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CONTENTS Page No.
Cover Story
SLMANEWS
THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
May 2015, Volume 8, issue 05
Summary of events of the fact finding mission on water pollution in Chunakkam, Jaffna
02, 03, 04
SLMA News Editorial Committee-2015
News
Editor-In-Chief: Prof. Sharmini Gunawardena
President's message
02
Summary of events of the fact finding mission on water pollution in Chunakkam, Jaffna
02, 03, 04
Care of the Elderly in Sri Lanka Moving Towards A Filariasis Free Sri Lanka Physician to Manager: Paradigm shift
14, 16
Kurunegala Clinical Society and the SLMA
18, 19
Joint Regional Meeting of the
The award for the outstanding Regional 19, 20, 21
SLMA Research Grants
Dr. Amaya Ellawala Dr. Iyanthi Abeyewickreme Prof. Deepika Fernando Dr. Sarath Gamini De Silva
06, 07 08, 10, 14
Psychiatrist of 2013-2014
Committee:
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Events SLMA Run & Walk
21
Official Newsletter of The Sri Lanka Medical Association. Tele: +94 112 693324 E mail: office@slma.lk
Professor Jennifer Perera MBBS, MD (Col), MBA(Wales), PgDip MedEd (Dundee), PgDip Women’s Studies(Col). President, Sri Lanka Medical Association, No 6, Wijerama Mawatha, Colombo 7, Sri Lanka.
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May 2015
PRESIDENT'S MESSAGE
SLMANEWS
Dear Colleagues,
W
e are fast approaching the 128th Anniversary Scientific Congress and the Wijerama House has become a hive of activity. I am pleased to note that many members have come forward to assist SLMA in making this event a success. However, above everything else, it will be the numbers participating at the congress that will determine its' success. The registration fees have been subsidized to make it very affordable to all categories of doctors and health care professionals. The registration fee is only 20% of the actual cost of hosting a delegate for the congress. This has been made possible through generous sponsorships from non-governmental organisations, the Ministry of Health and the industry. Registration has been made easier and one does not have to visit the Wijerama House for this purpose. Please pay your registration fee online, using the online payment scheme through the payment gateway hosted by the SLMA website. If you have any problems in accessing this pathway for registration, please call Tharindu, the IT executive at the Wijerama House, for assistance. Additionally, I invite all of you to participate in events related to the congress which include several pre and post congress workshops and the health walk and run. The SLMA web-
site provides details regarding these planned events. Recently the Organisation of Professional Associations (OPA) invited the SLMA to participate in a panel discussion of the OPA together with the Sri Lanka Economic Association (SLEA) on the subject “Comprehensive Economic Partnership Agreement (CEPA) and Free Trade Agreement (FTA) with India and beyond. President SLMA, Chairman, SLMA Working Party on Trade in Services, Dr. Malik Fernando, and Council member, Dr. Sarath Gamini de Silva, participated at the meeting. The discussion was on liberalizing trade and services including medical services under CEPA/SATIS (SAARC Agreement on Trade in Services), and this sensitised participants on the issues involved so as to prepare professionals for the upcoming initiatives of the government. One of the panelists, an architect, expressed his concern for non provision of a forum for discussion of proposed trade agreements prior to drawing up schedules. The schedules drawn up by the inter-Ministerial committee did not include the Ministry of Health. He also pointed out that only doctors and other health professionals have a national registration procedure enabling the scrutiny of qualifications
of foreign nationals. However another member, a senior economist, pointed out very forcefully that Sri Lanka has to face realities and should be prepared to change. She further stated that the reality is that new trade agreements are seldom restricted to goods alone, but include services as well. As such, well thought out agreements will benefit people more than any possible adverse effects. She reiterated the advantages of “swimming with the current rather than against it” in realizing our economic objectives. As times and equations keep changing it is important to have an open view on these affairs and review our position from time to time. It was the general view of those present that Sri Lanka was not ready to embark on liberalising medical services under CEPA/SATIS at present. When there is a strong regulatory framework in the country to safeguard the national interest together with enforcement of laws, this position may be reviewed. The SLMA Working Party on Trade in Services will continue to meet and identify areas that need action by the medical professionals. If you have any comments regarding liberalization of trade in medical services, please write to Dr. Malik Fernando, c/o SLMA. Professor Jennifer Perera
Summary of events of the fact finding mission on water pollution in Chunakkam, Jaffna Held on 14th March 2015 by the Sri Lanka Medical Association Compiled by Dr. Jeyanthakumar Rasarathinam, Demonstrator, Faculty of Medicine, University of Colombo and reviewed by Professor Jennifer Perera, President SLMA 3rd April 2015 Observations and interviews during the field visit to Chunakkam, Jaffna The field visit was led by Dr. Kumarendran who directed the participants to the affected village and to the area with the power plants. Seven houses were visited and well water was examined with the naked eye and a thin film
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of oil was observed. Most residents stated that the problem had persisted over the past two years but the greasiness of water appeared to have reduced in the recent past. Some had tested their well water for oil through the National Water Supply and Drainage Board (NWSDB) with each test costing them Rs 2000/- and the re-
ports had indicated oil contamination of water. The detection limit of the test was 0.2mg/dl, which is the cut off value for safety. In the affected areas large plastic water tanks were present which were filled up by bowsers funded through the Pradeshiya Sabha. Contd. on page 03
SLMANEWS
May 2015
Contd. from page 02
Summary of events... However, people of the area expressed their concern regarding the quality of the water that was provided by the bowsers. They stated that a large “oil kulam” existed next to the power plant but it ceased to appear approximately two years ago after some transformers were erected over this exact area. Google maps have shown the presence of the oil kulam and are considered adequate evidence for its earlier existence. It was widely believed that some deep boring was done to remove the oil and this may have led to the contamination of deep waters in aquifers. On interviewing the villages to determine their concerns, they stated that they are worried about the limited water supplies in aquifers, quality of water provided through bowsers, having to pay for water in the future, and about chronic diseases that may be consequent to consuming contaminated water. They were expecting both short and long term solutions to their water requirements, which they believed was a basic need. A visit to the area where the two power plants were housed indicated that the Northern power plant had stopped its activities following an order issued by the High Court. The entry to the power plant premises was not possible as it was not open to visitors. This was probably as a result of some affected residents filing court cases against the power plant incriminating it as the source of contamination of their well water. The new transformer structures erected at the site of the original “oil kulam” (as indicated by the villagers) was also observed.
