DEALING WITH DISASTERS

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Utter devastation. More than 75,000 people in Sri Lankas Ampara district lost their homes in the tsunami; more than 10,000 died.

NEWS

The Tsunamis Psychological Aftermath

The massive psychosocial relief effort has had its problems, but most the Indian Ocean to gauge, and help alleviate,
survivors of the Indian Ocean disaster have shown remarkable resilience. the psychological toll of the tsunami. Perhaps
One positive outcome may be a much-needed increase in mental health more than any other disaster in recent history,
services for the region the tsunami triggered an outpouring of aid
for the devastated regionalong with
T IRRUKKOVIL , K ALMUNAI , AND C OLOMBO, S RI The young womans situation is com- unprecedented attention to the mental health
LANKA; CHENNAI AND CUDDALORE, INDIATwo mon, says Boris Budosan, a Croatian-born of the survivors, many of whom saw their
dusty vans pull up at a camp for displaced psychiatrist with the International Medical children or other family members carried
tsunami survivors near Tirrukkovil, a small Corps (IMC) who works in the camps away by the waves. Since the disaster, hundreds
fishing village on the east coast of Sri Lanka. around Tirrukkovil and elsewhere in of nongovernmental organizations (NGOs)
Several men hop out and begin setting up a Ampara district, the region in Sri Lanka have sent teams to the region to provide various
mobile medical clinic. They grab a table and a hardest hit by the 26 December 2004 forms of psychosocial aid.
few plastic chairs and set them up under a tsunami. People in this part of the world Eight months later, the full impact of
thatched roof supported by metal poles. Next almost never speak of mental anguish, the tsunami on the mental health of the
comes the pharmacy: a row of medicine jars Budosan says; its just not part of the culture. survivors remains unknown. The World
on a wood plank in a neighboring tent. As Instead, they complain of various aches, Health Organization (WHO), among others,
word spreads, a line forms to see Dr. Rajandra, pains, and discomforts that have no apparent has estimated that hundreds of thousands of
a physician sent from the ministry of health. physical cause. In the West you can ask people could suffer lasting psychological
The first two patients have respiratory somebody if hes sad, Budosan says. effects. Some early evidence, however,
infections, which flourish in the close confines Here, they dont talk that much about suggests that people may be coping better
of the camp. Next, a young woman in a batik their feelings. Even if the symptoms are than expected, aided by the Asian emphasis
dress complains of a headache that wont go masked, Budosan says, he and his colleagues on strong family and community ties. Given
away. She also has abdominal pain, numbness regularly find people living in the camps the scale of the catastrophe, the population
in her extremities, and, when asked, confesses who suffer from mental problems, especially has been remarkably resilient, says Harry
that she hasnt been sleeping well and hasnt depression, and who can benef it from Minas, a psychiatrist at the University of
felt much like eating. She slumps in her counseling or medication. Melbourne in Australia, who has worked
chair and stares blankly at the table but At the mobile clinic, Rajandra gives the with WHO and the Indonesian government
CREDIT: KIERAN DOHERTY/REUTERS

patiently answers the doctors questions. Her
symptoms began about 6 months ago, she
says, shortly after the tsunami swept away
her house and all her belongings and took
the lives of five members of her extended
family. Rajandra suspects shes suffering
from mild to moderate depression.
young woman a small plastic bag of anti-
anxiety and antidepressant pills, and a
worker from IMC gives her a short mental
health survey and will pass her name on to a
psychiatrist scheduled to visit the camp the
following week. Their work is part of a
massive effort under way in villages around
on the mental health of tsunami survivors.
Similarly, the verdict is not yet in on how
effective the myriad interventions have been.
The mostly Western relief groups arrived
with abundant good intentions and a wide
variety of strategies. But the field of disaster
mental health is relatively new, and little

