AN INTEGRATED APPROACH TO DISASTER MANAGEMENT

                                                  – WHO PERSPECTIVE OF PREVENTIVE PSYCHIATRY

Preventive medicine has played a very important role in reducing the mortality and morbidity in any population with regard to several important diseases such as plague, syphilis, cholera during several different times in the history of man. But, one grey area that has often taken us by surprise is the occurrence of disasters. The most recent example is Tsunami. The literature relating to disaster management is meager and there are several hollows that need to be explored. We shall now review the importance of Preventive medicine in terms of disaster management.

DEFINITION OF DISASTER

            ‘Disaster is a crisis situation that far exceeds the capabilities’.

                                                                                            - Quarentelly, 1985.

          ‘Disaster’ is defined as a crisis situation causing wide spread damage which far exceeds our ability to recover. Thus, by definition, there cannot be a perfect ideal system that prevents damage, because then it would not be a disaster. It has to suffocate our ability to recover. Only then it can be called as ‘disaster’.

        Disasters are not totally discrete events. Their possibility of occurrence, time, place and severity of the strike can be reasonably and in some cases accurately predicted by technological and scientific advances. It has been established there is a definite pattern in their occurrences and hence we can to some extent reduce the impact of damage though we cannot reduce the extent of damage itself. This demands the study of disaster management in methodical and orderly approach.

Disaster management cycle

Disaster management cycle includes the following stages/ phases

  1. Disaster phase

  2. Response phase

  3. Recovery/ Rehabilitation phase

  4. Risk Reduction/ Mitigation phase

  5. Preparedness phase
                 

Disaster phase – The phase during which the event of the disaster takes place. This phase is characterized by profound damage to the human society. This damage / loss may be that of human life, loss of property, loss of environment, loss of health or anything else. In this phase, the population is taken by profound shock.

Response phase – This is the period that immediately follows the occurrence of the disaster. In a way, all individuals respond to the disaster, but in their own ways. The ambulances and medical personnel arrive, remove the injured for transportation to medical camps or hospitals and provide first aid and life support. The public also take part in relief work. One can even find injured victims help other injured ones. Almost everyone is willing to help. The needs of the population during this phase are immediate medical help, food – ‘roti’, clothing – ‘kapda’ and shelter – ‘clothing’.

Recovery phase – When the immediate needs of the population are met, when all medical help has arrived and people have settled from the hustle – bustle of the event, they begin to enter the next phase, the recovery phase which is the most significant, in terms of long term outcome. It is during this time that the victims actually realize the impact of disaster. It is now that they perceive the meaning of the loss that they have suffered. They are often housed in a camp or in some place which is often not their house, along with other victims. During this time, they need intensive mental support so as to facilitate recovery. When the victims have recovered from the trauma both physically and mentally, they realize the need to return back to normal routine. That is, to pre-disaster life. During this phase, they need resources and facilities so as to enable them to return back to their own homes, pursue their occupation, so that they can sustain their life on their own, as the help from the government and other non governmental organizations is bound to taper in due course. Thus, they are provided with a whole new environment, adequate enough to pursue a normal or at least near normal life. This is called Rehabilitation.

Risk reduction phase – During this phase, the population has returned to predisaster standards of living. But, they recognize the need for certain measures which may be needed to reduce the extent or impact of damage during the next similar disaster. For example, after an earthquake which caused a lot of damages to improperly built houses, the population begins to rebuild stronger houses and buildings that give away less easily to earthquakes. Or, in the case of tsunami, to avoid housings very close to the shore and the development of a ‘green belt’- a thick stretch of trees adjacent to the coast line in order to reduce the impact of the tsunami waves on the land. This process of making the impact less severe is called Mitigation.

Preparedness phase – This phase involves the development of awareness among the population on the general aspects of disaster and on how to behave in the face of a future disaster. This includes education on warning signs of disasters, methods of safe and successful evacuation and first aid measures.

                   It is worth to note that the time period for each phase may depend on the type and severity of the disaster.

TYPES OF DISASTER

Disasters are mainly of 2 types,

  1. Natural disasters. Example – earthquakes, floods, landslides, etc.

  2. Man made disasters. Example – war, bomb blasts, chemical leaks, etc.

The phases of all disasters, be it natural or man made, are the same. The disasters often differ in quantity of damage caused or in quality of the type of medical consequences. For example earthquakes cause a lot of physical injury and fractures, floods cause drowning deaths and infections, chemical leaks cause toxic manifestations, etc.

