Ensuring migrant workers' rights
By Feizal Samath
Despite growing concerns about the plight of migrant workers abroad, Sri Lankan experts dealing with migrant workers are cautious about the need to tighten procedures, saying; "don't kill the goose that laid the golden egg."

"On the one hand, we need to protect our workers. On the other hand, we don't want to lose our share of overseas job markets in the Middle East and Europe to competitors," said M. Seevaratnam, a consultant at the state-run Sri Lanka Foreign Employment Bureau (SLFEB).

He was among a group who spoke of the dilemma of protecting close to one million Sri Lankan workers, the bulk of them women in the Middle East, from unscrupulous job agents here and abroad, rape and physical abuse by employers and a host of other problems.

"We need to protect our workers but we also need to be cautious in this process. If labour receiving countries feel we are placing restrictions on foreign employers, they may go to other labour supplying markets that are less restrictive," agreed S. S. Wijeratne, Chairman, Legal Aid Foundation of the Bar Association, who also said the demand for foreign labour in Europe, the Middle East and Asia was rising.

Speaking at a seminar last month on legal aid for migrant workers that the foundation is hoping to provide, Wijeratne said they were planning to provide the assistance of lawyers in the Middle East to workers while there was also hope that the UN Convention on the Rights of Migrant Workers would finally be implemented this year.

The UN Convention which provides for the rights of migrant workers across the world has been signed by more than 20 countries but only 19 have ratified it. It requires the ratification of 20 countries to be enforced.

"We are expecting Bangladesh to ratify it before the end of the year. That I hope would provide added protection to our workers," said David Soysa, Director, Migrant Services Centre (MSC), a non-governmental organisation promoting the rights of migrant workers. Under the UN convention, a special committee would be appointed in member countries to protect workers' rights.

According to a survey of returnee migrant female housemaids conducted by the MSC recently, more than 20 per cent of those interviewed suffered injuries due to physical abuse from employers while more than 50 per cent who have returned were under medical treatment for ailments like back pain, asthma, heart disease and other complications.

The study, conducted in 400 households in three Sri Lankan districts which provide a sizable number of migrant workers, also found that 24 persons were subject to sexual abuse while in employment, with two pregnancies occurring among two of them.

Of the entire sample survey, about 27 per cent said their employment experience had a negative impact on the family with problems like divorce or separation, social and health problems, husbands being addicted to alcohol, children dropping out of school and depression amongst family members, to mention a few issues.

The survey also found that annual incomes of migrant workers went up to Rs. 25,000 a month for 80 per cent of those interviewed suggesting that many financially benefited from overseas employment.

Migrant workers are an integral part of the Sri Lankan economy and are the highest nett foreign exchange earners, totalling about one billion US dollars annually. Such is the power of the industry that the government had to hastily withdraw a proposed 15 per cent tax on remittances by migrant workers proposed in the budget on November 5.

Public fury over the proposal was spread across the newspapers, television and radio stations forcing Finance Minister K. N. Choksy to concede that there had been some misunderstanding and that all references to a tax on remittances were being withdrawn. Remittances are tax-free and have been so for many years.

On the positive side, Seevaratnam said the government was considering amendments to the Sri Lanka Foreign Employment Bureau Act - which governs all migrant workers - and would invite representations from the public to strengthen and update it.

"There is a desperate need to update the Act and bring it in line with modern trends. It was enacted in 1985, at a time when there were not many women going abroad," he said.

Priyadarshini Karunaratne, Deputy Director, Consular Affairs Division, Foreign Ministry said amendments were also being drafted and would be presented to parliament shortly enabling females to register their children conceived abroad and apply for Sri Lankan citizenship through the country's embassies abroad.

There are a number of migrant women workers who have conceived children either after being raped or out of wedlock and are not able to obtain Sri Lankan citizenship for their child since local laws only allow Sri Lankan males this right. They return to the country with children who are often stateless.

"The new laws will change this discriminatory rule," she said. Karunaratne said 273 Sri Lankan migrant workers in the Middle East have died so far this year and the ministry had arranged for their bodies to be brought to Colombo. Most have died from heart failure due to a heavy workload in homes where they work.

Padmini Samarasinghe, a counsellor at Sorophistist International, an international NGO which helps underprivileged women, pleaded for a ban on the export of women labour.

