Mental health after natural disaster
This October marks a year since Pakistan
was hit by a devastating earthquake.
Hassan Mustafa Minhas looks at how the
earthquake has affected people's mental
health
In situations of severe damage to
physical and economic wellbeing
after a natural disaster, it is easy to
overlook the associated psychological trauma. The observer's eye is overwhelmed with images of
destruction, and the true psychological impact sinks in only after these
have been digested. Although the
dent in the psyche is less evident, the
consequences are no less profound.
RICHARD VOGEL/AP/EMPICS
This is just one
side of the coin
One commonly believed reason for the debilitating nature of mental
distress is that mental bruises take
much longer to heal than their physical counterparts, and even when
they do, they leave indelible scars.
Also, unlike physical damage, which
is usually restricted to only the person affected, psychological damage
affects many people around him, and
society as a whole.
Mental health in the
aftermath of a calamity
When the tsunami hit South East
Asia, ministries of health, the World
Health Organization, and other partners quickly assessed people's health
to determine the most pressing
needs. Surveys of the worst affected
regions categorised peoples' mental
health into three groups:
- People with mild psychological
distress that resolved within days
or weeks
- People with moderate or severe
psychological distress that may
resolve with time or with mild distress that may remain chronic
- People with mental disorders,
divided into people with:
• People with mild and moderate
mental disorders
• People with severe mental disorders
After a disaster, mild mental distress affects an estimated 20-40% of
people, and moderate or severe distress as many as 30-50%. The prevalence of mild and moderate mental
disorders (for example, mild and
moderate depression and anxiety disorders, including post-traumatic
stress disorder) rises from an average
of 10% to about 20%. Severe mental
disorders, loosely comprising psychosis, depression, and disabling anxiety, go up to 3-4% of the affected
population from 2-3% of the general
population.1
The quake that affected a
nation's health
Applying these percentages to the
73 000 people killed, the 70 000
people severely injured, and three
million or so people made homeless
may indicate a huge number of
people in the region left with mental
health problems.2 The problem is
compounded by the fact that
most affected people live in relatively inaccessible parts of the
mountainous north. Although medical aid has been able to reach these
isolated areas, psychological aid is
another thing altogether.
Access to mental health
With just 350 psychiatrists in Pakistan,3 looking after the mental health
of almost 150 million, that's more
than 400 000 people for each one.4
With so few psychiatrists, it is not
possible to provide mental health
services to the affected people without help, even if it were wanted.
The low importance attached to
psychiatric treatment also poses a
problem. Most of the people who
need help are uneducated and do
not realise the importance of psychological care. For them, mental distress
is a personal problem, not something
requiring the attention of others,
least not a trained healthcare
provider. Severe mental disorders,
for them, are the result of being possessed by spirits - entirely not in the
domain of men of medicine but in
that of mystic healers.
Even where there is some recognition of the fact that help would be beneficial, the stigma in most of the rural
population of being helped by a mental health professional is a deterrent.
The way forward:
community based
intervention
The responsibility of providing psychological treatment cannot lie solely
with psychiatrists. They should be
reserved for severe and intractable
cases. For less serious and more
prevalent problems, such as mild and
moderate distress, it would be more
practical for mental health professionals to train volunteer workers
and start a community based intervention. Non-medical mental health
volunteers should be taught the
basics of providing psychological first
aid. Counselling and psychosocial
support is something almost everyone is experienced at imparting, and
it would be of great benefit in combating mild mental distress.
Immediately after the earthquake,
to deal with the severe shortage of
staff, medical students were called to
the big hospitals to help. They
tended to minor injuries, helped in
bandaging and dressing wounds, and
gave psychological support. Volunteers were also recruited for the same
purpose. They were given short training courses by mental heath workers
and worked at the hospitals under
their supervision.
Elders in the community
The social set up of rural Pakistan is
such that certain religious leaders -
elders - are greatly looked up to. They
take on a multitude of roles - spiritual leader, a judge to resolve disputes, and
someone to consult before making big
decisions. People in turmoil, be it political, social, or psychological, seek and
follow their advice. This made their
role after the earthquake pivotal.
People with underlying psychological
effects would go to these elders for
help. If properly trained, they would
be able to provide basic psychological
first aid, in the form of counselling.
More serious cases could be sent to
trained mental health workers.
MARIE DORIGNY/PANOS
Remembrance
of things past -
but is that
enough?
Secondary consequences after a
disaster, which include the effects on
social and family life, are important
determinants of long term mental
health. Because of the dealth of so
many people, the fabric of society is
disrupted. A great void is created in
the survivors' lives because of the
sudden loss of many friends and family members. As with any stressful situation, trying to fill this void requires
a great deal of adaptive power. Community workers must realise this and
help reweave the societal fabric by
helping people to rebuild their family
and social life, just as they rebuild
their broken houses.
Although it has been almost a year since the earthquake, psychological
problems, if unresolved, tend to persist. Natural disasters expose the
weaknesses in our coping systems
and give us with a chance to make
them better. If non-medical volunteers were regularly trained and
awareness of mental health problems
is spread at grass root levels, Pakistan's health system would be better
able to cope should disaster strike
again.
Competing interests: None declared.
Hassan Mustafa Minhas, third year medical
student, Rawilpindi Medical College, Pakistan
Email: hassanminhas@gmail.com
studentBMJ 2006;14:309-352 September ISSN 0966-6494
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- World Health Organization. Pakistan health
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www.jang.com.pk/thenews/dec2005-daily/2312-2005/metro/k5.htm (accessed 8 Jan 2006).
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