What I Taught And Learnt In Sri Lanka

                            An Address to Former Peradeniya Medical Graduates

                                                      Las Vegas, May 2004

                           The Musings Of A Senile Teacher

One of the rewards for a teacher is to be invited to occasions such as this. It is adequate compensation for the Rs 9,500 a year (US $1,600 at that time) that the Peradeniya University paid me as a Senior Lecturer in Medicine between 1968 and 1976. There is a saying that if you pay peanuts, you get monkeys. By and large this is true – there were a fair few monkeys in the medical faculty. The ‘non-monkeys’ were quite mad to work for this salary.

As you know, I was trained in Cambridge and London at my expense, and had no obligation to return to Ceylon, except that my soul was there. Insanity? It probably was, since it was financial suicide. When I came to Ceylon in 1968 I had some Rs 60,000 in the bank. When I left seven years later, this had dwindled to Rs 12,000, not exactly a financial kill. I lost my entire provident fund because I had not returned a Rs 2 pamphlet to the library. It is an excellent way to make people bitter. For just two rupees!

I arrived in Australia in 1976 as Reader in Medicine (Associate Professor in today’s language), University of Queensland, and later, Senior Specialist Visiting Physician, Princess Alexandra Hospital, Brisbane. I arrived with a wife, two children and A$ 35 in my pocket. I had a job but no salary for a month because I had not actually worked. So, we were almost like refugees, “boat people”, except that we had arrived legally. But the ‘natives’ (Australians) welcomed me with open arms – in striking contrast to Jacko¹, Markar² and their ilk in Ceylon who did their best to make my life in my native Ceylon a living hell. This included dragging me before a “University Commission of Inquiry” on a charge that I had falsified my qualifications and was not even medically qualified! What? Falsified my qualifications to get a job in a backwater, a hole? They must have been joking. If so, a pathetic sense of humour.

Having had my whinge, looking back on the seven years in Ceylon, they were the most enjoyable. and certainly the most productive, years of my life. It was the only time that I felt that I was doing something useful and that if I had dropped dead, there would have been many, the medical students and the poor and underprivileged patients who constituted my ‘special area of interest’, who would have mourned my sudden demise. Many people who have worked and taught in the developing countries will express similar sentiments.

As for the medical students – I have been at this game from 1961 - I can say with absolute honesty that in these 43 years I have not had a more rewarding bunch to teach than the medical students in Peradeniya. It is for this reason that, despite pressing commitments in Australia, I agreed to fly some 22 hours for a ‘Baila’ party³ and return ASAP.

The students, without exception, were great to teach. A bonus was that I had some of the nicest people one could wish for as colleagues, both in the University and, even more so, in the General Hospital Kandy. There was Muthiah Kanagarajah (General Physician), Victor Benjamin (General Surgeon), “Pap” Joseph (General Surgeon), Chris Uragoda (Chest Physician, Kandy’s best researcher, perhaps because he was not in the University), Angelo Rodrigo (Professor of Psychiatrist), Dago Gunawardene (Dermatologist) and his wife Joyce (Psychiatrist), Mark Amarasinghe (Orthopaedic Surgeon who sent me hundreds of children with rickets to research on) and his wife Premini (Radiologist, who happily Xrayed them all), Raghu Ramalingam (Obstetrics), Anaesthetists Lakshman Wijeratne and Talwatte (who anaesthetized me to have my appendix removed, and then, as we will see, anaesthetized a pig for me to operate on ), ‘Venerable’ Aponso (Senior Lecturer Paediatrics –who for some strange reason ended each sentence with a grunt …Ugh), Chester Ratnatunga, a most competent Surgical Registrar who is now Prof. of Surgery, and Henry Eaton (Senior Lecturer in Surgery who had the dubious pleasure of removing my appendix which had ruptured. It had done so because I had for weeks denied that I had any abdominal pain since I was too busy to be ill even with an acute appendicitis.

Leading the pack was the incomparable Chelvarayan Barr Kumarakulasinghe, a friend of mine since 1946. He was the Senior Lecturer in Surgery and later Professor and Head of the Department of Surgery. Here was a man who could operate on any one, be it man or beast (as we shall see). The entire body was his domain. He would get into the brain, or go down and amputate a foot. In between he would remove the thyroid, the parathyroids, do a radical mastectomy, open the chest to resect an oesophageal cancer, do that horrendous Whipple’s operation which removes pancreas and duodenum, remove a kidney, yank out a colon, remove the urinary bladder or nip off an entire leg. This is the man who did a partial gastrectomy under a local anaesthetic and, despite his uncontrollable chatter, finished the job in 40 minutes. It was a patient of mine who was bleeding from a deep gastric ulcer. He was not only exsanguinated but we had exsanguinated the Blood Bank. I called Barr at 3am, about the time he finally sleeps. “Barr, you will have to do a gastrectomy”. Irresponsibly he asked, “ Will you give the anaesthetic, since there are no Anaesthetists or anaesthetics gases in Kandy today?” BS: “I can, but I doubt if the patient will survive. Instead of talking nonsense, why don’t you could do it under a local?” Barr, incredulous: ”You can’t do a gastrectomy under a local”. BS, undeterred, “Why not?” As I’ve said, in 40 minutes the stomach was out and not a drop of blood was given since there was none to give. It was my good fortune to work with such an outstanding bunch of people who were working under impossible conditions and producing world-class results.

Barr was a great surgeon and a great friend but above all someone to whom students could come to with every possible problem. He took upon himself the task helping students in every sphere, academic problems, of course, but also with their financial, domestic and family problems, their accommodation, in fact, any problem. He even got into helping students with major psychiatric problems (there were a couple). He would transport students in his rickety van between the hospital and the University – 4 miles apart. Some may remember standing at bus stops waving furiously to stop his van to get a lift. Whether they would succeed or not depended on his field of vision. He was severely myopic and could not see much beyond the tip of his nose. Barr was, and still is, a great soul, one of the greatest I have ever met.

I have already mentioned Kanagarajah, Benjamin, and Ramalingam. Not only did they shine in their specialties, but, what is more important, they were perfect gentlemen, people of honour and absolute integrity. When God made these people he must have thrown away the mould since they are no longer made. For my good fortune, my Tamil brothers I call them, Barr, Kanags, Victor, and Raghu, are all in Australia - unfortunately widely scattered in this vast country, which is the same size as the United States.

Having finished what I was doing I slipped into the ward and stood with the mass of students. Darrell was plugging for the causes of headache. “Cerebral tumour” said one, “tension headache” said another, the next one smiled, the next wiped his smile and said nothing and then he came to me. “You look a little more intelligent than the rest – what can you come up with?” My Registrar nudged Darrell and whispered “that’s Dr Senewiratne”. Poor Darrell, I have never seen a guy as embarrassed as that unassuming man.

The point was not lost on the students. “He is one of us”. That is what I wanted to be and if I achieved that, the entire seven-year stint in Ceylon was well worth it.

This identification with the students was a far cry from Cambridge and London. Lord Adrian, whose work in neurophysiology won him an FRS, was my physiology lecturer in Cambridge, Professor Verney, who discovered the osmo-receptors in the brain, was my pharmacology lecturer, Professor John Needham FRS and his wife Professor Dorothy Needham FRS were my biochemistry teachers. They were outstanding scholars but they were not “one of us”. They failed miserably as teachers; I’d give them 1 out of 10. I would not invite them for a student re-union.

Ironically, it was from one of these very famous people that I learnt the importance of being accessible. My teacher, as a clinical student in London and later as a Resident, was Sir Max Rosenheim, later Lord Rosenheim, Professor of Medicine at University College Hospital, London, and President of the Royal College of Physicians of London, who, among other things, introduced alpha methyl dopa to medicine. Despite his fame you could go to him with anything.

When the MBBS results were out, he refused to put them on the board until he had personally conveyed it to each one of us, a daunting task, given the number (200). “Let me be the first to greet you as Dr. Senewiratne”. When I got the much-coveted post as his House Officer, he wrote me a note (not typed) “I am delighted that you will be my next House Office. I look forward to working with you”. He visited Ceylon in 1958 when I was still a medical student, ferreted out my parents in the jungles of Veyangoda, visited them and told them “Your son is with me, don’t worry I will look after him” and look after me he certainly did. It were these simple things rather than the knighthood, the PRCP or being a member of the House of Lords, that made me worship the ground on which he stood. It was only a month ago (April 2004) while cleaning out the junk in my home that I discovered a hand-written letter from Lord Rosenheim to my parents dated January 1968. “Your roving son is returning home as Senior Lecturer in Medicine. You must be thrilled. I share your joy although I am losing a son.”

If you stand on a pedestal, be it as a teacher, or as a doctor treating patients, rest assured that you will achieve far less than you would if you identify yourself with your students and, for that matter, with your patients.

There is no better way to establish rapport with students than to invite them to your home. After my last lecture in Medicine for the year, I routinely invited all the students for dinner at my home. Some came, some did not. Those who came had a ball. Senior Staff from the University and the General Hospital Kandy were also invited. Feeding more than 100 students was not exactly a walk in the park but we managed with the willing help of many female students who played a key role in the kitchen. The males arranged the furniture, transported the booze and took charge of parking. The revelry went on till the early hours of the morning. Some were so drunk that they were in no state to return home. They spent the night sprawled all over my home, which they cleaned up spotlessly before they left. Several students became part of our family. These occasions were some of the most memorable I have of my life in Kandy and were well worth the sweat and expense it involved.

