NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH DEC-11-1993 AT NIMHANS, BANGALORE

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Title
NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH DEC-11-1993 AT NIMHANS, BANGALORE
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WHO/MNH/PSF/91.3 R^J
Englixh only
Diitr: General

PSYCHOSOCIAL CONSEQUENCES

/• __________________ ______________________________ _____________ _______________

OF DISASTERS
PREVENTION AND MANAGEMENT
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DIVISION OF AAENlAL HEA
WORLD HEALTH ORGANIZATION
GENEVA

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WHO wishes to acknowledge the valuable inputs info the development of this
document by Professor Bruno Lirr a, Johns Hopkins, Community Psychiatry Program;
Professor Lars Weisaethi Psychiatric Institute, University of Oslo; Professor Wolfram Schuffel,
Klinikum der Philipps-Universitat Marburg; Professor Beverley Raphael, Department of
Psychiatry, Royal Brisbane Hospital; as well as of Mr O. Almgren, UNDRO;
Dr T. Yazukawa; Division of Emergency Preparedness and Response, WHO.
i

Dr G. de Girolamo, Division of Mental Health, WHO and
Dr John Orley, Senior Med cal Officer, Division of Mental Health, WHO
had the technical responsibility for the production of this document.

Further copies of this document may be obtained from

Division of Mental Health
World Health Organization
1211 Geneva 27
Switzerland

© World Health Organization 1992

This document is not a formal publication of the World Health Organization (WHO),
and all rights ore reserved by the Organization. The document mcy. however be freely reviewed, abstracted,
reproduced or translated, in port or in whole, but not for sole or for use in conjunction with commercial purposes.
The views expressed in documents bv named authors are solely the responsibility of those authors.
Designed bv WHO Graphics

CONTENTS

i

Introduction
Background
Definition and description of disasters

Definition
Taxonomy
Transnational character of mony disasters
Epidemiology of disasters and mo rbidity profiles of
the affected populations

1
2
2
3
3
4

Epidemiology and description of psychosocial

reactions to disaster

_____

Historical perspective
Phases of emotional reactions to disaster
Epidemiology of psychological disorder following a disaster
Relationship between type of disaster and the type and
severity of reactions
Specific psychosocial consequences following disaster

Post-traumatic stress disorder

Grief

Alcohol, drug abuse and family problems
Secondary psychosocial stressors

Vulnerability
Stress upon rescuers
The psychological effects of disasters on children

Psychosocial interventions in disasters

Prevention and treatment of psychological disorders

5
5
5
6

8
8
8
8
9
9
9
9
10

1 1

1 1

Function of the mental health professional expert in
preparedness activities
Functions of the menial health team at the disaster site
Groups requiring psychosocial support
Establishing an information/support centre
Specific procedures for helping survivors
Help for bereaved families
Role of the psychosocial support team
The physically injured

Crisis interver:ion
Debriefing
Role of information
Possible adverse effects of public information

12
13
13
13
14
14
15
16
16
16
17
17

iii

CONTENTS
I

Training and infrastructure for a
psychosocial
response in disaster relief
Training programmes for prim^h^h^^
and omer relier workers
Planning and coordination of interventions in case of
disasters
Model 1
Model 2
Model 3

19

19
19
20
20
20

Possible research priorities

22
23

IV

1

INTRODUCTION

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£

■■;•■:

■

-

Background

i

!
t

UN General Assembly Resolution 42/169,
adopted on 11 December 1987, designated the
199Cs as a decade for natural disaster reduction:
this resolution reminds its readers that natural
disasters, such as those caused by earthquakes,
windstorms, tsunamis, Hoods, landslides, volca­
nic eruptions, wildfires and other calamities,
have killed about 3 million people worldwide
over the past two decades, adversely affected the
lives of at least 800 million more people, and
resulted in immediate economic damage ex­
ceeding US$ 23 billion. “The smallest and p oorest countries are affected most severely by natu­
ral disasters, and the poorest and most disadvan­
taged members of a disaster affected community
are likely to experience the most scHc-us conse­

quences (UNDRO, 1984). Therefore in the
majority of developing countnes, consequences
of disasters, because of their seventv and fre­

quency, represent a real public health priority.
Several agencies of
( the United Nations have
developed programmes which could help
\>countries to be
1 better prepared co cope with natural
and man-made
disasters. WHO
is p"—*--------is participating
in this effort and has produced this docuiment as
part of its contribution to countries’ prepared­
ness, prevention and mitigation of the effects of
disasters worldwide.
There are two United Nations Offices deal­
ing specifically with matters related to disasters
namely the UN Disaster Relief Co-ordinator’s
Office (UNDRO), which provided inputs into

(the Pan American Health Organization) is also
very actively involved in this area and has pro­
duced a slide programme on Mental Health
Management in Disaster Situations (in Spanish
and English).
There has been a general tendency in the past
to consider that the basic needs of the popula­
tions affected by a disaster were to be met essen­
tially in terms of providing shelter, food, sanita­
tion and immunization against epidemics. Their
psychosocial needs were seen as something too
secondary to attract the attention of relief agen­
cies and relief workers. Over the last few years
however, a different trend has become evident
and there is now wide recognition of the fact that
populations affected by a disaster have special
psychosocial needs.
WHO’s role m disasters has graduallv shifted
from providing emergency relief to incorporat­
ing also disaster preparedness, including involve­
ment m training and in the assessment or possible future needs. One of WHO’S strategies for
emergency preparedness and response is
strengthening the national capacity to cope with
disasters. WHO’s target for the Eighth General

Programme of Work, covering the years 199095, is thatby 1995 “70% of allcountnes willhave
developed master plans appropriate to theirparticular circumstances to deal with the health
aspects of emergency and disaster situations”
(WHO, 1987). Since m many countnes disas­
ters, because of their frequency and seventy,
lead to adverse affects on mental wellbeing,

the development of this document, and the Of­

these master plans should include a mental health

fice of the UN High Commissioner tor Refu­
gees (UNHCR). WHO is currently collaborat­
ing with UNHCR in the development of a
manual on refugee mental health, with an em­
phasis on applications in refugee camos in devel­

component.
In general, the key activities for coping with
disasters and disaster nsks are essentially pre­
paredness. which involves all actions designed
to minimize loss of life and damage, and to
prepare for timely and effective rescue, relief
and rehabilitation should disaster strike; pre­
vention. wmeh may be desenbed as measures

oping countnes.
Within WHO, the Division of Mental Health
collaborates with the Division of Emergency
Reher Operations, to provide a psychosocial
input into the activities of the latter programme,
lhe WHO Regional Office for rhe Americas

designed to prevent phenomena from causing or
resulting in disasters or ocher related emergency
situations: ana finally mitigation, which, means

7

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

reducing the effects of severely damaging events
on man and his environment once they have has
occurred.
The importance of preventive measures and
preparedness, the integration of an emergency
response within regular WHO programmes,
and the linkage with development have been
emphasized in rhe resolutions adopted by WHO
m 1981 and 1985. Each of these aspects of coping
with disasters should include consideration of
the related psychosocial components. These can
have an impact on people’s behaviour before,
during and after a disaster occurs, as well as
being important in influencing the overall pat­
terns of post-disaster morbidity.

Much of the confusion in defining adisasteris
caused by the diverse interests of those dealing
with the event, be it in medicine, sociology,
political science or ecology. The definition
adopted usually reflects the role of the organiza­
tion using that specific definition.
From a psychosocial perspective, it is impor­
tant to consider both the medical disaster defini­
tion (an emergency situation in which the vic­
tims are so numerous that the treatment needs
far outweigh rhe resources available at the mo­
ment; here there is an immediate need to bring in
extra resources) and the sociological.
Common elements to be considered in the
conceptualization of disasters include:

Definition and description of
disasters

1. A disaster disrupts the social structure and
cannot be handled by the usual social mecha­
nisms. This disruption may create more diffi­
culties than the physical consequences
(Quarantelli, 1980).

Definition

: '.t

A disaster is a severe’ disruption, ecological and
psychosocial, which greatly exceeds the coping
capacity of the affected community. This will be
the definition that is used in this document.
However, what constitutes a disaster for one
community might not necessarily do so for
another. The difficulties of conceptualization
arise because, “upwards a disaster is unlimited,
downward one has to draw a line somewhere”.
In common daily usage, the term “disaster”
refers to a great misfortune causing widespread
damage and suffering.
There is, however, no consensus on a scien­
tific definition of the term: there are in fact more
than 40 different definitions of disaster in the
literature (Korver, 1987). A disaster is a very
complex, multi-dimensional phenomenon. An
event may be a disaster along certain dimen­
sions, such as ecological, economic, material,
psychological or social, but is unlikely to be one
along all of these m any specific event. Often the
numoer of human Lives lost is an important
criterion for deiimng a disaster.
The definition may be dependent upon the
event itself, or solely on the consequences of the
event. The term disaster ordinarily emphasizes
fast, destructive change. This mav exclude per­
manent problems from the disaster definition,
for instance famine in many parts or the world,
even when rhe consequences of the starvation
are disastrous. To declare an event a disaster may
influence, among other things, the amount of
help offered. The concept also has emotional
and political imolications.

2

2. There are several important variables which
can moderate the impact of disasters. These
include, the ability of the victims to adjust
psychologically, the capacity of the commuruty structures co adapt co die crisis and die
amount of help available.

3. The concept of disaster changes overtime and
among different cultures. Among some popu­
lations, especially m developing countries, a
lengthy first-hand expenence of coping with
natural disasters has produced the creation of
specific “disaster sub-cultures”, which are
likely to affect their partem of psychosocial
reactions to the disaster situation.
4. Since catastrophic events are frequent in many
developing countries, this mav unfortunately
raise the threshold for an event to be consid­
ered a disaster. Nevertheless this should not
lead to a failure to recognize and respond to
the adverse effects that may occur, even with
repeated disasters; these may undermine the
morale and resources of the communitv even
further, and may lessen its capacity to adjust.

The term “personal disaster” (Raphael, 1985)
has been used to refer to a severe trauma affect­
ing a small group or a single individual. This
document however, deals only with those disas­
ters affecting large numbers of people.

INTRODUCTION'

Taxonomy
There arc many possible ways to classify' disas­
ters which may have important consequences
with regard to the way people react and the
types of help required.
From the prevention and preparedness view­
point, the following classification is generally
used:

Natural disasters — Earthquake, flood, cyclone,
hurncane, tornado, landslides, volcanic erup­
tion, drought.
Man-made disasters —Technological disasters
such as toxic, chemical and nuclear accidents,
dam collapse or transport accidents.

1 Man-made disasters are caused by human
failures or accidents, or are due to violence or
war. The feeling that someone is to blame may
make it more difficult for victims to cope with
w:
the situation. However, a clear distinction be­
tween what is man-made and what is natural is
sometimes impossible, because of the increasing
effects of man’s actions on the overall ecological
balance or other human contributions.
For instance in an earthquake, the poor con­
struction of buildings can contribute signifi­
cantly to damage and loss of life. The failure of
authorities to provide adequate warning of a
“ natural "danger can contnbute to the loss of life
and damage. Any rise in the level of the oceans
due to pollution causing a “greenhouse” effect,
may increase the likelihood of floods. Famine or
social conflicts may strike certain parrs of coun­
tries, not just because of drought and crop fail­
ure but also because of transport problems,
hindenngthe movement of food. Bushfires may
or may not be starred by man. These examples
are just a few amongst many possible ones that
demonstrate the blurring that can exist between
natural and man-made disasters.
The speed of occurrence is another important
dimension to be considered in assessing disas­
ters and their consequences on the affected popu­
lation. Perhaps the most well known typology
or disasters however, is that of Barton (1969). He
suggested four mam dimensions: scope of im­
pact (geographical, number of people); speed of
onset (sudden, gradual, chronic); duration of
impact (e.g.repeated episodes); and social pre­
paredness of the community'.
r\ further important dimension has been added
(Green, 1982) which refers to whether disasters
are central or peripheral with respect to a geo-

graphic community. In one which happens to a
group of people who have come together by
chance (e.g.an airplane crash), survivors rerum
to their respective ^geographic communities
where the physical setting and social support
networks are still intact. Such disasters could be
considered geographically peripheral. An inter­
mediate type, according to this dimension, would
be one which occurs to a group of people within
a community and, hence, affects the whole com­
munity in some sense, but where there still
unaffected members of the community and the
physical settings (homes, neighbourhoods) re­
main unchanged.
The most central type of disaster would be
one in which the whole physical and organiza­
tional structure of the community is deeply
changed (e.g.earthquake, floods, etc.), because
homes are destroyed, people are relocated in
different surroundings with strangers, etc. In
this central type the traumatic aspects are not
limited to the impact of the physical event itself,
but may continue for a relatively long period of
time and include many subsequent additional
traumas, changes, and disruptions especially of
a psychosocial kind, requiring further adjust­
ments.

Transnational character oF many disasters
Many disasters are transnational or international
in their effects and impact. For instance nuclear
or toxic accidents may have effects on many
countries across frontiers and at considerable
distances from the place where the event oc­
curred. The nature of frontiers (legal, official,
political) cannot prevent this, and there are many
implications fordisasterresponse. Similar prob­
lems may anse m international transport acci­
dents such as air crashes.

An adequate response to such transnational
disasters has to be set up at the same transnational
level. This means that international coordina­
tion by a specialized health agency such as WHO
is undoubtedly needed in terms of preparedness
and intervention programmes, in order to en­
sure consistent and uncontradictorv responses
m rhe various countries affected. Moreover
WHO is in a special position to ensure a com­
mon scientific international language among the
various researchers and clinicians active in the
medical and psychological field.The adoption at

an international level of the 10th Edition of the
ICD is an important step in this direction (WHO,
1990).

• 3

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

Epidemiology of disasters and
morbidity profiles of the affected
populations

In general the number of deaths and injuries
and the amount of damage is closely related to
the prevailing level of economic development.
An
UNDRO publication (1984) shows a list of
Estimates of the major disasters which occurred
disasters
for the period 1960-81 resulting in the
worldwide (excluding the United States) from
greatest
numbers
of people killed. All occurred
1900 up to 1988, indicate that, in these 9 decades,
in
countries
characterized
by a low-income
about 339 million people have been affected by
economy:
Bangladesh
(633
000
deaths), China
floods, with a total of 36 million rendered home­
(247 000 deaths), Nicaragua (106 000 deaths)
less; 26 million have been affected by earthquakes, with similar numbers affected by ty- .
Ethiopia (103 000 deaths).
The extent of risk among many populations,
phoons and^feyclones, creating another almost
especially in developing countries, has increased '
10 milh<3^^?meless people; finally, 3.5 million
over the last few decades due to increasing popu­
have beeh affected by hurricanes, resultingin 1.2
lation size, greaterpopulation density in vulner­
million people without homes. From 1970 to
able areas and the strong tendency of large popu­
1981, floods, were the most frequent disaster,
lations towards urbanization. There has also
comprising more than one-third of all disasters
been a concurrent increase in the magnitude of
occurring inithat decade. Windstorms were the
certain types of man-made disaster. Very little
next most frequent disaster (one fourth of the
however is known about the stress-related dis­
total number), while earthquakes caused the
orders
caused by such events, which represent
greatest number of deaths and monetary loss.
an
important
area in need of investigation.
The actual numbers killed in disasters is esti­
In
disaster
situations
certain vulnerable groups
mated to be some 3"or 4 times higher in develop­
tend
to
exist.
High
mortality
may be seen among
ing countnes than in the developed. The striking
elderly
people
and
young
children.
Children up
difference however is in the number of survivors
to 2 years old may show lower mortality than
who are affected, which is estimated to be some
their elder brothers or sisters, perhaps because
40 times higherin the developing countries. One
parents protect their youngest children but can­
must presume that this indicates a massive
not afford to help older ones. Pregnant or lactat­
psychosocial as well as physical need for this
ing
women and persons already suffering from
latter group.
existing
disease are also more vulnerable, as are
The geographical distribution of disasters
the poor or certain minonry groups who might
between developed and developing countnes
for instance, have no choice but to live in flooddeserves attention, as there seems to be a rela­
prone areas.
tionship between the location of adisasteron the
The morbidity: mortality ratio, as well as its
one hand, and the seventy of its consequences
relation
to property destruction, is specific to
on the other. Out of the 109 worst natural
each
type
of disaster. For example, in big earth­
disasterswhichoccurredbetween 1960 and 1987,
quakes
the
ratio of morbidity: mortality' is usu­
as selected and studied by Berz (1989), 41 oc­
ally
3:1.
Floods
show high mortality rates but
curred in developing countnes; however, the
few
injuries.
Humcanes
cause fewer injuries
number of deaths caused among the affected
and
deaths,
but
great
loss
of
property.
populations was far greater in the developing
countnes (758 850 deaths in developing coun­
tries as compared to only 11 441 in developed
countnes).

4

■ EPIDEMIOLOGY AND DESCRIPTION OE
PSYCHOSOCIAL REACTIONS TO DISASTER

Ifcfjrieal perspective

.. . injury, d.„
5=r .„
um„ .„
d |loss./fc
o„
danger
traumas
and-

1^^^^^lcsmdiesofthepSychoIogic<- Lindemann, 1944). Until the 1970s?.ho,wever,
Xz* Tr!
T T^l
n C /~i 11 o r-\/-* izkz' zxt— _ _ — '•*■
'
rr>P r>r'rFrr!/>rr\/',^ I
----- •
•.
consequences
of a J..
disaster
wdreHvdrhepsychosocial
disaster
lit'eratu
cure was.p^nodic
unqcfri-aken by Eduard Scierlin (1909) from '' and
Tn'^
<?■’---- -u_
unintegrated. Since
the m-r.
1970s a rich litera­
Zurich who investigated 21 survivors of a min­
ture, largely American and Australian, has been
ing disaster in 1906 and 135 persons two months
published. There is also important work in other
after the earthquake in Messina in Italy in 1908.
languages (German, Russian, Spanish and
The history of traumatic neurosis in European
French). As a research field, however, the study
medicine is well described by Fisher-Hornberger
of the psychosocial consequences of disasters is
(1975) who demonstrated that the understand­
still relatively untouched.
ing of the disorder during the 19th and early
20th century was very much influenced by po­
Phases of emotional reactions to
litical, military, economic and cultural factors,
disasters
with an over-emphasis on an organic basis for
Emotional reactions may be divided into the
traumatic neurosis. However, during World War
immediate
expenence during the disaster and
I the psychological nature of the disorder was
chose
reactions
occurring after the event, some
better understood.
of
which
may
appear
soon and others late.
During World War II, the study of how
civilian populations reacted co disaster traumas
The immediate experience
was further advanced. The air raids against cities
The
immediate reactions reflect the most homwas the background for a series of valuable
fymg dimensions of disaster related to severe
investigations carried out in England during the
physical injury, exposure to extreme danger,
early war years. A striking finding was chat the
witnessing
death of close ones or mass deaths
expectations of "mass neuroses” in a bombed
and injuries, traumatic experiences of helpless­
civilian population did not occur. Unfortunately
ness, hopelessness, separations, and the need to
the war time psychiatric experiences have not
choose between helping others or fighting for
been fully incorporated into the disaster litera­
one’s own survival. Maladaptive reactions dur­
ture, although psychosocial interventions in di­
ing exposure to a disaster such as paralyzing
sasters have been influenced by insights gained
anxiety,
uncontrolled flignt behaviourand grouo
dunng war, lately the Vietnam war. Among
panic, may be incompatible with survival. In
wartime psychiatric cases both stable as well as
studies of disaster behaviour the individual’s
vulnerable personalities were found, but the
level of preparedness, disaster training and edu­
latter did not recover within weeks as did the
cation have appeared as the most important
rormer. The military psychiatric experiences
determinants of a gooo outcome (^/eisaeth,
from World War II influenced civilian clinical
1989). (Being able to cope in the immediate
practice with the introduction of the therapeutic
ttu-Uma situation also came our as a strong pro­
community, group treatment, forward psychi­
tector in terms of longer term psychiatric
atric treatment and cnsis intervention.
sequelae).
Of special note is the Coconut Grove night
Panic is said to be rare in natural disasters, but
club fire disaster in Boston in November 1942,
in crowded areas like suoways, trains and sky­
which claimed the lives of 491 persons. This
scrapers, disasters can evoke panic more easily.
disaster has come to occupy a special position in
Health education programmes and previous
disaster psychiatry because it represents one of
training m simulated disaster situations can help
the rirst systematic civilian studies on the acute
affected populations to avoid panic and respond
51 Fl

psychological refections in victims of phvsical

more appropriately.

5

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

•j-•

Emotional reactions after the "event"

Many different emotional reactions may occur
after a disaster. In the beginning many people
feel numb, or even elated and relieved, often
with strong positive feelings about having sur­
vived. Gradually however, the stress effects may
show, although these reactions are usually rela­
tively short-lived and may be considered a nor­
mal reaction to a traumatic expenence.
Common post-disaster reactions include in­
tense feeling of anxiety, which may be accompa­
nied by “flashbacks” or intrusions and frighten­
ing memories of the expenence. There may be
nightmares, waking the person with panic. Any
reminder may trigger these feelings, and the
person may try to avoid all such reminders or to
shut out feelings (avoidance response). Anxiety
and intrusive memories or reexpenencing, espe­
cially of life threatening or gruesome encounters
with death, may alternate with numbness and
avoidance. The affected person may also be
highly aroused, as he or she is fearful and trying
to protect himself or herself from a return of the
frightening expenence. Normally all these reac­
tions settle over the first weeks. If however,
rhese reactions are maintained at a high level and
for more than a few weeks, they represent a
post-traumatic stress disorder (PTSD). Occa­
sionally the symptoms may not appear for sev­
eral months or more. Spontaneous recovery
occurs in the majonty of cases but in a small
proportion the conditions can last many years.
In silent toxic or nuclear disasters, when no
impressive destructive event occurs, the external
danger mav be invisible and people are likely to
focus on their physical health. Uncertainty and
insecurirv mav create anxiety and fear reactions
and their accompanying somatic symptoms may
induce a false perception of being physically ill,
resulting in pressure on somatic health services.

Epidemiology of psychological
disorders following a disaster
As stated bv Perry and Lindell (1978) and by
UNDRO (1984), different views have been ex­
pressed by various authors about the extent of
psychological disorders following a disaster.
Some hold the position that disasters represent
catastrophic events producing adverse psycholosdcal reactions among most victims, while oth­
ers suggest that the extent of the problem has
been overestimated, and that psychological prob­
lems due to the stressful event(s) appear only

6

among people with a preexisting vulnerability.
The latter view can be found especially in some
of the sociological literature, mainly from the
US. There may be certain reasons why this view
has been put forward: (a) some of the disasters
cited involved little loss of life and mainly in­
volve material damage, (b) poor detection meth­
ods were used to find psychological distur­
bance.
There may be a tendency in some cases to
dismiss certain severe psychological reactions to
disaster as only “natural”. It should be noted
however that severe bruising and fractures may
be quite “natural” reactions to a fall from a
height, but this does not diminish the intensity
of the suffering or obviate the need to help those
affected.
Up to a few years ago, little was known about
the psychiatric epidemiology of disasters in de­
veloping countries. In fact with the exception of
some recent work in the United States and Aus­
tralia, very little is known of the true incidence
of psychological traumas and related distur­
bances following disasters even in developed
countnes. Previous research was based on un­
systematic clinical observations or crude indica­
tors of psychiatric morbidity such as admissions
co psychiatric hospitals (e.g. Ahearn, 1981). Only
following disasters m recent years in Colombia
1985, Mexico 1985 and Puerto Rico 1985, have
systematic studies been earned out. They sug­
gest that victims present marked and prolonged
psychosocial problems whose prevalence is sig­
nificant. Because of the often devastating physi­
cal impact which natural disasters have on popu­
lations living in developing countnes and be­
cause of the scarcity of resources there, inter­
ventions have generally been confined to rescue
and to the provision of basic medical care, with
a corresponding neglect of psychological needs
and related epidemiological research and inter­
vention. Furthermore, the existence of some
clear “disaster sub-cultures” among populations
with lengthv expenence in coping with natural
disasters, especially in developing countries,
makes it difficult to apply findings from re­
search carried out among populations only ex­
ceptionally affected by a disaster”. The different
culture patterns, social structures, and coping
behaviours may reasonably modify the inci­
dence, the severity, and the psychosocial out­
come, pointing to a need for specific research on
these populations.
The specific oehavioural pattern, character­

ized bv a stunned, dazed, and apparently disen-

/

EPIDEMIOLOGY AND DESCRIPTION OF PSYCHOSOCIAL REACTIONS TO DISASTER

gaged behaviour, called “disaster syndrome”,
has been described as a response to impact and
immediate aftermath. It is said to occur m about
25% of those affected by disaster (Frederick,
1981; Raphael, 1986). On the other hand Duffy
(1988) has stated that a “disaster syndrome”,
represented by the immediate post-disaster re­
action, is present m up to 75% of victims during
the first hours or days after the event. Anxiety or
anxiety-related reactions are extremely com­
mon. They may continue from the high arousal
that comes with impact or, more often, emerge
after a latent period of a few hours or days. In
different studies which employed a psychiatric
screening schedule to assess the psychological
status of the victims of the disaster, the percent­
age reacting over the first weeks as shown by the
questionnaire score seems‘to vary from 70% or
more to 20%, in large part correlating with the
severity of the experience. Levels may remain
high in the early weeks. Then, by 10 weeks, there
is usually a significant drop with a gradual de­
crease continuing over the first year (Raphael,
1986).
Disturbances may carry over from the imme­
diate disaster experience impact phase to the
immediate oost-disaster phase: for example in
some industrial disasters studied, about 15% of
the affected populations displayed the
derealization/aoathy symptoms of the disaster
syndrome with absence of emotions, lack of
response, inhibition of outward activity' with
stunned, shocked and dazed appearances. Dis­
organized flight behaviour is common, whereas
brief psychotic reactions occur only in a small
minority. The physical symptoms of anxiety
and stress are more frequent. These symptoms
are important in chat they hamper the person’s
ability to carry out planned actions, and may
become the starting point of a somatization
process (which can be misinterpreted as physi­

cal injury, illness, toxic poisoning etc.).
According to Raphael (1986), psychological
morbidity tends to affect some 30-40% of the
disaster population within the first year follow­
ing it. At two rears, levels are generally less but
with a persistent level of morbidity'’ that seems to
become chronic for some individuals and for
some disasters. Disasters that are man-made and
with high shock and destruction show persist­
ing levels of over 30% severe impairment. Con­
trasting findings from different studies can be
explained in terms of differences in sampling
methods, methodologies, diagnostic categories,
and wpes of disasters under study, as well as

differences in interpretations of the same data.
More specific evaluations of morbidity patterns
have examined.mortaiity, psychosomatic illness,
mental health probJems, physical sympto­
matology, consultation-based health care utili­
zation, hospital admission and alcohol and drug
usage. Mental health problems, as defined bv a
range of different measures, are shown as in­
creased in systematic studies. The diagnostic
inconsistencies among different studies and dif­
ferent research groups are especially important.
The ICD-10 (WHO, 1990) provides a useful
conceptual framework for clinicians and re­
searchers active m this field, recognizing three
mam diagnostic categories o.u disorders caused
by exceptionally stressful life events producing
an acute stress reaction, or by a significant life
change leading to continued unpleasant circum­
stances which result in an adjustment disorder.
The three main diagnostic categories are: (i)
acute stress reaction (F43.0); (ii) post-traumatic
stress disorder (F43.1); (iii) adjustment disorder
(F43.2). In addition the ICD-10 recognizes en­
during personality change after a catastrophic
experience (F.62.0).
A recent thorough review has analyzed the
relationship between disasters and subsequent
psychopathology’ for52 studies which used quan­
titative measures (Rubonis & Bickman, 1991).
The authors examined relationshios among four
sets of variables: (a) the characteristics of the
victim population, (b) the charactenstics of the
disaster, (c) the study methodology and (d) the
type of psychopathology. In the studies exam­
ined, between 7 and 40% of all subjects showed
some form of psychopathology. The type of
psychopathology with the highest prevalence
rate was general anxiety (almost 40% or the
studied subjects), although its variability is also
among the highest. Phobic symptoms (32%),
psychosomatic symptoms (36%) and alcohol
abuse (36%) appeared to show slightly lower
levels of prevalence, with depression (26%) and
drug abuse (23%) somewhat lower still. Using
meta-analytic techniques, the authors showed
that in these studies a positive relationship
emerged between disaster occurrence and psy­
chopathology, indicating an Increase of approxi­
mately 17% in the prevalence rate of psychopa­
thology (compared with a predisaster or control
group rate) as a result of a disaster. The number
of female victims in the samoles studied, the
death rates, and the amount of time that had
elapsed since the disaster event were all directiv
related to the amount of psychopathology’.

7

•.•-.•J.-.

' PSYCHOS°C|A,L CONSEQUENCESOF DISASTERS: PREVENTION AND MANAGEMENT

Finally, higher impairment estimates were Found
for naturally
/caused disasters (e.g.volcanic erupcions) as o pposed co chose caused, ac least in part,
by humans ((e.g.nuclear accidents). This latter
finding however concradicts
----------- much
---- -.1 o the liceracure published so far.
The severity of the stressor (f >r example
threat or loss) has been strongly cc rrelated in
all studies, with the severity of th( pathology
or reaction engendered, although c ther vulner­
ability factors are also important. The main
clearly defined syndromes that appear follow­
ing disasters are the PTSD, the survivor syn­
drome and the disaster bereavement svndrome.
As regards the first, social withdrawal concributes most to impairment. An interestma finding

rfrom
------------. <■ is
■ chat
,
some studies
irritability, anger and

aggression increased over the four-year follow­
up. Irritability is in fact, a very common reac­
tion, and is perhaps especially so with “man­
made disasters in which a human agency can be
blamed. Bereavement disorders, when chronic,
are notoriously resistant to treatment.
Not only psychological disorders bur also
physical disorders and mortality races have been
shown to be higher in survivors of disaster. In
particular rhe rate of coronary heart disease
morbidity and mortality is increased. This has
been shown in a study of earthquake survivors
(Karsayanm etal., 1986).Stud- 2s havealsoshown
that this increase in physical disease is particu­
larly market! in the year after: le disaster amongst
the relatives or people who died ac chat time. It is

presumed that this increase in disease is caused
by psychological factors.

‘

likely to be adverse. Similarly when there is little

support or people feel helpless and unable to
take charge of their own recovery, this also has
a negative effect orrthe outcome.

Spocific psychosocial
consequences following disaster

Post-traumatic stress disorder
The most severe psychiatric disorder conse­

quent upon disaster is represented by posctraumacic stress disorder. This arises as a de­
layed and/or protracted response co a natural or
™/Tade
of an exceptionally threatenmg or catastrophic nature, which is likely co
cause (pervasive distress in almost anyone,
As stated in the clinical descriptions and diag­
nostic guidelines accompanying ICD-10, typi­
cal PTSD symptoms include episodes of re­
peated reliving of the trauma in intrusive memo­
ries ( flashbacks ”) or dreams, occurring against
the persisting background of a sense of “numb­
ness and emotional blunting, detachment from
ocher people, unresponsiveness co surroundmgs, anhedorua, and avoidance of activities and
situations reminisoenrofrherrai.ima Commonly
there is fear and avoidance of cues chat remind
the sufferer of the original trauma. Rarely, there
may be dramatic, acute bursts of fear, panic or
aggression, triggered by stimuli arousing a sud­
den recollection and/or re-enactment of the

trauma or of the original reaction co it.
There is usually a state of autonomic
hyperarousal with hypervigilance, and enhanced
startle reaction, and insomnia Anxiety and de­

pression are commonly associated with the above
symptoms and signs, and suicidal ideation is not
infrequent. Excessive use of alcohol or drugs
may be a complicating factor.
________________________________
Some people may respond co crauma with
The seventy or psychosocial
reactions to a disas­

Relationship between type of
disaster and the type and severity
of reactions

depend on many factors in the individual
terwill
’
and me community. Where there is great loss of
hie there is likely co be much grier and oerhaps
disruption or rarmly and commumry life. Loss
of homes and property may destroy the sense of
the community and create stress in association
-------- o
with the hardships. Where support
is avuxiduic
available
can be made of what has
and some meaning
r

symPcoms which last only briefly or with milder
symptoms which hardly justify a diagnosis of
disorder . Some workers in the field have re­
ferred co these as “post-traumatic stress reac­
tions”.
The onset follows the trauma with a latency
Period which may range from a few weeks or
m°nths(butrareiyex«eds6monchs).Thecourse

happened, and especially when there are op- • is tluctuaung but recovery can be expected in the
majoriry of cases.
portumcies for individuals and the community
.0 oe actually involved tn their own recovery,
Grief
me outcome is likely to be better. Where there is
obvious blame, human negligence, malevolence
ror those people who have experienced signifi­
or violence, and little support, the outcome is
cant loss, the emotional reactions which occur
8

I

EPIDEMIOLOGY AND DESCRIPTION OF PSYCHOSOCIAL REACTIONS TO DISASTER

’
‘

5

after the disaster are likely to be those of grief.
There may be grief for the loss of loved ones, or
home, treasured possessions; livelihood or com­
munity. The severity of.the morbidity is greater
for the individual when associated with personal.
loss due to death ofa loved family member- The
emotional reactions’of grief include sadness',
distress, anger, and’longing and yearning for
what has been lost. The bereaved person may be
preoccupied and miserable. Usually grief reac­
tions diminish to some extent by 4-6 weeks,^
although stresses'may complicate dr prolong
’ them and anniversaries may induce recurrences.
A number of studies have pointed out a number
of factors that might increase psychological
morbidity among the bereaved: lack or weak­
ness of social supports, female gender, loss of a
child. There are circumstances of violence and
the dead body has been unable to be found or
viewed bv the bereaved. For some of those who
have suffered losses, grief may become chronic
and the emotional reaction may intensify into

severe depression.

I
Alcohol, drug abuse and family problems

zcv/ srddics have shcv/n increases m alcohol
and drug consumption folio wing a disaster, while
social withdrawal, particularly in association

with numbing, can be the most frequent form of
morbidity in interpersonal relationships. The
prolonged stress of the aftermath, the preoccu­
pation with painful memories or losses, or the
disruption of home, family and community life
and even work, may all adversely affect adjust­
ment. Family conflicts and problems may occur.
Children may be overprotected and sometimes
family violence may result. For most families
and individuals these problems are short lived
and transitional, but for some they are delayed
or become chronic. Others may respond to the
challenge of the disaster and appear- to show
greater strength and coping, so that rather than
social pathology or community breakdown,

I

there may be enhanced social and community

functioning.

fabricand the breakdown of traditional forms of
social support. “Temporary camps" providing
inadequate facilities, are known to house victims
for years. Disruption of families can also have
important psychosocial consequences upon the
membersand particularly on small children with
no accompanying adults.
Unnecessary hasty procedures for dealing
y th dead bodies, under the guise of preventing
outbreaks of communicable diseases, can lead to
such rapid burials that proper identification may
not be-'possible and full mourning procedures
may not occur. Likewise, overenthusiastic vac­
cination programmes may be initiated for the
same reason. Other misbeliefs may lead to un­
necessary extra stress on victims of disasters.

Vulnerability

When disaster is no: followed by new and addi­
tional stressors, early prediction based on an
evaluation of risk factors (risk situations, risk
individuals and risk reactions) may be possible,
thus allowing the health workers to concentrate
their intervennons on high risk cases.
Am immediate adverse psychological response
to trauma can be a predictor of PTSD Thu*?
screening instruments measuring the mental state
shortly after a disaster can be used to idennrv
risk cases. Bv combining this with individual
risk factors (such as previous psychiatric im­
pairment) and the intensity of disaster stress
exposure, high predictive power has been

achieved.
The results from longitudinal studies can be
summarized as follows: after exposure to a brief
disaster trauma, a person without marked
premorbid vulnerabilities may experience the
symptoms of a post-traumatic stress reaction
but should be expected to gradually overcome
and finally to recover completely'from these
symptoms, provided that the conditions are made
favourable tor rehabilitation, that qualified treat­
ment is offered when needed and that the person
is motivated to work with his problems. The

majority or survivors who develop long-stand­
ing PTSD have been found to surfer from some
kind of pre-morbid vulnerability.

Secondary psychosocial stressors
Certain specific stresses can arise in the wake of
disasters, consequent upon social changes. These
include the disoiacement or individuals to other
geograohical areas, housing people in camps,
unemployment, inactivity apd lack of recre­
ational possibilities, the fostering of dependency
in survivors. general disruption or the social

Stress upon rescuers

There are nv'O categones of rescuer the non­
professional and the professional. The stress
upon the non-proressional rescuers may re­
semble that on the victims, inasmuch as they
mav be caught uo in the impact or the disaster.

9'

PSYCHOSOCIAL CO^OUENC* U7 DISASTERS: PREVENTIUN~ ND MANAGEMENT

As volunteers or bystanders in the interim pe-

no
e ore professional help arrives, they may
suffer the terrible trauma of not being able to

on^^ildren,O9iCa'

°f disasters

It has been pointad
ac icve success in their rescue attempt. Also for
■990)) thatseveral
SthTn P°T
u °T
£
of the
early(YU1C
studiesand
of children's
the professional, failure to be able to rescue
T dlSaSter trauma ^ered from methvictims, especially children, is a significantstresodolOgIca
For instance severa] of
sor, comparable only to the loss of a collea-ue
Even a professional rescuer, such as a fireman
scales frequently used to assess the psycho­
logical consequences of disaster were never in­
may be overwhelmed by rhe magnitude of a big
tended to measure the effects of trauma on chil­
disaster as compared to an individual catastro­
dren, or have a poor validity for this purpose
phe Tne available resources usually seem too
I here is now a consensus that teachers report
small, creating feelings of powerlessness and of
being ternbly alone. As always, stress is better
ess psychopathology among child survivors
en ured when expenenced as an active partici­
an parents do, and that both teachers and
pant rather than as a passive victim. In disasters
parents report far less than the children them­
selves. In this type of research screening instru­
affecting people one knows personally, such as
ments
used on theirown, withoutdetailed inter­
m company and community disasters, rescuers
views with the child, are of limited value In
especially need to adopt a very “professional
combination, however, they reveal a consider­
attitude .
able
amount of post-disaster stress reactions
Exposure to death and dead bodies has been
among affected children (Pynoos er al., 1987)
repeatedly identified as a major stressor follow­
Rj-ys.ve behaviours with clinging to parents
ing all such events. Children's bodies represent
and heightened dependency are frequent find­
cYPes
exposures (Ursano,
ings.
1987). The psychosocial consequences on both
The early studies showed that in the majority
survivors and rescuers of a large number of dead
ofcasesthedisturbancesareshorrlived(Garmezv
bodies also presents needs co be taken account
and Rutter 1985), but only a few studies have
or, and is probably best dealt with bv havin-

certain formal procedures laid down on how to
deal with this situation. It is very unlikely that
those wno have died will have been suffering
from intectious diseases. Some of the enforced
ygieruc , measures seem to reflect people's
iear of dead bodies, more than any actual health
< anger, and may lead to considerable psychological distress in the
...e survivors.
It follows from the
the definition
definition ((exceeding the

>n vestigated the effect of major disasters in which
t e children had been exposed to life threatening
rhi
factors.
In
the
aftermath
of
the
Buffalo
J...
aiiermatn ot the Buffalo Cre.S
Cre-k
disaster Newman (1976) found, among chil­
dren under 12 years of age, an enhanced vulner­
ability to future stress, and an altered sense of

power over the self. The effects upon the chil­
dren seemed to depend upon their developmen­
tal level at the time of the trauma, their percep­

i

coping capacity) that in the initial phase of a
disaster not only the victims but al.
also the rescu­
ers/ health personnel are faced th a demandinSituation where not everyone can be helped
optimally, this is the essential difference be­
tween emergency medicine and disaster medinne. Although the practice of emergency medi­
cine is the basis for disaster medicine, the latter
calls tor a much simpler and less resource de­
manding practice. Helpers mav find it difficult
to change their way of working. In particular,
Key may find it difficult to have to leave some
people that need help without anv helo because
or insufficient resources. It is imoortant for the
disaster workers to be well aware of the lowest
leve. of interventions that is still acceptable and
to oe trained to tolerate feelings of insufficiency,
powerlessness and heiolessness.

10

trons of family reactions to the catastrophic
Tu
de§ree °{ direct exPosure of the
children themselves to the trauma. It should be
noted thatstud^s(Blochetal., 1956) havefound
that children tend to reflect their parents’ reacnons.
As in many adult survivors of acute trauma
suffering from PTSD (Weisaeth, 1989b) psy­
chic numbmg has also been difficult to detect in
Children and adolescents, and often takes the

orm of withdrawal into uncustomary
behavioural parrems (Frederick, 1985). The sense
of foreshortened future, which is a symptom of
1 IbD, resultmgfrom the exposure to mass deaths
may have particularly severe effects in children,
causing them to give up their involvement in
education, expectation of havingtheirown famibes in the future, etc.

PSYCHOSOCIAL INTERVENTIONS
IN DISASTERS

Prevention and treatment of
psychological disorders
brom the psychological point of view, the pri­
mary prevention of disasters must deal with
denial as a common psychological reaction to be
found among populations exposed to a threat.!
The negation of an imminent threat can make
forewarning useless, and expose populations to;
avoidable risks by producing adelay in adopting
preparedness measures. Therefore health work­
ers may have an important role in reinforcing
warnings and thus, making timely and effective
prevention possible.
Psychosocial prevention can also play an es­
sential part in preventing and minimizing the
psychological consequences of disasters, esperiqlly rhe occurrence of PTSD. In terms of inter­
vention programmes aimed at preventing and
treating psychological disaster-related disorders,
the mam needs rollowing natural disasters exist
in developing countnes and among socioeco­
nomically deprived individuals. Since in developmg countnes the resources devoted to mental
health are often inadequate to meet even routine
needs,-the pnmary health care system is the first
and often the only health network available in
the case of a disaster. It should not be forgotten'
however that the population affected bv a disas­

psychological distress in somatic terms
(Goldberg & Bridges, 1988). In order to cope
with general anxiety and also uncertainty about
the possible health effects of the disaster,^people
focus on the more tangible aspects of their physi­
cal state of health, seeking out the health care
system and requesting explanations. Especially
in the absence of reliable data about the health
effects of the accident (for example in the case of
toxic, chemical and nuclear disasters), medical
workers lack adequate explanations and may
well respond with extensive and intensive diag­

nostic screening of populations and individual
patients. The paradox in the situation, however,
is that attempts to reduce such illness behaviour
and such extensions of the diagnostic proce­
dures, in order to diminish the probably un­
founded attribution of symptoms to the disas­

ter, would deprive people of a coping strategy if
no alternative were made available. For all these
reasons, the pnman health care worker repre­
sents the crucial locus tor the intervention. The
proper handling of the psychological problems
associated with a disaster is of great importance
and must be included in the training programme
of all health workers potentially involved in the
care of affected people. The training of primary
health care workers to give appropriate treat­

ter might well retain considerable coping ca­
ment to people attending health centres and
pacities. They should not be treated as com­
showing emotional distress due to a very stress­
pletely helpless, and assistance should be di­
ful event, deserves priority (Lima, 1986); such
rected at mobilizing local strengths wherever
training represents one of the main prepared­
possible. Moreover, for socioeconomically de­
ness activities.
prived individuals, primary care is the only mean
Tnere are other considerations which undzrof extending health and mental health sendees.
score the importance of integrating mental health
In addition, in many disasters, besides a certain -services within the Framework of the existing
number of people who have been severely af­
health system, and especially the primary care
fected by it, there will be a much larger number
system:
of less affected people who wiP however, dis­
play a variety of Functional complaints and psy- .
1. Many potential users do not come to a facility
chological disorders. Functional complaints and
^vhich is openly labelled as a mental health
somatization disorders will be particularly com­
device, since they co not see themselves as
mon among people attending primary health
peop: --seeding specialized help but consider
care and medical Facilities, as the majority of
themselves only as victims of extreme adver­
people :n developing colmtnes tend to exoress
sity.

11

M C°NSEQUENCES OF OISASTEko; PRtVtNHON AND MANAGEMENT
■

,*'•

i

2. It is well known chat the large majority of
cases of psychological distress among
artenders of health centres go unrecognized
do not receive proper care and represent an

important burden for the health services. Bet­
ter and prompt recognition and management
of these disorders, including PTSD, can im­
prove their outcome and reduce the burden
on the health services.
3. The primary health care network, thanks to
its central position in the community, can
guarantee proper follow-up of victims and
their families for as long as they need.

In this framework, the role of the specialized
mental health team should essentially be one of
supervision and training, and only especially
difficult cases should be referred for direct treat­
ment.
Two recent papers have reviewed the empiri­
cal evidence for the effectiveness of a range of
treatments for post-traumatic stress disorder
(Davidson, 1992; Solomon et al., 1992). With
regard to drug treatment, amitriptyline and

imipraimne are both effective, and will help with
disturbed sleep. Doses up to 200-300 mg/day
may be required, although attention should be
given to possible side effects. Treatment should
be continued for at least 8 weeks. Other studies
have examined the efficacy of behavioural tech­
niques, consisting of different forms of system­
atic desensitization or flooding; these techniques
have been found helpful, especially in terms of
reducing PTSD intrusive symptoms. Cognitive,
psychodynamic and hypnotic techniques also
hold promise. Clinical experience tends to sug­
gest that bnef short term counselling may be
helpful in the early stages of the disorder, before
it becomes entrenched. This is particularly so if
rhe person is able to deal with the effects of
helplessness and fear that surround everybody
after a disaster, through catharsis, support and

cognitive restructuring of the experience. Fur­
ther research ho wever, is needed before any firm
conclusion can be drawn as to the comparative

etreenveness of different treatment methods.

Teaching preventive psychiatry

This will involve educating and training the
entire spectrum of professions concerned with
disaster rescue operations in the basics of disas­
ter psychiatry, such as emotional first aid. The
target groups are not only the medical, paramed’cal personnel and ancillary staff (such as
switchboard operators, who have a vital role to
play) found in a hospital, but also personnel in
the associated organizations such as the police
f>re bngade, civil defence, the clergy, industrial’
safety personnel, and administrators with spe­
cial responsibility for disaster planning etc.
Leadership

The semor professional should organize and
lead the specialized disaster psychiatric teams
made up of other mental health professionals as
wel. as others that are activated during the acute
phase of an actual disaster (loss support group
haison psychiatric team, stress management/

debriefing teams, as set out below).
Mental health care during the first 6 months

The first 6 months after a disaster mav require
general counselling for those who present to
primary care with recognition and referral of
‘'Typcciai mental health problems such
as 1 IbD, depression and gnef. Early treatment
may help to prevent problems.

Planning long-term follow-up of victim groups
The second 6 months or so after a disaster, that
is between the acute phase and the longer term,
is an important time, as much of the psvchological work is done then.

During this stage, one should be aware that
anniversary” reactions tend to crop up; certain
days may serve as reminders of what the victims
have Peen through. There may also be a need to
rollow-up avoidapte behaviour, because this
may indicate a delayed onset of symptoms in
victims who have not displayed the full post-

traumatic stress syndrome.
Mobilizing support at different levels

This includes the giving of advice to victims and

f-uncfion of the mentaJ health
professional expert in
preparedness activities
The mental health professionals) at the national

Or suonational (e.g.orovincial) level should be
responsible for

helpers about coping techniques and the mobi­
lization of support from family, friends, work
mates and neighbours. A clearing house for
mrormation on available resources should be set
up.
It may be useful to have some model pam­
phlets presenting essential information that can

12

PSYCHOSOCIAL INTERVENTIONS IN DISASTERS

be rapidly adapted to a particular disaster situa­
tion and distnbuted to relevant groups, such as
survivors, bereaved families, rescuers etc.
In massive disasters particularly in third world
countries, killing tens of thousands of people,
the only active element of the psychosocial or­
ganization that is possible in the turmoil of the
acute post-disaster phase may be that at the
senior staff level, trying to influence decisions
and providing psychological support.

Functions of the mental health
team at the disaster site

7. Health personnel(mass injury situations that
demand difficult prioritizing)
,•__
8. Persons holding responsibility
9. Workmates (in company disasters), and
10. Evacuees.

Individuals at the disaster site displaying
grossly deviant behaviour or other severe psy­
chological reactions should be raoidly re­
ferred to psychiatric care.

Establishing an information/support
centre

1 This centre can be located either at a hospital or
at a convenient place not too far from the disaster
area, (hotel, town hall school, etc.) but neverboth to developed and developing countries, the
■
theless
far enough away from where rescue ac­
following proposals, focusing on the functions
tivity
is
taking place, so that congestion and
of the specialized mental health team, are appli­
interference
is reduced. If the identity of the
cable especially in the developed countries. Only
dead is uncertain (which is frequent), or the
these countnes can usually afford the heavy
number of dead is unknown for a rime, a great
burden of setting up and maintaining a specialist
number of families will be distressed until they
mental health service which can be mobilized at
ascertain that their missing family member is
times of disasters. Nevertheless, it is hoped that
safe. Establishing an information support cen­
the following guidelines can provide useful leads
tre has turned out to be useful. The existence of
for those working in developing countnes.
such a centre and its telephone numbers should
be distributed by radio and TV. Families who
Groups requiring psychosocial support
are worned that one of their number is amongst
Psychosocial support at the site of a disaster
the victims should be invited to come to the
should in principle be earned out by the rescue
centre. Survivors may also be asked to gather
workers and emergency health personnel. The
there. Particularly after transport/communicaleader of the mental health team with collaboration disasters -when people die far away from
cors should establish the priorities of
their homes, this centre may be useful, for sev­
psychosocial support activities, mainly based on
eral reasons: it gives the bereaved a chance to
their evaluation of the particular traumatic as­
meet survivors to get a first hand report about
pects of the disaster, taking into account the
what happened to their loved ones, how they
different groups which are to be considered:
died, perhaps even what they uttered before
they perished, and what was done to rescue
them. The survivors and possibly also onlook­
1. The next-or-kin
2. The injured survivors and their close ones
ers and rescuers have information that often
cannot be given by others.
3. The uninjured survivors
For the survivors it is often an important
These grouos are likely to have suffered the
experience to be or help to the bereaved.
The main functions of such an information/
most severe stressful expenences and thus re­
quire support and preventive activities. Often a
support centre are:
family may include all three above. Other groups
-provide rapid, authoritative information
about tragic news that can be conveyed in a
need to be considered, but they usually have less
humane, direct way in a setting sheltered
pressing needs, namely:
While rhe considerations described so far apply

4. Onlookers (particularly ar risk are the help-

5

less helpers)
5. Rescue teams (particularly when failing to
rescue, esoecially children)
6. Persons doing body handling (particularly
when thev are non-professionals)

from public and media attention,
2. To provide support and a holding environ­
ment for both survivors and helpers,
3. To serve as a forum or meeting place where
affected individuals and families can support
each other. Self-help groups mav develop
from this forum.

.1-3

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

4. To be a place where the police can collect
identification data about missing/dead per­
sons from their close ones,
5. At times the police should be able to use the
centre to interrogate surwivors about the di­
sastrous chain of events as a part of their
investigation,
6. The information/support centre should help
to reduce the convergence of people on the
disaster site that may create congestion and
therefore movement problems for rescuers.

A meeting may be organized for everyone
affected (this may be possible for up to one
thousand people) or at least one or two repre­
sentatives from each affected family. At such a
meeting information can be given about rescue,
identification, investigation of causes, insurance,
psychosocial support services and religious ser­
vices.
Attempts can also be made for early identification of p ersons at nsk. The Post-Traumatic
Symptoms Scale - 10 for instance, can be used
after a few days. The survivors’ mental state can
be evaluated, as can the
i
possibility for mobilizing social support from people’s own networks
(family, work colleagu es, fnends, neighbours).

When disasters involve people away from
their home areas, it may be necessary to help
them to establish supportive contacts with health
or social service, professionals in their home
district. One of the first needs of survivors in
these circumstances, is to be able to inform their
families about their fate, preferably even before
the media have announced news of the disaster.
Some may have an urgent need to get home
themselve's. This makes organization of a men^
1health support service more complicated than if
the victims are local people or members of a
homogenous social system.

Help for bereaved families
^as been demonstrated quite clearly that the
f- ■’ is the unit providing the most important
family
source of strength for eindunng a disaster.loss.
There is strong evidence that sudden and violent
death causes more pathology in the bereaved
than expected losses and this can be made worse
by the ternble circumstances surrounding the
death in disasters, perhaps even witnessed by the
family. Equally distressing however, are deaths
happening far away from them, possibly with
times of waiting and uncertainty for the family
unun unC ocatn is comirmeu.

Specific procedures for helping survivors
The mental health team should reach the scene
of the disaster as soon as possible. There have
been very positive responses to anticipatory
guidance, i.e., information about the natural
post-traumatic stress reactions that may be ex­
pected. Information meetings are effective means
to talk about this and what the survivors them­
selves and their close network can do to help.
Anticipatory guidance works by helping the
victim accept the reactions as normal and ex­
pected, and not as pathological, thus reducing
uncertainty’ and feelings of helplessness. Night­
mares suffered by the victim are often alleviated
by physical contact; if this fails it may be better
to wake the patient and let him go back to sleep
again afterwards. Hypnotics may be given briefly
for severe sleep disorders.
At this early stage most survivors are psycho­
logically open and willing to talk about their
experiences, an attitude, however, that may soon
change into a defensive, withdrawn, non-coop­
erative position if time is allowed to pass with­
out attempting to make contact. Therefore it is
of utmost importance that the survivors are
encouraged to seek help if problems develop.

14

Sometimes the bereaved may be unable to
travel to the site or they may never seethe dead
because the remains may not be identifiable or
even found. Frequently, this failure to retrieve
the body or to identify the remains has compli­
cated gnef work. In the acute phase, measures
taken to alleviate the consequences should have
as the first goal, to help the family fully grasp the
death of one or more of their number, and
secondly to help start them on the road to
accepting the loss. The full realization of the loss
seems to be helped by the identification of the
dead body and an awareness of the physical
aspects of death, as well as the circumstances in
which it happened.
Experience in Norway

The psychiatric team working with the be­
reaved families after a disaster, (the loss sup­

port group), usually sets up Its headquarters
at the local hospital, for example in the out­
patient department of internal medieme. Each
team consists of a psychiatrist, chaplain
(priest), psychiatric nurse, clinical psvchologist and sometimes a social worker or others
experienced m loss and gnef reactions. Gath­
ering the bereaved families in one place pro-

PSYCHOSOCIAL INTERVENTIONS IN DISASTERS

tects them from wandering aimlessly around
or engaging in unplanned searches for miss­
ing family members. Some experience indi­
cates that the support group should work
exclusively with the bereaved families and
not combine this work with support to survi­
vors, because of the entirely different needs of
the clients. Each family has two group mem­
bers designated as personal contacts. The
group will work in close cooperation with the
police which is the agency that carries out the
identification work.
In disasters where people die away from their
homes, the team will have some hours to
organize the reception of the bereaved fami­
lies. If there is a large number of dead, it is
important to join the different families into a
cohesive group by, for instance, lodging them
m the same hotel. If the dead come from a
similar background, as in a school-bus acci­
dent, the parents will already have a natural
affinity with each other, and this will
strengthen the bonds for an extt:ended period.
If the dead make up a group which h.las come
together by chance however, as in a some
airplane crashes, the bereaved may form a
group onlv during the acute phase when they
are sharing many of the same services and
undergoing many of the same experiences.
The first day after a disaster is usually filled
with a succession of practical problems to be
solved. The bereaved families are encouraged
to travel with a companion (who might be a
local priest or a friend of the family), because
it has been showm that the breaking of the
strong bonds that often arise between the
team and the bereaved family will be made
less difficult in the aftermath of the event
when a continuing link to an after-care ser­
vice at the home place is provided through
this person.

the full facts about the death; this is a Iburden for
both parties involved.-If the body hlas not yet^ ..
been recovered, the next-of-kin will nearly al­

ways express a strong, wish to travel to the scene
of the disaster.
Identification of the body

A. member of the team should be present when
the next-of-km is asked by rhe police to make a
positive identification of the body.
Viewing the dead

It is important that the bereaved are provided
with an opportunity to see the body of the dead
if they wish and if this is possible, and that they
are provided with information about the death.
It is also important that as far as possible, appro­
priate funeral and mourning rituals are provided
in accordance with rhe practice of the bereaved’s
culture. An. important task for the support group
has been co arrange for this viewing of the dead
bodies.. This must be scrupulously planned after
evaluation of each family and considering the
state of the body. Meeting rhe dead gives the
family a chance to see, talk and touch and co fully
comprehend chat the loss is real, chat the uncer­
tainty is over, and chat they must take a final
farewell. If the face is too mutilated to be seen,
other parts of the body may be recognized. For
children it can be a help to leave something in the
coffin, a favourite doll, a drawing or a letter co
the dead mother or father.

Information about the circumstances of death
Regularly the family has many questions about
how the dead person was found and the manner
of death. Therefore they should be given an

opporrumry to meet survivors who have some­
thing to tell, the rescuer who found the body,
and any nurses and doctors who tried to resus­
citate the victim. It may be necessary to ask the
pathologist to provide information.

Role or the Psychosocial Support Team
Visiting the site of death

The psychosocial support team may be involved
in the following acdvities for the bereaved fami­
lies:
Notification of death

Seeing that this dues’ is carried out in an appropnate way by the local police, priest, etc. It is
important that notification is given in such a way
chat the family can be helped to grasp what has
happened. It is a common experience chat the
bearer or die sad message is not in possession of

The team normally encourages viewing of the
scene of the disaster to be earned out m groups,
and a rather private memorial ceremony may be
arranged there. This allows the bereaved fami­
lies to come close to their dead and express their
solidarity'. This final farewell must be shielded as
much as possible from the intruding gaze of
outsiders and the media.
Public memorial service

The bereaved families should also be helped to

15

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS.-PREVENTION AND MANAGEMENT '

attend some kind of public memorial service.
Public mourning is an important symbol of the
wider society’s support to those bereaved.
Personal relationships are particularly im­
portant m rhe emotional reactions after disas­
ters, providing support and help in dealing with
the stress. People are also very distressed when
separated from those they love during and after
a disaster, and information and support services
to help the reunion of family members are likely
to be helpful. Special relationships and closeness
between people of all social groups who have
suffered the same stressful experience together
may provide a “therapeutic community” effect
after the disaster, where people talk through
what has happened, share feelings and support
one another in several ways that may help recov­
ery. Similar bonds may be formed between vic­
tims and rescuers.

The physically injured
Many hospitals are capable of handling 20 or
more injured cases, but not many can take care
of the one hundred or more close family mem­
bers belonging to this number of injured. This
may be a reflection of the usual emphasis on
physical injunes in disaster planning. The surgi­
cal and intensive care personnel should there­
fore be reinforced by a psychiatric liaison team
who can have responsibility for both the injured
and for their family members. As regards han­
dling the injured, the most common error in
psychological handling is leaving the injured
alone; they are especially vulnerable to being
abandoned in darkness.

Crisis intervention
“The good talk” is the psychotherapist’s main
tool. It is as important as the scalpel to the
surgeon and contains several therapeutic ele­
ments: the interpersonal contact, the verbaliza­
tion which increases control, the cathartic effect
of ventilating emotions and the need for work­
ing through the experiences again and again, if
the fragmented and overwhelming impressions
are to be neutralized and integrated. To turn the
passive reliving of the trauma, as in nightmares,
into an active reconrrontation seems to work
well if the patient feels that the therapeutic endronment is !$afe enough. It is natural to use the
group approach with victims of collective trauma
because, having faced danger together, strong
oonds have been created between them.

:I6

Debriefing
The majority of rescuers report a need to work
through the emotional disaster experiences by
sharing their feelings with others. Debriefing
should aim to:

— review the helper’s role;
— ease the expression of feelings;
explore particular problems encountered and
solutions found;
— identify positive gains;
explore consequences of disengagement;
— identify those at risk;
provide education about normal reactive pro­
cesses to acute stress;
explain how to cope with stress adaptively.
The psychiatrist can act as the formal leader
of the debnefing group or may give training to
professionals in rescue organizations so that
they can lead such activities. Frequently it is a
great advantage to have taken part in the rescue
operation when leading such a group, but there
may be occasions when a neutral professional
should take on this role. Debnefing involves
going through, in detail, the sequence of events
as experienced by each participant. The rescuers
should also share with the rest of the group their
thoughts and feelings dunng and after the disas­
ter. It is generally easier to begin the debriefing
by first reporting factual information. The descnption of the professional activities of the
rescuers can lead on naturally to the more deli­
cate issue of their emotional and psychological
reactions. Reviewing how helpers felt and coped
requires consideration of positive as well as
negative aspects. On the negative side, these
individuals may have expenenced a sense of
despair, afear or beinguseless and overwhelmed,
or they may be having problems at home be­
cause of their involvement in disaster work.
Some may suffer from what has been called
performance guilt” believing that their contri­
bution was inadequate. Positive reactions may
include a feeling of satisfaction of a job well
done, the finding of a victim alive, the forging of
important relationships among helpers, or asense
or reassurance about having been able to cope.
The sustained emphasis on the positive aspects
of the work provides a powerful antidote to the
sense of being overwhelmed, and helps to achieve
a feeling of mastery over the unpleasant features
of disaster work. The briefing session should
encourage the expression of these positive as­
pects. Sometimes a powerful continuing rela-

I
__________________ .

----------

PSYCHOSOCIAL INTERVENTIONS IN DISASTERS •
“- :

icw

1

3
tionship may develop between a helper and one
or more of the person rescued. Both this and
powerful relationships thatmay have developed
with other helpers can cause problems by cut­
ting across family relationships.

Role of information
Accurate information is very important at every
stage of disaster response. As part of prepared­
ness, people should be provided with clear in­
formation about what to do in the event of a
disaster affecting their community. Such infor­
mation should be relevant to disasters that are
frequent or likely to occur, but also be of general
utility for unexpected circumstances. It should
convey the nature of the threat and what to do
about it in simple and concrete terms. Informa­
tion in the event of an imminent threat should be
reported through at least several channels in-

■

<

i

by those who are seen as trustworthy leaders.
Training, including information on what to do,
should be incorporated into community life in
places which are frequently subjected to threat.
During disasters, particularly in developing
countries, victims arc often poorly informed
about the events that are occurring. Rumours
are frequent, authorities give conflicting infor­
mation and ineffective action follows. Illiteracy,
a multiplicity of languages or dialects and a lack
of media, can all contribute to difficulties in
' ’ disseminating information rapidly and accu­
rately.
The responsibility for transmitting informa­
tion rests with both public authorities and the
mass media. The authonties should take and
retain the initiative in communicating with the
public m the event of an emergency. Communi­
cation within the government should be well
coordinated, and the authonties should seek to
■ establish a climate of trust with the media, which
should handle the information given in an open
and unambiguous manner. To achieve these
objectives, the national authorities responsible
for the various aspects of disaster protection
should coordinate their actions as far as pos­
sible. International organizations may also be
sending out mrormation. Diverse interpreta­
tions from rhe various national and interna­
tional organizations of the potential public health
consequences or a disaster, can seriously con­
fuse the public, and create difficulties for na­
tional authorities.

■

Developing country populations are notori­
ously non-comphant with warnings for evacua­
tion. While a variety of psychological mecha­
nisms can be invoke^to understand these reac­
tions, a more concrete approach must also be
taken. The evacuation order expects the victim
to leave behind all his possessions with no protection against looting. Often survival is dep endent upon small-scale agriculture or livestock,
making it very difficult for people to leave behind all their wealth and means of subsistence.
Failures of prediction can also diminish trust,
when evacuation orders are given for events that
never occur.
Accurate, trustworthy, and easily understood
information about adisastershould be provided
to the population at a local level. Such informa­
tion should be provided in collaboration with
local leaders and community representatives. In
particular:
— specially prepared brochures and pamphlets,
updated as necessary, should be widely dis­
tributed to the population of the affected
areas, as far as possible in collaboration with
the local media;
— dialogue should be encouraged between the
community, the authorities, scientists and
health professionals, as also envisaged bv the
European Charter on Environment and

Health;
Possible adverse effects of public
information
Public information can however lead to adverse
psychosocial consequences by creating a sense
of confusion and mistrust. Reassuring asser­
tions by experts may be contradicted bv other
experts or by later events. It is the right, even the
duty, of scientists to give an opinion on a scien­
tific matter, but they must do it in a way that will
avoid -any- confusion between facts and judg­
ments on facts. A further difficulty is in the
nature of communication between scientist and
non-scienast. The latter may be trained to think
in arbitrary terms requiring “yes” and “no”
answers and they may in consequence be both­
ered by the scientist's answers in terms of grada­
tion and multiple qualifying considerations. This
pressure for what might be thought of as “bipo­
lar” thinking and decision-making is bound to
be a source of great exasperation, misunder­
standing and irrational decision: the authorities
feel they are getting answers which are imoos-*

17

ESYCHOSUCIAL CONSEQUENCES OF DIFFERS: PREVEWiON AND MANAGEMENT

•

s‘ •

sible to use, while the scientist feels he is being
confronted with unanswerable questions and
........... coerced .or.tempted into committing himself.
In considering the provision of information
to victims”, it is necessary to consider their
definition. Traditionally victims of a catastro­
phe would be defined as those who were physi­
cally touched by its effects. On the contrary,
however, the notion of victim cannot be limited
to those persons physically exposed to toxic
emissions or physically affected by the disaster.
1 he victim group of a m:iajor
‘ disaster potentially

encompasses all those who receive the bad news
of the accident. For larger populations, the bad
news will not necessarily be accompanied by
uirecdy visible events or damage. This is espe­
cially the case of toxic/nuclear disasters, and
many of the following considerations refer spe­
cifically to this type of disaster. The Chernobyl
disaster was especially striking in this regard. In
the first weeks and months after the accident,
very limited public information was provided to
the affected populations. Over the following
years however, these populations have been ex­
posed to a barrage, of information, with many
contradictory and inconsistent news items and
rumours, all of which have resulted in an infor­
mation overload. The "victims;5 therefore now
include large numbers of people who are suffer­
ing because they think they may be affected by
the accident, but who in fact have never been
exposed to toxic levels of radiation.
bmties in the field of public safety and health
have therefore a clear duty to provide both
general and specific background information.
Diverse interpretations from these organizaD°nsofuiepotenti al public heal th consequences
of
lie, and

health effects should be provided to the popula­
tion at a local level. Equally or even more impor­
tant, is the way in which the authorities should
present information if an accident occurs. In
many cases, people have been flooded with in­
formation and nobody has shown them how to
deal wlth it. One of the few “principles” in this
held that seems to be useful is that comparisons
are more meaningful than absolute numbers or
probabilities, especially when these absolute

playedZln ilT311’

r°le

cial at this level, since the information provided
by it is generally seen as more “neutral” and
authoritative” than that coming from’other
sources, and it can therefore facilitate public
compliance with necessary measures, prevent or

minimize worries and fears likely to produce
exjensive psychosocial consequences, aAd fi­
nally help to restore a cooperative climate.
Building a better public understanding of
nsks and informing the public correctly in the
case of an emergency is only a part ofwhatneeds
to be achieved if people are to be enabled to
respond more rationally to a future emergency,
he central issue then is how to facilitate an
evolution from the provision of information
and recommendations, to a situation of effective
learning, which allows people to develop better
coping strategies during and after an accident,
betting up such effective learning imnlies more
rk-.
"
* 1

—a a* — - .

1

1

•

wid,
stances through improved risk analysis and as­
sessment. It also implies improving die knowl­
edge and understanding of the reactions and
needs of individuals and groups in times of
emergency.
This last supposes a substantial change in the

c„ln" I”"””1”’" *

ch“'S'»

current methods of risk analysis, risk assessment
' ,ee MNH/PSF.91 docu­

ment).

^18

-------------- —-------- ----------------------- —--------------------

1 RAINING AND-INFRASTRUCTURE
FOR A PSYCHOSOCIAL RESPONSE
IN DISASTER RELIEF

Training programmes for primary
health care vrorkers and other
relief workers

"

Planning and coordination of
interventions in case of disasters

A senior mental health professional should be
Target groups for training programmes should
identified at a national level to head and plan
come from both the health and other sectors as
mental health resources and consulting for di­
the first group. These should include primary
saster preparedness and relief measures. Since
health care workers, often medical doctors of
national or local disaster teams are primarily
first aid teams, communiry nurses, or other
concerned with the provision of emergency
trained health care workers such as social work­
medical care and are often headed by a surgeon
ers, administrators from local and national ad­
for instance, it can be useful if the professional
ministrations, policemen and firemen in reserve
coordinating mental health inputs is also a phy­
teams.
sician (e.g.a psychiatrist), in order to be able to
Training programmes for health care providprovid­
operate more easily in these circles and within
ers should include the health aspects of disasters,
the disaster circumstances. Such a specialist liai­
general psychological and psychophysiological
son officer will take part in the multidisciplinary
concepts about people’s reactions after a disas­
decision-making groups and also coordinate
ter and other stressful situations, and variations
mental health aspects and mental health teams
in the way different groups of people perceive
when these are available, most importantly, he
the risk from different types of hazards. The
or she can act as a consultant to train and support
programmes should also include simple ways of
the preventive and other activities of the pri­
dealing with psychosocial problems and the
mary health care workers.
teaching of simple skills for the recognition,
Attention should also be paid to the mental
possibly using a checklist, and the treatment of
health needs of the care givers themselves, who
psychologically distressed victims (interview- ••■are-faced with'heavydemands*during disasters
ing skills, counselling, brief and simple
and who are themselves exposed to a substantial
psychotherapeutic methods, targeted pharma­
nsk of stress-related disorders.
cotherapy, group therapy, etc.).
As for service planning, it must be remem­
For administrators the training can help them
bered that sciences should be provided on the
to identify vulnerable groups, demonstrate the
basis of the actual needs rather than on the basis
reason why mental health services should be
of the demand: this applies both to the timing
integrated into the general disaster plan and how
and to the magnitude of the interventions (Ross
a psychosocial component can be included in a
& Quarantelli, 1976).
comprehensive disaster plan.
A major boon for the overall field of disaster
The training of general health workers in
prevention, preparedness and mirigarion should
mental health seems to be effective and longcome from the UN General Assembly Resolu­
lasting. In the context of a WHO collaborative
tion 42/169, designating the 1990s as the Inter­
study in six developing countries, general health
national Decade for Natural Disaster Reduction
workers were assessed after training aimed at
(IDNDR) (Lechat, 1990; WHO, 1989a, 1989b).
improving their knowledge, attitudes, skills and
The objective of this decade would be to reduce
capacity to provide mental health care; it was
the loss of life, property damage and social and
shown that the improvement was maintained up
economic disruption caused by natural disas­
to iollow-up at 18 months and was; of equal
ters, particularly in developing countnes. In the
magnitude in all countnes (Ignacio et..il., 1989).
context of the IDNDR, WHO will play a major
technical role in the health sector, including in
the specific area or mental health.

\9

V

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS:’ PREVENTION AND MANAGEMENT

Given the above constraints and consider­
ation, the following points need to be high­
lighted:
1. A long range plan, including a full scale men­
tal health intervention strategy, should be
developed at national and international level.
Many preparatory steps must be taken. The
comments that follow present a progression
from the current position towards an ulti­
mate goal which is unlikely to be fully reached
in less than 5-10 years.

I

2. Concurrently work on preparedness response
and rehabilitation is needed, with the Full
understanding that these levels may proceed
at different paces and influence each other
(e.g.while preparedness efforts are poor, re­
sponse measures may need to be emphasized;
when preparedness improves other response
measures may be reduced).

3. Belo w, three possible models for a
psychosocial response to disasters are de­
scribed; these may vary from country to coun­
try and they will need to be adapted to local
realities.

Model 1 (International reliance)
This is the current structure seen in most devel­
oping countries.
A_n international consultant may be called
upon to provide mental health assistance after a
disaster has occurred, typically to the Ministry
of Health, through WHO.-The consultant will
meet with an emergency committee and will
acquire information on the country and the
disaster. The consultant can advise the national
Ministry of Health and the health authonties of
the disaster area (and a local mental health of­
ficer if one exists) on the setting up of an appro­
priate emergency structure for ensuring a
psychosocial component within the disaster re­
lief operation.
The mental health workers in the area will be
involved m some direct patient care, but the
international consultant should promote the
development and implementation of a model of
care m which the general or primary health
worker will take the responsibility for provid­
ing mental health care to victims with the sup­
port or mental health professionals. The role of
the international consultant wall be of educating

20

the mental- health officers at the national and
local levels, who in rum will take the responsi­
bility for training the local health workers in
relevant mental health issues. The consultant
should make available appropriate materials.

Model 2 (National reliance)
Continuing efforts to achieve disaster prepared­
ness even before a disaster occurs, should be
taken to ensure national capability for managing
the mental health consequences of disasters.
These include the development of appropriate
training materials (e.g.manual, slides, video tapes)
which will be used to train national staff to be
responsible for the disaster mental health activi­
ties within their home country. Without there
being a disaster, a workshop could be convened,
to be led by one or more international consult­
ants with the national mental health authorities
and designated staff who would be responsible
for a disaster mental health programme. The
goal of the workshop would be to develop the
appropriate training materials and plan fortheir
use. When a disaster strikes a country, the inter­
national consultant should no longer be needed
and tne country will have attained a greater
degree of self reliance.
Given that an international consultant does
not have to be recruited for work to be initiated,
interventions can be implemented much earlier,
probably within one week of the disaster. It will
also be possible to involve the mental health
workers almost entirely m supervision and sup­
port or direct service providers.
To achieve Model 2, the following prelimi­
nary steps are suggested:
1. Development of a core of training material
for national or Regional use: manual, slide set,
video, etc. These should be available for vari­
ous levels of staff, e.g.
(i) die mental health professional;
(n) the general health professional;
(iii) the auxiliary health workers;
(iv) the community (non-health) workers.
2. Compilation of a literature review accessible
to non-mental health professionals.

