The end of the Sri Lankan civil war, a conflict that lasted from July 1983 through to May 2009, may have ushered in an era of peace, but for many people in the most impacted areas of the island, particularly in the north and east, it was a hard peace. Tens of thousands of people impacted by this war, one marked by its repeated use of explosive weaponry, were left with a wide spectrum of health problems that would impact their lives for years to come.
There were those who had lost limbs or their sight; there were those whose bodies were wracked with pain, shards of shrapnel still imbedded in their bodies; and there were those who were left with unseen scars, mental anguish born of bereavement and suffering experienced through the war. Both sides of the conflict suffered these painful legacies, as did the civilians caught in the middle of the conflagration.
In this section of AOAV’s report – analysing the reverberating effects of explosive violence long after the bombs have stop falling – we will examine the health impacts of explosive weaponry in Sri Lanka in all its aspects.
One of the most immediate impacts of explosive violence in the war was that many hospitals in the North of Sri Lanka were destroyed or extensively damaged during the war. By February 2009, it was reported that shelling between the government forces and the insurgent group the LTTE had destroyed ‘the last functioning hospital in the north of the country’.
So it was, that even though hospitals are meant to remain safe even within conflict – they are protected under international law – medical centres in Sri Lanka were the object of frequent attacks. At one point in the conflict, makeshift hospitals providing care for wounded LTTE fighters stopped providing their coordinates to the Red Cross, as there was strong evidence that they were being deliberately targeted by the Sri Lankan government forces. A 2011 report on the conflict by the UN reiterated that it appeared likely that such areas were deliberately targeted:
“The Government systematically shelled hospitals on the frontlines. All hospitals in the Vanni were hit by mortars and artillery, some of them were hit repeatedly, despite the fact that their locations were well-known to the Government. The Government also systematically deprived people in the conflict zone of humanitarian aid, in the form of food and medical supplies, particularly surgical supplies, adding to their suffering.”
This bombardment of hospitals had profound consequences. As one review put it succinctly: ‘Three decades of internal conflict in the North and East of Sri Lanka have taken a toll on the health care system in that area.’
Not only did it mean that an untold number of wounded civilians and LTTE fighters died in the absence of proper medical assistance, but it also meant that even for those who survived this carnage, with injuries and physical disabilities from the explosive violence, their lives were made worse by a profound lack of access to medical care. This lack of access to proper medical facilities can be still felt today – many areas still have a paucity of health care facilities, and few doctors and nurses to fill them.
This targeting of hospitals was to have its deepest impact on civilians too, as civilians were the ones most impacted by the violence. Both government and LTTE violence prevented civilians from escaping the conflict area, the LTTE used civilians as human shields, and the government failed to grant access for humanitarian agencies to assist the wounded.
Until the final months of the war, the death toll was thought to be about 70,000. However, the final phase, as government forces and rebels fought for control, saw the largest levels of civilian deaths. For the final assault, estimates range from 20,000-75,000 killed, though the government estimate put the figure at about 9,000. U.N. data suggests that 40,000 people died. However, recent research has suggested the toll could be closer to 100,000. Estimates for the number of disabled living in the Northern Province range from 20,000 to 40,000.
Health statistics were one of the first casualties of the war, and data even today – years after the conflict ended – is still extremely patchy. However, it is undeniable that a very large number of civilians, and ex-combatants, still suffer from the effects of explosive violence. The President of the Spinal Cord Injury Association, in the Northern Province, told AOAV that an estimated 90% of their patient-members suffered from war-related injuries, particularly from shelling.
Unexploded ordinance (UXO) and landmines
The guns may have fallen silent, but there still exists a considerable threat in certain areas from the existence of landmines and explosive remnants of war (ERW). So much so that whilst huge tracts of contaminated land have now been cleared, there nonetheless remain large areas in need of clearance. Even in areas declared safe, deaths and injuries from undetected explosives still occur. AOAV met with a family with two young children, who had recently lost their grandfather due to a UXO blast. After lighting a bonfire of logs and other garden waste, an unseen round in the waste had caused an explosion, with shrapnel hitting the elderly man in the stomach, killing him.
