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Ethical Responses to the COVID-19 Pandemic—Lessons from Sri Lanka

Abstract

The COVID-19 pandemic has undoubtedly become an era-defining challenge for the entire world. It has implications not only in the public health sector but also in the global economy and political landscape. The prevention strategy that has been followed in Sri Lanka is unique. Early action taken by the government and the ministry of health, being one of pre-emptive quarantining and isolation of suspected contacts even before they developed symptoms, was vital to contain the spread of the disease. During the early phase, a nationwide lockdown in the form of a curfew was imposed which helped mitigate the spread of the virus. However, due to several lapses, there was a threat of community transmission; this was swiftly brought under control through ongoing government interventions. Thus, strict social/physical distancing measures enforced by the government, together with an increase in testing capacity, prevented widespread community transmission. Strictly containing the outbreaks as and when they were identified made it easier to bring the spread under control through contact tracing. In this article, we give an account of the strategy taken by Sri Lanka to mitigate the pandemic and comment on the lessons learned concerning the ethical responses to the COVID-19 crisis.

Introduction

The COVID-19 pandemic has spread alarm and panic the world over, with many countries unprepared to respond quickly, and sometimes ethically, to the disease outbreak. Even counties that had faced pandemics such as influenza in the past failed in the face of the COVID-19. Hence, the current pandemic has demonstrated unequivocally that every country should have a plan that can be executed effectively during future pandemics. In response to this public health emergency, the World Health Organization (WHO) has put forth best practice guidelines (World Health Organization 2020). The importance of recent changes in international health regulations was emphasized by the WHO, which included that all public health emergencies of international concern should be notified without delay. Furthermore, there needs to be a national focal point to respond in such a situation. Having core capacities that are urgently needed, and recommended measures to implement without delay to safeguard the public, is of paramount importance (Ferhani and Rushton 2020). In this article, we outline the strategy that has been adopted by Sri Lanka, which at the time of writing has only 13 reported deaths (i.e. 0.6 per 1 million people) attributable to COVID-19. Against this apparent public health success story, we assess the ethical lessons to be learned from adopting a strategy such as that deployed by Sri Lanka.

Sri Lanka’s Strategy

Sri Lanka took strong measures to manage and mitigate the crisis at the initial stages of the pandemic. Since the first local case of COVID-19 was confirmed in March 2020, the country went into extremely stringent lockdown within days. This curfew style lockdown adopted by Sri Lanka is different from the lockdown that was seen in many other countries, such as the UK, many European countries and America. The curfew and lockdown began on the 20th of March 2020, with complete restrictions on people’s movements and prohibition of social gatherings. Unlike the lockdowns seen in other countries, where citizens were able to drive to the grocery store or a walk in the park, the curfew imposed by the Sri Lankan authorities ensured that people stayed at home. This was mainly to prevent non-essential travel those who were essential workers or had a valid reason to leave their homes required a curfew pass from the area police. Workplaces, schools and businesses were unexpectedly closed. Only private sector, government, grocery and food retailers and essential service providers were given permission to continue services and make deliveries to residential areas. The new regulations caused major disruptions of lives and income of the Sri Lankan people. A COVID-19 task force was immediately implemented under the leadership of the president which consisted of a team of multidisciplinary experts such as epidemiologists, medical administrators, infectious disease specialists, military teams, police, social workers, politicians and media teams. The military played a leading role in response to the crisis, from overseeing quarantine centers to contact tracing, while the police managed the curfew, responding to reports of violations and arresting suspected violators. According to some media outlets quoting police reports, “more than 56,000 curfew violators have been arrested after curfew was imposed on March 20th 2020” (News 1st 2020). Even though having armed forces involved in the mitigation strategy may not seem ethically sound, this move was seen as an institutional strategy for crisis management. Sri Lanka being a low-middle income country had no option but to use all available resources to tackle and prevent the epidemic. The use of the military could be seen as restricting individual freedom and autonomy. However, that had to be balanced with the effects of COVID-19. Military involvement differs in terms of their tasks, their mission and the force used in any given situation. In this instance, it was to build national resilience against the pandemic and hence was seen in a positive light.

The government implemented further strict measures, including a temporary suspension of inbound flights and on-arrival visas, mandatory quarantine of travelers arriving from high-risk countries in special quarantine centers and regularly disinfecting marketplaces and public transport stations, all of which have successfully reduced the rate of disease transmission. Major celebrations, such as the Sinhala and Tamil New Year, and Vesak, which is the most important period in the Buddhist calendar, were confined to the households. Subsequently, during July 2020, Sri Lanka rapidly increased its testing, and the number of confirmed cases reached 3363 as of September 2020, with more than 3230 recoveries and only 13 deaths (Epidemiology Unit 2020a, b, c, d). Therefore, we believe there are lessons to be learned from Sri Lanka’s mitigation strategy.

