Sri Lanka: Twenty-year-old Sanduni breaks down while talking to the doctor at the gynaecology ward of Base Hospital, Dambulla, situated in the Central province of the crisis-ridden country. Six weeks into her pregnancy, Sanduni had a miscarriage after she was unable to find insulin - the required medication to treat her diabetes.
"She had trouble at home," the doctor told BOOM without explaining further. However, she said that the pregnant women who have visited the hospital in the last few months are all showing signs of anemia. "They are not getting enough nutrition because the food prices have skyrocketed," Dr Sasikala said. "The difficulty in visiting clinics because of the high fuel prices make it worse for them," she said.
Over 150 kms away, in Colombo, the capital city of Sri Lanka where protests had started in late March 2022 after the worst ever economic crisis in the country showed its pangs, leading to the fall of the Rajapaksa government, has almost cleared out now.
The protests had peaked after tens of thousands poured into Gotabaya Rajapaksa's presidential palace on July 9, forcing him to flee and eventually resign. Days after that, security forces were accused of using excessive force to evict the demonstrators. More than 80 people suffered injuries that required hospitalisation and dozens of activists have since been arrested. Fearing more arrests, the demonstrators are now packing up. However, the economic crisis that led to a shortage in fuel and nearly quadrupled food prices have left pregnant women and new mothers in Sri Lanka struggling to find three meals a day.
BOOM travelled across Sri Lanka to meet pregnant women, mothers and doctors to understand how the economic crisis impacted them.
"We Stay Hungry At Night"
Twenty three year old Gayani Dilrukshi eats two meals a day. In the morning, she makes a noodle soup for her and her 4-year-old daughter. For lunch, they eat rice— some days with vegetables, other days without with water. "We cannot afford to eat three meals a day so we stay hungry at night," she said. Gayani is seven months pregnant.
The doctors have told her that she is very weak and her haemoglobin level is at 6, which is ideally supposed to be at 16.
"We buy vegetables once that we ensure lasts us for at least 2-3 weeks," she said. Each meal for her and her daughter cost 1,000 Sri Lankan rupees. "The other day my daughter asked for milk with her tea, but we cannot afford milk. It's too expensive," Gayani, who lives in the Homagama town, about 50 kms away from Colombo. A litre of fresh milk cost around 1,000 Sri Lankan rupees. A kg of milk powder cost nearly 2,500 Sri Lankan rupees.
Nilanthi Sandamali, who lives with her daughters and husband at Siyapath Sevanna, the colony built for working class people of Colombo and has over 1600 families, gave birth to her baby two weeks ago. She said that she mostly survived on daal and rice through her entire pregnancy term and right now at home, the only food that is available is rice.
"There was not much to eat at home," she recalled, holding her two week old baby tightly. "I was nauseous throughout my pregnancy, the only thing I could eat was fruits. But, fruits and even vegetables were unaffordable," she said. The one time her husband, a worker at the postal service department, got her fruits she reeled in guilt as she ate them and couldn't give it to her daughters.
"Mothers will usually feed their kids first before themselves, which means that in impoverished households, mothers will lose their sources of nutrition first. There were some instances I came across where the mother had to select which child to give the more expensive food items (eg: milk, to the child who's the youngest and losing weight) vs her older children," a doctor told BOOM. The doctor from a district in Western Province of Sri Lanka said that she has met families with children who went days without any food.
"Most of the mothers are anaemic because they are unable to afford even the most basic nutrition," said another gynaecologist from the same region. "We have been unable to ask mothers to give nutrition rich food to kids because they are unaffordable," the doctor said.
Meanwhile, with the economic crisis, fathers - who are the principal breadwinners of these families have taken more to alcoholism, leading to increasing reports of domestic violence in Sri Lanka, the doctor added.
The doctor said that in the rural areas of the country, families have cut down their food intake — those who were having three meals a day had decreased to two, those who were eating two meals had decreased to one.
Devika Kodituwakku, the president of the Government Midwives' Association, a Sri Lankan trade union, said that the lack of nutrition can have significant health effect on the mother, the child, and also cause complications during childbirth. "The mother's body goes through a major process at birth, and needs to be strong enough to withstand that," she told BOOM.
Much of the population in Sri Lanka are from working class families, she said, where the household income is around 1000 - 1500 Sri Lankan rupees a day. "With the recent increases in the price of food, there has been a big decline in the nutriotiousness of the meals peopleare consuming," she said.
The WFP report said about 6.7 million people in Sri Lanka are not consuming adequate diets and 5.3 million people are reducing the number of meals eaten owning to the high food prices. Adrija Bose/BOOM
Breaking down the prices and the unaffordablity of it, she said, "Rice itself is so expensive, and if you want to add a protein - either eggs, or fish, or meat - and vegetables to that, it can cost more than 1000 Sri Lankan rupees. "To even buy 500 grams of fish now, you have to spend more than 500 Sri Lankan rupees. That's for not even the best kind of fish," she said.
