She Smiled

Colombo is the capital of Sri Lanka.  It is trying to be a modern, cosmopolitan city.  There are shops and hotels, and some of them are pretty expensive.  There are cars and motorcycles, and more tukk-tukks that you can count.  There are rich people, nouveau riche, and poor people.  And there are beggars.

We were having a bite for lunch at a local restaurant.  Around the corner from where we were seated, there was a woman sitting on the curb, looking at the people passing by her with a gentle longing in her eyes.  I'd seen beggars before.  They have them in New York, and Philadelphia, and Chicago.  There was one in Decorah, once, I think, but I'm not sure.  I have always been told to ignore them, to look the other way.  To give them money would be the same as encouraging their bad habits.  They would buy drugs, and booze.  So to soothe our guilt at passing them by, we would give them food.  Perhaps an apple, or a muffin.  At least it wasn't drugs.

But in Colombo, it is different.  I watched the people approach this woman, and give her some money.  They would greet her, and look at her, not look away and pretend to be busy.  Business men in nice suits would reach into their pockets and find some rupees to donate.  I watched one man give her a larger bill because he didn't have a small one.  He asked her for change, and she held out her hand with her money in it, and he took a couple of smaller bills.  She smiled and nodded at him, grateful for his honesty.

She was unfortunate.  Somehow misshapen in an accident of birth, or of life.  Unable to work or create a living for herself, she was dependent on the kindness of others.  And they stepped up to the plate.  As I watched, hardly anyone went by without acknowledging her.  If they didn't have the money to give her, the greeted her with a nod, a smile, a gesture or a touch.  As we got up to leave, we all went out the other door, so that we could give to her.  I didn't have much, maybe 20 rupees.  I nodded, as I didn't know the correct greeting in Singala.  I gave her the 20 rupee note, and as she reached up to me, the white guy, she smiled at me in thanks.  Her eyes were dark chocolate brown, and her face was contorted from whatever had affected her.  She put her hands together and gently bowed her head in the traditional greeting.Yet through it all, she smiled.  There was a gentleness there.  She didn't ask for pity.  She didn't look critically at the few who passed her by.  It seemed that the sun shined on her, and she returned that glow, reflecting the warm rays back into the people on the street.

The Salt in the Ocean

The blue of the Indian Ocean is a gentle blue.  Not that fierce, cold blue of the the Atlantic, but rather the warm colors we see in friendly eyes.  Those waters can change from the gentle caressing of the sands to waves that slap the shores and can be heard like rolling tympani.  In 2004, the waters became angry and slipped onto the land in the tsunami.  The ocean has a way of reminding us of our hubris.

It is warm, this ocean.  It licks our legs like an innocent puppy's soft tongue.  The small crabs in the sand scuttle back and forth, avoiding the waves in what appears to be a game of tag.  Small fish jump as they try to escape the unseen predators below.  It is a living thing, beating like a heart, pulsing through arteries that are made up of currents and tides, ebbs and flows.  It is where life began.

There is something almost primal about the ocean.  I am drawn to it, in all of its complexity, and yet in its unassuming simplicity.  It warms me, and surrounds me, like a hug from a friend who is glad of my return. There is also a sadness there, somewhere.  The feeling that somewhere, sometime, I have left something there.  Something that was a part of me at one time.  Something that I now miss in my being, that is now absent.  Perhaps it is a memory of a different time, of a different place.  All I do know is that the taste of the salt in ocean is the same as the taste of salt in my tears.  Maybe that is why the ocean is so big.  It has to contain the tears of so many.  And it stills welcomes us back without judgement or criticism, mixing together the tears of our souls.

The Game Changer

She asked me the hard question.  She, the two time Olympic medalist, who knew what questions to ask, who had proved more than ever needed to be proved.  She who always smiled at me, yet had an intimate knowledge of the dark places where most fear to go.  She understood the depths of pain as well as the victories that happen when that pain is ignored.

She tried to send me coffee, when I was in a place that didn't have any.  Just the thought of that effort makes me smile.  But yet she asked me the question, I think, already knowing the answer.

Karen Kraft asked me if it was a game changer, this experience with MSF.  I took that to mean, was this experience enough to change my ideals, my attitudes, and perhaps, my life?  Was medalling in two different Olympic competitions a game changer to her?  Damn right it was.  But there are only a few who can relate to her experience.  And there are only a few who can relate to the MSF experience.  Was it the medalling that changed her, or was it the journey to get there?  For me, was it being in Sri Lanka with MSF, or was it the process that made that possible?

So the answer is an emphatic YES, this is a game changer.  But how do you change the game?  The rules of the game may not change.  What changes is how we play.  And how we play depends on who we are, and who we are depends on our experiences, and that is why this is a game changer.  So how do we change how we play?  We reach into those places where no one else dares to look, and we bring out the best of ourselves.  We ignore the comforts of home and we strive to be better.  We look at our scars, and we remember where we got them.  Sometimes those scars may hurt, but they are what paint the picture of who we are, and who we will become.  The more scars, the prettier the picture.

So the game has changed.  She knew it had.  But she asked, knowing the answer, because she could.  And I answered her because I could, that, yes, it was a game changer.

We Are the World

A bunch of strangers showed up in Sri Lanka at the request of Medecins Sans Frontiers to help a population in need.  The Tamil people, nearly exterminated, are trying to scratch a life from the red clay.  They carry with them the wounds of the war.  They have limbs that are missing, or non-functional.  They have pieces of steel lodged in their muscles and sinews.  They have memories that they can't forget.  And yet somehow they are able to smile at us, we strangers.

There were a couple of Japanese, a Hong Kong Chinese, Western Europeans, and a couple of Americans and an occasional African.  I have wondered at what has bonded us together.  Why did our friendships blossom and grow?  We didn't know each other.  I'm not sure that I ever learned people's full names.  We didn't even speak each other's language well.  But we tried.  And we smiled at each other, and we created a bond between us that will be hard to break.  I'm sure that our reasons for being there were as different as the countries that we represented.  But I believe that there was a common thread.  Somehow, we felt driven to help people in need.  We felt that we could let go of our comforts of home, to become strangers in a harsh land, in order to make a positive difference to a people who were uncertain of their tomorrow.

In a way, we were the refugees, the strangers in the new land.  We shared the bond of exiles, the bond of the dispossessed.  Our belongings were shared, we didn't really own anything.  And we shared a hope for a future, not only for the Sri Lankan people, but for ourselves;  for the world that we live in, and for the friendships that have formed.  I hope that the bond between us never breaks.

The Risks of Helping People

The Singala people, the majority in Sri Lanka, refer to the Tamils as terrorists.  The rebel faction, called the LTTE, for the Liberation Tigers of Tamil Eelam, were rebels.  And I suppose at one time they did use some tactics that would be called terrorist.  But so did the SLA (Sri Lanka Army), although they deny it.  The Tamil people lost the war that started in the early eighties, and lasted until 2009.  Many Tamil people lost their lives, and near the end of the war, the few who remained, fled into the jungles around Mullaitivu.  The Tamil people were, and are defeated.  They have lost nearly everything except their pride.  The MSF project that I have been working on has concentrated on the Tamil people who are now being repatriated into the area.  They have nothing.

