1. Procter, Nicholas G. PhD, RN

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Children are at various risk across the region.


"Even one child I could not save." Mani Natrajan, a fisherman in Cuddalore, India, whose wife and all 3 children were killed in the tsunami that devastated coastlines across southern Asia.1


"Now people hate the sea-they hate it." Dudley Silva, an irrigation engineer in Sri Lanka.2


The earthquake of December 26, 2004, was the world's largest in 40 years. And, as we have seen, the quake triggered a tsunami-a series of large waves-that spread thousands of kilometers over several hours. The tsunami moved through the ocean at speeds of up to 800 km/hr, causing widespread devastation from Indonesia as far as the coast of Africa some 7000 km away.


In what has been an unimaginable natural disaster, it will not be good enough in the short- or long-term to impose community and mental health supports from a monologic or mono-cultural perspective. The tsunami is not a tragedy whereby people are expected to "snap back" to good mental health on their own, or where human suffering can be "turned off like a tap." As United Nations officials have already observed, the tsunami has brought psychological suffering that may last for generations. It is hard to imagine the fear, confusion and desperation of survivors, especially children, who have seen enormous waves wash away their worlds and their dreams.


As international aid agencies deal with the aftermath, one of their goals must be to empower local communities by incorporating long-term mental health initiatives into recovery efforts.


This process has already begun with the government of Sri Lanka calling for doctors, psychologists and pediatricians to come forward to give counseling to the large numbers of children left without parents.


Yet, as the immediate physical health consequences of the tsunami enter their denouement and the media coverage recedes from our newspapers and television screens, there will continue to be big events occurring at a much deeper level for the people of Asia-events that will reverberate for many years. In the post-tsunami period it is the high-impact injuries that most understandably often find center stage-the identification of bodies, emergency medical help and the prevention of infectious disease-as these are necessarily more immediate priorities.


However, it would be misguided to underestimate the long-term impacts of trauma, grief and stress, and many other mind impacts of the tsunami disaster. The problem facing ravished countries is that many have very limited resources that can deliver mental health services to those who need them.


India (where more than 9,000 lives were lost and 140,000 people, mostly from fishing families, are in relief centers) has only 2 to 3 psychiatrists per million inhabitants compared with 50 to 150 per million in developed countries. According to a recent United Nations report, Sri Lanka, which has the highest death toll from the tsunami outside Indonesia at more than 30,500, with thousands more missing and hundreds of thousands of people in relief centers, has the inglorious reputation of having the highest suicide rate in the world at 49 per 100,000. At the time of writing, there are an estimated 38 psychiatrists, 17 occupational therapists, and 410 psychiatric nurses in Sri Lanka for a total population of 19 million.3


The victims of the Asian tsunami now face many new dangers and risks. The United Nations estimates that there could be about 150,000 pregnant women in tsunami-hit areas.4 At the same time, criminals and opportunists are trying to cash in on the survivors' misfortunes. There are already reports of looting in many of the affected countries, with homes, shops and even dead bodies being targeted. And, in Sri Lanka, some of the disaster victims have allegedly been raped in refugee camps. One of the most disturbing allegations is that criminal gangs are befriending children orphaned by the tsunami, and selling them to sex traffickers.5


Children are also at risk across the region in the following ways:


* Sri Lankan children face the additional threat of plastic landmines dislodged by the tidal waves;


* In India, aid agencies have expressed concern that orphan siblings are being split among relatives eager to receive the money promised for tsunami survivors;


* In Aceh, Indonesia, reports speak of children dying of pneumonia after inhaling contaminated water.



Given the notable scale of the disaster, it is fortunate that only isolated examples of crime have emerged so far. But, for the already traumatized victims and their families, the impact can be re-traumatizing.


Traumatized survivors had no time to save loved ones or personal possessions. Tsunami survivors and refugees face specific and complex stressors and are at very high risk of developing clinical syndromes such as post-traumatic stress disorder, and secondary morbidity which might occur with it, including major depression, substance use disorders, and a range of social and emotional difficulties. Further experiences such as motor vehicle or workplace accidents, minor floods and inter-ethnic violence might reawaken this trauma in later years.