3. Workshop/conference on “disaster mental
health training” for the national mental health
leaders and/or persons designated by them.

TRAINING AND. INFRASTRUCTURE FOR A PSYCHOSOCIAL RESPONSE I’N DISASTER REUEF
~

.7- :■ -•;•

1-

"v-Ci

4. Specific allocation of money from the general
should be formed, rather than relying on the
health budget should be obtained in order to . national authorities when disaster strikes. This
implement the above mentioned plans;’------- requires-that the Ministry of Health organizes
training for selected Ipcal mental health officers.
t
. .
iiUsing this model, mental health intervenModel 3 (Local reliance)
rions can occur sooner. The mental health offic-

Later on, and m zones at clear risk for disaster, •<vers will only be directly responsible for those
- -• the local mental health team (if one exists) should1. • ' referred by the general health worker, including
be responsible for managing the psychosocial*.., those requiring hospitalization. The greaterproxcomponents of disaster relief in its area of reimity to the community allows fora much greater
sponsibility, and a local disaster committee • ■ degree of community participation.

21

< •:

POSSIBLE RESEARCH PRIORITIES

1. Much of the research on the psychosocial
effects of disasters has been earned out among
Western populations. It is therefore impera­
tive to carry out extensive research with popu­
lations from developing countries, those that
are most affected by natural and man-made
disasters, both large and small-scale; this re­
search will allow the study of cross-cultural
vanatiohs m frequency, ..symptomatology,
temporal patterns and outcome of psycho­
logical disorders, and will clanfy the moder­
ating effect of culture on these disorders. This
research, to be practically and ethically fea­
sible, needs to follow stnet guidelines, and
should adopt a ngorous research methodol­
ogy. To achieve this, every effort should be
made to obtain reliable pre-disaster baseline
health data (preferably from various sources);
to have a control grouo; to have high follow­
up response rates; to use a longitudinal de­
sign, and to find valid screening instruments
to be employed as a first step in mass screen­
ing programmes in the acute post-disaster

phase.
2. Although there is agreement that social sup­
port and intense kin relationships are highly
supportive and facilitate post-disaster recov­
ery'- among victims, little empirical evidence is
available in this regard. Therefore, the spe­
cific role of these variables m modifying the
overall frequency, seventy and course of psy­
chological disorders needs to be further ex­
plored, as do the importance of personal vul­
nerability and prior psychopathology in their
occurrence. Specific groups, particularly de­
pendent on social support (such as children,
the elderly, the physically ill) should be care­
fully investigated.

22

3. Investigations into physiological determinants
and correlates of psychological and psychiatnc disorders, especially PTSD, so far mainly
laboratory-based, should be strengthened and
should be mainly clinically based. It would
therefore be useful to find reliable, valid and
feasible physiological measures of stress to be
used as diagnostic tools. For practical rea­
sons, this research is more feasible with indi­
vidual victims of a single trauma or in more
limited accidents or disasters occurring in
developed countries.
4. The diagnostic specificity of the symptoms of
PTSD also needs to be further explored, as
does the natural history of this disorder.
5. An important area of research’s comorbidiry,
especially among persons suffering from
PTSD: for instance, substance abuse, fre­
quently associated with PTSD, has been in­
terpreted as a long-term anempt to numb
oneself against intrusive images and night­
mares, thus representing a secondary response
to primary PTSD symptoms.

6. The experience of facing a trauma as an indi­
vidual, versus the effect of trauma when expe­
rienced with others needs to be investigated.

7. Finally, treatment of the main psychological
and psychiatric post-traumatic disorders is
an important area for research. The main
psychotherapeutic and pharmacological treat­
ment methods deserve detailed consideration
and need to be adequately tested and verified
for cross-cultural applicability as well as for
general effectiveness.

......................

•

.

_

..
.'.a -

-

--

- Agency for-Intemational Development (1989).
Disaster History: Significant Data on Major
Disasters Worldwide, 1900-Present. Wash­
ington, DC: Office of U.S. Foreign Disaster
Assistance, Agency for International Devel­
opment.

Aheam, F.L. (1981). Disaster and mental health:
pre- and post-earthquake companson of psy­
chiatric admission rates. Urban and Social
Change Review. 14, pp. 22-28.
Barton, A. (1969). Communities in Disasters.
New York: Basic.-Books.

Benz, G. (1989). List of major natural disasters,
1960-1987. Earthquakes & Volcanoes,20,226228.
Cohen, Raquel E. and Frederick L. Ahearn, Jr.
Handbook for mental health care of disaster
victims. The Johns Hopkins University Press:
Baltimore and London, 1980.

Davidson, J. (1992), Drug Therapy of Posttraumatic Stress Disorder. British Journal of
Psychiatry. 160, 309-314.
Duffy, J.C. (1988). Common psychological
themes in societies’ reaction to terrorism and
disasters. Military Medicine, 153, 387-390.

Fischer-Hornberger, E. Die Traumatische
Neuroset'uon somatishen zum sozialen Leiden.
Bern: H. Number 1975.
Fraser, R., Leslie, LM.and Phelps,D. (1942/43)
Psychiatric effects of severe personal experi­
ences during bombing. Proceedings of the
Royal Society of Medicine. 36, 119-123.

Frederick, C.J. (1981). Violence and disasters:
immediate and long-term consequences. In:
Helping Victims of Violence. Proceedings of a
WHO Working Group on :he Psychosocial
Consequences or Violence. The Hague, 6-10
April 1981. oo. 32-46.

----

•<; j

REFERENCES AND
SELECTED READING

Goldberg, D. & Bridges, K. (1988). Somatic
presentation of psychiatric illness in primary
care settings. Journal of Psychosomatic Re­
search, 32, 137-144.

Green, B.L. (1982). Assessing levels of psycho­
logical impairment following disaster. Jour­
nal ofNervous and Mental Disease. 170,544552.

Ignacio, L.L., De Arango, M.V., Baltazar, J.,
D’Arrigo Busnello, E., Climent, C.E.,
Elkahim, A., Giel, R., Harding, T.W., Ten
Hom, G.H.M.M., Ibrahim, H.H.A., Srinivasa
Murthy, R.& Wig, N.N. (1989). Knowledge
and attitudes of primary health care person­
nel concerning mental health problems in
developing countries: A follow-up study.
international Journal of Epidemiology, 13,'
669-673.

Korver, A.J.H. (1987). What is a disaster?
Prehospital and Disaster Medicine, 2, 152153.
Lechat, M.F. (1990). The International Decade
for Natural Disaster Reduction: Background
and Objectives. Disasters. Volume 14, Num­
ber 1.

Lima, B.R. (1986). Primary mental health care
for disaster victims in developing countries.
Disasters, 10, 203-204.

Lindemann, E. (1944). Symptomatology and
management of acute grief. American Journal
of Psychiatry. 101, 141-148.
Manni, C.& Magahni, S. (1989). Disaster medi­
cine: A new discipline or a new approach?
Prehospital and Disaster Medicine, 4, 167170.
Perry, R.W. & Lmdeil, M.K. (1978). The psycnologicai consequences or natural disaster:

A review or research on Amencan communi­
ties. Mass Emergencies, 3, 105-115.

23

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

Poumadere, M. (1990). The credibility cnsis. In
B. Segerstahl & G. Kromer (eds.), Chernobyl
and Europe: A Policy Response Study, Berlin:
Spnnger.
Quarantelli, E.L. (1980). Sociology and social
pathology of disasters: Implications for Third
World and developing countnes. Disaster Re­
search Center, The Ohio State University.
Paper prepared for presentation at the 9th
World Civil Defense Conference in Rabat,
Morocco, 5 November 1980.

Radjak, Abdul et al. WHO Indonesia. Inter­
regional workshop on disaster preparedness
and health management. WHO/Ministry of
Health Indonesia, Jakarta, 1987.
Raphael, B. (1986). When Disaster Strikes.
Hutchinson, London
Ross, G.A. and Quarantelli, E.L. (1976). Deliv­
ery of mental health services in disasters: The
Xenia tornado and some implications. The
Ohio State University: The Disaster Research
Center Book and Monograph Senes.

Rubonis, A.V. and Bickman, L. (1991). Psycho­
logical Impairment in the Wake of Disaster:
The Disaster-Psvchopathology Relationship.
Psychological Bulletin. 109.(3), 384-399.
Schwarz, Robert Flood forecasting and warn­
ing: the social value and use of information in
West Bengal. 1981. Geneva: UN Research
Institute for Social Development.

Solomon, S.D., Gemty, E.T. and Muff, A.M.
(1992). Efficacy of Treatments for Posrtraumatic Stress Disorder — An Empirical Re­
view. Journal of the American Medical Asso­
ciation, 268(5), 653-638.
StierlinE. (1909). Uberpsycho-neuropathischen
FoDezustdnde
be: den Uber'.ebenden der
o
Katastrophe von Coumeres an 10 Mdrz 1906.
Zurich: Universitat Zurich. 139 pp. Disserta­
tion.

United Nations Disaster Reher Co-ordinator
(UNDRO) (1984). Disaster Prevention and
Mitigation, VoLlI: Preparedness Aspects. New
York: United Nanons.

24

UNICEF, Assisting in Emergencies, UNICEF, ■
1986, New York.
Ursano, R.J. (1987). Posttraumatic stress; disorder: the stressor criterion. Journal ofNt'eruous
and Mental Disease. 175, 273-275.

Weisaeth, L. (1989). A study of behavioural
responses to an industrial disaster. Acta
Psychiatrica Scandinavica. Suppl. 355,80,1324.

WHO, ICRC (1989). Coping with natural di­
sasters: the role of local health personnel and
the community. Geneva, WHO.
World Health Organization (1987). Eight Gen­
eral Programme of Work, covering the period
1990-1995. Geneva: World Health Organi­
zation.
World Health Organization (1989a). Interna­
tional Decade for Natural Disaster Reduction
1990-2000 (IDNDR). Geneva: PCO/EPR7
89.1.
World Health Organization (1989b). Resolu­
tion on the International Decade for Natural
Disaster Reduction. Geneva: A/44/832/Add.l.

World Health Organization (1992). ICD-lOThe
ICD-10 Classification of Mental and
Behavioural Disorders: Clinical descriptions
and diagnostic guidelines, World Health Or­
ganization, Geneva.

The following have also keen published by the
United States National Institute of Mental
Health (NIMH)
NIMH (1981). Manual for Child health Work­
ers in Major Disasters.

NIMH (1984). Disasters and Mental Health: An
Annotated Bibliography.
NIMH (19S5). Disaster and Mental Health:
Selected Conternporary Perspectives.
NIMH (1985). Innovations in Mental. Health
Services to Disaster Victims.

II
i

-i>4

2 1 l/KU n i 1

I T

fe.l

Tdble 7
PTSD Criteria According to DSM-III-R
Diagnostic Criteria for 309.89 Post-traumatic Stress Disorder
Thp nprqon has experienced an event that is outside the range of usual human
A. experience and tha^would be markedly distressing to almost anyone e.g serious
threat to one's life or physical integrity; serious threat or harm to ones chil
dren soouse or other close relatives and friends; sudden destruction of one s home or
community or seeing another person who has recently been, or is being, seriously

II
i’’ I

B.

injured or killed as the result of an accident or physical violence.
The traumatic event is persistently reexperienced in at least one of the following ways:
recurrent*andi intrusive Hictroccinn
distressing rAonllections
recollections of
ofthe
the event
event (in
(in young
youngchildren,
children repetitive play in which themes or aspects of the trauma are expressed)
(2)
(3)

Is
I

I

i'lIIf

C.

episodes, even those that occur upon awakening or when intoxicated)
intense psychological distress at exposure to events that symbolize or resemble
(4)
an aspect of the traumatic event, including anniversaries of the trauma
Persistent avoidance of stimuli associated with the trauma or numbing of general
responsiveness (not present before the trauma), as indicated by at least three of the

following:
(1) efforts to avoid thoughts or feelings associated with the trauma
efforts to avoid activities or situations that arouse recollections of the trauma
(2)
inability to recall an important aspect of the trauma (psychogenic amnesia)
(3)
markedly diminished interest in significant activities (in young children, oss ot
(4) _____ a|. .
//-»iz>r*rr»or»+ai ekiiic qi ich
trsinincj or lancusqe skills)

I

r tfCci itiy av/^uii cu ocs v di. iw.

D.

I!
1 i!
E.

w

-

(5) feeling of detachment or estrangement from others
(6) restricted range of affect, e.g., unable to have loving feelings
(7) sense of foreshortened future, e.g., does not expect to have a career, marriage, or
children, or a long life
Persistent symptoms of increased arousal (not present before the trauma), as indicated
by at least two of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(4) hypervigilance
(5) exaggerated startle response
physiologic reactivity upon exposure to events that symbolize or resemble an
(6)
aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks
out in a sweat when entering any elevator)
Duration of the disturbance (symptoms in B, C, and D) of at least one month.

Specify delayed onset if the onset of symptoms was at least six months after the trauma.

Source: DSM-JII-R [4].

I have discussed here some of the cardinal signs and symptoms of PTSD, with an
emphasis on the most important key experience: loss of control over the representa­
tion of ideas, images, and/or emotions, or loss of volitional control of behavior.
People complain of unbidden images and nightmares, of broken sleep and intolera-

1

kJ

l' mmwi

yur-tw—

PSYCHOSOCIAL ASPECTS OF PTSD

29

£

E

£

Normal Response

i-

Event

essful life events. Please check each
rue for you duringihe past seven days,
"not at all" column.

■

OUTCRY
Fear, sadness,
rage

Mean endorsement

Violence group
(n = 38)

Death group
(n = 43)

,39
o.32

3.64
2.88

3.50
3.00
3.95
1.87
2.66
1.18
2.59
3.35
3.29
3.16

1.95a
2.67
3.60
1.09b
2.12
2.05a
2.33
3.39
3.53
3.52

3.34
3.78
2.26

2.40a

Pathological
Response

!

OVERWHELMED^
swept away by immediaio
pmHlional rnaclion BE

I
fc

■ PANIC OR K
■ EXHAUSTION B

refusing to face
memory of disaster

resulting from escalated
emotional reactions

INTRUSION
unbidden thoughts
of the event

riB EXTREME
Bi AVOIDANCE B|
resorting to such measures
l^as drugs to deny the painJ

WORKING
THROUGH
facing the reality of
what has happened

3.77
2.53

je subset = 2,3,7, 8,9, 12,13, 15. Mean
■vhere 0 = not experienced, 1 = rarely
a experienced during the last week,
group.
group.
in vio1

FLOODED STATES
disturbing persistent
images and thought of
■|B the event ■■9

COMPLETION
going on with life

■

PSYCHOSOMATIC

RESPONSES

■

r I

II

Ii
I

s,|

I

bodily complaints develop il
lhern i«; no resolution I

’tperience of intrusive and avoidant
oth situations (see Table 3).
ems in the Impact of Event Scale,
ress disorder include the apparent
ms include significant omissions of
onal intentions, or significant omisble, but fail to occur. These missing
ial phase of response to traumatic

CHARACTER

■I DISTORTIONS B
long-term disorders of the
■ability to love or work ■

■?

8
Figure 1. Normal and pathological phases of poststress response
Source: Horowitz [2].

Figure 1. Intrusive and omissive

■1

Ill ■
■

-

■

DM 6-X

Crisis Counseling Programs for Victims of Presidentially
Declared Disasters
Federal Emergency Management Agency
Center For Mental Health Services
■LEGISLATIVE AUTHORITY

Section 416 of The Robert T. Stafford Disaster Relief and Emergency
Assistance Act (Public Law 100-707) authorizes the President to
provide training and services to alleviate mental health problems
caused or exacerbated by major disasters. The Act reads as follows:

X

Crisis Counseling Assistance and Training. The President
is authorized to provide professional counseling services
including financial assistance to State or local agencies'
or private mental health organizations to provide such
services or training of disaster workers, to victims of
major disaster in order to relieve mental health problems
caused or aggravated by such major disaster or its aftermath.

PURPOSES AND OBJECTIVES

This crisis <counseling program for victims of major disasters
provides support for direct services to disaster victims.
A
training component in disaster crisis counseling for direct
services staff of the project
[
J
and for training of other disaster
services workers may, be- included,
------- • This program has been developed
in ^cooperation
Management Agency (FEMA)
m
cooperation with the Federal Emergency U
and the Center For Mental Healthu Services',
------- (cmhs) .
The law was enacted and the program developed in response to the
disasters produce a variety of emotional and
Sal±altXd}S?fbanCes which' if untreated, may become long
term and debilitating.
Such problems
as phobias,
sleep
disturbances depression, irritability, and family discord occur
following a disaster.
Programs funded under section 416 are
designed to provide timely relief and to prevent long-term problems
from developing.

Assistance under this program is limited to Presidentially declared
major disasters. Moreover, the program is designed to supplement
the available resources and services of States and local
governments.
Thus support for crisis counseling services to
disaster victims may be granted if these services cannot be
provided by existing agency programs. The support is not
automatically provided.

-1-

DEPARTMENT OF
HEALTH & HUMAN SERVICES

Public Health Service
Alcohol, Drug Abuse, and
Mental Health Administration
Rockville, MD 20857

BULK RATE
POSTAGE AND FEES PAID
PHS/ADAMHA
PERMIT NO. G-283

Official Business
Penalty for Private Use $300

National Institute of Mental Health

>

Human Problems
in Major Disasters:
A Training Curriculum for
Emergency Medical Personnel

DHHS Publication No. (ADM) 90-1505
Alcohol, Drug Abuse, and Mental Health Administration
Printed 1987 Reprinted 1988, 1990

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Alcohol, Drug Abuse, and Mental Health Administration

1

Contents
Overview

I:

Basic Concepts in Understanding Disaster Behavior

II:

Phases of Disaster-Related Behaviors

III:

Postdisaster Intervention Strategies for Mental Health Problems: Acute
Phase
General

Special Mental Illness, Drug Abuse, and Alcohol Problems
Disaster Worker Stress

|
I

Overview

psychological reactions from a
disaster include people who:

Mental health intervention in posttraumatic responses of victims
following a disaster is designed to
assist the victims in maximizing their
coping and adaptation skills to
effectively deal with multiple
problems arising in the postdisaster
situation.
It is widely assumed that most
victims were functioning adequately
before the catastrophe, but that their
ability to cope may have been
impaired by the stresses of the
situation. Victims are unlikely to
view themselves as exhibiting
psychopathology even if they are
experiencing stress-related symptoms.
The treating professional should resist
the temptation to view the victim as
being psychopathological until such a
diagnosis is clearly established.
Disaster victims may include all ages,
socioeconomic classes, and racial or
ethnic groups because catastrophes
affect the entire population in an
impacted area.
Research findings confirm that
large-scale naturaldisasters can result
in severe mental health problems,
including substance abuse, for about
10 percent of victims. Some victims
suffer more than others, depending
upon several interrelated factors.
Those who may be particularly
susceptible to physical and

• are vulnerable from previous
traumatic life events
• are at risk because of recent ill
health
• experience severe stress and loss
• lose their system of social and
psychological supports
• lack coping skills

The frail elderly in general may find
it difficult to cope with disaster and its
consequences. It is not unusual to find
older victims who are isolated from
their support systems and live alone.
As a result they are often afraid to
seek help. Typical postcatastrophe
problems with this group are
depression and a sense of hope­
lessness. Unfortunately, a common
response among some frail elderly
people is a lack of interest in
rebuilding their lives.
Children are a special group
because they usually do not have the
capacity to understand and rationalize
what has happened. Consequently,
they may present emotional and
behavioral problems at home or at
school. Perhaps the most prominent
disturbances reported in children after
a disaster have been phobias, sleep
disturbances, loss of interest in school,
and difficult behavior.

3

2

Those with a history of mental
illness may also require special
attention. Under the stress of a
disaster situation, relapses may occur
in this population due to the addi­
tional stress or the difficulties in
obtaining regular medication.

In sum, although the particular atrisk groups identified merit close
attention from the disaster worker,
victims can be found among all
social, economic, and ethnic strata,
and among all segments of the
population in the disaster area. The
task then is to identify those who need
special help in order to provide such
help quickly and effectively, and to
deal sensitively with all victims
realizing that they are under
emotional strain.

Special attention must also be given
to the disaster workers themselves,
including medical personnel, who face
unprecedented personal demands in
meeting the needs of victims. They
too may experience fatigue, fear,
anger, and acute stress reactions.
They need organizational and
coworker support to function with
competence and sensitivity
throughout the course of the
emergency.

I.

Basic Concepts
in Understanding
Disaster
Behavior

The key constructs used to
understand how individuals respond to
disaster include stress resulting from
the crisis, social supports at time of
crisis, and coping skills of the
individual victim. Each is discussed in
turn.
• Some of the most significant work
about individual response to
disaster comes from theoretical
formulations about stress.
Dohrenwend and Dohrenwend
(1981) linked stressful life events,
mediated by social situations and
personal dispositions, to health and
mental health consequences for
individuals. The authors offered
several interpretations about these
linkages. One interpretation is
straightforward cause and effect:
stressful life events result in
adverse health changes. Other
interpretations concern the
intensification of stressful life
events by social and personal
dispositions; these combinations of
factors result in adverse health
change.
Several theories relate stress to
specific disaster situations, focusing
on the event itself, and on individual,
social, and cultural responses to such

emergencies. Frederick (1980) and
others theorized that technological
disasters create more mental stress
than do natural disasters because they
are defined, not as originating from
God, but as originating from man.
Other theoreticians considered the
phases of a disaster. Baker (1964)
differentiated between more frequent
immediate psychological effects of the
disaster experience and less frequent
long-term consequences of disaster for
the individual. Others looked at the
magnitude of the disaster.
Kastenbaum (1974), for example,
hypothesized a significant difference
between disasters that affect the
individual’s whole environment and
those that affect only a part of it.

• Human service workers have little
control over factors in the
environment that cause stress
among clients. Their efforts, thus,
are focused on increasing the social
supports and coping skills of these
persons so that they are better
equipped to manage the stress and
are less at risk for emotional
problems. With regard to social
supports, Taylor (1978) showed the
importance of political, economic,
and family interactions and supports
in disasters. Political supports
referred to functions served by
public figures at disaster sites.
Economic supports were defined as
financial institutions that provide

funds in aid of recovery of the
community. Family supports
referred to the functioning of family
members in warning system
evacuation and extended family
assistance.
Barton (1969) pointed to the
existence of a two-part emergency
social system. The first part is
identified by exploring individual
patterns of adaptive'and
nonadaptive reactions to stress,
particularly the motivational basis
of various types of helping behavior
(e.g., altruism and close relationship
to the victim). Barton concluded
that discrete patterns of individual
behavior can be conceptually
aggregated to reflect the com­
munity's informal mass assault
on disaster-generated needs. The
second part of the system is the
community's formal organization.
Barton broadened his initial
discussion of the individual basis of
helping behavior by examining a
community model of the same.
• Formulations that relate individual
coping responses to mass disasters
focus on perception, personality
characteristics, and social
behaviors. Slovic et al. (1979)
looked at the perception of risk in
disaster situations. They stated that
those persons who perceive the risk
as great are more likely to heed
warnings and to take some

4
individual action to avoid or
ameliorate consequences than those
who do not. In the case of
technological risks, those who
perceive the risk as great are also
more likely to blame the
Government for politics that allow
the risk to occur.
Cohen and Ahearn (1980) pointed
out that coping is partially depend­
ent on emotional or psychological
tools, those personal characteristics
of individual strengths and weak­
nesses. These individual resources
include ability to communicate,
sense of self-esteem, and capacity
for bearing discomfort without
either disorganization or despair.

Lystad (1985b) stated that coping
also depends upon one’s ability to
seek support, understanding, and
aid in problem resolution. Her work
shows that disaster victims are
better able to handle the losses of
loved ones and property if they are
well integrated into a social matrix
of family, friends,and neighbors
who are able to provide immediate
assistance of comfort, food,
clothing, housing, and physical care
at times of crisis.

5

II.

Phases of
DisasterRelated
Behaviors

The experiences of mental health
professionals have shown that the
postdisaster period consists of several
phases related to the emotional
responses of victims as they
experience and cope with crisis (see
Cohen and Ahearn 1980; Farberow
1983).

• The first phase occurs at time of
impact and immediately afterwards.
Emotions are strong and include
fear, numbness, shock, and
confusion. People find themselves
being called upon and responding to
demands for heroic action to save
their own and others’ lives and/or
property. Altruism is prominent,
and people cooperate well in
helping others to survive and
recover. The most important
resources during this phase are the
family, neighbors, and emergency
service workers of various sorts.
• The second phase of disaster
generally extends from one week to
several months after the disaster.
Symptoms include change in
appetite, digestive problems,
difficulties in sleeping, and
headaches. Anger, suspicion, and
irritability may surface. Apathy and

Mental health disaster workers have noted age-specific reactions of individuals to disaster
(NIMH, 1983; Lystad, 1985a). These reactions to stress may appear immediately after
the disaster or after the passage of days or weeks. The following composite list is not
all inclusive

Preschool
Reactions

Latency Age
Reactions

Preadolescent
and Adolescent
Reactions

Adult
Reactions

Senior Citizen
Reactions

Crying

Headaches,
other physical
complaints

Headaches,
other physical
complaints

Psychosomatic
problems, such
as ulcers and
heart trouble

Depression,
withdrawal

Depression

Depression

Confusion

Withdrawal,
suspicion,
irritability

Agitation, anger

Fears about
weather,
safety

Thumb­
sucking
Loss of bowel/
bladder
control

Fear of being
left alone, of
strangers
Irritability
Confusion

Poor
performance

Anger

Aggressive
behaviors

Loss of
appetite

Confusion

Withdrawal
and
isolation

Sleep problems

Memory loss

Loss of
interests in
everyday
activities

Accelerated
physical
decline

Disorientation

Immobility
Fighting

Withdrawal
from peers

Irritability,
suspicion

Poor
performance

Confusion

Inability to
concentrate

Apathy

Changes in
peer group,
friends

depression may occur, as well as
withdrawal from family and friends
and heightened anxiety about the
future. On the other hand,
survivors, even those who lost loved

Increase in
number of
somatic
complaints

ones and possessions, develop a
strong sense of having shared with
others a dangerous experience.
During this phase, supported by the
influx of local, State, and Federal

6

agencies who offer all kinds of help,
the victims clear the debris and
clean out their homes of mud and
wreckage. They anticipate that
considerable help in solving their
multiple problems will soon be
available. Community groups that
develop from the specific needs
caused by the disaster are especially
important.

• The third phase of the disaster,
generally lasting up to a year, is
characterized by strong feelings of
disappointment, resentment, and
bitterness if delays occur and hopes
for, and promises of, governmental
aid are not fulfilled. Outside
agencies may pull out, and some of
the indigenous community groups
may weaken or disappear. During
this phase, victims may gradually
lose the feeling of shared
community found earlier as they
concentrate on solving their own
individual problems.
• The last phase, reconstruction, may
last several years if not the
remainder of the lives of some
victims. During this time the victims
of large-scale disasters realize that
they will need to solve the problems
of rebuilding their homes,
businesses, and lives largely by
themselves, and they gradually
assume responsibility for doing so.
The appearance of new buildings
replacing old ones, the development

7

of new programs and plans, can
serve to reaffirm the victims’ belief
in their community and their own
capabilities. When such positive
events are delayed, however,
emotional problems which do
appear may be serious and intense.
Community groups — political,
economic, religious, fraternal —
with a long-term investment in the
community and its people become
crucial elements to successful
reconstruction.

III.

Postdisaster
Intervention
Strategies for
Mental Health
Problems:
Acute Phase

General
1. Dealing with extreme emotional
stress caused by the emergency:
The symptoms of extreme stress
reactions include clear signs of fear,
anxiety, disorganized speech, and the
inability to be consoled or quieted
down. A mild sedative should be used,
accompanied by an attempt to find a
“victim-companion” to help for a
limited time. Most acute, severe

I I

reactions are short-lived when the
victim is surrounded by other
individuals in similar situations who
offer role models with good coping
skills to deal with the present
situation. If the victim has received a
physical trauma, then the reactions
will have to be evaluated in terms of
pain dependence, fear of
abandonment, and central nervous
system functional status as a reaction
to trauma and/or medication.
2. Relocation factors likely to
increase/reduce stress:
One of the most painful experiences
for a victim is a sense of disorientation
and lack of control in his life. This
experience is aggravated by the
further relocation activities that most
victims find necessary. The process of
preparing, supporting, and assisting
the victims in all location changes can
intensify or ameliorate their
discomfort. Consideration of the
fears, anxiety, and lack of knowledge
about the “authorities” who are doing
all the discussing and making all the
decisions will guide professionals in
their behavior. Any support or
information that can be given to the
victims to enhance their sense of
control over their choices, which in
turn will moderate their anxiety and
elevate their self-esteem, will be
helpful. Keeping closer to their
support systems — friends, clergy, and
family — will be beneficial for

recovery of psychological health.
Communicating to the victim
information concerning imminent
changes will also help.
3. How to lessen the stress of hospital
setting and relocation:
Starting with the premise that
people housed in a hospital setting
have been relocated and may face
further relocations, it follows that
some effects of the stressors will be
manifested by psychophysiological
reactions. Lessening the stressor
impact on these populations at risk is
the objective of planners and disaster
workers. Two major areas are
important: (1) reactions to the event
itself, including the rescue, and (2)
reactions to hospital conditions.
With regard to the first source of
stress, helping victims share their
stories and ventilate some of their
pent-up tensions is very valuable. With
regard to the second source of
stress—the living conditions in the
hospital—some flexibility could be
instituted by providing information
about their physical status, prognosis,
plans of care, and guidance and
support in relation to schedules of
medical intervention. Daily bulletins
with clear information and methods
for dealing with rumors about what
has happened to their neighborhood
are helpful.
Identification of problemsolving
hospital teams that can expedite

9

8

simple requests or explain to victims
when some of their problems cannot
be solved or attended to immediately
is useful. This type of education can
diminish expectations that could, if
unchecked, culiminate in further
painful disappointments. Most victims
would prefer to be busy, active, and
helpful, so functions that realistically
could be assigned to them will prove
to be morale boosting. Household and
clerical tasks, organization of
recreational activity, and group
exercises are examples.
Personnel trained to absorb painful,
emotional, angry expressions of
distress without reacting personally
and becoming defensive, or without
promising immediate solutions, are a
most valuable resource in lowering
effects of the stressor and mitigating
victims’ reactions.
4. Guidelines for the use of
psychotropic medication with
disaster victims:
Basic medical precautions are
needed when prescribing medication
to victims. In general, the approach
should be conservative in dealing with
anxiety and psychophysiological
reactions (headaches, stomachaches,
and sleeplessness), which are the
primary manifestations during the first
few days. Although the victim may
wish to short-circuit very uncom­
fortable emotions, some considera­
tion should be given to first trying

some reassurance and coun­
seling, with attention to the living
conditions, to test if the anxiety
ameliorates without medication. If this
does not happen, and psychological
efforts are ineffective or the anxiety is
overwhelming, then anxiolytic
medication may be necessary.
Medication for pain should be
provided as needed. Pain itself is a
major cause of stress.
Appropriate medication should be
used for individuals with a history of
severe mental disorder, for example
those diagnosed as suffering from
schizophrenia, who are living in the
community; also, patients with
dysthymic disorders (mania or
depression).
Medication usage has to be
continually monitored as victims’
judgement may occasionally become
dysfunctional.
5. How to mobilize social support
systems after an emergency:
An outpouring of interest and
resources is characteristic of
individuals in the community during
and after a disaster’s aftermath. The
problem of support systems is not the
quantity, but the quality. That is. the
appropriate fit between the needs of
the victim (age, sex, culture,
socioeconomic status, health, etc.)
and the presence of interested,
available human support groups. The
matching of assistance to victims has

to be organized in some professional
manner, which could be flexible and
simple, but with genuine and serious
attention to motivation, consistency,
and appropriateness.
Many organized groups exist in
different regions of the United States
whose objectives are to assist
individuals in crisis. Also, religious
groups are available from the different
denominations if the victims ask for
special religious affiliation.
A list of available groups could be
identified on regional bases. The
informational support groups
(nonfamily), while generally generous
and enthusiastic, may need some
management and organization to
genuinely assist the victim.

6. How to coordinate with mental
health professionals:
Ideally, predisaster planning at
the State level should incorporate
mental health components in
emergency operations. A direct line of
communication to mental health
professionals potentially available for
disaster work should be already
established. When this is the case,
once the decision to participate and
the plan of action is in effect, mental
health professionals can assist in the
triage operations, in crisis counseling,
and in debriefing of disaster workers.
To smoothly coordinate all these
efforts the administrative design
should include the mental health

professional in decisionmaking,
logistics, schedules, and function
priorities. When this is not the case,
local community mental health
centers and mental health associations
should be contacted for assistance.
7. Use of mental health professionals
in the initial postdisaster period —
how they can assist in triage:
Disaster triage operations are the
procedures used by mental health
professionals to evaluate behavior,
ascertain level of crisis, and supply
information. This knowledge is
provided to the assisting team so that
disaster planning can alleviate the
severity of the psychophysiologic
reaction of victims. Since victims
become cognitively and emotionally
impaired for a short interval of time,
intervention focuses on increasing
awareness of the emotional effects of
disaster and improvement of the
ability to cope.
The mental health professional has
begun to enhance the disaster
emergency efforts by bringing
knowledge that is needed to deal with
behavior patterns not only of the
victim but of the helpers as well. The
knowledge base of mental health
professionals working side by side
with medical teams is continually
increasing as more begin to practice at
a field level.
8. Use of mental health professionals
in the initial postdisaster period —

11

10

how they can assist in crisis
counseling to victims:
Postdisaster crisis counseling is a
mental health intervention technique
that seeks to restore the capacity of
individuals to cope with and resolve
stressful situations as well as to
provide assistance for individuals in
reordering and integrating their new
circumstances. This is accomplished
by a process of education about
and interpretation of the over­
whelming feeling which results from
postdisaster stress; it is designed
to instill a greater sense of self
confidence and hope.
Postdisaster intervention, a new
area of applied psychiatry, offers a
unique model for mental health
services by broadening the
perspective of service providers and
offering the possibility of a resolution
to crisis reactions for victims. To be
effective, however, the mental health
component of the intervention
program must prove useful to the
victims and comfortable for the
community service providers.
9. Use of mental health professionals
in the initial postdisaster period —
how they can assist in debriefing
disaster workers:
A mental health debriefing is an
organized approach to the
management of stress responses
following a traumatic or critical

incident. It is a specific, focused
intervention to assist workers in
dealing with the intense emotions that
are common at such times. It teaches
them about normal stress responses,
specific skills for coping with stress
and providing support for each other.
A debriefing involves a one-to-one or
group meeting between the worker(s)
and a trained facilitator. Group
meetings are recommended, as they
provide the added dimension of peer
support.
A debriefing is not a critique. A
critique is a meeting in which the
incident is discussed, evaluated, and
analyzed with regard to procedures,
performance, and what could have
been improved. A critique is a valid
and important meeting. It can help
workers to sort out facts, get
questions answered, plan for what to
do in the future. A debriefing though
has a different focus, that of dealing
with the emotional aspects of the
experience.

10. Use of mental health professionals
in a later postdisaster period —
how can they help in long-term
referrals of victims or disaster
workers:
Although most disaster victims do
not suffer adverse mental health
effects, a conservative estimate is that
10 percent experience mental health
consequences over time. Larger
percentages are found in disasters that

are sudden and unexpected, where
many deaths and injuries occur, when
the potential for recurrence is higher,
and where the affected population is
high risk. Mental health professionals
can evaluate those individuals who
continue to appear emotionally
stressed and unable to cope in order
to refer them to appropriate
community mental health facilities for
longer term care.

Special Mental Illness,
Drug Abuse, and Alcohol
Problems
1. How to identify the mentally ill:
Individuals suffering from a diverse
variety of mental illnesses present
differing reactions to the many
stressors following the consequences
of a disaster. Three major categories
will need attention.
(a.) Individuals living in hospitals
situated in the damaged or physically
unapproachable areas. Problems in
their daily living arrangements have
resulted from lack of availability of
electricity, water, food, medical care,
and/or nursing staff.
(b.) Individuals living in group
homes. These individuals may be
affected by losing their homes or not
having medication available. Their
habitual structured surroundings may
be altered, and the loss of a familiar
setting may increase the acuteness of
their emotional reactions.

(c.) Individuals living with their
own or foster families. These
individuals also may have increased
symptoms due to factors the same as
those noted in Item b. above.
If these individuals are found after
the disaster accompanied by a helping
familiar adult (for example, a foster
parent), it may not be difficult to
ascertain the diagnosis and the
medication needed. If the individual is
discovered alone, then the signs of
disturbance in cognition, life
disorientation, and bizarre
communication (severe difficulty in
explaining who he/she is and what has
happened) will identify an individual
that needs special attention. Also, an
individual that cannot understand
commands or suggestions to follow
certain simple, life-preserving actions
will need individual monitoring. It is
always necessary to rule out any
undiagnosed head injuries during the
disaster that may cause similar
symptoms.

2. How to differentiate between those
suffering from acute stress and
those who are mentally ill:
Individuals who behave
inappropriately for the situation
should be given a rapid evaluation to
sort out the following:
(a.) intense stress reaction
(b.) acute psychotic reaction
(c.) effect of head injuries

13

12
i

(d.) disorganization of functions
in a mentally retarded
individual
Those four conditions are
accompanied by several signs that
differentiate them:
(a.) Stress reactions are mani­
fested by changes in (1) cognition­
orientation—poor memory,
thinking changes, varying difficulty in
making a decision, and (2) emotions
— lability, blunting, flatness. There is
no break with reality awareness or loss
of self-identity. The person behaves
with a certain social composure and
relates in a passive way during the
acute stage.
(b.) Acute psychotic reactions
occur as anxiety, affective, or thinking
disorders. In general, diagnosed
psychiatric patients are subdued and
calmer than usual when they are faced
with emergency situations. A number
of individuals may have psychotic
breaks if they suffer severe and
prolonged trauma. Their behavior
could include apathetic, depressed,
or bizarre thinking; difficulty in
understanding the routine of the
shelter/hospital; and/or hyperactive,
manic, unrealistic, and difficult-tocontrol behavior.
(c.) The effects of head injuries
can mimic many psychiatric
symptoms, but a careful neurological
exam may elicit localized signs of
trauma. This diagnosis should be ruled

out whenever a severe, acute clinical
picture emerges that indicates mental
disorganization.
(d.) Mentally retarded individuals
show more infantile behaviors, have
simple and concrete speech, and
slowness in understanding orders or
suggestions. They may manifest
disorganized and disoriented behavior
due to the sudden changes in their
routines. Their expression of this new
experience may include anxiety and
infantile clinging behavior, which is
alleviated by simple orders, support,
and guidance.
3. What to do to assist the mentally
ill:
A large number of mentally ill
patients are dependent on psycho­
therapeutic pharmacological
treatment. Obtaining information
about their regimen should be one of
the first priorities. This should be
followed by an attempt to structure
their schedules and to remove them
from intense stimuli situations, if at all
possible. Using other victims to assist
the mentally ill patient in basic daily
living activities may benefit both of
them.

4. Some of the common medication
regimens that people might be on:
Psychotropic medication is
prescribed for different types of
mental disorders. The three most

common medications are anti­
psychotics—for example, in
schizophrenic syndromes;
antidepressants—for example, in
minor and major depressive disorders;
and lithium for bipolar illness. Most
patients know about their medication
and would respond to inquiry in this
regard.
If these medications are
unavailable, one or more of the
following might be used during a
short, transition period: (a) anti­
anxiety medication; (b) chloral
hydrate; or (c) mild barbiturates.
Someone will need to ascertain the
differences between toxic reactions to
a specific drug and symptoms
reappearing due to decrease in a
patient's medication in the
bloodstream.
Toxic reactions to antipsychotic
drugs are varied. They include
neurologic and hepatic effects in
chronic cases. In the intitial period,
one can observe drowsiness, or
restlessness (akathisia), orthostatic
hypotension, occasional bizarre
involuntary movements, stiffness with
difficulty moving, distortions of body
positioning produced by changes in
muscle tone, anticholinergic effects
like mild dryness of the mouth, or
tachycardia.
5. How to identify the drug addict:
Behavioral disturbances are
frequent consequences of drug

intoxication and result from affective
and cognitive disturbances with
variable reality contact. As with most
drug reactions, symptoms are usually
nonspecific. Disruption of the rest­
activity cycle is often part of the
overall picture of drug addiction and
withdrawal. These disturbances may
range from insomnia or fragmented
sleep accompanying stiijiulant
intoxication or sedative-hypnotic
withdrawal to hypersomnia
accompanying stimulant withdrawal
or sedative-hypnotic intoxication.
Physical signs of drug addiction may
include needle tracks, subcutaneous
abscesses, or eroded or irritated nasal
septum with rhinorrhea (running
nose). Acute panic or paranoid
reaction may follow the
administration of psychotomimetic
agents (LSD, STP, mescaline, etc.), an
amphetamine or cocaine in high
doses, or marijuana. Adverse
reactions to LSD are often
characterized by an extremely labile
affective component, one affect
shifting abruptly to another, with the
user in the grips of a “runaway”
experience. Few physiological
changes other than mydriasis (large
pupils) are seen in LSD intoxication,
except those induced by emotional
stress.
The clinical picture of
amphetamine intoxication includes
sweating, tachycardia, elevated blood
pressure, mydriasis, hyperactivity, and

4

15

14
an acute brain syndrome with
respiratory bronchioles
confusion and disorientation. A
(5) increased venous pressure
progressive organic brain syndrome
(6)
increased pulmonary arterial
accompanies long-term amphetamine
pressure
abuse. Moderate overdose of an
(7) increased respiratory rate
amphetamine or cocaine may induce
paranoid delusions of persecution with
(8) increased renal blood flow
dangerous assaultive behavior.
(9) increased contracture of
Aggressive behavior of lesser
urinary sphincter musculature
proportions may accompany the brain
(10) appetite suppression
syndrome induced by alcohol or
barbiturates in high doses, but rarely if Central Nervous System Depressants:
ever characterizes opiate intoxication,
Intoxication often presents itself as a
which leaves the user in a placid state
decreased
level of alertness, perhaps
of drive satiation.
bordering on sleep. There is difficulty
Convulsive seizures may be the
in arousability, increased reaction
direct result of intoxication with
time, and accompanying cognitive
amphetamines, methylphenidate,
problems.
With opiate intoxication,
propoxyphene,codeine,
miosis (small pupils) is usually evident
methaqualone, strychnine, or LSD.
Stupor or coma caused by
Concurrent withdrawal of a barbi­
depressant drug poisoning presents
turate, alcohol, or some nonbarbi­
the characteristic picture of severe
turate sedatives taken in high doses
metabolic brain disease. Ultimately,
would enhance the likelihood of
respiratory and circulatory functions
seizures.
are compromised. When this occurs,
6. Psychophysiological signs of
treatment is essential or death will
addictive drug intoxication or
follow.
overdose, by type of drug:
The combination of
unresponsiveness,
preserved or
Central Nervous System Stimulants:
sluggish pupillary reactions, absent
Systemic effects (those affecting the
oculo-vestibular reactions, motor
entire body) include:
areflexia, hypothermia, and
depression of respiration and
(1) increased cardiac
circulation is clinically diagnostic of
contraction
sedative-anesthetic drug poisoning.
(2) increased blood pressure
(3) increased heart rate
(4) relaxation and dilatation of

Psychotomimetics:

Central sympathomimetic stimulation
occurs within 20 minutes after
ingestion. The clinical findings may
include:
(1) mydriasis (widening of
pupils)
(2) hyperthermia
(3) tachycardia
(4) elevated blood pressure
(5) piloerection (hair raised on
body)
(6) increased alertness
(7) facilitation of monosynaptic
reflexes
(8) nausea and vomiting
(9) heightened perceptions
which may become overwhelming
(10) prolonged afterimages which
may overlap with ongoing perceptions
(11) perception of objects as
moving in a wavelike fashion, or
melting
(12) illusions and synesthesias,
the overflow of one sense modality to
another
(13) a sense of unusual clarity
and a feeling that one's thoughts are
extraordinarily important
(14) a feeling of slow passage of
time
(15) body distortions

(16) true hallucinations with loss
of insight
(17) wide range in affect or mood
(18) panic reactions

7. Characteristics of drug withdrawal,
by type of drug:
Much misunderstanding has
centered around the subject of drug
withdrawal. It is true that some drugs
in high doses induce sericfus physical
dependence (opiates, barbiturates,
ethanol, antianxiety agents) and
other induce little if any physical
dependence (marijuana, amphet­
amines. cocaine, antipsychotic
agents). It is untrue, however, that
withdrawal of a drug producing
physical dependence is necessarily
more dangerous or difficult than
withdrawal of one that does not.
Withdrawal of opiates or barbiturates
is completely safe if accomplished
gradually; withdrawal of
amphetamines and often cocaine, on
the other hand, is often dangerous no
matter how it is accomplished because
of psychic depression with suicidal
ideation.
Physical dependence, as indicated
by abstinence signs and symptoms,
develops from all central nervous
system general depressants. A
characteristic, general depressant
withdrawal syndrome occurs and is
similiar to the symptoms of
withdrawal from alcohol. It varies in
severity, depending on the drug, dose,

J,

17

16

and frequency of use. In contrast to
the opioid withdrawal syndrome,
withdrawal from depressants may be
life-threatening.

Symptoms accompanying drug
withdrawal are both physical and
psychological. In the case of opiates
and barbiturates, the physical
symptoms are fairly constant from
individual to individual and
characteristic of the class of drugs, so
that specific “abstinence syndromes”
may legitimately be described. The
most characteristic signs of opiate
withdrawal are anxiety, restlessness,
and drug craving after several hours
since last use. After 8-15 hours since
last use lacrimation (running eyes),
rhinorrhea, moderately dilated and
reactive pupils, yawning, and
perspiration appear. After additional
hours since last use comes restless
sleep, the so-called “yen sleep,” after
which the addict awakens with more
severe withdrawal symptoms and signs
including dilated pupils, sneezing,
sniffles, anorexia, nausea, vomiting,
abdominal cramps, bone pains,
tremors, weakness, insomnia,
piloerection (“gooseflesh,” responsible
for the expression “cold turkey”),
and very rarely, convulsions or
cardiovascular collapse. If convulsive
seizures (which are not characteristic
of opiate withdrawal) occur, it is
assumed that the patient was also
taking barbiturates, either knowingly

It
I i

or unknowingly (e.g., as an adulterant
on his heroin supply).
Barbiturate withdrawal, as an
example of the general depressant
withdrawal syndrome, is characterized
by early tremulousness, extreme
motor restlessness, and insomnia,
followed by an acute brain syndrome
with confusion and disorientation.
Convulsive seizures are a serious risk
during the entire withdrawal period
unless withdrawal is accomplished
slowly over 1 to 2 weeks. Especially
with antianxiety agents, longer term
withdrawal effects recurring
intermittently for months past the
cessation of usage include dis­
turbances in the rest-activity cycle
and affective lability.
Withdrawal from high doses of
amphetamines and cocaine is
characterized by lethargy, som­
nolence, and psychic depression,
often severe. An organic brain
syndrome overlies the other symptoms
and may resolve slowly over the
ensuing months; it results from the
insult of chronic unremitting
stimulation by high doses of
amphetamine and is manifest by
lessened mental acuity, impaired
recent memory, shortened attention
span, and increased emotional lability.
8. What acute medical measures
should be taken for acute drug
reaction (see also Shader, 1975):

Definitive diagnosis of an acute
drug reaction is often difficult. As
with any disease, the reaction to a
drug (or drugs) depends upon a
number of variables, including: (1)
the type of drug use, (2) its purity,
(3) its dosage, (4) the presence of
contaminants, (5) the duration of
time since the drug was taken, (6)
underlying medical or psychological
problems, (7) the degree of tolerance,
if any, having developed in the
individual toward that drug, (8) the
chronicity of prior use, and (9) the
utilization of multiple drugs.
The first step needed to deal with a
victim experiencing drug withdrawal
is, when possible, to obtain a history
of drug use and, particularly,
identification of the drug(s) from
which the individual is withdrawing.
Withdrawal from narcotic drugs such
as heroin, morphine, and other
synthetics with morphine-like actions
will produce acute discomfort.
Withdrawal from sedatives or
hypnotics may produce life­
threatening situations and require
ongoing medical management and
supervision. Common sedatives
are benzodiazepines such as
chlordiazepoxide (Librium), diazepam
(Valium), oxazepam (Serax), and
meprobamate (Miltown, Equanil).
Common hypnotics include
ethchlorvynol (Placidyl), flurazepam
(Dalmane), temazepam (Restoril),
triazolam (Halcion), glutethimide
(Doriden), methyprylon (Noludar),
chloral hydrate (Noctec),
methaqualone (Qualudes), and
barbiturates (phenobarb and others).

It should be noted that cross
tolerance exists within each of the
drug groups noted above. In addition,
while narcotic drugs present rapid
withdrawal onset, late onset (from 6 to
7 days) is more characteristic of other
drug groups.
9. What to do about alcohol abuse
after the emergency:
Individuals who are addicted to
alcohol will show signs of withdrawal
if they have no access to alcoholic
beverages. Unless the abuse has been
chronic and severe, these individuals
will show differing signs of central
nervous system irritability and general
discomfort but will “weather” the
acute stage of the postdisaster period.
If the behavior is dysfunctional, the
individual will present a problem to
the management personnel of the
shelter.
To assist the individual who shows
disorganized and dysfunctional
behavior, the use of medication
(chlordiazepoxide) and a structured
schedule can be instituted. Generally,
these individuals are difficult in a
passive-aggressive manner instead of
actively and aggressively disrupting
the living areas.

10. Signs of alcohol withdrawal:
(a.) Mild or early symptoms
(impending DT’s—delirium tremens)
can appear in the first week after the
last drink. All of the body’s systems
are affected: gastrointestinal,
muscular, central nervous system,
vegetative (sleep), and general
psychological and behavior patterns.

18

(b.) Advanced or severe
manifestations can be seen in victims
who had early symptoms. The
emergence of increased irritability,
severe tremulousness, and auditory
hallucinations may be indications of
imminent DT's.
11. What to do about antisocial
behavior patterns in emergency
situations:
Antisocial behavior is defined as the
intrusive manner in which individuals
clash with the norms of the
community in which they live. The
victims of disaster are suddenly and
painfully congregated into a disparate
and unfamiliar setting. The behaviors
that emerge as they try to cope and
adapt could be defined by the
authority group as being “antisocial”
because these individuals (1) break
rules; (2) never seem to accept
schedules; (3) refuse to take their turn
to deal with helpers; and (4) in
general, become identified as
“troublemakers” who may also steal
and lie. How to diagnose these
behaviors and sort out which are
motivated by anxiety and which by
character disorders challenges the
skills of the most seasoned mental
health professional.
During the emergency stage, the
diagnostic procedure has to be rapid,
and thus it may be difficult to
ascertain the motiviating emotions
supporting antisocial behavior. The

19

best approach is to exert increasing
limit-setting to the disruptive actions
practiced by the individual.
Victims who act out because of
anxiety will experience relief if
structure and support are provided.
They will express mortification, guilt,
and will verbalize some of their fears.
With individuals whose general
modality of dealing with their
environment is aggressive, self­
centered, and nonempathetic, the
need for stronger measures, including
segregation from the group, may be
necessary until more individual
measures are available. Antisocial
behavior cannot be tolerated if
victims are in a medical setting.
12. Example of antisocial behavior:
Mr. B., a 34-year-old white male,
was having difficulty in sleeping. He
complained about the discomfort and
noise of the ward and expressed
irritation at all the rules that
regimented their living activities. He
was verbose, sarcastic, and angry.
After an evaluation it was decided
that no medication would be
prescribed but that he would be
assigned a new sleeping area in the
ward. This change necessitated a
rearrangement of bedding, and Mr. B.
did not like the new setting either. He
began to disobey the rules of group
living, had problems in accepting
taking turns in bathroom use. Small
objects began to disappear in his unit,

I 1

1

which necessitated a search.
His affect was generally annoyed,
and he verbalized how he did not like
rules and he had his “ways” of dealing
with authority. The demanding,
manipulative behavior and lack of
sensitivity to the rights of others, plus
the boasting of his “ability” to disobey
authority are typical examples of
antisocial behavior.
An example of “increasing limit­
setting to disruptive actions” can be
obtained from episodes found in
emergency wards where individuals
begin to fight, first verbally, and then
escalate to physical interchanges or
actions against individuals that add
misery to their living conditions. The
first level of “limit-setting” is a
personal discussion with the
“aggressor,” which is followed by
increased controlling conditions as the
fighting escalates.

13. Special need of the mentally
retarded:
Except for severely mentally
retarded individuals, most retarded
persons will not need special
measures. Some of them may need
assistance with instructions on how to
get along in the shelter. Some careful
explanation of what has happened and
what plans have been made for the
next few days may be of great relief to
them.
In some cases where mental
retardation is severe and accompanied

by physical handicaps, it may be
necessary to ask another victim to
assist in daily hygiene, feeding, and
sleeping activities.
14. Other illness or injuries that
masquerade as retardation:
Many etiological syndromes are
accompanied by symptoms of
intellectual retardation. Individuals
may be taking anticonvulsants if they
are suffering from epilepsy and may
appear to have some degree of
intellectual retardation.

Disaster Worker Stress
1. Sources of stress for disaster
workers:
Disaster workers are subject to
three main sources of stress in their
work, one arising out of the disaster
itself, one from occupational
pressures, and the third from
organizational pressures.
At least three distinct types of
disaster event stressors have been
identified:
(a.) personal loss or injury: a
worker is exposed to toxic substances
on the job or a team member is
injured or dies
(b.) traumatic stimuli: a high
incidence of injury or death;
gruesome sights, sounds, or activities
(c.) mission failure or human
error: a situation which could
seemingly be prevented or no

21

20

opportunity exists for effective action,
such as an incident with no survivors
Occupational pressures include:
(a.) time pressures and work
overload
(b.) physical and emotional
demands on workers, due to long
hours, chaotic situations, and life-ordeath decisionmaking
(c.) physical properties of the
work environment: hazardous work
conditions, limited human resources,
bad weather
Organizational pressures include:
(a.) problems in role clarity and
role conflict: role ambiguity occurs
among workers who are unsure of
their responsibilities in the disaster;
role conflict occurs when a worker
must face competing demands from
other personnel, the media, or the
public
(b.) chain of command: when
multiple response agencies are
involved in the incident, it may be
difficult to ascertain who is in charge
(c.) organizational conflict, either
within or between organizations, over
allocation of resources, responsibility,
or blame
2. Effects of stress on disaster
workers:
Disaster workers are normal
persons who generally function quite
well under the responsibilities,
hazards, and stresses of their jobs. At

I

i II

times, when workers have been
subjected to severe or prolonged
stress in a disaster or traumatic
situation, they may show signs of
emotional and psychological strain.
These reactions are normal reactions
to extraordinary and abnormal
situations and are to be expected
under the circumstances. These
reactions are usually transitory in
nature and rarely imply serioius
mental disturbance or mental illness.
Relief from stress and the passage
of time usually lead to the
reestablishment of equilibrium.
Physical symptoms are often the
first to occur in acute stress reactions.
They include increased heartbeat,
respiration, blood pressure; nausea,
upset stomach, diarrhea; sweating or
chills; muffled hearing; headaches;
soreness in muscles; lower back pain;
pains in chest; faintness or dizziness.
All cognitive processes usually
diminish under stress. These
symptoms are often the next to appear
after physical symptoms in an acute
stress situation: memory problems,
disorientation, slowness of thinking,
mental confusion, difficulty using
logic, poor concentration, loss of
objectivity.
Psychological and emotional
symptoms include anxiety and fear,
anger and blaming, irritability,
sadness, guilt, feelings of isolation and
estrangement.

Behavioral symptoms include
inability to express oneself verbally or
in writing; hyperactivity; decreased
efficiency; outbursts of anger;
increased use of alcohol, tobacco or
other drugs; social withdrawal and
distancing.
3. Predisaster interventions for
workers:
Some of the most important stress
management interventions for disaster
workers take place predisaster. These
activities are important in preparing
workers for what they will likely
encounter in the disaster situation.
Preparation by both the individual
worker and the organization can help
minimize the effects of stress when it
occurs and can help individuals and
the organization cope with stress in a
more efficient manner. The following
are some useful predisaster
interventions:
(a.) Collaborative relationship
between emergency services teams
and mental health professionals
(b.) Orientation and training to
stresses likely to be encountered and
to normal reactions to such stress
(c.) Disaster planning, training,
and drills, with an emphasis on the
team approach and on support for
team members

4. Interventions during the disaster:
(a.) During the alarm phase, as
much factual information as possible

about what the team will find at the
scene should be relayed to the
workers.
(b.) Look for stress reactions
among coworkers in field operation;
early identification and intervention
are key in preventing worker burnout.
Use mental health assistance in field
operation if plans have been made to
do so.
(c.) Supervisors should try to
rotate workers between low-stress
assignments, such as staging areas,
moderate stress assignments, and highstress tasks. They should limit workers
time in high-stress assignments, such
as triage or morgue, to an hour or so if
at all possible.
(d.) Supervisors should ask
workers to take breaks if effectiveness
is diminishing or order them to do so
if necessary. On breaks, try to provide
workers with bathroom facilities, a
place to sit or lie down, food and
beverages, shelter, an opportunity to
talk about their feelings.
5. Interventions after the disaster:
a. A debriefing should be
arranged for all team members
involved in the disaster. A debriefing
is a specific, focused intervention to
assist workers in dealing with the
intense emotions that are common at
such a time.

»:l i
22

(b.) Plan for the let down of team
members after the experience. Discuss
normal stress reactions in team
meetings.
(c.) If workers’ reactions are
severe or last longer than 6 weeks,
encourage them to use professional
counseling assistance. This use does
not imply weakness; it simply means
that the event was so traumatic it had
a profound effect on those individuals.
6. Disaster workers as survivors:
Hartsough and Myers, National
Institute of Mental Health (1985),
emphasize that emergency and
disaster workers are highly motivated
and highly trained individuals. They
perform strenuous, stressful, and often
dangerous work. They seek to ease
the suffering of victims. At the same
time they put themselves at high
emotional risk for stress reactions that
may be harmful to themselves, their
work life, and their family life.
It is important to remember and to
give recognition to the inherent
strengths and qualities of these
workers, who embody the traits of the
survivor personality:
A sense of commitment to and
involvement in life
Traits of gentleness and strength,
trust and caution, self-confidence
and self-criticism, dependence
and independence

23

A feeling of control over their
circumstances, and the willing­
ness to admit what can’t be
controlled
The ability to see change as
challenge, not just a threat; the
commitment to meet challenges
in a way that will make them
stronger persons.

Supplementary Materials
National Institute of Mental Health.
Disaster Work and Mental Health:
Prevention and Control ofStress Among
Workers, by Hartsough, D., and Myers, D.
DHHS Pub. No. (ADM)85-1422.
Wshington, D.C.: Supt of Docs., Govt
Print Off., 1985.
National Institute of Mental Health.
Training Manualfor Human Service
Workers in Major Disasters, by Farberow,
N. DHHS Pub. No. (ADM)86-538.
Washington, D.C.; Supt of Docs., U.S.
Govt Print Off., 1986.

Shader, R., ed., Manual ofPsychiatric
Therapeutics: Practical Psychopharmacol­
ogy and Psychiatry. Boston: Little, Brown
and Company, 1975.

References
Baker, G. Comments on the present status
and the future direction of disaster research.
In: Grosser, G., Wechsler, H, and
Greenblatt, M., eds. The Threat ofImpend­
ing Disaster. Cambridge: Massachusetts
Institute of Technology Press, 1964.
Barton, A Communities in Disaster.
Garden City: Doubleday and Company,

Cohen, R. and Aheam, F. Handbookfor
Mental Health Care ofDisaster Victims.
Baltimore: The Johns Hopkins University
Press, 1980.
Dohrenwend, B. and Dohrenwend, B., eds.
Stressful Life Events and Their Contexts.
New York: Prodist, 1981.
Frederick, C. Effects of natural vs. humaninduced violence upon victims.
Evaluation and Change. Special Issue: 7175,1980.

Kastenbaum, R. Disaster, death and human
ecology. Omega 5(l):65-72, 1974.
Lystad, M. Innovative mental health
services for disaster victims. Children Today
14(1):13-17,1985a.
Lystad M. Human response to mass
emergencies: A review of mental health
research. Emotional First Aid 2( 1 ):5-18,

Slovic, P.; Lichtenstein, S.; and Fischoff,
B. Images of disaster Perception and
acceptance of risks from nuclear power. In:
Goodman, G. and Rowe, W., eds. Energy
Risk Management London: Academic
Press, 1979, pp. 223-245.
Taylor, V. Future directions for study. In:
Quarantelli, E., ed. Disasters: Theory and
Research. Beverly Hills, Calif.: Sage
Publications, 1978. pp. 251-280.

i1
U. S. Government Printing Office: 1990 - 261-217 (24822)

1

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WHO/MNH/PSF/91.3 Rev.1
English only
Distr: General

PSYCHOSOCIAL CONSEQUENCES
OF DISASTERS
PREVENTION AND MANAGEMENT

DIVISION OF MENTAL HEALTH
WORLD HEALTH ORGANIZATION
GENEVA
•

' -' *Wj* ■ ■

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i-

WHO wishes to acknowledge the valuable inputs into the development of this
document by Professor Bruno Linr.a, Johns Hopkins, Community Psychiatry Program;
Professor Lars Weisaeth, Psychiatric Institute, University of Oslo; Professor Wolfram Schuffel,
Klinikum der Philipps-Universitat Marburg; Professor Beverley Raphael, Department of
Psychiatry, Royal Brisbane Hospital; as well as of Mr O. Almgren, UNDRO;
Dr T. Yazukawa, Division of Emergency Preparedness and Response, WHO.

Dr G. de Girolamo, Division of Mental Health, WHO and
Dr John Orley, Senior Med.cal Officer, Division of Mental Health, WHO
had the technical responsibility for the production of this document.

Further copies of this document may be obtained from
Division of Mental Health
World Health Organization
1211 Geneva 27
Switzerland

© World Health Organization 1992

This document is not a formal publication of the World Health Organization (WHO),
and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted,
reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.
The views expressed in documents by named authors are solely the responsibility of those authors.

Designed by WHO Graphics

aJBBHr-.A--

CONTENTS

Introduction_______ ___________________________
Background
Definition and description of disasters
Definition
Taxonomy
Transnational character of many disasters
Epidemiology of disasters and morbidity profiles of
the affected populations

1

1
2
2
3
3

4

Epidemiology and description of psychosocial
reactions to disaster
Historical perspective
Phases of emotional reactions to disaster
Epidemiology of psychological disorder following a disaster
Relationship between type of disaster and the type and
severity of reactions
Specific psychosocial consequences following disaster
Post-traumatic stress disorder

Grief
Alcohol, drug abuse and family problem s

Secondary psychosocial stressors
Vulnerability
Stress upon rescuers
The psychological effects of disasters on children

Psychosocial interventions in disasters
Prevention and treatment of psychological disorders
Function of the mental health professional expert in
preparedness activities
Functions of the menial health team at the disaster site
Groups requiring psychosocial support
Establishing an information/support centre
Specific procedures for helping survivors
Help for bereaved families
Role of the psychosocial support team
The physically injured
Crisis intervention
Debriefing
Role of information
Possible adver se effects of public information

5
5
5
6

8
8
8
8
9
9
9
9
10

11
11

12
13
13
13
14
14
15
16
16
16
17
17
iii

• 4.

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CONTENTS

fc; /*-

fl bl
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4

Training and infrastructure for
a psychosocial
response in disaster relief
Training programmes for primary health
care workers
and other relief workers
Planning and coordination of intei
srventions in case of
disasters
Model 1
Model 2
Model 3

19
19
19
20
20
20

Possible research priorities
22

References and selected reading

23

iv

Sou. .'MS?

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Un?

INTRODUCTION
I
i

.- )

i

IL 41'- 4 •
if
.
J"

Baclcground

i

UN General Assembly Resolution
--------- ,
------------- 42/169,
adopted on 11 December 1987, designated the
1990s as a decade for natural disaster reduction:
this resolution reminds its readers that natural
disasters, such
.1 as those caused by earthquakes,
windstorms,
indstorms, tsunamis, floods,
Hoods, landslides, volca­

■

i

...

i i,
,.wx

!

I

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i

nic eruptions, wildfires and other calamities,
have killed about 3 million people worldwide
over the past two decades, adversely affected the
lives of at least 800 million more people, and
resulted ini immediate economic damage ex­
ceeding US$ 23 billion. ''The
“The smallest
smallest and
and p
poorI
est countries are affected most severely
by natu­
---- j -/
ral disasters, and the poorest and most disadvantaged members of a disaster affected community
are likely to experience the most serious conse­
quences” (UNDRO, 1984). Therefore in the
majority of developing countries, consequences
of disasters, because of their severity and fre-

quency, represent a real public health priority.
Several agencies of the United Nations have
developed programmes which could help
1 f
--.pcountries; to be ’better prepared to cope with natural
and iniui-iiiaae
WtlO is participating
h____ r___ &
man-made disasters. WHO
in this effort and has produced this document as
part of its contribution to countries’ prepared­

II
I
■i

(the Pan American Health Organization) is also
very actively involved in this area and has pro­
duced a slide programme on Mental Health
Management in Disaster Situations (in Spanish
and English).
There has been a general tendency in the past
to consider that the basic needs of the popula­
tions affected by a disaster were to be met essen­
tially in terms of providing shelter, food, sanita­
tion and immunization against epidemics. Their
psychosocial needs were seen as something too
secondary to attract the attention of relief agen­
cies and relief workers. Over the last few years
however, a different trend has become evident
and there is now wide recognition of the fact that
populations affected by a disaster have special
psychosocial needs.
WHO’s role in disasters has gradually shifted
from providing emergency relief to incorporat­
ing also disaster preparedness, including involve­
ment in training and in the assessment of pos­
sible future needs. One of WHO’S strategies for

emergency
and icopviisc
response IS
is
--- o----- 7 rpreparedness
---- r V.X
anvi
strengthening the national capacity to cope with
disasters. WHO’s target for the Eighth General

Programme of Work, covering the years 199095, is that by 1995 “70% of all countries will have
ness, prevention and mitigation of the effects of
developed master plans appropriate to their par­
disasters worldwide.
ticular circumstances to deal with the health
There are two United Nations Offices deal­
aspects of emergency and disaster situations”
ing specifically with matters related to disasters
(WHO, 1987). Since in many countries disas­
namely the UN Disaster Relief Co-ordinator’s
ters, because of their frequency and severity,
Office (UNDRO), which provided inputs into
lead to adverse affects on mental wellbeing,
the development of this document, and the Of­
these master plans should mclude a mental health
fice of the UN High Commissioner for Refu­
component.
gees (UNHCR). WHO is currently collaborat­
In general, the key activities for coping with
ing with UNHCR in the development of a
disasters and disaster risks are essentially pre­
manual on refugee mental health, with an em­
paredness, which involves all actions designed
phasis on applications in refugee camps in devel­
to minimize loss of life and damage, and to
oping countries.
prepare for timely and effective rescue, relief
Within WHO, the Division of Mental Health
and rehabilitation should disaster strike; pre­
collaborates with the Division of Emergency
vention, which may be described as measures
Relief Operations, to provide a psychosocial designed to prevent phenomena from causing
.' -.
dor
input into the activities of the latter programme.
res
’ 1 ' in
’*
*
‘
resulting
disasters
or other
related
emergency
The WHO Regional Office for the Americas
situations; and finally.mitigation, which
i means

i

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

reducing the effects of severely damaging events
on man and his environment once they have has
occurred.
The importance of preventive measures and
preparedness, the integration of an emergency
response within regular WHO programmes,
and the linkage with development have been
emphasized in the resolutions adopted by WHO
in 1981 and 1985. Each ofthese aspects of coping
with disasters should include consideration of
the related psychosocial components. These can
have an impact on people’s behaviour before,
during and after a disaster occurs, as well as
being important in influencing the overall pat­
terns of post-disaster morbidity.

Much of the confusion in defining a disaster is
caused by the diverse interests of those dealing
with the event, be it in medicine, sociology,
political science or ecology. The definition
adopted usually reflects the role of the organization using that specific definition.
From a psychosocial perspective, it is important to consider both the medical disaster defini­
tion (an emergency situation in which the vic­
tims are so numerous that the treatment needs
far outweigh the resources available at the mo­
ment; here there is an immediate need to bring in
extra resources) and the sociological.
Common elements to be considered in the
conceptualization of disasters include:

Definition and description of
disasters

1. A disaster disrupts the social structure and
cannot be handled by the usual social mecha­
nisms. This disruption may create more diffi­
culties than the physical consequences
(Quarantelli, 1980).

Definition

A disaster is a severe disruption, ecological and
2. There are several important variables which
psychosocial, which greatly exceeds the coping
can moderate the impact of disasters. These
capacity of the affected community. This will be
include, the ability of the victims to adjust
the definition that is used in this document.
psychologically,
the capacity of the commu­
However, what constitutes a disaster for one
nity structures to adapt to the crisis and the
community might not necessarily do so for
amount of help available.
another. The difficulties of conceptualization
arise because, “upwards a disaster is unlimited,
3. The concept of disaster changes over time and
downward one has to draw a line somewhere”.
among different cultures. Among some popu­
In common daily usage, the term “disaster”
lations,
especially in developing countries, a
refers to a great misfortune causing widespread
lengthy
first-hand experience of coping with
damage and suffering.
natural disasters has produced the creation of
There is, however, no consensus on a scien­
specific “disaster sub-cultures”, which are
tific definition of the term: there are in fact more
likely to affect their pattern of psychosocial
than 40 different definitions of disaster in the
reactions to the disaster situation.
literature (Korver, 1987). A disaster is a very
complex, multi-dimensional phenomenon. An
4. Since catastrophic events are frequent in many
event may be a disaster along certain dimen­
developing countries, this may unfortunately
sions, such as ecological, economic, material,
raise the threshold for an event to be consid­
psychological or social, but is unlikely to be one
ered a disaster. Nevertheless this should not
along all of these in any specific event. Often the
lead to a failure to recognize and respond to
number of human lives lost is an important
the adverse effects that may occur, even with
criterion for defining a disaster.
repeated disasters; these may undermine the
The definition may be dependent upon the
morale and resources of the community even
event itself, or solely on the consequences of the
further, and may lessen its capacity to adjust.
event. The term disaster ordinarily emphasizes
fast, destructive change. This may exclude per­
The term “personal disaster” (Raphael, 1985)
manent problems from the disaster definition,
has
been used to refer to a severe trauma affectfor instance famine in many parts of the world,
_________
____________
ing
a small group or a single individual. This
even when the consequences of the starvation
are disastrous. To declare an event a disaster may__ document however, deals only with those disas....
ters affec^ng large numbers of people.
influence, among other
things, the amount of
help offered. The concept also has emotional
and political implications.

2

I
t

INTRODUCTION*

Taxonomy
There are many possible ways to classify disas­
ters which may have important consequences
with regard to the way people react and the
types of help required.
From the prevention and preparedness view­
point, the following classification is generally
used:
Natural disasters — Earthquake, flood, cyclone,
hurricane, tornado, landslides, volcanic erup­
tion, drought.

I

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Man-made disasters — Technological disasters
such as toxic, chemical and nuclear accidents,
dam collapse or transport accidents.
Man-made disasters are caused by human
failures or accidents, or are due to violence or
war. The feeling that someone is to blame may
make it more difficult for victims to cope with
the situation. However, a clear distinction be­
tween what is man-made and what is natural is
sometimes impossible, because of the increasing
effects of man’s actions on the overall ecological
balance or other human contributions.
For instance in an earthquake, the poor con­
struction of buildings can contribute signifi­
cantly to damage and loss of life. The failure of
authorities to provide adequate warning of a
“natural ” danger can contribute to the loss of life
and damage. Any rise in the level of the oceans
due to pollution causing a “greenhouse” effect,
may increase the likelihood of floods. Famine or
social conflicts may strike certain parts of coun­
tries, not just because of drought and crop fail­
ure but also because of transport problems,
hindering the movement of food. Bushfires may
or may not be started by man. These examples
are just a few amongst many possible ones that
demonstrate the blurring that can exist between
natural and man-made disasters.
The speed of occurrence is another important
dimension to be considered in assessing disas­
ters and their consequences on the affected popu­
lation. Perhaps the most well known typology
of disasters however, is that of Barton (1969). He
suggested four main dimensions: scope of im­
pact (geographical, number of people); speed of
onset (sudden, gradual, chronic); duration of
impact (e.g.repeated episodes); and social pre­
paredness of the community.
A further important dimension has been added
(Green, 1982) which refers to whether disasters
are central or peripheral with respect to a geo-

graphic community. In one which happens to a
group of people who hare come together by
chance (e.g.an airplane crash), survivors return
to their respective •geographic communities
where the physical setting and social support
networks are still intact. Such disasters could be
considered geographically peripheral. An inter­
mediate type, according to this dimension, would
be one which occurs to a group of people within
a community and, hence, affects the whole com­
munity in some sense, but where there still
unaffected members of the community and the
physical settings (homes, neighbourhoods) re­
main unchanged.
The most central type of disaster would be
one in which the whole physical and organiza­
tional structure of the community is deeply
changed (e.g.earthquake, floods, etc.), because
homes are destroyed, people are relocated in
different surroundings with strangers, etc. In
this central type the traumatic aspects are not
limited to the impact of the physical event itself,
but may continue for a relatively long period of
time and include many subsequent additional
traumas, changes, and disruptions especially of
a psychosocial kind, requiring further adjust­
ments.

