Psychosocial Dynamics of the Khorwah Medical Camp – an Overview

paddy fields near Khorwah

There are instances when theory doesn’t exactly translate into practice – rather as I call it, it undergoes a transduction process. Each fragmented element, becoming whole through subjective perception. Let’s just say that the Khorwah medical camp held on 31^st July 2011, barely a day before Ramadan, was another of such instances. A brainchild of the 4×4 Offroaders Club, this was my first experience with this group in their medical camp and their dedication to the cause is appreciable.

Khorwah, is located in the north east of Karachi and it took us almost 4 hours to reach there by bus. The land may be fertile for paddy fields but it is a hard life for the locals who have a hand-to-mouth living at best. The main profession in the area is hiring oneself out as farm labourers and its secondary adjunct is grazing cattle. A few luckier ones, according to the local definition of ‘luck’, are ironsmiths or carpet weavers, basket weavers and tradesmen who do not have to undergo the hardship of toiling in the hot climate.

While a quick online search shows that there are apparently two schools in the vicinity for boys and girls, not one of the children we came across has ever attended a school there and several of the elders shook their heads when asked about the existence of a school. Another ‘ghost school’ perhaps? From a psychological perspective the absence of a school makes the task of psychologists harder for the assessment of children. How does one gather data for any child’s achievement level when there is no available baseline? Simon – Binet and Wechsler, the fathers of intellectual testing, take the backseat in the face of pastoral and cultural dynamics. For my part, I found that I could easily add in a number of intelligences to Gardener’s Theory of Multiple Intelligence while assessing intellectual ability based on performance in Khorwah.

Towards Sujawal and beyond

The harsh climate, the financial hardships, the lack of knowledge, the focus on medicine only as the cure-all, and the disinterest in prevention over symptomatic treatment are definite barriers to creating awareness of diseases and disorders. There is also a tendency to label all mental issues as ‘pagalpan’ or madness – no matter what the age of the person under speculation. The language and dialect barrier is also hard to overcome. A slightly different inflection of the voice even if close to the original Sindhi word, was very difficult for the people, especially the womenfolk to understand. However, all is not as bleak as it looks. There is a definite interest in learning new ways and in the fact that for once there is a ‘different kind of doctor’ – someone who cares, wants to help and is ready to listen and, with no disrespect on my part, is not ‘just a journalist who will listen, go back and write or publish photos and not offer any concrete suggestions for our ailments’. Children with behavioural, intellectual and emotional issues were curious, and eager to try out new exercises yet too afraid of the doctor label to be able to open up and relax.

Most of the prevalent diseases are a result of poor health awareness and future programmes can be chalked out to include large scale group therapy with at least one translator available per group. This time we initiated a focus group venture but it did not succeed too well due to the low voice of the translator and addressing partial groups in the audience, neglecting those seated at a distance. It also didn’t help that the translator had her own views regarding what would help the women and what would not and most of the sentences spoken had to undergo negotiation before they were translated. Some of the women who had partially understood the sentence followed the negotiation ball as in a tennis match with frustration writ large on their faces.

A group of local women with the volunteer doctors

Among the common issues faced by the villagers that would require preventive awareness programmes, skin diseases are almost at the top of the list, and poor hygiene conditions make it very difficult to say that these will be eradicated anytime soon. The villagers walk barefoot in the fields in all weather and deformed calluses caused by incessant scratching and its resultant sores that may get infected, are very common. Again the issue is greater in women than in the men, who being seen as the main breadwinners, are less likely to go barefoot. Hand washing is a luxury and whether scratching sores, or tending to cattle or cleaning up their own or their children’s faecal matter with stones and leaves or hands, just a quick sieving of the fingers through sand or a nearby muddy pond is considered enough to cleanse the hands. The same hands then return to their own body, to the food they cook and the utensils in which they eat and drink. Clothes are not washed more than once in two weeks if there is time left over from working in the fields. Cotton cloth is tied round, washed after a day and reused in times of menstruation. Several women believe that having a bath during menstruation is bad for health and here the case was no different. I witnessed many garments soiled and stained with blood that are not washed at all and are kept aside only to be worn during the time of menstruation on a monthly basis. There is dire need of awareness and presentation of cost effective, easy alternatives to deal with the hygienic aspects of preventive health care in the region. Abdominal aches due to intestinal worms and other genitourinary problems

Another issue is of oral and dental health care. Many women are addicted to various substances used by their husbands and chewing hard betel nuts coupled with calcium deficiency along with other forms of nutritional deficits, leads to brittle teeth, swollen gums and cavities.  There is hardly any concept of brushing or even the traditional ‘miswak’ or ‘tooth stick’ use and dry twigs are used if anything gets stuck in between the teeth. The use of salt as a cleansing agent was advocated in front of quite a few women as a cheaper alternative to fill Dentonic bottles once they would get empty. Children were especially eager to show off shiny teeth and this factor can always be used to motivate them on future occasions.

