ENVIRONMENT AND HEALTH

H.M.M.B. SENEVIRATNE

ISBN 978-624-95429-0-7
-

1
Preface

The second edition has a few new pages as the environment of

Sri Lanka has remained stagnant and dirty since the publication
of the first edition. Health profile remains unchanged with low
mortality from infectious diseases, but high prevalence of
infectious diseases and increasing mortality and high
prevalence of chronic diseases. Though, national data indicate a
health profile of low mortality in infectious diseases viral
diseases are still a serious threat in Sri Lanka, with Dengue
epidemics. Heavy use of antibiotics by the general practitioners
and self made doctor of various types have managed to prevent
mortality from infectious diseases, but the harmful effect of
lack of proper monitoring of this nonchalant use and its side-
effects may be hidden in many other medical and health issues.

Top photo –

Smelly drain which is a common scene in Sri Lankan, towns

and even in cities. This is the drain which produces mud during
wet times and dust during dry times mixed with faecal remains
of stray dogs and cats and urine deposits of humans, which may
breed many types of viruses, mosquitoes and worms.

Lower Photo – Massive complex of a provincial and a teaching

hospital

2
Chapter 1

Environment and Health

Environment in this book refers to the natural and manmade

elements and factors which affect health of an individual. As
there are many books and publications on the general health
environment of the world this book will draw elements and
factors from the tropical environment with specific examples
from Sri Lanka. Tropical environments of the world are
generally identified as warm and underdeveloped. The natural
environment of Sri Lanka is identified as tropical and the
societal environment is defined as developing. The tropical
environment has its own systems of health and disease and the
developing countries in the tropical environment are subjected
to poor health environment due to prevailing corruption and
poverty.
A discussion on environment and health within the context of
environmental management cannot be discussed without
referring to development as health status is a product of level of
development of a society. When the development is properly
conducted there is a status of good health and unplanned
development results in the formation of a poor health status.

3
 Environmental Management perspective of Environment and
Health

In a study of environment and health it can be argued that the

managed environment has a higher level of health than the
unmanaged environment. The managed environment has a well
organised habitat and a population governed by behaviour
suitable for the sustenance of that habitat. This type of
environment is more secure and long-lasting than an
unmanaged environment. The unmanaged environment is in
chaos with no cohesion between habitat, population and
behaviour, which is constantly troubled by poverty and disease.
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

4
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.

The most important part of environment and health is the

relationship between social factors and health. Social factors
are generally associated with environmental management
because it is the society which decides the process of
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

Health is commonly known as “not sick, staying fit or I am

OK”. It is commonly known that good health is a complete
physical, mental and social fitness. World Health Organisation
(WHO) defines health as “a status of complete, physical,
mental and social-well being and not merely the absence of
disease and infirmity”, which is linked to socio-political aims
and objectives of the organisation, but difficult to achieve.
This book is written for the purpose of providing information
on the health environment of developing countries and to store
information on the local environment (Sri Lanka), which will
be used as teaching and reference material for students
following the courses related to environment and health at
University of Rajarata Sri Lanka.
This course taught within Environmental Management uses
approaches from Medical Geography and Health Geography,

5
which are widely taught disciplines in the developed world.
These researchers from the developed countries are engaged in
detailed research on the relationship between environment and
health as this form of knowledge is required to prevent
epidemics which may affect developed world in an age of high
mobility of populations. In addition drug manufacturers in the
developed world support the study of environment and health,
as they conduct all the fundamental research on future
requirement of drugs.

Health in a developing country

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 8th
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.

6
Then health or being healthy has no universal truth and health
cannot have universally acceptable definition. It is because that
behavioural development of man is a valuable factor
responsible for the status of health.
In general terms for the purpose of this book we use a
definition made in the survey of health status of a sample of
farmers from Sri Lanka (Seneviratne, 2003).
“ Sick is defined in this book for the Sri Lanka environment as
the status of health identified by a registered medical
practitioner” and all people reported not sick were considered
healthy, though they had minor illnesses which required no
continuing medical attention (Seneviratne, 2003).

Health environment management: theoretical overview

Health environment management is required today more than

any other time in the human civilisation because the balance
between resources and man is weaker than any other time of
the human civilisation. Further it is required for the reason that
there is an environment of imbalanced development process in
the developing or poor countries of the world where more than
two thirds of the people live.
Environment is rapidly changing as a result of human and
geological influences resulting in chaos and hazards. This
raises the need for a study of environmental management for
health, which aims at preparing a healthy environmental with
the use of best available scientific methods and technologies.
Environmental management began as a response to major
problems like air pollution, water pollution, soil erosion and
emergence of new diseases. It is clear that all the environment
problems around us are linked to these three basic damaging
activities. However, we cannot conserve as we like and the
rising populations demand that more and more resources are to
be utilised if they are to be provided with the basic necessities
of life.

The traditional health environment management

7
The traditional health management system of the era of
modernisation is based on the provision of modern health
facilities with bio-medicine. Environmental management of this
period was conducted through the establishment of Strict
Natural Reserves, Protected Forests and Grassland, Sanctuaries
etc. it was more of protecting bio-resources than a true holistic
plan. However the emergence of ecological management,
development of geomorphology and organisational structures in
business management led to the construction of the field of
environmental management in the early 1980s.
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.

The new health environment management

The new environmental management treats environment as a

multi faceted resource with enormous capacity to provide many
types of items from a single unit of the resource. Here the
resource is blended in to the systems of economic development,
where each and every product can acquire a value. For
example, a tree was treated as a source of wood or crop or a
unit in the protection of water source in the old system of
environmental management system. Today a tree is part of a
harvest system which produces wood, wood chips, compost
raw material, preserve water and soil. Then a tree is treated as
an object to interfere with and looked after according to the
principles of forest harvesting. Within the technology of forest
harvesting tree is checked for disease regularly, cleaned to
avoid fungi formation, broken or damaged parts or branches of
the tree (by wind, rain and animal action) are removed and cut
at the prime maturity level to obtain the best wood or wood
chips for paper industry.
The provision of healthy environment is established through
the construction of systems of drainage for all types of waste,
provision of clean drinking water, keep air within the
acceptable limits of pollution, noise control, identification of

8
carcinogens, and provision of proper housing with strict control
on building materials and designs suitable for climate where
they are built.
To achieve the above conditions firstly there should be proper
use of standards in all types of human activities. The health
authorities should be empowered to check product and service
qualities of all types of consumptions. For example the public
health service should be able to investigate and prosecute any
break in these standards.
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

Environmental change is the process of changing environment

through physical and human activities with use of technology,
social and political ideology. Physical changes are initiated by
geological changes of landforms and climate which in turn lead
to changes in biological environment (Seneviratne, 2006).
Human activities are controlled by the available technology,
social structures and political ideology.
For example the ancient civilisation of Sri Lanka was based on
the concept of irrigation and a strong monarchical rule, which
arranged the environment to suit the sustainability of a
hydraulic civilisation. This civilisation has experienced periods
of climatic fluctuations which were controlled through the
cascade system of irrigation. But there were times of
extremities where famine and flood has created havoc and
destabilised the settled environment (Seneviratne, 2005).
Recovery from these changes were easier than today because
there was only a minimal amount of chemical pollution and any
other forms of pollution were controlled through very strict
system of environmental control (Read Case study 1). After the
fall of the Ancient kingdom the survivours have made an

9
attempt to adjust and adapt to the new wet environment of the
south, south west and the mountains. However the technology
of tank cascade system was not applicable to the new wet areas
and dry phases of climate made them to drift more into the
wettest areas of the country. They managed to use the canal
irrigation but drainage systems suitable for hill ranges and
mountains were difficult to master. Survival was difficult in the
new environment and population dropped to an all time low
due to exposure to new endemic diseases of the wet zone for
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).

10
 Figure 1.1, Flow of activity of the new environmental
management system

Investment programme

Environmental – natural and societal resources

Sustainability

Economic, social (health) and institutional

policies

Government agencies and other resources users (including

health care providers)

Theoretical background to principles of health environment

management
Health environmental management is required to organise and
utilise the environmental resource with optimum benefits to the
populace. In the process of this organisation and utilisation
system two major principles are to be followed.
1. Understand the dynamics of natural and societal systems of
health and the effect of them on disease scenarios
2. Understand the causes of disease and the organisational
structure of disease management systems best suitable for
control, recovery and rehabilitation from health threats

11
1. Understand the dynamics of natural and societal systems of
health and the effect of them on disease
This is the primary task of health environment manager
because without a proper understanding of the dynamics of
natural and societal systems of health and the effect of them
on disease, the health manager cannot provide the direction
required for the progress of the users.
Firstly there is the presence of ever changing nature of value
of natural and societal resources based on the technology
available. It is now clear that the traditional measures of
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

12
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
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.

2. Understand the causes of disease and the organisational

structure of disease management systems best suitable for
control, recovery and rehabilitation from health threats

Once the change is properly identified the health

environment manager has to investigate the causes of the
disease systems and the disease management systems best
suited for control, recovery and rehabilitation. Principal
cause of disease is the unplanned process of human
development which is not based on development ideology.
Two major development ideologies have been used since the
industrial revolution to develop human environment with an
aim of improving health. They are modernisation and
alternative development which can be used to improve
environment and health. Though Sri Lanka has made a
serious attempt to raise the living standards and improve
health status of its citizens since independence poor quality
national planning and corruption has made it a dream which
is yet to be fulfilled like in all the other developing
countries.

13
Environment, development and health: geography to
environmental management

It is clear from the discussions on macro-economic

development, health sector development, demographic and
epidemiological transitions and poverty, that all these
processes are notably affected by the physical environment
of the tropics, which are capable of year round breeding of
vector borne and bacterial pathogens. Further, poverty has
its own array of conflict, which enhances the possibility of
continuing morbidity as Sen (1999) has indicated. The
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.

14
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).
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

15
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.

Disease Ecology/ Political Ecology

These types of changes have been studied within a

framework of disease ecology and/or political ecology of
disease by many authors in Africa, Latin America and Asia,
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

16
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.
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.

17
Political ecology is used in this type of study by Mayer
(1996:454):
Political ecology as popularly defined by Blaikie and
Brookfield (1987) combines the concerns of ecology and
political economy within a spatio-temporal perspective. This
is a powerful basis for the analysis of disease ecology,
especially in the developing world where many facets of
national and local politics may override optimum resource
use, as detailed by Grossman (1981). Political ecology
emphasises the role of individuals and collective action, and
it acknowledges that these different types of action are
constantly affected by socio-political processes.
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

18
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
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

19
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
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

20
 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
countries, because health is more a political issue in these
countries where development is guided by political
decisions than environmental planning.

Chapter 2

Human Ecology of disease

Studies on human ecology treat habitat, population, and

behaviour as the vertices of a triangle that encloses the state
of human health.

Habitat is the living environment of people. Landforms,

climate, vegetation, animals, health care facilities,
transportation and communication systems and systems of
government control are included under this topic.

21
Population studies humans as an organic unit and a group
which can be hosts of disease. Natural immunity levels of the
population in relation to genetics, nutritional status,
immunological status, and its immediate physiological status
with regard to time of day or year are also considered within
this topic. The effects of age, family composition and the
personnel habits can also be considered under this topic.

Behaviour is the area of culture which can be clearly

identified through the way of life of people. This is related to
cultural precepts, economic status, social norms, and
individual psychology. It includes mobility, roles, cultural
practices, and technological interventions.

Habitat

Habitat contains all the elements of the physical and biotic

environment, which affect human health. However, today,
most of the humans live mainly in built-up environment of
housing and other infrastructure. Therefore today our health is
primarily controlled from the built-up environment, clean or
dirty.

Frequency of intestinal infections is reduced when proper

drainage facilities are constructed and droplet infections are
increased when a proper ceiling is not installed in the house.
Malaria disappeared from Southern Europe after all the
swamps were drained and Dengue is on the increase in Sri
Lanka as unplanned filling of lowlands have blocked
drainage. Viral infections are on the increase in Sri Lanka due
to breeding of viruses by all the city and town waste dumps
due to low environment literacy of urban area dwellers and
administrators.
The occurrence of dysentery, tuberculosis, dengue, influenza,
viral fever and typhoid are directly associated to poor
housing, which is confirmed by the economic status of the
patients. A survey conducted on three base hospitals in Sri
Lanka revealed that 64.4 percent of the patients treated for

22
infectious diseases came from low income households with
less than 40000 rupees monthly income.
An investigation into the prevalence of chronic diseases also
related to income levels. Hospital mortality records confirm
that about 84 percent of the people with chronic diseases are
from the income group above 20,000 rupees per month.
Tables 2.1 to 2.3 indicate the present status of habitat in
general, where no place on earth is free from some form of
chemical or organic disturbance. This is because, the global
environment is surrounded by all types of waste produced by
geological and human forces.

Table 2.1 Nature and habitat

Physical Health Problem Reason Exposed

characteristic population
Lowland Respiratory Lack of proper Poor and low
humid housing income
Limestone Diarrhoea Rapid All categories
aquifer drainage
Limestone Renal failure Weak filtration All categories
basement in system
Dry Zone
Highland wet Respiratory Exposure to Estate
mist and workers
drizzle
Lowland Helminthic Poor drainage Poor urban
wetlands dwellers

23
 Table 2.2 Development and habitat

Habitat Economic Management Health Major

Type status level status health
effect
Natural Developed Controlled Protected Chemical
and harvested pollution
Fast Initial control Fairly Low
developing and protected chemical
harvesting and high
has begun organic
pollution
Slow Very limited Not Low
developing inconsistent protected chemical
control and high
organic
pollution
Poor No control Not High
protected chemical
and
organic
influx
Built-up Developed Controlled Well Chemical
and managed protected pollution

24
 Fast Initial control Fairly Low
developing and protected chemical
management and high
has begun organic
pollution
Slow Disorderly Not Low
developing protected chemical
and high
organic
pollution
Poor Highly Not High
disorderly protected chemical
and
organic
influx

Table 2.3 Extremely dangerous habitats

Habitat Disease Origin

Tropical Malaria, Filaria, viral Mosquito,
forests fevers and possibly monkeys
AIDS
Tropical Schistosomiasis, Snail, fly
savanna onchoriasis
Semi desert Cerebro Spinal Virus from faecal
– Sahel meningitis deposits
Migratory AIDS Careless sexual
work camps activity
Southeast Bird Flu Careless animal
Asian rearing
Chicken an
duck farms

For example Dust raised by storms in Taklamakan desert in

Central Asia is found deposited in the ice sheets of European
Alps and sometimes they drift over Sri Lanka. The effect of
Ozone hole in the Antarctica is felt in Sri Lanka through the

25
activities of El Nino weather systems. These dust flows and
El Nino occurrences lead to an increase in respiratory diseases
and failures in children and old age people. Therefore today
we cannot identify any place or space as natural, though
locally a few areas may have natural characteristics identified
by biologists. For example, the Clod forest of Samanala
Range and Rain forest in Sinharaja are considered by
biologists as natural, but the air and water in them are found
to be contaminated with sediments from the surrounding
areas.
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

Settlement is the unit where people live together in a

constructed environment. Settlement has primary and
secondary units of constructions. Housing, roads,
communications, drainage, sewage systems and waste
disposal systems are the major constructed items in a
settlement. The micro climate, aerodynamics, flow hydraulics
and biology of the settlement form the secondary
environment, which affect people living in the settlement.

These constructions are made from chemical mixtures and the

designs formed by these constructions can affect the health of
the dwellers. Today most of he housing is constructed with
cement and iron related material and applied with paint
manufactured from petroleum residue. Most of the furniture
has plastic coatings or paint coatings made from various types
of chemicals.

26
Roads in and around settlements are constructed with bitumen
and concrete, which are manufactured from chemical
mixtures. Communication equipment is primarily plastics and
metallic in nature. We hold communication equipment very
dear to us and connect them to some form of electricity.

The story of the ability of portable communication equipment

in the formation of some bodily stresses is studied in detail
and some of these stresses are found to be harmful to health.
For example in Sri Lanka noise generated from bus stereo
systems and music system in town areas have higher noise
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.

27
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
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, Age, weather and behaviour are the most important

factors within a population with reference to its health status.

28
Genetics

Human genetics is a new science but the value of genetics in

health has been under observation for a long period of time.
Knowledge on DNA (deoxyribonucleic acid) has changed the
way medical science approaches problems of health and made
possible to have a deeper understanding of health.
Immunity, tolerance and sometime behaviour are also related
to genetic information, through collection of data on certain
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.

Age is an important factor as health is constantly related to

the life cycle of a human being. Life cycle has its own health

29
capacities and threats in relation to age. Infant is highly
susceptible to infectious diseases and almost 80 percent or
more infant deaths occur due to them. Bacterial and viral
diseases affect the childhood as the child is always
experimenting with new products, environments and
behaviours.
Adults are the most threatened in the modern world as they
are exposed to many types of environments within a day and
some even travel between two types of endemic environments
daily. For example a bus driver travelling from Vauniya to
Colombo, begins his journey from the malaria endemic
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

30
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

Cultural behaviour is the most important factor in the

environment and health as it forms the basis of the level of
development of environment. Cultures can be identified in
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

31
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
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

32
in the developing world is partially a result of corruption in
governance which diverts funding away from essential
services to private use.

