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.

dav

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].

EQ-2015-sindhupalchowk (37)

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.

sdr

The health worker providing medicine in district health post.

hdr

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].

manosamjik-app-Screenshot_2017-01-31-10-16-52

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.

3 months on: What is the status of mental health and psychosocial support in Nepal?


IMG_5546Three months ago, the mega earthquakes hit Nepal on April 25 & 26 followed by another big one on May 12. According to Nepal government official report, over 8844 people lost their lives, over 22000 were injured, over 150 went missing and hundreds of thousands lost their homes and property in the aftermath of the disaster. In addition to physical impacts, there has been invisible but significant mental health and psychosocial consequences as well. Fortunately, from worldwide research, we know that while people experience acute stress and ongoing fear and uncertainty due to recurring aftershocks, the majority of people will recover naturally over time. That said, we must not ignore others who will need longer term care and support to restore their psychological well-being. Even if only 1% of the 8 million people who experienced the earthquake have ongoing psychological distress, that means at least 80,000 people will be in need of psychosocial and mental health services.

According to the World Health Organization (WHO), during the emergencies such as natural disasters, diagnosable mental health problems increase at least temporarily. Estimates vary, but the WHO suggests that serious mental disorders (e.g. psychosis, severe depression, anxiety and trauma) may increase between 2-3% to 3-4%, whilst mild and moderate problems may increase from 10% to as much as 15-20% of the total population—an estimated 8 lakh of Nepali men, women, and children. However, such numbers need to interpreted with extreme caution because as of now, there are no published data yet regarding the incidence and prevalence of the psychosocial and mental health problems. Comprehensive data will come later as projects start with baseline assessment before their interventions.

In an article published in national daily, Dr. Brandon Kohrt emphasizes that earthquake survivors who maintain and strengthen social bonds are less likely to develop PTSD contrary to widespread assumption that the majority of the population who experienced the disaster will be traumatised. It was concerning how the media and even some professionals were expressing the views that most survivors will develop PTSD and psychologists from other countries took interest for the PTSD treatment based on such reports.

Psychologist Alessandra Pigni from the University of Oxford wrote “Psychologists stay home: Nepal doesn’t need you” based on her experiences in humanitarian aid and reminded Western experts/well-wishers that affected populations are resilient and pathologising suffering and immediate reactions after a traumatic event will hinder the process of healing and recovery. Well-aware of that fact, she decided to stay back home and turned down the offer to go to Haiti mission following the earthquakes in 2010. Research has shown that forced counseling, specifically Critical Incident Stress Debriefing, will help little and may even be harmful because survivors need to go through the natural grieving process and the vast majority will not develop PTSD, nor any other psychological disorder. Psychological first aid and community based psychosocial support are suggested to be more helpful because they build on existing social support and positive coping mechanisms without forcing survivors to recount their traumatic experiences. IMG_6102

American Psychological Association (APA) made their position clear on what could be the role of the US psychologists in response to the international disasters. “The statement cautioned U.S. psychologists against travelling to a disaster-affected country unless they were invited, experienced, worked from a public health or community perspective, and were prepared to provide program support, not direct interventions. The statement also cautioned psychologists to know about and follow internationally-developed guidelines and standards for disaster relief”, Merry Bullock, senior director of APA’s Office of International Affairs said. It gave important messages for psychologists from other countries as well who are interested to come to Nepal to support earthquake survivors. As she mentions, psychologists can contribute to sustainable recovery through research on disaster response, recovery and preparation by lending their expertise to training/educational efforts, and not being involved in interventions without adequate information about context and needs of the people. Meaningful participation of local partners, community and beneficiaries is crucial for sustained psychosocial recovery process. Professor Jamie Hacker Hughes, President of the British Psychological Society, also made a statement following the second earthquake in Nepal and emphasized that support for basic needs come first and a need for more MHPSS support for individuals and groups come later.

In order to better organize the disaster relief efforts at district and national level, the UN cluster approach came into effect and two clusters are active in the MHPSS response: the Psychosocial Support sub-cluster under the Protection cluster and the Mental Health sub-cluster under Health cluster. The psychosocial-support-technical-working-group has been formed to coordinate and share the information among organizations and professionals. This group has created and shared the draft work plan for mental health and psychosocial support (MHPSS) projects for better coordination and to prevent duplication by following Inter-Agency Standing Committee (IASC) guidelines which has been contextualized and implemented locally. It has targeted for five major outputs: coordination among project partners, provision of psychological first aid, provision of counseling services to vulnerable groups, provision of specialized mental health & psychological services and awareness raising on psychosocial support through mass media by implementing various activities.

