Kids work side by side at a temporary school for those displaced by floods in eastern Nepal. Many children experience trauma, fear or other psychological impacts of natural disasters, but few receive the necessary treatment. Credit: Mallika Aryal/IPS

By Mallika Aryal
SURKHET, Nepal, Feb 13 2015 (IPS)

On the night of Aug. 14, 2014, 10-year-old Hari Karki woke up to his grandfather’s loud yelling in the family’s home in Paagma, a small village in east Nepal.

He was warning Hari’s family to move out of the house immediately because they were getting flooded. It had been raining non-stop for a couple of days. Hari could hear the water gushing. He grabbed his sister’s and grandfather’s hands, waded through knee-deep water in his living room, and ran as fast as he could.

“Advocating for mental health itself is such a big challenge in Nepal. We are not even close to getting specialised services such as mental health programmes that focus entirely on children." -- Shristee Lamichhane, mental health advisor with the United Mission to Nepal (UMN)
On the other side of the village, on much higher ground, is a primary school. They took shelter there for the night as heavy rains devastated the village, washed away Hari’s school and his neighbours, and inundated his house.

“Life changed forever for us that night,” says Hari’s father, Dhan Bahadur Karki. The floods and landslides that took place in Surkhet district in mid August last year affected more than 24,000 people, according to the District Disaster Relief Committee, a Nepal government-led coalition of international aid organisations and local NGOs.

The disaster displaced 12,000 people and killed 24; 90 still remain missing. More than 40 percent of those affected were children. For them, experts say, the horror of surviving such a disaster does not simply fade away; often, it lingers for a lifetime.

“Children lose their homes, school, friends and family members,” says Manoj Bist, a child protection officer with Save the Children, Nepal, which has been working in the flood affected areas of mid-west Nepal. “When their support system is lost, children become vulnerable to violence, disease and abuse.”

Five months since the disaster, those displaced by floods are still living in tents. Karki’s family has pitched their tent across the river from where their home used to be. “I see what used to be my house from my tent everyday, but I can’t get myself to go back there and try to rebuild,” says Dhan Bahadur Karki.

Along with their belongings, the flood washed away the little saving they had in the house. So money is tight for the Karki family and Dhan Bahadur is planning to leave for Malaysia to work in a mobile phone factory as soon as he gets a visa.

Even as Dhan Bahadur plans his departure, he is most worried about his two children and the state of their mental health.

Hari complains about not being able to concentrate at school. A good student before the floods, his grades have slipped. “I can’t fall asleep at night and when I do, I have nightmares,” says Hari as he comes out of his temporary classroom in a bamboo trailer. Last month, Hari could not be found on his bed at night. When his relatives went looking for him, they found him near the woods, sleepwalking.

“The kind of psychological stress a child goes through after a natural disaster is profound, and has to be dealt with early on in life so it doesn’t have a long-term consequence ” Saroj Prasad Ojha, associate professor in the department of psychiatry at the Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, tells IPS.

In Nepal, there is a near-total absence of official data on the number of children in need of mental health care, from young victims of sexual abuse and domestic violence, to children affected by natural disasters, to kids suffering from conflict-related stress and trauma.

Still, health professionals and social activists here say it is a major issue that calls for swift government action.

Stigma scuppers progress on mental health

The World Health Organisation estimates that 450 million people worldwide have a mental disorder, and mental illnesses account for 13 percent of the global disease burden.

There are no official numbers for the 28 million in Nepal, but the Christian charity United Mission to Nepal (UMN) that works on mental health issues estimates that approximately 20-25 percent of all out-patients attending primary health care services show some kind mental or behavioral disorder often presented with multiple physical complaints.

“The problem lies in the fact that mental illness is not seen as a health issue,” says Sailu Rajbhandari, clinical psychologist with Transcultural Psychosocial Organisation (TPO)-Nepal.

Nepal spends less than two percent of its 334-million-dollar health budget on mental health services. The 50-bed, Kathmandu-based Mental Hospital is the only one in the country that exclusively provides mental health and psychiatric services. There are 70 psychiatrists in Nepal, one for every 380,000 people, and only one child psychiatrist.

Other mental health-care providers such as clinical psychologists, social workers and nurses are even more scarce.

“Advocating for mental health itself is such a big challenge in Nepal. We are not even close to getting specialised services such as mental health programmes that focus entirely on children,” says Shristee Lamichhane, mental health advisor with UMN.

