As Southasia continues to feel the impact of COVID-19 pandemic, in this episode of Himal Interviews we explore a possible “third wave” of health crises – those in the sphere of mental health. Speaking to psychiatrists from India, Pakistan and Sri Lanka, we look at the mental-health infrastructures in these countries and how COVID-19 has exacerbated or generated new challenges across the region. How have countries attempted to account for or manage the third wave? We also unpack mental-health challenges faced by women, the pros and cons of using technology in providing mental-health care, the impacts of stigma, and the roles of funerals in dealing with loss.
Himal Southasian speaks to Dr Asma Humayun from Islamabad, Dr Soumitra Pathare from Pune and Professor Daya Somasundaram from Jaffna. Dr Humayun is a member of the Royal College of Psychiatrists and has over 25 years of experience in clinical care, service development and capacity building. Dr Pathare is a consultant psychiatrist and director of the Centre for Mental Health Law and Policy at the Indian Law Society in Pune, India. Professor Somasundaram is a senior professor of psychiatry at the Faculty of Medicine, University of Jaffna, and a consultant psychiatrist working in northern Sri Lanka for over two decades.
Editors’ note: These videos contain discussions on the topic of suicide. Please go to the end of the page to find suicide-prevention phone numbers for countries in Southasia.
Mental Health & COVID-19 – Introducing the speakers
This is an unedited transcription from the interview. Please listen to the corresponding audio before quoting from it.
Amita Arudpragasam: This is Amita Arudpragasam from Himal Southasian. Today we are going to discuss the impact of the COVID-19 pandemic on mental health in Southasia. I am joined by three panelists who are experts in the field of psychiatry and psychosocial health policy from Pakistan, India and Sri Lanka.
Dr Asma Humayun from Islamabad in Pakistan, is a member of the Royal College of Psychiatrists and has over 25 years of experience in clinical care, service development and capacity building.
Dr Soumitra Pathare is a Consultant Psychiatrist and Director of the Centre for Mental Health Law and Policy at the Indian Law Society in Pune in India.
Finally Professor Daya Somasundaram from Jaffna in Sri Lanka was a Senior Professor of Psychiatry at the Faculty of Medicine in the University of Jaffna and a Consultant.
Pre-COVID-19 mental-health issues and infrastructure (in Pakistan, India & Sri Lanka)
AA: So prior to COVID-19 could you tell us what were the major prevailing mental health issues in your country of focus and was the mental health infrastructure effective in managing these issues?
Asma Humayun: Thank you Amita. In terms of mental health needs and resources in Pakistan we are not much different from other middle income countries in the region.
The prevalence for common mental disorders is also similar, which is expected to be around a lifetime prevalence of about 20 percent. What that means is that one fifth of the population is likely to suffer from a common mental disorder at some point in life.
Poverty, unemployment, literacy and all this is contributing hugely to the burden of our health infrastructure. Pakistan has been engaged in a conflict with Afghanistan for four decades now and at the moment has been hosting one of the largest refugee populations in the world.
The third factor, which I think is very important for the context of mental health needs, is climate change. This has major implications in terms of how people have lost their habitat, the loss of livelihood, food insecurity, water insecurity, energy insecurity and also a massive rural to urban migration. We already know that the prevalence of common mental disorders — they are likely to double in times of crises.
In terms of our mental health resources, they are very scarce with a limited number of trained mental health professionals who are largely located in tertiary care hospitals based in urban sectors. At the district level at best we would have one qualified psychiatrist and there are many districts with no trained psychiatrists at all. We do not have mental health integrated in primary care in Pakistan. As far as legislation goes, we had mental health legislation enacted in three provinces. But there has been no systematic implementation so far.
Soumitra Pathare: The real issue has been the lack of any kind of access to services, that’s been one of the biggest challenges in India in terms of mental health. So, although at a policy level we seem to have made a lot of improvements in the last few years – we’ve got a brand new mental health policy for the first time in 2014, we also got a new piece of legislation in 2017. The challenge has been actually in implementation. The challenge has been converting these policies and laws into something real on the ground.
