While on a return trip through the broken and washed away city of Kesennuma in Miyagi Prefecture to meet with two nongovernmental organizations Direct Relief supports, I saw a familiar house on the other side of a huge ship grounded among immense piles of debris. It was a two-story house, which I remembered visiting months ago at the onset of Direct Relief’s activities in this ravaged area. I first saw this community just a few days after the earthquake and tsunami struck Japan. This was my first trip there to inspect and analyze our projected recovery and involvement of such grand and unimaginable devastation.

When I first visited months ago, the house was held up by only the barest and essential features of support as it leaned slightly toward a dry concrete-lined riverbed.  The river was filled with the wreckage of cars, ships, and the remains of everything that had been destroyed or ripped from foundations. Many kilometers from the river’s mouth, the house barely “stood” among other downed houses scourged by the tsunami’s sudden force up the channel. The walls of the house had been ripped away to expose the beams, joists, and rafters. I dared not take one single photo of the house or family, but the images were forever burned in my mind.

On that first day, I met with the homeowner and the director of the International Volunteers of Yamagata (IVY).  IVY’s director was on hand to manage cleanup efforts and restore the house to a habitable condition through a program called “cash for work.”  

The IVY workers on site were all affected in some way by the earthquake. Traumatized better describes the experience of “cash for work” workers. Each person was living in the pulverized community and had suffered similar losses of property, vocation, and family members during the disaster. One worker lost her mother and child, and needed the work just to stop crying.

On their knees sorting glass from debris on the ground and up to their knees removing black, putrid mud from under the house, these workers shared a common interest and drive to get healthy and help others. No job was too small or too big.

Now, months later, this house is standing upright, clean and occupied. The trashed grounds and downed houses that previously littered the yard and lots nearby had been cleared away.  I stopped and found the owner coming out of his workshop. I hardly recognized that this was the same man—he had recovered as much in appearance as his house. Untraditional of Japanese customs, the man embraced me with an immediate recognition and flashed a big smile as he pointed to his house. He took me inside and asked me to share his story and thank IVY.

The owner credited the resurrection of his spirit and house to IVY and Direct Relief. He said that before IVY came along, he had no desire to fix the property and had lost any idea of recovery. He felt shame at the prospect of volunteers from outside coming into his house and fatigued by the daunting task of restoring his life. IVY’s workers understood the culture in his community and had shared some of his experience. These people, to whom he could feel reciprocity, turned his life from hopeless to inspirational. The house is now fully restored and the owner has reopened his fishing-flag print shop. Inscribed on every new flag is the date of his shop reopening.

August 26 to September 1, 2011

September 11 marks the six-month anniversary of the earthquake and tsunami in Japan. As we reach this milestone in the recovery process, Floyd Mori (Executive Director, Japanese American Citizens League), Bhupi Singh (Direct Relief’s COO/CFO), Carl Williams (Direct Relief’s Japan Disaster Relief Coordinator), and I visited the groups Direct Relief and JACL are supporting.  To date, Direct Relief and JACL have provided over $2.4 million to eight groups providing a variety of services in Iwate, Miyagi, and Fukushima Prefectures. Our trip started in the north, and we worked our way south to Fukushima. This is a brief summary of our trip.

Shanti International Volunteer Association (SVA) is providing a mobile library service to 13 temporary housing centers in four towns on a biweekly basis. The libraries in these towns are either destroyed completely, all the books have been destroyed, and/or the librarians are deceased. We saw both young kids and senior citizens at the mobile library at one temporary housing community with about 150 households. Residents of all ages use the mobile library to escape the heat and socialize.

We visited Association for Aid and Relief, Japan (AAR JAPAN), which is focusing now on meeting mid- and long-term needs.  This includes distribution of items to support everyday life, income-generating activities, and continuous surveying of needs. We briefly visited a kindergarten and adult day care center that AAR supports.  Although the kindergarten is being repaired from the tsunami damage and used by 40 children, the grounds are unsafe and the facility will have to be relocated within two years.  The adult center provides mentally disabled adults with piecework making and packaging small cookies and products to sell in Tokyo and elsewhere, allowing those families to earn some income. AAR repaired the earthquake-damaged parking lot.

We traveled next to Kesenuma City, where the damage is quite shocking still. Many of the buildings and piles of debris in smaller, more remote villages have not been cleared yet. We met a team of workers from International Volunteer Center of Yamagata (IVY)'s Cash for Work program who were clearing an elderly woman’s land. She told us that she was living alone in the house, which she moved into when she got married 50 years ago. She seemed to really enjoy the company of the workers and the opportunity to get out of the temporary housing.  One of the IVY workers we met had cleaned over 70 homes.

Next, we visited the Japan International Volunteer Center (JVC) office, where the secretary general described their challenges.  Here, 63 houses are usable among the 251 that stood before. The group’s activities, with the help of 10 to 15 weekly volunteers, include provision of water, hot baths, fish-net repair, transportation, childcare, and collaboration with local business owners. Leadership at JVC is now assessing winter preparations, community revitalization projects, income-generating projects, and infrastructure support.

We then met with Service for the Health in Asian & African Regions (SHARE), whose staff gave a brief update on their work in the medical sector. A common theme that arose in discussions with SHARE, as well as JVC and AAR, is the challenge of providing psychological care to the victims. These include a disapproval of the practice in Japanese society, lack of infrastructure to connect mental health professionals with people who need treatment, government restrictions, and lack of sufficient information about needs. Most of the groups Direct Relief supports are working to improve mental health among survivors through community-building activities.

One evening we attended a seminar hosted by Japan NGO Center for International Cooperation (JANIC) about temporary housing, attended by more than a dozen organizations concerned with this topic. The group discussed the failures and successes of the temporary housing establishments. Concerns with the physical infrastructure of the housing units were raised, especially with the upcoming winter. Participants also shared best practices and lessons learned about community-building efforts in these facilities.

In Ishinomaki we visited Peace Boat, whose numerous projects and accomplishments are impressive. We visited a temporary bathhouse and a soup kitchen run by Peace Boat volunteers. Between 250 and 280 volunteers, many of them students from Tokyo, help each week with these activities as well as cleanup work. We drove out to one of the cleanup sites, a cemetery devastated by the tsunami, surrounded entirely by debris. The work is back-breaking and it is difficult to fathom the amount of time and effort it will take to return the cemetery to a semblance of a resting place. The volunteers are enthusiastic, which is encouraging.

At the end of our trip, we spent a day in Fukushima, where JANIC staff took us to an evacuation center operating in a sports arena. We also visited a temporary housing unit and spoke with several members of the elderly population there, most of whom did not know each other before the earthquake and tsunami and have homes in the nuclear evacuation zone.

We spent some time at Shapla Neer’s office nearby, where a few dedicated staff and volunteers work just outside - and occasionally inside - the nuclear evacuation zone to support displaced and disconnected residents. In addition to needs assessment and personalized support, Shapla Neer has distributed needed household items such as window screens, blankets, and almost 1,000 sets of kitchen utensils.

It is a privilege to work with organizations that are genuinely committed and invested in the revival of these communities and individuals.  As response transitions into recovery, Japan continues to demonstrate its resiliency and strength against disaster.

Brett is an EMT and spent several months in Pakistan following last year's tragic earthquake, directing emergency shelter efforts; he later coordinated emergency response efforts in Java following the Yogjakarta earthquake.

March 2007
Kabul, Afghanistan

Several related factors plague women's health in Afghanistan.

Little Infrastructure, Few Health Professionals, Limited Access: The province of Badakshan, which is northeast of Kabul, exemplifies the enormous health challenges that women confront in Afghanistan. An estimated two percent of women give birth with a trained health professional present. "Trained health professional" doesn't mean a doctor -- it means a nurse or a skilled birth attendant. According to a recent study conducted by UNICEF, Badakshan province has the highest maternal mortality ever recorded.

Access also is affected by geography. Most of the villages in the mountains cannot be reached for many months of the year due to poor roads and snow. Moreover, even when a clinic facility exists, the likelihood is very low that a trained female health provider would be present to assist a woman expecting a child.

Thirty years of war in Afghanistan caused a major brain drain - most of the educated professionals having fled with their skills. Among other consequences, this resulted in a generation living with a severe shortage of healthcare providers.

Our Afghan partners have explained how cultural norms also affect women's access to health services. Women traditionally do not travel unaccompanied and, typically, an expectant mother would need to be granted permission from her husband, her father-in-law, and her mother-in-law in order to make the journey to the clinic. Families who are unaware or uneducated about the risks of a complicated pregnancy may forego seeking prenatal care or assistance in delivering a child, choosing instead to follow the tradition of giving birth at home. In general, people living in rural areas tend to adhere more closely to these traditional practices.

Maternal and child health are affected by many factors, but these are among the major factors reported that combined have caused such a high rate of maternal mortality in Afghanistan. The AIL staff, most of whom are deeply committed Afghani women, are working tremendously hard to improve circumstances in these areas.

January 3, 2007
Kutch, India

The opening ceremony for Bidada Hospital’s 33rd medical and surgical camp was held on January 3, 2007. I arrived at the facility the following day, and the medical screenings, consultations, and pre-operative services were already in full swing. The hospital is administered by the Shree Bidada Sarvodaya Trust, and has been providing quality healthcare services to the people of Kutch, in the state of Gujarat , for decades. Their annual medical and surgical camp, held during the first three weeks of January, treats thousands of patients who have no other access to specialty services. In 2006, the camp provided examinations and treatment to 28,284 people, and conducted 1,173 surgical procedures, all free of cost.

This was my second visit to Bidada Hospital, a facility that Direct Relief has been supporting ever since the devastating Gujarat earthquake that occurred in 2001. The hospital, one of the only health facilities that wasn’t damaged or destroyed in the quake, treated thousands of earthquake survivors and still handles an increased patient load as many of the pre-existing medical facilities were never rebuilt. Direct Relief provided multiple earthquake-related emergency shipments to the facility, and subsequently decided to continue our support of the hospital by supplying medical goods for their on-going services and medical camps.

The district of Kutch has a population of approximately 1.6 million people and is home to many different nomadic and semi-nomadic tribal populations. The area’s ethnic diversity is very apparent at Bidada Hospital , with men sporting turbans of various colors and women with tattooed necks wearing fabrics and jewelry representing their respective tribes. A total of 35 medical specialties were being offered at this year’s camp with urology, diabetes, endocrinology, ENT, speech and audiology, cardiac, pediatric ophthalmology, and general surgery services all scheduled for the first week. Healthcare professionals from the U.S. , Canada , and other areas in India volunteer their services during the camp with many coming year after year. Dr. Manibhai Mehta, an Indian-American urologist who resides in southern California, comes to the camp each year to help with the urology consultations and surgeries.

Due to the mineral content of the local water, there is a very high incidence of kidney and bladder stones and many people live with excruciating pain for weeks, months, and even years before getting treatment. During the first three days of the camp, Dr. Mehta, along with three other urologists and a radiologist, examined over 200 patients and performed more than 50 surgical procedures, many involving the removal of 15 or more large stones. When I visited some of the patients in recovery, they expressed their heartfelt gratitude to the hospital, the physicians, and to Direct Relief which had donated many of the surgical instruments, catheters, and medical supplies needed for the procedures.

I also had the opportunity to observe the second day of cardiac screenings when approximately 50 patients are selected to travel to Mumbai to receive surgical procedures. The most common heart problems requiring surgery include congenital heart defects for children and valve replacement for adults. One woman who was examined by one of the volunteer cardiac surgeons was informed that, due to rheumatic heart disease, she needed to have valve replacement surgery. Hospital officials explained to her that all of her costs would be covered, someone would be available to take care of her during her stay in Mumbai, and that she would receive a free lifetime supply of medication. She was scared and overwhelmed by the diagnosis and need for surgery, and said she needed time to decide if she was willing to take advantage of this generous but frightening offer. I then watched the examination of a young boy who needed surgery to fix a hole in his heart. His family had traveled over 100 kilometers to reach the camp, and they were overjoyed that the boy would receive this lifesaving opportunity free of charge.

It was great to see Direct Relief-donated medications, supplies, and equipment items being used at the camp, and many of the hospital administrators and volunteer physicians conveyed their appreciation. They also asked if it was too soon to submit a new list of needed items for 2008. I assured them that Direct Relief was honored to work with such a first-rate institution, and that we would do our very best to support their efforts in the future.

January 2007

The boat arranged by the village chief arrived on schedule, and we loaded it with medical goods then climbed aboard. I was accompanying a medical team, organized by the U.S.-based Loloma Foundation, and we were traveling by boat around the Yasawa Island group in northwestern Fiji. The team, which consisted of three physicians, an optometrist and his assistant, and the project director, was conducting medical clinics and delivering critically needed medical products, such as medications, first aid and clinic supplies, and screening and diagnostic equipment items, to regional nursing stations.

The Loloma Foundation was established to support the limited healthcare and educational services in Fiji. Every year, the Foundation distributes medical materials, including Direct Relief-donated products, to inadequately-supplied hospitals, clinics, and nursing stations located throughout the island nation. In collaboration with Scripts Memorial Hospital of San Diego, the Loloma Foundation also organizes teams of medical professionals to travel to Fiji to conduct medical clinics in extremely difficult to reach areas such as the Yasawa Islands. These coral and volcanic islands stretch out for approximately 80 kilometers and can only be reached by boat or seaplane. They are rarely, if ever, visited by Ministry of Health physicians.

Major health issues in Fiji include bacterial and fungal skin infections, muscle and joint pain, ear and respiratory infections, filariasis, hypertension, and traumatic injuries. Nursing stations have been established on selected islands and each station is staffed by a trained nurse/midwife who provides basic services to the local community or geographic division. The most critical issues with regard to the availability and quality of healthcare services in Fiji include the number of individuals a nurse may be responsible for taking care of (up to 3,500), the cost and logistical difficulties required to reach a nursing station, and the chronic shortage of medical products and diagnostic tools available.

Yasawans, like most rural Fijians, live a subsistence lifestyle by fishing (both reef and deep sea) and growing/harvesting fruit and vegetables, such as cassava, yams, breadfruit, papaya, bananas, and pineapple. Many Fijians still live in bures - traditional one-room homes with woven mat walls and palm thatched roofs. Most villages do not have electricity or running water. Village life is very communal, and frequent ceremonies and religious services bring people together. Before a clinic begins, the village chief, his spokesman, and other ranking villagers hold a kava (drink made from the crushed root of a pepper plant) ceremony to welcome us.

Our first stop in the Yasawa Islands was to the village of Yasawa I Rara. After being transported to the shore we walked to the village community center where stations for the various physicians had been prepared. The nurse responsible for the area had arrived early and had already started to hand out patients’ medical record cards to those waiting in line. He also worked closely with the physicians all day to provide context, to help translate, and to schedule any required follow-up.

As the incidence of hypertension and diabetes has been rising in Fiji in recent years, all adults received blood pressure and blood glucose screenings before their consultation with one of the physicians. The dermatologist screened hundreds of people as bacterial, fungal, and parasitic skin infections are extremely common among both adults and children. She provided customized treatment plans for each person using an assortment of systemic and topical medications. Micronutrient deficiencies are also an issue in Fiji and vitamin A deficiency, due to the limited diet on outer islands, can put children at risk for vision problems and limit their ability to recover from serious illnesses.

To address these concerns, I worked with the nurse and local school to provide high-dose vitamin A to all village children between the ages of one and 15. Supplements to continue this distribution program (only one capsule is required every six months) for the next 18 months were left with the nurse.

There was also a long line to see the optometrist who was able to diagnose an array of vision problems as well as prescribe prescription eyeglasses, reading glasses, or sunglasses which were then dispensed on site. Cataracts and other eye disorders are common among the rural Fijian population, especially among women who typically spend four or more hours each day fishing on the reef. If a patient can arrange to get to the host hospital – an expensive proposition with the high cost of fuel – they can receive surgery to restore their sight.

Yasawa I Rara was only one of the many island villages that we visited during our time in Fiji. The villagers were extremely grateful for the opportunity to obtain medical screenings and care and upon leaving we were often thanked with songs, dancing, and handmade gifts. In addition, each nursing station visited received a midwife kit, diagnostic and testing equipment, and an assortment of medications and supplies. These stations will now be on the official Loloma Foundation list and will receive a supply of medical goods every six months.

December 26, 2006
Port Blair, Andaman Islands, India

On December 26, 2006, in a modest event commemorating the second anniversary of the Asian Tsunami, a small assembly of people, including officials from India’s national and local governments, gathered in the Andaman Island capital of Port Blair. Together, they intended to illustrate that there is more than grief to be recognized, and more than tragedy to be remembered. Although sadness made its presence felt, the event acknowledged achievement and hope for the future by officially handing over to the government 34 new health care facilities, funded by Direct Relief International, to replace those that were literally washed away in the Tsunami,

Looking back two years, it is not difficult for most to remember reports of the Asian Tsunami, the wrath it brought, and the quarter of a million lives it took. The wave wreaked havoc on five costal countries, each experiencing a great deal of damage. The Andaman and Nicobar Islands—a chain of small, sparsely populated islands located 1,000 kilometers to the East of mainland India—were no exception, and bore witness to a great deal of death, injury and destruction.

Comprised of hundreds of islands, the Andaman and Nicobar chain is India’s most remote state, famous mostly for its underwater scenery, lush tropical forests, wildlife, and, for its remoteness. With a population of less than half a million, it is also India’s least populated state, and many on the 36 inhabited islands are aboriginals from one of twelve original tribes. Still today, many of the islands have little to no contact with the outside world, and parts of their culture, indeed even the size of their population, are officially unknown. Few, if any, other living human populations have experienced such long-lasting isolation.

Interestingly, it is alleged that of those island communities that still survive in their traditional way, not a single person perished in the Tsunami. The reason commonly believed is that due to being more in-tune with nature, they recognized the impending danger in the agitated behavior of the wildlife, and were therefore able to escape to higher ground.

After the Tsunami, many of the islands, especially those in the South closer to the epicenter, were devastated. More than 7,000 lives were lost and 40,000 lost their homes, left to live in one of the 150 aid-camps set up around the islands. Of the many problems faced on the islands after the tsunami, one of the most significant was the slow pace of reconstruction due to a general lack of transportation and medical infrastructure, lack of cargo space and the great length of time needed to reach the islands by boat to deliver supplies.

Prior to the tsunami, the healthcare infrastructure on the islands was based on primary healthcare centers, sub-centers and a few hospitals. After the tsunami, a large number of these (30 primary healthcare sub-centers and 4 primary healthcare centers) were totally destroyed. This created an almost complete breakdown in the healthcare infrastructure and crushed the islanders’ ability to return to their home islands.

As part of its large-scale Tsunami Relief grant program, Direct Relief began funding the reconstruction of these 34 centers shortly after the tsunami hit. The project was carried out through the joint efforts of Direct Relief and Bharatiya Jain Sanghatana (BJS), an Indian charitable organization that engages in and supports education, job training, and disaster relief. By means of the $1.5 million dollars donated by Direct Relief International, and with the permission of the Indian government to rebuild the health clinics, BJS and Direct Relief embarked on reconstructing the healthcare infrastructure throughout the island chain.

The first step of this project was to spend time with and talk to the local communities whose health care centers were lost. Only after asking them what they wanted, what should be built, where it should be built and what services they really needed, was the construction phase begun. And the results and feedback received thus far have been outstanding.

The new health centers that have now been built are of an even higher quality than those that they replaced. The desire to build back better encouraged those working on this project to not only expand the centers, but also to redesign them so as to resist damage by earthquake, flood, and cyclone level winds. In addition, for each center, the project includes an 18-month training program and, for the first time, living quarters for a full-time, live-in, health-care provider or midwife. Lastly, Direct Relief sent four 40-foot containers to the islands in order to equip the centers with the basic supplies they will need.

The entire project was massive, and will have an equally massive impact on people’s health for years to come. For me to be present at this auspicious gathering was a real honor. Not only was I asked to speak to the delegation of national, state and local officials, but the significance of the occasion was ever present and obvious: no other NGO had stepped forward to offer such a large scale reconstruction project on the islands, and the Health Department made it clear that it did not have sufficient funds itself to rebuild the centers and sub-centers. Therefore, if it were not for the many generous donations given to Direct Relief, and Direct Relief’s subsequent funding of this project, it is unlikely that the health care infrastructure would have been rebuilt to this day.

Participating in the handing over ceremony with me were the National President and National Secretary of BJS, the Union Minister of State for Home Affairs, a member of the National Disaster Management Authority, the Director of Health Services of the Andaman and Nicobar administration, and the Secretary of Health.

I will not soon forget this occasion, just as I will not soon forget that tragedy is not the only thing to be remembered each December 26.

December 24, 2006
Cochin, Kerala State, India

I went to southern India to visit a hospital that was using a telemedicine van that Direct Relief International had bought for them. Recently there had been an international conference about the van put on by the United Nations and the Indian Space and Research Organization, and I was going to see the van for myself. While I was there, however, I heard of something perhaps even more impressive: a miracle that was about to happen near to where I was. Just a few days ago, on January 14, as it does every year, the miracle occurred—at least that’s what thousands of Hindu Indians who witnessed the miracle from high atop Mount Sabarimala will tell you.
 
For many weeks now, spiritual devotees have been making their way from all over India and all over the world, to reach Mount Sabarimala, the eternal dwelling place of the Hindu Lord Ayyappa. And far below the peaks of the divine mountain and its Hindu Shrine, at its base camp in Pampa, in what could perhaps be called a perfect paradox between religion and science, faith and reason, stands a fully functional telemedicine van, outfitted with the most high-tech bio-medical equipment on the market—the same one that I had now traveled half-way across India to see.

Located in the southwestern-most state of Kerala, 400 kilometers from the coastal city of Cochin, Mount Sabarimala (‘mala’ meaning mountain), is visited each year by tens, if not hundreds of thousands of devoted worshipers, some of whom make the trip a yearly sacrifice. They come to celebrate, pay their respect to, and worship Lord Ayyappan, a Hindu symbol of religious unity and communal harmony. Most of the last part of the journey is undertaken on foot, and many walk for days on end to reach this sacred place. In order to participate in this ceremony, pilgrims must fast for 41 days, and are not permitted liquor, tobacco or sexual relations.

The only complaint that I’ve heard made about the experience is that injuries and illness are a fairly common occurrence along the path. Which makes sense, when one takes into account the fact that there are countless thousands of people, walking long distances in unpredictable weather over rough, rural and wild terrain with animals and sickness hiding in every corner. One example of the dangers involved occurred just a few years back, when so many people had jammed their way onto a hillside that the hill collapsed, killing a large number of people.

But what is there to do when the mountain is so far from any form of health care? Bring the doctors to the pilgrims, says Dr. Kumara Menon, who is the telemedicine director at AIMS Hospital in Cochin, Kerala. The Amrita Institute of Medical Sciences and Research Center (AIMS) is a multi-specialty, charitable, non-profit medical center that provides healthcare services to thousands of low-income and indigent patients. The 800-bed facility was established in 1998, and has already treated tens of thousands of inpatients and hundreds of thousands of outpatients. The hospital also runs half a dozen educational programs and medical universities. Beyond their on-site activities, however, AIMS is perhaps better known for their free or low-cost community-based health programs, medical outreach camps, health awareness campaigns, and other services provided to people living in remote areas throughout the state.

Another example of their service is evidenced by their response to the tragic effects of the tsunami that devastated much of Kerala State’s coast. Immediately thereafter, AIMS deployed teams of medical personnel and ambulances to the hardest hit coastal areas in Kerala and its neighboring state of Tamil Nadu. Numerous medical camps were quickly set up and free services were given to tens of thousands of tsunami survivors. Those that needed additional treatment were transported back to AIMS or to other local hospitals.

Unfortunately, the medical directors at AIMS still faced problems: they realized that temporary camps were only able to provide so much care; some cases were difficult, if not impossible to treat at the camps without more advanced equipment or specialists; and other, even more remote places, were still not receiving any health care services. But they had an idea.

If they had a telemedicine van that was able to move amongst the camps as well as travel to the more remote areas where camps had not been established, they would be able to improve their services and increase the number of patients they could treat. “Telemedicine” means using satellites and internet technology to send and receive data from a more rural site to a more sophisticated hospital. There, experts and specialists stationed at the hospitals who could otherwise not help or advise patients, are able to be of service to them. Utilizing telemedicine, patients—regardless of where they are—can be ‘seen’ by doctors at the AIMS hospital, diagnosed, and treated on site, or can be transported back to the AIMS hospital to be given more advanced care.

Having worked with Direct Relief in the past, and having just received from them a huge amount of supplies, medicine and relief immediately after the tsunami, AIMS thought of asking Direct Relief for help and support in their project. Prior to their request to Direct Relief, AIMS had already received a commitment for a portable satellite link from the Indian Space Research Organization (ISRO), which is the rough equivalent to NASA in the United States. Because AIMS proved that they had the technical capabilities to handle the project, and had proven their dedication to service based on their work before and after the tsunami, Direct Relief International agreed to fund the project. Shortly thereafter, the fully-functional telemedicine van was in operation, equipped with general diagnostic supplies, an X-ray, a lab, as well as endoscopy, cardiac and ophthalmic equipment, not to mention the ISRO satellite.

When I visited AIMS hospital in early January 2007, the tsunami was two years in the past, and much of the physical injuries and suffering had thankfully ended. As I arrived at the hospital, they at first appeared very apologetic, and I immediately assumed the worst. Luckily, I soon surmised that they were apologizing that the van was not at the hospital, and thus I was unable to see it firsthand. I, on the other hand, was thrilled that it was not at the hospital, because it presented proof that it was out working as intended.

“Where is it?” I inquired. “Glad you asked”, they replied. They then asked me to follow them, as a patient had just entered the van, and they wanted me to witness the consultation between a doctor at the hospital and the doctor in the van. Up the stairs in the hospital’s beautiful, cylindrical main building, we came to a small, white door. Inside was a massive wide-screen TV, computers, cameras, a sound system, a couch and two reclining chairs. This was not an entertainment room, but instead the main center for telemedicine conferencing. And there, on the TV screen, was the patient, wearing the same traditional outfit that I had seen a hundred others wearing earlier in the day. As I was driving to the hospital, I saw many pilgrims as they walked along the road on their way to Mount Sabarimala. Now, one had made it to its base camp, but something had gone wrong. Luckily for him, that is also where the tele-medicine van had been sent.

