Abstract: In the summer of 2005, 21 acupuncturists, three massage practitioners and a homoeopath traveled to Sri Lanka for three weeks as part of an Acupuncture sans Frontieres project to offer treatment to a population suffering the consequences of the tsunami of December 2004. This article consists of a personal account of the trip by three of the practitioners.
Keywords: Sri Lanka, acupuncture, tsunami, Buddhism.
“Whoever tends to the people, tends to me”. (Budddha).
With these words, accompanied by chanting, prayers and (numerous) speeches, the Acupuncture sans Frontieres (AsF) team were welcomed to the Buddhist temple in Matara, one of the three areas where we would work for the next three weeks. Our relief at seeing a sizable audience of potential patients eager to start treatment was mixed with considerable trepidation. The monks had already distributed 750 tickets for treatment (“Mr Danny shall we take it up to 1000?” the head monk asked me). The welcome was similarly warm wherever we went, with garlands placed round our necks, sweet tea and cake and invitations to participate with local dignitaries in lighting the ceremonial oil lamp. “We want you here” said the head monk of the temple.
It was a relief to start working. It had seemed a long time coming, though in hindsight things actually progressed very quickly, taking just six months from the initial idea to getting 21 acupuncturists, three massage practitioners and a homoeopath out to Sri Lanka to work in three formidably busy clinics. The big break for the project came with an introduction to the Venerable Makure Mangala, Chief Incumbent at the East London Buddhist Centre and a hugely kind and able man, who on hearing of the project was fully committed. We shared a similar aim - relief for the suffering of the people affected by the Asian tsunami. We were told at the opening ceremony of the first clinic that Buddhist monks had been providing this kind of charity work for hundreds of years and that the monasteries were the “First NGO (non-governmental organisation)” in Sri Lanka, a tradition which lives on to this day.
We found ourselves divided across three clinics in Galle, Matara and further north in Negumbo, and faced with a sea of people in desperate need of treatment. Driving along the coastal roads the evidence of destruction was not hard to see; everything had been flattened. Skeletons of buildings and scattered groups of graves mingled with ragged cities of tents and bustling building sites.
The three clinics worked in different ways, although all followed a system where the local (and not so local) people would queue up and be given tickets. The practitioners would then work at their own speed - some seeing 40 people in a morning, some just four. We used interpreters - some of whom we paid for (young university students from Colombo), and some of whom worked for free (usually local devotees of the temple). Negotiating with the interpreters was a skill in itself as some could be quite creative with their translation, sometimes even offering their own diagnosis of the condition in question. They were wonderful people, however, and have all asked to be given certificates of their work with us, which will be held in high regard when they seek employment.
Management of the clinics was not easy. Having so many people desperate for treatment sometimes led to something of a mob mentality amongst the patients, although the situation never became violent. Many would have to wait patiently for a whole day before we could see them, and then would return the next day to wait again. There were constant negotiations with the monks of the temple who wanted to ensure that everyone was seen by us once. They saw it as a special honour for these people to be able to tell their story to us and be given treatment, whether or not we could see them for repeat treatments. From our perspective we were concerned that to make our medicine effective we needed to see people more than once. In the end we reached a compromise; the majority of patients received regular treatment with the most serious conditions given priority.
Before we left for Sri Lanka there had, understandably, been questions about the effectiveness of an acupuncture project lasting just three weeks. The feedback from patients and other Sri Lankans involved in the project was, however, that these doubts were unfounded. To see the effectiveness of acupuncture in treating the kind of acute diseases that presented in clinic was inspiring. It brought alive why in the Chinese texts, both ancient and modern, you often see quite extreme indications for acupuncture points. For those of us who had never been to China it was exciting to have our eyes opened to this aspect of acupuncture treatment. We realised there is so much in the acupuncture toolbox that we rarely use. Bleeding treatment came into its own. With so much blood stasis, bleeding produced results that simply would not come from simple needling. I will not forget the man who had come in to the clinic barely able to walk, and who after his bleeding treatment proceeded to dance around showing us various calisthenic exercises with a big grin across his face; a result of a single treatment bleeding Weizhong BL-40 and the other purple, distended veins in his legs.
