Datuk Dr Andrew Mohanraj is in his room in Aceh in Indonesia, resting after a long day in the field, when he feels it - the first tell-tale signs of impending after-tremors that have become the norm here post-tsunami.
Instinctively obeying his training, he runs out of the door and down the stairs as the whole house heaves and shakes around him, his heart pounding, sweat streaking down his face.
When he turns around at the bottom of the steps, the stairs are gone.
*****
“You have earned yourself a place in heaven by choosing this field.”
That’s what Dr Andrew’s lecturer told him on the first day of his psychiatry housemanship.
Dr Andrew himself isn’t particularly sure about that, but he does know that since 24th December 2004, when the tsunami hit and he found himself surrounded by news reports and photos of the death and devastation it left in its wake, he knew he had to do something.
“It was really very upsetting for me,” he says, “so when the call came urgently looking for psychiatrists to work in Indonesia or Sri Lanka, I jumped at the chance. They wanted native Tamil speakers in Sri Lanka, and I thought, okay, that’s perfect.”
Unfortunately, he got turned down. “They wouldn’t let me go,” he says. “There was a shortage of psychiatrists - well, there still is - and we needed people here.”
He let it go and tried to get on with his work, but couldn’t get rid of a nagging feeling that he was meant to be doing more.
Then, destiny struck: “Three months later, the call came that psychiatrists were needed in Aceh,” he recalls.
“And this time I didn’t let it go. I begged my head of department to allow me the time away. And I think he got so irritated with my constant nagging that he allowed me to go for six months.
Six months later, I asked for an extension, so they gave me another year. And after that year, I asked for another extension, so they put their feet down and said ‘no.’ So I said ‘I quit.’”
This was how Dr Andrew kicked off his career in disaster psychiatry - probably one of the few, if not the only, disaster psychiatrist in Malaysia. “For me, Aceh was a complete eye opener,” he says.
“Most of what I studied - the formal Western education that teaches you the principals of psychiatry, of disaster-related trauma and the like - it just really didn’t make any sense when I got there.”
Initially, his job was organising psychosocial activities - basically any activities that help people get back to normalcy as quickly as possible. One of the favourite pastimes among the villagers was volleyball, so Dr Andrew and his colleagues took it upon themselves to organise a volleyball tournament among villages.
“It may sound crazy - who cares about volleyball when people need food and water and homes?” he says.
“But it helped people feel like their lives hadn’t quite been turned upside down, that there was something there still familiar and real.”
And as an added bonus, some who thought their family members had been swept up by the waves found them instead among the spectators or players of opposing teams, and rejoiced.
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In any post-disaster situation, whether one caused by man or nature, there is a segment of the population vulnerable to psychiatric or psychological distress brought about by the immense stress of dealing with tragedy.
But in addition to this, the group often forgotten are those with pre-existing conditions that could be exacerbated by trauma.
“People were cut off from supplies of medication, or cut off from access to mental healthcare,” says Dr Andrew.
“So we did see a lot of psychosis. And we saw a lot of substance abuse, which happens after every disaster.”
Even so, that wasn’t their biggest challenge.
“What was my biggest challenge was the fact that Aceh had very high numbers of people who were mentally ill and chained, physically restrained,” he says.
“In every village we went to, there were at least one or two people who were tied up, or locked up in a room, or even kept in a cage under a tree.”
After some probing, what he found was that this was not an act of punishment, but an act of love.
“Most of it is not punitive - people don’t want to punish their loved ones like that - but they have no choice, because there were episodes of aggression.
Some of the people who I treated had actually killed somebody, but thanks to a lingering fear of the police and military after the war 30 years prior, the villagers agreed that they wouldn’t take legal action – as long as they remain tied up.
One family I saw kept their son locked in a room, like a cage; yet, in his room there was a bed and a mattress, while the rest of the family slept on the bare floor because mattresses were a luxury they couldn’t afford.”
This, Dr Andrew knew, couldn’t go on.
“Antipsychotic medication was invented in the 1950s, and is so cheap at 15 or 20 cents per tablet at most. Yet in these global times, they still didn’t have access to this?”
Something had to be done. “If there was anything that I felt I had to do in my life, this was it,” he says. “These people had to be liberated.”
So he set about figuring out how to bring antipsychotics to Aceh. “The biggest challenge wasn’t making the medications available or even finding the neighbourhood volunteers willing to pass them out,” he says.
“The biggest challenge was convincing families and communities that these people, who had done some truly terrible things, needed to be untied and deserved to be forgiven.”
In this, his biggest allies were the ulamas, the religious heads who listened to his plans and told him to leave it to them.
In a society that clings to its faith like a balm against the ills of the world, to hear an ulama telling them to trust these doctors and allow them to try these medications was exactly the stamp of approval Dr Andrew needed.
