Field Notes

We All Have A.D.D. (Attention Deficit Disorder)

2010-03-21T10:42:00.000-07:00

The toilets are everywhere: Hundreds of unused outhouses peek from between the palm trees dotting the coastal road south from Batticaloa to the village of Thirukkovil. Built just after the 2004 Tsunami devastated Sri Lanka’s eastern coast, the mildewing boxes, some just yards apart from each other but far from villagers’ homes, are a glaring example of emergency humanitarian aid that has gone unused just a few years after the crisis.

The cornucopia of bathrooms was well intentioned and sanitation is certainly an important need here but this is one of the problems that crops up when NGOs do not necessarily consider the communities’ needs and practices from the very beginning of a project: A wasted investment of money and effort that does not benefit the community in the long term.

The lesson for humanitarian NGOs is: Listen to the needs, allocate aid in a usable way, involve the community so that its members take ownership of the project, and have a sustainable exit strategy so that the benefits last.

The lesson for donors and philanthropists is: Research the sustainability practices of the NGOs to which you donate.

* * *

Standing in stark contrast to the unused bathrooms on the road into town, the Thirukkovil Community Center is full of life and is transitioning into local hands. Used by over 100 people a day – whether adults for individual counseling or children for tutoring and relaxation – the Center is an essential part of village life. When the Center first opened its doors in 2007, it was a slow process of trust building and managing security risks from paramilitary groups. But now, with morning counseling and home visits, afternoon children’s traumatic stress relief programs, an income generation strategy, and a handover to the Sri Lankan Consortium of Humanitarian Organizations (CHA) , it is clear that the Center will not only be here for years to come but will be used and owned by the people of Thirukkovil as a psychosocial resource.

The transition process is a delicate one: Over six months, starting in April, CAM will hand over responsibility for the program’s management to CHA while providing transitional funding and advice. Sustainable transitions do not just happen: They take planning from the very conception of a program and careful nurturing throughout. It’s an investment not only in the community but in making donors’ dollars last – The money that CAM put into the Community Center will not evaporate into thin air, like the money that made all of those toilets seems to have.

From left: CAM Desk Officer for Sri Lanka, Samantha Brangeon, CHA Deputy Executive Director, Firzan Hashim, and CHA Pyschosocial Consultant, Chrishasa Pasanavikana

CHA’s Deputy Executive Director, Firzan Hashim, drives home the point: We all have A.D.D. (Attention Deficit Disorder).

“The needs now are more than six months ago - Money came in during the war. Now, we have no excuses [for not providing aid]. Now people are looking for normalcy and we are letting them down. We are letting them down but there are no funds.”

* * *

It is compassion fatigue: We watch in horror as disasters, wars, and earthquakes consume whole countries, we rush for our wallets to make a donation, we hope we do some good, we move on with our lives, we forget about the day after. And it is the day after that is so crucial.

International donors – governments, global organizations – are often the same. Donor cycles seem to move from disaster to disaster – departing Sri Lanka for Haiti, from Haiti to the next crisis. This pattern leaves little room for sustainable transitions to local hands.

And the cycle continues: Disaster brings in emergency aid but few sustainable projects; attention fades and a post-crisis funding gap chokes off aid; perhaps further down the line development projects will begin, long after the investment of emergency aid can be salvaged.

That’s what we do: Plug the post-crisis gap. It is a kind of Adderall for humanitarian aid, extending our focus a bit longer. By providing private funding to NGOs committed to sustainable transitions and local capacity building, like CAM, we try to refocus attention on those places that have lost the limelight and the resources that sadly go with it: Sudan, Chad, Angola, Central African Republic, Sri Lanka.

It is not adrenaline-pumping or glamorous or sexy. It will not be a breaking story on CNN or Fox News – although it should be. But if we could all travel to this forgotten corner of Sri Lanka, full of devastation and resilience, we might not lose your focus.

Instead, it might become crystal clear: The pain does not disappear when the cameras do, and neither should our attention.

To sustainably support communities transitioning from crisis to development, please donate.