We have a huge treatment gap, you know the national mental health survey which was done in 2016, showed that the treatment gap for various conditions ranged anywhere from 60 percent – 85, 90 percent in different parts of the country. In some parts of the country we have reasonably good services, especially in the South like Kerala and Tamil Nadu have extremely good services, but if you go North and East, for example Bihar, Jharkhand, Uttar Pradesh now that’s where the services are really really lacking, and also the whole model of mental health services has been primarily a very biomedical model.
So we’ve not really done enough work to address, either the psychosocial drivers of it, or even the psychosocial interventions for it.
And finally, there are some very special groups which are completely forgotten in mental health in India. These are like the elderly with mental health problems. We have a large population with dementias and other old age problems. And the other extreme age group which is forgotten is children.
The problem has not been just a matter of money. The problem is everyone says we need more resources. Well in India, very often, the budgetary allocations for mental health do not get utilized in the whole year, so you know, money goes back to the treasury, because it is unused, and the reason that happens is because the mental health systems absorptive capacity is really a problem. So there are all of these supply side problems. There’s of course demand side issues, but I think unless we solve the supply side issues, raising demand without addressing supply is always going to be a huge problem.
Daya Somasundaram: What has happened in Sri Lanka, I suppose it’s the same in many other countries around the area in Southasia and so on.
The legacy of the British medical system that they built up. Generally we were focused on severe mental illnesses, and they were being treated in institutionalized services. There were two big institutions in Sri Lanka and few other outreach services particularly in the urban areas.
But subsequent developments particularly after the tsunami, there has been a gradual spreading and peripheral development of mental health services. So generally the services were available almost at a district level, all the district hospitals had a mental health, even an in-ward and out-station clinic. And that has been now even extended to peripheral areas, there are outreach clinics and so on.
So generally I would say that Sri Lanka was fairly well managing the severe mental illnesses, meaning the psychosises, schizophrenias, bipolars and so on, and to some extent the management of alcohol and drug problems which were also coming up, has been developing quite a bit.
After the — during the, COVID-19 also, that became quite a big problem because of the sudden availability issue, many of the drugs being abused were not available and people went into withdrawal, and there were quite bad reactions.
But as far as the management of what Asma referred to as the ‘common mental health disorders’ or the ‘minor mental health disorders’ — they have been fairly neglected and there has been not much development prior to the major disasters that Sri Lanka faced – the big war and then the tsunami. Subsequent to that, there has been some development of facilities and services to address these issues, but not enough and not in a broad way.
Mental-health impacts of COVID-19 and the scope for collective trauma in Southasia
AA: What are the major impacts that you see on communities in your respective countries and do you think there is an increased scope for collective trauma now in light of the COVID-19 crisis?
AH: Compared to developed countries where the systems offer security and stability, our communities have been facing ongoing challenges, and are in many ways somewhat resilient to crisis. But the impact of this pandemic has been palpable. In view of the dearth of our resources, it has taken us the last three, four months to organize the basic emergency response.
The greatest stressor has been access to healthcare for those who were infected or who were addressed for infection and the second greatest challenge has been loss of income and this has particularly hit those who are non salaried or working on daily wages.
Your question on collective trauma is definitely valid. The closer communities have suffered collective trauma, but I think that even those communities which are geographically not closely located because of the exposure to media have also been suffering together since the pandemic. In Pakistani communities, faith has been instrumental in dealing with the crisis and helping people recover.
AA: Dr Pathare perhaps you can say something on this question.
SP: Interestingly enough, in India the first people with mental health problems to experience the impact of COVID-19, were people who were dependent on alcohol, for example.
So you know in the couple of weeks, after lockdown was declared we had almost 25 or 30 suicides which were related to the non-avaibility of alcohol and people going into alcohol withdrawal, and then there was suicide.
So that was the group which got initially affected, then as people got out of withdrawal that kind of seemed to have gone away and then other concerns started coming up.
And as the lockdown has gotten extended over periods of time, we started with a three week lockdown and then another three weeks, and then another three weeks, I think it has started to test people’s coping capacities and resilience.
And then you started getting a different bunch of people experiencing mental health problems. So that it started with people who had severe mental disorders, for example not getting access to their medicines because supply chains of drugs got disrupted, or not having access to psychiatrists, because you know their regular clinicians, because of the lockdown. So you started seeing that kind of group getting affected.
