Saturday, 20 August 2016 17:36

Medical Student Re-discovers Jaffna

by Gayathri Naganathan in Scarborough

I was born at the Vavuniya General Hospital in the winter of 1988, in a town that is often referred to as the gateway to the northern Vanni region. As so many other families before us, we fled Sri Lanka during the civil war, amid death, destruction and uncertainty.

We arrived in Scarborough, Canada, in the early 90’s, in what would become the single largest Sri Lankan Tamil diaspora community outside of South Asia. I grew up speaking Tanglish (a blend of Tamil and English), eating string hoppers and spaghetti, and listening to A.R. Rahman and the Backstreet Boys.

In short, I am a ‘third culture’ kid, a blend of the home we left behind in Jaffna and the home we worked hard to create in Canada. So as a Canadian medical student when I was presented with the opportunity to spend several weeks training in any field and in any country around the world, the natural choice for me was to go “back home”.

Having spent over two decades away, I didn’t quite know what “back home” would mean on this first visit back. After months of phone calls, emails and planning, at the end of June, I arrived at the Jaffna Teaching Hospital, ready to start my five weeks of electives in internal medicine and general surgery. Unsurprisingly, I spent the first few days overwhelmed by the experience.

I have been volunteering, working, and learning in hospitals for most of my life. For most, hospitals are places that cause anxiety and stress, but for me, they are often a place of familiarity and comfort, somewhere where I feel engaged and useful. Despite years in this environment, the Jaffna Teaching Hospital felt foreign to me. The wards, the equipment, the staff uniforms, the very rhythm of the place was completely alien.

Patient autonomy

The most obvious difference was that everything was done by hand. There was not a single computer in sight. Having worked in a health system that is increasingly digital, this was a big change for me. I also soon discovered that patient records are not kept locked away in a filing cabinet at the clinic or hospital.

Rather, the patients themselves carry their clinic books, lab reports and even MRI scans to each appointment with them. While cumbersome and running the risk of losing documents, this system gives full autonomy to patients over their personal health records and also allows for the mobility of those records from one site to the next.

Despite (or perhaps because of) this system, the consultants (in Canada, we call them “attendings”) are able to see a massive case load in a very short period of time. This was most obvious on clinic days where upwards of 40 patients were assessed, treated, and dismissed and/or given a date for follow up, all within the span of two to three hours. It’s a whirlwind of papers shuffling, names being called, patients shifting in and out of the examination rooms, and notes hurriedly scrawled into clinic books.

I was equally stunned the first time I stepped into the casualty theatre – a carryover, it seemed, from Sri Lanka’s civil war, when trauma patients would flood into the hospital every day. Two tables, with one anesthetist each, for procedures that require general anesthesia.

All other procedures were conducted under local anesthesia on stretchers flying in and out of the large operating theatre. And, at the centre of it all, a group of dedicated and talented registrars and surgeons operate on everything from in-grown toenails causing infection to inguinal hernias, all using proper aseptic and clean protocols.

As a student, it was incredible to move from one table to the next and see so many different techniques and procedures happening simultaneously.

Controlled chaos

To me, this was controlled chaos. And this phrase echoed through my mind again and again as I proceeded through my weeks of training in Jaffna.

But beyond the differences, the language of medicine remained a constant thread to which I could hold. Human anatomy is the same the world over. And I marvelled as I watched my general surgery preceptor carefully reveal the facial nerves of a patient with a suspected tumour over his jaw bone. Like the branches of a tree, the branches of cranial nerve seven spread out across one half of the patient’s face, beginning to divide and separate just in front of the ear. It was like I was looking at a diagram in a textbook, the dissection down to the tumour was so precise and clean.

Acetaminophen too is the same all over the world. Whether we call it Panadol, Paracetamol or Tylenol, all three can be used to bring down a fever, all three can be used to relieve pain.

Moving mountains

Though the medicine was fascinating, the most enriching aspects of this journey to Jaffna were the people that I had the privilege of meeting. From the patients, nursing staff, and fellow medical students to the registrars and consultants who served as my teachers and mentors, the people I met throughout my five weeks at the Jaffna Teaching Hospital made the experience unforgettable. They worked to bridge the cultural and linguistic gaps between us, provided thoughtful and insightful answers to my questions, and facilitated opportunities to practice clinical skills and learn new techniques.