Just Play

2010-03-12T08:07:00.000-08:00

The soccer field is made of dust, the sidelines of encroaching jungle grass; cleats are bare feet, flip flops if they are lucky; uniforms are simply whatever clothes they have – t-shirts, long sleeve button-downs, slacks two sizes too short, rolled up jeans, a Yankees cap; three iron poles create a single net-less goal, far larger than regulation size. And the soccer ball? Donated.

This is soccer boiled down to its basics and the young men from the resettled IDP villages of Vadamunai and Utuchennai are eating it up at a training clinic from the Comite d’Aide Medicale’s psychosocial team and the government Sports Officer for Kiran Division. You see, these boys and men, some no older than 16, others already 25, never had a chance to learn how to play: They were fighting. Most members of this eighteen person team are former child soldiers recruited at the age of fourteen by the Liberation Tamil Tigers of Eelam (LTTE) from a now-defunct base on a hilltop just half a mile away.

Childhoods disrupted, war endured, families dispersed, and, finally, the slow return to normalcy: The 2008 resettlement of several hundred families in the most neat and ample sheet metal and UNHCR tarp homes of any resettled village yet – marigolds lining a garden path, a child’s drawing pasted on the front door, goats jostling in their shed; the rebuilding of a destroyed school; a busy harvest season; a visit from the Zonal Director of Education, Mrs. S. Chakkaravarthy, who lauds the work of NGOs like CAM for reinvigorating the drive, confidence and curiosity of once listless children and youth.

But for now, there is only the intense focus of the youth, gathered in the shade of a tree, listening as Aputhuraj Sivakummar, the Division Sports Officer, explains the rules of the game: This is a throw in, this is a corner kick, here is where the striker runs, this is the goal keeper’s domain. And then they train – running laps, passing drills, shooting drills, heading practice. Though serious in the shade, once playing, the boys’ laughter stretches across the school yard – shouts and screams and giggles on the wind.

Mr. Sivakkumar has been working with CAM to bring volleyball, soccer and handball clinics to five remote resettled villages in the savannas and jungle of eastern Sri Lanka. With several co-led clinics already under his belt, he runs this one on his own - planning the two hour clinic carefully and, whistle in hand, putting the young men through their paces. This was a first for him but, he says, it won’t be his last: Even if the CAM program closes because of a lack of international funding for post-crisis eastern Sri Lanka, he will continue the trainings and the Division-wide tournaments that could bring these tiny marginalized villages recognition, resources and a source of pride.

Despite the unavoidable enthusiasm at the clinic, engaging the youth was a painstakingly slow process, CAM’s Psychosocial Advisor, Stanley Prabaharan, says. More skeptical than the women’s groups and less of a captive, curious audience than the school children, it took months of trust-building before the captain of the Utuchennai/Vadamunai soccer team called CAM, eager to know when the next training would be.

It was the sports that drew them in but the community that keeps them coming back. Go to a soccer field in Richmond, Virginia on a Saturday and any coach there can rattle off the list of psychological and social benefits of participating in a team sport: Developing trust and relationships; building a community; learning the skills of teamwork, communication, and diligence; gaining confidence, destressing and having an emotional outlet; building an identity.

Take those lessons to a dusty schoolyard hours down a dirt track in the jungle and rice paddies of Sri Lanka, where the scars of war remain, and you see the same joy, the same intensity on the faces of the players that you might find in Brookline, Massachusetts. The only difference is, here, this is as close to a therapeutic environment - to any outlet from years of violence and trauma, other than alcohol - that these young ex-combatants will likely ever get. The game is the focus, freeing them momentarily from the memories of the past and the demands of the present; the team operates as a support group; and the ball does the rest.

For now, they just play.

The Heavy Load

2010-03-09T07:41:00.000-08:00

Sellva’s children are beautiful – and traumatized. Mathigaran, 11, moans and twists in his chair, where his atrophied legs lay useless and slightly askew; Tharani, 7, stares, mute, at her mother as she explains: For the last four years, they have lived on the move.