Discussion forum on Water Pollution in Chunakkam, Jaffna The discussion forum on water Pollution in Jaffna organized by the Sri Lanka Medical Association was held on Saturday the 14th of March 2015, from 1.45pm to 5.30pm, at the Medi-
cal Faculty Hostel Auditorium, University of Jaffna.
Participants at the Discussion Forum on Water Pollution in Jaffna
The forum was chaired by Prof. Jennifer Perera, the President, SLMA and Dean, Faculty of Medicine, University of Colombo, with Dr. Vallipuranathan Murali President, Jaffna Medical Association.
Prof. Jennifer Perera, President, SLMA and Dr. V. Murali, President, JMA at the Discussion Forum on Water Pollution in Jaffna.
The discussion started with Prof. Jennifer Perera’s address. She thanked Dr. B. Kumarendran, Lecturer, Department of Public Health, Faculty of Medicine, University of Kelaniya and Dr. Murali, the President, Jaffna Medical Association, for their valuable contribution in organizing this discussion forum on behalf of SLMA. She also explained that SLMA had decided to provide leadership in this issue following several requests from different stakeholders. The participants then introduced themselves with their designations (if any) and professional affiliations. Following the introductory session, Prof. Jennifer Perera explained the importance of this fact finding mission. She stated that health is not merely the absence of disease. She also stressed the importance of having a collaborative effort by different stakeholders of the community and the government in finding solutions to this problem. She said that the SLMA is willing to explore this situation in a holistic manner in order to make recommendations to the relevant authorities in solving this issue both in the short and the long term. Thereafter, Prof. Jennifer Perera invited Dr. Murali to express his views and concerns. Dr. Murali stated that
the Ministry of Health had analyzed 25 samples from different wells of the affected areas, all of which were positive for significant levels of oil and grease. Next, Dr. Inoka Suraweera, CCP, Directorate of Environmental and Occupational Health, Ministry of Health, provided the details of the report of the above analysis. Following this, Prof. Jennifer Perera discussed the field visit to the affected areas surrounding the two power plants, Uthuru Janani (CEB) and Northern Power Plant (business venture by a subsidiary of Walkers Limited) - both are located in close proximity to each other. The audience was also briefed about the perceptions of people living in the affected areas which included anxiety, fear of disease and anger towards the culprits. Prof. Perera invited several key figures to express their views on the matter and a discussion ensued. Some of the speakers/discussants included: Dr. Sumanaweera, representative from the WHO; Mr. NJ Fernando, a retired engineer from the NWSDB having vast experience in dealing with water pollution especially in North Central Province; Dr. S Sivakumar, President, Sri Lanka Institute of Engineering and Head, Department of Civil Engineering, University of Jaffna; Ms. Vijitha Sathyakumar, Deputy Director, Northern Provincial Office of the Central Environmental Authority; Eng. Bharathythasan, District General Manager of the NWSDB; Prof. Gunawardene, Contd. on page 04
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SLMANEWS
May 2015 Contd. from page 03
Summary of events... Dr. Sumanaweera, the representative from WHO, addressing the Discussion Forum
Emeritus Professor from University of Colombo and the President, Ceylon College of Chemists; Mr. S. Ravi, Assistant Director, Disaster Management Unit, District Secretariat, Jaffna; Dr. Noel Wijesekara, Senior Registrar, Disaster Preparedness and Response Unit, Ministry of Health; Dr.
Senthuran, Secretary, GMOA – RDHS Jaffna; Dr. S Ketheeswaran, Provincial Director of Health Services; Retired engineers from the Jaffna Managers’ Forum; Representatives from the Jaffna community; Dr. Mayurathan, President of the GMOA – Jaffna; and the representative from the UNICEF. To conclude the meeting, the president of the Jaffna Medical Association presented the recommendations that were discussed, and gave suggestions to overcome the current issue. He also thanked the different stakeholders for their valuable presence.
Recommendations proposed at the discussion forum In the immediate future: 1. Provide safe water to the affected areas 2. Monitor the quality of the supplied water 3. Try to get water from the aquifers other than the Valihamam aquifer since it can collapse 4. Define this as a disaster affected zone or as a risk prone zone 5. Anticipate problems of water sources during the drought season in the upcoming months 6. Create awareness among the public through the MOH In the medium term: 1. Need multi-specialty support, liaise with the central government and other NGOs 2. Look for the possibility of or providing household level purification through use of biosand filters for home use after testing its efficacy 3. Look for the possibility of community based reverse osmosis water purification plants 4. Need to have continuous monitoring of each source at 3 monthly intervals with at least 10 identified sites to determine progress of contamination 5. Need to identify the individual components in the hydrocarbons to determine their health effects 6. Need for having a training of the trainers programmes for the MOHs 7. Implement active and passive surveillance – reporting system on the adverse health effects of use of the contaminated water 8. Find measures to tackle if pollution is due to a Board of Investment project 9. Consider and act against other possible pollutants 10. Need to check for heavy metal 11. Need to create awareness on technical aspects of pollution in the public domain In the long term: 1. Consider the establishment of state owned reverse osmosis plants as it cost around 50 cents / liter 2. Government should review the Board of Investment exemption from environmental assessments as informed by CEA representative 3. Possibility of establishing a permanent water supply system in 3 years 4. Need to ensure that the Government Analyst Department develop facilities to detect oil level up to 0.2 mg/dl as at current point the lowest limit detectable is 1mg/dl 5. Dealing with the problems of waste disposal in the hospitals and the sewage disposal systems 6. Use of strong anion exchange resins to remove nitrates 7. Reconsider the allowance of commercial plants establish RO plants 8. Government should review the BOI exemption in environmental aspects 4
SLMANEWS
May 2015
Care of the Elderly in Sri Lanka Dr. Dilhar N Samaraweera Consultant Physician Base Hospital, Pimbura, Agalawaththe, President of the Sri Lanka Association of Geriatric Medicine
E
very one out of four will be over the age of sixty by the year 2041 in Sri Lanka1. The country is experiencing a demographic transition which is likely to strain the current healthcare system which is not geared to take care of the rapidly ageing population. Sri Lanka has one of the most rapidly ageing populations in the world. It took 115 years for France and 85 years for Sweden for the population over 60 years to increase from 7% to 14%2. The elderly population which was 9.2% in 2000 is predicted to increase to 16.7% in just 17 years in Sri Lanka1. The rapid increase in the elderly population is taking place without a major change in the infrastructure and per capita level of income. Thus Sri Lanka will need a spectacular rate of economic growth to provide the healthcare services for this rapidly ageing population. It is timely to re-orientate health care delivery to enable detection and management of specific problems of the elderly3. The health problems of elderly cannot be simply assessed in general medical clinics and managed in general medical wards. The busy medical units in our public healthcare system are overburdened with patients with acute medical conditions. These units have a high turnover of patients and have a high demand for beds. The patients with acute problems get priority over the elderly patients with chronic problems. The time which can be spent on an elderly is very minimal resulting in overlooking of many problems in this vulnerable older population. The delivery of care by a multidisciplinary team consisting essentially of a Geriatrician / Physician, specialized nurse, physiotherapist, occupational therapist and a social worker is needed to provide a comprehensive package to the elderly. Other members such
