Jaffna Medicine at the Cross Roads
Address (1980/1981) delivered by
“Members of Council, Ladies and Gentlemen,
The Office of Presidency of this Association is the supreme honour that members can bestow on one of their fellows and it is with a sense of humility that I express my gratitude for this distinction. The office is not merely an honorific, it carries an implied obligation for delivering a Presidential Address, which by custom dwells commonly on the field of academic interest of the incumbent, setting forth his own work and achievements. Less commonly the address has been based on a general topic or matter of national interest and I have adopted the latter as the times in which we live demand the attention of all members of the medical profession and, more particularly of those members of this Association. I have chosen my subject – JAFFNA MEDICINE AT THE CROSS ROADS.
In order that we might properly conceive the situation, perhaps even the dilemma in which we are placed, firstly it is necessary to retrace the path that has been trod by our forebears; secondly, to realize the current situation and then to assess the various options open to us before we chose which path to follow in the future.
The Jaffna Medical Association was established only in 1969 during the Presidency of Dr.Kolitha Karunaratne, but it was only a change of title for an active body termed the Jaffna Clinical Society founded in 1941 and the President was the late Dr.S.Subramaniam, Provincial Surgeon. However, this was merely the formal establishment of a society for the advancement of medical knowledge in the Northern Region of Ceylon as it was then called.
The influence of Western Medicine had its impact in Jaffna in the early part of the Nineteenth Century when 5 members of the American Mission Society arrived here in September 1816. It is possible that some form of Western Medicine was practiced for the benefit of the Portuguese, Dutch and early British establishment in Jaffna, but they were not intended for the local population. The intention of the American Mission Society had been to establish this Mission in India, but the East India Company forbade such an intrusion into what was considered a British Preserve and so the five members arrived at Point de Galle and traveled by the highly scenic coastal road to Colombo. Previous correspondence with the Governor had implied that they would be allowed to practice in Ceylon, but at the time of their arrival the then Governor, Sir Henry Brownrigg was about the depart. The Lieutenant-Governor Sir Edward Barnes vigorously opposed the granting of permission of the American Missionaries, to settle and practice in Ceylon. However, Sir Henry Brownrigg overruled him, asserting that, while he still remained in the island, he retained all the rights of governorship, and had given his consent to the Mission. Contrary to popular opinion, these 5 Missionaries were not banished to the arid North but had probably sought the region as being closest to the Indian mainland and where a language that was in usage in India, too was spoken. Two of their number, Mr.Richards and Mr.Warren had attended the Medical College of Philadelphia and had received some tuition in the practice of medicine in the hospital of that city prior to embarking for Ceylon. They became the first practitioners of Western Medicine in Jaffna. However, their period of stay was brief for they had contracted tuberculosis and succumbed to the disease in 1821 and 1822 respectively. However in the brief period available to them, they brought Western Medicine to the people of Jaffna, where it was received in lukewarm fashion.
In the 1820s Dr.John Scudder, a medical missionary, arrived in Jaffna and was followed some years later by Dr.Samuel Green. They were New Englanders of the American Mission Society with its headquarters in Boston, Massachusetts. It is to the dedication, enthusiasm and zeal of these 2 men that western medicine was established in Jaffna 150 years ago.
Practice of Medicine by Scudder
Dr.John Scudder established his dispensary at Pandatherippu on June 18, 1820 and worked long hours attending on patients with diverse diseases and taught medicine to a few local men. Dr.Scudder performed many heroic and successful operations in the 1820s. To quote just a few, successful plastic reconstruction of mutilated ears, amputation above the knee, excision of large tumours, and even cataract operations. These were stupendous feats in those days when there were no facilities for anaesthesia, blood transfusion and sterility as obtains today.
He and his wife had many trials. They lost 3 children in 18 months. Neither work nor calamity overwhelmed them. In 1832 he erected a dispensary building at Pandatherippu which still stands. A memorial tablet placed in the dispensary building by a grateful mission in recognition of his 16 years of labour in Jaffna can yet be seen.
Dr.Scudder left Jaffna for Madras and later shifted to Vellore. Many of Scudder family lived and died in India. Dr.Ida Scudder, Founder and Principal Emeritus of the Vellore Christian Medical College, was a grand daughter of Dr.John Scudder.