I quickly learned that this traveler had been bitten by a snake as he ambled, barefoot, in the grass. His heart rate was irregular, and the doctor in the telemedicine van at the base of the mountain was unsure how to diagnose the problem. Over the computer screen came digital photos of the bite and real-time EKG heart monitoring that were sent by satellite from the van. In addition there was video and audio that Dr. Kumar, who I was with, used to see and talk to the patient and the other doctor in the van. I was amazed at the clarity of the video and that the information was being seen at both locations simultaneously. My only problem was that I couldn’t understand the language being spoken.

More interesting than my own amazement, however, is the long list of others who have been amazed at this van. A few months back, the United Nations, in coordination with ISRO, sponsored a conference at the AIMS medical campus, specifically to talk about the van. As it is the first of its kind in India, and was so unique in the world, and has performed so successfully, the UN was interested in learning more about it, as they were toying with the idea of utilizing the same technology in Afghanistan.

At another event I was attending a few days earlier on the Andaman and Nicobar Islands to commemorate the second anniversary of the Asian Tsunami, I was on stage sitting next to Mr. M. Shashidhar Reddy, who is a member of the national disaster management authority in New Delhi. As we were chatting about other international programs designed at preventing and reacting to natural disasters, he mentioned his desire to see more mobile tele-medicine being used throughout India, and said that the program in Cochin was a good example of the system he would like to see used more.

Additionally, just before I arrived at AIMS hospital, another group of visitors arrived to take a look at the van and learn more about it. This group was from National Geographic, and they had come to document and record a special program for National Geographic about the van.

It seems in the end, that the Direct Relief International funded telemedicine van has been a success, and hopefully it will be the forbearer of more technology like it to come. And, even though I was not able to see the van in person to verify its capabilities, I was able to experience it through the miracle of modern science and technology. Now, if only I could figure out a way to experience that other miracle that was occurring on the mountaintop, high above the van...

September 14, 2006: Angkor Hospital for Children, Siem Reap

As we entered the Angkor Hospital for Children’s open air courtyard, located between the outpatient department and the surgical ward, we were greeted by the smells of Khmer cooking. Mothers, grandmothers, and other relatives of sick or injured boys and girls were busy making lunch. Patients’ relatives are responsible for preparing meals for family members, and are provided with a variety of high-protein, nutrient-rich foods by the hospital.

The cost of the fish, meat, and vegetables, purchased daily at the market, is currently covered through a Direct Relief-supported nutrition education and support program. This facility-designed, comprehensive nutrition program is being funded by Abbott, one of our most active and generous corporate partners.

Under the ruling of the Khmer Rouge in Cambodia, health facilities were destroyed and most of Cambodia's medical professionals were killed or escaped (in 1979, at the end of the regime, all but 40 of Cambodia’s doctors had either perished or fled the country). Today, after decades of conflict, Cambodia is struggling to rebuild the infrastructure of its health system as well as that of its work force.

During a series of photographic trips to Cambodia’s Angkor monuments, international acclaimed photographer Kenro Izu had numerous encounters with children disfigured by landmines and in desperate need of medical care. He decided to dedicate himself to establishing a pediatric hospital in the region, and as a result of his efforts and determination, the Angkor Hospital for Children (AHC) was founded in 1999. Located in Siem Reap, the city closest to Angkor Wat, the facility was established to provide both quality health care for the children of Siem Reap and neighboring provinces, and to provide training for healthcare providers countrywide.

AHC provides outpatient (average of 300 to 500 patients per day) and inpatient services, basic surgery, 24-hour emergency service, and dental care. The hospital’s acute care unit includes three emergency room beds and three intensive care beds. Each month the hospital serves 600 to 700 emergency patients and 25 to 35 intensive care patients, with the majority of cases involving acute respiratory distress/failure or trauma. Other common illnesses seen at the facility include dengue fever, dysentery, tuberculosis, HIV/AIDS, malaria, and intestinal parasites. Malnutrition and dehydration is clinically evident in 66 percent of children admitted to the hospital, and 10 percent of admissions are due primarily to severe malnutrition.

Due to the extreme shortage of trained medical professionals in the country, AHC was initially staffed by an international team of healthcare providers and administrators. The facility immediately began to provide intensive training to Cambodian doctors, nurses, dentists, and other hospital personnel, and has since handed over most of the medical, nursing, management, and other positions to an extremely motivated and enthusiastic local staff. In 2003, AHC was recognized by the World Health organization as the only pediatric medical training facility in Northern Cambodia. The hospital also participates as a training site for the Ministry of Health (MoH), WHO-led Integrated Management of Childhood Illnesses (IMCI), playing a key role in improving the quality of pediatric care for the entire country.

Direct Relief has supported AHC with shipments of medical and nutritional products since 2003. The Family Nutrition Education and Support Program had just been launched on September 1, 2006, and I was visiting the facility with Thomas Tighe, CEO and President of Direct Relief, and Reeta Roy, Vice President of Abbott Citizenship and Policy. While visiting, we observed nutrition trainings, cooking classes, the care and utilization of demonstration gardens, and the distribution and use of donated nutritional products – all essential components of the program.

We watched as the family members of malnourished children learned about the importance of serving balanced meals containing a source of protein such as fish, meat, eggs, or beans, as well as fruits and vegetables that can be easily grown or inexpensively purchased. Nutrition education staff members discussed the health effects of the different foods, and demonstrated the best manner to prepare them in order to preserve essential vitamins and minerals. One-on-one bedside nutritional counseling is also provided for parents of severely malnourished children, and provides specific advice and guidance on how to care for the acute and on-going needs of their particular child.

We also accompanied the outreach team on one of their home visits to check on a two-year old boy who had recently been admitted to the hospital with severe malnutrition and dehydration. The team was expected by the boy’s family and other community members had been encouraged to meet at their home. Over 50 adults and children were waiting for us when we arrived, and the outreach team took advantage of the gathering to provide nutrition and hygiene education, as well as to distribute Direct Relief-donated albendazole, or de-worming tablets, to the children. Eliminating, or reducing the worm load in children can significantly improve their nutritional status and overall health. Boys and girls, ages one year and up, now receive the medication twice yearly – an easy and very effective intervention.

Over the past four years, seven shipments of Direct Relief-donated medical goods have been provided to AHC. The most recent shipment consisted of an ocean freight container of Abbott-donated nutritional and medical products. The new partnership between Direct Relief and Abbott, to provide critically needed products and fund the facility’s expanded nutrition program, will allow the hospital to more effectively address the high incidence of pediatric malnutrition, and improve the health of thousands of Cambodian children and their families.

September 24, 2006:
Aceh Province , Indonesia

“How do you protect yourselves and your families from getting malaria? What are three good sources of protein? What vegetables are high in vitamin A?”

I posed these health-related questions to the 100 or so women gathered at the large wooden community center built in between rows of barracks at an IDP (internally displaced persons) camp in Banda Aceh. The women were divided into teams and received 100 points for each correct answer. They were all anxious to display their newly acquired knowledge, and every correct response received a round of applause from the competing teams and from the representatives of Direct Relief’s partner agency Yayasan Psikodista.

Yayasan Psikodista is an Indonesian NGO that provides critically needed psychosocial care for the population still living in relief camps in Nanggröe Aceh Darussalam, or Aceh Province, on the hard hit island of Sumatra. This women-led indigenous group, which had years of experience counseling conflict victims before the tsunami, has received funding from Direct Relief to provide services at eight different sites in the region.

I visited one of the sites with Nur Janah, the director of Psikodista, and a few of the organization’s staff psychologists. This particular camp, called Klieng Cot Arun, is one of the smaller ones and is home to 516 tsunami survivors who continue to wait to be relocated or return to their villages. The conditions at the camp are cramped and dreary, and after 21 months, residents are becoming impatient and disheartened with the seemingly endless wait for replacement housing.

Over 8,000 tsunami survivors have received individual or group counseling from Psikodista via focus group discussions, psychodrama, story telling, drawing, recreational activities, and relaxation techniques. Health education is incorporated into these activities, and the women had clearly acquired valuable information regarding a variety of important health issues. Community leader training, designed to educate selected members of the community in psychosocial assessment and techniques, and income generating courses such as sewing and baking, have also been provided.

Following the health education game a dancing competition was held for the 65 children in attendance that day. Rap music blared from the loud speakers and kids from six months to 12 years leaped, hopped, and twisted to the beat encouraged by the clapping and laughter of the crowd. I had the difficult task of choosing three winners and then everyone sat down together to eat a picnic style lunch cooked by the women and served in homemade paper boxes. It was good to see everyone enjoying themselves despite the gloomy and difficult living conditions at the camp.

It was very clear that Psikodista is providing a number of essential services for IDP (internally displaced persons) camp residents, and that their professional but caring and affectionate approach was working wonders with this extremely vulnerable population.

June 8, 2006

We spent almost all of Thursday with Direct Relief partner CHF, Community Housing Finance. Alia Patton, CHF’s project director, served as our guide for the day as we toured three villages that had Direct Relief-funded projects. Born in Jakarta, Alia was an incredible asset as we visited some of the more remote villages in the district of Bantul Her perfect Indonesian, easy sense of humor, and generous nature meant that we were welcomed with open arms as we walked among the rubble of people’s homes.

When you walk into any of the villages, there are several common features. First, there is an incredible level of activity dedicated to excavation. People are not sitting around and waiting for aid or external help. Men and women are intensely working to break down their damaged homes and begin the process of rebuilding.

Second, there is a high level of community work to rebuild, as opposed to just individual efforts. Alia said the Indonesian word was “gotong royong,” meaning “working together as a community.” It’s a deeply held principle in these communities, most likely for both ethical and practical reason since people live so closely together.

And this leads to the third commonality. The densely populated villages have been built right up to the edge of the one lane roads that enter the village, with their agricultural fields on the other side of the road. Consequently, when the homes were destroyed, there was little to no room to move except into the road. The small roads are therefore taken over with temporary shelter and as we walk into the village, you are literally walking through the bedrooms of several families.

Seeing all the shelter in the middle of the road, reminded us of something that Mr. Sumadi, the program coordinator for PKPA, told us the day earlier. He said, “If you walk down the road at night, you will see a peculiar thing. People are all sleeping in front of their houses and shops because they are scared to sleep in their cracked homes.” The lack of space combined with the fear of physical structures means that practically entire communities are sleeping on or in the road, with only small paths for people to walk through the community.

All of this activity in such a small space has meant an increased opportunity for injury. And while we did see some face masks used during construction, flip-flops were also standard foot wear. Through CHF, Direct Relief has funded twenty nurses from Persatuan Perawat Nasional Indonesia (PPNI), the Indonesian National Nursing Association, to work in Bantul and Klaten. As we walked through the village of Bendok in the Imogiri district, the nurses explained that they were seeing a second wave of injuries caused by the demolition work.

This village alone had suffered 100 percent damage and many people suffered from lacerations on their arms and legs from moving broken bricks and concrete. These people were then vulnerable to infection and skin diseases due to a lack of clean water combined with hot and humid weather.

As we walked through the village, the nurses stopped to check several people’s stitches. Along with injuries from the earthquake and rebuilding, some of these rural communities are receiving health care for the first time. The nurses checked on one woman who had a stroke 17 years earlier, but had never received care.

The team of doctors is treating patients for medical conditions that range from upper respiratory infection from the dust and smoke in the air, to suturing lacerations from broken rebar and concrete. These dedicated health professionals are working hard to keep abreast of the evolving injury patterns as the relief efforts mature. They understand the importance of keeping the people healthy and able while they work together to rebuild their lives “gotong royong.”

June 7, 2006

As we drove along the main artery that links the city of Yogyakarta and the farming villages of Bantul, the only thing as common as the rubble and rice paddies were the children who lined the narrow road begging for aid. This is a new phenomenon to the area, something born out of the tragedy of the earthquake. Pusat Kajian dan Perlindungan Anak (PKPA), a child protection agency and one of Direct Relief’s partners in the earthquake response, is concerned about the surge in children begging. Not only is the act physically dangerous for children, but the roadside begging also breeds dependency on charity and hinders any type of normalization for the traumatized children. There is little to stop the children from begging though as the older members of the family work to excavate their homes and care for the sick.

PKPA is working in Bantul to ensure that children have another opportunity other than begging and that this vulnerable population stays healthy – both physically and mentally. PKPA has set up several “child safe zones” in the district, and today we visited one of their projects in the village of Ganti Warno. At PKPA,, the safe zone includes a Direct Relief-funded health post, with a medical team of three doctors, three nurses, and one midwife.

PKPA’s community center was literally like stepping into a world untouched by the tragedy of the earthquake. While the small road leading up the project was lined with the shells of destroyed homes, the yard of the PKPA center was clean of any debris with children playing outside. Children sat on the wide porch and colored pictures, while others played badminton in the front yard or sang along with one of the staff members.

Inside the building, the medical team reviewed their outreach work from the previous day r and talked about the upcoming needs assessment of a neighboring village. It is all a reminder that despite all the of the discussion on improving coordination among NGOs and the Indonesian government and the transition from the humanitarian phase to long-term recovery, sometimes the most needed item is space for kids to play.

June 4, 2006

Pulling into the front of the hospital, we were immediately greeted with Direct Relief’s distinct blue pallets shipped just days before from our warehouse in Santa Barbara, California. The pallets, filled with $372,000 of specifically requested medicine had reached Jakarta the day before and had been trucked to the hospital in “Yogya” in lightning speed.

Muhammadiyah’s main hospital in Yogya is a 250-bed tertiary facility. The light green, three-story hospital  resembled a Japanese tea house, with courtyards of  fish ponds and gardens. The hallways and rooms were much less Zen like, with patients filling every possible space. The earthquake caused a severe spike in patient load, and each room housed three patients, accompanied often by their families.

Nurse Ani explained that within hours of the earthquake, the hospital had received approximately 1,000 patients. The hospital currently houses over 350 patients, though this figure does not include the patients’ family members that were resting on the benches outside or sitting on the veranda railings.

The vacant building neighboring the hospital used to be a bank, but was converted into an additional ward and filled with 40 earthquake victims. The space served not only as a ward for overflow patients, but also as a temporary shelter for their families made homeless by the earthquake.

We next visited one of Muhammadiyah’s community centers recently converted into a ward for post-op patients in need of consistent observation. The Muhammadiyah staff did an impressive job organizing the area filled with patients and their families. Patients were kept in rows labeled Block A-K, the “block” marked with paper signs that hung across the room on a makeshift clothes line. The staff of approximately eight nurses and two doctors kept detailed medical records of all in the room, and performed morning rounds to check on wounds and for possible infection. While the community center had hosted a wedding two weeks before, it now served as a high-functioning patient ward. The professionalism of the staff, particularly considering the circumstances, was commendable.

Outside a tent kitchen prepared food for the injured and their families. Another room served as the pharmacy and repository for patient records. Amazingly, this community center was only one of three overflow areas that the Muhammadiyah team had created in order to care for these people.

As we left the community center, we passed thanks from Direct Relief and its donors to Dr. Taufier. A quiet man with simple English, he humbly answered, “I am just trying to do right by the patients.”

As we drove from Yogya to Bantul (the town closest to the epicenter), evidence of the massive earthquake became overwhelming, the streets lined with rubble.. Roofs were stripped of their tiles, and often all that remained was the bare wooden skeleton of a building. Most haunting was a house that had completely collapsed, except the furniture remained exactly in order, most likely put back into place by the tenants to recreate some sense of normalcy within the chaos. Children lined the streets holding bowls, hats, and boxes to collect money from passing motorists.

Most people stayed near their homes to prevent looting, and they stretched tarps over the rubble to create tents. Some people found shelter in the camps of international aid groups, in tents often set-up on the edge of the rice fields that dominate the landscape of the agricultural community of Bantul.

Parked in front of Muhammadiyah’s Bantul Hospital was their ambulance, smashed by falling debris (Direct Relief is providing two new ambulances). The story at this hospital was familiar: crowded beyond capacity, a tent was set up in the back to handle overflow and the road had been closed to allow a place for the 1,500 patients treated in first two days following the earthquake.

June 2006

It has been a bitter-sweet return to Pakistan being only six months since I was last in these mountains and nine months after the devastating 7.6 magnitude earthquake ravaged the northern areas.  In a country where bureaucracy runs deep and progress is measured in millimeters, the reconstruction and rehabilitation effort are maintaining status quo and moving at a snail's pace.  I have spent the last week and a half driving through the remote villages of Pakistani Administered Kashmir and the North West Frontier Province visiting Direct Relief’s partners as well as assessing new needs.  The United Nations Humanitarian Air Service has stopped flying the helicopter trips that provided the most time effective way of traveling to these far off villages.  You truly understand the difficulties of life when you spend seven hours driving on nearly vertical roads that are paved in broken rock, so that when the monsoon rains start your four-wheel drive can grip these sharp stones as you climb deep into the foothills of the Himalayas.  I am on my way to see what is left of a Rural Health Center in the village of Chitra Topi 8,000 feet above sea level.

Health care is provided on four tiers of care ranging from the smallest most rural Basic Health Unit (BHU), which provides primary care on an outpatient level only; to the largest referral hospital called the District Headquarters Hospital (DHQ) located in the major urban areas.  These DHQ hospitals are supposed to cover all specialties.  The system is designed so that even the most remote places have at least one BHU that has one full-time doctor and dispenser.  Some larger villages have a facility called a Rural Health Center that is closer to a two-bed hospital that focuses on outpatient care but in a pinch could help deliver babies or house serious cases while someone looks for a truck to drive the patient to the nearest Tehsil Headquarters Hospital (THQ), which is a fully functioning hospital with an emergency room.  In the case of Chitra Topi, it would mean a two and a half hour drive on extremely rough roads to the large tent facility that is serving as Bagh’s DHQ.  If the case needed special care that could only be found in Islamabad that would mean another five hour drive, if the roads are clear of snow, over the mountains.  This is Pakistan’s rural healthcare system. 

In order to understand the importance of these Rural Health Centers and BHUs, a man who works for NRSP told me, “you can hike ten days towards the foot of K2 and think you are as far from civilization as possible and the next thing you know there are 10 kids playing cricket at 12,000 feet and an 80 year old man herding 20 goats, people live on every inch of this country.” These remote health outposts are the only available medical centers for someone who lives in the mountains of Pakistani Administered Kashmir.  These primary care centers help treat the basic needs of a population living in a harsh environment by solving the basics: scabies, diarrhea, indigestion, and upper respiratory infection so that these people don’t have to travel hours to a hospital to obtain basic antibiotics and oral re-hydration solutions.  The specialists can remain focused on what they do best and not have to deal with medical issues that can be treated at the village level.

Once the dust had cleared and the emergency phase of the relief effort was over the Pakistani Government established an administrative body, the Earthquake Reconstruction and Rehabilitation Authority (ERRA), who adopted the Clinton Tsunami Slogan “Build Back Better” and drafted a 40 page procedures guide to the reconstruction process.  In the document, the Government outlines a three year timeline of the reconstruction and rehabilitation of the rural health care system with the goal of returning governmental control and administration of these facilities.  The enforcement of seismically safe reconstruction was at the heart of ERRA’s thoughts when creating this document, while ignoring the feasibility of this expense with modern construction techniques.  In reality, they have added five new layers of bureaucracy to the relief effort and slowed the progress to a near halt.  NGOs who were willing to pay for new seismically safe health centers are getting tired of navigating the minutia of stamps and official approvals.  They are starting to leave in droves, their six months of funding ran out three months ago and the government who had promised to take over in six months has not rebuilt a single facility or posted a doctor to these areas. ERRA has planned on rebuilding 67 health facilities in 2006 but not one foundation has been laid.

The American Refugee Committee immediately established a Rural Heath Center in the village of Paddar, Bagh District after the October quake.  Their specialty is that they have the only female OB/GYN in all of Bagh Province and act as the major referral center for all female related health issues.  They started running the only RHC in Paddar but were quickly asked to adopt two more destroyed BHUs and another RHC.  There really wasn’t another option, no one else would administer these facilities and the local people in these areas would be forced to travel to the next closest health facility, which in some cases could be 17 kilometers away.  Bear in mind that 17 kilometers in these mountains means a minimum of two hours by car and who knows how long by walking.  I have been lucky enough to visit each of these four health facilities over the last three trips to Pakistan and they are the best health centers in the earthquake-affected area. ARC has started to train Lady Health Visitors (LHV) who are similar to nurses.  They have provided family planning classes as well as contraceptives to those who want them.  In addition, they have provided a vocational training class for local women who have lost their husbands and a small school for children whose parents are working.  Overall, they have raised the standard of care for the surrounding villagers to a level of excellence and accomplished it all on six months of funding.  Direct Relief is planning on continuing support through a combination of material aid and cash assistance until ARC decides it is appropriate to transfer these facilities back to the Government.

January 2006

In the temperate city of Islamabad it has been raining for a solid 3 days.  The weather is a minor annoyance down at this elevation, but it is a constant reminder that winter has descended upon the villages of Pakistani-administered Kashmir.

Many of the most complicated medical cases have been evacuated via helicopter to the capital, where other evacuee victims of the Oct 8th earthquake now dwell in tent cities or hospital waiting rooms.

They wait, trying to put the pieces of their new much more complicated lives back together. The process is slow; the need for extensive long-term rehabilitation is among the most important parts of the relief effort and the most difficult.  Previous to the earthquake the people who lived in these rugged mountain villages relied on their physical and mental strength to survive the harsh natural elements, now both are being tested to the limits.

The earthquake has created an entire population of people with disabilities, from the very young to the very old, forever limiting their ability to move freely in these remote mountainous areas. Before the quake, living conditions in northern Pakistan were not easy; for people now dealing with amputations, paraplegia, and limited mobility, the difficulties of daily life are unimaginable.

Pakistan Institute of Medical Sciences (PIMS) has become the headquarters of the medical relief effort for the World Health Organization and the Pakistan Ministry of Health in Islamabad. Today, Scott and I met with the Director of the College of Medicine Technology, Dr. Azra Qureshi.  She didn’t hesitate to explain her opinion on how the relief effort is being handled and what the clear weaknesses are.

Dr. Qureshi explained that the earthquake has created a demand for physical therapy and rehabilitation programs that otherwise didn’t exist before October 8th. She offered that the government of Pakistan had been responsible for these duties, but that this scale of  medical challenge has simply overwhelmed the capacity to administer this program.”

Dr. Qureshi and her staff have helped create an EMT, Nursing, and Physical Therapy School, which will complement the new rehabilitation center created at the National Institute of Health, a satellite facility of the PIMS center. We visited both facilities, and it is clear that they are in dire need of modern rehab equipment and trained staff. They have already started a referral program for both amputees and paralyzed patients that will insure the complete care of each patient from the initial visit to the end of their rehabilitation.

I'm pleased that Direct Relief has the opportunity to help this amazing facility, which will play a key, anchoring role in the country for many people who have a tough road ahead of them.  We are completing the logistical details to complete the financial support.

Scott and I also attended meetings with the American Refugee Committee (ARC), AAI, Afghan Institute of Learning (AIL), the Marafie Foundation and National Rural Support Programme (NRSP). Will report on these meetings in a few days when we visit their facilities in the affected areas.

Tomorrow we are going to the only prosthetic limb center in Islamabad.

Situation: Sri Lanka
The tsunami of December 26, 2004 killed an estimated 40,000 Sri Lankans, predominantly on the eastern and southern coasts of the country. In affected areas, housing and infrastructure were destroyed—healthcare facilities, railway tracks, and entire neighborhoods were damaged beyond repair. The recovery process has been slow, even though Sri Lanka boasts a strong central government with solid social service institutions, and international NGOs have been quick to provide material aid, monetary aid, and technical assistance for relief projects.

There is a strong sense of frustration among affected individuals, many of whom have lived for months in temporary-home internally displaced persons (IDP) camps with no timetable for permanent housing. However, progress is being made in selected areas, and health experts have touted the national and international medical response that prevented any major outbreak of disease as a success.

The political situation in Sri Lanka is a delicate one. More than 20 years of civil war in the eastern and northern regions of the country between government forces and Liberation Tiger of Tamil Eelam (LTTE) troops, coupled with a natural disaster that leveled many communities in both government-controlled and rebel-controlled regions, and the August 12, 2005 assassination of the Foreign Minister, Lakshman Kadirgamar, has contributed to the sense of instability. In late August, President Chandrika Kumaratunge called for presidential elections in November 2005. All parties involved in tsunami relief in Sri Lanka are anxious to see the results of the election, as it is thought that a power shift could alter government policy toward relief work.

Foundation for Social Welfare
As a Sri Lankan nonprofit social service organization based in Moratuwa, the Foundation for Social Welfare (FSW) has been active in tsunami relief activities along the southwestern coastal belt of the country. Direct Relief has partnered with FSW to rebuild a maternal and child health clinic in Moratuwa. With a $73,535 grant from Direct Relief, FSW, in close partnership with the Moratuwa Office of the Ministry of Health, will oversee construction of a two-story center offering maternal health care, child health care, nutritional counseling, chronic disease screening, and mental healthcare services to expectant women, infants, and children in the primarily lower income tsunami-affected district of Murawatte. Direct Relief has also provided medicines, supplies, and equipment to the 15 undamaged public maternal & child health clinics in Moratuwa. These clinics are operating over capacity while providing services to residents of the area’s 13 displaced persons camps.
 
When I arrived, construction on the clinic was ready to begin. FSW hosted a Laying of the Foundation Stone ceremony, which was attended by the Mayor of Moratuwa, Ravinath Goonesekera, several city council members, the President of FSW, Dr. Francis de Silva, and several Medical Officers of Health for Moratuwa. Various friends, political colleagues, university staff, and neighborhood residents attended. Along with the Mayor and the President of FSW, I laid a (symbolic) foundation stone to begin construction.

Oral Health Program
In partnership with the Moratuwa Ministry of Health Direct Relief continues to support a dental program designed to provide oral health services to residents of displaced persons camps in the areas south of Colombo. The program is administered by the oral surgeon for the Moratuwa Office of the Ministry of Health. The program’s objectives include basic dental check-ups in relief camps and referral services for severe cases to one of the two public clinics offering surgeries. Direct Relief provided two new dental chairs to be housed in the two public dental clinics, as well as medicines for surgeries, and toothbrushes and toothpaste for disbursement at relief camps.  

