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1
Health began in the domain of culture and medicine originated
from healing. Health was identified as “ being well”, “lack of
disease” or “no illness” (the conception of illness as dis-ease is
derived from the old French word aise meaning „comfort‟).
Medically, health can be defined as “not sick”, but even the
modern definitions of health cannot be neutral as even the
concepts of medicine are constantly influenced by metaphors of
the society which it is situated. However, health is a “state of
freedom” or “being well”, which is a stage of management.
Though medicine became secular and highly influenced by
modern discourses, it is not totally free from culture. Then it is
this medicine-culture connection which is important in the
study of environment and health within environmental
management. This is because the need for environmental
management is higher than ever in the history of man as his
habitat is threatened by many known and unknown forces of
human development.
There is enough evidence that management of environment has
reduced the threat of disease in the old kingdoms and empires
and once this balance was destroyed there was chaos (Page 55).
Modern developed world provide ample examples to the need
for environmental management for the reduction of health
threats.
The Health Belief Model identifies the validity of personal
environmental factors like level of concern, motivation and
previous experience (Rosenstock 1965), in behaviour which
result from the evolution of the living environment of an
individual. This living environment varies over space and time
but the level of management at each step shapes the behaviour.
Theory of Reasoned Action (Fishbein 1967), the Theory of
Planned Behaviour (Ajzen 1985), and the Health Action
Process (Schwarzer 1992), have developed and clarified the
Health belief Model but the importance of personal
environmental factors remained unchanged.
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management required by them. The relationship between
poverty and health was discussed in Marx
(Doyal 1979; Navarro 1976), when Engels observed the close
relationship between the distribution of poverty and the
distribution of illness. The strict management of the
environment was also required both in the capitalist Marxist
and Socialist Marxist state. Both these groups of states have
achieved higher levels of environmental management and
health.
Health
3
Health in the context of developing countries is a status, where
disease is not serious enough to seek medical attention. In here
the status of disease is also weighed according to its long term
or debilitating effect. As there is no regular health check-up
system and continuous medical record system the treatment is
conducted in an isolated sphere from the natural and social
environment of the person. Therefore it is believed that the
health measured by commonly known variables like life
expectancy at birth, child mortality and maternal mortality may
have only a marginal picture on health status of the developing
world including Sri Lanka. In addition availability of
unregistered medical practitioners and pharmacy network
facilitates some sick to be not counted at any stage in studies of
environment and health.
In addition poverty in the developing world makes some people
with good physical health to have hidden mental sicknesses
which are not detected until they are subjected to certain
stresses. For example newspaper reports collected from some
dailies of Sri Lanka indicate that a bus conductor (passed 8 th
grade in school) has behaved in an indecent manner to a
passenger and was discovered to be suffering from the problem
of sadist behaviour under medical examination. A university
student has acted like a mafia person in an attack on another
student. A minister with a degree in Sociology has used abusive
words on his opponent in politics. Therefore people with good
physical health may be mentally unstable under stress or inbuilt
hidden mental status.
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healthy, though they had minor illnesses which required no
continuing medical attention (Seneviratne, 2003).
5
However this phase has to mature into a more organised way of
managing the environment if we are to feed the rising
populations, provide employment and provide a healthy living
environment.
6
Secondly, independent academic bodies should be activated
with full public powers to monitor and make recommendations
to the health authorities on public health problems.
In addition concepts of environmental change and change of
environment are also considered here as important in the study
of new environmental management, because of their spatio-
temporal impact on health.
Environmental change
7
which they had very low immunity. It is believed that a
population of about 6 million around Ad 1200 has dropped to
about a million in and around 1400 AD. Major diseases which
led to this destruction of population were malaria, dysentery
and typhoid fever which originated as a result of destruction of
water supply and drainage system. Since the arrival of western
colonists environment of Sri Lanka was changed to suit the
cultivation of tree crops and spices. We are still in this
environment and have begun to introduce an unplanned urban
and rural settlement expansion. Therefore our environment is
becoming more and more polluted, dangerous and chaotic to
live (Read History of Disease Environment – page 55).
Change of environment is the change of living environment by
migration for the purpose of living and economic activity.
Migration to farm settlements, urban areas and emigration
result in change of environment. Again if these activities are
not planned properly, the new environment is subjected to
pollution, becoming dangerous and chaotic to live. When
emigration is not conducted in a proper manner the emigrants
are subjected to many legal and social difficulties, which may
result in abuse and trauma.
The holistic view of the environment is utilised in the new
concept of health environment management, where value of
health environment is weighed on the basis of its long-term
sustainability within the environment. Therefore the new
concept is constantly linked to agriculture, industry,
investment, monetary policy, livelihoods and economic
planning. This enables the health environment manager to
begin at the point of investment and end at sustainable control
(Figure 1.1).
Investment programme
8
Environmental – natural and societal resources
Sustainability
9
national income have a very limited relationship to the well
being of people. This is primarily a result of not accounting
the cost of health on real income. For example unless the
infectious diseases are controlled wellbeing of the people are
degraded. This is exactly the situation almost all the poor
countries of the world including Sri Lanka.
There are two major forces in action in a given environment
in the formation of disease: Physical systems and Societal
systems. These two systems should operate on a highly
complementary state if success is to be achieved in the
programme of health environment management.
The physical systems operate on the principles of natural
sciences and form many types of risks. The endemic
environment is decided upon by the climate and topographic
environment of a given place. For example malaria in the
dry zone is formed from a combination of seasonally dry
climate and even landscape with slow flowing streams.
Respiratory diseases in urban environment result from lack
of control of air pollution and living in houses without
proper ceilings where droplet spray settles in the night.
Amount of water available in a given country is of utmost
importance to its health and development. The amount of
water available in a given country is related to its rainfall,
runoff and storage. This amount of water changes over space
and time. For example in Sri Lanka, its ancient civilisation
depended on a total forest cover of the highlands, which
enabled them to receive large quantities of spring water to
the rivers flowing across the plain. At that time there was
slightly higher rainfall in Sri Lanka, runoff was low due to
thick forest cover and storage was high due to non-clearance
of upper catchment forests and a well designed settlement
plan. Since the movement of civilisation to the wet zone,
gradually the highland forests were destroyed and today Sri
Lanka is an area of constant water shortages. This is due to
inability of the present environmental managers to
understand the true dynamics of the water supply system of
Sri Lanka. The designs of the countries where problem of
water is minimised indicate that the holistic view they have
incorporated into their environmental planning has yielded
10
expected results. These planning systems utilise the value of
upper catchment conservation and settlement planning as an
integral part of conservation of water. Modern settlement
utilise massive quantities of water and water supply in them
cannot be maintained well without recycling of water.
11
poverty itself has to be eliminated with the help of the
physico-ecological environment of the developing world,
because the primary step towards alleviation of poverty is to
provide food and shelter. In this context migration becomes
a necessity as the present areas of habitat are not sufficient
to provide these basic requirements of food or shelter in the
developing world, where rapidly rising populations and
epidemiological puzzles are common.
Mayer (1990), in a general evaluation of the traditions of
geographical and medical geographical thought, discuses the
utilization of spatial, human environment, physical and
regional traditions in medical geography and explains the
value of an ecological approach in the study of disease
patterns within the human environment tradition. He further
indicates that there is a close association between the human
environment tradition and disease ecology.
Curtis and Taket (1996) identify two major traditions in
medical geography and two strands under each of the two
traditions. Spatial patterning of disease and health and
service provision is categorized as the two strands of
traditional medical geography. Contemporary medical
geography is studied within the humanistic tradition and the
structuralist/materialist/critical turn. The final strand under
contemporary medical geography is named transgressing the
boundaries – the cultural turn. The cultural turn has begun to
pay more attention to place and health, reviving an old
tradition in a new perspective.
Kearns and Moon (2002: 612-613) have investigated this
changing nature of medical geography and the emergence of
health geography. They explain that the complexity of
theory in medical or new health geography arises from the
nature of health and health related problems themselves,
which keep changing with changes in development and
natural ecology.
This diversity of approaches in medical and health
geography is provided by writers such as May (1954 and
1982) Mead (1976), Kjekshus (1977), Turshen (1984)
Mayer (1996 and 1999), Gatrell (2001), Kearns and Moon
(2002) and Seneviratne (2003).
12
The evolution of the study of health related issues in
geography therefore originated from the epidemiological
method, but geographers have utilised a more human
approach and have begun to move away from physical
epidemiology. However, the value of ecology remains
extremely important in studies of the development world
where the incidence and prevalence of environment related
diseases have not been adequately controlled. This situation
demands the continuation of an ecological model either in
full, or as it becomes relevant to a particular study.
The settlers in this study, and in most parts of the developing
world, encounter a change of environment and an
environmental change which results not only in a change of
developmental level, but also a physical one. As explained
earlier under the sub topic of development strategies, the
resettlement programme of Sri Lanka is a product of its
political authority. This is because the present state of
landlessness in the wet zone is a product of colonial land
policies, and the continuation of the same policies beyond
independence. Recent high demand for land by farming
families of the wet zone can be linked to the early
achievement of better health status among them, which
resulted in a population explosion between 1950 and 1970.
Therefore it is evident that an environmental change for the
better in the wet zone has increased its farming population
rapidly, and that the excess population has to be
accommodated in the dry zone to prevent them being a
challenge to plantation land or feudal land. This situation
leads to provision of land in the dry zone for the farmers
who wish to continue their paddy rice cultivation. This
situation is common to many developing countries where
land is a commodity of the rich and powerful and national
planning has not prepared land for the use of the poor.
13
which inspired the adoption of a similar approach in this
study.
In his presentation of the disease ecology approach, May
(1954) identified the importance of biology and material
aspects of culture in disease complexes, and the interaction
between humans and their environment as a progenitor of
disease in humans.
Hughes and Hunter (1970) have dealt with the impact of
modernization and socio-political development in relation to
understanding disease, implying the importance of
development in change of environment or environmental
change. Turshen (1984) gives a presentation of the political
ecology of disease in Tanzania, and emphasizes the
importance of development strategies and ecological
consequences in the study of health. Kjekshus (1977) and
Desowitz (1981) have presented strong empirical evidence
for the importance of ecology within a geographical and
historical and context. Meade et al (1988:19) utilizes the
ecological model in a discussion of resettlement and health:
Packard et al (1989) indicates the increase use of
geographic, climatic, economic and political factors in
studies of health and disease. These theoretical submissions
rely on the importance of ecology in the construction of
disease scenario of the tropical developing world. The
development of resistant varieties of bacteria and viruses,
and encounters with new diseases as discussed earlier,
further enhance the value of investigating the role played by
change of ecological environment due to modern
developmental process.
The use of an ecological model of disease and its evolution
is summarized by Mayer (1996), who explains the use of
social and psychological contexts by both geographers and
epidemiologists. Further he presents a detailed investigation
of research connected to disease ecology.
As suggested by Packard et al (1989), disease ecology can
be taken a stage further by incorporating geographic,
climatic, economic and political factors that affect disease
patterns.
14
Studies of health and disease have recognized the limitations
of research, which depends on narrow biological
determinants of disease. This type of inquiry has resulted
from the increasing link that is made between political
process and development, which results in health
implications from epidemics and the high prevalence of
easily controllable infectious diseases. Brownlea (1981)
indicate the neglect of this aspect of power and politics in
the analysis of health care systems and epidemiological
questions. In a study of environmental change and disease in
Tanzania, Turshen (1977) has criticized May (1954) for
neglecting politics, and Kjekshus (1979) uses a political
economy approach without much consideration of disease
ecology. The way to find an approach is through the
understanding of May (1958) in a context that he was a
medical doctor and implicitly or explicitly excluded the role
of politics in health (Mayer, 1996). Studies on malaria in
Trinidad (Fonaroff, 1968), and Malaysia (Meade, 1976)
emphasise the importance of political policy making in the
proliferation of disease, but have not incorporated the full
contribution of politics in the formulation of disease
scenarios. However, these studies can from a basis for the
political ecology of disease, which will be flexible and allow
political and economic considerations to be included in
ecologically based studies.
15
Another aspect of political ecology is its ability to
accommodate varying scales ranging from the local to the
global. The important place of historical analysis in political
ecology provides an understanding of structural change over
time and its effect on social structure and social relations.
These characteristics enable political ecology to be used as
an alternative to disease ecology, when socio-political
factors have an overwhelming influence on the formation of
health and disease scenarios. Studies by Meade (1976),
Turshen (1977), Kjekshus (1979), Grossman (1988),
Packard (1989) and Mayer (1996) have contributed to the
emergence of this valuable approach, which is applicable to
developing areas of the world where ecological
considerations have become secondly to political
programmes, resulting in many troublesome health and
disease scenarios. Resettlement and encroachment on
marginal land in the developing world has increased the
prevalence of infectious diseases, and these programmes
either directly or indirectly have been initiated by socio-
political forces operating within societies and from outside.
Prothero (1994:661) discusses the health problems
associated with resettlement in detail and his analysis
applies well to the situation under study in this book,
because the macro scenario of disease prevalence in the
study areas indicates higher morbidity among settlers than
their siblings in the home villages. This high morbidity
arises from the high prevalence of infectious diseases in
resettlement programme areas, which can be explained as
resulting from changes in physical environment and the
core-periphery relationships of modernization.
The impoverishment risks/restoration model presented by
Cernea (1996:21) identified increased morbidity as one of
the eight factors which can contribute to multifaceted
impoverishment. Kjekshus‟s work (1977) is very relevant to
the situation under discussion in this book, as a basis for
discussion of the environmental change associated with poor
to middle income groups of people. In his study attention is
focused on the issues relating to man and his environment,
and the role played by the economic basis of indigenous
16
initiatives in the evolution of change in new environments.
The study shows that far from being initiators of a defensive
reaction to a crisis situation, nineteenth century East
Africans were on the offensive against a hostile ecological
system, and until the end of the century they were the victors
in the struggle. Within this structure early settlements of the
region were organized around permanent water, and more
advanced agricultural societies had narrow border strips of
forest between the tribal heartlands. The cattle were kept on
the savanna, which was burned annually to prevent disease
and provide fodder.
Prior to land acquisition for plantations, the environment of
the wet zone villages in Sri Lanka was in a state of balance
equivalent to that of late 19th century East Africa. The land
acquisition of the colonial period in the wet zone of Sri
Lanka resulted in a loss for villagers of fodder, medical,
timber and other forest resources. The aftermath of this
environmental change was the fragmentation of ancestral
land. The rapid increase in population in the early 1950s
caused modern development planners to utilize resettlement
as a solution to landlessness.
This type of expansion of the farming habitat in the
developing world began with the establishment of
independent states after the Second World War and was
primarily encouraged by policies of food production. These
were implemented using irrigation farming in dry areas, cash
crop cultivation in forest areas, expansion of grazing lands
and provision of energy through the production of hydro
electricity. The development of dam and canal systems in
Asia, Africa and Latin America was based on the principle
of multipurpose utilization of natural resources, as
developed in the Western model of river basin development.
The initial rapid implementation/development of the
programme was further accelerated by a rapid expansion of
population, resulting from control of the most deadly
infectious diseases like smallpox, measles and cholera.
Meade (1976) identifies five major hazards of resettlement
in the tropical rain forest in Malaysia, resulting from change
of environment and environmental change. The construction
17
of canals in the dry zones of India and its impact on malaria
incidence is explained in detail by Whitcomb (19950. The
rise of ground water and associated rise in soil moisture and
humidity due to canal construction is given as the major
reason for high malaria incidence in this area. All the canal
areas were extremely malarious and fever mortality was
high. A similar scenario occurred in the Punjab with the
construction of the Triple Canal Project.
The impact of change of environment and environmental
change on health has been identified in relation to
development in many parts of the developing world. One of
the paths to marginalisation is through the loss of economic
power due to ill health. III health can create a situation
where a large portion of income is lost to treatment and
because of an inability to farm. As observed by Cernea
(1996), health contributes to impoverishment in resettlement
related development due to exposure to change of
environment.
These studies indicate that neglect of the health implications
of resettlement exposes the settler to serious health hazards.
This is primarily due to lack of understanding of the process
of environmental change, or neglect of the ecological factor
in planning resettlement. Therefore, resettlement can lead to
the creation of a group of people who are vulnerable to
disease and marginalisation due to neglect of the ecological
factor. A similar scenario is suspected in the study area, as
even the resettlement schemes established more than 50
years ago in Sri Lanka have not shown a marked change in
the disease prevalence profiles.
The theoretical basis for the environment and health in this
book is based on the principles of environmental
management, which is supported from the concepts of
medical and health geography. The existing concepts of
medical and health geography provide the basis for studies
of environment and health within environmental
management, when these studies are kept in the theoretical
domains of disease ecology and political ecology. However
the theoretical domain of political ecology is better suited
for the study of environment and health in the developing
18
countries, because health is more a political issue in these
countries where development is guided by political decisions
than environmental planning.
Chapter 2
19
individual psychology. It includes mobility, roles, cultural
practices, and technological interventions.
