In the Tsunami's Wake

Sunday, 1/16/05, 20:00, Colombo
Vaji and I spent today with a mobile health clinic run by a prominent local family practitioner. With a team of 30-40 doctors, nurses, pharmacists and others, we went about two hours south by bus to two separate refugee camps near the coastal town of Bentota. Both were in Buddhist temples, the first housing 100-120 families, and the other about 80 families. At the first camp, we saw about 300 patients and at the second about 150. Swanthi, a pediatric nurse from Oakland Kaiser came with us and did some wound care and served as my translator.

Tuesday, 1/18/05, 19:40, to Ampara
We set off by 8 a.m. to make our way east on a 4-5 hour ride to our destination, but had to detour because a mud slide had closed our primary road. We came upon cars and trucks rushing to turn around and head back the way we had come, to escape an agitated elephant that had struck a passing car. After 20 minutes, the elephant left the road, and we proceeded. At a rest stop, a woman who served us drinks asked about her arm, which had been swollen for over a month. With some questioning, we realized she had filarisis; since we did not have appropriate medicine with us, we referred her to her local clinic for treatment.

Arriving at the coast town of Kalmunai near Ampara at 4 p.m., we met with the Deputy Provincial Director of Health Services for Ampara, a medical school classmate of Vaji's sister-in-law. He gave us a tour of the area. Even with the bodies cleared, much of the rubble in piles and after three weeks cleaning up, the extent of devastation was apparent. The beach and almost all structures were destroyed for 200 yards inland as far as the eye could see.

We joined a meeting for health, environment, and sanitation for the Ampara district attended by WHO, UNICEF, GOAL (an Irish NGO), several other NGO's, and various local governmental agencies.

Tonight we stay in Ampara. The Deputy Director plans to place us in a small hospital in the town of Lahugala, 1.5 hours south. This serves a community of 20,000 locals, and also 5-6 refugee camps currently housing 15-20,000. There is a German health care team in the same area with whom we may work.

Christine Fernando and Sarah Beekley made it safely to Colombo. They plan to do the whole 8-10 hour trip to the east coast tomorrow, going to Batticoloa, where Christine has contacts and an invitation from a local bishop. I plan to evaluate Lahugala tomorrow, then join them Thursday in Batticoloa. This will allow us to work in the most devastated areas of Sri Lanka.

I once again feel great privilege for the opportunity to work here. I am struck by the huge need, and feel grateful for the opportunity to help and to make a positive difference.

Wednesday, 1/19/05, 22:00 Ampara
We spent last night as guests of the Deputy Provincial Director of Health Services in his "hospital quarters" house. The accommodations were quite modest, but the hospitality very nice. In the morning, after a 2.5 hour drive south, we arrived at the Lahugala Hospital. It is staffed by two physicians, and two midwives. Community members serve as nurses, drivers, and cook. There is no lab or x-ray, and no anesthetist.

After meeting with the doctors and unloading gear into our quarters, we set out to meet with the Medical Officer of Health, a local physician responsible for the preventive health of the community (among other things). He has oversight of the 16 refugee camps in his district.

We visited three camps we are likely to take on as our own, each with about 1,000 people. Many children have only one parent or are orphaned. Some families didn't lose their homes, but lost livelihoods and have come to the camps for relief supplies. No standardized health surveillance is conducted. Sanitation is poorly handled at many camps. All the camps need health education and much preventive health maintenance. Many camps are being relocated; they are in schools which are trying to reopen.

Thursday, 1/20/05, 20:05 to Batticoloa
We stayed in the Lahugala Hospital in the southern Ampara District, and participated in an ante-partum clinic where Vaji helped the doctor see 200 patients. They then went to a remote camp requiring a boat ride because of a collapsed bridge. The population there did not have many casualties, but was isolated and needed supplies and medical aid ferried to them. They reported having a great day finally getting "to see patients."

I, on the other hand, sat in a car with our driver for 4.5 hours to go 60 miles north to the Batticoloa. We drove the coastal road three-fourths of the way, past mile after mile of palm trees felled at the stump, collapsed structures with rubble everywhere, and sand mounds cleared off the road, detouring the last 1/4 mile where the road was closed. Many squatters are still living in collapsed structures, and it's clear there are many, many others affected other than the tens of thousands in refugee camps.

