After War’s End, a Long Struggle to Patch Invisible Wounds

KILINOCHCHI, Sri Lanka — One by one the villagers arrive, each carrying a little blue book that chronicles a history of loss and heartache.

On the back of each book is the patient’s name. Inside, on the first page, a family tree. An “X” is scrawled next to each loved one who has died. A “?” next to the missing. Underneath the symbol is the cause, and more often than not, it is written in simple capital letters: “WAR.”

If bearable, their trauma would have remained private, behind the walls of modest homes in this northern part of Sri Lanka shaded by coconut trees and often still bearing the scars of bullets and fire. But it’s not. So they come for monthly public counseling, lining up to see Dr. V. Jegaruban.

Known as Dr. Jegan, he is a government psychiatrist who has made it his mission to help people piece their lives back together after the small island nation’s devastating civil war ended in 2009, after 26 years and more than 100,000 civilian deaths.

“Everyone is focusing on building roads, building houses, building hospitals after war,” Dr. Jegan told me this year, lamenting the lack of urgent attention to addressing “the collective trauma.”

“Very few people focus on the lives, on helping bring back the happiness,” he said. “It is not easy.”

Our world is one of traumatic wars that fade from one to another, rarely affording any chance for large parts of a generation to look beyond the daily struggle for physical survival.

The hope one clings to is this: Even the longest of wars do end some day. I have kept coming back to Sri Lanka to see what even a deeply scarred peace looks like.

Many of the fundamental inequalities and ethnic divisions that led to Sri Lanka’s civil war remain. But it is hard not to be moved by how everyday people, driven by a culture of volunteerism, have rallied to deal with the deeper trauma that continues to grip large parts of the society.

The government estimates that nationwide about 10 percent of Sri Lanka’s roughly 22 million people suffer from some form of mental disorder, with nearly 800,000 suffering from depression.

Research suggests those numbers are far worse in northern areas, where much of the fighting was concentrated. Small studies in the northeast around the war’s end found the prevalence of post-traumatic stress disorder among children as high as 30 percent.

Sri Lanka’s suicide rates long remained among the 10 highest in the world. Improvements in infrastructure to access hospitals over the past decade, as well as restrictions on deadly pesticides that people have used to kill themselves, have improved things. But the country still ranks in the worst 20 percent.

The police see a profound problem, registering about 10 such deaths a day. Activists estimate the number may be as high as 15. A more worrying and telling number, according to activists, is this: At least another 100 to 150 people attempt suicide each day.

“There is a lack of reliable data to capture the true burden of the mental health, but it’s probably much more than the numbers the government is putting out,” said Nivendra Uduman, a Colombo-based psychologist and activist who has walked coast to coast to raise awareness. “Some of the issues are probably more prevalent in the north and east. But the main disorders — depression and anxiety — are across the board.”

“It’s not just result of traumatic events,” he added, “it’s also daily pressures.”

Sometimes, it is government psychiatrists like Dr. Jegan who are trying to meet the demand for treatment. But more often, that burden falls on volunteers — a recently retired banker, a former nurse, a local business dispute mediator — who have been trained as counselors. They answer calls at suicide hotlines or help with program’s like Dr. Jegan’s.

Dr. Jegan is based in Kilinochchi, a district of about 130,000 that saw some of the worst fighting in the last phase of the war. It was the capital of the rebel Tamil Tigers, who years before had broken with the ethnic Sinhalese majority-dominated government over accusations of abuses and unfair treatment.

President Mahinda Rajapaksa’s brutal offensive had hemmed the rebels into Kilinochchi, and the Sri Lankan Army, unmoved by accusations of war crimes, closed the area to international observers and unleashed its wrath. At one point, the area’s entire population was displaced. In the absence of exact casualty counts, the United Nations says at least 40,000 civilians were likely killed in the last stage of the war.

The trauma of that chapter has barely dulled, and for many it has been refreshed by the latest political crisis.Mr. Rajapaksa is again at the center of power, his face looming from posters on the street.

Dr. Jegan’s method of going door to door in the villages surrounding Kilinochchi helps break a taboo around mental health issues that, in the past, would have seen many of his patients heavily stigmatized. With him, their pain has a cause, a history — recorded in the little blue books.

“Husband died of heart attack, one daughter died of war, a sister committed suicide,” he read from one family tree. The patient, a woman in her 60s, sat quietly in front of him.

In his notes, the doctor keeps track of important dates — death anniversaries loom large — so he can be ready when parents come to his sessions with more trouble in their hearts.

Ulaganathan Nagendram, 67, came with his wife, Umadevi, fearing that he was having a heart attack.

Dr. Jegan did not detect anything physically wrong with him. He asked another question: What was Mr. Nagendram worrying about?

The patient insisted that he was not worrying about anything. But his wife offered an explanation: Two of their sons had been killed in the war, and the anniversary of one’s death had just passed.