[quote align="center" color="#999999"]I was truly in awe to see the mountains that these health providers move on a daily basis with less than a hundredth of the resources we have available to us in Canada, and with significantly more challenges.[/quote]

What do you do, for example, with a patient with diabetic foot ulcers who can’t afford to buy shoes? Or having to label an otherwise medically fit patient as a “poor candidate” for kidney transplant because all such surgeries are done in the private sector and require hundreds of thousands of rupees to carry out?

I feel honoured to have had the opportunity to be a learner in Jaffna, and to speak to patients and practise medicine in my mother tongue, Tamil. I feel especially privileged to have met the dedicated, passionate, and talented physicians and medical students who propel medicine forward in Jaffna. Despite systemic barriers, low resources and a significantly complex patient population, they persevere, they innovate and they thrive.

As a teacher and friend from my general surgery elective in Jaffna so poignantly stated, “We have the resilience gene”. And I could not agree with him more.

Gayathri Naganathan is a second year medical student at McMaster University in Ontario, Canada. She is a daughter of the Tamil diaspora and a proud “third culture” kid.

Published in Health

by Ranjit Bhaskar in Toronto

May 2009, the civil war in Sri Lanka was grinding its way to an excruciating end.

Government forces were in a decisive push against the separatist Liberation Tigers of Tamil Eelam (LTTE) after more than 25 years of bitter fighting.

Caught in the crossfire were thousands of Tamil civilians, but governments around the world were stoic about human suffering despite blatant rights violations by both sides in the conflict.

The LTTE’s terror tactics had increasingly alienated them from the Tamil cause for an independent homeland.

This forced the Sri Lankan Tamil diaspora, by now scattered across the globe due to the war, to take to the streets to bring attention to the suffering.

[quote align="center" color="#999999"][G]overnments around the world were stoic about human suffering despite blatant rights violations by both sides in the conflict.[/quote]

With Canada being home to the largest Sri Lankan Tamil population outside of the island nation, diaspora activism was at its peak here. They had been demonstrating since December 2008 and their protests in various cities had almost become routine by May.

But Canadians were ambivalent about a minority community protesting about a conflict happening far away from them. The display of the flag of the LTTE, by now a proscribed terrorist organization, also did not help in the battle for the hearts and minds.

So, even as the LTTE fighters were making their last ditch stand in Sri Lanka, the public relations battle in Canada was lost by the evening of May 10.

As dusk fell that Sunday night, several thousand Tamil protesters swarmed the elevated Gardiner Expressway. A crucial artery for downtown Toronto, it was effectively shut down till about midnight.

Anecdotes abound about how those caught in the traffic chaos suffered on that day. That it also happened to be Mother’s Day, and many were prevented from visiting their families, dealt the final blow in the court of public opinion.

It took the Tamil community several years to repair the damage done.

[quote align="center" color="#999999"]It took the Tamil community several years to repair the damage done.[/quote]

But how did a community, that began gaining critical mass in the early 1980s, start organizing themselves on such a large scale?

Scholarly scrutiny

The answer to this question can be found in Pain, Pride, and Politics, a recently released book by Amarnath Amarasingam.

The genesis of diaspora activism specific to Sri Lankan Tamils forms the core of this book as it delves into an issue that needed scholarly scrutiny.

Until now we only had a crude understanding of this diaspora, its struggles and successes, and more importantly its links to the civil war.

A post-doctoral fellow in the Resilience Research Centre at Dalhousie University, Amarasingam weaves together a narrative that give us an insider’s view with the studied detachment of an academic.

However, the author’s lived experience as a young Tamil growing up in Toronto informs what would have otherwise become too academic. This is evident right from the introduction when he describes an encounter with the LTTE’s infamous money collectors in front of his home in the early 1990s.

‘Big egos, short fuses’

Amarasingam acknowledges that many Tamils did indeed give willingly and generously to these collectors every month. However, for others, they were an ever-present nuisance: “young men with big egos equipped with dangerously short fuses,” the author writes.