Lessons Learned

Policy and Regulations

In Sri Lanka, we have learned many lessons as policymakers, healthcare workers and a community. The international health regulations are implemented under the Quarantine and Prevention of Disease Ordinance Act & Public Security Ordinance (Section 16 - Curfew subject to Gazette of Sri Lanka (http://www.documents.gov.lk/en/gazette.php). Through the ordinance which is updated from time to time via gazette notifications, a mandatory 14-day quarantine at a center and further 14 days of self-quarantine for all inbound passengers were imposed. This further reduced the likelihood of the disease spreading in the community. The strict adherence to the measures enforced through the Quarantine and Prevention of Disease Ordinance Act could be further strengthened by making the wearing of face masks, mandatory quarantine and social distancing which are considered only as guidelines issued on COVID-19 prevention, legally binding, at least during an outbreak, so that more citizens follow these measures stringently.

Maintaining a Steady Supply Chain

In the face of rapidly escalating cases, even the most developed countries went short of medical facilities, including intensive care beds, face masks, personal protective equipment, sanitizers, intubation and ventilation equipment and lab facilities to screen and confirm cases (Mikhael and Al-Jumaili 2020). Therefore, surveillance of these capacities at timed intervals to face future situations should be emphasized. Particularly as a developing nation, we felt the need to establish a mechanism to manufacture laboratory and medical equipment and to ensure a continuous food supply chain in the face of the closure of ports and airports.

A Phased Lockdown

During the past few months, many Sri Lankans faced economic hardships due to a long lockdown period, which commenced on the 20th of March in Colombo and Gampaha districts, until the middle of May. An early and very strict lockdown was essential in the name of public health and to prevent limited health resources from being overwhelmed. However, as this was not sustainable in ethical or economic terms, a phased lockdown was implemented in mid-May, where there was a slow easing of restrictions. This phased return to a more open society, as opposed to a strict and complete lockdown for a long period, is ethically viable as it does not disproportionately restrict civil liberties and economic freedom. Another feature of Sri Lanka’s unique strategy was that not all districts experienced lockdown to the same degree. While the districts of Colombo and Gampaha experienced the most stringent lockdown, the other districts were relatively less strict. Furthermore, even though the strict lockdown did not seem ethically sound, given the number of ICU beds available in Sri Lanka, it was the opinion of the public health experts that we employ a method known as “the hammer and the dance”. This method involved a two-phase strategy (Assenza et al. 2020), where an initial strong confinement stage (the hammer), was followed by a more relaxed phase (the dance). The relaxed phase was implemented once the local transmission reached a point that could be curtailed with community measures such as wearing a facemask, good hand hygiene practices and social distancing.

The government’s preventative measures, while indispensable, have led to the economy taking a major downturn, particularly as the pandemic comes in the wake of the 2019 Easter bomb attacks (United Nations Sri Lanka 2020). The disruption of livelihoods has caused concern in some communities, particularly among daily wage earners, who felt the effects of the pandemic the most. The Sri Lankan Government struggled to support these people economically, and although the government has expressed concern for the low-income earners, emergency food relief and other basic support were delayed. By mid-April, the government had arranged for financial support to those citizens whose livelihoods had come to a standstill, and a sum of Rs 5000 was granted to each person. Many local charities collaborated with the authorities to supply dry rations and other essential items to those who had fallen on hard times. We must, therefore, have a plan to support the daily wage earners and small businesses until the country returns to normalcy. Locking down a country and exiting the lockdown is a difficult process and it is therefore imperative to have a pre-prepared plan for future pandemics. As stated above, the public health measures implemented by the Sri Lankan Government could have been argued by some as non-ethical as it could be seen as an undue infringement on an individual’s autonomy as well as an interference with civil liberty. However, in a broader context, preventing death due to the lack of resources if the number of cases of COVID-19 reached overwhelming figures, as seen in our neighboring country India, would have outweighed the ethical concerns pertaining to the enforced lockdown.

Free Healthcare for All

The most important asset for Sri Lankans was the free healthcare system, which enabled the country to face a public health problem of such magnitude with confidence. Both curative and preventive healthcare systems are free in Sri Lanka. The private healthcare system mainly works in the curative aspect with some contribution to preventive care as well, like cancer screening and screening for non-communicable diseases. The strength of our preventive health system is one key determinant behind the success in facing the epidemic. It was therefore vital that this resource was protected from being overwhelmed during the pandemic crisis as mentioned above. Due to the curfew and strict lockdown measures imposed by the government, our healthcare system was thus protected.