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as a dietician, speech and language therapists, podiatrist and tissue viability nurse would be useful to care for these elderly patients. The training of members of the multidisciplinary staff is a challenge that needs to be met by the Ministry of Health. The Post Graduate Institute of Medicine has already started a Diploma in Elderly Medicine which has enabled dissemination of knowledge in elderly care among medical officers. The MD pr ogramme in Geriatric Medicine which will produce Geriatricians is due to be launched this year. It is vital that training of nurses in Geriatric Medicine takes place simultaneously to enable team work in the delivery of care to the elderly. There is no structured programme currently for this purpose and this needs attention by the authorities. There are currently training programmes in place for the physiotherapists and occupational therapists as well as for social workers. However these members essential for multidisciplinary care are not available in the general medical wards which currently take care of the elderly patients. The care provided in the hospitals will not lead to a better quality of life without proper follow up in the community. The needs of the patient at home or the need of an alternative placement could be organized only if a social worker is available as a member of the multidisciplinary team in the hospital. The elderly patients who are admitted to the General Medical wards who need walking aids, home adjustments, and community rehabilitation are at present discharged with no proper follow up in the community. Thus the integration of social services with the curative sector is vital in bringing the best outcome for the elderly patient. Long-term care of the elderly is a very costly affair. In Sri Lanka and many other Asian countries the concept of extended family support is an asset needed to be maximally
utilized in organizing long term care. In Sri Lanka we have a very strong community health team consisting of Medical Officers of Health (MOH) and midwives who are mainly involved in antenatal and postnatal care which is the reason for the very low maternal mortality index. The village leader (Grama Sevaka), who looks after administrative issues in the villages, also plays a vital role in organizing community activities. We also have many elders societies scattered throughout the country. Thus the use of this already existing strong community network supported by the senior citizens representing the elders societies and the members of the extended family is a very cost effective strategy for development of a healthcare system for geriatric patients especially in a low resource setting. The experience I had in organizing elders clinics in the Medirigiriya MOH area by using the existing resources could give an insight as to how we should set about initiating a programme at National level. The clinics were organized in Grama Niladhari divisions with the cooperation of the MOH Medirigiriya. The staff of the MOH Medirigiriya, consisting of the MOH, Public Health Midwife (PHM), Public Health Inspector (PHI) and medical officers of the Medirigiriya Base Hospital took part in the clinics. The Consultant Rheumatologist of Polonnaruwa General Hospital was contacted and an agreement was made to arrange community based rehabilitation with the help of the hospital physiotherapist for the patients in need. The Consultant Psychiatrist agreed to accept referrals from the elders clinics for further evaluation of patients screened positive for dementia and depression. The MOH arranged the Eye Surgeon to conduct clinics for patient detected to have visual defects, and the community dentist took part in the clinics for assessment of oral health and correction of abnormalities. Contd. on page 07
SLMANEWS
May 2015
Contd. from page 06
Care of the... The Grama Sevaka with the help of the senior citizens in the area arranged the clinic in his division; the elderly were mobilized to the clinics by the PHMs and PHIs. The respected senior citizens and volunteers also took part in providing necessary equipment and provision of food. The clinics were held in schools during a holiday. People over the age of 60 years were assessed in these clinics using a simple tool consisting of assessment of depression, dementia, hearing, vision, oral health, gait and balance and activities of daily living. In addition assessment of body mass index, blood pressure and testing urine for albumin was done. Mini cog test was used to assess dementia; Geriatric depression scale 4 was used to screen for depression and the timed get up and go test was used to assess gait and balance. The difficulty in arranging referrals to required specialties due to the services which are already overburdened and finding resources, finances to arrange for hearing aids, lenses were some of the problems faced during follow up of these patients. The importance of existing manpower such as the staff of MOH divisions (MOH, PHM, PHI), Grama Niladharis and other community volunteers for implementation of a programme for the elderly at community level was exemplified well in this programme at Medirigiriya. At present there are many programmes for the elderly conducted in Kadugannawa, Kotte and Horana. However there is a great need to start a programme at the National level to enable equity of services to the entire elderly population. Evidence from studies done during the past decade in the country, show that the lack of specialized units and tools for examination of the elderly has resulted in overlooking of problems of the elderly patients. A preliminary study done in hospital admitted
patients in a unit at the National Hospital of Sri Lanka detected depression in 40%, cognitive dysfunction in 73%, 6/60 or worse visual acuity bilaterally in 34%, hearing impairment in 8.3%, and unprovoked falls in 23%, while 57.6% could not or took longer than 30 seconds to perform the timed get up and go test 4. Visual problems have been found in a high proportion in the elderly. The National survey in elders (60 years and above) in 2004 has revealed poor vision in 65% and complete blindness in 2%; poor hearing in 28% with no hearing at all in 2%5. In a society affected by poverty and unemployment and other issues affecting even the younger population, the care of the geriatric population is given less prominence. Thus the most important aspect of developing healthcare services for the elderly is to create awareness to bring about a change in attitude towards caring for the elderly. The Association of Geriatric Medicine was formed in 2014 to develop Geriatric services and create an elderly friendly environment in Sri Lanka. The vision of our Association is to ensure active healthy ageing in Sri Lanka. Our Mission is to ensure promotion of geriatric education among the medical fraternity and the public in order to facilitate the development of an elderly friendly environment in healthcare institutions and in the community. We endeavour to integrate the elderly activities carried out by various organizations for the common goal of promoting good health and well being among the senior citizens. We held our first academic sessions on the 12th and 13th of November 2014 on the theme titled “Towards Achieving a Brighter and Healthier Silver Age”. Many of our ancestors have searched without success for the secret formula to enable eternal living. We cannot stop the ageing process but we could change the perception of old age. The Sri Lanka Association of Geriatric Medicine has a special vision
to make the Silver Age brighter and happier for our elders. In the march towards this mission we have requested the public to replace old age with the new term ‘Silver Age’. In re-orienting the health system, attention should be paid to the following key segments: strengthening health promotion and prevention to ensure better quality of life in elderly persons, integrating management of primary prevention and primary care for the elderly using the maternal and child health network in the community, increasing public funding on improving the infrastructure of hospitals and expanding the intermediate care facilities for the elderly, and promoting education and research in elderly care3. The development of the healthcare system to provide comprehensive care with multi disciplinary teams in an elderly friendly environment by dedicated elderly care units is a national priority. It is important to develop a sustainable community model and strengthen primary care to deliver community and home based healthcare and rehabilitation to enable a happy silver age for all in Sri Lanka.