Habitat
20
Table 2.1 Nature and habitat
21
Table 2.2 Development and habitat
22
organic
influx
23
Man has effectively interfered with the natural systems and
made the habitat orderly or disorderly, but he is not capable of
keeping it truly natural. This affects the health status of people
living all over the earth. The resurgence of old diseases like
Tuberculosis and emergence of new diseases like Dengue and
Avian Flu confirm the poor control man has over his natural
domain.
Settlement patterns
24
levels, which can harm ears and brain. The impatience of the
transport operators (drivers and conductors) may be linked to
“ beta music” played and “ language used” FM radio
networks. Vary many accidents occur as a result of use of
these equipment on the run as attempt to play the equipment
can deviate your mind from controlling a vehicle. Field data
collected on 100 traffic accidents has revealed that about 8
percent of them were caused by attempts to use
communication equipment while driving.
Drainage, sewage and waste disposal systems are the
measures which can be used to identify the risk of infectious
diseases in the settled environment. The basic difference
between development and poverty is measured from the rate
of presence of infectious diseases. For example Colombo was
known as the Garden city in the 1960s, because its drainage
and sewage system was sufficient enough to keep the city
clean even after a very heavy rain storm. But lack of proper
planning since then has made Colombo to be one of the
dirtiest cities in Asia, with a common presence of Filaria,
Tuberculosis and Dengue.
Poor planning of city and town landscapes lead to
accumulation of heat and dust which forms unhealthy micro-
climates. Non-utilisation of aerodynamics and flow hydraulics
leads to local flooding in the settled areas. Accumulation of
waste material in large quantities can attract various types of
micro-organisms and animals into settled environment. There
are constant reports of increase of diarrhoea in and around
urban garbage dumps in the developing countries.
The settlement form can be a factor in health. Nuclear
settlement is the most economical form of settlement type in
the provision of modern facilities. However it has to be
constructed well with a highly organized system of waste
control. If not there is high risk from infectious diseases.
The dispersed settlement is one of the best models for healthy
living but large populations cannot be accommodated in this
type of settlements. Therefore they cannot be used as an
example of healthy settlement type in a modern habitat.
A linear settlement is also not a suitable option as it consumes
a large area of land and as in developing countries when they
25
are formed along main roads they cause congestion and death
from cross-road movement of people. For example in Sri
Lanka about 30 to 35 deaths and 300 to 400 injuries are
caused by this type of behaviour in linear settlements.
The relationship between health and settlement is clearer
when it is studied within a given developmental region. This
is because level of technological development decides the
level of health threat in a settlement.
Most human infectious diseases survive in urban areas,
because only cities have a large enough population to support
the continuing circulation of disease agents.
Today disease agents can easily cross continents and oceans
on an airplane and space agencies have special “bacteria
detectives” to prevent contamination from space travel. The
airplanes and ships are regularly sprayed with anti-bacterial
cleaning fluid and goods are quarantined.
The accelerating mobility of the human population also seems
to have created different disease entities by the sheer intensity
of transmission that has been made possible, as is illustrated
in the discussion of the development of dengue hemorrhagic
fever in Sri Lanka in page.
Population
Genetics
26
general problems of populations. Immunity of the people of
poor countries to certain types of diarrhoea, intestinal
infections are believed to be related to genetic evolution. This
may be a result of historical exposure to these diseases in the
areas where sanitation has not improved.
Lactose intolerance or resistance to milk is identified as a
geographic puzzle in human ecology. This may be a result of
inability to rear animals due to humid tropical climate where
animals are subjected to permanent wet ground, which lead to
foot and mouth diseases. The inability of Europeans to eat hot
food may also be a result of loosing their natural taste system
after they have migrated to cooler climates where hot chillie
will not grow. Some believe colour, size and hair are strictly
controlled by genetic factors. African hair and height of the
Nordic Europeans are considered to be two very strong
genetic systems in relation to cross marriages. Though many
people relate various types of factors to genetics, we are yet to
discover the true nature of genetics in life. However the
genetic scientists are hopeful of the unlimited value in
genetics in the treatment of serious disabilities which affect
children and young.
Our face, walk and talk are related to genetics in gossip, but
this type of resemblance may or may not be true some times.
Therefore any information on genetics of populations should
be treated with care.
27
environment and ends his journey in a filarial endemic
environment. Someone travelling from Kandy to
Anuradhapura to work leaves a non-endemic environment for
malaria and enters the malaria endemic environment around
Nalanda on route A 9.
Adults also experience with alcohol, sex and other adventures
when they are between teen and late 30s, and most of them
encounter accidents and diseases related to those experiences.
Marriage is another break point in adult health life as they
have to cope with increased expenses and psychological
support for children. Today this has become a serious problem
in poor countries where life has become a continuous struggle
due to socio-political corruption in them. Family is seriously
under pressure from the cultural infiltration from western
modernist ideals and lack of proper law and order makes the
life of a father and mother in poor countries a serious threat to
individual health.
For example it is estimated that about 80 percent of the
families in Sri Lanka is under serious psychological threat due
to culture clash originating from uncontrolled modernization.
This is very clear among the students of Public Universities,
where uncertainty arising from poor rate of economic
development due to political corruption makes them to be
uneasy and boisterous.
The aged are the most vulnerable to ill health as the age after
60 is considered to be the time of loss of control in the body
system. Control of food, behaviour and ready availability of
treatment are the only ways to combat serious health threats at
this age. This type of health environment is not readily
available in the developing and poor countries of the world
and the aged living in these countries suffer and die from
easily curable illnesses and diseases.
Behaviour
28
many ways in relation to health and in this study it is
identified as developed world culture and undeveloped world
culture. This division is adopted, because the author believes
that we are today at a stage of development which we have
never witnessed in the history of human evolution and the
only way to achieve a satisfactory status of health is to follow
the modern system of health care with sufficient help from
traditional health care systems. When this type of approach is
made there will be only a minimal amount of conflict between
culture and health.
Control of waste in the habitat has to be made safe with all the
possible applications from both systems. It is clear from the
experiences of the developed world the only way to keep the
habitat safe is to remove corruption and utilize law and order
in managing the environment. For example the solid waste
removal is a responsibility of the local authorities and they
must plan properly and enforce rules and regulations in a free
and fair manner. The settlement design is paramount to
environmental management, expenditure on the provision of
essential services like water, electricity, transport and
communications. Therefore all habitat related activities should
aim at providing a healthy environment.
Modern world is a massive mix of life styles. However these
many types of life styles can be divided into two major
groups: Safe and unsafe. It is the responsibility of the
governance to encourage safe life styles and strictly limit
unsafe life styles with the use of powers available to public
order and security. The unsafe life styles should be controlled
with the use of modern technology available and
rehabilitation from unsafe life styles can utilize local cultural
support.
Waste is the most important variable in the management of a
healthy environment. Where there is unattended or untreated
waste there is always a health risk. Therefore the behaviour of
populations should be guided in a way that the authorities
should be able to collect and dispose of it orderly.
People have managed to evolve many protection systems
through their culture and religion and these are very valuable
in the formation of a healthy environment. In modern times
29
the use of alternative medicine has sometimes reduced the
health cost of nations by a considerable amount. The role of
these treatment systems are not clearly indicated in research
but if there is no harmful element in them these systems can
be utilized with guidance from elders or traditional healers. It
is estimated that there may be more than 20,000 to 30,000
unregistered traditional healers in Sri Lanka and the
occurrence of malpractices are rare.
Protection also comes from food habits, cleaning systems and
dress. Buddhism and Hinduism prohibit meat, Islam prohibits
Pork and Christians are not supposed to eat meat on Friday.
Giving alms to poor people and taking care of the disabled is
preached in all the religions, which indicate universality in
helping the poor to be healthy. Modern developed societies
utilize a social security system for the purpose of care o the
poor, which is primarily supported by the funding from
religious and cultural societies.
Terrorist behaviour has become the most destructive human
behaviour of the word today. It is estimated that annually
about 60,000 die, 300,000 are injured and another 100,000 are
traumatized by terrorism or terrorism related activities.
Though terrorism has been an integral part of human
existence, today it has become one of the major problems in
the health environment.
Corruption in governance also lead to a serious weakness in
the health environment through misuse of funds allocated for
the provision of preventive and curative medicine in the
developing world. The high prevalence of infectious diseases
in the developing world is partially a result of corruption in
governance which diverts funding away from essential
services to private use.
30
Chapter 3
31
utilisation systems. The following tables will provide you
with the major characteristics of the environment and health
in the developed world where impact of infectious diseases
are minimised to the level
Table 3.1 Environment of the developed countries of
Europe, North America, Japan, Australia and New Zealand
Category Latitude in Majority of the Nature of living
degrees People (more than environment of the
north of 80 percent) majority (more than
Equator 80 percent)
Warm and From 35 to Low immunity to Planned drainage
cool south 45 degrees unclean and sewage disposal.
North and environment and Very good quality
South water. Fair skinned health support
and can be systems.
subjected to sun
burn
Cool From 46 to Very Low Planned drainage
centre 55 degrees immunity to and sewage disposal.
North and unclean Very good quality
South environment and health support
water. Fair skinned systems
and can be
subjected to sun
burn
Cool to 55 to 65 Extremely low Planned drainage
cold North and immunity to and sewage disposal.
north/south South unclean Very good quality
central environment and health support
water. Very fair systems
skinned and can be
subjected to sun
burn
Cold 66 to 90 Extremely Low Planned drainage
north/south North and immunity to and sewage disposal.
South unclean Very good quality
environment and health support
water. Extremely systems
fair skinned and
can be subjected to
sun burn
32
that they are incapable of causing more than 0.5 percent of
the deaths. However the industrial pollution and comfortable
lifestyles have increased the incidence of chronic diseases in
them.
Table 3.2 Socio-economic and immediate living
environment in the developed countries
Area Status Health status Reason
Urban areas Fairly Good – low risk of High literacy and
clean infectious diseases income. Strict
enforcement of
environment law
Rural Clean Very good – very High literacy and
low risk of income. Very strict
infectious diseases enforcement of
environment law
Special areas Very clean Excellent - very low High literacy and
risk of infectious income. Extremely
diseases Strict enforcement
of environment
law
Table 3.3 Developed countries: Nature of basic construction
required for a health living environment
Construction Status Health Reason
status
Housing Planned and Good with High literacy and
properly built proper income. Strict
drainage enforcement of
and waste environment law
disposal
Work place Planned and Good with High literacy and
properly built safety income. Very strict
enforcement of
environment law
Transport Planned and Good with High literacy and
properly built safety and income. Extremely
speed Strict enforcement of
environment law
33
Developing world is synonymous with tropical world as
almost all the countries categorised as developing are
situated in the tropical world. These areas of the world are
constantly ravaged by environmental mismanagement,
wastage of resources and imbalanced income distribution.
However, it is abundantly clear that these areas have
enormous resources of natural resources which are able to
provide a sound basis of development for their inhabitants,
but prevented due to socio-political corruption.
34
heavily subsidized treatment system but the living
environment of majority of the people remains dirty
resulting in the heavy presence of diarrhoea and dysentery.
35
maternal mortality
Humid Monsoon forest Poor live in No planned drainage
and savanna unclean and sewage disposal.
average wood land environment and Very poor quality
relative water. health support systems.
humidity Tuberculosis, Cholera,
above 45 Dysentery,
percent Schsitosomiasis,
and below Onchocerciasis,
60 percent Leishmaniasis,
Trypanosomiasis,
Heaptitis high infant
and maternal mortality
Dry Monsoon Very Poor live in No planned drainage
woodland, unclean and sewage disposal.
average scrub and environment and Very poor quality
relative thorny bushes. water health support systems
humidity Under threat
above 25 from Tuberculosis, Cholera,
percent Dysentery, Meningitis,
desertification
and below Heapatitis, very high
45 percent infant and maternal
mortality
Arid Semi arid and Very Poor live in No planned drainage
hot desert/ unclean and sewage disposal.
relative oasis living environment and Very poor quality
humidity water health support systems
below 25
percent Tuberculosis, Cholera,
Dysentery, Meningitis,
Heapatitis- very high
infant and maternal
mortality
36
diseases application and
enforcement of
environment law
Conserved Fair Fair - very low risk Low environment
areas of infectious literacy and
diseases income. Non
application and
enforcement of
environment law
37
disposal environment law
Transport Unplanned and Extremely Extremely low general
hastily built risky with and environmental
poor road literacy and income.
surfaces Lack of enforcement
and lack of of environment law
traffic
control
38
nutrition through as the systems in
good economic action are disturbed
programmes by corruption
Literacy Provide quality Do not provide
literacy through quality education
education, training and training due to
and governance. bad governance
The Is utilised for the Is not properly
traditional development of organised and
belief system modern medicine developed other
of health than in a few fast
developing
countries
Health Regulated through Regulated only at
behaviour education and law times of sickness or
in the families with
quality education.
39
India 62 99
Bourkina 47 186
Faso
Sierra 40 242
Leone
40
Lanka (Farmer, 1957 and Litsios, 1996). Furthermore, the
ridge and valley nature of the plain topography and the
extensive spread of acidic soils may have helped the quick
out flow of flood water and rapid fermentation of vegetative
matter, which limit the formation of unsanitary pools of
water.
Agent-host relationships
41
(1948). The “emerging disease” (Mayer, 1999) and disease
causing agents have not shown a market impact on the
disease system as HIV / AIDS has not made a substantial
impact in Sri Lanka for the last decade. Increases are
recorded in chronic disease especially in the categories of
heart, diabetes and cancer. The largest increases are
recorded in the category of road accidents, insecticide
poisoning and war related injuries, which are results of
socio-political manifestations (Ministry of Health, 1996).
Malaria is the disease with the highest morbidity, with three
protozoan parasites, Plasmodium vivax, P.falciparum and P.
malariae, causing benign tertian, malignant tertian and
quartan fevers (Dissanaike, 1984). The parasite is transferred
from an infected person through the female anopheline
mosquito, through the vector of the Anopheles culicifacies,
though A. maculatus, A varuna and subpictus are now
present in the vectorial scenario in Sri Lanka (Carter, 1930
and Amarasinghe et al, 1997). These vectors are mainly
present in the dry zone of Sri Lanka and rarely found over
1000 meters above sea level. The peak prevalence of
mosquitoes begins with the rainy season in mid October and
reaches a maximum in January, but they can live and breed
continuously in the water logged areas, shallow riverbeds,
irrigation canals, quarries, wells and pits throughout the
year. Therefore the vector ecology of malaria is a product of
climate and drainage of the dry zone and the wet zone is
invaded only at times by epidemics of malaria. As
mentioned the wet zone rivers have rapid gradients and year
around flow, which prevents the breeding of mosquitoes and
it also seems feasible that the heavy use of chemical
fertilizers and pesticides in the plantations may also has an
important controlling effect.
The studies carried out in new settlements in the north
central and eastern provinces of Sri Lanka clearly indicate a
continuous high prevalence of malaria associated with
irrigation and reduction and selectivity of certain species of
anopheles with time, though its consequences have not yet
been identified. Ramasamy et al (1992) and Amarasinghe
and Indrajith (1994 and 1995) have come up with recent
42
evidences from the Mahaweli Development areas on the
reduction and selectivity of certain species of Anopheles
mosquitoes. Furthermore, researchers have discovered a
historical and recent significant relationship between the
intensity of the south west monsoon activated by EI-Nino
activity and increase of malaria incidence in Sri Lanka,
indicating its relationship to climatic fluctuations (Bouma
and vanderKaay, 1996).
Filariasis is concentrated in the wet zone coastal wet land
areas, while viral hepatitis and tuberculosis are common in
urban areas. Filariasis is concentrated on a particular habitat
where agents are supported by the wet land ecosystem. The
presence of tuberculosis is related to poverty as majority of
the cases are reported from poverty stricken urban poor
households (Ministry of Health, 1996).
Domesticated animals
43
Therefore, animal rearing is limited by ecology and culture,
both in the dry zone and wet zone.
Buddhism advocates a vegetarian diet and eating of meat is
prohibited, which limits the use of meat in the diet of
Buddhist farming families. Their special requirements are
supplied by the Moslem or Christian traders in the nearest
village centre or town. Further, the traditional belief system
has a caste association to animal rearing as hunters and
nomads are treated as of low caste and farmers were not
expected to rear animals for meat. Although, a change in this
traditional system can be observed today, it is extremely rare
animals for meat in this community. Another aspect of
culture controls the distance between the animals and
humans as the Buddhist farmer keeps his animals away from
his house either in a shelter or tied in the open limiting
contact between him and the animal. Therefore, it is possible
to conclude that these factors limit the man-animal contact
and the consumption of man-animal products, which reduce
the capacity for origin and spread of diseases in the Buddhist
farming community.
44
about 30 percent of the village settlements have safe
drinking water and more than 80 percent have no safe
bathing water facilities (Department of Census and
Statistics, 1994). Housing is mainly in the categories of mud
or mud brick or partial brick and cement with no ceiling or
proper arrangement of ventilation facilities. The pit toilets
are not properly built or maintained and pose a serious
health risk in terms of breeding of diarrhoea related bacteria.
