by Andrew Mohanraj Chandrasekaran
December 26, 2024 marks 20 years of the Asian tsunami that created havoc in several countries in our region. Indonesia’s Aceh province was devastated both by a 30-year-old civil war and the catastrophe of the tsunamic itself. This is the story of a resilient people who overcame all odds in their journey to recovery.
When I arrived there, health workers were also placed in temporary housing with great challenges that we Malaysians are not used to. However, the preoccupation with clean water to bathe or fear of the mild daily after-quake tremors quickly pulled into insignificance when faced with tragic stories that resonated from the mouths of the survivors.
Take Aisyah, for example. She recalled grabbing her two young children from bed and running ahead of blue waves of water that were threatening to engulf their housing area. She ran as fast as she could, holding one child in each hand but soon she had to swing one child to safety, fully aware that in the split second, the other child would be swept away by the waves.
How could a mother choose between two children in such a situation? The guilt never left her. I was overwhelmed when I heard Aisyah’s story but soon, I realised there were many more like Aisyah, who battled the guilt of having to make similar decisions.
Farouk on the other hand presented to me with suicidal intentions. Clearly, he was depressed, having lost significant weight and having poor sleep since the tsunami.
He recalled that fateful morning of the tsunami when his only son ran up to him in the yard of their house., shouting “Ayah, people in the village say, large waves from the sea are heading towards us.”
Farouk slapped his son and told him to go inside the house to complete his homework and that he would have none of his son’s usual pranks. The child went into the house sobbing and that was the last Farouk saw his son.
When the waves hit their house, Farouk was swept to safety on to the rooftop of a building a few kilometres away but his son and wife had no such luck. The next day when the situation somewhat settled, Farouk frantically looked for them.
He found their bodies lying close to each other and felt guilty for chasing his son into the house. He argued that God should have taken him instead and that his son should have been spared.
Treating Farouk was a challenge and counselling and medication saw him through his turmoil, although the pain lingers on even to this day. Again, there were many more like Farouk throughout Aceh with similar heartbreaking experiences.
Months passed and many survivors were seen through their difficulties faced, in their temporary housing or accessibility to education, water and sanitation, livelihood and even the opportunity to mourn the dead.
Soon after the tsunami, the Indonesian military, with the help of foreign and aid workers cleared the bodies that were scattered all over the coastal areas devastated by the catastrophe. In one site alone in Banda Aceh, 45,000 bodies were dumped into a mass grave site the size of a football field. This unceremonious burial disturbed many.
To facilitate the mourning process, together with the local population, in the spirit of gotong royong, we landscaped the area and built a large structure over it that would serve as a place of contemplation and to perform tahlil prayers. Such small gestures meant a lot to the grieving survivors of the tsunami.
Six months into the aftermath, I was asked to come back in my job as a psychiatrist in Hospital Kuala Lumpur. I pleaded for an extension of one more year to complete my work in Aceh. The then Director-General of Health graciously agreed to the request but reminded me that I have to be back to serve my own country after the extension.
Six months became one year and the recovery process in Aceh had only just begun. People were slowly moving back to new houses and some to the old houses which were repaired or rebuilt but the aftershocks and tremors continued to worry many.
Every day I slept in my normal work clothes with passport and US dollars in my pocket, in case of another earthquake. True enough, in the early hours of an otherwise quiet and salubrious morning in the surroundings of a paddy field, I felt my bed shake violently and heard window panes shattering.
I quickly ran down from the first-floor bedroom and when I heard concrete collapsing behind me. I turned back to see the whole staircase had crumbled into a pile of bricks. I ran out of the house unscathed except for some minor bruises but soon after that traumatising incident, I was faced with dilemma. Should I just quit and go back to safe Malaysia where such dramatic scenes are only seen in the movies? Or should I continue and just hope for the best?
After three days of vacillating between the two possibilities, I decided to stay and fulfil my promise to the Aceh Provincial Health Office that I would help in the recovery process.
Soon, my 18 months in Aceh went by. Certainly, there was much improvement and survivors were going about their lives, demonstrating resilience that surprised many including the World Health Organisation that predicted a slower recovery. Yet, there was still much to be done.
Aceh had no mental health services except for the sole mental hospital in the capital city of Banda Aceh., catering for a population of 4.2 million people. At any given time, the bed occupancy rate in the 140-bedded hospital was between 150 and 200 per cent. Mental health service was mainly custodial in nature but the tsunami opened up minds of the otherwise rigid bureaucracy and political structure.
I saw an opportunity to develop community mental health services. This meant shifting from traditional institutional care to community-based care that would envisage a more humane, less stigmatising and accessible mental health care.
In the meanwhile, I received reminders from the otherwise friendly administrative staff at Hospital Kuala Lumpur that I would face disciplinary action if I did not report for duty after my one and a half years of “leave without pay”.
Again, I had to make a choice, should I leave my work in Aceh uncompleted or should I just pack my bags to go back to comforts of government service in Malaysia?
I took the bold step of resigning from the Ministry of Health to continue my work in Aceh. There was no turning back and that was the real beginning in my long-term commitment to mental health development in Aceh.
Training in mental health was given to nurses and doctors and primary health clinics and home visits incorporated as routine outreach services. The main challenge was to convince the local governments on the long-term sustainability of such programmes.
It was an uphill task to convince each district administration to make the necessary budgetary allocation, given the decentralisation of government and political structure in Indonesia with a high level of autonomy for the districts. Fortunately, this idea caught on and the scaling up of services even went one step further in the establishment of psychiatric in-patient care in several district hospitals.
The greatest fulfilment for me in my years of developing mental services in Aceh was in the removal of physical restraints in people with chronic mental illness. Aceh had very high numbers of such people, who for lack of proper mental health services, were chained or locked up by their family members.
Agam, for instance, suffered from schizophrenia, a chronic mental illness characterised by psychotic episodes. One day, he stabbed his neighbour with a kitchen knife and since then, for five years he was chained under a tree outside his house. When my team found him, we convinced his family members and other pessimistic elders in the village that Agam could recover with proper medication and supervision by a caring family.
Today, Agam is gainfully employed in a sawmill, thus living of dignity like the rest in his village. The establishment of community mental health services meant hundreds of mentally ill people like Agam in Aceh are now free to live a life of self-respect, demonstrating that even people with chronic mental illness can also recover and be productive. They too have a right to lead normal lives like every other human being.
As a result of untiring advocacy, Aceh became the first province in Indonesia to have a Mental Health Law or Qanun to protect the rights of those with mental illness. Much has changed in Aceh, from a province that suffered the double blow of 30 years of civil war that culminated in the devastating Asian tsunami.
The proud people of Aceh with a glorious history of Islamic civilisation have demonstrated to the outside world that with strong commitment and faith, such a psychologically fractured society can again stand up and be counted. The bustling city of Banda Aceh, which today bears no trace of the destruction it faced 20 years ago, is testimony of the resilience of the Acehnese.
The above essay was taken from a collection of essays in a just-released book by Prof Dato’ Dr Andrew Mohanraj Chandrasekaran entitled “A Journey Through Mental Health and Society”.
The author had served the Ministry of Health, Malaysia for 12 years before taking up an international assignation in Aceh after the Asian tsunami of 2004.
Besides currently running his own practice in Kuala Lumpur, Dr Andrew is engaged in short-term consultation to provide mental health services to refugees and asylum seekers. He is actively involved in the mainstreaming of mental health issues in Malaysia as the President of the Malaysian Mental Health Association. In the academic field, Dr Andrew is Academic Professor at Taylor’s University, Malaysia.