ew countr.ies can be so beautiful as Sri Lanka, with its incredible variety of lush trees, fruits and flowers, its rich animal and bird life, and its stunning sea-coast adorned with coconut palms bent gracefully sea- wards by the wind. In this island live a harmonious and hardworking people, striving to develop their resources and raise their standard ofliving, for poverty, malnutrition and avoidable diseases are still the lot of many of them. Health care in Sri Lanka is an interest- ing blend of public, private, traditional, "Western" and Ayurvedic- a 1974 survey showed that each person has some form of care within four-fifths of a mile, and a government service within three miles. The Ministry of Health, now preparing a national plan for PHC, is concerned to promote among the people an awareness of individual responsibility for health. This is also one of the roles of the Volunteer Health Workers, who have 14 written a continuing success story of community action for development m the Sri Lankan villages. The volunteers are mostly young people, the great majority of them women, between school-leaving age and their early twenties. They do their health work while waiting to find jobs, their reward the satisfaction they obtain from contributing several years to valuable ser- vice in their village. I took the bus to Kalutara, about an hour south of Colombo, to visit the National Institute of Health Sciences and find out more about the volunteers of that area. Dr S.D. de Silva explained that the Institute trains four categories of PHC workers-the public health mid- wife, the public health nurse, the public health inspector and the assistant medi- cal practitioner-and also the volun- teers, chosen on the advice of a midwife and the local leaders. The volunteers learn from a team including nurses, in- spectors, midwives and the NIHS training staff. Then they work as part of this team, relieving the health staff of many duties, surveying the village and its needs, and promoting health and general development. "Our training programme is based on the relevant problems we see around us", said Dr de Silva, "diarrhoea, respiratory infections, hepatitis, TB, occasionally polio. The living conditions are very bad and overcrowded in some areas; toilet facilities are poor, and there are people who still drink straight from the well or the river. Some are so poor that they haven't even another cloth to change into. Often the children are neglected too because the mothers have to work, as rubber-tappers or weavers- they can't do without the extra few rupees." Some of the families, I was told later, live on 20 rupees a day (about US $1) for per- haps eight people. Volunteer health workers~mostly young peo- ple waiting to find jobs~sweep and burn the fallen leaves in a temple garden in Sri Lanka. They do many kinds of health, social, agricul- tural and educational work in their own and neighbouring villages. (Photo WHO/D. Gibson) The Institute covers an area around Kalutara of 52 square miles, and Mr M. Moorcy, who is a public health in- spector, took me to the Gamagoda field practice area where he works among 13,500 people in a 15 square-mile area requiring 125 volunteers. "Much of my time is spent on environmental health", he told me, "and that's not achieved in no time. You have to get everyone to cooperate. So I thought to ask the people to participate and create an awareness of health problems." At Mr Moorcy's instigation a Central Health Committee was set up by the leaders (gramasevikas) of the six villages in the area, to promote not only health but total development through voluntary effort. The Committee chooses the volunteers together with Mr Moorcy and his colleagues, the public health mid- wives and nurses, who then give the training. "For example, two-thirds of my area floods during the rainy season, so the volunteers come with me afterwards to chlorinate the unprotected wells. Each one looks after 25 houses and gives health education advice, such things as drinking boiled, cooled water." The · volunteers don't limit themselves to health work, though. " In the villages they find the bad roads and go in a team to put them right, while the whole society collects funds to provide lunch and tea for them during the work. Then we have 'do you know?' contests every three months in the schools, with prizes, to im- prove general knowledge, and we put health and sanitation questions in too. " Mr Moorcy introduced me then to Mr William Godellawatta, President of the Gamagoda Central Health Commit- tee and himself from Bombuwala village. Mr Godellawatta has done voluntary social work ever since leaving school and has been a village council member for 16 years, deriving his happiness from the satisfaction he finds in his work. A few of his volunteers are older, like himself, but most are young, from 16 upwards. "They clean up the gardens and help the poor people put up latrines and dig compost pits and