When we diverted off the coastal highway we detoured through local towns on pothole-covered dirt roads, passing through a Liberation Tigers of Tamil Elam (LTTE) checkpoint. It was Tamil rebel territory, the home of suicide bombers. There has been a ceasefire for two years and the State Department, the Embassy, NGOs working in the area, and many Sri Lankans feel it is safe for relief personnel to go there. It felt weird going through a military-style rebel checkpoint, but we made it to Batticoloa and met up with Christine and Sarah by 11:30.

We spent the afternoon doing here what Vaji, Swanthi and I had done in Ampara: meeting with the regional Deputy Provincial Director of Health Services and with a local MOH, and visiting a refugee camp with 900 people. Prior to my arrival, Christine and Sarah visited the local hospital (soon to have a medical school), and met with the Director of Health Services, who was excited about the possibility of our working there. This region has at least 9 refugee camps, each with around 900-1,500 people. The medical need in this region is as great as that in the Pottuvil region farther south where Vaji and Swanthi are located, and support services and opportunities to interface with other NGOs and local government agencies are far greater here.

Saturday, 1/22/05, 18:00
This was our second straight day of patient care in refugee camps. We set out early for a 2-hour drive to the Mankerni Church Farm Colony Camp, after picking up two Tamil-speaking nurses who worked with us yesterday. We also picked up water and lunch from a local store. After a long ride through bad roads and a few more military check points, we made the camp of 1,496 people. The camp leader was away, so we collected some of the more helpful refugees and went through the camp paperwork.

The camp has 487 families, 333 children under age 5, 75 people over 65, and 60 pregnant women. The fresh water was adequate (7 tanks and one chlorinated well). But the nice new latrines built by OXFAM had flooded in the heavy rains overnight. In addition, we saw many flooded refugee tents. The firewood used for cooking was wet; deliveries of infant formula were enough for only 250 of the 300 children under 2. We had to explain we could only provide medical care and would have to pass on their problems to other agencies that can help.

While we were there, the staff from OXFAM-UK arrived and we discussed the sanitation in this camp as well as the one we had visited yesterday, and now have a direct contact with the agency responsible for water and sanitation for our three camps. We saw more wounds and wound infection than in any previous camp. Everything from removing wound packing placed by prior medical teams, to wound dressing changes, to new wound infections.

A man with an abscess on the plantar surface of his foot from a puncture wound required I&D. We were out of scalpels and used a freshly sharpened pocket knife. A little Ceftriaxone and a wound dressing that included a plastic bag to protect his bare feet from the muddy roads, and he was off with a follow-up appointment with us when we are back in a couple of days.

We also saw an extensive deep space foot infection in an 8-year-old. We were trying to figure out how to get him to the nearest hospital 20 Km away when the Medical Officer of Health came by with a government medical team, and provided transportation for the child. But I thought the highlight of the day was Christine Fernando giving a 20-minute talk to 80-100 women and children on hygiene, hand washing, latrine use, and food preparation.

The mood of this camp was very somber. Living conditions were bad because of extensive flooding, the limited firewood for cooking, and a swamp soon to be mosquito-infested. It looks much like a camp that should be relocated, but from all signs it may become permanent.

Sunday, 1/23/05, 17:00
Sunday is supposed to be a day of rest. After nine straight 16-hour days, we needed to regroup, repack meds, make order of all the scraps of notes on various papers, and catch up on calls and e-mails. However, a disaster usually dictates your schedule and when opportunities present themselves they simply cannot be passed up.

Christine and Sarah dropped off some medical supplies at a community hospital and ran into two members of the Batticoloa Rotary Club - the secretary and the Director of Community Service, who is also one of the two OB/GYN doctors at the Batticoloa General Hospital. They discussed the relocation of some refugee camps out of schools. Three camps of 1,275, 500 and 300 people, respectively, were re-settlements in the past 6 days, having had no health evaluation or medical team visits. The OB/GYN left his clinic (with patients waiting) to help get us to these camps so we could do a health needs assessment.

Planning only quick visits, we took no medical equipment to deliver care. The biggest camp has only two water tanks (we will ask for more); latrines are being built; there are many non-medical needs like clothing, cooking utensils, and milk for the children.

It turns out Sarah's aunt in Connecticut is affiliated with the Rotary Club, and Sarah knew a tanker ship container full of such supplies sent by the Connecticut Rotary Club should arrive in Colombo this week! She gave these contacts to the Rotary Club people here so they could request these supplies for Batticoloa.

