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October 2013 Volume 06 Issue 10

President's Column Dear all, It is so good to be with all of you, once again. I am happy to report on the activities of our Association and keep you informed of what has gone on in the last couple of months. Our initiative on the organization of a sustainable programme of recording and providing some of the Continuous Professional Development activities of the SLMA through a web-based platform in collaboration with Dialog Axiata has been very successful. Presently we are in the process of getting things finalized and it should be possible to start this venture off within the next couple of months. We do wish to acknowledge that Dialog Axiata is helping us a great deal with the provision of funding and expertise. The Regional Meeting with the Jaffna Clinical Society from the 10th to the 12th of October was quite successful. We are most grateful to UNICEF for funding this project. We organized a CPD activity for the doctors on the 11th of October 2013 and a programme for nurses and midwives in the Tamil Language took place on the 12th. The participants were really appreciative of all our efforts.

Page No.  Notice Board


 Measles-the current outbreak


 Optimising care for children with disabilities: A pre congress workshop  Workshop on Development and Validation of Data collection tools


 Highlight Of SLMA Foundation


 SLMA regional meeting - Jaffna


 Jawatte Lunatic Asylum


 Chronic Kidney Disease of Uncertain Aetiology


Our Advertisers GlaxoSmithKline Pharmaceuticals. MCSL Financial Service Limited

The Sir Nicholas Attygalle Oration is scheduled for the 2 of November 2013. It will be at the SLMA Auditorium, starting at 6.00 pm. It will be delivered by Dr. Harshini Rajapakse on The most challenging of them all: ‘The patient with nothing wrong’.

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The Annual General Meeting (AGM) of the SLMA would be on Saturday the 14th of December 2013. This is a gentle reminder to all the members to participate in the AGM. With the very best of wishes.

Dr B J C Perera President, Sri Lanka Medical Association, No.06, Wijerama Mawatha, Colombo 07, Sri Lanka


Medical Officers 2013

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We will be going to Batticaloa from 6th to the 8th of November 2013, to Matara from the 20th to the 21st of November 2013 and to Avissawella on the 13th of December 2013. All these programmes are aimed at providing state of the art knowledge to those working in the periphery. The Medical Dance has been scheduled for the 7th of December 2013 at Waters Edge. On the same day there will be a 6-a-side Cricket Tournament open to all professional colleges and associations organized by the SLMA at Wesley Grounds. We do hope that many of our members will grace these events.

 Annual Career Guidance Seminar for Junior

We had the Foundation Sessions in Anuradhapura from the 23rd to the 25th of October 2013. It was very successful with several programmes that were combined with the Annual Scientific Sessions of the Anuradhapura Clinical Society. nd


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This Source (Pvt.) Ltd etc., No 3/1, Rajakeeya Mawatha, Colombo 07, Sri Lanka Tele: +94-115-921317


Notice Board

October, 2013




SLMA membership No: Residential Address: (Please tick the appropriate) Council member <10 years from graduation:

Date of graduation:

Council member > 10 years from graduation:

Date of graduation:

Provincial representative: Southern Province Eastern Province North Central Province Central Province Sabaragamuwa Province Northern Province Uva Province Wayamba Province Proposed by:

Name: SLMA Membership No: Signature:

Seconded by:


Name: SLMA Membership No: Signature:


I hereby agree to be elected to the Council of the Sri Lanka Medical Association as a Council Member. Signature of nominee: Date:


The completed form should reach the Honorary Secretary, SLMA on or before 29th November 2013 2


October, 2013



ummary of the symposium presentations on “Measles” held on 26th June 2013. The resource persons were, Dr. Ananda Amarasinghe, Consultant Epidemiologist, Epidemiology Unit, Ministry of Health, Dr Geethani Galagoda, Consultant Virologist, Medical Research Institute, Dr Devan Mendis, Consultant Paediatrican, Lady Ridgeway Hospital, Colombo & Dr Deepa Gamage, Consultant Epidemiologist, Epidemiology Unit, Ministry of Health.