"There are serious problems when women leave their children and go abroad. Yes, it is nice to talk of the government earning foreign exchange but what about the children who are left behind to fend for themselves?" she asked, acknowledging however, that she was among the minority who felt that way.

She said the government with the help of society should take care of the children left behind by these migrant workers. "The children are subject to all kinds of abuse, drop out of school and are dragged into drugs and crime. We need to devise a system where the children are looked after while their mother is away."

Samarasinghe, a group director at one of Sri Lanka's top companies - Browns -, said her organisation has tried to convince some women - at a village outside Colombo - who want to go abroad to do so when their kids are grown up. "We have been urging women with children as young as 1-2 years to go abroad only after their children are older and more mature," she said.

Exclusive Sri Lankan delicacies
The concise guide to the Anglo-Sri Lankan lexicon by Richard Boyle - Part xix
Although curry is too universal to be considered part of the Anglo-Sri Lankan lexicon, there are three culinary items recorded in the second edition of the Oxford English Dictionary (OED2) that are exclusively associated with Sri Lanka. These are pol sambol, punatoo and short-eat. In addition, there are a handful of fruits and vegetables partly associated with the island, such as bilimbi, carambola, bread-fruit, jack, moringa/murunga, and pompelmoose/pommelo. Last but not least is the sweetener, jaggery. Date of first use is provided in brackets.

Bilimbi (1772-84). According to the OED2 it is: '[Tamul bilimbi, Malay bilimbing, Cingalese bilin.] A tree (Averrhoa Bilimbi) growing in India and Ceylon, which yields a juice used by the natives for the cure of skin-diseases; also its fruit.'

This fruit is also known in Sri Lankan English as the country gooseberry or cucumber fruit.

None of the references given in the dictionary has relevance to Sri Lanka. The earliest from English literature pertaining to the island is by James Cordiner from A Description of Ceylon (1807:223): 'The billimbirg, or country gooseberry, in shape and colour resembles a girkin, or young cucumber, having five flat sides, and a strong acid taste. It is used in making tarts and preserves.'

A 20th century reference is provided by Harry Williams in Ceylon, Pearl of the East (1950[1963]:224): 'The rambuttans, avocado pear, morro, bilimbi, cashew nut and rose apple all have their advocates.'

There is a corresponding entry in the second edition of Hobson-Jobson (H-J2) with the headword blimbee.

Bread-fruit (1697). Sinhala rata del. 'The farinaceous fruit of a tree; especially that furnished by Artocarpus incisa of the South Sea Islands, etc., of the size of a melon, and having a whitish pulp of the consistency of new bread. Also short for Bread-fruit tree.'

This species now bears the scientific name Artocarpus altilis.

Both Percival (1803) and Cordiner (1807) employ bread-fruit tree, but it is Lord Valentia, writing in Voyages and Travels (1809[1811]:274), who first uses bread-fruit: 'I again read Thunberg, and was astonished at the scantiness of his intelligence respecting Ceylon, and at his having made several very singular mistakes. Among these is his having given a list of dishes formed from the bread-fruit, when, in fact, every one of them refers to the jack, a very different fruit, and on which the natives in a great degree subsist.'

Carambola (1775). Sinhala karma-ranga. '[Several Portuguese writers of the 16th century state that this was the native name in Malabar; Molesworth has Mahratti karamabal; Forbes Watson has a Hindi name karmal, Singhalese and Hindi karma-ranga.] The acid fruit (golden-yellow, ellipsoid, obscurely ten-ribbed) of a small East Indian tree Averrhoa Carambola.'

This fruit is also known in Sri Lankan English as the Chinese gooseberry, or star fruit.

Knox (1681:20) is the first to use the Sinhala term karma-ranga in English literature pertaining to Sri Lanka. In contrast, a modern reference to carambola comes from the Ceylon Daily News (April 10, 2000): " ... three new varieties each of waraka and tomato, and one each of winged bean, green gram, potato, sweet potato, grapes, camaranga (carambola), makunuwenna, gotukola and beans.'

Jack (1613). Sinhala kos. 'The fruit of a tree (Autocarpus integrifolia) of the East Indies, resembling the bread-fruit, but larger and of coarser quality. Also the tree itself.' This tree now bears the scientific name Autocarpus heterophyllus.

