Thousands of families and relatives of the missing persons all over the world continue to wait for their loved ones who have disappeared in course of armed conflict, disasters, migration or other events. They continue to live in ambiguity due to lack of accurate information. The ambiguous loss is one of the most painful, difficult loss to deal with as it is unclear and without closure.
Having worked with families of missing persons (during armed conflict: 1996-2006) in a comprehensive psychosocial program supported by International Committee of the Red Cross (ICRC), I am thoughtful even more on this day about them and both their suffering and strength of facing such adversity. Nepal government has been trying to address the issues of families of missing in conflict through the Commission of Investigation on Enforced Disappeared Persons (CIEDP) while there has been little efforts made in search for missing migrants and helping their families. ICRC and Nepal Red Cross Society (NRCS) jointly have been trying to help such families through its tracing and restoring family links (RFL) activities. It is hard to estimate the number of missing migrants because little records are available.
In recent years, one of the major attempts to help Nepali migrants has been Safer Migration Project (SaMi), a bilateral initiative of the Governments of Nepal and Switzerland. HELVETAS Nepal and the Ministry of Labour and Employment are implementing the project at the district level in over 19 districts through local NGOs and government agencies. SaMi aims to promote safer and beneficial migration by helping migrants to be informed, skilled and safer in context of foreign employment. My interaction with colleagues and local people recently in Saptari and Dhading have indicated that SaMi project could produce some estimate of missing migrants that have been reported by the families in the Information and counseling centers (ICC).
Ms. Sanu Maya Aryal is a psychosocial counselor working in Chandrajyoti Integrated Development Society (CIDS) for Safer Migration (SaMi) project supported by Helvatas. She highlights the phenomenon of missing cases among migrant workers in Dhading district. In the last two years, they have helped over 411 migrants/their families in a comprehensive manner for safer migration. Out of 411, they have recorded 60 cases of still missing migrants and 14 cases have been solved which were initially recorded as missing. The families are completely unaware of whereabouts of their loved ones who have gone for foreign employment. She herself is familiar with an agony of having a missing family member as her father had disappeared during an armed conflict.
Ms. Aryal says, “Definitely this issue of missing migrants has not received an adequate attention on the national level, I can say there are many unreported cases of missing migrants. I have been to places in Dhading where people do not speak Nepali, are illiterate and so poor (lack resources) that they cannot report the case of disappearance to the authorities or NGOs. One of the major challenges while coming across such cases is lack of proper documents with the family. They show us the photograph of a person which is like 7-8 years old and creates difficult for identification of the person.”
She recalls, “ It is a very challenging task to search for missing migrants. And sometimes, even when the person is helped to reestablish family relations, an unfortunate event can take place. It is not a happy ending. There was one case in which a female migrant had lost contact with family for over 5 years. The family reported her as missing and after much efforts, she was rescued back to Nepal. She had suffered as housemaid and had been traumatized. Upon her return, she was further traumatized when she came to know that her husband had remarried and she had little means to support her two children. She ultimately committed suicide.”
Migration is one of the major national issues with migrant population contributing to over one third of national GDP through remittance. Nepal is one of the countries with highly remittance-dependent economy in the world. It has been major force in improving economic conditions of majority of Nepali despite decades of political instability and pace of extremely slow development. It is important to note that it brought about many significant economic and social changes. The government of Nepal, concerned departments and related agencies should pay proper attention to migrants in general and also to the issue of missing migrants and their families.
Expressing solidarity with families of missing persons (in conflict and migration) on International Day of the Disappeared.
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. 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 . The government needs to take interest in such innovative attempts and replicate the program in a larger scale by considering their feasibility and efficacy.
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 .
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 .
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 .
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 .
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.
The health worker providing medicine in district health post.
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 . 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, people living with disabilities, older people, and of women (single women or women who husbands have migrated abroad for work). 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 . 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].
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.
The 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 . 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 . 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 . 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 .
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) . 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 . With that in effect, Nepali people will have improved access to MHPSS services from formal sector in normal times as well as disaster.
- Government of Nepal, Ministry of Home Affairs. Nepal Disaster Report 2015
- 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
- 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.
- 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’
- Nepalitimes (2015). Tamang Epiccentre. 10-16 July 2015#766, http://nepalitimes.com/article/nation/April-25-earthquake-Tamang-epicentre,2407
- 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.
- 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 & therapeutics, 15(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 Psychiatry, 201(4), 268-275. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461445/
- 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.
- Tewa & Nagarik Aawaz. (2016). A Gendered Look into Bhaktapur’s Recovery and Rebuilding: An Applied Research. Kathmandu, Nepal.
- 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.
- 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
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:
Last month I started a new job at Action Contre la Faim (ACF)- [Action against Hunger], as Mental Health and Care Practices Programme Manager covering Nuwakot and Rasuwa districts. ACF is working in those districts after the earthquakes and has remained one of the most active organizations for humanitarian response following the disaster last year. Through its nutrition and mental health & care practices programmes, ACF prevents, diagnoses and treats acute malnutrition in those most at risk, including young children and pregnant or breast-feeding/lactating women by integrating nutrition and mental health aspects, emphasizing on strong mother-child bonding, increasing community sensitization about care practices for child development, and building capacity of staff of health facilities & teachers of schools of Nepal government in collaboration with District Health Office and District Education Office and reaching out to the community through local NGO partners.
Just got started, excited for this new adventure…