Sri Lanka 17 years of humanitarian actions

Report

Released by Médecins Sans Frontières in june 2003

Document en provenance du site internet de Médecins Sans Frontières http://www.msf.fr

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Background & context page 3 With the hope of lasting peace, the situation This document was inspired by a simple is slowly changing in the northern and eas- idea: how to mark the end of our missions 17 years of MSF programmes page 5 tern areas of Sri Lanka. The in after 17 years in this unique region of the these former zones of conflict is being resto- world. page 6 red and doctors and nurses are returning to We wanted to put something down in writ- take up long vacant positions. After suffering ting and to thank those who were there and & page 8 the consequences of the conflict, the popula- contributed to the programmes. tions are also returning to their villages in But we also wanted to share the experience page 11 the hope of building a new life. with those who did not necessarily partici- pate. Vavaniya page 17 Outside the zones of conflict, the Sri-Lankan So we decided to set about gathering the health system has always been highly develo- experiences and memories of those who Madhu page 18 ped and effective, with competent staff. Most were in Sri Lanka, as a way of helping others importantly the health system is free of char- to understand what it was like. Personnal memories page 20 ge and therefore accessible to the poorest There are no analyses, no comments, no cri- members of society. What could be better ticisms… We have compiled this account of Human resources page 25 than applying this system throughout Sri facts and emotions experienced by all those Lanka, to all Sri-Lankans? The reasons for working in Sri Lanka and have published Thanks page 26 MSF’s presence in the areas isolated by the without commentaries. conflict no longer exist. MSF France has the- We would like to thank all those who contri- refore decided to close its programmes by the buted to this document, near or far, directly end of June 2003 but MSF Holland continues and indirectly. to support the obstetrical and gynaecological Many thanks to all institutional donors who services in the of Puthukkudiyiruppu. help to finance the mission. Photos : Front and back pages : D. Lefèvre - P. 3 : D. Lefèvre MSF-Holland is also training the hospital - P. 4 : E. Bouvet - P.5 : D.Lefèvre - P.6 : Y. de volunteers there. A new programme in the Our apologies to those who we were unable Fareins - P. 7 : D. Lefèvre, MSF - P. 8 : MSF - P. 9 : D. Lefèvre, MSF - P.10 : MSF, D. Lefèvre - P. 11 : D. hospital of Mullaitivu will start soon. In to include, because of time or distance. Lefèvre, S. Crisan/MSF - P. 12 : MSF - P. 13 : G. , near the former front-line, MSF- We also apologise to any of the national staff Myers/MSF, MSF - P. 14 : MSF, S.Crisan/MSF - P. 15 : Holland is running a community-based and volunteers whose names may have been MSF - P.16 : MSF, Y. de Fareins - P. 17 : MSF - P. 18 : C. Perera/Gamma - P. 19 : D. Lefèvre - P. 20 : MSF - psychosocial project focusing on war trauma. forgotten at the end of the document. P. 21 : MSF - P. 22 : E. Bouvet - P. 23 : MSF - P. 24 : MSF. We would particularly like to thank the Front page: Rédacteur en chef: Anne Fouchard national professionals without whom our waiting for consulta- Rédaction: Isabelle Ferry 17 years of work would not have been pos- tions. Trincomalee hospital. Co-rédaction: Remi Vallet 1997. Graphisme et fabrication: TC graphite sible. Réalisation: juin 2003 Back page: Translation: C. Serraf, L. Brumer, D. Chanley Tamil family waiting for the SLA to release their sons. Many thanks to evryone who contribuated to this Point Pedro 1997. brochure: 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.

2 two W most of theadministrative positions under (mostly Hindu).Although theTamils held ty (mainlyBuddhist) andtheTamils tensions between theSinhalesecommuni- Buddhism the nationalreligion, stirred This newconstitution, whichmade under thenewconstitution. that theislandwasrenamed Sri Lanka its independence,butitwas not until1972 1948, theislandofCeylon finally gained control in1796,whichlasted 152years.In before17th century comingunderBritish then fellintothehandsof Dutchinthe Portuguese colonyinthe16thcentury. It turies, theislandlater becamea influence betweenthe14th and 16thcen- have longbeencoveted. Under Indian The naturalbeautyandrichesofSriLanka A COVETEDISLAND by over400,000overseastourists. the island’s beacheswere southern visited army andTamil rebels claimed4000lives, makers: in2000,whenclashesbetweenthe years ofcivilwarhavenotputoff holiday- friendly andwelcomingpeople.Twenty abundance ofwildfauna,andaboveall,the as fartheeyecansee,topicalforests, an ches linedwithpalmtrees, teaplantations mysterious traditionaldances,sandybea- fine architecture, archaeological treasures, r size. Alltheguidebooksacclaimtreasu- that itwasthemostpleasantislandofits this island,430kmlongand225wide, the coastofIndia.Marco Polooncesaidof Ocean, isanislandparadisejust50kmoff Sri Lanka,surrounded bytheIndian es ofthisislandthesizeIreland: the elcome to Paradise ! peace talks. Since then further steps T signed apermanent ceasefire with the from theopposingUnited NationalParty) prime minister RanilWickremasinghe is is from thePeople’s Allianceandwhose (whose president Chandrika Kumaratunga sing. InFebruary2002,the government tions, thecurrent talksseemtobepromi- After three failedrounds ofpeacenegotia- HOPE OFPEACE gees ormissing. and hundreds ofthousandspeople refu- conflict haveleftmore than60,000dead tion strikesaround Jaffna. 20 yearsof north thearmylaunchedmassiveretalia- T funeral inthecapitalColomboand3000 ambush. Riotsbroke outatthesoldiers’ army soldierswere killedinanLTTE civil warreally began.Thirteen SriLankan However, itwasnotuntil1983thatthe the Tamil peninsulainthecountry’s north. the mayorofJaffna, atownintheheart of gered notablywiththeTNTassassinating Lanka. Violent confrontations began,trig- provinces ofthenorth andeastofSri for anindependentconstitutionthe (LTTE) in1976.These movementscalled the LiberationTigers ofTamil Eelam V New Tigers (TNT) wasfoundedby nity. In1972,therebellion army, theTamil causing angeramongsttheTamil commu- claimed thecountry’s soleofficial language marginalized. In1956,Sinhalesewaspro- the British,afterindependencetheywere amil Tigers whichpaved thewayfor new amils were killed,meanwhileinthe ellupillai Prabhakaran,wholaterformed sist, hopehasreturned toSriLanka. boycott them.Althoughtensionsstillsub- 9th– 10thofJune.ButLTTE decidedto of talkswere duetotakeplacein Japan on northern andeastern regions. Newrounds 2002, theprincipleofautonomyin ted, inanagreement signedinDecember pendent state,andthegovernmentaccep- have abandonedtheirclaimforaninde- war. Onapoliticallevel,theTamil Tigers two sideshaveexchangedprisonersof disarmament process hasbegunandthe r links betweentheJaffna peninsulaandthe toward peacehavefollowed.Airandroad est oftheislandhavebeenreopened. The

Sri Lanka > > > > Republic ofSri Lanka Democratic Socialist Official name: > > P pendence in1948) ting thecountry’s inde- 4th February (celebra- National holiday: coastline km. 1,340kmof 65,610sq Land area: aa:1% Malay: , Burgher, other: 7% Moor: T 74% Sinhalese: hita:7%. Christian: 7% Muslim: 15% Hindu: 70% Buddhist: Religions: aia iy city: Capital ml:18%, amils: plto:19576783 opulation: Facts a Facts nd figures three 3 Médecins Sans Frontières in Sri Lanka War Timeline

> 1972 New constitution. Buddhism becomes the State religion. Birth of the Tamil New Tigers (TNT), Tamil armed rebel movement. > 1976 The TNT becomes the LTTE (Liberation Tigers of ). > 1982 Tamil party boycotts presidential elections. > 1983 Civil war begins. > 1985 First peace negotiations collapse. > 1987 Armed military offensive. The LTTE ON BOTH SIDES In the zones under LTTE control and the retreats to the Jaffna OF THE FRONT LINE so-called “grey zones” (those controlled peninsula. Deployment MSF set up missions both in towns under by the army but with pockets of LTTE of an Indian peacekee- ping force. Since 1986 Médecins Sans Frontières has government control and in zones held by resistance) MSF endeavoured to provide > 1987-1990 been working in Sri Lanka pursuing the the LTTE. We worked in public access to care for people in vulnerable Repeated LTTE attacks same objective: providing assistance to (some in the hands of the government situations, including many displaced peo- against Indian soldiers. populations directly victim of or isolated by others controlled by the Tigers – like ple. At Madhu and in the entire Jaffna The latter take revenge the conflict, while denouncing violations of Trincomalee, Point Pedro, Jaffna and peninsula, as well as around Batticaloa, we on the civilian popula- tion. human rights and humanitarian rights. Batticaloa) to help make up for the lack of provided food and medical assistance, and > 1990 Tamil specialist doctors (many of whom set up epidemiological prevention pro- Retreat of Indian troops. With these principles in mind, MSF set up had chosen exile to flee the conflict) as grammes and vaccination campaigns. > 1991 two types of programmes. The first set well as a lack of material resources. MSF LTTE assassinates Rajiv about to help existing health facilities to provided surgeons, anaesthetists, mid- Finally, making the most of our presence Gandhi, the Indian ensure essential services were provided in wives, nurses, and even paediatricians, on both sides of the frontline, MSF prime minister.s the large hospitals situated in the zones of gynaecologists, obstetricians, in addition transported many patients in need of > 1993 The President, conflict. Surgery was the main activity in to the usual administrators and techni- emergency medical care to appropriate Premadasa, is killed by this civil war context: over the 17 years, cians. We used our status as an internatio- facilities. a bomb. nearly 260 expatriate surgeons have wor- nal non-governmental organisation to > 1994 ked in the operating theatres of Sri Lanka. convince the ministry of health to allocate Again, our status as and an independent Chandrika Kumaratunga, The second type of programme involved the resources needed, and the ministry of NGO often enabled us to get past check- elected president, re-opens peace negotia- setting up mobile to provide the iso- defence to allow us access to the regions points and zones of fighting which pre- tions. lated population with access to care. affected by conflict. vented patients from getting to hospital.

