Project 04 - Tsunami Relief
Background Overall Purpose Stage 1 - Kayts Stage 2 - Jaffna Town Stage 3 - Kilinochchi Stage 4 - Batticoloa Stage 5 - Colombo Stage 6 – Batticoloa Recommendations
Background On 8 December 2004 Dr S Ratneswaren, Director of Centre for Community Development and General Practitioner and Miss Anenta Ratneswaren, medical student at Imperial College, arrived in Colombo, Sri Lanka with the view of holding clinics in the North-East of Sri Lanka before returning to London, England on the 30th December 2004.
Overall Purpose Currently the method employed by the health services in Sri Lanka is for patients to buy an exercise (‘copy’) book where doctors record diagnoses and medications. The hospitals may or may not hold patient records – the majority of these have been lost or are incomplete, and in any case, there is no consistent format across the region. This situation was been identified as a problem at previously held clinics in the North-East region, held since 1992. Therefore the main aim of the visit was to explore and establish methods and systems of collecting, recording and storing patient records. A model patient record form was agreed on, translated into Tamil and produced for use at the clinics. In addition, CCD purchased the prototype for a computerised patient records database program. The ultimate goal was to carry out clinics in identified regions, and hold patient’s information on that one database. A basic medical kit was taken and included a blood glucose testing kit, blood pressure monitor and dressing kit. CCD has partner Community Based Organisations in the North-East region, and health work was organised in association with these. A secondary purpose of the visit was to develop relations between the locally-based organisations and the Centre of Community Development base in the United Kingdom. Stage 1 Kayts 14.12.2004 – 20.12.2004 A clinic was set up at a house in Naranthinai. People from the village would come to see Dr S Ratneswaren here for check-up’s and health queries. Dr S Ratneswaren would perform routine checks, advise on lifestyle and medication and refer patients to local doctors as necessary. Stage 2 Jaffna Town 14.12.2004 – 20.12.2004 As in Kayts, but there was no base at which clinic could be carried out, so home visits were made to identified patients who found it difficult to access the base in Kayts. If medication were needed then Dr S Ratneswaren would go to the local pharmacy to buy the drugs and then return to distribute them. The team were based in Kayts and would travel to Jaffna Town on organised visits during this period. Stage 3 Kilinochchi 23.12.2004 It was intended to briefly visit Kilinochchi en route to Batticoloa, liasing with KAROD to carry out a short clinic for the disabled people, identified by KAROD.
KAROD Kilinochchi Association for the Rehabilitation of the Disabled (KAROD) is based in Kilinochchi. As one of Centre for Community Development’s partners, KAROD organised an open clinic in Palai, Kilinochchi. KAROD has a team of volunteers who are responsible for identifying the physically and mentally disabled in the entire Kilinochchi District and then providing those people and their families with support, advice and contact. Sister Lourdes is the Director of KAROD and the point of contact for CCD.
KAROD identified patients who needed to see Dr S Ratneswaren, informed patients of the details of the clinic, and arranged a site at which the clinic took place. The plan was to conduct the clinic between 10.00 hours and 16.00 hours at a community building in Palai, Kilinochchi. The team consisted of Dr S Ratneswaren, A Ratneswaren, KAROD staff and a student volunteer from Georgetown University, USA, Miss B Vasagar. In addition, the team aimed to provide registration forms and establish the concept of systematically obtaining and storing patient records.
The community building at Palai consisted of one large room, and two smaller rooms. One of these smaller rooms is used on a permanent and regular basis by a group of young girls learning about tailoring and handiwork. The team set the larger room as the registration and waiting area, and the smaller room as the consultation room. More patients than were anticipated arrived at the open clinic, and the team only left after 21.00 hours after everyone was seen properly. X people attended the clinic, were seen by Dr S Ratneswaren and their records obtained.  A Ratneswaren also formed friendships with the local girls who were using the second room of the building. This group of fourteen girls, ages ranging from seventeen to twenty-five are all due to finish their training in dress-making at the vocational centre in Kilinochchi. They were all displaced several times over the last ten years.  Case Study – Jaya Santhanam. Eighteen year old girl living with her parents, older sister and older brother in Pulopalai. Jaya was displaced in Vanni for two years and was seriously affected by the civil war. She does not have contact with her eldest brother who is a member of the L.T.T.E.. Her parents are fishing people, but they no longer work. She has just finished her dress-making and handicrafts training at the vocational centre in Kilinochchi, but she is worried she has no use for these skills since she has not got a sewing machine.