Sometime after 9/11, international law made aiding terrorist groups illegal.  This is referred to as the criminalization of humanitarian care.  There are groups who have been labelled 'terrorist', but have no access to medical care.  So MSF evaluates the needs, and if the need is there, helps to provide care to the people who need it. They don't care which side of the line people are on.  They want to help people who need help.  They help people on either side.  They help people of any religion, of any ethnicity, of any race.  They look at people as people.  Some people are in situations where they need help, and cannot get it.  And so MSF is there trying to help, and takes the risk of helping.

The Daniels

The whole time that I was in Sri Lanka, I was either referred to as 'the surgeon,' or as Dr. Daniel.  They didn't really use last names in the way that we do.  But that was fine.  In fact, it was refreshing for me.  But I was not the only Daniel.  There were two others, and I include them here.  Daniel with the glasses, was a translator, and a very excellent one at that.  His sense of humor was relentless, and he never stopped giving me a hard time.  Daniel, the other Tamil guy, worked with the mental health team, and was an excellent counselor.  I know of many people who requested him and him alone.  He had a special way with the people who were hurting, and didn't know where to turn.  His empathy for the Tamil people was so real, that many times we all shared their tears.

It is a huge honor to be sitting between them.  I don't think that Daniel was really their name, but I was sure proud that they had chosen that name to go by.

Lakshmi

She was always ready to break into a smile.  Our translator, Lakshmi.  Her eyes were dark pools, like looking into the deep waters in evening.  She flashed understanding with those eyes.  Speaking Tamil, and English, and Singala, she, at times was our voice -- our connection to another human being.  She never faltered, and I was jealous of Dr. Ben, who had her attention every day.  I was lucky once, when she came with me for an afternoon of surgery clinic.  She bridged the language gap with me.  She appreciated my efforts to say the days of the week in Tamil.  She always seemed happy, and I asked her about that.

She told me that her daughter had gotten a divorce after being treated badly by her husband.  Her sons were very ashamed of this, and actually tried to kill their own sister.  She helped her daughter to escape, and she is now safely out of the country.  One of her sons doesn't even speak to her.  I know from my own experience, that if one of my own children refused to acknowledge me or to speak with me, I would be devastated.  I cannot imagine what she has gone through, as a woman, as a mother, and as a family.  But she always was there, with her almost smile, and her irrepressible attitude, like the unsinkable Molly Brown.  She tells me that she wants to come to the states, and maybe take care of someone's children.  I have her contact information, and I hope that I can find a reason to call her.

The Hair of the Dog

One of the requirements, or strong suggestions from the CDC, is to have a series of rabies vaccinations prior to visiting Sri Lanka.  I overheard one lady wondering why she needed the vaccine.  She said that she was not planning on handling any wild animals.  After being there for only a couple of days, the answer became very clear to me.  It is not the handling of the wild animals that is the problem.  It is the presence of twenty million wild dogs.  They are everywhere.  They lay in the streets at night, and wander about all day.  One of the popular reasons to visit the Emergency Room is a dog bite.  The females are almost always either pregnant or nursing.  They have no owners, and are truly homeless, unless you call the streets their homes.

The dogs in Mullaitivu, as elsewhere, are missing much of their hair.  They appear to be in a constant state of mange.  Apparently the fleas and other biting things cause them to scratch so hard that they scratch their hair out.  And there are fights.  They always seems to be in the middle of the night, and sound like they are next door.  I'm never sure quite what to do, so I just lie there and listen, hoping for an early end.

Red Dust

I returned home on Wednesday.  The saga of getting home does not really need to be repeated, but I will say that it took about 5 days of travel, interrupted with debriefings in Paris and NYC.  Although I am glad to be home, my mind travels back to Sri Lanka regularly.  There were many more experiences than I have had the opportunity to share.  So I will continue to share, if you all are so kind enough to continue to read.

The soil in the Mullaitivu region was dry and red, clay and sand.  Very little loam.  It was very dusty, and the red dust permeated everything.  Nevertheless, the people of the region always wore very colorful clothes, especially the women.  They wore beautiful saris, and colorful punjabis.  They were adorned with gold bangles, and necklaces.  They wore silver anklets.  They didn't seem to be touched by the dust.

My little bicycle on the street

I have been unpacking, and have noticed that the red dust is throughout my clothes and belongings.  It colors my shirts and pants.  And I am glad for it.  Just seeing it brings back the sights, smells and sounds of a different country, living in a different time.  Memories of a people in need.  Memories of my colleagues and friends.  I hope that no one can shake the dust from my feet.

Broken

A man once asked that if you had the choice between a moment of happiness, knowing that sadness would follow, or the absence of happiness, knowing that there would be no sadness, which would you choose?  I know people who would choose the absence of sadness.  There are those who just cannot bear the thought of sadness at all.  I think it is why some of them like to sleep so much.  People can be happy, or scared, numb, or even angry in dreams.  You have to be awake to be sad.

There are those who would bravely choose the happiness, knowing that it is a risk.  It takes a certain amount of courage.  It is a risk of hurt and pain.  It is a risk of failure, and a risk of loss.  But it is also the risk of hope, for what is happiness really, but a belief in a future.  A belief that our heart will heal after it is broken in sadness.  A belief that happiness will follow.  And for every potential sadness, the potential happiness becomes greater.  This is what makes us human.  Earning that future by believing in happiness, despite the very personal knowledge of the sadness that is there.

It is not easy.  My friends in Sri Lanka, the people with whom I have lived with, laughed with, and cried with, have known more sadness than most of us can only imagine.  The depths of the sadness that they have experienced only makes the peaks of their happiness greater.  They are creating their future by making the hard choice.  The choice of a broken heart, and the hope that it will heal.

Freedom

This early morning, I have been reflecting on what I have seen and experienced.  While in Mullaitivu, I saw an incredible range of emotions.  There was a kind of resigned sadness at times, kind of the sadness of defeat.  But these times were rare.  I think that the sadness was understandable, the losses are incomprehensible.  But even more than the occasional feeling of sadness, there was a happy exuberance.  The smiles that we received were many, the thanks that we received were constant.  The hope that I saw in the eyes of my patients, and in the national staff that worked with our team, at times nearly broke my heart.  I felt that I couldn't fulfill the hope that they had for me.  I couldn't operate and remove the memories that haunted their nights, and shadowed their days.  But when they smiled, something else took over.  For a moment, it seemed like they were free, that they, just for a moment, would let the sadness go.

I wanted so badly to be able to bring that fleeting moment of freedom to these patients.  To fulfill their hope, and to remove their pain.  But all I had to offer was a smile and a kind touch.  It seems so little, but it means so much.

A Sarong Sung Blue

subtitle,  The Bare Chested Priest

We made our second visit to the temple, a different temple, just outside of Mullaitivu, on the road to Puttukuryruppu (PTK).  It is the temple of our cooks.  They dressed up the women in saris, and I got to wear my new 'sunday-go-to-meeting' sarong.  I include the pictures of me getting my feet washed before going into the temple.  The other picture is the priest.  Not your average Lutheran.

My Sunday Sarong

Not your average priest

The Team

Here we are, the OT team.  Ayumi, the OT Nurse, has poured her heart and soul into the creation of an operating room, that several months ago, was just a blank space.  Dr. Kim, the VOG (or ObGyn for you americans), has worked tirelessly against nearly every hurdle that has been thrown her way, and she has never stumbled.  She has created an ante-natal ward, post-natal ward, and delivery area despite bat droppings, minimal hygiene and a head nurse who has bucked every positive move that she has made.  I am the surgeon, the thorn between the two roses.