4 four 17 years of MSF programmes in a country at war Sri Lanka War Timeline

1988 hospital. Batticaloa carries out 3,400 ope- > 1995 the majority of doctors in the north and rations a year (of which 20% war surgery). Peace negotiations fail, LTTE renews bomb east of Sri Lanka leave the country to esca- In Vavuniya, a team covers the surgical attacks. Army launch pe the fighting. 50 MSF surgeons, and as and anaesthetic needs (2,200 operations a military offensive in the many anaesthetists, work in turns in the year). In 1996 Jaffna hospital is partially north: LTTE troops leave four hospitals in war zones: Trincomalee, destroyed. One year later, MSF obtains Jaffna. Mannar, Point Pedro and Batticaloa. First authorisation to work there and carries > 1996 Bomb explodes in mobile clinics in Batticaloa. out over 8,500 surgical operations. Colombo. Nationwide state of emergency declared. 1989-1991 1998-2000 > 1997 brief period of calm, then renewed fighting Supplying drugs and materials remains Major new military offensive against the resulting in a flood of wounded arriving in difficult. Activities are set up to improve LTTE. Point Pedro. Seven missions in total, surgery conditions (hygiene, asepsis, steri- > 1999 including four surgical. First mobile cli- lisation, post-operative care etc.). At the Wounded in an attack, nics in Mannar. end of 1999 emergency interventions Chandrika Kumaratunga increase, MSF therefore increases it teams. is re-elected president. After the bombing of Madhu church, MSF > 2000 Tigers make new 1992-1994 re-opens its surgical activities in Vavuniya. breacktrough. in the IDP camp in Madhu, four people per- In Batticaloa, surgery conditions improve > Décembre 2001 form minor surgery and evacuate patients with the renovation of the operating thea- New government. that require more complex surgery. New tres and the burn victims ward in the > Février 2002 surgery and programme in surgical department. In 2000, 13,354 Cease-fire signed, a Kilinochchi (October 94). First mobile cli- patients were admitted for surgery: pre-requisite for peace- negotiations. Norway nics in Madhu. 5000 operations were carried out, inclu- acts as mediator. ding 1,200 major operations (one out of are sent on short-term missions. In 2001, > Septembre 2002 five for war injuries). In January 2000, of the 24,067 patients admitted to the 1st round of negotiations 1995-1997 MSF re-opens its activities in Point Pedro. three surgical wards of Batticaloa, in Thailand. Road and violence escalates. It becomes more and A further surgeon and anaesthetist are Vavuniya and Point Pedro, 8,900 were air liaisons are re-opened between more difficult to provide assistance to the sent. operated, including 2.5% war wounded and civilian population. ‘Strategic’ drugs (far less than previous years). the rest of Sri Lanka. (anaesthetics, analgesics) and medical > Juin 2003 materials must be submitted for authorisa- 2001-2002 Negotiations are due to tion before being transported to conflict The effort put into improving working be held in Japan as well 2003 as a meeting with donor areas. In Kilinochchi, an LTTE town, the conditions and the case management of With the hope of lasting peace, the health countries for the recons- government refuses us authorisation to patients begin to show. In Batticaloa a pain facilities of the north and east of the island truction of Sri Lanka. open a surgical programme. The fighting management programme is set up for are functioning relatively well again. The LTTE boycott. around Jaffna pushes the populations major burn victims and patients in post- war surgery programmes are no longer jus- towards the east: Point Pedro hospital operative care. Specialised surgeons tified. Médecins Sans Frontières is closing becomes the only accessible surgical (orthopaedic surgeons, plastic surgeons) its programmes and leaving the country.

five 5 In the beginning, there was Trinco

After an initial evaluation mission in 1983 zone of Trincomalee is off limits to forei- permanently in the Trincomalee district. (which did not lead to an intervention), gners. Following our evaluation mission, Alain Rouvillois has replaced the former Personal MSF first began working in Sri Lanka in the ministries of Health and Rehabilitation coordinator Joaquim Miro. An ophthalmo- Memories 1987 with a surgical programme in the have offered to collaborate with us on an logist will soon join the surgical team. The eastern town of Trincomalee. assistance programme for the displaced conflict seems to have intensified over the people around Tincomalee. A surgical past few weeks. We are currently looking “I spent around a year in Below are extracts from Messages Sans team could work in the hospital and ano- at the possibility of setting up a mission in Trinco. The anaesthetists Frontières at the time. ther team could work in the camps and another district of Sri Lanka. called it the ‘Club Med’ mis- sion where they particularly isolated villages. The board has accepted enjoyed the ‘anaesthetist’s this new programme and we have begun beach’. MESSAGES NO. 4 - SEPTEMBER 1986 setting up a surgical team. MESSAGES NO. 12 - APRIL 1987 Joking aside, a few days after I arrived two members Françoise Body and Antoine Crouan On Friday 17 April, 10 km from of the house staff were recently went on an evaluation mission Trincomalee in the northeast of the island, arrested by the army in a following the deteriorating situation in the MESSAGES NO. 6 - 31 OCTOBER 1986 an armed group massacred 120 people and morning raid after a public northern and eastern areas of Sri Lanka. A new programme has just been opened in left around 50 injured. The Médecins Sans denunciation of Tamil sup- porters in the town centre. The conflict has divided the two ethnic Sri Lanka. An evaluation mission was Frontières team operated on the injured For several weeks I met with communities; the Singhalese (12 million) conducted in August 1986 in the north for 48 hours non-stop. the military chief in the and the Tamils (3 million). Tamil guerrilla and eastern zones of the island where zone, asking to visit and armies have been operating in the north Tamil guerrilla forces are fighting govern- talk to our arrested staff. I wanted to be sure they and east of the country since 1982, ment forces. were not being treated demanding full independence for this part The minister of health has accepted a badly and had not been “I remember a bomb that exploded at the Trinco mar- of the island: violent clashes have conti- medical-surgical assistance programme for ket in the middle of summer, 1989. It was devastating; deported to another camp. nued since. the displaced civilian population in the the mutilated bodies, the injured taken to hospital. The day they were both The horror… We were worried that some of the team released, the entire MSF MSF had sent a team to Sri Lanka in 1983 district of Tincomalee in the northeast of might have been caught in the explosion.” house in Trinco celebrated. to evaluate the medical needs of a group of Sri Lanka. displaced Tamils in the north of the coun- The programme is currently being set up. Anne-Marie Gloaguen, nurse in Trinco That same year our ambu- from February to August 1989. lance was attacked by the try. At the time, several Ceylonese organi- Joaquim Miro and Anne-Françoise army on the road to sations were providing assistance to the Basquin are heading the coordination Madhu. The teams were population there: MSF was not present. team. A surgical team should soon join the very shaken and our pro- The current situation means it is difficult first medical team. This surgical team will grammes were disrupted. We remained on stand-by for the civilian population to move about work in the district hospital, which is the for about three weeks, tur- the country, isolating them. MSF has the- only reference facility for the population ning things over in our refore sent an evaluation mission to the of 250,000 people. minds and discussing our district of Trincomalee in eastern Sri The violence is intensifying in this strate- motivation behind working with MSF and at what point Lanka. gic region. the risks become too great.” Of the 250,000 inhabitants in this district, 50,000 are internally displaced people. Ariane Betz, anaesthetist Several villages have been destroyed both MESSAGES NO. 10 - FEBRUARY 1987 nurse in Trinco, and then Monaregala, from March by resistance movements and by govern- Médecins Sans Frontières is sending more 1991 to May 1992. ment forces. Like Jaffna and Batticaloa, the volunteers. Nine people are now working

6 six Trinco Sri Lanka My best mission

Elisabeth Szumilin, now doctor with the evacuate two children: one was suffering medical department at headquarters in Paris, from severe de-hydration, the other had describes her second mission with MSF. It pneumonia with respiratory distress – all was in 1987-1988 in Trincomalee… that on a bicycle … We finally re-started working, along the same lines as before. I have very good memories of Sri Lanka. It From top to buttom: - Elisabeth Szumilin (doctor) and was my best mission. Master Léo (her translator) in consul- Although hard to believe, for 15 months MY LEAST PLEASANT SOUVENIRS? tation. Trincomalee district. 1987. - Hospital ward. I got up at 5.30am every morning, to get One day I was unable to save a mother’s - Queueing for consultations. Mobile the 6am boat. I don’t think we (Gigi, the fourth and last living son. He had attemp- clinics .Trincomalee. 1987. nurse and I) ever missed that boat. ted suicide by swallowing poison. I still I suspect that the captain may have ask myself today if I could have done delayed the departure a bit if he didn’t see more…. The anaesthetist was very sup- memories of the mission. It meant that we us at six o’clock sharp half asleep at the portive and spent a lot of time with me were accepted and respected by both par- front of the boat: what had become ‘our’ explaining that I had done everything pos- ties and thus able to work. spot (inside the smell of diesel could make sible. even a Parisian throw up). The neutrality was not a hoax. For me After the army attacked a camp, the Tigers there was no difference between a Tamil As soon as the villagers realized that they ‘strongly encouraged’ us to come and and a Singhalese patient. I refused could count on us at the time we had photograph the massacre: we saw only to learn either of the languages! It would arranged, they used to come. Sometimes women, children and elderly Tamils burnt have been seen as taking sides, or I would there were so many of them we could only in their homes. We found ourselves in the have had to learn both languages simulta- treat the most urgent cases. middle of the attack on the camp. After neously! I was terrified that I may have to ‘operate’ several hours, when the fighting had finis- in the jungle. In the evening, or at night, hed, we came out of the house where we To mark our neutrality, we also worked in after work, we would go and help the sur- were hiding and tried to go into the camp Singhalese facilities and supplied them gical team ‘hold the retractors’. I wanted to to offer our help to any wounded military. with drugs. Despite the fact that they had learn in case I came across an emergency They declined our help. But I still think far fewer needs, I carried out consultations in an isolated zone. The surgical team was that it was thanks to these ‘small gestures’ with them. great. I learnt a lot from them. that we were authorized to access the The army knew we supplied medication to One day the Tigers attacked Trincomalee. zones outside government control and the Tamils. I used to hand them to one My superiors forbade me to return! I still thus provide assistance to Tamil popula- person only, always the same: a second haven’t forgiven them !!! So I ended up tions who had no access to health care year medical student who had joined the staying longer. As I was convinced that because they did not dare approach the Tigers. The young man was killed. One of there were still many needs in the area, I checkpoints. our young civilian volunteers was also set out on another evaluation mission, on killed, and many others besides: the chief a bicycle (because of the remote controlled of the Singhalese military, who we were mines. It was safe on a bicycle, unless WORKING ON BOTH SIDES very fond of, was killed in a suicide attack someone really had it in for you). In the The neutrality of the teams I worked with in Colombo. He was curious about us, first village we visited, we urgently had to is one of the reasons I have such good about our culture….

