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| PERSPECTIVE |
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| Year : 2020 | Volume
: 2
| Issue : 3 | Page : 210-216 |
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Immediate Mental Health Response to Kerala Floods 2018 Victims
Praveenlal Kuttichira1, Roy Abraham Kallivayalil2, Anita James1, Chithira Thomas1, Abdul Rahiman1
1 Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
2 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala, India
| Date of Submission | 17-Aug-2019 |
| Date of Decision | 21-Nov-2019 |
| Date of Acceptance | 15-Dec-2019 |
| Date of Web Publication | 24-Dec-2020 |
Correspondence Address:
Praveenlal Kuttichira
Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Thrissur - 680 005, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/WSP.WSP_22_19
During 2018 monsoon, Kerala received 256% excess of rainfall resulting in floods affecting 5.4 million people, leaving 483 dead, 14 missing, and 140 hospitalized. The UN estimated a loss of Indian National Rupees 310,000 million. Our teams worked from the affected sites to the relief camps. As the disaster struck rapidly, prompt actions were taken based on quick assumptions. Mental health teams exposed to disaster preparedness manual and worked in tandem with health workers. Medical student volunteers indulged children in recreational activities. Feedbacks of their experiences were collected. Status in the rehabilitation centers was ascertained systematically, and services rendered were recorded. Postgraduate students of mental health discipline were trained using the WHO Tool Problem Management Plus (PM+), and their feedback was gathered. About 2086 people from 296 households in the relief camp were studied. Medicines were refilled for the psychiatric patients and psychological first aid was offered to those in distress; all of them had sought mental health services openly. Alcohol withdrawal syndromes observed were not severe. Children emboldened the adults. Out of the 13 long-term care centers, inmates had to be shifted out in three. PM+ workshop was rated beneficial by the participants. This is the report of experiences and action from the affected sites from day 1 of disaster. When hit by disaster, stigma against mental illness becomes less conspicuous. Expeditious orientation in disaster preparedness is feasible and advantageous for mental health professionals. Children are pivotal for suicide prevention in adults. Unlicensed care centers pose delay in providing support. Inclusion of disaster preparedness and intervention modules in the curriculum is to be considered.
Keywords: Disaster psychiatry, Kerala floods 2018, mental health response, resilience
How to cite this article:
Kuttichira P, Kallivayalil RA, James A, Thomas C, Rahiman A. Immediate Mental Health Response to Kerala Floods 2018 Victims. World Soc Psychiatry 2020;2:210-6 |
| Introduction | |  |
Kerala, an Indian state, received 256% excess of rainfall during 2018 monsoon, resulting in floods affecting approximately 5.4 million of people, one-sixth of 34.8 million of Kerala population.[1] After “the great floods of 99” in 1924, this was the worst experienced. All the 14 districts were under red alert for 10 days from August 9, 2018. Government of India declared Level 3 calamity, which is the highest.[2] By August 21, 2018, 776 villages were affected and 1,247,496 people were in 5645 relief camps across the state.[3] In the Special Assembly Session, the house was informed that 483 people lost their lives, 14 people missing, and 140 people admitted to hospitals. Around 4537 fishermen worked in the floodwaters – towns and villages otherwise – with 669 fishing boats, besides forces, military, and volunteers, managing the rescue of more than 65,000 people. By the end of the month, floodwaters began to recede and normal life started returning to Kerala. However, large parts of cities and villages became unlivable as “homes were muddied and wrecked; sewers overflowed and streets rubbish filled.” The UN Postdisaster Needs Assessment report estimated an overall loss of Indian National Rupees 310,000 million.[4]
The present report explains how it is possible to make relevant observations, form assumptions, and execute effective actions; all in a scientific manner, on facing flood disaster as and when it happens. From day 1 of floodwaters causing disaster in the region, staff and students of missionary-run medical college were in the affected area for health care at the rescue and relief points. All the actions were of spiraling up nature responding to requirements as and when it occurred and how and when it was possible. In a study on earthquake victims, higher prevalence of psychiatric disorders was observed among those living in affected area and rehabilitated area than in the control area, neurotic depression being the most common.[5] However, our focus was on actual events and immediate responses to it, rather than analysis of reasons behind observations and later reports about distress experienced by victims.
| Actions and Interventions | | |
The torrential rain started in the district on the day of August 15, 2018. By 16th early morning, the city was cut-off from rest of the districts on three sides when the main roads submerged underwater.
