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Public health and public health law in Ceylon
PUBLIC HEALTH AND PUBLIC HEALTH LAW IN CEYLON An Account of a Short-Term W H O Assignment By F R E D
GRUNDY,
M.D., M.R.C.P., D.P.H.
Mansel Talbot Professor of Preventive Medicine, University of Wales THE visit to India and Ceylon described in this note arose out of a request to WHO by the Government of Ceylon for technical assistance to help them bring up to date and consolidate the Island's Public Health Law. Technical aid of this particular character had not previously been provided anywhere, so that in agreeing to meet Ceylon's request, W H O was committing itself to an exploratory project with a considerable element of uncertainty. The degree of success which attended the assignment, and the reasons for seeking outside assistance, are questions of some general interest which will be touched on later. As both the general law and the public health law of Ceylon are based mainly on British models, it was natural that W H O should turn to the United Kingdom for consultants to undertake the work. Thus it was that in the autumn of 1957, I was invited to visit Ceylon on the understanding that I should have the assistance of a legal colleague for the task. Arrangements were made for me to leave England on the 23rd January, 1958, for a period of three months. M y legal colleague, a legal draftsman in the Ministry of Housing and Local Government, was to join me in Colombo some time in February. Two of the three months were spent in Ceylon and both the outward and return journeys were via Geneva (the seat of WHO headquarters) and New Delhi, where SEARO (the South-East Asia Regional Office o f WHO) is located. Surface transport was ruled out by the time factor, and the need for briefing and discussions meant that the routing would be through Geneva and New Delhi. So it was that I left a snow-covered England on the morning of Thursday, 23rd January, to begin general consultations at the Palais des Nations, Geneva, later in the day. The general briefing included a review of previous WHO assignments in Ceylon, and a discussion on the general nature of the present project. Two facts emerged. The volume of papers handed to me for perusal left no doubt that Ceylon was one of the most surveyed countries in the world. Discussions with WHO personnel made it abundantly clear that they could not tell us a great deal more about the state of public health law in Ceylon than we could ourselves glean from existing reports. This was very little. Our WHO colleagues stressed that the assignment was on new lines, and I was invited to comment, 363
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in due course, on its practicability and on the possible usefulness of suchlike projects in under-developed or rapidly evolving countries. The process of briefing continued in Delhi. The principles on which WHO technical aid is based were discussed--particularly the importance of training a local colleague (known as a "counterpart") who could continue the work begun by visiting experts after they had left. Little more information about the scope of the assignment was forthcoming than had been vouchsafed in Geneva, but at all events we itemised the steps that would have to be taken whatever the detailed character of the assignment turned out to be. It was agreed that we should have to begin by studying at first hand the organisation of health services in Ceylon, and the way they were working, and then proceed to familiarise ourselves with existing health laws and their operation. Only after completing these preliminaries would it be feasible to consider the questions of amending or amplifying existing law and of preparing consolidating legislation. SOME
FACTS
ABOUT
CEYLON
Ceylon is a pear-shaped tropical island some 270 miles long and 140 broad, separated from the great land mass of India by a narrow strip of shallow water --the Palk Strait. It has a central mountainous area rising to a little over 7,000 feet, an upland belt around the central area, and a coastal plain of varying depth. The whole country is well watered by many rivers and streams; in ancient times, large-scale irrigation was undertaken from tanks, many of which are maintained and in use at the present time (in Ceylon, reservoirs are called "tanks"). From 544 B.C., Ceylon was ruled uninterruptedly for 21 centuries by dynasties of Sinhalese kings. From the 16th century onwards Ceylon, or parts of the island, were possessed in turn by the Portuguese, the Dutch and the British. Under the British, Ceylon was unified, developed and introduced to the arts and sciences of the West. In 1948 the island was granted her independence. The climate is essentially tropical. In the low country the annual mean temperature is about 81 ~ F., but in the higher country the temperature falls off at a rate of about 1~ F. per 300 feet rise in altitude. The annual rainfall is heavy in most parts of the island. The population is about 8,750,000 and comprises the Sinhalese--the large majority--Tamils, Dutch Burghers, Indian Tamils, Europeans, Moors and a number of other races. One-fifth of the population live in a few large cities. e.g. Colombo, Kandy and Galle, and the remaining four-fifths in village communities. In the coastal strip, the villages lie among the main trunk roads, but inland they are relatively isolated jungle communities. A typical village dwelling is constructed of jungle timber covered with palm leaves, or of wattle and mud, with a floor of rammed earth. The principal crops are coconut and rice in the low country, and tea, rubber, coffee and spices in the hills. In rural areas the
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water supply is usually from wells, most of which are shallow and inadequately protected from pollution. Few houses outside the towns are provided with latrine accommodation of any kind. THE
HEALTH
STATUS
OF
THE
ISLAND
Vital statistics never give a complete picture of the health status of a country, but they are a good starting point. Two facts stand out: first, that Ceylon though in some respects lagging behind the best European standards of health, compares favourably with other Asian countries; and second, that very remarkable improvements have been made in the last 10 years. The crude death rate in 1956 was 10.1, while 10 years earlier it was over 14; the infant mortality rate, 67 in 1956, was 101 in 1947; the maternal mortality rate, 3"8 in 1956, was 15.5 in 1946. The crude death rate has, of course, a qualified significance as an index of health unless it is related to population structure, but less equivocal is the life expectancy at birth which increased from 44 years in 1946 to 60 years in 1956. It has, indeed, been described by WHO as "an unparalleled achievement in modern democracy". Reading between the lines the statistics leave no doubt that specific preventive measures and medical care services have undergone rapid and effective development during the last decade. Hospital and dispensary returns and data derived from special campaigns and surveys