seven 7 Jaffna and Point Pedro, in the heart of the peninsula

Jaffna peninsula, home of the Tamil Tigers, In the summer of 1995, the army launched still made the delivery of supplies very dif- lies off the north of Sri Lanka. Its former a major military operation called “bond en ficult. Jaffna hospital was back in service Personal population of 1 million inhabitants has hal- avant” to regain control of the peninsula. with 600 beds, but most of the wards were Memories ved to 500,000 as a result of the conflict. The town of Jaffna was the first to fall. still in need of specialist doctors. MSF The peninsula is linked to the rest of Sri Within a few weeks, hundreds of people stepped in at the request of the Sri Lankan Opening of Point Pedro Lanka by two bridges which were often clo- died in the offensive, many of them civi- Ministry of Health, and provided the sed during periods of fighting. As it was lians. The Sri Lankan army seemed to be human resources needed in general surge- The escalating fighting on therefore rarely accessible by road, the trying to crush the Tamil army forces to ry, paediatrics and obstetrics-. Jaffna peninsula in northern MSF teams used to take the ICRC boat force their leaders back to the negotiating Sri Lanka has resulted in a massive and prolonged from Trincomalee. Army blockades com- table, rather than simply trying to conquer flood of casualties admitted pounded the difficulty of getting supplies to the LTTE stronghold. Sadly many civilians A FRAGILE RECONSTRUCTION to the hospitals of this the peninsula. This isolated zone where paid for the fighting with their lives. In PROCESS region, as well as large Médecins Sans Frontières first set up a sur- September 1995, a flood of casualties arri- In 1997, the reconstruction process on the displacements of population. gical programme in 1987 in Manthikai ved at the hospital in Point Pedro where peninsula was under way and nearly A medical-surgical team hospital, Point Pedro, was under constant the MSF team was working. Fourteen 50,000 people were able to return to the made up of 9 MSF tension. The difficulties encountered in patients with serious injuries were admit- region. MSF sent another surgeon and volunteers (surgeons, doc- tors and nurses) left on providing assistance were numerous. ted on 21 September. Among them, four paediatrician to join its team in Jaffna 2 June. The government has children died from their injuries. The next hospital, and began reconstruction of part officially authorised MSF day the situation deteriorated even more, of the hospital despite the ongoing diffi- to work in Point Pedro. The population of Jaffna has been displa- and 25 more injured arrived, mostly culties with supplies. But the Sri Lankan The various parties seem to welcome our presence. ced many times and the peninsula’s infras- women and children. Ten of them died, government soon found the money nee- tructure, particularly the health facilities, including six children under the age of ded to make the public services function Messages Sans Frontières, have suffered from the escalating violence. ten. By 4 o’clock that afternoon, 150 chil- again. After ten years, MSF finally closed 12 June 1987 The conflicts began between various Tamil dren had been hospitalised after their its surgery programmes in Jaffna and Point movements from 1983 to 1992, then flared school was bombed. Fifteen of them later Pedro hospitals. MSF continued its paedia- up between the LTTE and the Indian pea- died. trics programme in Jaffna hospital, which cekeeping force between 1987 and 1990, had just restarted after the negative results and later shifted to the LTTE and the Sri It was not until May 1996 that the army of an evaluation of the premature infants Lankan army from 1990 until 2001. finally managed to take control of most of and intensive care wards. Nearly 160,000 people have been displa- the island, forcing the Tigers to retreat. ced within the zone during the various Jaffna hospital was partially destroyed in In January 1998, local elections were sup- conflicts. The entire population has been the battle of the town. It had been the posed to end military rule, paving the way isolated from the rest of the island with no second biggest university hospital in Sri for some kind of democracy. But this possibility of leaving the peninsula by Lanka with more than a thousand beds. transition was soon compromised when land. In June 1996, one year after the embargo the mayor of Jaffna was assassinated in that paralysed the population and its May the same year. For the first three health facilities had been lifted, basic food, months of the year, the situation remained A BLOODY SUMMER medicines and other medical equipment unstable, but the violence soon spiralled. From 1992 to October 1995, the Jaffna were still in short supply. The strict From December 1999 the sector known as peninsula remained under LTTE control. control held by the Ministry of Defence Elephant Pass was the scene of violent

8 eight Jaffna & Point Pedro Sri Lanka

ment and medicines. Goods, and more Facts and figures importantly people, were free to move Jaffna Programme about again. Supplies were also made pos- Surgical, paediatric and sible in zones controlled by the LTTE. obstetrics assistance MSF was able to relaunch its mobile pae- > Opened in March 1997

diatric clinics from Jaffna in three areas of > Closed in March 2003 the peninsula: Kayts Island, Tellipalai and Chankanai. The end of the embargo on > Population covered: 500,000 medical equipment enabled MSF to provi- de significantly more aid to the popula- > MSF staff 2002: 3 (2 paediatricians and tion. 1 nurse)

> Local staff: 4 The last programme MSF maintained on the peninsula was the epidemiological > University hospital in Jaffna: Total number of monitoring of the tens of thousands of admissions in paediatrics displaced people living in unsafe health in 2002: 7,950 conditions in the camps of the region (in Tenmarachchi, east of Jaffna near , and in the Weligaman zone). Owing to the concentration of clashes between the LTTE and the army. home. These precipitated forced displace- population in certain zones, a sentinel sur- Given the threat of heavy fighting and ments back to former zones of conflict veillance system of the various IDP sites large movements of troops, 150,000 civi- resulted in many accidents caused by anti- was set up. Each week, the network of lians were left with no choice but to flee personal land mines. The surgery depart- medical students went to the field to col- their homes. MSF reopened its surgery ment performed countless amputations of lect data in order to avoid the outbreak of programme in Point Pedro hospital after lower limbs. MSF began lobbying to stop epidemics. At the same time, the teams the fighting began, sending a team and the army forcing the population to return began looking into whether the people Point Pedro Programme Surgical Assistance much needed emergency equipment. In before proper mine clearance operations could be moved to safer areas, in collabo- Jaffna, the mobile paediatric clinics, which were performed. ration with the hygiene services and other > Initially opened: 1987 had been set up at the beginning of the NGOs. > Temporary closure: 1997 month, were temporarily suspended At the time, the situation was unstable and In February 2002, the new government > Reopened: 1999 during the fighting. The paediatrics ward gunfire was still daily occurrence. But the and the LTTE signed a definitive ceasefire > Population covered: at Jaffna hospital remained in operation, situation finally calmed, with no obvious agreement, and the peace process began. 100,000 with a further paediatrician and mid-wife fighting. It was not until December 2001 In December that year, MSF was able to > MSF staff (2002): sent to join the staff already there. that the situation became noticeably more transfer most of its activities to the hospi- 4 (1 surgeon, 1 anaesthe- calm. The new government signed a cea- tal’s authorities. In 2003, MSF continued tist, 1 gynaecologist-obs- sefire put forward by the LTTE, and this to provide a team of surgeons, as well as tetrician, 1 nurse) TOWARDS LONG-LASTING PEACE time the two parties respected the agree- some drugs and medical equipment to the > Local Staff: 3 In 2001 the army decided to send the ment. The following month, the govern- hospitals in Point Pedro and Jaffna, before population in the conquered territories ment lifted the embargo on medical equip- leaving in May.

nine 9 Jaffna & Point Pedro

From top to buttom: Hell next to paradise

- Women waiting for their anti-natal consultations, Point Pedro hospital. Maria Cartwright did two missions with clear sign that heavy fighting had taken tal to see if we could help. The United - Point Pedro hospital. MSF in Sri Lanka. Her first was in 1998 place. Once we reached KKS, the journey Nations told us two expatriates had been - Military checking the civilians paper when she was field coordinator in Jaffna for still wasn’t over because we had to take the killed. We were devastated because all the at the Check-point near the hospital. ten months. Her second was in 1999 when road in a long convoy to the town of expats knew each other. We searched for she was medical coordinator for four Jaffna. And security? I didn’t realise how them throughout the hospital, even in the months. Today, Maria is head of human dangerous it was until I got there. As soon morgue. resources for MSF Australia in Sydney. She as the boat left, the soldiers searched eve- remembers her first mission on the penin- rything, even the packets of tampons! We When I got back to the emergency ward, I sula well. had a lot of trouble with certain medicines saw the strangest thing in my life. I can because the transport agreements depen- hardly find the words to describe it. There In 1998, most of the Jaffna peninsula was ded on the Ministry of Defence. Once, were bodies lying on the ground. Then we under the control of government forces. when we wanted to take in ergometrine realised the two expatriates were in fact sol- But it was nevertheless impossible to get (to stop haemorrhaging), the authorities diers whose skin had been blown off and so there by road because the Tamil Tigers wouldn’t let us because they didn’t want they looked like white men. It was awful. held the northern part of the island. The the Tigers to use it to treat their war woun- On the other hand, one of my best memo- only way to get there was by sea. We used ded. And we always had problems brin- ries was when we went to the islands west of to leave from Colombo by car to ging in anaesthetics and analgesics. Jaffna. It was the nicest evaluation mission Trincomalee, where we took the ICRC I’ve ever done. After visiting the hospital in boat. It was an epic journey: our departu- The town of Jaffna was always unsafe. Kayts to see if everything was working well re depended on the intensity of the figh- That was also where I had the most dan- and to evaluate the needs of the hospital, we ting on the peninsula and the sea condi- gerous experience of my time in Sri Lanka. left for the islands where those seeking refu- tions, and we had to travel 50 km from the One day, we were near a civilian building ge in stopped on their journey. The coast to be out of reach of the firing. The where a big meeting was being held bet- population seemed to be doing well and had journey to Kankesanturai (KKS) took 20 ween the mayor and the military leaders. decent access to treatment. And those coral hours, and when we got to the port it was The Tigers exploded a bomb there. After islands, the white sand, the palm trees… it filled with boat that had been bombed – a the huge explosion, we went to the hospi- was like a post card. It was magnificent. Almost getting used to peace

We had almost forgotten what it was like. The With no people left in Jaffna, the Singhalese army bags or suitcases are offered a cup of tea or soup south of the island featured in the tourist catalo- took control of a deserted town. The lion on the when they arrive. Transport is then organised to gues again. But the tourists will not be able to national flag now watches over a town abando- Kilinochi. reach the north or east of the country. Last ned by the Tigers. A military victory for one side, spring, Tamil separatists broke the ceasefire sen- but a political victory for the other. It is difficult for the various humanitarian organi- ding the country back into another spital of vio- sations to evaluate the needs of the population. lence. Then in July, army offensives halted the Every day from mid-October, thousands of boats Out of the nearly 170,000 displaced people in the peace negotiations. The government concentrated crossed the lagoon separating the Jaffna peninsu- district of Kilinochi, 148,000 people are staying all its forces to regain control of Jaffna, the capi- la from the rest of the country. The journey is free with family or friends, 22,000 in schools, public tal of the Tiger rebellion. for some, others have to pay – it all depends on buildings and various temples. During the military advance, the population of the “relationship” the family has with the the peninsula gradually decreased as several Liberation Tamil Tigers of Eelam (LTTE) and with Valérie Brouchoud, thousands of people left in an exodus that was its “humanitarian” branch (TRO). Families lea- field visit, communications department, too well organised to have been spontaneous. ving everything behind them except for a few Messages, January 1996.

