A Paediatrics Elective in Sri Lanka

Sri Lanka, or Ceylon as it was previously known, is a land of contrasts. Its geography is tantalizing. Mountains flanked by rich jungle rise within its interior whilst swathes of dry scrub carpet the east and coconut plantations line the western coast. To the north lie the ancient fortified cities of Jaffna and Anurhadapura, whilst in the south one finds tiny villages nestled between a string of beautiful beaches. The island is shaped like a tear-drop situated beneath the Indian subcontinent and surrounded by the warm Indian Ocean. Like its landscape, Sri Lanka’s health care system is very diverse, ranging from the Lady Ridgeway paediatric hospital in Colombo, to the tiny medical hut in Hambantota.

The majority of people living on the island are Sinhalese, an ancient race that originated in northern India and came to Sri Lanka with the dawn of Buddhism some 2600 years ago during the reign of Ashoka the Great. Around 30% of the population are Tamil, the descendants of south Indian coolie laborers brought to Sri Lanka during the Middle Ages to work on the tea plantations. The two races contrast sharply, each having its own unique language and culture. Whereas the Sinhalese are predominantly Buddhist, Tamils are largely Hindu. This is reflected by their holy ceremonies where a spiritual Poya day of meditation centered around a Bodhi tree may well be drowned out by a rapturous Kovil festival of the Hindu gods. In Colombo, the island’s capital, and particularly within its hospitals, one will discover a thorough mix of cultures.

Like many other travelers to the island my first port of call was its steamy capital city. Colombo is an enormous sprawl of uneven buildings and narrow streets. One gets the impression that the city just mushroomed overnight, without any planning. Hindu temples jostle for space with office blocks and houses appear to be stacked upon one another to save space. Old colonial buildings are to be found everywhere, slowly decaying, whilst garish advertisements fill up every nook and cranny. I arrived in Colombo without any idea of where I was going to live for the next three months. My only plan was to visit the University, where the student exchange office was located, and ask some of the local students whether they knew of any good accommodation going cheap. The air was thick with heat and humidity as I emerged onto the street from the underground station. Giving up all hope of trying to find the correct bus to the University in the scorching heat, I collapsed into the nearest taxi I could find.

The taxi driver, whose name was Naveen, was the first Sri Lankan I had ever spoken to. He was an extremely jovial fellow with a short moustache and rounded belly and tended to say “yes very good sir” at the beginning and end of every sentence. He had a wife and four children, their smiles beaming out of the many black and white photographs that hung inside the taxi. He asked where I was going to stay and I replied that I did not have a clue. By stroke of luck his wife was a pupil at the same university and used to live in a student house belonging to a certain Kika and Wasanta. He called his wife for the address and we drove straight there. It was a pretty place, with a large veranda overlooking a school yard and a stretch of

river making its way down to the coast and flanked by palm trees and sawgrass. I was made to sit in their prize rocking chair from England as the owners of the house negotiated with my taxi driver on a price for my lodgings. They finally emerged and shyly asked if the place was to my liking and whether eight hundred rupees would be alright for three months. It was the equivalent of forty euros.

My first placement was at the Colombo South Teaching Hospital and I arose extra early the next morning for my first day of work. This was in part to avoid the unpredictable traffic jams that occur during rush hour, often caused by cattle wandering aimlessly across the streets but also to travel while the morning was still relatively cool. It took two buses to get to hospital from my accommodation and after seven o’clock they were packed full. Then, you would often have to make do with hanging on in the doorway until passengers left and you could actually squeeze into the bus. I arrived a lot sweatier than I had hoped for and after washing my face in one of the tiny sinks made my way to the paediatric wards. Doctors, nurses and patients eyed me curiously. I had not seen a single foreigner since my arrival in Colombo and I began to doubt whether the hospital had ever received an exchange student before. The paediatric wards were busy. Some of the cots held three babies in them. Nurses rushed this way and that, casting suspicious glances towards me and whispering to each other in hurried tones. The atmosphere was rather tense. We were all waiting for the consultant to arrive.

