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Are We Ready to Protect Persons with Acute Mental Illness in Humanitarian Emergencies?

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This guest blog comes to us from Hari Krishna Nibanupudi, a disaster resilience and climate change specialist at Safe Citizen International in Hyderabad, India. He has over two decades of experience in humanitarian work in Asia and Africa. He is an award winning Blogger and Short filmmaker on Issues of Climate Migration and Disaster Resilience and has published regularly on the subject in South Asia.

Recently, I was in Malawi to assess flood-affected communities. I noticed two young girls in a displaced perons camp who appeared to be suffering from not only disaster-related injuries but also acute mental illness. One stayed beside me throughout my interaction with the communities there. As we prepared to leave, she held my hand tightly and started crying loudly. As some members of the community took her away, a local told me that the girl was “crazy” and that she was crying because she thought I was her husband and that I was leaving her.

As I traveled back from Malawi, this incident stuck with me. The disaster-affected community was living in shabby tents, with minimal relief support. Most of them had lost their houses. They were to be sent back to their villages in two weeks’ time, to a community where they would have nowhere to stay. The two girls I met depended on this community for their physical safety, psychological care, and protection of their dignity. But is a community devastated by disaster able to take care of them?

In my two decades of humanitarian work across Asia and Africa, I have seen that the protection needs of persons with acute mental illness are rarely discussed. Even in inter-agency multi-sectoral needs assessments, the needs of people with pre-existing mental health needs are often not included in needs assessment check lists and surveys. Most of our vulnerability assessment exercises as part of disaster risk reduction projects also fail to take note of this extremely vulnerable section of our society. Whereas the continuous articulation of social inclusion needs has helped to build humanitarian capacity and make progress toward the inclusion of aspects such as gender, age, social discrimination, and physical disability, for instance, we have yet to sufficiently recognize the presence and suffering of persons with acute mental illness and build our capacity to protect them.

We often overlook the needs of people with mental illness, either because we neglect to think of them, or because we are not made aware of them in our training and orientations. Part of the problem is a continued lack of response capacity; a larger issue, however, is that these needs are simply overlooked. For one, mental illnesses are only occasionally visible to the eye, and may be easily missed by busy humanitarian practitioners operating in a compartmentalized manner. Moreover, the lack of humanitarian attention to the needs of persons with acute mental illness in disasters and conflicts may be an extension of the prevailing apathy and indifference in many societies already have towards them. Although rapid advancements have been made in psychiatry and neurosciences in recent years, they simply have not been matched by social attitudes and medical infrastructure to treat persons with serious mental Illness, especially in developing countries.

Without a doubt, there are several organizations addressing the post-disaster trauma of affected populations, and the knowledge and expertise in this particular field is advancing rapidly, with trained mental health workers who can provide psychological care. For instance, Disability Inclusive Disaster Risk Management by Disability Inclusive DRR Network for Asia, Handicap International, the Charter on Inclusion of Persons with Disabilities in Humanitarian Action and many similar organizations have been doing commendable advocacy work on disability inclusion in disaster risk management. However, it is difficult to find resources to assist people with preexisting acute mental illness who need psychiatric care in disasters and conflicts – especially in societies which lacked such resources prior to the emergency. For example, Handicap International’s Advocacy 2015 study report acknowledges that psychological impacts of disasters are the second most prevalent “personal impact of a humanitarian crisis”; nonetheless, the report largely talks about post-traumatic stress issues and not enough about preexisting mental illness, which may be exacerbated in a crisis setting. This omission highlights the fact that even more extensively developed measures for disability inclusion may overlook the unique protection needs of persons with pre-existing mental illness.

Indeed, the ambit of disability inclusion doesn't include protection needs of persons with pre-existing acute mental illness such as schizophrenia, depression, bipolar disorder, or others. While definition vary somewhat, the United States Centers for Disease Control and Prevention defines mental illness as “collectively all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.” Individuals with mental illness often face stigma and discrimination, are at risk for high levels of physical and sexual abuse, and in certain cultures may even be labeled as “crazy”. In some cases, loved ones take care of them; in other cases, they are cared for by paid or voluntary social workers or institutions. In extreme cases, they are restricted in mental asylums, where care and treatment varies. The vulnerability of this population is further exacerbated in disaster or conflict situations that may cripple their natural protection system of family and community. In such emergency settings, the increased risk of physical and sexual violence poses an additional protection concern for those with mental illness.

Many developing countries lack sufficient facilities for the care, protection, and treatment of persons with acute mental illness. For instance, in Malawi in 2013, there were just 0.37 beds for psychiatric treatment available per 10,000 people, and only 2.5 psychiatric nurses per 100,000 people. Furthermore, according to WHO’s Mental Health Atlas 2014, there is a paucity of epidemiological data on mental illness in Malawi. UNHCRs “Operational Guidance Mental Health & Psychosocial Support Programming for Refugee Operations” provides much-needed guidance on how to provide care and protection to people with mental health issues in refugee camps. There is an urgent need for widespread dissemination of such guidelines and enhanced capacity of the humanitarian system to take up protection needs of persons with pre-existing acute mental illness in humanitarian crisis situations.

A civilized society cannot abandon individuals suffering from severe mental illness, particularly in times of disaster, conflict, and other crisis situations. To assist people with acute mental illness, humanitarian agencies must focus on five fundamental objectives:

i. In the process of multi-sectoral needs assessment missions, identify and record the presence of individuals with acute mental illness in disaster affected communities. Some communities may not openly disclose the existence of mentally ill people among them, either due to ignorance or to stigma. As such, the multi-sectoral assessment teams should consist of one or more members who have sufficient orientation on mental health issues and skills to elicit information from communities. They should subsequently inform local mental health institutions or organizations so that they can provide care to these individuals;

ii. Identify individuals with acute mental illness as part of vulnerability mapping exercises in disaster preparedness programs;

iii. Identify a network of mental health institutions, organizations, and experts in the country who could be mobilized to assist people with acute mental illness in disasters. List those resources as part of disaster contingency plans;

iv. With support from these institutions and experts, train community volunteers in primary care, support and protection of the dignity of mentally ill people in disasters and conflict; and

v. Work with local governments to identify gaps, assist in the development of suitable policies to provide for the care of people with acute mental illness during humanitarian emergencies, and to improve local mental health facilities and capacities.

Humanitarian organizations must consciously pursue these objectives to ensure that persons with mental illness are traced, identified, and protected in the same way as other vulnerable populations are. Humanitarian agencies should augment resources and capabilities to better protect and provide psychiatric care for people with acute mental illness in humanitarian crisis situations. Most importantly, specific care and protection needs of people with acute mental illness should be brought into the scope of SPHERE Minimum Standards in Health Action and SPHERE protection principles related to preventing physical and psychological harm arising from violence and coercion. Finally, the care and protection of persons with acute mental illness must be pursued as a matter of the fundamental rights and innate dignity of these individuals.