To get
a complete picture of the Permanente physician, it is important to
highlight life outside the normal work environment. Possibly nothing
demonstrates the compassionate heart of Permanente better than the
amazing response to the December 2004 tsunami disaster.
Approximately
three weeks after the tsunami struck the northern Sumatra province
of Indonesia, I joined a medical-surgical team of volunteers from
Baltimore. Although I have been on numerous short-term missions to
developing countries, I was not prepared for the devastation. I was
not alone; many other Kaiser Permanente (KP) volunteers joined the
relief effort. You will see from their stories that they also had
life-changing experiences.
To give
the Journal reader a glimpse of what these physicians and other clinicians
experienced during their volunteer work in Sri Lanka and Indonesia,
we have prepared this edited compilation of writings from some of
these relief workers. Writing their stories is important not only
for sharing experiences with others but also for these physicians
to gain perspective and insight into their own personal experience.
Writing deepens empathy. The testimonies and pictures are only the
tip of the iceberg--many others in KP contributed.
--Lee
Jacobs, MD, Section Editor
Banda
Aceh, Indonesia
Introduction
Physicians
take many paths to finding meaning in medicine. For the doctors of
the TPMG International Tsunami Disaster Relief Team, humanitarian
medical work in South Asia provided meaning and much more.
In the
following collection of essays, you will read of these experiences
and of the lessons learned. Teams confronted rare diseases and complicated
medical cases with minimal resources. They developed large-scale public
health programs as part of a collaborative international team. As
medical volunteers in areas ravaged by both civil war and tsunami,
teams were challenged to be resilient and flexible, to maintain an
open mind, and to improvise. We were reminded of the tremendous wealth
of our communities, the value of our own skills, and the personal
rewards of serving where the need is so great. Both our international
colleagues and our patients inspired us to maintain our hope and idealism
in the face of immense tragedy and sorrow. Above all, we shared with
our colleagues, our staff, and even with our patients, a tremendous
sense of pride and gratitude as we watched KP set the standard for
corporate compassion and responsibility.
However,
the most important stories are about the people we served. Bearing
witness to their experiences and learning first hand of their lives
was not always easy. As Brian Hertz, MD, our Team Lead, recently explained
upon accepting the American Red Cross, Bay Area Region, International
Humanitarian Hero Award, "Humanitarian work requires that one
struggle to be present and stand in close proximity to those who are
suffering." Supporting this work, he says, "... allows us,
as relief workers, the opportunity to continue to expand the boundaries
of human consciousness. This is a consciousness that says that humanity
in its highest form does not willingly leave its wounded to suffer
alone on the road. It is through these actions that we truly make
our lives richer."
December 26, 2004
Banda Aceh, Indonesia
Banda
Aceh was a city of approximately 450,000 people located at the northern
tip of Indonesia. The epicenter of the 9.0 earthquake (one of the
largest on record) was approximately 150 miles off the coast of Sumatra
at the boundary of the India and Burma tectonic plates in the Andaman-Sumatran
subduction zone. It has been reported that one of these plates suddenly
dropped 100 feet creating a plunger-like effect resulting in the tsunami.
Satellite photography suggests that the waves traveled up to 200 mph
until they approached Indonesia. The first waves struck northern Indonesian
shores within 15 minutes, at approximately 9:00 am on December 26th.
Gigantic waves continued to strike the shores throughout the Indian
Ocean over the next 4-5 hours. The countries most severely affected
were Indonesia and Sri Lanka.
The people
of Banda Aceh did not have a chance. The destruction was not just
the coastal villages, but also included the city's flat, highly populated
area that extended up to two miles inland from the shore. As of January
26th, the dead and lost in northern Indonesia approached 230,000 with
2000 bodies found that first day.
The devastation
in and around Banda Aceh was indescribable. Miles and miles of cement
slabs were all that was left. The scene from an atom bomb could hardly
be any different. I was reminded that large numbers of people had
lived here when I passed by the many mass graves.
