Mental health needed for caring capacity

By Saskia van der Kam

Kaz de Jong and Maureen Mulhern also contributed to this article.

Saskia van der Kam is the headquarters nutritionist in MSF Holland. Kaz de Jong, is a psychologist in HQ MSF Holland. Maureen Mulhern carried out the survey on Post Traumatic Stress Disorder (PTSD) in Freetown Sierra Leone in May 1999.

The UNICEF Framework of Underlying Causes of Malnutrition and Mortality identifies three underlying factors that influence nutritional status: food security, mother and childcare, and public health (see figure 1). In this essay, I want to discuss one aspect of the social / care environment in emergency interventions which I believe is often overlooked in emergency interventions and which my branch of Medecins Sans Frontieres has begun to address since 1990. Médecins Sans Frontières, is traditionally an emergency health organisation whose interventions focus on improving the health environment of emergency affected populations.

When the conceptual framework was presented in the 1980s the social/care environment component was very mother and child health-focussed. It drew attention to the need for specific programmes to address malnutrition, like growth monitoring, improving weaning practices and strengthening health education. However, emergency organisations began to broaden the concept of caring practices so that it included factors and processes that influenced the level of care given by, and to, any member of a household. A household was to become conceptualised as an economic and social entity. Additionally, caring practices were seen to operate at the level of the community rather than just at household level.

This article considers the importance of mental health programmes after emergency events in relation to the care environment at household and community level. It draws a direct link between the mental state of emergency affected populations and care provision at household and community level and argues that nutritional status is often influenced by the mental health of emergency-affected populations. The mental health of individuals can affect their ability to provide care for dependants. In addition a mentally traumatised individual may him/her-self require care. This can be a significant burden on the time and resources of the other family members. A reduced capacity to care for dependants will have repercussions for the physical and nutritional state of these dependants. In order to be able to address malnutrition in a community effectively it is therefore important to determine the extent of mental trauma in a community and its significance as a public health problem.

When an emergency is over, it may appear that populations can resume their normal economic and social activities. However, the psycho-social and mental health consequences of war on civilians may remain and are all too often neglected. Even after hostilities cease, the war may continue in people's minds for years, decades, or perhaps even generations. To address only the material restoration and physical needs of the population denies the reality of shattered emotional worlds; ignores the broken basic assumptions of trust and benevolence between human beings and leaves unaddressed the corrupted moral and spiritual consequences of war.

After an event (or series of events) people can have symptoms of traumatic stress. This is a normal psychological reaction, which helps the person to deal with the event. Traumatic stress symptoms often disappear after a while. Post Traumatic Stress Disorder (PTSD) is said to occur when these symptoms do not disappear. Symptoms of PTSD include flashbacks, nightmares, re-living the events as well as avoidance of situations, places, conversations or people that remind them of the events.

Mental health and psycho-social programmes can greatly contribute to the alleviation of the suffering of people in war and disaster-stricken areas. In these programmes key people in the community are trained to recognise symptoms of traumatic stress as well as Post Traumatic Stress Disorder. The people who have these symptoms are treated with group therapies which are guided by local health professionals who have in turn been trained by professionals.

In Sarajevo in 1994 MSF health teams observed that the health clinics were confronted by large numbers of people with psycho-somatic complaints; physical symptoms like headaches, stomach problems, general body pain, dizziness or palpitations. Recognition of the association between traumatic stress, PTSD symptoms and these complaints triggered the development of the community based mental health programmes.

MSF is developing a tool to measure the level of traumatisation in a community. The technique is based on a simple questionnaire using nutrition survey sampling techniques.

Mental health effects of conflict in Freetown, Sierra Leone

The first time MSF tried to assess the extent of PTSD in a community was in Freetown, Sierra Leone in May 1999. Five months earlier in the year, in January 1999, the population of Freetown had faced severe traumatic events related to the escalation of a long lasting conflict between several armies. The population was brutalised and terrorised. Based on health and nutritional survey design, a two-stage cluster sampling method was used. The sample consisted of 30 clusters of 8 respondents. Eight respondents per cluster was believed to be sufficient as the intra-cluster variation was anticipated to be reasonably small given that most traumatic events take place at community level and not on an individual level.

The responses to questions about experienced events showed that a high percentage of the population had experienced several events: 99% of those surveyed suffered some degree of starvation, 90% witnessed others being wounded or killed, and at least 50% lost someone close to them. The intensity of the fighting was demonstrated by the percentage that experienced direct consequences of the battle: 73% endured destruction of their homes, 62% the burning of their property while 65% endured shelling. Many were physically harmed: 7% had suffered amputation while 39% had been 'maltreated'. Just over half of those surveyed had witnessed torture, 41% had seen executions and one-third had observed (attempted) amputations.

Those surveyed were asked to indicate which events had been most disturbing to them. Surprisingly, it was starvation which was singled out as most traumatic (21%), followed by burning of house (17%) and possessions (13%). These experiences are life threatening and either occur over a long period or have a long-term impact.

The survey which was implemented among respondents from all suburbs of Freetown, found high levels of traumatic stress among the population. Using western measurement standards, 99% of the population had suffered traumatic stress. Even when the criteria for defining traumatic stress was raised to twice the cut-off level used for European populations, a quarter of the population would have been identified as suffering from traumatic stress in Freetown.

The 'physical health' findings on those surveyed only served to confirm the extent of the problem. Traumatic stress associated with physical complaints, like headache (39%) and body pains (12%), were reported most frequently while the percentage of respondents visiting health facilities was relatively high (42%).

The high levels of traumatic stress and PTSD indicated a clear need for psychosocial or mental health interventions to address the needs of the survivors of violence in Freetown.

A population that is psychologically healthy can prosper and overcome events of the past. Psychologically healthy people can also solve their disagreements in less violent ways. Helping traumatised people is a matter of restoring the social bond between the individual and surrounding family, friends, community and society.

Traumatisation of a population can dramatically alter caring practices during and after an emergency. Social and caring behaviour can have a critical impact on the nutritional wellbeing of dependants following an emergency when physical resources are no longer a limiting factor. Additionally, a society needs to be mentally healthy to make optimal use of the 'rehabilitation' resources made available by agencies in the wake of an emergency in order to improve nutritional and food security, e.g. agricultural programmes, nutritional education, etc. Clearly it is not the role of the nutrition community to develop expertise in mental health during emergencies. However, given the general acceptance of the UNICEF conceptual framework for causes of malnutrition and the importance of the caring environment, nutritionists and other health workers should recognise mental trauma as an important component of care needs and therefore advocate assessment of mental health status and relevant interventions where appropriate.

For further information contact: Saskia van der Kam at: saskia_vd_kam@amsterdam.msf.org