International Medical Health Organization

Report

Summer Experience at Vanni as a NGO Medical Officer

Dilini Annappah-Reynold, MD

“Mingling so closely with the locals made me realize so many of their difficulties, suffering and frustrations. The holistic approach to medicine started to take its form. Listening to local people made me feel humble. I lost the appreciation for superficiality of life. The simplicity of the people, giving so much when they had so little touched me very much.” Photo: Mullaitivu Beach With respect and appreciation With newfound confidence With unshaken hope With incredible memories… Dilini Annappah-Reynold, MD
	Table of Contents Introduction Work Experience Specific Activities Conducted Observations To Think About Acknowledgement

Introduction I worked as a NGO Medical Officer mainly at North and North East of Sri Lanka for more than two months under the Summer Internship 2004 of The Student Volunteer Program (www.tsvp.ca), which is a Canadian NGO. The internship upheld the health sector as its primary focus. The team consisted of 5 girls and 1 boy. For the health sector of the internship, TSVP partnered International Medical Health Organization (IMHO), USA thus my mentors were Dr. Raguraj and Dr. Thavam Thambipillai. Before the internship, I was also in touch with Dr. Shiamala Suntharalingam of MIOT, UK. I also did a lot of coordination between MIFT, Canada especially with Drs. Figurado, Santhakumar, Mariampillai and Selvakone. The Summer 2004 projects of TSVP consisted of: health education: primary prevention via health education, and health development through clinical enhancement procedures and clinical support, as well as other non-health sector work. Before departure, I had a brief meeting with Dr. Raguraj at Toronto. He gave a thorough orientation about possible work involvement at Vanni. I also met with my MIFT colleagues, who were kind enough to donate a lap top for the education of Assistant Medical Practitioner (AMP) students in Vanni, as well as some pharmaceutical drug samples. The appeal for a laptop was suggested to me by Dr. Raguraj. After a trans Atlantic, trans Indian flight to Malaysia and visiting my grandmother, I arrived at Sri Lanka, ready to set out for Vanni in a few days. My mother had constantly warned about the dangers of interning at Vanni, yet confident in my ability to speak the language, adjust easily to surroundings, be easy going with people, extensive travel repertoire, and my skills as a medical doctor, I was able to convince my family and myself that this was what I wanted to do; this was where I wanted to be. With extreme confidence and self assurance in my knowledge and myself, I set out on this journey. All plans had been made months in advance. All the dates and times were carefully arranged, used as I was to an orderly, perhaps machine-like, life. I learnt quickly this was not so, in laid-back Sri Lanka. After a few days of shopping at Colombo, settling into Colombo, and meeting up Ministry of Health workers and Medical Council of Sri Lanka members for my licensing, I awaited my trip to Vanni eagerly. It came as a shock that the organization that was supposed to pick me up failed to keep the appointment and all my efforts at contacting them were in vain. I was supposed to be at Vanni on a certain day. I had no clue about going to Vanni. Infact, I didn’t even know how the towns at the Vanni region looked like. Hence, it was a scary prospect to be stranded in Colombo. Luckily, my mother was able to get hold of Dr. Gnanam Thambipillai who was coordinating the travel arrangements and I was smoothly on my way to Vanni albeit a day late. Therefore, I recommend that this should be an area of focus for improvement. It is not very comfortable to have schedules thrown off, although once you start living and working in Sri Lanka, you will understand that this is somewhat of a norm there. Thus, efficiency in traveling has to be improved or travelers should be pre-warned about possible delays, and encouraged to have alternative measures at hand.

Work Experiences I arrived at Kilinochi’s, Centre for Health Care (CHC - www.centreforhealthcare.org) for a late lunch after leaving from Colombo around 5:30AM. Unfortunately no rooms or lunch were ready for me as CHC was not sure about my date of arrival. I was very tired and hungry after enduring grueling checking at Omanthai and Pulliyangulam. Thus, both travel and accommodation have to be better coordinated in the future. However, the accommodation and living abodes of CHC were comfortable so it was fairly easy to settle in. The people at CHC were very gracious, hospitable and welcoming. It was Monday when I arrived there. Following old traditional superstitious beliefs, I commenced my work at Vanni the very same day of my arrival at 4pm, as I didn’t want to start my work on a Tuesday, with pediatric ward rounds at Kilinochi District Hospital KNDH, after a brief meeting with their District Medical Officer (DMO), Dr. Siva.

