The College of Community Physicians of Sri Lanka (CCPSL) is the apex professional body for the practice of public health in Sri Lanka. The CCPSL functions as a strong and informed professional body to advocate promotion and prevention of disease of the people of Sri Lanka. The CCPSL is responsive to the current and emerging public health challenges and conforms to evidence based approaches and principles.
The membership consists of specialists in Community Medicine. In addition to these professionals, there are members from other specialties as well.
Has Sri Lanka done enough or done what has been shown to be effective?
The epidemic is continuing. The country has implemented a multi-faceted, multi-stakeholder and society-oriented strategies at their best to counteract the expected damage. Learning from the successes and failures of other countries which faced similar situations would be of immense help to reshaping the current strategies and introducing new modalities.
We emphasize that “China has rolled out perhaps the most ambitious, agile, and draconian disease containment effort in history.
Are we on track?
The CCPSL firmly believes that we are on the right track and that we have strategically implemented many of the interventions far ahead of other countries. However, the country needs to continue on the same path on a heightened scale with appropriate new strategies.
We acknowledge the strong political leadership provided by the President, the Prime Minister and the Minister of Health. Their commitment is in line with the Director General WHO’s call for a “Whole Government Approach”. The Army Commander’s role and contribution brought success of the total quarantine process. This could not have been achieved with only the health sector. Sri Lanka Police is ensuring law and order during the social distancing. All the other ministries, agencies and professional bodies are supporting at their highest level in the response.
The CCPSL proposals for the future challenges in the epidemic response
Sri Lanka sets an example to the entire world, with its timely and effective response to the global epidemic despite being a low- and middle-income country. This highlights the importance of investing in public health. Although, we have done so far sensibly, the CCPSL proposes following strategies to address the future challenges in the epidemic response;
1. Learn from the successes of other countries:
Success of China, South Korea, Japan and South Korea and also the failures of Italy, Spain, Germany, UK and USA should be analyzed in depth and thereby, current strategies need to reshaped.
We should acknowledge the importance of a whole government approach with optimal intersectoral collaboration and coordination
- a total system approach to manage health security (clinical services, population health, surveillance, science);
- transparency and accountability
2. Streamline lockdown strategy
Several issues have been encountered in the implementation of this strategy. To address the challenges, it is necessary to introduce a people-friendly intermittent relaxation of lockdown and improve social responsibility through culture change. It is imperative to strengthen non health measures such as availability of food and medicines, economic packages for all sectors affected, special care for financially vulnerable families, enforce laws to improve infection prevention and social distancing. We suggest to review the strategy after two weeks and change where necessary.
3. Personal hygiene and social distancing
Further strengthening community mobilization and mass campaign for personal hygiene and social distancing adopting new behaviors in the outbreak context should be considered as a ‘nation at war against COVID -19’. It is crucial that we sensitize the public to their active role in the response, such as on social and physical distancing – staying home and the one meter rule at all times including transport
4. Sub-national and non-health sector preparedness and response plans
Engage with key partners to update national and sub-national preparedness and response plans.
Building on the existing strategic preparedness and response plan of COVID-19, exploration of possible collaboration options with the non-health sector should be undertaken.
5. Raising health system capacity & readiness
In addressing the challenges in raising health system capacity & readiness, the aims should be;
• preventing transmission in facilities and homes and not to overburden system;
• ensure capacity to treat severe and critical patients while maintaining essential health services
• protect health workers for continued care and service
When the severity profile of COVID-19 cases is considered; 40% mild, 40% moderate (with Pneumonia), 15% severe and only 5% become critical cases. Severe patients need oxygen therapy and critical cases need mechanical ventilation.
Estimated numbers requiring hospitalization based on current size of outbreak cannot be precisely predicted.
At the same time, it is essential to expand the capacity of mild patient admission and to deploy/ surge medical teams from nationwide depending on the increasing case load.
6. Self-quarantine process
More stringent quarantine process for persons exposed and close contacts should be deployed. Singapore showed the success of the strict quarantine rules. Introduce quarantine for persons with fever/other symptoms, suspects and close contacts for better compliance and outcomes.
7. Protection and appreciation of key healthcare workers
Sustenance of the epidemic response is largely dependent on the active involvement of the healthcare workers. It is equally important to protect them from being victims of the epidemic itself and also to keep their morale high. This is very much needed for public health staff as their contribution has not been adequately recognized or appreciated at national level. Ultimately, they might become unsung heroes of the ongoing battle.
It is important to ensure adequate supply of personal protective equipment (PPE) for all the HCW dealing with patients and in preventive sector, and also to ensure the rational use of any PPE based on Ministry of Health guidelines which was adopted from WHO guidelines.
8. Disease stigma
The CCPSL is concerned with the stigma generated on identified cases and contacts by officials and media. We, CCPSL, reiterate that stigma is harmful to people and to the outbreak response. Stigma can drive people to hide the illness to avoid discrimination, stop people from seeking health care immediately and prevent people from adopting healthy behaviors.
9. Sustaining care for the non-COVID patients
Ensuring survival of the other patients is also crucial. When the whole system is geared to protect people from Covid19, the focus for other disease entities and non-Covid patients will be diluted.
Therefore, it is essential to introduce triage systems, reserving tertiary main hospitals for non-COVID patients. Vulnerable groups include: patients with chronic diseases who need regular treatment and drugs, e.g. dialysis; critical patients such as cancer patients, and those who have to seek rare medical treatment elsewhere; pregnant women who need regular prenatal check-ups; older people, those unable to leave the house and residents of different kind of institutions
10. Further collaborations with media on providing public awareness on COVID and getting the public mobilized to meet their obligations as responsible citizens through dissemination of authentic and evidence-based messages and information on the epidemic.
There is already a successful media campaign launched by the Health promotion Bureau. It should be strengthened by giving dedicated media time for dissemination of current epidemic information.
11. Compilation of the evidence of COVID-19 of all countries in a dynamic e-repository.
The future challenges
Epidemic response is a dynamic process and strategies may also need to change depending on the dynamics of the outbreak. The general public needs to understand this reality and have a right to know the true facts. They should develop trust on the government’s country-specific approaches and maximally support such efforts as all the interventions are executed with a valid reason and purpose. However, both the authorities and the people need to think carefully, weigh risks in context, and pursue interventions commensurate with the magnitude of the challenge.
We are reaping the gains again of the well-structured public health system of this country bringing about astounding results in this pandemic situation. In Sri Lanka, already existing public health system consisting of a battalion of field health staff are geared for needy interventions which is seen as a feasible task and an approach immensely helping to flatten the curve.
At the same time, it should not be ignored that we may be at greater risk of exaggerated fears and misplaced priorities as history suggests. We should understand the limited evidence on epidemic progression in tropical countries like Sri Lanka. With 95 years of experience in having a strong public health system and being a tropical country, the behaviour of the epidemic will be more likely to be different to the temperate countries. As such, what may be predicted may not be applicable in unique contexts of our country.
We urge the government, community leaders, other stakeholders and general public on the need of concerted efforts to fight against the country’s worst challenge in the millennium.
At the same time, the CCPSL is happy that the Covid19 outbreak forced an entire community to take refuge in a multiple healthy behaviours which we would have never been adopted with the traditional health education approaches and behavior change. Capitalizing on the context of the Covid19 outbreak, our long term target is a “Healthy Sri Lanka”.
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