After the Deluge

I am not sure just what it was that made me drop everything on December 31 and join six colleagues on a medical relief mission to Sri Lanka. At the moment I made the decision, it simply seemed like the right thing to do, and in retrospect it still does. But it turned out that the need for our small group was very different than we had anticipated: there was far less acute disease and injury than expected, but the human misery was of a sort that will require attention for years to come. In a strictly clinical sense, we accomplished far less than we had hoped. And yet it was important to be in that place at precisely that time. Ultimately, we did what doctors have always done, even before the Hippocratic physicians of ancient Greece enunciated their code of professional responsibility: we tried to help, as did so many others.

Six of us were doctors, the seventh being a young woman with degrees in public health. Like three others of our team, she had considerable experience in disaster areas located in various parts of the globe, and brought a perspective based not only on that but also on an overview of relief efforts within the context of large population groups and long-range problems. Before we left for home after two weeks in the refugee camps and seaside towns of the devastated country, we had all come to realize that the greatest contribution that can eventually be made to the people of Sri Lanka must come from a sober assessment not only of the long-term effects of the tsunami itself, but of the cruelly battered society and economy on which it visited its dreadful wrath. Disaster relief is only the most immediate kind of relief that this punished place requires.

Our entire time in the small island nation was attended by a series of strokes of circumstance conspiring to allow us not only the opportunity to bear witness to individual and collective tragedy, but also to confer with business and government officials, some of whose willingness to be candid in their assessment of their country's needs and problems was nothing less than astonishing, accustomed as several of us were to the usual blandness or obfuscation that characterizes such discussions, especially when they take place between public figures and virtual strangers who are thought to have some sort of waiting audience in their home countries. Our privileged situation came from two sources: our early arrival on the scene and the fact that two of our number had been born in Sri Lanka and had maintained relationships that brought us, almost immediately on reaching the capital city of Colombo, into contact with officials who opened doors that would otherwise have been inaccessible.

On passing through customs at 2:30 a.m. on the Sunday after the tsunami, we were met by a small delegation, several members of which would prove invaluable in helping us find our place, literally and figuratively, in the relief effort. The early arrival in Sri Lanka was due less to any forethought on our part than it was to the cumbersome nature of the steps necessary effectively to mobilize a huge juggernaut such as the Red Cross, a relief arm of the United Nations, or even one of the many NGOs that would sweep onto the island within a few days of our appearance. But we had joined together spontaneously within a period of forty-eight hours, made some telephone and e-mail inquiries, and then simply boarded a plane at Kennedy Airport, all without any accurate notion of what to expect. We had in mind only our certainty that doctors would be urgently needed to treat those many injured and diseased by the effect of towering waters that had blasted their way as far as two kilometers beyond the beaches, with the force of a wave traveling at a speed of approximately five hundred miles per hour.

IN RETROSPECT, WE were like an amateur and astonishingly nave flying squad or rapid-response team, arriving when only the extraordinary Doctors Without Borders and a very few other relatively small groups had managed to begin work. After a few hours of sleep immediately after arrival, we met with a man who in the next two weeks would come to epitomize to us the spirit of Sri Lanka's own relief effort and also the selfless dedication of some of its public officials. Dr. Amal Harsha De Silva (whose name is a reminder of the Portuguese possession of the island, which ended in the seventeenth century) is a pediatrician by training, though his official title is director of private health sector development. This means that he has been the government's designated liaison with any aid groups that might need assistance in organizing their relief efforts, and he also has contact with private organizations in Sri Lanka itself and the rest of the world.

De Silva's job had exploded in its responsibility in the seven days since the tsunami, and he was functioning on little rest and a heavy burden of care. His office is located in the sort of old, poorly lit building that is to be seen all over former colonial countries, furnished with what appear to be the same languid ceiling fans, peeling desks, and rickety chairs that the British or others left behind on the day they withdrew, but now more than half a century older and barely functional. Displaying a large map of the country, De Silva pointed out that the worst destruction had occurred in the north and the east of the island, though the south coast had been hit almost as hard. Some 850,000 people had been displaced from their homes, while many were living on their own or with relatives rather than in one of the nine hundred refugee camps set up by the government.

This large number of camps meant, as we would soon verify for ourselves, that the census in each one was within reasonable bounds, so there were limits to the possible spread of common post-disaster diseases such as infectious diarrhea, respiratory viruses, typhoid, and the dreaded cholera. As soon as a serious case of dysentery or other communicable disease was identified, the patient could be isolated in a hospital or other care facility, a strategy that markedly decreased the possibility of contagion. Since the ministry of health had been extremely effective in the immediate provision of suitable quantities of pure water not only for drinking and cooking but also for personal hygiene and washing dishes and cutlery, few major infections had occurred.