About 2086 people from 296 households lost their houses and belongings in the “blink of an eye.” Affected people were rescued by local youth affiliated to cadre-based political parties. Government-organized camps were manned by volunteers unrelated to any groups or organizations. Donated supplies reached the camp from the neighborhood and far away, apart from government supplies. There were adequate food and drinking water. Young people, using social media, successfully provided location and extent of emergency about stranded persons and guided rescue teams to reach the spot. They procured needed supplies and managed distribution logistics.
Interventions had to be immediate as the floodwaters came in within hours and affected people were many. Our interventions started from the same night and continued till the 1st week of September. In this study, inferences were based on information gathered from participants in the rescue and relief works and not from the target population who received care. General observations from the action site and their own experiences were collected [Box 1].
The relief works merged into rescue and mental health care got amalgamated to physical health care; all as a natural response. There was no time or opportunity for planning, preparing, monitoring, or systematic observations. Our initiatives were based on sequence of events and intervention.
Observation 1
The feedback from the volunteers in the camps and members of health teams prompted the need for mental health care to the victims. Four mental health teams (MHTs) were formed and at least two were in the field every day for the next 2 days. The reported observations and action taken by MHTs are given in [Table 1].
Assumption 1
Offering mental health care along with general health care will be feasible. Less emphasis on treatment with medicines will make it more acceptable.
Action 1
Our institution volunteered health care in two relief camps – Chembukkavu and Thalore. Mental health interventions were focused in Thalore Camp.
Four multi-professional MHTs got oriented in “disaster mental health” and delivered services for 2 consecutive days. Postgraduate residents (PGRs) learned the manual and made in-house presentations in a purposely planned faculty–postgraduate (PG) program. Each group had one psychiatrist, one PGR, one clinical psychologist/psychiatric nurse/social worker, and two interns. They were given specific guidelines for work in the relief camp [Box 2]. MHTs visited the camp and worked in collaboration with the healthcare teams.
Observation 2
The survivors were preoccupied with their losses, whereabouts of missing relatives, and anxious about rebuilding their lives. There was an incident of suicide by hanging by the head of a household who had gone home alone to see the status of devastation.
Assumption 2
Returning to the devastation site of one's own house and leaving the social support in the relief camps will be stressful and interventions are required before it.
Action 2
The news was withdrawn from TV after a single scroll on government's request, to avoid copycat phenomenon. A relevant article by a popular psychiatrist was in the newspaper the next morning.[6]
Observation 3
Camp organizers, volunteers, and MHTs reported the presence of children in large numbers in the camp. In the camp, the children were enjoying, but many showed signs of distress, though they were not as worried as adults. The responses of medical student volunteers (MSVs) and observation reports by MHTs are given in [Table 2]. | Table 2: Medical student volunteers feedback and mental health teams observations
Click here to view |
Assumption 3
Happiness of children will strengthen the “will to live” in family members.
Action 3
A group of MSVs engaged children with songs, stories, and origami [Box 3]. MSVs were primed about the rationale behind the intervention among children and were given confidence that MHTs also will be in the same camp.
Observation 4
About 200 inmates were stranded in an unlicensed psychiatric center where the river had over-flown.
Assumption 4
Care centers for mentally ill/challenged will be the last point of concern in affected areas, and their resource channels will dry up due to change in priority and shifting focus to elsewhere.
Action 4a
The inmates of the psychiatric center were safe as they were shifted to the upper floor and caretakers gave extra dose of medications to calm them. They were cautioned against giving high doses and to avoid lithium till adequate availability of drinking water and food. The local volunteers provided supplies and medicines by swimming in neck deep water at night.
Action 4b
A list of long-term care centers in the district were collected from Kerala State Mental Health Authority and practicing psychiatrists in the district.[7] Communications were established through phones, social media, or volunteers; their status was gathered and current needs were assessed [Box 4]. The centers were visited and collected resources were provided wherever possible. All the inmates were reported to be safe. Details are given in [Table 3].
