Sri Lanka 17 years of humanitarian actions

Report

Released by Médecins Sans Frontières in june 2003

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Sri Lanka :17 years ofhumanitarianactions

the french section ofMédecins Sans Frontièresclose all its projectsin Sri Lanka.

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With the hope of lasting peace, the situationis slowly changing in the northern and eas-tern areas of Sri Lanka. The health system inthese former zones of conflict is being resto-red and doctors and nurses are returning totake up long vacant positions. After sufferingthe consequences of the conflict, the popula-tions are also returning to their villages inthe hope of building a new life.

Outside the zones of conflict, the Sri-Lankanhealth system has always been highly develo-ped and effective, with competent staff. Mostimportantly the health system is free of char-ge and therefore accessible to the poorestmembers of society. What could be betterthan applying this system throughout SriLanka, to all Sri-Lankans? The reasons forMSF’s presence in the areas isolated by theconflict no longer exist. MSF France has the-refore decided to close its programmes by theend of June 2003 but MSF Holland continuesto support the obstetrical and gynaecologicalservices in the hospital of Puthukkudiyiruppu.MSF-Holland is also training the hospitalvolunteers there. A new programme in thehospital of Mullaitivu will start soon. InVavuniya, near the former front-line, MSF-Holland is running a community-basedpsychosocial project focusing on war trauma.

This document was inspired by a simpleidea: how to mark the end of our missionsafter 17 years in this unique region of theworld.We wanted to put something down in writ-ting and to thank those who were there andcontributed to the programmes.But we also wanted to share the experiencewith those who did not necessarily partici-pate.So we decided to set about gathering theexperiences and memories of those whowere in Sri Lanka, as a way of helping othersto understand what it was like. There are no analyses, no comments, no cri-ticisms… We have compiled this account offacts and emotions experienced by all thoseworking in Sri Lanka and have publishedwithout commentaries.We would like to thank all those who contri-buted to this document, near or far, directlyand indirectly.Many thanks to all institutional donors whohelp to finance the mission.

Our apologies to those who we were unableto include, because of time or distance.We also apologise to any of the national staffand volunteers whose names may have beenforgotten at the end of the document.

We would particularly like to thank thenational professionals without whom our 17 years of work would not have been pos-sible.

contents

Background & context page 3

17 years of MSF programmes page 5

Trincomalee page 6

Jaffna & Point Pedro page 8

Batticaloa page 11

Vavaniya page 17

Madhu page 18

Personnal memories page 20

Human resources page 25

Thanks page 26

Photos :Front and back pages : D. Lefèvre - P. 3 : D. Lefèvre- P. 4 : E. Bouvet - P.5 : D. Lefèvre - P. 6 : Y. deFareins - P. 7 : D. Lefèvre, MSF - P. 8 : MSF - P. 9 : D.Lefèvre, MSF - P.10 : MSF, D. Lefèvre - P. 11 : D.Lefèvre, S. Crisan/MSF - P. 12 : MSF - P. 13 : G.Myers/MSF, MSF - P. 14 : MSF, S. Crisan/MSF - P. 15 :MSF - P. 16 : MSF, Y. de Fareins - P. 17 : MSF - P. 18 :C. Perera/Gamma - P. 19 : D. Lefèvre - P. 20 : MSF -P. 21 : MSF - P. 22 : E. Bouvet - P. 23 : MSF - P. 24 :MSF.

Rédacteur en chef: Anne FouchardRédaction: Isabelle FerryCo-rédaction: Remi Vallet Graphisme et fabrication: TC graphite Réalisation: juin 2003Translation: C. Serraf, L. Brumer, D. Chanley

Many thanks to evryone who contribuated to thisbrochure: Arnaud L., Anouck S., Anoulack P.,Diana T., Guillermo B., Karine P., Kate D., Sean H.,Stéphanie P. and especially Chris B. et Yves C.

Front page: Patients waiting for consulta-tions. Trincomalee hospital.1997.

Back page: Tamil family waiting for theSLA to release their sons. Point Pedro 1997.

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Facts and figures

Official name:

Democratic SocialistRepublic of Sri Lanka

> Land area: 65,610 sqkm. 1,340 km of coastline

> Capital city: Colombo

> National holiday:4th February (celebra-ting the country’s inde-pendence in 1948)

> Population: 19 576 783

> Sinhalese: 74%Tamils: 18%,Moor: 7%other: Burgher, Vedda,Malay: 1%

> Religions:Buddhist: 70%Hindu: 15%Muslim: 7%Christian: 7%.

Welcome to Paradise !

Sri Lanka, surrounded by the IndianOcean, is an island paradise just 50 km offthe coast of India. Marco Polo once said ofthis island, 430 km long and 225 km wide,that it was the most pleasant island of itssize. All the guidebooks acclaim the treasu-res of this island the size of Ireland: thefine architecture, archaeological treasures,mysterious traditional dances, sandy bea-ches lined with palm trees, tea plantationsas far as the eye can see, topical forests, anabundance of wild fauna, and above all, thefriendly and welcoming people. Twentyyears of civil war have not put off holiday-makers: in 2000, when clashes between thearmy and Tamil rebels claimed 4000 lives,the island’s southern beaches were visitedby over 400,000 overseas tourists.

A COVETED ISLANDThe natural beauty and riches of Sri Lankahave long been coveted. Under Indianinfluence between the 14th and 16th cen-turies, the island later became aPortuguese colony in the 16th century. Itthen fell into the hands of the Dutch in the17th century before coming under Britishcontrol in 1796, which lasted 152 years. In1948, the island of Ceylon finally gainedits independence, but it was not until 1972that the island was renamed Sri Lankaunder the new constitution.

This new constitution, which madeBuddhism the national religion, stirredtensions between the Sinhalese communi-ty (mainly Buddhist) and the Tamils(mostly Hindu). Although the Tamils heldmost of the administrative positions under

the British, after independence they weremarginalized. In 1956, Sinhalese was pro-claimed the country’s sole official languagecausing anger amongst the Tamil commu-nity. In 1972, the rebellion army, the TamilNew Tigers (TNT) was founded byVellupillai Prabhakaran, who later formedthe Liberation Tigers of Tamil Eelam(LTTE) in 1976. These movements calledfor an independent constitution for theprovinces of the north and east of SriLanka. Violent confrontations began, trig-gered notably with the TNT assassinatingthe mayor of Jaffna, a town in the heart ofthe Tamil peninsula in the country’s north.

However, it was not until 1983 that thecivil war really began. Thirteen Sri Lankanarmy soldiers were killed in an LTTEambush. Riots broke out at the soldiers’funeral in the capital Colombo and 3000Tamils were killed, meanwhile in thenorth the army launched massive retalia-tion strikes around Jaffna. 20 years ofconflict have left more than 60,000 deadand hundreds of thousands of people refu-gees or missing.

HOPE OF PEACEAfter three failed rounds of peace negotia-tions, the current talks seem to be promi-sing. In February 2002, the government(whose president Chandrika Kumaratungais from the People’s Alliance and whoseprime minister Ranil Wickremasinghe isfrom the opposing United National Party)signed a permanent ceasefire with theTamil Tigers which paved the way for newpeace talks. Since then further steps

toward peace have followed. Air and roadlinks between the Jaffna peninsula and therest of the island have been reopened. Thedisarmament process has begun and thetwo sides have exchanged prisoners ofwar. On a political level, the Tamil Tigershave abandoned their claim for an inde-pendent state, and the government accep-ted, in an agreement signed in December2002, the principle of autonomy in thenorthern and eastern regions. New roundsof talks were due to take place in Japan on9th– 10th of June. But LTTE decided toboycott them. Although tensions still sub-sist, hope has returned to Sri Lanka.

> 1972New constitution.Buddhism becomes theState religion. Birth ofthe Tamil New Tigers(TNT), Tamil armedrebel movement.

> 1976 The TNT becomes theLTTE (Liberation Tigersof Tamil Eelam).

> 1982Tamil party boycottspresidential elections.

> 1983Civil war begins.

> 1985 First peace negotiationscollapse.

> 1987Armed military offensive. The LTTEretreats to the Jaffnapeninsula. Deploymentof an Indian peacekee-ping force.

> 1987-1990Repeated LTTE attacksagainst Indian soldiers.The latter take revengeon the civilian popula-tion.

> 1990 Retreat of Indian troops.

> 1991LTTE assassinates RajivGandhi, the Indianprime minister.s

> 1993The President,Premadasa, is killed bya bomb.

> 1994 Chandrika Kumaratunga,elected president,re-opens peace negotia-tions.

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Since 1986 Médecins Sans Frontières hasbeen working in Sri Lanka pursuing thesame objective: providing assistance topopulations directly victim of or isolated bythe conflict, while denouncing violations ofhuman rights and humanitarian rights.

With these principles in mind, MSF set uptwo types of programmes. The first setabout to help existing health facilities toensure essential services were provided inthe large hospitals situated in the zones ofconflict. Surgery was the main activity inthis civil war context: over the 17 years,nearly 260 expatriate surgeons have wor-ked in the operating theatres of Sri Lanka.The second type of programme involvedsetting up mobile clinics to provide the iso-lated population with access to care.

ON BOTH SIDES OF THE FRONT LINEMSF set up missions both in towns undergovernment control and in zones held bythe LTTE. We worked in public hospitals(some in the hands of the governmentothers controlled by the Tigers – likeTrincomalee, Point Pedro, Jaffna andBatticaloa) to help make up for the lack ofTamil specialist doctors (many of whomhad chosen exile to flee the conflict) aswell as a lack of material resources. MSFprovided surgeons, anaesthetists, mid-wives, nurses, and even paediatricians,gynaecologists, obstetricians, in additionto the usual administrators and techni-cians. We used our status as an internatio-nal non-governmental organisation toconvince the ministry of health to allocatethe resources needed, and the ministry ofdefence to allow us access to the regionsaffected by conflict.

In the zones under LTTE control and theso-called “grey zones” (those controlledby the army but with pockets of LTTEresistance) MSF endeavoured to provideaccess to care for people in vulnerablesituations, including many displaced peo-ple. At Madhu and in the entire Jaffnapeninsula, as well as around Batticaloa, weprovided food and medical assistance, andset up epidemiological prevention pro-grammes and vaccination campaigns.

Finally, making the most of our presenceon both sides of the frontline, MSFtransported many patients in need ofemergency medical care to appropriatefacilities.

Again, our status as and an independentNGO often enabled us to get past check-points and zones of fighting which pre-vented patients from getting to hospital.

Médecins Sans Frontières in Sri Lanka War Timeline

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War Timeline

> 1995Peace negotiations fail,LTTE renews bombattacks. Army launchmilitary offensive in thenorth: LTTE troops leaveJaffna.

> 1996Bomb explodes inColombo. Nationwidestate of emergencydeclared.

> 1997Major new militaryoffensive against theLTTE.

> 1999Wounded in an attack,Chandrika Kumaratungais re-elected president.

> 2000Tigers make newbreacktrough.

> Décembre 2001New government.

> Février 2002 Cease-fire signed, a pre-requisite for peace-negotiations. Norwayacts as mediator.

> Septembre 2002 1st round of negotiationsin Thailand. Road andair liaisons are re-opened betweenJaffna peninsula andthe rest of Sri Lanka.

> Juin 2003Negotiations are due tobe held in Japan as wellas a meeting with donorcountries for the recons-truction of Sri Lanka.LTTE boycott.

1988 the majority of doctors in the north andeast of Sri Lanka leave the country to esca-pe the fighting. 50 MSF surgeons, and asmany anaesthetists, work in turns in thefour hospitals in war zones: Trincomalee,Mannar, Point Pedro and Batticaloa. Firstmobile clinics in Batticaloa.

1989-1991brief period of calm, then renewed fightingresulting in a flood of wounded arriving inPoint Pedro. Seven missions in total,including four surgical. First mobile cli-nics in Mannar.

1992-1994 in the IDP camp in Madhu, four people per-form minor surgery and evacuate patientsthat require more complex surgery. Newsurgery and obstetrics programme inKilinochchi (October 94). First mobile cli-nics in Madhu.

1995-1997 violence escalates. It becomes more andmore difficult to provide assistance to thecivilian population. ‘Strategic’ drugs(anaesthetics, analgesics) and medicalmaterials must be submitted for authorisa-tion before being transported to conflictareas. In Kilinochchi, an LTTE town, thegovernment refuses us authorisation toopen a surgical programme. The fightingaround Jaffna pushes the populationstowards the east: Point Pedro hospitalbecomes the only accessible surgical

hospital. Batticaloa carries out 3,400 ope-rations a year (of which 20% war surgery).In Vavuniya, a team covers the surgicaland anaesthetic needs (2,200 operations ayear). In 1996 Jaffna hospital is partiallydestroyed. One year later, MSF obtainsauthorisation to work there and carriesout over 8,500 surgical operations.

