True Grit. A series of conversations with people on Mental Health and Resilience.
Episode 4: Tan Sri Dr Jemilah Mahmood. Physician and founder of Mercy Malaysia
Brought to you by Etiqa
The Hippocratic oath is one of the oldest binding documents ever. One of the lines goes as such:
“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”
The oath requires physicians to treat patients—with patients being the operative word, not ailments—to the best of their abilities. After her years of service, it’s safe to say that Tan Sri Dr Jemilah Mahmood, founder of Mercy Malaysia, and current Professor and executive director of Sunway Centre for Planetary Health has gone above and beyond.
In this interview, Dr Jim speaks to our very own Editor-in-Chief and CEO, Kassandra Kassim who is filling in for our resident host for the series, Azran Osman-Rani. Dr Jim shares her experience working in various environments. For this doctor, the work may be laborious, but it’s never futile.
Let’s walk through your state of mind today. What are your new projects?
Actually, I woke up this morning feeling really good because yesterday I planted five mangrove saplings together with a group of people and we planted 500. It was tough. I didn’t realize how tough it was going to be. I didn’t think I would be fit enough to do that, but it felt really good so I woke up feeling good and looking forward to talking to you of course.
Right now I head up a brand new center for planetary health at Sunway University, and because we have to address the root causes of why people are unhealthy nowadays, and a lot of it has to do with the way we’ve treated the environment and climate change, all the impacts of the destruction that human beings have created.
Apparently, there is a link between mental health and the environment, is that correct?
Yes, it’s a very clear link. Climate change itself is very strongly associated with mental health. When someone comes out of a crisis or within a crisis that is a result of climate change, whether it’s a cyclone or storm, floodings, it’s always a result of how we’ve treated the environment and the risk we’ve created. Even in a crisis situation, obviously, you will feel very depressed. Chances are you feel unsettled, anxious, and so on and so forth. Global temperatures are rising and just increases in temperature itself has been associated with mood swings, a greater incidence of depressive illnesses, and also exacerbates other mental health issues like schizophrenia. There’s a lot of research now on climate and health and it also encompasses mental health.
So you treat the planet better, you feel better, basically?
What I’m doing now in planetary health is to raise much more awareness but also do things because we cannot have human health without planet health—everything is linked. One of the things that we have to be aware of is that pandemics don’t just come out of the blue; it happens when there’s many, many years of environmental destruction, and therefore men with insatiable desire to develop and to destroy. Dietary habits also play a role. What we call zoonotic leaks, where the viruses that are actually in animals and live quite happily within animals but because of the consumption patterns that have changed, the viruses jump from one animal to another and then it gets to us humans.
Going back to the pandemic, you’re quite a central figure in that. How do you look at COVID-19 and its impact on mental health?
I think the impact of COVID-19—or any pandemic for that matter—in mental health is something that we have to take very, very seriously. It affects everyone, whether you’re ill or whether you’re not. Obviously if you have had the misfortune of falling sick with COVID-19, there could be long-term consequences, or what we call long COVID. And that can really take a toll on mental health.
There’s also people who have not been infected, people like you and me who have had to restrict our movements. Especially if you are someone who is an extrovert, and likes the company of people, I think it’s very depressing if you can’t even visit people you really love. But on top of that, there are also everyday people who actually have to go out and find a job and to raise enough money to put food on the table, so the economic and social consequences of the pandemic have a tremendous effect on mental health.
Then there’s young people who will have to go to school, university and it is not just about the classes. It’s also about the interactions so the entire norms of how children and young people develop is disrupted. That can cause quite severe mental health problems as well. I want to focus on women, as I think women have more pressure during the pandemic and there has been some research that is quite alarming, that the suicide rates among women were actually higher than men.
Women have multiple ascribed gender stereotype roles, which is “you are at home, you have to cook, you have to clean, you have to do all the housekeeping, and on top of that you have to take care of the children”, so when you actually go to work, you actually escape a little bit from that pressure. On top of that, you’re with a spouse constantly. I think the incidents of domestic violence have also increased during the pandemic. All this adds on to the many layers of mental health pressures that women will have to undergo.
