and prisoner labour. Tanks were built and allocated primarily for the supply of drinking water to the city and bathing both of people and animals were banned in these tanks. The royal palaces, temples and houses of the elite were supplied with water fountains and baths for personnel use, which were connected to tanks by underground canals and systems of drains or pipes. Toilet cisterns and seats carved of stone have been unearthed from palace and temple ruins, which date back to 300 BC and defecating and urinating in public places, were banned by edict. The origin of the practice of early morning sweeping and cleaning of the garden in the village, which still prevails, descends from the Aryan method of household sanitation. The farmers, labourers and other groups of people who can be grouped as commoners lived in mud houses below the embankment of the tank or along the canal with poorer sanitary conditions than the elite and royalty, because society as elsewhere in the ancient world, was based on monarchic hierarchy and feudal capitalist system. Health education is recorded as an important sector of learning for royalty, elite and priests. The health service system was organized around a Royal physician who was a key advisor in the palace. Physicians and priests with competency in health care were appointed to serve all parts of
the kingdom and these units of service continued through the development of the tradition of ‘doctor families’ and ‘priest units’ which even continue in to modern times. Maintenance of the physician and any service unit of the health service was the responsibility of the regional administration with constant support from the king. The physicians and priests were allocated land, which was cultivated by the village and upkeep of the land was the responsibility of the village administration with constant support from the king. The treatment system was mainly of Ayurvedic origin, but supplemented by many ritualistic methods. There was regular contact with the development of Ayurveda in India either through the invitation of renowned specialists for treatment pf royalty and elite or by way of voluntary emigration from India or forced migration at times of invasions to South Indian kingdoms. The existence of two different units of general medicine and specialist medicine is indicated in the evidence provided by the chronicles and inscriptions. The general medicine was based on pulse and symptoms, while the specialist medicine dealt with fractures, anti-venom treatment and surgery. Preventive medicine was centred on the concept of isolation in case of infectious diseases, regulation of food and bathing and use of water. Herbs in combination with some mineral salts and soils were used in the diet for the treatment of vitamin deficiencies. Major health problems were the maternal and infant mortality and tropical infectious diseases like cholera, typhoid and hepatitis. Civil strife and war have had a serious effect on the population as the ancient kingdom was continuously ravaged by internal power struggles and regular invasions from South Indian kingdoms. The impact of malaria is not clearly known, but fever associated with body pain and shaking (gehena una), is well documented in the traditional and Ayurvedic literature and is recorded as one of the most difficult to care (Gnanawimala, 1950). If we follow the general argument of the proliferation of malaria through clearance of forest and exposing of streams, malaria could not have become a serious
health problem until the establishment of extensive irrigated farming system in and around 500 AD. Diarrhoeal disease and infectious diseases like measles, chicken pox and mumps have been an integral part of the disease panorama of South Asia and these types of diseases could have expanded to a scale of epidemics during major and minor droughts or in the aftermath of large were so extensive and damaging, that even the seat of government was moved temporarily to the hills or the southern kingdom (Seneviratne, 1989). Any form of epidemic would have had a great impact on the common people, because the traditional medical treatment is of low value against serious viral and bacterial infections as shown in the history of plagues all over the world. In addition malnutrition would have been common as the diet was mainly based on vegetative matter and carbohydrates with low consumption of protein. Literature on the downfall of the ancient civilization indicates that there is some level of uncertainty connected to the role of malaria and they believe that malaria was the effect not the cause, though it is possible that malaria became a major health problem towards the end of the Anuradhapura period and thereafter as the first major disruption of the extensive network of tanks and canals were initiated during the first major war with south Indian invaders in and around 950 AS. In addition the continuing major expansion of the habitat towards South West during the Anuradhapura and Polonnaruwa kingdoms can be considered as a response to possible threat of malaria in the northern (Wanni) and eastern (Thamankaduwa) regions. As observed from the maps showing the location of tanks of the ancient civilization, it is clear that these two regions were not very suitable for tank construction due to flatness of landscape. This presence of flat landscape and winding rivers may have formed the best habitat for malaria breeding, when destroyed by war or land degradation or both (Figure). Case study 3.1
Tank Cascade system ( Weva saha Gama Parisara Kalamanakarana kramaya Wegaakala Kramaya) of environmental and health management : A time tested programme for areas with seasonal drought. (Term Weva is used in the following presentation as tank is not suitable for the reservoir which was constructed not only to store water, but to fulfil many other requirements of the area which it is situated) Cascade system of environmental management is one of the best sustainable solutions to seasonal drought, which is practised today in a more modernised form in many developed countries for irrigation, power generation and urban water supply. This system is also capable of providing a health environmental management system which is universally acceptable in environmental management. The system practised in Sri Lanka during the period of ancient civilisation was designed to fulfil the following requirements. Collect high runoff from the catchments where rocky ridges and hardpan latosols resulted in high rate of runoff during thunderstorms and depressional rain. Both rocky ridges and hardpan latosols have low infiltration and very low percolation capacity. An experiment conducted in Mihinthale area between October 2005 and May 2006 revealed that between 80 to 90 percent of the runoff from the two 2 sample sites (forest cover and cultivated) were released into the streams or interfluve clay pans. Stabilise the surface ground water flow in the catchment to support a system composed of forest, shrub, grassland, village, tank and cultivated areas. The experiment indicates that the stabilisation is present in the areas with more than 60 percent forest cover. Direct runoff as soon as possible to the storage system of tanks, where evaporation is efficiently controlled.
Weva is not the central point in this management system, because its success was determined not by the size of the weva or amount of water collected in it, but by the environmental management installed to make the weva to be filled during the rainy season and prevent water wastage by the users. The weva was designed on the basis of available quantity of water, where stream order and discharge was calculated with precision ( Paranavitane, 1959). The first order weva (Kulu Weva) were followed by the second order weva (Kuda weva) and the third order weva (Maha Weva) were the last in the system though many complex patterns are present within the weva hierarchy. There may be a relationship between the weva order and stream order as the experiment indicated. The first order weva were constructed on the 4th or higher order (Strahler, 1967) streams at the field mapping level. Most of these appear as 1st or 2nd order streams in Aerial Photos and mostly as 1st order in 1:50,000 topographic sheets. The 1st and 2nd order streams in this identification are truly ephemeral unless fed by an artificial source like wastewater from a settlement or cultivated land. The 3rd and 4th order streams flow between 1 to 3 days after rain from middle of November to mid January. The system is not always simple and there were complex construction systems to handle local situations, which demanded special techniques. These local situations arose from the variations of rock type, soil cover, slope and land use. The experiment showed that micro-slopes were responsible for loss of water to the stream and to weva. The average slope in most of the cascades is in the region of 1:10,000 to 1:25,000, where a slight variation in slope will result in accumulation of water in the micro-basin type formations on latosols. During the experiment it was clear that a rise of slope by 2 to 3 inches locally would lead to heavy blockage of water flow to the stream. Then it was paramount that the settlement, cropland, shrub land and forest were kept in pristine condition. The most important disturbance to the regular flow of water into the stream system generally originates from human activities.
Firstly, the settlement in this system was located in a high ground besides the weva or cultivated area. This prevented wastewater, seepage of sewage residue and animal waste and other types of solid and liquid waste entering weva. Further the location allowed the settlement to direct its wastewater into some type of wastewater pond, which was used as a recycling unit. Non-existence of chemical waste may have allowed these ponds to be non-toxic and some types of plants and fish may have been used in this organic recycling or cleaning system. There is evidence that craft industries like iron, silver and paint production was situated in special locations where there waste was not allowed to enter weva. This systematic arrangement was able to limit helminthic and diarrhoeal diseases in the period of ancient kingdom as all waste water was properly controlled. There were set ethics, rules and regulations in the use of environment and heavy punishment was advocated to prevent any break of order. Secondly, though it is not very clear, inscriptions and designs of the sacred and built up areas of the ancient civilisation support an existence of a highly developed hydrological management system. The wastage of water was controlled with heavy legal and communal commands and user-friendly system was maintained. Rocky ridges were not utilised for settlements and they were either fully conserved or kept in the custody of monks, who managed the area in pristine condition. The experiment conducted on these areas indicate that the rock ridges under the care of monks had about 4 to 6 times more springs than the areas closer to other types of settlements. The specific purpose of the shrub, forest and the upper catchment of weva were defined by law and tradition and the law breakers were punished. These arrangements were responsible for the existence of clean drinking water and low air pollution through conservation of rocky ridges. The priests living on the rocky ridges were always environment friendly and understood the principles of clean environment through the preaching of Lord Buddha. The priests were given a heavy public support through heavy punishment for intrusion into temple property and errand priests were also punished.
This system was capable of maintaining a population of about 5 million 8 million between the period of 100 and 1100 AD, when the civilisation was in full bloom. National plan for the civilisation was in operation with periods of rapid and slow phases of weva building , resettlement in the peripheries and inter-basin water transfer (Paranavitane, 1959). There were only a few instances of epidemics in the kingdom and they were mostly initiated by the destruction caused by internal conflict, war and prolonged drought, which are mostly beyond any management control system. Non-use of toxic substances kept the environment of this kingdom free from chemical pollution, though heavy use of iron, silver and brass may have required smelting. It is clear that smelting was carried out in the outskirts of the main cities.
Today the total disregard for the weva cascade system originate from the public sector planning of settlements (including Resettlement programme since 1930), construction of roads and railways, establishment of forest plantations, construction of large government and private sector institutions, waste dumping and land fill. These activities have increased the regular blockage of 1st, 2nd and 3rd order streams in the area, destroyed some of them totally and redirected water to local depressions where they accumulate and evaporate, thus seriously starving the 1st order weva system. It is clear that the present civilisation of the wet zone has never managed to understand the principle of environmental management of the ancient civilisation though rhetoric is evident in all types of utterances and unscientific publications. It is time that we attempt to understand that it is not only the existence of the cascade system which made possible for the development of the dry zone civilisation, but the hydrological management system in operation through various royal instructions and laws, which defined the terms of water conservation and water use. Existence of officials like dolosmaha-vatan, va-vajarama, vel-kami and compensation paid for loss due to royal order clearly indicate this existence of an efficient management system. If the orders of the palace were not conducted properly the officials responsible were punished. Then it is clear that this system of management was user friendly, community oriented, but strictly legal and orderly (Paranvitane, 1959). The king himself was well educated on his duties and was under the guidance of council of ministers and high dignitaries.
We must understand the value of drainage and hydrological management if we are to solve the major problem in Sri Lanka and prevent the destruction caused to regular flow of streams in the dry zone during the wet season. The present planning system or the legal system is not built on this type of regularisation and today we are forced to depend on inter-basin water transfer. However, it is clear that we are even unable to maintain a well operational inter-basin water transfer system at present due to poor upper watershed management. There is chaos in the drought control system and it is high time we understand that this problem can be solved only through a wellmanaged scientific system and not by just feeding the area with water from somewhere as we do today. Stage 2 – AD 1200 to 1815, the intermediate period Stage two begins with the establishment of isolated princely states, which were located mainly in the wet zone between AD 1200 and 1500 AD. The shift of the kingdom and centres of population in this period. The arrival of the Portuguese and their domination of the coastal areas resulted in the retreat of the Sinhalese to the Kandy kingdom, though some brief resistance was made by the rules of Sitawaka. This pattern continued under Dutch rule from 1697 to 1796 and with the defeat of the Kandyan kingdom in 1815, British rule was fully established on the island. This period is identified as the time of uninterrupted decline by Silva (1981), and the people had to adjust to farming with rain water, though minor irrigation techniques were employed for the diversion of water from upper valley slopes. Slash and burn cultivation and collection of forest products became an important part of the economy. Anyhow the techniques of terracing, diversion of streams through the construction of weirs and the construction of small tanks and canals were continued during this period. About 400 to 500 various types of minor irrigation works found in the wet zone of Sri Lanka, which belonging to the period between 1200 and 1815. Most of these are noted in the archival documents and the larger ones have been rehabilitated and are in use at present. The
instability and war with the Portuguese, Dutch, and British between 1505 and 1815 resulted in a continuous movement of the majority of the population and the civilization was unable to develop any form of technology to enhance cultivation of food crops or develop a strong craft industry in the wet zone. Portuguese and Dutch medical records indicate the presence of cholera, tuberculosis and many helminthic infections during and after flooding (de Queyroz, 1617). Western medicine was available to the elite through the services of government doctors of Portuguese and Dutch rules and the Dutch managed to establish the first network of dispensaries in the area of cinnamon production and coastal towns during their rule (Uragoda, 1979). Traditional and Ayurvedic system were in decline due to lack of proper institutional support. The influence of Hinduism increased in the kingdom as royalty established marriage bonds with South Indian kingdoms and many ritualistic traditions infiltrated traditional medicine this period. Stage 3 – 1815 to 1948, British colonial rule Stage three begins with the total domination of the island by British rulers and the introduction of plantation agriculture, which is regarded today as the primary process of a massive environmental change and control in the modern history of the nation. The change of land ownership, abolition of traditional labour organization, recruitment of labour for massive road and railway building programme and establishment of the national administrative system exposed Sri Lanka to European governance. The result of all these policies and actions were felt mostly by the farmers, who were attached to their ancestral or feudal land and based on the beliefs of the cast system, which caused them to refuse to become labourers (Farmer, 1957). The new political faithful were allocated land by the British, thus creating a new landlord class outside the traditional feudal leadership, which were viewed with suspicion after the 1818 and 1848 rebellions (Silva, 1981).
The establishment of the plantation system was the beginning of the present system of environment control in Sri Lanka. This was a system of massive forest clearance, redirection of drainage, slope reorientation and village relocation, aided by high capital investment and strong political authority. There is a serious disagreement between the numerous authors who have published on the advantages and disadvantages of the plantation system. However, the plantation system was capable of introducing a new form of environmental control in comparison to the old system of sedentary farming. The income generated by the plantation system was also responsible for the development of health services and other social services in Sri Lanka during this period. From the 1920s onwards, western medical facilities were established in the populated wet zone, with greater emphasis in the western and southern district and the plantation areas. The high level of acceptance by the populace and the implementation of sanitary law helped the wet zone to reduce its major infectious diseases, but the urban poor population suffered continuously from many infectious diseases arising from congestion, poor sanitation and housing. The forest and grazing reserves established by the British deprived the farmer of the slash and burn cultivation and many farmers migrated to newly established townships in the coastal areas (Roberts, 1977). The population of the south and south west regions were seriously affected by this land scarcity and in 1927 the land Commission was advised to consider resettlement of farmers in the dry zone areas where old reservoirs were to be restored. Therefore after a lapse of 700 years, the introduced system of environmental change of the wet zone resulted in a revisit to the dry zone. The final result of this policy was the establishment of more than 40 major resettlements in the period between 1930 and 1970 and many other Trans Basin resettlement programmes since then. Therefore the history of disease prevalence in relation to this thesis as presented here completes a full cycle for the Sinhala farmer. In addition to geopolitical failure of the ancient kingdom, malaria was a causative factor in the abandonment of the dry zone environment. In between 1200 and 1815 they
were in the wet zone and they established a rural landscape with a traditional health system. Under British colonial rule their land was forcibly taken and the excess population was directed to be settlers in the dry zone. The wet zone: dry zone disparity in the disease environment The presence of comparatively more developed infrastructure facilities in the wet zone has helped it to achieve a better standard of health than the dry zone. The dry zone, which has a seasonal rainfall regime, is a malaria endemic environment in Sri Lanka. Further, the dry zone is less developed due to its location in the periphery and less poor quality health service facilities in comparison with the wet zone. Some researchers have indicated the importance of the intermediate zone in the study of disease environment, but the present administrative structure data base provides no facility for an exercise of that nature as the narrowness of the land belt of the intermediate zone leads to a mix of data from both the wet and dry zones. Some of the variables selected to illustrate the basic difference between the three environments are given in Table Data shows the clear difference between wet and dry zones and the transitional nature of the intermediate zone. However, it should be noted that the use of cultural environmental data for the intermediate zone is totally based on estimates made by the author as there was no source material available. It is clear that the dry zone- wet zone boundary is not so general and that there are many local variations within both of these zones, but these were not utilized in the analysis, as the aim of the research is limited to identifying a macro level difference between the wet and dry zones. Table 4.1 Some basic information related to the environment of the wet, dry and intermediate zones.
Mean annual rainfall (mms.)
Number of medical officers (curative services per 100,000)
Number of schools per 50 sq. km.
Paddy lands (mean hectares per district)
Mean number of malaria cases reported to government health facilities (Per 100,000)*
More than 10 Intermediate 1500 to 5 to 9 zone** 2000 Dry zone 1000 to Less than 1500 5
15 and Less than Less than 100 above 15000 7 to 14 16 to 100 to 250 19000 Less than More More than 7 than 300 20000 Sources: Rainfall, number of medical officers, number of schools and paddy lands extracted from Arjuna’s Atlas of Sri Lanka (1979) * Ministry of Health (1996). ** Authors’ estimates, as the district data is extremely difficult to use for this purpose. Disease environment of the Wet zone The ecological environment of the wet zone revolves around year long high humidity and temperatures, which result in the excessive breeding of many types of biting mosquitoes (not anopheles), rodents and many other types of insect hosts. Further the humid warm environment proliferate the formation of microorganisms, which are hosted both by animals and man. This results in the high prevalence of diarrhoeal diseases, tuberculosis and respiratory diseases as shown in general medical statistics and survey data, which confirm the effect of warm humid climate on the disease environment. The poverty of the farming population is reflected in their living environment. They live mostly away from the major
roads in the village units located on the valley slopes of the ridge and valley topography (Figure). This results in poor accessibility to health services, but prevents flood damage. The major source of drinking water is a well, but many other sources like stream, river and spring are used. The availability of safe drinking water is limited to large settlements and less than 20 per cent of the farming communities have drinking water. In addition, for about 50 to 60 days a year, the heavy rains of the monsoon and thunderstorm origin result in the flooding of farmland and contamination of streams and wells which are used for bathing and washing. Farming families of the wet zone Sri Lanka record an average literacy of 60 per cent or above. The villagers have access to a developed western health care system and a wellestablished system of traditional medical service. The combined existence of the western and traditional medical service system has increased the awareness of preventive care in the wet zone villages Figure 4.3 A graphical representation of the location of farmer households in the wet zone of Sri Lanka
PP P PH H D2 R P D H
Key: R- Stream or river/ P – Paddy/ D- Main road/ D2 – Sub Road/ H – Housing of farmers/ PP – Plantation (tree crops) / PH – housing of land owners
In a majority of the farming family households, the surroundings are kept clean, most of the basic advice on preventive care is adhered to and waste disposal is carefully carried out. During the survey, it was observed that the general cleanliness of the farming villages is much higher than in the settlements of the poor sub-urban and urban dwellers. Disease environment of the Dry zone The disease environment of the dry zone is a result of its harsh climate and prevalence of malaria. The physical environment is composed of an undulating plain on which the planned settlements are located adjacent to the rice paddy and the reservoir for irrigation (Figure). The long dry season with high temperatures and evaporation for more than eight months of the year results in dehydration in case of any form of sickness or disease, and increases the incidence of respiratory complaints and risk of death. Shortage of safe drinking water in the dry season results in high prevalence of diarrhoeal disease and typhoid fever, especially towards the latter part of the season. The short wet season is the major season with a high incidence on malaria, and many diarrhoeal diseases occur due to local flooding of low land areas and spill over of waste disposal systems. Figure 4.4 A graphical representation of a resettled village in the dry zone of Sri Lanka
Key: W – Weva/ MC – Main Canal/ SC – Sub Canal/ SH – System or Colony housing/ S- Scrub/ CS – Cash crops/ P Paddy The effect of malaria and diarrhoeal diseases is enhanced in the dry zone settlements due to three major reasons. Firstly, the comparatively poor housing situation of the farming communities contributes heavily to the high prevalence of malaria, as more than 90 per cent of the farmers live I mud houses without proper ceiling, masonry or ventilation. These living conditions make the continuous exposure of farmers to mosquitoes and dusty conditions, which result in high incidence of malaria and respiratory diseases. Secondly, as they live in a frontier agricultural region, they have limited access to quality health facilities, both western and traditional. Thirdly, the slow rate of infrastructure development prevents the development of potable drinking water and waste disposal systems, which can highly reduce incidence of malaria and diarrhoeal diseases. In terms of receiving proper treatment from the best source, they have identified the necessity of the use of western medical treatment in case of malaria and diarrhoeal diseases associated with serious symptoms. These attitudes have enabled the farming families to reduce mortality to a negligible level in case of both malaria and diarrhoeal diseases, but the continuing prevalence is still an unsolved problem, which could be explained as a situation related to poverty of the nation. Most of the farming families in the resettlements schemes of the dry zone of Sri Lanka have a marginally higher literacy level in comparison to their sibling families in home villages due to very low literacy levels among their parents or grand parents living in the home villages. However, literacy of the resettled farmers is lower than that of their other siblings who have moved out of the home village in search of employment in the wet zone urban or suburban areas. The life style of the farming families is similar to that of families in the wet zone, but the isolated location of the
settlements in the dry zone makes them to be more rural in appearance. As some researchers have indicated, women of the new settlements have lost the valuable advice from their siblings and parents who live in home villages and this has an important effect on the health status of the family in the dry zone, through lack of knowledge of home remedies or first-aid at time of emergencies. Farming families of the dry zone have devised a system of survival to live a healthy life in the dry zone through use of many types of resources. In relation to malaria, they employ many types of coping skills such as use of malaria prophylaxis, immediate treatment from the nearest western medical service centre and use of many home remedies to reduce the dangerous side effects. In relation to diarrhoeal diseases they use the home remedies first and then refer the case to the hospital or dispensary for treatment, which sometimes results in a dangerous delay and cause death especially in children. Any forms of high fever and sickness of children are most of the time immediately treated in hospitals and sometimes they have travel out of the district to specialist hospitals or home village facilities with better diagnostic and treatment facilities. The specialist hospitals at Anuradhapura, Polonnaruwa, Batticaloa, Trincomallee and Hambantota in the dry zone and Kurunegala, Kandy, Badulla, Ratnapura and Galle in the wet zone are extensively used by the people of the dry zone when in need of treatment and this has reduced the mortality in a great many cases. Further, the availability of many base hospitals which can successfully handle all cases of malaria and diarrhoeal disease have also contributed to the low rates of mortality in the dry zone since 1980s. The effect of war as a stress factor was noted in the farming families of the dry zone. This is a result of a large number of unemployed youth of the resettled families being employed in the armed forces, which increases the mortality of the young age group. Further, the farmers in the front line villages live in constant fear of war damage and massacres.