Practice of Medicine by Green
Dr.Samuel Green sailed from Boston in 1847 and arrived in Madras on September 14th and in Jaffna on October 6th, crossing the Palk Strait. Dr.Green surveyed the field. Ignorance and superstition was rife and people were in hands of untrained physicians for medical relief. The common diseases [then] prevalent in Jaffna are obtained from his recordings – frequent epidemics of cholera and small pox, fever and lung infection during dewy season, an itch of a virulent kind perhaps scabies, fever and ague with enlarged spleen which we now know as malaria, cancer of the mouth arising from habitual use of quicklime with betel quid and the wealthy died of diabetes, the effect of vegetarianism and indolence combined. He decided that for his work to be of any lasting benefit to the people, he should in his own words ‘study the province with well educated physicians’.
In February 1848 he set up a dispensary at Manipay and organized the Mission Medical School with 7 students, selected from Batticota Seminary, now known as Jaffna College, giving instruction in Western Medical Science in English. The medical curriculum was based on the lines as those followed by the Medical Faculties of the American Universities. The students used standard textbooks of Medicine and passed an examination at the end of the course. In 1861-64, the following textbooks were in use.
1. Anatomy by Wilson
2. Physiology by Carpenter
3. Chemistry by Comstock
4. Dispensary by Christison and Griffith
5. Physician’s Vade Mecum by Hooper
6. Surgery by Druitt
7. Dublin Practice of Midwifery by Mansell
8. Diseases of Children by West
9. Disease of Women by Churchill
10. Medical Jurisprudence by Taylor
The students attended the Mission Dispensary regularly and twice weekly clinic at the Friend in Need Society Hospital at Jaffna, established by Ackland Dyke, the Government Agent, N.P., with the assistance of Dr.Green and in collaboration with the Friend-in-Need Society of Jaffna. This hospital has grown into what is now the General Hospital, Jaffna. After successfully completing the examination the students had to gain practical experience before the certificate of qualification was issued. The first batch graduated in 1850.
To make medical education available to a wide group, Dr.Green initiated medical teaching in the vernacular which was a revolutionary idea – at least 100 years ahead of his time. He translated the standard texts and journals into Tamil. From 1850-1907, the medical staff of the Friend-in-Need Society Hospital were drawn almost totally from the graduates of Dr.Green’s Medical School. Few of his outstanding students were Gould, Town, Evarts, Danforth, Mills and Paul. They eventually manned and pioneered the Government Medical Services of the country. However, the establishment of the Colombo Medical School in 1870 resulted in the closure of Dr.Green’s Medical School in 1875.
Dr.Samuel Green was a surgical giant of his days and was the first Visiting Surgeon of the Friend-in-Need Society Hospital. When he commenced surgery there was first just a trickle and then a flood of patients. This is well illustrated by quoting from a letter written by him to his brother John in January 1849. To quote,
‘…the number on my register today is 2,544 (in 13 months). Many of these are surgical cases, one third of them or more. I have removed cataract several times, operated on strangulated hernias, amputated the arm once, removed several cancers, amputated fingers, toes, and portions of hands several times, treated a good many fractures and several burns, attended some very bad cases of childbirth… Last Monday I removed the left upper jaw and cheek bones for a cancerous fungus in the antrum filling the whole mouth and left nostril…’
Since Dr.Green practiced abdominal surgery it is likely that he brought with him the news about anesthesia, first demonstrated at Massachusetts General Hospital on October 16th 1846 by Morton.
Scott and Nursing Education
Dr.Green left Jaffna in 1873 but did not return. Dr. and Mrs.Scott arrived at Manipay in 1893. Dr.Scott had qualifications in Arts, Theology and Medicine. But his biggest asset was his wife, also a doctor – the first lady doctor to serve in Jaffna. Mrs.Scott started a Nursing School, another pioneering effort at Manipay. The present school of Nursing in Jaffna was established only in 1960, almost 70 years later.
Jaffna Medicine, 1907-1950
The Friend-in-Need Society Hospital administered by the Friend-in-Need Society of Jaffna as a voluntary one in 1907 came under Civil Medical Department of the Government. The Civil Medical Department was the successor of the Military Medical Department of the Nineteenth Century. The hospital was renamed the Jaffna Civil Hospital. The Provincial Surgeon, Northern Province, had his office inside the hospital. The Provincial Surgeon was a purely administrative officer and did not usually operate.