help to complete the picture. The facts show that, apart from occasional isolated cases, Ceylon is now free from smallpox, cholera, plague, louse-borne typhus and yellow fever. The available figures also show that malaria is now under control and may well be eradicated altogether in the next few years, and that leprosy and tuberculosis, though still problems of considerable magnitude, are rapidly diminishing causes of sickness and death. It is worth mentioning that the large colonisation schemes in the north-western and eastern provinces of the island (i.e. the resettlement of urban populations in cleared jungle areas) would have been impossible but for the successful control of malaria. This is obviously a fact of profound social and economic significance for the island. A matter of some relevance to our assignment was the health hazard Ceylon has to face from the importation of disease by illicit immigrants from southern India. These immigrants slip across the narrow northern straits, sometimes in considerable numbers. I was fortunate enough to visit the scene of a local outbreak of smallpox from this source in the Jaffna area, in the company of Dr. W. A. Karunaratne, deputy director of health services, and consequently to reach an understanding of why it was necessary to include in the public health law provisions for compulsory vaccination and the control of the movements of people within, and in and out of, infected areas--powers which are, of course, deemed unnecessary in countries like our own. The leading causes of sickness and death in present-day Ceylon are gastrointestinal infections, round-worm infestations (often accompanied by sub-
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nutrition and chronic anaemia), filariasis and, somewhat unexpectedly, pneumonia and other acute lower respiratory infections. The gastro-intestinal infections include bacillary dysentery, amoebiasis, enteric and salmonella infections, and a great deal of unspecified gastro-enteritis and colitis. They are mainly water-borne, and their control, by general consent, will be brought about by the provision throughout the country of safe water supplies and the means of disposing of human excreta--in practice, suitable domestic latrines. The general provision of these basic sanitary services is the really big public health and medical problem which Ceylon must face to achieve European health standards. Better medical care services--more doctors and more hospital beds will not solve these problems. Gastro-intestinal infections, mosquitoborne disease and worm infestations are all eminently preventable diseases which have to be prevented mainly at their sources. For instance, hook-worm infestation is widespread--some 16 ~o of schoolchildren have been found to harbour the worm. The condition could be practically abolished either by ensuring that the entire population wore suitable foot-wear or, alternatively, by the general provision of water-seated latrines which the population could be persuaded to use. The first method is ruled out not only on grounds of cost, but also because rural populations as well as a great part of urban populations in the tropics, not unnaturally, resist wearing boots or shoes of any kind. The alternative is an immense problem in terms of material resources and population attitudes. THE
ENVIRONMENTAL
SANITATION
PROJECT,
KURUNEGALA
An environmental sanitation project in a jungle village area near Kurunegala is worth special mention. The project was operated by the Government of Ceylon with the assistance of WHO and UNICEF. The aim was to improve rural water supplies and excreta disposal, and to teach the rural population about intestinal diseases and the way they are contracted. In essence, the project was a pilot scheme to devise simple, cheap and acceptable sanitary works and to test their effectiveness in a number of selected RURAL ENVIRONMENTAL SANITATION PROJECT--KURUNEGALA PRE-OPERATIONAL HEALTH SURVEY IN A P A I R OF " K O R A L E S " Tissawa Korale (worked)
Positive for .... .... .... ....
Hookworm ... Ascaris ...... Shigella ...... Salmonella ... Ent. hist . . . .
Giratalana Korale (control)
Number
~
Number
107 38 13 11 17
71 "3 25 "3 8-7 7"3 11 "3
108 33 4 7 21
72"0 22"0 2"7 4"7 14-0
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"korales" or villages. A type of simple water-sealed latrine was supplied to the villagers. They were assisted with digging the pit and installing the squattingplate and then left to add their own superstructure of jungle timber, leaves and mud. Three areas were chosen, each consisting of a pair of rural korales, one of which was provided with modern wells and domestic latrines and the other left as a control. Before beginning operations in the worked korales health ,;urveys, sanitary surveys and attitude surveys were carried out. The table shows the results of a health survey done in one pair of korales. Altogether there were 2,351 houses in the survey areas, with not a single protected well and only 62 latrines. To most of the people living there the idea of using latrines was completely new. N o connection whatever between disease and uncontrolled human voiding acts, or between disease and infected water supplies, had ever entered their heads. Evil spirits were still generally believed, in these areas, to be the causes of all diseases. The intention is to repeat health surveys in the paired korales after the sanitary facilities have been in use for two years. At the end of a year's run it appeared that only about half the latrines provided were in use. In some instances the syphons were broken, sometimes the squatting-plate was fouled; in some instances male members of the household refused to use the same latrine as female members; and others had a firm jungle prejudice against using the same place twice. As one man explained to me, "Even a dog or a cat wouldn't do that". On the other hand, there had been little difficulty in persuading the village communities to use the wells provided. The scarcity of water was usually a sufficient inducement, though in a few instances, there was a prejudice against using water drawn from a pump. Facts such as these may appear somewhat remote from legislative questions, but failure to take them into account would have rendered the drafting of public health law an unrealistic, academic exercise. HEALTH
AND
MEDICAL
SERVICES
The health and medical services are less easy to describe briefly than the health situation; we must be satisfied with a bare outline. Any statement about the strength of the medical profession in Ceylon is complicated by the existence of some 4,000 indigenous or ayurvedic practitioners alongside doctors with the usual modern training. (The ayurvedic practitioner is a sort of first-aid man and herbalist. They are said to have a limited usefulness, especially in rural and jungle areas.) There are at present about 1,000 Western practitioners in the island, or approximately one doctor for every 9,000 persons. It will be seen from the schema (see p. 368) that over 100 of them are public health officers.