And it was not just the diaspora Tamils who grew weary and concerned by the LTTE’s presence and activity.

[quote align="center" color="#999999"]Governmental and policy circles started seeing Tamils as ... fundamentally corrosive to the prospects of peace in Sri Lanka.[/quote]

Soon the whole community got tainted in the eyes of mainstream Canada. Governmental and policy circles started seeing Tamils as overly radical and fundamentally corrosive to the prospects of peace in Sri Lanka.

Although some of these concerns were perhaps justified, much of the anxiety was exaggerated by misunderstandings.

This book now provides an in-depth examination of the ways in which a separatist socio-political movement has been carried forward, altered and adapted by the diaspora.

To make sense of this process, its first chapter examines the rise and fall of Tamil militancy in Sri Lanka. It gives a detailed account of how ethnic grievances, political mobilisation, and events on the island led to armed conflict.

The focus then shifts to diaspora activism in Canada. The book comes into its own here as it attempts to fill two broad gaps in literature on diaspora politics.

Peace or trouble makers?

First, much of the writings examine diaspora communities as either peacemakers or troublemakers in relation to conflicts in their old countries. This black and white approach fails to acknowledge the greys of diaspora activism in its own right.

Second, in setting out to address this issue, Amarasingam cross-fertilizes his diaspora study with extensive literature on social movement theory.

It helps us better understand the street protests, the organizational dynamics and the process of identity formation in the post-civil war Tamil diaspora.

The futility of dividing the community between a “moderate majority” and a “pro LTTE bloc” is also brought forth.

Understanding future diaspora groups

Even though Pain, Pride, and Politics is the first such book-length treatment of Tamil diaspora politics in Canada, it does have self-set boundaries.

[quote align="center" color="#999999"]With 25,000 refugees from Syria to soon settle across Canada, this treatise on a group that came here under very similar circumstances is very opportune.[/quote]

Issues like inter-generational religious identity, the proliferation of temples and ethnic Tamil churches, debates about caste identity, refugee experiences, mental health issues affecting the community and gang violence are not touched upon.

By skimming on these diaspora issues and a fuller account of post-colonial political developments in Sri Lanka, maybe Amarasingam is setting himself up for another book in the future.

But what he gives us in the present is a periscopic view of the singular dynamics that propel diasporic communities into uncharted spaces.

With 25,000 refugees from Syria to soon settle across Canada, this treatise on a group that came here under very similar circumstances is very opportune.

The insights offered make it an essential read for understanding the struggles future diaspora groups are likely to face and maybe even for helping us mitigate or prevent some altogether.


Ranjit Bhaskar is a Toronto-based journalist and writer with a keen interest in Canadian politics and immigration and South Asia.  

{module NCM Blurb}

Published in Books
Thursday, 10 September 2015 10:36

“One Tiny Creature”

by Jonathan Kay

During the first week of September, I stopped looking at Facebook. My news feed was full of one picture: an image of a drowned three-year-old Syrian boy named Alan, face down, head turned away, in the surf of a Turkish beach.

I have a daughter who is the same age. And the shape of the boy’s corpse corresponds to her preferred sleeping position. I thought that if I avoided looking at the photo, it would stop haunting me. So far, that hasn’t worked.

The armies that propelled Alan’s family out into open water are fighting a complex civil war half a world away from us. They have confusing Arabic names and fly obscure banners. It’s hard to know who is the greatest villain.

And so Canadians instead have found it easier to direct moral outrage at our own government. Chris Alexander is our Minister of Citizenship and Immigration. His department decides whom we save, and whom we don’t. Somehow, this must be his fault.

Human beings are visual creatures

A young child’s suffering is regarded as a special kind of evil, so powerfully felt that a single image blots out everything else from our moral universe.

“I took the case of children only to make my case clearer,” Ivan says to his brother Alyosha in the novel The Brothers Karamazov, after reciting a list of infamous horrors visited upon young Russian boys and girls. “Of the other tears of humanity with which the earth is soaked from its crust to its centre, I will say nothing.”

