Episode 120      25 min 02 sec
Mental health strategies in post-crisis Sri Lanka

Psychiatrist Prof Harry Minas, A/Prof Daya Somasundaram, and Dr Palitha Mahipala discuss the mental health landscape in Sri Lanka after decades of armed civil conflict and recent tsunami devastation. With host Jennifer Cook.

"If someone is in a very dysfunctional family, or in a community which has been fragmented either by natural disaster or a other means, then you can do all you like about individual treatment of that person’s mental health problems but you are not really going to get very far." -- Associate Professor Harry Minas





           



Associate Professor Harry Minas
Associate Professor Harry Minas

Professor Harry Minas graduated in medicine and surgery, and medical science, from the University of Melbourne, and was elected a Fellow of the Royal Australian and New Zealand College of Psychiatrists in 1985. In 1988 he was invited to take up the position of foundation director of the Victorian Transcultural Psychiatry Unit. He has served as a member of the Executive of the Mental Health Council of Australia and on numerous state, national and international boards and committees, and has been a member of state and national ministerial advisory groups. He has led the development of research, teaching and service development activities in the area of transcultural mental health and in the field of international mental health development. He has been a consultant to the Commonwealth Department of Human Services, the International Organization for Migration, and the World Health Organization, and leads a WHO Collaborating Centre for Mental Health and Substance Abuse. Prof Minas was recently appointed to the WHO International Panel of Experts on Mental Health and Substance Abuse.

Assoc Prof Daya Somasundaram
Assoc Prof Daya Somasundaram

Daya Somasundaram was a Senior Professor of Psychiatry at the Faculty of Medicine, University of Jaffna and Consultant Psychiatrist working in Northern Sri Lanka for over a decade. He has also worked in Cambodia for two years in a community mental health programme with the Transcultural Psychosocial Organization. Apart from teaching and training a variety of health staff and community level workers, his research and publications have mainly concentrated on the psychological effects and treatment of disasters including the long-term effects on communities. He is now writing a sequelae to his earlier book, Scarred Minds, that concentrates more on how families and communities are affected by trauma.  He is a Fellow of the Royal College of Psychiatrists, UK and Royal Australian and New Zealand College of Psychiatrists. Currently, he is working in Australia as a consultant psychiatrist at Glenside Hospital, and Clinical Associate Professor at the University of Adelaide. For the last two years he has been associated with STTARS in Adelaide, helping refugees and asylum seekers who have survived torture and severe trauma.

Dr Palitha Mahipala
Dr Palitha Mahipala

Dr Palitha Mahipala is Additional Secretary for Health Services in the Sri Lanka Ministry of Health

Credits

Host: Jennifer Cook
Producers: Kelvin Param, Eric van Bemmel
Series Creators: Eric van Bemmel and Kelvin Param
Audio Engineers: Gavin Nebauer
Voiceover: Nerissa Hannink
Transcription: Andy Fuller

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Mental health stratgies in post-crisis Sri Lanka

VOICEOVER
Welcome to Up Close, the research, opinion and analysis podcast from The University of Melbourne, Australia.

JENNIFER COOK
I’m Jennifer Cook, thanks for joining us. How does a nation, ravaged by three decades of civil war and then subjected to a devastating tsunami rebuild not only its infrastructure, but the lives of its people? This is the enormous task facing the Pearl of the Indian Ocean, the island nation of Sri Lanka. The war may have ended in 2009, but the long term impact on the nation – over 300,000 people were displaced during the conflict – is still being measured on a day by day basis. The Seventh International Mental Health System Development Conference held recently at The University of Melbourne asked what is being done, what more can be done, and how can we ensure that the help reaches those most in need of mental health service? These are all vital questions for a country that has the highest female suicide rate in the world and only one psychiatrist for every 500,000 people. But even in the face of such overwhelming statistics, our guests today believe that improvements are being made, programs are being implemented and there is a way forward in making sure appropriate effective and affordable health services are available to all of the Sri Lankan people. Joining us on Up Close is the Director, Centre for International Mental Health, Melbourne School of Population Health here at The University of Melbourne, Prof Harry Minas. He is joined by Dr Daya Somasundaram who is a senior professor of psychiatry at the University of Jaffna and has worked in northern Sri Lanka for over a decade. He is the author of a paper that has gathered a number of eyewitness accounts detailing the horrors faced by many Sri Lankans. Daya is currently a consultant psychiatrist and Clinical Associate Professor at the University of Adelaide. Also with us is Dr Palitha Mahipala, he is the Additional Secretary for Medical Services for Sri Lanka’s Ministry of Health. Gentlemen, thank you for joining us.