Transnational character of many disasters
Many disasters are transnational or international
in their effects and impact. For instance nuclear
or toxic accidents may have effects on many
countries across frontiers and at considerable
distances from the place where the event oc­
curred. The nature of frontiers (legal, official,
political) cannot prevent this, and there are many
implications for disaster response. Similar prob­
lems may arise in international transport acci­
dents such as air crashes.
An adequate response to such transnational
disasters has to be set up at the same transnational
level. This means that international coordina­
tion by a specialized health agency such as WHO
is undoubtedly needed in terms of preparedness
and intervention programmes, in order to en­
sure consistent and uncontradictory responses
in the various countries affected. Moreover
WHO is in a special position to ensure a com­
mon scientific international language among the
various researchers and clinicians active in the
medical and psychological field. The adoption at
an international level of the 10th Edition of the
ICD is an important step in this direction (WHO,
1990).

3

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PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

Epidemiology of disasters and
morbidity profiles of the affected
populations

in general the number of deaths and injuries
and the amount of damage is closely related to —*
the prevailing level of economic development.
An
UNDRO publication (1984) shows a list of
Estimates of the major disasters which occurred
disasters
for the period 1960-81 resulting in the
worldwide (excluding the United States) from
greatest
numbers
of people killed. All occurred
1900 up to 1988, indicate that, in these 9 decades,
in
countries
characterized
by a low-income
about 339 million people have been affected by
economy:
Bangladesh
(633
000
deaths), China
floods, with a total of 36 million rendered home­
(247
000
deaths),
Nicaragua
(106
000 deaths)
less; 26 million have been affected by earth­
quakes, with similar numbers affected by ty.- . an^ Ethiopia. (103 000 deaths).
1
1
‘
.11.
The pvtonr
extent of nclz
risk among rmrur
many nnmilntinnc
populations,
pnoons anaWyclones, creating another almost
especially
in
developing
countries,
has
increased'
10 milh<Jj^meless pedjjle; finally, 3.5 million
over
the
last
few
decades
due
to
increasing
popu­
have beenaffected by hurricanes, resu king in 1.2
lation
size,
greater
population
density
in
vulner
­
million people without homes. From 1970 to
able
areas
and
the
strong
tendency
of
large
popu
­
1981, floods were the most frequent disaster,
lations
towards
urbanization.
There
has
also
comprising more than one-third of all disasters
been a concurrent increase in the magnitude of
occurring in that decade. Windstorms were the
next most frequent disaster (one fourth of the certain types of man-made disaster. Very little
total number), while earthquakes caused the however is known about the stress-related dis­
orders caused by such events, which represent
greatest number of deaths and monetary loss.
an important area in need of investigation.
The actual numbers killed in disasters is esti­
In disaster situations certain vulnerable groups
mated to be some 3‘or 4 times higher in develop­
tend
to exist. High mortality may be seen among
ing countries than in the developed. The striking
elderly
people and young children. Children up
difference however is in the number of survivors
to
2
years
old may show lower mortality than
who are affected, which is estimated to be some
their
elder
brothers or sisters, perhaps because
40 times higher in the developing countries. One
parents
protect
their youngest children but can­
must presume that this indicates a massive
not
afford
to
help
older ones. Pregnant or lactat­
psychosocial as well as physical need for this
ing
women
and
persons
already suffering from
latter group.
existing
disease
are
also
more
vulnerable, as are
The geographical distribution of disasters
the
poor
or
certain
minority
groups
who might
between developed and developing countries
for
instance,
have
no
choice
but
to
live
in flooddeserves attention, as there seems to be a rela­
prone
areas.
tionship between the location of a disaster on the
The morbidity: mortality ratio, as well as its
one hand, and the severity of its consequences
relation
to property destruction, is specific to
on the other. Out of the 109 worst natural
each
type
of disaster. For example, in big earth­
disasters which occurred between 1960 and 1987,
quakes
the
ratio of morbidity: mortality is usu­
as selected and studied by Berz (1989), 41 oc­
ally
3:1.
Floods
show high mortality rates but
curred in developing countries; however, the
few
injuries.
Hurricanes
cause fewer injuries
number of deaths caused among the affected
and
deaths,
but
great
loss
of
property.
populations was far greater in the developing
countries (758 850 deaths in developing coun­
tries as compared to only 11 441 in developed
countries).

4

EPIDEMIOLOGY AND DESCRIPTION OF
PSYCHOSOCIAL REACTIONS TO DISASTER

H^ical Perspecrive

inj?urX) dang,

unqcirta'ken by Eduard Stierlin (1909) from
Zurich who investigated 21 survivors of a min­
ing disaster in 1906 and 135 persons two months
after the earthquake in Messina in Italy in 1908.
The history of traumatic neurosis in European
medicine is well described by Fisher-Hornberger
(1975) who demonstrated that the understand­
ing of the disorder during the 19th and early
20th century was very much influenced by po­
litical, military, economic and cultural factors,
with an over-emphasis on an organic basis for
traumatic neurosis. However, during World War
I the psychological nature of the disorder was
better understood.
During World War II, the study of how
civilian populations reacted to disaster traumas
was further advanced. The air raids against cities
was the background for a series of valuable

itiil-ir
----- ­
and nnirrt-ocrt-jr^rl
unintegrated. Since the 1970s—a __rich
litera
ture, largely American and Australian, has been
published. There is also important work in other
languages (German, Russian, Spanish and
French). As a research field, however, the study
of the psychosocial consequences of disasters is
still relatively untouched.

jer traumas and- los.^; traumas
TJ^^^Srgpiatic studies of the psycholbgi^^T^^lihdernann,i, 1944). Until th<6 1970s^h^jvever,
an^^4^^^&^cbnsequenCes of a disaster we^e^^fep^/chQSOcial disaster literature was^riodic

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investigations earned out in England during the
early war years. A striking finding was that the
expectations of mass neuroses” in a bombed
civilian population did not occur. Unfortunately
the war time psychiatric experiences have not
been fully incorporated into the disaster literacure, although psychosocial interventions in disasters have been influenced by insights gained
during war, lately the Vietnam war. Among
wartime psychiatric cases both stable as well as
vulnerable personalities were found, but the
latter did not recover within weeks as did the
former. The military psychiatric experiences
from World War II influenced civilian clinical
practice with the introduction of the therapeutic
community, group treatment, forward psychi­
atric treatment and crisis intervention.
Of special note is the Coconut Grove night
club fire disaster in Boston in November 1942,
which claimed the lives of 491 persons. This
disaster has come to occupy a special position in
disaster psychiatry because it represents one of
the first systematic civilian studies on the acute
psychological reactions in victims of physical

£

Phases of emotional reactions to
disasters
Emotional reactions may be divided into the
immediate experience during the disaster and
those reactions occurring after the event, some
of which may appear soon and others late.
The immediate experience

The immediate reactions reflect the most horri­
fying dimensions of disaster related to severe
physical injury, exposure to extreme danger,
witnessing death of close ones or mass deaths
and injuries, traumatic experiences of helpless­
ness, hopelessness, separations, and the need to
choose between helping others or fighting for
,
• , ;, r .
ing exposure to a disaster such as paralyzing
anxiety, uncontrolled flight behaviour and group
panic, may be incompatible with survival. In
studies of disaster behaviour the individual’s
level of preparedness, disaster training and edu­
cation have appeared as the most important
determinants of a good outcome (Weisaeth,
1989). (Being able to cope in the immediate
trauma situation also came out as a strong pro­
tector in terms of longer term psychiatric
sequelae).
Panic is said to be rare in natural disasters, but
in crowded areas like subways, trains and sky­
scrapers, disasters can evoke panic more easily.
Health education programmes and previous
training in simulated disaster situations can help
affected populations to avoid panic and respond
more appropriately.

5

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT
.4 -b-.-r

Emotional reactions after the "event"

Many different emotional reactions may occur
after a disaster. In the beginning many people
feel numb, or even elated and relieved, often
with strong positive feelings about having sur­
vived. Gradually however, the stress effects may
show, although these reactions are usually rela­
tively short-lived and may be considered a nor­
mal reaction to a traumatic experience.
Common post-disaster reactions include in­
tense feeling of anxiety, which may be accompa­
nied by “flashbacks” or intrusions and frighten­
ing memories of the experience. There may be
nightmares, waking the person with panic. Any
reminder may trigger these feelings, and the
person may try to avoid all such reminders or to
shut out feelings (avoidance response). Anxiety
and intrusive memories or reexperiencing, espe­
cially of life threatening or gruesome encounters
with death, may alternate with numbness and
avoidance. The affected person may also be
highly aroused, as he or she is fearful and trying
to protect himself or herself from a return of the
frightening experience. Normally all these reac­
tions settle over the first weeks. If however,
these reactions are maintained at a hi^h level and
for more than a few weeks, they represent a
post-traumatic stress disorder (PTSD). Occa­
sionally the symptoms may not appear for sev­
eral months or more. Spontaneous recovery
occurs in the majority of cases but in a small
proportion the conditions can last many years.
In silent toxic or nuclear disasters, when no
impressive destructive event occurs, the external
danger may be invisible and people are likely to
focus on their physical health. Uncertainty and
insecurity may create anxiety and fear reactions
and their accompanying somatic symptoms may
induce a false perception of being physically ill,
resulting in pressure on somatic health services.

Epidemiology of psychological
disorders following a disaster
As stated by Perry and Lindell (1978) and by
UNDRO (1984), different views have been ex­
pressed by various authors about the extent of
psychological disorders following a disaster.
Some hold the position that disasters represent
catastrophic events producing adverse psycho­
logical reactions among most victims, while oth­
ers suggest that the extent of the problem has
been overestimated, and that psychological prob­
lems due to the stressful event(s) appear only

6

among people with a preexisting vulnerability.
The latter view can be found especially in some
of the sociological literature, mainly from the
US. There may be certain reasons why this view
has been put forward: (a) some of the disasters
cited involved little loss of life and mainly in­
volve material damage, (b) poor detection meth­
ods were used to find psychological distur­
bance.
There may be a tendency in some cases to
dismiss certain severe psychological reactions to
disaster as only “natural”. It should be noted
however that severe bruising and fractures may
be quite “natural” reactions to a fall from a
height, but this does not diminish the intensity
of the suffering or obviate the need to help those
affected.
Up to a few years ago, little was known about
the psychiatric epidemiology of disasters in de­
veloping countries. In fact with the exception of
some recent work in the United States and Aus­
tralia, very little is known of the true incidence
of psychological traumas and related distur­
bances following disasters even in developed
countries. Previous research was based on un­
systematic clinical observations or crude indica­
tors of psychiatric morbidity such as admissions
to psychiatric hospitals (e.g. Ahearn, 1981). Only
following disasters in recent years in Colombia
1985, Mexico 1985 and Puerto Rico 1985, have
systematic studies been carried out. They sug­
gest that victims present marked and prolonged
psychosocial problems whose prevalence is sig­
nificant. Because of the often devastating physi­
cal impact which natural disasters have on popu­
lations living in developing countries and be­
cause of the scarcity of resources there, inter­
ventions have generally been confined to rescue
and to the provision of basic medical care, with
a corresponding neglect of psychological needs
and related epidemiological research and inter­
vention. Furthermore, the existence of some
clear “disaster sub-cultures” among populations
with lengthy experience in coping with natural
disasters, especially in developing countries,
makes it difficult to apply findings from re­
search carried out among populations only ex­
ceptionally affected by a disaster”. The different
culture patterns, social structures, and coping
behaviours may reasonably modify the inci­
dence, the severity, and the psychosocial out­
come, pointing to a need for specific research on
these populations.
The specific behavioural pattern, character­
ized by a stunned, dazed, and apparently disen-

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EPIDEMIOLOGY AND DESCRIPTION OF PSYCHOSOCIAL REACTIONS TO DISASTER ' ^15^ •

gaged behaviour, called “disaster syndrome”,
has been described as a response to impact and
immediate aftermath. It is said to occur in about
25% of those affected by disaster (Frederick,
1981; Raphael, 1986). On the other hand Duffy
(1988) has stated that a “disaster syndrome”,
represented by the immediate post-disaster re­
action, is present in up to 75% of victims during
the first hours or days after the event. Anxiety or
anxiety-related reactions are extremely com­
mon. They may continue from the high arousal
that comes with impact or, more often, emerge
after a latent period of a few hours or days. In
different studies which employed a psychiatric
screening schedule to assess the psychological
status of the victims of the disaster, the percent­
age reacting over the first weeks as shown by the
questionnaire score seems to vary from 70% or
more to 20%, in large part correlating with the
severity of the experience. Levels may remain
high in the early weeks. Then, by 10 weeks, there
is usually a significant drop with a gradual de­
crease continuing over the first year (Raphael,
1986).
Disturbances may carry over from the imme­
diate disaster experience impact phase to the
immediate post-disaster phase: for example in
some industrial disasters studied, about 15% of
the affected populations displayed the
derealization/apathy symptoms of the disaster
syndrome with absence of emotions, lack of
response, inhibition of outward activity with
stunned, shocked and dazed appearances. Dis­
organized flight behaviour is common, whereas
brief psychotic reactions occur only in a small
minority. The physical symptoms of anxiety
and stress are more frequent. These symptoms
are important in that they hamper the person’s
ability to carry out planned actions, and may
become the starting point of a somatization
process (which can be misinterpreted as physi­
cal injury, illness, toxic poisoning etc.).
According to Raphael (1986), psychological
morbidity tends to affect some 30-40% of the
disaster population within the first year follow­
ing it. At two years, levels are generally less but
with a persistent level of morbidity that seems to
become chronic for some individuals and for
some disasters. Disasters that are man-made and
with high shock and destruction show persist­
ing levels of over 30% severe impairment. Con­
trasting findings from different studies can be
explained in terms of differences in sampling
methods, methodologies, diagnostic categories,
and types of disasters under study, as well as

differences in interpretations of the same data.
More specific evaluations of morbidity patterns
have examined mortality, psychosomatic illness,
mental health protdems, physical sympto­
matology, consultation-based health care utili­
zation, hospital admission and alcohol and drug
usage. Mental health problems, as defined by a
range of different measures, are shown as in­
creased in systematic studies. The diagnostic
inconsistencies among different studies and dif­
ferent research groups are especially important.
The ICD-10 (WHO, 1990) provides a useful
conceptual framework for clinicians and re­
searchers active in this field, recognizing three
mam diagnostic categories of disorders caused
by exceptionally stressful life events producing
an acute stress reaction, or by a significant life
change leading to continued unpleasant circum­
stances which result in an adjustment disorder.
The three main diagnostic categories are: (i)
acute stress reaction (F43.0); (ii) post-traumatic
stress disorder (F43.1); (iii) adjustment disorder
(F43.2). In addition the ICD-10 recognizes en­
during personality change after a catastrophic
experience (F.62.0).
A recent thorough review has analyzed the
relationship between disasters and subsequent
psychopathology for 52 studies which used quan­
titative measures (Rubonis & Bickman, 1991).
The authors examined relationships among four
sets of variables: (a) the characteristics of the
victim population, (b) the characteristics of the
disaster, (c) the study methodology and (d) the
type of psychopathology. In the studies exam­
ined, between 7 and 40% of all subjects showed
some form of psychopathology. The type of
psychopathology with the highest prevalence
rate was general anxiety (almost 40% of the
studied subjects), although its variability is also
among the highest. Phobic symptoms (32%),
psychosomatic symptoms (36%) and alcohol
abuse (36%) appeared to show slightly lower
levels of prevalence, with depression (26%) and
drug abuse (23%) somewhat lower still. Using
meta-analytic techniques, the authors showed
that in these studies a positive relationship
emerged between disaster occurrence and psy­
chopathology, indicating an increase of approxi­
mately 17% in the prevalence rate of psychopa­
thology (compared with a predisaster or control
group rate) as a result of a disaster. The number
of female victims in the samples studied, the
death rates, and the amount of time that had
elapsed since the disaster event were all directly
related to the amount of psychopathology.

7

s::'-

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PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

Finally, higher impairment estimates were Found
likely to be adverse. Similarly when there is little
for naturally caused disasters (e.g.volcanic erup­
support or people feel helpless and unable to
tions) as opposed to those caused, at least in part,
take charge of their own recovery, this also has
by humans (e.g.nuclear accidents). This latter
a negative effect on*the outcome.
finding however contradicts much o the litera­
ture published so far.
The severity of the stressor (f >r example
Specific psychosocial
threat or loss) has been strongly cc rrelated in
consequences following disaster
all studies, with the severity of the pathology
or reaction engendered, although c ther vulner­
Post-traumatic stress disorder
ability factors are also important. The main
The most severe psychiatric disorder conse­
clearly defined syndromes that appear follow­
quent upon disaster is represented by posting disasters are the PTSD, the survivor syn­
traumatic stress disorder. This arises as a de­
drome and the disaster bereavement syndrome.
layed and/or protracted response to a natural or
As regards the first, social withdrawal contrib­
man-made disaster of an exceptionally threaten­
utes most to impairment. An interesting finding j
ing or catastrophic nature, which is likely to
from some studies is that irritability, anger and
cause pervasive distress in almost anyone,
aggression increased over the four-year follow­
As stated in the clinical descriptions and diag­
up. Irritability is in fact, a very common reac­
nostic
guidelines accompanying ICD-10, typi­
tion, and is perhaps especially so with “man­
cal PTSD symptoms include episodes of re­
made disasters in which a human agency can be
peated reliving of the trauma in intrusive memo­
blamed. Bereavement disorders, when chronic,
ries ( flashbacks”) or dreams, occurring against
are notoriously resistant to treatment.
the persisting background of a sense of “numb­
Not only psychological disorders but also
ness
and emotional blunting, detachment from
physical disorders and mortality rates have been
other people, unresponsiveness to surround­
shown to be higher in survivors of disaster. In
ings, anhedonia, and avoidance of activities and
particular the rate of coronary heart disease
situations reminiscent of the trauma Commonly
morbidity and mortality is increased. This has
there is fear and avoidance of cues that remind
been shown in a study of earthquake survivors
the sufferer of the original trauma. Rarely, there
(Katsayanni et al., 1986). Stud- js have also shown
may be dramatic, acute bursts of fear, panic or
that this increase in physical disease is particu­
aggression,
triggered by stimuli arousing a sud­
larly marked in the year after i ic disaster amongst
den recollection and/or re-enactment of the
the relatives of people who cued at that time. It is
trauma or of the original reaction to it.
presumed that this increase in disease is caused
There is usually a state of autonomic
by psychological factors.
hyperarousal with hypervigilance, and enhanced
startle reaction, and insomnia. Anxiety and de­
pression are commonly associated with the above
Relationship between type of
symptoms and signs, and suicidal ideation is not
disaster and the type and severity
infrequent. Excessive use of alcohol or drugs
of reactions
may be a complicating factor.
wrawioaoSome people may respond to trauma with
The severity of psychosocial reactions to
a disas­
mPtoms which last only briefly or with milder
ter'will depend on many factors in the individual
symptoms which hardly justify a diagnosis of
and the community. Where there is great loss
life there is likely to be much grief and perhaps
dls
disorder
°rder””. Some
Someworkers
workers in
in the
thefield
field have
have re­
ich grief and perhaps
ferred
disruption of family and community life. Loss
. ea to these
^ese as “ post-traumatic stress reac:e. Loss
tions”.
of homes and property may destroy the sense of
The onset follows the trauma with a latency
the community and create stress in association
period which may range from a few weeks or
with the hardships. Where support is available
months (but rarely exceeds 6 months). The course
and some meaning can be made of what has
is fluctuating but recovery can be expected in the
happened, and especially when there are op­
majority of cases.
portunities for individuals and the community

to be actually involved in their own recovery,
the outcome is likely to be better. Where there is
obvious blame, human negligence, malevolence
or violence, and little support, the outcome is
8

Grief
For those people who have experienced signifi­
cant loss, the emotional reactions which occur

*

JI__ _______ -------------------------- K-S-

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EPIDEMIOLOGY AND DESCRIPTION OF PSYCHOSOCIAL REACTIONS TO DISASTER

' -

L
■. .

<

'■

W.

•

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fabric and the breakdown of traditional forms of
after the disaster are likely to be those of grief.
social support. “Temporary camps” providing
There may be grief for the loss of loved ones, or
inadequate facilities, are known to house victims
,
home, treasured possessions, livelihood or com­
for years. Disruption o*f families
can also have
munity. The severity of.the morbidity is greater
— ------------------for the individual when associated with personal
irfiportant psychosocial consequences upon the
1
» .i: ofa
: r loved rfamily
—rnemben The
members and particularly on small children with
: 'loss
due to death
emotional reactions of grief include
sadness,
no accompanying adults.
inc
distress, anger, and longing and yearning for
//Unnecessary hasty procedures for dealing
what has been lost. The bereaved person may be '. with dead bodies, under the guise of preventing
preoccupied and miserable. Usually grief reacoutbreaks of communicable diseases, can lead to
■ •, tions diminish to some extent by 4-6 weeks, such rapid burials that proper identification may
although stresses may complicate 6r prolong not be possible and full mourning procedures
' them and anniversaries may induce recurrences.
may not occur. Likewise, overenthusiastic. vacA number of studies have pointed out a number
cination programmes may be initiated for the
of factors that might increase psychological
same reason. Other misbeliefs may lead to Un­
morbidity among the bereaved: lack or weaknecessary extra stress on victims of disasters,
ness of social supports, female gender, loss of a
child. There are circumstances of violence and
the dead body has been unable to be found or
viewed by the bereaved. For some of those who
have suffered losses, grief may become chronic
and the emotional, reaction may intensify into
severe depression.

r

Alcohol, drug abuse and family problems
Ax few studies have shown increases in alcohol
and drug consumption following a disaster, while
’ ' in associationi
social withdrawal, particularly

4

*
i

with numbing, can be the most frequent form of
morbidity in interpersonal relationships. The
prolonged stress of the aftermath, the preoccu­
pation with painful memories or losses, or the
disruption of home, family and community life
and even work, may all adversely affect adjust­
ment. Family conflicts and problems may occur.
Children may be overprotected and sometimes
family violence may result. For most families
and individuals these problems are short lived
and transitional, but for some they are delayed
or become chronic. Others may respond to the
challenge of the disaster and appear to show
*
greater strength and coping, so that rather than
social pathology or community breakdown,
there may be enhanced social and community
functioning.

I

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Vulnerability
When disaster is not followed by new and addi­
tional stressors, early prediction based on an
evaluation of risk factors (risk situations, risk
individuals and risk reactions) may be possible,
thus allowing the health workers to concentrate
their interventions on high risk cases.
An immediate adverse psychological response
to trauma can be a predictor of PTSD Thus
screening instruments measuring the mental state
shortly after a disaster can be used to identify
risk cases. By combining this with individual
risk factors (such as previous psychiatric im­
pairment) and the intensity of disaster stress
exposure, high predictive power has been
achieved.
The results from longitudinal studies can be
summarized as follows: after exposure to a brief
disaster trauma, a person without marked
premorbid vulnerabilities may experience the
symptoms of a post-traumatic stress reaction
but should be expected to gradually overcome
and finally to recover completely- from these
symptoms, provided that the conditions are made
favourable for rehabilitation, that qualified treat­
ment is offered when needed and that the person
is motivated to work with his problems. The
majority of survivors who develop long-stand­
ing PTSD have been found to suffer from some
kind of pre-morbid vulnerability.

Secondary psychosocial stressors
5

Certain specific stresses can arise in the wake of
disasters, consequent upon social changes. These
include the displacement of individuals to other
geographical areas, housing people in camps,
unemployment, inactivity and lack of recre­
ational possibilities, the fostering of dependency
in survivors, general disruption of the social

Stress upon rescuers
There are two categories of rescuer, the non­
professional and the professional. The stress

upon the non-professional rescuers may re­
semble that on the victims, inasmuch as they
may be caught up in the impact of the disaster.

9

PSYCHOSOCIAL CONSEQUENCES OF DISASTLko. fktVtNIION AND MANAGEMENT

As volunteers or bystanders in the interim pe­
riod before professional help arrives, they may
suffer the terrible trauma of not being able to
achieve success in their rescue attempt. Also for
the professional, failure to be able to rescue
victims, especially children, is a significant stres­
sor, comparable only to the loss of a colleague,
riven a professional rescuer, such as a fireman,
may be overwhelmed by the magnitude of a big
disaster as compared to an individual catastrophe. The available resources usually seem too
small, creating feelings of powerlessness and of
eing terribly alone. As always, stress is better
endured when experienced as an active partici­
pant rather than as a passive victim. In disasters
affecting people one knows personally, such as
m company and community disasters, rescuers
especially need to adopt a very “professional
attitude .
Exposure to death and dead bodies has been
repeatedly identified as a major stressor follow­
ing all such event*. Children’s bodies represent

The psychological effects of disasters
on children
mom5?**" pointad ouc (Yule “d Williams,
1 WO) that several of the early studies of children’s
response to disaster trauma suffered from meth­
odological limitations. For instance several of
the scales frequently used to assess the psychoogical consequences of disaster were never in­
tended to measure the effects of trauma on children, or have a poor validity for this purpose,
there is now a consensus that teachers report
less psychopathology among child survivors
than parents do, and that both teachers and

parents report far less than the children them­
selves. In this type of research screening instru­
ments us id on their own, without detailed inter­
views wmh the child, are of limited value. In
combination, however, they reveal a consider­
able amount of post-disaster stress reactions
among affected children (Pynoos et al., 1987).
Regressive behaviours with clinging to parents
and heightened dependency are frequent find­
of exposures (Ursano,
ings.
1^8/). lhe psychosocial consequences on both
The early studies showed that in the majority
survivors and rescuers of a large number of dead
of cases the disturbances are shortlived (Garmezy
bodies also presents needs to be taken account
and Rutter,
1985_)_, but only “a ifew
studies have
have
of, and is probably best dealt with by having
•
ew studies
certain formal procedures laid down on how to 1"vesngated the effect of major disasters in which
the children
with this situation. It is very
unlikelyhad
thatbeen exposed to life threatening ...............
factors.’ XU
In the
aftermath o*
of the
the Buffalo
Buffalo Creek
Creek
those who have died will have been suffering
7°
UIC artermatft
infectio' diseases. Some of the enforced
from infectious
(1?76) foUnd’ amonS chilhygienic
rdren under 12 years of age, an enhanced vulner­
ygienic ” measures
seem to reflect people’s
fear
ability to future stress, and an altered sense of
tear of dead bodies, ~
more than any actual health
danger, and may lead to considerable psycho­
power over the self. The effects upon the chil­
dren seemed to depend upon their developmen­
logical distress in the survivors.
tal level at the time of the trauma, their percep­
It follows from the definition (exceeding the
tions
of family reactions to the catastrophic
coping capacity) that in the initial phase of a
event and the degree of direct exposure of the
disaster not only the victims but also the rescuchildren themselves to the trauma. It should be
ers eat personnel are faced with a demanding
noted
that studies (Bloch etal., 1956) have found
situation where not everyone can be helped
that children tend to reflect their parents’ reacoptimally. This is the essential difference be­
tions.
tween emergency medicine and disaster medi­
As in many adult survivors of acute trauma
cine. Although the practice of emergency medi­
suffering from PTSD (Weisaeth, 1989b), psy­
cine is the basis for disaster medicine, the latter
chic numbing has also been difficult to detect in
calls for a much simpler and less resource de­
children and adolescents, and often takes the
manding practice. Helpers may find it difficult
form of withdrawal into uncustomary
to change their way of working. In particular,
e avioural patterns (Frederick, 1985). The sense
they may find it difficult to have to leave some
people that need help without any help because
which is a symPtom of
15L), resulting from the exposure to mass deaths
of insufficient resources. It is important for the
may have particularly severe effects in children,
disaster workers to be well aware of the lowest
causing them to give up their involvement in
level of interventions that is still acceptable and
education, expectation of having their own fami­
to be trained to tolerate feelings of insufficiency
lies in the future, etc.
powerlessness and helplessness.

10

PSYCHOSOCIAL INTERVENTIONS
IN DISASTERS

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Prevention and treatment of
psychological disorders
From the psychological point of view, the pri­
mary prevention of disasters must deal with
denial as a common psychological reaction to be
found among populations exposed to a threat.
The negation of an imminent threat can make
forewarning useless, and expose populations to
avoidable risks by producing a delay in adopting
preparedness measures. Therefore health work­
ers may have an important role in reinforcing
warnings and thus making timely and effective
prevention possible.
Psychosocial prevention can also play an es­
sential part in preventing and minimizing the
psychological consequences of disasters, espe­
cially rhe occurrence of PTSD. In terms of inter­
vention programmes aimed at preventing and
treating psychological disaster-related disorders,
the main needs following natural disasters exist
in developing countries and among socioeco­
nomically deprived individuals. Since in devel­
oping countries the resources devoted to mental
health are often inadequate to meet even routine
needs, the primary health care system is the first
and often the only health network available in
the case of a disaster. It should not be forgotten
however that the population affected by a disas­
ter might well retain considerable coping ca­
pacities. They should not be treated as com­
pletely helpless, and assistance should be di­
rected at mobilizing local strengths wherever
possible. Moreover, for socioeconomically de­
prived individuals, primary care is the only mean
of extending health and mental health services.
In addition, in many disasters, besides a certain

number of people who have been severely af­
fected by it, there will be a much larger number
of less affected people who will however, dis­
play a variety of functional complaints and psy­
chological disorders. Functional complaints and
somatization disorders will be particularly com­
mon among people attending primary health
care and medical facilities, as the majority of
people in developing countries tend to express

psychological distress in somatic terms
(Goldberg & Bridges, 1988). In order to cope
with general anxiety and also uncertainty about
the possible health effects of the disaster, people
focus on the more tangible aspects of their physi
cal state of health, seeking out the health care
system and requesting explanations. Especially
in the absence of reliable data about the health
effects of the accident (for example in the case of
toxic, chemical and nuclear disasters), medical
workers lack adequate explanations and may
well respond with extensive and intensive diag­
nostic screening of populations and individual
patients. The paradox in the situation, however,
is that attempts to reduce such illness behaviour
and such extensions of the diagnostic proce­
dures, in order to diminish the probably un­
founded attribution of symptoms to the disas­
ter, would deprive people of a coping strategy if
no alternative were made available. For all these
reasons, the primary health care worker repre­
sents the crucial locus for the intervention. The
proper handling of the psychological problems
associated with a disaster is of great importance
and must be included in the training programme
of all health workers potentially involved in the
care of affected people. The training of primary
health care workers to give appropriate treat­
ment to people attending health centres and
showing emotional distress due to a very stress­
ful event, deserves priority (Lima, 1986); such
training represents one of the main prepared­
ness activities.
There are other considerations which under­
score the importance of integrating mental health
services within the framework of the existing
health system, and especially the primary care
system:
1. Many potential users do not come to a facility
which is openly labelled as a mental health
service, since they do not see themselves as
people needing specialized help but consider
themselves only as victims of extreme adver­
sity.

11

r^KXJAL CONSEuUtN<.tS Of OSAStHS:, KLvtNIluN AND MAHAGEMENf

i

2. It is well known that the large i..„
majority of
cases of psychological distress
among
attenders of health centres go unrecognized'
do not receive proper care and represent an
important burden for the health services. Bet­
ter and prompt recognition and management
ot these disorders, including PTSD, can im­
prove their outcome and reduce the burden
on the health services.
3. The primary health care network, thanks to
its central position in the community, can
guarantee proper follow-up of victims and
their families for as long as they need.

In this framework, the role of the specialized
mental health team should essentially be one of
supervisum and training, and only especially
difficult cases should be referred for direct treatment.
Two recent papers have reviewed the empiri­
cal evidence for the effectiveness of a range of
treatments for post-traumatic stress disorder
(Davidson, 1992; Solomon et al., 1992). With
regard to drug treatment, amitriptyline and

imipramine are both effective, and will help with
disturbed sleep. Doses up to 200-300 mg/day
'"’.A6 rcquircd
aLlcnclon should
snould br
be
--------’ ^though
------------- attention
given
to
possible
side
effects.
Treatment
should
F
.*
.--.J. A.* uauiucilL snouio
be continued for at least 8 weeks. Other studies
have examined the efficacy of behavioural tech
tech-­

mques, consisting of different forms of system­
niques,
atic desensitization
desensi tization or flooding; these techniques
have been found helpful, especially in terms of
reducing PTSD intrusive symptoms. Cognitive
psychodynamic and hypnotic techniques also
hold ]promise
'
Clinical- experience tends to suggest that brief short term counselling may be
helpful in the early stages of the disorder, before
.
,r
it becomes entrenched. This is particulariv
if
deJ
?rr 7 S° lf
the person is able to cL„'
deal with the effects of
helplessness and fear that surround everybody
after a disaster, through catharsis, support and
cognitive restructuring of the experience. Fur­
ther research however, is needed before any firm
conclusion can be drawn as to the comparative
effectiveness of different treatment methods.

Function of the mental health
professional expert in
preparedness activities
The mental health professional^) at the national
or subnational (e.g.provincial) level should be
responsible for:

12

Teaching preventive psychiatry

ThlS wi!1 involve educating and training the

entire spectrum of professions concerned with
disaster rescue operations in the basics of disas­
ter psychiatry, such as emotional first aid. The
target groups are not only the medical, para­
medical personnel and ancillary staff (such as
switchboard operators, who have a vital role to
p ay) found in a hospital, but also personnel in
the associated organizations such as the police,
ire brigade, civil defence, the clergy, industrial
safety personnel, and administrators with spe­
cial responsibility for disaster planning etc.
Leadership

The semor professional should organize and
lead the specialized disaster psychiatric teams
made up of other mental health professionals as
well as others that are activated during the acute
phase of an actual disaster (loss support group
liaison.psychiatric team, stress management/
debriefing teams, as set out below).
Mental health care during the first 6 months

The first 6 months after a disaster may require
general counselling for those who present to
P"™1?; care with recognition and referral of
“
™th,SpeciaI mental health problems such
as
“ PTSD,
, , ’ <dePresslon “d grief. Early treatment
may help
to P
prevent
P tO
revent problem;
problems,

■ Planning long-term follow-up of victim groups
;The second 6 months or so after a disaster, that
is between the acute phase and the longer term

is an important time, as much of the psychologi­
cal work is done then.
During this stage, one should be aware that

a^vereary” reactions tend to crop up; certain
days may serve as reminders of what the victims
have been through. There may also be a need to
follow-up avoidance behaviour, because this
may indicate a delayed onset of symptoms in
ictims who have not displayed the full posttraumatic stress syndrome.
Mobilizing support at different levels

This includes the giving of advice to victims and
helpers about coping techniques and the mobiization of support from family, friends, work
mates and neighbours. A clearing house for
information on available resources should be set
up.

It may be useful to have some model pam­
phlets presenting essential information that can

PSYCHOSOCIAL INTERVENTIONS IN DISASTERS

tejarr.”

be rapidly adapted to a particular disaster situa­
tion and distributed to relevant groups, such as
survivors, bereaved families, rescuers etc.
In massive disasters particularly in third world
countries, killing tens of thousands of people,
the only active element of the psychosocial or­
ganization that is possible in the turmoil of the
acute post-disaster phase may be that at the
senior staff level, trying to influence decisions
and providing psychological support.

Functions of the mental health
team at the disaster site
While the considerations described so far apply
both to developed and developing countries, the
following proposals, focusing on the functions
of the specialized mental health team, are appli­
cable especially in the developed countries. Only
these countries can usually afford the heavy
burden of setting up and maintaining a specialist
mental health service which can be mobilized at
times of disasters. Nevertheless, it is hoped that
the following guidelines can provide useful leads
for those working in developing countries.

7. Health personnel{mass injury situations that
demand difficult prioritizing)
8. Persons holding responsibility
9. Workmates (in company disasters), and
10. Evacuees.
Individuals at the disaster site displaying
grossly deviant behaviour or other severe psy­
chological reactions should be rapidly re­
ferred to psychiatric care.

Establishing an information/support
centre
This centre can be located either at a hospital or
at a convenient place not too far from the disas­
ter area, (hotel, town hall school, etc.) but never­
theless far enough away from where rescue ac­
tivity is taking place, so that congestion and
interference is reduced. If the identity of the
dead is uncertain (which is frequent), or the
number of dead is unknown for a time, a great
number of families will be distressed until they
ascertain that their missing family member is
safe. Establishing an information support cen­
tre has turned out to be useful. The existence of
such a centre and its telephone numbers should

Groups requiring psychosocial support

are worried that one of their number is amongst
the victims should be invited to come to the
centre. Survivors may also be asked to gather
there. Particularly after transport/communication disasters when people die far away from
their homes, this centre may be useful, for sev­
eral reasons: it gives the bereaved a chance to
meet survivors to get a first hand report about
what happened to their loved ones, how they
died, perhaps even what they uttered before
they perished, and what was done to rescue
them. The survivors and possibly also onlook­
1. The next-of-kin
ers and rescuers have information that often
2. The injured survivors and their close ones
3. The uninjured survivors
cannot be given by others.
For the survivors it is often an important
experience to be of help to the bereaved.
These groups are likely to have suffered the
The main functions of such an information/
most severe stressful experiences and thus re­
quire support and preventive activities. Often a
support centre are:
family may include all three above. Other groups ._1. To-provide rapid, authoritative information
about tragic news that can be conveyed in a
need to be considered, but they usually have less
humane, direct way in a setting sheltered
pressing needs, namely:
from public and media attention,
2. To provide support and a holding environ­
4. Onlookers (particularly at risk are the helpment for both survivors and helpers,
less helpers)
3. To serve as a forum or meeting place where
5. Rescue teams (particularly when failing to
affected individuals and families can support
rescue, especially children)
each other. Self-help groups may develop
6. Persons doing body handling (p;particularly
when they are non-professionals)
from this forum.

Psychosocial support at the site of a disaster
should in principle be carried out by the rescue
workers and emergency health personnel. The
leader of the mental health team with collaborators should establish the priorities of
psychosocial support activities, mainly based on
their evaluation of the particular traumatic as­
pects of the disaster, taking into account the
different groups which are to be considered:

13

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

4. To be a place where the police can collect
identification data about missing/dead per­
sons from their close ones,
5. At times the police should be able to use the
centre to interrogate survivors about the di­
sastrous chain of events as a part of their
investigation,
6. The information/support centre should help
to reduce the convergence of people on the
disaster site that may create congestion and
therefore movement problems for rescuers.

A meeting may be organized for everyone
affected (this may be possible for up to one
thousand people) or at least one or two repre­
sentatives from each affected family. At such a
meeting information can be given about rescue,
identification, investigation of causes, insurance,
psychosocial support services and religious ser­
vices.
Attempts can also be made for early identifi­
cation of persons at risk. The Post-Traumatic
Symptoms Scale - 10 for instance, can be used
after a few days. The survivors’ mental state can
be evaluated, as can the possibility for mobiliz­
ing social support from people’s own networks
(family, work colleagues, friends, neighbours).

Specific procedures for helping survivors
The mental health team should reach the scene
of the disaster as soon as possible. There have
been very positive responses to anticipatory
guidance, i.e., information about the natural
post-traumatic stress reactions that may be ex­
pected. Information m<teetings are effective means
to talk about this and what the survivors them­
selves and their close network can do to help.
Anticipatory guidance works by helping the
victim accept the reactions as normal and ex­
pected, and not as pathological, thus reducing
uncertainty and feelings of helplessness. Nightmares suffered by the victim are often alleviated
by physical contact; if this fails it may be better
to wake the patient and let him go back to sleep
again afterwards. Hypnotics may be given briefly
for severe sleep disorders.
At this early stage most survivors are psycho­
logically open and willing to talk about their
experiences, an attitude, however, that may soon
change into a defensive, withdrawn, non-coop­
erative position if time is allowed to pass with­
out attempting to make contact. Therefore it is
of utmost importance that the survivors are
encouraged to seek help if problems develop.

14

When disasters involve people away from
their home areas, it may be necessary to help
them to establish supportive contacts with health
or social service professionals in their home
district. One of the first needs of survivors in
these circumstances, is to be able to inform their
families about their fate, preferably even before
the media have announced news of the disaster.
Some may have an urgent need to get home
themselves. This makes organization of a mental
health support service more complicated than if
the victims are local people or members of a
homogenous social system.
Help for bereaved families

It has been demonstrated quite clearly that the
family is the unit providing the most important
source of strength for enduring a disaster loss.
There is strong evidence that sudden and violent
death causes more pathology in the bereaved
than expected losses and this can be made worse
by the terrible circumstances surrounding the
death in disasters, perhaps even witnessed by the
family. Equally distressing however, are deaths
happening far away from them, possibly with
times of waiting and uncertainty for the family
until tnc Gcatn is comirmed.
Sometimes the bereaved may be unable to
travel to the site or they may never see the dead
because the remains may not be identifiable or
even found. Frequently, this failure to retrieve
the body or to identify the remains has compli­
cated grief work. In the acute phase, measures
taken to alleviate the consequences should have
as the first goal, to help the family fully grasp the
death of one or more of their number, and
secondly to help start them on the road to
accepting the loss. The full realization of the loss
seems to be helped by the identification of the
dead body andI an awareness of the physical
;aspects of' death,
* \ as well as the circumstances in
which it happened,
Experience in Norway
The psychiatric team working with the be­
reaved families after a disaster, (the loss sup­
port group), usually sets up its headquarters
at the local hospital, for example in the out­
patient department of internal medicine. Each
team consists of a psychiatrist, chaplain
(priest), psychiatric nurse, clinical psycholo­
gist and sometimes a social worker or others
experienced in loss and grief reactions. Gath­
ering the bereaved families in one place pro-

-------------- ----------------------------

PSYCHOSOCIAL INTERVENTIONS IN DISASTERS

tects them from wandering aimlessly around
or engaging in unplanned searches for miss­
ing family members. Some experience indi­
cates that the support group should work
exclusively with the bereaved families and
not combine this work with support to survi­
vors, because of the entirely different needs of
the clients. Each family has two group mem­
bers designated as personal contacts. The
group will work in close cooperation with the
police which is the agency that carries out the
identification work.
In disasters where people die away from their
homes, the team will have some hours to
organize the reception of the bereaved fami­
lies. If there is a large number of dead, it is
important to join the different families into a
cohesive group by, for instance, lodging them
in the same hotel. If the dead come from a
similar background, as in a school-bus acci­
dent, the parents will already have a natural
affinity with each other, and this will
strengthen the bonds for an extended period.
If the dead make up a group which has come
together by chance however, as in a some
airplane crashes, the bereaved may form a
group only during the acute phase when they
are sharing many of the same services and
undergoing many of the same experiences.
The first day after a disaster is usually filled
with a succession of practical problems to be
solved. The bereaved families are encouraged
to travel with a companion (who might be a
local priest or a friend of the family), because
it has been shown that the breaking of the
strong bonds that often arise between the
team and the bereaved family will be made
less difficult in the aftermath of the event
when a continuing link to an after-care ser­
vice at the home place is provided through
this person.

Role of the Psychosocial Support Team
The psychosocial support team may be involved
in the following activities for the bereaved fami­
lies:
Notification of death

Seeing that this duty is carried out in an appro­
priate way by the local police, priest, etc. It is
important that notification is given in such a way
that the family can be helped to grasp what has
happened. It is a common experience that the
bearer of the sad message is not in possession of

the full facts about the death; this is a burden for
both parties involved. If the body has not yet.
been recovered, the next-of-kin will nearly al­
ways express a strong wish to travel to the scene
of the disaster.

?;T3 '''-swrjittoi; x mJ

Identification of the body

A member of the team should be present when
the next-of-kin is asked by the police to make a
positive id entification of the body,
Viev/ing the dead

It is important that the bereaved are provided
with an opportunity to see the body of the dead
if they wish and if this is possible, and that they
are provided with information about the death.
It is also important that as far as possible, appro­
priate funeral and mourning rituals are provided
in accordance with the practice of the bereaved’s
culture. An important task for the support group
has been to arrange for this viewing of the dead
_____
r_____ planned
_________
bodies. This must be
scrupulously
after
evaluation of each family and considering the
state of the body. Meeting the dead gives the
family a chance to see, talk and touch and to fully
comprehend that the loss is real, that the uncer­
tainty is over, and that they must take a final
farewell. If the face is too mutilated to be seen,
other parts of the body may be recognized. For
children it can be a help to leave something in the
coffin, a favourite doll, a drawing or a letter to
the dead mother or father.
Information about the circumstances of death

Regularly the family has many questions about
how the dead person was found and the manner
of death. Therefore they should be given an
opportunity to meet survivors who have some­
thing to tell, the rescuer who found the body,
and any nurses and doctors who tried to resus­
citate the victim. It may be necessary to ask the
pathologist to provide information.
Visiting the site of death

The team normally encourages viewing of the
scene of the disaster to be carried out in groups,
and a rather private memorial ceremony may be
arranged there. This allows the bereaved fami­
lies to come close to their dead and express their
solidarity. This final farewell must be shielded as
much as possible from the intruding gaze of
outsiders and the media.
Public memorial service

The bereaved families should also be helped to

15

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

attend some kind of public memorial service.
Public mourning is an important symbol of the
wider society’s support to those bereaved.
Personal relationships are particularly im­
portant in the emotional reactions after disas­
ters, providing support and help in dealing with
the stress. People are also very distressed when
separated from those they love during and after
a disaster, and information and support services
to help the reunion of family members are likely
to be helpful. Special relationships and closeness
between people of all social groups who have
suffered the same stressful experience together
may provide a “therapeutic community” effect
after the disaster, where people talk through
what has happened, share feelings and support
one another in several ways that may help recov­
ery. Similar bonds may be formed between vic­
tims and rescuers.

The physically injured

Many hospitals are capable of handling 20 or
more injured cases, but not many can take care
of the one hundred or more close family mem­
bers belonging to this number of injured. This
may be a reflection of the usual emphasis on
physical injuries in disaster planning. The surgi­
cal and intensive care personnel should there­
fore be reinforced by a psychiatric liaison team
who can have responsibility for both the injured
and for their family members. As regards han­
dling the injured, the most common error in
psychological handling is leaving the injured
alone; they are especially vulnerable to being
abandoned in darkness.
Crisis intervention
“The good talk” is the psychotherapist’s main
tool. It is as important as the scalpel to the
surgeon and contains several therapeutic ele­
ments: the interpersonal contact, the verbaliza­
tion which increases control, the cathartic effect
of ventilating emotions and the need for work­
ing through the experiences again and again, if
the fragmented and overwhelming impressions
are to be neutralized and integrated. To turn the
passive reliving of the trauma, as in nightmares,
into an active reconfrontation seems to work
well if the patient feels that the therapeutic envi­
ronment is safe enough. It is natural to use the
group approach with victims of collective trauma
because, having faced danger together, strong
bonds have been created between them.

’16

Debriefing

The majority of rescuers report a need to work
through the emotional disaster experiences by
sharing their feelings with others. Debriefing
should aim to:

—review the helper’s role;
—ease the expression of feelings;
—explore particular problems encountered and
solutions found;
—identify positive gains;
— explore consequences of disengagement;
—identify those at risk;
—provide education about normal reactive pro­
cesses to acute stress;
—explain how to cope with stress adaptively.
The psychiatrist can act as the formal leader
of the debriefing group or may give training to
professionals in rescue organizations so that
they can lead such activities. Frequently it is a
great advantage to have taken part in the rescue
operation when leading such a group, but there
may be occasions when a neutral professional
should take on this role. Debriefing involves
going through, in detail, the sequence of events
as experienced by each participant. The rescuers
should also share with the rest of the group their
thoughts and feelings during and after the disas­
ter. It is generally easier to begin the debriefing
by first reporting factual information. The de­
scription of the professional activities of the
rescuers can lead on naturally to the more deli­
cate issue of their emotional and psychological
reactions. Reviewing how helpers felt and coped
requires consideration of positive as well as
negative aspects. On the negative side, these
individuals may have experienced a sense of
despair, a fear of being useless and overwhelmed,
or they may be having problems at home be­
cause of their involvement in disaster work.
Some may suffer from what has been called
performance guilt” believing that their contri­
bution was inadequate. Positive reactions may
include a feeling of satisfaction of a job well
done, the finding of a victim alive, the forging of
important relationships among helpers, or a sense
of reassurance about having been able to cope.
The sustained emphasis on the positive aspects
of the work provides a powerful antidote to the
sense of being overwhelmed, and helps to achieve
a feeling of mastery over the unpleasant features
of disaster work. The briefing session should
encourage the expression of these positive as­
pects. Sometimes a powerful continuing rela-

• -

----

— ■ TT’-’T ■;

.
--------- - |
PSYCHOSOCIAL INTERVENTIONS IN DISASTERS
i.

s

tionship may develop between a helper and one
or more of the person rescued. Both this and
powerful relationships that may have developed
with other helpers can cause problems by cut­
ting across family relationships.

Role of information
...... r""’"

fl
■

/k

Accurate information is very important at every
stage of disaster response. As part of prepared­
ness, people should be provided with clear in­
formation about what to do in the event of a
disaster affecting their community. Such infor­
mation should be relevant to disasters that are
frequent or likely to occur, but also be of general
utility for unexpected circumstances. It should
convey the nature of the threat and what to do
about it in simple and concrete terms. Informa­
tion in the event of an imminent threat should be
reported through at least several channels in­
cluding TV and radio and should be presented
by those who are seen as trustworthy leaders.
Training, including information on what to do,
should be incorporated into community life in
places which are frequently subjected to threat.
During disasters, particularly in developing
countries, victims arc often poorly informed
about the events that are occurring. Rumours
are frequent, authorities give conflicting infor­
mation and ineffective action follows. Illiteracy,
a multiplicity of languages or dialects and a lack
of media, can all contribute to difficulties in
disseminating information rapidly and accu-“
rately.
The responsibility for transmitting informa­
tion rests with both public authorities and the
mass media. The authorities should take and
retain the initiative in communicating with the
public in the event of an emergency. Communi­
cation within the government should be well
coordinated, and the authorities should seek to
establish a climate of trust with the media, which
should handle the information given in an open
and unambiguous manner. To achieve these
objectives, the national authorities responsible
for the various aspects of disaster protection
should coordinate their actions as far as pos­
sible. International organizations may also be
sending out information. Diverse interpreta­
tions from the various national and interna­
tional organizations of the potential public health
consequences of a disaster, can seriously con­
fuse the public, and create difficulties for na­
tional authorities.

Developing country populations are notoriously non-compliant with warnings for evacua­
tion. While a variety of psychological mecha­
nisms can be invoke^ to understand these reac­
tions, a more concrete approach must also be
taken. The evacuation order expects the victim
to leave behind all his possessions with no pro­
tection against looting. Often survival is depen­
dent upon small-scale agriculture or livestock,
making it very difficult for people to leave be­
hind all their wealth and means of subsistence.
Failures of prediction can also diminish trust,
when evacuation orders are given for events that
never occur.
Accurate, trustworthy, and easily understood
information about a disaster should be provided
to the population at a local level. Such informa­
tion should be provided in collaboration with
local leaders and community representatives. In
particular:

—

j

—

—specially prepared brochures and pamphlets,
updated as necessary, should be widely dis­
tributed to the population of the affected
areas, as far as possible in collaboration with
the local media;
—dialogue should be encouraged between the
community, the authorities, scientists and
health professionals, as also envisaged by the
European Charter on Environment and

Health;
Possible adverse effects of public
information
Public information can however lead to adverse
psychosocial consequences by creating a sense
of confusion and mistrust. Reassuring asser­
tions by experts may be contradicted by other
experts or by later events. It is the right, even the
duty, of scientists to give an opinion on a scien­
tific matter, but they must do it in a way that will
avoid any confusion between facts and judg­
ments on facts. A further difficulty is in the
nature of communication between scientist and
non-scientist. The latter may be trained to think
in arbitrary terms requiring “yes” and “no”
answers and they may in consequence be both­
ered by the scientist’s answers in terms of grada­
tion and multiple qualifying considerations. This
pressure for what might be thought of as “bipo­
lar” thinking and decision-making is bound to
be a source of great exasperation, misunder­
standing and irrational decision: the authorities
feel they are getting answers which are impos-

17

KYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVtNIION ANO MANAGEMENT
f • H

J
>e provided to the popula­
tion at a local level. Equally or even more impor­
tant, is the way in which the authorities should
present information if an accident occurs. In
many cases, people have been flooded with in­
formation and nobody has shown them how to
deal with it. One of the few “principles” in this
field that seems to be useful is that comparisons

coerced or tempted into committing himself.
«n ^nsidering the provision of information
to “victims ”, it is necessary to consider their
definition. Traditionally victims of a catastro­
phe would be defined as those who were physi­
cally touched by its effects. On the contrary,
however, the notion of victim cannot be limited
are more meaningful than absolute numbers or
to those persons physically exposed to toxic
probabilities, especially when these absolute
emissions or physically affected by the disaster.
values are quite small. The key role which can be
The victim group of a major disaster potentially
played by an international organization is cru­
encompasses all those who receive the bad news
cial at this level, since the information provided
of the accident. For larger populations, the bad
by it is generally seen as more “neutral” and
news will not necessarily be accompanied by
authoritative” than that coming from other
directly visible events or damage. This is espe­
sources,
and it can therefore facilitate public
cially the case of toxic/nuclear disasters, and
compliance with necessary measures, prevent or
many of the following considerations refer spe­
minimize worries and fears likely to produce
cifically to this type of disaster. The Chernobyl
extensive psychosocial consequences, and fi­
disaster was especially striking in this regard. In
nally
tally help to restore a cooperative climate.
the first weeks and months after the accident,
Building a better public understanding of
very limited public information was provided to
risks and informing the public correctly in the
the affected populations. Over the foil. ’
________ s
be achieved if people are to be enabled to
posed to a barrage of information, with many
respond more rationally to a future emergency.
contradictory and inconsistent news items and
The central issue then is how to facilitate an
rumours, all of which have resulted in an infor­
evolution from the provision of information
mation overload. The “victims” therefore now
and recommendations, to a situation of effective
include large numbers of people who are suffer­
learning, which allows people to develop better
ing because they think they may be affected by
coping strategies during and after an accident.
the accident, but who in fact have never been
Setting up such effective learning implies more
exposed to toxic levels of radiation
th-r —ciicuuve learning implies more

ta=™do„al

“b re™nli.

binties in the field of public safety and health
have therefore a clear duty to provide both
general and specific background information.
Diverse interpretations from these organiza­
tions of the potential public health consequences
of an accident could seriously confuse the pub­
lic, and create additional difficulties for national
authorities. Accurate, trustworthy, and easily
understood information about radiation and its

-18

associated with industrial activities and sub­
stances through improved risk analysis and as­
sessment. It also implies improving the knowl­
edge and understanding of the reactions and
needs of individuals and groups in times of
emergency.
This last supposes a substantial change in the
current methods of risk analysis, risk assessment
and risk management (SeeMNH/PSF.91 docu­
ment).

_____________________________________________________________
?7t-

:

TRAINING AND INFRASTRUCTURE
FOR A PSYCHOSOCIAL RESPONSE
IN DISASTER RELIEF

Training programmes for primary
health care workers and other
relief workers

T-FG.-

Target groups for training programmes should
come from both the health and other sectors as
the first group. These should include primary
health care workers, often medical doctors of
first aid teams, community nurses, or other
trained health care workers such as social work­
ers, administrators from local and national ad­
ministrations, policemen and firemen in reserve
teams.
Training programmes for health care provid­
ers should include the health aspects of disasters,
general psychological and psychophysiological
concepts about people’s reactions after a disas­
ter and other stressful situations, and variations
in the way different groups of people perceive
the risk from different types ot hazards. The
programmes should also include simple ways of
dealing with psychosocial problems and the
teaching of simple skills for the recognition,
possibly using
and
. - a checklist,
.
e the
e treatment of
psychologically distressed victims (interviewmg skills, counselling, brief and simple
psychotherapeutic methods, targeted pharma­
cotherapy, group therapy, etc.).
For administrators the training can help them
to identify vulnerable groups, demonstrate the
reason why mental health services should be
integrated into the general disaster plan and how
a psychosocial component can be included in a
comprehensive disaster plan.
The training of general health workers in
mental health seems to be effective and longlasting. In the context of a WHO collaborative
study in six developing countries, general health
workers were assessed after training aimed at
improving their knowledge, attitudes, skills and
capacity to provide mental health care; it was
shown that the improvement was maintained up
to follow-up at 18 months and was of equal
magnitude in all countries (Ignacio et al., 1989).

Planning and coordination of
interventions in case of disasters
A senior mental health professional should be
identified at a national level to head and plan
mental health resources and consulting for di­
saster preparedness and relief measures. Since
national or local disaster teams are primarily
concerned with the provision of emergency
medical care and are often headed by a surgeon
for instance, it can be useful if the professional
coordinating mental health inputs is also a phy­
sician (e.g.a psychiatrist), in order to be able to
operate more easily in these circles and within
the disaster circumstances. Such a specialist liai­
son officer will take part in the multidisciplinary
decision-making groups and also coordinate
mental health aspects and mental health teams
when these are available, most importantly, lie
or she can act as a consultant to train and support
the preventive and other activities of the pri­
mary health care workers.
Attention should also be paid to the mental
health needs of the care givers themselves, who
are-faced with heavy demands during disasters

and who are themselves exposed to a substantial
risk of stress-related disorders.
As for service planning, it must be remem­
bered that services should be provided on the
basis of the actual needs rather than on the basis
of the demand: this applies both to the timing
and to the magnitude of the interventions (Ross
& Quarantelli, 1976).
A major boon for the overall field of disaster
prevention, preparedness and mitigation should
come from the UN General Assembly Resolu­
tion 42/169, designating the 1990s as the Inter­
national Decade for Natural Disaster Reduction
(IDNDR) (Lechat, 1990; WHO, 1989a, 1989b).
The objective of this decade would be to reduce
the loss of life, property damage and social and
economic disruption caused by natural disas­
ters, particularly in developing countries. In the
context of the IDNDR, WHO will play a major
technical role in the health sector, including in
the specific area of mental health.

K9

■i •

PSYCHOSOCIAL CONSEQUENCES OF DISASTERS; PREVENTION AND MANAGEMENT

SSL

■ '

ites.s- a ’’"a-

-

Given the above constraints and consider­
ation, the following points need to be high­

lighted:
1. A long range plan, including a full scale men­
tal health intervention strategy, should be
developed at national and international level.
Many preparatory steps must be taken. The
comments that follow present a progression
from the current position towards an ulti­
mate goal which is unlikely to be fully reached
in less than 5-10 years.

2. Concurrently work on preparedness response
and rehabilitation is needed, with the full
understanding that these levels may proceed
at different paces and influence each other
(e.g.while preparedness efforts are poor, re­
sponse measures may need to be emphasized;
when preparedness improves other response
measures may be reduced).
3. Below, three possible models for a
psychosocial response to disasters are de­
scribed; these may vary from country to coun­
try and they will need to be adapted to local
realities.

Model 1 (International reliance)
This is the current structure seen in most devel­
oping countries.
An international consultant may be called
upon to provide mental health assistance after a
disaster has occurred, typically to the Ministry
of Health, through WHO.-The consultant will
meet with an emergency committee and will
acquire information on the country and the
disaster. The consultant can advise the national
Ministry of Health and the health authorities of
the disaster area (and a local mental health of­
ficer if one exists) on the setting up of an appro­
priate emergency structure for ensuring a
psychosocial component within the disaster re­
lief operation.
The mental health workers in the area will be
involved in some direct patient care, but the
international consultant should promote the
development and implementation of a model of
care in which the general or primary health
worker will take the responsibility for provid­
ing mental health care to victims with the sup­
port of mental health professionals. The role of
the international consultant will be of educating

20

the mental health officers at the national and
local levels, who in turn will take the responsi­
bility for training the local health workers in
relevant mental health issues. The consultant
should make available appropriate materials.

Model 2 (National reliance)
Continuing efforts to achieve disaster prepared­
ness even before a disaster occurs, should be
taken to ensure national capability for managing
the mental health consequences of disasters.
These include the development of appropriate
training materials (e.g.manual, slides, video tapes)
which will be used to train national staff to be
responsible for the disaster mental health activi­
ties within their home country. Without there
being a disaster, a workshop could be convened,
to be led by one or more international consult­
ants with the national mental health authorities
and designated staff who would be responsible
for a disaster mental health programme. The
goal of the workshop would be to develop the
appropriate training materials and plan for their
use. When a disaster strikes a country, the inter­
national consultant should no longer be needed
and the country will have attained a greater
degree of self reliance.
Given that an international consultant does
not have to be recruited for work to be initiated,
interventions can be implemented much earlier,
probably within one week of the disaster. It will
also be possible to involve the mental health
workers almost entirely in supervision and sup­
port of direct service providers.
To achieve Model 2, the following prelimi­
nary steps are suggested:
1. Development of a core of training material
for national or Regional use: manual, slide set,
video, etc. These should be available for vari­
ous levels of staff, e.g.

(i) the mental health professional;
(ii) the general health professional;
(iii) the auxiliary health workers;
(iv) the community (non-health) workers.

2. Compilation of a literature review accessible
to non-mental health professionals.
3. Workshop/conference on “disaster mental
health training” for the national mental health
leaders and/or persons designated by them.

% •
TRAINING AND INFRASTRUCTURE FOR A PSYCHOSOCIAL RESPONSE IN DISASTER RELIEF

4. Specific allocation of money from the general
health budget should be obtained in order to
implement the above mentioned plans. 1 —

. . j I o

|

..

.

Model 3 (Local reliance)
Later on, and in zones at clear risk for disaster,
the local mental health team (if one exists) should
be responsible for managing the psychosocial
components of disaster relief in its area of responsibility, and a local disaster committee

should be formed, rather than relying on the
national authorities when disaster strikes. This
requires that the Ministry of Health organizes
training for selected Jpcal mental health officers.
Using this model, mental health interven-

canoccursooner The menul heakh offic_

ers will only be directly responsible for those
referred by the general health worker, including
those requiring hospitalization. The greaterproximity to the community allows for a much greater
degree of community participation.

’ cm

21

7

g

POSSIBLE RESEARCH PRIORITIES

I

1. Much of the research on the psychosocial
effects of disasters has been carried out among
Western populations. It is therefore impera­
tive to carry out extensive research with popu­
lations from developing countries, those that
are most affected by natural and man-made
disasters, both large and small-scale; this re­
search will allow the study of cross-cultural
variations in frequency, symptomatology,
temporal patterns and outcome of psycho­
logical disorders, and will clarify the moder­
ating effect of culture on these disorders. This
research, to be practically and ethically fea­
sible, needs to follow strict guidelines, and
should adopt a rigorous research methodol­
ogy. To achieve this, every effort should be
made to obtain reliable pre-disaster baseline
health data (preferably from various sources);
to have a control group; to have high follow­
up response rates; to use a longitudinal de­
sign, and to find valid screening instruments
to be employed as a first step in mass screen­
ing programmes in the acute post-disaster
phase.

2. Although there is agreement that social sup­
port and intense kin relationships are highly
supportive and facilitate post-disaster recov­
ery among victims, little empirical evidence is
available in this regard. Therefore, the spe­
cific role of these variables in modifying the
overall frequency, severity and course of psy­
chological disorders needs to be further ex­
plored, as do the importance of personal vul­
nerability and prior psychopathology in their
occurrence. Specific groups, particularly de­
pendent on social support (such as children,
the elderly, the physically ill) should be care­
fully investigated.

22

3. Investigations into physiological determinants
and correlates of psychological and psychiat­
ric disorders, especially PTSD, so far mainly
laboratory-based, should be strengthened and
should be mainly clinically based. It would
therefore be useful to find reliable, valid and
feasible physiological measures of stress to be
used as diagnostic tools. For practical rea­
sons, this research is more feasible with indi­
vidual victims of a single trauma or in more
limited accidents or disasters occurring in
developed countries.
4. The diagnostic specificity of the symptoms of
PTSD also needs to be further explored, as
does the natural history of this disorder.
5. An important area of research is comcrbidity,
especially among persons suffering from
PTSD: for instance, substance abuse, fre­
quently associated with PTSD, has been in­
terpreted as a long-term attempt to numb
oneself against intrusive images and night­
mares, thus representing a secondary response
to primary PTSD symptoms.

6. The experience of facing a trauma as an indi­
vidual, versus the effect of trauma when expe­
rienced with others needs to be investigated.
7. Finally, treatment of the main psychological
and psychiatric post-traumatic disorders is
an important area for research. The main
psychotherapeutic and pharmacological treat­
ment methods deserve detailed consideration
and need to be adequately tested and verified
for cross-cultural applicability as well as for
general effectiveness.

■

_____________________________ ____________ -

REFERENCES AND
SELECTED READING

Agency for International Development (1989).
Disaster History: Significant Data on Major
Disasters Worldwide, 1900-Present. Wash­
ington, DC: Office of U.S. Foreign Disaster
Assistance, Agency for International Devel­
opment.

Ahearn, F.L. (1981). Disaster and mental health:
pre- and post-earthquake comparison of psy­
chiatric admission rates. Urban and Social
Change Review. 14, pp. 22-28.
Barton, A. (1969). Communities in Disasters.
New York: Basic-Books.

Berz, G. (1989). List of major natural disasters,
1960-1987. Earthquakes & Volcanoes, 20,226228.
Cohen, Raquel E. and Frederick L. Ahearn, Jr.
Handbook for mental health care of disaster
victims. The Johns Hopkins University Press:
Baltimore and London, 1980.
Davidson, J. (1992), Drug Therapy of Posttraumatic Stress Disorder. British Journal of
Psychiatry. 160, 309-314.

Duffy, J.C. (1988). Common psychological
themes in societies’ reaction to terrorism and
disasters. Military Medicine, 153, 387-390.
Fischer-Homberger, E. Die Traumatische
Neurose: von somatishen zum sozialen Leiden.
Bern: H. Number 1975.

Fraser, R., Leslie, I.M.and Phelps,D. (1942/43)
Psychiatric effects of severe personal experi­
ences during bombing. Proceedings of the
Royal Society of Medicine. 36, 119-123.
Frederick, C.J. (1981). Violence and disasters:
Immediate and long-term consequences. In:
Helping Victims of Violence. Proceedings ofa
WHO Working Group on the Psychosocial
Consequences of Violence. The Hague, 6-10
April 1981, pp. 32-46.

Goldberg, D. & Bridges, K. (1988). Somatic
presentation of psychiatric illness in primary
care settings. Joumai of Psychosomatic Re­
search, 32, 137-144.
Green, B.L. (1982). Assessing levels of psycho­
logical impairment following disaster. Jour­
nal ofNervous and Mental Disease. 170,544552.

Ignacio, L.L., De Arango, M.V., Baltazar, J.,
D’Arrigo Busnello, E., Climent, C.E.,
Elkahim, A., Giel, R., Harding, T.W., Ten
Hom, G.H.M.M., Ibrahim, H.H. A., Srinivasa
Murthy, R.& Wig, N.N. (1989). Knowledge
and attitudes of primary health care person­
nel concerning mental health problems in
developing countries: A follow-up study.
Intemationai joumai of Epidemiology, 18,
669-673.
Korver, A.J.H. (1987). What is a disaster?
Prehospital and Disaster Medicine, 2, 152153.

Lechat, M.F. (1990). The International Decade
for Natural Disaster Reduction: Background
and Objectives. Disasters. Volume 14, Num­
ber 1.
Lima, B.R. (1986). Primary mental health care
for disaster victims in developing countries.
Disasters, 10, 203-204.

Lindemann, E. (1944). Symptomatology and
management of acute grief. American Journal
of Psychiatry. 101, 141-148.
Manni, C.& Magalini, S. (1989). Disaster medi­
cine: A new discipline or a new approach?
Prehospital and Disaster Medicine, 4, 167170.

Perry, R.W. & Lindell, M.K. (1978). The psy­
chological consequences of natural disaster:
A review of research on American communi­
ties. Mass Emergencies, 3, 105-115.

23

-I:'

1
PSYCHOSOCIAL CONSEQUENCES OF DISASTERS: PREVENTION AND MANAGEMENT

Poumadere, M. (1990). The credibility crisis. In
B. Segerstahl & G. Kromer (eds.), Chernobyl
and Europe: A Policy Response Study, Berlin:
Springer.
Quarantelli, E.L. (1980). Sociology and social
pathology of disasters: Implications for Third
World and developing countries. Disaster Re­
search Center, The Ohio State University.
Paper prepared for presentation at the 9th
World Civil Defense Conference in Rabat,
Morocco, 5 November 1980.

Radjak, Abdul et al. WHO Indonesia. Inter­
regional workshop on disaster preparedness
and health management. WHO/Ministry of
Health Indonesia, Jakarta, 1987.
Raphael, B. (1986). When Disaster Strikes.
Hutchinson, London

Ross, G.A. and Quarantelli, E.L. (1976). Deliv­
ery of mental health services in disasters: The
Xenia tornado and some implications. The
Ohio State University: The Disaster Research
Center Book and Monograph Series.
Rubonis, A.V. and Bickman, L. (1991). Psycho­
logical Impairment in the Wake of Disaster:
The Disaster-Psychopathology Relationship.
Psychological Bulletin. 109.(3), 384-399.

Schwarz, Robert Flood forecasting and warn­
ing: the social value and use ofinformation in
West Bengal. 1981. Geneva: UN Research
Institute for Social Development.
Solomon, S.D., Gerrity, E.T. and Muff, A.M.
(1992). Efficacy of Treatments for Posttraumatic Stress Disorder — An Empirical Re­
view. Journal of the American Medical Asso­
ciation, 268(5), 633-638.

StierlinE. (1909). Uberpsycho-neuropathischen
Folgezustande bei den Uberlebenden der
Katastrophe von Courrieres an 10 Marz 1906.
Zurich: Universitat Zurich. 139 pp. Disserta­
tion.
United Nations Disaster Relief Co-ordinator
(UNDRO) (1984). Disaster Prevention and
Mitigation, Vol. II: Preparedness Aspects. New
York: United Nations.

24
-

.

UNICEF, Assisting in Emergencies, UNICEF,
1986, New York.

Ursano, R.J. (1987). Posttraumatic stress disor­
der: the stressor criterion. Journal ofNervous
and Mental Disease. 175,273-275.

Weisaeth, L. (1989). A study of behavioural
responses to an industrial disaster. Acta
Psychiatrica Scandinavica. Suppl. 355,80,1324.
WHO, ICRC (1989). Coping with natural di­
sasters: the role of local health personnel and
the community. Geneva, WHO.

World Health Organization (1987). Eight Gen­
eral Programme of Work, covering the period
1990-1995. Geneva: World Health Organi­
zation.
World Health Organization (1989a). Interna­
tional Decadefor Natural Disaster Reduction
1990-2000 (IDNDR). Geneva: PCO/EPR/
89.1.

World Health Organization (1989b). Resolu­
tion on the International Decade for Natural
Disaster Reduction. Geneva: A/44/832/Add.l.
World Health Organization (1992). ICD-10 The
ICD-10 Classification of Mental and
Behavioural Disorders: Clinical descriptions
and diagnostic guidelines, World Health Or­
ganization, Geneva.

The following have also been published by the
United States National Institute of Mental
Health (NIMH)

NIMH (1981). Manualfor Child health Work­
ers in Major Disasters.
NIMH (1984). Disasters and Mental Health: An
Annotated Bibliography.
NIMH (1985). Disaster and Mental Health:
Selected Contemporary Perspectives.
NIMH (1985). Innovations in Mental Health
Services to Disaster Victims.

Dm 6-s"

Mm. Htaith, VoL 1?, No. 2, pp. 30-35
M. B. Sharpe, In<^, 1990

R. Srinivasa Murthy

Bhopal
On the night of 2/3 December, 1984, about 40 tons of methyl iso cyanate (MIC)
from tank 610 of the Union Carbide India Limited factory at Bhopal (central India)
leaked into the surrounding environment. Diis leak of an “extremely hazardous
chemical, which occurred over a short span of a few hours, covered the city of
hopa! in a cloud of poisonous gas Following the gas leakage, at around midnight,
people living in die direction of the gas leakage woke up with feelings of suffocation, intense irritation, and vomiting.
Initially most people thought that a neighbor had “burnt chillies.” However as
they realized the real cause of their symptoms, panic struck the population. People
ran to escape from the gas, often without concern for their famdy members. Many
died on the spot; others fell while running to escape; and many others reached safe
places only after hours of running. The number of dead has been estimated to be
around 2,500 Of the tn!3i population of n^pg!
7 millicn), abOu. 0.3
were exposed to the poisonous gas [1].
The Bhopal disaster is of importance in the relevant literature for a number of
reasons. First, it is one of the largest man-made disasters in a developing country
a
effeCtS Were 3 combin^on of both the chemical substances
inhaled and the psychological effects. Third, no formal mental health infrastructure
was available to provide postdisaster mental health care, and this led to the develop­
ment of innovative approaches to care. Fourth, this disaster has been the subject of
h^thv^e^Xi^01 CrOSS’SeCtionally and longitudinally, from physical and mental

-

This report deals with the magnitude of the mental health problems and the
mechanisms developed to provide mental health care.
Magnitude of the mental health problems

Information is available about the mental health problems from a number of
sources. The initial assessments were made in the first week of February 1985 I
(about eight weeks after the disaster) by Professor R. Srinivasa Murthy, of the
National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore
and Professor B. B. Sethi, of K. G. Medical Coliegee (KGMC), Lucknow. Their
observations, over a week’s time, were based on visits to affected people at home '
charge
and]I“d of the Department of Psychiatry and officer in
wLte of
l,H
Adv“ced Research on Community Mental Health, National
te of Mental Health and Neuro Sciences, Post Bag No. 2900, Bangalore, 560 029, India.