The only reference with relevance to Sri Lanka given in the dictionary is by James Emerson Tennent from Ceylon (1859:II.111). He uses the common form in Sri Lankan English: "The jak with broad glossy leaves and enormous yellow fruit."

There are many references to jack throughout English literature pertaining to Sri Lanka, the earliest of which is by Knox (1681:14): 'There is another fruit, which we call Jacks; the inhabitants when they are young call them polos, before they be full ripe cose, and when ripe, Warracka or Vellas.'

The first reference after Knox is by Percival (1803:316): 'The jacka, or jack-fruit, grows upon a tree of a very large size.'

Another early reference is by Valentia (1809[1811]:227): 'Towards night we entered an avenue of most magnificent jack trees, which extended the whole way to Caltura.'

Jaggery (1598). 'A coarse dark brown sugar made in India by evaporation from the sap of various kinds of palm.'

The sole reference with relevance to Sri Lanka in the OED2 is by Knox (1681:15): 'The which liquor they boyl and make a kind of brown sugar, called jaggory.'

The first of many references after Knox from English literature pertaining to Sri Lanka is by Percival (1803:320): 'The toddy is likewise made into vinegar, and yields a species of coarse black sugar known by the name of jaggery.'

Moringa (1753). '[Adoption of modern Latin moringa.] The Ben-nut tree (Moringa pterygosperma). Also attributively.' This tree now bears the scientific name, Moringa oleifera.

Moringa is not adopted from modern Latin but from a name of much older and probably Indian origin, which appears in Sinhala dictionaries as murunga and in Tamil dictionaries as marunkai. This shortcoming will be rectified in the third edition of the dictionary.

There are no references with relevance to Sri Lanka in the dictionary. The first from English literature pertaining to Sri Lanka is by Cordiner (1807[1983]:219): 'Moringa is a tree which grows to the size of a mountain-ash, with very small pinnated leaves, and a yellow blossom. Its root and bark possess the flavour and pungency of horseradish, and are used in the same manner.'

Murunga (1681). Needless to say, there are many references to murunga rather than moringa in English literature pertaining to Sri Lanka. These have been forwarded to the OED, and I am informed that the third edition of the dictionary will include a separate entry for murunga.

Knox (1681:19) is the first to use the term: 'They have several other sorts of fruits which they dress and eat with their rice, and taste very savoury, called carowela, wattacul, morongo, cacorebouns, &c., the which I cannot compare to any things that grow here in England.'

The first reference after Knox is by Anthony Bertolacci from A View of the agricultural, commercial and financial interests of Ceylon (1817[1983]:89): 'The toddy vinegar improves by being kept a long time, and by a small quantity of the bark of the moronga - tree being infused into it.'

There are many modern references from fiction. For instance, A. Sivanandan writes in When Memory Dies (1997:347): 'Superbly cooked, I must say,' observed Vijay, working through his fourth crab-belly. 'The murunga leaves make all the difference.'

Then there is Michael Ondaatje, who writes in Anil's Ghost (2000:240): 'It was legendary that every Tamil home on the Jaffna peninsula had three trees in the garden. A mango, a murunga, and the pomegranate. Murunga leaves were cooked in crab curries to neutralise poisons.'

H-J2 does not include an entry for moringa, but there is one for the synonym, horse-radish tree.

Epilepsy: The surgery option
Dr. J. B. Peiris, Senior Consultant Neurologist clarifies some issues and misconceptions on epileptic surgery
Surgical treatment for epilepsy was commenced in Sri Lanka recently. Many patients who are on medication are inquiring whether they could have a permanent cure by one operation, instead of continued medication for a few years.

Surgery for epilepsy is not new. Surgery as a form of treatment for epilepsy was introduced around 50 years ago and has been available in the neighbouring countries like India for over 40 years. While treatment with drugs (previously called anti-convulsants, now preferably termed anti-epileptic drugs -AED) is the mainstay in the management of an epileptic patient, there is a limited place for surgery in selected patients with poorly controlled epilepsy.

