Teaching Tamil Tigers

For over two decades, there has been savage conflict in Sri Lanka between a minority group of Tamils who claim traditional rights for land in the north-east and the majority, Sinhalese, government in Colombo. The conflict has consumed tens of thousands of lives, displaced hundreds of thousands, sown agricultural land with mines, laid waste plantations, and stunted a generation of children. It could be argued that the only rule of warfare is the respect each side has for the capacity of the other to terrorise: the desire for self-preservation has tended to restrict the number of civilians being bombed. Nevertheless, human rights organisations have reported over 4000 Tamil deaths in recent months. The conduct and cost of the conflict is obscured by suppression of the press on the government side and lack of access of the press to the other.
The Ceasefire Agreement in 2002 between the leaders for Tamil autonomy, the Liberation Tigers of Tamil Eelam, and the government in Colombo, and the effects of the Asian tsunami in 2004 have combined to reduce hostilities and permit greater access to the north-east by foreigners. In this time of relative peace, I visited the region in January and again in May 2005, delivering antibiotics and then ventilators and surgical equipment to hospitals throughout the island, supplied through the generous response of North Queensland to the tsunami.

Sri Lanka and southern India
Driving north from Colombo to Jaffna, I was struck by the poverty on the Tamil side of the armed border, the lack of facilities in the hospital in Kilinochchi (the administrative centre of the “Tamil” land) and the dilapidation of the tertiary hospital in Jaffna. Only the crowds in the corridors and the patients on the floors obscured the filth on the walls and passageways. Nothing obscured the suffering of apparently half-dead people being carried on bare metal stretchers at perilous angles up and down the stairs, buffeted in the surge. I was struck by the whites of their fingers as they clung to the metal. Nothing prevented the recycling of dengue through unscreened windows from sullage that pooled from broken pipes alongside the wards. One piddling tap leaned vainly against cross-infection in the crowded children’s barn. Why was this hospital so different to the many I had visited in the Sinhalese areas? I later learned of economic sanctions and underfunding by Colombo.
I volunteered to return to Sri Lanka in September 2005, originally to work as a paediatrician on the east coast, but diverted by my hosting organisation to work in Kilinochchi for a couple of weeks and teach “some students who had missed out because of the war”. I remembered the needs of Kilinochchi and was willing to comply. About three weeks later, I discovered that my students comprised the medical wing of the “terrorist” Tigers!
I met them in a shed whose walls reached halfway to a roof of corrugated iron that creaked in the heat of the sun, then roared with the monsoon rains as the weeks extended to three months, and I swapped tales of sick children for tales of my students’ lives.
We began awkwardly. As I entered, there was a sudden scraping of chairs on the concrete floor and then a silent standing to attention. I was further surprised by how many there were — 32 — and their being perhaps a decade older than I had expected. I introduced myself and asked them to sit. There was more scraping of chairs. Now they were sitting stiffly and silently. “Does anyone speak English?” I asked, and began to try to work out what they knew and what they needed. I had no idea I would grow to love them.

A home visit by one of the medical students
I realised they needed grounding in the old-fashioned approach of taking a history, examining methodically, and making provisional diagnoses and plans of management, though I soon sensed they had had profound experiences in triage and trauma. They had seen a lot of sick children but were thin on theory, so I decided to prolong my stay and start at the beginning.
After about two weeks, we had worked our way to the examination of the respiratory system and it was then that I discovered how close my students had been to the acute end of medicine. I invited a man to remove his shirt and a woman to demonstrate her method of examination and was surprised by the divot out of the man’s shoulder. Asking him what had happened, I noticed a similar deformity in the woman’s forearm. Shrapnel and a bullet, they explained, and everyone began to laugh. “Well, who hasn’t been shot?” I asked, and, to my astonishment, only about a third raised their hands. “Didn’t you notice our wooden legs?” someone asked and, adding to my foolishness, three were waggled for my inspection, with the class now in uproar. Who are these people? I wondered, and began the journey of discovery.
They comprised the medical wing of the Liberation Tigers of Tamil Eelam and were the remainder of an original group of over 70 who had been chosen from the ranks of the infantry because their commanders had concluded they had the potential to become doctors. The struggle for a Tamil homeland, Tamil Eelam, had entered a violent phase in the late 1980s, and the problem of casualties had originally been solved by taking them in small boats to sympathisers in nearby Tamil Nadu, in India. As the numbers increased and the political situation altered, they were taken to the hospital in Jaffna. But lives and limbs were lost in transportation through jungles or around the coast from distant front lines, and the need for the movement’s own medical wing became obvious.
In time, I asked them all why they had joined the Tigers and learned of the deaths and torturing of family members, of schools bombed, of the bodies of neighbours washing ashore, of mobs rampaging against Tamils and of discrimination in education and language. Each one had a saga and each had joined the Tigers because “they spoke less and did more” to protect their race against what they were all convinced was genocide. They had all been trained as infantry, but none had forgotten the speech by their leader, who had asked them to forego fighting for the greater goal of healing their people.