The importance of a mental health dimension to the tsunami disaster is further highlighted by a global disease burden for mental illness. Neuropsychiatric conditions account for 13% of the total disability adjusted life years lost due to all diseases and injuries in the world, and this is estimated to increase to 15% by the year 2020.6 Mental disorders represent not only an immense psychological, social and economic burden to society, but also increase the risk of physical illnesses. Given the severity of impact, the current limitations in reaching vulnerable tsunami populations, and the ineffectiveness of treatment modalities for decreasing disability due to mental disorders, the only sustainable method for reducing the burden caused by this disaster are community-based models of intervention and prevention.


If global health agencies and regional governments are to provide clinically relevant, integrated and sustained mental health supports, they should be applied in nature, not imposed by a predetermined coalition of forces. Being so applied, they are in partnership with the needs of local and regional communities. Emphasis must be given to the provision of recovery and relapse prevention services and these concepts should guide partnerships in service delivery.


The massive relief operation involving food, shelter and re-building of infrastructure will go a long way to promote mental health and reduce emotional suffering. Improved nutrition and physical activity provide substantial insight into the role of risk and protective factors in the developmental pathways to mental disorders and poor mental health. High co-morbidity among mental disorders and their interrelatedness with physical illness and social struggle stress the need for integrated public health activity (such as that embedded in a global mental health response), which will target clusters of related problems, common determinants, early stages of multi-problem trajectories, and populations at multiple risk.


At the core of a global mental health response will be a willingness of international aid and assistance to be open to multiple meanings and a wide range of interpretation of health and human needs, thus making co-operation and engagement between individuals and groups as culturally appropriate. Termed "cultural intelligence" (CQ) by Earley and Mosakowski,7 CQ is an outsider's seemingly natural ability to interpret someone's unfamiliar and ostensibly ambiguous gestures, behaviors and actions the way that the person's compatriots would.


Showing a willingness to engage with and understand another culture and a willingness to enter into another world at a time of heightened trauma will go a long way in forming a trusting therapeutic relationship. This will be particularly helpful when working with survivors who feel they have no will or reason to live after losing family, possessions and means of employment. Emphasis on trust and the therapeutic relationship is consistent with a recent extensive and critical review of literature about treating suicidal and life-threatening behavior. Rudd et al8(p14)conclude that "it is the trust inherent in the therapeutic relationship that allows the person to take the necessary risks, do things differently, reach out during periods of acute and excruciating vulnerability, and experiment with new skills, all essential for progress and recovery."


The therapeutic interaction between community people and mental health professionals could also be supported by understanding the "explanatory model" of cultural awareness in mental health. Based on the work of Kleinman and Seeman,9 this means examination of the way in which the symptoms of mental distress are understood and presented, the way help is sought and the way care is evaluated by those who receive it. This process links the mental health experiences of tsunami victims as they are held by community people, their healers, and other concerned individuals and groups (defined broadly and in a culturally congruent way) with mental health professionals' interpretation of them. Based on principles of "reciprocity"-giving in return between health worker and local community-the clinical task will involve looking at the "cognitive distance"10 between tsunami survivors with mental health difficulties and what practitioners see as different perceived causes of illness, optimal care and culturally appropriate support and treatment. Adaptation of the Kleinman and Seeman9 explanatory model will also help bring about more informed and compassionate awareness and respect for the alternative points of view held by traditional communities.




1. The New York Times on the Web. December 28, 2004. Available at: Accessed January 2005. [Context Link]


2. The New York Times on the Web. January 5, 2005. Available at: Accessed January 2006. [Context Link]


3. World Health Organization. Working with countries: mental health policy and service development projects: Sri Lanka. Available at: Accessed January 2005. [Context Link]


4. UN urges aid for tsunami orphans. January 1, 2005. Available at: Accessed January 2005. [Context Link]


5. Criminals target tsunami victims. January 4, 2005. Available at: Accessed January 5, 2005. [Context Link]


6. Prevention of Mental Disorders: Effective Interventions and Policy Options. Geneva: World Health Organization; 2004. [Context Link]


7. Earley C, Mosakowski E. Cultural intelligence. Harvard Bus Rev. 2004:139-153. [Context Link]


8. Rudd MD, Joiner T, Rajab MH. Treating Suicidal Behaviour. New York: Guilford Press; 2001. [Context Link]


9. Kleinman A, Seeman D. Personal experience of illness. In: Albrecht GL, Fitzpatrick R, Scrimshaw SC, eds. Handbook of Social Studies in Health and Medicine. London: Sage; 2000:230-242. [Context Link]


10. Weiss MG. Cultural epidemiology: an introduction and overview. Anthropol Med. 2001;8:1-29. [Context Link]