And now as the lockdown has gone on you start seeing the effects, mental health effects, also start to appear on children and adolescents. Because now you know schools have been shut for a while, there is a question of school exams — are they happening or not happening? When will colleges reopen? And all of those issues are coming in.
And now you also start seeing a whole new bunch of people getting affected, and those are the people who are now beginning to worry about what’s gonna happen to my job? will I have a job when this whole thing gets over?
So it’s kind of gone in phases. Different people, different groups of people have got affected at different times. I think one of the things that you don’t see in the writings from outside maybe Southasia is maybe the notion of collective trauma. And some of the things I worry about is how we manage our pandemic response, for example our families not being able to do the last rites for people who’ve died in their family, and that can create a real problem as we go forward you know in terms of grief reactions, which have not been dealt with at all, so I think, those are the things we’ve not dealt with or the kind of reactions that people are getting to, you know if you’re living in a block of flats, and somebody is being diagnosed with COVID-19 and then the ostracization that happens to that family or that person.
AA: Dr Somasundaram perhaps you can weigh in on this question.
DS: The fear and anxiety that was there, prevalent, it seems to be diminishing, quite a bit now. And in fact it may be increasing the risk of the second wave, and so on, when people don’t follow the restrictions like social distancing or staying at home when in various places like in shops or in temples or religious festivals, and so on.
Another common mental health problem that we saw was the kind of obsessive cleanliness, people who had this predisposition, and also maybe many who were not clinically — who became very, in fact there was a kind of a phobia for the virus, and whether they will get infected.
There were a group of people who were extremely careful and cleaning and, as mentioned already, the problems of people who were dependent or addicted to various substances, not only alcohol, for even the heroin, and so on. They went into severe reaction and that became a big problem managing any of these patients who became quite ill in withdrawal.
In a longer term, I think some of the problems cropped up because of the lockdown, access to medication, people being able to come to psychiatric clinic, many of the, more severe illnesses — there were relapses and people tended to develop these problems at home and had to manage there without a proper medical care and so these issues also cropped out.
Belatedly people are beginning to recognize that now in the recovery phase, we are going to face a host of mental health problems due to what has happened, and also the economic issues and deaths that have happened, and separations, and all the difficulties that people have gone through. There is going to be a whole host of problems that are going to crop up. They are even saying that it will be kind of a ‘third wave’, the mental health problems in a post-COVID-19 time. Depression, suicide, anxiety, and so on. So I don’t think the facilities and even authorities are actually ready for this and are planning how they are going to deal with this. So i think we may face these problems.
Now the problem of collective trauma is more difficult. Collective impact on society is immense. I think many of the normal processes and functions and the way that society functions has been affected – by these long lockdowns and the way that people have been kept at home, and so on. So to get back to a kind of social normality is going to be, in fact, there are predictions that we will never be the same again, society in a post-COVID-19 era will be a different type of society with different priorities and values and so on.
National mental-health responses to COVID-19 (in Pakistan, India & Sri Lanka)
AA: On the national response to protecting the mental health of individuals, do you believe that it’s been sufficient and what do you think could have been done better from a state perspective?
AH: As far as the national response is concerned, very much like India and Sri Lanka, the initial responses have been fragmented, ad hoc efforts. You keep hearing of these random reports and different medical institutions, or some helplines with online counselling, set up by NGOs.
At the national level for the first time, the Ministry of Planning, Development and Special Initiative is launching an MHPSS (Mental Health and Psychosocial Support) initiative soon. We’ve been planning and working for this for three months now. It’s a multi level initiative, as recommended by inter agencies standards imaging guidelines. It’s a very comprehensive, integrated, web-based plan. We followed a hybrid model, so there is the digital solution to it, but also we are trying to ensure a person-to-person contact with counsellors or mental health professionals if needed.
SP: You also have to look at what was the existing infrastructure and human resource availability you had before COVID-19 to say that, oh have we done better or have we not done as well. And I think if you take that as a measure, then I am quite enthused by the fact that the government has actually put in a reasonably good response. Given the restraints and constraints that do exist, they have tried to do their best.