Today, the family live in fear that this might happen again, the parents fearful that their children may trigger another explosion. Such fear persists, even though clearance had already been carried out on the land and it had been declared safe. In another area AOAV visited, also declared safe less than a month before, two subsequent shells had been found. These were reported and removed by a de-mining organisation, but it shows that the threat – and the fear of the threat – persists even in the face of substantive efforts.
Such fear is not unwarranted. In 2014, UNICEF reported that there had been over 22,000 casualties from mines and explosive remnants of war in Sri Lanka, including at least 1,603 civilians. Whilst these numbers have significantly reduced since the end of the war, there continues to be casualties from these explosives each year. In 2013, there were 22 casualties from landmines and ERW, whilst 2014 saw 21 – there is no recorded public data available since 2014, though it is clear casualties continue.
In addition, explosive remnants of war prevent people from returning and utilising farmland, further impacting levels of poverty in the areas that remain contaminated. According to the HALO Trust representatives in the North, there were approximately 650 mine fields in need of clearance due to the war – of these about 70 remain, though some need reassessment. It is also estimated that around 2,500 people are waiting to resettle on the land that remains contaminated, even eight years on, whilst other areas are needed for farming and agriculture.
Disease and mortality rates
A variety of factors stemming from the reverberating impact of explosive violence appears to have also caused the spread of disease and effected mortality rates, particularly in the north and east of the country.
The maternal mortality rate, for instance, is significantly higher than the national averages in at least three of the districts in the Northern Province and in two of the three districts in the Eastern Province. Similar poor outcomes are also noted for infant mortality. AOAV was informed by a Jaffna doctor, Dr Sathiadas, that in the Northern Province this stemmed from lack of proper facilities, particularly a neonatal intensive care unit, that had yet to be developed in 2014. After the war, redevelopment of hospital infrastructure was slow and other areas were prioritised first. At the time, Jaffna had the only teaching hospital in Sri Lanka which lacked such neonatal services.
However, it should be noted that the death rates from hospitalisation with most non-communicable diseases appears lower than average.
In the Northern Province, particularly Jaffna, there is a high-level of water contamination which has caused significant rises in related diseases such as dysentery and typhoid. For example, the number of people suffering from dysentery in Jaffna is more than double that of the next highest district, Batticalou, a war-impacted district in the Eastern Province. The level of water contamination in the North was identified at the end of the war to be a key issue to be resolved. Whilst projects have been proposed, there have been delays due to both funding and the potential impacts projects could have on an agriculture sector that is still struggling to rejuvenate after the war. While no proper survey has been conducted, people with whom AOAV spoke asserted that explosive violence had had an impact on drains and water-pipes, damage that had not been addressed with the end of the war. It is hard to prove, but such damage might be a causal factor in the above health issues.
Of course, there are other factors at play as well. Water contamination is rife as all-to-often often latrines are situated too close to wells. Further, the Northern and Eastern Provinces have the least access to toilet facilities across the provinces. But such poor sanitation issues have been allowed to continue owing to high regional levels of poverty, caused by the war, and damage suffered during the war not being addressed.
One doctor AOAV spoke to also said that the high number of people who left the region during the war, particularly younger Tamils, has had another impact. Traditionally, locals would clear their streets and stop rubbish and contaminated water from pooling near their homes. This was often the task of the younger members of the family. So many young people have left the region, though, and so many homes remain abandoned, that such care and maintenance of public space has fallen to the wayside. While no formal report on this has been published, the doctor believed that the widespread issue of Dengue fever was in part exacerbated by this drop-off in tending for one’s own garden, as mosquitos flourished in the midst of puddles and rubbish piles.