Rationale of treatment
To understand what we are trying to achieve in treating epilepsy, we need to understand epilepsy. In the majority of instances, epilepsy is a transient, paroxysmal or intermittent disturbance of brain function commonly resulting in a fit or seizure, or impairment or loss of consciousness or awareness. As it is transient or short lasting, a seizure or fit recovers spontaneously or on its own within a few minutes. An attack or 'ictus' requires no treatment. During an attack, all that is required is to turn the person to a side for secretions to flow out and to position the patient to prevent injury. Inserting objects like spoons to the mouth is not recommended.

Then what is it that requires treatment? What is aimed at in treatment is prevention of recurrent attacks. In 75-90% of patients, this is achieved easily with regular drug treatment. Drugs are gradually withdrawn after the patient has been free of attacks for about two years, which may be shorter in selected patients. Rarely, in attacks lasting longer than 30 minutes in where there is no return to consciousness (status epilepticus), hospitalised treatment may be required. To sum up, treatment is directed to preventing attacks or for prolonged or complicated attacks. Most patients tolerate the currently available effective drugs like sodium valproate, carbamazepine, phenytoin sodium, clonazepam or phenobarbitone well. Often, control is possible with one drug alone. Multiple drugs or newer drugs are sometimes required.

Recommendations for evaluation for surgery
The Institute of Neurology, Queen Square, London, the Royal College of Physicians and UK National Society, London have laid down the guidelines for selection of patients for surgery clearly, for epilepsy. Let me quote some of their recommendations and conclusions:

General criteria for referral
* Any patient with medically intractable epilepsy which has not responded to adequate medical therapy and willing to consider brain surgery could be considered for an opinion with a view to surgery. Only a minority of these patients will be suitable for surgery.
* In most instances, patients will have been on treatment for a minimum of three years and will have had at least four of the anti-epileptic drugs.
* In most instances, a patient will be having more than two seizures a month. The epilepsy should be sufficiently severe and disabling, to warrant consideration of surgery, taking into account the patient's view on the matter.
* Diagnosis of epilepsy must be certain and non-epileptic conditions should have been confidently excluded.
* There should be no contraindication for surgery.
Features which predict a beneficial outcome of surgery
* Patients with the variety of epilepsy known as 'temporal lobe epilepsy' - epilepsy originating from the temporal lobe confirmed by EEG and MRI scanning.
* Childhood onset of temporal lobe epilepsy with a history of febrile convulsions
* EEG evidence of epilepsy arising from one temporal lobe
* MRI evidence of disease of one temporal lobe, particularly an entity known as hippocampal sclerosis
* No history of generalized fits.

Aim of surgery and predicted outcome
The aim of surgery is total relief of seizures. Surgical outcome depends on the underlying cause. In temporal lobe epilepsy with hippocampal sclerosis (a particular pathological change), approximately two thirds of carefully selected patients are rendered seizure free. A further 20% has a reduction in a number of seizures. It is important to stress that careful selection of the patient is absolutely essential for a successful outcome. Following surgery, disabling neurological complications occur in about one in 50 operations. These include such serious deficits as weakness of one side (hemiplegia), impaired vision on one side (hemianopia), loss of speech and loss of memory. Minor complications are more common. Depression and psychosis may also occur.

Relative contraindications and chances of poor outcome
* Severe intellectual deficit or mental retardation
* Psychosis unassociated with a fit
* Frequent or multiple seizures
* Frequent abnormality in both temporal regions or other regions
* Normal high resolution MRI scan
* Age over 40

The team for epilepsy surgery
While the surgery is entrusted to a neurosurgeon with expertise in epilepsy surgery and the patient is evaluated and referred by an equally motivated neurologist or a specialised epileptologist, input from a multi-disciplinary team is essential. A neurophysiologist analyses the Electro-encephalographic records to confirm the origin of the focus causing epilepsy, as it is partial seizures of temporal lobe origin, which have a particularly good surgical outcome. The services of a neuropsychologist, a neuropsychiatrist and appropriate counseling facilities are also considered essential to ensure proper selection and follow up.

Investigations required for evaluation and selection of patients

Before any operation for epilepsy can be performed, there has to be a period of careful testing and evaluation

These tests are done to make sure the surgery has a good chance of being successful and won't affect any of the important functions of the brain.

Most of the tests are used to pinpoint the area of the brain where seizures begin or to locate other areas like speech and memory that have to be avoided.

How many tests have to be done depends on the kind of operation that is being planned and how much information each test produces.