Sarvodaya
Sarvodaya Shramadana Sangamaya is the oldest and largest Sri Lankan nonprofit, non-political social service organization. Established in 1958, the organization currently has a presence in 15,000 villages across the country and conducts programs aimed at improving the economic, social, political, and spiritual lives of Sri Lankans. Sarvodaya’s response to the tsunami was rapid. The organization was active in medical emergency response as well as in the establishment and operation of relief camps. To assist their efforts, Direct Relief air freighted a shipment of medicines, supplies, and personal care products to Sarvodaya to be distributed in IDP camps. In July 2005, Direct Relief granted $135,555 to Sarvodaya to support community health and disaster preparedness programs in tsunami-affected villages. With this financial assistance, Sarvodaya will establish 30 local primary healthcare centers in 15 tsunami-affected districts and will procure a mobile unit to reach more isolated areas.

At the organization’s Moratuwa headquarters, Perine Fernando, Direct Relief’s In-Country Coordinator for Sri Lanka, and I met with Dr. Vinya Ariyaratne, Executive Director of Sarvodaya. We were introduced to Dr. L.P. Chandradasa, Director of the Community Health Unit who is in charge of implementing the programmatic objectives included in the Direct Relief grant. In Galle District, three villages had been selected and establishment of the community health posts were underway. In Matara District, two of the three sites had been selected and had begun. Sarvodaya was in the final stages of selecting three village sites in Trincomalee District; by the end of September, all villages will have been identified in Batticaloa and Ampara Districts . Dr. Chandradasa targeted villages that were tsunami affected but had not received relief through other programs. Dr. Chandradasa reported that the mobile medical unit, funded by Direct Relief, had been ordered from the manufacturer and Sarvodaya was awaiting its arrival.

Tropical and Environmental Diseases & Health Associates
Tropical and Environmental Diseases and Health Associates (TEDHA) was founded by Dr. Pandu Wijeyaratne, a medical professional with over 30 years of experience working on vector-borne disease control projects. In response to the potential public health risks posed by the tsunami, TEDHA’s efforts in the area of vector-borne disease control have increased. TEDHA’s initial relief work focused on the Thotagamuwa-Hikkaduwa area, located on the southwestern coast of Sri Lanka. Encouraged by Direct Relief, the organization expanded its work to the severely affected district of Hambantota, located on the southeast coast of the country.

TEDHA’s multi-pronged approach to vector control includes the provision of insecticide-treated mosquito nets to residents of IDP camps, the fogging and spraying of identified vector breeding grounds, and the implementation of awareness training to minimize risks of disease contraction. Direct Relief provided a $94,000 grant to support these preventative health activities in Hikkaduwa and Hambantota.

With a group of community health assistants, employed by TEDHA with funds from Direct Relief, I visited a displaced persons camp in Hikkaduwa. The hastily-built camp consisted of barracks style rows of one-room homes in which families lived with virtually no amenities or privacy. Many families in this camp had received treated mosquito nets from Direct Relief, with usage training, usage monitoring, and re-treatment assistance from TEDHA. Recipients of mosquito nets had hung them in their one-room homes, and the nets often covered most or all of the dwelling.

Several women reported that all of their children were able to sleep under the net, while the parents slept unprotected on a mat. Dr. Pandu encouraged families to use the nets during the day to avoid the bites of daytime dengue-carrying mosquitoes (as opposed to malaria mosquitoes which bite at night). We were pleased to see children napping and one mother nursing under the nets during the day. In addition to provision of bed nets, Direct Relief procured two foggers and 10 sprayers for the Hikkaduwa office of the Ministry of Health. These will be employed in the coming months to eliminate vector breeding grounds.

Later that week, I traveled with Dr. Pandu Wijeyaratne to Hambantota District. This district, the poorest district in Sri Lanka, lost approximately 5,000 residents in the tsunami. I was pleased to see that a good amount of progress toward permanent housing had been made in the area. As an expansion of their vector-control programs in Hikkaduwa, TEDHA partnered with the Ministry’s Regional Malaria Officer for the region, Dr. Lalanthika Peiris, to implement measures toward curbing outbreaks of vector-borne disease. At her offices in Hambantota, we met with Dr. Peiris, a very knowledgeable and dedicated woman who had herself lost family members in the disaster. We reviewed the Regional Malaria Office’s activities to control vector-borne diseases since the tsunami, and Dr. Peiris summarized what she saw as ways to continue the good progress—a combination of bed net distribution, spraying only when needed, and educational measures.

With Dr. Peiris, we traveled to the town of Ambalantota in the Hambantota District to visit families who had received insecticide-treated mosquito nets procured by Direct Relief. While some families had received conical bed nets and others rectangular, the general consensus was that the conical type was preferable. As in Hikkaduwa, the provision of nets would be complimented by fogging and spraying. Dr. Peiris explained a delicate balance was needed between insecticide chemicals so that resistance by vectors would not be created.

Foundation of Goodness
The enclave of Seenigama is located close to Hikkaduwa. The area draws many on-lookers as the neighboring village, Peraliya, is where a twisted, derailed train sits in memorial to the hundreds of people who lost their lives trapped inside as they crowded in to seek refuge in what they though was a sturdy and safe metal structure.

Seenigama itself was hit hard, though rebuilding work is progressing well due in large part to the Foundation of Goodness. The Foundation had operated out of Seenigama prior to the tsunami and was able to utilize strong community ties when the disaster struck.

Under normal circumstances, the Foundation operates a maternity child health clinic, pediatric clinic, provides free English and computer lessons, and supports micro-enterprise programs. These activities have continued after the tsunami; and, in addition, the Foundation has rebuilt more than 10 new homes for tsunami survivors in the area, all on land that was previously owned by the residents. Foundation of Goodness has seen a swell in patient load at their clinics as a result of the tsunami. A shortage of physicians in the areas has caused the Foundation to bring in help from Colombo. Direct Relief purchased a vehicle for transport from Colombo of physicians serving 2 to 3 times per week in the maternity child health and pediatric clinics.

Karapitiya Teaching Hospital/ Galle Medical Association
The Karapitiya Teaching Hospital is a multi-specialty referral hospital serving the Galle District. In response to the tsunami, which severely affected Galle, physicians at the hospital established the Galle Medical Association with the goal of helping affected hospital employees rebuild their homes and return from IDP camps to resume work. Direct Relief assisted this project with a two-part grant totaling $80,000. The Galle Medical Association, in turn, has issued small grants to 100 individual healthcare workers to repair and/or rebuild their homes. The physicians that make up the Association are very involved in each step of assistance from selecting individual beneficiaries to monitoring construction progress. Additionally, the Karapitiya Teaching Hospital has received material aid as part of multiple Direct Relief shipments to the Ministry of Health.

At the main hospital facility, I met with Dr. Chrishantha Perera, a cancer surgeon at the Karapitiya Teaching Hospital and member of the Galle Medical Association. Dr. Perera reported that the project was in its final phase; nearly all beneficiaries had received both segments of their two-part assistance grant. In the physician’s office, I met with three female healthcare workers who had received assistance from the Association for the reconstruction of their homes. Each shared her story about the day of the tsunami and the effects it had had on her family; one woman broke down into tears telling us about the death of her sister and sister’s family. Leaving the hospital, we accompanied another woman to her home that had just been completed. She was incredibly proud of the rebuilt home, which had lost three walls in the disaster. On her front porch she had laid out papers and photos to take advantage of the mid-day sun’s drying effects; even six months later, she continued to work to salvage her damaged personal items.

BECT Foundation
Near Tangalla, a city in the Hambantota District, we met the BECT Foundation construction site supervisor, Newton. The BECT Foundation had originally focused on animal rights in Sri Lanka, but when the tsunami hit, Chairman Dr. Jayantha Jayawardena decided that, rather than form a separated NGO, BECT would expand its activities. Through Direct Relief’s US-based NGO partner, International Relief and Development (IRD), Direct Relief funded BECT Foundation’s construction of a clinic for a new village of relocated tsunami survivors in Ruvingama, a small village near Tangalla.

After a typically warm welcome which included tea and wood apples, Newton accompanied me to the construction area where the building of homes was well under way. Though construction of the clinic had not yet begun, the site, next to the site of the community center and village store, was cleared and prepped. Although the water lines had not yet been laid, several families had already moved into the partially constructed village. Newton explained that affected families were eager to stake their claims on new homes. Residents of the new village were selected through an application process based on need, and the units were held for them, making claim-staking an unnecessary practice. The labor for construction was drawn from local communities, which helped to infuse money into the stalled local economy.

Hambantota Base Hospital
The Hambantota Base Hospital provides medical care to the entire Hambantota District; with a population of over 550,000, the district’s high levels of poverty means free, public health care is sought by a large percentage of the population. The Base Hospital functions as the main public health provider for the region offering primary care, out-patient services, secondary care, and tertiary care free of charge. After the tsunami, which killed approximately 5,000 in the District, the hospital’s already overcrowded state was exacerbated.

I met Dr. Ariyawansa, the Medical Superintendent, at his home, located adjacent to the hospital. According to his report, patients travel long distances to visit the facility rather than utilizing closer their public health clinics. There is a feeling that care in hospitals is superior to that of clinics. The hospital had been the major public health provider of secondary and tertiary care in response to the injuries and illnesses caused by the tsunami, and the facility was operating well beyond capacity.

A tour of the hospital proved that the overcrowding was worse than Dr. Ariyawansa had described. Though well-maintained and staffed, in each ward, patients lay on cots on the floor, in the hallways, or in hammocks. Since the hallways in public hospitals in Sri Lanka are covered but have no walls, these patients were, in effect, outside. Dr. Ariyawansa presented a request to me for Direct Relief assistance. In particular, the hospital was in dire need of a high pressure sterilizer for general use and an operating microscope. Dr. Ariyawansa took us to see the current pressure sterilizer that functioned only 50 percent of the time. On a given day, the medical staff did not know if the sterilizer would work, and on days it did not work, items were sent on a several hour drive to Matara for sterilization. I was amazed by Dr. Ariyawansa’s ability to help so many with minimal resources and outdated equipment. Since this trip, Direct Relief has procured a high pressure sterilizer and operating microscope for the hospital, along with three year warranties on each, which will raise the level of care available to the lower income residents of Hambantota District.

Ministry of Healthcare, Colombo
In order for medical donations to be cleared duty-free, all shipments must be consigned to the Ministry of Healthcare. Since January 2005, Direct Relief has sent multiple shipments to the Ministry with a wholesale value of more than $4 million. Sri Lanka boasts a strong, state-run healthcare system, and the Ministry has taken the lead on distribution of donated tsunami-relief medical goods. However, nine months after the tsunami, a stagnant backlog exists in the Colombo port, and for humanitarian consignments, there are still major obstacles for clearance and distribution.

The backlog in the port shows no immediate signs of abating, and the many containers of donated product filled with inappropriate or expired goods slowed the Ministry’s efforts at clearance even further. At a meeting with Dr. Beneragama, Director of the Medical Supplies Division at the Ministry of Healthcare, he expressed gratitude that Direct Relief donations were always of high quality and the medications were consistently long-dated. Dr. Beneragama requested that Direct Relief suspend shipments of material aid for two months time until the backlog could be alleviated. Dr. Beneragama confirmed that Direct Relief could specify shipments for local Ministry offices or projects, but added that Direct Relief would be responsible for charges that were normally paid by the Ministry of Health and would need to arrange and fund transport to the local Ministry office.

St. John’s Ambulance Brigade
St. John Ambulance, Sri Lanka is a nearly 100 year-old, predominantly volunteer-operated affiliate of the International Order of St. John. The organization, based in Colombo, provides emergency services, including ambulance services, first aid, CPR, and EMT trainings to Sri Lankans in all districts across the country through satellite centers. St. John’s was actively involved in search and rescue work during the tsunami, offering immediate response along the coastal belt. In addition, the organization assisted with the establishment of IDP camps and attended to the medical needs of survivors.

I met Dr. Jayatilaka, the Executive Director of St. John Ambulance, Sri Lanka, at the St. John’s headquarters in Colombo. One of the three ambulances provided to St. John’s by Direct Relief was present at the offices. The other two were in the field—one in Jaffna and one in the greater Colombo area. Dr. Jayatilaka gave me a tour of the facility and expressed St. John’s desire to create a central emergency response system for the greater Colombo area. He was interested in receiving additional ambulances for local work and field activity, and he viewed equipment as the most important future need.

During my visit, EMT and driver training were being conducted by three British trainers, and a graduation ceremony was being held at the headquarters that day. Fourteen newly trained emergency workers from across the country would be receiving certificates of course completion. These individuals would return to their home districts to train the organization’s field volunteers. I was pleased to see that systematic EMT training of volunteer emergency workers was a top priority for St. John’s. Direct Relief is currently considering a grant for the purchase of two additional ambulances to be deployed to affected areas.

International Medical Corps
We drove from Colombo to Ampara District, a ten-hour drive broken up into two days to avoid traveling dangerous roads at night. The Ampara District, a geographically thin sliver of land covering the majority of the southeast coast of the country, had suffered over 10,000 lost lives in the tsunami, more than twice the number of deaths in any other district. The devastation I saw along the coastline of the Ampara District was worse than anything else I had witnessed. Entire neighborhoods were flattened. The buildings appeared as concrete skeletons with one or two walls standing and often no roof. Many homes and businesses were reduced to only the foundations. Though the devastation was more thorough and acute than anything else I would see, the rubble and debris had been fairly well disposed of.

Direct Relief partner, International Medical Corps (IMC), is a global humanitarian nonprofit in operation since 1984. IMC is based in Los Angeles and works in 21 countries to implement healthcare-focused development programs. In February of 2005, Direct Relief granted $541,664 to IMC Sri Lanka to implement a variety of projects including mobile medical camps, psychosocial trainings of Medical Officers of Health, and livelihoods programs.

I met IMC Country Director for Sri Lanka, Hussien Ibrahim, at the IMC field staff offices in Ampara for a briefing on programmatic progress before driving to the coastal city of Kalmunai. Kalmunai, a relatively large city that borders the Batticaloa District to the north, is one of Sri Lanka’s most ethnically diverse areas with a population comprised of Muslim, Tamil, and Sinhalese residents.

We visited the site of IMC’s livelihoods projects. The livelihood component of the Direct Relief grant included two categories—cash for work and micro-credit programs. Cash for work activities had commenced with an effort to clear debris along the Kalmunai coast. We toured the stretch of coast that had been cleared by the program’s workers; there was a marked difference between it and the other sections.

The program was on hold as the harvest season had begun and all available labor was needed in the fields. It was decided that when work re-commenced, smaller groups would be organized to ensure better time management. There was, and continues to be, a significant duplication of effort among NGOs running cash for work initiatives, and various NGOs are clamoring to take charge of what is left to be done. Hussien explained that their focus would shift from debris clean up to community-requested small construction projects. To incorporate objectives from cash for work and micro-credit programs, IMC would partner with two local NGOs that had identified community priorities including construction of toilets, water & sanitation improvements in relief camps, nutritional programs, and HIV/AIDS awareness trainings. These training activities would take place in a newly constructed community center, which the cash for work program would take the lead in building.

In addition to livelihoods rehabilitation, the Direct Relief grant included the implementation of psychosocial program work, as the need for mental health services was acute in affected neighborhoods and relief camps. IMC experts and Sri Lankan psychiatrists had trained the local Ministry of Health’s Medical Officers of Health on methods for identifying and treating people suffering from mental illness. The Medical Officers of Health, in turn, were in the process of training their districts’ Public Health Inspectors, Public Health Nurses, and Public Health Midwives in identification of at risk individuals; those individuals identified would then be referred back to the Medical Officer of Health for treatment. The initial trainings had been completed, and trained mental health identifiers are present at the MOH medical camps that continue to operate along the coastal region with logistical support from IMC.

Ampara General Hospital
The Ampara General Hospital is renowned for being one of the best government hospitals in the country. Patients come from across the district, even from Batticaloa and Trincomalee Districts, to receive what is considered the best public healthcare. Five public hospitals were destroyed by the tsunami in the eastern province, and the Ampara General Hospital has absorbed the added patient load in addition to the influx of tsunami-related illnesses and injuries.

Through the US-based organization I-FREED, established in 1992 and comprised mostly of volunteer Sri Lankan expatriates, Direct Relief has provided $169,000 for the procurement of a Toshiba CAT Scan machine for the Ampara General Hospital. The CAT scan will be the first in the Ampara District and will offer an advanced level of diagnostic health services to the most severely tsunami-affected population. Dr. Jayasinghe, the Medical Superintendent of the hospital, met us at his home, adjacent to the hospital and gave us a tour of the facility. The hospital was extremely clean and well organized. Though a good portion of the equipment was old, everything was meticulously maintained. I could hardly believe that the hospital was reported to have been “worse than a cow barn” before Dr. Jayasinghe’s arrival, only five years before.

The room that would house the CAT scan was nearly complete, and the machine had arrived in the Colombo port. Dr. Jayasinghe explained to me that the Ampara General Hospital was under-equipped to handle the long-term increased patient load, and the doctor requested assistance from Direct Relief to provide equipment items for the ICU unit. Direct Relief is currently reviewing the request.

Guardian Foundation
Guardian Foundation is a Sri Lankan community based organization established in 1995. Its mission is the rehabilitation of IDP in the northeastern provinces of Sri Lanka, populations displaced by the country’s 20-year civil war. With a head office in Colombo and two branch offices in the eastern Ampara District, the Guardian Foundation has ten years of experience providing temporary shelter, water and sanitation projects, and mobile medical camps to displaced ethnic minority groups. Using this experience, Guardian Foundation was able to respond to the needs of tsunami affected populations in the worst-hit geographical region.

Guardian Foundation was in the fortunate position of having a solid infrastructure in the eastern and northern regions of the country, areas that many NGOs, both Sri Lankan and international, find it difficult to work in due to lack of infrastructure along with ethnic and political instability. Through IRD, Direct Relief granted $30,000 to Guardian Foundation to construct 25 wells and 40 toilets in affected neighborhoods of Nintavur.

With Gordon Bacon, Program Manager for IRD Sri Lanka, we drove from the city of Ampara to Nintavur, a town on the Ampara coast south of Kalmunai. We began at the headquarters of the Guardian Foundation’s Nintavur operation, a home and office complex of two buildings. We were met by Dr. Cader Rafei, Chairman of the Foundation who also holds the post of HIV/AIDS Awareness and Prevention Director for the Ministry of Health in Colombo. Accompanying him were a group of approximately 40 tsunami affected women and men who came to share their stories with us. Nearly everyone had lost an immediate family member and many had lost their entire families.

From the offices, we traveled to the coastal neighborhoods where the water and sanitation program was being implemented. We visited the homes of recipients of new toilets; people were still living in partially damaged homes, and some had made impromptu repairs while others had enough funds to make solid repairs. Wells were built in a central location so that multiple families could benefit, and they were remarkably large and sturdy. Access to clean water is an acute need in these neighborhoods. Existing wells had been overrun with saltwater, and corpses had been found in several wells near the homes we visited. Guardian Foundation had made tremendous progress on Direct Relief-funded activities—in the three weeks since funds were disbursed, 16 wells and 20 toilets had been completed.

We traveled to an IDP camp, several hundred meters inland. Inland several hundred meters was a displaced persons camp. The residents of the camp recognized the Guardian Foundation staff members who accompanied us, and we were invited to view their homes.

The conditions of the camp were similar to that which we had seen across Sri Lanka. Families slept on straw mats, and, in most homes, one sheet provided a divider of the room. The interiors were made of metal sheeting, making them unbearably hot in the afternoon sun. One woman showed me the camp’s community kitchen, a wooden slab on the end of a row of homes which was occupied by a woman cooking with communal crockery. The camp was fairly clean, but remarkably sparse, dry, and stifling hot. Through a bilingual Guardian Foundation staff member, the women of the camp shared their difficulties. Though lorries of water were trucked into the camps daily, the water supply ran out each afternoon. Each morning, women stood in lines to collect water. One woman in her mid-thirties explained how her husband returned each evening from the fields and there was no water for him to drink. She told me how badly her family needed drinking water and asked what I could do to help. Dr. Refai, Executive Director of the Guardian Foundation, explained the ongoing need for water and sanitation improvements and requested continued support from Direct Relief, which we have been able to provide.

Situation: India
Over 11,000 deaths were reported in India as a result of the tsunami disaster. The coastline of Tamil Nadu, the southeastern-most state of the subcontinent, was hardest hit. Additionally, the states of Andhra Pradesh and Kerala, and the Andaman & Nicobar Islands were affected. Unlike Indonesia and Sri Lanka, the Indian government did not accept monetary aid from foreign governments nor did it welcome an onslaught of international NGOs. A relatively small group of international groups, including Direct Relief, are working to meet the needs of affected individuals along with Indian NGOs and the Indian government.

Hindu Mission Hospital
Hindu Mission Hospital is a 160-bed multi-specialty hospital, located in an area just outside of Chennai. The Hospital offers sliding scale and free services to needy patients and, since the tsunami, has conducted extensive medical outreach initiatives in affected coastal areas. To assist these efforts, Direct Relief has procured an ambulance to transport referral cases from the Kanchipuram and Thiruvalluvar districts to the main hospital facility. Direct Relief has also provided a grant in the amount of $77,778 for the construction of three community health centers to be built by and operated under the auspices of Hindu Mission Hospital. Centers will be constructed in Chinnadikuppam, Meyyurkuppam, and Alikuppam. Hindu Mission Hospital continues to be a recipient of Direct Relief material medical aid for use in the main hospital facility and in its outreach programs.

At the main hospital complex, I met with Mr. D.K. Srinivasan, the Director of the hospital. He provided an update on the hospital’s tsunami relief activities and plans for facility expansion. Hindu Mission Hospital’s tsunami relief has included Direct Relief-supported medical outreach programs, including mobile camps, as well as a larger volume of patient intake per month. Mr. Srinivasan gave me a tour of the hospital facility in which I saw many Direct Relief provided material medical items.

Meenakshi Mission Hospital & Research Centre
With 46 specialized medical departments and 500 beds, Meenakshi Mission Hospital & Research Centre (MMHRC) offers free and reduced cost services to the southern Tamil Nadu region. MMHRC mobilized a significant response to the tsunami, offering referral services at its main facility and mobile medical camps in affected areas. Early in the tsunami relief effort, Direct Relief partnered with MMHRC to provide funding for mobile medical camps, a mobile medical unit to support these activities, and medical goods for use in camps and at the main facility. To expand mobile medical activities and utilize MMHRC’s capabilities, Direct Relief is planning to provide a mobile CT scanner to the hospital for use in the affected region. This piece of highly specialized equipment will offer the first-ever mobile CAT scan services in India.

I was taken on a detailed tour of the main hospital, which included tours and discussion with physicians in various departments including Cardiology, Hematology & Blood Bank, Intensive Respiratory Care, Neurology, Pediatrics & Neonatal ICU, the specialty Clef Palate Centre, and the Mother Teresa Ward, the only HIV/AIDS ward in a private hospital in India.. After the tour, specialists from over ten departments attended a meeting to share stories about the surge in activity and responsibility resulting from the tsunami. The doctors reported on their involvement in medical activities along the coast and detailed the continuing needs of patients there.

We drove from Madurai to Nagapattinam, one of the most severely affected districts in Tamil Nadu, to visit a mobile medical camp. Held in the large open patio of a Hindu temple, the medical camp was attended by hundreds of patients. As we drove into the coastal neighborhood where the camp was located, I could see temporary shelter homes made of wood and palm leaves. Along the coast, many homes were severely damaged, though families remained in partially damaged ones.

The well organized camp was run by two doctors, several nurses, a pharmacy tech, and two individuals offering administrative assistance. A registrar would take names and vital information before the patient had a consultation with the doctor. A pharmacist would then dispense medicines as per the doctors’ recommendations. The Direct Relief-procured mobile medical unit was parked outside the camp; it acted as a private room for female patients as well as a means to transport medicines, equipment, furniture, and personnel. In the next two days, I visited Direct Relief-sponsored medical camps in Cuddalore and Chennai, both administered by MMHRC physicians.

With MMHRC, Seshadri Iyer, Direct Relief’s In-Country Coordinator for India, and I visited a displaced persons camp on the outskirts of Chennai. The camp was located in a sunken area next to an industrial site. The camp consisted of many rows of tents—it was the only IDP camp I had seen in which residents remained in tents. The camp was overcrowded and filthy standing water was present between rows of plastic tents. There were no visible drinking water or toilet facilities, and I was told that residents used the nearby bushes as toilets.

The camp was by far the unhealthiest, dirtiest, most crowded I had witnessed; but even so, life continued for these unfortunate individuals and families. A group of men squatting in a circle in the mud played a game, kids played on piles of debris, and women hung laundry on makeshift clothes lines strung to the top of adjacent tents.

We were approached by a tired looking woman in her twenties carrying her baby. She spoke to an MMHRC physician that accompanied us about the poor health of her child—an infant with a rash across its arms and legs and blond tips on its hair, a sign of malnutrition. MMHRC was to conduct a three-day mobile medical camp in the IDP camp the following week, and the physician gave the woman some preliminary advice and instructed her to bring the child to see him at the camp the next week.

Shuddham
Shuddham is a social service organization focused on environmental improvements and waste management located in Pondicherry, a former French colony and Union Territory of India. Established in 1992, the organization has 17 staff members, one of which is Mr. Bhupendra Maru, a philanthropist from Pondicherry and Vice President of the organization. Mr. Bhupendra discussed the activities of his organization, both normal charity activities and tsunami relief activities. Seshadri Iyer and I traveled with him into Pondicherry. Shuddham has undertaken an environmental management program in Pattipulam in response to the environmental degradation caused by the tsunami which deposited organic and non-organic waste across the seven hamlets that comprise Pattipulam.

Mr. Bhupendra explained that this waste had not been cleaned and posed a serious health risk to villagers. Shuddham has requested assistance from Direct Relief with environmental improvements included in this clean-up and waste management program. Behavior change objectives including the establishment of trash pick-up and recycling services are incorporated into the program’s objectives so that improvements may be sustainable.

Madhar Nala Thondu Niruvanam
Madhar Nala Thondu Niruvanam (MNTN) was established in 1981 to assess and improve the living conditions of rural women in Cuddalore, Tamil Nadu. The organization’s program work focuses on the economic and social empowerment of impoverished women through “self-help” groups meant to foster income generating activities, provide community-based health care and nutrition and maternal health education. The “self-help groups”—the core of MNTN’s social work — presently numbers 1,200 with over 22,000 female members. In recent years, the organization has expanded its services to include free medical camps for underprivileged Cuddalore women, including Free Eye Camps and Mobile Medicare Units, in addition to housing for elderly women and homeless women. The self-help groups, in combination with the more formal medical camps, aim to improve the health of impoverished women through nutritional education, immunization, and personal hygiene, and to raise their standard of living through micro-loans and financial assistance.

