Education and Training
Capacity building in environmental and occupational health in Sri Lanka†
Article first published online: 27 DEC 2011
Copyright © 2011 Wiley Periodicals, Inc.
American Journal of Industrial Medicine
Special Issue: Research Contributions from the United States International Training and Research in Environmental and Occupational Health Program: Part 1
Volume 56, Issue 1, pages 1–10, January 2013
How to Cite
Wickremasinghe, A. R., Peiris-John, R., Nandasena, S., Delzell, E., Tipre, M. and Sathiakumar, N. (2013), Capacity building in environmental and occupational health in Sri Lanka. Am. J. Ind. Med., 56: 1–10. doi: 10.1002/ajim.21999
Disclosure Statement: The authors report no conflicts of interests.
- Issue published online: 20 DEC 2012
- Article first published online: 27 DEC 2011
- Manuscript Accepted: 27 NOV 2011
- National Institutes of Health-Fogarty International Center (NIH-FIC). Grant Number: 5 D43 TW05750
- ITREOH program;
- Sri Lanka;
- environmental and occupational health (EOH)
Although environmental and occupational health (EOH) research and services in Sri Lanka have a long history, policies related to EOH are outdated.
We review the International Training and Research in Environmental and Occupational Health (ITREOH) program in Sri Lanka that commenced in 2006 as a collaboration between the University of Alabama at Birmingham and the Faculty of Medicine of the University of Kelaniya, Sri Lanka.
The program has trained over 20 scientists in conducting EOH research. New pioneering research in EOH was initiated. The program was instrumental in furthering the training and research in EOH by initiating a MPH degree program, the first in the country.
The program has established North–South, South–South and in-country collaborations between institutions and scientists, increasing the visibility of EOH in the future. Am. J. Ind. Med. 56:1–10, 2013. © 2011 Wiley Periodicals, Inc.
Beginning in 2001, the National Institutes of Health-Fogarty International Center-sponsored University of Alabama at Birmingham (UAB)-International Training and Research in Environmental and Occupational Health (ITREOH) has focused on capacity building in environmental and occupational health (EOH) in Southeast Asia. In the first five-year cycle, the UAB-ITREOH program working with the Aga Khan University concentrated on building EOH capacity in Pakistan. In the second five-year cycle, beginning in 2006, the UAB-ITREOH expanded to include the University of Kelaniya (UKe) in Sri Lanka and Manipal University (MU) in India. In Sri Lanka, the UAB-ITREOH has been instrumental in promoting the prominence of EOH in the country by pioneering EOH-related research and training, two areas that are relatively under-developed in the country. In this paper, we highlight the contribution and the salient achievements of the ITREOH-supported EOH initiatives in Sri Lanka during a five-year period.
Sri Lanka, an island of 65,610 km2 and 20.06 million people, is located to the south of the Indian subcontinent in the Indian Ocean. Compared to other countries in South Asia, Sri Lanka's social indicators are unique in that it is a low middle income country (LMIC) providing universal free health care facilities and other social services such as free education enabling the achievement of relatively high standards of social and health development [WHO, 2009a].
The Sri Lankan government is promoting research and development as a means of poverty reduction through rapid economic development in the post-conflict era after the end of the 30-year old civil war. The government envisages to develop and build a critical mass of trained scientists that would propel the country from a LMIC to a middle-income country with a doubling of the per capita income from USD 2,000 to USD 4,000 by 2016 [Rajapaksa, 2005].
EOH Services in Sri Lanka
Historically, the first references to health concerns related to environment and sanitation dates back to almost 2,500 years ago. The Mahawamsa, the Pali chronicle of Sri Lankan history, refers to the sanitary measures taken by ancient Sinhala kings to safeguard the health of the people [Geiger, 1925]. Since then, the country has gone through various stages of development of public health systems under a plethora of rulers including the South Indian rulers and colonial powers such as the Portuguese (1505), the Dutch (1656), and the British (1796). The British introduced modern public health systems and modern western medicine in Sri Lanka. Many public health legislation focussing on environmental health, some of which are still in use, were promulgated during British rule which ended in 1948. In 1858, the Civil Medical Department was established and in 1912, the Sanitary Branch of the Civil Medical Department was established which subsequently became the public health branch of the Department of Health Services [Uragoda, 1987; Herath, 2001].
