Humayun et al. Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Asma Humayun, Nadia Azad, Israr ul Haq, Faisal Rashid Khan, Ambreen Ahmad & Rai Khalid Farooq Following armed con£ict in the North Waziristan Agency, a mental health and psychosocial support Key implications for practice initiative was launched for internally displaced per- Humanitarian crises provide oppor- sons in Bannu, Pakistan. This was convened by tunities for collaboration between volunteer mental health professionals, in collabor- mental health professionals and ation with a variety of agencies (provincial govern- humanitarianagenciestostrengthen ment, military, humanitarian agencies) in a existing services security compromised region. As part of the initiat- Estimates of common mental dis- ive, monthly camps were held for a period of six orders in an IDP population have months. Mental health needs wereassessed. Amulti- been found, with 60% of this mor- disciplinary team (psychiatrists, psychologists, psy- bidity existing before displacement chiatric nurses and psychosocial workers) o¡ered There is a dire need for a public mental health care to 680 people who attended the mental health approach to address camps, of which 28% were under the age of18 years the existing burden of mental dis- old. Twenty-one percent returned for follow-up, orders while others were followed-up in the community by psychosocial teams. Estimates of common mental disorders were found. Both pharmacological and and Afghanistan on the other. It is part of a psychological treatments were o¡ered, according to Federally Administered Tribal Agency existing guidelines. Active e¡orts were made to (FATA), which refers to a semi-autonomous conduct holistic assessments and avoid a pure region under the control of the federal gov- biomedical approach. This also provided an ernment through a special law called Fron- opportunity for training non specialist sta¡ and led tiers Crime Regulations (FCR). This to formal (World Health Organization) mental region is known for its di⁄cult terrain and healthgapactionplan training forprimarycaresta¡. old, virtually unchanged tribal lifestyle termed as pashtunwali, where a jirga is Keywords: internally displaced persons, consulted for disputes. Parochial structures mental health, Pakistan and arcane traditions have tended to disre- gard health needs, especially for vulnerable segments of the population, such as women Introduction and children. As a result, formal health Background facilities are scarce, which barely cover basic Pakistan has had its share of con£ict related healthcare needs. (United Nations O⁄ce trauma. This is especially true for the North for Coordination of Humanitarian A¡airs Waziristan Agency (NWA) in the north wes- (OCHA), 2014). Traditionally, the majority tern part of Pakistan, adjoining the province have been highly sceptical and sometimes of Khyber Pakhtunkhwa (KPK) on one side hostile in terms of western medicine, Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.33 Mental health and psychosocial support for the internally displaced persons in Bannu, Pakistan Intervention 2016, Volume 14, Number 1, Page 33 - 49 particularly vaccines. The impact of such contributed signi¢cantly towards mental hostility is re£ected in the fact that NWA health problems in Afghanistan, a neigh- reported the highest number of polio cases bouring tribal region (Miller, et al., 2008; among all the districts of the world in 2014 Panter-Brick, et al., 2009). Additionally, a (USAID, 2014). However, there has been a high prevalence of common mental dis- growing awareness and acceptance of wes- orders has also been reported in the tribal tern medicine in recent years, with most regions of Pakistan and Afghanistan people beginning to travel to other cities in (Cardozo, et al., 2004; Scholte, et al., 2004; KPK for specialised care. Mufti, et al., 2005; Hussain, Chaudhary, Due to a non existent, non functioning border Afridi,Tomenson, & Creed,2007.These rates with Afghanistan and a predominantly are nearly twice as high as reported else- Pushtun population, NWA and its adjacent where in Pakistan (Mirza & Jenkins, 2004) territories have su¡ered over two decades of and much higher than other developing incessant con£ict, social service neglect and countries facing con£icts andtherefore, need unmitigated humanitarian fallout. Militants to be interpreted carefully (Bolton & Betan- frequently spill over from adjoining areas of court, 2004; Ventevogel, 2005). Similarly, a Afghanistanintotribalagenciestotakerefuge, high rate of psychiatric morbidity have also and vice versa. The unending nature of the been reported in Afghan refugees (Kassam armed con£ict and violence has led to pro- & Nanji, 