Chapter 3

Development and Health

Socio-economic development is aimed at constructing a

healthy living environment. However the programme of
development is not universally active due many social and
political reasons. Therefore there is always a difference of
health status between developed and developing countries.
International evaluations on health and development are
based on some selected criteria like
1. rates of total mortality, infant and child mortality
2. case prevalence or incidence at hospitals
3. national health and population surveys
4. local or regional health surveys

33
 5. estimates from combined services
Environment of the developed world and developing world
are taught under many courses in environmental
management and the following description provides the
reader a summary of the environment in a tabular form.
Environment and health in the developed world
Developed world is where public sector services are run on
the principles of environmental and economic planning.
They have long term plans for environmental control and
economic stability supported by the selected resource
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 and
cool south 45 degrees unclean 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 and
centre 55 degrees immunity to 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 and
cold North and immunity to sewage disposal.
north/south South unclean Very good quality
central environment and health support
water. Very fair systems

34
 skinned and can be
subjected to sun
burn
Cold 66 to 90 Extremely Low Planned drainage and
north/south North and immunity to sewage disposal.
South unclean Very good quality
environment and health support
water. Extremely systems
fair skinned and
can be subjected to
sun burn

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

35
 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

Developing world - Tropical environment

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.

Rapid development in Singapore from a developing nation

to a developed nation revealed that it is the establishment of
an organisational structure for development which was
required in this minute island nation. Malaysia has shown
that there developing status is not physical, but social and
political. The tables 2.4 to 2.6 provide the basic details of
tropical developing world with reference to the majority of
the population which live under constant threat of ill health
or disease.
This book will concentrate on the details of this majority of
the people who have very little or no health security in case
of ill health or disease in the present socio-economic
environment of their respective countries or nations. The
group of people under study form about 90 to 95 percent of
the population of the developing countries, which are
politically marginalised by the organisational structure of the

36
public service system in them. These people have a
minimum of about 1 US Dollar a day (monthly Sri Lanka
Rupees 3000) to about 7 US Dollars a day (monthly Sri
Lanka Rupees 20,000) income per family, though their
earnings can fluctuate heavily when affected by ill health or
disease. These people lack social security in health and only
a handful have some form of medical insurance.
Most of these people live in unhealthy housing and drainage
environment. Fast developing Malaysia and Taiwan are the
only countries which have an acceptable level of living
environment among developing tropical countries. Some of
the countries like Sri Lanka and Cuba have established a
heavily subsidized treatment system but the living
environment of majority of the people remains dirty
resulting in the heavy presence of diarrhoea and dysentery.

37
 Table 3.4 Climatic and immediate living environment of the
tropical developing areas
Category Vegetation Majority of the Nature of living
People (more than environment of the
80 percent) majority (more than 80
percent)
Ultra Equatorial Rain Poor live in No planned drainage
humid forest or unclean and sewage disposal.
average monsoon rain environment and Very poor quality
relative forest water. health support systems.
humidity
above 60 Tuberculosis, Filariasis,
percent Cholera, Dysentery,
high infant and
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 desertification Dysentery, Meningitis,
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

38
Table 3.5 Socio-economic environment of the low and
middle income people in the tropical developing countries
Area Status Health status Reason
Urban areas Dirty Poor - high risk of Low environment
infectious diseases literacy and
income. Non
application and
enforcement of
environment law
Rural Fair to Fair – moderate Low environment
dirty risk of infectious literacy and
diseases income. Non
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

39
Table 3.6 Developing countries: Nature of basic construction
required for a healthy living, working and travelling
environment

Construction Status Health Reason

status
Housing Unplanned and Risky with Low environmental
hastily built poor literacy and income.
drainage Lack of enforcement
and waste of environment law
disposal
Work place Unplanned and Very risky Very low
hastily built with poor environmental literacy
drainage and income. Lack of
and waste enforcement of
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

The detailed study on development and health is presented

under the headings of
Agent-host relationships
Domesticated animals
Immediate living environment
Nutrition
Literacy
The traditional belief system of health and
Health behaviour, which are established in the living
environment through the efforts of development.
Table 3.7 Factors of developmental environmental factors
and their status in relation to development
Factor Type of control/ Type of
developed control/developing

40
Agent-host Heavily controlled Low to no control
relations through use of as the systems in
hips management and action are disturbed
technology by corruption
Domesticated Heavily controlled Low to no control
animals through use of as the systems in
management, action are disturbed
technology and law by corruption
Immediate Heavily controlled Low to no control
living through use of as the systems in
environment management, action are disturbed
technology and law by corruption
Nutrition Provide required Low to no control
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.

Table 3.7 indicates the major differences between developed

and developing countries with reference to factors of
developmental environment.

41
Table 3.8 show the basic differences in two primary factors
used in the differentiation between developed and
developing.
Table 3.8 Development and health
Country Life expectancy at Child (under 5)
birth mortality per 1000
Norway 77 9
Sweden 79 6
Japan 80 6
Sri Lanka 73 19
China 69 43
India 62 99
Bourkina 47 186
Faso
Sierra 40 242
Leone

Sri Lanka has a very high level of health when compared to

other developing nations due to high quality dedication of
majority of the medical personnel and a low priced private
sector “private practice doctor” service provided in the semi-
urban and rural areas of the country. Further the tradition of
limited contact between animals and humans in a majority
Buddhist population and early acceptance of western
medicine may also have contributed to this high state of
health (Seneviratne, 2003).
Environment and health of the tropical underdeveloped
areas
Case study - Disease environment of Sri Lanka
The disease environment of Sri Lanka is primarily a product
of its island location, ecological characteristics, development
of social services and belief system of health. The island

42
location, macro level landform structure of a central hill
country surrounded by plains, heavy social welfare
spending, literacy level, gender equality and the existence of
a pluralistic belief system of health are identified by many
researchers as factors responsible for the relatively better
health situation in Sri Lanka, in comparison to its South
Asian neighbours (Nordstrom, 1988; Wolffers, 1988 and
Caldwell, 1993).
The island location reduces the risk of transmission of
diseases and epidemics, and its advantageous effect is
clearly shown during the outbreak of epidemics of cholera,
typhoid and measles in the neighbouring countries. The
ecological characteristics formed by the macro level
landform structure with a central hill country, which
constructs fast flowing rivers, has been identified as a factor
for very low incidence of malaria in the wet zone of Sri
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.

In the global context of disease environment, Sri Lanka is

situated within a region of high prevalence of tropical
diseases. Malaria, diarrhoeal diseases, intestinal infections,
tuberculosis and anemia dominate its regional and local
disease prevalence scenario (Ministry of Health, 2000). The
discussion on disease environment of Sri Lanka is presented
under sub-chapters on agent-host relationships, immediate
living environment, nutritional status, literacy and gender, to
link it with the tropical setting and explain the presence of
many types of infectious diseases.

Agent-host relationships

The tropical humid climate of Sri Lanka facilities the

breeding of many types of disease causing agents common

43
to its south Asian neighbours, but the severity of infection is
reduced by cultural practices like use of traditional
antiseptics, low consumption of raw food and adherence to
advice on health.
The breeding of agents causing dengue and diarrhoeal and
respiratory diseases are always associated with heavy rain,
flooding and poor sanitation. The high incidence of rabies in
Sri Lanka can be related to nonchalant attitudes in the
rearing of dogs and the existence of a large rat population,
specially in the urban areas of the country where rabies has
been identified as a serious health risk (Ministry of Health,
1996). However, a definitive agent-host relationship cannot
be established due to dearth of research.
Malaria, dengue and influenza causing agents have shown
drug resistance in recent decades, but their effect on the
disease scenario is reduced mainly due to early identification
and improved health care support as noted by Abayasekara
(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

44
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
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

The connection between many infectious disease and

animals is well established as the epidemics are traced back
to some of the nodes with a special animal-man relationship.

45
The role of animals in the disease environment of the
farming villages of the Sinhala Buddhist community is
examined within this understanding. This because the
presence of a belief that the low prevalence epidemics of
infectious disease in the home villages is due to their low
level of contact with animals. Though specific data is not
available, observations made during the field visits led the
researchers to investigate this contention. Cattle and water
buffaloes were kept mainly as a source of “beasts of burden”
to be used in carts and work respectively. Pets were rare
though a small number of dogs and cats were seen
occasionally. A few households kept chickens to collect eggs
and occasional use for meat.
The wet zone with its heavy annual rainfall and forest type
of vegetation has limited supply of fodder and is known to
harbour many animals disease arising from high humidity.
The dry zone environment is suitable for animal rearing, but
scarcity of forage in the dry season limits its expansion.
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.

46
 Immediate living environment

The immediate living environment is identified by many

researchers as a very important variable in disease origin
and spread. Although there is no set model to the immediate
living environment, it consists of the house and garden.
Three major types of immediate living environments can be
identified in Sri Lanka in relation to prevalence of infectious
diseases.
Firstly, the urban and rural rich and middle class, which
makes up about 10 percent of the population live in modern
housing and rarely affected by infectious diseases.
Secondly, farmers, labourers and other low-income groups
live in small units of nuclear family houses with a small
garden, a toilet and a well for drinking water, which is
normally, is shared with relatives or neighbours. Bathing is
normally done in a communal well, stream or river. Only
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.

47
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.

Figure 2.1 Infant and Child Mortality rate per 1000

by residence, 1993

Nutrition

Nutrition or level of nutrition is an indicator of the state of

health and form an integral part of the disease environment
because of the established relationship between nutrition and

48
health. It is evident from macro data that the marginalised
groups are more vulnerable to malnutrition and under
nutrition than the rest of the population.
General surveys indicate as an important factor in nutritional
status. Gunasekera (1996) using DHS data stresses the
importance of literacy of the mother in general and in relation
to plantation areas in particular. There is high rate of stunting
in the category of mother not attending school and the rate of
stunting is reduced where the mother has received the
secondary level education. In the estates where there is a large
concentration of mothers with no schooling, 45 per cent of
children are stunted compared to 18 per cent in the urban
sector and 13 per cent in the category of some education
beyond secondary level.
Loganathan (1990) and Gajanayake et al (1991) have both
indicated the relationship between low literacy and high
mortality of Tamil plantation workers, which stresses the role
of poverty for this deprived population.
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

49
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

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.

Table 2.10 Attainment of education by sector 1996/1997

(As a percentage of population aged 5 years and above)

Sector Primary and Secondary and Post

above above secondary
Urban 94.1 66.7 29.6
Rural 92.1 56.7 20.5
Estate 76.1 20.2 2.1
All 91.4 56.2 20.7
sectors
Source: Central Bank of Sri Lanka, 1996

50
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.

The traditional belief system of health

Records on the history of traditional medicine go back to the

beginning of civilization in Sri Lanka. Evidence reveals there
was a well organized medicare system with hospitals, rest
homes, herb gardens and conserved forests of medicinal trees
and shrubs located in various parts of the island. These are
well recorded in various inscriptions and chronicles
(Paranavitana, 1959).
Two major sub-systems can be identified in the traditional
medicine: The first system is the herbal-ritual system based on
many beliefs such as deities, telepathy, sound, herbs etc.,
which is identified here as the ancient system. The deity
(God) is at the centre of this treatment system where an edura
(faith healer) is the messenger between the deity and the
patient. The treatment process involves either a full ritual with
a sacrifice or a promise to the deity of an offering. Sometimes
the ritual may accompany herbal treatment. A full ritual
programme is composed of offerings, sacrifices and chanting,
which is mainly used in the treatment of mental disorders and
spiritually-caused sicknesses resulting from shock and

51
depression. Ritual and herbal treatment are used in the
treatment of many other sicknesses and diseases, especially
communicable diseases like chicken pox, measles and
mumps. In the treatment of these traditional infectious
diseases, the patient is strictly forbidden to ingest any animal
products, the patient is kept in a dark room without any
contact with other than a selected group of people and is given
many herbal mixtures. The faith healer (edura) is called for to
chant verses. Finally a promise will be made to make
offerings at the nearest shrine of the goddess Paththini and to
give alms to seven or more women devoted to the worship of
goddess Paththini.
The herbal tradition is utilized by a group of practitioners who
live in the villages and practice their method of treatment
(Jayasekara, 1957 and Ambatalawa, 1994). The most common
specialties are available in from of anti-venom, asthma and
fracture treatment, which are utilized heavily by the general
populace. There is very little written knowledge in this
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.

52
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
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.

53
Health behaviour

Aitken and Jellicoe (1989). They identify environmental,

cultural, group and personal factors as the four major factors,
which construct the health behaviour of a social group. The
environmental and cultural factors were discussed under the
topics of immediate living environment and domesticated
animals in the previous sub-sections and this discussion
intends to investigate group and personal factors in relation to
farming population of Sri Lanka.

Health is highly valued in the farming community as there is

no proper social security benefit system in operation for
farmers in Sri Lanka. Therefore people depend on siblings,
relatives and friends for advice and selection of treatment as
identified by Wolffers (1988).
The self-control, hardiness and coping skills are included in
the personal life style factors within health behaviour.
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

54
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
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.

55
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.

Development and health in Sri Lanka

Modernization and alternative development

Structural functionalism has combined naturalism and

rationalism to form the philosophical basis for an evolutionary
theory of modernization covering all aspects of social activity
(Peet and Hartwick, 1996). Both sociological and economical
and economic modernization theories are built on structuralist
ideology where societies are expected to utilize normative
systems in development by limiting the place of affective
expressions. Linguists and social anthropologists have
attempted to study the deep structures present in many
languages and cultures, and this type of structuralism, which
is interested in the universal and basic structures of the human
mind, is known as structure as construct. However, the type of
structuralism that investigates structures at societal level has
had a stronger impact on geography (Johnston, 1986).
Structuralists hypothesise that there are hidden mechanisms
which produce divisions within society based on ethnicity,

56
gender, class and age. Power relations are established within
these groups, and some groups attempt to dominate other.
This domination is achieved mainly through developing
ideologies which are supported by the hidden mechanisms.
There are two major variants of economic modernization
which believe in authoritative intervention through the use of
economic growth models and aid mechanisms.
Firstly, Keynesian ideology paved the way for intervention
through the new idea of the role of the government in
managing the economy (Preston 1996). Keynes was of the
belief that government borrowings could finance expenditure,
which in turn would generate more revenue, which together
with higher tax returns from increased revenue, could be used
for the repayment of these borrowings. Myrdal (1957)
brought forward the concept of circular cumulative causation,
which became popular through the notion of the vicious cycle
of poverty. He regarded development as a social process, and
stressed that the power structures of the developing world
have to be changed either by evolution or revolution as a
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

57
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.

Hagerstrand (1952) and Gould (1964) saw modernization as a

spatial diffusion process beginning at the cities and
administrative centres, and transmitting along transport routes.
The rate of progress was measured by a set of statistical
indices related to the development of economic and social
status.
The continuing poverty of the developing world led to a
rethinking of the validity of the modernist and dependence
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.

Health and under development in Sri Lanka

58
A development strategy, which emphasizes social services is
the key to the current better health status of Sri Lanka. The
social welfare programme was an extensive programme and
was operated in the 1950s and 1960s by a group of leaders,
whom Framer (1957) identified as “very able Ceylonese”.
This socially oriented development has helped the poor to
escape from extreme poverty and live on a welfare system
provided by the government.
Caldwell (1993) clearly formulates the value of societal and
political commitment in establishing a healthy environment
and concedes that both are available in Sri Lanka. Wolffers
(1988) believes that the secret of the better health situation in
Sri Lanka rests in its well-established cosmopolitan system of
public health.

Table 3. 1 Some basic socio-economic indicators related to

disease environment of Sri Lanka and its closets neighbours.

Country GNP per Expenditure on Life

capita health and expectancy at
(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

Sources: World Bank, 1996: 1 data from US census data

base, 2000

Table 3.1 clearly shows the high expenditure on welfare and

public sector employment in Sri Lanka, which may have laid
the foundation for the better health and living conditions of
the poor. Further, it is my belief of the researcher, that the
close association with the extended family and friends and
the acceptance of the positive health practices by the

59
 majority of the people have enabled the construction of a
disease environment of moderate risk in Sri Lanka.
In addition, rapid rise in literacy, early empowerment of
women, and a comparatively less corrupt political system
have also been noted by some researchers as a reason for the
batter health situation of Sri Lanka, since the 1950s.

Macro-economic development strategies

In a global context, Sri Lanka is unique in achieving

remarkable success in the health sector without affecting
economic growth. A spectacular transition from high to low
mortality in Sri Lanka, which has been recorded since 1946
despite its low per capita income, reflects the achievements of
the health services and health care systems. Since
independence, successive government in Sri Lanka have
committed themselves to providing free and promotive,
preventative, curative and rehabilitative medical care through
a systematic network to the whole population. Therefore,
within a South Asian context, Sri Lanka has achieved
impressive high life expectancy at birth, the lowest infant,
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

60
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 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

61
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
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,

62
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.
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

63
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.

Health sector development

Health sector development during this period was guided by

two major political programmes. Firstly, the health of the
nation was treated as a primary responsibility of the
government. Programmes for education, health, food,
nutritional subsidy and free social security payments were
maintained by successive governments between 1948 and
1970. These programmes consumed an average of 25 to 30
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

64
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
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.

65
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.