Problems Several issues were raised throughout the course of the clinic. 1. Establishing an order for people to see Dr S Ratneswaren. There were a lot of patients to see one doctor, and they had all been told the doctor would be arriving at 10.00 hours on 23.12.2003 and instructed to come as early as possible to make sure they were seen. This meant there was a constant stream of people wanting to be seen as soon as possible.
A Ratneswaren and B Vasagar introduced a numbered ticket system to establish an order but team staff did not see the importance of upholding the system and disorder was restored. 2. The situation was exacerbated because · Many patients had work or family commitments that they abandoned in order to come to the clinic. Therefore they worried, for example, about the children they had left alone, the cooking they had to do, the jobs they had to get back to, the money they lost by taking a day off work.· The clinic was targeted at those with physical or mental difficulties. A vast majority of patients at the clinic had severe mental and/or physical disability and were restless and agitated.· Several of the patients were babies and children and became playful and restless.· Many of the patients travelled from distant villages with great difficulty, considering their physical disabilities. The only form of transport available to them was the bus, and many grew anxious about missing the last bus home (around ten patients had to get the last bus to xxx at 17.00 travelling over 2 hours).People were very stressed and worried whilst they waited to be seen and this did not create an optimal environment for the doctor or for the patients. A Ratneswaren, B Vasagar and KAROD staff gave priority to those patients who had transport difficulties or severe disability – but of course this is a subjective task that proved very difficult since every patient had some reason to be prioritised over the next. Also thought A Ratneswaren and B Vasagar had taken responsibility for issuing queue tickets, KAROD staff re-adjusted the order giving priority to certain patients. Therefore no one person maintained overall authority and the queue order disintegrated. 3. The people were so eager to see the doctor, the waiting room was so packed full of people, and there was no door in the doorway of the consultation room. This led patients to lean in the doorway and hover inside the consultation room whilst Dr S Ratneswaren was consulting with other patients. This was a massive problem, considering the stigma attached to disability and many of the patients came from the same villages where communities are especially close-knit. A Ratneswaren endeavoured to ensure that privacy and confidentiality were maintained, improvising with a ‘curtain door’ and then pleading with people to wait a given distance from the doorway. However, this good practice proved extremely difficult to maintain and there was a lack of respect for authority in that situation. 4. In addition the consultation became a through-fare for staff. Excluding the doctor and the patient, there was a minimum of three people in the consultation room at any given time. Working alongside KAROD staff, it would not have been sensitive to have raised the issue during the clinic. However, at the team evaluation it was stressed that the consultation should be as restricted to the patient and the doctor and then other healthcare professionals or medical students present only with the patient’s consent. 5. The clinic finished late in the evening due to the large number of patients that needed to be seen. There was no electricity at the community building in Palai, and the consultation room became very dark. Therefore the tables and chairs were moved outside and the last two hours of the clinic were carried out with the light of the moon and a bottle lamp.
Stage 4 Batticoloa 26.12.2004 – 28.12.2004
Dr S Ratneswaren and A Ratneswaren witnessed the people of the village come running to the stairs of the hotel to safety. However many of these were mothers who lost their children in the water before they arrived at the rest house. Case Study –
Dr S Ratneswaren assisted at Batticoloa Hospital on 27.12.2004 and on behalf of CCD, donated twelve BNF handbooks and four stethoscopes to Batticoloa Hospital. A Ratneswaren spent the day with Thadaham, a local community based organisation based in Kiran, Batticoloa and a partner of the Centre for Community Development. A Ratneswaren assisted with clothes distribution at the following camps: - Valachenai Puthokudoirapu Dinayalhaperum Myeaivikarache Navaladi Junction. 
Thadaham owns a truck, and after distributing clothes, the truck was used to transport people from Navaladi Junction and various destroyed sites, to shelter – and the Pentecostal Church Mission was set up as a Refugee Camp. Meanwhile, Dr S Ratneswaren saw approximatey 50 patients identified by Thadaham who came to the centre in Kiran.