2006; Naeem, et al., 2005. A found adversity with reference to mental previous armed con£ict with the Taliban in health care inthe region (Khalily,2011).From 2009 displaced three million people in 2007,untilquiterecently,therewasanongoing KPK, Pakistan. Mujeeb (2015) found signi¢- armedcon£ictinNWAthatwas¢nallyhalted cant levels of psychological distress in that by a military operation started in June 2014. population, but the estimates of common Operation Zarb-e-Azb led to mass civilian mental disorders in internally displaced evacuation so that terrorists could be ident- persons (IDP) in Pakistan have not been i¢ed and targeted through land and air documented. attacks. As a result, over one million people (74% women and children) were displaced into the neighbouring district of Bannu, in Mental health care in Bannu KPK (United Nations High Commissioner The district of Bannu had an indigenous for Refugees, (UNHCR),2014) population of one million. For the two million people now residing in Bannu, cur- rent mental health services are limited to a Mental health and displaced single psychiatrist, with mental healthcare populations in the region not prioritised in Pakistan, as in many other A consequent rise in common mental dis- low and middle income countries (LMIC) orders in post con£ict/displaced populations (Saxena, Thornicroft, Knapp, & White- around the world is well established (Salah ford, 2007). Additionally, the country lacks et al, 2013; Turnip, Klungsoyr, & Hau¡, a mental health policy since the devolution 2010; de Jong, Komproe, & van Ommeren, of health responsibility to the provincial 2003). At the same time, the lack of capacity governments in 2011. Despite repeated of over burdened countries to respond to emergencies, only fragmented and sporadic mental health needs of con£ict related, dis- e¡orts have ever been made in terms of placed populations is also well documented developing an emergency mental health (Quosh, Eloul, & Ailani, 2011). Evidence response, disseminating training, involving suggests that in addition to war related con- stakeholders or advocacy at a national level. £icts, daily stressors and traumatic events The disaster/emergency preparedness plan Copyright34 © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Humayun et al. for mental health has also been defunct considered unsafe. As a result, community since 2006 (World Health Organisation based activities were extremely hard to (WHO),2009). coordinate/conduct. As a result, mental health services in Bannu While it was clear that such an emergency are typical of those o¡ered in most other situation required immediate attention peripheral districts in Pakistan (Bolton, in order to address mental health care 2013). The role of a psychiatrist tends to be needs, the key question remained: whose narrowed down to clinical responsibilities responsibility was it to coordinate any even in a tertiary care hospital. That, too, initiatives? The government (Health focuses mainly on a biological model of prac- Department & Provincial Disaster Man- tice of psychiatry. Bannu had a teaching agement Authority) was struggling to pro- hospital comprised of one professor of psy- vide basic needs to IDPs, so any additional chiatry with no other faculty to support agenda was a burden beyond their capacity. him. Despite an academic title, the job Mental health professionals have no pre- description is very much non academic, with scribed responsibility beyond their depart- pronounced administrative and medico^ ments. The military had the expertise, but legal responsibilities that compromises had no precedence to provide psychosocial clinical care. Additionally, there were few support to a civilian population. National teaching/training activities conducted by nongovernmental organisations (NGOs) the department. do not have the capacity, nor the expertise, Therefore, most people with mental to address the issues, while international disorders sought private consultations (pro- NGOs tend to focus on general health care vided largely by the same psychiatrist, after needs only. working hours). Limited in-patient facility was available for female patients only, especially for those who had travelled a long Mental health and psychosocial distance. There was a psychologist engaged support initiative at the psychiatry department, but who had It was under these di⁄cult conditions that a been working without pay for seven months. mental health and psychosocial support All cases of drug dependence were referred (MHPSS)initiativewasdesignedon humani- to a private facility nearby, which was not tariangroundsbyavolunteerteamofmental supervised by quali¢ed sta¡. Despite the health professionals from Islamabad,