The Mango Tree

The yard at the MSF ex-pat house has no grass to mow.  There are scattered dieffenbachia and bougainvillae.  We have a number of coconut palms in the back.  But there was a big bare area on the southwest side of the front of the house.  Kim, the second VOG, who is on her way to Nigeria, and myself, the first surgeon at the project, wanted to leave something more than a memory.  So we planted a mango on the morning of our departure.  The guard helped dig the hole, and assured me that he would water it regularly. One of the other national staff made a sign with our names on it.  It is a stick, nailed to another stick, and placed in the ground.  It looks likes it marks a grave, but he was so proud of the work, that I couldn't bear to tell him.

A Gift from the Sea

I was trying to arrange my packing so that it made some sort of sense, and I came across a small bag that I had no recollection of.  I opened the bag, and in it was a sea shell, a special gift from someone who must realize that there is no way to give a gift that can contain the smell of the sea breeze, or the salty taste of the Indian Ocean.  The true gift is the memory.  The memory of the sun, and the heat, and the sand, and the curry.  The memory of Sri Lanka, Serendip, Tabropane and Ceylon.

The Train Home

It was Friday morning, and we had packed our lives into canvas bags, and stored memories onto flash drives, and burned those memories into the deep hidden parts of our hearts, hopefully for later retrieval.  We loaded the van for the movement to Vavuniya, where we would catch the train to Colombo.  The trip to Vavuniya takes over two hours over rough roads lined with banyan trees and teak.  The tone in the van is subdued.  I am leaving the project after nearly two months in the field.  Kim, the VOG, is leaving the project 2 weeks early, and is being sent to Nigeria to fill in a gap in VOG coverage.  Charlotte is getting a long overdue break in her work as acting FieldCo and Psychologist, and will be diving with friends in the Maldives.  Ayumi, our OT nurse, is taking a break to visit Kandy in the mountainous region of Sri Lanka.

We get to Vavuniya, and have lunch, before catching the train.  Our tickets, up until this morning, were third class.  However, we just found out that we got moved up to first class.  I'm not sure that there is much of a difference, really.  The train trip is over six hours of lurching, jerking and pitching back and forth.  It is difficult to rest, and is so loud that it is hard to even talk.

Arriving after nightfall in Colombo, we stand together at the station.  I think that we all realize that this is the end of this chapter.  But we also realize that the world has become smaller, and we hope, a little better.  Our efforts, at times, seemed to be so insignificant.  But the smiles of our friends in Mullaitivu, and the efforts by everyone to tell us 'good-bye' before leaving, makes me believe that in some small part, we have made a positive difference.

My Friend Paul

He goes by the name Paul, but that is not his real name.  He has an easy smile, and mischief in his eyes.  He is a playful spirit, who I connected with immediately.  We spent hours on the roads together, trying to get to different mobile clinic sites.  He was not only my driver, but acted as translator, since I had not been allotted one.  He taught me the history of the area, taught me about snake houses, and shared his precious coconut wine, which I couldn't bear to tell him, tasted more like goat urine.  He is off of work this week, taking the leave that he hasn't used.  Yesterday, he took the bus for a two hour ride from his home in Kilonochchi, to meet me at the hospital, just to goodbye.  Once we drove to where he had been living during the war.  The church that he attended was destroyed.  All of his belongings were stolen.  I asked if he played any instruments, and he lamented that he loved to play the guitar.  I have tried for nearly six weeks to find a guitar to give him, since his was destroyed.  But to no avail. I feel badly that I haven't come through for him, like he has for me.  But he doesn't see it that way.  He sees us friends, who can joke together, sing reggae together in the truck, and laugh together, despite the fact that pretty much everything that he has ever had, has been taken from him.  I love his spirit.

Envoys

Because of the recently released UN report on possible war crimes, the United States Envoy was sent to visit the area.   He ended up here in the Mullaitivu District.  Because of the sensitive nature of his visit, the few white people, me included, had to lay low.  We were not allowed to see or greet him, and a hand shake was out of the question. MSF works very hard at neutrality and impartiality.  This was a chance to see that out here in the real world.  Americans are not highly thought of everywhere.  Effigies of Obama were burned last week.  Some of us will revertto speaking Spanish or German.  Unfortunately for me, I am the only one who speaks German, so it is usually Spanish.

I was seeing a patient the other day, and was asking in Tamil if he had pain.  He showed no understanding of what I was saying, and I thought, boy, my accent and pronunciation must really be bad today.  However, I was immediately corrected, and told that this man was Singala, and didn't speak Tamil.  What a dilemma.  The Tamil women can be identified by how they dress and how they wear jewelry, but I guess that I'm not sure how to identify a Singala man, unless he has on an army uniform.

Guano

Over the only stair case that is accessible to patients, is a somewhat porous roof.  In fact, all of the roofs here are pretty flimsy.  The hospital roof, however, as become home to thousands of bats.  They produce enough guano, that the roof tiles started to leak it into the stairway, and into the area next to the maternity ward.  If guano smells bad in Iowa, think of what 90 degrees and 100 percent humidity does to the fragrance.  I will tell you.  It magnifies it.  To the point that going up the stairs would make your eyes water.  There is apparently a secondary problem, in that the monkeys like to catch the bats, and will climb on the roof at night.  So, as part of the deal to bring the hospital up to a better grade, the roof is being fixed.  I'm not sure that is the final answer to the bats, but I hope it will keep the smell down.  There are so many smells in Sri Lanka that are unusual to the western nose.  I'm not really sure how to catalog them.  I'm sure that they will evoke many memories if I ever smell them again.  Of bats, and monkeys, and cows walking down the middle of the road, and the ever present burning of trash and manure.  But there are good ones as well, like the smell of curry, the ocean salt breeze, fresh fish, and prawns on the grill.  I will try to remember the good ones.

Sunday, May Day

It is May Day here.  For some reason, that corresponds to a holiday.  Since May Day is on a Sunday, that means that most of the people get Monday off.  We don't get the day off on Monday, but there will be reduced staffing.  Several of the women in our groups have purchased saris.  These are basically eight to ten yards of material that is wrapped around a person in a very particular way.  Being that today is a holiday, the women wanted to dress up in their saris, and go to the temple.  The problem is that none of them know how to get into a sari. So our local staff who help with the cooking and cleaning came over for a lesson.  Ayumi, our OR nurse, and Dr. Kim, our VOG, were dressed in their new saris.  I wore my best sarong.  And we all went to the local temple.  The Hindu temple is really quite something.  We spent about two hours going through the temple grounds, and at the end, were fed some of the food that is prepared by the priests.  This includes a spiced fruit and rice dish served on banana leaves.  It is actually quite good.

When we returned to our house, we changed into more casual wear, and went to the local beach, where we watched the fisherman bring in their catch.  We bought a kilo of fresh fish, small, anchovy like fish, and brought them home.  We fried them up in hot oil and salt and pepper, and have been munching on a tasty snack, fresh from the sea.  Now to get ready for Monday.

