The legacy of a president in peril – the island
By Kusum Wijetilleke
Sleepwalking towards tragedy
About 9,185 Sri Lankans had succumbed to Covid-19 as of September 1. There are extraordinary scenes across the country with patients leaving overwhelmed hospitals. Widely circulated video shows patients lined up on the floor along the halls of Colombo North University Hospital in Ragama. There were emergency purchases of medical oxygen from India in May and reports suggest that Sri Lanka is currently facing a severe shortage of intensive care beds.
As the health system reaches a breaking point, there is an inescapable feeling that Sri Lanka has lost control of a situation that many saw coming. The data from India and many other countries was clear; B.1.617.2 also known as the Delta variant would soon arrive preparations and precautions were needed to protect the public.
Before and during the Sinhala / Tamil New Year period, medical experts were calling for a lockdown to at least delay the inevitable spread of the Delta variant. At the time, the total death toll in Sri Lanka stood at just over 600, the death toll per day was in single digits. Community spread of the Delta variant was officially reported for the first time in Sri Lanka on June 18. The April destructive peak in India was proof enough of its severity. The medical community had been consistent: the Delta variant was more aggressive and more transmissible.
Unfortunately for thousands of Sri Lankans, the preservation of human life has had to be made subordinate to the most urgent priority of keeping open a struggling economy to serve what is apparently the greatest national good. During his last national speech, as the walls continued to close on citizens, the president asked “everyone in the country to be ready to make more sacrifices …”. tragic loss of life.
Speaking to the media on August 13, the executive director of the Institute for Health Policy, Dr Ravindra Rannan-Eliya said that based on current projections, the death toll in Sri Lanka could exceed 20,000. by the end of 2021. He also highlighted the rate of double vaccinations at the time, which was around 10%; far too low to make a significant difference in the overall transmission rate. He further said that Sri Lanka is at the lower end of the spectrum when it comes to testing and tracing capabilities.
A few weeks later, Sri Lanka was able to rapidly increase the full vaccination rate to 30%, a testament to the effectiveness of the Sri Lankan military and its 24-hour vaccination centers. As a result of these efforts, Sri Lanka now has a much better full immunization rate than many other lower middle income countries; Bangladesh (3.8%), Egypt (2%), Indonesia (12%), Pakistan (6%), Kenya (1.5%), Iran (5%), India (10%).
However, in a rapidly evolving global pandemic, timing is of the essence. As vaccination rates rise, the number of cases and deaths also continues to rise. As Dr Rannan-Eliya points out, Sri Lanka lags behind some of the peer group when it comes to testing volumes and capacity. Daily tests per million in Sri Lanka were around 500 during the last week of August. India (1,384), Iran (1,159), Vietnam (1,644) and the Philippines (520) are all tested at higher rates than Sri Lanka.
To put in context how dire the situation in the country is currently, in the seven days leading up to August 30, 2021, Sri Lanka recorded the fifth highest number of deaths per million in the world, at 54. The countries alone that worsened over those seven days were Botswana (57), Eswatini (64), North Macedonia (72) and Georgia (102).
Priorities: public health or political?
Thanks to a truly exceptional vaccination campaign, the military provided significant coverage for the government’s many missteps at crucial times. Most countries suffered a high death toll in the first months of the pandemic in 2020, but Sri Lanka had one of the lowest death rates in the world at the time. At no point in 2020 has Sri Lanka’s health infrastructure risked being overwhelmed. President Gotabaya Rajapaksa declared victory against the pandemic, wondering why Sri Lanka was not recognized as a model nation in this regard. Indeed, in April 2020, CMA Australia’s Global Response to Infectious Disease (GRID) index ranked Sri Lanka’s response to the pandemic as the 9th best in the world.
Colombo is not Dhaka or New Delhi; Sri Lanka’s dense urban populations do not have the same intensity or frequency as many other countries in the South-East Asia Region. Considering the lead Sri Lanka has enjoyed throughout 2020, a lot could have been done until 2021. The total number of deaths as of December 31, 2020 stood at 204, which, considering the number current deaths, is an indicator of the severity of the pandemic. managed since the beginning of the year.
The current lockdown was not so much a decision by the government, but a decision imposed by a chorus of critics. Last week, the WHO Independent Technical Expert Group in Sri Lanka, made up of around 14 medical specialists, including Dr Padma Gunaratne, Professor Saroj Gunaratne and Professor Neelika Malavige, called for an extension of the lock and increase restrictions within it. The group pointed to a study from Monash University, which calculated that the lockdown until September 18 would help save 7,500 lives.
