Paper Presented at a Seminar on Medical Supplies and Health Care in Jaffna.
[Colombo, Sri Lanka; January 2002]

PROHIBITIONS AND RESTRICTIONS ON PHARMACEUTICAL PRODUCTS TO JAFFNA
PRESENTATION OF A FIELD SURVEY

By Dayala Deva (Former Director, IFRC)

Introduction:

The Sri Lankan Health Service has been a model for developing countries. In Sri Lanka, the Northern Province was one of the regions which had a very high standard of Health Care Service. Traditionally, the literacy rate, life expectancy, hygiene, intake of nutritional diet were of very high standards, while maternal and infant mortality rates were far less when compared to other demographic areas in Sri Lanka. The Jaffna Teaching Hospital and the peripheral Hospitals provided best Health care facilities.

The ethnic conflict in Sri Lanka, which started almost two decades ago, has now metamorphosed into a large-scale civil war - if not a conventional war. All sectors of the people have been affected. However the most affected are the people living in the North-East of Sri Lanka. Health care services have deteriorated to very low levels. Some of the indicators of health in the North-East, may not be as low as in other countries ravaged by civil war, but certainly there is a downward trend, which could eventually lead to situation worse than war torn countries like Ethiopia.

They say that Health is Wealth. But as far as North is concern there is neither wealth nor health. The deterioration of Health Care in war torn areas like Jaffna could be due to many factors. The experienced and seniormost doctors, who have come here from Jaffna will explain those factors in detail.

Objectives:

Today we have assembled here at Sri Lanka Foundation Institute, driving in smoothly without going through any checkpoints or barricades. In fact, if we have had this seminar a month ago the situation would have been totally different.

Actually, when we started this project on Prohibitions and Restrictions on Pharmaceutical products to Northern Province in last September we never anticipated that these changes would occur so quickly. We started our project before the dissolution of parliament. We continued our survey and the field study during the election period and completed just prior to the General Elections.

Now, we have a new Government. They say that the economic embargo including on Pharmaceutical items will be lifted. I do not know whether these are temporary makeshift arrangements. [I say this] because there were such temporary arrangements similar to the present ones on earlier occasions too in 1990 and in 1994.

Our objective is that there should not be any sort of prohibitions or restrictions on medical items at any stage in future. It is a fundamental human-right of every citizen of this country, wherever he or she lives to get basic Health Care. In a conflict area, when there is a war, the ‘terrorists’ or the ‘government soldiers’ could get killed, but the government cannot deny the basic Health facilities to the civilians living in the conflict areas.

Now we are all aware that according to the Ministry of Defence 90-95% of Jaffna peninsula is under the control of Government forces. If that is the situation - we do not know why the government should enforce [an] ‘economic embargo’ in a government-controlled area.

When we decided to take up this project, first we wanted to clarify the decision on embargo from the Ministry of Defence and Ministry of Health. The senior officials from the Ministry of Health said “Whatever items which are requested by the Medical Superintendent of Jaffna Teaching Hospital and by the D.P.D.H.S of Jaffna are delivered”.

Then we made inquiries from Jaffna, but unfortunately they were so scared to say either yes or no. This may be due to the political pressures prevailing in Jaffna before the elections.

Colombo officials were defensive and the Jaffna officials were in a desperate state.

We started our survey from Colombo.

We were fortunate enough to obtain copies of the Medical Supplies Division (M.S.D.) and Ministry of Defence (M.O.D.) clearance documents for the year 2001. These documents, which were sent from Jaffna M.S. and D.P.D.H.S., were scrutinized by the M.S.D. and M.O.D. When we studied the entire documents we were shocked to find that nearly 21 vital medicines were totally not approved, and more than 40 medical items were restricted [to] below 75% and 50%. Therefore we have with us the documental evidences on Prohibitions and Restrictions on Pharmaceutical products to Northern province.

Now, let us get back to the history, the ethnic conflict started way back in1983. In 1987 the economic embargo was introduced by late Lalith Athulathmuthali as Minister of National Security. Actually at the beginning the embargo was introduced only for certain items - which the government feared could reach the hands of L.T.T.E. The consecutive governments expanded the lists of items which included Pharmaceutical products.