1998-2000 Supplying drugs and materials remainsdifficult. Activities are set up to improvesurgery conditions (hygiene, asepsis, steri-lisation, post-operative care etc.). At theend of 1999 emergency interventionsincrease, MSF therefore increases it teams.After the bombing of Madhu church, MSFre-opens its surgical activities in Vavuniya.In Batticaloa, surgery conditions improvewith the renovation of the operating thea-tres and the burn victims ward in the surgical department. In 2000, 13,354patients were admitted for surgery: 5000 operations were carried out, inclu-ding 1,200 major operations (one out offive for war injuries). In January 2000,MSF re-opens its activities in Point Pedro.A further surgeon and anaesthetist aresent.

2001-2002 The effort put into improving workingconditions and the case management ofpatients begin to show. In Batticaloa a painmanagement programme is set up formajor burn victims and patients in post-operative care. Specialised surgeons(orthopaedic surgeons, plastic surgeons)

are sent on short-term missions. In 2001,of the 24,067 patients admitted to thethree surgical wards of Batticaloa,Vavuniya and Point Pedro, 8,900 wereoperated, including 2.5% war wounded(far less than previous years).

2003 With the hope of lasting peace, the healthfacilities of the north and east of the islandare functioning relatively well again. Thewar surgery programmes are no longer jus-tified. Médecins Sans Frontières is closingits programmes and leaving the country.

17 years of MSF programmes in a country at war

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In the beginning, there was Trinco

After an initial evaluation mission in 1983(which did not lead to an intervention),MSF first began working in Sri Lanka in1987 with a surgical programme in theeastern town of Trincomalee.

Below are extracts from Messages SansFrontières at the time.

MESSAGES NO. 4 - SEPTEMBER 1986Françoise Body and Antoine Crouanrecently went on an evaluation missionfollowing the deteriorating situation in thenorthern and eastern areas of Sri Lanka.The conflict has divided the two ethniccommunities; the Singhalese (12 million)and the Tamils (3 million). Tamil guerrillaarmies have been operating in the northand east of the country since 1982,demanding full independence for this partof the island: violent clashes have conti-nued since. MSF had sent a team to Sri Lanka in 1983to evaluate the medical needs of a group ofdisplaced Tamils in the north of the coun-try. At the time, several Ceylonese organi-sations were providing assistance to thepopulation there: MSF was not present.The current situation means it is difficultfor the civilian population to move aboutthe country, isolating them. MSF has the-refore sent an evaluation mission to thedistrict of Trincomalee in eastern SriLanka.Of the 250,000 inhabitants in this district,50,000 are internally displaced people.Several villages have been destroyed bothby resistance movements and by govern-ment forces. Like Jaffna and Batticaloa, the

zone of Trincomalee is off limits to forei-gners. Following our evaluation mission,the ministries of Health and Rehabilitationhave offered to collaborate with us on anassistance programme for the displacedpeople around Tincomalee. A surgicalteam could work in the hospital and ano-ther team could work in the camps andisolated villages. The board has acceptedthis new programme and we have begunsetting up a surgical team.

MESSAGES NO. 6 - 31 OCTOBER 1986 A new programme has just been opened inSri Lanka. An evaluation mission wasconducted in August 1986 in the northand eastern zones of the island whereTamil guerrilla forces are fighting govern-ment forces.The minister of health has accepted amedical-surgical assistance programme forthe displaced civilian population in thedistrict of Tincomalee in the northeast ofSri Lanka.The programme is currently being set up.Joaquim Miro and Anne-FrançoiseBasquin are heading the coordinationteam. A surgical team should soon join thefirst medical team. This surgical team willwork in the district hospital, which is theonly reference facility for the populationof 250,000 people.The violence is intensifying in this strate-gic region.

MESSAGES NO. 10 - FEBRUARY 1987Médecins Sans Frontières is sending morevolunteers. Nine people are now working

permanently in the Trincomalee district.Alain Rouvillois has replaced the formercoordinator Joaquim Miro. An ophthalmo-logist will soon join the surgical team. Theconflict seems to have intensified over thepast few weeks. We are currently lookingat the possibility of setting up a mission inanother district of Sri Lanka.

MESSAGES NO. 12 - APRIL 1987On Friday 17 April, 10 km fromTrincomalee in the northeast of the island,an armed group massacred 120 people andleft around 50 injured. The Médecins SansFrontières team operated on the injuredfor 48 hours non-stop.

PersonalMemories

“I spent around a year inTrinco. The anaesthetistscalled it the ‘Club Med’ mis-sion where they particularlyenjoyed the ‘anaesthetist’sbeach’.Joking aside, a few daysafter I arrived two membersof the house staff werearrested by the army in amorning raid after a publicdenunciation of Tamil sup-porters in the town centre.For several weeks I met withthe military chief in thezone, asking to visit andtalk to our arrested staff. I wanted to be sure theywere not being treatedbadly and had not beendeported to another camp.The day they were bothreleased, the entire MSFhouse in Trinco celebrated.

That same year our ambu-lance was attacked by thearmy on the road toMadhu. The teams werevery shaken and our pro-grammes were disrupted.We remained on stand-byfor about three weeks, tur-ning things over in ourminds and discussing ourmotivation behind workingwith MSF and at what pointthe risks become too great.”

Ariane Betz, anaesthetistnurse in Trinco, and thenMonaregala, from March1991 to May 1992.

“I remember a bomb that exploded at the Trinco mar-ket in the middle of summer, 1989. It was devastating;the mutilated bodies, the injured taken to hospital.The horror… We were worried that some of the teammight have been caught in the explosion.”

Anne-Marie Gloaguen, nurse in Trinco from February to August 1989.

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Elisabeth Szumilin, now doctor with themedical department at headquarters in Paris,describes her second mission with MSF. Itwas in 1987-1988 in Trincomalee…

I have very good memories of Sri Lanka. Itwas my best mission.Although hard to believe, for 15 months I got up at 5.30am every morning, to getthe 6am boat. I don’t think we (Gigi, thenurse and I) ever missed that boat. I suspect that the captain may havedelayed the departure a bit if he didn’t seeus at six o’clock sharp half asleep at thefront of the boat: what had become ‘our’spot (inside the smell of diesel could makeeven a Parisian throw up).

As soon as the villagers realized that theycould count on us at the time we hadarranged, they used to come. Sometimesthere were so many of them we could onlytreat the most urgent cases.I was terrified that I may have to ‘operate’in the jungle. In the evening, or at night,after work, we would go and help the sur-gical team ‘hold the retractors’. I wanted tolearn in case I came across an emergencyin an isolated zone. The surgical team wasgreat. I learnt a lot from them.One day the Tigers attacked Trincomalee.My superiors forbade me to return! I stillhaven’t forgiven them !!! So I ended upstaying longer. As I was convinced thatthere were still many needs in the area, Iset out on another evaluation mission, ona bicycle (because of the remote controlledmines. It was safe on a bicycle, unlesssomeone really had it in for you). In thefirst village we visited, we urgently had to

evacuate two children: one was sufferingfrom severe de-hydration, the other hadpneumonia with respiratory distress – allthat on a bicycle … We finally re-startedworking, along the same lines as before.

MY LEAST PLEASANT SOUVENIRS? One day I was unable to save a mother’sfourth and last living son. He had attemp-ted suicide by swallowing poison. I stillask myself today if I could have donemore…. The anaesthetist was very sup-portive and spent a lot of time with meexplaining that I had done everything pos-sible.

After the army attacked a camp, the Tigers‘strongly encouraged’ us to come andphotograph the massacre: we saw onlywomen, children and elderly Tamils burntin their homes. We found ourselves in themiddle of the attack on the camp. Afterseveral hours, when the fighting had finis-hed, we came out of the house where wewere hiding and tried to go into the campto offer our help to any wounded military.They declined our help. But I still thinkthat it was thanks to these ‘small gestures’that we were authorized to access thezones outside government control andthus provide assistance to Tamil popula-tions who had no access to health carebecause they did not dare approach thecheckpoints.

WORKING ON BOTH SIDESThe neutrality of the teams I worked withis one of the reasons I have such good

memories of the mission. It meant that wewere accepted and respected by both par-ties and thus able to work.

The neutrality was not a hoax. For methere was no difference between a Tamilpatient and a Singhalese patient. I refusedto learn either of the languages! It wouldhave been seen as taking sides, or I wouldhave had to learn both languages simulta-neously!

To mark our neutrality, we also worked inSinghalese facilities and supplied themwith drugs. Despite the fact that they hadfar fewer needs, I carried out consultationswith them.The army knew we supplied medication tothe Tamils. I used to hand them to oneperson only, always the same: a secondyear medical student who had joined theTigers. The young man was killed. One ofour young civilian volunteers was alsokilled, and many others besides: the chiefof the Singhalese military, who we werevery fond of, was killed in a suicide attackin Colombo. He was curious about us,about our culture….

My best mission

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From top to buttom:- Elisabeth Szumilin (doctor) andMaster Léo (her translator) in consul-tation. Trincomalee district. 1987.- Hospital ward.- Queueing for consultations. Mobileclinics .Trincomalee. 1987.

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Jaffna and Point Pedro, in the heart of the peninsula

Jaffna peninsula, home of the Tamil Tigers,lies off the north of Sri Lanka. Its formerpopulation of 1 million inhabitants has hal-ved to 500,000 as a result of the conflict.The peninsula is linked to the rest of SriLanka by two bridges which were often clo-sed during periods of fighting. As it wastherefore rarely accessible by road, theMSF teams used to take the ICRC boatfrom Trincomalee. Army blockades com-pounded the difficulty of getting supplies tothe peninsula. This isolated zone whereMédecins Sans Frontières first set up a sur-gical programme in 1987 in Manthikaihospital, Point Pedro, was under constanttension. The difficulties encountered inproviding assistance were numerous.

The population of Jaffna has been displa-ced many times and the peninsula’s infras-tructure, particularly the health facilities,have suffered from the escalating violence.The conflicts began between various Tamilmovements from 1983 to 1992, then flaredup between the LTTE and the Indian pea-cekeeping force between 1987 and 1990,and later shifted to the LTTE and the SriLankan army from 1990 until 2001.Nearly 160,000 people have been displa-ced within the zone during the variousconflicts. The entire population has beenisolated from the rest of the island with nopossibility of leaving the peninsula byland.

A BLOODY SUMMERFrom 1992 to October 1995, the Jaffnapeninsula remained under LTTE control.

In the summer of 1995, the army launcheda major military operation called “bond enavant” to regain control of the peninsula.The town of Jaffna was the first to fall.Within a few weeks, hundreds of peopledied in the offensive, many of them civi-lians. The Sri Lankan army seemed to betrying to crush the Tamil army forces toforce their leaders back to the negotiatingtable, rather than simply trying to conquerthe LTTE stronghold. Sadly many civilianspaid for the fighting with their lives. InSeptember 1995, a flood of casualties arri-ved at the hospital in Point Pedro wherethe MSF team was working. Fourteenpatients with serious injuries were admit-ted on 21 September. Among them, fourchildren died from their injuries. The nextday the situation deteriorated even more,and 25 more injured arrived, mostlywomen and children. Ten of them died,including six children under the age often. By 4 o’clock that afternoon, 150 chil-dren had been hospitalised after theirschool was bombed. Fifteen of them laterdied.

It was not until May 1996 that the armyfinally managed to take control of most ofthe island, forcing the Tigers to retreat.Jaffna hospital was partially destroyed inthe battle of the town. It had been thesecond biggest university hospital in SriLanka with more than a thousand beds.In June 1996, one year after the embargothat paralysed the population and itshealth facilities had been lifted, basic food,medicines and other medical equipmentwere still in short supply. The strictcontrol held by the Ministry of Defence

still made the delivery of supplies very dif-ficult. Jaffna hospital was back in servicewith 600 beds, but most of the wards werestill in need of specialist doctors. MSFstepped in at the request of the Sri LankanMinistry of Health, and provided thehuman resources needed in general surge-ry, paediatrics and obstetrics-gynaecology.

A FRAGILE RECONSTRUCTION PROCESSIn 1997, the reconstruction process on thepeninsula was under way and nearly50,000 people were able to return to theregion. MSF sent another surgeon andpaediatrician to join its team in Jaffnahospital, and began reconstruction of partof the hospital despite the ongoing diffi-culties with supplies. But the Sri Lankangovernment soon found the money nee-ded to make the public services functionagain. After ten years, MSF finally closedits surgery programmes in Jaffna and PointPedro hospitals. MSF continued its paedia-trics programme in Jaffna hospital, whichhad just restarted after the negative resultsof an evaluation of the premature infantsand intensive care wards.