I met with Dr. P. Rajendran, the Executive Director of Madhar Nala Thondu Niruvanam (MNTN), and his wife and daughter, both active in the local social service non-profit, at the retirement home and orphanage run by the organization. Direct Relief has assisted MNTN’s tsunami relief work by providing a grant in the amount of $61,500 for the construction of two community health centers, the procurement of one mobile medical unit, and the procurement of medicines to support the mobile medical camps. Dr. Rajendran requested that Direct Relief consider extending funding for the medical camps for a period of four to six additional months, which, since my return, we have been able to provide.

The first community healthcare center in Cuddalore had been completed, and I attended the inauguration ceremony. After a greeting and ribbon cutting, the ceremony continued with short speeches from Dr. Rajendran and me after which a traditional puja was conducted. Approximately thirty community leaders and healthcare staff members were in attendance, and school children waited outside for candy that I was given to distribute. Immediately after the ceremony concluded the doctors in attendance set up their equipment and medicines in the office/exam room and began seeing patients.

Vishranthi Charitable Trust
Vishranthi Charitable Trust, located in Chennai, was established by Mrs. Savitri Vaithi in 1978 with the mission of providing food, shelter, and health care to impoverished women in their old age. The Trust administers a residential home and a skilled nursing facility, providing lodging and medical care to over 100 women with a focus on caring for the elderly street population, especially those afflicted with dementia, Alzheimer’s, or amnesia. Recently, the Trust’s activities have expanded to include the provision of health care for orphans. The Trust’s activities are financed by and overseen by a board of nine trustees with ties to the Monday Charity Club, an umbrella organization of charitable institutions.

I visited the headquarters of the Vishranthi Charitable Trust in Pallavakam, an area in Chennai. The headquarters compound included a home for the elderly, and the women had been eagerly awaiting my visit. About twenty elderly women came out into the common area to meet me, though only two or three spoke any English. One particularly vivacious woman with no teeth spoke a good deal of English; she was 105 years old. With funds from Direct Relief, Vishranthi has constructed a healthcare center on Pulicot Island. Mrs. Vaithi briefed me on the successful completion of the center.

Conclusions
Nearly nine months after the tsunami, relief and reconstruction efforts have been successful in some areas and lacking in others. Perhaps the most touted success is the absence of any disease outbreak or epidemic as predicted by many healthcare experts. Comparatively few lives were lost after the initial day of the disaster. However, the living conditions of survivors are very poor. Temporary homes in IDP camps have few amenities and often lack adequate water & sanitation facilities. Livelihoods that were lost in the disaster are slow to be recovered, and international NGO programs aimed at addressing this need have had mixed results. Internal political problems in Sri Lanka have stalled the government’s relief effort, and these issues have affected the relief efforts of international NGOs, most often stalling them.

Despite the challenges of a recovery effort on a scale as large as that of the tsunami, Direct Relief’s projects, administered through partner healthcare facilities and organizations, are overwhelmingly quality operations. It is advisable that Direct Relief continue our successful partnerships in Sri Lanka and India as we work to include more projects aimed at rebuilding the damaged healthcare infrastructure of both countries.

Photographs by: Jayne Kulzer

Indonesia Demographic Information

    * Total population: 219,883,000
    * Net primary school enrollment 87%
    * Total literacy: 87%
    * Life expectancy: 67
    * GNI annually per capita: US $810
    * Infant mortality rate: 31/1000
    * Under five mortality rate: 41/1000
    * Corruption ranking: 5 th in the world
      (Transparency International)
    * Source: UNICEF, unless otherwise indicated

TRIP PURPOSE

I conducted a tsunami-site visit to Indonesia to 1) assess the current post-tsunami situation 2) evaluate our current projects in the tsunami-affected region of Aceh; 3) determine how we can further assist with both product and cash donations; and 4) build rapport with current and potential partners.

This report covers the current post-tsunami situation, details each partner site visit in terms of activities and impressions, and highlights one potential partner site visit.

CURRENT POST-TSUNAMI SITUATION

Climate
The gravity of loss in the area is daunting, over 200,000 deaths when the confirmed deaths are combined with the missing. The internally displaced population (IDP) number about 500,000 and carry with them the loss of loved ones, homes, jobs, communities, and life as they knew it. Pre-tsunami, Aceh province was cut off from the world due to internal conflict. That in itself has made progress even more challenging - there was a pre-existing lack of infrastructure, resources, and networks to support fast-track rebuilding in Aceh, the area hit hardest by the tsunami. In other tsunami-affected countries like in India and Thailand, established networks with the western world combined with governmental support have likely enhanced rehabilitation efforts. Nevertheless, the world responded boldly post-tsunami to Aceh and around 700 national and international organizations and the Indonesian government have mobilized to assist in rehabilitating the area.  

Tsunami recovery has now graduated from the emergency phase to the development phase, a 3-5 year timeframe for restoration and 10 years for improvement. I constantly heard about how the IDP population is continuously shifting - from destroyed homes and villages to relief camp tents, then to government constructed barracks, and now back to their villages with a tent as a temporary shelter. Although I did see plenty of IDP populations that had returned to their villages, I also saw thousands of IDPs still living in relief camps and in government barracks. Some live in a barracks on the weekend and return to their village to work or clean up during the week. Up until now, NGOs were actively maintaining water and sanitation at IDP camps, providing cash for work, and other immediate response activities. Now services such as water and sanitation have been turned over to the municipality and the IDP communities themselves.

Livelihood development, home construction, and re-establishment and strengthening of pre- and existing services such as water, sewers, roads, bridges, harbors, health facilities, schools, and human resources are the current areas of focus for community development. Environmental conditions appeared to vary considerably between camps and with the recent shift in camp management, I think it is an important to time for healthcare workers to pay extra attention to disease prevention and treatment efforts.

Progress is slow but evident in the area. Mountains and miles of debris have been cleared, yet given that 500 miles of the coastline was destroyed many miles of debris remain to be cleared. Banda Aceh is a larger town than I anticipated and it is bustling and functioning, but at a very diminished capacity. Decisions and projects that will affect long-term progress are beginning to happen. For instance, USAID is sponsoring the construction of a new thoroughfare road along southwest Aceh, it will be 5-7 miles inland, whereas the previous route was along the coast. The former road has been deemed unfixable. Since the population has traditionally lived along the coast, it will be interesting to see how this new road affects the communities and their evolution. NGOs have started constructing homes, it appears each have their own blueprint. They are small, but lend themselves to additions.

The important part is getting people back in a home of their own. The government estimates that 100,000 homes need to be rebuilt. According to the BRR (see below for definition) 30,000 homes are to be built in 2005. Land rights and allocation is an ongoing issue that will take time to resolve.

Politics
Peace Agreement: After 30 years of conflict and 15,000 lives lost, on July 17th, the Indonesian government and GAM signed a peace agreement in Helsinki, Finland. The agreement will allow the GAM to have political representation in Aceh province and amnesty. The official peace treaty was signed in August. Indonesia will reduce its military and police presence in Aceh and GAM will lay down their weapons once the troops start withdrawing. As the troop withdrawal takes place, the European Union and five Asian countries will send peace monitors for six months. The overall reaction is positive, yet many have a ‘let’s wait and see attitude” – they are cautious given the history. The tsunami and reconstruction efforts likely fueled the agreement, the world is watching and wants to see progress and results in Aceh.

BRR Formation: From about January to April the Indonesian government was wary of the international presence in Aceh, perhaps fearing it would fuel support for the GAM. However there has now been a complete shift in attitude. Indonesia has begun to work extremely cooperatively with both the national and international NGOs toward the common cause of rehabilitating and strengthening the area.

As part of the effort, the government formed a committee, “Rehabilitation and Reconstruction Body for Aceh Province & Nias Island in North Sumatra (BRR),” that is charged with coordinating all relief efforts in a cooperative, transparent, and accountable approach with a strong commitment to integrity and speed. The BRR was inaugurated in May 2005 by Indonesian President Susilo Yudhoyono.

The BRR will implement a master plan for Aceh and Nias and manage nearly five billion dollars in aid funding over a four-year period. An executive board and an advisory board govern the BRR and Kuntro Mangkusubroto, a respected former energy minister, leads the executive board.

The specific BRR roles include: 1) helping to match projects that address community needs with donor funds; 2) tracking and disseminating use of donor funding and the status of projects; 3) compiling input from government agencies and local communities to determine priority needs; 4) expediting fund disbursements to priority areas and resolving any delays. In matching donors to projects, the BRR will verify that the activities are aligned with the Master Plan; and 5) emphasizing capacity-building so that communities can continue to develop after the four-year period.

Since the volume of NGOs and projects in the area is daunting, the BRR provides a much needed service and plays an important role. As the coordinating body for relief efforts they have the potential to serve as the reference point for project tracking and accountability and can prevent project overlap and highlight major gaps in rebuilding efforts.

EXISTING PARTNERS

Acehkita
Description/progress: Acehkita, based in Jakarta, is a local organization that focuses on humanity, justice, peace, welfare, and health. Their Aceh Province programming includes health service delivery and tsunami-related statistical data gathering. Direct Relief sponsors the operation of a clinic in Banda Aceh and mobile medical care in Pidie. We have also provided them with two shipments of medical product donations. An important niche of Acehkita’s is that they primarily serve IDPs living in villages with extended family members rather than those in camps and barracks. Since many IDPs do opt to live with extended family over the camps and barracks, Acehkita is filling a vital service gap in the community. By June, they had served 1,865 people in 12 villages.

In Jakarta, I met with Rachman Risman (Executive Director) and Mario Leonardo (Logistics). We briefly discussed Acehkita’s immediate need for medicines and the priority for establishing a Sigli site clinic. From there I attended one of the activities organized as part Acehkita’s two-year birthday celebration: a forum for journalists to discuss their influence on conflict and recovery.
 
In Aceh, I met with Diana Devi (Program Coordinator). She took me on a day trip to Sigli, a 2.5 hour drive southeast. I had the privilege of observing a mobile clinic in action, when we went to the rural village of Meti. Acehkita conducts mobile clinics each Saturday rotating between five different sites. They serve a high volume of people, about 130 people per mobile visit. The mobile clinic was held in the town mosque. Women, men, and children were crowded on the porch. Inside Acehkita was treating patients in an impressively efficient manner. Utilizing a circuit approach, patients moved from station to station. Patients first registered, then moved on to have their blood pressure checked by a nurse, next to the doctor for consult and exam (2 doctors), then to the pharmacist to fill their prescription of Direct Relief sponsored and locally procured medical products.

I saw plenty of Direct Relief donated shampoo, toothbrushes, eye drops, cortisone cream, cold medicine, cough medicine, multivitamins (liquid for children), B complex among other items being dispensed. One thing I noted was the personal time each doctor and pharmacist spent with each patient. There was time to ask questions and give proper instructions. The services and products were free. The most common health problems reported were upper respiratory, skin problems, arthritis pain, and hypertension. Hypertension was being treated with nifedipine. Since each patient expects a packet, Acehkita undoubtedly goes through a high volume of medical and hygiene products. We also distributed get-well cards from school children in Santa Barbara.  

Impressions: Acehkita fills a vital niche in the community. Direct Relief is fortunate to be their partner in health care.

Community.Habitat.Finance International (CHF)

Description/progress: Community.Habitat.Finance (CHF) International is a U.S. based NGO with over 50 years of experience working with underprivileged populations to improve their living standards through economic and health programs. Their tsunami-related efforts have primarily involved economic revitalization along the western coast from Banda Aceh through small grants provision to market vendors, boat builders, fishing associations, and handicraft associations. They are working closely with the governmental and partner agencies on infrastructure strengthening, and have plans for port and irrigation system development. In fact, one of CHF's most recent accomplishments is the signing of a Memorandum of Understanding between the BRR, Banda Aceh Mayor’s Office, AIG, and CHF to rebuild the Peunayong Market, the largest fish market in Banda Aceh.

I spent one morning with Louis O’Brien (Country Director) and Rick Schroeder (Aceh Director). Over the course of the morning we discussed the complexities associated with reconstruction, attended the official handover of Direct Relief sponsored computers to the Aceh Provincial Health Office (PHO), and future collaboration opportunities. Reconstruction in Aceh has been slow, largely due to the delay in drawing up the reconstruction master plan and implementing the BRR. CHF works closely with the governmental agencies and noted the toll the tsunami has taken on the public sector: loss of life to the public servants, destruction of office space and records, new leadership, inefficiency, and unprecedented demand for services and supplies.

Direct Relief sponsored the provision of 6 laptops, 30 desktops, printer/copiers, 30 MS Office software, 1 LCD projector, and 30 units of office equipment for the PHO. CHF went through a rigorous bidding process and purchased high quality Toshiba and HP equipment locally. Together we attended the official handover to the PHO. The PHO Head, Dr. Kepala Dinas, was extremely pleased with the donation and noted that the equipment will greatly improve their administrative and operational ability, particularly in remote areas. The generators will compliment the computer equipment by providing a consistent power source to each of the recipients.

The PHO was thrilled with the LCD projector (never owned one before and pleaded for this one), they even prepared a Powerpoint presentation for me on the Aceh tsunami response. They discussed the creation of 55 satellite healthposts in tsunami-affected areas, health facility reconstruction efforts assigned to international NGOs, and the major health concerns in the area: communicable diseases, nutrition, lack of facilities, lack of water supply, and environmental problems.

Impressions: This Direct Relief and CHF collaborative effort is one step towards rebuilding infrastructure and strengthening capacity, particularly for remote facilities.

International Relief & Development (IRD)
Description/progress: IRD has been registered in Indonesia since 1999 and has an Aceh staff of 160 with operations in six of the province’s cities (Lhokseumawe, Biren, Sigli, Banda Aceh/Aceh Besar, Mealobah). IRD works closely with government agencies, local professional and social organizations. Their Aceh efforts are focused on water and sanitation, health education and promotion, and livelihood development.

IRD graciously hosted me throughout my stay in Banda Aceh. Together we visited ten of the 13 local partners in the Direct Relief sponsored grant program.

Beth Rogers-Witte and Nur Hidayati are the Health Officers managing the Direct Relief sponsored grant program. The local partners are engaged in a variety of health services including basic health care for IDPs, reproductive health and HIV/STD prevention, water well cleaning, psychosocial health care, vector control, and health education via media. One large component of the grants program is the capacity-building workshops, which enable the local partners to clearly define their program goals, objectives, targets, and indicators as well as develop workplans and detailed budgets.

IRD has also been clearing and distributing Direct Relief sponsored in-kind products and procured mosquito nets. They have provided distribution reports summarizing the distribution to hospitals and clinics in the area. The mosquito nets will total 36,100 by the time the next order arrives.

Impressions: IRD is doing a fabulous job of managing the Direct Relief sponsored health program. They are working closely with each partner, monitoring activities well, and making constructive suggestions along the way. The added value of the capacity-building training is particularly important to for the local partners. It is giving them the skills to conduct quality programming and to compete more successfully for additional funding opportunities.

IRD LOCAL PARTNER SITE VISITS

Psikodista Foundation (PF)
Description/progress: Psikodista Foundation (PF) is providing crucially needed psychosocial care for the IDP population. They are an indigenous group that has a solid reputation in the area and a great deal of experience in counseling conflict victims. PF focuses their efforts on women and children within five barracks. Their activities include individual and group counseling via focus group discussions, psychodrama, story telling, drawing, recreation and relaxation.

They also provide psychological education for communities through radio, cassettes (music therapy); printed materials (leaflets, brochures, and newspapers); and income generating courses to crisis-affected individuals.

In reference to the radio talk show program that they host, they mentioned that calls during the first few months were mainly trauma related (nightmares, children with behavior problems, etc), but they have noticed a shift towards more pragmatic issues (finding a job, working out finances, etc). The leader of PF is a warm-hearted and dynamic woman.

I attended a large children’s song and dance performance that she orchestrated. The performance was to launch a tape cassette of the children’s music. The songs were all written and produced by PF with uplifting messages. The children were dressed in traditional costumes and proud to be performing for such a large audience.

Impressions: They are extremely well received in the barracks and their work brings life and vitality to the IDPs. I believe their success is rooted in their sincere compassion, history and respect in the community, and ability to touch those most in need in creative ways. Direct Relief and the IDPs are extremely fortunate to have PF as a partner.  

Embun Pagi Foundation (EPF):
Description/progress: The Embun Pagi Foundation (EPF) provides reproductive and general health care to IDP women and their children in camps. This was the first Direct Relief – IRD local partner that I visited. They were in the midst of setting up their clinic in a large barrack located in the midst one of the tsunami-devastated areas in town. Since this barrack is in town, there seemed to be a few NGOs providing various services. I asked about coordination and was told that generally the barrack leaders welcome most NGOs offering services. EPF makes barrack visits twice a month and operates their services from 9-12pm. They staff two midwives and five EPF volunteers, as well as 12 IDP volunteers recruited from the barracks. They see about 35 patients a day, about 15 pregnant women and about 20 infants, providing them with vitamins, minerals, treatment for common conditions (like uric acid, upper respiratory, colds, pain) and food supplements such as bananas and boiled eggs. They also conduct trainings and seek to empower IDP women through health education and volunteerism.

EPF recently hosted a tent and radio discussion on pregnancy psychology by the local psychiatrist Dr. Jaward. They did mention the Aceh women generally deliver at home and that they are currently not dispensing contraception but plan to in the future.

Impressions: Reproductive health services are extremely needed in the area and it was gratifying to see this organization devoted to such important services.
 
The Indonesian Planned Parenthood Association-Aceh (PKBI)
Description/progress: “I’ve had two babies at PKBI and would never have a baby anywhere else because of the great care” stated a mother due to have her third baby at PKBI. The Indonesian Planned Parenthood Association-Aceh (PKBI) pioneered reproductive health programs in Aceh several years ago. PKBI had to re-locate to a new facility when their former site was destroyed by the tsunami. Direct Relief funds portions of the new clinic operations, clinic supplies, and their youth program (teaches reproductive health in local high schools and hosts a weekly radio program). In addition to reproductive health, PKBI is engaged in gender equity and income generation activities.

The new clinic is a nice, well-equipped two-story facility. The facilities include one delivery room, three recovery rooms, one nurse’s room, and separate area for the youth programming.
 
In an average month they deliver about 20-30 babies and treat about 40 women for general issues and family planning. The pill, IUD, and injection are the most common forms of birth control. They have condoms, but they are not very popular. Generally about 6 women are referred to the hospital for emergency deliveries. During June, the youth program counseled at schools and barracks and reached 280 youths and trained 55 peer educators, generally they conduct two programs a day. They cannot distribute birth control to youth, only information. Their youth information spans STDs, reproductive health, drugs, and provides counseling. They did cite unwanted pregnancies as a problem in the area. We discussed abortions and they said that women travel to Medan, it is just not possible in Aceh. Their staff includes two obstetricians, one general practitioner, two midwives, two nurses, and 10 youth program volunteer facilitators. Two facilitators died in the tsunami.

Impressions: This well regarded organization is providing vital services; reproductive health, particularly youth programming, is virtually absent in the area.

Persatuan Perawat Nasional (PPNI)
Description/progress: Persatuan Perawat Nasional (PPNI) is a nursing association Direct Relief is funding to conduct health services at five IDP camp posts. I visited their site at the at Lambada Lhok IDP camp which is situated amongst a great deal of rubble and is home to about 600 people including 200 families. Most of the residents are men and boys. The surviving women, daughters, and very young are residing in barracks that are located in safer surroundings. The clinic is a basic canvas tent with one narrow patient bed, a table, and some shelves for medicines. They have a staff of ten: one doctor and nine nurses.  

While I was there they were treating a gentlemen with a laceration on his arm. They estimate seeing about 25 patients a day and find that upper respiratory is the predominant ailment. Their monthly reporting has been impressive in terms of indicating numbers treated per condition. They are the only clinic within this particular camp.

Impressions: The facilities were extremely basic, yet providing essential and immediate care. Apparently all of their health posts are located in very damaged areas with a void of health services. This seems like a very committed local outfit who is doing their job well.

Solidaritas Perempuan Bungoeng Jeumpa Aceh (SP)
Description/progress: The Solidaritas Perempuan Bungoeng Jeumpa Aceh (SP) provides health education on HIV/AIDS, STI, and reproductive health in five barracks. This is a women-run organization, the headquarters are in Jakarta and they have 14 field offices, including this one in Aceh. We paid them a visit one afternoon in the pouring rain. They were sewing pillow cases in preparation for an upcoming international meeting they were hosting. Representatives from five other Asian countries - Sri Lanka, India, Malaysia, Burma, and Pakistan will comprise the meeting.  
Students
Students

To date, SP’s HIV/AIDs efforts include conducting a four-day comprehensive HIV/AIDS/STD and contraception training in early July for four SP staff and ten SP volunteers (two volunteers from five barracks each). A doctor from their Jakarta office led the training. A training focused on reproductive health is scheduled next. Those trained are expected to disseminate information via a campaign within the barracks. They do have a booklet/manual to follow and are engaged in making a brochure, pins, and preparing a radio show targeted at women. I asked how people were reacting and was told that people are not receptive yet, the prevailing thought is “we don’t have AIDS here”. We discussed their plans to succeed. They want to involve religious leaders and community leaders to help break the stereotype.

Impressions: HIV/AIDS continues to be an extremely sensitive subject. In Aceh, the perception is that it is only among high risk populations like female sex workers and IV drug users. The challenges are great for SP, they may want to consider broadening their intervention topic so that initially rapport is established with less sensitive topics or programs.

Islamic Medical Association and Network (IMANI)
Description/progress: The Islamic Medical Association and Network (IMANI) provides general and specialist medical care, health worker training, and community health education in the Aceh Besar area. They operate a clinic in town and a mobile clinic that visits six barracks and treats 350 patients per week free of charge. The mobile clinic stays out in the field for two weeks at a time with a rotating team of doctors including specialists. They are part of a larger organization called the Islam Medical Foundation and pre-tsunami they were only in Jakarta. They would like to maintain a permanent program in Aceh.

They maintain a staff of 25: nine nurses, eight general practitioners, eight specialists (two pediatricians, two internists, one surgeon, one dentist, one ear, nose, and throat doctor, and one obstetrician), many of whom are employed on-call.

Impressions: This is terrific organization. They are improving access to essential care by their sheer solid presence in the barracks, its a rarity for specialists to be so accessible. To date, they have referred 10 patients for surgery. IMANI quickly compiled a list of medical products needs they would like us to provide. Also, they would like to begin conducting disaster management for district health workers.

InfoAceh
Description/progress: InfoAceh is an innovative group that is compiling the health materials from all 13 of the Direct Relief sponsored local partners and producing lively radio dramas, comic books, and newsletters to get health messages out to the community in meaningful and engaging ways. They just completed their media research to determine the best way to reach the public with targeted health messages. The group is comprised of a production manager, radio program manager, print manager, evaluation team, scriptwriter, and editor.  

The radio program airs weekly for 30 minutes and the newsletter and comic book are produced monthly. They tend to utilize non-news approaches for more effective behavior change, for example much of their programming includes testimonials and dramas. They call it “edu-tainment”. Once programs have aired on the radio, they will make CDs for the local partners to use in the field as tools to promote health promotion and to initiate follow up discussions and activities.

Impressions: InfoAceh is also doing a great job of unifying the local partners as they work together on contributing to the newsletters and programming.

Pusat Kajian dan Perlindungan Anak – Center for Study and Child Protection (PKPA)
Description/progress: This organization provides children-centered health services, primarily aimed at preventing malnutrition. Direct Relief is sponsoring their operations in Kota Jantho. Kota Jantho is mountain town in Aceh Besar that is home to four IDP camps. PKPA operates a permanent clinic, mobile services, growth-monitoring (every 3 months), health education, and a feeding program for IDPs. The clinic serves about 5,000 in the area and sees 15-20 outpatients a day, the clinic also has one in-patient bed. The clinic and mobile services are opened 24/7 and staffed by two doctors (husband and wife), one nurse, and a pediatrician who visits bi-weekly.

PKPA maintains a healthpost in the Parmuka IDP camp where the mobile services, feeding program and health education programs are conducted. The feeding and health education program take place six days a week at 10 a.m. and about 128 children participate. Only families that participate in the clinical growth-monitoring are able to participate in the feeding program.

The PKPA clinic was well organized and equipped. The IDP camp was something out of Shangra-La, despite living in canvas tents the community had created a neighborhood with groomed walkways, flower gardens, fenced in vegetable gardens, and spotless latrines. Apparently, this camp is comprised of people from one of the small islands northeast of Aceh, and unlike most relief camp dwellers, they have embraced living relief camp setting. I had the opportunity of observing the feeding program in action; it is largely run by IDP volunteers. Mothers bring their children and each child got a hardboiled egg, porridge, and a biscuit.  

PKPA takes advantage of the gathering and holds health education during the feeding program. Topics include hygiene, nutrition, childrens’ health, and other basic health topics. A corner of the healthpost includes educational posters and children’s books. An IDP camp volunteer gathers the children at 2 p.m. daily to read a story and cover a health or science topic. We discussed sustainability of the feeding program. Recently the Jantho village head gave the IDP camp 100 hectares to farm. In August, subsistence farming will begin and PKPA will be facilitating the project. This is an effort toward self-sustainability.

The PKPA clinic and the local public sub-district clinic are the only services in the area, according to PKPA, the public clinic is pleased they are in the community since the public facility is poorly staffed. PKPA believes that about 90% of the kids are not immunized and plans to initiate, in partnership with the local sub-district clinic, a two day immunization program followed by outreach to any missed children.

PKPA is based in Medan and appears to be very experienced in child health. Post-tsunami they expanded their programming to Jantho and Mealuboh. Funding dependent, they hope to run a program in Simeuleu. One additional note, upon leaving I wanted to distribute some bubbles to the kids, but the doctor said I should give them to one of the two orphanages they run for tsunami-affected children in Jantho. The orphanage that I visited was in a residential area and set up very homey and family like – bedrooms with bunkbeds, plenty of toys, busy kitchen, and family room with TV. Nearly all of the 20 kids who live there were off at primary school, one was home sick.