--
Lee Jacobs, MD
First
True Chance
By Sarah
Beekley, MD Sri Lanka
Regional Chair, Physician Satisfaction and Wellness Leaders
Redwood City, CA
A team
of three doctors, we were part of the initial humanitarian response
sent by our colleagues at KP to a remote refugee camp for the villagers
from Mankerny, where aid had only just begun to trickle in. We set
up our mobile medical clinic with a few scavenged chairs and tables,
and the lines of patients began to form.
Toward
midday, the line was interrupted by a small child's request for the
doctors to visit her 18-year-old sister who, the night before, had
delivered a seemingly healthy baby at 36 weeks. The family had heard
that an American pediatrician was in the camp and they hoped that
we would come to check the newborn. The young girl led us down a dusty
footpath, until we crossed the boundary between the makeshift tent
camp and the neighboring village. The village's palm frond fences
marked the borders between thatched huts, and we could see what life
must have looked like in better times. Finally, we reached a small,
tidy compound of huts. By this time, a shy and inquisitive crowd,
made up of three generations of the young girl's family, had joined
us.
Among
the crowd was the midwife who had delivered the baby. Reportedly 80
years old, she was lithe and nimble and moved with the grace of a
ballerina. She invited us into the compound and explained, with obvious
pride, that this new baby was the fourth generation of this family
that she had delivered.
"How
many children have you delivered?" We asked. "I don't know,"
she replied "the wave took my journal, as well as all of my equipment,
including my only pair of scissors." She stated, with obvious
pride and authority, "We cut the cord with a well-boiled kitchen
knife." With that explanation, she brought us to the door of
the smallest of the shelters in the compound. Inside, legs outstretched,
on a palm mat that was her only protection from the mud, sat the smiling
young mother. Cradled in her lap, swaddled in worn, but freshly washed
clothes, lay the small but perfectly formed child. With her new mother's
pride tempered by maternal protectiveness, she gingerly undressed
the infant for us to examine. Between two delicate pieces of cloth
lay the umbilical cord, still thick and gelatinous, as clear evidence
of the newness of this life. Tiny but perfect, covered in the dark
hair of its preterm birth, the infant captivated all of us. The first
grandchild, the first baby born since the tsunami overwhelmed their
family, the first chance for true hope--the first source of true joy.
Despite having attended hundreds of births, I had never felt such
awe at the blessings of a healthy child, or such gratitude for having
been invited to witness the wonder of it.
As the
day ended, we said our goodbyes and were escorted by the midwife and
her young companion down the dusty paths to our mobile clinic. There,
with gratitude once more expressed from all sides, we said our goodbyes.
The senior member of our team rustled through the trunks of supplies
that KP had sent with us and presented the midwife with a suture kit
as a replacement for her lost scissors. Watching the midwife walk
away, holding the precious and unexpected gift close, we all wished
we could be at her next birth, to share in the experience, and to
learn from her skill.
That
night our team quietly shared the wonders of the day. In the last
few weeks, we had witnessed tremendous tragedy, suffering, struggles,
dignity, pride, and now, joy. Sharing these life-altering events with
the people of Sri Lanka was a precious gift. However much we accomplished
during our medical mission, we felt as though we were the ones who
had benefited the most. To quote a colleague, Randy Bergen, MD, "Seeing
their strength has made me stronger. And being able, in a small way,
to share their pain allows me to feel the good and bad of this world
more intensely."
I have
heard many colleagues say that doing humanitarian relief work always
gave them back much more than they felt they had given to their patients.
It is now my turn to say the same.
Young girls at Vattuwan Displaced
Person's Camp, Sri Lanka.
Photo by Sarah Beekley, MD
Drs Beekley
and Meghani, Mankerny Camp.
Photo by Regina Pietersen, RN.
.
Compassion--An
Ever-Present Mission
By Hernando
Garzon, MD Sri Lanka
Emergency Physician
Sacramento, CA
I write
about my experiences in Sri Lanka on the tenth anniversary of the
Oklahoma City bombing. That day ten years ago, when I searched the
smoldering rubble of the childcare area of the Murrah Federal Building
frantically looking for a living survivor but finding only body parts,
is as vivid for me today.
Although
these experiences are traumatizing, disaster relief work has become
the most profoundly positive and deeply moving work I have ever done.