In January 1998, local elections were sup-posed to end military rule, paving the wayfor some kind of democracy. But thistransition was soon compromised whenthe mayor of Jaffna was assassinated inMay the same year. For the first threemonths of the year, the situation remainedunstable, but the violence soon spiralled.From December 1999 the sector known asElephant Pass was the scene of violent

PersonalMemories

Opening of Point Pedro

The escalating fighting onJaffna peninsula in northernSri Lanka has resulted in a massive and prolongedflood of casualties admittedto the hospitals of thisregion, as well as largedisplacements of population.A medical-surgical teammade up of 9 MSF volunteers (surgeons, doc-tors and nurses) left on 2 June. The government hasofficially authorised MSF to work in Point Pedro. The various parties seem towelcome our presence.

Messages Sans Frontières,12 June 1987

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Facts and figuresJaffna ProgrammeSurgical, paediatric and obstetrics assistance

> Opened in March 1997

> Closed in March 2003

> Population covered:500,000

> MSF staff 2002:3 (2 paediatricians and 1 nurse)

> Local staff: 4

> University hospital inJaffna: Total number ofadmissions in paediatricsin 2002: 7,950

Point Pedro ProgrammeSurgical Assistance

> Initially opened: 1987

> Temporary closure: 1997

> Reopened: 1999

> Population covered:100,000

> MSF staff (2002):4 (1 surgeon, 1 anaesthe-tist, 1 gynaecologist-obs-tetrician, 1 nurse)

> Local Staff: 3

clashes between the LTTE and the army.Given the threat of heavy fighting andlarge movements of troops, 150,000 civi-lians were left with no choice but to fleetheir homes. MSF reopened its surgeryprogramme in Point Pedro hospital afterthe fighting began, sending a team andmuch needed emergency equipment. InJaffna, the mobile paediatric clinics, whichhad been set up at the beginning of themonth, were temporarily suspendedduring the fighting. The paediatrics wardat Jaffna hospital remained in operation,with a further paediatrician and mid-wifesent to join the staff already there.

TOWARDS LONG-LASTING PEACEIn 2001 the army decided to send thepopulation in the conquered territories

home. These precipitated forced displace-ments back to former zones of conflictresulted in many accidents caused by anti-personal land mines. The surgery depart-ment performed countless amputations oflower limbs. MSF began lobbying to stopthe army forcing the population to returnbefore proper mine clearance operationswere performed.

At the time, the situation was unstable andgunfire was still daily occurrence. But thesituation finally calmed, with no obviousfighting. It was not until December 2001that the situation became noticeably morecalm. The new government signed a cea-sefire put forward by the LTTE, and thistime the two parties respected the agree-ment. The following month, the govern-ment lifted the embargo on medical equip-

ment and medicines. Goods, and moreimportantly people, were free to moveabout again. Supplies were also made pos-sible in zones controlled by the LTTE.MSF was able to relaunch its mobile pae-diatric clinics from Jaffna in three areas ofthe peninsula: Kayts Island, Tellipalai andChankanai. The end of the embargo onmedical equipment enabled MSF to provi-de significantly more aid to the popula-tion.

The last programme MSF maintained onthe peninsula was the epidemiologicalmonitoring of the tens of thousands ofdisplaced people living in unsafe healthconditions in the camps of the region (inTenmarachchi, east of Jaffna nearVadamarachchi, and in the Weligamanzone). Owing to the concentration ofpopulation in certain zones, a sentinel sur-veillance system of the various IDP siteswas set up. Each week, the network ofmedical students went to the field to col-lect data in order to avoid the outbreak ofepidemics. At the same time, the teamsbegan looking into whether the peoplecould be moved to safer areas, in collabo-ration with the hygiene services and otherNGOs.In February 2002, the new governmentand the LTTE signed a definitive ceasefireagreement, and the peace process began.In December that year, MSF was able totransfer most of its activities to the hospi-tal’s authorities. In 2003, MSF continuedto provide a team of surgeons, as well assome drugs and medical equipment to thehospitals in Point Pedro and Jaffna, beforeleaving in May.

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Maria Cartwright did two missions withMSF in Sri Lanka. Her first was in 1998when she was field coordinator in Jaffna forten months. Her second was in 1999 whenshe was medical coordinator for fourmonths. Today, Maria is head of humanresources for MSF Australia in Sydney. Sheremembers her first mission on the penin-sula well.

In 1998, most of the Jaffna peninsula wasunder the control of government forces.But it was nevertheless impossible to getthere by road because the Tamil Tigersheld the northern part of the island. Theonly way to get there was by sea. We usedto leave from Colombo by car toTrincomalee, where we took the ICRCboat. It was an epic journey: our departu-re depended on the intensity of the figh-ting on the peninsula and the sea condi-tions, and we had to travel 50 km from thecoast to be out of reach of the firing. Thejourney to Kankesanturai (KKS) took 20hours, and when we got to the port it wasfilled with boat that had been bombed – a

clear sign that heavy fighting had takenplace. Once we reached KKS, the journeystill wasn’t over because we had to take theroad in a long convoy to the town ofJaffna. And security? I didn’t realise howdangerous it was until I got there. As soonas the boat left, the soldiers searched eve-rything, even the packets of tampons! Wehad a lot of trouble with certain medicinesbecause the transport agreements depen-ded on the Ministry of Defence. Once,when we wanted to take in ergometrine(to stop haemorrhaging), the authoritieswouldn’t let us because they didn’t wantthe Tigers to use it to treat their war woun-ded. And we always had problems brin-ging in anaesthetics and analgesics.

The town of Jaffna was always unsafe.That was also where I had the most dan-gerous experience of my time in Sri Lanka.One day, we were near a civilian buildingwhere a big meeting was being held bet-ween the mayor and the military leaders.The Tigers exploded a bomb there. Afterthe huge explosion, we went to the hospi-

tal to see if we could help. The UnitedNations told us two expatriates had beenkilled. We were devastated because all theexpats knew each other. We searched forthem throughout the hospital, even in themorgue.

When I got back to the emergency ward, Isaw the strangest thing in my life. I canhardly find the words to describe it. Therewere bodies lying on the ground. Then werealised the two expatriates were in fact sol-diers whose skin had been blown off and sothey looked like white men. It was awful.On the other hand, one of my best memo-ries was when we went to the islands west ofJaffna. It was the nicest evaluation missionI’ve ever done. After visiting the hospital inKayts to see if everything was working welland to evaluate the needs of the hospital, weleft for the islands where those seeking refu-ge in India stopped on their journey. Thepopulation seemed to be doing well and haddecent access to treatment. And those coralislands, the white sand, the palm trees… itwas like a post card. It was magnificent.

We had almost forgotten what it was like. Thesouth of the island featured in the tourist catalo-gues again. But the tourists will not be able toreach the north or east of the country. Lastspring, Tamil separatists broke the ceasefire sen-ding the country back into another spital of vio-lence. Then in July, army offensives halted thepeace negotiations. The government concentratedall its forces to regain control of Jaffna, the capi-tal of the Tiger rebellion. During the military advance, the population ofthe peninsula gradually decreased as severalthousands of people left in an exodus that wastoo well organised to have been spontaneous.

With no people left in Jaffna, the Singhalese armytook control of a deserted town. The lion on thenational flag now watches over a town abando-ned by the Tigers. A military victory for one side,but a political victory for the other.

Every day from mid-October, thousands of boatscrossed the lagoon separating the Jaffna peninsu-la from the rest of the country. The journey is freefor some, others have to pay – it all depends onthe “relationship” the family has with theLiberation Tamil Tigers of Eelam (LTTE) and withits “humanitarian” branch (TRO). Families lea-ving everything behind them except for a few

bags or suitcases are offered a cup of tea or soupwhen they arrive. Transport is then organised toKilinochi.

It is difficult for the various humanitarian organi-sations to evaluate the needs of the population.Out of the nearly 170,000 displaced people in thedistrict of Kilinochi, 148,000 people are stayingwith family or friends, 22,000 in schools, publicbuildings and various temples.

Valérie Brouchoud,field visit, communications department,Messages, January 1996.

Jaffna & Point Pedro

Almost getting used to peace

From top to buttom:

- Women waiting for their anti-natalconsultations, Point Pedro hospital.

- Point Pedro hospital.- Military checking the civilians paper

at the Check-point near the hospital.

Hell next to paradise

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Batticaloa, or Batti as it is often called, was inthe middle of an ‘uncleared’ area in easternSri Lanka. Already, 50km before the town,the military presence was clearly visible withever frequent checkpoints on the road linkingit to the rest of the island. Although the town,and the road that led to it, were controlled bythe army, the surrounding area was in thehands of the Tamils. Frequent fighting madeall travel and transport of goods extremelydifficult. The entire zone was blocked: as aresult thousands of people had no access tohealthcare, the clinics were closed, and to getto the only hospital still running people hadto obtain endless authorisations and then suc-ceed in getting through the various militarycheckpoints.

MSF opened its programme in the hospitalin 1987 and was the only foreign presenceuntil 1989. Right from the start, our pro-gramme was essential in order to providehealthcare to the population, but also tospeak out about the violation of humanita-rian law. We first started working in the sur-gical wards as almost all the surgeons hadfled the region: those that had remainedwere not able to cope with the influx ofwounded during emergencies. MSF therefo-re provided the hospital with help, essential-ly surgeons and paediatricians.In October 1990, given the escalating violen-ce which isolated the populations aroundBatticaloa even more and prevented themfrom having access to healthcare, MSF deci-ded to set up mobile teams. These teams hadto overcome numerous security problems:apart from the medical assistance theseteams provided in the isolated villages, ourvery presence was a comfort to these popu-

lations who could talk to us about their pro-blems, express their fears. Our visits weretherefore not only useful, we were also theonly foreign witnesses there. It was only in1997 that MSF increased its mobile teams, inclose collaboration with the Ministry ofHealth.

TO IMPROVE THE QUALITY HEALTH CAREFor many years MSF focused on war andemergency surgery: however in recent yearsit has concentrated on improving the condi-tions in which surgery is performed. Since1998, the objective has been to improve thehygiene and asepsis around surgery. Thecombination of MSF renovating the opera-ting theatre in 1999 and the governmentrenovating four or five surgical wards, has ledto improved hygiene conditions. This workcontinued through 2000 and 2001 withhospital waste management activities. MSFhas also worked with the nurses and doctorson the organisation of patient follow up. Theimprovement in surgery conditions meantMSF was able to send specialists (plastic sur-geons, orthopaedic surgeons) for specificcases the teams could not operate, but thatwe could follow-up. We thus introducedhand surgery and in 2000 improved the casemanagement of burn victims (of which thereare many in Batticaloa). Sri Lanka has one tothe highest suicide rates in the world, andself-immolation is frequent, leaving conside-rable sequelae. From the start, MSF began toimprove the case management of the burnpatients. In 2002 we helped burn victimswith a pain management programme, plasticsurgery and general case management.

Facts and figuresBatticaloa Programme

> Opened in 1987

> Closed in June 2003

> Population covered in theregion: 500,000 people,(two thirds are Tamils,one third Muslim).

Batticaloa Hospital

> 600 beds, including 165 for surgery

> 13,354 admissions in2000: 9,180 operationsbetween September 2000and September 2001,including 845 major surgery, 254 emergenciesand 50 war victims.

> International staff :4 permanent

> National staff: 11

Batticaloa, trapped in the east

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Batticaloa hospital

> June 1990 LTTE controls the entirezone

> 1992 Government troopsregain control ofBatticaloa as well asthe main towns androads. The LTTE forcesare entrenched in thejungle

> April 1995Renewed fighting – permanent tension inthe zone of Batticaloa

> 1996 – 1997 Military operations inthe region of Vanni (inthe West) have reper-cussions in the east.Security incidentsincrease.

> End of 1998 Regular attacks andfighting in the town.Waves of woundedarrive in the hospital.

> October 1999 The military authoritieslimit the mobile clinics;access to the popula-tions in LTTE zones isimpossible.

> December 1999 The mobile clinics startworking again. Thecoastal towns are veryunstable switching backand forth under govern-ment and LTTE control.

