Sri Lanka: Faith, hope and irony
International aid and foreign investment are endowing Sri Lanka with a medical and emergency infrastructure that must run to keep up with a potential tourism boom. Robin Gauldie went to see it for himself
First published in ITIJ 124, May 2011
International aid and foreign investment are endowing Sri Lanka with a medical and emergency infrastructure that must run to keep up with a potential tourism boom. Robin Gauldie went to see it for himself
The Arab traders who first arrived in Sri Lanka more than 1,000 years ago called it Serendib – ‘the fortunate’. Its modern name means ‘Lanka the Blessed’. And at first sight, this does indeed look like the archetypal tropical paradise, with miles of golden sandy beaches, coconut palms and turquoise seas. But in view of the Indian Ocean island nation’s recent history those soubriquets seem somewhat ironic.
Sri Lanka was still reeling from the impact of the tsunami that struck its south and east coasts on 26 December 2004 – killing more than 30,000 people and making around 500,000 homeless – when in 2008 the Sri Lankan government began its final ‘Northern Offensive’ against the Liberation Tigers of Tamil Eelam (LTTE). Civilian casualties were heavy, and around 250,000 people were driven from their homes. Many remain in government camps.
The LTTE – also known as the ‘Tamil Tigers’ – fought a guerrilla war from the mid-1980s until their final defeat in 2009, in pursuit of an independent state in for Sri Lanka’s Tamil Hindu minority. As a result, much of northern and eastern Sri Lanka, the main theatres of conflict, were intermittently no-go zones for some 25 years, with the UK Foreign and Commonwealth Office and the US State Department issuing various levels of warnings against travel to these areas until very recently.
Medical care that meets acceptable international standards can be difficult to find, essential medical supplies may not be available, and many hospitals and doctors require payment in cash, regardless of whether the patient has travel health insurance.
No sooner had Sri Lankans begun, cautiously, to celebrate a final end to more than two decades of civil war, than a fresh humanitarian emergency threatened, with massive floods that killed around 40 people and forced at least 350,000 from their homes.
Despite its recent troubles, the country offers a host of features that attract a steady stream of international visitors each year. This brings with it both ongoing and new challenges; but Sri Lanka is responding with vigour.
Hospital challenge
Inland from the coast, the island boasts a portfolio of ancient temples and palaces, many of which are rated as UNESCO World Heritage Sites, as well as an array of national parks that shelter wildlife including wild elephants, leopard, deer and a stupendous number of endemic and migrant bird species.
Offshore, there are some fine scuba dive locations and some of the world’s best surfing, and whale watching is another emerging interest. Hot-air ballooning trips over the ancient ruins of Sigiriya are another new activity.
In short, despite recent setbacks, Sri Lanka looks set to finally reap a tourism ‘peace dividend’ and again live up to the promise of its name. In fact, visitor numbers were up by 46 per cent in January 2011 compared with January 2010.
But this imminent tourism boom may pose new challenges for travel insurers. Relatively risky holiday activities such as scuba diving, surfing, off-roading and hot air ballooning draw growing numbers of visitors, and demand for such activities far outstrips the current capability of emergency services and medical facilities to deal with potential accident victims. For example, although Sri Lanka attracts thousands of scuba divers each year and has a growing number of dive centres offering holiday courses for novice divers, it has just one hyperbaric chamber for emergency decompression cases. This is located at the Trincomalee Naval Base and is operated with a high degree of professionalism by Sri Lankan Navy medical officers. But Trincomalee, in the northeast, is some 320km (200 miles) from Sri Lanka’s most popular tourist dive resorts, which are clustered near the southwest tip of the island – a flight time of at least 90 minutes for the fastest available medevac helicopters in Sri Lanka, or a road transfer time of up to eight hours.
“The HB chamber in Trinco is the only one in the entire country,” says Dharshana Jawawardena of Dive Sri Lanka, one of the country’s top scuba operators. Asked whether it is adequate to provide emergency coverage for all Sri Lanka’s growing number of visiting scuba divers, his answer is unequivocal: “It’s not adequate.”