When
the tsunami struck, the entire world had front-row seats, thanks to
the technology of cell phones, videocams, and Web blogs. The $2 billion
pledged so far and the thousands of disaster relief workers that have
poured into the affected areas are clear indication of the global
empathy for the victims of this disaster. I'm very proud to belong
to an organization that sent 300 volunteers to relief efforts. I'm
privileged to have been one of the first to go.
As with
other disaster relief experiences, Sri Lanka has filled me with some
degree of internal conflict. How do I come to terms with such positive
feelings and sense of personal growth when such devastation and suffering
has occurred in the lives of so many? Sri Lanka has also given me
a greater sense of appreciation for the simple things in my life.
I am more grateful for my life, my family, my patients, and my friends.
It is easier and also imperative to be a compassionate being. To relieve
suffering in any way I can is an ever-present mission.
Excerpts
from Robert Pearl, MD's address to TPMG Board of Directors, at the
April 2005 Directors Meeting
"We
have now completed our efforts to assist the victims of the tsunami
in Sri Lanka and prevent an epidemic of malaria in Indonesia. The
success of these programs exceeded my greatest expectations. In Sri
Lanka, our physicians cared for thousands of individuals, both those
with acute problems from the disaster itself and those with secondary
problems from contaminated water, infectious diseases, and psychological
trauma. In Indonesia, our three teams completed a three-month partnership
with the MENTOR Initiative. They made significant inroads in malaria
control and abatement, potentially saving tens of thousands of lives."
"As
the premier medical group in this country, we are fortunate to have
the ability to support a unique relief effort such as this one. Our
organizational culture of compassion and commitment allowed us to
respond swiftly and effectively to this natural disaster. Hundreds
of our physicians volunteered their services, but unfortunately, we
were not able to utilize all of their expertise. Our hope was to send
more physician teams to Sri Lanka, but given the circumstances, no
additional teams will be going overseas. I appreciate your willingness
to volunteer your services."
"Our
history as a program includes many fine examples of when Kaiser Permanente
was willing to step forward, and as a result, serve as an example
and role model to the rest of medicine and the nation. I am grateful
to those who went to South Asia and to their colleagues who remained
here and provided outstanding medical care to the patients of these
physicians."
"As
an organization, we try to do the right thing, and in this case, we
did just that. I know that we will be ready to help should something
of this magnitude occur again. I am confident that should our assistance
be needed that you and your colleagues will once again volunteer to
serve. On behalf of our entire medical group, I thank you."
--
Editor's note: On September 12th, working in collaboration with the
US Department of Health and Human Services, Kaiser Permanente fielded
the first of multiple teams to the Gulf Region to assist the victims
of Hurricane Katrina.
A
Cough and a Child
By Cathy
Baker, MD Sri Lanka
Ob/Gyn
Roseville, CA
I keep
thinking about this guy. He initially asked for treatment for his
cough, a common complaint associated with the stresses that all the
tsunami refugees suffered. I thought of it as their culturally appropriate
way of expressing posttraumatic stress syndrome. Nonetheless, I listened
to his lungs, checked his blood pressure and asked him about his other
symptoms. Everything appeared normal for a middle-aged man.
Then
we asked him about his family. He and his wife had tried for many
years to have children. Five years ago, they had finally had a daughter,
a delightful child and a joy to be with, she was his reason to laugh.
He delighted in being her father. Now he had lost everyone--his beloved
child, his wife, and all of her family.
He sobbed.
The interpreter, also crying, could barely talk. I was crying. The
only thing I could do was to give him a prescription for vitamins.
Maybe it would help his immune system.
A
Wave and Two Children
By Christine
Fernando, MD Sri Lanka
Rheumatologist
Sacramento, CA
From
Colombo, the capital of Sri Lanka, it's an eight-hour drive to Batticaloa,
one of the areas most affected.
At the
earliest opportunity, we visited the campsites of the tsunami victims.
All related heart-wrenching stories of loss. One woman described how
the waves pulled her month-old infant and three-year-old son out of
her hands.
In addition
to giving medical assistance, I became a counselor, often returning
to our vehicle to cry. A few asked, "Why am I still living?"