> 2000 Particularly violentyear. Bombs kill or injure civilians, regular-ly shooting. Frequent

12 twelve

Despite the population’s growing isolationcaused by the fighting, MSF’s mobile clinicstreated around 400,000 people in the dis-trict of Batticaloa. Set up in 1990, the teammade up of an expatriate doctor and nurse,a local doctor, a translator and a driver,travelled from village to village in bothLTTE and army controlled areas.Checkpoint after checkpoint, negotiationsafter negotiations, incident after unexpec-ted incident, made it extremely difficult forthe teams to reach the population. But theaccounts from these three women show therisk was worth it.

Adventures in the Batti bush

ELIZABETH BERGERON, NURSE INCHARGE OF THE MOBILE CLINICS –BATTICALOA, SEPTEMBER 1990 TOMARCH 1991“I have so many memories of the mobileclinics in Batti. Trying to build a good rela-tionship with the Singhalese authorities,meeting with the head of the LTTE toremind him of the rules: no weapons allo-wed in the medical facilities, and no uni-forms either, no pressure on the local staff,no misappropriation of medicines for trai-ning camps. Just basic diplomacy.Deciding where to go, protecting the localstaff, travelling daily from governmentcontrolled zones to LTTE controlled bushareas. Everyday we had to weigh up therisks. It was a huge responsibility.Without my driver, my contact at the mili-tary base, the willingness and the intelli-gence of the doctors and nurses from thehospital, none of this would have been

possible. I particularly remember threeincidents:- One day, all 25 years old that I was, I gotreally mad at the brigadier because therewas no distribution of petrol that morning.I reminded him of the agreements and toldhim he had no right to stop us from trea-ting people. To my surprise, he burst outlaughing and gave me the petrol couponswe needed.- Once a week, we went to the northernlimit of the district more than two hoursby road. We knew there was an LTTE trai-ning camp on the way. One day a soldieron the side of the road stopped us to ask ifwe could send a dentist to the camp. Afterthe usual considerations, we were able to

find a Burmese dentist willing to go. Foronce there were a surprising number ofmen in our consultation! At the end of theday, they were left with half a bucket full ofteeth that had been pulled out.- One morning I made a security call tocheck if the mobile clinics could go to thecentre of the district. We were refusedauthorisation for military reasons; afterwaiting for three days, we were finally ableto go in.

In the heart of the bush

Time line

Up until 2003, MSF provided all the medi-cation and equipment needed in the mobileclinics that travelled between over ten villagesfrom the north to the south of the Batticaloa zone:Kattiravelly, Vakeneri, Pondukalchenai, Kithul,Thihliveddai, Kirumichchai, Kaddumurivu,Vakarai, Mathuramukulam, Ammanthanevelly.

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attacks in the surroun-ding areas.

> Beginning of 2001The situation is stilltense; bombs and minesregularly explode…Families try to sendtheir children awayfrom the region ofBatticaloa to avoid theLTTE recruiting them.

> End of 2001 and thebeginning of 2002Daily shootings and thesituation remains fragi-le, but the cease-fire andthe lifting of the embar-go unblocks the situa-tion.

> 2003 The entire zone is openand the population canmove around freely.

We were taken to an IDP camp which hadbeen burned to the ground and deserted. Avision of disaster!”

CATHERINE BRUNN, DOCTOR INTHE MOBILE CLINICS FROMDECEMBER 2000 TO MAY 2001“One afternoon on the way back a man stop-ped us to help a women giving birth. It wasaround 4 o’clock in the afternoon. There Iwas in the middle of a rural area with myemergency kit wondering what catastrophe Iwas heading for. The women had given birth at 5 o’clock inthe morning, but the placenta still hadn’tcome out.I knelt down in the darkness of the hut totake the women’s pulse and blood pressure:it was her ninth child. Her blood pressurewas 8.5, pulse 130/ minute. It wasn’t great,but the bleeding seemed to have stopped.The nurse put her on a drip and her bloodpressure came back to around 10.When I got closer, I heard the sound of ababy. I separated the woman’s legs and liftedup her skirt. To my surprise, I saw a littlebaby on the ground with the umbilical cordstill attached. I said to myself, if this younggirl is strong enough to spend more than 11hours on the ground still attached to hermother, she is going to have a long life. Shewas a lovely baby. I cut the umbilical cordand held the baby in my arms. “Tankatchi” Itold them, which means “girl”. After findinga clean cloth, I handed the girl to her grand-mother.

All this time, Simon, my translator had beengiving instructions on how to make a stret-

cher. The men gathered two poles, the clothfrom the fertiliser bags, and a pillow, and thatwas that.

We walked back through the huts and rice-fields and got into the 4X4. We more or lessmanaged to lie our new patient down along-side the two other mothers and childrenalready in the vehicle, as well as Simon,Pascaran and Norbert. The grandmotherwanted to come too. I tried in vain toconvince her to stay, but she had alreadybeen pushed into the car by the rest of thefamily and friends that had gathered around.In the end I was glad she came because shewould have taken care of the baby if any-thing had happened to the mother.We were off, driving slowly to avoid thebumps in the road. At 7:30 that evening wearrived and I cried out “Batti!” triumphantly.The patient was transferred to the operatingtheatre.She pulled through in the end, and was ableto go back to her (very large) family. Thepeople in the region where we worked hadno access to treatment. No medicines, nonurses, just a few rare volunteers trained infirst aid doing what they could. The nearesthospital was sometimes a one-hour driveaway, but most of them only had bikes –sometimes, the most well-off, had a tractoror a motorbike.”

REBECCA SOUTH, DOCTOR, RECALLS IN HER MISSIONFOR SEVEN MONTHSIN BATTICALOA IN 1998.“We often had minor incidents at checkpoints”. The soldiers had to search the car

and we had to negotiate with them to getthrough. Sometimes we did this over a cupof tea: they would get bored, so a niceyoung white girl was something of a curio-sity for them. After that, they would let usgo on with our journey. A bit further downthe road, we would cross into Tigercontrolled territory and again had to nego-tiate our way through. We let both sidesknow a month in advance which roads wewould take, and we stuck to our plan sothat they would both know where wewere.

The Sri Lankan army had control of thetown and the road that went along thenorthern coast, but the rest of the zonewas controlled by the Tamil rebels.

In charge of the mobile clinics, I used totravel along the coast in a minibus visitingthe various villages and treating peoplealong the way. The zone was vast andmany thousands of people lived there. Forthese people, the mobile clinic was oftentheir only access to healthcare.

We saw a lot of cases of malaria and diar-rhoea, some of whom died from their ill-nesses. We were scared that cholera wouldbreak out, but in the end it never did.There were also cases of traumatism, someof them war-related. Occasionally we sawsome rarer cases such as leprosy. We heldconsultations, gave out drugs and, whene-ver possible, brought people back to thehospital if needed. Safety was always aproblem. Although I never feared for mylife, dangerous incidents often occurred.Once we were woken up by an attack on a

BatticaloaTime line

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14 fourteen

police station a little further down theroad. Another time, we were in the smallclinic further north along the coast and aship began bombing 100 metres fromwhere we were. We had told the army inadvance that we would be there, but theysimply replied the ship knew nothingabout it. It was probably the most frighte-ning moment in my life. We got back inthe car and left as quickly as possible”.

AMALATHAS STANISLAUSTRANSLATOR, BATTICALOA“When I joined M.S.F in 1993 there wereonly two mobile services. At that time, theBatticaloa district was divided into twosections : the first named “cleared” wasunder the control of armed forced and thesecond named “uncleared” under thecontrol of the L.T.T.E. The only NGO thatrendered medical services to the people inthose remote areas of Batticaloa was MSF.M.S.F also took in charge the children'sward at the general hospital Batticaloa andprovided a doctor for the smooth functio-ning of the above ward.

When Isabelle was the co-coordinator,M.S.F extended its services to Mutur inthe Trincomalee district.

When she went on vacation to Pottuvil,she was shot at by an unknown person.That was the first time an M.S.F sustainedgun injury.

Later Catherine was appointed co-coordi-nator of M.S.F. One day, while M.S.F wasengaged in rendering medical service, tothe people of Kathiraveli, several people ofthe nearby village Vakarai were injureddue to the shelling and firing undertakenby the armed forces. M.S.F came to therescue of these injured people, renderedthem first aid and transported them to thegeneral hospital of Batticaloa. When Yradj was the co-coordinator, ashell fell a short distance away from theM.S.F vehicle and exploded, on its wayback from a clinic in Pondukalchenai, butfortunately no one was injured.Mari, a doctor from Japan, was assisted forthe first time by a local doctor. M.S.Fcontinued to extend its services by organi-zing dental and eye clinics in several diffi-cult areas and many people benefited.During the latter part of 2002, the M.S.Fcoordinator Christine paid special atten-tion to the care of children and appointeda private nurse to look after them. MissClaire, who succeeded Miss Christine as aco-coordinator, paid special attention tothe problem of malnutrition and healthcare of children.”

KANDIAH SIVASHANMUGARAJAHWATCHMAN DURING TEN YEARS INBATTICALOA“In May 1996, one of our mobile clinic cars(“mobile 9”) went to the clinic with our

coordinator, one Catherine, to a locationcalled Kankachiweddai. On their way backto the base, they heard firing noise and theydid not know what was happening. Thecoordinator called me over the radio andasked me to contact the 232 Brigade.

When I received the message no expatriatewas in the house. I contacted the 232 Brigadeimmediately and informed them that ourvehicle was on its way back to the base. TheBrigade told me that at the place calledVellaneli the LTTE and the army were firingat each other. I passed the message to thearmy personnel to stop the fire for 10 minu-tes and let our vehicle pass that place veryquickly. Then I informed our car by radioand they came back to the base in half hourunharmed. I'll never forget this.One time, the hospital authorities was una-ble to supply water to us. With the coordina-

Renovation and waste management activi-ties have been an important part ofBatticaloa programme over last few years.

To photo:- an operating theatre in Batticaloa beforerenovation.middle and buttom photos:- two stages in the construction of the deMonfort waste incinerator which is nowused on many MSF missions.

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15fiveteen

Batticaloa

tor's permission, I went to the DivisionalSecretariat where I met the accountant andasked him to supply us water twice a week.He gave a written order to the officer in char-ge to supply water for MSF free of charge.

Finally, I can tell that after MSF is leavingBatticaloa, the people living in remote areasand suffering will be unable to get propertreatment. The surgical wards in Batticaloahospital will face the same problem.But I thank MSF for the good job inBatticaloa.”

SIMON JESUTHASANTRANSLATOR, BATTICALOA“In 1999, Mobile 5, got stuck in the mudon its way to Thihiliweddai. A vehicle wascalled from Batticaloa and towed it back.In December 1999, we were doing our cli-nic at Kaddumurivu. Then there was aSLA camp at Kaddumurivu. As we had notinformed them of our arrival at the site,the SLA rounded us up. The mobile doctorhad to face them.

In 2000, we were doing our clinic atVakarai, when suddenly a confrontationbegan between the LTTE and the SLA. Wehad to pack our things and leave the site.In 2000 too, our team was travelling nearPaddipalai, when a landmine blasted. Wehad fearful times.

In 2002 we were returning from Vakarai.Mobile 18 broke down at Mankerny. Avehicle had to come from Batticaloa forrepairs.

In many occasions expecting motherswere brought to the hospital and threedeliveries took place in the MSF vehicle.Many children were brought to the hospi-tal in critical condition. One fromPondukalchenai, one from Vahaneri andone from Thihiliveddai passed away onthe way.

On Hartal days we saw many tyres andlogs burning on the roads. We had to driveon other roads and come back toBatticaloa.

In the end, we have saved many lives bybringing people to hospital.”

Despite the willingness of the teams right fromthe start, it was extremely difficult to set uppain management activities. In June 2001, the MSF team in Batticaloa orga-nised a conference on pain for all the doctors inthe hospital. In October an evaluation was car-ried out on the wards that showed that painmanagement was very insufficient: the drugsused were inadequate and the medical andpara-medical staff had little training on the pro-blems of pain. In November 2001 the nurses on the surgicalwards were trained to better evaluate thepatients’ pain and new drugs were introduced.

At the request of the team, a specific program-me was set up. In October 2002, a team (com-posed of a specialised doctor and nurse) gavethe personnel the means required to improvepain management.Protocols were drawn up detailing the use ofsimple, more appropriate, analgesics as well astools to measure pain. The medical and para-medical personnel were trained and after sixmonths modest improvements have been achie-ved with the beginning of change in prescrip-tions habits and the personnel’s attitudetowards the patients. We hope things willimprove further still.

Pain management

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Self immolation

MSF has begun treating a growing numberof burn victims in the Batticaloa hospital,including an alarming number of femalesuicides.