One of the most important things about the mental health response in India, which is quite interesting and I hope it lasts, is the fact that there is a huge awareness, even among policy makers as well as the general public. Now this is something we’ve been trying for many years, but not with great success, but it required a tragedy like a pandemic to actually make that happen.
So you know we had our Union Health Secretary, which is the top most health bureaucrat, write a couple of articles on mental health issues in big, large newspapers, for example. We’ve had Ministers talk about mental health, which wouldn’t have happened, up to now. And there’s been a kind of, even among social media in India, mental health is quite high on priority. So there’s always a talk about, you know, the COVID-19 treatment, and then there’s mental health. So in that sense, I am quite enthused by it.
The challenge really is going ahead, what I’m worrying about is the fact that mental health problems are going to hit India with a certain lag, you know, six months down the road or twelve months down the road. We’re gonna face a lot more problems, and I don’t see at the moment, us doing anything to get ready for that deluge, in a sense. The mental health response has been a very narrowly bio-medical, bio-psychological kind of related intervention. So it’s been like let’s have some counselling, let’s help people. And what is really missing is the social interventions that are required either to prevent mental health problems or to even address, I think that’s a real huge lacunae in our response.
Mental-health issues for women during COVID-19 (in Pakistan & beyond)
AA: Could you talk to us a little bit about how women are being impacted in Pakistan and perhaps across the region and what challenges they are facing from a psychosocial perspective?
AH: Thank you for asking this question Amita, this is very important.
Women are probably the largest, vulnerable group and their difficulties have certainly multiplied after the pandemic. So, particularly for Pakistan, I would like to say that Pakistan is a patriarchal society where men are primary authority figures and most women have a subordinate role. These patriarchal values are deeply embedded in our local traditions, culture, religion and largely they predetermine the social value of genders.
So, during the pandemic what has happened is that those women who work and were then forced to work from home, they were dealing with additional responsibilities not just of the household, but also of childcare, either supporting online schooling or providing education themselves. Many of the patients that I directly work with, have explained that they cannot even take the time out for their follow up appointments, because 4 or 5 hours during the day is taken up by online schooling. They have to supervise the children. Those who were not working in formal employment, they were facing stress, because their partners who worked, were now working from home.
Since the pandemic, increasingly the rates of gender based violence, particularly, in domestic settings, are being reported to be increasing. There is sudden upsurge of sexual harassment being reported, mostly against young women in some of the prestigious educational institutions.
It is not clear whether this is just a coincidence – upsurge of reporting has happened during the pandemic or because they were staying at home and home was the safest place for them to start thinking and reporting these cases, it’s not clear.
Women are known to be higher at risk for common mental disorders. It is also known that they have a much reduced access to health care and this was multiplied during the pandemic. The media was constantly reporting that women had lesser access to both the testing opportunities and also for hospital care if required.
Suicide rates & COVID-19 (in India)
AA: I thought it would be a good time asking you about your work raising awareness on suicide in India and whether you have any data on the impact of COVID-19 on suicide rates amongst different communities.
SP: So the National Crime Records Bureau does collect data on suicides in the country. Now there are lots of problems with the NCRB data, largely to do with under-reporting. So probably it’s underreported to the extent of 30, 40 percent, even 100 percent if you went by the GBD data. But that’s only one part of the problem.
The second part of the problem is that the National Crime Records Bureau does not release the data early enough. Normally they’ll release data after you know 12 months, or 24 months in arrears and they tend to release data in summary statistics rather than release the data, so for example they won’t release monthly data. So it’s very difficult to then corelate whether there is an increase in suicide or there isn’t an increase in suicide. Some of us have been looking at say for example media reports on suicide, to see whether the media reports of suicide are presentig a different profile. You can’t really estimate numbers, but at least you can check whether media reporting or the profile has changed.
Three different large cities, the police commisionerates have reported an increase in suicide in the months of May and June, so they dipped in April and then they went up in May and June, that’s been their experience. Again, this is very small area data and the Police Commissioner data in that sense is a bit more reliable because that’s the data which feeds into the National Crime Records data. But it’s small area data, you’ve got police commissioners in Pune, Calcutta, Ludhiana– so this is three different parts of the country and in three large urban settings, reporting some increases in suicides in their jurisdiction.