Of course, I do not know whether these prohibitions and restrictions affected the L.T.T.E. in anyway. According to the Defence Ministry Statements the L.T.T.E. have Surface to Air Missiles, Rocket Propellers, War Tanks, Automatic Rifles and various others modern war equipments. I do not understand why the government bans a small pocket size box of antibiotic tablets with an idea to stop it reaching L.T.T.E., where in reality that L.T.T.E. could possess such large modern war equipments.

I am sure that these equipments wouldn’t have gone through the ICRC escorted cargo ships with thorough Navy and Air Force checking at Trinco and Point Pedro! There are beneficiaries of the economic embargo on both sides - but we must understand that only the ordinary civilians are affected by these prohibitions and restrictions.

Established Procedures:

In order to get a clear picture regarding the availability of Pharmaceutical products, let us take Jaffna peninsula as an example. The estimated population of Jaffna peninsula is little more than 500,000. Apart from the Government Teaching Hospital there are 19 peripheral government hospitals. Jaffna University has a faculty of medicine.

Since 1992, the procedures to obtain medicines for the above mentioned hospitals have changed and new rigid controls have been imposed.

The Medical Superintendent and the Deputy Provincial Director of Health Services prepare the lists of all Pharmaceutical items according to the basic requirements of the hospitals for the whole year. The list is divided into four Quarters and sent to Colombo. The prepared lists are sent to the Medical Supplies Division by the M.S. and D.P.D.H.S.

The Jaffna Health authorities have appointed two senior health officials as co-ordinators in Colombo. They take the lists of Medical Items to M.S.D., M.O.D. and ICRC.

Two Assistant Directors from the Medical Supplies Division scrutinize the lists sent from Jaffna for each quarter. They delete some items if those items are not available with the State Pharmaceutical Corporation. They delete and restrict certain items according to the defence policies, which change from time to time.

From the M.S.D. the lists are sent to the M.O.D. The defence authorities where I understand two assistant directors make the final decision on the quantity of items that could be sent to Jaffna. Further they disapprove certain medical items according to the defence policies, which again vary from time to time.

The final lists are given to the coordinators who are stationed here in Colombo by the Jaffna Health Authorities. These coordinators collect the medical items from the State Pharmaceutical Corporations and transport the items by lorries to Trincomalee. In Trinco the parcels are opened and subjected to severe checking by the Navy Officials. Then the medical items are loaded in the ICRC ship and sent to Jaffna. The items are unloaded at Point Pedro harbour, checked again and sent to Jaffna Teaching Hospital and various other peripheral hospitals.

Before concluding the procedures of sending medical items to Jaffna, we will have to take note of following defaults and shortcomings.

Nearly 20% of the medical items sent to Jaffna are with very short expiry period. When the parcels which contain medical items are opened and packed again, on many occasions, finally before they reach the destination, nearly 12-15% of the items are pilfered or damaged. The environmental conditions such as high temperature and exposure to sunlight too damage the effectiveness of the medical items.

Prohibitions and Restrictions on Pharmaceutical products:

According to the various interviews and discussions we conducted in Colombo and Jaffna and also according to documents that we were able to gather for the four quarters of year 2001, the following facts were observed:

The items not approved.