30

BHOPAL

31

and examinations of those attending the medical facilities. These initial observations
placed the magnitude at 50% of those in the community and about 20% of those
attending medical facilities [1].
Following these observations, systematic studies were carried out by a KGMC
team [2J. As a first step, ten general medical clinics in the disaster-affected area
were chosen. A team consisting of a psychiatrist, a clinical psychologist, and a
social worker visited one clinic a day, by rotation in a randomized fashion, on three
occasions and screened all the newly registered adult patients with the help of a
self-reporting questionnaire (SRQ) [3]. Subjects identified as probable psychiatric
patients were then evaluated in detail by the psychiatrist with the help of a standard­
ized psychiatric interview, the Present State Examination (PSE) [4]. Clinical diag­
noses were based on the International Classification of Diseases (9th revision)
(ICD-9).
During a period of 3 months (February-May 1985), of the 855 patients screened
at the 10 clinics, 259 were identified, on the basis of their SRQ scores, as having a
mental disorder. Of these potentially mentally ill people, 44 could not be evaluated,
and 215 were given the PSE. The final number of psychiatric patients was 193,
yielding a prevalence rate of 22.6%. Most of the patients were females (81.1%)
under 45 years of age (74%). The main diagnostic categories were anxiety neurosis
(25%), depressive neurosis (37%), adjustment reaction with prolonged depression
(20%), and adjustment reaction with predominant disturbance of emotions (16%).
Cases of psychosis were rare, and they were not related to the disaster.
Subsequently, the same team conducted a detailed community-level epidemio­
logical study, beginning in June 1986. The results of the first-year survey involved
4,098 adults from 1,201 households. A total of 387 patients were diagnosed to be
suffering from mental disorders, giving a prevalence rate of 94/1,000 population.
Most of the population consisted of females (71%); 83% were in the age group
16-45 years. Ninety-four percent of the patients received a diagnosis of neurosis
(neurotic depression, 51%; anxiety state, 41%; and hysteria, 2%) and had a temporal
correlation with the disaster [1]. For the last three years, the KGMC team has
repeated annual surveys and follow-up of the initial patients identified by the com­
munity survey. Detailed case vignettes and descriptive accounts of the patients from
the Bhopal disaster are also available [11.
Training in mental health care

The initial visit of two psychiatrists eight weeks after the disaster revealed a large
number of people with emotional reactions and a lack of mental health services to
care for them. The team therefore recommended rapid organization of mental health
services utilizing the existing medical personnel.
In April 1985, a second visit was made to develop a training program, including
instructional audio and video materials, and to finalize the arrangements for the
training. The actual training was given from 22 April to 4 May 1985.
About fifty medical officers were working in the various health facilities in the

32

R. SRINIVASA MURTHY
BHOPAL

of
/
re d hiaa
““ “no
u uan,,
"« ,n
training
in menlaJ
mental neaJU
health’ as
r~ pan
~
of then imtiid medical education, and this was reflected in their poor perception ofi
reflected
in
their
poor
perception
emottonai needs of the disaster victims. The basic orientatioZ Ed“torc
the vie8 th medl“ybl01°8ical- In pretraining interviews, most of them expressed!
the v ew that distribution of monetary compensation would solve the physicid com
te were the reason for the weaknesses and inability to work of whica mostl
natienK
The medical officers believed that the “lethargy” of their|
Sr?
‘o medical care or the use of t^gs, bm by
PPlng the distribution of free ratioi^ and compensation money
' i
The basic aim of the training was to enhance the sensitivity of the medical I
fleers to their patients’ emotional needs and their skill in recognizing diagnosing I
period^nn rrT^ng
required) P^16 with mental health problems The!
T'"8
WOfking
11 was decided ‘hat the uainingl
should be as practical as possible, and should be imparted to groups consisting of no I
more than twenty persons. The training methods took into ZunTpriSJ ofl
fr
T™1’?’ • VIZ ’ an Open ieam'ng environment in which participant; were!
free to share their needs and experiences, with considerable stress on interactive!
^r,ng' d predomlnantly lecture approach was changed to one consisting of case!
feet rT an .^“P discussions> facilitated by audiovisual, taped material of the af I
fected population, with maximum learner involvement [5]
I

Rich morning, the two faculty members visited the different health facilities and I

by the medical officers, 38 of whom took pan in the training

~

I

1

quainted with each other. The tramee doctors were asked to share their expectations 1

1M

” 8i”!

“ ■“■tom'itos I

ot noma! and abnormal behavior. Patients with different symptoms and presenta I

wercoXSr Vla VldeOtaPeS- TyPeS' featUreS’ and Causes of mental d'ne'sses I
3: DiaCUSsi0n cenlered 011 to approach to patients with emotional distur I
SliTf° ri"8 eJ,“StOry of Such Patients- “d the mental examination Winter-1
Dav 1 i
W3S facilitated audiotaped and videotaped interviews I
D y 4‘
sesslon was considered to be a crucial one, as the problems faca 1 bv I
the trainee doctors daily in their outpatient clinics were discussed The training I
during the first three days provided the basic background required to understand th! I
psychological nature of many of the patients’ complaints. Various clinical presenta-1

•'.n'.i *> ■

tions of the gas-affected patients were discussed. In this session all the audio and *<.
video material used pertained to the patients seen in the various clinics in Bhopal.
Since the emotional reactions of people to disasters, irrespective of the nature of
the disaster or where it occurs, follow a similar pattern, some of the classic docu­
ments on psychological sequelae of disasters were reviewed and discussed. Many
children were brought for consultation for various kinds of compliants, and some
time was therefore devoted to discussion of the emotional reactions of children to
sudden, severe stress. Many interviews with children, both on audiotape and video­
tape, were presented.
.. I
■. i
Assessment of people with varying degrees of physical disability due to proven
gas-related physical illnesses (such as fibrosis of the lungs) posed a problem for
many doctors; hence, emotional responses to physical disability and chronic physi­
cal illnesses were covered. The availability of patients (on videotape) from the local
clinics for discussion greatly enhanced the interest and involvement of the partici­
pants. The emotional dimension of patients’ complaints was completely new to
most of the participant doctors.
Day 5: By the 5th day of training, most of the participants were able to recognize
and appreciate the emotional disturbances in a great many of the patients attending
their clinics. The participants were able to elicit, in many patients, various mental/emotional symptoms. At this stage of training, we considered it appropriate to
discuss the approaches to management of such patients. This session therefore
emphasized the importance of psychological management.
After an initial introduction by the faculty, the session proceeded with a role-play
exercise in which interviewing a patient was simulated. The basic principles of
psychological management, the importance of appropriate interview techniques in
establishing a satisfactory doctor-patient relationship, and the methods of reassur­
ance, suggestion, and psychological help were discussed. Audio recordings of psy­
chotherapy by the faculty with some of the local patients were used to illustrate the
techniques.
Day 6: During the last session, pharmacological management and other ap­
proaches to patient care were covered. A good part of the time was taken up by
discussion of “implementation of the mental health care program” among the
affected population in Bhopal. The last 30 minutes were devoted to obtaining post­
training responses from the participants.
Some of the comments of the participants in the post-training evaluation con­
firmed the utility of the training. Most of them felt that with this training, they
would be able to provide much more help to patients with mental illness and to
others with physical problems as well. Some doctors confessed that earlier they had
been accustomed to giving their patients only symptomatic treatment, but that after
the training, they were able to consider and diagnose conditions also in terms of a
psychiatric approach. Some mentioned that they had not been aware of any mental
problems and had thought that patients were malingering and presenting vague
symptoms to evoke a sympathetic response and get more medicines. All the doctors
who took part in the training agreed that there were needs for privacy for interviews.

34

R. SRINIVASA MURTHY

BHOPAL

support from a psychiatrist for difficult cases, and psychotropic drugs.

Discussion
The studies of the Bhopal disaster population illustrate both the needs for mental
health care and the scope for utilizing existing resources. In most developing coun­
tries, formal mental health resources are extremely limited, and the focus has to be
on mcluding mental health components in the training of the “helping groups”
working with a disaster population.
Kinston & Rosser [6] in 1974 expressed the view that the general field of inquiry
in m y enc°mpassed by the tenn disaster has not yet found an established position
m die psyctuatnc canon. There seem to be theoretical, practical, and emotional
reasons for this. The situation has been gradually changing in the last 15 years
There ts a vast literature on the mental health aspects of disasters [7], but experience
Pinf C0Un‘n.ef iS limited (8’9]- StiU mQre Umited is experience in ink­
ing to provide mental health care by utilizing the resources available
The Bhopal disaster, being a major man-made disaster, provides an opportm ity
fn sU h rSn n g me
devel°Ping culture-specific interventions
in sucn situauons.
I
Acknowledgment
MperiirniTntlOn h rTam WaS undertaken widl 1(16 support of the Indian Council of

Nr7™^yC’Dir^0^

References
!S,|!

I

1. Srinivasa Murthy, R„ Isaac, M.K., Chandrashekar, C.R., & Bhide A (19R71

bSo^'tcMRCct'^ °f
patit^atendin;

-?

he^hvcaref°r
TT*’ IK‘’ &

Sf, M5.S m gaS

(ICMr’-ACMH, nL zj
H' (1987) Psychiatric morbidity in

m BhOpaL ,ndian lournal ofM^Re-

j 3- Harding, T\W DeArango, M.V., Battazar, I, Climent, C.E., Ibrahim, H.HA Ignacio
smdi o^X
y’ R alWig’ N N-(198O) Mental dis°rd(« “ P^n^y heali c^ t
10/231.
frequency and dll>gn°sis m four developing countries. Psychological Medicine.
5

! .

4

J K; CoOpcr-J E-* Sartorius, N. (1974) The measurement and classdication of
psychiatric symptoms. London: Cambridge University Press
viciL^T
R7.
ISaaC’ M K’ (1987)
health needs of Bhopal disaster
rXmSIp 5L
°
" mental heallh aSpeCtS- ,ndian Jo-rJof Medical

35

6. Kinston, W., & Rosser, R. (1974) Disaster Effects on mental and physical state.
Journal ofPsychosomatic Research, 18,437.
7. National Institute of Mental Health (1984) Disaster and menial health: An annotated
bibliography (DHSS Publication No. [ADM] 84—1311). U.S. Department of Heidth, Educa­
tion. and Welfare. Rockville, MD: ADAMHA. [See pp. 87-88 of Vol. 19, No. 1, of this
journal.)
8. Narayanan, H.S., Sathyavathi, K., Nardev, G., & Thakrar, S. (1987) Gref reactions
among bereaved relatives following a fire disaster in a circus. NIMHANS Journal, 5, 13.
9. Lima, B.R., Pai, S., Santacruz, H., Lozano, J., & Leena, J. (1987) Screening for the
psychological consequences of a major disaster in a developing country. Armero, Colombia.
Acta Psychiatrica Scandinavica, 76, 561.

Mcrt. Htahh, Vol 19, No. 2, pp. 30-15
M. B. Sharpe, Inc, 1990

R. Srinivasa Murthy

Bhopal
On the night of 2/3 December, 1984, about 40 tons of methyl iso cyanate (MIC)
from tank 610 of the Union Carbide India Limited factory at Bhopal (central India)
leaked into the surrounding environment. This leak of an “extremely hazardous
chemical,“ which occurred over a short span of a few hours, covered the city of
Bhopal m a cloud of poisonous gas. Following the gas leakage, at around midnight,
people living in the direction of the gas leakage woke up with feelings of suffoca­
tion, intense irritation, and vomiting.
Initially most people thought that a neighbor had “burnt chillies.” However as
they realized the real cause of their symptoms, panic stnick the population. People
ran to escape from the gas, often without concern for their family members. Many
died on the spot; others fell while running to escape; and many others reached safe
p aces only after hours of running. The number of dead has been estimated to be
amund 2;5OO Of the ?0»al populsdon of Bhopal (0.7 .millicn), about 0.3 million
were exposed to the poisonous gas [1].
The Bhopal disaster is of importance in the relevant literature for a number of
reasons. First, it is one of the largest man-made disasters in a developing country.
Second, the disaster effects were a combination of both the chemical substances
inhaled and the psychological effects. Third, no formal mental health infrastructure
was available to provide postdisaster mental health care, and this led to the develop­
ment of innovative approaches to care. Fourth, this disaster has been the subject of
intense study, both cross-sectionally and longitudinally, from physical and mental
health viewpoints.
'Hus report deals with die magnitude of the mental health problems and the !
mechanisms developed to provide mental health care.

Magnitude of the mental health problems

Information is available about the mental health problems from a number of
sources. The initial assessments were made in the first week of February 1985
(about eight weeks after the disaster) by Professor R. Srinivasa Murthy, of the
National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore
and Professor B. B. Sethi, of K. G. Medical Coliegee (KGMC), Lucknow. ITiefr
observations, over a week’s time, were based on visits to affected people at home
Dr. Snmvasa Murthy is Professor and Head of the Department of Psychiatry and officer in
^tateof M
H
f°5rAdvanced Research on Community Mental Jfcalth. National
Institute of Mental Health and Meuro Sciences, Post Bag No. 2900, Bangalore, 560 029 India.

30

BHOPAL

31

and examinations of those attending the medical facilities. These initial observations
placed the magmtude at 50% of those in the community and about 20% of those
attending medical facilities [1].
Following these observations, systematic studies were carried out by a KGMC
team [2]. As a first step, ten general medical clinics in the disaster-affected area
were chosen. A team consisting of a psychiatrist, a clinical psychologist, and a
social worker visited one clinic a day, by rotation in a randomized fashion, on three
occasions and screened all the newly registered adult patients with the help of a
self-reporting questionnaire (SRQ) [3]. Subjects identified as probable psychiatric
patients were then evaluated in detail by the psychiatrist with the help of a standard­
ized psychiatric interview, the Present State Examination (PSE) [4]. Clinical diag­
noses were based on the International Classification of Diseases (9th revision)
(ICD-9).
During a period of 3 months (February-May 1985), of the 855 patients screened
at the 10 clinics, 259 were identified, on the basis of their SRQ scores, as having a
mental disorder. Of these potentially mentally ill people, 44 could not be evaluated,
and 215 were given the PSE. The final number of psychiatric patients was 193,
yielding a prevalence rate of 22.6%. Most of the patients were females (81.1%)
under 45 years of age (74%). The main diagnostic categories were anxiety neurosis
(25%), depressive neurosis (37%), adjustment reaction with prolonged depression
(20%), and adjustment reaction with predominant disturbance of emotions (16%).
Cases of psychosis were rare, and they were not related to the disaster.
Subsequently, the same team conducted a detailed community-level epidemio­
logical study, beginning in June 1986. The results of the fiist-year survey involved
4,098 adults from 1,201 households. A total of 387 patients were diagnosed to be
suffering from mental disorders, giving a prevalence rate of 94/1,000 population.
Most of die population consisted of females (71%); 83% were in the age group
16-45 years. Ninety-four percent of the patients received a diagnosis of neurosis
(neurotic depression, 51%; anxiety state, 41%; and hysteria, 2%) and had a temporal
correlation with the disaster [1], For the last three years, the KGMC team has
repeated annual surveys and follow-up of the initial patients identified by the com­
munity survey. Detailed case vignettes and descriptive accounts of the patients from
the Bhopal disaster are also available [1].

Training in mental health care
The initial visit of two psychiatrists eight weeks after the disaster revealed a large
number of people with emotional reactions and a lack of mental health services to
care for them. The team therefore recommended rapid organization of mental health
services utilizing the existing medical personnel.
In April 1985, a second visit was made to develop a training program, including
■nstructionai audio and video materials, and to finalize the arrangements for the
‘raining. The actual training was given from 22 April to 4 May 1985.
About fifty medical officers were working in the various health facilities in the

•

i.

I

'

. .

i

32

R. SRINIVASA MURTHY

I

BHOPAL

the view tha distnbution of monetary compensation would solve the physical comp^mu of many of their patients. Some thought that the free rations provLec by the
Stete were the reason for the weaknesses and inability to work of which most
patients complained. The medical officers believed that the “lethargy” of their
patients would disappear not thanks to medical care or the use of Jugs, but by
stoppmg the distribution of free rations and compensation money
Hie baste aim of the training was to enhance the sensitivity of the medical
cers to their patients’ emotional needs and their skill in recognizing, diagnosing I
Sri^ d re.fcrrlng (when ^uired) people with mental health problems The’l
ttaiT,ng WaS Sk W°rking days' 11 was decide£l that the training]
more th™ nTT “ P0'Sh°Uld imparted 10 S™?5 “ting of no I
“d tJt
» Persons. The training methods took into account principles of]
TnUnf’ ■ V1Z” 3n Open ieamin8 environment in which participant were!
free to share their needs and experiences, with considerable stress on interactive]
studiei8and predom.lnantly lecture aPProach
changed to one consisting of case]
studies and group discussions, facilitated by audiovisual, taped material of the af I
fected population, with maximum learner involvement [5],
]
A
traininS
°Ut *" two 8rouPs by two consultant psychiatrists fl

wom
sx*
frl,y “"bers v“““'I
worked with the medical officers tn order to help them learn interview techniques I

and counseling methods. This “hands-on” experience was considered very tX I
by the medical officers, 38 of whom took part in the training.
I
Day 1: The mam objectives of the first session were to form the group facihtate I
interaction of the faculty and the participants, and enable all to bL™ well ac I
quainted with each other. The tramee doctors were asked to share their expectations I
“Hung the program. Hie pretraining views of all the doctors were obtmmcd on a I
structured response sheet.
1
Day 2: The aim of the second session was to give the doctors an understanding I
of normal and abnormal behavior. Patients with different symptoms and pres.mta8 I
wereoTtlin^ " V‘a V‘deOtapeS- Types’ features’ “d “uses of mental illnesses I
D*®CUSS1°n centered °n the approach to patients with emotional distur- |
°f SUCh PadentS’ and the mentaJ “amination (inter- I
Z, 1 ™
W3S facilitaled by audiotaped and videotaped interviews. I
the rJ- ’
sessl°n.ya! considered to be a crucial one, as the problems faced by fl
dnrinTth rd0C^re d*,ly In thelr outpatient clinics were discussed. The training fl
Stnl
?S Pr0Vided the baSiC background required to underatand the fl
psychological nature of many of the patients’ complaints. Various clinical presenta-1
•I

I

u.
■r

33

tions of the gas-affected patients were discussed. In this session all the audio and
video material used pertained to the patients seen in the various clinics in Bhopal.
Since the emotional reactions of people to disasters, irrespective of the nature of
the disaster or where it occurs, follow a similar pattern, some of the classic docu­
ments on psychological sequelae of disasters were reviewed and discussed. Many
children were brought for consultation for various kinds of compliants, and some
time was therefore devoted to discussion of the emotional reactions of children to
sudden, severe stress. Many interviews with children, both on audiotape and video­
tape, were presented.
Assessment of people with varying degrees of physical disability due to proven
gas-related physical illnesses (such as fibrosis of the lungs) posed a problem for
many doctors; hence, emotional responses to physical disability and chronic physi­
cal illnesses were covered. The availability of patients (on videotape) from the local
clinics for discussion greatly enhanced the interest and involvement of the partici­
pants. The emotional dimension of patients’ complaints was completely new to
most of the participant doctors.
Day 5: By the 5lh day of training, most of the participants were able to recognize
and appreciate the emotional disturbances in a great many of the patients attending
their clinics. The participants were able to elicit, in many patients, various mental/emotional symptoms. At this stage of training, we considered it appropriate to
discuss the approaches to management of such
This session therefore
emphasized the importance of psychological management.
After an initial introduction by the faculty, the session proceeded with a role-play
exercise in which interviewing a patient was simulated. The basic principles of
psychological management, the importance of appropriate interview techniques in
establishing a satisfactory doctor-patient relationship, and the methods of reassur­
ance, suggestion, and psychological help were discussed. Audio recordings of psy­
chotherapy by the faculty with some of the local patients were used to illustrate the
techniques.
Day 6: During the last session, pharmacological management and other ap­
proaches to patient care were covered. A good part of the time was taken up by
discussion of “implementation of the mental health care program” among the
affected population in Bhopal. The last 30 minutes were devoted to obtaining post­
training responses from the participants.
Some of the comments of the participants in the post-training evaluation con­
firmed the utility of the training. Most of them felt that with this training, they
would be able to provide much more help to patients with mental illness and to
others with physical problems as well. Some doctors confessed that earlier they had
been accustomed to giving their patients only symptomatic treatment, but that after
the training, they were able to consider and diagnose conditions also in terms of a
psychiatric approach. Some mentioned that they had not been aware of any mental
problems and had thought that patients were malingering and presenting vague
symptoms to evoke a sympathetic response and get more medicines. All the doctors
who took part in the training agreed that there were needs for privacy for interviews,

d

I
34

R. SRINIVASA MURTHY

BHOPAL

support from a psychiatrist for difficult cases, and psychotropic drugs.
Discussion

The studies of the Bhopal disaster population illustrate both the needs for mental
health care and the scope for utilizing existing resources. In most developing coun­
tries, formal mental health resources are extremely Umited, and the focus has to be
on melading mental health components in the training of the “helping groups”
working with a disaster population.
Kinston & Rosser [6] in 1974 expressed the view that the general field of inquiry
oosely encompassed by the term disaster has not yet found an established posiiion
m Oie psychiatric canon. There seem to be theoretical, practical, and emotional
reasons for this. The situation has been gradually changing in the last 15 years
There is a vast literature on the mental health aspects of disasters [7], but experience
from developing countries is limited [8,9], Still more limited is experience in intefvening to provide mental health care by utilizing the resources available.
for a f°P^dlSaSter’ being 3 maj0r man-made disaster, provides an opportunity
S suchsiSt^ me
health
and devel0ping cultoe-specific interventions

Acknowledgment

Merf;rn?TntlOn fr°Janl was undertaken with d16 support of the Indian Council of
Narayana Sy, Dir^

References

i
r ■

1. Srinivasa Murthy, R„ Isaac, M.K.. Chandrashekar, C.R & Bhide A I1QR71 T,,
°f
healJhV
mediCal Off‘CerS dCMR’-ACMH No5l).

patiCTte^Jdin’’ Sl— M” T^Cdi- IK- & Singh- H- (1987) Psychiatric morbidity in

S^18,M5S ln 8aS

Bh°Pal-

lournal

3. Harding, T W DeArango, M.V., Battazar, J., Climent, C.E., Ibrahim, H.HA Ignacio
hh; ^VaslMurthy- R- & Wig’ N N- (198O> Mental disord^ in PriX health c^ \ i
smd^of their frequency and diagnosis in four developing countries. P^hZgic^Medici, i

I

„JJ8, JK; CoTr-JE- & Sartodus, N. (1974) The measurement and classification of
psychtalrtc symptoms. London: Cambridge University Press
massgteanon of 3
vicrimfZ^’ Murthry'
& Isaac’ M K- (1987) Mental heal,h neetis Of Bhopal disasttr

rXmS..°p 5L

OffiCerS " mental health aSPeCtS'

Jo^f^icol I

35

6. Kinston, W., & Rosser, R. (1974) Disaster Effects on mental and physical state.
Journal ofPsychosomatic Research, 18,437.
7. National Institute of Mental Health (1984) Disaster and mental health: /In annotated
bibliography (DHSS Publication No. [ADM] 84-1311). U.S. Department of Health, Educa­
tion, and Welfare. Rockville, MD: ADAMHA. [See pp. 87-88 of Vol. 19, No. 1, of this
journal.]
8. Narayanan, H.S., Sathyavathi, K., Nardev, G., & Thakrar, S. (1987) Grief reactions
among bereaved relatives following a fire disaster in a circus. NIMHANS Journal, 5,13.
9. Lima, B.R., Pai, S., Santacruz, H., Lozano, J., & Leena, J. (1987) Screening for the
psychological consequences of a major disaster in a developing country. Armero, Colombia.
Acta Psychiatrica Scandinavica, 76, 561.

4

A PILOT PSYCHIATRIC STUDY OF CHILDREN (0-15yr) EXPOSED TO MIC AT BHOPAL.
Deportment of Psychiatry, K.G’s. Medicol College, Lucknow.
FART I-A
PSYCHIATRIC SYMPTOM SCREENING SCHEDULE

Date of study
1.

Serial No 'of study (23

SI. No.

)

Name of Children

i'

2.

Serial No of Family I

|!

Age

Sex

](

|l

I!

| 3.

Fathers Name
Symptom Number present

1.
2.
3.
4.

5.
6.

7.

8.
9.

10.
* — This symptom is not to lie rated below six years of age.
** — This symptom is not to be rated below four years of age.

*** — This symptom is not to be rated below three years of age.

0
3

i

PSYCHIATRIC SYMPTOM SCREENING SCHEDULE

1.

Mental retardation

14.

Irritability

2.

Delayed poor development of speech

15.

Depressed

*3.

Scholastic backwardness

16.

Fit

4.

Disobedient / Stubborn

17.

Headache

5.

Temper tantrum

18.

Disturbed Sleep

6.

Aggressive

♦ 19.

Gross neglect of personal hygniene

7.

Bullies other children

20.

Irrelevant talk

21.

Talks to himself

*22.

Laugh without reason

*8.

Wandering
*9. Truancy school/home; Inregular to School.

♦**10.

Inattention / Distractibility

♦ 23.

Cries without reason

***11.

Overactivily

24.

Hallucination

**12.

Enuresis I Encopresis

25.

Preoccupation with self

13.

Nervous / Anxious

26.

Any other problem.

PRESSTO

1

✓

313 H 33ICIH c^s did 3Iin&
®T fijJTiafl (wlgoft)
f<b 55IH a dfff din 3Jiq^ fdwt drd jj t ?
S. Noof child

Symptom and suggested
Probe

1. Mental Retardation : below
average Intelligence.
sth
are H | ?
2.

Delayed/poor development
of speech.
SUT’PT
atqsft

gHHT Si W*T!Kt

ihf 'Urn

I?
* 3. Scholastic backwardness.
wm
^?tf Jr

fq^t fsn | (w Jr
a HTvf ?

4.

«

Disobedient/Stubborn.
^IT STTR^T
fent
5TH

SreHT
mHiTT t,

fs; mm mr^ mt ?
sn^mr mtf
shht
mT'Et fas mw
ssmt
HHHTm-HHmT 3JSHT HHTJ

gfrmHf

t?

TO <51 |, ®TOI
_________________
Example

Dura­ Fre­
tion quency

Absent/
Present

Remarks

S. No.
of child

Symptom and suggested
Probe

5. Temper tantrums.
’TT

JR

33HT | ?

<TT

vfH ST

rTE

6.

I

Aggressive
STT’T^T

sFisft

3TSHT

snnr

ST

fvTlT SSTT T^cTT | ?

7.

Bullies other children
^sr sns^T

anssT

3TT^ Tt

sfrt

HSTcU

I ST q^TTS STTai t ?

*8. Wandering
^TT STTS^T

*9.

qqF SfS^

ST

fast

Tt

fast

STS^ SSST T^cTT | ?

Truancy : School/home or
Irregular to school
^ST STTSWiT

S^T

^TTS^T (sfsa)

fsST
%

ST

ST FF^T

STS 3TTST | ?

^ST

^HT

STT H 3Tfs^

Example

Fre­
Dura­
tion quency

Absent/
Present

Remarks

MEh lb atfe fekk |H>bJ It £
ifeifej It lib± ^hK ^fefe IfetJ

UfebllS IHhK 1th
sisaidooug/sisainaug

Ifeit

71**

‘1^

JtJ

HUlltti Ih |
'iJB 1± mj

ib

Ituy lEH

ShlL
lb £11£
‘ybte ‘I l^^i

IPU>»X iUlMbi ‘I lUSteH

2JS

lifefe |!hllh

‘Jbk ih

IHhK Ifeab |yb UhblK Ihte
XiiAporisAO

II***

il ante

2JE b yais

H1® l2^

felts 1±H£ fa felijb $
%
hub <feb mij ibbts ibfe i I

Ifelb liifei jib Hfelhb hty
(2fetaJ° b-X l>) itbj bbH sS
felts IfehK U HlSte ih lb. yi±J
Ih^P iJi lihlls ifebK Ifeb
XiniqTjopiJsip/uouusnBui
i I lfell£ l£fe

01***

<£ St:b

( fefeje ) Jbblls JHSjJ IfebJ itteK
Ifeafe
UbhlK 1th i I Ibsj

s^ieuuay

xuesajj
/luasqv

Aouanb

uoh

-ajj

-ejn'a

aidiuexg

Pliqa jo
°N S

oqojj

paisaBBns pue tuoidiuAg

I

/ .

S. No
of child

Symptom and suggested
Probe

m qraiHT

13.

14.

??TT I ?

Nervous, Anxious
tot sn<TTO

fapn farrft

n

TTOT fan T^cTT

?

sttot

Irritability
rqt sn'T^T

s^t

arta'f st

ftrsR-n

sn<n | ?

15.

16.

Depressed
TOT 3TTOTO

^TOT 3TTOT

TOfSt 35TH

| ?

Fits
auq^t
strat | ?

17.

arermwr
tot

jte% stIt

sntt | ?

Headache
tot STTTTO

S^T

3TTOT

TO'Ti't HT TO TO farfTOtf tfiTHT

JHTt 3tWT f^TTT
(faTOHT)
TO
| ?
18.

% fax it SFTqtf

Disturbed sleep
TOT ST^TTT STfqTO sptf SFSWT
f^T fTOft

(nrdfx^)

Exampie

Dura­ Fre­
tion quency

~
/
Absent/
Present

Remarks

S. No.
of child

Symptom and suggested
Probe

a^sffe at afea
ma Si afe & at a^f arai
| ? (^a atax |
a<t atai) ?

*19.

st

feeja

Gross neglect of Personal
hygiene
tot snaTO a?tf a^at a^ar
fear feat to 5 st Tfet n?<T
Tgai
aaat aanf
afa
a?tf TOta a^r £ai | ?

20. Irrelevant talk
tot

feat
^t
ara
^t ^tat | fea^r
aaara a^f fe^rai ?

2b Talks to himself without
any obvious reason
am anaaa aftf a^ar sraar

fear feat
aia a^at T^ar ?

snait

*22. Laugh without any obvious
reason

Shi fent
*23.

|?

Exclude Mental Retardation
Cries without any obvious
reason.

Example

Dura­ Fre­
tion quency

Absent/
Present

Remarks

S. No.
of child

Symptom and suggested
Probe

3^t

snt

fam

Dura­ Fre­
tion quency

Example

It Ttat | ?

24. Hallucinations
mit StT'TFt Ttf ar^t

fa stuta H
crni ut srg^at

5

arfaig
f (aft

farft sffa aft
|) afa
fa ^ft fant
aft atan m
fmarf t, ur artf snant
gmf I ? am snaatt aftf 4^t
a^m | far tjft fadt
art
am
’tt
ut artf
fata m faat
^tm | ?
25

Preoccupation with self

am snaart artf
srqa ana
£t fatm T^en <aat far g-nart
arfa 3tTH-atH ar tftaf
artf
Hmaa a$t T^at ?
26. Any other problem

artf sffa ^rre mtt (famt
mgfat ma art
atfuar st,
faat rrar ^at^art aa a atrma snat ar faat qa> arta art
mr-STT shRtar ar afar aai
aft araa fa as arta
ar sart at^rr^ ft aftf arram
a^t i? affa a^ faaiT ar arta
a^ araat aaff faare azar
11 ar^TH ft aarst ata, ^artarar arffa lr faftt sfa an
f^aar at arsarat i

r

Absent/
Present

Remarks

Poyehasooial Aroojrm-juL of
Mar a I hwadu Eaxl bhquake 7 i e Ilins

Ka Iy Gandovi a and
V1 n o ’J I a Chib a 1 o

Drosenbed al the National
Works hoi-’ on D1 s as t or and
Mental Ileal th held on
December 11. 1993, at
NIMIIANS . Bangalore

T a I- a I n u t i I u I c a f 3 c* i a 1 S c i cirJ c s
Sion Troinb-ay Ro ad . Doon ar
Bombay 400 088

INTRODUCTION

The

devastating earthquake that struck the

Osinanabad. Latur

and Nilangc districts of the Marathwada region in Maharashtra

in

the early morning of September 30,1993,left in its wake death and
des truetion.
The

the

majority of the area in the districts is

farmland

and

major occupation of people is agriculture.The

villages

af-

fee ted

the most line on both the sides cf the Terna river

which

forms

the dividing lie between the Latur district on

the

nor th

and the Osmanabad district on the South.The soil is black

co t tun

and the majur yield in this area is of jowar, rice,

baj ra.

suil

sunf1owe r. ud1d.

tur.sugarcane and grapes.

Most of the structures in the affected villages were made of

mud

roofing.

The

composition of must of the villages have been mixed

wi th

and stone walls with mud and stone or wooden

e Lhnic

specific occupation reserved for specific groups.
The

firs t

ear thuuake

struck one and all equally.Soon

af ter

the

many others and followed many people found

them­

selves trapped under the ruins of their own mud and stone

build­

tremor,

ings which collapsed like a pack of cards.The initial rescue work
was carried out by the relatives and friends of the victims and a
little

villages

In

many

man.v

were

later by volunteers from neighbouring villages.

the

ceiling of the house had given way and

trapped under heavy slabs.

Moving this proved Lu be very

diffi­

cult and until professional iielp arrived; it is reported that

1

of

II

the Hia.ior evacuation work or
those buried had already died.Though
the dead bodies was carried out by the army which arriyeu on the
scene after a day.the family members had managed bo pull out

the

bodies of their dear ones and had cremabed them in the nibule

of

-heir own houses.
the

Those who escaped death but were injured were rushed to

hospilai

ncaresL
rhe sc

were

again by the re 1 a t ie s and

the

admitted in the government hospitals

local
in

.you th.

latur

and

shifted to Civil hospiHmarsah. Those with serious injuries were
those
lai and eight others -private hospitals in Solapur. Hany of
on

the

their

own

wi Hi

minor

injuries wore treated by the army i>ersonnel

spo L.

Many

rola Lives

had taken their relatives

accord to private hospitals in Latur,

on

Umargah, Osmanabad and even

Solapur.

The

Tulsapur,
Soon

has a rural campus a t
Tata Ins Li Lute Of Social Science
Osmanabad dis brie I■ (core of lhe quake hib dis trie ts).

aft-er the disaster some sbal’f members of lhe

rural

c ami »us

of TISS involvement
visited the area to look into the jxjssibill ty
other NGOs from all over India,
in relief work. Many local and
also reached Lhe si.be within three /four days af ter ear thhad
than
IL was reported that there were more relief workers
quake.
a situation of confusion
the victims in the area and this led to
seal the area from further relief
which forced the government to

workers gathering there.

Once

Coinmi t Lee .

the situation cleared up the

Ear thquake

CoerdinaLion

comprising of Government and Non-Governmen L

2

agencies

...

decided

-

. . ..

. ...-U4

villages

a survey of 30.000 households in 67 affected

undertook

and

with the help of students from Social Work colleges in

bay :.

Sholapur

and

Nagpur and other

Bom-

Institute

the

volunteers

ga th-

completed the survey in a record time or 4 weeks. Data was

ered

z o r man y a spe c ts

trauma t o the v i ct ims.

surveys

including loss, injury and

p s y c ho 1 o g i e a 1

Along with this survey many other smaller

conducted for .specific groups one of which

were

Assessment

' ’ P s y c ho - s o e i a 1

of

was

up

by

assess

the

and ocher victims of

the

on

the

Victims".

OU t

in

two hospitals in Sholapur and

followed

visiting

a

few

villages in the affected areas

to

psychological trauma among the injured

For

was

This

The Injured

carried

earthouake.

We

areas.

undertake a rapid survey of the affected

lo

this purpose information was

ga thered

nature of inJury, socio-economic status care givers and

supperts

The

men tai

status of the patients, their psychological adjustment to

injury

available

and

rehabilitation needs of the victims.

and quality of coping with crisis were a1so assessed

A checklist

was used while Lalkiny: bo bhe rabieub and bhe care givers present
al the hospital. Table 1 gives de bails of the extent of injuries

3

TABLE-1, EXTENT OF INJURIES
reraentcige

Frequency

Type of injury
Head Injury
Pelvis
Femur
Fibula
Tibia
Radio Ulna
Spine
Hc-murus
Ribs
Mu1Liple FracLures
Bluni injuries
Bruises
Lu'. ura Lion & Con Lusi
OLhers
Nov specifled

‘ 90

81
40
44 —
27
37
17
8
2
48
98
206
104
11

11 . 1
10.0
4.9
5.4
3.. 3
4.6
2.1
1.0
0.2
5.9
12.1
25.3
12.8
1.3

Totui

813

100.0

Lhe viliune level some of Lhe patients

AL

inLerviev/ed Lo assess Lhcir
Lhcr hospiLals ucrc
like
env i ronnicn L. This included areas

Lhc SholuPUr and
in

r c ad, i u s I ific n L
pic Soil i-

r-iacc

t*.

f 1C S'

of residence, medical

family's

facili Lies

manlies Led

by

Lo
Lhulii

Lo

and pulienVs perception of prts.nl problems.

T i ic r ap 1 d s u r v e y

rcacLed

to

living,

•jompliance v?ith LrcaLmcnL- psycholoEical adjus Lmenb

disuLillLy (if any)

have

cundi Lion,

wibh brcttUaciib rcnaxrcm.-iits. jaanaEbtucnb of daily

■j'jm'Oly

from

discharged

lo- Included InioxiuuLicn on how the victims

Lhe d i sas Le r and

The

Lhe

I»s y c ho 1 o e i c 1

of

Lhe

and fear of impending danger.

The

iutd-ur syitii'botus seen in most

-■'illa/zes inciudc sicepiessness

sympLoms

£oil'.".-(iuE l-ublc ePcs -Ac bulls (Tt-.bie 2.01.

4

1 ,./W

*

TABLE 2 INCIDENCE OF MAJQK MENTAL HEALTH PROBLEMS IN SOME EARTH-.
QUAKE AFFECTED VILLAGES
Name o ’.L

VilluEC

i

?

1. Ki 1lari
2 . Tai aril
3 MtuiHi ul
4 Gu bal
b Gan.’iaukiicda

45 . 3
b 8.9
27 . 4
58 6
82 3

6.

b’/ . 3

8.
9.
10 .
11.
12.
13.
14.
1516
17 .
18.
19 .
20.
21 .
22 .
23 .
24
25 .
26 .

27 .
28 .
29
30
31
32
33
34
3b
36
37
38
39
40
41

Fear of impending
Disaster(%i

61 ccp D1 fj lu biincc

GirfJtii
Nandur^a
barufii
Hui-al/-:, a on.
Lani.latL*.'
-ji'.nkral

J cl/?: a
Banc/? ao n
Mulkhon.'i 1
LuhaLa
TuriEi (k)
Li mb a la. Diihsj.
Ac-Li v
Ujahi
DuvcEaon.
Mai uni bra
Wanvpj.da.
liippureu (Sayyau)
Nuichiikur
VenLui
Wun.e J1
Be1kunde
Hippurbii
Chinuholi (Son)
Holl
Musa iEuc’n
Ekundi
Bubal jU'r
Huroli
Mukuni
Mud/?: ad Eko&j.
lUije^uon
KunCfenon
Thoruhiba

4 b. 3
65.5
20 2
61 6
67.6
43.3
68.1
51.5
58.. 1
48 . 7
55.1
48.. 2
70.6
62.1
64.9
55.4
66.7
51.7
50.4
56.2
47.6
37.5
56.1
40.3
65.8
25.6
21 > 5
67.3
44.3
48.7
36.0
59.3
12 2
40.2
30.2
55.6
25.4
37.5
39.0
28 2
65.8

62.9
48 9
51 4
48.4
bb 5
•44 5
18 0
2b 4
27.5
34 5
■J* ’J
i'-j

-

J’
•-*

28.5
29.8
33.2
27.5
32.3
56.8‘
1 6.9
62 7
46 7
44 8
62.3
62.6
56.0
52.3
58.1

48.2
49.2
58.7
64.4
51.2
54.6
53 0
49.3
62.7

5

Total

Population
2255
. 472
405
237
113
150
213
.528
179
587
1154
1110
657
409
222
388
158
635
395
671
1109
344
132
385
NA
1034
334
260
535
462
17 4
NA
NA
NA
242
306
1529
538
NA
667
418

PSYCHOLOGICAL IMPACT OF THE DISASTER

Th-

(J.eEr.C-C

Lhosc

tin-.t lyi'C ■.>£ rcucLlc-n •Uf£’JL<-d tiiiiOfiE

v/hC'

were hospitalised with severe injuries than those who were treat­
postinjury U
ed with minor injuries and those who escaped any
the ’victims .
traumatic dep r e s s i on ■ • w a & visible among many of
deafness and
Functional conditions like aphasia, blindness and
who
past-partum psychosis were also reported among some of those
with mental
escaped without injuries. A few cases of patients
illness before the earthquake were identilled

The family report-

signs
cd that since the disaster they had been showing increased
the slightest
of Illness. They were fearful and jumped up al
to be
noise and ran around wildly. They were also not willing
open al nights.
left alone and insisted on sleeping out m the
as
This last behaviour was visible even in the general population
L r c mo r s s Lili continue.

For the survivors the whole trauma of rushing the injured bo
hespilais}

disposing

the dead bodies

looking for

the

missing

ones

and witnessing mass scale destruction lias left its mark

on

the

psyche of the surviving victims of the earthquake

Many

of

like
adults and also quite a few children manifest symptoms
giddiness, weakness
fear of impending disasLer, pa1pitaLion,
suicidal
free floating ana i eL y and some even have
headache,
They also report sleep and appetite di s I. urbanue s . have
ideas.
crying spells, tremor of hands and an overall duli/numu feeling.
t tie

These

are

all post traumatic symptoms and

w ou 1 d

dec rea se

and

e v e n tu a 11 y s t op a s the people pick up their broken threads and go
with
on w ith the i r lives. Some of them may need help in coping

6

grief and the changed family structure and adjust to a new way of

life.

being

in­

ones.

One

thought that troubled them was that they could not

even

that of

have had to face more trauma

Patients

and that of losing one or more of their loved

jured
nagging

see their loved one before their bodies were disposed off as they

themselves were unaware of the death.

Guilt at not being able to

save

specially their children was another constant feeling

that

many

patients

their

dead

expressed.

see

Many of them still

Many of

children in their dreams and long for them to come back.

off

to

This time they

are

are sleepless as they are afraid to

pa tients

the

sleep least an earthquake takes place again.

will die as they cannot run away from

su ro­ they

fall

the

situation

be cause of injuries.
One

their

look at the hospitalised victims was enough

s bate

pressed.

of'mind.

and

The majority/ of them looked sad

had a da^ed and frightened look.

Some

were disturbed and agitated and cried easily.

convey

bo

de

o thers

Still

were

Most of them

s1eeples s and had nightmares.

Some had blunted affect and seemed

resigned to their condition.

Most- of these are normal

reac bions

to a crisis and in tills case most of the injured had lost

either

husbands,

wives>

a

paren t

or

grand-paren ts ?
were

both of them. sons ,
uncles

undergoing

the

daughters,

aunts or a cousin.

process of GRIEVING

Most of the

mo s b

pa tients

essential

to

enable them to regain their equilibrium and start their lives all
over again.

r7

of

the

Information was sought on items

like

the patient"s general appearancebehaviour, orientation to

time

in the ho s p ita1.

patients

mood

memory,

place,

and

status

list was used to gauge the.mental

check

A

and

affect,

processes.

perceptual

thought

con tent,

This

was

gathered

through

observation while an in-depth interview of

the

patient

insight

and judgement.

and iiis family member was conducted.

Secondary data was obtained

from the case papers of each patient

Analysis

in

revealed that most- of the patients appeared to

control of themselves.

sometimes

Their speech was clear but

specially when they were talking of their losses.

soft and slow

Their ability was restricted as most of them were in some kind of

con traption

due

to their injuries.

In a few cases

unclear, euphoric or had stopped completely.
si oil

The facial

expres-

distress.

Words

the patients revealed their hurt and

of

was

speech

eyes

like blank, dejected, depressed, sad, pained- dased, sunken

expres-

and abnormal look were used to describe patient's facial

si on.

Their behaviour and appearance were in keeping

wi th

the

Baring a few, most of

the

pa-

seen

tha t

situation

they were undergoing.

tients

were well oriented to lime and place.

those

pa ti exits

marked

deterioration

who

aIre ady 11 ad a
in

psychiatric

condi tion.

their

It was

eg.

his lory

d1so r ie n tat ion

place, memory block.. I»e r c e 'p i u a 1 dis L o r t i o ns a nd b i s s a i r e
•jon ten t

(about the earthquake) were nt?ticed in

showed

these

thought
patients .

Their judgement was imi»aired and insight poor.

8

l

r
<

of

emotions

their interview in particular and also in their

interac-

Most
during

of the other patient's displayed a range

tions in the ward in general<

These included *

Anger (at self/ o thers/eod).
or

Irritability (at being res brie ted to the bed by traction

plaster., etc.)
Anxiety (.about, younger children, other merabers in the hospitai or about the future)

Fear

(about

fur ther ear bhouakes . abou b no t

recovering

or

becoming dependent on .others for life).
Depression (triggered by loss of lives and property).
reduced).
Sadness (al the state to which the family was
no b even
Apabhy (no t willing bo balk of the future -

of

discharge from I lie hospital).

think of future consequences of
Indifference (nob willing to

the injury).

Thus

it

was found that in most of the cases the

mood

In a few

ai>p r o i* r i a be bo t he sit ua t ion the patient was in.

was

eases

uUly the patients were unduly elated but later burst into tears.

As

about their
far as the insighl of the patients

1’roblems

the majority were aware that they had a idiysical problem but most
of

them did nob seem to realise the severity of

eg.

fracture

spine

cases were making plans

to

their

resume

problem,

normal

It
functioning when they had lost sensation in both their legs.
nalure of their
seemed they had nob been explained about the

injuries.

9

sions for future.

decided

deci-

affected the patienb’s ability to make rational

This

to

A few patient's were so distraut that tney had

move to a bigger town or city as they no

felt

more-

like going back where they had lost- everything.

As

as the pabientrs and family's

far

ability

for

crisis

to
i b was seen that they were responding emotionally
Some verbatim statements given below clearly
situation.

managemenb

the

brings this out
"I

go

far

and

took

away

lias happened has happened. I will have bo

bear

with

liave

lost everything.

Now I want to go

away

away
’‘This

is

God' s

will.

He gave every thing

everything".
’’What

HIS will".
"Only GOD will now look after me".
"I will show HIM I can survive even w i thout his will .

I will have to stand up and

face

"Maybe I will remain alive, maybe I will die tomorrow,

w hat­

"I

am a s o c i a 1 w o i’ke r,

s■

life”.

difference does it make now .
I will sit on a chair

and

"Will my husband and in-laws accept a crippie like mer

I am

"So what if I have lost- my foot?

run a small hotel".

sure I will have to stay with my parents now".

now that I am
"I am sure my husband will bring another woman
like this".

10

r

i

All these and iiians' such responses indicate their response to

their

their coping Pith the loss and the separation from

inJury,

loved ones is that or extreme GRIBF.

Thus to sum up it is seen that1.

the hospitalised injured i>aLicnts had

of

Mos I

tend

sad

a

depressed look on their faces.

2.
3.

More severe the injuries, more depressed were the patients.
depressed than
Those whose family member/s died were more
the other.

wire iiad sdvport from their family members

Those

4

rela Live

s ta^v ing

with them or a relative visiting them regularly.
minor
Those female pa Lien ts who were treated for

injuries

depressed

b.

less

were

than

those w iio did no 1 iia^C' a

and

like cuts and lacerations had recovered in 3 weeks time
were back at managing their homes.

6.

It

seemed that since wc-men had to .get back to

routine for tile sake of the surviving

their

daily

i n d i v i du a 1 s / ch i 1 d r en,

were showing better coping.

7.

look

after

house and children so they got to work in right

ear­

the follow- up was eonductea within the liist 3

weeks

younger

Tiie

their

married patients were expected to

nes t.

8.

Since

still in
af ter the earthquake the seriously injured are

the

hospi tai.

Impac t

on Children-

Children form a vulnerable group of society and as such need
protection and caring from adults around.

11

In case of personal or

11 a t u r a i c a i am i t y ■.

But

Lhe children also suffer from its impact.

of ten the adults around them are in a shock/trauma and

are

preoccupied with dcaliiig with their own feelings and reality

and

very

as

such do nob try to deal with the child's traumatic

feelings.

try to be £>roteutive about

children

often the adults als

Qui te

and do not discuss or talk to them about the incidence so as

not

bo remind them of it.

Children's physical needs are a btended

bo

but bhab’s nob enough.

The children need bo be helped bo express

their anxiety . fears, e be. so as. to be able to view and dear witn
the

si tua bion be b t s r.

ings and things in them which needs b

patients .

of

informants

and

wi th

some

children

Seen

children.

■.jn

ehildr=jii

•jbserva t ions
and

who

made.

baren ts were the mam

cou 1 d jxpr e s s ver ba 11 y

coupled

The various reaction amongst

reported by the parents were anxicty

as

discharged

attempt was made to study the psychological impact.

■jar t hquake

older

be taken care of.

carrying out survey work and follow- up of

While

feel-

Impact of any such disaster evokes

mild

to

severe,

f car­ • of darkness, sounds. d i 3turbed s1eep, nigh tmare s, s i gns of
like i r r i t a b i 1 i ty, er an kidisburbed behaviour due to stress
wi bhdrawn and became ^ery quiet. clung bo the
ness , crying,
few parenbs
adulbs •and did not like to be left alone. Qui be a
going bo their
repor ted children asking about- and ms is ting
abbending
Those children who had coped up well were
homes.
school and going about their regular routine. Bub the moment it

star ted

getting dark and night, fell they would should

anxie by,

impending

would

fear and would become restless.

signs

Any

create startling reaction in them and they would flee

12

of

sound
ou t

?

their shelters screaming.

of

breioors were felt.

dear

func tioning

Children

ones.

adults have the capacity of springing back

unlike

t hem

A sense of insecurity caused due to homeless-

in some cases loss of near and

and

ness

still

Their fears continued since

continue

and

normally but at the moment if some help is given

to

the normalcy process would be strenguhened.

important thing was to see that the children were kept
the schools
occupied and hence it was heartening to see that
started functioning in the tents put up in the villages and quite
The

no te

books

un i f o rm. eIc. from

aid

The children received

of children were present.

1o I

a

voluntary

of
The

urganisalions.

feedback about children from the teachers would be also helpful.

Some of the observations made were'*

1.

Aid to school-child by teachers was made on consideration of
Aid was given first to children coming from upper
cas te.
The children
class and belter things were given to them.

from lower class were aware of this.
2.

Various organisational and individuals visiting the villages
to reto dis tribute aid made the children very expectant
ceive something. At times questions like what are you going
to

give us was asked.

children

This may be an unhealthy

may grow up to receive things and ask

trai I
for

for

things

instead of being self-sufficient.

Some issues that can be raised from the above report are
follows•

13

as

I

Due

death and injury the exiting

bo

social

itmriiial

alid

As social workers what can we

networks have been.disturbed.

bee t

do to enable the society and the family to function as

as possible?

af ter

children have been separated froifi their parents

Some

the earthquake as they have been sent to Pune for educationPsychologically^ this will prove d e t.r i me n t a 1 to

al purposes.

children and the parents.

the

most

essential

o lher

to enable them to grieve together and

lives.

•What can be done to rectify this situation.

Due

to lack of physical facilities and

for

the

disabled individuals there is a

some

of

the

is

wi th

each

restar t

their

that family members must remain

follow-up

services

possibili ty

tha t

others

may

injuries may become chronic

become disabled fur life.

it

After a crisis

bo th

and

Can some arrangements be made (as

early as possible) to provide .the needed phy si ca1 iac i1itio s

follow up

services to those needing it at their door

s tup.

What can be done about it?

have resumed
of the injured specially the- women

their

Some

life and the work they have to du like lifting

heavy

daily

the floor fur long lime
loads, fetching water, sauabbing on
to
may aggravate their condition. Most of them do nob seen

realise this.
Women

Wliab can be done about Lilis'

Whu have underguae sUriliaalion operabions now

find

o f them,
a venerable situation as fox some
inconsolable
their children had all died. Their despair is
their husbands
as they feel they have no f u bu r e a b all a s
Thus the whole
may marry again bo continue the family name.

themselves

in

14

S

/

current-137

though the initial assessment has been over

Even
the

staff from the Tul^ai>ur campus is involved in

the

collector"s

office both in Labur and

with

working

Osmanabad

districts.

Thekv are also involved with community organisation work in Ra.jeg-

aon

villages.

o ther

and

The Institube

has

village

prepared

used

and other reports in special areas which are being

reports

by various NGOs and the governineiil to plan and implement rehabil-

itabion in various villages.
There is need to undertake research in many areas namely

the

strategy

coping
old

des ti bu be

of

children,

orphaned

widowed

women,

their

paren ts,

victims, children separated from

could

Research on pcs t - trauma tic situacion of the vici/ims

e be.

on

frlsa be undertaken.
Training

programmes for the youth to equip them for

fulure

>•

disas’ters is a inus t in today" s situation as it is a reality

tremors

continue and unless people feel equipped bo face

fu ture

f u ture.

Also

calami ties
all

that

they will not feel secure about their

the plans of rehabilitation and promises made by

government

and non-government organisations will have to be translated

into

action to provide real relief bo the earthquake victims.

Fu ture In terventions
At the Macro Level
1.

Sebting up a mobile rehabilitation team going around following

ui>

on

occuT»a lienal

injured persons

and

providing

therapy (OT/PT) as repaired.

tai> wisciiiiiatlc’U

Lc>mL’U/

17

phy s i o the r apy /
For this

s hu w n 1 n t -s- e s t.

volun-

I

2.

scheme to educate people about the benefits available

A

to

them as earthquake relief should be started.

3.

management beam at the district

crisis

A

would

level

be

useful in managing disasters faster and more systematically.
4.

The District Rehabilitation Centres run by the State Govern-

men b

be used for the reliability bion of

could

injured

the

individuals.

5.

The National Mental Health Programme could be implemented in
doc LUX’S

these areas bo help the victims by training the Pno
and other staff.
Ab the Micro Level

6.

Some

those

to

temporary facility should be made available

injured individuals who may find it difficult to live in the
tin sheds and for those who require OT/PT as a part of tnuir

rehabiliba bion.
6.

Some

c ompens a ti on

of disability should be thought

bhe

of

government as those seriously disabled will need some

ma be-

ria1 suppor b for survi va1.

8.

Services

for children and adults who continue to show

psy-

chological

symptoms months after the eart-hquaks would

have

over

their

All these measures will help in promoting the mental

heal th

bo

bu­ s bar bed.

This would unable them, b-? gob

prob1ems and f ace 1i fe wi bhuub handiuap.

of

bhe

victims and enable them to race life

with

courage

and

deberminabion.

18

1

social order may change.

What- can be done?

Mental Health Intervention

hospital, it was observed

were

the

the researchers were interviewing the victims in

While

moving

that many organisation representatives

giving maternal aid to

around

them.

family

Some

members ran to them. others did not at all and some ever refused.
Some

annoyed

patients who were by passed by the benefactors got

where as others did not bother at all.

Leris tics

of

people.

This revealed the charactalk

a

Some of them were api>roached and

o ther

them enabled them to ventilate their feelings. Of ten

wi th

family members joined in and it often happened that group discussi on

on various earthquake related topics were

This

conducLed.

was reported as being very helpful to the fandly members.
thougii

Even

Some Lime

iewed every bedy wanted tu talk about their probleitis.
was

inter-

no L

each and every injured person was

spent wi til who ever wanted, to see the researcheis

and

this

to ventilate, clear their doubts and plan

for

trie

feelings

and

helped

them

future.

A

few of the patients verbalised

their

after

maxibioned that even though the staff and volunteers looked

their physical and medical needs Lliey did not find any one caucpL

to them.

the researchers ready to ’’listen

Thus in itself it was

a major intervention.
Ano ther

type

of

intervention

was

arranging

small

for

conven i ence s for the patients which added to their comforts

like

in

the

village,, arranging a meeting with their relatives or village

kin

helping

in

sending

a message to their family

members

15

/

r.

from

another ward? etc.

All this added to the

post Live

mental

health of the individual.
Meeting with hospital social workers and other staff ox

the

the
hospital helped not only' in gathering more information about
and plan
victims but. also helped them to discuss the situation

better facilities for them.
As .the s Lucients from the two social work schools in

Solapur

had very little idea of gnthering psychological infomcion s
had

to be trained to do so.

Tliis was done through lectuxes

data gathering.

This enabled the researchers

manpower a v a i 1 ab i 1 i t y t

collect mental health data.

actual

they

Co

exi>and

In the villages, discussions with key personnel, victims ana
the researchers to have a be tier
other relief wo rkera enab1ed
By discussing individually and
idea of the existing situation.
about their problems and by allowing the victims to
in groups
ventilate about their fears - specially about impending disaster
it enabled them clarify their doubts.
By following UP individual coses discharged from the Solopur

trie

shelters
throu.gh home v i s i t s to their newly acquired
researchers were able to provide guiuance and suggestions.

also made the victims feel that some one cared for them

thus

It

Many other village r s ai >p r o a c he d

the

hospitals,

boosting their self-esteem.

talk about their grief and
researchers and most'- C‘f them wanted to
intervention as
Efforts were made to i>rovide as TfiU1—h
guilt.
disposal of the researchers.
possible in the limited time at the

id

-4.4^'
]

>

■

case history of hahadsv bhuee
Ms. Frericy 11a 1 ia

Family Com; osliion and Condi Li on Prior Lo. Eari-hnuahe
rlanade v

an 18 year old younE boy>

Is

in

He lived

Saslur

and

village and the family consisted of his parents^ grandmother
two

younger brothers and a sister.

was

married

agricultural land.
Mahadev

had

large

fairly

His father did farming helped by his

mother.

SSC tmd Lhen did ITI btchnicai

course.•

h’id aludied

They had a house of their own

and

Mahadev was looking out for a job and

in

siblings were in school.

II is

The family

nearby v illage.

in

Mahadcv

The sisfer older to

they 11^ed peacefully.

fact he had gone to Aurangabad for a Job interview on that day.
Aftor the Earthquake

Mahadcv's house collapsed completely and there was no sufvit/fj r

except him.

On his return from Aurangabad on 30th oeptombor.

that

he was shocked to see the state of his own home and learned
1.3

no

The shock was so great that for a lang Lime he

J ust

sal

Lili his cousin came and

look

him

baring

him

more.
s taring

aI

away.

and hi s mar ri cd s1s Lur

the de vas La Iion >

his immediaLu family

The PHCs nursing staff had found him emotionally disturbed

bu I

they

and

helping

him.

Al i)rcscnt he is slaying with his i»aLcrnal uncle s

family.

In

that family loo his paternal uncle. his one older son

and.

grandchild
and

did not know how to go about counselling

depressive

H i s aun I boo ax *peared

dis liurbcd

Mahadev"s s late of mind was disturbed.

apx jeared

died in the mishap.

withdrawn.

a

and numb with shock.

On talking to him it was

20

z•

found

'

.. ■■U

bha b

he

did consider ending his life earlier hub

now

felt

he

-'R

urow&ndointgi^ HuiIby for no b beina uier« bt> lic-li’ his iaffi-i-iy xn -w
added bo
He had alsu lost 2-3 of his friends which added io ms
way .
or
Ini bially , he just kepi to hitaself, not balking lauch
sorrow.
at his cousin's shop
going ou t. Bub lately he goes out to sit
Its like he is
bub he does nob wanb bo go bo his village sbill
sleepless nighis and
trying bo £orget but cannob* There were

day s when he did not eat.

He still appears grieved ana coniuseu

Helief Received

Help in form of clothes and ration was given to the

ramily.

They built ui> their own □he11cr thougn.
Perception
Ab

cannot

r future

the

moinen t

approhens1ve

and

He does balk about taking up a

job

he appears confused

plan for his future.

and

is
outside and sLarbintJ afresh kill- at bhu saac time his presence
His married
c tc.
required to es tablish claim and compensation,
stay with her bub he is nob keen
sis ter has also invited him to
the tragedy
It will bake him a long- time to gut over
•jn that.
General comments.

Hahade v

definitely is in need of immeuiaiu

counselling

to

to help him to restart life and

deal with his grief and feelings

Also concrete help to find a

go L

over wlia Lever happened .

able

job since he is IIT trained.

He was given

keeping himself busy rather than sit alone.

21

sul t-

suggesbions

of

i

CASE HISTORY of GODAVARI VITTHAL MADALS

Dr. (M.5) La 11 ba Maha j an
Family Com; osiLion and Conditi-Xi prior to Earthgu&Ks.

Godavari, 25, female, married lived in a joint family in the

village. She belongs to agriculturist family, had studied upto

7

prior

to

She

standard.

had two school going children.

Sven

earthuuahe she had some marital 'problems.
Position after earthquake

Godavari
She

has

and

emotionally.

Her husband

and

herself

1 o s t bo th lie r c h i 1 d re n .

hos x> i ta1 a b So1apur.

ac I- i v i b y on he r o w n .

tai

are

She has suffered from spinal injury and was kept in

injured.

priva be

is a shattered woman physically

a
any

It is difficult for her to do

Her brother shifted her bo a private hospi-

breatmeni

for treatment since he was not satisfied with the

given in the x:,ublie hosxdtal.

She is staying with her mother in a relief camp in
Her

had

rarely

At x>resenb her mother is helloing tier in all her

dally

li a d v i s i b e d 1 io r o n c e .

in laws

<'isi ted.

Killari.

Bui her husband

ac bivities.

Loss exper1eneed due bo ear thuuake

from material loss like home belongings. loss of

tier

At

presenb

her

brother spends (Rs .6,000./- ) money for tier treatment.

She i s

not

Apar b

children

had

pul- her in psychological trauma.

very sure o£ her fu ture.

bill by

had

added bo i b.

As she had marital problems this

She apx>eared lost.

22

d 1 s in te re s te d

disa-

and

young

o trier

T he r r e e en c e c- £

talk about her,eel£.

reluc bant

bo

children

in bhe ramily consbanbly reminded her of her

children.

She did express .the feeling “why did I survive?"

reality

Experience o£ the f aroily in cowing tii bey tbs wi tn

knop

As we could nob meet her husband and in laws we do nob

Bub her mobher eaid bhat now she becomes

abou b-

them.

then

it will be bhe end o£ her married life.

dependent

A b p r e s e 11 b s lie

is

and
staying with her brother, where lobs ox other xamily members
her bo
small children are present- which makes it- difxicult ior
She has wibhdrawn herself and does not balk

x o r g e b lie r c h i 1 d r e n.
much with anybody.

persenbion

One can see the blitnk ioek in her eyes.

future

Godavari is still in traumatic condition.

The day we visib-

ed her she was jus I no I ready bo balk bo us.

Problems bhe family may face

If

her

village,

in-laws
she

back

and husband do not take her

will be a big responsibility

for

bo

her

bhe
na tai

family, whe bher they wou1d con tinue 1ooking after hei.

She needs phys i o therapy a1ong w i th counselling.
Her in-laws and husband also need counselling.

Some financial help for her treatment and after care.

23

-

k

CASE history of nagorao dhanraj kamble

Dr. (Ms) Lalita Mahajan
Family

and Condition prior to Earthquake.

a

family

joint

65., and Kave r i 60 y e ar s, lived in a

Narayan,

They had 3 sons and 1 daughter<

Tho

Till the day of earthquake

they

with

their sons in Makni.

sons

and daughter are married.

were have a peaceful and happy life.

Children are highly educat-

cd with one having a post-graduate degree in Commerce wors±ng
a

nationalised

diploma

bank
ITI.

from

one

had

completed

Narayan comes from Warkani.

Every

year

he

He seems

to

The other

at Bombay.

goes to Pandharpur on both the yatras.

religiously

in

be having tremendous faith in God.

He is a carpenter by

profes-

sion.

After the earthquake

Bo th
Kayeri
PHC

Narayan

lost her mother and nephews

Along

wi th

Both of them were taken

and later on Kaveri was shifted to Solapur hospital

youngest son.

her

and his wife got injured.

Her leg is fractured.

by

this

to
her

She is still having pain in

hand and not yet come out of trauma of loosing her near

and

dear ones.
They were staying in a shed which they themselves have built

on their own land.
really

lake

As the family is very well knit both the sons

care of their ill parents.

When we

me t

them

the

upse t.

As

family was slowly coming back to normalcy.
Apar t

from material loss Kaveri is emotionally

24

her

family support is vex'y solid she is trying to come

back

to

But coining to normalcy in their case is

no t

de-

terms

with

self.

normal

The family has started already coming to

pressing.

reality and planning for future.

Relief received
They had received not much hell-1 from government but lots

of

In the hospital timely

and

The hospital

peo-

voluntary organisations helped them.

care was taken by all hospital staff.

proper

ple/staff brought her back to the village in their own vehicle.
o

Perception
Narayan

future
fu ture.

their

and Kaveri had started planning for

But it will take little time for Kaveri to forget the loss of her

mo ther.

The family support is very good.

Narayan in fact

said

that he will start reading/rending from Gynaneshwari soon.
Problems the family may face.
They do not expect much help for housing from government but

Narayan

sLa ted

that

if

Bank gives him

loan

buying

for

his

carpentry instruments he can restart his workshop.
General Comments-

As
fai th

Narayan

in God.

comes from religious group

he

had

why

no t

But somewhere he liked people

from

He said that it was God's wish. that is

many villages were affected.

Makni that is why we did not loose so many lives.

God

tremendous

has really helped hirn in bringing hiiti back to

This faith

in

normalcy

and

think and plan for future.

25

i

BiaHr .-^-.rrwTniBihir

——as"

a-

CASE HISTORY OF MR, RAJARAM BHAU PADWAL
Mrs. Vineeta Chitale

Referral Note

Hospital}

Mr. Rajarain Bhau Radical was admitted to the Civil
Solapur

aphasia

func tional

oh 16.10.93, with the complaint of

He was referred from the District Hospital, Umarga, after initial

medical

He

ENT checkup which was found normal (NAD).

and

was

referred for psychiatric opinion and treatment.
Personal and Family Details

Fajaram

works

as

has been educated upto 10th Std.

He

is

a

30

year old man who

labourer.

He

works­ a t

village

Osmanabad.

He belongs to a joint family.

3

TaIuka

He is married and

Chandrakan t

His

his

two

One

of

youngest

the

studying

is

lives in Solapur where he

has

years.

children (12 members in all).

their wives

and

District

Umarga,

bro thers s tay s a t Karad, wi th hi s fami1y, and

brother

lives

consists of his parents, his wife and children.

bro thers,
his

Makdache,

their ages ranging from 7 years to 11

children,

family

Upale,

landless

a

in

Shahu College.

The Incident
Rajaram's
(

1993.

and

there

house is a "kuccha" house made of mud and

Rajaram was badly shaken by the event but

started performing his daily duties.
was

another almost major quake

Rajaram "out of his wits”.

26

soon

adjusted

on

8.10.93,

However,

which

Sep tember,

30th

) and thus, survived the earthquake on

bamboo

really

frightened

Trie description of this incident- in Rajaram's words -

again

was very badly shocked when the earthquake struck

“I

on the night of 8th October.

preserved

Our hut is in .the fields and it was

the earthquake on 30th September.

in

We were sad but

also

another

big

All started running out

of

were very much shaken but unhurt.

members

family

my

All

thankful that nothing happened to us.

night of Sth October, 1993, there was

the

On

All of us were in a panic.

tremor.

the

house.

ou t

bu t

I

I was terror-struck.
could not move.

i n c ap a c i t a t e d.

totally

I wanted bo take

my

children

ou t,

but

I

felt

any

one.

I wanted to cry

I could not cry; out and call

to

some time the hustle died down and people settled down

Af ter

I too was lying down on my bed, very much

sleep.

worried

w hat-

I do

not

Will the earthquake strike again?

will

happen to us?

know

when I got sleep.

My

wife was calling me up.

the

But I got up very late in

morning.

I wanted to speak but I found I

had

lost my voice”.
Interventi on

Rajaram
Psychiatry.

wakeful

and

was

treated in the hospital in the

Department

of

bu t

was

He showed no apparent signs of agitation.

and tense.

He was explained the nature of

that his cooperation was necessary for his

his

early

illness
recovery.

He relaxed when he came to know that he would be able to recover.

Counselling
session

wi th

sessions

were conducted by TISS team

his relatives about their role in

helping the patient bo recover was also useful.
speaking normally by 19th October, 1993.
27

i

everyday.

A

supperting

and

Patient

started

CASE HISTORY OF PATIL FAMILY

Ms. K.Y. Gandevia
Before the earthquake
The Patils of Path Sangvi, owners of wany. acres of farm land

resided

in a "wada" with ‘’25 khans".

under one roof.

There 20

members

staying

They employed farm labour and often took care of

The women folk owned lots of jewellary. saries

and

many conveneances in the ki bchen.

There were 4 kitchens but

all

of them lived like a big family.

The menfolk had never worked on

poor people.

the i r

"social

farms and were mostly involved in doing

service"

for the villagers.

After the earthquake

The earthquake of September 30th did not spare them and like
They also lost 3

others lost all their belongings in 10 seconds

adults and 2 children;

Mo the.

(wife of the householder)

60 years

Son (married)

35 years

Son (married)

32 years

Grand-son

10 years

Grand-son

7 years
the

household

Civil

Hospital,

Solapur:. in an unconscious condition and a few others

(including

Three

were

female

members and 2 male members of

severely injured and were hospitalized in

children) sustained minor injuries which were treated by the army

personnel.
28

i

The present and th

future

The injured have sustained fractures of the spine, right and

All

left

legs, hands and one in a 1 e rri e mb e r h a s h e a d i n J u r i e s .

them

will take a lontf time to recover ail d some may remain

bled for life.

of

di sn­

The rsycholofiical trauifia has left them sleepless.

unwilling bo go back home and despite all the social support and
back to
land back al home inosl of the injured do not want to go

home .
the researcher visited Peth Sangvi,

When
came

she

adults

were

things they could salvage from tnc ruins.

In

the

the courtyard were remains of. a funeral pyre

of

the

across the ruins of the big wada where 2 male

looking

for

middle

of

accidentally

five dead family members!

The once thriving rd ace looked like

a

ghos t

town.

they

are

housed

in separate "sheds" and no one knows what will happen

in

The .joint family is now disintegrated as

the future

29

1

CASE HISTORY OF RAGHUNATH PRSMAJI KAMBLE

Mrs. Vines ba Chitale
Mr. F.aEhvinaih Prema Ji Ramble was admitted in Civil Hospital,
Solai>ur, on 1 st October, 1993, for treatment of several

injuries

after

from

the

earthquake on 30.9.93.

He was transferred

the

District Hosi’ital Umerga on the same day earlier; as it was found
that his injuries needed expert care.

He

and

had fracture tibia, fibula and femur and

lace rat-ions.

unconscious.
j.nd

children

When he was admitted to the hospital.

cuts

he

was

Before losing consciousness , he had seen his

wife

buried

had

under the rubble of

thought they had all died.

his

house,

and

i

eonscious-

However, after recovering

he learnt that his wife had survived.

ncss

multiple

become

She has

se­

vcrcly disabled (x>araplegia) due to a spinal injury.
was living at village Tavshigad when the

Raghunath
occurred.

Hu

Tavshigad.

His

•Lhuir

due to the earthquake.

lives

thoroughly

a tuauher in the

is

Zilla

Purishad

parents were living with him.
Raghunath

school

at-

too

lost-

They

is

now

shattered, having lost- his parents and his

tragedy

fueling
children,

his

home crumbled into ruins, his wife disabled permanently

and

his

own, s t a t e t e mi* o r a r y

story

to:

disabled.

He tells his own

the intu rv iuwe l ■
” When

sad.
lessen

you were in t-er vicw i ng me, I was feeling

HoH Q-an this unhappiness be contained?
this grief?

How can

really

very

What can be done bo

this nssare be shortened'?

Why

had

30

■

-

■'

•

n

>

God put me in this condition?

It cannot be measured.

sleeping

P e a c e f u 11 y .

Elec tricity

bomb-bl as t

there was a big noise like a

Suddenly

VisarJan,

After we came back from Ganesh

children, my parents and I were

wife,

earthquake?

the

can I say what and how much I lost in

How

my

Did he not like ay happy family?

I was
was di sconnected and the house started falling down on us.
I got help from
buried upto my chest. All others were buried.
and all
my neighbours . But there was another tremor at 6.30 a.m.
No one was willing to
those who were alive ran for their life.
I s aw
help me find my children. Help came after a few hours.
I lost
wife .
them taking ou t the bodies of my children.. my
consciousness.

description is from Tavshigad village.

This

I saw with

they

how
own eyes, how my children were buried under the debris.
still hear my son’s cry.

died.

What can I do, how can I forget this?

ears .

in

r e v e r be.r a t i n g

It is

my

my

I n eed coun so11i ng,

I need to know how can I forget all this.
children were Sandhya - 13 years old, Vidya -

11

years

3 years old.

I

could

On how can

forge t

this

How can this crevice of grief be filled’.'

cannot

bear

in

the

No one had

e vex'

My
old,

Pradeep - 7 years old and Sandeep

no t

even

pain?

perform their last rites.

this.
My

Sandhya had topped in Maths.

Vidya stood first

board exam.

Pradeep got 1st rank in his class.

complained

abou t them.

There was no cause.

I was

not

present

31

a

V

for their funeral.

But I salute them in my poem.

Please help me

to reach this poem to them:
Accept, Oh My Children
i.ccept your parents last respects!

We gave you birth

Just that we could not help you to fulfil your life.
Why did He give you such helpless parents

Who could not save their children, darlings like -you?
I could not do anything .for you

Whom shall I call (my children) now?
Oh will you be bom again

and make us again your parents?

Help me to take this message to my children.

no help available there.

was

There

I was brought to Umerga Hospital from Tavshigad.

Crying was my only medicine.