References 1
Sri Lanka demographic transition: the challenges of an ageing population with few resources, Oct 10, 2012, Human Development Unit, South Asia Region.
2
World Population Ageing, United Nations. New York 2013, Department of Economic and Social Affairs Population Division. Sri Lanka Addressing the Needs of an Ageing Population, May 28, 2008, Human Development Unit, South Asia Region.
3
4
Weerasuriya N, Jayasinghe S. A preliminary study of the hospital admitted older patients in a tertiary care hospital: CMJ 2005;50:18-19 National Secretariat for Elders 2004, National Survey of Elders, 2003 – 2004. Ministry of Women’s Empowerment and Social Welfare, Colombo.
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SLMANEWS
May 2015
“MOVING TOWARDS A FILARIASIS FREE SRI LANKA” Summary of the symposium organized by the SLMA Expert Committee on Communicable Diseases on the 19th of March 2015 from 11.30am – 1.15pm at the Board Room, Faculty of Medicine, University of Colombo Lymphatic filariasis: Aetiological and clinical perspective Dr. Hasini Banneheke MBBS, PG Dip (Med. Micro), MD (Parasit) Convener / SLMA Expert Committee on Communicable Diseases Senior Lecturer / Consultant in Medical Parasitology, Faculty of Medical Sciences, University of Sri Jayawardenepura
L
ymphatic filariasis has infected 120 million people living in 73 countries with 1.39 billion vulnerable persons worldwide. In Sri Lanka, 9.8 million people living in 8 districts in 3 provinces (North Western - Puttalam, Kurunegala; Western - Gampaha, Colombo, Kalutara; and Southern - Galle, Matara, Hambantota) are at risk. The disease has resulted in serious incapacitation among 40 million sufferers. Genital symptoms in men and elephantiasis has accounted for 25 and 15 million cases respectively. It is responsible for the loss of 5.5 Million Disability Adjusted Life Years. It has been estimated that lymphatic filariasis patients spend 10-60% less time at work. Chronic nature of the disease and disabilities lead to socioeconomic problems such as loss of employment opportunities, stigmatization and marital problems. These factors have made lymphatic filariasis a disease needing urgent attention.
Lymphatic filariasis (LF) is caused by tissue nematodes Wuchereria bancrofti, Brugia malayi and Brugia timori. W. bancrofti is responsible for over 90% of the lymphatic filariasis cases in the world while most of the remainder is caused by B. malayi. LF is a vector borne disease transmitted by mosquitoes of the genus Culex, Anopheles and Mansonia in different geographical localities. In Sri Lanka, the main aetiological parasite W. bancrofti is transmitted by Culex quinquefasciatus mosquito. B. malayi which was once thought to have been eliminated from Sri Lanka is re-emerging and the vectors Mansonia uniformis and Mansonia annulifera carry the pathogen. B. timori which is confined to Indonesia is spread by Anopheles barbirostris. There are certain factors that facilitate the elimination of filariasis such as absence of animal reservoirs, absence of multiplication within the vector and the need of prolonged exposure for establishment of the disease. However B. malayi has been found in macaques, leaf monkeys and civet cats. The disease has a wide array of clinical manifestations. However, the great majority are asymptomatic. During acute infection, patients can present with filarial fever, lymphangitis, lymphadenitis, adenolymphangitis (ADL), orchitis and epididymitis. Lymphoedema of limbs, breasts, genitals, hydrocoele and elephantiasis are the chronic manifestations of the disease. Other less common manifestations include tropical pulmonary eosinophilia (TPE), chyluria, chylascites, arthritis and skin lumps. Interrupting transmission and preventing morbidities and management of disabilities among patients already affected by LF are the two main areas
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focused by the Global Programme for Elimination of LF. Clinical manifestations are useful from the planning stage up to monitoring and evaluation of the elimination programme. A reduction in the frequency and intensity of episodes of adenolymphangitis for people with lymphoedema and a reduction in the number of new cases of lymphoedema and hydrocoele to a level where there are no new cases due to lymphatic filariasis demonstrate the success of the elimination programme.
Contd. on page 10
SLMANEWS
May 2015 Contd. from page 8
Moving towards... lines and results showed very low transmission of the disease in the endemic districts. Under the purview of the Ministry of Health, the AFC is planning to submit a dossier to the WHO to be considered for certification of LF elimination. However, Sri Lanka has to continue the control and surveillance activities, until the disease is eradicated from the country.