“He always lapses into grief at this time,” she said of her husband. “He keeps it all bottled up and denies feeling upset or unhappy. At least we women talk to each other and cry if necessary. He won’t do that, ever.”

In the last stages of the war, the eldest son of Illaythamby Ganesamoorty, 60, was forcibly conscripted by the Tamil Tigers, a practice that grew as the government noose tightened around them. The war ended, but the son never returned.

After looking unsuccessfully for him, Mr. Ganesamoorty sank into a deep depression. He tried to commit suicide three times by drinking poison. After a fourth suicide attempt, he ran away from the hospital. Dr. Jegan followed him nd persuaded him to come to his monthly clinics in the village instead.

“He is still searching — going behind every information, reading newspapers, reading the media,” Dr. Jegan said of Mr. Ganesamoorty. “He can’t accept his loss.”

Mr. Ganesamoorty has come every month since May 2015, sitting across from Dr. Jegan, nodding or murmuring brief answers to questions before receiving his antidepressant prescription. But with each passing month, Dr. Jegan says that the man speaks less and expresses fewer emotions.

“According to his history, he was a perfectly normal man before the war,” Dr. Jegan said, leafing through the man’s blue book. “Now he is like this.”

Their Hope, Their Friend

For Dr. Jegan, being posted to Kilinochchi as the mental health officer at the general hospital was like going back in time.

Though he went to school and trained in Colombo, he was born in the north. He had watched his father, also a doctor, treat wounds under kerosene light during the war.

Studying his new beat, he found that about 80 percent of the population work in farming or fishing. In many of the villages, the bus comes only twice a day. Going to the hospital to seek help for mental illness is a day trip that many avoided.

“General statistics say about 10 percent of people in need of mental health services are coming to a proper service in this part of the world,” he said. “Nearly 90 percent of people in need are not coming. They are either going to a healer, or a temple or self-medicating. Or they are not getting anything at all — they are accepting ‘this is my fate.’”

Many are stopped by the stigma that comes with discussing mental health. In close-knit villages, someone could be branded as crazy just for seeking help.

So Dr. Jegan set out to take his service to them, village by village.

Before he arrives for his sessions, his assistants simply announce: “The doctor is coming.” They don’t say “psychiatrist.” Part of that is to avoid the stigma, but the other part is simple: For many of the villagers, he is the only medical help they will ever get. So he tries to treat anything that comes his way.

“How to improve the mortality of mentally ill patients?” Dr. Jegan told me. “One way is to treat the physical problems. Balance the sugar level. Balance the blood pressure level.”

“Nobody dies of schizophrenia,” he said. “They die because when you have mental health problems you ignore the physical health. You get heart attacks, you get kidney failure.”

His village visit days are long ones, often stretching past 10 p.m. But even his typical office days at the Kilinochchi hospital keep him apart from his wife and children, who live in Colombo. Every other weekend, he takes the overnight bus at the end of work on Friday to visit them.

His village services rely on a number of community service officers. In between the doctor’s monthly visit, the officers — all women — keep an eye on the patients.

One of Dr. Jegan’s most active helpers is Sathyabaminy Nesarajah, a jubilant 46-year-old woman.

Her husband, who was conscripted by the Tamil Tigers, disappeared in 2008. She is the sole source of support for three children, ages 16 to 22. She covers nine villages on her motorcycle, visiting about 230 patients at least once a month.

“Apart from identifying patients, it is my job to check on those who come to the clinics — whether they are maintaining their medical records properly, taking their medicines regularly, coming to clinics regularly,” Ms. Nesarajah said.

For many of the patients that Dr. Jegan sees, he knows medicine can’t really cure the pain of their losses. But what he can still offer is hope — something to look forward to in his visit, a chance to talk.

One of his regular patients, a young war widow with two children, used to be mostly silent as he asked her questions. On this day, she was responding more fully, even breaking into a wide smile for him.

“This is my reward,” he said. “This is why I can sleep so well at night.”

Divani Santakumari, 60, lost a son to government airstrikes. Her daughter disappeared in the last stages of the war in 2009.

Ms. Santakumari and her husband, who is 70, live off 15 coconut trees. She has diabetes, high blood pressure and anxiety, and Dr. Jegan prescribes her medicine each month.

“I take the medicine because I believe in him,” Ms. Santakumari told me. “But I don’t really feel better.”

When the war ended and her daughter did not return, she started attending protests and tried to track down any information about her whereabouts.

A building damaged in the war, near Jaffna.Credit Adam Dean for The New York Times

Nine years later, any hope she had has faded. She has stopped going to protests. Just a day before we met, hundreds of parents had staged a gathering in Kilinochchi demanding answers for their lost children.

“I didn’t go,” said Ms. Santakumari, wearing prayer ropes on her wrists. “The doctor said you are just getting mentally more upset. They are not giving any answers.”