by Dr. Shiamala Suntharalingam
MB BS, BSc (Hons), DFFP, DRCOG, MRCGP
May to November 2003
20 years of war has taken its toll on all aspects of society in Sri Lanka, but the NorthEast of the island has been most affected. Homes destroyed, farmland mined, schools, temples, churches & hospitals have been damaged in varying degrees 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. The embargo, as well as the effects of war, has caused poor health amongst the community in the NorthEast of the island.
War has caused not only internal displacement, with 250,000 in refugee camps in NorthEastern Sri Lanka, but also many fled to India. Southern India houses nearly 70,000 refugees in camps, with many more who can afford to living in rented accommodation. Hundreds of thousands are refugees in Europe, Canada, the USA and Australia.
Since February 2002 a ceasefire has been 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 NorthEastern 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. I agreed, 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 was 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 checkpoints to a slower pace of life, poor roads and two major checkpoints; the Sri Lankan Army checkpoint, followed by the ICRC no man’s land, then the LTTE checkpoint. Reality now really does hit you. War-affected school buildings, most people walking or on bicycles, poor, pot-holed roads [although the A9 is now better than the roads in the South – editor], 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 Murukandy Temple, an ancient Temple just south of Kilinochchi where everyone travelling along the road stops, prays, breaks a coconut to make sure the rest of their journey is safe, is a tradition.
Kilinochchi Hospital, February 2003
In Kilinochchi, the heat must have been turned up! Electricty supply was by a generator and only available from 6-10pm and 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! I had to have torchlight 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 in bed! 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?
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 ran out of many of our supplies quickly, 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 my Tamil was basic. The Japanese nurses knew 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 of 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 to 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 blood pressure and temperatures and then again the people 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, headaches, 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 actually 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 were no physical findings. 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 – maybe a little pain with a needle does have a huge placebo effect! Or does it cause a release of endorphins?
Access to health care is poor. One temporary hospital in Kilinochchi Town with 3 MB BS doctors, 2 retired re-employed Registered Medical Officers (RMO’s) and a scattering of nurses works hard to provide some care. There is no telephone communication. There are two temporary tin wards each with 12 beds only. The children are mixed in with the adult females and any extra patients are put on the floor. The maternity ward is 2km South of the main hospital with no bleep system or telephone, just a bicycle or three wheeler to get a doctor for a woman in labour who has problems!
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 with 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 the 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 were being trained in nursing. The centres were in temporary buildings [some permanent buildings are now going up with the help of TRO, THO, etc – Editor] and are 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 such as well as acute asthma, snake bites, MI, emergency deliveries. 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, educated 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 and valuable for my students to keep as a reference book. Our classroom 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 were shy, but being the 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 understand 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 an American group, the 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 backpacks. 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 feeding of identified underweight children. And many more projects are underway, from 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 20 years 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 young Canadian Tamil students from TSVP and a USA corps at Vanni Tech, as well as visiting students from Norway, Sweden 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 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. Despite me not being there at the moment, I know my commitment to improving the health care system in the NorthEast of Sri Lanka and education of Primary Care Practitioners is a lifetime commitment and I will return there soon. In the meantime, 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 save many more lives.
Further information for those interested in helping or visiting NorthEastern Sri Lanka for a working holiday please e-mail
Useful websites:
Pictures taken during this visit can be viewed at http://www.sangam.org/articles/view2/index.php?uid=540 [Now at Working in Post-war Northern Sri Lanka – Ilankai Tamil Sangam]