INTRODUCTION Measles, is a highly contagious disease and there is at least a 90% risk of secondary infection in susceptible contacts. It can affect people of all ages, despite being considered primarily a childhood illness. The current measles outbreak in Sri Lanka has become a major health problem to everyone. It has not only affected the health of the children and adults but also has become a burden on health care workers and policy makers. Measles virus is a single-stranded, lipid enveloped RNA virus of the Genus Morbillivirus , family Paramyxoviridae. The portal of entry is either through the respiratory tract or conjunctivae by aerosol droplets. The infective period is from three days prior to the rash up to six days after onset. Measles infection consists of a prodromal period, an exanthematous phase and a recovery phase. Initially the virus replicates in the tracheobronchial epithelial cells. After two to four days, the virus infects local lymphatic tissues due to carriage by pulmonary macrophages during the incubation period. During the prodromal phase the virus disseminates to various organs. The exanthematous phase is manifested by the appearance of the rash.

EPIDEMIOLOGY Measles still occurs worldwide although the incidence of measles decreased substantially in regions where high coverage of vaccination is present. Last outbreak of measles occurred in Sri Lanka in 1999/2000. The number of cases rapidly increased to 20,000 within 2-3 months and the outbreak subsided in nine months without any intervention. The majority of the susceptible population got infected naturally during the outbreak and herd immunity barrier was re-established to its threshold, and transmission slowed down. In order to interrupt transmission there should be 92-94% vaccination coverage. The factors that could increase the potential for outbreaks are presence of a significant number of susceptible persons, continuous virus circulation, conditions facilitating contact between susceptible and infectious individuals.

Measles and Rubella elimination targets for Sri Lanka: • Less than 5 measles cases/ million population by 2015 & < 1 cases/ million population by 2018 • Less than 10 Rubella cases/ million population by 2018

• Less than 1 CRS case/ 100,000 Live births by 2018

Measles elimination strategies • Maintain high immunization coverage [>95% in each district] ( at 1 & 3 years) • Active surveillance: case based surveillance: Laboratory confirmation of almost all cases is a requirement. (except Epidemiological linked cases if >2 ) • Outbreak prevention and adequate investigation of outbreaks • Effective case management and prevention of complications & mortality

As shown in Figure 1 the majority of cases occurred in the prevaccination group (<1year)

CLINICAL MANIFESTATIONS The symptoms of the prodromal phase include mild fever, conjunctivitis, coryza, cough and Koplik spots. A red maculopapular rash appear initially in the face and neck and spread down to the torso during the the exanthematous phase. The rash fades off with fine desquamation and pigmentation during recovery. The subclinical cases can be confused with conditions such as rubella, adenovirus, enterovirus, EBV, mycoplasma and , Kawasaki disease.

Fig 1: Measles cases reported to epidemiology Unit by age, from 1st January 2013 to May 2013 (Source Epidemiology Unit)

Contd. on page 04



October, 2013 Contd. from page 3

MEASLES... tion, transient measles-specific IgM antibodies appear in the blood and IgA antibodies appear in mucosal secretions; IgG antibodies persist in the blood for years. Vaccination also induces measles virus-specific CD4+ and CD8+ T lymphocytes.

Fig 2 :Measles, MR and MMR vaccine Coverage and Measles Cases by Year, in Sri Lanka, 1951-2012 (Source Epidemiology Unit)

COMPLICATIONS The risk factors for development of complications include malnutrition, underlying immunodeficiency and vitamin A deficiency. The associated complications are diarrhoea, pneumonia, otitis media, encephalitis, corneal ulceration. Subacute sclerosing panencephalitis (SSPE) is a delayed complication.

MANAGEMENT There is no specific treatment and most patients will recover with rest and supportive treatment with antipyretics, hydration and nutrition. A systematic review of trials found significant reduction of mortality in children aged < 2 years treated with Vitamin A. The WHO recommends all children in measles endemic countries receive 2 doses of vitamin A supplements, given 24 hours apart. The use of antivirals is not helpful. Ribavirin is used in adults, but there are no controlled trials in children.

POST EXPOSURE PROPHYLAXIS The vaccine is preventive if administered within 3 days of exposure. Human immunoglobulin prevents disease in susceptible contacts (immunocompromised children) if administered within 6 days of exposure.