Lymphatic filariasis in Sri Lanka; What have we done? Where are we now? Dr. Sandya Dilhani Samarasekara, Consultant Community Physician, Anti Filariasis Campaign, Ministry of Health Lymphatic filariasis (LF), is one of the most disfiguring diseases in the world which causes permanent disability leading to social stigma, economic loss and a heavy burden on health systems. LF is the one of the leading causes of permanent and long-term disability in the world. The Anti Filariasis Campaign (AFC) is the National Programme of the Ministry of Health responsible for control and prevention of filariasis in Sri Lanka. Filariasis is endemic in the Western, Southern and North Western provinces of Sri Lanka. Two types of filarial parasites have been reported from Sri Lanka i.e. Wuchereria bancrofti and Brugia malayi. A majority of microfilaria positive cases is due to W. bancrofti. The AFC conducts parasitological, entomological and clinical activities mainly in endemic districts and in addition, in nonendemic districts. After the Mass Drug Administration (MDA) programme in 2002-2006, Sri Lanka conducted post MDA surveillances according to the WHO guide-
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The microfilaria (mf) rate in the endemic districts in Sri Lanka in 2014 was 0.05% with 177 mf positives. As there were high risk areas, especially in the Galle district, the AFC decided to conduct MDA programmes in selected Medical Officer of Health areas in 2014 and 2015.
showing least coverage. The WHO recommendation at that stage was 80% coverage. This was later reduced to 65%. WHO has stipulated that the monitoring and assessment during the surveillance phase at the conclusion of the five year MDA period as mandatory. Studies conducted by AFC and FRTSU in the Southern province covering low and high endemic sites showed significant reduction in microfilaria rates and density and antigen antibody rates. Certain sites still had fluctuating mf rates of more than 1%. As a result, the AFC conducted MDAs in Galle district in 2014, which was a positive move towards the elimination goal.
Elimination of filariasis: Is it a success story? Professor Mirani V Weerasooriya, Senior Professor of Parasitology, Faculty of Medicine, University of Ruhuna The Anti Filariasis Campaign initiated the Programme for Elimination of Lymphatic Filariasis (PELF) in 2002 covering the three endemic provinces and completed five rounds of annual MDA in 2006. The mopping up MDA followed in 2007 covering selected sentinel sites where relatively high microfilaria rates were reported. The morbidity management ran in parallel to the MDAs. Monitoring and epidemiological assessment of MDAs were guided by the Programme Managers. Monitoring and evaluation were also carried out by independent groups, University of Kelaniya, Ragama, University of Colombo and our Filariasis Research Training and Service Unit (FRTSU), University of Ruhuna. In an initial evaluation by FRTSU in 2003 the coverage in all eight districts was 79%. Urban and Municipality areas showed a poor response, Colombo
Contd. on page 14
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SLMANEWS
May 2015 Contd. from page 10
Moving towards... In a FRTSU study in Walgama, Matara, despite 96% coverage and seven to thirteen MDAs over six years the mf rate was still over 1% with 15 non responders. Studies conducted by Kelaniya and Colombo University units in Gampaha and Colombo districts too had confirmed lower parasite rates. The immunochromatiographic test, ICT, a simple sensitive and specific antigen detection assay for Wuchereria bancrofti was used by the AFC and other units in Transmission Assessment Survey (TAS) studies. Application of Polymerase Chain Reaction (PCR) to Vector studies have also been conducted by the AFC. Ongoing monitoring by the AFC in Kegalle and FRTSU studies fulfill the requirements of elimination. The FRTSU studies in Ratnapura and other areas and in selected sites in North and Eastern provinces are being carried out using modern tools. Rapid Assessment Procedure (RAP) has been used for mapping new areas and infections confirmed by urine
ELISA, a sensitive Enzyme Linked Immunosorbent Assay which detects W. b. specific IgG4 in urine. We evaluated the newly developed Alere Filariasis Test Strip by a USA team in Matara and later ran a parallel experiment with ICT card test. There were many more positive Alere Test strips than positive ICT card tests. We also successfully tested a new loopmediated isothermal amplification method (LAMP) for detecting DNA in W. bancrofti. The detection of more than 13 B. malayi cases needs specific attention. Identification of zoonotic reservoirs, monitoring of Mansonia mosquito infections and detection of further positives by immunodiagnosis are activities highly recommended. The second strategy of the GPELF is managing existing morbidities to prevent disability. This activity primarily focuses on care of acute infections, lymphoedema including elephantiasis and hydrocele. FRTSU studies in Southern Province, University of Kelaniya and other teams in clinical and
community based studies in the Western Province have highlighted the lack of awareness about Community Home Based Care (CHBC) among patients. The majority had neglected their limbs and had poor quality of life as measured by Dermatology Life Quality Index (DLQI) scores. Ongoing CHBC evaluation studies at the FRTSU have shown promising results on the improvement of the limb appearance and skin hygiene, lymphoedema grade and quality of life. We recommend more media coverage and propaganda on this activity. Above observations have shown that SL had achieved a marked reduction in the Filariasis situation and provides criteria for the dossier for verification to the WHO. Further to this main success, continued vigilant surveillance, vector control activities, attention to Brugia infections and enhanced morbidity control activities are strongly recommended. It is imperative that the Ministry of Health strengthens the activities of AFC by providing funds and personnel to achieve the goal of elimination.
