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Sri Lanka behind closed doors
by Pierre Salignon, former Project director of the Health and Nutrition Tracking Service (2008-2009) and former Director of MSF France (2003-2007)
In early July 2009, following on from the closing weeks of fighting between the Sri Lankan army and Tamil Tiger rebels (LTTE), a Times journalist raised the alarm on the mortality rate in the internment camps, opened by the Sri Lankan government. The article reported 1,400 deaths a week in Manik Farm camp, which then held around 280,000 people. Presenting no methodology or basis for this figure, and without naming any names, the journalist cited “a humanitarian source” . This was a serious accusation, corresponding to a rate of 7 deaths per 10,000 persons per day. The emergency threshold applied in crises stands at 1 per 10,000 per day. In other words, according to The Times’ survey the internally displaced in Manik Farm were dying en masse, “mainly due to the sanitary conditions", deprivations and a lack of assistance.
Unsurprisingly, the Sri Lankan Ministry of Health’s version of events differed from the British journalist’report. According to a bulletin covering the period 15th June to 15th July 2009, an average of 5 to 6 people died every day in Manik Farm camp - a mortality rate of under 0.25 deaths per 10,000 per day (the official national average in Sri Lanka stands at 0.15 per 10,000 per day). Despite the ferocity of the fighting during the conflict’s final weeks, the Sri Lankan authorities found no cause for concern in the camps in June and July – when the Times was concluding the opposite.
How can such troubling and contradictory estimates be explained? Given the lack of access to more specific data, we should turn to other sources. What do NGOs and others present in the field have to say?
NGOs unable to evaluate the needs
NGOs describe the difficult working conditions and intimidation endured at the hands of the authorities. Operational space is restricted as well as the capacity to evaluate the needs of civilians. NGOs and the UN all work under the government’s thumb, with little or no access to the camps. Allowed only occasional and tightly supervised visits, they have had no choice but to operate outside the camps’ perimeters. Survivors are transported to health facilities by the military or police. The general perception is that the patients they receive are the “presentable” ones making it difficult to ascertain the true situation.
Whilst NGOs generally agree on the particularly deadly nature of the conflict and the dire state of survivors on arrival in the camps, humanitarian workers do not accept the Times’ data published in July. One aid worker insisted “200 deaths a week: we would have known about it”. Granted, “the health situation is far from perfect, and providing assistance to more than 280,000 internally displaced persons battered by several months of war takes a little time. But even so, from that to such a high number of deaths… it is impossible”.
A fragile situation, but under control
Despite the restrictions cited above, humanitarian workers have managed to gather some hard data. In June 2009, a morgue receiving the camps’ deceased, based in a hospital in Vavuniya district, recorded 10 to 15 corpses a day. This mortality rate approaches the emergency threshold for South East Asia, but is still far less than the rates observed by humanitarian workers during other crises, particularly in Africa. Thus mortality in the internally displaced camps did not seem “unduly high” at the onset of summer, although no one can confirm the authorities’ count.
The humanitarian dilemma: stay silent but involved, or speak out and be expelled
At present, there are more human rights concerns about the situation than medical ones. Allegations of human rights violations against the internally displaced abound, including a number of reported disappearances and summary executions. There are no figures available, but the authorities reject outright the accusations levied by human rights organisations. According to the Sri Lankan government, the situation is in the process of being normalised. Now the war is over, NGOs should start preparing to leave.
Humanitarian workers face a dilemma: Should they stay silent but involved, or speak out and be expelled? Are NGOs and the UN assisting a population in distress or are they accomplices in a large scale internment operation?
Diplomatic pressure is required
There are still too many worrying unknowns concerning the conditions of the internally displaced in these camps. In crisis situations, epidemiological methods exist for measuring the human consequences of man-made disasters. In Darfur, the DRC or elsewhere, aid workers conduct regular surveys - on the level of mortality rates or on the coverage of needs - to guide activities and adapt assistance.
In Sri Lanka, information collection and circulation is barred. The authorities discourage independent surveys. The impediments here are political, not technical. Without international diplomatic pressure applied to the Colombo government the fate of the internally displaced will remain solely in the hands of the authorities.... while those of humanitarian workers are tied.
 The HNTS is an international interagency initiative, hosted by WHO, established in late 2007, which aims to provide impartial, credible and timely information on mortality and nutrition rates in population affected by crises and emergencies (http://www.who.int/hac/techguidance/hnts/Intro/en/index.html ).