The following tests are most often used before a decision to operate is made:

* Electroencephalography (EEG) tests record electrical activity in the brain and identify areas of the brain where seizures occur.

* Magnetic resonance imaging (MRI) scans take pictures of the inside of the brain. MRI scans may show tumours, abnormal blood vessels, cysts, and areas of brain cell loss or other brain damage.

* Simultaneous video (TV) monitoring and EEG recording help identify the type of seizure that is taking place.

* Neuropsychological tests, including IQ, memory, and speech tests, tell doctors more about where the seizures (or the brain damage which is causing the seizures) are located.

* An intracarotid sodium amobarbital test locates speech and memory centers. A drug is injected into an artery leading to the brain. It puts half of the brain to sleep for a short period of time. The doctors then check speech and memory on the side of the brain not put to sleep. Not done as yet in Sri Lanka.

* Positron Emission Tomography (PET) scans may be used in certain cases to help identify where seizures are taking place. PET measures how intensely different parts of the brain use up glucose, oxygen, or other substances. Not available in Sri Lanka

Recommended optimal facilities

* Routine and sleep EEG recordings

* Continuous EEG recording with video telemetry and scalp electrodes

* Psychiatric evaluation

* A MRI scan to confirm temporal lobe pathology

* Neuropsychological assessment including measures of intellectual and language function, and memory tests.

* Facilities for intracranial EEG for a minority of patients who may need this investigation.

The above facilities are the optimal facilities recommended by the joint committee of London neurologists, physicians and epileptologists but all of these are not essential for provision of this important arm of treatment for the poorly controlled epileptic in the developing countries. However, we must be aware of the deficiencies and the pitfalls that may accompany their non-availability.

Single Photon EmissionComputed Tomography (SPECT) scans also help identify where seizures are taking place by measuring blood flow. Simultaneous video monitoring, intra-carotid sodium amylobarbitone, SPECT and PET scanning is not available in Sri Lanka, at present.

Even after all the previously described tests are done, additional information may be needed to identify the epileptic area in the brain. This is because electrodes sometimes can't find the area of seizure activity attached to the surface of the head. It is envisaged that an annual turnover of about 25 patients undergoing epilepsy surgery is needed for the team to develop and maintain necessary skills.

Pre-Surgical Testing in advanced centres

* To obtain that additional information, two separate operations may be required.

* The first operation places electrodes in or on the brain itself. These special electrodes are called depth or subdural electrodes.

* After they are placed, the patient remains in the hospital with the head wrapped in a large dressing, with wires attached to the electrodes coming out of the dressing. Seizures are then recorded directly from the brain, often on simultaneous video and EEG. This process is called electrocorticography.

* Both kinds of recording instruments may be kept in place for some time while doctors monitor signals from within the brain during seizures.

* The brain may be stimulated with mild electrical impulses via the electrodes to identify special areas controlling speech, movement and sensation. In addition, further electrical recording to map out the seizure focus (the exact area to be removed) may be done.

* If the tests show that there is a single epileptic area and it can be removed safely, a second operation is performed to remove the affected area. If not, surgery is done only to remove the electrodes.

* Sometimes all the tests and procedures rule out surgery as a suitable treatment. At other times, the tests may fail to give enough information and the doctors may decide not to recommend surgery.

* This method of localisation is not carried out as yet in Sri Lanka. At present, only selected patients with very definitive localised areas of abnormality responsible for epilepsy defined by EEG and MRI are subjected to surgery.

The operation is done with the hope of removing the focus in the brain, which produces the epilepsy. The resection may be directed to removal of the lesion (lesionectomy), removal of the whole temporal lobe (temporal lobectomy) or removal of the whole of one cerebral hemisphere (hemispherectomy). Patients and relatives who have suffered many years may feel the ultimate answer has arrived - but brain surgery is not to be taken lightly except for those who really need it and who will do well after it.

For the patient and relatives to make an informed decision he or she should have a co-ordinated input from the neurosurgeon, neurologist, neuropsychologist and access to appropriate counselling. Surgical conversion of a retarded severe epileptic into a retarded non-epileptic with the original behaviour abnormalities may create new abnormalities for the family. However, the availability of the surgical option for the appropriately selected patient is a blessing that should not be denied.

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