And there were the “miracles”; patients carried down to the clinic who got up and hobbled out; children that had never spoken who started talking. Countless times we saw people for the second time and their conditions had improved so much that we were continually questioning what we were seeing. Our reputation spread. We regularly chuckled in disbelief and thanked the gods of placebo (and any other spirits who were assisting us in our work), as some of the results we were getting just weren’t normal, at least in our experience of our clinics in the U.K. We wondered whether it is the case that acupuncture becomes more powerful the more out of balance someone is. In our clinics in England we tend to see people who have conditions which have either been moderated by other medicines, or which are simply mild due to such a plentiful diet, good hygiene, not having to work in the fields all day, etc.
This was a “tsunami relief” trip, and whilst we treated great numbers of people who had been affected by the tragedy, it became clear that a large part of what we were treating was the effects of poverty. Most of our patients had no recourse to any medicine - conventional or otherwise. If these people contract a disease or injury, they are stuck with it unless it clears up spontaneously. The pressures on them are great; many were manual labourers on the tea plantations. One morning as we travelled through the fields I watched an elderly woman carrying what I can only describe as a tree trunk on her back. This gave me a context for the number of acute back, shoulder and knee problems we saw in clinic.
And of course we saw many people who were evidently haunted by their experience of the tsunami. We could see it in their eyes as a deep sorrow and emptiness. Many times we would check the pulse at the end of a treatment, and find the Heart pulse barely palpable. Shenmen HE-7 was an important point. On the whole though, people did not speak of the tsunami. The Sri Lankans are such an unremittingly cheerful people, often inappropriately so. Many times we were told stories of harrowing destruction and horror, whilst the storyteller chortled away in the most macabre fashion. Initially I thought that this veneer of joy could not really run so deep, and underneath must lie the misery of their situation. In hindsight, however, and having spent more time with Sri Lankans, I was left feeling that this cheerfulness is a fundamental part of the Sri Lankan psyche; perhaps a legacy of Buddhist acceptance, perhaps a blessing from the land.
They brought everyone to see us. Paralysis, cancer, leprosy, elephantiasis, epilepsy, severe skin diseases, asthma; even people with learning difficulties. We did what we could and they were grateful. By far the most encountered conditions, however, were musculoskeletal problems - knees, backs, shoulders. Towards the end we started to run out of time and developed an efficient “conveyor belt” system where all those needing treatment on their knees were lined up and needled, and an assistant would go along and give moxibustion to everyone.
We also saw a great deal of numbness, indeed it seemed that every second patient had numbness, either in the hands and feet, or the arms and legs, or even the entire sides of the body. Often this was associated with diabetes, which was rife, unsurprisingly so given the Sri Lankan love of sugar. They even put it in fresh sweet fruit juice and we regularly saw five teaspoons of sugar going into a small cup of tea, to be eaten with cake or other sweets. Part of our job there became simple health education - and of course Chinese medicine is invaluable in this respect. Many people with chronic phlegm in their lungs, for example, were living on a diet of sugar, curd, milk, curry and bananas. Although Sri Lanka has a long tradition of ayurvedic medicine, it seems that this is being lost. Dr. Sunil Kari, who helped to set up the project, talked of his sadness at seeing the chronic health problems of his people, aggravated by modern junk-food, much of which could be easily treated by a return to a traditional diet of local produce.
As practitioners we represented a great diversity of acupuncture traditions and methods and we were able to learn a lot from each other. This was an exceptionally fertile and exciting environment in which to practice and we supported each other, made suggestions, demonstrated treatments and checked pulses and tongues. Many of us have come back to the UK enamoured with the Chinese way of practising acupuncture - a room full of people being treated at the same time. This can make acupuncture more affordable and seems to change the dynamic of the consultation and treatment in quite a refreshing way.
However with only two days off in three weeks, working in this way was highly pressurized and took most of us firmly out of our comfort zones. Some of us inevitably got sick with infected bites, exhaustion and diarrhoea. Living conditions, local diet and the working premises all presented difficulties. Some of the patients were extremely unwell, indeed some were dying. But we stuck together, supported each other, treated each other, and came out the other side as very dear friends.
We wanted to leave something behind us, so with help from John Tindall in designing the course, some of the group taught a group of local ayurvedic students and monks to administer ear acupuncture in a safe and effective way. The teaching clinic was a great success, and strong links have been forged with the ayurvedic college in Galle.