Conclusion In the global context of disease environment, Sri Lanka is situated within the region of high prevalence of tropical diseases. Malaria, diarrhoeal diseases, intestinal infections, tuberculosis and anaemia dominate the regional and local disease prevalence scenario. Many believe that the secret of a better health environment in Sri Lanka rests on its wellestablished cosmopolitan system of public health. However, its natural ecology and belief systems have also contributed extensively heavily to its present disease environment. This is why Sri Lanka has a better control of their disease environment in comparison with its South Asian neighbours as shown by indicators related to disease environment. The belief system is rooted in a traditional treatment system, which is based on an herbal tradition. This system was friendly to influence and readily accommodated the cosmopolitan medicine at an early stage of modernization. Immediate living environment, nutrition, literacy and gender are the primary elements which constitute the present day disease environment of Sri Lanka. Basic climatic variation has always been a divide in the disease environment of Sri Lanka. During the time of ancient civilization from around BC 250 to 1200 the wet zone was considered to be inhabitable due to its unsuitability for large scale grain cultivation. After the drift of population to the wet zone, the dry zone was treated as disease ridden and inhabitable due to the presence of infectious diseases. This change of status in the disease environments of the wet and dry zones of Sri Lanka is a result of the environmental change initiated by man under various types of technologies and belief systems. Disease prevalence in Sri Lanka and the two study areas Introduction Sri Lanka is experiencing a change in the trend in disease prevalence. However, there are many variations to this
national situation, which will to be shed light on in this discussion. The chapter begins with a presentation of the data sources and factors, which will form the background to the empirical data. The second part will use both mortality and morbidity data from various sources and an account of the present day variation of disease prevalence between the wet zone and dry zone is presented in the final part of the chapter. Data sources The modern data collection on population in Sri Lanka began with the conduction of the first population census in 1871, and since then regular censuses were held until 1991, except during the Second World War period. The existence of the organized from of health statistics goes back to the formation of a department for Registration of Births and Deaths in 1897 and a Medical Statistics unit under the Department of Census and Statistics in 1920. In this period from 1897 to 1920 data on health statistics were dispersed around many sectors of the health service like Preventive Services and Hospital and dispensary records. Most of the data have been collated and incorporated into the newly formed Medical Statistics unit under the Ministry of Health since its establishment in 1970. The present rate of registration of illness and disease is primarily based on medical statistics provided by the public health services and registered private health service providers, and a survey conducted by the Department of Census and Statistics in 1980 indicated that about 98.8 per cent of the total births and 94.0 per cent of the all deaths are properly registered. The morbidity statistics are based on the data provided by the hospital records and preventive services which cover about 80 per cent of cases, but the absence of a developed medical records department seven in large hospitals has hindered the analysis of discharges for important epidemiological information such as age, sex, place of residence, etc. (Ministry of Health, 1996). The statistics of disease prevalence in Sri Lanka is primarily collected district wise by the government health service units and hospitals, and they are published in the Annual Health
Bulletin. The other form of data originates from national census, demographic surveys and the office of the Registrar General. This presentation therefore is based on the above two data, sets, which are fairly reliable in character and strength, though the data on private medical services are not fully represented in them. Temporal change in mortality and disease prevalence Mortality levels and trends The transition from high to low levels of mortality, especially during the last six decades, provides information on disease prevalence in Sri Lanka. The time trend of death statistics from 1936 clearly shows that the crude death rate (CDR) and its components of infant death rate (IMR) and maternal death rates (MMR) were high up to the middle of this century (Table). The overall crude death rates, which were considerably high as of two digits, fluctuating between 20 and 40 per thousand before 1946 dwindled substantially to a low level as a single digit death rate in the 1950s. Although the decline trend in mortality has been witnessed since the 1930s, the remarkable decrease in the crude death rate in Sri Lanka was particularly marked between 1946 and 1956.
Table 4.2 Some key mortality indicators in Sri Lanka: 1931 – 1995 Period Crude Death Infant Maternal Mortality Mortality
Rate Rate Rate (CDR) (IMR) (MMR) Per 1000 Per 1000 Per 1000 1936-1940 21.4 160.2 19.2 1941-1945 19.9 131.1 14.6 1946-1950 14.3 100.5 9.3 1951-1955 11.2 74.8 4.7 1956-1960 9.5 62.6 3.6 1961-1965 8.4 54.2 2.6 1966-1970 7.9 50.5 1.7 1971-1975 8.2 46.6 1.2 1976-1980 6.9 39.2 0.8 1981-1985 6.2 28.0 0.5 1986-1990 6.0 20.3 0.4 1991-1995 5.5 17.0 0.3 Source: Department of Registrar General, Vital Statistics for various years This declining trend in mortality continued and its remarkable reduction has been apparent since the late 1950s. During the years 1950-95 period, the CDR accounted for 60 per cent of the reduction from 12.7 in 1950 to 5.5 in 1999. In the case of the infant mortality, a 79 per cent reduction (from 75 per 1000 live births in 1951-55 to 16 in 1966-99) and the maternal mortality for 96 per cent of reduction (from 5.6 per 1000 live births in 1950 to 0.2 per 1000 live births). Moreover, the child mortality (ages 1-4) has also declined considerably, from 29 per 1000 in 1950 to 1.2 per 1000 in 1994. This trend in mortality has appeared in all age groups as well, as appears from Table. The reduction was substantial in the age groups 0-4 and above 55 years of age. The percentage of decline is also notable in the age groups 5-9, 15-19 and 35-44 (Table). Table 4.3 a Age specific death rates (rate per 1000) Sri Lanka, 1946-1995, years 0 to 24
Year 1946 1961 1981 1995* % change (-) (19461995)
0-4 61.1 18.1 8.3 4.3 93.0
5-9 6.7 2.2 0.8 0.6 91.0
1014 3.3 1.1 0.6 0.5 54.5
1519 5.6 1.5 1.5 1.2 78.6
2024 6.7 1.9 2.1 2.2 67.2
Table 4.3 b Age specific death rates (rate per 1000) Sri Lanka, 1946-1995, years 25 to 55 and over Year 1946 1961 1981 1995* % change (-) (19461995) 2534 9.1 2.3 2.4 2.4 73.6 3544 12.4 3.3 3.0 2.8 77.4 45-54 18.5 6.1 6.2 5.8 68.6 55 & Over 72.9 41.7 33.9 28.1 61.4
Source for tables 4.3 a and b is Registrar General’s Department, Vital Statistics, 1946-1995 *Provisional Thus the age specific mortality profile depicts a steep decline of death rates for all ages during last six decades. The decline in mortality as expressed by the age specific rate is confirmed
by the change in life expectancy at birth from 45 in 1950 to 73.7 in 1996 (Table). Table 4.4 Expectation of life at birth by sex, 1946 – 2001 Year Both Male Female Excess of sexes Female Expectation Over Male Expectation 1946 42.2 43.9 41.6 -2.3 1953 58.2 58.8 57.5 -1.3 1962 61.7 61.9 61.4 -0.5 1971 65.5 64.2 66.7 +2.5 1981 69.9 67.7 72.1 +4.4 1991 72.5 69.5 74.2 +4.7 1996* 73.7 70.6 75.3 +4.7 2001* 73.9 70.8 75.5 +4.7 Source: Department of Census and Statistics, life tables, 19461991 *Projected based on UN Method assuming log of increment is constant. As seen in Table, The longevity has increases substantially for both male as well as females over the six decades since 1946. The most notable gain in longevity was achieved during the period 1946 to 1953, when the average gain per year for both males and females was 2.3 years. A steady increase of female life expectancy has taken place since 1960s and therefore the gap between male and female longevity marked about 5 years difference (Table). This improvement of life expectancy is commendable compared to other Asian countries (Pieris and Caldwell, 1997). Undoubtedly, the decreasing trend of age specific death rates, especially the fall of infant mortality in the future, which is inversely related to life expectancy at birth, will eventually increase the life expectancy at birth to 74 years in 2001. This notable decrease in mortality is primarily a result of proper control of infectious disease through provision of pre and post natal care. In addition literacy and public sector
welfare policies have also played an important role in the decrease of infectious diseases. Evolution of disease prevalence The evolution of disease prevalence over a period of 21 years in Sri Lanka is given in Table. It indicates a reduction in the prevalence of infectious diseases and an increase in the chronic diseases, which led to an epidemiological transition in recent times. A close examination on morbidity indicates that the intestinal infections and malaria are recorded as the two most important infectious diseases. This corresponds to the disease situation of many developing countries in which poor sanitation and water supply, low calorie diets and endemic diseases record a high prevalence. The increase in the chronic diseases reveals the arrival of the epidemiological transition in the period covered by Table.
Table 4.5 The hospital in-patient morbidity 1975 and 1996 in Sri Lanka (prevalence per 100,000). Disease group 1975 Intestinal infections 970 Malaria 800 Anaemias 430 Helminthiasis 231 Nutritional deficiencies 198 Hypertensive 122 Tuberculosis 114 Diabetes mellitus 96 Ischaemic heart disease 76 Diseases of the liver 39 Source: Ministry of Health, 1996. 1996 676 290 101 15 13 340 53 154 256 92
Malaria The temporality of malaria is clearly visible in the Figure, with an epidemic malaria situation indicated by the data between 1945 and 1950 and a reduction in total number of cases up to the mid 1960s. The rapid fall in number of cases from 1950 to 1965 show the well-known success of the malaria eradication programme in Sri Lanka. The resurgence from 1968 and rise and fall regime of malaria cases may be Figure Malaria in Sri Lanka 1945 – 1996 (Number of disease cases in log scale) (Source: Ministry of Health, 1996) Associated with the dry years, the establishment of new resettlement schemes (Amarasinghe and Indrajith, 1994), relaxation of the spending on the malaria eradication programme (Silva, 1997) and the emergence of the drug resistant strains. However, it should be noted here that the causes and factors of resurgence of malaria are mostly based on generalized estimates only. When compared to the total population in 1945 the rate was 450 per 1000 and in 1996 it was 1.2 per 1000. This reduction of malaria cases indicate the general advance made by health authorities and people in the reduction of infectious diseases highlighting the health behavioural pattern and role of public sector social services. Spatial variation of mortality and disease prevalence Spatial variation arises from the developmental and environmental factors. It is clear that poverty, literacy and accessibility to health services play an important role in this variation. The effect of ethnicity on spatial variation is identified by some researchers, but the exact nature of its influence is yet to be fully understood. The discussion here will be conducted in relation to spatial variation of infectious disease and mortality. Finally some examples of mobility and ecology are presented to show their effect on spatial variation of disease prevalence.
Infectious diseases Tuberculosis, typhoid and viral hepatitis are the three important infectious diseases noted in health statistics in Sri Lanka (Ministry of Health, 1996). The high prevalence of tuberculosis corresponds well with the areas of highest population density, where the poor urban population is concentrated. The excessively high incidence of typhoid in the Jaffna district is commonly associated with continuous pilgrimage to South India and trade between the two areas, but the reality is yet to be fully understood. The prevalence of viral hepatitis is concentrated in the areas along the two major transportation routes to the highland and the northern parts of Sri Lanka, respectively. The other infectious diseases recorded under the category of notifiable diseases are dysentery, viral encephalitis, dengue haemorrhagic fever, measles, rubella, cholera and whooping cough. These are the diseases, which have a tendency to emerge suddenly and spread rapidly along the major communication routes in Sri Lanka. Dysentery is the most commonly occurring infectious disease in Sri Lanka with a heavy presence in the urban areas and dry zone. In addition it can emerge after floods, and landslides in any part of the country. Dengue occurs mostly in the western part of the country in the lowland areas and spread into highlands between July and October and has become a national health problem due to its effect on children. Mortality Although Sri Lanka’s national infant, child and maternal mortality rates are relatively low, there are several regional disparities that policy makers should pay extra attention to. The average national infant mortality rates for 1994 -1996 (18 per thousand live births), conceal the marked variation in this rate across about 210 DS (District Secretariat) divisions. A few DS divisions in Vavuniya, Mannar, Anuradhapura, Trincomalee, Polonnaruwa, Kurunegala, Ratnapura, Kegalla,
Matara, Galle, Badulla and Nuwara Eliya districts have higher average infant mortality rates (IMR above 25 per thousand live births) than the other DS divisions. Among these divisions, the Ratnapura DS division in the Ratnapura district recorded the highest average infant mortality rate as of 105.3 per 1000 live births for 1994 -96 period. The factors for this high rate of IMR are yet remains to be fully investigated because there are no specific factors attributable for this striking rate. Moreover, the Matara DS in the Matara district (93.8 per 1000 live births); Nuwaragam Palatha East (98.3) in Anuradhapura, Badulla (73.4) in Badulla, Thamankaduwa (60.8) in Polonnaruwa, Kegalle (56.1) in Kegalle and Chilaw (51.6) in the Puttalam district also recorded more than 50 infant deaths per 1000 live births during 1994 - 96. In brief, forty eight (48) DS divisions recorded average infant mortality rates higher than the national figure. The districts variations in infant mortality rate are more striking when only a few districts, which have recorded relatively high average IMR rates by DS division, are taken into account. The under five-child mortality and maternal mortality rates are also varied across the DS divisions and districts respectively in 1996. The regional disparity in the under five child mortality varies considerably from 1.8 per 1000 live births (Yatinuwara in the Kandy district) to 389 per 1000 live births (Koralepatthu west in the Batticaloa district). Seventy two DS divisions recorded under five child mortality rates higher than the national figure (21 per 1000 live births in 1996). Although Sri Lanka recorded a remarkably low level of maternal mortality rate of 0.2 per 1000 live births in 1996, there are marked regional disparities across districts. Kilinochchi recorded the highest MMR (1.3 per thousand live births) followed Ampara (1.1), Mannar (1.0) Nuwara Eliya (.7), Polonnaruwa (.5 per 1000) and Batticaloa (.5 per 1000) whilst the lowest MMR was recorded in Kegalle, Kurunegala, Matara and Colombo with a rate of 0.1 per thousand live births. Many reasons are given for these extreme situations in the surveys conducted on specific vulnerable groups. The primary
reason is poverty or a poverty based factor such as malnutrition and accessibility. Some of these areas (Nuwaragam Palatha, Thamankaduwa and Koralepattu west) are located in heavily forested or isolated areas in Sri Lanka, where high level of poverty is recorded. However, the presence of some urban areas (Chilaw, Kegalle, Matara, Badulla and Ratnapura) in this group of DS divisions indicates that effect of urban slum living also has a role to play in high mortality rates. Observations made in these urban areas indicate that a large number of slum dwellers live in and around swamps and wet lands. However, lack of data on these communities prevent making of a reliable conclusion. The estates, where Indian Tamils live, have the highest mortality levels, especially among infant and children. During 1948-1974, the infant mortality rate in the estate sector was 134 per thousand live births and the child mortality was 36. This pattern remains unchanged even after 1974 as recorded in the DHS Surveys in 1987 and 1993. According to the 1987 and 1993 DHS surveys, the infant mortality rate and child mortality rate were highest in the estate sector due to increasing poverty. Meegama (1980) has pointed out that the high level of infant mortality in the estates during 1946 to 1974 was due to malnutrition among mothers, lack of antenatal care, and lack of trained midwives and low level of institutional births. The comparatively high incidence of tuberculosis, viral hepatitis and dengue in the districts of Colombo, Gampaha, Kalutara and Kandy, which are the most urbanized, is a confirmation to this fact, though no definitive conclusions can be made on the relationship between socio-economic factor and high prevalence (Table).
Table 4.6 The rankings of the major notifiable diseases in the four most populated districts of the wet zone of Sri Lanka. District Viral hepatitis Colombo 2 1 Gampaha 1 2 Kalutara 7 11 Kandy 3 6 Source: Ministry of Health, 1996 Mobility The increased mobility of modern populations either internally or internationally has been recognized as an important factor in disease diffusion. Commuting to work, long distance travel to home villages and pilgrimages have been cited by health authorities of Sri Lanka as the cause of rapid dissemination of cholera, dengue, respiratory infections and influenza epidemics. The irrigation canals have been associated with the spread of cholera and malaria in the dry zone and spread of malaria into marginal areas of the wet zone and the wet zone has been associated with long route mobility, as Meade (1976) has discovered in Malaysia. The spread of the 1998 cholera epidemic was mapped by the researcher, on the basis of reports from the Divisional Health Service and National Television, which strongly favour a possible connection between the long distance express bus service and diffusion of cholera as illustrated in Figure. The major routes of mobility in Sri Lanka operates along five road arteries radiating from Colombo and media reports indicate an association between occurrence of epidemics of infectious diseases and, the towns and linear settlements served by these major routes, although this contention is yet to be confirmed by a proper research programme. Tuberculosis Dengue 1 4 5 6
KeyHighway link – Main bus terminus – Direction of spread Direction of spread from pilgrim centres Pilgrim centres
Place of origin Dehiattakandiya
Figure 4. 5 Spread of cholera epidemic in 1998, which was transmitted along long distance express bus routes and pilgrim routes Source: Media reports and data given to media by the Ministry of Health Graphical evidence for spatial variation of malaria The district prevalence data on malaria arranged in an axis along the ecological zones from wet to dry indicate an interesting visible relationship between prevalence and district. Figure indicate that there is a sudden increase from all the Wet zone districts to dry zone districts and a similar pattern is recorded in prevalence between highland districts and the dry zone.
Figure 4.6 Increase of malaria cases from wet zone to dry zone (based on district data, arrows show the direction away from wet zone), Ministry of Health, 1996.
120 100 80
Figure 4.7 Distribution of health personnel , Ministry of Health, 1996
60 40 20
1 00% 90% 80% 70% 60% 50% 40% 30% 20% 1 0% 0%
ol om bo G am pa ha Ku ru ne An ga ur la ad ha pu ra
Key – 1 Medical Officers of Health 2. Health administrators
at hn ap u
3. Dental surgeons 4. Registered Assistant Medical practitioners 5. Public health Nurse 6. Public Health inspectors 7. Public Health midwife The wet zone – Dry zone disparity The general morbidity situation within the wet zone is a product of its human development, which was acquired through the association with the colonial rule of the Portuguese, Dutch and British, spanning the period from 1505 to 1948 and the post independence governance. Within this comparative healthy situation, there is some local and district based variation resulting from extreme weather conditions and landform processes, such as high intensity rainfall and landslides, and these events have been important factors in the local disease and epidemic scenarios. Most of these events are generally followed by epidemics of diarrhoeal diseases, viral infections or typhoid fever, which for most part are well contained by the present health authorities. The highest number of malaria incidence is reported from the Anuradhapura and Vavuniya districts, which are dotted with more than 2000 abandoned reservoirs known as tanks. In the beginning of the rainy season these reservoirs become shallow water pools and escalate the breeding of mosquitoes until washed by the subsequent heavy rains in the last weeks of November and in the beginning of December. This corresponds well with the reported increase of malaria in the late December and early January period as recognized by many researchers in the early days of resettlements and in the Mahaweli Development Programme.
Figure 3.7 shows the basic difference in the availability of health services personnel, which reflects the wide disparity in the quality of services available in the dry zone. The
population ratio between the dry zone and wet zone is about 1 to 3 and the very low numbers in the dry zone indicate a severe scarcity of qualified health care personnel in the dry zone. It should also be noted that most of these medical personnel operate from the wet zone or intermediate zone urban areas and their physical presence is limited to shift type of operation and week days only, which makes the services highly inefficient. A detailed examination of prevalence of malaria in the intermediate zone is not possible from the district base data, but an attempt was made to separate the wet zone districts from the intermediate zone districts. In this attempt any district, which had a physical connection to the dry zone, but not located fully in the zone was grouped as intermediate zone districts. Kurunegala, Matale, Badulla, Ratnapura and Matara were identified as intermediate zone districts. However the prevalence rates of the dry zone districts were about twice of that of the intermediate districts. The wet zone has less than 1 per 1000 prevalence, and the intermediate zone has approximately a three fold increase in prevalence in comparison to the wet zone. However, it should be noted that the validity of this selected boundary and the attempt to relate it to the prevalence of malaria only have an observational value.
Figure 4.8 Malaria prevalence per 1000 population, based on district data, Ministry of Health, 1996, Intermediate zone figure is an estimate calculated on the basis of hospitals located in the intermediate zone
600 500 400 300 200 100 0 Wet zone Intermediate zone Dry zone
Figure 4.9 Prevalence of three other infectious diseases in the wet and dry zones, Ministry of Health, 1996
0.6 0.5 0.4 0.3 0.2 0.1 0 Typhoid Viral hepatitis Wet zone Dry zone Tuberculosis
The data on prevalence of other infectious diseases in Figure show that the major difference between the wet and dry zones arises from the high prevalence rates of malaria in the dry zone. The other major infectious diseases recorded by the Ministry of Health fail to identify this difference, except in case of tuberculosis, which is regarded as an urban disease in Sri Lanka. An attempt was made to investigate the variation in disease prevalence between the wet and dry zones on the basis of four major disease categories of malaria, respiratory, bacterial and viral. The prevalence of four major infectious diseases at home villages, System C, Anuradhapura district and the national averages were graphically represented in Figure All the data used here was
collected from the national data base (Annual Health Bulletin, 1996) and at System C data from Dehiattakandiya hospital was used. The national situation shows low prevalence of malaria, moderate prevalence of bacterial and respiratory diseases, and a notable presence of viral diseases. The home villages have no viral diseases, but have a high prevalence of respiratory diseases and moderate prevalence of bacterial diseases. The Anuradhapura district
Figure 4.10 Prevalence of infectious diseases in the four major areas selected
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% National Malaria Home villages Anuradhapura Respiratory Bacterial System C
Data sources: National data and Anuradhapura data from , Ministry of Health , 1996: Home villages data from Home village Hospital data, System C data from Dehiaththakandiya hospital (Seneviratne, 2003).
Figure 4.11 A simple graphical representation of the prevalence of infectious diseases per 1000. Data sources: National data and Anuradhapura data from , Ministry of Health , 1996: Home villages data from Home village Hospital data, System C data from Dehiaththakandiya hospital (Seneviratne, 2003).