Demographic and epidemiological transitions

The demographic transition theory was presented as a model

by Notestein (1954), and suggests that there is a relationship
between population change and socio-economic development.
Population change within the model is initiated by spatio-
temporal variations of death, birth and fertility rates
associated with modern development. Development in the
model refers to modernization conducted through a western-
style economic development, which will transform an agrarian
society into a modern industrial society.
The model depends on three major postulates. The first is that
decreases in mortality are the direct result of socio-economic
change. Second, fertility is less responsive to socio-economic
change, and decreases in fertility occur some time after
decreases in death rates. Thirdly, the socio-economic process

66
is evolutionary and agrarian societies will change to modern,
industrial urban societies. Based on these three major
postulates, a four-stage model is constructed. Stage one is a
period of high death and birth rates resulting in a period of
low stable population, which has been experienced by the
human species throughout most of its history. Stage two is a
transitional stage with falling death rates and high birth rates
due to the initiation of the modernization process, which
brings modern medicine and information, although fertility
remains high because of its control by traditional belief
systems. Stage three is another transition stage in which birth
rates begin to fall as urbanization increases and low death
rates are sustained by improved health. Stage four is a
balanced state of low birth and death rates in which a high
stable population live in a modernized industrial urban
society. Recently, however, a fifth stage has been identified
where birth rates fall below death rates, which leads to
population decline.
State one scenario of the demographic transition in Sri Lanka
was established around 1946 by a shift from high to low
mortality. This was a result of the achievements by the health
services, which were heavily supported by the policies of free
preventive, curative and rehabilitative medical care and social
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

67
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
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

68
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
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

69
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

Development, health and environment in the context of this

study have to be placed within a low-income situation, where
poverty has an important role to play in the spatio-temporality
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

70
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
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.

A proposal for a environment and health environment

management plan for present linear settlement system
(Seneviratne, H.M.M.B. and Siddhisena, K.A.P., Control of

71
Sedimentation of waterways through a household based
programme, Relating environment to Regional Development,
Programme and Abstracts, USJ-Sida/SAREC Research
Cooperation Project and Ministry of Environment and Natural
Resources Joint International Conference, 16 to 16th
September, 2002, Trans Asia, Colombo)
The primary objective of this paper is to present the available
information on the value of household empowerment in the
regional development, with special reference to the problem
of sedimentation and its effect on regional and national
development of Sri Lanka. The secondary objective is to
present the experiences gained in this area of research and
forms a strategy in the control of sedimentation, at the
household level. The alternative development as presented
succinctly by Friedman (1992) indicates the importance of
household in the modern development process.
The household and the farmland are identified as the major
sediment supplier to the sedimentation system. Home gardens
of Sri Lanka are poorly organized to prevent the flow of
sediments to the local network of drains. In turn the
authorities poorly maintain the local network of drains
responsible for the prevention of soil erosion. In all the seven
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

72
hoped to be achieved through household based sedimentation
control program.
Chapter 4

History of disease environment

History of disease environment is an important study in the

identification of the evolution of the preventive and curative
medicine in a given place or space. The history of the disease
environment is presented with the expectation that it will
provide information on the evolution of the present day
disease environment.

History of disease environment in Sri Lanka

History of disease environment of Sri Lanka is constructed on

many sources from the written records, inscriptions and
explanations of ruins. This presentation is expected to shed
light on the medical service and treatment systems from the
time of the ancient kingdom of Rajarata to present modern
medical treatment environment. However major part of this
presentation is referred to the Sinhala people as most of the
written records of the ancient time is provided under their
culture and governance.

Historical material will explain the gradual development of

the systems of health and strategies of environmental change
in the Sinhala culture. Figure 4.1 provides an explanation to
this interrelationship, which is constructed with the help of
many sources quoted in the stage-wise discussion given
below. The link between developmental change and disease in
the ancient period is linked to the dynamics of hydraulic
civilization. The hydraulic civilization was the pivot of
settlement expansion, with its three interdependent structures:
tank, canal and paddy. This is because mean annual rainfall
was not sufficient enough to provide a sufficient among of
food and maintain the infrastructure. This is the reason for

73
veneration of some of the kings who have succeeded in
uniting the warring fractions, defeat any foreign invaders and
built water storage (tanks) and transmission systems (canals,
aqueducts, diversion weirs and tunnels). The construction of
many types of units of water storage and transmission led to a
parallel increase in the human population (hosts), many
disease agents and vectors (mosquitoes, domesticated animals,
shallow water snails etc.) including malaria mosquitoes. Most
of the evidences point to conclude that the hydraulic
civilization was threatened by soil degradation, civil wars and
invasions and the final push factor was a malaria epidemic.
The individual or combined effect of these factors forced the
centre of civilization to move first towards east and then to the
South West.
The destruction of irrigation infrastructure and any long delay
in repair and rehabilitation lead to an increase in disease
agents and vectors. The few venerated kings may have
prevented this form of decline, but most of them were unable
to provide a strategy to halt the decline making the system to
edge towards collapse in and around AD 1200. The collapse
may have come from either the disunity within the Sinhala
kingdom or a massive outside invasion. However, the inability
to re-conquer the invaders was a result of disunity among
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.

1. Stage 1 – 500 BC to 1200, Ancient period

2. Stage 2 – 1200 to 1815, Intermediate period
3. Stage 3 – 1815 to 1948, British colonial rule

Stage 1 – 500 BC to 1200, Ancient period

74
The beginning of human settlement on Sri Lanka dates back
to Neolithic culture where its existence in many parts of the
island is quoted well in Allchin (1958) and Deraniyagala
(1971). The arrival of Aryans and the environmental change
and control, which they established in the ancient civilization
and its relationship to the health environment of the ancient
civilization of Sri Lanka, is discussed in this presentation on
the basis of three major texts (Paranavitana, 1959; Perera,
1984 and Seneviratne, 1989) with supplementing material
from many other case studies.
The direction of movement of Aryans and their journey along
the rivers Malwathu Oya and Me Oya in the north central
province of the dry zone is shown in Figure 4.2, based on
Paranavitana (1959). Population and wealth in this civilization
grew steadily with the development of irrigated agriculture.
The three major elements tank, canal and village formed the
immediate living environment of the permanent settlement
and the migratory pattern was highly restricted. Firstly,
storage capacity of the tank or the supply capacity of the canal
decided the size of the settlement. Secondly, the building of
massive structures of religious symbols and royal monuments
needed support from additional environmental resources,
which were obtained manly from the forests and mineral
resources within and outside

75
Figure, 4.1 Historical model of environmental change and
disease environment

2. Natural environment – Endemic diseases up to BC 300

1. Technology of Ancient hydraulic ivilization

3. CONTROLLED ENVIRONMENT/ENDEMIC AND

EPIDEMIC DISEASE UNDER CONTROL – B.C 300 TO RESTORED
AD 1200

4Temporarily disturbed controlled environment by war/

internal dissent / drought – resurgence of diseases

Not restored

DESTRUCTION OF THE CONTROLLED ENVIRONMENT AND

CIVILISATION BY AD 1200

Migration to a new habitat

76
NEW ENDEMIC AND EPIDEMIC ENVIRONMENT AD 1200 TO 1800

Colonial domination and moderen medicine

MODERN CONTROLLED ENVIRONMENT/ AD 1800 TO PRESENT

TIME ENDEMIC AND EPIDEMIC DISEASES ARE CONTROLLED

the habitat. In this period habitat were divided into three

major regions on the basis of geopolitical structure.

The core of civilization was identified as Rajarattha (country

of Kings) and the sub-kingdom in the south was named
Rohana (country of heir to the throne). The central hill
country was named Malaya and it was uninhabited and used
mainly as a source for valuable timber, minerals and
medicinal plants. The regions of present Kotmale, the middle
Mahaweli valley complex and Matale hill complex were used
as areas of retreat in the face of foreign invasions.
The climatic history of the kingdom has not been investigated
in detail, but on the basis of the density and selection of sites
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

77
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.

78
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

Direction of minor migrations

Major ancient irrigation works
Capitals of historical times

Periods 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

79
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

80
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

81
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).

Case study 3.1

82
 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.

(Term Weva is used in the following presentation as tank is

not suitable for the reservoir which was constructed not only
to store water, but to fulfil many other requirements of the
area which it is situated)

Cascade system of environmental management is one of the

best sustainable solutions to seasonal drought, which is
practised today in a more modernised form in many
developed countries for irrigation, power generation and
urban water supply. This system is also capable of
providing a health environmental management system which
is universally acceptable in environmental management.

The system practised in Sri Lanka during the period of

ancient civilisation was designed to fulfil the following
requirements.

1. Collect high runoff from the catchments where rocky ridges

and hardpan latosols resulted in high rate of runoff during
thunderstorms and depressional rain. Both rocky ridges and
hardpan latosols have low infiltration and very low
percolation capacity. An experiment conducted in
Mihinthale area between October 2005 and May 2006
revealed that between 80 to 90 percent of the runoff from the
two 2 sample sites (forest cover and cultivated) were
released into the streams or interfluve clay pans.
2. Stabilise the surface ground water flow in the catchment to
support a system composed of forest, shrub, grassland,
village, tank and cultivated areas. The experiment indicates
that the stabilisation is present in the areas with more than
60 percent forest cover.
3. Direct runoff as soon as possible to the storage system of
tanks, where evaporation is efficiently controlled.

83
84
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 1st 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.

85
Firstly, the settlement in this system was located in a high
ground besides the weva or cultivated area. This prevented
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.

86
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
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.

87
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.

88
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.

Stage 2 – AD 1200 to 1815, the intermediate period

Stage two begins with the establishment of isolated princely

states, which were located mainly in the wet zone between
AD 1200 and 1500 AD. The shift of the kingdom and centres
of population in this period. The arrival of the Portuguese and
their domination of the coastal areas resulted in the retreat of
the Sinhalese to the Kandy kingdom, though some brief
resistance was made by the rules of Sitawaka. This pattern
continued under Dutch rule from 1697 to 1796 and with the
defeat of the Kandyan kingdom in 1815, British rule was fully
established on the island.
This period is identified as the time of uninterrupted decline
by Silva (1981), and the people had to adjust to farming with
rain water, though minor irrigation techniques were employed
for the diversion of water from upper valley slopes. Slash and
burn cultivation and collection of forest products became an
important part of the economy. Anyhow the techniques of
terracing, diversion of streams through the construction of
weirs and the construction of small tanks and canals were
continued during this period. About 400 to 500 various types
of minor irrigation works found in the wet zone of Sri Lanka,
which belonging to the period between 1200 and 1815. Most
of these are noted in the archival documents and the larger
ones have been rehabilitated and are in use at present. The

89
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.

Stage 3 – 1815 to 1948, British colonial rule

Stage three begins with the total domination of the island by

British rulers and the introduction of plantation agriculture,
which is regarded today as the primary process of a massive
environmental change and control in the modern history of the
nation. The change of land ownership, abolition of traditional
labour organization, recruitment of labour for massive road
and railway building programme and establishment of the
national administrative system exposed Sri Lanka to European
governance. The result of all these policies and actions were
felt mostly by the farmers, who were attached to their
ancestral or feudal land and based on the beliefs of the cast
system, which caused them to refuse to become labourers
(Farmer, 1957). The new political faithful were allocated land
by the British, thus creating a new landlord class outside the
traditional feudal leadership, which were viewed with
suspicion after the 1818 and 1848 rebellions (Silva, 1981).

90
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

91
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.

The wet zone: dry zone disparity in the disease environment

The presence of comparatively more developed infrastructure

facilities in the wet zone has helped it to achieve a better
standard of health than the dry zone. The dry zone, which has
a seasonal rainfall regime, is a malaria endemic environment
in Sri Lanka. Further, the dry zone is less developed due to its
location in the periphery and less poor quality health service
facilities in comparison with the wet zone.
Some researchers have indicated the importance of the
intermediate zone in the study of disease environment, but the
present administrative structure data base provides no facility
for an exercise of that nature as the narrowness of the land
belt of the intermediate zone leads to a mix of data from both
the wet and dry zones.

Some of the variables selected to illustrate the basic

difference between the three environments are given in
Table Data shows the clear difference between wet and dry
zones and the transitional nature of the intermediate zone.
However, it should be noted that the use of cultural
environmental data for the intermediate zone is totally based
on estimates made by the author as there was no source
material available.
It is clear that the dry zone- wet zone boundary is not so
general and that there are many local variations within both
of these zones, but these were not utilized in the analysis, as
the aim of the research is limited to identifying a macro
level difference between the wet and dry zones.

Table 4.1 Some basic information related to the environment

of the wet, dry and intermediate zones.

92
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 government
(curative per health
services district) facilities (Per
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.

Disease environment of the Wet zone

The ecological environment of the wet zone revolves around

year long high humidity and temperatures, which result in
the excessive breeding of many types of biting mosquitoes
(not anopheles), rodents and many other types of insect
hosts. Further the humid warm environment proliferate the
formation of microorganisms, which are hosted both by
animals and man. This results in the high prevalence of
diarrhoeal diseases, tuberculosis and respiratory diseases as
shown in general medical statistics and survey data, which
confirm the effect of warm humid climate on the disease
environment.
The poverty of the farming population is reflected in their
living environment. They live mostly away from the major

93
 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

Key: R- Stream or river/ P – Paddy/ D- Main road/ D2 –

Sub Road/ H – Housing of farmers/ PP – Plantation (tree
crops) / PH – housing of land owners

94
 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.

Disease environment of the Dry zone

The disease environment of the dry zone is a result of its
harsh climate and prevalence of malaria. The physical
environment is composed of an undulating plain on which
the planned settlements are located adjacent to the rice
paddy and the reservoir for irrigation (Figure).
The long dry season with high temperatures and
evaporation for more than eight months of the year results in
dehydration in case of any form of sickness or disease, and
increases the incidence of respiratory complaints and risk of
death. Shortage of safe drinking water in the dry season
results in high prevalence of diarrhoeal disease and typhoid
fever, especially towards the latter part of the season. The
short wet season is the major season with a high incidence
on malaria, and many diarrhoeal diseases occur due to local
flooding of low land areas and spill over of waste disposal
systems.

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

95
Key: W – Weva/ MC – Main Canal/ SC – Sub Canal/ SH –
System or Colony housing/ S- Scrub/ CS – Cash crops/ P -
Paddy

The effect of malaria and diarrhoeal diseases is enhanced in

the dry zone settlements due to three major reasons. Firstly,
the comparatively poor housing situation of the farming
communities contributes heavily to the high prevalence of
malaria, as more than 90 per cent of the farmers live I mud
houses without proper ceiling, masonry or ventilation. These
living conditions make the continuous exposure of farmers to
mosquitoes and dusty conditions, which result in high
incidence of malaria and respiratory diseases. Secondly, as
they live in a frontier agricultural region, they have limited
access to quality health facilities, both western and traditional.
Thirdly, the slow rate of infrastructure development prevents
the development of potable drinking water and waste disposal
systems, which can highly reduce incidence of malaria and
diarrhoeal diseases.
In terms of receiving proper treatment from the best source,
they have identified the necessity of the use of western
medical treatment in case of malaria and diarrhoeal diseases
associated with serious symptoms. These attitudes have
enabled the farming families to reduce mortality to a
negligible level in case of both malaria and diarrhoeal
diseases, but the continuing prevalence is still an unsolved
problem, which could be explained as a situation related to
poverty of the nation.
Most of the farming families in the resettlements schemes of
the dry zone of Sri Lanka have a marginally higher literacy
level in comparison to their sibling families in home villages
due to very low literacy levels among their parents or grand
parents living in the home villages. However, literacy of the
resettled farmers is lower than that of their other siblings who
have moved out of the home village in search of employment
in the wet zone urban or suburban areas.
The life style of the farming families is similar to that of
families in the wet zone, but the isolated location of the

96
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.

97
Conclusion

In the global context of disease environment, Sri Lanka is

situated within the region of high prevalence of tropical
diseases. Malaria, diarrhoeal diseases, intestinal infections,
tuberculosis and anaemia dominate the regional and local
disease prevalence scenario. Many believe that the secret of a
better health environment in Sri Lanka rests on its well-
established cosmopolitan system of public health. However,
its natural ecology and belief systems have also contributed
extensively heavily to its present disease environment. This is
why Sri Lanka has a better control of their disease
environment in comparison with its South Asian neighbours
as shown by indicators related to disease environment.
The belief system is rooted in a traditional treatment system,
which is based on an herbal tradition. This system was
friendly to influence and readily accommodated the
cosmopolitan medicine at an early stage of modernization.
Immediate living environment, nutrition, literacy and gender
are the primary elements which constitute the present day
disease environment of Sri Lanka.
Basic climatic variation has always been a divide in the
disease environment of Sri Lanka. During the time of ancient
civilization from around BC 250 to 1200 the wet zone was
considered to be inhabitable due to its unsuitability for large
scale grain cultivation. After the drift of population to the wet
zone, the dry zone was treated as disease ridden and
inhabitable due to the presence of infectious diseases. This
change of status in the disease environments of the wet and
dry zones of Sri Lanka is a result of the environmental change
initiated by man under various types of technologies and
belief systems.