And what next? By the time you are reading this we should be back in Sri Lanka for AsF mark 2 - an opportunity for a new group of practitioners to carry on the work we started. At the time of writing we are also trying to establish contacts in Pakistan to see if, at an appropriate time, we might go over to treat the people affected by the earthquake. If there is one main lesson we have learnt from this first AsF project, it is that acupuncture has a huge amount to offer people who are suffering from disasters, poverty and trauma, and that there is a staggeringly large need for this kind of help across the world.
If you are interested in this work, or can help in any way with funding, contacts, or advice, contact Daniel Maxwell at email@example.com
This was probably the most fulfilling work I have ever done. More importantly, it was clear that the team made a huge difference to the people we treated. In my group I was one of the two practitioners with experience in treating children, so I spent a lot of time with under tens, doing the gentlest Japanese acupuncture techniques I could think of, and teaching the parents how to do daily massage. Some cases were very sad: we saw an infant with liver cancer on my last day. We weren’t able to do much, but we did baby-sit him while his mother got some much needed treatment for her stress and depression. Some teenagers responded very quickly to treatment and felt changes as soon as they got off the table. One 20 year old boy was blind and had had terrible headaches and dizziness daily since he was four. The headache stopped during his first treatment and didn’t come back during the two weeks I was there.
Even with such deep-set and chronic conditions some people experienced great relief, even after one session. One patient’s changes seemed so miraculous that at one point I thought she was just trying to please us, and I asked the translator if she was joking. Her numbness had gone, her pain had gone, her limp was gone. Apparently she was really telling us how she felt.
I realised something else about this kind of work; it feels to me what healing should be about. We were not distracted by any sense of transaction: no bills to pay, no charges to levy. It was just giving, out of a sense of human kindness or community, and in that giving we received something very special, a sense of worth and purpose that I for one, had never before experienced.
“Teaching a monk to fish”
When I was first asked whether I would be interested in going to Sri Lanka to offer acupuncture to people who had been affected as a result of the tsunami, I became very excited about the possibility of such a trip.
After that initial excitement, however, I began to think that even if we could go out and make a great difference to people's lives
in the short term, what would happen after we left? Would there be anything long-lasting to make a difference? Bearing in mind the Chinese proverb “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime”, I thought that if we were able to offer training in basic acupuncture to some local Sri Lankans, then we would have left behind skills that would continue to benefit peoples’ health long after we had left.
Before we left I had a chat with John Tindall, who had previously been to Ecuador on an acupuncture trip and had trained members of local tribes there. His experience helped inform me about the kinds of things that could be taught quickly to complete novices, making sure that health and safety considerations were a top priority. So when we left for Sri Lanka I packed a training manual that we had written and had translated into Sinhalese.
I did worry about how effectively one could teach acupuncture in such a short time, and whether I could demonstrate adequate integrity and respect for the knowledge that takes new acupuncturists in the UK much longer to learn. But I also remembered from a previous course how quickly a room full of novices could learn some basic ear acupuncture. I thought that if I was careful, emphasised health and safety at each step and gave the students just the right amount of information for their level, then no matter how much we covered, at least what the students did learn would be sound.
Two of us had decided to teach, and our makeshift classroom was an area behind one of the halls of the temple in Galle, which
had a roof, a few benches and a very old blackboard. The class was made up of some monks from the temple (including
one who was also an Ayurvedic doctor), a couple of Ayurvedic doctors/teachers and ten of their first year students (mainly young women all dressed in white saris). We had one translator with us, so progress was steady but slow while we waited for our comments to be translated into Sinhalese (only a couple of the girls and the Ayurvedic doctors could speak a little English). The students were all very diligent and eager to learn, and after a couple of days they were able to safely insert a needle into each others' ears using a flying needle technique. They had fun
learning some shaking qigong, and spent lots of time watching the body acupuncturists give treatments in the main clinic area.
One evening after a long bus journey back to our accommodation, we had a group meeting to discuss the clinics in the three different parts of the country. Two things were said there that changed the course of the student clinic.
In Matara, over 700 people had turned up for treatment on the first day, and the acupuncturists there were understandably
feeling quite overwhelmed. Also, one of the translators had shed some light on the nature of the peoples’ troubles by saying that after the tsunami, everyone in the region was suffering from depression. She said that people were so happy that we were there that even if they weren’t getting treatment, just to receive attention from us was helping. She suggested that if we could treat just one thing, then we should treat their depression.
