We must speak the truth – the lockdown failed and we need fresh thinking

Given what we know about the new cases detected in the past two weeks, it was no longer justifiable to relax COVID control measures on Monday (April 27), including lifting the curfew in Colombo. This is a monumental and totally avoidable policy failure and an unmitigated fiasco. If accountability meant anything in this country, there would have been consequences for those involved in setting the health response. And to be absolutely clear, I do not mean the President, who has so far only acted in good faith on the advice he has been given.

When the government imposed an island-wide curfew on the evening of March 20, we only had 72 cases. Until that point, almost all were people who had acquired the infection overseas and returned before we stopped all incoming flights on March 19. There were just a dozen other cases of local transmission, involving people in the community who had been infected directly or indirectly by a local arrival or foreign tourist.

The curfew should have had three clear objectives:

(1) To contain the virus to arrivals — This required screening all recent arrivals for infection and rapidly tracing and safely quarantining all cases and contacts of infected arrivals or any other cases to stop dead the spread of virus to others.

(2) To establish capacity and a system to rapidly detect, trace and isolate any cases of hidden infection in the community.

(3) To reduce social interaction so as to slow down person-to-person spread of any virus lurking in the population long enough for the first two objectives to be achieved.

We passed four weeks of lockdown on April 17. In the subsequent ten days we have had over 220 new cases. Almost all of these involve local transmission of the virus, as shown in shades of red in the chart below.

Epidemic curve of COVID cases in Sri Lanka by transmission category, 17 Jan–24 April 2020

Let me be clear what this means.

One, we have failed to contain the virus to arrivals and their immediate contacts. Other countries did this in four weeks, we did not.

Two, we have failed to establish the capacity to rapidly detect, trace and isolate new cases — Despite officials saying repeatedly that we have enough testing capacity, laboratory experts around the country are now scrambling to urgently expand what they can do. In the past few weeks, several opportunities to acquire the large testing machines we need have been turned down. At the very minimum, we need capacity to do an average of 5,000–6,000 tests each day, and even with completion of a new test facility at Mulleriyawa, we will be well short. We also still lack a testing policy that is adequate to keep this country safe in the coming months – even the simplest measure such as mandating the testing of all ICU admissions has still not been done.

Three, we have failed to use the curfew to reduce the rate of person-to-person spread of the virus to a level where epidemic spread cannot occur. One or two infected cases in places as diverse as Colombo and the navy camp in Welisara have snowballed into major incidents. If we lift the curfew now in the absence of adequate measures to educate the public in social distancing and basic hygiene measures, such as providing people with face masks, we face a significant risk that undetected cases in the community will rapidly spread the virus to others.

We need to maintain the lockdown for at least another two weeks, and maybe longer. Until such time that we are sure we have isolated the contacts of all known cases, and until we are sure that explosive undetected spread will not occur if the lockdown is lifted. Avoiding explosive spread in the absence of a lockdown requires rapid action to develop an action plan to achieve industrial scale testing, and stepped up efforts to improve social distancing and public hygiene measures to keep us safe.

We can still do all of these things. What worries me is that it will not happen. 

The hard truth is that we wasted the past month of lockdown and did not do what had to be done. It did not happen because of a lack of money, or because of unwillingness by the President, the military and our doctors, nurses and lab experts to do what they were told, or because the public was not willing to make sacrifices. 

It is hard to avoid the conclusion that at the root of the failure was a mindset unable to rise to the urgency of the hour, to fully understand the challenge we face, and to think outside the box. 

I fear and we should all fear that this mindset remains. In the coming year, COVID is going to constantly test us with a succession of new problems, many of which will be unlike anything in our past experience. We are at the start of a very long war. If that mindset cannot change, the government would be wise to think of new direction for the health response or getting fresh, independent guidance from those who fully understand what we face and what we need to do.