Victims and survivors

                           Almost everyone in the population is affected by a disaster. No one is untouched by it. Those who suffer damage are called victims. The victims may die or live. Those who manage to live are called survivors. These survivors can be classified as,

  1. Primary survivor – One who is exposed to the disaster first-hand and then survives. They are called ‘survivor victims’.

  2. Secondary survivor – One who grieves the loss of primary victims. Example, a mother who lost her child, or a man who lost his friend.

  3. Third level survivor – The rescue and relief personnel. These people are also affected due to the disaster as they are at the site of disaster and undergo almost the same mental trauma as the other victims.

  4. Fourth level survivor – Reporters, Government personnel, traders, etc.

  5. Fifth level survivor – People who read about or see the event in media reports.

THE Second Disaster

                  The actual disaster results in a lot of damage to the population in terms of loss of life and property. This direct result can be dubbed as the ‘first disaster’. The impact of the first disaster sends another wave of damage triggered by chain of events relating to the first disaster by means of cause-and-effect, resulting in indirect damage to people remote from the original disaster. This can be called the ‘second disaster’. For example, tsunami had caused loss in terms of life, damage to houses, etc. This is the first disaster. This leads to disruption in the trade of fishing industries, which suffers massive financial losses. The losses suffered by these industries results in lower wages and salaries to those involved in the fishing business. These people cannot repay their loans, resulting in losses to money lenders, and so on. Such events can also result in higher incidences of heart attacks, strokes, suicides and homicides. This is called ‘second disaster’ and can be in greater magnitude than the ‘first disaster’. Proper rehabilitation and care of the victims of first disaster can break the chain of events leading to the second disaster.

PECULIARITIES OF TSUNAMI

There are few ways in which tsunami differs from other disasters,

  1. Time duration of the attack was very small. The entire attack took place in a matter of a few minutes.

  1. Extent of damage was very large, grossly disproportionate to the duration of attack. Extensive damage took place in a matter of few minutes, which took the people by surprise and awe. Everything seemed to be normal….. all of a sudden water flows in….. Boom! Everything seems different. There was no time for people to adapt to the disaster.

  1. The victims are either alive and healthy or simply dead. There was very less physical injury and hence there was no great need for medical facilities, unlike other disasters.

  1. There have been no precedents of this type. People have not even heard of this type of a disaster.

  1. There were no outbreaks of any infections, which are common in floods. This point is of note because in floods, it is freshwater – a good culture medium for organisms. And, when water stagnates, organisms flourish even more. But, in tsunami, it was seawater which is hypertonic saline which is unfavorable for microorganisms. Moreover, there was no stagnation as the water receded back completely.

Psycho social aspects of disaster

                                                       Often, minimal importance is given to the mental trauma suffered by the victims of a disaster. They are overshadowed by the excessive importance to physical and financial needs of the victims which are considered by the relief personnel to be more than sufficient to alleviate the suffering of the victims. Unlike physical and material damage, the damage to the psyche (mind) cannot be obviously seen, until and unless, it is looked for. And, to look for, the relief personnel need to be aware of the possible effects on the mind, which can be permanent and disabling.

‘The psycho social needs are generally seen as something too secondary to attract the attentions of relief agencies, relief workers & governmental organizations’

                                                                           - Jaswan 2000 

                       There is a phenomenal increase in the incidence of psychiatric disorders in the affected population. The common problems include

  1. Acute stress disorder

  2. Post traumatic stress disorder

  3. Anxiety disorders

  4. Depression

  5. Alcohol and drug abuse

  6. Aggravation of previous disorders if any.

  POST TRAUMATIC STRESS DISORDER

             The most important of the above is post traumatic stress disorder (PTSD), which if occurs is a permanent damage. There is definitive damage to the hippocampus of the brain, and hence is important to identify the people vulnerable and provide adequate psychiatric intervention.

