The Impact of War on the Health of Our Nation

by Dr. Vairvapillai Rajayogeswaran, March 22, 2008

Speech delivered at the international conference held on 22 and 23 March 08 at University of East London (Dockland Campus) by GPSG UK.

Thank you Chairman,
My learned friends from various countries,
Ladies and gentleman.

Friends, in tracing this ethnic conflict, one could clearly see that we (Ceylonese) at the time of independence were very unfortunate for not having political leaders on either side of our communities who were capable of building the nation. In other words, Our Sinhala brethrens were not keen on Nation-Building. but Division of the nation, which was given to us by the British after 150 years. Sinhala politicians were covertly formulating schemes to change the demography of the Tamil areas and to reverse what they perceived as British-favoured Tamil positions. Our Tamil leaders, not realizing these cowardly acts, had continued to contribute to Sinhala politicians' plans with their self-interest and, thereby, dragged our community into this present quagmire. We Tamils still face newer threats by these so-called 'Tamil moderate' politicians of the present day.

The Sri Lankan ethnic conflict now turned into war was an anticipated phenomenon. The conflict was simmering from the early 20th century. Could the ethnic conflict be attributed to the awakening of Sinhala nationalism? Nationalism was based on the hatred spins seen in the 6th century chronicle, the Mahavamsa.  The “Mindset” of many past and present Sinhala politicians and Buddhist monks seems to havebeen geared towards this ethnic hatred. The imposition of the Official Language Act “Sinhala Only” in June 1956 brought about a superior sense of dominance into the mind of the Sinhala community. The hatred turned into frequent communal riots, and grew into genocidal pogroms by 1983. These pogroms were State-sponsored “Ethnic cleansing” acts.

Since 1983 the ethnic conflict has transformed into ethnic war. It has become one of the most intractable wars in the post colonial era. This war has been termed the “No Mercy War” by the International committee of the Red Cross (ICRC). It has caused at least 70,000 deaths, many thousand disabled, widowed and up to one million displaced. It is also very hard to comprehend when severe human right abuses are being openly committed by the armed forces and their conniving paramilitaries to escape impunity. The war has received little attention outside the region. Since July 2001 it has taken on an international dimension involving the US, Norway, India and Japan.

Sri Lanka when it was known as Ceylon had achieved impressive social indicators, such as a high literacy rate and life expectancy, low rates of infant and maternal mortality. During the past three decades, however, these indicators have slipped. The overall figures mask wide disparities within the ethnic and regional groups and conceal the devastating impact of the war on demography, health, education and housing.

The troubles are rooted primarily in the practice of dominance and failing to address or unwillingness to resolve the political and economical grievances and aspirations of Tamils. Since independence the Sinhala majority governments have attempted to reverse what they viewed and perceived as British-favoured Tamils in education and government positions. Successive governments instituted policies that were very detrimental and discriminatory against Tamils in language, higher education and employment.

Let us now view the impact of the war on the Tamil nation, which will provide us an insight into currently available information.

The first legislative blow to Tamils was in 1949, with the passing of the bill to disenfranchise the upcountry Tamils, who were and are the backbone of the Island's largest income providing economy.  Unfortunately, some of our Tamil leaders did support this bill. The second blow was directed against us - Ceylon Tamils, with the “Sinhala Only” official language act. By this act of parliament many Tamils who were in employment were unemployable in their posts overnight. Following this discriminatory act, the state instigated assaults on the Tamil community in “Gal Oya” where the new Sinhala colonies had been settled in 1950. These assaults were followed by a peace pact (the B-C Pact) in 1957, which was abrogated. The Tamil party conference in Trincomalee calling for nonviolent protests against the government met for the first time and had to face a violent communal riot in May, 1958, which created over 30,000 IDP’s in the south. Since this event, many periodic episodes of pogrom have taken place to subjugate the Tamils until July, 1983. Burning of Jaffna Library by two Sinhala Ministers and the armed forces had reached the pinnacle of cultural genocide of Tamils. Since 1983 the ethnic conflict has turned into ethnic war on Tamils.

Slide 3 -

Before we proceed any further let us pause to define who constitutes “A Tamil Nation” and our “Homeland”. According to a reference Dictionary

– Nation –n, A people inhabiting a certain extent of territory and united by common political institutions; an aggregation of persons speaking the same or cognate language.

The English –Tamil Lifco Dictionary defines,

People of common ties-descent, language and history bound together within a territory.

Our homeland is as shown on the map North east of the Island; Or if we connect all the bombed and bullet-pierced lands, this will constitute the Tamil Homeland.

Slide 4 -

The British Medical Journal (BMJ) vol324; P-732; of 19th Feb 2002. In this publication it had an article on the Sri Lankan Ethnic War titled “Health Service is a Casualty of 20 years of war”. This article describes four salient points,

1. Epidemiological Vulnerability- due to lack of public health activities in the war torn areas from Malaria, Measles, Diarrhoeal diseases, Acute Respiratory Infections, TB, Dengue, Rubella, HIV/AIDS.
2. Migration of health care workers causing shortages.
3. Damage to Infrastructures
4. Changes of social values.

