The Sunday TimesPlus

8th December 1996



Dengue throws up hospital shortcomings

Patients on floor and two in bed

By Chamila Jayaweera and Chandimal Mendis

The dengue epidemic that spread through the country like poison through one's veins brought to light some horrifying truths. Firstly that there had been no proper control by the authorities to safeguard people from the deadly mosquito. Secondly, the frightening extent to which the majority of hospitals in the country are overcrowded.

A resident of Panadura, Mrs. S. Liyanage had a shocking experience to report. Her eldest daughter was warded in a private hospital with the deadly fever, and then her second child had contracted it as well.

Unable to manage the high hospital fees for a second time, she and her husband had immediately taken the girl to a state hospital in Colombo.

Upon arrival however, they had changed their mind. "We didn't care if we went bankrupt as long as our daughter was cured," they said. What had led to their decision was the sight of several patients in the hospital, receiving blood and saline while seated pitifully on wooden benches.

The Liyanage family was fortunate enough to have the option of being able to resort to the services of a private hospital; but what about others? The ones who cannot afford the high fees and had no other choice whatsoever? Did they have to be content with a bench, instead of a bed?

Of course, the situation is no better now, even though a Dengue Day was declared last week to create more awareness of the dreaded disease. Dengue, or any other illness needs proper care and visits to some of the hospitals around Colombo proved that not all patients receive this, despite the best efforts of doctors and nurses largely due to the lack of facilities available.

In one of the male wards in the National Hospital of Sri Lanka, half the occupants were seen to share beds with others. The rest had no option but the cold, hard, cement floor.

The Cancer Hospital in Maharagama is packed and overflowing. Obviously, the functioning Cancer Wards in other places are no different. Acting Deputy Director, Dr. Cyril de Silva, explained the situation.

"There are functioning Cancer Units in both the General Hospitals in Kandy and Karapitiya. The facilities in both these institutions are about the same as those in Maharagama. There are Cobalt machines for radiotherapy, and there are Surgeons there, but still we get a steady flow of patients from around these areas. The only additional piece of equipment we have here is a CT Scanner, that we got down recently," Dr. Silva pointed out.

He believes it is the attitude of patients that needs to be changed. They need to have more faith in hospitals around the areas they live in, without flocking to Colombo for the slightest ailment. The bed strength of the Maharagama Cancer Hospital is now 562. However, Dr. Silva revealed that simply adding extra beds would not solve the issue.

With three and a half acres of empty land available near the hospital, plans are apparently being discussed to put up a new hospital complex, within the next three or four years, for which foreign assistance is being sought. This will no doubt help in overcoming the issue of overcrowding to an extent

Director of the Lady Ridgeway Hospital and the Castle Street Hospital, Dr. Wimal Jayantha, had a few suggestions to offer to tackle the problem of overcrowded hospitals.

Having conducted a study on the matter, he said, the tendency for patients to bypass small institutions, where the occupancy rate was about 65%, could be tackled by adopting various strategies. The Primary Health Care system which a lot of developing countries focused on was considered very effective. Here education was used in preventing and alleviating a lot of diseases, with vaccinations against viruses being the main.

Another option, was the referral system, where the forward and back referral cases were used. Legally, Dr. Jayantha pointed out, every patient had the right to go anywhere he pleased in order to get better treatment. With the "forward referral" system, patients were sent to larger hospitals, if facilities were not available at their local units, or a Specialist's advice was needed. With the "back referral" system, patients were given treatment when admitted to any hospital, and then referred back to their local area hospitals , where they would be more comfortable due to less crowding there.

Expansion in the private sector would help those patients who could afford to pay for their treatment in private hospitals, and leave more room for those who couldn't in the government institutions, since it was hard for most of these to take on the heavy load of patients, Dr. Jayantha said.

Dr. Terrence de Silva, Director of the National Hospital, Colombo, too, observed that adding more beds just to accommodate patients was not the proper solution. The average number of beds in a hospital, he said, was between 600 to 800. The number of beds currently in his hospital amounted to 2750. This represents six percent of the total beds in the public sector hospitals in Sri Lanka. With Lanka's population of our isle topping 17 million, and steadily increasing , can hospitals cope with the thousands more who will pour in through their doors by the year 2000 ?

With a bed occupancy rate of 101 % at the National Hospital ,as 1995 statistics show, the probability of patients not having sufficent beds in the years to come is high. The average length of stay of patients is about 6.2 days and the number of admissions a year as much as 162,340. Patients were admitted on rotation to various wards, with non-urgent cases dismissed as effectively as possible to avoid overcrowding.

