Don't move a muscle. They haven't seen me.

Day Two at the Anti-Filariasis/Anti-Malaria combined Units in Werahara, this time here for a presentation on malaria. Given that it’s a disease still killing 400,000 people worldwide each year, malaria is something we hardly think about in New Zealand. When was the last time I got worried about being bitten by a mosquito?

I knew a few basics going in, but there were a lot of details to sink my teeth into. Malaria is caused not by one but by five different species of Plasmodium parasites, which primarily attack the red blood cells. The life cycle, drug resistance and treatment protocol, and disease prognosis varies between each species.

Another success story, Sri Lanka was certified as having successfully eliminated malaria in 2016 as the fruits of an enormous healthcare campaign. This result had been hard-fought. Sri Lanka began its eradication programme in 1958, and in 1963 only 17 new cases were reported in the country. But the country dropped its gloves, thinking the battle was already over, and just six years later faced a 500,000-case epidemic that swept the nation. Edit: I’m currently reviewing these posts during the COVID-19 international outbreak, as discussions about how long to maintain lockdowns now that new cases of COVID-19 have begun to drop. continue to be debated overseas. This cautionary lesson stays on my mind. The road back towards elimination was a long and difficult one, and I was struck by the fact hat it had been achieved despite the three decade-long year civil war that shook the country from 1983 to 2009. I asked how it could even be possible to continue a public health battle while locked in civil war. The professor at the unit explained to me that pockets of disease were found amongst soldiers in the far north where fighting concentrated, and dangerous, life-threatening work was carried out to transport treatments up past military lines for distribution as widely as possible. I couldn’t imagine doing such a job.

Kottu, probably the most famous local staple.

Now, the control of malaria is dependent on remembering these lessons and ensuring doctors still consider malaria as a diagnosis, as now that cases are only ever imported from overseas it is understandably low on the list when considering differential diagnoses. Malaria is easily misdiagnosed as dengue or another illness, and often presents with very general symptoms like fevers, headaches, muscle aches, and diarrhoea. All this combines to produce a vulnerability to its re-introduction, that threatens to build into a wave of cases going undetected until the epidemic is well underway. Caution was very apparent behind the well-deserved pride in the Unit’s success. Malaria was dormant for now, but if these lessons were ever forgotten, there was no guarantee about the future.

After thanking the wonderful staff at the Werahara clinics, I made my way back to the University of Sri Jayawardenapura to hit the books for my surgical placement next week. I’ve never seen so many people actually reading textbooks instead of pretending to. I found my favourite part of the library – beanbags to sleep on – but soon gave up trying to blend in and went back to the swot. I caught up with my friend Kasun again, who invited me to visit his village home on the upcoming long weekend. I’ve been trying kottu from a few places, a local staple of chopped up meat, eggs, and spices, and he taught me how to eat with my hands. My immediate instinct was to dive in with both hands outstretched like a tiger pouncing. Don’t do this! I have the swing of it now – right hand only, curl the fingers tightly, and spring-load the top of your tucked in thumb with a bolus of food to push into your mouth. It’s surprisingly intuitive once you get going. Unfortunately, I had successfully managed to feed myself spice beyond my dismal tolerance levels. These are tears of joy, I swear.

Sometimes you beat the spice, and sometimes the spice beats you.

I’ve started to notice that there’s a number of heightened security measures around me. The supermarket doesn’t let me bring my bag in, and neither does the library. I’m not sure if these are related to the tragic church bombings that happened in 2019, or overhangs from the civil war. My friend told me how people danced in the street when the fighting finally ended in 2009 – for many young people, that was the first time they had seen peace in their lifetime. It’s very easy as a short-term tourist to lose track of the fact there was ever a war here at all, let alone one that lasted 26 years. I found out that during the war there had been bombings in downtown Colombo, and at the airport I’d flown into as well. I have a lot of questions about how such a protracted, bloody war impacts people here today from both  medical and personal perspectives, but I don’t know that it’s really my place to ask all of them. Some things are still understandably sensitive, and as an outsider here for only a month I can’t begin to scratch the surface in any reasonably respectful and informed way. I think it’s safe to say that a large amount of the population will be suffering from a degree of PTSD and other psychological impacts, and the effects on the healthcare system as a whole must have been immense and surely will still face some impacts today. With only a month here, I know I’m missing a lot of context behind what I see.