Mortality and Morbidity Trends and Poverty in Sri Lanka

LAKSHMAN DISSANAYAKE

Senior Lecturer

Department of Demography

University of Colombo

Colombo, Sri Lanka

Introduction

In general, demographers or other social scientists who have examined the demographic transition in Sri Lanka have failed to explore the importance of the contribution made by changes in mortality on the major demographic changes occurred in the country. They have been mainly concentrating on the levels and patterns of fertility change, especially in the post-transitional fertility regime. However, changes in mortality can affect social economic lives of the people or vice-versa in variety and complex ways. Conference on Demography and Poverty held in 1995, Florence, indicates that poverty can influence demographic outcomes in many ways. Traditionally, the studies that focussed upon demography and poverty have concentrated on the relationship that how population growth may cause poverty. In fact, the impact of poverty on demographic variables, particularly mortality is rare. One of the major problems of scarcity of such analyses is mainly due to complexity as well as unavailability of accurate time-series data. Most studies that focus on the impact of poverty on mortality examine how household income or maternal and paternal education affects child mortality. It is also interesting to note that AIDS also has become an outcome of conditions that constitute various dimensions of poverty such as economic hardship, sexual powerlessness, and poor health services. Changes in mortality can also have socio-economic implications (Dissanayake, 2001). For example, increase in mortality can decrease the productivity of the labour force. This means unhealthier adult workers cannot work better while more potential workers are not expected because of less surviving children. In addition, relatively high mortality status can reduce the intellectual activity of the general population since low level of childhood nutritional status can influence mental development. In the case of Sri Lanka, it is yet to establish the association of mortality and poverty even at national level. As a first step in that direction, this paper attempts to contribute to the existing world literature on mortality and poverty by examining the association of mortality and poverty in Sri Lanka.

In this study, mortality, morbidity trends and poverty relationship will be analyzed by concentrating on three distinct time periods in terms of the pattern of mortality prevailed in the country: until the mid 1940s, from the mid 1940s to 1970s and from 1970s and beyond. It appears that these three distinct time periods coincides with the stages of the epidemiological transition. In this context, this study will be examining the direction and magnitude of the relationship between mortality and poverty and attempting to explore whether the relationship different or similar during these three time periods.

Until the Mid-1940s

Sri Lanka's pattern of mortality before 1945 exemplifies the Age of Pestilence and Famine. Many of the peaks and high plateaus of mortality observed were due to the epidemics, which recurred periodically, throughout this period (Figure 1). Annual average rate of growth of the population was fluctuating around 1.5 percent per annum until the mid 1940s. These characteristics are very similar to those suggested by Omran (1971) for defining the Age of Pestilence and Famine, which characterizes high mortality, but fluctuating, thus precluding sustained population growth. The life expectancy at birth in this stage is low vacillating between 20 and 40 years. Table 1 shows that only 11 years added to the expectancy of life during the first 46 years in the twentieth century.

Malaria Epidemics have been identified by a number of writers such as Collumbine (1950), Newman (1965) and Abeysundera (1976), as the major factor contributed to high mortality before the mid 1940s. During the 1906-1920 period, there were two epidemics: malaria epidemic of 1911 and influenza epidemic of 1918. The influenza epidemic of 1918-19 was responsible for the highest crude death rate of 37.6 ever recorded in Sri Lanka. It was reported that the excess number of deaths causing influenza epidemic were about 57,000 (Turner, 1923: 74).

Cholera was one of the major health problems in Sri Lanka before the 1880s (Figure 2). However, the prevalence of cholera was reduced substantially because of the effective measures introduced by the colonial administration of that time.

Although a downward trend in mortality is seen after 1920, it is also quite reasonable to claim that there was no sustained decline in mortality levels until the mid 1940s. The island was badly exposed to malaria epidemic in 1935 and this year is regarded as the worst malarial year since it recorded the maximum number of deaths. This epidemic began in October 1934 and malarial mortality rose from 2,332 in 1932 to 47,326 in 1935. The records indicate that malaria epidemic in 1935 was no less disastrous than the influenza epidemic during the 1918-19 period. This epidemic in fact had been accompanied by a dysenteric form of diarrhea and convulsions in children. It is important to note that the economic depression prevailed during this period also had a disastrous effect on this epidemic. Gray (1974) has calculated that malaria control in Sri Lanka was responsible for about 23 percent of overall mortality decline in the country. He claimed that improvements in medical services, nutritional status and economic and social factors accounted for the remainder of mortality decline.

It appears that poor sanitary conditions in the country led to the spread of various infectious diseases, such as dysentery, diarrhea and typhoid and consequently to high mortality rates. Meegama (1986) has shown that diseases like diarrhea, dysentery and enteritis and hookworm were major diseases that caused high death rates in the estates where tea, coffee and rubber are grown. Famines were a major cause of death in Sri Lanka in the nineteenth century. However, it is not quite possible to estimate the precise contribution of the famines to mortality levels mainly due to unavailability of reliable vital statistics. It has been argued that creation of a commercial economy, which allowed the importation of food helped overcome the problem of famine:

"The colonial transformation of Sri Lanka in the mid nineteenth century from a subsistence economy to one based on plantation crops for export had important effects on health of the people. ;Foreign exchange earnings of the plantation industry made it possible for the country to import a stable and increasing supply of food (Meegama, 1986: 11)"