LABORATORY DIAGNOSIS AND SURVEILLANCE Laboratory diagnosis involves virus Isolation, molecular assays (PCR and genotypic characterization) and serology. The specimens for virus isolation are naso-pharyngeal aspirates, throat swabs / nasal swabs and less often urine sediments (easy to obtain ) and oral fluid. The samples for virus isolation should be collected within 5 days of onset of rash. The recommended assay for serology is an IgM ELISA (WHO). A serum sample should be collected between 3-28 days of onset of rash. During the first 72 hours 77% of the samples are IgM positive while 100% are positive between 4 - 11 days. Virus Isolation is confirmed by immunofluorescence and RT-PCR. Oral Fluid Samples have been successfully used for surveillance of measles (and Rubella and Mumps) in the UK. Molecular techniques when used in conjunction with standard epidemiologic techniques will assist in early detection of outbreaks of infection.

VACCINATION Measles vaccine induces both humoral and cellular immune responses comparable to those following natural infection, although antibody titers are usually lower. Following vaccina-

Vaccinating infants before or at the age of 6 months often fails to induce seroconversion due to the immaturity of the immune system as well as the presence of neutralizing maternal antibodies. In countries with ongoing transmission in which the risk of measles mortality among infants remains high, the first dose should be administered at the age of 9 months and in countries with low rates of measles transmission ( near elimination) the first dose may be administered at the age of 12 months. Sri Lanka introduced measles vaccine in 1983. Initially only single dose monovalent measles vaccine was administered at the age of 9 months and a 2nd dose of measles vaccine was introduced in 2001 to be administered at 3 years. In 2011, the monovalent vaccine was replaced by MMR and the first dose was rescheduled to 12 months and second dose of MMR remained at 3 years. The factors considered during introduction of MMR at the age of 12 months were aimed at reaching the highest sero-conversion rates as per WHO recommendation for countries with low rates of measles transmission.

Strategy used in outbreak control in 2013 (current outbreak) Infants aged of 6-12 months were given an additional dose of monovalent measles vaccine as they are the highest affected and the most vulnerable group for complications of the disease. Compiled by Professor Jennifer Perera, Chairperson, Subcommittee on Communicable Diseases


October, 2013

Optimising care for children with disabilities: A pre congress workshop Compiled By Dr Samanmali Sumanasena Honorary Secretary SLMA

â&#x20AC;&#x153;Optimising care for children with disabilitiesâ&#x20AC;? a full day workshop, conducted at the Lady Ridgeway Hospital for Children in collaboration with a group of experts practicing in Abudhabi was one of the main highlights at the pre congress workshops held during the 126th Anniversary Scientific Medical Congress in July this year. A determined Sri Lankan mother Mrs. Chandanie de Silva, who has a child with special needs and is presently residing in Abhudhabi, initiated this venture through Dr. B.J.C. Perera the President of the SLMA. The workshop was well attended by all members of the multidisciplinary team working for the betterment of children with disabilities. They included Paediatricians, Paediatric Neurologists, Child Psychiatrists, medical officers, allied health professionals, nurses, teachers and parents representing the governmental, private and the non-governmental sectors. Following the formal training workshop a meeting for the parents of children with Down Syndrome was conducted by the team. Prof. Hemamali Perera, consultant

Psychiatrist and Dr. Jithangi Wanigasinghe, Consultant Paediatric Neurologist representing the Expert Committee on Disability of the SLMA chaired the academic programme. Dr. Eeva Lisa Langille a Consultant Neonatologist led the team of experts and a speech and language therapist, a nutritionist, a nurse coordinator, an administrator and a special needs education teacher joined her to conduct the workshop. During the first session of the workshop the team briefly discussed relevant topics. These topics included providing medical care, nursing and establishing services for special needs, nutrition, speech and language therapy and special education needs. As a prelude to the programme a parent from Sri Lanka and Abudhabi shared their experiences about obtaining services within the two settings. Breaking news about the birth of a child who may be a potential candidate for special needs, providing continuity of care and support, taking care of the family and social welfare needs were some of the main discussion points. The participants also took part in

group work with each resource person where they enthusiastically discussed how they could improve the care they provide for children with special needs at their own stations. Most participants enjoyed the special education station where they practised methodologies and strategies to be adopted within their practise. The event ended up with session for the parents which was chaired by Dr. Samanmali Sumansena, Consultant Paediatrician. During this session the main messages given to the parents were to identify the strengths of the children and observe developmental progression giving adequate opportunities and time for the children. The parents were requested to safe guard the rights of their children always. The session was attended by the WHO Country Representative, Dr. Firdosi Rustom Mehtha and the WHO donated the book titled You and Your Disabled Child authored by Margaret Barret translated to Sinhala and Tamil by the Cerebral Palsy Lanka Foundation for free distribution amongst the participants. Dr. Leenika Wijeratne (Consultant Psychiatrist) on behalf of the SLMA coordinated the organization of this event at the LRH