The regime of President Gotabaya Rajapaksa has been blamed for the economic crisis. While Rajapaksa pushed through tax cuts that shrunk the state's coffers, he borrowed heavily from China to fund ambitious infrastructure projects. "What is the point of the Lotus Tower that Rajapaksa built? There was a lot of such useless spending on vanity projects," Sasanka, who used to be a tour guide before the crisis, said. The 350m tall Lotus Tower - considered to be South Asia's tallest structure built in the heart of Colombo comprises a television tower, a hotel, a telecommunications museum, restaurants, auditorium, an observation deck, a shopping mall and a conference centre. The tower was constructed at a cost of over $100 million, 80% of which was funded by China under the Chinese government's ambitious Belt and Road Initiative (BRI).
Amid a struggling economy, the pandemic arrived and hit tourism, forcing people like Sasanka out of jobs. And then the war in Ukraine sent oil prices rocketing, only making the situation worse in Sri Lanka.
In June, the mayor of Colombo had said that the capital has enough food only upto September. However, the World Food Programme, the food assistance branch of United Nations, said that 6.3 million people (28.3 per cent) in the country are food insecure and this is likely to deteriorate as the crisis unfolds. Of these, at least 65,600 people are severely food insecure. The WFP report said about 6.7 million people in Sri Lanka are not consuming adequate diets and 5.3 million people are reducing the number of meals eaten owning to the high food prices.
"We usually tell pregnant women to add some sprats (dried fish), eggs, or an extra piece of fish, to the meals they would normally eat, but how will they even afford it?" Kodituwakku pointed out. An egg, the basic and the cheapest form of protein that would earlier cost for 11 Sri Lankan rupees is now sold at 60 Sri Lankan rupees.
"It's very difficult for preganant women to get a well-rounded, nutritious meal. There's a major barrier to their nutrition," Kodituwakku added.
A program by the Sri Lanka government to give pregnant and lactating mothers a nutritional supplementary food called "Thriposha" wasn't available for months on end. "I got Thriposha only on my last visit to the clinic, more than six months since I conceived," Gayani said.
Doctors at several government hospitals confirmed to BOOM that they haven't been able to provide pregnant mothers Thriposha for months. In some hospitals, it's still not available. "We didn't have any stock of Thriposha for about nine months," Kodituwakku said.
"I Walked To The Train Station On The Day I Delivered My Baby"
Nilanthi Sandamali, 36, gave birth on 20 July, twenty days before her delivery date. On the day her third daughter was born, she walked nearly 2 kilometres, took a train, got off and walked another 2 kilometres to reach the clinic. She had to spend 11 days at the clinic after the doctors found that her premature baby had jaundice and Nilanthi's haemoglobin level was dangerously low.
For days after giving birth, Nilanthi couldn't hold her baby. "I cried and cried. I kept blaming myself for my baby's poor health," she said. "I couldn't get the nutrition that I was able to with my previous pregnancies," the 36-year-old mother said. She said the doctors at the clinic wanted to send her to psychiatric ward at the hospital but later was able to calm her down.
On one of the nights during her stay, the hospital ran out of water.
Gayani said she walks for about 30 minutes to get to the bus station and then walks further to get to the clinc, for every visit.
For days after giving birth, Nilanthi couldn't hold her baby. Her baby was premature, weak and had jaundice. Adrija Bose/ BOOM.
The fuel crisis in Sri Lanka that led to unavailability of transport, long queues at petrol stations and eventually a growing a black market that escalated the prices of already expensive fuel meant that pregnant mothers had to walk for miles to get to the clinics for their regular visit.
"Even the lowest bus fares are so expensive now. They often have to spend 100 Sri Lankan rupees or more just to get to a clinic appointment," Kodituwakku, the President of the Midwives' Association said.
With the introduction of QR-code system in fuel rationing, the prices have stabilised at 450 Sri Lankan rupees per litre. But even just a month back, the prices could be anything — when it was being sold in the black market. Dr Vikrama, the medical superintendent at the Base Hospital in Dambulla said that the staff was worried when the husband of a mother who had given birth didn't come to visit for two days. "When he turned up he said he had to spend 2,000 Sri Lankan rupees for a litre of petrol," he said.
Nilanthi's husband would walk a distance of over 10 kms every alternate day to visit his wife for the 11 days she was at the hospital.
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But transport is not just a challenge for the expecting mothers. The country that would boast of free, quality healthcare has suffered tremendously due to the fuel crisis. Kodituwakku said that midwives switched to motorbikes for their home visits but the fuel rationing has meant that they are now allowed a maximum of 4 litres per week.