Throughout 2020 Sri Lanka wasted precious time and resources elsewhere instead of building the necessary test-trace-isolate infrastructure that many medical experts, including Dr Rannan-Eliya, had requested. Instead, there were general elections, major constitutional changes, and political theater turning into a barely believable telenovela about the dynasty. The international borders were opened, then closed and reopened again. At some point after the borders reopened, tourists from Russia and Ukraine arrived in the country as the number of cases and deaths in those respective countries increased.
Vaccine supply: too little, too late
Despite these clearly sub-optimal decisions, Sri Lanka still had every chance to get ahead of the global curve. A revealing article by attorney Dr Gehan Gunatilleke laid out some startling facts about the timing and process for purchasing vaccines in early 2021.
Sri Lanka’s National Medicines Regulatory Authority (NMRA) approved the Covishield vaccine manufactured by Serum Institute India (SII) on January 22, 2021. Cabinet approval was granted a few days later and on January 28, Sri Lanka received its first batch of 500,000 doses as a donation from India due to its “neighborhood first” policy.
The first purchased batch of 500,000 Covishield vaccines did not arrive until February 25, nearly a month later. This crucial delay appears to have been caused by the passage of a local agent pre-authorized to the State Pharmaceutical Corporation (SPC). Since NMRA approval was obtained by the local agent in January, the government could have placed an immediate order with SII and received a large shipment in early February. Everything was in place for such an order until the need arose for SPC’s intervention.
Some reports claim that SII requested a supply through the SPC, but according to Dr Gunatilleke, the NMRA report made no mention of it and in addition, SII had already delivered 5 million doses to Bangladesh through a local agent in January. Was it the Sri Lankan authorities who requested the intervention of the CPS? A new approval had to be obtained by the SPC, which involved repeating the entire procurement process, including obtaining the approval of the purchase contract.
A Cabinet briefing revealed that the price per dose of Covishield was $ 5.25; Sri Lanka would end up paying $ 15 per dose for the Sinopharm vaccine. In a February 19 article, the Hindustan Times quoted Indian officials that the State Pharmaceutical Corporation of Sri Lanka had signed an order for 10 million doses that SII had reserved for Sri Lanka.
In a separate report from June 2021, lawyer Ranil Angunawela said: “In our opinion, if Sri Lanka already received donations of an NMRA-approved vaccine before January 28, 2021, and the price of a dose said vaccine vaccine has been predetermined, there is no other obstacle in the purchasing guidelines that prevents a “very urgent and exceptional” purchase order from being placed within days of NMRA approval “, Angunawela said.
Cabinet approval for the purchase of Covishield through the SPC was granted on February 22, and the purchased first batch of 500,000 doses arrived on the 25th. The delay of nearly a month has left Sri Lanka at the mercy of unpredictable externalities; a fire at SII’s manufacturing plant has been compounded by a sharp rise in the number of cases in India, leading to a temporary ban on Covishield’s exports.
The facts point to a missed opportunity: Had Sri Lanka taken delivery of a large vaccine order at any time in February, several thousand Sri Lankans could have been saved from the Delta variant. Another point to consider: why has the Government not diversified its risk on vaccine supply; Has there been overdependence on the Serum Institute of India and Covishield?
In the public interest
Public health decisions have been influenced by economic and political considerations. For much of 2021, the message has been clear; human lives are important but not as important as the economy. Health issues are important, but not as important as cultural considerations such as the traditional New Year or the Esala Perahera. President is under pressure to request an independent report on vaccine supply, but must go further and consider Sri Lanka’s entire response to the pandemic, especially public health policy and stabilization measures economic and stimulus.
It is safe to say that the only aspect of Sri Lanka’s response that can be considered an absolute success is the vaccination campaign. Questions remain on almost every other aspect of the government’s response. Aside from vaccine procurement and pricing, have the necessary investments been made to expand “test-trace-isolate” facilities? Have adequate measures been taken to increase the number of intensive care beds and severe addiction units (HDU)? Have there been early orders for supplies of medical oxygen, C-PAP devices and ventilators? Has the government considered antiviral therapies like hydroxychloroquine or ivermectin, which India has approved? Has the administration prioritized the elderly who account for the lion’s share of hospitalizations and deaths? Were the lockdowns introduced in a timely manner with sufficient time for citizens to plan and prepare?
Given the sacrifices made by Sri Lankans, given the state of the economy and the rising death toll, the president must realize that his legacy is now on the line.