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PUBLIC HEALTH VOL. LXXIII NOS. 10-11 ORGANlSATION
OF D I R E C T O R A T E
OF
HEALTH
SERVICES
Director of Health Serviccs
I l
Deputy Director (Medical Services)
I
Deputy Director (public Health Services)
I
Deputy Director (Laboratory Services)
I I
15 Superintendents of Health Services 94 Medical Officers of Health (Permanent) 53 Supervising Public Health Officers in charge of Health Offices 774 Public Health Inspectors 108 Public Health Nurses 1,186 Pub!ic Health Midwives
I
Superintendents of Specialised Campaigns Superintendent, Anti-Malaria Campaign Superintendent, Filariasis Campaign Superintendent, Leprosy Campaign (Medical and Health) Superintendent, TB. Campaign (Medical and Health) Superintendent, V.D. Campaign (Medical and Health)
There are three hospital beds per 1,000 of population, though only a proportion of them are in hospitals with anything like Western facilities. In addition to hospitals there exists also a network of "peripheral units" to provide medical facilities in remote rural areas. This type of medical institution consists of a central dispensary, a rural hospital and a maternity home. There are 55 such units in the country, 34 of them under the charge of fully qualified medical officers and 21 in the charge of specially trained apothecaries. The medical profession--particularly the public health medical personnel--are supported by well-trained health nurses and midwives and a highly competent body of public health inspectors. During the last 10 years, a policy of decentralising health services has been pursued, and at the present time 15 administrative health districts, each under a superintendent of health services, cover the island. Such was the general and medical background against which our task had to be viewed. THE
ASSIGNMENT
ON
THE
SPOT
Once in Ceylon, the conduct of the assignment fell into three fairly distinct periods. First of all there was a period of consultations with colleagues, of reading legal instruments, memoranda and reports and of becoming familiar at first hand with the administration of medical services and the many projects already in being. After this, there was a period of visits of observation up and down the country to see things for ourselves, and finally, a period of reporting and drafting, which began while we were travelling about the country, and was finally completed in Delhi and Geneva on the way home.
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Our main task was dominated by the fact that there was too much, not too little, public health law in Ceylon, and a deal of redundancy and overlapping. They had, for example, promulgated public health powers separately for each of the five types of local authority in the island, in fairly lengthy local government ordinances, and these we had somehow to bring together in one substantive statute. The problem was greatly complicated by extensive proposals for local government reorganisation, which we understood had been accepted in principle by the Government of Ceylon. We were, in fact, compelled on the one hand to accept local government as it stood, and yet at the same time to take into account these proposals for its reform. The proposals we ultimately made represented a compromise between what actually existed and what it seemed likely that the Government of Ceylon would accept. In a few instances, existing legal provisions had outlived their usefulness and had to be got rid of. This was a simple matter. A much greater difficulty arose out of the fact that no up-to-date reprint of Acts and Ordinances incorporating amendments of the law had been issued at the time of our visit. As a consequence, we had to read each enactment with the instruments amending it, and often also to take into account changes in the constitution of Ceylon subsequent to the date of the various enactments. It may be of some interest to set forth here the procedural steps we found it necessary to take. They were: (1) To assemble the public health law and other relevant statutes. (2) To prepare a master copy of each public health Act or Ordinance which incorporated amendments made to the principal Acts and amendments due to redistributions of functions and changes in the constitution. (3) To decide on the content of each part of our proposed draft Act. (4) For each of the parts : (a) to identify and exclude obsolete sections and duplicated provisions; (b) to amend the remaining sections when necessary; (c) to introduce new provisions required after reviewing the existing circumstances and services with local officers of the Ministry of Health and the Department of Justice. The volume of tedious work all this entailed was a little disheartening, but there was a reassuring side to the task. In discussions with the Minister and senior medical and legal officers, we were assured that we could narrow the scope of our detailed review on a number of grounds: in some instances, because statutes were recent and operating quite well; in other instances, either because they were outside the scope of public health law as ordinarily understood, or because they were the responsibility of central departments other than the Ministry of Health. By far the biggest exclusion we were able to make was the law relating to water and sewage disposal schemes. This was possible
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because a National Water and Drainage Board had already been accepted in principle by the Government as the right body to assume responsibility for these major sanitary works. It was agreed that we should limit our draft Act to three main subjects: (1) Environmental sanitation; (2) The control of infectious diseases; (3) The abatement of nuisances; adding, for convenience, a number of special subjects such as, for instance, the supervision of nursing homes, the provision of domestic latrines and the control o f markets and slaughterhouses, giving particular attention to ministerial supervisory and default powers, and powers for the making of statutory instruments. Proposals for local authorities to secure adequate latrine accommodation in their areas, and a provision empowering the Minister of Health to require local authorities to make surveys of latrine accommodation and submit programmes for the systematic provision of domestic latrines, were important items in our draft. In preparing this part of our draft, we had in mind the following principles: (1) That latrines would have to be offered rather than imposed if they were to be used and maintained; (2) That local authorities would have to include a survey of the attitude o f householders towards domestic latrine accommodation as well as a physical survey; (3) That an accompanying educational programme would be required; (4) That most of the cost would have to be met out of Exchequer funds. A fact of general interest that claimed our attention was that no statntory obligation existed for local authorities in Ceylon to appoint medical officers o f health or other health personnel, and the then existing legislation contained no provision prescribing their qualifications and duties. We were told on many occasions that because of these omissions, the medical officer of health was often impeded in the effective discharge of his duties and sometimes brought into conflicts with his authority, which suitable legal provisions might have avoided. From the facts brought to our notice, we recommended the following provisions: (1) The M.O.H. should be declared to be the executive officer of the local authority within his professional province, i.e. that the council, having agreed its policy on health matters on the advice of the M.O.H., should then leave the M.O.H. to carry out their directions without further intervention from the chairman or other members of the authority. (2) The Minister should have power to prescribe by regulation the method o f appointment of M.O.s H. and public health inspectors, and to define their duties.