grow flowers and vegetables", he told me. "Sometimes they help in oth- er villages too . The services they render can't be judged by money value; the satisfaction they get is worth much more to them." I asked then if the volunteers' work wasn't more than just health and sanita- tion but had cultural and philosophical aspects too. Mr Moorcy took up the reply : "Yes, it's educational, social, reli- 15 gious ... they arrange sales to get income for the temple, for example, and organize circulating libraries to increase knowl- edge. Also the Central Health Commit- tee invites to its meetings other agencies which can render a service to the vil- lage- the Colombo Plan, the People's Bank, and agriculture and irrigation agents- so that the people are put in touch with all possible sources of assistance." In 1975, five creches were started for children of mothers out at work doing rubber-tapping and wrapping beedis- smalllocally-made cigarettes. Volunteers run the creches too (among them Mr Godellawatta's daughter) , assisted by the probation and social services and supervised by a committee of five moth- ers, the president and secretary of the Health Committee and the midwife. Soon they hope to get supplies of Tripo- sha, a nourishing food mixture, for the children. The creche at Bombuwala is held in a room in the postmaster's house- this is his contribution to the community's welfare. Another is held in a room set aside by the Buddhist priests at the temple, where volunteers were clearing the garden and burning the fall- en leaves on the day I visited. The volunteers support the health staff during epidemics, and also help the Insti- tute in its training programmes by foster- ing good relations between trainee health professionals and the population . " We always remember this with gratitude", says Dr de Silva. " In return I think we do a service for these young people too, by keeping them occupied in a gainful way. They avoid the psychological problems that can come from idleness and acquire knowledge that will be useful to them all their lives." Back at the Institute in Kalutara, I met Mrs Weerasuriya and Mrs Jayaratne, tutors in public health . Mrs Weerasuriya described how the volunteers help the nurses and midwives: " They do domestic nursing services, first aid, environmental sanitation, nutrition and MCH," she said, "whatever they can do on their own, either in the child welfare clinics or the homes. For example, one of the nurses has taught them to dress the cord on new-born babies, and to look for scabies and pediculosis . Usually only the women work in the clinics but the young men follow the classes too and help the public health inspector during epidemics and in mass vaccination and education programmes. All this is very useful to them later when they themselves become mothers and fathers. " In answer to my question about prevention she replied : " The concept has been there for some time but now it's really taking on because it's emphasised to all categories of trainees and the idea comes to everyone from the top down." Mrs Jayaratne recalled the time long ago when as a public health nurse she thought of asking volunteeers to do non- technical tasks so that she could work in a larger area and do more health educa- tion. "It was quite a success- our im- munization and family planning figures went up noticeably. Now the nurses and midwives are helped a lot by the volun- teers. It 's hard for the midwife to attend to all the post-natal cases, but with volunteers to dress the cords she can spend more time with people who need intensive care." She told me about a health centre where the volunteers realised that the health team were working m too A silver lining The volunteer health worker scheme is still be- ing fashioned to meet the primary health care needs of Sri Lanka; this promising concept represents a silver lining for the nation's health care system. Left: Shivering beneath his blanket, a feverish patient consults the malaria volunteer. The sign indicates that malaria treatment can be obtained here. Right: Watched by her father from whom she took over the malaria work, volunteer Kalyani Thilakalatha Bandara discusses her cases with Dr R. Bernard, in charge of malaria control in Anuradhapura district. ( Photos WHO/D. Gibson) cramped conditions and of their own ac- cord got the villagers to build an exten- sion from their own resources. How was it that there was such a good community spirit here, I asked. " It just takes one person to build on that spirit- the peo- ple are willing to help but someone has to motivate and coordinate them- that's what we try to teach our trainees to do. " Mrs Jayaratne would like to make volun- teers of the childre11 too: " You know, even little children can motivate their parents- some of them won 't eat without washing their hands with soap! If we can do something through the schools it will be even better." Sometimes the Volunteer Health Workers