HARRY MINAS
Thank you.

PALITHA MAHIPALA
Thank you.

DAYA SOMASUNDARAM
Thank you.

JENNIFER COOK
Daya, I’d like to begin by asking you, if you would, by reading out one of the eye witness accounts from your paper ‘Collective Trauma in the Vanni: A Qualitative Inquiry into the Mental Health of the Internally Displaced due to the Civil War in Sri Lanka’.

DAYA SOMASUNDARAM
Sure. Mullivaikal became very scary. Our environs were hit by multibarrel (40) shells. We did not know what was happening. The surrounding palmyrah were burning. I fell without realization. After a few moments, I look around. Everywhere there was oppari, meaning wailing. The elder in the next shack was killed while eating. I had just talked to him. He had said that he had not eaten in
the morning, due to shortage of food; only at midday. I had seen the 14 year old female child next door cooking a rotti. It was around 12 noon. The shells hit at around 1 PM. The white rice the elder was eating had turned red. One of the rotti’s that the child had been cooking was thrown on top of our torn tharappan roof. The child’s abdomen had been torn asunder and was eventually sent by ship to Pulmoddai. Deaths became common. Some died inside the bunkers. They would then all be simply buried therein.

JENNIFER COOK
Daya, thank you for that. How did you go about collecting these accounts? And, in what ways was this man’s experience indicative of what others in the region experienced?

DAYA SOMASUNDARAM
Well, these accounts were taken from survivors and those who managed to come into the camps within a few weeks and months after they arrived there. So, in a way it is reflective of what people went through during those final months when they had to flee, the shelling and the bombing and the fighting that was going on and tried to get out of the areas of fighting.

JENNIFER COOK
In light of these accounts and the obvious trauma, that the people of Sri Lanka have experienced what is the way forward? What are we dealing with here?

DAYA SOMASUNDARAM
We are dealing with I guess several issues that need to be addressed. There is an immediate need to help them settle down, to calm them, to come back to a sense of reality where they can continue with their daily life. So, they need a lot of support, in that sense. And then in the longer term they need to come to terms with what has happened and then start rebuilding their lives. That may take a little more effort and resources to help them to go back to their homes and then to provide the services there. And then to provide them with the where-with-all to re-start their lives. So, that may include economic, include educational services for their children, may include health services, may include the whole infrastructure that we usually consider important, basic in any community.

JENNIFER COOK
Prof Minas what can you tell us about your work in Sri Lanka and does your experience with the Sri Lankan people support Daya’s first hand account?

HARRY MINAS
Our work in Sri Lanka was following the tsunami in late 2004. Our main focus was in the south of the country, in the southern province and our intent was to contribute to the development of mental health services that could respond to the many losses that people had experienced as a result of the tsunami. What we found was, in working with our partners was, with World Vision Australia, with the World Health Organisation, what we found was a remarkable capacity to innovate in the context of very difficult circumstances including very limited resources.

JENNIFER COOK
And where did you think that comes from, innovation?

HARRY MINAS
Well, I think it is clear that the Sri Lankan people are very resilient. They’ve dealt with very difficult circumstances of many kinds in the past. I think people are able to make a great deal out of very little in terms of resources. And I think there is a sort of creative flair which has become apparent in these difficult circumstances, that I think has been quite remarkable.

JENNIFER COOK
It is interesting what you said, if you frame it in terms of three decades of civil war and then the tsunami, it really raises the question of, what is normal life?