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research exists on what interventions best
stave off long-term psychological problems.
Problems have arisen in the aid effort, but
many experts say the spotlight on mental
health has benefited tsunami survivors and
provided political leverage for revamping
health policy in the region to include mental
health care. This would be a welcome devel-
opment for a part of the world where mental
health problems are thought to take a heavy
toll butas in much of the developing
worldare largely unrecognized.
Gauging the impact
One reason solid epidemiological data arent
yet available is that many research teams felt
it would be unethical to conduct studies in the
immediate aftermath of the disaster. When
we saw what the situation was, we threw our
[survey] sheets away, says Prathap Tharyan,
a psychiatrist at Christian Medical College
in Vellore, India, describing a visit he and
colleagues paid to coastal Tamil Nadu state
shortly after the tsunami. Instead of doing
research, the team found itself on cleanup
duty. Now, 8 months in, we will get approval
from our ethics committee and go do a survey,
he says. Researchers in other tsunami-affected
regions have similar plans.
Some of the most-cited estimates of the
toll come from WHO, which in February
suggested that up to half of the 5 million
people affected by the tsunami would expe-
rience moderate to severe psychological
distress that would fade without intervention
over the course of a year or more. Roughly
5% to 10% would develop more persistent
problems, such as depression, posttraumatic
stress disorder (PTSD), or other anxiety
disorders that would be unlikely to resolve
themselves without intervention. And perhaps
1% to 2% would be left with incapacitating
mental problems such as major depression
or psychosis. WHO also cautioned that
the tsunami could trigger acute episodes
for thousands of patients with preexisting
conditions, especially those who were dis-
CREDITS (TOP TO BOTTOM): G. MILLER/SCIENCE; PALLAVA BAGLA
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DEALING WITH DISASTERS
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placed from psychiatric facilities or lost their By the end of the first year, youve done so
medicine in the disaster. many rituals youre not grieving anymore.
Talking to psychiatrists [in the affected Sadly, a long-standing familiarity
areas], we get a feeling that our general with upheaval and tragedy may also have
assessment was more or less valid, bolstered the coping mechanisms of many
says Shekhar Saxena, WHOs coordinator tsunami survivors. The idea that people
for mental health evidence and research who have chronic stress and now have an
in Geneva, Switz-
erland. Preliminary
surveys and anec-
dotal reports suggest
that the tsunami has
indeed affected peo-
ple deeply. Many
women have been
wracked with guilt
and anxiety over
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children they were
u n a bl e t o s ave .
Children have been
afraid to leave their
parents to go to
school. Men have
found it hard to
return to the sea to Supportive community. Even in displacement camps, like this one near
fish, and many have Tirrukkovil, strong social networks seem to be helping tsunami survivors cope.
turned to alcohol to
help cope. Survivors complain of night- acute stress will break down is not entirely
mares, flashbacks, and intrusive thoughts true, says Saxena. Sometimes they cope
of the disaster. One of the challenges for better. In Sri Lanka, ethnic conflict between
the upcoming epidemiology studies will the majority Sinhalese government and
be to distinguish normal stress and grief armed Tamil rebels killed at least 60,000
responses from psychopathology. people and displaced at least 800,000
At the same time, many people who have between the early 1980s and a 2002 cease-fire
worked with tsunami survivors are struck by agreement. Much of the violence took place
their resilience. Asian culture, with its in the Tamil homeland in the north and east
emphasis on group welfare over individual of the country, the areas worst hit by the
self-reliance, seems to have been a powerful, tsunami. Struggle is accepted by people here
positive influence. People came together as a given in life, says P. M. Vincentine, a
to support each other and look after the counselor for SHADE, a psychosocial NGO
necessities, says Athula Sumathipala, a Sri founded to help war trauma survivors in
Lankan psychiatrist who has worked with northern and eastern Sri Lanka but which
tsunami survivors in the south and west of has shifted its focus to tsunami survivors.
the country. A man who lost his own son There is a Tamil saying: Through the
would care for someone elses son. struggle, you have to live, he says.
In India, most people try to deal with Similar sentiments can be heard across the
grief in the context of community activities, region, from war-torn Aceh province in
explains Tharyan. Indonesia to coastal India. People here have a
In the West, public tough life to begin with, says Tharyan. The
grieving is not en- expectations in life are very different from
couraged, but at fun- those in the West. Many people in Tamil Nadu
erals here people cry, view the tsunami more as the latest obstacle
scream, shout. That life has thrown at them than as a cataclysmic
has helped people blow, Tharyan says.
cope, in Tharyans
view. So has religion. Chaos on the ground
Hinduism has many Into this cultural milieu came the psycho-
r i t u a l s r eg a r d i n g social NGOs. Prominent international relief
d e a t h , h e s ay s . groups like Mdecins Sans Frontires and
the Red Cross brought psychiatrists, psycho-
Talking it out. NGOs logists, and other workers with extensive
have provided a range field experience in disaster areas. The Scien-
of counseling services tologists brought Volunteer Ministers who
for tsunami survivors. trained local people to do touch assists, a
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 DEALING WITH DISASTERS
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technique that reputedly eases The Tsunamis Reach

suffering by restoring communi-
cation between injured body BANGLADESH
parts. Other groups brought 2 dead
everything from trauma coun- Arabian
selors to swim instructors to Sea BURMA THAILAND
teddy bears. 90 dead 5395 dead
The upshot, especially in the Bay 2845 missing
INDIA Bangkok
early days, was chaos. It was 10,749 dead of
Bengal China
nearly impossible to keep track 5640 missing Sea
of who was coming and what 647,599 displaced Chennai
they were doing, Saxena says. MALAYSIA
Coordinating the NGOsa task SRI LANKA 68 dead
31,229 dead 8 missing
taken on by WHO and other
Colombo 4100 missing 8000 displaced
U.N. agencies in consultation 516,150 displaced Banda Aceh
with local governmentshas Mal
been a major challenge through- Kuala Lumpur

