Sri Lanka's health service is a casualty of 20 years of war

Sri Lanka's 20 years of war has killed over 60,000 people and displaced hundreds of thousands more.
The LTTE (the Liberation Tigers of Tamil Eelam) has been fighting for its own state, resulting in areas of permanent conflict in the north and east of the country. Civilians are caught in crossfire; landmines and unexploded ordnance pose a constant threat; hospitals have been destroyed. Médecins Sans Frontières runs a substitution medical programme in the northern rebel controlled area, known as the Wanni, supplying specialists, including a surgeon, a paediatrician, an obstetrician, and an anaesthetist. Most medical professionals have fled: 21 of the 27 vacancies for government doctors in the region remain vacant, and only 34 of the 108 midwife positions are filled (rates of maternal and neonatal death are higher than the national average). Government training of medical workers has not taken place in the region since the war began. Population displacement has led to a rise in infectious diseases and malnutrition. As a result, malaria has increased 20-fold since the conflict began owing to disrupted vector control activities and limited access to treatment facilities, being among the leading causes of death in some areas. For seven years many essential supplies to the Wanni, including basic items such as sutures, surgical gloves, and oxygen, were subject to government embargo, and drugs and medical materials are often critically low. No postoperative analgesics are available, and often only life saving essential surgery can be performed. In sharp contrast to many other conflicts, humanitarian law is for the most part respected: soldiers fight soldiers. Both sides cooperate on certain health issues such as emergency patient transfers across the front line and temporary ceasefires to allow polio immunisation campaigns to take place for children. Sri Lanka's conflict seems nationally and internationally to be have been accepted as a chronic, ethnic conflict, but there are signs of improvement. In January the government embargo was lifted, and previously limited medical supplies are beginning to become available, albeit sporadically. Medical transfers should now be easier. Peace talks are planned. More could be done to protect the health of civilians. Official training leading to government certification should be given in the rebel controlled area to meet the acute demand for medical staff, and the LTTE should assume greater responsibility for health care in regions under its control. In Sri Lanka as elsewhere, the terrible damage caused by the war to people's health and life expectancy should not be accepted as an inevitable consequence of the fighting. Brigg Reilley, epidemiologist. Isabel Simpson, head of mission. Médecins Sans Frontières, Colombo, Sri Lanka Nathan Ford, access to medicines adviser. Médecins Sans Frontières, London EC1R 5DJ Marc DuBois, humanitarian affairs adviser. Médecins Sans Frontières, Amsterdam, the Netherlands