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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 31st 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.


Rehabilitative mental health care in Karachi – A case study of a single psychiatric set up.

It is 9:00 A.M. The wide green lawn ensconsed in the quadrangle of the double storey building  is bathed in mellow hues. Soon enough, they start emerging from their rooms, wearing fresh clothes after their morning showers. Single file, they are guided downstairs to begin the daily morning excercise session. A variety of expressions meets the eyes. Some look bored, a few seem indifferent, while others are quite enthusiastic – smiles lighting up their features. No, these are not children from a boarding school. They are mentally ill patients and residents of Karwan-e-Hayat PCRC (Psychiatric Care and Rehabilitation Centre) located in Keamari, in Karachi, Pakistan.

People have varied and often gross misperceptions about mental health institutions and their resident patients. A rehabilitation centre is often thought to be at par with an assylum with violent, drooling, dishevelled and possibly jumpy patients sitting in dark, narrow cells restrained by chains and administered electric shocks daily. These impressions belie the image of a rehabilitation centre like Karwan-e-Hayat PCRC. Though the entrance hall is flanked by burly security guards and has strong grills in order to prevent the patients from escaping, the rest of the Centre is bright, airy, clean and built on the model of Western rehabilitation centres. There are separate dining halls, activity rooms that are lined with the patient’s own creations and indoor game rooms for male and female patients. Two buildings adjacent to each other within the same compound house the male and female residential wards, semi private rooms and airconditioned private rooms. Presently it has 65 beds but in future there are plans to increase the number to 100 beds which is the Centre’s actual capacity. In short, it epitomizes the modern residential and Day Care facility for the mentally ill.

Karwan-e-Hayat started out as an NGO in 1983 committed to caring for the underprivileged  mentally ill patients. It got off to a good start with names such as Begum Ra’ana Liaquat Ali Khan, Cardinal Joseph Cordeiro, Ms. Anita Ghulam Ali, Prof. Dr. Zaki Hasan, and Dr Zafar Quraishi, who is currently the President of the NGO, as its founding members. In a city like Karachi where mental illness had a great deal of stigma associated with it they made the correct move – that of  organizing awareness camps. The target? Again, smartly enough – katchi abadi and slum dwellers who stood in utmost danger of being fleeced by miracle workers and fake pirs. In a simultaneous move, seminars were arranged in high profile schools like St. Joseph’s Convent and Karachi Grammar School. Since then, the NGO has come a long way. The Consultant Psychiatrist of Karwan-e-Hayat PCRC, Dr S. Ajmal Kazmi, met with Dr. Zafar Qureshi in 1995, then the Director of Karwan-e-Hayat. This interaction led to the concept of a rehabilitation centre in Karachi. The next few months brought on a search for a suitable location. KPT (Karachi Port Trust) were the owners of this premises in Keamari and after spending around Rs. 80 lacs for renovation, it became fully functional in 2004. As it is primarily a charity organization, 90% of the patients are treated free of cost thanks to various donors like Rotary Club Karachi and Infaq Foundation.

Theoretically, Karwan-e-Hayat combines two concepts – a rehabilitation program and a crisis  house. As such it provides services like medical examination and assistance, rehabilitation counselling and occupational training opportunities found in rehabilitation programs. As a crisis house in a community setting it is based on the model of rehabilitation and accordingly is staffed by mental health care professionals. The relatively little research that exists on such centres has not only found that they are very acceptable to their residents, but also suggests that they may be able to offer an alternative to inpatient care for about a quarter of the patients admitted to hospital, and that they may be more cost-effective in the long run than inpatient care since most patients are eventually assimilated back into society!

Karwan e Hayat follows a  multidimensional approach for treatment of adult patients between the ages of 18 years to 65 years. Drug addicts were earlier not treated here due to the vast differences in treatment methodology and other complexities. However, drug addicts suffering from psychoses are now admitted and treated.

