cross cultural mental health ocean tsunami€¦ · 0930 1.0 0830 tsunami strike times sunday,...

CROSS CULTURAL MENTAL HEALTH CROSS CULTURAL MENTAL HEALTH AND AND

THE INDIAN THE INDIAN OCEAN TSUNAMIOCEAN TSUNAMI

WHATWHAT’’S AHEADS AHEAD

The tsunamiThe tsunamiOperation Unified AssistanceOperation Unified AssistanceFocus on behavioral healthFocus on behavioral health–– InfrastructureInfrastructure–– ObservationsObservations–– Considerations for actionConsiderations for actionHome stretchHome stretch

The most powerful earthquake in 40 years erupted under the The most powerful earthquake in 40 years erupted under the Indian Ocean near Sumatra on Dec. 26, 2004. It caused giant, Indian Ocean near Sumatra on Dec. 26, 2004. It caused giant,

deadly waves to crash ashore in nearly a dozen countries, killindeadly waves to crash ashore in nearly a dozen countries, killing g tens of thousands. tens of thousands.

THE TSUNAMITHE TSUNAMI

ABOUT THE EARTHQUAKEABOUT THE EARTHQUAKEThe 9.0 earthquake occurred along 1,200 km of The 9.0 earthquake occurred along 1,200 km of seabed at a depth of 10 kmseabed at a depth of 10 kmit was so powerful, it made the earth wobble on it was so powerful, it made the earth wobble on its axis and permanently altered the regionits axis and permanently altered the regionit generated energy equivalent to the it generated energy equivalent to the simultaneous explosion of 23,000 Hiroshima simultaneous explosion of 23,000 Hiroshima atomic bombsatomic bombsit moved small islands off Sumatra's coast by it moved small islands off Sumatra's coast by as much as 20 and the northas much as 20 and the north--western tip of western tip of Sumatra by 36 Sumatra by 36 metresmetres

ABOUT THE TSUNAMIABOUT THE TSUNAMIThe tsunami struck on a Sunday morning when The tsunami struck on a Sunday morning when families had gathered for a day at the beachfamilies had gathered for a day at the beachWhen the water receded, adults and children When the water receded, adults and children alike ran to pick up fish lay flapping in the sandalike ran to pick up fish lay flapping in the sandThe first wave was small in comparison to the The first wave was small in comparison to the destructive second wave. In Banda Aceh, destructive second wave. In Banda Aceh, survivors described the approaching wave as survivors described the approaching wave as “…“…a black wall the height of a coconut tree.a black wall the height of a coconut tree.””[70[70--100 ft tall]100 ft tall]

0759

0930 1.0

0830

Tsunami Strike TimesSunday, December 26, 2004

083009002.0

09303.5

10006.0

KOH LANTA, THAILAND

PHUKET BEACH, THAILANDPHUKET BEACH, THAILAND

WORLDWIDE SUMMARYWORLDWIDE SUMMARY

BANDA ACEH, INDONESIA

BANDA ACEH SUMMARYBANDA ACEH SUMMARY

127,000 dead. 30,000 missing127,000 dead. 30,000 missing40% municipal employees perished40% municipal employees perished90% all public buildings destroyed90% all public buildings destroyed12 of 21 health centers, 5 of 7 hospitals 12 of 21 health centers, 5 of 7 hospitals destroyeddestroyed100 schools rendered unusable100 schools rendered unusableCoastal fisheries, rice fields destroyedCoastal fisheries, rice fields destroyed

BANDA ACEH SUMMARYBANDA ACEH SUMMARY

2/3 of all land records lost2/3 of all land records lostMajority of bank records goneMajority of bank records goneCement industry ruinedCement industry ruinedMain commercial strips leveledMain commercial strips leveledWarehouses flattenedWarehouses flattened88--12 inches of dense, salt12 inches of dense, salt--saturated mud saturated mud covers the city up to 3 km from the shorecovers the city up to 3 km from the shore

OPERATION UNIFIED ASSISTANCE

275 Medical Personnel:Physicians, Nurses, Corpsman, Specialists

USNS MERCY

►Floating Tertiary care hospital► 1000 bed capacity, 250 for OUA

► 12 Operating Rooms, CT, Pharm, O2► Full crew – 1,200+ personnel

► Built a Supertanker in ’74, convt’d ’86► 894 ft long, disp 70,000 t.

► Last key mission: Persian Gulf War 1990► Instances of previous use of flight deck

for patient operations: 0

90 Medical Personnel:Physicians, Nurses, Social Workers

18 Pub Health Personnel:Physicians, Nurses, Environmental Health,Medical engineerPsychologistsSocial workers

**Primary mission: Project support ashore. Primary mission: Project support ashore.

Project Primary Care medical capability ashore: Project Primary Care medical capability ashore: Primary Medical Care Primary Medical Care -- Internal Medicine, Internal Medicine, Infectious Disease, OB/GYN, Pediatrics, Infectious Disease, OB/GYN, Pediatrics, Optometry, Dental, and Optometry, Dental, and Mental HealthMental Health..