10 ten Batticaloa, trapped intheeast very presence wasacomfort to thesepopu- teams provided in theisolatedvillages, our apart from the medical assistancethese to overcome numerous securityproblems: ded tosetupmobile teams.Theseteamshad from having accesstohealthcare, MSF deci- Batticaloa even more andprevented them ce whichisolatedthepopulations around In October1990,giventheescalating violen- ly surgeons and paediatricians. re wounded duringemergencies. MSFtherefo- were notabletocopewith theinfluxof fled theregion: thosethat hadremained gical wards asalmostall thesurgeons had rian law. We firststarted workinginthesur- speak outabouttheviolation ofhumanita- healthcare tothepopulation, butalsoto gramme wasessentialinorder toprovide until 1989.Rightfrom thestart, ourpro- in 1987andwastheonlyforeign presence MSF openeditsprogramme inthehospital checkpoints. ceed ingettingthrough thevariousmilitary to obtainendlessauthorisationsandthensuc- to theonlyhospitalstillrunningpeoplehad healthcare, theclinicswere closed,andtoget r difficult. Theentire zonewasblocked:asa all travelandtransportofgoodsextremely hands oftheTamils. Frequent fightingmade the army, thesurrounding area wasinthe and theroad thatledtoit,were controlled by it totherest oftheisland.Althoughtown, ever frequent checkpointsontheroad linking the military presence wasclearlyvisiblewith Sri Lanka.Already, 50kmbefore thetown, the middleofan‘uncleared’ area ineastern Batticaloa, orBattiasitisoftencalled,wasin esult thousandsofpeoplehadnoaccessto

provided thehospitalwith help,essential- surgery andgeneral casemanagement. with apain management programme, plastic patients. In2002 wehelpedburnvictims improve the casemanagementofthe burn rable sequelae. From thestart, MSFbeganto self-immolation isfrequent, leavingconside- the highestsuicide ratesintheworld,and are manyinBatticaloa).Sri Lankahasoneto management ofburnvictims(of whichthere hand surgery andin2000improved thecase we couldfollow-up.We thusintroduced cases theteamscouldnotoperate, butthat geons, orthopaedic surgeons) forspecific MSF wasabletosendspecialists (plasticsur- improvement insurgery conditionsmeant on theorganisation ofpatientfollowup.The has alsoworkedwiththenurses anddoctors hospital wastemanagement activities. MSF continued through 2000and2001with to improved hygieneconditions.Thiswork r ting theatre in1999andthegovernment combination ofMSFrenovating theopera- hygiene andasepsisaround surgery. The 1998, theobjectivehasbeentoimprove the tions inwhichsurgery isperformed. Since it hasconcentratedonimproving thecondi- emergency surgery: howeverinrecent years For manyyearsMSFfocusedonwarand THE QUALITYHEALTH CARE TO IMPROVE Health. close collaborationwiththeMinistryof 1997 thatMSFincreased itsmobileteams,in only foreign witnessesthere. Itwasonlyin therefore notonlyuseful,wewere alsothe blems, express theirfears.Ourvisitswere lations whocouldtalktousabouttheirpro- enovating fourorfivesurgical wards, hasled >>>

Sri Lanka Batticaloa hospital > > > > Batticaloa Hospital > > > Batticaloa Programme 4 permanent International staff : and 50war victims. 254emergencies surgery, including 845major and September2001, between September2000 9,180operations 2000: 13,354 admissionsin ainlsaf 11 National staff: one third Muslim). (two thirds are Tamils, 165 forsurgery including 600 beds, re P Closed inJune 2003 Opened in1987 opulation covered inthe Fa g o:500,000people, ion: cts andfigures eleven 11 In the heart of the bush

Time line Despite the population’s growing isolation possible. I particularly remember three find a Burmese dentist willing to go. For caused by the fighting, MSF’s mobile clinics incidents: once there were a surprising number of treated around 400,000 people in the dis- - One day, all 25 years old that I was, I got men in our consultation! At the end of the > June 1990 LTTE controls the entire trict of Batticaloa. Set up in 1990, the team really mad at the brigadier because there day, they were left with half a bucket full of zone made up of an expatriate doctor and nurse, was no distribution of petrol that morning. teeth that had been pulled out. > 1992 a local doctor, a translator and a driver, I reminded him of the agreements and told - One morning I made a security call to Government troops travelled from village to village in both him he had no right to stop us from trea- check if the mobile clinics could go to the regain control of LTTE and army controlled areas. ting people. To my surprise, he burst out centre of the district. We were refused Batticaloa as well as the main towns and Checkpoint after checkpoint, negotiations laughing and gave me the petrol coupons authorisation for military reasons; after roads. The LTTE forces after negotiations, incident after unexpec- we needed. waiting for three days, we were finally able are entrenched in the ted incident, made it extremely difficult for - Once a week, we went to the northern to go in. jungle the teams to reach the population. But the limit of the district more than two hours > April 1995 accounts from these three women show the by road. We knew there was an LTTE trai- Up until 2003, MSF provided all the medi- Renewed fighting – cation and equipment needed in the mobile permanent tension in risk was worth it. ning camp on the way. One day a soldier clinics that travelled between over ten villages from the north to the south of the Batticaloa zone: the zone of Batticaloa on the side of the road stopped us to ask if Kattiravelly, Vakeneri, Pondukalchenai, Kithul, > 1996 – 1997 Adventures in the Batti bush we could send a dentist to the camp. After Thihliveddai, Kirumichchai, Kaddumurivu, Military operations in the usual considerations, we were able to , Mathuramukulam, Ammanthanevelly. the region of Vanni (in the West) have reper- cussions in the east. ELIZABETH BERGERON, NURSE IN Security incidents CHARGE OF THE MOBILE CLINICS – increase. BATTICALOA, SEPTEMBER 1990 TO > End of 1998 MARCH 1991 Regular attacks and “I have so many memories of the mobile fighting in the town. Waves of wounded clinics in Batti. Trying to build a good rela- arrive in the hospital. tionship with the Singhalese authorities, > October 1999 meeting with the head of the LTTE to The military authorities remind him of the rules: no weapons allo- limit the mobile clinics; wed in the medical facilities, and no uni- access to the popula- tions in LTTE zones is forms either, no pressure on the local staff, impossible. no misappropriation of medicines for trai- > December 1999 ning camps. Just basic diplomacy. The mobile clinics start Deciding where to go, protecting the local working again. The staff, travelling daily from government coastal towns are very unstable switching back controlled zones to LTTE controlled bush and forth under govern- areas. Everyday we had to weigh up the ment and LTTE control. risks. It was a huge responsibility. > 2000 Without my driver, my contact at the mili- Particularly violent tary base, the willingness and the intelli- year. Bombs kill or injure civilians, regular- gence of the doctors and nurses from the ly shooting. Frequent hospital, none of this would have been

12 twelve giving instructions on howtomake a stret- All this time, Simon,my translatorhad been mother. a cleancloth,I handedthegirltohergrand- told them,which means“girl”.Afterfinding and heldthebaby inmyarms.“Tankatchi” I was alovelybaby. Icut theumbilicalcord mother, sheisgoingtohavealonglife.She hours ontheground stillattached toher girl isstrong enoughtospendmore than11 still attached.Isaidtomyself, ifthisyoung baby ontheground withtheumbilical cord up herskirt. To mysurprise,Isawalittle baby. Iseparatedthewoman’s legsand lifted When Igotcloser, Iheard thesoundofa pressure camebacktoaround 10. The nurseputheronadrip and herblood but thebleedingseemedtohavestopped. was 8.5,pulse130/minute.Itwasn’t great, it washerninthchild.Herbloodpressure take thewomen’s pulseandbloodpressure: I kneltdowninthedarknessofhutto come out. the morning,butplacentastillhadn’t The womenhadgivenbirth at5o’clockin was headingfor. emergency kitwonderingwhatcatastrophe I was inthemiddleofaruralarea withmy around 4o’clockintheafternoon. There I ped ustohelpawomengivingbirth. Itwas “One afternoononthewaybackamanstop- DECEMBER 2000TOMAY 2001 THE MOBILECLINICSFROM CATHERINE BRUNN,DOCTORIN vision ofdisaster!” been burnedtotheground anddeserted. A We

were takentoanIDPcampwhichhad points”. Thesoldiershad tosearch the car “We oftenhad minorincidents atcheck IN BATTICALOA IN1998. FOR SEVENMONTHS DOCTOR, RECALLS INHERMISSION REBECCA SOUTH, We thing hadhappenedtothemother. would havetakencare ofthe babyifany- In theendIwasgladshecamebecause family andfriendsthathadgathered around. been pushedintothecarbyrest ofthe convince hertostay, butshe hadalready wanted tocometoo.Itriedinvain Pascaran andNorbert. Thegrandmother already inthevehicle,as well asSimon, side thetwoothermothersandchildren managed tolieournewpatientdownalong- fields andgotintothe4X4.We more orless We was that. from thefertiliser bags,andapillow, andthat cher. Themengathered twopoles,thecloth or amotorbike. sometimes, themostwell-off, hada tractor away, butmostofthemonlyhad bikes– hospital wassometimesaone-hour drive first aiddoingwhattheycould. Thenearest nurses, justafewrare volunteerstrainedin no accesstotreatment. Nomedicines, no people intheregion where weworkedhad large)to gobackher(very family. The She pulledthrough intheend,andwasable theatre. The patientwastransferred totheoperating arrived andIcriedout“Batti!”triumphantly. bumps intheroad. At7:30 that eveningwe

