Features
History of Leprosy in Sri Lanka: Saga of three millennia
By Ifham Nizam
Nearly 1500 new patients with leprosy are diagnosed each year. Almost 50 percent of them are residents of four districts, Colombo, Kalutara, Gampaha and Batticaloa. Some areas in the northern, Uva and Central provinces have very few cases and may be considered areas that have “eliminated” leprosy in the true sense, says a senior medical officer.
Dr. Indira Kahawita, Consultant Dermatologist, Anti Leprosy Campaign, Sri Lanka, told The Island that 10 percent of the patients are children below 14 years of age.
“This is an indication of ongoing transmission within the country. About seven percent of the patients have permanent nerve damage at the time of diagnosis. This means there is a delay in diagnosis,” Dr. Kahawita stressed.
Excerpts of the interview with Dr. Kahawita:
* Does leprosy have a long history in Sri Lanka?
Yes, the history of leprosy is as long as the history of the country itself. There is evidence from the ancient medical books, as well as from the chronicles on history. But one need to remember that the disease wasn’t called leprosy then.
In some of my descriptions I have used the terms leper and asylum. These words are used only in the historical context. In the modern world these words are considered discriminatory and are not used.
* Then how is it possible to come to conclusions?
Firstly, some ancient books on medicine, written in the Anuradhapura era, describe symptoms and signs of skin diseases, similar to leprosy. The most notable among them are; Sarartha Sangrahaya” by the Surgeon King Buddhadasa in the 5th century, “Yogarnavaya”, written by Bhikku Buddhaputhra in the 12th century, and “Bhesajja Manjusawa”, written by “Paspiruvan mula/head of five piriven” Bhikku in the 13th century. All these books describe several presentations of “kushtha” that are identical to leprosy. The same is true for the well known Ayurvedic books, “Charaka Sanhithawa” and “Susrutha Sanhithawa”.
After going through these texts very carefully, one can deduct that the word “kushtha” was an all-encompassing term similar to the word ‘rash’ in today’s context, and that leprosy was definitely one of them. Both the Sushrutha and Charaka Sanhitha give almost identical descriptions of “kushtha poorwa roopa”or symptoms of “kushtha”. The absence of sensation, absence of sweating, paraesthesia, goose bumps, unusual pain in the wound (neuropathic pain), ulcers that occur easily and last longer and numbness of organs have been described as symptoms of “kushtha”. Several types of “kushtha” described in the books written in Sri Lanka are identical to the individual features of leprosy.
Secondly, the “Mahawansa” narrates how king Buddhadasa cured a leper of his deranged mental condition when he used abusive language at the king in the marketplace. The statue “Kushtaraja Gala” in Weligama, is now established as an Avalokitheswara bodhisatva. Bodhisatva worship was used for relief from illness and it is believed that lepers of the South worshipped this statue seeking relief.
* What about the legend of the “lion” and Suppa Devi and the
beginning of the Sinhala race?
If one were to think of a medically plausible explanation for the lion, the most suitable would be a well-built young man with lepromatous leprosy who had who had fled to the jungles due to his disease. In fact, the changes in the face in lepromatous leprosy are termed “leonine facies” – face of a lion.
If this is the case, the fact that their offspring were later received at the Royal Court confirms that discrimination against those affected was minimal at that time.
* Was leprosy a dreaded disease in the ancient past?
It is difficult to say that persons affected were not discriminated at all. But the story of Sinhabahu and the fact that the leper who abused king Buddhadasa was able to do so in the market place suggest that those affected were allowed to live freely within the society. The Thripitaka contains the “Suppabuddha Kutti suttha” narrating the story of a person affected who sat in the audience with the others to listen to the preachings of the Buddha who gained enlightenment as the Buddha preached aiming him specifically. Even the bioarcheological work in the Indus valley have shown evidence that there was an empathetic attitude towards those affected.
* What was the status of leprosy in the colonial period?
Even though there are no written records from the Portuguese period, many documents from the Dutch period give details about the status of leprosy. The disease was prevalent in the areas under the Dutch rule and the rulers had started to segregate those affected in order to prevent further transmission. Initially, they were banished to Tutucorin, in India. Later the Dutch East India company allocated funds to build the leper asylum in Hendala. Leprosy was a major health problem in the Dutch era and the officials had been prompt in tackling the situation.