Currently, EOH in Sri Lanka comes under the purview of different ministries and departments whose functions overlap to some extent. The directorate for EOH under the Ministry of Health operates through the medical officers of health (MOHs) who are field level managers of the primary health care team [Ministry of Health, 2005]. The mechanism of delivery of EOH-related services in the country is complex given the diversity of institutions that are responsible for different aspects. Overall, the majority of work is carried out by public health inspectors (PHIs) appointed by the Ministry of Health. PHIs, managed by MOHs, are field level workers who are customarily assigned a population of about 10,000 [Herath, 2001]. Their primary responsibilities are maintenance of water quality, regular inspection of factories, prevention activities related to communicable diseases, food hygiene in commercial food preparation units, etc.
New environmental and occupational hazards such as air pollution and climate change and their effects have not been included in routine monitoring activities of the Ministry of Health. However, limited air pollution and climate change effects are monitored by the Central Environmental Authority of the Environment Ministry. Standards for air pollutants that have been set for Sri Lanka are based on WHO norms. Occupational health activities are mainly carried out by the Department of Labour.
EOH Issues of Priority in the Country
At the onset of the ITREOH program, we identified the following EOH issues of priority in the country.
Urbanization and industrialization in Sri Lanka over the past few years has affected the environment to a great extent. Emissions of various air pollutants from an increasing vehicle fleet, deteriorating traffic congestion, and establishment of small and medium scale factories with poor emission control technologies in urban settings have contributed substantially to poor air quality [Batagoda et al., 2004]. Based on the 2004 Sri Lankan health statistics, the World Health Organization (WHO) estimated the number of deaths attributable to indoor and outdoor air pollution to be 4,300 and 1,000, respectively [WHO, 2009b]. Irrespective of the advances in the curative and the preventive health sectors in the country, there is an increase in the occurrence of respiratory diseases requiring out-patient visits [MoH SriLanka, 2003, 2005] that utilize a large proportion of the health care expenditure.
In developed countries, smoking and environmental tobacco smoke (ETS) are reported to be the leading causes of low birth weight (LBW) [Bruce et al., 2000]. In developing countries, nutritional, reproductive, and socioeconomic factors are considered to be the main risk factors for LBW [Boy et al., 2002, Chhabra et al., 2004], but risk factors such as exposure to combustion of solid fuels and ETS have been less subjected to research [Dinh et al., 1996]. Although the prevalence of active smoking among Sri Lankan mothers is less than 3%, their exposure to several air pollutants inside their homes, primarily from solid fuel use and ETS, may be considerable. The Global Youth Tobacco Survey (GYTS) of 2007, reported that paternal smoking is 29.9% (95% confidence interval (CI) = 25.6%–34.5%) [Gunasekara et al., 2008]. With almost one-third of males smoking, second hand smoke in households may still be high and needs to be explored quantitatively [Gunasekara et al., 2008].
Biomass fuel use is a major environmental hazard in Sri Lanka. Based on the Demographic and Health Surveys of 2000 and 2007, firewood is the principal type of cooking fuel in 78.3 and 78.5% of households in Sri Lanka, respectively [DCS, 2002, 2009]. It is unlikely that a higher proportion of Sri Lankans will shift to cleaner fuels in the near future [Nandasena et al., 2009]. Most of the local stoves used traditionally for firewood have incomplete combustion resulting in high pollutant emissions [Amarasekara and Sepalage, 1988]. This, coupled with poor ventilation, can produce very high levels of indoor air pollution [Amerasekera, 2004].
Only a few epidemiological studies have assessed the health effects of air pollution in Sri Lanka. A recently conducted review of epidemiological studies on air pollution prior to June 2009 reported findings from 16 studies (10 studies on outdoor air pollution and six studies on indoor air pollution) [Nandasena et al., 2010]. These studies have assessed the association of respiratory health, blood lead levels, emergency department visits, cataracts and low births weight, and air pollution. Half of these studies had collected exposure data only through questionnaires which may have led to poor quantification of risk estimates.