walked backthrough thehuts andrice- were off, driving slowlytoavoidthe ” Once we were woken upbyan attack ona life, dangerous incidentsoften occurred. problem. Although Ineverfeared formy hospital ifneeded. Safetywasalwaysa ver possible,brought peoplebackto the consultations, gaveoutdrugsand,whene- some rarer casessuchasleprosy. We held of themwar-related. Occasionallywesaw There were alsocasesoftraumatism,some break out,butinthe end itneverdid. nesses. We were scared thatcholerawould r We their onlyaccesstohealthcare. these people,themobileclinic wasoften many thousandsofpeoplelived there. For along theway. Thezonewasvastand the variousvillagesandtreating people travel alongthecoastinaminibusvisiting In charge ofthemobileclinics,Iused to was controlled bytheTamil rebels. northern coast,buttherest ofthezone town andtheroad thatwentalongthe The SriLankanarmyhadcontrol ofthe were. that theywouldbothknowwhere we would take,andwestucktoourplanso know amonthinadvancewhichroads we tiate ourwaythrough. We letbothsides controlled andagainhadtonego- territory the road, wewouldcross intoTiger go onwithourjourney. Abitfurther down sity forthem.Afterthat,theywouldletus young whitegirlwassomethingofacurio- of tea:theywouldgetbored, soanice through. Sometimeswedidthisoveracup and wehadtonegotiatewiththemget hoea, someofwhomdiedfrom theirill- Batticaloa

saw alotofcasesmalaria anddiar- >>>

Sri Lanka > > > L Batticaloa toavoid the from theregion of their children away F r tense; bombsandmines T Beginning of2001 go the liftingofembar- but thecease-fire and le, situation remains fragi- Daily shootingsandthe beginning of2002 End of2001andthe tion. move around freely. and thepopulationcan T 2003 ding areas. attacks inthesurroun- egularly explode… TTE recruiting them. amilies try tosend he situationisstill he entire zone isopen T

unblocks thesitua- ime line thirteen 13 >>>

police station a little further down the When she went on vacation to Pottuvil, road. Another time, we were in the small she was shot at by an unknown person. further north along the coast and a That was the first time an M.S.F sustained ship began bombing 100 metres from gun injury. where we were. We had told the army in advance that we would be there, but they Later Catherine was appointed co-coordi- simply replied the ship knew nothing nator of M.S.F. One day, while M.S.F was about it. It was probably the most frighte- engaged in rendering medical service, to ning moment in my life. We got back in the people of , several people of the car and left as quickly as possible”. the nearby village Vakarai were injured due to the shelling and firing undertaken by the armed forces. M.S.F came to the AMALATHAS STANISLAUS rescue of these injured people, rendered TRANSLATOR, BATTICALOA them first aid and transported them to the “When I joined M.S.F in 1993 there were general hospital of Batticaloa. only two mobile services. At that time, the When Yradj was the co-coordinator, a was divided into two shell fell a short distance away from the sections : the first named “cleared” was M.S.F vehicle and exploded, on its way under the control of armed forced and the back from a clinic in Pondukalchenai, but second named “uncleared” under the fortunately no one was injured. coordinator, one Catherine, to a location control of the L.T.T.E. The only NGO that Mari, a doctor from Japan, was assisted for called Kankachiweddai. On their way back rendered medical services to the people in the first time by a local doctor. M.S.F to the base, they heard firing noise and they those remote areas of Batticaloa was MSF. continued to extend its services by organi- did not know what was happening. The M.S.F also took in charge the children's zing dental and eye clinics in several diffi- coordinator called me over the radio and ward at the general hospital Batticaloa and cult areas and many people benefited. asked me to contact the 232 Brigade. provided a doctor for the smooth functio- During the latter part of 2002, the M.S.F ning of the above ward. coordinator Christine paid special atten- When I received the message no expatriate tion to the care of children and appointed was in the house. I contacted the 232 Brigade When Isabelle was the co-coordinator, a private nurse to look after them. Miss immediately and informed them that our M.S.F extended its services to Mutur in Claire, who succeeded Miss Christine as a vehicle was on its way back to the base. The the Trincomalee district. co-coordinator, paid special attention to Brigade told me that at the place called the problem of malnutrition and health Vellaneli the LTTE and the army were firing care of children.” at each other. I passed the message to the army personnel to stop the fire for 10 minu- Renovation and waste management activi- ties have been an important part of tes and let our vehicle pass that place very Batticaloa programme over last few years. KANDIAH SIVASHANMUGARAJAH quickly. Then I informed our car by radio

To photo: WATCHMAN DURING TEN YEARS IN and they came back to the base in half hour - an operating theatre in Batticaloa before BATTICALOA unharmed. I'll never forget this. renovation. “In May 1996, one of our mobile clinic cars One time, the hospital authorities was una- middle and buttom photos: - two stages in the construction of the de (“mobile 9”) went to the clinic with our ble to supply water to us. With the coordina- Monfort waste incinerator which is now used on many MSF missions.

14 fourteen Batticaloa Sri Lanka

tor's permission, I went to the Divisional In many occasions expecting mothers Secretariat where I met the accountant and were brought to the hospital and three asked him to supply us water twice a week. deliveries took place in the MSF vehicle. He gave a written order to the officer in char- Many children were brought to the hospi- ge to supply water for MSF free of charge. tal in critical condition. One from Pondukalchenai, one from Vahaneri and Finally, I can tell that after MSF is leaving one from Thihiliveddai passed away on Batticaloa, the people living in remote areas the way. and suffering will be unable to get proper treatment. The surgical wards in Batticaloa On Hartal days we saw many tyres and hospital will face the same problem. logs burning on the roads. We had to drive But I thank MSF for the good job in on other roads and come back to Batticaloa.” Batticaloa.

In the end, we have saved many lives by SIMON JESUTHASAN bringing people to hospital.” TRANSLATOR, BATTICALOA “In 1999, Mobile 5, got stuck in the mud on its way to Thihiliweddai. A vehicle was called from Batticaloa and towed it back. In December 1999, we were doing our cli- nic at Kaddumurivu. Then there was a SLA camp at Kaddumurivu. As we had not informed them of our arrival at the site, the SLA rounded us up. The mobile doctor had to face them. Pain management

In 2000, we were doing our clinic at Despite the willingness of the teams right from At the request of the team, a specific program- Vakarai, when suddenly a confrontation the start, it was extremely difficult to set up me was set up. In October 2002, a team (com- began between the LTTE and the SLA. We pain management activities. posed of a specialised doctor and nurse) gave In June 2001, the MSF team in Batticaloa orga- the personnel the means required to improve had to pack our things and leave the site. nised a conference on pain for all the doctors in pain management. In 2000 too, our team was travelling near the hospital. In October an evaluation was car- Protocols were drawn up detailing the use of Paddipalai, when a landmine blasted. We ried out on the wards that showed that pain simple, more appropriate, analgesics as well as had fearful times. management was very insufficient: the drugs tools to measure pain. The medical and para- used were inadequate and the medical and medical personnel were trained and after six para-medical staff had little training on the pro- months modest improvements have been achie- In 2002 we were returning from Vakarai. blems of pain. ved with the beginning of change in prescrip- Mobile 18 broke down at Mankerny. A In November 2001 the nurses on the surgical tions habits and the personnel’s attitude vehicle had to come from Batticaloa for wards were trained to better evaluate the towards the patients. We hope things will repairs. patients’ pain and new drugs were introduced. improve further still.

fiveteen 15 Self immolation Batticaloa

figures MSF has begun treating a growing number of the victim’s body, and 49% in suicide of burn victims in the Batticaloa hospital, attempts”, Veronique explained. “These including an alarming number of female patients are often neglected by busy staff > 345 burn victims were admitted between June suicides. owing to the difficult nature of the nurses’ 1999 and July 2001 work. The work is also very demoralising > 64% were accidents for the staff because one out of every four > 25% were suicide Since MSF arrived in 1987, the problem of victims dies from their wounds. Over the attempts burn victims had not been properly dealt past few years, burns have proved more > 78.5% were Tamil vic- with until relatively recently. A study deadly than the war itself.” tims conducted by Véronique Laloe, head sur- To make matters worse, the only burn > 19% were Muslim geon at the hospital, showed that between treatment facility is in the country’s capital > Average age: 21 (17 for July 1999 and June 2001, 345 patients had Colombo, an 8-hour drive away. “We sim- accidents, 29 for suici- been hospitalised for burns. Of these, 64% ply cannot transfer patients in critical des) were caused by accidents, 25% were self- condition,” Véronique continued, “becau- > Patients with burns to more than 50% of the inflicted, and the rest were caused in se they need to be on a drip, which requi- body die attacks on the victim or by unknown cau- res massive amounts of liquid. This is > 27% of patients admit- ses. Women made up a large part of all impossible to provide in the under-equip- the surgical ward by asking them ques- ted died; for attempted these categories, except those caused by ped ambulance we would have to take.” tions, offering counselling, and talking suicide, the rate was criminal attacks. The horrifying hospitalisation conditions about suicide to help them to de-stigmati- 71% of these patients can no longer be ignored. se the problem. “Under the pretext of iso- Nor can we remain insensitive to the lating the patients to avoid secondary NOT ENOUGH CARE AVAILABLE immense physical and mental suffering as infections, they were kept out of sight far “This has become a serious problem well as the stigma they will carry with away from human contact,” Véronique because on average the burns cover 25% them for the rest of their lives. We also explained. Treating these patients can need to acknowledge the effects the vic- pose many problems as there are various tims’ injuries have on the teams. We have factors involved. We have been able to worked closely with the teams from the increase our capacity to treat burn victims Ministry of Health to try to provide better by making structural improvements to the and more humane care to these victims hospital ward, by closely working with the who suffer the additional burden of being nurses, improving patient nutrition, redu- treated with distance by the hospital staff, cing pain and offering physiotherapy.

The suicide rate in Sri Lanka is one of particularly the many cases of attempted With the help of the psychiatric ward, the the highest in the world. In an attempt to suicide. patients were able to talk to an MSF mem- explain this phenomenon, the psychia- ber on a daily basis, and the efforts of the trist from the Batticaloa hospital sugges- ted suicide was part of the nation’s plastic surgeons have helped to reduce the characteristics. He describes suicide as TREATING THE PATIENTS scarring. We can confidently say that the an “inability to resolve problems”, sug- gesting that most of the population are WITH MORE DIGNITY team has managed to provide better care unable to solve everyday problems. Discussion groups with the staff were set for burn victims in the hospital, and has up with the help of the hospital’s psychia- removed the stigma associated with the tric ward. They worked with the nurses in suicide cases.