Disease prevalence in Sri Lanka and the two study areas

Introduction

Sri Lanka is experiencing a change in the trend in disease

prevalence. However, there are many variations to this

98
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

The modern data collection on population in Sri Lanka began

with the conduction of the first population census in 1871, and
since then regular censuses were held until 1991, except
during the Second World War period. The existence of the
organized from of health statistics goes back to the formation
of a department for Registration of Births and Deaths in 1897
and a Medical Statistics unit under the Department of Census
and Statistics in 1920. In this period from 1897 to 1920 data
on health statistics were dispersed around many sectors of the
health service like Preventive Services and Hospital and
dispensary records. Most of the data have been collated and
incorporated into the newly formed Medical Statistics unit
under the Ministry of Health since its establishment in 1970.
The present rate of registration of illness and disease is
primarily based on medical statistics provided by the public
health services and registered private health service providers,
and a survey conducted by the Department of Census and
Statistics in 1980 indicated that about 98.8 per cent of the total
births and 94.0 per cent of the all deaths are properly
registered. The morbidity statistics are based on the data
provided by the hospital records and preventive services
which cover about 80 per cent of cases, but the absence of a
developed medical records department seven in large hospitals
has hindered the analysis of discharges for important
epidemiological information such as age, sex, place of
residence, etc. (Ministry of Health, 1996).
The statistics of disease prevalence in Sri Lanka is primarily
collected district wise by the government health service units
and hospitals, and they are published in the Annual Health

99
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.

Temporal change in mortality and disease prevalence

Mortality levels and trends

The transition from high to low levels of mortality, especially

during the last six decades, provides information on disease
prevalence in Sri Lanka. The time trend of death statistics
from 1936 clearly shows that the crude death rate (CDR) and
its components of infant death rate (IMR) and maternal death
rates (MMR) were high up to the middle of this century
(Table). The overall crude death rates, which were
considerably high as of two digits, fluctuating between 20 and
40 per thousand before 1946 dwindled substantially to a low
level as a single digit death rate in the 1950s. Although the
decline trend in mortality has been witnessed since the 1930s,
the remarkable decrease in the crude death rate in Sri Lanka
was particularly marked between 1946 and 1956.

Table 4.2 Some key mortality indicators in Sri Lanka: 1931

– 1995

Period Crude Infant Maternal

Death Mortality Mortality
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

100
 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

This declining trend in mortality continued and its

remarkable reduction has been apparent since the late 1950s.
During the years 1950-95 period, the CDR accounted for 60
per cent of the reduction from 12.7 in 1950 to 5.5 in 1999. In
the case of the infant mortality, a 79 per cent reduction (from
75 per 1000 live births in 1951-55 to 16 in 1966-99) and the
maternal mortality for 96 per cent of reduction (from 5.6 per
1000 live births in 1950 to 0.2 per 1000 live births).
Moreover, the child mortality (ages 1-4) has also declined
considerably, from 29 per 1000 in 1950 to 1.2 per 1000 in
1994.

This trend in mortality has appeared in all age groups as

well, as appears from Table. The reduction was substantial
in the age groups 0-4 and above 55 years of age. The
percentage of decline is also notable in the age groups 5-9,
15-19 and 35-44 (Table).

Table 4.3 a Age specific death rates (rate per 1000) Sri
Lanka, 1946-1995, years 0 to 24

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

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 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)

Source for tables 4.3 a and b is Registrar General’s

Department, Vital Statistics, 1946-1995
*Provisional

Thus the age specific mortality profile depicts a steep decline

of death rates for all ages during last six decades. The decline
in mortality as expressed by the age specific rate is confirmed
by the change in life expectancy at birth from 45 in 1950 to
73.7 in 1996.

Table 4.4 Expectation of life at birth by sex, 1946 – 2001

Year Both Male Female Excess of
sexes Female
Expectation
Over Male

102
 Expectation
1946 42.2 43.9 41.6 -2.3
1953 58.2 58.8 57.5 -1.3
1962 61.7 61.9 61.4 -0.5
1971 65.5 64.2 66.7 +2.5
1981 69.9 67.7 72.1 +4.4
1991 72.5 69.5 74.2 +4.7
1996* 73.7 70.6 75.3 +4.7
2001* 73.9 70.8 75.5 +4.7

Source: Department of Census and Statistics, life tables, 1946-

1991
*Projected based on UN Method assuming log of increment is
constant.
As seen in Table, The longevity has increases substantially for
both male as well as females over the six decades since 1946.
The most notable gain in longevity was achieved during the
period 1946 to 1953, when the average gain per year for both
males and females was 2.3 years. A steady increase of female
life expectancy has taken place since 1960s and therefore the
gap between male and female longevity marked about 5 years
difference (Table). This improvement of life expectancy is
commendable compared to other Asian countries (Pieris and
Caldwell, 1997). Undoubtedly, the decreasing trend of age
specific death rates, especially the fall of infant mortality in
the future, which is inversely related to life expectancy at
birth, will eventually increase the life expectancy at birth to
74 years in 2001.
This notable decrease in mortality is primarily a result of
proper control of infectious disease through provision of pre
and post natal care. In addition literacy and public sector
welfare policies have also played an important role in the
decrease of infectious diseases.

Evolution of disease prevalence

The evolution of disease prevalence over a period of 21 years

in Sri Lanka is given in Table. It indicates a reduction in the

103
prevalence of infectious diseases and an increase in the
chronic diseases, which led to an epidemiological transition in
recent times. A close examination on morbidity indicates that
the intestinal infections and malaria are recorded as the two
most important infectious diseases. This corresponds to the
disease situation of many developing countries in which poor
sanitation and water supply, low calorie diets and endemic
diseases record a high prevalence. The increase in the chronic
diseases reveals the arrival of the epidemiological transition in
the period covered by Table.

Table 4.5 The hospital in-patient morbidity 1975 and 1996 in

Sri Lanka (prevalence per 100,000).

Disease group 1975 1996

Intestinal infections 970 676
Malaria 800 290
Anaemias 430 101
Helminthiasis 231 15
Nutritional deficiencies 198 13
Hypertensive 122 340
Tuberculosis 114 53
Diabetes mellitus 96 154
Ischaemic heart disease 76 256
Diseases of the liver 39 92
Source: Ministry of Health, 1996.

Malaria

The temporality of malaria is clearly visible in the Figure,

with an epidemic malaria situation indicated by the data
between 1945 and 1950 and a reduction in total number of
cases up to the mid 1960s. The rapid fall in number of cases
from 1950 to 1965 show the well-known success of the

104
malaria eradication programme in Sri Lanka. The resurgence
from 1968 and rise and fall regime of malaria cases may be
Figure Malaria in Sri Lanka 1945 – 1996 (Number of disease
cases in log scale) (Source: Ministry of Health, 1996)
Associated with the dry years, the establishment of new
resettlement schemes (Amarasinghe and Indrajith, 1994),
relaxation of the spending on the malaria eradication
programme (Silva, 1997) and the emergence of the drug
resistant strains. However, it should be noted here that the
causes and factors of resurgence of malaria are mostly based
on generalized estimates only. When compared to the total
population in 1945 the rate was 450 per 1000 and in 1996 it
was 1.2 per 1000. This reduction of malaria cases indicate the
general advance made by health authorities and people in the
reduction of infectious diseases highlighting the health
behavioural pattern and role of public sector social services.

Spatial variation of mortality and disease prevalence

Spatial variation arises from the developmental and

environmental factors. It is clear that poverty, literacy and
accessibility to health services play an important role in this
variation. The effect of ethnicity on spatial variation is
identified by some researchers, but the exact nature of its
influence is yet to be fully understood. The discussion here
will be conducted in relation to spatial variation of infectious
disease and mortality. Finally some examples of mobility and
ecology are presented to show their effect on spatial variation
of disease prevalence.

Infectious diseases

Tuberculosis, typhoid and viral hepatitis are the three

important infectious diseases noted in health statistics in Sri
Lanka (Ministry of Health, 1996). The high prevalence of
tuberculosis corresponds well with the areas of highest
population density, where the poor urban population is
concentrated. The excessively high incidence of typhoid in the

105
Jaffna district is commonly associated with continuous
pilgrimage to South India and trade between the two areas,
but the reality is yet to be fully understood. The prevalence of
viral hepatitis is concentrated in the areas along the two major
transportation routes to the highland and the northern parts of
Sri Lanka, respectively.
The other infectious diseases recorded under the category of
notifiable diseases are dysentery, viral encephalitis, dengue
haemorrhagic fever, measles, rubella, cholera and whooping
cough. These are the diseases, which have a tendency to
emerge suddenly and spread rapidly along the major
communication routes in Sri Lanka. Dysentery is the most
commonly occurring infectious disease in Sri Lanka with a
heavy presence in the urban areas and dry zone. In addition it
can emerge after floods, and landslides in any part of the
country. Dengue occurs mostly in the western part of the
country in the lowland areas and spread into highlands
between July and October and has become a national health
problem due to its effect on children.

Mortality

Although Sri Lanka’s national infant, child and maternal

mortality rates are relatively low, there are several regional
disparities that policy makers should pay extra attention to.
The average national infant mortality rates for 1994 -1996 (18
per thousand live births), conceal the marked variation in this
rate across about 210 DS (District Secretariat) divisions. A
few DS divisions in Vavuniya, Mannar, Anuradhapura,
Trincomalee, Polonnaruwa, Kurunegala, Ratnapura, Kegalla,
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

106
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
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

107
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).

Table 4.6 The rankings of the major notifiable diseases in the

four most populated districts of the wet zone of Sri Lanka.

District Tuberculosis Viral Dengue

hepatitis
Colombo 2 1 1
Gampaha 1 2 4
Kalutara 7 11 5

108
Kandy 3 6 6
Source: Ministry of Health, 1996

Mobility

The increased mobility of modern populations either

internally or internationally has been recognized as an
important factor in disease diffusion. Commuting to work,
long distance travel to home villages and pilgrimages have
been cited by health authorities of Sri Lanka as the cause of
rapid dissemination of cholera, dengue, respiratory infections
and influenza epidemics. The irrigation canals have been
associated with the spread of cholera and malaria in the dry
zone and spread of malaria into marginal areas of the wet zone
and the wet zone has been associated with long route mobility,
as Meade (1976) has discovered in Malaysia.
The spread of the 1998 cholera epidemic was mapped by the
researcher, on the basis of reports from the Divisional Health
Service and National Television, which strongly favour a
possible connection between the long distance express bus
service and diffusion of cholera as illustrated in Figure. The
major routes of mobility in Sri Lanka operates along five road
arteries radiating from Colombo and media reports indicate an
association between occurrence of epidemics of infectious
diseases and, the towns and linear settlements served by these
major routes, although this contention is yet to be confirmed
by a proper research programme.

109
 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

110
Figure 4. 5 Spread of cholera epidemic in 1998, which was
transmitted along long distance express bus routes and
pilgrim routes

Source: Media reports and data given to media by the

Ministry of Health

Graphical evidence for spatial variation of malaria

The district prevalence data on malaria arranged in an axis

along the ecological zones from wet to dry indicate an
interesting visible relationship between prevalence and
district. Figure indicate that there is a sudden increase from
all the Wet zone districts to dry zone districts and a similar
pattern is recorded in prevalence between highland districts
and the dry zone.

111
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.

Figure 4.7 Distribution of health personnel , Ministry

of Health, 1996

Key – 1 Medical Officers of Health

2. Health administrators

112
 3. Dental surgeons
4. Registered Assistant Medical practitioners
5. Public health Nurse
6. Public Health inspectors
7. Public Health midwife

The wet zone – Dry zone disparity

The general morbidity situation within the wet zone is a

product of its human development, which was acquired
through the association with the colonial rule of the
Portuguese, Dutch and British, spanning the period from
1505 to 1948 and the post independence governance. Within
this comparative healthy situation, there is some local and
district based variation resulting from extreme weather
conditions and landform processes, such as high intensity
rainfall and landslides, and these events have been important
factors in the local disease and epidemic scenarios. Most of
these events are generally followed by epidemics of
diarrhoeal diseases, viral infections or typhoid fever, which
for most part are well contained by the present health
authorities.
The highest number of malaria incidence is reported from
the Anuradhapura and Vavuniya districts, which are dotted
with more than 2000 abandoned reservoirs known as tanks.
In the beginning of the rainy season these reservoirs become
shallow water pools and escalate the breeding of mosquitoes
until washed by the subsequent heavy rains in the last weeks
of November and in the beginning of December. This
corresponds well with the reported increase of malaria in the
late December and early January period as recognized by
many researchers in the early days of resettlements and in
the Mahaweli Development Programme.

Figure 3.7 shows the basic difference in the availability of

health services personnel, which reflects the wide disparity in
the quality of services available in the dry zone. The

113
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.

Figure 4.8 Malaria prevalence per 1000 population, based

on district data, Ministry of Health, 1996, Intermediate zone
figure is an estimate calculated on the basis of hospitals
located in the intermediate zone

114
 Figure 4.9 Prevalence of three other infectious diseases in
the wet and dry zones, Ministry of Health, 1996

The data on prevalence of other infectious diseases in Figure show

that the major difference between the wet and dry zones arises from
the high prevalence rates of malaria in the dry zone. The other
major infectious diseases recorded by the Ministry of Health fail to
identify this difference, except in case of tuberculosis, which is
regarded as an urban disease in Sri Lanka.
An attempt was made to investigate the variation in disease
prevalence between the wet and dry zones on the basis of four
major disease categories of malaria, respiratory, bacterial and viral.
The prevalence of four major infectious diseases at home villages,
System C, Anuradhapura district and the national averages were
graphically represented in Figure All the data used here was

115
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

Figure 4.10 Prevalence of infectious diseases in the four

major areas selected

116
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).

Figure 4.11 A simple graphical representation of the

prevalence of infectious diseases per 1000. 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).

117
was resettled mainly between 1940 and 1960 and it has a fair
presence of malaria which is higher than both the national and
home village averages. Respiratory diseases dominate the
prevalence in Anuradhapura district, which is followed by
bacterial and viral diseases respectively. System C profile is
dominated by respiratory diseases, but it has about 20 times
malaria more than the home villages, and also compared to
the presence of viral diseases. The major difference between
the home villages and System C arises from the presence of
malaria and viral diseases. This disparity allows for the
suggestion that these two diseases are the lowest recorded in
the home villages and when they are encountered by the
settlers they may not have any immunity and succumb in large
numbers.
It can be inferred that the presence of respiratory diseases
increase with poverty and low accessibility to health services.
However, the influence of air pollution in the urban areas and
dust in the dry zone has been identified as ever increasing
causative factors for the increase of respiratory diseases in Sri

118
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

The effective control of most of the dangerous infectious

diseases by a welfare state is the primary factor responsible
for the present day pattern of disease prevalence in Sri Lanka,
though there is a positive contribution from the rapid rise in
literacy and social modernization in the last fifty years. The
free provision of western and Ayurvedic health care facilities

119
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.

120
Case study 3

Case Study on health profiles of a migrant and their sibling

families – an example of change of environment

Introduction

The changing health status associated with the migration to

frontier farm settlements in the developing world has
become an important topic of study in medical geography.
The resettlement of farming families in the dry zone of Sri
Lanka includes both voluntary and involuntary migration.
This is because some of the farmers move to resettlement
areas as a response to the opportunities given by the land
development authorities, and another group is resettled in
the farm settlements due to displacement resulting from dam
construction, catchment conservation or war. Scudder (1975)
identifies the mixing of the voluntary and involuntary
participants in resettlement studies in a review of Palmer
(1974) and indicates that the agricultural type resettlement
may contain complex situations. In this context the
resettlement programme is not considered to be totally an
involuntary resettlement.
Health within the context of developmental change initiate
complex changes in the factors of population, habitat and
behaviour, which affect the disease systems (Meade, 1988).
The developed world has experienced positive demographic
transitions and mortality and morbidity are lowered on a
long-term time scale, but has encountered the problem of

121
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

The area designated as System C is the largest single

resettlement programme in the Michaela Development
Project in Ova, Eastern and North Central Provinces of Sri
Lanka, where malaria is endemic and many other infectious
diseases prevail due to poor quality living environment and
drinking water. The home villages are a group of rural
settlements located in the wet zone of Sri Lanka, which is
comparatively healthy and malaria free. The detailed
statistical tests conducted on the two different environments
confirmed that the environment at Michaela System C is
more hazardous than the home villages (Seneviratne, 2003 b
, p 169-170).

122
Immediate living environment

The study of environment in relation to disease prevalence is

generally conducted within the framework of geography of
health with the use of techniques and methodologies adapted
from environmental epidemiology.
The studies of May (1956), Meade (1976, 1977 and 1978)
Harrison (1978) and Packard and Brown (1996) indicate the
effect of tropical environment in relation to endemic and
epidemic diseases in resettlement programmes of the
tropical world. They all have identified the effect of the
general environment and immediate living environment of
the settlers in relation to the endemic and epidemic
situations.
Meade (1976) in her presentation on the land development
and human health in west Malaysia indicates the importance
of human ecology in the study of human health and shows
that human disease in large measure is a product of human
culture. Further she indicates that the levels of health or
disease reflect the adaptability and fitness of cultural
interactions with the environment. In the detailed study of
the topic she indicates that major land development
programme necessitates fundamental alterations in the
interactions of behaviour, population and environment,
which influence disease patterns. Levine and Levine (1995)
refer to the immediate living environment factors associated
with diarrhoeal diseases and indicate that much of the
developing world's population lives in substandard housing,
under crowded conditions, without piped water or sanitation.
Under these conditions of pervasive faecal contamination,
the various bacterial, protozoa and viral agents that cause
diarrhoeal illness are readily transmitted. Water supply,
sanitation and waste disposal are identified as strong
contributors to overall health and Silfverberg (1994)
suggests that they should be all components of primary
health care.
The sample population of this study is the Sinhala Buddhist
farming society of Sri Lanka, with an average monthly

123
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.