Sir William Twynam, Government Agent, N.P., writing on the medical institutions in 1906, has this to say. To quote,
‘In 1848 there was not a hospital with the exception of the military and gaol hospital and the so-called immigration hospital in the Province. There are now besides the FINS Hospital and Dispensary, a Government Outdoor Dispensary, the American Mission Hospitals at Manipay and Inuvil, a small hospital at Karaidivu, … hospital and dispensary at Chavakachcheri worked by the lady doctors at Inuvil, Government Hospital at Point Pedro, Mannar, Mullaitivu, Vavuniya and a hospital at Mannar island. What were Immigration Hospitals were still kept at Pesalai, Vankalai and Pulliadirakam. And in addition to these, there are about 15-20 village dispensaries. Good permanent buildings have been erected at the back of Fort to serve as Cholera and Smallpox Hospital. And For Hammonheil, near Kayts, has been converted into an excellent Quarantine Station…’
Inspite of the knowledge explosion since 1920s, followed by the therapeutic explosion in 1940s, no significant development was observed at the Jaffna Civil Hospital during this period. A prejudice prevailed among the people against the Civil Hospital and the hospital was referred to as the Pauper Hospital. However 3 qualified Surgeons worked at the Jaffna Civil Hospital from the mid 1920s to early 1930s. They were Dr.I.T.Kunaratnam, F.R.C.S, Dr.A.H.C.de Silva F.R.C.S and Dr.Milroy Paul F.R.C.S. The total bed strength of the hospital was 200 (including a 6 bed ward for private patients – the Thirunavukarasu Memorial Ward). The total medical staff consisted of 4 doctors in the capacity of Physician, Surgeon and Eye Surgeon and one houseman. Dr.Milroy Paul on his arrival got an experienced Theatre Sister appointed, got down a high pressure sterilizer from Colombo, trained a Theatre Attendant and did casualty operations even at night under Petromax and torch light. Dr.Paul records in 1931, post operative sepsis was uncommon in elective surgery which he felt was due to lack of overcrowding, the total lack of visitors except during prescribed hours, the strict observance of asepsis and mostly to the excellent nursing in both the Theatre and the Ward.
During this period Dr.W.Jameson dominated the medical scene from Manipay Hospital. He was the builder of the modern Manipay Green Memorial Hospital. With his arrival in 1923 he transformed this hospital scene for the next 15 years and enjoyed tremendous popularity in Jaffna. He was an able surgeon: he performed over 500 operations annually; [an] efficient administrator and fluent in Tamil. There was development and planned extension of the hospital. He secured grants from the Government and donations from the people and erected several buildings and built up endowments. He raised the professional standard of his assistants by sending the doctors for postgraduate training abroad to such centers as London, Edinburgh, Berlin and Vienna. He equipped the hospital with X-ray plant, ECG recorder, BMR apparatus and Choul apparatus for the treatment of cancer. He attracted patients not only from Jaffna but from all over Ceylon.
Jaffna Medicine, 1950-1978
Rapid expansion and development commenced in the 1950s in the Government sector of the Health Services of Jaffna. With the appointment of specialists to the basic and sub-specialities, Jaffna Civil Hospital became a General Hospital. In the 1960s, Jaffna General Hospital was a recognized centre for postgraduate training of doctors for the Final Examinations of the Royal Colleges of England. Many Surgeons and Physicians followed in the trail of Dr.Samuel Green, with the gradual development of surgery and gynecology in the province. However, medical practice in Jaffna seems to have been confined to the treatment of physical ailments.
Psychiatry was not given consideration or the importance it deserved. Psychiatric illness remained largely submerged in the population until 1966, when the first psychiatric unit was opened in Jaffna. Until this time patients had to travel to Angoda Hospital which was overcrowded. The term Angoda became a term of abuse and synonymous with insanity. In fact, most psychiatric patients remained in Jaffna. A few were perhaps treated inadequately by physicians qualified in western medicine, but the majority were treated by Ayurvedic physicians, spiritualists and faith-healers. A popular method of treatment employed included ritual baths after which the disturbed patient was mercilessly assaulted to quieten him. It is difficult to imagine that this state of affairs was prevalent up till only 15 years ago.
From the start of the Psychiatric Unit in Jaffna there was a rush of patients who were admitted voluntarily into two hospitals at Point Pedro and Kankesanthurai. A special mention must be made of the pioneer psychiatrist, the late Dr.T.Arulampalam, who worked relentlessly to popularize psychiatry and dispel false beliefs and misconceptions. In his first year, he treated 9,000 patients. He gave several talks to the public – about 40 talks in four and a half years. He established a society called ‘Friends of the Psychiatric Unit at KKS’ to encourage welfare of the mentally ill patients.