This in itself was a minor miracle and a great surprise to us, especially in view of long-standing complaints we would later hear from villagers and others of an accustomed state of governmental inefficiency and even corruption. On our departure two weeks later, we were shown national disease statistics confirming the success of the ministry's emergency policies. The figures for cholera and the other diseases were no higher after the tsunami than before.

WHILE WE WERE speaking to De Silva and determining where we might most effectively be sent, an episode occurred that would become increasingly significant in determining our overall comprehension of the country's relationship with its government, and of the ways in which foreign aid might best be used. We were introduced to an executive of the David Pieris Motor Company, one of the largest businesses in Sri Lanka, involved in the automotive industry, information communications technology, and financial services. The company is not a corporation, and, as David Pieris himself would later tell us when we met him on the day before our return to the United States, he is answerable to no stockholders and can do as he chooses with his profits. What he chooses is service to the people of his country. The service comes, as his managing director, Sumith Cumaranatunga, put it in an e-mail message received after we had returned home, "with an underlying philosophy that we can only be as successful as the society in which we live."

Upon the news of the tsunami, Pieris immediately donated fifteen million rupees—about $150,000, in a country where a middle-class family can build a comfortable house for less than $600—to relief efforts, and was prepared to do much more. But a crucial clue about the relationship between the private sector and the administration was evident in the recipient whom Pieris had chosen to determine the proper uses for the money and then distribute it appropriately: he had given it to the universally respected De Silva, who, though an official of the health ministry, is known for his probity and dedication. Pieris will not deal with the upper levels of government any more than the functioning of his business demands that he do, and he takes great pains to say so, not hesitating to use language impugning a bureaucracy that he and his executives view with suspicion. "To us, our reputation is everything," wrote Cumaranatunga, "and we are no respecters of personages when it comes to defending our principles." During our two weeks in Sri Lanka, speaking to civil servants, villagers, military officers, merchants, medical personnel, taxi drivers, and so many others, we would have ample opportunity to confirm that Pieris and his company live up to those words.

When Pieris heard of our arrival, he offered us the use of two vans and a pair of drivers for each to transport our team and its stockload of drugs and equipment to the areas in which we were to work. But these were no ordinary drivers. Fifteen percent of every executive's time is donated by the company to social service, and we were about to be taken to our destination by a group headed by Surendra Hettiarachchi, the Pieris regional manager for central Sri Lanka. The following morning we set out on a cross-country drive from Colombo, in the southwest, to Batticaloa, a city of 200,000 people on the east coast, to which at that time no medical team had yet made its way. Though the distance between the two cities is no more than 160 miles, there are no roads that pass directly across the island. The country's highway system is so inadequate that it was necessary to follow an indirect path that took us northward and then back in a southerly direction, adding some sixty miles to the journey.

Like the roads in other Third World countries, Sri Lanka's are two-laned and congested with a wide variety of motorized vehicles that cloud the air with pungent black clouds of carbon monoxide-laden exhaust and follow rules comprehensible only to the drivers who make them up as they go along. Traffic lessened considerably as we approached our seacoast destination, but the roads became increasingly worse. We bumped and banged our final twenty miles over a highway so broken up and rutted because of the cheaply constructed pavement (local people blame this on graft by low-level government officials) that a speed of three kilometers per hour was more than we could usually attain. Between the traffic and the slow pace dictated by the almost impassable roadbed, the trip of some 220 miles took more than ten hours.

Batticaloa, the coastal city where we spent much of our first week, is in the upper third of Sri Lanka that is Tamil and therefore primarily Hindu. Military checkpoints are frequent, as are armed government soldiers patrolling on the sides of the road and on the streets of each town through which we passed on the final phases of our journey. Though very few members of the local population support the twenty-five-year-old rebellion of the Tamil Tigers (whose stronghold is well north of the region in which we were), the rebels persist in claiming that this territory is rightfully theirs, and they periodically do something violent to prove it; there have been enough incidents of terrorism that troops with rifles at the ready guard every one of the refugee camps that have been set up within a few miles of the city and well interior to the massive destruction along the shoreline.

IN THE CAMPS of that area, as well as in the Sinhalese and primarily Buddhist south near Matera, where we spent several days during our second week, we followed a routine in which we would arrive, set up a pharmacy and medical stations, and then begin seeing the many men, women, and children who lined up as soon as our vans came to a halt. In all, we held nine clinics in the two locations, seeing between 150 and 200 patients in each. Most of them were displaced persons, but some were local villagers who thronged toward the airless and filthy schoolrooms where most of our visits were made. The temperature was always near ninety in the outside air, and the humidity was the same.

