MULLEYAVALAI, Sri Lanka - Compared with the setup Dr. Joseph Angelo has back in Bel Air, Md., the medical office here was unimpressive, just a faded lime-green picnic table of slatted wood and a few small chairs on the bare concrete floor of a schoolroom.
There was no electricity to operate equipment, and whatever diagnosis the internist made, there would be only one or two medications available, sometimes decades-old remedies no longer typically used in the United States.
But for the people living in or anywhere near this relief camp in northeastern Sri Lanka, this was the best care within reach, and dozens of patients waited in hopes of seeing the doctor.
Some of the medical complaints dated from long before last month's tsunami; others were especially cruel side effects of the disaster. Angelo and his colleagues were seeing the pathology of poverty as well as that of catastrophe.
There was the mother who brought in 2 1/2 -year-old Thusanth, his belly bulging from probable hernias that had gone undiagnosed for more than a year, a condition that if left untreated could lead to fatal complications.
There was 40-year-old Kunch, virtually catatonic after losing her husband and her two grown sons, her once-flowing long hair cropped short after getting tangled in barbed wire during the sea surge.
And there was Regina Santhia, who lost three of her four children in the tsunami and, three weeks later, came to the clinic feeling strangely dizzy.
She left when she saw that dozens of people were waiting to see Angelo, but she returned in the arms of a priest less than an hour later, limp and frothing at the mouth from a seizure.
Then there were 9-year-old Kusiyaniha and the other children outside the doctor's office in the camp, who now live in a school but cannot yet attend one. Kusiyaniha's mother, killed by the tsunami, had wanted her bright daughter to get a scholarship and become a teacher, but the school won't take her or many other children in this camp unless they have shoes, socks, uniforms and exercise books - a cost of about $40 per child - plus $10 tuition.
The sense of need
Nearly everyone's story at this relief camp added to the sense of need in northeastern Sri Lanka, an impoverished region ravaged by nearly 20 years of civil war, then devastated by the tsunami.
Most of the bodies have been found, the worst injuries have been treated and fears about deadly infectious disease have passed.
Sri Lankan-born Angelo, 44, and a group of fellow Tamil doctors and other volunteers from the International Medical Health Organization, a nonprofit group dedicated to advancing health care here, learned last week how much more needs to be done.
"Now we have to treat the survivors and improve the health care system so that they can come up in life," Angelo said.
Countless volunteers, along with charities big and small, descended on Sri Lanka's more accessible southern disaster zones, but the north is harder to reach, isolated by checkpoints that require permits or cumbersome passport checks.
The recovery here is complicated by questions about the notorious group that controls this area, the Tamil Tigers, and the government that historically discriminated against the Tamil people who predominate here.
Arriving as a medical volunteer here inevitably means cooperating in some way, even if indirectly, with the Tigers, who are considered a terrorist organization by the United States and other countries.
Angelo and other volunteers, many of them expatriate Tamils, have converged here to help the people beyond the checkpoints and the controversies, people without means and struggling to recover.
Vignashvary, the mother of the boy with the hernia condition, had taken Thusanth to a local doctor once before but had been told there was nothing to worry about. Angelo recommended surgery.
"I'm happy that he came, and I feel comfort that the problem will be solved," said Vignashvary, who, like most Sri Lankan Tamils, has one name.
Kunch had come to the clinic when she noticed a Tamil volunteer counselor from Britain whom she had seen the day before.
She spoke one sentence to the counselor, Nira Ravindran: "I have a fever and I haven't been given anything." Kunch didn't speak again that morning; children looked on bewildered while Ravindran tried to communicate with her.
"You can talk to her for two hours and maybe get a sentence out of her. She's going to need years of therapy," said Ravindran, who came to the northeast this month with her dermatologist husband. "Really, it's beyond my capabilities, but since they don't have specialists here who can deal, anything is better than nothing."
Angelo recommended a brain scan for the patient with the seizure, 25-year-old Santhia, who had suffered another seizure about six months before.
The scan will be free under the government's nationalized health program, but she will need the help of the Red Cross or another agency to make the three-hour-plus journey to a hospital that has the necessary equipment.
This makeshift clinic, visited by volunteer doctors about twice a week, is in more than one way a hundred miles from a modern hospital.
"It's like 19th-century medical care. It's so primitive. They deal with one or two medicines for each condition," Angelo said.
To treat an elderly woman's asthma attack, Angelo could have used a nebulizer machine that he had brought along, but there was no electricity to run it; the camp gets power only in the evenings. "What can we do? We have to work with the minimum that we have," he said.
Santhia, like so many other relatives of the 38,000 people killed here by the tsunami, needs more help than modern medicine can provide. The day before her seizure, with her husband hospitalized for blurred vision, she had searched in other villages for her three lost children but had given up hope.
Her surviving daughter, 8, has not accepted that her two brothers and sister are dead, but she asked her mother to put away a family picture because she was upset by the sight of her siblings. Now, the girl is with Santhia's sister, partly because Santhia is disturbed by the sight of her only remaining child.
"I can't bear the pain of feeding just one child when just a few weeks ago I was feeding four children," she said in the camp clinic. Sitting by her side trying to console her was Andrea L. Warnick, a nurse from Canada who received a master's degree in the sociology and psychology of death last year from Hood College in Frederick.
'The world knows'
Warnick urged her to keep her daughter with her in the camp with other children who have lost parents, to help her daughter grieve. She asked Santhia the names of her dead children. Warnick then asked a volunteer who was translating to tell Santhia this: "Can you tell her the whole world knows about the tsunami, and everybody feels horribly about it?"
It was a message that Warnick and another volunteer, Abigail L. Thomas of Baltimore, considered important to deliver in a place that has so little contact with the outside world.
