Letter From Sri Lanka

Last decade witnessed a revolution in the practice of respiratory medicine in Sri Lanka. These include better diagnosis of lung diseases, advanced therapeutic modalities, wider use of technology and increased awareness on respiratory illnesses including diseases of airways, interstitium and pleura among medical fraternity and the public. These changes have occurred in parallel with the advancement of pulmonology as a medical specialty in the National Health System. While celebrating such achievements and advances in the developing Island Nation, this is a good juncture to look back over the path treaded, identify challenges waiting around the corner and propose the way forward for respiratory medicine in Sri Lanka beyond 2020. Respiratory diseases have a major impact on the Sri Lankan Health System. Together, chronic respiratory diseases and pneumonia caused the highest number of hospital deaths in 2017, which accounted for 39.3 (18.0%) out of 218.5 deaths per 100 000 population. Furthermore, comparison of proportionate mortality data during the past decade revealed a rising trend of deaths in hospital due to these two conditions (Fig. 1). In Sri Lanka, obstructive lung diseases comprise a major proportion of lung diseases in all age groups. These carry a huge disease burden, both socially and economically. Prevalence of wheezing or persistent nocturnal cough among preschool and school children was over 20% in the Sri Lankan arm of the International Study of Asthma and Allergy in Children in 2002. A survey of self-reported diseases in 2014 found asthma to be the most prevalent chronic disease in those aged younger than 35 years. A substantial gap between the disease prevalence and asthma management was observed in a cross-sectional study in 2016, which found wheezing prevalence in adults to be 24% (95% CI: 22.0–25.9%) but only 11% (95% CI: 9.6–12.5%) was using medication. The Burden of Lung Diseases (BOLD) survey revealed an overall prevalence of chronic obstructive pulmonary disease (COPD) of 10.5% (95% CI: 8.8–12.2%) among Sri Lankan adults aged over 40 years. Among males, the prevalence was 16.4% (95% CI: 13.2–19.5%) compared to 6.0% (95% CI: 4.2%–7.7%) in females who are largely non-smokers. Some plausible causes include outdoor and indoor air pollution. The rising problem of poor air quality is claimed to be responsible for the rise of respiratory diseases, namely obstructive lung diseases, interstitial pneumonitis and lung cancers. Urbanization and exponential increase of motor vehicles are blamed for poor ambient air quality throughout the country. Many groups of professionals and conservationists have been lobbying for an improvement in air quality in the recent past, creating a substantial public awareness on the quality of air they breathe. However, there is no proper air pollution-monitoring network maintained in most congested zones. Furthermore, the awareness on indoor air quality remains poor. Just as outdoor air pollution is a growing problem in the cities, indoor pollution emerges as a threat in rural communities, where firewood is used for cooking in poorly ventilated kitchens. Late-onset wheezing is more prevalent among non-smoking women from rural communities. The Sri Lankan Government and the National Authority on Tobacco and Alcohol (NATA) can be proud of its anti-smoking campaign during the last decade. They have succeeded in restricting public smoking by introducing new legislations, increasing duty on imported tobacco and displaying 80% pictorial warnings on cigarette pack covers. Nevertheless, tobacco smoking remains a challenge among certain social strata, especially among manual labourers and unemployed. Despite the reduced rates in tobacco smoking, lung cancer is rising, especially among non-smokers and females. This could partly be explained by increasing detection, which is due to the wider availability of diagnostic facilities, including chest radiographs, computed tomography and bronchoscopy. While the free availability of newer anti-cancer drugs in the health system is one of its major achievements, health professionals are much concerned that a large fraction of cancers are still diagnosed at a late stage. The Island Network of Preventive and Curative Services of the National tuberculosis (TB) Campaign in Sri Lanka has been successful in maintaining the Figure 1 Hospital deaths due to diseases of the respiratory system (J12–18, J20–22, J40–98) excluding upper respiratory tract infections and influenza in Sri Lanka during 2010–2017 (Source: Annual Health Statistics 2017 by Medical Statistics Unit, Ministry of Health).