"Simply building an additional ward, or adding a few beds does not alleviate problems, it is only a temporary measure," Dr de Silva said, agreeing that patients on the floor or two per bed would most likely be neglected. "There is only a limited number of staff members in a hospital. These personnel are allocated, (sometimes five to a bed in the Intensive Care Unit) in such a way that everyone receives adequate attention. However, if a hospital becomes overcrowded, then the staff faces the problem of distributing their time equally among patients," he pointed out.

He wasn't however, aware of the instances when patients had received blood and saline while seated on benches , though he added it might have been an extreme measure.

Till the regional hospitals are brought up to a sufficient standard, then, people will continue to suffer, and spend vast amounts on private medical institutions to care for their sick and wounded. Dexter Fernando of Wattala, had to travel to Nawaloka Hospital to get the tests for his wife's spinal problem analysed. And even then, she had to sit stiffly on a bed with another patient.

President of the Nurses Union Ven. Muruththettuwe Ananda expressing his views said that this problem arises due to the lack of facilities at rural hospitals. He also pointed out that even the nurses are more stressed out , as they have to attend to more patients as a result of this problem.

Minister of Health A.H.M. Fowzie lamented the fact that doctors had not agreed to his suggestion to pay for using the facilities in hospitals for private practices, which he said could have been utilised to better the conditions, as well as make sure the availability of a doctor close by always.

He said however that they had sought the help of several NGO's and foreign aid, although they were yet to respond positively.

When asked if they planned to reform regional hospitals, he acknowledged that a lot of work still needed to be completed before people regained confidence in them, and added that they had already begun the process.

Minister Fowzie also briefly described a new system set up between Sri Jayawardenapura hospital and Nawaloka hospital which would aid greatly in saving theatre time. "This system will allow surgeons to perform operations at the same rate as in Sri Jayewardenapura, where patients would only have to pay for the cost of consumables. The hospital will be paid through the President's fund, but they will forego about Rs 100,000 per operation at the same time," he explained.

However at present there is already a list of about 4000 patients waiting to undergo cardiac surgery, and the process is set to start immediately.

A national health policy is also being implemented in order to improve the services of the medical sector, geared for the future . The health policy of the government will be directed at consolidating the earlier gains as well as adopting new policies to raise the health status of the people towards a healthy nation.

TRI: meeting challenges of world tea trends...

Adding flavour to your cuppa

by Hiranthi Fernando

The Tea Research Institute (TRI) of Sri Lanka is located amidst lush green hills of tea in the cool climes of Talawakelle. It extends over an area of 96 hectares of which 70 hectares are planted in tea. The complex which is the headquarters station of the TRI, includes administrative offices, laboratories, plant nurseries and two divisions of tea, St. Coombe's and Lamiliere, with a tea factory at St. Coombe's. Comfortable staff quarters and a club with recreational facilities for staff members are also located on the premises.

The need for a tea research institute was felt in the 1920s, by which time, the tea industry was well established in Sri Lanka (then Ceylon). R.G. Coombe, a prime mover in the campaign for a tea research station, placed a resolution before the General Committee of the PlantersÕ Association. The proposal was officially mooted by the Planters' Association in 1923. D.S. Senanayake, then Minister of Agriculture, supported the proposal along with 97% of the tea industry.

The TRI now functions under the control of a Board, well represented by the tea industry, appointed by the Minister of Plantations. The Board is headed by a full time Chairman and the Institute is administered by a Director, responsible to the Board. In addition to the Headquarters Station, sub-stations have been set up at Ratnapura, Deniyaya, Kottawa, Passara and Hantana. Briefly, the TRI carries out all aspects of research connected with the cultivation and processing of tea through nine research divisions. For example, Plant Propagation and Breeding, Plant Physiology, Plant Pathology, Entomology, Agronomy, Biochemistry and Agricultural Economics are some areas of research carried out. The research findings are conveyed to the tea producers by circulars and bulletins as well as through the Advisory and Extension Service which is the link between the producer and the research.

