Part 2 of a three part series on the history of Rockfeller engagement and the development of public health in Sri Lanka.
The International Health Board’s hookworm control campaign came to an abrupt end in 1922 due in part to the unwillingness of British estate owners to cooperate, but the IHB decided to resume work in the villages. In addition to carrying out treatment for hookworm infections in villages and towns, Dr. William P. Jacocks proposed that a survey should be undertaken to determine the prevalence of major health problems and their underlying causes across the island.
Although the Rockefeller Foundation's hookworm control campaign for plantations failed to achieve the intended goal, it provided a window of opportunity for IHB representatives in Sri Lanka to gain first-hand knowledge about the socio-economic conditions under colonial rule and their impact on public health across the country. It also gave them an opportunity to reflect more closely on the importance of sanitation and public health in preventing disease.
The hookworm campaign in the towns and villages in the Western province received a better response from both the people and government officials. Life outside the plantations among the locals was relatively free from the exploitation suffered by immigrant laborers. The community cooperated with the hookworm program while voicing their criticism of its limited scope in view of their wide-ranging health problems. They demanded attention be turned toward urgent health problems and questioned the rationale of giving treatment for hookworm infections when there were numerous other diseases such as typhoid, smallpox, dysentery, and malaria, which were more serious and debilitating.
The government at the time was reorienting its policies toward public health in the countryside. The IHB collaborated with the government to develop a program to address basic sanitary services, vaccinations for communicable diseases, maternal and child care, and public health education and training. This was the beginning of a public health program that became known as "health units."
The health unit system was the IHB’s landmark sanitary engineering and health education program that was started in 1926 when the first unit in Asia was established at Kalutara, Totamune, a suburb of Colombo. Those who designed the Sri Lankan health unit program focused on the specific health problems of Sri Lanka.
The core principles of the program were disease prevention and health education because poor sanitation and inadequate public health services were identified as the root causes of the health problems in communities across the country. Health units were mainly focused on the prevention of infectious diseases, health education, and maternal and child welfare services. They eventually became the cornerstone of the public health infrastructure in the country.
The key strategy was to attack health problems on a priority basis: from the most serious infectious diseases causing the greatest number of preventable illnesses and deaths to the least preventable diseases. Jacocks advocated beginning on a small scale in a restricted area with preventable diseases. The public health officials would perform a careful survey of the area and thoroughly study the causes of morbidity and mortality there in order to determine what was the highest priority. The work would then be gradually enlarged to include all of the public health problems in the area.
A health unit referred to a geographical area comprising up to 80,000 to 100,000 inhabitants. According to the program, Sri Lanka would be divided into approximately 63 health units, with an average population of 83,000 people per health unit.
The health survey of the Kalutara health unit area identified eight infectious diseases as the major causes of death in the population there: dystentery, typhoid, hookworm infection, measles, tuberculosis, influenze, smallpox, and whooping cough. In addition, among infants below one year, three major causes of death were identified: convulsion, premature birth, and infantile debility.
As the first health unit in Asia, the health unit at Kalutara was important because it was used as the model for future health units in other areas of Sri Lanka and throughout Asia.
Hewa, Soma. n.d. "Colonial Labor, Rockefeller Philanthropy, and the Development of Public Health in Sri Lanka: From 'Model Colony' of the British Raj to 'Crown Jewel' of the Rockefeller Foundation." (unpublished research paper)
Hewa, Soma. 2011. "Rockefeller Foundation's Typhoid Control Campaign at Kalutara-Totamune in Sri Lanka." Galle Medical Journal, Vol. 16, No. 1.
Hewa, Soma. 2011. "Sri Lanka's Health Unit Program: A Model of 'Selective Primary Health Care." HYGIEA, INTERNATIONALIS, Vol. 10, No. 2.
Hewa, Soma. 2011. “Sri Lanka’s Approach to Primary Health Care: A Success Story in South Asia.”Galle Medical Journal, Vol. 16, No. 2.