70 60 50 40 30 20 10 0 Malaria National Respiratory Home villages Bacterial Anuradhapura
Viral System C
was resettled mainly between 1940 and 1960 and it has a fair presence of malaria which is higher than both the national and home village averages. Respiratory diseases dominate the prevalence in Anuradhapura district, which is followed by bacterial and viral diseases respectively. System C profile is dominated by respiratory diseases, but it has about 20 times malaria more than the home villages, and also compared to the presence of viral diseases. The major difference between the home villages and System C arises from the presence of malaria and viral diseases. This disparity allows for the suggestion that these two diseases are the lowest recorded in the home villages and when they are encountered by the settlers they may not have any immunity and succumb in large numbers. It can be inferred that the presence of respiratory diseases increase with poverty and low accessibility to health services. However, the influence of air pollution in the urban areas and dust in the dry zone has been identified as ever increasing causative factors for the increase of respiratory diseases in Sri
Lanka. The high presence of bacterial disease in national profiles is a result of urbanization, where drainage and access to safe water are inadequate. The gradual reduction in the bacterial diseases towards the rural periphery may also be a result of both a cleaner village environment and non-reporting to hospitals. This is a result of treatment of common bacterial diseases by freely available antibiotics and by the villagers in Sri Lanka. A simple line diagram was also constructed using disease categories on the X axis and prevalence on the Y axis (Figure). Although this line diagram has no statistical value, it revealed a fascinating picture of the stages of evolution of disease prevalence. Assuming that the line representing the national averages is an evolution of about 70 years of western medicine in Sri Lanka and a living environment established over a period of equal length, System C is expected to take a long time period of time to reach that stage. The home villages and the Anuradhapura district show some parallel existence, which may be explained as the probable path of evolution for the System C line. This evolution is associated also with the development change in health services, which are felt much stronger in national data due to the limited presence of infectious diseases in the middle and upper classes, which have reached a stage with a heavy presence of chronic diseases among them. The economically strong classes have reached this stage mainly through their improved immediate living environment and use of western medicine. Conclusion The effective control of most of the dangerous infectious diseases by a welfare state is the primary factor responsible for the present day pattern of disease prevalence in Sri Lanka, though there is a positive contribution from the rapid rise in literacy and social modernization in the last fifty years. The free provision of western and Ayurvedic health care facilities
by the government has enabled the poor to have access to preventive and curative medicine. However, the ability and willingness to use the facilities and the selection of the medical systems originates from literacy. The place of women in society is also a major supportive factor in achieving better levels of health in Sri Lanka. However, the continuing high prevalence of malaria indicates the strength of the tropical climate and poor living conditions in a developing world health situation. This constructs the primary disparity of the disease prevalence between the wet and dry zones of Sri Lanka. Firstly, the comparatively high disease prevalence of the infectious diseases in the dry zone originates from the presence of endemic malaria, which results from the tropical climate. Secondly, the poor living conditions of the farmer are primarily a sign of the poverty of the nation, which is unable to provide an acceptable level of employment and social security. Therefore, the dry zone farmer is affected both by poverty and endemic malaria in comparison to his counterpart in the wet zone who is subjected to poverty, but less impacted by infectious diseases. As discussed in the text, the minor variations between the urban and rural areas and some ethnic influence emanate from either environmental or behavioural factors, which record only highly localized situations. These situations cannot be supported by the existing data structures. The national data indicate a situation of epidemiological transition, but a detailed analysis indicate that the national data base is becoming irrelevant to marginalized groups like resettled people and parts of the wet zone farming population of Sri Lanka. Furthermore, it is clear that malaria forms an integral part of the zone disease prevalence until a major environmental control is established by the developmental change.
Case study 3 Case Study on health profiles of a migrant and their sibling families – an example of change of environment Introduction The changing health status associated with the migration to frontier farm settlements in the developing world has become an important topic of study in medical geography. The resettlement of farming families in the dry zone of Sri Lanka includes both voluntary and involuntary migration. This is because some of the farmers move to resettlement areas as a response to the opportunities given by the land development authorities, and another group is resettled in the farm settlements due to displacement resulting from dam construction, catchment conservation or war. Scudder (1975) identifies the mixing of the voluntary and involuntary participants in resettlement studies in a review of Palmer (1974) and indicates that the agricultural type resettlement may contain complex situations. In this context the resettlement programme is not considered to be totally an involuntary resettlement. Health within the context of developmental change initiate complex changes in the factors of population, habitat and behaviour, which affect the disease systems (Meade, 1988). The developed world has experienced positive demographic transitions and mortality and morbidity are lowered on a long-term time scale, but has encountered the problem of
rising prevalence of chronic and new diseases. The developing nations have rapid increases in population, which has resulted in negative effects on health. Environmental change is the process of change of the nature and dynamics of space and place. The concept of environmental change emerged from the studies on changing nature of earth systems, like green house gases, ozone depletion, soil erosion, desertification and emergence of new diseases. The geological forces of the environment create changes in the physical environment and form various types of health hazards. Society change space and place through many types of consumption systems from cultivation to recreation and in the present civilisation, culture has become the primary force behind change of natural space and place. Human activities utilise culture to develop space and place and in doing so create a constant competition for places (Sack, 1999). Therefore we can assume that, changes in health profiles are formed when there is a crisis between nature of place and culture. Study areas The area designated as System C is the largest single resettlement programme in the Michaela Development Project in Ova, Eastern and North Central Provinces of Sri Lanka, where malaria is endemic and many other infectious diseases prevail due to poor quality living environment and drinking water. The home villages are a group of rural settlements located in the wet zone of Sri Lanka, which is comparatively healthy and malaria free. The detailed statistical tests conducted on the two different environments confirmed that the environment at Michaela System C is more hazardous than the home villages (Seneviratne, 2003 b , p 169-170).
Immediate living environment The study of environment in relation to disease prevalence is generally conducted within the framework of geography of health with the use of techniques and methodologies adapted from environmental epidemiology. The studies of May (1956), Meade (1976, 1977 and 1978) Harrison (1978) and Packard and Brown (1996) indicate the effect of tropical environment in relation to endemic and epidemic diseases in resettlement programmes of the tropical world. They all have identified the effect of the general environment and immediate living environment of the settlers in relation to the endemic and epidemic situations. Meade (1976) in her presentation on the land development and human health in west Malaysia indicates the importance of human ecology in the study of human health and shows that human disease in large measure is a product of human culture. Further she indicates that the levels of health or disease reflect the adaptability and fitness of cultural interactions with the environment. In the detailed study of the topic she indicates that major land development programme necessitates fundamental alterations in the interactions of behaviour, population and environment, which influence disease patterns. Levine and Levine (1995) refer to the immediate living environment factors associated with diarrhoeal diseases and indicate that much of the developing world's population lives in substandard housing, under crowded conditions, without piped water or sanitation. Under these conditions of pervasive faecal contamination, the various bacterial, protozoa and viral agents that cause diarrhoeal illness are readily transmitted. Water supply, sanitation and waste disposal are identified as strong contributors to overall health and Silfverberg (1994) suggests that they should be all components of primary health care. The sample population of this study is the Sinhala Buddhist farming society of Sri Lanka, with an average monthly
income of 5000 rupees and categorized in the economic literature as low income group of people. This group of people do not own enough area wet land or highland to support their families and constantly engaged in many other labour type jobs during the off season period in their home villages. That is why they attempt to migrate to land development schemes when they are offered the ownership of wetland and highland. Their immediate living environment comprises of a house, a well for drinking water, toilet, and site for dumping of refuse, a few fruit trees, open space for drying food items and clothing and recreation. Therefore the immediate living environment of the house is a unit of complex use, which makes it an important element in the discussion of disease prevalence. The immediate living environment is identified as an independent factor from the general socio-economic environment, because of its importance to family hygiene and health in its micro environmental perspective. Further, the sample population has no institutionalized sanitation and water supply system, which makes the organization of the household environment an important aspect of their health. Socio – economic environment Environmental data presented here is divided into two major sub-divisions as socio-economic and immediate living environment. The developmental environment originating from level of income, literacy, health care facilities and belief system on health are studied under the socio economic group based on data for educational level. The house type, source of water supply, toilet quality and waste disposal is evaluated within the immediate living environment. The household income and literacy are studied under the subtopic of socio-economic environment. The income was recorded at the household level and three major categories were chosen to represent the data. The category of the lowest income level is based on the average monthly income of the occupations related to agriculture as
given by Department of Census and Statistics (1997). However, it should be noted that these income levels are continuously devalued by continuing inflation in Sri Lanka (Table 7.1). Table 4.7 Monthly income of the Household head Income Home villages System C level No. Percent No. Percent Sri Lanka rupees* Below 4000 2 2 10 11 4001 to 6000 69 77 76 84 6000 and above 19 21 4 5 Total 90 100 90 100 • rate at the time of survey stood at Rs. 46.00/ per US dollar Source : Seneviratne (2003) The lowest income group in System C has five times more respondents than that of home villages, which indicates the presence of a higher number of poor families in System C. Disease and lack of supporting children caused four of the System C households to be in this category, while alcoholism of the male household head, was recorded as the major cause foe low income in six households. The two lowest income households at home villages had no support from children and were living on ancestral property. The 4001 to 6000 category is the majority group in the sample both at System C and home villages. These are the households in which there were few complaints on ill health and problems associated with farm income. However, it was noted that the majority of household heads in this category
had an auxiliary income source from either craft work or daily paid labour. The 6001 and above category is primarily the group either supported by children, who are employed in the public or private sector or derive income from non-farm activities such as trade related activities. The children of the System C respondents in this category either send remittances or help in financing the farming or other types of activities. The income level of the farming population is mainly a product of the occupational structure and total number of employed persons in a household. The employment structure in the study areas is of a complex nature as shown in Table 7.2. However, the home villages have a higher degree of complexity than System C, because of more than one family in the household and the availability of many types of employment in the urban areas of the wet zone.
Table 4.8 Employment structure of the two study areas Type of combination Farmer only Farmer / labourer Farmer supported by children, who do the farming Farmer / trader Farmer / kiosk owner Farmer / illegal alcohol seller Farmer / carpenter Farmer / mason Farmer / rice miller Farmer / mechanic Farmer / civil servant Farmer supported by employed Home villages No Percent 5 6 3 3 21 12 3 0 9 6 0 0 0 27 23 13 3 0 10 7 0 0 0 31 System C No Percent 11 13 7 8 0 9 4 3 3 4 5 2 1 24 0 10 4 3 3 4 6 2 1 27
children Farmer supported by an employed wife 0 Farmer supported by friends living together 0 Farmer supported by parents living together 0 Farmer / mahout 1 Farmer / latex tapper (rubber) 3 Total 90 Source : Seneviratne (2003)
0 0 0 1 3 100
8 3 6 0 0 90
9 3 7 0 0 100
The Statistical Abstracts of 1996 of Sri Lanka, identified 96 types of occupations available to unskilled and semi-skilled labour and most of these are utilized by the sample population at home villages and System C. In the home village sample, the children who have achieved a senior professional status of training (one university lecturer, one employed graduate teacher and four higher technical officers) support six of the households. Farming is conducted with the use of hired labour. In the System C sample, a civil servant has inherited the land from his father and has used hired labour in cultivating his wetland. Two wives are employed as trained teachers and their husbands have established rice mills with the help of them. The literacy of the householders and their wives are given in Tables 7.3. and 7.4. They are calculated on the basis of the major educational levels used in the national surveys. The settlers at System C have higher literacy than their parents and the age groups of 30 and above of the home villages have had less schooling than that of their siblings in System C. This indicates less use of education by the farming population about 50 years before the present as given in national data. The disparity under the category of secondary education between home villages and System C may result from migration of them to urban areas for employment. Table 4.9 Literacy of the householder in the two study areas
Literacy group No formal schooling Primary Junior secondary Senior secondary and above
Home villages No Percent 22 66 2 0 24 73 2 0
System C No Percent 5 56 21 8 90 6 62 23 9 100
90 100 Source : Seneviratne (2003) Literacy group No formal schooling Primary Junior secondary Home villages No Percent 34 38 56 62 0 Senior secondary and above 0 0 0 0
System C No 14 36 28 12 90 Percent 16 40 31 1 3 100
Many of the home village sibling family male householders are old and have lower literacy rates than their sons who have become resettled farmers at System C, which accounts for the high percentage of junior secondary schooling in System C householders. In addition, as explained earlier the highly educated males of the sibling families have migrated to urban centres or another more developed area in the wet zone making the least educated to remain at home villages. Table 4.10 Literacy of the wife in the two study areas Source : Seneviratne (2003) The literacy of wife indicates a similar scenario to that of male householders. Firstly, the sample of home village
wives is mainly composed or an older group and has not had the opportunity of the free education facility, which began after independence. System C women have had the opportunity to attend free schooling and record higher literacy level than their mothers at home villages. Secondly, the higher level of literacy of women of younger age is a result of the tradition of long duration of schooling for girls in the farming community. The young girls, in both areas valued schooling as a way to prosperity and active social and political life. The information on the marriages of the children indicate that some girls in the home villages and System C were able to marry a person of higher income due to extra schooling in the district capital or provincial capital.
The immediate living environment
The immediate living environment was investigated in detail and the house and environment was evaluated on the basis of its relationship to healthy living as perceived by the national health standards. This analysis was conducted in order to build a background for the study of environment risk, which is used to identify the major differences in living environment between the two areas. The landform characteristics have the most impressive difference in the study of immediate living environment of the two sample areas. Based on the observations made during the survey, some descriptions are given here on the size and plants in the home garden. The average size of the home garden at home village is 0.4 hectares, covered with a few economic trees, fruit trees and flowering plants. This type of land use design is identified as a forest garden in Sri Lanka, where the house hidden in the thick cover of vegetation. The size of the System C home garden varies from about 2.5 to 1.6 hectares from 1986 to post 1986 settlements respectively. These are more open compared to home village home gardens, but settlers have made a serious attempt to cover it with many types of trees and shrubs.
The quarterly observations of the field survey have revealed the importance of tree cover in the reduction of temperature of the house during the warm season in both home village and System C, where the maximum temperature in the open gardens were about 36 to 38 degrees C, while the forested gardens recorded a maximum of about 32 Cc. The income level primarily decides the size of the home garden of the farmer in the home villages. The majority of them live on the inherited land and the rest live on land donated by the philanthropic landlords and housing schemes established by various government agencies since independence. Farmers with supporting children have larger and better-cultivated home gardens than the families with no support from children. Three features of the immediate living environment were recorded during the survey using the questionnaire and observation. They are the quality of the house, water supply and toilet.
The quality of the house
The quality of the house in the study was measured through the occupancy rate of the house, on the basis of density of persons per room (Table 7.6). This measurement is used because it combines the size of the house with the number of people in the house. The poorest of the farmers live in a mud house with one living room, which is used for sleeping, resting, eating and entertaining visitors. Most of the farmers and the poor live in a house with two rooms. One of them is used as a common room for all activities and a sleeping area for male children and the father. The other is an inner room, which is used by female children and the mother for sleeping and to keep valuables. Table 4.11 Quality of house calculated on the basis of population density per room
House Home villages quality No Percent 2 per 76 84 room or less 3 to 4 14 16 per room More 0 0 than 4 per room Total 90 100 Source : Seneviratne (2003)
System C No Percent 44 49 39 7 43 8
The data in Table 7.5 show the level of congestion in housing, both in the home villages and System C. The categories of number of rooms in this data table include the general living area of the house. The average size of a room is between 8 to 9 square meters with an average height of two meters. There was a marked variation in the nature of construction between the home villages and System C. The houses of the home villages were mostly built with bricks and have cement plaster and better ventilation. The houses in the System C area are mostly of a compressed earth and burnt brick combination with neither cement plaster nor proper ventilation. The System C house is still under some from of change and construction. During the survey period 84 percent of the houses in System C were undergoing a change in the structure, while only 6 percent of the houses in the home villages showed any structural change. The national data indicate that the compressed earth is still being used by 40 to 45 percent of houses in the rural districts of the eastern, southern and northern parts of Sri Lanka
(Wanasinghe, 1997). However it should be noted that this figure is affected by better housing in urban centres and for village areas and for new settlements the figure can be as high as 70 percent or more. These houses are generally dusty and packed with farm produce waiting to be sold, an amount kept for consumption, personal belongings and other household furniture. It is common to see the bicycle, motorcycle and the hand tractor being parked in the living area of the house, and the loosely kept pets freely roaming around. There is a continuous attempt to keep the house as clean as possible and the houses are swept daily and incense is burned regularly. Therefore the rooms are designated simply for sleeping. The data for source of water supply for drinking and bathing and the type of toilet is given in tables 4.12 and 4.13.
Table 4.12 Source of water supply Type of supply Public mains Tube well Protected well Unprotected well Sri Lanka (Percent) 19 5 44 23 Home villages No Percent 4 5 1 20 57 1 22 63 System C No Percent 0 0 2 0 41 2 0 46
River, tank 4 2 2 46 51 and stream Other 5 6 7 1 1 Total 100 90 100 90 100 Source : Ministry of Health, 1996 for Sri Lanka data and Seneviratne (2003) Table 4.13 Quality of toilet Type Sri Lanka Percent 38 26 22 Home villages System C
No Percent No Percent Water seal 3 3 1 1 Pour flush 38 43 10 11 Pit 46 51 53 58 Others (mostly temporary) 1 0 0 15 18 Shared No data 3 3 9 10 No toilet 13 0 0 2 2 Total 100 90 100 90 100 Ministry of Health, 1996 for Sri Lanka data and Seneviratne (2003)
The quality of drinking water is of prime importance to health as most the serious tropical infectious diseases are associated with contaminated water. The contamination of water can occur at any place between the source and consumption. In the farming communities of Sri Lanka, both the primary generator of consumption can be equally contaminated. The source is the primary generator of the disease, while the point of consumption can be the secondary node of infection. The hazardous effect of the source is lessened by factors like literacy and adhering to advice on use of contaminated water. The hazardous nature in the source of drinking water is reduced in the farming families in this study
through use of boiled water for children and careful storage of drinking water. The home villages have limited problems of contamination due to year round rainfall and availability of better quality sources and 74 percent of the households use boiled water for children and very old people. In System C there is a high probability of contamination of drinking water during the dry season as people travel far to collect safe drinking water or depend on the resettlement authority to provide it by water tankers. Toilet facilities The toilet facilities have a similar scenario to the supply of safe water, but the hazardous effect of poor quality toilet facilities is lowered by the health habits formed through literacy and adherence to advice on use of toilets. The most noticeable was the common habit of cleaning after use of toilet, which is practiced by about 55 to 60 percent of the population. The researcher saw the toilets of all the households and 94 percent of them were in a satisfactory sanitary condition. The toilets of unsanitary nature were the temporary toilets and a few of the pit toilets. In general the toilets of the home villages were in better sanitary condition than those of System C, which have many poorly built and maintained pit toilets. The financial and material support given by the government, the development authority and NGOs have been heavily utilized by the farmers to build safe toilet. During the course of the survey 11 new toilets were built in the System C area with the support of these various funding agencies and another four were built by the combination of the supply of the “base block” from the development authority (the base block is the concrete base for the pit toilet) and private financing of the farmer.
The wastewater disposal was observed during the survey through the assessment of risk associated with the open drains, which drain wastewater from kitchen and garden. The risk was calculated on a two-point scale, which was based on the strength of bad odour emanating from the drain. More than 83 percent of the home village households had drains with a bad odour during the rainy season. System C sample fared better with 57 percent. The higher level of bad odour in the home village area grains is related to fermentation of organic matter in a humid environment and the presence of more roadside waste due to high-density population.
Presence of mosquitoes
There are many types of biting mosquitoes in the humid tropical environment of the wet zone, many which have not been studied due to their low capability in disease transfer. Fifty five percent of the wet zone home village respondents reported that there is a mosquito problem during the months after the two major rainy periods and sometimes even during the dry spells in the rainy season (Table 7.8). These mosquitoes are not malaria mosquitoes and some of them are known to transmit dengue and filarial. The case of System C is as expected from a malaria Table 4.14 Problem of mosquitoes as perceived by the respondents Level of problem No problem Seasonal problem All season problem Home villages No. Percent 35 55 0 39 61 0 System C No. Percent 0 9 81 0 10 90
Total 90 100 Source : Seneviratne (2003)
endemic zone with 81 percent of the respondents reporting under the category of all season serious problems. The detailed observations revealed that the mosquito density increases in the dry days after a rainy spell, which is a common meteorological characteristic of the monsoon weather.
Sometimes the location of the house within the village unit has imposed severe restrictions on accessibility to health services and good quality water. This was clearly evident in the home villages of the hilly and mountainous areas and the outback locations of the new settlement. Twelve percent of the households in the home villages were located more than a kilometre away from main road and 9 percent have difficulties getting good quality water supply due to hilly or mountainous terrain. Seven percent of the System Cc respondents live more than a kilometre from the main road and about 24 percent have a water problem during the dry months as their wells cannot supply sufficient amount of safe water. The accessibility to medical facilities is considered to be an important variable of the health status of modern populations through it is a difficult component to measure due to wide disparities in spatial distribution and functional level of services. An equation is formed on the principles given in Meade et al (1988) to calculate the accessibility of normal and emergency conditions to identify the major difference between the two study areas. Under normal conditions A = d* h / t, where A, is accessibility, d is distance to the service, h is number of government hospitals visited and t is travel time. In case of emergencies the value of t is replaced by the mean cost of travel to hospital. The
data for the calculation was collected on the basis of number of health care facilities visited by the respondents (Table 3.15).
Table 4.15 Accessibility ratios to health care facilities under normal and emergency conditions Variable Mean distance to hospital in kilometres (d) Number of hospitals visited Mean Travel time (minutes) Mean Cost of emergency transport (Rupees) Source : Seneviratne (2003) Home villages 13 13 66 400 System C 15 02 85 318
The distance to hospitals was calculated on the basis of the route taken and the number of hospitals visited gives the total number of hospitals visited by the sample population. The travel time and the cost of emergency transport were the estimates made by the respondent. The mean values were calculated for comparison and the results show that there is a clear difference in the level of physical accessibility to health services between the two study areas as expected. The basic difference arises from the number of health care facilities available for visiting and receiving, which has a ratio of 1:6 in favour of the home villages. The rest of the factors do not have much variation between the two areas.
However, in case of rare infectious or chronic disease, which could not be diagnosed properly by the hospital at System C, the mean travel time and cost of emergency can record extremely high values. The highest recorded value for an emergency is the transfer of a typhoid patient from System C to Colombo Specialist Hospital, which took ten hours of travel time and a cost of 6000 rupees.
Environment risk score
The quality of the immediate living environment was calculated to form an environment risk score, using the data on house quality, water supply, toilet type and mosquito presence (Table 7.10). These factors were condensed into three categories and assigned a value between 1 and 3. One represents the low risk, while 2 and 3 respectively represent moderate and high-risk levels. The risk score was calculated by adding the four numbers allocated to an individual household (Table 4.16). The levels of low, moderate and high risk were formulated with the help of White (1979) in relation to risk arising from the natural environment and hazards. The total obtained from the addition of values from the four variables is 12, which is equal to the risk level 3. The calculation of the risk levels for an individual house enables the researcher to place it in one of the following categories: Low risk – 4 to 7 Moderate risk – 8 to 11 High risk – 12 and above
Table 4.16 Computation of the variables into three risk levels House quality Environment risk score 2 per room 1 3 to 4 per room 2 More than 4 per room 3
Type of water supply
Public mains Tube well Protected well Unprotected well River, tank and stream Other 1 2 2 3 3 3
Type of toilet
Water seal Pour flush Pit Others (mostly temporary) Shared No toilet 1 2 3 3 3 3
No problem Seasonal problem All season problem Source : Seneviratne (2003) 1 2 3
Table 4.17 Risk level of the environment Risk Home villages level No. Percent Low 16 20 Moderate 40 54 High 16 25 Source : Seneviratne (2003) System C No. 4 12 74 Percent 4 13 82
The risk level information as presented in Table 3.17 confirms the difference in the quality of the immediate living environment between the two areas. The two data sets show that while 74 percent of the home village people live in a moderate and low risk immediate living environment more than 80 percent of System C respondents live in a high risk immediate living environment. This agrees with the observations made during the field survey. This disparity arises from two major sources. Firstly, the house and garden units of the home villages are located in a setting of a more developed sanitary infrastructure, which makes the immediate living environment much safer to live than at System C. Secondly, the availability of many auxiliary income sources at home villages makes most of the siblings living at home villages to maintain a better immediate living environment than their counterparts at System Cc. Therefore developmental change contributes heavily to the risk score on immediate living environment through the presence or absence of infrastructure facilities and auxiliary income sources.
