Dr. W.M.T.B. Wijekoon of Sri Lanka was recruited to run the Anti-Malaria Campaign in the rural northern districts during the country’s recent civil war, which ran from 1983 to 2009. He operated in an undesirable and dangerous area, and both he and his wife suffered from malaria while there. Under his leadership, however, the number of infections in the northern districts decreased ten-fold – from 100,000 cases per year to 10,000. Now, with Global Fund support, the entire country is on the cusp of malaria elimination. Friends was fortunate to sit down with Dr. Wijekoon, now a country-level Global Fund project director, to get a first-hand account of his work.
Friends: Tell us about how you got started in the fight against malaria.
Dr. Wijekoon: In 1983, I began treating a lot of malaria cases. In 1985, I moved to the most northern – and most rural – part of the district, about 60 km away from the ancient capitol of Anuradhapura. I was the only medical doctor in charge of an area of about 50,000 people. Before I came, there was a doctor there who had committed suicide, and nobody wanted to go there. Because of the war, the remoteness. There was no water, no electricity, no telephone.
I volunteered to go. I took my family – my wife and I had a daughter at that time, and my son was born while I was there. He’s now a medical student.
I was in charge of everything: immunizations, education, maternal and child health, school health inspections. And I was treating about 200 malaria cases per day.
“And so with the Global Fund’s commitment and support, we’ve increased our own commitment as well. Through the dedication of the campaign and the medical officers, we were able to drive malaria down to a low level.”
You yourself contracted malaria, is that right?
At this time, malaria was very high. I got three attacks. Even my wife had two attacks.
This was 25 years ago. What was the treatment like then?
Even in those days, in the drugstores, you had malaria drugs. You always had the biggest stocks of painkillers, antibiotics and malaria drugs. So we had to take those drugs. Later we decided to take prophylactics.
When my wife was pregnant, we knew that we had to take prophylactics, because she would have risked losing the pregnancy if she’d gotten malaria. Once we began taking prophylactics, I didn’t contract malaria for the remaining six years we lived there.
Tell us about your more recent work for the campaign.
When I transferred to the general hospital in Anuradhapura, I came as medical officer of health, then later I became the head of the hospital and, eventually, the Provincial Director. I was looking after the entire province.
These districts were highly malarious areas, because of agriculture and the rice-growing areas, where water would pool. Those conditions were very conducive for malaria and mosquito breeding. Every three months during this period, they came and sprayed with DDT, malathion. Everything was sprayed, even the chairs, walls and roof.
I continued the Anti-Malaria Campaign on the provincial level. With support from the World Health Organization and Roll Back Malaria (I still admire the effectiveness of that program), we started active detection of cases.
During that time, we had upwards of 100,000 cases a year in the province. We mobilized our staff to the field and did active detection to detect the parasite. Every day they went to collect blood for sampling, collect mosquito larvae and conduct spraying.
In your testing, did you find that there were hot spots, or areas where malaria was thriving?
Oh yeah, more resources would be mobilized to those areas. So when we started focusing on the highest-risk areas, we recognized that malaria was gradually going down. I was very happy that when I left Anuradhapura in 2004 and returned to the capitol, malaria was down to fewer than 10,000 cases.
Since you reached this new low, what has been the impact of Global Fund resources?
First, let me give you some background. In 1963, the country’s malaria situation was similarly under control, after a big spraying campaign. Then the country started relaxing, and everybody thought malaria was over. Then after that, the epidemic came roaring back.
So we should not make that mistake again. You have to be vigilant. It’s easy to bring something down from an epidemic level to a low level, if you put in the effort, but to bring the level to zero is very difficult. Because the people’s commitment dies off, the resources die off, the human resources also. In the 1960s, sprayers started doing something else. The supplies and resources were diverted. Money was moved from the malaria campaign for something else.
Since then, we’ve worked to get back to those same low levels. With the Global Fund, we were able to scale up our programs dramatically all across the country, bringing us to this pre-elimination stage.
And this time around, the Global Fund has helped prevent any slipping. When resources from the Global Fund arrive to fight malaria, they are kept for malaria. We know that the Global Fund puts conditions on the money that we have to follow to keep the support. And so with the Global Fund’s commitment and support, we’ve increased our own commitment as well. Through the dedication of the campaign and the medical officers, we were able to drive malaria down to a low level.
We have now come to the elimination period.
How does the strategy change as you move from control to elimination?
The imported cases are now our threat. So screening at the airport is a big part of the strategy. Anyone who comes with a fever, they can get screened and sent to the health center right away to get treated. Whoever is going outside the country also needs to be educated about the threat. If a case is detected, there would be a lot of investigation now.
How do the new strategies remain sustainable, so that malaria doesn’t return?
Now the ministry commitment is strong, and we haven’t diverted the program. We still have training programs and policy guidelines – so those activities are carried on. Mobile screening, entomological surveillance, and prevention programs are all still continuing as well.
But there are risks. There are fewer medical professionals with experience. My son, for example, who is medical school, doesn’t see patients with malaria. Now when a patient has a fever, the doctor often doesn’t think about malaria. That is one of our problems. That is just one risk area.
But we know the consequences of backing down on malaria—and we won’t make that mistake again.
This post was originally published in August 2013.