Lund (1979), Marga (1988) and Konradsen et al (1977) have
identified the impact of poor living environment in relation
to the abundance of malaria and diarrhoea in the Sri Lankan
environment, and this is confirmed in the most recent
available health data (Ministry of Health, 1996).
Thirdly, the marginalised groups live in specific geographic
areas such as remote rural communities, fishing communities
in coastal areas, estate communities, communities in urban
slum areas, village expansion colonies and areas affected by
ethnic conflict. Studies on these groups have begun recently
(Ariaypala, 2000 and Sarath Ananda, et al 2000) however the
conclusion so far is that the immediate living environment of
these people is considered to be harmful to their health.
There are no detailed studies on the impact of immediate
living environment on disease prevalence in Sri Lanka, but the
grouping of the population on the basis of their major contact
environment reveals that there is a variation in infant and
child mortality rates between rural and urban areas, and
between urban and rural and estate environments (Figure).
These three categories and based on the identification given
by administrative authorities and used in the national surveys
on data collection (Department of Census and Statistics,
1993). District level disease prevalence data suggest that
resettled people can be placed in between rural and estate in
this profile, but no definite conclusions can be made due to
lack of specific data.
45
70
60
50
40
30
20
10
0
Urban Rural Estate
MR CMR
Nutrition
46
The observations of Gunasekara (1996) add an additional
dimension to the nutritional status, which he associates with
the geographical distribution of the population.
He indicates that Uva, Anuradhapura and the north- western
provinces have recorded the highest levels of stunting. There
is a reduction in the categories of moderate and severe
stunting between 1987 and 1993, but insufficient data on
instability of residence may hide the exact nature and
distribution of stunting, when compared with the data from
the established old village environment.
Ariaypala (2000) identifies the plight of children in a slum
area in Nugegoda in relation to nutrition and discover that 62
per cent of them are malnourished. The nature of the meal in
this group of people is decided by the daily wage of the
income provider and girls suffer from malnutrition more than
boys. A similar study in the Kandy slum revealed an alarming
99 per cent of malnutrition among children (Sarath Ananda et
al, 2000).
The nutritional status of the children living in the north and
east is definitely poorer than the national levels. Under –
weight in the age group of 0 to 5 years is 50 per cent for the
children in the conflict area compared to 37.6 per cent of the
country average (W.H.O., 2002). Fernando et al. (2000).
Found that school children in the rural areas of the
Moneragala district are affected by malnutrition and high rates
of hook worm. Further they have evidence to show that the
girls are more underweight than the boys. The iron intake of
the adolescent school girls in the rural periphery of southern
provinces is a good indication of the nutritional deficiency
among the poor (Jayatissa and Piyasena, 1999).
The studies on nutrition are conducted within different groups
of people in the category of marginalized. However, valuable
information concerning like living environment and its
resources, which can be utilized for improving the nutritional
condition is yet to be fully investigated.
Literacy
47
Education has played a vital role in the construction of the
present disease environment of Sri Lanka, mainly through
general increase in literacy. Universal free education and adult
education, which was supported by the extensive health
education programmes of the 1950s and 1960s, have enabled
most adults to acquire knowledge of reading and writing. This
has developed a keen interest in reading newspapers which are
the primary tool in the rapid dissemination of advice on
health.
The rural sector in which the farmers live has a high literacy
level, when compared to the South Asian situation. The level
of primary and secondary education among the farmers is
almost equal to the all sectors literacy levels. It should be
noted that the lower age groups are presented as noted in the
source material and the sole purpose of this table intended
only to compare values between the groups (Table). This high
level of literacy has resulted in the schooling of girls and this
had an effect on efforts of decrease in birth rate and maternal
and infant mortality rates from the 1960s, through birth
control and postponement of marriage. Throughout the 1970s
and 1980s, the average family size was reduced from 6 to 4,
and at the end of 1994 it was further reduced to 3.2 (Statistical
Abstracts, 1996), and this can be explained by a lowering of
fertility due to heavy use of birth control.
48
The traditional belief system of health
49
tradition and the practice is considered a family tradition,
which is given only to male members of the family. Herbal
medicine in the form of mixtures, pastes and oils are used in
the treatment along with strict dietary control. However, in
recent times the influence of Ayurveda has made these
practitioners to use some Ayurveda has made these
practitioners to use some Ayurvedic medicine in their practice
(Gnanawimala, 1950; Ramanayake and Ponnamperuma, 1985
and Ambatalawa, 1994).
The second system is Ayurveda, which is of Vedic origin and
believed to have originated in the second millennium BC,
probably in the land between present-day Pakistan and Iran
(Ariyadasa, 1982). The traditions and teachings of Ayurveda
entered Sri Lanka with the arrival of the Aryans and
developed steadily through continuous contact between India
and Sri Lanka.
Since its establishment in Sri Lanka, Ayurveda and traditional
medicine were practiced together probably with the same
patronage, but seeking the higher level of Ayurveda when
needed. In the civilization of the early Anuradhapura period
the physician was considered an important professional.
During this period a notable feature of civilization was the
importance attached to the establishment and maintenance of
hospitals for the treatment of sick. Among the kings of ancient
Sri Lanka King Buddhadasa (circa 337-365 B.C) was reputed
to be a skilful physician and he appointed a physician for
every ten villages. (Paranavitana, 1959). This tradition
continued throughout the ancient and modern history and by
the time of arrival of Western medicine there was a well
established health care delivery system in Sri Lanka
(Ramanayake, 1985). Antibiotics are not mentioned in the
Ayurvedic medical literature, but some of the mixtures used in
it are found to be antibiotic in nature (Silva, 1991).
The term indigenous medicine is official used today to
identify a system of medication and treatment, which include
both the ancient and the Ayurvedic systems. The continuing
struggle of the organized group of activists of indigenous
medicine led to the establishment of the Department of
Indigenous Medicine even before independence (Ramanayaka
50
and Ponnamperuma, 1985). The establishment of Ministry of
Indigenous Medicine, Institute of Teaching and Research in
Indigenous Medicine and registration of indigenous medical
practitioners as government physicians have enhanced the
value of traditional and Ayurvedic medicine among the local
populace and foreigners. Today it is estimated that more than
40 per cent of the total out patients registered daily, use
indigenous medicine related services and among the poor the
percentage may be as high as 60 per cent (Kannangara, 1962).
Today, indigenous medicine is the most important health
service system at first referral level for most of the poor until
their economic status is elevated. For the rest of the richer
classes its use is restricted to times of special need. Recent
modernization of herbal preparations have actually led to an
increase in popularity of indigenous medicine and associated
treatment systems (Ekanayake and Chandrasekara, 1989).
With the impact of developmental change, the existence of the
pluralist tradition of medicine has negated most of the ill
effects of the tropical disease environment of Sri Lanka.
Health behaviour
51
Farming population have acquired many health practices of
western medicine and have used them successfully to enhance
their self-control, hardiness and coping skills. This is a result
of increased literacy over the last two to three decades and
constantly improving living standards. Further, they have
accepted family planning and increased their resistance to
common aliments and sickness through extensive use of
western and traditional medicine. As shown in the hospital
utilisation data in the Ministry of Health (1996), 37 million
patients were treated at the Government facilities and the total
number receiving treatment from registered health service
both the public and private health care facilities may be as
high as 45 million.
The health behaviours of personal nature are learned through
the process of family living, and the mother-daughter and
mother-child relationship as identified in Liiman (1974). In
the farming community under study health of the family is
observed mainly by the wife as men spend only a limited time
with children. It is the women, who teachers children health
behaviour, prepares home remedies, accompany children to
immunization, dispensary or hospital and even take care of the
man‟s health by washing his clothes, cleaning his room etc
(Baker, 1998).
Drug utilization surveys conducted in the South Asian region
refers to the common practice of misuse and over-prescription
of pharmaceutical drugs in Sri Lanka.
This situation is common to almost all the developing nations
and misuse and Organization, 2002, Daily News, 2002 and
International Planned Parenthood Federation, 2002). This type
of abuse occurs mostly in the pharmacy system, which is
mostly operated by unqualified or under-qualified personnel.
Further, the unregistered medical practitioners of various
types use western medicine in their treatment system in the
rural areas where the authorities are less vigilant. The present
situation is well summarized by Laing (2001:3)
It is not pertinent to leave this discussion without a
presentation on suicide and alcohol abuse in Sri Lanka, as
they contribute heavily to the increased incidence of health
risks within the disease environment through causing chronic
52
diseases and contraction of infectious diseases. It is believed
that the farming community is highly affected by these two
behavioural traits, though detailed studies are yet to be
conducted. The suicides are responsible for about 6 percent of
all the deaths registered in Sri Lanka (Department of Census
and Statistics, 2000). Therefore, Sri Lanka has one of the
highest suicide rates in the world and it is difficult to relate to
any single cause. The most common cause is identified as
depression arising from failure. Kearney and Miller (1988)
has conducted a study on the internal migration and suicide in
Sri Lanka and concludes that there is a strong association
between suicide and the percentage of migrant population in
the dry zone of Sri Lanka.
The medical professionals identify alcohol abuse as a serous
threat to the health of adult males. The primary effects leads
to chronic diseases in the liver by drinking poisonous
preparations brewed by the illegal alcohol traders. Secondary
effects are less serious, which originate through the
contraction of infectious diseases by consumption of locally
made food or wild meat while drinking alcohol.
Many research workers and media publications identify
alcohol abuse and alcoholism as two of the major behavioural
factors in the increase of health risks in men of Sri Lanka.
Hettige (1990) and Wickramasinghe (1993) have given some
recent information on this issue though many medical articles
appear in the Ceylon Medical Journal regularly. Hettige
(1990), indicates that there is an increasing trend of alcohol
use in Sri Lanka, which has not been duly recognized by the
socio-political institutions. However, the diseases or deaths
originating from alcohol abuse are not recorded properly in
the medical records and therefore it is impossible to
understand the true effect of alcohol abuse in the Sri Lanka
society. It is clear that most of the families with extreme
poverty in Sri Lanka are affected by the alcohol abuse of the
householder, but the status of the alcohol as a cause or effect
cannot be properly understood due to lack of detailed
research.
53
Development and health in Sri Lanka
54
prerequisite for development. Rostow (1960), presented a
model based on five stages, which will be experienced by all
societies in the transformation of their economies from
undeveloped to developed. It assumes that increased
production leads to growth, and that redistribution of capital
will occur in the process of this growth. Capital accumulation.
Growth of the labour force and scientific and technological
advancement are woven into the process of development I five
major stages outlined in this theory. It was still a pre-eminent
theory of modernization in the early 1960s (Preston, 1996).
Secondly, the dependency school formulated an under-
development theory through the writings of many radical
researchers, which contained Marxist language, mode of
analysis and ideological and theoretical projects. In parallel to
the theory of under-development, the problems of
modernization were discussed in structural Marxism, which
originates from the French school of Marxist studies. This
theory explained the importance of class relations in
development gave a strong critique of capitalism and
explained the process of development. The influence of
structural Marxism can be seen in some other critical
traditions of the dependency school (Frank, 1966 and Dos
Santos, 1970) and world systems theory (Wallerstein, 1974).
The dependency approach explains the way in which the
capitalist world exploits the periphery and keeps the
developing world in a state of underdevelopment. The world
systems theory views the spatial relationships between the
core, semi-periphery and periphery as exploitative.
The spatiality of modernization was studied by geographers in
detail to identify this centre - periphery relationship.
55
theories, and a search for a better alternative in development
ideology. The Cocoon conference in 1974 discussed the idea
of sustainable development, and the International Foundation
for Development Alternatives (IFAD) recommended the
establishment of a humanist model of development.
Following this conference, many world gatherings were
convened in the 1980s to find a serious alternative to the
current development strategy. The need for a paradigm which
could focus on ways of improving the productivity of the poor
through social, economic and political empowerment became
vital. Therefore, the alternative development approach became
an action oriented programme based on humanistic and post-
structuralist methods. Among many poststructuralist
sociologists, Giddens (1979 and 1984) had the most marked
influence on human geography.
56
(US $) 1 education birth*
(percent
budgetary
allocation)
Sri Lanka 620 4.8 72
India 386 3.8 63
Bangladesh 325 3.8 60
Pakistan 445 3.6 61
57
maternal and child mortality rates (World Bank Report,
1998/99).
Sri Lanka is diverse in terms of social and cultural context,
and is frequently cited as a plural society because it has
different religious and ethnic groupings, each possessing
distinctive characteristics based on language, historical
antecedents, and cultural variations. The ethnic distribution of
18 districts which were fully enumerated in the 2001 census,
records that the Sinhalese constitute 81.9 per cent, Sri Lanka
Tamils 4.3 per cent, Moors 8.0 per cent, Indian Tamils 5.1 per
cent, with Burghers, Malays and others making up the balance
of Sri Lanka‟s population in 2001.
The lasted census of population in 2001 estimated a
population of 18.7 million, with an average annual growth rate
of 1.1 per cent. The population in 1981 was 14.85 million.
Unlike prior to 1946, Sri Lanka experienced rapid population
growth during the post-independence period. Over a period of
54 years from 1871 to 1925, the first scientifically enumerated
population of 2.4 million in 1871 doubled. The second
doubling of the population took place in only 37 years from
4.6 million in 1925 to 9.6 million in 1960. The highest annual
growth rate ever recorded in Sri Lanka (2.8%) was recorded in
the inter-censual period of 1946-1953. As a result of this high
growth rate, doubling of the population from 6 million in 1946
to 12 million in 1971 has taken only 25 years. However, the
growth rate has declined by 1.7 per cent during 1971-1981.
Even though the present trend indicates a further slowing
down of the population growth rate, it is estimated that at least
another 1.8 million people will be added to the population
between 2000 and 2010 at the rate of 180,000 a year, leading
to a population of about 23 million around the year 2030.
From independence to the introduction of the open market
economy in the 1980s, the development process in Sri Lanka
has been guided by a structured set of strategies. Keynesian
ideology, Rostow‟s theory, Marxism and dependency
thinking have been utilized by the development planners of
the respective capitalist and socialist governments of Sri
Lanka during this period. Myrdal‟s thinking was of great
importance to development planning in the 1960s, where his
58
notion of a vicious cycle of poverty was regularly utilized in
development rhetoric.
The salient feature of this time period was an attempt to
construct time related planning programmes in the form of
three-year, five-year or ten-year developing plans.
Development planning was a strategy used by both
development and developing nations in the post war period.
This was aimed at initiating structural changes in the systems
of production, and to promote social development (Fernando,
1997). The first exercise in planning was presented in a
document entitled “Ceylon Today – A government by the
People” in 1952. The “National Plan” was a section of this
document, which outlined action related to agriculture
industry, transportation, post and telecommunications, health,
education and food subsidies. The second planning
programme was the six-year programme of investment,
1954/55 – 1959/60, published in 1955, which only dealt with
government investment expenditure, and which was
abandoned by the newly elected government in 1956. The
Marxist orientation of this government led to the formulation
of a ten-year plan. A policy of working towards a socialist
society and a mixed economy in the spheres of trade, industry
and agriculture was proposed in this plan. Major strategies
that were identified were the development of the export
sector, development of the dry zone, improvement of
productivity in non-estate agricultural and industrialization.
Social service sector expenditure was maintained with a
limited reduction in food and nutritional subsidies. The
weakest point in the plan was the lack of explanation on the
modalities of private sector participation, though the private
sector was invited to invest in the national economic
development programme. This plan was abandoned in 1965
by the newly elected government, but state control of
development was continued with the allocation of control of
the national budget to the Planning Ministry. The foreign
exchange budget became the responsibility of the Department
of Foreign Aid, and a dual rate of foreign exchange was
introduced to exert more state control on the import-export
trade. This was aimed at controlling the fast dwindling foreign
59
exchange, which had resulted from a fall in income from the
export of traditional plantation products like tea and rubber.
The 1966-70 Agricultural Development Proposals and Plan of
Development was prepared with the aim of achieving self
sufficiency in rice and other food crops. Green revolution
ideology was used, and particular attention was paid to the dry
zone resettlements by provision of high yielding varieties,
chemical fertilizers, agro chemicals, tractors, other
agricultural machinery, increased extension services and
agricultural credit. A change of government in 1970 did not
exert a major change on the strategies, although a Five Year
Plan (1972-76) was initiated in 1972. Like the Ten Year Plan,
this was a comprehensive plan covering all sectors of the
economy. However it was centred on public sector
programmes and was not detailed enough on the role of
private sector participation. The effect of the petroleum price
increases and drought of 1973 affected its implementation,
and the set goals and objectives were not given priority by the
government (Radhakrishnan, 1979). Therefore from the time
of independence to about 1977, Sri Lanka adhered to
programmes of modernization based on a structuralist mode.