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(3) The M.O.H. should normally attend meetings of the local authority or :its health committee in an advisory capacity. (4) The M.O.H. should be required to prepare annual and special reports o n the health of his area, and should have the obligation to send copies to the Minister. We suggested, in addition, that as few local authorities appointed a health ,committee, the Minister of Local Government should consider whether in the future certain local authorities should be required by law to do so. Another point of interest was an unexpected discovery we made in relation to sanitary and water law. We learned in the course of our enquiries that a sanitary code had already been prepared under a direct aid scheme which included these subjects. The code was coupled with a proposal to establish a statutory Health Council for Ceylon with code-making powers and was based on the assumption that the code itself would have the force of law without reference to the legislature. This approach, which is fairly common in the United States of America, was the antithesis of our way of tackling the problem. Our aim was to bring together items of public health law in statutory :form, embodying appropriate regulation-making powers. The choice between these alternatives rested, of course, with the Government of Ceylon. As it seemed virtually certain that radical organisational changes in local government and health services would be made in the near future, the moment was not ideal in Ceylon for preparing comprehensive consolidating legislation. A period of rapid growth and change, whether in services or administration, is not the best time for this kind of thing. We were, nevertheless, able to make proposals, in a draft Act, for a limited consolidating measure. We return now to a question left outstanding in the early part of this note. Why was the Health Department of Ceylon unable to review their Public Health Law without outside assistance ? In theory they should have been able to do this, for there were in Ceylon medical and legal officers of the highest competence. In fact, they needed outside assistance for two reasons. First, there was no organisation in the Health Department for keeping the law under a continuing review, and there were no trained legal assistants in the department; and secondly, the Ministry of Justice could not provide the necessary legal assistance to undertake a task of this magnitude because of the volume of work they were ;already committed to. The proposals we made for the future included the following: (1) A senior officer in the Ministry of Health should assume responsibility for indexing existing public health law, and keeping a dossier of suggestcd ;amendments. (2) Arrangements should be made for the appointment of legal assistants. (3) Provisions should be made for the in-service training of junior legal officers in the techniques and procedure of drafting.
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The last proposal, it should be noted, requires the appointment in the first place of legal personnel in excess of current requirements for departmental duties. The principle of making such supernumerary appointments in almost every medical field is something we usually take for granted in Britain, but i t had not yet become an accepted practice in Ceylon. SIGHTSEEING,
AND
GENERAL
COMMENTS
ON
CEYLON
For readers unfamiliar with the island, a few general comments may be acceptable. On one pretext or another we travelled up-country through tea and rubber estates, through long stretches of undeveloped jungle, and we contrived to pay short visits to the ancient ruined cities of Anuradhapura and Polonnaruwa, and the fantastic rock fortress of Sigiriya. As we moved about the country we generally lodged in rest-houses, modest but comfortable travellers' hostels under government control. They were built during the British colonial period for the convenience of officials who had to travel to remote parts of the country, and they are now indispensable to travellers in places where there are no hotels. We met many public health inspectors in different parts of the country. They were a well-informed, efficient cadre of officials, uniformed, and usually provided with motor cycles. The walls of their jungle offices were lavishly decorated with charts and diagrams and their weekly returns so voluminous, that it was a wonder they had time for work in the field. A word about certain habits of the people of Ceylon. Outside the towns, the entire population--men, women and children--take a daily bath in c o n venient streams or irrigation channels. Throughout the country, laundering is done by the time-honoured method of dhobying. A high proportion of the adult population in town and country indulge in the habit of chewing betel-nuts. The daily bath in the open air is remarkable for its modesty. Members of the family stand, or crouch, in the waterway and pour bucket after bucket o f water over their heads. They took their baths fully clothed, thus washing their garments as well as their bodies. Thereafter, they dried in the sun and then repaired to their jungle huts to change and complete their toilets. The sight of street loafers ejecting blood-red sputum on to the pavements, and the red blotches which fouled the roads and side-walks of Colombo misled me for a moment into thinking that haemoptysis was unbelievably common in the city. Second thoughts put me right. The sputum and stains were the end products of chewing the betel-nut. For this purpose the nut is wrapped in a leaf with a small pellet of lime, chewed from time to time, and held for long periods between the teeth and the cheek. Cancer of the cheek is common in Ceylon. SIGNS
OF
C1V1L
UNREST
Ceylon has been in the news a great deal during the last year or two. When we were there a year ago there were already signs of political unrest in their
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new independence. Racial feelings were beginning to run high; notices and signboards in Tamil were being defaced in the large towns; and the red-robed Buddhist priests were lying down in the streets obstructing traffic as a protest against some aspect of the Government's policy. There were docks strikes, gas strikes, threats of strikes by the Civil Service and, what affected us more particularly, there were hotel strikes which, on one or two occasions, added to our living problems. Since we left the country, as most of you will know, Ceylon has been in a state of emergency--a sort of uneasy truce. I read that the accepted policy of the Government is now to adopt Sinhalese as the official language. For many years English has been the official language, and the common language of all races and sects in the island. Whatever the merits of Sinhalese, or any other tongue which is not widely spoken in other parts of the world, it seems to me, as it did to most of the leaders of thought in Ceylon, that to abandon English as the island's common language will be a serious loss. It must have grave disadvantages, both in the short term and in the long run. There still remain with me as I write, vivid memories of a gay and colourful people and, above all, of many friends and colleagues of all nations who put themselves out to help us in our work and enrich our leisure. Particularly, I recall the courtesy, friendliness and many kindnesses extended to us by Dr. D. L. J. Kahawita, director of medical services, Dr. W. A. Karunaratne, deputy director; Dr. P. Rajasingham, our unfailing counterpart, and by the many medical officers, public health inspectors and other health personnel we met in the course of our visits and enquiries. It was especially gratifying to find that, by and large, the people of Ceylon, whatever their politics, held the British people in high regard and spoke well o f their contribution to the island's development and well-being. I have long since forgotten much of the detail of the assignment, but I retain a better insight into the purpose and form of Public Health Law than I would have previously laid claim to. I believe, moreover, that our visit contributed something, however little, towards a technical aspect of the island's public health problems and, more important, to international good-will and respect which, in the last resort, is one of the big factors upon which the future welfare of mankind depends.
