Nepal Earthquakes 2015: Disaster & Mental Health


Nepal faces the risk of different forms of natural disasters like avalanches, floods, earthquakes, landslides, etc. which can potentially create acute short-term impact on the mental health on individual, family, and community levels which can develop into long-term psychosocial and mental health problems if they are not supported and treated on time[1]. The healthcare systems of Nepal government should include mental health and psychosocial support from the primary level in order to facilitate easier access to the services. Some organizations have tried to integrate MHPSS services in primary health care facilities in few districts as a pilot program [2]. The government needs to take interest in such innovative attempts and replicate the program in a larger scale by considering their feasibility and efficacy.

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A damaged house in Dhunchhe, Rasuwa waits for the rebuilding.

Two years after the earthquakes, the adverse impact on physical infrastructure and many aspects of lives is still present in the highly affected districts of Nepal. Majority of the people are still waiting for the government assistance to rebuild their homes. Many people are also in need of mental health and psychosocial services to overcome the adverse effects of the disaster although the level of disorders is low but the distress level among the population is quite high due to different reasons according to the various studies.

Immediately after the earthquakes, there were many national and international organisations providing disaster relief including MHPSS services on the ground which ranged from psychological first aid, community-based psychosocial support programs (psychosocial counseling, support groups, etc), to psychiatric treatment at district headquarter level. The activities covered almost all the levels as illustrated in IASC intervention pyramid [3].

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The Red Cross team interacting with female community health volunteers (FCHVs) in Sindhupalchowk about the impact on mental health and psychosocial wellbeing after earthquakes.

As Red Cross staff, I led the team in Sindhupalchowk few weeks after the earthquakes for providing psychological first aid (PFA) service with team members who had also been trained in physical first aid, it was important to be able to provide support both physically and psychologically. Our work involved providing non-intrusive emotional support, coverage of basic needs through coordination with other units, protection from further harm, reestablishing family links and reinforcing local resilience and social support [4].

Two weeks after the PFA intervention in 5 most affected districts, I visited Gorkha and Dhading, for quick review meeting with field teams and visited some sites to interact locally and observe the impact of the service.  field visit report  [5].

Dr. Dhana Ratna Shakya, Additional Professor, Department of Psychiatry, BPK Institute of Health Sciences (BPKIHS) in Dharan, who conducted a survey among 500 victims of the earthquake in Bhaktapur, reflects, “Through this disaster experience, what I have learned so far is that disasters, as awful as they are, can turn out to be an opportunity for mental health professionals to improve mental health literacy in our communities and sometimes across a whole country.”  Indeed, there has been a lot of investment into reinforcing MHPSS services and increasing mental health literacy and awareness among the people [6].

In addition to providing relief and psychosocial support directly, there were also many attempts on capacity building of stakeholders at local levels who could intervene in absence of trained mental health professionals like psychosocial counselors. For example: Many training programs focused on training health workers to include MHPSS component in their regular services to support people visiting the health posts, teachers’ training to provide emotional and psychosocial support to students at school level, and so on. However, there is a question on the effectiveness of short-term (few days) trainings considering they already have enough workload and there is little incentive and supervision to monitor the changes and how they are making use of the knowledge obtained from the trainings.

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The health worker providing medicine in district health post.

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Trained teacher encouraging students to practice a relaxation exercise at the beginning of his class.

Nevertheless, there have been some reports on the potential misuse of such funding or lack of remarkable results from the MHPSS programs despite heavy expenditure. The critical post by BBC highlighted the immense use of funding for the psychosocial services in the affected districts, mainly Sindhupalchowk and questioned the effectiveness of such programmes which focused on the training of the people [7]. It highlights the need for proper assessment of the psychosocial needs of the people and then after, solid monitoring and evaluation mechanisms in place for the services delivered to show the effectiveness of MHPSS programmes. One of the senior psychiatrists is quoted as saying that after one year of disaster, the psychosocial problems of the people are likely to end which is not realistic given the slow pace and social & political circumstances of the recovery.