Days like today remind me that adaptability is essential in relief work. Many times one is led by the circumstances of the disaster to what one must do. We come to deliver medical care, but we also play significant roles in disease prevention, education, health surveillance, and sometimes we are gofers for whatever might be needed. When I thanked the hospital OB/GYN for taking time from his clinic and asked him to thank his patients for waiting, he said we came all the way from America to help, and it was the least he could do. Who says we don't work in a utopian community?

Monday, 1/24/05, 21:30 to Vahari Hospital
First off, a disclaimer: Although some of you might think I led the charge today into Liberation Tigers of Tamil Elam territory, I did not. Blame Christine and Sarah. The refugee camp we were scheduled to visit today, Panichchankarni, is a half mile from the washed-out bridge, and my adventurous partners decided to visit the area north of the bridge (while I was napping on the ride up). Within 5 miles of that area, you enter into Tamil rebel territory and pass through Sri Lankan army check points followed by LTTE check points. We encountered exactly what we have heard from all the NGOs in the area, and from the U.S. Embassy staff. The LTTE were helpful and welcoming.

The only way to get beyond the washed-out bridge is a free boat taxi service set up by the Tamil Relief Organization, the service arm of the LTTE. On the other side, you have to find other transportation. But at the crossing, we met a group with the "highest" level connections - Anglican ministers. We hopped a ride with them and went along the coast right to the area of the hospital. I am amazed at times how things fall effortlessly into place. Destiny, you might say.

Vaharai hospital was brand new, set to open on January 5. How tragic that this facility 100 yards from the beach is now a shell without power, water, or equipment despite such great need. A New Zealand team has been cleaning out the hospital to set up a base for medical teams to serve remote and isolated refugee camps in that area. They plan to establish a working clinic at that site as well.

We stepped off the boat into a wooded area with downed barbed wire fences and collapsed homes. This is LTTE area, and it is not certain that it has been cleared of land mines. We found a boy playing and asked him for the hospital, knowing he would know the paths to take - "step somewhere that someone else has stepped before" is the rule. Along the way, we saw a collapsed school and playground, and next to it, off the road, mounds marked by simple sticks; the ministers said they were the graves of children. How silent the road became at that moment.

We finally got to the hospital. Christine again became immediately essential for her language skills as patients started to drift in. I had a tour to evaluate the latrines being built, the well that needs to be pumped of salt water, and the feasibility of setting up clinic space and housing. We had not planned to stay long, but the need was there and we stayed close to 2 hours. On our way back, we brought back an 8-year-old girl with a severe puncture wound to the foot. She and her mother rode a boat across the river to our van and supplies, she got a tetanus booster, and they were off across the river again.

Once we arrived at the refugee camp of Panichchankarni, we rushed to set up a clinic. This is a camp of nearly 2,000, and we had less time than planned. With no nurses to assist, Christine and Sarah saw patients and I became a pharmacist. We saw five cases of dysentery (reportable to the health department), a handful of wounds; we did wound checks, suture removals, and other primary care. Sarah's talents were particularly useful as we saw 70 percent children.

When I re-read my updates, they frequently sound devoid of the depth of our days. So much more happens than is described in these e-mails: the orphaned 10-year-old girl whose white dress was covered with red hearts; the 8-year-old girl who lost her two brothers but survived because she chased after her parents who went to get water - she wakes up screaming in the middle of the night; journalists and doctors and other relief workers who come to tears because of what they see and hear. I have a friend who, when asked how many victims there were in the Oklahoma City bombing, answers that there were 200 million victims; he feels all Americans were affected. At times here, it feels like the whole world cannot help but notice this crisis. We have all been affected in some way.

Thursday, 1/27/05, 10:00
Yesterday was a travel day to Colombo. We discovered an international NGO that provides helicopter transport free for NGO personnel, and I traveled with a group of Americans from Northwest Medical Group. From the air, it is easier to see the 100-200 meter stretch of brown and dying palms and brush that border the coast. The vegetation, if not toppled by the tsunami, is being killed by salt water. I also saw the damaged bridge and the washed-out hospital we had visited two days earlier. In Ampara, our expected 4-hour stay on a hot runway turned into a comfortable afternoon in the officer's air-conditioned lounge with a nice lunch.

I am writing from The Colombo Plaza hotel, where Christine Fernando stays when she comes with family, and where U.S. Embassy staff and U.S. A.I.D. personnel stay. It is pricy by Sri Lanka standards, but average by ours ($120 a night), and well worth the cost for a good day of rehab.

hernando.garzon@kp.org