HARRY MINAS
Well, as we know there are many parts of the world where the challenges we in Australia and places like the US and so on would find difficult to imagine. We also do a lot of work in Indonesia. The frequency of natural disasters is unimaginable in Indonesia. And it is similar where there are situations where there has been civil unrest, conflict. So that I think all of that in a sense is normal life. But with particular, very severe challenges. In the context of those challenges I think people learn to do a great deal more and probably more than many of us can imagine.

JENNIFER COOK
And, can you give us some examples of the programs that have been implemented and what is working on the ground there?

HARRY MINAS
I think a great deal is working on the ground and if you look, the tsunami had an impact right across the Indian Ocean. But, I think what distinguished Sri Lanka was that a number of very new approaches to providing services in very resource poor environments were established. Now, they didn’t come out of thin air. That kind of innovation had been happening for quite a long time and a number of people, a number of very talented and committed people working in the north for instance, in the east, Dr Ganesan and a lot of other people who had been providing services in very resource poor environments came to the fore and really started to build the kinds of services that we talk about here in Australia, but that you can actually see in Sri Lanka. What I mean by that is the importance of fully engaging the community in providing support assistance, understanding. Thinking about the role of not only highly trained professionals, but also of community volunteers and others, who with relatively little minimal training can make a remarkable contribution to making a system work.

JENNIFER COOK
This idea of building from the ground up.

HARRY MINAS
Yeah.

JENNIFER COOK
This is Up Close, coming to you from The University of Melbourne, Australia. I’m Jennifer Cook. Our guests today are Prof Harry Minas, Dr Daya Somasundaram and Dr Palitha Mahipala. And we are talking about the provision of mental health services in Sri Lanka. Now, Daya, in your article you say the western mental health model’s sharp focus on the individual is not necessarily the best way forward to help the Sri Lankan people. Instead, you are calling for strategies that take into account the effect the trauma has had on the family, the village, and the community on the collective consciousness of a nation, if you will. Why do you think this is the more effective path to take?

DAYA SOMASUNDARAM
Well, it is a different way that the community functions, not in a different way but I guess it is something we call a collective stick community. The family for example is very central to how a person looks on the world and how he experiences himself, experiences his well-being. And in a way the way they respond to something that happens like the trauma to a person the family responds. Once there has been such a massive trauma the family is affected in many ways. There are separations; one member of the family may be killed. So, if we can direct our efforts to rebuilding the family, the unity, the family dynamics, the family understanding, then the individual is taken care of within the family. The family will do the healing and they may not need an oriented type of therapy that we usually do in the western system of having the individual, say, come in for cognitive therapy or medication. The family themselves will through their interaction and relationship help the person get back to normal functioning.

JENNIFER COOK
It seems like bricks in a wall, doesn’t it? You have the individual, the family, the community. Prof Minas would you agree that the health of the individual unless they are surrounded by safe structures, unless they’re feeling safe, all the mental health in the world isn’t going to…

HARRY MINAS
That is absolutely right. What we are talking about is mental well-being, the ability of people to live a normal life. You know, to function well in relationships, in work, in education. For that to happen, there has to be a context that allows those things to occur and that enables and supports them to occur. Now, if someone is in a very dysfunctional family, or in a community which has been fragmented either by natural disaster or a other means then you can do all you like about individual treatment of that person’s mental health problems but you are not really going to get very far. And, I think particularly in a community where peoples’ sense of themselves is a much more collective one. “Who I am” is kind of the same as “who my family is”. Something bad happens to me, it happens to all of my family. “I do something wrong and it doesn’t only reflect on me, but it reflects on all of my family.” So this very connected way of being, makes it even more important that the kinds of approaches that Daya is talking about are taken in recovery from these terribly events that have happened in Sri Lanka.

JENNIFER COOK
Palitha as Additional Secretary Medical Services Sri Lankan Ministry of Health, do you share Daya’s view of what these communities are undergoing? And could you give us an overview of what programs are being set up in Sri Lanka?