Socio – economic environment

Environmental data presented here is divided into two major

sub-divisions as socio-economic and immediate living
environment. The developmental environment originating
from level of income, literacy, health care facilities and
belief system on health are studied under the socio economic
group based on data for educational level. The house type,
source of water supply, toilet quality and waste disposal is
evaluated within the immediate living environment. The
household income and literacy are studied under the sub-
topic of socio-economic environment.

The income was recorded at the household level and three

major categories were chosen to represent the data. The
category of the lowest income level is based on the average
monthly income of the occupations related to agriculture as

124
 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).

Table 4.7 Monthly income of the Household head

Income Home villages System C

level No. Percent No. Percent
Sri
Lanka
rupees*
Below
4000 2 2 10 11
4001 to
6000 69 77 76 84
6000
and
above 19 21 4 5
Total 90 100 90 100
 rate at the time of survey stood at Rs. 46.00/ per US dollar
Source : Seneviratne (2003)

The lowest income group in System C has five times more

respondents than that of home villages, which indicates the
presence of a higher number of poor families in System C.
Disease and lack of supporting children caused four of the
System C households to be in this category, while
alcoholism of the male household head, was recorded as the
major cause foe low income in six households. The two
lowest income households at home villages had no support
from children and were living on ancestral property.

The 4001 to 6000 category is the majority group in the

sample both at System C and home villages. These are the
households in which there were few complaints on ill health
and problems associated with farm income. However, it was
noted that the majority of household heads in this category

125
 had an auxiliary income source from either craft work or
daily paid labour.

The 6001 and above category is primarily the group either

supported by children, who are employed in the public or
private sector or derive income from non-farm activities
such as trade related activities. The children of the System C
respondents in this category either send remittances or help
in financing the farming or other types of activities.

The income level of the farming population is mainly a

product of the occupational structure and total number of
employed persons in a household. The employment structure
in the study areas is of a complex nature as shown in Table
7.2. However, the home villages have a higher degree of
complexity than System C, because of more than one family
in the household and the availability of many types of
employment in the urban areas of the wet zone.

Table 4.8 Employment structure of the two study areas

Type of combination Home villages System C

No Percent No Percent
Farmer only 5 6 11 13
Farmer / labourer 3 3 7 8
Farmer supported by children,
who do the farming 21 23 0 0
Farmer / trader 12 13 9 10
Farmer / kiosk owner 3 3 4 4
Farmer / illegal alcohol seller 0 0 3 3
Farmer / carpenter 9 10 3 3
Farmer / mason 6 7 4 4
Farmer / rice miller 0 0 5 6
Farmer / mechanic 0 0 2 2
Farmer / civil servant 0 0 1 1
Farmer supported by employed 27 31 24 27

126
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)

The Statistical Abstracts of 1996 of Sri Lanka, identified 96

types of occupations available to unskilled and semi-skilled
labour and most of these are utilized by the sample
population at home villages and System C. In the home
village sample, the children who have achieved a
senior professional status of training (one university
lecturer, one employed graduate teacher and four higher
technical officers) support six of the households. Farming is
conducted with the use of hired labour. In the System C
sample, a civil servant has inherited the land from his father
and has used hired labour in cultivating his wetland. Two
wives are employed as trained teachers and their husbands
have established rice mills with the help of them.
The literacy of the householders and their wives are given in
Tables 7.3. and 7.4. They are calculated on the basis of the
major educational levels used in the national surveys. The
settlers at System C have higher literacy than their parents
and the age groups of 30 and above of the home villages
have had less schooling than that of their siblings in System
C. This indicates less use of education by the farming
population about 50 years before the present as given in
national data. The disparity under the category of secondary
education between home villages and System C may result
from migration of them to urban areas for employment.

Table 4.9 Literacy of the householder in the two study areas

127
 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 90 100 90 100

Source : Seneviratne (2003)
Home System C
Literacy group villages
No Percent No Percent
No formal schooling 34 38 14 16
Primary 56 62 36 40
Junior secondary
0 0 28 31
Senior secondary and
above 0 0 12 13

Total 90 0 90 100
Many of the home village sibling family male householders
are old and have lower literacy rates than their sons who
have become resettled farmers at System C, which accounts
for the high percentage of junior secondary schooling in
System C householders. In addition, as explained earlier the
highly educated males of the sibling families have migrated
to urban centres or another more developed area in the wet
zone making the least educated to remain at home villages.

Table 4.10 Literacy of the wife in the two study areas

Source : Seneviratne (2003)

The literacy of wife indicates a similar scenario to that of

male householders. Firstly, the sample of home village
wives is mainly composed or an older group and has not had

128
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.

The immediate living environment

The immediate living environment was investigated in detail

and the house and environment was evaluated on the basis
of its relationship to healthy living as perceived by the
national health standards. This analysis was conducted in
order to build a background for the study of environment
risk, which is used to identify the major differences in living
environment between the two areas. The landform
characteristics have the most impressive difference in the
study of immediate living environment of the two sample
areas. Based on the observations made during the survey,
some descriptions are given here on the size and plants in
the home garden.
The average size of the home garden at home village is 0.4
hectares, covered with a few economic trees, fruit trees and
flowering plants. This type of land use design is identified as
a forest garden in Sri Lanka, where the house hidden in the
thick cover of vegetation. The size of the System C home
garden varies from about 2.5 to 1.6 hectares from 1986 to
post 1986 settlements respectively. These are more open
compared to home village home gardens, but settlers have
made a serious attempt to cover it with many types of trees
and shrubs.

129
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.

The income level primarily decides the size of the home

garden of the farmer in the home villages. The majority of
them live on the inherited land and the rest live on land
donated by the philanthropic landlords and housing schemes
established by various government agencies since
independence. Farmers with supporting children have larger
and better-cultivated home gardens than the families with no
support from children.

Three features of the immediate living environment were

recorded during the survey using the questionnaire and
observation. They are the quality of the house, water supply
and toilet.

The quality of the house

The quality of the house in the study was measured through

the occupancy rate of the house, on the basis of density of
persons per room (Table 7.6). This measurement is used
because it combines the size of the house with the number of
people in the house. The poorest of the farmers live in a mud
house with one living room, which is used for sleeping,
resting, eating and entertaining visitors. Most of the farmers
and the poor live in a house with two rooms. One of them is
used as a common room for all activities and a sleeping area
for male children and the father. The other is an inner room,
which is used by female children and the mother for
sleeping and to keep valuables.

130
 Table 4.11 Quality of house calculated on the basis of
population density per room

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)

The data in Table 7.5 show the level of congestion in

housing, both in the home villages and System C. The
categories of number of rooms in this data table include the
general living area of the house. The average size of a room
is between 8 to 9 square meters with an average height of
two meters.

There was a marked variation in the nature of construction

between the home villages and System C. The houses of the
home villages were mostly built with bricks and have
cement plaster and better ventilation. The houses in the
System C area are mostly of a compressed earth and burnt
brick combination with neither cement plaster nor proper
ventilation. The System C house is still under some from of
change and construction. During the survey period 84
percent of the houses in System C were undergoing a change
in the structure, while only 6 percent of the houses in the
home villages showed any structural change.

131
The national data indicate that the compressed earth is still
being used by 40 to 45 percent of houses in the rural districts
of the eastern, southern and northern parts of Sri Lanka
(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.

These houses are generally dusty and packed with farm

produce waiting to be sold, an amount kept for consumption,
personal belongings and other household furniture. It is
common to see the bicycle, motorcycle and the hand tractor
being parked in the living area of the house, and the loosely
kept pets freely roaming around. There is a continuous
attempt to keep the house as clean as possible and the
houses are swept daily and incense is burned regularly.
Therefore the rooms are designated simply for sleeping.

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.

Table 4.12 Source of water supply

Type of Sri Lanka Home villages System C

supply (Percent) No Percent No Percent
Public 19 4 5 0 0
mains
Tube well 5 1 1 2 2
Protected 44 20 22 0 0

132
 well
Unprotected 23 57 63 41 46
well
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)

Table 4.13 Quality of toilet

Type Sri Home villages System C

Lanka
Percent No Percent No Percent
Water seal 38 3 3 1 1
Pour flush 26 38 43 10 11
Pit 22 46 51 53 58
Others
(mostly
temporary) 1 0 0 15 18
Shared No data 3 3 9 10
No toilet 13 0 0 2 2
Total 100 90 100 90 100
Ministry of Health, 1996 for Sri Lanka data and Seneviratne
(2003)

Drinking water

The quality of drinking water is of prime importance to health as

most the serious tropical infectious diseases are associated with
contaminated water. The contamination of water can occur at any
place between the source and consumption. In the farming
communities of Sri Lanka, both the primary generator of
consumption can be equally contaminated. The source is the
primary generator of the disease, while the point of consumption
can be the secondary node of infection. The hazardous effect of the

133
source is lessened by factors like literacy and adhering to advice on
use of contaminated water. The hazardous nature in the source of
drinking water is reduced in the farming families in this study
through use of boiled water for children and careful storage of
drinking water.

The home villages have limited problems of contamination due to

year round rainfall and availability of better quality sources and 74
percent of the households use boiled water for children and very old
people. In System C there is a high probability of contamination of
drinking water during the dry season as people travel far to collect
safe drinking water or depend on the resettlement authority to
provide it by water tankers.

Toilet facilities

The toilet facilities have a similar scenario to the supply of

safe water, but the hazardous effect of poor quality toilet
facilities is lowered by the health habits formed through
literacy and adherence to advice on use of toilets. The most
noticeable was the common habit of cleaning after use of
toilet, which is practiced by about 55 to 60 percent of the
population. The researcher saw the toilets of all the
households and 94 percent of them were in a satisfactory
sanitary condition. The toilets of unsanitary nature were the
temporary toilets and a few of the pit toilets. In general the
toilets of the home villages were in better sanitary
condition than those of System C, which have many
poorly built and maintained pit toilets. The financial and
material support given by the government, the development
authority and NGOs have been heavily utilized by the
farmers to build safe toilet. During the course of the survey
11 new toilets were built in the System C area with the
support of these various funding agencies and another four
were built by the combination of the supply of the “base
block” from the development authority (the base block is the
concrete base for the pit toilet) and private financing of the
farmer.

134
Wastewater disposal

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

There are many types of biting mosquitoes in the humid

tropical environment of the wet zone, many which have not
been studied due to their low capability in disease transfer.
Fifty five percent of the wet zone home village respondents
reported that there is a mosquito problem during the months
after the two major rainy periods and sometimes even during
the dry spells in the rainy season (Table 7.8). These
mosquitoes are not malaria mosquitoes and some of them
are known to transmit dengue and filarial. The case of
System C is as expected from a malaria

Table 4.14 Problem of mosquitoes as perceived by the

respondents

Level of Home villages System C

problem No. Percent No. Percent
No
problem 35 39 0 0
Seasonal
problem 55 61 9 10

135
 All
season
problem 0 0 81 90
Total 90 100 90 100
Source : Seneviratne (2003)

endemic zone with 81 percent of the respondents reporting

under the category of all season serious problems. The
detailed observations revealed that the mosquito density
increases in the dry days after a rainy spell, which is a
common meteorological characteristic of the monsoon
weather.

Accessibility

Sometimes the location of the house within the village unit

has imposed severe restrictions on accessibility to health
services and good quality water. This was clearly evident in
the home villages of the hilly and mountainous areas and the
outback locations of the new settlement. Twelve percent of
the households in the home villages were located more than
a kilometre away from main road and 9 percent have
difficulties getting good quality water supply due to hilly or
mountainous terrain. Seven percent of the System Cc
respondents live more than a kilometre from the main road
and about 24 percent have a water problem during the dry
months as their wells cannot supply sufficient amount of
safe water.

The accessibility to medical facilities is considered to be an

important variable of the health status of modern
populations through it is a difficult component to measure
due to wide disparities in spatial distribution and functional
level of services. An equation is formed on the principles
given in Meade et al (1988) to calculate the accessibility of
normal and emergency conditions to identify the major
difference between the two study areas. Under normal
conditions A = d* h / t, where A, is accessibility, d is

136
 distance to the service, h is number of government hospitals
visited and t is travel time. In case of emergencies the value
of t is replaced by the mean cost of travel to hospital. The
data for the calculation was collected on the basis of number
of health care facilities visited by the respondents (Table
3.15).

Table 4.15 Accessibility ratios to health care facilities under

normal and emergency conditions

Variable Home System C

villages
Mean distance to hospital in
kilometres (d) 13 15
Number of hospitals visited 13 02
Mean Travel time (minutes) 66 85
Mean Cost of emergency
transport (Rupees) 400 318
Source : Seneviratne (2003)

The distance to hospitals was calculated on the basis of the

route taken and the number of hospitals visited gives the
total number of hospitals visited by the sample population.
The travel time and the cost of emergency transport were the
estimates made by the respondent. The mean values were
calculated for comparison and the results show that there is a
clear difference in the level of physical accessibility to
health services between the two study areas as expected. The
basic difference arises from the number of health care

137
facilities available for visiting and receiving, which has a
ratio of 1:6 in favour of the home villages. The rest of the
factors do not have much variation between the two areas.
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.

Environment risk score

The quality of the immediate living environment was

calculated to form an environment risk score, using the data
on house quality, water supply, toilet type and mosquito
presence (Table 7.10). These factors were condensed into
three categories and assigned a value between 1 and 3. One
represents the low risk, while 2 and 3 respectively represent
moderate and high-risk levels. The risk score was calculated
by adding the four numbers allocated to an individual
household (Table 4.16).
The levels of low, moderate and high risk were formulated
with the help of White (1979) in relation to risk arising from
the natural environment and hazards.
The total obtained from the addition of values from the four
variables is 12, which is equal to the risk level 3. The
calculation of the risk levels for an individual house enables
the researcher to place it in one of the following categories:
Low risk – 4 to 7
Moderate risk – 8 to 11
High risk – 12 and above

138
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 water supply

Public mains 1
Tube well 2
Protected well 2
Unprotected well 3
River, tank and stream 3
Other 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)

139
 Table 4.17 Risk level of the environment

Risk Home villages System C

level No. Percent No. Percent
Low 16 20 4 4
Moderate 40 54 12 13
High 16 25 74 82
Source : Seneviratne (2003)

The risk level information as presented in Table 3.17

confirms the difference in the quality of the immediate
living environment between the two areas. The two data sets
show that while 74 percent of the home village people live
in a moderate and low risk immediate living environment
more than 80 percent of System C respondents live in a high
risk immediate living environment. This agrees with the
observations made during the field survey. This disparity
arises from two major sources. Firstly, the house and garden
units of the home villages are located in a setting of a more
developed sanitary infrastructure, which makes the
immediate living environment much safer to live than at
System C. Secondly, the availability of many auxiliary
income sources at home villages makes most of the siblings
living at home villages to maintain a better immediate living
environment than their counterparts at System Cc. Therefore
developmental change contributes heavily to the risk score
on immediate living environment through the presence or
absence of infrastructure facilities and auxiliary income
sources.

140
Presentation of rates and ratios

This discussion is presented in two parts with analysis on

education and health followed by environment risk and
health.

Education and health in the two areas

The data on literacy of household head and wife show

(9Tables 7.3 and 7.4) that there is no marked variation in the
level of education of the respondents between the two areas.
Most of them have received primary education and a few
have proceeded to levels above secondary level. This agrees
with the scenario recorded in national data of the farming
population of Sri Lanka. However the following analysis on
education and health of the two areas utilizes data of all the
individuals living in the household.

Age specific rates

An attempt is made here to compare health status for the

same educational groups in the two areas, controlling for
age. Table 3.18 record the results of this analysis, which
indicate that only the age group 15 to 39 in the no schooling
and primary category records a significant difference. This
lack of a

Table 4.18 Status of significance of age specific rates

between home villages and System C in the selected age
groups

141
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

Significant difference contradicts the country status on

education and. The presence of a marginalized group among
this group of farmers in relation to educations and health has
not been identified in the country profile. It is clear now
after the primary investigation of this group of farmers that
poverty contributes in preventing long duration schooling in
the farming families, which affect their socio-economic
advancement and health.

142
 Age adjusted rates

Age adjusted rates for all the categories indicate a

significant difference between the two areas as shown in
(Tables 7.13 to 7.15) and show the difference in age adjusted
rates of health status between the two areas. Then it can be
argued that the adjusted rates have manages to confirm the
existing difference in health status, though the there is no
major differences in literacy between the two areas.
Table 4.19 Literacy – no schooling and primary education
category sick / not sick crude
And adjusted rates per 100

Area Sick n Crude rate Adjusted

rate
Home 83 324 25.6 18.63*
villages
System 87 285 30.5 36.39*
C
 significant at 95% confidence level

Table 4.20 Literacy- junior secondary education category

sick/not sick crude and Adjusted rates per 100

Area Sick n Crude rate Adjusted

rate
Home 36 136 26.47 16.90*
villages
System 34 102 33.33 34.06*
C

The age-adjusted analysis indicates a gradual reduction of

sick and age adjusted rates in both study areas in relation to
increased level of schooling. However, the reduction
between no schooling and primary and junior secondary
categories is not negligible (Tables 3.19 and 3.20), which is
difficult to explain. It may arise from the inability to

143
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.