2. Caring And Compassion

Caring and compassion are what this game is all about. If you do not care, you are not worthy to be a member of this profession, however good you may be as a doctor. The caring must cut across social and economic levels. It is easy to care (or pretend to do so) when one is looking after a VIP. It is much more difficult to do so when looking after someone at the bottom of the heap.

One of my colleagues in Brisbane left this country, the USA, for that very reason. He was a senior ophthalmologist in one of your famous hospitals. A colleague had operated on a patient’s eye. That night my friend was on call and was summoned to the ward since the patient had developed a complication.

Out of courtesy he called his colleague, the ‘owner’ of the patient, to inform him and said that he could deal with it if he wanted him to. The question asked by his colleague was, “Is she important?” to which my friend replied, “I thought all your patients were important.” Shortly after that he handed in his resignation and returned to Australia where he is earning a pittance compared to what he was in the US. He has no regrets.

I woke up to this business of caring for patients fairly early in the piece in Ceylon. I had just arrived in Kandy and Macan Markar, Professor of Medicine, took me to ward 19B to show me my new kingdom. Having been trained in London I had never seen what went on in a public ward in Ceylon. There were patients on the beds, under the beds, between the beds and heaps of them sitting on benches on the verandah open to the elements. I asked, “Who are all these people?” Markar replied: “They are your patients”. BS seeks clarification: “But you said I’d have twelve beds”. Markar explains: “You have twelve beds” and he went onto count them “1, 2, 3 …10, 11, 12.” BS: “But there are scores of patients ”. Markar: “You do have 12 beds, but not 12 patients. The two are not synonymous”.

That night, still recovering from shell-shock, I decided to see what exactly was going on in what was now my ward, whose patients I had to care for. I decided to pay the ward a nocturnal visit and arrived at midnight. I had never seen anything like that in my life. There were patients, two in a bed, three in a bed, some lying across the bed with two beds pushed together. Some had typhoid, some had TB, others had neither but were likely to pick them up.

I decided that if this was what “caring for the sick” was in Ceylon, I’d better quit. An American who had arrived on the Hope ship said, “You can’t run, this is your country. Rather than run, may I suggest that you do something about it.” He reminded me of a famous philosopher who said, “Everyone complains about the weather but no one does anything about it”. That might have been an impossible task but the point was taken. It was a challenge to step outside medicine if necessary, and meet the challenge. This is what triggered that extension I built to ward 19B in the face of fierce opposition from the Medical Superintendent, a cretin whose name I cannot remember, and from Macan Markar.

Why the opposition when I was paying for it myself? The Hospital said that I could not “interfere with Government property” despite my assurance that I would not take it away with me when I left. Another objection was that if one Ward was better than the others, patients would clamour to get into it! The University objected that if one University Ward was better than the other, it discriminated against those who worked in the other Ward. Boy Oh Boy! If you want opposition and obstruction for the sake of it, you cannot beat Sri Lanka. Not even Parliaments, where this is the ‘norm’, could beat Sri Lanka. It is what is driving aid-givers, NGOs, and others, mad. It drove me crazy.

Fortunately, my ward was in such a remote corner that I was able to ‘quietly’ build the extension. It was, of course, finally discovered and all hell erupted. I calmly invited the authorities to pull it down, knowing full well they would not dare to. They did’t, and ward 19B became the only ward where patients were not exposed to the elements. The point I want to make is that where there is a challenge, it must be accepted. To run is not an answer. To act, even taking the law into your own hands, is sometimes necessary. There are some people whom it is our duty to offend. I will get back to this point later.

Caring doesn’t end with patients. It extends to one’s students and even one’s colleagues. I had some unusual requests from students, which were dealt with in an equally unusual manner. Students came to me asking if I could get the University to build some toilets in the Kandy Hospital. Jacko was the Dean and I took up the problem with him. The answer was “No they don’t need toilets”. So we decided to give him a lesson in basic renal physiology (see below).

There were other issues too. Medical students did not have gloves to assist at surgical operations. The guy who approached me, now in Sydney, did not speak the Queen’s English. “Sir, we don’t have cloves.” I thought “what the hell does he want cloves for?” A fellow Northerner translated, “Sir, what he wants is gloooves” (as in glows). So now we needed toilets and gloves. I went back to Jacko. Jacko: “No they don’t need gloves, they can watch the operations without gloves” BS: “But they have to assist in the operations, don’t they?” Jacko: “No they don't need to”

Then there were problems with the library which closed as 8pm and many students, especially from the lower economic stratum, could not afford the books. We had to keep it open till 10pm. “No. Not possible”, the standard reply of all incompetent and uncaring administrators who cannot see the problem or don’t want to.

We had no weapons to fight this tin-pot dictator. All we had was “people power”, i.e. the students. So we hatched a master plan to get Jacko to see reality. We crept in one night and padlocked the toilet in the Dean’s Office and decided to surround the office the next day. Jacko drove in the following morning, very nearly running over some of the hundreds of students who were massed outside his office. I stood with them. Dr Kanagarajah, a physician at the Kandy Hospital, who did not have a University appointment, came with me to bring my body back if Jacko got too violent.

Jacko, mad at the best of times, went berserk when he saw the mob. He came out of his office, spotted me and yelled, Come here you bastard”. I politely told him that my parents were married well before I was conceived, adding, “I have no problem but your students do”. He ordered some student representatives to come and discuss the problem(s).

As the meeting dragged on, to show what fine people we were, we sent him those wonderful bottles of “orange barley water” which the unsuspecting Professor of Anatomy, whose brain was not too cluttered with neurons, drank. As would be expected on basic principles of renal physiology, what goes in has to come out – one way or the other. As the bladder filled, he tried the toilet door. Locked. He now had the option of wetting his pants, which would be somewhat unbecoming for a Dean, or peeing into the washbasin – equally unbecoming – with students in front of him and many more peering in through every window. As the bladder reached breakpoint, instructions went out to the University maintenance staff that two toilets be built in the Kandy Hospital for the use of students, gloves provided for their use in operating theatres, and the library should stay open till 10pm. We gave him a loud cheer and even provided a guard of honour to the nearest toilet.

Compassion is an extension of caring. Let me tell you a story of a little boy from the tea estates who died in my ward. It was the time when Prime Minister Sirima Bandaranaike’s goons were storming the tea-estates and driving out the tea estate workers who were dying on the streets of Kandy. I used to do what I called my “nocturnal ward round” when I went round the streets of Kandy (some of you came with me) to collect the human refuse, pile them into my car and take them into my ward where they could die with dignity, love and care.

It was May, when the south-west monsoon breaks in all its fury. I had worked all day and was returning home dead beat. On the streets were the human refuse huddled on the pavements. I had to stop and pick the ones who looked the sickest and take them back to Ward19B.

Returning home, I saw more but pretended not to see them. I had dinner and crawled into bed. Half an hour later there was a deafening thunderclap and the rain came down in buckets. I listened to the pouring rain and felt that I had to get out and see how my friends on the streets were doing. Coming into Kandy town I saw a bundle on the pavement. I thought that some poor soul had left his earthly belongings and had gone to take shelter from the rain. I had a bit of plastic in the car and thought that I might put it over the bundle to prevent the contents from getting soaked. When I got to it I found that it was a bundle containing a ten year old boy. I asked him how he was, he replied in Tamil, a language I don’t understand. An interpreter said, “Sir, he says that he is alright. His parents have gone back to the estate to rescue what they could.” I shone my torch and was not as optimistic as the occupant of the bundle. He was severely dehydrated with a pulse that was barely palpable. What I thought was rainwater soaking his clothes was in fact the rice-water stools of cholera.

I decided to cart him back to ward 19B which as you may remember, was a female ward, but the sex was not important under the circumstances. Moreover, I was the ‘boss’! I set up a drip in a useless attempt to achieve the impossible. I sat with him as the night dragged on. Not a word passed between us – neither being able to communicate with the other. He held my hand in a vice-like grip, holding on to the only thing he had left. His big black eyes were glued to my face. I said a quiet prayer to whoever controls these things, that my little friend would go to some place where he would be better treated than he and his people had been in Ceylon which had just become the ‘Democratic Republic of Sri Lanka’, to boot.

I was dialysing a patient overnight and two medical students had offered to sit up all night monitoring the patient and changing the dialysis fluid. Seeing me come into the ward, they walked across to see what was going on. Seeing my distress, they decided to sit with me, rotating between me and the patient being dialysed.

After some hours, the boy said something in Tamil, which the student translated. “Sir, he wants you to go home since it is very late. He says he will be alright now“. I said, “Tell him I have no intention of going anywhere”.

As the pulse got weaker, the tears started to roll down my cheeks. The boy smiled and then turned as if to reach that locker which, you may remember, stood beside the bed. I thought he wanted some water and reached for the cup. No, it was not water but the rag next to it that he wanted. He picked it up and went straight to my face to wipe the tears that were streaming down. It was a touching experience in more ways than one. I noted with interest that tears were also rolling down the cheeks of the two students – males, I might add. It must have been an interesting sight to see the Consultant and two students weeping beside the bed of a dying boy whom none of them knew. I have no idea what happened to those two students but I am sure that they must be two very caring doctors somewhere on this globe.

Four hours later it was all over. I had not done anything useful in that the boy died but I thanked God that I had returned home to experience one of the most fulfilling days of my life.