Madam Goona is the professor and principal consultant of paediatrics and neonatology at the hospital. She introduced herself and the rest of her firm at once and we began the ward round. She was a short lady who wore thick rimmed spectacles and a stern expression. She reminded me of a large owl. No sooner had we reached our first patient, a two year old girl, than she had given me a spot diagnosis.

“What is this?” She asked, pointing towards a rash affecting the lateral border of the girl’s right foot.

“It looks like a maculo-papular..” I began but was cut short.

“It’s a dengue rash”, she stated. “We are currently having a dengue epidemic in Colombo”.

And so they were. Dengue fever is a viral-borne disease that is spread by the Aedes mosquito. Some early monsoon rains had resulted in a flooding of the surrounding coconut plantations, leaving the boggy crops to rot and the pools of water to stagnate in the fetid weather that followed, giving the mosquitoes a chance to lay their eggs. Symptoms include fever, headache, muscle and joint pains, and the characteristic skin rash that is similar to measles. In a small proportion of cases the disease develops into the life-threatening Dengue Hemorrhagic fever, also known as ‘Breakbone fever’ resulting in bleeding, low levels of blood platelets and blood plasma leakage. In an even smaller percentage this develops into Dengue Shock syndrome, where dangerously low blood pressure occurs.

It is in fact an autoimmune condition targeted towards the Dengue virus. Once infected by the virus, short term immunity occurs. Subsequent infection then results in an exaggerated immune response that leads to the destruction of endothelial cells lining the blood vessels in which the virus resides. The result is the rupture of blood vessels, with leaking of plasma and blood into the tissues. On my first day at the hospital a 12 year old girl who was perfectly fine in the morning died of a cerebral haemorrhage that same afternoon. There is no vaccine and the treatment of acute dengue is supportive. It involves intravenous rehydration for mild or moderate disease, and blood transfusion in cases of severe bleeding. My role was to help triage patients as they entered the hospital and monitor their progress to resuscitative therapy by checking their parameters. Children would have their PCV (packed cell volume) monitored until a threshold was reached for transfusion. It was horrifying to see the pathophysiology of the disease manifest itself clinically, starting with the innocuous rash to the deadly complications of cerebral haemorrhage, disseminated intravascular coagulation and hypovolaemic shock. The grief and despair shown by so many parents during that week was close to intolerable.

The dengue epidemic visibly settled over the next couple of weeks. The cots began to empty and the cases became more and more sporadic.

“It always ends as rapidly as it surfaces”, was the way Madam Goona put it.

I had arrived during the peak of the urban cycle in Colombo and now the disease was shrinking away into the rural areas where the rivers were still swollen. The paediatric wards began to look a lot happier. All of the nurses and doctors now knew all about Malta, but they wanted to know more! They were extremely friendly and very, very curious. I was asked everything under the sun. I remember receiving my first letter from home during my third week at the hospital. My mother had sent me a newspaper cutting with an article about how all of the Arriva buses were going the wrong way and breaking down. There were also a few photos of my brothers and dogs having fun on a beach. Fifty pairs of eyes scanned the article as I held it up and the photographs passed through fifty pairs of hands. Once the work had settled down to a comfortable flow they half-demanded that I cook everyone a Maltese dish. The giant bowl of linguine vegeteriana created a lot of amusement as everybody attempted to twirl the pasta round in their forks. It is customary to eat with one’s bare hands in Sri Lanka, and to share a flat dish of eight different curries.

We began to encounter other endemic diseases at the hospital. A seven year old girl was referred to the hospital for further investigation after her school doctor thought she looked anaemic and unwell. On close examination, pale macules were present over her trunk and limbs, erythematous patches appeared over her cheeks and tiny yellowish-pink nodules had erupted over her forehead and nose. She also had a palpable spleen. It resolved that she was suffering from visceral leishmaniasis or Kala-Azar syndrome, a zoonotic infection caused by protozoa that belong to the genus Leishmania and spread by sandflies.

