Death by tsunami and poverty
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7482.0-f (Published 06 January 2005) Cite this as: BMJ 2005;330:0-f
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One aspect of the response to the Asian disaster concerns what some call "disaster mental health". The tsunami has prompted the Department of Health to circulate briefing papers on acute stress reactions and post- traumatic disorder throughout NHS trusts,and various experts have stated that as many as 25% of child survivors will develop "post-traumatic stress disorder" which will need professional intervention.
So too following the recent Beslan school disaster. A Lancet paper described a team of 48 psychiatrists, psychotherapists and psychologists, assembled before the siege was even over, to address "profound psychological scars". A team of psychologists was still manning a 24 hour hotline 3 months later amidst expectations that many surviving children still needed trauma debriefing or would carry longterm psychiatric problems in the shape of post-traumatic stress disorder (1).
“Disaster mental health” rests not on medicopsychological discoveries but on Western cultural trends. The concept of a person, most particularly a child, now emphasises not resilience but vulnerability, and there is a cultural preoccupation with “trauma” and the language of emotional deficit. (2) In this climate there is a real risk that our horror at what these children endured will too easily transform itself into assumptions about psychological damage.
These trends are comparatively recent, and it is instructive to compare Beslan with another school tragedy that shook the nation, the engulfing of 144 schoolchildren and teachers in 1966 when a coal waste tip slid into the Welsh village of Aberfan. Surviving children resumed school 2 weeks later so that their minds would be occupied, there was no counselling, and no dire predictions of long term traumatisation and disability. Newspaper reports commended the villagers for getting back on their feet so admirably and with little need for outside help. A child psychologist noted some months later that the children appeared normal and well adjusted, and there is no suggestion that this has not remained true over subsequent decades (3).
Literature reviews suggest that trauma debriefing should now be generally accepted as being ineffective, and even harmful- a professional intervention may unwittingly cement a preoccupation with what happened and thus retard natural recovery. By coincidence, the WHO have just published a concensus statement on post-emergency mental and social health:this endorses social assistence as having the primary role,and questions the public health value of post-traumatic stress disorder as a concept, particularly in non-Western, low-income countries (4). The longer term outlook for these children will depend on the possibilities for the resumption of ordinary life within the family and the wider community.
The public pronouncements of the supposed experts are influential, and can colour how society sees the Beslan children, or those in tsunami- affected areas,and indeed how they see themselves. The danger is that some children will go on to fulfill the dire prophecies being made about their future health and wellbeing. I’m afraid that “disaster mental health” is largely an oxymoron.
Derek Summerfield
derek.summerfield@slam.nhs.uk
Institute of Psychiatry, King’s College, London SE5 8AF
1 Parfitt T. How Beslan’s children are learning to cope. Lancet 2004; 364; 2009-10.
2 Summerfield D. Cross-cultural perspectives on the medicalisation of human suffering. In: Rosen G, ed. Posttraumatic Stress Disorder: Issues and Controversies. Chichester: John Wiley & Sons, 2004.
3 Furedi F. Therapy Culture: Cultivating vulnerability in an uncertain age. London: Routledge, 2004.
4 Van Ommeren M, Saxena S, Saraceno B. Mental and Social Health during and after acute emergencies: Emerging concensus? Bulletin of WHO 2005 83; 71- 76.
Competing interests: None declared
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dear sir,
We all have been greatly moved by the tragic tsunami catastrophe that had affected many nations including India. But recently watching the news channels i was appalled over forgery in distribution of the relief material to the affected families in Tamil nadu,Kerala(southern states in India). It is ridiculous to observe that none of the politicians (irrespective of the ruling or opposition party) or the government officials are bothered about the dilapidated condition of the worst stricken lot, instead the entire nation looks forward towards the controversies around the religious leaders and other popular figures. Although ,attempts are been made by various people around the world to extend support in monetary or other forms for the tsunami affected people but this alone is not sufficient because the relief distribution system at the grass root level needs proper surveillance otherwise the hearty gestures of the fellow countrymen and helping hands around the world (includind Mr. Blair) will go in vain, and the few unscrupulous officials will mint quick money on the graves of the hapless victims.