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out the region, but especially
so in Sri Lanka, which has MALDIVES INDONESIA
attracted more psychosocial 82 dead INDIAN 128,645 dead
26 missing OCEAN 37,063 missing
relief groups than other coun- KEY
21,663 displaced 532,898 displaced
tries. At times there were more Affected areas
tents set up for the people trying
to help than for the people being Heavily affected areas
helped, says Saxena.
This has occasionally led to
friction and even competition as
psychosocial NGOs have tried to stake mental health, especially in non-Western Exporting trauma?
their claims in the refugee camps. At a settings. The harshest critics see PTSD as Some critics question the entire enterprise of
recent psychosocial coordination meeting a bogus diagnosisa medicalization of psychosocial aid to disaster victims, particu-
in Colombo, several participants said this normal grief. But even more moderate larly in non-Western countries. Derek Sum-
is still going on. Kids get attached to vol- exper ts think the diagnosis has been merfield, a psychiatrist at Maudsley Hospital
unteers, and then new groups come and overemphasized. Its not at all clear that in London, is among the most vocal. The idea
offer incentives for the children to join this is the disorder that burdens people of disaster mental health is culturally alien
their activities instead, said T. Gadamban- most, says Mark van Ommeren, a spe- outside the West, Summerfield says: We
than, a psychiatrist in the eastern town of cialist in disaster mental health at WHO. cant imagine something like this happening
Trincomalee. Children are torn between Its only one of many problems that arise in our countries without our needing coun-
these loyalties, and it can be traumatic. after a disaster. seling, so we take it all to Sri Lanka.
Another problem early on was that People who come looking for PTSD Instead of putting tsunami survivors in
many aid workers lacked fluency in local will find itand miss half the people who our shoes, we should begin by asking what
languages and knowledge of local culture, need help, says Minas of the University of they actually want, says Summerfield, who
says Sumathipala. In the first weeks after Melbourne. In Bosnia, for instance, spe- has worked in Bosnia and other war zones
the tsunami, for instance, some foreign cial centers set up to find and treat people and advised Oxfam and other NGOs on
groups buried bodies in mass graves due to with PTSD proved to be a disaster, he their psychosocial aid programs. In his
fears of disease. We have thousands of says. People with war-related depressive experience, people want help rebuilding
years of culture here, particularly with and anxiety disorders other than PTSD their homes, reestablishing their liveli-
regard to death and mourning, says were overlooked, as were people with pre- hoods, and getting the children back to
Sumathipala, who believes that casting aside existing conditions that were exacerbated school. They dont want foreigners coming
these traditions added to peoples suffering. by the war. over and saying, Youve suffered a deep
Efforts to dispose of bodies quickly were By putting out bulletins and using its wound in your psyche, and youre going
likely misguided anyway: Research has contacts with NGOs in the field, WHO has to need our help getting over it, he says.
shown that dead bodies do not pose an tried, with mixed success, to discourage R. Thara, a psychiatrist and director of
imminent threat of disease, and WHO and teams from focusing exclusively on PTSD. SCARF, a mental health NGO based in
other groups have discouraged mass burials The organization has also tried to discour- Chennai, India, that has done psychosocial
to allow time for traditional practices. age the use of single-session debriefing, work with tsunami survivors in Tamil Nadu,
In terms of psychological services, one a controversial intervention intended to agrees that counseling has been overempha-
of the biggest problems, say many reduce posttraumatic stress. In these sized. We had a needs assessment where
SOURCE: U.N./WFP/ODAP AND USAID

experts, has been an overemphasis on sessions, survivors are encouraged to relive we asked people what they needed, [and]
finding and treating cases of PTSD, which the traumatic event shortly afterward. But counseling was the last thing they checked,
is characterized by flashbacks, emotional the bulk of research has failed to f ind and probably only because wed mentioned
detachment, sleep difficulties, and other evidence that it reduces the incidence of it. Sumathipala says the same is true in Sri
disruptions. Recent years have seen a PTSD or other psychological problems, Lanka. People want material help, people
lively debate among mental health experts and some studies have suggested that it may are not asking for counseling, he notes.
over the importance of PTSD in disaster even increase the likelihood of problems. Two surveys in the north and east of the