I had brought with me a set of surgical instruments to be used as though in a field hospital, assuming that my principal work would be to treat the late consequences of major trauma. I was wrong. The tsunami had an effect similar to that of September 11, when emergency rooms all over Manhattan prepared themselves for an influx of the seriously injured, and very few came. The reason was the same: almost everyone caught up in the disaster was killed. The great majority of those who survived had minor wounds or no wounds at all. The few severely injured who somehow survived were immediately evacuated to the inadequate and dreadfully maintained hospitals that we later saw, where they were languishing dispiritedly on bare mattresses covering rusty bedsprings, amid open drainage conduits filled with fetid standing water.

My own surgical work would consist in the management of relatively minor and usually infected wounds, the great majority of which had been sustained in the days following the tsunami, during the phase of digging out, when families were seeking bodies and lost possessions. I saw at least half my patients while functioning as what might be called a family physician, much as my five colleagues were doing. The refugees who came to us, apathetic and worn down by a chronicity of poverty and despair to which the tsunami had added a magnum of hopelessness, lined up because they needed to see, or wanted to see, a doctor, for any of several reasons. Sometimes those reasons would prove to be related to the most recent disaster in minimal or unexpected ways, as would be impressed on us again and again in our travels from camp to camp.

We soon discovered that the real good we were doing was not what we had expected it to be. It was not medical need, strictly speaking, that made our presence so important to the families in these crushed places to which we had come from half a world away. It was our physical presence that counted. A warm smile and an arm around the shoulder probably did more for most of our patients than the medications that we gave them for the various complaints so often unaccompanied by any physical findings that might account for them. It was the touching of a hand, the lingering of a man or woman's hand in my own, that seemed to mean so much, or the unexpected hug that made a frightened child laugh in surprise. Comparing notes at the end of our first day, we realized that we were dealing far less with physical than with psychological wounds and inflammations.

The prevailing mood of our patients—virtually all of whom had been living a bare pre-tsunami subsistence on the yields of fishing or the milk derived from the spavined cows and goats that roamed every byway and street to graze on garbage and similar detritus—was a kind of resigned lethargy. Except in a few instances, we never saw sorrow or any evidence of grieving, despite the reality that so many had lost loved ones, and all had lost their homes and everything they owned. There must have been plenty of widows and widowers and orphans among our patients, but no detached observer could tell which of these dispirited people they were. All of this contrasted remarkably with the general atmosphere of Batticaloa itself, where people in the shops and the streets were going about their business seemingly unaffected by the horrific events that had taken place so close to them.

The members of our team, who came from a variety of professional backgrounds and specialties, and who ranged in age from late twenties to early seventies, were in agreement that the repressed mourning that soon became so obvious was manifesting itself in symptoms that could arise only from that very suppression of overt emotional response. Physicians call such symptoms psycho-physiological. They typically consist of the assortment of complaints that I would hear over and over as our interpreters struggled to make English sense of what they were being told: "I shake a lot now"; "I can't feel my arms and legs anymore"; "I have an itching inside my chest"; "My belly is swollen"; "I have headaches all the time"; "I can't sleep." All these reports of inner states were without any objective findings associated with them, as was the too-frequent abdominal pain, or the invisible rash insistently described to me and my incredulous interpreter by one middle-aged man.

In any culture in the world, including those that are reputed to have the ability to face hardship and loss with a religious serenity, these are worrisome complaints, because they tell a physician that rage, guilt, conflict, or any of several other unhappy and unwelcome emotional states are being converted into symptomatology that is mistakenly attributed to organic causes. Of course, there were some dehydrated children who needed treatment, and the occasional respiratory or middle ear infection or relatively mild diarrhea as well as a variety of other minor illnesses and that assortment of infected wounds that I cleaned and dressed—but all of us agreed that we were witnessing an alarming phenomenon, the kind of situation that too frequently foretells later overt psychological breakdown.

It was not enough that we were observing these warnings in so many individuals. The greater concern was that a society that has suddenly lost more than 35,000 souls and an untold number of homes, a society filled with bereft and haunted adults and children who have not only lost so much but have also seen so much, a society of which so many members were impoverished and without hope long before the tsunami—this is a society in danger. The danger lies in the virtual inevitability in the months to come of widespread manifestations of the condition known as post-traumatic stress disorder, in essence a serious form of depression recognized under various names for more than a century in survivors of major calamities, but only in recent decades fully described in all of its perilous characteristics. No matter how individuals may suffer, an even greater danger is a kind of national inertia, loss of productivity, and an inability to deal with the realities of everyday life.