That is one guess, the other thing of course is that there are many women-headed households, who have to fend for their children and their families as well. Women are also carers for the older and the elderly. I was speaking to friends in psychiatry… I’m not a psychiatrist or psychologist, but certainly this is something that they are now further interrogating, because usually suicides are higher in men. We’re surprised that it was higher in women last year.
Has there been a rise of other illnesses that you see during COVID, with the stress?
I think one of the biggest challenges we faced during the pandemic is because the focus was on the pandemic and the infection that was caused by the virus. Other illnesses were kind of put aside, particularly if you are from the lower or middle income group and need to go to public hospitals for care. You can’t, your elective surgery is put off. We have no idea, to be very honest, how much mortality might have been caused because someone couldn’t get a heart-bypass or couldn’t get some cancer surgery on time, so these are other things that we have to look at: the implications or the impact of COVID-19 on other health parameters.
And then you’re cooped up at home, you can’t exercise. People tend to gain weight. Everybody loves to cook during the pandemic, and with less activity, there is a tendency that people will put on weight. That itself is a problem, because Malaysia is one of the most obese countries in the world. We have the highest incidence of non-communicable diseases in the region. One in four people walking around in Malaysia is hypertensive, so all this is also exacerbated by stress.
How has the impact on mental health been on health workers—because you are in the thick of it—what have you observed and what have you seen?
I counsel a lot of young doctors. My mobile number’s given to almost everybody I meet. I will say that many of them are really, really exhausted and burnt out. Some have quit the profession, as you may have heard. Not just doctors, but also nurses, and paramedics because one can only tolerate that much pressure, the way that the surges have come in Malaysia.
Many of them are telling me they’re depressed because they are working and they see people out there not wearing a mask, just enjoying themselves, not bothering to take a vaccine, so there’s a lot of pressure on healthcare workers. But you took a Hippocratic oath, and you want to do your best, so people persevere but there’s no outlet. When they go home, they also have their families to tend to, so on top of being exhausted and burnt out and tired—physically tired—they also are anxious, because they have children at home. They worry that they bring home the disease to their elderly parents, or their kids. They worry that the children’s education is disrupted. Doctors are humans and nurses are humans; they worry about things that non-medics worry about, on top of having to take care of patients with COVID-19.
You’ve been and seen so much. How do you keep it together when you’re dealing with the things that you are?
You can choose to either be mentally strong. Mind you, I go through my stress and depression as well. I think you’ve got to acknowledge that it’s hard. I know when my mood is down, but I know when I’m feeling that I’m a bit overwhelmed. I have clear defense mechanisms. One is I retreat. I go into my room. I need my own space, my reading. For me, the spiritual side is very, very important, reconnecting with that.
Having people you trust, that you can talk to. I have a fantastic husband, who is my rock. He’s unperturbed, he’s the coolest personality. Here we are, I’m type A and he’s like type C, so it’s balanced. And then, of course, your friends who you can trust, who are there to listen to you, but then you also channel the energy into something else.
For me I channel it into helping others. I channel it into planting vegetables in my garden. I channel into things that I think are positive and I can see results. That’s something better, growing your own food, your vegetables. You pick them, and you can give them to your friends. It just makes you happy.
But I think the most important thing is really acknowledging and having that self-awareness. If you need help, professional help, you should ask for it.
I notice that you’re wearing a green ribbon—clearly mental health has been an issue that’s been at the forefront for you for a while now?
I love this green ribbon, it was a gift from Tengku Iman who’s really championing mental health. For me, having gone through so many challenges in my own personal life, in my work and also being exposed to the risks of mental health, and also treating people with mental health issues, the green ribbon symbolises that we need to normalise how we talk about mental health, how we create much more awareness about it, and also try to destigmatise it. Because whether we like it or not, it’s still a very stigmatised issue in countries like Malaysia. I think my friends in the US will say “I have three psychologists”, very proudly. But here, even for a Malaysian to say “I have a psychologist”, is difficult.