As Ivan systematically knocks out the underpinnings of his brother’s faith in a benevolent ruler, he asks a question that has become well-known among philosophers:

Imagine that you are creating a fabric of human destiny with the object of making men happy in the end, giving them peace and rest at last, but that it was essential and inevitable to torture to death only one tiny creature — that baby beating its breast with its fist, for instance — and to found that edifice on its unavenged tears, would you consent to be the architect on those conditions?

Alyosha is repelled by this seemingly monstrous hypothetical. But what Ivan described was a reality in feudal societies such as Russia, where a serf child could be murdered in front of his parents for injuring a lord’s favourite hunting dog, and the most grotesque forms of suffering were seen as pathways to God’s grace.

[quote align="center" color="#999999"][N]o act of moral imagination is required to internalize the suffering of children everywhere. Just open your news feed and let the photos and video wash over you.[/quote]

When Fyodor Dostoevsky was writing The Brothers Karamazov in the 1870s, he compiled his macabre case studies by clipping scattered articles from local newspapers. There were no pictures, and details were scant: Sadistic treatment of children was not unusual, and these were not considered journalistically important stories.

In 2015, however, no act of moral imagination is required to internalize the suffering of children everywhere. Just open your news feed and let the photos and video wash over you.

We always have known, somewhere in our pampered Western heads, that while we eat our breakfast and brush our teeth, unspeakable things are happening to innocent people everywhere. But human beings are visual creatures: It is one thing to hear of death, and another to see it.

With so much of the world’s savagery now landing on our screens, technology has made us the eternal Alyosha, besieged every day by the eternal Ivan. Our brains, conditioned by evolution to manage life and death within small clans, lack the circuitry to process an endless digital cascade of global grief.

Railing against government

Ivan Karamazov observed the suffering of children and railed against God. We observe the suffering of children and rail against government — the welfare state having replaced the Supreme Being as the mercy-provider of last resort.

But this God always will fail us, because in a globalized media age, our point-and-shoot moral demands have become geographically infinite and politically unstable.

Our federal government has settled 2,300 Syrian refugees to date. Thomas Mulcair wants to accept 10,000 more this year. For Justin Trudeau, the number is 25,000.

That sounds like a lot. But what happens if refugee number 25,001 is photographed washing in with the tide? Why not 50,000? Or 100,000? And what happens when a dead child is photographed on a beach in Honduras? Or Libya? Will the number be the same? More? Less? Why should there be any limit at all?

[quote align="center" color="#999999"][R]easonable debates about foreign aid and immigration policy seem to evaporate in the face of Dostoevsky’s “one tiny creature.”[/quote]

These are not just questions for politicians, but for ordinary Canadians as well. During the first weekend in September, I received an e-mail from a friend: “I think we have all been haunted by the image of Alan’s tiny lifeless body. A group of our neighbourhood friends is thinking of sponsoring a Syrian family. The approximate cost to privately sponsor a family of 4 or 5 is about $25,000 . . .”

An effective altruist has to keep reminding himself that there are little children dying all over Africa from preventable diseases, sometimes in hideous ways that might make a drowning at sea seem humane by comparison. estimates the cost of saving one of these lives at about $3,000

The math here is stark. But reasonable debates about foreign aid and immigration policy seem to evaporate in the face of Dostoevsky’s “one tiny creature.” That dissonance was captured perfectly by the mask of helpless frustration on our immigration minister’s face, as he clumsily tried to justify his government’s policies to CBC host Rosemary Barton. Which of course he couldn’t, since no one can win an argument against a dead child.

As I wrote this, I began looking at that picture again. I had to. If any of us purport to have an opinion on what must be done to address the world’s horrors, then we have a responsibility to face up to them in some small way. However, we should not expect that our instant emotions be translated into policies that will affect Canada for generations — an expectation that always will turn our politics into a sort of unsustainable humanitarian bidding war.

Every humane society must listen to “that baby beating its breast with its fist.” But we will not be able to do our part in fixing the “fabric of human destiny” if we can hear nothing else.

Re-published in partnership with The Walrus.


Published in Commentary

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