In Sri Lanka the ethnic conflict had raged for two decades, with the Sri Lankan government, predominantly Sinhalese, fighting a violent insurrection by the Tamil Tigers of Tamil Eelam (LTTE), based in the north and east. Thousands of young men and women have died, many thousands of families left to mourn and survive the loss of their breadwinner. Tens of thousands have been displaced, living in fear and intolerable conditions for years, virtually ignored by all.

I worked in a place called Vavuniya district from August 2000 until July 2004. It is a place close to the line that divides the rebel-

controlled territory and the government-controlled territories right in the centre of the country so it's not near all the beautiful beaches that Sri Lanka is famous for: you're really stuck in the heart of the country.It was the last town

that you could go to take supplies into the north: so it was strategically useful for the Sri Lankan army as well as for the LTTE. Part of the reason MSF was present in this area was because there were no medical specialists and MSF was supporting the hospital programme in the LTTE-controlled area.

In Vavuniya district, there were what was called ‘welfare centres', which for a long time people thought meant were places where you went to get some help but eventually it became clear that they were actually internally displaced camps. They were built in 1990 to house those refugees who had fled to India during the eighties and who would be returning to their own homelands. Unfortunately, the war never really ended and so it wasn't possible for these people to go back. The temporary shelters became permanent shelters – and not only for that population but also for an increasing number of people who where displaced from the north.

Assessments in the camps of Vavuniya district found a camp population living in spaces of 10 feet by 10 feet, separated only by plastic sheeting, many of whom had been there for 10 years. There was no privacy, poor hygiene and erratic food supply. A rigorously enforced pass system meant that people were only allowed to move within the district and were subjected to interminable checks at frequent roadblocks. Those in the camps had to have special permission to leave, which made finding work almost impossible and left people feeling like prisoners. Most people had experienced multiple displacements, witnessed the violent death of loved ones and were often separated from remaining family members. There was a strong sense of fear and suspicion and an apparent lack of community among people who had come from a number of different places and who had no shared ancestry. There were high levels of suicide attempts, chronic alcoholism, family violence and a palpable sense of hopelessness. Later issues such as experience of torture, child physical and sexual abuse, recruitment of children, violence against women and fear of forcible return became more evident.

We witnessed a wide range of symptoms in the camps and we were often presented with things that were more psychosomatic than they were physical. There's a whole range of physical problems: hypertension – so high blood pressure, backaches and headaches are very common. One thing that you see very often in Sri Lanka is something called ‘Frigophobia': where people come with a sense that part of their body is frozen or numb. One patient had presented herself to the counsellors with a sense that her head was completely numb and that she couldn't feel it: that it was really, really cold and in order to heat up her head, she set fire to it; so she had all these burn marks on her skull. So it's a very strange kind of phenomenon, but common enough that the doctors and various surgeries throughout the north and east have come across.

After an assessment within the welfare centres, MSF realised the need for a psycho-social programme. Though the camps were the initial priority for the programme, the service was available for anyone in need. We used both MSF and national staff to start the plan in a culturally acceptable way

We recruited and trained 20 national counsellors and 40 community health promoters who were trained in education messages using culturally appropriate techniques. They visited the camps and the resettlement villages as well as children's homes to provide psycho-social services. The vast majority of the selected staff had experienced displacement themselves and had lived in camps. Some members continued to live in the camps or relocation sites. The staff worked hard to develop trust through a confidential and non-judgemental service that avoided the use of labels and this became the basis of the programme. It was also became important to help those members of staff who had themselves suffered, thus self-awareness and a system of helping the helpers were integral to the programme.

Over the three years over 4,500 clients used the counselling service, spending more than 7 hours with their counsellor. Over 21,000 people used the community health promoters for support and many thousands more attended dramas and dance campaigns. Although it was difficult to measure the concrete outcomes of the programme, the attempted suicide rate in the camps dropped from three times that of those living outside the camp to two times after one year of the programme, with numbers outside the camp actually increasing.

After months of discussions, we managed to find independent funding for the project and handed it over to national staff. We agreed to support the new organisation SHADE through training and evaluation over the next three years, but funding, proposals and future direction had become something for the new team to decide. After three and a half years building the programme it was a joy to leave knowing that there was a reasonable chance of a future without fear for the people and that the investment made by MSF would continue to benefit the people.