A mother brought her five year old boy to the ward after she had discovered dark red, irregular blotches over her child’s thighs. He had been running a fever and had conjunctivitis. On examination, the blotches were non-blanching when a glass was applied to their surface and were also found over the child’s palate. He was found to be suffering from leptospirosis, a disease that is caused by pathogenic spirochetes of the genus Leptospira. It is transmitted via direct contact with the body fluid and urine of an infected animal or chronic carrier, such as a rat. The child had been running around barefoot through the backstreets of his slum.

Also commonplace were malaria, tuberculosis and HIV-associated infections. Each necessitated a dedicated clinic and it was a great experience to work in each of these and witness the constellation of medical problems posed by each disease, from cerebral malaria to miliary tuberculosis.

Some of the diseases we met were quite peculiar. Though once quite rare, they are now recognized as re-emerging infectious diseases in South Asia, mainly as a result of an increasing population and poor standards of sanitation. An eight-year old boy was brought to hospital complaining of abdominal pain and haemoptysis. He had developed a urticarial-type rash along with fever and organomegaly and was found to have eosinophilia on a routine complete blood count. The boy was diagnosed with paragonimiasis, a food-borne parasitic infection, three cases of which had already been encountered by the ward that year. It is caused by the lung fluke, most commonly Paragonimus westermani and is common in East Asia. The eggs of the parasite are swallowed and passed with stool. In the external environment, the eggs hatch and miracidia seek the first intermediate host, a water snail, and penetrate into its soft tissues. Miracidia develop into cercariae which emerge from the snail. The cercariae invade the second intermediate host, a crustacean such as acraborcrayfish, where they encyst and become metacercariae. This is the infective stage for the mammalian host. Human infection occurs by eating inadequately cooked or pickled crab or crayfish that harbor metacercariae of the parasite. The metacercariae excyst in theduodenum, penetrate through the intestinal wall into the peritoneal cavity, causing abdominal pain, and then through the abdominal wall and diaphragm into the lungs, causing haemoptysis. Here they become encapsulated and develop into adults. The worms can reach other organs and tissues, such as the brain and striated muscles and infections may persist for 20 years in humans. The boy was treated with Praziquantel.

It was interesting to explore the range of health centres existing on the island. Once my rotation at the Colombo South Teaching Hospital was up, I was given a placement at the prestigious Lady Ridgeway Paediatric Hospital. With a bed-strength of over 1100, it is now considered to be the largest children's hospital in the world. It was established by public subscription in 1895 by the wife of the then British governor, Sir Joseph West Ridgeway. The oldest quarter of the hospital still retains its colonial architecture. As a tertiary care centre for children, it contains various specialised units including Cardiology and Cardiothoracic Surgery, Orthopaedic Surgery, Rheumatology, Dermatology, Ophthalmology, Psychiatry, Neonatology, Intensive Care, Orthodontics, Maxillo-Facial Surgery, Plastic Surgery, ENT Surgery and others. Cases from all over Asia are received by the hospital and every week I was able to work within a different specialty. It served as an incredible source of exposure to all paediatric fields.

Although Colombo is well served with two excellent paediatric hospitals, health care facilities in the rural areas are hardly comparable. If a village is large enough, one will find a clinic of some type. However, most villagers must face a long walk or railway journey to the nearest centre. Once, whilst hiking from village to village through the tea-coated hills and paddy fields around the mountain town of Kandy, I was unfortunate enough to have my left leg bitten by a dog. It was a domesticated dog that had bolted out of his master's home on my approach and gave me a quick nip, leaving a tiny wound. No sooner had I bent down to fish out a bandage than the entire village had surrounded me in a circle. They all wore a mortified expression. I tried to reassure them that it was alright but they would not be put off. They signalled that I must rest and led me to a quiet room with a bed of hay and a single window. I was seen by the oldest man in the village. He rubbed a green paste into the wound and instructed me to lie down for a while. I was eager to get on with my hike but could not very well move because half the village took it in turn to peer through the window whilst I supposedly rested in a bed of hay. I later thanked the man who introduced himself as the village doctor and the room as his hospital.