Having no answers was the hardest thing for me.
At the
end of long days, we had each other for support. I am so grateful
to my teammates, Sarah Beekley and Hernando Garzon, for their support
and their friendship. We all became true friends as we traveled in
Sri Lanka.
This
will not be the end of my involvement in disaster relief. And I look
forward to the ways that I can contribute more in the future.
Strange
Alliances
By D
Scott Smith, MD Indonesia
Internist and Infectious Disease Specialist
Redwood City, CA
The tsunami
stopped the war and brought many people together from incredibly diverse
backgrounds--from around the world and from the local area. It was
exhilarating to work shoulder to shoulder for long hours, in an effort
to make things a little better.
If some
of the strange alliances that developed after the disaster would only
persist, this world would be a much better place: The Terminix Company
worked together with the Indonesian military to spray for insects;
the military took on completely different roles: delivering food to
the hungry and setting up diagnostic testing centers.
Like
others, I was amazed by the devastation, but I felt uplifted by the
opportunity to be part of the unified effort.
The
Pictures Children Drew
By Heena
Majmudar, MD Indonesia
Hospitalist
Walnut Creek, CA
I always
wanted to help people in need and make a difference in their lives.
When the tsunami hit, we all know that there was tremendous devastation
and that several thousand families lost loved ones. The aftermath
created the possibility of another catastrophe. An epidemic of malaria
could worsen the problems of an already suffering people. When KP
offered me this opportunity to go to Banda Aceh and help the people
affected by the tsunami, it perfectly matched my vision of helping
people in need.
I delivered
backpacks to one of the elementary schools. It felt so good to see
smiles on the children's faces. The children drew pictures of how
they were saved from the tsunami to show their gratitude and appreciation.
Being
a part of the Aceh community and getting to know the Acehnese people,
I was able to see their strength and to share their pains in a small
way. I was impressed by the resilience and courage of these people,
and that made me stronger. This experience helped me realize the importance
of life. It was a journey on an incredible mission.
A child's
toy in the mud in Indonesia. Photo by Randy Bergen, MD.
Dr
V, Batticaloa Attending
By Joshua
Weil, MD Sri Lanka
Chief of Emergency Medicine
Santa Rosa, CA
Today
was a nice day. I'm beginning to feel comfortable being driven around.
Getting behind the wheel here would be bumper-car madness. I like
the sights that are now becoming familiar--funky traffic, school children
in waves on bicycles, street vendors, working cattle, strolling cattle,
goats, dogs, shops, colorful clothing, and the daily bustle that is
Batticaloa.
We are
still organizing the new phase of mobile clinics for the camps, so
we are unable to go back until Saturday--I hope. Today I rounded on
the cardiac care ward, ICU, poison ward, and medicine ward--about
70 patients. It is fascinating. Dr Vivekanandarajah is the attending
for all of these wards. In the US, often a different physician would
attend each ward, for larger wards like medicine. Dr V has attended
at this hospital since the 1970s. He says that in the 60s it was a
pretty good place to practice, with plenty of staffing and a new facility.
However, since the civil war, neglect resulted in physicians leaving.
For a time, he was the only physician for the entire hospital! Now
he feels it's about 40 years behind the times. Though better than
a few years ago, it would be easier for him to practice in the capital
(Colombo) or even in the UK. However, he is dedicated to the people
of this area. To me, he embodies the important qualities of a physician
and a person.
Two
Little Girls and My Daughter
By Linda
V Packia Raj, MD Sri Lanka
Physician Medicine and Rehabilitation Integrative Medicine
Santa Clara, CA
For me,
the most cherished moment is the same as the toughest day. It was
hot when the grenade went off at the political office a block from
the hospital Sarah (McCarthy) and Cathy (Baker) were driving by. We
were sharing a house with eight people. Half of the team wanted it
cool, half wanted it hot. Half of the team felt it was dangerous in
the house; the other half thought it was safe because the incident
was like a drive-by shooting in LA. We were expressing internally
the external turmoil we were in. We were concerned that if we were
injured, it would jeopardize the future of "Kaiser International,"
as we thought of ourselves. We went to the orphanage to see a displaced
five-year-old. She did a little dance; she acted so cute. Just behind
her stood a girl in a pink, ruffled dress, crying. She had just come
to the orphanage the day before because her parents had lost everything
and had to give her up for her survival. Watching them ... my daughter
is three, I love her so much; I can't imagine how terrible it would
be to have to give up your child, the sacrifices people made out of
love.