We have noticed that disasters tend to aggravate vulnerabilities of rural areas, socially disadvantaged groups, ethnic minorities[8], people living with disabilities, older people, and of women (single women or women who husbands have migrated abroad for work)[9]. In fact, women, constituted a disproportionately high percentage of disaster fatalities. Those who survived, experience risks to personal security, inadequate sanitary/hygiene facilities, exclusion from decision making, and problems in receiving assistance for lack of human resources, information and personal documents [10]. They are also more likely than men to be psychologically affected. Research by Kohrt et al. (2009 &  2012) in rural Nepal has shown gender (female) to be a risk factor for the mental health problems [11a, 11b].

hdr Palsang Lama, Community Psychosocial Worker (ITDS, Nuwakot) is seen here providing home-based counseling session on nutrition to a pregnant woman.

In larger number of cases, persons with disabilities face multiple layers of exclusion and discrimination, such as ethnic woman with disability (visually impaired) who is overwhelmed by hierarchies of gender, caste, and disability, severely limiting her educational, economic, and social opportunities who thus becomes more vulnerable to psychological distress. The woman below from one of the IDP camps is visually impaired who lacked citizenship and disability card, thanks to the psychosocial workers from LACCOS who accompanied her to get them. Now, despite having them, she still lacks opportunities for education and employment.

hdrThe visually impaired woman sharing her difficulties of living as a person with disability in IDP camp.

The study on disaster and disability by Lord et al. (2016) has confirmed prior findings that intellectually disabled persons and people with mental health problems are perhaps the most marginalized and vulnerable group in Nepal [12]. The report consists of three thematic sections which consider the mental health and intellectual disability issues. It discusses about intellectual disabilities & caregivers, underreporting of mental disabilities and the post-earthquake mental health gap. There is clearly a lack of disable-friendly MHPSS programs.

The study done by Tewa and Nagarik Awaz (2016) tried to explore the impacts on the lives of women and men of Bhaktapur [13]. The disaster has forced them to break many cultural norms and experience cultural festivals as moments of sadness, and annoyance instead of the reason for joy, and social cohesiveness. On the positive side, the post-disaster conditions allowed for an increase in social harmony, and solidarity as everybody was suffering from the similar consequences. Females worried about forced separation from a joint family into nuclear families, changes in their roles and life patterns in terms of their daily activities, deprivation of cultural activities such as celebrations of festivals and social gatherings with relatives, psychological distress and need to compromise for a lower standard of life. The males worried that their daily routine has changed as they were compelled to work in the kitchen and care for the babies because women had to spend more time fetching drinking water from distant sources. The gender roles were clearly challenged and men also had to participate in the tasks from which they would otherwise refrain from in normal times.  Males also admitted the increased intake of alcohol with the misconception that it might help them reduce their levels of stress.

The study done by TPO and IMC in three most affected districts: Gorkha, Sindhupalchowk and Kathmandu showed depression among 34.2%, anxiety among 33.8%, PTSD among 5.2%, alcohol use problems among 20.4% and prevalence of suicidal ideation of 11%. It reveals there were high levels of distress but low levels of disorders and functional impairment after four months of the disaster. It also showed that support for mental health problems was provided mainly by traditional healers, religious leaders and staffs mobilized by national and international organizations [14]. The alcohol use problem was prevalent as a negative coping as mentioned in the study above conducted in Bhaktapur. It would be interesting to revisit them and see how they are faring after twenty-four months of the earthquakes.

One of the major learnings of this disaster for Nepal have been to include MHPSS aspect into disaster preparedness in the future.  The agencies coordinating disaster relief need to integrate MHPSS services while providing support for the basic needs as psychosocial support needs are equally important as food, drinking water, shelter, and emergency medical aid. Like Dr. Dhana said above, disaster has also brought some opportunities in MHPSS field, awareness has increased among people regarding mental health issues and resources have also been developed in context of disaster and other situations. The mobile app with helpful information has been developed by TPO Nepal [15].