The next couple of days were spent in a buzz of activity split between going to Thileepan Medical Centres, which are primary health care centres, and working at KNDH. In the next couple of weeks, I and Vidhya Sivanantham, a nurse from Mt. Sinai Hospital, Toronto, who was also a TSVP intern, along with Dr. Gowribalan from UK and Dr. Kanthi Kanapathipillai from Australia, held a clinic at Mangulam Thileepan Medical Centre. It was an excellent turn out. It was tiring, but very productive. This was the first time I had ever engaged in medical clinic for a rural population. I was moved and amazed by the simplicity and the hospitality of the workers from these medical centres. I was quite impressed to know that the Medical Corps, who was heading the medial centre, was thoroughly knowledgeable in the holistic approach of medicine.

Although I was physically exhausted when we went back to CHC, but felt emotionally enriched. During the next couple of days, I visited Iyankullam, another Thileepan Medical Centre with Dr. Kanthi Kanapathipillai and had an orientation by Bhairavi, the Medical Corps in charge there. I visited Poonakari Thileepan Medical Centre with Dr. Gowribalan. At Poonakari, we had an orientation of the Medical Centre by the Medical Corps of that centre, Nalayini. We also discussed pediatric asthma treatment and management options. After discussing with Thilakan anna, the in-charge person at CHC at that time, we both came up with a schedule for me to work at KNDH and when there were clinics, at Thileepan Medical Centres. Thus, I established a routine of rounds and rotations at Pediatrics and Women’s wards of KNDH, occasional obstetric work just to enhance my own skill in obstetrics, and regular OPD hours. I was very busy: from morning 8:30-4:30 with lunch to spare. I also engaged in evening ward rotations. Women’s and Pediatric ward duties are normally shared between the husband and wife team of Drs Brighton. As Dr (Mrs.) Brighton was on maternity leave, Dr. Brighton welcomed my help in covering his wife’s duties. Clinic at Poonahari would remain an unforgettable experience that brought a new percept in my life. I and Vidhya were taken to Poonahari Thileepan Medical Centre just because we were going to spend a teaching day there, talking about health education and have a seminar on wound care. When we went to Poonahari, there were a few patients. Nalayani, the in-charge Medical Corps who was highly knowledgeable, let me and Vidhya examine the patients. So we both started working in a make-shift, cramped up environment just to oversee some patient care. I have no words to describe my feeling of incapability that day. I was overwhelmed with the amount of work I ended up doing.

What started off with a handful of patients, kept increasing and increasing. I believe news of the foreign medical team had reached the Poonahiri village via the existing handful of patients, accounting for the sudden influx of patients. Imagine a clinic day with just one doctor and a nurse. You must recall that at the last clinic, held at Mangulam, there were three doctors and a nurse. Here, we had the same amount of patients with only one doctor and a nurse. I worked in a trance. I didn’t even have time to take a break and drink water or juice. One after the other, patients kept coming. Before a seat was vacated, another patient would sit down. I realized if I took a break, they had to stand in the hot sun for a longer time. Furthermore, there were only two times the buses operated to bring people to and fro from far away villages to this Thileepan Medical Centre. Thus, if they missed these two times for the buses, they were stuck at the medical centre over night. Me and Vidhya worked non-stop, without lunch or refreshment to meet the overwhelming patient load. By the time we finished, it was late into the day. We were tired, sweaty, and exhausted but beaming. Both of us had never done such a thing. I had never seen so many patients in one day. I didn’t even know that I had the capability to manage such a load. It was an unforeseen metamorphosis, as a result of which, I immerged as a confident doctor. I also started having a different outlook on people’s suffering. All I know is that I became a different person: I was moved to be humble. During this time, I, Vidhya, Drs Gowribalan and Kanthi Kanapathipillai went to Puthukudiyirruppu (PKI) for an orientation of their ultra modern facilities and be exposed to the scope of medical care at Ponnambalam Hospital – PKI. We had an orientation by one of their hospitable and humorous Medical Corps, Kathiravan anna. After a lengthy conversation on each of their facilities, we met Drs. Rajani and her husband, Dr, Rajaram from USA before heading back to Kilinochi.