Physician to Manager: Paradigm shift Dr. KDP Wijesinghe (Director, District General Hospital, Kalutara) Dr. HMK Wickramanayake (Deputy Director, Accident Service, NHSL) Dr. DS Kiriwandeniya (Deputy Director, Anti-Filariasis Campaign) Dr. V Gunasekara (Director, Lab Services, Ministry of Health) Dr. P Atapattu (Director, Tertiary Care Services, Ministry of Health)
Introduction According to the WHO today many countries have impressive health systems with promotive, preventive, curative and rehabilitative services1. The same source further says that within all systems there are many highly
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skilled, dedicated people working at all levels to improve the health of their communities. These health systems play a bigger and more influential role in people’s lives and, on the whole, people around the world today enjoy much healthier and longer lives than several decades ago1. Managing the complex health systems is not an easy task for a manager. Management of public sector health care institutions in Sri Lanka is done by medically qualified doctors. These institutions vary from Central Dispensaries in the curative care and office of Medical Officers’ of Health in the preventive health care to Teaching
Hospitals and Directorates of the Ministry of Health. Managers of the lower level health care institutions up to Base Hospitals are appointed purely on grade seniority. All of them have the MBBS qualification and some of them have post graduate qualifications in clinical specialties or preventive health care. Above the level of Base Hospitals up to Directorates of the Ministry of Health, the managers are medical officers with post graduate qualifications in health service management or preventive health or clinical specialties. Contd. on page 16
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Physician to manager... When a medical doctor becomes a health manager irrespective of the level of the institution, there is a shift in the paradigm he/she has to work in. A medical doctor spends a long period of time in formal studies for obtaining qualifications and an even longer period of experience to develop clinical competence. Their position is highly trusted by the clients (patients) without a separate effort to earn that trust. Therefore the physician managers expect this sort of behavior from all they come into contact with professionally. The change of three A’s from physician to manager Authority - Highly related to knowledge and technical skills and that is trusted at the outset. Accountability - High accountability to patients. Autonomy - Decisions can be made alone and they are rarely questioned. When a physician becomes a manager the three A’s will change in the following way. Authority - with new management knowledge he/she will have to demonstrate achievement and build trust. Accountability - high and broad, expected to perform as a manager. Autonomy - low and can make unilateral decisions at one’s own peril. Health managers at health care institutions below the level of Base Hospitals take on management positions without formal training in management. Very often they come to the position merely on grade seniority, ambition and leadership capabilities. However the role requires management rather than leadership skills. The scenario becomes worse when leadership is not accepted by their colleagues who are difficult to be managed. The expected paradigm shift is hardly seen among this group of medical managers.
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The health managers at the higher level institutions, who take on formal positions after one year of training in health service management or postgraduate qualifications in public health or clinical specialties, tend to assume themselves as leaders (suddenly). Although some of them often have good ideas and want to make positive changes, their leadership may not be organizationally based or context specific at the outset. Their leadership capabilities should be harnessed by aligning them with the organizational goals. Coping with the realities in the new position will be difficult if the paradigm shift is not well understood by them. As Joel Barker2 explained in the business of paradigms “When paradigm changes we all go back to zero”. When clinicians change into management they should not expect to be trusted, everyone listening to them and to get everything they want as before. They should understand the need of consulting before taking decisions and making non-clinical teams. Furthermore they should learn the art of handling trade union leaders, difficult consultants and medical officers. They should use the management approach rather than the clinicians approach. They must understand that they have gone back to zero and are in an unconscious incompetence zone. Some medical managers are lucky if they are posted as deputies of senior managers so that they can get some hands on experience of what they have learnt in theory during the masters’ course. Four stages of learning3: Consciousness
leagues is undisputed. Also, the importance of aligning the willingness to change and driving this change towards organizational goals should be well understood. The health manager should have the passion to be the leader of the team, making the institution a place to be proud of. Finally, the new managers should be willing to learn new skills and apply them in changing the environment of the institution. The key soft skills a medical manager should have are communication, influencing, managing people and understanding how the system works.
How should the Ministry of Health assist physicians to make the transition? New health managers should be given coaching and hands on training with senior managers at least for a period of three months before they assume duties at their new place of work. They should be given assistance and guidance by the relevant supervising authority and should be corrected timely. Furthermore they should have opportunity for sharing their experiences with colleagues and seniors. There should be a fair performance appraisal system and rewarding mechanism.
References World Health Organisation. www.who.int/topics/health systems/en/. 1
Barker, J. A. 2001 The New Business of Paradigms.ILI press.
2
Howell, W. S. 2011. Aspiring to be unconsciously competent, Facilitative Leadership & Facilitator Training. 3
Characteristics of leadership skills that a medical manager should display: The importance and benefits of being a role model for peers and col-
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May 2015
Joint Regional Meeting of the Kurunegala Clinical Society and the SLMA By Dr. Shamini Prathapan (Asst. Secretary, SLMA)
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he joint regional meeting of the SLMA in collaboration with the Kurunegala Clinical Society was held on the 18th of March 2015 at the Kurunagala Teaching Hospital. The theme of the meeting was ‘Cardiology and Paediatrics: latest knowledge and the challenges in a low resource setting’. The President of the Kurunegala Clinical Society, Dr. Dileep Karunaratne, delivered the welcome speech. Prof. Jennifer Perera, President of the SLMA also addressed the gathering. The event was well attended by around 100 medical officers and consultants from the hospital. The first session on Cardiology was chaired by Dr. Thilak Sirisena and Prof. Jennifer Perera. The panel of speakers were Dr. Bhathiya Ranasinghe, Consultant Cardiologist from the District General Hospital, Trincomalee, Dr. Aranjan Karunanayake, Senior Lecturer in Anatomy at the University of Kelaniya and Specialist in Sports & Exercise Medicine and Dr. Shehan Perera, Consultant Paediatric Cardiologist at the Lady Ridgeway Hospital, Colombo. Dr. Bhathiya Ranasinghe started off the session with his lecture on “Valvular heart disease: from guidelines to clinical practice". He described the types of valvular heart diseases, the symptoms and signs of each, the investigations that should be performed and discussed the management of each as specified by the 2014 American Heart Association (AHA) and the American College of Cardiology (ACC) valvular heart disease guidelines. He further explained the problems encountered in clinical practice in Sri Lanka with regards to the guidelines. Dr. Aranjan Karunanayake, next
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spoke on “Pre–participation screening assessment for sports”. He specified that pre–participation screening assessment for sports is also a leading cause of mortality worldwide with a significant number in Sri Lanka too. He stressed the need for screening assessments at all stages, from school to national level. Dr. Shehan Perera, spoke on “GUCH service (grown-ups with congenital heart disease) - past, present and future". He emphasized that GUCH are increasing, providing evidence from international journals and from Sri Lankan data. He emphasized the problems faced by GUCH such as failure of guided transition from paediatric to adult care, the inadequate number of specialty clinics, inadequate access or availability of insurance cover, insufficient education of patients/caregivers regarding nature of the disease and follow up, inadequate system of management of cognitive or psychosocial impairment of patients and inadequate infrastructure for case management. The second session on Paediatrics was chaired by Dr. Ajith Kularathna and Dr. Asiri Rodrigo. The speakers were Dr. Rohini Premarathna, Consultant Paediatrician from the Teaching Hospital Kurunegala, Dr. Navoda Athapattu, Consultant Paediatric Endocrinologist from LRH, Dr. Kapila Piyasena from the Health Education Bureau and Dr. D. M. Munasingha, Consultant Dermatologist of the Teaching Hospital Kurunegala. Dr. Rohini Premarathne gave an update on ‘Febrile seizures and management of status epilepticus’. She highlighted the occasions when neuroimaging and EEG are not required as part of the routine evaluation and when and to which age group the lumbar puncture should be mandatory. The lecture concluded with treatment and preven-
tion modalities. Dr. Navoda Athapattu’s lecture was on childhood obesity. She began with the evaluation of the child and went on to discuss the medical causes and problems encountered. She emphasized that the approach should be to intervene early with the support of the family, to educate families about medical complications of obesity, involve the family and all caregivers to institute permanent changes, educate the family on how to monitor eating and activity, help the family make small gradual changes and to encourage and empathize and not criticize. She also stressed the need for medical management if needed. Dr. Kapila Piyasena’s lecture was on “Health promotion hospital and effective communication”.