Arun Raj Kunwar, Nepal’s only child psychiatrist, faces this challenge every day at work.

“Our society and health system cannot even grasp the concept that children can have mental health issues,” says Kunwar. He says children’s trauma may be disguised and could manifest in the form of physical ailments because children cannot clearly express grief or fear.

Kunwar says that children need extra attention and trained specialists to deal with mental trauma.

A crucial link in the developmental chain

Experts say that mental health should be prioritised along with the other developmental goals of the country.

“It is surprising that children’s mental health is often left out from our development plans, considering children are the future, the next productive generation of the country,” explains Ojha of the Tribhuvan University Teaching Hospital.

Ojha says there’s a need to properly train professionals so that they know how to deal with various types of mental health issues. “Counseling children who have gone through the trauma of natural disasters is different from those who have gone through the trauma of war – we need specialised focus.”

Official data on the number of children affected by Nepal’s decade-long ‘People’s War’ that ended in 2006 is missing. However, a 2008 National Human Rights Commission report states the war orphaned over 8,000 children and displaced over 40,000 children.

Few, if any, of them are receiving necessary mental health services.

There is also an urgent need to prioritise mental health at the local level. Lamichane of UMN recommends stationing trained mental health professionals at the 30 public hospitals across Nepal.

“But mental health has to be integrated at the primary health care level because that is where patients first come with their problems,” says Lamichhane.

Nepal is a party to the United Nation’s global commitment to prevention and control of non-communicable diseases. In 2014, the country formulated the Multi Sectoral Action Plan for Prevention of Non-Communicable Diseases 2014-2020, which positioned mental health as one of the country’s priority areas.

Psychiatrists and mental health professionals are hopeful that this move will encourage the government to pay attention.

“It may be slow, but mental health issues are getting a little more attention than they were a few years ago,” says Lamichhane “This is the time to make a case for children, really hammer the issue home so that the issue of children’s mental health is not forgotten,” adds Lamichhane.

In Paagma village, local psychosocial counselor Santoshi Singh has begun working with Hari and his sister. “Depending on what his case is like, there are a few things I can do to help Hari as a counselor,” says Singh, “But if the case is severe, I am really unsure where I can send him so he can get the kind of help that he needs.”

Edited by Kanya D’Almeida

Soundus, a young girl being treated in hospital for injuries from Israeli shelling of Gaza (August 2014). Credit: Khaled Alashqar/IPS

By Khaled Alashqar
GAZA CITY, Aug 16 2014 (IPS)

“My child became blind and lost the ability to speak, his dad died and his three brothers are seriously wounded. He still has not been told about the loss of his dad,” says the mother of 7-year-old Mohamad Badran. 

Mohamad is in hospital for treatment after being seriously injured in Israel shelling of Gaza. “My only way to communicate with him is by hugging him,” his mother adds.

Israeli air attacks and shelling in Gaza have left more than 1,870 dead and thousands injured. They have caused damage to infrastructure and hundreds of homes, forcing a large number of families to seek shelter in schools run by the U.N. agency for Palestine refugees (UNRWA).Some of the children have suffered serious injuries which cannot be treated in Gaza due to the limited medical infrastructure and capacities caused by the Israeli blockade.

In a news note, the U.N. Children’s Fund (UNICEF) said that Israeli airstrikes and shelling have taken a “devastating toll … on Gaza’s youngest and most vulnerable.” It said that at least 429 children had been killed and 2,744 severely injured.

Some of the children injured have suffered serious injuries which cannot be treated in Gaza due to the limited medical capacities caused by the Israeli blockade.

According to UNICEF, about 400,000 children – half of Gaza’s 1.8 million people are children under the age of 18 – are showing symptoms of psychological problems, including stress and depression, clinging to parents and nightmares.

Monika Awad, spokesperson for UNICEF in Jerusalem, told IPS that 30 percent of dead as a result of the Israeli military attacks are children, and “UNICEF and its local partners have been implementing psychosocial support programmes in Gaza schools where refugee families are sheltering.”

”We have a moral responsibility to protect the right of children to live in safety and dignity in accordance with U.N. charter for children’s rights,” she added.

However, the acute psychological effects of the Israeli attacks Gaza that have emerged among children, such as loss of speech, are among the biggest challenges that face psychotherapists.