However much the delivery of medical services was rewarding, working with the administration at Vanni was frustrating. There was strict red-tape on many issues. In terms of ideals and beliefs, it was hard to adjust as well having lived outside of Sri Lanka for more than twenty years. The Vanni medical administration unfortunately seemed to adopt a chauvinistic attitude towards women and was extremely patronizing. Added to this, the interns unconsciously imposed cultural imperialistic ideas which resulted in unfavorable consequences. Many, who have previously been to Vanni and done medical work, had discussed with me the benefits of such work. No one adequately prepared me for the ensuing struggles that I had to overcome in regards to commonly held perceptions and beliefs. I strongly believe that everyone should be given the right to make their choices knowing the full dimension and magnitude of their work at Vanni. They should not be lulled into believing that everything is going to be perfect for their entire stay. In the midst of this, Dr. Raj from UK arrived from UK. I had a lengthy discussion with him. Dr. Raj had worked at Vanni several times and I was at a loss to understand how he could endure the frustrating system at Vanni. I have naturally been taught to understand the concept of Cultural Imperialism by my parents before. Yet, the difficulty I reckon, after my lengthy discussion with Raj, had been putting into practice what I had learnt. I understood that at the roots of my turmoil had been the lack of understanding as to my purpose of being at Vanni. Did I come to impose my superior knowledge of medical system onto them? Did I come to save them? I had disturbing questions of power dynamics. I also talked to him about the long suffering of these people and where some of their untrusting attitude and en guarde attitude stemmed from. Dr. Raj talked about individual episodes of these people, especially the freedom fighters. He had tears in his eyes while recounting some of their experiences. Perhaps the emotion-filled, passionate speech or the dawning of true understanding, I felt different after my discourse with Dr. Raj. I believed that I gained some maturity that day for my outlook pertaining not only to the Vanni community, but in life general, changed. I went to bed emotionally drained knowing that I would not be the same person again. Thus, it is highly recommended that for all forthcoming sessions, every single volunteer without previous exposure to work in Sri Lanka, be briefed and educated on cultural beliefs and perceptions. They should also be told the difficulties they might encounter. Furthermore, it is absolutely necessary that they should acknowledge the concept of cultural imperialism and to be able to deal with it effectively. While working at KNDH, I and Dr. Raj went to visit Dr. Jeyanthan, the busy visiting surgeon at KNDH. Unfortunately he had back to back operations scheduled and we were unable to meet him. So we went over to Ponnambalam Hospital - KN to visit the famous Dr. Gengatharan. We had a comfortable chat with him about struggles of health care system in Northern, Sri Lanka. Meanwhile, Dr. Dharmendra, the Mullaitivu (MT) DMO asked me via CHC to render my services at Mullaitivu, as it was short staffed for medical doctors. I had concerns about going to MT. At MT, I would be isolated from my friends from Kilinochi, it would not be easy to make telephone calls to my parents as they did not have a telephone line at the hospital, and I would not have an opportunity to interact with peers of similar background as me. Yet, I was there at Vanni to help, so I responded in the affirmative to Dr. Dharmendra. I had to leave to Colombo at that time as I had an appointment with the high commissioner of Canada at Sri Lanka. I met with the Honorable Valerie Raymond, the high commissioner. I spoke in length about my experiences and observations at Vanni, TSVP and their projects, and tried to get directives about CIDA funding and possible partnerships in the future.