Impressions: Without a doubt, this was one of the best and most comprehensive set of health services that I observed on this trip.

Gardamadina Institute (GI)
Description/progress: “Free well-cleaning May – October 2005, call…” is painted on Gardamadina’s (GI) truck. Its a refreshing and blatant display of the exact Direct Relief sponsored activities. GI assessed two tsunami-affected communities and discovered that about 1,200 wells (the primary water source) that are used by thousands of people were contaminated with salt and mud. By October 2005, they will clean 1,200 wells. They promote livelihood by employing 15 IDP a day. They hire IDP university students living in barracks. For equity purposes GI changes laborers weekly. Equity seems to be one of their core values; to best manage who’s well is cleaned when, GI obtains data from the community head and then moves through the entire community before moving on to the next community.  

I watched them clean two wells, one at a family home – and the well was located in the middle of the kitchen! The other was a well shared among a few families. GI cleans about 8 wells per day and has completed 500 wells to date. Cleaning requires pumping the existing water out, hand scrubbing the entire well, filling it to rinse, pumping it out again, and then filling it and treating it with chlorine. About 20% of the 500 have required some repair and about 3% GI said they couldn’t fix. We discussed what would be involved to fix those and they said it involves replacing rings, mixing and pouring cement, and labor costs, roughly about $20 per well. They have also determined a need for well covers and filters; without trees, the wind is emptying plenty of dirt and debris into wells. Filtering would be done the traditional method which includes sand, stone, and layering.

Impressions: This group is a good example of a team that does one job and does it well. It is gratifying to know that Direct Relief is part of a collaborative effort that is re-storing safe water to thousands of tsunami-affected people.

Wahana Amal Sesama Mahluk Allah (WALSAMA)
Description/progress: The Wahana Amal Sesama Mahluk Allah (WALSAMA) is sponsored by Direct Relief to conduct health promotion activities at 15 barracks in the Lhok Nga sub-district of Aceh Besar, an area hit severely by the tsunami. WALSAMA is a large organization providing humanitarian assistance in six Indonesia provinces, their headquarters in Suribaya, Java has a staff of 400. They have had a team in Aceh since 2002 working in 27 Islamic boarding schools. Their staff in Aceh includes five staff from headquarters and seven Acehnese. I did not get a chance to see them in action, but meet with the WALSAMA project managers and coordinators at the IRD office. They were recently funded and have just launched their activities. In early August they are conducting a training which will cover sanitation, hygiene, and HIV/AIDS for 26 volunteer representatives from the barracks. They follow the Indonesian Doctors Association/WHO curriculum for healthy behaviors. Their approach utilizes the snowball effect, train trainers who will then train the community with WALSAMA oversight. Sanitation has been sighted as a big problem, particularly as NGOs turn camp responsibility over to the community. They realize that they will encounter resistance with HIV/AIDs, but have experience in this area. Part of the curriculum focus is on teaching women how to be assertive using religious and culturally appropriate approaches. They also plan to include religious leaders to help provide awareness since they are the influential leaders in the area. WALSAMA also plans to integrate traditional medicine using a spiritual process, reflexology, and pressure points.

Impressions: There project has just begun, but I have a sense that they will reach a wide array of people with their comprehensive services.

RSX Meuraxa Hospital
Description: IRD and I met with Dr. Leala, the RSX Meuraxa Assistant Director, and toured the facility. It is the only district level public hospital in the Banda Aceh area, however there are four private hospitals. The RSX Meuraxa had a new facility with 86 in-patient beds that had opened its doors last fall. Then the tsunami hit and demolished the building. A Hungarian and Austrian group is building them a state of the art hospital, but construction is about a year away. In the meantime, they are housed in a temporary one-story building that resembles a small apartment complex with about seven rooms. The temporary facility has 30 in-patient beds; all occupied when I visited. The hospital is currently serving 200 outpatients a day and has reproductive, maternal, pediatrics, internal medicine, surgery, and general care services as well as a laboratory on loan from the MOH. Due to a shortage of equipment, they are primarily providing basic treatment and consult and referring patients to the provincial hospital for additional care.

They have a staff of 142 including 12 doctors, five specialists, four dentists, 12 midwives, 51 nurses, and administrative staff. They lost a lot of staff to the tsunami, so re-staffing and training are important now. Their vehicles include three ambulances which are used for emergency services. They do not conduct any general mobile care. The facility includes seven operating rooms, one delivery room with four recovery beds, two in-patient dormitory rooms – one for males and one for females, one dental office, one consultation room, and one emergency room with two beds. I did see two Direct Relief sponsored obstetrics tables, they were distributed by IOM to the hospital.

Zainal Abidin Hospital
Description/progress: IRD and I met with Dr. Jefri Effendi of the Zainal Abidin Hospital. It is the provincial hospital serving all of Aceh Province. It is also a teaching hospital with 1,000 medical students. It is an extremely long two-story building that the tsunami hit hard. The structure is still standing, but three meters of water engulfed the building and destroyed equipment, supplies, and medical books among other items. The tsunami rehabilitation masterplan has slated it to be rehabilitated and re-equipped in 2006. Pre-tsunami the hospital had 400 nurses of which 80 died. They now have 250 nurses. The hospital provides comprehensive services, however our visit was centered on the surgical ward. Pre-tsunami: eight operating tables and 18-20 operations were a day. Post-tsunami: three operating tables and 6-8 operations were per day. There are nine surgeons (three general, two orthopedics, one plastic surgeon, one gastro-intestinal, and two urologists) and 15 nurses. The surgical ward consists of 33 beds for males and 26 for females. Their biggest supply plead was for cloth surgical gowns/scrubs.

International Medical Corps (IMC)
Description/progress: International Medical Corps is a global humanitarian nonprofit organization dedicated to saving lives and relieving suffering through health care training and relief and development programs. Established in 1984 by volunteer doctors and nurses, IMC is a private, voluntary, nonpolitical, nonsectarian organization. In Aceh, IMC has 220 staff of which 21 are ex-pat. In Nias they have 50 staff, two of which are ex-patriots. Their tsunami-relief efforts span livelihood development, mental health care, and medical care, training, and reconstruction. Direct Relief is sponsoring psychosocial and mental health programming, livelihood programming, and vehicle procurement to support medical operations.

Livelihood/micro-credit: I spent a morning with Bernando Roa (Livelihood and Community Development Officer) in Banda Aceh. This program is solely sponsored by Direct Relief. To date, this program has revitalized 11 cooperatives. All cooperative members participate in a capacity building workshop that involves formulating a business plan. We visited a few of the micro-credit programs. One cooperative, 63 members pre-tsunami and only 30 members post-tsunami, were in the middle of a training workshop when I was there. They re-established their brick making facility and have been quite successful in the marketplace, the cooperative is equally men and women. They make 60,000 bricks per week manually and sell them for 7 cents per brick. A percent of the interest goes toward investment in their office establishment, for example to purchase a computer for administrative purposes. Another group was a garment-making cooperative located at a member’s home.

They purchased a couple of overlock and standard sewing machines and are currently taking orders from businesses and the public. This sewing cooperative is enabling several women who have become sole-providers to their children since the tsunami to support their families and work from home. I also visited a large urban vegetable market with 110 cooperative members. This program enabled them to return to operations with a much smaller overhead than pre-tsunami.

Impressions: This program is doing a tremendous job of getting people back on their feet as well as improving overall well-being and personal recovery.

Mental health/Psychosocial: Tagging along with an IMC clinical psychiatrist, Dr. Andrew, I had the opportunity to visit a barrack and tent camp one afternoon. Several IDPs put a human face to the overwhelming loss that the tsunami produced. One 40ish man told me that the waves tore his three small children from his arms. He survived, his wife and children did not. He now resides in one of the government barracks with others who share similar experiences. The combination of counseling and anti-depressants have restored his ability sleep and reduced his nightmares. He is beginning to circulate more and is helping with relief efforts – he says it fills a void and makes him feel better.

Another IDP talked about her loss. Her first husband was shot by the GAM in 2000. Then the tsunami took her second husband and 4-year old son. She tumbled in the sea and rubble for three hours and spent days searching for her son. She was able to identify his body by his unusual fingernails. Being unable to bury him properly was a huge crush to her, the magnitude of the situation only allowed for mass burials. She has a tough fighting spirit and like many she attributes the tsunami to Allah’s will, saying that perhaps it was Allah’s anger over the conflict – his way of indicating that it is time for peace and rebuilding.

Impressions: The shared loss among the IDPs is enormous, yet a pervasive strength to rise above it is clear. It was humbling to witness the healing; no doubt healing is a lifetime process for the population.

Next we traveled to Gano, a town where only 20% survived in this devastated village. People have moved back to their concrete pads and place a tent on top. Due to the destruction of the shore and unseasonable rains, the temporary shelters are surrounded by water. Tents are saturated at the base and children, with no where else to go, play in the standing water. Nearby, new homes are being built on drying ground. Dr. Andrew is counseling some of the inhabitants and working closely with the community on improving current conditions.

Over the course of the afternoon I learned more about IMC’s mental health programming operations. In addition to Dr. Andrew, I also spent some time with Susie Morrison (Psychosocial Coordinator).

IMC’s mental health programming involves direct counseling and care, curriculum development, and health worker training. The overall aim is to strengthen local capacity by integrating mental health care into primary care. Pre-tsunami mental health care was essentially non-existent, with the exception of a mental health hospital that served more as a lock-up facility. The curriculum development component is in partnership with the MOH and WHO. IMC has two clinical psychiatrists and one psychologists who are work in Banda Aceh, Banda Besar, and Sigli. They lead weekly staff and health worker training, conduct home visits for counseling, and facilitate psychosocial activities (recreational) in barracks and camps. A nurse trained in mental health care co-leads or leads the counseling.

Impressions: The mental health and psychosocial programming is going exceptionally well and the need is great. One noted challenge was keeping up with the growing number of referrals for home visits. They are hoping to transition into more group counseling to address this problem. Dr. Andrew recently came to IMC from a clinical government post in Malaysia. He appears to be a great match for the communities given his professional expertise and approach, ability to connect so well with the people, speak their language, and strong commitment to his work.

Vehicles: In Jarkata, I spent a day with the then current Country Director, the Deputy Country Director, and the Global Procurement Manager. We sponsored the procurement of ten vehicles: two 4WD Toyota Land Cruiser ambulances, three Mitsubishi ambulances, two Toyota Land Cruiser Station wagons, and 2 4WD Toyota pickups. The 4WD Land Cruiser ambulances were particularly crucial for the rugged terrain in Aceh, however they were immediately deployed to Nias island to facilitate evacuation from the 28 March earthquake that literally shattered the island. Roads and bridges had collapsed preventing access to clinics. IMC paid locals to temporarily repair a 50km stretch (within a day) with local scraps of metal and timber so that they could reach remote sites.

Over the course of 5 days, the ambulances were used to evacuate more than 300 critically injured patients and IMC credits the ambulances with saving at least 35 of those lives. Without the rugged vehicles, the most critical of patients would have never made it to health facilities. There were many untreated fractures that had manifested into severe infections with swelling. Patients were stabilized and transported to a make-shift hospital IMC had converted the local morgue into – since the hospital was so severely damaged.

Impressions: The vehicles are well used for the provision of medical services and for the transport of relief provisions.

POTENTIAL PARTNER

Muhammadiyah
Description: Initially, I met with Dr. Markus Sudihyo in Jakarta to discuss a possible partnership for medical product donations. The organization is a private, nonprofit that has been around for 90 years. It is a Muslim organization that initially started in orphan care and has now grown into the fields of health, education, social services, and business. Currently they purchase their medicines from pharmacies and they frequently experience a shortage of supplies. They feel that if we could provide medical product donations, it will free up some of their funding for other purposes.
Muhammadiyah’s overall operations include:
 
    * 10,000 schools, including 166 universities
    * 300 orphanages
    * 200 social service programs for the elderly, blind, and other populations in need
    * 150 economic sector business including 81 microfinance programs
    * 1 national hospital with 500 beds
    * 47 general hospitals (provincial level 200-300 beds)
    * 70 maternity hospitals (provincial level 200-300 beds)
    * 217 maternity clinics, child health clinics, polyclinics and other health facilities
    * 62 facilities for training health personnel

A few days later I met with Dr. Sudihyo Markus and Dr. Arief Yachya in Aceh, at their Banda Aceh clinic. We toured the clinic and their neighboring midwife school. Their Banda Aceh clinic is very close to the soccer field size diesel electric floating barge that the tsunami dramatically carried two miles inland from its seaside dock. It flattened everything in its path and now sits on numerous homes as it provides electricity to the local community. Remarkably it landed undamaged.

Muhammadiyah’s Banda Aceh clinic was their only clinic in the province pre-tsunami. Post-tsunami they expanded to eight clinics and also had 1,500 volunteers involved in the grim work of body clean up. They coordinated closely with the IOM for the volunteer work. According to Muhammadiyah, the conditions are worsening and since the emergency phase is over it is more difficult to recruit doctors and other health care workers. The most common health problems they have noted in the area follow environmental disease patterns which in the Aceh include ARI, skin diseases, and infections. They also operate a maternal health training facility in Banda Aceh. It is a three-year program and 80 per year graduate. There is a big demand for midwives. The facility was very damaged by the tsunami, bodies stains remain on the walkway. The facility will be rebuilt and I believe funding has been obtained. The facility is well equipped: library, computer lab, and practicum facilities which included some terrific dummies for vaginal delivery that were donated by WHO. The clinics are free of charge for the tsunami areas, one site in the SW was less affected and does charge a small fee. For sustainability reasons, fees will be phased in over time.

Impressions: This organization is well-respected and providing good medical care to the community. We will work on establishing a partnership for in-kind donations and possible cash grant assistance.

CONCLUSION

I learned a tremendous amount on this trip. I have better understanding of the people, place, culture, and complexities that comprise the Aceh Province. The loss and destruction is still hard to comprehend and properly articulate, but what is most amazing to me is the resilience of the people; faith and a fighting spirit prevail as they accept what they call Allah’s will and focus on rebuilding their lives.

Direct Relief and our donors are fortunate to be able to help them in that process. Our in-kind donations and grant funding are providing valuable assistance, filling important health needs in the area, and transforming lives.

Since the tsunami of December 26, 2004, Direct Relief International has provided more than $26 million in both direct material aid and cash assistance to tsunami-affected countries.

In late April, Direct Relief International's President and CEO Thomas Tighe and I traveled to Indonesia, Thailand, and Sri Lanka to perform on-site assessments of the various in-country and international nongovernmental organizations (NGOs) and government agencies Direct Relief is working with for its tsunami response activities.
 
Until April, Direct Relief was unable to send a staff member to Banda Aceh, Indonesia, the closest point to the epicenter of December's earthquake, which received the worst damage from the tsunami. This trip allowed us to hold meetings with several in-country and international groups in Banda Aceh to see and understand the various relief and development projects. Other trip activities included meeting with potential partners in Thailand and spending time with Direct Relief's in-country representative in Sri Lanka, who is helping to coordinate and implement aid activities, and to evaluate the progress Direct Relief has made with both our cash and material support.

In each country, the trip provided an opportunity to better understand the current reconstruction and relief efforts that are underway, and helped us formulate Direct Relief's future efforts.

This report is broken down first by the countries we visited, and second via the meetings held with NGOs and government representatives.

Community, Habitat, Finance (CHF)
Baicoy Satellite Health Post
Banda Aceh, Indonesia

The drive reminded me that while the images and reporting focused on the tsunami, this disaster was prompted by a massive earthquake that reduced many buildings to rubble.

April 16th, 2:15 pm

Located on the northern tip of Sumatra, Aceh is renown for its desire for political independence and resistance to the Indonesian government. Recently Aceh witnessed renewed conflict between the Indonesian military and separatist movements. This conflict is rooted in cultural and religious issues and the control over natural resources - particularly oil.  Weeks before we arrived, the Indonesian government threatened to remove all non-Indonesian aid workers out of Aceh, in order to prevent international assistance to separatist movements, and to further consolidate Indonesian control of Aceh. The political situation is tense, but fortunately the Indonesian government has yet to follow through with their threats. However, many of the international and Acehnese NGOs we contacted were weary of the motives behind the Indonesian government assistance.

The drive from the airport in Banda Aceh was incredibly difficult to take in all at once. The airport is not near the coast, but the road takes you from the outlying rural, agricultural area into the city center of Banda Aceh. The drive reminded me that while the images and reporting focused on the tsunami, this disaster was prompted by a massive earthquake, which collapsed many buildings into rubble. Along the way, houses and businesses were flattened into piles of debris.

Community, Habitat, Finance (CHF)

We began our work with Martin Shapiro, Louis O'Brien, and Rick Schroder of Community, Habitat, Finance (CHF), a U.S.-based NGO that works to support long-term developmental projects (social, economic, and environmental) for disadvantaged people throughout the developing world. Their efforts focus on community development issues including infrastructure and revitalization, emergency management, grants management, youth programs, microfinance, water management, and democracy and governance.  When the tsunami struck, Mr. Shapiro, Mr. O'Brien, and Mr. Schroder quickly assembled a team that was in Banda Aceh within two weeks to assess programmatic options. Now more than three months since their arrival, CHF identified the resettlement of internally displaced persons (IDPs) and economic revitalization as their primary focus.

The Indonesian government estimates that there are more than 500,000 IDPs in Aceh province, though other sources estimate the number as high as 800,000.  In their efforts to assist the IDP population, the government responded with temporary housing in camps and through the construction of semi-permanent barracks. The resettlement issue is controversial. Many of the Acehnese believe the barracks are a tool of the Indonesian government to strengthen their control, since many communities have been split apart and relocated far from the destroyed villages and towns.

Due to the intense damage, resettlement programs in Aceh will be extensive and must include the entire construction of homes, sewage lines, roads, power grids, sanitation, and other major infrastructure. The Indonesian government has provided limited and often contradictory statements regarding the resettlement of IDPs. Though NGO community hopes to assist with resettlement, they must wait until the Indonesian government finalizes its policies and programs.

While shelter issues remain a large issue, CHF is assessing and undertaking a wide range of projects.  These projects comprise rebuilding a wholesale fish market, supporting a women's cooperative, constructing sanitation systems for outdoor markets, and sustaining a government health clinic located in an IDP camp.  We accompanied CHF on site visits to several of their projects, where we met with different Acehenese groups.

CHF Site Visit, the Baicoy Satellite Health Post
April 16th, 4:00 pm

After learning about the tsunami, Dr. Haryati, a physician educated in Jakarta, wanted to provide her medical services. The Ministry of Health contracted Dr. Haryati for a six month contract with the local government to run the Baicoy clinic. The clinic began providing services on March 21st, and provides care to 1,600 people living in the nearby government-built barracks, serving 50 patients a day. Dr. Haryati identified the major health concerns at her clinic to be upper respiratory infections, skin diseases, and gastrointestinal problems. As we were to learn, these issues were similar to much of the areas of Banda Aceh. The health professionals we spoke with said the main health conditions they were treating were back to what they were prior to the tsunami.

The clinic is staffed with six nurses, two public health workers, one nutrition worker, one sanitation worker, and one midwife (Dr. Haryati said she was in need of another). Government assistance for basic drugs and supplies was sporadic, causing great difficulty in supporting the daily operations of the clinic. Dr. Haryati identified transportation for referrals to and from the clinic as her the greatest need. Currently the only way of transporting a patient to a hospital, is to flag down a passing motorist and see if they can help. Despite these set backs, the Baicoy clinic is an important resource to the people living in the barracks and was quick to act to existing health concerns.

Direct Relief may be in a position, through the assistance of CHF, to material resources to the Baicoy clinic. CHF would need to assist with transportation and distribution of Direct Relief medical supplies, and monitor the Baicoy clinic's needs as they develop.

Zoë's Ark Foundation
Provincial Office of Health
Banda Aceh, Indonesia

Accompanied by Community, Habitat, Finance (CHF), we met representatives of Zoë's Ark Foundation, a French NGO that advocates for tsunami-affected youth.  CHF's Louis O'Brien arranged a meeting with the Provincial Office of Health for Aceh Province. This meeting provided us with a detailed understanding of the government's response and development projects.

Zoë's Ark Foundation
April 17th, 9:00 am

Accompanied by CHF, we met with representatives of Zoë's Ark Foundation, a French NGO that advocates for tsunami-affected youth.  A French 4-wheel drive company initially funded the foundation, to address the lack of services targeted towards children, especially orphans.  Zoe's Ark's staff provided background information on the post-tsunami situation of children.  They estimate there are tens of thousands of orphans in Aceh province.

Currently, Zoe's Ark works with UNICEF and the Indonesian government's Child Protection Program in various capacities at Ikeun, an IDP camp.  CHF is exploring the potential of partnering with Zoë's Ark to possibility construct semi-permanent structures at the camp.

After the briefing, we visited Ikeun. The camp was basic and functional; existing of rows of tents, an area for clean water that is refilled weekly, an outside covered praying and general purpose area, and latrines.  Many of the camps have been "sponsored" by an NGO who works to provide services around a single area, since the government is unable to service every IDP camp. Food is delivered weekly and other necessities arrive depending on the different aid agency that is working with the camp.  Unfortunately, we were told that many NGOs are not sure how much longer they can continue providing their services. Many of the groups that began their efforts were focused on the immediate relief and were not geared towards long-term development plans.

One of the camp's residents walked us through the camp, introducing us to its members. Towards the back of the camp, we were taken to a roped off area, where the resident explained that nearby there was a mass grave of approximately 2,000 tsunami victims. This image was very powerful and underscored the massive effect of the tsunami on the lives of hundreds of thousands of people in the region.  The people of the camp were not concerned with the proximity of the grave to their living area.  The resiliency of the survivors is remarkable; while the death toll is unimaginable, people know that they must continue with their lives to maintain hope in their future.

Provincial Office of Health
April 18th, 9:30 am

CHF's Louis O'Brien had arranged a meeting with the Provincial Office of Health for Aceh Province. This meeting provided us with a detailed understanding of the government's response and development projects. We met with Dr. Muhammad, the Provincial Health Chief, and Dr. Rochman the Local District Health Officer. The conversation began by Dr. Muhammad explaining that half of the office staff in the room we were meeting in perished. All items in the building were destroyed during the earthquake and Tsunami and the tables in chairs that were in the room were pulled from the street. The office currently had a single computer in which to perform all of the local government projects, and it had recently been donated to them by the World Health Organization (WHO).

Dr. Muhammad and Dr. Rochman stated that 14 of the 21 health districts in Aceh Province, or were affected by the tsunami. The structure of the Aceh health system is centered on the Puskesmas, or neighborhood health posts. The Puskesmas is a basic building staffed with a government physician or health assistant and they treat general primary care medical cases and make referrals to one of the district hospitals for more serious cases. The government supports the Puskesmas with regular replenishments of basic supplies and medicines, though many of them had been wiped out and the logistical channels are incredibly difficult to manage.  The government estimated that there are more than 121,000 confirmed deaths and more than 93,000 people missing.  Many of the missing are assumed dead putting the total dead at more than 200,000.

The Provincial Office of Health's main health concerns include mental health issues, infections, traumatic injury, environmental heath problems, and nutrition. They underscored to us that the whole health system in Aceh was almost completely devastated.  It has been extremely difficult for the government to organize personnel movement and communication between facilities.  The patient volume is high and the logistical capability is limited. In addition to providing support for governmental hospitals and Puskesmas, more than 520,000 total IDPs in 183 separate locations require medical attention.

While the NGO support has been valued, the local Health Office has had a difficult time finding the resources they need, since the NGOs mentioned by Dr. Muhammad and Dr. Rochman carried out their own relief efforts, many with out consulting the local government.  In late April, only two new health posts had been constructed. We provided Drs. Rochman and Muhammad with a listing of supplies and pharmaceuticals Direct Relief could provide.  They were extremely excited about the potential of a medical assistance shipment, and were willing to arrange transportation and storage of potential supplies. We left them our contact information and they said they would begin to assemble a request.

International Medical Corps (IMC)
Aceh Province, Indonesia

Direct Relief and IMC have a long history and have worked together on prior occasions. Currently, Direct Relief is working with IMC providing pharmaceuticals, medical supplies, and medical equipment along with cash assistance for the procurement of mobile medical units.

April 18th, 2:45 pm

The next day, Thomas and I met with International Medical Corps (IMC), a Los Angeles-based aid organization.  International Medical Corps is a global humanitarian nonprofit dedicated to medical care and relieving suffering through health care training, and relief and development programs that focus on building local capacity. IMC provides hands-on training of health and managerial skills to restore self-reliance to damaged health systems.

In Indonesia, there are more than 100 IMC staff (the majority are Indonesian) currently supporting their tsunami recovery programs throughout the island of Sumatra.  IMC health teams provide outreach services via fixed and mobile clinics to the severely damaged west coast areas of Sumatra, remote inland areas, and the north coast of Aceh Province. In each of the areas, IMC is assisting in the reconstruction and rehabilitation of the Puskesmas, in cooperation with the Indonesian Ministry of Health.

Direct Relief and IMC have a long history and have worked together on prior occasions. Currently, Direct Relief is working with IMC providing pharmaceuticals, medical supplies, and medical equipment along with cash assistance for the procurement of mobile medical units.

During the initial days directly following the tsunami, IMC reported that mobile medical clinics were needed to deliver services to displaced Acehnese who were reluctant to stay in IDP camps.  Direct Relief responded with the purchase of ten four-wheel-drive mobile medical units and rented two ocean-worthy boats for use in the region by the IMC medical staff.  In addition to cash support for mobile medical units, Direct Relief provided a 28-pallet shipment that was prepared for IMC physicians and medical staff.

We met with Naomi Wyles, IMC's Regional Director for the programs in Aceh Province. Ms. Wyles thanked us for our support and was eager to inform us of their efforts.  Accompanying Ms. Wyles at the meeting were four other IMC staff members with experience in psychosocial health services, economic livelihood, and logistics and operations.

IMC's operation is large, in addition the mobile medical units, IMC focuses on the refurbishment of damaged Puskesmas'.  Their work relies on volunteers who help construct and repair damaged facilities, assist with staff and village health trainings, and distribute supplies and medicines.  IMC's volunteers are placed in training programs and moved to the different districts where they serve the local community for a month with the ability to extend their stay.