Windows and Doors

One of the things that one finds in more tropical climates is the absence of windows or doors.  That is, if we think of windows as glass partitions between the inside of the building and the outside of the building.  And if we think of doors as something that closes once we are outside.  I guess that we have windows here, but they are merely holes in the walls.  We have doors, or should I say, doorways.  Mostly there is nothing to close or hit you in the butt on the way out.  These openings are very good for airflow, as long as the air moves.  It also means that other things have free and unrestricted access to your living quarters.  It is no longer a shock to me, but there are always things crawling around.  Primarily insect life, but others include gecko like things, toads, tree frogs, and other feral animals.  Of all of the shots that were required to come to Sri Lanka, the most valuable was probably rabies.  I have not been bitten, but there are many feral dogs, and fewer feral cats.  They are everywhere.  In our emergency department, many of the visits are for treatment of bites.  Ironically, these do include human bites.  And of course, those are probably the worst.

The War Hoard

There is an interesting phenomenon in times of war, and I am sure other potentially lean times.  It is what we refer to here as hoarding.  I first noticed with people who have gone through World War II, and the depression.  Those people would take a couple of extra jellies from the restaurant, in case they may need them someday in the future.  Here in SL, there is a similar attitude about things.  New things are saved, and not used.  They are stock piled, and admired, but not used.  We at MSF have provided many materials for the hospital.  However, the Matron, remember her, doesn't want to use anything that is new.  She would rather save the new stuff for something else.  I am not sure what.  When we brought this up in our small groups, everyone agreed that we were seeing war hoarding.

I'm not sure how long it lasts.  But I would guess it is a generation.  At least.

Sisters

They were fleeing through the woods, trying to avoid the gunfire and the barrage of shells.  But they got separated.  A man and his wife and her sister.  He wandered for days looking for his wife, but she was gone, either killed or perhaps worse, captured.  He had to remain hidden, and moved usually at night when the fear and the tears couldn't be easily seen.  One day he heard a sound, a soft call to him, using his name.  He looked, and saw his wife's sister.  They hugged, and held each other quietly.  Silent tears came and went, rains came and went, yet they stayed together.  Again they looked for his wife, her sister.  But there was no one there.  She was gone.  After weeks became months, they realized that his wife was gone.  They only had each other, and they found what little solace was left between the two of them.  There were nights when all that they could do was hold each other.  He decided to go on one last search.  He gave his wife's sister a final hug, and left on his search.  About two days later, he stepped on the mine.  The shrapnel tore his left leg off, and burned through his femoral artery on the right.  His strength was not enough to keep the pressure on the remaining leg, and he closed his eyes, and layed back to die.

Nearly four months later, as people were being moved between camps, his wife's sister saw her.  She recognized the soft brown eyes, lowered in sadness.  When she called the name of her sister, her eyes brightened and they ran to each other.  They were back together again.  His wife asked about her husband, but the sister could only look down and shake her head. She explained that he had left, looking for his wife, but had not ever returned.

They were able to live together, the wife and her sister.  The childless widow, and her sister.  And when the pregnancy began to show, it was only the two of them left.  The widow, and her sister, who was to bear the child of the dead husband.  She is nearly ready to deliver.

A Cold Shower, or One Stop Shopping

I have tried to introduce some of the team from MSF here in Sri Lanka.  I should also tell you a little about our living arrangements.  Everyone has their own little room.  I think that I described mine earlier.  We do have a nice shower out in the back by my room.  It is dark and made of cement.  There are a multitude of little creatures who share the shower with you.  Yesterday it was a tree frog.  So far, no snakes.  One of the things that strikes you after the initial shock, is the fact that there is only one knob on the shower.  It is the 'on' knob.  There is no hot water, just cold.  What is interesting is that you really don't miss the hot water.  Usually you are in the shower to try to cool off.

The other shower in the main house is conveniently located next to the toilet and the sink.  You can, in reality, shit, shower, and shave all at once.  Some refer to it as S cubed.  The rest refer to this shower as one stop shopping.  Similar arrangements are noted in Point Pedro, although they did install some sort of heater for some of their water.  I never really tried that one.  It just didn't seem right.

The French Connection

Charlotte is our psychologist, and is currently acting Field Coordinator since Sam left.  She is from Paris, and can roll her own cigarrettes.  In fact, her family is nice enough to send her very special tobacco from the Basque region, and very special papers, that I believe are somehow organic.  Certainly not average.  Her plate is full, with the mental health team, and now FieldCo.  She does a great job of keeping things running, despite her increase in responsibilities.

Frederik is our psychiatrist.  She has been here for a couple of weeks, and actually extended for a couple, but is getting ready to leave.  She works for MSF in Paris, and has done many missions.  She doesn't roll her own, but buys them already made.  Frederik has a great deal of experience, and really does a great job.  She is able to keep things in perspective, and realizing what the resources locally are, appropriately does what she can.

The mental health needs are great.  This is situation where families do not know where their loved ones are, or if they are even alive.  The suicide rate is very high, and does not seem to be going down.  They are dealing with career ending injuries, so that they have no way of making a living.  When you hear the stories, it is hard not to cry.  Many people of been skeptical about MSF delving into mental health, but afte seeing what is out there, I am convinced that in situations like this they are invaluable.

The French pretty much hang out together, and fall back into their native language.  But it is nice to have some Europeans about.  They make sure we have beer in the fridge, and cheese for breakfast.

The Hospital Gods

The Temple at the Hospital

As I have pointed out in a previous post or two, the primary religion in the north of the country is Hindu.  The majority of the Tamils are Hindu.  There are a few scattered Buddhists around, but mostly in the southern Singala area.  There are a few Moslems, and a few Christians, filling in the smaller percentages.  The hospital at Point Pedro has a small shrine as you go into the main entrance to Ganesh, the Hindu god with the head of an elephant, with one tusk going up, and the other going down.  In his left hand, Ganesh is holding something.  The local people tell me that Ganesh is holding Sri Lanka in his left hand.  At the Operating Theater, there is a big picture of Ganesh as you go through the OT doors.  However, the picture above the Recovery Room is of Jesus.  On Ward 2, just off of the nursing station, along the wall is another small shrine.  This shrine has Christmas lights in red, green and white, flashing all of the time.  This morning, incense was burning.  The shrine consists of a series of pictures.  Again, Ganesh is there.  There is also a Buddha.  There is a crucifix at the end, and a picture of baby Jesus dressed in Sri Lankan clothes.  I didn't really recognize Jesus, as I was always taught that he was born in the Middle East, and was slightly embarrassed after asking the Hindu nurses what the name of this god was.  They seem to be very inclusive.  They don't really think one god is better than another.  I think, just to hedge their bets, they try to get as many gods as they can.  Just in case.

The First of the Last

It is Easter Sunday, and I just finished making rounds at the hospital.  In a land where most of the people are Hindu, and the rest are Buddhist, the Easter morning celebrations are muted.  There does not appear to be an Easter Bunny, at least I didn't find any jelly beans hidden in the corners of my room, despite my looking and hoping for some.  It is my last day of rounds in Point Pedro.  I will leave for Mullaitivu tomorrow morning.