In light of this information, I decided that the priority should be to just teach the class a simple ear point protocol for depression and shock and then take the students to help out at the busiest clinics to ensure that as many people as possible could benefit. The point combination I used was shenmen, kidney, heart, subcortex and adrenals.
It took another two days before the class was up to speed with this point formula and the necessary patient handling techniques, and then they were ready for their first day of treating. When you think back to that first day in the clinic with your first real patient, you can remember the nerves and the anxiety that you experienced. Just imagine how that first day would have been if you had had to treat over 200 people. I took the five best students with me, and two of the Buddhist monks to ‘hold the space’ at the clinic. We were working on patients sitting in the waiting area at the clinic, so it was important for someone whom the people respected to stop patients walking around with needles in their
ears etc. The students performed admirably, and between them they treated over 200 people on that first day without a
single needle stick injury or accident.
After that first day, the students were split up between the two southern clinics so that there were five to seven students
helping in each clinic every day. Working so closely with the local Sri Lankans in this way gave me some insights into their background and culture. One day I arrived at the clinic in Galle to pick up some of the girls to take to the clinic in Matara, but they indicated that they could not come along that day. Once I had found a good translator, I discovered that their parents were worried about the extra travelling time which would get them get home a bit later than usual. The only way I could get their parents' permission for them to come was if I personally took responsibility for them and promised to return them to a particular bus stop in Galle at a certain time. Of course, these ‘girls’ were actually 20 year old women but they are controlled by their parents until they marry.
I also discovered that women are expected to marry between the ages of 21 and 23, and any woman who isn't married by this
time is then considered a burden by their parents. As far as I was concerned, these young women could perform ear acupuncture just as well as (and in some cases better than) acupuncturists that I have seen in the UK, and if they continued studying they could all be really good practitioners some day. In Sri Lanka, though, they might be unable to pursue such a career because of their status in society and the possibility of them having to conform to the will of a disapproving husband or parents.
Overall I think the student clinic was a success. The students all showed a real enthusiasm for acupuncture and were able to see first-hand how effective it could be in a crisis situation. The Ayurvedic doctors were generous to us with their knowledge of Ayurvedic methods and herbs, and we shared the view that Ayurveda and acupuncture could fit well together as a treatment modality (and in fact, there is evidence to suggest that a large contribution to acupuncture theory was made as a result of the transport of Ayurvedic ideas from India to China in the third century B.C.E.). The abundance of extra (student) acupuncturists certainly helped us run more efficient clinics and by the end of our time there, everyone who had come in for treatment had received something from us, even if it was only the basic ear acupuncture protocol. We demonstrated that basic acupuncture techniques could be taught effectively in a short space of time, despite language difficulties, although if there was one thing I learnt on this trip it was to make sure that you have a really competent translator who can stay with you as much as possible. Students were able to learn a good technique and good point location with exemplary health and safety (not one needle stick injury), and the cross-cultural exchange was enhanced by working so closely with the monks, doctors and students in this way. I left Sri Lanka with many fond memories, and am still in contact with my students. I am sure that this experience has left something positive and long-lasting in their hearts, as it has in mine.
Appendix: Patient audit
From the results that were collected on the trip, those that had the most complete records were selected for the purposes of analysis. In total, 2101 patient records were analysed, consisting of 1270 female patients and 830 males.
Figure 1: Distribution of patient ages.
Figure 2: Distribution of symptoms.
Figure 1 shows the distribution of patient ages for both sexes. Figure 2 gives a graph of percentages for the different symptom groups encountered in this sample of patients. It is clear from these graphs that the majority of patients treated were middle aged, and suffered primarily from pain and musculoskeletal conditions.
This sample of patients was collated from the results recorded at all 3 clinics. Overall, 44% of patients were asked whether they had experienced a positive change, no change, or a deterioration in their main condition as a result of treatment. 56% were not asked, either because the practitioner failed to ask, or because it was their first and only visit.
Of the 44% of patients asked about their experience, 77% of those reported a positive benefit from the treatment/s. 5% experienced a worsening of their condition, and 18% experienced no change.