Workshop on Development and Validation of Data collection tools


he fifth research training workshop organized by the Research Promotion Committee of the SLMA aimed to familiarize participants with the principles and issues in design of data collection tools, and introduce them to the concepts related to the validation of such tools. It was successfully conducted by Dr. Nalika Gunawardena on Saturday 14th September 2013. The workshop drew an audience of 50 participants from disciplines in medicine and biomedical sciences. The workshop focused on design principles for questionnaires, observation checklists, and clinical audits. Issues in tool selection, item construction, and respondent instructions


were clarified through examples. Participants engaged in an hands-on activity of designing appropriate tool/s for given scenarios, followed by feedback by Dr. Gunawardena and an active discussion. The next workshop will focus on different validation techniques. It will be conducted by Dr. Nalika Gunawardena on 16th of November. Those interested in participating can contact the SLMA office on 2693324 for details. We are also planning to hold a workshop on qualitative research in November. We invite suggestions from our readership on future workshops (please email


October, 2013

Annual Career Guidance Seminar for Junior Medical Officers 2013


he Seminar was held on Sunday 15th September 2013 at the Lionel Memorial Auditorium of the SLMA. The seminar was well attended with 108 pre-intern doctors registering for the seminar. The seminar was inaugurated by Dr B.J.C. Perera, President SLMA. The President in his address pointed out the myriad of functions carried out by the SLMA and its role as the apex professional organization for all grades of doctors in Sri Lanka. He impressed upon the audience importance of â&#x20AC;&#x153;youngâ&#x20AC;? doctors getting involved in academic and professional activities of the SLMA. The seminar has been organized by the Health Management Committee of the SLMA as an annual event since 1992 to achieve the following objectives: a. To increase awareness of the advantages and disad-

vantages of working in different specialties in the state and private sectors in Sri Lanka; b. To help guide junior doctors in the selection of a future career; c. To ensure in the long term a more equitable planned distribution of doctors for all specialties;

leges for their support in providing the resource person for the seminar. The Committee acknowledges the contribution made by GlaxoSmithKline in the organization of the seminar.

d. To make participants aware of the opportunities available outside the Department of Health, locally and abroad. The seminar was very interactive with the participating pre interns clarifying their doubts from the resource persons from various specialties. The Committee obtains feedback from the participants and revises the programme to cater to the career guidance need of the junior doctors. The segment on private sector opportunities was introduced to the progrmme in 2012 based on analysis of the feedback received in 2011. The Committee places on record its appreciation to all respective Col-

Dr B.J.C. Perera addressing the gathering


Grand Offers through the dedicated, affiliated and SLMA branded Hatton National Bank (HNB) Credit/Debit Card to SLMA members Hatton National Bank joined hands with the SLMA to offer an affinity Signature and Platinum Visa Debit/ Credit card exclusive to the SLMA members in May 2013. The primary objective of this card is to promote membership through a 9 monthly instalment payment scheme. In addition, with each purchase through this card the SLMA receives a percentage revenue. This is from HNB and is not an extra payment by the card holder. The HNB has organized several special offers given exclusively to the SLMA-HNB Card Holder members during the festive season up to the 31st of December 2013. 1. Jaya bookshop 15% discount 2. Hameedias 12.5% discount 3. All electrical goods, laptops, cellular phones from Servo Trading 10% discount

The Keels Hotels offer 50% discounts for all HNB card holders. Hatton National Bank Credit/Debit Card is also offering several other attractive facilities exclusive to the SLMA members. New and existing members are hereby cordially invited to join the SLMA Credit Card Scheme. Dr. B.J.C. Perera President, Sri Lanka Medical Association




October, 2013

Highlight of SLMA Foundation Sessions Jointly with Anuradhapura clinical society

Ceremonial procession with the Chief Guest Prof Vajira Dissanayake accompanied by the President SLMA and the President of the ACS

President SLMA Dr. B.J.C. Perera addressing the gathering

Dr Damitha Chandradasa clinical society delivering the welcome speech at the Inaugural ceremony of the Annual sessions


E.M. Wijerama endowment lecture by Dr. Eugene Corea

Chief guest Prof Vajira Dissanayaka at the Annual academic sessions

SLMA president Dr B.J.C. Perera awarding the medal for the Sir Marcus Fernando oration to Prof. Surangi Yasawardena.