I start my rounds with Dr. Ruantha on Ward 2.  Once these are completed, I go to Ward 7, and round with Dr. Prim.  I was feeling a little sad that I was leaving, after just getting to know them.  Both doctors are very talented and smart.  They are efficient, and have good senses of humor. They asked me to come back to Ward 2, where I had started.  When I arrived, I was asked to sit down.  Shortly thereafter, the nurses and Dr. Prim arrived from Ward 7.  The nurse from Ward 2 had made up some small plates with food, and a tray of cups filled with Sprite.  She handed these out to all of us, thanking me for being there.  I tried to tell her that it is I who should be thanking them.  They were always going out of their way to be nice to me, and to make sure that I was in the right place at the right time.  I was very touched by this effort.  The food was a small piece of cake, a couple of biscuit cookies, and a vegetable wrap.  It was pretty hot and very humid, and the spices in the vegetable wrap were HOT!!  I ate the whole thing.  My upper lip was sweating, my nose was running, and my brow was dripping.  It was great!  They had known me for less than two weeks, but had completely included me in everything.  And now they were thanking me with a special midmorning "tea".  I fear that this is the first of the last suppers.  As my time here winds down, it is hard to ignore the kindness of the people who have survived a 29 year civil war, yet have a smile on their faces, and a cheerful greeting every morning.  I am sure that they have scars that we will never see, that they keep hidden in their effort to maintain normalcy.  They have so little in the way of possessions and money, but they have so much when it comes to kindness and compassion.  I have learned so much.

Sonoko

The Emergency Room (EU) doctor in Point Pedro is Sonoko.  She is from Japan, and this is her second mission with MSF.  Previously she was in Pakistan.  Along with Dr. Ben, who I have mentioned before, she is one of the strongest ER physicians that I have seen.  The things that come into the ER include everything from penetrating trauma (knife and gun injuries) to blunt trauma (car and vehicle accidents), to snake bites and sepsis.  She handles it all, and never gets flustered.  Even beyond that, she is designing the disaster management plan for the hospital.  At the house, she and Yuko team up to cook some very excellent meals.  They always seem to be Asian meals, I'm not sure why.  She told me that she is going to have to go back to Japan and work for a while before she can do another mission.  I'm not sure when she is scheduled to leave SL, but whenever it is, she will leave a significant void.

The VOGs

Rainy and Dr. Kim at Point Pedro

As of now I am the only surgeon for MSF in Sri Lanka.  I am supposed to be based out of Mullaitivu, but am currently helping out in Point Pedro.  MSF is lucky to have two VOG's.  This is MSF speak for ObGyn doctors.  Rainy, the shorter of the two is based in Point Pedro.  This is her first mission.  She was a classmate of mine at my information days in NYC, where MSF had the final say as to whether or not we were worthy of joining.  She is retired from her private practice, but she does do locums work when she is in the states.  She has also done a lot of other volunteer work. This is her first mission with MSF.  I think that SL has been a bit tough on her.  The food doesn't agree with her, and she requires Diet Coke, which is nearly impossible to find.  One of the admin guys did find a stash of Diet Coke in Jaffna, about 30 miles from Point Pedro, and bought as much as he could for her.  She is very dedicated, and works extremely hard to give the best care possible.  Rainy is from the New England area of the USA.

Dr. Kim, melting the Icy Matron (Flying Nun)

Dr. Kim, as she is known, is based in Mullaitivu.  She arrived a couple of weeks after I did.  She and I have worked as a team to help set up the new Operating Theater in the hospital at MTV.  She has also been saddled with reorganizing and improving the ObGyn department, primarily Labor and Delivery in the hospital.  Her biggest obstacle has been the Matron.  Basically the highest ranking nursing officer in the hospital whose empire was primarily L and D.  We refer to her as the flying nun, although she technically is not a nun.  Dr. Kim is melting the ice that the Matron throws her way.  It has not been easy as the Matron is jostling for position and power.  However, L and D is now the best area of the hospital, and the Matron is almost ready to admit it.  Dr. Kim is from Texas, and has a smile as wide as the state.  She loves to say "Y'all."  This is her first mission.  She recently gave up her private practice to join MSF.

The two VOG's and myself make up the American contingent.  As you may have realized by reading these posts, most of the people on this mission are from Asia or Europe.  It is very interesting having the majority of the team speak English as a second (or third) language.

Toto

Toto is from Japan, and is our chief logistician.  He is based out of Colombo, the capital city.  The picture of him doesn't do him justice.  He is not only a great DJ at a party, but a great cook of Japanese and Asian cuisine.  He has a unique ability to see through a lot of fog and make sense out of what is left.  He understands what is needed for a mission, and he makes it happen.  And he knows how to drink beer.

When I met him, he was getting ready to leave for Japan, shortly after the earthquake.  MSF had asked him to go for several reasons, but the main ones were that he speaks the language, and that he can prioritize needs for a mission.  As he waited to be shipped to Japan, the orders changed, and he was able to remain in SL to continue our missions here.  I'm not sure how we would have managed without his knowledge of the missions here in SL.  I'm sure we would have been OK, but Toto definitely enhances the medical mission by making sure that we have what we need.

Toto, I have a feeling we're not in Kansas anymore.

Loss

They come in to the emergency room after losing half of their circulating blood volume.  Their faces are striking -- blank stares, pale skin, pain, sorrow -- all reflected in a quick glance.  They can barely talk they are so weak.  They are are 16 or 17 years old.  An older one may be 20.  They were raped.  Their last period was 8 to 12 weeks ago.  The pregnancy would make them outcast, unable to ever marry.  So they try to take care of it themselves.  But after a couple of days of bleeding, they finally arrive at the hospital in shock, with barely enough blood to get to their brain.  Hemoglobins around 4.  We do what we can.  Support the intravascular volume, transfuse.  Try to get them stable enough for a D and C.  Some need an urgent hysterectomy to save their lives, but they don't have enough blood to survive the operation. They have used up all of their clotting factors, so the bleeding only worsens.

The ones that live will never be the same.  They are scarred for life, both physically and emotionally.  It is a great loss.  And it is very sad that it has to be done this way.

There are countries where abortion is illegal.  Like in Sri Lanka.  But that doesn't mean that abortions do not take place.  They do.  They are done covertly, in non-sterile back rooms, by untrained people.  Amazingly, this also happens in the US.

This isn't birth control.  This is an attempt to maintain human dignity.  To have hope for a possible future.  For when that hope is extinguished, the will to live disappears.

Fanta

I have been told that in many places around the world the drink selection is fairly limited.  Here in SL, there are really two drinks, Fanta and Coke.  Now some places have Pepsi, but Coke and Pepsi, for all practical third world purposes, are the same.  Fanta is like orange pop.  Like Orange Crush, except not very cold.  It is very special here on the island.  If the nurses think that you have been working too hard, and need a break, they will bring you a Fanta.  Sometimes the Fanta is perhaps a little old, and has lost its fizz.  Then it is like warm Tang.  Remember Tang?  The stuff the astronauts used to drink?  When the nurses bring you a Fanta, it is a sign of deep respect.  They want desperately to do something nice, and this is what they can do.  So you must accept.  You drink the Fanta while they watch you and smile at you.  I have to smile back, give them a big satisfied sigh, and thank them for their thoughtfulness in my best Tamil.  I don't really know how much Fanta I have had, but I will keep accepting their gift.