The global change of development strategies in the 1970s
towards alternative development was not immediately felt in
the economy of Sri Lanka. This was primarily a result of two
major factors. Firstly, the inward looking economic policies of
the 1970s were aimed at achieving self-sufficiency in the face
of declining foreign exchange income from the plantation
sector. These policies were intended to increase local farm
production, develop cottage industries and establish a heavy
industrial base. Secondly, the strong influence of „Warsaw
pact‟ economic aid during this period guided Sri Lanka away
from the new policies of open market economics. However,
by 1977, it was clear that the inward looking economic
policies had not achieved their objectives, and a change of
political leadership resulted in an attempt in 1977 to introduce
the alternative development strategies of the western
developmental model into the Sri Lankan economy, through
the establishment of an open market economy.
60
From around 1980, open market reforms began to result in
some fundamental changes to the economy and employment
structure. De Vroey and Shanmugaratnam (1984) investigated
the nature of his economic transformation within the
resettlement programme. In their view the need for
colonization arose not only from population pressure on the
land, but also from lack of investment in the economy for
diversification of the labour market. Three other economic
changes have resulted in the overall transformation of the
economic structure from a state controlled to an open market
system. They are the employment generated by the Middle
East labour market, the establishment of export-orientated
industries and the war economy. These three changes have
resulted in the empowerment of the resettlement dwellers and
the poor in general. The findings of researchers indicate the
improved level of empowerment, through allowing their
wives and daughters to be employed as ready-made garment
factory workers, housemaids in the Middle East labour market
and in the armed forces.
Institutionalized attempts to provide development alternatives
were introduced to facilitate the poor and the marginalized,
through national programmes of small-to medium-scale
animal rearing and „Samurdhi‟ (a partially voluntary type of
employment and an employment training programme
established by the government). Private sector participation in
export crop production, NGO support for community banking,
water supply and maintenance of visiting health care
professionals have emerged in the latter half of the 1990s, as a
result of the changing structure of development strategies.
61
percent of total government expenditure during the period
immediately after independence. Health expenditure
amounted to 7 to 8 percent of total government expenditure on
average, which was one of the highest in the developing world
(Ministry of Health, 1996). This was a period which saw the
establishment or improvement of the health sector‟s
infrastructure, and an accelerated training of doctors and
auxiliary service personnel. Financing came from the nation‟s
healthy economic environment, which was supported by
programmes like the Colombo Plan and Commonwealth
Financial Aid. The recognition of Ayurveda as an alternative
form of medicine, and the establishment of the scientific
teaching of Ayurvedic Medicine in the 1960s, may also have
helped Sri Lanka to achieve a better health status than many
other developing countries. In general, therefore, within the
period when modernization strategies were employed, health
has achieved a remarkable level of improvement in contrast to
the weakening economic status of the nation (Caldwell, 1993).
Secondly, programmes related to community health,
nutritional supplement, the eradication of parasitic and
infectious diseases and immunization were vigorously
pursued by the government. All these programmes were
funded by public funds and foreign aid. Malaria and
tuberculosis eradication, child and maternal immunization,
and infectious disease control were the major preventive
medical programmes in this category. The success of these
programmes was notable in Sri Lanka compared to other
countries in the developing world. Welfare policies were
highly politicized and they remained in place despite many
attempts to change or reduce them.
This trend continued until 1977 without many alterations,
although some peripheral changes were introduced into the
social welfare programme. There was a revenue problem in
the period from 1970 to 1977 (Jayasundera, 1986), but social
services were sometimes supported from foreign borrowings
and aid. Liberalisation of the economy led to the emergence of
a powerful private health care service of a special category in
Sri Lanka between 1980 and 2000. This private health care is
operated by many types of qualified and non-qualified
62
personnel, and pharmacies have become places of treatment.
The slack attitude of the law enforcement agencies and the
lack of general policy in this area enabled some of operators
to provide an illegal, but low cost service, which could be
afforded by anyone other than the poorest people. Thus the
population ahs created an enabling structure in response to
economic realities, though it may non- yield a safe end result.
The poorest are supported by social welfare, many non-
governmental organizations, and in the case of serious
illnesses, by a Presidential Fund. In the last 5 to 10 years,
public health services have begun to suffer seriously from a
number of problems including lack of drugs, qualified staff,
machinery, buildings and other infrastructure facilities, but
most of the staff has remained in service by engaging
themselves in private practice.
Recent research (Alailima, 1997; Sarath Ananda et al, 2000;
Ariaypala et al, 2000; and the Asia Development Bank, 2000),
indicates that the situation of the marginalized has not
considerably changed in the last 20 years. This is a result of
continuing poverty and rising inflation, which leads to erosion
of the buying power of the poor. These researchers further
identify a rise in malnutrition, under nutrition and respiratory
disease in Sri Lanka, which are linked to poor diet and
housing. A high variation in mortality conditions by sectors
such as urban, rural and estate is noticeable. Meegama (1980)
has pointed out that the high level of infant mortality in the
estates from 1946 to 1974 was due to malnutrition among
mothers, the lack of antenatal care and trained midwives, and
the low level of institutional births. The estates, where Indian
Tamils live, had the highest mortality levels during the last
few decades, especially infant and child mortality. According
to the 1987 and 1993 Department of Health Services (1994)
surveys, the infant mortality rate and child mortality rate were
highest in the estates and lowest in the urban sector.
63
Demographic and epidemiological transitions
64
support. Stage two lasted for about ten years between the
census years 1946 and 1953, and stage three lasted from 1953
to the 1981 census. The fall of birth rates in the general
populace is related to a heavy use of contraceptives, high
general literacy and delayed marriage due to rising
opportunities for higher education and employment for
women (Siddhisena, 1989 and Silva, 1997). At present Sri
Lanka is advancing towards stage four at an extremely slow
pace and natural increase is still above 1 percent, which is
expected to yield a heavy growth in actual numbers in the next
decade. This slow pace is not yet fully understood due to lack
of detailed research, but a considerable contribution is made
by the tradition of having at least one child within a marriage.
As discussed earlier in the sub chapters on strategies of
modern socio-economic development, demographical change
in Sri Lanka shows no agreement with its economic
development or urbanization. Though there have been many
investigations into this dichotomy, a final conclusion cannot
be reached due to a lack of studies on marginalized groups
like the rural and urban poor, estate workers, resettled
population and people affected by conflict; and a detailed
study to evaluate the role of statistics related to private
medical care.
Omran (1971) proposes a five stage epidemiological transition
model. In stages one and two there is a strong presence of
parasitic, bacterial and viral diseases, with women and
children forming the high risk group. The third stage initiates
a significant decline in mortality from infectious diseases, and
non-infectious diseases become important. The mortality risk
of women and children declines during this period, but is still
higher than in the rest of the population. Stage four indicates
the prominence of non-infectious diseases, and a decline in
the mortality risk of women of all ages is recorded. Stage five
is dominated by non-infectious diseases, but diseases
associated with environmental pollution and viral infections
begin to grow in significance. All members of the population
are at risk, especially children.
Data recorded in the Annual Health Bulletin (Ministry of
Health, 1996) indicate that Sri Lanka has reached the third
65
stage in the epidemiological transition, but the case of the
marginalized is less clear. A recent study by Siddhisena and
Seneviratne (2002) has observed some striking differences
between the health of children and mothers of the
marginalized and general populace. Many researchers have
observed these local variations, but a standardized result has
yet to be produced on the health status of the marginalized. In
addition, endemic malaria is a serious morbidity problem in
the dry zone, and parasitic diseases cause regional or local
epidemics, Lung infections and viral disease also remain a
threat in urban areas, related either to pollution or congestion.
Changes in the developing world have not shown much
agreement with the general models of demographic and
epidemiological transition. This is primarily due to the
slowness of modernization, which result in the continuation of
poverty and poor health service facilities. Modernization is
based on the experiences of the Western industrial world,
where urbanization, literacy, the rapid development of health
facilities and social security systems were established in rapid
succession. This form of development led to the formation of
better sanitation, and maternal and infant health. Further, the
modernization of Western culture allowed more freedom for
both men and women in their choice of life style. The
occurrence of this type of socio-economic change in the
developing world was limited to the urbanized and literate,
while the rest have lagged behind, resulting in only a partial
achievement of the transitions as described by the models.
Literacy is identified as the primary factor behind
demographic transition in Sri Lanka, though the contributions
made by many social and ethnic factors are yet to be fully
investigated. The place of women in society and ethnicity has
shown a close association with local variations in
demographic transition, but true relationships cannot be
established from the available evidence. Investigations are
further delayed due to the difficulty of conducting research in
a period of serious ethic conflict and a lack of trained
personnel in the fields of demography, anthropology and
health geography. Omran (1981) and Mc Glashan et al (1995)
have indicated the complex scenarios which originate from
66
various patterns of socio-economic and health sector
development in developed and developing countries. This is
specially observed in the third stage and beyond, where local
changes become important. Omran (1981) places Sri Lanka
within the contemporary or delayed model, where dynamics
of mortality and fertility change are mainly affected by social
settings. There is no clear agreement between demographic
and epidemiological transition and economic indicators in Sri
Lanka. This has puzzled many, as discussed in detail in the
previous sub-chapter on health.
The resettled group seems to have a different status than the
general model of demographic and epidemiological transition
in Sri Lanka. At the commencement of resettlement, the
demographic profile indicates an abnormality with many old
and middle-aged, and very few young. The absence of young
people is temporary as they will arrive once housing and
schooling is ready. Within a period of about ten years of
resettlement, a rapid growth of population is experienced due
to natural increase brought about by second-generation
marriages. With this growth of population the area enters the
second stage profile, and most of the resettled areas stay in
this stage for a long period of time adding a large number of
young people to the population.
Settlers in this study have left their wet zone home villages,
which are in the late third stage epidemiological transition,
and are more affected by infectious diseases at present than
when they were living in their home villages. This makes the
settlers revert back to the second stage where the effect of
infectious diseases is important. The researcher attempts to
present a case of „reversed process in the morbidity transition
profile by the resettled people‟, because of the higher
morbidity from infectious diseases in the health profile of the
settler.
Poverty
67
of disease prevalence. The meaning of poverty has changed
from its definitions based on economic indicators, to one of a
multidimensional nature as given in the World Development
Report 2000/2001. In this new definition, health, education,
vulnerability to risk and empowerment are placed alongside
economic indicators in the identification of levels and location
of poverty. This indicates the influence of structuration and
alternative development strategies in the identification of
poverty and planning for its alleviation.
The structuralist strategies for poverty reduction used in Sri
Lanka resulted in the achievement of high levels of human
development at a relatively low gross national product. The
present policies are within the structuration mode, and are
directed towards strengthening households, remedying income
disparity and increasing opportunities of empowerment. These
actions are linked to observations made by Sen (1982, 1987
and 1999) and Chambers (1984 and 1997), who have
identified various discrepancies in the existing strategies for
alleviating poverty.
The poverty of the farming population of Sri Lanka is linked
to the rapid growth of their numbers between 1950 and 1980,
and the inability of the socio-political authorities to find a
strategy to accelerate economic development. Lund (1979 and
1989), and De Vroey and Shanmugaratnam (1984), have
indicated the nature of existing poverty in the resettled
population and relate it to a lack of access to markets and the
failures of the socio-political authorities. Scudder (1995)
reveals the relationship between corruption and poor
resettlement planning with reference to the Mahaweli
Development Programme.
Empowerment as a strategy in poverty reduction is still a new
enterprise in Sri Lanka, but the high literacy rate and access to
democratic governance since independence has meant that the
poor are better placed in society than in many other countries
of South Asia. However, there are serious lapses in relation to
ethnic and caste affiliations, as indicated by recent poverty
research. The relationship between caste and poverty is widely
discusses in Sri Lanka in the identification of marginalized
68
groups of people, but detailed research is limited (Peiris, 1968
and Morrison et al, 1979 and Lund, 1979).
The loss of income from the export of agricultural raw
material and the poor pricing and taxation policies of
successive governments since independence, are the major
causes of modern poverty in Sri Lanka. The poor pricing and
taxation policies have resulted in corruption and a wide rich-
poor gap, which leads the landless and unemployed to depend
on social benefits and suffer from social inequality. The
programmes of resettlement attract this group of landless and
unemployed, who are socially unprepared to either go abroad
for employment or to migrate to urban areas as temporary
labourers.
69
provinces where the data was collected, none of the town, city
and municipal council had clean drains and full of bad odour.
It is the view of many medical practitioners that the increase
in respiratory diseases in urban areas results mainly from poor
air quality.
The rapid increase in the population of the farming areas of
Sri Lanka has increased the housing density of these two
villages by an average of 30 to 40 percent in the last decade,
but the removal of excess water produced by pavementation
has not been considered important. Rural areas are seriously
affected by chemical fertiliser pollution and poor quality
drinking water.
The paper will attempt to forward a long term program, which
is aimed at reducing the maintenance cost of regional
authorities on roads, minor irrigation works and increase the
environment value through improved water situation which is
hoped to be achieved through household based sedimentation
control program.
Chapter 4
70
presentation is referred to the Sinhala people as most of the
written records of the ancient time is provided under their
culture and governance.
71
Sinhalese and resulted in the abandonment of irrigation
infrastructure. The landscape full of artificial depressions and
dug-out canals became the ideal breeding grounds for malaria
and associated diseases and by the time resettlement began the
dry zone was a land full of many infectious diseases.
Three stages are identified in the period between 250 BC to
Independence, on the basis of the relationship between disease
environment and development change.
72
Figure, 4.1 Historical model of environmental change and
disease environment
73
4Temporarily disturbed controlled environment by war/
internal dissent / drought – resurgence of diseases
Not restored
the habitat. In this period habitat were divided into three major
regions on the basis of geopolitical structure.
74
for settlements, it is likely that the mean annual rainfall was
higher than today. There are about 3000 tanks in an area of
7,752 square kilometres in the Anuradhapura district and as
observed by Tennakoon (1974) has observed some of these
tanks are so small, that they run completed dry if there is no
rain for about two months. However, it can be estimated that a
higher vegetation density of the catchment area and the total
forest cover in the hill country would have supplied at least
three to four times the present amount of water in the river
system.
The existence of three types of tanks-village tanks, big tanks
and storage tanks in the cascading system of drainage was the
basis for the ecosystem and the limited clearance of forest
have caused a limited amount of environmental damage. The
expansion of the kingdom in all directions from Anuradhapura
in the early period and later from Polonnaruwa is an
indication of a strategy adopted to disperse the population into
every possible corner of the kingdom. This institutionalized
dispersion in addition to evidence of restricted mobility
between regions as given in inscriptions can be cited as
planned action against uncontrolled urbanization.
75
Figure 4.2 Historical change of disease environments by Sinhala farmers
between BC 500 to 1800 (based on Pranavitana et al, 1959)
Key:
Direction of mass migrations
BC 500 to 250
Aryan AD 900 to 1000
Landing circa
AD 1200 to 1300
BC 500
AD 1400 to 1500
AD 1600 to 1800
Home village
System C
Present capital
Portuguese 1505
Dutch 1679
British 1796
Approximate
Boundary of
The dry zone
Ancient route of
North south
contact
76
In addition foreign invasions and frequent civil wars, long
drought periods, crop failures and consequent famines,
coupled with epidemics would have reduced the population
and its continuous growth (Perera, 1948), although the
chronicles have not indicated the occurrence of these disasters
in detail.
The macro health environment of the civilization can be
described only on the basis of evidence of administrative
structure and belief system as given in chronicles, depicted in
stone inscriptions and existing ruins of hospitals and
convalescence homes, which are quoted in, Parnavitane
(1959) Deraniyagala (1971) and Seneviratne (1989).
Sanitation and health was regarded as an important aspect of
the general administration of the kingdom. In the city
administration refuse collection and street cleaning were
organized by special units, which utilized low caste and
prisoner labour. Tanks were built and allocated primarily for
the supply of drinking water to the city and bathing both of
people and animals were banned in these tanks. The royal
palaces, temples and houses of the elite were supplied with
water fountains and baths for personnel use, which were
connected to tanks by underground canals and systems of
drains or pipes. Toilet cisterns and seats carved of stone have
been unearthed from palace and temple ruins, which date back
to 300 BC and defecating and urinating in public places, were
banned by edict. The origin of the practice of early morning
sweeping and cleaning of the garden in the village, which still
prevails, descends from the Aryan method of household
sanitation. The farmers, labourers and other groups of people
who can be grouped as commoners lived in mud houses below
the embankment of the tank or along the canal with poorer
sanitary conditions than the elite and royalty, because society
as elsewhere in the ancient world, was based on monarchic
hierarchy and feudal capitalist system.
Health education is recorded as an important sector of
learning for royalty, elite and priests. The health service
system was organized around a Royal physician who was a
key advisor in the palace. Physicians and priests with
competency in health care were appointed to serve all parts of
77
the kingdom and these units of service continued through the
development of the tradition of „doctor families‟ and „priest
units‟ which even continue in to modern times. Maintenance
of the physician and any service unit of the health service was
the responsibility of the regional administration with constant
support from the king. The physicians and priests were
allocated land, which was cultivated by the village and upkeep
of the land was the responsibility of the village administration
with constant support from the king.