The highlights of the British period are the lepers ordinance no 4 of 1901, the building of the leprosy hospital in Manthivu, off Batticaloa, and the introduction of the early treatments for leprosy. The Lepers Ordinance imposes compulsory segregation of those confirmed to have leprosy. Since all those diagnosed could not be housed within the leprosy hospitals, home quarantine was also practiced.
* What is the status of leprosy hospitals now?
The hospital at Hendala houses patients who were admitted several decades ago. They are there as they have lost family ties due to long separation. In its prime the hospital had boasted of around 700 patients, the best possible medical care and nursing support of religious sisters from many sects. The eminent doctors had done immense service to leprosy care in the country and some have even been honoured by the British empire.
The hospital at Manthivu was opened in 1921 due to the logistic difficulties in transporting patients from the East to Handala. It was decided to close the hospital and transfer 38 patients to Hendala due to safety concerns during the civil unrest in 1996. Two patients who had refused to be moved still remain there.
A leprosy colony, meant for able bodied patients to undergo inpatient care while being economically independent, functioned at Uragasmanhandiya, in the Galle district, for a short period, from 1952 to 1963.
* Why were patients segregated?
There was no effective treatment at that time. In fact, in the Dutch period, it wasn’t even known that leprosy was caused by a bacterium. But it was accepted that spread of the disease could be contained by removing those affected from the community. Initially, segregation was voluntary but after 1901 all patients diagnosed were under segregation, irrespective of their status.
* Does it mean that there was no treatment whatsoever during those days?
The initial treatment options were oils extracted from certain plants as external applications. During the late 19th century, two oils; gurjun oil extracted from the plant Dipterocarpus turbinatus and chaulmoogra oil extracted from the plant Hydnocarpus wightianus were used as massage oils.Chaulmoogra oil became the mainstay of therapy in the 1920s, when better techniques of preparation made it possible for the oil to be used as an oral drug and an injection. But the injections were painful and the response to treatment was around 50%.
With the introduction of a group of drugs called sulphones in the 1930s the treatment took a new turn. By the 1950s dapsone, a better and newer sulphone, was used as monotherapy (single drug therapy) for long periods. Since the organism has the tendency to alter itself to escape the effects of one antibiotic resistance to dapsone was soon identified.
* When was effective treatment for leprosy available in Sri Lanka?
In 1982 the World Health Organization (WHO) introduced a combination of antibiotics called the Multi Drug Therapy (MDT). Sri Lanka started using the MDT island-wide in 1983 and approximately 100 000 patients have been treated with MDT over the past 40 years. There are two types of treatment, paucibacillary (PB) given for six months for those with less severe disease and multibacillary (MB) given for 12 months for those with the more extensive form of the disease. The treatment is provided free of charge by the WHO and is available at government hospitals island-wide. The treatment can be used safely even in pregnant and lactating mothers and children.
*There were popular awareness programmes in the past. Were they effective?
The most effective awareness programme was conducted in the late 1980s with messages about the signs and symptoms of leprosy and that leprosy is curable over all available media. The two teledramas, “Ella langa walawwa” and “Ira Paya” were very effective in taking the message about leprosy to the masses. With improved awareness, the number of patients identified almost trebled in 1990. Many patients presented for treatment by themselves. Since 2000, approximately 1500 to 2000 new patients have been diagnosed each year. There was a drop in the detection of new cases after the COVID-19 pandemic, the Anti-Leprosy Campaign has started a social marketing programme over mainstream and social media called “LIFE Sri Lanka” in 2022.
* Has Sri Lanka eliminated leprosy?
When the WHO introduced the goal of “Eliminating leprosy as a public health problem” in the 1990s the parameter used was “less than one patient with leprosy per 10,000 population”. This highly technical point was not understood even by some healthcare workers. So, the message that was accepted by the public was that “Sri Lanka has eliminated leprosy, or leprosy is no longer present in Sri Lanka”. This misconception may have led to the missing of the diagnosis in many patients. If we look at the statistics for leprosy in Sri Lanka for the past 60 years, we can see that the numbers detected in the country have been within the WHO’s parameters even in the 1960s.
* What is the status of leprosy in Sri Lanka now?