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country in recent years found that people in future disasters. Many NGOs are reluctant entire country. Nearly all of these meager
displaced by the civil war who sought to do research, Minas says, because they see resources are concentrated in Colombo,
mental health treatment were actually providing service as the first priority. He where many patients are relegated to
more concerned with finding employment thinks that view reflects a misunderstanding outdated government-run asylums. In
than relief from psychological symptoms of the purpose of research. Lots of people are June, a Colombo newspaper visited the
such as flashbacks. ready to just get in and do things without any Mulleriyawa womens asylum near the
Still, Thara, Sumathipala, and others evidence of whether what theyre doing helps capital and photographed patients tied to
insist that for a small proportion of tsunami people or maybe even does harm. I think the beds with strips of cloth. The hospital,
survivors, counseling is in fact needed. As a its negligent to do that without evaluating built to house 400 patients, holds hundreds
psychiatrist I believe a certain amount of whats going on. more, some of whom have been there for
people would need psychological interven- decades, Mahoney says: Places like this
tion, including counseling and medication, Looking forward shouldnt exist.
says Sumathipala. Despite the glitches in the relief effort and Earlier this summer, the Sri Lankan Min-
The critique by Summerfield and others problems with particular NGOs, most istry of Health approved a plan developed
highlights how little is known about the best observers say the psychosocial response has by WHO, in consultation with local health
way to care for the mental health of people who been benef icial overall. There are also officials, that would close Mulleriyawa and
have lived through a disaster. The bulk of the encouraging signs that the influx of money another large mental hospital while vastly

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research to date has been carried out in devel- and the expertise of the better trained groups increasing access to mental health services,
oped countries. As a result, much of what is may help pave the way for a stronger mental especially for people outside the capital.
being tried in Asia, for instance, is based on health care infrastructure. WHO has pushed for this plan before with-
good intentions rather than good science, says The need is great. In Sri Lanka alone, WHO out much success, but with the momentum
Minas. I think theres a real obligation to carry estimates that before the disaster some 384,000 from the tsunami behind them, Mahoney is
out good quality evaluation of
whats being done and the conse- Health and psychosocial service
quences of the disaster, he organizations in Sri Lanka by district
says. But theres an ethical 37
quandary about what 417
kind of research, and 1830
14
carried out by whom. 3142
In the f irst few 19
4355
months after the tsu- 5668
nami, says Sumathipala,
several foreign researchers
Trincomalee
were found to be con- 49

ducting research without

approval from any
authority in Sri Lanka, or,
at least in some cases, 6

approval from their home 59 Here to help. Many NGOs have been active in Sri Lanka (left) and
institution. Sumathipala Tamil Nadu, India (above), where fishing boats bear the names of the
has been keeping a list of Kalmunai groups that donated them.
such incidents to push the
government to set up a 4 68 Tirrukkovil people suf- now optimistic that reform is possible.
Colombo
national medical ethics fered from seri- Now things will happen, he predicts.
16
review board. His list ous mental disorders A key component of the WHO plan is to
CREDITS (LEFT TO RIGHT): HUMANITARIAN INFORMATION CENTRE SRI LANKA; G. MILLER/SCIENCE

includes a Japanese group such as major depres- provide mental health training to primary care
15
he says collected blood from sion, bipolar illness, doctors, community health workers, and mid-
tsunami survivors to search for and schizophrenia, and wives in Sri Lanka. Rajandra, the ministry of
35
biomarkers of PTSD, without 49 perhaps 2 million who were health physician from Tirrukkovil, for exam-
47
previous approval. A ministry of afflicted by less severe mental ple, recently attended a series of mental health
health official seized their samples disorders. These numbers dwarf even workshops put on by IMC. NGOs are provid-
and insisted that they get approval, the worst case estimates for mental health ing much of the humanand financial
which they subsequently have done. Many problems related to the tsunami. (WHO resources for this training.
groupsuniversity researchers as well as estimates that 22,000 to 44,000 tsunami Similar plans are in the works for Aceh,
local and foreign NGOscirculated surveys survivors in Sri Lanka will develop psycho- where mental health care was virtually non-
in the aftermath of the tsunami. Some of these logical problems serious enough to require existent, and Tamil Nadu in India. The
were inappropriate, Sumathipala says, includ- long-term treatment.) trick, of course, will be to keep the ball
ing one distributed by a German group that But the country has just 41 psychiatrists, rolling after the tsunami aid money dries
asked young children detailed questions including academics. About four times that up. If the plans succeed, however, they may
about sexual abuse. many Sri Lankan psychiatrists practice in represent the most lasting legacy of the
Minas is working on a set of guidelines the United Kingdom, says John Mahoney, tsunami in terms of mental health.
that could be used by communitiesaided by WHOs point person in Sri Lanka for mental GREG MILLER
consultants from local universities and other health. There are no psychiatric nurses and Reporting for this story was supported by a fellowship
institutionsto evaluate research proposals only eight psychiatric social workers for the from the Carter Center.

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