Dr Sami Eweda, a consultant and psychiatrist with the Gaza Community Mental Health Programme (a local civil society organisation working on trauma and healing issues), told IPS: “When the Israeli war against Gaza ends, psychotherapists will grapple with many expected dilemmas such as the cases of the murder of entire families and the murder of the parents who represent the central protection and tenderness for the children. Such terrible cases put children in a state of loss and shock.”

According to Eweda, “we first need to stop the main cause of these traumas and psychological problems, which is the Israeli war against Gaza, and then begin an emergency intervention to support children’s health and treat traumas and severe psychological effects, including the loss of speech, which is considered as one of the self-defence mechanisms for overcoming traumas.”

Throughout the Gaza Strip, where entire neighbourhoods such as Shujaiyeh and Khuza’a have been destroyed by the Israeli invasion and heavy bombardment, access to basic services is practically impossible.

Displaced children in a UN-run school in the Shujaiyeh neighbourhood of Gaza (August 2014). Credit: Khaled Alashqar/IPS

People in these areas have been suffering difficulties in accessing drinking water and have been living in an almost complete blackout since the Israeli shelling of the power station which was the sole source of electricity in besieged Gaza.

Social Watch– a network of civil society organisations from around the world monitoring their governments’ commitments to end poverty and achieve gender justice – Thursday called on the international community to declare the Gaza Strip an “international humanitarian disaster zone”, as requested by Palestinian NGOs.

“The unrestricted violation of international law and humanitarian principles adds to the instability in the region and further fuels the arms race and the marginalisation of the issues of poverty eradication and social justice that should be the main common priority,” said Social Watch.

“The recurrence of these episodes in Gaza is the result of not having acted before on similar war crimes and of not having pursued with good faith negotiations towards a lasting peace,” it added.

In a press release, Save the Children, the world’s leading independent organisation for promoting children’s rights, said: “Children never start wars, yet they are the ones that are killed, maimed, traumatised and left homeless, terrified and permanently scarred.”

“Save the Children will not stop until innocent children are no longer under fire and the root causes of this conflict are addressed. If the international community does not take action now, the violence against children in Gaza will haunt our generation forever.”

In an interview with IPS, Save the Children’s spokesperson in Gaza, Asama Damo, said: ”We call for a permanent ceasefire and for lifting the siege on Gaza to ensure the delivery of humanitarian aid and basic services to children.”

“We also need the international community to intervene to end the catastrophic humanitarian situation and fight the skin diseases that are widely spreading among the refugees at UNRWA schools due to overcrowding and congestion.”

According to UNRWA, 87 of their schools are being used as shelters by the refugees, half of whom are children under the age of 18. Ziad Thabet, Undersecretary of the Ministry of Education in Gaza, told IPS:

“Israel deliberately targeted educational institutions and the education sector in general; large proportion of those killed and wounded are children and school students. Many schools and kindergartens were attacked.”

In the current disastrous situation in Gaza, it seems not only that the burnt bodies of Gaza’s children are the heritage of war, but also that their educational and health future is being burned.

(Edited by Phil Harris)

Doctors examine internally displaced children from North Waziristan Agency at a free medical clinic in Bannu, a district of Pakistan’s northern Khyber Pakhtunkhwa province. Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Jul 21 2014 (IPS)

Some fled on foot, others boarded trucks along with luggage, rations and cattle. Many were separated from families, or collapsed from exhaustion along the way. They don’t know where their next meal will come from, or how they will provide for their children.

In the vast refugee camps of the Khyber Pakhtunkhwa (KP) province, civilians who fled the Pakistan Army’s military offensive against the Taliban in the country’s northern Waziristan Agency now walk around in a state of delirious confusion.

Medical officials here say that almost all the 870,000 internally displaced people in KP are deeply traumatised by over a decade of war in the northern provinces, where they were caught in the crossfire between government forces and militants who crossed the border from Afghanistan into Pakistan’s Federally Administered Tribal Areas (FATA) in 2001.

“We examined about 300,000 patients at the psychiatry wards of the KP hospital in 2013; 200,000 of them belonged to FATA. This included 145,000 women and 55,000 children." -- Muhammad Wajid, a psychiatrist at the Khyber Pakhtunkhwa Teaching Hospital in Peshawar
Now, as the army conducts air raids on the 11,585-square-kilometre North Waziristan Agency in a determined bid to wipe out the Taliban, war-weary civilians are once again bearing the brunt of the conflict, forced to leave their ancestral homes and seek refuge in neighbouring KP where shelter, clean water, food and medical supplies are stretched thin.

