20
years of war has taken it’s toll on all aspects
of society in Sri Lanka, but the North East of the
island being most affected. Homes destroyed, farm
land mined, schools, temples, churches & hospitals
in varying degrees of damage from aerial bombardment
as well as roads, communication, water supply and
sanitation all being affected. An economic embargo
imposed by the Sri Lankan Government from 1990 severely
reduced items such as fuel, medicines and food as
well as the effects of war has caused poor health
amongst the community in the North East of the island.
War has caused not
only internal displacement with 250,000 in refugee
camps in North Eastern Sri Lanka but also many fled
to India. India houses nearly 70,000 refugees in
camps in Southern India with many more who can afford
living in rented accommodation. Hundreds of thousands
are refugees in Europe, Canada, USA and Australia.
Since February 2002
a ceasefire was brokered by the Norwegians between
the two parties to the conflict; the Sri Lankan
Government and LTTE. After one year of the ceasefire
holding up I decided it was now the time for me
to go and see for myself what I could do there.
I put on hold a fulltime job in General Practice
in an affluent leafy part of South London and also
put on hold GMS targets, appraisal, the MRCGP –
consultation module as well as friends and family
to take up this adventure I had known I wanted to
do for some time. At the last minute I was asked
by contacts at the Centre for Health Care, a local
NGO in North Eastern Sri Lanka who I was going to
work with, whether I would work with a Japanese
NGO – Association for Medical Doctors of Asia (AMDA)
as they required a doctor on their mobile clinic.
Of course – as this would make life easier with
the red tape in Sri Lanka and also being of Tamil
origin, although with a posh Surrey accent I was
still a Tamil and if problems occurred I was at
least with the Japanese! (although altruistic in
this adventure, I still needed to take care of myself
if the inevitable occurred and war broke out again).
With the support
of my practice and staff having raised £1,100
by car boot sales, raffles and selling old clothes
to each other, I purchased some basic equipment
and books to take out with me. I was armed with
my Oxford Handbook of Tropical Medicine, stethoscope
and had shipped out a box of medical books, equipment
and BNF’s and on my way.
In Colombo I was met by the Japanese team and it
was a delight to meet a group of enthusiastic young
people who really wanted to do what they could do
help the country. They already had a Health Education
Programme in Hambantota in the South of the Island
and they now wanted to get a mobile clinic started
in Kilinochchi, Northern Sri Lanka. This was all
part of their Peace Building Project – through Health.
I was whisked away to Kilinochchi the same day I
arrived in Colombo – which was a 12hr journey by
road. North of the town of Vavuniya the scenery
changes from busy towns full of armed army check
points to a slower pace of life, poor roads and
two major check points; the Sri Lankan Army check
point followed by the ICRC no mans land then the
LTTE check point. Reality now really does hit you.
War affected school buildings, most people walking
or on bicycles, poor pot holed roads, an even slower
pace of life and watches are 1hr behind in the Tamil
Administrative areas (Colombo put clocks forward
by 1hr as they did not wish to follow Indian time!).
An obligatory stop
at Murugandy Temple an ancient Temple where everyone
travelling along the road stops, prays, breaks a
coconut to make sure the rest of their journey is
safe is a tradition.
In
Kilinochchi,
the heat must have been turned up! Electricty supply
was by a generator and only available from 6-10pm
after that it was suffer the heat, one of my Japanese
Nurses kindly gave me a fan but I had to be awake
to use this!, so I had to have torch light showers
3-4 times the first few nights until I had
aclimatised.
I then invented the cold water bottle – filled up
some plastic bottles with water and had them all
lined up around me! Frogs also appeared to be everywhere
as well as lizards and other tropical creepy crawlies.
Anyway wasn’t this part of the adventure of working
in a developing country?
Crowded Tin wards
Within 48 hours of being in Kilinochchi, I had met
with the Director of Tamil Eelam Health Services,
the staff at Centre for Health Care the local health
NGO and we as a team had started our mobile clinic.
Our team project co-ordinator was an Aussie Tamil,
Nithian and without his logistical help much of
the clinic work would not have been possible. Initially
we saw up to 200 patients each morning and had run
out of many of our supplies so after Mr Akashi the
Japanese Peace Envoy had seen our work we put on
hold our clinics until adequate supplies and a routine
had been organised. I was the only doctor with a
team of 4 Japanese Nurses, 2 local Tamil Nurses,
2 drivers and a translator. My Japanese was zilch
and Tamil was basic. The Japanese nurses new very
little English and no Tamil – but we all managed
and ended up learning a bit of each others languages.