Presentation of rates and ratios
This discussion is presented in two parts with analysis on education and health followed by environment risk and health.
Education and health in the two areas
The data on literacy of household head and wife show (9Tables 7.3 and 7.4) that there is no marked variation in the level of education of the respondents between the two areas. Most of them have received primary education and a few have proceeded to levels above secondary level. This agrees with the scenario recorded in national data of the farming population of Sri Lanka. However the following analysis on education and health of the two areas utilizes data of all the individuals living in the household.
Age specific rates
An attempt is made here to compare health status for the same educational groups in the two areas, controlling for age. Table 3.18 record the results of this analysis, which indicate that only the age group 15 to 39 in the no schooling and primary category records a significant difference. This lack of a
Table 4.18 Status of significance of age specific rates between home villages and System C in the selected age groups
Category No schooling and primary
Age group 0 – 14 15 – 39 40 – 59 60 and above 0 – 14 15 – 39 40 – 59 60 and above 0 – 14 15 – 39 40 – 59 60 and above 0 – 14 15 – 39 40 – 59 60 and above 0 – 14 15 – 39 40 – 59 60 and above 0 – 14 15 – 39 40 – 59 60 and above
Senior secondary and above
No schooling and primary
Senior secondary and above
Status of significance Not significant significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant
Significant difference contradicts the country status on education and. The presence of a marginalized group among this group of farmers in relation to educations and health has not been identified in the country profile. It is clear now after the primary investigation of this group of farmers that poverty contributes in preventing long duration schooling in the farming families, which affect their socio-economic advancement and health.
Age adjusted rates
Age adjusted rates for all the categories indicate a significant difference between the two areas as shown in (Tables 7.13 to 7.15) and show the difference in age adjusted rates of health status between the two areas. Then it can be argued that the adjusted rates have manages to confirm the existing difference in health status, though the there is no major differences in literacy between the two areas. Table 4.19 Literacy – no schooling and primary education category sick / not sick crude And adjusted rates per 100 Area Sick n Crude rate Adjusted rate 25.6 18.63* 36.39*
Home 83 324 villages System 87 285 30.5 C • significant at 95% confidence level
Table 4.20 Literacy- junior secondary education category sick/not sick crude and Adjusted rates per 100 Area Sick n 136 102 Crude rate Adjusted rate 26.47 16.90* 33.33 34.06*
Home 36 villages System 34 C
The age-adjusted analysis indicates a gradual reduction of sick and age adjusted rates in both study areas in relation to increased level of schooling. However, the reduction between no schooling and primary and junior secondary categories is not negligible (Tables 3.19 and 3.20), which is difficult to explain. It may arise from the inability to
understand information on health at this playful age group or lack of health education or both. The very marked difference in sick not sick rates between junior secondary (Table 3.20) and senior secondary (Table 3.21) can be supported by research. The close association between the best levels of health and senior secondary and above education in Sri Lanka is confirmed by the data in Table 7.15. Though there is no significant difference between the two areas on this category it is clear that this category of literacy reduces the number of sick drastically in comparison to two other categories. Table 4.21 Literacy – senior secondary and above category sick / not sick crude and Adjusted rates per 100 Area Sick Home 9 villages System 15 C n 172 124 Crude rate 5.23 12.1 Adjusted rate 2.30 3.86
Further, it confirms the increase in infant and maternal health recorded by national health surveys in the group of mothers who have had schooling at senior secondary or above. The national data indicate a relationship between senior secondary education and health status of infants and mothers. The general reduction in sick in all categories as shown in Tables 7.13 to 7.16, confirm the country situation as mentioned above. The ability to read and white, understand the value of immunization and adhere to simple emergency procedures like oral rehydration and referring to a registered medical personnel have increased with senior secondary level schooling. The respondents of this category
were mainly teachers and grade civil servants who conducted their farming through sibling or hired labour. In addition this group of people live in a low-risk immediate living environment, always seek treatment from qualified medical personnel and cope better with disease and ill health than the rest of the farming population.
Environment risk and health
Age specific rates
The data on environment risk is highly skewed between home villages and System C, which makes it difficult to conduct a full comparison for age specific rates, in particular the low risk group suffers from lack of data in System C (Appendix 7.3). The only significant difference is recorded in the high-risk group 40 to 59 years age group. This makes the age specific analysis for risk groups a difficult task and an adjusted rate comparison is attempted as conducted in the previous analysis.
Age adjusted rates
Age adjusted rates for all categories are significant at 95 percent confidence level confirming the observed variation of the two areas (Tables 3.22 and 3.23). The variation of the disease environment, infrastructure facilities and immediate living environment are confirmed by this analysis. Table 4.22 Environment risk-low category sick/not sick crude and adjusted rates per 100
n 134 21
Home 33 village s System 3 C
Crude rate Adjusted rate 24.63 20.26 14.29 20.72
Adjusted rate 2.30 3.86
The disease rate is lowest in the moderate category and highest in the high-risk category. The method used in the analysis suggests that adjusted rates calculated for values below 10 will product unreliable results and this implies that the results of the low risk category cannot be taken as valid as the results of the other two categories. Table 4.23 Environment risk – moderate category sick / not sick crude and adjusted Rates per 100 Area Sick n Home villages 83 342 System C 17 74 • significant at 95% confidence level Crude rate 24.27 22.97 Adjusted rate 13.24* 14.25*
The high – risk category records the widest difference in disease rate among the three groups used in the analysis, which arises from the heavy presence of mosquitoes at System C in comparison to home villages. Table 4.24 Environment risk-high category sick/not sick crude and adjusted Rates per 100 Area Home villages System C Sick 22 106 n 156 416 Crude rate 14.1 25.48 Adjusted rate 20.4 29.67
The changing pattern of risk between the two areas is also explained by the adjusted rate. Therefore as in the analysis of disease prevalence age adjusted rates have eliminated the bias of age in the population being compared and has provided a reliable rate for comparison purposes. The use of age specific and age adjusted rates for the analysis of education and health and environment risk and health was aimed at comparing the health status for educational groups and environment risk groups controlling for age. The results indicate that age specificity is not very useful in the analysis, which may arise from the skewed distribution of data and lack of cases. However, the primary intention of the analysis was to make a comparison between home villages and System Cc. This was achieved with the use of age-adjusted rate, which is weaker than the age specific rate in the measurement of absolute levels but useful for purposes of comparison. This indicates that the technique of age adjusted rate has managed to identify the difference between the two areas controlling for age.
The socio-economic and the immediate living environment construct the built environment in which man lives. The relationship, which exists between the socio-economic variables and disease prevalence, is of a complex nature. In here an attempt is made to study the relationship between the disease prevalence and literacy and immediate living environment with the use of univariate and bivariate statistics. The home villages have an established socio-economic environment with developed educational and health facilities. Their immediate living environment is better with more sanitation and water supply facilities than System C. This is a result of the age difference of the
two selected settlement types, which made the new settlements of System C vulnerable to more control from natural environment as explained by the concept of environmental change. The environment risk score was able to identify the marked difference in the immediate living environment of the two study areas and its relationship with disease prevalence is accepted. This is because the univariate and bivariate data and confidence intervals are able to identify a basic difference in the environment and disease prevalence. The district based national data on sanitation and water supply are questioned by this analysis, because the percentages recorded in them are not confirmed during the survey, though the researcher managed to utilize the same categories. This may be a result of detailed recording of these facilities and checking the location of facilities conducted during the survey, which may not have been carried out during national surveys. Therefore, this analysis reveals a glimpse of the value of environmental change in the formation of disease scenario in a newly settled area. The study of differences in literacy levels and environment risk revealed that there is a significant difference between the two areas on the basis of age-adjusted rates. This confirms the observed difference in the health status of the two study areas, which is also possible to explain by controlling for age distributions.
Chapter 5 Disease prevalence and morbidity a low income community in Sri Lanka System C and home villages
Introduction This chapter presents the analysis of survey data on disease prevalence with the help of univariate and bivariate statistics. The primary analysis is cantered on age specific distributions and tables generated by SPSS. Then the matching of sick and nonsick categories at Mahaweli System C and home village samples are subjected to a test of significance by way of confidence intervals calculated on age specific rates and age adjusted rates. Some of the findings of the quantitative analysis is supported by observations and information collected through life history survey. Therefore the presentation is in a mixed format of quantitative and qualitative analytical techniques. As already mentioned in chapter 3, in this study an illness, sickness or disease, which was treated by a registered medical practitioner (Western, Ayurvedic or traditional) on a prescription, is used to identify a situation to be recorded as a valid entry of disease prevalence. The presentation begins with a discussion on the age structure of the sample population. It is followed by the presentation of data on all diseases, infectious disease, and non-infectious diseases under various categories as recorded during the survey. Then the seriousness of the disease and gender variations is discussed respectively.
Age structure The age distribution of the sample shows (Table 4.1) conformity with the national surveys conducted by the Department of Census and Statistics (1993) and Central Bank (1996) economic surveys, with the highest percentage population in the age group of 15 to 39 years. The system C sample records a comparatively high percentage of 0 to 14 years age group and a lower percentage of 60 years and over age group, than the home villages. This is explained as a result of the lower mean age of migrants compared to their siblings and the presence of the parents and grant parents of the migrants in the home village sample. The high percentage of 0 to 14
year group in the system C area results from the lower age of the migrant population, which is still in the process of family formation or inclusion of the their grandchildren living in the same household. These complexities in the population characteristics result in a percentage difference of the age profiles of the two areas within 0 to 14 and 60 and above age groups. Table 5.1 Age structure of the sample Home villages No. Percent 0 to 14 years 150 24 15 to 39 years 274 43 40 to 59 years 126 20 60 and above 82 13 Total 632 100 Source: Seneviratne, 2003 Age group System C No. 166 237 98 10 511 Percent 32 46 19 2 99
Total sample No. P 316 2 511 4 224 2 92 8 1143 1
The age groups given in the tables were identified on the basis of its relationship to active participation in farming and amount of exposure to disease within the Sinhala farming community of Sri Lanka. The children join the full time farming activities at an average age of 14 to 15, and continue till about 60 years of age. The males are involved in the clearance, ploughing, sowing and threshing, while females play an important role in weeding, cutting, packing the harvest for threshing and final preparation of rice. The most active period of life of a farmer is from 15 to 39 years, during which he inherits land for farming or becomes resettled, gets married and forms a family. During this period he and his wife have only limited help from their children and have to work extremely hard to raise children and provide them with basic necessities of life. It is common to see the presence of the father or other of either the farmer or his wife staying with the family during this early period of farming life. In the third age group, which begins at 40, the farmer receives help from his adult children and sometimes migrates with a young child to a new area for farming. After 60 years of age most of the farmers hand over fulltime farming to their children, while their wives become household helpers. Therefore it is assumed here that the highest exposure to occupational hazards and disease in a life of a farmer occurs in the age group of 15 to 59.
Table 5.2 Age structure of sick and not sick for the total sample Age Not Sick group sick 0 – 14 278 38 15 – 39 443 68 40 – 59 131 93 60 and 27 65 above Total 879 264 Source: Seneviratne, 2003 N 316 511 224 92 1143 Percent sick 12.02 13.31 41.52 70.63 23.10 Prevalence/1000 120 133 415 706 231
Table 6.2 indicates the steady increase of disease prevalence with age in the total sample. The prevalence value for the total population is exceeded by the two age groups 40 to 59 and 60 above indicating a high prevalence of disease in mature adults. Further analysis of this data is conducted in the latter part of the chapter with the use of confidence intervals on crude and age adjusted rates. Gender structure Table 5.3 Gender structure of the total sample Gender Area Home village No. Percent Male 286 45 Female 246 55 Total 632 100 Source: Seneviratne, 2003 System C No. Percent 280 55 231 45 511 100 Total No. 566 577 1143
Percent 50 50 100
The gender distribution as presented in Table 6.3 follows the general trend of the national data. The higher percentage of females in the home villages result from the survival of old females, while the higher percentage of males in the System C is due to permanent presence of male siblings or friends, who have come as domestic or farm help. It was observed in 11 households that either the brothers or friends have accompanied the householder from the beginning or
joined him at a later stage to help in the farm or in the house work such as building work, collection of fire wood and taking children to school. Data analysis on disease prevalence
Levels of measurements
The data disease prevalence was collected both on an individual and household basis in order to build a database with individual and environmental information respectively ()Table 6.4). The disease records were utilized to identify the type, status and treatment of disease. The age, gender, education, employment data was collected from the questionnaire data. The environment data was collected from the questionnaire and observation data. This chapter will focus on the individual perspective of disease prevalence and the environmental information is presented in the next chapter. Table 5.4, Level of measurement Variable Disease Prevalence at each visit Expenditure on health Age Gender Education Use of health care/type of treatment Employment House quality Water supply Toilet Drainage Mosquito density Environment risk level Health care accessibility Individual X X X X X X X X X X X X X X X Household
Source: Seneviratne, 2003
The discussion on disease prevalence is presented with the analysis of data on infectious diseases followed by the non-infectious disease. The data presented in the Tables 4.5 to 4.8 portrays the number of cases and disease prevalence as they were recorded in the two study areas during the survey period for all four visits, from January to December 1998. The basic data presented in the Tables 6.5 and 6.6 are the total number of records for all the four visits. The Tables 6.6 and 6.8 show the prevalence data calculated from the basic data.
Table 5.5 Infectious disease – number of cases – for all individuals having experienced a case of sickness any time during the four visits
Infection disease Home village- N = 632 1st 2nd disease** disease* No. No. 3 0 19 2 3 0 2 0 1 0 0 0 1 0 3rd disease*** No. 0 0 0 0 0 0 0 System C – N = 511 1st disease* 2nd disease** No. 26 27 7 3 2 2 0 No. 3 8 2 1 2 0 0
Malaria Respiratory Urinary tract Skin Bacterial Viral Eye
N 0 0 1 1 0 0 0
Other intestinal Total
Source: Seneviratne, 2003 *Principal disease present as noted by the respondent ** Second disease present as noted by the respondent *** Third disease present as noted by the respondent Table 4.6 Non-infectious disease – number of cases – for all individuals having experienced a case of sickness any time during the four visits Table 5.6 Non-infectious disease – number of cases – for all individuals having experienced a case of sickness any time during the four visits
Non- infectious disease Home village – N = 632 1st 2nd disease* disease** No. No. 44 0 20 12 21 3 10 0 3 1 1 0 3 0 1 1 2 2 6 6 1 0 112 25 3rd disease*** No. 0 0 0 0 0 0 0 0 0 0 0 0 System C – N = 511 1st 2nd disease** disease* No. No. 14 12 3 5 9 2 5 0 3 2 9 0 0 0 3 1 1 1 5 7 3 0 55 30
Respiratory systems Musculo skeletal Circulatory Cancers Nervous system Digestive system Ear nose and throat Skin disorders Mental disorders Eye Dental Total
No 0 1 1 0 2 0 0 0 0 1 0 5
Source: Seneviratne, 2003
Table 5.7, The prevalence of infectious diseases per 1000 individuals - for all individuals having experienced a case of sickness any time during the four visits Home village – N = 632 System C – N = 511
Infectious 1st 2nd 3rd 1st 2nd disease disease* disease** disease*** disease* disease** Malaria 103 0 0 382 44 Respiratory 655 3.16 0 397 118 Urinary tract 103 0 0 103 29 Skin 69 0 0 44 15 Bacterial 34 0 0 29 29 Viral 0 0 0 29 0 Eye 34 0 0 0 0 Other intestinal 0 0 0 15 0 Source: Seneviratne, 2003 Table 5.8 prevalence of non-infectious disease – per 1000 individuals for all individuals having experienced a case of sickness any time during the four visits Non- infectious Home village System C st nd rd disease 1 disease 2 disease 3 disease 1stdisease Respiratory 393 0 0 212 systems Musculo skeletal 179 107 0 58 Circulatory 188 27 0 173 Cancers 89 0 0 96 Nervous system 27 9 0 58 Digestive system 9 0 0 173 Ear nose and 27 0 0 0 throat Skin disorders 9 9 0 58 Mental disorders 18 18 0 19 Eye 54 54 0 74 Dental 9 0 0 58 Source: Seneviratne, 2003 The four major infectious diseases reported from the two study areas during the survey period were in the broad categories of malaria, respiratory, urinary tract and skin infections. All the infectious diseases have recorded a higher prevalence level in the System C than in the home villages. The high prevalence of malaria inn System C is shown by its importance as a first and second disease, which is not present in home villages. The respiratory
3rd disease 0 0 15 15 0 0 0 0
2nd disease 231 96 38 0 38 0 0 19 19 135
19 19 0 0 0
0 0 19 0
diseases are the most common group of diseases in the home villages and respiratory diseases as a whole is the second most important disease in the System C area. A similar prevalence can be noted in the urinary tract infections, but it is not recorded as a second disease at home villages. Figure 4.1 The percentage prevalence of selected groups of diseases Sources: Field data for System C and home villages, and National data from Ministry of Health (1996) The System C area recorded it as a second and third disease of recognizable importance. A similar scenario is present in the prevalence of skin infections, but System C records it as an important second and third disease. The presence of bacterial, viral and intestinal infections have also recorded higher prevalence levels in System C, in comparison with the home villages. The prevalence of infectious diseases as recorded during the survey can be supported by the macro data available on the major cause of hospitalization in Sri Lanka (Ministry of Health, 1996). Figure 6.1 shows the percentage share in prevalence of infectious diseases in the two study areas and their relationship to the national averages on the prevalence of infectious diseases. It is not possible to make a direct comparison between the study data and macro data due to simplification of the categories in the macro data as given in the Annual Health Bulletin, 1996, but some visible differences can be observed, Figure 6.1 confirms that the two major infectious diseases in the two study areas correspond well with the hospital morbidity data taken from the Ministry of Health (1996). The group of diseases under “other” in the national data includes many types of infectious diseases including urinary tract, intestinal tract and skin infectious, which are identified separately in the study sample. The national discussions conducted with the medical personnel, revealed that, heavy congestion in the public transport system, incursion of epidemic type viruses from other parts of Asia and the habit of consumption of extremely alcoholic (60 to 70 percent) beverage have definitely contributed to the high prevalence of
respiratory diseases in the farming population. The life history information also confirms the above view as a healthy 95 – year-old farmer said “The respiratory diseases were rare during our childhood. The air was good and we never drank dangerous things like kassippu. We ate a lot of leaves, which had the quality to keep your respiratory systems strong. The major sicknesses of our times were worms and fevers”. This is the general view is the general view of the heavily old farmers, who believe that air pollution and new ways of life have increased morbidity related to respiratory diseases. The sickness associated with worms and fevers can be related to intestinal infections and viral fevers of the past. Through malaria is an incessant problem in System C, it is not regarded as a dangerous disease, due to availability of treatment facilities. However, its effects are considered as highly debilitating both by young and old. “Oh! I nearly died and I hope it will never come to me” was a common way of referring to the disease during the questionnaire survey and informal interviews. The information on the severity of diseases was received mainly during the questionnaire survey, as there was some reluctance to reveal the severity of disease in a group situation. Three malaria cases recorded in the home village sample are recorded from three different home villages from three different parts of the country. Two of the cases are not related to their connection with the resettled families as there was no contact between them, but the third case was a result of a visit to the new settlement. It should be mentioned here that malaria is reported from all the districts of Sri Lanka, though the wet zone records only less than 100 per 100000 individuals (Ministry of Health, 1996). Though the malaria mosquito is not present in the elevations above 1000 meters, all the major hospitals record malaria cases, which
indicate the important role of mobility in the spread of malaria in Sri Lanka. The impact of mobility cannot be fully explained, due to lack of detailed records on the locality of the patient and the visiting of home village medical facilities for treatment by the zone settlers.
Non – infectious diseases
The prevalence of non-infectious diseases in the home village sample is in conformity with the national data, in that the respiratory, circulatory and musculo skeletal categories register the highest values. The System C area records the respiratory, circulatory and digestive system diseases as the three primary noninfectious diseases indicating a slight deviation from the national trend. The respiratory system diseases were distributed among all the age groups and the highest prevalence was recorded for the ages above 40 in both areas. The home villages recorded 75 percent of all the cases of respiratory diseases and this high prevalence can be related to the presence of numerous aged people. The musculo skeletal group of diseases has a clear association with the aging process as 70 percent of the cases were in the age groups of 60 and above. The major type of disease within this group was arthritis or arthalgia, which is common in the farming population of Sri Lanka, which may be a result of poor nutrition and working in the water logged rice fields as described in Chapter 4. Therefore, the low prevalence of these diseases in System C can be related to the comparatively younger age of the migrants. The circulatory system diseases are generally on the increase in Sri Lanka as given in the Chapter 2, which is confirmed by the empirical evidence of the survey. These diseases are also age related and 44 percent of the total was present in the age group above 60 in the home village sample. However, the disease was present in the age group of 40 to 59 years in both areas at an equal proportion, which may be explained as resulting from the similarity of the life style or an indication of the age of onset of the disease. The two most common diseases recorded were hypertension and high blood
pressure, which accounted for 84 and 9+1 percent of all the cases of circulatory diseases at the home villages and System C respectively. Many types of cancers were recorded in both areas as an important chronic ailment. Breast cancer in women and cancer in the liver of men are recorded as the most common. The cancer in the liver of men was associated with heavy use of alcohol by the general diagnosis (in the hospital cards). The highest prevalence of cancer is in the age group of 40 to 59 and 60 and above in the home villages and 40 to 59 years at System C. The diseases of the nervous system were recorded only in the form of chronic diseases within the sample. These types of diseases in the System C area are almost twice that of the home village, which is attributed to the stress caused by the employment of their sons as soldiers in the armed forces, and eloping of daughters. The home village cases of nervous disorders have resulted from various causes like old age, malignant cancer of the husband and chronic respiratory disease. The home village sample did not record any special stress related illness arising from the employment of their children in the armed forces, but parents did show signs of worrying. The high prevalence of the digestive system diseases recorded in the System C data relate mainly to liver damage occurring as a result of excessive use of alcohol, which was identified as a rising cause of disease among farmers in the System C area by the medical personnel. The digestive system diseases were present in the age groups of 15 to 39 in the home villages and 15 to 59 in the System C. The Table 6.9 records the alcohol consumption of the household in the two study areas, which indicate a definite increase of heavy consumption at System C. In System C, one household head died by mistakenly drinking a weed killer, when he was intoxicated with alcohol and another died during the last visit of the survey as a result of a lung infection resulting from heavy alcohol consumption. The researcher witnessed a seriously ill household head in the home village sample suffering from acute liver cancer, which was diagnosed as resulting from heavy alcohol consumption. In addition the researcher observed the high availability of the illegal and
dangerous local brew known as ‘kassippu’ in all the study areas and he met many villagers with the bad smell associated with it during the survey. Table 5.9 Alcohol consumption among household heads Level of consumption No Slight (accepted by wife) Heavy (wife complained) Total Source: Field data Home villages No. Percent 2 2 84 94 4 90 4 100 System C No. Percent 16 18 63 71 11 90* 11 100
Seventy five percent of the skin disorders were reported from the System C area with 50 percent of the cases in the 40 to 59 year age groups. The only case of skin disease at the home villages was a child of a respondent, who was asked to leave System C by the medical professionals, who noticed an increases severity of the disease, when the child lives as System C. The mental disorders have arisen from two major sources. Firstly, the cases in home village come from a family, which has a case history of mental disorders, who associate the situation to ‘the work of an enemy of the family,’ (the prescriptions or diagnostic reports were not available to the researcher as they were not produced voluntarily). The case at System C is related to excessive consumption of alcohol and ‘hard drugs’ per the family and no medical records were available to the researchers for verification. The mental disorders were recorded in the age groups of 15 to 59 and 67 percent were in the age group of 40 to 59, with an equal distribution in the home villages and System C. The weak eyesight was common among the people over the age of 70 but was reported in the age group of 40 to 59 at System C. Some of the System C respondents were of the view that preventive and curative drugs used for malaria had caused early loss of normal
vision in them. The medical practitioners generally accept this, though firm scientific evidence is not available. Figure 4.2 illustrates the percentage prevalence of non-infectious diseases in the two study areas, which is agreeable to the general trend in the national data. However, a Figure 4.2 The percentage prevalence of selected group of noninfectious diseases Source: Field data Comparison between the national and study area is not possible due to the simple recording system used in the hospital records.
