The Unmet Mental Health Needs of the North

Photo by Ama Koralage

The ramifications of Sri Lanka’s civil war live on in the north, especially in the matter of mental health where the lack of human, physical and financial resources to address complex trauma and create a healing environment are sorely lacking.

A study conducted in 2019 on the prevalence of mental health disorders in the north by a group of researchers found that among 533 female and 482 male participants, 58.8 percent were suffering from a range of problems including anxiety, depression, Post Traumatic Stress Disorder (PTSD), psychosis and physical symptoms brought on by trauma.

With the end of the war, the estimated 500,000 Internally Displaced Persons (IDPs) began to rebuild their livelihoods; however insecurity, lack of services, poverty and loss of previous livelihoods exacerbated the already unstable psyche, resulting in immediate and long term psychiatric issues. This has resulted in unemployment, decline in output and a decrease in self-resilience in Jaffna society, the study said.

In children who experienced trauma as a result of separation from their families, high percentages of malfunctioning such as cruelty and anti-social behaviour, withdrawal from play and loss of concentration or loss of memory were identified, it said.

The consequences of war included displacement, death and disappearances. “In addition to exposure to extreme war-related traumatic events such as witnessing or experiencing torture, injury and death, many in Sri Lanka have experienced ruptured familial and community relationships, outmigration of loved ones, changing social values, and loss of livelihood and education,” the study said, adding that many households had turned to daily wage labour as their main livelihood source after losing work in the agriculture sector, fisheries and industries, resulting in lower wages and increased levels of poverty.

The effects of unmet mental health needs could be seen in the high incidence of substance abuse, suicide, domestic violence and child abuse affecting communities in the north, particularly in the Kilinochchi and Mullaitivu Districts where many ex-combatants lived.

Dr S. Sivathas is a consultant psychiatrist Jaffna Teaching Hospital. In May 2009, as soon as the war ended, he offered his services to help the displaced, leaving his family in Colombo and going to the Vavuniya hospital where he served for 10 years. For the past five years Dr Sivathas has been at the Jaffna Hospital but also covers Mullaitivu and Kilinochchi to make up for the dearth of psychiatrists.

“Initially it was very difficult but I got used to it and became less sensitive. I have the motivation to do it because they are my people. I studied in a state medical faculty so I have to do my duty to my country and to my people. It is very important because it helps me to heal myself. Rather than watching from outside, I am doing something and it gives some meaning. Otherwise I couldn’t have survived for 15 years,” he told Groundviews.

Here are excerpts from the interview:

What is the mental health situation of people in the north?

Studies have shown that 40 per cent of the people in the war affected areas have a depressive disorder compared to 10 percent in the south. Professor Daya Somasundaram, Professor of Psychiatry at Jaffna University, is doing a new study that shows that nearly 60 percent of people have depressive conditions and mental health related problems. A study by WHO said that in any war affected area mental health problems affect 22 percent of the population but ours is more than double that. The incidence of domestic violence in Jaffna is 40 percent and 50 percent in Kilinochchi while national level is 17 percent. The suicide rate in northern province is 30 per 100,000 while the national level is 15 per 100,000. Alcohol consumption in Jaffna is the highest in the country with around 20 to 30 percent of the population being affected. This shows that there are huge mental issues even 15 years after the war. Mental health disorders also affect work capacity and are less productive for country. It also leads to  poverty for the individual.

Is it mainly older people who have been directly affected by the war who have mental health disorders?

Those people have problems but the next generation is also affected. Transgenerational transmission of trauma has been well documented. People have lost their parenting skills due to the war and are not responding to needs of their children; they are not sensitive enough to care for their children and are unable to put down rules and regulations. Unaddressed trauma results in domestic violence affecting maternal mental health and children’s mental health. People affected by the war have accumulative trauma impacting their interpersonal capacities. They start to fight with their partners; they are prone to take alcohol to overcome symptoms of trauma, resulting in conflicts.

What is lacking to tackle these mental health disorders?

Human resources are not enough. We are a low income country with few psychiatrists. We have failed in the area of public health, especially in mental public health because we have no resources and no plan to solve the problems. Studies in countries such as Rwanda, Kosovo and Afghanistan have shown that war has a big impact on children and women. If not properly addressed, the trauma will continue. There is no rehabilitation centre or rehabilitation programme for war affected people or torture victims. There must be a public mental health policy and programmes for early intervention. Media, political leaders, civil society and religious leaders all have to take responsibility to deal with this. The problem is for society and priority should be given for healing by creating a healing space to stop hurting and encourage healing. This is not only for Tamil community but for whole community. It is a huge task.

What happens when trauma is left unaddressed?

Accumulative trauma happens when trauma continues for a long time repeatedly such as in the case of prolonged child abuse. Accumulative trauma leads to personality change. I have heard people say, “He was such a nice person before the war but now he has completely changed.” Ex-militants have had training for war but people who are not trained are more vulnerable, especially children and women. The ex-militants have a different problem; after war ended they were not incorporated into society and the Tamil community didn’t accept them properly. This frustration has led to violence and substance abuse. Ex-militants and also civilians show increased alcohol abuse, child abuse and domestic violence. Unemployment and poverty also leads to problems. The Mullaitivu district has highest rate of poverty in the country. People in Kilinochchi and Mullaitivu witnessed the last phase of the war. From January to May the war was intense. Many people were trapped, a lot of people were killed and their relatives couldn’t perform last rituals to ease the grieving process. The families of the disappeared have no closure; there is no full stop, only a comma.

How do you help people to heal?

I encourage them to focus their on daily life skills and to look after their families rather than only focussing only on the disappeared so that they several other problems to deal with including other children and husbands. Group therapy has positive outcomes. Volunteers can be trained from the local community to act as facilitators and in the process they can heal themselves while healing others. Commemorations are very important for healing process as it is important to address the grief. People who are affected have to initiate it and not allow people who are not affected, such as politicians, to use it for their vested interest. It should be spontaneous. People who are really connected to family members and others can move on more easily. I have seen mothers recover from trauma after having grandchildren. That is the most powerful tool for recovery because they started looking after children and to forget everything else. Also other relationships and marriages for children also help. People who have a faith and sense of spirituality recover faster. Those who have jobs have dignity and income and can focus on a daily routine. A small percentage have medication and treatment. I have seen more than 1,000 ex-combatants in the past 15 years and around 20,000 IDPs and I found that instilling hope is one of the most important factors for those affected by trauma.