GRUNDY,
M.D., M.R.C.P., D.P.H.
Mansel Talbot Professor of Preventive Medicine, University of Wales THE visit to India and Ceylon described in this note arose out of a request to WHO by the Government of Ceylon for technical assistance to help them bring up to date and consolidate the Island's Public Health Law. Technical aid of this particular character had not previously been provided anywhere, so that in agreeing to meet Ceylon's request, W H O was committing itself to an exploratory project with a considerable element of uncertainty. The degree of success which attended the assignment, and the reasons for seeking outside assistance, are questions of some general interest which will be touched on later. As both the general law and the public health law of Ceylon are based mainly on British models, it was natural that W H O should turn to the United Kingdom for consultants to undertake the work. Thus it was that in the autumn of 1957, I was invited to visit Ceylon on the understanding that I should have the assistance of a legal colleague for the task. Arrangements were made for me to leave England on the 23rd January, 1958, for a period of three months. M y legal colleague, a legal draftsman in the Ministry of Housing and Local Government, was to join me in Colombo some time in February. Two of the three months were spent in Ceylon and both the outward and return journeys were via Geneva (the seat of WHO headquarters) and New Delhi, where SEARO (the South-East Asia Regional Office o f WHO) is located. Surface transport was ruled out by the time factor, and the need for briefing and discussions meant that the routing would be through Geneva and New Delhi. So it was that I left a snow-covered England on the morning of Thursday, 23rd January, to begin general consultations at the Palais des Nations, Geneva, later in the day. The general briefing included a review of previous WHO assignments in Ceylon, and a discussion on the general nature of the present project. Two facts emerged. The volume of papers handed to me for perusal left no doubt that Ceylon was one of the most surveyed countries in the world. Discussions with WHO personnel made it abundantly clear that they could not tell us a great deal more about the state of public health law in Ceylon than we could ourselves glean from existing reports. This was very little. Our WHO colleagues stressed that the assignment was on new lines, and I was invited to comment, 363
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in due course, on its practicability and on the possible usefulness of suchlike projects in under-developed or rapidly evolving countries. The process of briefing continued in Delhi. The principles on which WHO technical aid is based were discussed--particularly the importance of training a local colleague (known as a "counterpart") who could continue the work begun by visiting experts after they had left. Little more information about the scope of the assignment was forthcoming than had been vouchsafed in Geneva, but at all events we itemised the steps that would have to be taken whatever the detailed character of the assignment turned out to be. It was agreed that we should have to begin by studying at first hand the organisation of health services in Ceylon, and the way they were working, and then proceed to familiarise ourselves with existing health laws and their operation. Only after completing these preliminaries would it be feasible to consider the questions of amending or amplifying existing law and of preparing consolidating legislation. SOME
FACTS
ABOUT
CEYLON
Ceylon is a pear-shaped tropical island some 270 miles long and 140 broad, separated from the great land mass of India by a narrow strip of shallow water --the Palk Strait. It has a central mountainous area rising to a little over 7,000 feet, an upland belt around the central area, and a coastal plain of varying depth. The whole country is well watered by many rivers and streams; in ancient times, large-scale irrigation was undertaken from tanks, many of which are maintained and in use at the present time (in Ceylon, reservoirs are called "tanks"). From 544 B.C., Ceylon was ruled uninterruptedly for 21 centuries by dynasties of Sinhalese kings. From the 16th century onwards Ceylon, or parts of the island, were possessed in turn by the Portuguese, the Dutch and the British. Under the British, Ceylon was unified, developed and introduced to the arts and sciences of the West. In 1948 the island was granted her independence. The climate is essentially tropical. In the low country the annual mean temperature is about 81 ~ F., but in the higher country the temperature falls off at a rate of about 1~ F. per 300 feet rise in altitude. The annual rainfall is heavy in most parts of the island. The population is about 8,750,000 and comprises the Sinhalese--the large majority--Tamils, Dutch Burghers, Indian Tamils, Europeans, Moors and a number of other races. One-fifth of the population live in a few large cities. e.g. Colombo, Kandy and Galle, and the remaining four-fifths in village communities. In the coastal strip, the villages lie among the main trunk roads, but inland they are relatively isolated jungle communities. A typical village dwelling is constructed of jungle timber covered with palm leaves, or of wattle and mud, with a floor of rammed earth. The principal crops are coconut and rice in the low country, and tea, rubber, coffee and spices in the hills. In rural areas the
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water supply is usually from wells, most of which are shallow and inadequately protected from pollution. Few houses outside the towns are provided with latrine accommodation of any kind. THE
HEALTH
STATUS
OF
THE
ISLAND
Vital statistics never give a complete picture of the health status of a country, but they are a good starting point. Two facts stand out: first, that Ceylon though in some respects lagging behind the best European standards of health, compares favourably with other Asian countries; and second, that very remarkable improvements have been made in the last 10 years. The crude death rate in 1956 was 10.1, while 10 years earlier it was over 14; the infant mortality rate, 67 in 1956, was 101 in 1947; the maternal mortality rate, 3"8 in 1956, was 15.5 in 1946. The crude death rate has, of course, a qualified significance as an index of health unless it is related to population structure, but less equivocal is the life expectancy at birth which increased from 44 years in 1946 to 60 years in 1956. It has, indeed, been described by WHO as "an unparalleled achievement in modern democracy". Reading between the lines the statistics leave no doubt that specific preventive measures and medical care services have undergone rapid and effective development during the last decade. Hospital and dispensary returns and data derived from special campaigns and surveys help to complete the picture. The facts show that, apart from occasional isolated cases, Ceylon