Dawn was just breaking when I left the ward. I left strict instructions that the body was not to be moved until I returned in the morning and spoke with the parents. When I returned, the parents were there and fell at my feet to express their gratitude. As I bent down to pick them up I whispered that I should be down on my knees at their feet thanking them for putting our country on the map with their blood, sweat and toil on the tea estates from which they were now being hounded out.

1. To do what you can with what you have

Let me get back to those tea estate workers. With the Sri Lankan Government not interested in their health or welfare. we decided to run a free medical clinic in the Anglican Church in the Peradeniya Campus which you may remember, was on the perimeter of the campus, just adjoining the tea estates. People flocked there from the tea estates on Sunday afternoons. The clinic was run by some of you – most of them non-Christians. We stole drugs and dressings from the Kandy Hospital, went on a begging mission to the Kandy Pharmacy for out-of-date drugs and did what we could to manage with what we had or, in this case, what we did not have.

With the clinic in full swing the University authorities, for reasons best known to them, decided to act in the most destructive way. They ordered us off the University premises (the Anglican church was on University grounds). Unwilling to be beaten, we cut the barbed wire at the perimeter of the University, stepped across the line and functioned from under a tree just outside the campus. It was some of you who sacrificed your Sunday afternoons for this thankless, indeed risky, job of caring for these downtrodden people. I was so proud that they were my students who were doing this outstanding work.

Having just completed my MD thesis on electrolyte metabolism in cirrhosis in Dame Sheila Sherlock’s Liver unit, an atomic absorption spectrophotometer was an essential item for my survival. “No, not a hope in hell, we have no money to buy a pipette. If you want your fancy gadgets, go back to where you came from” was the unhelpful advice from the Professor of Medicine. I nearly did. The Hope Ship was fortunately visiting Colombo and the Yanks were streaming in to show the natives how to remove an appendix. A couple of them came my way and asked me if I had problems on my ward.”I do. Two urgent ones. One is to give this filthy ward a coat of paint. The other is that I need an atomic absorption spectrophotometer.” They replied, “We will certainly help you to paint the ward but that gadget you mention, we’ve not even heard the word. We are psychiatrists. In any case what the hell do you want if for?” I said that I was studying rickets with Mark Amarasinghe and wanted to do serum and urinary calciums. Unimpressed they said, “How did they manage here all these years? There must be another way to do this.” There sure was, a simple titration which, in fact, gave as accurate a result, thanks to my outstanding lab technologists, one of whom is with me in Brisbane. (Mark and I showed that more than half of childhood rickets was not due to Vit D deficiency, but to Vit D resistance from a genetic defect).

I finally got my toy but it packed up a few weeks later. With the technician some ten thousand kilometers away in England, my toy, an expensive one at that, lay on the table unused for the next six years, and then retired to its resting place in a store-room.

I have just returned (July 2003) after a visit to one of the more remote parts of the Solomon Islands. I visited the laboratory in the Adventist mission hospital to find that it was packed with toys from the United States donated by well-meaning but ill-informed folk. Not one of them was functional. I would strongly advise you to keep these toys where they are, and not export them to places where they cannot be serviced and maintained. I fear that you might send some of these toys to the more remote parts of Sri Lanka where they cannot be used because of the humidity or lack of maintenance. They will end up as impressive ornamental objects.

Let me turn to your help in managing a practical clinical problem. When I arrived in Ceylon, young people were dying from acute renal failure after being bitten by the Russel’s viper. “Why don’t we dialyse them?” The cretin who ran the hospital replied, “We don’t have the solutions, nor the catheters”. I protested, “But it’s only salt and water and Ceylon, by the grace of God, is an island with salt and water around it.” Some of the medical students said, “Tell us what to do and we will give you a hand to prepare the solutions”. They did. Dialysis solution was now available in bucket loads but there were only two peritoneal dialysis catheters which soon became unusable. One of the more enthusiastic types suggested a young flexible bamboo shoot with the nodes drilled through. It worked. An endless supply of homegrown dialysis catheters emerged.

We then ran into an unexpected problem. There were no plastic tubes to connect the catheter to the bottle. One of you, a bicycle enthusiast, said that he could fix it. He disappeared into Kandy town and came back with miles of rubber tubing which I gather is used for ?bicycle tyre valves. We boiled it up and it sure did work to transfer the fluid from the bottle to the catheter. With these improvisations we dialysed some three hundred patients with locally made solutions sterilised in our domestic pressure cooker, supple bamboo shoots as catheters and some rubber tubes to carry the fluid. I might add that the complication rate was no higher than in London, with all its sophistication..

I stress all this because some of you, I hope, will return albeit for a short time, to that sinking country. If you do, don’t try to make it into a Los Angeles or a New York. It won’t work. Let it be what it is – Kandy, Jaffna, Kilinochchii or Colombo, and do what you can with what is available. I hope the Americans, currently setting up cardiac surgery in Jaffna, are listening.

1. Clinical decision making

In an age where you scan first and think later, I hope I taught you the importance of taking a proper history and doing a proper physical examination. With few exceptions, if at the end of the history you are not within striking distance of the diagnosis, you’ll probably not get there. If at the end of a full physical examination you are not there, the scan will probably not help. If you do find something unexpected, it will probably be an “incidentaloma”, an incidental finding which will send you chasing red herrings, doing more harm than good. Doing every possible investigation on every patient is not only a complete waste of money but a major cause of (unnecessary) anxiety.

May I suggest that you go back to Sri Lanka for a while. It might be beneficial to both parties. Sri Lanka will benefit from your undoubted expertise and you will benefit from the experience and satisfaction of making a clinical diagnosis using your brain and not some exotic toy.

2. Communication

In an age where medical education has degenerated into filling boxes in MCQs, we are training doctors who are unable to communicate with patients. Indeed, some of those who are taught in Australia are afraid of patients and even afraid of touching them. We have got down to the point where a patient presenting in the Emergency Department has to say, “Doctor, which of the following statements about me are not correct.” I urge you to touch your patients, it is a good start to a clinical examination. I urge you to spend some time explaining to patients in language they can understand the nature of their disease and what you are going to do about it. It will pay enormous dividends. “That brown doctor spent so much time with me. This is the first time I have understood what diabetes is, having suffered from the disease for the past two decades”, is something that I have heard on more than once in Australia. Rather than an attempt at self-adulation, I look at this as an absolute condemnation of the way Medicine is practiced today.

6. Research

There was no research laboratory when I arrived. The gentlemen who were there had argued for years that it was not possible to look after patients, teach students and do research. I was determined to challenge this bluff. I partitioned off a tiny space 8-foot by 8-foot at the end of the ward just next to the stinking toilets where patients defaecated on the floor being unable to reach their destination. I called it my “Research lab”. The Professor of Medicine gave me a table, chair, microscope, paper and pencil. “That’s it” he said.

With these somewhat ‘limited resources’, we embarked on a research project on betel chewing, that terrible addiction which is such a potent cause of buccal and lower oesophageal cancer. It were the medical students, some present here, who did that outstanding bit of research, visiting every house in Kandy interviewing each of the occupants. This, and other epidemiological surveys done with a pencil, paper, legs to walk on, and the enthusiasm to drive them, made their way to The American J. Trop. Med. and Hyg. (1973.22.416-422).and was the only publication of its kind, perhaps even to date, and to the J.Trop. Med and Hyg.(1971.74.145-147).

I tried to introduce you to critical thinking. On a ward-round faced with a patient with profuse diarrhoea, I said, with typical British know-all, “That’s amoebic dysentery”. Turning to one of you I asked, “What do you think?” The reply: “Amoebic dysentery”. BS: “Why?” Student: “Because you said so”. I responded, “Just because I said so it does not necessarily mean it is correct. Take some faeces to the ’research laboratory’ (i.e. the room next to the toilet) and see if you can find amoebic cysts or trophozoites”. She was back in a flash. “Sir, there are Giardia”. BS “So I was wrong. Why don’t you all do a research project and see how many of the diarrhoeas treated as amoebiasis are actually correct?” So started another research project. As other excited students joined her in a mad rush to get into this poky little room, in walked Professor Graham Wilson, an emissary from Lord Rosenheim, sent to see how I was faring. Wilson was Professor of Medicine, Glasgow University and a VIP in the Nuffield Foundation. He was about to fundamentally change my life in Ceylon. Seeing the madly rushing students he asked “What’s going on here?”. BS: “These are students in my research laboratory working on the pathogenesis of diarrhoea.” Wilson: “Is this your research laboratory?” BS “Yes. Why, what’s wrong with it?”

He returned to London and I got a letter from the Nuffield Foundation that I had been awarded one of the largest research grants ever awarded to any Ceylonese to set up a clinical research laboratory. It remained nameless but should have been called, “The Medical Student’s Clinical Research Laboratory”. It was the only clinical research laboratory in the whole of Ceylon. I did not intend to make all of you into research workers but I hoped to have a place so that anyone could try out any idea, however crazy it sounded.

The building of this laboratory was not only interesting but carried a few lessons. It was built on that almost vertical slope just behind my ward. This building came up, but not without a fight. On the proposed site was a jak tree – old as the hills. The Government had declared that no jak tree could be cut because the fruit had value as a food. But this tree was menopausal – not having had children in living memory. So I asked the cretin who ran the hospital whether I could cut it down to build my laboratory. “No, there is a Government regulation”. BS “But this is a tree which is senile and most certainly menopausal”. The gentleman, who had three Betz cells which did not synapse, was unmoved. “No, it cannot be done”.