43 thoughts on “We must speak the truth – the lockdown failed and we need fresh thinking

  1. I think your summary is well thought out, written and is absolutely correct in its content. We in the UK are in a similar state, however we do have greater testing capacity which you may think is great, the actual tests being completed in Wales is around 20% of the takeup and not much more across the rest of the UK. This is for various reasons, ie logistically, setting up the testing centres was easy, setting up the administrative side is proving harder eg who goes first, nurses, doctors, care workers, cleaners and all others in hospitals. Drafting up a database of these people and contacting them is proving difficult so they opened up a website where anyone who is a care worker could register themselves for a test. It shutdown in England after 2 hours due to high volumes trying to access and all slots taken. In Wales they have now deferred opening the website until they can guarantee anyone trying to get a test booked wont get shutout. The other issue with testing is that the test centres could be as far away as 140 miles round trip. Low paid workers cannot afford to take time off and care workers are needed daily so this also puts a barrier to getting tested. Mobile test stations, maybe in the back of lorries would help to alleviate this however no one seems to have thought of this yet.

    I cannot say our lockdown has failed as it is still in place. There is pressure being applied in a number of ways eg political opposition parties, economic experts and news from the US/Berlin showing the public animosity, to get this lifted sooner rather than later. Thankfully the govt are resisting all calls to say when it will be lifted although the general consensus is the 1st June may see a lifting of some restrictions. Having personally suffered quite badly and survived this virus, I would be happy for the restrictions to be kept in place until we can identify a 90% touch rate for testing and identify location of those not tested. I wouldn’t dream of allowing flights in/out unless all passengers had been tested and proven clear prior to travel. This may have a negative impact on the economy but ask yourself the question, would you rather holiday in a country that has stringent criteria on persons entering the country and also a robust testing and tracking system in place, or one where there is a possibility of a 2nd or 3rd peak of the virus. There will be alot of people who will want to go away on holiday and this could make a big difference to the economic income of the country with the best systems in place. A number of people I have spoken to have no intention of leaving this country in the next 12 months for the fears I have expressed so tourism will suffer for a few years yet.

  2. It’s always the public who is responsible for fliers. Before telling the people to talk the truth, the writer must walk the talk. Who allowed the match. Who brought the kith and kin of politicians on public accounts before closing down, who discriminated other people at quarantine centres, who failed to map the incidents and warn the public adequately, who enforced curfew and did nothing else to equip the public to meet the simple tools even with the sufficient aid coming, who is desperately getting ready for a useless election that is going to make absolutely no difference other than looting and robbing from the poorest. So add this truth.

    • Channa,
      I think the biggest problem today is that the political leaders have not been well advised by the technical experts. The technical people must have proper understanding of the problem and they must tell the leaders what needs to be done without fear – this is not happening.

  3. Thank you Ravi – that was an excellent analysis of the situation we face. The key point is that public co-operation is at a minimum level. The gravity of the situation has still not been understood . We are by nature a very easy going people. But once activated then we act with speed and enthusiasm. So the public mindset has to be changed. Political leaders instead of talking about elections must tell the people how serious this problem is. Like wise religious leaders, specially the Sangha should appeal to the people.

    • Godwin,
      I think that the political leaders have not been well advised by the technical experts. So the problem is on the technical side.

  4. You’ve said twice that the political leaders have not been well advised by the technical experts. Do you mean the healthcare professionals? Because both the GMOA and the Ceylon college of physicians handed in thorough exit strategies which were not even given a second thought by the politicians.

    • Rashmira,
      The political leaders are not public health experts, and they have mostly in this case listened to the recommendations they are officially provided – I don’t see much evidence of them not doing that. Professionals, specialist colleges, the unions, researchers, others can only offer advice. In our system of government, it is up to the senior officials in the health ministry to process the information including different views, make good judgements, and then recommend to the political level. That official process is entirely sensible and appropriate. But the failure seems to be there in that official process.

    • Hi Rashmira,

      Have you read the exit strategies presented by them? Do they advocate when to exit; either in terms of possible dates or criteria that need to have met in order to exit? Those are the crucial information in my understanding, more than the strategy itself, which may not require a very high level of expertise.

      There are other issues like do we do enough testing and do we have access to enough and correct data, on both some casts doubt.

      The positions of the GMOA and CCP seem to differ at least on the matter of testing. The former recommends aggressive testing while the President of the CCP participating in one TV discussion said that he is satisfied with the current level of testing and there is no need to increase it unnecessarily, and he does not believe that community surveys using random samples are required at this stage. If they are required among risk groups, such as those with respiratory symptoms without a positive contact and travel history, that were essential to test as per the initial criteria, is not clear. Also if they are included in the revised criteria for testing I do not know.