Dengue fever, Japanese encephalitis, Chikugunya fever, AH1N1 (swine flu) and malaria are all present in the country, and as tourist numbers increase and tourism spreads to previously unexploited areas of the country (mainly in the north and east), cases affecting visitors may increase. Furthermore, although a new coastal highway will soon extend all the way from Colombo to Hambantota on the south coast, roads elsewhere are in a poor state of repair, erratic driving is common and road accidents are frequent, the UK Foreign and Commonwealth Office advises. Trauma is the main cause of hospitalisation here, with 600,000 admissions a year. Road accidents have increased by around 250 per cent in the last 30 years – due mainly to a huge increase in the number of vehicles on the roads – and fatalities increased by some 160 per cent.
visitor numbers were up by 46 per cent in January 2011 compared with January 2010.
Visitors have access to the same facilities as the local population, notes Dr Kimberley Chawla from East West Rescue, a New Delhi-based company that is the largest medical assistance provider to Sri Lanka, providing medical evacuation services to several major UK, US and EU insurers. “There are reasonable facilities in Colombo and Galle to handle most cases,” Dr Chawla says. “For complex cases, sometimes transfer is required to India.”
In Colombo, Dr Chawla pinpoints the Nawaloka, Lanka Hospital, Durdans, Asiri and Central hospitals as models of good practice, along with the Rohana Hospital and International Medical Clinic in Galle. But there are examples of less good practice, and the Sri Lankan government has been accused by some of its own medical officials of inadequate oversight of the fast-growing private hospital sector.
For example, Dr Ananda Gunasekera, director of Sri Lanka’s National Blood Bank, has described the fees charged for blood transfusions by some private hospitals as ‘horrendous’. The National Blood Bank supplies blood free to private hospitals, charging only a nominal 1,500 Sri Lanka rupees (US$13.50) per pint processing fee. But, claims Dr Gunasekera, some private hospitals charge patients Rs50,000 to Rs100,000 per pint for transfusions.
Winds of change
With a population of around 21.5 million, Sri Lanka had a public hospital bed strength of 69,500 in 2010 (up by some 600 beds from the previous year). Beyond the capital, smaller hospitals and clinics are less well-equipped to handle foreign cases. Medical care that meets acceptable international standards can be difficult to find, essential medical supplies may not be available, and many hospitals and doctors require payment in cash, regardless of whether the patient has travel health insurance.
Things are changing, however. The tsunami exposed shortcomings in the country’s emergency services and hospitals, and since 2004 large amounts of foreign aid have been pumped into renovating and improving both. Historically, health services in the conflict zones of the north and east were poorer than in the relatively untroubled south, west and central areas of the country. In 2003, Sri Lanka had just under 49 doctors per 100,000 people nationwide, but the Batticaloa region in the northeast had just 21 physicians per 100,000 people, while infant mortality in Batticaloa was almost double the national average.
This, too, is changing as health facilities in the formerly troubled regions improve. USAID began work in 2009 on renovating and improving the run-down and ill-equipped Navatkadu hospital, adding three new wards and 63 inpatient beds and creating a fully functional facility in line with the latest government standards, according to Robert Blake, deputy chief of mission at the US Embassy in Colombo.
That project was followed in 2010 by similar work on the Karadiyanaru hospital, also in Batticaloa district. Ironically, in a country whose people are overwhelmingly either Buddhist or Hindu, significant practical help has been brought to Sri Lanka by Christian, faith-based voluntary organisations from the US and western Europe.
although Sri Lanka attracts thousands of scuba divers each year … it has just one hyperbaric chamber for emergency decompression cases.
Since 2004, the American charity AmeriCares has invested more than US$17 million in projects including the upgrading of the Elpitiya Hospital in southern Sri Lanka, and is continuing to work with the Ministry of Health on the upgrading of Trincomalee Disrict Hospital.