Presence or absence of disease
The data on disease prevalence was utilized to calculate the presence or absence of sickness during the survey period of one year (Table 4.10). Table 5.10, Number of sick and not sick in the sample Health status Area Home village No. Percent Not sick 494 78 Sick 138 22 Total 632 100 Source: Field data System C village No. Percent 385 75 126 25 511 100 Total No. 879 264 1143 percent 77 23 100
A total of 264 people or 23 percent in a sample of 1143 individuals were identified during the one year long survey as sick on the basis of clarifications made at the beginning survey. This is divided between the home villages and System C as 22 percent and 25 percent respectively, indicating a slightly higher percentage of sick in System C. Table 5.11, The level and seriousness of sickness Level of sickness Area Total number
Home village No. Percent Minor sickness-one treatment only Sick-discontinuous treatment Seriously sick-continuous treatment Very seriously sick-in bed or no admission Total Source: Field data 1 12 8 8 1 13 8 1 93 5 1 100
System C village No. Percent 11 111 3 1 126 9 88 2 1 100
No. 12 239 11 2 264
The level of sickness varied according to the nature and severity of disease, and is categorized into four types on the nature of the treatment (Table 4.11). The infectious diseases were present, only at a particular visit while the chronic illnesses had a continued presence throughout the survey with some variation in intensity of suffering and treatment. The categories made of the level and serious nature of sickness is firmly attached to a definite health situation such as treatment or a limitation of physical activity and therefore can be taken as suitable for making general conclusions. The higher percentage of sickness in the System C is as expected in the study programme, but the low percentage difference between the two study areas has to be explained. Firstly, the bias introduced by the higher number of old respondents in the home villages, who suffer from many types of old age chronic illnesses increase the number of sick people, within the home village sample. Secondly, the impact of malaria is reduced by the use of western health advice and preventive measures like mosquito nets and repellents. All the respondents indicated that they use a repellent commonly known as ‘mosquito coils’ and the researcher witnessed the practice of use of nets for all the infants in the sample. The use of mosquito nets was common and 64 percent of the households reported of using them during them season of intense mosquito activity.
The respondents who did not complain of any sickness or disease were questioned about their health and asked whether they had taken any self-treatment for many types of cold and flu in the village environment of Sri Lanka. 84 percent of them reported that they have taken self-medication in form of pain relievers and vitamin supplements without being prescribed by qualified medical personnel. These medicines were obtained from shops, kiosks and some unregistered ‘quacks’, which operate in the village markets or service centres. I had the opportunity to meet about five of them (three in the home villages and two in the System C) during the course of the survey and found that they sell many brands of traditional and western medicine. All the respondents in this group had used some form of herbal treatment at least once during the survey period and the respondents over 60 years of age are regular users of these types of treatment, though they do not accept that they are sick. Presentation of rates and ratios Absolute counts of events are difficult to analyse and compare between various geographic areas because of population differences. Rates and ratios are constructed in demography and epidemiology to present mortality and ,morbidity statistics. Rates give the frequency of the numerator relative to denominator within a specific period of time. In this study the numerator is the diseases or mortality cases and denominator is the population at risk. The study sample indicates considerable age differences between home villages and System C. Therefore presentation and analysis of crude rates of disease prevalence are of little value, since the overall rates will be influenced by age (Table 6.2). This guides us to operate in two stages in constructing rates, which will enable the researcher to arrive at more precise comparisons. First stage presented here is the construction of age specific rates, which are capable of conducting comparisons among places and times periods (Meade et al, 1988). Age specific rates are simple to
compute and may show interesting features with regard to disease in different age groups in the two study areas. On the other hand the number of cases will be smaller than the total sample, and statistically significant difference between the populations in home villages and System C may be therefore be more difficult to obtain. Second stage is the calculation of age-adjusted rates for the total population of home villages and System C. An age-adjusted rate makes a crude rate of the sample population comparable to the standard population. The crude rates can be adjusted for differences in the proportion of the population at various ages, sex, ethnicity, income and other classifications (Meade et al, 1988). The statistical testing of significance differences will be done by computing confidence intervals for the rates, using the procedure given in Pennsylvania Department of Health, Health StatisticsTechnical Assistance, Tools of the Trade, (2000). The confidence intervals for a crude rate method are utilized to calculate the upper limit and lower limit values. As given in the Pennsylvania Health Department (2000), the use of confidence intervals in the analysis and presentation of rates increases the value of the study and aptly qualify and guide the results of any study. Ratio gives the proportion between two rates and shows the scale of difference, but not the magnitude. However, ratios are valuable in gathering a basic understanding of the difference between two events or areas and are used alongside rates to describe basic characteristics of two populations. Standard mortality ratio, relative risk, population per hospital bed and populations per physician are the most commonly used ratios and risk ratio is used in this study in the detailed explanation of some age specific and standardized rates.
Age specific analysis
The calculation of age specific rates, confidence intervals and 95 percent significance level was carried out in five categories of sick/not sick of the sample population. They are all male female non-infectious diseases. All male and female categories in
Table4.12 shows the total sample for all diseases. None of the age groups record a significant difference though System C age specific rates are higher than that of home villages. The age group 0 to 14 indicates a ratio of 1 to 2.52 between home villages and System C and all the 15 to 39 age group has a ratio of 1 to 1.86. The other two age groups 40 to 59 and 60 and above have ratios of 1.37 and 1.15 respectively. The difference in ratio of age specific rates between the two areas decreases steadily with increasing age. The all male category in Appendix 6.1 records a significant difference in the 0 to 14 age group and no significance difference is found in the other three ages Table 5.12 States of significance of age specific rates between home villages and System C in the selected age groups Category All males and females Age group 0 – 14 15 – 39 40 – 59 60 and above All males 0 – 14 15 – 39 40 – 59 60 and above All females 0 – 14 15 – 39 40 – 59 60 and above Infectious diseases – all 0 – 14 males an all females 15 – 39 40 – 59 60 and above Non- infectious diseases – 0 – 14 all males and females 15 – 39 40 – 59 60 and above Status of significance Not significant Not significant Not significant Not significant Significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant Significant Not significant Not significant Not significant Not significant Not significant Not significant Not significant
groups. The age group of 60 years and above show a reversal in the age specific rate with a higher rate at home villages (Appendix 6.1). The all female situation fails to record any significant difference in all the age groups (Table 6.12). The infectious disease all male and female category indicate no significant difference between the two areas (Table 6.12), but the age group 15 to 39 has a marginal situation (Appendix 6.1). The age specific rate for the age group 0 to 14 records a ratio of 1 to 4.96 and more than 1 to 2 in all the other age groups between home villages and System C (Appendix 6.1). The non-infectious diseases all made and female category record no significant difference foe any of the age groups and there is only a narrow difference in the age specific rates (Appendix 6.1).
Age adjusted rates
The age-adjusted rates were calculated with the use of total sample population within each age group as the standard population. The standard population and percentage weights used are given in the Table 4.13. The ratio of total sample population to total population of a given age group was used as the weight for each age group. Table 5.13 Standard population and percentage weights used in the calculation of Age –adjusted rates Age group 0 – 14 15 – 39 40 – 59 60 and above Total sample Standard population 316 511 224 92 1143 Weights .28 .45 .19 .08 1.00
The age-adjusted rates revealed a clearer picture of the differences than the age specific analysis between the two study areas (Tables 4.14 to 4.20). The results indicate and confirm the observed difference in disease prevalence foe all the categories except for male and female non-infectious diseases. Further the ratio between age adjusted rates indicates a marked difference in all the categories
other than non infectious diseases, which has more sick values at System C.
Table 5.14 Age adjusted rate for all males and females all diseases sick/not sick crude and adjusted rates per 100 Area Sick n Crude rate 21.8 24.7 Adjusted rate 13.4* 22.8*
Home village 138 632 System C 126 511 * Significant at 95% level
The all male and female category given in Table 4.14, confirms the observations made and preliminary analysis conducted on sickness levels. This agrees with the contemporary research as given in chapters 2 and four and the data sources from Ministry of Health and other national and regional surveys, which record higher rates for resettled area. Further the significant variations shown in the two categories of all male (Table 6.15) and all female (Table 4.16) support the general conclusions made in the macro data and the significant difference recorded in Table 4.14. Table 5.15 Male all diseases sick/not sick crude adjusted rates per 100 Area Home village System C Sick 68 68 n 286 280 Crude rate 23.78 24.46 Adjusted rate 19.32* 26.87*
Table 5.16 Female all disease sick/not sick crude and adjusted rates per 100
Area Home village System C
Sick 70 58
n 346 231
Crude rate 20.23 25.10
Adjusted rate 17.42* 31.18*
The factors responsible for the significant differences are further clarified by the data in Tables 4.17 and 4.18, which show the results for infectious diseases category. Both males and females at System C suffer seriously from infectious diseases and give the two highest ratios recorded in the age adjusted analysis, both in crude rates (4.43 and 2.01) and adjusted rates (4.60 and 2.78). Therefore, it is possible to confirm that the prevalence of infectious diseases can be utilized to identify the marked difference between the two study areas. Further, this significant difference supports the existing relationship between poverty, prevalence of infectious disease and developmental change.
Table 5.17 Male infectious diseases sick/not sick crude and adjusted rates per 100 Area Home village System C Sick 9 39 n 286 280 Crude rate 3.14 13.93 Adjusted rate 2.85* 13.12*
Table 5.18 Female infectious diseases sick/not sick crude and adjusted rates per 100 Area Home village System C Sick 19 31 n 346 280 Crude rate 5.49 11.07 Adjusted rate 5.43* 15.10*
The case of non-infectious diseases (Table 4.19 and 4.20) confirms the demographic and epidemiological profile of the two populations and indicates firmly the presence of non-infectious diseases across age group boundaries, which was indicated in the age specific data. The highest number of cases for non-infectious diseases was recorded in the age group of 15 to 39, with respiratory disease leading. This may be a result of poor housing and low nutrition as indicated by medical research. Table 5.19 Male non-infectious diseases sick/not sick crude and adjusted rates per 100 Area Home village System C Sick 54 29 n 286 280 Crude rate 18.89 10.36 Adjusted rate 15.07 13.75
Table 5.20 Female non-infectious diseases sick/not sick crude and adjusted rates per 100 Area Home village System C Sick 48 27 n 346 280 Crude rate 13.87 9.64 Adjusted rate 14.22 16.16
Therefore, the highest sick ratio at System C are found in the categories of infectious diseases male and female, which confirm the macro data situation and environment risk in the dry zone. The significance identified at age specific level in the category of infectious diseases, all males and females further validate the significant difference in the most vulnerable group as suggested by medical research in Sri Lanka. The results of non-infectious diseases indicate the effect of older population at home villages and agree with wet zone macro morbidity data as explained in chapter 4.
The inability to find a clearer picture at age specific level can be explained as originating from low value of entries and the clearer picture of the age adjusted rates originate from the larger numbers in the calculation of rates. Conclusion In this chapter an attempt was made to study the disease prevalence and its relationship to age and gender, using univariate and bivariate statistics. The results indicate that there is a difference in the disease prevalence between the two areas. However, the difference is not indicative of a clear-cut boundary as expected, but a more complex one as shown in the significant differences recorded in the level of sickness and the distribution of infectious diseases among the males. The two most important facts, which emerge from the analysis, are that, the age adjusted analysis was able to reveal the observed difference in disease prevalence between the two areas and the lack of age specificity can be taken as an indication of the overriding effect of environmental conditions on disease prevalence. Secondly, as explained in chapter two and four the resettled people suffer continuously from the inappropriate economic development strategies and suffer from high prevalence of diseases. The differences given in age-adjusted rates confirm a clear difference between the two areas, which can be linked to the presence of a more disease ridden living environment at System C. Therefore, except for the category non-infectious diseases females, the remaining six categories confirm that there is a significant difference in the disease prevalence between the settlers at System C and their home village sibling families.
Case study on Health and disease – Diganhalmillewa, Anuradhapura district, Sri Lanka A.K.S. Dissanayaka
Diganhalmillawa village is situated 3 kilometres away from Kahatagasdigiliya town. Right turn from Kahatagasdigiliya will take you to the Village. Primary objective is to study the major diseases present and cost of diseases. Secondary objective is to calculate the total cost with travelling and other expenses incurred in the treatment of diseases. A selective sample was taken from our family and family friends. Informal discussions with the respondents and observations carried out for a period of about 2 months were used as data collection methodology. Major diseases present • Heart related complaints and diseases and diabetes were present in the disease scenarios. • Five other diseases are identified in the disease scenario as minor diseases. Data analysis Age and disease sick group is between 22 and 75 years. This is because most of these people are actively engaged in farming and threatened by many elements of weather and other stresses. Further they consume many types of alcohol and engage in smoking. Taking alcohol and smoking is common in the age group of 46 and above (Table 1). Table 1. Age group of the sample Age group Number 0-4 0 5 – 14 1 15 - 21 0 22 - 45 5 46 - 60 9 61 – 75 8 Over 75 0 Source: Dissanayake, (2006) Percentage 0 4.3 0 21.7 39.1 34.7 0
Table 2 Housing House type Number Permanent 22 Temporary 1 Dissanayake, (2006) Percentage 95.6 4.4
Most people live in permanent housing as they are employed and able to build a house of their own (Table 2). Source of water Most people get water from well as well water is of good quality in the area (Table 3). Table 3 Source of water Source of water Number Percent Tube well O 0.0 Well 17 73.9 Tube well and well 6 26.0 Dissanayake, (2006) Use of alcohol and smoking Use of alcohol and smoking among the sample population is generally high which part of the general trend among farmers is. They indicate that drinking alcohol helps them to get rid of body pain after heavy manual labour in the fields. Some drink to forget family problems related to economic and social status. Treatment system
People regularly visit the clinics available in the area. However majority visit the area hospital at Kahatagasdigiliya (Table 4). Table 4 Treatment System Type Number Clinic 13 Hospital 10 Dissanayake, (2006) Use of hospital facilities People use many hospitals in the region and outside the region for treatment. The use of far away hospitals is due to lack of specialist care in the area and sometimes at Anuradhapura (Table 5). Percentage 56.5 43.4
Table 5 Use of hospital facilities Location Kahatagasdigiliya Anuradhapura Kandy Kahagasdigiliya and Anurdhapura Kahatagasdigiliya, Anuradhapura and Kandy number 4 5 0 4 3 Percentage 17.3 21.7 0.0 17.3 13.0
Dissanayake, (2006) Figure 1shows the correlation between distance and cost of treatment. Pearson’s R showed a 0.4581 value and it shows that there is about a 50% chance that when people travel far for treatment their cost on treatment will increase. Further both type of disease and behaviour of the accompanying people are directly related to the increase in cost. If the disease cannot be properly treated within the region patients have to travel far. Further, cost of treatment is increased when the patient has to be accompanied by
helpers as our hospital system is not fully equipped with total patient care (Figure 1). Figure 1 Relationship between distance and cost of disease
Relationship between distance and cost of treatment
20000 15000 Cost 10000 5000 0 0 50 100 150 200 250 Dis tance
Cost of disease in this sample include the transport, food for the patient, medicine not available in the hospital and food and lodging fro the accompanying people.
Findings Major disease recorded is the heart disease, with the presence of diabetes and other minor ailments (Table 6). Table 6 Disease type present Age grou p 0-4 5– 14 15 21 22 45 46 60 61 – 75 Over 75 Percent Disease Pe/1000- Disease one Local – two Region 0 4.3 0 21.7 39.1 34.7 0 0 Fever 0 Heart related Heart related Heart related 0 174 / 188 261 / 188 522 / 188 0 0 3.3 / 382 0 0 Respiratory 130 / 231 Respiratory 174 / 231 Respiratory 130 / 231 0 Pe/1000 Local – Region 0 0 Disease three 0 0 0 Arthalgia Arthalgia 0
Dissanayake, (2006) KEY : Pe/1000 – Prevalence per 1000 Local – prevalence of the locality Region – Resettled people (Seneviratne, 2003) Disease type present reveals many interesting factors. Respondents between 22 and 75 of the study area have higher prevalence ratio for heart related diseases than their counterparts of the region. In a study of prevalence of the same disease of the resettled population of System C
Seneviratne (2003) submits a figure of 188 per 1000 and the prevalence among the age group 61 and 75 is more than twice that of the region. Similar result is shown for Arthalgia in the region. However, the figure for respiratory diseases is lower than of Seneviratne (2003). The following explanations are given, but they cannot be conclusive. 1. there may be a heredity factor or heavy smoking involved in the presence of heart related diseases, as the investigator managed to confirm many cases of the deceased relatives. 2. respiratory disease is lower because of better housing in the area (personal communication from Dr. H.M.M.B. Seneviratne, Supervisor). 3. arthalgia is higher due to weakening from heart related diseases and heavy use of alcohol. Suggestions and Recommendation A detailed investigation on the high presence of heart related diseases should be conducted in the area aimed at presenting a critical analysis. Facilities at Kahatagasdigiliya hospital should be improved for the treatment of heart related diseases and respiratory diseases.
Case study on village water supply situation of the Dry Zone of Sri Lanka, K.S. Karunasena Household water use Thuruwila, Anuradhapura Thuruvila is located in Nachchaduwa Farm Settlement Scheme, Anuradhapura. This is situated in a dry zone area of Sri Lanka.
Primary objective is to study the cost of water at Thuruvila village as ther is no comprehensive plan to supply water to this village. Secondary objective is to study the cost incurred by people of the village to supply them with good quality drinking water and water for other types of water. Methodology utilizes a questionnaire and informal interviews on a selected group of people. Sources of drinking water Drinking water is taken from three types of wells and another group uses the neighbour’s well for their drinking water supply. Well water of the study area are of fairly good quality and people who use neighbour’s well attend to those wells because of the higher water quality in them (Table 1) Table 1 Sources of drinking water Source Public well Tube well Own well Neighbour’s well Karunasena (2006) Source of bathing water Tank, well and tank and canal and tank are the sources of bathing and washing. Tank is used heavily for bathing because it is easily accessible and water in the wells are reserved for drinking and canals run dry soon after rainy season or faming season (Table 2). Table 2 Source of bathing and washing Source Tank Well and tank Canal and tank Number 19 5 6 Percent 63.3 16.66 20.00 Number 8 6 7 9 Percent 26.66 20.00 23.33 30.00
Distance to drinking water Half the number of people travel more than 200 meters and another 33.33 percent travel 100 and 150 meters to get drinking water.83.33 percent have to make an effort to get drinking water ((Table 3). Table 3 Distance to drinking water Distance in No. meters 0-49 4 50-99 1 100-149 2 150-199 8 Over 200 15 Karunasena (2006) Distance to bathing and washing 33.33 percent of the people have to travel more than 500 meters for their bathing and washing purposes (Table 4). Table 4 Distance to bathing and washing Distance in meters 0-99 100-199 200-299 No. 4 5 2 Percent 13.33 16.66 6.66 Percent 13.33 3.33 6.66 26.66 50.00
300-399 3 400-499 6 Over 500 10 Karunasena (2006) Income group
10.00 20.00 33.33
Half the population are in the low income category. The problem of cost of water is a burden to them (Table 5).
Table 5 Income group Income group No (monthly income in Rupees) 0-3999 15 4000-9999 10 Over 10,000 5 Karunasena (2006) Percentage 50.00 33.33 16.66
Figure 1 Relationship between income and spending on water
Karunasena (2006) There is a positive relationship between cost and income Table 6 Distance –cost relationship/ Drinking water – cost per year in Rupees Distance Number in meters Mode of transport / total cost per year in rupees Bicycle Motor Other bicycle machinery 1450 1625 9375 2875 9843
0-99 9 100-199 11 200 and 5 over Karunasena (2006) * no cost of transport was calculated for people on foot
In the collection of drinking water, cost increases with the distance to source. Mechanical power is used by people who travel far to water source (Table 6). Table 7 Distance –cost relationship/ Bathing and washing – cost per year in Rupees Distance Number in meters Mode of transport / total cost per year in rupees Bicycle Motor Other bicycle machinery 2250 2750 12187 8750 3375 15000 20,625
0-99 5 100-199 7 200 and 7 over Karunasena (2006)
Cost of traveling to bathing and washing is increased as the distance to source is increased. Other vehicles used by the higher income group are vans, tractors etc (Table 7). Income level and expenditure on water has a Pearson’s correlation of .6696, which is a high positive situation. This is because the increase in income leads to an increase in water requirement Findings It is clear that spending on water is hidden and not easily counted, but it is an important factor in the reduction of real income. Villagers undergo many difficulties due to water scarcity. In addition time waste and stress created by water shortage is also an important social factor. Recommendations There should be a proper water supply in the village which will reduce their spending and may increase their capital and monetary situation. Proper water supply will reduce time waste and stress. So far there is no proper plan, but there should be one
Case studies from North Central province Renal failure ( Chandrasekara, T. ,2006, Final Year Dissertation, Department of Social Sciences) Impairment or loss of kidney function is called kidney failure and the medical terminology for such condition is RENAL FAILURE. Renal Failure is of two kinds: Acute and Chronic. Acute Renal Failure ( ARF) is a result of poisoning and other traumatic conditions. The origin of Chronic Renal Failure (CRF) and its relationship to environmental factors is still a mystery in medical science.
