After the Deluge
Is disaster mental health serving tsunami survivors?
BY ROB WATERS
The tsunami that battered Southeast Asia at the end of 2004, killing some 300,000 people and leaving hundreds of thousands more to cope with almost unbearable losses, has inspired an enormous outpouring of charity. As millions of dollars flowed in, foreign governments, international organizations, and aid groups launched massive relief operations to provide emergency food, shelter, and medical care to the beleaguered survivors. These efforts appear to have succeeded in preventing starvation and the spread of disease, but as humanitarian efforts have shifted from relief to recovery, health officials and aid organizations have resumed a simmering debate over how to attend to disaster victims' psychological needs in a culturally appropriate manner.
In the wake of the tsunami, some experts predicted a spectacular increase in mental-health disorders. In February, at a Bangkok conference on managing PTSD, sponsored by the pharmaceutical company Pfizer, Jonathan Davidson, a psychiatrist who directs the anxiety and traumatic-stress program at Duke University, projected that "between 50 and 90 percent of the population will experience symptoms such as post-traumatic stress disorder and depression." But based on previous disasters, the World Health Organization (WHO) estimates, by contrast, that 5 to 10 percent of the population will develop a tsunami-induced mood or anxiety disorder.
The dispute over numbers reflects the larger debate within the trauma-specialist community between those concerned with expanding treatment for PTSD and those who advocate more community-based interventions. Last year, a group of psychiatrists specializing in trauma treatment published a consensus statement recommending the early use of antidepressant medication, cognitive-behavioral therapy, or both for people showing symptoms of distress, starting three or four weeks after experiencing a major trauma. The authors drafted their statement in Ireland under the sponsorship of GlaxoSmithKline, which produces the antidepressant Paxil. Psychosocial advocates decry the medicalization of post-disaster services, however, calling instead for efforts that help local people come together to rebuild homes and communities, provide mutual support, reopen schools, and maintain rituals, such as mourning the dead. They worry that continued massive operations by international aid groups could undermine the ability of local communities to develop their own methods of support and healing within the context of local cultural beliefs.
"Applying the concept of trauma to populations that have their own cultural and religious explanations for this extremely stressful event may not be the best approach to helping," says Bhava Poudyal, a Nepali psychologist with the International Catholic Migration Commission. He's worked for the past two years with torture survivors in Aceh, the Indonesian province hardest hit by the tsunami. According to Poudyal, the Acehnese view the tsunami as "a test from God to see if you will still remember him and obey his laws in times of trouble. It is in your takdir [fate] to have experienced that." He says some survivors believe Allah called their loved ones to him. "Everyone is praying five times a day, trying to follow Muslim practices. The society is very close-knit, supportive, and respectful of each other. Neighbors are taking care of each other, orphans are being taken in by other families."
Poudyal worries that aid groups may "take away people's resiliency, their meaning, and impose the PTSD model--which is new and medical for them. Because of this, they now become 'sick.' And if you are 'sick,' you need medications, you need doctors. Grandma's advice, which used to work before, now does not."
He reports that some 250 nongovernmental organizations (NGOs) are working on tsunami relief in Aceh, and are just beginning to coordinate services. …