      In addition the GMOA is attacked for not being a “professional organisation” hence implying that they do not have the right to provide recommendations or their recommendations do not matter. Some also question as to why they speak to media that could influence public opinion. But they were included in the Presidential Task Force appointed at the early stages. What role this Task Force have played and what recommendations they are making, if any is unclear. So is where do they stand in terms of flow of information and decision making process. All in all there does not seem to be a good, structured flow of information to the political leadership and I believe it is the task of the leadership to establish that and make use of the recommendations made by various parties.

      Note to Dr. Rannan-Eliya, Heard that they have fired Professor Neil Ferguson, any thoughts?

      • Correction – according to many British newspaper reports Professor Ferguson stepped down as he was found to have violated lock down protocols when he got his girl friend to visit him as exposed by the Telegraph. This seems to be the understanding of the public or at least those who work in the NHS seems to have. Nevertheless one writer of the Independent did not hesitate to write that he was sacked. Regardless there seems to be quite a bit of a tussle between governments and the academia/scientists or subject experts in many countries US and UK included which is absent in Sri Lanka. Any thoughts?

  5. Fully agree Ravi. Just a few hours ago, I learnt from an on-the-ground health worker that the lockdown in Keselwatta was called off by the Police. This was allegedly announced through a mobile public address system. Its is claimed that people immediately started to move about as if the curfew had been lifted leave aside lockdown! Testing that had been happening for the past 10 days or so has also been called off today. May be the main reason is probably something I had personally being fearing the most – drug cartel. The lockdown/curfew put breaks on illicit drug distribution system! Drug cartel in Sri Lanka has many sponsors and beneficiaries at all levels of our society. Covid or not, business needs to go on! Very very sad.

  6. Thank you for the very insightful and analytical article. A breath of fresh air compared to the unpalatable nonsense that’s dished around in which most of the saner souls of this blessed land are left to suffocate from, sometimes even by the so called professionals and technical experts. But I am inclined to think you give more credit than they deserve to the political leadership and see it as a failure on the part of the technical experts in the Ministry of Health to advise them properly. Do you think given the ‘yes sir’ culture that prevail in this country would enable or equip any public official to challenge either the government or any politician, where as coercing the public officials or even the business community, including media, to support a narrative the government and the politicians desire is the game!? Would also like to read your views on Excess Deaths, which is gaining popularity as a measure of the impact of the pandemic on populations. We at least in the public domain do not have this data for Sri Lanka. If looked at I feel may shed some additional light to the Sri Lankan situation.

    • Ruch,
      We are not the only country where the health advisors have got it seriously wrong. The UK’s COVID disaster follows wrong advice given initially by their Chief Medical Officer and the Chief Scientific Advisor.The UK government has been criticized for not challenging their own experts. But I think it is too much to expect our political leaders, many of them lacking any scientific training, to have done more than those in London. I think the doctors do have much more latitude to say what needs to be said to the political leaders or even the military than you might think in this crisis – even during the war doctors were always treated with kid gloves by the army. I think the relevant doctors have not given the correct advice because I suspect they do not themselves comprehend the nature of the challenge.

      • Thanks for the reply. Yes, it’s a possibility that the health officials may hot have grasped the gravity of the situation in order to inform the government. Recalling how the Secretary to the Ministry of Defense responded to a foreign media person in the aftermath of the Easter attacks, this inability to grasp the gravity of a situation seems to be the norm with public officials for some reason. But I am not altogether convinced of the other concern I highlighted in my original comment is not at play!. anyway in the UK I think both the Chief Scientific Officer and Chief Medical officer were informed by the academics led by the universities Oxford and Imperial College, headed, if my memory is right, by one Professor Neil Ferguson, whose team in fact did the modelling and worked out the numbers to advocate Herd Immunity. The differences I see is that upon heavy criticism they revisited and revised their model and came out and said that they made a mistake. Not only that who is instructing whom with what is very clear. Unlike in Sri Lanka where ghost experts seems to call the shots! Anyway nice to read your views on this topic.Looking forward to see more of them. What about making your Personal Scripts available on Medium!? WordPress is bit ancient 🙂

        • Ruch,
          Just to correct on the UK story. The CMO and CSAHMG did their own departmental official modeling and this misinformed the UK govt for several weeks. It was later that independent academic modeling by Imperial gave a different view. UK govt had to deal with that since the Imperial modeling was going to be published anyway. One big difference though is that the UK tax payer also finances the work of Imperial – there is nothing like that here. Prof Ferguson also has never advocated herd immunity – Imperial’s modeling said from the start this was a crazy idea. Imperial has improved on its work since, but its basic conclusions were arrived at the beginning and actually are pretty obvious once you know the basic epidemiology of COVID. I was saying pretty much the same thing more than a month ago.