Table 4.21 Literacy – senior secondary and above category

sick / not sick crude and Adjusted rates per 100
Area Sick n Crude rate Adjusted rate
Home 9 172 5.23 2.30
villages
System 15 124 12.1 3.86
C

Further, it confirms the increase in infant and maternal

health recorded by national health surveys in the group of
mothers who have had schooling at senior secondary or
above.
The national data indicate a relationship between senior
secondary education and health status of infants and
mothers. The general reduction in sick in all categories as
shown in Tables 7.13 to 7.16, confirm the country situation
as mentioned above. The ability to read and white,
understand the value of immunization and adhere to simple
emergency procedures like oral rehydration and referring to
a registered medical personnel have increased with senior
secondary level schooling. The respondents of this category
were mainly teachers and grade civil servants who
conducted their farming through sibling or hired labour. In
addition this group of people live in a low-risk immediate
living environment, always seek treatment from qualified

144
 medical personnel and cope better with disease and ill health
than the rest of the farming population.

Environment risk and health

Age specific rates

The data on environment risk is highly skewed between

home villages and System C, which makes it difficult to
conduct a full comparison for age specific rates, in particular
the low risk group suffers from lack of data in System C
(Appendix 7.3). The only significant difference is recorded
in the high-risk group 40 to 59 years age group. This makes
the age specific analysis for risk groups a difficult task and
an adjusted rate comparison is attempted as conducted in the
previous analysis.

Age adjusted rates

Age adjusted rates for all categories are significant at 95

percent confidence level confirming the observed variation
of the two areas (Tables 3.22 and 3.23). The variation of the
disease environment, infrastructure facilities and immediate
living environment are confirmed by this analysis.

Table 4.22 Environment risk-low category sick/not sick crude and

adjusted rates per 100
Area Sick n Crude rate
Home 33 134 24.63
villages
System C 3 21 14.29

The disease rate is lowest in the moderate category and highest in

the high-risk category. The method used in the analysis suggests
that adjusted rates calculated for values below 10 will product

145
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.

Table 4.23 Environment risk – moderate category sick / not sick

crude and adjusted Rates per 100

Area Sick n Crude rate Adjusted rate

Home villages 83 342 24.27 13.24*
System C 17 74 22.97 14.25*
 significant at 95% confidence level

The high – risk category records the widest difference in disease

rate among the three groups used in the analysis, which arises from
the heavy presence of mosquitoes at System C in comparison to
home villages.

Table 4.24 Environment risk-high category sick/not sick crude and

adjusted Rates per 100

Area Sick n Crude rate Adjusted rate

Home villages 22 156 14.1 20.4
System C 106 416 25.48 29.67

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

146
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 socio-economic and the immediate living environment

construct the built environment in which man lives. The
relationship, which exists between the socio-economic variables and
disease prevalence, is of a complex nature. In here an attempt is
made to study the relationship between the disease prevalence and
literacy and immediate living environment with the use of
univariate and bivariate statistics.

The home villages have an established socio-economic environment

with developed educational and health facilities. Their immediate
living environment is better with more sanitation and water supply
facilities than System C. This is a result of the age difference of the
two selected settlement types, which made the new settlements of
System C vulnerable to more control from natural environment as
explained by the concept of environmental change.

The environment risk score was able to identify the marked

difference in the immediate living environment of the two study
areas and its relationship with disease prevalence is accepted. This
is because the univariate and bivariate data and confidence intervals
are able to identify a basic difference in the environment and
disease prevalence.

The district based national data on sanitation and water supply are
questioned by this analysis, because the percentages recorded in

147
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.

The study of differences in literacy levels and environment risk

revealed that there is a significant difference between the two areas
on the basis of age-adjusted rates. This confirms the observed
difference in the health status of the two study areas, which is also
possible to explain by controlling for age distributions.

Chapter 5

Disease prevalence and morbidity a low income community in

Sri Lanka

System C and home villages

Introduction

This chapter presents the analysis of survey data on disease

prevalence with the help of univariate and bivariate statistics. The
primary analysis is cantered on age specific distributions and tables
generated by SPSS. Then the matching of sick and nonsick
categories at Mahaweli System C and home village samples are
subjected to a test of significance by way of confidence intervals
calculated on age specific rates and age adjusted rates. Some of the
findings of the quantitative analysis is supported by observations
and information collected through life history survey. Therefore the
presentation is in a mixed format of quantitative and qualitative
analytical techniques.

148
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

The age distribution of the sample shows (Table 4.1) conformity

with the national surveys conducted by the Department of Census
and Statistics (1993) and Central Bank (1996) economic surveys,
with the highest percentage population in the age group of 15 to 39
years. The system C sample records a comparatively high
percentage of 0 to 14 years age group and a lower percentage of 60
years and over age group, than the home villages. This is explained
as a result of the lower mean age of migrants compared to their
siblings and the presence of the parents and grant parents of the
migrants in the home village sample. The high percentage of 0 to 14
year group in the system C area results from the lower age of the
migrant population, which is still in the process of family formation
or inclusion of the their grandchildren living in the same household.
These complexities in the population characteristics result in a
percentage difference of the age profiles of the two areas within 0 to
14 and 60 and above age groups.
Table 5.1 Age structure of the sample

Home villages System C Total sample

Age group
No. Percent No. Percent No. P
0 to 14 years 150 24 166 32 316 2
15 to 39 years 274 43 237 46 511 4
40 to 59 years 126 20 98 19 224 2

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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

Age Not Sick N Percent Prevalence/1000

group sick sick
0 – 14 278 38 316 12.02 120
15 – 39 443 68 511 13.31 133
40 – 59 131 93 224 41.52 415
60 and 27 65 92 70.63 706
above
Total 879 264 1143 23.10 231
Source: Seneviratne, 2003

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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

Table 5.3 Gender structure of the total sample

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

The gender distribution as presented in Table 6.3 follows the

general trend of the national data. The higher percentage of females
in the home villages result from the survival of old females, while
the higher percentage of males in the System C is due to permanent
presence of male siblings or friends, who have come as domestic or
farm help. It was observed in 11 households that either the brothers
or friends have accompanied the householder from the beginning or
joined him at a later stage to help in the farm or in the house work
such as building work, collection of fire wood and taking children
to school.

Data analysis on disease prevalence

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

151
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.

Table 5.4, Level of measurement

Variable Individual Household

Disease X
Prevalence at each visit X
Expenditure on health X
Age X
Gender X
Education X
Use of health care/type of X
treatment
Employment X
House quality X
Water supply X
Toilet X
Drainage X
Mosquito density X
Environment risk level X
Health care accessibility X

Source: Seneviratne, 2003

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

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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.

Table 5.5 Infectious disease – number of cases – for all individuals

having experienced a case of sickness any time during the four
visits

Infection disease Home village- N = System C – N = 511

632
1st 2nd 3rd 1st 2nd 3rd
dise disea diseas disea diseas diseas
ase se** e*** se* e** e***
*
No. No. No. No. No. No.
Malaria 3 0 0 26 3 0
Respiratory 19 2 0 27 8 0
Urinary tract 3 0 0 7 2 1
Skin 2 0 0 3 1 1
Bacterial 1 0 0 2 2 0
Viral 0 0 0 2 0 0
Eye 1 0 0 0 0 0
Other intestinal 0 0 0 1 0 0
Total 29 2 0 68 16 2

153
154
Non- infectious Home village – N = 632 System C – N = 511
disease 1st 2nd 3rd 1st 2nd disease** 3rd d
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
*Principal disease present as noted by the respondent
** Second disease present as noted by the respondent
*** Third disease present as noted by the respondent
Table 4.6 Non-infectious disease – number of cases – for all
individuals having experienced a case of sickness any time
during the four visits
Table 5.6 Non-infectious disease – number of cases – for all
individuals having experienced a case of sickness any time during
the four visits

Source: Seneviratne, 2003

Table 5.7, The prevalence of infectious diseases per 1000

individuals - for all individuals having experienced a case of
sickness any time during the four visits

Infectious Home village – N = 632 System C – N = 511

disease 1st 2nd 3rd 1st 2nd 3rd
disease* disease** disease*** disease* disease** disease
Malaria 103 0 0 382 44 0

155
Respiratory 655 3.16 0 397 118 0
Urinary tract 103 0 0 103 29 15
Skin 69 0 0 44 15 15
Bacterial 34 0 0 29 29 0
Viral 0 0 0 29 0 0
Eye 34 0 0 0 0 0
Other intestinal 0 0 0 15 0 0
Source: Seneviratne, 2003
Table 5.8 prevalence of non-infectious disease – per 1000
individuals for all individuals having experienced a case of sickness
any time during the four visits

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

156
noted in the urinary tract infections, but it is not recorded as a
second disease at home villages.

Figure 4.1 The percentage prevalence of selected groups of diseases

Sources: Field data for System C and home villages, and National
data from Ministry of Health (1996)

The System C area recorded it as a second and third disease of

recognizable importance. A similar scenario is present in the
prevalence of skin infections, but System C records it as an
important second and third disease. The presence of bacterial, viral
and intestinal infections have also recorded higher prevalence levels
in System C, in comparison with the home villages.

The prevalence of infectious diseases as recorded during the survey

can be supported by the macro data available on the major cause of
hospitalization in Sri Lanka (Ministry of Health, 1996). Figure 6.1
shows the percentage share in prevalence of infectious diseases in
the two study areas and their relationship to the national averages
on the prevalence of infectious diseases. It is not possible to make a
direct comparison between the study data and macro data due to
simplification of the categories in the macro data as given in the
Annual Health Bulletin, 1996, but some visible differences can be
observed, Figure 6.1 confirms that the two major infectious diseases
in the two study areas correspond well with the hospital morbidity
data taken from the Ministry of Health (1996). The group of
diseases under “other” in the national data includes many types of
infectious diseases including urinary tract, intestinal tract and skin
infectious, which are identified separately in the study sample.

The national discussions conducted with the medical personnel,

revealed that, heavy congestion in the public transport system,
incursion of epidemic type viruses from other parts of Asia and the
habit of consumption of extremely alcoholic (60 to 70 percent)
beverage have definitely contributed to the high prevalence of
respiratory diseases in the farming population. The life history
information also confirms the above view as a healthy 95 – year-old
farmer said

157
“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.

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.

“Oh! I nearly died and I hope it will never come to me”

was a common way of referring to the disease during the

questionnaire survey and informal interviews. The information on
the severity of diseases was received mainly during the
questionnaire survey, as there was some reluctance to reveal the
severity of disease in a group situation.

Three malaria cases recorded in the home village sample are

recorded from three different home villages from three different
parts of the country. Two of the cases are not related to their
connection with the resettled families as there was no contact
between them, but the third case was a result of a visit to the new
settlement. It should be mentioned here that malaria is reported
from all the districts of Sri Lanka, though the wet zone records only
less than 100 per 100000 individuals (Ministry of Health, 1996).
Though the malaria mosquito is not present in the elevations above
1000 meters, all the major hospitals record malaria cases, which
indicate the important role of mobility in the spread of malaria in
Sri Lanka. The impact of mobility cannot be fully explained, due to

158
lack of detailed records on the locality of the patient and the visiting
of home village medical facilities for treatment by the zone settlers.

Non – infectious diseases

The prevalence of non-infectious diseases in the home village

sample is in conformity with the national data, in that the
respiratory, circulatory and musculo skeletal categories register the
highest values. The System C area records the respiratory,
circulatory and digestive system diseases as the three primary non-
infectious diseases indicating a slight deviation from the national
trend.

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 musculo skeletal group of diseases has a clear association with

the aging process as 70 percent of the cases were in the age groups
of 60 and above. The major type of disease within this group was
arthritis or arthalgia, which is common in the farming population of
Sri Lanka, which may be a result of poor nutrition and working in
the water logged rice fields as described in Chapter 4. Therefore, the
low prevalence of these diseases in System C can be related to the
comparatively younger age of the migrants.

The circulatory system diseases are generally on the increase in Sri

Lanka as given in the Chapter 2, which is confirmed by the
empirical evidence of the survey. These diseases are also age related
and 44 percent of the total was present in the age group above 60 in
the home village sample. However, the disease was present in the
age group of 40 to 59 years in both areas at an equal proportion,
which may be explained as resulting from the similarity of the life
style or an indication of the age of onset of the disease. The two
most common diseases recorded were hypertension and high blood
pressure, which accounted for 84 and 9+1 percent of all the cases of
circulatory diseases at the home villages and System C respectively.

159
Many types of cancers were recorded in both areas as an important
chronic ailment. Breast cancer in women and cancer in the liver of
men are recorded as the most common. The cancer in the liver of
men was associated with heavy use of alcohol by the general
diagnosis (in the hospital cards). The highest prevalence of cancer is
in the age group of 40 to 59 and 60 and above in the home villages
and 40 to 59 years at System C.

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
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.

The high prevalence of the digestive system diseases recorded in the

System C data relate mainly to liver damage occurring as a result of
excessive use of alcohol, which was identified as a rising cause of
disease among farmers in the System C area by the medical
personnel. The digestive system diseases were present in the age
groups of 15 to 39 in the home villages and 15 to 59 in the System
C. The Table 6.9 records the alcohol consumption of the household
in the two study areas, which indicate a definite increase of heavy
consumption at System C. In System C, one household head died by
mistakenly drinking a weed killer, when he was intoxicated with
alcohol and another died during the last visit of the survey as a
result of a lung infection resulting from heavy alcohol consumption.
The researcher witnessed a seriously ill household head in the home
village sample suffering from acute liver cancer, which was
diagnosed as resulting from heavy alcohol consumption. In addition
the researcher observed the high availability of the illegal and
dangerous local brew known as ‘kassippu’ in all the study areas and

160
he met many villagers with the bad smell associated with it during
the survey.

Table 5.9 Alcohol consumption among household heads

Level of Home villages System C

consumption No. Percent No. Percent
No 2 2 16 18
Slight (accepted by 84 94 63 71
wife)
Heavy (wife 4 4 11 11
complained)
Total 90 100 90* 100
Source: Field data

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

161
vision in them. The medical practitioners generally accept this,
though firm scientific evidence is not available.

Figure 4.2 illustrates the percentage prevalence of non-infectious

diseases in the two study areas, which is agreeable to the general
trend in the national data. However, a

Figure 4.2 The percentage prevalence of selected group of non-

infectious diseases
Source: Field data

Comparison between the national and study area is not possible due
to the simple recording system used in the hospital records.

Presence or absence of disease

The data on disease prevalence was utilized to calculate the

presence or absence of sickness during the survey period of one
year (Table 4.10).

Table 5.10, Number of sick and not sick in the sample

Health status Area Total

Home village System C village No. percent
No. Percent No. Percent
Not sick 494 78 385 75 879 77
Sick 138 22 126 25 264 23
Total 632 100 511 100 1143 100
Source: Field data

A total of 264 people or 23 percent in a sample of 1143 individuals

were identified during the one year long survey as sick on the basis
of clarifications made at the beginning survey. This is divided
between the home villages and System C as 22 percent and 25
percent respectively, indicating a slightly higher percentage of sick
in System C.

Table 5.11, The level and seriousness of sickness

Level of sickness Area Total number

162
 Home village System C village No. P
No. Percent No. Percent
Minor sickness-one treatment
1 1 11 9 12 5
only
Sick-discontinuous treatment 128 93 111 88 239 9
Seriously sick-continuous
8 5 3 2 11 4
treatment
Very seriously sick-in bed or no
1 1 1 1 2 1
admission
Total 138 100 126 100 264 1
Source: Field data

The level of sickness varied according to the nature and severity of

disease, and is categorized into four types on the nature of the
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.

The higher percentage of sickness in the System C is as expected in

the study programme, but the low percentage difference between
the two study areas has to be explained. Firstly, the bias introduced
by the higher number of old respondents in the home villages, who
suffer from many types of old age chronic illnesses increase the
number of sick people, within the home village sample. Secondly,
the impact of malaria is reduced by the use of western health advice
and preventive measures like mosquito nets and repellents. All the
respondents indicated that they use a repellent commonly known as
‘mosquito coils’ and the researcher witnessed the practice of use of
nets for all the infants in the sample. The use of mosquito nets was
common and 64 percent of the households reported of using them
during them season of intense mosquito activity.

Healthy

163
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
users of these types of treatment, though they do not accept that
they are sick.

Presentation of rates and ratios

Absolute counts of events are difficult to analyse and compare

between various geographic areas because of population
differences. Rates and ratios are constructed in demography and
epidemiology to present mortality and ,morbidity statistics. Rates
give the frequency of the numerator relative to denominator within
a specific period of time. In this study the numerator is the diseases
or mortality cases and denominator is the population at risk.

The study sample indicates considerable age differences between

home villages and System C. Therefore presentation and analysis of
crude rates of disease prevalence are of little value, since the overall
rates will be influenced by age (Table 6.2). This guides us to operate
in two stages in constructing rates, which will enable the researcher
to arrive at more precise comparisons.

First stage presented here is the construction of age specific rates,

which are capable of conducting comparisons among places and
times periods (Meade et al, 1988). Age specific rates are simple to
compute and may show interesting features with regard to disease in
different age groups in the two study areas. On the other hand the

164
number of cases will be smaller than the total sample, and
statistically significant difference between the populations in home
villages and System C may be therefore be more difficult to obtain.

Second stage is the calculation of age-adjusted rates for the total

population of home villages and System C. An age-adjusted rate
makes a crude rate of the sample population comparable to the
standard population. The crude rates can be adjusted for differences
in the proportion of the population at various ages, sex, ethnicity,
income and other classifications (Meade et al, 1988).