Thadaham Thadaham is a local organisation based in Kiran, Batticoloa. Mrs Chandra is the Director of Thadaham and the point of contact for CCD.
Problems Many of the clothes were old and dirty rendering them useless. Though the clothes had been organised, there was little time to ensure people received the most appropriate clothes. At camps that had been established the day before, no arrangements had been made for waste disposal and the grass immediately outside shelters was a common dumping site for food.
Stage 5 Colombo 29.12.2004 – 30.12.2004 Dr S Ratneswaren and A Ratneswaren returned to Colombo to gather drug supplies with which to return to Batticoloa. First a comprehensive list of drugs currently available and prescribed in Sri Lanka was requested and collected from State Pharmaceuticals Corporation of Sri Lanka via Ms S Perera, Deputy General Manager. Funds were collected, made up of individual donations. Having made a preliminary health needs assessment in Batticoloa, Dr S Ratneswaren used the funds to buy drugs to meet those health needs. The drugs were purchased from different pharmacies, since not all pharmacies had complete stock of all required drugs and collecting these drugs was a time consuming process. In addition to the basic drugs supply, Dr S Ratneswaren collected a large supply of baby and infant milk foods from City Medicals, Colombo, toothbrushes and toothpaste, and feeding bottles. 
The team also went to the Health Education Bureau, Ministry of Health, Colombo with the aim of gathering any health education material to distribute at the refugee camps. Dr S Ratneswaren met with Dr K Ariyarathne, Community Physician, who was able to supply a sample of a ‘Health Tips for Women in Refugee Camps’ leaflet in Tamil and Sinhala (see Appendix 1). This was the first contact made by any team, body or organisation with the Health Education Bureau in regards to educating the public about health in the post-tsunami situation. Educating the population about a healthy and clean lifestyle contributes greatly to developing public health, which in turn develops society – and promoting health education at the camps was crucial in promoting good health, our primary aim. Problems Obtaining large quantities of drugs Availability of certain drugs Transport. On the route back to Batticoloa, the roads, at the best of times ridden with pot holes, were under 4 feet of water after the flash floods. The flooded roads were encountered on the outskirts of Eravur, Batticoloa at 22.00 hours so there was no light except for the headlamps of the van. Dr S Ratneswaren, the driver and local men had to push the van through the affected roads. Stage 6 Batticoloa 01.01.2004 – 06.12.2004 In the process of making contact with the Batticoloa branch of the Sri Lankan Red Cross (SLRC), Dr S Ratneswaren met a group of fifteen final year medical students, studying at Jaffna University but on leave and back at their homes in Batticoloa. Immediately a team was formed consisting: -
Dr S Ratneswaren - General Practitioner* Mr Mubarak - Public Health Inspector Batticoloa District* Dr G Murugan – Doctor, Batticoloa Hospital Mr M Mylashan – Final year Medical Student, Jaffna University* Mr P Sureshkumar– Final year Medical Student, Jaffna University* Mr V Sivashanker – Final year Medical Student, Jaffna University* Mr A Swarnan – Final year Medical Student, Jaffna University Mr G Ratheesh – Final year Medical Student, Jaffna University Mr Balamurah – Final year Medical Student, Jaffna University Mr Myuran – Final year Medical Student, Jaffna University Mr Thuvaharan – Third year Medical Student, Jaffna University Mr Skanthan – Third year Medical Student, Jaffna University Mr Jeyakanth – Third year Medical Student, Jaffna University* Miss A Ratneswaren – First year Medical Student, Imperial College* The team then used the van hired by Dr S Ratneswaren for the entire visit to Sri Lanka, to visit the most remote camps in the Batticoloa District and the Amparai District. The persons highlighted (*) were present at every camp visit. The team liased with the Batticoloa branch of SLRC and they provided a dressing kit and a trained volunteer to help dress the wounds of the people at the Refugee Camp at Mandressa on 01.01.2005. 01.01.2005 Refugee Camp, Mandressa Batticoloa Health Task Force Meeting This meeting was chaired by Dr Ganeshan and was attended by those who have since formed the Batticoloa Health Task Force – including Ms Marie-Jeane and Dr?, Sri Lankan Government Public Health Representative. Problems 02.01.2005 Refugee Camp, Thalavalar School, Chenkaladi Refugee Camp, Chenkaladi 
03.01.2005 Refugee Camp, Karuwakerni Community Health Centre, Valachenai Muslim Women Rights and Development, Eravur Murakadancheri School, Murakadencheri Thadaham Centre, Kiran
Muslim Women Rights and Development Centre Muslim Women Rights and Development Centre is a local community based organisation, based in the Muslim Tamil village of Eravur, Batticoloa. Mr Mubarak, Public Health Inspector in Batticoloa is the Director of Muslim Women Rights and Development Centre and the point of contact for CCD.
