What it takes to sustain a malaria-free Sri Lanka


This article was written to commemorate the World Malaria Day 2015. The writer is an independent consultant and an international expert on malaria, formerly of the World Health Organisation, Geneva.

by Dr Kamini Mendis

Yesterday, April 25thwasWorld Malaria Day, so declared as a means of highlighting the need to combat a disease which has plagued mankind over millennia, and which still continues to do so. It is an important day for us Sri Lankans, as now, and for a period of just over two and a half years the country has been free of this disease - an achievement of great significance given that malaria has, over many centuries, devastated Ceylon’s and then Sri Lanka’ development as no other disease has done. It is a cause for celebration, but more importantly, a time for careful reflection on what it takes to sustain a malaria-free Sri Lanka.

As we bask, today, in the comfort of an environment free of malaria – making it possible for rural folk to farm, and their children to school, uninterrupted by frequent episodes of a life-threatening fever, for the more affluent to roam the natural parks and enjoy the stark beauty of the dry zone sans the threat of acquiring a deadly disease, and the tourist industry to flourish in areas which just a few decades ago were hotbeds of malaria, it is well to remember how the country suffered from malaria in the not-so-distant past. In a globally much cited and famed Ceylon epidemic of 1934/35, the country experienced over 1.5 million cases of malaria and 80,000 deaths over a period of just eight months. Since then, by applying advanced public health tools at a considerable cost, the disease was brought under some degree of control, with the incidence still hovering in the range of a few hundred thousands annually – there having been a reported 400,000 cases as recently as in 1991. With numbers like this, it takes little to imagine the health implications of malaria, but more subtle and insidious effects of malaria loomed beneath the surface unknown to many - repeated malaria infections impairs learning in children – stunting the growth of the nation, and the effects of malaria on the economy due to losses in trade, commerce and tourism have been estimated to be gigantic.

We have "eliminated" or in technical terms "interrupted the transmission" of malaria in Sri Lanka. This begs the question: What Now? The answer is: - the battle is not over, because the threat of malaria being re-introduced to the country is ever present, as the experience of the 1960’s starkly reminds us. In the late 1950’s then Ceylon joined the World Health Organisation’s drive to ‘eradicate’ malaria from the world, and success was imminent in 1963 when, from hundreds of thousands of cases malaria was brought down to a mere 17 cases, 11 of them reportedly acquired beyond our shores. As Ceylon, and indeed the world, prepared to celebrate this public health success, malaria returned to the country with a vengeance to persist at endemic levels for nearly five decades thereafter. The "near eradication" of malaria from Ceylon in the 1960’s and its resurgence soon after remains deeply etched in global public health chronicles as a reminder of the tenacity of this disease and its ability to prevail, defying modern public health interventions.

The prospect of a return of malaria to Sri Lanka is real, because the mosquito that transmits malaria is widely prevalent in the country although the malaria parasite that causes the disease is no longer present here. However, in today’s global village that we live in, there is a constant stream of persons entering the country with malaria contracted elsewhere, who if not rapidly diagnosed and treated, could potentially transmit the parasite to a mosquito and begin a cycle of transmission in the country – an occurrence that could take us back to a time when malaria was endemic. This, however, is not inevitable, as the past two and a half years have shown - that it is possible to prevent a return of malaria. The aim of this article is to highlight the multitude of efforts that are ongoing in Sri Lanka to keep the country free of malaria.

Today, as in the past two and a half years, every possible step is being taken to ensure that malaria patients entering the country are diagnosed promptly and treated effectively in order to ensure that they will not transmit the disease to others. The Anti Malaria Campaign (AMC) – at air and seaports rigorously implements surveillance, such as when our peace-keeping troops return from malaria endemic countries, or irregular would-be immigrants of Sri Lankan origin are brought back to the country. Their blood is examined for malaria, and when positive, as some have been found to be, they are treated rapidly. Visitors to Sri Lanka from malaria endemic countries are informed on entry to report to the AMC in the event of fever. Sri Lankans traveling abroad to malaria-endemic countries, who have been identified as the main source of our "imported" malaria cases, are provided preventive treatment free-of-charge by the AMC on request, and advised on action they should take in the event of fever on their return. Refugees from neighbouring countries now living in Sri Lanka under the aegis of UN agencies such as the UNHCR, have been significant sources of imported malaria in Sri Lanka during the past two years as has been a growing body of foreign migrant labour found in construction companies, ports, and industries, several of whom have been found to be infected with malaria. Screening programmes conducted regularly by the AMC in these communities at a considerable effort, and treating those who were found to be positive for malaria has helped to mitigate this risk, but not entirely. Sri Lanka nationals and not just migrants, are being regularly screened for malaria by the AMC. Each year blood films of more than a million Sri Lankans are examined for malaria by the AMC, and extensive mosquito collections are being examined throughout the country by the AMC in an effort to keep us free of malaria.