Exposure to heavy metals has widespread health effects [Byrne et al., 2009]. Environmental studies conducted in Sri Lanka have found high levels of heavy metals including lead, cadmium, chromium, and mercury levels in ground water and soil [Bandara et al., 2011; Chandrajith et al., 2011]. Exposure to heavy metals may lead to a decline in the mental, cognitive, and physical health of the individual. Some of the known health effects include chronic kidney diseases, adverse reproductive outcomes, birth outcomes, and impaired neurodevelopment in children [Byrne et al., 2009].
Chronic renal disease (CRD) of unknown etiology is a major public health problem in the North Central Province of Sri Lanka [Hittarage, 2004]. Unlike other countries where long-standing diabetes and hypertension are the leading causes of renal diseases, the majority of CRD patients from this part of Sri Lanka do not show any identifiable cause (Chandrajith et al., 2011). An environmental etiology for CRD in Sri Lanka has been suggested [Wanigasuriya et al., 2007].
Another area of health concern associated with heavy metals is endometriosis. Morbidity due to endometriosis is known to have profound economic effects [Gao et al., 2006]. In 2002 alone, the estimated cost of diagnosing and treating endometriosis in the USA was $22 billion [Giudice, 2010]. Despite extensive research, the etiology of endometriosis remains elusive.
Organorphospahte (OP) pesticides are widely used in agriculture and in homes in many parts of the world including Asia. Biologic monitoring studies in Sri Lanka (Samarawickrema et al., 2008; Peiris-John et al., 2002) indicate that there is widespread low-level OP exposures in adults, including pregnant women and children. Studies found that the timing of restrictions on the import and sale of WHO Class I toxicity pesticides in 1995 and endosulfan in 1998 due to the high incidence of self poisoning, both intentional and accidental, coincided with a reduction in pesticide-related suicides in both men and women (Gunnell et al., 2007). At present, pesticide use, the users, and the impact on the environment are not monitored by the regulatory authority. Human studies are needed to bridge gaps in our knowledge of the health effects of exposure to OPs and to help inform primary prevention and intervention, and the regulatory process in the country.
Over the past decade, Sri Lanka has seen a marked increase in the incidence of dengue fever (DF) and dengue hemorrhagic fever (DHF) outbreaks. Despite several measures including prevention/control activities including increased surveillance, vector control, social mobilization, and improved management of DF/DHF cases, there is an increasing trend in the incidence of DF/DHS country-wide. Current evidence suggests that inter-annual and inter-decadal climate variability have a direct influence on the epidemiology of vector-borne diseases (Githeko et al., 2000). Weather patterns affect vector population and disease transmission dynamics, with temperature and humidity considered key variables. Studies need to be conducted to assess whether climate change is contributing to an increase in vector-born disease occurrence in the country.
In the recent past, Sri Lanka has experienced a number of natural and man-made disasters. A 30-year-old civil war, a tsunami estimated to have killed about 40,000 persons in 2004, and the most devastating floods in over 100 years in the beginning of 2011 have left a trail of destruction, loss of life, displaced communities, and major challenges to the health sector. It is expected that environmental disasters are likely to occur more frequently in the future due to climate change. Thus, the effects of climate change and the related environmental hazards in human health need to be understood in the context of the Sri Lankan population to design interventions to mitigate their impact.
Musculoskeletal problems are a common health problem in various occupational groups and settings. Epidemiological research has linked the occurrence of back, neck, and upper limb disorders with various physical activities in the workplace, and also with work-related psycho-social factors (e.g., time pressure, monotonous work) and stress symptoms (e.g., high perceived work stress, job dissatisfaction) [Bongers et al., 1993]. However, these established risk factors do not adequately explain the striking temporal changes that have been observed in disability attributed to such disorders. Although occupation-related disability is a common health problem in various occupational groups, the cultural and the psychosocial influence on disability has not been evaluated in Sri Lanka as well as in many other countries in the region.