Two documents were produced rapidly after the earthquakes to help guide MHPSS services. The International Medical Corps (IMC) produced a rapid MHPSS situational assessment. A desk review of research on culture, context, and care for MHPSS in Nepal was completed on behalf of the Inter Agency Standing Committee (IASC) Reference Group for MHPSS in Emergency Settings. These tools help humanitarian actors in proper needs assessment and understanding the local context and culture to carry out the support programs. As of latest update available online, over 20 organizations are actively working in the 14 most affected districts of Nepal and over 86 psychosocial counselors and psychologists have been deployed in field to assist the affected people at local level. The Ministry of Health and PopulatioIMG_6006n in coordination with WHO and Transcultural Psychosocial Organization Nepal (TPO Nepal) conducted an mhGAP Humanitarian Intervention Guide (mhGAP-HIG) training of trainers and supervisors for Nepali psychiatrists who will be deployed for trainings in the most affected districts. They will train MBBS doctors and other primary care workers in diagnosing, treating and referring the people with psychosocial problems and mental illness. One major goal of this program is to prevent inappropriate use of medications that may hamper social recovery processes.

Nepali psychologists have created online groups to share information, organize events for trainings and workshops and provide professional support. Nepalese Psychology Network (NEPsychNet) was also active in sharing messages online and linking up psychologists from NATAN (Israeli Humanitarian organization) to CPSSC (academic institute) to organize two workshops for professionals. NEPsychNet in collaboration with Claudia Van Zuiden organized solution-focused supervision workshops to support counselors who are helping survivors to maintain and to support their own mental health and well-being while being involved in their work. In addition, a telephone hotline for psychosocial support and referrals has been established for toll-free telephone calls within Nepal (phone number: 16600102005). Several websites, blogs, articles, TV interviews, media messages have also helped the public to understand the psychological impact of the disaster and how to cope with it.

Three months on, Nepalese are getting back to their regular business. No doubt the earthquake left behind much damages and ruins but Nepalese are optimistic that it is also an opportunity to rebuild better.  Now, the people are paying close attention to the new constitution that the political parties have promised to promulgate soon that will hopefully end the structural inequalities and discrimination and prevent people from being more vulnerable when such disasters hit.


Note: I would like to thank Dr. Brandon Kohrt for reviewing this post. Please, follow the links for attached reference materials and readings. IMG_5997-0

#NepalQuake Sindhupalchowk pictures


Sindhupalchowk, the worst affected district by 7.8 magnitude earthquake on 25 April has been further severely affected by the 7.3 magnitude earthquake that followed on 12 May. Over 95% buildings have been reported damaged in Chautara. Over 3426 deaths have been confirmed dead from this district alone. I visited it last week: 10-15 May.

  This previously damaged house collapsed in front of us 10 minutes after the 12 May Quake.   The situation at Sano Sirubari, Chautara Municipality.

   On the way to Sindhupalchowk, over 66000 have been damaged by EQ.

The damaged house and old men at Sano Sirubari.

NRCS volunteers providing psychological first aid to women in Kubinde.

The house that titled backwards in Chautara. A tenant remarks our house is sleeping now.

  We were inside this tent, conducting group discussion with female community health volunteers, when the Tuesday earthquake occurred.

The community orientation about psychological first aid at Kalika VDC.

#NepalQuake Mental Health and Psychosocial Support (MHPSS) Response


IMG_5109

Many compassionate people around the world have been touched by this disaster and suffering. They are starting to provide help in many ways. There are also initiatives being taken for mental health and psychosocial support response.

MHPSS.NET has opened up Nepal 2015 Earthquake Response Group  to share resources and information about the MHPSS response to the 25 April Disaster. If you are involved in the response or would like to contribute to resources, please join http://mhpss.net/groups/current-mhpss-emergency-responses/nepal-2015-earthquake-response/ Thanks to Ananda Galappatti (Sri Lanka), from The Good Practice Group and Wietse A. Tol for taking lead to organize and contributing valuable resources in this group.

HeartMind International in collaboration with TPO Nepal is preparing the response for both the short-term and long-term consequences of the earthquake on psychosocial well-being and mental health. They have made an appeal for donation for this effort: http://heartmindinternational.org/earthquake_response.html Dr. Brandon Kohrt have worked in Nepal for over a decade now and he is going to lead the response in order to ensure providing culturally appropriate and sustainable psychosocial services and interventions to earthquake affected families and children.

Several crowd funding have started online to support MHPSS activites in coming days.

Nepal Earthquake Relief Fund, Scotland UK: https://www.indiegogo.com/projects/nepal-earthquake-relief-fund-scotland-uk has been created by Claudia van Zuiden, solution-focused practitioner who have worked in Nepal before.

Disaster Relief and Psychological First Aid Near the Epicenter: https://www.indiegogo.com/projects/kopila-nepal-earthquake-response–2 has been created by Bonnie Walker on behalf of Kopila Nepal.

Nepal Red Cross Society have mobilized 12 PFA volunteers in Kathmandu valley from today and plans to extend this service with more volunteers in other districts as well.

TPO Nepal has started its work in Sindhupalchowk from today, Dristy Gurung, a friend shared in her facebook status.

Mental Hospital, Lagankhel is organizing mobile clinic around the valley for the services.

Some information can be obtained at: http://www.humanitarianresponse.info/en/operations/nepal/protection and can be learned how different humanitarian actors and organizations are supporting at this time.