This thesis is centred on a study of Chronic Renal Failure, which is reported into the clinics and hospitals in the study region. In addition CRF is believed to be preventable and it is the aim of the researcher to find out spatial relationship between the disease and many other environmental or other factor (life style, poverty), may be connected to the disease as shown in the field study. At present CRF is a troublesome disease in the Sri Lanka. The number and the ratio of such patients reported in North Central Province (NCP) are very much higher compared to other district. Table: - 1 Number of Cases/ Deaths of CRF in Sri Lanka Colom bo C/D 1983/ 316 1133/ 338 1060/ 303 1069/ 301 882/2 74 Mata Kuruneg le ala C/D C/D 19/4 27/3 51/6 70/4 141/ 11 254/27 352/105 447/125 461/120 305/57 Puttal am C/D 18/2 44/7 73/9 85/12 75/10 Anuradha pura C/D Polonn a ruwa C/D Sri Lanka C/D 5475/8 70 4827/9 92 5526/1 042 6194/1 095 5841/1 035
Renal Failur e 1996 1997 1998 1999 2000
745/136 176/31 746/119 283/28 1102/138 288/51 1267/167 341/47 1354/202 345/39
Source :- Regional Health Educational Department- Anuradhapura. In 1996, 16.8% of the total kidney patients in Sri Lanka were from NCP. The percentage morbidity increased to 29% in year 2000. High incidence, prevalence, and high mortality due to Renal Failure have been identified in the NCP in recent past. Having identified this issue recent media report have highlighted that alarmingly high
incidence of Renal Disease in certain clusters of geographical areas of the province mainly district secretary areas of Madawachchiya, Padaviya, Nuwaragampalatha Central (NPC), Galenbidunuwewa, Wilachchiya, Kahatagasdigiliya etc. may be related unidentified causes and environmental factors. Table :- 1:2- CRF Admission Villages Padaviya Madawachchiya Nuwaragampalatha(NPE ) Nuwaragampalatha(NP C) Nochchiyagama Out side Anuradhapura Talawa Galenbidunuwewa Wilachchiya Kabithigollewa Horowpathana Kahatagasdigiliya Rabawa Thirappane Kakirawa Mihinthale Rajanganaya Ipalogama Tabuthtegama Palgala Galnewa Percentage 50 (17%) 32 (11%) 27 (10%) 24 (9% ) 24 (8% ) 19 18 17 14 13 13 12 11 10 09 08 08 04 03 02 02
Source :- Regional Health Educational Department- Anuradhapura. There was large number of deaths in the Madawachchiya area in the recent past due to CRF. In addition large number of kidney patients who reported first to government hospital in
Madawachchiya were also transferred to the Anuradhapura, Kandy and Colombo (General) hospitals. The only way of identify this disease is a urine test. At this test they identify protein is mixed with urine. However it is difficult to identify the symptoms of the disease in its early stage as continuous health monitoring is absent in Sri Lanka. When finally it is identified for many it is too late as their failure rate has reached 40%-60% levels. The cause of Renal Failure is not fully established though the diabetes and Hypertension are related and identified as two main causes of renal disease in other countries. But these two diseases are not commonly associated with the patients admitted to Kandy hospital and a substantial proportion of patients (21%) have come from the NCP of Sri Lanka. They realized that 60% of the attendance did not have a proper causative factor for the RF. On the basis of this information Divisional level kidney protection committees were established at district secretary areas of Medawachchiya, Padaviya and provincial council has established a Provincial Renal disease protection in Anuradhapura and Polonnaruwa Districts. Renal disease management and research center at provincial Hospital Anuradapura with collaboration of the Kandy Kidney Foundation has been inaugurated recently. A base line survey to identify the presence of renal disease, in a community of apparently healthy individuals in randomly selected 4 villages in Medawachchiya are carried out by a study group of University of Peradeniya and Kandy renal unit, shows that there is a prevalence of 3.7% RF positive cases in early stages. They have identified 150 kidney patients out of 4059 total populations in 4 villages of Mahadiulwewa, Puhudiula, Thammannealawaka, Yakawewa. The Madawachchiya renal center was started in July 2003 .At percent there are 857 Kidney patients and temporary patients are 256 in the area. At the moment there are 51 villages of kidney patients Medawachchiya area. This is a problem which requires detailed investigation.
Data Presentation and Analysis The objective of this chapter is collected data and information are presented using presentation tools such as tables, charts, graphs. Primary data analysis According to the data obtained from the questionnaires the following table are prepared to as certain the necessary information , which are related to the relevant objective of the study. According to the data obtain from medical registration book in Medawachchiya renal Care And Research Center (RCR). Researcher obtain 150 patients out of total 857. As reveal by the table 3:3:1 majority are male of the patients. It is 87 out of totally 150. female are 63 of the total (Table 3.31) Age Group Male Female 0-10 3 3 11-20 7 12 21-30 4 11 31-40 4 8 41-50 21 8 51-60 24 9 61-70 14 8 71-80 7 3 80< 3 1 Total 87 63
Table 3:3:2 aging group Age Group <30 30 -60 60< Total Male 14 49 24 87 Female 26 25 12 63
According to the above table 4:1:2 the highest patients are from the aging group between “30-60” and it is 49 male out of 87.Female are from the aging group between <30.Which It is 26 patient Table : Age distribution – Ward admission due to CRF- Year 2003 Age No of patients 10-19 01 20-29 03 38 30-39 24 40-49 43 50-59 77 188 60-69 68 70-79 68 80< 12 80 Total Source : Regional Health Educational Department As given by the table Majority kidney patients are aging group between 30-69. It is highest range according to above data. There are some reasons for this statement. - Range of labor force are between 30-60 years. - Cultivation are main Ex- majority are farmers Table : Admission due to CRF, Year 2003 General Hospital Anuradhapura
Sex No of Patients Percentage (%) Male 250 74.8 Female 84 25.1 Total 334 99.9 Source : Regional Health Educational Department According to the above table 250 patients are male. 84 kidney patients are female. Through this majority are male. Several reasons affect for this situation. - Male are employed then female . Example- For cultivation - Male use Drugs According to the data obtain from medical registration book in Medawachchiya renal Care And Research Center (RCR). Researcher obtain 150 patients out of total 857. Table 4:1:1 The sample classification according to the sexuality in Medawachchiya. Sexuality Male Female Total Percentage of patients (%) 60 40 100
As reveal by the above table 4.1.1 ,the majority of the patients are male. It is 60% out of the total. And 40% out of the total are female
Table 4:1:2 Sample classification according to the Age group in Medawachchiya area. Age group 30> 30-60 60< Total Percentage (%) 15 65 20 100
As revealed by the above table, the highest percentage of patients from aging group between 30-60. It is 65% out of the total. 15% of patient than 30 years. There are 20% of patients more than 60 years. Table 4.1.3 level. Sample classification according to the Educational Educational level Primary O/L A/L Degree Diploma Professional Total Percentage of patients (%) 72 18 10 100
The above table shows the educational level of patients in Medawachchiya area . As reveal by table the majority of patients are primary level. It is 72% out of total.18% of patients have O/L.10% have Advance Level. But There are no Degree, diploma and professional level patients Table 4.1.4. Employment The sample classification according to the Percentage of patients (%) 88 10 02 100
Employment Farming Businessmen Private sector Government sector Total
The above table indicates the employment of patients. As reveal by the table the majority of patients are farmers. It is 88% out
of the total. 2% patients are government sector. 10% patients are privet sector. There are no others.
Table 4.1.5 The sample classification according to the income level Income level 3000> 3000-5000 5000-7000 7000-9000 9000< Total Percentage of patients (%) 80 06 04 100
The above data was received from the questions based on income level of patients. According to the table 80% patients are income and rang of less Rs.3000. And also 6% of patients are in the rang of 3000-5000. 4% patients are in the income range of Rs 5000-7000 . Assessment of the living Environment that affect the patients The objective of these question was to understand what are the most influence factors of kidney failure that affect to kidney patients in medawachchiya area. Table 4:2:1 Chemical uses Response level Yes No Total Percentage (%) 96 04 100
The above data was received from the question based on chemical use of patients for their cultivation. According to the above table
96% patients used chemical for their cultivation. 4 % patients are rejected it. They don’t use chemical for their cultivation. Table 4:2:2 Drinking water Statemen t Yes No Total Past (%) 10 90 100 Present (%) 60 40 100
The above data was received from the questions based on drinking water of faddy field. According to the above table 90% patients say that , they dinked water from faddy field in the past. 10% Patients say that , they didn’t drink water of faddy in the past. But in the present 60% 0f patients drink water 40% of patients don’t drink in the faddy fields.
Table4.2.3 Cooking Vessels Vessels Aluminum vessel Clay vessels Total Past 90 10 100 Percentage(%) 20 80 100
According to the above table 90% patients used aluminum vessels in past for their cooking purposes. It was the highest of the total. But 10% patients used clay vessels in past. It is very lower percentage. But 20% patients used aluminum vessels and 80% patients used clay at present for their cooking purposes. Table 4:2:4 Water supply Source of water Percentage (%)
Pipe Tube Well- Protected Well Non Protected Well Total
16 80 04 100
As shown by the table 4:2:4, 80% of patients get water from Tube well or protected well. 16% of patients from pipe. Some patients get water from non protected well as river, lake and stream. It is 4% out of total. Table 4:2:5 Drinking Boiled water Response Yes No Total Percentage (%) 10 90 100
These question about boiling water. According to the above table 4:2:5,10% patients say that, they drink boiled water. But 90% patients say that, they don’t it. Table 4:2:6 Drinking filtered water Response Yes No Total Past (%) 10 90 100 Present (%) 60 40 100
The above data was received from the question based on filtered water for drink. According to the above table 10% kidney patients dinked filtered water and 40% don’t dinked filtered water in past. At present 60% patients drink filtered . But 40% patients don’t drink filtered water yet.
Table 4:2:7 Instrument for Filtering
Instrument Filter Cloths Other Total
Percentage (%) 20 70 10 100
These data include about use of instrument for water filtering. According to the above table 20% patients use filter for filtering water. 70% patients use cloths for water filtering. 10% patients use other instrument like ……………… Table 4:2:8 Use of Drugs Drugs Hard Drugs Alcohol Total Legal (%) 6.66 6.66 Illegal (%) 6.66 66.66 73.32
This is composite sample. male patients used drugs both legal and illegal drugs. According to above data, 6.66 per cent male patients used illegal hard drugs . But male patients didn’t use legal hard drugs. 6.66 percent male patients used legal Alcohol and 66.6 percent used illegal Alcohol. 86.66 percent male patients smoking. Smoking is higher than use of other drugs. Table 4:2:9 Use of Birth Control Statement Yes No Total Percentage (%) 20 80 100
These data obtained from women only. According to above data 20% Kidney patients of women use birth control. 80% Patients of women don’t use birth control.
Table 4:2:10 Use of meat Statement Yes No Total Past (%) 84 16 100 Present (%) 10 90 100
As reveal data based on use of meat for their meals. As shown by the table 84% kidney patients used meat for their foods and 16% kidney patients didn’t use meat in the past. At present 90% kidney patients don’t use meat for their meals. But !0% kidney patients use meat now a days. Table 4:2:11 Other Patients in their family Statement Yes No Total Percentage (%) 20 80 100
According to the above table 20% patients have other kidney patients in their family. But 80% patients haven’t other kidney patients in their family. Table 4:2:12 Relationship among Kidney patients Relationship Father Mother Brother Sister Grand Mother Grand Father Total Percentage (%) 30 20 15 05 10 20 100
These data include relationship among patients .If there are kidney patients in their family what are the relationship among patients. As reveal by the above table 30% other kidney patients are fathers. 20% are mothers. 15% are brothers. 5% are sisters. 10% are grand mothers. 20% grand fathers. Table 4:2:13 Morbidity Relatio High ns relea se of urine in to the night Husba 37 nd Wife 24 Childr 06 en1 02 2 Others 04 1 05 2 Total 78 Table 4:2:14 Other Diseases Statement Yes No Total Statement 80 20 100 Low freque ncy of urinati on. 38 23 05 03 05 05 79 Prot Arthal ein gia in urine at test 34 23 05 01 03 04 70 38 24 05 02 08 10 87 Swelli ng at ankle and face 36 26 06 03 06 07 84
According to above table,80% of patients say that ,they have other diseases in addition to that Renal Failure.20% patients say that, they haven’t other diseases. Table 3:2:6 Other Diseases Diseases Diabetics Hypertension Others Total Percentage (%) 45 40 15 100
As indicate in the table,45% of patients have Diabetics ,40% of patients have Hypertension in addition to Renal Failure out of total 100%. And also 15% patients have other diseases . Table 4:2:7 Treatment Treatment Medical treatment Dialysis Kidney transplantation Total Percentage (%) 90 10 100
As shown by the above table 3:3:7 majority of the patients are getting medical treatment . There are 90% patients out of total.10% patients are getting dialysis. There are no patients of kidney transplantation. Table 4:2:8 Medical Facilities Statement Yes No Total Percentage (%) 100 100
As reveal by the above table, 100% patients also agree with facilities are not enough for kidney patients of kidney failure. 4:3 Secondary data Presentation Table 4:3:1 Live Discharges and death – Anuradhapura. Year 1993 1994 1995 1996 1997 1998 1999 2000 2001 Total Live Discharge 377 479 525 484 396 634 698 703 856 5152 Death 52 65 79 131 113 132 149 188 184 1091 Ratio 1:7 1:7 1:6 1:3 1:3 1:4 1:4 1:3 1:4 1:5 Percentage 13.8 13.6 15.0 27.1 28.5 20.8 21.3 26.7 21.5 21.2
Source: Regional Health Educational Department According to the above table 377 kidney patients was live discharge and 52 death in year 1993. It is 1:7 ratio and 13.8 percentage. In year 1996, 484 kidney patients was live discharge and 131 death. The ratio was 1:3 and percentage 27.1. In Year 1999, total live discharge patients was 698 and total death was 149. The ratio and percentage was 1:4 and 21.3. In year 2001 live discharge kidney patients was 856 and death was 184. Ratio and Percentage between live discharge and death was 1:4 and 21.5%. Conclusion and Recommendations Conclusion The major purpose of this study is identify major reasons of Chronic Renal Failure . It is very difficult to identify reasons from one patients. There fore it has
been chosen randomly 50 patients and 150 registration patients in 4 villages of medawachchiya area, and also according to some select factors researcher identify reasons for Chronic Renal Failure. But all factors are here consider hypothesis. Majority of this disease male patients are higher than female. According to the age the higher amount can be seen between age 30-60 , among these patients males are high. In this range those people suffering from such disease are belong to working carder. When we consider education level of this patients they are very low grade. They don’t have enough education facilities to obtain higher education. Majority of them have only primary education. When consider their economic condition majority of them are in low income rate. These people are leading hand to mouth live. As occupation they do farming, their working hard. The main features of dieses appear at the last , until them they do work hard having not known about the disease . The only experiment to identify this disease is urine text . But even these poor people they don’t have enough capacity to under go this text. Because their main goal of the life is directed to toward to another problem. When consider fluoride contain in the water it is higher in dry zone than wet zone. Using this water and using aluminum vessel without proper advice of MOH or any other government agencies . It may be cause to increase this disease .If patients have reduce using aluminum vessel today, it was very high in the past.
As people don’t have good health life there suffering from diabetic ,hypertension may be cause to increase this dieses . 75% of Chronic Renal Failure patients suffering from such dieses . Therefore we can gust above dieses can be provided base for this dieses. Chronic Renal Failure treatments are very expensive. People in this area can’t reach this treatment. Because these people are very poor.
Recommendations According to the research information the researcher is identify the following suggestion. At least twice a year the urine test should be done. The only way of identify this disease is urine test. At this test they identify protein is mix with urine. stage of the beginning the symptoms of the diseases don’t identify . But at the last when identify diseases 40%60% of kidney are failure. Using a pure water in high amount in every day. Using a protective methods when going to use pesticides. Good health habits. Protect from snake bites. Awareness programmers. Ex- Heath and community medicines Government involvement should be higher condition .
Using organic foods Rain water harvesting. Stop using aluminum vessel.
Health and disease – diganhalmillewa, Anuradhapura district, Sri lanka Diganhalmillawa village is situated 3 kilometers away from Kahatagasdigiliya town. Right turn from Kahatagasdigiliya will take you to the Village. Primary objective is to study the major diseases present and cost of diseases. Secondary objective is to calculate the total cost with traveling and other expenses incurred in the treatment of diseases. A selective sample was taken from our family and family friends. Informal discussions with the respondents and observations carried out for a period of about 2 months were used as data collection methodology. Major diseases present • Heart related complaints and diseases and diabetes were present in the disease scenarios. • Five other diseases are identified in the disease scenario as minor diseases. Data analysis
AGE AND DISEASE sick group is between 22 and 75 years. This is because most of these people are actively engaged in farming and threatened by many elements of weather and other stresses. Further they consume many types of alcohol and engage in smoking. Taking alcohol and smoking is common in the age group of 46 and above. Table 1. Age group of the sample Age group Number 0-4 0 5 – 14 1 15 - 21 0 22 - 45 5 46 - 60 9 61 – 75 8 Over 75 0 Source: Dissanayake, (2006) Table 2 Housing House type Permanent Temporary Number 22 1 Percentage 95.6 4.4 Percentage 0 4.3 0 21.7 39.1 34.7 0
Most people livein permanent housing as they are employed. Source of water Most people get water from well as well water is of good quality in the area (Table 3). Table 3 Source of water Source of water Tube well Well Number O 17 Percent 0.0 73.9
Tube well and well
Use of alcohol and smoking Use of alcohol and smoking among the sample population is generally high which is part of the general trend among farmers. They indicate that drinking alcohol helps them to get rid of body pain after heavy manual labour in the fields. Some drink to forget family problems related to economic and social status. Treatment system People regularly visit the clinics available in the area. However majority visit the area hospital at Kahatagasdigiliya (Table 4). Table 4 Treatment System Type Number Clinic 13 Hospital 10 Use of hospital facilities People use many hospitals in the region and outside the region for treatment. The use of far away hospitals is due to lack of specialist care in the area and sometimes at Anuradhapura. Table 5 Use of hospital facilities Location Kahatagasdigiliya Anuradhapura Kandy Kahagasdigiliya and Anurdhapura Kahatagasdigiliya, Anuradhapura and Kandy number 4 5 0 4 3 Percentage 17.3 21.7 0.0 17.3 13.0 Percentage 56.5 43.4
Figure 1shows the correlation between distance and cost of treatment. Pearson’s R showed a 0.4581 value and it shows that there is about a 50% chance that when people travel far for treatment their cost on treatment will increase. Further both type of disease and behaviour of the accompanying people are directly related to the increase in cost. If the disease cannot be properly treated within the region patients have to travel far. Further, cost of treatment is increased when the patient has to be accompanied by helpers as our hospital system is not fully equipped with total patient care. Figure 1 Relationship between distance and cost of disease
Relationship between distance and cost of treatment
20000 15000 Cost 10000 5000 0 0 50 100 150 200 250 Distance
Cost of disease in this sample include the transport, food for the patient, medicine not available in the hospital and food and lodging fro the accompanying people.
Findings Major disease recorded is the heart disease, with the presence of diabetes and other minor ailments. Disease type present Ag Per Dis e cent ease gro one up 04 5– 14 15 21 22 45 46 60 0 4.3 0 21. 7 39. 1 0 Fev er 0 Hea rt relat ed Hea rt relat ed Pe/1 000Loca l– Regi on 0 3.3 / 382 Diseas Pe/1 e two 000Loca l– Regi on 0 0 0 0 174 / Respir 188 atory 261 / Respir 188 atory 0 Dise ase three Pe/1 000Loca l– Regi on 0 0 0 0
130 / 0 231 174 / Arth 231 algia
86 / 19
61 – 75 Ov er 75
34. 7 0
Hea 522 / Respir rt 188 atory relat ed 0 0
130 / Arth 231 algia 0
43 / 19
KEY : Pe/1000 – Prevalence per 1000 Local – prevalence of the locality Region – Resettled people (Seneviratne, 2003) Disease type present reveals many interesting factors. Respondents between 22 and 75 of the study area have higher prevalence ratio for heart related diseases than their counterparts of the region. In a study of prevalence of the same disease of the resettled population of System C Seneviratne (2003) submits a figure of 188 per 1000 and the prevalence among the age group 61 and 75 is more than twice that of the region. Similar result is shown for Arthalgia in the region. However, the figure for respiratory diseases is lower than of Seneviratne (2003). The following explanations are given, but they cannot be conclusive. 4. there may be a heredity factor or heavy smoking involved in the presence of heart related diseases, as the investigator managed to confirm many cases of the deceased relatives. 5. respiratory disease is lower because of better housing in the area (personal communication from Dr. H.M.M.B. Seneviratne, Supervisor). 6. arthalgia is higher due to weakening from heart related diseases and heavy use of alcohol.
Suggestions and Recommendation A detailed investigation on the high presence of heart related diseases should be conducted in the area aimed at presenting a critical analysis. Facilities at Kahatagasdigiliya hospital should be improved for the treatment of heart related diseases and respiratory diseases.
Traditional medicine – Case study
Banda Seneviratne: Traditional Belief System of Health A comparative study of the traditional health services of a new farm settlement (Mahaweli System C) and its respective home villages, Sri Lanka. The article was edited and brought on-line by Tormod Kinnes. Contents 1. Introduction 2. Service System 1. Traditional Health Service System 2. Ayurveda Health Service System 3. Systems of Treatment 1. Preventive Care - Home Remedies 2. Curative Care 4. Conclusion 5. Appendices 6. Works Cited Traditional Belief System of Health:
A comparative study of the traditional health services of a new farm settlement (Mahaweli System C) and its respective home villages, Sri Lanka
1 Introduction THE TRADITIONAL belief system of health in Sri Lanka consists of many types of treatment systems, but in this study only two major components, namely traditional medicine and Ayurvedic medicine, will be used. They will be called the indigenous health service system in this study. Records on the history of traditional medicine go back to the beginning of civilisation in Sri Lanka. Evidence reveals there was a well organised medicare system with hospitals, rest homes, herb gardens and conserved forests of medicinal trees and shrubs located in various parts of the island. These are well recorded in various inscriptions and chronicles. (Paranavithana, 1959; Senadheera, 1970 and Kumarasingha, 1982).