is now free from smallpox, cholera, plague, louse-borne typhus and yellow fever. The available figures also show that malaria is now under control and may well be eradicated altogether in the next few years, and that leprosy and tuberculosis, though still problems of considerable magnitude, are rapidly diminishing causes of sickness and death. It is worth mentioning that the large colonisation schemes in the north-western and eastern provinces of the island (i.e. the resettlement of urban populations in cleared jungle areas) would have been impossible but for the successful control of malaria. This is obviously a fact of profound social and economic significance for the island. A matter of some relevance to our assignment was the health hazard Ceylon has to face from the importation of disease by illicit immigrants from southern India. These immigrants slip across the narrow northern straits, sometimes in considerable numbers. I was fortunate enough to visit the scene of a local outbreak of smallpox from this source in the Jaffna area, in the company of Dr. W. A. Karunaratne, deputy director of health services, and consequently to reach an understanding of why it was necessary to include in the public health law provisions for compulsory vaccination and the control of the movements of people within, and in and out of, infected areas--powers which are, of course, deemed unnecessary in countries like our own. The leading causes of sickness and death in present-day Ceylon are gastrointestinal infections, round-worm infestations (often accompanied by sub-
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nutrition and chronic anaemia), filariasis and, somewhat unexpectedly, pneumonia and other acute lower respiratory infections. The gastro-intestinal infections include bacillary dysentery, amoebiasis, enteric and salmonella infections, and a great deal of unspecified gastro-enteritis and colitis. They are mainly water-borne, and their control, by general consent, will be brought about by the provision throughout the country of safe water supplies and the means of disposing of human excreta--in practice, suitable domestic latrines. The general provision of these basic sanitary services is the really big public health and medical problem which Ceylon must face to achieve European health standards. Better medical care services--more doctors and more hospital beds will not solve these problems. Gastro-intestinal infections, mosquitoborne disease and worm infestations are all eminently preventable diseases which have to be prevented mainly at their sources. For instance, hook-worm infestation is widespread--some 16 ~o of schoolchildren have been found to harbour the worm. The condition could be practically abolished either by ensuring that the entire population wore suitable foot-wear or, alternatively, by the general provision of water-seated latrines which the population could be persuaded to use. The first method is ruled out not only on grounds of cost, but also because rural populations as well as a great part of urban populations in the tropics, not unnaturally, resist wearing boots or shoes of any kind. The alternative is an immense problem in terms of material resources and population attitudes. THE
ENVIRONMENTAL
SANITATION
PROJECT,
KURUNEGALA
An environmental sanitation project in a jungle village area near Kurunegala is worth special mention. The project was operated by the Government of Ceylon with the assistance of WHO and UNICEF. The aim was to improve rural water supplies and excreta disposal, and to teach the rural population about intestinal diseases and the way they are contracted. In essence, the project was a pilot scheme to devise simple, cheap and acceptable sanitary works and to test their effectiveness in a number of selected RURAL ENVIRONMENTAL SANITATION PROJECT--KURUNEGALA PRE-OPERATIONAL HEALTH SURVEY IN A P A I R OF " K O R A L E S " Tissawa Korale (worked)
Positive for .... .... .... ....
Hookworm ... Ascaris ...... Shigella ...... Salmonella ... Ent. hist . . . .
Giratalana Korale (control)
Number
~
Number
107 38 13 11 17
71 "3 25 "3 8-7 7"3 11 "3
108 33 4 7 21
72"0 22"0 2"7 4"7 14-0
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"korales" or villages. A type of simple water-sealed latrine was supplied to the villagers. They were assisted with digging the pit and installing the squattingplate and then left to add their own superstructure of jungle timber, leaves and mud. Three areas were chosen, each consisting of a pair of rural korales, one of which was provided with modern wells and domestic latrines and the other left as a control. Before beginning operations in the worked korales health ,;urveys, sanitary surveys and attitude surveys were carried out. The table shows the results of a health survey done in one pair of korales. Altogether there were 2,351 houses in the survey areas, with not a single protected well and only 62 latrines. To most of the people living there the idea of using latrines was completely new. N o connection whatever between disease and uncontrolled human voiding acts, or between disease and infected water supplies, had ever entered their heads. Evil spirits were still generally believed, in these areas, to be the causes of all diseases. The intention is to repeat health surveys in the paired korales after the sanitary facilities have been in use for two years. At the end of a year's run it appeared that only about half the latrines provided were in use. In some instances the syphons were broken, sometimes the squatting-plate was fouled; in some instances male members of the household refused to use the same latrine as female members; and others had a firm jungle prejudice against using the same place twice. As one man explained to me, "Even a dog or a cat wouldn't do that". On the other hand, there had been little difficulty in persuading the village communities to use the wells provided. The scarcity of water was usually a sufficient inducement, though in a few instances, there was a prejudice against using water drawn from a pump. Facts such as these may appear somewhat remote from legislative questions, but failure to take them into account would have rendered the drafting of public health law an unrealistic, academic exercise. HEALTH
AND
MEDICAL
SERVICES
The health and medical services are less easy to describe briefly than the health situation; we must be satisfied with a bare outline. Any statement about the strength of the medical profession in Ceylon is complicated by the existence of some 4,000 indigenous or ayurvedic practitioners alongside doctors with the usual modern training. (The ayurvedic practitioner is a sort of first-aid man and herbalist. They are said to have a limited usefulness, especially in rural and jungle areas.) There are at present about 1,000 Western practitioners in the island, or approximately one doctor for every 9,000 persons. It will be seen from the schema (see p. 368) that over 100 of them are public health officers.