In the context of healthcare workers, the importance of continued medical education with concepts of good medical practices was felt more than ever before. An example is the skill of intubation, which was deemed to be crucial in the management of severe cases. Every healthcare worker should have sound knowledge regarding notification and surveillance systems of a specific disease. To this end, responsible authorities need to organize awareness programs for healthcare workers. This is also a good opportunity to educate medical practitioners on medical ethics, especially as it was found that in a recent survey 81.2% of doctors did not have sufficient knowledge of medical ethics. However, most (> 90%) of the participants had expressed their willingness to learn (Ranasinghe et al. 2020).

Procedures for handling an emerging/re-emerging infection, including evidence-based clinical practice, epidemiological surveillance, investigation and control measures, implementing preventive measures with behavioural, environmental changes, laws and regulations, monitoring and evaluation and research should also be streamlined (World Health Organization 2018). In Sri Lanka, when suspected COVID-19-positive cases were admitted to the hospital, the hospital ward setting was changed to prevent the spread of the disease. Guidelines were issued early on from respective professional colleges, with guidance from the WHO, to enable a quick response. These guidelines were readily accessible via the Ministry of Health Epidemiology Unit website www.epid.gov.lk (Epidemiology Unit 2020a, b, c, d). The importance of a global partnership in handling a pandemic was felt very strongly in this instance.

Accountability of Citizens and Community Awareness

Taking into account the experiences and lessons learned from the COVID-19 pandemic, not only is the government’s response vital but every citizen should have a plan to prepare for and respond to future pandemics. Many Sri Lankans started home gardening to face problems with food supply; thus, the importance of being self-sufficient was strongly felt among the citizens (Rodrigo 2020). The majority of Sri Lankans have a high literacy rate owing to the free education system and hence, they were equipped with basic skills to understand and implement necessary preventive strategies such as wearing a face mask, hand hygiene measures and social distancing, all of which were strictly enforced by the government. Adherence to directed self-discipline either volunteered or forced (in some instances) is one other key determinant to the success in fighting this crisis. “Vidya dadathi vinayang”, a saying by Lord Buddha, means “being informed or knowledgeable, generates discipline”. Furthermore, we did not have people overtly objecting to or flouting the rule of mask wearing, as seen in America, Australia and Europe. Literacy in information and communications technology was also vital, with the concept of working from home and homeschooling children during the lockdown period. Due to the feasibility and convenience of working from home, some companies decided to continue this concept indefinitely, even after the pandemic settled with time. In the face of such a pandemic, the Sri Lankan people understood that the suffering caused by being irresponsible affects everyone in society, including oneself and one’s family.

Local governments, while providing fundamental facilities, should under the directive of the provincial director of health services arrange awareness programs with the help of the area medical officer of health (MOH) and public health inspectors (PHI), to increase awareness at a community level, thus promoting autonomy and preparedness at a micro-level in case of a future pandemic.

Role of the Media

The mass media in collaboration with the Sri Lankan Government was an important aspect of our fight against COVID-19. Media support was vital for the dissemination of correct information, de-stigmatization and myth-busting efforts executed by the government. A substantial amount of funding, donated by various organizations, was spent on media advertisements to control the spread of the disease. Positive health behaviour was greatly advocated through the mass media as it played a major role in preventing COVID-19 (Health Promotion Bureau 2020). However, the issue of false or misleading news was also strife in the media, and as citizens, we learned that getting updated with accurate information from responsible parties was vital to prevent unnecessary panic caused by fake news. There have been instances of unethical behaviour by the local media, who had reported identifiable personal information about COVID patients as well as publicizing the ethnicity of the patients who died due to COVID-19. This leads to the stigmatization of these persons and their families in society (Ayub 2020). Some international media outlets also picked up and reported on this unethical reporting by local media, urging Sri Lankan authorities to act (Mukhopadhyay 2020). The International Press Institute has reported 426 media freedom violations during the COVID-19 pandemic, and nearly half of these violations were reported from Asia (International Press Institute 2020).

While the crisis strengthened the society and improved social cohesion, as shown by examples of social solidarity and community initiative from all parts of the country, at the same time, incidences of stigmatization and exclusion counter these positive narratives. For example, there were media reports that when a person was found to be tested COVID positive in the community, not only the individuals’ family but the whole street was quarantined. However, the regional epidemiologist claimed that they took an evidence-based approach towards controlling clusters, stating in an article “first-line contacts are the immediate home contacts of the index case. These contacts undergo mandatory testing and immediate isolation as they are at an increased risk of contracting COVID-19 and are most likely to spread it to others. The second and third contacts are kept under the radar and closely monitored” (Hettiarachchi 2020).