Project other support functions ashore: Project other support functions ashore: Disease Surveillance, Field Testing, Laboratory Services, Disease Surveillance, Field Testing, Laboratory Services, Immunizations, Insect Control, Preventive Medicine, Veterinary Immunizations, Insect Control, Preventive Medicine, Veterinary Assistance, Engineer, Supply Distribution and fieldAssistance, Engineer, Supply Distribution and field--based based services determined by HN and NGO partners.services determined by HN and NGO partners.

**Secondary mission: Shipboard Health ServicesSecondary mission: Shipboard Health Services

MISSIONMISSION

1

MERCY OPERATIONS SEQUENCEMERCY OPERATIONS SEQUENCE

RTHP San Diego

05 May6 Jan 29 Jan

Singapore VIC Banda Aceh, ID

Majuro, MH

22 Apr

Transit TransitHADR Assistance

Ops

Medical / Dental TSC

Events

LOCATIONKepualuan

Alor, ID

Dili, TP

SingaporeU/W from San

Diego

Pearl Harbor

3 Feb 19 Mar

Madang, PG

As of 17 Mar 05

UnclassifiedUnclassified

USPHS1ST Rotation

INDIA

INDONESIA

Colombo

U-tapao

SRI LANKA

Medan

Med Team

Aceh

2 x C-130

LPA – CJTF 629Helos x 2

Khao Lak

1 x DVI Team

Male

Med Team

Ships x 4Helos x 3Fixed wing x 3Medical Team x 4

Ships x 5AN-32 x 7MI-8/17 x 6Helos x 3Fixed Wing x 2Medical Team x 2

C-130 x 6B-707 x 1UH-1 x4

LST x 2

C-130 x 5CH-47 x 4Super Puma x 4

Darwin

Hospital ShipHelos x 2

French Ships X 2Helos x 8 Med TeamSwiss Helos x 3ETA: TBD

FFG ARS2 x helos

Ship x 1 Enroute

C-130 x 1Ships x 2LPD/AOR CH-47 x 3 HH-60 x 2Med Team

Participating Nation Military OperationsParticipating Nation Military Operations

C-130 x 1 Ships x 2

C-130 x 2 Ships x 2Eng Team

UNCLASSIFIEDUNCLASSIFIED

C-130 x 1Water System

Field Hospital

C-130 x 2Ships x 2Helos x 3Med Team Eng Team

Field Hospital Eng Team

Fixed wing x 1MP Team

C-130 x 1

Hospital Ship

Ship x 1C-130 x 2Helos x 2Med TeamEng Team

RNZAF B-757 in region

MeulabohShip x 1 Helo x 1 DART Team

ROWPU x 4Med TeamEng Team

Forensic Team

C-130 x 1LST to IDLST to SL

Helos x 4

K.L.

Helos x 1C-160 x 2

Field HospEng Team x 2ALT x 2

HH-60 x 2 Field Hospital

Ships x 30 Helos x 30 Fixed Wing x 22

Med Team

Eng Team

C-130 x 2

AUSAUT

BGD

IND

JPN

KOR SGPNZL

MYSGBR

FRADEU

PAKCHE

CANBRN NOR

LKAIDA

THA

Ships x 7

Ships x 12 Helos x 13 Fixed Wing x 5 Ships x 28

Helos x 2Fixed Wing x 15

USA

26

Click to edit Master text stylesClick to edit Master text stylesSecond levelSecond levelThird levelThird levelFourth levelFourth levelFifth levelFifth level

CLERK

INDIA

CHINA

PHILIPPINES

Diego Garcia

Medan

Jakarta

B-AcehMale

Phuket

U-Tapao

ColomboMALDIVES

SRI LANKA

AUSTRALIA

SINGAPORE

INDONESIA

MALAYSIA

Darwin

THAILAND

Butterworth

Sumatra

Meulaboh

THAILAND35 NGOs Operating - Thai Red Cross: food

distribution- World Vision Int’l: building

materials, water/sanitationfacilities

THAILAND35 NGOs Operating - Thai Red Cross: food

distribution- World Vision Int’l: building

materials, water/sanitationfacilities

ANDAMAN / NICOBAR- ICRC- Catholic Relief Services:home rebuilding

ANDAMAN / NICOBAR- ICRC- Catholic Relief Services:home rebuilding

MALAYSIA (Near KL)- Malaysian Red CrescentMALAYSIA (Near KL)- Malaysian Red Crescent