It's time to introspect the flaws in the relief material distribution system ,merely donating Dollars , Pounds and Rupees in the name of tsunami victims won't help the cause. The need of hour is to ensure delivery of the necessary services to the needy ,leaving aside our own personal interests,only then can we fight the natural calamity compounded with impassive behaviour of the officials.
Competing interests: None declared
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Many professionals have probably assisted in the psychosocial support of people returning from the affected areas. The Norwegian government established medical and psychosocial services at the national airport, and also sent out professional teams to the other Scandinavian major airports receiving flights from South East Asia. The assigned tasks were to provide a safe welcome of care, support, information, medical aid and psychological advice, to assess possible risk factors for later trauma-related disturbances, and to assist in connecting to local health services for people who wanted or needed it.
Our basic principles were to lower the immediate stress reactions by emotional first-aid, prepare for further events and the meeting with relatives, the public and the media, encourage to restore sleep and nutritional deficits, seek company and support from relatives and friends, and to protect oneself from media and public exposure.
As a general rule, we advised people to establish a story to be told from their experiences, leaving the most awesome details and pictures out of it, especially when children were involved. Traumatic details and troublesome emotional experiences we advised people to write down for themselves, as a therapeutic process.
The follow-up of people needing further support are generally the task of the community support teams and general practitioners. If signs of persistent posttraumatic stress reactions are experienced, we encourage to seek more specific professsional help.
Competing interests: None declared
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Dr Chittarvu is quite right in his observation that poverty doesn't lead to disaster - it can of course compound the after effects.
However, with the La Palma volcano, the San Andreas fault and the Yellowstone Caldera, one can argue that it's only a matter of time before the US, as one example of the Developed World, requires some kind of international aid. If the La Palma tsunami, as expected, affects Northern Europe also then things really will get interesting - and of course the Yellowstone eruption may not signal so much a light dusting over the Mid- West as the end of the human race, but that's by the by.
We should all be humbled by the fact that nature is far more destructive than even Mankind can be - and far less prejudiced about who suffers.
In our lifetimes? One hopes not.
Nick Bennett njb35@cantab.net
Refs:
http://www.solcomhouse.com/yellowstone.htm
http://www.bbc.co.uk/science/horizon/2000/mega_tsunami.shtml
http://www.es.ucsc.edu/~es10/fieldtripEarthQ/EarthQWelcome.html
Competing interests: None declared
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I applaud the BMJ's rapid editorial response to the Tsunami disaster and in particular Tony Blair's committment to reducing the burden of poverty in Africa. As stated this is easier said than done. Part of this committment requires a self reflective process within the UK on their post -colonial role in developing the African diaspora, in particular the health care and service delivery to millions.
In South Africa one of our primary concerns is to maintain all levels of health care but particularly nodes of excellence within the tertiary sphere. These nodes help to sustain the infrastructure that is required to meet and sustain primary health care demands. However, our training and service delivery is constantly undermined by the loss of our health care professionals who choose better opportunities in the developed world.
How then can we, in the developing world address this attrition that impoverishes our local worlds leaving them reliant on inadequate secondary and primary care when we are unsupported by a sophisticated machinery that entitles health care for all in the developed world. Indeed even the future cost of the BMJ means that once again our ability to voice and gain legitimacy for the real issues in the developed world is marginalised.
I suggest that we need a collaboration that begins with governments in the developed world not recruiting from the developing world. Instead we should jointly offer schemes that empower universities and health care facilities to offer bridging courses for a six monthly exchange of health professionals. This would allow doctors and nurses to benefit from the medical opportunities offered in the context of either a developed or a developing world scenario. In South Africa we would then retain the vital infrastructure that provides daily care to families from doctors who can continue to pursue medical excellence in their field in the context of their homes and communities.