We undertook 3 morning
clinics, travelling to 3 different villages each
day and setting up a clinic in either a bombed out
cinema, a village headman’s hut or borrowing a newly
built nursery school. We travelled 1 hour each morning
to get to clinics but the villagers would have to
travel longer to get to the local hospital in Kilinochchi
and many only had their feet or a bicycle as modes
of transport. As our routine was set people knew
in advance we would be there each morning and many
would be patiently waiting in the morning heat.
Some walked 3-4km carrying their children. In contrast
with the possible 45 patients plus one home visit
a day I was doing in London I was seeing up to 200
patients each morning. The drivers would register
each patient and give them a record sheet and undertake
basic measurements of height and weight. The nurses
would then do BP and temperatures and then again
they would wait patiently to see me. Many of the
problems that were presented were basic primary
care problems we see the world over! Cough, URTI’s,
backache, head aches, diarrhoea, wounds etc. Yes
we had the acute asthmatic, the myocardial infarction,
the colles fracture who refused to go straight to
hospital as she had to tie up her goat! And the
many anaemic women and children, stunted children
and underweight infants.
There were many
occasions I really wondered what was I really doing
to help? But the listening to their problems appeared
to be enough for many. One elderly lady often came
with vague symptoms of aches pains, headaches but
when checked there was no physical findings, but
when enquired as to whether she could be depressed
and have worries she admitted to not sleeping as
she was worried about her son who had been arrested
by the Sri Lankan Army in 1990 (this was a true
heart-sink patient). She still did not know his
whereabouts, whether he was alive or not. Maybe
just listening to her problems gave her some relief
– what more could I do?
I realised while
working on this mobile clinic that patients are
the same whether here or the UK. Even when there
is access to health care professionals, adequate
hospitals and medication available for free for
those who cannot afford. People even in Northern
Sri Lanka still think that as doctors we have some
magical cure for all their ailments, is it not the
same with our patients in the UK!, they still need
education, and antibiotics are not the panacea for
all ills!. One thing that was different in Sri Lanka
was the expectation that an injection was better
than a tablet – may be a little pain with a needle
does have a huge placebo effect! Or does it cause
a release of endorphins?
Malnutrition and Stunted growth
But access to health care is poor. One temporary
hospital in Kilinochchi Town with 3 MB BS doctor
and 2 retired re-employed Registered Medical Officers
(RMO’s) and a scattering of nurses work hard to
provide some care. There is no telephone communication.
Two temporary tin wards each
with 12 beds only. The children
mixed in with the adult females and any extra patients
on the floor. The maternity ward is 2km South of
the main |
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hospital, no bleep system or telephone, just a bicycle
or three wheeler to get a doctor for a woman in
labour who has problems!
Internally Displaced People Refugee Camp
No electricity except by a generator on occasions,
no running water, no theatre facility, no automated
laboratory but a lab technician looking at blood
slides and comparing to the WHO Hb chart or using
Benedict’s solution to check for urine glucose,
an old X-ray machine run by technicians with only
basic training was what was available to a population
of 150,000 and this despite one year of peace, promises
from international NGO’s and governments to improve
their lives. But despite this the staff worked hard
and still had a smile on their faces and patients
wait patiently and no complaints procedures yet!
It must have been worse during war, so at least
they had these facilities now.
Since we had most
afternoons available, after a siesta I would teach
a group of Rural Medical Practitioner (RMP) students
who were being trained by Centre for Health Care.
They were a batch of enthusiastic young Tamils who
had some basic health care knowledge and were being
given general medical training so that they would
be able to work independently with a team of volunteers
in rural clinics. 10 such Primary Care clinics had
been set up and named after Thileepan a medical
student who fasted to death during the Indian Peace
Keeping Force Occupation. The 10 centres in Northern
Sri Lanka were manned by RMP’s and local volunteers
were employed to dispense and trained in nursing.
The centres were in temporary buildings and open
24hrs a day. The RMP’s and volunteers lived in the
centres. Despite only having a sphygmanometer, stethoscope
and one suture needle and basic drugs they were
able to manage common minor problems as well as
acute asthma, snake bites, MI, emergency deliveries
and other problems they could stabilise were transferred
by three wheeler or motorbike to Kilinochchi Hospital.