Observation 5
Government initiated mental health training programs for participating volunteers. A program was organized in our district for a heterogeneous group of more than 1000 volunteers from different backgrounds. At the end of the session, members of a few nongovernment organizations (NGOs) who were actively involved in the field expressed the need of professionals, who know “how to deal with such problems rather than diagnosing mental illness and prescribing.”
Assumption 5
Addressing the mental health needs by locally available experts will be a good method for service delivery. For enhancing experts' specific skills, continuing professional development (CPD) programs are required, rather than orientation or sensitization.
Action 5
A workshop was organized focusing on colleges running mental health courses and institutions running mental health services (other than hospitals) in the severely affected areas for using Problem Management Plus module (PM+)[8] [Box 5]. Thirty-seven participants (PGs or PG students of psychology or social work) from one care center (National Institute of Physical Medicine and Rehabilitation) and two colleges (Christ and St. Joseph's Colleges, Irinjalakuda) participated in the workshop which had nine sessions. The participants shared their own experiences as victim and as volunteer in relief camps. The results are given in [Table 4]. They were satisfied with the information given and were confident of utilizing the knowledge. Information was then passed on to the agencies and NGOs working among flood victims in concerned localities.
 | Table 4: Responses of participants on problem management plus training program
Click here to view |
Summary of the events and interventions are given in [Box 6].
| Discussion | | |
Disasters are large-scale events leading to threat of harm or death to large number of people, disruption to social processes – services, social networks, and supplies – and secondary consequences on physical and mental ill-health among affected.[9],[10],[11] It challenge human adaptation at the level of individual, family, and society regardless of nation and culture. “Disasters and Mental Health” edited by López-Ibor et al. and published in 2005 is a comprehensive resource for mental health professionals working with disaster victims. It covers experiences from different countries of the world.[12] The frequency and human impact of disasters have been increasing owing to climate change and growing population density. In 2005, ~162 million people were affected by disasters globally, whereas in 2010, the number increased to ~330 million.[13]
When compared to people affected, deaths in any disaster are small, up to 0.1% appearing in reports.[13] However, the death rate in Kerala Floods 2018 was 0.34% which was three times higher. Absence of prediction, lack of preparedness, and unfamiliarity could have contributed to this high figure.
The present study was not formal research; testing a hypothesis using standard methodology and drawing conclusions with statistical significance. Expertise could not be invited from elsewhere as the disaster was unpredicted and happened within hours. According to Bryant and Litz, “helping victims with their social needs is the priority in the immediate aftermath of a disaster”.[14] Our study also followed the same principle. We were active in the field from “hour 1,” and the responses were to meet the needs as they came by. It started with successful shifting of patients to our hospital from intensive care units (ICUs) of other hospitals in the city on the same night. Our engineers converted a few general wards to semi-ICUs.
The WHO recommends at least one healthcare staff member oriented in mental health care in every general health facility during humanitarian emergencies. Healthcare staff, oriented to mental healthcare principles, provided services to more than 300,000 victims of Kerala 2018 floods.[15] Political and administrative leaderships actively worked together. A shift from ordinariness to altruism was evident in many. Senior officials and celebrities served in relief camps, most of them in anonymity. Youngsters worked through social media and their network functioned as virtual control room.
Disaster mental health is preventive and the goal is to reach most of the distressed people as early as possible. It has to be in the front line to “know” how it was, to plan for response, and to decide the priorities. Setting up mental health services in relief camps was hence assumed, planned, and executed. Ensuring continuity of care for mentally ill and managing withdrawals was successful in our experience. The role of psychotropic medication is limited and debriefing is not established while cognitive behavioral therapy is promising.[16] However, lack of trained personnel and large number of affected persons made the latter not feasible.
Disproportionately, weighing each complaint in isolation and fitting into familiar diagnosis is a usual approach which makes mental health unwelcome. Addressing symptoms as signs of distress and managing without diagnostic label were our approach. During the immediate period, we encouraged ventilation and facilitated teaming up. Long-term care was neither a matter of concern nor feasible at that time.