16 sixteen Sri Lanka Vavuniya, a strategic town

Vavuniya, a few kilometres from the front ‘uncleared’ areas, so that everyone could Facts and figures line, is a large Tamil town in a government have access to quality healthcare. controlled area in northern Sri Lanka. Vavuniya programme Under military administration, (never > Surgery, hygiene and renovation of operating under Tamil control) the town was under AN IMPORTANT PIVOT theatre constant tension throughout the conflict. FOR LOGISTIC > Mission opened: The different neighbourhoods were Besides the surgical activity and the fol- April 1995 controlled by various Tamil militias, either low-up of quality pre and post operative > Closed definitively: pro or anti LTTE: and there was considera- care, the teams also referred patients to March 2003 ble contraband with the north of the coun- other departments e.g. neurology, paedia- > Population covered: try. In April 1995 the fighting intensified trics or obstetrics. approx 150,000 people and MSF opened a programme in Vavuniya in 2001/2002 hospital where there was a lack of sur- Vavuniya was also a strategic logistics geons. position for MSF: the town was a pivot for Vavunya hospital material and drugs between Colombo and > Approx. 250 beds, including 55 surgical Madhu on the other side of the front line. > 2002: 16,500 April 1995. Hostilities between the LTTE It was here that the transport of all the admissions and and the government of Sri Lanka recom- materials by convoy to Tamil held zones 2,400 operations menced. Up until then, 400,000 people was negotiated. > 20% of surgical living in the Tiger controlled zone north of admissions came from the front line between Kilinochchi, After four years in Vavuniya, MSF closed ‘uncleared’ zones Mannar, Mullaitivu and Vavuniya had no its surgical activities in January 1999. The > International staff (2002): 3 permanent access to surgery. When lucky, Tamils decision was justified by the fact that the and 3 for short term were transferred to , 60km front line had moved further north and technical support south of the front line, in a Singhalese consequently the number of operations > National staff: 6 zone. However many Tamils were appre- had decreased. However in November hensive about going into this zone, and 1999, MSF re-positioned a surgical team the post-operative care did not seem to be in Vavuniya hospital: the Tigers were at MSF started activities to improve the as good for Tamils as for Singhalese. the doors of the city (the LTTE had asked hygiene and asepsis around surgery, as the population to evacuate), the combats well as the triage and incineration of On request from the ministry of health, intensified and the number of wounded waste. A Monfort incinerator was built in MSF sent a team of three, a surgeon an increased dramatically – however there Vavuniya and raised considerable interest anaesthetist and a nurse, to cover the was no national surgeon posted in the from the Sri Lankan health authorities. emergency surgery in Vavuniya hospital. hospital. This new mission, which was at This type of incinerator was also built in This activity covered all the civilian popu- first to last one year given the instability of Point Pedro, Mannar and Batticaloa. In lation, both Tamil and Singhalese, in the the zone, finally lasted until September December 2000, these activities, particu- regions of Vavuniya and Vanni (north of 2002 when the surgical activities were larly those concerning waste incineration, the front line). MSF therefore also ensured handed over to a Sri Lankan surgeon. were handed over to the hospital staff. A the transfer of patients to the hospital Meanwhile in March 2000, on the recom- few months later, in March 2003, the mis- from this isolated Tamil region or from mendation of a surgeon and a logistician, sion closed in doors definitively.

seventeen 17 When the Bombs Fell on Notre Dame de Madhu

Personal Madhu is not just any town-the Virgin Mary Memories is said to have appeared here. This Christian sanctuary, located in the Mannar district on Sri Lanka’ northwest coast, became an “In November 1999, the Tigers launched offensives important site for religious pilgrims. When in all directions. war broke out, the sacred place became a The Vavuniya mission refuge for tens of thousands of civilians and opened the same day that was quickly transformed into a displaced per- the Madhu church was bom- bed. Véronique, the sons’ camp. Thanks to the infrastructure Batticaloa surgeon, arrived established for the pilgrims (including a in the morning and that church-sponsored clinic, a water distribution night she was faced with system, grounds for setting up tents and tem- 60 wounded people! We decided to open Vavuniya. porary shelters), all elements were in place to After the Madhu events, the ensure that a health disaster would not break teams tried to return get out. The only problem was that there were no back there. At that point, the sanctuary was closed off running public health facilities and no medi- to all humanitarian aid. cal workers. The team left in two cars. This was the context in which Médecins Sans When they reached the Frontières opened an assistance program in checkpoint, they “forced” their way through, insisting 1990 for displaced populations in the sanc- that they must be able to tuary town of Madhu. It was the first pro- Madhu was thought to be safe, but it was never- theless bombarded, resolting large number of see the population and gram to be set up in the area under the civilians casualties. what was happening. control of the Sri Lankan rebels, the based in Mannar and, then in Madhu — They managed to get through but they couldn’t Liberation Tigers of Tamil Eelam (LTTE, or made it possible to provide medical assis- MSF Holland had been operating a surge- get back. They knew they Tamil Tigers), just behind the front line. tance to all the region’s isolated popula- ry mission. Facing major transport and would face that risk. There tions, with an emphasis on maternal- travel problems, the teams found it diffi- was no way to make a infant care and childhood vaccinations. cult to provide humanitarian aid. Patient U-turn and go back the other way--or to buy any- EVER GROWING NEEDS The MSF teams worked together in the transfer sometimes took up to four hours, thing to eat. Their cars Throughout the civil war, the Mannar dis- little Madhu church hospital, offering the rather than the 11/2 hours typically requi- were full of medicine but trict experienced repeated offensives and surrounding populations high-quality, red for the trip. Supplying the entire they didn’t have a tooth- brush among them and counter-offensives. As the theater of many comprehensive care. It was not until 1995 area—and particularly Madhu—with barely an MSF T-shirt. They battles, it also experienced major popula- that teams set up an ambulance system to medicines and medical supplies became remained blocked there for tion movements and, as a result, growing transport the most seriously ill patients to very difficult because the Sri Lankan three weeks. They worked humanitarian needs. In 1987, MSF began the reference hospital in Vavuniya, in the defense ministry had imposed an embargo hard, of course. They ate whatever the displaced peo- working in the region and set up surgical government-held zone. If they were una- and lengthy waiting periods. “We often ple in Madhu gave them and obstetrics programs in the Mannar ble to reach Vavuniya, they went to the waited weeks for authorization to bring in and slept alongside them.” hospital. In 1998, MSF came to the aid of Kilinocchi hospital (before it was bom- our supplies and medicines,” recalled populations who had taken refuge in India bed). Beginning in 1997, the teams took Nicolas Beaudoin, a logistician in 1996-97. Guillermo Bertoletti, program manager, Paris, and were returning to Sri Lanka. also patients to the Mallavi hospital in the “As soon as we got them, the soldier in 1997-2001 Finally, in 1990, mobile clinics — initially heart of the Tigers’ Vanni region, where Vavuniya had to inspect everything before

18 eighteen Madhu Sri Lanka

we could leave for the military post at the Palampidy, the only remaining site served, front line, just ahead of the two kilometer was maintained from the Murunkan (one mile) no-man’s land separating us hospital, where MSF had opened a clinic from Madhu. We could not transport more program in early 1999. material than stipulated in the authoriza- tion and our lists had to specify contents down to the number of rolls of toilet THE ATTACK paper. Some drugs, like pain medication or ON THE MADHU CHURCH anesthetics, were simply forbidden while In November 1999, fighting intensified in other items--like batteries with which the the region, leading to major population LTTE could manufacture bomb detona- displacements as people sought refuge in tors!--were very restricted.” Madhu. A tragic event occurred during a battle for the control of Madhu between region. “Under the terms of international the Tamil Tigers and the Sri Lankan army. humanitarian law, the parties to conflicts Facts and figures FROM RESTRICTION TO TOTAL At 11 p.m. on November 20, the Madhu must not directly attack civilians or their SUSPENSION OF OUR ACTIVITES church was bombed four times. It was property. The bombing of the Madhu > 1987 MSF continued its activities until 1999. unclear which side was responsible for the church, known to civilians as a ‘safe haven,’ Surgery and obstetrics in The Madhu clinic became the only referral attack. The Madhu church sheltered was an obvious violation of that law,” the the Mannar hospital center in the sector. The mobile clinics around 3,000 people. Thirty-eight people MSF press release announced. Three days > June 1990 and the system for transporting patients to died in the bombing, including 13 child- later, the team received authorization to Mobile clinics based in Mannar cover the Madhu nearby hospitals operated very smoothly. ren. Six other people died of their injuries resume its work in the region and the war- region In late March 1999, the army retook while being transported to the Vavuniya ring parties agreed to establish Madhu as a control of Madhu. Access to areas under hospital or after admission. In the end, 44 demilitarized and safe zone. MSF resumed > Late1990 Support to the Madhu LTTE control, where MSF’s mobile clinics people were killed and dozens of others its activities, providing support to the health hospital, mobile clinics circulated, became increasingly difficult, wounded during the blood bath. The MSF center, mobile clinics and ambulance and ambulance transfers restricting the teams’ travel and the sites surgical team admitted 68 patients to the transport. The team also brought assistance > June 1999 visited. Nonetheless, the Madhu clinic Vavuniya hospital on the night of November to the people of Tatchanamadhu and other Madhu activities continued to provide medical care to the 20. Fifty-one women and children were sites. After the ceasefire signed between the suspended population. Beginning of April 1999, mili- among them. On November 23, the LTTE LTTE and the Sri Lankan government in > March 1999 tary restrictions limited the mobile clinic retook control of Madhu. February 2002, the embargo ended and two Support to Murunkan team’s access to the Palampidy displaced access points were opened to the LTTE zone hospital and mobile cli- nics. persons’ camp. The ambulance service Several weeks later on December 10, the day from Mannar district. Little by little, the operated as a patient transfer service and MSF received the Nobel Peace Prize, the displaced people who had taken refuge in > November 1999 Reopening of the Madhu also transported Madhu’s cholera treat- teams in Columbo took advantage of the Madhu returned to their villages. MSF shif- mission; same activities ment kits. In June 1999, when the entire event to denounce the use of antipersonnel ted its activities, emphasizing mobile clinics resume.