Since MSF arrived in 1987, the problem ofburn victims had not been properly dealtwith until relatively recently. A studyconducted by Véronique Laloe, head sur-geon at the hospital, showed that betweenJuly 1999 and June 2001, 345 patients hadbeen hospitalised for burns. Of these, 64%were caused by accidents, 25% were self-inflicted, and the rest were caused inattacks on the victim or by unknown cau-ses. Women made up a large part of allthese categories, except those caused bycriminal attacks.

NOT ENOUGH CARE AVAILABLE“This has become a serious problembecause on average the burns cover 25%

of the victim’s body, and 49% in suicideattempts”, Veronique explained. “Thesepatients are often neglected by busy staffowing to the difficult nature of the nurses’work. The work is also very demoralisingfor the staff because one out of every fourvictims dies from their wounds. Over thepast few years, burns have proved moredeadly than the war itself.” To make matters worse, the only burntreatment facility is in the country’s capitalColombo, an 8-hour drive away. “We sim-ply cannot transfer patients in criticalcondition,” Véronique continued, “becau-se they need to be on a drip, which requi-res massive amounts of liquid. This isimpossible to provide in the under-equip-ped ambulance we would have to take.”The horrifying hospitalisation conditionsof these patients can no longer be ignored.Nor can we remain insensitive to theimmense physical and mental suffering aswell as the stigma they will carry withthem for the rest of their lives. We alsoneed to acknowledge the effects the vic-tims’ injuries have on the teams. We haveworked closely with the teams from theMinistry of Health to try to provide betterand more humane care to these victimswho suffer the additional burden of beingtreated with distance by the hospital staff,particularly the many cases of attemptedsuicide.

TREATING THE PATIENTS WITH MORE DIGNITYDiscussion groups with the staff were setup with the help of the hospital’s psychia-tric ward. They worked with the nurses in

the surgical ward by asking them ques-tions, offering counselling, and talkingabout suicide to help them to de-stigmati-se the problem. “Under the pretext of iso-lating the patients to avoid secondaryinfections, they were kept out of sight faraway from human contact,” Véroniqueexplained. Treating these patients canpose many problems as there are variousfactors involved. We have been able toincrease our capacity to treat burn victimsby making structural improvements to thehospital ward, by closely working with thenurses, improving patient nutrition, redu-cing pain and offering physiotherapy. With the help of the psychiatric ward, thepatients were able to talk to an MSF mem-ber on a daily basis, and the efforts of theplastic surgeons have helped to reduce thescarring. We can confidently say that theteam has managed to provide better carefor burn victims in the hospital, and hasremoved the stigma associated with thesuicide cases.

The suicide rate in Sri Lanka is one ofthe highest in the world. In an attempt toexplain this phenomenon, the psychia-trist from the Batticaloa hospital sugges-ted suicide was part of the nation’s characteristics. He describes suicide asan “inability to resolve problems”, sug-gesting that most of the population areunable to solve everyday problems.

figures

> 345 burn victims wereadmitted between June1999 and July 2001

> 64% were accidents

> 25% were suicideattempts

> 78.5% were Tamil vic-tims

> 19% were Muslim

> Average age: 21 (17 foraccidents, 29 for suici-des)

> Patients with burns tomore than 50% of thebody die

> 27% of patients admit-ted died; for attemptedsuicide, the rate was71%

Batticaloa

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Facts and figures

Vavuniya programme

> Surgery, hygiene andrenovation of operatingtheatre

> Mission opened:April 1995

> Closed definitively:March 2003

> Population covered:approx 150,000 peoplein 2001/2002

Vavunya hospital

> Approx. 250 beds,including 55 surgical

> 2002: 16,500 admissions and 2,400 operations

> 20% of surgical admissions came from‘uncleared’ zones

> International staff(2002): 3 permanentand 3 for short termtechnical support

> National staff: 6

Vavuniya, a strategic town

Vavuniya, a few kilometres from the frontline, is a large Tamil town in a governmentcontrolled area in northern Sri Lanka.Under military administration, (neverunder Tamil control) the town was underconstant tension throughout the conflict.The different neighbourhoods werecontrolled by various Tamil militias, eitherpro or anti LTTE: and there was considera-ble contraband with the north of the coun-try. In April 1995 the fighting intensifiedand MSF opened a programme in Vavuniyahospital where there was a lack of sur-geons.

April 1995. Hostilities between the LTTEand the government of Sri Lanka recom-menced. Up until then, 400,000 peopleliving in the Tiger controlled zone north ofthe front line between Kilinochchi,Mannar, Mullaitivu and Vavuniya had noaccess to surgery. When lucky, Tamilswere transferred to Anuradhapura, 60kmsouth of the front line, in a Singhalesezone. However many Tamils were appre-hensive about going into this zone, andthe post-operative care did not seem to beas good for Tamils as for Singhalese.

On request from the ministry of health,MSF sent a team of three, a surgeon ananaesthetist and a nurse, to cover theemergency surgery in Vavuniya hospital.This activity covered all the civilian popu-lation, both Tamil and Singhalese, in theregions of Vavuniya and Vanni (north ofthe front line). MSF therefore also ensuredthe transfer of patients to the hospitalfrom this isolated Tamil region or from

‘uncleared’ areas, so that everyone couldhave access to quality healthcare.

AN IMPORTANT PIVOT FOR LOGISTICBesides the surgical activity and the fol-low-up of quality pre and post operativecare, the teams also referred patients toother departments e.g. neurology, paedia-trics or obstetrics.

Vavuniya was also a strategic logisticsposition for MSF: the town was a pivot formaterial and drugs between Colombo andMadhu on the other side of the front line.It was here that the transport of all thematerials by convoy to Tamil held zoneswas negotiated.

After four years in Vavuniya, MSF closedits surgical activities in January 1999. Thedecision was justified by the fact that thefront line had moved further north andconsequently the number of operationshad decreased. However in November1999, MSF re-positioned a surgical teamin Vavuniya hospital: the Tigers were atthe doors of the city (the LTTE had askedthe population to evacuate), the combatsintensified and the number of woundedincreased dramatically – however therewas no national surgeon posted in thehospital. This new mission, which was atfirst to last one year given the instability ofthe zone, finally lasted until September2002 when the surgical activities werehanded over to a Sri Lankan surgeon.Meanwhile in March 2000, on the recom-mendation of a surgeon and a logistician,

MSF started activities to improve thehygiene and asepsis around surgery, aswell as the triage and incineration ofwaste. A Monfort incinerator was built inVavuniya and raised considerable interestfrom the Sri Lankan health authorities.This type of incinerator was also built inPoint Pedro, Mannar and Batticaloa. InDecember 2000, these activities, particu-larly those concerning waste incineration,were handed over to the hospital staff. Afew months later, in March 2003, the mis-sion closed in doors definitively.

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When the Bombs Fell on Notre Dame de Madhu

PersonalMemories

Madhu is not just any town-the Virgin Maryis said to have appeared here. This Christiansanctuary, located in the Mannar district onSri Lanka’ northwest coast, became animportant site for religious pilgrims. Whenwar broke out, the sacred place became arefuge for tens of thousands of civilians andwas quickly transformed into a displaced per-sons’ camp. Thanks to the infrastructureestablished for the pilgrims (including achurch-sponsored clinic, a water distributionsystem, grounds for setting up tents and tem-porary shelters), all elements were in place toensure that a health disaster would not breakout. The only problem was that there were norunning public health facilities and no medi-cal workers. This was the context in which Médecins SansFrontières opened an assistance program in1990 for displaced populations in the sanc-tuary town of Madhu. It was the first pro-gram to be set up in the area under thecontrol of the Sri Lankan rebels, theLiberation Tigers of Tamil Eelam (LTTE, orTamil Tigers), just behind the front line.

EVER GROWING NEEDSThroughout the civil war, the Mannar dis-trict experienced repeated offensives andcounter-offensives. As the theater of manybattles, it also experienced major popula-tion movements and, as a result, growinghumanitarian needs. In 1987, MSF beganworking in the region and set up surgicaland obstetrics programs in the Mannarhospital. In 1998, MSF came to the aid ofpopulations who had taken refuge in Indiaand were returning to Sri Lanka. Finally, in 1990, mobile clinics — initially

based in Mannar and, then in Madhu —made it possible to provide medical assis-tance to all the region’s isolated popula-tions, with an emphasis on maternal-infant care and childhood vaccinations.The MSF teams worked together in thelittle Madhu church hospital, offering thesurrounding populations high-quality,comprehensive care. It was not until 1995that teams set up an ambulance system totransport the most seriously ill patients tothe reference hospital in Vavuniya, in thegovernment-held zone. If they were una-ble to reach Vavuniya, they went to theKilinocchi hospital (before it was bom-bed). Beginning in 1997, the teams took also patients to the Mallavi hospital in the heart of the Tigers’ Vanni region, where

MSF Holland had been operating a surge-ry mission. Facing major transport andtravel problems, the teams found it diffi-cult to provide humanitarian aid. Patienttransfer sometimes took up to four hours,rather than the 11/2 hours typically requi-red for the trip. Supplying the entirearea—and particularly Madhu—withmedicines and medical supplies becamevery difficult because the Sri Lankandefense ministry had imposed an embargoand lengthy waiting periods. “We oftenwaited weeks for authorization to bring inour supplies and medicines,” recalledNicolas Beaudoin, a logistician in 1996-97.“As soon as we got them, the soldier inVavuniya had to inspect everything before

“In November 1999, theTigers launched offensivesin all directions. The Vavuniya mission opened the same day thatthe Madhu church was bom-bed. Véronique, theBatticaloa surgeon, arrivedin the morning and thatnight she was faced with 60 wounded people! Wedecided to open Vavuniya. After the Madhu events, theteams tried to return getback there. At that point,the sanctuary was closed offto all humanitarian aid. The team left in two cars.When they reached thecheckpoint, they “forced”their way through, insistingthat they must be able tosee the population andwhat was happening. They managed to getthrough but they couldn’tget back. They knew theywould face that risk. Therewas no way to make a U-turn and go back theother way--or to buy any-thing to eat. Their carswere full of medicine butthey didn’t have a tooth-brush among them andbarely an MSF T-shirt. Theyremained blocked there forthree weeks. They workedhard, of course. They atewhatever the displaced peo-ple in Madhu gave themand slept alongside them.”

Guillermo Bertoletti,program manager, Paris,1997-2001

Madhu was thought to be safe, but it was never-theless bombarded, resolting large number ofcivilians casualties.

19nineteen

we could leave for the military post at thefront line, just ahead of the two kilometer(one mile) no-man’s land separating usfrom Madhu. We could not transport morematerial than stipulated in the authoriza-tion and our lists had to specify contentsdown to the number of rolls of toiletpaper. Some drugs, like pain medication oranesthetics, were simply forbidden whileother items--like batteries with which theLTTE could manufacture bomb detona-tors!--were very restricted.”

FROM RESTRICTION TO TOTALSUSPENSION OF OUR ACTIVITESMSF continued its activities until 1999.The Madhu clinic became the only referralcenter in the sector. The mobile clinicsand the system for transporting patients tonearby hospitals operated very smoothly.In late March 1999, the army retookcontrol of Madhu. Access to areas underLTTE control, where MSF’s mobile clinicscirculated, became increasingly difficult,restricting the teams’ travel and the sitesvisited. Nonetheless, the Madhu cliniccontinued to provide medical care to thepopulation. Beginning of April 1999, mili-tary restrictions limited the mobile clinicteam’s access to the Palampidy displacedpersons’ camp. The ambulance serviceoperated as a patient transfer service andalso transported Madhu’s cholera treat-ment kits. In June 1999, when the entireMadhu population was evacuated, MSFdecided to suspend its clinic work andsupplied the local staff with emergencystocks. The ambulance transport systemwas also halted. Mobile clinic service to

Palampidy, the only remaining site served,was maintained from the Murunkanhospital, where MSF had opened a clinicprogram in early 1999.

THE ATTACK ON THE MADHU CHURCH In November 1999, fighting intensified inthe region, leading to major populationdisplacements as people sought refuge inMadhu. A tragic event occurred during abattle for the control of Madhu betweenthe Tamil Tigers and the Sri Lankan army.At 11 p.m. on November 20, the Madhuchurch was bombed four times. It wasunclear which side was responsible for theattack. The Madhu church shelteredaround 3,000 people. Thirty-eight peopledied in the bombing, including 13 child-ren. Six other people died of their injurieswhile being transported to the Vavuniyahospital or after admission. In the end, 44people were killed and dozens of otherswounded during the blood bath. The MSFsurgical team admitted 68 patients to theVavuniya hospital on the night of November20. Fifty-one women and children wereamong them. On November 23, the LTTEretook control of Madhu.