The treatment system was mainly of Ayurvedic origin, but
supplemented by many ritualistic methods. There was regular
contact with the development of Ayurveda in India either
through the invitation of renowned specialists for treatment pf
royalty and elite or by way of voluntary emigration from India
or forced migration at times of invasions to South Indian
kingdoms.
The existence of two different units of general medicine and
specialist medicine is indicated in the evidence provided by
the chronicles and inscriptions. The general medicine was
based on pulse and symptoms, while the specialist medicine
dealt with fractures, anti-venom treatment and surgery.
Preventive medicine was centred on the concept of isolation in
case of infectious diseases, regulation of food and bathing and
use of water. Herbs in combination with some mineral salts
and soils were used in the diet for the treatment of vitamin
deficiencies.
Major health problems were the maternal and infant mortality
and tropical infectious diseases like cholera, typhoid and
hepatitis. Civil strife and war have had a serious effect on the
population as the ancient kingdom was continuously ravaged
by internal power struggles and regular invasions from South
Indian kingdoms. The impact of malaria is not clearly known,
but fever associated with body pain and shaking (gehena una),
is well documented in the traditional and Ayurvedic literature
and is recorded as one of the most difficult to care
(Gnanawimala, 1950). If we follow the general argument of
the proliferation of malaria through clearance of forest and
exposing of streams, malaria could not have become a serious
78
health problem until the establishment of extensive irrigated
farming system in and around 500 AD.
Diarrhoeal disease and infectious diseases like measles,
chicken pox and mumps have been an integral part of the
disease panorama of South Asia and these types of diseases
could have expanded to a scale of epidemics during major and
minor droughts or in the aftermath of large were so extensive
and damaging, that even the seat of government was moved
temporarily to the hills or the southern kingdom (Seneviratne,
1989).
Any form of epidemic would have had a great impact on the
common people, because the traditional medical treatment is
of low value against serious viral and bacterial infections as
shown in the history of plagues all over the world. In addition
malnutrition would have been common as the diet was mainly
based on vegetative matter and carbohydrates with low
consumption of protein.
Literature on the downfall of the ancient civilization indicates
that there is some level of uncertainty connected to the role of
malaria and they believe that malaria was the effect not the
cause, though it is possible that malaria became a major health
problem towards the end of the Anuradhapura period and
thereafter as the first major disruption of the extensive
network of tanks and canals were initiated during the first
major war with south Indian invaders in and around 950 AS.
In addition the continuing major expansion of the habitat
towards South West during the Anuradhapura and
Polonnaruwa kingdoms can be considered as a response to
possible threat of malaria in the northern (Wanni) and eastern
(Thamankaduwa) regions. As observed from the maps
showing the location of tanks of the ancient civilization, it is
clear that these two regions were not very suitable for tank
construction due to flatness of landscape. This presence of flat
landscape and winding rivers may have formed the best
habitat for malaria breeding, when destroyed by war or land
degradation or both (Figure).
79
Tank Cascade system ( Weva saha Gama Parisara
Kalamanakarana kramaya Wegaakala Kramaya) of
environmental and health management : A time tested
programme for areas with seasonal drought.
80
81
Weva is not the central point in this management system,
because its success was determined not by the size of the weva
or amount of water collected in it, but by the environmental
management installed to make the weva to be filled during the
rainy season and prevent water wastage by the users. The weva
was designed on the basis of available quantity of water, where
stream order and discharge was calculated with precision (
Paranavitane, 1959). The first order weva (Kulu Weva) were
followed by the second order weva (Kuda weva) and the third
order weva (Maha Weva) were the last in the system though
many complex patterns are present within the weva hierarchy.
There may be a relationship between the weva order and stream
order as the experiment indicated. The first order weva were
constructed on the 4th or higher order (Strahler, 1967) streams at
the field mapping level. Most of these appear as 1 st or 2nd order
streams in Aerial Photos and mostly as 1st order in 1:50,000
topographic sheets. The 1st and 2nd order streams in this
identification are truly ephemeral unless fed by an artificial
source like wastewater from a settlement or cultivated land. The
3rd and 4th order streams flow between 1 to 3 days after rain
from middle of November to mid January.
The system is not always simple and there were complex
construction systems to handle local situations, which demanded
special techniques. These local situations arose from the
variations of rock type, soil cover, slope and land use. The
experiment showed that micro-slopes were responsible for loss
of water to the stream and to weva. The average slope in most of
the cascades is in the region of 1:10,000 to 1:25,000, where a
slight variation in slope will result in accumulation of water in
the micro-basin type formations on latosols. During the
experiment it was clear that a rise of slope by 2 to 3 inches
locally would lead to heavy blockage of water flow to the
stream.
Then it was paramount that the settlement, cropland, shrub land
and forest were kept in pristine condition. The most important
disturbance to the regular flow of water into the stream system
generally originates from human activities.
Firstly, the settlement in this system was located in a high
ground besides the weva or cultivated area. This prevented
82
wastewater, seepage of sewage residue and animal waste and
other types of solid and liquid waste entering weva. Further the
location allowed the settlement to direct its wastewater into
some type of wastewater pond, which was used as a recycling
unit. Non-existence of chemical waste may have allowed these
ponds to be non-toxic and some types of plants and fish may
have been used in this organic recycling or cleaning system.
There is evidence that craft industries like iron, silver and paint
production was situated in special locations where there waste
was not allowed to enter weva. This systematic arrangement
was able to limit helminthic and diarrhoeal diseases in the
period of ancient kingdom as all waste water was properly
controlled. There were set ethics, rules and regulations in the
use of environment and heavy punishment was advocated to
prevent any break of order.
Secondly, though it is not very clear, inscriptions and designs of
the sacred and built up areas of the ancient civilisation support
an existence of a highly developed hydrological management
system. The wastage of water was controlled with heavy legal
and communal commands and user-friendly system was
maintained. Rocky ridges were not utilised for settlements and
they were either fully conserved or kept in the custody of
monks, who managed the area in pristine condition. The
experiment conducted on these areas indicate that the rock
ridges under the care of monks had about 4 to 6 times more
springs than the areas closer to other types of settlements. The
specific purpose of the shrub, forest and the upper catchment of
weva were defined by law and tradition and the law breakers
were punished. These arrangements were responsible for the
existence of clean drinking water and low air pollution through
conservation of rocky ridges. The priests living on the rocky
ridges were always environment friendly and understood the
principles of clean environment through the preaching of Lord
Buddha. The priests were given a heavy public support through
heavy punishment for intrusion into temple property and errand
priests were also punished.
This system was capable of maintaining a population of about 5
million 8 million between the period of 100 and 1100 AD, when
the civilisation was in full bloom. National plan for the
83
civilisation was in operation with periods of rapid and slow
phases of weva building , resettlement in the peripheries and
inter-basin water transfer (Paranavitane, 1959). There were only
a few instances of epidemics in the kingdom and they were
mostly initiated by the destruction caused by internal conflict,
war and prolonged drought, which are mostly beyond any
management control system.
Non-use of toxic substances kept the environment of this
kingdom free from chemical pollution, though heavy use of
iron, silver and brass may have required smelting. It is clear that
smelting was carried out in the outskirts of the main cities.
Today the total disregard for the weva cascade system originate
from the public sector planning of settlements (including
Resettlement programme since 1930), construction of roads and
railways, establishment of forest plantations, construction of
large government and private sector institutions, waste dumping
and land fill. These activities have increased the regular
blockage of 1st, 2nd and 3rd order streams in the area, destroyed
some of them totally and redirected water to local depressions
where they accumulate and evaporate, thus seriously starving
the 1st order weva system. It is clear that the present civilisation
of the wet zone has never managed to understand the principle
of environmental management of the ancient civilisation though
rhetoric is evident in all types of utterances and unscientific
publications. It is time that we attempt to understand that it is
not only the existence of the cascade system which made
possible for the development of the dry zone civilisation, but the
hydrological management system in operation through various
royal instructions and laws, which defined the terms of water
conservation and water use. Existence of officials like dolos-
maha-vatan, va-vajarama, vel-kami and compensation paid for
loss due to royal order clearly indicate this existence of an
efficient management system. If the orders of the palace were
not conducted properly the officials responsible were punished.
Then it is clear that this system of management was user
friendly, community oriented, but strictly legal and orderly
(Paranvitane, 1959). The king himself was well educated on his
duties and was under the guidance of council of ministers and
high dignitaries.
84
We must understand the value of drainage and hydrological
management if we are to solve the major problem in Sri Lanka
and prevent the destruction caused to regular flow of streams in
the dry zone during the wet season. The present planning
system or the legal system is not built on this type of
regularisation and today we are forced to depend on inter-basin
water transfer. However, it is clear that we are even unable to
maintain a well operational inter-basin water transfer system at
present due to poor upper watershed management. There is
chaos in the drought control system and it is high time we
understand that this problem can be solved only through a well-
managed scientific system and not by just feeding the area with
water from somewhere as we do today.
85
instability and war with the Portuguese, Dutch, and British
between 1505 and 1815 resulted in a continuous movement of
the majority of the population and the civilization was unable
to develop any form of technology to enhance cultivation of
food crops or develop a strong craft industry in the wet zone.
Portuguese and Dutch medical records indicate the presence
of cholera, tuberculosis and many helminthic infections
during and after flooding (de Queyroz, 1617). Western
medicine was available to the elite through the services of
government doctors of Portuguese and Dutch rules and the
Dutch managed to establish the first network of dispensaries
in the area of cinnamon production and coastal towns during
their rule (Uragoda, 1979). Traditional and Ayurvedic system
were in decline due to lack of proper institutional support. The
influence of Hinduism increased in the kingdom as royalty
established marriage bonds with South Indian kingdoms and
many ritualistic traditions infiltrated traditional medicine this
period.
86
The establishment of the plantation system was the beginning
of the present system of environment control in Sri Lanka.
This was a system of massive forest clearance, redirection of
drainage, slope reorientation and village relocation, aided by
high capital investment and strong political authority. There is
a serious disagreement between the numerous authors who
have published on the advantages and disadvantages of the
plantation system. However, the plantation system was
capable of introducing a new form of environmental control in
comparison to the old system of sedentary farming. The
income generated by the plantation system was also
responsible for the development of health services and other
social services in Sri Lanka during this period.
From the 1920s onwards, western medical facilities were
established in the populated wet zone, with greater emphasis
in the western and southern district and the plantation areas.
The high level of acceptance by the populace and the
implementation of sanitary law helped the wet zone to reduce
its major infectious diseases, but the urban poor population
suffered continuously from many infectious diseases arising
from congestion, poor sanitation and housing.
The forest and grazing reserves established by the British
deprived the farmer of the slash and burn cultivation and
many farmers migrated to newly established townships in the
coastal areas (Roberts, 1977). The population of the south and
south west regions were seriously affected by this land
scarcity and in 1927 the land Commission was advised to
consider resettlement of farmers in the dry zone areas where
old reservoirs were to be restored. Therefore after a lapse of
700 years, the introduced system of environmental change of
the wet zone resulted in a revisit to the dry zone. The final
result of this policy was the establishment of more than 40
major resettlements in the period between 1930 and 1970 and
many other Trans Basin resettlement programmes since then.
Therefore the history of disease prevalence in relation to this
thesis as presented here completes a full cycle for the Sinhala
farmer. In addition to geopolitical failure of the ancient
kingdom, malaria was a causative factor in the abandonment
of the dry zone environment. In between 1200 and 1815 they
87
were in the wet zone and they established a rural landscape
with a traditional health system. Under British colonial rule
their land was forcibly taken and the excess population was
directed to be settlers in the dry zone.
88
Area Mean Number Number Paddy Mean number
annual of of schools lands of malaria
rainfall medical per 50 sq. (mean cases reported
(mms.) officers km. hectares to
(curative per government
services district) health
per facilities (Per
100,000) 100,000)*
Wet zone 2000 More 15 and Less than Less than 100
than 10 above 15000
Intermediate 1500 to 5 to 9 7 to 14 16 to 100 to 250
zone** 2000 19000
Dry zone 1000 to Less than Less than More More than
1500 5 7 than 300
20000
Sources: Rainfall, number of medical officers, number of
schools and paddy lands extracted from Arjuna‟s Atlas of
Sri Lanka (1979)
* Ministry of Health (1996).
** Authors‟ estimates, as the district data is extremely
difficult to use for this purpose.
89
roads in the village units located on the valley slopes of the
ridge and valley topography (Figure). This results in poor
accessibility to health services, but prevents flood damage.
The major source of drinking water is a well, but many other
sources like stream, river and spring are used. The
availability of safe drinking water is limited to large
settlements and less than 20 per cent of the farming
communities have drinking water. In addition, for about 50
to 60 days a year, the heavy rains of the monsoon and
thunderstorm origin result in the flooding of farmland and
contamination of streams and wells which are used for
bathing and washing.
Farming families of the wet zone Sri Lanka record an
average literacy of 60 per cent or above. The villagers have
access to a developed western health care system and a well-
established system of traditional medical service. The
combined existence of the western and traditional medical
service system has increased the awareness of preventive
care in the wet zone villages
Figure 4.3
A graphical representation of the location of farmer
households in the wet zone of Sri Lanka
SC/F PP PP
SC/F
P R P
PH H D2 D H
90
In a majority of the farming family households, the
surroundings are kept clean, most of the basic advice on
preventive care is adhered to and waste disposal is carefully
carried out. During the survey, it was observed that the
general cleanliness of the farming villages is much higher
than in the settlements of the poor sub-urban and urban
dwellers.
Figure 4.4
A graphical representation of a resettled village in the dry
zone of Sri Lanka
W MC SC SC SH
P P P CS
91
Key: W – Weva/ MC – Main Canal/ SC – Sub Canal/ SH –
System or Colony housing/ S- Scrub/ CS – Cash crops/ P -
Paddy
92
settlements in the dry zone makes them to be more rural in
appearance. As some researchers have indicated, women of
the new settlements have lost the valuable advice from their
siblings and parents who live in home villages and this has an
important effect on the health status of the family in the dry
zone, through lack of knowledge of home remedies or first-aid
at time of emergencies.
Farming families of the dry zone have devised a system of
survival to live a healthy life in the dry zone through use of
many types of resources. In relation to malaria, they employ
many types of coping skills such as use of malaria
prophylaxis, immediate treatment from the nearest western
medical service centre and use of many home remedies to
reduce the dangerous side effects. In relation to diarrhoeal
diseases they use the home remedies first and then refer the
case to the hospital or dispensary for treatment, which
sometimes results in a dangerous delay and cause death
especially in children. Any forms of high fever and sickness
of children are most of the time immediately treated in
hospitals and sometimes they have travel out of the district to
specialist hospitals or home village facilities with better
diagnostic and treatment facilities. The specialist hospitals at
Anuradhapura, Polonnaruwa, Batticaloa, Trincomallee and
Hambantota in the dry zone and Kurunegala, Kandy, Badulla,
Ratnapura and Galle in the wet zone are extensively used by
the people of the dry zone when in need of treatment and this
has reduced the mortality in a great many cases. Further, the
availability of many base hospitals which can successfully
handle all cases of malaria and diarrhoeal disease have also
contributed to the low rates of mortality in the dry zone since
1980s.
The effect of war as a stress factor was noted in the farming
families of the dry zone. This is a result of a large number of
unemployed youth of the resettled families being employed in
the armed forces, which increases the mortality of the young
age group. Further, the farmers in the front line villages live in
constant fear of war damage and massacres.
93
Conclusion
Introduction
94
national situation, which will to be shed light on in this
discussion. The chapter begins with a presentation of the data
sources and factors, which will form the background to the
empirical data. The second part will use both mortality and
morbidity data from various sources and an account of the
present day variation of disease prevalence between the wet
zone and dry zone is presented in the final part of the chapter.
Data sources
95
Bulletin. The other form of data originates from national
census, demographic surveys and the office of the Registrar
General. This presentation therefore is based on the above two
data, sets, which are fairly reliable in character and strength,
though the data on private medical services are not fully
represented in them.
96
Rate Rate Rate
(CDR) (IMR) (MMR)
Per 1000 Per 1000 Per 1000
1936-1940 21.4 160.2 19.2
1941-1945 19.9 131.1 14.6
1946-1950 14.3 100.5 9.3
1951-1955 11.2 74.8 4.7
1956-1960 9.5 62.6 3.6
1961-1965 8.4 54.2 2.6
1966-1970 7.9 50.5 1.7
1971-1975 8.2 46.6 1.2
1976-1980 6.9 39.2 0.8
1981-1985 6.2 28.0 0.5
1986-1990 6.0 20.3 0.4
1991-1995 5.5 17.0 0.3
Source: Department of Registrar General, Vital Statistics
for various years
Table 4.3 a Age specific death rates (rate per 1000) Sri
Lanka, 1946-1995, years 0 to 24
97
10- 15- 20-
Year 0-4 5-9
14 19 24
1946 61.1 6.7 3.3 5.6 6.7
1961 18.1 2.2 1.1 1.5 1.9
1981 8.3 0.8 0.6 1.5 2.1
1995* 4.3 0.6 0.5 1.2 2.2
% 93.0 91.0 54.5 78.6 67.2
change
(-)
(1946-
1995)
Table 4.3 b Age specific death rates (rate per 1000) Sri
Lanka, 1946-1995, years 25 to 55 and over
55 &
25- 35-
Year 45-54 Over
34 44
1946 9.1 12.4 18.5 72.9
1961 2.3 3.3 6.1 41.7
1981 2.4 3.0 6.2 33.9
1995* 2.4 2.8 5.8 28.1
% 73.6 77.4 68.6 61.4
change
(-)
(1946-
1995)
98
by the change in life expectancy at birth from 45 in 1950 to
73.7 in 1996 (Table).
