FLOOD MENTAL HEALTH RESPONSE

Flood Mental Health Response

Climate change has wreaked Havoc throughout Pakistan recently. With heavy rainfalls,
Urban and rural flooding, Pakistan is in a state of emergency. Around 1100 people have
lost their lives, at least 33 million have lost everything including their ancestral lands and
homes and one-third of the country is submerged in water. This has resulted in the
worst humanitarian crisis the country has ever seen.

To respond to this crisis, Aga Khan University has set up health camps in affected areas
of the country. Though efforts have been put in to respond to the health needs of the
people, mental health needs are to be prioritized the most. With so much destruction
and loss all around, the need for mental health support and counseling is now more
than ever. Since the disaster has just struck, there is a room of six weeks to provide
psychological first aid and trauma counseling to the flood affected to prevent the
epidemic of post-traumatic stress disorder and complex traumas in these communities.
There is also the need to build their resilience and self-reliance to counter learned
helplessness in the long term and dependence on external aid.

So, the department of community health science in collaboration with the brain and
mind institute Aga Khan University intends to provide the following services:

1. Set up mental health services within the AKU medical health camps to deliver
high-quality psychological first aid and stress and trauma counseling.

2. Build the capacity of the health care staff at these camps to provide trauma-
informed care

3. Carry out the community building exercises to identify and mobilize community
resources to help themselves
Current crisis and assessment of the camp:

A four-day visit was made to one of the health camps set up by the Aga Khan University
(AKU) in Thatta. The camp is set up by the Pakistan Army and within the temporary
settlement AKU has set up its health camp. The flood relief camp is set up in a hilly area
to prevent evacuation in near future due to more expected rain and further flooding. It is
set up in three zones. There is a central zone, the picture shown below where tents are
set up in a circle and the health camp is placed in the center. Then there is the East
zone across the road where tents are set up along the road and water puddles. The
North and South zones are the temporary shelters made by the locals themselves still
awaiting proper tents in aid. These shelters are made of straws, wood, cloth, and
charpoy. A picture is shown below for reference. Further to the south, there is an
abandoned jail building where most of the people are kept.

Camps set up in central zone

There are approximate, 3000-3500 people in this camp. For all the flood victims, there
are 14 washrooms in total for all zones. None of which is designated for females. The
shelter tents set up by the army are equipped with basics like a mat, a charpoy, and two
cans of water. Besides that, other shelters are not fit for taking refuge. The jails are
dark, dungy, and full of mosquitoes, bugs, and snakes. In terms of accessibility, the
entrance is a high platform with no stairs making it difficult for old people, children, and
pregnant women.

Camp set up in abandoned jail building

 Make-do shelter

Besides AKU, the district health office has also set up a camp where a GP sits every
day and dispenses medicine as well. HANDS provides drinking water that is not filtered
and treated but chlorinated to kill a broad spectrum of germs. HANDS only provides
drinking water to the central zone and the other zones and jail settlements rely on water
puddles as a source of their drinking and cleaning water. The district government brings
a water tanker to the jail settlement twice a week, which is completely untreated and put
in an uncovered water reservoir. There is no access to clean water for cleaning and
washing. All the people rely on rainwater puddles for this purpose.
 Drinking water in jail camps

The food in the camps is provided twice by the district government. They serve them
cooked food. The food is not edible at all as it is always stale and swarmed with
maggots. The locals in a very desperate situation eat some mostly just plain roti and are
better off preparing their meal.

There is no electricity arrangement in the camps, so it becomes pitch black after sunset
and the people make a fire to keep them safe and warm.

Most people in the camp have survival skills knowing how to make shelter, fire, and
hunt for food but they seem to show classic learned self helplessness and are solely
depending on the government aid to provide them with necessities despite being able to
do it themselves. If the situation is analyzed from the trauma lens it shows the "freeze
and submit" response. It is a state where traumatized people perceive a complete loss
of power over their surroundings and situation and submit to whatever they are
subjected to.

This lack of mobility and initiative is leading to a couple of major public health
challenges which can be curtailed if their source of trauma is addressed.
First of all, they all know to make shelter but despite this, they are choosing to sit all day
in scorching heat and cold nights. Shelters can protect most of them from dehydration
and heat stroke.

They have access to locally grown edible plants and roots. They also have access to
meat in the form of pigeons, rabbits, and fish. They can make nets as well to catch them
but they still are eating stale food. Food is the major cause of breakouts of diarrhea,
food poisoning, and other diseases in these communities. If food can be changed, the
burden of GI diseases would drastically drop in a short time. There are also cases of
sexual exploitation of women without any male member in the family in return for extra
food, if the people can prepare their food then we can also prevent this hidden problem
in the camps.

We can also mobilize the people from the community to add sulfur to the nearby ponds
as they know the landscape too well to reduce the skin diseases contracted from water.