Approximately 1500 new patients with leprosy are diagnosed each year. Almost 50% of them are residents of four districts, Colombo, Kalutara, Gampaha and Batticaloa. Some areas in the northern, Uva and Central provinces have very few cases and may be considered areas that have “eliminated” leprosy in the true sense
10% of the patients are children below 14 years of age. This is an indication of ongoing transmission within the country. About 7% of the patients have permanent nerve damage at the time of diagnosis. This means there is a delay in diagnosis.
*What measures have the authorities taken to control leprosy in Sri Lanka?
The Anti Leprosy Campaign (ALC), the organization in charge of leprosy control, is using a multi-pronged approach to improve awareness about leprosy, both among healthcare workers and the public. The ALC has mapped the country into risk areas according to the WHO’s most recent recommendations and is now in the process of using GIS technology to identify areas with high disease burden and to target those areas for awareness and case detection.
Our aim is to use strategies specifically suited for each area of the country so that all possible cases are diagnosed and started on treatment early. Since treatment of cases and minimizing the reservoir of infection is the only effective method of disease control for leprosy, we are hopeful that the improved strategies will take the country towards zero leprosy or true elimination of the disease.
by Dr Gotabhya Ranasinghe
Senior Consultant Cardiologist
National Hospital Sri Lanka
When we sought a meeting with Hon Dr. Ramesh Pathirana, Minister of Health, he graciously cleared his busy schedule to accommodate us. Renowned for his attentive listening and deep understanding, Minister Pathirana is dedicated to advancing the health sector. His openness and transparency exemplify the qualities of an exemplary politician and minister.
Dr. Palitha Mahipala, the current Health Secretary, demonstrates both commendable enthusiasm and unwavering support. This combination of attributes makes him a highly compatible colleague for the esteemed Minister of Health.
Our discussion centered on a project that has been in the works for the past 30 years, one that no other minister had managed to advance.
Minister Pathirana, however, recognized the project’s significance and its potential to revolutionize care for heart patients.
The project involves the construction of a state-of-the-art facility at the premises of the National Hospital Colombo. The project’s location within the premises of the National Hospital underscores its importance and relevance to the healthcare infrastructure of the nation.
This facility will include a cardiology building and a tertiary care center, equipped with the latest technology to handle and treat all types of heart-related conditions and surgeries.
Securing funding was a major milestone for this initiative. Minister Pathirana successfully obtained approval for a $40 billion loan from the Asian Development Bank. With the funding in place, the foundation stone is scheduled to be laid in September this year, and construction will begin in January 2025.
This project guarantees a consistent and uninterrupted supply of stents and related medications for heart patients. As a result, patients will have timely access to essential medical supplies during their treatment and recovery. By securing these critical resources, the project aims to enhance patient outcomes, minimize treatment delays, and maintain the highest standards of cardiac care.
Upon its fruition, this monumental building will serve as a beacon of hope and healing, symbolizing the unwavering dedication to improving patient outcomes and fostering a healthier society.We anticipate a future marked by significant progress and positive outcomes in Sri Lanka’s cardiovascular treatment landscape within the foreseeable timeframe.
by Fr. Emmanuel Fernando, OMI
Jesuit Fr. Aloysius Pieris (affectionately called Fr. Aloy) celebrated his 90th birthday on April 9, 2024 and I, as the editor of our Oblate Journal, THE MISSIONARY OBLATE had gone to press by that time. Immediately I decided to publish an article, appreciating the untiring selfless services he continues to offer for inter-Faith dialogue, the renewal of the Catholic Church, his concern for the poor and the suffering Sri Lankan masses and to me, the present writer.
It was in 1988, when I was appointed Director of the Oblate Scholastics at Ampitiya by the then Oblate Provincial Fr. Anselm Silva, that I came to know Fr. Aloy more closely. Knowing well his expertise in matters spiritual, theological, Indological and pastoral, and with the collaborative spirit of my companion-formators, our Oblate Scholastics were sent to Tulana, the Research and Encounter Centre, Kelaniya, of which he is the Founder-Director, for ‘exposure-programmes’ on matters spiritual, biblical, theological and pastoral. Some of these dimensions according to my view and that of my companion-formators, were not available at the National Seminary, Ampitiya.