          • Thanks for correcting the info about what happened in the UK. My awareness mainly comes from ad-hoc media news articles I read. Didn’t know that the govt had it’s own modelling done initially. Also the fact that the Imperial initiative is publicly funded. Highlights the importance of public funding of entities and initiatives. Additionally the fact that they were about to publish their modelling in contrast with what Professor Manuj Weerasinghe said about the modelling he has done in the SLMA webinar; that it is done for the purpose of the experts to make decisions, therefore the details of it, are not necessary to be released to the public! Despite being employed by an institute that is publicly funded. Yes, I read your blog post on herd immunity referring to the Austrian study. Sadly in the absence of any good explanations here in Sri Lanka, there are many people who are still mis-informed about the concept and what it means. Some of them hold very influential positions when it comes to shaping public perception, especially among the business community.

  7. Ravi,

    You said “we have failed to contain the virus to arrivals and their immediate contacts. Other countries did this in four weeks, we did not.” This is a misrepresentation.

    You divide the NZ numbers by their population count and our numbers by our population count. Then, you see who did better. Sri Lanka has done better!

    You are relying only on numbers. Look at who are in those numbers qualitatively. The recent surge came with many infections in the Welisara Navy camp. We have to understand that they are under control. What worries is only those who are in the society. You cite Taiwan, which is having a population almost equal to ours. Until Navy personnel at Welisara got infected, we did better than Taiwan too on raw quantitative figures. But, look at the qualitative side as to who are less risky because of better discipline.

    Infections coming from Keselwatte and Suduwella are very much under control now. There were a few such tough situations. There will always be some.

    Your statements in the article have lots of misrepresentations;grossly lack quality in analysis.

    • Darshi,

      I’m afraid the comparisons with NZ and Taiwan (and Australia) put us in very bad light. The first epidemiological question is what was their initial dosage of infection from imported arrivals? As highly globalized economies, they had much higher potential and actual exposure than we did. Taiwan is tightly integrated with China economically, eg iPhone production, but it took action much earlier than us to control its border (starting end of Dec 2019). Despite that, both Taiwan and later NZ imported far more cases than us because of their European air traffic.

      The population ratio is irrelevant. One case will multiply to 1,000 cases in the same time regardless of population size.

      The issue is how well did they and we do in forcing case numbers down and preventing further spread. Both did much better. They did much better in preventing leakage of the virus beyond arrivals and their first contacts. And despite higher initial numbers they have reduced to near zero much faster. We have failed to do that. Plus we have significant infections leaking into second, third and higher level contacts.

      No expert can honestly say today we have the navy outbreaks under control. We know that many contacts were on leave and we know that family members were infected. There is a high risk of further spread. To say otherwise is not based on science.

      Read our analysis here for more detail: http://www.ihp.lk/blogs/ravi/2020/652/

  8. Dear Dr. Rannan – Eliya,
    Thank you for this extremely important and informative article.

    My only hope is those who are in power and are responsible for making policies in our country listen to this advice. I hope the government ramp up testing and contact tracing.

    However, like a previous commentator noted, l too think that you are being too kind about the way the politicians handled the situation. The failure of achieving the expected outcome of the lock down cannot be placed fully on the technical (medical expert) side. The politicians in our country who are squabbling whether to have a parlimentary election soon or not are also to be blamed to at least some extent. From the top down.
    True, even the health experts of SL (medical researchers and such) may not have fully understood the gravity of the situation yet, but the political leadership should have in their hearts the elimination of this threat of Covid-19 as the first priority!
    What do we get from them though? A mixed message at best!
    One does not need to be an expert to understand that this virus is highly contagious and right now, the only way to stop human to human transmission is by reducing direct human interaction through social distancing. But has that message given to us unequivocally by SL leaders? Sadly no.
    You have mentioned about NZ. Theirs is a relatively successful battle. I think it’s greatly due to PM Ardent ‘s clear and precise measures and honest messages in addition to their medical experts’ accurate advices.