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PUBLIC HEALTH VOL. LXXIII NOS. 10-11 ORGANlSATION
OF D I R E C T O R A T E
OF
HEALTH
SERVICES
Director of Health Serviccs
I l
Deputy Director (Medical Services)
I
Deputy Director (public Health Services)
I
Deputy Director (Laboratory Services)
I I
15 Superintendents of Health Services 94 Medical Officers of Health (Permanent) 53 Supervising Public Health Officers in charge of Health Offices 774 Public Health Inspectors 108 Public Health Nurses 1,186 Pub!ic Health Midwives
I
Superintendents of Specialised Campaigns Superintendent, Anti-Malaria Campaign Superintendent, Filariasis Campaign Superintendent, Leprosy Campaign (Medical and Health) Superintendent, TB. Campaign (Medical and Health) Superintendent, V.D. Campaign (Medical and Health)
There are three hospital beds per 1,000 of population, though only a proportion of them are in hospitals with anything like Western facilities. In addition to hospitals there exists also a network of "peripheral units" to provide medical facilities in remote rural areas. This type of medical institution consists of a central dispensary, a rural hospital and a maternity home. There are 55 such units in the country, 34 of them under the charge of fully qualified medical officers and 21 in the charge of specially trained apothecaries. The medical profession--particularly the public health medical personnel--are supported by well-trained health nurses and midwives and a highly competent body of public health inspectors. During the last 10 years, a policy of decentralising health services has been pursued, and at the present time 15 administrative health districts, each under a superintendent of health services, cover the island. Such was the general and medical background against which our task had to be viewed. THE
ASSIGNMENT
ON
THE
SPOT
Once in Ceylon, the conduct of the assignment fell into three fairly distinct periods. First of all there was a period of consultations with colleagues, of reading legal instruments, memoranda and reports and of becoming familiar at first hand with the administration of medical services and the many projects already in being. After this, there was a period of visits of observation up and down the country to see things for ourselves, and finally, a period of reporting and drafting, which began while we were travelling about the country, and was finally completed in Delhi and Geneva on the way home.
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Our main task was dominated by the fact that there was too much, not too little, public health law in Ceylon, and a deal of redundancy and overlapping. They had, for example, promulgated public health powers separately for each of the five types of local authority in the island, in fairly lengthy local government ordinances, and these we had somehow to bring together in one substantive statute. The problem was greatly complicated by extensive proposals for local government reorganisation, which we understood had been accepted in principle by the Government of Ceylon. We were, in fact, compelled on the one hand to accept local government as it stood, and yet at the same time to take into account these proposals for its reform. The proposals we ultimately made represented a compromise between what actually existed and what it seemed likely that the Government of Ceylon would accept. In a few instances, existing legal provisions had outlived their usefulness and had to be got rid of. This was a simple matter. A much greater difficulty arose out of the fact that no up-to-date reprint of Acts and Ordinances incorporating amendments of the law had been issued at the time of our visit. As a consequence, we had to read each enactment with the instruments amending it, and often also to take into account changes in the constitution of Ceylon subsequent to the date of the various enactments. It may be of some interest to set forth here the procedural steps we found it necessary to take. They were: (1) To assemble the public health law and other relevant statutes. (2) To prepare a master copy of each public health Act or Ordinance which incorporated amendments made to the principal Acts and amendments due to redistributions of functions and changes in the constitution. (3) To decide on the content of each part of our proposed draft Act. (4) For each of the parts : (a) to identify and exclude obsolete sections and duplicated provisions; (b) to amend the remaining sections when necessary; (c) to introduce new provisions required after reviewing the existing circumstances and services with local officers of the Ministry of Health and the Department of Justice. The volume of tedious work all this entailed was a little disheartening, but there was a reassuring side to the task. In discussions with the Minister and senior medical and legal officers, we were assured that we could narrow the scope of our detailed review on a number of grounds: in some instances, because statutes were recent and operating quite well; in other instances, either because they were outside the scope of public health law as ordinarily understood, or because they were the responsibility of central departments other than the Ministry of Health. By far the biggest exclusion we were able to make was the law relating to water and sewage disposal schemes. This was possible
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because a National Water and Drainage Board had already been accepted in principle by the Government as the right body to assume responsibility for these major sanitary works. It was agreed that we should limit our draft Act to three main subjects: (1) Environmental sanitation; (2) The control of infectious diseases; (3) The abatement of nuisances; adding, for convenience, a number of special subjects such as, for instance, the supervision of nursing homes, the provision of domestic latrines and the control o f markets and slaughterhouses, giving particular attention to ministerial supervisory and default powers, and powers for the making of statutory instruments. Proposals for local authorities to secure adequate latrine accommodation in their areas, and a provision empowering the Minister of Health to require local authorities to make surveys of latrine accommodation and submit programmes for the systematic provision of domestic latrines, were important items in our draft. In preparing this part of our draft, we had in mind the following principles: (1) That latrines would have to be offered rather than imposed if they were to be used and maintained; (2) That local authorities would have to include a survey of the attitude o f householders towards domestic latrine accommodation as well as a physical survey; (3) That an accompanying educational programme would be required; (4) That most of the cost would have to be met out of Exchequer funds. A fact of general interest that claimed our attention was that no statntory obligation existed for local authorities in Ceylon to appoint medical officers o f health or other health personnel, and the then existing legislation contained no provision prescribing their qualifications and duties. We were told on many occasions that because of these omissions, the medical officer of health was often impeded in the effective discharge of his duties and sometimes brought into conflicts with his authority, which suitable legal provisions might have avoided. From the facts brought to our notice, we recommended the following provisions: (1) The M.O.H. should be declared to be the executive officer of the local authority within his professional province, i.e. that the council, having agreed its policy on health matters on the advice of the M.O.H., should then leave the M.O.H. to carry out their directions without further intervention from the chairman or other members of the authority. (2) The Minister should have power to prescribe by regulation the method o f appointment of M.O.s H. and public health inspectors, and to define their duties.