In Hambantota, on the south coast, a huge new seaport and a large international airport, both built by Chinese investors, are expected to turn a somnolent coastal community of 10,000, which suffered severely from the tsunami, into a commercial and tourist hub of more than 50,000 people. Here, a new surgical theatre and ward complex of 360 beds opened in the public Hambantota General Hospital, and new emergency treatment units, an outpatient department unit and ICU facilities are being financed by the Hungarian Government. The Sri Lankan government also intends to open a new 1500-bed hospital in Hambantota within the next three years.
Indian companies are becoming major players in Sri Lankan healthcare too. At Dickoya, in Central Province, the Indian company Green Valleys Shelters signed an agreement in March 2011 to invest US$10.5 million in a new 150-bed general hospital to be completed by January 2013. Also in March, India’s Fortis Global Healthcare Holdings bought a 26.8 per cent stake in Lanka Hospitals, which runs a modern 350-bed hospital in Colombo. Its majority shareholder is the government-owned Sri Lanka Insurance Corp.
The Indian company Apollo, which owned the hospital until 2006, is also reported to be keen to re-enter the Sri Lankan market. Previously, Apollo had hoped to develop the medical tourism sector, both for cosmetic surgery and for treatments such as heart surgery.
State of emergency
In recent years, emergency medical services have undergone considerable modernisation, with a public-private system providing ambulance services overseen by the Ministry of Healthcare’s new Pre-Hospital Care Committee and Trauma Secretariat. When the first dedicated public EMS ambulance unit started operations in Sri Lanka’s capital in 2009, with four modern ambulances donated by the German charity Johanniter International Assistance and Sri Lanka’s own St John’s Ambulance, it made national headlines.
“Usually what happens in Sri Lanka is that as soon as an accident takes place, well-meaning helpers gather round, pull out the victims in whatever way they can, double them up and pack them into the nearest trishaw and send them to hospital,” wrote journalist Kumudini Hettiarachchi in the Sri Lankan Sunday Times newspaper. But this, too, is changing for the better.
A growing cadre of emergency medical technicians (EMTs) is trained to standards that are claimed to be comparable to those of the UK College of Emergency Medicine and the US National Registry of EMTs.
Meanwhile, as reconstruction of Jaffna and the north continues, Medical Teams International has, over the last two years (since February 2009), helped to establish a ‘simple but comprehensive’ emergency medical system, beginning with basic first aid education and continuing with building hospital capacity for emergency and trauma services.
roads … are in a poor state of repair, erratic driving is common and road accidents are frequent
The programme includes the ongoing upgrading of ambulances, retraining of 150 ambulance officers as emergency medical technicians, and the training of 600 nurses in basic trauma and medical emergency management and 50 doctors in primary trauma care.
Rescue missions
The end of the 25-year civil war, during which the main role of the Sri Lankan Air Force (SLAF) was providing air support to the Sri Lankan Army, has freed the SLAF’s helicopter arm – based at SLAF Hingurakgoda – to find a new purpose for its Bell 212 and Mi-17 helicopters as an emergency medical evacuation supplier. During the floods that struck north central Sri Lanka in February 2011, the SLAF’s choppers flew rescue missions to evacuate dozens of civilians – including a number of expectant mothers, one of whom gave birth onboard.
Deccan Aviation, a joint Indian-Sri Lankan venture, launched a medical evacuation service in 2008. With a maximum range of around 680km, Deccan Aviation’s Bell 206B-3 Jet Ranger helicopter is capable of reaching any point in the island country from the company’s bases at Bandaranaike International Airport and Ratnamalana Airport in Colombo. In April 2011, the company was due to take delivery of an Australian-built Gippsland Aeronautics GA8 Airvan. While mainly intended for luxury charter use, the GA8 is capable of operating on airstrips as short as 500 metres and so is also ideally suited for the medical evacuation role.