Maveerar Naal: health, trauma, and resilience amid decades of war

Every year on 27 November — and throughout the month of remembrance — Eelam Tamils worldwide observe Maveerar Naal, honouring those who lost their lives during Sri Lanka’s war (1983–2009). While traditionally centred on fallen fighters, this period also serves as a vital opportunity to reflect on the epidemiology of trauma, the collapse of public health systems, and the long-term physical and psychological consequences carried by Eelam Tamil communities after more than two decades of conflict. This article reframes Maveerar Naal not only as a commemoration, but also as a scientific reflection on the humanitarian, physical, and psychological cost of war — and the resilience of those who survived it.

A health system under siege

From the mid-1980s onward, northern and eastern Sri Lanka experienced a chronic, escalating humanitarian emergency. Repeated mass displacement, food scarcity, blocked medical supply routes, and intermittent bombardment steadily eroded the region’s healthcare infrastructure. Clinics became inaccessible due to shelling or military restrictions, and maternal and child health services deteriorated sharply. Early epidemiological observations from the 1990s documented widespread anxiety, depression, and trauma symptoms among civilians, demonstrating that mental-health consequences were emerging long before the war’s final years.

By the late 2000s, the public health crisis intensified dramatically. As the conflict entered its final phase — from late 2008 to May 2009 — more than 2.5 million people were trapped in active conflict zones, while approximately 800,000 civilians were internally displaced. Entire districts lost functional hospitals; others were forced to convert schools, churches, and tarpaulin shelters into emergency medical centres.

Human resource shortages reflected the near-total systemic collapse: in some northern districts, only 34 of 108 midwife posts and 6 of 27 doctor posts remained filled. Pregnant women delivered in makeshift bunkers, neonatal mortality spiked, and infectious diseases spread rapidly through overcrowded displacement camps. For many, survival came at the cost of long-term disability, untreated injuries, and profound psychological trauma.

Physical health consequences across populations

The physical scars of the war persist across generations. Civilians experienced blast injuries, shrapnel wounds, burns, and amputations, often without access to timely surgical care. Emergency operations were performed in unsterile environments; in some cases, anaesthesia was unavailable, forcing staff to improvise with inadequate substitutes. Conditions in displacement camps — overcrowding, poor sanitation, contaminated water — led to outbreaks of diarrhoea, hepatitis A and E, and vector-borne diseases.

For combatants, chronic health burdens are well-documented. Peer-reviewed studies, including research published in journals such as the International Journal of Social Psychiatry and the Journal of Rehabilitation Medicine, report the following long-term conditions among injured veterans:

• Back pain: 69.4%

• Knee osteoarthritis: 18.8%

• Hypertension: 22.4%

• Diabetes: 34.2%

• Phantom-limb pain among amputees: over 77%

• PTSD among amputees: ~41.7%

These outcomes reflect years of untreated injuries, limited rehabilitation access, chronic stress, and long-term nutritional deficiencies.

Psychological trauma and intergenerational consequences

The psychological impact of the war has been profound. Medical workers described witnessing mass casualties with inadequate supplies — a situation that produced significant moral injury, compassion fatigue, and long-lasting mental-health consequences.

Among severely injured fighters, mental-health assessments published in trauma and rehabilitation journals report:

• PTSD: 41.7%

• Adjustment disorder: 16.4%

• Depressive disorder: 15.6%

• Somatoform/dissociative disorders: significant prevalence

  
  

Civilians exposed to high-intensity conflict show similarly alarming patterns. Studies from humanitarian organisations and academic institutions report that approximately:

• 64% of civilians exhibited long-term trauma-related effects

• 27% experienced PTSD

• 26% had anxiety disorders

• 25% had depression

• 18% experienced functional disability due to psychological distress

  
  

Notably, emerging research has identified intergenerational transmission of trauma, with children of survivors — even those born after 2009 — displaying elevated rates of anxiety, behavioural challenges, and trauma-related symptoms. This represents a critical area for continued scientific study and intervention.

Health workers on the frontline: the hidden scientific story

The war’s final months produced some of the most extreme medical working conditions documented in modern conflict settings. For ethical, political, and safety reasons, this article does not name frontline medical staff; however, their experiences are well-recorded in reports by Physicians for Human Rights (PHR), Human Rights Watch (HRW), and eyewitness testimonies.

