Dengue outbreak in Sri Lanka highlights deteriorating public health services

By Ajitha Gunaratna
16 June 2004

An island-wide outbreak of dengue fever in Sri Lanka in recent months has underlined the steady deterioration of public health care and preventative measures to contain the disease.

Up to June 8, there had been 4,347 cases officially recorded for the year, including 22 deaths. In May alone, there were 1,532 cases—three times more than for April. Health officials admit that for the first quarter of the year the figure was 40 percent higher than for the corresponding period last year. The capital of Colombo as well as Gampaha, Kandy and Kurunegala districts are among the worst affected areas.

Across the island, public hospitals are overcrowded with patients suffering from dengue and other viral fevers. The lack of facilities has been compounded by an outbreak of dysentery, with 2,800 cases since January, particularly in Nuwara Eliya, Matale, Badulla, Kaluthara, Colombo and Gampaha districts.

Dengue fever is a debilitating mosquito-borne disease that is potentially fatal, particularly to young children and the elderly. It was first reported in Sri Lanka in 1965 but has become a regular epidemic since 1989. The peak incidence of the disease generally comes after the monsoon season, when the density of the two mosquito carrier species— Aedes aegypti and Aedes albopictus—is especially high.

Government and health ministry officials try to paint a picture of the dengue epidemics as unpreventable natural disasters. But the real reasons for the spread of the disease lie in poor sanitation, ineffective government preventative measures and financial cutbacks to public health services.

“Dengue control” has become an annual piece of theatre aimed more at appeasing widespread concern about the disease than dealing with the underlying causes. Special task forces and committees are set up to “curb” the outbreak but each year since 1989 the number of dengue cases has risen.

Like previous governments, the ruling United Peoples Freedom Alliance (UPFA) tries to blame ordinary people for not eradicating mosquito breeding sites. Health Minister Nimal Siripala De Silva warned recently that the government is preparing laws to punish those who do not heed notices to clean up their premises. The Colombo municipal council has already filed legal action against nearly 200 housing units and institutions after issuing some 1,800 warning letters.

But local governments and municipal councils are directly responsible for many of the largest mosquito breeding areas. There have been frequent protests against the creation of large uncovered garbage dumps near residential areas and the failure to clean stagnant canals, sewerage sites and other pits and potholes filled with polluted water. Environment Minister A.H.M Fouzie was recently forced to visit a garbage dump in the Colombo suburb Dehiwala after protests by local residents.

Unplanned urban development has created a large number of mosquito breeding sites. The high mosquito population is responsible for spreading not only dengue but other diseases like malaria, filaria and Japanese encephalitis. According to Dr Amal Harsha De Silva, Sri Lankans burn on average three large containers of mosquito coils a month to try to ward off mosquito bites.

The Government Entomological Assistants Union (GEAU), whose members study insects and their links to various diseases, has accused successive governments of ignoring their surveys and not using their technological assistance. Surveys earlier this year revealed that even during the dry season the Breteau Index for the two mosquito species linked to dengue was far in excess of World Health Organisation (WHO) guidelines.

The Breteau Index is the proportion of housing units found to have the mosquito larvae out of the total surveyed, then multiplied by 100. The WHO warns that a figure of more than 5 constitutes a dengue risk. The Colombo suburbs of Mahara, Maharagama and Kotte were found to have a Breteau Index of 18, 12 and 30 respectively.

The Chief Medical Officer of Health for the Colombo Municipal Council, Pradeep Kariyawasam, explained to the WSWS that one of the problems was that control programs could not be started at the proper time. “The dengue mosquito’s flying range is only 100-200 metres. So if we could start our control and education programs early it would be easy to reduce casualties.”

Kariyawasam added: “The biggest problem we face is a lack of manpower as a result of not recruiting people for 10 to 15 years. We do not have a single entomological assistant. We need at least 50 public health inspectors but we have only 23 now. We have only 22 field assistants to cover the work of 75. We employ only 70 health instructors though we need 150.

“Our budget does not allow us to communicate our educative messages in the electronic media and press. TV companies charge 20,000 rupees per 15 seconds. A one-page newspaper advertisement costs 100,000 rupees. Even in the state-owned media we do not get a chance.”

The situation has worsened as council services have been privatised. A resident in the Sri Jayawardanapura municipal council area told the WSWS: “After the cleaning services were privatised, the number of sanitary workers has been further reduced and we have to keep our garbage for several days until someone comes. The spraying of insecticides for mosquitoes has been halted or curtailed. I have not seen any spraying for several months.”

Health care has also been subject to cutbacks and privatisation. As private health operators have no interest in preventing diseases, the budget for such activities has declined sharply. Government expenditure on health services has fallen from 2.3 percent of the gross national product in 1989 to 1.4 percent in 2003. Of that only 15.3 percent is allocated to community health services, including disease prevention.

GEAU secretary R.P. Kuruppuarachchi explained: “Most of the special control programs have failed as the direct result of decentralisation and drastic funding cuts. These special programs are functioning only in an advisory capacity. Provincial councils and local governments can ignore the advice provided to them if it does not fit with their budgets. See what has happened to our Anti-Rabies Campaign: Dogs are not inoculated against rabies and stray dogs are not being caught. Other campaigns, including the dengue control program, face a similar fate.”

Consultant epidemiologist Dr. Paba Palihawadana also pointed to the lack of adequate prevention programs. “I think the fund allocation for the prevention side is very low. It is very difficult to contain epidemics like dengue without having national-level control programs supplied with sufficient funds and manpower.”

The resultant dengue outbreaks place severe strains on public hospitals, with wards filled to overflowing with patients. Staff have cited cases of wards with a capacity of just 60 patients being forced to accommodate around 150. Patients have to share beds with one or two others while scores of patients lie on the floor.

Even relatively simple things, such as providing a mosquito net for patients and staff at government hospitals, are not done. An attendant at the Colombo South General Hospital told WSWS: “We have number of dengue patients in our ward now. Two nurses on our ward have also contracted dengue. They may have got the disease here.”

In addition, government hospitals lack sufficient blood testing facilities to determine whether patients have dengue fever. As a result, patients are forced to turn to private laboratories. The country’s leading private laboratory service, Asiri, does more than 1,000 Full Blood Count (FBC) tests and at least 100 dengue serology tests a day. None of the government hospitals have the facilities to carry out dengue serology tests—the only means of definitely confirming the disease. Many patients simply cannot afford the cost.

Nurses at the National Hospital in Colombo explained: “Most of the dengue patients here are casual workers working at building sites. Others are those who do odd jobs in Colombo city. They can’t afford to have blood tests done outside. An FBC [Full Blood Count] test costs half a day’s salary—that is 200 rupees [$US2]. We have been allocated money for very limited FBC tests. And for a dengue serology test they have to pay 1,000 rupees to have it done outside.”

For dengue patients in a critical condition, matters are even worse. They should be treated in Intensive Care Units but such facilities are in limited supply. Only a few government hospitals have such units and, even where they exist, spare beds are rare. Moreover, the blood transfusion and platelet transfusion services sometimes needed for critically-ill dengue patients are not available in most of hospitals.

Despite the deterioration of public health services and preventative programs, the government has no intention of making any improvements. Last month Health Minister De Silva cynically dismissed growing public concerns about the dengue outbreak by declaring that treatment of the disease had fared much better than prevention. “Our health system has all the drugs and funds required to combat dengue. So patients do not need to worry about treatment,” he declared.