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Mobile App Screenshot. Also available in web version: manosamajik.com.np

Post Disaster Recovery Framework 2016-2020 of Government of Nepal published by National Reconstruction Authority has envisioned the provision of psychosocial services in education and health sectors under Strategic Recovery objective three: Restore and improve access to services, and improve environmental resilience (p. 8) [16]. Ministry of Health has recently endorsed the revised National Mental Health Policy of 1997, it will go into implementation once it is approved by the cabinet of Nepal government [17].  With that in effect, Nepali people will have improved access to MHPSS services from formal sector in normal times as well as disaster.

References:

  1. Government of Nepal, Ministry of Home Affairs. Nepal Disaster Report 2015

http://www.drrportal.gov.np/uploads/document/329.pdf

  1. Integrating MHPSS services in primary health care facilities in post-earthquake Nepal. Accessed on 24.04.2017, http://www.mhinnovation.net/innovations/integrating-mhpss-services-primary-health-care-facilities-post-earthquake-nepal
  2. Sherchan S, Samuel R, Marahatta K, Anwar N, Van Ommeren MH, Ofrin R. Post-disaster mental health and psychosocial support: experience from the 2015 Nepal earthquake. WHO South-East Asia J Public Health. 2017; 6(1):22–29. http://www.searo.who.int/publications/journals/seajph/issues/seajphv6n1p22.pdf

4. ICRC (2015). Nepal earthquake: Helping communities face their fears https://www.icrc.org/en/document/nepal-earthquake-communities-face-fears

5. Maharjan, S. M. (2015). Field Mission Report: Psychological first Aid Response for earthquake-affected communities.

  1. Shakya, D. R. (2016). The Nepal earthquake: use of a disaster to improve mental health literacy. BJPsych International, 3 (1), 8-9.

7. BBC Nepali Service (2017). ‘एकै जिल्लामा मनोपरामर्शका नाममा डेढ अर्ब’

http://www.bbc.com/nepali/news-38610412

  1. Nepalitimes (2015). Tamang Epiccentre. 10-16 July 2015#766, http://nepalitimes.com/article/nation/April-25-earthquake-Tamang-epicentre,2407
  2. Neumayer, E., & Plumper, T. (2007). The Gendered Nature of Natural Disasters: The Impact of Catastrophic Events on the Gender Gap in Life Expectancy, 1981–2002. Annals of the Association of American Geographers , 551-566.
  3. Halvorson, J. P. (2007). The 2005 Kashmir Earthquake: A Perspective on Women’s Experiences. Mountain Research and Development, 296-301.

11a. Kohrt, B. A., & Worthman, C. M. (2009). Gender and anxiety in Nepal: the role of social support, stressful life events, and structural violence. CNS neuroscience & therapeutics15(3), 237-248. http://onlinelibrary.wiley.com/doi/10.1111/j.1755-5949.2009.00096.x/pdf

11b. Kohrt, B. A., Hruschka, D. J., Worthman, C. M., Kunz, R. D., Baldwin, J. L., Upadhaya, N., … & Jordans, M. J. (2012). Political violence and mental health in Nepal: prospective study. The British Journal of Psychiatry201(4), 268-275. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461445/

  1. Lord, A., Sijapati, B., Baniya, J., Chand, O., & Ghale, T. (2016). Disaster, Disability, & Difference: A Study of the Challenges Faced by Persons with Disabilities in Post-Earthquake Nepal. Published by Social Science Baha and the United Nations DevelopmentProgramme in Nepal: Kathmandu.
  2. Tewa & Nagarik Aawaz. (2016). A Gendered Look into Bhaktapur’s Recovery and Rebuilding: An Applied Research. Kathmandu, Nepal.
  3. Kane, J. C., Luitel, N. P., Jordans, M. J. D., Kohrt, B. A., Weissbecker, I., & Tol, W. A. (2017). Mental health and psychosocial problems in the aftermath of the Nepal earthquakes: findings from a representative cluster sample survey.Epidemiology and Psychiatric Sciences, 1-10.
  4. TPO Nepal (2016). Andriod App, Manosamajik. https://play.google.com/store/apps/details?id=com.suswasthya.manosamajik.manosamajiksuswastha