Having failed after a series of attempts at ‘peaceful negotiations’ to settle the problem I decided to turn to violence – as so often happens. I hired two axe-men who arrived at 2am to attack the tree. It was so rotten that when we had cut it halfway the rest crashed down. Mission accomplished, we vanished.

The following morning I breezed in as if nothing had happened. The entire hospital administration was there in force. They headed straight for me, “Did you cut that jak tree?” BS “No, I cut only half the tree and Newton did the rest”. My line was that I had committed only half a crime, the other half being committed by Newton. The Medical Superintendent (MS), “You’ll go to jail for this. In any case, who the hell is Newton”. Rather than go into the laws of gravity, I tried to be helpful. “I am more than willing to replant it”. MS: “You can’t do that”. BS: “Can I have that in writing that the Superintendent of the Kandy Hospital has prevented the planting of a jak tree. May I respectfully point out that this contravenes Government policy for which you could well go to jail”. The man blew his top, wet his pants in anger (I think he had a problem with the emotional control of his bladder), and stormed out. When the dust had settled we chopped up the tree and made begging bowels which we donated to the Buddhist monks in the temple just above the lab-to-be. We thought that this might get us enough brownie points to go in the direction of Nirvana for the crime we had committed. I might add that it was at a time when Buddhist monks (at least a few of them) did go begging as Buddha had ordered them to. Today they go ‘begging’ in their Mercedes or go ‘begging’ to get into Parliament. O tempora! O mores!

The purpose of this narrative is to indicate that where peaceful negotiations fail, force may be the only answer. Any analogy to the political situation in Sri Lanka is entirely unintentional. The jak tree out of the way, we got on with the business of building a research laboratory. It was here that some of you had your first taste of medical research, basic stuff – nothing to shake the world but important in the total training of the developing mind. Students were welcomed to try whatever crazy ideas they had or, if they had none, to try one of my crazy ideas – I had plenty. One, who was later to become my adopted daughter, was researching the effects of food on the ESR. Was it really necessary to starve patients to do an ESR as was thought, or did it not really matter? She did not win a Nobel Prize but today is a successful rheumatologist in Sacramento. Incidentally I suspect this lass had more than a small role to play in inviting me on this mad jaunt across the Pacific.

Another worked on the pattern of poisoning in a developing country which made its way to the British J. Prev. and Social Med. (1974. 28. 32-36). Going on to work on lactase deficiency in Sri Lankans, information about which was totally lacking in the world literature, she had the work published in the prestigious journal Gastroenterology (1977.72.1257-1259) She went on to submit the work to London University and was awarded a Doctorate in Medicine (MD).

Another who had all his research experience in this laboratory was appointed as the Professor of Medicine in a Medical School in Southern Sri Lanka and later as a research worker in a major pharmaceutical company in England. Yet another is also the Director of drug research in another major pharmaceutical company, also in England.

There were scores of you who worked with international research workers from the famed UCLA on anaemia and the health problems on tea-estate workers, which had never been done before nor since.

Midnight madness.

From the time I was dissecting corpses as a medical student in the mid 1950s, I had been curious as to why God put the parathyroids in such an unlikely place,almost embedded in the thyroid gland with which it has no physiological link. I had a vision of atoms of calcium going to the thyroid and telling it to tell its neighbour, the parathyroid glands, to do something about the falling blood calcium level. Here at last was the time to look into this crazy idea.

The pig is one of the few animals where the thyroid and the parathyroid glands have readily separable blood supplies. I decided to cannulate the thyroid artery and the parathyroid veins, alter the calcium concentration of blood supplying the former and see what happened to the latter. This was surgery well beyond my technical ability. I called Barr.

BS “Barr, I want you to operate on a pig”. Barr “OK . What about 11 o’clock?” BS “No I have to give a lecture at 11” Barr “What? At 11pm?” BS “Oh pm? Why pm?” Barr “Why not?” Barr had (and still has) a major problem with sleep. When the rest of the world thinks it’s time to go to sleep, Barr is just getting warmed up for the day. So 11pm it had to be.

I was keen on getting the medical students involved, partly because I wanted them to see how exciting medical research was and/or how crazy research workers could be. Besides, I needed physical help and asked for volunteers. There was no shortage. We needed some able-bodied men to hold down a 300 lb pig while it was being anaesthetised and then hoist it up to the “operating table”. The females were needed to make sure the pig would not suddenly wake up, to run between the pig and my laboratory assistants in the next room carrying blood samples, and to make innumerable cups of coffee to keep us ll awake. The lads arrived on their bikes, the girls were transported in Barr’s ramshackle van, the boot of which had to be tied down with ropes.

I explained to them my crazy idea and suggested that they could come up with an even crazier idea. These will all be checked out. I told them that we could hit the jackpot but were much more likely to find that it was a complete waste of time. That was what medical, indeed any, research was all about.

Pig No.1 had an early demise since I was the anaesthetist. We carved up the 300 lb of pork and stuffed it into every available refrigerator - Barr’s, mine, that of our friends and even our enemies.

We were now on Pig No.2, this time with a real Anaesthetist – Dr Talwatte, ‘borrowed’ from the Kandy Hospital. I was demoted to surgical assistant. We started as usual at 11pm. Barr opened the neck and was fiddling trying to find something that neither of us had a clue where it was. He finally gave me a clamp with a loop of thread round it. “Hold this”. Barr went on fiddling in a small hole down which I could not see. I doubt if he could either. Some half an hour later with sleep and boredom getting the better of me, the clamp was beginning to sag. Barr: “Can you please concentrate? This is very delicate surgery.” I protested that I was, with clear evidence to the contrary. Half an hour later, with Barr still fiddling, sleep got the better of me and I slowly sank to the ground taking the thyroid artery with me. I woke up to find Barr desperately trying to clamp something which was spurting blood at the bottom of a deep hole.

Unhelpfully I drew his attention to a ‘technical problem’. BS: “Barr, I think we have a technical problem”. Barr: “You think I don’t know?” BS: “I don’t think you do. It is that we can’t afford to lose another 300 lb pig. Our refrigerators are full and there is no room for any more pork.”

Barr is the most unflappable person on this planet. This was about to change. I saw his pupils dilate, the sweat was beginning to run, a slight but definite tremor was noticeable. I knew his adrenals appreciated the gravity of the situation. The animal was bleeding to death with no blood transfusion since pig blood was ‘O.S’. (Sri Lankan for “Out of Stock” which applied to most drugs, indeed to most things in the Hospital). I said a quick prayer that Barr would find what he was blindly searching for. It worked. He clamped something and the bleeding stopped. My faith in God (and Barr) was restored.

You may wonder what happened to that beautiful research laboratory which produced more papers per unit time than any other laboratory in the whole of Ceylon. With my departure, it was vandalised and later turned into the matron’s quarters. An even greater tragedy, which I will address later, was that my laboratory research assistant, an outstanding village lad whose laboratory skills were unparalleled and who was cited in more publications in international journals than the Professor of Medicine, was demoted to cleaning drains after I left. Such is the tragedy of Sri Lanka

What I have learned.

Let me now turn to what I have learnt over the years.

1. Not to be arrogant.

One lesson that I learnt fairly early in the piece after returning to Sri Lanka is not to be arrogant. It was one of your fellow medical students who taught me that lesson. I had just finished one of those horrendous Outpatient clinics when one of your colleagues, a diminutive lass, asked if she could see me privately. I thought she was sick. No, she was not. In a soft voice she said “Sir, that first patient you saw, what was the problem?” BS: “Some form of rheumatism, perhaps rheumatoid arthritis “. She “And what did she ask you”? BS “Whether acupuncture would help”. She “And your response? “. BS “That it is crap”. She “Sir, when we heard you were coming here as a senior lecturer in medicine we were delighted. We thought at last we were getting a scientist, and a man of learning. After that remark of yours I realised that in addition to the vast string of British medical degrees after your name, they had also given you a good dose of British arrogance”. She went on in her soft voice to ram it in “Sir, with no intention to be insulting, what is your experience with acupuncture? You have been trained in a different type of Medicine. What makes you such an authority in an entirely different type of Medicine to so arrogantly dismiss something that has survived a thousand years as “crap”?

It was an invaluable lesson and I am deeply grateful to her. The lesson learnt from this medical student was that it is never wise to step outside your area of expertise and make ex cathedra statements on subjects about which you know nothing. Acupuncture, homeopathy, devil dancing, a visit to Mecca, touching a statue of the Virgin Mary, do they work? God knows - and if He does, He has certainly not told me. Until that happens, I should say “ I don’t know”.

That lesson in not to be arrogant extended even to my work on the wards. I could not manage to look after all those patients in Ward 19B and decided to delegate responsibility to my Registrar and House Officer. They looked after most of my patients. I was a spectator. There were many times that I did not totally agree with their management but decided to let them do what they intended to do as long as they did not harm the patient and this I monitored closely. Often their management turned out to be as good, if not better, than what I could have achieved.

This delegation of responsibility also gave the junior staff the confidence to stand on their own two feet and not lean on me. I remember a patient with an amoebic abscess, which had to be drained. The Registrar asked me to do it saying that he had never done one in his life. I told him “Well, it is your patient, if you do not know how to drain a liver abscess, duck out to the library, here are my car keys, find a book called “Clinical Amoebiasis” by A.J. Wilmott, have a read and make it quick, there is no time to waste lest the abscess ruptures.“ He came back within the hour. I was waiting for him. I stood at a respectable distance, not breathing down the back of his neck as he stuck a 15 gauge needle and the expected anchovy sauce pus drained out to everyone’s delight, not least of the elated operator. That is how you make Residents and Registrars into Consultants – not by behaving like a demi-God or, God himself.