It is a backbreaking load to carry: A single mother of five children under the age of 15 - three of whom are mentally and physically handicapped from the trauma of war - with no income, little security, far from her home and relatives scattered in the war-devastated North, sick with an undiagnosed illness but unable to leave her children to visit a hospital, mourning a husband in prison, living day to day on donated food, and sleeping in a dark two room hut, their meager possessions scattered here and there, piled in the seat of a dusty, broken wheelchair.

And yet, Sellva’s face creases slowly, shyly into a wide smile when she sees Malini, a Comité d’Aide Médicale psychosocial counselor. For the last two months, Malini has visited Sellva at her tiny tin and brick home twice a week. It is one of the few times that Sellva can unload the weight of her story – filled with enough pain to last 1,000 years, let alone Sellva’s 32 – to a sympathetic listener, a rarity in a community filled with trauma survivors.

Trained in Cognitive-Behavioral Therapy (CBT), which emphasizes an individual’s control over his or her own thoughts and reactions as opposed to simply weathering external events, Malini integrates small but powerful coping exercises – meditation, relaxation and breathing – into her counseling sessions. CBT is a strategic choice: For survivors of three decades of unpredictable violence, displacement and uncertainty, exercising agency – even if only over their own minds – can be powerful. As with all of her daily home visits, Malini has worked closely with the government Mental Health Unit on Sellva’s case, bringing in a government Mobile Officer of Health for a home visit, applying for a new wheelchair at the Hospital for the Handicapped, and linking her with a livelihood project.

But mostly, Malini listens. Listens to stories about the two years that Sellva’s family of seven lived in underground bunkers – spaces that didn’t allow for normal upright movement or children’s muscular and emotional development; about how they endured combat, uncertainty and fear; about how they moved from place to place in northern Sri Lanka; about how Sellva herded her children – one in the womb, another mute and suffering seizures, a third unable to walk or communicate, the eldest two missing years of schooling – through the squalid Internally Displaced Person (IDP)camps that line the roads crisscrossing northern Sri Lanka.

She left the camps last year. But here, in this coastal village, in a hastily constructed hut on her husband’s relatives’ land far from her own home in the Vanni, Sellva’s hopelessness set in again. Still, she lives on, day by day. When Malini first met Sellva, on a referral from another counseling client, the young mother was deeply depressed and overwhelmed. Though she is still mired in her family’s trauma, destitution and disabilities, she knows she is not forgotten. She is heard, she is seen, she endures. Her struggle is validated.

Sellva’s future may be unclear, but this she knows: Next week Malini will come.

Smiles Are Contagious

2010-03-05T09:47:00.000-08:00

They dance with abandon. The girls and the boys – once reserved – are gleeful, bouncing to the South Indian beat.

The children rushing through the front gate, gossiping in corners, stepping slowly in walking meditation, are far more engaged and outgoing than those from the remote resettlement villages. Many of these glowing children are poor and all survived the Tsunami, the internal conflict in their village, some only just arrived with their resettled families, but their lives – with help from the Comite d’Aide Medicale Community Center – are infinitely more stable than the children just a few hours away in the recently resettled village of Kudumbimalai.

The soft green building of offices, counseling rooms, a computer room, a tutoring room and a playroom faces a bright blue open-air auditorium, with a stage perfect for the cultural events – dance, music, plays –featured there regularly. In the mornings, the Center is peaceful and private, with men and women filtering in for counseling sessions and psychosocial workers setting off on home visits; in the afternoons, minutes after the school days ends, the Center hums with the youthful energy of 80 children.

Even in the U.S., this would be more than your average Community Center. But in a poor community still reeling from waves (literal and figurative) of trauma, this place is a minor miracle. This is a Community Center with deep roots in the community; a Center that opened its doors in 2007, when violence was an everyday reality; a Center whose sandy grounds were once strewn with the bodies of Tsunami victims; a Center which provides individual and group counseling, clinical referrals to psychiatrists, meditation, tutoring, therapeutic arts and a safe space for a community traumatized by decades of war and disaster; a Center which will remain in the community’s hands as the Comite d’Aide Medicale transitions it to a Sri Lankan NGO, Consortium of Humanitarian Agencies (CHA), a model of careful planning and sustainability.