99
welfare policies have also played an important role in the
decrease of infectious diseases.
100
Malaria
101
Infectious diseases
Mortality
102
Matara, Galle, Badulla and Nuwara Eliya districts have higher
average infant mortality rates (IMR above 25 per thousand
live births) than the other DS divisions. Among these
divisions, the Ratnapura DS division in the Ratnapura district
recorded the highest average infant mortality rate as of 105.3
per 1000 live births for 1994 -96 period. The factors for this
high rate of IMR are yet remains to be fully investigated
because there are no specific factors attributable for this
striking rate. Moreover, the Matara DS in the Matara district
(93.8 per 1000 live births); Nuwaragam Palatha East (98.3) in
Anuradhapura, Badulla (73.4) in Badulla, Thamankaduwa
(60.8) in Polonnaruwa, Kegalle (56.1) in Kegalle and Chilaw
(51.6) in the Puttalam district also recorded more than 50
infant deaths per 1000 live births during 1994 - 96. In brief,
forty eight (48) DS divisions recorded average infant
mortality rates higher than the national figure.
The districts variations in infant mortality rate are more
striking when only a few districts, which have recorded
relatively high average IMR rates by DS division, are taken
into account. The under five-child mortality and maternal
mortality rates are also varied across the DS divisions and
districts respectively in 1996. The regional disparity in the
under five child mortality varies considerably from 1.8 per
1000 live births (Yatinuwara in the Kandy district) to 389 per
1000 live births (Koralepatthu west in the Batticaloa district).
Seventy two DS divisions recorded under five child mortality
rates higher than the national figure (21 per 1000 live births in
1996).
Although Sri Lanka recorded a remarkably low level of
maternal mortality rate of 0.2 per 1000 live births in 1996,
there are marked regional disparities across districts.
Kilinochchi recorded the highest MMR (1.3 per thousand live
births) followed Ampara (1.1), Mannar (1.0) Nuwara Eliya
(.7), Polonnaruwa (.5 per 1000) and Batticaloa (.5 per 1000)
whilst the lowest MMR was recorded in Kegalle, Kurunegala,
Matara and Colombo with a rate of 0.1 per thousand live
births.
Many reasons are given for these extreme situations in the
surveys conducted on specific vulnerable groups. The primary
103
reason is poverty or a poverty based factor such as
malnutrition and accessibility. Some of these areas
(Nuwaragam Palatha, Thamankaduwa and Koralepattu west)
are located in heavily forested or isolated areas in Sri Lanka,
where high level of poverty is recorded. However, the
presence of some urban areas (Chilaw, Kegalle, Matara,
Badulla and Ratnapura) in this group of DS divisions indicates
that effect of urban slum living also has a role to play in high
mortality rates. Observations made in these urban areas
indicate that a large number of slum dwellers live in and
around swamps and wet lands. However, lack of data on these
communities prevent making of a reliable conclusion.
The estates, where Indian Tamils live, have the highest
mortality levels, especially among infant and children. During
1948-1974, the infant mortality rate in the estate sector was
134 per thousand live births and the child mortality was 36.
This pattern remains unchanged even after 1974 as recorded
in the DHS Surveys in 1987 and 1993. According to the 1987
and 1993 DHS surveys, the infant mortality rate and child
mortality rate were highest in the estate sector due to
increasing poverty. Meegama (1980) has pointed out that the
high level of infant mortality in the estates during 1946 to
1974 was due to malnutrition among mothers, lack of
antenatal care, and lack of trained midwives and low level of
institutional births.
The comparatively high incidence of tuberculosis, viral
hepatitis and dengue in the districts of Colombo, Gampaha,
Kalutara and Kandy, which are the most urbanized, is a
confirmation to this fact, though no definitive conclusions can
be made on the relationship between socio-economic factor
and high prevalence (Table).
104
Table 4.6 The rankings of the major notifiable diseases in the
four most populated districts of the wet zone of Sri Lanka.
Mobility
105
Key-
Highway link –
Main bus terminus –
Direction of spread
Direction of spread from
pilgrim centres
Pilgrim centres
Anuradhapura
Place of origin
Dehiattakandiya
Colombo
Galle Kataragama
106
Figure 4. 5 Spread of cholera epidemic in 1998, which was
transmitted along long distance express bus routes and
pilgrim routes
107
Figure 4.6 Increase of malaria cases from wet zone to dry
zone (based on district data, arrows show the direction away
from wet zone), Ministry of Health, 1996.
120
100
80
60
40
20
ta
bo
ha
a
la
le
a
ra
ra
al
al
ur
ar
ho
ga
al
pa
om
pa
pu
ag
ag
ap
at
G
nt
ne
Am
am
ha
M
er
er
ol
hn
ba
ru
C
on
on
ad
G
at
am
Ku
ur
M
R
H
An
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1 2 3 4 5 6 7
108
3. Dental surgeons
4. Registered Assistant Medical practitioners
5. Public health Nurse
6. Public Health inspectors
7. Public Health midwife
109
population ratio between the dry zone and wet zone is about 1
to 3 and the very low numbers in the dry zone indicate a
severe scarcity of qualified health care personnel in the dry
zone. It should also be noted that most of these medical
personnel operate from the wet zone or intermediate zone
urban areas and their physical presence is limited to shift type
of operation and week days only, which makes the services
highly inefficient.
A detailed examination of prevalence of malaria in the
intermediate zone is not possible from the district base data,
but an attempt was made to separate the wet zone districts
from the intermediate zone districts. In this attempt any
district, which had a physical connection to the dry zone, but
not located fully in the zone was grouped as intermediate zone
districts. Kurunegala, Matale, Badulla, Ratnapura and Matara
were identified as intermediate zone districts. However the
prevalence rates of the dry zone districts were about twice of
that of the intermediate districts. The wet zone has less than 1
per 1000 prevalence, and the intermediate zone has
approximately a three fold increase in prevalence in
comparison to the wet zone. However, it should be noted that
the validity of this selected boundary and the attempt to relate
it to the prevalence of malaria only have an observational
value.
600
500
400
300
200
110
100
0
Figure 4.9 Prevalence of three other infectious diseases in
the wet and dry zones, Ministry of Health, 1996
0.6
0.5
0.4
0.3
0.2
0.1
0
Typhoid Viral hepatitis Tuberculosis
111
collected from the national data base (Annual Health Bulletin,
1996) and at System C data from Dehiattakandiya hospital was
used.
The national situation shows low prevalence of malaria, moderate
prevalence of bacterial and respiratory diseases, and a notable
presence of viral diseases. The home villages have no viral diseases,
but have a high prevalence of respiratory diseases and moderate
prevalence of bacterial diseases. The Anuradhapura district
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
National Home villages Anuradhapura System C
112
Data sources: National data and Anuradhapura data from ,
Ministry of Health , 1996: Home villages data from Home
village Hospital data, System C data from
Dehiaththakandiya hospital (Seneviratne, 2003).
70
60
50
40
30
20
10
0
113
Malaria Respiratory Bacterial Viral
114
Lanka. The high presence of bacterial disease in national
profiles is a result of urbanization, where drainage and access
to safe water are inadequate. The gradual reduction in the
bacterial diseases towards the rural periphery may also be a
result of both a cleaner village environment and non-reporting
to hospitals. This is a result of treatment of common bacterial
diseases by freely available antibiotics and by the villagers in
Sri Lanka.
A simple line diagram was also constructed using disease
categories on the X axis and prevalence on the Y axis
(Figure). Although this line diagram has no statistical value, it
revealed a fascinating picture of the stages of evolution of
disease prevalence.
Assuming that the line representing the national averages is an
evolution of about 70 years of western medicine in Sri Lanka
and a living environment established over a period of equal
length, System C is expected to take a long time period of
time to reach that stage. The home villages and the
Anuradhapura district show some parallel existence, which
may be explained as the probable path of evolution for the
System C line.
This evolution is associated also with the development change
in health services, which are felt much stronger in national
data due to the limited presence of infectious diseases in the
middle and upper classes, which have reached a stage with a
heavy presence of chronic diseases among them. The
economically strong classes have reached this stage mainly
through their improved immediate living environment and use
of western medicine.
Conclusion
115
by the government has enabled the poor to have access to
preventive and curative medicine. However, the ability and
willingness to use the facilities and the selection of the
medical systems originates from literacy. The place of women
in society is also a major supportive factor in achieving better
levels of health in Sri Lanka.
However, the continuing high prevalence of malaria indicates
the strength of the tropical climate and poor living conditions
in a developing world health situation. This constructs the
primary disparity of the disease prevalence between the wet
and dry zones of Sri Lanka. Firstly, the comparatively high
disease prevalence of the infectious diseases in the dry zone
originates from the presence of endemic malaria, which
results from the tropical climate. Secondly, the poor living
conditions of the farmer are primarily a sign of the poverty of
the nation, which is unable to provide an acceptable level of
employment and social security. Therefore, the dry zone
farmer is affected both by poverty and endemic malaria in
comparison to his counterpart in the wet zone who is
subjected to poverty, but less impacted by infectious diseases.
As discussed in the text, the minor variations between the
urban and rural areas and some ethnic influence emanate from
either environmental or behavioural factors, which record
only highly localized situations. These situations cannot be
supported by the existing data structures.
The national data indicate a situation of epidemiological
transition, but a detailed analysis indicate that the national
data base is becoming irrelevant to marginalized groups like
resettled people and parts of the wet zone farming population
of Sri Lanka. Furthermore, it is clear that malaria forms an
integral part of the zone disease prevalence until a major
environmental control is established by the developmental
change.
116
Case study 3
Introduction
117
rising prevalence of chronic and new diseases. The
developing nations have rapid increases in population,
which has resulted in negative effects on health.
Environmental change is the process of change of the nature
and dynamics of space and place. The concept of
environmental change emerged from the studies on changing
nature of earth systems, like green house gases, ozone
depletion, soil erosion, desertification and emergence of new
diseases. The geological forces of the environment create
changes in the physical environment and form various types
of health hazards. Society change space and place through
many types of consumption systems from cultivation to
recreation and in the present civilisation, culture has become
the primary force behind change of natural space and place.
Human activities utilise culture to develop space and place
and in doing so create a constant competition for places
(Sack, 1999). Therefore we can assume that, changes in
health profiles are formed when there is a crisis between
nature of place and culture.
Study areas
118
Immediate living environment
119
income of 5000 rupees and categorized in the economic
literature as low income group of people. This group of
people do not own enough area wet land or highland to
support their families and constantly engaged in many other
labour type jobs during the off season period in their home
villages. That is why they attempt to migrate to land
development schemes when they are offered the ownership
of wetland and highland.
Their immediate living environment comprises of a house, a
well for drinking water, toilet, and site for dumping of
refuse, a few fruit trees, open space for drying food items
and clothing and recreation. Therefore the immediate living
environment of the house is a unit of complex use, which
makes it an important element in the discussion of disease
prevalence. The immediate living environment is identified
as an independent factor from the general socio-economic
environment, because of its importance to family hygiene
and health in its micro environmental perspective. Further,
the sample population has no institutionalized sanitation and
water supply system, which makes the organization of the
household environment an important aspect of their health.
120
given by Department of Census and Statistics (1997).
However, it should be noted that these income levels are
continuously devalued by continuing inflation in Sri Lanka
(Table 7.1).
121
had an auxiliary income source from either craft work or
daily paid labour.
122
children
Farmer supported by an
employed wife 0 0 8 9
Farmer supported by friends
living together 0 0 3 3
Farmer supported by parents
living together 0 0 6 7
Farmer / mahout 1 1 0 0
Farmer / latex tapper (rubber) 3 3 0 0
Total 90 100 90 100
Source : Seneviratne (2003)
123
Home villages System C
Literacy group
No Percent No Percent
No formal
schooling 22 24 5 6
Primary 66 73 56 62
Junior secondary 2 2 21 23
Senior secondary
and above 0 0 8 9
Total 90 0 90 100
124
wives is mainly composed or an older group and has not had
the opportunity of the free education facility, which began
after independence. System C women have had the
opportunity to attend free schooling and record higher
literacy level than their mothers at home villages. Secondly,
the higher level of literacy of women of younger age is a
result of the tradition of long duration of schooling for girls
in the farming community. The young girls, in both areas
valued schooling as a way to prosperity and active social
and political life. The information on the marriages of the
children indicate that some girls in the home villages and
System C were able to marry a person of higher income due
to extra schooling in the district capital or provincial capital.
125
The quarterly observations of the field survey have revealed
the importance of tree cover in the reduction of temperature
of the house during the warm season in both home village
and System C, where the maximum temperature in the open
gardens were about 36 to 38 degrees C, while the forested
gardens recorded a maximum of about 32 Cc.
126
House Home villages System C
quality No Percent No Percent
2 per 76 84 44 49
room
or less
3 to 4 14 16 39 43
per
room
More 0 0 7 8
than 4
per
room
Total 90 100 90 100
Source : Seneviratne (2003)
127
(Wanasinghe, 1997). However it should be noted that this
figure is affected by better housing in urban centres and for
village areas and for new settlements the figure can be as
high as 70 percent or more.
The data for source of water supply for drinking and bathing
and the type of toilet is given in tables 4.12 and 4.13.
128
River, tank 4 2 2 46 51
and stream
Other 5 6 7 1 1
Total 100 90 100 90 100
Source : Ministry of Health, 1996 for Sri Lanka data and
Seneviratne (2003)
Drinking water
129
through use of boiled water for children and careful storage of
drinking water.
Toilet facilities
Wastewater disposal
130
The wastewater disposal was observed during the survey
through the assessment of risk associated with the open
drains, which drain wastewater from kitchen and garden.
The risk was calculated on a two-point scale, which was
based on the strength of bad odour emanating from the
drain. More than 83 percent of the home village households
had drains with a bad odour during the rainy season. System
C sample fared better with 57 percent. The higher level of
bad odour in the home village area grains is related to
fermentation of organic matter in a humid environment and
the presence of more roadside waste due to high-density
population.
Presence of mosquitoes
131
Total 90 100 90 100
Source : Seneviratne (2003)
Accessibility
132
data for the calculation was collected on the basis of number
of health care facilities visited by the respondents (Table
3.15).
133
However, in case of rare infectious or chronic disease, which
could not be diagnosed properly by the hospital at System C,
the mean travel time and cost of emergency can record
extremely high values. The highest recorded value for an
emergency is the transfer of a typhoid patient from System
C to Colombo Specialist Hospital, which took ten hours of
travel time and a cost of 6000 rupees.
134
Table 4.16 Computation of the variables into three risk levels
House quality Environment
risk score
2 per room 1
3 to 4 per room 2
More than 4 per room 3
Type of toilet
Water seal 1
Pour flush 2
Pit 3
Others (mostly temporary) 3
Shared 3
No toilet 3
Mosquito presence
No problem 1
Seasonal problem 2
All season problem 3
Source : Seneviratne (2003)
135
Table 4.17 Risk level of the environment
136
Presentation of rates and ratios
137
Category Age group Status of
significance
No schooling 0 – 14 Not significant
and primary 15 – 39 significant
40 – 59 Not significant
60 and above Not significant
Junior secondary 0 – 14 Not significant
15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
Senior secondary 0 – 14 Not significant
and above 15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
No schooling 0 – 14 Not significant
and primary 15 – 39 significant
40 – 59 Not significant
60 and above Not significant
Junior secondary 0 – 14 Not significant
15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
Senior secondary 0 – 14 Not significant
and above 15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
138
Age adjusted rates
139
understand information on health at this playful age group or
lack of health education or both.
The very marked difference in sick not sick rates between
junior secondary (Table 3.20) and senior secondary (Table
3.21) can be supported by research. The close association
between the best levels of health and senior secondary and
above education in Sri Lanka is confirmed by the data in
Table 7.15. Though there is no significant difference
between the two areas on this category it is clear that this
category of literacy reduces the number of sick drastically in
comparison to two other categories.
140
medical personnel and cope better with disease and ill health
than the rest of the farming population.
141
unreliable results and this implies that the results of the low risk
category cannot be taken as valid as the results of the other two
categories.
The changing pattern of risk between the two areas is also explained
by the adjusted rate. Therefore as in the analysis of disease
prevalence age adjusted rates have eliminated the bias of age in the
population being compared and has provided a reliable rate for
comparison purposes.
