Addressing Mental Health in Pakistan Along With Cultural Needs

By: Mahmood Iqbal
August 31, 2010

Akora Khattak, Pakistan - As International Medical Corps makes mental health care a priority in our emergency relief efforts, we are providing psychosocial services to help Pakistanis cope with the enormous emotional toll of the floods. In addition to providing individual and group support sessions through our mobile clinics, we also deployed a female psychologist to deliver specialized care to women and children.

“We have been witnessing behavioral changes, particularly in women,” said Dr. Sanam Rahim, a female psychologist working at our clinic in the civil hospital in Akora Khattak, about 9 miles east of Nowshera. “The majority have psychosomatic symptoms and increasingly complain of body aches and other illnesses.” Dr. Rahim is able to provide culturally-sensitive care to Pakistani women who feel more comfortable consulting with a female doctor.

Having already had extensive experience working with the internally displaced people in violence-torn Buner District, Dr. Rahim notes that the worst natural calamity in recent history has caused severe mental stress and psychological reactions among flood-affected people. She spoke of 45-year-old Roshmeena who complained of having body aches, but after clinical examination and psychosocial counseling was found not to be physically ill. A resident of Akora Khattak village, Rashmeena has 10 children and an unemployed husband. Already struggling financially, the floods washed away the family’s home and all of their belongings, leaving them without even the most basic resources. “Mental stress and anxiety can convert to psychosomatic disorder,” Dr. Rahim explained. “We want to see Roshmeena for regular follow-up visits and advised her to do muscle relaxant exercises.”

Like Roshmeena, others in Pakistan also complain of body aches and other illnesses, which are actually symptoms of psychological distress, according to specialists. Dr. Rahim recalled seeing a 10-year-old boy complaining of severe hiccups. His mother explained that he had feigned hiccups since the floods struck their village.

“Such psychological illnesses are growing among the flood victims,” Dr. Rahim said, noting that counseling of the child revealed that children in the area had lost all recreational facilities to the floods. “The schools are closed and the lack of recreational activities often leads to mental complications among the children.”

Comparing the displacement of people from Buner district to the devastation and displacement caused by the recent floods, Dr. Rahim notes that a natural disaster often leaves deeper after-effects on local populations because it is so unexpected and sudden that victims have no chance to prepare emotionally. “In Buner and Swat, people knew beforehand that a conflict was brewing in the area. In a sense, they were mentally prepared to leave their houses. But, with the floods, there was no warning. People were caught unaware and they could not even find time to rescue their most valuable items.”

Through International Medical Corps’ mobile clinics in Pakistan, patients suffering from emotional stress are identified during clinical check-ups and referred for further psychosocial counseling.

“When stress converts to depression, it becomes a long-term process to cure,” Dr. Rahim says. “Early psychosocial counseling helps lower the stress and prevent the conversion into acute post-traumatic stress disorders.”

To date, International Medical Corps’ psychosocial support staff has conducted individual and group sessions for approximately 920 individuals, including young children.

Nursing 101 in the Tropics

Perspective from a nurse volunteer in Haiti

Sheri Hathaway RN was a volunteer with in Haiti for International Medical Corps and is currently a Clinical Manager with Bayada Nurses.

On May 16, I left Pittsburgh, PA for the experience of a lifetime to work as a volunteer nurse in support of relief efforts in Haiti. My trip was arranged through my employer, Bayada Nurses, a national home health care agency that is recruiting and sponsoring registered nurses and licensed practical nurses to work in Haiti for one month. Bayada is coordinating the trips for registered nurses through International Medical Corps, a non-profit organization that has been sending medical personnel to assist with relief efforts around the world for over 25 years. Bayada previously worked with International Medical Corps in Kosovo in 1999.

I am an experienced nurse and supervisor, but nothing could have prepared me for how I would deliver skilled nursing services to my patients. Nursing curriculum in the US briefly details diseases endemic in the tropics such as malaria, typhoid, diphtheria, and tetanus. Most nurses in America will not care for people with these diseases in their lifetime, but in Haiti, it is an everyday occurrence.

Metrics used to measure health in the West do not apply in developing countries. For example, people in Haiti function at much lower hemoglobin levels, largely due to chronic under-nutrition and malaria. Children are typically small for their age compared to growth charts used in the US as the result of chronic under-nutrition. Before the earthquake, access to medications and health care was infrequent or non-existent for most. It also appears that infections here are resistant to drugs that are effective in the US.

My assignment was split between one of International Medical Corps’ 15 primary health clinics, located in the heart of the “tent city” that now fills the grounds of the former Petionville Country Club, and the emergency department of L’Hospital Universitat d’etat Haiti (HUEH), the largest hospital in Port-au-Prince. My work in the clinic and the hospital were two very distinct experiences, with each one having their own separate set of challenges.