From the Mid 1940s to 1970s

According to the theory of epidemiological transition the Age of Receding Pandemics begins when mortality decline progressively; the rate of decline accelerates as epidemic peaks become less frequent or disappear. The average life expectancy at birth increases steadily from about 30 to about 50 years. Population growth is sustained and begins to take off exponentially (Omran, 1971:9). The age of receding pandemics commenced in the Mid-1940s. Caldwell (1986) has shown that Sri Lankan mortality breakthrough occurred during the 1946-53 period, adding over an additional decade to the expectation of life at birth during that seven-year period. Although Sarkar (1957) suggests that this is a lag effect after the retardation of health advance by depression and war, Caldwell (1986) claims that the more specific origins of the 1946-53 breakthrough were threefold:
First, the spectacular malaria outbreak 0f 1943-35, with the death rate almost doubling to 37 per thousand, led to plans to cover all rural areas with cottage hospitals (primary health units). The plans were postponed by World War II but received top priority at its end. During the next five years the number of such centers increased by 117 percent in the endemic malarial one and 67 percent elsewhere. During this expansion, free treatment was provided for the poor and after 1950 for everyone.
Second, the wartime food rationing system guaranteed a minimum level of nutrition for the poor and established a structure for subsidizing staples thereafter. Subsidized food was supplemented by free school meals. Infant mortality fell dramatically – by almost 30 percent between 1946 and 1947 – as larger quantities of imported milk products again entered the country (seemingly significant evidence on the importance both of supplementation and a nutritional floor).

Third, these years witnessed a tremendous leap in the availability of new health technology such as penicillin and greater use of sulfa drugs. It was the period when malaria was, for the time being at least, eradicated through DDT spraying. The question of the contribution of the campaign against malaria to the total mortality decline produced one of the most famous debates in the history of demography, with estimates ranging from 100 to 12.5 per cent, the latter probably being closer to the truth. By 1950, in a population of 7.5 million, hospitals were treating 12.3 million patients a year, an increase of 61 percent over the figures five years earlier, or, more significantly, of 150 percent if malaria cases are excluded (World Bank, 1952, part 2, p. 383). It was essentially a clinical service and in 1950 over 90 percent of treatment was given to outpatients (although, during that year, one in mine of the population was an inpatient being treated and accommodated free for an average of nine days). The population readily accepted the expanded services.

With epidemic receding progressively, mortality declined substantially. The high peaks of mortality became lower and more spaced. Infective and parasitic, endocrine nutritional and metabolic, diseases of blood and blood forming organs, digestive group of diseases, diseases of nervous system and sense organs and respiratory diseases showed a decline trend. Deaths caused by infective and parasitic group of diseases ranked among the first five leading causes of deaths especially among younger groups. (Gaminiratne, 1984). However, degenerative causes such as accident group circulatory group and malignant neoplasm did not show any decline during this period.

Although the DDT campaign was a major contributory factor for the decline of mortality, there had been many other developments in Sri Lanka as well. Universal adult franchise was granted in 1931 and for the first time some of the members in the parliament demanded that health services should be provided for the areas where there were no or inadequate facilities (Meegama, 1967). There had been a considerable expansion in the number of health facilities in Sri lanka which was especially rapid after the mid 1940s. Toward the end of this stage, fertility started to show sustained decline, especially after 1960 (Dissanayake, 1988).

From 1970s and Beyond

The age of Degenerative and Man-Made diseases generally begins "when mortality continues to decline and eventually approaches stability at a relatively low level. The average life expectancy at birth rises gradually until it exceeds 70 years" (Omran, 1971:9).

This stage of the transition started in Sri Lanka in the 1970s. During this stage, it appears that diseases like heart diseases, cancer, stroke and diabetes become increasingly prominent gradually displacing pandemics of infection as causes of morbidity and mortality. Consequently, life expectancy of the Sri Lankans also has increased because of the shift from infectious diseases known as the killers of the 'young' to degenerative diseases which are associated with adult age group. It has been argued that when death rates fall below 10 per 1000 population as in Sri Lanka at present, death rates cease to be a sensitive indicator of a population's health (Omran, 1977:18).

In such a situation, health progress needs to be measured more by morbidity than by rates of mortality. In fact, the improvement in morbidity has been much less than in mortality. It is important to note that Traumatic Injuries, diseases of the respiratory system, excluding diseases of upper respiratory tract, influenza and pneumonia and symptoms, signs and abnormal clinical and laboratory findings have become the three leading causes of hospitalization In Sri Lanka in 1997 (Table 5). Morbidity and mortality rates in selected sub groups of government hospital patients indicate that the major substantial increase is seen in the group of hypertension and Ischimic heart diseases during the period 1965 to 1981 (Table 6).

As shown in Figure 6 that Sri Lankan women enjoy better health status of women. In contrast to the other countries of the region where the overall life expectancies at birth of the two sexes are similar, female life expectancy in Sri Lanka exceeds male life expectancy by several years. In this context, Sri Lanka, in fact seemingly has more in common with countries outside South Asia than other countries within the region. The major factors of these differences include the development of the health system, public health measures that have reduced maternal mortality as well as socio-economic changes that have changed female status and the value of the parents, both the mother and the father, of girls relative to boys (Pieris and Caldwell, 1997).

The 1995 nutritional assessment indicates that the number of pre-school children population suffering from stunting is about.33 million; 0.21 million are wasted; and 0.54 million are underweight. In addition, 0.66 million children suffer from Vitamin A deficiency while 0.72 million pre-school children are anemic. Nearly one third of adult population in the island has been classified as undernourished (Tudawe, 2001). It has been already established that there is a strong relationship between health, nutrition and labour productivity. Tudawe and Wickramanayake (2000) point out that iron supplementation in the plantation sector in the country has led to significant increase in productivity. Nanayakkara (1994) has shown nutritional deficiency increases with food insecurity as the food insecure poors earning capacity becomes limited due to ill health and malnutrition.