16. Nepal Earthquake 2015: Post Disaster Recovery Framework – 2016-2020 http://reliefweb.int/report/nepal/nepal-earthquake-2015-post-disaster-recovery-framework-2016-2020

17. Himalyan Times (2017). Mental health policy coming to effect soon. https://thehimalayantimes.com/nepal/mental-health-policy-coming-effect-soon/

Note: This is a follow up post for the ones I have published earlier, first one three months later and the other one on the occasion of first anniversary. I look forward to receiving your comments and feedback.

And some music from Rohit Shakya with beautiful backdrop of Boudhanath:

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Learning Vipassana


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I learnt Vipassana meditation three years ago at Dhamma Terai, Birgunj. It was a wonderful experience. My experience featured in the podcast a week ago by Psychbigyaan team for a radio program. I highly recommend to learn this meditation technique to all. It is an invaluable learning.

SLC ko Khusi


Just as I am about to start a new day in my office, didi comes with a pack of sweets (laddu) and share it with me. It is a tradition in our office to distribute chocolates and sweets to colleagues when somebody comes from aboard or there is some good news. So, I ask her who is it from and what is the occasion? She says one of the colleague’s daughter has passed SLC with A+ grade and to share that good news he has sent us the sweets.

Yes, School Leaving Certificate examinations (SLC) results were finally out yesterday, hundred of thousands of students from all over the country, their parents and relatives were eagerly waiting for the results. Passing SLC is considered as crossing the iron gate and is seen as the most important examination in the school system. Students face a lot of pressure to do well, they spend a lot of anxious time anticipating the results, and when it is out- for those who do well, new freedom is found. The unfortunate ones who could not perform well due to various reasons are looked down upon as failures.

No matter what the results are, all students must receive proper attention and appreciation during this time, it is especially important for the ones who lagged behind in their performance. An encouraging pat is crucial for those who could not succeed. I hope we won’t have to hear news to students giving up  on their lives just because they failed in this particular exam. Life gives many opportunities and lessons after failure.

With this, many young people’s further study is determined by the results esp, which faculty and subject they opt for. Parents and friends largely influence during the decision making process beyond SLC. However, it is too early to conclude on the academic success and aptitude of a student just based on SLC results. Just at the time of this writing, one of my school teachers posted this status in facebook:

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The above status represent the concept of Book Smart vs. Street Smart. It is often true that the street smart students are ahead in other aspects of life than book smart students who do extremely well with the exams but who might not do well in the real life situations. However, it would be wrong idea to promote just one of them, in fact, combination of both book and street knowledge is desirable to become optimally functional.

For those of you who have passed SLC, my congratulations and I would like to encourage you to study Psychology if you are interested in psychological well-being, the invisible activities of the mind and their relationship with our behavior, here is a link for you:

https://sujenman.wordpress.com/2012/06/16/studying-psychology-after-slc/

 

Seminar on Contemporary Research in Psychology in Nepal


Last week, a seminar on ‘Contemporary Research in Psychology in Nepal’ was organised by Nepalese Psychological Association (NPA) and Central Department of Psychology (TU) on 28 May 2016  (15 Jestha 2073, Saturday) at Padma Kanya Campus, Kathmandu.

The program started with formalities and speeches as usual. It was followed by paper presentations by 8 professionals and students who are engaged in research work. I was invited to present my paper on ‘Bibliography of Psychological Research in Nepal.’ See full schedule here: seminarNPA2016schedule

The first session was chaired by Prof. Dr. Santa Niraula, Head of Psychology Department, TU in which 4 papers were presented:

1) ‘Feasibility Study on Development of Children’s Emotional and behavioral problem checklist’ . By Suraj Shakya & Sunita Shrestha
2) ‘Ethnic Self-Labeling Among Nepalese Adolescents’ by Sandesh Dhakal
3) ‘Bibliography of Psychological Research in Nepal’ by Sujen Man Maharjan
4) ‘Survey on Psychological Well-being and perceived organizational support in the aftermath of Nepal Earthquake’ by Yubaraj Adhikari.