    • Fully endorse the view. Look at the presidential task force that was initially appointed. What were the criteria to select members for that? If you look at certain people that were included one can not help but think that they were selected only because their blind loyality to a certain party and politicians. When you select members for such committees I think qualifications, technical expertise and experience in the relevant subject matter should be the criteria, not the party politics they play.

  9. Sri Lanka needs a balance between the low level of people with antibodies achieved by New Zealand and the high level of people with antibodies achieved by Sweden, nearing herd immunity. It must be also within the capacity of our health care system. The spreading of the infection to the Navy Camp should be treated as a blessing in disguise, as it provides a pool of people with antibodies to function effectively in the Covid ridden global economy. The drop in the infections to 30 on 29th April indicates a rapidly declining number of cases with the light at the end of the tunnel in sight. Hence, I believe we have struck the right balance and hope that opening of the economy will proceed as planned.

    • Lal,

      These are hazardous analogies. First, population exposure in NZ is probably ten times higher than here—with effective strategy, we can still remain below NZ. But it does make its current level of almost zero new cases even more remarkable!

      Sweden does not get much attention because of its small size and its very good health infrastructure which meant that its hospitals were not overwhelmed, but Sweden has suffered one of the highest death rates in the world so far, much higher than China, Germany or its Scandinavian peers. Adjusting for population size, this would be equal to around 5,000 deaths in Sri Lanka. Despite this, only 5% of the Swedish population has been infected, a long way from herd immunity which needs 60%-70%. The Swedish authorities do suggest a much higher level of exposure in Stockholm—up to one third, which is still short of herd immunity—but only one in ten Swedes live in Stockholm, so I think the 5% number is the more important one.

      As for light at the end of the tunnel – a month ago, we could have also said there was light at the end of the tunnel, since we only had a handful of cases. It is foolhardy to predict ahead given current numbers, since this only tells us the status of infection two weeks ago. Given also that many of the military cases had traveled across the island and to their villages before they were isolated, we should be doubly cautious.

      • Doesn’t the WHO caution against the so called immuno-certification of people who have had the infection therefore now have antibodies; due to various issues like the sensitivity or more importantly specificity of the antibody tests, the quality of the test kits as well as possible Antibody Dependent Enhancement (ADE)? The very prospects Lal above thinks, is a blessing in disguise!? It also may potentially lead to other issues – like social and human rights (discrimination) issues for example. But then again do we care about such matters in Sri Lanka… In addition aren’t there already speculations about the possibility of this virus evolving into a more Seasonal flu like one that would easily produce strains that could evade and by pass the immunity developed for previous strains?

        • Yes, WHO does warn against these tests for those reasons. However, even if the tests worked 100% perfectly, they would not help us in Sri Lanka very much because I am quite sure that the infection rate in Sri Lanka will remain below 1%, far too small for herd immunity to work.

          Yes, the virus will evolve, but we now have good data to indicate that it does not mutate that fast, so the virus is likely not to change too much. What we don’t really know is how long immunity will last this has never been researched properly for corona viruses before.

          • Yes! I completely forgot about the uncertainties of the duration of immunity! When you say Corona viruses before, are you referring to the endemic ones or the other recent pandemics like SARS and MERS?

          • All, but including the endemic ones that cause only colds.

  10. Sri Lanka with a death rate of 0.3/1 million is better than New Zealand at 4/million. We cannot compare the living conditions in low income areas where the infections occurred with the living conditions in New Zealand. Hence, we cannot compare the time taken to control the virus in New Zealand with the time taken to control the infection in Sri Lanka.

    • Lal, Unfortunately, the virus does not discriminate between rich and poor—it’s just a ball of genetic code wrapped up in an oily protein coat. The maths of its transmission does not vary and is similar in all settings. The same interventions done the same way work have the same effect in all settings. If you don’t want to compare with NZ, compare us with Vietnam or Bhutan or Mauritius which have achieved the same outcomes as NZ. Americans who thought that differences of living standards, culture and whatever else matter and would protect them from an Asian virus are now paying a heavy toll for their arrogance and stupidity as thousands of their loved ones die every week. In contrast, New Zealand did not say: “Oh, what China does is irrelevant to us because we are white and richer” NO. They assumed that the virus would work the same way in their country, and they acted on the logical implications.