Precious as the Center may be, its staff deals with the most basic of human struggles: alcoholism, domestic violence, depression, anxiety, poverty, single mothers and widows struggling in a patriarchal culture, grief, traumatic stress, desperation, hopelessness, suicide, disability, the hidden painful pasts that blaze, life-like, in people’s everyday lives. Working closely with government health officers, psychiatric units, and handicapped services, the team of five carefully listens to, refers, encourages, and, in some small ways, helps heal their clients.

You can pick out the new ones. They are hesitant. Quiet. Slightly removed from the others. The smiles come slowly, almost catching the child by surprise when they finally spill out and crack that protective mask. Valentine, the Center’s Program Manager, grins knowingly: The dancers started out that way too. It did not last long. The joy is contagious. Before you know it, it catches you.

“Your Presence Is Important To Us”: Lessons In Building Trust

2010-02-28T06:55:00.000-08:00

The women are in an uproar, yelling out the open air windows of the bright turquoise and yellow community center, shaking their hands, muttering to each other. The man, drunk and in retreat from the screams, wearing just a lungi around his narrow waist, tells them to go to the fields: It’s harvest time. It isn’t just any harvest time; it’s the first harvest this community will have since returning from years of disjointed displacement to their demolished homes and uprooted fruit trees in Meeranakadvai eight months ago.

And yet twelve women sit in plastic chairs inside the cool concrete shade of the brand new community center, their “home” as they put it. It was a meeting of the Meerankadvai Women’s Group, led by Nirosh, another of CAM’s psychosocial workers under the supervision of Stanley Prabaharan, CAM’s Psychosocial Advisor, and that – for the moment – took priority over the other many responsibilities of these mother and grandmothers. It took months of careful trust-building to get even this handful of women to meet regularly with CAM’s team; after years of violence, confusion, false promises, and hopelessness, they are wary of strangers and often live the present through the recurring nightmares of the past.

Building trust, CAM Psychosocial Coordinator Sophie Wodon emphasizes, is the key. She isn’t talking about individual counseling, although CAM’s psychosocial workers do manage dozens of individual cases at any given moment; she is talking about rebuilding an entire community whose ties were shattered during three decades of war and displacement. A son was lost, a mother is mourned, and many simply disappeared – possibly dead, maybe alive in an equally isolated resettlement village or IDP camp.

Still, there is energy coursing through in the room. The women are planning their own celebration of International Women’s Day on March 8, 2010. The psychosocial team points to the American in the corner and emphasizes that the Women’s Day of Meeranakadvai is just as important as the Women’s Day of New York City; in this heavily patriarchal culture, especially in the remote villages where alcoholism and domestic violence are widespread, it is a novel concept to devote a whole day to celebrating women.

The celebration itself though is less important than the dynamic building between these women: They are trusting again, talking about their pain and grief, regaining their identities, finding reasons to live, developing the confidence to advocate for themselves and for their community, creating a support network. When an elderly woman with a wide, warm face, snow white hair and a deeply bent back, exclaims that she “can’t do anything” to help the celebration, the others quickly dismiss this, saying, “But your presence is important to us.” It’s a support group cum community organizing, a rarity in such a tiny village with such a pained history.

In a place where, according to CAM staff, 80% of the people have lost an immediate family member to the war, where marrying girls at the age of 14 is common, where 30% of the women are single – whether widows or simply left by their husbands – and without sources of income or sustenance, where domestic violence is ever present, the resilience of these women – at least in for a few moments in this community center - triumphs.

One woman, wearing a colorful sari, triumphantly crows, “Without women, there is no life.” And with that, they file out the door, returning to the fields.

* * *

Sitting in neat semi-circle on brightly patterned straw mats lain on the floor, the 20 young students at remote Kudumpimala Kumaran School squirm with excitement. It is the weekly workshop led by the Comité d’Aide Médicale’s (CAM) psychosocial team in this village hidden deep in eastern Sri Lanka’s paddies and plains.