The statistical testing of significance differences will be done by

computing confidence intervals for the rates, using the procedure
given in Pennsylvania Department of Health, Health Statistics-
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.

Age specific analysis

The calculation of age specific rates, confidence intervals and 95

percent significance level was carried out in five categories of
sick/not sick of the sample population. They are all male female
non-infectious diseases. All male and female categories in
Table4.12 shows the total sample for all diseases. None of the age
groups record a significant difference though System C age specific

165
rates are higher than that of home villages. The age group 0 to 14
indicates a ratio of 1 to 2.52 between home villages and System C
and all the 15 to 39 age group has a ratio of 1 to 1.86. The other two
age groups 40 to 59 and 60 and above have ratios of 1.37 and 1.15
respectively. The difference in ratio of age specific rates between
the two areas decreases steadily with increasing age. The all male
category in Appendix 6.1 records a significant difference in the 0 to
14 age group and no significance difference is found in the other
three ages

Table 5.12 States of significance of age specific rates between home

villages and System C in the selected age groups

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).

166
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).

Age adjusted rates

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 5.13 Standard population and percentage weights used in the

calculation of Age –adjusted rates

Age group Standard population Weights

0 – 14 316 .28
15 – 39 511 .45
40 – 59 224 .19
60 and above 92 .08
Total sample 1143 1.00

The age-adjusted rates revealed a clearer picture of the differences

than the age specific analysis between the two study areas (Tables
4.14 to 4.20). The results indicate and confirm the observed
difference in disease prevalence foe all the categories except for
male and female non-infectious diseases. Further the ratio between
age adjusted rates indicates a marked difference in all the categories
other than non infectious diseases, which has more sick values at
System C.

167
Table 5.14 Age adjusted rate for all males and females all diseases
sick/not sick crude and adjusted rates per 100

Area Sick n Crude rate Adjusted

rate
Home
village 138 632 21.8 13.4*
System C 126 511 24.7 22.8*
* Significant at 95% level

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

Area Sick n Crude rate Adjusted

rate
Home
village 68 286 23.78 19.32*
System C 68 280 24.46 26.87*

Table 5.16 Female all disease sick/not sick crude and adjusted rates
per 100

Area Sick n Crude rate Adjusted

rate
Home 70 346 20.23 17.42*

168
village
System C 58 231 25.10 31.18*

The factors responsible for the significant differences are further

clarified by the data in Tables 4.17 and 4.18, which show the results
for infectious diseases category. Both males and females at System
C suffer seriously from infectious diseases and give the two highest
ratios recorded in the age adjusted analysis, both in crude rates
(4.43 and 2.01) and adjusted rates (4.60 and 2.78). Therefore, it is
possible to confirm that the prevalence of infectious diseases can be
utilized to identify the marked difference between the two study
areas. Further, this significant difference supports the existing
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

Area Sick n Crude rate Adjusted

rate
Home
village 9 286 3.14 2.85*
System C 39 280 13.93 13.12*

Table 5.18 Female infectious diseases sick/not sick crude and

adjusted rates per 100

Area Sick n Crude rate Adjusted

rate
Home
village 19 346 5.49 5.43*
System C 31 280 11.07 15.10*

The case of non-infectious diseases (Table 4.19 and 4.20) confirms

the demographic and epidemiological profile of the two populations

169
and indicates firmly the presence of non-infectious diseases across
age group boundaries, which was indicated in the age specific data.
The highest number of cases for non-infectious diseases was
recorded in the age group of 15 to 39, with respiratory disease
leading. This may be a result of poor housing and low nutrition as
indicated by medical research.

Table 5.19 Male non-infectious diseases sick/not sick crude and

adjusted rates per 100

Area Sick n Crude rate Adjusted

rate
Home
village 54 286 18.89 15.07
System C 29 280 10.36 13.75

Table 5.20 Female non-infectious diseases sick/not sick crude and

adjusted rates per 100

Area Sick n Crude rate Adjusted

rate
Home
village 48 346 13.87 14.22
System C 27 280 9.64 16.16

Therefore, the highest sick ratio at System C are found in the

categories of infectious diseases male and female, which confirm
the macro data situation and environment risk in the dry zone. The
significance identified at age specific level in the category of
infectious diseases, all males and females further validate the
significant difference in the most vulnerable group as suggested by
medical research in Sri Lanka. The results of non-infectious
diseases indicate the effect of older population at home villages and
agree with wet zone macro morbidity data as explained in chapter 4.

The inability to find a clearer picture at age specific level can be

explained as originating from low value of entries and the clearer
picture of the age adjusted rates originate from the larger numbers
in the calculation of rates.

170
Conclusion

In this chapter an attempt was made to study the disease prevalence

and its relationship to age and gender, using univariate and bivariate
statistics. The results indicate that there is a difference in the disease
prevalence between the two areas. However, the difference is not
indicative of a clear-cut boundary as expected, but a more complex
one as shown in the significant differences recorded in the level of
sickness and the distribution of infectious diseases among the
males.

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.

The differences given in age-adjusted rates confirm a clear

difference between the two areas, which can be linked to the
presence of a more disease ridden living environment at System C.
Therefore, except for the category non-infectious diseases females,
the remaining six categories confirm that there is a significant
difference in the disease prevalence between the settlers at System
C and their home village sibling families.

171
Chapter 6

New trends

New health hazards

Since the publication of the first edition in 2007, the global health
status has undergone a few changes in the developed world, but
there is a trend of increasing health risks in the developing world
and in Sri Lanka. Intrusion of new diseases, an increase of viral and
respiratory diseases and traumatic injuries are recorded in many
nations.

Continuing Change in Health Hazards in Sri Lanka

Increase of viral and respiratory diseases are related to
environmental change and change of environments.
Most of the new diseases are related to new or mutated viruses and
bacteria, stress originating from misuse or inability to adapt to new
technologies and disease causing pathogens originating from
unhealthy environment and climate change.
Traumatic injuries have increased sharply due to war, conflict,
migration, natural disasters and increased mobility of populations.
Emerging trend of good health in the rich and poor health in the
poor remains stronger than ever

Increase of viral and respiratory diseases – general

Viral diseases
Dengue

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Viral hepatitis
Ebola virus
Avian influenza A (H7N9) virus
Middle East respiratory syndrome coronavirus (MERS-CoV)

Pandemic (H1N1) 2009

Many types of viral fevers –influenza type and non influenza type

Worldwide increase of viral

Respiratory diseases

Middle East respiratory syndrome coronavirus (MERS-CoV)

Respiratory diseases originating from air pollution

Bacterial infections

Bacterial infections remain a major threat in all the developing

countries

173
Some new health hazards developing into serious hazards in the last
10 years in Sri Lanka
Disease Cause
Rabies Lack of enforcement of
law on domesticated
animals / low
environment illiteracy of
policy maker and society.
All the religions advice
that pets have to be
properly treated.
However, lack of proper
understanding of religion
by a small minority of
people and the low
literacy on pet care of the
policy makers,
administrators, religious
bodies and media in Sri
Lanka has resulted in
large number of stray
dogs and cats.
Dengue Poor waste and waste
water disposal system
mainly in urban areas
Solution
Employ the existing
laws on pets, with
registration and
ability of the owner
to keep pets. Some
owners in the low
income group cannot
get a decent meal a
day, but try to rare
pets and when they
acquire disease or
have litter they
dispose the pet and
litter to the road.
No proper policy
planning and low
environmental
174
 literacy of a minority
who have no
concern for others.

Traffic Low driving literacy, No proper policy planning

accidents low mannerisms, poor and low environmental
road designs and literacy of a minority who
corruption have no concern for
others. Most of the roads
have no proper pedestrian
areas which makes people
to walk on road. Poor road
designs (unnecessary
curving and improper
cambering) and drainage
on roadside leads to
breakages, which affect
traffic flow.
Renal Poor quality drinking Poor policy on water
failure water and poor early supply and health
detection facility management

Ministry of health sources indicates that above hazards result in

rising health expenditure in the last 10 years.

Continuing rise in respiratory diseases are related mainly to

atmospheric pollution emanating from, increased threat from solid

175
and fluid waste, high density of chemical substances (vehicular and
industrial) and poor quality housing.

Problems due to waste disposal and poor quality housing are due to
low environment literacy of the people and policy makers. There is
no set policy or mannerism in waste disposal as the urban housing
density has increased without any support on waste disposal. Waste
recycling has faced serious problems due to lack of local strategic
planning and the habit of “free waste throwing culture”.

Most of the housing has adopted open system high frontage designs
allowing the droplet spray to enter living area of the house. If
proper ceilings are not installed these types of housing produces
heavy inflow of droplets in the humid climate, which leads to many
respiratory problems mainly in children. All major urban centers
have highly polluted air due mainly to lack of proper planning on
parking and traffic flow. The urban roads are widened and parking
is allowed on the widened area, which makes the road congested as
before. Parking areas are not provided and traffic flow is highly
interrupted by congestion which in turn leads to heavy burning of
diesel and petrol resulting in high air pollution. The pavements are
blocked by traders and pedestrians are not provided with
underground or over ground crossings, which makes the urban area
a trap of polluted air for at least 15 hours a day.

High density of chemical substances in the air results from low

environment literacy of the policy makers.

Increased incidence of cancer may be related to high density of

chemical substances in air, water and food resulting from poor
quality control of related material by policy makers. Respondents,
freely express their dissatisfaction on types of fertilizers,
insecticides, tobacco, alcohol, paints and preservatives available in
the market. General public has little or knowledge of use of modern
chemicals and use them at will to satisfy their needs. In addition,
increase in aged population due to availability of easy treatment
methods for geriatric complaints and diseases can also cause high
incidence of cancer among the aged. Further, inability of the policy
makers to fund monitoring programmes for aged prevents early

176
detection of most of the cancers. Rich and political elite utilise
foreign treatment and surveillance facilities for acute chronic
diseases, but the low and middle income group suffer heavily. It is
a common scene to find low or middle income person collecting
donations, media advertisement calling for donations and
mortgaging or selling his property for treatment of serious cases.

The increase in heart related diseases and diabetes is a result mainly

of ageing population, food, tobacco and beverages related chemical
reactions and stress originating from changing life styles. There was
a drastic change in the global and Sri Lankan life style in the last 20
years, which took population away from mostly active to relaxing.
Walking and home related hard manual labour is a thing of the past
and people accumulate sugar and fat in large amounts in their body.
Sri Lanka has become highly mobile with the availability of tree
wheelers and motor bikes, which has prevented even short distance
walking. Therefore, obesity has become a problem in all income
groups.

Strict regulatory measures are not applied due to fear of loss of

votes by the policy making authorities and people have no proper
understanding on following proper regulations as their environment
and health knowledge is poor though Sri Lanka boasts of a general
literacy rate about 90 percent. The general education system has no
effect on the populace on the value of safeguarding a healthy
environment and mannerisms associated with it.

Change in Treatment system in Sri Lanka

The treatment system has experienced a change in the last 10 years

mainly due to increased per capita income of the middle and lower
middle class of the population and increased services provided by
the national public health service.

About 53 million visited the public health service out patient service
in 2016, which is lower than the average of the period between
2000 and 2015 (61 million). This is mainly result of increased
attendance at private medical services, which has increased from

177
about 1.2 million in 2012 to 6.3 million in 2017 (estimates made
from a random survey conducted in 17 districts).

The public hospitals serve about 95 percent of the emergencies and

serious case admissions. The doctors, nurses and other supporting
staff provide a commendable service. However, out-patients,
hospital admissions and off and on hospital treatments
(radiotherapy, and clinical checks) are affected by long delays.

The increase in the employment in the private sector and medical

insurance systems offered by banking system in the last 10 years
have constructed, private health insurance schemes, which enable
patients to visit private medical service. Private medical facilities
have increased by about 70 percent between 2005 and 2015.
Availability of a private general practitioner has increased by about
82 percent in the same period.

The good services of the public health sector, fairly high literacy on
the selection of the proper treatment system by the populace (65
percent) and support of private medical services has led to a nation
of good health. However, the risk of infectious diseases remains
high and chronic diseases are on the increase in Sri Lanka. Risk of
infectious diseases is mainly a result of low health literacy of the
populace and policy makers. Increase in chronic diseases is mainly
a result of life style change and low health literacy of the policy
makers.

Problem Environment

Changing Life style

Globally, two major types of life style factors result in increase in

both infectious and chronic diseases.

Increased mobility is one of the major factors in creating a new

global disease environment. Motorised transport has increased the
percentage of people on the move and spread of disease. Developed
nations have managed to limit the impact of new infectious diseases
with their advancement in medical sciences and creating safer living

178
environments. However, the developing world is unable to manage
their health properly due t inefficient and poor governance
practices.

Chronic diseases have become a serious problem in both developed

and developing due to increase in stress originating from climate
change, high demands for efficiency and evolution of complex life
styles.

Intra- regional, national and international travel in Sri Lanka has

increased by about 30 percent in the last 10 years.

This increase is mainly associated with combined trips made on

tourism – pilgrimage habit in Sri Lanka. Availability of cheap fares
in group travel has led to about 2000 to3000 trips made by a total of
about 3 million people on the move across climatic and cultural
boundaries in Sri Lanka. Distant destinations like Katharagama,
Anuradhapura, Polonnaruwa, Nuwaraeliya and Jaffna are connected
by express bus services and group type smaller units on van
services. Accommodation and food supply facilities of towns of
these destinations have grown by about 50 percent in the last 10
years, with Katharagama and Anuradhapura recording about 30
percent growth in accommodation and food supply facilities. Small
towns along the routes to Anuradhapura and Katharagama have
seen a growths between 20 to 40 percent in the last 10 years. The
tourists on these routes have limited health protection due to poor
quality water, food and toilet facilities available to them and
produce a high quantity of waste along the route and at destination.
About 80 percent of the people in this category are from low and
lower middle income group with limited capacity to obtain proper
healthy services and are at risk of infectious diseases. Though
deadly infectious diseases are rare, about 15 to 20 percent of this
group are subjected to viral or bacterial infections, which require
outpatient type treatment resulting in increased morbidity recorded
in health statistics.

There is notable increase in mobility of population resulting from

long distance travel to work and education, which results in an
increase of traumatic injuries, fatalities from accidents and viral and

179
bacterial diseases contracted from unhealthy town and city
environments. Town and city environments of Sri Lanka record
unhealthy air pollution levels resulting from poor waste disposal
and vehicle emissions. All major cities (over 2 million) record
continuous occurrence of smog with an increased prevalence of
respiratory diseases (asthma and bronchitis) diarrhoea and various
types of fevers.

Dengue fever is mainly associated with urban areas and notably the
urban conglomeration of Colombo and the surrounding districts due
to inability of urban planners to provide a solution to problem of
drainage and low environmental literacy of the population, which
boasts of a general literacy rate over 90 percent. It should be
mentioned here that either there is a serious error in the variables
used in Sri Lanka to calculate literacy rate or people provide
incorrect answer to the question on literacy or though they have the
literacy on the basis of their education, the education system has
failed to instil proper environmental knowledge in them. Detailed
investigations indicate that people give incorrect information on
their educational level in the surveys conducted and education
system which allows students to “just proceed” to GCE OL, without
any serious measure of knowledge level has created a majority of
citizenry (about 60 percent of the total population) without a proper
understanding of environmental cleanliness.

Further, the policy makers and politicians have forgotten the use of
environmental laws, to achieve political success. With reference to
cities and towns, planning for parking space (vehicles of visitors
and commercial sector), waste disposal (liquid and solid) and
issuance of building permits frequently have no logical explanation.
These activities are conducted at free will of the people, making
traffic congestion and rotting waste a serious health hazards. It is
the responsibility of the policy makers to keep the city and town
environment clean to avoid an increase in morbidity and fatalities
from traffic accidents.

Traumatic injuries are at all time high in both developed and

developing world due to increased density of motorised transport,
terrorism and industrial accidents.

180
Sri Lanka has recorded a massive increase in traumatic injuries,
Heart related situations, diabetes and cancer in the last ten years.

Increasing of traumatic injuries is related to traffic accidents and

gang violence. The low literacy level and traffic accidents have a
significant relationship, as most of the fatal accidents caused by
drivers under the influence of alcohol or hard drugs. Second most
important reason for increased traffic accidents is over wrk and
falling asleep while driving. There is no significant increase in
homicides, industrial and domestic accidents.

Heart related illnesses, diabetes, cancer and many other chronic

diseases are related to multitude of factors. Stress, lack of exercises
and use of chemicals in farming and industrial production have
contributed to increase in these diseases.

Reduced walking and manual work may be the major reason for
obesity.

High level of diesel vehicle emissions can contribute to high

prevalence of respiratory diseases and cancer.

The effect of mobile phones on ear is noticed by researchers.

Diseases related to Addiction to alcohol and drugs and sexually

transmitted diseases continue to increase slowly.

The complex social structures built by globalisation have influenced

the global health and morbidity. However, the developed world with
their health insurance schemes and advances made in medical
sciences has managed to limit the effects of new diseases.

Non- availability of Holistic National planning in Sri Lanka leads to

its underdevelopment. Sri Lanka is blessed with all the basic
resources, but the financial mismanagement in the political system
has led the populace to disregard any meaningful stable
development process. Majority of the populace have no proper
understanding on the basic premise of development and believe

181
higher income will lead to development. The political authority is
always in disorder and inefficient. Therefore populace has a way of
by-passing the proper operational system and engage in disorderly
practices to achieve their goal. Therefore, it is the vicious cycle of
disorder and failure, which leads to a nation still troubled with poor
health.