IDPs have been streaming in since the military operation began on Jun. 15, reaching close to a million by mid-July, officials here say. So far, aid has come in the form of food rations and medical supplies for the wounded, as well as those left dehydrated by the scorching 45-degree heat.

But very little is being done to address the psychological trauma that affects nearly everyone in these camps.

“The displaced population has been living in rented houses or with relatives where they lack water, sanitation and food due to which they are facing water and food-borne ailments,” Consultant Psychiatrist Dr. Mian Iftikhar Hussain tells IPS. “But the main problems are psychological disorders, which are ‘unseen’.”

Sitting in front of the Iftikhar Psychiatric Hospital in Peshawar, capital of KP and 250 miles from the largest refugee camp in Bannu, 50-year-old Zarsheda Bibi tells IPS her entire family fled Waziristan, leaving everything behind.

Far worse than the loss of her home and possessions, she says, is the loss of her one-year-old grandson, who died on the long and arduous journey to KP.

“She doesn’t sleep properly because she dreams of her deceased grandson every night,” says Iftikhar, who is treating Bibi for post-traumatic stress disorder (PTSD).

According to Javid Khan, an official with the National Disaster Management Authority, PTSD is one of the most common ailments among the displaced.

He recounts to IPS his recent interaction with a woman in a camp in Bannu, whose husband was killed by shelling in Miramshah, the headquarters of North Waziristan.

“Now she is completely disoriented and extremely concerned about the future of her three sons and one daughter,” he says, adding that those who were uprooted are sure to develop long as well as short-term disorders as a result of prolonged stress, anxiety and fear.

Other conditions could include de-personalisation, classified by DSM-IV as a dissociative disorder in which a person experiences out-of-body feelings and severe disorientation; as well as de-realisation, an alteration in perceptions of the external world to the point that it appears unreal, or ‘dream-like’.

Experts say that people torn from their native villages, thrust into completely new surroundings and experiencing insecurity on a daily basis are highly susceptible to these types of conditions, which are associated with severe trauma.

Khan says women and children, who comprise 73 percent of IDPs according to the World Health Organisation (WHO), are likely to be disproportionately impacted by PTSD, as well as disorders related to anxiety, stress, panic and depression.

Muhammad Junaid, a psychologist working with the displaced, says that victims are also suffering from poor self-esteem, as they are forced to occupy tents and shacks, in extremely unsanitary conditions.

Mothers are particularly impacted by their inability to provide for their families, he tells IPS, adding that permanent phobias are not uncommon.

Another major concern among health officials here is how the situation will affect children, many of whom are at a very sensitive age.

“From childhood to adolescence, a child passes through dramatic phases of physical and mental development,” Junaid says. “During this transition, they gain their identity, grow physically and establish familial relationships, as well as bonds with their community and society as a whole.”

Ripped from their ancestral homes and traditional communities, he says, this process will be interrupted, resulting in long-term mental conditions unless properly addressed.

Parents are equally worried about what displacement might mean for their children’s education.

“Two of my sons are very good at their studies,” Muhammad Arif, a shopkeeper from Mirali, an administrative division in North Waziristan, confides to IPS. “They would do well in class and get good positions. Now there’s no school and I fear they will not progress with their education.”

Even if they were to return to Waziristan, he says, the future looks bleak, since the army operation has devastated homes, buildings and business establishments. Everything will have to be built back up from scratch before the people can return to a normal life, he laments.

After nearly a month in the camp, Arif’s 10-year-old son Sadiq has all but given up hope. Through tears, he tells IPS that children like him have “no sleep, no play, no education.”

“I don’t know what the future holds for us,” he says.

For long-time health experts in the region, the situation is a frightening climax of a crisis that has been building for years, ever since the army began a crackdown on insurgents in the rugged, mountainous regions of northern Pakistan nearly 12 years ago.

“Around 50 percent of the residents of FATA have suffered psychological problems due to militancy and subsequent military operations,” Muhammad Wajid, a psychiatrist at the Khyber Pakhtunkhwa Teaching Hospital in Peshawar tells IPS.

“We have examined about 300,000 patients at the psychiatry wards of the KP hospital in 2013; 200,000 of them belonged to FATA. This included 145,000 women and 55,000 children,” he says.

Since 2005, nearly 2.1 million FATA residents have taken refuge in KP, according to Javid, posing a real challenge to the local government, which has struggled to balance the needs of the displaced with its own impoverished local population.