Mental Health Response Strategy:

The flood affectees are in the acute phase of rehabilitation where it has been less than
three weeks and a mental health response focusing on stress and trauma counseling,
trauma relieving exercises, and trauma-informed care by the physicians should be
delivered. With trauma intervention in the acute stress phase, it is expected that we can
prevent the epidemic of mental illnesses in an aftermath of the disaster. This will also
support the affected communities to build resilience and in long-term rehabilitation.
The response is planned to be three-tiered as listed below:

1) Non-Verbal Somatic Trauma Release: Tension and Trauma Release Exercises :

TRE is an innovative series of exercises that assist the body in releasing deep muscular
patterns of stress, tension, and trauma. The exercises safely activate a natural reflex
mechanism of shaking or vibrating that releases muscular tension, calming down the
nervous system. When this muscular shaking/vibrating mechanism is activated in a safe
and controlled environment, the body is encouraged to return to a state of balance.
Tension & Trauma Releasing Exercises (or TRE) is based on the fundamental idea,
backed by research, that stress, tension, and trauma is both psychological and physical.
TRE’s reflexive muscle vibrations generally feel pleasant and soothing. After doing TRE,
many people report feelings of peace and well-being. TRE is designed to be a self-help
tool that, once learned, can be used independently as needed throughout one’s life,
thereby continuously supporting and promoting personal health and wellness.

Due to the somatic nature of the training and the short time available, this technique will
be used to move the mind and bodies of the victims to reset their bodies from the hyper-
aroused phase to the normal phase. This technique is non-verbal it will be
understandable in most rural communities as the literacy level is low there.

2) Trauma-Informed care and Psychological First Aid Training:

Trauma-Informed Care (TIC) is an approach in the human service field that assumes
that an individual is more likely than not to have a history of trauma. Trauma-informed
services do no harm i.e. they do not re-traumatize or blame victims for their efforts to
manage their traumatic reactions, and they embrace a message of hope and optimism
that recovery is possible. In trauma-informed services, trauma survivors are seen as
unique individuals who have experienced extremely abnormal situations and have
managed as best they could. This training will be for the doctors and physicians to help
them build trauma-informed awareness and language, to administer psychological first
aid to trauma survivors, and appropriate medical care and support including recognition
of mental illness symptoms especially trauma, and referral to specialists.
 3) Certified Trauma Support Specialist:

Mental health counselors will be trained in the principles of trauma-informed care;

understanding both the top-down and bottom-up approaches, and how to implement an
intervention effectively for individuals impacted by trauma.

Implementation Plan

The program will be implemented in the following steps:

1. One country coordinator, two Trainers, and 14 psychologists will form the mental
health response team. All the trainers and 14 psychologists will be filtered on
Adverse Childhood Experience (ACE) scale and those who have a low score on
the scale will be part of the team. Studies have shown people with low ACE
scores have more capacity to hold safe space for providing care to people with
trauma.

2. All the trainers will be trained in Tension and Trauma Release Exercises,
Trauma-Informed care Psychological First Aid Training and Trauma Support by
Trauma Release and Wellness centre. The trainers will then in turn be
responsible to train the psychologists, student volunteers and physicians on
ground. They will also ensure the quality of service by paying quality visits and
providing refreshers.

3. The Country coordinator will be responsible for identification of the personnel,

their rota and logistics throughout the health camps set up by Aku to ensure
smooth execution of the plan.

4. The psychologists will be deployed in each health camp. We will begin the pilot
from Thatta health camp as it is nearest to Karachi and easier to commute. First
of all the psychologist will begin with TRE in small groups. It will aim to cover all
the interested people. TRE will not only be the first point of care contact with the
 community but it will provide a strong foundation on which more specialized work
can be done.

5. High-risk participants will be identified from these groups will be enrolled for
specialized trauma support.

6. Meanwhile the GPs will be trained in trauma informed care to identify patients
with somatic disorder, dissociation and other related mental illness and refer
them specialized trauma support services by the psychologist.

7. We will also collaborate with district health office and request services of a
psychiatrist twice a week to prescribe medication for patients also requiring
pharmacological care.

8. Besides, the trauma focused care, we will train our student volunteers to hold
narrative building exercises with the community led by Habib Afsar to help them
identify resources and skills they have as a community to build back on their
own.
The summary is shown in the pyramid below:

Pharmacological and
in hospital
intervention
(Specialized care)
Trauma specialized care
provided by the trauma
specialist (Low to moderate
intensity services)

Trauma Informed care by GPs to identify

people with somatic symptoms and
dissociation (Screening)

TRE & Narrative building exercises to reset the mind and

body and help idenitify resources int he communtiy to
build resilience (Preventative)

Flood Mental Health Response

Conclusion:

Like all the previous disasters, mental health is not a focus of medical aid. From the
lessons learned in the past, if mental health of the people affected by disaster remain
unaddressed it will further increase the mental health burden of the population and but
more strain on the resource limited and expensive specialized care that only a few can
afford to avail. Our intervention at this point can prevent significant number of people
from developing trauma elated mental illness including PTSD and complex trauma and
can deliver the right kind if care who need help right now.