Sensitization to illness and the risk of death: An explanation for Sri Lanka's approach to good health for all

Recent research has shown clearly that levels of mortality are not determined solely by income levels and the provision of modern health services. There appears to be an important sociocultural component so that the same density of health services produces lower mortality in one country than in another. Sri Lanka has achieved an expectation of life at birth of 68 years with an annual per capita income of U.S.$330 and no greater provision of health services than most countries at that income level. This paper records the investigation of how such success has been attained. A collaborative program of the University of Colombo and the Australian National University, beginning in 1985, employed both demographic and anthropological methods to study almost 11,000 persons in seven localities of southwestern Sri Lanka. It was found that the major geographical mortality differentials are no longer urban-rural but between the richer and poor areas of Colombo. The low mortality was found to be based on a great sensitivity to illness and the risk of dying. This is ancient in origin but has been heightened by a nineteenth century religious reform movement and twentieth century mass education. It has been further increased by universal death registration, the carrying out of post-mortems wherever necessary with the informing of the police if the death was unnecessary, and by the erection of a system for examining the circumstances of sudden death. This sensitivity was not sufficient to produce low death rates in conjunction with traditional medicine but only with modern medicine. Traditional medicine is still widely practiced, and exorcism is a major cause of expenditure in many families. Nevertheless, the key findings were two. First, where modern medicine can save a life, the sick person nowadays is nearly always exposed to it while there is still sufficient time for a cure. Modern medicine is now usually obtained at a shorter distance and more cheaply than traditional medicine. Second, and of central importance, is the continuing evaluation of sickness from its first appearance and the quick resort to new treatments if the present treatment does not appear to be efficacious. Because of an apprehension of an unnecessary death occurring during their treatment, healers frequently refer cases, from traditional to modern medicine and from general practitioner to hospital. Nevertheless, most changes of treatment are decided by the sick themselves and their relatives so that unsuccessful treatment is changed on average every 5 days. The highly efficient use of curative services appears to have been of key importance in the mortality transition. Individual hygienic behavior, such as insistence on drinking safe water or on the best sanitation procedures, was not as widespread as had been anticipated.