October, 2013


SLMA regional meeting - Jaffna


n keeping with the SLMA policy of taking its activities out of Colombo SLMA held it’s third regional meeting of the year in collaboration with Jaffna Medical Association on 11th October 2013 at the Nurses’ Training School Auditorium of Teaching Hospital Jaffna. The main theme of this meeting was “Nutrition” and an eminent panel of resource personnel conducted the program. This was an immensely popular session with nearly 100 doctors, RMPs and medical students representing Jaffna and Kilinochchi Districts attending. The meeting was kicked off by Dr. B.J.C. Perera, President SLMA who in his welcome address stressed on the importance SLMA places in these regional meetings. Dr. S. K. Arulmoli, Consultant Paediatrician TH Jaffna talked on the topic of “Feeding the infant” and he explained the “science” behind the nutritional practises pro-

moted today and common mistakes made by medical professionals when giving advice to mothers and other caregivers in this regard. Dr. Shanthini Ganeshan, Consultant Paediatrician BH Mulleriyawa then discussed prevention and management of acute and chronic malnutrition which was thought to be very relevant to this region. Dr. S. Shivaganesh, Regional Epidemiologist described the nutritional situation in the Nothern Province and she drew comparisons with the other provinces of Sri Lanka. Dr. Geetha Sathiyadas, Senior Lecturer in Paediatrics, Faculty of Medicine, University of Jaffna then spoke on “Nutrition of the girl child: Impact on the offspring.” This was once again thought to be a very relevant topic for the region. In the afternoon session full use of modern technology was made when Prof Mandika Wijerathna and Prof Chandrika Wijerathna ad-

Dr. B.J.C. Perera, President SLMA addressing the gathering.

dressed the audience from Colombo via “Skype” when they talked about the “NIROGI Pada” and “NIROGI Matha” concepts respectively. The meeting was brought to a close by Dr. V. Sujanitha, Consultant Physician, TH Jaffna and Dr. Malik Fernando, Marine naturalist and former President of SLMA with their address on “Jellyfish stings in Jaffna: Searching for culprits.” All presentations were well received and were followed by lively discussions. Participants were unanimous in the view that the entire program was highly educational and informative. SLMA conducted a similar educational program on nutrition to the Nurses, Public Health Midwives and Nursing students on the following day at the same premises which again was very well received with over 150 participants.

Dr. B.J.C. Perera, President SLMA and Dr. S.Udayakumar, President Jaffna Medical Association lighting the oil lamp to inaugurate the conference.

Section of the audience of the session held for nurses and midwives.



October, 2013 Contd. from September issue

Jawatte Lunatic Asylum: the forgotten relict of the colonial era... The Jawatte Asylum-. By

eighteen-seventy five the debilitated structure, poor sanitary conditions and constant overcrowding had caused serious health hazards resulting in increasing deaths of inmates in the Borella asylum. On the recommendations of the Principle Civil Medical Officer Dr. W.R. Kynsey, a decision was made by the then Governor, Sir William Gregory to construct a new asylum to replace the existing one which accommodated about 230 inmates at the time. From the time this decision was made there had been considerable discussions between the Governors, Gregory and his successor Sir James Robert Longdon, the Superintendent of the asylum, PCMO, Colonial Office, Lunacy Commission in the UK, Crown Agents and the Special committee appointed by Governor Longdon on a number of issues related to the new asylum. These discussions dragged on for the next seven years. The discussions were related to the unsuitability of the site, inadequacy of the extent of land, inappropriateness of the design to tropical climates and care of lunatics, and inadequacy of the number of rooms to suit patients with different grades of illness and social circumstances. Dr. J.W. Plaxton who was recruited from England by the Colonial Office to manage the new asylum was the chief critic of the plans recommended by the Governor and the local architects. The Lunacy Commission in the U K went on to say that the site has been selected more for “convenience” than for health reasons. Finally after a lengthy discussion, Governor Longdon with the concurrence of the Colonial Office decided to go ahead with the construction at the fourteen acre site at Jawatte with certain modifications to original plans which were considered by the