Overall, we found among the people interviewed, a similar range of issues as a 2007 research project undertaken, where it was concluded that ‘The major health problems in Northern Province were high maternal mortality, significant shortage of human resources for health (HRH), and inadequate water and sanitation systems.’ This, alongside poor access to health facilities, lack of basic health knowledge, insufficient health awareness programs for inhabitants, and mental health problems among communities seemed to be lingering issues, unaddressed for the decade thereafter.
Job loss and income
Many Tamils and Sinhalese were left with such profound physical injuries that they were often unable to carry out the jobs they had before the war. This placed a considerable strain on family incomes. All of those injured in the war that AOAV spoke to expressed considerable worry over this loss of income and the impact that had had on their family. All of those harmed by explosive weaponry needed to change their careers and this new labour was almost always worse paid than before. The main source of work in the North was often manual labour; injured veterans and civilians could not perform such arduous work with their injuries. This meant that many of those AOAV spoke to had had to become handy men, take on casual work or become 3-wheel taxi drivers – these were jobs that their injuries permitted but meant that they were often paid less.
At the Spinal Cord Injury Association, the President explained that for some it had been possible to find better and more suitable jobs through assistance from the Tamil diaspora, but the reality stands that those who suffered injury from the war continue to bear this financial legacy.
Impact of psychological health
Many of those that AOAV spoke to commented on the impact of the war on their psychological health. It was generally found that people were aware that the war could have such an impact (and this in itself may cause many to speak on the matter), but the causes of this psychological harm were more complex than just that of witnessing violence and then suffering from such trauma.
For instance, those individuals who were left unable to carry on the lives they did before often expressed how profound a strain this put on individuals and families in relation to their psychological health.
Those that received no assistance also explained that since the incident that caused their injury they suffered depression and anxiety. Some even said it would have been better if the incident had killed them rather than just injured them. For others, depression and a sense of being a burden on their family led to suicidal thoughts.
Physical injuries also serve as a reminder of the war. For example, those who are left with shrapnel fragments in their body, are often left in pain – with this acting as a constant reminder of the trauma suffered.
Access and assistance
In the years after the war, whilst the long process of rebuilding health care facilities in the impacted areas took place, the local populations were left with poor access, availability and quality healthcare.
In 2007, it was stated that ‘Sri Lanka still experiences vital health problems in all stages of the life cycle, mainly related to lifestyle and the epidemiological transition associated with widespread societal and economic crises.’ It is fair to say both that ‘societal crises’ is an understatement of sorts for a civil war, and that such issues still persist a decade on.
Profound issues emerge – people with mobility issues report deep frustration at their inability to use their wheelchairs and other devices in impacted areas. It is rare for buildings to have ramps or other accessibility, and the post-war rebuild did not cater for the high proportion of disabilities existing. AOAV was informed that disabled students particularly suffered due to the lack of accessibility in schools.
Mobility for amputees was also hindered owing to the cost of prosthetics and other medical assistance. It is estimated that about 90% of Sri Lanka’s 160,000 amputees lack access to appropriate surgical procedures and prosthetic limbs. Even though in theory, people with amputations should have been equipped with a state-purchased prosthetic limb, the reality is far from this. AOAV interviewed one victim of a shelling where he lost most of his foot. Only now, 8 years after the end of the war, did he say that he was receiving his first prosthetic.
A 2014 review of provision of healthcare for spinal cord injury in Sri Lanka said that complex care was possible, but that it needed a ‘multidisciplinary approach, including psychological support along with partnerships with local and international organizations with specialized expertise.’ Such a multidisciplinary approach is understood, but resources available to fulfil such complex needs were not available in a number of centres visited, with staff and financial shortages cited as a reason for the absence of such provision.