                                   There are several abnormal behaviors and complaints that have been seen in disaster victims such as

  1. excessive crying

  2. irritation

  3. restlessness

  4. fatigue

  5. sleeplessness

  6. flashbacks

  7. panic attacks

  8. mood swings

  9. guilt

  10. anger

               The list is long and indefinite. But one thing is to be borne in mind - ‘all these are not abnormal reactions. They are just normal reaction to an abnormal event’. But these reactions must resolve in due course, failure of which is the diagnosis referred to as PTSD. This should be prevented as it is disabling disorder with very less promising outcomes.

DISASTER SYNDROME

                          This is an observed disorder that can be identified in disaster victims. As a matter of fact, about 75% of the population of the population is affected, immediately following the disaster (Duffy, 1998). By the 10th week, there is a significant drop, and by the end of the first year, it drops to about 30 – 40% of the disaster affected population. It is also observed, that there is a 17% higher occurrence of long-term sequelae in the disaster affected population, as compared to other control populations (Roubonis, 1991).

                               The observation by Duffy of the widespread occurrence of symptoms following a disaster (75%) implicates that they are a normal reaction to an abnormal event (by the concept of Normality by majority). The ensuing drop in the prevalence of symptoms in the following year shows that they are resolving ‘on the own’. The rest who suffer continual symptoms may be the victims of a failure of resolution of the normal reaction. Though there is a view that these psycho social issues should not be medicalised (WHO, 1992), the logical deduction from the observations of Duffy and Roubonis implicates that facilitation of the resolution can bring about lower psychiatric morbidity in the disaster affected population.

MEANING OF LOSS

                             It has been oft repeated mistake to assess severity of a disaster by means of calculating the loss in terms of numbers, quantity figures or units such as number of deaths, number wounded, number of houses damaged, surface area of affected land, etc. But, this is not the actual measure. The meaning of the loss rather the loss itself is a much more significant measure. In other words, the impact of the disaster rather the disaster itself is more important. For example, the loss of a neighbor may mean a great loss to one person but a minimal loss to another. Similarly, loss of animal life may mean nothing for one victim but may mean a lot for an animal lover. The loss of a house may mean less for someone who is thankful for having survived, but more for someone who has a sentimental attachment to his house. Thus, the actual damage being less, the impact may be disproportionately severe. Though the entire population experiences the same disaster, each one perceives it in a different and unique way. The governmental relief agencies need to see the damage alone, but we, health care personnel cannot afford to do that. We much see what the loss means to the victim; only then, can we assess the impact the disaster has had on that person.

INTEGRATED APPROACH

                        There is need for a change in the approach towards disaster management. There is now no orientation among health care providers. This is because the health care providers are actually oblivious of the actual needs of the victims. The need of the hour is ‘integration’. Integration of what? Integration of medical help and resource provision. And integration of mental health services with other medical services.

               A lot of victims suffer from mental agony and pain that needs grief counseling, so that the recovery happens. Else, it results in permanent psychiatric sequelae. But, the victims themselves are not ready to seek psychiatric help as they feel that they don’t need it. This is because food, clothing and shelter are the most essential needs which need to be satisfied urgently. The next most significant need is that of financial support. Without these, psychiatric help will not sought by the victims. So it is essential that medical personnel and mental health care providers don’t go empty handed. In other terms, financial and basic need support should reach them as soon as possible so as to be able to make the victims ready for counseling. Thus, mental health care will not be accepted if financial needs are not met.

                  Yet, the importance of mental health services should not be underestimated. Without a healthy mind and sound mental health, the relief measures will not serve its end in improving the general quality of life of the disaster affected individuals. Thus, financial help does not serve its end without mental health care provision. Now it should be clear what an integrated approach means. Integration of financial support with mental health care, in the right temporal sequence – the right thing at the right time.