latter as a “partial solution to the question” given the limitations of funds. The entrance and two wings connected to the central administration block accommodated patients, staff and service areas. In 1889 the construction of the asylum for 400 inmates was completed by which time all patients from the Borella Asylum had been transferred to the Jawatte Asylum. Subsequently many additions were made in response to emerging needs. The Governor also had to contend with the criticism that the new asylum was an extravagant project and was palatial in nature and likely to be a white elephant. Governor Longdon defended his plan and stated “As compared with filthy hovels which some of the insane poor inhabit, the building may certainly be called palatial: and I trust that when new asylums or hospitals are built in this or any other colony, they will be an improvement on the huts of the native peasantry. The asylum is a series of one-storey buildings of the plainest type. The walls are of brick plastered, because of the climate plastering is found requisite for the preservation of buildings. There is no expensive ornamentation, or indeed any ornament at all, unless a short ungraceful and inexpensive tower over the entrance designed for the clock can be called an ornament. The enclosing walls are of ordinary cabook, such as is universally used for garden walls in Colombo.

Problems of the Jawatte Asylum- Dr. J.B. Spence who suc-

ceeded Dr. Plaxton as the Superintendent in the mid eighteen eighties continued to be concerned about the lack of staff, space for patients, staff and the superintendent, fee levying rooms in the context of relative lack of funds. The Superintendent had one assistant medical officer and

a few attendants to look after more than 500 patients, attend to administrative and medico-legal work. The new asylum at Jawatte built over a period of fifteen years, was overcrowded within years of completing to give way to an even bigger asylum. These problems were in fact predicted by the previous superintendents and other professionals during the planning phase and even earlier but authorities showed very little interest in responding to these. It is interesting that while a considerable amount of discussion, planning and funds were allocated to the building of the Jawatte Asylum, very little discussions took place or resources allocated to train and recruit staff, provide additional facilities or to the improvement of care. Thus the quality of care provided at the Jawatte Asylum became even worse than what was available at the Borella Asylum earlier and this has been referred to over and over again by successive Superintendents. One of them, Dr. Van Dort, went to the extent of questioning the suitability of constructing large expensive buildings instead of structures modeled on “Cottage” design which are much cheaper and more appropriate for local conditions. The Jawatte Asylum was closed down in the mid-twenties and the buildings were offered to public institutions including the newly established University of Ceylon.

Angoda Asylum- In 1911 a new

Asylum was planned at Angoda and building commenced in 1917 almost on the same design as the Jawatte Asylum. Inherent problems of staff, training and provision of facilities continued to get worse from the beginning. It was inevitable that the new Angoda Asylum built for 1800 inmates in mid twenties became outdated even faster than the Jawatte Asylum. Contd. on November issue


October, 2013

Re : Chronic Kidney Disease of Uncertain Aetiology (CKDu)


he final report on Chronic Kidney Disease of Uncertain Aetiology (CKDu) funded by the National Science Foundation (NSF) and the WHO is now released. Several recommendations have been proposed by the authors of the report and its time that we begin to discuss how these could be implemented in Sri Lanka. The following actions are proposed to facilitate this process. The proposals are merely points to initiate discussion. Possible actions for the SLMA and the medical profession are given within brackets.

o 1.

Recommendation Supply safe drinking water to households

Proposed actions


Strengthen Regulatory Framework relating to fertilizer

a. Engage with Customs and other institutions and identify banned pesticides b. Restrict on unethical advertising and promotion of chemicals by industry

1.Supply safe drinking water to households:

a) Advocacy role to lobby for universal access to safe drinking water (This was highlighted in the previous SLMA Newsletter and was the topic of two Symposia. What else should the SLMA do in this regard?) b) Monitoring the implementation of water supplies in respective MOH areas. (Is this a feasible option for the preventive sector?) c) Estimate economic benefits of safe water, in order to lobby Min of Finance for resources to provide safe water to all households (Is this a suitable topic for a MD in Community Medicine?)

3. 4.