1. X-Ray Developer (M.P).

2.  Anti D (Rho) Immunoglobin.

3.  Inj. Gammaglobulin.

4. Inj. Heparin.

5. Chloramphenicol Eye Drops.

6. Tap – Spironolactone 25mg.

7. Caps – Nifidepine 10 mg.

8. Inj. Glyceryl Trinitrate 10 ml.

9. Bandage Elastic Adhesive.

10. Bandage W.O.W.

11. Tab. Glibenclamide 5mg.

12. Tab. Stilbesterol 1mg.

13. Inj. Lionocaine Plain 2%.

14. Chlrmaphenicol Eye oint.

15. Pilocarpine Eye Drops 4%.

16. Benzyl Benzoate Application.

17. Hydrogen Peroxide.

18. Betamethozone oint.

19. Framycertin skin cream.

20. Tab. Aluminium Hydroxide.

21. Surgical Blades.

The items restricted to below 25% and 50%,

1.  X’Ray Film 30x24cm.

2. X’Ray Film 35.6x35.6cm.

3. Dental Occlusoal.

4. Inj. Ergomatrine Maleate.

5. Antivenom serum Inj.

6. Inj. Oxytocin 210.

7. Inj. Panouronium.

8. Oral Penicillin Tab.

9. Metronidazole Inj.

10. Amoxycillin Syrup. 100ml.

11. Metronidazole Inj.

12. Isosorbide di nitrate.

13. Frussumide 40mg.

14. Inj. Atropine Sulphate 1ml.

15. Tab. Verapamil Hydrochloride 40mg.

16. Tab. Procainamide Hydrochloride.

17. Tab. Prozosin Hydrochloride.

18. Tab. Captopril.

19. Tab. Diltiozem 60mg.

20. Folic Acid Rab. 50mg.

21. Vitamin A+D Capsules.

22. Vitamin B Compex Tabs.

23. Hydroxo cabala mine Inj.

24. Surgical Sprit.

25. Plaster Adhesive.

26. Gauze Absorbent Meter.

27. Sannitary Pads.

28. Inj. Hydrocorltson 100.

29. Tab. Norethisterone.

30. Tab. Metroabloparine 50mg.

31. Tab. Asathioprin.

32.Inj. Diazepam.

33.Pimozide Tab 4mg.

34.Clonnzepam Tab.

35.Dextrose 5%.

36.Chloramphenical Ear Drops.

37.Tab. Chlorpheniramine 100ml.

38.Cap. Indomehacin 25mg.

39.Tab. Methionine 500mg.

40.Oxygen Cylinders.

41.Antibiotic Dis. Slides.

42.Modicate injection.

43.Extension Plaster of pairs.

44.Inj. Sodium Tetradecy salphate.

Apart from the above-mentioned procedures, we will have to take note that Pharmaceutical items are also being taken to Jaffna by the following:

The above-mentioned get direct clearance permits from the M.O.D. Most of the Non Governmental Organizations supply the medicine mainly for Internally Displaced people.

Situation in Jaffna:

As mentioned above the MSD and MOD by not approving vital medical items and restricting more than 40 items have caused drastic health hazards in Jaffna peninsula.

We observed the following serious health problems prevailing in Jaffna, which need urgent attention from the newly formed Government.

1.   On average only 50 to 55% of the patients who visit O.P.D. in Jaffna Teaching Hospital and peripheral hospitals receive the required medicines.

2.   Patients suffering from chronic illness such as Diabetes, Arthritis, Cancer, Kidney Failures, Asthma do not get their medicines continuously.

3.   Patients who are supposed to undergo urgent major surgeries under General Anaesthesia suffer due to lack of facilities in the Operating Theatre. Some patients are transferred to Colombo by ICRC, and some get surgeries done under local anaesthesia.

4.   The conditions of the Operation Theatre are appalling.

5.   Shortage of painkillers known as Analgesic drugs, and sedatives make the patients undergo unbearable sufferings.

6.   Availability of Oxygen cylinders is limited. Only 10 Oxygen cylinders are given at a time, while keeping the main stocks at Palaly Army Base. For any emergency Jaffna Teaching Hospital staff will have to go to Palaly Army Base, which is almost 25Km away, and obtain Oxygen cylinders. Such procedures take nearly four hours

7.   Pregnant mothers suffer severely due to shortage of certain vital drugs and injections such as Anti Tetanus, Ergometrine, Sedatives and Strong Antibiotics.

8.   Severe shortage of items such as Glucose strips, Sanitary Pads, Gauze, Surgical spirit, Adhesive plasters, Strong antibiotics and certain other medicines required for surgeries was observed.

9.   Patients with kidney failures have no facilities to undergo Haemodialysis, as there are no Dialysers or solutions. Patient in critical conditions are given peritoneal dialysis.

10.  The condition of the Intensive care unit is miserable.

11.  Psychiatric drugs are totally inadequate. Modicate injections which are essential for psychiatric patients are not available.

12.  The laboratory facilities in Jaffna Teaching Hospital are in very poor conditions. There is no Pathologist available in Jaffna Teaching Hospital. The samples for Biopsy, sera and viral studies are sent to Colombo and results arrive only after long delays. Such delays to chronic and highly infected patients cause fatal results.

13.  The chief MLT complained that shortage of laboratory facilities and lack of modern lab equipments are the main factors that cause malfunction of the Microbiology studies.

14.  Another major problem, which we observed, was that some vital medicines are with very short expiry period and sometimes medicines of expired dates are also sent.

15.  Malnutrition and Anaemic conditions among children and pregnant mothers are common due to shortage of nutritional diets, vitamins Iron supplements.