      • Having a technocrat as President, we too started off well following in the footsteps of China and East Asia. We also introduced innovations such as using intelligence services for contact tracing and root ball operations, trying to cut out the infection paths from society the same way a malignant tumour is cut from the body. But just like in cutting out a malignancy it is vital to catch all the malignant cell mass or else face resurgence at a faster rate, it was crucial to uproot the entire infection route and isolate it. To do this we needed the entire root ball operation or contact tracing operation to be fully supported and complemented by a very aggressive and expansive testing criterion. This became our achilles heel. Our contact tracing was very Asian but testing remained very English- intensely restricted. This is probably because our health ministry- epidemiology mandarins had their post graduate qualifications in England and was looking to England for ideological guidance. So from the beginning, we needed a testing criterion which was as loose as a courtesan’s morals but what we actually had was as tight as a miser’s purse strings. In fact I saw one SL epidemiologist come on TV and repeat in Sinhala the exact same thing the British Health Authorities had said about WHO’S test test test, that WHO is the World Health Organization and what it says is meant for the whole world not necessarily what’s best for a particular country. In fact the President of the Ceylon College of Physicians, Dr. Ananda Wijewickrema said recently on Derana that ‘we did the amount of testing we needed at the particular point in time and if we had done more we would have wasted our testing capacity. Now at this point we need more testing so we are increasing capacity- not that we fell short earlier’. This is the kind of eye wash which derailed our operations. Of course we fell horribly short of testing and failed to catch some vital parts of the root ball because out testing remained faithfully English. For example the index case of the bandaranaike mawatha cluster developed respiratory symptoms 15 days after her return from India. She visited the National hospital, but instead of testing her they remained English and explained away the respiratory symptoms as her habitual asthma. The rest is history. The second patient to die, had also visited National Hospital with his symptoms before visiting Nawaloka Negombo and they were blind. they say because testing criteria required suspicious travel or contact history and the patient withheld these. But patients always withhold. For aggressive detecting, doctors needed very generous testing criteria, which these old codgers with their King’s College qualifications were not giving. Welisara had a positive outcome. The old codgers let go of the jealously guarded testing purse strings. Now the testing will hopefully stop being so English and become more and more East Asian.

        • Let’s go a little easy on the English shall we? Because its the right wing Tory policies that we see not all of them voted for Johnson.

          Plus without them we in Sri Lanka would not have our health system (including some of the infrastructure that we still use) that we speak very highly of!

          • Ruch: It’s the British, not the English! But they did not design or build our health system! We should be always grateful for their decision to grant universal franchise and self-government in 1931, something that they were not forced to do, and which those responsible recognized with great prescience would lead to a better health system here. Our health system is the product of that decision, but was developed here and paid for by us in response to pressure from voters. So we need to thank the British for the democratic legacy as well as our own people’s good sense in making use of that. As well as successive governments here who ignored the British and who did—with precious little help from them and the West’s “coalition of the willing”—what needed to be done in ’89 and ’19 to defeat the most mortal threats to our democracy—the terrorism of the JVP and LTTE.

  11. Yes! The lockdown miserably failed with ending with an unexpected spike involving so many Navy personnel. If crossing a District is prohibited for every Dick, Tom and Harry how come they crossed many Districts to go home? On the other hand, because of the lock down there are some who are without their basic medication, despite all the delivery mechanisms. My good friend tells me, with the implied permission to walk, he went to a leading private hospital, consulted a specialist who prescribed oral medicines and creams to apply, went to the hospital pharmacy to get the medicine, received every medication in the prescription BUT NO COTTON WOOL to apply the cream. Despite a lock down and strict curfew some did travel to other places (Not the Navy personnel) and spread it to their “friends and relatives” in Colombo itself. If we make the lock down more strict it could result in a spike of non-COVID19 deaths which will not be highlighted in any of the media. We need fresh thinking. Now as per published statistics, there were 7 deaths, a number exceeding hundred cured and sent home and not a single patient in the Intensive Care Unit. All others in the hospital get alternate medicine such as inhaling medicated steam, all kinds of “Osu-pan” and outdoor exposure in Sun-light. SO! Do we need an Infectious Diseases Hospitals or Infectious Diseases Nursing-Homes? Only the high risk fellows such as obese, diabetic and kidney problem cases need be in the hospital. Others should be in appropriate enclosures being administered the same alternative treatment that is administered in the hospital. If a nursing home patient is turning out to be bad than he can be transferred to the hospital. I think this is food for thought.