2. Why people leave Sri Lanka. The critical shortage of trained personnel.

One of the things I learnt was why people such as you, leave Sri Lanka and the other reasons for the serious shortage of trained personnel in that country. I analysed this in two large articles on the Emigration of Doctors in the British Medical Journal (1975. 1. 618-620, 665-671). Incidentally, when these articles hit the deck in Sri Lanka, I was suspended from my job as Senior Lecturer in Medicine, the charge being that I had not got permission from the Dean (Jacko – God forbid) and the Vice-Chancellor (a similar cretin) before “bringing the University and the country to disrepute”. When it was pointed out that I could sue the pants off the University for wrongful dismissal, I was promptly reinstated. That is the sort of stupidity that can only happen in universities.

I was reinstated but my salary was docked for the two days I had been suspended. It was Rs 9,700 divided by 365 x 2 = Rs 52. What did I do? Nothing. I think the phrase is ‘grin and bear’. There was nothing else one could do. Indeed, there is nothing you can do even today. This is important since if you intend to go back to Sri Lanka even for a few weeks to work there – in the South, and especially in the North and East, and you don’t have a sense of humour, the ability to ‘grin and bear’, don’t go. But I digress.

Sri Lanka is facing serious problems – some of its own making and others a direct consequence of British colonial policy which I have gone into in detail in other fora. Everyone knows about the ethnic problem. There are other equally serious problems such as increasing poverty, lawlessness, galloping corruption, and abysmally poor governance. However, the biggest problem and the one that will make Sri Lanka virtually impossible to help, is a serious depletion of trained man-power – the loss of the likes of yourselves which that country can ill afford.

This problem continues at a haemorrhagic pace. The rest of the world calls this the “brain drain“. Jacko, the mad Dean we unfortunately had, preferred to call it “the welcome departure of ‘drained brains’”. So, when you left Sri Lanka, you were already depleted of brains. That you made good in this and many other countries is something beyond the comprehension of Jacko and similar idiots who have been at least as responsible as politicians for wrecking that country and sending it hurtling down into a basket case. At Independence in 1948 Ceylon was economically on par with Singapore. Fifty years later, thanks to those who ran the two countries, Singapore is fast becoming the country with the highest per capita income in the world while Sri Lanka is heading towards the bottom of the pile. Singapore’s success is not only because Singaporeans are hard working but are able to keep the likes of yourselves while Sri Lanka’s outstanding ability is to lose them.

Why Did You Leave?

Why did you leave? I don’t know – you tell me. The popular perception that people believe or would like to believe, is that all of us left in search of money. I would challenge this. Most of us left because we were treated like dogs or there was the real possibility of being treated so judging from what had happened to others. Treated like dogs, discriminated against on the basis of ethnicity, not having the necessary political connections, or some such crucial factor, which apparently is essential for survival in Sri Lanka.

Speaking for myself, I did not return to Ceylon in search of money. I did not turn down a Consultant appointment in a major teaching hospital in London – complete with an already established Harley Street private practice of my boss, the late Dr John Walters, Senior Physician Hospital for Tropical Diseases whose Senior Registrar I was, to return to some bankrupt dump (see photo below) looking for money. I knew it was financial suicide at an annual salary of Rs 9,500 – something I could earn in less than a week in London. I returned because I wanted to live and work in the country of my birth and among my people.

I did not come back to Sri Lanka in search of money, nor did I leave it in search of money. I left because I was told that the country did not need a troublemaker (read: he who pointed out what was wrong), and a “black Englishmen” (read: someone who opposed the teaching of medicine in Sinhalese saying that it would set the clock back 200 years). My departure was not a great loss – it was, after all, a “drained brain”. The fact that the clinical research laboratory, the only one in Sri Lanka, shut down, the renal dialysis unit ceased to function (dialysis was restarted many years later), that the medical school lost a dedicated teacher, that the country lost a Physician which it had got gratis, were not important. What was important was that they had got rid of a pain in the arse. I gather that a high-up in the Medical Faculty in Peradeniya had told someone in the Australian High Commission in Colombo that Australia has done a lot for Sri Lanka but the greatest help was to relieve Sri Lanka of a bastard – a pain in the arse, myself.

I can tell you of a far greater loss, the loss of Dr Karunyan Arulanandam. Karunyan, whom I did not know at the time, applied for a post of Lecturer in Paediatrics in Peradeniya. He was by far the best of the applicants. Who was appointed? Not Karunyan but Pep Jayasena’s wife. What were her qualifications? None other than the fact that Pep was the friend and stooge of the Dean of the Faculty of Medicine, Prof Senaka Bibile. The gutless selection board thought this enough reason to make this outrageous appointment. It was like choosing a cheap trinket when one could have a gold chain. I was devastated, even more so than Karunyan. I wrote him a letter asking him to accept my apology on behalf of the saner members of the Faculty at this grave injustice. He still has that note written over three decades ago. Karunyan, seeing the writing on the wall, quit and is today one of the most competent and best loved Endocrinologists in Lancaster, California, and his wife, Inpam, a most competent Pathologist. So, in one irresponsible act of favouritism, an act of academic barbarism, we lost two outstanding people but then they were “drained brains”. I am sure you have many more stories of a similar kind involving yourselves and your friends.

Who replaced you? Doctors from the Philippines and elsewhere who know little English (they certainly know no Sinhalese or Tamil) and even less medicine. These are the “brains” who have replaced the “drained brains”. A short while ago I had a personal letter from President Chandrika Kumaratunga, a woman I know. Let me quote, “My dear Brian …the greatest problem I face as Head of State is to find trained people and people who can do a job of work. If you can help in getting such people to come and work here, even for a short period, I would very much appreciate it …” Well, I thought, it is of your making and the making of your parents and others from both sides of the political divide, whose ‘work of art’ this is. The chickens, now fowls, are coming home to roost. Perhaps I should have added, “Do you want the ‘drained brains’ (a la Jacko – your mother’s trusted friend who changed the colour of his tie from green to blue and vice versa depending on the political party in power) to come back?”

Let me digress to tell you a tragic story of “Sene”, that hyperactive young man in short trousers who used to flit around my research laboratory and my ward doing anything and everything.

“Sene”, mercifully shortened from “Nuwan Bandara Seneviratne Gannoruwa Athouda Seneviratne” (no relative I hasten to add) was a village boy who was cleaning the drains in the University and its extension in the General Hospital Kandy, when I arrived there in 1968. I was working late one night when I saw two eyes peering through the window. “Who the hell are you and what are you doing?” I asked in Sinhalese-English – i.e. Sinhalese as spoken by a Black Englishman. “Sir, I have to lock up.” I told him that I was capable of closing a door and would he kindly go away since it might be the early hours of the morning before I finished. “No Sir, I will get the sack if I don’t lock up. You can take your time.” I said, “Then, at least, come in and sit down”. He did, on the ground, not that there were no chairs.

Having watched me for some time he mustered enough courage to ask, “Sir, what are you looking at?” I said I was looking for malaria, “the things that cause the fever.” Sene:“Can you see them?” BS “Yes, if you know what to look for. Would you like to see one? Why don’t you come and have a look?” Sene:“Sir, I have no education.” BS: “You don’t need an education to look.” So I showed him a Falciparum ring. I then moved the slide and said, “Find me one and I will give you 10cents”. They were not abundant and I had taken half an hour to find one. In five minutes his eyes brightened up, “Sir, is this one of those things?” It sure was – a classic Falciparum ring. I told him that I was appointing him my laboratory assistant the following day – a rapid promotion from cleaning the drain.

Joyce Achong, the Chinese lass who some of you may know, was a Senior Medical Laboratory technologist in London who had done most of the laboratory work for my MD Thesis. I contacted her and told her I was having enormous problems in getting my research lab going. Would she come over at least for some time and give me a hand? Resigning her post in a major teaching hospital she came over at the princely salary of Rs 250 a month (US$40) which was what laboratory technologists were paid in Ceylon irrespective of their training.

She got on like a house on fire with Sene. Joyce, of course, could not speak Sinhalese, Sene could not speak English. Joyce would shout “Get me a pipette”. Sene would bring a petrie dish. She would shout louder “a pipette”. Sene, always willing to oblige, would try bringing a blood agar plate. The room was so small that with three of us in it, Joyce in a frock, Sene in shorts, the two with bare legs often burned them touching the autoclave.

Within a month, the language barrier notwithstanding, Sene was pouring every bacteriological culture plate – McConkey Agar, blood agar, blood culture media – the lot - and then plating out the urines, doing blood cultures, sputum cultures and looking for acid fast bacilli in sputum and parasites in stools. Joyce, a Fellow of the Institute of Laboratory Technology in England, saw to it that Sene could do everything she could do in bacteriology and parasitology. Sene’s technical ability knew no bounds. He did all the venepunctures, including jugular vein punctures on kids since we were looking into the problems of childhood rickets. He went on to do bone marrow aspirates in our studies on megaloblastic anaemia. He even put in the peritoneal dialysis catheters in patients who were being dialysed. Scientists from the famed UCLA in California came to work with us on health problems in plantation workers. Sene did all the fieldwork for them. Professor Reggie Edgerton, who is still at UCLA, will testify to this. When these scientists were due to return to Sri Lanka a year later, they specifically asked if Sene could be assigned to them.