Those victims that had received a degree of multidisciplinary assistance were clear on the profound difference receiving help made on their lives. From physical assistance, to relieving stress, interventions such as physiotherapy and psychological intervention contributed significantly to their overall well-being. However, in almost all cases this assistance came from an NGO rather than the state, and as the years add up, the urgency of provision is seen by some donors to be watered down – other conflicts, such as Syria and Iraq, strip away funding streams and a sense of urgent need, leading to NGOs leaving the country. Without state intervention in their place, those with lifetime conditions caused by explosive violence are left to fend largely for themselves.
Preventing such a slow erosion of aid is important. Support for victims has been seen to provide them with a sense of independence and an ability to be a constructive participant in societal and familial life. Many of those interviewed reported that after they received health assistance, they were able to think of their future again. This was particularly evident when talking to those at the Spinal Cord Injury Unit, where a community has formed and where progress has been made to better recognise the rights of the disabled. However, this unit is under constant resource stress – they are frequently approached by those with other physical disabilities in need of support, as these victims of explosive violence cannot access similar assistance elsewhere.
As to be expected, an issue brought up consistently by those AOAV interviewed, both civilians and experts alike, was the psychological impact of the war. Such trauma was caused by the constant bombardment, fear of death and the impacts in the aftermath. And, in the impacted areas in the north, patients in need of psychiatric help appears to be on the rise, at least according to health professionals interviewed.
There are particular groups that seem more vulnerable from suffering psychologically. These include ex-LTTE combatants, war widows, and children. The reality, though, is that no group appears immune; in pre-war years the most common conditions being seen by psychiatrists were predictable mental health conditions, such as schizophrenia and related symptoms. Today, depression and related illnesses, such as PTSD and bipolar disorders are said to be more common; such a shift was, at least according to one senior psychiatrist interviewed, related to conflict trauma and grief.
In the past, it is estimated that about 30% of those coming to outpatients’ departments in the Northern Province were displaying symptoms of depression. After the war this has risen to about 48%.
Whilst it is difficult to establish concrete links between a psychological condition and the cause, experts explained that, ‘whenever you talk to a patient about their history, invariably the war comes in. They have all borne loss and seen the horrors of war.’ Explosive violence in particular is thought to lead to experiences that produce greater trauma, often due to its indiscriminate and harmful nature.
One 2007 report on psychological health in the north established that: ‘the chronic war situation caused… fundamental social transformations. At the family level, the dynamics of single parent families, lack of trust among members, and changes in significant relationships, and child rearing practices, were seen. Communities tended to be more dependent, passive, silent, lacking in leadership, mistrustful, and suspicious. Additional adverse effects included the breakdown in traditional structures, institutions and familiar ways of life, and deterioration in social norms and ethics.’
It is fair to say that the same sentiments were shared universally a decade on. The psychological reverberations appear to have been caught in a sort of interminable stasis – no resolution, little healthcare and no sense of improvement – keeping huge swathes of the population in the north caught in a permanent state of despair and depression.
Death of family member
Our field research found a trend in single parents being left to provide for families alone, due to the loss of a family member during the war. The high death toll from explosive weaponry has meant that there are thousands of ‘war widows’ in the north and east.
Such widows – the majority being mothers – are put under increased strain to provide, as well as being forced to deal with on-going bereavement. Many of these women, fuelled by a lack of government compensation, have felt pressure to take out loans. The paying back of such loans has caused a further burden; those that cannot pay are often exploited, with many women forced to provide sexual favours in return for more time or to prostitute themselves to cover their loans. Those women who talked to AOAV about this issue all reported personally knowing of cases where widows under this stress had committed suicide.
Suicide is of particular concern. Sri Lanka’s suicide rate has decreased since the 1980s when many toxic pesticides were banned. However, the areas most impacted by war retain rates that are amongst the highest across the country, particularly Mullaitivu, Jaffna and Kilinochchi. The national rate still remains amongst the highest in the world and is linked to the inadequacy of the mental health services in the country.