  12. Dr RRE,

    The truth and the facts are that;

    • Sri Lanka has 1,177/million test which is higher than India, Pakistan, Bangladesh. Sri Lanka has been increasing the daily test rates and Japan is the next country to catch up to in Asia
    • Sri Lanks’s 5 day rolling average of new cases is 22.5/per day as of (3 May 2020) which is one of the lowest in the world. If the new cases are adjusted to remove the Navy Cluster this is even lower.
    • In Sri Lanka only 7 lives were lost 0.3/million. This is lower than 4.0/million in NZ which seems to be your benchmark. NZ has higher (1487) incident rate to Sri Lanka (705). This is not withstanding NZ having a much higher societal discipline and lower population density (17/sq km) compared to Sri Lanka. Both SL and NZ closed the border on the same day as Sri Lanka on 20 March 2020.
    • Vietnam a single party communist country closed it border on 31/1/2020 with China which is the reason they avoided the pandemic
    • Bhutan or Mauritius did not have a pandemic to deal with as they did not have an expatriate work force returning home to seed in the outbreak in the first place.

    Looks like your blog is a usual rant from the opposing side of the political spectrum(?)

    • Dear Dr G:

      I’ve been attacked on this blog for defending the government and I guess by you for doing the exact opposite. I will let the readers decide who is ranting here…This country is in such a mess because so often everything is reduced to political, ad hominem attacks on each other’s motives without engaging objectively with each other’s ideas and arguments. I don’t know what university you obtained your “Dr” from, but where I was trained intellectual openness and respect for others views was the basis of how we were trained.

      If you had bothered to read the posts here you would know that my discussion has not been about absolute numbers. In fact, because our overall numbers are still low, I have been consistently arguing that we need to go for “elimination”, something that most countries cannot hope to do. But if elimination is the goal, we should be seriously worried, because we are not doing enough to get there.

      With an infectious disease where spread is exponential, the key concern has to be with the percentage change in cases. I try to avoid technical jargon, but this is what epidemiologists call R0. If we want to know we are doing well, we need to have evidence that R0 has fallen and stayed below 1.0, ie that case numbers are falling, and relatedly that infection is not spreading from arrivals. Both those are clearly not the case.

      It is certainly true, and I have noted this, that New Zealand, Australia, Hong Kong and others have had more cases. This reflects much more exposure to foreign arrivals. But what is important is that these places have done a far better job in reducing the incidence of new cases than we have, and this was even before the navy camp cluster. As of now, New Zealand, Hong Kong and Taiwan all have fewer cases each day than us. And if you look at all the countries you mention, the one thing they have in common and which I note you said nothing about is that they all test more aggressively than we do.

      As Sri Lankans living in this island we need to learn what we can from the best experiences abroad without sticking our heads in the sand. If countries like New Zealand and Australia are doing better than us in bringing numbers down by testing aggressively and copying East Asian nations, should we deny this option to our own people by not talking about it? That would not be genuine patriotism in my mind.

  13. Thank you Ravi. These blogs are extremely helpful for us to get a better/accurate understanding of the situation. There also seems to be a huge gap in effectively communicating information/advice – the public in general is relatively unaware of the facts – and either lax or apprehensive as a result. Is the communication gap a demand or supply-side issue (i.e. experts advise policymakers, but policy makers in turn either fail to take this advise/listen and fail to pass the information on to the public)? I can think of several very simple ways in which to help the public understand the ground situation – campaigns are held for various other reasons – I wonder why it’s not being done here?

    • Educating the public is not what we Sri Lankans traditionally do. Withholding as much information as possible and providing them the bear minimum is the norm. Sri Lankan doctors are notorious for this.

