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).