Ever since that time, our Oblate formators/ accompaniers at the Oblate Scholasticate, Ampitiya , have continued to send our Oblate Scholastics to Tulana Centre for deepening their insights and convictions regarding matters needed to serve the people in today’s context. Fr. Aloy also had tried very enthusiastically with the Oblate team headed by Frs. Oswald Firth and Clement Waidyasekara to begin a Theologate, directed by the Religious Congregations in Sri Lanka, for the contextual formation/ accompaniment of their members. It should very well be a desired goal of the Leaders / Provincials of the Religious Congregations.
Besides being a formator/accompanier at the Oblate Scholasticate, I was entrusted also with the task of editing and publishing our Oblate journal, ‘The Missionary Oblate’. To maintain the quality of the journal I continue to depend on Fr. Aloy for his thought-provoking and stimulating articles on Biblical Spirituality, Biblical Theology and Ecclesiology. I am very grateful to him for his generous assistance. Of late, his writings on renewal of the Church, initiated by Pope St. John XX111 and continued by Pope Francis through the Synodal path, published in our Oblate journal, enable our readers to focus their attention also on the needed renewal in the Catholic Church in Sri Lanka. Fr. Aloy appreciated very much the Synodal path adopted by the Jesuit Pope Francis for the renewal of the Church, rooted very much on prayerful discernment. In my Religious and presbyteral life, Fr.Aloy continues to be my spiritual animator / guide and ongoing formator / acccompanier.
Fr. Aloysius Pieris, BA Hons (Lond), LPh (SHC, India), STL (PFT, Naples), PhD (SLU/VC), ThD (Tilburg), D.Ltt (KU), has been one of the eminent Asian theologians well recognized internationally and one who has lectured and held visiting chairs in many universities both in the West and in the East. Many members of Religious Congregations from Asian countries have benefited from his lectures and guidance in the East Asian Pastoral Institute (EAPI) in Manila, Philippines. He had been a Theologian consulted by the Federation of Asian Bishops’ Conferences for many years. During his professorship at the Gregorian University in Rome, he was called to be a member of a special group of advisers on other religions consulted by Pope Paul VI.
Fr. Aloy is the author of more than 30 books and well over 500 Research Papers. Some of his books and articles have been translated and published in several countries. Among those books, one can find the following: 1) The Genesis of an Asian Theology of Liberation (An Autobiographical Excursus on the Art of Theologising in Asia, 2) An Asian Theology of Liberation, 3) Providential Timeliness of Vatican 11 (a long-overdue halt to a scandalous millennium, 4) Give Vatican 11 a chance, 5) Leadership in the Church, 6) Relishing our faith in working for justice (Themes for study and discussion), 7) A Message meant mainly, not exclusively for Jesuits (Background information necessary for helping Francis renew the Church), 8) Lent in Lanka (Reflections and Resolutions, 9) Love meets wisdom (A Christian Experience of Buddhism, 10) Fire and Water 11) God’s Reign for God’s poor, 12) Our Unhiddden Agenda (How we Jesuits work, pray and form our men). He is also the Editor of two journals, Vagdevi, Journal of Religious Reflection and Dialogue, New Series.
Fr. Aloy has a BA in Pali and Sanskrit from the University of London and a Ph.D in Buddhist Philosophy from the University of Sri Lankan, Vidyodaya Campus. On Nov. 23, 2019, he was awarded the prestigious honorary Doctorate of Literature (D.Litt) by the Chancellor of the University of Kelaniya, the Most Venerable Welamitiyawe Dharmakirthi Sri Kusala Dhamma Thera.
Fr. Aloy continues to be a promoter of Gospel values and virtues. Justice as a constitutive dimension of love and social concern for the downtrodden masses are very much noted in his life and work. He had very much appreciated the commitment of the late Fr. Joseph (Joe) Fernando, the National Director of the Social and Economic Centre (SEDEC) for the poor.
In Sri Lanka, a few religious Congregations – the Good Shepherd Sisters, the Christian Brothers, the Marist Brothers and the Oblates – have invited him to animate their members especially during their Provincial Congresses, Chapters and International Conferences. The mainline Christian Churches also have sought his advice and followed his seminars. I, for one, regret very much, that the Sri Lankan authorities of the Catholic Church –today’s Hierarchy—- have not sought Fr.