The kids, skeptical and dull-eyed in the first months, have opened up to Sri and Kogulan, the psychosocial workers who visit every Wednesday with a new, creative lesson about preserving the environment and keeping their village clean. Environmental health is an important message. But the larger lessons are more subtle: Be creative, ask questions, it is ok to talk about your fears and dreams, it is ok to trust others, you can be a leader, and there can be order and stability despite the chaos of displacement. Slowly, they are taking hold. The children are acting more like the six, seven, eight and nine year olds that they are: Engaged, active, curious. Call it arts and crafts version 2.0.

It has not always been this way: These elementary school students have lived most of their lives as Internally Displaced Persons (IDPs) who finally returned to their ancestral villages eight months ago, after fleeing the nearby fighting between the Sri Lankan government and the Liberation Tamil Tigers Eelam (LTTE). The villages, essentially flattened in the fighting because of their proximity to former LTTE outposts, are slowly being rebuilt, piece by piece. The school, a single large open air room with chalk boards at each end and a bright mural on the outside, is one of two permanent structures in this tiny farming community. For an eight year old in this school - looking incongruously proper in his collar and tie uniform - chaos, violence and uncertainty has been the norm for his entire life; For the school’s principal and sole teacher, war and displacement has consumed the last 25 years of their lives; consistent schooling, engaged students, and creative outlets were figments of the imagination up until a few months ago. Now, as life tentatively regains a bit of normalcy, the prospect is real.

Sri and Kolugan are joined by the village teacher as they help the students recycle collected trash by turning it into individual art projects. The students are not the only ones learning; the teacher receives coaching from the psychosocial workers on similar activities that build trust, confidence, engagement, stability and creativity. In this way, the village will have their own basic psychosocial resource for years to come and the village’s children will continue to receive the attention, support and stability that are so essential for their basic emotional and intellectual development.

The emergency NGO frenzy has already left Sri Lanka, abandoning it to the fates of the future. But walking through the village, the needs during this vulnerable transition from crisis to basic development could not scream louder. Compared to more established resettlement villages like Pirambadithivu, Kudumbimalai and its neighbor, Meeranakadvai, are each a handful of hastily constructed basic shelters - sticks, tarps, palm branches - reestablishing the villagers’ claim to the land. Here, there is an eerie absence of anyone between the ages of 10 and 20; they have all been sent to the nearby towns, where there are schools above grade five and little risk of forced recruitment as child soldiers. In a culture where children are thought of as the center of a family’s life, the legacy of disappearances generates a deeply rooted fear in parents, despite the fact that there is little risk of it now.

Back in this classroom-against-the-odds, the children focus intently on the bright paper fish they are making out of scraps of paper and old paper plates, each a bit different from the next. Holding their fish aloft for inspection, tentative but proud smiles break out on the serious faces.

Searching for Pirambadithivu

2010-02-25T03:10:00.000-08:00

To find the village of Pirambadithivu, you have to hunt for it. Searching the backwaters of eastern Sri Lanka with a fine tooth comb, you'll find it hidden among the paddies, inaccessible during the monsoon season, and down 20 kilometers of such pocked and crumbling dirt roads that it takes two hours to drive there. The village of 1,400 has no store, no primary school, and no health center of its own. When the mobile medical team arrives, the doctor, nurse, two health workers and a psychosocial worker quickly head for a small concrete building with a tin roof and walls covered in children’s drawings: the nursery school becomes a clinic in under fifteen minutes. Stethoscopes, scales and antibiotics; Registration to the right, doctor behind the screen, nurse in the far corner. And a line out the door.

Once a week, the Comité d’Aide Médicale (CAM), a MAC grantee, sends one of its three mobile medical teams to this isolated community – providing the only primary health care for the community within miles. Most of the villagers arrived from northern Sri Lanka four years ago after being displaced by the LTTE-government war – dropped in a relative no man’s land without even the most basic services. Now they scrape by as farmers, often sharing a single meal a day with their families in homes made of cobbled together tin siding, palm branches, fraying UNHCR tarps and concrete.

This is not simply rural poverty in the developing world; this is that level of poverty and isolation compounded by the disruption and uncertainty of displacement, the emotional and physical legacies of decades of war, and the traumas of the 2004 Tsunami, which ravaged Sri Lanka’s eastern coast.