Implement comprehensive Public Health measures


Strengthen tobacco control


Regulate use of herbal medicine Strengthen Health Services


Welfare to those affected Research



10. Accountability

a. Develop new clinics b. Allocate resources to identified hospitals c. Develop guidelines d. Provide necessary drugs (e.g. ACEI) e. Optimum control of NCDs a. Provision of social support a. Cabinet Sub-Committee and Parliamentary Select Comm

d) Campaign on adequate fluid intake for farmers

a) Engage with Customs and other institutions and identify banned pesticides. (Do we as health professionals know the list of banned pesticides? Can we publicize the list in the Newsletter? )

g) Disposal of batteries etc

f) Advice on eating certain vegetables

5.Strengthen Tobacco Control Measures

Use the data on Cadmium to reinforce campaign against tobacco growing and sales in the area 6.Strengthen Health Services to combat the disease in endemic areas (For discussion by the Health Management Committee of SLMA and Committee on NCDs)

a) Develop new clinics

a) Engage with Pesticides Registrar (Should the SLMA have a meeting with the MoH and the National Poisons Information Centre at NHSL?)

b) Allocate resources to identified hospitals

b) Enforce use of safety apparatus (Is the Ministry of Labour responsible for this?)

d) Provide necessary drugs (e.g. ACEI)

c) Restrict unethical promotion of chemicals (Should this be an area for SLMA to tackle?) 4.Implement comprehensive Public Health measures (SLMA can facilitate this process by developing a set of core public health messages that can be disseminated to the public)

a) Dangers on the use of chemicals


c) Develop guidelines (Should the Ceylon College of Physicians and Nephrologists take a lead in this area?)

Partners Min of Water Supplies and Drainage and other stake holders

Phasing out of tobacco planting in these areas Press conference to increase awareness

Min of Agriculture if this is feasible

A suitable package to be developed and launched by the Health Education Bureau and MOHs and Provinces

A comprehensive plan is required with the assistance of the Provinces and Min of Health.

a. Policy relevant priority research areas

c) Control sale of chemicals and promote alternatives e) Harms of tobacco

3.Strengthen Regulatory on banning and implementation of ban of pesticides and weedicides

a. Increase awareness

b) Compulsory safety clothing

2.Strengthen Regulatory Framework relating to fertilizer

b) Restrict on unethical advertising and promotion of chemicals by industry (Should this be an area for SLMA to tackle?)

a. Dangers on the use of chemicals b. Compulsory safety clothing c. Control sale of chemicals d. Campaign on adequate fluids e. Harms of tobacco f. Advice on eating certain vegetables g. Disposal of batteries etc a. Reiterate chemical effects of tobacco.

Comments / Questions Obtain plans developed by the relevant authorities and see if health concerns are captured Could Med Off of H help monitor implementation? Who implements the ban? Can the PDHS or Med Off of Health (MoH) be involved at a local level? How do we restrict advertising of chemicals? Can the MoH be included in inspection of occupational exposure, and adherence to safety measures?

Hospitals to work closely with the Social Services Allocate funds from available resources specifically to CKDu Attempt to obtain further information that is available to the public on this matter

c) Advocacy

HEB. ?conduct a workshop to identify and finalize the messages that we should give the public

Min of Indigenous Med MoH and Provinces Role of Sri Lanka Society of Nephrology and Transplantation Role of CCP Min of Social Services MRI and MoH (ET and R) Secy Health

Establish research programme based on new findings (This is already being done by the National Research Council. Applications have been called for in this area). 9.Accountability

Promote accountablilty by forming Task Force (Discuss with the Ministry of Health) The way forwards is to

1. Discuss the above at the council 2. Improve and agree on plan of action 3. Submit to MoH 4. Circulate it in newsletter / publish in CMJ to obtain further inputs from membership 5. Meet with MoH (Secy of Health) and team on how SLMA could be engaged and assist in the process to tackle CKDu. Thank you Yours sincerely

7.Welfare for those affected (To discuss with the Ministry of Health. This could be one opportunity to lobby for a cadre of Health Social Workers)

b) Mobilize NGOs

Min of Labour Min of Agriculture


e) Optimum control of NCDs

a) Liaise with social service sector

Min of Labour Min of Agriculture

Prof Saroj Jayasinghe Health Equity Committee Council Member of SLMA

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SLMA News 2013 10  

The official news paper of the Sri Lanka Medical Association