They also did home visits by bicycle, health education
to their community and during the rainy season educate
the local villagers in boiling drinking water and
clearing areas to prevent the spread of cholera
and mosquitoes. This was an innovative introduction
of Primary Care to a developing country that has
no Primary Care system.
Luckily I had shipped a box of BNF’s, an invaluable
tool to teach pharmacology without going into too
much detail. But valuable for them to keep as a
reference book. Our class room was only a tent and
a blackboard but despite this learning was not affected.
It was difficult to initially accept the students
standing when you arrived to teach and calling you
miss! And even having a cup of tea brought to you.
But it was fun. They also asked for English lessons
as they wanted to improve their spoken English and
despite a lack of books we managed to get copies
of a weekly Sunday paper and used the kids section
– the “fun day times” to get them to read a paragraph
and understand the meaning of the article. Some
where shy but being a bully that I am they were
still forced to read aloud!
After one month of being there I was often approached
to explain to people who were visiting about the
health needs and projects. The local doctors had
become understandably fed up of visitors coming
for 1-2days taking photo’s, collecting statistics
and leaving with promises but those promises never
materialising. Visiting small dispensaries and Primary
Health Care Centres was the only way that outsiders
would know of the situation and explaining practical
ways of helping to improve the services. Through
these visits we managed to get funds for a variety
of projects. Previous visits by overseas doctors
had provided solar panels for the Primary Care Centres
to supply electricity that was funded by a Canadian
NGO; MIFT and a USA group TRRO, provided nebulisers
now that electricity was available and small DC
fridges purchased to maintain the cold chain for
vital vaccines.
Following one visit
with some visiting doctors to one Thileepan Centre
we realised basic equipment such as a thermometer
was not available so funds were soon sent to buy
basic medical equipment to put together medical
back packs. Also doctors in the UK funded 25 bicycles
for Public Health Inspectors and MIOT –UK funded
the start of a medical library for students and
doctors.
Sponsorship of students
by several doctors in the UK has been helping meet
the needs of students as well as paying for visiting
local lecturers to complete their syllabus and their
exams. Sponsorship of a children’s nursery for low
income families has been vital to help supplement
the feeds of identified underweight children. And
many more projects are underway, with the setting
up Primary Care Centres in the East of the island
to building a Medical Library, Lecture Theatre and
Learning Centre for training of Primary Care and
Paramedical students, Phase 1 of the Institute of
Medicine, Dentistry and Health Care studies that
is being set up to train Primary Care Medical, Dental
and Paramedical professionals. Giving the younger
generation opportunities in further education and
vocational training will hopefully stop the cycle
of violence that existed over the past 20years as
well as providing a much needed health care service
to the local people as more internally displaced
return back to their homes and as land is de-mined
and peace hopefully continues.
Apart from me being
part of the British Tamil contingency and Nithian
from down under, there were Canadian young Tamil
students from TSVP and USA corps at Vanni Tech,
as well as visiting students from Norway, Sweeden
and Denmark. The enthusiasm and commitment by so
many other young Tamils was inspiring and also extremely
supportive to each other despite us all working
in different areas. The TSVP students were poached
for a few hours teaching under a tent for our RMP
students on computers. Some of the students had
never seen or touched a computer and it was inspiring
for them to have this opportunity. There were many
late dinners at 1-9 Lodge or Cheran’s restaurant
and we often walked back to our rooms in the pitch
dark with the stars above. There was also the pineapple
parties at Vanni Tech and since there were no TV
we organised our own entertainment with charades
or articulate.
It’s not all work!
It was sad to
leave after 6months of living, working, teaching
and having fun in the sun. Seasonal affective
disorder was not a diagnosis for me there and
leaving the friends, colleagues and students was
hard but life goes on and despite me not being
there I know my commitment to improving the health
care system in the North East of Sri Lanka and
education of Primary Care Practitioners is a lifetime
commitment and I will return there soon. In the
mean time sharing my experiences, encouraging
others to go and share their skills and see how
life in a developing country is, and learning
that modern hospitals with expensive equipment
such as MRI, or the latest hip operation or breast
enlargement procedure is not always required to
improve lives. A listening ear, a comforting touch,
basic medical equipment, basic medicines, health
education and public health measures saves many
more lives.
Further
information for those interested in helping
or visiting North Eastern Sri Lanka for a
working holiday please e-mail shiamala@hotmail.com |
useful websites:
www.centreforhealthcare.org
www.tamilshealth.com
www.miot.org.uk
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