in Sri Lanka are used for spe- cial projects like malaria control, and it was to visit a malaria volunteer that I made a seven-hour journey northwards to Anuradhapura district, where ancient buildings and vast irrigation schemes remain from a civilisation of 2,000 years ago . This is the dry north-eastern zone, with vast open spaces and far fewer trees to offer their welcome shade, where the rain has to be collected carefully during only two wet months to irrigate the rice fields, and where mynah birds and small green parrots feed from the rice-ears. At Walaswewa lives Kalyani Thilaka- latha Bandara, a calm and friendly young woman with a welcoming smile who took over as VHW from her father two years ago on leaving school. Outside the house where she lives with her family a sign announces that malaria treatment can be obtained here. Anyone with fever comes to her ; she knows the signs of malaria, and after taking a blood film gives the patient a five-day course of tablets of two colours: one type kills the parasite and the other prevents a relapse.
Volunteers run this village creche at Bombu- wala, near Kalutara, in rooms made available by the postmaster in his house, as a service to the community. Left : The malaria volunteer hoes the garden be- tween visits from clients. In the background, the family rice-plot . (Photos WHO/D. Gibson) If there is no improvement after a few days, she refers the person to a clinic . She also does family planning work and distributes contraceptive pills to her neighbours- although she is young and unmarried, the married women show no hesitation in accepting her advice. She is trained too to give first aid for accidents that happen in the fields- round here the homes are very scattered and it's a long journey to the nearest dispensary. In the intervals, she goes on with her agricul- tural work on the family's farm next to the house, and cultivates the garden. Dr R. Bernard, the Regional Medical Officer for Anuradhapura district, told me that about 600 such volunteers are helping the Malaria Control Programme in his area. The local carrier of malaria is the culicifacies mosquito, which breeds in the sunshine in rain-pools after show- ers. "Because the population are spread out it is difficult for them to get to an in- stitution for treatment, so they may suf- fer for a number of days and meanwhile the parasite has time to develop. So the idea emerged that the people should look after themselves, with one volunteer holding the tablets for 50-60 houses, giv- ing treatment, taking blood films and promoting collaboration with the health services for other activities too." The volunteers take an active part in house-spraying with malathion. "They explain why spraying is necessary and what to do when the sprayers come- the best time to bring the subject up is when the people are actually sick! " This makes the job easier for the sprayers because it is something of an annoyance to the householder to have to take all the furni- ture out and the pictures down every three months. Dr Bernard considers the malaria volunteers to have been a success. "Without them 90 per cent of the people here would be sick. They are cultivators and can't leave their crops, so they would wait until desperate for treatment, and by that time the parasite would have been passed on by mosquito bites to many other people. Now, they can con- tact the volunteer within an hour and get their tablets. If we could train the volun- teers further we could certainly reduce the number of people coming to the out- patient departments, and then the num- ber of hours per day available for work would increase." For the country as a whole the volun- teer programme comes under the respon- sibility of the Health Education Bureau, whose officers are constantly criss-cross- ing the countryside organizing training programmes. Dr Merle Perera told me that the volunteers conduct discussions with mothers on breastfeeding, encour- age them to use the child health clinics, immunization facilities and family plan- ning services, promote the use of local vegetables, and bring fathers for vasecto- my sessions. The reason why health edu- cation is so successful here is threefold, he said. "We have a high literacy rate; in 25,000 square miles we have 1,000 government health institutions ; and we have 10,000 schools- with which we work closely- even · in the most rural areas." The Sri Lanka Volunteer Health Workers are continuing in a tradition of service that goes back to the earliest times of the country's civilisation. In his book, "Volunteer Health Worker in Sri Lanka", a Health Education Bureau publication, Dr Waiter Patrick writes: "The VHW as a concept and an ad hoc ac- tivity has been with us for a long time. It is now being fashioned to meet the pri- mary health care needs of Sri Lanka. It is full of promise and is certainly a silver lining in the difficult challenge the health care system has to meet." • 19