Several weeks later on December 10, the dayMSF received the Nobel Peace Prize, theteams in Columbo took advantage of theevent to denounce the use of antipersonnelmines and methods of warfare that threate-ned civilians. The teams issued an officialrequest to government and LTTE authori-ties to halt attacks on civilians and allowhumanitarian aid workers free access to the

region. “Under the terms of internationalhumanitarian law, the parties to conflictsmust not directly attack civilians or theirproperty. The bombing of the Madhuchurch, known to civilians as a ‘safe haven,’was an obvious violation of that law,” theMSF press release announced. Three dayslater, the team received authorization toresume its work in the region and the war-ring parties agreed to establish Madhu as ademilitarized and safe zone. MSF resumedits activities, providing support to the healthcenter, mobile clinics and ambulancetransport. The team also brought assistanceto the people of Tatchanamadhu and othersites. After the ceasefire signed between theLTTE and the Sri Lankan government inFebruary 2002, the embargo ended and twoaccess points were opened to the LTTE zonefrom Mannar district. Little by little, thedisplaced people who had taken refuge inMadhu returned to their villages. MSF shif-ted its activities, emphasizing mobile clinicsso that it could be closer to the populationsreturning to villages. These clinics allowedthe teams to reach around 18,000 people,while the Madhu health center met theneeds of some 25,000.

Madhu

Facts and figures

> 1987Surgery and obstetrics inthe Mannar hospital

> June 1990Mobile clinics based inMannar cover the Madhuregion

> Late1990Support to the Madhuhospital, mobile clinicsand ambulance transfers

> June 1999Madhu activities suspended

> March 1999Support to Murunkanhospital and mobile cli-nics.

> November 1999Reopening of the Madhumission; same activitiesresume.

> February 2000Mobile clinics added.

> March 2003MSF ends activities in theregion.

Sri

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20 twenty

We will never repeat if enough : withoutthe Sri Lankans, Médecins Sans Frontières’missions would not have been possible.Now that the time has come to close downour last programmes many of them areheavy-hearted, as are the expatriate volun-teers. Many of the national staff have beenworking with MSF since we opened in SriLankan. With unfaltering patience andmotivation they have seen hundreds ofvolunteers go by. Here are a few tributessome of them would like to pay to the asso-ciation, and some we would like to sendthem …

BY RECILDA DALIMA, EX-FIELDCOORDINATOR, VAVUNIYA“For the past 16 years, I have been wor-king with MSF France. Sweet, sad, remar-kable memories make me recollect the

past and wish to share it with you. I hopethe following few lines will make youhappy while remembering the story ofMSF France in Mannar, Madhu andVavuniya.In May 1988, I joined MSF France as ahealth worker. Only now I realize howremarkable a day it was: since then, MSFhas offered me various skills, up to that ofa field coordinator, for which I offer mysincere thanks.After a while as a health worker, I wasselected to become translator for the phy-sician. I started my work at Dalai Mannar,said to be my birth place, which is as wellthe part where Sri Lankan refugees fromIndia came back to the island. MSF Francethen had to switch over to mainland ofMannar District, following the request ofUNHCR and the Ministry of Health. Latteron, we received information saying thatpeople are evacuating and piling at MadhuChurch, due to safety reasons, so we wentto visit the Madhu shrine. We were wellreceived by the authorities. After our visitwe decided to call the place the MadhuCamp, and MSF France continued its ser-vice there. The MSF Madhu mission was very popu-lar among the public. At that time I, too,had the opportunity to serve the public aswell as the expatriate as a translator. WhileI enjoyed my work, day by day the numberof the patients was increasing. The Madhuhealth unit became a true hospital, withspecial care given to the maternity section,thus enabling the hospital to meet out anyemergencies other than surgical.From my point of view, the meaning inFrench of Médecins Sans Frontières - and

its English translation “doctors withoutborders” - is true. Doctors who work withMSF do so without restricting the humani-tarian services rendered to the Tamil com-munity. The Tamil people who took shel-ter as refugees at Madhu Camp were theluckiest people in the Vanni region, as faras the medical service is concerned. SinceI also belong to the Tamil community, onbehalf of it I should express my sincerethanks, but I couldn’t find the best wordsdo so.Once a team was on a journey, one SriLankan army (SLA) helicopter shot at thecar. Immediately they got out of the vehi-cle and waved the white MSF T-shirt tostop the shooting, but the SLA didn’t doso. They were injured and with the help ofan ICRC representative, they were taken toColombo hospital by a special plane. Onespecial delegate visited Sri Lanka for thatreason. His name is Oliver. The first thingthat he did was to see the driver and onlyafter that he met the other expatriate inju-red. This clearly shows their care for thenational staff. As time passed and people in were retur-ning to their respective places, we set upmobile clinics. I worked as a translatorand help nurse. In 1996 MSF hired morestaff and gave them proper training in nur-sing and brought an expatriate nursingtrainer who conducted practical classesand examinations. Now these persons areemployed in the government medical ser-vices, have a job security and are praisingMSF Apart from the medical services, MSFoffered some humanitarian valuable servicesto the national staff. I can give several exam-ples like that. For everything there is an end.

Farewell Tributes

Sri

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21twenty-one

In 1999 November SLA captured Madhushrine and surrounding area without anyopponent activities, because all felt Madhuwas a pilgrimage place and had accommo-dated thousands and thousands of refu-gees. As soon as the SLA captured Madhu,they started to forcibly send back the peo-ple to their respective villages, under thecover of rehabilitation. By July 1999,Madhu camp had become Madhu Shrineagain, and MSF had to leave Madhu, butstarted their activities in Murunkan. On request of the health ministry, MSFextended the service of an expatriate sur-geon to Vavuniya Hospital since 1995 tillDecember 2002. Vavuniya office played amajor role in supplying the necessary sup-plies to Madhu and Murunkan. FromMadhu 2 normal transfers and other emer-gency transfers were conducted and areturn journey for patient to Madhu aftertreatment, while filling in all the docu-ments needed for permission and passfrom SLA authorities.Since 1988 to 2002 it was not an easy taskto pass checkpoints, but MSF took theresponsibility of taking the patients withrelevant documents on either way provi-ding transport in their own vehicle (whenthere is a need) all at the risk of MSF Icouldn’t find words to praise MSF for thistask. I think no other voluntary organiza-tion would have rendered such a service tothe people. In Madhu, the simplicity of the expatriatephysicians played a high ethical role, min-gling with the refugees and respectingtheir culture. A quality service at theappropriate time to serve the needy is thegoal of MSF, which they achieved inMadhu.I was in Murunkan till November 1999,when I was transferred to the Vavuniyaoffice. From then till the 31st March 2003

I had the pleasure to work on the followingpositions at MSF: health worker ; transla-tor ; help nurse ; pharmacist ; radio opera-tor ; transfer manager ; assistant adminis-trator ; and finally field coordinator. During the 16 years I walked through orjumped over several stages due to MSFand its executive at the local and higherlevel. I am proud to state that I have spentover 25% of my life with MSF I had gained

knowledge from various aspects and withthat I could comment the following forfuture mission work.1. Before making a decision try to contactseveral national staff individually and getthe opinion that may give you a correctpath to walk on or may rectify you.2. Logistical side: more attention to bepaid to the purchasing part; proper recordsto be kept as far as the vehicle fuel and itsdistance covered are concerned.I will be failing my duties if I do not men-tion at least a few among the ones I met.

Dr. Peter Noel is a doctor who selected meinto MSF France. He was the first personto give me a reference letter. Sabine who isa nurse and Sologne, the same. It was apleasure to work with them. Marie is aMedical doctor. These three and my selfare thick pals.Then Dr. Corinne showed and tought mehow to be active during an emergencytime. Dr. Mew, an American Doctor: he has

a power to predict the disease prior to theconsultation. Florence, midwife who tooktwo contracts for 16 months at Madhu. Dr.Rahul from the Philippines. Patients lovedhim so much. Veronique a short time visi-tor. Then came Dr. Richard, a Mexican. I studied a lot from him. Then I thinkabout the head of mission: Guillermo, ser-ving at present as an executive at the inter-national head quarters, Paris. Next cameGabriel who tried to understand others'difficulties, Manana the MedicalCoordinator, with her we can discuss any

Anne-Marie Gloaguen, nursein Trinco from February toAugust 1989.

I would like to pay particu-lar tribute to Shitra, the OTnurse in Trinco. She was sointerested and attached toMSF that she came toFrance in 1991 as a politi-cal refugee, rather than toEngland where here familywas. It was a piece of theSri Lankan adventure thatcontinued.

She is now married andlives in London since 2002.

Guillermo Bertoletti

As doctor in Batticaloa in1992, head of mission inColombo from 1996-1997and finally programmemanager in Paris from1997-2001, I have many,many memories of SriLanka. As I am afraid ofleaving someone out, I pre-fer not to mention anynames – but prefer to thankeveryone. I would like topay tribute to all the national staff, to thankthem for their precious col-laboration, patience andkindness. I hope I will beable to go the MSF leavingparty at the end of Juneand go over the good andthe bad times together.

Best of luck to all.

22 twenty-two

important matters at any hour. Now it istime to think about my residence,Vavuniya MSF France office. Pascale,Estelle, Luca, it is easy to write thesenames. But its impossible to erase from myheart Yves and Oana both life partners andadministrative partners, Head of the mis-sion and Administrator respectively. It isonly two years I served under them, theirsoft corners towards the employee arealways fragrantly of fresh smelling flowers,if there is anything to be rectified eventhey politely infuse the matter so as theemployee listen and obey, there are days Iwould have contacted them over the tele-phone more than four or five times but Ihear the sweet voices, now I render mysincere thanks to this couple.

I am also duty to thank PascaleNoterdaeme, as Medical Coordinator, I really love her for her way of approach.Likewise if I look into the administratorand field aspect I believe about 90% of thevisiting expatriates has rendered theirdedication towards the Tamil community.If you look into a just blooming gladiolaflower you will be able to see several budson the one and the same stalk. But all don’tbloom at once, only two or three buds willbloom, while the blooming process is onone or two buds may get spoiled one fromthe stalk. However flower continues tobloom until the last bud blooms, this isMSF one or two with different attitudesbut on whole MSF had served the commu-nity by large and rich. Also endorse thefact that no other organization would havereached or gained the highest honor whatthe people are having in MSF France.I, Recilda Dalima, loved, love, and willalways love MSF France. Now over to myconclusion. I take this opportunity tothank each and every one either expatria-

tes or national staff, in a small way or bigway for their cooperation renderedtowards me in all aspect also thanking thecompetent authorities for giving permis-sion to frame these few lines, I know verywell your service is needed badly by otherpeople somewhere in another part of heworld. You have to move and it is time. Iam awaiting a chance to meet my old col-leagues in any part of the world at anytime. Let god help me for this.Bye,”

A. THEAGALINGAMDOCTOR WITH THE MOBILE TEAMSIN BATTICALOA.“I arrived in Sri Lanka in 1997; first towork for the government, then in a priva-te hospital. On March 22nd 1999 I startedworking with MSF as a doctor with themobile teams.The more I work with MSF, the better Ifeel. It is very motivating to work for anassociation that understands the popula-tion’s difficulties, that listens to them,genuinely takes into account their needs –builds a veritable relationship with thepopulation is it providing care to. WhenMSF arrived in Sri Lanka it knew exactlywhat decisions had to be taken straightaway to respond to the needs: hiring ofsurgeons and nurses to respond to theneeds in the field. The government hadabandoned many areas of health care andMSF filled these gaps by providing thenecessary drugs and paying the medicalstaff.As a doctor with the mobile teams, I workin very isolated areas. I really feel MSF’ssupport. The population also feels MSF islistening and taking into account theirneeds. The relationship with MSF is verymuch appreciated. The local staff and

expatriate volunteers get on very well.I am sad to be leaving this mission in June.I feel like that when MSF leaves it will taketime to fill the empty space it will leave.There will be the hospitals, but no doctors.I feel like I am abandoning the populationand I fear that the population also feelsthat we are abandoning them.I worked 22 years before joining MSF; butI have never experienced the same humanrelations anywhere else.I would like to thank all the doctors I haveworked with, as well as all the team”.