MALDIVES17 NGOs Operating- Save the Children

MALDIVES17 NGOs Operating- Save the Children

SINGAPORE- ICRC Regional HubSINGAPORE- ICRC Regional Hub

SRI LANKA84 NGOs Operating- ICRC: household items,shelter, water, medicalcare

- IFRC: household items,shelter, food, water,medical care

- Oxfam: water, sanitation- IOM: water- Care Int’l: general reliefitems

- Mercy Corps: cash-for-work, household items,food, water

SRI LANKA84 NGOs Operating- ICRC: household items,shelter, water, medicalcare

- IFRC: household items,shelter, food, water,medical care

- Oxfam: water, sanitation- IOM: water- Care Int’l: general reliefitems

- Mercy Corps: cash-for-work, household items,food, water

Civilian Relief OperationsCivilian Relief Operations

Banda Aceh- Indonesian Red Cross: cooking/hygiene items; water/sanitation

- World Vision Int’l: food aid- Medecins Sans Frontieres- Mercy Corps: cash-for-work,food, relief supplies

- IOM: shuttling IDPs- Care Int’l: food

Banda Aceh- Indonesian Red Cross: cooking/hygiene items; water/sanitation

- World Vision Int’l: food aid- Medecins Sans Frontieres- Mercy Corps: cash-for-work,food, relief supplies

- IOM: shuttling IDPs- Care Int’l: food

Meulaboh- Indonesian Red Cross- Medecins Sans Frontieres- Mercy Corps: cash-for-

work, food

Meulaboh- Indonesian Red Cross- Medecins Sans Frontieres- Mercy Corps: cash-for-

work, food

Medan- Medecins Sans Frontieres- IOM: shuttling IDPs

Medan- Medecins Sans Frontieres- IOM: shuttling IDPs

INDONESIA68 NGOs OperatingINDONESIA68 NGOs Operating

Kuala Lumpur

UnclassifiedUnclassified

OUA MISSIONOUA MISSION(from 40,000 ft. level)(from 40,000 ft. level)

Part humanitarian reliefPart international diplomacyPart global public relationsPart experiment in military-civilian joint operations

Constraints of timing– on-site arrival (6 weeks post-incident) defines

nature of med/surg and mental health activitiesConstraints of access– to potential aid recipients, planning partners and

ready communicationConstraints of time (in theater)– limiting access to target populations and

organizations– limiting scope and scale of aid projects– limiting ability to leverage targets of opportunity

CONSTRAINTS TO MENTAL CONSTRAINTS TO MENTAL HEALTH MISSIONHEALTH MISSION

OPERATIONS PLANOPERATIONS PLAN

FOCUS ON BEHAVIORAL FOCUS ON BEHAVIORAL HEALTHHEALTH

BANDA ACEH, INDONESIABANDA ACEH, INDONESIA

Mental Health InfrastructureMental Health InfrastructureAceh Province, IndonesiaAceh Province, Indonesia

Before the disaster– Psychiatry rare ~1/2 dozen in province– One psychiatric hospital. No institutionalized

system of community care for the seriously mentally ill.

– No psychology– No social work– Unable to determine the nature and extent

of role of Islamic leaders in psychosocial care

Before the disaster– One psychiatric hospital, 4 locked units– 2 short-stay units (male, female)– 2 long-stay units (male, female)– ~200 patient hospitalized

After the Tsunami– One flooded, marginally cleaned, still US

1950’s vintage psychiatric hospital– 60+ patients remain, the others died in the

wards or escaped as the waters rose

Mental Health InfrastructureMental Health InfrastructureAceh Province, IndonesiaAceh Province, Indonesia

BANDA ACEH, INDONESIA

Factors promoting emergence of Factors promoting emergence of psychosocial symptomspsychosocial symptoms

The acute response phase of the disaster has passedIn addition to the enormous loss of life, there is widespread social disruption and economic and institutional destructionRebuilding is on a slow track because of endemic mismanagement and tepid political support for the province

Acute response phase has passedGreat loss of life + widespread social, economic and institutional disruptionRebuilding slowed - mismanagement and tepid political support for the provinceUnavoidable, omnipresent traumatic reminders (everything has been touched by earthquake / tsunami)


The large number of missing delays the important process of grieving for manyPopulation has access the emotions of pain and loss and the Culture has language to express itEmergence of religious justification of eventsUnavoidable, omnipresent traumatic reminders (everything has been touched by the earthquake and tsunami)


12 August 2005

“…the tsunami triggered an...unprecedented attention to the mental health of the survivors, many of whom saw their children or other family members carried away by the waves.”