So was it

The all pervading sound in Umerga was of crying.

for others.

I

go t ve ry sc ared there.

my

own

But I met my relatives who also started crying with

me!

felt

I

throat?

like

killing myself.

Should

But then my younger brother Rohida came.

I

s trangle

He brought me to

Sola-

pur, on the advise of Dr. Mahajan.

In Solapur, I am being 1ooked af ter we11.
have

helped

living.
a

lot.

only

one

Solapur

I feel that humanity

us with open arms.

A11 doctors and nurse s are very dedica ted.

is missing in their work.

That

is

still

They help us

I can never repay all that they have done for

thing

ci tisens

is

me.

Bu t

love

and

32

r--

I

friendly

talk.

bell them "do

net-

Only such talk

will

But they

are

If they talk to the patients,

worry! we will be always there to help you .

help us to recover.

We do not even need medicine.

only doing their duty.

Do they know what is the meaning of love?

Bu t

all doctors are not like this.

In Umerga., Dr. Shedge

talks

so

sweetly to his patients that all of them recover fast.

This

is the true story.

to

my

mother.

You were nc'b (only) asking me questions, your heai t

was

talking

to

hear t

was

you were interviewing me, I felt I was taiKing

When

burs ting,

me.

When I was telling my.story,

your

Your

and the tears were falling down from your eyes.

eyes told me "Do not grieve, my -son! Have courage!'

There is a poem by Madhav Julian,
asks "0 Mother will you be born again?
I

It is about 'Mother".

He

Can I be your son again?"

want to ask like him "Can my children be born again - be

born

to me/"
T

tion

wrobe so many things - bub I come back to the same

uues-

"What can I do so that I can forget this sorrow?" On

tell

me please!
There are many more questions which I want to ask.

Will you

answer me?

How can we live our life again?
For whom?
What about- money?

Both of us are now disabled?

33

■'.j

. -J

, •• ii :

. i,.

- - ■ ;

' —Ak.

’ .fl

ii

.1.

We

have lost ever}'thing ~ children, parents.

home,

money,

all.

What can we do now?
ha v e

got myself sterilised - I can never

have

children

again?

How can I work now?
I look forward to your blessings

Give me the blessing that my home will be again there
Give me hope to live again
If I have it I will shine my life like gold
Give me God, the thinking and tlie will-power to live again

Do not give me thoughts of dying".

This

was

the

ques tions;

has

shared

s tory

his

of Raghunath.
agony.

He

He

has

raised

some

has

also

made

some

the helping professionals.

observations which will help us

34

OUTLINE Ob INFORMATION FOR ADMINISTRATORS
PROGRAMME TO PROVIDE MENTAL HEALTH CARE TO THE PEOPLE OF
MAHAtHWADA AFFECTED BY THE EARTHQUAKE ON SEPTEMBER 30. 1993.

R. Srinivasa Murthy
Professor of Psychiatry

Dr. R. Pathasarathy
Addl. Professor of Psy. Sac. Wo r k

(she outline for group discussion focussing on the Administraters
(Managers)
is written keeping the most recent earthquak e as the
focus, for purpose of emphasis,
The text of the document can be
adapted for other disaster situations).

THE EVE.NT;

In the early hours of September 30, the Marathwada area was
rocked by severe earthquakes- The result was over 10.000 persons
dead,
thousands physically injured and over
1,OO,000
home I
xuuiviquais.
ine devastation has been of an
-~ unprecedented degree
especially due
to the time of occurrence of the earthquake as
we 11
due to the type of construction (looseIv b ui11 hous e s
with
rocks and mud on black
b1ack soil).
The disaster has been
variously described as "darkness
darkness at dawn",
dawn”. "death in
the dawn11
and 'Human Catastrophe .
The

iseverity
‘’

- of- the
damage has broughtforth both general
public support and governmental actions to meet the needs of the
affected population to an unprecedented degree.
The work of
the
first 4 weeks have been characterised by swift and specific
governmental action
to mobile medical help , shelter,
food
and
expression of commitment
to rebuild the shattered homes and
1ives.

Of the many needs of the population, mental health needs
are important ones.
This is both for short term and
long term
interventionsThis need has been well recognised
in western
countries.
For example,, USA has the following provisions.

1

2. PSYCHOSOCIAL CONSEQUENCES OF DISASTER:

and
A disaster
is a severe disruption - ecological
the
psychological — which greatly exceeds the coping capacity of
the
affected population
(WHO,
1992).
The mental health and
rece ived
psychological
consequences of disasters have not
1 acu.nae
is
adequate attention they deserve (Luhat,
(Luhat, 1990).
The
especially so from the developing countries.
From India,
systematic studies have been made
about
the
mental health effects of disasters as well
as mental health
interventions since 1980'sThe most notable are those relatives
to the survivors and their families of the circus fire tragedy at
Bangalore in 1981, the Bhopal gas disaster in 1984 and the Bombay
riots of 1993.
These experiences have provided information
for
1993planning of interventions.

2.1. Haqnitu.de of Mental Health Needs:
morb id i ty
Raphael
(1986) has reported that psychological
the first
affect some 30—40% of the disaster population within
generally
year following the disaster. At two years, levels are
seems to
less but with a persistent level of morbidity that
become chronic :for some individuals and for some disasters,
Disasters,
like Marathwada earthquake,
earthquake,
with high shock and
destruction can be expected to show persisting levels of over 30%
* .T=p 1 rmer. t.

2-2. Disaster and Mental Health:

It is widely known that following any disaster the effect
on the emotional health is an important component of disaster
effect.
The disaster literature points to universality of the
reactions in terms of the manifestations as well
as
the
the studies
magnitude.
The following section summarises some of the
of mental health consequences of a wide variety of disasters.

1.
Following the coconut grore fire disaster in Boston on
November 2,
1942,
131 persons were admitted to Boston Ci ty
the
Hospital.
Of these 46 were examined psychiatrically during
the
46,
20
acute stage and followed up longitudinally.
Of
comp
1
icat
ions
.
persons
(43.48%) did not develop any psychiatric
26 (56.52%) presented symptoms of nervousness and anxiety for at
least 3 months and at 9 months 13 of the 26 suffered the same
effects.
crashed
into
2.
On Ju 1 y 25 , 1956 , a Swedish ship StocAhoIcrashed
the
Italian ship Andrea Doria resulting in one of the worst
The survivors of the passengers were seen by
maritime disaster,
two psychiatrists.
Initially, the survivors appeared passive and
excessive sleep
and
compliant. They also shewed slowness,

2

sometimes loss of memory. After the initial shock had worn off,
a
in
their story
the survivors had a great ineed to tell
In order to
repetitive fashion to anyone who would listen.
master the overwhelming trauma, many 'looked for a scapegoat'.
das? burst, flooding EuTtalo Cree#
3.
On February 26,7 1972 a dam
Valley^ West Virginia (USA) leaving 118 dead, 7 missing and 4000
' homeless- Many mental health problems were noted in the affected
(i i )
population such as: (i) problems with grief management,
( i v)
(iii)
fear of rain, thunder and
loud noises,
insomnia,
overconcern wi
with
bodily
functions,
th bodi
1y funct
ions, (v) survival guilt feelings,
reported
Families were
(vi) amnesia, and (vii) eating problems,
of
their
to be host
hostile,
resentful and depressed as a result
i1e,
placement in overcrowded trailer parks.
4.
Psychiatric assessment of 11 children under 12 years of age
who survived the Buffalo CreeA tlood showed that impaitment was
a function of developmental levels at the time of the d isaster,
perceptions of the families reactions and the amount of e xposure
to the disaster.
Observation of death had permanently altered
their sense of reality and of personal power.

:atastrophic storm hit Xenia,
Ohio
On April 3, 1974, a catastrophic
5.
32
persons,
injuring
2500
and
causing
damage
to
killing
(USA)
Fallowing
this,
despite
the
fact
that
most
residents
desp
i
te
2757 homes.
Direct
they suffered psychological problems.
victims
surv ived,
another
tornado,
d i sp1ayed symptoms of anxiety, anger, fear of
Indirect
depression and an inability to cope with difficultisc.
victims often felt guilty that they escaped harm and experienced
stress
induced physical symptoms, accidents and arguments with
fam i1y and friends.
6=
In 1978 a cyclone struck Sri Ian/i‘a killing 889 and thousands
homeless.
It was noted that
with injuries and more than one lakh homeless,
77
psychiatric morbidity increased following the catastrophe,
The
per cent of the population showed a variety of symptoms,
effects of the symptoms continued to affect the majority of the
population even after one year.
7.
The Three Hila
Nils Island disaster relates to a nuclear
facility^
Im this no deaths occurred, no property was damaged
but there was a prolonged period of threat.
Mothers, workers and
mental health system clients were examined at 9 months and one
year intervals. Mothers and pregnant women at the time of the
accident were affected most by clinical anxiety and depression.
Inadequate social support, proximity to the plant,
and prior
psychiatric history were correlated with the above symptoms8.
On February 7, 1981 a major fire accident occurred in the
city of Bangalore taking a heavy toll of life.
The investigating
The
psychiatric team visited 58 families with 70 family deaths.
The
t e am visited each family many times and provided support.
reactions of the 58 families showed chron ic grief
emotional
sleep
(75%);
excessive guilt
(52%);
excessive anger
(31%):

7;

disturbance
(67%);
eating problems
(57%);
preoccupat ion with
thoughts,
vivid memories and perceptual anomalies
(90%); death
wish
(18%)
and change in pattern of social
and
recreational
^CLivimes
(45%).
In
addition,
46
per
cent
reported
deterioration in health.
F'
'•
□f the
affected family members, 74 per
cent gave evidence of depressed feelings,.
Some of the males were
consuming more alcohol.
36 per cent of the members were
identified to need psychiatric help.

cf the Cental Health N^ed= in Bhopal:
Bhopal is the best studied disaster in India. ’ Information
is available acout the mental health effects of Bhopal disaster
rrom a number ct sources. The first assessments were made in the
rirsr week ot February 1985 by visiting affected population
at
home and examining those attending the medical facilities,
These
unsysi;em=iic studies showed that approximately 50 per cent of
those
in the community and about 20 percent of
those
attending
medical
facilities are essentially suffering
from psych iatric
prob 1ems.

Since February 1985, more systematic studies have been
carried out by the psychiatric team from K.G.
Medical
College,
Lucknow.
They support the initial observation of high prevalence
of psychiatric problems in the disaster affected population.

Of the S55
B55 patients screened in
10 of the peripheral
cimics using a simple 25 item questionnaire (SRQ)
and
further
h y a detailed psychiatric interview (PSE)
interviewed by
193 were
found to be psychiatric patients. Thus 22.6 per cent or
of the
patients attending the general medical clinics' were found to be
JPsychiatric disorders.
Most of the patients were
females (81.10%) and were under 45 years of age
(74%).
The main
categories were anxiety neurosis
diagnostic ^categories
(25%)
depressive
(37%),,
adjustment reaction with prolonged depression
(20%)
and adjustment reaction with predominant disturbance of
(16%),
Psychoses was rare and was not related to
emotions
(16%).
to the
disaster.

At the community
r
level random sample of 409S adults
from
1201 households have been surveyed..
A total of 387 patients were
i
diagnosed to be
suffering from psychiatric disorder,
giving
a
prevalence
rate of 94/1000 population.
M a .j o r i t y
of
the
population were female (71%). S3 per cent were in the age group
of 16-45 years.
94 per cent
of the patients rece i ved a
d iagoosis of neurosis (neurotic depression 51 per cent,. anxiety
state 41
per cent and hysteria 2 per cent)
-- ) and had a
temporal
correlation with disaster.
Another study was carried out by the Medico Friends Circle
in two areas, namely, J.P. Nagar (one of the worst affected)
and
Anna Nagar (least affected),
The findings of the survey showed
anxiety depression was seen in 44 per cent* and many peop1e
described a definite change in their memory.
The disturbances
4

were more
area. ii

in the affected area as compared

to

the

unaffected

2.4. Type of Needs:

The range of mental health needs range from availability of
accurate
information during the pre disaster phase to providing
long term care during the rehabilitation and resettlement phases.
Some of the specific needs identified in a large review covering
52 disasters all around the world are:

2.4.1.
The immediate experience of disaster related to severe
phys i c a1 injury. exposure to extreme danger, witnessing death of
close ones or mass deaths and injuries, traumatic experiences of
helplessness,3
hopelessness, separations and the need
to choose
between helping others or fighting for one s own survival
(WHO.
1992).
2.4.2. Emo t i on a1 reactions after the “event”:

In the beginning many persons feel numb, or even
elated
and relieved, often with strong feelings about having surv ived.
Common
post-disaster reactions include
intense
feeling
of
anxiety, which can be accompanied by ‘flashbacks' or
interslons
and frightening memories of the experience.
The
specific
relationships that influence the outcome are the characteristics
Of

uHe

vAUtliiiS aiid of

tiie disaster.

Specific
psychosocial consequences following
disaster
include (i) post traumatic stress disorder, < i i ) grief react ions,
(iii)
alcohol
and drug abuse, (iv)
family p rob 1 ems and
(v )
psychosocial stresses.

2.5.

Impact of mental health Consequences:

Impact of mental health consequences lies at
two levels,
Firstly, it is an important need of the population and should be
given
importance
as much as other needs
like food,
shelter,
clothing, medical care, and welfare support.
Secondly. there
is
evidence to
indicate that people
experiencing disasters have
increased physical disorders.
Not only psychological disorders
but also physical disorders and mortality rates have been shown
to be higher in survivors of disasters.
In particular, the
rate
of coronary heart disease morbidity and mortality is
increased.
Studies have also shown
that this increase in physical disease
is particularly marked in the year after the disaster amongst
amonqst the
relatives of people who died at that time.
It is presumed
that
this
increase
in disease is caused
by psychological
factors
(WHO, 1992).

5

3. SCOPE FOR INTERVENTION
A large number of studies carried out in the last 40 years
have shown
that
it
is possible
to implement
psychosoci al
interventions in disasters which is generally recognised that
it
is best to integrate all services and especially mental health
service with general health service for the following reasons.
There
are other considerations which underscore
importance of
integrating mental health services within
framework of
the existing health system,
and espec i ally
primary care system.

the
the
w < 1 CT

1=
Many potential users do not come to a f ac i1i ty wh ich
is
openly labelled as a mental health service, since they do not see
themselves as people needing specialized he Id but consider
themselves only as victims of extreme adversity.
2.
It
is we 11
known that the
large majority of cases of
□ syc hoiog i c a1 distress among attenders of health centres go
unrecogn ised,
do not receive proper care and represent an
important burden
for the health services.
Better and p romp t
recognit ion and management of these disorders,
including oTcn
i
< ,
can
improve
their outcome and reduce the burden on the heal th
serv ices =
i iij

3.
The primary health care network,
thanks to its central
□osit ion
in the community, can guarantee proper follow up of
v i c t ims and their families for as long as they need.
In this framework,
the role of the specialized mental
health team should essentially be one of supervision
and
training, and only especially difficult cases should be
referred
for direct treatment.

4. BACKGROUND TO THE VISIT TO AFFECTED AREA:
Dr.
R.
Srinivasa Murthy and Dr.
R.
Parthasarathy from
NINHANS,
Bangalore,
visited the earthquake
affected areas on
October 9th and 10th to understand the needs of the population as
well as to interact with people working with the disaster people.
Th i s visit was undertaken
against the background of
oast
experience of working with Bhopal population
and continued
interest
in developing programmes for the disaster affected
populations =.
The field visit was also coordinated with the team
members from Solapur (Dr. S. Pathankar), Pune (Dr.
Mohan Agase
and his team), and Bombay (Dr.. V.N. Vahia).
This coordinated
v i s i t helped us to understand the totality of the prob 1ems as
well
as the way the resources of different centres can be
utilised to the best advantage.

6

5. OBSERVATIONS DURING THE FIELD VISIT:
5.1. Current situation of the population:
The visit was made on the 10th and 11th days after the
Majority of the population were
disaster on November 6-7, 1793.
There was
in temporary shelters away from the villages.
housed
adequate provision of food, temporary shelter and other support
severely
The villages visited
though
to the population.
the individuals were very hopeful and appreciated the
affected,
cemmitment by the government in providing them support and hope
that
During the visit, it was also noted
of rehabilitation.
efforts
efforts to establish communications using solar energy.
to provide water supply through digging bore—wells, setting up or
shelters
,
was actively in progress.
There was
general
appreciation of the rapidity with which the government have moved
to provide care to the population.

5.2. Health care prov ision:
The most impressive aspect of the work was the di fferent
village
levels of health care already started in places from the
for each
level
to Solapur.
There were about 80 teams,
one
level
village, who were providing day-to-day medical care at the
of the homes and villages.
In addition, there was facility of
The more
services at
the Taluka district
level hospitals,
col1ege
severely affected have already been moved to the medical
Ths
hospital where they were recovering following treatment,
for­
current method was to have a rotating team of medical people
7 days at a time and to make them available as close to th e
people
as possible.
We were also able to see the
inputs from
The
international agencies in terms of drugs and other supports,
Additional
Directors,
presence of the Director of Health Service,
Health Services at Solapur, Latur and Umerga were all responsible
for the active health care system which had come into operation.

5.3. Mental health infrastructure:
It
is very creditable that Maharashtra recognised the
mental health needs of the disaster affected population within
By the time we visited, there were
the few days of the disaster,
in addition
mental
health
teams
at
Latur and Umerga
to
already
In
addition,
the existing Department of Psychiatry at Solapur.
to assess **"viseo
teams had visited the village
mental health
the village level and sensitize the papalat ion to
prob 1ems at
regal ar
There were plans to have
features of mental disorders.
the district
teams of mental health professionals at
rotating
train
In addition, the need to
hosp i tals on a long term basis.
the medical officers and other personnel in mental health skills
was well articulated.

—»

5.4. Interviews 'Aiith general caGU.lation:
In a cross section of interviews with population, the more
striking aspect of it was the presence of psychological symptoms
in
the
form
of sleep
disturbances,
anxiety,
sadness,
preoccupation with the disaster and fear of future,
There were
some people who expressed hopelessness
and h e1p1essn ess.
In
general,
the atmosphere was one of positive approach
to their
Th i s was partially due to the traditional
future.
This
mourning
period they were going through as well as the support that
the y
were receiving in day—to—day life.
In detailed interviews,
they
had
expressed concerns about how they would cope with the major
changes
in their living conditions, family life, and rebuilding
their personal lives.

5.5.

In t e rv i aws wi t h the care providers:

5.5,1.Doctars:
The primary care doctors were providing very good physical
care.
However, their awareness of psychologica1 problems was not
adequate.
They either consider them as not real or as natural.
The concept of PTSD and how care has to be provided
to these
ere not known to the doctors working at various levels.
people w
were

5.5.2. P o1i c y m a k e rs:

The awareness of mental health needs of the population was
v e ry s t r i ki ng
at the
level of Addl.
DHS and
the
Heal th
Comm i ss i on e r.
They recognised the different
stages
that
papulation
would go through as well as the need
to provide
psychosoci al
support to these persons,
They were also aware of
the complex needs of the orphan children,
elderly without
support,
single women and other vulnerable groups.
They iwere
open
to the possibilities of developing training programmes
to
include mental health as part of the total care programmes.
5.5.3. Mental health arotessionals:

The
mental
health professionals of
Maharashtra
had
recognised the importance of providing mental health care to
the
disaster population.
This
was evident by, the field visits
already made as well as the recognition for coordinated action at
all
levels.
In this work, the centres at Solapur,
Pune,
and
Bombay will have to play an important role.

8

6. PLANNING FOR INTERVENTION:
6.1.
The administrators when working with disaster population
are
faces with the need for providing multiple
inputs to re­
establish a life style for the affected population.
Often the
ohvsical needs take priority over others.
The current earthquake
illustrate this point.
We have seen total destruction of
large
numbers of
houses which has meant
rebuilding /
re—locating
them.
In all these efforts it is very easy to forget the human
th is
dimension.
However, a large number of researches cone
in
group of populatiohs have shown that there is as much a need to
rebuild the emotional lives as well as their physical needs.

Providing integrated services should be the goal *
In most
6 - 2.
settings,
the administrators identify a key field
level wor k e r
for every 20 to 50 families, so that that person can coord inate
affected
the multiple needs and multiple interventions of the
different
population.
This point is especially important when
NGC's are providing segmental support- Uncocrdinated effort can
The need for
be wasteful as well as confusing to the population,
in
the area of
coordination exists in all areas but especially so
The experience with Bhopal
medical care and mental health care,
population has shown how the unnecessary use of drugs and
aval1able
i < i ja -h i fj _=i f: i fn n =.
h V d 1 f f S T S C! t aoencies h av e d ra ineh th p
the
for
is
import ant
It
resourc es
i n app rop r i at e1y =
all
at
c
oo
rd
i
n
at
ion
administrators to recognise t h e need tor
stages of intervention.

6.3.
The range of interventions for mental health care can be
Specifically there will be need
thought of as a pyramidal modelfor simple
interventions for majority of
the population
and
highly complex intensive interventions for a limited number.^ An
outline for such a need based structure is given in Fig- 1.
This
can be enlarged to include a number of other needs
falling in
the range from bottom of the pyramid to the top of the pyramid.

LEVELS QF NEEDS AND CARE

HELPERS NEEDS
INST./REFERRAL CARE

DEVIANT BEHAVIOUR
NAJOR NENTAL DISORDERS

KNOWN PSYCHIATRIC PATIENTSCONTINUITY OF CARE
CHRCNIC CONFLAINERS
'MINCR' MENTAL DISORDERPART OF PHC
SRIEF PROCESS
SCHOOL CHILDREN DESENSITISATION

SPECIAL SUPPORT FOR ’SPECIAL SROUPS'
:-R*jLiD •“COTTON T ^Y SUPPORT COHESION

STRENGTHENING OF THE FAMILY UNIT
ACCURATE INF

PREVENTION

RELAXATION ACTIVITY

in all
the
6.4. The resources for intervention is crucial as
international
resources are
limited.
The
the
countries
experience has shown that the FOCUS SHOULD BE TO UTILISE THE
The
AVAILABLE COMMUNITY RESOURCES IN PLANNING INTERVENTIONS,
health
mental
for various
likely resource that can be used
activities are given under Figure 2.

1O

RESOURCES FOR MENTAL HEALTH CARE

1.

AFFECTED POPULATION

FAMILY MEMBERS

LEADERS FROM COMMUNITY
4.

SRAM SEVAKS / SEVIKAS

5.

HEALTH WORKERS

6»

DOCTORS

7.

SCHOOL TEACHERS

8.

REVENUE / OTHER OFFICIALS

9-

VOLUNTEERS

NSS / NCC

10. NSO STAFF

11 . RELISIOUS LEADERS
12. ADMINISTRATORS
13. =VT. PROFESSIONALS

1^-. MENTAL HEALTH PROFESSIONALS

This list again is not “OfD.p reh ens i ve and should
1oc ally ava i1 ab1e resources.

include

other

In providing mental health care we need to think­ of
levels of care , namely -

five

6.5. Level-s of care:

1
jT

4
5

C omcnun i t y level
Health facility level
School level
Specialised facilities at districts
Tertiary care level.

Each of these levels can have inputs from the different resources
out1i ned
in Table
III. As it can be seen the effort
is to
consider interventions appropriate to the different resources as
well as levels of care.

1.1

SERVICE PROGRAMME

COMMUNITY LEVEL
Vo 1 un t e e r s
NGO
Health wor ke rs
Village officials
“CommLin i ty ”
HEALTH FACILITY LEVEL
Doctors
Nurses
Mental Health professionals

SCHOOLS
School Teachers
Ch iIdren
NGO / Vo 1 un tee rs / MPW ' s

DISTRICT,

SPECIALISE FACILITIES

MH Team at District
In-Patient care
MED. COLLEGE

TERTIARY CARE LEVEL

ABOVE.

In-patient care
Specialised therapy
Rehab i1i tat ion

6.6.

;raining of gersonnel:

the
An urgent need that comes up for mental health care or
disaster population
is the training of a wide variety at
personnel.
Virtually everyone who has to work with disaster
poculation needs some amount of training as their past experience
would not have paegared them for the work.
as well
as the
experience
of wcrkino with disaster population
itself
is_
emo t i onall y
demand i ng.
It would be right to point out tnat
every one from the senior most administratcr to the junior most
persons providing care requires graded opportunity to learn about
the disaster experience as well as the needs of the population.
The
training needs can be grouped under 6 groups as given
in
Table IV.

12

TRAINIFMG NEEDS

ADMINISTRATORS
DOCTORS OF PHC

GOVT. / PVT.

3.

HEALTH AND OTHER PERIPHERAL PERSONNEL

4.

'TRANSIENT' PERSONNEL
NGO / NSS / VOLUNTEERS

5.

SCHOOL TEACHERS

6.

PRESS AND MEDIA

PRIMARY
MIDDLE
HIGH SCHOOL

•6.7. Mental =up port ’ n f r ast ru.c tp.re :

it
is
All along
in the planning of mental health care
necessary to recognise the integration and utilisation of the
health
e ;< i sting
r e_s c u r c e s .
However,
a
basic
mental
training
of
the
infrastructure
to carry OLl
outt
the work of
support;
Th is team
zmonncl .»
suop-ert and supervision
-upervioion io necessary.
nc
should
be multi-disciplinary,
consisting of
psychiatrists.
clinical psychologists, psychiatric social workers, psychiatric
occupational
therapists,A
to be able to provide both
nu r sas =
medical model oriented care as well as psychosocial care to the
population as well as those working with the pcopulation.

This need is very urgent in the earthquake affected area of
the time of the earthquake both the
affected
Mah a rasht r a,
At
not
have
any
mental
health
inf
rastructure
.
The
d istricts did
Government of Maharashtra has rightly moved professicnals to
infrastructure in the two districts.
However.
th is
estab 1ish
for
strengthening
of
the
Department
of
Psychiatry
there is a need
at Solapur (increase of staff , transport, drugs and training for
In addition, there is a need for active
the existing staff).
linkages with the psychiatric centres at Pune as well as Bombay.
A.S.

Media:

It is very important to involve the media in the overal1
p1anni ng
Th e media as seen from
including mental health care.
are very
in
the various newspapers,
magazines.
the coverage
They often
sensitive to the human dimension of the disaster.
present case h istories, lapses and inadequacies and other human
dimensions.
Th is
is very helpful. However,
it can become
13

counter productive if they do not realise the essential nature of
the
disaster experience
and
the type of symptoms
people
experience
irrespective of the level of support provided at
different postedisaster phases. For example,
the acute distress
reconstructicn
the
experience during the grief period, during
phase will have to be understood and kept as the perspective
to
report
about the disaster population’s needs as we 1 I
as
intervent ions.

A regular briefing and making available the educat i ona1,
Often the
technical
material
to the media is very important,
media is left to interpret the disaster experience like any other
experience which can result in unfortunate situation of
’finding
faults*

7. PLAN OF ACTION:

the complex
nature of
the needs
the
of
I n view of
i s bes t
population and the interventions that are required, it
health care
is
long-term plan of action for mental
that a
possible. preferably within the first 2
prepared as early as possible,
By this time the extent of the damage, the needs of
the
weeks.
population,
would have become very clear.
The
fol lowing steps
are suggested for a plan of action.

7. 1. Formation of an Advisory Committee:
This Advisory Committee can consist of local professionals,
administrators, along with representatives of major mental health
the state as wel1 as in
the country.
It
is
fac i1i t i es
in
especiaI 1y valuable to have those who have worked with other
disasters to guide
in making realistic plans and using
the
experience of the past work,
This Advisory Committee should meet
initially once a month for the first 6b months, once in 2 months
for the next 6 months and after that atleast- once in 6 months for
the next 3 to 5 years.

7.2. Continuous evaluation of needs:
The mental health needs of the disaster affected population
cannot be seen as a static situation.
There
is a need
to
periodically assess the needs at all levels by specific measures.
Following measures are considered useful:

1. Community level assessment by sample surveys using standard
i nstruments.

Screening of the primary medical care faci1ities for assess ing
the pattern
and
the magnitude of
menta1
hea1 th prob 1ems
presenting at that 1 eve 1.

14

the patients reaching the psychiatric facilities-

3.

Review of

4.

Survey of the children

in the schools.

There are sufficient screening instruments and
method o1ogy
available
for
this
ac t i v i ty.
activity.
All these material
need
to
be
translated
to
the
1 oca 1
local
languages and
made
use
of
by
the
t i me
survey
administrators.
11
It
is
often
seen
that
a
one
continues
to
guide the activities which can
be
inappropriate,
This
periodic
evaluation
of needs should not
be
seen
as
an
academic
luxuary
but
an essential part of
guiding
p 1 ans
for
intervention.

7.3.
AsAs noted
noted earlier under 6.7 there isis a aneed
need to
strengthen
faci1it ias
the
facilities
at the district level as well as
upgrading
the
facility at Solapur.
These structures again needs to be assessed
as to their adequacy periodically, as there is no fixed ratio
of
up
mental
health teams to a particular population.
The setting
of
these
centres at various levels will have to depend
on
the
evaluation as noted under 7.2.

7.4,

Development of

training material:

An important need is to utilise the available train i ng
iut?d 1 VJcA 1
ma teria1
{fur
example,
manual of mental
health
r or
of f icers
in Bhopal disaster developed by R.Srinivasa
et
Murthy
al.,
NIMHANS,
Bangalore)
to the
local
situation.
Al 1
the
training
material
should be specific to a particular
group
of
persons
as
well as to a level of activity.
It
is
noted
that
general
multipurpose
manuals
are
not
appreciated
peop1e
by
work i ng
at different levels in the disaster area.
The
p1anned
workshop
on Disaster and mental health on 11th December 1993
at
NIMHANS. Bangalore. has made the development of training material
for
8
levels
of personnel as its goal.
The
outcome
of
this
workshop should provide a broad framework for initiating work
in
this area.
7.5.

Phasing of

interventions:

Though
the needs of the population has to be seen
in
the
global
long-term
perspective,
it is
necessary
to
phase
the
interventions at different stages of post-disaster interventions,
The
first 6 weeks should be to provide the basic
mentaI
heal th
infrastructure, 6 weeks to 12 weeks for assessment as out 1 ined in
7.2.
From
the period of 3 to 6 months should be’
for
training
programmes
and initiating
service activities,
Foilowi ng
this
every
3
months there should be an evaluation
and
interventi on
planned
accordingly.
It is specially important to
review
the
work at the end of one year in a systematic manner and every time
there is a major shift in the pattern of needs in the population.

15

8. RESEARCH:
research priorities for disaster has been out 1i ned
The
to
(Chatterjee,
1993 - Group V). It
isis important
seperate1y
1iterature
that currently the available international
recognise
pattern for understanding of
does
not provide an universal
There are many issues relating to the culture,
disaster effects,
type of disaster, characteristics of the population, the we 1 fare
differing
that
interdigitate
to result
in
infrastructure
and needs.
In view of this research shou1d be
man ifestations
in
care,
important priority for service,
recognised as an
state and
the academic needs. The involvement of
add i t ion
to
work can be
level
institutions for
this
part of
nat i ona1
v aIuab1e.

9, ROLE OF NATIONAL AND INTERNATIONAL AGENCIES:
The above agencies should be approached for the purposes
noted
of obtaining
information,
aid, and for evaluation as
obtain i ng
World
with
earlier.
There
is a lot of experience available
New
ICMR,
Health Organization,
Organ izat ion, institutions in the country like
quick
1y
Delhi,
NIMHANS,
Bangalore, TISS, Bombay etc., who can
i
n
the
out
Iined
provide the
inputs
for various
activities
section 7 and 8.
10. CONCLUSIONS:

The disaster experience, both for the population as we 1 1 as
It
the administrators poses a challenge of exceptional nature .
meet
calls for sensitivity, commitment and planning to optimally
These can be achieved by a process
the needs of the population.
of systematic understanding of the process, periodic evaluation
of the needs, phasing of interventions, continuous monitoring and
at
utiIisat ion of all available resources within the community,
level
and
at
the
international
level.
the national

16

6-/0

NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH
Draft material prepared by : Dr. Parthochoydhary
Senior Resident in Psychiatry
NIMHANS, BANGALORE
FOR

MENTAL HEALTH PROFESSIONALS

Disasters are events that suddenly and unexpectedly disrupt
the ecology of a human environment with a huge loss of persons
and property which is outside the coping capacities of the given
community. Floods, hurricanes and earthquakes are the
examples
of naturally occurring disasters whereas industrial accidents and
nuclear leaks are the instances of man-made disasters.

Disasters are unquestionably catastrophic for most members
of the society and there are major psychosocial consequences that
pose considerable mental health problems apart from physical
morbidity and mortality.
Developing countries are part iculary
affected by disasters of all kinds.

that is directly hit by the disaster is
The population
that
bears
the brunt of psychosocial morbidity,
usually the on e
and
considerable
impact on the
rescuers
Also there
is a
involved
in
the
aftercare
of
the
victims.
caregivers who are

The immediate or short-term mental disorders include acute
stress reactions
(with primarily anxiety features)
and grief
reactions related to deaths and physical injuries.
The long term
problems are in the form or delayed or complicated grief,
posttraumatic stress disorders,
alcohol and drug abuse,
conduct
problems and family conflicts.

A disorder affects hundreds and thousands of lives and the
consequent magnitude of mental health problems is clearly outside
the capacity of the existing care giving system.
The management
of mental health problems should therefore, be in the form of a
health
planned and co-ordinated program in which the mental
professionals should work along with the personnel from health,
welfare and education departments.

1

in
A preliminary health care system is the best one
disaster
providing care of physical as well as mental health in a
situation.
This
is not only bcause the primary health care
avai1able
system is the first and often the only health network
the
the case of a disaster.
Indeed, this system works with
in
the
treating
affected masses in close proximity, takes care of
emergencies, provides regular treatment andI follow up
,physical
a- — the health
care and is instrumental in educating the masses about
problems prevalent in the community.

i
from the movements of community mental health
Experiences
i
the
developing
countries
has
proven
the
in
part icularly
care
integrating
mental
health
of
the
approach
of
e f f ec t i ven ess
In aa disaster
In
a1on g with the primary health care system.
Mental health
the
same
approach
can
be
employed.
situation too,
need
to
function
as
a
vital
part
of
the al1-round
professionals
that
could
be
provided
to
disaster
victims.
carZe i

1 , IDENTIFICATION OF THE NEEDS:

A mental health professional is one of the leaders of a
health
team that caters to the affected population's mental
manner
.needsHe is required to function in a multi-dimensional
often
up.
in
providing
his services.
He has to take
simultaneously the diverse roles of
- a consultant therapist,
- a trainer of doctors, multipurpose health workers and other
auxilliary health personnel,
of
- a resource person
for planning and
implementation
preventive, treating and rehabilitative health care services,
- a researcher concerning mental health problems,
- a liaison - person among different groups of care-givers namely
workers,
leaders of
the
the rescuers and community
community level
level
administrators,
teachers
affected populace, security services,
and educators and welfre organizations.

health
In
this framework,
the
role of
the
mental
should
professional
as part of a specialized mental health team
essentially be one of training, supervision andI co-ordination and
should he
only especially difficult cases of mental illnesses
ill
referred for direct treatment.

The mental health professional functions in a key pasit ion
re 1ated
in the overall management plan of psychosocial morbidity
to a disaster.
He should be involved in various stages and
levels of such plans.

Preparedness Activities;

a
A comprehensive plan should be drawn up to p r e a r e
be
wou
1
d
infrestructure of mental health care system
which
activated,
should a disaster strike.
Such preparedness is
particularly relevant for the developing countries.

an
As part of an
international collaborative
effort,
international consultant may be brought in through WHO to provide
The
expert mental health assistance in a disaster situation,
consultant can advise the national Ministry of Health and the
the
health authorities of the disaster / disaster-prone area and
concerned mental health professionals, on the setting up of an
appropriate emergency structure for ensuring
a psychosocial
component within the disaster relief operation.

level,
level,
continuing efforts to achi eve
At the national
national
to ensure
preparedness
should
be
taken
disaster
consequences
of
for
managing
the
mental
health
capab i 1 i ty
These
should
include;
disaster.

or
1.Development of a core of training material for national
These shouldi be
manual, slide set, video, etc.
regional use:
available for various levels of staff e.g..

a)
b)
c)
d)

The
The
The
The

mental health professional
general health professional
multipurpose health workers
community (non—health) workers.

2. Compilation of a literature review acessible
health professionals.

to

non—mental

training"
3, Workshop / conference on ” Disaster Mental Health
at national / regional levels.
4. Specific allocation of money from the general health budget
should be obtained in order to implement the above men t ioned
p1ans.

Later on
on,,
and in zones at clear risk for disaster,
the
local health care teams (primary health care and other sectors)
should be responsible for managing the psychosocial components of
in
their area of
responsibi1ity and a local
d isaster reief
This requires that the
d isaster committee should be formed.
Ministry of Health organizes training for selected healthi care
(both mental
and general).
The mental
Ihealth
pe rsonne1
mental
should
consider
the
preventive
aspects
of
professional
health care in a disaster situation.

"T

This will
involve educating and training the
entire
spectrum of professions concerned with disaster rescue operations
first
psychiatry such as emotional
in the basics of disaster psychiatry,
para—medial
target groups are not only the medical,
aid.
The
anc i11i ary staff found in a hospital but also
and
personne1
the associated organizations such as the police,
in
personne1
olergy,
civil defence,
the clergy,
industrial safety
fire br igade,
administrators with special
responsibility for
spec i al
and
' personnel
disaster planning etc.

The emotional first aid provides early support to disaster
victims.
The techniques of crisis intervention contain several
therapeutic elements, vizs— The interpersonal contat,
- The verbalization which increases control,
- The cathartic effect of ventilating emotions,
— The need for working through the experiences again and again.

All
this helps in neutralization and integration of
and overwhelming impressions of disaster experiences.

fragmented

require
first 6 months after a disaster
will
The
health
psychiatric help for all those who present to the mental
Early treatment
care team either directly cr threugh a referral
comprising both drug therapy and psychosocial interventions may
help to prevent further problems.

include everybody
The preventive work should
suffered a psychological injury following a disaster.

who

has

The next—of—kin; the injured survivors and their close ones
and the uninjured survivors are likey to have suffered the most
and
sever stressful experiences and thus require special support
preventive activities.
Often a family may include all 3 above.
there could be situations where a child would be
left behind
without parents or any other care givers, or a set of parents
without any of their children, or a widow without any support or
also there would be people with pre-existig
means of sustenance,
retardat ion
physical disorder or defermity or mental illness or
who would be further victimized by the disaster.
Also there are
very
the specially vulnerable groups of the very young and the
old.

4

The mental health professional should be particularly
sensit i ve in identifying such special groups of disaster victims
from the beginning
for their early
and he should arrange
care
and
support
followed
by
maintained
psychosocial
detection
and rehabilitation.

need to be considered
Other social
groups too,
additional inputs of detection and care, namely -

for

— Onlookers (particularly at risk are the helpless helpers)
especi ally
— Rescue teams (particularly when failing to rescue,
ch iIdren)
— Persons doing body handling (particularly when they are nonO—
professionals)
— Health personnel (mass injury situations that demand difficult
prioritizing)
rescue
and
relief
— Persons holding responsibi1ity in overall
situations.
— Workmates (in company disasters). and
— Evacuees.

The rescuers as a group report a need to work through their
emotional experiences by sharing their feelings with others,
process is called debriefing and should be under the
This
supervision of a mental health teamj headed by a professional.
Debriefing should aim to - Review the helper's role,
- Ease the expression of feelings;
- Explore particular problems encountered and solutions found,
- Identify positive gains,
- Explore consequences of disengagement;
- Identify those at risk,
- Provide education about normal reactive processes to acute
stress;
- Explain how to cope with stress adaptively.

The mental health professional should also function as an
advisory in the areas of relief work.
He should stress the point
that as far as possible, members of the same family and people of
the same social or occupational groups should be housed together
during the allotment of living quarters together the victims.
and
Members of the same social group provide
a comforting
supporting human environment for one—another that go a long way
toward psychosocial recovery.

5

2. SPECIFIC INFORMATION RELEVANT TO THAT GROUP:

health
the diversified needs,
the mental
Considering
in the care of disaster victims in a
professionals involved
and
training
country like ours need to undergo an orientation
period prior to their actual participation.

They also need to obtain detailed and precise
about the following:—

informat icn

(i)
The concept of disaster, its kinds and manifestations,
details of damage to persons and property and major health
consequences particularly the psychosocial ones;

(ii)
The nature and severity of the disaster at hand and the
extent of mortality and morbidity (both physical and mental);

(iii) The availability of health care resources in the particular
situation including manpower and materials;
The details of rescue operations, transport and relocation,
(i v)
emergency care;
(v)
The proceduresof administratianal and
legal
activities
involving governmental and non-governmental organizations;

<vi'
The
feasibility and the logistic^ r»f organising mental
Th =
health care services within the existing network of health care
systems (primary and other services).

3. DETAILS OF TRAINING TO ACHIEVE INFORMATION TRANSFER:

1.
Mental health professicnals need to have a period of 1 week
(approximately) so as to impart them the required information and
of
know-how
concerning the development and
implementation
disaster—related mental health services.
It could be a full time
training of 1 week or could be spaced over 2 or 3 weekends.

the
2.
They should obtain
information
about disasters,
disaster at hand,
psychosocial consequences
of
part icular
long
of presentation of such problems and their
disasters, modes
i
and short term sequelae.
They should learn the essential techniques of counse11ing,
3.
intervention,
supportive psychotherapy,
crisis
brief
and
aspects
of
of
debriefing
and
other
relevant
procedures
They should also learn
about the
intervention.
psychosoc i a1
problems,
management plans of common psychosoci a1
overal1
including pharmacotherapy.

6

4.
They should be
trained to train other health care
personnel i.e., the doctors and multipurpose health workers,
who
will form the mental health team together.

5.
They should also be able to train other care givers in
disaster situations namely the community workers,
rescuers,
community leaders and teachers etc.
6.
They should be well-versed with the liaison work with other
help-giving systems viz., welfare, law, security, education etc.
and should be ready to train them as and when necessary regardint
the psychosocial aspects of disaster management.

SUPPORT AND SUPERVISION:
The group of mental health professionals should maintain a
c 1 os e co-ordination among
themselves and support each other
during their work.

They should support and supervise the work of other members
of the mental health team in a disaster situation.

ihey should maintain an active communication wi th orner
supervisory agencies viz.,
viz..
psychiatric services of
med ical
colleges and district mental health authorities.

There should be meetings regularly with other care givers.
It
is important to have regular re-examinations
of
the
professionals'
health status and any signs
of
emotional
disturbance should be managed with appropriate debriefing.

INDICATORS GF EFFECTIVENESS OF THEIR WORK:
The mental
health professionals should keep
«detai 1ed
records of their work in all spheres of disaster-related! mental
health care viz:
therapeutic work
Details of epidemiological work
ups,
Details of teaching and training
(classes,
workshops, field visits etc.)
Details of liaison work and supervision.

y

and

follow

seminars,

The
indices of work performance of all the groups
trained
by mental health professionals are another source of such
indicators.

REFERENCES:
1.

Psychosocial consequences of Disaster - Prevention
and
Management
(1992) - Division of Mental Health, WHO, Geneva.

2.

Leehat F.M. (1000)
-- — Updates — The Epidemiology of Health
Effects of Disasters.
----Epidemiological Reviews, 192-195.

3.

The Problems of Mental Health and Adjustment.

4.

Rubonis A.V. and Bickman L. (1991)- Psycholog ical
Impairment
syc hopathology Relationship.
Psychol. Bulletin,
vol.
109,
No.3, 384-399.

8

€-ii

NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH
Dr. R. Parthasarathy
Addl. Professor,
Dept, of Psy. Soc. Work,
NIMHANS, BANGALORE.

Draft mterial prepared by :

HELPING

CHILDREN COPE WITH STRESSES OF DISASTERS : A MANUAL
TEACHERS.

FOR

Children are born and brought up in families,
They get
strength and
learn good ways of life
through family members,
neighbours,
friends, school teachers and classmates,
Ch iIdren
and adolescents attach importance to their dear and near ones. In
their interaction with the parents, siblings, re 1 at i ves, teachers
and friends, they get immense satisfaction;
at times they happen
to get into adjustmental difficulties resulting in a wide variety
of stresses and strains. Even in ordinary times,
the ch iIdren
manifest several
problems in their behaviour,
learning and
interpersonal
relationships. Whether one is from rural area or
urban area, different situations act as threatening
factors to
the growing children. We also need to understand the fact that
what
is
'threatening'
to one child may not be so to another
childChildren vary in their reactions to day to day events of
life.
Many factors contribute towards such varied
reactions;
ctre iiuiate abilities
or disabilities,
or disabilities,
p<irei>Lai
p<irei>Lai
support ur
its deprivation, cooperation from bothers and sisters, or severe
feelings or conflicts and competition among them,
presence or
absence of relatives who understand the children's problems;
friends' company,
and the teachers who are not only good
in
teaching the subjects but also kind in helping and guiding them
in their day to day activities.

Teachers play a vital role
in shaping
the children's
attitudes, values and social skills- They can be the real source
of help to the children who are in distress.
Such supportive
services prevent many serious problems among children; strengthen
the self confidence among the children; more than anything else,
the student-teacher relationship becomes stronger and meaningful
ultimately
resulting in effective teaching
and
en joyable
learn ing.

Many
attempts are made to assess the magnitude
of
psychological
problems among school children.
Generally, i t
is
found that 5% to 15% of the children are affected
with
psychosoc i al problems; teachers, if trained or ’oriented
towards
such problems, could be helpful to identify these problems and
solve
them to a great extent,
If the problems are severe
and
persistent,
the teachers could refer them to the nearby >child

1

guidance clinics,
professionals.

or

mental health centres

or

mental

health

Certain
special
spec i al situations like natural disasters
earthquakes,
floods,
floods,
and cyclones, impose a severe strain on
everyone in the community; children are a particularly vulnerable
group and require special attention and programmes. Children and
adolescents may be affected with any one of the following:
a)
b)
c)
d)
e)
f)
y>

h)

death of father or mother or both
hospitalisation of father or mother or both for severe
injuries/' il In esses .
loss of siblings or severe injuries / handicap
witnessing the death of near and dear ones
friends succumbing to severe injuries and illnesses
disruption of harmonious routine life, loss of property etc.
struggle for food, shelter and other basic amenities
perception of bleak future

When
the whole community, the governmental
and voluntary
shelter,
agenc i es are actively involved with provision of food,
emergency care etc., it is but natural that the needs of the
e i ther
ch iIdren especially psychological and social needs are
the
or
misunderstood.
This in turn,
increases
ignored
to help
responsibi1ity of teachers and other school personnel
these children and adolescents to help themselves.

The
situations
aspects:
(i )
(ii )
(iii)
(iv)
<v)

resourcefulness
of the
teachers
in
d isastrous
be enriched if they understand the fol lowing
could

Phases of disasters
Psychological reactions of children to disasters
Helping techniques
Referral to mental health services
Collaboration with mental health professionals.

Phases of Disasters:
F rom a mental health view point, work with victims of
disasters has suggested a classification related to emotional
reactions:

I. Heroic phase:
is
appears at the time of the disaster and
This phase
characterized by people working together to sa^e each other and
their property.
Excitement is intense and people are concerned
with survival.

2

II. Honeymoon phase;

This is a relatively short (2 weeks to 2 months) post­
disaster period in which the victims feel buoyed and supported by
the promises of governmental and nongovernmental help and see an
opportunity to reconstitute quickly, optimism continues> high,
losses are counted, and plans to reestablish are made.
III. disillusionment phase:
Lasting anywhere from several months to a year or more,
which
failures
this
phase contains unexpected delays and
Victims
emphasize the frustration from bureaucratic confusion,
their own
lives and solving
turn to rebuilding their own
individual problems.

IV. Reconstruction Phase:

This phase, may last for several years, It is characterized
by a coordinated individual and community effort to rebuild and
reestablish normal functioning.
the
The stages outlined above are helpful in understanding
pressures affecting children; as adults go through these stages,
their abilities to handle the disruptions and frustrations have
botn direct and indirect effects on the children.
These effects
contribute to the emotional reactions of the children,
who may
already be emotional about the disruption and / or loss of secure
environment, stable relationships and predictable
interactions,
children's psychological reactions need to be understood
Hence,
in the context of family's reactions and the
impact of the
disaster or. the family's life.

PSYCHOLOGICAL REACTIONS OF CHILDREN TO DISASTERS
Emotional distress in children are indicated by the Changes
in their behaviour or Regression.

The children change their behaviour, reacting and doing
Change:
things wh
which
For
ich are neither typical nor in their usual styleexample,
they may change from active and friendly children to
apathetic or aloof ones, or from being
independent
to being
clinging and dependent.

3

Regression:
Behaviours which were seen in earlier phases
development, such as thumb sucking or soiling may reappear.

of

It is important to remember that it is normal for ch iIdren
after
to show stress reactions or exhibit problem behaviours
scary and painful experiences, Most of the disaster expe ri ences
introduce changes into the daily lives of children, leaving
them
frightened,
insecure and angry.
These feelings are exacerbated
if children do not understand the changes and if they receive no
from their parents or teachers on how to cope with their
help
new circumstances
circumstances..
Children's stress reactions are cons idered
severe when they become very intense, last for a long time,
and
alter the way family, teachers.
teachers, peers or others respond
to the
childIn these instances, children require more speci alised
help than what parents or teachers can offer.

COMMON PROBLEMS OF CHILDREN AND ADOLESCENTS:
1. Clinging behaviour;
After a stressful experience, very young children become
very fearful at
/ or
of actual things in their environment and
imagined things.
Those who lost a parent may develop
a strong
things.
fear that the other parent or close family members may be killed,
Such children do not like their mothers / fathers leave them even
They may not play with other children and need
■^or little time,
These children may
look
constant presence of their parent(s).
Abandonment
is a major fear
in
these
anxious or tearful.
ch iIdren.

2. Bed-wetting:
Subsequent to the disastrous situation, the child may start
wetting the bed.
Many children start wetting themselves because
or
of psychological
reactions such as being scared,
anxious,
feeling insecure.
This might be due to the child's witnessing
of scary events like collapse of the houses and re 1 at i ves dying
helplessly,
being away from homes, separation from loved ones,
and worry about the safety.

3. Problems related to bed time:

These may be refusal to go to bed, nightmares and night
terrors. Children often have nightmares and wakeup crying,
Most
that
nightmares are symbolically related to events or things
frighten the child­

4

Likewise,
the child with night terrors may cry,
scream, but remains only partially awake.

talk

or

These children seem sleepy in the classrooms.

4- School related problems:
This may include school refusal,
loss of
interest
in
studies,
lack of concentration
in studies, drop
in school
performance,
withdrawal from friends etc.
These problems might
be due to different reasons like change of schools, or stressful
memories, and other preoccupations with problems in family.

5. Anxiety, and Depressive problems:

ChiIdren become fearful of new situations develop nervous
habits such as stuttering, nail-biting
etc.
They may also
complain of physical aches and pains.
Ch iIdren
also manifest sadness , isolation and withdrawn
behaviour.
This might be because of children moving to a new
place
leaving behind family and close
friends,
witnessing
terri fying events,
serious injury to self, death of parent or
dear ones, and disruption of family life.

HELPING TECHNIQUE

The teachers need to be aware of the basic
helping process.

princ ip 1es

of

Depending on the nature of disaster, the local situation,
the
needs of the community, the helping process requires creative
application to meet the current needs.
Reactions of children to disasters have both short—term and
long-term effects.
They may be short or long term in
respect
to duration. in terms of immediate or delayed appearance after
the disaster or both.
The children and their families are primarily normal
peop1e,
because of the severe stress,
their functioning may be
disrupted
temporarily.
Informed
intervention can
speed
recovery,
I
however,
and
in many instances prevent serious
problems later.

In handling the problems of the children,
to be involved.

5

fami1y members

need

The helping techniques could be broadly divided into 2.
(a)
(b)

At group level
At individual level.

At Group level:

1 . Encourag ing
the preschool children to play with toys wh i c h
resemble the disaster situations they are exposed to.
For
to.
example, small groups of children are helped to play with puppets
and dolls - replicating the
incidents they observed during
earthquake,
collapse of houses, injured persons,
admission to
hospitals etc.
This will help the children to ventilate the i r
feelings about what has occurred.

2.
Preschool children are encouraged to play group games
involve physical touching among children with a structure,
games help children gain a sense of security.

that
Such

the children do painting with topics such as
3.
Have
' what
happened in your house?' Afterwards they could discuss in group.

4. In small groups, have each child take a turn at answering the
question,
"If you were an animal, what would you be and what
W
A
UVA
Xi 1
situation?"
This can be riuM
threatening way for the children to express their fears _
The
teacher might end each turn by having them tell how they wou 1 d
make themselves safe as a child rather than as an animal.
-

•

’

—1

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• —", •

•

••

•• r —

•—•

cm

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=3 J.

11
C i Z
V U Ci tr A U/I i :

11113

5. Have the children create short stories about their
in the disaster.

experi ence

6.
Encourage class activities in which children can organize or
build projects thus giving them a sense of mastery and ability to
organize what seem like chaotic and confusing events.
7.
Encourage
'disaster' games in which children set
rul es and
develop outcomes which can allow them to develop
feelings of
mastery over events.

S. Conduct a class discussion on how the students might help
the
community rehabi1itiation effort.
It is improtant to help them
develop concrete and realistic ways to be of
assistance This
helps
them to overcame the
feelings of heIp1essness
and
frustration.

6

the students to collect newspaper items,
articles
9.
Ask
from
magazines
and
discuss
the
issues
in
comparison
disaster
their own experience.

on
to

10.
Have a guest speaker from the mental health professions
Let
the students
involved
in disaster work with victims,
anxieties
interact with him / her revealing their fears and
freely and frankly.
Encourage the students' helping each other in
11 =
and solving the problems.

underat and i ng

Arrange discussion on the services provided in the community
12.
by different agencies.

At Individual level:
1 . Involve the parents as far as possible.
2 e Discuss the possible reasons for sleep related problems with
the parents.
3. Establish rapport with the student and maintain close contact
with him/her.
— Placing the student in the front row in the class room
and away from distractions.
in
— Spending 10-15 minutes with the student helping him
his class assignment or listening to h is fears and
anxieties.
— Appreciate or recognise any progress in his behaviour.
— Encourage/comfort him or her

4.

that he
is not alone
Make the student understand
experiencing the problems, Others in the class room too
similar experience.

in
had

5.

Motivate him to concentrate in his studies,
attention in cocurricular activities etc.

divert

his

REFERRAL TO MENTAL HEALTH SERVICES
Usually the psychological reactions can be dealt with by
individual and group support extended by the techers and feelings
However
of understanding and acceptance by the family members.
However,
some children may be in need of more than these services.
Such
children
require additional psychiatric or psychclogical
help.

7

to
Hence,
it
is extremely important for a teacher to> be able
identify such behaviours, indicating a degree of severity that
must be handled by specialists.

The teacher need to look for the following behaviours in
child
eh iIdren for referral to nearby mental health services!
the
time
and
crying
a
lot.
feeling sad all
- Child not eating and is losing weight
- Is tired all the time and wants to stay in bed
- Is unable to sleep at night
- Expresses suicidal ideas or wishes
- Nightmates every day
- Decreased interest in enjoyable activities
- Extreme nervousness.

If all
these behaviours persist for more than
teachers should seek help from specialists.

one

month,

the

COLLABORATION WITH MENTAL HEALTH PROFESSIONALS

Teachers need to be aware cf the mental health
Usually these services are
available in their taluk or district,
psychologists,
psychiatric social
provided by psychiatrists,
They work in District Hospital
workers and psychiatric nurses.
Child Guidance Clinics and
Institutes of
Psychiatric Units,
Some mental health professionals serve as private
Mental Health,
pract i t ioners.

trained
In some places, the doctors and health workers are
to offer mental health services in Primary Health Centres and
General Hospitals.
health
Once
the children are seen by these mental
professionals, they need to go for follow up services regularly.
the
required
Teachers can piny an important role in securing
mental health services for the severely disturbed children and
adolescents.
health
In addition, the teachers could invite the mental
teachers
for
p rofessionals for some special lecture programmes
and parents.

8

Such efforts would
wou 1 d go a long way in strengthening
collaboration with mental health professionals to help
children cope with the stresses of disasters, .pa

the
the

REFERENCES
-r

Helping children cope with the stresses
Nona Macksoud (1933):
A Manual for Parents and teachers, UNICEF, New York.
of War:
for
(1981):
Manual
Farberow, N.L.
& Gordon, N.S.
Health Workers in Major disasters, NiMH, Maryland.

J.E.
(Eds)
G.V.
Hamburg, D.A.
Adams,
3. Coelho,
Coping and Adaptation. Basic Books Inc 3 New York.

Child
(1974):

The child in his
(1973):
4. Anthony, E.J. & Koupernik, C (Eds)
vol.2, John Wiley
the impact of disease and death.
family:
Sons, New York.
Psychosocial consequences of Disasters Prevention
5. WHO (1992):
Division of Mmental Health, World Health
and Management,
Organ isat ion, Geneva.

9

Dm 6’17-

F

NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH

DRAFT PAPER PREPARED BY :

INFORMATION

TO

BE

Dr.Srikala Bharath
Asst. Professor of psychiatry
NIMHANS, BANGALORE

GIVEN TO THE POPULATION
DISASTER (EARTHQUAKE)

AFFECTED

BY

THE

Dear Friend,
through
a
disastrous
You and your family have been
The experience of the
experience
i.e.,
i.e3
earthquake recently.
peop1e's
disaster must be still fresh in your and other affected
minds.
Though help has been extended to as many people as
possible from various quarters the painful experience of the
disaster and its consequences must be very personal to you.
You
must be seeing people reacting in various ways to this unexpectec
to
event.
Often you may find it difficult to talk about
it
a
others as they also have been affected equally and are not in
position
to offer solace.
In this hour of distress,
the
following information we hope will help you to understand
about
the feelings and reactions strirred up by an unexpected disaster
in the people affected. This, we hope would reassure you that
like the experience (event) the feelings (emotions) also have a
common ground.
From the earlier recorded experience of other
people affected by different types of disasters information will
be provided by us about what help or difficulties you could face
in
future in your strife to reorganize your and
family's
life.
We will also suggest a few ways to cope and reestablish yourself.

At the time of disaster:
1. Shock:
The earthquake struck at the most unexpected time
(night).
Naturally you would have been shocked. Often you might not have
felt it was real but a bad—dream (disbelief).

2.
Many panic Often your heart may go fast, mouth may become
dry.
However fear is more common and understandable. For eg., if
1OOO people are trapped in a small space, in panic all
of them
may try to get out at the same time causing a stampede.

3. Even now, though the disaster is over, often you would feel
helpless and abandoned and may look forward for rescue. You may
feel
like going away to a place of safety.
However safety of
your children, old parents and women would became more
important
People in disasters help each other
th an your personal safety.
is a
It
and try and stay together to give and take help.
strength.

This may be
4. Often you may feel e1 ated that you have survived,
puzzling and frightening to you — when you have 'lost' a near and
dear person and must be feeling depressed, how is i t you are
feeling happy and relieved. It is a normal feeling, Do not feel
guilty abou t it.

5,
Hereafter, you may remember and reexperience the disaster
earthquake repeatedly - including the shaking,
rumb1e‘
and
cracking of the earth, shrieking of people,
Even small sounds
may trigger these experience,
This may happen more at nights as
the earthquake happened in night.

6. You may find yourself too alert - responding to each and every
sound,
light
in the surrounding, looking for signs of further
disasters.
This may prevent you from sleeping.
Sometimes you
may become irritable and angry.

You may find others being 'numb and empty',
They may fail
feel
anything
even the
loss of near and dear.
It may
surprising and worrying to you.
8. Very few can have a total breakdown - excited,
wandering, saying same things again and again.

to
be

confused,

The above said start decreasing in most of the people when
they
initiate some actions to reorganize
reestablish
and
themse1ves.
After a few weeks / months though the memories of
the disaster will be there, they do not stop you from getting on
with your life.
In some however
1. There may be repeated recall of the disaster, decreased sleep,
irritability,
decreased concentration may continue or
increase
and
interfere with their daily functioning.
These people need
help from mental health professionals.

2. Many especially children may develop physical complaints
like
abdominal
pains,
headache,
body—pain.
In these people,
the
mental stress acts in the body and causes these complaints,
If
given
the required help to express their emotions and to cope
their bodily complaints would decrease.

Seme of the difficulties you / others may face in futures

I-

If you have lost a near and dear one
parent or sib you may feel —

(1)
(2)
(3)
(4)

Why me and my family, when there are others?
Gui11y that you h av e survi v ed
Guilty that you did not try enough to save the dead relative
You may not be able to even mourn for the dead as you have
to protect and provide for the living. This increases guilt
and anguish.

like

spouse,

child,

II.
If you have not lost any family members but only property,
there may be a sense of relief, elation.
However, as days go by
the difficulties in reestablishing yourself would be there due
to:
(1) Loss of house, land, cattle, personal belongings.
(2) Lack of facilities , at the temporary residence.
(3)
Having
to depend on friends and
relatives who are not
affected by the disaster, governmental and non-governmental
o rg an i z a t i on .
(4)
The help
and aid from the above said quarters may start
drying out.
(5)
Help from government in getting you permanent house,
land.
job may be slow.

The above can make you feel angry or depressed,
the troubles you already have.

This may add

to

Hence uie suggest that:~
Personal level :

1. Seek and get information about the disaster and its
i ts recurrence
and not believe in rumours which go around during such times.

2.

If you / family members are not seriously hurt try and be with
together.
them together.
Sending women and children to far off places
for the sake of safety may be anxiety producing,
Even
in
temporary dwellings be with known community people
peopl
i.e. same
villagers.

3.

If some family member has to be shifted to a far off hosp i tai
for treatment, keep him / her informed abou*t your safety,
Get
information about his/her condition as often as possible.

3

-■■■■■

—
-

■

*

4. Though all of you have had the same experience do talk or even
write about the disaster, you experiences and feelings to your
family members eg., spouse, friends, acquaintances.
It will
help you to give way to your emotions.

5. Touching and comforting your family members
especially
children and old people is beneficial to you and others.
6.If you have lost family members, to the extent possible try to
do the last rites.
It is necessary to say
'Bye'
to the
departed in your own way.

7. Rituals like ‘prayers, mourning' are very helpful;
or initiate such rituals.

SQ

join

8.If you are unhurt take part in rescue operations.

Community level:
1.

Give
information to others about
either through talking
(loud
placards.

disaster,
speakers)

help available
or posters
/

2. Organize group for * rescue operations, disbursement of food
water nd medicines.
Identify a leader for each group,
Each
group should have a specific work.

Later:
1 < Seek information about aids extended and organize groups to
represent your village to seek the help / aid.
2. Be prepared for delays and difficulties
3. Organize 'self help groups' to <1) procure aid, (2) to discuss
emotions associated with the disaster.
People who have
lost
family members
i
could join together to grieve and
later work
through it.
4. Encourage
and
listen to other people talking about the
disaster.
Some 111
i
the personnel who will be involved in giving help / aid
in a disaster (at the time of disaster). 1. Local
administrative
~ Tahsildar, panchayat people.
collector, BDO

2.
3.
4.
5.
6.

Local health authorities: Doctors, nurses,
nurses. health
anganwadi workers, mental health professionals
Fire brigade
Army
Voluntary organizations
Media

A

;'

workers.

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Later;
1- Local Administrative authorities
authorities

2. Block Development authorities

3. Agricultural officers
' 5* PWDSrinary
Animal husbandary officials
6. Local health authorities.

.

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DM G-’3
Date : 4/10/1993

DISASTER MANAGEMENT AT LATUR:

ROLE OF MENTAL HEALTH PROFESSIONALS

- Dr. Harish Shetty
M.D. D.P.M.
Research Psychiatrist

The Latur earthquake is one of the major disasters affecting the country in recent times. The magnitude of the

catastrophe in terms of death and destruction has not yet been fully comprehended.
The effect of a disaster though of a short duration is always long lasting. The consequences depends on various factors
like, degree of development of the community (third world countries are more severely affected), its resistance, its culture and its
present level of functioning.
A disaster could be described as an event that destroys all kinds of material and social cues, rendering part of the
community ineffective and inoperative resulting in a collapse of cultural identification with alteration of behaviour.
Literature on disasters have mentioned that mental health professionals could aid in all phases in a disaster, though
their intervention is seldom asked for and their role resisted by organizations initially and the victims later.
Consistent findings show an increase in post disaster prevalence of depressive, generalised anxiety and post traumatic
stress disorder in people exposed to earthquakes, fires, volcanic eruptions, floods, riots and wars. On long term evaluation
disaster victims feel more overwhelmed by daily problems, have a greater decline in their health status and more loss in
employment.
.. A
Following earthquake in Nicaragua several years back & study conducted by the Nicaraguan National
Hospital Hospital concluded that emotional problems persisted even three years following the quake. Hospital admission due to

mental illness increased.
Following the earthquake at Armenia in 1988, Armenian Hospitals reported a sharp rise in the stress level in the
community There was a significant increase in the number of heartattacks, suicides and acts of violence.
Mexico was devastated by an earthquake in 1985 on September 19. A study conducted by’ the> Dept of medical
psychology and psychiatry of the school of Medicine of the Autonomous National University of Mexico (UNAM), revealed that

survivors did suffer from post traumatic stress disorder, anxiety and depression.
Hiroshima Survivors showed that they lived as a separate class, living a life of grief with a loss of their original identify,
Survivors of the Bhopal gas tragedy revealed a prevalence rate of 94/1000 population of mental disorders even after

two years of the tragedy as studied by R. Srinivas Murthy from NIMHANS Bangalore.
Many more studies conducted on disaster victims ieveal similar findings all over the world.
This calls for incorporating mental health professionals in the disaster management cell very early at Latur.
The health ministry should immediately establish links with mental health personnel in the institutions g®°P^Ph'ca,|y
close to the study such as Nagpur, Nasik, Pune, Bombay. Voluntary organizations working in the field of mental health should
also be contacted.
Information on the psychological consequences of the disaster and ways to deal with them should be disseminated
throuqh the media. A list of resources in psychological ai d psychiatric care and instructions of how to gain access should be
prepared. These Centres could be the Primary health care centres government hospitals and Swami Vivekananda Mission

hospital at Latur.
Mental health activities should be aimed at camps the preliminary task is to identify people with mental disorders and

treat them at institutes.
People incharge of camps should be given training in Basic listening skills, identifying major disorder. Basic counselly
(hereby improving the quality of all-round care of the victims.
Dr Vihang Vahia from the Dept of psychological Medicine, R. N. Cooper Hospital, Dr. Hemangi Dhawale Head Dept, of
Psychological Medicine, Nair Hospital and Dr. Shubhangi Parker Head of Unit Dept, of Psychological Medicine, KEM Hospita
have recently gained rich experience in tackling the psychological problems of the recently riot affected at Bombay.^The en a
Health Professionals of the above departments would provide a rich source of information and aid evolution of the Mental health
unit of the Disaster management cell at Latur.
This experience will provide a rich source of learning and help tackle similar problems in the future. It will also provide
the much required training in the field of social psychiatry to mental health professionals as treatment strategies are still largely
restricted to cubicles and institutes.
The Loma Prieta earthquake, Northern California on October 17,1989 is an example of excellent Disaster management.
This was possible due to the response of the citizens who had prior awareness. Prior training and access to information made
the startling difference. The Buildings and the infrastructure designed to meet current standards of earthquake engineering

helped withstand the shock.
Liason with the Earthquake Engineering Researcti Centre at the University of California, Berkeley is recommended.
Dr. Harish Shetty,
Research Psychiatrist, Dept, of Psychological Medicine, R. N. Cooper Hospital.

Tel. Res. 8321780 Clinic 8360720

NATIONAL WORKSPiOF ON DISASTER AND MENTAL HEALTH

Dr. Harish Shetty
Sr. Research officer
R.N. Cooper Hosp i t a1

Draft fflterial prepared by :

LATUR EARTHQUAKE -

PSYCHOSGCIAL STUDY

30th September 1993 spelt the death knoll of a hundred and
partial 1y
56
thirteen
villages,
24 completely destroyed,
38,000 families have been affected
devastated,
and 33 damaged.
w i th the approximate economic loss of 800 crores.
researcher
The magnitude of'z. the catastrophe stimulated the
understand
the
psychosocial study to
to conduct a preliminary
j
impact of this disaster on the local population.

METHODOLOGY:
u sample
of 59 survivors from 21
villages were
saaipl e
A random
A
interviewSd,
i. semistructured proforma with open ended questions
'•>4used to evaluate
1, the current symptoms
2
losses experienced
sequel
of crises
3.
people
’
s
perception towards
4a) relief agencies
b) government’s role

Hamiltons Anxiety Scale and Hamiltons Depressive Rating Scale was
used to score the symptoms.

OBSERVATIONS:

1. Of the 59 survivors 35 were males and 24 females,
2. The highest reported symptoms were a)
b)
c)
d)
s)
f)

Insomnia
Starle reaction
Palpitations and fearfulness
Sadness of mood and hopelessness
Flashbacks
N i ghtmares

1

injury

and

3.

Of
the sample 50% experienced death or personal
rated high on Hamilton’s Depressive Rating Scale.

4,

Those who suffered no loss in terms of death or
higher on the Hamilton’s Anxiety Rating Scale.

5»

of the sample received help within 4
38%
received help after 24 hours.

S,

52%
27%
18%
3 %

7,

66%
of
those who perceived the
I 1 1iterates.

8.

84%
expressed
the feeling that
an
intensity would hit the area again.

9,

faith i n the
Gender-wise the females (75%) expressed complete
measures.
government ’s
role
in
relief
efficiency
of
the
Whereas only 37% of males expressed a similar view.

hours

8%

whereas

perceived the cause of the earthquake to be God’s wish,
expected, the quake to occur
gave 'don’t know’ as an answer.
refused to answer.

cause

of

ear thquake

ear thquake

of

of
quake
interviewed expressed the need
IO.A 11
those
houses to prevent destruction in the near f uture.

11.

rated

injury

86% wanted

were

s i m i1 ar

proof

to be pre-warned by the government.

SUGGESTIONS
risk cases such as sole
survivors.
children,
High
of whom who had a past history of psychiatric
those
to be targetted by mental health personnels on
need
term basis.

2

Information on the psychological consequences of the disaster
and ways to deal with them should be disseminated through the
psych iatric
media.
A list of resources in psycho 1ogica1 and
should
be
how to
gain
access
care
and
instructions
of
prepared and disseminated.

3.

to
trained
be
to
in relief work need
Personne1
i nvo1ved
bas
ic
prov
ide
major psychiatric symptoms and
the
identify
counse11ing.

4.

contex t
Interventions should be tailored within the cultural
No
alien
and
should
be
culture
sensitive.
of the population,
the
Coping
mechanisms
during
symbols
should be introduced,
to
used
predisaster
period
should be studied and could be
evolve fresh strategies.

2

I

widows,
i11ness
a
1 ong

1.

5.

duties
and
should be encouraged to resume
normal
Ch i1d ren
tel ling
could not, should be involved
in
story
those who
orphaned
games and disaster relief.
Adoption
of
sess ions,
should be within the community and any shifting
of
chi 1dren
be
to geographically distant
areas
should
the
population
d i scouraged.

5=

incorporate
psychiatry
Postgraduate
iinstitution
ns t itut ion in
in
should
disaster
management
in
their
training
and
send
their
the i r
af t acted
residents
for
atleast three months to
the
quake
in
area.
This
would
give them the much
needed
training
for
social psychiatry as well as provide motivated personnel
mental
health
relief in these areas.
Rural
internshio
of
MBBS graduates in Maharashtra could be arranged likewise.

3

_C>r\ 6-1^

PSYCHOSOCIAL MANAGEMENT OF
DISASTER CONSEQUENCES

(MARATHWADA EARTHQUAKE p 3 Oth 3eptO(7 ’93)

bv. Mo\an

*

he MeJvi.

An earthquake measuring 6.8 on Richter Scale with the
epicentre located at Killari in District Latur of Marathwada,
struck the region in the early hours (3.58 am) of 30tty Sept
1993.

It was experienced widely within the radius of

approximately 300 kms.
Maximum devastation was caused in 62 villages of the two
districts namely Latur and Osmanabad, affecting a population

of over 1.5 lakhs.

Geographically these villages are located

in a narrow strip on the banks of the Terna river. This area
is located 4 5 kms from the toryvn of Latur and 2 0 kms from Omerga.

Pre-Quake Geography and Sociology of the iReqion :
The affected sites are located in the districts of Latur
Sc Osmanabad which are in Maharashtra region of the State of
Maharashtrao

Geographically,
Geographically5 Marathwada forms Southeast border

of the state which touches the states of Karnataka & Andhra

Pradesho

Part of the erstwhile Nizam state, Osmanabad has a

long history and the two districts of Osmnabad & Latur were

separated a decade ago to facilitate administrationo

The

affected area falls within three talukas of these two districts
viz

Ausa and Nilanga in Latur and Omerga in 0smanabado

Pre-Quake population and Area of these districts is as follows-t
Latur 2 Population

16,73,060

Area:

7^157 Sq.km*

Osmanabad: Population

12,71870

Area

7^569 Sqokmo

Ausa ( Latur )

: Population 89,265

Population

Nilanga (Latur): Population 23,468
of the three
Omerga (Osmanabad)sPopulation 73,169 affected talukaso
•4

Agricultural activity is the chief means of livelihood in
this region0
In the rural areas^ almost half of the population
owns lando Though chronic drought has adversely affected the
economy of this region^ good quality black cotton soil .and

increasing availability of Irrigation facilities have gone a

long way to counter-balance the adversities..
sugarcane

Sunflower,
o

2/-Contdo

2

and grape are the main crops on irrigated farms while Jawar is
grown on the non-irrigated land® The region has rich trade links wif
the neighbourino areas and one of the worst hit townships namely

Killari was a major trade centre in this area o

The village size here ranges from 700 to 13^000 populationo
Majority are Hindus ( Predominantly Marathas, Lingayats and
Dalits)but Cmerga has sizeable Muslim population as well® There
are few Buddhistso

Socio-culturally, this region has retained orthodox out­

look® Extended and joint families are common and people are
religious by orientation. Festivals like Ganapati festival
are celebrated enthusiastically in which the whole villages
participates. Bhajan Mandals are common in these villages. Despite
orthodoxy in other social spheres, literacy is very high and in
the State of Maharashtra, Latur has been doing extremely well
on the literacy drive score.