PALITHA MAHIPALA
Well, as it has been mentioned already, Sri Lanka had to face two devastating situations. One is [the] tsunami in 2004, where most of the coastal areas including northern, eastern and southern parts of the country has been affected. And of course, many measures have been taken by the government with the other countries and national and international non-governmental organisations to restore the situation. And the measures have been taken to do that within a very short time period. And then the other situation is the conflict situation which has come to an end now. And I would like to state the visionary leadership given by His Excellence, the President, Mr.Mahinda Rajapaksa. And he has clearly mentioned that the development of northern and eastern provinces is being identified as top priority in the development agenda of the government. And over the last two years there were a lot of infrastructure development taking place and also many emphasis has been focused on development of human resources infrastructure, road and many things in the northern and eastern provinces. Coming to the particular topic about mental health, as it has been defined by the World Health Organisation, health has been recognised as a state of well-being – physically, mentally, socially and spiritually. So, which clearly elaborate[s] the involvement of the mental health aspect as well so, we need not to really talk separately about the mental health. Health itself clearly recognise the importance of that mental aspect as well.

JENNIFER COOK
So, you have just said to us that mental health is part of an overall state of well-being.

PALITHA MAHIPALA
That is right. So, therefore measures being taken by the government to develop the infrastructure, the education, social services and many other sectors which need to be strengthened to achieve the state of well-being of the people. So therefore I think the government of Sri Lanka has over the last two or three years has focussed attention, not only on health but also the general well-being of the people. Even this budget re-allocation, health has been recognised as, in a very high place. The third highest budget re-allocation is to health. The second highest budget re-allocation is for the infrastructure development of the country where the major chunk of money is being diverted to northern and eastern provinces. Eastern provinces already has been developed to a great extent. And now our attention has been more focused on the northern province. So, health, I think the new concept is being considered as a part of [the] development agenda, to see that the northern part is being normalised within a very short time period.

JENNIFER COOK
And as additional secretary medical services Sri Lanka’s Ministry for Health, it is an enormous responsibility, what are you going to be doing?

PALITHA MAHIPALA
Well, of course I have been involved in this these last two or three years, the conflict time has well, you know, I was visiting almost every weekends the with the time of a high officials from the Ministry of Health to see that, what is the best we could do for the people in the northern part of the country and eastern part of the country. And we were able to provide, I think, a very much better health care services, compared to many other countries which have been affected by conflict situations. During even the internal displaced people were gathered in you know few areas where the Ministry of Health was able to mobilise the medical officers, medical specialists, other health care staff, all within a very short time period and was able to provide a very comprehensive and quality care service to them. And we were able to establish infrastructure for hospitals within a very short time period. The clinic centres have been built up so that the comprehensive care was provided. And I was thoroughly involved with that. And still the main priority of the health ministry in Sri Lanka is to see that the infrastructure, human resources, equipment, drugs, whatever needed to ensure provision of a quality and comprehensive health care services to be provided to the people in the northern and eastern provinces. I think we have achieved that target up to a certain extent. And of course I am very much grateful to the government of Australia, and especially the International Centre for Mental Health, headed by Prof Minas where they have extended enormous support to us in restoring the mental health services in those areas as well as after tsunami.

JENNIFER COOK
You’re listening to Up Close coming to you from The University of Melbourne, Australia. I’m Jennifer Cook. We’re talking about the provision of mental health services in Sri Lanka. And we are joined by Prof  Harry Minas, Dr Daya Somasundaram and Dr Palitha Mahipala. Harry, I wanted to ask you, just what do universities, such as The University of Melbourne, bring to the table? We’ve talked about the importance of forging partnerships, you’ve mentioned World Vision, and the Victorian State Government, has even funded research which is quite unusual for a state government to get involved in international affairs.