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Joint regional meeting... He stressed that health promotion is the process of enabling people to increase control over the major determinants of health and that if we promote our hospitals as health promotion institutes we will see behaviour change in the staff, patients and community at large. He also voiced that one key component in this endeavour is “effective communication”, and that by following simple guidelines, you can improve your communication skills greatly, promote better understanding in your relationships, and enhance not only your quality of life but the quality of life of people around you. Dr. D. M. Munasingha, presented photographic images of several cases, with further discussions to highlight the challenges in diagnos-
ing leprosy. The session concluded with a final discussion and the vote of thanks delivered by Dr. Priyamali Jayasekera, Chairperson of the academic activities of the Kurunegala Clinical Society. The SLMA would like to take this opportunity to thank the Kurunegala Clinical Society for all their efforts in making this meeting a success. A special thank you to Dr. Dileep Karunaratne and Dr. Priyamali Jayasekera for having coordinated the event with the SLMA. The SLMA would also like to thank the State Pharmaceuticals Corporation of Sri Lanka, Torrent Pharma (neuropsychiatric range) and Cadila – Rabeloc for their sponsorships to make this event a success.
The award for the outstanding Regional Psychiatrist of 2013-2014 and the development of inpatient psychiatric and community mental health services in Matale District. Dr. Gihan Abeywardena, Consultant Psychiatrist, District General Hospital, Matale 2009-2014
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he Sri Lanka College of Psychiatrists on an initiative by the incumbent President Professor Samudra Kathriarachchi decided to reward the most outstanding regional psychiatrist of the past 2 years to appreciate the services rendered by the psychiatrist to the respective hospital and the district as a whole. It was also meant to encourage its membership to develop psychiatric services in the peripheries. I was fortunate enough to receive this award at the inauguration of the annual academic sessions of the Sri Lanka College of Psychiatrists held on the 27th of March 2015 at Hotel Taj Samudra in Colombo. While expressing my sincere grati-
tude to the President and the Sri Lanka College of Psychiatrists for further encouragement and recognition of my services and Prof. Jennifer Perera, President of the SLMA for requesting me to elaborate on my services to the Matale district, let me take this opportunity to briefly describe the development of psychiatric services initiated by me in Matale.
Overview: • Initiation of inward psychiatric facilities for both male and female patients. • Introducing recreational and occupational activities for inpatients. • Starting a mini-farm adjoining the ward with vegetable and fruit cultivation for vocational training / recreation for the long stay patients. • Starting state of the art Electro-Convulsive Therapy (ECT) facilities at D.G.H. Matale.
• Strengthening rehabilitation activities with horticulture and self employment projects for the chronically mentally ill patients in the 2 rehabilitation centres. • Reintegration of chronically mentally ill patients back with their loved ones. • Awareness among schoolchildren on managing school/ exam stress and substance misuse. • Conducting a survey to determine the prevalence of psycho-active substance misuse among schoolboys in Matale district. • Awareness on stress management and child abuse for schoolteachers • Conducting of awareness programmes for midwives and primary health care staff of the district as well as government officers attached to divisional and district secretariats to educate them on common mental health issues and primary interventions. Contd. on page 20
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The award for... • Starting a specialized school for children with Autism and Learning Disability in Matale with trained teaching staff. • Raising awareness on mental health among schoolchildren by conducting an inter-school quiz competition. • Raising awareness and de-stigmatizing mental illnesses by organizing a street drama competition among health care workers. • Specialized group therapy for patients with social phobia and a simplified Dialectical Behaviour Therapy (DBT) group therapy for patients with Borderline Personality Disorder.
Service Development Activities: The District General Hospital in Matale had only an outpatient psychiatric clinic up until 2010. I was appointed to D.G.H. Matale as the Consultant Psychiatrist in February 2009 and the then clinic consisted of 2 small rooms partitioned by hardboard, 3 chairs and desks and a waiting area for the clients with few plastic chairs. The existing clinic building was refurbished and converted to a male psychiatric ward with 16 beds and an isolation unit in 2010 and the adjoining Dermatology ward was vacated and converted to a female psychiatric ward also with 16 beds in April 2013. A library with books on fiction, general knowledge and religion was started inside the ward for the use of patients in the ward. An exercise machine (OrbiTrek) was obtained from the Divisional Secretariat for physical exercise of the long stay patients. The adjoining land to the ward was fenced off and a cultivation project with vegetable plants and fruits was started. The male patients were encouraged to participate in cultivation and watering of vegetable plants. This project proved to be beneficial for the patients who have lost their skills due to their illness and had an added value due to Matale being a predominantly agricultural district.