Impact on children
Future generations continue to be impacted by the deaths and injuries caused by explosive weapons years before. Many children have experienced the loss of parents or other loved ones to such violence, or have witnessed their parents’ grief and suffering as they try to put their lives back together. It is estimated that 92% of children in northeast Sri Lanka experienced severely traumatising events during the war, and 25% present with symptoms of PTSD.
A local paediatrician pointed to a loss of familial bonding as a consequence of the war as parents try to deal with the trauma of the violence, which may also exacerbate mental health issues in children. Schoolteachers and administrators also identified a loss of parental contact and bonding as an issue impacting the development and behaviour of their children. Two out of every five children are thought to have mental health disorders.
Jaffna, compared to other Northern districts, sees a better level of services aimed at children’s well-being, though how far these services are utilised is another question.
Rise in use of drugs and alcoholism
Both doctors and school teachers in the Northern Province linked poor mental health to a rise in other behaviours, such as an increase in the use of drugs and alcohol, learning difficulties, and weight gain. Local media regularly report on the alarming rise in alcohol and drug use in the Northern Province.
Whilst it doesn’t appear to be closely monitored, according to national data, alcoholism also seems to be an issue; some of the districts in Northern Province are amongst the worst affected in the country for this. Screenings carried out for Sri Lanka’s National Non Communicable Disease (NCD) Prevention and Control Programme, indicate that Vavunia, Mullaitivu and Kilinochchi saw a greater percentage of people suffering from alcoholism than the national average.
In a survey carried out by the Alcohol and Drug Information Centre in 2013, the northern district of Mullaitivu had the second-highest rate of alcohol consumption in the island across the 10 districts examined. A researcher at the Point Pedro Institute of Development in Jaffna explained that there was evidence to suggest a significant rise in alcohol consumption since the end of the war, alongside an increase in the production of illegal alcohol. This behaviour is also thought to exacerbate poverty and fuel domestic violence.
Rise of militarism
For many, the increasing militarisation of the area has had considerable psychological consequences. There are economic incentives to take jobs provided by the military and some cannot turn down the wage offered. However, it also means they have to wear the military uniform of those that caused, only eight years ago, so much destruction and continue to “occupy” what many consider are Tamil lands.
A representative from Samutthana, a charity that works to address trauma and mental health in Sri Lanka and working in the impacted areas, explained that many working for the government reported depression from having to wear the uniform of those that had been responsible for killing loved ones.
The gap between need and services for mental health is high, particularly in remote areas. In 2011, there were only 0.29 psychiatrists per 100,000 population and the number of psychiatric beds for children throughout the whole country remains at 12 for children and a further 9 for adolescents – all were in Colombo, the capital. Specialised consultant care for children is non-existent in the impacted provinces.
In the North, an area severely impacted by the war, there are just four psychiatrists. In Jaffna, there are just two psychiatrists for a population of about 600,000 and the majority of these people experienced the impact of war. The psychiatrists are therefore also over-worked trying to manage excessive caseloads. Beyond the psychiatrist themselves, there are barely any approved personnel to carry out treatment such as counselling and similar non-pharmacological treatment paths. Due to the lack of ‘manpower’, this means pharmacological treatment is the most used pathway. Psychiatrists also see a high rate – about 90% – of readmission, as the social services element of the care is lacking.
Due to the high rate of emigration during and after the war, there is also a brain-drain on existing staff and on future doctors and nurses. Those that train in the most impacted areas will often go and join families overseas or set-up a practice abroad, where they can earn a better income and have a lighter workload. This has had a significant impact on medical and care services, and has meant that there is today a growing shortage of care for the elderly; nurses have simply left. This is causing a profound societal shock – traditionally, children used to care for aging or sick parents, but these children now live in Canada, the US, UK, Australia or elsewhere. Their parents are refused visas to come to live with their children, and so they remain in the north. Even with their offspring earning considerable funds overseas, there is such a chronic shortage of trained nursing staff that even such financial leverage is insufficient to pay for care. This leaves many alone and without care, even those suffering illnesses such as dementia.
