Dateline: Batticaloa

Relationships between the two major Sri Lankan communities, the Sinhala and
the Hindu Tamils, have been increasingly strained since the 1950s. At that
time, Solomon Bandaranaike enacted the Sinhala-only policy decreeing
Sinhala the national language and Buddhism the national religion. In
following years, clashes between increasingly militant Tamil groups and
Sinhala security forces escalated. In 1983, Tamil extremists killed 15
Sinhala soldiers. Subsequent reprisals saw 3000 Tamils die, 18000 homes
destroyed, and 125000 refugees in the capital Colombo.

Sri Lanka has been in a state of civil war ever since. The effects for each
side have been numerous and severe. Injuries are frequent and health care
has suffered, especially in the "uncleared areas" controlled by Tamil
Tigers' militia where central dispensaries and local hospitals have been
destroyed. As Pierre Harze, of Medecins Sans Frontieres (MSF) has said, in
such a conflict "there can be no good or bad victims".

As early as 1983, MSF sent an exploratory team to the Jaffna peninsular but
decided against a mission. 3 years of surveillance followed. By the end of
1986, owing to a severe lack of medical supplies and staff, the National
Director of Health Joe Fernando allowed MSF into the Tamil port town of
Trincomalee. This was the first international mission in the conflict zone,
and MSF have been there ever since. Sri Lankan doctors not surprisingly
refuse postings to rural and war-torn areas outside Colombo or Kandy where
there are teaching-hospital facilities, better equipment, and staff.
Needless to say, there is a shortage of all medical staff in the conflict
zone; the role of MSF there is "substitution".

In the eastern region of Batticaloa, with a population of 500000, MSF
provide the only surgeon and paediatrician. They also provide two doctors
for the jointly run Ministry of Health and MSF mobile medical clinics for
the 100 000 people living in uncleared areas. In the rest of the country
there is one doctor for every 7000 people. In Batticaloa town, the
proximity of the conflict is all too frequently announced by the sounds of
shelling and gunfire. One evening during my stay, the local leader of the
Tamil splinter group TELO was assassinated. The atmosphere in the town was
tense and the bursts of automatic rifle fire alarmingly close. The MSF
field coordinator and the surgeon for Batticaloa were exhausted. The
surgeon had been on call every night since he arrived 3 weeks earlier on
his first day to treat 24 wounded off-duty soldiers whose bus had hit a
road mine. The surgeon's rotate every month. As for the coordinator and the
other doctors, pacing is more important because their contracts are for 6
months.

The principal health-care problem arising from the war is allergy to
bullets, the coordinator says wryly. "Its the number-one cause of injury,
but you won't find statistics anywhere, especially related to mortality-nor
to births for that matter, most are attended by local midwives." Many of
the injured are civilians, often children, from both sides, who have been
caught up in cross fire, grenades, or landmines. Many patients are under 12
years old. Respiratory diseases, worms, diarrhoeal diseases, scabies, and
self-poisonings are endemic in the district, especially in the uncleared
areas. The paediatrician reports deaths from ordinarily preventable causes
such as meningititis, tetanus, and prematurity. MSF have opened a premature
baby unit at the Batticaloa Hospital to try to address the high infant
mortality rate.

PHOTO (COLOR): Recovering in Batticaloa

Other areas have their share of problems. Attacks by Tamil extremists have
recently increased. On March 5, 34 Sinhalese civilians were killed by a
bomb in Colombo, the third in as many months. In the northern uncleared
areas, severe malnutrition is not uncommon. The government recently stopped
distributing triposha, a grain meal supplement, because of a reported
breakdown in the machinery at the factory. MSF have since had to start
their own nutritional programme. Restrictions on insecticides in uncleared
areas means malaria is also on the increase. Yet some 20 years ago, Sri
Lanka boasted the near-eradication of the disease. Ironically, there
remains enough pesticide for the many suicides in Batticaloa, which has
perhaps the highest suicide rate in the world.

The main logistical problem is transport, and referrals to Colombo are
common for the specialty services such as complex surgery for which
Batticaloa is not equipped. However, Tamils are very reluctant to travel to
the predominantly Sinhala west. Those without identification cards simply
cannot leave uncleared areas and rely solely on the MSF/Ministry of Health
or Red Cross mobile clinics. Even if seriously ill patients can leave the
conflict zone or are willing to be referred, the difficulties are not
resolved because many speak only Tamil. For the few patients who make the
trip, the reception is often poor. The coordinator told me of a baby born
to a mother for whom it was the only successful pregnancy in four. The baby
had severe respiratory problems and had to be manually ventilated from
birth. A ventilator was reserved in Colombo, but the one ambulance was
being serviced so the baby was "bagged" for 24 hours until the ambulance
was ready. The team continued ventilation for the 8-hour journey until they
arrived in Colombo to find that the reserved ventilator was occupied.
Ventilation was stopped and the baby died within 2 minutes. "The whole
thing is ridiculous...and that's typical."

Back in the relative peace of Colombo, I asked the MSF country manager
whether their presence somehow removed the responsibility for health care
in the conflict zones from the government. "I don't think so but we are
evaluating the situation." And there have been improvements: two Tamil
surgeons are now posted in Jaffna and MSF are preparing to withdraw their
own surgeon. "Are we going in the right direction and am I proud?", asked
the Batticaloa coordinator. "Yes. Story by story, life by life we are
making a difference." War surgery continues as usual.
Philip Stevenson
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