Daniela, the Pharmacist

I met Daniela on the day that I arrived in Colombo.  She works as the head pharmacist for MSF in Sri Lanka, and is therefore based out of the capital.  She does get around, and has to make regular visits to the smaller sites.  She just arrived in Point Pedro, and will go to Mullaitivu in a day or two.  The Pharmacist is not only responsible for the medications that we use, but is also responsible for the medications that the Ministry of Health (MOH) has.  Any supplies used for medical treatment also comes through the pharmacy.  It is a big job.  Daniela does it well.  She is from Italy and other than her blond hair and green eyes, she is quintessentially Italian.  Her Italian accent is hilarious, and is better than anything out of the Godfather.  She will say, "Good-a morning-a.  Is-a there-a some-a bread-a?  Are you-a going-a to the hospital-a?"  She keeps a great attitude, despite the sometimes frustrating interaction with the MOH.  I think that this is her first mission.  She gave up her flat, and her belongings to go on the mission.  She likes to cook, and spent an entire day with our cooks in Mullaitivu teaching them how to make pasta.  We are all very thankful for those efforts.

Update on Yuko

Yuko and the grandchildren

You may remember the cat that had kittens under Yuko's bed.  They are almost a week old.  Yuko has two beds in her room.  The large one which she uses, and a smaller one if there are visitors that need a bed.  The cat and the kittens were under the larger bed.  Yesterday, Yuko was napping, and the cat brought all of the kittens up to lie next to Yuko.  So Yuko did the logical thing, she made a space for the cat and the kittens.  Last night, she decided to take the smaller bed, and let the new family have the bigger, supposedly more comfortable bed.  Not long into the night, the cat brought all of the kittens to the small bed to be with Yuko.  Although she has no children of her own, Yuko is now a grandmother.  It is luck for the cat, and I think, for Yuko, that she had to stay, instead of going home to Japan.

Bargaining

 

I remember a statement made by Billy Graham when asked if he prayed on the golf course.  He said that of all the places where he prayed, that was the place where God was least likely to answer.  Prayer for many people is a bargaining.  Trying to reach an agreement or compromise.  "God, if you let me make this 12 foot putt, there is $50 more in the plate on Sunday."  Or "God, if I can get at least an 85% on this final exam, I'll only drink one six pack in celebration."  There just doesn't seem to be the dedication to always make the deal.  The other day, however, I had the chance to see some Hindu prayer.  Now this is real bargaining.  There were two men suspended by hooks through their skin, and arrows through their mouths.  They were essentially hanging from a long boom in front of a tractor.  The tractor was moving down the road relatively slowly, attempting to soften the bumps, but with the state of the roads, they were still swinging up and down quite wildly.  I was actually amazed that the skin had not torn through.  They don't appear to be in pain.  I have been told by my Hindu colleagues that this is a special prayer, and not everyone does that.

The Local Hooch

I remember the homemade moonshine that came from Bosnia.  It was called slivovitz, and was made from apples, pears, and whatever else was around.   It was generally clear.  Each family usually made their own, and they were quite proud of the results.  It was close to a vodka, or a grappa.  They were always eager to share a shot, or what we call in the old country, a wee dram.  In Sri Lanka, the local hooch is called Arrack, and is made from coconut.  It is golden in color, and comes in several grades.  The usual stuff you see has a green label, with Singala and Tamil writing upon the label.  David, the field coordinator from Point Pedro introduced me to his own mix.  I had always tried Arrack either strait up, or on the rocks.  He, however, showed me how to mix the Arrack with lime juice and ice cubes.  Not a bad mix, if I do say so myself.  A little of this liquid treat, and you may almost think your back in civilization.

Yuko

Yuko, the yoga master, and me

Yuko is the Operating Room nurse in Point Pedro.  She is from Japan.  She has been here for 8 months.  She has done an amazing job organizing the Operating Room, and also the wards.  Her resourcefulness is incredible.  She saved all of the ice cream containers (we don't have these in Mullaitivu) from the MSF house, cleaned them, and then brought them to the hospital, where they are now used as containers for the dressing cart, and for organizers in the shelving units.  She is rarely in the OR, but spends her time organizing our assets by seeing the bigger picture of the hospital.  She is also a great cook, Punjabi shopper (the local women's wear), and yoga girl.  Yuko finished her mission (her first) in Point Pedro today, and is already scheduled for her second mission, which will start in about a month.  She packed her bags and left this morning, only to be turned around because her return visa has not been approved.  So she will stay here for a while.  She did not want to risk not being able to get back.  Over her stay, she has actually learned a fair bit of Tamil.  Pretty impressive to me.

Dr. Ben

Dr. Ben at his garden

I have failed tell you about the great people with whom I work.  Dr. Ben is an Emergency Room doctor in Mullaitivu.  I think that this is his second mission with MSF.  He is from Hong Kong.  Although he is rich with experience, he appears quite young.  I am very impressed with Ben.  He handles the ER as well as anyone.  He is cool under pressure, and never shows much strain.  He is very well trained, but despite that, he is going to back for a residency for Anesthesia, so he is always studying, except when he is fishing.  After work, nearly every day, Ben rides one of our bikes about 8 km to a bridge near the ocean.  There he fishes to his heart's delight.  He brings back his catch, and shares with everyone.  One of his specialties is fish soup, made with fresh ginger.  Sometimes he will fry up the small fish, which none of us can identify, and we will eat them that way.  He was very excited last week because he caught a big eel, but it was too big for his line, and the line broke.  He is also a gardener, and has planted ginger, mint, and a couple of pineapples.  If he can get things to grow in this soil, he is in the wrong business.  Ben is fiercely independent, and it seems like nothing fazes him.  I sure hope to see him again on another mission.  He provides humor, perspective, and food.

Cornerstones

As some of you may remember, the Operating Theater, and the Maternity Ward of the Mullaitivu Hospital were gifted by a rich donor through UNICEF.  This means that there was an official dedication of the OT and the Maternity Ward.  All of the bigwigs were there, including a three star SLA General, the regional governor, the regional head of UNICEF, and many others.  The deal was that UNICEF would provide the equipment, and MSF would provide the human resources.  It may not have been a perfect marriage, but things are working out.  There was some give and take, especially between UNICEF, MSF, and the Ministry of Health.  Nevertheless, we are going forward.  During the morning long celebration, several of us were chosen to place the cornerstones of the new building, of which we didn't really know about.  Apparently the plans include the building of a new wing sometime during the next year.  Although I am not a mason, or a mason's son, I had the chance to lay a stone for the new hospital wing.

Directions

The hospital in Point Pedro is laid out in some sort of maze. It is pretty much on just one floor, except for the lab and some admin offices. Each of the wards are numbered, but they don't go in order. I have to attend at Ward 2, the female surgical ward, and Ward 7, the male surgical ward. In between these two wards is the in-patient psych unit, several other wards, not in numerical order, and the kitchen and morgue. I thought that this sign was instructive.

Down to One

For the first month of my stay in Sri Lanka, there were two general surgeons for MSF on the island, with me being one of them. Today, Debbie Aaron left Point Pedro, and I moved up to Point Pedro. She is leaving after nearly 4 months without hardly a break. Boy, do I have some shoes to fill. Debbie was loved by the community and the people in the hospital. And she loved them back. I made rounds with her this morning so that the patients could be properly handed off to my care. The tears that were shed for her were countless. It was one of the most moving experiences. I was already feeling sorry for myself, in that I had to move away from my friends in MTV, and go to Point Pedro, where I hardly know anybody, except Debbie, and she is leaving. I don't know my way around the hospital which is laid out like a maze, and I was feeling pretty alone. I thought that I was going to get misty eyed. But the phone started ringing with consults and cases, and I had to jump in. So we are down to one surgeon. I expect to be moving back and forth between MTV and PPD, but it will depend on needs. The real need is flexibility, and the ability to adapt to changing pressures and demands. I will do my best.