The use of age specific and age adjusted rates for the analysis of
education and health and environment risk and health was aimed at
comparing the health status for educational groups and environment
risk groups controlling for age. The results indicate that age
specificity is not very useful in the analysis, which may arise from
the skewed distribution of data and lack of cases. However, the
primary intention of the analysis was to make a comparison
142
between home villages and System Cc. This was achieved with the
use of age-adjusted rate, which is weaker than the age specific rate
in the measurement of absolute levels but useful for purposes of
comparison. This indicates that the technique of age adjusted rate
has managed to identify the difference between the two areas
controlling for age.
Conclusion
The district based national data on sanitation and water supply are
questioned by this analysis, because the percentages recorded in
143
them are not confirmed during the survey, though the researcher
managed to utilize the same categories. This may be a result of
detailed recording of these facilities and checking the location of
facilities conducted during the survey, which may not have been
carried out during national surveys. Therefore, this analysis reveals
a glimpse of the value of environmental change in the formation of
disease scenario in a newly settled area.
Chapter 5
Introduction
144
As already mentioned in chapter 3, in this study an illness, sickness
or disease, which was treated by a registered medical practitioner
(Western, Ayurvedic or traditional) on a prescription, is used to
identify a situation to be recorded as a valid entry of disease
prevalence. The presentation begins with a discussion on the age
structure of the sample population. It is followed by the presentation
of data on all diseases, infectious disease, and non-infectious
diseases under various categories as recorded during the survey.
Then the seriousness of the disease and gender variations is
discussed respectively.
Age structure
145
60 and above 82 13 10 2 92 8
Total 632 100 511 99 1143 1
Source: Seneviratne, 2003
The age groups given in the tables were identified on the basis of its
relationship to active participation in farming and amount of
exposure to disease within the Sinhala farming community of Sri
Lanka. The children join the full time farming activities at an
average age of 14 to 15, and continue till about 60 years of age. The
males are involved in the clearance, ploughing, sowing and
threshing, while females play an important role in weeding, cutting,
packing the harvest for threshing and final preparation of rice. The
most active period of life of a farmer is from 15 to 39 years, during
which he inherits land for farming or becomes resettled, gets
married and forms a family. During this period he and his wife have
only limited help from their children and have to work extremely
hard to raise children and provide them with basic necessities of
life. It is common to see the presence of the father or other of either
the farmer or his wife staying with the family during this early
period of farming life. In the third age group, which begins at 40,
the farmer receives help from his adult children and sometimes
migrates with a young child to a new area for farming. After 60
years of age most of the farmers hand over fulltime farming to their
children, while their wives become household helpers. Therefore it
is assumed here that the highest exposure to occupational hazards
and disease in a life of a farmer occurs in the age group of 15 to 59.
Table 5.2 Age structure of sick and not sick for the total sample
146
Table 6.2 indicates the steady increase of disease prevalence with
age in the total sample. The prevalence value for the total
population is exceeded by the two age groups 40 to 59 and 60 above
indicating a high prevalence of disease in mature adults. Further
analysis of this data is conducted in the latter part of the chapter
with the use of confidence intervals on crude and age adjusted rates.
Gender structure
Gender Area
Home village System C Total
No. Percent No. Percent No. Percent
Male 286 45 280 55 566 50
Female 246 55 231 45 577 50
Total 632 100 511 100 1143 100
Source: Seneviratne, 2003
Levels of measurements
The data disease prevalence was collected both on an individual and
household basis in order to build a database with individual and
environmental information respectively ()Table 6.4). The disease
records were utilized to identify the type, status and treatment of
disease. The age, gender, education, employment data was collected
147
from the questionnaire data. The environment data was collected
from the questionnaire and observation data. This chapter will focus
on the individual perspective of disease prevalence and the
environmental information is presented in the next chapter.
Infectious diseases
The discussion on disease prevalence is presented with the analysis
of data on infectious diseases followed by the non-infectious
disease.
The data presented in the Tables 4.5 to 4.8 portrays the number of
cases and disease prevalence as they were recorded in the two study
areas during the survey period for all four visits, from January to
December 1998. The basic data presented in the Tables 6.5 and 6.6
148
are the total number of records for all the four visits. The Tables 6.6
and 6.8 show the prevalence data calculated from the basic data.
149
disease 1st 2nd 3rd 1st 2nd 3rd
disease* disease** disease*** disease* disease**
No. No. No. No. No. No
Respiratory systems 44 0 0 14 12 0
Musculo skeletal 20 12 0 3 5 1
Circulatory 21 3 0 9 2 1
Cancers 10 0 0 5 0 0
Nervous system 3 1 0 3 2 2
Digestive system 1 0 0 9 0 0
Ear nose and throat 3 0 0 0 0 0
Skin disorders 1 1 0 3 1 0
Mental disorders 2 2 0 1 1 0
Eye 6 6 0 5 7 1
Dental 1 0 0 3 0 0
Total 112 25 0 55 30 5
Source: Seneviratne, 2003
150
Non- infectious Home village System C
disease 1 disease 2 disease 3 disease 1stdisease
st nd rd
2nd disease 3rd
Respiratory
393 0 0 212 231 0
systems
Musculo skeletal 179 107 0 58 96 19
Circulatory 188 27 0 173 38 19
Cancers 89 0 0 96 0 0
Nervous system 27 9 0 58 38
Digestive system 9 0 0 173 0 0
Ear nose and
27 0 0 0 0 0
throat
Skin disorders 9 9 0 58 19 0
Mental disorders 18 18 0 19 19 0
Eye 54 54 0 74 135 19
Dental 9 0 0 58 0
Source: Seneviratne, 2003
The four major infectious diseases reported from the two study
areas during the survey period were in the broad categories of
malaria, respiratory, urinary tract and skin infections. All the
infectious diseases have recorded a higher prevalence level in the
System C than in the home villages. The high prevalence of malaria
inn System C is shown by its importance as a first and second
disease, which is not present in home villages. The respiratory
diseases are the most common group of diseases in the home
villages and respiratory diseases as a whole is the second most
important disease in the System C area. A similar prevalence can be
noted in the urinary tract infections, but it is not recorded as a
second disease at home villages.
151
and intestinal infections have also recorded higher prevalence levels
in System C, in comparison with the home villages.
“The respiratory diseases were rare during our childhood. The air
was good and we never drank dangerous things like kassippu. We
ate a lot of leaves, which had the quality to keep your respiratory
systems strong. The major sicknesses of our times were worms and
fevers”.
This is the general view is the general view of the heavily old
farmers, who believe that air pollution and new ways of life have
increased morbidity related to respiratory diseases. The sickness
associated with worms and fevers can be related to intestinal
infections and viral fevers of the past.
152
Through malaria is an incessant problem in System C, it is not
regarded as a dangerous disease, due to availability of treatment
facilities. However, its effects are considered as highly debilitating
both by young and old.
153
The respiratory system diseases were distributed among all the age
groups and the highest prevalence was recorded for the ages above
40 in both areas. The home villages recorded 75 percent of all the
cases of respiratory diseases and this high prevalence can be related
to the presence of numerous aged people.
The diseases of the nervous system were recorded only in the form
of chronic diseases within the sample. These types of diseases in the
System C area are almost twice that of the home village, which is
attributed to the stress caused by the employment of their sons as
154
soldiers in the armed forces, and eloping of daughters. The home
village cases of nervous disorders have resulted from various causes
like old age, malignant cancer of the husband and chronic
respiratory disease. The home village sample did not record any
special stress related illness arising from the employment of their
children in the armed forces, but parents did show signs of
worrying.
155
Seventy five percent of the skin disorders were reported from the
System C area with 50 percent of the cases in the 40 to 59 year age
groups. The only case of skin disease at the home villages was a
child of a respondent, who was asked to leave System C by the
medical professionals, who noticed an increases severity of the
disease, when the child lives as System C.
The mental disorders have arisen from two major sources. Firstly,
the cases in home village come from a family, which has a case
history of mental disorders, who associate the situation to „the work
of an enemy of the family,‟ (the prescriptions or diagnostic reports
were not available to the researcher as they were not produced
voluntarily). The case at System C is related to excessive
consumption of alcohol and „hard drugs‟ per the family and no
medical records were available to the researchers for verification.
The mental disorders were recorded in the age groups of 15 to 59
and 67 percent were in the age group of 40 to 59, with an equal
distribution in the home villages and System C.
The weak eyesight was common among the people over the age of
70 but was reported in the age group of 40 to 59 at System C. Some
of the System C respondents were of the view that preventive and
curative drugs used for malaria had caused early loss of normal
vision in them. The medical practitioners generally accept this,
though firm scientific evidence is not available.
Comparison between the national and study area is not possible due
to the simple recording system used in the hospital records.
156
Presence or absence of disease
157
treatment (Table 4.11). The infectious diseases were present, only at
a particular visit while the chronic illnesses had a continued
presence throughout the survey with some variation in intensity of
suffering and treatment. The categories made of the level and
serious nature of sickness is firmly attached to a definite health
situation such as treatment or a limitation of physical activity and
therefore can be taken as suitable for making general conclusions.
Healthy
The respondents who did not complain of any sickness or disease
were questioned about their health and asked whether they had
taken any self-treatment for many types of cold and flu in the
village environment of Sri Lanka. 84 percent of them reported that
they have taken self-medication in form of pain relievers and
vitamin supplements without being prescribed by qualified medical
personnel. These medicines were obtained from shops, kiosks and
some unregistered „quacks‟, which operate in the village markets or
service centres. I had the opportunity to meet about five of them
(three in the home villages and two in the System C) during the
course of the survey and found that they sell many brands of
traditional and western medicine. All the respondents in this group
had used some form of herbal treatment at least once during the
survey period and the respondents over 60 years of age are regular
158
users of these types of treatment, though they do not accept that
they are sick.
159
Technical Assistance, Tools of the Trade, (2000). The confidence
intervals for a crude rate method are utilized to calculate the upper
limit and lower limit values. As given in the Pennsylvania Health
Department (2000), the use of confidence intervals in the analysis
and presentation of rates increases the value of the study and aptly
qualify and guide the results of any study.
Ratio gives the proportion between two rates and shows the scale of
difference, but not the magnitude. However, ratios are valuable in
gathering a basic understanding of the difference between two
events or areas and are used alongside rates to describe basic
characteristics of two populations. Standard mortality ratio, relative
risk, population per hospital bed and populations per physician are
the most commonly used ratios and risk ratio is used in this study in
the detailed explanation of some age specific and standardized rates.
160
Category Age group Status of
significance
All males and females 0 – 14 Not significant
15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
All males 0 – 14 Significant
15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
All females 0 – 14 Not significant
15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
Infectious diseases – all 0 – 14 Significant
males an all females 15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
Non- infectious diseases – 0 – 14 Not significant
all males and females 15 – 39 Not significant
40 – 59 Not significant
60 and above Not significant
groups. The age group of 60 years and above show a reversal in the
age specific rate with a higher rate at home villages (Appendix 6.1).
The all female situation fails to record any significant difference in
all the age groups (Table 6.12). The infectious disease all male and
female category indicate no significant difference between the two
areas (Table 6.12), but the age group 15 to 39 has a marginal
situation (Appendix 6.1). The age specific rate for the age group 0
to 14 records a ratio of 1 to 4.96 and more than 1 to 2 in all the other
age groups between home villages and System C (Appendix 6.1).
The non-infectious diseases all made and female category record no
significant difference foe any of the age groups and there is only a
narrow difference in the age specific rates (Appendix 6.1).
161
The age-adjusted rates were calculated with the use of total sample
population within each age group as the standard population. The
standard population and percentage weights used are given in the
Table 4.13. The ratio of total sample population to total population
of a given age group was used as the weight for each age group.
Table 5.14 Age adjusted rate for all males and females all diseases
sick/not sick crude and adjusted rates per 100
162
The all male and female category given in Table 4.14, confirms the
observations made and preliminary analysis conducted on sickness
levels. This agrees with the contemporary research as given in
chapters 2 and four and the data sources from Ministry of Health
and other national and regional surveys, which record higher rates
for resettled area. Further the significant variations shown in the two
categories of all male (Table 6.15) and all female (Table 4.16)
support the general conclusions made in the macro data and the
significant difference recorded in Table 4.14.
Table 5.15 Male all diseases sick/not sick crude adjusted rates per
100
Table 5.16 Female all disease sick/not sick crude and adjusted rates
per 100
163
relationship between poverty, prevalence of infectious disease and
developmental change.
Table 5.17 Male infectious diseases sick/not sick crude and adjusted
rates per 100
164
Home
village 54 286 18.89 15.07
System C 29 280 10.36 13.75
Conclusion
165
The two most important facts, which emerge from the analysis, are
that, the age adjusted analysis was able to reveal the observed
difference in disease prevalence between the two areas and the lack
of age specificity can be taken as an indication of the overriding
effect of environmental conditions on disease prevalence. Secondly,
as explained in chapter two and four the resettled people suffer
continuously from the inappropriate economic development
strategies and suffer from high prevalence of diseases.
A selective sample was taken from our family and family friends.
Informal discussions with the respondents and observations carried
out for a period of about 2 months were used as data collection
methodology.
166
• Five other diseases are identified in the disease scenario as
minor diseases.
Data analysis
Age and disease
sick group is between 22 and 75 years. This is because most of
these people are actively engaged in farming and threatened by
many elements of weather and other stresses. Further they consume
many types of alcohol and engage in smoking. Taking alcohol and
smoking is common in the age group of 46 and above (Table 1).
Table 2 Housing
167
Most people live in permanent housing as they are employed
and able to build a house of their own (Table 2).
Source of water
Treatment system
People use many hospitals in the region and outside the region for
treatment. The use of far away hospitals is due to lack of specialist
care in the area and sometimes at Anuradhapura (Table 5).
168
Table 5 Use of hospital facilities
Dissanayake, (2006)
Figure 1shows the correlation between distance and cost of
treatment. Pearson‟s R showed a 0.4581 value and it shows that
there is about a 50% chance that when people travel far for
treatment their cost on treatment will increase. Further both type of
disease and behaviour of the accompanying people are directly
related to the increase in cost. If the disease cannot be properly
treated within the region patients have to travel far. Further, cost of
treatment is increased when the patient has to be accompanied by
helpers as our hospital system is not fully equipped with total
patient care (Figure 1).
20000
15000
Cost
10000
5000
0
0 50 100 150 200 250
169
Distance
Dissanayake, (2006)
Cost of disease in this sample include the transport, food for the
patient, medicine not available in the hospital and food and lodging
fro the accompanying people.
Findings
170
15 - 0 0 0 0
21
22 - 21.7 Heart 174 / Respiratory 130 / 0
45 related 188 231
46 - 39.1 Heart 261 / Respiratory 174 / Arthalgia
60 related 188 231
61 – 34.7 Heart 522 / Respiratory 130 / Arthalgia
75 related 188 231
Over 0 0 0 0
75
Dissanayake, (2006)
171
2. respiratory disease is lower because of better housing in
the area (personal communication from Dr. H.M.M.B.
Seneviratne, Supervisor).
3. arthalgia is higher due to weakening from heart related
diseases and heavy use of alcohol.
Case study on village water supply situation of the Dry Zone of Sri
Lanka, K.S. Karunasena
172
use neighbour‟s well attend to those wells because of the higher
water quality in them (Table 1)
Tank, well and tank and canal and tank are the sources of bathing
and washing. Tank is used heavily for bathing because it is easily
accessible and water in the wells are reserved for drinking and
canals run dry soon after rainy season or faming season (Table 2).
Half the number of people travel more than 200 meters and
another 33.33 percent travel 100 and 150 meters to get drinking
water.83.33 percent have to make an effort to get drinking water
((Table 3).
173
Table 3 Distance to drinking water
Income group
Half the population are in the low income category. The problem of
cost of water is a burden to them (Table 5).
174
Table 5 Income group
1000
cost in rupees
800
600
400
200
0
0 1 2 3 4
income levels
Karunasena (2006)
There is a positive relationship between cost and income
175
bicycle machinery
0-99 9 1450
100-199 11 1625 9375
200 and 5 2875 9843
over
Karunasena (2006)
* no cost of transport was calculated for people on foot
Findings
It is clear that spending on water is hidden and not easily
counted, but it is an important factor in the reduction of real
income. Villagers undergo many difficulties due to water
176
scarcity. In addition time waste and stress created by water
shortage is also an important social factor.
Recommendations
There should be a proper water supply in the village which
will reduce their spending and may increase their capital and
monetary situation. Proper water supply will reduce time
waste and stress. So far there is no proper plan, but there
should be one
177
Colomb Matal Kuruneg Puttala Anuradha Polonn Sri
o e ala m pura a ruwa Lanka
Renal C/D C/D C/D C/D C/D C/D C/D
Failur
e
1996 1983/3 19/4 254/27 18/2 745/136 176/31 5475/87
16 0
1997 1133/3 27/3 352/105 44/7 746/119 283/28 4827/99
38 2
1998 1060/3 51/6 447/125 73/9 1102/138 288/51 5526/10
03 42
1999 1069/3 70/4 461/120 85/12 1267/167 341/47 6194/10
01 95
2000 882/27 141/1 305/57 75/10 1354/202 345/39 5841/10
4 1 35
In 1996, 16.8% of the total kidney patients in Sri Lanka were from
NCP. The percentage morbidity increased to 29% in year 2000.
