Dato' Dr. Andrew Mohanraj © Aneeta Sundararaj

“Same old. Same old. 2004 has been so boring.” These were the words my friend said on Christmas Eve. Neither of us was aware that our belief that the year would end on a dull note was premature. On Boxing Day, I was at home in Alor Setar. I was busy caring for my puppy who was recuperating from an operation. I’d shortened her leash by twirling it around one leg of our dining table so that she would remain in one spot. Suddenly, the glasses in our cabinets rattled and the dining table shook. This tiny little dog is too strong, I thought. Yes, looking back, this makes little sense. At the time, though, I was so focused on trying to make sure my fussing dachshund stayed still that no other reason for the house shaking occurred to me.

“Did you feel that earthquake?” My mother asked some fifteen minutes later when she came downstairs.

“Oh! So that’s what it was,” I replied as comprehension dawned.

We talked a bit more about this over a late breakfast and then thought nothing more of it. Slowly, news began to filter through about the gravity of what had happened. The earthquake, with its epicentre in the Indian Ocean off the west coast of Sumatra, Indonesia, measured 9.1 on the Richter scale. In the next three to seven hours, a tsunami followed and caused devastation in more than 14 countries in the region. The hardest hit was Indonesia followed by Sri Lanka, India and Thailand. By midnight on Boxing Day 2004, more than 250,000 people died and millions of people lost their livelihood, homes and family.

When I spoke with my friend two days later, we discussed how we could and would offer help to the victims of this monumental tragedy. Perhaps, we could make a monetary donation to an aid organisation. We would rummage through our closets and find clothes we could donate to the needy. Victims of this disaster could seek temporary shelter in our houses. Not once did either of us consider offering aid at the disaster site as we were not at liberty to leave our families. We were not going to risk financial security by taking a temporary leave of absence from our jobs to help rebuild towns and cities that no longer existed. We wouldn’t move our world simply to tend to these victims whose needs far outweighed ours. One man did – Dato’ Dr. Andrew Mohanraj.

When I first meet Andrew for a chat, he introduces himself with a bright smile and says, “I’m a simple psychiatrist.” Instinct warns me not to be fooled by this. I was already aware that in the aftermath of this, one of the deadliest natural disasters in recorded history, Andrew made his way to the worst-hit place, Aceh in Sumatra. It was reported that the waves generated by the force of the tsunami were up to 15 metres high. When he first arrived, the challenges in rebuilding this land ravaged by nature seemed insurmountable. Nothing was left and it was almost wasteland. Yet, through perseverance and determination, in the course of the next three years, he became a pioneer in the region for creating sustainable psychosocial rehabilitation and community mental health services. Nothing simple about that.

IN THE SHADE OF A MANGO TREE

This calling to serve and help people wasn’t something spontaneous that occurred overnight. Agreeing to my request, he recounts a story from his childhood as the eldest of four children. Gradually, I can see that this pattern of selfless giving began long before he became a doctor.  Indeed, his quiet demeanour belies a steely determination to ensure the well-being and health of one of the most stigmatised people in society, people with mental health issues. You risk his wrath if you trivialise mental illness, poke fun at those suffering and living with mental illness or make ‘mental’ jokes.

“Until I was eight years old, I stayed with my grandparents in Taiping, Perak,” he says, his speech measured and calm. He wears a soft smile when he describes his grandfather and says, “He liked to wear a veshti and never a sarong.” Sighing, he adds, “We sat in the shade of a mango tree in the garden and we discussed things. Every day.”

Cocking his head to one side, he says, “I mean, who has discussions with a seven-year-old boy?” True, this seemed unlikely, even more so when Andrew explains that their discussions were never about frivolous stuff such as games the boy played or toys he wanted. Instead, with a life-long habit of reading the daily newspapers already instilled into the little boy, grandfather and grandson discussed world news. All these adult-like conversations had a huge impact on the boy and he flourished in his studies. He did so well that he decided to tutor the other urchins of the neighbourhood.

What on earth could a seven-year-old boy teach others? “Schoolwork,” he replies, quite matter of fact. All such efforts had to come to a stop, unfortunately, when the boy Andrew decided that he should not be offering his tutoring services for free.