This was a period of time when community hospitals developed by the people on a cooperative basis became popular. The most important hospital in this category was Moolai Cooperative Hospital. From 1950s until early 1970s, this hospital was the scene of much development and popularity centred around the personality of Dr.N.T.Sampanthan FRCS. The Cooperative Hospitals are now failing, probably due to poor management.
The Present Jaffna General Hospital
The increased health needs and demands brought about in the Jaffna General Hospital extensions and constructions of new buildings without a comprehensive long-term plan resulting in a clumsy, overcrowded hospital. The impact of social and political changes and the rising cost of drugs, hospital equipment and consumable items began to have an effect in the health services. It has now become a common occurrence for many to be told that treatment cannot be given or operations carried out due to shortages of various sorts. To make matters worse, there has been a large scale migration of doctors to other countries from about 1968, and more recently of nurses and para-medicals, leaving grave deficiencies. Despite vast advances in medicine in the past 20 years, it would be correct to say that the quality of patient care has not improved appreciably.
Dr.J.F.Stokes, W.H.O. Consultant in Medical Education who was in Sri Lanka in 1979, in his Stokes Report speaks of Jaffna Hospital as a hospital that has ‘run-down’. He comments that the hospital is not clean, security poor with a general lack of administration and seriously deficient nursing staff. He concludes that Jaffna Hospital is unsuitable for postgraduate education, at present.
Present Health Needs and Demands
For the purpose of ranking health needs and demands with regard to their importance to the population, three major problem groups have been identified.
It is clear that such a breakdown is more or less artificial, since all these 3 categories of problems are interlinked very closely. However from the point of view of quantification of problems, such a division is very convenient.
1. Needs arising from population dynamics: The distribution of population by age and sex influences the special distribution of health services and size of the health problem. The proportion of population between the ages 0-14 and over 65 shows an increase in comparison to the proportion in the age group 15-65 years, over the years. This tends to increase the dependency ratio and the health problems pertaining to these groups.
2. Disease control Problems or the problems arising from the spread of diseases: In this area, improvement of environmental sanitation especially water supply, sewerage disposal and vector control and preventive health technology will reduce the problem. In the rural Jaffna district, 91.2% of the households obtain their water from open wells; 58% of these wells are shared and therefore are considerably exposed to the risk of pollution. For the district as a whole, 49% of the houses do not have any toilet facilities while the situation is worse in rural areas with 57% of the households being devoid of any latrines.
3. Problems of demand for Medical Care: Any citizen of Sri Lanka has the option to express his demand for medical care services either to Government or private sector. And in each sector, he can choose between Western medicine and Ayurveda. In the private sector, there are also homeopathic doctors and quacks. Although the district is well served with medical institutions, the General Hospital is overcrowded, providing even primary health care. The smaller institutions are underutilized due to lack of basic facilities and lack of proper referral system.
Criteria for Selection of Priority Health Problem
In making decisions to give priority to some health problems and pay less attention to others we are guided by several criteria based on different aspects of the health problems. The order of importance of these criteria, as I see it, is as follows:
Infectious diseases still dominate the morbidity pattern. There are two reasons why a study of the patterns and causes of mortality may be important. First, mortality is a useful indicator of the major health problems of community. Unlike morbidity, which is difficult to define and measure, mortality is more readily identified and easily counted. Second, our understanding of the epidemiology of mortality is fundamental to effective health planning. Leading causes of death today are heart diseases, accidents and suicides, diarrheal diseases and diseases of infancy and immaturity.
Medical School: Jaffna University 1978
With the intention of increasing the output of doctors to meet the needs and demands of the country two new medical schools were established in Sri Lanka, at Jaffna and Galle. Jaffna has thus once again become a center for medical education. The Jaffna Medical School started functioning by admitting the first batch of medical students, in a temporarily acquired building at Kaithady – designed for an Ayurvedic medical school (sited 5 miles away from the University and Hospital center) for the pre-clinical studies in 1978. After effecting makeshift arrangements in the already congested Jaffna Hospital, the batch of medical students moved into Jaffna Hospital for the clinical and para-clinical studies in June 1980. As a consequence of the establishment of Jaffna Medical School, Jaffna Hospital became elevated to the status of a Teaching Hospital. The change of title means nothing unless changes necessary to effect its new role are implemented.