One regional physician coordinated makeshift hospitals inside schools and religious buildings. With no supplies, he sterilised instruments over open flames, used sarongs as dressings, and suspended IV fluids from tree branches. He performed dozens of emergency surgeries daily, sometimes operating while artillery fire struck nearby.

A field-hospital superintendent described conducting amputations without anaesthesia, supported only by volunteer nurses. When their facility was shelled — an incident documented by multiple international observers — dozens died instantly. Survivors were treated in trenches illuminated by mobile phone torches.

Another medical coordinator reported overseeing triage for thousands of displaced civilians, many severely dehydrated or malnourished. He described having to prioritise patients based solely on survivability, an ethically devastating but necessary decision in conditions of extreme scarcity.

PHR and HRW documented at least 30 direct attacks on hospitals between December 2008 and May 2009. These incidents — some among the most thoroughly investigated attacks on medical facilities globally — illustrate the catastrophic collapse of health infrastructure and the extraordinary resilience of those who continued to provide care.

Reflection, healing, and the path ahead

Maveerar Naal is, at its core, a day of remembrance. Yet for many Eelam Tamils, it is also a day of scientific reflection — a moment to acknowledge the measurable, long-term consequences of conflict on physical health, mental well-being, and community resilience.

Healing requires investment in:

• Long-term mental-health services rooted in trauma-informed care

• Rehabilitation programmes for amputees and individuals with chronic injuries

• Public health research into intergenerational trauma

• Accessible healthcare for survivors living in diaspora communities

• Preservation of evidence and health data for historical and scientific record

By understanding the epidemiology of suffering, communities can better design strategies for recovery. By recognising the extraordinary resilience of civilians, fighters, and health workers, they honour all forms of courage. And by grounding remembrance in scientific truth, Maveerar Naal becomes not only a memorial, but a commitment to protecting health, dignity, and humanity for future generations.

In remembering the past, we build the foundation for a more compassionate, prepared, and resilient future.

Written by Jeevana Thavarajah

Related articles: Impact of war on health (series) / South Asian Mental Health

REFERENCES

Amnesty International (2009) Sri Lanka: Twenty Years of Make-Believe. Available at: https://www.amnesty.org/en/documents/asa37/005/2009/en/ 

BBC News (2009) Sri Lanka shells no-fire zone. Available at: http://news.bbc.co.uk/2/hi/south_asia/8046136.stm

Catani, C. et al. (2008) ‘War trauma, child abuse and PTSD in Sri Lankan children’, Journal of Child Psychology and Psychiatry. Available at: https://pubmed.ncbi.nlm.nih.gov/18673497/ 

Channel 4 News (2011) Sri Lanka’s Killing Fields. Available at: https://www.channel4.com/news/sri-lankas-killing-fields 

Fernando, G. and Ferrari, M. (2013) ‘Short- and long-term psychological effects of war in Sri Lankan populations’, Asian Journal of Psychiatry. Available at: https://pubmed.ncbi.nlm.nih.gov/23885541/ 

Human Rights Watch (2009) Sri Lanka: Repeated Shelling of Hospitals. Available at: https://www.hrw.org/news/2009/05/08/sri-lanka-repeated-shelling-hospitals 

International Committee of the Red Cross (ICRC) (2014) War injury rehabilitation and prosthetics – Sri Lanka. Available at: https://www.icrc.org/en/document/sri-lanka-prosthetics-rehabilitation 

International Crisis Group (2010) War Crimes in Sri Lanka. Available at: https://www.crisisgroup.org/asia/south-asia/sri-lanka/war-crimes-sri-lanka 

Office of the High Commissioner for Human Rights (OHCHR) (2015) OISL Report: Sri Lanka. Available at: https://www.ohchr.org/en/hr-bodies/hrc/oisl-sri-lanka 

Physicians for Human Rights (PHR) (2009) PHR calls for inquiry into detention of doctors and war crimes in Sri Lanka. Available at: https://phr.org/news/phr-calls-for-inquiry-into-detention-of-doctors-and-war-crimes-in-sri-lanka/ 

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