Slide 5 -

NGO’s Consortium report of June 2005 states “A visiting WHO official said – Negligence of GoSL in providing health services to costal villages in the North East affected by Tsunami."

WHO – 2006 – Based on the present health system and health needs of the North-East, efforts for recovery of the health system will need US$8.2 Million.

Slide 6 -

North East conflict area WHO, IASC report August 2006 - Key Issues:

1. Security situation remains unpredictable- unscheduled bombing, firing, bomb blasts.
2. Large number of Internally Displaced Population on both sides (Government &LTTE controlled areas).
3. Assault on INGOs by civilians or armed forces.
4. Over crowded Camps, inadequate sanitation facilities.
5. No protection for women and children.
6. No privacy –ladies changing clothes in toilets.
7. Water quality not tested (no pH meters).
8. Many people with Diabetes, Hypertension and other Non-Communicable Diseases are without regular treatment.
9. Non-Availability of Doctors in some camps due to insecurity.
10. Medical Supplies inadequate.
11. Health delivery system in place / non functional most times.
12. Mechanism for regular monitoring of health situation in camps needs to be established.

Slide 7 -

25 years of violent conflict in the north east of the Island has led to -

• Breakdown of family structures and social safety nets.
• Coping mechanisms and resilience are pushed to the limits.
• Exhausted and vulnerability of the Tamil speaking community.
• Renewed violence – aerial bombardment, multi-barrel rockets, shells and gun battle.
• Education disrupted, unavailability or unwilling to supply text books, teachers by GoSL.
• In 2006 800 Tamils disappeared or killed, 200, 000 displaced.
• Relief and Aid agencies face threats, attacks, limitations to access and new bureaucratic procedures imposed by GoSL.

Slide 8 -

This slide showing the bombed wards in Jaffna hospital in the late 1980’s

Insets from Professor John Whitehall (Australia) - 2005.

“Driving north from Colombo to Jaffna, I was struck by the poverty on the Tamil side of the armed border, lack of facilities in the hospital in Killinochi.”

 “Why was the hospital so different to many I had visited in the Sinhalese areas?”

Slide 9 - Direct health impact of renewed violence.

Morbidity and Mortality

1. Large number of civilian casualties, loss of staff, damage to equipments, scarcity of medicines, increased level of Ill health within IDPs
2. Health infrastructure and system failure.
3. Economic distress, social disruption and insecurity.
4. Gaps in health coverage are severe, shortage of skilled staff, specially an urgent need in the northeast.
5. Communicable diseases in camps. Lack of preventive measures.

Slide 10 - Indirect Health Impact.

• Damage to water plants and other vital infrastructures or life lines.
• Camps littered with garbage and waste, no system in place to clear.
• Inadequate shelters, leaks when rains, too hot during day time from scorching sun. IDPs seek shelter under trees.
• Inadequate toilets, poor sanitation facilities.
• Unemployment and frustration among IDPs and civilians under Government controlled areas.

Slide 11 - The state of Mental Health in the North.

Prof Daya Somasundaram. Int. Journal of Mental Health Systems 2007; 1:5doi:

"Post traumatic Mental State of Tamils."

• 25% of the population suffers from clinical depression.
• 27% from Anxiety disorder.
• 14% Post traumatic stress disorder.
• Schizophrenia 1% of the population, striking at a young productive age and running a chronic course into old age.
• Suicide rate 31 in 100,000; men / women 44.6 to 16.8 especially among IDPs.

Slide12 -

This Data is based on the present context of the Ethnic War in the Northeast of Srilanka. - Online News agencies.

• Affected more than 2.5 Million Tamil-speaking people.
• 70,000 deaths since 1983.
• 350,000 remain displaced living in camps, with relatives after 1995 mass exodus from Jaffna.
• 450,000 remain displaced in makeshift shelters, partially reconstructed houses following Tsunami December 2004.

Renewed violence since April 2006 to Date.

• 800 or more killed.
• 200,000 displaced in the east.
• Violations of human rights and growing risks for civilians in the GOSL controlled areas by armed security forces and mercenary paramilitary groups.

Slide 13 - TIC report 2007.

Damages to Health institutions such as Hospitals, Dispensaries and medical clinics in Northeast. About 400 institutions in the whole of the NE.

• 55 totally destroyed –bombed.
• 49 could not function due to lack or shortage of essential drugs and equipments.
• Remaining institutions partially damaged, no repair work, over crowding of beds and wards.
• Shortage of Health care workers- migration, displaced, killed (Doctors, Dentists, AMPs, Nurses, Midwifes, Lab Technicians, radiographers Etc).
• Sanitation poor, lack of clean water supply to institutions.
• Health facilities to the population of north east “a will full denial” by GoSL or enforced implementation by its armed security forces.
• Ambulance service inadequate due to lack of parts to vehicle, no new replacements.
• 80% of the population under poverty line - malnutrition is a poverty indicators – National level is only 10%.