Under Yuko's Bed

A little over a week ago Dr. Kim and I visited Point Pedro for a couple of days. We were there to look at the operating room set-up, the clinic set-up, and the relationship between the MSF physicians and the MO's (medical officers from Sri Lanka.) During this visit, we were introduced to Ward 7, the small kitten that adopted the MSF house. The kitten was pregnant at the time. However, 2 nights ago she delivered her first litter of 4 kittens. She apparently howled all night long, keeping Yuko, the nurse, up and awake. After all, she delivered the kittens in a small box under Yuko's bed. That is where they remain. Under Yuko's bed. There are probably few higher compliments than being adopted by a cat, with the possible exception of being chosen as the delivery room for a litter of kittens. Good job Yuko.

At the Temple

A quick shot of me after the temple celebration.

Changing Position

I am writing from Point Pedro, in the far north of the island. The surgeon who has been here for several months leaves tomorrow to go home. That left them without a surgeon. The anesthetist who is supposed to come to Mullaitivu is being held up in the visa process. I am a team player, and to help the team, I am now in Point Pedro. I found out last night. There was no time for a proper good-bye to my team at MTV. So we had breakfast together this morning. I quickly packed my things, said too-quick good-byes, and got in the van. Now there is a surgeon in the same place as an anesthetist. Work can carry on. But the people that I have been with at MTV are very special. We have gone through a lot together. We have started from scratch in a hospital that had no operating room. We have laughed and cried and shared frustrations together. We have played darts, and UNO, and watched movies without any sound. We have shared recipes, and tried recipes together. We have become friends. So to you my friends, I raise my glass. To Ayumi, Charlotte, Frederika, Dr. Ben, and Dr. Kim, I am with you all in spirit. To the others, including Betty, and Laurence, I hope to see you soon, and am sorry you couldn't have breakfast with us. I will be back.

The UN

There is a trickle down effect on NGO's in Sri Lanka. Essentially the government does not really want us here, but realizes that it currently does not have the capacity to do the things that we are doing, especially in an area like Mullaitivu. OXFAM got kicked out of the country. The Red Cross got kicked out of the country. We, at MSF, are walking carefully through the snake infested rules and regulations that have been set up, to try to avoid being kicked out. We are the only medical NGO in the country. And in our area alone are over 200,000 people without adequate access to medical care. So currently, we tread lightly. The UN is starting its investigation into war crimes committed by the SLA at the end of the civil war. Whenever there appears to be bad press about Sri Lanka, the government takes it out on the NGO's. It feels that the NGO's are the only ones that would communicate these types of things to the world. Reporters are not admitted to the country. It couldn't be our own people saying anything bad. It must be those damn do-gooders. So we are very careful. The government will limit our access, and can restrict our movements. But even moreso, it can adversely affect the visa process. Visas for engineers can be gotten in about 2 weeks. Visas for humanitarian medical care take about three months. Now that the UN is investigating war crimes, which it should do, those of us that are here, may feel the backlash.

Apologies

I was looking over the last post, and realized that I must apologize for the lack of paragraphs, as well as the lack of parentheses, whose absence may not be obvious, other than the fact that I have to try to re-arrange sentences because they are not available. The MSF computer doesn't have all of the keys functioning. It is an interesting dilemma at times. I'm not sure why my paragraphs disappear, but I appreciate your kindness and understanding of the situation. I will continue to the best of my limited abilities, using the keys that seem to work.

More New Years News

First of all, I was reviewing what I had written last, and sadly feel that I misspoke. The Sinhala New Year and the Buddhist New Year in Sri Lanka are the same. The Hindu New Year for the Tamils is one day later. Hence the several day slow down in the country. The area where I live, is primarily Hindu. One of our drivers, a local Tamil fellow, invited several of us to the temple for the celebration. It was amazing. I have to admit, that whatever I knew about the Hindu religion, other than the names of a few gods, I have forgotten. And this didn't really help. The temple was pretty big, for around here. There are many small temples, but this is one of the bigger in the area. We took off our shoes, and walked through an open area with statues of gods lining the way. The priest, still bare chested, but in a temple sarong, greeted us. We asked if we could take some pictures, and he indicated that that would be ok. Then he placed white powder across our foreheads, and placed an orange dot just below the white stuff. We walked in to the sound of crazy cool music played on some sort of double reed horns and drums. There was smoke from incense burners everywhere. Four men in priestly garb were holding up a representation of Ganesh in a litter. Ganesh is the god with the head of an elephant. After some chanting and singing, the priest threw a bunch of white flowers in the air, and Ganesh and his carriers started coming my way. I tried to respectfully get out of the way, but the drummers and horn players snuggled right next to me. They were glistening with sweat. I, on the other hand, was soaked with sweat. I could feel it dripping off of my fingers. I wasn't sure how the drummers could hang to the stick. They use a stick in one hand, and their fingers on the other hand. It is very loud and wonderful. I thought originally that it was just a bunch of random banging, but it wasn't. It was carefully choreographed complex rhythm structures. The horns looked like the kind that you would charm a cobra with, only bigger. Boy, did they work them. Everyone was sweating. Smoke everywhere. Flowers being thrown. And there were no pews. Next, a priest, there seemed to be many, come by with a pot of liquid that he scooped into the palm of your hand. We drank it, and I think it must have been some sweeted coconut milk. Then, another priest or acolyte came by, and placed two more dots on our foreheads, of different colors. I think this was to indicate that we had completed the ceremony. Our local driver escorted us out of the temple, back into the area with the god statues, where another priestly fellow scooped some fruit compote into our hands for us to eat. It was actually quite good, flavored with local spices. We looked for our shoes, and were only short one pair. I am told that it is an honor to lose your shoes at the temple. It means that you have given a gift to someone who needed the shoes more than you did. I'm glad I didn't give mine away. Finding shoes in my size in a country of very small people is difficult, and I only have the one pair. I may have been relagated to hanging out at the temple waiting for someone with big feet to go in, so that they could give a pair of shoes to me. Our driver brought us to his house around the corner for lunch. It was some of the best food that I have eaten yet in this country. The house was very modest. Still full of bullet holes, and larger holes from rocket launchers and artillery. There was still a shell fragment that was impaled into the wall above the front door. I have no idea how they cooked up this food for the six of us, but they did. It was such an honor to be invited. They have two small girls who just gazed at the white people, and smiled. I wish that I could get some of the pictures to share, but we just don't have the bandwidth. Sorry.

Happy New Year

Today and tomorrow are big days in Sri Lanka. One of the days is the Buddhist New Year, and the other day is the Sinhala New Year. That makes up Wednesday and Thursday. The president, in a show of good will, gave the country Friday off as well. Last week was the last day of exams in the schools prior to a two week vacation. As a result of this perfect storm of time off, we are short on drivers, translators, national staff nurses and medical officers at the hospital. We are also missing cooks, cleaners, masons, carpenters, and people who put the air in our bike tires. In fact, I didn't even see the monkeys at the hospital this morning. I was hoping to hire one, but maybe they have vacation as well. It will be slower pace over the next few days. That is probably ok. After watching carefully for a couple of weeks, I have figured out how to change gears, so I think that I can drive the tukk tukk, but I'm not sure that they will give me permission. I hope we don't run out of food.