Conclusion

Poor governance, corruption and lack of rule of law prevent the

establishment of a comprehensive health care and insurance system
in Sri Lanka. The public health care system is based on age old
methods of organisation with hospital or clinic based system, which
prevents the service to be society oriented. Therefore all types of
patients flock in a chaotic form to hospitals and waste many
valuable hours staying in queue.

Corrupt financial establishment leads to heavy wastage of funding

on the maintenance of political and administrative elite, thus
preventing supply of necessary preventive health care, by physical
environmental management and provision of general practitioner
system (GP system). Information collected from media reports
(2013 January to 2018 December) indicates that the political and
administrative elite have utilised about 60,000 million rupees on
treatment abroad. This figure does not include travelling and
subsistence paid to their accompanying family members and
security personnel. It was a common scene in the last 20 years even
the Minister of Health to travel abroad to receive treatment for non-
life threatening illness. 34 respondents out of a total of 500, during
the data collection visits pointed out that the financial resources
wasted yearly by political elite for medical expenses abroad may
provide sufficient financial resources to provide full drug support
for low income people in Sri Lanka.

Some respondents questioned, the constitutional right of a member

of parliament (member, minister, prime minister or even president)
to utilise government funding for treatment abroad. The
constitutional rights of Sri Lanka have no special facility for anyone

182
to utilise government funding for treatment abroad. Anyone
utilising government funding for treatment abroad has to pay back
the amount in instalments (except the amount of aid given) after
returning to Sri Lanka. However, neither government publications
or audit reports or media reports have records of such payments.

Then, with reference to health care and support there is a massive

violation of constitutional rights by the political and administrative
elite, which is punishable by judicial process.

Folk knowledge and Treatment scenario

Global interest on the traditional medicine originates from the

advancements made in the extraction of medicinal products from
herbal sources. Genetics have paved way to extract and test
biological material with precision in the last decade. These
advances have led to extract highly valuable medical products,
which are safer and sometimes more virulent than the chemical
products.

Originating from the knowledge accumulated from the traditions of

Yakkha and Naga and additions from Auyrveda, there is a massive
folk knowledge base with reference to diagnosis and treatment
system in Sri Lanka. Some of this knowledge have been tested by
modern scientific method and proven safe.

Both bio-medicine and traditional medicine face a challenge in

treatment of diseases of unknown aetiology. Further, the privacy
and related ethical values restrict the administration of treatment.

In Sri Lanka myths and beliefs also prevent people from seeking
proper medical care. Myths in relation to chronic diseases lead to
delay in treatment which sometimes results in loss of life.

In a sample of 210 members in an extended family, there are two

serious cases of disease within a span of 10 years, which were a
result of avoiding regular medication for disease. These two
individuals (aged 54 and 56) were changing and stopping
medication and breaking the treatment cycle at their will. Today,

183
these two are yet to recover from cancer and undergo heavy
medication. There were about six other members (aged 30, 54, 60,
68, 64, and 63) who have recovered well by adhering to medical
advice.

Two members who neglected the treatment have high literacy and a
good financial capacity, but they were identified by the family as
arrogant and careless.

This is common situation in Sri Lanka, where some people mix

treatments as they wish, without listening to expert medical advice.
The study of the sample given above for 20 years, it was clear that
there is always a possibility of mixing of treatment system and
achieving good results when the mix is performed by proper expert
advice.

Important points for future

Population has increased rapidly in the period between 1950 and

1980 due to vaccines, satisfactory level of environmental
management and availability of cheap public health care.
Eradication of epidemics and good service cover enabled the entry
of people with many congenial or body system weaknesses, which
otherwise would have died early.

The period between 1980 to present the nation lost its ability to
manage a healthy living environment and provide a good preventive
health care due to inefficient and corrupt governance. Within this
scenario the policy makers were unable to establish a sustainable
development plan in health.

The emergence of new infectious diseases and rapid increase in

chronic diseases is basically a result of non-availability of
natural and societal environmental management.

Most nations have lost control of their population numbers

184
They have poor governance systems

Health environment has entered a chaotic existence.

185
Appendix 1

Traditional medicine in Sri Lanka– Case study (written in 2002)

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

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
1 Introduction
THE TRADITIONAL belief system of health in Sri Lanka consists
of many types of treatment systems, but in this study only two
major components, namely traditional medicine and Ayurvedic
medicine, will be used. They will be called the indigenous health
service system in this study.
Records on the history of traditional medicine go back to the
beginning of civilisation in Sri Lanka. Evidence reveals there was a
well organised medicare system with hospitals, rest homes, herb
gardens and conserved forests of medicinal trees and shrubs located

186
in various parts of the island. These are well recorded in various
inscriptions and chronicles. (Paranavithana, 1959; Senadheera, 1970
and Kumarasingha, 1982).
Today the glory of this system has been subdued by the 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.

Two major sub-systems can be identified in the traditional

medicine:

Beliefs and rituals

A system based on many beliefs such as deities, telepathy,

sound, herbs etc. The deity (God) is at the centre of this
treatment system where an edura (faith healer) becoming the
messenger between the deity and the patient. The treatment
process involves either a full ritual with a sacrifice or a promise
to the deity of an offering or a ritual and an herbal treatment. A
full ritual programme is composed of offerings, sacrifices and
chanting, which is mainly used in the treatment of mental
disorders and spiritually-caused sicknesses resulting from shock
and depression. Ritual and herbal treatment are used in the
treatment of many other sicknesses and diseases, especially
communicable diseases like chicken pox, measles and mumps.
In the treatment of these traditional infectious diseases, the
patient is strictly forbidden to ingest any animal product, is kept
in a dark room without any exposure to direct sunlight, and
given many herbal mixtures. The faith healer (endure) is called
for to chant verses. Finally a promise will be made to make
offerings at the nearest shrine of the goddess Paththini and to
give alms to seven or more women devoted to the worship of
goddess Paththini.

187
 Herbal medicine

A system based on herbal medicine and traditional medical

practitioners who live in the villages and practise according to
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).

Ayurveda is of Vedic origin and believed to have originated in the

second millennium BC, probably in the land between present-day
Pakistan and Iran (Kumarasingha, 1981). The traditions and
teachings of Ayurveda entered Sri Lanka with the arrival of Aryans
and developed steadily through continuous contact between India
and Sri Lanka.
Since its establishment in Sri Lanka, Ayurveda and traditional
medicine were practised together probably with the same patronage,
but seeking the higher level of Ayurveda when needed. In the
civilisation of early Anuradhapura period the physician was
considered as an important professional. During this period a
notable feature of civilisation was the importance attached to the
establishment and maintenance of hospitals for the treatment of
sick. Among kings of ancient Sri Lanka King Buddhadasa (circa
337-365 B.C) was reputed to be a skilful physician and have
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 are definitely antibiotic
in nature (Silva, 1991).
Indigenous medicine was considered weaker by the Western
educated and urban populace with the introduction of Western

188
medicine in Sri Lanka, but British rulers knew of the value of herbs
and kept the traditional medicine under observation and control.
However the dedication of few highly qualified specialists,
managed to save the core of the traditional and Ayurvedic medicine
(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

189
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
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

Indigenous health services are located and developed in association

with the growth of a settlement by its operators and very rarely they
are established by the government under a programme of health
care delivery. This is basically a result of choice of people and
preference of authorities to keep Western medical services as the
major form of outpatient treatment, because inability of the
indigenous medical services to provide a universal health care and
universal acceptance of the Western health care as the modern
scientific system of health care (Table 1).

Table 1: Types of Practitioners in the Indigenous

health services (percent)
Type of Practitioner Mahaweli System C Home villages
Local Ayurvedic physician 56 21
Local Ayurvedic Dispensary 13 14
Renown specialist 00 06
Ayurvedic Hospital 00 01
Traditional Physician 13 45
'Edura' * 18 13

*'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

190
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
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.

2.1 Traditional Health Service System

The distribution of traditional health services available to Mahaweli
System C settlers is shown in Table 2. 'Edura' and traditional
medical practitioner in Mahaweli System C area are farmers by
occupation but practise their medical service as a part time
occupation. Ayurvedic physicians have come from outside the
resettlement area and have established their clinics in town centres
at Girandurukotte, Lihiniyagama and Siripura. Government
dispensaries of the Ministry of Indigenous Medicine are located at
Girandurukotte and Lihiniyagama, which are patronised by a few.
These services are skeletal and seasonal in nature as some of the
'eduras' and traditional practitioners travel to home villages during
the dry season periods and no specialities are available other than
for simple fractures. For all the other requirements in the traditional
health services, the respondents travel to Mahiyangana, Kandy or
their hometowns. Therefore service status is still in its infancy as
common to any newly settled area in Sri Lanka.
Traditional health services are at an advanced level of operation
in home villages with all types of facilities available to the user. On
the basis of number of contacts made by respondents there are nine
times more facilities at home villages than in Mahaweli System C
(Table 3). Ratnapura, Mirigama and Mawanella recorded the
highest percentage of units, which could be explained by the
existence of highly developed local traditions in these areas. Rest
has low density of practitioners and service units, mainly due to
distant location from well known traditions in indigenous medicine.

191
Table 2: Number of indigenous health service system
operators in Mahaweli System C
Mahaweli Government Edura Traditional Ayurveda
System C Dispensary practitioner Physician
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)

Source: Field Data

Table 3: Number of indigenous health service system

operators in home villages
Home Village Ayurvedic Government Renowned Ayurvedic Traditional Edura
Physician Ayurvedic specialist hospital practitioner
dispensary
Badulla 5 2 1 0 3 2
Teldeniya 3 0 0 0 5 3
Ratnapura 8 5 2 1 10 5
Mawanella 9 3 2 0 16 2
Yatiyantota 4 0 0 0 4 3
Mirigama 11 3 3 1 33 10
Nikaweratiya 2 0 0 0 6 3

192
Source: Field Data
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.

2.2 Ayurveda Health Service System

The Ayurveda system is a very important element in health care

delivery system of Sri Lanka, but its spatial distribution may vary
from one area to the other as it operates mainly through private
clinics and dispensaries. In addition the existence of some notable
Ayurvedic doctor family traditions have influenced the distribution
pattern of these services. Most clinics and dispensaries are located
in the house of the practitioner with a branch at the town centre.
Graduates of College of Indigenous Medicine and Ayurveda
specialists of Gampaha, Keraminiya and Sabaragamuwa traditions
are the major operators identified in the study areas. Most of the
practitioners used a mixture of both Ayurveda and Western as it is
practised in Sri Lanka today, but the use of Western drugs is limited
to use of antibiotics at emergencies and some general pain killers.

3.0 Systems of Treatment

193
Indigenous medicine is based on herbal mixtures and different types
of 'power' sources. Comprised mainly of the local physician and the
spiritual healer, the traditional treatment system is a mixture of
many ancient systems of treatment, which is taught to the
apprentice 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.

3.1 Preventive Care - Home Remedies

Home Remedies are mandatory in preventive care in both

traditional and Ayurvedic medicine. They appear in many forms and
are used concurrently with all types of medicine as an aid or
activator for the main course of treatment. Knowledge of the home
remedies is normally transferred by hearsay from one generation to
the other and is preserved in the minds of family elders who become
the major agents of preventive medicine in the indigenous medical
care system. In recent times the commercial scale production of
home remedies has led to a much wider use of them by all the
respondents in all of the study areas (Table 4). Today ingredients for
most of the home remedies are either bought from the shop or
obtained from the Ayurvedic practitioners as the technique of
growing of medicinal plants and herbs has been destroyed or
pollution has restricted the growth of them to few areas of the
country. Modernisation and commercialisation of traditional and
Ayurvedic medicine in the recent past have produced packed instant
drinks and mixtures which are used freely as home remedies by
almost everybody. Samahan, Peyawa, Kasaya Pack and Siddhalepa
are the trade names available in any part of the country at any time
and heavily used as remedies for all types of ailments and
sicknesses.
Regular use of home remedies is an integral part of life among
rural poor, especially for minor ailments, cold, running nose,
sprains, arthalgia and arthritis. Some home remedies are even taken
as food in the form of porridge, vegetable and food-drink. It is the

194
belief of the respondent that taken at the precise time and adhered to
advice most sicknesses can be controlled successfully if not totally
by the use of home remedies. Therefore most of the respondents
have used home remedies when needed than on a regular basis.

Table 4: Use of Home Remedies

Commercially available home Mahaweli System Home
remedy C villages
Samahan 100 100
Peyawa 85 100
Siddhalepa 65 82
Oils 36 49
Arishta 20 35
Pastes 13 22
Kasaya packets 84 94

Source: Field Data

3.2 Curative Care

MAHAWELI System 'C' respondents have used indigenous
medicine for 13 different types of diseases and sicknesses including
fractures and general weakness. 94 percent of the time this
treatment was carried out by the specialist at home villages and
locally available practitioners or specialists at Mahiyangana,
Polonnaruwa or Kandy attended to the rest. At home villages 40
percent of the respondents went for treatment at the indigenous
medical practitioner for six major sicknesses and diseases.
Fractures, general weakness, disability, paralysis, arthritis and skin
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

195
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.

Table 5: Percent attended Indigenous Health Services

for treatment (percent)
Ailment, sickness or disease Mahaweli System C Home Villages
Respiratory problems 14 23
Urine infection 00 20
Paralysis 00 23
Arthritis 29 50
Disability 23 43

196
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
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

197
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.

198
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

Appendix B

A. Accessibility Equation
A = d · h/t

199
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.

B. Priority Group Identification

High Priority Medium Low Priority
Priority
Malaria Respiratory Jaundice
Viral hepatitis Dysentery
Urinary tract
Diarrhoea
infections
Chickenpox, Measles,
Mumps

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%
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%

200
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%

Changing face of Traditional medicine in Sri Lanka

Traditional medicine in Sri Lanka has made some advances in the

last decade as it has benefited from global research data base.

Firstly, recognition of its value in the treatment of fractures,

arthalgia, artharities and obesity is noted by many researchers.
These developments have led to the establishment of specialised

201
hospitals of traditional medicine and availability of drugs within the
general pharmacy system.

Locally, the use of modified versions of traditional pain killers has

gained a high popularity.

Spas, specialising in oil and paste treatments are frequented by

locals and foreign tourists.

Treatment system has seen many positive developments, but some

types of treatment have lost its place as a reliable treatment,
specially due to loss of knowledge (Table 6).

Table 6, Types of Practitioners in the Indigenous health

services (percent)
Type of Practitioner Mahaweli System C Home villages
Local Ayurvedic physician 56 – (61) 21 – (29)
Local Ayurvedic Dispensary 13 – (19) 14 – (19)
Renown specialist 00 – (02) 06 – (08)
Ayurvedic Hospital 00 – (01) 01 – (03)
Traditional Physician 13 - (07) 45 – (21)
'Edura' * 18 – (05) 13 – (08)
Spa type services 00 – (05) 00 – (12)

The values within brackets represent the status at the end of 2017

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203
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Appendix 2

Change in Treatment system in Sri Lanka

About 53 million visited the public health service out patient service
in 2016, which is lower than the average of the period between
2000 and 2015 (61 million). This is mainly result of increased

204
attendance at private medical services, which has increased from
about 1.2 million in 2012 to 6.3 million in 2017 (estimates made
from a random survey conducted in 17 districts). 98.4 percent of the
specialist staff in the private hospitals and clinics is part timers from
the public sector.

The public hospitals serve about 95 percent of the emergencies and

serious case admissions. The doctors, nurses and other supporting
staff provide a commendable service. However, out-patients,
hospital admissions and off and on hospital treatments
(radiotherapy, and clinical checks) are affected by long delays.

The increase in the employment in the private sector and medical

insurance systems offered by banking system in the last 10 years
have constructed, private health insurance schemes, which enable
patients to visit private medical service.

Private medical facilities have increased by about 70 percent

between 2005 and 2017. Availability of a private general
practitioner (94 percent of the private general practitioner is part
time government employed doctor) has increased by about 82
percent in the same period.

Health tourism has begun in Sri Lanka in the 1990s, with the advent
of globalised knowledge of Ayurveda treatment system. By 2017
there were more than 120 highly modern health spa units operated

205
by the ayurveda sector in Sri Lanka, which is used by the foreign
tourists and rich and middle income group Sri Lankans (session
from 5,000 to 20,000 rupees).

In addition more than 2000 ayurvedic spas for lower middle and
low income users (Rs. 650 to 1,000 per attendance) were identified
in a tour of 1500 field kilometer trip conducted in 17 districts in
2017. The back-packer type tourists heavily use these low priced
spas.

The pharmacy has become a unit of treatment for many low and
lower- middle income people with non-life threatening illnesses and
people with low intensity chronic diseases. 100 pharmacies in 17
districts were visited during the survey with a prescription issued
for a drug and as the researchers were waiting in the queue, to
obtain the drug, 76 pharmacies have issued drugs without
prescription for various ailments and diseases.

The treatment system has experienced a change in the last 10 years

mainly due to increased per capita income of the middle and lower
middle class of the population and increased services provided by
the private health care service.

The public health care system is unable to provide a full and

satisfactory service to the populace due to rapid rise in population
and poor governance which results in wastage of national resources.

206
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