Today the glory of this system has been subdued by the Western medical system based on the European tradition with the help of the multinational pharmaceutical industry. Though the majority of the populace uses Western medicine in curing many of their diseases, traditional medicinal mixtures are very much used in all types of communities in Sri Lanka, where a pluralistic medicare system has been used for a long period, as told above. Two major sub-systems can be identified in the traditional medicine:
Beliefs and rituals A system based on many beliefs such as deities, telepathy, sound, herbs etc. The deity (God) is at the centre of this treatment system where an edura (faith healer) becoming the messenger between the deity and the patient. The treatment process involves either a full ritual with a sacrifice or a promise to the deity of an offering or a ritual and an herbal treatment. A full ritual programme is composed of offerings, sacrifices and chanting, which is mainly used in the treatment of mental disorders and spiritually-caused sicknesses resulting from shock and depression. Ritual and herbal treatment are used in the treatment of many other sicknesses and diseases, especially communicable diseases like chicken pox, measles and mumps. In the treatment of these traditional infectious diseases, the patient is strictly forbidden to ingest any animal product, is kept in a dark room without any exposure to direct sunlight, and given many herbal mixtures. The faith healer (endure) is called for to chant verses. Finally a promise will be made to make offerings at the nearest shrine of the goddess Paththini and to give alms to seven or more women devoted to the worship of goddess Paththini. Herbal medicine
A system based on herbal medicine and traditional medical practitioners who live in the villages and practise according to their specialities (Jayasekara, 1957; 1981 Sisirakumara, 1991 and Ambatalawa, 1994). There is very little written knowledge and the practice is considered a family tradition and is normally given only to male members of the family. Herbal medicine in the form of mixtures, pastes and oils are used in the treatment along with strict dietary control. However, in recent times the influence of Ayurveda has made these practitioners use some Ayurvedic medicine in their practise (Gnanawimala, 1950; Senadheera, 1970; Ramanayaka et al, 1985 and Ambatalawa, 1994). Ayurveda is of Vedic origin and believed to have originated in the second millennium BC, probably in the land between present-day Pakistan and Iran (Kumarasingha, 1981). The traditions and teachings of Ayurveda entered Sri Lanka with the arrival of Aryans and developed steadily through continuous contact between India and Sri Lanka. Since its establishment in Sri Lanka, Ayurveda and traditional medicine were practised together probably with the same patronage, but seeking the higher level of Ayurveda when needed. In the civilisation of early Anuradhapura period the physician was considered as an important professional. During this period a notable feature of civilisation was the importance attached to the establishment and maintenance of hospitals for the treatment of sick. Among kings of ancient Sri Lanka King Buddhadasa (circa 337-365 B.C) was reputed to be a skilful physician and have appointed a physician for every ten villages. (Paranavitana, 1959). This tradition continued throughout the ancient and modern history and by the time of arrival of Western medicine there was a well established health care delivery system in Sri Lanka (Ramanayake, 1985). Antibiotics are not mentioned in the Ayurvedic medical literature, but some of the mixtures used in are definitely antibiotic in nature (Silva, 1991). Indigenous medicine was considered weaker by the Western educated and urban populace with the introduction of Western medicine in Sri Lanka, but British rulers knew of the value of herbs and kept the traditional medicine under observation and control.
However the dedication of few highly qualified specialists, managed to save the core of the traditional and Ayurvedic medicine (Gnanawimala, 1950). The continuing struggle of the organised group of activists was successful in the establishment of the Department of Indigenous Medicine even before independence (Ramanayaka, 1985). Establishment of Ministry of Indigenous Medicine, Institute of Teaching and Research in Indigenous Medicine and registration of indigenous medical practitioners have enhanced the value of traditional and Ayurvedic medicine among the local populace and foreigners. Today it is estimated that more than 40 percent of the total out patients registered daily, use indigenous medicine related services and among poor the percentage may be as high as 60 percent (Kannangara, 1962). Inability of the Western system to provide a proper health care service, and fear of side-effects from many types of Western drugs have driven even many Western educated and people of Western origin away from Western medicine in the past decade. As noted in the survey Siddhalepa, this is a traditional medicinal preparation, used as a painkiller and pain reliever has more sales than the combined sales of similar medications of Western origin. Therefore, today the traditional medicine and its impact are higher than in any other time in the modern history of Sri Lanka. Indigenous medicine has been and will be the most important health service system at first referral level for most of the poor until their economic status is elevated and for the rest of the richer classes it is to be used in the times of special need. Recent modernisation of herbal preparations have actually led to an increase in popularity of indigenous medicine and associated treatment systems (Ekanayake et al, 1989). The main objective of this study is to carry out a comparative study of the importance of indigenous health service system in a new frontier farm settlement (Mahaweli System 'C' - established in 1981-1987) and their respective old established home villages. It is clear that indigenous health service system plays a vital role in the health status of respondents as they depend heavily on it for most of the ordinary cases of ill health. The evolution of indigenous health system in the study areas and its impact on the health status is studied under the sub topics of preventive and curative health care. The home villages are located in Badulla, Teldeniya, Ratnapura,
Mawanella, Yatiyantota, Mirigama and Nikeweratiya, which belong to the traditionally developed wet zone of Sri Lanka. The villages of the new settlement (Nuwaragala, Paludeniya, Mudungama, Ridee ela, Rathmalkandura, Sandamadulla and Belaganwewa) are located in the dry zone which was opened to development between 1981 and 1987, under the Mahaweli Development programme. Service System Indigenous health services are located and developed in association with the growth of a settlement by its operators and very rarely they are established by the government under a programme of health care delivery. This is basically a result of choice of people and preference of authorities to keep Western medical services as the major form of outpatient treatment, because inability of the indigenous medical services to provide a universal health care and universal acceptance of the Western health care as the modern scientific system of health care (Table 1).
Table 1: Types of Practitioners in the Indigenous health services (percent)
Type of Practitioner Local Ayurvedic physician Local Ayurvedic Dispensary Renown specialist Ayurvedic Hospital Traditional Physician 'Edura' * Mahaweli System C 56 13 00 00 13 18 Home villages 21 14 06 01 45 13
*'Faith healer' Source: Field Data Resource inequality is consistently found within developing countries, especially in terms of health service facilities. In Sri Lanka urban areas have more health resources than rural areas as in any other developing country (Navarro, 1994). This is basically a result of the existing distribution of goods and services, which are
often controlled by the age of settlement. Old established settlements of home villages have a well-established health service resource system than new settlements of Mahaweli System 'C'. The Chi square value of 71.4 with five degrees of freedom confirms well the existing difference between the two areas, which is significant at 99.9 percent level. 2.1 Traditional Health Service System The distribution of traditional health services available to Mahaweli System C settlers is shown in Table 2. 'Edura' and traditional medical practitioner in Mahaweli System C area are farmers by occupation but practise their medical service as a part time occupation. Ayurvedic physicians have come from outside the resettlement area and have established their clinics in town centres at Girandurukotte, Lihiniyagama and Siripura. Government dispensaries of the Ministry of Indigenous Medicine are located at Girandurukotte and Lihiniyagama, which are patronised by a few. These services are skeletal and seasonal in nature as some of the 'eduras' and traditional practitioners travel to home villages during the dry season periods and no specialities are available other than for simple fractures. For all the other requirements in the traditional health services, the respondents travel to Mahiyangana, Kandy or their hometowns. Therefore service status is still in its infancy as common to any newly settled area in Sri Lanka. Traditional health services are at an advanced level of operation in home villages with all types of facilities available to the user. On the basis of number of contacts made by respondents there are nine times more facilities at home villages than in Mahaweli System C (Table 3). Ratnapura, Mirigama and Mawanella recorded the highest percentage of units, which could be explained by the existence of highly developed local traditions in these areas. Rest has low density of practitioners and service units, mainly due to distant location from well known traditions in indigenous medicine.
Table 2: Number of indigenous health service system operators in Mahaweli System C
Mahaweli Government Edura Traditional Ayurveda
System C village Belaganwewa
Dispensary 2 1 0 1 1 1 1
practitioner Physician 1 2 0 0 1 0 1 1 (Lihiniyagama) 1 (Girandurukotte) 0 0 1 (Siripura) 1 (Siripura) 1 (Siripura)
1 (Lihiniyagama) 1 Sandamadulla (Girandurukotte) Redeeela 0 Rathmalkandura 0 Mudungama 0 Paludeniya 0 Nuwaragala 0 Source: Field Data
Table 3: Number of indigenous health service system operators in home villages
Home Village Ayurvedic Government Renowned Ayurvedic Traditional Physician Ayurvedic specialist hospital practitioner dispensary Badulla 5 2 1 0 3 Teldeniya 3 0 0 0 5 Ratnapura 8 5 2 1 10 Mawanella 9 3 2 0 16 Yatiyantota 4 0 0 0 4 Mirigama 11 3 3 1 33 Nikaweratiya 2 0 0 0 6 Source: Field Data Kinship connections inherited practices and the level of modernity of the people always affect location of indigenous health services. Edura
2 3 5 2 3 10 3
Normally, indigenous medical practitioners tended to concentrate in the older, higher density residential areas and also in the urban areas, where Western health care system cannot cope with the demand fully. Further, the specialist traditions, government policies and political influences can lead to the concentration of facilities in certain selected areas than in the rest. Mirigama, Ratnapura and Mawanella have large number of indigenous health service units due to their association with one or many of the above mentioned factors. The pattern emerging from the data given in Table 2, show the availability of more facilities in old units such as Belaganwewa and Sandamadulla compared to the rest, which were settled later. These patterns were identified by Navarro, (1974) and Ramesh and Hyma, (1981) in Latin America and India respectively. 2.2 Ayurveda Health Service System The Ayurveda system is a very important element in health care delivery system of Sri Lanka, but its spatial distribution may vary from one area to the other as it operates mainly through private clinics and dispensaries. In addition the existence of some notable Ayurvedic doctor family traditions have influenced the distribution pattern of these services. Most clinics and dispensaries are located in the house of the practitioner with a branch at the town centre. Graduates of College of Indigenous Medicine and Ayurveda specialists of Gampaha, Keraminiya and Sabaragamuwa traditions are the major operators identified in the study areas. Most of the practitioners used a mixture of both Ayurveda and Western as it is practised in Sri Lanka today, but the use of Western drugs is limited to use of antibiotics at emergencies and some general pain killers. 3.0 Systems of Treatment Indigenous medicine is based on herbal mixtures and different types of 'power' sources. Comprised mainly of the local physician and the spiritual healer, the traditional treatment system is a mixture of many ancient systems of treatment, which is taught to the apprentice only on the basis of inheritance or friendship. Sometimes a document or a narration will give the basic elements of the
treatment and today the materials required for treatment are partially obtained from gathering and mostly from a drug manufacturer (Wanninayaka, 1982). The two variants of the treatment system, the preventive and curative care are identified here for a detailed investigation. 3.1 Preventive Care - Home Remedies Home Remedies are mandatory in preventive care in both traditional and Ayurvedic medicine. They appear in many forms and are used concurrently with all types of medicine as an aid or activator for the main course of treatment. Knowledge of the home remedies is normally transferred by hearsay from one generation to the other and is preserved in the minds of family elders who become the major agents of preventive medicine in the indigenous medical care system. In recent times the commercial scale production of home remedies has led to a much wider use of them by all the respondents in all of the study areas (Table 4). Today ingredients for most of the home remedies are either bought from the shop or obtained from the Ayurvedic practitioners as the technique of growing of medicinal plants and herbs has been destroyed or pollution has restricted the growth of them to few areas of the country. Modernisation and commercialisation of traditional and Ayurvedic medicine in the recent past have produced packed instant drinks and mixtures which are used freely as home remedies by almost everybody. Samahan, Peyawa, Kasaya Pack and Siddhalepa are the trade names available in any part of the country at any time and heavily used as remedies for all types of ailments and sicknesses. Regular use of home remedies is an integral part of life among rural poor, especially for minor ailments, cold, running nose, sprains, arthalgia and arthritis. Some home remedies are even taken as food in the form of porridge, vegetable and food-drink. It is the belief of the respondent that taken at the precise time and adhered to advice most sicknesses can be controlled successfully if not totally by the use of home remedies. Therefore most of the respondents have used home remedies when needed than on a regular basis.
Table 4: Use of Home Remedies
Commercially available home remedy Samahan Peyawa Siddhalepa Oils Arishta Pastes Kasaya packets Source: Field Data Mahaweli System C 100 85 65 36 20 13 84 Home villages 100 100 82 49 35 22 94
3.2 Curative Care MAHAWELI System 'C' respondents have used indigenous medicine for 13 different types of diseases and sicknesses including fractures and general weakness. 94 percent of the time this treatment was carried out by the specialist at home villages and locally available practitioners or specialists at Mahiyangana, Polonnaruwa or Kandy attended to the rest. At home villages 40 percent of the respondents went for treatment at the indigenous medical practitioner for six major sicknesses and diseases. Fractures, general weakness, disability, paralysis, arthritis and skin rash were treated by these practitioners successfully and in all other cases they were used as first referral level or helpers (Table 5). The ability to treat fractures by the indigenous medical services has been noted even by Western biomedical treatment system. Four patients
with fractures were advised by their Western doctors to obtain services of the indigenous medical practitioner for a better and faster care. Therefore all minor cases of fracture and sprains were treated directly by the indigenous medical practitioner and hospital treatment was sought only at times of requirement of surgery or medical certificate. In here patient returned to the indigenous medical practitioner after the surgery or receiving the medical certificate. In terms of general weakness, aged preferred the indigenous medical services to Western biomedical treatment. Fear of the side effects of pain killers were noted by the aged as a reason for taking indigenous medical treatment for most of the common illnesses and sicknesses. In all the other cases it was the failure of Western biomedical system, which guided the patients to return to indigenous medical practitioners and be cured. The reasons for the failure of Western biomedical system are not clear, but according to most of the respondents wrong diagnosis was the major factor for the failure. Generally, respondents are satisfied with the services of indigenous medical practitioners, other than for a few who have operated without proper qualifications and caused hardship to them. Two and six respondents at Mahaweli System C and at Home villages respectively, had serious complaints against indigenous medical practitioners but they have not regarded it as a reason for rejection of the total system of indigenous treatment service. Therefore 75 percent at Mahaweli System C and 86 percent at Home villages used the indigenous medical services when needed. It is clear that there is a marked difference between the two study areas as the Chi square value obtained was significant at 99.9 percent level.
Table 5: Percent attended Indigenous Health Services for treatment (percent)
Ailment, sickness or disease Respiratory problems Urine infection Paralysis Arthritis Mahaweli System C 14 00 00 29 Home Villages 23 20 23 50
Disability 23 43 General weakness 42 50 High blood pressure 17 61 Diabetes 00 33 Goitre 00 33 Cancer 00 25 Ear, Nose and Throat 06 25 Skin rash 20 40 Source: Field Data As shown in the data a higher percentage of patients have sought help from indigenous health services, for many degenerative diseases like high blood pressure, diabetes, goiter, cancer, arthritis and paralysis. This is a result of availability of renowned specialists who have had more success in controlling the severity of these diseases than curing them as none of the patients with above mentioned diseases have been completely cured up to today. 4 Conclusion INDIGENOUS medicine has sustained a healthy nation other than at times of epidemics of infectious diseases throughout the history of Sri Lanka. Communicable and infectious diseases have always posed a serious threat to the credibility of indigenous medicine but it has managed to stay on as a major supplier of health services throughout history. Today with the loss of many documents, traditions and beliefs associated with the treatment system, the indigenous medical service system is faced with a problem of survival against the challenge of Western medicine. There is a marked difference between the two study areas in terms of availability and utilisation of indigenous medical services, which is a result of age of settlement as shown by the Chi square analysis of data (Appendix A). As expected there is no significant difference between the areas in the use of home remedies, but the percent used indigenous health facilities were definitely higher in home villages than in Mahaweli System C. Various treatments of the indigenous medicine are heavily used at various levels of preventive and curative care. The pattern or system of utilisation is not direct, but common as it is used, at all
referral levels, without any clear order and purely based on need and advice given by the elders. Most of the minor ailments and sicknesses were treated first by indigenous medicine and if symptoms persist a Western medical practitioner was visited either at the hospital or private practice. In case of serious sickness and disease, almost all the respondents have consulted the Western medical practitioner as their first referral level and if the treatment was not successful, they return to the specialist indigenous practitioner for re-treatment. The cases of cancer, goitre and paralysis have shown this type of changed treatment and have had some success with the change of treatment, but at the time of survey none of them have been cured by traditional medicine. Pluralism in medical services of Sri Lanka was clearly shown in the data of the study areas. Indigenous medical service at its present level of operation is definitely weaker than its Western counterpart in many areas of action notably in the area of infectious and modern communicable diseases. However the indispensable role of indigenous medical services in preventive and curative care in the study areas can never be ignored.
Appendices Appendix A Variables Types of practitioners Use of home remedies Treatment Medicare by indigenous
Chi Square 89 20 213
Level of Significance 99.9 % not significant at 99.9% level 99.9%
A. Accessibility Equation A = d · h/t A = Accessibility d = mean distance to hospital h = number of hospitals available t = time taken to travel at under normal conditions or cost of travel under emergency situations.
B. Priority Group Identification High Priority Malaria Viral hepatitis Diarrhoea Chickenpox, Mumps Measles, Medium Priority Respiratory Low Priority Jaundice Dysentery Urinary infections
Appendix C Factor of Comparison
Income level Mean risk level of the 116.6 living environment Occupational structure of 100.8 respondents Disease panorama408.3 outpatient treatment Disease panorama67.4 inpatient treatment
Degrees of freedom 2 4 7 8 8
Significance level Not significant Significant 99.99% Significant 99.99% Significant 99.99% Significant 99.99%
at at at at
Priority grouped diseases 106.0 at outpatient Priority grouped diseases 55.8 at inpatient Morbidity by age group Morbidity by sex - male 144.8 73.4
2 2 2 2 2 2 9 6 3 3 3
Morbidity by sex - female 106.1 Alcohol consumption 3.1 Types and sources of 132 treatment Sources of information on 56.1 health Adherence to advice 8.7 Types of indigenous 41.8 medical practitioners Accessibility 31.9
Significant 99.99% Significant 99.99% Significant 99.99% Significant 99.99% Significant 99.99% Not significant Significant 99.99 % Significant 99.99% Not significant Significant 99.99% Significant 99.99%
at at at at at
References – Case study Traditional Medicine 1. Ambatalawa, S.G (1994) Science of Pulse (Research Publication - 1), Colombo, Samayawardena. (in Sinhala)
2. Ariyadasa, K (1981) Health Conservation of Health in Ayurveda. Department of Ayurveda, Colombo. (in Sinhala) 3. Ariyadasa, K (1982) History of Ayurveda. Colombo. (in Sinhala) 4. Central Bank of Sri Lanka (1981) Annual Report. 1980, Colombo 5. Department of Agriculture (1979) Bio-Climatic regions of Sri Lanka. Colombo. 6. Ekanayaka, A.T and Chandrasekara, H.I (1989) Medicinal Herbs and Plants of Sri Lanka. Deparment of Ayurveda, Colombo. (in Sinhala) 7. Gnanawimala, Kirielle Reverend (1950) Encyclopaedia of Indigenous Medicine. Sasthrodaya Printers, Ratnapura. (in Sinhala) 8. Jayasekara, D.C (1957) Dictionary of Nerve related Diseases. Colombo (in Sinhala) 9. Marga (1988) Seasonality of Health, A Study of the socioeconomic environment of ill health in five locations. Colombo, Marga. 10. Meade, M.S; Florin, J.W and Gesler, W.M (1988) Medical Geography. New York, Guilford Press. 11. National Housing Development Authority (1955) Census and Statistics Division, Colombo. 12. Kannangara, J.C (1962) Family Doctor. Gunasena, Colombo (in Sinhala) 13. Liyanarachchi, S.K (1991) Bhagna Chikitsa Chintamani. Anuradhapura, Gunasekara. (in Sinhala) 14. Navarro, V (1974) "The Underdevelopment of health or the health of Underdevelopment: An analysis of the distribution of human health resources in Latin America." . International Journal of Health Services., 4, 5-27. 15. Paranvithana, S (1959) Civilisation of the Early Anuradhapura Period, History of Ceylon. University Press, Colombo. 16. Ramesh, A and Hyma, B (1981) "Traditional Indian Medicine in Practice in an Indian Metropolitan city". Social Science and Medicine, 15 , p 69-81. 17. Ramanayaka, L and Ponnamperuma, A (1985) . Survey of Ayurveda:
Annals of Ayurveda No.2, A. 079483- 2550 (84/09) Publication of the Department of Indigenous Medicine, 12 sub volumes. (in Sinhala) 18. Silva, K.T (1991) "Ayurveda, Malaria and the Indienous Herbal Tradition in Sri Lanka". .Social Science and Medicine, Vol. 33, No.2, 153-160. 19. Wanninayaka, P.B (1982) "Ayurveda in Sri Lanka". Ministry of Health, Colombo. 20. Whyte, A and Burton, I (eds) (1980) Environmental Risk Assessment. New York , Wiley.
References - General list
Aase, A. (1991) Towards a methodology for a regional welfare planning, Norsk Geografisk Tidskrift, Vol. 45, 213-227, Oslo. Aase, A. and Bentham, G. (1994) The geography of malignant melanoma in the Nordic countries : the implications of stratospheric ozone depletion, Geografiska Annaler, 76 B, p 129-139.
Aase, A. (1996). Nasjonalatlas for Norge, bind om Helse/ National Atlas of Norway, Volume on health, Statens kartverk, Honefoss. Abayasekara, A.W. (1984). Migration and modernisation: A case study of Sri Lanka, University of Pennsylvania, University of Michigan, Microfilms International, Michigan. Alailima, P.J. (1997) Social policy in Sri Lanka,: Fifty years of economic change in Sri Lanka, Lakshman, W.D. (Ed.) Sri Lanka Association of Economists, p 127-169. Allchin, B. (1958). The late Stone-age of Ceylon, Journal of the Royal Anthropological Institute, 88,2,p. 179-201. Airhihenbuwa, C.O. (1995). Health and Culture. Beyond the Western Paradigm, Sage, London, p 24-43. Aitken, S.J. and Jellicoe, B. (1989) Health Behaviour, Berg, New York. Amarasinghe, F.P. and Indrajith, N.G. (1994). Post-Irrigation breeding breeding patterns of surface water mosquitoes in the Mahaweli Project, Sri Lanka, and comparisons with preceding developmental phases, Journal of Medical Entomology, 31, 4, p 516-523. Amarasinghe, F.P. and Indrajith. N.G. (1995). Nocturnal biting rhythms of mosquitoes (Diptera-Culiciade) in Sri Lanka, Tropical Zoology, 8, 1, p 43-53. Amarasinghe, F.P.; Konradsen, F; Fonseka, K.T. and Amarasinghe, P.H. (1997). Anopheline (Diptera-Culiciadae) breeding in a traditional tank-based village ecosystem in north central Sri Lanka, Journal of Medical Entomology, 34, 3, p 290-297. Ambatalawa, S.G (1994) Science of Pulse (Research Publication – 1), Colombo, Samayawardena. (in Sinhala)
Angunawela, I.I and Tomson, G. (1990) Drug prescribing patterns: A study of four institutions in Sri Lanka in Drug utilisation studies in Sri Lanka: Towards an understanding of medicines in society, IHCAR, Stockholm, Sweden. An Independent survey on Mahaweli System C (1993) A survey conducted by a group of University students, unpublished report. (at Mahaweli Ministry Library). Ariyadasa, K (1982) History of Ayurveda. Colombo. (in Sinhala) Ariyapala, M.W.C.S. (2000). Children living in shantytown on the periphery of Colombo, Relevance and expression of child rights in contemporary Sri Lanka, A set of Exploratory, Micro-level, Initiative in Research and education for Development in Asia (INASIA), Colombo, Sociological Studies, Vol.12. Asian Development Bank (2000) Country report, Kualalampur. Ajzen 1985 Baker, V.J. (1998) A Sinhala village in Sri Lanka, Coping with uncertainly, Harcourt Brace and Co., Fort worth. Balakrishnan, N. (1985) Sri Lanka as a welfare state: An overview, Economic Review, People’s Bank, 11, p 485. Bergstrom, S. (1994) The pathology of poverty, in Health and disease in developing countries, (Eds.) Lankinen, K.S.; Bergstrom, S; Makela, P.H. and Peltomaa, M, Macmillan, London, p 3-12. Balikie, P. and Brookfield, H. (1987) Land degradation and society, Methuen, London. Brownlea, A. (1981) From public health to political epidemiology, Social Science and Medicine, 15D, p 57-67. Burns, R.B. (2000) Introduction to research methods, Sage, London.
