Qualitative findings of this study generated four major themes such as post-disaster mental health conditions, perceived need for support, vulnerability related to age, gender and availability of mental health services. We have presented the experiences, perception, thoughts and insights from the in-depth interviews (IDIs) of affected population & key informant interviews (KIIs) of health care professionals, NGO workers & volunteers.
Post-disaster mental health conditions & perceived need for support
Findings from IDIs of affected population
Survivors of natural disasters mentioned sadness, frustration, grief & guilt after such traumatic events. Many of them had continued survivor guilt even after many years because when these disasters strike, they attempted to survive and take care of their own safety. Some frightenedly observed the death of their kids & dear ones. These eventually led to survivors’ guilt. One mother said,
“I lost my only son in front of my own eyes to the increasing tidal waves. Every night I have nightmares till then and I feel frightened, sad and cry for the whole night”.
One respondent mentioned that someone found another person’s dead son’s body and buried him. This caused the father of the child to have a psychotic breakdown instantly and it continued for long. He was declared as a pagol (crazy) by locality eventually. The respondent also mentioned incidences of conflicts & aggressiveness towards each other in such circumstances.
The cyclone warning system was considered as a catalyst for creating anxiety & panic among local uneducated people by two respondents. They described the situation as, Tsunami alert was announced just before the cyclone Aila (2009) and people rushed to the cyclone centres and took shelter in different places, but the Tsunami was not significant enough to affect them. The next day, they overlooked the signal for Aila thinking that nothing will happen but experienced a horrific disaster. This created panic and stress with warning sirens, any hydraulic horns, thunders & lightening or even loudspeakers trigger feelings of anxiety. This continues to happen.
Most of the affected people mentioned about developing a feeling of helplessness and uncertainty about the future. They specifically stated periods of silence & loneliness, grumpy moments, excessive talking, frustration & excessive anger. One mentioned about denial of reality & period of thinking about what they lost with significant anxiety. Two respondents identified themselves with self-harm attempts & suicidal ideations. The researchers tried to understand the duration of sufferings and they described it as acute phases to year-long symptoms to date (almost 10 years in some cases).
Findings from the KIIs of health care professionals, NGO workers & volunteers
One local health care professional described a haunting experience. Two weeks after the cyclone Aila, he with a rescue team discovered an empty land with lots of mud surrounded by flooding everywhere with tidal bore. One middle-aged person and his young son sat silently. They did not answer any question just took some foods and water after repeated requesting. He later came to know from the son that this gentleman lost his wife and two of his daughters during the cyclone. They found one dead body of his youngest daughter and did not find the others. After this trauma, he became totally silent and spent all the time at a place where he once had a house.
One NGO worker mentioned that,
“I have seen many people after the natural disaster, detached from the home and normal life with intense restlessness & very sensitive with the loss.”
One government health professional described his experience of dealing with many cases with mental issues during and after any disaster including recent flood during his working placement in that area. He also focused on co-morbidities with mental disorders as most of the cases were presented with physical symptoms and his clinical judgement separated the specific findings related to mental health disorders. He indicated that such natural disasters had a profound impact on family relations & psycho-social factors. He experienced many divorces, domestic violence incidences & contemporary suicidal attempts after such disasters where cases were directly or indirectly related to the disaster events or consequences. The respondent observed lack of self-care mostly in families who lost many members during such disasters.
One of the schoolteachers described the experience of a teenage school going girl after Aila:
“A girl was found in after 5 to 6 months of the cyclone with repeated fainting and abnormal behaviour. Prior to the flood & devastation, she was completely normal and among the top of her class. After a series of investigations, we explored that she was a victim of sexual assault in the relief camp and she had never told about her experiences before to anyone.”
The government health professional reported similar cases of sexual assault or harassments during & immediately after disasters with acute stress reaction, chronic depression, withdrawn, reluctant, depersonalized, indifferent & psychotic cases.
He shared a traumatic event related to AILA. He met a father and his 8-year old son who had lost all members of his family. He explained further,
“An example of depersonalization was seen in a relief line. A father was standing by holding his 8-year old son’s hand and there was no hurry in taking relief by him or his son. Both of them were with empty eyes. When we asked them about taking the relief and food items, the father said calmly, “you can give if you want.” We later found out that they lost all their family members during AILA and from then on, they have no interest in living”
Mental health vulnerability related to age
Age was raised as a factor that increases one’s susceptibility to developing mental health problems. Children and elderly were pointed out as most vulnerable because they tend to depend on others for shelters, transportation, collecting food and toileting during emergencies. They often remain frightened and panicked longer and need more time than others to come back to the normal life.
Whilst talking about children, a respondent described that children were unable to share their experience and kept the fear inside their mind for a long time. For many, the experience of a natural disaster was very new, and they might not have even heard about such devastation before. One NGO worker explained that, he observed many frightened children who saw many dead bodies, lost homes, schools, playgrounds, lost books, stationaries, toys, pets, stayed in the shelter houses without food, drinking water, and electricity and sometimes without their own parent. He identified changed pattern of conversation, attitudes and playing games among them. He further added:
“After the cyclone (Aila), I found many children of Koyra were playing grave-grave, burial-burial. They made dolls and buried them in clay made burials. Even some of them have made small trees and were destroying them by false sound of wind remembering the disaster.”