The clinic at Petionville Club is made up of two tents that sit on a wooden platform above a sea of red and blue tarps that are home to some 40,000 men, women, and children who were displaced by the earthquake. Many of the cases we see here are women and children with skin diseases, diarrhea, and malaria. While these ailments are both treatable and preventable, diarrhea, and preventable childhood disease account for 80 out of every 1,000 deaths in children younger than five, according to the World Health Organization. That is why having care available to these vulnerable populations is so critical to saving lives, particularly as the rainy season approaches.

In contrast to the primary health setting of the clinic, my work at the hospital has focused on emergency and intensive care as part of International Medical Corps’ response to the immediate aftermath of the earthquake. At the height of the response, more than 900 people came through the hospital seeking medical services, most of which was provided in tents averaging 100-degree temperatures. At present, the patient load has lowered significantly and the Emergency Department was able to move back inside the hospital to its original location.

No Westerner would be able to believe what the hospital system is like here. I am amazed at how the hospital has evolved in such a short time because of International Medical Corps’ and similar groups’ ongoing efforts. But the hospital still lacks advanced medical technology, forcing US-trained medical professionals to think on our feet and make do with what is available. On any given day, the way we administer treatment might change depending on what is available to us.

We see many kinds of cases here, including anxiety and mental distress, violent trauma, gunshot wounds in adults and children, severe lacerations, and advanced malaria and tetanus. HIV/AIDS is also highly prevalent. We have also been treating many "hysterias" or PTSD. This experience has shown me how different cultures manifest traumatic stress differently. In Haiti, people will seem to experience paralysis and catatonia. It’s very strange, but if you give them a Tylenol they recover. Some people arrive DOA via ambulance, family members carrying them, via makeshift stretchers.

One patient that that I will always remember is Christopher, a 27-week gestation male infant, who came into the Emergency Department with hypothermia and very near death. Without an incubator on-hand, we used a technique called “Kangaroo Mother Care,” where skin-to-skin contact between mother and baby is used to raise the infant’s core body temperature. Largely because of this technique, we were able regulate his body temperature, even in the absence of an incubator. Christopher fought for life for more than 72 hours under our care, but tragically did not make it. We all called Christopher our miracle baby while he was with us in the ER. and I think many of us will always remember him because he held on against all odds.

What we do is so appreciated by the local people. While they are visiting the clinic or hospital, they want to be seen for everything because they may not have the chance to be seen again for a long time. I was changing the dressing of a patient with an amputation and the father of a young man in the next bed said, "You Americans are good people."

I felt so proud to be an American.

But beyond the international assistance, it is the resilience of the Haitian people that will rebuild Haiti. Regardless of where I worked, the transition in Haiti from emergency response to long-term development is evident. The nursing school at HUEH that collapsed in the earthquake, killing more than 100 students, is now resuming class. HUEH residents and staff now have a more regular, consistent presence around the hospital. National doctors and nurses, rather than international volunteers, now run the primary health clinics.

At the hospital, the patients’ families are just as important for patient care as we are, making sure their family member is bathed, clothed, fed, and nurtured. In the camps, people come to visit the clinic in perfectly ironed shirts and dresses, even though they are living in tents. Everywhere you look, people are carrying on and rebuilding their lives.


It is this resilience that I will bring home with me and it is why I am confident that I have learned more from the Haitian people than they have from me.


For information on International Medical Corps and their work in Haiti, visit http://www.internationalmedicalcorps.org/.

To learn about Bayada Nurses for Haiti, Volunteer Relief Campaign, visit www.bayada.com/haiti.

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In Haiti’s Sea of Loss, A Life Gained

Crystal Wells is a Communications Officer for International Medical Corps and is currently in Haiti helping with the relief effort

The late night hours were filled with panic, dread, and death.

It was midnight on January 13 in Port-au-Prince. Just seven hours earlier, a 7.0-earthquake shredded the capital, leveling whole city blocks and burying thousands in concrete tombs. But in the tragedy and destruction, one woman was fighting to bring new life into the world.

On January 12, Turlanje, 32, was nine months pregnant with her third child. Just before lunch, she started to feel the first pangs of labor. They continued throughout the day and then, just before 6 pm, her house started to shake violently. “I did not know what was going on,” she said. “It was not until later did I find out it was an earthquake.”

As a result of the quake, her neighbor’s house toppled over her two-room home, causing the roof to crash down. Miraculously unscathed, she and her husband emerged to find their neighborhood reduced to slabs of concrete and webs of rebar. Dazed, they joined the steady stream of people heading to the grounds of St. Bernadette’s Church in Bolosse.