IMC has contributed greatly to the psychosocial and mental health services needs of tsunami survivors.  Their work is critical since the emotional impact of the tsunami affects every survivor.  Most everybody we met had a story of loosing a family member.  Thus, to successfully cope and recover from the tragedy, IMC provides individual mental health counseling. This is done by integrating mental health services into the primary health care system. Nurses and healthcare workers receive mental health training from psychologists and IMC staff.

Direct Relief continues to work with IMC and receives updates on their work.  IMC has distributed Direct Relief medical shipments to the facilities they work with effectively, and possibility of future shipments the future is likely.

Acehkita / Rumohkita
Banda Aceh & Sigli, Indonesia

Acehkita's disaster relief effort is spearheaded by their humanitarian arm, Rumohkita. In the days after the tsunami, they delivered medical assistance to victims in Aceh Province, specifically in the town of Banda Aceh They also provided a service of news dissemination to the general public (through their media department) about the current status of the disaster relief process, instructing victims on gaining access to relief supplies.

April 19th, 8:00 am

After a day of meetings with U.S. based groups, we were able to meet with Acehkita, an Indonesian-based NGO that was founded in July 2003 by a coalition of local and international agencies and individuals, working in the areas of human rights, law, and international relations. It was a welcomed opportunity to better learn, from nationals, the situation and the ideas they had in improving their communities. The organization is comprised of two departments, Acehkita (translated "Our Aceh"), a news-based department that runs a magazine and website focusing on various human rights issues and current events. The other is Rumohkita (translated "Our Home"), the organization's humanitarian department that delivers aid to Aceh's underserved. Both departments of Acehkita concentrate on peace education, journalism concerned largely with humanitarian issues, and humanitarian relief (including physical and mental health services).

To support their ongoing work, Acehkita has established relationships with local and international journalists, NGOs, and the Indonesian government. They currently receive funding from a range of sources including, U.S. Agency for International Development, the British and Danish Embassies, and other international aid agencies. The aid that was distributed in the days and weeks after the tsunami came from the Indonesian pubic, individual supporters of Acehkita, and from foreign embassies.

Acehkita's disaster relief effort is spearheaded by their humanitarian arm, Rumohkita. In the days after the tsunami, they delivered medical assistance to victims in Aceh Province, specifically in the town of Banda Aceh They also provided a service of news dissemination to the general public (through their media department) about the current status of the disaster relief process, instructing victims on gaining access to relief supplies.

We met with Risman Rachman and Diana Devi Nurdin, coordinators for the Acehkita. They provided us a detailed analysis of their efforts and highlighted current issues, including an update on the medical and cash assistance programs, and on the three mobile medical vehicles provided by Direct Relief.

Mr. Rachman and Ms. Nurdin prepared a slideshow presenting their initial response phase and outlining Acehkita's upcoming projects. During the immediate tsunami aftermath, Acehkita pulled together a team of 6 doctors, 12 nurses, several mental health workers and a mediation group to assist victims. Further, Acehkita established a clinic at their office in Banda Aceh that provided basic primary care and served to refer people to the government hospitals. After their initial response effort, Acehkita decided they could be most effective by focusing their efforts on their clinics in Sigli, one of the districts in Aceh Province, and maintaining their clinic in Banda Aceh.

Sigli is located three hours west of Banda Aceh. Acehkita identified it as a place to target ongoing relief efforts because it was largely neglected by other aid organizations and the government. Sigli is comprised of 30 sub-districts of approximately 500,000 people. Though Sigli is located in the highlands and was not directly affected by the tsunami, Ms. Nurdin explained that a large number of people who had lost their homes during the tsunami and were afraid of staying near the coast, fled to Sigli to live with friends and relatives. In the recent weeks many more had migrated to that area because they were dissatisfied with conditions in the IDP camps and barracks.

Acehkita's Sigli operation utilized the Direct Relief-donated mobile medical clinics to provide biweekly mobile clinics and for referral patients needing to be transported to the hospital in Banda Aceh. Direct Relief's assistance of medicine also assisted with health services in the mobile clinics and in Banda Aceh, which see approximately 200-300 patients a month.

For future projects, Acehkita hopes to establish a permanent primary care clinic in Sigli. This clinic would service the population in that area with better care than the local Puskesmas, and assist with the recent increase in patient volume.

Mr. Rachman and Ms. Nurdin accompanied us on a day trip to Sigli to show us their programs. The trip was cleared with the local government and the police, as it was an area that experiences a high degree of the Acehnese resistance movement. We were the first foreigners Acehkita had taken to Sigli, and thus were escorted by the police throughout the day for our protection.

We stopped at Garot Cut village where we were introduced to a family of eight living in a small two room house. Many of the members of the family had fled Banda Aceh because of the worsening situation in the IDP camps. The people described their situation, starting with a man living at the house who explained that he had lost several of his family members in the tsunami. Prior to the tsunami he worked making furniture, but now has no means of income as the shop, and much of the staff was destroyed. He makes the almost three-hour drive via minibus into Banda Aceh to try and find work, but he had been unsuccessful thus far. The other people in the house had similar stories; each person had lost a loved one, some had lost several.

After meeting the families, we continued through the town where we stopped at the site for the proposed clinic. It is a large building in poor shape that needs much work to develop it into a fully functioning clinic. With the increased IDP population, it was clear that Acehkita's programs are servicing an essential need.

After the site visit we made the trip back to Banda Aceh and discussed how Direct Relief could play a further role in supporting Acehkita's future efforts. Ms. Nurdin and Mr. Rachman said they planned to submit further grant requests for new proposals.

IRD works closely with government agencies, local professional and social organizations. Immediately after the tsunami, IRD dispatched a health team to, among other things, control the potential spread of malaria.

April 19th, 8:00 pm

That same evening, after returning from Sigli, we met with Rod Snider, Nur Rokhmah-Hidayati, and Beth Rodgers, three representatives from International Relief and Development (IRD). IRD is an U.S.-based NGO that provides assistance to people in several disaster-affected countries worldwide. IRD concentrates on water and sanitation health, malaria, infectious disease control, reproductive health, nutrition, community-based primary health care, and health education and promotion. IRD works closely with government agencies, and local professional and social organizations. Immediately after the tsunami, IRD dispatched a health team to, among other things, control the potential spread of malaria.

Direct Relief provided IRD with a grant of $500,000 to distribute in smaller amounts to various Indonesian NGOs and projects targeting tsunami-affected populations, given their strong in-country presence. Though Direct Relief had recently provided a cash grant, at that time they were evaluating various project proposals. One project they had identified was an anti-malaria effort. Direct Relief procured 50,000 treated mosquito nets for distribution to local health centers and hospitals.

The meeting served as a solid introduction to the IRD staff and their potential projects. They informed us that they had arranged for a site visit for the distribution of some mosquito nets the following morning.

International Relief and Development Site Visit
April 20th, 8:00 am

We visited Fakinah Hospital, one of two hospitals that was spared damage from the tsunami. During their response effort, the government took over the hospital for emergency use and facilitated the treatment of thousands of patients. Unfortunately due its status as one of the few undamaged hospitals in Aceh, the hospital was expanded beyond its capacity.

We met with the Director of the hospital who informed us about the three types of hospitals in Banda Aceh; the Ministry of Health's two public hospitals; the three private hospitals, and two military hospitals. Until recently, the government retained control of Fakinah. Now that the situation had returned to some degree of normalcy, the director cited infections and the potential spread of malaria as the major post-tsunami health concerns. Unfortunately treating the patients is difficult, as the hospital has been depleted of supplies while treating tsunami patients. This has been further exacerbated by gaps in the supply chain.

After the briefing and tour of the hospital we distributed 200 mosquito nets - two nets for each bed of the hospital. The Director thanked us for the donation, but it was the work of him and his staff that made the real difference in the days and weeks of recovery.

From Indonesia to Thailand
April 20th, 10:30 am

The visit to Aceh was difficult, and I still have trouble putting what I observed into words. The damage is vast and incomprehensible. One vivid image I have is of an ocean freighter that held a staff of more than 150 crew members that must have weighed several thousand tons. It was lifted and carried five miles inland, crushing houses and buildings throughout its path, ending atop a village crushing several houses and cars. Another image is experiencing the shock of viewing a mass grave containing 2,000 bodies within steps of an IDP camp.
 
Aceh's task is monumental - whole systems need to be repaired, many completely replaced. Fortunately Aceh has not experienced an outbreak of diseases, starvation, or political turmoil. This can be attributed to the expedient action of the Indonesian government, the on-the ground expertise of NGOs, and the generous financial support from international NGOs, governments, and private donors. Most importantly it is due to the resiliency of the people of Aceh, who are truly remarkable. It will be because of their hard work and dedication that their country will recover. This trip displayed that promise.

Thailand overview
Crisis Corps
Phuket & Khaolak, Thailand

Our trip to Thailand was to find potential Direct Relief partner organizations that were in need of cash grants or material medical assistance.

The damage in Thailand was far less severe than in Indonesia. This is due to a number of factors including the development of the coastal areas with hotels and resorts. The buildings, unlike the homes of the citizens of Banda Aceh, where built with sound infrastructure and when the wave struck, many of the costal buildings absorbed its force saving many lives. These buildings overtime had also displaced the costal communities, forcing the villages that once occupied the costal areas to move inland. The result was there were less people living on the coast in Thailand compared to both Indonesia and Sri Lanka.  

Regardless, the southwest coast of Thailand was still severely hit, including Phuket and Khaolak where we were able to visit. Fortunately, the Thai government responded quickly and effectively, moving to create barracks and temporary housing for IDPs, and providing immediate disaster relief. Thailand did not make an international appeal for disaster relief aid, but it has requested technical help to identify the victims of the tsunami, a process which continues today. It is estimated that more than 5,300 people are confirmed dead, including 1,700 foreigners. More than 2,900 remain missing, most are presumed to have perished.

The purpose of our trip to Thailand was to find potential Direct Relief partner organizations that were in need of cash grants or material medical assistance. At that time we had not had any tsunami-related partners in Thailand.

Crisis Corps
April 21st, 10:30 am

The morning after we arrived in Phuket, we traveled up to the west coast to see some of the impact of the tsunami. We witnessed small pockets of devastation along the way until we reached Khaolak. Khaolak experienced some of the worst devastation in the country. There we met with Bill Knowles, the Crisis Corps country coordinator, and spoke with local Thai groups to learn of their potential needs. Crisis Corps mobilizes former Peace Corps Volunteers on a short-term basis to help countries address critical needs, often due to disasters. Crisis Corps volunteers have an advantage because of their past work, language skill, and understanding of the affected country. Crisis Corps volunteers, enroll for short-term assignments ranging from three to six months. Interested former Peace Corps volunteers are maintained in a database for Crisis Corps work, and when requests for volunteers come in, the Crisis Corps responds with eligible skilled volunteers.

As we drove to the different sites, Mr. Knowles explained the program led by five Crisis Corps volunteers - two performing on resource development to fund local programs, two database development specialists assisting local Thai government offices, and a tradesman working to construct homes for tsunami survivors. Eventually 30 volunteers will work with Crisis Corps over the next year.

The affected areas we visited consisted of a stretch of coastline with a series of resorts. The reconstruction effort was moving along rapidly - many of the hotels are part of large global corporations who have incentive to quickly reopen the hotels to prevent further loss in profits. The damaged hotels also had access to financial resources to promptly begin rebuilding. In most of the areas we visited construction crews had begun reparing. This is in contrast to Indonesia, where we did not see any reconstruction of the costal areas,

After the tour we met with a Crisis Corps Volunteer, a high school teacher from Dade County, Florida. Previously, he had spent five years in Thailand. When he heard of the tsunami's damage, Jonathan wanted to help immediately. Since he was unable to make a financial contribution, he decided to leave his job for the summer and join the Crisis Corps. Having lived in Thailand, and speaking Thai, he thought he could provide useful skills. He now performs database development with a local government office. We were able to speak with him about his experience and get his impressions on the recovery activities. He was frustrated with the time it had taken to get things started, but his frustration was steeped in his passion for making progress.

The day with the Crisis Corps representatives proved useful. We left with a good understanding of their activities and informed them that if they discovered a potential project that needed funding, they could contact Direct Relief.

Sustainable Development Foundation (SDF)
Thailand

Meeting with the Crisis Corps and SDF was helpful to better understand some of the longer-term development that is occurring. It was also useful in identifying potential partners who are performing relief and development work who may potentially become groups we could assist with our financial resources.

April 23rd, 8:45 am

Following a day of travel to Bangkok, we met with the Sustainable Development Foundation (SDF). SDF is a coalition of Thai-based NGOs working to coordinate efforts of many smaller sector and regionally-based groups working on a variety of issues. SDF is comprised of three groups, staff in regional offices (of which there are 25), staff in their headquarters (of which there are 11), and the consortium of Thai NGOs (of which there are dozens) that SDF represents.

We met with Ms. Ravadee, the President of SDF, who provided us with briefing on SDF and its activities. She also presented a proposal that would assist Thai fisherfolk in the Andaman Islands whose boats were damaged and destroyed in the tsunami. She went on to say while the Thai government had been successful in the immediate response efforts; they were neglecting many issues needed for healthy long-term development, such as looking to improve costal economies. She felt SDF, which is independently audited by Ernst & Young, could do a good job directing financial resources to worthy projects.

Ms. Ravadee was an articulate and passionate spokesperson for her organization and SDF's credentials were impressive. We left with her contact information and a proposal, which is currently under review in our grants committee.

From Thailand to Sri Lanka

While our time in Thailand was brief, it was spent judiciously. Meeting with the Crisis Corps and SDF was helpful to better understand some of the longer-term development that is occurring. It was also useful in identifying potential partners who are performing relief and development work who may potentially become groups we could assist with our financial resources.

Sri Lanka Overview
International Medical Corps (IMC)
Batticaloa, Sri Lanka

Direct Relief's involvement with Sri Lanka has been extensive in the last months. After news of the disaster broke, we were able to package and send an emergency shipment with a team of physicians to provide their services three days later.

Sri Lanka

Sri Lanka's southern and eastern coastlines were ravaged with destruction from the tsunami. It was the hardest hit country per capita - homes, crops, fishing boats, and roads were destroyed leaving whole economies devastated. Similar to Indonesia, Sri Lanka's initial response to the damage caused was successful, as widespread disease outbreaks were prevented, and the overall health of the country has returned to its pre-tsunami levels. The government is currently focused on reconstruction of its coastal towns, estimating the total costs of reconstruction to be $3.5 billion. There is a significant amount of international funding available, but it is an ongoing logistical challenge to transform the money into relief and development. Current estimates of people killed are 31,000, with more than 4,000 missing. The number of homeless is estimated between 800,000 and 1 million.
 
Direct Relief's involvement with Sri Lanka has been extensive in the last months. After news of the disaster broke, we were able to package and send an emergency shipment with a team of physicians to provide their services three days later. Shortly after we made contact with the Ministry of Health and sent an air freight shipment of 11 pallets with specifically-requested goods. More shipments followed in the next weeks and months, both to the government, a few international NGOs, and to Sarvodaya a Sri Lankan, Buddhist-based NGO.

To evaluate our initial support, Direct Relief sent Chris Brady, Vice President of Programs and Kelly Darnell, Program Officer, to Colombo and Galle to assess the on-the-ground situation and identify partners. Once in the country, Mr. Brady and Ms. Darnell became aware of how much work was needed, and decided it was necessary to establish an in-country presence. They were introduced to Perine Fernando, a native Sri Lankan who had a history of relief and development work, who agreed to help Direct Relief in its efforts.

International Medical Corps
April 25th 2:00 pm

Mr. Hussein Ibrahim is International Medical Corps' (IMC) Country Director and was dispatched to Sri Lanka soon after the tsunami. Mr. Ibrahim provided a general overview of IMC's programs, including a detailed breakdown of the ones Direct Relief supported. These programs include; a shipment of psychotherapeutics to assist with mental health programs, funding for seven mobile medical clinics, and cash support for the rebuilding of a hospital in Batticaloa region.

IMC's psychosocial programs utilize WHO-approved training manuals to educate four Ministry of Health appointed Sri Lankan psychiatrists to work within various tsunami-affected districts. The psychiatrists will work to train the primary care providers at the district level in hopes of integrating care for people in need of mental health support with their primary services.

The other projects were proceeding with some difficulty. The government of Sri Lanka at times is intensely bureaucratic and requires meeting and working with many different parties to accomplish set goals. There was some issue with the clearance of the mobile medical units Direct Relief had procured for IMC's use. Along the same vain, Mr. Ibrahim was experiencing great difficulty in navigating the constantly-changing policies of the Sri Lankan government with respect to the rebuilding of a damaged hospital in the Batticaloa District. Direct Relief provided medical donations and cash assistance for the rebuilding of this hospital, but unfortunately, IMC was forced to change their original intent of the project. Instead we were informed that IMC is assisting in the construction of a new clinic in a new location. The government issued a new law that prevented to construction of any building within 100 meters of the coast, in an effort to protect itself from future tsunamis. This action forced the relocation of the hospital project.

Ministry of Health, Sri Lanka :
Director of Medical Supplies Division
Director General of Health Services
Minister of Health

The meetings with the government officials provided an excellent opportunity to fully understand much of the relief work occurring in Sri Lanka.

Director of Medical Supplies Division, Ministry of Health Sri Lanka
April 25th, 3:00 pm

In our second meeting of the day with Dr. Beneragama, the Director of the Medical Supplies Division for Sri Lankan government. He spoke about the huge logistical challenge of moving medical supplies areas in need through Sri Lanka. He explained that the Ministry is focusing on ways to streamline donation acceptance and clearance procedures, as they are completely overwhelmed with product, which is causing storage and transportation issues. Currently, he said there are 40 ocean containers, 40 feet in length, floating in the port waiting to be cleared. While the backlog in product is significant, it is moving through the system, albeit slowly.
 
The Ministry of Health is currently working to design a new system to decrease product delivery delays and to ensure that all shipments include needed medical product donations. Regrettably, illegal drugs and military equipment have been found in some shipments, thereby delaying the medical donation clearance. To allow for a smooth customs clearance process, he said Direct Relief should provide a packing list before the shipment is sent, something that Direct Relief does with all its shipments. He was able to review our latest shipment with the paperwork we brought and ensured us that it was in the process of being distributed to the health posts throughout the country.

Director General of Health Services, Ministry of Health Sri Lanka
April 25th, 5:45 pm

Immediately after the meeting with the Director of Health Services, we were able to meet with Dr. Kahandaliyanage, the Director General of Health Services. Dr. Kahandaliyanage informed us that tsunami relief efforts were a priority for the Ministry, however in recent weeks they were also focusing on other health issues. For example, he explained that there was recently a dengue fever outbreak in a hospital in Kandy and they were in need of treated mosquito nets to prevent the further spread of the disease. In an incredibly fortunate coincidence, Direct Relief had recently procured treated anti-malarial mosquito nets for distribution in Sri Lanka with the help of IRD. Having just been informed of the outbreak, we were able to offer some of the nets we had procured to the Ministry and Dr. Kahandaliyanage, who was ecstatic. We provided the contact information of IRD, and asked them that when they arrived they should provide the amount needed by the Ministry for the hospital in Kandy.

Dr. Kahandaliyanage asked if Direct Relief was in a position to assist with transportation and logistics in Sri Lanka. A tentative agreement was established between Direct Relief, International Aid, and IMC to further analyze and offer suggestions and ideas to alleviate any medical product delays.

The Director General described his biggest challenge in the next six months will be to rehabilitate and revitalize the tsunami-affected health system. This centered mainly on rebuilding the physical infrastructure for multiple district health facilities in the eastern and southern Sri Lanka.

Minister of Health, Sri Lanka
April 25th, 6:30 pm

Shortly after the meeting with the Director General, we were informed that the Minister of Health would be interested in speaking with us. Nimal Siripala de Silva provided a general introduction to the health situation the Sri Lanka post-tsunami. Although still rebuilding from the damage, he stated that that Sri Lanka is also in dire need of kidney dialysis machines, cancer drugs, and rabies vaccines. He went on to explain he was concerned with the sustainability of the tsunami reconstruction work. Apparently many of the international NGOs that provided initial relief have since pulled out of Sri Lanka. Minister de Silva urged Direct Relief to consider the long term ramifications of our assistance and to ensure sustainability through our donations. It was a point well taken and we assured him that our support was focused on long-term assistance. Direct Relief received an assurance that the Ministry of Health will help with the clearance process for any donated medical supplies.

Thomas showing Nimal Siripala de Silva (left, Minister of Health) Direct Relief's latest air-freighted shipment
The meetings with the government officials provided an excellent opportunity to fully understand much of the relief work occurring in Sri Lanka. They effectively explained the donation acceptance, clearance, and distribution process, which allowed Direct Relief to better understand the choke points. Working with the Ministry is an essential component of any successful assistance project, as the government's control in the health sector is vast. We were fortunate to have a meeting with the Minister of Health and able to solidify our relationship with the Ministry for our future relief and assistance efforts.

Sarvodaya
Moratuwa, Sri Lanka

Sarvodaya is one of the oldest and largest Sri Lankan-run NGOs...an essential component to their work is an emphasis on a holistic approach to their services to build a sense of empowerment among people the serve.

April 26th, 9:00 am

After our day-long meetings with the Ministry officials, Ms. Fernando accompanied us to meet with Sarvodaya and Dr. Vinya Ariyaratne, its Executive Director. Sarvodaya is one of the oldest and largest Sri Lankan-run NGOs. It aims to cover gaps in the Ministry of Health's services, including assistance in reproductive health, nutrition, preventing violence against women, and other preventive health services. Following the tsunami, Sarvodaya was asked to operate 90 of the 850 camps for internally displaced people. Each camp houses about 100 people who received food, shelter, and medical care. Direct Relief provided Sarvodaya with a shipment of basic first aid supplies, cough and cold medicine, oral rehydration salts, and sanitary napkins.

At their headquarters in Moratuwa, south of Colombo on the west coast, Ms. Humaira Mussammil, who works in the Field Operations Division, provided us a tour of the and a briefing of their activities in the past months, much of which centered on improving the IDP camps. Sarvodaya had decided to broaden their efforts in the camps by providing education to improve and benefit community health via physical infrastructure (building of wells, latrines, etc.), micro financing, mental health programs, documentation, legal assistance, housing construction, along with general education for children. As demonstrated in her explanation, an essential component to their work is an emphasis on a holistic approach to their services to build a sense of empowerment among people the serve

After the tour by Ms. Mussammil, we were invited to have lunch with Dr. Ariyaratne. Dr. Ariyaratne is a physician who also holds a Master's in Public Health from John Hopkins University. His father started the organization close to 50 years ago, and it is continued today by Dr. Ariyaratne. He is an incredibly impressive and passionate spokesperson for Sarvodaya and our conversation covered a lot of ground. It is clear that Direct Relief is in a fortunate position of being able to assist the work of such an effective organization. In our discussion we asked if Dr. Ariyaratne would be willing to come to Santa Barbara to speak at Direct Relief's annual Shareholders' meeting, which he enthusiastically agreed to do. Sarvodaya's ability to reach a large number of people through their work in the IDP camps allows for a good partnership with Direct Relief.

Foundation for Social Welfare and meeting with the Mayor of Moratuwa
Moratuwa Region, Sri Lanka

Most of the people from the surrounding communities were living with family members or friends in the community, since their houses were destroyed.

April 26th, 2:00 pm

After our lunch with Dr. Ariyaratne, we left Sarvodaya and headed up the coast of the Moratuwa region to see the areas affected by the tsunami, and meet with a group who was planning on constructing a new clinic. There we were introduced to Dr. de Silva, a young Medical Officer in the Mental Health Division. Dr. de Silva took us to a community center and nearby IDP camp that was being used as a temporary clinic and houses 100 families. Most of the people from the surrounding communities were living with family members or friends in the community, since their houses were destroyed. She explained that the understaffed clinic was unable to treat all of the patients requiring medical assistance. In addition, the transportation infrastructure was also severely understaffed; residents were forced to walk more than five miles to receive treatment. With all of the other issues, her focus was on how to provide services to the dozens of community members who needed psychological care. Dr. de Silva's task was large, but she provided us with a plan that was composed of a variety of funding requests including the construction of a medical clinic and a community center to focus on psychosocial health services. We agreed that it was something that Direct Relief could support.

Mayor of Moratuwa
April 26th, 5:00 pm

After a tour of the Moratuwa area, we were able to meet with the Mayor, Mr. Goonesekera, and the District's Chief Engineer. Expanding on some of the issues that Dr. de Siva addressed, Me. Goonesekera explained the need of Direct Relief's assistance because the Sri Lankan government had not done an efficient job of coordinating some of the tsunami rebuilding efforts. In particular, the government failed to deliver fogging machine and sprayers that the Mayor had requested. They are crucial for malaria prevention before the rainy season begins. This was of immediate concern for the Mayor as it potentially put thousands of his citizens at risk, particularly those at the IDP camps.

After the discussion, we offered to see if we could assist with the purchase of such a machine. He was very appreciative and put us in contact with several local fogging machine distributors. The next day we were able arrange a meeting with the distributors and the Chief Engineer, who did the anti-malaria spraying. After some discussion on different models, we were able to purchase one and provide it to the Engineer who was able to return to the community and begin the fogging that week.

Galle Medical Association
Karapitiya Teaching Hospital
Galle, Sri Lanka

To date, the Galle Medical Association's fund has assisted 36 hospital employees and their families to rebuild their homes that were destroyed during the tsunami.

April 27th, 9:00 am

The day following our meetings with the Medical Officer and Mayor of Moratuwa, we visited the Karapitiya Teaching Hospital, the largest hospital in the southern region of Sri Lanka, located in Galle. Two months prior our visit, Chris Brady and Kelly Darnell had visited the hospital and offered assistance to the hospital's physician association (the Galle Medical Association) that raised funds to rebuild the hospital's staffs' homes that were destroyed during the tsunami. We were there to perform follow-up and evaluation of Direct Relief's financial assistance - the largest contribution to the physician association's fund. To date, the association's fund has assisted 36 hospital employees and their families.

We also discussed the medical needs of the hospital. Medical supplies and especially medical equipment is in great demand as the patient volume is large. Fortunately the hospital has its own account that can handle donations of money for the procurement of hospital equipment. It also is outfitted with a biomedical unit that has staff to repair and refurbish any equipment. It was clear that while we were able to effectively support the financial needs of the hospital employee's who were homeless, the hospital itself would benefit greatly from a donation of supplies, pharmaceuticals, and equipment. Each of the physicians we met with provided us with a needs-list from their department which we were able to take with us for further review at Direct Relief.