Aloy’s expertise for the renewal of the Catholic Church in Sri Lanka and thus have not benefited from the immense store of wisdom and insight that he can offer to our local Church while the Sri Lankan bishops who governed the Catholic church in the immediate aftermath of the Second Vatican Council (Edmund Fernando OMI, Anthony de Saram, Leo Nanayakkara OSB, Frank Marcus Fernando, Paul Perera,) visited him and consulted him on many matters. Among the Tamil Bishops, Bishop Rayappu Joseph was keeping close contact with him and Bishop J. Deogupillai hosted him and his team visiting him after the horrible Black July massacre of Tamils.
Sri Lanka-Singapore Free Trade Agreement
By Gomi Senadhira
senadhiragomi@gmail.com
“You might tell fairy tales, but the progress of a country cannot be achieved through such narratives. A country cannot be developed by making false promises. The country moved backward because of the electoral promises made by political parties throughout time. We have witnessed that the ultimate result of this is the country becoming bankrupt. Unfortunately, many segments of the population have not come to realize this yet.” – President Ranil Wickremesinghe, 2024 Budget speech
Any Sri Lankan would agree with the above words of President Wickremesinghe on the false promises our politicians and officials make and the fairy tales they narrate which bankrupted this country. So, to understand this, let’s look at one such fairy tale with lots of false promises; Ranil Wickremesinghe’s greatest achievement in the area of international trade and investment promotion during the Yahapalana period, Sri Lanka-Singapore Free Trade Agreement (SLSFTA).
It is appropriate and timely to do it now as Finance Minister Wickremesinghe has just presented to parliament a bill on the National Policy on Economic Transformation which includes the establishment of an Office for International Trade and the Sri Lanka Institute of Economics and International Trade.
Was SLSFTA a “Cleverly negotiated Free Trade Agreement” as stated by the (former) Minister of Development Strategies and International Trade Malik Samarawickrama during the Parliamentary Debate on the SLSFTA in July 2018, or a colossal blunder covered up with lies, false promises, and fairy tales? After SLSFTA was signed there were a number of fairy tales published on this agreement by the Ministry of Development Strategies and International, Institute of Policy Studies, and others.
However, for this article, I would like to limit my comments to the speech by Minister Samarawickrama during the Parliamentary Debate, and the two most important areas in the agreement which were covered up with lies, fairy tales, and false promises, namely: revenue loss for Sri Lanka and Investment from Singapore. On the other important area, “Waste products dumping” I do not want to comment here as I have written extensively on the issue.
1. The revenue loss
During the Parliamentary Debate in July 2018, Minister Samarawickrama stated “…. let me reiterate that this FTA with Singapore has been very cleverly negotiated by us…. The liberalisation programme under this FTA has been carefully designed to have the least impact on domestic industry and revenue collection. We have included all revenue sensitive items in the negative list of items which will not be subject to removal of tariff. Therefore, 97.8% revenue from Customs duty is protected. Our tariff liberalisation will take place over a period of 12-15 years! In fact, the revenue earned through tariffs on goods imported from Singapore last year was Rs. 35 billion.
The revenue loss for over the next 15 years due to the FTA is only Rs. 733 million– which when annualised, on average, is just Rs. 51 million. That is just 0.14% per year! So anyone who claims the Singapore FTA causes revenue loss to the Government cannot do basic arithmetic! Mr. Speaker, in conclusion, I call on my fellow members of this House – don’t mislead the public with baseless criticism that is not grounded in facts. Don’t look at petty politics and use these issues for your own political survival.”
I was surprised to read the minister’s speech because an article published in January 2018 in “The Straits Times“, based on information released by the Singaporean Negotiators stated, “…. With the FTA, tariff savings for Singapore exports are estimated to hit $10 million annually“.
As the annual tariff savings (that is the revenue loss for Sri Lanka) calculated by the Singaporean Negotiators, Singaporean $ 10 million (Sri Lankan rupees 1,200 million in 2018) was way above the rupees’ 733 million revenue loss for 15 years estimated by the Sri Lankan negotiators, it was clear to any observer that one of the parties to the agreement had not done the basic arithmetic!