Anecdotally, if you talk to people, especially you know if you see for example there’s been much more reporting around say doctors’ suicides or junior doctors’ suicide, and that’s really taken up, you know there’s been a very active discussion not only in media, social media but also among the officials as to what are we going to do about that.
So you know, I think my guess is probably as good as yours, but based on the little data that we have — it appears there is some increase in suicide rates, or atleast the profile of the suicides seem to be changing, so you know it seems to be happening. But unless we have good quality data, or unless we have some national data it’s difficult to draw conclusions. So many of us have been requesting the National Crimes Records Bureau to actually release the data sets early enough so that we can start looking at the data sets and try and make sense of it from a researcher’s perspective. And for attempted suicide, we just don’t collect any data so what you’re left with is only anecdotal data.
Technology and access to mental healthcare during COVID-19 (in Pakistan & beyond)
AA: How are individuals accessing mental health care during lockdown periods. What are the challenges you have faced as your clients transition to digital platforms? Are there foreseeable opportunities? Could you tell us a little bit about that experience?
AH: Let’s discuss the opportunities for online services at different levels, at the individual person-to-person psychiatric service or psychological service, or at the level of institution which could be a medical institution, or at the level of the province or nationally.
One of the huge challenges for us in developing countries is that mental health services are inaccessible and at least 75 to 80 percent of the population of the people who suffer from mental disorders do not have access, thus comprising a huge treatment gap. So the online services are I think very promising in the way that if people are living in far-fetched areas, or if there is a dearth of specialists in a particular city, then it’s easy to access a specialist in another place. But of course this would be resource-dependent and we would need not just access to a computer but a good internet connection also, which is not very common if you look beyond the urban centres or beyond a certain social strata, socio-economic strata.
What I found was extremely helpful is that when after the pandemic — in the first two weeks of course nobody could understand how to suddenly offer alternative services online, I too was taking time — what I noticed that even in that period when I was not sure, I could still provide emergency care to patients or give them brief emergency interventions because I could connect with them online. So for emergency care, I definitely found that this was very helpful.
One of the experiences that I had as a practitioner was that I found that not very many people have the privacy in their homes to have a psychiatric consultation. So especially those where I was working with long term complex childhood trauma, I found that they were very uncomfortable sitting and talking in a room where they could be overheard in another room and more than a couple of times, I think thrice or three, four times what has happened is, patients chose to go and sit in their car to have a session with me. So also I’ve had some experiences where a young man who had some paranoid ideation, he was constantly looking around the screen and looking at buttons and finally he asked me whether I was recording the session or not. Also, I find that engaging children on the screen is very difficult. The work that I do with the families where you have many members of the family come together it becomes very difficult to see all of them together on a camera. Sometimes they are squeezing, sitting together, squeezing on a settee, and then of course, they are so uncomfortable it becomes difficult to see the dynamics. So I particularly don’t think online services is good for family work. Learning disability is very difficult, not everyone is technologically savvy. I had some difficulty understanding where to look, I still don’t know if I look at the right place in the screen or not.
So another problem I found was although in my everyday person-to-person clinical work I was doing regular 4-5 hours of clinic everyday, but here working online was very exhaustive, and after a couple of hours you know I feel, this has been described as zoom fatigue, whether it’s zoom fatigue or that we are not feeling revived because of the human connection, which is so important in a psychotherapeutic setting. So that’s been my kind of individual experience as a practitioner.
But going on to what we are doing for the pilot project that we are working to implement, I think that digital technology has offered us tremendous opportunity, because in the pandemic, when it was not safe to meet people face-to-face, so this was an alternative way of reaching out. One, it’s extremely helpful to train large cohorts who might be geographically spread out, and there is a lot of travel cost, a lot of training cost goes into the travel expense and bringing people together in a room.
Also, I find that some of the training that we are discussing, we are now very easily thinking of involving specialists who are not living in the city, which was not very feasible before, even we’ve been thinking of engaging specialists or experts who are living in other countries, so this has become possible. So I think that there is a huge opportunity for us to design interventions in low-resource settings where there is a dearth of specialists — where there is a dearth of trainers, specialists and large populations to be served.
Rethinking mental health policy post-COVID-19 (India)
AA: If you had to redraft India’s mental health policy post COVID-19, what changes if any would you make?
