Reflections of a MSF Psychologist in the Myanmar Delta

On 2nd May 2008, Cyclone Nargis struck Myanmar, causing widespread destruction and massive casualties. An estimated 140,000 people were killed or remain missing. Damage was most severe in the Delta region, where the effects of the 200km/h winds were compounded by a 3.6 meter storm surge. I had just returned from the MSF post-earthquake intervention in Sichuan, China, when I was notified about the field psychologist position in Myanmar. MSF was looking to start a mental health intervention for Nargis survivors in Padegow, one of the hardest hit regions in the Irrawaddy Delta. Prior to my departure, I enquired about living conditions in the field. The emergency administrator wrote back, “You will be living on a boat. Bring a good raincoat and lots of mosquito repellant.”  It was late August when I arrived in Yangon, the largest city of Myanmar. Early the next morning, we set off for the field. The first leg of the journey comprised a 50-minute helicopter ride to Bogalay Township, followed by a three-hour boat ride to our base in Padegow. As our small motorized boat chugged along the narrow waterways, I saw tell-tale signs of the horror that had taken place months earlier – broken stilts in the water supporting absent jetties that led to homes that were no longer there, remnants of tattered clothing stuck to tree tops, and two weathered human skulls sitting side-by-side on the riverbank. It was a painful sight to behold.  It was close to evening when we arrived at Padegow base. A mid-sized cargo boat lay anchored to the side of the river. A wooden gangway connected the boat to a small wood and plastic sheeting structure on the land. The latter housed our emergency clinic, kitchen, and national staff living quarters. Surrounding the main boat were ten other boats of varying sizes…our MSF 4x4s! All around us, there was nothing but miles and miles of muddy ground and murky waterways as far as the eye could see. So, this was to be my home for the next four months… Our mental health team got to work right away. On our first week out to the villages in the area, we found the delta covered in a blanket of eerie silence. There were no movements on the water save for MSF boats. It was days before we spotted any signs of life – a lone bird perched on a tree. During this time, we observed minimal activity in the area. Most people stayed home in their makeshift shelters of sticks and plastic sheets, afraid to venture out for fear of another cyclone. They told us that it was not possible for them to fish or plant rice because all their nets, boats, and farming tools were either lost or damaged by Nargis.   There were high casualties in many of the villages where we ran our mobile clinics. One small fishing village southeast of our base originally had 900 inhabitants. Only about a hundred survived the cyclone. Later on, they were joined by another hundred displaced individuals from surrounding villages that were completely wiped off the map. In some villages, it was still possible to continue with classes because the school building remained intact and the teacher had survived. In other villages, this was not possible because they were no more children left in the village. During the post-cyclone period, many of our counseling clients evidenced trauma-related stress reactions (e.g., shock, fearfulness, emotional numbness, exaggerated startle response, etc.). Without exception, everyone we met was grieving over the loss of their family members and friends. Those that could afford to leave the area did so; we were told that some survivors had already moved to Bogalay to start life anew, away from the grim reminders of devastation and loss. Those that stayed behind evidenced signs of helplessness and hopelessness. It was not uncommon for people to tell us that they were “waiting for another cyclone to end their misery.”      As a counselor, being able to help others is, of course, an extremely rewarding experience, but there exist inherent challenges. For example, one of the functions of a counselor is to provide clients with a safe place to express their thoughts and feelings. At times, this can prove difficult for the counselor as the client may share a particularly painful experience. On one of our mobile clinic visits, the village monk referred a 12-year-old girl, Aye So, to our team for counseling. He informed us that Aye So had not been her usual self since Nargis. She was moody and becoming increasingly defiant at home. A session was immediately arranged in the village monastery. Aye So came willingly and started to share with us her experiences during the cyclone. When Nargis struck Aye So’s village, she was blown away by the strong winds and was separated from her family. In the ensuing chaos of howling winds and swirling waters, she was hit on the head by flying debris and subsequently passed out. When she regained consciousness, Aye So was greeted by a frightful scene. Dead bodies lay all around her, many of them naked. Several of the bodies hung from trees, their hair tangled among the branches. Lost and afraid, Aye So started to flee. Soon after, she chanced upon another survivor. It was her friend, a girl about the same age from her village. The two girls tied their wrists together so that they would not be separated. However, her friend eventually succumbed to injuries and died.  After two days by herself with nothing to eat or drink, Aye So was rescued by a group of fishermen and taken to Bogalay. She said her rescuers had to tie her down because she was hysterical and kept trying to jump from the boat. Ultimately, she was reunited with her family. Both her parents and a brother had survived but her two younger sisters drowned when the water rose almost ten feet above the riverbank. Like most homes in their village, Aye So’s house had disappeared, swept away completely by the tidal-like waves. Even as I write this, months after the end of my mission, I find myself choked up with emotion, as I did the first time Aye So described her harrowing experience to us. There were many such stories during the course of our work in Padegow.         Over a period of three months, we provided psychological support to Nargis survivors via individual and family counseling. Our counselors also trained schoolteachers to better support their students in the classroom, particularly those who were still exhibiting trauma-related symptoms. Additionally, we provided psychoeducation to communities to raise awareness about disaster-related psychological reactions and to teach survivors self-help strategies to manage their symptoms.  Despite the severe psychological, physical, and environmental damage inflicted by Nargis, the survivors in the Delta persevered. With great courage, they picked up the pieces of their lives and began the process of rebuilding. Once the reconstruction phase was well underway, remarkable changes speedily transformed the landscape in the delta. By October, many communities had resumed their daily routine. This included the re-opening of schools and monasteries, revival of businesses (e.g., teashops, grocery stands), return to daily work (e.g., fishing, catching crabs, farming), and increased communal participation in recreational activities such as group sports and karaoke. Additionally, we noted increased movements on the waterways with boat taxis and ferries plying the routes to major towns and surrounding villages.  Importantly, when speaking to the people, we noted a more positive future orientation with renewed feelings of hope and determination. Whilst all agreed that the road to complete recovery would be long and difficult, it was nonetheless possible. The hopelessness that plagued the survivors in the earlier post-Nargis months was all but gone. We closed the mental health program in Padegow at the end of November 2008. My team of counselors disbanded first, leaving me to tie up loose ends and write the final mental health report. That last week of my mission gave me some time to reflect on my role as a MSF field psychologist. Yes, I’ll admit, living conditions on the boat were tough. There were ever-present challenges, including the constant battle against local arthropods (picture mosquitoes and grasshoppers doing nose dives into your curries), lack of privacy (I doubt I will ever get the opportunity to live with 25 boatmen in future missions), dubious water supply (did I mention that we showered with water from the river and by the way, our latrines were at the back of the boat), and my two weeks of diarrhea (I’ll save that for a different story), to name but a few.  On the upside, it gave me the opportunity to bear witness to the resiliency of the human spirit. It is both humbling and inspiring to see people reaching out to other people, and to witness firsthand how individuals are able to reclaim their lives in the aftermath of a horrendous catastrophe like Nargis.  And that is why I continue to volunteer for MSF.    Marlene LEE, PhD. Field Psychologist MSF Padegow, Myanmar August 2008 - December 2008