There are not many psychologists in Malaysia as well. I hope the green ribbon movement will strengthen. I really hope that more people will understand that it’s just like any other disease, whether it’s hypertension or diabetes or anything else. Mental health is also a health problem.
The more you engage with exercise and much more healthy living, your mental health resilience will probably be strengthened.
There’s a famous story of you conducting surgery even though you’ve been shot. That must have taken a whole lot of mental resilience. Can you just walk us through that?
That’s a subject that’s very hard for me to talk about, but I will tell you the consequences of that. It is true. That happened April 12th 2003, at 1:00 PM. It was in Iraq and I was caught in a crossfire. I lost two staff members, and my colleague got very badly injured. It just so happened that, as we got deeper and deeper into the very, very dangerous area, a woman came in with three previous cesareans, very anemic and I was the only obstetrician at the hospital. There was one junior obstetrics officer.
She said “can you help me, because this is going to be difficult?” What choice do you have, right? I had to go in there and do the surgery. I tell this story because I feel that women are so strong and I, as a surgeon and as someone who’s had surgery before on me, I know how painful it is after abdominal surgery. I remember saying to her “I’ll come back”. I said to the nurse after six to seven hours, I will see how she’s doing postoperatively. I came back and I saw her packing her clothes on the bed. I had to ask again, is this really the woman I operated on, and she said “yes”, and I said “where are you going?” She said something to me that will stick with me for the rest of my life. She said “if the bombs dropped tonight, I want to be with my children”.
At that point I said my pain is nothing compared to her surgery, my stress is nothing compared to what she’s going through. I will continue working. I didn’t want to get the bullet out of my hip anyway, because there was no one to do the surgery on me that I trusted. When you’re in that situation where the adrenaline is high, you block out all the mental stress that you’re going through. You just carry on.
When I got home and I had the surgery then, I really went into deep depression. A lot of things were running through my head. I relived the whole situation in the shooting, wondering if I made the right choices. I had to call my colleagues to go through the security protocol, ‘did we do the right thing?’ we did. It was just really bad luck—being in the wrong place at the wrong time. But I guess I was at the right place at the right time for someone.
I had to rationalise all that, and I got help. I actually got a psychiatrist friend to talk to me, to help me with medication to help me sleep. It triggers [every now and] again. You asking me, it relives in my head. It doesn’t hurt, it’s okay, I can deal with it now.
That has really also alerted me around how vulnerable healthcare workers or humanitarian workers are to mental stress. When you go through something like this and you meet your friends in the sector who have also gone through the same thing not long after that… Margaret Hassan was a friend, she’s from CARE, Irish woman, and amazing. She disappeared and was probably killed. We had worked on a project together in Iraq.
For other friends in the humanitarian sector who have had to go through kidnapping, and all sorts of things. You realise people see us as kind of heroes. But heroes bleed too and die, and go through so much stress. At the end of the day we’re just human beings trying to make a difference.
I’m very empathetic towards people with mental health illness. The challenge though, with many people with mental health illness, is the stigmatisation which is still very strong in Malaysia. For a person here to go and get help, they are seen as weak. They seem to be unable to cope. The minute you’re seeing a psychiatrist or psychologist, people think there’s something wrong up there. Actually it’s not the case. It’s an illness, just like hypertension, just like diabetes, it is about chemical imbalances in your head. But most of the time, it’s also stress. I don’t think I have endogenous depression, but when you are sad, it’s a natural tendency to feel anxious or worried, so I really hope that we can all work together, destigmatise mental health illness. There are categories of mental health illness: on one hand you’ve got the severe, the schizophrenias, the bipolar disorders and so forth; and on the other hand, you have the anxiety, reactive depression which are all very easily treatable with psychology and behavioral treatments. Malaysians need to be kinder to each other number one, and number two, we need to really help each other to get help when we need it.
Security, safety, and comfort usually anchor a person into the sense of mental well-being. But in your humanitarian work, clearly people who live in war-torn countries will not have any of these, but yet they endure. How do you think they do that, from what you’ve seen?