The
Small Things
By Karen
J Kruger, MD Sri Lanka
Pediatrician
Richmond, CA
Our first
visit to the beach in Batti was one of the most memorable moments
of my life. Tropical beaches are my favorite of nature's gifts. Tremendous
efforts had been made to partially remove debris, but uprooted trees
and demolished homes were still everywhere. The small items grabbed
my heart ... a child's shoe up in a tree; a broken pot; one lone fishing
boat at sea; families afraid of the water, angry at the water; young
men hanging out at the shore, talking and laughing like you would
see on any beachfront, except they were carrying rifles. I saw the
generosity and resilience of human nature: terror, joy, peace, faith,
love, destruction, and reconstruction. That day, I heard stories at
the camps of heroes saving neighbors' and strangers' lives; stories
of unimaginable loss and unimaginable strength. It was profound to
stand in one place where all these parts of life took place. I am
tremendously grateful to KP for supporting this project. I am enormously
proud to be working for such a terrific organization.
Schoolchildren's drawing, Indonesia
Indonesia--What
We Heard: Eyewitness Accounts From Survivors
Because
emotional support was a major focus of our clinics, we discussed the
tsunami with everyone we cared for and so heard firsthand from those
who witnessed the disaster.
We heard
amazing stories--some of survival but almost all tragic. It was repeated
several times that in these villages, unlike in the city where almost
no one survived near the water, you only lived if you could run fast
and climb a tree. Fathers away from home returned only to learn that
their wives and children were killed. Everyone we saw in our clinic
had heartbreaking stories to relate.
--Lee
Jacobs, MD
People
Lost Everything Twice
By Malti
Charlu, MD Sri Lanka
Medical Director of the Anticoagulation Clinic
Santa Teresa, CA
When
we arrived, the geopolitical situation in Sri Lanka was rapidly changing,
and the acute disaster relief was evolving into a long-term rehabilitation
mode. Our task was to identify projects that would make a significant
improvement in their health care system, thereby making "Kaiser
International," as we were known, an unforgettable entity in
Batticaloa.
Each
of us, in our own specialty, focused our energy on the Batticaloa
General Hospital, even though we were fortunate enough to visit the
relief camps assigned to us by the local health care professionals.
Knowing Tamil, the local language, helped me communicate with the
people so enormously affected by the tsunami and by the 20-year civil
war. People had lost everything twice in their lifetimes. We were
helpless listening to their stories, because we could offer no immediate
solution except just to listen and to cry with them.
Many
people had chronic medical conditions, such as hypertension and diabetes--out
of control due to the disaster. We could do very little to help. Many
sought our medical expertise from the neighboring towns and villages
after traveling long distances to see us. We could often treat acute
ailments such as fever, various infections, aches and pains, sprains
and fractures, insomnia, and pregnancies. Most people were anemic,
and all we could offer were a few iron pills and vitamins!
What
strikes me most is that our administration stepped outside the box
and took a major risk by committing the personnel and funds to help
those in need from a distant disaster. During this project emerged
the best in all of us and our families and made us proud to be a part
of KP--or "Kaiser International" as the locals call
it.
The
Importance of Working Together
By Mary
Meyer, MD Sri Lanka
Emergency Physician
Walnut Creek, CA
The prevailing
atmosphere of goodwill and helpfulness of the refugees and all the
health care providers I met struck me the most. I had the privilege
of interacting with a number of volunteer organizations in Batticaloa,
including the Italian Red Cross, Oxfam, Unicef, and Doctors of the
World Greece.
At one
point, when my partner, Lali Thambi, and I found ourselves homeless,
a volunteer group from England moved mattresses to make room for us.
We later returned the favor and took in two nurses who were having
trouble finding housing. We met physician staff from the local hospital,
Batticaloa General and, during our three-week stay, were invited to
dinner at several homes.