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(3) The M.O.H. should normally attend meetings of the local authority or :its health committee in an advisory capacity. (4) The M.O.H. should be required to prepare annual and special reports o n the health of his area, and should have the obligation to send copies to the Minister. We suggested, in addition, that as few local authorities appointed a health ,committee, the Minister of Local Government should consider whether in the future certain local authorities should be required by law to do so. Another point of interest was an unexpected discovery we made in relation to sanitary and water law. We learned in the course of our enquiries that a sanitary code had already been prepared under a direct aid scheme which included these subjects. The code was coupled with a proposal to establish a statutory Health Council for Ceylon with code-making powers and was based on the assumption that the code itself would have the force of law without reference to the legislature. This approach, which is fairly common in the United States of America, was the antithesis of our way of tackling the problem. Our aim was to bring together items of public health law in statutory :form, embodying appropriate regulation-making powers. The choice between these alternatives rested, of course, with the Government of Ceylon. As it seemed virtually certain that radical organisational changes in local government and health services would be made in the near future, the moment was not ideal in Ceylon for preparing comprehensive consolidating legislation. A period of rapid growth and change, whether in services or administration, is not the best time for this kind of thing. We were, nevertheless, able to make proposals, in a draft Act, for a limited consolidating measure. We return now to a question left outstanding in the early part of this note. Why was the Health Department of Ceylon unable to review their Public Health Law without outside assistance ? In theory they should have been able to do this, for there were in Ceylon medical and legal officers of the highest competence. In fact, they needed outside assistance for two reasons. First, there was no organisation in the Health Department for keeping the law under a continuing review, and there were no trained legal assistants in the department; and secondly, the Ministry of Justice could not provide the necessary legal assistance to undertake a task of this magnitude because of the volume of work they were ;already committed to. The proposals we made for the future included the following: (1) A senior officer in the Ministry of Health should assume responsibility for indexing existing public health law, and keeping a dossier of suggestcd ;amendments. (2) Arrangements should be made for the appointment of legal assistants. (3) Provisions should be made for the in-service training of junior legal officers in the techniques and procedure of drafting.
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The last proposal, it should be noted, requires the appointment in the first place of legal personnel in excess of current requirements for departmental duties. The principle of making such supernumerary appointments in almost every medical field is something we usually take for granted in Britain, but i t had not yet become an accepted practice in Ceylon. SIGHTSEEING,
AND
GENERAL
COMMENTS
ON
CEYLON
For readers unfamiliar with the island, a few general comments may be acceptable. On one pretext or another we travelled up-country through tea and rubber estates, through long stretches of undeveloped jungle, and we contrived to pay short visits to the ancient ruined cities of Anuradhapura and Polonnaruwa, and the fantastic rock fortress of Sigiriya. As we moved about the country we generally lodged in rest-houses, modest but comfortable travellers' hostels under government control. They were built during the British colonial period for the convenience of officials who had to travel to remote parts of the country, and they are now indispensable to travellers in places where there are no hotels. We met many public health inspectors in different parts of the country. They were a well-informed, efficient cadre of officials, uniformed, and usually provided with motor cycles. The walls of their jungle offices were lavishly decorated with charts and diagrams and their weekly returns so voluminous, that it was a wonder they had time for work in the field. A word about certain habits of the people of Ceylon. Outside the towns, the entire population--men, women and children--take a daily bath in c o n venient streams or irrigation channels. Throughout the country, laundering is done by the time-honoured method of dhobying. A high proportion of the adult population in town and country indulge in the habit of chewing betel-nuts. The daily bath in the open air is remarkable for its modesty. Members of the family stand, or crouch, in the waterway and pour bucket after bucket o f water over their heads. They took their baths fully clothed, thus washing their garments as well as their bodies. Thereafter, they dried in the sun and then repaired to their jungle huts to change and complete their toilets. The sight of street loafers ejecting blood-red sputum on to the pavements, and the red blotches which fouled the roads and side-walks of Colombo misled me for a moment into thinking that haemoptysis was unbelievably common in the city. Second thoughts put me right. The sputum and stains were the end products of chewing the betel-nut. For this purpose the nut is wrapped in a leaf with a small pellet of lime, chewed from time to time, and held for long periods between the teeth and the cheek. Cancer of the cheek is common in Ceylon. SIGNS
OF
C1V1L
UNREST
Ceylon has been in the news a great deal during the last year or two. When we were there a year ago there were already signs of political unrest in their
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new independence. Racial feelings were beginning to run high; notices and signboards in Tamil were being defaced in the large towns; and the red-robed Buddhist priests were lying down in the streets obstructing traffic as a protest against some aspect of the Government's policy. There were docks strikes, gas strikes, threats of strikes by the Civil Service and, what affected us more particularly, there were hotel strikes which, on one or two occasions, added to our living problems. Since we left the country, as most of you will know, Ceylon has been in a state of emergency--a sort of uneasy truce. I read that the accepted policy of the Government is now to adopt Sinhalese as the official language. For many years English has been the official language, and the common language of all races and sects in the island. Whatever the merits of Sinhalese, or any other tongue which is not widely spoken in other parts of the world, it seems to me, as it did to most of the leaders of thought in Ceylon, that to abandon English as the island's common language will be a serious loss. It must have grave disadvantages, both in the short term and in the long run. There still remain with me as I write, vivid memories of a gay and colourful people and, above all, of many friends and colleagues of all nations who put themselves out to help us in our work and enrich our leisure. Particularly, I recall the courtesy, friendliness and many kindnesses extended to us by Dr. D. L. J. Kahawita, director of medical services, Dr. W. A. Karunaratne, deputy director; Dr. P. Rajasingham, our unfailing counterpart, and by the many medical officers, public health inspectors and other health personnel we met in the course of our visits and enquiries. It was especially gratifying to find that, by and large, the people of Ceylon, whatever their politics, held the British people in high regard and spoke well o f their contribution to the island's development and well-being. I have long since forgotten much of the detail of the assignment, but I retain a better insight into the purpose and form of Public Health Law than I would have previously laid claim to. I believe, moreover, that our visit contributed something, however little, towards a technical aspect of the island's public health problems and, more important, to international good-will and respect which, in the last resort, is one of the big factors upon which the future welfare of mankind depends.