The latest wave of refugees has only added to the government’s woes, and many in the region fear the situation is on a knife’s edge, especially in the holy month of Ramadan, when there is a desperate need for proper sanitation and food to break the daily fast.

(END)

Nurses treat an injured child at the Lady Reading Hospital in Peshawar. Credit: Ashfaq Yusufzai/IPS.

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Nov 16 2013 (IPS)

Ajab Gul is haunted by bloody scenes. He hears women crying and children screaming. “I can’t sleep,” says the 25-year-old health worker at a well-known Pakistani hospital in the frontier city that tends to terror victims.

He works at Lady Reading Hospital (LRH) in Peshawar which is said to receive 98 percent of all terror attack cases in the restive Khyber Pakhtunkhwa province.

And Gul’s job is particularly difficult. Posted at the hospital’s accident and emergency department  – one of the largest in Pakistan – he has to stitch and bandage wounds.

“I see flashes of bloodied faces and bodies. The cries of women and children who are brought here for treatment ring in my ears every night,” Gul tells IPS.“They asked me who attacked them and why? I had no answer.”

The ferocity and frequency of bombings and suicide attacks in Khyber Pakhtunkhwa and the adjacent Federally Administered Tribal Areas (FATA) have had a chilling impact on the lives of doctors, paramedics and nurses in the region.

Their wounds may not be visible, but run deep. “Most of us develop psychological problems,” says Gul.

Peshawar, the capital of Khyber Pakhtunkhwa, used to be a peaceful city. But after the Taliban government in Afghanistan was toppled in 2001, many of its militiamen crossed over to Pakistan and took refuge in the border areas along FATA.

For years now, the Tehreek Taliban Pakistan (TTP) has been targeting the armed forces, government installations as well as public places like markets and schools.

Police say at least 210 attacks have been carried out by the Taliban in Peshawar since 2005.

Professor Arshad Javaid, chief executive officer of LRH, says, “Healthcare providers treat terror attack victims and see their trauma from a close range. Many use anti-depressants, tranquillisers and sleeping pills to avoid nightmares.”

There are around 12 big hospitals in Khyber Pakhtunkhwa, which is home to 22 million people. But most terror attack victims land up at the 1,650-bed LRH.

The state-owned LRH has treated more than 6,000 victims of violence since 2005, says Javaid.

“It is our mission to reduce mortality from terror attacks,” Javaid tells IPS.

But close encounters with severed limbs, bloodied faces, tears and screams leave their scars on the most dedicated of health workers.

“I keep seeing the charred bodies of children in my dreams,” says Rifat Bibi, a 28-year-old nurse at the hospital. “Many times I wake up.

“It is heart wrenching to see children suffering or dying for no fault of theirs,” she says. “They remind me of my own children, sisters and mother.”

Some are unable to put up with the trauma of their jobs.

“About a dozen of my A&E colleagues have got themselves transferred to other wards because they couldn’t stand the stress,” she says.

The twin suicide bombings at All Saints Church on Sep. 22, in which around 80 people were killed, are still fresh in Bibi’s mind.

“A woman, with a bloodstained face, who lost two young brothers that day, wept so much over their bodies that the memory still haunts me,” Bibi tells IPS.

Jauhar Ali is the president of KP Paramedics, which works with various hospitals in the city. He says its 560 paramedics provide diagnostic services and treatment to all kinds of patients.

“But our priority is those who suffer multiple injuries in bomb attacks. We need to stop the bleeding, and bandage their wounds,” he says.

“Even when we are not working, the scenes keep flooding back to mind,” says Jauhar Ali, who also conducts X-rays.

Two years ago he encountered three severely wounded children who were in Grade I. “They asked me who attacked them and why? I had no answer.”

Now he worries endlessly for his own children.

“My children are the same age, they too could become terror targets some day.”

Dr Amjad Ali, a psychiatrist at LRH, says healthcare providers are also vulnerable to rough treatment at the hands of victims’ families.

Citing the Sep. 22 church attack, he says, “That day we received 233 victims within one hour. All were provided treatment. But the angry relatives of some victims attacked health workers.”

Nurses and paramedics often develop mental health problems, he says.

“They burst into tears when they see people in pain. One in 10 shows symptoms of psychological illness. I have examined dozens of health workers who required anti-depressants and counseling,” Amjad Ali tells IPS.

“When you see bloodied bodies so often, how can you not be affected?”