Bouma, M.J. and Vander Kaay, H.J. (1996) The EI-nino oscillation and the historic malaria epidemics on the Indian sub-continent and Sri Lanka: An early warning system for future epidemics?, Tropical medicine and International Health, 1 p. 86-96. Britton, M (Ed.) (1990) Mortality and geography: a review in the mid-1980s: The Registrar General’s decennial supplement for England and Wales, Office of Population Censuses and Surveys, Series DS/ Government Statistical Service, No. 9, HMSO, London. Caldwell, J.C. (1993). Health transition: The cultural, social and behavioural determinants of health in the third world, Social Science (D) 1, p. 57-98. Central Bank (1984) Survey schedules for National Consumer Survey. Central Bank (1994) Annual report, Colombo. Central Bank (1996) Annual report, Colombo. Central Bank (1999) Annual report, Colombo. Cernea, M..M. (1996) Understanding and preventing impoverishment from displacement, Reflections on the state of knowledge in understanding impoverishment: The consequences of development induced displacement, (Ed.) Mc Dowell, C., Bergham Books. Chambers, R. (1984) Paradigm shifts and the practise of participatory research and development, Institute of Development Studies, Brighton, England. Chambers, R. (1997) Whose reality counts, Putting the first last, Intermediate Technology Publications, London. Crew, E. and Harrison, E. (1998) Whose development: an ethnography of aid, Development studies, Zed Books, London.
Curtis,S and Taket, A (1996). Health and Societies: Changing Perspectives, Arnold London. Cuzick, and Elliot (1996) Small area studies: purpose and methods in geographical and environmental epidemiology: methods fro small area studies, in (Ed.) Elliot. P., Cuzick, J., English, D. and stern, R., World Health Organisation, Oxford University Press, Oxford, p. 1422. Department of Agriculture (1979) Agro-ecological map of Sri Lanka, Department of Agriculture, Colombo. Department of Census and Statistics (1993). Annual abstracts, Colombo. Department of Census and Statistics (1994). Annual abstracts, Colombo. Department of Census and Statistics (1997). Annual abstracts, Colombo. Department of Census and Statistics (2000). Annual abstracts, Colombo. Department of Health Service (1994) Annual Report, Colombo. De Queyroz (1617) History of the Dutch governed Ceylon, quoted in History of Ceylon, Vol I, Paranavitana, S. (Ed.) (1959), University Press, Colombo. De Vaus, D.A. (1996) Surveys in Social research, London, UCL Press, 4th edition. De Vroey, M. and Shanmugaratnam, N. (1984) Peasant resettlement in Sri Lanka, Tri Continental Centre, Lonvain-la-Neave, p 105-113. Deraniyagala, S.V. (1971). Prehistoric Ceylon- a summary in 1968, Ancient Ceylon, 1 p 3-47.
Desowitz, R.S. (1987). The fly that would be kind, New Guinea Tapeworms and Jewish grandmothers, Tales of parasites and people, W.W. martin and company, London. DHSS (1980) Inequalities in Health: report of a Working Group, Department of Health and Social Security, London. Dissanaike, A.S. (1984) Ecological aspects of some parasitic diseases in Sri Lanka, A survey of Glucose-6 phosphatedehydrogenase deficiency in the north central province of Sri Lanka, American journal of Physical Anthropology, 3, p 353-369. Dorling, D. (1995) A new social atlas of Britain, John Wiley, London. Dos Santos, (1970) The structure of dependence, American Economic Review, p 231-236. Doyal 1979 Dube, S.C. (1988) Modernisation and development, Studies on socio-cultural development alternatives in a changing world, United Nations University, Tokyo. Ekanayake, A.T and Chandrasekara, H.I (1989) Medicinal Herbs and Plants of Sri Lanka. Department of Ayurveda, Colombo. (in Sinhala) Evans, R.G., Barer, M.L. and Marmor, T.R. (1994) Why some people healthy and others not, Aldine De Druyter, New York. Farmer, B.H. (1957). Peasant colonisation in Sri Lanka, Cambridge University Press. Farmer, B.H. (1983). South Asia, Methuen, London. Fernando, l. (1997) Development planning in Sri Lanka, in Lakshman, W.D. (Ed.) Dilemmas of development.; Fifty years of
economic change in Sri Lanka, Sri Lanka Association of Economists. Fernando, S.D.; Paranavitane. S.R.; Rajakaruna, J.; Weerasinghe, S.; De-Silva, D. and Wickremasinghe A.R. (2000). The health and nutritional status of School children in two rural communities in Sri Lanka, Tropical Medicine-and-International-Health, 5 6, p 450-452. Fishbein 1967 Fonaroff, L.S. (1968) Man malaria in Trinidad: ecological perspectives on a changing health hazard, Annals of the Association of American Geographers, p 58, 526-56. Frank, A.G. (1966) The development of underdevelopment, in Corbridge, S. (Ed.) Development studies: A reader, 1995, Arnold, London. Friedman, J. (1992) Empowerment: the politics of underdevelopment, Blackwell, London. Furset, H. (1995) Women’s use of health care, A study of Mahaweli System C, Department of Geography, University of Trondheim. Gatrell, A.C. (2002) Geographies of Health: An introduction; Blackwell, London. Gajanayake, I.; Caldwell, J.C. and Caldwell, P. (1991). Why is health relatively poor on Sri Lankas’ Tea estates, Social Science and Medicine, 32, 7, p 793-804. Giddens, A. (1979) Central problems in social theory, Macmillan, London. Giddens, A. (1984) The constitution of society, Polity Press, Cambridge. Giddens, A. (1991) Giddens Theory of Structuration : A critical appreciation, Routledge, London.
Gnanawimala, K. (1950) Encyclopaedia of indigenous medicine, Sasthrodaya, Ratnapura, Sri Lanka (in Sinhala). Gould, P. (1964) A note on research into the diffusion of development, Journal of Modern African Studies, 2, 123-125. Grossman, L.S. (1981) The political ecology of banana exports and local food production in St. Vincent, eastern Caribbean, Annuals of the Association of American Geographers, 83, p 347-367. Gunasekara, H.R. (1996). Nutrition Status of Children in Sri Lanka, Findings from Demographic and Health Surveys, Department of census and Statistics, Ministry of Finance and Planning/ United Nations Children’s Fund, Colombo. Hagerstrand, T. (1952) The propagation of innovation waves, Lund Studies in Geography, Series B, No.4 , C.W.K. Gleerup, Lund, Sweden. Heenkens, C.H.; Buring, J.E and Mayrent, S.L. (1987) Epidemiology in medicine, Little Brown, Boston. Hettige, S.T. (1990) Social research on alcohol in Sri Lanka, Background, Issues and Prospects, NAD- Publication, 18, p 206223. Hettne, B. (1990) Development theory and three worlds, Longman Development studies, Harlow. Hoselitz, B.F. (1957) Non-economic barriers to economic development studies: A reader, (Ed.) Corbridge, S., Arnold, London. Hughes, C.C. and Hunter, J.M. (1970) Disease and development in Africa, Social Science and Medicine, 3, p 443-493. Jayasekara, D.C (1957) Dictionary of Nerve related Diseases. Colombo (in Sinhala)
Jayasundara, P.B. (1986) Fiscal policy in Sri Lanka since Independence, Central Bank of Sri Lanka, Staff Studies, 21 (1&2), p 27-62. Jayatissa, R.; Piyasena C. (1999). Adolescent schoolgirls: Daily or weekly iron supplementation? Food-and-Nutrition-Bulletin. 20()4): 429-434. Jayawardena, R.A. (1995) Health care management in the Mahaweli Project, in Blurring of a Vision –The Mahaweli, its social, economic and political implications, (Ed.) Muller, H.P. and Hettige, S.T., p 204-220. Johnston, R. (1986) On Human geography, basil Blackwell, Oxford. Kabthimer, G.T. (2000) Malaria and environment in Ethiopia : The case of Wonji Shoa sugar estate, M.Phil. Thesis in Social Change, Norwegian University of Science and Technology, Trondheim. Kannangara, J.C. (1962) Family Doctor. Gunasena, Colombo (in Sinhala) Karunadasa, J.M., Dharmawardena, G, Siddhisena, KA.P.and Seneviratne, H.M.M.B. (2002) A survey report on the success of participatory development projects in the Mahaweli development authority areas: An independent study conducted at the request of the Minister of Irrigation and Water management, Ministry of Irrigation and Water Management, Colombo. Kasturiarachchi, N.D. (1989) Interaction of medical systems and the cultural construction of leprosy in Sri Lanka, UMI cop., Ann Arbor, Michigan. Kearns, R.N. Moon, G (2002) From medical geography to health geography: novelty, place and theory after a decade of change, \progress in Human Geography, 26,5, p 605-625.
Kearney, R.N. and Miller, B.D. (1988) Suicide and internal migration in Sri Lanka, Journal of Asian and African Studies, 23, 34, p 287-304. Kjekhus, H. (1977). Ecology control and economic development in East African history. The case of Tanganyika, 1850-1950, University of California Press. LA. Kloos, H. (1985) Water resource development and scihtosomiasis ecology in the Awash valley, Ethiopia, Social Science and Medicine, 20, p 609-625. Konradsen, F.; VanderHoek, W.; Amerasinghe, P.H.; Amerasinghe, F.P and Fonseka, K.T. (1997). Household response to malaria and their costs: A study from rural Sri Lanka, Transactions of the Royal Society of Tropical medicine and Hygiene, 91, 2, p 127-130. Laing, R. (2001) Health and pharmacy systems in developing countries, Paper presented, Hosbjor, Norway. Lakshman, W.D. (1997) Dilemmas of development,: Fifty years of economic change in Sri Lanka, Lakshman, W.D. (Ed.) Sri Lanka Association of Economists. Liiman, R. (1974) Family and health behaviour, Mcmillan, New York. Lindsay, J..M. (1997) Techniques in human geography, Routledge, New York. Li, B. (1994) Child welfare and development: a study in System C of the accelerated Mahaweli development programme, Sri Lanka, Hovedoppgave i geograafi – Universitetet i Trondheim. Litsios, S. (1996) malaria, Miseria, and under population in Sardinia: Malaria blocks development cultural mode, Medical Anthropology, 17, 3, 255-278. Loganatyhan, K. (1990). The plantation system in Sri Lanka and the search for sustainable development, Memorandum No. 2,
Department of Economies and Social Sciences, Agricultural University of Norway, Norway. Lund, R. (1979) prosperity through Mahaweli : Women’s living conditions in a settlement area, Thesis for Cand. Philo, University of Bergen, Norway. Lund, R. (1983) The need for monitoring and result evaluation in a development project: experiences from the Mahaweli project/ Arbeider fra Geografisk institute, Universitetet I Trondheim, 36, p. 171-186. Lund, R. (1989) Women in the Mahaweli area – A feminist assessment, Paper for CENWOR women’s convention, March, Colombo. Lund, R. (1992) Welfare gender and social change, Arbeider fra Geografisk institute, Universitetet I Trondheim, 128, p 241-252. Lund, R. (1993) Gender and Place: Towards a geography sensitive to gender, Place and social change, Volume 1, Thesis submitted for the Dr. Polit. Exam, Department of Geography, University of Trondheim, Norway. Mahaweli Development Authority (1998) Statistical Handbook, Colombo. Marga (1988) Seasonality of Health, A Study of the socio-economic environment of ill health in five locations, Colombo. Marmot, M.G. and Syme, S.L. (1976) Acculturation and coronary heart disease in Japanese Americans, American Journal of Epidemiology, 104, 225-247. May, J. (1954). The ecology of human disease, MD Publications, New York. May, J. (1982). Red River brings life and death to North Vietnam, The Geographical Magazine, and 36 p 24-28.
Mayer, J (1990) The centrality of medical geography to human geography: the traditions of geographical and medical geographical thought, Norsk Geografisk Tidsskrift, 44, 4, 175-188. Mayer. J (1996), The political ecology of disease as one new focus for medical geography, Progress in Human Geography, 20,4, Mayer, J. (1999) geography, ecology and emerging diseases, Social Science and Medicine, December Mc Glashan, N.D., Aase, A, Ryba, M and Nymoen, E.H. (1995) Omran’s Omission? Fourth stage of the epidemiological transition, Geomedical research, Franz Steiner Verlag, Stuttgart. Mc Neil, H. (1979), Plagues and peoples, Penguin, London. Meade, M. (1976). Land development and human health in west Malaysia, Annals of the association of American Geographers, 66, 3, p 428-439. Meade, M., Florin, J and Gesler. W (1988). Medical geography, Guilford. London. Meegama S.A., (1980), Socio-economic determinants of infant and child mortality in Sri Lanka: An analysis of post-war experience, Scientific Reports, World fertility Survey, No. 8, March. Mensah, A. (1997) Fertility change in a time and space perspective: lessons from three Ghanaian settlements, Dr. Polit. Avhandling, Geografisk Institute, NTNU, Trondheim. Ministry of Health (1996). Annual Health Report, Governmenr of Sri Lanka. Morrison, B.M., Moore, M.P. and Ishak Lebbe, M.U. (1979) Disintegrating village: Social change in Sri Lanka, Lake House Investment, Colombo.
Myrdal, G. (1957) Economic theory and underdeveloped regions, London. Navarro 1976 Nordstrom, C.R. (1988). Exploring pluralism many facets of Ayurveda, Social science and Medicine, 27, 2, p 479-489. Notestein (1945) Population: The Long view. In: Fertility change in a time space perspective: lessons from three Ghanaian settlements, Dr. Polit. Thesis, 1997, NTNU, Trondheim. Omran, A.R. (1971). The epidemiologic transition theory: A theory of epidemiology of population change, Milibank memorial Fund Quarterly, 49, p 6-47. Omran, A.R. (1983) The epidemiologic transition theory: A preliminary update, Journal of Tropical paediatrics, 29, p 305-316. Openshaw, S. (1983) The modifiable area unit problem, Concepts and techniques in modern geography, Environmental Publications, Norwich. Packard, R.M., Wisner, B and Bossert, T. (1989) Introduction, Social Science and Medicine, 28, p 405-14. Packard, R.M. (1997) Malaria dreams: post war visions of health and development in third world, Medical Anthropology, 17, p 279296. Paranavitana, S (Ed.). (1959). History of Ceylon, parts I and II, Ceylon University Press Board, Colombo. Peet, R. and Hartwick, E (1999) Theories of development, Guilford Press, London. Peiris, G. (1978) Land reform and agrarian change in Sri Lanka, Modern Asian Studies, 12, 4, p 611-628.
Peiris, I and Caldwell, B. (1997) Gender and health in Sri Lanka, Health Transition Review, 7: p 173-186. Pennsyvania Department of Health (2000) Health statisticsTechnical assistance, tools of the trade. http:// www.health.state.pa.us/hpa/stats/techassist/ Perera, L.S. (1984). The pali chronicles of Ceylon, (Ed.) Philips, C.H., Historians of India, Pakistan and Ceylon, Oxford University Press, London. Phillips. D.R. (1990) Discourses of Development: State, Market and Polity in the analysis of complex change, Avebury, Aldershot Prothero, L. (1961). Population movements and problems of malaria eradication in Africa, World Health Organisation Bulletin, 24, p 405-425. Prothero, R.M. (1965). Migrants and Malaria. Longmans, London. Prothero, R.M (1994) Forced movements and population and health hazards in tropical Africa, International Journal of Epidemiology, 23, 4, p 657-664. Radhakrishnan, P.N. (1979) Development Planning in Sri Lanka: A Survey, Ministry of Finance and Planning, mimeo, Colombo. Ramanayaka, L and Ponnamperuma, A (1985). Survey, of Ayurveda: Annals of Ayurveda No.2, A. 079483-2550 (84/09) Publication of the Department of Indigenous Medicine, 12 sub volumes. (in Sinhala) Ramasamy, M.S.; Kulasekara, R.; SriKrishnaraja, K.A. and Ramasamy, R. (1992). Population dynamics of anthropophilic mosquitoes during the north east monsoon season in the , malaria epidemic zone of Sri Lanka, Medical and Vet nary Entomology, 8, 3, p 265-274.
Ratnayake, V.U. (1997) Environmental Issues, in Arjuna’s Atlas of Sri Lanka, Somasundara, T. and Godellawatta, H. (9Ed.) Arjuna Consulting Co. Ltd., Sri Lanka, p 53-55. Roberts, M (Ed.). (1977). Documents of the Ceylon National Congress and nationalist politics in Ceylon, 1929-1950, Department of National Archives, Colombo. Rosenstock 1965 Rostow, W.W. (1960). The stages of economic growth, noncommunist manifesto, Cambridge University Press, Cambridge. Sarath Anandaa, A.; Vijitha Fernando; Bimali Amarasekara and Sunimal Fernando (2000). Relevance and expression of child rights in contemporary Sri Lanka, A set of Exploratory, Micro-level, Initiative in Research and education for Development in Asia (INASIA), Children and their rights in a slum community in Kandy, Sociological Studies, Vol. 13. Scudder, T. (1995) Constraints to the development of settler incomes and production oriented participatory organisations in large-scale government sponsored projects: The Mahaweli case, in the Blurring of a Vision- The Mahaweli, its social, economic and political implications, (Ed.) Muller, H.P. and Hettige, S.T. p 148173. Scudder, T. (1997) Development-induced impoverishment, resistance and river basin development, in Understanding impoverishment: consequences of development induced displacement, Mc Dowell, C. (Ed.), Bergham Books, London. Seers, D. (1983) Political economy of nationalism, Oxford University Press, Oxford. Sen, A (1982) Poverty and famine: An essay on entitlement and deprivation, Oxford University Press.
Sen, A. (1987) The standard of living, Cambridge University Press, Cambridge. Sen, A. (1999) Development as freedom, Alfred S. Knopf, New York. Sen, A. (2001) Many faces of gender inequality, The Frontline, India. Seneviratne, A. (1989) The springs of Sinhala civilization: an illustrated survey of the ancient irrigation system of Sri Lanka, Navrang, New Delhi. Seneviratne, H.M.M.B. (1977) Micro-erosion and sedimentation study of Nilambe- Oya and Maha- Oya, Upper Mahaweli Feasibility Survey, UNDP/ Ministry of Planning and Plan Implementation/University of Colombo, Colombo (unpublished Working Paper). Seneviratne, H.M.M.B. (2003) Health and Resettlment, PhD Thesis, NTNU, Norway. ISBN 82-471-5222-5 Siddhisena, K.A.P. (1989). Family composition and infant and child mortality in Sri Lanka, PhD., Thesis, University of Michigan, (unpublished). Siddhisena, K.A.P. and Seneviratne, H.M.M.B. (2002) Strengthening of Health Systems in Sri Lanka, JICA, Literature review, Ministry of Health, Sri Lanka. Silva, K.M. (1981) A history of Sri Lanka, C. Hurst, London. Silva, K.T. (1991). Ayurveda, Malaria and the indigenous herbal tradition in Sri Lanka, Social Science and medicine, Vol. 33, 2, p. 153-160.
Silva, K.T. (1997). Public health for whose benfit? Multiple discourses on Malaria in Sri Lanka, Medical Anthropology, 17, p 195-214. Snow, J. (1854) On the mode of communication of cholera, in Meade, M., Florin, J and Gesler, W. (1988). Medical geography, Guilford, London. Sorensen, B.R. (1996) Relocated lives, VU University Press, Amsterdam. Steen;amd, K and Deddens, J.A. (1997) Design and analysis of studies in environmental epidemiology, in Topics in Environmental Epidemiology, Steenland, K and Savitz, D.A. (ed.) Oxford University Press, p 9-27. Starkloff, R. (1998) Water scarcity in Kitulwatte,: The Social causes and consequences of environmental degradation in a highland Uva village of Sri Lanka, World Development, 26,6, - 913-932. Tennakoon, (1974) Drought in some selected resettlement schemes in North Central Province, Sri Lanka, (unpublished PhD. Thesis), University of London, London. Turshen, M. (1977) The political ecology of disease, Review of radical of political economics, 9,p 45-60. Turshen, M. (1984) The political ecology of disease in Tanzania, Rutgers University Press, New Brunswick, NJ. Uphoff, N. (1996) Learning from Galoya, IT Publications, London. Uragoda, C.G. (1979) History of medicine in Sri Lanka, Ceylon Medical Association, Colombo. Uragoda, C.G. (1997). A cohort study of graphite workers in Sri Lanka, Occupational medicine-Oxford, 47, 5, p 269-272.
VanderHoek, W.; Konradsen, F.; Dijkstra, D.S.; Amerasingha, P.H. and Amarasinghe, F.P. (1998). Risk factors for malaria: a micro epidemiological study in a village in Sri Lanka, Transactions of the Royal Society of Tropical medicine and Hygiene, 92, 3, p 265-296. Wallerstein, I. (1974). The modern world system, Wiley, New York. Wanasingha, Y.A.D.S. (1997). Settlements, in Arjuna’s Atlas of Sri Lanka, (Eds.) Somasekaram, T and Godellawatta, H, Arjuna Consulting Co. Ltd. Sri Lanka, p 53-55. Wanigaratne, R. (2000) Mahaweli settler household incomes: Trends, determinants, constraints and choice, in (Ed.) Indraratne, A.D.V.de.S, A Quarter Century of Mahaweli: Retrospect and Prospect, National Academy of Sciences of Sri Lanka, Colombo. Wanninayake, P.B. (1982). Ayurveda in Sri Lanka, Ministry of Health, Colombo. Waxler, N.C. (1984) Behavioural convergence and institutional separation: An analysis of plural medicine in Sri Lanka, Culture, Medicine and Psychiatry, 8, 187-205. Waxler-Morrison, N.E. (1988). Plural medicine in Sri Lanka: Do Ayurvedic and western medical practices differ?, Social science and Medicine, 27,5, p 531-544. Wessen, A.F. (Ed.), Hooper, A, Huntsman, J., Prior, I.A.M. and Salmond, C.E. (1992) Migration and Health in a small society – The case of Tokelau, Clarendon Press, Oxford. Whitecombe, E. (1995) Malaria and irrigation: a survey of Rajasthan canal projects, UNESCO, New York. Wickramasinghe, A. (1993) Changing family life: Case of Men’s alcoholism in rural Sri Lanka, International Journal of Sociology of the family, 23, 2, p 99-105.
Wolffers, I. (1988). Illness behaviour in Sri Lanka: Results of a survey in two Singhalese communities, Social Science and Medicine, 27, 5, p 545-552. World Health Organization (2002). Health System and Health Needs of the North-East Sri Lanka, Colombo. World Bank (2000) World development Report, Oxford University Press, New York. World Bank (1998/99) Country Report: Sri Lanka, Washington. Yemane,B, Wall, S, Kebede, D, Emmelin, A, Enquselassie, F, Byass, P, Muhu, L, Andersson, T, Deyessa, N, Gossaye, Yegomawork, Atalay, U and Dahlblom, K. (1999) Establishing an epidemiological field laboratory in rural areas-potential for public health research and interventions, The Butajira Health Programme 1987-99, Ethiopian Journal of health Development, 13, Special issue.