Need for EOH Research and Training
Sri Lanka is facing several challenges in the area of EOH. The rapid economic development that is currently taking place and the advent of new industries such as the development of the petrochemical industry is likely to further challenge the EOH services of the country. Despite the incorporation of EOH in the existing public health system, EOH is not a priority area in terms of research or training in the country. EOH activities are primarily concerned with provision of safe water, sanitation, and food safety. EOH research in the country is sparse, isolated, and rudimentary. The lack of sustained research funding for EOH in Sri Lanka is evident by the fact that there is very little research on EOH as compared to other areas of research. Research in EOH is needed at many levels, e.g., studies of exposure to hazards, impacts of environmental and occupational hazards, outcome ascertainment, intervention research, etc. Similarly, training in EOH is very limited. Although elements of EOH disciplines are incorporated within other programs (post-graduate programs pertaining to Community Medicine, etc.), there are no organized graduate programs in EOH. Thus, there is a clear need to build capacity in research and training in EOH.
Beginning in 2006, the UKe in Sri Lanka was added as one of the participating foreign institutions in the UAB-ITREOH program. The program goals were to assist the country in mitigating the impacts of EOH hazards through training of local scientists, and to inculcate the practice of the use of EOH research to guide evidence-based policy. The ultimate goal was to ensure that a competent mass of well-trained public health professionals are available in the country to meet the current and future challenges in EOH.
The training program concentrated on establishing EOH training infrastructure at the partnering institutions, enhancing research skills and expanding research capacity in the country. Mid- to senior-level faculty at UKe, young researchers, and public health professionals from varied backgrounds including from Ministry of Health in Sri Lanka have had the opportunity to train and develop skills while working on a variety of mentored research projects as well as participating in training activities. This training program has contributed building blocks for EOH research in the country by strengthening EOH research and initiating the first MPH graduate program in public health in the country.
EOH Research Training
A major feature of the training component of the ITREOH program is the bi-annual in-country regional training workshops, which has progressed from basic to more advanced training. The training was offered primarily to mid- to senior-level academic faculty to develop a core group of researchers in the country. However, the training opportunities were not confined only to UKe but also included entry- and mid-level professionals of the Ministry of Health, industry and non-governmental agencies.
Faculty at UAB and from other institutions such as Harvard, Columbia, Centers for Disease Control and Prevention (CDC) were invited to conduct the workshops and short-term training programs. Training was conducted in various aspects of EOH research including exposure assessment, outcome ascertainment, data collection, research management, data analysis, scientific grant writing, and use of analytical software. Manuals with step-by-step instructions were developed for several analytical software including R, Epi-Info and geographic information systems (GIS). Trainees received hands-on instructions on the use of these software and were encouraged to apply them in their research projects.
Overall, more than 70 trainees received short-term training. Of these, 19 were identified as the core group to lead EOH research and training in the country and received medium- and long-term training (Table I). Medium-term training involved skill-building in specialized areas. For example, a psychologist from UKe was trained at UAB in administering and validating the Bayley III scales to assess neurodevelopment in Sri Lankan children. Subsequently, this trainee validated the scales in the Sri Lankan setting, the first validation from a developing country (manuscript being developed for publication). Long-term training pertains to mentoring of doctoral level students in Sri Lanka by UAB faculty and mentoring at UAB for board certification by the Board of Study in Community Medicine of the Postgraduate Institute of Medicine of the University of Colombo to work as specialists in the Ministry of Health, Sri Lanka. Profiles of medium- and long-term trainees provided in Table II indicate the building of a diverse and representative scientific community dedicated to ensuring health equity among all people.
|Short-term in-country training (skill building training)||5||50||12||21|
|Medium-term training (substantive training in specialized areas)||10||12||15||19|
|In-country long-term training||—||—||1||4|
|US long-term training||—||—||—||1|
|University of Kelaniya||9 (47.3)|
|University of Sri Jayewardenepura||3 (15.8)|
|Ministry of Health||6 (31.6)|
|Atomic Energy Authority||1 (5.3)|
As part of the ITREOH, medium- and long-term trainees were mentored to design and implement research projects targeting areas of EOH that are well-recognized hazards in the Sri Lankan context. Each year, trainees were requested to submit proposals on designated dates, which were then reviewed by external reviewers following NIH guidelines and scoring criteria. Only the best proposals were selected for ITREOH funding (13 studies funded out of 24 submitted over a period of 4 years). As part of the training process, the trainees whose projects were selected were expected to present their research proposal before a review panel to further refine their work. Through several of these projects, trainees have gained skills related to exposure assessment (specifically in the areas of indoor air pollution, heavy metals, and pesticide exposures) and in outcome ascertainment (specifically neuro-developmental scales).