In each
case, the people we encountered were eager and excited to share resources,
information, and emotional support. It was a true pleasure to work
in such an environment, and something that I brought home with me.
I work in a busy ER, and sometimes in my day-to-day life at KP, it's
difficult to remember the importance of functioning as a team, of
lending a helpful hand or ear to my colleagues. When I am tempted
to put blinders on, I remember the universal generosity of those I
encountered in Sri Lanka, and it inspires me to do better. It is one
of the best things that came from my experience.
School
House Horror
By Randy
Bergen, MD Indonesia
Chief of Pediatrics; Pediatric Infectious Disease Consultant
Walnut Creek, CA
My hardest
moment was at a village called Lamno, on Sumatra's west coast. While
delivering supplies during malaria training, we drove by a school.
The sight of this school brought me to tears--I missed my own two
girls. On the ground floor of a very solid, three-story building,
only a skeleton of the support columns remained--all the walls were
gone. On the second floor, the exterior walls were gone; and on the
third floor, above the level of the wave it was completely intact.
No child on the ground floor survived. Most on the second floor died
as well, but all of the children on the third floor lived. What horror
those children must have experienced.
Unlike
the clinical work of the Sri Lankan teams, our work was almost exclusively
public health: teaching, and advising. In that role, it is harder
to be certain of your impact. When we left for the airport, our Indonesian
coworkers and friends filled the vehicles, and we formed our own motorcade,
rivaling the VIPs. The people there know that even wealthy Californians
care about them and want to help them recover from this disaster.
Mama
Donut
By Nancy
Torres, MD Indonesia
Pediatrician
Roseville, CA
I will
always remember "Mama Donut." She was a woman on a small
island at the most northern tip of Aceh Province. She told me how
she had lost several relatives in the tsunami, including her young
son. He had run down to the ocean excitedly when the water receded
to see many fish jumping. He was grabbing at fish as she stood watching
on the hillside when the wave took him. She did not cry telling me
her story, but her face showed her unbearable grief. I felt so helpless.
All I could do was buy more donuts from her than I could ever eat
and hope that by listening and acknowledging, I might offer some solace.
KP
Made a Difference
By Regina
Pietersen, RN Sri Lanka
Pediatric Nurse
The Netherlands
Most
of KP teams had one person able to speak the local language. It makes
things easier, removing a barrier and putting you closer to the people,
and the people closer to you. Although some doctors might think they
achieved little, they showed a different way, a change of perspective.
If you were a doctor who listened, you made a difference.
Working
with KP gave me the opportunity to work outside my normal work as
a pediatric nurse/neonatal nurse trainer. I shared my knowledge about
the country, the city, the culture. Many people from around the world
worked together.
A
Casualty Come to Life
By Sarah
McCarthy, MD Sri Lanka
Obstetrician; Assistant Physician in Chief
Vallejo, CA
The physical
evidence of the tsunami was overwhelming, incomprehensible.
Our team
quickly accepted the omnipresent military presence, the frequent checkpoints,
the bunkers and garrisons, and the warnings about landmines. After
all, life in town went on. It was only through the refugees' telling
of stories that I began to understand the larger impact of the decades-long
civil war.
One family
recounted their second stay in the refugee camp; the first was after
fleeing from rebel fire, the second after losing their home to tsunami.
They voiced no self-pity, borrowing cups for limeade from a neighbor
tent to extend their hospitality to our team. A six-year-old girl's
new home was an orphanage after her father died in a bomb explosion
at a full moon festival on the beach. At first, she was considered
a casualty until someone witnessed her slight movement in the morgue.
People told many stories of lives, families, and homes disrupted from
poverty and the civil war, which had caused twice as many deaths as
the tsunami.
As the
international effort transitioned from tsunami relief to development
efforts, I was struck by the fundamental discrepancy in the way the
world responds to a natural disaster as opposed to a man-made disaster.
What could we, as citizens of the world, accomplish if each individual
annually contributed the amount s/he donated to tsunami relief? How
much suffering from starvation or AIDS could we prevent? Choose an
international relief effort and let us find out.