THE LATEST PERSPECTIVE

                  When, there is major disaster such as the tsunami, where the affected population is huge, to the tune of several lakhs, it is very difficult to get enough health care personnel to work there, especially for a long time. All non governmental organizations and international aid will offer help for a few weeks or few months to alleviate the immediate crisis, but they cannot afford to stay for a long time. But long term continuing health care is essential for improved long term outcomes. Moreover, when mental health care is considered, it is very important that the counselors and psychiatrists speak the native language. This is true to some extent even when medical help in general is considered. Thus it is easier, more cost effective and yielding to train volunteers from the population who are willing to work for the aggrieved to identify those in need for specialist consultation by consultants who are often in lack. For example, the affected population in Sri Lanka after tsunami runs in lakhs but there are only 27 psychiatrists or so. Though the Tamil speaking population was affected at large, only 3 out of the 27 were Tamil speaking, out of which only one was actively practicing in the affected areas. These few consultants are overwhelmed by the number of cases, the majority of which don’t need specialist help and can be handled by trained counselors and primary health care workers. And, it is nearly impossible for consultants to visit the affected site. So, a new plan has been proposed a way to handle this – POST TRAUMA COUNSELLING.  It involves training of volunteers to become counselors who meet every victim, collect the identity details and talk to them. These counselors are taught to identify normal grief reactions from abnormal reactions. The normally aggrieved victims are counseled

 and the abnormally aggrieved are referred to the consultants. The advantages of this method,

  1. The case load for the consultants is reduced, making it more comfortable to spend more time on each case and work up completely.

  2. The method is cost effective. It is unfeasible to pay consultants to see so many cases

  3. The method is time saving. We always have fewer consultants than counselors. Few consultants take more time to scan the population than many counselors doing the same job.

  4. The victims feel easier to talk to counselors who are often from affected lot rather than to a specialist.

  5. It is easier for counselors to keep track of the victims who may drop off. The counselors can visit the victims at their doorsteps and ensure continued surveillance of the victims.

There is an age old aphorism – ‘God cannot be everywhere… so, he created mothers’. Similarly, psychiatrists cannot be everywhere, so, we create counselors.

WORSHOP ON POST TRAUMA MANAGENMENT & COUNSELING – 5th and 6th March, 2005

          Under this plan, a non governmental organization called the Chartered Management Institute(CMI), with their central office in UK and a branch in Sri Lanka, in collaboration with The Management Club(TMC), an association of leading corporate personnel in Sri Lanka, requested the Indian Association of Private Psychiatry (IAPP) which under the instance of Dr. M. Thirunavukarasu, its national level advisor, sent a six member delegation of mental health care personnel to the affected areas to train volunteers to become counselors so as to identify those in need of psychiatric intervention. The program was recognized and welcomed by the WHO representative to Sri Lanka Mr. Kun Tan. It was two day program in three places – Colombo, Galle and Batticaloa. The total number of participants was about 200.

The first day included the following seminars,

  1. Introduction to Mind and Mental Health

  2. Impact of Tsunami

  3. What is Disaster?

  4. Psycho- social aspects of Disaster

  5. What is counseling?

  6. Basics of Counseling

  7. Management of children affected by the disaster.

  8. Summary

The second day consisted of,

  1. A recap of previous day topics

  2. Interview techniques

  3. Difficult to handle victims

  4. Role play of simulated counseling situations by participants

  5. Introduction of questionnaires to record responses by victims

  6. Interactive session

In addition to the interactive session participants were encouraged to ask doubts and share their experiences after each topic. Paper, pens, student files and feed back forms were given. The response from the Sri Lankan public was superb and surpassed expectations. The feedback showed the overwhelming response of the Sri Lankan public for these measures. The mental health services now are taking place actively with the aid of trained counselors, in Sri Lanka. The questionnaires provided to them are expected to give us ample material for further study.

ACKNOWLEDGEMENTS

  1. Dr. M. Thirunavukarasu, Prof and Head of Psychiatry, Stanley Medical College, Chennai

  2. Dr. Joseph Zohar, M.D., Prof. and Director, Dept. of Psychiatry, Chaime Sheba Medical Center, Tel Hashomer, Israel.

  3. Dr. Mohan Isaac, Prof. of Psychiatry, NIMHANS, Bangalore.

  4. Dr. K. Thangarajan, Prof. of Psychiatry, Gopu Nursing Home, Tanjore.

REFERENCES

1. Disasters and Mental Health ; Appendix – Statement by the World Psychiatric Association on Mental Health Implications of Disasters (approved by General Assembly on August 26, 2002)– Juan J, George C, Mario M, Norman S, Ahmed O – World Psychiatric Association (also visit www.wiley.com)   

Prepared By
Dr. PRAGATHEESHWAR THIRUNAVUKARASU
MADRAS MEDICAL COLLEGE.