It is this that maintains stability and democracy and this means primary health care for all and a reduction of poverty in Africa. No aid schemes or interventions can replace systems of health care that are enabled to participate in a global discourse on well-being.
Lauraine Vivian
Lecturer
Primary Health Care Directorate,
Faculty of Health Sciences,
University of Cape Town
Competing interests: None declared
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Dear Mr editor,
This a disaster unprecedented in world history. It was unexpected with no warnings. There is no relation here of poverty of the affected countries. It could happen to the so called rich nations some time in spite of the existing technologies. What is important to the G8 RICH countries is humanity and kind response and help in such a disaster of mankind... not theories and delayed responses.
I am in this country and I can tell you that people were hurt and surprised by the lack of empathy and delayed respones of US and UK. They acted of course after a period of 3 days and it is not bringing credit to the higher values their civilisation professes. If you think poverty causes Tsunamai disasters may God help you. If all the G8 riches which are many times ahead of the poorer other 250 countries cannot help dead and dying victims of the world God save our earth and complacenccy will only look very very odd and some thing is eroding the much loved western values of love and service and kindness and ....culture. One day may the Rich realise all is not in money. There is always Destiny which commands all of us..!
Competing interests: None declared
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Dear Editor, Having worked in India, UK, and the United Nations, I have a world view of global economics.It is interesting that Mr. Tony Blair makes unfounded statements about alleviating poverty in Africa.It is a known fact, that each year the United Kingdom recieves one billion pounds from Africa as part of the third world debt repayments.The United Kingdom, is in actual fact instrumental in causing poverty in Africa. It is indeed disheartening to hear such obvious nonsense from the British Prime Minister's office.If Tony Blair had any feeling for the impoverished in Africa, he would do away with the third world debt in Africa.Mr. Blair has 5 billion pounds to expand the British NHS, why bleed the poor in Africa, who are anyways dying of HIV epidemics.? There appears to be no human justice in Mr Blair's actions or statements.May the good Lord help him. kind regards, Dr VM Verma General Practitioner,New Zealand, Ex-Medical Advisor UNHCR, India, Ex-Health Advisor UNWFP, India. email vmverma@hotmail.com
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I've tried without success to find either voluntary or professionally -led support programmes for people returning to the UK after escaping the impact of the tsunami. There must be hundreds of people who 'escaped with their lives' who are now feeling traumatised and finding it difficult to settle back into routines. I've yet to locate a website or newspaper article giving basic advice to such people - most of whom don't want or need to be medicalised. Can anyone help?
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According to a leading Delhi based daily newspaper, India has decided not to accept any international aid to deal with the tsunami havoc appears to be in keeping with its role as a benefactor in the South Asian region. Though the Centre hasn’t completely ruled out taking aid if required, it is unlikely to do so. The international community has already pledged $1.2 billion of aid to tsunami-affected countries.India, for one , cannot be seen to be accepting assistance after it has stepped out to do its duty by providing relief to its smaller neighbours. The government has, for instance, dispatched seven naval ships to Sri Lanka besides sending supplies to Indonesia, Maldives and other countries. IT has already committed Rs. 100 crore to Sri Lanka.
Analysts also see a political element in the move. With her sheer size and level of resources, India dominates the region, her growing economy only adding to the stature she first acquired when she played a leading role in the non-aligned movement during the Cold War era. A nuclear India is now looking for a new role in the comity of nations by seeking a permanent seat in the UN Security Council along with veto power. India, in fact, is part of the four-member core group which includes the US, Australia and Japan- set up to handle aid to victims.
The Indian government estimates total financial losses from the devastating tsunami that hit the country's eastern shore was about 53.22 billion rupees ($1.20 billion).The four states that bore the brunt of the Dec. 26 tsunami are the southern states of Tamil Nadu, Andhra Pradesh, Kerala and Pondicherry. A government statement said on Thursday a detailed assessment of the losses in the Andaman and Nicobar islands, some 1,200 km (750 miles) off India's East coast, was still being made.The weekend tsunami left nearly 16,000 people dead or feared dead in India. More than 6,000 people are missing and presumed dead on the Andaman and Nicobar islands, although only 900 bodies have been found. Reserve Bank of India Governor Y.V. Reddy said on Thursday he expected little impact on India's economic growth from the tsunami but said it would put some upward pressure on the federal fiscal deficit.