Sene was the co-author in several publications and was cited as providing technical assistance in many more. When I left Sri Lanka, Sene was cited in more publications in international journals than the half-drunk joker who was appointed as the Professor of Medicine. (He was not ‘half-drunk’ but fully drunk after 2 pm and later died of a cirrhosis of the liver). And what happened to that outstandingly talented and highly trained lad with enormous potential? Unbelievably he was demoted back to clean the drains as soon as I left. Unable to adjust to his new job he resigned. I bought him a small plot of land on which I built him a little “kade” (corner shop) where he sells curry powder and rice to this day. This is the tragedy in Sri Lanka and why I think it is a country without a future.

Sene’s ‘problem’ was that he was born to a poor peasant family without the necessary ‘connections’. From washing the drains he came: to washing the drains he went. That he is very talented, very well trained and exceptionally hard working could not get him out of it.

Sene who unfortunately has a similar name to mine is, I stress again, no relative of mine although I wish he was. He is all that I have left in Sri Lanka and if I ever go back to that mess it would be to give him one big hug and thank him for all the research he did which got me my job in Australia. I am not asking you for help. Sene is my responsibility but God, or whoever decides these things, has seen to it that Sene has a son, now an 18-year-old bioscience student, who has a congenital heart block and needs a pacemaker.

Unable to cope with the altitude in Kandy, the family is relocating in the “low-lands”. I am in the process of building a house for them in Kegalle. If there are any expatriate Sri Lankan doctors who have benefited from Sene’s help while they were medical students (he often allowed students to practice doing venepunctures on him and also showed some of them their first malarial parasite, and much more) and would like to help him, let me know. Sri Lanka stands condemned for the way it has treated Sene and unfortunately, many thousands like him, including doctors. It is this, or the possibility (indeed probability) of this, happening to you that made many of you leave the country and come to countries where you are judged by your training and your achievements rather than by who you are and your ‘connections’. I repeat – many of Sri Lanka’s problems, especially the critical shortage of that invaluable resource – trained manpower - are problems of Sri Lanka’s own making. The situation is not getting any better, the peace process or any other gimmick notwithstanding.

One of your Senators in Washington presented some data a few years ago. He showed that the total aid given by the US to India, Pakistan and Sri Lanka, was less than 5% of the aid given to the US by these countries in the form of trained manpower. This is just one example, (there are many more), of aid being given from the 3rd World to the so-called 1st World.

However, the other side of the coin is that the 3rd World does not want you – you are “drained brains” – a disposable commodity. The tragedy is that the people in the 3rd World need you. By ‘people’ I exclude the elites, the politicians and the wealthy, who only pretend to be in Sri Lanka but, for all practical purposes, are abroad. That’s where they shop, that’s where they send their children when they want them educated and that’s where they go when they get sick. They do not have to queue up at 4am outside the General Hospital Colombo to be sure they are seen 12 hours later when the shutters go up. They simply jump the first flight, business class of course, and head off in the direction of the UK, US or Australia. Abroad is also where they educate their children. Don’t just look at President Chandrika Kumatunga whose children were sent to Cambridge, look further afield at others in Colombo, Jaffna, and even in the Wanni and Batticoloa and you will see that what is sauce for the goose is not sauce for the gander. This is the hypocrisy of Sri Lanka, both among the Sinhalese and the Tamils, among the militant Sinhala groups and the militant Tamil groups. They do not necessarily practise what they preach. Whom am I referring to? Well, that’s a bit of homework for you. If you can’t work it out send me a quiet email and I’ll spill the beans.

3 University politics not education, is the name of the game.

It took me some time to work out that university politics – an extension of national politics, was the name of the game in Universities. It is certainly not education. Today in 2004 this is widely recognised and constitutes a serious problem in Sri Lanka. It was there in the 1970s, but at a much lower key and unrecognised by many, myself included. Universities in Sri Lanka, especially in the non-medical arena, are (and have been) the main recruiting grounds for supporters of one or other political party.

In the Medical Faculty, the game was somewhat different. A national problem was the emigration of doctors. This was a problem created by politicians and bureaucrats. Instead of addressing the problem, they tried erecting a barrier to block departure. Everyone, except the fools who run Governments, knows that a barrier is an invitation to either jump over it or creep under it, which is precisely what happened.

Unable to control the escalating loss of doctors, they then turned to the Medical Schools for help. The latter came up with a much more sinister idea. This was to make the MBBS course such that the Degree would not be recognised in any country outside Sri Lanka. It took me some time to work this out. Various characters from the Faculty of Medicine were sent to crazy universities abroad and returned with crazier ideas which were hailed as “major advances” requiring major changes in our curriculum and hence in the course. If this strategy succeeded, I could see an outstanding MBBS course being turned into a joke.

Urgent action was needed to stop the destruction of the medical degree. I knew I could not handle this single-handed and decided to seek help. A “Resistance Movement”, “War Council”- if you like, was set up. In the War Council was Kanagarajah (Physician), Benjamin (Surgeon), Dago Gunawardene (Dermatologist), and myself. “Underground meetings” or, as was the case here, “Secret meetings above ground” were held at regular intervals in my Research Laboratory which doubled as a War Centre.

We mapped out a strategy to counter this blatant attempt to make our medical degree a joke. We shot through a paper to the British Medical Journal on “Undergraduate Medical Education (BMJ 1975.4. 27-29) and another on Postgraduate Education (BMJ 1975.3. 213-215).

There was widespread international support, some of it published in Letters to the Editor (BMJ) over the next several weeks. We brandished these as evidence that our Medical Degree was outstanding and that attempts to wreck it would not be tolerated. Those who were bent on sabotaging the Degree for political purposes (to stop doctors from leaving the country) decided to back down.

Apart from myself, none of the others in the “Resistance Movement” had a University appointment. You, and all those who came after you, owe these three gentlemen who had no University responsibility, a huge debt for saving our medical degree from political wolves dressed in academic garb.

Another lesson I learnt was that a University don, especially in the Medical Faculty, had a passport to tour the world, courtesy of the World Health Organisation (WHO). There was an epidemic of WHO Fellowships for all sorts of crazy conferences. At one stage, the entire Department of Bacteriology was abroad. God knows who taught the students. Perhaps the technicians.

I was the only person in the entire Medical Faculty who had not left the country since joining it. At a Faculty meeting I was asked to go on some jaunt to India for a Conference on “ Population Control in the Himalayas” which did not interest me in the least. Why this sudden generosity, I wondered. It transpired that I was the only one in the entire Faculty with room in my passport. Would I please go? I was told I could bring some sarees for my wife and also visit the Taj Mahal. It would be such a pity to let a WHO Fellowship go waste. It would send the ‘wrong signal’ to the WHO. Of course I did not go - I had better things to do in Kandy.

Having exhausted all WHO and numerous other grants for jaunts, the Dean of the Faculty of Medicine persuaded me to me fund a trip to London. For what? He would visit various Research Laboratories and come back with invaluable information to help me tackle some major problems I was facing in Thin Layer Chromatography, Atomic Absorption Spectrophotometry and Amino Acid Sequencing of Abnormal Haemoglobins (Finger Printing). Like a fool I agreed – did I have an option? Having wasted my money, he returned after a grand tour with information I could have got from numerous published papers (I guess he had read some of these on the trip). More importantly he returned with a State-of- the Art Hi-Fi set up for his living room. He was not only a Professor and Head of a Department but also, as I have said, the Dean of the Faculty of Medicine. Hypocritically he was a card carrying member of one of the Left parties whose main concern was the “Common man”. The Hi-Fi he brought back was certainly not “common”. These were some of the “monkeys” I referred to in the opening paragraph of this piece. There were more, plenty more. The widely held view was “Join the University and see the World”, - true to this day, and not just confined to Sri Lanka.

4. Money is not everything

One lesson I’ve learnt (in retrospect) is that money is not everything. For sure, it is handy to have some and not have to have to lead the hand to mouth existence we did in Sri Lanka. However, with the change in the scene to Australia and astronomical incomes, (but still significantly less than in the US), I have began to wonder whether excessive wealth necessarily means a better life. It certainly gives me more satisfaction to do what I am now doing, supporting three students from the Tea Plantations in the Engineering Faculty in Peradeniya, than to go out and buy a Mercedes.

While amassing wealth, which seems to know no bounds, it is worth remembering that at the end of the day one cannot take it away. All your sweat and toil may well be squandered by those who have not done an honest days work in their lives – nor would they have the incentive to do so, if all they need to do is to wait for the sun to set.

I suggest that you factor into your budgetary calculations the plight of a million orphaned, maimed and homeless children in Sri Lanka’s North and East who are where they are through no fault of theirs. Having said that I would caution you against filling every outstretched hand since there are a fair few crooks in this aid game, both at a national level and even among NGOs.

5. Standing up for students is very rewarding.

I have learnt that one of the most satisfying things to do is to stand up for students where an injustice has been done. For some reason, and this might well be my good fortune or pure imagination, the medical students that I have met in Sri Lanka and in Australia are some of the nicest people I have come across. Standing up for them has been one of the most rewarding things that have come my way. You end up with a lot of very grateful people and, what is more important, some very good friends. A number of my former students have become my life long friends – indeed part of my extended family. On my numerous trips campaigning for various causes, which I am not going to detail here, I have had problems coping with their generosity and friendship. I have had the embarrassing and impossible task of trying to fit in 3 lunches and 3 dinners all in one day, flitting from one student’s house to the other for a meal and pretending that I am hungry when in fact, I have just had lunch/dinner a short while earlier.