"With that much fuel they are able to do their home visits in their area for three days in one week. The other two days they don't have fuel. The fuel shortage has really hurt both the midwives and the pregnant mothers," the President of the Midwives' association said.
Nilanthi said that her high blood pressure condition made her more vulnerable so she was a priority on the midwives' visit list. "It was not the case with every mother," she said.
For the last three months, no midwife has been able to visit seven month pregnant Gayani.
A survey conducted by the United Nations in May revealed that an estimated 215,000 women are currently pregnant, including 11,000 adolescent girls, and around 145,000 women will deliver in the next six months. "Approximately 60,000 women may require access to surgical interventions," it noted.
A Collapse of The Medical System
Back in July, a 26-year-old pregnant woman went into labour while waiting in the queue at the passport office. She had been waiting there for two days with her husband. The Army personnel stationed got her to a hospital and she was able to deliver her baby.
Before the crisis, 99% of deliveries in Sri Lanka took place in healthcare facilities. With the fuel crisis, that isn't the case anymore. "I have heard of many such cases where the woman is delivering at home, or tuktuks on their way to the hospital. We can only help them once they reach the clinic," the chief nurse at the delivery ward of Dambulla Base hospital said.
At the peak of the crisis, the lack of fuel made it impossible for doctors to get to the hospitals. "It was very difficult for us to go back and forth from the hospital, so some of us would just spend nights at the hospital and then go home," a doctor at the government hospital said.
In May, Sri Lanka's neonatologists made a desperate call for urgent medical supplies to treat and save newborns needing emergency care as the country started running out of them. Through a YouTube video, Dr. Saman Kumara, a senior neonatologist, sent a 'critical message' to his overseas colleagues. "We have come to the stage of reusing ET tubes to ventilate newborn babies," he said in the video message. Meanwhile, doctors in Mullaitivu District General Hospital took to the streets carrying posters with messages such as "no medicines here".
"There was a massive shortage of essential drugs and medical equipments," Dr Vikrama, the medical superindendent at the Base Hospital in Dambulla said. "While we have been able to procure many of those drugs, we are still unable to provide some of the basic ones. Too often we are having to use an alternate drug instead of the prescribed one," he said adding that for months now they have kept their health services "only for the essentials".
Delivery count of babies in July at the government hospital in Dambulla, Sri Lanka. Adrija Bose/BOOM
The hospital staff told BOOM that morphine, that is still in short supply, went missing for months. Now, they try to ration morphine usage. "We are only providing morphine to patients suffering from a heart attack," a doctor at the hospital said. For other cases, the doctors are using pethidine, an alternate drug used as an anaesthesia and to reduce pain during childbirth or other surgeries. But that drug comes with some side effects, the doctor said explaining why using an alternate to the non available drug has not been the best solution.
As some social media posts revealed, state hospitals were asking women to bring gloves, blades and other basic materials needed for safe childbirth when they visited the state hospital to deliver.
"The health situation was intolerable, hospitals had even run out of towels, linens and napkins to provide to women," the superindenet of the hospital who is also a part of Sri Lanka's Hospital Development Committee said. The committee, he said, has able to fund and procure some of those basic drugs and medical tools for now.
But the effects of the crisis may be felt much more when it comes to lactating mothers and new borns, the doctor said. "The consequences of the lack of nutrition will follow," he said.
Over the years, Sri Lanka has worked hard to improve its maternal and infant mortality rates. In 1950, a year before free health care was nationalised, 10% of newborns didn't survive past their first birthday; in 2020, the first-birthday survival rate had reached 99%. A doctor from the Western Province said that during the crisis "healthcare workers have truly created miracles out of thin air in protecting and treating people, stretching resources available to them and going beyond the line of duty".
The UNFPA has now appealed for $10.7 million for 'critical' women's healthcare including sexual and reproductive health services, maternal healthcare and access to contraception.
Kodituwakku said although so far they haven't seen major changes in the weight of the child at childbirth, but the children who are a few months old are now losing weight. "That's a substantial change from what used to be," Kodituwakku said.
For every 50 children, doctors have noticed a reduction of weight in about 20 of them. "The mother will do whatever it takes to feed the child," she said, adding that somehow mothers are being able to breastfeed for the first six months. However, she fears a looming crisis. "When they have to supplement that with food, that's when we will see a drop in children's weight," she said.
Nilanthi has been breastfeeding her two-week-old. "The whole family is surviving on just daal and rice. On some lucky days, we get vegetables. If the prices don't fall this is what we will have to keep eating," she said. Sasanka, the former tour guide, said that he hasn't been able to buy eggs for his family of three in the last six months. "The doctor says my wife and my one-year-old lack nutrition. But I can't afford the food they need to eat," he said.