The Karapitiya hospital was not affected by physical damage from the tsunami, but it was overwhelmed by people with injuries and bodies, since the hospital serves a population of more than 5 million people. During the weeks following the tsunami, between 5,000 and 7,000 patients were treated at the Karapitiya Hospital. In the view of the Galle Medical Association, which is comprised of two dozen or so physicians from the hospital, to keep treating the influx of patients, they needed to make sure they had adequate staff. They decided one way they could assist their fellow staff was to assist the hospital's employees with a fund in which the employees could apply for house reconstruction funding. Though land is expensive, the physicians estimate with an additional $50,000 to $70,000 they should be able to repair every hospital employee's home that was damaged by the tsunami. Since this is a volunteer effort, none of the money raised was used for administrative purposes. During our conversation, we were shown pictures of some of the employee's houses that were rebuilt, along with the final information of the fund to demonstrate the willingness for transparency.
The Galle Medical Association physicians were hard-working, energetic, and effective with their efforts. We agreed to consider funding an additional grant for their home reconstruction project and look into the potential of supporting their material medical needs.

International Relief and Development (IRD),
Tropical Environmental Diseases and Health Associates (TEDHA),
St. John Ambulance Brigade,
Colombo, Sri Lanka

We left Sri Lanka knowing we are in a fortunate position of having established relationships with incredibly motivated groups, and hopefully our support can help them better the situation for people in need.

International Relief and Development (IRD)
Tropical Environmental Diseases and Health Associates (TEDHA)
April 27th, 4:00 pm

Heading north towards Colombo after leaving the Karapitiya Hospital, we met with Gordon Bacon, IRD's Sri Lankan representative. Mr. Bacon spoke of a number of initial ideas that he has for Sri Lankan recovery, and has been encouraged by the efforts of local Sri Lankan NGOs. This was exceptionally heartening to hear, considering Direct Relief recently provided $250,000 to IRD for funding of smaller grants for local Sri Lankan organizations.

Dr. Pandu is a committed man and it was thought he would be a great candidate for financial assistance from the money Direct Relief had provided to IRD. It also seemed that his project could benefit from some of the anti-malaria nets that IRD was distributing on Direct Relief's behalf.

Mr. Bacon introduced us to the Chairman of one of the Sri Lankan NGOs he spoke about, Dr. Panduka Wijeyaratne (known as Dr. Pandu). Dr. Pandu runs an organization called Tropical and Environmental Diseases and Health Associates (TEDHA). Incredibly in our conversation we found that he is a colleague of Direct Relief's Vice President of Programs, Mr. Chris Brady. TEDHA has established their operations in a village south of Colombo and is looking at ways to make positive health impacts, chiefly through basic surveying of the current health issues and analyzing data to see where the most influential health impacts are possible. Currently TEDHA is assessing the potential impacts of health prevention education classes, water treatment, proper sanitation, anti-malarial netting, and nutrition issues. Dr. Pandu is working with a team of high school-aged children to gather most of the date for TEDHA's program research.

St. John Ambulance Brigade
April 28th, 11:00 am

On the final day of our stay in Sri Lanka and our visit to Asia, we met with the Chief Commissioner and Executive Officer of the St. John Ambulance Brigade, Dr. J.G. Jayatilaka. The St. John Ambulance Brigade, Sri Lanka is based out of Colombo, but retains offices throughout the country, to further their services.

The brigade was established in 1906 as an affiliate of the Order of St. John, with the mission to encourage and promote relief activities for peoples suffering from sickness, distress, or danger without regard to distinctions of race, class, or religion.

Dr. Jayatilaka was pleased we were able to meet him, specifically to show us the ambulances that Direct Relief had helped fund for their use. St. John's Ambulance brigade was actively involved in search and rescue effort during the tsunami's aftermath, offering immediate response for people along the coastal belt in the north and throughout the east. St. John Ambulance Brigade succeeds in large part due to their 60,000 volunteers countrywide that perform a multitude of tasks. Currently, the organization assists with the establishment of IDP camps and helps provide medical assistance transportation tsunami victims and survivors.

Our engaging meeting paved the way for potential future assistance for St. John's request for more ambulances to expand and improve services.

From Sri Lanka to the United States

The long days we spent ended quickly as we left the office at St. John's to return to our hotel for our flight that evening. Our five day stay provided a solid framework for our knowledge of the different relief and development projects occurring in Sri Lanka. Our meetings with the government officials, U.S.-based NGOs, and Sri Lankan NGOs allowed us to get a sense of the full spectrum of activities groups are taking in their efforts. It is clear also that Direct Relief benefits greatly from the hard, dedicated work of Ms. Fernando. Her focus and resolve is inspiring and with her ears and eyes in-country, she is able to assess and hone in on projects with high potential. We left Sri Lanka knowing we are in a fortunate position of having established relationships with incredibly motivated groups, and hopefully our support can help them better the situation for people in need.

Conclusion

Returning home from the 36 hour journey to Santa Barbara I had time to reflect on the trip and reoccurring experience stood out. In each country we visited, we met with incredible local people who were performing relief and reconstruction efforts under unimaginable circumstances. Their passion and devotion to the cause of improving their county, is the leading force to building a better future. These experiences are what drives Direct Relief's approach of identifying in-country health providers and organizations, and providing the necessary supplies and resources to effectively help communities in need. Direct Relief International is in a fortunate position, able to work with smart, ethical, and hard-working partners, and through their efforts; we can help create a healthier, better world.

Background

On December 26, 2004, the most powerful earthquake in 40 years registering 9.0 on the Richter scale occurred just off the coast of the Indonesian Island of Sumatra. It triggered a series of deadly tsunamis that radiated across the Indian Ocean, catching entire populations off-guard, sweeping through villages, towns, and cities, and leaving an unprecedented path of death and destruction in 14 countries. The massive devastation affected not only Indonesia, but regional countries such as Sri Lanka, Thailand, India and even Somalia, Kenya, and Tanzania on the eastern coast of Africa. More than 200,000 people are believed to have been killed in Indonesia alone, where entire villages were literally obliterated. The final death toll could surpass 300,000, considering the magnitude of the tragedy.  

India

In the tsunami-affected regions of South India, close to 11,000 people are confirmed dead. Nearly 600 relief camps have been established in the affected states of Tamil Nadu, Kerala, and Andhra Pradesh, and have been sheltering hundreds of thousands of people who lost their homes and belongings in the tsunami. The nation’s remote islands of Andaman and Nicobar, located in the Bay of Bengal, were hardest hit by the disaster. More than 1,300 people are now known to have died on this island chain and a further 5,600 people are still missing. As it is in other affected countries, the need for ongoing and advanced medical assistance is strongest in remote areas.

Direct Relief History in India

Direct Relief has provided medical assistance to charitable healthcare facilities and programs and responded to natural disasters in India for 45 years. Direct Relief is registered under the Indo-U.S. Bilateral Agreement concerning humanitarian aid, which permits duty-free importation of medical goods into India. Direct Relief has been approved under this agreement for 25 years, during which time we have provided over $40 million in material aid (wholesale value) to support healthcare services in dozens of locations in India. This strong history and presence in India facilitated our rapid response to the disaster and emergency medical needs in the tsunami-affected areas of the country. In the first thirteen weeks following the tsunami, Direct Relief has supplied more than 25 tons of emergency medical material to support clinics, hospitals, camps housing internally displaced people, and health projects serving people in the southern coastal areas damaged by the tsunami.  

Relief Overview

Many of the in-country medical institutions and local service agencies sent out medical teams, deployed their facility vehicles such as ambulances and mobile medical vans, distributed food, nutritional products, and shelter and living supplies, and cared for seriously injured survivors. Direct Relief's donations of medicines, first aid, surgical and general hospital and clinic supplies, nutritional supplements, and basic diagnostic equipment all supported these immediate and intermediate-term efforts. These products, which are still being used to provide medical services throughout the area, were adequate to treat over 700,000 patients.

In addition to providing emergency medical material, Direct Relief has partnered with in-country health facilities through cash support of over $98,000. $20,000 was spent in the immediate aftermath of the tsunami to buy nutritional items for displaced persons. Our ability to provide cash grants to local facilities and organizations is also making a huge impact on the availability and quality of healthcare services. Direct Relief has funded medical camps in a number of fishing villages which has helped to ensure that people who need continued medical attention are receiving it, and that medical issues resulting from crowded living conditions and poor diets are adequately addressed.

Direct Relief has also purchased fully equipped ambulances and mobile medical vans that can be used to transport patients and to travel from village to village to provide services – especially to villages that are extremely remote and only reached via very rough roads. In addition, we are finalizing the funding for the construction of community health and welfare centers in Tamil Nadu and primary healthcare centers and subcenters in the Andaman and Nicobar Islands, which will help rebuild and improve the healthcare infrastructure.

Assessment/Evaluation Trip

I recently returned from an assessment trip to India where I spent two weeks traveling in the tsunami-affected states of Tamil Nadu and Kerala, and the Union Territories of Pondicherry and the Andaman and Nicobar Islands. In Tamil Nadu and Kerala, I visited a number of Direct Relief-supported healthcare institutions and organizations that provided emergency services to the tsunami-affected areas. I met with facility and program health providers and administrators to evaluate their response activities and use of donated medical goods, and to develop both near and long-term plans for assistance.  

I also had the opportunity to meet with government officials in New Delhi and Port Blair (Andaman and Nicobar Islands), including Mr. K.S. Sidhu, who was recently appointed by the Prime Minister to be the Chief Coordinator of India’s Tsunami Rehabilitation Program. Mr. Sidhu requested that Direct Relief continue to provide needed material assistance and focus its financial support on helping to rebuild the primary healthcare infrastructure in the most affected regions of the country.

At the request of Mr. Sidhu and local health officials, I traveled to the Andaman and Nicobar Islands, Indian Union Territories located in the Bay of Bengal roughly 700 miles from Calcutta that were particularly hard-hit by the tsunami. While in the capital city of Port Blair, I met with the Director of Health for the Andaman and Nicobar Islands, the Chief Engineer at the Andaman Public Works Department, and the Secretary to the Lieutenant Governor, and offered Direct Relief’s assistance to rebuild medical facilities that had been completely destroyed.

Our Partners: Madhar Nala Thondu Niruvanam
Cuddalore District, Tamil Nadu

Madhar Nala Thondu Niruvanam (MNTN) was established in 1981 to assess and improve the living conditions of rural women in the District of Cuddalore, Tamil Nadu. The organization’s program work focuses on the economic and social empowerment of impoverished women through “self-help” groups meant to foster income generating activities. There are currently over 1,200 self-help groups with over 22,000 members. MNTN also provides community-based health care as well as nutrition and maternal health education. In recent years, the organization has expanded its services to include free medical camps for underprivileged Cuddalore women, including cataract surgery camps, and mobile medicare units and housing for elderly or homeless women. The self-help groups, in combination with the more formal medical camps, aim to improve the health and raise their standard of living of impoverished women.  

MNTN administers three residential facilities, including a home for elderly and destitute women, a short-stay home for victims of domestic violence, and an orphanage. These facilities are all built on a three-acre plot of land that was given to the organization by the District Collector. The residents tend a large garden and orchard on the property which furnish a significant percentage of their daily food needs. As these facilities are located on the top of a hill, villagers living along the coast who lost their homes in the tsunami were immediately offered shelter. Over 3,500 people were cared for at these residences before moving to government relief camps.

There were 55 villages in Cuddalore that were affected by the tsunami. Approximately 90 percent of the people in these villages make their living by fishing with the remaining 10 percent working in fields located close to the coast. With so many fishing boats and nets destroyed, and with much of the agricultural land saturated with salt and rendered unusable, villagers are at risk for malnutrition and specific micronutrient deficiencies. In an effort to address the shortage of protein, calories, and nutrients that could lead to serious health problems, MNTN distributed a large percentage of the protein biscuits, powdered milk, baby food, and other nutritional products that Direct Relief procured in India.  

Additional tsunami response activity has concentrated on the treatment of injury and illness and the prevention of infection through medical camps which have been conducted in 14 villages in the affected coastal regions of Cuddalore, Kurijipadi, and Parangipettai. In addition, MNTN has established 20 centers for psycho-social counseling for children and has assisted with improving sanitation in affected villages.

MNTN was identified by Direct Relief’s India In-Country Coordinator, Mr. Seshadri Iyer. On his recommendation, Direct Relief helped to fund MNTN’s medical camps held in the months of January, February, and March. The organization has now submitted a tsunami response proposal requesting funds to build two community health centers in locations central to affected villages, purchase one medical mobile van, and continue the operation of weekly medical camps for a period of four months. The health centers would offer accessible health care for villages living along the coast, and MNTN estimates that a total of 16,000 people will be treated or served by the new health centers in the period of one year.  

When I visited the organization, I reviewed their activities with staff and volunteers in their Cuddalore office, toured their residential facilities, and visited the communities chosen as sites for the proposed health centers. MNTN already has a presence and an excellent reputation in the tsunami-affected districts of Cuddalore, and the staff and volunteers are doing a terrific job responding to the specific needs created by the tsunami.

Our Partners: Vishranthi Charitable Trust
Chennai, Tamil Nadu

The Vishranthi Charitable Trust, located in Chennai, was established by Mrs. Savitri Vaithi in 1978 with the mission of providing food, shelter, and health care to impoverished women in their old age. The Trust administers both a residential home and a skilled nursing facility, providing lodging and medical care to over 100 women with a focus on caring for the elderly street population, especially those afflicted with dementia, Alzheimer’s, or amnesia. Recently, the Trust’s activities have expanded to include the provision of health care for orphans. The Trust’s activities are financed by and overseen by a board of nine trustees with ties to the Monday Charity Club, an umbrella organization of charitable institutions.  

The Vishranthi Charitable Trust was identified and comes highly recommended by Mr. Seshadri Iyer, Direct Relief’s In-country Coordinator for India. The Trust helped to purchase and distribute nutritional products such as milk powder and baby food, purchased with Direct Relief’s initial disbursement of procurement funds, to a number of tsunami-affected villages including those on Pulicat Island.

Pulicat Island is located 60 kilometers north of Chennai and is surrounded by ocean and salt water rivers. Pulicat has a population of approximately 30,000 which is comprised predominantly of fishermen who belong to the traditional marine fishing caste called Pattanavan. There are no healthcare facilities located on the island and people in need of medical services must travel by boat to the mainland. A number of island residents were killed by the tsunami, there were numerous injuries, many homes were destroyed, and over one-half of all of the fishing boats and nets were lost or damaged. Vishranthi Trust was the only organization that provided food, nutritional products, cooking utensils, and shelter materials to the island’s residents. The President of Lighthouse Village, one of the many villages on the island, approached the Trust and requested assistance to build a community health and welfare center which would provide healthcare education and services, including psychological counseling, to thirteen of the island’s villages.
 
In response to the request from Lighthouse Village, the Vishranthi Charitable Trust has requested funds from Direct Relief to construct and operate a health and welfare center in Pulicat. The proposed community center will include a medical clinic as well as a child care center, and space for health education classes and women’s self-help groups to meet. The center would be staffed full time by a healthcare worker, and both a physician and a nurse would be employed half-days, six days per week.  

During my trip to India, I visited the Vishranthi Charitable Trust’s residential facilities in Chennai as well as the Lighthouse Village on Pulicat Island. The land for the proposed center had already been allocated by the village and the blueprint and cost estimate had been completed by the engineer that Vishranthi had used for their skilled nursing facility. I was impressed with the emergency response activities of the Trust as well as the commitment of both the Trust and the villagers to making basic medical care more accessible.

Our Partners: Hindu Mission Hospital
Tambaram, Tamil Nadu
 
The Hindu Mission Hospital, located in Tambaram on the outskirts of Chennai, has been in operation for 22 years. Its main facility is a 160-bed multidisciplinary hospital housed in a 66,000 square foot compound. The hospital’s 60 physicians and 220 medical staff treat over 800 patients daily. For impoverished populations in need of medical attention, Hindu Mission hospital offers, onsite and free of charge, surgeries, medicines, artificial limbs, kidney care, annual check-ups, eye care, and follow-up medical care. Hindu Mission Hospital physicians and medical staff operate two mobile medical clinics that regularly visit villages around Tambaram to treat patients and dispense medicines. The hospital’s mission, both in its onsite work and outreach activities, is to provide medical care to impoverished populations free of charge and without regard to caste, creed, religion or social status.  

Following the tsunami, physicians and medical personnel from Hindu Mission Hospital visited 40 tsunami-affected villages, many several times, to offer emergency medical care to survivors. In support of these efforts, Direct Relief donated medications, medical supplies, and medical equipment items for use both at the hospital and in their outreach programs. I traveled to a number of the Hindu Mission Hospital-supported fishing villages in Kanchipuram District, Tamil Nadu, with Mr. Srinivasan, the director of the facility.

The hospital has been conducting medical outreach camps in Kanchipuram for years and was holding a medical camp on the morning of December 26 when the tsunami struck. Although they lost their medical supplies and equipment, the staff members were all able to reach higher ground and were on hand to help the injured. Numerous trauma cases were transported back to the hospital for emergency treatment, and the Hindu Mission Hospital became one of the major referral hospitals for tsunami trauma cases. During my tour of the hospital’s operating rooms, a number of surgeons and surgical nurses explained how important Direct Relief’s donation of respiratory, orthopedic, and general surgical supplies had been to the hospital since they treated so many seriously injured patients with many requiring multiple procedures.  

As the need for transporting so many injured and ill patients to and from the hospital became apparent, the Hindu Mission Hospital contacted Direct Relief with a request to cover the purchase and operating costs of an ambulance. When visiting the facility, I had the honor of handing over the keys to their new vehicle, which is equipped with both purchased and Direct Relief-donated emergency equipment and supplies.
In the coming months the facility’s tsunami response efforts will focus on two major areas. The hospital plans to assist survivors who have become disabled as a result of tsunami-related injuries. Specifically, those who have lost limbs will receive needed surgeries, be fitted with artificial limbs, and provided needed follow-up care and counseling. The paramedic team has begun to visit coastal villages to identify those who have lost limbs or have incurred other major orthopedic or spinal cord injuries.  

In addition, the Hindu Mission Hospital will continue to conduct the mobile medical camps which provide free services to coastal communities on a weekly basis. Direct Relief has helped to cover the costs of these camps and will continue to fund them through the end of July.

Our Partners: Meenakshi Mission Hospital
Madurai, Tamil Nadu
 
The Meenakshi Mission Hospital and Research Centre (MMHRC) is a 500-bed non-profit hospital and medical research center located in Madurai near the famous Shri Meenakshi Temple. Dating as far back as 1600 B.C., the Meenakshi Temple is heralded for its extensive array of ornate towers and statues built for various idols, festivals, and military battles.  

The MMHCR has been in operation since 1986, serving the low-income and indigent population of Madurai and the Southern Tamil Nadu region through its 46 specialized medical departments. Its mission includes the combining of state of the art medical service with social work and community outreach, with a specific focus on primary health care, preventive health care, and women’s and children’s health. The hospital provides a wide variety of services, and since its inception, has treated hundreds of thousands of patients. Notable activities have included AIDS prevention research under the umbrella of the AIDS Prevention and Control Project – aimed at successful policymaking in the effort to combat the spread of the disease, and the Save the Children Club, which has provided free surgery for children with heart diseases. In addition to the activities of the main hospital, MMHCR operates seven community subcenters that provide villagers in more rural areas with primary and secondary level medical services.

In response to the tsunami, MMHCR provided emergency relief in numerous ways including implementing a tetanus vaccination campaign throughout the affected areas of Tamil Nadu, conducting medical camps, providing medicines and first aid supplies as well as food, clothing, and blankets, and providing assistance with community reconstruction.
Direct Relief’s donation of pharmaceuticals, nutritional products, and medical supply items reaches MMHCR just in time to restock their mobile units headed to the coast. In addition, Direct Relief funded the purchase of a mobile van which was designed to handle rugged road conditions and is currently traveling north and south along the coast providing medical services to numerous fishing villages and relief camps.

Our Partners: Amrita Institute of Medical Sciences and Research Centre
Cochin and Kollam District, Kerala
 
The Amrita Institute of Medical Sciences & Research Centre (AIMS), located in Cochin, Kerala State, is a multi-specialty, charitable non-profit medical center that provides healthcare services to thousands of low-income and indigent patients. The 800-bed facility was established in 1998, and in its six years of operation, has treated over 57,000 inpatients and more than 590,000 outpatients. In addition to its onsite activities, AIMS is acclaimed for providing free or low-cost community-based health programs, general medical and ophthalmic outreach camps, health awareness campaigns, and other medical services to people living throughout the city of Cochin and those residing in remote areas of the state. In the aftermath of the tsunami, AIMS deployed teams of medical personnel and a number of ambulances, serving as mobile surgical units, to the hardest hit coastal areas in Kerala and Tamil Nadu.  

A 24-hour medical center was set up on Vypeen Island to provide care to hundreds of villagers, with the most serious trauma cases transferred to the hospital. Relief efforts continued round-the-clock, with AIMS taking full responsibility for the medical needs of over 50,000 affected individuals.
 
This institution has received over 22,000 lbs. of medicines, nutritional products, medical supplies, and diagnostic equipment from Direct Relief for use in its extensive tsunami response efforts. Medical Director Dr. Prem Nair explained how important this infusion of material has been for the facility since they hospital staff had responded immediately to treat the injured throughout the affected areas in Kerala, and in Nagappatinam, the hardest hit district in southern Tamil Nadu, and had exhausted their stock of supplies.

The Amrita Kripa Hospital is an AIMS satellite facility located approximately 100 kilometers north of Cochin in the district of Kollam. This district, and especially the peninsula situated between the Arabian Sea on the system of backwater rivers, was particularly hard hit by the tsunami which crossed the peninsula, traveled over the backwater area, and onto the mainland. The hospital serves the coastal villages and the 2,600 residents of Amritapuri, including 1,200 computer and engineering students that live in hostels. The hospital has an emergency room equipped for cardiac arrests, asthma attacks, and other basic emergency procedures, and a small lab for blood and urine tests.  
 
Due to its proximity to the water, the first floor of the Amrita Kripa Hospital was flooded by the tsunami and all of the in-patients at the facility had to be evacuated. All of the hospital staff, however, was on hand to treat people who needed emergency medical attention. Patients who had serious medical needs due to trauma or near drowning incidents were transferred to AIMS for treatment.

With so many villages in the areas affected by the tsunami, and so many homes damaged or destroyed, both government and AIMS relief camps were established. Over 10,000 people were relocated to temporary housing in relief camps set up throughout the area where in additional to shelter they have been receiving nourishing meals and free medical care. Each relief camp is staffed by a medical officer from the Amrita Kripa Hospital who provides on-site consultations and treatment with the use of Direct Relief-donated medications and medical supplies. The Hospital also has a telemedicine system set up at both the hospital and one of the relief camps which allows healthcare providers attempting to make a difficult diagnosis to receive real time assistance from physicians at AIMS.

Our Partners: Bharatiya Jain Sanghatana
Andaman and Nicobar Islands

I also traveled to Andaman and Nicobar Islands which are a chain of 572 islands stretching over 500 miles in the Indian Ocean. This island chain, one of India’s Union Territories since 1947, is located in the Bay of Bengal between India and Myanmar, roughly 700 miles from Calcutta. Marco Polo is said to have been the first official visitor to the islands. Comprised of a hilly topography and heavy rainforests, 99.8 percent of the land is considered rural. The 36 inhabited islands have a population of approximately 370,000.  

The islands, especially the Nicobar Islands, which are comprised of a number of the southern archipelagos, were hit particularly hard by the tsunami due their close proximity to the earthquake epicenter. Great Nicobar, the southern most island, is located less than 100 miles from the epicenter. Close to 7,000 residents of the Islands are confirmed dead or missing.

One of the most devastating effects of this disaster has been the near-extinction of specific tribal groups.The Andamanese are the aboriginal inhabitants of the islands. There are twelve distinct tribes, each with its own clearly-defined locality, dialect, and traditions. These tribes have been living on the islands for thousands of years with little contact with the outside world. Few, if any, other living human populations have experienced such long-lasting isolation. Due to the tsunami, 150 of the previously remaining 389 members of the Shompen tribe are missing and presumed dead.  

Around 40,000 survivors continue to live in the 150 aid camps scattered across the islands. Relief efforts have been slow due to lack of road infrastructure, lack of cargo space, poor medical infrastructure, and lengthy ferry journeys required to deliver supplies. Many of the islands have sunk between one and two meters, leaving homes and coconut plantations under water. Much of the land that has not been submerged is saturated in salt, making it useless for agriculture.

In collaboration with Bharatiya Jain Sanghatana (BJS), an Indian NGO that we have worked with in past disaster situations, Direct Relief has received approval from the Indian Government Planning Commission, local government officials, and the tribal council for the Andaman and Nicobar Islands, to construct 30 primary healthcare subcenters to replace the ones that were completely destroyed by the tsunami. One will be located in Andaman, and 29 will be scattered throughout the islands of Nicobar. The islands selected are very remote and difficult to reach with construction materials and equipment, making them an extremely challenging place to rebuild. Direct Relief is fortunate to be working with Bharatiya Jain Sanghatana, an organization that specializes in construction following disasters.

Established in 1985, Bharatiya Jain Sanghatana (BJS) is a charitable Indian organization headquartered in Pune. Founded by Mr. Shantilal Muttha, its goal is to improve socioeconomic progress in India through improvements in education. BJS specializes in the reconstruction of schools and orphanages in the wake of natural disasters. BJS has responded to the earthquake disasters of Latur (1993), Jabalpur (1995), and Gujarat (2001). In addition, BJS runs an educational development program with a focus on developing marketable job skills and extracurricular activities for students and provides student and teacher support.

BJS focused their initial tsunami response efforts on providing food and shelter relief in six camps in Tamil Nadu. They have also received approval and have already started rebuilding 20 schools that were destroyed by the tsunami in the Andaman Islands. The primary care subcenters, funded by Direct Relief, will be expanded in size in order to accommodate the living quarters for a trained nurse/midwife. For the first time, a health provider will be available full time to care for and treat islanders who may otherwise have no access to medical services. A physician, traveling by boat or helicopter, will also visit each subcenter on a weekly basis.