In the macro structure of village social distance is
4- -

i

coa

->

wc?*=»o

,-F -fho

2I

q

2?1 ,or' A-bod

at

the

Those from socio-economically backward
classes stay in huts or tin roofed houses & better off ones
have large house -"Wadas"0 many of which are ancestral, Their

periphery of the village.

architectural peculiarity is that the slab is laid either
on a wooden frame (called Imla) or white mud is plastered on

stones arranged on the frame ( Called Malwad type roof)o Deep
foundation pillars are conspicuous by their absence and walls ®
are made of piles of large square stones.

It is this particular

type of houses which piayed a significant role in determining

the magnitude of human loss and hence the disaster®

Seismic Activity in the Areao
Though originally categorized ( by the Geological Survey

of India) as a low risk zone, the region has been experiencing
tremors of varying intensities at regular intervals in the

past yearo

This initially had triggered off concern in the

villages but it gradually died down and people got adapted as
it becemes a regular feature®
Health/Mental Health Facilities in the Region*

In the Government sector^ Public Health has its netiwork

3

of Primary Health Centreso

There is a Civil Hospital at each

district place and rural hospitals at the taluka places.

As far as mental Health facilities are concerned, there
is no resident Government Psychiatrist in these two districts

but a visiting one from Regional Mental Hospital, Pune visits
each Civil Hospital once a month providing outpatient services

In Private sector, a psychiatrist Couple has started
their Practice at Latur in 1991 while Osmanabad has none •
Description of the Disaster:

When the quake brought down Imla Sc Malvad poofs

most
of the population was fast asleepo Electricity went off
immediately and people got trapped in the debris.
Because of a rumour that the dam on the river Terna,
located nearby had got burst and there was danger of flood as
well^ the survivors reportedly fled from the spot to save
their lives.

Another tremor rocked the area within a few minutes and
again after an hour to make the devastation total which claimed
approximately 10^000 lives.

Because of extended or joint family sharing of a common
roof t a pattern of loss emerged such .that multiple losses
tended to cluster in families i o e a Survivors who had physical

injuries had also lost relaties (Usually multiple) apart from
property losses, While cither group of survivors had no major
injuries or human loss.
Level of Exposure and Post Disastier Environment,
Large number of Survivors were trapped in the debris and
had near death experience. They also witnessed their relaties

crying for help and ultimately succumbing to their injuries.
Young adults were involved in immediate rescue operation
as well as recovering the bodies of the deceased and creamating
them and thus had a high level of exposure too
Almost a week following the earthqu*ake? the region

experienced heavy rains making the rescue-soperations difficulty

Tremors of less intensity continued to rock the area periodically
The significance of high level of exposure and harsh
post disaster environment lies in the fact that it amounts
to greater psychological stress and may affect vulnerable
• • o

a •

4

individuals adversely both in the early phase as well as a

delayed reactiono

Immediate Relief Measureso
Immediate relief was provided by citizens of Latur

& Osmerga who rushed to the spot within an hour of the first
quake. They transported the wounded to the hospitals.
State machinery also moved in at a quick pace and the army

was summoned in to helpo
Immediate relief measures were in the form of provi­
ding shelter and food and looking after the physical health

of the survivors.

76 Medical teams from the public health

were posted, one at each village who took preventive steps
in controlling communicable diseases as well apart from
treatment of minor physical injuries. Government psychiatrists
rd
were deputed to work in the field from the 3 day post
disaster 0
The Maharashtra Institute of Mental Health/ Pune

took initiative in extending its expert manpower and resources
for identifying the possible role of psychological management
of disaster consequences and was identified as the nodal

agency by the State Government of Maharashtra inthe 1st week

of Octo,1993o

MIMEPs Activities in the Management of Consequences of
Disastero

Two NIMH teams

(One headedy by the Director and another

by DroMrs.Pande, Associate Professor) carried out initial
assessment by visiting the affected population in villages as

well as hospitals where the injured were being treated vizo

at Solapur/ Osmanabad & Latur.
The assessment was carried out utilizing.
Group interaction with the affected and the injured
(1)
both in the hospitals and at the fieldo
Assessment of representative individual cases chosen
(2)
from Various groups (Adult Males Sc Females, Adolescents,
elderly Sc Children, bereaved Sc non-bereaved, injured ones,

those who suffered multiple losses Sc minimal losses)

(3)
Informant interviews:! gathering perceptions of
(a) local Mental health professional (b) Other health
professionals both in the hospital and field (c)
o O

O 4 • Q O Q

■

.

(c) Senior health administrators

•<

>•

4^--

(d) Senior sixrtxx district &

State administrators o

Assessment Highlightstmultidimensional approach whs used to judge the type of
and the magnitude vizo severity of loss, phase of grief,
erebsion of social
network, presence of injuries
present location (in the field/hospital)etc•

The three broad categories errierged were:

(1)

Major Psychiatric morbidity.

(2)

High risk groups.

(3)

Remaining affected population.
Two remarkable observations about the lStgroup were:

(a) No increase in prevalence above the usual levelo
(b) Easily identified by lay peopleo (ii) High risk group:

This label has been given to those individuals who are either
symptomatic now or liable to develop psychological outcome.

Highest risk was considered for those individuals who
had a specific combination of certain variables viz. human
losses, physical injury, grief process delayed in progression

or having pathological features, erosion of social network

segregation and remote from the field reality etc.
iii) Remaining affected pppulation :-

Though almost every individual in the affected area was
experiencing sleep disturbances, heightened anxiety of dysphoria,
lack of concentration etc. it was felt that these emotions were
appropri. ate and natural for the disaster experience and
environmental conditions&per se didnot make them psychiatric
caseso Based upon the scientific literature pertaining to
disaster, it was expected that the psychological condition of the

majoritity of them would settle over a period of 2 weeks and
only a few of them may remain symptomatic to qualify for a
psychiatric easeo
Magnitude: (1) Geographically the high risk individuals were
located mainly in the 34 villages signed "A" ’category by the
District Administration:(
(A category criteria being, deaths morethan 5
9

more than 70% houses damaged ).
(18

villages in Ausa Taluka, 14 km in Omerga & 2 in Nilanga)
o o a 5 • o q

-

5 ...

Total population of this area is 55,000Approximately^ 15% population of (65,000) falls in the
high risk category (approx. 10,000 with tange of 6,500 -13,000)
at this point of time.

Needs emerging from the assessment;-

(1)

Highest risk individuals (viz hospitalized) to be
given psychol Q inputs as an immediate measure.

(2)

the high risk population in the field should have

at least one contact to screen them to identify a case and
initiate treatment.

Together, this would amount to initiation of primacy
and secondary prevention.)

Long term needs: These are determined by the long
term consequcnes of disaster as reported in literature viz.

increase psychological morbidity in vulnerable population in
the form of PTSD, pathological grief, substance abuse,

scholastic underachievement and other problems in children etc.

Highlights of the Action Plan for intervention

MIMH initiated on its own resources, delivery of immediate
service to those who were assigned the highest risk category.

(2)

A short term plan to cover all the high risk population

by organising outreach counselling & psychosocial services.
(3)
A long term plan to take care of the mental health

needs of the affected population in a continuous and comprehensive
manner through the Distric Mental Health Centres(DMHCs)
Immediate Intervention:

Intervention for the highest risk hospitalized population
was carried out in the 3RD week post disaster.
Apart from the felt psychological needs of this population,
the needs of intervention to this group was further heightened by
the fact that, medical personnel found it difficult to handle
their Psychological state and to convey then? the txtent of their
losses including breaking the news of deaths to survirors in some
instances. This group had also started posing discharge problems.
Method of intervention:-

(1)

Single session supportive Group Counselling by trained

Counsellor (Done under supervision)
000600*.

66....
(2)
Individual level counselling and or therapeutic interaction
especially for the nonambulatory caseso

Training: The training for this intervention was carried
out over 3 days in six sessions using audiovisual training

material.

The team of Counsellors comprised of 2 Psychiatric

' Social Workers, 2 nursing Counsellors and one Psychiatrist
who was deputed as DMHO at Latur.

All of them had previous experience in conducting psychoeducational Groups for relatives of mentally ill patients.
Immediate Intervention was carried out at the followrinqs!
Sites:-l) Solapur Civil Hospitalo

2) Osraanabad Civil Hospital.

3) Ambejogain Medical College Hospital.
Services were provided to 232 high risk individuals.

Short Term Intervention Plan:- Organisation of Outreach
Services:The Chief objectives of this phase ( beginning 4 weeks
post disaster) wereo
I i
— *

' /c.

n

i

i

i

a

r—
K. -u

cr* 3,*
A x.

XX

■. f
V X

a

A J. K-I

<-1114^1 AU C O

L- X I tT

Q X L CV. C

population in the field.

2)

Initiation of intervention for these individuals sc

defected (Preferentially psychosocial inputs and using medications
as and when essential)
3)

Providing information to the affected population about

continuous availability of mental health care facility through
DMHC & creating a referral system through network of resource
persons in the community as well as through Government health system.,
4)
Initiation of '’need-based'1 research (i0e0bo address

issues which are inportant from the point of view of effective
delivery of services e.go information about point prevalence,
types of psychological problems, studying the course of grief

process,9 anxiety problems^ cost effectiveness of case approach
etc.)
5)
Building a data base for all the detected high risk cases
and facilitate follow up of these cases as well as monietering
the services in the long run.

6)
Contacting and studying the problems of special groups
like children, elderly, young widows etc.
The short term plan commenced after 4 weeks of disaster
and is expected to continue till 12-14 weeks post disastero
--- 7 0 0*0

. . 7. .

Like the immediate intervention, this phase is also being

effected by MIMH on its own resourceso

Appropriate modification in tl

training modules has been done to accomdodate 11) the changing
time frame and the consequent socippolitical and other changes in
the post disaster environment & (2) The communities ±n gradual

closure compared to the openers to receive outside relief in the
earlier weeks.
The subsequent teams of counsellors thus trained in the
hands on intensive training package included student counsellors
enrolled for counselling course at the institute^ post graduate
students in Psychiatry and the Junior faculty members vizo
Assistant lecturers and lectures in Psychiatry o

Population covered so far ( for detection and. intervention)
is approximately 25,000 population in 15 villages from A Zone
Services provided to £J02 individuals,.
Follow up visits made in 4 villages so far revealed
Io

Positive indication of acceptance of our serviceso

2O

+ve indication regarding utility of ’’high risk ” label□

3O

New cases emerged, indicating need for periodic & regular
screening in future.
Planning & Preparation for the long term managemento

While the work of shott term intervention is ongoing^ the
institute has begun exoloring possibilities of identifying volun­
tary workers who could form the grass root level netv/ork. Administr
ative process for setting up and activating two Distric Mental
Health Centres at Latur and Omerga is in progress and the

Psychiatrists identified to work at these centres are already
working in the field with the MIMH teams.

The District Mental Health Unit would offer multifold
services

Outpatient & in patient (10 beds ) services at. the hospitals
Conducting training programmes for Medical Officers Q
multipurpose workers Ofr the PHG0s under the respective districts.
(1)
(2)

(3)

Supervision of the work done by the MO ’ s and R MFW’s along
with on job tnaining(4)
Conducto ng refreshers courses as designed by the Institute<,

(5)

Organising community involvement by

encour­

aging contribution from various voluntary agencies in the
district.

•o.8o«

-

; a-r.. -

■■'A

AAW*

■

..

..

. ..... .
rr'ir’r.-

'...............................................

■

F

NATIONAL WORKSHOP ON DISASTER AND MENTALHEALTH

Dr. Satish Girimaji
Assoc. Professor of Psychiatry
NIMHANS, BANGALORE.

Draft paper prpepared by:

COMMUNITY

FOR

LEVEL HELPERS
(VOLUNTEERS,
GRAMASEVAKAS, TAHSILDARS)

WORKERS,

HEALTH

SCHEME

1.
2.
3.
45.
6.

Introduction
Identification of needs
Specific information relevant to groups
Details of training to achieve information transfer
Support and supervision
Indicators of effectiveness of their work

1. INTRODUCTION:
This group forms an important link by the
virtue of their
being grass—root level workers and involvement in primary care
set up.
They are likely to be localites, know the community and area
well,
and often have close ties with several people
in the
village.

These aspects become an asset in post-disaster psychosocial
intervention, irrespective of heir level of training / expert ise
in disaster work.
They could have specific roles in early phases of disaster
(establishig contact when affected people are open,
public
education,
anticipatory guidance, reassurance <about symptoms,
wel 1
1 ater
detection / referral of gross break-downs), as well
in
phases
(detection and referral of PTSD, carrying out s i mp1e
psychosocial
interventions
such as
ventilation,
support,
guidance, follow up of affected persons).

—
Assisting
realities.

other team members in appraising

them

of

ground

2. IDENTIFICATION OF NEEDS:
This group, to function as disaster workers, are in eed
following kinds of inputs —

of
•

..

.

'

... ....

:

•

•

AAA:: .-‘-/’O’-’

A'.::AA-A 'A

■

I

„<

■A:

2.1. Orientation to disaster work
2.2. Skills training in detection / intervention skills

2.3. Support for involving in this kind of work support meaning
material, organisational and emotional.
atf1ictions in
2.4. Identification and remediation of personal
group members themselves.

3. SPECIFIC INFORMATION RELEVANT TO THIS GROUP:

This has also been dealt with under course content section
of training section.
Information provided to this group shou1d
serve the twin purpose of sensitising / focussing on the
importance of psycho-social work and enhancing the prearedness to
do such work.
Following is a list of areas of information
relevant to the group.

Specific information should cover

1. Some scientific information of the
severity, of disaster agent.

cause,

nature,

extent,

2. Information on type, extent, severity of the life / material /
physical damage as a result of disaster
information
3. Updating of such information periodically.
Such
would help in cognitive control over the event and also helps in
rumour control.

4. Theory of psychosocial aftermath*of disaster for e.g., dose of
peoples
exposure,
immediate responses,
phases of disaster,
responses to disaster, psychological consequences and impairments
following exposure to disaster, both immediate and delayed, and
intervention:
5.
Available knowledge about techniques
of
educating helpers about techniques of intervention, and also how
they work.

6. These aspects can be preared as a booklet or information sheet
in the form of simple message.

Affifi'"

L-U.

; r-

....-.... .......................... r.......... -...... ■-

■

—

-

2- ■

..•f.

.....................................................................

-

.

■

.

-

•

‘

■

r.

-

4. DETAILS OF TRAINING TO ACHIEVE INFORMATION TRANSFER:

Scheme

Aims and Objectives
Method of training (including duration)
Course content
Materials.

4.1. Aims and Objectives:

4.1.1.
4.1.2.
4.1.3.
4.1.4.
4.1.5.

Sensi tisation
Enhance knowledge base
Enhance degree of preareness for work
Skills of detection / intervention, follow up
Skills of working as a link

4.2. Method of Training:
Duration:

De to 5 days, depending on need.
Total number of hours - around 10.
- Group discussions: Facilitate sharing of own experiences,
giving details.
- Lectures, audio / video materials
- Hypothetical situations
- Role play
- Supervised field exercise
- Booster sessions with feedback.

4.3. Course content:

4.3.1. Key concepts of disaster:

Pre-disaster situations,
types of disasters,
people's
immediate responses, post—disaster phases, short-term and
longterm
psychological
effects and their determinents,
issues
concerning detection, rationale for early intervention,
effects
of
early interventions,
sub-populations
needing
prolonged
intrvent ions>,
techniques of interventions and their effects.
special population (for e.g. children).

4.3.2. Training in simple intervention skills in the following
areas:
Simple counselling skills: Skills of interviewing,
rapport
building,
allowing
ventilatidn,
reexperiencing, and emotional support.
■

.

■

3

empathising,
regriefing,

I
■/<.

.

■
■■

3

w

' W-

•-

■

.I
.■

I
--

-

intervention skills:
Crisis
Listening,
focussing,
problem
evaluation, resource evaluation. and developing plan of action.
Organising group meetings of survivors:
Skills of getting
survivors,
physically injured,
and bereaved
individuals and
families together, acting as facilitator for sharing experiences;
building a sense of togetherness,
and finally
encouraging
organised efforts by affected populations themselves.

4.3.3.
Awareness, prevention,
recognition
strategies in respect of stress/burn-out.

4.4.

and

self-initiated

Training materials:

- Simplified version of WHO document
- Simple manual covering information,
need for psycho—
social work, and detection/intervention skills.
- Checklists for psychosocial consequences, PTSD, etc.
- Examples of actual situations
- Video/Audio recordings of emotional aspects of previous
disasters.

5. SUPPORT AND SUPERVISION :
5.1.
5.2.

5.3.

5.4.
5.5.

Forum or opportunity to interact with organisers at h igher
levels.
They need to have a say - have to be involved in decision
making.
Need to be spoken to, preferably in groups, about updating
of information, clarifying doubts/ uncertainities about
rescue / relief/ rehabilitation work.
Debriefing
Identification and management of stress/burnout .

6. INDICATORS OF EFFECTIVENESS OF THEIR WORK :
6.1.
6.2.

Rapport enjoyed by workers in community,
satisfacton by a sample of affected people
received.
'Care' detection rte

4

expressed
about help

„ ..I

^3^

.

. ./ I . JHJ H |IL

"■

-__ • >

- - i-

Important source documents;

1.

WHO — Psychosocial consequences of disaster - prevention
management (1992)

2.

NIMH — Traiing Manual for human service
disaster, US Dept, of Health, NIMH (1978

3.

NIMH - Disaster work and mental
control of stress among workers.
Human Services (1985).

5

workers

in

and

major

health:
prevention and
US Dept,
of Health and

J 3)^1

NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH

Draft paper prepared by :

Dr. Somnath Chatterji
Addl. Professor of psychiatry
NIMHANS, BANGALORE.

RESEARCH PRIORITIES IN DISASTER AND MENTAL HEALTH

Though Samuel Pepys gave a graphic account of both his own
1966,
reactions and reactions of others to the fire in London in
effects
of
a more formal appraisal of the psychophysiological
Physicians
massive trauma began only in the nineteenth century,
importance of
were now becoming increasingly aware of the
environmental
familial factors in the etiology of psychiatric
illness.
Attention turned to the psychological effects of combat
characterised by a
and syndromes like the 'irritable heart'
nightmares and
range of physical symptoms as well as phobias,
'nervousness' were described in soldiers. Soldiers were seen to
and
insomn i a,
suffer from anxiety attacks.
Startle reactions,
of
other
forms
repetitive battle dreams.
Since then several
has
Interest
psychological
stressors have been examined,
focussed on both victims of community disasters like fires,
earthquakes,
etc., and on individual victims of extreme stress
such as rape, personal violence or kidnap.
that such
Despite this long history,
critics claimed
in
psychological
react
reactions
ions were mainly a form of malingering
maintained that
pursuit of personal gain like compensation or
i
they were really the manifestation of another psychopathological
The syndrome of
disorder,
eg.,
eg. , a form of personality disorder,
post traumatic stress disorder (PTSD) first received official
Diagnostic
and
recognition
in
the third edition of the
Statistical manual of mental disorders (DSM III) of the American
in 1980.
Since then it has been the
Psychiatric Association
of
extensive
research
and
has
been shown to carry risks
subject
and
morbidity,
mortality,
increased physical
of chronicity,
and
and impairment in
interpersonal
psychiatric disturbances,
occupational functioning.

A diagnosis of posttraumatic stress disoreer is established
by interview and additional questionnaires
may
supplement
information.
Rating scales like the Impact of Event Scale which
assess the degree of subjective distress experienced have been
used to rate the severity. Several methodological difficulties,
however, have been recognised latelyResponse rates
may
significantly influence estimates of prevalence because those who
refuse participation
part ic ipat ion are often those who suffer from the most
severe form of PTSD.
It is difficult to ’obtain a suitable
control group for the survivors of a disaster. The definition of
a traumatic event poses several problems because it is difficult

1

to define which events are outside
'usual experience
and are
markedly distressing to almost anyone'.
The most
critical
determinants seem to be the perception of life threat, perceived
physical violence,
experience of extreme fear and a sense of
helplessness.
Therefore, psychiatric and diagnostic measures
need to be validated against clinical interviews.
The DSN IV
’ task force believes that a data based field study is the best
way to define the nature of the stressor.
On the basis of this
data, it will be possible to arrive at a more informed opinion as
to whether the definition ought to be narrow or broad and whether
included
subjective response or event characteristics should be
or not.
available with
Presently,
adequate
information
is not
regard! to the natural history of PTSD because very few stud i es
have followed up cohorts systematically over time with repeated
intervention.
Repeated
planned assessments with and without
intervention,
of
the
same
population
has
revealed
a
functioning
sampling
oooulation
Further the need to study how symptoms vary
pattern of symptoms,
with coping mechanisms available within the cultural environment
PTSD is currently
recovery occurs has been emphasised.
where
is
as
an
anxiety
disorder
and
yet
dissociation
conceptualised
may
to
be
an
important
part
of
the
syndrome.
PTSD
considered
Though
vary across different subgroups eg. children vs. adults,
good interrater agreement and internal consistency have been
demonstrated for the PTSD criteria, there has been a
lack of
.3.3..—s i s t en t methdology.
Though PTSD ha^ been shown
to be
associated with alcoholism, other issues of comorbidity need to
be systematically assessed.
The methodology used to assess
comorbidity will often significantly influence rates.

Thus the research priorities in studying the mental
consequences of a disaster are as follows:

health

1.
A common methodology needs to be involved that will make
data collected from various parts of the world comparable.
impact
Towards this end common instruments for assessment of the
the
(unexpective of this specific nature),
of the disaster
for
* 1 cases with psychological problems and
screening of_ potential
detailed
assessment
of
psychiatric
symptoms
need
to
be
agreed
the l.
Presently the Composite International Diagnostic Interview
upon.
in
the
Schedules
for
Clinical
Assessment
(CIDI)
and
The
(SCAN) would serve the
latter purpose,
Neuropsychiatry
and
impact of Event Scale could be used to assess the intrusive
interview
Other semistructured
avoidance outsets of behaviour.
could be developed to assess loss, threat and dnger
techniques
stressfulness of an eventThe General Health
and
perceived
the
Symptom Check List
Questionnaire (in GHQ various versions) or
Thi^
would also then
(SCL - 90) could be used for screening,
rates
that could be
and
prevalence
give accurate
incidence
compared across studies.

2

!

react ions
2.
Acute
and chronic forms of psychological
following
trauma need to be identified more clearly in order to
differentiate them on other parameters like vulnerability, course
to
and outcome,
treatment response,
etc.
Factors related
chronicity need to be studied more extensivly.
the
3.
Behavioural patterns that
are more specific to
psychological
consequences of disaster (to the exclusion of
be
anxiety,
depression and dissociative states)
need
to
identified.
This would justify placing these disorders in an
independent category in future revisions of
classificatory
systems.
This would perhaps also help delineation of populations
for biological research and for issues related to compensation.

4.
The national history of the psychological consequences of
disaster needs to be examined over the years.
This would also
help identify especially vulnerable
individuals and perhaps
delineate special groups for more intensive intervention.
intervention
5.
Systematic studies need to be undertaken of
beyodiazepines,
these conditionsThough
techniques
for
group psychotherapy
individual psychotherapy,
antidepressants,
employed,
only one
techniques have all been
and behavioural
control1ed study exists to date and the comparative efficacy of
all these methods is largely unknownThis becomes all the imore
i < u i <«ick v ▲
wt
i ex v
auiiic
important in the context of some li
informations
that
some of these
techniques may in fact be harmfulFurther studies need to
a
address the question whether some of these techniques have
differential
effect on different subsets of symptomms that form
the larger cluster of post traumatic psychological syndromes.
This would help professionals provide more efficient treatment.
■»

»—I

—x

d isasters
6Long term and late mental health consequences of
from
this
also need to be studied. Data is not available
rises
country,
for example, as to whether alcohol and drug use
Long term
steeply in these populations as reported in the west.
enduring changes in personality also need to be examined.

Data needs to be generated on the comparative effects of
7.
different
different kinds of disaster eg., man-made Vs. natural,
kinds of natural disasters, different kinds of man-made disaster,
small scale vs. large scale disasters, etc.

is
increasing reason
to
believe
that
the
8.
There
response to a
trauma is also
biologically
psycholog ical
People may be prone to developing these reactions if
determined.
There
is a
need,
they carry a biological vulnerability.
also for a systematic set of studies looking at the
therefore,
biological aspects of a stress related disorder.

3

-S3

•R-~'

■
"
......................................................................................... .............. ............................................................................

■■

7

•wgfe

V'-

R

: •?-

In conclusion it must be emphasised that any research
in
this
area must enlist the cooperation of not
only
the
participants who are the victims of the disaster but also other
local leaders and mental health workers in the area.
area,
Researchers
must be culturally sensitive nd work in close cooperation with
'the local population. Research information must be constantly
used to improve services in this affected population.

... .'.v

■■ J-

<

4
■■■■»

;;

»

Dm 6-14
-

The Bombay Crisis
»»«»««««*«lt«**»«««»«it«ltltit»»ll«*««««»tt»««««»|||tltl||tll««»»«««««MII«l*«lltt»«««»«
Dr.

Dr.

V thong N.Vah.ia. X&n&aaa,y
and tPaef &f- ^^'yc/ilalay
^K.aiaKna Jy&ti 3Kaaadu>a/ - P^'ycKlataic ^f&ciat
Harish. AC. She tty - Cfenl&a ^^>caach Offiaea

I*

X.

and

‘S. If. Jtedicat

400 0f 6

Bombay witnessed massive ethnic and terrorist violence in the
recent
past. The magnitude of the disturbances is difficult
to
judge.
One
indicator of the social impact of the riots comes from the educat i on
department of
the Municipal
Corporation of Greater
Bombay.
This
department has reported
that 30,000 students had dropped out of
the
Municipal schools after the riots. (Dan'avate 1993). A month after the
riots,
a committee
of
mental
health professionals,
journalists,
teachers
and
social
workers,
was constituted by the
District
Collector of Bombay, to study the available data to identify,
contain
and remedy adverse psychological, psychosocial, ethnic or
sectarian
influences found to be prevailing
in the community,
Department
of
psychological medicine, Dr.R.N.Cooper Hospital, and Seth G.S.Medical
College Bombay; actively participated in this ectivity.

The department reviewed
the available
literature.
A proforma was
designed
to record occurrence of
intrusive thoughts
flashbacks,
avoidance behavior or any other riot related
psychological
distress,
Volunteer student nurses, non medical volunteers and college students,
working for the Sheriff’s Platform for Communal Harmony, were
trained
to fill the proforma and to conduct field interviews using
techniques
of free association,
semi-structured &< structured
interviews and
questions•
d i rect
In the months of January to April, 1993; the team made 17 field, trips
the
team
to six relief camps / riot affected areas, At every visit,
10 to 20
consisted of minimum of three department staff amongst its
initiated a
members. On arrival at the camp site, one
staff member
general talk with the community and other staff members spread out
to
The
identify
the more disturbed
or
skeptics
in the community,
community would be told that we had seen some emotionally disturbed
some
people in the hospital and the field trip was to help others get
1 eras.
help as well help us to gain insight into their prob
problems.
They were
members.
then asked to individually
speak
to the
team members.
Individual
interviews lasted 10 to 30 minutes, depending upon individual needs,

the
violence,
We surveyed over 4,000 directly affected victims of
the
Follow up visits, where possible, were two to four weeks
after
had approached the hospital
for
first visit. Fifty four cases who
interv iewed and
disaster related psychological
distress
were al so
details recorded on the proforma,
8^9 documented interviews were
ana 1yzed.
2

#*-

f
ft

2

The data thus collected by us,
observations:

1) al I

reveals following

saIi ent

qua 1i tat i ve

the victims wanted to talk to someone.

the
victims
and
2) the team was warmly received on follow up visits
on
suggest i ons
and
talked more freely about
their
perceptions
reassurance
of
as
follow up visits.
Rev i s i ts
Revisits
were perceived
support.

3)

the
the victims refused to come to the hospital to talk to
staff,
they willingly waited near their homes for the team to arrive.

community leaders felt
4) relief workers and local
visits were a boost to their morale.

that

the

team’s

5) areas and lanes where women were strong or took up initiative, were
to normalcy
norma 1cy quickly.
returned
either free of
disturbances or
arrival
of
external
with
However, the comradeship disintegrated
help,
numbness of
avoidance behav i or,
6) intrusive thoughts, flashbacks,
ghetto mentality
emotions, hyperarousal, 'existential di1emma* and
were evident in some areas.
active
or
i nact i on,
7) many victims perceived government’s apathy,
to
violence
ethnic
of
the
collusion with the
perpetrators
aggravate their suffering.
evidence
of
thoughts,
8) youth and
adolescents exhibit
intrusive
hyperarousal and a desire for revenge.
and
middle aged
9) avoidance behavior is more
frequent amongst the
middle and upper middle socio-economic groups
es
10 Help providers come up with spontaneously designed strategies
with
short term targets. Sustained long term efforts are not evident.

11 Participation of untrained enthusiastic volunteers should be
strict qualified supervision.

under

12 Long term impact should be studied.

Quantitative analysis of the data is enclosed. It represents trends in
to be
undertaken.
Statistical
analysis
is yet
the
population.
Following observations merit attention:
1) Children are under represented in the documented data,

2) Somatic symptoms are noticed in adults
over t
avo1 dance o r
have
less
3) Ch11 dren seem to adapt well,
depression.
groups•
age
4) Intrusive thinking is prevalent equally amongst all
Children
aport less symptoms of being hyper aroused.
5) The clinical presentation varies with geographical
camps.

locations of the

3

:: 3

6) There is no gender difference in clinical
presentation.
7) Avoidance is the commonest manifestation.
8) mnnfh
Hyperarousal
thinking
and hostility
r.K ’,intrusive
e thinkin
« and
increased
month of the event and decreased with passage of time.
9) Depression increased with passage of time.

10 Perception about the instigator s
the communities

of

the

r lots

differed

after

a

amongst

11 Many felt that the city will never be the
same again.
12 A persistent feeling of uncertainty
was
uncertainty
the commonest
negat i ve
emot i on. Adults tend to be philosophical
about it.
13 The Hindu community, police and politicians
were perceived as
the
perpetrators of the violence.
14 A need to strengthen the citizens peace committees was
large number of the rsurveyed population, 80% of whom felt voiced by
the need
to initiate efforts to
-j ensure that the disturbances do not recur.
Di scuss1 on:

The authors noted that me
administration is
the city
city administration
is not geared
to
dea 1
with major disaster in any preplanned systematic manner,
Absence
of
a
disaster imanagement
-------policy is further compounded by
lack
of
trained
staff and paucity of funds. We perceived an urgent
need
to
generate
awareness amongst mental
health professionals and
policy
pIanner
s
about the psychological aspects of disaster management.
The citizens of Bombay rapPear to be experiencing a perpetual state
of
hyper-arousal as evident by the ill-famous local
train mi shap
where
some 23 young working women leaped to death and by the deserted
city
roads after 8.00 pm, poor attendance at late night film shows
and a
vague sense of diffidence on the 6th December this year.
Our observations cannot be extrapolated to represent general
trend
of
the city population. Our sample consists of directly affected
victims
of the mass violence. We plan to conduct
a population
survey
to
identify consequences of the trauma inflicted upon the city
Suggestions :

1) The country should have a
or man-made disasters.

disaster

management

p 1 an

2) Psychiatric help
to the victims,
rescue workers,
psychiatric advice to the policy planners is of
great
and long term significance.

for

natura1

police and
short
term

3) Psychiatric assistance should commence immediately after a disaster
and continue till the stage of complete rehabilitation.

4

:: 4
4) It is rather tempting to compensate the non availability of
qualified mental health personnel in the acute stages of disaster
management, by inducting health professionals from other branches
and non medical volunteers. They should be trained to reach out to
the affected population and identify people in need of such help.
Strict supervision of the volunteer workers is recommended.

Acknowledgements:
is
The department of Psychological Medicine, Dr.R.N.Cooper Hospi ta1,
Dr
.
R.N.Cooper
grateful to the Medical Superintendent and the Matron,
the i r
for
Hospital and the Dean, Seth
G.S.Medical
College,
survey
The
encouragement and participation in planning the activity,
was partly funded by the Rotary Club of Bombay North.
The authors of this presentation are a part of the 1arger team,
Dr. N.Sapru,
N.Sapru,
consisting of, amongst others, Dr.
Dr. . A.Khatri, and Mrs.
S.Motiwala; thank the Medical Superintendent Dr.R.N.Cooper Hospi ta1
for permission to present the paper at the national workshop on
disaster management.

- J /\

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9 Existential Dilemma
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7-0

12

CERVICAL SPINE INJURY

Ventilatory support of the quadriplegic pat­
ient with respiratory paralysis by diaphragm
pacing. Surg. Clin. N. Am. 60:1055 (i960).

43. Brindley, G. S. Electroejaculacion : Its techni­
que, Neurological implications .vid use. J.
Neurol. Neurosurg. Psychiat. 44:9 (1981).

37. Multicericre Conference on the Multidisci­
plinary Care of the High quadriplegic C4
and above. Houston, Texas, USA, Novem­
ber. 1985.

44. Geisler, W. O., Jousse, A. T., Wynne Jones,
M. & Breithaupt; D. Survival in traumatic
spinal cord injury. Paraplegia 21:364 (1983).

NIMHANS JOURNAL, 5(l),J1nuiry 1987. pp 13-21

Grief Reaction among Bereaved Relatives
Following a
Fire Disaster in a Circus
H.S. Narayanan t, k. Sathyavathi,4 G. Nardev- & Shobhana Thakrar”
Dtpurmiemr of Psychi^, Clinical Psychology . & p
National Institute oj Mental Health & Neuro Sciences
Bangalore —560029, India.

38. Beresford, R. Development of Functional Sti­
mulation using an adaptive Electrode. PhJD.
Thesis,
University
of Southampton.
England.

39. Kxalj, A.. Bajd, T. & Turk, R. Electrical sti­
mulation providing functional use of para­
plegia muscles. Med. Prog. Technol. 7:3
(1980).

46. Wagner, F. C. J. & Chehrazi. B. Early
decompression and neurological outcome in
acute cervical spinal cord injuries. J. Neuro­
surg. 56:699 (1982).

40. Marsoiais, E. B. & Kobetric, R. Functional
walking in paraplegic patients by means of
electrical stimulation. Clin. Orthop. 175:30
(1983).

47. Wilmot, C. B. & Halt K. M. Evaluation of
the acute management of tetraplegia: Con­
servative versus surgical treatment Paraple­
gia 24:148 (1986).

Although the ttudv indicated that 49 bereaved I T
k**11 Pre,eiltedeHarric .y»pto„, re,oiring treILL "o"; l7r:L’r“V7rI,,O'’'d "id"” °fPTm.nt ,,, by way of al<;dication and
,|1„®pyed for
Th.

41. Moberg. E. Surgical treatment for absent
singie-iiAud grip and cicQ’.v extension in
quadriplegia. J. Bone Joint Surg. 57A.196
(1975).

48. Kossier, A. B., rou, D., SuiHito,}. & Dyro, F.
M. Post-traumatic cervical syringoravelia.
Brain 108:439 (1985).

K.y W„rd.-Dfa««r, Gri./C,^„?

42. Peckham, P. H-, Marsolais, E. B. & Mortimer.
J. T. Restoration ot the key grip and release
m the C6 cetraplegic patient through functi­
onal electrical stimulation. J. Hand Surg.
5:462 (1980).

bince Freud s’ explanation of the psy­
chodynamics of grief, there have been pub­
lications dealing with different aspects of
grief reaction- l2. rYccording to Parkes’,
when a love tie is severed an emotional and
behavioural reaction is set in train which is
termed as grief.

49. Vernon, J. D_ Silver. J. R. & Ohry, A. Pcsttraumaric syringomyelia. Paraplegia 19:67 (1981).

50. Williams. B., Terry, A. F.,Jones. F. & McSweeney, T. Syringomyelia as a sequel to traumatic
paraplegia. Paraplegia 19:67 (1981).

Singh and Tiwari13 opine chat grief is a
reaction to the loss of a loved object which
is a common and clearly recognised pheno­
mena and each culture has evolved its own
methods of coping with it. Further they
wnte: However, because of its specific
causation and its generally transient self
miting nature, it seldom comes to the
notice of a psychiatrist and is therefore
often dismissed as a normal condition
rather than a mental disorder”. If grief is
denied or avoided after a loss, it may mani.

est itself wtth a variety of morbid reactions
Which are designated as morbid or pathoiopeal or atypical grief reaction.14 Although
■^he usual duration of gnef subsequent to
Reprint requests

•H.'

*•

..

45. Harris, P.. Karmi, M. Z., McClemont, E.,
Mathloko, D. A. & Paul, K. .$. The prognosis
of patients sustaining severe cervical spine
injury (C2-C7 inclusive). Paraplegia 13:324
(1980).

the loss ot a loved object has been estimated
variously ranging from 1 to 12 weeks2-6’-15
it appears chat a proportion of mourners

continue to grieve for longer time.10
Unanticipated bereavement (due to
accidents or disasters resulting in mass fata­
lities) is qualitatively and quantitatively
different from grief resulting from antici­
pated death.16 Reaction of community to
such disasters follows the pattern most
often seen as initial shock, denial, excite­

ment, anger, depression and finally recons­
titution with concern.17 The psychological

the time of the acute event. Research pro­
vides evidence of long term deterioration in
health patterns and development of specific
syndromes in certain relatives of the
deceased after such disasters.1’ Thus living
through such a trauma is a uniquely stress­
ful and an overwhelming experience for

I

H.S. NARAYANAN ET AL.

GRIEF REACTION AMONG BEREAVED REL/m/VES

Present Study
The circus fire disaster occurred in Ban­
galore city, of Karnataka State on 7th
February 1981 taking a heavy toll of 70 per­
sons belonging to 58 families. A study of the
reaction of the relatives of these bereaved

families to this unanticipated disaster was
planned. As a first step, initial contact was
made with some of the families of the
accident Victims' to explore the possibil­
ity of eliciting the co-operation for such a

study. As it appeared promising, attempts
were made to obtain the addresses of these
families from sources like Hospitals, Police
Commissioner’s Office, Schools, Corpora­
tion Office and efforts were made to locate
these houses to establish contact with these
famiBes. A proforma was also devised to
collect data for the study from the bereaved
relatives of the victims of this accident.

Aim
The study aimed at exploring (a) the
pattern of reactions of grief in the bereaved
r

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iimillCj iiuu \l.'; iHC

k»ln rhflt rhe
-

mental health team could provide to those
family members who were in need of it.

Material and Method
The study group consisted of 137 rela­
tives of 70 victims from 58 families and the
the other 15 victims could not be included
due to non-availability of correct addresses
for locating the houses or due to the unwil­

lingness by bereaved relatives to parucipate

in the study.
Unlike the studies dealing with berea­
ved relatives having lost a spouse or a par­
ent or a child or a sib, unanticipated disas­
ters pose unique problems of losing
more than one individual from a single

and these children were given concession
tickets. Hence, this show was largely
attended by children. The age of these 70
victims ranged from 13 months to over 75
years. But 75.7% of these victims were
beiow 15 years. There was a predominance
of female over males with 65.7 % and 34.3 %
respectively. It was noted that 68.6% were
students, 7 % had not begun their schooling
aS yet while the remaining were either
housewives or engaged in different occupa­
tions. Majority of the victims were Hindus
(90 %) but there were Muslims (8.6%) and
Christians (1.4%) as well.

family. The present study indicated that 49
families had lost one member each in the
accident (i.e., one child each from 39 fami­
lies and one adult each from 10 families), 6
famihes had lost 2 members each (i.e. 1
child and 1 adult in 5 families and 2 children
from 1 fafiiily), and 3 families had lost 3
members each (i.e., 2 children and one adult
in 2 famifies and 3 children from one fam­
ily). Thus nearly 2/3 of the bereaved rela­
tives happened to be the parents of the

deceased victims.
Researchers have indicated that the
arbitrary upper limit for the third phase of
normal gnef reaction to be completed is
about six months by which time there is
resolution and detachment from the image
of the deceased and finding new outside
interests and activities. Keeping this in
view, the data collection started after the
rkp trasic occurrence. The
data was collected on the proforma through
home visits by interviewing the available
and willing relatives of the deceased. In all
...

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(b) Problem of identification of the victims: As
is usually common in mass disasters, there
were victims of the fire accident as well as
those who died due to stampede, shock,
asphyxia and other causes like boulders fal­
ling on them etc. In the present study also
60.3 % of the cases did not pose any prob­
lem of identification as they had mild bum
injuries or had died due to other reasons.
But in the remaining 39.7 % of cases, identi­
fication was difficult due to extensive bum
injuries but were identified on the basis of
remnants of clothes, jewellery, footwear,
waist belt etc. Many of the bereaved rela­
tives of these victims reponed that it was
impossible for them to remove from their
mind the image of the disfigured body of
the deceased due to severe bums. Parkes'9,
study also brought out that a painful death
or a mutilated or distorted corpse may
haunt the memory of the griever and shut
out happier memories of the dead person.
Although 68 victims could somehow be
identified, it was pathetic to learn that there
were 2 instances in which bodies of 2 child­
ren could not be traced and in 1 instance the
relatives were unsure whether the body
that was given to them was that of their

IiAiir rn

cases, luvariaoiy cue uuu« — —----- one hour was devoted for listening to their
recounting of their feelings and expe­
riences about the tragic accident.

Findings

Findings of the study are reported under 2
headings viz. (1) Data pertaining to the vic­
tims of the aeddent and (2) Dau concerning
the bereaved relatives of these victims.
1. Data pertaining to the victims of the accident

This dara is presented under 4 sub-head­
ings:
(a) Socio-demographic data: The particular
circus show during which the fire accident
occurred was meant for school children

own child.

(c) Condition of the victims at the time of dis­
covery : Of the 70 victims, 67.1 % were found
dead at the time of discovery, 30% were
alive but died subsequently, of which near­
ly half of them were conscious and could
speak prior to their death while others were
either uni onsc mu, ot 1 onscious but could
not speak. In the remaining 2.9 % of cases,
the relatives could not have the bodies as
they were not traced.
(d) Members accompanying the victims to the
circus: As indicated earlier, that particular
show of circus was meant for school child­
ren with concessional rates, it is understan­
dable that children were accompanied by
adults. Family members had taken the
children with or without other adults in
54.3% of victims, teachers in 40% of cases
and neighbours, friends or others in 5.7 % of
cases. It is of relevance to note here that rhe
bereaved parents or other family members
being on the spot of the accident, but not
being able to save the victim, had its posrhe subsequent morbid
reaction.
2.

Data pertaining to the bereaved relatives

In all 137 family members of these 70
victims could be interviewed and data eli­
cited on the proforma. All of them were
adults. The data is presented under six sub­
headings.

(a) Relationship of the interviewed to the vic­
tims: Of the 137 interviewed from 58 fami­
lies of victims. 43 were mothers of victims,
42 were fathers, 10 were spouses, 3 were
fathers as well as husbands (i.e. having lost
children as well as wives), 3 were mothers
as well as wives (i.e. having lost children as
well as husbands) while the remaining 36

I;

'

I

IS

1

16

GRIEF REACTION AMONG BEREAVED RELATIVES

were other relatives like siblings, grand­
parents, uncles, etc.

-

i.

!

(b) Immediate reaction of the family members:
Interviewees learnt about the news of the
accident through eye witnesses, teachers,
neighbours, relatives or general public. The
immediate reaction of these family memb­
ers were described as that of concern, fear,
anxiety, shock, confusion, disbelief and
horror which led to their frantic efforts to
get to know about those who had attended
that show by making enquiries at hospitals
(41.6%), police stations (23.8%), schools
(2.3%), neighbours and others (9.2%) and
many (23.1 %) had rushed to the spot of the
accident, to learn about the state of their
family members.

(c) Funeral rites ' After identifying and
obtaining the bodies of the victims,
arrangements were made by the bereaved
families for burial or cremation as was
customary in their respective castes. The
funeral itself is considered to give rise to
both positive and negative feelings for sev­
eral bereaved relatives and the funeral ser­
vice had “brought home” the reality of
what had happened1. This could have
occurred whemthe relatives participated in
the funeral rites of the deceased. Doha’s20
study brought out clearly that participation
in funeral rituals is important in facilitating
grief adjustment in the bereaved relatives.
But it was pathetic to note in the present
study that in 293 % of cases, the important
tamily members who were supposed to
carry out and/or to be present during the
funeral rites could not do so as they were
hospitalized due to bum injuries. This could
have played its role in the bereaved relatives’
morbid grief reaction. Further, Parkes7
among others reports that performance as

■ te

well as arrangements made for funeral and
the number of people attending it seems to
give some solace to the bereaved relatives if
it is considered by them as adequate and
satisfactory. Those who could not attend
the funeral had their own reservations
regarding the above aspect.

(d) Grief reaction: Shackleton21 concludes
from his review on the psychology of grief
that bereavement has subjective, physiolo­
gical, biological, behavioural, cognitive and
perceptual effects. According to Parkesfi,
reactions to bereavement as available from
literature are of bewildering variety from
ulcerative colitis to mania and from leuke­
mia to hysteria. Besides intensification, pro­
longation and exaggeration of depressive
features and mixed grief reactions, non-spe­
cific mixed reaction may cover the whole
range of stress disorders with particular
reference to psychosomatic, psychoneurotic and allcLliVc dibuidcis. Keeping these
complex ways of reactions to bereavement,
the proforma used in the present study eli­
cited the manner of grief reaction present
among the bereaved relatives even after 6
months of the tragedy. Thus the 137 rela­
tives were enquired for the presence of
symptoms of pathological grief reaction by
way of chronic grief, inhibited grief, exces­
sive guilt, excessive anger, over-idealisa­
tion, change in attitude towards God, eating
problems, preoccupying thoughts, memo­
ries or perceptual anomalies, attribution to
Karma and being worried, misidentifica­
tion, suicidal ideas or ruminations, death
wish, change of pattern in social and recrea­
tional activities, general health problems,
sleep disturbances and dreams.
It was found that one mother reconciled
to the loss of her two children as she could

H.S. NARAYANAN ET AL.

save her two other younger children.
Among the remaining 136 interviewees,
there were one or more symptoms of
pathological or morbid grief reaction.
These findings are reported in Table 1.
As shown in table 1, almost all the
bereaved relatives felt that it was their
Karma (past or present) that resulted in
such a tragedy. This is one of the characte­
ristic ways of some Indians to attribute
unpleasant or painful things to ‘Karma’!
Further it could be noted that in about 90 %
of the cases the bereaved relatives had tried
to idealize or overidealize the deceased
which is a common finding from other
researchers like Parkes,6,7 Singh and
Tiwari” among others. In the present

17

study, without a single exception, all the
bereaved relatives described the deceased
as highly good natured, intelligent, *no one
can be like him/her’ or the deceased was
‘worth his weight in gold’, ‘very beautiful
and cute’ or ‘very popular in the school’. It is
of interest to indicate here that Wallace
and Townes” have reported about the ten­
dency to idealise even during the anticipa­
tory mourning phase by the hospital staff of a
children s oncology ward regarding a child
with leukemia. Regarding idealising or
overidealising of the deceased, Parkes”
opines "... memories of the dead had a nos­
talgic, bitter-sweet quality and the dead
person tended to be idealised..."

Perceptual

anomalies

were

Table 1
Presence of symptoms of morbid oi pailiulugical grief reaction

Symptoms of morbid grief reaction

Attributing to Karma and being worried
Over idealisation
Preoccupying thoughts/imemories/perceptual anomalies

Chronic grief

Sleep disturbance
Eating problems

Excessive guilt
Problems of general health

Change of pattern in social and recreational activities
Dreams

Excessive anger
Change in attitude towards God

Misidentification
Death wish

Inhibited grief
Suicidal ideas or ruminations

Percentage
97.1
912

89.7

74.3

66.9
57.4

51.5
463

44.9
39.0
36.8
30.9

19.1
18.4
132

7.4

often

GRIEF REACTION AMONG BEREAVED RELATIVES

18

U.S. NARAYANAN ET AL.

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reported by the bereaved relatives in cer­
tain studies.7-6'13-'9”, in the present study
also it was found that pseudohallucinatory
experience and misidentification were
reported by 18% of the bereaved Relatives.
It was also observed that about 90% of
these relatives were preoccupied with the
thoughts of the dead leading to worry and
sadness.

■■
,
Coming to grief and its associated behaijft'^| ;l| viour phenomena, 74% of relatives gave

,r-

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.ih .< ? evidence of continued sadness even six

I ilpJM, months after the death by way of worry,
crying and disturbances in biological func­
tion (i.e. sleep disturbance in 66.9%, dis­
turbing dreams in 39 % and problems of eat­
ing in 57.4%). Most of the studies report
about the.grief in the bereaved but employ
different terminologie': like inhibited,
delayed, chronic, morbid or pathological
grief and the like6,7'3”. It is worth men­
tioning here that Lundin74 observed that
relatives of persons who died suddenly and
unexpectedly had more pronounced grief
reactions than those idatives of persons
whose deaths were expected. Further, it is
also of relevance <to note that Clayton et af.
pointed out that parents of deceased child­
I
ren appeared to respond to grief more seve­
rally than the relatives of other persons.
r
Referring to Sander's work, Rando” men­
i
tioned that as compared to bereaved
spouses or ’bereaved children, bereaved
parents had greater depression, despair,
guilt and anger. Soricelli and Utech76 point­
ed out that the death of a young child was
shocking and devastating to the parents as it
was outside the ‘natural order of events’.
Some of these observations could be of
relevance as nearly two-thirds of the
bereaved relatives in the present study
were parents i.e. fathers or mothers having

i

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AL...

lost one or more children suddenly and
unexpectedly.
In addition to sadness and other depres­
sive features, about 51 % of these bereaved
relatives reported that they felt guilty for
more than one reason such as: (a) not being
able to save the deceased in spite of being
with them on the spot; (b) having taken the
deceased to that particular show; (c)
although unwilling initially to take them to
that show but yielding subsequently to the
wish, request, pressure or demand of the
victims; (d) sending or taking the victims to
the circus without the knowledge of the
father/husband; (e) having saved one’s life
and forsaking the life of the deceased. It is
clear from this that the guilt feelings in the
relatives of the victims of this disaster are
enrnewhar different than in race *?f drath nf

persons due to illnesses or similar causes.
However, most of the literature on
bereavement and grief reaction have a
mention about guiltambngbereaved relativcs«.?.i3.i9.J3.n-36 Thcse feelings of guilt in

turn had led to remorse, self blame as well
as self reproachful behaviour in the rela­
tives included in the present study. It was
also observed that 18.4% had death wishes
and 7% exhibited strong suicidal ideas.
Another characteristic feature observed
in most studies on bereavement is anger felt
by the bereaved6-7'’3''’-”27-30. Lacey3'
observing the reactions of bereaved rela­
tives of children in a coal mine accident
reported that there was a felt need to
express! aggression towards an external
source in these parents. The anger noted in
the bereaved could be directed towards self
or the deceased or other people. In the pres­
ent study, anger was reported by 36.8% of
the relatives. Majority were angry with

themselves for having failed in the rescue
bid and/or having taken or permitting tinie
victims to the show. Secondly, they were
angry with the dead for leaving or deserting
them. Thirdly, they expressed greater anger
towards school teachers, government - for
giving licence to have the show near the
electric high tension wire - electrical
department, hospital, neighbours and God
also.
Finally, problems of health and somatic
complaints in the bereaved were reported
by the relatives as also observed in the study
of Murphy37. Further, shift in the pattern of
social or other activities of relatives like not
visiting temples or doing poojas, loss of
faith in God, avoiding people and places
which would remind them of the deceased7
engaging in various activities lest the vacant
hours would be filled with thoughts of the
deceased were some of the other features

present in the bereaved relatives for which
findings of other studies lend support.

The varied features of morbid patholo­
gical grief reaction shown by the bereaved
relatives are considered the result of mul­
tiple victimisation. When a husband is
dead, it is not only the mere loss of the per­
son as such but the loss of a bread win­
ner, companion, sexual partner, social sup­
port, a person responsible for one's status or
an enhancer of one’s self esteem, family
administrator and planner, disciplinarian of
children and the like. Similarly, when a
child dies before the death of the parents, it
is inappropriate and untimely in the ‘natu.
ral order of events’ and these parents are
su jects of multiple victimization by way
of losing one who is a part of oneself, losing
t?e. , r.eams and hopes invested on that
child, loss of their role as a protector, pro-

19

vider, advisor and problem solver. This
would make the parents to get a feeling of
being ‘mutilated and disabled’ as these roles
are robbed off leaving them with an over­
whelming sense of failure. In the present
study, there seems to be some justification
for these morbid grief reactions observed
since the death was sucMen and unexpected
as well as a number of these bereaved rela­
tives had lost more than one person from
their respective families.
«
(e) Coping behaviour: All the 58 families
had engaged in rituals not only in those
associated .with funeral but on monthly
and/or yearly basis either at home or
burial/cremation ground as per the norms
of their castes or communities.
In about 56.9% of the families, even
after 6 months, the photographs of the
deceased were kept separately or with the
photographs of Gods/Goddesses and wor­
shipped. In contrast to this, in 8.6 % of fami­
lies, all the photos of the deceased were
removed so that they did not bring dreadful
memories.
In 63.8% of families, the material pos­
sessions of the deceased were treasured as
sacred things while in 15.5% of families
they were distributed to outsiders. In the
remaining 20.7% family members were
allowed to use them.

In isolated cases, the house was named
after the deceased, and pooja was done to
the name plate of the deceased, the resid­
ence was shifted to avoid memories of the
deceased.
In spite of employing these various cop­
ing strategies, it was noted that some of
these interviewees could possibly benefit
from psychiatric treatment.

Lf *.

/

20

'I

GRIEF REACTION AMONG BEREAVED RELATIVES

(D Relatives requiring psychiatric help: The
interview brought out that nearly 74.3%
still had depressed feelings and about one
third of them wanted to be left alone.

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It was of interest to note that 11 male
relatives interviewed who were occasional­
ly drinking priora to the tragedy had
increased the frequency and quantity of
drinking, 1 person had reduced it losing
interest even in drinking and one other had
started the
habit afresh during the 6
months subsequent to the tragedy as a
result of not being able to bear with the
sudden loss of the relative.
An overall assessment of the relatives by
the psychiatrist indicated that 49 of them
could benefit from psychiatric interven­
tion. These persons were offered psychiatic help at N1MHANS, Bangalore. Of these
49, one who had lost his wife and a daugh­
ter and had psychotic breakdown was treat­
ed as an in-patient at NIMHANS and only
16 others with severe problems of feelings
of sadness, sleeplessness, preoccupation
with the thoughts of the deceased, diges­
tive upset, anxiety, etc., agreed to receive
psychiatric help. Of these 16, 4 attended
NIMHANS psychiatric outpatient of the 1
chief investigator ’while the remaining 12
were treated at their respective residences
by the chief investigator as they were
unwilling to visit NIMHANS for treat­
ment. These 16 persons w’ere put on antide­
pressants and minor tranquillizers. In addi­
tion, brief “re-grief therapy" was provided
to them at their residences by the therapist.
Three home visits were made for each of
these cases. With these treatments, 15 subjects made sufficient recover}’ and had
taken up their regular day today activities.

were followed up for periods
■4

I:

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iV ‘

H. S. NARAYANAN ET AL.

ranging from 1 ’A months to 18 months. Fur­
ther, it was observed that 2 subjects had
developed dependency reaction towards
the therapist and they would call on the
therapist as and when they felt the need.
Acknowledgements

The authors express their thanks to Dr.
G.N. Narayana Reddy, Director, NIM
HANS, Bangalore, for providing financial
grant for this research.
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6- 2-0

tfi
12

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?i97?)P1C8ia’J0'"1

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blowing .

Bangalore - 560 029, India.

Ur° Sc‘mCes

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servative versus surgical treatment Parat le^ia 24.148 (1986).
f
48. Rossier, A. B., Foo, D., Shillito, J. & Dyro, F.
M Post-traumatic cervical syringomyelia
Brain 108:439 (1985).
49. Vernon, J. D„ Silver, J. R. & Ohry, A. Posttraumatic syringomyelia. Paraplegia 19:67 (1981).

50. Williams, B„ Terry, A. F.,Jones, F. & McSweeney, T. Syringomyelia as a sequel to traumatic
paraplegia. Paraplegia 19:67 (1981).

Key word, ~ Disaster, Grief reaction,

Coping behaviour.

eXPi“a“0» of the psy.

I

chndlnCe

I

lie t yna7? Ot Sr,ef’there have b«n pub-

the ioss of a ioved object has been estimated

I
I
I

'‘options dealing with different
aspects of
gnLef ‘■eaction2-'!. According
to Parkes7,
a love tie is severed an
emotional and
------- is

variously ranging from 1 to 12 weeks2-6-’15

I

Singh and Tiwari" opine that grief is a

I

g

reacnon to rhe loss of a loved object whTch

I

Xana0~ rd

I
I

“ L Td 7ch Culture h“ evolved its own
wri«O“ h COpmg w‘ch
Further they

I

re“^d Pb“o

Xt.On a°7Ver' beCaUSe °f itS sP«ific

I

limiting natureltSitSenidrally tra"51ent self

I
I
I
I

notice
'
SC donl comes to the
often df a ps>;chutnst and is therefore
rather tt""
“ 1 nOrmal "^tion
de,? L
3 mental d‘s°rder". If gnef is

■
I
I

which arc de- ’ a
of morbid reactions
gieal or atv Slg.nated_as morbid or patholothe usuai?1^ 8ne^reaction-14 Although

■

I1 cWw:;
W;r■ tre,ue5tI

subsequent

‘t appears that a proportion of mourners
contmue to gneve for longer time.10

!

Unanticipated bereavement (due to
’
accidents or disasters resulting in mass fau- . 1 - J
l‘ucs) is qualitatively and quantitarive^jM

different from grief resulting from
pared death.16 Reaction of commukiry^l®^
such disasters follows the pattern most '!‘ 'J

often seen as initial shock, demal, excite- t if
ment, anger, depression and finally recons. A’t.
titution with concern.'2 The psychological 'Wil
trauma of the mass disasters is not limited »I
vtde
nU“ eTent Re«“cl> pro- >3
vides evidence of long term deterioration in- »
health patterns and development of specific ■ I
dec 077n certain «l“ives of the
deceased after such disasters.'* Thu, living
f
through such a trauma is a uniquely st^! if
ul and an overwhelming expeneLe for
he members of such bereaved families.
O
■1

GRIEF REACTION AMONG BEREAVED RELATIVE

Present Study

K.-

Kt' <j

The circus fire disaster occurred in Ban­
galore city, of Karnataka State on 7th
February 1981 taking a heavy toll of 70 per­
sons belonging to 58 families. A study of the
reaction of the relatives of these bereaved
families to this unanticipated disaster was
planned. As a first step, initial contact was
made with some of the families of the
accident victims to explore the possibil­
ity of eliciting the co-operation for such a
study. As it appeared promising, attempts
were made to obtain the addresses of these
families from sources like Hospitals, Police
Commissioner’s Office, Schools, Corpora~ j were made to locate
tion Office and‘ efforts
these houses to establish contact with these
families. A proforma was also devised to
collect data for the study from the bereaved
relatives of the victims of this accident.

Aim
The study aimed at exploring (a) the
pattern of reactions of grief in the bereaved
families and (b) the possible help that the
mental health team could provide to those
family members who were in need of it.
Material and Method
The study group consisted of 137 rela­
tives of 70 victims from 58 families and the
relatives from the remaining 12 families of
the other 15 victims could not be included
due to non-availability of correct addresses
for locating the houses or due to the unwil­
lingness by bereaved relatives to participate

in the study.

Unlike the studies dealing with berea­
ved relatives having lost a spouse or a par­
ent or a child or a sib, unanticipated disas­
ters pose unique problems of losing
more than one individual from a single

1

family. The present study indicated that 49
families had lost one member each in the
accident (i.e., one child each from 39 fami­
lies and one adult each from 10 families), 6
families had lost 2 members each (i.e. 1
child and 1 adult in 5 families and 2 children
from 1 family), and 3 families had lost 3
members each (i.e., 2 children and one adult
in 2 families and 3 children from one fam­
ily). Thus nearly 2/3 of the bereaved rela­
tives happened to be the parents of the

deceased victims.

Researchers have indicated that the
arbitrary upper limit for the third phase of
normal grief reaction to be completed is
about six months by which time there is
resolution and detachment from the image
of the deceased and finding new outside
interests and activities. Keeping this in
view, the data collection started after the
6th month of the tragic occurrence. The
data was collected on the proforma through
home visits by interviewing the available
and willing relatives of the deceased. In all
cases, invariably the initial half an hour to
one hour was devoted for listening to their
recounting of their feelings and expe­
riences about the tragic accident.

Findings
Findings of the study are reported under 2
headings viz. (1) Data pertaining to the vic­
tims of the accident and (2) Data concerning
the bereaved relatives of these victims.
1.

Data pertaining to the victims of the accident
This data is presented under 4 sub-head­

ings:
(a) Socio-demographic data: The particular
circus show during which the fire accident
occurred was meant for school children

H.S. NARAYANAN ET AL.

and these children were given concession
tickets. Hence, this show was largely
attended by children. The age of these 70
victims ranged from 13 months to over 75
years. But 75.7% of these victims were
beiow 15 years. There was a predominance
of female over males with 65.7 % and 34.3 %
respectively. It was noted that 68.6% were
students, 7% had not begun their schooling
aS yet while the remaining were either
housewives or engaged in different occupa­
tions. Majority of the victims were Hindus
(90%) but there were Muslims (8.6%) and
Christians (1.4%) as well.

(b) Problem of identification of the victims: As
is usually common in mass disasters, there
were victims of the fire accident as well as
those who died due to stampede, shock,
asphyxia and other causes like boulders fal­
ling on them etc. In the present study also
60.3 % of the cases did not pose any prob­
lem of identification as they had mild bum
injuries or had died due to other reasons.
But in the remaining 39.7 % of cases, identi­
fication was difficult due to extensive bum
injuries but were identified on the basis of
remnants of clothes, jewellery, footwear,
waist belt etc. Many of the bereaved rela­
tives of these victims reported that it was
impossible for them to remove from their
mind the image of the disfigured body of
the deceased due to severe bums. Parkes19,
study also brought out that a painful death
or a mutilated or distorted corpse may
haunt the memory of the griever and shut
out happier memories of the dead person.
Although 68 victims could somehow be
identified, it was pathetic to learn that there
were 2 instances in which bodies of 2 child­
ren could not be traced and in 1 instance the
relatives were unsure whether the body
that was given to them was that of their

15

own child.

(c) Condition of the victims at the time of dis­
covery : Of the 70 victims, 67.1 % were found
dead at the time of discovery, 30% were
alive but died subsequently, of which near­
ly half of them were conscious and could
speak prior to their death while others were
either uni ons< iou, ot 1 onscious but could
not speak. In the remaining 2.9 % of cases,
the relatives could not have the bodies as
they were not traced.
(d) Members accompanying the victims to the
circus: As indicated earlier, that particular
show of circus was meant for school child­
ren with concessional rates, it is understan­
dable that children were accompanied by
adults. Family members had taken the
children with or without other adults in
54.3% of victims, teachers in 40% of cases
and neighbours, friends or others in 5.7 % of
cases. It is of relevance to note here that the
bereaved parents or other family members
being on the spot of the accident, but not
being able to save the victim, had its pos­
sible effects on the subsequent morbid grief
reaction.
2.

Data pertaining to the bereaved relatives

In all 137 family members of these 70
victims could be interviewed and data eli­
cited on the proforma. All of them were
adults. The data is presented under six sub­
headings.

(a) Relationship of the interviewed to the vic­
tims : Of the 137 interviewed from 58 fami­
lies of victims, 43 were mothers of victims,
42 were fathers, 10 were spouses, 3 were
fathers as well as husbands (i.e. having lost
children as well as wives), 3 were mothers
as well as wives (i.e. having lost children as
well as husbands) while the remaining 36

■1W- ■

A' 16

GRIEF REACTION AMONG BEREAVED RELATIVES

were other relatives like siblings, grand­
parents, uncles, etc.

(b) Immediate reaction of the family members:
Interviewees learnt about thenews
---------of
ruthe
”
accident through eye witnesses, teachers,
neighbours, relatives or general public. The
immediate reaction of these family memb­
ers were described as that of concern, fear,
anxiety, shock, confusion, disbelief and
horror which led to their frantic efforts to
get to know about those who had attended
that show by making enquiries at hospitals
(41.6%), police stations (23.8%), schools
ig1
(23 %), neighbours and others (92 %) and
‘ i: ; many (23.1 %) had rushed to the spot of the
accident, to learn about the state of their
family members.
■

5i

F

(c) Funeral rites: After identifying and
obtaining the bodies of the victims,
arrangements were made by the bereaved
families for burial or cremation as was
customary in their respective castes. The
funeral itself is considered to give rise to
both positive and negative feelings for sev­
eral bereaved relatives and the funeral ser­
vice had “brought home” the reality of
what had happened7. This could have
occurred when the relatives participated in
the funeral rites of the deceased. Doka’s20
study brought out clearly that participation
in funeral rituals is important in facilitating
grief adjustment in the bereaved relatives.
But it was pathetic to note in the present
study that in 29.3 % of cases, the important
family members who were supposed to
carry out and/or to be present during the
funeral rites could not do so as they were
hospitalized due to bum injuries. This could
have played its role in the bereaved relatives’
morbid grief reaction. Further, Parkes7
among others reports that performance as

well as arrangements made for funeral and
the number of people attending it seems to
give some solace to the bereaved relatives if
it is considered by them as adequate and
satisfactory. Those who could not attend
the funeral had their own reservations
regarding the above aspect.

(d) Grief reaction: Shackleton21 -concludes
from his review on the psychology of grief
that bereavement has subjective, physiolo­
gical, biological, behavioural, cognitive and
perceptual effects. According to Parkes6,
reactions to bereavement as available from
literature are of bewildering variety from •
ulcerative colitis to mania and from leuke­
mia to hysteria. Besides intensification, pro­
longation and exaggeration of depressive
features and mixed grief reactions, non-spe­
cific mixed reaction may cover the whole
range of stress disorders with particular
reference to psychosomatic, psychoneuro­
tic and alLcciive di^uideis. Keeping these
complex ways of reactions to bereavement,
the proforma used in the present study eli­
cited the manner of grief reaction present
among the bereaved relatives even after 6
months of the tragedy. Thus the 137 rela­
tives were enquired for the presence of
symptoms of pathological grief reaction by
way of chronic grief, inhibited grief, exces­
sive guilt, excessive anger, over-idealisa­
tion, change in attitude towards God, eating
problems, preoccupying thoughts, memo­
ries or perceptual anomalies, attribution to
Karma and being worried, misidentifica­
tion, suicidal ideas or ruminations, death
wish, change of pattern in social and recrea­
tional activities, general health problems,
sleep disturbances and dreams.

H.S. NARAYANAN ET AL.

save her two other younger children.
Among the remaining 136 interviewees,
there were one or more symptoms of
pathological or morbid grief reaction.
These findings are reported in Table 1.
As shown in table 1, almost all the
bereaved relatives felt that it was their
Karma (past or present) that resulted in
such a tragedy. This is one of the characte­
ristic ways of some Indians to attribute
unpleasant or painful things to ‘Karma’!
Further it could be noted that in about 90 %
of the cases the bereaved relatives had tried
to idealize or overidealize the deceased
which is a common finding from other
researchers like Parkes,67 Singh and
Tiwari13 among others. In the present

study, without a single exception, all the
bereaved relatives described the deceased
as highly good natured, intelligent, ‘no one
can be like him/her’ or the deceased was
‘worth his weight in gold’, ‘very beautiful
and cute’ or ‘very popular in the school’. It is
of interest to indicate here that Wallace
and Townes22 have reported about the ten­
dency to idealise even during the anticipa­
tory mourning phase by the hospital staff of a
children’s oncology ward regarding a child
with leukemia. Regarding idealising or
overidealising of the deceased, Parkes”
opines “... memories of the dead had a nos­
talgic, bitter-sweet quality and the dead
person tended to be idealised...”

Perceptual

anomalies

were

Table 1
Presence of symptoms of morbid oi palhulugical grief reaction
Symptoms of morbid grief reaction

Attributing to Karma and being worried
Over idealisation
Preoccupying thoughts/i'memories/perceptual anomalies
Chronic grief
Sleep disturbance
Eating problems
Excessive guilt
Problems of general health
change of pattern in social and recreational activities
Dreams
Excessive anger

change in attitude towards God
Misidentification
Death wish

Inhibited grief

It was found that one mother reconciled
to the loss of her two children as she could

17

Suicidal ideas or ruminations

Percentage
97.1
912

89.7
74.3

66.9
57.4
51.5
463

44.9
39.0
36.8
30.9

19.1
18.4
132

7.4

often

18

GRIEF REACTION AMONG BEREAVED RELATIVES
H.S. NARAYANAN ET AL.

I

I

ie bereaved relatives in cer­
tain studies.7<’,3,,’,2:i. In the present study
also it was fcpund that pseudohallucinatory
experience and misidentification were
reported by 18 % of the bereaved Relatives.
It Was also observed that about 90% of
these relatives were preoccupied with the
thoughts of the dead leading to worry and
sadness.

■

|

f
ili'

Coming to grief and its associated beha­
viour phenomena, 74% of relatives gave
i
. evidence of continued sadness even six
i-J-V
months after the death by way of worry,
crying and disturbances in biological function (i.e. sleep disturbance in 66.9%, dis­
turbing dreams in 39 % and problems of eat­
ing in 57.4%). Most of the studies report
about the.grief in the bereaved but employ
different terminologiec like inhibited,
delayed, chronic, morbid or pathological
grief and the like6,7-13,23. It is worth men­
tioning here that Lundin24 observed that
relatives of persons who died suddenly and
unexpectedly had more pronounced grief
reactions than those relatives of persons
whose deaths were expected. Further, it is
also of relevance <o note that Clayton et at*.
pointed out that parents of deceased child­
ren appeared to respond to grief more seve­
rely than the relatives of other persons.
Referring to Sander’s work, Rando25 men­
tioned that as compared to bereaved
spouses or bereaved children, bereaved
parents had greater depression, despair,
guilt and anger. Soricelli and Utech26 point­
ed out that the death of a young child was
shocking and devastating to the parents as it
was outside the ‘natural order of events’.
Some of these observations could be of
relevance as nearly two-thirds of the
bereaved relatives in the prasent study
were parents i.e. fathers or mothers having
"l<.

S i

1
I"!
■

I'

/ i

g’:

•

I

■

lost one or more children suddenly and
unexpectedly.

In addition to sadness and other depres­
sive features, about 51 % of these bereaved
relatives reported that they felt guilty for
more than one reason such as: (a) not being
able to save the deceased in spite of being
with them on the spot; (b) having taken the
deceased to that particular show; (c)
although unwilling initially to take them to
that show but yielding subsequently to the
wish, request, pressure or demand of the
victims; (d) sending or taking the victims to
the circus without the knowledge of the
father/husband; (e) having saved one’s life
and forsaking the life of the deceased. It is
clear from this that the guilt feelings in the
relatives of the victims of this disaster are
tnrr>pwh?t different t^an in Ca«e of dea^b nf

persons due to illnesses or similar causes.
However, most of the literature on
bereavement and grief reaction have a
mention about guiltamongbereaved relatives6,7 ’3,”-23,27“36. These feelings of guilt in
turn had led to remorse, self blame as well
as self reproachful behaviour in the rela­
tives included in the present study. It was
also observed that 18.4 % had death wishes
and 7 % exhibited strong suicidal ideas.

Another characteristic feature observed
in most studies on bereavement is anger felt
by the bereaved67-13-19-23-27-30. Lacey31
observing the reactions of bereaved rela­
tives of children in a coal mine accident
reported that there was a felt need to
express aggression towards an external
source in these parents. The anger noted in
the bereaved could be directed towards self
or the deceased or other people. In the pres­
ent study, anger was reported by 36.8 % of
the relatives. Majority were angry with

themselves for having failed in the rescue
bid and/or having taken or permitting the
victims to the show. Secondly, they were
angry with the dead for leaving or deserting
them. Thirdly, they expressed greater anger
towards school teachers, government - for
giving licence to have the show near the
electric high tension wire - electrical
department, hospital, neighbours and God
also.