SP: In terms of policy in India they were very, it took a little bit of effort, but I think surprisingly our policy-makers responded very quickly. In terms of tele-mental health or tele-health, you know, they changed the regulations on it very quickly, so that people could be seen online and also prescriptions could be given online, because that was one of the major issues, that our existing regulations, do not allow online prescriptions. But they actually changed the regulations so that prescriptions could be sent online. And more importantly for chemists and pharmacists to accept those prescriptions which had come online on whatsapp or email and to dispense medication using those prescriptions. So there was some quick change in the regulatory thinking. I wouldn’t say that we need to really rewrite the mental health policy. The problem with the mental health policy in India, has not been the policy per se, as in the content of the policy, you know. The problem has been the lack of implementation.
The role of funerals in mourning and loss (Sri Lanka)
AA: In Sri Lanka, Muslims and Christian families have been asked to cremate the deceased instead of burying them, reportedly for health reasons, can you describe, the psychological functions of funerals in dealing with loss and grief?
DS: The traditional practices related to funeral ceremony and various observances that are done, and for the wider community to come together and grieve together, the kind of weeping, they call it oppari in Tamil, kind of lamentation and the various traditional practitioners who are involved, so all this creates a, it’s part of the process of coming to terms with what has happened and to understand it in a culturally appropriate way, so it’s part of the healing and when these are not done, there’s kind of a gap, kind of lack, a vacuum in people’s mind and it can lead to in psychiatric terms, prolonged grief or unresolved grief and so on, chronic depressive type of symptomology and culturally also for the community and for people who come, relations also very important to have these kinds of ceremonies and to follow the traditional practices. We saw that particularly during the war and even after the tsunami, when they didn’t get the body or they were not able to do the funeral observances and the practices that led to a lot of guilt that they have not done the right thing and it comes back in their dreams, it’s ongoing trauma that can’t be, it’s kind of an unresolved. So I think it was very inhuman to have this practice brought suddenly to cremate, to and in many cases, it was really not warranted. Even the WHO has said that it’s not necessary to cremate and a lot of the cases were just suspected even, so I think particularly for families and for the community not to be able to do the traditional practices for the person who has died can lead to long term mental health and even social consequences.
Stigma & COVID-19 (Pakistan)
AA: Dr Humayun, can you speak about the impacts of stigmatization on COVID-19 patients and healthcare workers. In your experience, do people actively seek out help?
AH: Stigma, I think, is a huge barrier for us to move forward and this stigma is not just for the pandemic, but even before the pandemic.
If you look at the cultural context of these countries, psychological issues are generally seen as a sign of weakness. People with mental disorders are looked down upon, and this stigma not just exists in people who are not educated or in low socio-economic class, but they are also prevalent in health professionals. And you can clearly see the stigma in the health policy and in medical education.
In Pakistan, we still do not have a formal exam in psychiatry for a doctor graduating. So a graduating doctor will have to do an exam in ENT but not in psychiatry. So what has happened after the pandemic is that because of the risk of infection, and I think that I might speak for all of us, when I say that the media might not have done justice in raising scientific awareness, at least in the earlier part, and the communities were more relying on myths rather than the scientific information about the pandemic. And as a result the people were very wary of those who were directly in contact with infected personnel. This is especially true for frontline responders, and I have supported a few women doctors and nurses and I know how difficult it was for them — because particularly for those who were living in joint family set-ups and had to go back to parents-in-law and how their job was seen as a direct threat to the elderly people in the family, and the pressures that they have sustained to continue their service.
Daya has already mentioned the challenges with burials and funerals. And unless we have culturally sensitive policies and practices where people can feel confident in accepting the scientific knowledge and overcoming stigma, I think we will continue to have problems.
In Pakistan, particularly during the pandemic, an example that comes to my mind of poor policy and practices in urban centres — what the police started doing, was they started putting this big notice outside the houses where a case of infection was detected. And as a result, the whole mohollah or the whole street would go and you know gossip about the family that they have a case. And the family was like ostracized in some way, not just physically isolated but ostracized because they have developed this infection. In the same way, there are numerous reports in the media that people who were infected — they would withhold this information from officials because they were afraid of being taken away from their families into quarantine centres.