In the teaching hospitals, 3 types of outputs are possible.
Adoption of teaching status brings about three groups of changes.
Group 1: Extra resources are required to facilitate the teaching and research outputs. E.g: extra rooms, extra [electrical] power.
Group 2: Therapy may be slightly modified in order to meet teaching and research objectives. E.g: extra diagnostic tests may be requested, patient’s stay may be lengthened.
Group 3: More advanced facilities and highly trained staff provide the scope for the pursuit of more complex, more advanced treatment.
The facilities in the Medical School and the associated Teaching Hospital in the way of buildings, personnel and equipment must be upgraded to a standard of medical education and patient care that is in keeping with the needs of the society and the aspirations of the personnel in service.
Undergraduate Medical Education
The objectives of medical education have changed through the ages and is still changing. The present trend is to make medical education relevant to meet the needs and demands of the society. It should be also in consonant with the times we live. The age-old system of apprenticeship led to a system of clerking and ressing in the wards where the physicians and surgeons imparted the clinical skills and knowledge by the bed-side. This has been the foundation on which the British System of Medical Education has been built over the years. We have adopted this system to our advantage and every effort should be made to preserve the system. The trend is moving towards an integrated, inter-departmental patient-oriented teaching.
Work in hospitals alone emphasizes solely on disease, diagnosis and therapy against promotion of health and prevention of disease that work in the field with communities and families would entail. This is more important today since the young doctors do not want to take to Community Medicine as a career speciality, because of the gross disparity of the earning potential between a hospital-oriented doctor and a community physician.
The curriculum should be designed to train doctors who would be competent in clinical and community medicine to staff the future Integrated Health Services of the Health Centre Innovation with the Teaching Hospital as a referral centre along with the other upgraded base hospitals. Since the undergraduate training will not include the entire body of knowledge necessary, the students should be trained to seek knowledge actively by themselves. Student research should be encouraged and facilities provided for continuing medical education after graduation. Tutory study of education should be discouraged as it denies the doctor passing out, the impetus for continued medical education.
Postgraduate Medical Education
The major cause of frustration in young doctors here is the lack of facilities for continuing medical education. This results in the emigration of many bright and enthusiastic students and is an important cause of brain drain.
The establishment and functioning of the Postgraduate Institute in Colombo brings in a series of Postgraduate examination. In themselves they are mere paper degrees. The Institute has recognized the importance of a proper course of Postgraduate Medical Education, initially in the four university towns of Colombo, Kandy, Galle and Jaffna and later extending it to other provincial capitals. But any such program must be implemented within the existing hospital system. However good the course and however excellent the teaching, postgraduate medicine cannot be learnt unless such medicine is practiced in the wards. It goes without saying that the University Centre with its associated hospital must be upgraded by way of buildings, trained personnel, equipment and library facilities, in keeping with the standards for Postgraduate Medical Education and should encourage research in both basic and clinical medicine and should become a referral center for the region.
In the training of specialists in various disciplines of medicine, it is necessary to make use of the technological advances we have today in the diagnosis and treatment of patients. The question often asked today is whether such advanced instruction is necessary for those who work in this country. An important point in favor of such instruction is that unless there are doctors who are aware of the advances, we shall never know how far away from this we are and as a consequence no improvement in the health services will occur.
The importance of research in the field of medicine is only too well known to need emphasis. The goal of medical research should be directed towards solving the health problems relevant to the country. But to my mind, the most important aspect of training in research is the acquisition of the methodology and the discipline which are necessary for one’s continued medical education.
Whilst we are on the subject of medical research, I would refer to a matter which may appear somewhat trivial and unworthy to address our attention on this august occasion. I refer to the need for the proper maintenance of the clinical records of patients in hospital. I think you will agree that our maintenance records leave much to be desired. If we are to take part and make our contribution to medical research the proper maintenance of such records is a sine-quo-non. Documentation, filing and retrieval systems should be well developed.
Ladies and Gentlemen, we have come 150 years from the times of Scudder and Green, when infectious diseases dominated the scene, when the outlook of medical men were befogged by miasmata and other emanations, when epidemics of cholera, smallpox and malaria were frequent – bringing in their trail of infirmity and death.