“I started charging them RM2.00 per month,” he says with a chuckle. His business venture was short-lived when, one day, the grandmother of a little girl he tutored stormed into his house and informed his grandparents about what he was doing. “But I didn’t keep the money for myself,” he says, defending his actions. “I helped the others.”

It’s those last three words he uttered that caused his grandfather to make two predictions: the boy Andrew would become a doctor for he was both intelligent and had the aptitude to study medicine. More than that, his grandson was sure to use his skills and knowledge to help people.

The first prediction came to pass soon after he finished his basic schooling in Kuala Lumpur because in the 1980s, Andrew became the recipient of a Commonwealth Scholarship offered by the Indian Council for Cultural Relations to study medicine at the Calicut Government Medical College in India. In time, he chose to pursue psychiatry and settled into a comfortable job with the Ministry of Health in Malaysia. Then, the tsunami happened.

A BLANK CANVAS

What faced Andrew when he first arrived in Banda Aceh under the auspices of the International Medical Corps (IMC) would have overwhelmed anyone. He becomes sombre when he refers to a published article he wrote ten years after the disaster and recounts some of the heart-breaking tales of the people he met when he first arrived in Aceh.[1] There was a mother who was forced to sacrifice one child to save another. A father had suicidal thoughts because his son may still be alive today had he not scolded the boy and insisted he go study inside the house that was subsequently washed away. In Banda Aceh, a mass grave site the size of a football field was dug and 45,000 bodies were placed there.

It wasn’t easy for the survivors of this disaster to contemplate carrying on with life when they were denied the ability to properly mourn their dead or seek closure for what had happened. Sanitation, proper food and medication were problems in temporary shelters. It was only a matter of time before people were bound to be seeking help for PTSD, depression and psychosis. Added to this was the fact that at that time, there was one mental hospital in Banda Aceh catering to a population of almost 4.2 million and most mental health services were custodial in nature.

At a glance, what Andrew faced was a daunting task. However, at some level, he had to be aware that what he now had was a blank canvas with which to work magic. He set to work and from the start, he knew that it did not make sense to opt for a quick fix. He could have trained local doctors and medical personnel about how to treat and care for mental health patients and left it at that.

“These people, however, were those at the top of the pyramid,” he explains. He feared that if he trained them alone, they wouldn’t stay and help with rebuilding Aceh. Instead, they would choose to leave for greener pastures. He saw an opportunity to develop community mental health services.

Although this meant that things in the mental health scene in Aceh had to change at a basic level, Andrew insists that his plans went further and were quite widespread. His aim was to create a framework for psychosocial rehabilitation that was sustainable. What did this mean, though?

Smiling, he explains, “Anyone can start something. But will it last?” His aim, therefore, was to create a system that would continue long after he’d left to return home. “This,” he says, “means shifting from traditional institutional care to community-based care.” More people should have access to mental health care which was humane in nature. Also, there must be less stigma attached to the treatment and therapy the patients received. He also listened to what these victims needed since he believed that support comes in different ways. It could be simple things, from playing a game, starting a small business or mourning together.

SHACKLES AND RESTRAINTS REMOVED

While everything seemed in place in theory, on a practical level, the challenges were many and recurring. Aceh remained unstable and aftershocks of the earthquake were a constant source of worry for everyone. Shuddering, Andrew says that he’d learnt to keep his passport and money on his person all the time. It was a wise thing to do because he woke up one morning to his bed shaking violently. He ran downstairs from his bedroom on the first floor. When he turned to look back, the entire staircase had crumbled.

Back at home in Malaysia, he faced another dilemma. Having not reported for work for a year and a half, his bosses were demanding that he return or face disciplinary action. Today, he describes the decision he made at this time as a bold one. This, he admits is with the benefit of hindsight because he now recognises that he was giving up a very stable career that would have seen him rise to the top of the government service. At the time though, none of this mattered. What did was the promise he’d made to the Aceh Provincial Health Office that he would help with the recovery process. With that, forty-year-old Andrew chose the only option available to him – he resigned from government service.

