This article appeared in Ceylon Today on Wednesday August 27 2014.
The Consortium of Humanitarian Agencies recently honoured me with an invitation to the launch, on August 15, in conjunction with the Marga Institute, of a publication titled: Issues of Truth and Accountability (The Last Stages of the War in Sri Lanka).
I first encountered CHA in 2010 when I purchased a magazine called Groundview. The Groundview magazine was published by CHA and contained an article that dealt with the aftermath of the war in Sri Lanka.
In that article, one Joshua M Shoop chastised the Sri Lankan government for its laggard lack of action in the Northern Province. “The destitution and ineptitude in Mannar Town and the surrounding area is visible to anyone,” he wrote. Josh was studying for a Masters in International Development at Tulane University in New Orleans, Louisiana. He had been living in Sri Lanka for all of three months when he wrote his article. “Natives are suffering immensely from the impacts of the war”. Does anyone use the word “natives” anymore? “In progressive nations, this is where a government would come in to assist.”
Josh conceded the government had built new roads, which help the local economy, but he was unhappy because the roads were “helpful for military operations”. This reminded me of the Monty Python sketch in which John Cleese as Reg of the PFJ (People’s Front of Judaea) complained, “What have the Romans ever done for us?” “Reg: All right, but apart from the sanitation, the medicine, education, wine, public order, irrigation, roads, the fresh-water system, and public health, what have the Romans ever done for us? PFJ Member: Brought peace? Reg: Oh, peace? SHUT UP!”
Josh claimed the military was depriving “the locals” (that is what tourists call “the natives”) of jobs. “Several international and community-based organisations are operating in the area, assisting where they can, while further perpetuating a dependence on foreign aid.” Josh was one of those perpetuating that and planning a career based on such dependence. I would be interested to know how his career had developed. A Google search did not enlighten me.
Third World Louisiana
“Natives” in Louisiana, particularly blacks, are still “suffering immensely from the impacts” of America’s own civil war. That war lasted four years and ended 145 years ago. Sri Lanka’s civil war lasted 30 years and only ended 16 months before Josh wrote his article. Today, Louisiana has poverty, crime and health indicators, particularly for blacks, equivalent to those of third- world nations. The average life span of an African-American in New Orleans is nearly as low as for a North Korean. By contrast, Sri Lanka is a paradise. The World Health Organisation has said that Sri Lanka’s health indicators are improving all the time.
Tsunami and Hurricane
We are coming up to the tenth anniversary of the tsunami that devastated Sri Lanka’s coastal areas. Hurricane Katrina hit Louisiana on Monday, August 29, 2005. It would be instructive to contrast Sri Lanka’s reaction to the tsunami with the US response to Hurricane Katrina. The immediate Sri Lanka state response to the tsunami on 26 December 2004 was weak, but an effective, spontaneous, immediate response was organized locally, followed by the government and international agencies. Temporary shelter for the displaced was provided in schools, other public and religious buildings, and tents. Communities and groups cooperated across barriers that had divided them for decades.
Susantha Goonathilake wrote in his book, Recolonization, “Monks gave up their robes to bandage victims, looked after their children and babies, fed them from whatever little provisions they had, and comforted them. Illustrative of the genuineness of this response was the remote Eastern province temple of Arantalawa. Here LTTE death squads had once hacked to death young Buddhist monks. Now Arantalawa opened itself to nearly 1,000 refugees, most of whom were from the Tamil community and may well have included the very assassins who had hacked the young Buddhist monks”.
Twenty thousand Sri Lankan soldiers were deployed in government-controlled areas to assist in relief operations and maintain law and order. Sri Lanka’s past investments in a broad-based public health system and community awareness of basic sanitary and hygienic practices ensured that there were no disease outbreaks. Essential medical aid, emergency food, and other relief supplies were mobilized within a day. It was possible to feed, clothe, and shelter survivors; provide the injured with medical attention; and ensure that the thousands of bodies were quickly cremated or buried.