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Tsunami and the poor: Some short-term and long-term implications
The editorial poignantly brings out the inextricable linkages between disasters and poverty (1). There is overwhelming evidence from many disasters across the world that it is the poorer sections which bear the brunt of the disasters. This is no different in the case of tsunami, except for a few unfortunate tourists from different countries. There are a number of lessons to be learned for both short-term and long-term disaster management practices especially from an epidemiological angle.
1. Firstly, there is a subtle difference between this disaster and the annual cyclone and flood disasters which occur in most of the Bay of Bengal rim states in India. The flooding that occurred due to tsunami was from salt water and as a result most of the drinking water sources were saline-affected and could remain so at least for a few months. The probability of water-borne diseases breaking out in these areas, therefore, could be a little less than that of ordinary floods due to rain water. Therefore, supplying fresh drinking water in these areas rather than chlorination of water assumes more importance.
2. The second issue is the mindless and disrespectful disposal of dead bodies in India (2). Many dead bodies were thrown into pits without proper identification. This would result in long-term miseries and legal tangles to those kith and kin who survived. In the age of digital technology and high-tech laboratory facilities, an effort should have been made to take digital photos and tissues for DNA analysis. An effort must be made at least now to decrease possible legal hardships by carrying out documentation of not only members lost but also of other proofs of identity such as bank accounts passbooks, ration cards etc. Attempts must then be made to carry out requisite paperwork to re-establish this data. In our present world much of our existence depends on these pieces of paper – hence efforts need to be made to help at this level.
3. Not only have families been fragmented but many members will forever be termed missing partly due to the fact that many bodies may never be recovered as well as due to the rapid disposal of bodies. This will lead not only to legal problems which will need to be handled as mentioned above but the mental trauma will need to be dealt with (3, 4, 5). Already teams are training people to handle this loss. However the Government will need to continue this assistance for a substantial period.
4. Large sections of the people affected by the tsunami are the fisher-folks. It is important to ensure that they be rehabilitated as rapidly as possible to help them return to their work. The fisherwomen who have lost their husbands will need special employment schemes to help them. Alternative employment along with land regeneration efforts are the strategies to be adopted for rehabilitation of the victims. Efforts should also be made to prevent exploitation of women and children. The presence of effective social and community organizations especially among the fish- workers could be utilized for the long-term rehabilitation efforts.
5. The role of both the State and the private sector in post-disaster activities also needs to be examined. Most of the post-disaster rescue, relief and rehabilitation efforts in Tamil Nadu and Kerala were carried out by the civil society and by the State agencies. Neither the private corporate hospital sector nor the small private hospitals were involved in any big way in rescue or relief efforts. This raises questions on the social commitment of the private medical sector. One area where the private sector, especially psychiatrists can really help is in the area of post-trauma rehabilitation work.
6. Finally it is important to remember that in many areas damage was severe due to destruction of the natural environment, eg. mangroves and removal of sand for construction work. Also the presence of houses close to the sea as in Nicobar and Port Blair caused greater loss of property. When reconstructing it would be important to keep in mind the Coastal Zone Regulations and also attempt to restore the natural environment as far as possible and prevent further exploitation of the area for commercial purposes.
References:
1. Abbsi, Kamran. Death by tsunami and poverty. BMJ 2005; 330.
2. Morgan O. Infectious disease risks from dead bodies following natural disasters. Rev Panam Salud Publica. 2004;15(5):307–12
3. Ghosh, Amitav. Overlapping faults. The Hindu, January 11, 2005
4. Ghosh, Amitav. No Aid needed. The Hindu, Janauary 12, 2005
5. Ghosh, Amitav. The town by the sea. The Hindu, January 13, 2005
Competing interests: None declared
Competing interests: No competing interests