04.01.2005 Al-Jazheera School, Kalkudai Periyaneelavalan, Kalkudai Case Study – Periyaneelavalan. Here a fifth year medical student had sole responsibility for the health of his village before the team arrived. They had received no medical attention since before the tsunami had destroyed houses. They were starting to rebuild houses.
05.01.2005 Dr S Ratneswaren liased with Professor Rudra at Batticoloa Hospital. Dr S Ratneswaren liased with the Batticoloa branch of SLRC. A Ratneswaren liased with representatives from Oxfam, International Committee Red Cross and United Nations Development Program. Case Study – Follow up visit to young couple, both injured by the tsunami and just discharged from Batticoloa Hospital. The young lady had suffered a broken hip, and serious neck and foot wounds. The couple lost both their children, their daughter, 9 and their son, 7.
Case Study – visit to a family of two sisters, 24 and 22, and their brother 18, who lost their parents. Their parents had gone to pray at the local church in Kalady. The two eldest sisters are studying Medicine at Jaffna University and their brother is studying towards A-Levels. In addition, A Ratneswaren spent another day with Thadaham, visiting the Pentecostal Church Mission Refugee Camp, Karuwakerni, to help prepare the meals. This was found to house a large number of families, but was very well organised and had a strong community atmosphere. From what was seen, this could be largely attributed to the group of local NGO workers from Thadaham, ZOA and the SLRC. Particularly useful was the permanent presence of a group of Thadaham staff camping with the refugees, and with vehicles onsite 24 hours a day in case of emergencies. This was crucial because of the complete lack of communication lines, poor state of the roads, the lack of public transport to remote areas, the lack of vehicles suitable for the severely damaged roads and the long distance to the hospital. It is important to note that a strong support network has been formed by local NGOs, who have forged links with those in the camps, on a very individual, personal level. Where International NGOs have been involved, that feeling of security and reassurance was not reported by the people displaced in camps. Problems Problems here were similar to those encountered at Kilinochchi. 1. It was difficult to organise the consulting areas since the camps held so many more people than the building’s capacity. 2. Access to camps was impossible in some cases because the water was so deep. 4x4 vehicles may have been more useful but there were none available for hire or otherwise.
3. Access to camps in Amparai District – due to distance, and the Army blocking the road back to Batticoloa at 22.00 hours. 4. Supplies of certain drugs were depleted and people had to be driven to the nearest pharmacy whilst the clinic was running to buy more drugs.  5. At the meeting with Batticoloa Health Task Force on 01.01.2005 two local people who established contact with the camps reported that two out of three toilets at a camp serving over 1000 people were still locked. It was decided by those at the meeting to write to the appropriate government officials in Batticoloa and Colombo to give the Task Force authority to then obtain the keys of the padlock from the principal of the school being used as a camp. Days were passing by with inadequate sanitation and this was contributing to the problem. Dr S Ratneswaren commented the toilets should be broken by force immediately.
Recommendations 1. Develop practical and detailed guidelines, that can be adapted to any of the above situations, for organising immediate open clinics in disaster situations. For example recommendations for how to set up a consulting area with limited resources would be crucial to such a set of guidelines. 2. Develop practical and detailed guidelines for organising mobile clinics conducted under ‘normal’ conditions. 3. Establish the notion of patient confidentiality and respect for privacy amongst all health care workers and also the confidence to make sure all consultations are carried out accordingly. 4. Continue to work closely with the locally based organisations, and encouraging all international and governmental organisations to liaise with those working at grass-root levels. 5. Access – roads, vehicles 6. Public Health initiatives must be encouraged and all available resources utilised.
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