Psychiatr News March 17, 2006
Volume 41, Number 6, page 29
© 2006 American Psychiatric Association
U.S. Psychiatrists Help Heal Earthquake's MH Wounds
Aaron Levin
Nongovernmental organizations are training primary care health workers
to assess and treat individuals for mental health problems in the wake of a
devastating earthquake in Pakistan.
The South Asia earthquake last October 8 killed 73,000 people and left more
than 3 million homeless. Many lived in isolated mountain areas, inaccessible
after roads were destroyed. The remoteness of the disaster, and perhaps
because it followed previous catastrophes like the Indian Ocean tsunami and
Hurricane Katrina, meant that it faded from television screens and newspaper
front pages all too quickly.
Relief efforts continue, though, first to care for survivors' need for food
and shelter during the mountain winter, but also to attend to longer-term
needs.
The Pakistan Ministry of Health, with the assistance of the World Health
Organization (WHO), coordinates reconstruction of basic health services in the
earthquake area.
Additionally, several nongovernmental organizations (NGOs) have been active
in mental health work in the earthquake area. Some provide direct patient
care, while others are pursuing longer-term goals.
"The main role of outsiders is in capacity building," said
Lynne Jones, M.D., mental health specialist for International Medical Corps
(IMC), a California-based NGO, in an e-mail interview from Sri Lanka.
"We avoid short-term, stand-alone counseling programs that disappear
with the funding." But building capacity has to be done in a culturally
appropriate manner, she added. "One size does not fit all, and different
health systems have quite different needs."
Needs Change With Culture
Even the nature of the victims may change with geography and culture, said
Jones. For example, women and children were the most vulnerable in Pakistan,
while in Aceh, Indonesia, men who had lost their entire families were at
greater risk after the tsunami.
In Pakistan, IMC now provides mental health training to primary health care
workers, preparing them to handle mental health cases themselves rather than
relying on specialists, said Jones. IMC has arranged weekly training sessions
for primary care staff in the towns of Balakot and Mansehra. (WHO also
provides mental health care and training there, too.)
They also run mental health clinics one day a week at Kashtri and Bassian
refugee camps. A camp doctor with additional mental health training sees the
patients, backed up by an IMC supervisor and supported by a Pakistani
psychologist. The psychologist counsels patients needing more intensive help
and conducts home visits. Every mental health care patient is assigned a
general practitioner, and follow-up appointments are conducted during the
doctor's normal clinic time.
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Photo courtesy of Syed Arshad Husain, M.D.
S. Arshad Husain, M.D. (right), of the University of Missouri addresses
mothers in training to become teachers in the "Mothers as
Teachers" program in Karachi, Pakistan. The 10 mothers enrolled in the
program learn to teach a first-grade course to five children aged 5 to
7.
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Women receive particular attention. Grief support, anxiety management,
literacy, and activity groups have been set up for women and teenage girls.
IMC has also trained women health workers and other camp volunteer staff in
community-support skills such as effective listening, problem solving, and
grief work.
"In disasters much of our initial work is paying attention to grief
and loss for the wider community and to the seriously mentally ill who are
often neglected in these situations," she said.
Psychiatrist Returns Several Times
One United States psychiatrist with long experience among traumatized
populations has returned to Pakistan several times since the quake to address
the needs of one especially vulnerable group of quake victims.
"The earthquake had a devastating effect on the region's
children," said S. Arshad Husain, M.D., a professor of child psychiatry
and child health at the University of Missouri in Columbia and a member of
APA's Committee on Psychiatric Dimensions of Disasters.
"For one thing, the earthquake struck shortly after children had
arrived at school. Many were killed or badly injured as school buildings
collapsed, and over 17,000 children were orphaned."
Husain is a native of India who lived for 15 years in Pakistan and trained
in England and Canada before joining the Department of Psychiatry at the
University of Missouri in 1970. He and a team from the International Center of
Psychosocial Trauma at the University of Missouri ran training programs for
mental health personnel after manmade disasters in Albania, Kosovo, and
Afghanistan, showing them how to train others. They spent two days in November
in Islamabad, Pakistan's capital, training school principals, mayors,
teachers, and physicians to recognize psychological reactions to trauma and
teaching some basic counseling skills.
"People suffer silently," said Husain. "Adults may see
symptoms in children but don't know what to do. Train them and they can
see."
In January, Husain secured land from the local government about 20 miles
outside Mansehra, arranged to purchase and ship 150 prefabricated shelters
from the United States, and hired a local manager to oversee their
installation. One hundred of the corrugated plastic shelters will form the
core of the "village of hope," he said.
Each shelter will house four orphans (defined in Pakistan as a child whose
father has died) and a mother or other houseparent. Some of the shelters will
serve as schools for children aged 6 to 12. Others will serve as a community
health center to provide physical and mental health care.
The U.S. team was scheduled to return to Pakistan at the end of February to
train and carry out a needs assessment that will also serve as a baseline for
future outcomes research.
"We hope to build local capacity and local support and then have
local personnel take over," said Husain. The team's work is funded by
Direct Relief International of Santa Barbara, Calif., the Association of
Physicians of Pakistani Descent of North America, and local donors in
Columbia, Mo.
"When I started, I didn't realize how complex it would turn out to
be—organizing the land, the shelters, the food," he said.
"But all the pieces are coming together now."
Lynne Jones also sees signs of progress in her corner of the quake
zone.
"We are at the beginning, but I am impressed by Pakistani doctors'
enthusiasm and interest in mental health and their engagement in the social
issues," said Jones. "The whole point of the IMC program is to
ensure sustainability by training staff who will continue to use the knowledge
in their general practice." 
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