As well as a drain on human resources, the post-war period has also seen a failure of state financial disbursement in the health services meeting need. Central finances are generally split equally among the provinces, though in the north and east there are understandably greater needs owing to the impact of the war. Politically, doctors told AOAV, there was no appetite to give the north and east a favoured status in terms of funding – leaving many services over-stretched and under-resourced.
This lack of funding, combined with a lack of suitable candidates for training, means that there is an acute shortage of professionals in the mental healthcare system. One psychologist informed AOAV that, owing to a huge patient list and no other members of staff to lighten his burden, he was granted just 90 seconds to do a full mental health analysis of a newly presenting patient. The strain on this doctor was considerable, and he professed a desire to return overseas as the work proved so stressful. He claimed he never took all his annual leave, he worked overtime everyday and that the only thing that stopped him leaving was that if he did leave, there would be nobody else to take his place.
Finally, there is an issue of access to suitable healthcare. While people can reach out to hospitals for psychological support, this is all dependent on a person’s ability and mental capacity to leave their homes and attend the hospital. Beyond hospitals, AOAV was informed that there was no systematic help from the government for those suffering psychologically from the war, despite a high need for psycho-social support services. The help that is provided mostly comes from the NGOs, but due to the high demand, as well as a culture where assistance is not usually sought for psychological support, many go without the assistance they require. This is a country where mental health issues still carry harmful cultural stigma and where the government still claims that only 2% of its population suffers from ‘serious’ mental illnesses.
Beyond the deaths and injuries that were directly caused by the explosive violence of the war and its aftermath, the damage to health services and other civilian infrastructure continues to have serious consequences on both the physical and mental health of Sri Lankans years after the cessation of the conflict. As the most educated and wealthy families left to escape the bombardment, the health system continues to suffer from a lack of trained and qualified personnel, exacerbating the burden on the already strained health services.
This has been particularly detrimental to those psychologically impacted and to the elderly, and continues to impact the well-being and development of the post-war generation. It appears that with such extreme challenges born from the war, the impact continues to afflict a large swathe of an already vulnerable population. Even those who did not directly suffer the bombardment and violence, and the future generations of those who did, are likely to remain impacted for years to come.
This article is part of AOAV’s research on the reverberating effects of explosive weapons. For the main report, ‘When the bombs fall silent’, see here. For an overview and some key findings, see here. Or, to reach other articles as part of this research, please see here.
 Taira, Breena R., et al. “Survey of emergency and surgical capacity in the conflict-affected regions of Sri Lanka.” World journal of surgery 34.3 (2010): 428-432.
 Interview with representative from the Spinal Cord Injury Association.
 Nagai, Mari, et al. “Reconstruction of health service systems in the post-conflict Northern Province in Sri Lanka.” Health Policy83.1 (2007): 84-93.
 Interviews with those injured during conflict.
 Interview with representative from the Spinal Cord Injury Association.
 Explained to AOAV in an nterview with a Samutthana representative on December 5th 2017.
 This could not be corroborated, but there was no obvious reason for the injured person to lie.
 Armstrong, Jo C., et al. “Spinal cord injury in the emergency context: review of program outcomes of a spinal cord injury rehabilitation program in Sri Lanka.” Conflict and health 8.1 (2014): 4.
 Interview with representative from the Spinal Cord Injury Association.
 Interview with senior doctor in the field.
 Interviews with practicing doctor in the impacted area.
 Based on the accounts of doctors in the impacted areas.
 Somasundaram, Daya. “Collective trauma in northern Sri Lanka: a qualitative psychosocial-ecological study.” International journal of mental health systems 1.1 (2007): 5.
 Interviews at a school in Kilinochchi.
 Interview with Samutthana representative on December 5th 2017.
 Based on observations from experts in the area.
 Interviews with NGO personnel.
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