Parting thoughts: mental-health trends, similarities and lessons learned across Southasia
AA: Do you have any concluding thoughts or remarks that you would like to share with everyone before we part with?
AH: I was very impressed with India’s progress in terms of allocating resources separately for mental health here.
But I totally understand what Dr Pathare mentioned more than once that unless we are able to implement, identify the barriers and devise a systematic approach to implementation, these policies and legislations — they don’t go anywhere, they don’t take us to any progress in terms of changing lives on the ground.
What has happened with India’s national health policy since 2014 is very similar to our story of mental health legislation which was first enacted in 2001, and was devolved to the provinces in 2011 and 2012, and then the provinces started enacting them, and still we have not seen much change in implementation.
Also listening to the cultural context of Sri Lanka and how the experience of tsunami has helped them think differently about community-level interventions is fascinating for me. I think that’s something that Pakistan is way back and one can only hope that a crisis like this will be impetus in, you know, for us to initiate those much needed interventions.
This pandemic is an opportunity where, like other colleagues said, there is a lot of talk on mental health and even if we can make one little dent in there –and start a process where we start thinking in terms of challenging the biomedical model of psychiatry that prevails — and this is the only concept of mental health in some countries like Pakistan — and also because this is the right time when policy makers and senior officials in the state are also sensitized to the mental health needs and maybe it might be easier for us.
But what is extremely important, is to make sure that whatever we plan, however small that is, it has to be done in a practical and feasible way where we can move forward rather than develop projects and policies on paper with no real time change.
SP: I think there is a lot that countries in the region can learn from Sri Lanka. As Dr Asma also mentioned that Sri Lanka because of its experience with the tsunami has actually put in place a lot of services and ways of dealing with it, and there’s an understanding which probably is much more culturally attuned to our Southasian communities.
And I think countries like India, Pakistan, Bangladesh and many of the countries in the region have a lot to learn from Sri Lanka, and the way Sri Lanka has been dealing, or has dealt with repeated crises in recent times. I mean in many ways, Sri Lanka is a star in terms of how community health, mental health services, can be provided.
The third thing that strikes me is how bureaucracy or how bureaucratic responses in many of our countries have been very similar. So Professor Somasundaram talked about you know police enforcing lockdowns, or Dr Asma talking about police or bureaucrats you know public officials going off and putting, sticking notices on people’s doors that oh this person has got a COVID-19 illness. Now this has happened in India too, and so it seems to me that there seems to be even a cultural similarity even in our bureaucratic responses, so not only in terms of our, you know culture, seems to carry over into our health systems, or our public health systems or our public systems respond to crisis.
So maybe there is some learning there too, which we could share and look at better practices or good practices to achieve the same result, without doing things that can be highly stigmatizing. Or as Dr Asma said, for example if you put these notices and people don’t come out and get themselves tested, or if they get themselves tested they don’t want to say that they might be infectious and actually cause a much bigger public health risk. I totally endorse the call from Dr Asma that we need a lot more of these kinds of communications especially in the context of mental health in Southasia.
DS: We do learn from the region, and from what has been happening and there are so many similarities. But, it’s also, on a different note, I would say that this experience of, the COVID-19 experience, has been something very unique.
In my lifetime, I mean the world has gone through so many of these kinds of pandemics, but this is something that happened in the full glare of the social media and the media, and it was real time. It was as if it was happening — although we were restricted, we were under lockdown, we were not travelling, and countries were all closed off and so on — still it was internationally, the drama took place in front of us, and we are still learning, this coronavirus has really taught us quite a bit about, and it has actually brought all these international, everybody together really, although we are separated and we are not able to, but we have been able to feel certain universal feelings.
I mean the coronavirus didn’t discriminate between, I mean, it went after everybody… So in a way we were all at the receiving end. So I think these important lessons are there, and there’s much more that we can learn as we go along.
AA: Thank you everyone for joining this conversation. It’s been really interesting to have you all together on one platform so that we can kind of help document Southasia’s response to COVID-19, but also perhaps collectively brainstorm and think about some of the potential responses that our countries can take. For more discussions like this one, please head over to our website and again thank you to our audiences as well for joining us.
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