178
Villages Percentage
Padaviya 50 (17%)
Madawachchiya 32 (11%)
Nuwaragampalatha(NPE) 27 (10%)
Nuwaragampalatha(NPC) 24 (9% )
Nochchiyagama 24 (8% )
Out side Anuradhapura 19
Talawa 18
Galenbidunuwewa 17
Wilachchiya 14
Kabithigollewa 13
Horowpathana 13
Kahatagasdigiliya 12
Rabawa 11
Thirappane 10
Kakirawa 09
Mihinthale 08
Rajanganaya 08
Ipalogama 04
Tabuthtegama 03
Palgala 02
Galnewa 02
179
patients who reported first to government hospital in
Madawachchiya were also transferred to the Anuradhapura, Kandy
and Colombo (General) hospitals.
The only way of identify this disease is a urine test. At this test they
identify protein is mixed with urine. However it is difficult to
identify the symptoms of the disease in its early stage as continuous
health monitoring is absent in Sri Lanka. When finally it is
identified for many it is too late as their failure rate has reached
40%-60% levels.
180
Data Presentation and Analysis
181
Total 87 63
According to the above table 4:1:2 the highest patients are from the
aging group between “30-60” and it is 49 male out of 87.Female are
from the aging group between <30.Which It is 26 patient
Age No of patients
10-19 01
20-29 03 38
30-39 24
40-49 43
50-59 77 188
60-69 68
70-79 68
80< 12 80
Total
Source : Regional Health Educational Department
182
According to the above table 250 patients are male. 84 kidney
patients are female. Through this majority are male. Several reasons
affect for this situation.
- Male are employed then female .
Example- For cultivation
- Male use Drugs
According to the data obtain from medical registration book in
Medawachchiya renal Care And Research Center (RCR).
Researcher obtain 150 patients out of total 857.
As reveal by the above table 4.1.1 ,the majority of the patients are
male. It is 60% out of the total. And 40% out of the total are female
183
Table 4.1.3 Sample classification according to the Educational
level.
Percentage of patients
Employment
(%)
Farming 88
Businessmen -
Private sector 10
Government sector 02
Total 100
184
Table 4.1.5 The sample classification according to the income level
The above data was received from the questions based on income
level of patients.
According to the table 80% patients are income and rang of less
Rs.3000. And also 6% of patients are in the rang of 3000-5000. 4%
patients are in the income range of Rs 5000-7000 .
The objective of these question was to understand what are the most
influence factors of kidney failure that affect to kidney patients in
medawachchiya area.
The above data was received from the question based on chemical
use of patients for their cultivation. According to the above table
96% patients used chemical for their cultivation. 4 % patients are
rejected it. They don‟t use chemical for their cultivation.
185
Yes 10 60
No 90 40
Total 100 100
186
Non Protected Well 04
Total 100
As shown by the table 4:2:4, 80% of patients get water from Tube
well or protected well. 16% of patients from pipe. Some patients get
water from non protected well as river, lake and stream. It is 4% out
of total.
187
Table 4:2:7 Instrument for Filtering
188
Yes 20
No 80
Total 100
189
Relationship Percentage (%)
Father 30
Mother 20
Brother 15
Sister 05
Grand Mother 10
Grand Father 20
Total 100
190
02 03 01 02 03
2
Others 04 05 03 08 06
1
2 05 05 04 10 07
Total 78 79 70 87 84
Statement Statement
Yes 80
No 20
Total 100
191
Medical treatment 90
Dialysis 10
Kidney -
transplantation
Total 100
192
Source: Regional Health Educational Department
According to the above table 377 kidney patients was live discharge
and 52 death in year 1993. It is 1:7 ratio and 13.8 percentage. In
year 1996, 484 kidney patients was live discharge and 131 death.
The ratio was 1:3 and percentage 27.1. In Year 1999, total live
discharge patients was 698 and total death was 149. The ratio and
percentage was 1:4 and 21.3. In year 2001 live discharge kidney
patients was 856 and death was 184. Ratio and Percentage between
live discharge and death was 1:4 and 21.5%.
Conclusion
193
When we consider education level of this patients they are
very low grade. They don’t have enough education facilities to
obtain higher education. Majority of them have only primary
education.
194
dieses . Therefore we can gust above dieses can be
provided base for this dieses.
Recommendations
The only way of identify this disease is urine test. At this test
they identify protein is mix with urine. stage of the beginning
the symptoms of the diseases don’t identify . But at the last
when identify diseases 40%-60% of kidney are failure.
195
Awareness programmers. Ex- Heath and community
medicines
A selective sample was taken from our family and family friends.
Informal discussions with the respondents and observations carried
out for a period of about 2 months were used as data collection
methodology.
196
• Heart related complaints and diseases and diabetes were
present in the disease scenarios.
• Five other diseases are identified in the disease scenario as
minor diseases.
Data analysis
Table 2 Housing
Source of water
197
Most people get water from well as well water is of good quality in
the area (Table 3).
Treatment system
People use many hospitals in the region and outside the region for
treatment. The use of far away hospitals is due to lack of specialist
care in the area and sometimes at Anuradhapura.
198
Anuradhapura 5 21.7
Kandy 0 0.0
Kahagasdigiliya and 4 17.3
Anurdhapura
Kahatagasdigiliya, 3 13.0
Anuradhapura and
Kandy
20000
15000
Cost
10000
5000
0
0 50 100 150 200 250
Distance
199
Cost of disease in this sample include the transport, food for the
patient, medicine not available in the hospital and food and lodging
fro the accompanying people.
Findings
200
Over 0 0 0 0
75
201
A detailed investigation on the high presence of heart related
diseases should be conducted in the area aimed at presenting
a critical analysis.
Facilities at Kahatagasdigiliya hospital should be improved
for the treatment of heart related diseases and respiratory
diseases.
202
Banda Seneviratne: Traditional Belief System of Health
A comparative study of the traditional health services of a new farm
settlement (Mahaweli System C) and its respective home villages,
Sri Lanka.
The article was edited and brought on-line by Tormod Kinnes.
Contents
1. Introduction
2. Service System
1. Traditional Health Service System
2. Ayurveda Health Service System
3. Systems of Treatment
1. Preventive Care - Home Remedies
2. Curative Care
4. Conclusion
5. Appendices
6. Works Cited
203
Western medical system based on the European tradition with the
help of the multinational pharmaceutical industry. Though the
majority of the populace uses Western medicine in curing many of
their diseases, traditional medicinal mixtures are very much used in
all types of communities in Sri Lanka, where a pluralistic medicare
system has been used for a long period, as told above.
Herbal medicine
204
their specialities (Jayasekara, 1957; 1981 Sisirakumara, 1991
and Ambatalawa, 1994). There is very little written knowledge
and the practice is considered a family tradition and is normally
given only to male members of the family. Herbal medicine in
the form of mixtures, pastes and oils are used in the treatment
along with strict dietary control. However, in recent times the
influence of Ayurveda has made these practitioners use some
Ayurvedic medicine in their practise (Gnanawimala, 1950;
Senadheera, 1970; Ramanayaka et al, 1985 and Ambatalawa,
1994).
205
(Gnanawimala, 1950). The continuing struggle of the organised
group of activists was successful in the establishment of the
Department of Indigenous Medicine even before independence
(Ramanayaka, 1985). Establishment of Ministry of Indigenous
Medicine, Institute of Teaching and Research in Indigenous
Medicine and registration of indigenous medical practitioners have
enhanced the value of traditional and Ayurvedic medicine among
the local populace and foreigners. Today it is estimated that more
than 40 percent of the total out patients registered daily, use
indigenous medicine related services and among poor the
percentage may be as high as 60 percent (Kannangara, 1962).
Inability of the Western system to provide a proper health care
service, and fear of side-effects from many types of Western drugs
have driven even many Western educated and people of Western
origin away from Western medicine in the past decade. As noted in
the survey Siddhalepa, this is a traditional medicinal preparation,
used as a painkiller and pain reliever has more sales than the
combined sales of similar medications of Western origin. Therefore,
today the traditional medicine and its impact are higher than in any
other time in the modern history of Sri Lanka.
Indigenous medicine has been and will be the most important
health service system at first referral level for most of the poor until
their economic status is elevated and for the rest of the richer
classes it is to be used in the times of special need. Recent
modernisation of herbal preparations have actually led to an
increase in popularity of indigenous medicine and associated
treatment systems (Ekanayake et al, 1989).
The main objective of this study is to carry out a comparative
study of the importance of indigenous health service system in a
new frontier farm settlement (Mahaweli System 'C' - established in
1981-1987) and their respective old established home villages. It is
clear that indigenous health service system plays a vital role in the
health status of respondents as they depend heavily on it for most of
the ordinary cases of ill health. The evolution of indigenous health
system in the study areas and its impact on the health status is
studied under the sub topics of preventive and curative health care.
The home villages are located in Badulla, Teldeniya, Ratnapura,
Mawanella, Yatiyantota, Mirigama and Nikeweratiya, which belong
to the traditionally developed wet zone of Sri Lanka. The villages of
206
the new settlement (Nuwaragala, Paludeniya, Mudungama, Ridee
ela, Rathmalkandura, Sandamadulla and Belaganwewa) are located
in the dry zone which was opened to development between 1981
and 1987, under the Mahaweli Development programme.
Service System
*'Faith healer'
Source: Field Data
Resource inequality is consistently found within developing
countries, especially in terms of health service facilities. In Sri
Lanka urban areas have more health resources than rural areas as in
any other developing country (Navarro, 1994). This is basically a
result of the existing distribution of goods and services, which are
often controlled by the age of settlement. Old established
settlements of home villages have a well-established health service
207
resource system than new settlements of Mahaweli System 'C'. The
Chi square value of 71.4 with five degrees of freedom confirms well
the existing difference between the two areas, which is significant at
99.9 percent level.
208
village
1 1
Belaganwewa 2 1
(Lihiniyagama) (Lihiniyagama)
1 1
Sandamadulla 1 2
(Girandurukotte) (Girandurukotte)
Redeeela 0 0 0 0
Rathmalkandura 0 1 0 0
Mudungama 0 1 1 1 (Siripura)
Paludeniya 0 1 0 1 (Siripura)
Nuwaragala 0 1 1 1 (Siripura)
209
Kinship connections inherited practices and the level of modernity
of the people always affect location of indigenous health services.
Normally, indigenous medical practitioners tended to concentrate in
the older, higher density residential areas and also in the urban
areas, where Western health care system cannot cope with the
demand fully. Further, the specialist traditions, government policies
and political influences can lead to the concentration of facilities in
certain selected areas than in the rest. Mirigama, Ratnapura and
Mawanella have large number of indigenous health service units
due to their association with one or many of the above mentioned
factors.
The pattern emerging from the data given in Table 2, show the
availability of more facilities in old units such as Belaganwewa and
Sandamadulla compared to the rest, which were settled later. These
patterns were identified by Navarro, (1974) and Ramesh and Hyma,
(1981) in Latin America and India respectively.
210
only on the basis of inheritance or friendship. Sometimes a
document or a narration will give the basic elements of the
treatment and today the materials required for treatment are partially
obtained from gathering and mostly from a drug manufacturer
(Wanninayaka, 1982). The two variants of the treatment system, the
preventive and curative care are identified here for a detailed
investigation.
211
have used home remedies when needed than on a regular basis.
212
rash were treated by these practitioners successfully and in all other
cases they were used as first referral level or helpers (Table 5). The
ability to treat fractures by the indigenous medical services has been
noted even by Western biomedical treatment system. Four patients
with fractures were advised by their Western doctors to obtain
services of the indigenous medical practitioner for a better and
faster care. Therefore all minor cases of fracture and sprains were
treated directly by the indigenous medical practitioner and hospital
treatment was sought only at times of requirement of surgery or
medical certificate. In here patient returned to the indigenous
medical practitioner after the surgery or receiving the medical
certificate. In terms of general weakness, aged preferred the
indigenous medical services to Western biomedical treatment. Fear
of the side effects of pain killers were noted by the aged as a reason
for taking indigenous medical treatment for most of the common
illnesses and sicknesses. In all the other cases it was the failure of
Western biomedical system, which guided the patients to return to
indigenous medical practitioners and be cured. The reasons for the
failure of Western biomedical system are not clear, but according to
most of the respondents wrong diagnosis was the major factor for
the failure.
Generally, respondents are satisfied with the services of
indigenous medical practitioners, other than for a few who have
operated without proper qualifications and caused hardship to them.
Two and six respondents at Mahaweli System C and at Home
villages respectively, had serious complaints against indigenous
medical practitioners but they have not regarded it as a reason for
rejection of the total system of indigenous treatment service.
Therefore 75 percent at Mahaweli System C and 86 percent at
Home villages used the indigenous medical services when needed.
It is clear that there is a marked difference between the two study
areas as the Chi square value obtained was significant at 99.9
percent level.
213
Respiratory problems 14 23
Urine infection 00 20
Paralysis 00 23
Arthritis 29 50
Disability 23 43
General weakness 42 50
High blood pressure 17 61
Diabetes 00 33
Goitre 00 33
Cancer 00 25
Ear, Nose and Throat 06 25
Skin rash 20 40
Source: Field Data
As shown in the data a higher percentage of patients have sought
help from indigenous health services, for many degenerative
diseases like high blood pressure, diabetes, goiter, cancer, arthritis
and paralysis. This is a result of availability of renowned specialists
who have had more success in controlling the severity of these
diseases than curing them as none of the patients with above
mentioned diseases have been completely cured up to today.
4 Conclusion
INDIGENOUS medicine has sustained a healthy nation other than
at times of epidemics of infectious diseases throughout the history
of Sri Lanka. Communicable and infectious diseases have always
posed a serious threat to the credibility of indigenous medicine but
it has managed to stay on as a major supplier of health services
throughout history. Today with the loss of many documents,
traditions and beliefs associated with the treatment system, the
indigenous medical service system is faced with a problem of
survival against the challenge of Western medicine.
There is a marked difference between the two study areas in
terms of availability and utilisation of indigenous medical services,
which is a result of age of settlement as shown by the Chi square
214
analysis of data (Appendix A). As expected there is no significant
difference between the areas in the use of home remedies, but the
percent used indigenous health facilities were definitely higher in
home villages than in Mahaweli System C.
Various treatments of the indigenous medicine are heavily used
at various levels of preventive and curative care. The pattern or
system of utilisation is not direct, but common as it is used, at all
referral levels, without any clear order and purely based on need
and advice given by the elders. Most of the minor ailments and
sicknesses were treated first by indigenous medicine and if
symptoms persist a Western medical practitioner was visited either
at the hospital or private practice. In case of serious sickness and
disease, almost all the respondents have consulted the Western
medical practitioner as their first referral level and if the treatment
was not successful, they return to the specialist indigenous
practitioner for re-treatment. The cases of cancer, goitre and
paralysis have shown this type of changed treatment and have had
some success with the change of treatment, but at the time of survey
none of them have been cured by traditional medicine.
Pluralism in medical services of Sri Lanka was clearly shown in
the data of the study areas. Indigenous medical service at its present
level of operation is definitely weaker than its Western counterpart
in many areas of action notably in the area of infectious and modern
communicable diseases. However the indispensable role of
indigenous medical services in preventive and curative care in the
study areas can never be ignored.
215
Appendices
Appendix A
Variables Chi Level of Significance
Square
Types of practitioners 89 99.9 %
not significant at 99.9%
Use of home remedies 20
level
Treatment by indigenous
213 99.9%
Medicare
216
Appendix B
A. Accessibility Equation
A = d · h/t
A = Accessibility
d = mean distance to hospital
h = number of hospitals available
t = time taken to travel at under normal conditions or cost of travel
under emergency situations.
Appendix C
Factor of Comparison Chi- Degrees of Significance
square freedom level
Income level 8.5 2 Not significant
Mean risk level of the Significant at
116.6 4
living environment 99.99%
217
Occupational structure of Significant at
100.8 7
respondents 99.99%
Disease panorama- Significant at
408.3 8
outpatient treatment 99.99%
Disease panorama- Significant at
67.4 8
inpatient treatment 99.99%
Priority grouped diseases Significant at
106.0 2
at outpatient 99.99%
Priority grouped diseases Significant at
55.8 2
at inpatient 99.99%
Significant at
Morbidity by age group 144.8 2
99.99%
Significant at
Morbidity by sex - male 73.4 2
99.99%
Significant at
Morbidity by sex - female 106.1 2
99.99%
Alcohol consumption 3.1 2 Not significant
Types and sources of Significant at
132 9
treatment 99.99 %
Sources of information on Significant at
56.1 6
health 99.99%
Adherence to advice 8.7 3 Not significant
Types of indigenous Significant at
41.8 3
medical practitioners 99.99%
Significant at
Accessibility 31.9 3
99.99%
218
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