Finally, problems of health and somatic
complaints in the bereaved were reported
by the relatives as also observed in the study
of Murphy32. Further, shift in the pattern of
social or other activities of relatives like not
visiting temples or doing poojas, loss of
faith in God, avoiding people and places
which would remind them of the deceased7
engaging in various activities lest the vacant
hours would be filled with thoughts of the
deceased were some of the other features

present in the bereaved relatives for which
findings of other studies lend support.
The varied features of morbid patholo­
gical grief reaction shown by the bereaved
relatives are considered the result of mul­
tiple victimisation. When a husband is
dead, it is not only the mere loss of the per­
son as such but the loss of a bread win­
ner, companion, sexual partner, social sup­
port, a person responsible for one’s status or
an enhancer of one’s self esteem, family
administrator and planner, disciplinarian of
chi dren and the like. Similarly, when a
child dies before the death of the parents, it
is inappropriate and untimely in the natura order of events’ and these parents are
subjects of multiple victimization by way
of losing one who is a part of oneself, losing
c c dl-eams and hopes invested on that

C 1 ’ oss

fheir role as a protector, pro­

19

vider, advisor and problem solver. This
would make the parents to get a feeling of
being ‘mutilated and disabled’ as these roles
are robbed off leaving them with an over­
whelming sense of failure. In the present
study, there seems to be some justification
for these morbid grief reactions observed
since the death was sudden and unexpected
as well as a number of these bereaved rela­
t
tives had lost more than one person from
t^eir resPcct’ve families.
(e) Coping behaviour: All the 58 families
had engaged in rituals5 not only in those
associated .with funeral but: on monthly
and/or yearly basis either at home or
burial/cremation ground as
per the norms
of their castes or communities.
In about 56.9 % of die families, even
after 6 months, the photographs of the
deceased were kept separately or with the
photographs of Gods/Goddesses and wor­
shipped. In contrast to this, in 8.6 % of fami­
lies, all the photos of the deceased were
removed so that they did not bring dreadful
memories.
In 63.8 % of families, the material pos­
sessions of the deceased were treasured as
sacred things while in 15.5% of families
they were distributed to outsiders. In the
remaining 20.7% family members were
allowed to use them.
In isolated cases, the house was named
after the deceased, and pooja was done to
the name plate of the deceased, the resid­

ence was shifted to avoid memories of the
deceased.

In spite of employing these various cop­
ing strategies, it was noted that some of
these interviewees could possibly benefit
from psychiatric treatment.

4

20

H

!

..

■K

I

IOp
':3-

(f) Relatives requiring psychiatric help: The

ranging from 1

interview brought out that nearly 74.3 %

ther, it was observed that 2 subjects had

still had depressed feelings and about one

developed dependency reaction towards

third of them wanted to be left alone.

the therapist and they would call on the

It was of interest to note that 11 male
relatives interviewed who were occasional­

therapist as and when they felt the need.

ly drinking priot^ to the tragedy had

Acknowledgements

increased the frequency and quantity of
drinking, 1 person had reduced it losing

G.N. Narayana Reddy, Director, NIM-

interest even in drinking and one other had
started the
habit afresh during the 6
months subsequentt to the tragedy as a
result of not being able to bear with the

■ ■'

sudden loss of the relative.
An overall assessment of the relatives by
the psychiatrist indicated that 49 of them

If; Sill .

could benefit from psychiatric interven­

■1 I

tion. These persons were offered psychiat-

i*

I

GRIEF REACTION AMONG BEREAVED RELATIVES

ic help at NIMHANS, Bangalore. Of these
49, one who had lost his wife and a daugh­

ter and had psychotic breakdown was treat­

were treated at their respective residences

by the chief investigator as they were
unwilling to visit NIMHANS for treat­

ment. These 16 persons were put on antide­
pressants and minor tranquillizers. In addi­

tion, brief “re-grief therapy” was provided
to them at their residences by the therapist.

Three home visits were made for each of
these cases. With these treatments, 15 sub.3

jects made sufficient recovery’ and had
ta^en UP ^eir regular day today activities.

i

^vc

!! h;
■

>>Vis. I

them were followed up for periods

14. Volkan, V.B. Normal and pathological grief
reaction - A guide for family physician, Vir­
ginia Medi.al Monthly. 93. 651-656 (1966)
15. Gorer, G. Death, Grief and Mourning in Con­
temporary Britan. London, cresset (1965)

References

17. <,rawshaw, R. Reactions to a disaster. Ar.h.
Gen. Psychiat. 9. 157-162 (1963)

1. Freud, S. Mourning and Melancholia, Collected
Papers, Vol. 4, London, The Hogarth Press
(1959)

18. Chamberlin, B.c. Mayo seminars in psy­
chiatry. Psychological aftermath of disaster.
J. ^lin. Psy.hiat 41. 238-244 (1980)

2. Lindemann, E. Symptomatology and mana­
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141-148 (1944)

19. Parkes, ^.M. Bereavement and mental ill­
ness Part 1. A clinical study of the grief of
bereaved psychiatric patients. Br. I. Med Psvchol. 38. 1-12 (1965)
‘ 7

3. Marris, P. Widows and their Families. London,
Routledge and Kegan Paul (1958)

5. Bowlby, J. Process of mourning.*/. Psychoanal. 42: 317-340 (1961)

NIMHANS psychiatric outpatient of the
chief investigator while the remaining 12

13. Singh, G. &’ Tiwari, S.K. Morbid grief-its
clinical manifestation and proposed classifi­
cation. Indian J. Psy.hiat. 22. 74-80 (1980)

16. Schultz, R. The Psychology of Death, Dying
and Bereavement. Massachusetts, Addision Wesley (1978)

16 others with severe problems of feelings
of sadness, sleeplessness, preoccupation

psychiatric help. Of these 16, 4 attended

H. S. NARAYANAN ET AL.

HANS, Bangalore, for providing financial
grant for this research.

ed as an in-patient at NIMHANS and only

tive upset, anxiety, etc., agreed to receive

r

The authors express their thanks to Dr.

4. Bowlby.J. Separation anxiety, Int. J. Psychi10anal. 41: 89-113 (1960)

with the thoughts of the deceased, diges­

!!

months to 18 months. Fur­

6. Parkes, C.M. Bereavement and mental ill­
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7. Parkes, C.M. Bereavement: Studies of Grief in
Adult Life, London, Tavistock Publications
(1972)
8. Maddison, C. C. & Walker, Wr.L. Factors
affecting the outcome of conjugal bereave­
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9. Clayton, P., Desmarais, L. & Winokur, G. A
study of normal bereavement. Am. J. Psy­
chiat. 125: 168-178 (1968)
10. Grossman, G.K. Recent Advances in Clinical
Psychiatry. London, Churchill (1971)
11. Greenblatt, M. The grieving spouse. Am. J.
Psychiat. 135: 43-47 (1978)
12. Hollender, M. H. & Goldin, M. L. Funeral
Mania. J. Nerv. Mental Dis. 166: 890-892
(1978)

20. Doka, K.J. Expectation of death, participa­
tion in funeral arrangements and grief
adjustment, Omega. J. Death Dying. 15.119•29 (Psychological Abstracts 1985 No
20138) (1984-85)
21. Shackleton, C.H. The psychology of grief20r5C0984^’' BcAfl,' Re5 Th'”Py * ™22. Wallace, E. & Townes, B. D. The dual role of

comforter and bereaved.

327-332 (1969)

21
Cental Hygiene 53.

23. Parkes, u..M. The first year of bereavement.
Psychiatry 33. 444-467 (1970)
24. Lundin, T. Long term outcome of bereave­
ment. Br.J. Psychiat. 145.424-428 (1984)

25. R^do T.A. Bereaved parents. Particular
difficulties, unique factors and treatment
issues. Soda! Work. 30. 19-23 (1985)
26. Soricelli B. A & Utech, ^.L. Mourning the
death of a child. The family and group
process, Social Work. 30. 429-434 (1985)
27. Zisook, S & Devaul, R. Measuring acute
grief. Psy.hiat. Med. 2. 169-176 (1984)
28. Edward, J. G. Psychiatric aspects of civilian
disaster. Br. Med. J. 1. 944-947 (1976)
29. Raphael, B. The management of bereave­
ment. In. Burrows, G.D, (Ed) Handbook of
Studies on Depression, Amsterdam, A.S. P.
Biuiugival View, 303-310 (1976)
30. Horowitz, M.J., Wilner, N„ Marmar,
&
Krupnu k, J. Pathological grief and the acti-

31. Lacey, G.N. Observations on AberfanJ Psy.
t ftworn. Res. 16. 257-260 (1972)
32. Murphy, S. A. Stress levels and health status
of
of a natural disaster. Res. Nursing
and Health. 7. 205-215 (1984)

NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH

December 11,1993

NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCE, BANGALORE
BACKGROUND:
December 1993 would mark the beginning of the 10th year of the Bhopal Disaster. The Bhopal Disaster was one of the biggest manmade
disasters in history. In the Indian context this has been a major milestone in the understanding of the effects of health in general and specifically
mental health aspects of disaster, as the health effects of this disaster received wide attention. Following Bhopal disaster the mental health
needs and problems received specific attention in the form of epidemiological studies and training programmes for medical officers for mental
health care.
In the last 10 years there have been other disasters, both natural and manmade, in different parts of India. Some of the populations of
these disasters have been studied by mental health professionals using differing methodologies. Currently there is no consolidated approach
to the understanding of disasters especially relating to the mental health aspects and development of care programmes.

OBJECTIVES:
1) Review the mental health needs of disaster populations in India;
2) Review the approaches developed for the mental health care of the disaster populations; and
3) Identify areas for research and service development in the country for the populations affected by disaster.

METHODOLOGY:
There will be presentation of experiences by professionals who have worked with populations affected by major disasters in the country
to present their experiences. This will be followed by group work to develop specific recommendations for research, training of personnel and
development of services relevant to India. Broadly the forenoon will be utilised for sharing of experiences and the afternoon for the develop­
ment of specific proposals and plan of action. The number of people for participation would be limited to about 75.
The registration charges would be Rs. 100/- (this will cover the documents and hospitality- lunch, coffee, etc. duringthe workshop). Travel
and local stay would be met by the participants. Limited hostel accommodation in the campus would be available on first come first served
basis.
Please make all Cheques/Drafts payable to Director, NIMHANS and send to Dr. R. Srinivasa Murthy.

Outcome:
(i) Document bringing together the experience of various disasters in India relating to mental health,
(ii) Specific recommendations for research and service development in the country.

Coordinator : Dr. R. Srinivasa Murthy
Professor of Psychiatry
NIMHANS, P.B. No. 2900, BANGALORE - 560 029.
Phone : 080 - 642121; Fax : 80 - 631830.

I

NATIONAL WORKSHOP ON DISASTER AND MENTAL HEALTH
DECEMBER 11. 1993
DRAFT TIME-TABLE
09.00

09.30

Inauguration
Background to the workshop
Introduction of participants

09.30

11.30

Experiences of working
affected populations.

with

1 . Bangalore Circus tragedy
2. Madras Moore Market fire
3. Bhopal gas disaster - Adults
4. Bhopal gas disaster - Children
5. Bombay blasts and riots
6. Marathwada Earthquake
7w Marathwada Earthquake
8. Training in Mental Health
for
population carers.

11.30

11.45

T

11.45

01.15

GROUP WORK

E

Disaster

Disaster

A

Group

1. Mental Health information to affected
population.

Group

2. community level helpers

Group

3. Medical personnel of primary care

Group

4. School teachers

Group

5. Administrators

Group

6. Mental health professionals.

Group

7.

Group

8. Research priorities in disaster related
mental health work.

of the victims of disaster

Cares

01.15

02.00

L

02.00

04.00

GROUP WORK (Con td.)

04.00

06.00

PLENARY SESSION

U

H

C

H

~ Presentation of group reports
— Recommendations
- Plan of work

NAT ! DNAL WORKSHOP DN D1SASTEH AMD MfeRIALJOklti
DECEMBER 11, 1893
SEMINAR HALL (LIBRARY BLOCK), NIMHAN &, BAHGAkQftK.

Venue

AGENDA
09.00
OMsOO
10.00

Registp^tion

0M.30

date kg round to the workshop
- D r ■. R-. Srinivasa Murtny
S.M;Ghannabasavanna
Inauguratiun
~
Key note address
~ Dr. K. BhasWaran
intruductiun of participants

tfelcQiae

PLENARY SESSION
10.00

BspsFiaHsas
1.
2.
3.
4/

5.
G7.
3.
9.

12.30

working with Diea.s ter—a££eQted papulationg.

Dr. H.S. Narayanan
Bangalore Circus tragedy
Adults - Dr. Ashok Bhiman
Bhopal gas disaster
Chi 1dren - Dr. S.K. Tandon
Bhopal gas disaster
Dr. Dr.Vahia, Dr.Bharadwaj
Bombay blasts and riots
and Dr. H.Shetty
Marathwada Earthquake - Dr. Mohan Agashe
Dr.S.Pande
Katy
Gandevia
& Ms.Chitale
Marathwada Earthquake - Ms.
Dr.
Pratap
Saran
Marathwada Earthquake
Dr. Somnath Chatterji
Marathwada Earthquake
Health
for Disaster population carers.
Training in Mental L- Dr. R.S.Murthy
Dr. M.K.Isaac
LUNCH

01.30

GROUP WORK

01.30
04.30

Group I.

Mental Health information to affected
population and Administrators (Seminar Baii)

Group I I. Curnmunity level helpers and Carers Of
victims of disaster (Cu.mm! ttee Room )

the

care
Group I I I- Medical personnel of primary
(Committee room. Adm. Block)

Group IV. Schoo I teachers (Adffllnistrative Block)
Group

04 3 40

Oh . ao

V. Mental health professionals and Research
priorities in disaster related mental health
work.
”
(Lounge)
PLENARY SESSION (Seminar Hall)
- Presentation of group reports
- Recommendations
- Plan of work

I

INEHAJN

SOCIETY OE HEALTH ADMINISTRATORS,
HANGALORE
(ISMA>,

********************************************************************
MATIONAL

SEMINAR

HEAJDTH tTANA GEMENT

DISASTER
JUNE

nt

CIS JI

ON .

19-23,

1995

f^ojYTEixr ' s jurocrsje:* 18,
UANGAlORE

INFANTRY ROAD,

**^*****************************************************************

OBJECTIVES:

To increase awareness and ability for health management t
policy and National programme management
' it

health

To share with the participants about disasters in India,
effects of disasters, particularly the health and health
related aspects, and the role of the management/administration
in disaster preparedness, mitigation and rehabilitation.
To increase awareness and ability to manage disasters
prevention, preparedness, management of acute phase, and

rehabilitation.

-To share
‘ 'years.

&

.■

experiences

of

disasters

managed

in

India

m

recent

WORKSHOP SCHEDULE

£
!»

Sessions

I
II
III
IV

V

09.00
10.45
12.00
02.00
03.45

AM
AM
PM
PM
PM

to
to
to
to
to

10.30 AM
12.00 PM
01.15 PM
03.30 PM
05.15 PM

Tea/Coffee
10.30 AM to 10.45 AM
03.30 PM to 03.45 PM

Lunch
01.15 PM to 02.00 PM

June 19, 1995
I

Inauguration

AS

II

Introduction of Participants, Resource Analysis

AS

III

India’s National Health Policy
Health Problems and Issues

IV
V

Achievements

AS

Disasters in India - Causes and Effects,
Governmant Policies and Programmes

AS

Disaster Planning and Management in Hospitals

AS

June 20, 1995

I

Disaster Plans at State Level

AS

II &
III

Management of blood and Cyclone Disasters

SPT

IV &
V

Management of Rail Disasters; Disaster Plans
of Railways

MSS

June 21,

1995

I & II-

Earthquakes: Management and Rehabiitation;
Experiences of Latur Earthquake

VDM

Role of Law and Order Agencies in Disaster
Management

ARN

III

IV

Health Emergencies

V

Group Discussion

June

Malaria and Plague

PNH

22, 1995

I

Planning and Management of Emergency Services

AS

II &
III

Management of Communal Riot Casualties - Disaster
Plan in Government Hospitals

CMJ

IV

Air Accident

V

Management of Fire Disasters

Disaster Plan of HAL Hospital

PMR
SM

June

23,

1995
Psychological Effects of Disasters

AS

I
II

Lessons Learnt from various Disasters in India
towards Preparedness, Mitigation and Rehabilitation

AS

III

Group Work

IV

Presentation of Reports

V

Concluding Session

RESOURCE FACULTY

1.

Shri A R Nizamuddin IPS
Former Director General &
Inspector General of Police
Karnataka State1
123, Infantry Road
Bangalore - 560 001 ■

2.

Mr S Malulkar
’ ■
Director General of Police
and Fire Services
1 and 2, Annaswamy Mudaliar Road
Bangalore - 560 042

3.

Mr M S Sulaiman
Divisional Railway Manager
Bangalore Division
Bangalore ~ 560 023

4.

Dr P Mohan Rao
Chief of Medical Services
HAL Hospital
Vimanapura Post
Bangalore - 560 017

5.

Dr C M Jayakeerthi
Medical Superintendent
Victoria Hospital
Fort
560 002
Bangalore

6.

Dr ’Shirdi Prasad Tekur
Coordinator
Community Health Cell
No. 36'7, Srinivasa Nilaya
Jakkasandra, 1st Main
1st Block, Koramangala
Bangalore - 560 034

i

7.

Dr P N Halagi
Additional Director (IPP)
• and Additional Secretary (Ping.)
Directorate of Health and Family Welfare Services
Ananda Rao Circle
Bangalore - 560 009

8.

Dr V D Male
Civil Surgeon
Civil Hospital
Latur, Maharashtra

9.

Dr A G Chandorkar
Professor & Head
Department of Pharmacology
D Y Patil Education Society’s Medical College
Kolhapur, Maharashtra

10.

Dr Ashok Sahni
Professor and Hony. Executive Director
Indian Society of Health Administrators
Bangalore, Karnataka
and Additional Faculty

WORLD HEALTH DAY—7 April 1991

BACKGROUNDER-

SHOULD DISASTER
STRIKE—
BE PREPARED!

CENTRAL HEALTH EDUCATION BUREAU
Directorate General of Health Services
Kotla Road, New Delhi—110002
10^

World Health Day—7 April 1991
BACKGROUNDER
r Each year many places on earth are struck by floods, storms,
landslides, forest fires, earthquakes, volcano eruptions, epidemics,
famines and wars which affect the human life. Besides, there are
other modern disasters caused by_man as a result of rapid indus­
trialisation and urbanisation like pollution of air, water and soil.
Together, they still afflict the world, carrying al^igwith them
horrifying tales of death, damage, and destruction/
It was in this context that tho/World Health Organization
(WHO) has decided to devote the World Health Day—7 April,
1991 to Disaster Preparedness and the slogan selected for the
Day is:
.

SHOULD DISASTER STR1KE-BE PREPARED !
The theme reflects the need for creating awareness of the great
damage to humaa'health that can be caused by natural and man­
made disasters./Modern technology and scientific progress has
made it possible to predict disasters which calls for appropriate
attention and actions required for preparedness to mitigate devas­
tating effects of disasters/
What is a disaster ?

/ WHO defines disasters as situations of unforeseen, serious
and immediate threat to public health and disruption of human
ecology./A disaster occurs like an explosive epidemic atlecting
masses'^nd usually culminates into undue loss of life and/or~pro7~
perty. It is always assqciated_with_mas& pamc_iipd usually large
staje”movement of population which disrupts the normal social
life including adminTstratTve organization of the community eftected? wSuch a slressful~sffuation imposes a sudden demand on
the public health machinery for which it is not usually fully prepared. The consequences of such un^reparedness are reflecteo by
ah increase in the amount of morbidity, mortality and disability
which the community suffers. It also~leags~To'unplanned expendi­
ture and efforts which could be minimised if the health services
are ready to take action on the basis of a plan prepared in
advance.
Disasters can be broadly categorised as:-

—Natural disasters, such as earthquakes, cyclones, floods and
sea surges, famines, droughts, epidemics, etc.
—Man-made disasters which may include wars, pollutions,
chemical disasters, etc.

High mortality and morbidity
/ Tropical^cyclanes viz., hurricanes, typhoons and other wind
relateTr disasters cause an yearly damag^-on an average of R&_3000
crores to the environment, property, livestock and agriculture and
an annual death Jpll which may reach, 30,000. Drought is still
causing enormous damage, particularly in/^sia threatening the
lives of millions of people. Such disasters are also a severe strain,
on the fragile economies of many developing countries. It has
been estimated that over the past twenty years three million people
have lost their lives and another 1000 million have had their lives
badly disrupted due to natural disasters all over the world.

The Bhopal gas tragedy bears ample testimony to the fact
that manmade disasters even if they take place within an indus­
trial uhit,'uh!ess promptly contained and controlled, have the
potential to inflict irreparable damage to public health and the
eco-systems outside the site of the disaster.
Earthquakes'. Earthquakes kill on an average .15,000 people
a yetfTworlHwTde and are not impartial in whom they kill and
mairiT. Most earthquakes damage is in cities, towns and villages,
nBt in the^coUnTfyside: In builtup areas, one finds greater population concentrations, as well as the problem of collapsing struc­
tures? Earthquakes' also kill_mpie_p_epple at night than during
the day, 'because more people are inside the homes at nights.
Severe injuries, specially spinal injuries and pelvic fractures are
common. There is an increased risk^of infection as exposure
by shelterless victims remains a potential problem.

During high winds, few deaths occur. Severe injuries are
moderate. Food scarcity is commonly seen and population
movements are rare. Hurricanes usually leave behind a signifi­
cant number of persons with .physical disabilities such as spinal
cord lesions, blindness and_deafness^_
During tidal wave and flash floods, many deaths occur although
severe injuries are few. Food—scarcity and population movements are common. Potential increased risk of infections is present.

During floods, deaths and severe injuries are few^ Food scar­
city and population movements are common. _ Potential risk of
infectious diseases is always present.
Besides above, the victims of any disaster are also prone to
suffer from a variety of psychological disorders, such as,

(i) Various forms of anxiety, depression in predisposed individuals,
and (ii) post-disaster syndrome (temporary ^confusions, disorientatioriU"
’
3

b
Increased risk of communicable diseases remains a potential
risk following natural disasters which result into overcrowding
and deterioration in environmental hygiene particularly affecting
the water supply and disposal of human wastes. This again
depends largely on the previous sanitary levels of that area.
Sometimes, shortage rather than contamination of water supply
emerges as a major problem.

During famines, prolonged malnutrition predisposes to gas­
troenteritis, measles and respiratory group of infections which
become leading causes of death.
Disasters also disrupt the ongoing disease control programmes
in the area.
Besides the above problems, burial/cremation of corpses and
disposal of carcasses are other major problems to be tackled with
on a war-footing.
Chemical accidents and their health hazards
Bhopal gas tragedy and Chernobyl nuclear disaster have
highlighted the risks of chemical accidents. Chemical accidents,
though avoidable, are inherent to the hazardous nature of chemical
industries. Apart from accidental releases during production,
even storage and transport of certain chemicals are intensely
hazardous operations. Both life system and environment are the
targets. We have today enough knowledge about the acute effects
of these chemicals, but we have very limited understanding of
their longterm health effects. Phosgene, a highly toxic industrial
chemical, was inhumanly used as a war gas in World War 1. Its
long-term effects on the soldiers who survived became evident only
30-40 years after exposure in 1914-15.

The pollutants released in massive quantities induce adverse
effects directly or after absorption
and transformation
within the lung. The net result is an overall toxic stress which
ends up in respiratory failure and death and permanent injury to
the respiratory system of many survivors The long-term effects
include functional disturbances or inadequacy of performance of
vital organs and general disability. Infections of the upper res­
piratory tract are exacerbated. The respiratory organs also be­
come more susceptible to infections and allergenic activation.
Effects on the eyes are a temporary or partial loss of vision
and more particularly premature cataract formation. In many
such premature cataract cases, it may be necessary to resort to
corneal transplantation. The most serious injury to the skin in
chemical exposures is first degree burn, acne or prolonged sensi­
tization reactions.
4

i

Other systemic effects of absorption of intensively toxic che­
mical through the lungs are noticeable in the blood forming pro­
cesses and in functions of the liver and kidney. Abortion can be
induced in pregnant women. Structural malformative changes
could be noticed.
Examples of some disasters

A few examples of disasters which are still fresh in the me­
mory of living generations are as under:(A) Atom Bombing of Hiroshima (6 August 1945) and
Nagasaki (9 August 1945) during the second world war is regar­
ded as the worst manmade disaster of the century with estimated
casualties of 120,000 and 75,000 respectively.

(B) Guatemala Earthquake (1976) in which 92% lost their
homes, about 76,000 sustained injuries and some 23,010 got killed.
A sample survey of victims of this disaster brought out such star­
tling findings as-

— 84% of the victims had no social security in the form of
insurance.
—46% were dissatisfied with the medical care received by
them.
— 13% could not return to their former employment because
of their injury, i.e., they needed vocational rehabilitation.
— 12% had to wait 2-3 days and lo% for one week before
admission into a hospital.
— Even for first-aid, 13% had to wait for 2-4 hours, 12% for
4-8 hours and 21 % for 2-3 days.
Earthquakes in 1990 of Peru, Iran and Philippines

<

1

On 29 May 1990, an earthquake spread panic in the inhabi­
tants of San Martin in the North Central Region of Peru. More
than 120 people died and about 40,000 were affected. Twenty
per cent of the dwellings were destroyed affecting the poorest.
On 21 June, 1990, a major earthquake struck the provinces
of Gilan and Zanjan in the Elburz mountains of North Western
Iran. Nearly 40,000 people were dead, 60,000 injured and
500,000 became homeless. At many places 60 to 90 per cent of
the homes were destroyed or suffered major damage.
On 16 July 1990,another major earthquake struck Central and
Northern Luzon areas of Philippines. Eight provinces and three
cities were devastated with 1000 people killed, over 100,000 houses
5

and buildings destroyed rendering 2,00,000 families homeless and
large numbers either injured or missing.
(C) The Tidal Wave And Cyclone Disaster in Andhra Pradesh
(1977) claimed some 25,000 lives. The victims included mainly
the young people, the old and the weak.
(D) Bhopal Gas Tragedy (1984) is regarded as the worst air
pollution disaster so far and was due to accidental leakage of
methyl isocynate (MIC) from its plant. It affected about two
lakh people and claimed 1,754 lives, according to one published
report.
(E) Chernobyl Nuclear Plant Disaster (1986) resulted in the
death of 28 people and 203 suffered from radiation sickness.
The material losses amount to two billion roubles approxi­
mately.
Should Disaster Strike : Be Prepared !
Emergency situations like war, earthquake, flood or any
other natural or man-made disasters can upset arrangements of the
community, municipality or Panchayat for the prompt and sani­
tary disposal of community wastes, supply of safe drinking water;
curative and preventive health services, etc.

These may give rise to diseases which we cannot risk in an
emergency situation. Here are a few suggestions for your guid­
ance in such a situation:
* Use less water for all purposes to minimise the quantity of
wastes. Also minimise the solid wastes.
* Always use a sanitary latrine as it will stop flies from com­
ing into contact with stools and thus prevent spreading
diseases like cholera, typhoid, dysentery, etc.,
* Utilise the waste water from kitchen, bathroom, etc., for
gardening inside the compound or divert it into deep pit for
sub-soil dispersion during an emergency.
* Collect all the solid wastes from the house and bury them
away from the house.
* Always keep your garbage tin or can covered.
* In case of disruption of water supply, boil water for drink­
ing purposes. If water is taken from a river, filter it before
using so as to avoid diseases such as guineaworm. Water
from ponds, lakes, etc, must be strained through two layers
of cloth and allow it to stand for a short while. The water
can then be purified by boiling or by using bleaching
powder.
6

* Private or community owned water sources should be pro­
tected from outside contamination. The same applies to
domestic containers and should be kept covered.

* Get yourself and your family members immunized against
diseases as it is the best form of preventive medicine.
Immunization is especially a practical step in preparing for
disaster situations because it can be taken in advance.

Emergency situations we may face

-1

* When a disaster strikes many lives are lost. People are also
seriously injured. They may need blood to save their lives.
In such a situation you can help by donating your blood.
Human blood has no other substitute.
* Person or persons receiving injuries during a disaster may
be in a state of shock. They may have serious bleeding
which must be stopped urgently. Fractures also result due
to injuries.
* We may get burnt by fires and heat as well as scalded by
hot or boiling liquids like water and oils.

Learn First-Aid
We must learn something about first-aid to help the victims of
disaster. Very simple hints about care during emergencies and
before the patients are provided specialised medical services, can
help save many lives. A few hints to control situations mentioned
above are :
* A patient in a state of shock should be laid on his back.
His head should be low and turned to one side, and his
feet raised. In case the patient has a head or a chest injury,
the head and shoulders should be raised and supported.
Loosen tight clothings. He should be kept warm by blankets.
Liquids must never be given if the person is unconscious or
in a severe shock or has abdominal injury, or is likely to be
operated upon within 3 to 4 hours.
* In case of bleeding, keep the patient lying down. Raise the
bleeding part. Stop the flow of blood immediately by apply­
ing pressure directly over the wound with a sterile gauze or
clean cloth or your thumb. Apply dressing of suitable size
and pad over the wound and press them firmly in position.
Remove him to a hospital as early as possible keeping his
head slightly lower.
* A man may die in few minutes if his breathing stops. He
needs help in breathing when breathing movements stop or
his lips, lounge and finger nails become blue. Give him
artificial respiration. Mouth-to-mouth respiration is best.
7

* If a person catches fire ask him to roll on ground or cover
him with a thick cloth or blanket and ask him to roll on
ground. Stop him from running when his clothes are on fire.
Move him to a hospital immediately.

♦ Fracture is a break or crack in a bone. In case of fracture
the patient should not be moved until the injured part has
been immobilized (preventing from moving). Bleeding, if
any, must be stopped before attending to a fracture. Make
the patient warm and comfortable and keep the injured
part steady and properly supported. Bandages should not be
very tight and should not be applied over the sight of the
fracture but above and below the site of the fracture.
* Transport the patient soon after first-aid to a hospital, Use
a hard stretcher if there is a fracture of the spine.
A few more hints to face a disaster
♦ Decide in advance where will be the safest place in case of
a disaster in your house as well as at the place of work,
keeping in mind the nature of disasters.
* Flashlights such as torches, etc., should always be kept in
reserve for an emergency created by electricity failure.
Candles, lanterns, lamps may also be used, but it must be
ensured that there is definitely no danger of explosion.

* In case disaster strikes we may need certain basic tools
such as a shovel, axe, hammer, a saw, a crowbar, etc. These
may be useful to move debris under which someone is
trapped.
* A first-aid medicine box to be kept ready for emergency use.
* A transistorised radio should be on hand and its batteries
kept fresh. The radio may be the only means of communi­
cation with the outside world for hours or even days.
>

>

Issued by the Central Health Education Bureau, D.G.H.S., Kotla Road,
New Delhi-110002 and printed at Aman Printers, Paharganj, New Delhi.
400 Copies/Feb ’91.
8

1

PSYCHOSOCIAL INTERVENTIONS
IN DISASTERS

Prevention and treatment of
psychological disorders

uu OSI“ dlstress in somatic terms
(Goldberg & Bridges, 1988). In order to cooe
hrom the psychological point of view, the pri­
With genera! anxiety and also uncertain^.- about
mary prevention of disasters must deal with
the possible health etfects of the disaster.'oeooie
denial as a common psychological reaction to be
focus on the more tangible aspects of their physi­
Found among populations exposed to a threat.
cal state of health, seeking out the health care
The negation of an imminent threat can make
system and requesting explanations. Esoeciallv
orcwarning useless, and expose populations to . m the absence of reliable data about the health
avoidable nsks by producing a delay in adopting' effects of the accident (for example in the case of
preparedness measures. Therefore health work­
toxic, chemical and nuclear disasters), medical
ers may have an important role in reinforcing
workers lack adequate explanations and mav
warnings and thus making timely and effective
we respond with extensive and intensive diagprevention possible.
nostic screening of populations and individual
Psychosocial prevention can also play an es­
patients. The paradox in the situation, however
sential pan in preventing and minimizing the
is that attempts to reduce such illness behaviour
psychological consequences of disasters, espeand such extensions of the diagnostic proce­
rnlly rhr occurrence of PTSD. In terms of interdures, in order to diminish the probaoiv un­
vcntion programmes aimed at preventing and
founded attribution of symptoms co the disas­
creating psychological disaster-related disorders,
ter, would deprive people of a coping strategy if
the mam needs following natural disasters exist
no alternative were made available. For ail these
in developing countries and among socioeco­
reasons, the primary health care worker repre­
nomically deprived individuals. Since in devel­
sents the crucial locus for the intervention. The
oping countnes the resources devoted to mental
proper handling of the psychological problems
health are often inadequate to meet even routine
associated with a disaster is of great importance
needs, the primary heakh care system is the firs:
and must oe included in the training programme
and often the only health network available in
of all heakh workers potentially involved in the
the case of a disaster. It should not be forgotten- care or arfected people. The training of primary
however that the population affected by a disas­
healcn care workers to give appropriate treat­
ter might well retain considerable cooing ca­
ment to people anending heakh centres and
pacities. They should not be created as com­
snowing emotional distress due to a ver.- stress­
pletely helpless, and assistance should be di­
ful event, deserves priority (Lima. 19S6;; such
rectea,ar mobilizing local strengths wherever
utainL.g .epresents one of the mam preoared-'
possible. Moreover, for socioeconomically deness activities.
pnveo individuals. pH man’ care is the only mean
1 nere are other considerations wnich under­
or extending Meaitn and mental heakh se.wi.ces.
score me importance or integrating mental hezim
In aaair.on. in many disasters, besides a certain
.services wntnin the rrzmework of the existing
numoer of people who have been severely afneaim system, and especially the primary care
fecteo byyr, -here ^lii be a much larger number
s vs tern:
of less affected people who wyP however, dis­
play a vunety or functional comolaints and osv1.
potential users do not come to a fcciiiry
^oiegical disorders. Fynctionaicompiaint^and ’
-men is openly kbei’ed as a menra: health
somznzctior.......................
’
' com­
.u J-particular:r
. since tney co not see t
mon..............................
...
„
••
.
o
....cnami; orima.w icmm
seeding spvciaiined heip
care and :n ”
' “* '
ives
Oiuy as victims of ■:
T.C 1
oeoo.'e in d;

■']
i

2. It is well known that the krge majon- of
cases of psychological distress among
attendees of health centres go unrecognized!
_ o not receive proper care and represent an
lmPonant burden for the health services Bet­
ter and prompt recognition and management
of these disorders, including PTSD, can im-

'

Teaching preventive psychiatry

This will involve educating and rr=' ’

in“ °! pr°,c^
■er

°PT”"“ "

b“i“

J™-

tarze/v
emotIonaI first aid. The
med' |rOUPS are nOt °nIy the
Para-

I , °UCCOmc ^d reduce the burden
on the health services.

3. The primary health care i
nerwork, thanks to
its central position in the
«e community, can
guarantee proper follow--up of victims and
their families for as long as they need.”.

r«PonS,M19, fOf di,„„r phm;n™
Leadership

In this framework, the role of the specialized
mental health team should essentially be one of

s

superv.smn and training, and only especially
d-Hicult cases should be referred for direct treat!
ment.
Trvo rrecent papers have reviewed the
empirical evide.
--nee for the effectiveness of a range of
tments for post-traumatic stress disorder
(Davi son, 1992; Solomon et al., 1992). With
regard to drug treatment, amitriptyline and

Mental health care during the first 6 months

.mipranune are both effective, and will help with
disturbed sleep Doses up to 200-300 mg/dav

Je first 6 months after a disaster mav require
general counselhng for those who present to

y e required, although attention should be
g> en to possible s.de effects. Treatment should

nmary rare w>th recognition and ref—' -~r
^SD d^cal
heakh Pr°b,t™ ^ch
« PTSD, depression and gnef. Early treatment
may help to prevent problems.

uic erncacy ot behavioural techruques, cons.stmg of different forms ofsystemocdesensmzanonornoodin^thesetechmques
helfM eSPCciJ]y in
ng PTSD intrusive symptoms. Cognitive
psyc..odynam,c and hypnotic techniques also’
hold promise Chmcal experience tends to suggeythat bne. shon term counselling may be
h= prul in rhe early stages of the disorder, before
k becomes entrenched. This is parricularlv so if
rh= person is able to deal with the effects of
he.plessness and rear that surround evervbodv
reduc

^^er a disaster, trough catharsis, suopon and
^ogmtive restractunng of the experience. Fur­
rer research however, is needed before anvfirm
concms.on can oe drawn as co the compa'rative
e—r.-.eness or umerenc treatment methods.

-

others that are activated during the acute

Phnr.ing long-term follovr-up of victim groups
The second 6 months or so after a disaster, that
■s between the acute phase and the longer term

. Durins this stage, one should be aware that

anniversary” reactions tend to crop up; certain
nays may serve as reminders of wha’t the vicrims
have peen through. There mav also be a ne~ -0
follow up avoidapte behaviour, because!'
!lyed °nSeC of scorns m
r ..... . Who hav« not displayed the bail post.
humane stress syndrome.
Mobilizing support at different levels

IJmcludcs the giving of advice to victims and

’■un5^on of the mentai heoifh
prcrsssionol expert in
Preparedness acdvih'es
he^ professiondfs) ar-de.-.anond
-.;or.d i.e.g.?rovinc:al) level should
respor.smie .-c•o

l

-pe.s aoout copmg techniques and the mobi-i-tmn or support from family, friends, work
■yes and neighbours. A clearing house -or
y ormar.on on available resources should be set
U D.

may be userui :o nave some mode! na
n i e. j p r 2$ e n n n csser.rmi
• •——
- • . . A-.
. . . % ..

PSYCHOSOCU.l INTERVENTIONS IN DISASTER ,

be rapidly adapted to a particular disaster situa­
7. HeakhpersonHeKm^s injury s.’ruarions that
tion and distributed to relevant-groups, such as .•
demand difficult prioritizing)
..
survivors, bereaved families, rescuers etc.
8. Persons holding responsibility
In massive disasters particularly in third world
9. Workmates (in company disasters), and
countries, killing tens of thousands of people,
10. Evacuees.
the only active element of the psychosocial or­
ganization that is possible in the turmoil of the
Individuals at the disaster site displaying
acute post-disaster phase may be that at the
grossly deviant behaviour or other severe psysenior staff level, trying to influence decisions
chological reactions should be rapidly reand providing psychological support.
ferred to psychiatric care.

Functions of the mental health
team at the disaster site

Establishing an information/support
centre
1 This centre can be located either at a hospital or

While rhe considerations
so far apply
1
j j j described
i - ----------rrv
* convcn’enf P^ce not too far from the disasoth to developed and developing countnes, the I ter area, (hotel, town hall school, etc.) but neverfollowing proposals, focusing on the functions j rheless far enough awav from where
. .‘
—- rescue acof the specialized mental health team, are appli- I, *ivic
'*. ,rplace, •so that congestion
y **s taking
and
cable especially m the developed countnes. Only
interference is reduced. If the identirv of the
these countnes can usually afford the heavy
wcau
uncertain (which
dead is
is uncertain
(which is
is fre
frequent), or the
burden of setting up and maintaining a specialist ■ number of dead is unknown for L d.
—■ a time, a great
mental health service which can be mobilized at 1 number of families will be distressed
I until they
times of disasters. Nevertheless, it is hoped that ' ascertain chat their missin f_ ’
issing family member is
the following guidelines can provide useful leads
safe. Establishing an informatir- - Ji’on support cen­
for those working in developing countries.
Itre has turned out to be useful. The existence of

( such a centre and its telephone numbers should
be distributed by radio and P/. Families who
Groups requiring psychosocial support
are worried that one of their number is amongst
Psychosocial support at the site of a disaster
the victims should be invited to come to the
should in principle be carried out by the rescue
centre. Survivors may also be asked to gather
workers and emergency health personnel. The
there. Particularly after transport/communicaleader of the mental health team with collaboranon disasters when people die far away from
tors snould establish the priorities of
their homes, this centre may be useful, for sev­
psychosocial support activities, mainly based on
eral reasons: it gives the bereaved a chance to
their evaluation of the particular traumatic as­
meet survivors to get a first hand report about
pects of the disaster, taking into account the
what happened to their loved ones, how they
different groups which are to oc considered:
died, perhaps even what they uttered before
they penshed, and what was done to rescue
1. The next-of-kin
them. The survivors and possibly also onlook­
2. Tne injured survivors and their close ones
ers and rescuers have information that often
3. The uninjured survivors
cannot be given by others.
For the survivors it is often an important
These groups are likely ro have suffered the
experience to be of help to the bereaved.
most severe stressful experiences and thus re­
The main functions or such an information/
quire support and preventive activities. Often a
support centre are:
family may include all three above. Other groups
—l..Tio_proYide rapio. authontative information
need to be considered, but they usually have less
about tragic news that can be conveyed in a
pressing needs, namely:
numane, direct way in a setting sheltered
from public and media attention,
4. Onlookers (parricuiariy ar risk arc the help­
2. To provide support and a holding environ­
less helpers')
ment tor both survivors and helpers;
5. Rescue tea.T.s 'parricuiariy —hen failing to
3. To serve is a rorum or meeting place where
rescue, especially children
affected maivtauais and families can support
6. Persons «io:nz bedv ba
Z ■,pr.r::c’j!ar:v
eacn otr.er. ieif-help groups mav develop
.-n :ney are non-oror.
■cis)
.Tom this Trum,

PSYCHOSOCIAL CONSEQUENCES OF D!SAST£RS; p^'ENTiON AND ^NAGEMENT

4. To be a place where che police can collect
.. identification data about missing/dead per­
sons from their close ones,
At times the police should be able to use the
centre to interrogate survivors about the di­
sastrous chain of events as a part of their
investigation,
6. The information/support centre should help
to reduce the convergence of people on the
disaster site that may create congestion and
therefore movement problems for rescuers.
A meeting may be organized for everyone
affected (this may be possible for up to one
thousyid people) or at least one or two repre­
sentatives from each affected family. At such a
meeting information can be given about rescue,
identification, investigation of causes, insurance,
psychosocial support services and religious ser­
vices.
Attempts can also be made for early identifi­
cation of persons at risk. The Post-Traumatic
Symptoms Scale - 10 for instance, can be used
after a few days. The survivors’ mental state can
be evaluated, as can the possibility for mobiliz­
ing social support from people's own networks
(family, work colleagues, friends, neighbours).

Specific procedures for helping survivors
The mental health team should reach the scene
of the disaster as soon as possible. There have
been very positive responses to anticipatory
guidance, i.e., information about che natural
post-traumaric stress reactions that may be ex­
pected. Inrormarion meetings are effective means
to talk about this and what the survivors them­
selves and their close network can do to help.
Anticipatory guidance works by helping the
victim accept the reactions
and
, . .as .normal
.
, .ex­
pected, and not as jpathological, thus reducing
uncertainn* and feelings of helplessness. Night­
mares suffered by the victim are often alleviated
by physical contact; if this tails it mav be better
to waKe tr.e patient ana let him go back to sleep
again afterwards. Hypnotics may be given briefly
for severe sleep disorders.
At this early stage most survivors are psvehologicolly open and willing to talk about their
experiences, an attitude, however, thatmav soon
change into a defensive, withdrawn, non-cooperanve position if time is allowed to pass with­
out attempting to make contact. Therefore it is
Oi utmost importance mat me survivors are
encouragea to seek he’p problems ceveioo.

When disasters involve people away from
their home areas, it may be necessary to help
them to establish supportive contacts with health
or social service professionals in their home
district. One of the first needs of survivors in
these circumstances, is to be able to inform their
families about rhei:
...eir fate, preferably even before
the media have :announced news of the disaster.
Some may have: an urgent need to get home

health support service more complicated than if
the victims are local people or members of a
homogenous social system.
He!p for bereaved families
It has been demonstrated quite clearly that the
family is the unit providing che most important
source of strength for cjnduring a disaster-loss.
There is strong evidence that sudden and violent
death causes more pathology in the bereaved
than expected losses and this can be made worse
by the terrible circumstances surrounding the
death in disasters, perhaps even witnessed by the
family. Equally distressing however, are deaths
happening far away from them, possibly with
Ornes of waiting and uncertainty for the family
.tmzu me acazn u vonrirmed.
Sometimes the bereaved may be unable to
..travel to the site or they may never seethe dead
because the remains may not be idenrifiable or
even found. Frequently, this failure to retrieve
the body or to identify the remains his compli­
cated grief work. Tn the acute phase, measures
taken to alleviati: t^c consequences should have
as the first goal, t« hiip the family fully grasp the
death ef one or more of their number, and
secondly to help starr them on the road co
accepting the loss. The full realization of the loss
seems to be helped by the identification of the
dead body and an awareness of the physical

aspects of death, as well as the circumstances in
which it happened.
Experience in Norway
The psychiatric team working with the bereaved families after a disaster, (the loss support group), usually secs up its headquarters
at the local hospital, for example in the outpauenr department of internal medicine. Each
team consists of a psychiatrist, chaplain
(pnest), psycruatnc nurse, clinical psvcholo^aid sometimes a social worKer or others
e.»^crenven in loss ana gnei reactio> 0 1erm^me oerezved families in one ozeeoro-

I

I

PS fCHOSOClAl INTERVENTIONS IN DlSASTc

tccts them from wandering aimlessly around
the full facts about the death; this is a burden for
or engaging iq unplanned searches for miss- •
-both panics involved.-If the body h
as not yer- ...
ing family members. Some expen’ence indi­
been recovered, the next-of-kin '
vill
nearly alcates that the support group should work
ways
express
a
strong,
wish
to
travel
to
thescene
---- ...e
exclusively with the bereaved families and
of the disaster.
not combine this work with support to survi­
vors, because of the entirely different needs of
Identification of the body
the clients. Each family has two <
group mem- .. A member of the ream should be present when
bers designated as personal contacts. The
the next-of-kin is a^ked by the police to make a
group will work in close cooperation with the
positive identification of the body.
police which is the agency that carries out rhe
identification work.
Viewing the dead
In disasters wnere people die awav from their
It is important that rhe bereaved are provided
homes, the team will have some hours to
with an opportunity to see the body of the dead
organize the reception of the bereaved fami­
if they wish and if this is possible, Lid that they
lies. If there :s a large number of dead, it is
are provided with information about the death.
important to join the different families into a
It is also important that as far as possible, approcohesive group by, for instance, lodging them
pnate funeral and mourning rituals are provided
m the same hotel. If the dead come from a
in accordihce with the practice of the bereaved’s
similar background, as in a school-bus acci­
culture. An important task for the support group
dent, rhe parents will already have a natural
has been to arrange for this viewing of the dead •
affinity with each other, and this will
bodies. This must be scrupulously planned after
strengthen the bonds for an <extendedJ penod.
_.L_.
evaluauon of each family and considering the
If the dead make up a group which has come
state of the body. Meeting the dead gives the
together by chance however, as in a some
family a chance to see, talk and touch and to fully
airplane crashes, the bereaved may form a
comprehend that the loss is real, that the uncer­
group onlv during; the acute phase when they
tainty is over, and chat they must take a final
are sharing many of the same services and
farewell. If the face is too mutilated to be seen,
undergoing many of the same experiences.
other parts of the body may be recognized. For
The first day after a disaster is usually filled
children it can be a help co leave something in the
with a succession of practical problems co be
coffin, a favourite doll, a drawing or a letter to
solved. The bereaved families are encouraged
the dead mother or father.
to travel with a companion (who might be a
local priest or a friend of the family), because
Information about the circumstances of death
it has been shown chat the breaking of the
Regularly the family h;
_
* las many questions about
strong bonds that often arise between the
how the dead person was found and the manner
team and c.ie bereaved family will be made
of death. Therefore they should be given an
less difficult in the aftermath of the event
opportunity to meet survivors who have some­
when a continuing link to an after-care ser­
thing to tell, the rescuer who found the body,
vice at the home place is provided through
and any nurses and doctors who tried to resus­
this person.
citate the victim. It may be necessarr :o ask the
pathologist to provide information.

Role or the Psychosocial Support Team
The psycnosoczu support ream mav be involved
m die roLlowing zcavines for the bereaved fami­
lies:
Notification of deam

Seeing mat trus cur.' is earned out in an : □ ropnate way by me ;ocal police, pnes*, e: Ir is
important mat noar.cation is given in sum
-T.at :ne ramily can ?e helped to 2rasp w? : has
r.-ippeneu. It is a common c.XDe.acnce th : die
nearer or me lcc tness.-vgc :s nut :n possession or

Visiting the site of death

The team normally encourages viewing of the
scene or the disaster to be earned our ;n groups,
and a rather private memorial ceremony mav be
arranged there. This allows the bereaved fami­
lies to come close to their dead and express their
sohdanty. This final farewell must be shielded as
much as possible from the intruding gaze of
outsiders and the media.
Public memorial service

.::c bereave- famines shouid also -z

■ ^CHOiOOALCONUu^ Of

-

i

attend some kind of public memon'al service,
Debriefing
rubiic mourning is an important symbol of the
wider society’s support to those bereaved.
The majority of rescuers report a need to work
. Personal relationships are particularly im­
through the emxmonal disaster experiences by
portant in the emotional reactions after disas
gs
ters, providing support and help in dealing with
the stress. People are also very distressed when
review the helper’s role;
separated from those they love during and after
ease
the expression of fe£ings;
a ‘“ster, and information and support services
—
explore
particular problems encountered and
to help the reunion of family members are likely
solutions
found;
to be helpful. Special relationships and closeness
identify
positive
gains;
between people of all social grouos who have
~ejpl°x C°nsecIucnces of disengagement;
surfered the same stressftal experience together
—
identify those at riskmay provide a “therapeutic community’ effect
-provide
education ab^utaor^al reactive proafter the d.saster, where people talk through
cesses to acute stress;
;
what has happened, share feelings and suoport
— explain how to cope with stress adaptively.
one another in several ways that mav help recov­
ery. Similar bonds may be formed between vicof t?eedP7C^tnSt Can aCt
formiJ '“der
oms and rescuers.
o the debnetmg group or may give training to
£ev cm P‘n
ns so ^at
The physically injured
they can lead such activities. Frequently it is a
Many hospitals are capable of handling 20 or
o eat advantage to have taken part in the rescue
more injured cases, but not many can take care
mav S0"
' Sr°UP’ but there
of the one hundred or more close family mem­
should r UC“,OnSLWhei? 1 neatral Pr°f«5ional
bers belonging to this number of injured. This
should take on this role. Debriefing involves
~2y be a reflecrion of chgomg through, in detail, the sequence of events
pnysical mjunes in disasterpianning. Thesurgishould "I'"0? °y
ParTlc?an'- ~fte rescuers
cal and mtens.ve care personnel should there­
should also share With the rest of the group their
fore be remforced by a psychiatric liaison ream
thoughts and feehngs during and after the disaswno can have responsibility for both the injured
bv rirsrS
r,er t0
Chc debriefing
and for their family members. As regards han­
scriorio
info™adon. The de
dling the injured, the most common error in
senpnon of the professional activities of the
psychological handling is fearing the injured
rescuers can lead on namrally.-a, the more delialone; they are especially vulnerable to being
i5su- or thejr emotional a-d psychological
abandonee -n darkness.
5
r««°‘-s. Reviewtng ho w helpers felt and coped
requires consideranon of positive as weifas

,

rPeCtS- °n Che ne^e side thes“

Crisis intervention
The good talk’ is the psychotheraoist’s main
■ool. It is as important as the scaloe! to the
surgeon ana contains several therapeutic ele■T.ems: the interpersonal contact, the verbaliza=on -vnicn mcreuses control, the ccmarttc effect
or ■•■ennlanng emotions and the need forwork-ng t.nrougn tne experiences again and again if

«l

-a to be neutralized and integrated. To cum the
. " si e . c.i, mg of ute trauma, as m nightmares
mto an acnve reconfrontanon seems to work
••e.m me pattent reels char the therapeutic envi■on...ent is sate enough. It is natural to use the
approacn ■.vim victims ofcoiiecuve trauma

• _

-

? —scrong
ber-r.'-cr -- —

'V1duals mav have experienced a sense of

orlev
b,emSU5e]ess --d overwhelmed,
c ute ofTPr°b;^ at
be­
cause of their involvement m disaster work
me may surer from what ms been called
perrormance gunt” believing mat their contri­
bution was maaequate. Positive reactions mav
mc.ude a feeling of satisfactmn of a iob wed
done, the Ending of a vicrim aiive. the forgin. of

unporrant relationships among neioers, or"sense
or reassurance about having bee- abl- -o -one
The sustained emohasis on'
?
r t
i
SIS Gn
Tosinve asoeers

Of*.-

, po„m=nrido

O

• --.no or n-.^s,em,-over tne unt.easanr-\--,.r
or disaster work. The br --- I • ' ' '"'“T
„ ___ _ _u
e =01-....^ .msten mould
—^pression r
peers. Soir.cn-: —
/ ••••"- is-

• PSYCHOSOCIAL INTERVENTIONS IN D1SAS7
•• }■*)

“f:

tionship may develop between a helper and one
or more of the person rescued. Both this and
powerful relationships that may have developed
with other helpers can cause problems by cut­
ting across family relationships.

Role of information

I

I
I

I

Accurate intormation is very important at every
stage of disaster response. As part of prepared­
ness, people snould be provided with clear in­
formation about what to do m the event of a
disaster affecting their communitv. Such infor­
mation should be relevant to disasters that are
frequent or likely to occur, but also be of general
utility for unexpected circumstances. It should
convey the nature of the threat and whac co do
abouc ic in simple and concrete terms. Informa­
tion m the event of an imminent threac should be
reported through ac lease several channels in­
cluding TV and radio and should be presented
by those who are seen as trustworthy leaders.
Training, including information on whac co do,
should be incorporated into community life in
places which are frequently subjected co threac.
During disasters, particularly in developing
,j
ccuncrie:, •ric:ims arc often poorly informeu
abouc the events chat are occurnng. Rumours
are frequent, authorities give conflicting infor­
mation and ineffective action follows. Illiteracy,
a multiplicity of languages or dialects and a lack
of media, can all contribute to difficulties in
disseminating information rapidly and accu^
rarely.
The responsibility for transmitting informa­
tion rests with both public authorities and the
mass media. The authonties should take and
retain the initiative in communicating with the
public in the event of an emergency. Communi­
cation within the government should be well
coordinates, and the authonties should seek co
establish a climate of tms: with the media, which
should handle the information given in an open
and unambiguous manner. To achieve these
objectives, me national authonties responsible
for the vanous aspects or disaster protection
should coordinate their actions as rar as pos­
sible. International organizations mav also be
sending out izrorma::??.. Diverse interpreta­
tions rrom the vanous national and interna­
tional organizations of the oorentiai
orer.za cubiic health
consequences or a disaster,■. can
can 5-seriously conruse me puoi-.c. and errare difficulties tor na-

Developing country populations are nocori- - ously non-compliantwich warnings for evacua­
tion. While a variety of psychological mccha- nisms can be invokec[to understand these reac­
tions, a more concrete approach must also be
taken. The evacuation order expects the victim
to leave behind all his possessions wdeh no procection agamsc loocing. Often survival is depen­
dent upon small-scale agriculture or livestock,
making it very difficult for people to leave be­
hind all their wealth and means of subsistence.- Failures or prediction can also dimmish trust,
when evacuation orders are given forevents that
never occur.
informacion about a disaster shoulc be provided
co the population at a local level. Such informa­
tion should be provided in collaboration with
local leaders and communitv representatives. In
particular:

— specially prepared brochures and pamphlets,
updated as necessary, should be widely discnbuced co the population of the affected
areas, as far as possible in collaooration with
the local media;
—dialogue should be encouraged between the
community, the authorities, scientists and
health professionals, as also envisaged bv the
European Charter on Environment and
Health;

Possible adverse effects of public
information
Public information can however lead co adverse
psychosocial consequences by creating a sense
of confusion and mistrust. Reassuring asser­
tions by experts may be contradicted bv other
experts or by later events. It is the right, even the
duty, of scientists co give an opinion on a scien­
tific matter, but they must do it in a wav that will
avoid any confusion between facts and judg­
ments on facts. A further difficulty is in the
nature or communication between scientist and
non-scienrist. The latter may be trained to think
in arbitrary terms requiring “ves” and “no”
answers and they may in consequence be both­
ered by the scientist’s answers in terms of grada­
tion and multiple qualifying considerations.This
pressure for what might be though: of as “binolar” chinking and decision-makir.z is bound to
be a source or great exasperation, misunc
standing and irrational decision:
tee: they are zemr.g inswers vt

• Fc

s:=ie to use, while the scientist feels he is beint?
health effects should be provided to the populacomronted with unanswerable questions and
Uon
at a local level. Equally or even more impor­
..... cocrccd-or.tempted into committing himself.
tant,
!S the way m which the authorities should
In considering the provision of information
present information if an accident occurs. In
tovictims”, it is necessary to consider their
many
cases, people have been flooded with incerimtion. Traditionally victims of a carastrorormation
and nobody has shown them how to
pne would be defined as those who were physi­
deal
w,th
it.
One of the few “principles” in this
cally touched by its effects. On the contrary,
held
that
seems
to be useful is that comoarisons
however, the notion of victim cannot be limited
are more meaningful than absolute numbers or
to those persons physically exposed to toxic
probabilities, especially when these absolute
passions or physically affected by the disaster,
V? UejaLC
sma^- The key role which con be
me victim group of a major disaster potentially
p
aye
y
2n
intemarionaj
organization is cruencompasses all those who receive the bad news
cial
at
this
level,
since
the
information
provided
or me accident. For larger populations, the bad
by
it
is
generally
seen
as
more
“
neutral
” and
news wall not necessarily be accompanied by
authoritative"
than
that
coming
from
other
□meetly visible events or damage. This is espe­
sources, and it can therefore facilitate public
cially the case of toxic/nuclear disasters, and
compliance
wlth necessary measures, prevent or
many of the following considerarions refer speminimize
worries
and fears likely to prbduce
cncaily to this type of disaster. The Chemobyl
eX||ent.1V|e
consequences, and fi­
oisasjer was especially striking in this regard. In
nally
help
to
restore
a
cooperative
climate.
the nrst weeks and months after the accident,
Building a better public understanding of
very limited public information was provided to
nsks and informing the public correctly in the
the affected populations. Over the following
case
of an emergency is only a part of what needs
years however, these populations have been ex­
to be achieved if people are to be enabled to
posed to a barrage of information, with many
respond
more rationally to a future emergenev.
contradictory and inconsistent news items and
lhe
central
issue then is how to facilitate an
rumours, all of which have resulted in an infor­
evolution from the provision of informarion
mation overload, me "victims’ therefore now
an recommendations, to a situation of effective
mc.ude large numbers of people who are suffer­
learning, which allows people to develop better
ing oecause they think they may be affected by .
the accident, but who in fact have never been ' coping strategies during and after an accident.
Setting up such effective learning implies more
exposed to toxic levels of radiation
’r J”""
ilcarninS implies more
ion, w"h
associated with industrial activities and sub­
bumes in the field of public safety and health
stances through improved risk analysis and as­
have therefore a clear duty to provide both
sessment. It also implies improving the knowl­
ger.e. J md specific background information.
edge and understanding of the reactions and
Diverse interpretations from these or-mizaneeds of individuals and groups in rimes of
□ons of the potential public health consequences
emergency.
or an accident could seriously confuse the pubThis last supposes a substantial change in the
hc,^a create additional difficulties fornational
current methods of nsk analysis, riskassessment
autnonties. Accurate, trustworthy, and eas”
‘Sily
and nsk management (See MNH/PSF.91 docuunderstood information about radiation and its
menc).

a

6-

RoundTable
Mental and social health during and after acute emergencies:
emerging consensus?
Mark van Ommeren,1 Shekhar Saxena,2 & Benedetto Saraceno3

Abstract Mental health caie programmes during and after acute emergencies in resource-poor countries have been considered
controversial. There is no agreement on the public health value of the post-traumatic stress disorder concept and no agreement on
the appropi iateness of vertical (separate) trauma-focused services. A range of social and mental health intervention strategies and
principles seem, however, to have the broad support of expert opinion. Despite continuing debate, there is emerging agreement on
what entails good public health practice in respect of mental health. In terms of early interventions, this agreement is exemplified by
the recent inclusion of a "mental and social aspects of health" standard in the Sphere handbook's revision on minimal standards
in disaster response. This affirmation of emerging agreement is important and should give clear messages to health planners.

Keywords Stress disorders, Post-traumatic/psychology/therapy; Mental health services/organization and administration; Social
adjustment; Adaptation, Psychological; Emergency services, Psychiatric; Trauma centers {source MeSH, NLM).
Mots des Etat stress, Post-traumatique/psychologie/therapeutique; Service sante mentale/organisation et administration; Adaptation
sociale; Adaptation psychologique; Service urgences psychiatriques; Service traumatologie {source: MeSH, INSERMj.
Palabras clave Estres postraumatico/psicologia/terapia; Servicios de salud mental/organizacidn y administracion; Ajuste social;
Adaptacibn psicoldgica; Servicios de urgencia psiquiatrica; Centres traumatolbgicos {fuente: DeCS, BIREME).

Arabic
Bulletin of the World Health Organization 2005;83:71-76.

Voir page 74 le resume en fran(;ais. En la pagina 74 figura un resumen en espanol.

Recent literature records a discussion about the concepts, values
and appropriateness of mental health interventions to reduce
the burden of war and other disasters in resource-poor countries
(/—ST). I hc post-traumatic stress disorder (PTSD) construct and
trauma-focused services arc the focus of controversy. Results
from epidemiological studies suggest (hat this disorder is preva­
lent (/(?) and, at least in (he USA, disabling (//). A vocal group
of observers, however, sees P I SE) as a pseudocondition with
no relevant burden — especially in non-western, traditional
societies (7, 6, 8). While these critics point to mcdicalization of
normal distress and the possible harm of assuming that western
models of illness and healing are valid across cultures, others
consider denial of the importance of traumatic stress a profes­
sional error and a denial of preventable suffering (2, 3, 5).
Trauma-focused interventions arc increasingly provided
to large segments of populations affected by disaster in resource­
poor countries. However, the interventions that arc most often
implemented to reduce traumatic stress — one-off psychological
debriefing (organized by international and local organizations)
and benzodiazepine medication (prescribed by local physicians)

- have little evidence of effectiveness, and their indiscrimi­
nate application can be harmful {12-14}. Following disasters
in resource-poor countries, foreign clinicians often arrive to pro­
mote PTSD case-finding and trauma-focused treatment (6)
in the absence of a system-wide public health approach that
considers pre-existing human and community resources, social
interventions, and care for people with pre-existing mental
disorders.
I he controversy is compounded by the recent develop­
ment of a new field — introduced by international organizations
working in low-income countries — that calls itself psychosocial.
The term is used to indicate commitment to non-medical ap­
proaches and distance from the held of mental health, which is
seen as loo controlled by physicians and too closely associated
with the ills of an overly biopsychiatric approach. Yet, despite
highly appropriate attention to mcdicalization and the impor­
tance o f n o n - m cd ica 1 i n tc rvc n t io n, sc pa ra ting psychosocial ca re
services from mental health care services may inadvertently pro­
mote exclusively biological care for the severely mentally ill by
drawing human resources skilled in non-biological interventions

1 Technical Officer, Mental Health Evidence and Research, Department of Mental Health and Substance Abuse, World Health Organization, 1211 Geneva 27,
Switzerland. Correspondence should be sent to this author (email: vanommerenm@who.int).
1 Coordinator, Mental Health Evidence and Research, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.
3 Director, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland.
Ref. No. 03-009951
Bulletin of the World Health Organization I January 2005, 83 (1)

\

71

) Round Table
I Mental health in emergencies

away from formal mental health services (15)- T his separation
further divides a care system that is already fragmented.
Because of the expression of these viewpoints, the impression
may have been created that programme planners are faced with
choosing between setting-up vertical (separate) trauma mental
health programmes, setting-up vertical psychosocial care pro­
grammes outside existing systems, or ignoring mental health care
altogether. Indeed, early editions of the highly influential Sphere
Projects minimum standards for disaster response (16,17) did not
cover mental health because of perceived expert disagreement (Nan
Buzzard, verbal communication, October 2002).
In order to generate sound advice on strategies to assist
countries, we commissioned a literature review and a postal
survey of expert opinion, involving responses by experts to
open-ended questions about mental health policy in the
aftermath of disasters (18). In addition, we studied available
consensus statements and guidelines (Wiy-22, 23-28), many
of them published by experienced international organizations.
The overall picture that emerged is that, although opinions
vary widely on the public health value of focusing on PTSD
and trauma services, there is agreement on basic issues: expo­
sure to extreme stressors is a risk factor for social and mental
health problems, including common mental disorders; further,
emergencies can severely disrupt social structures and ongoing
formal and informal care of persons with pre-existing disorders.
A range of strategies seem to have wide support of much expert
opinion, on the condition that they are tailored to the local
context, needs and resources.
On the basis of our study of the above-mentioned sur­
vey, consensus statements and guidelines, we have proposed
principles and strategics for populations exposed to extreme
stressors (20). The eight principles are: contingency planning
before the acute emergency, assessment before intervention,
use of a long-term development perspective, collaboration with
other agencies, provision of treatment in primary health care
settings, access to services for all, training and supervision, and
monitoring indicators (sec Table 1).

Mark van Ommeren et al.

Distinct intervention strategies should be considered for the
acute emergency and post-emergency phases, and these will be dis­
cussed separately. Also, we aim to achieve a conceptual distinction
between social and mental health interventions. The term social
intervention is used for interventions that aim primarily to have
social effects, and the term mental health intervention for those
that aim primarily to have mental health effects. It is acknowledged
that social interventions tend to have secondary mental health
effects and die converse. Social interventions are typically not in
the domain of expertise of mental health professionals. As such
interventions tend to deal with important factors influencing men­
tal health, however, health and mental health professionals should
work in close partnership with colleagues from other disciplines
(e.g., communication, education, community development, and
disaster coordination) to ensure that relevant social interventions
arc fully implemented.
Many of die strategies described here may be common
sense, but by making them explicit in documents and policy
statements they become a powerful tool for programme plan­
ning and evaluation. These principles and strategies have been
developed for resource-poor countries — where the vast major­
ity of disasters arise — bur they are also considered appropriate
for high-income countries. In high-income countries additional
strategies also apply, involving, for example, cognitive-behaviour
therapy (30) by clinicians with advanced training, who arc a rare
resource in poor countries (3/).

Acute emergency phase
For the purpose of this paper, the acute emergency phase is
defined as the period where tlie crude mortality rate is elevated
because of disaster-induced deprived physical needs (such as
food, shelter, physical security, water and sanitation), access to
health care, and management of communicable diseases. A key
early social intervention concerns information: a reliable flow
of credible information must be ensured about the emergency,

Table 1 Mental health in emergencies: basic principles
Principle

Explanation

1 Contingency planning

Before the emergency, national-level contingency planning should include (a) developing interagency coordination
systems, (b) designing detailed plans for a mental health response, and (c) training general health care personnel
in basic, general mental health care and psychological first aid.

2 Assessment

Assessment should cover the sociocultural context (setting, culture, history and nature of problems, local perceptions
of illness, and ways of coping), available services, resources and needs. In assessment of individuals, a focus on
disability or daily functioning is recommended.

3 Long-term perspective

Even though impetus for mental health programmes is highest during or immediately after acute emergencies, the
population is best helped by a focus on the medium- and long-term development of services.

4 Collaboration

Strong collaboration with other agencies will avoid wastage of resources. Continuous involvement of the government,
local universities or established local organizations is essential for sustainability.

5 Integration into primary
health care

Led by the health sector, mental health treatment should be made available within primary health care to ensure
(low-stigma) access to services for the largest number of people.

6 Access to service for all

Setting up separate, vertical mental health services for special populations is discouraged. Nevertheless, outreach
and awareness programmes are important to ensure the treatment of vulnerable groups within general health
services and other community services.

7 Thorough training and
supervision

Training and supervision should be carried out by mental health specialists (or under their guidance) for a substantial
amount of time, in order to ensure lasting effects of training and responsible care.

8 Monitoring indicators

Activities should be monitored and evaluated through key indicators that need to be determined, if possible, before
starting the activity. Indicators should focus on inputs (available resources, including pre-existing services), processes
(aspects of programme implementation), and outcomes (e.g., daily functioning of beneficiaries).

72

Bulletin of the World Health Organization I January 2005,83 (1)

Round Table
Mental health in emergencies I

Mark van Ommeren et at
efforts to establish physical safety, relief efforts (including what
each aid organization is doing and where it is located), and the
location of relatives. Access to valid information is a basic right
and is essential to reduce public anxiety and distress. Informa­
tion should be uncomplicated, so as to be comprehensible at
the cognitive level of local 12-year-olds, and empathic, showing
understanding of the situation of rhe survivors.
Two other core social strategies are likely to reduce public
stress: encouraging normal activities and encouraging active
participation in rhe community. For example, re-establishing
cultural and religious events is seen as helpful. Such events typi­
cally include funeral ceremonies and grieving rituals involving
spiritual and religious practitioners. For children, restarting for­
mal or informal schooling is considered important, together with
the provision ofsome recreational activities. Health professionals
should be active advocates for safe, physical space for all these
activities. In terms of achieving participation, adults and adoles­
cents need to be encouraged to engage in tangible, purposeful
activities of common interest, such as relief efforts. Community
activities that facilitate the inclusion in social networks of people
without families arc strongly recommended.
With respect to mental health interventions, The world
health report 2001 recommends making mental health treat­
ment available within primary and other health-care settings,
which requires staff training, supervision, and a referral system
(32,33). This recommendation tends to apply whether primary
health care is run by government or by nongovernmental or­
ganizations, because integrated care within primary and other
health facilities maximizes access to mental health care. Health
officials need to ensure the availability of essential psychotro­
pic medications for urgent psychiatric problems, for example
psychoses and severe depression. During the acute emergency,
most persons with urgent psychiatric complaints will have
pre-existing disorders, which may have been exacerbated by
suddenly discontinued psychotropic medication. We have out­
lined elsewhere essential strategies to address ongoing care and
protection ol people in custodial psychiatric hospitals during
acute emergencies (3^).
Some people will immediately seek help at health ser­
vices because of mental health problems directly related to their
exposure to extreme stressors. According to a recent consensus­
building exercise (26), most acute stress problems during acute
emergencies are best managed without medication following the
principles of psychological first aid, which involves non-intrusive
emotional support, coverage of basic needs, protection from
further harm, and organization of social support and networks.
When community workers arc available, outreach and psycho­
logical first aid may be organized in the community. Neverthe­
less, the weight of current evidence discourages the blanket use
of isolated sessions ol psychological debriefing that push people
to share their personal experiences beyond the extent to which
their natural inclination would prompt them to do so (72, 14).
The strategies outlined here may be adapted for use in
acute emergencies caused by unpredictable infectious diseases,
along the lines of the WHO document on public mental health
aspects of biological and chemical weapons (35).

Post-emergency phase
The acute emergency phase is followed by a post-emergency
phase when the crude mortality rate is again at a level com­
parable to that before the acute emergency or, in the case of
displacement, at the level of the surrounding population. In
Bulletin of the World Health Organization I January 2005, 83 (1)

complex disasters — typically with coexisting conflict, popu­
lation displacement, food scarcity, and the collapse of basic
health services (36) — rhe sequence of events is less linear, and
different areas of a country may oscillate between acute and
post-emergency phases.
In rhe post-emergency phase, the social interventions
outlined above should continue. Moreover, whenever disasterinflicted poverty becomes an evident ongoing source of suffer­
ing, it is appropriate for health workers to advocate economic
re-development initiatives, such as microcredit schemes or
income-generating activities.
1 )uring this phase, general health care should continue to
form die basis ol the mental health care system. Accordingly,
mental health specialists should provide thorough supervision
and on-the-job training to health-care staff (33). Community
workers may be trained and supervised to assist primary care
staff with heavy case-loads (33) and to conduct outreach activi­
ties. The development of a multitude of specialized traumafocused services should be avoided unless mental health care is
available in general health care and other community settings
(the school health system, for example). Trauma-focused care
may be best integrated into general mental health services.
Organizing community-based self-help support groups is
likely to provide a valuable form of assistance (25). The focus of
such groups is usually problem-sharing, brainstorming for solu­
tions or for more effective ways of coping (including traditional
ways of coping), and generation of mutual emotional support,
and sometimes promotion of community-level initiatives. In
certain contexts, collaboration with traditional resources such
as faith healers may be an opportunity in terms of care, provi­
sion of meaning, and generation of community support.
These post-emergency strategics need to be carried out
in synergy with ongoing mental health system development
priorities, especially the development of national plans for the
organization of mental health services (37), which is increasingly
a focus of work by WHO. Executing such plans involves down­
sizing existing custodial mental hospitals, making mental health
care available in general health care settings (4), and strengthen­
ing community and family care of persons with chronic, severe
mental disorders (32, 37).

Conclusion
I bis paper began with a summary of the debate on the con­
troversial value of PT SD and trauma-focused care during and
after acute emergencies. This debate has attracted much atten­
tion ami has been valuable in bringing to light fundamental
issues and various views with respect to the needs of trauma
survivors. We acknowledge that there is no agreement on the
public health value of the PTSD concept (c.g., the extent to
which non-comorbid PT SD is associated with disability), and
the appropriateness of vertical trauma-focused services. We share
the concern of Silove et al. (7) that because of heated expressions
ol opinions an impression has been created that programme
planners during and after acute emergencies are faced with a
choice between specialized, trauma-focused care or completely
ignoring mental health. We advocate the implementation of
social interventions and the integration of trauma-focused care
into general mental health care, which should be available in
general health care settings.
Despite ongoing debate, we argue that there is consid­
erable agreement on what entails good public mental health

73

Round Table
I Mental health in emergencies

Mark vein Ommeren et al.

practice. Most of our proposed early intervention strategies have
now been included in a “mental and social aspects of health"
standard in the health chapter ol the recently revised Sphere
handbook on minimum standards in disaster response (3^). It
is the first time that this widely used handbook — written to
improve humanitarian assistance and enhance accountability
— includes a standard covering mental and social health. Be­
cause of frequent war and other disasters in many regions of
the world, this affirmation of emerging consensus is important
and gives clear messages to health planners. B

Acknowledgements
Dr Alistair Ager, Dr Thom Bornemann, Dr Joop de Jong, Dr
Alessandro Loretci, Dr Srinivasa Murthy, Dr Bhava Poudyal,
Dr Beverly Raphael, Dr Derrick Silove and Dr Robert Ursano
reviewed an early draft of the described principles and strate­
gics and provided substantial comments. We are grateful to the
Governments of Finland ami Italy for financial support of rhe
work leading to this publication.