The landmarks in medical progress over the years have reduced the infant mortality rate, maternal mortality rate and crude death rates. Today Jaffna is reported to have the lowest infant mortality rate in Sri Lanka. Perhaps, the low infant mortality rate recorded in Jaffna (21 per 1,000 births; National rate – 36 per 1,00 births)compared to the other districts is due to wrong compilation of statistics. Jaffna mothers living outside the district generally return to Jaffna for their confinement, thereby increasing the denominator used in the calculation of the infant mortality rate. The increase in the expectation of life, resulting from the control of infections meant that people were surviving, to suffer diseases of middle and old ages. Such diseases like CHD and degenerative diseases are immensely complex and are attributable not to a single noxious agent such as a microorganism but to a combination of risks and factors closely connected to the structure and values of society. The consequence of these diseases, unlike the swift death brought by the scourges and infections, was to place a chronic burden on the society that created them. The success of the public health movement has brought a new challenge resulting in the metamorphosis of Public Health into Social Medicine and recently to Community Medicine. Hitherto hidden illnesses such as heart diseases have assumed increasing importance and today heart disease is reported to be the leading cause of death in Sri Lanka.
Historically, progress in medicine has followed two lines. The first line of progress was by observation and description of diseases. This method has reached its zenith by the middle of the 19th century. When Scudder and Green arrived here, they were quick to observe a disease profile different from that was prevalent in their country. They adapted measures for the treatment and prevention of these diseases and thereby popularized Western medicine in this area. The second line of progress was by clinical experiment and research. These two lines of progress should be fostered and preserved, in our medical education, for the progress of medicine in this country.
Traditionally medicine has been viewed as the art of healing the sick. To this role has been added, in more recent times, the prevention of specific diseases. Recently, however a broader concept has been emerging in many countries – that of improving the quality of life. This is a concept that is embodied in the W.H.O Constitution which defines health as a state of complete physical, mental and social well being and not merely, the absence of disease or infirmity.
The Cross Roads
Having traced the history of medicine in Jaffna from early part of the last [19th] century, we must rationally plan the direction for the future. There are three options open to us. The first course is to disseminate medical skills to the community. The second course is to meet the demands of the society. The third direction is to centralize and develop center of learning and expert medical care. It is pertinent to point out that Samuel Green attempted to develop all these lines of action.
Now 70% of the population live in rural areas and we could in the words of Samuel Green, ‘Study the province with educated Physician’. This is intended to deliver primary health care and improve the health status of the majority of people. This idea has been more recently advocated by persons such as David Morley of the Dept. of Tropical Child Health in London. 40% of the diseases seen in our hospital are preventable by the application of preventive health technology at low costs. Therefore a well-organized preventive health system will render a higher quality of life to the people.
Health technology is an important aspect of any health system and has to be made available to those in need. Health services in future should be developed, centered round a New General Hospital, which will function as the main teaching centre and as a referral centre for the region. The medical profession cannot remain complacent in only meeting the needs and demands of the society. Then we will be drifting in the horizontal direction from the cross-roads. The vertical path of progress leading to better health services, in keeping with the times can only be pursued, if the academic and professional standards are improved, by better patient care, research and better medical practice. This means that the Jaffna Medical School and its associated hospital should be a centre for training of doctors of high quality, both at the undergraduate and postgraduate levels. It is the obligation and responsibility of the teachers and consultants to ensure this and maintain high standards.
Sri Lanka has had a tradition of training doctors of good quality, able to fill the vacancies in many parts of the globe. We should not allow these standards to fall. There is a romantic notion among certain people that we should retrace the course of action taken by China. But we live in a different context. We have a long heritage of good medical education. So a solution worked out for a country like China cannot be applied here. John Scudder and Samuel Green have left a tradition of pioneering efforts, scholarship and service to the profession which should be preserved and followed.
Members of the Jaffna Medical Association [JMA], the present is a time of considerable importance in the history of our Association. The establishment of the Medical School in Jaffna in 1978 has not only increased the number of participants in the activities of the Association, but has imposed a responsibility to share in the undergraduate medical education and continuing medical education of the doctors in the region. Of great importance to the JMA is the establishment and functioning of the Postgraduate Medical Institute in Colombo, still in its infancy. Jaffna Medical Association has the responsibility to encourage postgraduate medical education by improving standards of medical practice and not merely organizing classes and courses.
The future is a matter of crucial concern to all of us. By creative thinking nurtured by experience we can plan for the future judiciously, directing our efforts to achieve our objectives. Let us make a joint effort, based on goodwill and understanding to make the future meaningful and rewarding for us all.