PNS Shifa hospital affords us psychologists at the Institute of Professional Psychology, a cushioned existence. It has taken us a while to build up our reputation and most doctors here at PNS Shifa now know what we do, we have interlinks and they many refer cases easily.  With the medical camp we went back to basics. I was all the while strongly reminded of the words of our colleagues working in remote areas and in other parts of interior Sindh. It took awhile to tell people at the camp a number of things. Firstly that psychologists do take a long while to diagnose and treat but depending on the type of test or clinical interview, diagnosis can be a quicker deal especially in cases of psychosis and neurological issues, secondly the fact that therapy and counselling does take a number of sessions but there are a number of techniques that can be taught in a shorter time and thirdly the idea for the patients that psychologists are not journalists and they ask questions to diagnose, not write only and that medicines are not a cure-all, there are times when medicines are just not needed.  In this entire process I hope we have re-educated more than just the visitors.  It was heartening to see many men come forward to discuss their wives genitourinary issues after they had been silently observing us from a distance and felt that they could get some assistance from this ‘different’ method of treatment and develop some understanding about how to deal with such issues. I was extremely glad to see one patient in particular who approached us on his own after watching us from a distance. He was worried about his wife’s growing weakness and low mood and a complete clinical interview revealed that she had been suffering from post partum depression since the past one year. He went back encouraged to know the dynamics of the disorder and a few pointers to help her deal with this period of stress.

The Medical Camp site sans tables and chairs that were earlier lined up with numbers assigned for each doctor's table. Beautifully organized.

In a hospital setting such as the one in which we are based, we take it for granted that in case of any illness – terminal or otherwise, the caregivers will need to be counselled about the mode of care, their issues of anger or treatment follow up and prevention but in Khorwah, out in the open it hit us hard that there are people out there who need to understand that still. Similarly, many patients with chronic chest conditions were referred to us directly and we asked them to first see the general practitioner and then approach us on their way out.

Clinical Psychologists who are interested in the types of psychological issues faced at this remote area and the interventions we used for them would find it interesting that we went far off the beaten track with generally good results. Neurological problems were at the forefront of most cases seen and neurological screeners were applied for evaluation along with intakes. The rush at the camp made many children nervous, cranky and prone to tantrums which made this test very difficult and reinforcement in the form of biscuits generally helped in soothing more than one terrified child. Children also kept thinking that they were going to receive an injection as soon as they closed their eyes for a few subtests and refused outright to close their eyes even for a few seconds. It would be idealistic and demanding to expect a secluded spot for such testing in a medical camp but we improvised by taking a few patients slightly away from the camp for relaxation and guided imagery in the case of anxiety disorders as well as the motor subtests of the neurological screeners. Some patients were referred to hospitals in Karachi for further medical treatment. They were also provided with guidance about occupational therapy and its correlates and demonstrations were given to each patient individually about the simple exercises they could do at home to help improve the gait or eye-hand coordination.

another view of the Medical Camp site

Complete diagnosis and treatment for many patients with psychotic features could not be initiated at the camp but initial diagnoses revealed Schizophrenia with prominent visual and auditory hallucinations and they were again given detailed directions for seeking psychiatric help in Karachi. Most of the patients earlier had no idea what to do about this condition of madness and had been at the mercy of faith healers who were fleecing them. Their caregivers were guided about their conditions, expectations, possible prognosis and types of treatment along with modes of care, and do’s and don’ts.

Suicidal ideation, suicidal attempts, self mutilating behaviour and depressive features with melancholic states were observed in a number of women. Considering the financial state and the early marriages, childbirth issues, and other problems these women face this does not come as a surprise. A number of Conversion disorder and Somatisation cases that had been labelled as various pain issues gradually floated over to the Psychologists’ table after getting a negative from other doctors present. Far more had been noticed when conversing with the women during the group therapy initiative. Contrary to what some doctors feel, it is important to state here that Conversion and Somatisation are distinct from Malingering and just because there is no physical evidence for the patient’s condition, it does not always mean that he is indulging in attention seeking behaviour or wishes to gain some material benefits. The managers of the estates will as a rule complain about the labourers not working properly and defining a patient as alright and having no pain just because nothing comes up during the course of the physical examination does not mean that from now on the patient will be fine. Conversion symptoms are like the flow of a river. You can barricade the pressure, but temporarily. Eventually, the course may change, the walls of the patient’s self may tumble down or he may experience other similar symptoms incorrectly labelled by many novices as Hypochondriasis. A better alternative is to refer such a case to a psychologist who can then deal with the entire etiological presentation of the case.

While there are successes, there are stark facts of unforgiving and harsh circumstances in many cases. A few really saddened us and I still think of the old man who was caught in a catch-22 situation. An ironsmith by profession, he showed initial signs of Parkinsonism, was well aware of the changes in his body and yet he had been abandoned to his current state by his six sons who considered this trade a demeaning one, did not help him financially and he was still looking after his two daughters. Only one son helped him from time to time and he too rebuked him and had been distancing himself from his father. In another case, a man who was the sole breadwinner suffered from severe congestion and asthmatic symptoms each time he was involved in threshing procedures. He had no idea about safety procedures and used no form of protection whatsoever. He was counselled briefly regarding safety procedures and provided with suitable alternatives.

The entire initiative on the part of the 4×4 Offroaders was well executed and very well organized in terms of crowd control from start to finish and I’m sure it is not the last one! The whole team deserves to be congratulated and I’ll refrain from taking any one person’s name in particular as each and every member was immensely dedicated. There is always room for improvement and I’m looking forward to the next trip already. Let’s see how many suggestions can be utilized and how far it is possible to correctly identify patients at source or educate each other about our respective roles so that maximum benefits can be derived from everyone’s contributions.

 N.B. All the photos were taken by me after the camp was almost over and during the camp there was no time to take photographs. Hence there are no photographs of the doctors or the patients undergoing treatment. A safe estimate, however is that nearly 800 – 1000 patients visited the camp that day and were given free medicines, free treatment and physical and mental examinations.