"It seemed amazingly empowering to have aid workers clearly from very far away," Thomas said of her first day visiting the camp. "They know they haven't been forgotten."
Warnick and Thomas, a graduate student in the international health department at the Johns Hopkins University, had come across the story of Angelo's medical partner, Dr. S. Raguraj, and his determination to get relief to the Tamils through the International Medical Health Organization, which he heads.
Before New Year's Day, Warnick and Thomas, both 28, had signed up with IMHO to come to a place they knew little about.
"People's religion or ethnicity should have no bearing on whether people receive aid," Thomas said. "It's a humanitarian crisis. It's human suffering."
That is an attitude that the Sri Lankan government, controlled by the nation's majority Sinhalese population, says it shares. How much attention the government devotes to this area, and how closely the Tigers choose to work with the government, will help determine the population's future.
Officials in Colombo say that the northern and eastern Tamil-majority districts - home to an estimated 2.6 million of Sri Lanka's 20 million people - have received more, not less government aid than the Sinhalese-dominated southern and western districts, to compensate for the difficulties faced by nongovernmental organizations trying to get here.
The government also says that its tsunami initiatives - such as sending all kids back to school with clothes and supplies by the end of this month, giving every affected family about $50 in cash and building modern housing for those displaced - will apply in the Tiger-controlled territories as well, though negotiating logistics with the Tigers will certainly cause delays.
But for many Tamils, including expatriate Tamil volunteers, little that the government says is taken at face value.
Despite the government's very public efforts to make amends with the Tamil people, there is too long a history of discrimination and violence to overcome in so short a time. Discriminatory laws and murderous ethnic riots sanctioned by the government helped spark a conflict that claimed more than 60,000 lives from 1983 until a cease-fire in 2002.
Hundreds of thousands of Tamils, including many well-educated families who were the elite of Tamil society, fled the country during the war for havens in India, Australia, Canada, Britain and the United States. A number of the expatriates returning as volunteers, including Angelo and Raguraj, left when the war started in 1983.
The Tamil homeland they returned to is the poorest part of the country: its buildings and infrastructure bombed out, many of its people condemned by isolation to low-paying jobs, subsistence fishing and farming, or unemployment.
About half a million of them are trapped by the politics of the conflict, ruled by the Tigers but dependent on the government for social services such as free health care and education. One of the results, obvious to Angelo and the others on their visit, was that the quality of health care is far below the standard elsewhere in the country.
At the flagship hospital in the heart of the Tiger-controlled region, Kilinochchi, the crush of tsunami-related injuries had passed by last week. Still, dozens of patients lay outside on mats or concrete under overhangs because the 125-bed hospital typically houses 250 patients a day.
There are no specialists other than one gynecologist - the Health Ministry in Colombo says it can't force doctors to work here - so some of the patients have to wait for help for days, until perhaps a Tiger-trained specialist comes to take patients. More serious cases are transferred to a better-equipped hospital in government-controlled territory.
Money, not time
Medicines are so frequently short in stock and the patients underfed that a government doctor at the hospital, Prasath Brighton, told Angelo the hospital would prefer that foreign doctors give their money instead of their time. Money can buy vital medicines and food, Brighton told him, while short volunteering stints would not do much good.
The International Medical Health Organization has shipped or, on this trip, brought with it as much as $500,000 worth of medicines and medical equipment, much of it donated by hospitals led by Johns Hopkins.
The IMHO also raised $50,000 shortly after the tsunami, about half of it from Raguraj and Angelo's patients in Bel Air, that it sent along with another $50,000 to a Kilinochchi-based charity, the Centre for Health Care. The group has paid for the construction of three of the Centre's five village clinics, where basic care is provided in part by Tiger medics and nurses.
When charities send their money and volunteers here, the issue of the Tigers confronts them.
For 19 years, the rebel Tigers fought a guerrilla insurgency during which they became known for suicide bombings and political killings. The Tigers also have a long history of recruiting children as soldiers, and this month UNICEF and Human Rights Watch reported that the rebels have done so even in tsunami relief camps.
The Tigers are in some way involved in every phase of the tsunami relief and recovery in their territory, and the money and aid flowing into locally run relief organizations could at least indirectly bolster them. Some expatriate Tamils volunteering here are troubled by the long-term prospects of authoritarian Tiger rule and by tales of their ruthlessness.
But given a choice between the rebel Tigers and the government, Angelo and a number of the returning Tamil expatriates choose the rebels. Angelo dismisses the stories of child recruiting as government fabrications. He rejects the terrorist label affixed to the group, calling the Tigers, also known as the LTTE, a national liberation movement.
"Anybody can clearly understand, LTTE has a goal: freedom for the Tamils," Angelo said.
Angelo, a compact man with a mustache who is given to showing his emotions, can speak as passionately about the responsibility of doctors to help people as he does about the Sri Lankan government's treatment of his people. Those twin passions brought him here, and they were never far from the surface.
He and some of the other expatriates believe the local Tamils' whispers that the government has sent spies into the territory under cover of tsunami relief. He doesn't believe the government's claims of sending significant aid to the north and east. He is sure that the government resents the Tigers' ability to lead a strong initial recovery from the tsunami.
The rebel Tigers have a natural interest in obscuring whatever role the government plays, deepening the distrust of the people they rule in the government they despise, just as the government has a natural interest in boasting of its role. The foreign minister of Norway, the country facilitating peace talks during the cease-fire, arrived in Sri Lanka on Thursday in an effort to help the two sides cooperate.
What Angelo was left to conclude for the moment was that after years of discrimination, war, isolation, an uneasy cease-fire and a tsunami, his people are in desperate need.
"I still like Sinhalese people," Angelo said. "But overall, I feel my country, Tamils, are neglected. Give them at least one opportunity - they can contribute a lot to the world."