Six years later, according to a report published by “The Morning” newspaper, speaking at the Committee on Public Finance (COPF) on 7th May 2024, Mr Samarawickrama’s chief trade negotiator K.J. Weerasinghehad had admitted “…. that forecasted revenue loss for the Government of Sri Lanka through the Singapore FTA is Rs. 450 million in 2023 and Rs. 1.3 billion in 2024.”
If these numbers are correct, as tariff liberalisation under the SLSFTA has just started, we will pass Rs 2 billion very soon. Then, the question is how Sri Lanka’s trade negotiators made such a colossal blunder. Didn’t they do their basic arithmetic? If they didn’t know how to do basic arithmetic they should have at least done their basic readings. For example, the headline of the article published in The Straits Times in January 2018 was “Singapore, Sri Lanka sign FTA, annual savings of $10m expected”.
Anyway, as Sri Lanka’s chief negotiator reiterated at the COPF meeting that “…. since 99% of the tariffs in Singapore have zero rates of duty, Sri Lanka has agreed on 80% tariff liberalisation over a period of 15 years while expecting Singapore investments to address the imbalance in trade,” let’s turn towards investment.
Investment from Singapore
In July 2018, speaking during the Parliamentary Debate on the FTA this is what Minister Malik Samarawickrama stated on investment from Singapore, “Already, thanks to this FTA, in just the past two-and-a-half months since the agreement came into effect we have received a proposal from Singapore for investment amounting to $ 14.8 billion in an oil refinery for export of petroleum products. In addition, we have proposals for a steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million), sugar refinery ($ 200 million). This adds up to more than $ 16.05 billion in the pipeline on these projects alone.
And all of these projects will create thousands of more jobs for our people. In principle approval has already been granted by the BOI and the investors are awaiting the release of land the environmental approvals to commence the project.
I request the Opposition and those with vested interests to change their narrow-minded thinking and join us to develop our country. We must always look at what is best for the whole community, not just the few who may oppose. We owe it to our people to courageously take decisions that will change their lives for the better.”
According to the media report I quoted earlier, speaking at the Committee on Public Finance (COPF) Chief Negotiator Weerasinghe has admitted that Sri Lanka was not happy with overall Singapore investments that have come in the past few years in return for the trade liberalisation under the Singapore-Sri Lanka Free Trade Agreement. He has added that between 2021 and 2023 the total investment from Singapore had been around $162 million!
What happened to those projects worth $16 billion negotiated, thanks to the SLSFTA, in just the two-and-a-half months after the agreement came into effect and approved by the BOI? I do not know about the steel manufacturing plant for exports ($ 1 billion investment), flour milling plant ($ 50 million) and sugar refinery ($ 200 million).
However, story of the multibillion-dollar investment in the Petroleum Refinery unfolded in a manner that would qualify it as the best fairy tale with false promises presented by our politicians and the officials, prior to 2019 elections.
Though many Sri Lankans got to know, through the media which repeatedly highlighted a plethora of issues surrounding the project and the questionable credentials of the Singaporean investor, the construction work on the Mirrijiwela Oil Refinery along with the cement factory began on the24th of March 2019 with a bang and Minister Ranil Wickremesinghe and his ministers along with the foreign and local dignitaries laid the foundation stones.
That was few months before the 2019 Presidential elections. Inaugurating the construction work Prime Minister Ranil Wickremesinghe said the projects will create thousands of job opportunities in the area and surrounding districts.
The oil refinery, which was to be built over 200 acres of land, with the capacity to refine 200,000 barrels of crude oil per day, was to generate US$7 billion of exports and create 1,500 direct and 3,000 indirect jobs. The construction of the refinery was to be completed in 44 months. Four years later, in August 2023 the Cabinet of Ministers approved the proposal presented by President Ranil Wickremesinghe to cancel the agreement with the investors of the refinery as the project has not been implemented! Can they explain to the country how much money was wasted to produce that fairy tale?
It is obvious that the President, ministers, and officials had made huge blunders and had deliberately misled the public and the parliament on the revenue loss and potential investment from SLSFTA with fairy tales and false promises.
As the president himself said, a country cannot be developed by making false promises or with fairy tales and these false promises and fairy tales had bankrupted the country. “Unfortunately, many segments of the population have not come to realize this yet”.
(The writer, a specialist and an activist on trade and development issues . )
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