In 2008, Judge Stanwood Duval of the US District Court placed responsibility for surge protection failures in New Orleans on the US Army Corps of Engineers (USACE). USACE could not be held financially liable because of sovereign immunity in the Flood Control Act of 1928.
Primum non nocere
Sheri Fink’s brilliant book Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital describes what happened to hundreds of patients stranded in the Memorial Hospital in New Orleans for five days.
The hospital was part of a private for-profit chain owned and operated by the Dallas-based Tenet Healthcare Corporation. There was no generator mechanic on duty; there was no evacuation plan, despite the city’s history of hurricanes and flooding. The hospital generators were expected to work for 72 hours, but most were in the basement, which soon flooded. On August 31, the last generator gave up. Sewer systems and essential medical equipment were not operating. Staff smashed windows to let in air. In some parts of the hospital oxygen supplies ran out. Fifty-two patients, few of whom could walk, were in an intensive care wing without light or air conditioning. Could they survive?
Doctors felt the need to make some hard decisions and later referred to their behaviour as “battlefield triage”. This was not a war. Conditions were difficult but the hospital had food and water and was only a mile from dry ground.
Patients who could walk were placed high on the priority list for evacuation and those with “do not resuscitate” orders were placed at the bottom. Evacuation began slowly on the third day. On the fifth day, the euthanasia began. On September 1, 2005, morphine and midazolam, a nervous-system depressant, were administered. Some of these patients, it later transpired, were not as infirm as they appeared, and fatal injections were given even after rescue helicopters had arrived.
New Orleans’s public Charity Hospital had about twice the number of patients as Memorial, a lower ratio of staff to patients, and no helipad or corporate assistance. There was similar flooding and lost power, but only nine patients died. The public hospital had a different ethos than the for-profit Memorial – “the sickest were taken out first instead of last”.
When the evacuation from Memorial was complete, 45 patients were dead. Forensic consultants determined that 23 corpses had elevated levels of morphine and other drugs, although few of these patients had been prescribed morphine for pain. The investigators decided that 20 patients were victims of homicide. One patient in particular, Emmett Everett, was alert and in the hospital awaiting surgery for a condition not acutely life-threatening. He was only 61. He had fed himself breakfast that morning. One of his nurses later told investigators he had said, “Cindy, don’t let them leave me behind.” Dr Anna Pou was alleged to have administered a lethal cocktail of drugs to Everett with the intent of ending his life.
One doctor admitted to Fink smothering a man to death with a towel when the morphine did not work. Fink focuses largely on the investigation into the actions of Dr Pou and two intensive care nurses, Cheri Landry and Lori Budo, all three of whom were charged with second-degree murder. Anna Pou was regarded locally as a heroine who worked under desperate conditions and was now being victimised by the inept authorities who were responsible for the city’s plight. The charges against Landry and Budo were eventually dropped, and a grand jury chose not to indict Pou in 2007.
The main precept of bioethics, enshrined in the Hippocratic Oath, is “given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good.” Dr Bryant King, an internist at Memorial, told CNN after he had escaped by boat, “I’d rather be considered a person who abandoned patients than someone who aided in eliminating patients.” Bioethicist Arthur Caplan wrote in his expert report that the administration of the drugs was “not consistent with the ethical standards of palliative care that prevail in the United States”. He wrote that the death of a patient must not be the goal of a doctor’s treatment; and death, in his opinion, was the goal in these in cases.
Anna Pou went on to make much money as a lecturer on “ethical considerations” in disaster medicine. In her lectures, she has been less than candid about the conditions at Memorial hospital. She neglects to mention her decision to inject her patients with fatal doses of morphine.
Licence to Kill
Orleans Parish District Attorney Leon Cannizzaro testified, “human beings were killed as a result of actions by doctors” at Memorial after Hurricane Katrina. …whether or not there was a homicide and whether or not there is a case that can be brought are different matters”. The documentation compiled by investigators (50,000 pages) has been sealed by Louisiana courts. Pou refused to be interviewed by Fink based on her lawyer’s advice.
Pou helped write and pass three laws in Louisiana giving immunity from most civil lawsuits to health care workers operating in mass casualty situations.