The baby was still coming and soon after they arrived at St. Bernadette’s Church, Turlanje and her husband were forced to get their midwife. “Everybody was crazy,” Turlanje says. “Even the midwife lost one of her children. But even in her loss, she took care of me.”

Around 10 pm, Turlanje realized she was going to have to deliver the baby in the yard of St. Bernadette’s Church, amidst the panicking crowds, clouds of dust, and piles of rubble. “I was worried,” Turlanje explained. “I was not expecting to deliver my child during a tragedy.”

Despite her fears and the chaos that ensued around her, Turlanje pushed. And pushed some more. “I was suffering a lot,” she says. “But I was helped by God.”

She pushed and pushed until 1 am, when she finally gave birth to a perfectly healthy baby girl. They named her Gael, after the baby’s father, Gaeton. “She was beautiful,” Turlanje says, beaming.

Now nearly six months old, baby Gael hardly ever cries. No matter where they are, she rests contently in her mother’s arms and watches the world pass by with wide eyes. Turlanje goes to church almost daily and wishes she could leave Port-au-Prince to live with her mother in the country.

After living in a camp at St. Bernadette Church for a few months, the family is now back in their two-room, block-like home in Bolosse. Half of their roof is still missing. “Life is difficult. My husband is not working,” Turlanje explains. “We are just trying to survive.”

Problems sadly not uncommon in Haiti, particularly as families try to pick up what was shattered in seconds on January 12.

But despite their troubles, Turlanje does not worry about medical care. Whenever she or her children need to see a doctor, Turlanje travels up the road to International Medical Corps’ clinic at Bolosse, where they can receive care regardless of their financial circumstances.

“This clinic means a lot to [us],” says Turlanje, resting Gael on her knee. “Sometimes when our children are sick, we might not have the money to send them to a doctor. Now we can bring them here. Thank you.”

It isn’t only the health care that keeps Turlanje coming back. She also has a special connection to the place. Hugging the side of St. Bernadette’s Church, the International Medical Corps clinic also marks the site where baby Gael was born six months earlier.

“I came here to this spot on January 12,” she says. “Other people were crazy...[a]nd I gave birth to this child.”

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Tabar-Issa Clinic

An International Medical Corps doctor gives a check up to a little boy upon his arrival to Tabarre-Issa, one of the new relocation camps in the outskirts of Port-au-Prince.

A sea of tarps at Petionville Camp, where some 50,000 relocated following the earthquake.

Above, children in one of International Medical Corps' medical tent at Tabarre-Issa

A baby is weighed in one of the International Medical Corps clinics at Tabarre-Issa as part of the health screening for new arrivals to Tabarre-Issa.

International Medical Corps volunteer doctor and a new arrival to Tabarre-Issa.

A Haitian girl sits on a suitcase after moving to Tabarre-Issa from the Valle Baudoin, an area prone to landslides and flooding.

Big thanks to our Former Field Site Coordinator for Port-au-Prince, Carrie Hasselback, for sharing these wonderful photos with us!

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"Lost Track of Days"

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti.

I've kind of lost track of days. It's Sunday. A large group of new doctors and nurses have arrived. That means a whole lot of the old people have left as of last night. We got a room for the 3 of us who deployed together. It's got a single gigantic king bed and smells like an ashtray but it's got a shower -- hallelujah! The shower I took this am was the second since I've been here.

Another improvement is the presence of Haitian staff. Hard to know who will be there at any given time and for how long but at least we are moving in the right direction for now. This is the major challenge during this transition time. We've introduced a very high level of care (by Haitian standards) and transitioning some (not all) of this will be the main work of the future.

There are great examples of excellent care being done exclusively by Haitian personnel. The pediatric feeding tent is a great example -- there are regular measured feedings of formula and measured daily weights and as a result, the kids getting better. One orphan was dropped off at our ED weeks and weeks ago by an aunt has since gained a kilogram. Came in at around 7 months and weighed 3.2 kg. That's about 7 lb. He's been in the feeding tent since then and doing well.

Another example is the TB program. Pretty much everyone gets oral observed medication (given and watched by an nurse). It’s supervised by Haitian nurses but single handedly lead by an Dr. Megan, who's down here on her own for who knows how long. She's essentially put her fellowship on hold to care for these patients.

I'm pretty tired now and eager to get some sleep. Worked the 10-7 swing shift. Am on at 7am tomorrow.

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Halfway Through Deployment

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti. We'll be posting his updates from the field over the next week.

At this point I am halfway through our deployment.