The Beach

The beach in Mullaitivu is about 7 km from where we are located, with our MSF house and nearby local general hospital. We are, by reports, pretty close to where the war essentially ended in April and May of 2009. The Tamils, along with their families, were driven by a much greater army force to the waters edge. About 30,000 men, women and children, were killed in the final days. In fact, it was probably many more. Some sort of a rapid fire artillery was used, and it cut the tops off of the palm trees as the shells ripped through the air. Now one can see huge, palm tree trunks, that reach for the sky. No leaves are left on these trees. They stand like tall sticks, as stark reminders to the recent battles. I'm not sure how big our district actually is. But there are over 200,000 Sri Lankan Army soldiers still here. Most are pretty young, and most do not speak Tamil. I try to smile at them, as I believe that many of them were not in the army during the war. They will actually smile back, and sometimes, when we are at a checkpoint, they will come up to me and try out their English.

Point Pedro

This last weekend I had the opportunity to visit another MSF hospital in Point Pedro. MSF has had a hospital there since 1986, with a small break in there somewhere. The hospital is being handed over to the Ministry of Health this summer, and MSF will extract itself. We will continue in Mullaitivu, however, until more support and capacity to handle the ongoing increasing population is available. Point Pedro is nearly the most northern part of the island. It is roughly 110 km from Mullaitivu, yet it takes 3 to 4 hours to make the trip. The hospital in Point Pedro is very nice, and seems to run relatively well. It is very busy. The outpatient clinics see about 450 people per day, and the OR, there is only one, stays busy as well. The gardens surrounding the wards were beautifully tended, and there is a spectacular Hindu temple at the center of the grounds. In fact, the priest was there for part of the day, and I had the chance to see him. He was bare chested, and wore a special sarong. Looked like a pretty nice guy.

White People

People who live near the equator tend to be dark skinned. This reduces the damage done to the skin by the sun. People who live in the northern latitudes have lighter skin, to absorb some of the rarified sunlight needed to convert vitamin D to a useable format. I'm from 43 degrees north latitude, roughly. I am currently near 6 or 7 degrees north latitude. I am noticeably white, while nearly everyone else is really dark. There seems to be a tendency to think that people of a different persuasion all look alike. You know, all Chinese people look a like, all Mexicans look alike, all Lutherans look alike.

Since I have arrived, I have been mistaken for Anderson Cooper, and just yesterday, I was told that I look like Clint Eastwood. I hope that was in his younger days. I have always liked Josie Wales. But you know us white people, we all just look alike.

Nescafe

There is a noticeable lack of brewed coffee in Sri Lanka. In fact, I'm not sure that I have seen or had a cup of coffee other than when a new expat comes and brings some. We lucked out a couple of weeks ago when someone generously brought some fine coffee from Italy. We were in heaven. But the box was small and lasted only a few days. The small cups of coffee were tiny, espresso sized, to make sure that everyone who wanted some got a taste.

There is Nescafe, however. In fact, they don't call coffee 'coffee', but rather, Nescafe. It's like 'would you like a cup of Nescafe?'. Just thinking of the fine organic coffees that I'm used to makes my mouth water. Yergacheffe from Ethiopa, here I am. Organic Driftless Morning, don't forget about me. Bike Fuel, I can see your label in my mind.

We are in the land of tea, and I do love tea. I drink it every day pretending it is a rich cup of coffee.

The Milkman

Nearly everyday the milkman comes. He is a pleasant, smiling man on a small moped. The moped is loaded with containers of fresh milk. Stopping at each house, the moped is parked, and he pours milk into the jug that is offered as the container. There appears to be a variety of milks offered, but I'm not sure exactly which. I suspect that there is cow's milk and goat's milk. There is no chocolate or strawberry milk. I do know that the buffalo milk that we make the curd from is being bought by our cook in this picture. Talk about local. The milk is not refrigerated, as no one has refrigerators here, unless you are MSF, and we have two small ones. There is no pasteurization, per se. The milk is fresh from the source.

The Market

The vegetable market near our MSF house in Mullaitivu.

At the Office

Here I am in one of my offices, with the waiting room seemingly converging on me. The kneeling guy in the blue shirt is my translator. The patient is a young boy in the orange shirt.

Ich habe kein Geld

Yesterday, on Friday the 8th, a small team of us travelled to Point Pedro, in the very north of the country. There has been a hospital here that has been managed by MSF since 1986. They are in the process of gradually handing the hospital over to the Ministry of Health (MOH.) That is likely to occur in August. We were welcomed to the MSF facilities with open arms and a great meal. We were here to look over the operating theater, and their post-op wards, to get some good ideas for the facilities in Mullaitivu. To help celebrate, a couple of us went to buy some gin. It was a good night for gin and tonics. While shopping at the local hooch store, we found some gin, but no tonic. We did find a lime, club soda and 7Up at an adjacent little shop. While standing there admiring the shop, a local Tamil man came up to me and asked, 'Sprechen Sie Deutsch?' Boy, was that a surprise. I must really look like a teutonic white person. The only thing that would have been more surprising would have been the same question, except in Norwegian. Anyway, I was thrilled to understand a language coming from a Tamil, so I answered in my best Hochdeutsch, 'Ja, Ich kann Deutsch sprechen.' It turns out that he was a multilingual beggar, and kept asking for money, stating that he has none. 'Ich habe kein Geld.' The driver from MSF quickly hustled me away before I was tempted to give over a few rupees, the whole time telling this man to leave us be. I can only imagine that there was some rich Germans in the area some time in the past. They must have been white, and looked like me.

Marcel Marceau

One of the concerns after a war, especially a bloody, long fought civil war, are the mines that remain. Some armies use GPS localization when placing mines, so that they know where they are. Sometimes a retreating army places as many mines as possible with apparently no way to find them. These are very difficult to manage, and are very dangerous. Many of the injuries that we see are due to mine injuries. Luckily, there are several international NGO's who specialize in clearing mines. We get an updated map regularly of the areas that remain dangerous and the areas that are clear. As I was returning from a mobile clinic site the other day, there was a sign posted in an area that clearing was taking place. It said, in its best broken English, 'Caution, Mimes.' I looked over the field, hoping to see some people pulling on an unseen rope, or trying to escape the invisible box. Not so lucky. No one was there.

A Surgical Starting Anew

The current war here inded in 2009. I have been assessing the Internally Displaced Peoples, which is a euphemism for refugees. We have set up clinics throughout the area, where people line up for medical care. Most are there for cold, pneumonias, fevers and the like. Others come to see me, the surgeon. I have been seeing wounds from a war that ended two years ago. Wounds that have healed, some well, some poorly. Most have left large scars on the body, and larger, unhealed wounds on the mind. There are pieces of the war that remain in these bodies. Shrapnel and shell fragments. Most of these are in places where they could remain. In fact, taking them out risks further injury. However, these patients, mostly young women, in fact, want any remaining shell fragment removed. Even when I tell them that it is dangerous, and could cause further pain or scarring, they want them out. I actually feel that they want this war removed from them, and by taking out the shell fragments, we will start to heal the wounds that are unseen. I hope we can do this. The surgical removal of a war is not something that is commonly taught, and I'm sure that it is never complete, despite our heroic efforts. We can only hope to start the healing.