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.

Ornithoptery

One of the interesting things about being in a strange land, is the strangeness of flora and fauna. Would that I had the lepidoptery experience of Nabokov. The butterflies here are magnificent. They have colors that we don't have words for, and sizes that range from tiny to nearly bird-like. That description also goes with the general description of the other insect life which abounds here, and sometimes scares the religion out of you. And the birds. They are magnificent. Colors and sizes that range from very small to very large. The bird calls are very strange to a westerners ear. I am often wondering if a sound is coming from a bird, a band of monkeys, a lost elephant, or the local ice cream man. Thus, my ornithology is a bit lacking, and Sir Audobon is nowhere near to help. I have thought about learning both about butterflies and birds. I would call myself an Ornithopterist. My friend, Frank Herbert, would understand.

Soup

Part of the adventure in visiting and working in a foreign land is testing and tasting the local cuisine. Our cooks are local Tamil women, who are trying very hard to feed and please us. They have tried frying potatoes, because someone asked for that. They have tried making pasta, because someone asked for that, as well. The potatoes were not bad, but the pasta was a solid, gooey mess. Our visiting Italian pharmacist spent a day with them teaching them to make pasta as best she could without the ingredients that she was used to. It tasted great, and was not a gooey mess. We told the cooks, cook what you know. Don't worry about what the ex-pats are asking for, but rather cook like you would for your own family. We would love to try your curries, and learn about your local food culture. Yesterday, gracing our otherwise meager table, was a big pot of squid soup. The squid, by the way, were whole. Not even cut up into smaller unrecognizable pieces, but big and tentacled. I think that we got what we asked for.

Losing

The Cricket World Cup is over, and Sri Lanka got beat by a very good Indian team. It would have a been a great win, but even in losing, it was a great ride. The people are very proud of their team. During the game, there were white sheets hung between trees, and a makeshift projector and a loudspeaker system was set up so people could see the match. There were soldiers watching, mixed in and among the local Tamil people. Maybe the national pride felt by a broken nation will be part of the first steps at recovery.

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I would say that I have at least put on several hundred miles visiting areas throughout the Mullaitivu district. I have been on the best roads that they have, which optimistically are cattle paths, and more pessimistically, barely goat paths. They are rough and eat vehicles for lunch. There are other NGO's here, but not medical NGO's. Demining operations, primarily, by several international groups. What is the vehicle used by us at MSF and these other NGO's I ask. It is, of course, the Toyota LandCruiser, or the Toyota HiLux small truck. If you pay attention to the news, the HiLux is also the chosen truck of the Taliban in Afganistan, and of the resistance fighters in Libya. So you know it must be tough.

The Indian Ocean

This afternoon, our team got into one of the MSF vans, and went to the beach. This was the beach adjacent to the town of Mullaitivu, about 7 km from our house. In 2004, the tsunami that hit Asia, also hit Sri Lanka, but we didn't really hear about it here. About 30,000 people were killed, and the town was pretty much wiped out. The rebuilding efforts have been minimal, as this was also the area where the most recent war ended. It seems that if the buildings weren't destroyed in the tsunami, they were destroyed in the final battles. An interesting building rises out of the ruins and sand. It is church-like, but is not a church, rather a memorial to people who died in the tsunami. Apparently the memorial was at least in part funded by a church in Michigan. Each of the pillars is lined with the names of the dead, written in the Tamil language. There is a beautiful metal sculpture of a woman holding her head with her hands as a wave comes up to her.

Saying Goodbye to Sam

Our Project Coordinator, Sam, left today. He has spent the last several days handing over the mission. The final hand-offs were today. We waited and watched and sadly helped him get into the vehicle to start the long journey home. I have only known him for a short time, but he has been and will continue to be an inspiration. He never let the mission be diluted by the political situation, but was always able to see what was best in the long term. He leaves us to go to his homeland in Liberia. He will have his hands full there, just as he did here. He is a good man, and I will miss his leadership, and his company.

2009

The war here ended in 2009. The most recent battles took place from 2006 to 2009. At the end of war, the Tamil people became refugees. The Sri Lankan government set up a camp called Menik Farm. It is essentially a concentration camp. In 2009, it held just under 300,000 people. Those people are now being resettled into the Mullaitivu district. We are carrying out assessments on these people. Yesterday, I made my first visit to a relocation camp. I used to feel that I knew or had seen people that had nothing. But now I know what nothing is. The scene is unbelievable. Tents have been donated for the people to live in. They are in small camps. I think some of them didn't want to leave Menik Farm, because they knew what they had there. The government pats itself on the back, saying that it is closing the Menik Farm camp, but what is really happening is that the people are just being moved to a different camp. The despair is nearly overwhelming.