I have seen a rapid transformation of the emergency department in a short period of time. Right before we arrived they had recently just moved all ED operations out of the tents and inside. That being said, in many ways it is not at all like an ED that you could imagine. To reiterate, we have no X-ray, no CT scan, no air conditioning, no flushing toilet, no running water even. We are using gel hand wash between patients. At one point while working in the ICU, I successfully discharged a patient with congestive heart failure (a major achievement) and the family started unplugging all these fans that were around her. I was a bit upset and not sure what to do about them stealing what to us was a precious commodity until I relized that all the fans in there were belonging of the patients and their families that they brought in.

All our oxygen comes from standing huge oxygen tanks that have to be rolled slowly and carefully around from patient to patient. During one ICU shift, we had to scramble to jerry rig some splicing and tubing to get 5 patients oxygen that normally would be allocated to one. There are no monitors to continuously monitor patients (well that is not true -- there is one but only one and saved for the sickest patient). We transfer patients to "the medicine ward" which is a frightening place with billions of sick patients packed in with near darkness and often no nurses or doctors to see them for days at a time. Honestly it is better to send people back to their home or tent even with severe illness than to the medicine wards which are at times affectionately termed “the catacombs”.

Still in many ways our ED has rapidly evolved to look exactly like an ED back home. This is amazing since there is no history of emergency medicine or even an "ER" in Port-au-Prince. True, they had a pre-existing "urgent" department but this was not in any way staffed 24 hours a day with an emergency specialist. Just 3-4 weeks ago they still were seeing ED patients in adjacent tents. So it is surprising to now see people coming to our ED with things like chronic pain, anxiety, sickle cell disease, hoping to get surgery for a long standing problems or at least a second opinion. These problems in the US are common ED presentations but are best dealt with in other departments.

It is also not uncommon to get "transfers" from other hospitals or clinics without much regard for our capacity or environment. Some other medical NGO's will not send us patients in an ambulance with a note in French stating need to be admitted for surgery or oncology care without any understanding that at the time our surgeons happened to be on strike (well not sure you can say they are on strike since they have not been paid for months many not since the earthquake. Is that called being on strike or is it just not having a job?). Anyway this movement of patients from hospital to hospital is a totally a common occurrence in the US and it is amazing to me that our ED and the overall health care delivery system has some of the same problems we see in the US. The good things are that we can transfer patients to higher level of care for some things, for example women who need a C-section. I recently got a patient of mine with burns over 50% of her body transferred to a hospital that specializes in burns.

Anyway, things here are progressing -- most would agree that the state of emergency health care here has never been better (at least for the poor in urban Port-au-Prince). The challenge is how to maintain it in a sustainable, local manner.

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"Survived the first night shift."

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti. We'll be posting his updates from the field over the next week.

OK. Survived the first night shift.

It's now day 6 in Haiti. Kirk and I were the night doctors and overall had an outstanding experience. We resuscitated a CHF patient who otherwise would have died -- as of this morning they were giving us the thumbs up sign. The usual machete wounds to the scalp were a bit more common at night. There was a case of diphtheria, which is minimal risk to us but maximal risk to Haitians with almost no vaccinations.

Yesterday we saw a kid with a leg fracture happy to be splinted and another standard shoulder dislocation. Unfortunately there was a very sick septic baby who may or may not make it but there is an unbelievable team of pediatricians here from Partners in Health -- many are from Boston Children’s Hospital. Bottom line is there is incredible talent here.

There are plenty more crazy medical stories but I've now really connected with the people here, which is perhaps equally rewarding. For example, our translators are young Haitians hired by International Medical Corps. Many of them live in tents. They speak Creole, French, Spanish and English and most are self taught. One guy is looking for an English slang dictionary to hone his skills. One is working 12 hours nights with us and then is in school during the day and is only 18. They are smart as can be and the hardest working people in hospital. We rely on them massively.

In medicine, without CT scans and blood tests, the history a patient tells you becomes all the more critical. I'm really looking at the positives. There are plenty of kids in school uniforms going to school every morning who are healthy. They hold hands and smile at each other like other kids. Things are clearly better than in the past and better than they could be. I'm just trying to add a bit to that. Sometimes just talking and listening to people is as helpful as medicine and high levels of US style care.

It's raining cats and dogs right now but cooling things off.....

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Figuring it Out

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti. We'll be posting his updates from the field over the next week.

Starting day three. Yesterday I worked triage. This was challenging; due to the very limited resources you really have to figure out if you should bring people back.

There is no CT scan -- the chest X-ray is reserved only for the most sick patients. We’ve been seeing lots of cerebral malaria but they get better pretty quickly after an IV of quinine. Bottom line is patients with symptoms that at home that would mean a hospital stay, like mild chest pain that could be early heart attack, sky high blood pressure, or moderate pneumonia, in Haiti are treated with some pills and returned to their home-tent. They almost have to be in some respiratory distress, altered mental status, or high fever. Almost everyone else gets sent out or treated in a triage chair.

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