On completion of the research project, trainees were expected to present the results of their studies at the annual trainee workshop and were critically evaluated by senior faculty at UAB, UKe, and other external reviewers. This process provided an opportunity to prepare the young scientists for presentation at scientific meetings. A highlight of the ITREOH program has been the dissemination of research findings not only among the scientific community but also among policy makers and the lay public. A special training program was conducted on lay communication.
Table III provides trainees' research projects, most of which were funded by the ITREOH program. Trainee projects have pioneered new research initiatives in the country in areas of public health importance that have been neglected primarily due to competing interests. Some of the research initiatives undertaken in the area of EOH include outdoor and indoor air pollution studies among women, children and in public places; investigation of heavy metals in the etiology of CRD, endometriosis and autism spectrum disorders; the impact of climate change on vector- and water-borne diseases; and musculoskeletal disorders in different occupational groups including mail sorting officers, nurses, computer operators, garment factory workers, and policemen. Selected projects are briefly described.
|Research topics||Funding sources|
|Indoor air pollution|
|A case-control study of biomass fuel use and acute coronary syndrome (ACS) among women||✓|
|A multi-center study to assess fine particle matter (PM2.5) air pollution due to secondhand smoke in public places||✓|
|Effect of indoor air pollution due to solid fuel combustion on childhood respiratory diseases||✓|
|Biomass fuel use trends and acute respiratory infections in children in Sri Lanka: An analysis of Demographic and Health Survey Data||✓|
|Prenatal exposure to solid fuel smoke and birth outcomes in Sri Lanka (R21)||✓|
|Heavy metal exposure and chronic kidney disease (CKD) in the North Central Province (NCP) of Sri Lanka||✓|
|Association between cadmium and endometriosis in Sri Lankan women of reproductive age||✓|
|Heavy metal exposures in autistic children in Sri Lanka—a preliminary study||✓|
|Prenatal and early exposure to organophosphates and central|
|nervous system impairment (PEPCI) in Sri Lankan children (under-review)||✓|
|Global climate change: Opinions of school teachers and general population in Sri Lanka||✓|
|Risk assessment of acute diarrheal episodes in children under 5 years (under review)||✓|
|Relationship between climatic factors and diarrheal and vector borne disease—A retrospective study (under review)||✓|
|Cultural and psychosocial influences on disability, Sri Lanka—A multi-country study (postal workers, garment workers, and nurses)||✓|
|Intervention to address low back pain among nursing officers: An extension of the study on CUPID (nurses)||✓|
|Pattern of noise pollution and prevalence and correlates of noise induced hearing loss among traffic policemen in the city of Colombo||✓|
|Validation of Bayley III scale-: A pilot study||✓|
Several studies were conducted on air pollution including two pioneer studies: Biomass fuel use and acute coronary syndrome (ACS) in women and biomass fuel and infant neurodevelopment. Biomass combustion in an inefficient cooking stove in poorly ventilated cooking areas causes heavy exposure to carbon monoxide (CO) and particulate matter (PM) especially fine particles of ≤2.5 µm in aerodynamic diameter (PM2.5). Based on previous literature, we postulated the hypotheses that exposure to indoor air pollution due to biomass fuel smoke exposure in women may be associated with ACS. A case-control study assessing the association between indoor air pollution due to biomass smoke and ACS in women is currently ongoing. Maternal exposure to CO and to PM2.5 is known to cause fetal anoxia. However, the evidence linking indoor smoke to adverse pregnancy outcomes is limited and sometimes conflicting; and the relation between indoor smoke to infant neurodevelopment has not been investigated adequately. A birth cohort study funded by the National Institutes of Environmental Health Sciences (NIEHS) in the USA is in progress to evaluate the relationship between prenatal exposure to solid fuel smoke exposure and fetal growth (low birth weight, head circumference, and length) and between solid fuel smoke and neurodevelopment at birth.