I came back to Vanni in eager anticipation of commencing my work at MT. Dr. Dharmendra assured me that once every week, he would take me to KN or Jaffna to keep in touch with my parents. I know my decisions shocked my parents, but I thought I had made the correct decision in going to MT. I took all my belongings to MT. En route to my new place of living, we stopped over Mullaitivu District Hospital (MTDH) Phase 2 at PKI, and had a brief orientation. Then we went to MTDH at MT and had an orientation. I was to learn that I was to manage MTDH at MT. I was overwhelmed. It was decided that I would do ward rounds, discharges, OPD and some hospital administration. I would use Dr. Dharmendra as consultant, as he would be mostly at MTDH at PKI. I was to live with an elderly, Tamil, ex-patriot, couple from Bergen, Norway as the hospital quarters have been destroyed by the war. An ambulance would pick me up every day to work and drop me for lunch and pick me up for work and drop me off again. Food would be brought to me by Shanthan, a hospital worker. I would have another hospital worker, Sumathy as my companion till the elderly couple came back from work every day. I was also to do on call duties. I was to work 24/7. Sunday was half day but on call made it impossible to take days off. I knew that it was a very demanding schedule, especially for a volunteer medical officer, yet I knew there was no other solution to meet the tremendous need and demands of the people of MT.

I believe “cope” was the word I should use in this situation. I had long tiring days, yet I have never learnt so much or had a more enjoyable time in my life. I got along well with the hospital staff and the elderly Rural Medical Practitioner (RMP) who was on re-employment. I worked as a Medical Officer for MTDH at MT. I had to issue police reports. I also had to do regular clinics, which was draining because the number of patients was more than the doctors available. However, I felt empowered. On call duties were horrendous. I was in midst of taking a shower, sleeping, hand washing my clothes or eating when the ambulance would come blaring its siren. Sometimes, I felt that I couldn’t manage the situation as most often I lacked the equipment to adequately assist the persons in ER. I have never prayed so hard, never had such fear but I learnt to be confident in what I knew and effectively manage the limited resources. Dr. Dharmendra and my parents were very supportive in guiding me through my fears, and I was humbled, more than anything, amazed at the knowledge of local doctors juggling between lack of resources and the surmount need.

I assisted in operations. I performed minor operations as well. All this was done at MTDH at PKI, as MTDH at MT doesn’t have an OR. I stretched my skills to the maximum to cater to the health care needs of the MT population. In the evenings, I took a leisurely stroll with Sumathy to the MT beach. It is a magnificent beach and I just lived less than 5 minutes away. All the locals came out of their houses to stare when we walked. Sometimes, I stopped to make conversations with them. Little by little, I not only had a confident professional life, but had a great social life as well. I had friends on my lane and the next lanes. Most of the habitants were related to each other, so everyone came to know about me. I also tried to attend the Catholic church, although with my on call duties, it was hard to be regular. I was invited for the local people’s baby showers, christenings and such. I never felt isolated as I had once feared. I went on boat rides with the locals as MT was a fishing, and farming, community. I partook in the Vinayagar Chathurthy activities at the hospital as well. Best of all, I learnt to ride a bicycle from my neighborhood children and my hospital staff.

Mingling so closely with the locals made me realize so many of their difficulties, suffering and frustrations. The holistic aspect of medicine started to take its form. Listening to local people made me feel humble anew. I lost the appreciation for superficiality of life. I went to Vettrapalai Amman Temple, Madu, Eranyamadu region, and also worked at Mullangavil hospital. I went to Jaffna when I was transferring patients, so as not to waste resources, and visited my family there for a few hours, talk to my parents, and get back to MT the very same day.

I know I made a difference as I improved cardiac care in the hospital. I know I made a difference because people especially came to solicit my services from far away areas. I know I made a difference because my co-workers had tears in their eyes when they bid farewell to me. I knew I would return to Mullaitivu. The simplicity of the people, giving so much when they had so little touched me very much. That is exactly what I promised them. I left to visit my family at Jaffna and work at Jaffna Teaching Hospital. I worked under the guidance of Dr. Raviraj, at surgical department, handling surgical casualties and ward rounds. I also met up with Faculty of Medicine Jaffna members and medical students. I visited some slums where the Community Medicine team was engaged in nutrition studies.