HARRY MINAS
It is unusual. And it was in the post-tsunami period that the Victorian State Government provided funding that allowed us, together with World Vision and WHO to do the work in the southern province but it is worth saying a few words about what an institution like The University of Melbourne can do. And of course, The University of Melbourne is not the only such organisation that has been involved. There have been many from many different parts of the world that have made contributions in Sri Lanka. There is a body of experience of, of course different, but somewhat similar organisations that can be brought into the discussion about what is the best way to go. It is also a privilege for an organisation like The University of Melbourne to be asked to contribute in this way because we learn a great deal from that contribution. I mentioned before that some of the approaches that are being taken to community mental health in Sri Lanka, we could learn a lot from in Australia. That is very true. I think if you look at the mental health policy that was promulgated by the ministry in 2005, I think it is one of the very best mental health policy documents that you could find pretty much anywhere. It is very comprehensive. It is focused on the right things. It does contain an implementation plan. It is not just a statement of intent. But it is also a plan of action. So, there are many things about the approach that have been done in Sri Lanka that I think are very useful also for other countries that are struggling with many of the same issues in terms of developing high quality services. Or moving from institution-based to community-focused care. So, one of the things that we as university can do is that we can approach this work in a reflective way. We can contribute to research. But we can also contribute to dissemination of the very best ideas from Sri Lanka or from Indonesia or from wherever. So that when a task like this is faced that the best evidence can be brought to bear on what is the most appropriate way to go. We can also say, okay, this is our intention, how are we actually doing in achieving this intention? So, monitoring any evaluation strategies for these kinds of policy approaches. The key thing to say is that the involvement of an organisation like The University, in this kind of work, is a process of mutual benefit.

PALITHA MAHIPALA
As you said, there have been many universities all over the world who have had collaboration with the government of Sri Lanka, Ministry of Health, for the restoration of the normal health service, to the people, you know, who have been affected by the conflict as well as tsunami. So all of them should be appreciated. And particularly The University of Melbourne for the excellent services they have rendered. And as Prof Minas said, it is of benefit to both parties. And sharing of experiences is always important. And it is exciting.

JENNIFER COOK
Daya, I’d really like your views on the way you see forward for Sri Lanka.

DAYA SOMASUNDARAM
Well, I think there is an opportunity to be grasped here. The country has gone through this calamity after the tsunami and this big war. The actual fighting has come to an end, it is a time that if it is grasped, particularly in the areas that were directly affected like Mullaitivu and Kilinochchi which are in northern Sri Lanka. Almost we can describe it like ground zero, where everything has been destroyed. Everyone was displaced and they have lost almost everything. If things can be rebuilt and re-done using the best evidence and what has been done in other post-conflict areas with contributions from The University of Melbourne and experiences elsewhere in the world, in the way that builds an equitable society where people don’t feel left out, where some of the problems that were there earlier for the conflict can be sorted out. And an opportunity given for the healing of memories and for people to come to terms with what has happened. And then the opportunities provided for their future, for their employment, for their education, for them to move forward. I think it would be a good example of how an area that has been affected by calamity can come out and what can be done and how the situation can be restored. So, I think there is a great opportunity that we can grasp. And I think it would be a great example for so many people around the world, that things can be done in a very positive way.

JENNIFER COOK
So, you are hopeful?

DAYA SOMASUNDARAM
Yes, I am hopeful.

JENNIFER COOK
Gentlemen, thank you so much, for joining us here today. And for taking the time to discuss what is a very challenging topic. Thank you.

HARRY MINAS
Thank you.

DAYA SOMASUNDARAM
Thank you.

PALITHA MAHIPALA
Thank you.

You’ve been listening to Up Close and I’ve been speaking with Prof Harry Minas, Dr Daya Somasundaram and Dr Palitha Mahipala about the issue of providing mental health services to Sri Lanka. Relevant links, a full transcript and more info on this episode can be found at our website at upclose.unimelb.edu.au. Up Close is brought to you by Marketing and Communications of The University of Melbourne, Australia. This episode was recorded on the 28th October, 2010 and our producers were Eric Van Bemmel and Kelvin Param. Audio engineering by Gavin Nebauer. Up Close is created by Kelvin Param and Eric Van Bemmel, I’m Jennifer Cook, until next time goodbye.

VOICEOVER
You've been listening to Up Close. For more information visit upclose.unimelb.edu.au. Copyright 2010. The University of Melbourne.


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