Direct Relief is very excited to be such a vital partner in a project that will rebuild the local infrastructure and provide critically needed healthcare services to a very distinct population for years to come.

Conclusion

Whenever I travel, especially after a major disaster, it is extremely difficult, and often discouraging, to see people struggling against such adverse circumstances. So many people in this world have to walk a tight rope daily, and it is a delicate balance between hope and despair. While witnessing these conditions can be disheartening, traveling as a representative of Direct Relief and knowing that this organization can make a meaningful difference in people’s lives, is very uplifting. By supporting emergency workers and healthcare providers in hospitals, clinics, and health projects, and in the case of the tsunami being able to provide funds to purchase medical vehicles and construct health facilities, millions of people will receive medical care that would otherwise not be available. Direct Relief will continue its commitment to improve the quality and availability of healthcare services for the communities affected by the tsunami, in India and throughout the region.

[Photographs by: Jay Farbman, Seshadri Iyer. Courtesy of Mata Amritanandamayi Math (selected)]

Within a week of the tsunami disaster that struck Southeast Asia and Indonesia on December 26th, Direct Relief International began sending specifically-requested medical supplies to local health organizations. Our aim is to strengthen local health and rebuilding efforts through the provision of medical supplies and cash grants.

Photo: Kelly Darnell Galle, southwest Sri Lanka

While there are scores of international relief organizations providing a tremendous amount of assistance to Sri Lanka, a story that seemed somewhat absent from global media has been the role of the Sri Lankan people themselves in the relief effort. In fact, in the days and weeks after the tsunami, the majority of the relief effort came from the Sri Lankan people who rapidly mobilized to mitigate the impact of the disaster.
 

Photo: Yonathan Weitzman

Our Partners: Sarvodaya

After 31 hours of traveling, and a few hours of rest, we met with our first new partner, an organization called Sarvodaya. Founded in 1958 by a small group of medical providers and community members, Sarvodaya is one of the oldest and largest Sri Lankan-run NGOs in the country. Typically, Sarvodaya’s 1,000 employees work in all nine provinces of Sri Lanka providing everything from reproductive health and nutrition education, to constructing latrines at public schools, and running orphanages. Today, the organization is directed by Dr. Vinya Ariyaratne, a medical doctor with an MPH from Johns Hopkins, and the son of one of the original founders.

Photo: Kelly Darnell Dr. Vinya Ariyaratne, New Jersey Senator Jon G. Corzine, and Direct Relief staff meet in Colombo to discuss medical supply needs in the region

We visited Sarvodaya’s busy headquarters outside of Colombo where we met with Dr. Vinya and his staff. We were told we had arrived at a good time. After weeks of working around the clock in response to the tsunami, they had finally had at least one good night of sleep.

In their newly created disaster operations center, staff and volunteers manned ringing phones, entered donated product into computers, and responded to hundreds of email inquiries.

In the weeks since the disaster, DRI has provided Sarvodaya with items such as band-aids, gauze, aspirin, cough and cold medicine, soap, and sanitary napkins which are then distributed to the camps. Due to the influx of donated products, Sarvodaya set up a temporary warehouse in the meeting hall of their headquarters. Here we found stacks of supplies filling the room and a half dozen volunteers organizing items into like categories of cooking pots, nonperishable food, water bottles, first aid, hygiene supplies, etc.

On the road to Galle - Sarvodaya

Photo: Kelly Darnell Bangladesh Medical Corps treating children in Sarvodaya IDP (internally displaced persons) camp, Galle

Looking closer, we could see baby clothes, family pictures, broken Buddha statues, and cooking utensils— bits and pieces of peoples lives lodged in the debris. A few houses were still standing, but most had at least been cut in half. We occasionally saw families that had forgone moving into an IDP camp, instead making a shelter out of scavenged metal, wood, and plastic.

We heard that although many of the families were staying in IDP camps at night, every morning they made their way back to the place where their home stood. Many feared losing their land because few people were able to salvage legal documentation proving ownership. I wondered if they also just needed to return home. Some survivors scavenged and piled tiles and bricks from their home. Others cleared debris using their hands or small shovels. Groups of children watched US Marines clearing debris by hand along the road. Many elderly sat forlornly in plastic chairs on what was left of their homes.
 

Photo: Yonathan Weitzman Sarvodaya IDP camp, Galle

On that day, a medical unit from the Bangladesh army was providing basic medical services at one of the camps. Most people appeared to have minor cuts that needed cleaning and re-dressing, while others complained of colds and body aches.

The accommodations were basic and crowded, but clean. Fortunately, none of the feared outbreaks of diarrheal illnesses had occurred.

I spoke to several women at both camps—each said they were receiving enough food and medical supplies, but all were anxious to hear news of when their homes might be rebuilt and if the government was going to impose a 100 meter no building buffer zone along the ocean front.

We left Sarvodaya with a commitment to continue to provide support to the IDP camps in the form of medical and personal care supplies. We also pledged to purchase mosquito nets for camp refugees, which were desperately needed but could no longer be found in the country.

Our Partners: Galle Medical Association

After leaving the IDP camps, we met with the Galle Medical Association (GMA), which is made up of nine physicians and surgeons from the Galle Teaching Hospital. They related what happened on December 26th in Galle, the fourth largest city in Sri Lanka and one of the hardest hit.

They said the first wave hit at around 9:30 in the morning. People inland saw the rivers rising and thought there was going to be a flood, so they moved toward the ocean. People living near the ocean ran inland shouting that the ocean was coming.

Many of those closer to the ocean were searching for family members when the second wave hit at 10:30 AM. Most of the people hit and injured by the first wave, drowned in the second. As such, the majority of cases rushed to the teaching hospital were minor trauma injuries, such as bad cuts and broken arms, as well as near-drowning cases.

The teaching hospital also had to absorb the patients evacuated from Galle’s other government hospital which sits directly across from the ocean. Despite being in the path of the tsunami, the hospital was able to save all but one of the newborn babies, and most of the staff and patients made it out alive.

Photo: Kelly Darnell
The destroyed delivery ward at Galle Hospital

Walking through the hospital, it was obvious that it was abandoned in a panic. The delivery ward was strewn with baby cribs and beds. In the corner stood a pile of incubators, gloves, nurses shoes, and medical supplies forced together by water into a disturbing conglomeration. In the weeks after the tsunami, Direct Relief provided the Ministry of Health with surgical supplies, first aid supplies and antibiotics to be distributed to the operational hospitals on the front line, such as the Galle Teaching Hospital.
 
Like many other grassroots efforts throughout the country, the members of GMA mobilized to provide assistance. Their mission is to provide funding to the medical staff whose homes were not completely destroyed and will not qualify for government assistance. It started with one nurse whose roof, furniture, and cooking utensils had been swept away. They soon found out that this had happened to many of the staff at the hospital. Their goal is to provide cash grants to these families over the next six months. Although cash grants are atypical for Direct Relief, this disaster has called on all relief organizations to find new ways of getting assistance to the thousands of people affected. We left the members of GMA with an offer to help.

Our Partners: St. Johns Ambulance Brigade

Next, we met with the St. John’s Ambulance Brigade (SJAB) of Sri Lanka. SJAB will be celebrating 100 years of service in 2006. This predominately volunteer-run organization provides first aid and CPR training around the country through a number of SJAB community centers. Last year alone, they trained over 10,000 people. In response to the tsunami, SJAB volunteers helped retrieve bodies, provided first aid to the injured, and transported victims to nearby hospitals. After the emergency phase, they started providing first aid in the camps as well. Unfortunately, SJAB only had three ambulances at the time of the disaster, one of which was 25 years old.  

During our meeting with the board of SJAB, which is mostly made up of physicians and community leaders, they discussed their need for more ambulances and trained paramedics in all coastal regions. Although it would not do much to help with the recent disaster, it would better prepare communities in the event of future disasters. We left with a commitment to provide SJAB with at least two new ambulances and first aid supplies. We also discussed the possibility of providing funding for paramedic/EMT training, and essential training materials in the future.

Our Partners: Ministry of Health

Although not a wealthy country, Sri Lanka boasts a very organized and reasonably well-equipped health structure that serves the island’s estimated 20 million people. The average life expectancy is relatively high at 67 years for men and 74 years for women, and child mortality is considered low with 18 deaths per 1,000. What is more, unlike many of its neighbors, close to 100 percent of women in Sri Lanka have access to pre and post natal care through a national network of no cost hospitals and clinics run by the Sri Lanka Ministry of Health (MOH). After the tsunami, the MOH was the primary agency responsible for rushing medical supplies to health facilities in affected areas.

We were told that upon arrival at the airport, all items consigned to the MOH are brought to their central stores in Colombo within 2-3 days. Here they are sorted by product type, with antibiotics going into their own temperature controlled environment, first aid supplies in another, etc. At the warehouse they were running two 12 hour shifts to keep up with the volume of incoming and outgoing medical supplies. About a half dozen people spent their entire shift just entering items into their computer inventory system. During our tour, we located our initial six pallets sent via air freight.

Photo: Kelly Darnell Direct Relief International FedEx shipment at Colombo Airport

The shipments included antibiotics, suction catheters, minor surgical procedure kits, and first aid supplies. During our visit to Sri Lanka, we met with representatives from the MOH at their central warehouse where we were given a tour and an overview of their procedures from handling the large volume of donations coming in from abroad.

Later that day we were escorted by MOH staff to the Colombo airport to find our second air freight shipment. At the airport, US Marines were working along side airport staff to unload and sort the daily plane loads of donated product. Two partially built airport hangers were being used to house the donations from around the world that included food, bottled water, tents, and medical supplies. Here, we found our newly arrived second airfreight shipment in good condition, and getting ready to be transported to the MOH warehouse. The MOH expresses their gratitude for the medical supplies donated by Direct Relief. We left the MOH with a promise to continue to look for ways we might be able to assist their efforts to restore the medical infrastructure in the country.

Conclusion

Photo: Yonathan Weitzman

It was an honor to meet our new local partners. Each is working hard to help their country move forward and the people left rebuild and return to normal healthy lives.

[Photos in the Sri Lanka Trip Report by: Kelly Darnell, Yonathan Weitzman, Jodie Willard. Photographs may not be distributed or reproduced without explicit written permission from the photographer.]

Each year an estimated 2,500-3,000 Tibetans travel by foot over the Himalayan mountains in an effort to reach India, home to a large Tibetan exile community and to the Tibetan spiritual leader, the Dalai Lama. Most are fleeing human rights abuses, religious persecution, or political repression at the hands of the Chinese authorities in Tibet.  

The long and arduous journey to the Nepalese border, the most direct and commonly used route, can take from one to four months depending on the weather and the point of departure - many of the asylum seekers are from Kham and Amdo, Tibet's northern and eastern provinces which significantly increases the distance.

They must travel through numerous mountain passes, often in waist-deep snow, where shelter, food, and water are scarce. Frostbite, snow blindness, injury, and malnutrition are common and many children and adults die during this perilous trip.

In the early 1990's, the Tibetan government-in-exile purchased a five-acre property on the outskirts of Kathmandu. In consultation with the United Nations High Commissioner for Refugees (UNHCR), the Tibetan Refugee Reception Center was built to assist new arrivals with shelter, food, and medical and psycho-social services.

In order to improve their nutritional status, recuperate from travel-related injuries or amputations due to frostbite, and receive psychological counseling, many of the Tibetans stay at the Center for up to four months before setting out for India, or if staying in Nepal, before finding other lodging and employment. In addition, due to more stringent requirements by the Indian government requiring entry into the country for Tibetans, there is a significant backlog in processing travel documents for new arrivals. As a result, up to 1,100 Tibetans - three times the facility capacity - must often be accommodated at the Center at one time. These crowded conditions can create additional health risks for people already weakened from a grueling journey through the mountains.  

Throughout the 1990's Nepalese authorities generally permitted Tibetans to enter the country and would assist or direct them to the Reception Center. In more recent years, however, due to pressure from the Chinese government, Nepal's attitude regarding Tibetans entering the country has changed.

Tibetan escapees, including young children, who do not have proper documentation when crossing the border are now often detained by the Nepalese police or immigration officers and either deported or handed over to the Chinese authorities. Others are robbed, sexually harassed, or forced to pay bribes while traveling between the border and Kathmandu. The UNHCR has investigated the cases of a number of detainees and continues to urge the Nepalese government to allow Tibetans safe passage into or through the country.

Direct Relief has been providing assistance to the Tibetan refugee population in India since 1960 soon after the arrival of the Dalai Lama who was forced to flee Tibet in 1959. Over the years, Direct Relief has supplied over $3 million of medical goods to the Tibetan Department of Health and directly to hospitals, clinics, and health programs in refugee settlements located throughout India and Nepal. During my recent trip to Nepal, I accompanied a shipment of primary healthcare medicines, first aid and clinic medical supplies, and diagnostic equipment to the medical clinic at the Tibetan Refugee Reception Center. The 30-bed in-patient facility is administered by the Center and is staffed mainly by Tibetan nurses and volunteer physicians from Europe, Australia, and the U.S.

When I arrived, I saw that every bed was occupied, some with more than one patient, and a chicken pox outbreak was taking its toll on a large percentage of both children and adults at the Center. In addition, due to the use of contaminated water supplied through the Kathmandu water system, a number of Tibetans had contracted cholera and needed to be taken to a public hospital for treatment.

Direct Relief's donation, which consisted of items such as antiparasitic agents, adult and pediatric antibiotics, ophthalmic agents, antihistamines, dermatological ointments, disinfectants, nutritional supplements, a blood pressure kit, and an oto-ophthalmoscope was received by Tsering Gyalpo, a volunteer medical student, and the clinic's head nurse. They were particularly appreciative of the antibiotics used to treat acute respiratory infections, the ophthalmic anti-infectives needed to heal corneal burns caused by snow blindness, and the antihistamines which would help to alleviate the intense itching for patients with chicken pox. The products included in the donation will help stock the clinic with medications and disposable supplies for approximately six months as well as provide essential diagnostic tools needed to check new arrivals and screen residents for serious health problems.

Namaste

The Indian greeting performed by placing both of the palms together and raising them below one's face, is a wonderful gesture of humility, peace, and welcome. I always feel welcome when I travel to India due to the extraordinary warmth and hospitality I receive from Direct Relief's partners. This was certainly true in January when my husband and I were hosted by the Diwaliben Mohanlal Charitable Trust, which had selected me to receive a humanitarian award.

The Diwaliben Trust was established in 1970 by Mr. Mafatlal Mehta in memory of his mother, Diwaliben, who raised him and his sister alone after losing her husband at a young age. The Trust's principal activities include importing and distributing food, medical goods, clothing, and other relief materials to health care sites, social service facilities, and disaster areas. It also provides financial assistance to construct and operate hospitals, clinics, maternity homes, schools, long-term care residences, medical and surgical camps, and makes grants for international fellowships for physicians in specialized medical fields.

In 1993, Mr. Mehta decided to recognize individuals who were working to improve the quality of life and reduce suffering for disadvantaged populations by giving annual awards for excellence in various areas of service. A jury committee, chaired by Justice P. N. Bhagwati (former Chief Justice of the Supreme Court of India and currently Vice Chairman of the U.N. Human Rights Committee), was formed to select the award recipients. It was a tremendous honor for me to receive this award, which previously had been given to many dedicated humanitarians including Nobel laureates such as the Dalai Lama and Albert Schweitzer.

The ceremony, held on January 21 at the Nehru Centre Auditorium in Mumbai, was lovely and gave me the opportunity to meet the other award recipients, all of whom were extraordinary individuals. I was inspired simply by being there with people of such incredible compassion who had taken action to improve the lives of others. The award I received is really a reflection of what Direct Relief has been able to accomplish in India over the past 40 years, and I therefore share it with all past and present Direct Relief staff, volunteers, and supporters.

One of the other award recipients was Dr. Armida Fernandez, a neonatologist who had resigned her position as the dean of a large municipal hospital in Bombay to establish SNEHA (Society for Nutrition, Education and Health Action for Women and Children), a nongovernmental organization located in the heart of the Dharavi slum. The largest slum in Asia, Dharavi is home to an estimated million people. SNEHA's activities include operating a center for women and children in crisis. The center is committed to restoring the physical, emotional, and psychological health of victims of domestic violence, providing medical services with a special focus on quality perinatal care, and offering health education, daycare for children of working women, vocational training workshops, income-generation programs, outreach activities for street children and adolescents, and a senior center. Some of the Direct Relief medicines, medical supplies, and diagnostic equipment items donated to the Diwaliben Trust have been passed on to SNEHA's medical programs. Dr. Fernandez took me on a tour of SNEHA's offices and programs, as well as some of Dharavi's neighborhoods where she spends an average of 15 hours a day. Although the word slum conjures up an environment of misery and the narrow garbage-strewn alleyways and overpopulated broken-down hutments, many without electricity, water, or sanitation, give one a feeling of deprivation and despair, I also observed incredible energy, joy, and ingenuity. SNEHA's comprehensive and holistic approach will greatly empower this disenfranchised population.

Whenever I travel to India, it is always extremely hard to see so many people struggling against such adverse circumstances. A large percentage of Indians walk a tightrope daily, and it is a delicate balance between hope and despair. While witnessing these conditions can be extremely disheartening, traveling as a representative of Direct Relief and knowing that we can make a meaningful difference in people's lives is very encouraging. Because Direct Relief supports healthcare providers in hospitals, clinics, and health projects across the country, thousands of people receive quality medical care that would otherwise not be available. For these individuals, and their families, this care means everything.

Working to improve the quality of life for people in India and around the world is Prasad, a Sanskrit word meaning a gift that carries blessings for both the giver and the receiver.

After a 33-hour trip from Los Angeles we arrived in Vientiane, the first stop on a three-week assessment trip. In Laos we visited two provincial hospitals and a pediatric residency program at the primary government hospital. We also met with two of Direct Relief's partner organizations: Health Frontiers, which coordinates a pediatric residency program, and a German organization called GTZ, which has been working in Laos for over 10 years. From Laos we traveled to Siem Reap, Cambodia, where we visited the Angkor Hospital for Children, and Mongkul Borey Hospital, a prospective rural hospital working to upgrade its pediatric department.

Laos
Of the countries in the former French Indochinese states, Laos is the least developed and often characterized as the most isolated. Maternal, infant, and under-five morbidity and mortality rates in Laos are among the highest in the region. Laotian children who live past age five suffer high rates of malnutrition, anemia, and malaria. Parasitic diseases, intestinal infections, and other communicable diseases (such as cholera and acute respiratory infections), contribute to one of the shortest life expectancies in the region.

Photographer: Kelly Darnell
Leila, Child, and Doctors at Mahosot Hospital

Our first site visit in Vientiane was to the 220-bed Mahosot Hospital, the primary government hospital in the country. The day we arrived, the hospital was crowded with children and their parents, many of whom had traveled days to reach the hospital. Until recently, there were only seven trained physicians to care for more than 2.5 million children in Laos. Mahosot is improving the skills of Lao physicians by working with a U.S. nongovernmental organization called Health Frontiers, which coordinates the country's first pediatric residency program. Direct Relief supports the program through various means, including, providing every student with a stethoscope, and blood pressure unit; equipping the pediatric department with necessary supplies; and giving each graduate a diagnostic set to take back with them to their communities.

Photographer: Bryan Watt
Nale Hospital

Leaving Mahosot, we drove three hours north to the mountain district of Nale, the poorest district in Laos and home to more than 35,000 people, most of whom are farmers. The region has high rates of infant and maternal mortality, and frequent outbreaks of cholera and malaria.

The 20-bed Nale Hospital provides primary care, immunizations, pre-and postnatal care, delivery services, and health education. On our second day in Nale, we traveled up-river to Ban Hadma, one of the 71 villages in Nale with a village health worker (VHW). The VHW's provide basic treatment for dehydration, malaria, anemia, and common colds, and refer villagers to the hospital for more serious conditions. The Nale Hospital trains and supplies the VHW's. Every three months stocks are replenished with alcohol, Betadine, scissors, bandages, quinine tablets, analgesics and oral rehydration salts.   

Photographer: Bryan Watt Kelly with Dr. Patsamone and a Patient at Nale Hospital

From Nale we drove farther north to the Chinese border and a hospital in the Muang Sing district. The community of Muang Sing has more than 30,000 people, 60 percent of whom are Aka, a Laotian tribe. Originally from China, the Aka immigrated to Laos and have historically lived in the mountain regions. Over the last decade, however, they have begun moving to lowland areas. Although the Aka now live near more civilized communities, they are still a geographically and culturally isolated people, making it difficult for them to adapt to the modern world.

The two head physicians and on-duty nursing staff met us at the Muang Sing Hospital. With several Aka women waiting to receive care, the staff acknowledged that communication and cultural barriers are a constant struggle. The hospital consists of three small wooden buildings facing a large empty lot. The inpatient ward is simply a small room with cement floors and 18 wooden beds. Most patients are treated for malaria, pneumonia, and diarrhea.

A month after our visit, Direct Relief's first shipment to Laos arrived and made the 30-hour journey to Nale and Muang Sing Hospitals.

Cambodia
Many of Cambodia's medical professionals were among the more than 2 million murdered under the Khmer Rouge regime; those who escaped came to the West, never to return. Thus, after 30 years of civil war and foreign occupation, Cambodia was virtually emptied of medical professionals and lacked a medical education system with qualified teachers and sufficient resources.
   
The Angkor Hospital for Children (AHC) in Siem Reap was founded in January 1999 by a Japanese-American photographer who wanted to help the children of northern Cambodia. The hospital's mission is to provide pediatric care and create a center for further education and clinical training of Cambodian medical professionals.

Photographer: Kelly Darnell Baby getting examined at Angkor Hospital for Children Community Outreach

Dr. Rathi Guhadasan, AHC's Medical Education Coordinator, and several staff took us three hours north of Siem Reap to visit Mongkul Borey Hospital. Mongkul Borey is a 240-bed provincial hospital serving an estimated population of more than 600,000. AHC is establishing a partnership with Mongkul Borey to upgrade and improve the pediatric department and its staff overall. AHC staff, recommended Mongkul Borey as a possible Direct Relief partner as well.

Mongkul Borey consists of a small surgical ward, inpatient and outpatient departments, tuberculosis ward, and pharmacy. The hospital's 25-bed maternity ward is staffed by nine trained midwives, a nurse-midwife and two surgeons. They attend 40 to 50 deliveries and perform about six Caesarian sections each month. The hospital also treats ovarian cysts, tumors, and ectopic pregnancies. During our visit we met with Pam Shepard, a VSO volunteer who is the hospital's management advisor. Ms. Shepard has been working at the hospital for more than a year and welcomed the possibility of creating partners with AHC and Direct Relief International.

Direct Relief's first shipment to AHC and the Mongkul Borey Hospital arrived in Cambodia in July 2003.

As the one year anniversary of the massive earthquake that hit the west coast state of Gujarat, India on January 26th, 2001 approached, I toured some of the hardest hit cities, towns and villages throughout the area. Great pain and sorrow was brought to this state which is known for its many celebrations as well as for its colorful nomadic tribes and forest dwellers. An extended visit to the Bidada Hospital in Kutch, allowed me to see first hand the extensive and on-going need for rehabilitation and other services for earthquake victims. The Bidada hospital, located only 50 km from the earthquake's epicenter, was one of only two hospitals left standing in the area. Its three operating theaters remained fully functional so doctors were able to treat patients sent to them from throughout Kutch. Physicians worked around the clock for 20 days in the immediate aftermath of the quake during which time many surgeries and amputations were performed.

It was heartbreaking to see so many earthquake related paraplegics and amputees, but I also saw an incredible resilience and optimism among patients who were determined to rebuild their lives despite the loss of family members and the occurrence of major life altering injuries. Physical and occupational therapy as well as artificial limb manufacturing and fitting are now major activities at the hospital. Plans for a significant expansion and upgrade of their rehabilitation department and training services were discussed and the particular needs that Direct Relief can help support were specified. With a dramatically increased patient load, the Bidada Hospital has also added other specialized services and has scheduled numerous medical camps in order to handle the thousands of patients requiring both trauma related and other health care services. A container of wheelchairs, orthopedic devices, surgical equipment and supplies, and other medical goods for Bidada Hospital arrived in Mumbai (Bombay) on January 26th and has now been delivered to the facility.

Children waiting for the semi-annual vitamin A distribution at a primary school in Vasai, Maharashtra (vitamin A distribution is done in collaboration with Vitamin Angel Alliance).

A variety of other health care, educational, and social service facilities, programs and organizations located in Gujarat were also visited during the trip. A special stop was made at the Rajkot Voluntary Blood Bank (RVBB). A long-term partner of Direct Relief, this excellent facility is the only blood bank in India that has been certified by the American Association of Blood Banks. The RVBB provided emergency services in the aftermath of the earthquake in addition to its ongoing charitable work of collecting and providing safe blood, creating awareness regarding the importance of blood donation, and screening for thalassaemia, a debilitating genetic blood disease prevalent in India. A special request had been made by this facility for assistance in obtaining a blood separation machine that divides whole blood into numerous components. This technology allows patients to receive only the blood components they need for their specific illness or condition and literally triples the number of patients that can receive blood donations. Through a grant from the i2 Foundation and other solicitation efforts, Direct Relief was able to raise funds to purchase this separation unit. On January 15, a day chosen as very auspicious for the event, a ceremony was held to celebrate the arrival and installation of this lifesaving equipment. The Sanskrit ritual, conducted by a Brahmin priest and attended by staff members, trustees and other volunteers and supporters of the facility, emphasized gratitude and a commitment to humanitarian aid.

In Mumbai, I met with the Diwaliben Mohanlal Mehta Charitable Trust which has distributed Direct Relief medical donations to health care institutions and programs throughout India for the past eight years. The Trust was Direct Relief's major partner for Gujarat earthquake relief efforts and their customs clearance experience, numerous warehouses and contacts throughout Gujarat made them the ideal organization to receive two emergency airlifts containing pain-relief medications, antibiotics, nutritional products and blankets, as well as first aid, surgical, and orthopedic supplies.

Direct Relief has provided aid to partner facilities and organizations in India since 1960. Our longstanding ties and our approved status under the Indo-U.S. Bilateral Agreement, allowing aid shipments to enter India on a duty-free basis, enables us to provide on-going assistance and respond quickly, effectively and on a large scale following any emergency situation. In the past six years, more than 150 shipments of medical supplies and equipment have been sent, valued at over $10 million.