ELISABETH SZUMILIN, DOCTOR IN TRINCO FROM 1987 TO 1988.“I would particularly like to mentionMaster Leo, my Tamil translator who wasin his sixties. Who never wanted this war.Also our cook Apu, which means ‘daddy’or grand-father, as well as his family. Allthe teams that have been in Trincomaleehave wonderful memories of this man. Ontop of everything, he was a great cook.When I said I was going to get up early…he would get up even earlier to prepareour picnic. Often it was the sound of himgrating coconut for us (the mobile team)that woke me up. He must have had to putup with a lot of green, unripe coconuts…The expat MSF teams: we always got ontogether (even with the surgeons, despitetheir renowned characters!!!). Now, whenI hear about team problems in the field Ialways ask myself… how was I so luckythat I never had those kind of problems onany of my missions? We always sorted itout between us.Finally I would like to mention my friendRohan Mendis, even if he is not a memberof MSF. A Singhalese diver who showedme the wonders of the ocean bed of this

Poetry done by MSFColombo security guard –Anthony

Good Bye MSF

Time has come for us to say good-bye.

To leave behind the dearest part of life.

Away from MSF shade work and hardness

To faraway place…

It grieves us to bid yougood-bye

To leave behind our soul

Knowing that MSF is verybreadth each spadework

Keep us alive…

We shall miss you oh!,so much

Look into our eyes and youwill see you in them

Look into yours and we seethe depth of your love

Boundless as the blueocean

Steady as the sunrise

Farewell my endless farewell…

Sri

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23twenty-three

island, as well as much more. I would verymuch like to see him again.”

SIMON JERUTHASAN – TRANSLATOR “I have been an interpreter with MSF since1997. It was a friend of mine who told methat MSF was looking for an interpreter. Istarted on a six-month contract, followedby a part-time contract and in the endworking full-time.Before MSF I had had various jobs, inclu-ding one working for the government.The doctors have always been very nice tome. The national staff and expatriatevolunteers get on very well together. I canthink of several personal examples. Thecoordinators helped me get a loan and alsohelped me and my sister-in-law financiallywhen we were in a very difficult situation.Another example; once some soldierswanted to talk to me - the doctor, awoman, refused to leave me alone withthem because she wanted to protect me.We also had lots of opportunities to bewith the expatriate volunteers: dinners,Christmas parties… We are sometimesvery sad when an expatriate leaves ….other times we are not.MSF has worked very hard: working in theclinics, on delinquency, dental work, sup-plying drugs, transporting patients. Thevolunteers organized training workshopsover several days. It was very good.I was happy to see the population provi-ded assistance, helped and defended.Today MSF is leaving. Personally, on theprofessional front, I have had an offer tobecome Product chief for NDO. If it does-n’t work out, I’ll go home.It is important that the Sri Lankan autho-rities now take over and assume theirmedical responsibility. MSF has workedvery well and has shown the way. But the

government is blind and I’m afraid theywon’t do anything.”

SUREASH KIRUBARAKAN, LOGISTICIEN – ADMINISTRATOR“Before Sri Lanka, I was working in SaudiArabia. Then I had the opportunity to

work as a volunteer for the Red Cross. Ithen got married and had two children, soI couldn’t carry on as a volunteer as it did-n’t pay well enough. At that time MSF waslooking for a polyvalent worker. I met anAmerican MSF coordinator who asked meif I had any experience working withradios. I told him I hadn’t, I had seen peo-ple working on radios but I had never tou-ched one myself. A few days training wasenough and I was away. I was the firstradio operator, as well as taking care of allthe logistics and the administration.I later accepted to work as a driver for themobile teams. I worked as a driver forthree years. We were constantly traveling

in dangerous zones: the military preventedmost civilians from crossing the checkpoints. As they couldn’t come to us to getmedical care, we had to go to them. Wesaw many, many dead. Our team wanted toknow what was happening, what peoplewere hiding from us. The military wouldask us to leave and to stop asking ques-

tions. We were to collect the bodies andleave. The population welcomed us andwere very supportive. When they had anyinformation about attacks they would tell us.Today the situation has improved. Peoplecan move around easily from one place toanother.I had a wonderful, intense experience withMSF. I became level 6 assistant logisticianin 2002. I would like to thank all the expa-triates and national staff. I hope MSFremembers me if they come this wayagain, even if I can’t honestly say theyshouldn’t leave.My future? I would like to work for ano-ther NGO, even though I would prefer

Ariane Betz, nurse anaes-thetist from March 1991to May 1992 in Trinco,than Monaregala.

Tribute to…

I would particularly liketo thank Apu, our cook inTrinco, who used to makeus the most deliciouscrab curry: but seeing asthe house has alreadybeen closed a long time,he will perhaps neverread this.

But I think this is a greatidea. If the programmesare closing in Sri Lanka,it’s a sign that things aregetting better, even wellperhaps, and I can onlybe happy about that…

I hope that peace lastslonger this time!!

24 twenty-four

MSF – the best humanitarian organizationI know. It’s true that I’ve always been verysatisfied with the MSF volunteers, but itwould have taken only one person to spoileverything.

SHOBANA CHRISTY, TRANSLATOR, THEN RADIO-OPERATOR.“I have one memory I would like to sharewith you. I was in Madhu at the time and

we had gone out with the mobile clinics toTachchinamadhu, which was consideredas ‘uncleared’ at the time. That day, in May1997, the Sri Lankan army entered Madhuby surprise. People started running andscreaming trying to get away. The MSFteam in Madhu called us on the radio tel-ling us to come back to the base immedia-tely. We were very scared, but we got intothe car and started driving back: we leftbehind one member of national staffbecause we didn’t know what could hap-pen on the road between Tachchinamadhuand Madhu. We heard some shooting andsaw blood on the road. We were terrified;we thought we were all going to die. Theteam in Madhu called us again on theradio. The field coordinator snatched theradio and starting calling “mobile 8, mobi-le 8?”. But there was no reply. As transla-tor I repeated her call. There was still noanswer. We finally got to Madhu. It wasonly then that our doctor noticed that themicrophone I was still holding wasn’tplugged in to the radio! All the while wehad been calling “mobile 8” on the radio,

we got no reply because we were infact“mobile 8”. Afterwards we laughed a lotabout it. I really had a good time with MSF.We did a lot for the population in the‘uncleared’ areas. I hope MSF will do moreand more in the world.”

JACQUES BRIOIS, NURSE ANAESTHETIST, VAVUNIYA,AUGUST 1995.“I was in Vavuniya for a month withAbdeslam Khairouni, a surgeon, andPatrice Vastel, the logistician. The hospitalhad a great team: Yogi, the nurse, had toput up with us and we worked very, veryhard.One day, I found I had run out of anaes-thetic gas. I was very, very worried; than afew days later a miracle! We received somefrom the Sri Lankan Minister of Health inColombo. She was an incredibly determi-ned and persistent woman!I planted a tree infront of the MSF house.I hope it will grow in a country at peace.Many thanks to all.”

Emmanuel Baron,doctor,Madhu April-November1995.

I would like to thankDoctor Sabah in Madhufor her competence, kind-ness and commitment.

ROCKSON COLLINS, LOGISTICIAN, JOINED MSF IN 1996 IN JAFFA HOSPITAL. HOMMAGE ACROSTICHEMemories flow sweet and hard like ebb and tide in our hearts. AndEvents are twinkling as morning stars on our pool minded sky. ThenDoctors, nurses travel on a train called “expats services”Enjoyed the journey with log and admin and also the national teamCarried the duty with spirit and honest in our shoulders – to the wayalongIn and out from 8 to 5 is the time for us from 1986 – In this pearlNovember on 99 was the greatest month on my track in MSF life – AsStarted the mission again in Madhu with my superiors on that time

Suffering people get the relief from sickness and diseasesAppreciate its service with joyful and thankfulNothing is impossible in emergency to start and rundownSpeed and selection are the need of necessity

France has the head quarters of our associationRefugees praised always its service in precarious situationOverall decisions always get us in front of leadingNorth and East, West and South, all are the parts of its bodyThank you again for its service in our island for seventeen yearsI’ll follow all my way of its wayEverywhere in missions are the good memories for publicRemembrance cannot be erasable from our heartsEnd of the mission and leave the country will not clear the mark of MSFbecauseStill it’s living and covering all of our soul.

25twenty-five

210 national staff et 860 international volunteers

Sri Lanka was always one ofMSF's largest mission in termsof human resources, with over70 departures a year.

The war surgery activitiesmeant that a high turnover ofvolunteers was one of the cha-racteristics of thiscountry.

253 surgeons, 145 physiciananaesthetists as well as 70 nur-seanaesthetist and OT nursesworked there in turn on veryshort missions.