A panel study was conducted in 2009–2010 to assess health effects of exposure to indoor and outdoor air pollution among children aged 7–10 years in two settings (urban and semi-urban) in Colombo, Sri Lanka. At baseline, children from the urban setting had a significantly higher prevalence of wheezing within the last 12 months as compared to children from the semi-urban setting (adjusted odds ratio (OR) = 2.36; 95% CI = 1.39–3.99). Indoor cooking with unclean fuels was a risk factor for wheezing independent of the area of residence (adjusted OR = 1.56, 95% CI = 1.01–2.43). The median indoor air quality levels of PM2.5 was 57.5 (25th–75th percentile, 25.2–620.6) µg/m3, of NO2 was 33.85(17.1–56.3) µg/m3, and of SO2 was 28.1(13.0–50.15) µg/m3 in the urban setting as compared to 36.8 (5.9–755.0) µg/m3 for PM 2.5, 11.6 (6.1–27.6) µg/m3 for NO2, and 10.4 (5.1–19.4) µg/m3 for SO2 in the semi-urban setting. All households in the urban setting and 70% of biomass using households (n = 42) in the rural setting exceeded the PM2.5 levels recommended by the WHO.
UKe along with other UAB-ITREOH partners participated in a multi-country study in collaboration with the University of Seoul, South Korea, to assess the indoor air quality levels in public places in seven Asian countries (Sri Lanka, India, Pakistan, Malaysia, South Korea, China, and Japan) [Lee et al., 2010]. Findings of the Sri Lankan study component shows that the average indoor PM2.5 ranged from 33 to 299 µg/m3 and the average outdoor PM2.5 ranged from 18 to 83 µg/m3. The indoor to outdoor PM2.5 ratio ranged from 1.05 to 14.93. The average indoor PM2.5 level was 124.9 µg/m3 (standard deviation (SD), ± 81.0).
We conducted secondary data analysis of the national Demographic and Health Surveys conducted in 2000 and 2007. While the analysis showed that the shifting of principal cooking fuel from wood to cleaner fuels in Sri Lanka was negligible from 2000 to 2007, the majority of estate sector households (96%) and about 34% of households in the urban sector used firewood in both surveys. Among the households which used wood as the principal cooking fuel, 65.3% of households cooked in the same building while only 9.5% of these households had a separate building for cooking. In 2007, the majority of households in all quintiles of wealth index except the richest quintile used wood as the principal cooking fuel; in the richest quintile, 71.6% of households used liquefied petroleum gas (LPG).
The ITREOH program has funded three projects investigating the effects of heavy metals on CRD, endometriosis, and autism spectrum disorders. An R01 grant application for a birth cohort study of prenatal OP pesticide exposure and infant neurodevelopment is under review.
We are conducting a cross-sectional survey to assess the knowledge, attitudes, and practices toward climate change in the general population. Retrospective analyses evaluating the effects of weather patterns on dengue transmission and diarrhoeal disease using modified WHO protocols are also underway.
A few occupational health studies have been conducted in the country. ITREOH has been instrumental in engaging trainees in occupational research as well. UKe is part of a multi-country Cultural and Psychological influence on Disability (CUPID) study, comprising over 20 other countries, that assessed the extent of the musculoskeletal disorders in different occupational groups (mail sorting officers, nurses, sewing machine operators, and computer workers). The training program is currently funding an extension on the CUPID study to assess the effectiveness of an intervention to address backache among nurses.
Noise is a growing concern in recent years in urban areas of Sri Lanka. We are conducting an innovative study to characterize noise pollution patterns in the Colombo district and modeling noise pollution on traffic densities. This study will investigate the relationship of noise-induced hearing loss in traffic policemen.