Over the years, the TRI has made many contributions to the growth of the tea industry in the country. Three among them stand out particularly. The long term fertilizer experiment initiated at St. Coombe's still continues and is believed to be the first of its kind on a tree crop. The widespread application of inorganic fertilizer at required rates during the post war period was the result of TRI research. The vegetative propagation of the 1950s resulted in the release of the TRI 20/20 series clones which showed a marked increase in productivity compared to seedlings. These clones have been used in many tea producing countries. Since then, newer clones, TRI 3000 and 4000 series have been developed. In the control of pests and disease too, TRI recommendations have been far reaching. The intensive research on the Blister Blight disease for instance, perhaps saved the tea industry from suffering the same fate as the coffee industry.

"The goal of the Institute's research is to help increase the productivity and sustainability of the tea industry and reduce the cost of production", says Dr. Wester Modder the current Director, who took over the post in June this year. "Our tea industry is the country's highest net foreign exchange earner" he said. "lts future is obviously tied up with future trends in the international tea market". He went on to explain that while the world production of black tea is estimated to grow at 3.9% per annum, the demand for it from importing countries is expected to increase only by 3.3%. The prices are therefore likely to decline and both small holders and the privatised tea sector will have to meet this challenge.

The TRI is thus engaged in a process of restructuring to cope better with the needs of the tea industry. Research departments are being merged to reduce overlapping of areas and make it more streamlined. Scientific research staff are encouraged to work in collaboration towards achieving their goals. Modern techniques and new approaches are being introduced.

In order to identify and assess the research needed by the tea industry, the TRI recently adopted the CADMAR (Composite Approach to Decision Making in Agricultural Research) methodology. This method has been successfully tried out in some other countries for planning their research activities. Following workshops and discussions with producers, priority areas for further research were identified in both cultivation and manufacture. Research thrusts were formulated for the next ten years. Many of these projects are already underway. The priority areas include breeding for improvement of crop, improvement of land productivity, crop management, post harvest technology, land use planning and improving labour efficiency.

TRI has begun adaptive trials for smallholdings with a view to reducing the period of soil rehabilitation in marginal tea lands identified by Tea Small Holders Development Authority. Multi-cropping trials are already in progress. In order to obtain maximum productivity and income per unit area of land, inter-cropping tea with rubber has been tried out at St. Joachim's estate of the Ratnapura substation. Promising results have been achieved by the experiments which now require fine tuning. This could be very beneficial to low country smallholders. In the mid country, soil degradation, erosion and deforestation have reduced yields of many tea lands. Inter-cropping with coffee and pepper is being experimented on to increase the productivity of these lands.

Participatory research is a new concept now used by TRI. "Partnerships between growers and scientists is proving to be beneficial in world agriculture today," commented Dr. Modder. "Growers should not only be endusers but partners in research. The TRI Advisory & Extension Service should not only be a one way conduit for technology transfer but also convey ideas and data from growers to our scientists. We are thus collaborating with estates, smallholders and universities to conduct joint research and develop technology. For instance we get good fields from estates and establish mother bushes. We can make use of plantations at different elevations for replicating clones and conducting experiments. The response from planters has been fantastic. The Planters' Association is also co-operating".

According to the Director, the Advisory and Extension Division of the TRI is doing a good job despite insufficient staffing and resources such as vehicles and audio visual aids. The substations need to be upgraded considerably in order to deal better with regional problems. Considering the immense number of estates and smallholders, the number of advisory and extension personnel is relatively small. Thus, estate visits and seminars cannot achieve all that is desired. A more realistic approach of "training the trainer" is now being tried out with TSHDA.

This year, for the first time, a forward extension programme for 96/97 was presented to a well attended meeting of plantation and TSHDA representatives for discussion and amendment. It is intended to continue this pattern in the future with improvements. "The response, co-operation and suggestions we received on this programme have been very encouraging", Dr Modder said.

On the environmental front, regaining soil fertility by incorporating organic matter, de-emphasising chemical fertilizers, reducing or eliminating the period of soil rehabilitation are being considered. The environment-friendly efforts at soil management and pest and disease control using biological agents would in time lead to a reduction in the use of imported fertilizers and pesticides also saving foreign exchange.

A fully fledged biotechnology laboratory for developing the perfect clone using micro-propagation and tissue culture, modern energy efficient and hygienic factory production methods, analytical equipment for ensuring that manufactured teas are free of extraneous matter and a solar energy project at the Ratnapura sub-station feature in the future plans for tea research. The TRI is working towards ISO 9000 certification for the two tea factories, St. Coombe's and St. Joachim's. Procedures in the factories will be examined, researched and amended in collaboration with the workers in order to achieve increased efficiency and acceptability.

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