Slide 14. To summarize the ethnic war, it could be described as; Ugly, Brutal and Bloody.

• Fear Tension and Trauma has scarred many of our children and women.
• Mental disorders, sense of hopelessness.
• Poverty and Ill health.
• Shortage of food, medicine and money - Embargo and closure of A9 trunk road to north.
• Repeated illness due to lack of proper nutrition.
• Diarrhoea, Skin disease, Anaemia, Malaria, TB.
• Change of social values, changing Socio-Cultural norms.
• Times of high standard of living and long life expectancy among Tamils have come to an end.
• Elderly face new social problems being abandoned.

Slide 15 -

Let us look at the causes of Tamil Migration. From Ceylon and then Srilanka.

• Post 1956 “Sinhala only” and Subsequent Riots of 1958. The Burgher community led the way first, followed by Tamils resigned their jobs as unable to work in Sinhala language and left with their families.
• The first wave of Tamil migrants to the West (UK, USA) started in 1959 and continued till pre-1983.
• Post 1983 – Mass exodus to India, UK, USA, France, Germany, Canada, Switzerland, Norway, Sweden, Denmark, Middle East, Australia and New Zealand. Reference Wikipedia.

Slide 16 - Who Make Up the Tamil Diaspora.

By definition; Diaspora is made up by those of us who have at some point chosen to walk away from our native land seeking for ourselves and our children safety, stability, prosperity and even happiness.

Slide 17 - Tamil Diaspora- Many million population spread around the globe.

• UK over 250,000 larger group made up of Professionals, over 6000 Doctors, Dentists, and medical scientists. Over 250 Law firms, Engineers, Accountants in both private and government sectors. About 5000 small businesses.
• USA over 200,000, mainly professionals.
• Canada 400,000 mixed group of professionals, skilled and unskilled workers.
• Australia 100,000; Germany 60,000; France 100,000; Switzerland 40,000; Netherlands 20,000; New Zealand 10,000; Norway 15,000; Denmark 7,000; Sweden 2000. Papua New Guinea 25 families.
• South India 160,000, as many as 75,000 refugees in 153 camps since 1983.
• Rameswaram Camp 20,000 from 2005-2008.
• Colombo 100,000 moved from North after 1995, Total population of Tamil speaking people in Colombo and its suburbs make up 500,000.
• Malaysia, Singapore, South Africa Tamils were taken by British to work from the 19th Century and they make up over 2 Million.
• Similarly Tamils in Mauritius, Seychelles New Guyana, Fiji, West Indies, and many African states.   

Slide 18 -

The Global Peace Support Group UK calls on the International Community to Assist Urgently on the following:-

• An Immediate stop to indiscriminate aerial Bombing in the Tamil civilian populated areas
• Create a safe haven / No fly zone.
• Remove Draconian Laws to persecute the Tamils.
• Stop White van Abductions & Disappearances
• Release all Tamil Political prisoners.
• Resume CFA and Meaningful Talks to resolve the present crisis.
• Talks to resolve the core issues on Tamil people’s grievances and their aspirations.

We had sixty years of oppression and subjugation. Leave us to live as equals and with dignity.

Slide 19 -

Conclusion

This Ethnic War Has had the direct Impact on the North & East Tamil Speaking Civilians.

• Loss of many thousands of lives. Many disabled and many widowed and orphaned.
• Psychological trauma.
• Infrastructure damage to homes, businesses, place of worship and hospitals
• Many thousands are displaced from their homes, villages and livelihood.
• Restricted mobility (Jaffna an open prison camp).
• Disruption of local economies.
• Disruption of community and institutional networks.
• Loss of Educational facilities, GoSL withholding textbooks to children in the North. Temporary teacher assignment to North & East. Many schools have IDPs and Army camps.
• Deterioration of Health Care system.
• Lack of Health Care workers due to migration, under training and insecurity.
• Scarcity of Medicine, Essential food items.
• High Infant mortality, stunted growth, premature deaths, and high rate of maternal deaths.
• Fear instilled by White –Van Abduction and disappearances.
• Loss of Law & Order, Tamil civilians bullied and harassed by armed security forces and Mercenary paramilitary groups used by the GoSL.

Slide 20 -

Excerpts from BMJ 2002; 325; 856 (19th October) Impact of war on Health.

• “The deadliest effects of war are often impoverishment and disease, rather than bullets and bombs”
• “Most die from malnutrition and disease than from direct violence”
• “Nation has been traumatized, lost a generation, brutalized and stigmatized”.
• Received from west “bread and counseling” what they did not receive are “physical protection, reparation or justice” which were much needed.

Dr. Vairavapillai Rajayogeswaran.
BDS (Cey); MSc (Lond); DDPHRCS (Eng); FDSRCS (Eng).
Retired Senior Clinical Lecturer Kings College London.