Specific Activities Conducted

KNDH has an excellent ICU. Unfortunately, they don’t have adequately trained nurses to effectively run it. As I was the team leader, I helped Vidhya get coordinated with her teaching efforts at KNDH. The focus was on ICU and ECG. There was wound care management workshops and ulcer management explored. There was also training given to nursing aids on basic ECG reading. I did community health education on diabetes and high blood pressure states at regular medical clinic days. I also facilitated health education which was directed towards 2 areas of focus: 1. Mental health, 2. Nutrition. I had a meeting with Dr. Sathiamoorthy of DPDHS, Kilinochi. We discussed the possibilities of effective delivery of workshops and primary prevention strategies in health care in Vanni. I also met up with Dr. Sujanthan and Kalaimahal acca of Ministry of Health (MOH) who were very supportive of our projects. After obtaining multiple tips from all of them, I sat down to work out a plan of action to carry out primary prevention activities and the proposed workshops in Vanni. Hence, I supervised the undergraduate life sciences students’ work in these spheres and helped them formulate the workshop contents. Both were very well received and effectively presented. The method of presentation was in the form of power point, with a follow-up question and answer session and refreshments. Both topics were found to be absolutely essential and beneficial to the community. There were 5 sessions on each of these held across various parts of Vanni, and different organizations were partnered to effectively deliver these workshops. Partnered organizations include: Vetri Manai, a home for female freedom fighters, Anpuchcholai, a home for parents of martyr freedom fighters, Sencholai, an orphanage, VanniTech, and KAROD (Killinochchi Association for Rehabilitation of the Disabled). In addition to the above, there was continuing clinical support and enhancement of existing medical services provided. There was also collaboration with Faculty of Medicine of the Jaffna Campus, Ministry of Health at Colombo, as well as the Sri Lanka Medical Council especially in nutrition research. Furthermore, there was evaluation on community medicine initiatives such as improving child nutrition. Observations: OPD patients sometimes were in excess of three hundred only for the morning or evening sessions only. This shows the number of people accessing health care services per half a day. The majority of illnesses seen were: upper respiratory infections (URTI), bronchial asthma (BA), gastrointestinal (GI) disorders such as ulcers, skeletal muscle injuries, and nutritional deficiencies. Patients need to be assessed from a holistic point of view, as social, environmental and financial factors had to be taken into consideration while treating the presenting medical condition. Many of the hospitals and clinics lack instruments and medical devices that are essential for adequate health care delivery. For example, MTDH at MT does not have a pulse oxymeter. I myself would’ve benefited so much had I been privy to one as I was treating my patients.

Medications are usually not ordered by research-based first line treatment, but by quantity of supplies which were present on a daily basis. Each morning the staff pharmacist updated the NGO medical workers about the available supplies for that day. Mostly patients were prescribed 3 day antibiotics dosages instead of the normal 7-14 day dosages because of the lack availability of these medications. Patients were always encouraged to know the name, and purposes of the medications they were taking which was not at all practiced in Northern, Sri Lanka. When patients came to the clinics for tertiary level care, relevant health teaching about their illness (such as diabetes and high blood pressure states), medications, as well as primary prevention strategies were conducted. The time spent with each patient had to be maximized because follow up of these patients was very difficult especially because most patients fail to come back for follow up when they feel their symptoms abate. To think about: The people of North and North East Sri Lanka, especially Vanni certainly appreciated the health care work and efforts. I made a difference and I felt very good about it. My unfailing efforts in health care delivery were extremely useful, as most regions were short staffed. I was able to fill the void temporarily. Thus, it is essential that qualified health care workers continuously serve Vanni’s needs. It is unrealistic to expect that the whole health care system of the Vanni region is going to rely on such a process. However, it would certainly help them to buy some time before more definitive and sustaining interventions could be established. Duration of work also comes into play if we examine qualified health care workers’ feasibility to work in SL. I would emphasize that 2 weeks of work is not enough. They must be there for at least 1 month in my opinion. I am not in the mind that something is better than nothing. To make some impact, it takes time. Furthermore, people need to settle into their surroundings before they begin to function in their regular ways. If you give them allowance for travel time and time to settle down, 2 weeks or less is inadequate. Unfortunately, there is not much to be done for people of no health care background in the very much needed, clinical health care sector. These regions have a severe lack of trained medical personnel. Although many non-clinically trained people/students are interested, and use such work possibilities to obtain a glimpse into medical care, there are ethical principles that need to be considered and adhered to. The patients, although they are in unfortunate circumstances, are not experimental objects. The same courtesy and care given to patients at Canada (for example) must be upheld in these circumstances as well. It is very easy to forget ethics in Sri Lanka as people here look up to doctors and medical professionals as something akin to god like figures. Yet, it should be us, as humans and trained individuals, to act in accordance to both personal and professional ethics. This brings onto the difficult question of what to do with these eager and aspiring, non-clinically trained individuals who want to engage in health care work. It should be emphasized that these individuals would not be able to touch, administer medicine to the patient, or engage in activities that require training and certain amount of skill. They are however allowed to observe procedures with permission from the patient, and are very much encouraged to involve in primary prevention measures i.e. health education. The focus should be quality and not quantity when we encourage people to work in the health care sector in Sri Lanka.