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Electro-Convulsive Therapy (ECT) was started in Matale after a used ECT machine was obtained from the Psychiatry Unit of the Kandy Hospital. A state of the art ECT machine with EEG monitoring was obtained in 2013. The services of an Occupational Therapist were obtained in 2010, but the services of a psychiatric social worker could be obtained only in 2013 following numerous requests to the Provincial Director of Health Services and the Mental Health Directorate. Counselling services to the inward and outpatient population was obtained by a qualified counselling officer with a degree in psychology and a postgraduate diploma in counselling attached to the District Secretariat of Matale who visited our unit twice a week. The rehabilitation and recreational activities of the medium stay psychiatric rehabilitation centre in Leliambe, and the long stay rehabilitation centre in Muwandeniya in the Matale district, were further strengthened and enhanced with regular visits and reviews by the multi-disciplinary team (MDT) staff comprising of the psychiatrist, occupational therapist, social worker and the counsellor. Horticulture / Minor Export Crop projects and training workshops on development of skills for future self employment projects for the patients with chronic mental illnesses were carried out with the help of the “Vidatha Technical Training Centre” attached to the divisional secretariat in Matale throughout 2013 and 2014. Family meetings were held regularly every three months at these two rehabilitation centres focusing on education of caregivers, reduction of high expressed emotions and awareness of common mental illnesses. The smooth reintegration of chronically ill patients back to their homes was facilitated by the MDT.
A specialized school for children with Autism and Learning Disability was started in an abandoned school 3km away from Matale town following refurbishment of the school. This school comprises of 2 classrooms with 14 children and has a large garden with ample space for outdoor activities and recreation for these differently abled children. Two trained teachers in special education were recruited with the help of the Ukuwela Provincial Council and the Zonal Education Office in Matale to teach these students who were rejected by mainstream schools with remedial teaching. The teachers obtained special hands on training in handling difficult behaviours of these children from the occupational therapist and the psychiatrist. A donation was obtained from Sri Lankans living in Western Australia to equip this special school with toys, play items, stationary and furniture. A comprehensive awareness programme and workshops on managing school stress, tackling youth problems, substance misuse, exam preparation skills and handling exam stress, life skills and also common mental health problems during adolescence for schoolchildren in Matale were carried out by the Consultant Psychiatrist and the Counselling Officer in 15 schools in the Matale district. Power point presentations and videos were shown to schoolchildren and they were encouraged to ask questions to make the session interactive. Subsequently a survey was conducted among schoolboys aged 13- 18 years in Matale to determine the prevalence of substance misuse, which showed that 28% of them had used at least one psycho-active substance and that 63.9% of them were in need of psychiatric intervention. Contd. on page 21
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Contd. from page 20
The award for... A separate programme was held in schools for the schoolteachers on detecting stress in children, stress management for teachers and emotional, physical and sexual child abuse. Awareness programmes for midwives and primary health care staff including MOH staff were held throughout the Matale district to familiarize them with the symptoms of common mental health issues and the interventions that could be carried out at their level. Awareness programmes on anxiety and common mental health problems were also organized for government officers attached to Divisional and District Secretariats and zonal education officers. Public awareness programmes were conducted annually in Matale to commemorate World Mental Health
Day in October. Inter-school Art / Quiz competitions were organized to raise awareness on mental health issues among school children and subsequently a street drama competition was held among the primary health care staff attached to different MOH divisions to de-stigmatize mental illnesses and educate the public on common mental illnesses. For the first time in Sri Lanka a simplified group therapy for clients with Borderline Personality Disorder was started in Matale and continued for 12 weeks with the help of the occupational therapist. Another group therapy for clients with Social Phobia was conducted simultaneously in 2014 by a counsellor with special training in Social Phobia.
Funding: Funding for the refurbishment and renovation of the two wards was obtained by the Sri Lanka College of Psychiatrists, Regional Director of Health Services of Matale and donations from several Pharmaceutical companies. The awareness programmes were supported by the fund in the psychiatry ward of Matale.
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SLMA RESEARCH GRANTS 2015 The Research Promotion Committee of the SLMA is pleased to call for applications from SLMA members for the following research grants: SLMA Research Grant This grant is offered in this seventh round of grants for research proposals on topics related to any branch of medicine. The maximum financial value of the grant is LKR 100,000.00. The grant is targeted for young researchers in their early career, for proposals on applied research that could be initiated (e.g. pilot study) or completed (e.g. audit) with the grant. The project should be supervised. SLMA/ GlaxoWellcome Research Grant This grant is offered for research proposals on topics related to any branch of medicine. The maximum financial value of the grant in 2015 is LKR 50,000.00. FAIRMED Foundation – SLMA Research Grant Three (3) grants funded by the Fairmed Foundation are offered in the area of Neglected Tropical Diseases. Preference will be given to projects on Leprosy and Leishmaniasis. The maximum possible financial value for all three (3) grants in total is LKR 1,000,000.00 and the funding will be equitably distributed between the three selected proposals as per the merits and requirements of the studies. Please note that a single proposal will not be given the full grant value. The selection criteria for funding include the relevance of the research project to Sri Lanka and control programmes in Sri Lanka, and multi-centre collaboration within Sri Lanka. Dr. Thistle Jayawardena SLMA Research Grant for Intensive and Critical Care This grant is offered for a research project with relevance to the advancement of Intensive and Critical Care in Sri Lanka. The maximum financial value of the grant is LKR 100,000.00. Institute for Health Policy – SLMA Research Grant This granted is funded by the Institute for Health Policy and is offered for a research project in the areas of health economics, health systems and policy research. The maximum financial value of the grant is LKR 100,000.00. N.B. All research projects should be completed within two years. Preference will be given for proposals that could be completed with the available grant. Utilization of grant funds should commence within six months. Proposals should include problem identification, detailed methodology, timeline, and itemized budget. Funding requests for conference registration and travel is discouraged. Ethical clearance should be applied for when submitting the grant application. The deadline for the applications is 19th of June 2015.The grants will be formally awarded at the SLMA Foundation Sessions in November 2015. The application forms are available from the SLMA office and the SLMA website.
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SLMANEWS THE OFFICIAL NEWSLETTER OF THE SRI LANKA MEDICAL ASSOCIATION
If undelivered return to : Sri Lanka Medical Association. No. 6, Wijerama Mawatha, Colombo 7 Registered at the Department of Post Under No: QD/27/NEWS/2015