Conflicts of interest: none declared.

Resume
Sante mentale et sociale pendant et apres les situations d'urgence aigue : emergence d'un consensus ?
accord se fait jour sur ce que comportent les bonnes pratiques de
Les programmes visant a dispenser des soins de sante mentale
sante publique en matiere de sante mentale. En ce qui concerne
pendant et apres les situations d'urgence aigue dans les pays a
les interventions precoces, cet accord est illustre par I'introduction
faibles revenus sont considers comme d'un interet discutable.
recente d'une norme sur les aspects mentaux et sociaux de la sante
Aucun accord n'a ete trouve sur la valeur en termes de sante
dans la revision du Manuel Sphere sur les normes minimales a
publique du concept de trouble de stress post-traumatique et sur
respecter dans la reponse a un desastre. Cette affirmation d'un
I'utilite de services verticaux (separes) dont I'activite est axee sur
accord emergeant est importante et devrait se traduire par des
les traumatismes. II semble cependant qu'une serie de strategies
messages dairs pour les planificateurs dans le domaine de la
d'intervention en sante sociale et mentale beneficie d'un large
sante.
soutien parmi les experts. Bien que les debats se poursuivent, un

Resumen

La salud mental y social durante y despues de las emergencias agudas: ^principio de consenso?
debates, se observa un principio de acuerdo sobre Io que definiria
Los programas de atencidn de salud mental durante y despues
las practices mas adecuadas de salud publica en el campo de
de las emergencias agudas en los paises con recursos escasos
la salud mental. En Io referente a las intervenciones precoces,
han sido objeto de polemica. No hay ningun acuerdo sobre
ese consenso se ve ilustrado por la reciente inclusion de una
el valor del concepto de trastorno de estres postraumatico en
norma sobre los «aspectos mentales y sociales de la salud» en
el terrene de la salud publica, ni Io hay tampoco acerca de la
la revision de Sphere handbook sobre las normas minimas de
idoneidad de los servicios verticales (independientes) centrados
respuesta ante desastres. Esta confirmacidn de un principio de
en los traumas. Sin embargo, hay varias estrategias y principios
acuerdo es importante y debe traducirse en mensajes daros para
de intervencidn en la salud social y mental que parecen gozar
de un amplio respaldo entre los expertos. Aunque prosiguen los
los planificadores de la salud.

Arabic

References
(References prefixed " IV"appear in the web version only, available from www.who.int/bulletin)

1. Bracken PJ, Giller JE, Summerfield D. Psychological responses to war and
atrocity: the limitations of current concepts. Social Science and Medicine
1995;40:1073-82.
2. deVries F. To make a drama out of trauma is fully justified. Lancet
1998;351:1579-80.
3. Dyregrov A, Gupta L, Gjestad R, Raundalcn M. Is the culture always right?
Traumatology 2002;8:1-10.

74

4. Jones L, Rustemi A, Shahini M, Uka A. Mental health services for waraffected children: report of a survey in Kosovo. British Journal of Psychiatry
2003;183:540-6.
5. Mezey G, Robbins I. Usefulness and validity of post-traumatic stress disorder
as a psychiatric category. BMJ 2001 ;323:561 3.
6. PupavacV. Therapeutic governance: psycho-social intervention and trauma
risk management. Disasters 2001;25:358-72.

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Mark van Ommeren et al.

7. Silove D, Ekblad S, Mollica R. The rights of the severely mentally ill in post­
conflict societies. Lancet 2000;355:1548-9.
8. Summerfield D. Bosnia and Herzegovina and Croatia: the medicalization of
the experience of war. Lancet 1999;354:771.
9. Wessely S. War and the mind: Psychopathology or suffering? Palestine-Israel
Journal of Politics, Economics and Culture 2003; 10:6-16.
10. de Jong JT, Komproe IH, van Ommeren M. Common mental disorders in
postconflict settings. Lancet 2003;361:2128-30.
11. Kessler RC. Posttraumatic stress disorder: the burden to the individual and
to society. Journal of Clinical Psychiatry 2000;61 Suppl 5:4-12.
12. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Marshall RD, Nemeroff CB,
et al. Consensus statement update on posttraumatic stress disorder from
the International Consensus Group on Depression and Anxiety. Journal of
Clinical Psychiatry 2004;65 Suppl 1:55-62.
13. Freeman C. Drugs and physical treatment after trauma. In: 0rner R,
Schnyder U, editors. Reconstructing early intervention after trauma. Oxford:
Oxford University Press; 2003:169-76.
14. Rose S; Bisson J; Wessely S. Psychological debriefing for preventing post
traumatic stress disorder (PTSD). Cochrane Database Systematic Reviews
2002;2:CD000560.
15. Saraceno B. Mental health: scarce resources need new paradigms. World
Psychiatry 2004;3:3-6.
16. Humanitarian charter and minimum standards in disaster response. Geneva:
Sphere Project; 1998.
17. Humanitarian charter and minimum standards in disaster response. Geneva:
Sphere Project; 2000.
18. Weiss M, Saraceno B, Saxena S, van Ommeren M. Mental health in the
aftermath of disasters: consensus and controversy. Journal of Nervous and
Mental Disease 2003;191:611-5.
23. Guidelines for programmes psychosocial and mental health care assistance
in (post) disaster and conflict areas: draft. Utrecht: Netherlands Institute
for Care and Welfare; 2001. Available from: http://websrv1.nizw.nI/nizwic/_
Werkdocs/Publications/guidelines.htm
24. Psychological support: best practices from Red Cross and Red Crescent
programmes. Geneva: International Federation of Red Cross and Red Crescent
Societies; 2001.
25. de Jong JTVM. Public mental health, traumatic stress and human rights
violations in low-income countries. In: de Jong JTVM, editor. Trauma, war,
and violence: public mental health in socio cultural context. New York (NY):
Plenum; 2002:1-93.

Round Table Discussion
The best immediate therapy for acute
stress is social
Derrick Silove'
The above paper by van Ommeren er al. is of immense impor­
tance in guiding future mental health service developments in
low-income countries afflicted by conflict. As such, the article
should be essential reading for leaders of international nongov­
ernmental organizations and United Nations agencies. Although
measured in its style, the arguments mobilized present a radical
challenge to those single-issue advocates promoting trauma
counselling programmes or short-term psychosocial projects.
1 believe that some of the arguments, however, need to
be considered further. One problem is that trauma advocates
do not distinguish sufficiently between common, self-limiting
psychological responses to violence and the persisting reactions
that become complicated and disabling. My rule of thumb is
that the best therapy for acute stress reactions is social: providing

Round Table
Mental health in emergencies |
26. National Institute of Mental Health. Mental health and mass violence:
evidence-based early psychological interventions for victims/survivors of
mass violence. A workshop to reach consensus on best practices. Washington
(DC): US Government Printing Office; 2002. NIH Publication No. 02-5138.
Available from: http://www.nimh.nih.gov/research/massviolence.pdf
27. Weine S, Danieli Y, Silove D, van Ommeren M, Fairbank JA, Saul J, for the
Task Force on International Trauma Training of the International Society for
Traumatic Stress Studies. Guidelines for international training in mental
health and psychosocial interventions for trauma exposed populations in
clinical and community settings. Psychiatry 2002:65; 156-64.
28. Psychosocial and mental well-being of migrants. Geneva: International
Organization for Migration; 2002.99th Session of Executive Committee.
29. Mental health in emergencies: psychological and social aspects of health of
populations exposed to extreme stressors. Geneva: World Health Organization;
2003. Available from: http://www.who.int/mentaLhealth/media/en/640.pdf
30. Shepherd IP, Bisson JI. Towards integrated health care: a model for assault
victims. British Journal of Psychiatry 2004; 184:3-4.
31. Atlas: mental health resources in the world. Geneva: World Health
Organization; 2001. Available from: http://www.who.int/mentaLhealth/
media/en/244.pdf
32. The world health report 2001 — Mental health: new understanding, new
hope. Geneva: World Health Organization; 2001. Available from: http://
www.who.int/whr2001/2001/main/en/pdf/whr2001.en.pdf
33. de Jong K, Ford N, Kleber R. Mental health care for refugees from Kosovo:
the experience of Medicins Sans Frontieres. Lancet 1999;353:1616-7.
34. van Ommeren M, Saxena S, Loretti A, Saraceno B. Ensuring care for patients
in custodial psychiatric hospitals in emergencies. Lancet 2003;362:574.
35. Mental health of populations exposed to biological and chemical weapons.
Geneva: World Health Organization; 2005. Available from: http://
www.who.int/mentaLhealth/prevention/mnhemergencies/en/
36. Toole MJ, Waldman RJ. Refugees and displaced persons. War, hunger, and
public health. JAMA 1993;270:600-5.
37. Organization of services for mental health. Geneva: World Health
Organization; 2003. Available from: http://www.who.int/mental_health/
resources/en/Organization.pdf
38. Humanitarian charter and minimum standards in disaster response. Geneva:
Sphere Project; 2004. Available from: http://www.spherepioject.org/
handbook/index.htm

safety, reuniting families, creating effective systems of justice,
offering opportunities for work, study and other productive
roles, and re-establishing systems of meaning and cohesion
— religious, political, social and cultural.
Nevertheless, there will be a small minority of persons
who do continue to suffer from severe traumatic stress reac­
tions, and that group emerges in increasing numbers over time.
Services then should be accessible, inviting (people with chronic
PTSD are wary of presenting themselves) and offer state-ofthe-art interventions: this is difficult to ensure, because such
interventions are multimodal and require substantial skills. Yet,
at present, nongovernmental organizations fuelled by donor
enthusiasm rush in to debrief trauma survivors in the early phase
when such interventions arc not needed and, commonly, leave
just at rhe point when the more chronic cases emerge, the mi­
nority who really do need expert assistance! In that respect, rhe
dictum “not too early but not too late” may serve as a useful
guide to reverse the present trend.
A second problem is that we have become accustomed to
cpiilcniiologic.il studies yielding rates of P PSD or depression

of 30-40% in postconflict populations. These figures provide
little guide to actual need. The rates of help-seeking behaviour
lor severe psychiatric disorders (including the minority with

' Professor of Psychiatry, University of New South Wales, Prince of Wales Hospital, Randwick, New South Wales, Australia; Director, Centre for Population Mental Health
Research, South Western Sydney Area Health Service (email: d.silove@unsw.edu.au).

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| Round Table
I Round Table Discussion

unremitting traumatic stress) may be more like 2-3% per year.
T his represents, in fact, a huge number of persons in dire need,
especially if one considers the adverse multiplier effect on fami­
lies and communities of caring for a person who is disabled,
acting in a bizarre way or possibly violent.
In my view, therefore, two key issues confront the field
from a practical point of view. The first challenge is changing
entrenched perspectives and practices of international agencies
and donors, so that they give priority to supporting integrated
community-based mental health programmes that focus on
social need arising from mental disturbance, rather than special
issues or particular diagnoses.
The second consideration is whether such programmes
can be undertaken entirely within primary health care systems,
given the wide range of skills needed to deal with psychosis, severe
mood disorders, postpartum disorders, severe anxiety disorders
including the minority with disabling PTSD, organic disor­
ders, and epilepsy and its complications, among others. Many
community health services in conflict-affected countries are
depleted of resources and skills and face overwhelming de­
mands in relation to other obligations. Brief training in mental
health is hazardous (and training-the-trainer programmes even
more so); in this field, a little knowledge is a particularly dan­
gerous thing.
In some resource-poor settings, therefore, there is a case
for establishing, at least as a developmental step, a small, expert
resource team with international input to provide supervision,
training and consultation in order to ensure rhe promotion of
skills and professionalism. As a core team develops and the initial
pressures of other work lessen to some extent, skills can then be
transmitted to primal)’ care workers. H

What exactly is emergency or disaster
"mental health"?
Derek Summerfield1
Firstly, 1 must own to being one of the “vocal group ofobservers”
mentioned in the paper by van Ommeren et al. a critic of the
field that sprang up little more than 1 5 years ago around the idea
that “post-traumatic stress” was an urgent public health mat­
ter in its own right. Indeed, “trauma” may now have displaced
hunger as the first thing the Western general public thinks about
when a war or other emergency is in the news.
The authors make succinct mention of some of the prob­
lems associated with the development of PTSD, but omit a key
one: the largely non-Western populations targeted did not ask
for interventions of this kind. As an illustration, I was recently
on a professional visit to rhe occupied Palestinian territories,
where something akin to a mental health melee has resulted
from a plethora of programmes imported to deliver counselling
because outsiders thought it was a good idea. Most Palestinians
do not: counselling is not a culturally familiar activity, and the
people use all their energy to survive in a deepening health and
human rights crisis.
Many programmes of this kind have been funded under
the umbrella term “psychosocial”, as mentioned in the base

paper. When I was a consultant to Oxfam 1 was against this
term since in practice it had become too quickly collapsible into
“psycho”. When van Omerren and colleagues opt for a concep­
tual distinction between social and mental health interventions,
(hey are reproducing the tradition since the Enlightenment to
regard the physical confines of the human individual as the basic
unit of study, and for the mind to be examined by a technical
methodology akin to that applied to the body. Thus mind, or
“psychology”, is to be located inside the body — between the
ears — whereas what is “social” is outside the body and outside
the frame of reference. But it would be more realistic to see our
psychology as having a root outside the body, in the way that
we live, and to consider the meaning of things — in particular
a sense of coherence — as arising from our practical engagement
with the world. Lack of coherence is bad for people: if there is
such a thing as a core fact about human response to disasters
and violent upheavals, it is that survivors do well (or not) in
relation to their capacity to re-establish social networks and a
viable way of life. Western mental health models have always
paid too little attention to die role of social agency, including
work, in promoting stable well-being and mental health.
The authors’ description of basic responses in the acute
emergency phase seems broadly right (though “psychological
first aid”, like “public mental health”, may be an oxymoron).
In relation to the restoration of normal activities, I was pleased
to see their mention ol schools: the child trauma literature
can sometimes give the impression that counsellors are more
critical than schoolteachers.
It is right to point out that in complex disasters there will
be no clear demarcation ol “emergency”. Indeed, we talk of d ie
trauma of war but not the trauma of hunger. Why arc the deaths
of millions — yes, millions — of children every year from the
diseases of poverty not an emergency, but “normal”?
In relation to advocating the training of primary health
workers by “mental health specialists”, whose knowledge counts?
I here has often been a tension in WHO material on mental
health between the wish to acknowledge local worlds and the
wish to promote Western mental health technology as a repro­
ducible toolkit. How, for example, would primary healdi workers
be trained about depression? Forecasts by WHO that within
two decades depression will cause the second highest disease
burden globally assume that the Western psychiatric construct
is valid everywhere. T his is surely to commit the same error
bedevilling most of the psychiatric literature on war and refu­
gees: it is what Kleinman called a “category fallacy” to assume
that, just because similar phenomena can be identified in vari­
ous settings worldwide, they mean the same thing everywhere.
Even the best back-translation methodologies cannot solve the
problem, as it is not one of translation between languages but
of translation between worlds. We need to remember that rhe
Western mental health discourse introduces core components of
Western culture, includinga theory of human nature, a defini­
tion of personhood, a sense of time and memory, and a secular
source of moral authority. None of this is universal.
Consensus statements have to keep their feet on the
ground, and I am pleased chat this one largely does so. The note

of caution seems wise, if only because the business of other
people’s minds is ultimately as much a matter of philosophy
as of science. S

' Honorary Senior Lecturer, Institute of Psychiatry, King's College, London; Research Associate, Refugee Studies Centre, University of Oxford, Queen Elizabeth House
21 St Giles, Oxford 0X1 3LA, England (email: derek.summerfield@slam.nhs.uk).
76

Bulletin of the World Health Organization | January 2005,83 (1)

Mark van Ommeren et al.

Round Table
Mental health in emergencies

References
1. Bracken PJ, Giller JE, Summerfield D. Psychological responses to war and
atrocity: the limitations of current concepts: Social Science and Medicine
1995;40:1073-82.
2. de Vries F. To make a drama out of trauma is fully justified. Lancet
1998;351:1579-80.
3. Dyregrov A, Gupta I, Gjestad R, Raundalen M. Is the culture always right?
Traumatology 2002;8:1-10.
4. Jones L, Rustemi A, Shahini M, Uka A. Mental health services for waraffected children: report of a survey in Kosovo. British Journal of Psychiatry
2003;183:540-6.
5. Mezey G, Robbins I. Usefulness and validity of post-traumatic stress disorder
as a psychiatric category. BMJ 2001;323:561-3.
6. Pupavac V. Therapeutic governance: psycho-social intervention and trauma
risk management. Disasters 2001;25:358-72.
7. Silove D, Ekblad S, Mollica R. The rights of the severely mentally ill in post­
conflict societies. Lancet 2000;355:1548-9.
8. Summerfield D. Bosnia and Herzegovina and Croatia: the medicalization of
the experience of war. Lancet 1999;354:771.
9. Wessely S. War and the mind: Psychopathology or suffering? PalestineIsrael Journal of Politics, Economics and Culture 2003; 10:6-16.
10. de Jong JT, Komproe IH, van Ommeren M. Common mental disorders in
postconflict settings. Lancet 2003;361:2128-30.
11. Kessler RC. Posttraumatic stress disorder: the burden to the individual and
to society. Journal of Clinical Psychiatry 2000;61 Suppl 5:4-12.
12. Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Marshall RD, Nemeroff CB,
et al. Consensus statement update on posttraumatic stress disorder from
the International Consensus Group on Depression and Anxiety. Journal of
Clinical Psychiatry 2004;65 Suppl 1:55-62.
13. Freeman C. Drugs and physical treatment after trauma. In: 0rner R,
Schnyder U, editors. Reconstructing early intervention after trauma. Oxford:
Oxford University Press; 2003:169-76.
14. Rose S; Bisson J; Wessely S. Psychological debriefing for preventing post
traumatic stress disorder (PTSD). Cochrane Database Systematic Reviews
2OO2;2:CDOOO56O.
15. Saraceno B. Mental health: scarce resources need new paradigms. World
Psychiatry 2004;3:3-6.
16. Humanitarian charter and minimum standards in disaster response. Geneva:
Sphere Project; 1998.
17. Humanitarian charter and minimum standards in disaster response. Geneva:
Sphere Project; 2000.
18. Weiss M, Saraceno B, Saxena S, van Ommeren M. Mental health in the
aftermath of disasters: consensus and controversy. Journal of Nervous and
Mental Disease 2003; 191:611-5.
W19. Psychosocial effects of complex emergencies: symposium report. Washington
(DC): American Red Cross; 1999.
W20. Utrecht guidelines: draft guidelines for the evaluation and care of victims of
trauma and violence. Geneva: United Nations High Commissioner for
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page_id=23
W21. Declaration of cooperation: mental health of refugees, displaced and other
populations affected by conflict and post-conflict situations. Geneva: World
Health Organization; 1999.
W22. Mollica RF. Kikuchi Y. Tokyo guidelines for trauma and reconstruction:
formulating new principles and practices for the recovery of post-conflict
societies. Available from: http://www.hprt-cambridge.org/Layer3.asp?page_id=22

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23. Guidelines fur programmes psychosocial and mental health care assistance
in (post) disaster and conflict areas: draft. Utrecht: Netherlands Institute
for Care and Welfare; 2001. Available from: http://websrv1.nizw.nI/nizwic/_
Werkdocs/Publications/guidelines.htm
24. Psychological support: best practices from Red Cross and Red Crescent
programmes. Geneva: International Federation of Red Cross and Red Crescent
Societies; 2001.
25. de Jong JTVM. Public mental health, traumatic stress and human rights
violations in low-income countries. In: de Jong JTVM, editor. Trauma, war,
and violence: public mental health in socio-cultural context. New York (NY):
Plenum; 2002:1-93.
26. National Institute of Mental Health. Mental health and mass violence:
evidence-based early psychological interventions for victims/survivors of
mass violence. A workshop to reach consensus on best practices. Washington
(DC): US Government Printing Office; 2002. NIH Publication No. 02-5138.
Available from: http://www.nimh.nih.gov/research/massviolence.pdf
27. Weine S, Danieli Y, Silove D, van Ommeren M, Fairbank JA, Saul J, for the
Task Force on International Trauma Training of the International Society for
Traumatic Stress Studies. Guidelines for international training in mental
health and psychosocial interventions for trauma exposed populations in
clinical and community settings. Psychiatry 2002:65; 156-64.
28. Psychosocial and mental well-being of migrants. Geneva: International
Organization for Migration; 2002.99th Session of Executive Committee.
29. Mental health in emergencies: psychological and social aspects of health of
populations exposed to extreme stressors. Geneva: World Health Organization;
2003. Available from: http://www.who.int/mentaLhealth/media/en/640.pdf
30. Shepherd JP, Bisson JI. Towards integrated health care: a model for assault
victims. British Journal of Psychiatry 2004; 184:3-4.
31. Atlas: mental health resources in the world. Geneva: World Health
Organization; 2001. Available from: http://www.who.int/mentaLhealth/
media/en/244.pdf
32. The world health report 2001 — Mental health: new understanding, new
hope. Geneva: World Health Organization; 2001. Available from: http://
www.who.int/whr2001/2001/main/en/pdf/whr2001.en.pdf
33. de Jong K, Ford N, Kleber R. Mental health care for refugees from Kosovo:
the experience of Medicins Sans Frontieres. Lancet 1999;353:1616-7.
34. van Ommeren M, Saxena S, Loretti A, Saraceno B. Ensuring care for patients
in custodial psychiatric hospitals in emergencies. Lancet 2003;362:574.
3 5. Mental health of populations exposed to biological and chemical weapons.
Geneva: World Health Organization; 2005. Available from: http://
www.who.int/mental_health/prevention/mnhemergencies/en/
36. Toole MJ, Waldman RJ. Refugees and displaced persons. War, hunger, and
public health. JAMA 1993;270:600-5.
37. Organization of services for mental health. Geneva: World Health
Organization; 2003. Available from: http://www.who.int/mental_health/
resources/en/Organization.pdf
38. Humanitarian charter and minimum standards in disaster response. Geneva:
Sphere Project; 2004. Available from: http://www.sphereproject.org/
handbook/index.htm

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THE SCIENCE OF DISASTERS
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Y. S. Gill
We have turned

tourism into a dis­

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“W' "MT irhen we talk about ‘natural disasters',
% A / the usual refrain is that they are the
V ▼ consequence of the interplay of the
forces of nature. However, they also are humanmade to a startling degree. Not only has human
intervention ravaged the earth's vegetative cover
and pushed innumerable life-forms into extinclion, it has also polluted nature in all its dimen
sions.
Floods, cyclones, landslides, and mudflows
have multiplied. Earthquakes increasingly threat­
en our megalopolises. Millions of people, living
in huge, unhygienic city slums, are prey to run­
away epidemics. Diseases have also piggy­
backed around the world with modem means of
travel.

Floods: deforestation adds to their
fury
Floods account for about half the destruction
wrought by natural hazards every year the world
over. The Indian subcontinent has seen the
world's worst flood-related destruction over the
years. The Ganga and the Brahmaputra have
annually flooded vast tracts of land for millennia.
Bloated by heavy monsoons and the Himalayan
snow-melt, subcontinental rivers, big and small,
punctually cause much havoc.
Their intensity and fury has been increasing
over the years mainly due to deforestation.
Denuded forests and other vegetative cover no
longer absorb the heavy monsoon rains. The
flowing water thus rampages down from the
higher altitudes to the low-lying areas. Ideally,
the water should be trapped in the roots of the

Natural disasters are often described as the
wrath of God. They are actually the wrath of
nature.
forest vegetation, some of it evaporating to form
new clouds. A cyclical evaporation and descend­
ing condensation Hoods land areas in a pre­
dictable manner, and water iecedes alter the
monsoons. The regulated flow of rainwater also
reduces soil or silt slippage into rivers — a pile­
up that can raise the riverbeds and greatly reduce
their water-holding capacity. But in the absence
of forests and other vegetative cover, even small
increases of water flowing into silted rivers result
in devastating floods.
The costs of rehabilitation are exorbitant.
However, the policy-makers have concerned
themselves more with treating the symptoms

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The 'eye' of a storm as
seen in a satteHte
image

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ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT

85

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The popular say­
ing that the forest
is the mother of
the river is no
folklore; it is a
scientific fact

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rather than the disease. There has been little
attempt at regeneration of the forests, building
higher and wider bridges and dredging silt to
improve channel capacity. Instead, the focus has
been more on constructing dams and flood
banks, and other short-term ‘flood-control’
measures.
Connected to floods are landslides, mudflows,
drought, and famine. Denuding mountain slopes
of their vegetation causes landslides. A landslip
occurs when an incline is too steep to resist gravity. Activities such as clearing of forests, con­
struction. and road-building, result in increased
soil eroison. In the absence of trees, waler seeps
into the ground and loosens the soil. After a few
showers, big sections of the hill start giving way.
A landslide into a lake or river can kick off dev­
astating Hash Hoods that gives no time to people
to move to safer heights.

Desertification and drought:
next of kin
While it is true that monsoon lands at the mar­
gins of deserts are prone to drought and famine,
environmental depredations have further con­
tributed to these phenomena. While forests
absorb excessive rainwater, they release moisture
into the air, leading to the formation of clouds
which precipitate over drier areas. This main­
tains the ecological balance between wet and dry
regions. Rivers carry enough water to remain
active during the monsoons because the forests
check the flow of mud or silt into them. Shallow,
silted rivers Hood easily during the monsoons,
but run dry in summer. The climate becomes
Fault lines running
drier
in the absence of plants, and direct sunshine
across the globe are
earthquake-prone plate dries the earth, making it uncultivable, it’s a short
boundaries
step to famine.

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The increase of carbon dioxide in the atmos­
phere warms up the earth. The building up of a
wraparound layer of carbon dioxide acts like a
blanket retaining the heat of the sun. This is
known as the 'greenhouse effect'. Scientists say
that this is the reason why droughts and famines
have increased in recent years.
Desertification threatens over a third of the
world's land. Every year, an area the size of
United Kingdom is either lost or severely
\ degraded due to overcultivation, overgrazing,

and deforestation. Desertification also adversely
affects the climate. Increasing dust prevents air
from rising freely and forming clouds, and vege­
tation loss reduces climatic moisture.

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Cyclones: beyond spin doctoring
Disasters have literally been spinning out of con­
trol lately. The ferocity of the 1998 Gujarat
would have been tempered had the coastal man­
grove forests been intact. This is merely one
instance where a devastated natural environ
struck back.
Cyclones are nature's means of circulating
heat to the colder areas. Extra-tropical cyclones,
outside the equatorial girdle, help reduce the
temperature differential between the equator and
the poles. Cyclones are regions of low pressure
or 'cold spots’. Extra tropical cyclones are large
and comparatively docile wind systems; tropical
cyclones are much smaller and sometimes
extremely violent. Known as hurricanes in the
Atlantic and the Caribbean, typhoons in the
Western Pacific and the China Sea, and willywillies off the Australian coast, severe tropical
storms have windspeeds exceeding 32 metres per
second, or 118 kilometres per hour.
The life of a tropical cyclone may vary from a
■ few hours to almost three weeks,
S although they usually last five to
| 10 days. Tropical storms begin
S over oceanic waters that are 27

| degrees centigrade or more in temJ perature. High temperatures have
resulted in the El Nino effect in
coastal areas; evaporation is high,
and the enormous weight of water
vapour leads to unsettled weather.
The rising hot air creates a cir­
cling wind How which accelerates
when it meets warmer, moist air.
The vapour condenses into water at

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INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

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colder high altitudes, releasing a large amount of
latent heat: 72 calories per cubic centimetre.Th is
leads to stronger winds, which in turn lead to a
further intake and updraft of larger volumes of
humid air, releasing more energy. The wind
swirls faster, the pressure drops considerably,
and the storm begins to spin violently. California
recorded the strongest gust measuring 316 kmph
. in 1966.
The 'eye' of a storm is Its calm, cloudless cen­
tre. Most cyclone damage is caused by winds
over 200 kmph, pressure differential on sealed
structures, and continuous, torrential rain.
Indirect damage is caused by 'storm surges’, sud­
den tides battering coastal areas, and rivers in
. spate.
Tornadoes are whirling dervishes accompa­
nied by rain and thunderstorms. Although infre­
quent in the subcontinent, Bangladesh was
recently struck viciously. Usually about 100
i** j1'
metres in diameter, with only the most violent
1
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ones lasting more than an hour, they cause incalv, j;.
I
culable damage. Windspeeds at The centre can
hurtle over 300 kmph.
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the Himalayas about 65 million years ago. Major
earthquakes occurring along subduction zones of
'converging plates' beneath the oceans have been
triggering the notorious tsunamis (harbour
waves) which endanger the Pacific's coastal
communities and islands. Tsunamis are often
mistakenly called ‘tidal waves’ but, they have
nothing to do with tidal action. They are waves
caused by oceanic seismic activity, submarine
lundNlidcs, und, infrequently, by eruptlonN of
island and undersea volcanoes. When the
seafloor moves several metres, an enormous
quantum of water is jerked into motion, sloshing
back and forth for several hours. A series of
waves races across the ocean at speeds exceeding
800 kmph. Their momentum can take them thou­
sands of kilometres from the epicentre of the
quake before slamming them into islands and
coastal stretches.

Epidemics

2

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Earthquakes: between rocks . . .
Given the structure of this planet, we will have to

I f! live with earthquakes. We live on vast land plates

-

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!!

that literally float on an ocean of semi-molten
rock. This molten liquid surrounds a solid inner
core, the main source of the earth's heat. The
skin, or the crust, is a giant, jagged jigsaw puz­
zle. There are three types of interlocking plate
boundaries, continuously redefined over thou­
sands of years.
Molten rock wells up from below, creating a
ridge when two plates diverge. 'Shearing plates'
have one plate moving horizontally away from
another. These plate boundaries are known as the
tectonic 'faults'. Plates crawl a few centimetres a
year but the stresses at the faults are immeasura­
ble. The incessant grinding causes sudden
upheavals, which are especially destructive
because most of the world's population lives on
the 'active faults'.
The dynamics of converging plates force one
under the other. For example, the movement of
the Indian plate towards the Asian plate created

Unlike earthquakes and volcanic eruptions, the
renewed surge of diseases and epidemics can be
attributed to humankind's short-sightedness. Our
medicinal profligacy is responsible for the cre­
ation and spread of drug-resistant and endlessly
mutating virus and bacteria.
For example, malaria is still the biggest killer
disease we have. After inuring most strains of
mosquitoes by overcompensating with DDT, we
have landed up with the deadly cerebral malaria.
The infinite mutagenic capability of AIDS
(Acquired Immuno-Dcficicncy Syndrome)
makes it almost impossible to treat. Its other
cousins, the terrifying Ebola and Maburg virus,
have no known remedies. They rode out of deep
Africa in the systems of ‘adventurers’, and were
contained, only by strictly quarantining and
allowing the affected populations to die.
Environmental malformations and changing
food habits and lifestyles are the largest cause of
' cancer. But the outbreak of the plague in India,
and its sporadic reappearance elsewhere, prove
that many 'eradicated' diseases are only waiting
for us to let our guards down.
We have, beyond doubt, made the world a
dangerous place to live in.

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ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT 87

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DISASTERS MAPPING

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A satellite can be
frozen ffeocentrically in place,
facilitating pre­
cise monitoring of
natural hazards

■

errain evaluation and analysis by satel­
lites, with continuously beamed as well as
timed photographs, has become intrinsic
to meteorological study. More satellite time is
devoted today to weather and geography scrutiny
than to any other field, except perhaps communi­
cation.
A satellite offers repetitive coverage, and it is
possible to examine particular locations at regu­
lar intervals. Remote sensing data and techniques
can be used in all three aspects of disaster man­
agement — vulnerability assessment, distant
early warning, and damage assessment. It can be
applied to all types of natural hazards — floods,
drought, storms, cyclones, landslides, crop fail­
ures, forest fires, volcanic eruptions, and earth­
quakes.

Floods
Flood detection, flood plain mapping, and flood

I■ fly v'

Satellite imagery has unlimited disaster pre­
diction and mitigation potential — but with
the right governmental attitude.

inundation mapping of rivers susceptible to
flooding is a basic satellite-imagery task.
In India, LANDSAT data has been used to
map floods in the Ganga-Kosi plains.1 The Space
Application Centre has also completed one
LANDSAT project with the Ganga Flood
Control Commission and the Survey of India.
Various features dike-river courses, river levels,
flood plains, and inundated areas have been com­
piled in standard Geological Survey of India
(GSI) accuracy-level maps.
Similarly, snow melt in the Sutlej-Beas catch­
ment and its inflow into the Govind Sagar reser­
voir has been carried out on satellite images from
the National Oceanographic and Atmospheric
Administration (NOOA), USA with 90 per cent
accuracy.2 Remote sensing has also been
employed to predict storm floods?

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Drought

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Drought, long considered a meteorological phe­
nomenon, is today increasingly believed to be
human-made. Drought vulnerability depends on
the extent to which physical and climatic condi­
tions play an adverse role in increasing unstable
agriculture.4
Agricultural drought is monitored through the
Crop Moisture Index (CMI), which is calculated
using a model that combines precipitation and
temperature data with that of soil, evaporation-

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INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

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?Remote sensing in India

JiSRO runs the following major institutes, focused on remote sensing:
: •. Space Application Centre (SAC), Ahmedabad
• National Remote Sensing Agency (NRSA), Hyderabad
"Sfework nruumAfw* Trevino and Command Network (ISTRAC), Ahmedabad
Watipnai Physical Laboratory (NPL), Ahmedabad
. E The majn objective of the Indian space programme is to provide operational research services to
. Ue’tatio^ esp^i'ally in the field of communications and remote sensing. These services include
i
'telecommunications, national television and radio networking, natural resource survey and manageMm ,
i
Pmeiit; environmental monitoring, meteorological data collection, and disaster warning.
■S*j f
fo Remote sensing has been included in different curricula, especially in geology, geography, and
KL, :
0 engineering courses in universities in every state. Almost all states have a Remote Sensing Institute
^(RSD^Many^hiversities,
including the
the Indian
Indian Institutes
Institutes of
ofTechnology
Technology (IIT),
(IIT), run
run courses
courses in
in Remote
Remote
■59
'■"ro
sn«Mflh^ivemities. includine
KS«^^d^^ogTammetry.\
; Sensing and Photogrammetry. Sr > ■. t< .. ■ ■
iJ^nSRO's decision to make its imagery available to international buyers is testimony that the qual(iity 0f
lity
of remote
retnbte sensing
Sensing imagery is tat .par with that of developed nations.
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transpiration, and other local factors. CMI
employs very limited point measurements, and
does not determine drought footprint or moisture
it L stress foci.
.
Drought remote sensing has been successfully
k
used during experiments- conducted by
Thompson and Wehmanen.3 One method is qual­
itative: it measures vegetative vigour by juxta­
ji- r : •
posing colour infrared LANDSAT images with
corresponding images of the previous year (if
that was a normal year), and with an immediate­
ly preceding image, of, say, 18 days previous.
''4
A second quantitative method, developed by
Kauth and Thomas6 and taken up at the Space
Application Centre, Ahmedabad, estimates
severity of drought. Accentuated ‘brightness­
greenness* in bands of images is an indication of
important agricultural features, and suppressed
in ‘yellowness-brightness’ and ‘none-suchbrightness’.7

■Wb.r: .fig

■£_ I I
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■

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-----------------------------------------------------------------

Remote sensing is
able to predict the
onset of insect
contamination
and disease infec­
tion of crops long
before it is visible
to human eyes

go together. Remote sensing continuously pro­
vides visual and infrared pictures of cloud devel­
opment, as well as land-sea temperature details.
Coupled with data on other meteorological fea­
tures like wind velocity, it is possible to forecast
cyclones to the day.
As in Gujarat recently, advance cyclone warn­
ing helps in evacuation and in limiting the
nature, extent, and magnitude of human and
material damage.

■

jg V
i'

Sensing the future
Satellite imagery is a fast-changing technology.
The next generation satellites will include newer
features. Improved techniques such as radar with
all-weather capabilities, microwave mapping of
rainfall, radar interferometry for ground move­
ments, and very high resolution optical sensors
are possible and will greately improve the accu­
racy of prediction. However, it is important to

.
■

■

-

Crop failure
.>

-£ •

>

■

Identification of crops on satellite imagery in
India is rendered difficult by large crop variation
in small fields. In countries like the USA and
Canada, with large field sizes and few simultane­
ously competing crops, crop identification and
yield forecasting using LANDSAT data have
shown 90 per cent accuracy. An ISRO-developed
system using satellite imagery in conjunction
with aerial photographs is currently in operation
in India.

?
■

f
b

Cyclones
In the public eye, cyclones and remote sensing

ISSUES OF SIGNIFICANCE. IND,A DISASTERS REPORT

>•Despite tremen­

dous progress
made in remote
sensing tech­
niques in India, iit

has remained
secluded from
policy and plan­

ning, except in

meteorology and
related matters.

integrate remote sensing in policy planning.
\since Independence, Forest Department offi-

Unfortunately, remote sensing has been con­
fined to universities, laboratories, and state insti­

ciaKhave maintained that 40 per cent of the
countr^s geographical area was under forest
cover. Based on satellite imagery from 1975-82.
the NRSA, Hyderabad prepaied a forest map of
India which shbwed that hardly 20 per cent of the
country was coveted under forests. For obs ious
reasons, the ForesK Department, through the
Forest Research Institute, was officially recog­
nised for preparing forcM^ maps ol the country

tutes.

using satellite data. The mqps are widely sus-

Earlier atteniptx

lo k impvvi'isv.

\

K 'uoh'
■

io apply /<
sensing to fore­
casting actually
put the Space
Department and

the Ministry of

Forests and
Environment on
the warpath

1
=!

•i

r

l.

\

-

•

'• ■' .

>V

'

Everi in olhei non couiiomi1 i.dsm . . <> '
has hardly been an attempt to chalk od\a nation­
al strategy based on the collected remote\ensing
data. A national Hood strategy based on\lood
mapping is absent, and the seismic zoning \ap

*

c

Endnotes
1 Bedi. N.. 1980, Proceedings of the First
llscr fnlcraction Seminar. National Remote Sensing
Agency, Hyderabad; Dhanju, M. S., 1978, Floods in
Ganga-Kosi Region. India’. Contributions of Space
Observation to Water Resource Management.
Perpman Press, Oxford and New York; Pal. S. K. and
A K BhalliK hiirya. 1981.1'nx eedings oj ISRO
(Uvup
<*>» Konote
,,

(

''

'

\vv\b
\

■Hl.:

■< '

'

c
c
c
c

I

AW

Sensing, Space Application Centre, Ahmedabad.
; Ramamoorthy. A. S.. 1983, ‘Forecasting of
Snowmelt Runoff of Sutlej River’. Proceedings of
Seminar on National Natural Resources Management

Systems, Hyderabad.
of India has not been upgraded since the l960s\
The consequences of such a cavalier attitude \ ' Lyne, A. W. H. and A. M. Radford. 1993, Prediction
could be serious. For example, in Delhi, there \ of Exceptionally Severe Storms, Natural Disasters.
^Protecting Vulnerable Communities, Royal Society
has been a gradual increase in the frequency and
Meeting. London.
magnitude of earthquakes over the past two
4 Mmistry of Irrigation and Power, 1972, Report of
decades, yet there has been no attempt to evalu­
the Irrigation Commission, Volumes I & II, New
ate the seismic risks to Delhi. This despite the
Delhi. \
fact that various scientific publications have stat­
’ Thompson D. R. and O. A. Wehmanen. 1978.
ed, clearly or obliquely, the possibility of a major
Application V LANDSAT Digital Data for
earthquake hitting Delhi in the near future.
Monitoring D\ught, Proceedings of the Technical
Satellite imagery can be of immense utility (in
Series. LACIE Symposium, Johnson Space Centre.
linement mapping, for instance) and, along with
Houston, USA. \
geo-dynamic measurements of strain accumula­
4 Kan th and Thomas^ 1976.
tion, can map earthquake prone areas in the
7 Dave. J. V.. 1981, Remote Sensing of the
country. However, the true potentials of this rev­
Environment, SAC, Ahmedabad.
olutionary reconnaissance tool are yet to be

I

tapped.

II !

I

I

!
J

90 INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

k

I

Despite tremen­
dous progress

i

made in remote
sensing tech­
niques in India, it
has remained
secluded from
I

policy and plan­
ning, except in
meteorology and

jj

related matters.
Earlier attempts
to apply remote
sensing to fore­
casting actually

I
ij!

put the Space
Department and

the Ministry of

Forests and
Environment on
the warpath

integrate remote sensing in policy planning.
Since Independence, Forest Department offi­
cials have maintained that 40 per cent of the
country's geographical area was under forest
cover. Based on satellite imagery from 1975-82,
the NRSA, Hyderabad prepared a forest map of
India which showed that hardly 20 per cent of the
country was covered under forests. For obvious
reasons, the Forest Department, through the
Forest Research Institute, was officially recog­
nised for preparing forest maps of the country
using satellite data. The maps are widely sus­
pected to be imprecise.
Even in other non-controversial areas, there
has hardly been an attempt to chalk out a nation­
al strategy based on the collected remote sensing
data. A national flood strategy based on flood
mapping is absent, and the seismic zoning map
of India has not been upgraded since the 1960s.
The consequences of such a cavalier attitude
could be serious. For example, in Delhi, there
has been a gradual increase in the frequency and
magnitude of earthquakes over the past two
decades, yet there has been no attempt to evalu­
ate the seismic risks to Delhi. This despite the
fact that various scientific publications have stat­
ed, clearly or obliquely, the possibility of a major
earthquake hitting Delhi in the near future.
Satellite imagery can be of immense utility (in
linement mapping, for instance) and, along with
geo-dynamic measurements of strain accumula­
tion, can map earthquake prone areas in the
country. However, the true potentials of this rev­
olutionary reconnaissance tool are yet to be
tapped.

9

90

INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

Unfortunately, remote sensing has been con­
fined to universities, laboratories, and state insti­

tutes.

Endnotes
1 Bedi. N.. 1980, Proceedings of the First
User- Interaction Seminar. Nutional Remote Sensing
Agency, Hyderabad; Dhanju, M. S., 1978. ‘Floods in
Ganga-Kosi Region, India’. Contributions of Space
Observation to Waler Resource Management,
Pergman Press, Oxford and New York; Pal. S. K. and
A. K. Bhattacharya. 1981. Proceedings of ISRO
Response Working Group Meeting on Remote
Sensing. Space Application Centre, Ahmcdabad.
5 Ramarnoorthy, A. S.. 1983. ‘Forecasting of
Snowmelt Runoff of Sutlej River’. Proceedings of
Seminar on National Natural Resources Management

Systems. Hyderabad.
’ Lyne, A. W. H. and A. M. Radford, 1993. Prediction
of Exceptionally Severe Storms, Natural Disasters.
Protecting Vulnerable Communities, Royal Society
Meeting, London.
4 Ministry of Irrigation and Power, 1972, Report of
the Irrigation Commission, Volumes I & II, New
Delhi.
’ Thompson, D. R. and O. A. Wehmanen, 1978,
Application of LANDSAT Digital Data for
Monitoring Drought, Proceedings of the Technical
Series, LACIE Symposium, Johnson Space Centre,

Houston, USA.
* Kanth and Thomas, 1976.
7 Dave. J. V., 1981, Remote Sensing of the
Environment, SAC, Ahmedabad.

I
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AMATEUR RADIOS: RIGHT
FREQUENCIES

3

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S. Suri

3

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Eleventh hour

1.

calls for lifesaving

3

medicines have

!

been passed by
amateur to ama­
teur till the donor

3
5

I

or provider has
We will speak out, we'will he heard,
Though all of earth's systems crack ....
James Russell Lowell

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mateur (ham) radio is a communications
tool that puts thousand* of people into
direct, two-way contact with each other
every day, all over the world. Over 3 million
amateurs around the globe pursue this as a
hobby, some with a consuming passion that takes

it beyond a mere pastime.
Amateurs communicate amongst themselves
using voice, data, and video formats. Orbiting
Satellite Carrying Amateur Radios (OSCARs),
designed and developed by hams themselves,
have been launched by many countries. Hams
are inveterate learners and conduct regular
experiments to improve communications tech­
nology through constant interaction. This ten­
dency towards innovation and open-ended learn­
ing drive can be used by people and govern­
ments, in situations both normal and extraordi­
nary.
Amateurs have, in fact, over the past decades,
offered their services to various governments,
groups, and individuals during disasters and
medical emergencies. Requests for aid and for
medical donors have often been forwarded by
amateurs in the dead of the night and when nor­
mal channels of communication have been found
dysfunctional or wanting. Amateurs, creatures of
the night, as it were, constantly monitor the air­
waves and often chance upon distress calls rang­
ing from aircraft and ship SOS signals to pleas
for medical evacuation. In places like the

Among the first victims of disasters are lines
of normal communication. Ham radio, which
has proved its value in disaster situations, if
sporadically, is waiting to take to the air
Australian outback and the deep Alaskan interi­
or, this has been of invaluable assistance.
These mechanisms work quietly, without
favour of media or reward. The first things to fall
victim to disasters are the normal lines of com­
munication. The media is usually better equipped
with communication facilities than government

been linked with
I

the caller

!

A lifeline in distress .
Ham's operations base

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ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT

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THE ROLE OF THE INTERNET

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11 disasters, whether natural or humanmade, have the common characteristics
of first disrupting the transportation and
communication systems.
Some areas can be benefited from planning in
advance. In areas where a floods forest fire, a volcano eruption, hurricane, or cyclone is likely,
advance evacuation steps can be taken. Relief
centres and accessible routes to rush men, medi­
cines, or other materials are crucial for disaster
management.
The four stages of Disaster Management
Planning — preparedness, response, relief, and
recovery — need to be well-planned. However,
no sensible planning is possible unless the
required information set is available and updat­
ed. It is in this context that the Information
Technology becomes crucial to the entire opera­
tion.

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How does Internet help?

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In any area of scientific inquiry, reliable and
updated information is a baseline requirement. In
order to understand the magnitude of any prob­
lem like natural disasters, wars or ethnic upris-'
ings which unsettle social and economic param­
eters, it is very important that global information
is available. This is when the Internet becomes
any easy source of material for any scientific
inquiry.
Information about past losses on account of
various disasters assists in preparing a systemat­
ic approach, when planning disaster manage­
ment. What went wrong in the past provides les­
sons for the future. No other system can provide

the much desired information in so cost-effective
a manner. The Internet can access data banks
world-wide and retrieve relevant data at any
time.
Internet also helps communicate to the outside
world details of any local disaster, and aid can
reach the affected areas through responsible and
authorised agencies. These Internet transactions,
needless to say, are paperless, instantaneous,
cost-effective, and hence most efficient.

■ -e

How to cost the net
Once Internet services are accessible, informa­
tion databases have to be searched using appro­
priate search engines. There are a number of
search engines on the net which offer this facili­
ty. By far, www.altavista.digital.com is the best
Rur.

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, ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT 9

V

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available for extensive and exhaustive searches.
The search engines are users friendly and one
simply needs to follow directions on the menu as
they appear. To look for a specific topic, a word
or a string of words must be indicated to set the
search in motion. A string of words must be set
within quotation marks. Foi example, let us say
we arc searching for infoimalion on disaster
management. We have Ihcrelore to indicate ’dis­
aster management in India’, if we wish to limit
this search to the Indian context. Just typing klisaster management' will result in a wider or glob­
al coverage.
The sites now available after search give a
brief outline of the document along with the link
and subject, thus enabling surfers to go to the
required site which is just a mouse click away!
Any document may be downloaded so that
the required data may be compiled for future ref­
erence.
Yahoo: www.yahoo.com is another conven­
ient, user-friendly search engine. The search is
made easier by an exhaustive listing of subjects.
In our context, select ’Society and Culture’ and
under this, click on 'Environment'. Choose
'Disasters' and you have now all subjects related
to disasters. The site also gives the user, the nor­
mal search option.
Others search engines in the order of suitabil­
ity may be listed as: www.webcrawler.com.
www.altavista.com and www.goto.com. The
search engines close to India arcwww.khoj.com
and www.l23india.com.

Visiting sites . . . .
!
Listed below are some documents available on
the net which deal with disasters. This is to illus­
trate the fascinating potential of Internet.
Readers arc advised io surf into (he original doc­
uments for full comprehension.

i

Ii

Effective Mass Marketing of Satellite Imagery
Stuart W. Nixon, President, Earth Resource
Mapping
Http://www.ermapper.com/reseller/info/
mmsatimg.html
This paper, presented at the Land Satellite
Information in the Next Decade conference held
in Virginia in September 1995 details Earth
Resource Mapping Strategy for promoting the
growth of remote sensing throughout the world
via a new data distribution plan.

f

ij
i

94

r

INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

!;i '

Satellite imagery can be used to forecast,
visualise, and to an extent prevent disasters using
powerful but affordable software.

(
Disaster Management Information System
S.K.Mittal. Senior Manager, Electronic Data
Processing
hltp://www.dqiiidia.com/apr3()96/3hd2211101.
Iiiml

The objective of this system is a collection of
information and communication technology
which helps in analysing and arriving at solu­
tions quickly so that the next time there is a sim­
ilar disaster, the concerned agencies would be
not only better equipped but also would be able
to minimise the losses in the form of human life
as well as public property.
This paper concludes that in a country like
India where the emphasis on safety is yet in its
infancy, it is essential to adopt a systematic
approach to handle any disaster. The proposed
system may prove to be a boon in power indus­
tries. railways, chemical industries, defence,
mines, etc. and against earthquakes, hurricanes,
toxic gas leaks, and floods.

c

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Satellite Imagery Investigations of Tropical
Cyclone Activity
Christopher W. Landsea, Principal Investigator
http://www.aonij.noaa.gov.hrd/projct97/cl.proj3.
html
Satellite imagery has assisted greatly in the
operational forecasting of hurricanes by allowing
estimates to be made for a storm's position and
intensity. Accessing real-time, satellite imagery
helps make disaster management an easier task.

y.'

'•

■

j:
GIS from a Disaster Management Perspective’.
An Overview
Sudha Maheswari, Rutgers University
http://www.spatial.maine.edu/ucgis/testproc/
maheswari/disaster.html
This paper reviews the current literature on
the use of Geographical Information Systems
(GIS) in the various phases of disaster manage­
ment, namely preparedness, response, recovery,
and mitigation.
Disaster Management Support Project: First
Meeting Report. Integrated Global Observing
Strategy
http://www.ceos.noaa.gov/minutes-lst mtg.html

1

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HUB-

Refugee monitoring using High-Resolution
Satellite Images

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The report on the first meeting of the Disaster
Management Support Project held on 29-30
May 1997 in Brussels presented here. It was
hosted by the European Commission (EC)
Directorate General for Science. Research, and
Development (DG-XII). This meeting addressed
the issue of how the participants might work
together to buttress disaster management support through the expanded use of Earth
.Observation (EO) satellite data.

Einar Bjorgo
http://www.nrsc.no:8001/~einar/UN/refmon_pro
posal.html
Because of the increasing scale and frequency
of natural and man-made disasters, a continuous
search for more effective emergency response
methods is necessary. In this context, high-rcsolutton satellite images may prove a very effective
tool to provide objective and accurate mformation in all phases of relief ojierarions. This is
more relevant to Indian context in view of our
large population.

Emergency Preparedness Information Exchange
(EP1X)
http://hishi.cic.sfu.ca/'anderson/about/about.epix
E-mail to andcrson@sfu.ca
The purpose of EPIX is to facilitate exchange
of ideas and information about the prevention of,
preparation for, recovery from, and/or mitigalion of risk associated with natural and sociotechnical disasters.

IT'

*3 '
>

*

Asian Disaster Preparedness Centre (ADPC)
International Consultancies and Alumni
Coordination
http://www.epix.sfu.ca/adpc/consult/consult.html
E-mail to rajesh@ait.ac.th
The ADPC is involved in matching specialist
expertise with the needs of disaster and development-oriented demands in the Asia and Pacific

_
El
!

region. This is facilitated through the
International Consultancies and Alumni Co-ordi­
nation Unit of adpe. This unit maintains frequent
contact with users of expertise and manages a
database containing more than 2000 adpc alum­
ni and international and national experts.
This also indicates UNDP Support to Disaster
Management in India as one of the possible new

activities.
Welcome to RclicfWcb
http://wwwnotcs.reliefweb.in
ReliefWcb is a project of the United Nations
Office for the Coordination of Humanitarian
Affairs (OCHA). Us purpose is to strengthen the
response capacity of the humanitarian relief
community through timely dissemination of reli­
able information on prevention, preparedness,
and disaster response.
And ... if a forest is on fire!

Let us imagine the consequences of a breaking
out a large forest lire. Admittedly there are no
transport or communication facilities to gauge
(lie iiite.nsily of Ihc Inc from wilhin. And Hie
ways to find the trend of its spread arc primitive.
In a situation of this nature, satellite imagery
comes lo your rescue and Internel and informa­
tion technology comes handy in distribution ol
such data across the globe in seconds.
Monitoring forest fires and preventing it from
further spreading can be done better if we have
the right data and information on real-time basis.
Temperature variations, direction of fire, etc. can
be observed remotely just by a click of the
mouse and this makes the task of fire fighting
less complicated.
Conclusion
The main objective of this article is to provide an
insight into the potential of Internet in the spccilic area of Disaster Management. However, those
interested in delving deep into the subject may
seek the assistance of Internet Help Desks of
VSNL available at all metros and other centres.
’ . >/

ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT

Ih

ROLE OF THE GOVERNMENT:
RESPONSIBILITIES AND
PERFORMANCE

If

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■ f1

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a

Bhagat Singh
a
u

1
eclaration of the current decade as
International Decade for Natural
Disaster Reduction (IDNDR) by the
United Nations has helped substantially in giving
more thrust on disaster preparedness and mitiga­
tion by the disaster managers in the country. It
has also helped in initiating various programmes
and activities at different levels to enhance the
capability of the country in the area of disaster
reduction. The decade has been instrumental in
generating a lot of concern among the various
governments, and non-governmental organisa­
tions, scientific and technical institutes, and the
community at large about the adverse impact of
disasters.
During this decade, India has faced many
major disasters, these include cyclones in
Andhra Pradesh (1990 and 1996) and Gujarat
(1998). earthquakes in Uttarkashi (1991). Latur
(1993), and Jabalpur (1997), landslide in Uttar
Pradesh (1998), in addition to floods of varying
degrees which is an annual feature. On an aver­
age, 3,000 precious life have been lost besides
destruction of public and private property in the
tune of over Rs 10,000.00 million.
On the basis of the objective of and goals of
the Decade as well as experience gained from the
natural disasters, many improvements have been
made in disaster response, preparedness, and
mitigation including forecasting and warning.
These are summarised below.

Disaster response
The basic responsibility for undertaking rescue,
relief, and rehabilitation measures in the event of

96

INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

natural disasters is that of the State Governments
concerned. The role of the Central Government
is supportive, in terms of physical and financial
resources and complementary measures in sec­
tors such as transport, warning, and interstate
movement of food grains. Relief Manuals and
Codes are available for undertaking emergency
operations.
However, there is a Crisis
Management Group headed by the Cabinet
Secretary and consisting of Secretaries of sup­
portive ministries and nodal ministries dealing
with various types of disasters. For natural dis­
asters, the. Ministry of Agriculture is the nodal
Ministry and the othei Ministries play a support­
ive role. In the event of a disaster, a multi-disci­
plinary Central Government team, at the invita­
tion of the affected State, carries out disaster
assessment and makes recommendation for
assistance.
A broad view of the administrative response al
the national, state, and district levels is given
below.

"t
T

State-level organisation
The subject of disaster preparedness and
response in the states is usually delegated to the
Relief and Rehabilitation Department or the
Department of Revenue. The Crisis Management
Group/Disaster Management Committee at the
state level is headed by the Chief Secretary of the
Government, with participation of all the related
agencies.

c*

«*«■

District level
A District Level Co-ordination and Review

’'’*9

8H

2

Committee in each district is headed by the
Collector/District
Magistrate/Deputy
Commissioner as chairman with participation of
all other related agencies and departments.

Arrangements for financing relief
Schemes for financing expenditure on relief and
rehabilitation in the wake of natural calamities
are governed by the recommendations of Finance
Commissions appointed by Government of India
after every five years. In the beginning of the
current decade, the system of financial response
underwent a change so as to reduce the time
between the occurrence of a calamity and the
provision of relief to the victims of the calamity.
Under the existing scheme for the period
1995-2000, each State has a corpus of funds
called the Calamity Relief Fund (CRF), adminis­
tered by a State-Level Committee. The size of
the corpus is determined having regard to the
vulnerability of the State to different natural
calamities and the magnitude of expenditure nor­
mally incurred by the State oh relief operations.
The corpus is built by annual contributions of the
Union Government and the State Governments
concerned. At present, the aggregate accretion in
the States’ CRF for a period of five years from
1995-2000 amounts to Rs 63,042.70 million.
The States are free to draw upon this corpus for
providing relief in the event of a natural calami­
ty. In the event of a major disaster warranting
intervention at the national level, a provision
exists in the form of a National Fund for
Calamity Relief with a corpus of Rs 7,000.00
million (for 1995-2000) for the Union
Government to supplement the financial
resources needed for relief operations.

Forecasting and warning
India has over the years, and specially in the
1990s, developed, upgraded, and modernised the
monitoring, forecasting, and warning systems to
deal with cyclones, floods, droughts, and earth­
quakes.

ports, fisheries, and aviation departments, and
vulnerable coastal areas. The warning system
provides for a cyclone alert of 48 hours, and a
cyclone warning of 24 hours. There is a special
Disaster Warning System (DWS) for dissemina­
tion of cyclone warning, in the local language,
through INSAT Satellite to designated
addressees at isolated places.
The extent of headway made in cyclone warn­
ing is evidenced by two situations of 1977 and
1990 in the Andhra Pradesh coast which was hit
by cyclones accompanied by high storm surges
of almost the same intensities. The number of
deaths in 1977 was over 10,000 whereas the loss
of human life in 1990 was less than 1,000.
Timely warnings issued by the IMD enabled the
administration in evacuating and transporting
over half a million people from the affected
areas.

Floods
The Central Water Commission (CWC) has a
flood forecasting system covering 62 major
rivers in 13 Stales with 157 stations for transmis­
sion of flood warnings on real time basis. In
1995, 8,566 forecasts were issued with a 95 per­
centage accuracy. There are also 55 hydro-mete­
orological stations in the 62 river basins.
The CWC monitors the levels of 60 major
reservoirs with weekly reports of water levels
and corresponding capacity for the previous year
and the average of the previous 10 years. Similar
monitoring of smaller reservoirs by the Irrigation
Departments of State Governments gives
advance warnings of hydrological droughts with
below average stream flows, cessation of stream
flows, and decrease in soil moisture and ground­
water levels.
VHF/HF wireless communication system is
used for data collection with micro-computers at
the forecasting centres. Hydrological models are
increasingly used for inflow and flood forecast­
ing. The forecasts are also communicated to the
administrative and the engineering departments
for dissemination through fax, e-mail, etc.

Cyclone
The Indian Meteorological Department (IMD) is
responsible for cyclone tracking and warning to
the concerned user agencies. Cyclone tracking is
done through INSAT Satellite and 10 cyclone
detection radars deployed at different locations
in the coastal areas. A warning is issued to cover

Droughts
The IMD has divided the entire country into 35
meteorological subdivisions. It issues weekly
bulletins on rainfall indicating normal, excess,
and deficient levels and also the percentages of
departure from the normal.

ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT 97

4;

Based on the input from IMD on the rainfall
behaviour and the water levels in the reservoirs
respectively and the information on crop situa­
tions received from the local sources, the
National Crop Weather Watch Group monitors
the drought conditions.
Remote sensing techniques are also used for
monitoring drought conditions based on vegeta­
tive and moisture index status as also for assess­
ing damage caused by floods, cyclones, and
droughts.

Earthquakes

On the basis ol past cailhquakvs ol magnitude 5
and above on the Richter scale and intensities
ranging from V to IX superimposed on tire mag­
nitude information, and also drawing upon tec­
tonic Icalurcs in the near past. Earthquake
Zonation maps have been prepared. IMD oper­
ated a network of 36 seismic monitoring stations.
After the Maharashtra earthquake of September
1993, a plan to upgrade and modernise the
national network of seismological operations
equipped with the state-of-art technology instru­
ments is now in progress.

Preparedness and mitigation measures
India, besides evolving effective post-disaster
management operations, has also formulated and
implemented pro-disaster mitigation pro­
grammes and sectoral development programmes
to reduce the impact of disasters as well as to
reduce the socio-economic vulnerabilities. The
reconstruction programmes in the aftermath of
disasters such as cyclones and earthquakes are
also aimed at building disaster resistant struc­
tures to withstand the impact of natural hazards
in the future.
India has prepared a Vulnerability Atlas in
1998 with the help of an expert group. Physical
vulnerability for floods, cyclones, and earth­
quakes has been depicted for each state and at the
district level.

Floods
Structural methods of flood mitigation have
attracted an investment of about Rs 40,000 mil­
lion between 1957 and 1995 in construction of
new embankments (I6,2(X) kms). drainage chan­
nels (32,000 km), and raising 4.7(X) critical vil­
lages above the Hood level. These measures have
protected an estimated area of 14.4 million

hectares.

san'

Multi-purpose dams and reservoirs have been
built with flood moderation as one of the objec­
tives. Examples of flood moderation through
multi-purpose dams are the Damodar Valley
System in eastern India, Hirakud Dam in Orissa,
and the Bhakra Dam on the river Sutlej. The
Damodar valley, system has a flood absorption
capacity of 1,867, mom which moderates prob­
able Hoods of 28,3(X) cusecs to 7,075 cusecs in
the valley.

nM

The increasing trend in the flood damage
observed in India (luring the l‘>70s led to
attempts lor the development of flood plains in a
regulated manner. A model Bill on flood plain
zoning was circulated to the State Governments
as early as 1975 to enact suitable legislation for
icstiicting the encroachment of the flood plains
and for their development in a regulated manner.
The model Bill lays emphasis on non-structural
measures. The main features of the model bill
arc: (a) designating Hood zoning authority, (b)
delineation of flood plain; (c) notification of lim­
its of flood plains; (d) restrictions on use of flood
plains; (e) compensation; and (f) power to
remove unapproved construction.

Droughts
India has paid adequate attention to irrigation
development by harnessing water through the
medium reservoirs, developing traditional sys­
tems of tanks, and exploiting groundwater. The
average annual investment on major and medium
term irrigation projects rose from Rs 7,500.00
million in the First Five Year Plan to Rs
250,000.00 million in the Eighth Five Year Plan,
creating a total potential of 38.0 million hectares.
The irrigation potential has not been fully
utilised for want of on-farm development works
like field channels, land levelling, and field
drains and the absence of appropriate systems of
water distribution to ensure appropriate water
management. The Government of India is now
operating a Command Area Development
Programme (CADP) to strengthen the water
management capabilities and enhance the effec­
tiveness of irrigation water application.
The Desert Development Programme (DDP)
started in 1977-8 aims at controlling the process
of desertification and mitigating the adverse
effects on drought in the desert areas through
such projects as afforestation, sand-dune stabili-

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INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

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Earthquakes

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sation, shelter belt plantation, grassland develop- •
Since much loss of life during the past earth­
ment, and soil and moisture conservation. A sim­
quakes in the world has occurred due to the col­
ilar programme directed at drought prone areas is
lapse of non-engineered traditional buildings of
under implementation since 1973 and is entitled
clay, stones, and bricks and since the bulk of the
Drought Prone Areas Programme (DPAP). The
housing in India consists of such buildings, stud­
DPAP is under implementation in 149 districts in
ies on this problem were started at the University
14 States and the DDP in 36 districts in 7 States.
of
Roorkee in 1960. Very useful recommenda­
A programme entitled National Watershed
tions regarding upgrading of such buildings were
Development Project for Rainfed Areas (NWDavailable in the Geological Survey of India's
PRA) has been devised and is under implemen­
memoirs of the 1934 Bihar earthquake. These
tation. The objective of this programme is to
efforts resulted in the preparation and publication
achieve conservation of rainwater, control of soil
ofIS:4326in 1976. After the Koyna earthquake,
erosion, regeneration of green cover, and promo­
the research efforts were devoted to shake-table
tion of dryland farming systems including horti­
tests on larger scale specimens for checking the
culture, agro-forestry, pasture development, and
validity of reinforcing recommendations of
livestock management as well as household pro­
IS:4326 and also to further refine the analysis
duction systems.
procedures. The monograph published by the
There are large areas of degraded land over
International Association of Earthquake
100 million hectares, in the country which could
Engineering, namely Basic Concepts of Seismic
be reclaimed.
A
National
Wasteland
Codes, Part II. Non-Engineered Construction,
Development Board has been constituted for pro­
1980, included many results of the Indian expe­
moting integrated wasteland development. The
rience, particularly in regard to masonry and
National Forest Conservation Act (1980) is an
wooden buildings. This monograph has been
attempt to bring down the erosion of forest cover
revised and updated as ‘Guidelines for
all over the country.
Earthquake
Resistant
Non-Engineered
Natural disasters, particularly droughts throw
Construction’, October 1986.
up huge unemployment and underemployment
The Department of Science and Technology
problems in the rural areas. The Jawahar Rozgar
(DST) is executing a World Bank assisted project
Yojana (JRY) envisaged for this purpose is the
on Seismological Instrumentation Degradation
largest such programme in the country. The
and other Collateral Geophysical studies in the
objective of the programme is to generate addi­
Indian Peninsular region. Major organisations
tional gainful employment for the unemployed
like India Meteorological Department (IMD),
and underemployed men and women in rural
National Geophysical Research Institute, Survey
areas. The Employment Assurance Schemes
of India, Geological Survey of India, and some
(EAS) me implemented to provide employment
academic institutions are participating in the
opportunities mostly in drought prone areas.
World Bank project. Under the project, it is
Cyclones
planned to (i) upgrade 20 existing seismological
Measures such as building of cyclone shelters,
observatories of IMD, (ii) set up 3 Telemetered
Seismic Clusters, (iii) establish 10 new Digital
afforestation in coastal areas, etc. have been
Seismic Observatories in the shield region, (iv)
undertaken
to
deal
with
cyclones.
Reconstruction projects have been taken up in
provide Strong Motion Instruments both for free
field and structural response studies, and (v) con­
areas affected by major calamities by building
duct geodetic studies using Global Positioning
elements for mitigation of possible future
System technology.
calamities. The Cyclone Reconstruction Project
implemented in the coastal Andhra Pradesh dur­
Activities for long-term mitigation/
ing 1990-3 consisted of such components as
reduction
housing and public infrastructure, drainage, and
To improve disaster management and to enhance
rural water supply. It also included such mitiga­
our capability to mitigate the impact of disasters
tion efforts as expanding road and communica­
in the country in the long-run, the following
tion network, planning of shelter belt plantation,
areas have been identified for implementation:
and building up of cyclone shelters.

ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT 99

■

!
I
■

/
/

'I

I

I .

(i) Intensive training for building up human
resource development to improve awareness and
capabilities for successful disaster management;
(ii) The documentation of events of various nat­
ural disasters so as to highlight the lessons learnt
in tackling future disasters;
(iii) Long-term mitigation measures which will
focus on various programmes keeping in view
the goals and objectives of IDNDR:
(iv) For achieving long-term results there is a
need to examine critically the development pro­
grammes in relation to disaster management in
different areas and suggest priorities and strate­
gies lor inclusion in the ongoing plans;
(v) To create awareness among the general pub­
lic about the various aspects of disasters and ben­
efits of the counter-measures.
(vi) Programmes of undertaking consultancy
services, research programmes etc. to increase
the level of understanding and evolving appro­
priate measures to improve the quality of the dis­
aster management;
(vii) To have an integrated approach in develop­
ing professional disaster management strategy;
(viii) Improvement of forecasting, warning and
communication system for effective disaster
management;
(ix) Community awareness;
(x) Modernisation of equipment, that is introduc­
tion of slate of art technology;
(xi) Designs of wind resistant and earthquake
resistant houses and amendments to building and
town planning laws at city levels.
Central Sector Plan Scheme on Natural
Disaster Management Programmes (NDMP) has
been implemented since December 1993. The
main objective of the scheme is to enhance the
national capability for disaster reduction, pre­
paredness, and mitigation. The programme is
also expected to enhance the level of awareness
of the members of the community about disasters
they are likely to face and prepare them ade­
quately to face the crisis situation. The compo­
nents of the programme are:
• Human resource department
• Activities under IDNDR,
• Research and consultancy services,
• Documentation of major events,
• Strengthening of Natural Disaster
Management administrations,
sEstablishnicnt and strengthening of National
Centre of Disaster Management (NCDM) al the

,

100 INDIA DISASTERS REPORT ISSUES OF SIGNIFICANCE

Centre and the Natural Disaster Management
Faculties in States
The major achievements of the programme so
far are:
(i) Setting up of the National Centre for Disaster
Management in the Indian Institute of Public
Administration, New Delhi in 1995;
(ii) Setting up of separate Disaster Management
Faculties in Training Institutes in 16 out of 25
states in the country;
(iii) Documentation of major events like
Uttarkashi and Latur earthquakes, research stud­
ies on landslides in Kerala. Sikkim, and Uttar
Pradesh, droughts in Rajasthan, and cyclone mit­
igation in Andhra Pradesh;
(iv) Preparation of source book for use of
trainees of the Lal Bahadur Shastri National
Academy of Administration;
(v) Oiganising/sponsoring of training programmes/seminars on various aspects of natural
disaster management;
(vi) Public education and community awareness
campaign through newspapers, postal stationery,
observation of World Disaster Reduction Day,
and films;
(vii) Reprinting of 45,000 copies of IDNDR pub­
lication for children in English and Hindi for dis­
tribution among school children.

Activities at regional/international
levels
India is committed to the goals and objectives of
the International Decade for Natural Disaster
Reduction. A strong delegation led by
Agriculture Minister participated in the World
Conference on Natural Disaster Reduction held
in Japan in 1994. Every year, die World Disaster
Reduction Day (2nd Wednesday of October) is
observed in a befitting manner. State govern­
ments, state level training Institutes, and some
organisations observe this day by organising var­
ious activities of public awareness.

Disaster reduction activities/plan for
the twenty-first century

I

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c
c
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c
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National Level
Inspite of initiating various disaster mitigation
measures, the trend of losses is not indicating
any sign of improvement. Population pressure,
environmental degradation, migration, and
unplanned urbanisation are some of the major

C

c

c

I C

e

’•Sat.

state

;

factors contributing to increased vulnerability.
As such, need has been felt to accelerate the pace
of disaster mitigation efforts in the country. Il is
planned to lay more emphasis on the following

• Hazard and vulnerability analysis
• Human resource development
• Exchange of information through the internet
• Disaster management network at the regional

areas:
• linkage of disaster mitigation with develop­
ment plans,
*
a effective communication system,
• use of latest information technology,
• insurance in all relevant sectors,
• extensive public awareness and education
campaigns particularly in the rural areas,
• legal and legislative support,
• involvement of the private sector,
• greater involvement of non-governmental
organisations,
• strengthening of the institutional mechanism,
including the Natural Disaster Management
Division in the nodal Ministry of Agriculture,
• International co-operation at regional and
bilateral level.

level
• Networking of the regional institutes
India over the years has evolved a well tested
disaster relief and rehabilitation mechanism.
Relief manuals and codes backed by a contin­
gency action plan, along with the allocation of
resources, facilitates the emergency management
operations. A Plan scheme has been initiated
with the objective of enhancing the national
capability for disaster reduction and prepared­
ness. The institutional mechanism has been
strengthened by establishing the disaster man­
agement centres at the national and state levels.
The
National
Centre
for
Disaster
Management, New Delhi is working in the area
of natural disaster management for human
resource development, creation of a data base,
documentation of disasters, research studies, and
networking of the institutions at the national and
international level. In addition, small Centres on
disaster management are also operating in the
State level training institutes. A large number of
institutes are already engaged in activities relat­

Regional cooperation
Most of the world’s worst disasters tertd to occur
between the Tropic of Cancer and Tropic of
Capricorn. Coincidentally, this covers most of
the Asian countries and some of them are among
' the poorest countries of the world. The disasters
cause enormous destruction and human suffering
in the developing countries. Some of the natural
disasters like floods and cyclones cause havoc in
more than one country simultaneously. The
excessive rain in the catchment area oi the rivers
of Nepal cause extensive flood damage in India
as well. Similarly, cyclone formation in Bay of
Bengal needs regional cooperation in informa­
tion dissemination and early warning. It under­
lines the necessity for coordinated international
action in order to strengthen all aspects of disas­
ter management wherever possible by learning
from one another and by sharing experiences.
Regional cooperation for an effective disaster
management system is needed broadly in the fol­
lowing areas:

ed to disaster reduction.
India will be happy to provide the available
expertise for disaster relief and rehabilitation,
human resource development, preparation of
relief manuals and codes, contingency action
plans, post disaster evaluation, and information
technology as also to join hands with other coun­
tries in the region in these and other related
fields.

These are excerpts from ‘Natural Disaster
Management in India — Country Report , a paper he
presented in his capacity as the Central Relief
Commissioner, Government of India , at the IDNDR ESCAP Regional Meeting for Asia’ held at Bangkok,
Thailand from 23-26 February, 1999.

ISSUES OF SIGNIFICANCE INDIA DISASTERS REPORT 101

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