Occupational therapy activities

Generally, firstly an RMO (Resident Medical Officer) medically examines the patient in the OPD and takes his history. Next he is sent to a Psychiatrist for consultation where, if needed, he is prescribed medication or admitted as an inpatient. The Centre offers admission to some patients who need inpatient care because of acute and severe mental health conditions like Schizophrenia, Bipolar Disorder etc. The patient may also be referred to the Clinical Psychologists for psychological testing and psychotherapy to resolve his inner conflicts. Inpatients are divided into three main categories for individual psychotherapy which takes place twice a week: 1. Obsessive Compulsive Disorder and Depression, 2. Schizophrenia, and 3. Personality disorders. Testing material worth Rs. 3.5 lacs has been acquired by the Centre to facilitate psychological diagnosis. Occupational Therapists attend to the patient in the Centre’s Day Care. They give the patient something  purposeful to do in the Activity Rooms with the intention of improving his general sense of self. Sessions for improving the patients’ awareness about their illness are also conducted frequently with a view towards helping them manage their self care. Various organizations such as the Institute of Professional Psychology and the Aga Khan Hospital send their students to the centre for internships and community service.

All these professionals work together to firstly diagnose and then help a chronically ill patient ease into society or at the very least sustain daily functioning ability. There are plans to include a Social Worker in the team this year as in other Western countries, but Dr Kazmi laments that the training provided in Pakistan at Masters level in Sociology or Social Work is far off the mark.

Karwan e Hayat ward

A typical day at the Centre starts with the ward boy waking up those in the Inpatient facility and encouraging them to wash themselves and take a shower. Some of the long term stable patients are encouraged to lead the morning Excercise Session. The patients then return to their wards or rooms for the morning round by the mental health professionals. Any decisions taken during this round are noted and the team then divides in two groups for better management of the not so stable inpatients and the Day Care activities. The Day Care group session includes both male and female patients who are stable enough to take part in discussions on basic topics such as “The importance of cleanliness”, “Ways to control anger” or “Hobbies”. The objective of such discussions is to draw the patients out of their fantasy world towards practical life and develop their interests.

All other activities apart from the group session are carried out in a segregated environment under supervision. During occupational therapy the patients are encouraged to make arts and craft items as per their interest. Many simply colour in drawing books and often the colours they pick or their manner of colouring is quite suggestive of their inner emotional states. Computers in the activity room are a relatively recent acquisition and selected patients are even taught programs like Microsoft Word by others. Evenings bring with them time for indoor games like table tennis, cards, carrom board and sometimes cricket. While it is encouraging to see the careful supervision of various activities, it is surprising that the patients are exposed to several cable channels and can watch movies – blood, gore and dances included, without a bat of an eyelid by the supervisors, in the activity room. Major activities at the Centre culminate with the Day Care closing at around 4:00 P.M. There is a skeleton staff for night duty to prevent possible mishaps.

Overall, it is creditable that Karwan-e-Hayat has not only managed to live up to its mission objectives by establishing centres such as its outpatient clinic on Khayaban e Jami and PCRC at Keamari during the past 24 years, but has fostered healthy links between psychiatrists, psychologists and occupational therapists – bringing them all under one roof at PCRC. Job satisfaction appears to be moderate amongst the staff members which is saying something, since the Centre is located at quite a distance from their homes. Yet many psychologists are sceptical about the level of therapeutic care being provided at the Centre as psychiatrists take centre stage in the proceedings.

There are several other rehabilitation centres – for drug addicts or psychotic patients etc located in the city but an impromptu survey taken from mental health professionals and patients revealed that most are not as spacious or as well organized. Moreover, there were complaints regarding the quality of meals provided elsewhere and the level of hygience maintained in the kitchens. Similar complaints of boredom, lack of good and comfort come from patients at this centre as well but they seem to be fewer in comparison.

The seemingly eternal rivalry between psychiatrists and psychologists has also proved to be a bone of contention in many cases with each faction wanting to show their supremacy over the other in terms of treatment efficacy. Dr. Kazmi’s rejoinder is interesting to note: ” Team work should always be there. If you work alone you can never do as well.  I’m lucky to be working with an honest and hardworking team. If someone is at the forefront, it is because there are several unnamed people at his back.”

Mental Health Professionals and policy makers would do well to take a leaf out of Karwan-e-Hayat’s book. With Schizophrenia at 11% and Depression at 15% world over, the demand for mental health facilities is bound to increase with the rise in population. Already, a figure of 1.5 million mentally ill people is estimated for Karachi. Karwan-e-Hayat’s PCRC is but a drop in the ocean. True, it is one of the few fairly good centres and is providing free treatment to poor patients but it is definitely too far from the city and has a limited capacity. There is dire need for many more centres, not only in Karachi but in the whole country.

N.B. This article was published in 2009 in Expose’ magazine, Karachi.

Photos courtesy: Karwan e Hayat website