16.  Anti Tetanus injections are restricted by 75%. Patients who suffer from cut injuries suffer due to non-availability of Anti Tetanus injections.

Drastic effects due to Prohibitions and Restrictions of Pharmaceutical Products to Northern Province

The health situation has deteriorated to very dangerous levels. In the health sector, the destroyed and closed down Health Institutions and lack of basic equipments are very obvious. The lack of manpower in health sector is also obvious. The insidious increase in the Infant and Maternal Mortality rates, water and food borne diseases, the lagging behind in the introduction of newer technologies in medical management are not so obvious but constitute a major problem. Comprehensive Data on Health Status is lacking in the Northern Province, as most of the surveys carried out in Sri Lanka after the on set of the conflict excluded the Northern Province.

According to the senior doctors and Health Authorities with whom we conducted interviews, the unofficial embargo on Pharmaceutical products to Northern province has caused drastic effects on the health conditions of the people.

1.   Death rates due to diseases have increased when compared to the situation prior to 1993.

2.   Mortality rate among infants and pregnant mothers have increased by nearly 18%.

3.   Mortality rate among children under five too has increased by 18%.

4.   Malnutrition among under-12 children, which was at 4.3% in 1983, has gone up to 40% in 2001.

5.   Death rates due to communicable infectious diseases, Malaria, Cancer, Diabetes and Cardio Vascular diseases have increased.

6.   Very high rate of Malaria cases (highest in Sri Lanka) and deaths due to Malaria are highest in the Sri Lanka.

7.   Even death rate due to common diseases has increased due to shortage of drugs.

8.   Many deaths have been caused by Septicaemia, which are mainly due to prohibitions of strong antibiotics.

9.   Patients with common diseases suffer because the duration of healing time rates are more due to non-availability of medicines.

10.  Monitoring and immediate care provided by the Intensive Care Unit have been hampered severely.

Conclusion

When we take the North and East provinces, leaving Vanni which includes Mannar Mainland, Killinochchi and Mullaitivu districts, almost 90-95% of the areas are under the control of Government Forces according to the Ministry of Defence.

Out of all these Districts - Batticaloa, Ampara, Kalmunai, Trinco, Mannar Island, Vavuniya - only Jaffna Health Sector has to obtain M.O.D. clearance to receive medical items. Even though the M.O.D. claims that 95% of the Jaffna peninsula has been cleared we do not know why the Health Sector in Jaffna has to obtain M.S.D. and M.O.D. clearances.

We would like to know whether the Government has no trust in the senior health officials in Jaffna. If the Government Agent of Jaffna can be trusted and sent more than 600,000 ballot papers – almost 100% excess of the original requirements – we do not know why they do not trust the senior health officials. There are almost nine army camps around Jaffna Teaching Hospital. Do they think that a group of Tigers will enter Jaffna Hospital and take away a box of Antibiotics?

Therefore there is something wrong somewhere – I would like to quote one example – Last year in March there was a severe shortage of an Analgesic injection called Dichlorofen Sodium. This is a very common injection used in all Hospitals. The M.O.D. did not give approval for this injection to be taken to Jaffna. But within two weeks an individual with political backup obtained a M.O.D. clearance for 100,000 Dichlorofen Sodium injections and sent them to Jaffna private pharmacies. The price of this injection in Colombo is Rs. 10, but it was sold in Jaffna for Rs.80.

Therefore I would like to request the Government to allow the Medical Superintendent of Jaffna Teaching Hospital and the D.P.D.H.S. of Jaffna to make indents to M.S.D. directly and obtain all the required medical items through ICRC. The Ministry of Health, The Ministry of Provincial government can co-ordinate and work out the budget allocations and medical requirements.

Once again I would like to stress that it is the fundamental right of every citizen in Sri Lanka to obtain basic medical facilities. It is imperative that the intelligentsia of the New Government should foresee the future and take all preventive action to avoid a Calamity that would befall on the future generation of Northern Province.

When I discussed with a very senior doctor in Jaffna regarding this prohibition and restriction of Pharmaceutical products to Jaffna, he simply asked me- “Why do you need a M.O.D. clearance to bring a tablet of Aspirin? You need a M.O.D. clearance only if you want to bring gunpowder!”

I thank the C.P.A. and the senior Health officials for their valuable advice for the preparation and appropriate projection of the health conditions in Jaffna.