“Then we went one step further and matched them with a livelihood, a way to earn some money,” he explains.
“Because without that feeling of self-worth, no amount of rehabilitation makes sense. One of his patients spent eight years in chains; now, he takes his medication regularly and works in a saw mill.
And the saw mill owner is the one who makes sure he takes his medication!”
These, says Dr Andrew, are the cases that make it all worth it.
“These people are still unchained and still living their lives. Whenever I go back, since I still advise both the provincial government in Aceh and the Ministry of Health in Jakarta on psychiatric services, I always make it a point to stop by and say hello.”
*****
After about 10 years spent going back and forth between Aceh and Kuala Lumpur, Dr Andrew was eventually called home. But his career in disaster psychiatry was far from over.
His services were called upon time and time again in the wake of the region’s most devastating events: the Padang earthquake, the volcanic eruption in Jogja, post-war Timor Leste and post-typhoon Haiyan in the Philippines.
Then came MH370.
On the 8th of March 2014, in a case that rocked Malaysia - and the entire world - the Malaysian Airlines flight carrying 239 people from Kuala Lumpur to Beijing disappeared without a trace.
Amidst all the confusion and the heartbreak, the government realised that families and loved ones of those on board would need some help to get through these strange, horrifying times. They called Dr Andrew.
“In the immediate aftermath of a disaster, the first thing we usually provide is psychological first aid, or PFA,” he says.
“The principles of PFA are to listen, to ensure basic needs are provided and to give reliable information as much as possible. In most cases, people will feel better after a few sessions.”
Others, especially considering the fog of uncertainty that surrounded MH370, would develop prolonged symptoms and issues suggestive of developing depression.
“For these,” he says, “a more frequent, deeper intervention was required. I had to refer some of them to see a psychiatrist in their respective countries as they continued to be psychologically distressed despite the PFA and the subsequent counselling sessions.”
The biggest challenge was actually making sure families continued to get the help they needed in the weeks after the plane disappeared.
“One-time contact is not very useful and can also be counter-productive at times,” says Dr Andrew.
“But following up was a real challenge after the families left the Everly Hotel and went back to their homes in their respective countries.
I followed up with telephone calls just to provide an opportunity for those affected to talk.”
Even now, after more than a year has gone by, he warns of long-term effects like clinical depression or anxiety disorder.
“Those who survived a disaster or a major catastrophe may themselves develop Post Traumatic Stress Disorder,” he says.
PTSD is a chronic long term psychological situation in which a person has persistent low mood, is easily startled by noise, avoids situations or places that reminds the person of the catastrophe, and constantly relives the situation in their dreams and nightmares.
Research suggests that the prevalence of PTSD among direct victims of disasters is 30–40 per cent, the prevalence among rescue workers is approximately 10-20 percent, and the prevalence in the general population is approximately 5-10 percent.
Strangely, while he is often called upon by other governments for his expertise, MH370 remains the only time to date the Malaysian government has asked for his help.
“I have offered my services to the National Disaster Council, but so far I have not been called to offer my expertise to the council,” he shrugs.
“Strange, because after the floods in Johor many years ago and lately after the Kelantan floods, I would have thought that psychosocial needs would have been highlighted.”
*****
Of course, working in areas struck by disaster - whether natural or man-made - isn’t without its dangers.
In the aftermath of Aceh, where after-tremors reverberated through the area for months afterwards, there were often instances where life had to stop for a moment as people sought shelter.
On the day Dr Andrew saw the staircase disintegrate before his eyes, he wondered if he had done the right thing.
“I was really shaken up,” he confesses. “I seriously considered coming back. But I got over it. It became routine.”
These are the stories he never told the family waiting for him back home.
“They actually bought the story that I was just going out there for six months,” he says.
“After I told them I was staying for another year, there was a lot of disappointment. Then I started going into other disaster-hit areas, and I think they just gave up.”
This, he thinks, plays a large part in why disaster psychiatrists in the region are so hard to come by.
“This is a branch of psychiatry that takes you away for home for long periods,” he says,
“And often in situations with very basic necessities, where there can be a lot of security concerns. It’s often not monetarily rewarding, compared to a psychiatrist in private practice, for example.
And there isn’t a clear career pathway as there are for those in government service. I wish there were more of us who could lend a helping hand to those in need.”
“Of course every now and then there is fear. But really, at some point in life you have to leave it to the hands of destiny.”
GILA: Who cares for the caregivers?
This is just one of the many stories featured in ‘GILA: A Journey Through Moods & Madness’ – an exploration of the landscape of mental illness in Malaysia through the personal narratives of patients, caregivers, psychologists, psychiatrists, volunteers and advocates.
Get your copy now at GerakBudaya, or online at www.gbgerakbudaya.com.