Madhu population was evacuated, MSF mines and methods of warfare that threate- so that it could be closer to the populations > February 2000 decided to suspend its clinic work and ned civilians. The teams issued an official returning to villages. These clinics allowed Mobile clinics added. supplied the local staff with emergency request to government and LTTE authori- the teams to reach around 18,000 people, > March 2003 stocks. The ambulance transport system ties to halt attacks on civilians and allow while the Madhu health center met the MSF ends activities in the was also halted. Mobile clinic service to humanitarian aid workers free access to the needs of some 25,000. region.

nineteen 19 Farewell Tributes

We will never repeat if enough : without past and wish to share it with you. I hope its English translation “doctors without the Sri Lankans, Médecins Sans Frontières’ the following few lines will make you borders” - is true. Doctors who work with missions would not have been possible. happy while remembering the story of MSF do so without restricting the humani- Now that the time has come to close down MSF France in Mannar, Madhu and tarian services rendered to the Tamil com- our last programmes many of them are Vavuniya. munity. The Tamil people who took shel- heavy-hearted, as are the expatriate volun- In May 1988, I joined MSF France as a ter as refugees at Madhu Camp were the teers. Many of the national staff have been health worker. Only now I realize how luckiest people in the Vanni region, as far working with MSF since we opened in Sri remarkable a day it was: since then, MSF as the medical service is concerned. Since Lankan. With unfaltering patience and has offered me various skills, up to that of I also belong to the Tamil community, on motivation they have seen hundreds of a field coordinator, for which I offer my behalf of it I should express my sincere volunteers go by. Here are a few tributes sincere thanks. thanks, but I couldn’t find the best words some of them would like to pay to the asso- After a while as a health worker, I was do so. ciation, and some we would like to send selected to become translator for the phy- Once a team was on a journey, one Sri them … sician. I started my work at Dalai Mannar, Lankan army (SLA) helicopter shot at the said to be my birth place, which is as well car. Immediately they got out of the vehi- the part where Sri Lankan refugees from cle and waved the white MSF T-shirt to BY RECILDA DALIMA, EX-FIELD India came back to the island. MSF France stop the shooting, but the SLA didn’t do COORDINATOR, VAVUNIYA then had to switch over to mainland of so. They were injured and with the help of “For the past 16 years, I have been wor- Mannar District, following the request of an ICRC representative, they were taken to king with MSF France. Sweet, sad, remar- UNHCR and the Ministry of Health. Latter Colombo hospital by a special plane. One kable memories make me recollect the on, we received information saying that special delegate visited Sri Lanka for that people are evacuating and piling at Madhu reason. His name is Oliver. The first thing Church, due to safety reasons, so we went that he did was to see the driver and only to visit the Madhu shrine. We were well after that he met the other expatriate inju- received by the authorities. After our visit red. This clearly shows their care for the we decided to call the place the Madhu national staff. Camp, and MSF France continued its ser- As time passed and people in were retur- vice there. ning to their respective places, we set up The MSF Madhu mission was very popu- mobile clinics. I worked as a translator lar among the public. At that time I, too, and help nurse. In 1996 MSF hired more had the opportunity to serve the public as staff and gave them proper training in nur- well as the expatriate as a translator. While sing and brought an expatriate nursing I enjoyed my work, day by day the number trainer who conducted practical classes of the patients was increasing. The Madhu and examinations. Now these persons are health unit became a true hospital, with employed in the government medical ser- special care given to the maternity section, vices, have a job security and are praising thus enabling the hospital to meet out any MSF Apart from the medical services, MSF emergencies other than surgical. offered some humanitarian valuable services From my point of view, the meaning in to the national staff. I can give several exam- French of Médecins Sans Frontières - and ples like that. For everything there is an end.

20 twenty office. From thentillthe 31stMarch 2003 when I wastransferred tothe Vavuniya I wasinMurunkan tillNovember1999, Madhu. goal ofMSF, which theyachievedin appropriate theneedyis timeto serve their culture. atthe Aqualityservice gling withtherefugees andrespecting physicians playedahighethical role, min- In Madhu,thesimplicityof the expatriate the people. tion wouldhaverendered to suchaservice organiza-task. Ithinknoothervoluntary couldn’t findwords topraise MSFforthis there isaneed)allatthe riskofMSFI ding transport intheirownvehicle (when r r to passcheckpoints,butMSFtookthe Since 1988to2002itwasnotaneasytask from SLAauthorities. ments neededforpermissionandpass treatment, whilefillinginallthedocu- re gency transferswere conductedanda Madhu 2normaltransfersandotheremer- plies toMadhuandMurunkan.From major role sup- insupplyingthenecessary December 2002.Vavuniya office playeda geon toVavuniya Hospitalsince1995 till ofanexpatriatesur- extended theservice On request of thehealthministry, MSF started theiractivities inMurunkan. again, andMSFhadtoleaveMadhu,but Madhu camphadbecomeShrine cover ofrehabilitation. ByJuly1999, ple totheirrespective villages,underthe they started toforcibly sendbackthepeo- gees. AssoonastheSLAcaptured Madhu, dated thousandsandofrefu- was apilgrimageplaceandhadaccommo- opponent activities,becauseallfeltMadhu shrine andsurrounding area withoutany In 1999NovemberSLAcaptured Madhu elevant documentsoneither wayprovi- esponsibility oftakingthe patients with turn journeyforpatienttoMadhuafter tion at least afewamong theones Imet. I willbe failingmyduties ifIdonot men- distance covered are concerned. to bekeptasfar asthevehiclefuelandits paid tothepurchasing part; proper records 2. Logistical side: more attentionto be path towalkon ormayrectify you. the opinionthatmaygive you acorrect several nationalstaff individuallyandget 1. Before tocontact makingadecisiontry future missionwork. that Icouldcommentthe following for knowledge from variousaspectsand with over 25%ofmylifewithMSFIhadgained level. Iamproud tostatethatIhavespent and itsexecutiveatthelocalhigher jumped overseveralstagesduetoMSF During the16yearsIwalkedthrough or trator ;andfinallyfieldcoordinator. tor ;transfermanagerassistantadminis- tor ;helpnursepharmacistradioopera- positions atMSF:healthworker;transla- I ha d thepleasure toworkonthefollowing time. Dr. Mew, anAmericanDoctor:hehas how tobeactiveduringanemergency Then Dr. Corinne showedandtoughtme are thickpals. Medical doctor. Thesethree andmyself pleasure toworkwiththem.Marieisa a nurseandSologne,thesame.Itwas to givemeareference letter. Sabinewhois into MSFFrance.Hewasthefirstperson Dr. PeterNoelisadoctorwhoselectedme Coordinator, with herwecandiscuss any difficulties, Manana the Medical Gabriel who tried tounderstandothers' national head quarters, Paris. Next came ving atpresent asan executiveattheinter- about thehead ofmission:Guillermo,ser- I studiedalot from him.ThenIthink tor. ThencameDr. Richard, aMexican. him somuch.Veronique ashort timevisi- Rahul from thePhilippines.Patients loved two contractsfor16months atMadhu.Dr. consultation. Florence, midwifewho took a powertopredict thediseaseprior tothe

Sri Lanka Best oflucktoall. the badtimestogether. and go over the good and party attheendofJune able togo theMSFleaving kindness. Ihope I willbe patienceand laboration, them fortheirprecious col- to thank national staff, pay tribute to all the ev names –butprefer tothank fer nottomentionany Ipre- leaving someoneout, Lanka. As Iamafraid of many memories ofSri Ihave many, 1997-2001, manager inParis from and finallyprogramme Colombo from 1996-1997 headofmissionin 1992, As doctorinBatticaloa Guillermo Bertoletti lives inLondonsince2002. She isnow married and continued. Sri Lankanadventure that w England where here family rather thanto cal refugee, Fr MSF thatshecameto interested andattachedto nurse in Trinco. Shewas so theOT lar tribute toShitra, I would liketopayparticu- August 1989. in Trinco from February to nurse Anne-Marie Gloaguen, as. Itwas apieceofthe ance in1991asapoliti- eryone. Iwould liketo twenty-one 21 important matters at any hour. Now it is tes or national staff, in a small way or big expatriate volunteers get on very well. Poetry done by MSF Colombo security guard – time to think about my residence, way for their cooperation rendered I am sad to be leaving this mission in June. Anthony Vavuniya MSF France office. Pascale, towards me in all aspect also thanking the I feel like that when MSF leaves it will take Estelle, Luca, it is easy to write these competent authorities for giving permis- time to fill the empty space it will leave. Good Bye MSF names. But its impossible to erase from my sion to frame these few lines, I know very There will be the hospitals, but no doctors. Time has come for us heart Yves and Oana both life partners and well your service is needed badly by other I feel like I am abandoning the population to say good-bye. administrative partners, Head of the mis- people somewhere in another part of he and I fear that the population also feels To leave behind sion and Administrator respectively. It is world. You have to move and it is time. I that we are abandoning them. the dearest part of life. only two years I served under them, their am awaiting a chance to meet my old col- I worked 22 years before joining MSF; but Away from MSF soft corners towards the employee are leagues in any part of the world at any I have never experienced the same human shade work and hardness always fragrantly of fresh smelling flowers, time. Let god help me for this. relations anywhere else. To faraway place… if there is anything to be rectified even Bye,” I would like to thank all the doctors I have they politely infuse the matter so as the worked with, as well as all the team”. It grieves us to bid you employee listen and obey, there are days I good-bye would have contacted them over the tele- A. THEAGALINGAM To leave behind our soul phone more than four or five times but I DOCTOR WITH THE MOBILE TEAMS ELISABETH SZUMILIN, Knowing that MSF is very breadth each spadework hear the sweet voices, now I render my IN BATTICALOA. DOCTOR IN TRINCO Keep us alive… sincere thanks to this couple. “I arrived in Sri Lanka in 1997; first to FROM 1987 TO 1988. work for the government, then in a priva- “I would particularly like to mention We shall miss you oh!, I am also duty to thank Pascale te hospital. On March 22nd 1999 I started Master Leo, my Tamil translator who was so much Noterdaeme, as Medical Coordinator, working with MSF as a doctor with the in his sixties. Who never wanted this war. Look into our eyes and you I really love her for her way of approach. mobile teams. Also our cook Apu, which means ‘daddy’ will see you in them Likewise if I look into the administrator The more I work with MSF, the better I or grand-father, as well as his family. All Look into yours and we see and field aspect I believe about 90% of the feel. It is very motivating to work for an the teams that have been in Trincomalee the depth of your love visiting expatriates has rendered their association that understands the popula- have wonderful memories of this man. On Boundless as the blue dedication towards the Tamil community. tion’s difficulties, that listens to them, top of everything, he was a great cook. ocean If you look into a just blooming gladiola genuinely takes into account their needs – When I said I was going to get up early… Steady as the sunrise flower you will be able to see several buds builds a veritable relationship with the he would get up even earlier to prepare on the one and the same stalk. But all don’t population is it providing care to. When our picnic. Often it was the sound of him Farewell my endless bloom at once, only two or three buds will MSF arrived in Sri Lanka it knew exactly grating coconut for us (the mobile team) farewell… bloom, while the blooming process is on what decisions had to be taken straight that woke me up. He must have had to put one or two buds may get spoiled one from away to respond to the needs: hiring of up with a lot of green, unripe coconuts… the stalk. However flower continues to surgeons and nurses to respond to the The expat MSF teams: we always got on bloom until the last bud blooms, this is needs in the field. The government had together (even with the surgeons, despite MSF one or two with different attitudes abandoned many areas of health care and their renowned characters!!!). Now, when but on whole MSF had served the commu- MSF filled these gaps by providing the I hear about team problems in the field I nity by large and rich. Also endorse the necessary drugs and paying the medical always ask myself… how was I so lucky fact that no other organization would have staff. that I never had those kind of problems on reached or gained the highest honor what As a doctor with the mobile teams, I work any of my missions? We always sorted it the people are having in MSF France. in very isolated areas. I really feel MSF’s out between us. I, Recilda Dalima, loved, love, and will support. The population also feels MSF is Finally I would like to mention my friend always love MSF France. Now over to my listening and taking into account their Rohan Mendis, even if he is not a member conclusion. I take this opportunity to needs. The relationship with MSF is very of MSF. A Singhalese diver who showed thank each and every one either expatria- much appreciated. The local staff and me the wonders of the ocean bed of this