Paraphrasing a student’s stories of his experiences
The course had started in 1992, with some students needing preparation in maths, chemistry and English because they had not finished high school. Others had graduated in biology from university. The course paralleled the curriculum at Jaffna University but had been interrupted by long periods of service in field hospitals, in public health campaigns against cholera and malaria, in the manning of general hospitals, and by the needs of the tsunami, which had wrecked the north-east coast. The Ceasefire Agreement of 2002 had allowed them to catch up on formal education, but they were lacking a module on paediatrics, when I turned up out of the blue. My 32 students were those who had stayed the course. Others had been unable to resist the call of the armed struggle, some had failed academically, and five had been killed on active duty.
It was obvious they needed tuition that emphasised infectious diseases and malnutrition and it was easy to gather cases for presentation from my rounds in the ward and from outpatients. The days began with a lecture or two, then moved to cases, and included examination of the newborn and resuscitation. The poverty in the nursery was painful — mothers used old handkerchiefs for nappies.
They had never performed any formal research and were keen to be divided into groups to review perinatal outcomes, nutrition, causes for acute admission, snake bites and emotional effects of the tsunami. We found mothers and children to be wasted and stunted, road accidents to reflect the dangerous driving through the town, snake bites to be handled well, and counselling to be effective for grief. The findings were presented on a special research day, which evolved into an emotional ceremony of graduation.

Student treating civilian wounded by artillery fire
As the weeks progressed, I learned more of their lives and could not rest until one began to translate short stories he had written about their experiences. We began to meet every night in a small gazebo, sometimes curtained with rain, and went over his stories, line by line, paraphrasing from Tamil and amplifying for a wider audience in English. My mind was fascinated by the stories of medicine, my emotions drawn by their humanity.
I learned of the development of the medical wing from first aid to reconstructive surgery, encompassing the triage of mass casualties, blood transfusions on the front lines, and end-to-end anastomoses of arterial wounds with ketamine anaesthesia by torch light under artillery fire that thudded shrapnel into the coconut-trunk walls of their bunker. I learned of organisation and secrecy that could construct a hospital overnight in preparation for a battle in the morning . . . and of my students who had worked and worked until the casualties stopped coming — in their uniforms stiff with blood, on legs that could barely stand and under the sustained threat of sudden death.
I could scarcely believe accounts reminiscent of the First World War, and insisted on interviewing all the students mentioned by name, others not mentioned, and particular patients, cross-checking the details. I went to battlefields to see if the layout was as described. It was. Though overgrown by jungle, the bunkers that had contained the operating theatres were still visible, confirmed by half-buried vials of empty medical containers. Mounds of dirt confirmed former protective walls, and abandoned paraphernalia confirmed the fighting. Bones and shredded uniforms confirmed casualties.
Why they continued to fight still puzzled me, especially as I visited war cemeteries and pondered the carnage in which over 17 000 Tamil young people have died in the past two decades. Understanding began on the afternoon of 27 November, their equivalent of Anzac Day. My students collected me and, for the first time, I observed them in uniform, making their way through the cemetery, squatting here and there with parents of the dead who had begun to arrive in droves to festoon the graves with garlands and food for their young men and women who “were living on in the spirit of Tamil Eelam”.
There were about 3000 graves and soon the cemetery was pulsating with grief. The burning sun sank beneath a row of palms and I anticipated some kind of communal eruption of emotion as candles were lit on the graves and flickered on distorted faces. But there was nothing. No hymns, no chants, no catharsis. Just a speech on the necessity for more sacrifice. Silently, the crowd shuffled away, leaving the garlands and the candles to the moonless night. I began to realise what some people are prepared to endure for freedom.
I had a farewell meal with my students before I left and before they were dispersed to look after the population of their Tamil Eelam and the casualties of a war that has escalated. We made speeches, and they presented me with what was clearly a special gift: a Tiger flag (which caused anxiety clearing Customs on the way out).

Students operating and giving anaesthesia
Private possession of a Tiger flag, I am informed, is not “recklessly supporting a terrorist organisation”, but detectives from the counter-terrorism team of the Australian Federal Police were keen to explore why I stayed in Kilinochchi when I learned the identity of the students. I figured teaching doctors how to resuscitate children was in the interests of the people, whoever controlled them, but wondered if my career had reached a crossroads!
Subsequently, I did not mind going over all our overseas phone calls with the police or explaining why my bank had sent money to England (for a course on radiation biology), but I was a bit unnerved by the attention I received from immigration officials when I recently left for New Guinea. Being profoundly Australian, I found it unsettling to be perceived as being on the “other side”! I hear, however, that the Department of Public Prosecutions is not proceeding with my case, which is good news. The bad news is that it is unlikely I will ever be able to return to Sri Lanka, and the needs of the north-east weigh heavily. Tamil friends assure me that publicity for the situation is the greatest help I could offer Sri Lanka. With that in mind, the collection of short stories I paraphrased will be published in the near future.

Competing interests