The collaboration between UAB-ITREOH and UKe has resulted in a mutual extension of research collaboration between the two institutions. The ITREOH program has also fostered links between institutions and programs of study in Sri Lanka. Even though the Faculty of Medicine of the UKe has taken the lead role in the collaboration funded by the Fogarty International Center, other institutions in the country were also included as beneficiaries. For example, scientists of the University of Sri Jayewardenepura, the Ministry of Health, University of Colombo, and the Atomic Energy Authority of Sri Lanka, are involved in different studies. Scientists and academic staff members of the University of Sri Jayewardenepura, Sri Lanka are directly funded by the program. The collaboration has also strengthened the newly commenced baccalaureate degree program in nursing of the University of Sri Jayewardenepura by funding research projects of its academic staff members and thereby, strengthening the research component of the nursing program.
In addition, trainees have participated in the implementation of several multi-institutional, inter-disciplinary, collaborative research projects involving the three ITREOH partner institutions in Pakistan, India, and Sri Lanka and other countries and with the WHO. The benefits of these multi-country projects include capacity building, institutional linkages, information sharing, the development and use of common methodologies, and valid extrapolation of site-specific results to wider recommendation domains. For example, the study on air pollution in public places has been used by policy makers to reduce exposures due to cigarette smoking in public places in Southeast Asia. The projects on vector-borne diseases have been undertaken using WHO-initiated protocols to spearhead retrospective analysis of available data in the region. The results of these studies will be useful to the WHO. The study on occupational musculoskeletal disorders is part of a 20-country study including both developed and developing countries. Results of these studies will be useful to develop interventions to reduce work-related musculoskeletal disorders.
Benchmarks of Research Productivity
Analytical epidemiologic studies
Overall, the ITREOH program has led to significant breakthroughs in EOH research in Sri Lanka. The level of research has transitioned from conducting simple surveys to robust case-control and cohort studies using advanced data analysis methods, designing and validating survey tools, developing of innovative tools in resource-limited settings, and upgrading exposure and outcome ascertainment methods to include use of biomarkers and environmental sampling. The quality of research being conducted by the trainees is on par with that in the developed countries. This would further enhance opportunities for international competitive funding. We have obtained a R21 grant for a birth cohort study to evaluate the impact of indoor air pollution on infant neurodevelopment. Other proposals are currently being developed.
Some of the trainees have been recognized and complemented at national and international fora such as the International Society of Exposure Science, the International Society for Environmental Epidemiology, and the college of Community Physicians of Sri Lanka for their research work (Table IV).
|Peer-reviewed (trainees as first authors)||11|
|Peer-reviewed (under review)||6|
|Abstracts (trainees as first authors)||20|
|In-country conferences led by trainees||1|
Trainees have opportunities to present their research projects, critically evaluate findings of research, and present the findings as manuscripts in peer-reviewed journals or as presentations at international fora. Trainees have authored 11 papers in peer-reviewed high impact journals. Another six papers are under review. They have also presented their research in almost 20 national and international conferences. Trainees have now begun to organize national conferences.
Inception of the First MPH Program in the Country
As in other developing countries, Sri Lanka lacks a critical mass of trained public health professionals with specialized training in areas of research, policy, organization, and health behavior. Even though medical professionals and allied health professionals receive training in basic concepts of public health in diploma and undergraduate courses, graduate level training in public health, in general, and in EOH, in particular, is limited. Field level public health workers receive a diploma level training at the National Institute of Health Sciences or one of its affiliated Regional Centres. Masters and doctoral level training in public health provided by the Postgraduate Institute of Medicine at the University of Colombo in Sri Lanka is limited to medical doctors. A Diploma program in Occupational Health is conducted by the Faculty of Medicine of the University of Colombo offered both to physicians and others in health-related fields. There is currently no graduate program in public health available for students from other fields except those in medicine.
A major outcome of the ITREOH program in Sri Lanka is the development of the MPH degree program at UKe, the first of its kind in the country. We believe that training of experts locally will orient scientists to find local solutions to local problems. In addition, we expect this to reduce opportunities for “brain drain” within developing countries.
The UKe MPH program was commenced in November 2011. The goal of the MPH program is to increase training in public health to a wide spectrum of professionals and to increase the critical mass of trained specialists in public health. Our year-long curriculum development process focused on identifying skills that would be optimal in the South Asian setting. We reviewed competencies developed by the Council for Education on Public Health (CEPH), the CDC, and the WHO and incorporated core elements from all of these sources, and adapted a locally-relevant competency-based education system that emphasized applied practice and research. We found that our curricula provide greater accountability for aligning theory with practice.