Ethics of Care in Sri Lanka’s Response

The ethics of care, which emphasizes solidarity, care and responsibility to the most vulnerable people in society, was important in Sri Lanka’s successful response to the pandemic. The phrase “ethics of care” was initially coined by psychologist Carol Gilligan (1982) and has its origins in feminist theory. Gilligan studied how little girls looked at ethics and found that in relation to boys, the moral development of girls usually came from compassion instead of being justice based. Her theory proposed that ethics should be focused on relationships and dependent on the context of the situation, instead of emphasizing autonomy and rules. The philosopher Nel Noddings (1984) further contributed to the theory by considering that values such as justice, equality and individual rights should operate together with values such as care, trust, mutual consideration and solidarity. In a recent paper describing Vietnams successful response to the COVID-19 pandemic, which attributed Vietnams success partly to the ethics if care prevalent in Vietnamese society, Ivic (2020) stated that “In light of ethics of care, the requirement for practicing social distancing for the good of vulnerable groups (elderly, ill, and so forth) represents the social responsibility towards our shared communities”. Similarly, in Sri Lanka during the COVID-19 pandemic, care ethics was seen in several different scenarios. It was manifested in the way people adhered to social distancing rules and the wearing of face masks, to protect the vulnerable groups. Peaceful and amicable adherence to the stringent curfew and lockdown by most citizens was also an example of care ethics. As seen in Vietnam (Ivic 2020), the ethics of care overcame binary oppositions: we/they, young/old, public/private, wealthy/poor; this is observed in Sri Lanka’s successful response as well. Many private sector companies offered their hotels and services for quarantine purposes and well-to-do citizens gave charitable donations of food to the needy and less fortunate. Furthermore, the ethics of care justifies an initial curfew-like lockdown to get the pandemic under control and was vital in the initial few weeks of the pandemic. However, if a resurge in COVID-19 cases occurs, this might prove not to be the case.

The decision by the government to open the country’s main international airport was primarily to prevent the economy from sinking further and salvaging the jobs and livelihoods of many citizens. In this context, it does not infringe upon the ethics of care principle. When considering preparedness in the context of care ethics, it is vital that essential health services must be freely available to all citizens to minimize COVID-19-related fatalities as well as additional deaths from the pandemic, especially with respect to chronic diseases. Free access to infection prevention, control, testing and treatment is vital to protect communities. Crucially, controlling a pandemic—disease detection, communication and containment efforts—all depend upon community engagement in terms of public cooperation, solidarity and responsibility.

Conclusions

The strategy employed by Sri Lanka, where an initial stringent lockdown period of 8 weeks was followed by the gradually easing of the lockdown, a phased approach, is an example of an ethically sound measure. This method can be further justified as one that would prevent our health system from being overwhelmed, thus saving many lives. The Buddhist teachings of self-discipline that prevails within Sri Lankan society have likely played a role in the adherence to the strict rules set by the government during the curfew and lockdown periods.

As the number of fatalities from the COVID-19 pandemic is low in Sri Lanka, many lessons can be learned from the country’s response to the crisis, from an ethical perspective. The way forward would be to have, firstly, ethics of care and self-discipline among the majority of people in society. The early strict curfew and lockdown followed by a phased out easing of the lockdown were necessary. Even though there are ethical concerns with this approach, it was vital in Sri Lanka’s successful response to the pandemic. However, this is a good lesson for future pandemics and an opportunity to establish an ethically sound system with broader dissemination of ethical practices among all healthcare works. Secondly, due to the issue of fake news being spread by social and mass media, it is important to use reliable sources of information. Thirdly, a strong and free healthcare system and a robust public health and community care system, such as that which is present in Sri Lanka, are important to combat a health crisis. Finally, to have a plan in place for disaster preparedness and especially to financially support people who have fallen on hard times is important. Having overcome past crises such as the civil war and the Easter attacks of 2019, Sri Lanka will no doubt find a way to renewed prosperity in the aftermath of the COVID-19 storm.

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Correspondence to Dineshani Hettiarachchi.

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Hettiarachchi, D., Noordeen, N., Gamakaranage, C. et al. Ethical Responses to the COVID-19 Pandemic—Lessons from Sri Lanka. ABR 13, 225–233 (2021). https://doi.org/10.1007/s41649-020-00153-z

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  • DOI: https://doi.org/10.1007/s41649-020-00153-z

Keywords

  • COVID-19
  • Sri Lanka
  • Strategy
  • Public health