WHITH EACH PASSING day of our mission, increasing numbers of NGOs and the larger agencies arrived to provide medical aid, until it seemed that we were all getting in one another's way. Before long, our small group became not only redundant but less effective than we had been at first. It became clear that, having obtained a microcosmic perception by our work in the camps, the best way to contribute something of macrocosmic and perhaps lasting significance was to make observations in the devastated areas, to speak at some length to survivors of the tsunami, and then—utilizing the knowledge of the members of our team with wide experience in Third World countries—to make recommendations to De Silva, Pieris, and any representatives of the Sri Lankan government who might wish to speak with us. As it turned out, these included the prime minister and the minister of health; but we soon came to realize that, with the exception of De Silva and Pieris, our other contacts seemed too concerned with the immediate problems (or perhaps with impressing upon us how well they were dealing with their country's fragility) to focus on matters that might become troublesome as the months wore on.

Of greatest concern is the significant probability—several of our number, myself included, consider it a virtual inevitability—of what might be called a national epidemic of post-traumatic stress disorder involving large segments of the populations directly or indirectly affected by the tsunami. There are only twenty trained psychiatrists in the entire country, so a great deal of help will be needed, especially skilled professionals to train physicians, nurses, men and women who work in social services. Many will be required in order to provide psychological counseling and various forms of support. For the heartbreaking number of children who have been left without parents, the country must have a complete overhaul of its orphanages and a critical evaluation of its adoption procedures.

But Sri Lanka will need far more than attention to the havoc caused by the tsunami itself. There is an absolute necessity to put people back to work—so soon, indeed, that it must be thought of as an emergency measure. As is true of so many Third World countries, this is a chronically depressed society in which large numbers of men and women are barely or not at all occupied in meaningful work. Upon this long-standing problem has been thrown the acute and immense psychological burden of enormous loss, displacement, and an exacerbation of underlying mistrust of the government, as well as a certain overt denial of the emotional effects of the tragedy, as manifest in ordinary behavior. To illustrate the prevalence of chronic clinical depression predating the tragedy, the national suicide rate is said to be so high that the major hospital in Batticaloa (and elsewhere as well, we were told) has a poison intensive care unit, because villagers and others so often try to do away with themselves by ingesting fertilizers and insecticides, the only sufficiently toxic materials available to the poor.

The urgent necessity to put people to work dovetails with the country's most important long-term need, which is a national undertaking to rebuild a woefully inadequate and even dangerous infrastructure of roads, bridges, hospitals, and dwelling places. Supplies and equipment have poured into the country since the tsunami, but transportation between parts of the island is so difficult that this, far more than any lack of materials, has been a major factor standing in the way of aid and recovery efforts. As part of achieving these goals, the entire hospital system must be rebuilt. Not only are the conditions for patients and staff appalling, but the very architecture of Sri Lanka stands in the way of effective care. The major hospitals are built in the antiquated pavilion style, the former colonial model long discarded for modern facilities because of its inefficiency and its difficulty to maintain.

As two of my medical teammates—an internist and an infectious-disease expert who have been involved in disaster relief in such places as East Timor, Kosovo, Chechnya, and several African countries—pointed out, there is no single international organization capable of responding immediately with massive aid and the ability to coordinate the efforts of the many NGOs and individual groups that begin to pour in once they have overcome the logistical problems of getting themselves under way. The huge outfits such as the Red Cross and the United Nations take too long to arrive in full force and seem far less systematized than one is led to believe. What is needed is an international working conference on disaster relief that brings together all the appropriate experts and groups, and coordinates a predictably functional system that is reviewed each year. What better place to hold such a conference than Colombo?

Sri Lanka needs a re-orientation of its national priorities. Its location and its extraordinary natural beauty have gifted the island nation with the potential to build one of the leading tourist industries in Asia--yet it has remained barely developed, largely because of poor infrastructure, little investment, sparseness of know-how, and a seeming inability to recognize possibilities. And there is the terrifying political context for all the island's miseries: the decades-long excruciation of an ethnic and religious war in which 64,000 people have so far been killed. (It was in this savage conflict that suicide bombing was invented as an instrument of war.) An outburst of economic accomplishment, with its accompanying improvement of conditions across the social and ethnic divisions within the country, would go a long way toward healing some of the open wounds that have served to perpetuate the Tamil rebellion and to frustrate the thus far inadequate internal and international efforts to solve it. The key to all this will very likely prove to be far less the role of the Sri Lankan government than the participation of its private internal organizations and the international business community.

Is there what Americans would call an "upside" to such a catastrophe? In the wake of such massive and arbitrary suffering, the search for a saving significance is inescapable. And so it is important to remember that success breeds success, and spreads its effects among the disaffected and rebellious as it spreads optimism, a sense of goodwill, and the capacity to compromise in order to perpetuate gains that are being made. By bringing the world's attention to the acute and chronic disasters of Sri Lanka, the tsunami may paradoxically have come with the silver lining that lifts the country, and some of the other involved areas, out of its long-standing state of neglect and torpor and despair.