thanks to 826 international staff

thanks to 210 national staff

26 twenty-six

A.S. Recilda DALIMA, A. Benadad CROOS, A. FERNANDO, A. Jayanthy FATIMA, A. MARY LUCIA,A. MOHAMED AZAD, A. NESARAJAH, A. NICOLAS, A. PRISKA VOJINI, A. THEAGALINGAM, A.UTHAYAKKUMAR, A.A. LOBENDHAN, A.F. REGINOLD, A.J. SRITHARAN, A.L. Godwin PHILLIP, Aloysa PIETEREZ, Anthony ANPARAJI, Anusha RUPASINGHE, B. AMIRTHAKUMAR, B. THURAISINGAM,B.S. Ishanthi I.SAMARAWEERA, Bernard R. COOMARASWAMY, C. ANTHONIPILLAI , C. SIVARATNAM, Chandra SELVARATNAM, Christopher S. KUNANAYAGAM, Dorin PRIYADHARSHINI, E.B.M.SHANTHIKUMAR, E.P. PONNIAH, Elizabeth SIMION, Elvis DELIMA, F.KANIKKAINATHAN, Gabriel AROKIYAVATHY, Ira NAVALEESVARAN, J. ANNAMMAH, J. JEGASOTHY, J. JESUTHASAN, J. JEYA-THA , J. KALANITHY, J. MARGRET, J. MARIYADAS, J. SEEMANPILLAI, J. Stalyn ISAC, J. THURAISAMY, J. VAITHIYANNATHAN, J.A. PREMALATHA, J.R. INDRANI, Jesus MARY, Jude F. VIJAYAKUMAR,K. BALASUBRAMANIAM, K. JAYAKUMAR, K. JEYARAJAH, K. KUGARANJINI, K. LEDCHUMYKANTHAN, K. MAHENDRAN, K. PATHUMANITHY, K. PURANTHARAKUMAR, K. RAVEENDRAN, K. SHAN-THINI DEVI, K. SIVANATHAN, K. SIVASHANMUGARAJAH, K. SUBRAMANIAM, K. SUREASH, K. THAMAYANTHY, K. THAMMAYANTHY, K.M.MANIVE, K.SABARATNAM, Karuppaiah THANGAIYA,Kathirkamu SIVANATHAN, L.M. Srinath GOONARATN, L.S.Dammika WIJEYAWARDENE, M. ANSALAM, M. Anton CHARLES, M. GOVINDARAJAH, M. INDRANI, M. JOSEPH, M. MANOHARAN, M.MYLVAGANAM, M. Nihal PERIS, M. RAMAYEE, M. RANGANATHAN, M. RATNASINGAM, M. SIVASHANMUGAM, M. STEPHEN, M. Vijitha SRIMURUGAN, M.A. WIJENDRAN, M.C. PATHINATHAN, M.E.METTILDA, M.F.J. ELAMURUGAN, M.N. AMUTHINI, M.P. ASOK KUMAR, M.T. PATHINATHAN, Maheshwaran FREDRICK KUMAR, Maria A. MATHALENA, Marie Dorres RODE, Marimuthu RUDRAN,Mary Pamela DISSANAYAKE, Mary S. MACTALIN, Michael CROOS, Murugesu JEYARANI, N. AMIRTHALINGAM, N. IYATHDURAI, N. JEGATHEESWARY, N. MAHENDRARASA, N. RAJENDRAN, N. SEL-LATHURAI, N. VARATHARAJ, N. VELAYUTHAPILLAI, N. VIJEYARANI, NAVARATANAM SUHANTHAN, Nirmalie Lucille PERERA JAYASINGHE, Nirosha V. BENEDICT, P. ARUMUGAM, P. MARY CHRIS-TIN, P. Michel CROOS, P. RITAMMA, P. SHANTHINY, P.D. DHARMAWANSA, P.Ranjan SIRIWARDANE, Paul GUNASEKARAM, Prarthana Sanjeewani KALUARACHCHI, R. INDIRAGANDY, R. MEGANA-THAN, R. PARAMARAJ, R. PUSHPAMALA, R. RAJAGUMAR, R. SELAVAMALA, R. SILVIYA PRIXIC, R. SINNAIAH, R. SUBRAMANIAM, R.K.ROHAN, R.P. GUNASENA, R.RANAGANATHAN, Rajini PASU-PATHI, Ramanathan KUMAR, Regina SANTHIAPILLAI, Rockson C. MARIYANAYAGAM, Roshan KUMARASWAMY, Roshini WIJESIRI, S. AMALATHAS, S. ANTHONIPILLAI DAISY, S. ARUNTHAVACHEL-VAN, S. ARUNTHAVACHELVAN, S. CHRISTY REVAL, S. CONCELLA, S. EASWARATHASAN, S. ELANKESWARN, S. JAYASEELAN, S. JESUTHASAN, S. KUMAR, S. Mactalin JOICY, S. MAHENDRAN, S.MARIYATHAS, S. NAKULAN, S. NILANTHY, S. PASKER BAGILON, S. PATHMANATHAN, S. PUVANENTRAN, S. RAGAVAN, S. RASANAYAGAM, S. SAVARI, S. SEBASTIYAMMA, S. SELASTINA MARIA, S.SELVARAJAH, S. SIVARAJAH, S. SIVARAJAH, S. SOROJINIDEVI, S. SUPPIAH, S. Suresh KUMAR, S. THONIAMMAH, S. VAKEESAN, S. VIJEYASRI, S. YOGARASA, S.G. JEBAMALAI , S.G. VIJAYAKUMAR,S.L.J. Stanley BABU, S.P. RAGUNATHAN, S.S. FIGIRADO, S.S. RAJASINGHAM, Samson JEROME, Santhan MICKALShobana CHRISTY, Simeon R. UTHAYAMALAR, Sinniah AMIRTHAMANY, SuppaiahDRAVADAKALA, T. ARIYAMALAR T, T. Eugene MICHAEL, T. MAHENDRAN, T. NASERATHAMMAH, T. NAVARATNAM, T. PRABAHARAN, T. PUSHPARAJAH, T. RAJASINGHAM, T. SIVAPRAGASAM, T.THARMARAJAH, T.S. SUBAHARAN, T.T. ANNATHURAI, V. A. REETAMMAH, V. AINGARALINGAM, V. ARUMUGAM V. ATHIMUTTULINGAM, V. NAVARATNARAJAH, V. SATCHITHANANTHAN, V. SEBA-MALAI, V. SITHIVICNESWARAN, V. SIVAKUMARV.D.M.S. SUARIS, V.FERNANDO, W.A.Jayantha P. GUNEWARDANE, Yacintha THARAMALINGAM, MICHELE ABRIQUET, LOUIS AKIKI, ZOEF ALATAS,NICOLE ALLARD, DOMINIQUE ALLEGRINI, JEAN CLAUDE ALT, ARTURO ALVAREZ LOPEZ, CHRISTELE AMIGUES, SOISIC AMOURIAUX, ALESSANDRO ANDREONE, DANIEL ANGER, MANANA ANJA-PARIDZE, PAUL LOUIS APPRIOU, TAKAKO ARAI, RODOLFO ARCOVEDO, MATTIAS ARMSTRONG, ERIC ARTHOT, MARGO ASWAD, VERONIQUE AUBIN, HELENE AUDOIN, ANNIE AUGE, BERNARDAUMAITRE, OSCAR AVOGADRI, CHARLES-LOUIS AYOUN, BRUNO BACHELARD, JACQUES BAILLEAU, LIDIA BAIOCCHI, KEVIN BAKER, ANNE BALLIGAND, PHILIPPE BARAIZE, JOANNE BARBIERI,MARGARET BARCLAY, CLAUDETTE BARDIN, PASCALE BARNEAU, EMMANUEL BARON, LOICK BARRIQUAND, ISABELLE BARTE DE SAINTE FARE, HELENE BARTHELEMY, THIERRY BARTHES, MURIELBARTHOME, ANNE FRANCOISE BASQUIN, PIERRE BATAILLE, GUY BATTEUR, PIERRE BAUDINNE, BRIGITTEBAUDOIN, PATRICK BAUDRY, EDGAR BAYLE, NICOLAS BEAUDOUIN, INGRID BEAUJARD,FLORENCE BEAUVILLIER, DAVID BECKER, PIET BEKAERT, CARLO BELLONI, LAURE BELOIN, PIERRE BELOSSI, MOHAMED SABEUR BEN BEN HADJ HAMIDA, ANDRE BENBASSA, GILLES BENIS-TAND, JEAN PAUL BERARD, PHILIPPE BERARD, JEAN CLAUDE BERERD, ELISABETH BERGERON, MARIE ROSAIRE BERIOT, JEAN BERNARD, JEAN DOMINIQUE BERNARD, PIERRE BERNARD-GRIF-FITH, HELENE BERNEUIL, JOSE BERNEX, GUILLERMO BERTOLETTI, MICHELLE BERTSCH, DIDIER BESSOU, ARIANE BETZ, ODETTE BEUGNET, FRANCOIS BEUZART, EMILIE BIARE, CLAUDINE BIRAISDEBOEUF, JEAN-PIERRE BISSUEL, FLORENCE BLANCHET, FRANCOIS BOILLOT, EMMANUELLE BOLLEY, LAURENCE BOLSIGNER, RAUL BONIFACIO, DANY BONIJOL, MARYSE BONNEL, JEANMICHEL BONNET, FRANCESCO BONSANTE, MARIE-THERESE BONY, JEAN PIERRE BORELLI, MARK BORST, MABROUK BOUALLAG, ODYSSEAS (ULYSSE BOUDOURIS, JEAN JACQUES BOUGAULT,GUY BOULOUDRINE, MICHEL BOULVAIN, BRUNO BOURDARIAS, MARTINE BOURGANEL, ANDRE BOURGEON, NADEGE BOURSE, CLAUDINE BOUYSSOU, AGNES BOVERHOF, MADO BOYER, PIER-RE BOYER, AICHA BRAHMI, JEAN BRANELLEC, MICHEL BRAUN, BERNARD BREE, VERONIQUE BRIAND, MARION BRINKER, JACQUES BRIOIS, JULIO BRIZ EYSSEN, LADISLAS BRODI, ANNIE BROU-CHET, ANTOINE BRUEL, JEAN BRUNEAU, CATHERINE BRUNN, INGRID BUCENS, VINCENT BUDILLON, DAVID BUNKER, SYLVIE BUQUET, FREDERIC BUREL, LORRAINE (LORI) BURGESS, MARIADEL MAR BURON NUNEZ, BERNARD BURTEY, DIDIER BUSCAIL, GEORGES BUSSIOS, ERIK BUTIN, CARSTEN BYRN, PHILIPPE CABANEL, ISIS CACHO, ROBERT CAMBERLIN, DOMINIQUE CAMBON,CHRISTINE CAMPO, PIERRE CANELLAS, SILVIA CARBONELL, VALERIE CARLIER, MURIELLE CARON, PIERRETTE CARON, CHARLES CARRO, MARIA CARTWRIGHT, RICHARD CASEY, JEANNE (GENE-VIEVE) CASTEL, JEAN CAUSSIN, BERNARD CAVALIE, ERIC CERCIAT, EDMUND CHALONER, BERTRAND CHAMARTY, MARIE GENEVIEVE CHANSON, FREDERIQUE CHAPUIS, SYLVAIN CHARBON-NEAU, GUY CHARIGNON, LAURENT CHARPENTIER, SANDRINE CHARPENTIER, COLETTE CHARRIER, YVES CHARTIER, IOANA CHARTIER GUGONEA, JACQUELINE CHATENET, CLAUDE CHAUS-SENDE, EMMANUELLE CHAZAL-BERTOLETTI, JOCELYNE CHEBANCE, ALAIN CHIAPELLO, DOLORES CHOLET, DOMINIQUE CHRAIBI, JEAN-LUC CHUZEL, CATHERINE CLEMENT, JACQUES CLE-MENT, MARIE ANNE CLEMENT, REMI CERFEUILLE, PHILIPPE COCHET, BENOIT COLOT, CHRISTIAN COMMENCAIS, MADELEINE CONTE SIFUENTES, AMILCAR CONTRERAS, LAEL CONWAY, MAR-ZIA CORINI, PASCALE CORION, REMI COSSON, JEAN PAUL COURT, ANNE COURTRAI, IAN CREE, ANTOINE CROUAN, PHILIPPE DABADIE, RABAH DAHMANI, RICHARD DALE, JEAN MARIE DANO,JEAN FRANCOIS DARCQ, ASISDAS, LAURENT DAUMAS, CATHERINE DAUNAY, ALAIN DAUTHY, PATRICK DAVID, CHRISTIAN DAVYDOFF, HELENE DAVYDOFF, SEGOLENE DE BECO, LUC DECHAMPS, VERONIQUE DE CHASTEIGNER, MARIE JACQUES DE CHAZELLES, YANN DE FAREINS, CATHERINE DE LA BOUSSINIERE, CAROLINE DE LAMINNE, JEAN YVES DE LEMPS, LAURENT DEMONES, CAIO MARIO DE VECCHIS, DAVID DE WAVRIN, YVES DEBAILLE, JEAN MICHEL DEBARACE, CECILIA DEBERDT, FRANCOISE DEBRABANT, JEAN-PHILIPPE DEBUS, STEVEN DEFAUW, LAU-RENT DEFONTAINES, BRUNO DEHAYE, MARIE BERTILLE DEHOUCK, MARIE ANNE DELAUNOY, MARC DELGRANGE, PATRICK DENESLE, FRANCOISE DENIAU, FRANCOISE DESBOIS, DENIS DES-CHESNES, JEAN CLAUDE DESLANDES, SOLANGE DESRUES, CHRISTINE DETOUR, PATRICK DEWAN, FRANCOIS DIOT, JEAN-PAUL DIXMERAS, MARIE-CHRISTINE DONVAL, BRIGITTE DOSNE, JEANDOMINIQUE DOUBLET, BRIGITTE DOUCET, MONIQUE DOUX, JEAN-NOEL DRAULT, SOPHIE DRAUX, JACQUELINE DREXLER, JEAN BAPTISTE DRIENCOURT, ERIC DROUILLY, JOSEPH DUBICQ,FRANCOISE DUBOIS, JEAN DUBOIS, VERONIQUE DUBOIS, MAGALI DUCLOS, CLAUDIO DUEK, JEAN-BAPTISTE DUFOURCQ, DANIEL DUMAS, MARIE FRANCE DUMAS, ALAIN DURAND, MURIELDURAND, THIERRY DURAND, GEORGES DUVAL, JOHN JEREMIAH DUWEL, JOSETTE DYCKMANS, WENDY; DYMENT, VINCENT ECHAVE, CAROLINA ECHEVERRI, FRANCOISE ECK, JERRY EHRLICH,STEFAN EIDEN, KAREN EIGEN, GHAZI EL HAJJAR, MELIKA EL YOUNSI, JANE CATHRYN ELLIS, MARIA ERNFRIDSSON, RICHARD ERNST, SABELLE ESQUIRO, FLORENCE ETTORI, MARIE EULRY-BERIER, HELTRAUT EXNER, LUC EYROLLE, GENEVIEVE FALISE, PIERRE FALISE, CHRISTIAN FALLEVOZ, PIERRE FARRET, CHRISTIAN FASSIN, PATRICK FAURE, CHRISTINE FAYAUD, ROLAND FAYOL-LE, ROLAND FELIX, XAVIER FENET GARDE, PASCAL FENOUIL, FERNANDO OLINTO FERNANDES, CLAIRE-MARIE FEVRE, CLAUDINE FICHOU, ALAIN FILLET, MARIE ALETH FILLEUL, GABRIELAFILLON, JEAN PIERRE FILLON, RUDIGER FINGER, VLADISLAV FIRAGO, MICHELE FLAMENT, DONATO FLATI; JÜRGEN MARCUS, FLEISCH, EVELYNE FLORIS, ANNETTE FOMPEYRINE, LUC FOUR-GEAUD, XAVIER FOURIE, GILLES FOURTANIER, BRUCE FRANK, VIVIENNE FRIES, BRIGITTE FRIRY, SYLVIE FRITSCH, JEAN FROMENT, VINCENT FRUHAUFF, JUANITA FU, JACQUES GAILLARD, JOSE-PHINE PATRICIA GALASSI, CAROLINE JANE GALE, DENIS GALLOT, PATRICK GANANSIA, MIGUEL GARCIA LOPEZ, ALAIN GAROU, LAURENT GAURIAU, CATHERINE GAUTIER, JEANINE GAYRAUD,OLIVIA GAYRAUD, EMMANUELLE GEFFRAY, NADINE GERAUD, ROGER GERAUD, BRUNO GERBAUD, BERNADETTE GERGONNE, GILLES GERMAIN, CHRIS GILBERT, ISABELLE GIRET, CHRISTINE GLE,