With the shackles of being in full time employment removed came the complete freedom for Andrew to do exactly what he wanted. He channelled all his energies into developing mental health services in Aceh. His greatest challenge, he says, was 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.’[2]

Nonetheless, Andrew and his team persevered. In three years, he’d set into motion projects for psychiatric and psychosocial rehabilitation in several districts in Aceh. At its most basic, these involved training medical personnel to care for mental health patients. When it was difficult to reach such patients, Andrew saw to practical issues like arranging for transport for medical personnel to travel to patients’ homes to provide the necessary care. He and his team organised community care awareness programmes which involved religious and community leaders, teachers, police personnel and women’s groups. Workshops with traditional healers helped to bridge that gap with villagers who were sometimes reluctant to open their hearts, minds and homes to new methods of treatment. Two ‘Quiet Houses’ built at mass gravesites became places where those who’d lost family and friends in the tsunami could grieve, rest and pray. Books such as ‘Where There is No Psychiatrist’ and guidelines for psychiatric nursing care were edited and distributed to all primary health care centres.

In time, patients with chronic mental illness who had to be physically restrained had such restraints removed. With proper medication and supervision, they regained their dignity and self-esteem thereby allowing them to lead productive lives. Today, Aceh is one of the few provinces that has a mental health law or qanun to protect the rights of those suffering from mental illness. The success that he and the people of Aceh achieved in those few years surprised many including the World Health Organisation which had predicted a longer recovery period.

When his tasks in Aceh were complete, he stayed on in Indonesia. In the course of the next few years, he became fluent in Bahasa Indonesia and worked with, among others, a German non-governmental organisation called CBM International. As the country Director for Indonesia, he oversaw both disability and mental health-related programmes. “In 5 years,” he explains, “I supervised over 100,000 surgeries (mainly removal of cataracts) making us the biggest prevention of blindness project in the country.”

Meanwhile, as word got around about all he’d achieved, Andrew began to receive accolades, titles and awards for the work he’d done. Among others, he was invited by the World Health Organisation to be a member of the Global Forum in Community Mental Health. He was also awarded a scholarship by the Royal Australian and New Zealand College of Psychiatrists to pursue a fellowship in community mental health at the University of Melbourne.

DISASTER PSYCHIATRIST

Today, he manages a practice in Malaysia and is also the President of the Mental Health Association of Malaysia. That said, as one of the few disaster psychiatrists in the region, he specialises in the branch of mental health care which provides psychiatric services to disaster victims and rescue workers. Naturally, his services have been called upon time and again such as after the earthquake in Padang, Indonesia, the volcanic eruption in Yogyakarta, post-war Timor Leste, after typhoon Haiyan in the Philippines and the disappearance of MH370.

Constantly on the go, Andrew is aware that being a disaster psychiatrist can keep him away from his home, family and friends for long periods of time. While others fear to go to some of these areas because of the security concerns, he’s optimistic and adventurous in equal measure and chooses to look at the positive aspects of visiting such places.

“It’s not always how the media portrays it,” he quips when sharing stories about Nauru, the tiny island country in Micronesia, northeast of Australia where Andrew is undertaking consultative work. Instead of doom and gloom, with his words, he paints a picture of a people who have learnt to go with the flow. They’re generous with everything from their resources, goodwill and love. “To a fault, almost,” he adds, surprised that Nauruans can be that selfless. I hide my smile, immediately aware of the irony of Andrew’s observations. He seems utterly oblivious to the fact that they’re probably holding a mirror to the remarkable work he’s done.

As our chat comes to an end, I am tempted to ask if he’d change anything about his career.  Would he have chosen to negotiate a manner in which he could have stayed in government service and still help those in disaster-hit regions? Does he regret the sacrifices he’s made? Then I remember his grandfather’s predictions for the boy Andrew and I know his answer. Unable to say no to anyone who needs help, Andrew would do it all over again. In a heartbeat.

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[1] Mohanraj, Dato Dr. A. (18 December 2014). Remembering Tsunami 2004: Diary of a disaster psychiatrist. (Retrieved from https://www.thestar.com.my/lifestyle/people/2014/12/18/diary-of-a-disaster-psychiatrist/)

[2] Mohanraj, Dato Dr. A. (18 December 2014). Remembering Tsunami 2004: Diary of a disaster psychiatrist. (Retrieved from https://www.thestar.com.my/lifestyle/people/2014/12/18/diary-of-a-disaster-psychiatrist/)

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