Sri Lanka struggles with mental health burden

Nearly a year after the brutal civil war in Sri Lanka was declared over by the government, Nayanah Siva reports on the mental health problems facing the conflict-scarred population.

It has been 23 years since Renuka’s (name changed) husband was shot dead in the street while he was waiting at a bus stop in Jaffna, north Sri Lanka. Renuka, who was heavily pregnant at the time with her second child, and her 3-year-old daughter had to flee the conflict-afflicted island and start a new life in the west. Now, Renuka lives in a tiny, dreary ground-floor public-housing flat in North America; the only furnishings are two garden chairs and a small television.

The television is blaring loudly when The Lancet visits Renuka, but she is numb and her eyes are vacant. A big bag of pill bottles rests on the floor beside her. 2 weeks previously she had been arrested by the police and sectioned under the mental health act, and now she is taking medication for post-traumatic stress disorder and psychotic episodes. Thousands of miles away from where it all began, and years later, Renuka has finally given into her grief and accepted treatment; she is one of thousands of victims of the Sri Lankan civil war.

In May, 2009, Sri Lanka’s President Mahinda Rajapaksa declared that the country’s 25-year conflict had finally come to an end. After nearly three decades of fighting, Sri Lankan emigrants all over the world and politicians celebrated the end of the war, and as the media spotlight moved elsewhere, the people of war-torn Sri Lanka had to pick up and continue with day-to-day life. And, as Renuka’s story shows, distance and time does not necessarily heal emotional and mental scars of being in the middle of a war.

Mental health has been a cause for concern in Sri Lanka for some time. The country has one of the highest suicide rates in the world, with an average of 6000 deaths per year; nearly 100 000 people will attempt suicide every year in Sri Lanka. In addition to the mental health problems typically reported in a stable environment, the prevalence of mental illness in the country is further compounded not only by the conflict but also by the devastating effects of the 2004 Indian Ocean tsunami. All of these factors would undeniably have caused intense stress for the people of Sri Lanka, increasing their risk of mental trauma.

Resources and funding for mental health in the country has always been low. And during a war situation even the most basic of services might not be functioning and in these cases mental health might be low down on the priority list. Basic Needs, a humanitarian organisation that mainly works with people with mental health problems in developing countries, states that there is only one psychiatrist for every 500 000 people in Sri Lanka, and most of these experts are concentrated in urban areas, leaving war-torn areas such as the northeast of the country that is most in need of mental health care, without adequate facilities.

“While Sri Lanka has always had good health indices, given its size and socioeconomic status, the limitations are the financial outlay required to attract, maintain, and provide services”, says Russel D’Souza, who is president of the section for Disaster Psychiatry in the World Psychiatric Association.

The psychological cost of war for those living in it can be huge. “In the lives of civilians—whether constantly exposed to combat or whether living in combat free areas—the war is an ever-present hazard, constantly looming in their minds”, stated Piyanjali de Zoysa and Tissa Weerasingha in a 2000 study published in the Sri Lankan Journal of Social Sciences.

Yolanda Foster, Amnesty International’s Sri Lanka researcher, told The Lancet about conversations she has had with some of the survivors of the conflict. “Parents talk of how their children are still scared of loud noises after months of shells raining down on them. Witnesses have described nightmares after months of bunker life and feelings of anxiety and hopelessness. For some there are feelings of guilt at not being able to give those they lost a proper burial.”

One of the biggest limitations in understanding the status of mental health disorders in Sri Lanka is the lack of information, particularly in rural areas of the country and in the northeast, where much of the war was taking place. “I think a proper evaluation of the mental health of both urban and rural populations has not yet [been] done; especially in the post-war scenario”, said Lalith Senarathna, a clinical researcher at the School of Publich Health at the University of Syndey, NSW, Australia, who also works in the South Asian Clinical Toxicology Research Collaboration at the University of Peradeniya, Sri Lanka. “The prevalence of undiagnosed mental health issues—temporary or permanent—may be higher than we expect.” Senarathna says that there is a history of a lack of health interventions among rural and war-affected areas. “Most of the most vulnerable populations were not assessed or approached”, therefore an overview of mental health issues in the country might have substantially underestimated the problem, he says.

Another key challenge in mental health care in Sri Lanka is the lack of trained staff within the health system, particularly in terms of health-care staff not understanding and recognising mental illness and disorders. Sherva Cooray, lead consultant in psychiatry of learning disability, Central and North West London NHS Foundation Trust, UK, notes that there is a “great shortage” of trained experts in mental health in Sri Lanka but she thinks that this is “slowly improving”, particularly as several programmes are being set up in the country with an effort to train health-care professionals about mental health issues.

Cooray and her husband, Marius, a retired physician, piloted a training scheme adapted from a WHO programme in Colombo last year, which they are now hoping to roll-out to the rest of the country. Funded by the World Psychiatric Association and WHO, their scheme includes holding workshops and providing training materials for doctors in Sri Lanka with the hope that these doctors will go on to train other health-care professionals in their institutions. “The courses will be concentrated intensive 5-day courses on mental health, which would give a comprehensive overview of mental disorders, their management, and prevention.”

Not only are there limitations in mental health facilities and trained experts in rural parts of Sri Lanka, but there has always been somewhat of a cultural issue with mental health in the country. “Mental health is not openly discussed in Sri Lanka. This is linked to cultural taboos”, says Foster.

“Stigma attached to mental disorders from a social and cultural perspective in both the Sinhalese and Tamil communities contributes significantly to the problem”, says Cooray.

As with any conflict, there is always considerable concern about children of the war and its effect on future generations. “Children are the most vulnerable of all in conflict and post-conflict situations”, says Patrick McCormick, Emergencies Communication Officer at UNICEF. “Many children in these situations have only known conflict, have only known fighting and violence, fleeing from place to place to escape the violence, and living in temporary camp locations. The physical and mental toll on young people trapped in conflicts is incalculable.”

A UN report from Major General Patrick Cammaert, Special Envoy of the Special Representative for Children and Armed Conflict, after a visit to Sri Lanka in December, 2009, drew attention to the issues of children in the conflict, and in particular he pointed to the rehabilitation needs of children who were recruited to fight by extreme groups such as the Liberation Tigers of Tamil Eelam.

Not only is the mental health of these former child recruits a key concern, but there is concern about the general wellbeing and human rights of these children, most of whom are still being kept in government-run rehabilitation centres. Two humanitarian organisations, the Watch List on Children and Armed Conflict, and the Coalition to Stop the Use of Child Soldiers, responded to Cammaert’s report last month, and they commented on the present situation in Sri Lanka, “in which independent monitoring of human rights is obstructed”.

“Despite the end of the war, the current environment in Sri Lanka is not conducive to the promotion and protection of the rights of children, including those affected by armed conflict who now face many challenges in returning and reintegrating into their families and communities.”

Foster from Amnesty International is very concerned about the present situation in Sri Lanka and talks about “politics of amnesia”.

“Violence has been erased from collective memory as the state has refused to acknowledge disappearances and the reality of large-scale terror. With the end of conflict it is time to recognise that civilians in Sri Lanka need to cope with grief and deserve accountability or their wounds will not heal”, she says.