Nutrition, child safety and welfare, and mental health remain important areas future focus. In terms of health: enhancement of child nutrition, asthma care, and URTI (upper respiratory tract infection) care should be promoted in these regions especially with the pediatric population. There should be a conscious effort to educate the public about circumventing trigger factors of asthma and URTI. I envision a peer education campaign using training the trainer strategies so that it gets disseminated to the whole population. Something akin to training selected members of the community to disseminate information about trigger factors for URTI and asthma, and adequate management has to be undertaken so that the population becomes knowledged and empowered. The best way would be via peer educators.

Also, basic wound care strategies have to be developed and educated. I saw many patients with sores on their soles of their feet and walking without slippers or shoes. When we cleaned the wound, it was naturally inflamed due to the sand debris found there In addition, there has to be a computer coding system developed for all diseases treated at each of the Thileepan Medical Centres. This would help the MOH to keep a good record and it would be very useful research purposes and when trying to develop strategies for disease prevention. My 2004 Summer Health Internship was dynamic enough to cover a wide area of focus in health, including different specialties. I would say my work there would be considered a resounding success based on the impact it made on the community at large, the manner it was received, the manner it was executed, the ideas that came out of it, and by my general satisfaction and experience.
Acknowledgement I would like to acknowledge: TSVP especially Kumaran, Ravi, Skanda, Vidhya, Manivillie and Raj, Dr. Shiamala Suntharalingam of MIYOT, UK, Drs. Raguraj, Thavam Thambipillai and Gnanam Thambipillai of THO-USA, Drs. Drs. V. Figurado, V. Santhakumar, G. Mariampillai, M. Selvakone and Mahesan Srivamadevan of MIFT-Canada for all their guidance, coordination and help. Deep appreciation to Mr. Arun and Mr. Thilakan of CHC, Dr. Suganthan and Miss. Kalaimahal of Ministry of Health, Kilinochi, Drs. Siva and Brighton of Kilinochi District Hospital, Dr. Raviraj, consultant surgeon at Jaffna Teaching Hospital, and especially Dr. Dharmendra of Mullaitivu District Hospital and his wife, Mrs. Shanthy Dharmendra, Mr. George and Mrs. Philominamma George of Bergen, Norway/Manalkudiyiruppu, Mullaitivu and Sumathy, Shanthan and other staff of Mullaitivu District Hospital for their invaluable support, encouragement and help. Sincere thanks also to Drs. Gowribalan and Thangaroopan (Raj) from UK and Dr. Kanthi Kanapathipillai from Australia. Thanks to Mr. Poologasingham of Sri Lanka Consulate General at Toronto,, The Honourable Valerie Raymond - High Commissioner of Canada at Sri Lanka, and LTTE and GOSL representatives as well as friends from VanniTech and all who helped to make my experiences at Vanni invaluable.