Independent Appeal: Mental scars of war and terror

Sri Lanka has one of the world's highest rates of mental illness but until now little medical help was available. <b>Fiona Barton</b> reports

Room 63 at Trincomalee General Hospital has little to recommend it. Hidden behind a green curtain in a crowded corridor, there is just room inside for a desk and two chairs. There is no waiting area, no privacy, and its bare, scuffed walls and small, high window, give it the claustrophobic air of a prison cell. But until three years ago, it was the sole mental health provision for a population of some 30,000 people.

It was a woefully inadequate service by any standards but particularly in Sri Lanka, a country which has a disproportionately high rate of mental illness – estimated at 10 per cent – and the seventh highest suicide rate in the world. And, even more shocking in Trincomalee. The east coast of Sri Lanka had borne a disproportionate share of the burden of the island's mental illness. It was here that the devastating wall of water which was the 2004 Boxing Day tsunami had taken its greatest burden. And it came on top of almost 25 years of killings, abductions, torture and displacement in Sri Lanka's bloody civil war. Here, almost one person in eight suffers from mental illness.

The moment the water struck is still alarmingly fresh in the mind of one of the town's residents, a woman named Marilya. On this day four years ago she and her family heard the shouted warnings as the sea swept up through the streets of their hometown. "We came out and saw the water coming and ran away to a higher place," she says. "We stayed there for three weeks and then we came back to clean up the mess." But when the physical task of clearing up was over, Marilya still carried the mental scars of the shattering experience of feeling her whole life washed away in seconds. She has been diagnosed with bipolar disorder.

The death toll left few families living on the coast unaffected.

Many of the cases of depression in the island are attributed to being displaced by the tsunami. But that trauma was only the final straw for many. "People have been displaced seven or eight times," Trincomalee's regional director of health services, E Gnanagunalan explained.

"They have lost close relatives and the things they love. They have lost their vocations and their futures. The conflict and the tsunami have affected the minds of so many, even some of the children."

What has made it far worse is that the tsunami came at the end of a prolonged period of cruel civil war in which many local people were forced from their homes and saw friends and relatives brutally or casually killed. People like Suhonamalar, a 34-year-old Tamil woman who was near the top of her school class when, at the age of 16, she and her family fled their home in Kinniya during the conflict. She has suffered psychotic episodes ever since.

"We lost everything, every belonging," she says. "We came with what we wore and our ID cards. Civilians died in our village and we were very afraid we would be killed, too. We went to a camp for refugees and lived in a big open hall for four years. There were about 100 families living there and we divided our space by putting up small tents. There were 10 of us in our family and my father was drinking heavily. It was very difficult.

"Now I am a burden on my family because no one will marry me. The grooms are chosen but their relatives tell them not to marry me because I am mentally ill."

Or Shafees, who, two years ago, at the age of 26, began displaying symptoms of schizophrenia. The community called him paithiyam – Tamil for "mad man" – and accused him of "thinking too much". His family believed he was possessed by an evil spirit and took him to be treated by their local religious leader. He says: "At first, my family thought I was play-acting to get out of working but later they brought me for spiritual treatment. I am a Muslim and they prayed and gave me herbal remedies. It did not work very well."

The future for them – and the thousands of men, women and children in Trincomalee district suffering from depression, separation anxiety, personality disorders and the terrible stigma of being seen as paithiyam – was bleak.

But a pioneering project at Trincomalee General Hospital, supported by VSO volunteers – one of the three charities being supported in The Independent's Christmas Appeal this year – is making a remarkable difference.

One VSO volunteer, Dave Bagley, a 44-year-old psychiatric nurse from London, has helped local medical staff develop a community mental health programme which serves 4,000 patients. The British charity is now the second biggest player in the field, after the Ministry of Health. It has placed five volunteers at Trincomalee General Hospital over eight years. Mr Bagley has completed two placements and seen the service grow from one room into a unit of trained staff with a team of community volunteers.

Dr Gnanagunalan describes VSO's presence as crucial to the success of the project. "It has given support to the unit and the community both technically and in terms of building capacity to the community approach. The volunteers have brought new ideas which they have transferred and we have adopted and customised to suit our own culture."

A twice weekly out-patient clinic at the hospital run by the unit's doctor (they still do not have a psychiatrist) is well-attended on the day we visit. Families have brought the relatives they used to hide – out of shame – until the VSO community mental health programme began to change local attitudes. Now they sit and and wait patiently to see the full-time doctor.

Those who live up to two hours from Trincomalee, the people who are too poor or sick to travel, can now be treated locally thanks to a mobile clinic. Mohamed Azad, the psychiatric social worker with the community mental health programme, and his team of eight volunteer community mental health assistants (CMHAs) visit patients in their homes, checking they are taking their medication and supporting them to find work and acceptance in their villages.

"Attitudes have changed and that is the significant change here," Mr Bagley says. "VSO has shared expertise and showed a different sort of behaviour towards patients. That behaviour, which treated patients as individual human beings, was there day after day and has made a difference. The changes are robust and the momentum is unstoppable. Whatever happens, mental health services will never revert to Room 63."