For a long time, Sri Lanka was a leader in the region in two key areas – public health and civic conservancy. But over the last year, the country is facing a major challenge in both, the most visible manifestation being the recent dengue epidemic that has claimed over 200 lives.

One tragedy closely followed another. In April, a massive trash mountain in suburban Colombo collapsed, killing 32 people and crushing over 150 homes. Affected residents are still struggling to recover from the disaster, and civic authorities confronted an obvious problem. With the city’s key waste-yard now out of bounds, they had no place to dump residents’ trash every day. Consequently, municipal collection has been very irregular, with rotting piles of trash left unattended across the capital. Soon after, Sri Lanka faced one of the worst floods and landslips in recent years. At least 200 people died and several thousands were displaced.

Meanwhile, dengue emerged a major public health challenge. According to data provided by the Epidemiology Unit of the Ministry of Health, as many as 69,380 suspected cases of dengue have been reported until now in 2017, a sharp rise compared to the 55,150 cases recorded in 2016. The increase in the number of cases has “shaken up” Sri Lanka’s public health machinery, said Preshila Samaraweera, a Consultant Community Physician attached to Sri Lanka’s National Dengue Control Unit. “The system was not prepared to handle as many as 70,000 cases.”

While around 42% of the cases were reported from in and around Colombo, in the Western Province, there was no district without a case, Dr. Samaraweera said, pointing to what has become a nationwide health concern. The fatality rate has increased to 0.3% this year, from last year’s 0.2%. Doctors point to the more virulent serotype 2 viruses replacing the earlier prevalent serotypes 1 and 4 as the main reason for the outbreak intensifying this year. The Health Department has come up with many responses to tackle the problem, ranging from fogging operations to spraying larvicides, to environmental management to legal action. “The case load is high but we are trying our best with a strategic plan to reduce the number of deaths, number of patients and the breeding grounds for the mosquitoes,” Dr. Samaraweera said.

Out of hand

Despite that, why did the situation go out of hand? Sri Lanka, after all, is a country that the World Health Organization declared malaria-free last year, hailing its public health strategies for the remarkable achievement. Social scientist Kalinga Tudor Silva, who has authored a widely-cited account on the social history of malaria in Sri Lanka, blames the government’s top-down approach in responding to dengue.

“The programmes are designed at the Centre, focussing largely on regulatory efforts like rigid checking by health inspectors. They pay little attention to local-level community participation,” he said.

Even the government’s malaria eradication programme was initially centralised. “After a resurgence in the late 1990s, the Health Ministry realised that such an approach will not work. They began involving community networks across the island. A similar shift is necessary in tackling dengue,” Prof. Silva said. Much of the causes linked to dengue are to do with human behaviour — such as garbage disposal, water storage at homes and gardening practices. “You cannot address the issue without people’s participation. More so in the case of dengue than in malaria. At some level, it is also a governance issue.”