My very existence on this planet is probably because of some of the medical students in your batch in Peradeniya. There were two incidents both involving ragging which, as you know, I have completely and unequivocally opposed.

As a schoolboy in the 1950s, I had, of course, heard of the terrible ragging that went on in the Medical College in Colombo. However, it was not until I had arrived in Kandy in 1968 as don in the University that I realised that “ragging” would be more accurately described as “sadism”. I exploded when a new entrant, a “fresher” , a girl, an Arts student from the rural areas (not that it mattered), jumped out of the window on the 2nd floor of Hilda Obeysekera Hall, ironically named after my aunt and God-mother (not that that mattered either), broke her neck and became a quadriplegic. She later died in one of my beds. Why did she jump out of the window? Because she was about to have a candle inserted in her vagina (she was a virgin, not that that mattered either- perhaps it did) as part of the so-called “ragging”.

When I said that this sadism, masquerading as ragging had to stop, what made my blood boil was the response. “Well, ragging is what we learnt from Cambridge University which is where Dr Senewiratne was educated”. In a detailed article which was published in the Sunday Observer and later (resorting to fair means and foul), published where it mattered, in the Sinhala paper, the “Silumina”, I explained that in Cambridge and Oxford, ragging was not of the First Year students but an exercise conducted by them. We, “the freshers” did the ragging and the victims were the civilian population of Cambridge who had to fork out a few coins (the wealthy ones much more)- the money going to the Widows and Orphans Fund. We not only collected money but we also entertained them. I was a “baila dancer” and gave a polished performance in the town square for which the spectators paid dearly. We had fun, so did most of the local inhabitants, and several charitable institutes benefited.

This was very different from sticking candles in vaginae, putting testicles in drawers and closing the drawer, throwing people into the shallow Lotus pond at the entrance of the Peradeniya campus having first put bits of broken glass into the pond, parading terrified new comers, some of whom had left home for the first time, and getting them to perform all sorts of crazy, and even obscene, acts in public.

I decided to act. I pinned a notice on the student’s notice board that ragging had to stop and that I was on the war path. I saw the Vice-Chancellor, a dim-bat (most of them are) whose name escapes me (no great loss). I told him that if I caught anyone ragging a fresher, he/she had to be suspended. Either he/she goes, or I go. If the latter, I was not going quietly.

Two days later I caught two students (from the Arts Faculty) ragging some of my medical students. I watched for a while, identified who was doing what, descended on them and took them to the Vice–Chancellor and had them suspended for two years. Harsh? Yes, but so was what was being done to my students.

The next day I had an anonymous message from a ‘fresher’, “We are going to be ragged in Arunachalam Hall at 11pm tomorrow. Please help”. I contacted several of my senior colleagues to ask whether they would come with me on a midnight ‘visit’ to Arunachalam Hall. Their excuses were unbelievable. “I would love to come with you but my mother-in-law has just had a heart attack”. “I think what you are doing is commendable. I would love to be associated but it is my daughter’s birthday” etc. Six brave souls offered to come with me – Barr Kumarakulasinghe, then a Senior Lecturer in Surgery, Arthur Sinnatamby Senior Lecturer in Physiology, Prof. Dissanayake (“Dissa”) Professor of Dentistry, Sri Pathmanathan, Senior Lecturer in Dentistry who had red lips, why I do not know, Arjuna Aluwihare also a Senior Lecturer in Surgery, and 2 others whom, I am ashamed to say, my deteriorating memory cannot recall.

We met outside Arunachalam Hall at 11.30pm and decided to walk in. Someone had clearly tipped off the hoodlums who were organising the ragging because when we arrived it was like a cemetery. Deathly quiet. However we could see doors slightly open and eyes peering at us through the slit.

Two so-called student leaders came forward. “Sir, what are you doing here”? I said that I was a Senior don and did not need his permission to walk into a Hall of Residence in my University. The response “Have you come to check whether there is any ragging? If you have, as you can see, there is none”. I said “Great. Keep it up” and led my band of anti-raggers out of the Hall.

We had hardly gone a few yards when all hell broke out. Hundreds of students appeared behind us hooting and throwing all sorts of missiles at us. In the melee that followed we were, of course, hopelessly outnumbered. Barr, blind as a bat, stood his ground. So did the rest. I was worried since I was the one who had initiated this and their safety was my responsibility. Obviously I did not want anyone seriously injured, a possibility, which now seemed a probability. To my great relief, there suddenly appeared a mass of students from the adjoining Halls who came to our aid. The medical students, hearing that we were under seriious threat, had quickly collected this rescue squad who came to our defence and prevented what could have been serious injury.

With increasing tension, I had an invitation from Anurachalam Hall ‘for a tea-party’ supposedly to “make peace”. Naïve as I was, I decided to accept the invitation. As I was about to leave my home, four medical students arrived on two motorcycles. “Sir, where are you going?” I replied “For a social or tea party or something like that”. They said “You are not going anywhere. Some of the Arts students are ready for you with bottles of sulphuric acid. If you go what you get is not tea but sulphuric acid. We intend to park our bikes across your drive and prevent you from going”. I am, and will always be, so very grateful to these four students who saved me from a lot of suffering, if not death.

The courageous stance taken by this small band of “anti-raggers” resulted in this abominable activity ceasing for several years. Thousands of students were spared humiliation and trauma, both physical and emotional. Unfortunately, it has restarted with such brutality that it has even resulted in the death of a student. What is outrageous is that no one has taken a firm stance, indeed any stance, on this. Presumably no one cares – they usually do only when their precious offspring are the recipients.

Let me now turn to Brisbane and tell you of my recent experience with medical students there. Most of you qualified in a 6 year MBBS course, two years in Anatomy, Physiology and Biochemistry and the rest in Clinical Medicine. So have all the senior people in Australia and many other countries across the world. Then came this crazy 4 year so-called “Graduate Course in Medicine” (GMC). 6 years was squashed to 4 years. Worse still, unlike all of you who had a background in Science (Biology, Physics and Chemistry) before entering Medical School, there are no such requirements needed for the GMC. You could do a degree, say in Arts, Ancient History or TV drama, and go into the GMC as a medical student. This madness, which I gather has been prevalent in Canada and the United States for some time, came our way some 7 years ago and has wrecked our medical degree. Those who have excelled in Science with a BSc in Anatomy , Physiology and Biochemistry are mixed up with those who have done no Science at any level. It was a recipe for chaos, which is what is happening. Let me give you an example. One of the latter asked one of the former “What is this thing call haemoglobin? Is it inside the red cell or outside?”. To compound the problem of a crazy so-called “Self-directed course” (Read: a Do-it-yourself course), what is even crazier is the abysmally poor assessment process. Loony questions asked by loony examiners with loonier answers expected. Sane and correct answers are marked wrong by examiners with no medical degree and others who have not touched human flesh for decades.

In December 2001, 1 in 10 Year1 students in the Queensland University Medical School failed the year and had to repeat it. In July 2002, some 75% of Year2 students failed one or more subjects in their mid- year examination. Many of them were good, some very good, many had not failed an examination in their lives. The outrageous failure rate was entirely due to poor assessment i.e. the answer papers being corrected by mad men - the likes of Jacko. A serious injustice had been done to students with a devastation of their self- confidence.

Having slept through all this, I suddenly woke up. Something had to be done. Someone had to put up a fight with the medical school authorities on behalf of the students who had been unfairly penalised because stupid examiners did not know medicine.

You will, if you have not done so already, be faced with a similar choice. Here is a problem - be it in politics, in the running of the hospital, in patient care, in the training of medical students, or whatever. Should you get involved? I weighed the pros and cons. Pro: someone had to do something. Con: why me? I have fought Jacko (Dean, Faculty of Medicine Peradeniya), Bibile (another Dean), Bennett Jayaweera (Prof. of Obstetrics), Macan Markar (Prof. of Medicine), Wadugodapitiya (Medical Superintendent General Hospital Kandy), and many more. I am tired of fighting. At 72 years of age, the temptation was to let it pass and let someone else do the fighting. The problem was that there was no one else who would.

I decided to act. I addressed the students and told them that I was turning my home into an emergency tutorial room and they were invited to come. Some 135 souls trooped in for emergency clinical coaching in batches of 8-10 throughout the day and well into the night.

I also decided to take on the Medical School and expose the crap that was going on and to see that students got a fair deal, in particular proper assessment. The possibility of succeeding was negligible. However, when the end of year exam results came (November 2003), the failure rate was 0%. So, July 2003 failure rate 75%, November 2003, 0%. That is not a result, it is a miracle. It shows what can be achieved even against impossible odds. Grateful students flooded my email with thanks. Others bought me gifts and flowers. It was a touching and gratifying experience.

There are three groups of people in this world. One group who makes things happen, the other who watch things happen and the other who do not know what happened. I urge you to be in that first group of people who make things happen.

The cost

I would warn all fighters that there is always a price to pay. In Sri Lanka, my fight with Macan Markar, Bibile, Jacko, and all the other clowns was to see that you got a decent medical education. This was ‘rewarded’ with a note sent to me by Bibile (Dean, Faculty of Medicine) that I need not bother to apply for the Chair in Medicine in Colombo. I would only be appointed over his dead body. Unfortunately he was not dead. So, despite my having five times more publications than all the other candidates put together, having taught medical students for twice as long as all the others put together, being an Associate Professor of Medicine while the others had not been within ear-shot of a university academic post, I was not appointed. I was furious at the time but now I thank God because if I was, I would probably still be in that hellhole. So, I have a photograph of Bibile, Jacko, and their ilk and offer incense for saving my career by not appointing me to the Chair of Medicine in that backbiting hellhole, Colombo.