22 twenty-two very welland hasshownthe way.very Butthe medical responsibility. MSF hasworked rities nowtake overandassumetheir It isimportant thatthe SriLankanautho- n’t work out,I’llgohome. become Product chiefforNDO.Ifitdoes- professional front, Ihavehadan offer to T ded assistance,helpedanddefended. I washappytoseethepopulation provi- good. over severaldays.Itwasvery volunteers organized training workshops plying drugs,transporting patients.The clinics, ondelinquency, dentalwork,sup- MSF hasworkedveryhard: workinginthe other timesweare not. very sadwhenanexpatriate leaves…. Christmas parties… We are sometimes with theexpatriatevolunteers:dinners, We them becauseshewantedtoprotect me. woman, refused toleavemealonewith wanted totalkme-thedoctor, a Another example;oncesomesoldiers when wewere inaverydifficult situation. helped meandmysister-in-law financially coordinators helpedmegetaloanandalso think ofseveralpersonalexamples.The volunteers getonverywelltogether. Ican me. Thenationalstaff andexpatriate niceto The doctorshavealwaysbeenvery ding oneworkingforthegovernment. Before MSFIhadvariousjobs,inclu- working full-time. by apart-time contract andintheend started onasix-monthcontract,followed that MSFwaslookingforaninterpreter. I 1997. Itwasafriendofminewhotoldme “I havebeenaninterpreter withMSFsince SIMON JERUTHASAN–TRANSLATOR much liketoseehimagain.” island, aswellmuchmore. Iwouldvery oday MSFisleaving.Personally, onthe

also hadlotsofopportunities tobe three years. We were constantly traveling mobile teams. Iworked asadriver for I lateraccepted toworkasadriverforthe the logisticsand theadministration. radio operator, aswelltakingcare ofall enough andI wasaway. Iwas thefirst ched onemyself. Afewdaystrainingwas ple workingonradiosbutIhad nevertou- radios. Itoldhimhadn’t, Ihadseenpeo- if Ihadanyexperienceworking with American MSFcoordinator whoaskedme looking forapolyvalentworker. I met an n’t paywellenough.AtthattimeMSFwas I couldn’t carryonasavolunteerit did- then gotmarriedandhadtwo children, so work asavolunteerforthe RedCross. I Arabia. ThenIhadtheopportunity to “Before SriLanka,IwasworkinginSaudi LOGISTICIEN –ADMINISTRATOR SUREASH KIRUBARAKAN, won’t doanything.” government isblindandI’mafraidthey ask ustoleaveandstopaskingques- were hidingfrom would us.Themilitary know whatwashappening,people saw many, manydead.Ourteamwantedto medical care, wehadtogothem.We points. Astheycouldn’t come tousget most civiliansfrom crossing thecheck in dangerous zones:themilitaryprevented ther NGO, eventhough Iwould prefer My future? Iwould liketowork forano- shouldn’t leave. again, evenif Ican’t honestly say they r triates andnational staff. I hope MSF in 2002.Iwould liketothankalltheexpa- MSF. Ibecamelevel6assistantlogistician I hadawonderful, intenseexperiencewith another. can movearound easily from oneplaceto T information aboutattacksthey wouldtellus. were verysupportive. Whentheyhadany leave. tions. We were to collect thebodiesand emembers me iftheycomethisway oday thesituationhasimproved. People The populationwelcomed us and

Sri Lanka longer thistime!! I hopethatpeacelasts aboutthat… be happy andIcanonly perhaps, g it’s asignthatthingsare are closinginSri Lanka, idea. Iftheprogrammes But Ithinkthisisagreat r neverhe willperhaps been closedalongtime, the househasalready butseeingas crab curry: us themostdelicious Tr ourcookin to thank Apu, I would particularly like Tr than Monaregala. to May1992in Trinco, thetist from March 1991 nurse anaes- Ariane Betz, ead this. tigbte,even well etting better, no whousedtomake inco, ibute to… twenty-three 23 MSF – the best humanitarian organization we had gone out with the mobile clinics to we got no reply because we were infact I know. It’s true that I’ve always been very Tachchinamadhu, which was considered “mobile 8”. Afterwards we laughed a lot satisfied with the MSF volunteers, but it as ‘uncleared’ at the time. That day, in May about it. I really had a good time with MSF. Emmanuel Baron, would have taken only one person to spoil 1997, the Sri Lankan army entered Madhu We did a lot for the population in the doctor, everything. by surprise. People started running and ‘uncleared’ areas. I hope MSF will do more Madhu April-November 1995. screaming trying to get away. The MSF and more in the world.” team in Madhu called us on the radio tel- I would like to thank SHOBANA CHRISTY, ling us to come back to the base immedia- Doctor Sabah in Madhu TRANSLATOR, tely. We were very scared, but we got into JACQUES BRIOIS, for her competence, kind- THEN RADIO-OPERATOR. the car and started driving back: we left NURSE ANAESTHETIST, VAVUNIYA, ness and commitment. “I have one memory I would like to share behind one member of national staff AUGUST 1995. with you. I was in Madhu at the time and because we didn’t know what could hap- “I was in Vavuniya for a month with pen on the road between Tachchinamadhu Abdeslam Khairouni, a surgeon, and and Madhu. We heard some shooting and Patrice Vastel, the logistician. The hospital ROCKSON COLLINS, LOGISTICIAN, JOINED MSF IN 1996 saw blood on the road. We were terrified; had a great team: Yogi, the nurse, had to IN JAFFA HOSPITAL. we thought we were all going to die. The put up with us and we worked very, very HOMMAGE ACROSTICHE team in Madhu called us again on the hard. Memories flow sweet and hard like ebb and tide in our hearts. And radio. The field coordinator snatched the One day, I found I had run out of anaes- Events are twinkling as morning stars on our pool minded sky. Then radio and starting calling “mobile 8, mobi- thetic gas. I was very, very worried; than a Doctors, nurses travel on a train called “expats services” le 8?”. But there was no reply. As transla- few days later a miracle! We received some Enjoyed the journey with log and admin and also the national team tor I repeated her call. There was still no from the Sri Lankan Minister of Health in Carried the duty with spirit and honest in our shoulders – to the way answer. We finally got to Madhu. It was Colombo. She was an incredibly determi- along only then that our doctor noticed that the ned and persistent woman! In and out from 8 to 5 is the time for us from 1986 – In this pearl microphone I was still holding wasn’t I planted a tree infront of the MSF house. November on 99 was the greatest month on my track in MSF life – As plugged in to the radio! All the while we I hope it will grow in a country at peace. Started the mission again in Madhu with my superiors on that time had been calling “mobile 8” on the radio, Many thanks to all.”

Suffering people get the relief from sickness and diseases Appreciate its service with joyful and thankful Nothing is impossible in emergency to start and rundown Speed and selection are the need of necessity

France has the head quarters of our association Refugees praised always its service in precarious situation Overall decisions always get us in front of leading North and East, West and South, all are the parts of its body Thank you again for its service in our island for seventeen years I’ll follow all my way of its way Everywhere in missions are the good memories for public Remembrance cannot be erasable from our hearts End of the mission and leave the country will not clear the mark of MSF because Still it’s living and covering all of our soul.

24 twenty-four 210 national staff et 860 international volunteers

Sri Lanka was always one of MSF's largest mission in terms of human resources, with over 70 departures a year.

The war surgery activities meant that a high turnover of volunteers was one of the cha- racteristics of this country.

253 surgeons, 145 physician anaesthetists as well as 70 nur- seanaesthetist and OT nurses worked there in turn on very short missions.

twenty-five 25 thanks to 210 national staff 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 , 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, Suppaiah DRAVADAKALA, 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, BERNARD AUMAITRE, 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, MURIEL BARTHOME, 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 BIRAIS DEBOEUF, JEAN-PIERRE BISSUEL, FLORENCE BLANCHET, FRANCOIS BOILLOT, EMMANUELLE BOLLEY, LAURENCE BOLSIGNER, RAUL BONIFACIO, DANY BONIJOL, MARYSE BONNEL, JEAN MICHEL 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, MARIA DEL 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 DE CHAMPS, VERONIQUE DE CHASTEIGNER, MARIE JACQUES DE CHAZELLES, YANN DE FAREINS, CATHERINE DE LA BOUSSINIERE, CAROLINE DE LAMINNE, JEAN YVES DE LEMPS, LAURENT DE MONES, 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, JEAN DOMINIQUE 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, MURIEL DURAND, 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, GABRIELA FILLON, 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, BERNADETTEthanks GERGONNE, GILLESto GERMAIN,826 CHRIS international GILBERT, ISABELLE GIRET, CHRISTINE staffGLE,

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