The program with the Applied Epidemiology track has begun in November 2011 and will add an EOH track in 2012. The EOH curriculum is also developed and will have the added advantage of a strong foundation in epidemiology. Funds from Fogarty International Center have supported the curriculum development and specialized training of UKe faculty to teach in the MPH program. Also, as described earlier, it has enabled a research agenda that will serve as a training base for the MPH program.
An innovative feature of the MPH program is that the curriculum was developed for three institutions in the South Asian region, namely, the UKe in Sri Lanka, Manipal Univeristy in India, and the Aga Khan University in Pakistan. A unique feature of this collaboration is the pooling of resources of these three institutions with that of the School of Public Health of UAB in conducting the MPH programs. This, by itself, is an important aspect of sustainability of the program not only through North–South collaboration but also through South–South collaboration.
The MPH program at UKe is targeted for mid-career professionals. It is hierarchical in that an enrolee may graduate from the Certificate to Postgraduate Diploma to the Masters level (Table V). This gives flexibility to enrol in each of the stages based on their needs and capacities. The program will be conducted during weekends so that no undue burden is put on the working enrolees.
|Type of course||Certificate||Diploma||Degree|
Future of ITREOH Research/Training
Developing a core research group to become leaders in the community
In Sri Lanka, tertiary education is limited to approximately 40% of those who qualify due to limited resources. Most of all those who enter tertiary educational institutions usually are employed. The few who qualify for postgraduate education invariably are employed as leaders or in decision-making positions in the government and the private sectors. Most of our trainees are employed or will be employed in the future in decision-making positions in the Ministry of Health or the private sector.
Fostering public health training at undergraduate and graduate level
Training of Sri Lankan scientists in EOH is bound to have ripple effects. The training of academic staff of UKe and Sri Jayewardenepura, the primary beneficiaries of this collaboration, will improve undergraduate research training in medicine and in the allied health professions especially in nursing. As a direct outcome of EOH training, more undergraduate and graduate research projects in EOH and a greater sensitization of EOH hazards and their mitigation is expected.
Mentoring in-country mentors
Another unique feature of this collaboration has been the joint mentoring of trainees by both UAB and UKe trainers. This has helped to develop mentoring capacities of UKe academics. We believe that this will, in addition to fostering more research and training in EOH in Sri Lanka, lead to better designed studies that will provide scientifically robust data for policy making not only in EOH but in public health in general.
The MPH program will overcome a long-felt lack of need of skilled knowledgeable and qualified public health professionals engaged in decision-making and in the implementation of focal points in the spectrum of public health from the public sector to the private sector. The program will help ensure the sustainability of EOH research and training and will improve the quality of public health services Sri Lanka.
The training opportunities afforded by this program to Sri Lankan scientists are in keeping with national policies where Sri Lanka is attempting to become a knowledge hub in South Asia to build a knowledge-based economy [Rajapaksa, 2005]. An important part of the ITREOH program has focussed on local training of scientists which besides being cost-effective, helps build capacity and ensures sustainability. The net result of these activities is that trainees have progressed from being novice researchers to professionals with EOH expertise. The pioneering research that has been funded by the ITREOH program are landmark projects in the EOH priority areas in the country which are likely to form the bases of public health policy such as the setting of country-specific standards for air pollution. Initiating the first MPH program in the country is a major accomplishment in building in-country capacity in EOH. In sum, our program has led to a significant North–South, South–South, and in-country collaboration between institutions and scientists. The achievements of the ITREOH program in this short span of time augur well for the future. The collaborations that have been made and the projects that are in the pipeline should extend the collaboration further. The impact of the ITREOH program in Sri Lanka will definitely be visible in the coming years.
The present work was supported by the University of Alabama at Birmingham International Training and Research in Environmental and Occupational Health program, Grant Number 5 D43 TW05750, from the National Institutes of Health-Fogarty International Center (NIH-FIC). The content is solely the responsibility of the authors and do not necessarily represent the official views of the NIH-FIC.
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