I think they have no choice. It’s easy to say they’re strong and they’re resilient. Actually, they don’t have a choice. What choice do you have if you are born in Syria or Yemen, and you don’t have enough money to get out? What choice do you have if you’re in Gaza and you can’t even have an opportunity to leave the country safely? I think we have to really respect the fact that sometimes it’s not a matter of choice.
The second thing, though, is that when you are under so much pressure, you learn how to adapt, adjust, and mitigate your stress. I always remember that the best diamonds are born under lots of pressure. It’s easy to say that but until and unless you’ve been through that kind of pain and stress—which can vary from one person to another. What might be considered terrible stress for me is nothing compared to somebody else’s. You ask me how I do it, I do it because I’m so grateful. Every time I think ‘why am I in this situation?’ I tell myself ‘hang on a minute, remember that situation’.
I want to tell you two stories if I may. I worked in Darfur in Sudan as an obstetrician and gynecologist. I walked into the labour ward and it looked like a cowshed and they were razor blades on the ground! Women were giving birth in this situation. I worked in a private hospital, where people are fussy even if the air-conditioning is not the right temperature. And then I looked at this and resolved that I would build a Reproductive Health Center in Darfur, so we did. Not only that, we work with the Ministry of Health. We trained midwives, we trained a lot of people. That was 2004-2005.
In 2009, I was already contemplating leaving MERCY Malaysia. I always feel leadership requires renewal, so as a founder, you can’t stay too long that people cannot isolate the organisation from you. So I thought 10 years is enough but still I was really, really nervous, whether it was the right decision to make. I said “God, show me a sign now, give me some signs that is the right thing to do. This my baby, I’m gonna let it go”.
I remember standing in front of the broken chair in Geneva right in front of the UN when I saw a bunch of women protesting. They were Sudanese women, and one of them walked towards me and looked at me and she said “you’re Malaysian, aren’t you?” and I said “yes”, and I said “you are definitely from Sudan,” and she said “no, I’m actually from Darfur”. They’re very proud. She said “I’m from Janina,” and I said “oh! I worked in Janina”, and she looked at me, she said “do you know this organisation called MERCY Malaysia?” I was like, “yes,” and she said “do you know Dr. Jemilah?” and I said “yes, why?” I was quite nervous, maybe she’s going to complain, and she said “the women of Darfur used to die at childbirth, but now the reproductive health center is there. Can you just pass a message, that we don’t die from childbirth? We have a place now to safely have a baby”.
This is unsolicited feedback. I knew then that was a sign I had to leave, but more importantly when you do something, you never think about the long-term impact. You do it because you think it’s the right thing to do. And then out of the blue, someone comes and tells you that “women are not dying now because there’s a safe place to have a baby,” or “less women are dying”. That gives you that mental strength to look at these pockets of light and these gifts that are really to strengthen your gratitude. You do things for these reasons.
There are also little stories I can tell you about spending Hari Raya on a mountaintop at the border of India and Pakistan after an earthquake, and feeling really, really sad, because my husband forgot to pack serunding—somehow he forgot to pass all the nice things that I wanted to eat. I feel really quite miserable for myself. I was sitting on the top of this hill, on the rubble, and a little girl came to me, with these grubbiest fingers but the sweetest smile, a little plate and she sticks up a little bit of sweet rice and she says “Eid Mubarak”. Then you realise that, gosh, yes, it’s Hari Raya. Yes, I’m not with my family, but to this little girl, your presence meant everything to her.
I think you’ve got to embrace that life is going to be hard, and it’s going to be challenging. Your time on earth is so finite, yet amidst all that horror and pain and suffering, these little lights that come to you to remind you that it’ll be okay. You just keep doing it and one day things will sort themselves out. I think that’s how I build my mental strength, to look back on not just the bad times, but also the really sweet, good times. You can then take comfort that amidst all that pain, there’s a lot of joy and love and that is so important.
Thank you very much on those inspiring words. Thank you very much for your time today.
Thank you. Thank you, Kassandra.
This series on Mental Health is brought to you by Etiqa. If you want to know more about insurance and takaful products that Etiqa has to offer, including those that cover mental illness, please click here.