​Indigenous forms of medicine are still widely practiced over the island. In the interior, where the jungle is thick and villages are largely cut off from one another, animism prevails over any religious beliefs. Medical therapy is sought from the essences and spirits of natural phenomena such as animals, rocks, plants and water. Ayurveda is native to Sri Lanka and a form of alternative medicine. It is one of the oldest medical practices known. Indeed the oldest known hospital was an Ayurvedic one, the remains of which lie in Mihintale. Hundreds of plant-based medicines are employed, including cardamom and cinnamon. Some animal products may also be used, for example milk, bones, and gallstones. In addition, fats are used both for consumption and for external use. Minerals, including sulfur, arsenic, lead, copper sulfate and gold are also consumed as prescribed, casting uncertainty over the safety of such practices. In some cases alcohol was used as a narcotic for the patient undergoing an operation, until the advent of Islam introduced opium for this purpose. Both oil and tar were used to stop bleeding. There is evidence that traumatic bleeding was stopped by ligation and chemical cauterization. Various oils were used in a number of ways, including regular consumption as a part of food, anointing, smearing, head massage, and prescribed application to infected areas.

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Throughout my travels in Sri Lanka I came across tiny villages that lacked any real medical services. One such place was Bambilipitiya, a smidgeon of a hamlet sandwiched between a lagoon and the ocean. It was so untouched by urbanization that residents still relied upon carrier pigeons to get their messages sent across. The country was dealt two heavy blows in recent years that crippled its health system. The civil war saw some 70,000 casualties and 300,000 internally displaced persons, refugees and camp detainees, held against their will and left without any medical attention. The east coast was awash with settler’s camps, some of them occupied solely by orphans. Abandoned hospitals far outnumbered those in use. Though the war ended unofficially in 2010, tension along long tracts of the east coast remains very high. I was once confronted by several hooded men brandishing rifles in a small, largely Muslim town called Pottuvil. They were protesting against the strict curfews imposed upon this heavily policed area and were yelling out anti- government chants. Three of them hopped onto the bus and waved flyers in the passengers’ faces. I dived under my seat. Suddenly the back of the bus broke out in laughter and an old lady said “they will never hurt a foreigner!” I hazarded a glance upwards to find the three hooded men looking down on me, appearing quite concerned.

​The second blow came on the 3rd of January 2005 at 4:35pm. Over 30,000 deaths occurred when the tsunami hit the island’s southern and eastern shores. One and a half million lost their homes. The death toll continues to rise as the threat of infectious diseases continues to loom with several outbreaks of cholera and even measles documented. No bridge, highway, paddy field or coconut plantation survived the pound. A train known as the ‘Queen of the Sea’ was lifted of its tracks near the village of Telawatta and swept into Colombo. All but a few of the 1,700 passengers died, including a grade five school field trip that had taken the train that day to visit the Welawatta bird sanctuary.

My last day in Sri Lanka was spent with the man who first introduced me to the idea of going there. I had met Professor Narada Warnasuriya in Malta during a conference on infectious diseases held by the Commonwealth Medical Association. A wonderful tea was laid out in his office and I enjoyed chatting with the professor and his kind wife over his work in paediatrics, life in Colombo and over our travels around the island. He picked out an old photograph of his medical school year on the day of their graduation. He pointed out each student in turn, explaining how one had become a consultant virologist, another a top ophthalmologist working in the south, another the country’s surgeon general and so on and so forth. The smiling faces, smudged and brown with age, gave me the impression of a family that had grown into a happy medical community, bent on improving the lives of their country’s inhabitants – and I was reminded of our own medical family in Malta.

Dr. Steve Micallef Eynaud

Mater Dei Hospital, Malta