One local volunteer gave an example of a 9 years old boy who was afraid of passing by a pond where he has seen couple of dead bodies including his playmate. This little boy suffered almost for 2 years. A very important observation on vulnerability of adolescents and young people was made by two respondents. The government medical professional identified the complexity of these age groups as they were too young to cope up with the emerging mental health challenges arising from devastations but severely overlooked by adults. The concrete operational stage of cognitive development of a child occurs in this age group (7–11 years), so this sort of experience caused a long-term scar in their cognition that hampered their personality in long run. He also suspected cases of drug addiction might have had relation with this vulnerability which was not investigated properly. Three survivors blamed their poor status as root cause of fragility in such contexts.
Four respondents also mentioned old age as a factor that could make one more susceptible to developing mental health conditions. In addition to the physical vulnerability they suffered psychologically more mostly after the disaster due to loss of carers, financial stress & anxiety induced by loss of income-generating personnel of the family and exposure to devastation. One elderly respondent experienced severe mood disorders after extended rainfall & flooding last year but never expressed as he had no idea that such symptoms have medical remedies. He explained these symptoms persisted long with other occasional episodes of insomnia & anger.
Mental health vulnerability related to gender
Most of the affected population (8), we interviewed described being female increases susceptibility to developing mental health conditions. One respondent explained, female take care of the young children, cook or manage food, collect water in a challenging environment so they cannot take care of themselves during disasters and afterwards heave workloads with no care makes them vulnerable to develop psychological disorders easily.
One NGO worker gave a different but very pragmatic perspective on this issue saying,
“…during a disaster age is a vulnerable factor but post-disaster gender factor is the most vulnerable”.
He explained, if a young lady lost her husband during a cyclone (disaster), she cannot live alone or earn to live. Everyone tries to exploit her starting from the relief workers to the sub district members and chairman. It is difficult to protect her from sexual abuse in the society. All these negatively contribute to her mental health condition. One government health official tagged the female as emotionally vulnerable group. He further explained,
“Female cry openly and become sad easily. They can express their feelings, but men are different in such expressions”.
He experienced some cases where men are addicted to drugs after devastating disasters (both Sidr & Aila). They had extreme fear of becoming workless which led to drug abuse chronic depression, anxiety & suicidal ideation. He stated,
“I have seen new cases of drug users just after disaster(s) specially among young male group. They manage these drugs in high prices and often get involved with violence, illegal trades as a short cut measure. Many of them said, they fear no job (joblessness) and no money. I managed suicidal attempts by adult male (earning member of the family) in such circumstances.”
Availability of mental health services
We asked about availability of mental health services in the locality and some common statements or concerns were portrayed by the respondents. The medical authority mentioned presence of 27 community clinics and one “fully functioning” health complex with health care services and no psychiatrist. Key informant interview respondents were concerned about the shortage of mental health professionals in the locality to meet the population mental health needs after each disaster. They stated that when disasters strike, institutions think of materialistic help including relief materials, oral saline, emergency physical trauma management kits, but not any support for mental health care. One respondent mentioned that only one psychiatrist give service only in divisional level hospitals and sometimes it’s difficult to reach him because of transport, money or time. Many respondents said they have never seen any doctor providing any service, prescribing drugs or counselling people for mental health issues at the grass roots except for severe mental health disorders. After Aila & Roanu, some programs have addressed mental health issues briefly, but this was usually short term and insufficient.
On a different note, during in-depth interviews, two respondents said that they never thought that such psychological problems have medical treatments and they can seek help for the symptoms. One respondent mentioned that it’s shameful to go to hospital for mental health symptoms as money should not be spent on symptoms without physical pain. One respondent mentioned,
“…after seeing the most deaths in one day I lost my normal speech and logical thinking capacity, but I have never talked to any doctor about this as I thought they will laugh at me.”
One NGO worker stated that he noticed presence of complementary medicine services such as homeopathic, unani, ayurvedic treatment provision in every sub-district in national budget but nothing was mentioned about provision of mental health care in grass-root level. He didn’t notice any substantial post-disaster plan by the government to utilize the professional or create such professionals where psychiatrist does not have position in district level hospital.
Key informant respondents mentioned that when people are fighting for basic needs, mental health always comes second line. The medical professional mentioned that,
“it is not possible to make a dramatic change only by physical help but can be possible by psychological treatment.”
He emphasized on availability of psychotropic drugs, recruiting mental health nurses and reduction of stigma related to mental health by mass-awareness. Most interviews turned as portrayal of general discussion on mental health status rather than confining to mental health after disaster. Many respondents stressed on specialized mental health support after such disasters as they personally have seen couple of incidences or experienced periods of vulnerability related to mental health by themselves.
One key informant interview respondent stated that mental health support provision after disasters is not a priority for government as the number of such professional is very low. He also mentioned there is a lack of understanding on importance of mental health at policy level and shared a statement by a high official:
“Our NGO is closely linked to the Ministry of Health. In one of the meetings, a high-ranking governmental official said “what is mental health? What is PTSD? What will I do with the crazy people after disaster? He wondered why we are talking about mental health when people cannot get food, have lost their houses, cattle and other resources.
An NGO respondent mentioned that many NGOs are actively working in Koyra and have specific agendas to address needs after disasters, but he has never seen any initiative related to mental health. He emphasised on appropriate training to make local persons as mental healthcare giver. Another affected person also mentioned that he will definitely visit a professional to get cured from these haunting symptoms even after many years of that disaster (Aila), but he is afraid to find such a professional on regular basis. He stated if these supports can be made available at the nearest community clinic that will be most convenient for him.