The session ended after the brief discussion on the papers and closing remarks by Dr. Niraula.

The second session was chaired by Prof Dr. Mita Rana, MPhil Clinical Psychology Department Head of TUTH in which 4 papers were presented:

1) ‘Prevalence of PTSD and its Influencing Factors Among the Government School Teachers After Nepal Earthquake 2015’ by Ganesh Amgain
2) ‘Possibility of Mental Illness in Adults Affected by Gorkha Earthquake in Tudikhel Camp- A Survey’ by Sujan Shrestha and Kripa Sigdel
3) ‘Home and Health Adjustment Among College Students with Their Locale of Five Development Region’ by Padam Raj Joshi
4) ‘Adolescents’ Concern non Problems with their Parents’ by Khem Raj Bhatta

The session ended after the brief discussion on the papers and closing remarks by Dr. Rana.

The program concluded with the closing speech by Dr. Nandita Sharma, Vice President of NPA.

The participation of the students was very enthusiastic. There were over 250 participants from different public and private colleges in Kathmandu, mostly students who are studying Psychology in Bachelor and Master levels. I remember this event had been organised after a long time, I wrote about similar event that took place five years back when I had presented my poster based on my MA thesis.

This program could have been better organized if the time had been properly set and logistics were in place properly. There were few shortcomings in the management but the program being organized deserves appreciation and I hope such events will be regularly organized, not after many years.

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Participants coming for the program in the PK premises.

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Distinguished guests of the program.

 

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Over 250 Participants were present in the seminar.

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The group picture of the paper presenters on bottom and professors & psychologists on the upper row.

 

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The group picture of participants, presenters and organizers.  WE ROCK!!

Thanks to the organizers for the opportunity to present the paper and the participants for showing so much interest in my paper. For those of you who did not receive the tiny handout of my presentation, here is the information to access the file:

Maharjan, S. M. (2012). Bibliography of Psychological Research in Nepal. [PDF file]  Retrieved from http://www.martinchautari.org.np/2012-08-27-08-45-41/bibilographies.html http://bit.ly/1TMOftz

Homes are broken but hearts are not: Nepal Earthquakes’ One Year Anniversary


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A year has passed by after Nepal was struck by some of the biggest earthquakes in its history. Looking back we have been through some of the worst times of our lives. Thanks to the political affairs, recurrent earthquakes were not enough to add pain to already difficult situation but political unrest and border blockades after the promulgation of the new constitution created the humanitarian crisis in the country.  It is likely that these events will stay with most of us as ‘flash-bulb memories’ throughout our lifetime. I still remember vividly to this day, the details of my experience on 25 April at home in Kathmandu and on 12 May when I was in field at Sindhupalchowk. Those memories have been saved in my mind like movies that I can replay anytime.

According to official reports, 8 million out of 28 million total population were severely affected and nearly 9000 people died, over 22000 got injured, 150 went missing and hundreds of thousands lost their belongings and shelter across 14 districts from Western to Central North Regions of Nepal. Eight months later, National Reconstruction Authority (NRA) was set up but the formal rebuilding program led by the government is yet to be started despite having international pledges of more than $US4 billion in aid. People have been forced to take loans to rebuild themselves although the government has promised them cash grants of NPR. 2,00,000 which have not been yet fulfilled. Seira Tamang correctly highlights that it’s the government’s duty to serve and protect its citizens at the times of blown up critical times like these but often they had found an excuse that Nepalese are resilient enough to bear these kinds of problems and they can cope up. We are sick and tired of those terms politically. Even psychologically, there are limits to such resilience and the government should be aware that to uphold the self-esteem and increase confidence of its citizens, it must respond to the needs and respect basic rights of its citizen.

