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Nov 18, 2010

People to People Delegation to India, Day 2

11/17/2010 Delhi, India-Morning Session:
After a short bus ride from our hotel “The Grand” we arrived at the National disaster Management Authority government of India where we met with Dr. K. Sekar, professor and head of the Dept of Psychiatric Social Work with the National Institute of Mental Health and Neuro Sciences. He explained the recent disaster which occurred the day we arrived in India. A high rise apartment building collapsed and seventy people were killed. Dr. Sekar talked about the services that are available and the compensation available to those who lost family members. However, he described a difficult situation where there were perhaps 15 people living in the same apartment and the difficulty in identifying who the surviving family member might who is the senior specialist with the National disaster Management authority government of India presented a slide show of the India profile and diverse language and religious diversity which presents some difficulty when dealing with natural disasters.

Fifty six percent of land in India is vulnerable to earthquakes. His department has created a hazard map of India which includes earthquake zones in order of likelihood of quakes. Sri Lanka refugees, 1984 gas tragedy, chemical disasters and oil spills present constant challenges. Biological threats include: plagues, avian flu and terrorist attacks. In 2002, there were riots between the Hindu and Muslims plus air crashes, cyclones, and earthquakes constantly present challenges for the National disaster Management Authority.

NIMHANS has worked for 25 years in the mental health unit. Psycho-social issues present an ongoing need to those who are injured and those who are left to cope with loss and caring for the injured. Natural and human made disasters presents different responses as those who are victims of human made disasters seem to have more difficulty dealing with anger. One quote that was very touching made by a mother who had lost a child, “Dr. Saab, would 90,000 rupees bring back my child.”

Young adolescents’ reaction to disaster was concern that they could not work. Dr. Jayakumar firmly believes that psycho-social help in needed after disaster. Tenants of PSC Higher impact of event, leading to distress, less functionality, and loss of coping capabilities. Former ideas of coping included prescriptions for depression. Today the spectrum of care includes emotional reactions and better coping skills taught by mental health workers. Also normalizing plays a huge part of coping. Producing trained helpers versus professional counselors to help with the enormous need after disasters. The facility provides support and supervision to workers with outcomes measured by methodological samples through the WHO and followed by cost comparisons with those who received care and those who received no care following tragedies. Stress management is provided for caregivers. National Disaster Act pushed the policy to include psycho-social disaster relief.

Creating caring communities and bringing in mental health workers -resident - to empower resources and present normalcy as a means for coping with these overwhelming issues. Dr. Sekar offered a time for Q & A and was very gracious and patient answering practical answers. Dr. Sekar explained how his organization has professional counselors train people in various communities who are already familiar with the culture and religious practice instead of sending professional counselors who could be at risk for burn out and may lack knowledge in the local belief system.

Dr. Jayakumar is the senior specialist in psychosocial support and Mental Health Services with the National Disaster Management Authority of India. Dr. Sikar spoke of issues involving family are more prevalent in India than perhaps other counties. He also spoke with previous trauma and stress involved when disaster strikes. A most interesting discussion involved children of HIV parents or those children who were child laborers and orphaned. Dr. Sikar talked about moving toward community based structured programs where children who have been traumatized can receive education, sports, and psycho-social help once a week. It appears one area where the United States could emulate the Indians is the area where the western model is reluctant to share training with those who are not licensed or university trained and the void between research and action .During Q & A, Dr. Sekar explained how the team works together to avoid burnout when they are in the field by supplying support, supervision, and allow time for talking about what they have seen, heard, and felt, also allowing time for crying and expressing their thoughts and feelings with the team members. The team work is scheduled so that workers are at the site for a limited time (<4 hours) then return to the home base on site where they can rest and de-stress for 3 hours. It seems there is much to be learned from our Indian cohorts in the way of disaster relief. Because of their history of many disasters, (tsunamis, earthquakes, fires, terrorism, floods), they have had time to take a look at what works and what does work.

Dr. Jayakumar spoke to our group about how there was no mechanism for natural disaster relief before 1990. They are building on cultural preparedness that is based on holistic approach, quick response and strategic response. The shift in thinking came about in changing from reactive to proactive readiness. One of the salient features of disaster management was the creation of National Disaster Mitigation fund and National disaster Response fund. Headed by the prime minister the policy and advocacy issues were mandated to take a holistic and integrated approach for preparedness to recovery. Mandated preparedness guidelines for the Nation, State, Ministries and departments approve d by NDMA. Because each state has different needs, these policies provide a guide or “Bible” for the individual and culturally diverse states. The guidelines come from the medical community, a steering group, and not only the government. Guidelines include building on what has already been achieved, defining approach, indentifying partners and stakeholders (states, military, universities, communities, NGO, corporate, professionals). Theories or documents must be prepared and sent to all ministries and departments and states for comments and final draft. There are only 43 state run mental hospitals in India. There are only 500 clinical psychologists, 400 psychiatric social workers that does not allow for a one on one with patients. There is no present research to look at the gaps between coordination of agencies and duplication of services. (Dr. Jayakumar related a story of talking with a child during the tsunami whom he asked to draw a picture. He child responded, “Ok, if you give me a bike.” The child had drawn pictures for many agencies that were there to help.

One interesting component for the policy was providing help for vulnerable people (elderly, sick, mentally ill, pregnant women, infants, special needs children, orphans).Every state has a health plan and the country is pushing for integration of the health plan and coordination with the government. The plans are organized with three levels of disaster relief according to destruction. (
It is the desire of India’s National disaster Management Authority Government of India to take their plan globally.

Afternoon session - UNICEF
Save the children. Our delegation met with Jarbjit Singh Sohota who is an Emergency specialist with United Nations children’s fund. Sahota talked about using the word and trauma very sparingly. In 1977 a tidal wave took >100,000 lives. Sohota noted that people just wanted to talk. His job was to help people build houses with bamboo, not concerned with structural issues. They quickly organized into groups to build one house to a group in order to get people back into homes quickly. He emphasized that stories need to be heard. In 1993 he met with a lady who had lost her entire family (4 sons and 4 daughters) and as he began to listen to this woman’s story, he captured her anguish on film and has used her story and pictures as a means of encouragement to aid workers. Through her story, he was able to understand what happens to people after disaster strikes in enormous ways.

Island storm people said they did not need psycho-social help as they had their own ways of dealing. His understanding of “wounded can help wounded,” created an understanding of ways to help people in a culturally sensitive perspective. For example, people were giving second-handed clothes that were rejected. After tsunamis psycho-therapy became psycho-social. People who brought food did not look people in the face – at times throwing food off a truck. On day to day basis they struggle and are better able to cope with disaster. When asked to explain what he meant by this statement, Sahota described how a person living in a rural area were used to providing food for their families day to day and knew how to survive off the land, where those who live in the cities are not accustomed to finding their own food and cooking for themselves. He explained how the rural people were more resilient since they were accustomed to day to day struggles and were more likely to be able to survive three days without food where a person from the city might be able to survive only one day without food.

Cirecie West-Olatunji, Associate Professor, Mental Health Track Coordinator Counselor Education at the University of Florida and ACA Governing Council Representatitve, is leading a People to People Disaster Mental Health Delegation to India. She will be sending us regular updates during her trip.

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