The “White Bibiles”, the “White Jackos” in the Queensland Medical School are no different. For standing up for the students and helping them, I have just been stripped of my title of Clinical Associate Professor of Medicine (not that it meant much anyway). I have now had a letter from the Dean of the Queensland Medical School that he is seeing his lawyers, presumably to sue me for defamation for saying that a bunch of dubiously competent people were running, or ruining, a medical course.

For standing up for my colleagues in Princess Alexandra Hospital and doing something about the struggle they were facing in providing an acceptable level of patient care in the public hospitals, the administration ‘forced’ me to quit my job as a Senior Specialist in the Hospital. They suggested that I “retire”. I told them that there were two separate words in Sri Lankan English – ‘retire’ and ‘resign’. ‘Retire’ is when you’ve done your dash and want to sit at home looking at the ceiling. ‘Resign’ is when you don’t want to work in a shit-house any more. It was the latter that I was about to do, and did.

So, what am I doing with myself now? Walking the streets? Not quite. I am seeing patients, heaps of them. Why? I’m not sure. Perhaps I should apply what I wrote on page 15. The situation is about to worsen where time is concerned. With a critical shortage of clinical teachers I am about to be recruited back to the Queensland University as Emeritus Professor of Medicine and to the Hospital as Emeritus Consultant Physician. I guess I’ll work till I drop dead, and perhaps even after that.

After years of fighting let me impart some words of wisdom. If you take on a fight, be it in politics, in teaching medicine, in the protection of human rights, in the poor care of patients, or anything, don’t expect a reward or recognition. The only reward you will get is the satisfaction that there was a problem, you tried to tackle it, and did not pass by on the other side of the road.

Though it might appear otherwise, the numerous fights I have had are not about politics, governments, university authorities or those who run hospitals. It is about power - the ruthlessness and the abuse of power. Let me give you an example.

I mentioned I,passing, my fight with the Professor of Obstetrics. and Gynaecology. What was that all about? This wretch was failing students in his specialty, not because they did not know their work but because he did not like their face or the part of Ceylon they came from. I was at a Faculty meeting and protested vehemently. I demanded to see the papers and the answers. He agreed, not knowing that I had a Diploma from the Royal College of Obstetrics and Gynaecology, London, which I did not usually ‘sport’ after my name. Seeing the papers incensed me more. I demanded a re-correction. “No problem”, he said. The problem was that this was done by him, with predictable results! I might add that one of the ‘failures’ later became a Consultant in that specialty, and a damned good one at that, which is more than I can say for the Professor.

In this and many other situations, what we saw (and still see) is a blatant abuse of power. Power, unfettered and unaccountable, in an institution, in a Government, a political group, a militant group or even in an individual can, and often does, result in excesses. It is this that has to be fought without fear or favour.

I would also warn against standing under a flag, be it your medical school flag, your country flag, your hospital flag or the flag of whatever you support. When I was critical of what was going on in the Peradeniya medical school, I was accused of being irresponsible. The same here, in Brisbane, “He is betraying the medical school in which he was a senior don and which trained his children.” Let me allude to what that outstanding Indian author, one of the bravest and best thinkers today, the Booker Prize winner, Arundhati Roy, said in her most recent publication. She says that flags are bits of coloured cloths that Governments use first to shrink-wrap peoples minds and then as ceremonials shrouds to bury the dead. In our setting, you can replace “Governments” with “Hospital authorities” or “Those who run Medical Schools”. When independent, thinking people, begin to rally under flags, when they blindly yoke themselves to those who wave the flag, it is time for all of us to sit up and worry. But this is becoming too political.

And I have been asked not to be political. However, a talk by me which is completely apolitical would be like a body without a soul. So let end with a political story which I pinched from one of the many newspapers that are sent to me by well-wishers. A flight left Colombo with 4 passengers and then ran into problems. The pilot said that the passengers would have to bail out - but there was a problem. There were only 3 parachutes. The first passenger, Chandrika Kumaratunga, said she was the President of Sri Lanka and the smartest woman in the country. Staking her claim she bailed out. The second was Velupillai Prabhakaran who said he was the leader of the Tamils and without him the Tamil struggle would collapse. He bailed out. The third was Ranil Wickremasinghe who told the fourth passenger a 10 year school girl that she could have the remaining parachute. He had had a full life and tried to bring peace to the country but had failed. The girl thanked Wickremasinghe but said that such a sacrifice was not necessary since there was another parachute. The smartest woman in Sri Lanka had jumped out with her school satchel.

Having expressed my profound political thoughts, I would end this by thanking you once again for inviting me as your chief guest. Do come and visit me in Australia but make sure you have a parachute and not a school satchel.

Brian Senewiratne 292 Pine Mountain Rd. Mt Gravatt, Brisbane, Australia 4122

Tel. +61 3349 6118, Mobile +61 419335334,

Email bsenewir@ozemail.com.au

May 2004 (If you don’t get through try briansen@bigpond.net.au) or (bsenewiratne@gmail.com)

                                                                   Errata And Omissions

Omissions are not surprising since this was written at midnight after a full days work. The punctuation is appalling. Victor Benjamin offered to send me a book on punctuation which he had used as a kid, but he had left it behind in Jaffna The verbal diarrhoea could do with some therapy.

Page 1. I told you how I was dragged before the Commission of Inquiry but not how it ended Applying for the job, I did, of course have to nominate 3 referees and also submit certified copies of my degree certificates. Despite this, the Peradeniya University actually contacted Lord Rosenheim and Dame Sheila Sherlock, under whom I had worked, and who, incidentally, were my referees, and asked them whether I really was a doctor. These two people, whom I know well, don’t mince their words and gave the University a belly full. They added that if I was of no use to them, could they send me back to England where there was a job awaiting me.

On the appointed day I duly appeared before the Commission, which informed me that I was actually a doctor and had no case to answer. Hallelujah! I should have sued the pants off the University for defamation, injury and insult, but was persuaded not to by the Vice-Chancellor, Professor E.O.E.Pereira, a fine man of absolute integrity, for whom I had the greatest respect. E.O.E tendered his personal apologies to me for something he was not responsible. Why I did not quit I do not know. Perhaps it was mother, who was looking forward so much to my return, which prevented me from buzzing off. Am I making all this up? I don’t need to because the facts are worse than any fiction could be.

Page 4. I referred to the extension I built to Ward 19b to house my ‘floor’ patients. That is correct but the room was temporarily used as my laboratory until the Nuffield building came up. When this extension was functioning as my lab a fascinating event occurred. I arrived one morning to find my lab assistants in disarray. All the lab equipment was gone, vanished overnight. It turned out that Macan Markar had ordered that all Peradeniya University equipment in the Kandy Hospital (i.e. equipment in my lab) be returned immediately to the Peradeniya campus. University security staff had come in the night and cleaned out my laboratory. The clear intention was to stop me from doing any work.

Fortunately, a wonderful American was visiting me. When he heard of this outrage he called his University in the USA and asked that all I needed be air lifted to Sri Lanka at once. It was. So we were back in business. Isn’t the story incredible? Not only did these rogues do no work at all, they thought of all sorts of ways of obstructing those who did. I regret to say, this is not an uncommon in Sri Lanka.

Page 14. I briefly alluded to attempts to sabotage our medical degree. I should have expanded on this and told you that it was your action that probably saved the day. As I said, I was a bit slow in appreciating the agenda of these academic hooligans. My eyes were opened when the General Medical Council (GMC) of the UK visited Peradeniya to review our medical degree. At a Faculty meeting I was speechless when, Senake Bibile, the Dean, told them that “Our needs are different from those of the UK and this should be reflected in our MBBS Course. The products of our medical school may not be acceptable to the GMC because, as I have said, we need a different type of end product to that required in the UK” (and, by extension, in other countries). That is when the penny dropped and I realised that the agenda of these hoodlums was to make our degree unacceptable abroad and hence stop the ‘brain drain’, or the loss of ‘drained brains’ as Jacko belied it to be.

I hastily arranged a meeting of all medical students. You came in hundreds, the huge lecture theatre was packed. Incidentally, we were barred from using the lecture theatre, but you came in anyway! I addressed you and apprised you of the master-plan. I then invited Bibile and his co-conspirators to come clean and defend their agenda. It was the tumultuous applause you gave me, and the stony silence that Bibile and his despicable bunch got trying to defend the indefensible, that convinced them that their master-plan would not work. This is not to diminish the work done by the “Resistance Movement” I referred to, but it was your overwhelming support that enabled this nonsense to be stopped and our MBBS degree to be saved. Generations of students who followed you, owe you a huge debt for your action.

I think this paper should be modified to exclude things of interest only to us, and be published in Sri Lanka so that the Public there will know why there is a serious shortage of doctors and why the Health Service is in crisis.BS
Brian Senewiratne

1 A.D.P.Jayatillike, Dean, Faculty of Medicine

2 Ajuard Macan Markar, Professor and Head, Department of Medicine

3 A popular ‘native’ dance, rather like a jive, introduced by the colonial Portuguese in 1505, and at which I excel.

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