On the local level, good hearted (upper)-middle class residents from Kathmandu and other districts rushed to the scenes to provide assistance to the victims by raising the fund from various sources.  It definitely provided the immediate relief to the needy people. However, as the days passed by, we even came to know that the same people had been receiving support number of times from new groups and the people from distant locations were left to fend themselves with nothing. Most of them had good intentions however, seeing them posting pictures of themselves in social media providing support focusing on themselves reminded me of the phenomenon called ‘white savior industrial complex’ termed by American writer Teju Cole who reminded the people who wanted to help that the ‘help’ should be provided by understanding the needs of the people rather than with the assumption that it should be given. Many NGOs and INGOs were also active immediately after the earthquakes but it is unfortunate that people from the affected districts say it has not made significant differences in their lives.

Regaining ‘sense of place’ is crucial in helping people affected earthquakes to adapt and restore their psychosocial well-being. People have a feeling/perception of belonging to the particular place where they feel safe and have a sense of authentic self. Often after disasters, the sense of place is lost or disrupted because of the physical destruction of the surroundings or forced movement to safer places. Social supports are broken, daily rituals/practices are hindered which further leads to loss of sense of place. Therefore, it is urgent to rebuild the communities as soon as possible and restore the ‘sense of place’ so that they feel comfortable, and have the sense of belonging. This theme has been well portrayed in a documentary titled ‘A Walnut Tree’ directed by Ammar Aziz which won Ram Bahadur Trophy For Best Film in Film South Asia 2015 Festival held in Kathmandu last year. Hope people will get assistance to rebuild their homes and communities before the upcoming monsoon but the time is running out. Sara Shneiderman & Mark Turin reports about Indigenous Thangmi community’s response to the  earthquakes.

In an English daily op-ed piece titled Time and Trauma, Dr. Brandon Kohrt writes that from the clinical perspective, the time frame of one month has special meaning. Often, medical professionals take that as the amount of time that must pass before a patient can qualify for a diagnosis of post-traumatic stress disorder (PTSD). One year later, there are still recurrent mild shocks above 4 magnitude that has occurred times and again that has scared the hell out of people and pushed them out to the streets for safety. In the recent training related to community-based psychological first aid training, there were questions that the time has passed beyond months and if an individual is showing the signs and symptoms of traumatic reactions, then, should he or she be diagnosed with PTSD. After discussion on this topic, we came to the agreement that since it is an ongoing trauma, we need to see beyond time frame, we should pay more attention to the level of impairment, duration of the occurrence of the symptoms and how the individual is coping. As labelling people with PTSD or severe mental health problems is often stigmatizing, it could be counter-productive step in helping them. Jack Board reports how the trauma victims are fighting prejudice to improve mental health.

Many people came out to seek services for the mental health services. When I visited hospitals at the districts and talked with local counselors, they confirmed that among those who came for services, many had already been suffering from mental health problems since many years but had not dared to come out to seek for professional support due to stigma or simply because lack of awareness that supports are available and those problems can be solved. We must be aware that people are already suffering due to pre–existing social and other factors like poverty, gender inequality, low socio-economic status, caste discrimination, etc. and now earthquakes and impoverished conditions have increased the intensity of that suffering.

Meanwhile, there are some protective factors in our cultures as well, let’s take an example of Saa Paru (Gai Jatra) which is the annual festival celebrated by the people of Kathmandu, esp. Newars to commemorate the loss of their loved ones. It is a day the relatives of the dead in the past year go out in a procession with make-ups (children painted and dressed as cows) to create humor and also carrying religious meaning and move on in life despite the unrecoverable loss of the family member. It helps in the grieving process and accepting the loss at the larger level beyond family and particular community. It can interpreted as a psychosocial intervention that is already available in Nepali culture. Similarly, in other cultures also, there are specific practices that helps to promote the psychosocial well-being which needs to considered to understand how people grieve and cope with their losses.

On this day, we commemorate the valuable lives we have lost to the earthquakes and reaffirm that our homes have been broken but our hearts are not so, we shall strive for better times as small steps we take can make big differences.

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I am grateful to Jamuna Maharjan Shrestha (Senior Counselor) for her advice and Jebin Gautam for his support while writing this post.