Perhaps the greatest challenge that the country faces is that, with the elimination of malaria, so has the attention, expertise and skills of our physicians and laboratory technicians to diagnose malaria, faded, and this is to be expected – young physicians in Sri Lanka have rarely, if ever, seen a case of malaria, and so, malaria will soon become a "forgotten" disease as far as the medical profession is concerned. There is now a major effort on the part of the AMC working with medical professional bodies to train and re-train practicing clinicians and medical undergraduates on the need to be alert on this disease – a formidable challenge in the face of a "phantom" disease. If there is a delay in our physicians diagnosing a malaria patient who contracted the disease abroad, not only would the life of the patient be at risk, as has happened on occasions in the past several years, but so would be the health of the entire nation at risk if the disease gets transmitted onwards from such a patient and leads to an epidemic. The AMC with its staff in headquarters and the Regional Malaria Offices and their staff in the Provincial Ministries of Health, are in constant vigil, mounting not only a massive surveillance operation throughout the country, but also taking elaborate steps when a case of imported malaria is detected. They arduously trace the origin of the infection (to a country), and then mount an operation around the residence of the person in Sri Lanka, performing mosquito control operations, and screening the population around that residence to make sure that the person has not transmitted the infection onwards.

The largest source of imported malaria to Sri Lanka is our neighbouring countries – notably India, which still carries a massive burden of the disease. Travel between Sri Lanka and India is extensive – for business, trade, tourism and pilgrimages. It is for this reason that after much spadework, the Government of Sri Lanka, through its Ministries of Health and Foreign Affairs has proposed a SAARC initiative to eliminate malaria from its member countries - a move that was initiated by His Excellency President Sirisena taking the opportunity of the recent visit of His Excellency Mr Modi, Prime Minister of India to Sri Lanka, which is now being accepted by the SAARC Health Ministers as a regional initiative - a magnanimous act on the part of Sri Lanka, but not entirely altruistic. For, unless our neighbours are free of malaria, Sri Lankans will live under the constant threat of a malaria resurgence.

The colossal effort that is now being made to keep malaria out of this country bears a financial cost. For the past decade or so, the budget of the Anti Malaria Campaign has been substantially supplemented by the Global Fund to fight AIDS, Tuberculosis and Malaria, but, this support is expected to cease with there being no more malaria in the country. The Government of Sri Lanka has pledged to take on the cost in its entirety, and a cabinet paper on malaria elimination is under preparation to harness the much required Government support. Sri Lanka is one of the first tropical countries in the recent past to have eliminated malaria and is thus being lauded by the World Health Organisation and the world over, and being held as an outstanding example in many a global public health fora. Singapore freed itself from malaria in 1981, and continues to remain so to date, probably at a high cost and effort. But the analogy between Singapore and Sri Lanka stops there, with Sri Lanka having a far lower per capita income, a much larger landmass and population and a far more diverse ecology than Singapore, all of which makes it more challenging to prevent malaria from returning. When a then senior official of Singapore, was asked by this writer, at a global meeting, for the monetary cost of Singapore’s malaria-free effort, he replied "I do not know, and we do not care; whatever the cost, we are prepared to bear it, to keep Singapore free of malaria". These words, I thought contained great wisdom, for, the cost of malaria to a nation is so great, that the investment, whatever it needs to be, to keep malaria at bay would be comparatively negligible. Proof of this is now being sought through an economic analysis being conducted by us together with international health economists, based on the Sri Lankan experience. The cost of keeping malaria away through a state-of-the-art surveillance and response programme as we must have now, needs to be thought of as a vaccination programmes to prevent a disease. This cost would, surely, be more than offset by the savings to the government on insecticides which amounted to several hundred million rupees annually just a few years ago, not to mention the hospital costs of hundreds of thousands of malaria patients which the Government of Sri Lanka bore when malaria was endemic.

It is clear that financial investments alone will not be sufficient to keep the country free of malaria. A proficient cadre of public health experts and malariologists, resourced adequately, and a rigourous work ethic supplemented by high quality research, all of which the Anti Malaria Campaign currently strives to develop and maintain in collaboration with Universities, Professional Medical Associations, and a diverse group of partners including and not least, the military, will be necessary. Such national investments in preventing resurgence of malaria will bring enormous returns to the country. We must hope that Sri Lankan governments of the future will take note that adequate financial investments and building human capital in pubic health will bring substantial returns for human development.

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