      When political spins are added by various media with their own objectives and agendas; in addition to not getting adequate amount of accurate technical information, the public are left with skewed narratives, though subtle, that drives them further from the truth instead.

  14. Dear Dr. Rannan-Eliya,

    Thank you for taking the time to respond and all the informative comments made. Since replying is either switched off or no longer possible on the particular thread about British (yes, the Brits not necessarily the English) being responsible for our health care system, the below excerpt from, Chapter 3 – The Sri Lankan Path to Health for All from the Colonial Period to Alma-Ata by Dr Margaret Jones,. in relation to Sri Lanka’s health care system may of relevance (Sourced from: https://www.ncbi.nlm.nih.gov/books/NBK316260/ )

    //The foundations of this health care system, which has made it a model for developing countries, were laid down in 1858 in the colonial period. From the beginning western trained Sri Lankans were providers of state medical care in hospitals and dispensaries. The Colombo medical school, founded in 1870, was crucial in the extension of the medical services as it was from these Colombo trained professionals that pressure for the extension of the health services to the general population came. The two decades of self-government before independence following the Donoughmore Constitution in 1931 with the instigation of universal suffrage contributed to a further rapid expansion of health services as politicians sought support from the electorate.//

    The local politicians and professionals may have been the designers of the system, however the western education and influence they may have had can not to be ignored in putting in place a health care system based on western medical practices largely replacing the indigenous practices existed during pre-colonial era…

    • Ruch:
      If the British medical influences were so critical, then most other British colonies should have made large advances in health outcomes. That did not happen – Sri Lanka did much better than the others, with only a few exceptions such as Malaysia, Botswana, Jamaica, etc who all happen to have maintained democratic systems. It’s also worth noting that until the 1940s, despite this British medical influence Sri Lanka’s health outcomes were worse than the rest of Brtish occupied South Asia (India, Pakistan, etc). The significant positive deviation in our health trajectories happened only after universal franchise was introduced, and here we were quarter of a century ahead of the rest of South Asia.

      • Fair argument.

        I would presume that much of Africa, that must be forming a large part of the common wealth, has issues unique to the continent and are lagging behind in many aspects.

        I have no comprehensive and comparative understanding of health system development and heath status/outcomes across commonwealth – so have to rest my case there. But I would presume that local factors too played a role.

        However wasn’t the universal franchise introduced across the Common Wealth during the same period? If so how come universal franchise didn’t improve health outcomes in other colonies? Or is there an established positive correlation between introduction of universal franchise and improvement in health outcomes, given the examples you have cited and their democratic governance?

        Then comes the question, if we were or are so smart how come we are lagging behind economically compared to others, at least in the region, who were far behind us at the time of independence but now well ahead of us? Do you agree that our success in terms of out comes seems somewhat peculiar to the health sector, may be education in some respect, with high literacy rates, but more in health. Yet economically we have not performed comparatively well? What would be the reason if/when both health and education outcomes are good?

        However do you disagree that replacement of pre-colonial indigenous system in the island with allopathic western system is by large due to colonialism? Last but not least the very introduction of universal franchise is because of colonial influence?

        Again thanks for all your responses I find this very educational.

        • Ruch:

          The health and economic success of Botswana and Mauritius – the only African nations to have sustained multi-party democracy – indicate that geography has little to do this. The British did not introduce universal franchise/democratic rule at the same time or early in most of the territories they controlled – for example they denied it to Hong Kong for over 150 years. If you were not white, it usually only happened in the 40s-60s when the British were leaving or soon after, and in most cases did not survive. Sri Lanka is very unusual – unbroken universal franchise longer than any other nation in Asia-Pacific except Australia and New Zealand. As for the impact of democracy on health, this has been known for a long time, see this paper.

          The idea that allopathic medicine only happened because of European invasion is a form of Western self-rationalization. The only counterfactuals we have are the two Asian nations that were not colonized – Japan and Thailand – all have well-developed allopathic systems. That said, the early establishment of universal franchise in Sri Lanka is a specific outcome of British rule and a minority political ideology (leftist Fabian/Christian socialism) in the UK that had a critical influence on the 1920s constitutional recommendations.

          As for the failure of economic growth, that’s a more complex issue and related to other things, although I would say that the reluctance of our elite to take East Asia seriously is part of it, and that is partly a legacy of European colonialism.

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