* * *

When you first meet Mala, 27, you would never know that she only has one leg. Wearing a worn print dress and a shy smile, she leads Tharshini, a CAM psychosocial worker, down the dirt road to her home – a small tin roofed hut shared with four members of her family. In the dirt yard, her sister sifts through drying rice, picking out the stones, while her grandmother sits in the shade of a single tree. Though Mala has been visited by Tharshini for weeks now, she was first identified as needing psychosocial attention at the mobile medical clinic, where she went for pain in her remaining leg. Understanding the intimate connection between physical and emotional well being – especially for those with traumatic histories, like the internally displaced – the medical and psychosocial teams refer cases to each other. While the mobile clinic treats the ill, Tharshini sets out on her five home visits in the village. Her support, however small and against the odds of poverty and displacement, is essential here; in addition to the weight of poverty and the living memory of war, domestic violence, alcoholism and school drop-out rates are rampant.

Having lost her leg in the war to a mine, and separated from her parents, Mala lives with her grandmother and sister, whose husband lost a leg and his sight to a mine. Sharing her story, her needs and her daily concerns – many of which center upon lack of income – with Tharshini, has helped Mala gain access to Sri Lanka’s government services for the handicapped, including a new prosthetic leg, which is on the way. Working with Mala each week allowed Tharshini to identify Mala’s sister, whose husband is blind and handicapped, and whose son, Pradeep, is deaf, as depressed; as with her other patients struggling through post-traumatic stress, depression and anxiety, Tharshini began working with her to unknot the frustration by listening and slowly teaching her coping and relaxation exercises, like meditation.

Sitting on a straw mat in the shade of her yard, Mala picks at the straw threads of the mat below her feet. When asked about her wishes for the future, Mala answers that she has, “no idea about the future." Just this: The uncertain poverty of farming, maintaining her modest household, and hoping to see her parents – lost in the frenzy of war – again.

* * *

53 patients patiently wait their turn to see the doctor behind a modest screen. A gaunt elderly man in glasses held together with string leans heavily on an improvised cane; a young woman in a brightly patterned but dusty, worn smock dress shifts her crying baby from one arm to the other; mischievous children tug on their grandmothers’ frayed but still immaculate saris; most are barefoot, a few children boast tattered but impossibly white school uniforms. Here, upper respiratory infections, gastrointestinal diseases, generalized pain – often a sign of psychological distress - are the most common diagnoses.

This is the last time that the mobile medical team make its weekly visit to Pirambadithivu. Frenetic international donor cycles have shifted attention from Sri Lanka – old news to most – to the next humanitarian crisis and with it the money needed to continue bringing health care to 19 villages of resettled Internally Displaced Persons (IDPs), like Pirambadithivu. It’s a classic and saddening case of donor interest expiring before the urgent needs of people like Mala do.

Though CAM’s intention is always to hand projects over to local authorities or community groups, sometimes the realities of too few doctors and resources make that impossible. CAM has conducted numerous trainings – on dengue fever, on first aid, on hygiene and preventive health – for the local Sri Lankan Ministry of Health to bolster their capacity; Regular meetings keep the officials informed of the massive health needs, and yet, they say they simply cannot provide care for these people.

Having stretched their resources as far as possible and with the local Sri Lankan Ministry of Health nowhere near the capacity to take over the clinics, CAM has little choice but to reduce the program to a single mobile medical team reaching just five villages, down from 19. This will leave thousands of people without prenatal checkups, treatment for skin, eye and respiratory infections, malnutrition screenings and the many other basic health and psychosocial services they need so badly.

Last year, MAC kept these very clinics going for another month with a bridge grant of $40,000. To help keep mobile medical clinics in villages like Pirambadithivu, donate now.

Welcome

2010-02-08T08:37:00.000-08:00

Welcome to the Medical Aid Committee's new blog: Field Notes.

Here you will find a personal look at the lives, facts, and stories behind our supported post-crisis humanitarian programs around the world, starting with Sri Lanka.

This month MAC's Program Officer, Lili Birnbaum, reports back from eastern Sri Lanka on the mobile medical clinics and psychosocial community centers that MAC supports through one of its grantees, the Comite d'Aide Medicale.

Stay tuned for more news!