The WHO suggested that:1) 50% of the 5 million affected people would experience

psychological distress that would fade without intervention overthe course of a year or more.

2) 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.

3) And perhaps 1% to 2% would be left with incapacitating mental problems such as major depression or psychosis.

NEWSNEWSThe TsunamiThe Tsunami’’s Psychological Aftermaths Psychological Aftermath

Mental Health ObservationsMental Health ObservationsBanda Aceh, IndonesiaBanda Aceh, Indonesia

Respectful reluctance to speak of events use of avoidance, redirection, rather than denialWillingness and interest in speaking of events when topic arises unavoidablyAn ability to express and share sadness– Father, son and former insurance agent

Mental Health ObservationsMental Health ObservationsBanda Aceh, IndonesiaBanda Aceh, Indonesia

Expressed optimism about the future and simply stated resignation about the tragedyAn understanding that events, feelings and function in the world are linked– the father and a foundation– psychosis and miscommunication

Faith and Psychosocial Resilience Faith and Psychosocial Resilience in Banda Acehin Banda Aceh

Islam teaches that human beings have no control over matters of life and death. The day of death for every individual is decided upon his birth.Daily prayer ritual provides continuation of pre-disaster routine and reminder of God’s presence and will.Islamic charities very active in humanitarian relief post-disaster

Faith and Psychosocial Resilience Faith and Psychosocial Resilience in Banda Acehin Banda Aceh

No well publicized modification of burial ritual for deadNo well publicized recommendations on mourning for the missingNo widespread dissemination of religious findings related to personal or collective culpability for the disaster

12 August 2005

NEWSNEWSThe TsunamiThe Tsunami’’s Psychological Aftermaths Psychological Aftermath

“At the same time, many people who have worked with tsunami survivors are struck by their resilience. Asian culture, with its emphasis on group welfare over individual self-reliance, seems to have been a powerful, positive influence.”

Sadly, a long-standing familiarity with upheaval and tragedy may also have bolstered the coping mechanisms of many tsunami survivors. People here have a tough life to begin with,…The expectations in life are very different from those in the West. Many people…view the tsunami more as the latest obstacle life has thrown at them than as a cataclysmic blow.”

What Interventions Make Sense?What Interventions Make Sense?

InstitutionalInstitutional–– Support existing institutionsSupport existing institutions–– Rebuild destroyed onesRebuild destroyed onesIndividualIndividual–– Provide individual or group servicesProvide individual or group servicesPopulationPopulation–– Adapt wellAdapt well--heeled population interventions to heeled population interventions to

current cultural contextcurrent cultural context

Considerations for population Considerations for population psychosocial intervention in Acehpsychosocial intervention in Aceh

Restore homes, community, institutions and economic infrastructure

Provide psychosocial education through community leaders, networks and structures (“erte”)


Primary care/mental health professional development– reconstitute preexisting established

professional structure– consider primary and maternal child care

cross-training– Use health care professionals and

paraprofessionals to disseminate pyscho-educational information


Make substantial outreach to faith leaders to encourage:– a declaration of pardon to relieve followers

who were not able to perform death rituals– a statement clarifying position on the

personal/population blame for the disaster– advice to those whose loved ones are still

missing– the provision of faith-appropriate psycho-

educational information

THE HOME STRETCHTHE HOME STRETCH

““They knew to runThey knew to run…”…”The Sydney Morning HeraldThe Sydney Morning HeraldBy Lindsay Murdoch, Correspondent in By Lindsay Murdoch, Correspondent in SimeulueSimeulue

December 30, 2004 December 30, 2004 They knew to run on They knew to run on SimeulueSimeulue, a palm, a palm--fringed island fringed island

closest to the closest to the epicentreepicentre of Sunday's devastating of Sunday's devastating earthquake.earthquake.

"Our ancestors have a saying "Our ancestors have a saying -- if there is an if there is an earthquake run for your life,"earthquake run for your life," DarmiliDarmili, the mayor of , the mayor of the island, said yesterday. "Thousands of our people the island, said yesterday. "Thousands of our people were killed by a tsunami in 1907 and we have many were killed by a tsunami in 1907 and we have many earthquakes here."earthquakes here."

Only five of 70,000 villagers on Only five of 70,000 villagers on SimeulueSimeulue were killedwere killed, , all of them in the earthquake that struck at 7.55am all of them in the earthquake that struck at 7.55am last Sunday. Nobody perished in the fivelast Sunday. Nobody perished in the five--metremetre--high high walls of water that followed.walls of water that followed.

A NARROW ESCAPE

LAMNO

LAMNOIsolated from points

North, South and East

A WALK THROUGH LAMNO

cross cultural mental health ocean tsunami€¦ · 0930 1.0 0830 tsunami strike times sunday,...

Documents