Doing something positive can help gaining sense of control[17] and reduce suicide risk,[18] which worked well among victims and volunteers. Stigma toward mental illness is universal but varies between diagnostic categories. Appreciating their distress as “a natural response to an unusual situation” shared by affected others could be the reason for openly seeking help, not fearing stigma. Rescue volunteers seeking help from the same desk also facilitated overcoming stigma.
All the economic, religious, ethical, moral, and social factors which oppose intentions to end life are suicide counters. “Attachment with children and spouses, stigma descending on family through generations, and the damnation to hell in the 'afterlife' were all such counters reported from South India.”[19] This was the basis for Assumption 2.
Kerala press was aware of the guidelines for media reporting of suicides following a workshop which had shown a positive impact in the reporting style.[20] On request, they stopped reporting about the suicide incident and an article on suicide prevention was published.[6] Witnessing devastation of one's own home alone was considered as the suicide trigger, and hence, it was decided to arrange returning in groups. A support kit (with food items and cash) was provided by government when the camps were closed. En mass cleaning programs were organized by volunteers who included people's representatives and celebrities. Safety, calming, connectedness, sense of efficacy, and hope are five themes to be promoted for transition from emergency to stability.[21] The same was overall approach in governmental response to flood victims.
Norris et al. have suggested four distinct symptom trajectories: resistance, resilience, recovery, and chronic dysfunction.[22] It is opined that resilience is different from recovery, more common than believed, and there are multiple pathways to it.[23] Studies of traumatic event experience have shown that most people who experience an event do not develop psychopathology.[22] Resilience, the capacity to continue functioning after a traumatic event is common.[24]
The orientation programs help activists or general public get a broad knowledge of the mental health possibilities available and lead to self-referral or referring others in need. Most of the healthcare professionals including mental healthcare professionals are untrained when it comes to disaster management. The need for a master document periodically updated and locally adaptable to guide development of protocols, procedures, and standards was appreciated. Training given based on developed manuals maintain uniform standard, draw baseline for follow-up, and ensure benefit to target population which would not be possible if training was given based on individual wisdom of an unfamiliar professional. PM+ was selected as it was accessible, readily available, and free.
In the present study, it was noted that several mental healthcare institutions are unlicensed, unlisted, and therefore could not be approached. This takes away their opportunity to receive support and evades responsibility to be accountable, both compromising the safety of inmates. Human causalities may go unreported especially when the mentally ill are abandoned by their families. The reasons for centers remaining unlicensed need to be explored and remedial measures taken.
Individuals with poor mental health are at high risk for injury or loss of life, while psychological preparedness helps people to think logically and wisely, decreasing the risk.[25] People who feel safe, connected, calm, and hopeful are likely to recover fast. The government was on lookout for experts who could advise them on specific programs. This awareness and relationship could be used to bring mental health into deserved prominence.
Four areas in the field of disaster mental health which may benefit most from further research are longitudinal assessments of disaster victims, the field needs studies, intervention studies aiming prevention of mental illness and studies on risk factors, and predisposition to develop poor mental health outcomes.[9],[11],[26] The human face of disaster needs to be understood as central and investigated as such. World Psychiatric Association opines that mental health professionals have a significant role to play as consultants to the health authorities and as advisors to decision-makers as well as general public.[27] In our present experience, we had taken up all those roles successfully.
| Conclusion | | |
The need for mental health component in disaster health care is demanded by victims, requested by volunteers, and appreciated by administrators. It was provided along with general health care with low priority for medical management. Adolescent volunteers with enhanced skill for storytelling, games, and origami can relate with children easily and cheer them up. Orientation to manuals for disaster preparedness can enhance the skill and confidence among mental health professionals. Unlicensed long-term care centers for the mentally ill remain out of attention. PGs in mental healthcare realized the lack of skill to provide services during disasters and opined its inclusion in the curriculum.
Acknowledgment
We would like to extend our sincere thanks to the Director of Jubilee Mission Medical College and Research Institute, Rev. Fr. Francis Pallikunath for his continued support and encouragement. We offer our sincere appreciation to Ms. Mridula Vellore, Research Assistant, JCMR, for her secretarial assistance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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